ADHD, Autism, Amenorrhea PDF

ADHD  Is one of the most common mental disorders affecting children. Considered as chronic and debilitating disorder and is known to impact the individual in many aspects of their life including academic and professional achievements, interpersonal relationships and daily functioning....

ADHD  Is one of the most common mental disorders affecting children. Considered as chronic and debilitating disorder and is known to impact the individual in many aspects of their life including academic and professional achievements, interpersonal relationships and daily functioning. It can lead to poor self-esteem and social function in children when not appropriately treated.  It is often first identified in school-aged children when it leads to disruption in the classroom or problems with schoolwork. More common in boys Boys – tend to have hyperactivity and other externalizing symptoms. Girls – tend to have inattentive type Diagnosis Presence of persistent symptoms that have occurred over a period of time and are noticeable over the past 6 months. Symptoms must be present before the individual is 12 years old and must have caused difficulties in more than one setting. Types 1. Inattentive type 2. Hyperactive-impulsive type 3. Combined type Inattentive type Doesn’t pay close attention to details or makes careless mistakes in school or job tasks. Has problems staying focused on tasks or activities. Doesn’t seem to listen when spoken to Does not follow through on instructions and doesn’t complete schoolwork, chores or job duties. Has problems organizing tasks and work Avoids or dislikes tasks that require mental effort Often loses things needed for tasks or daily life Easily distracted Forgets daily tasks Hyperactive Impulsive type Fidgets with or taps hands and feet, squirms in seat Not able to stay seated Runs about or climbs where it is inappropriate Unable to play or do leisure activities quietly Always on the go Talks too much Blurts out an answer before a question has been finished Has difficulty waiting for his turn Interrupts or intrudes on others Causes Genetics Low birth weight Premature birth Exposure to toxins during pregnancy Extreme stress during pregnancy Treatment Behavioral therapy Parent-Child Interaction Therapy Medication - Pyschostimulants – first line drug Amphetamines – only FDA approved medication Methylphenidate (Ritalin) – helpful if behavioral interventions prove insufficient  E A R H O R EN A M PRIMARY AMENORRHEA  IS AN ABSENCE OF SECONDARY SEX CHARACTERISTICS AND NO UTERINE BLEEDING BY 14-15 YEARS OF AGE, OR ABSENCE OF UTERINE BLEEDING WITH SECONDARY SEX CHARACTERISTICS BY 16 TO 16 ½ YEARS OF AGE.  NO UTERINE BLEEDING AFTER ATTAINING SEXUAL MATURITY RATING 5 (SMR 5) FOR 1 YEAR, OR AFTER BREAST DEVELOPMENT FOR 4 YEARS.  THE ETIOLOGY OF PRIMARY AMENORRHEA MAY BE ANATOMIC, HORMONAL, GENETIC, OR IDIOPATHIC.  A THOROUGH HISTORY AND PHYSICAL EXAMINATION WILL PROVIDE CLUES TO THE ETIOLOGY. SECONDARY AMENORRHEA  IS DEFINED AS THE ABSENCE OF MENSES FOR 6 MONTHS OR ATLEAST 3 CYCLES AFTER MENSTRUATION WAS PREVIOUSLY ESTABLISHED.  IRREGULAR MENSTRUAL CYCLES ARE COMMON WITHIN THE FIRST YEAR OR TWO AFTER MENARCHE.  THESE EARLY CYCLES MAYBE ANOVULATORY RESULTING IN REGULAR, IRREGULAR OR ABSENT BLEEDING; HOWEVER, CYCLE LENGTHS GREATER THAN 90 DAYS ARE RARE AND SHOULD BE INVESTIGATED.  GIRLS WITH LATER ONSET OF MENARCHE WILL TAKE LONGER TO ESTABLISH REGULAR OVULATORY CYCLES.  PREGNANCY IS THE MOST COMMON CAUSE OF SECONDARY AMENORRHEA AND SHOULD BE RULED OUT IN BOTH TYPES OF AMENORRHEA, EVEN IF BOTH THE ADOLESCENT DENIES SEXUAL ACTIVITY.  WHEN PREGNANCY HAS BEEN RULED OUT, THE HISTORY SHOULD BE EVALUATED FOR EVIDENCE OF STRESS, WEIGHT CHANGES, AND CHANGES IN THE ENVIRONMENT.  OTHER COMMON CAUSES OF AMENORRHEA IN ADOLESCENTS INCLUDE HYPERANDROGENISM, EATING DISORDERS , AND EXERCISE-INDUCED AMENORRHEA.  1 Autism The child with Cognitive Deficit  2 What is Autism?  is a complex neurological disorder that affects the functioning of the brain that typically appears in the first 3 years of life. The spectrum of disabilities in each unique person with Autism can range from mild to severe but they all share these characteristics on some degree… 1. Impairment in social interaction 2. Impairment in communication 3. Restricted or Repetitive Patterns of behaviour, interests and activities  3 History of Autism Autism was first described in literature by Leo Kanner in 1943.  He called the syndrome “early infantile autism.”  Autism was also often misdiagnosed as childhood schizophrenia.  Early psychologists hypothesized that children became autistic due to “cold and unnurturing” mothers. This theory was proven false in 1979.  4 Is classified as a developmental disability.  Occurs mostly in males. The ratio is about 4:1.  5 occurs in approximately 1 out of 250 births, and has a 10-17% annual growth rate. is found throughout the world in families of all racial, ethnic and social backgrounds. There is no cure, but lots of research is currently being done.  There are lots of treatments, and from researched based evidence, educational treatment is the most effective.  Autism remains throughout the individual’s lifetime, although with proper intervention symptoms can lessen.  6 Genetic link Unfavorable events such -Monozygotic twin as uterine bleeding, -Assoc. with fragile X induced labor, syndrome prolonged labor, - Recurrence if one hyperbilirubinemia child is affected Autism Impairment in Restricted or Repetitive social Impairment in Patterns of behaviour, interaction communication interests and activities  7 Manifestation of Autism Social Skills Communication Skills Behavior skills Deficits or differences Difficulties in using and Unusual and repetitive in social skills are understanding both movements of the common with verbal and non-verbal body individuals with autism. language. that interfere with the They - Failure to initiate or ability to attend to may exhibit the sustain conversational tasks following: interchange. or activities, such as -Lack of awareness of -Abnormalities in the hand flapping, finger the existence or pitch, stress, rate, flicking, rocking, hand feelings rhythm, clapping, grimacing or of others. and intonation of eye gazing. - Severe impairment in speech. -Marked distress over the ability to relate to changes in seemingly others. trivial aspects of the - Aloof and distant environment. from others. Laughing, crying, or - Appears not to listen showing distress for when spoken to. reasons not apparent to others.  8 Social skills Communication skills Behavior skills Manifestation Fails to produce of Autism Poor receptive and -Unreasonable appropriate facial expressive skills. insistence on expressions to specific -May echo words following occasions. (echolalic speech). routines in precise - Avoids eye contact. -May use screaming, detail. - Difficulty with changes crying, tantrums, in environment and aggression, or self-abuse routine. as ways to -Does not seek communicate. opportunities to interact - Repeating words or with phrases in place of others. normal, responsive - Unwillingness and/or language. inability to engage in cooperative play.  9 Early Symptoms – Birth to 18 Months Feeding problems, such as poor nursing ability. Apathetic and unresponsive – showing little or no desire to be held or cuddled.  Constant crying or unusual absence of crying.  Disinterested in people and surroundings.  Repetitive movements, such as hand shaking, prolonged rocking and spinning, head banging.  Sleeping problems.  Insistence on being left alone.  10 Early Symptoms – 18 Months to 3 Years Difficulties in toilet training.  Odd eating habits and preferences.  Late speech, no speech, or loss of previously acquired speech.  Sleeping problems, such as requiring only a few hours of sleep each night.  11 Other Common Characteristics of Autism Unresponsive to normal teaching methods.  Acts as deaf.  Apparent over- or under-sensitivity to pain.  No fear of real danger.  Uneven gross and fine motor skills.  May not want to cuddle or be cuddled.  Inappropriate attachment to objects.  Noticeable physical over-activity or extreme under- activity  12 Early Symptoms – Other Indications Does not have anticipatory response to be picked up.  Seems to “tune out” a lot.  Prolonged tantrums.  Doesn’t play appropriately with toys.  Seems to have a good memory.  Fails to respond to the affection of others.  13 Early symptoms- other indication May use an adult’s hand like a tool for accomplishing tasks.  Does not spontaneously imitate the play of other children.  Tendency to spend inordinate amounts of time doing nothing or pursuing ritualistic behaviour.  Difficulty with changes in environment and routine.  Does not seek opportunities for interaction with others.  14 Diagnostic Criteria for Autistic Disorder A. A total of six (or more) items from (1), (2), & (3), with at least two from (1), & one each from (2) and (3): (2) Qualitative impairment in social interaction, as manifested by at least two of the following: a. marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, & gestures to regulate social interaction. b. failure to develop peer relationships appropriate to developmental level.  15 Diagnostic criteria for autism c. A lack of spontaneous seeking to share enjoyment, interest, or achievements with other people (ex. By a lack of showing, bringing, pointing out objects of interest. d. Lack of social or emotional reciprocity. (2) Qualitative impairments in communication as manifested by at least one of the following: a. delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gestures or mime).  16 (b) In individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others. (c) Stereotyped and repetitive use of language or idiosyncratic language. (d) Lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level. (3) Restricted repetitive and stereotyped patterns of behavior, and activities, as manifested by at least one of the following: (a) Encompassing preoccupation with one or more stereotyped & restricted patterns of interest that is abnormal either in intensity or focus  17 (b) Apparently inflexible adherence to specific, non-functional routines or rituals. © stereotypes and repetitive motor mannerisms (ex. Hand or finger flapping or twisting, complex whole body movements. B. Delays or abnormal functioning in at least one of the following area with onset of before age 3 years; (1) social interaction, (2) language as use in social communication or (3) symbolic or imaginative play. C. The disturbance is not better accounted for by Rhett's disorder or childhood disintegrative disorder.  18 Prognosis Autism is usually a severe disabling condition. However some children improve with acquisition with language skills & communication with others (Some will achieve independence while others will need lifelong adult supervision. Aggravation of psychiatric symptoms occurs in about half of the children during adolescence, with girls having the tendency for continued deterioration.  19 Best Educational Practices for Children with Autism Educational practices should focus on the following:  Communication skills  Behavior  Functional academics  Self-help skills  Gross and fine motor skills  Social and leisure skills  Vocational and independence  Structure, routine and organization  20 Assessment Obtain information from the family about the child’s routines; likes & dislikes, and rituals. Child’s skills and abilities regarding self care will also be evaluated. Assessment includes child’s communication skills, interactive patterns, and response to others. Question about family support.  21 Nursing diagnoses 1. Risk for injury r/t the potential for self mutilation and sensory deficits Expected outcome: The child will not harm self. 2. Impaired verbal communication r/t limited language Expected outcome: The child will develop a means of communicating needs and wants others 3. Impaired social interaction r/t inability to develop and maintain social relationships and lack of social or emotional reciprocity Expected outcome: the child will acknowledge others in the environment and will attempt to initiate interaction with them 4. Caregiver role strain r/t to the child’s need for constant care or supervision, limited ability to relate to caregivers, & increased stress Expected outcome: The caregivers will discuss their need for respite (relief) care & their feelings related to frustrations & stress in caring for a child with autism.  22 Planning & Implementation Autism is very difficult to treat because it is considered as an irreversible childhood disorder. Communication 1. Determine the most effective mode of communication will greatly aid in client interaction. 2. The nurse should speak calmly when giving instruction in direct short phrases and repeat instructions if necessary. 3. Allow adequate time for delayed responses to questions.  23 Planning & Implementation Injury 1. Provide a safe and consistent environment to prevent self- destructive behavior & to minimize unpredictable behavior due to hypersensitivity to certain stimuli. 2. Hyperactive autistic child should wear “padded, weighted vest”. Pressure from the garments helps to calm the child.  24 Planning & Implementation Social interaction  Use of social stories and comic-strip conversations  Clear “rules” for behavior  Teach scripts for initiating, commenting  Use topics of interest to engage  Use other students as models & peer buddies  Drama as an elective  Protect from bullying  25 Other interventions include special education, extended day care services and respite services for the caregivers.  26 Medication Haloperidol, risperidone and Thiodarazine may be given to provide symptomatic relief of hyperactivity, stereotypical, or self destructive behavior. Selective serotonin reuptake inhibitors (SSRIs) – reduce aggression Melatonin – to promote sleep  27 Alternative Therapies for Autistic Children 1. Several nutritional supplements have been used such as high doses of pyroxine (vit. B6) and magnesium, ascorbic acid & dimethylglycine 2. Avoidance of food allergies and intolerance are also getting much attention. 3. Avoidance of rich foods such as those containing gluten (ex. Wheat & Barley) and casein ( found in milk). Burns  A burn occurs when there is injury to the tissue of the body caused by heat, chemicals, electric current, or radiation.  Second leading cause of accidental deaths in childhood.  Burns from hot liquid are most common in children younger than age 3.  Electrical burns are common in toddlers and adolescents Risk factors  Low socioeconomic status  Single parent Diagnostic Evaluation  Calculation of Burn Area  - Lund and Browder Chart (TBSA) Schematic Classification of Burn Severity  Minor burn – 10% TBSA, 1st & 2nd degree burn  Moderate burn – 10%-20% TBSA, 2nd degree burn Major burn  20% TBSA, 2nd degree burn  All 3rd degree burns greater than 10%, depending on age of child  All burns involving hands, face, eyes, ears, feet and genitalia  All electrical burn  Complicated burn injuries involving fracture or other major trauma.  All poor risk patients ( head injury, cancer, DM) Assessment  First degree – pink to red, slight edema  2nd degree (Partial thickness)– pink or red with blisters, edematous, weeping and elastic, wound moist and painful, hair does not pull out easily, reddened areas blanch on pressure, yellowish, sensitive to touch and cold air.  2nd degree (full thickness)  – destruction of epithelial cells  - reddened areas do not blanch  - not painful  - inelastic  Color varies from waxy white to brown  Destruction of epithelium, fat, muscles, and bone. Management  Fluid Resuscitation – PLR (isotonic solution) Burn Treatment  Burn maybe treated by open or closed method.  Hydrotherapy (shower/Whirlpool bath) – treatment of choice in cleaning wound with the use of isotonic saline solution.  Debridement – removal of dead or damaged tissue. Burn Treatment  Skin grafting (Allografting/Autografting)  Bacitracin Opthalmic Ointment – if child’s face was affected to prevent conjunctivitis. Burn Treatment  Topical therapy  Silver Sulfadiazine – drug of choice  Escharotomy – cut into eschar Complications  Acute infection- sepsis, pneumonia, UTI,Shock, phlebitis  Curling’s ulcer  Paralytic Ileus  Renal failure  CNS dysfunction  Anemia  Malnutrition  depression Long Term Effects  G & D delays  Scarring, disfigurement, contractures  Psychological trauma Assessment  Initially, Perform emergency assessment of the burn to determine priorities of care.  Obtain history of the injury  Obtain complete medical history  Subsequently, focus assessment on fluid volume balance, condition of burn wound, and signs of infection.  Assess level of comfort and emotional status. Nursing Diagnosis  Decreased cardiac output  Risk for infection  Impaired gas exchange  Risk for injury  Imbalanced nutrition less than body requirements  Impaired physical mobility  Acute pain  Disturbed body image  Fear and anxiety  Impaired parenting  Supporting cardiac output  Be alert for signs and symptoms of shock (tachycardia, hypothermia, hypotension, anuria, shallow respirations).  Monitor IV fluids  Maintain and record I&O  urine output – preferred 1ml/kg/hr minimal (0.5ml/kg/hr )  Insert indwelling catheter (severe burn)  Daily weight  Monitor electrolyte and hematocrit result for fluid replacement guide  Provide a rich oxygen environment to combat hypoxia  Maintain a warm, humidified ambient environment to maintain temperature. Preventing Infection  Reverse Isolation  meticulous skin care  Administering antipruritics  Obtain serial culture  Observe burn wound with each dressing change  Administer antibiotics as ordered  Be alert for UTI and pneumonia.  Administer tetanus prophylaxis based on immunization history. Optimizing Gas Exchange  Monitor for respiratory distress  O2 therapy  Monitor ABG  Have intubation supplies available Relieving Gastric Dilation & Preventing Stress Ulcer  Maintain NPO if distention or decreased bowel sounds develop.  Insert NGT  Monitor for return of bowel sounds  Administer H2 blockers ( Cimetidine, Tagamet) Ensuring Adequate Nutrition  Be aware that hypernutrition is impt due to hypermetabolism.  - high caloric intake  - high protein  - vitamin and mineral supplement  Offer small amount of food  Give choice of food, determine favorites  Make meals a pleasant time, unassociated with treatment or unpleasant interuuptions. Ensuring Adequate Nutrition  TPN  Serum albumin or fresh frozen plasma to combat hypoalbuminemia.  Monitor nutritional status through weight Preserving Mobility  Physical and OT must begun early  Apply splints  ROM exercises  Use play therapy  Medicate for pain before therapy or exercise. Controlling Pain  Adminsiter analgesics as ordered  Provide diversional activities appropriate for age.  Relaxation techniques Preventing Negative Body Image  Encourage child to talk about the way he feels or looks  Treat the child with warmth and affection  Support child on viewing self in mirror when ready and with the presence of family members.  Encourage early contact with other children  Psychiatric consultation  Consult with plastic surgeon or burn cosmetic specialist Reducing Fear and Anxiety  Explain procedures, treatments and surgeries  Allow child to express fears through puppets, doll.  Expect regression  Parents should stay with the child  Involve in group play Promoting Effecting Parenting  Encourage counseling  Assess the effects to other children  Actively involve parents in child’s care  Keep parents informed of child’s progress  Give them time to discuss their feelings Cerebral palsy  Cerebral palsy is a comprehensive diagnostic term used to designate a group of nonprogressive disorders resulting from malfunction of the motor centers and pathways of the brain. Although there are varying degrees and clinical manifestations of cerebral palsy, it is generally characterized by paralysis, weakness, incoordination, or ataxia. Cerebral palsy occurs in approximately 2 per 1,000 live births. It is a major cause of disability among children.  Causes: prenatal factors (most common) Infection, such as rubella, toxoplasmosis, herpes simplex, and cytomegalovirus. Maternal anoxia, anemia, placental infarcts, abruptio placentae. Prenatal cerebral hemorrhage, maternal bleeding, maternal toxemia, Rh or ABO incompatibility. Prenatal anoxia, twisting or kinking of the cord. Genetic factors. Miscellaneous toxins, drugs.  Perinatal Factors Anoxia from any cause. – Anesthetic and analgesic drugs administered during labor. – Prolonged labor. – Placenta previa or abruptio placentae. – Respiratory obstruction. Cerebral trauma during delivery.  Perinatal factors Complications of birth. – Small for gestational age babies, prematurity, immaturity, postmaturity, low birth weight (especially < 1,500 g). – Hyperbilirubinemia. – Hemolytic disorders. – Respiratory distress. – Infections. – Electrolyte disturbances (hypoglycemia, hypocalcemia).  Postnatal factors Head trauma. Infections. – Meningitis. – Encephalitis. – Brain abscess. Vascular accidents. Anoxia. Neoplastic and late neurodevelopmental defects. Classification by clinical type 1.Spasticity: 40%-50%; usually appears by age 6 months Persistent primitive reflexes; delay of normal posture control, spastic paresis Arms pressed against body with forearm bent at right angle and hand flexed against forearm; in milder cases, fingers overextended and rotation of wrist on reaching Legs usually more involved than arms, but may be less involved Mild cases: wide-based gait on walking Moderate cases: slow and labored movements; walking jerky; balance poor Severe cases: unable to sit or walk unsupported Bilateral leg involvement: contractures cause scissoring (legs crossing and toes pointing 2. Dyskinetic (extrapyramidal) – Coordination & movements are affected A. Dysthnesia (Athethoid) 20%-25%; accentuated by emotional stress Involuntary extraneous motor activity known as athetosis Jerky, irregular, twisting movements of any or all extremities, especially the fingers and wrists, except when sleeping Walk writhing, lurching, stumbling with incoordination of the arms  b. Ataxia - 1%-10% Improvement when well rested and calm Difficulty achieving and maintaining balance, gross or fine motor incoordination High-stepping, stumbling, or lurching gait Nystagmus 3. Mixed – a mixture of different types of cp - A most common combination is spastic and athetoid  Topographical classificaation 1. Hemiplegia (35%-40%) – – Findings limited to one side of the body, Arm usually involved more than leg. – 2. Diplegia (10%-20%) – -Similar parts of both sides of body involved, legs usually involved more than arms. – 3. Paraplegia (10%-20%) - only legs involved – 4. Quadriplegia (15%-20%) – - All four extremities involved, upper and lower extremities affected equally – 5. Monoplegia (rare) - Only one extremity involved – 6. Triplegia (rare) - Three extremities involved  may produce hemiplegia, paraplegia, quadriplegia or diplegia.  Classification by Degree of Severity Mild Only fine precision movement is impaired Moderate Gross and fine movements and speech impaired Able to perform usual activities of daily living Severe Inability to perform adequately the usual activities of living (walking, using hands,  Clinical manifestations Early signs may include one or more of the following: Asymmetrical movements. Listlessness or irritability. Difficulty in feeding or swallowing or poor sucking with tongue thrust. Excessive, high-pitched, or feeble cry. Long, thin infants who are slow to gain weight. Poor head control. Late signs may include one or more of the following: Failure to follow normal pattern of motor development. Delayed gross motor development is a universal manifestation of cerebral palsy. Persistence of infantile reflexes. Weakness. Preference for one hand before the infant is age 12 to 15 months. Abnormal postures.  Common associated findings Seizures. Hearing deficiency. Visual defect. Perceptual disorders. Mental retardation. Language disorders. Growth disorders. Gastroesophageal reflux. Behavioral problems.  Diagnostic evaluation Thorough evaluation of prenatal, perinatal, and postnatal factors; Apgar scores. Computed tomography (CT) scan or magnetic resonance imaging (MRI) and blood testing to rule out presence of toxins, infectious processes, neoplasms. Psychological testing to determine cognitive functioning.  Correction or alleviation of specific neuromotor deficits or associated disabilities. – Administration of antispasticity medications, such as dantrolene (Dantrium) or diazepam (Valium), Baclofen. – Administration of antireflux medications, such as metoclopramide (Reglan) or bethanechol (Duvoid). – Orthopedic management of scoliosis, contractures, dislocations. – Selective dorsal rhizotomy (surgical section of a nerve root) in an attempt to decrease spasticity.  Developmental enrichment experiences. – Development of prevocational, vocational, and socialization skills. – Emotional, behavioral, and social adjustments. Family's ability to carry out supportive and participant roles in rehabilitation key determinant of the success of any comprehensive management program.  complication Contractures  Perform a functional assessment; determine ability to perform activities of daily living (ADLs). Perform a developmental assessment; Use MMDST or other screening tool. Evaluate ability to protect airway, gag reflex, swallowing. Assess nutritional status growth, signs of deficiency  Assess neuromuscular function and mobility range of motion (ROM), spasticity, coordination. Assess speech, hearing, vision. Evaluate parent-child interactions. Determine parents' understanding of and compliance with treatment plan.  Impaired physical mobility r/t neuromuscular impairment Goal - establish locomotion Interventions: – Encourage sitting, crawling, and walking at appropriate ages. – Carry out therapies that strengthen and improve control. – Assist child in using reciprocal leg motion when learning to walk. – Provide incentives to locomote. – Ensure adequate rest before attempting locomotion activities. – Incorporate play that encourages desired behavior. – Employ aids that facilitate locomotion such as parallel bars, crutches. – Prepare child and family for surgical procedures if indicated  Impaired physical mobility r/t neuromuscular impairment Goal – prevent deformity Interventions: – Apply and correctly use braces. – Carry out and teach family to perform stretching exercises. – Employ appropriate range of motion exercises. – Perform preoperative and postoperative care for child who requires corrective surgery.  Bathing/hygiene, dressing/grooming, feeding, toileting self care deficits r/t physical disability Goal : promote self –help. Interventions: – Encourage child to assist with care as age and capabilities permit. – Select toys and activities that allow maximum participation by child and that improve motor function and sensory input. – Avoid undue persistence to accomplish a goal. – Encourage activities that require both unimanual and bimanual activities.  Adapt utensils, foods, and clothing to facilitate self-help, e.g. ,large-bowled spoon with padded handle, finger foods and foods that adhere to, rather that slip from, utensil, and clothing that opens from front with self –adhering closings rather than buttons. Assist parents in toilet training the child.  Potential for injury r/t physical disability,neuromuscular impairment, perceptual and cognitive impairment Goal: prevent physical injury Interventions: – Provide safe physical environment (padded furniture, side rails on bed, sturdy furniture that does not slip, avoid scatter rugs and polished floors). – Select toys appropriate to age and physical limitations. – Encourage sufficient rest. – Use restraints when child is in chair or vehicle.  Provide child who is prone to falls with protective helmet and enforce its use. Institute seizure precautions for susceptible child. Administer anticonvulsant drugs as prescribe.  Impaired verbal communication Goal: facilitate communication Interventions: – Enlist the services of a speech therapist early. – Talk to child slowly – Use articles and pictures to reinforce speech. – Employ feeding techniques that help facilitate speech such as using lips, teeth, and various tongue movements. – Teach and use nonverbal communication methods to dysarthric child who would benefit. – Help family acquire electronic equipment to facilitate nonverbal communication (e.g., typewriter, microcomputer with voice synthesizer )  Fatigue r/t increased energy expenditure Goal: ensure balanced diet Interventions: – Provide extra calories to meet energy demands of increased muscle activity. – Monitor weight gain. – Provide vitamin, mineral, and/or protein supplements if eating habits are poor. – Devise aids and techniques to facilitate feeding.  Goal: promote relaxation Interventions: – Maintain a well regulated schedule that allows for adequate rest and sleep periods. – Be alert for incidence of fatigue, which tends to aggravate symptoms  Goal: promote general health Interventions: – Ensure regular routine health maintenance –Physical assessment –Dental care –immunizations  Body image disturbance r/t perception of disability Goal: promote a positive body image Interventions: – Capitalize on child’s assets and provide compensation for liabilities. – Praise child for accomplishments and “near” accomplishments such as partial completion of a task. – Plan activities and goals with the child.  Altered family process r/t a child with lifelong disability Encourage the parents to express their feelings about the child and cerebral palsy, and help them to deal with these feelings. Assist the parents to appraise the child's assets so they may capitalize on these positive features. – Early recognition of the extent of the child's disability and realistic direction for obtainable goals are essential. – Help the parents to recognize immediate needs and identify short-term goals that can be integrated into the long-range plan.  Acknowledge the numerous challenges of daily care of a child with cerebral palsy, and allow the parents to express frustration over the many demands and limited resources for such care. Provide positive feedback for effective parenting skills and positive approaches to caring for the child..  Assist the parents to deal with siblings' responses to the disabled child. – Encourage parents to find time to spend with each sibling separately. – Encourage family to maintain contacts with friends and community and engage in outside activities as much as possible. – Suggest family counseling  Assist the parents to secure respite care to provide a break from the day-to-day care of the child with cerebral palsy when needed. Assist parents to find local resources to help in the child's care.  Family Education and Health Maintenance Instruct the parents in all areas of the child's physical care. Encourage regular medical and dental evaluations. – The child should receive all regular immunizations. – Dental visits should occur every 6 months, starting at age 2 years. Advise parents that the child needs discipline to feel secure and relaxed. – Set realistic limits within which the child can function successfully. – Be firm but not rejecting.  Maximizing Growth and Development Evaluate the child's developmental level and then assist with tasks within that level. Provide for continuity of care at home, daycare, therapy centers, and the hospital. – Obtain a thorough history from the parents regarding the child's usual home routines, weaknesses and strengths, and likes and dislikes. – Communicate with representatives from all disciplines involved in the child's care. – Formulate a consistent care plan that incorporates the goals of all related disciplines and meets the needs of the child and family. Include in the care plan guidelines for the following: Feeding. Sleeping. Physical therapy. Play. Other ways to foster growth and development. Special interests and emotional needs such as use of security objects During feeding, maintain a pleasant, distraction-free environment. – Provide a comfortable chair. – Serve the child alone, initially. After the child begins to master the task of eating, encourage the child to eat with other children. – Do not attempt feedings if the child is very fatigued. – Find the eating position in which the child can be most self-sufficient. – Allow the child to hold the spoon even if self-feeding is minimal. – Stand behind and reach over the child's shoulder to guide the spoon from the plate to the child's mouth. – Serve foods that stick to the spoon, such as thick applesauce or mashed potatoes. – Encourage finger foods that the child can handle alone. – Provide appropriate assistive devices for independent feeding, such as spoon and fork with special handles, plate and glass holders, and special feeding chair. – Disregard messy eating; use a large plastic bib, smock, or towel to protect the child's clothes.  If the child must be fed, do so slowly and carefully. Be aware of difficulty sucking and swallowing caused by poor muscle control. – Cut solid foods into small pieces. – Place the food back on the tongue for ease in swallowing. Be alert for associated sensory deficits that delay development and could be corrected. – Hearing, speech, vision. – Squinting, failure to follow objects, or bringing objects very close to the face. CHILD MALTREATMENT Child Maltreatment Includes intentional physical abuse, emotional abuse or neglect, and sexual abuse of children, usually by adults. Child Neglect Is the most common form of maltreatment, and more than 80% of cases involve children less than 4 years of age. Refers to failure of a parent or other person legally responsible for the child’s welfare to provide for the child’s basic needs and an adequate level of care. Contributing factors of child neglect Lack of knowledge of child’s needs Lack of resources Caregiver substance abuse Types of Neglect Physical neglect – involves deprivation of necessities such as food, clothing, shelter, supervision, medical care education. Emotional neglect – failure to meet the child’s needs for affection, attention and emotional nurturance. Neglect may also include lack of interventions for or fostering of maladaptive behavior such as delinquency or substance abuse. Emotional Abuse Deliberate attempt to destroy or significantly impair a child’s self-esteem or competence. May take the form of rejecting, isolating, terrorizing, ignoring, corrupting, verbally assaulting or overpressuring the child. Physical Abuse Deliberate infliction of physical injury on a child, usually by the child’s caregiver. Can involve anything from bruises and fractures to brain damage. Predisposing factors to child abuse PARENTAL CHARACTERISTICS: Younger parents Single parent families Parents with substance abuse problems Parents with low self-esteem and little knowledge of appropriate parenting skills. Abusive families are often socially isolated and have few supportive relationships. Abusers were abused or observed some types of abuse in their home. Predisposing factors to child abuse CHARACTERISTICS OF THE CHILD: Children from birth to 1 year Children with disabilities Premature infants CONTRIBUTING FACTORS Disciplinary action Quarrel between caretakers (marital discord) Stress ( debt, poverty, illness, unemployment) Alcohol or drug intoxication Surrogate caregiver Lack of effective parenting, inappropriate parent-child bonding, and punitive treatment Sexual Abuse TYPES: 1. Incest – any physical sexual activity between family members; blood relationships is not required. 2. Molestation – indecent liberties such as touching, fondling, kissing, masturbation, oral-genital contact. 3. Exhibitionism – indecent exposure of a genitalia by an adult man to children or women. 4. Child pornography – arranging or photographing in any media, sexual acts involving children, alone or with animals or adults, regardless of consent by the child’s legal guardian. Sexual Abuse 5. Child prostitution – involving children in sex acts for profit and usually with changing partners. 6. Pedophilia – preference of an adult for prepubertal children as the means of achieving sexual excitement. Characteristics of Abusers and Victims Have full time jobs Active in the community May not have prior criminal records Employed or volunteers in positions such as teaching & coaching. Incestuous relationship between fathers/stepfather & daughter are generally prolonged Boys (victim of intrafamilial or extrafamilial abuse) Significant risk factors for child abuse Parental unavailability Lack of emotional closeness and flexibility Social isolation Emotional deprivation Communication difficulties Note: most sexual abuse is committed by men and by persons known to child. Management Goal: Ensure emotional and physical safety of the child Rehabilitation of parents Cleft Lip and Palate  Cleft Lip O Is a congenital anaomaly involving one or more clefts in upper lip. O Degree of cleft varies from a small notch to a complete separation.  Cleft Palate O Is a congenital anomaly consisting of a cleft ranging from soft palate involvement alone to a defect including hard palate and portions of maxilla in severe cases.  Etiology O Hereditary O Environmental- antiepileptic drug, smoking, etc. O Teratogenic factors O Cleft lip occurs approximately 1 in every 1000 births; more common in boys. O Cleft palate in 1 in 2,500 births; incidence is double in girls.  Pathophysiology O These defects occur during embryonic development. O Cleft lip results from failure of fusion of lateral and medial tissues forming upper lip occurring around 7 weeks of gestation. O Cleft palate is a failure of fusion of tissues forming palate which occurs around 9 weeks gestation.  Assessment O These defects are readily apparent at birth O 1. cleft lip involves a notched upper lip border, nasal distortion and may include unilateral or bilateral involvement. O 2. cleft palate is a visible palpable gap in ovula, soft palate, hard palate, and/or incisive foramen with exposed nasal cavities and associated nasal distortion. O Careful PA to rule out other midline birth defects.  Nursing Diagnosis O Ineffective airway clearance O Ineffective family processes O Risk for infection O Risk for injury O Deficient knowledge O Imabalance nutrition: less than body requirements O Pain  Planning O Surgical repair would depend on severity of defect and general health of child. O Surgical correction of cleft lip is typically done at 1-2 months. O Cleft palate is generally repaired between age 6 and 18 months. O Cleft palate maybe corrected through several operations performed in stages. Preoperative Nursing Care O Assess respiratory status continuously diring feedings. O Feed infant in upright position O Feed slowly (18-30mins.) and burp frequently O Use ESSR( Enlarged nipple, Stimulate suck by rubbing nipple on lower lip, Swallow, Rest after each swallow to allow for complete swallowing) O Use crosscut nipple O Use alternative feeding devices such as elongated nipple (lamb’s nipple) or breast shield. Preoperative Nursing Care O Using a squeezable bottle (eg, Mead Johnson Cleft Palate Nurser) or plastic liner can be helpful by applying rhythmic pressure along with the infant's normal sucking and swallowing. O Using a squeezable bottle (eg, Mead Johnson Cleft Palate Nurser) or plastic liner can be helpful by applying rhythmic pressure along with the infant's normal sucking and swallowing. Preoperative Nursing Care O Avoid repeated removal of nipple due to fear of choking. This may only frustrate the infant, causing crying and increasing chances of aspiration. Preoperative Nursing Care O Assess degree of cleft and ability to suck. O Provide post-operative feeding instructions O Encourage parents to verbalize fears, concerns, negative emotions. O Facilitate grief responses of shock, denial, anger and mourning. Preoperative Nursing Care O Encourage touching, holding, cuddling and bonding. O Provide parents with pictures of other children before and after surgical repair. O Discuss infant’s positive characteristics. O Refer to community resources and parent support group.  Postoperative Care O Monitor child for respiratory distress O Encourage deep breathing without placing stress on suture line. O No oral temperature taking O Advance feedings as tolerated O No straws, pacifiers, spoon, or fingers in or around the mouth for 7-10 days. O For cleft lip resume preoperative feeding techniques.  Postoperative Care O Cleft palate O Liquids can be taken from a cup O Soft foods can be taken off side of spoon O Child is not allowed to feed himself/herself to reduce risk if injury.  Postoperative Care O Clean lip from suture line out after feedings and PRN. O Apply antibacterial ointment as ordered O Use elbow restraint to keep infant from putting fingers in mouth or touching surgical site. O No toothbrushing for 1-2 weeks  Postoperative Care O Place infant in side lying position on unaffected side to avoid excessive contact with bed linens. O Monitor site for redness, swelling, excess bleeding, purulent drainage, or fever. O Assess pain using appropriate tools O Provide comfort measures to decrease stress, such as crying, on suture line; encourage rocking, cuddling, and holding.  Postoperative Care O Provide analgesics and sedatives on a scheduled basis. O Provide age-appropriate activities for diversion. Child and Family Education O Teach precautions to prevent aspiration of formula. O Provide instruction on CPR O Teach parents safety and care issues regarding the use of restraints. O 1. do not apply too tightly. O 2. remove at least ever 2H & play games to encourage flexion. O 3. remove only 1 restraint. Child and Family Education O Stress importance of follow-up care and referral appointments. O Make appropriate and early referrals for speech therapy. O Encourage good dental hygiene and orthodontic follow-up.  It is also important to remember that not all fussy babies suffer from colic. Most Infants normally cry 2-3 hours per day, but this is usually spread out during the 24-hour period.  Abdominal discomfort and intestinal gas (e.g., caused by abnormally rapid digestion [hyperperistalsis], or high levels of intestinal hormones, such as motilin) Allergy or intolerance to formula or breast milk Hunger or overfeeding Immature digestive system or central nervous system Oversensitivity to stimulation (e.g., activity, excitement, anxiety)  Allergy Paroxysmal Crying Infant temperament >3 Hrs/day Swallowed air >3 days/week First 3 months Emotional tension Infantile colic typically begins at about 2 to 3 weeks of age, reaches its peak at 2 months, begins to subside by 3 months, and is gone by 3 ½ to 4 months of age The crying or fussing most frequently begins suddenly, and often after a feeding. The cry is loud and continuous, and the spells last from one to four hours. The baby's face often gets flushed or red. The belly is sometimes distended or prominent, the legs alternating between flexed and extended straight out; the feet are often cold and the hands clenched. The episodes, while they can occur at any time of the day or night, typically begin in the late afternoon or early evening, just when parents or caregivers are most exhausted. Crying is often unrelieved by parental interventions and leads to frustration and feelings of helplessness 1. Change to a casein hydrolysate formula. E.g. Nutramigen, Pregestimil, Alimentum. 2. Breast-feeding mothers are instructed to avoid milk products. 3. Medications: Simethicone drops, phenobarbital, chloral hydrate. Pain related to abdominal cramps secondary to cow’s milk sensitivity, overstimulation of immune central nervous system. 1. Assess timing of the crying spells: relationship to eating is going on in the home at the time. 2. Assess the infants current diet. 3. If breast-feeding, assess mothers diet for foods that may be upsetting. 4. Assist the mother to change her diet for a few days to see if this helps. 5. Teach parent to carry the infant in front- carrier or wrapped in a shawl held closely against the chest. 6. Suggest other comfort methods for the parents to try. 7. Inform parents about OTC drops that may decrease gas. 8. Instruct parents to consult the primary caregiver if these actions don’t help or infant fails to gain weight, vomits, etc.  Impaired parenting r/t difficult to console infant; young, inexperienced parents 1. assess parenting behaviors by observations and questioning. Observe for eye contact, physical touch, how the parent speaks and tries to comfort the infant. Note the reciprocal interactions between the parent and infant. 2. ask parents to describe their baby and his behavior. E.g. who is he like? Does he like to be held or prefer being wrapped tightly? 3. encourage the family to explore problem infant behaviors: when does it happen? What is going on? What interventions have the parents tried and what has been the result? 4. encourage parents to express their frustrations with the infant and the parent role. Indicate that they are not alone in feeling irritated and discouraged at times. 5. teach family about normal infant development. Inform them that colic may be a result of too much stimulation and generally disappears by 3 months of age. 6. suggest changing the infant’s schedule to decrease stimulation in the afternoons. Ask parents to identify how they might do this. 7. discuss the infant’s need for appropriate parenting in order to develop a sense of security and trust. Specify that the infant’s needs should be met in a consistent and timely manner. 8. discuss family beliefs about discipline. Stress that the infant is too young for any form of discipline. Ask family to verbalize understanding. 9. ask the family to identify their support system. Who takes care of the baby? Is there a trusted person who could care for the baby while the parents take a break? 10. suggest that the parents plan sometime away from the infant during his colicky periods. Ask a friend or relative to watch the baby while parents go for a walk or out to a movie. Explain that the baby may cry. 11.Teach the parents that colic usually abates by 3 months of age without any harm to the infant.  12. offer parents for positive parenting that the parents exhibit. Reinforce the need to protect the infant and ask the parents to agree to provide safe care for their baby.. 13. refer parents to local parenting resources/classes or online resources if available.  Other nursing diagnosis Anxiety r/t perceived threat to infant’s well-being Health seeking behaviors r/t lack of knowledge of infant health promotion DYSMENORRHEA SIGNS AND SYMPTOMS Cramping Abdominal pain Backache Leg ache PRIMARY DYSMENORRHEA Is painful menses not related to any pelvic disease. The pain begins with menstrual flow or hours before the onset of bleeding each month, usually continuing for 48-72 hours. The exact etiology is widely debated. The pain is clearly related to ovulatory cycles. The overproduction of uterine prostaglandins has been implicated, and women with dysmenorrhea have higher levels of prostaglandins. Overproduction of vasopressin(a hormone that stimulates the contraction of muscular tissue) may also contribute to dysmenorrhea. SECONDARY DYSMENORRHEA When the discomfort is related to endometriosis, infection, adhesions from peritonitis, or other pelvic disease. THERAPEUTIC MANAGEMENT THE GIRL SHOULD BE INSTRUCTED TO BEGIN THE MEDICATION AT THE FIRST SIGN OF CRAMPING OR BLEEDING. GIRLS WITH VOMITING AT THE TIME OF MENSTRUATION BENEFIT FROM BEGINNING THE MEDICATION 1-2 DAYS BEFORE THE ONSET OF THEIR MENSES. THE MEDICATIONS SHOULD BE TAKEN WITH FOOD. CYCLIC ESTROGEN THERAPY AND ORAL CONTRACEPTIVES ARE ALSO EFFECTIVE. SIMPLE EXERCISES SUCH AS PELVIC ROCKING, ASSUMING THE KNEE-CHEST POSITION, AND BREATHING EXERCISES MAYBE BENEFICIAL. ENCOURAGING ADEQUATE PERSONAL HYGIENE, PARTICIPATION IN REGULAR ACTIVITIES, AND METHODS TO DECREASE STRESS SHOULD BE DISCUSSED WITH THE ADOLESCENT. A BALANCED DIET AND SPECIFIC DIETARY CHANGES THAT MAYBE HELPFUL INCLUDE THE ELIMINATION OF CAFFEINE FROM THE DIET AND ADDITION OF HERBAL TEAS. MANY DIETARY AND HERBAL TREATMENTS HAVE BEEN TRIED INCLUDING VITAMINS B12, B6, AND E, OMEGA-3 FATTY ACIDS, AND MAGNESIUM. VITAMIN B12 100 MG DAILY, IS THE ONLY DIETARY TREATMENT WITH A LARGE CLINICAL TRIAL TO DEMONSTRATE ITS EFFECTIVENESS. USE OF MAGNESIUM HAS SHOWN PROMISE IN SMALLER STUDIES. NURSING CARE MANAGEMENT ALL ADOLESCENT NEED REASSURANCE THAT MENSTRUATION IS A NORMAL FUNCTION. HEALTH TEACHINGS ON MENSTRUAL PHYSIOLOGY AND HYGIENE, AS WELL AS THE IMPORTANCE OF A WELL-BALANCED DIET, EXERCISE, AND GENERAL HEALTH MAINTENANCE. HEALTH TEACHING CAN DISPEL MYTHS ABOUT MENSTRUATION AND FEMININITY. WHEN ASSESSMENT INDICATES A POTENTIAL PROBLEM AND THE NEED FOR EVALUATION, REFERRAL TO AN APPROPRIATE PRACTITIONER, HEALTH SERVICE, OR CLINIC MAY BE NECESSARY. ONE OF THE MOST DIFFICULT EXPERIENCES FACING THE ADOLESCENT GIRL IS THE GYNECOLOGIC EXAMINATION. WHETHER IT IS HER FIRST EXPERIENCE OR NOT, SHE IS OFTEN FILLED WITH APPREHENSION. ALMOST ALL ADOLESCENTS ARE EXTREMELY SELF-CONSCIOUS ABOUT THEIR BODIES AND THE CHANGES TAKING PLACE. THEY NEED CONTINUING SUPPORT IN THE FORM OF ANTICIPATORY GUIDANCE REGARDING WHAT TO EXPECT AND SUGGESTIONS OF WHAT TO DO TO RELAX DURING THE PROCEDURE. USUALLY THE STRESSFUL EXPERIENCE OF BEING PLACED IN STIRRUPS FOR PELVIC EXAMINATION CAN BE AVOIDED. THE ADOLESCENT GIRL WHO IS RELAXED MAY BE EXAMINED IN THE SUPINE POSITION WITH HIPS AND KNEES ABDUCTED. IF A FEMALE NURSE IS NOT THE EXAMINER, IT IS ESSENTIAL FOR HER TO REMAIN WITH THE PATIENT DURING THE EXAMINATION TO OFFER SUPPORT AND GUIDANCE. DYSMENORRHEA SIGNS AND SYMPTOMS Cramping Abdominal pain Backache Leg ache PRIMARY DYSMENORRHEA Is painful menses not related to any pelvic disease. The pain begins with menstrual flow or hours before the onset of bleeding each month, usually continuing for 48-72 hours. The exact etiology is widely debated. The pain is clearly related to ovulatory cycles. The overproduction of uterine prostaglandins has been implicated, and women with dysmenorrhea have higher levels of prostaglandins. Overproduction of vasopressin(a hormone that stimulates the contraction of muscular tissue) may also contribute to dysmenorrhea. SECONDARY DYSMENORRHEA When the discomfort is related to endometriosis, infection, adhesions from peritonitis, or other pelvic disease. THERAPEUTIC MANAGEMENT THE GIRL SHOULD BE INSTRUCTED TO BEGIN THE MEDICATION AT THE FIRST SIGN OF CRAMPING OR BLEEDING. GIRLS WITH VOMITING AT THE TIME OF MENSTRUATION BENEFIT FROM BEGINNING THE MEDICATION 1-2 DAYS BEFORE THE ONSET OF THEIR MENSES. THE MEDICATIONS SHOULD BE TAKEN WITH FOOD. CYCLIC ESTROGEN THERAPY AND ORAL CONTRACEPTIVES ARE ALSO EFFECTIVE. SIMPLE EXERCISES SUCH AS PELVIC ROCKING, ASSUMING THE KNEE-CHEST POSITION, AND BREATHING EXERCISES MAYBE BENEFICIAL. ENCOURAGING ADEQUATE PERSONAL HYGIENE, PARTICIPATION IN REGULAR ACTIVITIES, AND METHODS TO DECREASE STRESS SHOULD BE DISCUSSED WITH THE ADOLESCENT. A BALANCED DIET AND SPECIFIC DIETARY CHANGES THAT MAYBE HELPFUL INCLUDE THE ELIMINATION OF CAFFEINE FROM THE DIET AND ADDITION OF HERBAL TEAS. MANY DIETARY AND HERBAL TREATMENTS HAVE BEEN TRIED INCLUDING VITAMINS B12, B6, AND E, OMEGA-3 FATTY ACIDS, AND MAGNESIUM. VITAMIN B12 100 MG DAILY, IS THE ONLY DIETARY TREATMENT WITH A LARGE CLINICAL TRIAL TO DEMONSTRATE ITS EFFECTIVENESS. USE OF MAGNESIUM HAS SHOWN PROMISE IN SMALLER STUDIES. NURSING CARE MANAGEMENT ALL ADOLESCENT NEED REASSURANCE THAT MENSTRUATION IS A NORMAL FUNCTION. HEALTH TEACHINGS ON MENSTRUAL PHYSIOLOGY AND HYGIENE, AS WELL AS THE IMPORTANCE OF A WELL-BALANCED DIET, EXERCISE, AND GENERAL HEALTH MAINTENANCE. HEALTH TEACHING CAN DISPEL MYTHS ABOUT MENSTRUATION AND FEMININITY. WHEN ASSESSMENT INDICATES A POTENTIAL PROBLEM AND THE NEED FOR EVALUATION, REFERRAL TO AN APPROPRIATE PRACTITIONER, HEALTH SERVICE, OR CLINIC MAY BE NECESSARY. ONE OF THE MOST DIFFICULT EXPERIENCES FACING THE ADOLESCENT GIRL IS THE GYNECOLOGIC EXAMINATION. WHETHER IT IS HER FIRST EXPERIENCE OR NOT, SHE IS OFTEN FILLED WITH APPREHENSION. ALMOST ALL ADOLESCENTS ARE EXTREMELY SELF-CONSCIOUS ABOUT THEIR BODIES AND THE CHANGES TAKING PLACE. THEY NEED CONTINUING SUPPORT IN THE FORM OF ANTICIPATORY GUIDANCE REGARDING WHAT TO EXPECT AND SUGGESTIONS OF WHAT TO DO TO RELAX DURING THE PROCEDURE. USUALLY THE STRESSFUL EXPERIENCE OF BEING PLACED IN STIRRUPS FOR PELVIC EXAMINATION CAN BE AVOIDED. THE ADOLESCENT GIRL WHO IS RELAXED MAY BE EXAMINED IN THE SUPINE POSITION WITH HIPS AND KNEES ABDUCTED. IF A FEMALE NURSE IS NOT THE EXAMINER, IT IS ESSENTIAL FOR HER TO REMAIN WITH THE PATIENT DURING THE EXAMINATION TO OFFER SUPPORT AND GUIDANCE.  Failure to Thrive The child with a Psychosocial Disorder 1 2 Definition  Children whose weight is significantly lower than norms for their age and gender  Growth noted to be low or decreased over time  Height or weight less than 3rd of 5th percentiles for age >once  Height or weight measurements falling 2 major percentile lines on the growth chart  Weight Altered parenting r/t - knowledge deficit - poverty 17 Expected outcomes 1. Child gains weight (specify; usually a minimum of 1 to 2 oz/day). 2. Child displays a positive response to interventions (ex. Social smile) 3. Family demonstrates ability to provide appropriate care to child. 4. Family experiences reduction of anxiety and follows through on programs and activities. 18 Plan of care & Implementation  The highest goal is providing an infant with sufficient nutrient for growth.  Parental education.  When serious psychosocial factors are involved, hospitalization is needed and additional interventions are required to meet the needs of both the child and family. 19 Goals for hospitalized child  The child will experience weight gain.  The child will demonstrate positive response to develop mental stimulation.  The family will demonstrate ability to provide appropriate care to the child.  The family will receive adequate support and home services. 20 Feeding children with NFTT  Provide a primary core staff to feed the child.  Provide a quiet, unstimulating atmosphere.  Maintain a calm, even temperament throughout the meal.  Talk to the child by giving directions about eating. “take a bite, Lisa” is appropriate and directive.  Be persistent. This is perhaps one of the most important guidelines. 21 Feeding children with NFTT  Maintain a face- to –face posture with the child when possible.  Introduce new foods slowly.  Follow the child’s rhythm of feeding  Develop a structured routine.  Feed on demand or increase intake as tolerated  Offer frequent, small portions of a wide variety of foods.  Offer high protein, high caloric snacks 22 Interventions  Ensure adequate nutrition- keep careful record of intake and output so that the number of calories being consumed everyday can be evaluated.  Nurture the child- because child with failure to thrive are suffering from emotional deprivation, they need parenting nurses to care for them.  Support and encourage parents- encourage them to visit as much as possible while the child is hospitalized. Give them some suggestions about how the child communicates. “look how he turns his head at the sound of your voice. He recognize you” Evaluation  Effectiveness of nursing interventions is determined by continual reassessment and evaluation of care, based on the following observational guidelines and expected outcomes. 1. Record weight and caloric intake daily; document child’s reaction to feeding environment; review notes to see whether changes were made as necessary to improve eating and whether consistent group of nurses fed the child. 2. Perform developmental screening test as needed. 25 Evaluation 3. Document parent’s relationship with the child, staff, and other supportive individuals. Note length of time parents visit, appointments kept with referrals services, and any request for help. 4. Keep a record of all patient teaching and note whether outcome behaviors are met. 26 Febrile seizures  definition Is a seizure associated with a febrile illness in the absence of a central nervous system infection in children older than 1 month of age without prior neonatal or unprovoked seizures and not meeting the criteria of other acute seizures.  Most common neurologic conditions of childhood affecting 4% of children. Occur after 6 months of age and before age 5 years, with the average age of onset at 18 months of age. Boys and girls are affected similarly, but there appears to be an increased familial susceptibility.  The cause is still unknown.  Signs and symptoms Temp. exceeds 101.8 degree Fahrenheit (38.8 degree Celsius) Seizure occurs during the rise rather than after a prolonged elevation. Alert: if a febrile seizure lasts more than 5 minutes, parents should seek medical attention right away.  Pharmacologic Management Seizure – IV or rectal diazepam Fever – acetaminophen or ibuprofen  Family Education and Health Maintenance Discuss and demonstrate emergency management of seizures. – The child should be positioned on the side, on a flat surface from which he or she cannot fall. – The surface should be padded, if possible, to prevent injury. – An adult should stay with the child to monitor the airway and breathing until the seizure is complete. – If the child vomits, immediately clear the mouth of all foreign material.  Nursing intervention Ensuring Safety during a Seizure Use preventive measures. – Remove hard toys from the bed. – Pad the sides of the crib or side rails of the bed. – Have a suction machine available to remove secretions during a seizure. – Have an emergency oxygen source in the room in case of sudden respiratory difficulty. Make sure the child can be readily observed.  During a seizure, monitor vital signs and assess neurologic status frequently. After a seizure, check the child frequently and report the following: – Behavior changes. – Irritability. – Restlessness.  Preventing Respiratory Arrest and Aspiration During a seizure, take the following emergency actions: – Clear the area around the child. – Do not restrain the child. – Loosen the clothing around the neck. – Turn the child on side so saliva can flow out of the mouth. – Place a small, folded blanket under the head to prevent trauma if the seizure occurs when the child is on the floor.  Suction the child, and administer oxygen as necessary. Do not give anything by mouth or attempt to place anything in the mouth. After the seizure, place the child in a side-lying position. HIRSCHSPRUNG Hirschsprung’s disease is a congenital anomaly resulting from an absence of ganglion cells in colon. Also known as megacolon and congenital aganglionosis ETIOLOGY It is believed to be familial, congenital defect Rate of occurrence is about 1 in 500 live births and is about 4 times more common in males than in females; there is a higher incidence in children with Down Syndrome and genitourinary abnormalities. Rectosigmoid region is most commonly affected Health y large intesti ne: Nerve cells are found through out the intestin e. Hirschs prung's disease large intestin e: Nerve cells are missing from the last part of the intestin e. Sometimes the ganglion cells are missing from the whole large intestine and even parts of the small intestine before it. long-segment disease - when the diseased section reaches to or includes the small intestine. short-segment disease. When the diseased section includes only part of the large intestine.  An arrest in embryologic development affecting the migration of parasympathetic nerve innervation of the intestine. No peristalsis occurs in the affected portion of intestine (ie, spastic and contracted). This section is usually narrow · Filled with fecal material & gas · Hypertrophy of muscular coating · Ulceration of mucosa ASSESSMENT Clinical manifestations vary according to child’s age at time of diagnosis 1. Newborns Failure to pass meconium Reluctant to ingest fluids Abdominal distention 2. infants FTT Constipation Abdominal distention Vomiting Episodic diarrhea (ribbon –like stool or fluid filled) 3.Toddlers and older children Chronic constipation Foul-smelling stool Abdominal distention Visible peristalsis Palpable fecal mass Malnourishment Signs of anemia and hypoproteinemia Rectal examination typically reveals an absence of stool Laboratory studies and diagnostic tests commonly reveal an enlarged portion of colon and a rectal biopsy confirms absence of ganglion cells. COMPLICATIONS Infection bursting of the colon death NURSING DIAGNOSIS Constipation Risk for deficient fluid volume Impaired skin integrity Risk for infection Imbalanced nutrition: less than body requirements Disturbed body image PLANNING AND IMPLEMENTATION Medical treatment involves removing aganglionic bowel; a temporary colostomy is created soon after diagnosis or around 6 months ; this colostomy will be closed and the bowel reanastomosed at a later time , usually around age of 2 years; older children and some infants will just have one surgery which is pull through at the time of diagnosis. Preoperatively, assess bowel function and characteristics of stool; measure abdominal circumference; monitor the child for vomiting and respiratory distress. Monitor urine specific gravity; monitor electrolytes; assess hydration status Prepare child for surgery and temporary placement of colostomy Administer antibiotics as ordered Monitor vital signs; measure abdominal girth; assess surgical site for redness, swelling, drainage after surgery. Assess stoma for color, bleeding, breakdown of surrounding skin Assess anal area after pull-through for patency of appliance, presence of stool, redness, drainage Provide meticulous skin care, use appropriately sized stoma supplies Notify physician of any fever, unusual drainage, redness , or odor Keep child on NPO until bowel sounds return or flatus is passed, maintain NG tube, administer IV fluids as ordered, obtain daily weights, and begin with clear liquids and progress as tolerated. Assess pain using age-appropriate scales, provide comfort measures and involve parents, provide pain medications on regular basis as ordered, notify physician if pain is not managed Involve child in quiet age-appropriate activities for diversion Assess parents’ level of understanding of condition, home care, and treatment, encourage parents to share feelings, anxieties, and concerns about rectal irrigations and ostomy care, explain surgical repair and recovery process. CHILD AND FAMILY EDUCATION Encourage preschool and early school-age children to draw pictures, use dolls, and play to express concerns about bodily appearance, irrigations, and colostomy. Provide parents with instructions about how to complete rectal irrigations and allow time for return demonstration. Teach ostomy care during immediate postoperative period and encourage parents to participate and learn while in hospital, encourage child to assume care as soon as possible. Teach parents how to assess for distention and obstruction , and importance of reporting these Hydrocephalus  Description Hydrocephalus is a condition characterized by imbalance between CSF production and absorption resulting in enlarged ventricles and an increased ICP; if untreated this condition can cause permanent brain damage.  There are four ventricles in the human brain. CSF is formed by structures within these ventricles. Once formed, CSF circulates among all the ventricles before it is absorbed and returned to the circulatory system. When the ventricles are obstructed, the CSF cannot circulate and be absorbed. An elevated level of CSF in the brain leads to pressure within the ventricles. This pressure pushes against the soft tissues of the brain, resulting in damage to these tissues.  types 1. Communicating hydrocephalus is the most common type and exists when one or more passages connecting the ventricles become blocked. This blockage prevents the movement of CSF to its drainage sites in the subarachnoid space just inside the skull. 2. Non-communicating hydrocephalus - the tissue within the brain responsible for absorption of CSF is damaged.  Etiology/pathophysiology Congenital Can be acquired from meningitis, trauma, or intraventricular hemorrhage in premature infants Etiology is idiopathic in up to 50 %  assessment For infants, increased head circumference, split cranial sutures, high-pitched cry, bulging fontanels, irritability when awake and seizures. Toddlers and older children may also present setting-sun eyes, seizures, irritabilty, papilledema, decreased LOC, and change in vital signs (increased BP and widening pulse pressure)  All children can present with vomiting, lethargy, and cheyne-stokes respiratory pattern. Diagnosis confirmed by CT scan and MRI to reveal location of CSF obstruction Transillumination – skull filled with fluid  Priority nursing Diagnosis Ineffective tissue perfusion:cerebral Risk for infection Risk for impaired skin integrity r/t large size of head and inability to move  Planning and Implementation Surgical insertion of tube or shunt into ventricles with the end in either the peritoneum or atrium; the most common version is ventriculoperitoneal shunt. Preoperatively monitor child for symptoms of increased ICP  Postoperatively, position child flat and on unoperative side; if held, it is important not to allow the head to be elevated. Postoperatively, monitor child for symptoms of infection; notify physician if symptoms are present: fever, change in LOC, excessive redness at incision site or along shunt tract, elevated WBC count with leukocytosis  Medication therapy Client may be on prophylactic antibiotics postoperatively  Child and family education Teach caregiver symptoms of shunt infection and malfunction and what actions to take should symptoms develop.  Signs of shunt malfunction 1. infant whose cranial suture lines have not fused; signs include increased in head circumference, high-pitched cry, bulging fontanel, irritability when awake, and seizures.  Toddlers and older children display vomiting, irritability, and headache; as condition persists, sunsetting eyes, seizures, papilledema, decreased LOC, and change in vital signs (increased BP and widening of pulse pressure) occur.  Older children have difficulty with balance and coordination. All children may have lethargy and Cheyne- Stokes respiration  Some children with hydrocephalus have brain damage that results in motor, language, perceptual, and intellectual disabilities; parents may need referrals to early intervention professionals to provide long- term rehabilitation services.  Children with hydrocephalus and myelomeningocele have increase risk of latex allergies; teach parents to avoid nipples, pacifiers and toys made of latex products. IMPERFORATE ANUS  Malformations of the anal opening (imperforate anus) occur as often as 1 in 5,000 births.  The obvious lack of an anal opening in the newborn is simple to recognize, but imperforate anus also occurs as a blind rectal opening.  Frequently, a fistula accompanies the malformation from the distal part of the rectum into the perineum or genitourinary system. Anomalies associated with anorectal malformations  VACTERL syndrome: vertebral, anorectal, cardiovascular, tracheoesophageal, renal, and limb.  Esophageal atresia  Intestinal atresia  Malrotation  Renal agenesis  Hypospadias  Vesiculoureteral reflux  Bladder exostrophy  Cardiac anomalies  Skeletal anomalies TYPES  1.High lesions –the colon is higher up in the pelvis and may end with a fistula from the bowel to the bladder, urethra or vagina.  This type necessitates a colostomy to divert the colon to a stoma for a period of time after anorectoplasty is performed in order to allow healing to occur. 2. Low lesions – the colon remains close to the skin. There may be stenosis of the rectum or anus is missing altogether with rectum ending a blind pouch. have a perineal fistula, and dilation of fistula can be performed to correct the lesion. Some infants require a staged repair in which the bowel is connected to the anal opening is created. Often several corrective surgeries must be performed to correct the genitourinary problems associated with imperforate anus. Low lesion High lesion Assessment  1. Assess for signs and symptoms of intestinal obstruction:  abdominal distention  Bilious vomiting  Newborn: observe for appropriate anal opening  - if anal opening exists, observe for a meconium  stool to be passed within 24 hours of life.  2. Assess urine output to identify genitourinary problems Nursing management  Preoperative: provide IV fluids, on NPO status to decrease intestinal motility.  Postoperative:  1. Teach colostomy care to the family whose child required a permanent or temporary colostomy for passage of stool.  2. Assess for and teach the parents about post-op complications, including strictures, prolapse, constipation, or incontinence.  3. Review long-term care regarding bowel incontinence with the family; the child with a high lesion may have problems with fecal incontinence up to school age.  After the intestinal pull-through procedure is done when the infant is several months old, it will be the first time that stool has passed through the anal sphincter.  The stool may be quite loose depending on the severity of the imperforate anus.  The perineal skin is at significant risk for breakdown, so a barrier cream should be used on that area and it should be cleaned once daily with soap and water. Otherwise, wipe liquid stool off the barrier cream with mineral oil and cotton balls. Most of the barrier cream will remain intact, protecting the infant’s perineal area.  IS AN INVAGINATION OR TELESCOPING OF ONE PORTION OF THE INTESTINE INTO ANOTHER.  CHILDREN BETWEEN 3-12 MONTHS OF AGE.  MALES  CYSTIC FIBROSIS  CELIAC DISEASE  ILEOCOLIC – THE MOST COMMON SITE IN WHICH THE ILEUM INVAGINATES INTO THE CECUM AND THEN FURTHER INTO THE COLON.  ILEOILEAL – ONE PART OF THE ILEUM INVAGINATES INTO ANOTHER SECTION OF THE ILEUM.  COLOCOLIC – ONE PART OF THE COLON TELESCOPES INTO ANOTHER AREA OF THE COLON.  AS A RESULT OF INVAGINATION, THERE IS OBSTRUCTION TO THE PASSAGE OF INTESTINAL CONTENTS BEYOND THE DEFECT.  IN ADDITION, THE TWO WALLS OF THE INTESTINE PRESS AGAINST EACH OTHER , CAUSING INFLAMMATION, EDEMA, AND EVENTUALLY DECREASED BLOOD FLOW.  AS INCARCERATION CONTINUES, NECROSIS RESULTS WITH HEMORRHAGE, PERFORATION, AND PERITONITIS.  Invagination Obstruction to the passage of intestinal contents beyond the defect 2 walls of the intestine press against each other Inflammationedema decreased blood flow Necrosis Hemorrhage Perforation peritonitis  SUDDEN EPISODE OF ACUTE ABDOMINAL PAIN.  TYPICAL BEHAVIOR INCLUDES SCREAMING AND DRAWING THE KNEES UP TO THE CHEST.  THESE EPISODES OF SEVERE PAIN ARE CHARACTERIZED BY INTERVALS IN WHICH THE CHILD APPEARS NORMAL AND COMFORTABLE. DURING THE INITIAL PERIOD: - VOMITING OCCURS AND THE CHILD PASSES ONE NORMAL BROWN STOOL. AS THE CONDITION WORSENS, THE VOMITING INCREASES, THE CHILD BECOMES APATHETIC, AND SUBSEQUENT STOOLS ARE RED AND CURRANT JELLY-LIKE FROM THE PASSAGE OF STOOL MIXED WITH BLOOD AND MUCUS.  THE ABDOMEN BECOMES TENDER AND DISTENDED.  A SAUSAGE-SHAPED MASS MAYBE FELT IN THE UPPER RIGHT QUADRANT (hallmark sign).  THE LOWER RIGHT QUADRANT USUALLY FEELS EMPTY(DANCE SIGN) AS THE BOWEL DISTAL TO THE OBSTRUCTION IS LESS INVOLVED AND FREE OF CONTENTS.  IF TREATMENT IS NOT SOUGHT, THE CHILD BECOMES ACUTELY ILL WITH FEVER, PROSTRATION, AND SIGNS OF PERITONITIS.  DIARRHEA, CONSTIPATION, OCCASIONAL VOMITING, AND PERIODIC COLIC.  FREQUENTLY DIAGNOSIS CAN BE MADE ON SUBJECTIVE FINDINGS ALONE.  BARIUM ENEMA- WHICH CLEARLY DEMONSTRATES THE OBSTRUCTION TO THE FLOW OF BARIUM.  RECTAL EXAMINATION REVEALS MUCUS, BLOOD, AND OCCASIONALLY A LOW INTUSSUSEPTION ITSELF.  NON-SURGICAL HYDROSTATIC REDUCTION BY BARIUM ENEMA – THE INITIAL TREATMENT OF CHOICE.  - THE PRINCIPLE BEHIND THIS PROCEDURE IS THAT THE FORCE EXERTED BY THE FLOWING BARIUM WILL BE SUFFICIENT TO PUSH THE INVAGINATED PORTION OF THE BOWEL INTO ITS ORIGINAL POSITION, SIMILAR TO PUSHING AN INVERTED “FINGER” OUT OF A GLOVE.  ALTERNATIVE PRESSURE REDUCTION TECHNIQUES  USE OF SALINE FOR HYDROSTATIC PRESSURE UNDER UTZ, WHICH REDUCES THE RISK OF RADIOGRAPHIC EXPOSURE AND SPILLING OF BARIUM INTO THE PERITONEAL CAVITY.  PNEUMONIC INSUFFLATION WITH AIR OR OXYGEN HAS ALSO BEEN USED IN REDUCTION.   IF THERE ARE CLINICAL SIGNS OF SHOCK AND PERFORATION, THE CHILD IS ALSO PREPARED FOR SURGERY BEFORE THE ATTEMPTED REDUCTION.  SURGICAL INTERVENTION INVOLVES MANUALLY REDUCING THE INVAGINATION AND, WHERE INDICATED, RESECTING ANY NON-VIABLE INTESTINE.  EXPLAIN THE BASIC DEFECT OF INTUSSUSEPTION TO THE FAMILY.  FOR CHILD WITH SIGNS OF ELECTROLYTE IMBALANCE , HEMORRHAGE, OR PERITONITIS, ADDITIONAL MEDICATION PREPARATION SUCH AS REPLACEMENT FLUIDS, WHOLE BLOOD OR PLASMA, AND NG SUCTIONING MAY BE INCLUDED.  ALL STOOLS ARE MONITORED BEFORE SURGERY.  POST-OP: SPECIAL OBSERVATION OF STOOL PASSAGE AND RETURN OF BOWEL SOUNDS.  HYDROSTATIC OR AUTO REDUCTION: OBSERVE FOR PASSAGE OF BARIUM AND STOOL PATTERNS.  THE CHILD IS KEPT IN THE HOSPITAL FOR 2-3 DAYS BECAUSE INTUSSUSEPTION ARE MOST LIKELY TO OCCUR WITHIN 36 HOURS AFTER THE REDUCTION. Juvenile Rheumatoid Arthritis/ Juvenile Idiopathic Arthritis  Is an autoimmune inflammatory disease causing inflammation of the joints and other tissue with an unknown cause. Has 2 peak ages of onset: bet. 1-3 years old and bet. 8-10 years old. Pathophysiology The disease process is characterized by chronic inflammation of synovium with joint effusion and eventual erosion, destruction, and fibrosis of the articular cartilage. Adhesions between joint surfaces and ankylosis of joints occur if the inflammatory process persists. Clinical Manifestations Severe or minimal joint damage Joint deformity Subtypes 1. pauciarticular (oligoarthritis) onset – involves 4 or less joint. 2. polyarticular onset – involves more than 4 joints. 3. systemic onset – high fevers with late evening spikes, transient maculopapular rash, hepatosplenomegaly, pericarditis, pleuritis, and lymphadenopathy. Diagnostic Evaluation Elevated erythrocyte sedimentation rate (ESR) Leukocytosis present during exacervation of systemic JIA. Antinuclear antibodies (ANA) are common but not specific to arthritis. Medications NSAIDs (Naproxen or Ibuprofen) – first line drug Methotrexate – second line drug who have failed with NSAIDs alone. Corticosteroids – for life threatening complications, incapacitating arthritis and uveitis. Medications Etanercept – a tumor necrosis factor (inhibitor) alpha receptor blocker. - used for children who are non-responsive to methotrexate. Slow Acting Anti-Rheumatic Drugs (SAARDS) - require months to be effective and works in combination with NSAIDs. Nursing Care Management Physical therapy Occupational therapy Exercise in a pool is excellent therapy. - if there is pain on motion, a hot pack or warm bath may help. Night time splinting to help minimize pain and reduce flexion deformity. - joints frequently splinted are the knees, wrist and hands.  Positioning during rest is also important. - the child rest on a firm mattress with no pillow or a very low one. Moist heat application is best for relieving pain and stiffness. Painful hands and feet can be immersed in a pan of warm water for 10 mins. 2- 3x/day. LGA Large for gestational Age ( Macrosomia) LGA Infant who fits in the 90th percentile or above on the growth chart. Etiology Genetic Obese mother DM Multiparity Beckwith-Wiedemann syndrome (general body overgrowth) omphaloceles Complication 1. Birth trauma (caput succedaneum or cephalhematoma) 2. Asphyxia and even death 3. Broken clavicle (swelling, pain, or tenderness in the affected area, or a reluctance to use the affected extremities) 4. Fractured humerus (pain, tenderness, edema and decreased movement) 5. Hypoglycemia for up to 6 hours (born to diabetic mothers, in response to maternal diabetes, infants produce more insulin, after birth, this infant will continue to produce insulin (up to 24 hours of life) and can be at risk for hypoglycemia). Interventions 1. Neurological examination if there is birth trauma. 2. Do not manipulate affected extremity and diagnosis can be verified by radiologic examination for broken clavicle and humerus. Immobilization of the affected extremity. 3. Monitor serum glucose for hypoglycemia 4. Initiate oral feedings and supplement as necessary with an IV glucose Meconium Aspiration Syndrome RISK FACTORS  Physiologic stress at the time of labor and delivery (eg, due to hypoxia caused by umbilical cord compression or placental insufficiency or caused by infection) may cause the fetus to pass meconium into the amniotic fluid before delivery  meconium passage is noted in about 10 to 15% of births. During delivery, perhaps 5% of neonates with meconium passage aspirate the meconium, triggering lung injury and respiratory distress, termed meconium aspiration syndrome.  Post term infants delivered through reduced amniotic fluid volume are at risk of more severe disease because the less dilute meconium is more likely to cause airway obstruction.  post maturity, oligohydramnios Other intrauterine stress Hypoxia relaxation of the fetus’ anal sphincter passage of meconium into the amniotic fluid swallowed meconium goes into the lower airways partial obstruction air trapping hyperinflation, hypoxemia, acidemia Surfactant destruction overdistention of the alveoli Increased pulmonary vascular resistance Atelectasis & often air leaks ductal shunting (LA to RA) further increases with hypoxia s/sx: Tachypneic, hypoxic, expiratory grunting, nasal flaring, & retractions similar to RDS may have barrel chest due to hyperinflation, may complicate to respiratory failure Signs and symptoms  Tachypnea, nasal flaring, retractions, cyanosis or desaturation, rales, rhonchi  Greenish yellow staining of the umbilical cord, nail beds or skin.  Meconium staining maybe visible in the oropharynx, larynx and trachea  Neonates with air trapping may have barrel chest  Chest x-ray result shows hyperinflation with variable areas of atelectasis and flattening of diaphragm, fluid in the lung fissures or pleural spaces & air maybe seen in the soft tissues or mediastinum Diagnostic test  Chest x-ray Treatment  Suctioning is done when needed or with poor APGAR score.  Endotracheal intubation (3.5-4mm) as needed- poor muscle tone, depressed resp. , bradycardia  Mechanical ventilation as needed  Supplemental O2 as needed  IV antibiotics  SURFACTANT for mechanically ventilated neonates NURSING CONSIDERATIONS  ENSURE THAT EQUIPMENT SUCH AS OXYGEN AND SUCTION IS FUNCTIONING PROPERLY AND ASSISTS WITH CARE AT DELIVERY.  ALTHOUGH MECONIUM IS STERILE, LUNG DAMAGE PROMOTES THE GROWTH OF BACTERIA. CLOSE MONITORING OF INFANT FOR INFECTION IS VERY IMPORTANT TO PREVENT FURTHER COMPLICATION. Meningitis  Description Meningitis is an inflammation of meninges This is the most common infection of the CNS Two primary classifications include viral or aseptic and bacterial.  Etiology Viral etiology is a wide variety of viral agents or enteroviruses. Bacterial causative organisms include haemophilus influenza (type B), streptococcus pneumoniae and neisseria meningitides (meningococcal).  Assessment Clinical manifestations of viral meningitis 1. infants and toddler are irritability, lethargy, vomiting, and change in appetite. 2. older children, infection is usually preceded by a nonspecific febrile illness; child presents with headache, malaise, muscle aches, nausea/vomiting, photophobia (sensitivity to light) and nuchal or spinal rigidity.  Clinical manifestations of bacterial meningitis: 1. infant and toddlers: poor feeding/suck, vomiting, high-pitched cry, bulging fontanel, fever or hypothermia depending on the maturity of infant’s neurological system, and poor muscle tone.  2. children and adolescent: abrupt onset, fever and chills, headache and nuchal rigidity (stiffness of the neck); vomiting, alterations in sensorium, photophobia, delirium, extreme irritability, aggressive behavior, seizures and/or drowsiness;  positive kernig’s or brudzinski’s sign (indicates meningeal irritation); opisthotonus posture (hyperextending the head and neck) may relieve some discomfort from meningeal irritation; petechial or purpuric rash will be seen if it is a meningococcal infection.  Diagnostic test CSF is obtained by lumbar puncture for analysis; findings can differentiate viral from bacterial meningitis; cultures can determine the causative agent.  Comparison of CSF in meningitis normal Viral Bacterial meningitis meningitis pressure 5-15 mmHg Normal or elevated slightly elevated appearance clear clear cloudy leukocytes 0-5 Slightly elevated elevated Protein 10-30 Slightly elevated (mg/dL) elevated Glucose 40-80 Normal or decreased (mg/dL) decreased  Priority nursing diagnosis Risk for ineffective breathing pattern Pain Risk for injury Risk for ineffective thermoregulation  Planning and implementation Monitor respiratory status and administer oxygen and maintain artificial airway. Provide an environment that will minimize ICP elevation; this can include elevating head of bed 15 to 30 degrees, avoiding neck extension or flexion, and maintaining head in a neutral position; keep environment quiet and handle child in a gentle manner.  Monitor for cerebral edema; child may be at risk for syndrome of inappropriate antidiuretic hormone (SIADH);suspect this if urine output decreases but serum sodium also decreases; restrict oral fluids and monitor IV fluids to prevent fluid overload. Administer antipyretics as needed for temperature elevation Assess for evidence of pain with all routine assessments; administer pain medication as prescribed; however, narcotics should be avoided, elevated ICP can be masked by narcotic analgesics.  Children with bacterial meningitis will need to be isolated until at least 24 hours of antibiotic therapy have been completed. Monitor child for complications of meningitis (seizure, hearing loss, visual alterations); neurologic sequelae such as mental retardation, cerebral palsy, and hydrocephalus may occur; a complication of meningococcal meningitis is meningococcemia, an overwhelming septic infection that can lead to circulatory collapse and tissue necrosis.  Viral meningitis is treated symptomatically; usually only infants are hospitalized for viral meningitis.  Medication therapy Bacterial meningitis is treated with intravenous antibiotics sensitive to causative organism. Treatment usually continues for 7-14 days Preventive care includes a vaccine currently available to protect all young children from haemophilus influenzae infection Individuals who have close contact with children diagnosed with meningococcal and H. influenzae meningitis may receive rifampin (rifadin) prophylactically  Child and family education Provide information to the parents about disease and its transmission, need for isolation and antibiotic therapy, and need for prophylactic treatment for those in contact with child. Provide parents with information about possible development of sequelae from disease and possible side effects of medications. Share information about follow-up as well as rehabilitation services with family. Neural tube defects  Description Neural tube defects (also known as spina bifida or myelodysplasia) develop during first trimester of fetal development; defect can occur at any place along spinal canal.  Etiology Etiology is unknown but maybe associated with maternal dietary folic acid deficiency. The degree of disability is determined by the location of defect and amount of spinal nerves encased in sac. The higher the defect, the greater the neurologic dysfunction.  Types of spina bifida 1. spina bifida occulta: posterior vertebral arches fail to fuse, but there is no herniation of spinal cord or meninges ; no loss of function. 2. Meningocele: posterior vertebral arches fail to fuse, and there is a saclike protrusion at some point along posterior vertebrae; sac does contain meninges and CSF but not spinal cord.  3. Myelomeningocele: posterior vertebral arches fail to fuse; saclike herniation contains meninges, CSF, as well as portion of spinal cord or nerve roots; sometimes leakage of CSF occurs. 4. Encephalocele: brain and meninges herniate through defect in skull into a sac. 5. Anencephaly – absence of cerebral hemipheres. 6. microcephaly – fetal brain grows slowly  Assessment 1. prenatal diagnosis of open spinal defects can be determined by elevated levels of alpha- fetoprotein (AFP) in maternal serum and fluid obtained by amniocentesis; can also be assessed on prenatal ultrasound. Meningoceles, myelomeningoceles, and omphaloceles are obvious at birth ; SB occulta may have an associated abnormal tuft of hair, dimple, sinus tract or subcutaneous mass at the site.  During postnatal period, monitor for leakage of spinal fluid from sac as well as possible systemic or CNS infection. Assess degree of sensation at or below level of lesion; this can be evidenced by lack of movement or sensation in legs, and neurogenic (lacking innervation) bladder or bowel. Measure head circumference since there is high risk of hydrocephalus  Priority Nursing Diagnosis Risk for infection Risk for impaired skin integrity Impaired urinary elimination Bowel incontinence/ Colonic constipation Impaired physical mobility  Planning and Implementation Collaborative management: the defect /sac is surgically repaired during first 48 hours after birth. Focus preoperative care in maintaining skin integrity of sac and keeping it free from infection; position infant on side or abdomen to attain this; keep sac moist with sterile, saline-soaked dressings; avoid contamination of sac area by urine and feces. Individuals with myelodysplasia have an increased incidence of latex allergies, monitor for this  Neurogenic bladder: frequent, straight catheterization is preferred method of management; maintain home schedule as much as possible. Neurogenic bowel: work with family to develop a bowel management plan using control of high- fiber diet, adequate fluid intake, and pattern for evacuation of bowels; in some cases, laxative and enemas are used as prescribed by physician.  Collaborate with physical therapy to develop modes of transport, such as using braces with crutches or wheelchair. Since areas with altered sensation are prone to skin breakdown, teach child and family to reposition frequently and inspect affected areas on a regular basis.  Medication therapy low-dose antibiotics may be prescribed to prevent UTIs  Child and family education Teach family about possibility of child developing hydrocephalus and signs and symptoms of increased ICP and what to do if changes develop. Since most children with neural tube defects (except for those with spina bifida occulta) have some neurogenic bladder, teaching about clean intermittent straight catheterization is important; work with family to develop bowel management program also Otitis Media  Otitis Media Otitis media is an inflammation of the middle ear. Otitis media occurs in the area between the tympanic membrane (the end of the outer ear) and the inner ear, including a duct known as the eustachian tube. The inflammation can be acute or chronic, infectious or noninfectious, and can occur with or without effusion (accumulation of fluid in the ear or pleural cavity). Ex. Milk formula that drips from mouth to ear.  Types of Otitis Media Acute otitis media (AOM) - a n infectious process caused by pathogen invasion through the eustachian tube and into the middle ear with a sudden onset and short duration. Generally associated with ear pain. Otitis media with effusion (OME) – an inflammation of the middle ear with fluid (effusion) behind the tympanic membrane and without signs of infection. OME can be found in an asymptomatic child. Chronic OM – an inflammation of the middle ear that persist beyond 3 months and may or may not have effusion.  Incidence and etiology More common disease in childhood. The peak incidence occurs in children ages 6-18 months with most having had atleast one episode of OM during their first year of life. (Faden, et. Al.; Huether, 2000a). AOM is generally caused by streptococcus Pneumoniae, Haemophilus Influenzae, and Moraxella Catarrahalis (Deeks, et. Al., 1999; Faden, et al., Huether, 2000a; Murray, et al., 1998). OME peaks when URTI are prevalent. URT, allergies, sinusitis, cleft palate & immune deficiency, down syndrome are also predisposing factors.  Pathophysiology Anatomic differences of eustachian tube of children under three years of age. ( Eustachian tubes are wider, shorter, & straighter than those of older children, positioned horizontal that allows microorganism and nasopharyngeal secretions to enter invasion of microorganism causes inflammation with or without infection inflammatory process leads to an accumulation of exudates in the middle ear stagnant fluid impedes the middles ear’s ability to transmit sound and creates and environment conducive to pathogen colonization fluid also blocks the connection between the middle ear and pharynx, interrupting the eustachian tube’s pressure equalizing function. enlarged lymphoid tissue can further obstruct the flow of drainage of the middle ear. As volume increase, pressure increases. If unrelieved, rupture of tympanic membrane may occur.  Signs and symptoms Pain due to pressure on surrounding structures Irritability Temperature 40 degree celsius Postauricular and cervical lymph nodes enlargement Rhinorrhea Vomiting Diarrhea  complications