Peds Exam 3 Chapters 38, 42, 43, 45 PDF

Peds: Exam 3 Chapters 38, 42, 43, 45 Chapter 38 Karen- DONE Please don’t forget to cover the the following points for your chapter: Seizure disorders (Table 38.2) Hydrocephalus Craniosynostosis Plagiocephaly Bacterial vs...

Peds: Exam 3 Chapters 38, 42, 43, 45 Chapter 38 Karen- DONE Please don’t forget to cover the the following points for your chapter: Seizure disorders (Table 38.2) Hydrocephalus Craniosynostosis Plagiocephaly Bacterial vs viral meningitis Head trauma Automatisms Compare how the anatomy and physiology of the neurologic system in children differs from adults. Development of CNS occurs in the first 3-4 weeks of gestation from the neural tube. At birth, the cranial bones are not well developed and are not fused. Therefore there is an increased risk for fracture. The brain is highly vascular, leading to an increased risk for hemorrhage. Premature infants are at an increased risk for intracranial bleeding due to capillaries in the periventricular area which can rupture because they are fragile. If sutures and fontanels close too early or too late they can cause problems with brain growth. The spine is very mobile especially in the spine region resulting in a high risk for cervical spine injury. The immaturity of the CNS in preterm infants can result in delayed development of motor skills. Episodes of apnea can be problematic in the preterm infant due to the underdevelopment of the nervous system. Discuss common laboratory and other diagnostic tests useful in the diagnosis of neurologic conditions. Test Explanation Indications Nursing implications Lumbar puncture Withdrawal CSF Measure spinal fluid Assist with proper positioning. LP) (typically 3 tubes) pressure and from the diagnose Help the child maintain position and remain subarachnoid still. hemorrhage, space for analysis. infection (high Use distraction technique that will allow the protein and low child to remain in the proper position such as glucose in bacterial storytelling or music. meningitis, viral meningitis minimal Maintain strict asepsis. protein), obstruction Assist with collection and transport of specimen. Monitor respiratory status, changes in consciousness, heart rate, pain level. Encourage fluids after procedure, if not contraindicated. Keep child flat for 1 hour if ordered. Apply EMLA cream to puncture site 30–60 minutes before procedure to reduce pain, if ordered. The child is also encouraged to drink a glass of water to help prevent cerebral irritation. May develop a HA afterwards, an analgesic may be administered for pain relief. Head and neck Radiographic Detects skull and Children may be afraid. x-ray images of the head spinal fractures. (Head Trauma) and neck will show Allow a parent or family member to skull and spine Shows location and accompany the child. structures. course of ventricular catheters. If the child is unable or unwilling to stay still for the radiograph, restraint may be Reveals information necessary. about increased intracranial pressure The time of restraint should be limited to the (ICP) and skull amount of time needed for the radiograph. defects. ICP monitoring A sensing device is Used to monitor ICP Usually monitored in critical care setting. placed in the head resulting from that monitors the hydrocephalus, Monitor for signs and symptoms of increased pressure acute head trauma, ICP (bulging fontanels, blurred vision, bulging intracranially. and brain tumors. eyes, HA.  Ventricular catheter Monitor for infection. also allows for draining of CSF to Keep head of bed elevated 15–30 degrees. help reduce ICP. 30-45 degrees* Alarms for monitoring device should remain on at all times. Reduce stimulation and avoid interventions that may cause pain or stress and result in an increased ICP. Fluoroscopy Radiographic Assesses cervical Same as head a neck radiographs. examination that spine for instability uses continuous during movement. x-rays to show live up-to-date images. Electroencephal Measures electrical Diagnosis seizure Must remain still (if unable, then sedatives ogram (EEG) activity of the brain. and brain death. may be necessary but should be avoided because sedatives can alter the EEG Evaluate brain reading). tumors, subdural hematomas, intracranial hemorrhages. MRI Use of magnetic Assess tumors and NO METAL DEVICES (internal or external), field to show inflammation. ensure gowns have no metal snaps. different tissue compositions. Diagnosis If done w/ contrast, ensure there is no allergy congenital to shellfish and iodine. abnormalities (neural tube defects, shows normal v.s abnormal brain tissue) Cerebral X-ray study of Assess for vessel Assess for allergy to contrast medium and angiography cerebral blood defects or possible NPO status. vessels. Involves space-occupying injection of a lesions. Push fluids following procedure, if not contrast medium contraindicated to help flush out contrast and use of medium. fluoroscopy. Discuss common medications and other treatments used for treatment and palliation of neurologic conditions. Treatment Explanation Indications Nursing implications Shunt A catheter is placed in the ventricle Hydrocephalus, Monitor: placement to pass the CSF to the peritoneal increased ICP cavity,a trium of the heart or neural LOC/VS spaces. S/S of infection: elevated VS, (ventriculoperitoneal shunts are poor feeding, vomiting, commonly used). decreased responsiveness, seizure activity, inflammation near shunt site. Ventilation Hyperventilation to decrease Increase ICP Monitor: PaCO2, which will result in vasoconstriction and therefore ABGs decrease ICP. S/S of increased ICP Adequate oxygenation to prevent Pulse ox hypoxia and further damage to the brain. Vagal nerve A nerve stimulator is implanted and Short and long term Monitor: stimulator a lead wire running under the skin is seizure wrapped around the vagus nerve. management in Seizure activity children older than The stimulator is programmed to 12 years of age. S/S of infection provide the appropriate dose of stimulation at preset intervals. Ketogenic diet Diet involves high intakes of fats, Prevention, control, Avoid Beans, Corn, bread adequate protein, and a very low and reduction of pasta, sugars, milk, rice intake of carbs. seizure in particular 5% carbs for children with 30% proteins difficult to control 65% fats seizures. External A catheter is temporarily placed in Most commonly Monitor: ventricular the ventricle and CSF is drained in a used with shunt Monitor drainage drainage (EVD) closed system to an external infections until CSF reservoir. is sterile and shunt For signs and symptoms of can be replaced. increased ICP (60-100)cerebral perfusion Treats acute-onset hydrocephalus, Neurologic status closely meningitis, encephalitis, Level of consciousness and tumors that can vital signs cause blockage of CSF, closed had For signs and symptoms of injury, infection  subarachnoid hemorrhage, Level of collection container increased ICP when drain is unclamped Ensure its unclamped at all times! -Zero at clavicle level. -Clamp when child movement Ventricular tap* To reduce accumulation of CSF and Increased ICP Monitor: decrease ICP LOC and neuro status Not permanent PT/OT/ST Therapies are used to improve Head injury, Ensure adequate motor function and ability of children intellectual communication exists within with neuro disorders. disability. interdisciplinary team. Identify various factors associated with neurologic disease in infants and children. Common types of seizures Onset Type Description Characteristics Unknown onset Motor: Mode of seizure onset Occurs in series or clusters. Tonic-clonic, epileptic unknown, whether focal(one Presents as symmetrical flexing or spasm side of brain) or extending, in variant clinical patterns generalized(both). of the neck, arms, legs and trunk. Nonmotor: May see: Behavior arrest Type of epileptic spasm seen Extension of neck, trunk, arms and in infancy (usually seen legs. between 3-12 months of age, Flexion of neck, trunk and extremities peak incidence 3-7 months with contracting of abdominal and rarely seen after the age muscles (may cause body to bend of 18 months) forward, often referred to “jackknife seizure”) Generalized Absence (formerly Onset 4-12 years old -Abrupt onset and offset onset Nonmotor petit mal) Ends by teen years -Sudden cessation of motor activity or - Typical Motionless blank stare speech with a blank facial expression - Atypical Minimal to no change in or rhythmic twitching of the mouth, - Myoclonic behavior. eyebrows, chin, eyelids or other parts - Eyelid of the face. myoclonic -Child may experience countless seizures in a day. -May go unrecognized or mistaken for inattentiveness because of subtle change in child’s behavior. Generalized Clonic (think Crazy) Type of generalized seizure -Muscles will spasm, jerk, then relax. (both lobes of that presents with repeated -Spasm/jerking cannot be stopped by the brain)onset jerking movements. restraining or repositioning. Motor -Clonic seizures alone are rare, may precede a tonic-clonic seizure. Generalized Tonic (think Tight) Type of generalized seizures Consciousness is usually preserved. onset that present with stiffening of Tightening of chest muscles may lead Motor the muscles, typically the to cyanosis, seen in children with back, legs, and arms. Lennox-Gastaut syndrome. Generalized Tonic-clonic Extremely common Safety of the child is a primary onset (formerly grand mal) generalized seizures. Most concern. Motor dramatic seizure type. Associated with an aura. LOC occurs and may be preceded by Tonic phase: piercing cry, a piercing cry. cyanosis, generalized Presents with entire body stiffening of the body and experiencing tonic contractions limbs and back arched. followed by rhythmic clonic 10-20sec contractions alternating with relaxation of all muscle groups. Clonic phase: salivary Cyanosis may be noted due to apnea. frothing, incontinence, clonic Saliva may collect in the mouth due to jerks of limbs, body and inability to swallow. (Suction available head. postictal) 1-2 minutes Child may bite tongue. Alternating flexing and Loss of sphincter control, especially relaxing of the muscles. bladder. Postictal phase: child will be semicomatose or in a deep sleep for approx. 30 mins-2hrs, usually responds only to painful stimuli. Child will have no memory of the seizure, may complain of HA and feeling fatigue. Generalized Myoclonic Type of generalized seizure Sudden, brief, massive muscle jerks onset that involves the motor cortex that may involve the whole body or Myoclonic–tonic– of the brain. May occur along one body part. Motor clonic with other seizure forms. Child may or may not lose Myoclonic–atonic consciousness. Generalized Atonic Type of generalized seizure Sudden loss of muscle tone. In onset often referred to as “drop children, may only be a sudden drop Motor attacks.” of the head. Child will regain consciousness within a few seconds Seen in children with to a minute. Lennox–Gastaut syndrome.  Can result in injury related to violent fall. No contact sports No flashing sports Teach parents on helmet use! Focal onset Motor: Automatisms, Seizure that occurs in one Motor activity characterized by clonic with retained atonic, clonic, part of the brain. The or tonic movements involving the consciousness/ hyperkinetic, symptoms seen will depend face, neck, and extremities. awareness myoclonic, tonic on which area of the brain is (previously affected. Can include sensory signs such as referred to as Nonmotor: numbness, tingling, paresthesia, simple partial autonomic, behavior changes in vision and hearing, seizure) arrest, cognitive, possible hallucinations, or pain. emotional, sensory Can include autonomic symptoms Automatism: such as changes in blood pressure, Chewing, lip heart rhythm, bowel function. smacking, rapid blinking, smelling Can include psychic symptoms such unusual odors, as triggering emotions of fear, anxiety, rising sensation in joy, sadness. abdomen Unusual taste, Child remains conscious and may feelings of fear and verbalize during the seizure. deja vu! No postictal state  Status epilepticus Common neurologic Prolonged or clustered seizures emergency in children. Can where consciousness does not return occur with any seizure between seizures. activity. Febrile seizures are the most common type. In The age of the child, cause of the children with epilepsy, it seizures, and duration of status commonly occurs early in the epilepticus influence prognosis. course of epilepsy. Can be life threatening. Prompt medical intervention is essential to reduce morbidity and mortality. Treatment: - Basic life support—ABCs (airway, breathing, circulation) -Administration of anticonvulsants to cease seizures is crucial. Common medications include benzodiazepines such as lorazepam and diazepam, and fosphenytoin. - Blood glucose levels and electrolytes along with evaluation of the underlying cause should be initiated. Epilepsy: A common neurological condition in which seizures are triggered recurrently from within the brain. Defined by the presence of the following conditions: two or more unprovoked (or reflex) seizures, which occur more than 24 hours apart, one unprovoked (or reflex) seizures and a chance of further seizures the same as the genera, recurrence risk (at least 60%) after 2 unprovoked seizures happening over the next 10 years, and diagnosis of epilepsy. This disruption results from an imbalance between excitatory and inhibitory mechanisms in the brain, causing the neurons to either fire when they are not supposed to or to fire when they should. Glutamate is excitatory and GABA is inhibitory Health History: Age of onset of seizures Earlier onset worse prognosis later in life. Seizure control- what medication are the child taking and have they been able to take them, when was their last seizure? Description and classification of seizures- does the child lose consciousness, does the child become apneic? Precipitating factors that may contribute to the onset of seizures (e.g Flashing lights, increases stimuli)  Adverse effect related to anticonvulsants medication Compliance with medication regimen. A common cause of breakthrough seizures is medication noncompliance. Physical examination: Time of onset and length of seizure activity Alterations in behavior such as a cry or changes in facial expression, motor abilities, or sensory alterations before the seizure that may indicate an aura Precipitating factors such as fever, anxiety, just waking, or eating Description of movements and any progression Description of respiratory effort and any apnea noted Changes in color (pallor or cyanosis) noted Position of mouth, any injury to mouth or tongue, inability to swallow, or excessive salivation Loss of bladder or bowel control State of consciousness during seizure and postictal (after seizure) state—during the seizure, the nurse may ask the child to remember a word; after the seizure, assess if child is able to recall it, to help accurately establish current mental state Assess orientation to person, place, and time; motor abilities; speech; behavior; alterations in sensation postictally Duration of postictal state Management: Focuses on preventing injury during seizures Focuses on controlling seizures or reducing their frequency Relieve anxiety, instruct parents to remain calm and ensure the child is eased to the ground with no objects/furniture near them. Primary mode of treatment is the use of anticonvulsants. ★ Diazepam, phenytoin, carbamazepine, valproic acid, fosphenytoin sodium, topiramate, lamotrigine and clonazepam ★ Decrease incidence and severity of seizures. ★ Medication is based on the clients age, type of seizure and other medical factors. ★ A single medication is initiated at low dosage and gradually increased until seizures are controlled. A second medication can be added to achieve seizure control. ★ Monitor for seizure control, assess allergies, monitor adverse effects, monitor for therapeutic blood medication levels for required medication. ★ Take the medication at the same time every day to enhance effectiveness, be aware of food interactions, observe for adverse reactions, dosage may need to be increased as the child grows, blood cells counts, urinalysis, and liver function test will need to be obtained at frequent intervals to determine effect on organ function. Patient education: Encourage parents to be involved in the management of their child’s seizures but encourage the child to learn about the disorder and its management as soon as they are old enough.  Any activity restrictions, such as limiting swimming, or participation in sports, will be based on the type, frequency, and severity of the seizures the child has. Febrile Seizures: Most common type of seizure in children less than 5 years of age, peak incidence occurring in children between 12-18 months old, most commonly seen in boys and there is an increased risk for children who have a family history of febrile seizures. Associated with a fever that is not the result of an intracranial infection or metabolic imbalance. They are usually related to a viral illness. These seizures are usually benign, but rarely may be a sign of dangerous underlying infection such as meningitis or sepsis. Febrile seizures occur most often in preschool children but can occur as late as 7 years of age. They occur when the child has a rapid rise in temperature and are not associated with the development of seizures later in life. Administering correct dosages of acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures. Assessment: Usually associated with a rapid rise in core temperature to 102.2 F or higher. A simple febrile seizure is defined as a generalized seizure lasting less than 15 minutes (usually a few seconds to 10 minutes) that occurs in a 24-hour period and is accompanied by a fever without any CNS infection present. A brief postictal period is often seen when the child appears drowsy. The seizure is likely to have stopped by the time a child receives medical attention. In some cases, LP and/or neuroimaging may be performed to rule out meningitis or encephalitis (this is based on the age and clinical presentation of the child). Management: Determination and treatment of the cause of the fever and interventions to control the fever. Rectal diazepam has been shown to be safe and effective in terminating febrile seizures and may be used in children at high risk for febrile seizures or in children whose parents are extremely anxious. Buccal and intranasal midazolam has also been found to be effective and intranasal lorazepam as well. Neonatal Seizures: High incidence of seizures during the neonatal period. The immature brain is more prone to seizure activity and metabolic, infectious, structural and toxic disease are likely to be seen in this age group. Seizures that occurs within the first 4 weeks of life and are most commonly seen within the first 10 days. Most seizures in newborns are associated with a specific underlying cause such as hypoxic ischemic encephalopathy (most common), metabolic disorders (hypoglycemia  and hypocalcemia), neonatal infection (meningitis and encephalitis), cerebral infarction, and intracranial hemorrhage. Assessment: Hard to recognize clinically and may be accompanied by a normal EEG to distinguish from non seizure behaviors such as stretching, sudden random sucking movements, coughing or gagging, Management: Should be treated aggressively because repeated seizure activity may result in injury to the brain. Treatment focuses on addressing the underlying cause such as correcting metabolic disturbances, treating CNS infections, ensuring adequate ventilation and CV support, and possible anticonvulsant therapy. Phenobarbital is often used in the initial management of neonatal seizures but efficacy remains uncertain. Structural Defects Hydrocephalus: https://www.osmosis.org/learn/Hydrocephalus:_Nursing_Process_(ADPIE)?query=Hydrocephalus%253A_Nursing_process_%28AD PIE%29&language=en Not a specific illness, but results from underlying brain disorders. Not a neural tube defect. It can occur with other neural tube defects. Results from an imbalance in the production and absorption of CSF. CSF accumulates within the ventricular system and causes the ventricles to enlarge and increases ICP to occur. CSF is formed primarily in the ventricular system by the choroid plexus. It flows because of the pressure gradient that exists between the ventricular system and the venous channels. CSF is absorbed primarily by the arachnoid villi. Hydrocephalus results when there is an obstruction in the ventricular system or obliteration or malformation of the arachnoid villi, resulting in impaired absorption of circulation of the CSF. Obstructive or noncommunicating hydrocephalus occurs when the flow of CSF is blocked within the ventricular system, more common than communicating hydrocephalus. The most common cause of obstructive hydrocephalus in children is aqueductal stenosis which results from narrowing fo the aqueduct of Sylvius (a passageway between the third and fourth ventricles in the middle brain). The VP shunt is placed in the third Ventricle! Nonobstructive or communicating hydrocephalus occurs when the flow of CSF is blocked after it exits from the ventricles. CSF can still flow between the ventricles. Most commonly results from subarachnoid hemorrhage. Congenital hydrocephalus is present at birth and is often due to a genetic disposition or environmental influences during fetal development. ○ Causes: abnormal intrauterine development as in the case with myelomeningocele or other NTDs or intrauterine infections. Acquired hydrocephalus develops at the time of birth or at some point after, it can occur at any age and can result from injury or disease.  ○ Causes: intention or unintentional trauma, intraventricular hemorrhage in premature infants, neoplasma (posterior fossa brain tumor), infections (meningitis) or malformations (Chiari malformations) Children are at an increased risk for developmental disabilities, visual problems, abnormalities in memory and reduced intelligence. Management: The goal of treatment includes relieving hydrocephalus and managing complications associated with the disorder such as growth and developmental delays. Most commonly treated with surgical placement of an extracranial shunt such as ventriculoperitoneal (VP). The shunt will need to be replaced as the child grows, therefore the child will undergo shunt revision surgery at various times during their life. Assessment: Assess for changes or decreases in LOC may be noted along with brisk reflexes and spasticity of the lower extremities In infants, the most obvious indication is often a rapid increase in head circumference. In older children, loss of developmental and changes in personality may be seen. In infants, palpation of the fontanels may reveal wide-open, bulging fontanels, they will be nonpulsatile and feel tense and very full. CT and MRI are used to evaluate the presence of hydrocephalus and can also aid in identifying the cause of hydrocephalus. Skull x-ray may reveal separation of sutures.  Early signs of ICP: Late signs of ICP: -HA -Lowered LOC -Vomiting, possibly projectile -Decreased motor and sensory responses -Blurred vision, diplopia -Bradycardia -Dizziness -Irregular respirations -Decreased pulse and RR -Cheyne-Stokes respirations (a period of fast, shallow -Increased BP breathing followed by slow, heavier breathing and -Pupil reaction time decreased and unequal moments without any breath at all-apneas) -Sunset eyes -Decerebrate or decorticate posturing (arms and legs -Changes in LOC, irritability held straight out, toes pointed downward, head and -Seizure activity neck backward and tightened muscles.) -In infant you will see: bulging, tense fontanel, Fixed and dilated pupils wide sutures and increased head circumference, dilated scalp veins and high-pitched cry Rapid drainage of CSF, which may occur if the child sits up without the EVD system being clamped, will decrease ICP and can lead to extreme headache, collapse of the ventricles, formation of subdural hematomas, and neurologic deterioration. ★ Cushing’s Triad: bradycardia, widened pulse pressure, irregular respirations (LATE SIGN OF ICP)!!!!!! Nursing management: Maintaining cerebral perfusion. Minimizing neurological complications. Maintain adequate nutrition. Promoting growth and development. Supporting and educating the child and family. Preventing and recognizing shunt infection and malfunction: S/S of shunt infection: elevated VS, poor feeding, vomiting, decreased responsiveness, seizure activity, and signs of local inflammation along the shunt tract. Infection can occur at any time but is more common 1-2 months after placement and is treated with antibiotics, if the infection is persistent the shunt will be removed and an external ventricular drainage system will be put in place until the CSF is sterile. Keeping the peritoneal surgical incision free from feces and urine can help prevent infection. S/S of shunt malfunction: vomiting, drowsiness, and HA. Malfunction of the shunt can occur due to kinking, clogging, or seperation of the tubing. Blockage is the most common reported complication. Supporting/Educating the child and family: Requires lifelong follow-up and regular evaluations. Children will require future surgeries and hospitalization, which can place a strain on the family and its finances as well as potential growth and developmental disabilities are an additional strain. The family should be involved in the child's care from the time of diagnosis. Referral to support groups can be helpful for both the family and the child. Craniosynostosis: https://www.osmosis.org/learn/Craniosynostosis:_Nursing Premature closure of the cranial sutures that can inhibit brain growth and cause a distorted skull appearance. When one suture is fused, neurologic impairments are rarely seen, when two or more sutures are fused, neurologic complications such as hydrocephalus with increased ICP are more likely to occur. Prognosis is good for the majority of infants presenting with craniosynostosis and normal brain development will occur. Surgical correction may be done and allows for normal expansion of the brain and acceptable appearance of the head and skull. If one suture is fused, surgical intervention is done mainly for cosmetic reasons. If one or more suture is fused, surgical intervention is essential to prevent neurologic complications. Scaphocephaly- most common form, sagittal suture is closed, the head grows long and narrow in anterior and posterior direction. Broad forehead and prominent occiput present. Football head turned 180 Trigonocephaly- metopic suture closed, a ridge down the forehead can be seen or felt, triangular-shaped forehead and eyebrows may appear “pinched” on either side, eyes may also appear close together. Anterior plagiocephaly- early closure of one side of the coronal suture, forehead and eyebrow have a flattened appearance on that side, eye on affected side has different shape. Posterior plagiocephaly- early closure of one lambdoid suture, flattening of back of the head, similar to shape found in position molding or positional plagiocephaly. Brachycephaly- very flat, tall, recessed forehead, skull is shortened in the anterior-posterior direction, side-shaped head. Nursing Management: Focuses on post-op care, evaluating hemoglobin and hematocrit levels due to large volumes of blood loss that can occur and observing for pain, hemorrhage, fever, infection and swelling. Due to the location of the surgery and incision line, large amounts of facial swelling may be present, resulting in an inability of the child to open their eyes for a few days post-op. This is a normal finding. Positional Plagiocephaly: Asymmetry in head shape without fused sutures, results from gravitational force exertion on the developing cranium. Torticollis (when the neck muscles are too tight, have an inadequate tone or are shorter on one side) can contribute to plagiocephaly. Management: Changing the infant’s position, encouraging “tummy time” and avoiding excessive use of the car seat for infant seating outside of the automobile. Molding helmet Reposition the infant to decrease time spent with the flattened area in the dependent position, positon the infant so that turning away from the affected side is necessary for them to view objects of interest. Place a rolled washcloth along the affected side of the head to discourage turning the head in that direction. Hold the child upright over the shoulder at times throughout the day, rotate feeding positions and change the direction the infant lies in the crib. Bacterial Meningitis: An infection of the meninges, the lining that surrounds the brain and the spinal cord, it is a serious illness in children and can lead to brain damage, nerve damage, deafness, stroke, and even death. Causes inflammation, swelling, purulent exudates and tissue damage to the brain and can occur as a secondary infection to URIs, sinus infections, ear infections, direct introduction through LP, skull fracture, severe head injury, neurosurgical intervention congenital abnormalities (spina bifida) or the presence of foreign bodies (ventricular shunt or cochlear implants). Droplet Causative organisms: Newborn and infants (birth-3mo): E. coli, group B strep, listeria monocytogenes, streptococcus pneumoniae (pneumococcal) Infants and children (3 mo–6 yr): Streptococcus pneumoniae, Neisseria meningitidis (meningococcal meningitis), Haemophilus influenzae type B, group B Streptococcus Older children and adolescents (6–16 yrs): Streptococcus pneumoniae, Neisseria meningitidis (meningococcal meningitis) Expected findings and physical assessment findings: Photophobia Vomiting Irritability HA Newborns: no illness is present at birth, but progresses within a few days ➔ Poor muscle tone ➔ Weak cry  ➔ Poor suck ➔ Refuses feeding ➔ Vomiting or diarrhea ➔ Possible fever or hypothermia ➔ Neck is supple ➔ Bulging fontanels and nuchal rigidity are late findings 3 months- 2 years: ➔ Seizures with high-pitched cry ➔ Fever and irritability ➔ Bulging fontanels ➔ Possible nuchal rigidity ➔ Poor feeding ➔ Vomiting ➔ Brudzinski’s and Kernig’s signs not reliable for diagnosis ➔ Opisthotonic position- head and neck are hyperextended to relieve discomfort. 2 years throughout adolescence: ➔ Seizures (often initial finding) ➔ Nuchal rigidity ➔ Positive Brudzinski’s sign (flexion of extremities occurring with deliberate flexion of the child’s neck) ➔ Positive Kernig’s sign (resistance to extension of the child’s leg from a flexed position) ➔ Fever and chills ➔ HA, vomiting ➔ Irritability and restlessness that can progress to drowsiness, delirium, stupor and coma ➔ Petechia or purpuric-type rash (with meningococcal infection) ➔ Involvement of joints (with meningococcal and Hib) ➔ Chronic draining ear (with pneumococcal infection) Lab Test: Bacterial CSF Analysis Viral CSF Analysis ➔ Cloudy color ➔ Clear color ➔ Elevated WBC ➔ Slightly elevated WBC ➔ Elevated protein content ➔ Normal and slightly elevated ➔ Decreased glucose content protein content ➔ Positive gram stain ➔ Normal glucose content  ➔ Negative gram stain Management: Administer prescribed antibiotics as soon as possible after obtaining cultures. Length of therapy is determined by the client’s condition and CSF results (normal blood glucose levels, negative culture) Therapy can last up to 21 days depending on which infectious organisms are present. Corticosteroids (dexamethasone) may be ordered to help reduce the inflammatory process, not indicated for viral meningitis. Most effective for reducing neurologic complications in children who have infections caused by Hib. Administer antipyretics such as acetaminophen and NSAIDs such as ibuprofen. Use cooling blankets, fans, cold compresses and tepid baths to help reduce fever. Avoid measures that cause shivering because it increases heat production. Monitor VS and temperature every 2 hours and decrease environmental stimuli because loud noises and bright lights can stimulate the child to cry and increase ICP. Preventing bacterial meningitis: It is transmitted by direct close contact with respiratory droplets from the nose or throat. Most at risk are those living with the child or anyone with whom the child played or was in close contact. Vaccinations: ➔ Hib vaccine: routine starting at 2 months of age and all children should be immunized to continue the reduction of bacterial meningitis caused by Hib ➔ Pneumococcal vaccine: routine for all children starting at 2 months of age. ➔ Meningococcal vaccine: routine for all children 11-12 years of age with a booster at age 16. Head Trauma Head injury is a frequent cause of death and disability in childhood. Common causes of head trauma include falls, motor vehicle accidents, pedestrian and bicycle accidents and child abuse (nonaccidental head trauma). Traumatic brain injury (TBI) occurs when a head trauma results in a disruption of the normal function of the brain, not all head trauma results in a TBI. Types of Skull Fractures: Linear fractures: the most common and involve a single fracture beginning from the point of impact and do not cross the suture line. Can result form minor head injuries such as being struck by a rock or stick or other object, MVA. Depressed fractures: occur when broken bone fragments are pushed inward.results from a forceful impact from a blunt object such as a hammer. Comminuted fractures: are made up of more than one linear fracture and occur following intense impact or repeated trauma to the head (abuse). Basilar fractures: involve those at the anterior or posterior base of the skull.  ➔ S/S: Battle sign (bruising or ecchymosis behind the ear) and “raccoon eyes” (blood leaking in the frontal sinuses causing an edematous and bruised periorbital area) Open fractures: involve a break in the scalp or mucosa of the respiratory tract and can lead to osteomyelitis. Growing fractures: occur when a fracture worsens due to pressure from brain herniation, dilated or a cyst. Concussion: a mild traumatic injury to the brain that alters the way the brain functions caused by a bump, blow, jolt, jarring or shaking. Contusion: bruising of cerebral tissue Subdural hematoma: collection of blood between the dura and cerebrum Epidural hematoma: collection of blood located outside the dura but within the skull Expected findings: History of events leading up to the injury, including any reports of dizziness, HA, diplopia and/or vomiting Amnesia before or after injury Alcohol or ingestion of controlled substances Loss of consciousness Minor Injury Progression of Severe Injury Skull fractures Injury -Possible loss of -Marked changes in -ICP Depressed: skull consciousness VS Infants: bulging fontanel, separation of cranial appears misshapen -Temporary period -Altered mental sutures, irritability, restlessness, increased sleeping, high-pitched cry, poor feeding, Basilar: blood behind of confusion status setting-sun sign- distended scalp veins the tymopanic -Vomiting -Focal neurologic membrane, over the -Pallor deficits Children: nausea, Ha, forceful vomiting, mastoid process, or -Irritability -Increase in blurred vision, increased sleeping, inability to around rhe eye orbits, -Lethargy agitation focus on simple commands, decline in school leakage of CSF -Drowsiness performance and seizures. rhinorrhea or CSF otorrhea. Late findings: alterations in pupillary response, posturing (flexion and extension) bradycardia, Open: tissue decreased motor response and response to laceration over the painful stimuli, Cheyne-Stokes respirations, fracture, possible CSF optic disc swelling, decreased LOC and coma otorrhea and rhinorrhea. Flexion posturing: severe dysfunction of the cerebral cortex, demonstrates the arms, Growing: skull defect, wrists, elbows, and fingers flexed and bent scalp edema, inward onto the chest and the legs extended neurologic changes and rotated internally. can occur months to years after the initial Extension posturing: severe dysfunction at the injury (HA, level of the midbrain, demonstrates a hemiparesis, seizures,  backward arching of the legs and arms, flexed intellectual difficulty) wrists and fingers, extended neck, clenched jaw and possibly arched back. Measurement of ICP: The expected reference range is 5-10 mm Hg, a level greater than 15 mm Hg requires further assessment. Caring for the child with Mild to Moderate head injury: Most children with this type of injury can be cared for and observed at home. The majority make a full recovery. Stay with the child for the first 24 hours and be ready to take the child to the hospital, if necessary. Wake the child every 2–4 hours to ensure that he or she moves normally, wakes enough to recognize the caregiver, and responds to the caregiver appropriately (instructions for frequency and if wakening is necessary will be given based on the child's symptoms and exam). Call the medical provider or bring child to the emergency room if the child exhibits any of the following: ➔ Constant headache that gets worse ➔ Slurred speech ➔ Dizziness that does not go away or happens repeatedly ➔ Extreme irritability or other abnormal behavior ➔ Vomiting more than two times ➔ Clumsiness or difficulty walking ➔ Oozing blood or watery fluid from ears or nose ➔ Difficulty waking up ➔ Unequal-sized pupils ➔ Unusual paleness that lasts longer than 1 hour ➔ Seizures Caring for the child with Severe head injury: Maintaining the child’s airway Monitoring breathing and circulation and neuro status closely Preventing and ceasing any seizure activity and treating any injuries that may have occurred because of the trauma. Focus on neuro status and changes in LOC as well as S/S of ICP. Maintain a quiet environment to help reduce restlessness and irritability. Manage pain and administer sedation as ordered (observe level of sedation to ensure that LOC will not become altered which will hinder the ability to assess adequately for neuro changes) Monitor for development of complications such as hemorrhage, infection, cerebral edema, and herniation. Pediatric Coma Scale Popular scale used to standardize degree of consciousness Consists of three parts: eye opening, verbal response, and motor response. When assessing LOC in children, consider that the infant or child may not respond to unfamiliar voices in an unfamiliar environment. It may be helpful to have the parent present to elicit the response. Parents will often be the first to notice changes in their child’s LOC. Listen to parents and respond to their concerns. What 3 things are we testing for in Pediatric Coma scale: 1. Eye opening 2. Motor response 3. Best response to auditory and verbal stimulus 0-3 unresponsive >8 comatose Best score 15. Chapter 42- Paige- DONE Please don’t forget to cover the following points for your chapter: Gastroenteritis & Dehydration Failure to thrive GERD Malabsorption/Celiac Disease Pyloric Stenosis Cleft lip and palate Hernias Intussusception Hirschsprung’s Disease Short Bowel Syndrome 1. Compare the differences in the anatomy and physiology of the gastrointestinal system between children and adults. a. Mouth i. Common point for infectious invaders (infants and young children bring objects to their mouths) b. Esophagus i. The lower esophageal sphincter (LES) prevents the regurgitation of stomach contents up into the esophagus/ mouth. LES develops around 1 month. ii. Edema or narrowing of the esophagus occurs in a child with undeveloped esophageal muscle tone aks dysphagia c. Stomach i. Newborn stomach capacity: 10-20 mL ii. 2 months capacity: 200 mL iii. 16 years capacity: 1,500 mL iv. Adulthood capacity: 2,000 - 3,000 mL v. Hydrochloric acid aids in digestion and reaches the adult level by 6 months old d. Intestines i. Small intestines are not functionally mature at birth ii. Full-term infant: 250 cm // adult: 600 cm e. Biliary System i. Pancreatic enzymes continue to develop postnatally, reaching adult levels around 2 years of age f. Fluid balance and losses i. Infants and children have a proportionately greater amount of body water than adults. ii. Fever increases fluid loss iii. Fluid loss via skin accounts for ⅔ of insensible fluid loss (infants have a relatively larger body surface area)  iv. Metabolic rate in children is higher to support growth v. Real immaturity does not allow the kidneys to concentrate urine as well 2. STOOL Specimen collection Variation a. If the child is in diapers, use a tongue blade to scrape a specimen into the collection container. b. If the child has runny stool, a piece of plastic wrap in the diaper may catch the stool specimen. Very liquid stool may require application of a urine bag to the anal area to collect the stool. c. The older ambulatory child may first urinate in the toilet, and then the stool specimen may be retrieved from the new or clean collection container that fits under the seat at the back of the toilet. d. For the bedridden child, collect the stool specimen from a clean bedpan (do not allow urine to contaminate the stool specimen). 3. Discuss common medical treatments for infants and children with alterations in bowel elimination (gastrointestinal disorders). Abdominal Visualizes abdominal organs and related vessels ultrasonography Barium swallow, small Visulizes the form position, mucosal folds, peristaltic activity, and motility of the bowel series esophagus, stomach, and upper GI tract -Small bowel series is done in conjunction with upper GI series to visualize the small intestine contour, position, and motility Blood work: amylase, -amylase:An enzyme that changes starch to sugar, which enters the blood with electrolytes, lipase, inflammation of the pancreas LFTs -electrolytes:Sodium, potassium, CO2, chloride, blood urea nitrogen (BUN), creatinine -lipase:An enzyme that changes fat to fatty acids and glycerol appearing in the blood with pancreatic change -LFTs:Enzymes that have high concentrations in the liver Esophageal Test the esophagus for normal contractile activity and effectiveness of manometry/ swallowing by measurement of intraluminal pressures and acid sensors esophageal pH probe -pH probe: a single or du Endoscopy -Gastro.: Allows visualization and biopsies of the upper GI tract (mouth to (gastroscopy, upper jejunum) with a fiberoptic instrument colonoscopy) -Colon.: Allows visualization and biopsies of the lower GI tract from the anus to the terminal ileum with a fiberoptic instrument Hemoccult, stool -Hemoccult: Checks for occult blood in the stool sample/culture, stool -stool sample: Stool is smeared on culture medium and assessed for growth of O&P bacteria over a period of days. -O&P:Checks for the presence of parasites or their eggs in the stool Hepatobiliary (HIDA) Visualizes the gallbladder and determines patency of the biliary system by use scan of a radionuclide. The amount of radionuclide ejected from the gallbladder (ejection fraction) is calculated Abdominal Visualizes abdominal organs and related vessels ultrasonography Barium swallow, small Visulizes the form position, mucosal folds, peristaltic activity, and motility of the bowel series esophagus, stomach, and upper GI tract -Small bowel series is done in conjunction with upper GI series to visualize the small intestine contour, position, and motility Blood work: amylase, -amylase:An enzyme that changes starch to sugar, which enters the blood with electrolytes, lipase, inflammation of the pancreas LFTs -electrolytes:Sodium, potassium, CO2, chloride, blood urea nitrogen (BUN), creatinine -lipase:An enzyme that changes fat to fatty acids and glycerol appearing in the blood with pancreatic change -LFTs:Enzymes that have high concentrations in the liver Esophageal Test the esophagus for normal contractile activity and effectiveness of manometry/ swallowing by measurement of intraluminal pressures and acid sensors esophageal pH probe -pH probe: a single or du Endoscopy -Gastro.: Allows visualization and biopsies of the upper GI tract (mouth to (gastroscopy, upper jejunum) with a fiberoptic instrument colonoscopy) -Colon.: Allows visualization and biopsies of the lower GI tract from the anus to the terminal ileum with a fiberoptic instrument Hemoccult, stool -Hemoccult: Checks for occult blood in the stool sample/culture, stool -stool sample: Stool is smeared on culture medium and assessed for growth of O&P bacteria over a period of days. -O&P:Checks for the presence of parasites or their eggs in the stool Liver biopsy A test done to evaluate the microscopic hepatic structures Lactose tolerance After ingesting lactose, this tests the hydrogen levels in the breath, which will test, urea breath test increase with lactose build-up in the intestines -Urea breath test: Used to detect the presence of H. pylori in the exhaled breath 1. Cleft Lip + Palate https://www.osmosis.org/learn/Cleft_lip_&_palate:_Nursing?query=Cleft_lip_and_palate%253A_Nursing&from=%2Fplaylis t%2FY4T9k5dkxn0&language=en a. Cleft lip (CL) results from the incomplete fusion of the oral cavity during intrauterine life. Cleft palate (CP) results from the incomplete fusion of the palates during intrauterine life. i. Lip fuses by 5-6 weeks and plate closes between 7-9 weeks b. Although a CL and CP can occur together, either defect can appear alone. The defects can be unilateral (one-sided) or bilateral (two-sided) c. Assessment i. Risk factors 1. Genetic syndromes  2. Family history 3. Exposure to alcohol, cigarette smoke, anticonvulsants, retinoids, or steroids during pregnancy 4. Folate deficiency deficiency during pregnancy; folic acid supplements during pregnancy can prevent clefting ii. Expected findings 1. CL is visible separation from the upper lib toward the nose 2. CP is visible or palpable opening of the palate connecting the mouth and the nasal cavity d. Therapeutic management i. CL repair is done between 2-3 months of age ii. CP repair sone between 6-12 months of age iii. No pacifier e. Complication i. Feeding difficulties, difficulty forming an adequate seal around nipple leading to excessive air intake 1. Burp infant well to expel excess air taken ii. Altered dentition iii. Delayed or altered speech iv. Otits media (ear infection) v. More prone on having heart defects vi. Altered dentition 2. Hypertrophic Pyloric stenosis- https://www.osmosis.org/learn/Pyloric_stenosis:_Nursing_Process_(ADPIE)?query=Pyloric_stenosi s%253A_Nursing_process_%28ADPIE%29&from=%2Fplaylist%2FY4T9k5dkxn0&language=en a. Hypertrophic pyloric stenosis is the thickening of the pyloric sphincter, which creates an obstruction. b. Usually occurs the first few weeks of life. c. Risk factors: i. Genetic predisposition 1. Occurs more in males than females + first-born infants d. Expected findings i. Vomiting often occurs following a feeding but can occur up to several hours following a feeding and becomes projectile as obstruction worsens. ii. Nonbilious vomitus can be blood-tinged. iii. Constant hunger. iv. Olive-shaped mass in the right upper quadrant of the abdomen and possible peristaltic wave that moves from left to right when lying supine.  v. Failure to gain weight and manifestations of dehydration (pallor, cool lips, dry skin, and mucous membranes, decreased skin turgor, diminished urinary output, concentrated urine, thirst, rapid pulse, sunken eyes). e. Nursing Management i. Preoperative- fluid management and correcting abnormal electrolyte values ii. Provide emotional support to the family + teach about surgical procedure iii. After surgery, infants usually resume oral feeding after 1 to 2 days f. Therapeutic Procedures i. Pyloromyotomy 1. Performed by laparoscope g. Preoperative Nursing Actions i. IV fluids for correction of dehydration and electrolyte imbalances ii. Nasogastric (NG) tube for decompression iii. NPO iv. I&O v. Daily weights h. Postoperative Nursing Actions i. Obtain routine postoperative vital signs. ii. Provide IV fluids. iii. Monitor daily weights and I&O. iv. Administer analgesics for pain. v. Assess for manifestations of infection. vi. Start clear liquids 4 to 6 hr after surgery. Advance to breast milk or formula as tolerated 24 hr after surgery. vii. Document tolerance to feedings. 3. Intussusception a. The proximal segment of the bowel telescopes into a more distal segment, resulting in lymphatic and venous obstruction causing edema in the area. With progression, ischemia and increased mucus into the intestine will occur. b. Common in infants and children ages 3 months to 6 years. Most common 1-2 years or 18 months and males. c. Expected finding: i. Sudden episodic abdominal pain RUQ ii. Screaming with drawing knees to the chest during episodes of pain iii. Abdominal mass (sausage-shaped) iv. Stools mixed with blood and mucus that resemble the consistency of red currant jelly v. Vomiting vi. Fever vii. Tender, distended abdomen d. Therapeutic procedures- (BOTH non-surgical procedures)  e. Diagnosed by ultrasound and shows a bullseye i. Air enema- involves injecting air into the colon to treat or diagnose conditions such as intussusception pushes the bowel back into its normal position. 1. Performed by a radiologist ii. Hydrostatic enema- A liquid is injected into the bowel under the guidance of ultrasound or fluoroscopy to reduce the intussusception. 4. Appendicitis a. Inflammation of the vermiform appendix caused from an obstruction of the lumen of the appendix. b. Average client age is 10 years. c. Expected findings i. Abdominal pain in the right lower quadrant (McBurney’s point) ii. Rigid abdomen iii. Decreased or absent bowel sounds iv. Fever v. Diarrhea or constipation vi. Lethargy vii. Tachycardia viii. Rapid, shallow breathing ix. Anorexia x. Possible vomiting d. Labs + Diagnostic Test i. CT scan: visualize the appendix ii. CBC: elevated WBC count + C-reactive protein elevated e. Nursing Care i. Prepare the child and family for surgery using developmentally appropriate techniques. ii. Avoid applying heat to the abdomen. iii. Avoid enemas or laxatives. f. Therapeutic Procedures i. Removal of non-ruptured appendix→ Laparoscopic surgery 1. Preoperative Nursing Actions a. Administer IV fluid replacement as prescribed. b. Administer IV antibiotic. 2. Postoperative Nursing Actions a. Assess respiratory status and maintain airway. b. Provide supplemental oxygen as prescribed. c. Obtain vital signs. d. Administer analgesics for pain as prescribed. e. Assess surgical site for bleeding or any other abnormalities. f. Assess bowel sounds and bowel function. ii. Removal of the ruptured appendix → Laparoscopic or open surgery  1. Preoperative Nursing Actions a. Administer electrolyte and fluid replacement as prescribed. b. Place NG tube for decompression. c. Administer IV antibiotics. 2. Postoperative Nursing Actions a. Assess respiratory status, and maintain airway. b. Provide supplemental oxygen. c. Obtain vital signs. d. Administer analgesics for pain. e. Assess surgical site for bleeding or other abnormalities. f. Assess bowel sounds and bowel function. g. Administer IV fluids and antibiotics. h. Maintain NPO status. i. Maintain NG tube to low continuous suction. j. Provide wound irrigation care for open surgical sites with antibacterial solution or saline-soaked gauze. k. Provide drain care. 3. Assess for peritonitis. a. Fever b. Sudden relief from pain after perforation, followed by a diffuse increase in pain Needs to be reported immediately. c. Irritability d. Rigid abdomen e. Abdominal distension f. Tachycardia g. Rapid, shallow breathing h. Pallor i. Chills 5. Gastroesophageal Reflux Disease a. Gastroesophageal reflux (GERD) occurs when gastric contents reflux back up into the esophagus, making esophageal mucosa vulnerable to injury from gastric acid. b. Gastroesophageal reflux disease (GERD) is tissue damage from GER. c. GER is self-limiting and usually resolves by 1 year of age. d. Risk factors: i. GER: Prematurity, bronchopulmonary dysplasia, neurologic impairments, asthma, cystic fibrosis, cerebral palsy, scoliosis ii. GERD: Neurologic impairments, hiatal hernia, morbid obesity e. Expected Finding: i. Infants 1. Spitting up or forceful vomiting, irritability, excessive crying, blood in vomitus, arching of back, stiffening 2. Respiratory problems  3. Failure to thrive 4. Apnea ii. Children: Heartburn, abdominal pain, difficulty swallowing, chronic cough, noncardiac chest pain f. Diagnostic Procedures i. Upper GI endoscopy to detect GI structural abnormalities ii. 24-hour intraesophageal pH study to measure the amount of gastric acid reflux into the esophagus iii. Barium swallow iv. Esophageal varices/Baretts precancerous v. Endoscopy with biopsy to detect esophagitis and strictures vi. Scintigraphy to identify the cause of gastric content aspiration g. Nursing Care i. Offer small, frequent meals ii. Avoid food that causes reflux (caffeine, citrus, peppermint, spicy or fried foods) iii. Assist with weight control. iv. Position the child with the head elevated after meals. v. Place infants supine to sleep, rather than prone, side-lying, or sitting upright vi. GERD: Initiate interventions for GER, plus administering a proton pump inhibitor (omeprazole, esomeprazole, pantoprazole and rabeprazole), or an H2-receptor antagonist (cimetidine or famotidine). h. Therapeutic Procedures i. Nissen fundoplication 1. Laparoscopic surgical procedure that wraps the fundus of the stomach around the distal esophagus to decrease reflux. 2. Used for clients who have severe cases of GERD. i. Complications i. Recurrent pneumonia, weight loss, and failure to thrive ii. Repeated reflux of stomach contents can lead to erosion of the esophagus or pneumonia if stomach contents are aspirated. iii. Metoclopramide 6. Hischsprung disease (congenital aganlionic megacolon) a. https://www.osmosis.org/learn/Hirschsprung_disease:_Nursing b. Hirschsprung’s disease (congenital aganglionic megacolon) is a structural anomaly of the GI tract caused by lack of ganglionic cells in segments  of the colon resulting in decreased motility and mechanical obstruction. c. Risk factors i. Family history d. Expected findings i. Newborn 1. Failure to pass meconium within 24 to 48 hr after birth 2. Episodes of vomiting bile 3. Refusal to eat 4. Abdominal distension 5. Poop foul smell → ribon like poop ii. Infant 1. Failure to thrive 2. Constipation 3. Episodes of diarrhea and vomiting iii. Child 1. Undernourished, anemic appearance 2. Abdominal distension 3. Visible peristalsis 4. Palpable fecal mass 5. Constipation 6. Foul-smelling, ribbonlike stool e. Lab test → blood electrolytes + CBC f. Diagnostic procedures→ Rectal biopsy to confirm the absence of ganglion cells g. Nursing care i. Prepare family + client for surgery ii. Assist family with improving nutritional status until surgery 1. High-protein, high-calorie, low-fiber diet 2. Total parenteral nutrition in some cases iii. Preoperative 1. Prepare family + child for surgery 2. Monitor for enterocolitis 3. Bowel prep with saline enemas and oral antibiotics 4. Ileostomy or colostomy 5. Pull through procedure. iv. Postoperative 1. Assess surgical site for bleeding 2. Assess bowel sounds and bowel function 3. Ostomy care if appropratie h. Complications i. Enterocolitis (inflammation of the bowel) 1. Treatment focuses on resolving inflammation, preventing bowel perforation, maintaining hydration, initiating antibiotic therapy, and performing surgery for colostomy or ileostomy if extensive bowel involvement exists.  ii. Nursing action 1. Vital signs, asses abdominal girth (measure grith at the level of the umbilicus or widest point of the abdomen) 7. Short bowel syndrome (SBS) a. The clinical syndrome of nutrient malabsorption and excessive intestinal fluid and electrolyte losses occurs following massive small intestinal loss or surgical resection. b. Expected findings i. If terminal ileum is lost → vitamin B12 deficiency and bile salt malabsorption may occur c. Therapeutic management i. We want to minimize bacterial overgrowth 1. Antibiotics may be used to control bacterial overgrowth ii. Maximize the child’s nutritional status 1. Many will need TPN for extended periods to achieve adequate growth 2. Vitamins and minerals supplementation is necessary because the small intestine is usually where fat-soluble vitamins (calcium, magnesium, and zinc) are absorbed iii. Antidiarrheal agents (loperamide and gastric acid-suppressive meds) may be used to decrease stool output d. Nursing assessment i. Review health history→ noting diarrhea (the primary symptom of SBS) ii. Assess hydration status iii. Inspect stool for consistency, color, odor, and volume iv. Review laboratory results 1. Evaluate hydration status 2. Liver function tests → may reveal evolving cholestasis (impairment of bile flow) secondary to long-term TPN use e. Nursing management i. Focuses on nutrition and family coping f. Encouraging adequate nutrition i. Most children will need TPN until they can tolerate enteral feeds w/o significant malabsorption and most will need long-term IV access 1. IV access places the child at high risk for infection + sepsis 2. Monitor for s/s of infection and report immediately to HCP if child has fever, redness, or drainage at the IV site ii. When starting enteral feeding must be administered very slowly, usually feeding is continuous 24 hours per day via a feeding pump iii. Assess for feeding tube residuals and abdominal distention or discomfort  iv. Strict I&O to avoid dehydration v. Asses stool for signs of carbohydrate malabsorption 1. Stool w/ pH less than 5.5 2. Test for the presence of glucose 3. Floating stool vi. Teach the family about enteral feeding tubes, feeding pumps, and medication g. Promoting effective family coping i. Long-term hospitalization is almost always required ii. Encourage families to become experts on their child’s needs and condition 1. Provide teach and focus on info about TPN and central line care, enteral feeding, assessing for hydration status, and medications 8. Celiac Disease a. Celiac disease (celiac sprue) is an immunologic disorder in which gluten causes damage to the small intestine. The villi of the small intestine are damaged due to the body’s immunologic response to the digestion of gluten. The function of the villi is to absorb nutrients into the bloodstream. When damaged malnutrition occurs b. Risk factors i. Family history and person with autoimmune or genetic disorders ii. Caucasian European decent c. Treatment i. Strict gluten-free diet 1. When eliminated gluten the villi can heal and function normally d. Nursing assessment i. Classic symptoms of celiac disease: 1. Diarrhea 2. Steatorrhea (fatty stools) 3. Constipation 4. Failure to thrive or weight loss → 5. Abdominal distention or bloating→ 6. Poor muscle tone→ 7. Irritability and listlessness 8. Dental disorders 9. Anemia 10. Delayed onset of puberty or amenorrhea 11. Nutritional deficiencies ii. Autotissue transglutaminase IgA is a first-line test → if the result is negative the antiendomysium IgA test is specific for celiac disease e. Nursing management i. Providing child + family about adhering to GF diet  ii. Foods to avoid → no yogurt iii. They can eat, all fruits, skim milk, rice and quinoa. iv. 9. Inguinal and umbilical hernias → Defects that occur during fetal development a. Inguinal Hernia i. When the processus vaginalis fails to close completely an inguinal hernia may occur ii. The hernia sacs that develop most often contain bowel in males and fallopian tubes or ovaries in females 1. Boys are more likely to develop + premature infants iii. Surgical correction is usually performed when the infant is several weeks old and has been thriving iv. Nursing assessment 1. Assess for the presence of a building mass in the lower abdomen or groin areas 2. Often the mass is seen only during crying or straining 3. Palpate the external inguinal canals for the presence of inguinal hernias, often elicited by having the child turn the head and cough or blow up a balloon. v. Nursing management 1. If mass if felt upon palpation the HCP may attempt to reduce the hernia by pushing it back through the external inguinal ring. The HCP may ask the nurse to assist by holding the child in a position that will allow the HCP to reduce the hernia 2. Reduction is only temporary → must be surgically corrected 3. If the hernia is incarcerated (doesn’t move) this could lead to bowel strangulation 4. Teach the family how to reduce the hernia until surgery b. Umbilical hernia i. Occurs commonly in preterm infants and much more frequently in African Americans compared to Caucasians ii. Caused by an incomplete closure of the umbilical ring iii. Most children will have spontaneous closure of the umbilical hernia by 4 years of age 1. Surgical correction is necessary for the largest umbilical hernia that has failed to close by 4 years old iv. Nursing assessment 1. Assess if hernia can be reduced → notify HCP if hernia will not reduce  2. Incarceration is rare but the child will report abdominal pain, tenderness, or redness at the umbilicus v. Nursing management 1. Since surgery is not likey the focus is education and teaching family how to reduce the hernia 2. Teach the child coping skills to help relieve anxiety 10. Failure to Thrive a. https://www.osmosis.org/learn/Failure_to_thrive_(FTT):_Nursing b. Inadequate growth resulting from the inability to obtain or use calories required for growth. It is usually described in an infant or child who falls below the fifth percentile for weight (and possibly for height) or who has persistent weight loss. Failure to thrive (FTT) can be classified according to the cause: i. Inadequate caloric intake (incorrect formula prep, breastfeeding difficulties, or excessive juice consumption) ii. Inadequate absorption (cystic fibrosis, celiac, or Crohn’s disease) iii. Increased metabolism (hyperthyroidism) iv. Defective utilization (Down syndrome) c. Risk factors i. Preterm birth with low birth weight or intrauterine growth restriction ii. Parental neglect, lack of parental knowledge, or disturbed maternal-child attachment iii. Poverty iv. Health or childrearing beliefs v. Family stress vi. Feeding resistance vii. Organic Causes: 1. Cerebral palsy, chronic kidney failure, congenital heart disease, hyperthyroidism, cystic fibrosis, celiac disease, hepatic disease, Down syndrome, prematurity, and gastroesophageal reflux d. Expected findings i. Less than the fifth percentile on the growth chart for weight ii. Malnourished appearance iii. Poor muscle tone, lack of subcutaneous fat iv. No fear of strangers v. Minimal smiling vi. Decreased activity level vii. Withdrawal behavior viii. Developmental delays ix. Feeding disorder x. Wide-eyed gaze, absent eye contact xi. Stiff or flaccid body e. Nursing care  i. Child may need to be removed from guardians’ care in order to evaluate carefully and receive therapy. ii. Obtain a nutritional history. iii. Observe parent-child interactions. iv. Obtain accurate baseline height and weight. Observe for low weight, malnourished appearance, and manifestations of dehydration. v. Weigh the child daily without clothing or a diaper. vi. Maintain I&O and calorie counts as prescribed. vii. Establish a routine for eating that encourages usual times, duration, and setting. viii. Reinforce proper positioning, latching on, and timing for children who are breastfed. ix. Provide 24 kcal/oz formula as prescribed. x. Provide high-calorie milk supplements for children. xi. Administer multivitamin supplements including zinc and iron. xii. Limit juice to 4 oz/day. xiii. Provide developmental stimulation. xiv. Nurture the child (rocking and talking to the child). xv. Encourage caregivers to do the following. xvi. Maintain eye contact and face-to-face posture during feedings. xvii. Talk to the infant while feeding. xviii. Burp the infant frequently. xix. Keep the environment quiet and avoid distractions. xx. Be persistent, remaining calm during 10 to 15 min of food refusal. xxi. Introduce new foods slowly. xxii. Never force the infant to eat. f. Client education i. Recognize and respond to the infant’s cues of hunger. ii. Mix the formula properly according to the provided step-by-step written instructions. g. Complications i. EXTREME malnourishment 1. Nursing action: prepare the client and parents for tube feeding or IV therapy 11. Diarrhea a. Diarrhea is either an increase in the frequency or a decrease in the consistency of stool i. Acute diarrhea is most commonly caused by viruses but also bacterial or parasites 1. Viruses injure the villous cell (the absorptive surface) resulting in decreased fluid absorption and disaccharidase deficiency 2. Bacteria injure the intestine by invading the mucosa, damaging the villous surface, or releasing toxins ii. Chronic diarrhea is diarrhea that lasts for more than 2 weeks b. Risk factors for acute diarrhea i. Recent ingestion of undercooked meats ii. Foreign travel iii. Daycare attendance iv. Well water c. Therapeutic management i. Since most cases of diarrhea are acute and viral management is usually supportive → maintaining fluid and nutrition ii. Probiotic supplementation may be useful in the prevention of diarrhea but be not effective in its treatment d. Health history → important info related to diarrhea i. Number and frequency of stool ii. Duration of symptoms iii. Stool volume iv. Associated symptoms (abdominal pain, cramping, N/V, and fever) v. Presence of blood or mucus in the stool vi. Ask about urine output (decreases w/ dehydration) vii. Recent travel e. Physical examination i. Note the child's appearance and color ii. Note decreases tear production, sunken orbits, or dry mucous w/ moderate to severe dehydration iii. Skin turgor iv. Note abdominal distention or concavity v. Auscultation 1. Hypoactive (obstruction or peritonitis) 2. hyperactive (diarrhea or gastroenteritis) f. Lab + diagnostic test i. Stool culture: may indicate the presence of bacteria. ii. Stool for ova and parasites (O&P): may indicate the presence of parasites. iii. Stool viral panel or culture: to determine the presence of rotavirus or other viruses. iv. Stool for occult blood: may be positive if inflammation or ulceration is present in the GI tract. v. Stool for leukocytes: may be positive in cases of inflammation or infection. vi. Stool pH/reducing substances: to see if the diarrhea is caused by carbohydrate intolerance. vii. Electrolyte panel: may indicate dehydration. viii. Abdominal radiographs (KUB): presence of stool in colon may indicate constipation or fecal impaction (hardened immobile bulk of stool); air–fluid levels may indicate intestinal obstruction.  g. Nursing management i. Focuses on restoring fluid + electrolyte balance and providing family education h. Restoring fluid and electrolyte balance i. Continue the child’s regular diet if the child is not dehydrated. ii. Initial nursing management of the dehydrated child with diarrhea is focused on fluid and electrolyte balance restoration. iii. After rehydration is achieved, it is important to encourage the child to consume a regular diet to maintain energy and growth. 12. Dehydration a. Dehydration occurs more in infants + young children than adults because: i. increased extracellular fluid percentage ii. relative increase in body water compared to adults iii. Increased Metabolic rare iv. Increased ratio of BSA to body mass v. immature renal function vi. increased insensible fluid loss through temperature elevation b. Dehydration left untreated can lead to shock, hypovolemic shock c. Levels of dehydration i. Mild 1. Weight Loss 2. 3% to 5% in infants 3. 3% to 4% in children 4. Manifestations a. Behavior, mucous membranes, anterior fontanel, pulse, and blood pressure within expected findings b. Capillary refill greater than 2 seconds c. Possible slight thirst ii. Moderate 1. Weight Loss 2. 6% to 9% in infants 3. 6% to 8% in children 4. Manifestations a. Capillary refill between 2 and 4 seconds i. Possible thirst and irritability ii. Pulse slightly increased with normal to orthostatic blood pressure iii. Dry mucous membranes and decreased tears and skin turgor​​ iv. Slight tachypnea v. Normal to sunken anterior fontanel on infants iii. Severe 1. Weight Loss 2. Greater than 10% in infants  3. 10% in children a. Manifestations i. Capillary refill greater than 4 seconds ii. Tachycardia present, and orthostatic blood pressure can progress to shock iii. Extreme thirst iv. Very dry mucous membranes and tented skin v. Hyperpnea vi. No tearing with sunken eyeballs vii. Sunken anterior fontanel viii. Oliguria or anuria d. Nursing assessment i. The goals of therapeutic management are to restore appropriate fluid balance and to prevent complications ii. Risk factors for dehydration 1. Diarrhea 2. Vomiting 3. Decreased oral intake 4. Sustain high fever 5. Diabetic ketoacidosis 6. Extensive burns e. Teaching guidelines → Oral rehydration therapy i. Oral rehydration solution (ORS) =should contain 75 mmol/L sodium chloride and 13.5 g/L glucose (standard ORS solutions include Pedialyte, Infalyte, and Ricelyte). ii. Tap water, milk, undiluted fruit juice, soup, and broth are NOT appropriate for oral rehydration iii. Children with mild to moderate dehydration require 50(mild)–100(moderate) mL/kg of ORS over 4 hours. iv. After reevaluation, oral rehydration may need to be continued if the child is still dehydrated. v. When rehydrated, the child can resume a regular diet. f. Nursing actions i. Oral rehydration is attempted first for mild and moderate cases of dehydration. 1. Mild: 50 mL/kg rehydration fluid within 4 hr 2. Moderate: 100 mL/kg rehydration fluid within 4 hr 3. Replacement of diarrhea losses with 10 mL/kg each stool ii. Administer parenteral fluid therapy as prescribed. 1. Initiate when a child is unable to drink enough oral fluids to correct fluid losses, and those with severe dehydration or continued