Care of the Child

1. NCM 102:
Care of the Child with
Disorders

2. Nursing Care of the Child with
Respiratory Disorders

3. Review of the Respiratory System
1. Thoracic cavity encased by a bony
framework of the ribs, vertebrae and
sternum.
2. Lobes of the lungs: Right= 3; Left=2
3. Mediastinum contains the esophagus,
trachea, large blood vessels and the
heart.
4. Two pleural membranes are separated by
enough fluid for lubrication.

4. Chest:
1. Round configuration at birth
2. Infant’s chest diameter is decreased
during respiration.

6. Airways:
* Infants are nose breathers
I. Upper: (shared by both the respiratory
and alimentary tracts)
a. Sequence of airway muscle activation
is different in breathing and swallowing.
b. Inspiration is short during crying,
coughing, sneezing

7. Airways:
II. Lower Airways
a. Newborn airways have little smooth
muscles
b. Growth of the respiratory system
follows a general growth curve during the
early weeks of life.
c. Airways grow faster than the thoracic
and cervical portions of the vertebral
column

8. Respiratory Units: *Gas exchange
a. Infants and young children have less
alveolar surface area for gas exchange
b. Respiratory rate steadily decreases until
it levels off maturity
c. Infant Breathing: diaphragmatic,
abdominal
d. Respiration facilitated by 2 processes:
1. a. Compliance 2. Resistance
b. Recoil

9. Respiratory Units:
• Compliance is normally high in the mature
newborn and infant
• As the child grows, chest wall compliance
decreases and elastic recoil increases

10. Upper Respiratory Disorders

11. ACUTE
NASOPHARYNGITIS (Viral)
Common Colds
* Usually self-limiting and resolves
within 4-10 days without
complications
Causative Agents:
a. Rhinovirus
b. Respiratory Syncitial Virus
c. Adenovirus
d. Influenza virus
e. Parainfluenza virus

12. Clinical Manifestations:
1. Fever- may complicate to otitis
media
2. Nasal inflammation
3. Vomiting and diarrhea may be
present
4. Dryness and irritation of nasal
passages and pharynx
5. Sneezing
6. Chills
7. Muscular aches
8. Irritating nasal discharge

13. 9. Cough
10. Skin irritation to the nares
THERAPEUTIC MANAGEMENT
1. Antipyretics
2. Rest
3. Decongestants
4. Cold suppressants containing
Dextromethorpan
5. Elevate crib or mattress
6. Adequate fluid intake

14. THERAPEUTIC MANAGEMENT
Prevention of Transmission:
1. Avoid contact with affected
persons.
2. Carefully dispose tissues; wash
hands
3. Cover the mouth when sneezing;
wash hands

15. ACUTE STREPTOCCOCAL
PHARYNGITIS
Causative agent:
Group A beta Hemolytic
Streptococus (GABHS)
Manifestations:
*Varies from subclinical to severe
toxicity
* Onset is abrupt
1. Pharyngitis
2. Headache
3. Fever

16. 4. Abdominal pain
5. Anterior cervical lymphadenopathy
6. Pain
Complications:
a. Acute glomerulonephritis
b. Rheumatic fever
DIAGNOSIS:
*Throat culture

17. THERAPEUTIC MANAGEMENT
1. If due to GAHBS
-Oral Penicillin for 10 days
-IM Pen G benzathine
- if allergic to penicillin=
Erythromycin
Other drugs to treat GAHBS
pharyngitis:
a. clarithromycin e. amoxicillins
b. azithromycin
c. clindamycin
d. cephalophorins

18. 2. Bed rest
3. Cold and warm compress to the
neck
4. Saline gargles
5. Cool liquid/ ice chips
6. Antibiotic therapy compliance

19. TONSILLITIS
Predisposing factors:
1. Pharyngitis
2. Young children
3. Viral/ Bacterial infections
CLINICAL MANIFESTATIONS:
1. Inflammation of the palatine tonsils
2. Difficulty of swallowing and breathing
3. Dry and irritated oropharynx

20. THERAPEUTIC MANAGEMENT:
1. If with viral pharyngitis- symptomatic
treatment
2. If caused by GABHS- Antibiotic treatment
3. Surgery: Tonsillectomy
Conditions that will allow for surgery:
a. With frequent streptococcal infection
b. History of development of peritonsillar
abscess
c. Massive hypertrophy that results in

21. difficulty of breathing or eating
d. Malignancy or obstruction of the
airways that results in cor pulmonale
Adenoidectomy (removal of the adenoids)
Condition that will allow for Surgery:
a. With hypertrophy of the adenoids that
obstruct nasal breathing

22. Contraindications for Tonsillar or Adenoidal
Surgery:
1. Cleft palate
2. Acute infections at the time of surgery
3. Uncontrolled systemic diseases
4. Blood dyscracias

23. THERAPEUTIC MANAGEMENT
1. Soft/ Liquid diet
2. Cool-mist vaporizer
3. Warm saline gargles
4. Throat lozenges
5. Analgesics/ Antipyretics

24. Post Surgery Management:
1. Supine / Side lying
2. Suctioning
3. Discourage to cough frequently, clear
the throat and blow the nose
4. Inspect secretions and vomitus for fresh
bleeding
5. Ice collar
6. IV analgesics

26. Post Surgery Management:
7. Local anesthetics
8. Antiemetics
9. Food and fluid restriction until the child
is fully alert and without signs of
hemorrhage.
10. Soft foods
11. Observe for signs and symptoms of
hemorrhage

27. Home Care
Discharge instructions include:
1. Avoid foods that are irritating highly
seasoned
2. Avoid gargles
3. Avoid vigorous tooth brushing
4. Discourage coughing or clearing of the
throat
5. Prevent from putting objects into the
mouth

28. 7. Use of analgesics and ice collar for pain
8. Limit activity- to decrease the risk of
bleeding

29. INFLUENZA (flu)
Causative Agents:
Orthomyxoviruses
*Most common in wet months
*1-3 days incubation period
* Infected persons are most
infectious for 24hours before and
after the onset of symptoms

30. CLINICAL MANIFESTATIONS:
1. Dry nasal mucosa and throat
2. Dry cough
3. Tendency towards hoarseness
4. Sudden onset of fever accompanying:
a. Flushed face
b. Photophobia
c. Myalgia
d. Hyperesthesia
e. Prostration
5. Subglottal croup/
laryngotracheobronchitis

31. THERAPEUTIC MANAGEMENT:
1. Uncomplicated type= symptomatic
treatment
a. Acetaminophen/ paracetamol/
ibuprofen
b. Hydration
2. Zanamavir and rimantidine- given in
children under 18 years old
3. Tamiflu (oseltamavir)- given to children
over 1 year and adults

32. PREVENTION:
INFLUENZA VACCINE (Trivalent
Inactivated Influenza Vaccine)
- given to 6 months old and older with risk
factors:
1. a. Asthma
b. Cardiac diseases
c. HIV
d. Diabetes
e. Sickle cell disease

33. 2. Health workers
3. Those who are in close contact with
persons in groups at high risk
* Given also in healthy children 6-23 months

34. CROUP SYNDROMES

35. * Occurs most often in boys than girls
CROUP SYNDROMES classic signs:
1. Hoarseness
2. Inspiratory stridor
3. Varying degrees of respiratory distress
from swelling and obstruction in the
region of the larynx
4. Steeple sign

37. ACUTE
LARYNGOTRACHEOBRONCHITIS
- Affects children younger than 5
years old
- Causative microorganisms:
1. Parainfuenza virus type 1,2 and 3
2. Respiratory syncitial virus
3. Influenza types A and B
4. M. pneumoniae
- Usually preceded by URI

38. Clinical Manifestations:
1. Gradual onset of low grade fever
2. Barky, brassy cough
3. Inflammation of the mucosal lining
4. Inspiratory stridor with suprasternal
retractions
5. Cough
6. Hoarseness
7. Respiratory distress in infants

40. 8. Hypoxia
9. Respiratory acidosis
THERAPEUTIC MANAGEMENT
Goal: Maintaining airway and providing
adequate respiratory exchange
1. High humidity with cool mist; with
supplemental Oxygen
2. Increase fluid intake; IV therapy

41. 3. Nebulized (racemic) epinephrine if not
alleviated by cool mist
4. Corticosteroids
5. Severe cases: Mix helium to Oxygen
6. Cardiac, respiratory and non-invasive
blood gas monitoring
7. Intubation equipment and bag and valve
mask equipment should be readily
accessible.
8. Rest to conserve energy.

42. PNEUMONIA
• Inflammation of the pulmonary
parenchyma
Morphologic Classification:
1. Lobar pneumonia
2. Bronchopneumonia
3. Interstitial pneumonia

43. CLINICAL MANIFESTATIONS:
• May vary depending on the etiologic agent,
child’s age, systemic reaction to infection,
extent of lesions and degree of bronchial
and bronchiolar obstruction
General signs of Pneumonia:
1. Fever
2. Cough- unproductive to productive with
whitish sputum
3. Tachypnea

44. 4. Ronchi or fine crackles
5. Dullness to percussion
6. Chest pain
7. Retractions
8. Nasal flaring
9. Pallor to cyanosis
10.X-ray: Diffuse or patchy infiltration; with
peribronchial distribution
11. GIT signs: anorexia, vomiting, diarrhea,
abdominal pain

45. TYPES of Pneumonia:
1. Viral pneumonia- associated with URIs
S/S:a. mild to high fever
b. slight cough to severe cough
c. malaise
d. fatigue
e. cough with small amounts of whitish
sputum

46. f. Breath sounds: wheezes, fine crackles
g. X-ray: Diffuse patchy infiltration with
peribronchial distribution
THERAPEUTIC MANAGEMENT *Symptomatic
1. Oxygen administration
2. Chest physiotherapy
3. Postural drainage
4. Antipyretics
5. Increase fluids

47. 2. Primary atypical pneumonia
Most common cause: M. pneumoniae
- most common in ages between 5-12
years old
S/S:
a. General systemic symptoms:
1. fever
2. chills (in older children)
3. headache

48. 4. anorexia
5. myalgia
b. Symptoms followed by:
1. rhinitis
2. sore throat
3. dry, hacking cough
c. Initial non-productive cough, progresses
to mucopurulent to blood-streaked
d. X-ray: 1. Round cell infiltrate

49. 2. edema of the alveolar septa
3. with varying distribution of areas of
inflammation, necrosis and ulceration of the
mucosal lining of bronchi and bronchioles
4. with areas of consolidation
5. emphysema
Nursing Management:
1. Symptomatic treatment
2. Convalescence

50. 3. Bacterial Pneumonia- acquired through
aspiration; hematogenous
- Staphylococcus pneumoniae: most
common bacterial pathogen (community
acquired)
S/S:
1. Acute onset fever- usually high
2. Toxic appearance
3. Headache
4. Chills

51. 5. Abdominal pain
6. Chest pain
7. Meningeal symptoms
8. Increase respiratory rate; air hunger;
tachypnea, circumoral cyanosis
9. Cough with adventitious breath sounds

52. Diagnosis:
1. X-ray: pulmonary infiltrates with lobar
consolidation or pleural effusion
2. Gram stain and culture of sputum,
nasopharyngeal specimens, blood cultures
3. Lung aspiration and biopsy
4. Increased WBC
5. Increased antistreptolysin O titer

53. PULMONARY CONSOLIDATION

54. THERAPEUTIC MANAGEMENT:
1. Antibiotic therapy: Oral amoxicillin, co-
amoxiclav, erythromycin
2. Bed rest
3. Liberal fluid intake
4. Antipyretics
5. Hospitalization- if with pleural
effusion/empyema
6. Oxygen administration

55. Prevention:
HEPTOVALENT PNUEMOCOCCAL
VACCINE
*Recommended in infants and children
younger than 23 months
*To be administered at 2,4,6,12 and 15
months of age
*Given every 5 years

56. TUBERCULOSIS
*Causative agent: M. Tuberculosis
*Transmission: Inhalation of
microdroplets into the respiratory
tract after someone has coughed
or sneezed
Pathophysiology:
Droplet/airborne
↓
Invasion of the bronchial tree
↓
Implantation into the bronchioles/
alveolus

57. ↓
Multiplication
↓
Inflammatory process
↓
Bacilli leave the focal area and carried to the
regional lymph nodes
↓
Extension of primary lesion
↓
Extensive tissue destruction
↓
Erosion of blood vessels to near distant sites
↓
Bleeding

58. Clinical Manifestations:
1. Fever
2. Malaise
3. Anorexia
4. Weight loss
5. Aching pain
6. Tightness of the chest
7. Hemoptysis
8. Lung on the affected side does not
expand well
9. Diminished breath sounds
10.Crackles
11. Dullness to percussion

59. Diagnosis:
1. History of contact with infected person
2. TB test/ PPD test= 5 tuberculin units to
.0.1 ml of solution
Results:
I. Induration more than or equal to 5mm
a. children in close contact with known
or suspected cases
b. with suspected tuberculosis disease

61. c. with clinical evidence of TB
d. Receiving immunosuppresssive
therapy, immunosuppressive conditions
e. CXR- with active or previously
active TB
II. Induration more than or equal to 10 mm
a. With increased risk of
disseminated disease
b. increase risk of exposure to TB

62. a. Born and with parents in high
prevalence TB regions of the world
b. Frequently exposed to adults who are
HIV infected, homeless, users of illicit
drugs, residents of nursing homes,
incarcerated or institutionalized persons,
or migrant farm workers

63. III. Induration of more than or equal to
15mm
a. without any risk factors

65. 3. Bacteriologic exam
- Sputum exam
- Gastric lavage
4. X-ray

66. Management: for Latent tuberculosis
infection with (+) positive Skin testing
1. Isoniazid (INH)- given for 9 months or
direct observation therapy alternately 2-
3 times a week
2. Rifampin- daily for 6 months
- if resistant to INH
3. Combi = INH, Rifampin and PZA
(Pyrazinamide)

67. Nursing care:
1. Prevention- avoid contact
2. Isolation
3. Airborn precautions
4. BCG
5. proper diet, adequate rest, avoidance
ofinfection

68. ASTHMA

69. ASTHMA is a chronic inflammatory
disorder of the airway that causes
airway hyperresponsiveness, mucosal
edema and mucus production.
It is the most common chronic disease
of childhood

70. Risk Factors:
1. Age
2. Heredity
3. Gender
4. Mother under 20 years old
5. Smoking
6. Ethnicity
7. Previous life threatening attacks
8. Lack of access to medical care
9. Psychologic and psychosocial problems

71. Predisposing/ Triggering factors:
1. Allergens
1. Seasonal
2. Outdoor
3. Perennial
4. Irritants
2. Animals
3. Medications
4. Stress/ Emotional upsets

72. 5. Food
6. Food additives
7. Conditions- Gastroesophageal reflux,
tracheoesophageal reflux

73. PATHOPHYSIOLOGY
Contact with triggering factors
↓
Initial release of inflammatory mediators from
the bronchial mast cells, macrophages and
epithelial cells
↓
Migration and activation of other inflammatory
cells
↓

74. ↓
Alteration in epithelial integrity and autonomic
neural control of airway
↓
Increase in airway smooth muscle responsiveness
Alteration in epithelial integrity and autonomic
neural control of airway tone
↓
Wheezing, dyspnea, smooth muscle
responsiveness

75. Conditions relating to ASTHMA occurrence:
1. Patients with asthma may experience
symptom-free periods alternating with
acute exacerbations.
2. Many children with asthma exhibit an
allergic component
3. Vagal and sympathetic nerve influences
are responsible for the tone of bronchial
smooth muscles

76. Conditions relating to ASTHMA occurrence:
4. Narrowing and shortening of the airway
increases airway resistance to airflow.
5. The number of ventilated alveoli affects
the oxygen levels of the blood.

77. Manifestations:
1. Dyspnea
2. Wheezing
3. Coughing
4. Prodromal itching at the front of
the upper neck or the upper part
of the back
5. Discomfort, irritability,
restlessness, apprehension
6. Headache, tired feeling
7. Tightness of the chest

78. 8. Respiratory symptoms
9. Wheezing
10. Shortness of breath, deep
breathing
11. Expiratory phase becomes
prolonged with audible wheezes
DIAGNOSIS:
1. Pulmonary function test
1. Incentive spirometry
2. Peak expiratory flow meter

79. 2. Bronchoprovocation testing
3. Skin testing
4. Laboratory tests
- CBC
5. X-ray- frontal and lateral
MANAGEMENT
1. Allergen control
2. Drug therapy
Long term control meds
1. Inhaled corticosteroids

80. 2. Cromolyn and Necrodomyl
Sodium
3. Beta adrenergic agents
4. Methylxanthines
5. Anticholinergics
6. Leukotriene modifiers
2. Chest physical therapy
3. Hyposensitization
4. Exercise

81. Cardiovascular System Disorders

82. Review of the Cardiovascular
System
Cardiac Development and Function
1. The heart is a 4-chambered organ
2. The heart’s location is slightly to
the left of the sternum in the
space between 2 pleural cavities
3. Layers:
Myocardium
Endocardium
Pericardium
Pericardial space

83. Fetal Circulation:
Highly oxygenated blood from the placenta
↓
Umbilical vein
↓ ↓
Inferior vena cava Ductus venosus
↓
Right atrium
↓

84. ↓
Foramen ovale
↓
Left atrium
↓
Left ventricle
↓
Aorta
↓

85. Return of blood to the heart via SVC
↓
Right atrium
↓
Tricuspid valve
↓
Right ventricle
↓
Pulmonary artery

86. ↓
Pulmonary artery
↓ ↓
Lungs Ductus arteriosus
↓
Descending aorta
↓
Umbilical arteries
↓
Placenta

87. Post Natal Development
1. Heart is larger in relation to body size
2. Heart occupies a large space within the
mediastinum
3. LV walls become thicker; LV pressures on
the L side is increased

88. Cardiac Physiology:
The primary function of the heart is to provide
effective oxygen transport to meet the
body’s metabolic need
3 factors that influence stroke volume:
1. Preload- volume of blood returning to the
heart
2. Afterload- resistance against which the
ventricles must pump when ejecting blood

89. 3. Contractility- efficiency of the
myocardial fiber shortening
Frank Sterling’s Law of the Heart:
“The greater the myocardial fiber length or
stretch, the greater is the force of
contraction”
Contractile state (Inotropic State)- vigor
of contraction

90. Congestive Heart Failure

91. Congestive Heart Failure
It is the inability of the heart to
pump adequate blood to the
systemic circulation at normal
filling pressures to meet the body’s
metabolic demands
Causes:
1. Volume overload
2. Pressure overload
3. Decreased contractility of the
myocardium
4. High cardiac output demands

93. Right- sided Heart Failure

94. Pathophysiology: (Systemic congestion)
RV unable to maintain an adequate output
↓
Increased end-diastolic pressure of RV
↓
Increased CVP
↓
Systemic venous engorgement/ congestion
↓

95. Pathophysiology
↓
Increased pressure
↓
Pooling of blood in the venous circulation

96. Diagnosis: (Made based on clinical
symptoms)
1. Chest x-ray- cardiomegaly
2. Electrocardiogram- ventricular
hypertrophy; determination of causes
3. Echocardiogram

97. Clinical Manifestations:
1. Hepatomegaly- enlargement of
the liver
2. Generalized edema (anasarca)
3. Weight gain
4. Distended neck and peripheral
veins

98. Left-sided Heart Failure

99. Pathophysiology: (Pulmonary Congestion)
LV dysfunction
↓
Increased LV end diastolic pressure
↓
Increased pressure in the LA and pulmonary
veins
↓

100. Pathophysiology: (Pulmonary Congestion)
↓
Backing up of blood to the lungs
↓
Congestion

101. Clinical Manifestations:
1. Tachypnea
2. Hypoxemia
3. Mild cyanosis
4. Dyspnea
5. Inability to feed; Poor weight gain
6. Costal retractions with pliable chest wall
in the infant
7. Labored breathing

102. 8. Nasal flaring
9.Pulmonary edema
10. Orthopnea
11. Wheezing
12. Productive cough
13. Hoarseness of voice
14. Increased metabolic rate

103. Therapeutic Management
1. Improve cardiac function
Drugs that enhance the cardiac
function:
a. Digitalis glycosides
b. Ace inhibitors
c. Beta Blockers
2. Remove accumulated fluid and
sodium
a. Diuretic administration
b. Fluid restriction

104. c. Low salt formulas
3. Decrease cardiac demands
a. Provide neutral thermal
environment
b. Treat existing infections
c. Reduce effort of breathing
d. Provide rest and decrease
environmental stimuli
4. Improve tissue oxygenation
a. Oxygen – humidified
5. Reduce respiratory distress
6. Maintain nutritional status

105. KAWASAKI DISEASE
It is a form of vasculitis identified by an
acute febrile illness with multiple
system involvement
With widespread inflammation of the
small and medium-sized blood vessels,
usually the coronary arteries
Cause: Unknown but may be due to:
1. Autoimmunity/ Passive immunity
2. Young age
3. Infection
4. Genetic predisposition

106. Pathophysiology
Progressive inflammation
↓
Damage of walls of the vessels
↓
Coronary artery aneurysm
↓
Affected vessels continue to enlarge
↓
Aneurysm of the peripheral vessels

107. Clinical Manifestations:
A. Acute Phase
a. Abrupt onset of fever
b. Bulbar conjunctiva of the eyes
become reddened
c. Inflammation of the pharynx
d. Oral mucosal inflammation with
cracked lips; strawberry tongue
e. Rash with desquamation

108. f. edema of the hands and feet
g. Erythema of the palms and soles
h. cervical lymphadenopathy
i. Myocarditis with decreased LV
function
Coronary arteries begin to enlarge

109. B. Subacute Phase
a. Resolution of fever
b. Enlargement and dilatation of the
arteries
c. Thrombocytosis
d. Periungal desquamation of the hands
and feet
e. Arthritis affecting the large
weight-bearing joints

110. C. Convalescent Phase
All clinical signs are resolved but have not
yet returned to normal
Diagnosis:
1. Elevated ESR
2. Elevated CRP
3. Sterile pyuria with mononuclear cells on
microsopic analysis

111. 4. Transcient elevation ofliverenzymes
5. Aseptic meningitis
6. Electrocardiogram
Management:
1. High dose of IVIG wit salicylate therapy
2. Aspirin
3. Low-dose salicylate therapy
4. Warfarin

112. Prognosis:
Most children recover fully after treatment
Death occurs rarely if cardiovascular
complications are treated promptly.

113. Gastrointestinal System

115. Review of the anatomy and physiology:
Primary function:
Digestion and absorption of nutrients
The mechanical functions of digestion are
immature:
1. Swallowing
-Automatic reflex action for the 1st 3
months

116. - No voluntary control unless the
striated muscles of the throat establish
cerebral connections
- Voluntary control begins
approximately 6 week of age
- At the start of the 6th month,
capable of swallowing, holding food in the
mouth and spitting it out

117. 2. Sucking
- Reflexive activity of the newborn
with the muscular action of the tongue to
do a forward thrust
3. Chewing
- Facilitated by the eruption of the
primary teeth

118. The GIT Anatomy and Physiology:
1. Stomach
-round until 2 years old; elongates until
7 years old
- stomach capacity increases with age
2.Intestinal tract
- functional at birth
- salivary amylase to moisten the
mouth and throat

119. - at 2 years old, more enzymes are
excreted to aid in digestion
Functions:
1. Digestion
a. Mechanical/ muscular activity
producing GI motility (movement)
b. Chemical or enzymatic activity
resulting from GI secretions

120. 5 types of GI secretions:
1. Enzymes
2. Hormones
3. Hydrochloric acid
4. Mucus
5. H2o and electrolytes

121. Process of Digestion:
Biting and chewing; mixing of food with
saliva
↓
Salivary amylase begins process of digestion
of complex starches and CHO
↓
Upper esophageal sphincter relaxes
↓

122. ↓
Peristalsis
↓
Esophagus
↓
Lower esophageal sphincter relaxes
↓
LES contracts to prevent food reflux
↓

123. ↓
Gastric glands secretes enzymes, HCl acid
and mucus and mix with food
↓
Partially digested food and watery gastric
secretions are delivered to the small
intestines
↓
Absorption of nutrients in the small
intestines

124. B. Absorption- occurs in the small intestines
The large intestines completes the process
of absorption
C. Elimination of waste products
*Bacteria affects the color and odor of stool
and gas formation:
a. Brown color
b. Bleeding
1. Tarry black/ melena
2. Bright/ dark red

125. 3. Scybala
*Defecation occurs when the internal and
exernal anal sphincters relaxes following
distension of the rectum by feces
*Frequency of defecation is increased in
newborns

126. GASTROINTESTINAL
DISORDERS

127. HIRSCHSPRUNG’S DISEASE
(Congenital Aganglionic Megacolon)
- A congenital anomaly that results
in mechanical obstruction from
inadequate motility of a part of the
intestine

128. Pathophysiology:
Absence of ganglion cells in the affected
areas of the intestine nervous system
stimulation
↓
Lack of independent enteric nervous system
stimulation
↓
Loss of rectosphincteric reflex
↓

129. ↓ ↓
Decreased ability Absence of
of the internal peristalsis
sphincters to relax
(Contraction of abnormal
bowel)
↓ ↓
Inability to pass out stools

132. Clinical Manifestations:
1. Newborn period
1. Abdominal distension
2. Vomiting
3. Constipation
4. Failure to pass meconium
5. Signs of acute intestinal obstruction
6. Bilious vomiting

133. 2. Infants
a. abdominal distention relieved by rectal
stimulation/ enema
3. Older infants and children
a. constipation
b. abdominal distention
c. vomiting
d. history of delayed meconium passage
e. chronic constipation

134. Older children
a. evidence of previous GI dysfunction
b. Failure to thrive
c. chronic constipation
DIAGNOSIS:
1. Barium enema
2. Rectal biopsy
3. Anorectal manometry

135. THERAPEUTIC MANAGEMENT
A. Surgery- majority of cases
- Removal of aganglionic portion for the
purposes of:
1. relieving obstruction
2. restoring normal motility
3. preserving the function of the
external anal sphincter

136. Procedure:
1. Initial prep- Fluid and electrolyte
replacement
2. Creation of an ostomy proximal to the
aganglionic site
3. Complete, corrective surgery

137. Surgeries performed:
1. Soave endorectal pull-through
2. Anorectal myomectomy
- if with short segment disease
Nursing Care:
A. Pre-op care
1. Enema
2. Low fiber, high calorie, high
protein/ TPN
3. GOLYTELY- with pull-through
procedure

140. 4. Measure abdominal circumference
5. Educate parents for ostomy care
B. Post operative care
- same with any abdominal surgery
1. NPO
2. NGT to suction
3. MIO
4. Monitor return of bowel sounds
and passage of stool
5. Colostomy care

141. GASTROESOPHAGEAL REFLUX
- Transfer of gastric contents to the
esophagus
Pathophysiology:
Feeding
↓
Food propelled towards the esophagus
↓ ↓
Stomach Episodes of
↓ transient relaxation
↓ of LES

142. ↓
Increase abdominal pressure
↓
Inadequate adaption of internal sphincters
↓
Reflux
↓
Vomiting

143. Factors that contribute to the presentation
and severity of GERD:
1. Frequency of reflux
2. Gastric acidity
3. Gastric emptying
4. Esophageal clearing mechanisms
5. Integrity of the esophageal mucosal barrier
6. Sensitivity of the viscera
7. Responsiveness of the airway

144. Factors that affect LES pressure:
1. Gastric distention
2. Increased abdominal pressure
High Risk:
1. Premature infants with bronchopulmonary
dysplacia
2. Tracheoesophageal or esophageal atresia
repairs
3. Neurologic disorders

145. 4. Scoliosis
5. Asthma
6. Cystic fibrosis
7. Cerebral palsy
CLINICAL MANIFESTATIONS
1. Passive regurgitation or emesis/ vomiting
2. Anorexia
3. Dysphagia

146. 4. Irritability
5. Hematemesis
6. Anemia
7. Failure to thrive
8. Older children: adult-like pattern
a. heartburn
b. regurgitation
c. reswallowing
9. Barrett mucosa
10. hoarseness

149. DIAGNOSIS:
1. History of vomiting
2. Stool Guaiac test
3. Assessment of growth and nutritional
status
4. Barium swallow
5. Esophageal pH monitoring
6. Endoscopy with biopsy
7. Scintigraphy and manometry

150. 8. Empiric medical therapy
THERAPEUTIC MANAGEMENT
1. Small, frequent feedings of thickened
formula
2. Frequent burping
3. Positioning- prone if awake
4. Decrease fat intake, spicy foods

151. 5. Pharmacologic therapy
a. Acid suppressant meds
Eg. Omeprazole. Lansoprazole
b. Antacids
Eg. Aluminum hydroxide (Maalox)
6. Surgery
Nissen fundoplication- creation of an
antireflux valve around the portion of the
intra-abdominal esophagus by decreasing the
diameter of the distal esophagus

153. APPENDICITIS
Inflammation of the veniform appendix
Causes:
1. Obstruction of the lumen of the
appendix by hardened fecal material,
foreign bodies, microorganisms, parasites
2. Fold of peritoneum causes the appendix
to adhere to the cecum
3. Lymphoid hyperplasia

154. 4. Fibrous stenosis from inflammation or
stenosis
5. Diet high in sugar and low in fiber
CLINICAL MANIFESTATIONS
1. Colicky, abdominal pain located around the
umbilicus
2. Vague periumbilical localization (referred
pain)
3. Focal abdominal tenderness (Mc Burney’s
Point)

155. 4. Rebound tenderness
5. Nausea and vomiting, anorexia
6. Pain at the right hip
7. Low-grade fever
8. Psoa’s sign
9. Obturator sign

156. Diagnosis:
1. History and PE
2. CBC, Urinalysis, Pregnancy test
3. UTZ
MANAGEMENT
1. Assessment: location and extent of pain
2. Auscultate for the presence of bowel
sounds

157. 3. Appendectomy before perforation
4. If ruptured:
a. IV fluids/ electrolytes
b. Systemic antibiotics
c. NG tube suction
5. Post op management
a. Semi-fowler’s, knees up
b. Restrict activity
c. Ice bag over abdomen for comfort

158. d. Antiemetics/ analgesics
e. Avoid indiscriminate palpation of the
abdomen

159. INTUSSUSCEPTION
The proximal segment of the bowel
telescopes into a more distal
segment, pulling the mesentery
with it.
Cause: Unknown
1. Males
2. Cystic fibrosis

161. Pathophysiology
Telescoping
↓
Mesentery compressed and angled
↓
Lymphatic and venous obstruction
↓ ↓
Edema Venous engorgement
↓ ↓

162. ↓ ↓
Arterial blood flow Leaking of blood
stops and mucus to
intestinal lumen
↓ ↓
Ischemia Currant jelly-like
stools
↓
Pouring of mucus into
the intestine

163. CLINICAL MANIFESTATIONS
1. Crampy, abdominal pain
2. Bilious vomiting may occur
3. Lethargy
4. Classic Triad:
1. Pain
2. Palpable sausage-shaped abdominal
mass
3. Currant jelly-like stools

164. 5. Vomiting
6. Rectal bleeding/ hematest positive stools
7. If distal bowel remains distended,
necrosis and perforation may occur
Diagnosis:
1. Barium enema
2. Abdominal radiograph
3. Rectal exam

165. MANAGEMENT
1. Initial treatment of choice: Non-surgical
hydrostatic reduction
2. Administration of air pressure
- With IVF administration, NG
decompression, antibiotic therapy
(before hydrostatic reduction)
3. Surgery: Manual reduction of the
invagination with resecting any non-
viable intestine

166. NCM 102
Care of Mother, Child, Family and Population
Group At-risk or With Problems
CYGNETTE SIRON- LUMBO
Lecturer

167. THANK YOU VERY MUCH !!!