Whether this is true in our own lives or the lives of those that we have the privilege to interact with and help this is so true. We can and do make a difference
This paradigm certainly is changing. What we saw in PPEC is the direct result of being able to save those tiny preterm babies. Peds nurses: Patient teaching to educate and empower the family to care for the child in the home setting. Opportunities for education: Your child’s schoolChurch groupsYouth groupsGirl scoutsSportsYou will always be on duty! But you won’t mind.
Something you can measure When reading journals for EBP talk about q/q changes.
This occurs through growth, maturation and learning Give child opportunities pos or negSome children that we see with have developmental delays. They need greater opportunities to explore. Causes of Delay - lack of knowledge, child been very ill, family stress, other children, substance abuse. Overuse of TV***All stages dependent upon environmental, genetic, nutritional factors. Nathan
Baby girls are born with eggs in their ovaries, but they don’t mature until pubertyOrgan transplant/regeneration of islet cells/stem cell transplantNeural cells are modified. Synapses have to learn to communicate with each other.
Have to give opportunities Role model. Have to see. How many have kid? Do your kids do what you tell them to do or do they do what they see you do. Er kids modeling language of parent.
Opportunities give children a chance to developSensitive periods reflected on ranges seen on G &D matrix.Change not expected in one day but over several weeks.
HEREDITY - Inherited characteristics, sex, body size and shape, hair colorNEUROENDOCRINE - hormones affect heredity – PKU test or now called infant screening – able to assess thyroid disease, CFNUTRITION Single most important influence on growth. INTERPERSONAL relationships critical role in emotional, intelligence, and personality development. EX: Romanian babies.SOCIOECONOMIC – Lack the knowledge or resources for a safe, stimulating environmentDISEASE – Ethan/KendraENVIRONMENT – injuries r/t consequences of environmental dangers. – chemicals, labeling, new cleaner FABULOSO – looks like a sports drink. Tobacco – passive smoking, nicotine and drugs from breast feeding. Lead paint older homes, cribs-retardationSTRESS – age of occurrence is a factor, duration - how long, > # stress at one time, health, temperament. May have a change in behavior. Need to help kids cope and how to solve problems. Staged cardiac surgery, critical illness (ICU stay)MEDIA- technology opened up our world. + and - OL courses, face book, TV, violence, promiscuity seen on TV. Identify with media. TV on for > 6 hrs day ½ American families. Watch 21-28 hours per week. AAP - Powerful influence on the dev of unhealthy beh and neg attitudes in kids Development does occur in order, but each child progresses at their own rate. Sensitive periods. First three months of PN life are sensitive periods for later G&D. Need loving and warm relationship with caregiver
What do children learn through play? Write on boardGet along with others.Large muscle coordination and developmentCardiovascular healthFine motor skillsPersonality developmentCooperation and problem solvingEmpathySelf confidenceBrain developmentInspire them Learn to manipulate objects - textures, shapes, colorsAssociate words with objects Expand knowledge
Practice play doing what ever their attention is focused to. What ever….Symbolic play – pretend play Begins 11-13 monthsAct out roles that they see in role models, Imitate you, parents, telephone, Burger King, store, school, nurse etc Games – Young pat a cake, older cooperative (tea time) and competitive play (T-ball)
Muscle development Release of excess energyHow children explore their world. Problem solvingHow they feel about themselvesInteract with others Practice skills Right from wrong Creativity Provides for a release of tension and stress. Medium to try out fearful situations . Learn they can do it. Learn to communicate Code of conduct for the group if they are to be accepted. Learn to conform to the standards of the group.
Some parents are aware of safety. Others need your help. Teaching the parent. One of the things that I try to talk about with all of my families is…. To help to avoid some of the bumps and bruises along the way. If in doubt, just talk about safety in a non threatening way. Don’t accuse, parents become defensive. On a road trip…. Good gas prices, good hotels etc. Many parents just haven’t thought about safety. Car seat and seat belt safety. Electric plugs, cabinet locks, cleaners out of reach, water in mop buckets, toilet lids closed, sharp edges, water heaters, more mobility at the various stages. Toys – loose parts, strings, cords, items they will put in their mouth, loud noises that might damage ears. IPODS, music too loud. Older generation HOH, new generation will be HOH too. Need for constant supervision. Education of older siblings. Need to keep toys out of reach. Bicycle helmets, knee pads, Lead - old furniture, plastic bags. Seat belt survey
Injuries are a major cause of death during infancy. Aspiration (hot dog)Clothes for buttons Mobiles inspected Plastic eyes on stuffed animalsBalloons Syringe capsbandaids
Children are separated from normal environment. Don’t have the ability for abstract thinking. EX: Clinic – children playing in the garbage can. Parents weren’t watching the child.
Loss of control can increases the perception of threat and decreases coping skills. Give choices. Look at facial expression of distress. Cry, grimace. Toddlers /preschoolers like autonomy – Like rituals. Routine is upset.
Rituals from home Include family Minimize loss of control I liked the style of the nurse in the video. Taking the child for a ride in the wagon and orienting the mom at the same time. Bonding with the mom and child. FunEducationalInformativeMany parts of your assessment are completed.
Barriers to immunizations? Nutrition – amount of formula, table foods, food groups underweight or overweight SiblingsFactors affecting immunizations: Cost, transportation, distance to clinics, communication, long wait times, lack of education regarding efficacy. Fear of dangers Pertussis. Autism ASSESSMENT Asking direct and indirect questions. You ask/parent provides on form. Chief complaint – open ended questions. What brings you here? The matter? How can I help you? Present IllnessPast historyMedicationsG and Dev
Have toys for distractionPrivacyDevelop therapeutic relationship, but separate enough to distinguish own feelings and fears
Child – Life
Immokalee Study: Looked at Farm Workers and any potential correlation between chemicals/pesticides and CLEnvironmental Factors: Maternal infectionRadiation exposureAlcohol ingestionCorticosteroidsTranquilersAntiepilepticssmoking
ELMO PAGE 856
Parents need support due to being both a cosmetic and functional defectCan interfere with bonding. Sometimes surgery done within days. Palate in stages. Support: Show before and after pictures Teach feeding techniques Preemie nipples Increase size of opening, long tubing, extra long nipple that goes beyond the cleft, Syringe with an extension tubingDropperFeed upright Burp frequentlyExplain need for longterm followup. Clear milk from mouth to prevent infection
Page 858Esophagus ends in a blind pouch or narrows into a thin cord and no continuous pathway to the stomach TEF is an abnormal connection between the trachea and the esophagusMaternal hydramnios is a common finding. SGA. Other embryonic defects = cardiac, cleft lip and or palate, vertebral, UY abdominal wall defect
Significant respiratory difficulty .Excessive oral secretions drooling/feeding intolerance Cough and gag with feeding through nose/mouthAnd cause aspiration
Left because that is the side of the diaphram that fuses last. Dx PN on US. Can have fetal surgery. – poor outcomes due to PT labor Decreased breath sounds. Bowel sounds are heard in the chest Heart sounds heard on the right side – heart displaced by abd contentsFlat or scaphoid abdomenGastric tube to decompress stomach Symptomatic within the first few hours = poor survival rate (50 %) Technology improving outcomes.
Tx shuntSurgery to relieve obstruction – tumor Unidirectional flow valve that drains fluid from the ventricle to the peritoneum Open when the pressure reaches a certain point, and closes when not needed. Hazards = infection and malfunction. > risk 1-2 wks after placement Septicemia, bacterial endocarditis, wound infection, menengitis, venticulitisKinking, plugging, separation or migration ABX first, then if no improvement removal of shunt HC measurement s/sx icp:Widening sutures, and fontanels, distended scalp veins, lethargy, poor feeding, vomiting, irritability, opisthotonic, high pitched cry.
Distortion of the spinal cord and the nerve roots coming from the spine by fibrous bands or adhesions Fatty tumours in the spine, under the skin or in surrounding tissues Cysts in the skin or just under it Cysts filled with cerebrospinal fluid in the spine (syrinxes) Divisions in the spinal cord Spinal cord tethered or held down at the site (unable to move freely in the spinal canal) To avoid confusion, the term often used to for spina bifida occulta with these associated problems is occult spinal dysraphism (OSD).In addition to these structures which are usually hidden from view, there are a number of signs which may appear on the skin (cutaneous signatures) and give a clue to the underlying problems with the central nervous system. These signs can appear on their own but quite often they appear in combination. Some common ones are:An abnormal hair growth over the thoracic or lumbar spine A dermal sinus or small tract which leads from the skin surface down through to the spinal cord. Blind sinuses or pits which do not lead into the spine are common in newborns especially in the crease of the bottom and do not indicate underlying problems. A fatty mass (lipoma) just under the skin A rudimentary tail A capillary haemangioma (stork bite) over the lower spine. Haemangioma over the back of the head are more common and do not indicate underlying problems.
Cord not involved
Child has motor and sensory deficits below the deficit.Visible at birth Usually in the lumbosacral areaUsually covered with a very fragile, thin membrane.Can tear easily, allowing the CSF to flow out. Infection in.
Use the palms, not the fingers when the cast is wet. Cast care 1809Plaster casts 10-72 hours to drySynthetic – 5-30 minutes Synthetic don’t mold to body parts as well.
Use of non-well water for infant formula
No Bubble Bath
Often secondary to NEC
Infant spring 12 without graphics
NUR 2310 Pediatric Nursing Concepts ANDREA STORRIE,MSN, CPNP
GROWTH AND DEVELOPMENT Unit 1 Developmental influences on child health promotion
One hundred years from now it will not matter What kind of car I drove. What kind of house I lived in. How much money I had in my bank account. Nor what my clothes looked like. But the world may be a little betterBecause I was important in the life of a child.
CHILDREN’S HEALTH A CHANGING PARADIGM• Sixty years ago leading causes of death were infections and catastrophic disease• Today’s leading causes are complications of low birth weight, congenital anomalies and injury• Antibiotics, immunizations and cancer advances changed the paradigm• How do pediatric nurses function now and how will the future change pediatric nsg.?
GROWTH AND DEVELOPMENTGROWTH – Increase in the size and number of cells resulting in increased size and/or weight of a part – Quantitative change
GROWTH AND DEVELOPMENTDEVELOPMENT• Gradual change and expansion progressing from lower to advanced complexity. The emerging and expanding of individual capacities• Qualitative change
G & D CONTINUEDMATURATION – An increase in competence and adaptabilityDIFFERENTIATION – Process by which early cell structures are systemically modified to achieve specific properties. – A development from simple to more complex activities and functions. – All four of these processes are interrelated simultaneously. – None occur without the other.
BASIC ASSUMPTIONS ABOUT CHILD DEVELOPMENT• Development is orderly• Development has direction• Development is complex• Each child is unique• Development necessitates practice• Development requires a role model
BASIC ASSUMPTIONS CON’T• Development requires energy to be expended• Children develop through conflict and adaptation• Development goes through cycles• Development has sensitive periods
DEVELOPMENTAL INFLUENCESPATTERNS OF GROWTH & DEVELOPMENT:DIRECTIONAL TRENDS – CEPHALOCAUDAL – PROXIMODISTAL (NEAR TO FAR) – DIFFERENTIATION – GENERAL (MASS) TO SPECIFIC
FACTORS INFLUENCING GROWTH AND DEVELOPMENT• Heredity • Disease• Neuroendocrine • Environmental factors hazards• Nutrition • Stress• Interpersonal • Mass media relationships – AAP• Socioeconomic factors
ERIKSON’S STAGES OF PERSONALITY DEVELOPMENT• Involves a specific conflict or developmental task• Infant - Trust vs. Mistrust• Toddler - Autonomy vs. Shame and Doubt• Preschooler - Initiative vs. Guilt• Schoolager - Industry vs. Inferiority• Adolescent - Identity vs. Role Confusion• Adulthood- Intimacy vs. Isolation
Piaget’s Stages of Cognitive Development• Sensorimotor (Birth to 2 years) progress from reflex to sense of cause and effect• Preoperational (2 to 7 years) egocentric - thinking is concrete and tangible• Concrete operational (7 to 11 years) increasingly logical and coherent - develop conservation• Formal operations (11 to adulthood) think abstractly - adaptable and flexible
FREUD - PSYCHOSEXUAL DEVELOPMENT• Oral stage - birth to one year• Anal stage - one to three years• Phallic stage - three to six years• Latency period - six to twelve years• Genital period - age twelve and over DURING CHILDHOOD, CERTAIN REGIONS OF THE BODY ASSUME A PROMINENT PSYCHOLOGIC SIGNIFICANCE WHICH SHIFTS FROM ONE PART OF THE BODY TO ANOTHER
PLAY• Universal medium for learning• Children learn what no one else can teach them• Play is the work of childrenhttp://www.brightcove.tv/title.jsp ?title=894297564&channel=82 5544798
CLASSIFICATION OF PLAYPractice play referred to as functional or sensorimotor playSymbolic playGames
SOCIAL ASPECTS OF PLAY• Solitary play• Onlooker play• Parallel play• Associative play• Cooperative play
FUNCTIONS OF PLAY • Physical development • Cognitive development • Emotional development • Social development • Moral development • Therapeutic value
Anticipatory Guidance• Parents need to know how to a provide safe environment for their child• Need to know what to expect before it happens• Based on childs developmental level• Awareness of the child’s changing capabilities allows the parents to be more alert and reactive to safety hazards the child is likely to encounter
SAFETY PRECAUTIONS WITH INFANT TOYS• Select toys that are smooth and rounded and made of wood or plastic• Plastic toys should be made of tough and resilient material• Avoid fuzzy and furry stuffed animals• Inspect toys for small removable parts• Check toys for toxic paint• Supervise infants if playing with paper, string, or cloth
PEDIATRIC UNIT SAFETY PRECAUTIONS• Baby proof room• Provide only age appropriate toys• Remove all medical equipment except when used for treatments• Cords out of reach• Outlets covered• Crib rails up to highest adjustment• Maintain physical contact if infant or toddler is on an unguarded surface such as a scale or treatment table• NEVER LEAVE UNATTENDED NEAR WATER !
CHILDREN’S RESPONSE TO HOSPITALIZATION• Separation Anxiety: – Protest: crying, screaming, wrongly viewed as misbehavior – Despair: decreased activity or withdrawal, often viewed as a good thing or “settling in” – Denial or detachment: starts to play & form other attachments, resigned not content
CHILDREN’S RESPONSE CON’T• Fear of the unknown• Fear of pain or mutilation• Loss of control• Anger• Guilt• Regression
PARENTAL STRESSORS• Fear of the unknown• New environment• Separation from child• Guilt• Financial burden• Fear that child will suffer or even die• Fatigue• work, care of other children, distance to hospital
COMMUNICATING WITH CHILDREN• Allow time to feel comfortable• Avoid rapid advance or other threatening gestures• Talk with parent if child is initially shy• Communicate through transition objects such as dolls or puppets• Assume an eye level position
COMMUNICATION CON’T.– Speak in a quiet, unhurried, confident tone of voice– Speak clearly, be specific, and use simple words and short sentences– State directions and suggestions positively– Offer a choice only if one exists– Be honest– Allow time to express concerns and fears– Give older child the chance to talk without parents present
GUIDELINES FOR ADMISSION• Introductions• Orient child and family• Apply identification• Explain hospital rules• Perform nursing admission history• Take baseline vital signs & obtain specimens• Support child and parents as necessary
HEALTH HISTORY• Immunizations current?• Well Child Care?• Sick Care only?• Who is the provider?• What routines are normal for the child? – Bedtime ritual? Read a story? Rock?
ASSESSMENT GUIDELINES• Perform in an appropriate, nonthreatening area• Provide time for play & getting acquainted• Observe for readiness to cooperate• Avoid prolonged explanations about procedures• Involve child and parent in exam process• Use a firm, direct approach• Proceed with exam in an organized sequence• Reassure child throughout exam & use praise• Discuss findings with the family
Pediatric Assessment• Toddlers are the most challenging to examine – Sequence is flexible• What are some differences of a pediatric assessment vs. the assessment of an adult?• Lymph nodes are often palpable in healthy infants and children up to 12 years or age (cervical, axillary, inguinal, and occipital areas)
PLAGIOCEPHALY (POSITIONAL)• Misshapen head• Back of head is flattened due to constantly being placed in supine position• Infants need belly time• Treatment – DOC band – Need to be worn 23 hours a day – Frequent adjustments
PERFORMING A PEDIATRIC PROCEDUREBefore the procedure – Offer ways to cope with pain or discomfort – Use developmentally appropriate words – Give choices when possible – Be sure consent form is signed – Always wash hands thoroughly
PERFORMING A PEDIATRIC PROCEDURE During the procedure Talk to the child if he/she desires Keep the child informed of progress Tell the child when the ”worst is over”
PED PROCEDURES CON’TAfter the procedure – Praise the child for attempting to cooperate – Provide an opportunity to vent feelings – Reunite the child with parents – Reward the child in an age-appropriate way – Record the process and it’s outcomes
ADDITIONAL PROCEDURES WITH VARIATIONS• Measurement of I & O• Parenteral fluid therapy• Inhalation therapy• Chest physiotherapy• Postural drainage• Gavage or gastrostomy feeding• Ostomies
BIOLOGICAL DEVELOPMENT• GAINS 5-7 OUNCES WEEKLY FOR 1ST 5-6 MO.• DOUBLES BIRTH WEIGHT BY 6 MO.• TRIPLES BIRTH WEIGHT BY 12 MO• BIRTH LENGTH INCREASES 50% BY 12 MO.• HEAD SIZE INCREASES 33% BY 12 MO.
BIOLOGICAL DEVELOPMENT• BRAIN INCREASES IN WEIGHT BY 2 ½ TIMES• ORGAN SYSTEMS BEGIN TO MATURE• GROWTH CHARTS ARE MOST ACCURATE ASSESSMENT OF CHILD’S GROWTH
BIOLOGICAL DEVELOPMENT• BRAIN INCREASES IN WEIGHT BY 2 ½ TIMES• ORGAN SYSTEMS BEGIN TO MATURE• GROWTH CHARTS ARE MOST ACCURATE ASSESSMENT OF CHILD’S GROWTH
GROSS MOTOR MILESTONES• HEAD CONTROL ESTABLISHED @ 4-6 MONTHS• TURNS ABD. TO BACK @ 4-5 MONTHS• TURNS BACK TO ABD. @ 6-7 MONTHS• SITS WITHOUT SUPPORT @ 8-9 MO.• CRAWLS AND PULLS UP @ 8-9 MO.• STANDS ALONE @ 10-12 MO.• WALKS W/ ONE HAND HELD 10-12 M• WALKS INDEPENDENTLY 12-15 MO.
FINE MOTOR MILESTONES• 1 MONTH - HANDS FISTED – PALMAR GRASP• 3 MONTHS - CAN HOLD RATTLE• 4-5 MONTHS – BEGINS REACHING & GRASPING WITH PALMS• 6-7 MONTHS – PICKS UP OBJECT WELL -TRANSFERS OBJECTS FROM HAND TO HAND
FINE MOTOR MILESTONES• 8-9 MONTHS - PINCER GRASP DEVELOPS, REACHES FOR TOYS, RAKES FOR OBJECTS• 10-12 MONTHS – RELEASES CUBE INTO CUP AFTER DEMO. – PINCER GRASP COMPLETE – FEED SELF WITH SPOON
SOCIAL MILESTONES• SMILES RESPONSIVELY TO STIMULI @ 6-8 weeks.• SHOWS FEAR AND ANGER @ 4-8 MO.• SMILES AT SELF IN MIRROR @ 6-7 MO – PLAYS PEEK- A -BOO
SOCIAL MILESTONES• STRANGER ANXIETY HEIGHTENS @ 6-8 MO.• QUIETS SELF AND QUIETED BY MUSIC @ 10-12 MO.• HAS MOOD CHANGES @ 10-12 MO.
LANGUAGE MILESTONES• RESPONDS TO SOUNDS @ BIRTH• COOS, BABBLES- 3 MOS• BABBLING COMMON @ 4-5 MONTHS• MAKES VOWEL SOUNDS “ee, ah, ooh”- 4-5 months
LANGUAGE MILESTONES• BELLY LAUGHS & TALKS TO TOYS 6-7 MO.• First few words have meaning- 8-9 mos “mama, dada” – Understands simple demands- “wave bye bye” – Comprehends –”No,no”• 10 -12 months says “mama or dada”• By 1 year recognizes objects by names• CAN SAY 3-5 WORDS WITH MEANING BY 1 YEAR – Knows own name – Enjoys jabbering
PSYCHOSOCIAL DEVELOPMENT-ERIKSON• TRUST VS. MISTRUST – THE BASIC DEVELOPMENTAL TASK OF INFANCY – TRUST OF SELF, OTHERS , AND THE WORLD – TRUST DEVELOPS WHEN INFANT’S NEEDS ARE CONSISTENTLY MET – IF NEEDS NOT CONSISTENTLY MET MISTRUST OF WORLD DEVELOPS
COGNITIVE DEVELOPMENT PIAGET• SENSORIMOTOR – INITIALLY RELATES TO WORLD THROUGH REFLEXES – Realize others besides themselves control the environment – Object permanence by 9 months • One of the key tasks of this stage • Seen in the development of separation anxiety
COGNITIVE DEVELOPMENT PIAGET– FOUR STAGES DURING INFANCY • USE OF REFLEXES – Sucking, rooting, grasping • PRIMARY CIRCULAR RESPONSE (1-4 months) – Replacement of reflexive behaviors with voluntary acts • SECONDARY CIRCULAR RESPONSE -Continuation of primary lasts until 8 months - Primary circular reactions are repeated and prolonged for the response that results • COORDINATION OF SECONDARY SCHEMAS – Use previous behavioral achievements primarily as the foundation for adding new intellectual skills – Object permanence
Development of Body Image• Parallels sensorimotor development• As physical needs are met they feel comfort and satisfaction with their body• Messages convey by caregivers reinforce these feelings• Object permanence is basic to development of self image• By the end of the first year they realize they are distinct from their parents – At the same time is increased interest in their image – Smile at themselves in the mirror
IMMUNIZATIONS REQUIRED FIRST 6 MONTHS• DTaP SERIES• HEPATITIS B SERIES• POLIO SERIES• STREP PNUEMOCOCCUS SERIES (Prevnar)• H. INFLUENZA B- HIB SERIES• Rotavirus vaccine
INFANT NUTRITION• HUMAN MILK MOST DESIRABLE COMPLETE DIET FOR THE FIRST 6 MONTHS• BREAST MILK OR FORMULA UNTIL 12 MONTHS• IRON SUPPLEMENTS @ 4-6MO FOR BREAST FED BABIES D/T DEPLETED IRON STORES• FORMULA BABIES MAY HAVE ENOUGH FROM DIET• NO BOTTLES IN MICROWAVE TO HEAT• NO SOLIDS UNTIL 4-6 MONTHS – EARLY EXPOSURE TO SOLIDS CAN PRODUCE ALLERGIES – EXTRUSION REFLEX IS STRONG IN YOUNG INFANTS
ADDITION OF SOLID FOODS• IRON FORTIFIED RICE CEREAL USUALLY FIRST• FRUIT JUICES CAN BE ADDED AFTER 6 MONTHS• STRAINED VEGETABLES USUALLY NEXT• FOLLOWED BY STRAINED FRUITS, THEN MEATS• EGGS, COW’S MILK, AND CITRUS ARE THE MOST COMMON INFANT ALLERGENS. DELAY INTRODUCTION UNTIL INFANT 12 MONTHS OLD
INTRODUCING SOLID FOODS TO INFANTS• INTRODUCE WHEN INFANT IS HUNGRY• BEGIN BY PUSHING FOOD TO BACK OF TONGUE BECAUSE OF EXTRUSION REFLEX• USE A SMALL SPOON WITH A STRAIGHT HANDLE• BEGIN WITH 1-2 TEASPOONS OF FOOD, INCREASE GRADUALLY• INTRODUCE FOODS ONE AT A TIME WITH 4-7 DAYS BETWEEN ADDING NEW FOODS
• AS AMOUNT OF SOLID FOOD INCREASES, DECREASE AMOUNT OF FORMULA TO PREVENT OVERFEEDING• DO NOT INTRODUCE FOODS BY MIXING WITH FORMULA IN THE BOTTLE• EARLY FEEDING EXPERIENCES ARE SLOPPY• CHILDREN CAN’T BE PRESSURED INTO EATING NEATLY UNTIL THEY HAVE MANIPULATIVE SKILLS
PLAY• SOLITARY OR ONE-SIDED PLAY• OVER THE YEAR BECOMES MORE SOPHISTICATED AND INTERDEPENDENT• SENSORY STIMULATION IS VERY IMPORTANT• INFANTS NEED TO BE PLAYED WITH, NOT MERELY ALLOWED TO PLAY
CLEFT LIP & CLEFT PALATE• MULTIFACTOR ETIOLOGY• TENDS TO RUN IN FAMILIES• ENVIRONMENTAL TERATOGENS MAY PLAY A ROLE• CHROMOSOMAL ANOMALIES OFTEN HAVE CLEFTS AS A FEATURE• MATERNAL SMOKING IN 1ST TRIMESTER ASSOCIATED WITH 10 % OF CASES• APPEARS MOST OFTEN IN ASIAN AND NATIVE AMERICAN INFANTS - LEAST IN AFRICAN-AMERICAN• Maternal intake of folic acid may prevent (NIH, 2007)
CLEFT LIP & CLEFT PALATE• PATHOPHYSIOLOGY- FAILURE OF THE MAXILLARY AND PREMAXILLARY PROCESSES TO MEET AND FUSE. NOTHING IS MISSING, ALL THE PIECES ARE THERE.• CAN BE INCOMPLETE OR COMPLETE• CLEFT PALATE CAN BE MISSED. FULL VISUALIZATION AND PALPATION OF THE PALATE NEEDED DURING NEWBORN EXAMINATIONS• CLEFT LIP CAN BE UNILATERAL OR BILATERAL – EXTENT OF CLEFT AND NASAL DEFORMITY IS VARIABLE
CLEFT LIP & CLEFT PALATE• SURGICAL TREATMENT – CLEFT LIP REPAIRED BY AGE 3 TO 6 MO – CLEFT PALATE REPAIRED AT 6-24 MO.• MULTIDISCIPLINARY TEAM APPROACH D/T PROBLEMS WITH SPEECH, ORTHODONTIA AND EARS/SINUSES
CLEFT LIP & CLEFT PALATE• NURSING CARE- CLEFT PALATE REPAIR – PERFORMED BEFORE FAULTY SPEECH HABITS OCCUR – PREOP- DEAL WITH FEEDING PROBLEMS – POST OP- PREVENT INFANT CRYING, ASSESS FOR PAIN, PREVENT CHILD FROM INSERTING HARD OR POINTED OBJECTS IN MOUTH AND AVOID HARD FOODS – NEED TO MONITOR RESPIRATORY STATUS CLOSELY – OBSERVE FEEDING ONCE RESUMED- I & O • Liquids to soft diet within 48 hours
ESOPHAGEAL ATRESIA WITH TRACHEAL-ESOPHAGEAL FISTULA• PATHOPHYSIOLOGY:• FAILURE OF THE ESOPHAGUS TO FORM AS A CONTINUOUS PASSAGE• THE PROXIMAL SEGMENT TERMINATES INTO A BLIND POUCH• THE DISTAL SEGMENT IS CONNECTED TO THE TRACHEA OR THE PRIMARY BRONCHUS BY A SHORT FISTULA
CLINICAL MANIFESTATIONS– EXCESSIVE SALIVATION AND DROOLING– THE THREE “C’s”= COUGH, CHOKING AND CYANOSIS– APNEA– RESPIRATORY DISTRESS WITH FEEDS– ABDOMINAL DISTENTION
ESOPHAGEAL ATRESIA WITH TRACHEAL-ESOPHAGEAL FISTULA• THERAPEUTIC MANAGEMENT – PREVENTION OF ASPIRATION AND PNEUMONIA • NPO AND IV FLUIDS • “POUCH TUBE” TO REMOVE SECRETIONS • ELEVATE HEAD • GASTROSTOMY TO DRAIN STOMACH CONTENTS (decompression) - SURGICAL CORRECTION
ESOPHAGEAL ATRESIA WITH TRACHEAL-ESOPHAGEAL FISTULA• NURSING CARE – PREOP – IF SUSPECTED MAKE INFANT NPO – ELEVATE HEAD – CLEAR SECRETIONS WITH CONTINUOUS SUCTION – OXYGEN FOR RESPIRATORY DISTRESS
ESOPHAGEAL ATRESIA WITH TRACHEAL-ESOPHAGEAL FISTULA• NURSING CARE- POST OP – MAINTAIN GASTROSTOMY TUBE – If a staged repair- care of cervical esphagostomy – SLOW RETURN OF ORAL FEEDS – DISCHARGE AFTER ORAL FEEDINGS RESUMED AND G-TUBE REMOVED
DIAPHRAGMATIC HERNIA• FAILURE OF DIAPHRAGM TO CLOSE PRENATALLY ALLOWING ABDOMINAL ORGANS TO BE DISPLACED INTO THE ABDOMEN
DIAPHRAGMATIC HERNIA• DEFECT ON IS USUALLY ON THE LEFT SIDE. BOWEL ENTERS THE CHEST CAVITY AND PUSHES HEART TO THE RIGHT. IMPEDES GROWTH OF THE LUNG• AFTER BIRTH THE BOWEL FILLS WITH AIR WHICH FURTHER COMPROMISES BREATHING AND CIRCULATION
DIAPHRAGMATIC HERNIA• CLINICAL MANIFESTATIONS – HEART SOUNDS LOUDER ON THE RIGHT – SCAPHOID ABDOMEN – BOWEL SOUNDS IN CHEST – INCREASING RESPIRATORY DISTRESS• STABILIZATION PRE-OP – RESUSCITATED WITH ET TUBE NOT MASK – ELEVATE HEAD OF BED – AFFECTED SIDE DOWN – NPO AND GASTRIC DECOMPRESSION (NG TUBE)
HYDROCEPHALUS• IMBALANCE BETWEEN PRODUCTION AND ABSORPTION OF CSF CAUSING ACCUMULATION IN VENTRICLES – Communicating – Noncommunicating• FOUND EARLY ON WELL EXAMS BY SERIALLY MEASURING AND GRAPHING HEAD CIRCUMFERENCES• VERY OFTEN ASSOCIATED WITH MYELOMENINGOCELE
HYDROCEPHALUS• EARLY PHYSICAL SIGNS – BULGING FONTANELS – DILATED SCALP VEINS – SEPARATED SUTURE LINES• LATE PHYSICAL SIGNS – SETTING SUN SIGN- SCLERA VISIBLE ABOVE IRIS – SHRILL HIGH PITCHED CRY DUE TO ICP – OPISTHOTONOS
HYDROCEPHALUS• VENTRICULAR-PERITONEAL SHUNT USUALLY NEEDED (VP shunt)• Infection is greatest hazard• Monitor closely for signs of infection and ICP• Pain management• Educate parents on signs of infection and increases ICP• Teach parents how to change dressing
NEURAL TUBE DEFECTS• SPINAL BIFIDA OCCULTA – DEFECT PRESENT IN VERTEBRA – NO SAC PRESENT – NO OBVIOUS DEFICITS BUT “SOFT” SIGNS MAY BE PRESENT
Spina Bifida Cystica• Meningocele• Sac contains meninges and spinal fluid but no neural elements• Not associated with neurological defect
Spinal Bifida Cystica• Myelomeningocele• Sac contains meninges, spinal fluid, and nerves• Manifestations relate to degree of defect, which is determined by the level of the lesion
NEURAL TUBE DEFECTS• CAN BE DETECTED BY ULTRASOUND• CAN BE DETECTED BY AFP• INITIAL CARE – PREVENTION OF INFECTION – NEUROLOGIC ASSESSMENT – DEALING WITH IMPACT ON FAMILY
Nursing Considerations• After birth: – Prone positioning – Radiant warmer to maintain temp without clothing – Application of moist, nonadherent sterile dressing over sac – Prevent infection
Nursing Considerations• Post op care same as any surgical procedure• Latex allergy precautions• Family support• Education
DEVELOPMENTAL DYPLASIA OF THE HIP• HIP JOINT INSTABILITY• MULTIFACTORAL ETIOLOGY• FRANK BREECH PRESENTATION HAS HIGH ASSOCIATION WITH D.D.H.
DEVELOPMENTAL DYPLASIA OF THE HIP• DIAGNOSTIC EVALUATION – POSITIVE BARLOW OR ORTOLANI MANEUVERS DURING ASSESSMENTS – RESTRICTED ABDUCTION – ASYMMETRICAL SKIN FOLDS ON POSTERIOR THIGHS – APPARENT FEMUR SHORTENING – DDH
DEVELOPMENTAL DYPLASIA OF THE HIP• THERAPEUTIC MANAGEMENT – “DOUBLE DIAPER” – PAVLIK HARNESS – HIP SPICA CAST • AVOID INDENTING WET CAST WITH FINGERS. USE FLATS OF HANDS • DO NOT PULL ON ABDUCTION BAR • PROTECT CAST FROM SOILING
CLUB FOOT• FOOT TWISTED OUT OF THE NORMAL POSITION• EXACT CAUSE NOT KNOWN• UNILATERAL CLUB FOOT IS MORE COMMON• IF MILD TREATED WITH EXERCISES• IF MORE INVOLVED SERIAL CASTING IS PERFORMED• IF MAXIMUM CORRECTION IS NOT ACHIEVED 3-6 MO., SURGERY FOLLOWS• LONG-TERM FOLLOW UP INDICATED
CLUB FOOT• Serial casting is begun immediately• Correction usually takes 8 to 12 weeks• Severe case or cases in which casting does not correct deformity require surgery – Done between 4 months and 1 year of age
Care of child with a cast• Assessments – Circulation – Sensation – Movement• Interventions – Elevate limb – Avoid indenting the cast while it is drying – Parent education
IRON DEFICIENCY ANEMIA ANEMIA CAUSED BY INADEQUATE SUPPLY OF DIETARY IRON MATERNAL IRON STORES ADEQUATE FOR 4-6 MONTHS (FULL- TERM) AND 2-3 MONTHS (PREEMIE) TREATMENT IRON FORTIFIED FORMULA ORAL IRON SUPPLEMENT VITAMIN C DECREASE WHOLE MILK AND ADD Iron Fortified CEREALS, VEGETABLES, AND MEATS
IRON DEFICIENCY ANEMIA ANEMIA CAUSED BY INADEQUATE SUPPLY OF DIETARY IRON MATERNAL IRON STORES ADEQUATE FOR 4-6 MONTHS (FULL-TERM) AND 2-3 MONTHS (PREEMIE) TREATMENT IRON FORTIFIED FORMULA ORAL IRON SUPPLEMENT VITAMIN C DECREASE WHOLE MILK AND ADD Iron Fortified CEREALS, VEGETABLES, AND MEATS
Anemia: Lab Evaluation– Normal Peripheral Smear • Iron Deficiency Anemia
• ATOPIC DERMATITIS ATOPIC DERMATITIS ECZEMA / IS PROBABLY GENETICALLY DETERMINED WITH CONTRIBUTING FACTORS• A PRURITIC ECZEMA ASSOCIATED WITH DRY SKIN, ALLERGY, AND EMOTIONAL STRESS WHICH STARTS IN INFANCY & MAY CLEAR BY 2-3 YRS.• AFFECTS 9-12% OF YOUNG CHILDREN
ECZEMA/ATOPIC DERMATITIS THERAPEUTIC MANAGEMENT MOISTURIZE SKIN REDUCE INFLAMMATION (TOPICAL OR ORAL STEROIDS) RELIEVE ITCH (MEDS AND LUBRICATION) PREVENT SECONDARY INFECTION REMOVE IRRITANTS AND ALLERGENS IDENTIFY AND AVOID POTENTIAL FOOD TRIGGERS
ECZEMA/ATOPIC DERMATITIS• TREATMENT METHODS – AVOID ENVIRONMENTAL TRIGGERS SUCH AS OVERHEATING, SOAPS, WOOL, ETC. – ORAL ANTIHISTAMINES (Atarax, Benadryl, Claritin) – INFREQUENT TEPID BATHING, WET COMPRESSES, OCCLUSIVE CREAMS AND COOL COMPRESSES – LOW POTENCY ANTI-INFLAMMATORY CREAMS (Elocon, Cutivate)
FAILURE TO THRIVE (FTT)• PERSISTENT DEVIATION FROM NORMAL GROWTH CURVE (GROWTH < 5TH PERCENTILE)• ORGANIC FTT- THERE IS A PHYSICAL PATHOLOGICAL PROCESS PRESENT. THE FTT MAY OR MAY NOT BE CORRECTABLE DEPENDING ON THE UNDERLYING CAUSE.
FAILURE TO THRIVE (FTT)• NON-ORGANIC FTT – CAUSES • DISTURBED PARENT-CHILD RELATIONSHIP • POVERTY • HEALTH BELIEFS • INADEQUATE NUTRITIONAL KNOWLEDGE • FAMILY STRESS• MIXED FTT – Combination of organic and inorganic etiologies
FAILURE TO THRIVE (FTT)CLINICAL MANIFESTATIONS • GROWTH FAILURE • DEVELOPMENT DELAY • APATHY • POOR EYE CONTACT/RADAR GAZE • STIFF POSTURE • NO FEAR OF STRANGERS
FAILURE TO THRIVE (FTT)• MANAGEMENT – Reversal of malnutrition – Treat any underlying medical conditions – Multidisciplinary approach
Nursing Considerations• Accurate assessment of initial weight and height• Record of all food intake and eating behaviors• Assessment of parent child relationship
SUDDEN INFANT DEATH SYNDROME (SIDS)• UNEXPLAINED DEATH AFTER POST MORTEM EVALUATION OF A CHILD LESS THAN 1 YR. OLD• EPISODES HAVE DECREASED 40% SINCE THE “BACK TO SLEEP” CAMPAIGN• INCIDENCE NOW 0.6 IN 1000 LIVE BIRTHS• PEAK AGE 2-4 MONTHS• 95% OF DEATHS OCCUR BY 6 MONTHS
SUDDEN INFANT DEATH SYNDROME - SIDS• MANY THEORIES BUT NO KNOWN ETIOLOGY• SLEEP APNEA NOT THE CAUSE OF SIDS• MONITORING OF SUBSEQUENT SIBLINGS NOT RECOMMENDED - 99% CHANCE OTHER INFANTS WILL NOT DIE OF SIDS
Risk factors• Infants born weighing less than 3.5 pounds.• Infants exposed to cocaine, heroin, or methadone during the pregnancy.• Infants who have had an apparent life- threatening event.
Reducing the risks Supine position only No more side lying (AAP, 2005) No blankets, soft, bedding, bumpers, toys etc in the crib Do not over clothe the infant Pacifiers use at time of sleep (controversial) No co-sleeping
SUDDEN INFANT DEATH SYNDROME - SIDS CARE OF FAMILY AFTER SIDS EVENT COMFORT FAMILY AND ALLOW OPPORTUNITY TO SAY GOODBYE PROVIDE WRITTEN MATERIAL ARRANGE FOR F/U HOME VISIT WHEN FAMILY IS READY REFER TO SIDS SUPPORT GROUP
Cystic Fibrosis Pathophysiology: Increased viscosity of mucous gland secretions Elevation of sweat electrolytes (NA) Mechanical obstruction as a result of thick secretions Small passages in organs become obstructed (lungs and pancreas) Meconium ileus Pancreatic fibrosis
CYSTIC FIBROSIS• AUTOSOMAL RECESSIVE• MULTISYSTEM DISEASE – RESPIRATORY SYSTEM – DIGESTIVE SYSTEM – INTEGUMENTARY SYSTEM – REPRODUCTIVE SYSTEM
CYSTIC FIBROSIS DIAGNOSIS FAMILY HISTORY ABSENT PANCREATIC ENZYMES INCREASE SWEAT CHLORIDE - >60 mEq/L CHRONIC PULMONARY INVOLVEMENT THERAPEUTIC MANAGEMENT PREVENT/MINIMIZE PULMONARY COMPLICATIONS ENSURE ADEQUATE NUTRITION ASSIST CHILD/FAMILY TO ADAPT TO ILLNESS
CYSTIC FIBROSIS• GASTROINTESTINAL CARE – PANCREATIC ENZYMES-IF CAN NOT SWALLOW PILLS MAY BE MIXED WITH A LITTLE FOOD – HIGH PROTEIN, HIGH CARB, HIGH CALORIE DIET – VITAMINS A,D,E AND K, IN WATER SOLUBLE FORM
Cystic Fibrosis Related Diabetes• Shares features of Type I and Type II• Unique an distinct form that requires special management• Average age of onset is 18- 21 years of age
GASTORENTERITIS• CAUSES ARE VIRAL, BACTERIAL, METABOLIC AND PARASITIC• MOST PEDIATRIC CASES ARE VIRAL• EVEN VIRAL GASTROENTERITIS CAN KILL A CHILD THROUGH DEHYDRATION• Approximately 400 children aged 1 month to 4 years die annually as a result of volume depletion
GASTORENTERITIS• DEHYDRATION AND KIDS – ASSOCIATED WITH METABOLIC ACIDOSIS – KIDS HAVE A GREATER EXTRA CELLULAR FLUID TO INTRACELLULAR FLUID RATIO THAN ADULTS WHICH RESULTS IN GREATER AND MORE RAPID LOSS OF FLUID – CHILDREN EXPERIENCE GREATER INSENSIBLE WATER LOSS
WATER BALANCE DIFFERENCESInfants and young children have a greater need for waterMore vulnerable to alterations in fluid and electrolyte balanceGreater I & O relative to sizeHigher basal metabolic rateGreater production of metabolic wasteImmature kidney function
EXTRACELLULAR FLUID COMPARTMENTConstitutes more than half total body water at birth Has greater ECF until about age 2 Greater and more rapid water loss during this age
WATER LOSS 2/3 of insensible water loss is through skin 1/3 through respiratory tract Insensible fluid loss is increased by heat, humidity, temperature and respiratory rate Infants and toddlers tend to be more highly febrile
Dehydration• Sodium is the main solute in the ECF• When ECF volume is reduced in acute dehydration, total body sodium is almost always reduced, regardless of serum values
Types of DehydrationIsotonicHypotonic (hyponatremic)Hypertonic (hypernatremic, hyperosmotic) ISOTONIC DEHYDRATION Primary form of dehydration in children Water and salt are lost in equal amounts Major loss is from ECF Reduction in plasma volume, circulating volume, Shock is greatest threat to life Child will display characteristic symptoms of hypovolemic shock Serum sodium remains normal (130-150 meq/L)
Lab ValuesK+ normal to lowNA initially normal but then may be lowBUN and Creatinine – HighCO2- low (indicator of severity of dehydration)
Signs and Symptoms of Dehydration Fewer wet diapers than usual No tears when crying; inside of mouth dry and sticky Irritability, high-pitched cry Difficulty in awakening Increased respiratory rate or difficulty breathing Sunken fontanel, sunken eyes with dark circles Abnormal skin color, temperature, or dryness Slow cap refill Decreased turgor
GASTORENTERITIS ORAL REHYDRATION THERAPY MAY AVOID HOSPITALIZATION CHOICE OF IV FLUID REPLACEMENT IS BASED ON THE CHILD’S TYPE OF DEHYDRATION (ISOTONIC, HYPOTONIC OR HYPERTONIC). MAKE SURE THE CHILD IS VOIDING BEFORE ADDING K+ TO ANY IV FLUID.
PYLORIC STENOSIS PYLORUS MUSCLE INCREASES IN SIZE AND MASS OBSTRUCTS FOOD FROM LEAVING THE STOMACH IF UNTREATED DEATH FROM DEHYDRATION AND ELECTROLYTE IMBALANCES REQUIRES SURGICAL CORRECTION (PYLOROMYOTOMY)
PYLORIC STENOSIS CLINICAL MANIFESTATIONS – VOMITING BEGINS BETWEEN 1 TO 10 WEEKS OF AGE – VOMITING BECOMES PROJECTILE – PALPABLE PYLORIC MASS (OLIVE SHAPED) – VISIBLE GASTRIC PERISTALTIC WAVES – IRRITABLE AND HUNGRY INFANT DIAGNOSTIC PROCEDURES – ULTRASOUND – BARIUM SWALLOW
PYLORIC STENOSIS NURSING CARE – PREOP MANAGE FLUIDS & ELECTROLYTES • DECOMPRESSION OF STOMACH BY NG TUBE • IV FLUIDS AND ELECTROLYTES – MAY HAVE K, Na, & Cl DEPLETION – POST OP - MONITOR FEEDINGS • CLEAR LIQUIDS 4-6 HR. AFTER SURGERY • STEP WISE PROGRESSION TO FULL FORMULA OR BREAST MILK OVER 48 HOUR PERIOD
INTUSSUSCEPTION TELESCOPING OF INTESTINE USUALLY AT THE ILEOCECAL VALVE – Terminal ileum telescopes into the ascending colon OCCURS BETWEEN AGES OF 3 MONTHS AND 5 YEARS - HALF IN INFANTS UNDER 1 YEAR SYMPTOMS DEVELOP BECAUSE BLOOD SUPPLY TO COLON IS COMPROMISED
INTUSSUSCEPTION CLINICAL MANIFESTATIONS WAVES OF COLICKY SEVERE PAIN VOMITING CURRANT JELLY STOOLS LETHARGY (LATE IN COURSE) COMPLICATIONS ISCHEMIA PERFORATION AND PERITONITIS SHOCK
IntussusceptionBARIUM ENEMA IS PRIMARILY DONE AS A DIAGNOSTICPROCEDURETHE BARIUM ENEMA MAY REDUCE THE OBSTRUCTION BYHYDROSTATIC PRESSURE.NONOPERATIVE REDUCTION SUCCESSFUL IN 80-90% OF CASESBARIUM ENEMA IS NOT DONE IF SIGNS OF SHOCK ORPERFORATION ARE PRESENT
Vesicoureteral Reflux -VUR• Retrograde of urine into ureters – Reservoir for bacteria• Primary – congential abnormal insertion of the ureters into the bladder• Secondary – due to an acquired condition
Complications• Associated with recurring kidney infections – Pyelonephritis – high fever, vomiting, chills – Can cause renal scarring in children • Can occur with the first episode of febrile UTI
Management• Prevent bacteria from entering the kidney – Low dose antibiotic therapy – Urine culture every 2-3 months and prn fever – Many will outgrow – Annual cystourethrogram – Surgery if significant anatomic abnormality , UTI’S, non compliance with meds, VUR after puberty especially in females
Prognosis• Usually excellent with prompt treatment at time of diagnosis• Early diagnosis essential to prevent long term complications
Nursing education• Wipe from front to back• Observe frequently for signs of pain, difficulty voiding