chapter 31- care of child with a physical disorder
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Chapter 31- Care of Child with a Physical Disorder
Jessica Gonzales RN, MSN
Cardiovascular assessment
clubbing
Periorbital edema
Monitor BP for hypo or hypertension
Monitor apical and peripheralPulses for rate, rhythm, and qualityAuscultate for extra heart sounds
Monitor respirations for rate and effortAusculate for adventitious sounds
Assess heightAnd weight, Growth failure Can occur with Sever cardiac disease
Peripheral edema• Palpate• inspect
cyanosis
EngorgedNeck veins
Abdominal distensionPalpate forHepatomegalyAndsplenogmegaly
Congenital Heart Disease
Etiology and pathophysiology:♥ Family history of CHD♥ Mom comes in contact with certain substances during first
few weeks of pregnancy♥ Mom with seizure disorder and on meds♥ Depression and lithium♥ Uncontrolled diabetes or lupus♥ Rubella♥ Chromosomal abnormalities (downs syndrome, turners)♥ infection
1. Inferior and superior vena cava from body into right atrium2. Right atrium to right ventricle via tricuspid valve3. Through pulmonary valve to pulmonary artery4. Pulmonary artery to lungs5. To pulmonary veins from lungs
6.Pulmonary veins to left atrium7.Through mitral valve into left ventricle8.Through aortic valve to aorta9. To body
Tissue Paper My AssestsR u i oI l t rC m r tU o a iS n l cP i I cD
Left ventricle
Left atrium
tricuspid
Superior vena cava
Inferior vena cava
pulmonicaortic
mitralRightatrium
Right ventricle
• Types of defects:
♥ Pulmonary Blood flow
♥ Pulmonary Blood Flow
♥ Obstruction to systemic blood flow♥ Mixed blood flow ♥ Cyanotic♥ Acyonotic
Cyanotic Acyanotic Pulmonary Blood flow
♥TGA
Pulmonary Blood flow♥VSD♥PDA♥ASD
Pulmonary Blood flow
♥TOF
Normal Blood Flow♥COA
R L
LR
Cyanotic
Acyanotic
4 T’s• Tetralogy of fallot• Truncus Ateriosus• Transportation of the great vessels• Tricuspid Atresia
• PDA• ASD• VSD
Clinical manifestations• Cyanosis • pallor• Cardiomegaly, • additional heart sounds (pericardial rubs, murmurs,) • Discrepancies between apical and radial pulses• Tachypnea• Dyspnea, grunting, crackles, and wheezes• Digital clubbing • Hepatomegaly, splenomegaly
Acyanotic
https://health.google.com/health/ref/Patent+ductus+arteriosus
Patent ductus arteriosus (PDA) is a condition in which a blood vessel called the ductus arteriosus fails to close normally in an infant soon after birth. (The word "patent" means open.)
IncreasedPulmonary Blood flow
AcyanoticIncreased pulmonary blood flow
Atrial septal defect (ASD) is a congenital heart defect in which the wall that separates the upper heart chambers (atria) does not close completely. Congenital means the defect is present at birth.
Ventricular septal defect (VSD)describes one or more holes in the wall that separates the right and left ventricles of the heart. Ventricular septal defect is one of the most common congenital (present from birth) heart defects. It may occur by itself or with other congenital diseases.
acyanotic Increased pulmonary blood flow
Opening between ventricles
A large ventricular septal defect (VSD): a hole in the part of the septum that separates the ventricles, the lower chambers of the heart. The hole allows oxygen-rich blood from the left ventricle to mix with oxygen-poor blood from the right ventricle.
Pulmonary stenosis
Pulmonary stenosis : This defect is a narrowing of the pulmonary valve and the passage through which blood flows from the right ventricle to the pulmonary artery. In pulmonary stenosis, the heart has to work harder than normal to pump blood, and not
enough blood reaches the lungs.
Right ventricular hypertrophy
Right ventricular hypertrophy : This defect occurs if the right ventricle thickens because the heart has to pump harder than it should to move blood through the narrowed pulmonary valve.
Overriding aorta
An overriding aorta: the aorta is between the left and right ventricles, directly over the VSD. As a result, oxygen-poor blood from the right ventricle flows directly
cyanotic
Decreased Pulmonary Blood flow
Children with TOF may develop "tet spells“ (acute hypoxia)
• The precise mechanism of these episodes is in doubt
• presumably results from a transient In resistance to blood flow to the lungs with flow of desaturated blood to the body
• characterized by a sudden, marked, increase in cyanosis followed by syncope, and may result in hypoxic brain injury and death, prolonged crying, irritability
treatment:• Calm infant- hold over shoulder or in knee chest position or have child
squat (increases pressure on the left side of the heart, decreaseing the R to L shunt thus decreasing the amount of deoxygenated blood entering systemic circulation)
• Morphine (to decrease spasm and supress resp center)
• Oxygen (it is a potent pulmonary vasodilator and systemic vasoconstrictor. This allows more blood flow to the lungs)
• Consider sedation and parlaysis with intubation if these measures fail
Transposition of the great vessels is a congenital heart defect in which the two major vessels that carry blood away from the heart -- the aorta and the pulmonary artery -- are switched (transposed).
cyanotic Increased Pulmonary blood flow
Aortic coarctation is a narrowing of part of the aorta (the major artery leading out of the heart). It is a type of birth defect. Coarctation means narrowing
Acyanotic Normal pulmonary blood flow
Hematological assessment
Pallor,flushingJaundice,Purpura,Petichiae,Scratch markscyanosis
Jaundice, sclera, retinal hemorrhage
TachycardiaAuscultate for murmurs
Tachypnea, orthopnea, dyspnea
Impaired thoughtProcess or lethargy
Palpate decreased cap fill time
Joint swelling,Bone and joint tenderness
Blood in urine and abnormal Mentsraulbleeding
Gingival pallor or bleeding
Lymphadenopathy or tenderness
Abdominal tenderness,Hepatomegaly,splenomegaly
Decreased muscle mass
Disorders of Hematological Function
• Anemia: The condition of having less than the normal number of red blood cells or less than the normal quantity of hemoglobin in the blood. The oxygen-carrying capacity of the blood is, therefore, decreased
Failure to produce (hem)oglobin due to
lack of iron
Iron containing O2 transport protein
that carries O2 from the lungs to
the body
Iron needed to bind
O2
Reduces O2 carrying
capacity of the blood
O2 state to the tissues: dyspnea on exertion, fatique,
fainting, lightheadedness, tinnitus, headache
In anemia selective vasoconstriction of
blood vessels allows nonvital
areas to be bypassed to allow
more blood to flow into critical areas. The skin is one of
the areas to be considered
“nonvital” and the result is pallor.
Tissue hypoxia= ↑cardiac input= ↓PVR & ↓blood viscosity (thinner
blood) = tachycardia and heart murmur
A genetic disorder characterized by an abnormal form of hemoglobin within the
erythrocyte
Ischemia in the small blood vessels and infarction in the
small bones
Ischemia in the small blood vessels and infarction in
the small bones
↓ O2 = sickle shaped red blood cells break apart
not acting effectively
Damaged sickle RBC’s clump
together and stick to the walls of blood vessels, blocking
blood flow causing sever pain and
permanent damage to brain, heart,
lungs, kidneys, liver, bones, and spleen
↑Risk of infection due to damaged spleen from sickled
cells getting trapped
Aplastic Anemia is a rare but potentially life threatening syndrome of bone marrow failure characterized by pancytopenia
↓RBC’s fatigue due to ↓O2
infections
Bruising and bleeding
Failure to produce hemoglobin due to
lack of iron
• Iron replacement therapy
• Nutritional or dietary counseling
• Treatment of underlying cause
• Infection• Pain
• Fatigue • Shortness if
breath
broad spectrum antibiotics
Pain medications, local heat application
** hydration to prevent sickling
• Pallor• Dyspnea• Petechiae• bleeding
• Fever• Infection
Administer O2, semi-fowlers postion
Good oral hygiene, patient safety
Prophylactic antibiotics
• Transfusions as needed• Isolation precautions per institute (reverse isolation)
platelets bleeding
• Prevent bruising• Control bleeding
• Counsel family to not use salicylate drugs• Transfusion of RBC’s
• IV gamma globulin and anti-D antibody therapy• splenectomy
Idiopathic thrombocytopenic purpura (bleeding
in the tissue)
A bleeding disorder
in which the immune system
destroys platelets, which are necessary
for normal blood clotting.
Persons with the disease have too few platelets in
the blood*antiplatelet
antibody in the spleen
Hemophillia• Hereditary (x-linked recessive transmitted by females found predominately in
males) bleeding disorder characterized by deficincy in a blood clotting factor (*factor VIII{A} or IX {B})
plateletsBleeding into the tissue
Bruising and
petichiaeMinimize bleeding
Prednisone: decreases antiplatelet antibodies
IVIG
Anti D antibody
Disorders of Hematological FunctionLeukemia -ALL (acute lymphoblastic leukemia) uncontrolled proliferation of blast cells,which accumulate in the marrow causing crowding and depression of other cells
• Hodgkins disease-This is a malignant lymphoma distinguished by painless, progressive enlargement of lymphoid tissue.
Assessment of the Immune System
Temperature for hyperthermia
Inspect skin for hives, edema, lesions
Conjunctival redness
Palpate for spleneomegaly
Assess the joints forSwelling, redness, Tenderness, decreasedmobility
Palpate foradenopathy
Auscultate for abnormalBreath sounds
Auscultate for tachycardia
Disorders of the Immune SystemInfection with HIV produces Lymphopenia resulting in immunosupression and AIDS
Symptoms may not Appear for 1 to 2 yrs• Nonspecific clinical manifestations
• Prevent opportunistic infections• Administer prophylactic therapy for P. carnii (co-trimoxazole) beginning at 6 mos of age• Immunizations• Pulmonary hygiene• Promote adequate nutrition• Foster healthy growth and development
Disorders of the Immune System
Clinical manifestations:• Daily afternoon
temperature spikes• macular rash on
trunk and extremities
• joint involvement- swelling, pain, redness
Medical management• Nonsteroidal anti-
inflammatory drugs• antirheumatic drugs• cytotoxic drugs• corticosteroids
Assessment of the Respiratory System
Temperature for hyperthermia
Inspect skin color changes, especiallycyanosis
Auscultate for abnormalBreath soundsMonitor respirations for rate, depth, and quality, Note any dyspnea, use of accessory musclesPercuss for dullness which indicates fluid
Observe forAlertness, changeIn mental status
Intercostsal, suprasternal, Sternal and substernalretractions
Chest diameter
Disorders of the respiratory system
Bronchopulmonary Dysplasia Premature lungs needing mechanical ventilation (high 02 and PIP) can injure the aveolar Saccules and lead to fibrosis of these structures
• Long term O2 therapy• Cyanosis when breathing RA• Manifestations of right sided failure
• Administer medications: bronchodilators, diuretic• Planned rest periods to decrease respiratory effort and conserve energy • Small frequent meals to prevent over distension of stomach• Counsel parents in ways to prevent respiratory infection• Teach parents CPR
Disorders of the respiratory system
• pneumoniaAcute inflammation of the lung parenchyma (bronchioles, alveolar ducts, and sacs, and alveoli)
Impairs gas exchange
• Antibiotics if bacterial• Assess for respiratory distress
• Provide family teaching
RespiratoryDistress
• Wheezing, crackles• Use of accessory
• muscles
Disorders of Respiratory Function-Bronchitis/Bronchiolitis
Viral infection of the lower respiratory tract characterized by inflammation of the
Bronchioles and production of mucous (usually caused by RSV)
• Wheezing• Crackles
• Tachypnea• Retractions
• Assess forrespiratory
Distress• Contact isolation
• Prescribed Medications (RT)• O2 if needed
• Fluids
Inflammation and edema of muscle (spasms) • Wheezing
• Use of accessory muscles
Production of thick mucosa resulting in increased airway resistance, premature closure Of airways, hyperinflation, increased work of breathing, impaired gas exchange
• Increased RR• Cough• Fatigue• Anxiety• dyspnea• Assess respiratory status
• Administer prescribed meds• Promote adequate O2
• Fowler’s position
Asthma is a chronic, reversible, obstructive airway disease, triggered by various stimuli
Disorders of the respiratory system
• Respiratory distress syndrome- mainly caused by a lack of a slippery, protective substance called surfactant, which helps the lungs inflate with air and keeps the air sacs from collapsing. Common in premature babies whose lungs are not fully developed.
• Sudden infant death syndrome• Acute pharyngitis (sore throat)-inflammation of the pharynx• Tonsillitis • Croup – inflamation of the larynx (voice box)** • Acute epiglotitis –bacterial infection of t he epiglottis• Pulmonary tuberculosis-chronic bacterial infection caused by bacillius
mycobacterium tuberculosis• Cystic fibrosis- an inherited disorder of the exocrine glands characterized by
excessive thick mucous that obstructs the lungs and GI tract
Assessment of the GI System
Temperature for hyperthermia
Inspect skin for pallor, jaundice, carotenimia
Inspect abdomen for distention, depression, umbilical herniationAuscultate to assess bowel sounds (do first)Palpate for tenderness, rigidity, masses and organomegaly
Inspect the anus for rectal bleeding and nonpatency
Inspect mouth For caries, periodontalDisease, lesions,And clefts
Palpate hard and soft palates for defects
Measure height And weight for growth failure
Disorders of Gastrointestinal FunctionCleft lip and cleft palate are birth defects that affect the upper lip and roof of the mouth. They happen when the tissue that forms the roof of the mouth and upper lip don't join before birth. The problem can range from a small notch in the lip to a groove that runs into the roof of the mouth and nose. This can affect the way the child's face looks. It can also lead to problems with eating, talking and ear infections.
Treatment usually is surgery to close the lip and palate. Doctors often do this surgery in several stages. Usually the first surgery is during the baby's first year. With treatment, most children with cleft lip or palate do well.
• Ensure adequate intake of food and fluids without aspiration.
• Special feeding devices may be used.
• Frequent burping is necessary.
• Assist parents in dealing with the diagnosis
Disorders of Gastrointestinal Function-constipation/dehydration
The passage of hardened stools; may be associated with failure ofcomplete evacuation of the colon withdefecation
• Add fluid or carbohydrate to the formula, add foods with bulk, and increase fluid intake.
• Manually dilate the sphincter; administer mild laxatives/enemas.
• Obtain history of bowel patternseducate on dietary changes and normal stool patterns.
Disorders of Gastrointestinal Function- diarrhea/gastroenteritis
• May be a result of a number of disease processes that cause abnormal losses through the skin, respiratory, renal, and GI systems –vomiting/diarrhea
• Diarrhea- A disturbance in intestinal motility characterized by an increase in frequency, fluid content, and volume of stools
• Assess for clinical manifestations of dehydration.
• Observations should include I&O; vital signs; body weight; skin color, temperature, and turgor; capillary refill; presence or absence of the sensation of thirst; and in infants, assessment of the fontanels.
• I&O, promotion of rehydration, correction of electrolyte imbalances, provision of age-appropriate nutrition, prevention of the spread of the diarrhea, prevention of complications, support of the child and family
Disorders of Gastrointestinal Function-
• Gastroesophageal reflux
• Hypertrophic pyloric stenosis
• Intusseception
• Hirschprungs disease
The backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the
lower esophageal sphincter
Narrowing of pyloric sphincter at the outlet of the stomach
Pyloromytomy:Relieves
obstruction
Telescoping of one portion of the Intestine into an adjacent portion
Causing an obstruction
Congenital anomaly characterized by absence of nerves to a section of the intestine causing inadequate mobilityWhich leads to the absence of propulsive movements,
causing accumulation of intestinal contents and distention of bowel
Disorders of Gastrointestinal Function-hernias
• Umbilical • Femoral• Inguinal• Hiatal • Diaphragmatic
A protrusion of the bowel through an abnormal opening in the abdominal wall
Most common in
children
Usually closes by the time the child is 3 years
old
Surgical repair
Assessment of the GU System
Temperature for hyperthermia
Inspect skin for peripheral cyanosis, slow cap refill time, pallor, peripheral edema
Monitor RR for abnormal rate and depth of respiration
Inspect the anus for rectal bleeding and nonpatency
Measure height And weight for growth failure
Monitor blood Pressure for hypoOr hypertension
Abdominal distension
Uremic encephalopathy-Lethargy, poor concentration, confusion
Hypospadias, epispadias
Ear abnormalities
Palpate kidneys for Tenderness, and enlargemnt
BladderFordistension
Disorders of Genitourinary Function-• UTI- characterized by inflammation, usually of bacterial origin, of the urethra, bladder,
ureters, or kidneys• Nephrotic syndrome- characterized by proteinuria, hypoalbuminemia, hyperlipidemia,
altered immunity and edema. Increased permeability to protein, protien leaks through the glomerular membrane resulting in albumin in the urine. Once albumin is lost colloidal osmatic pressure decreases permiting fluid to escape from the intravascular spaces to the intirstial spaces. The volume decrease stimulates antidiuertic hormone to reabsorb water = edema.
• Acute glomerulonephritis- antibodies interact with antigens that remain in the glomeruli, leading to immune complex formation and tissue injury, filtration decreases and excretion of less Na and H2O. High Blood pressure, edema, and heart failure may result.
• Wilm’s tumor-
• Structural defects of gu tract
Assessment of the EndocrineSystem
Inspect skin for color changes, hirsutism, easy bruisingPalpate to note dryness, coldness, changes in texture
Measure height And weight for growth Failure, plot size of head
Monitor blood Pressure for hypoOr hypertension
Lethargy, poor concentration, confusion, irritability
Assess for sexual development
Monitor pulseIncrease= hyperthyroidDecrease=hypothyroidAuscultate to note for murmurs
Assess vision
Facial abnormalities, mouth for abnormal odors andDental delay’s
Palpate hair & nails
Assess muscle Strength and tone
Disorders of Endocrine Function
• Hypothyroidism• Hyperthyroidism
• Diabetes mellitus
A chronic conditionCharacterized by inadequate amount of thyroid hormone to meet metabolic needs. Congenital- T4 is not produced which is essential for growth and development especially brian development, left untreated = MR.Acquired- inadequate amount of T4
A chronic metabolic disorder that results from either a partial or complete deficiency in insulin. Type 1- characterized by beta cell destruction, leading to absolute insulin deficiency.Type II- insulin resistance, progressive deterioration of Insulin secretion
3 p’s• Polydipsia• Polyuria
• Polyphagia
Assessment of the Musculoskeletal SystemMeasure height And weight for growth
Inspect posture and gait
Observe for structural abnormalitiesAsymmetrical limbs
Palpate boneyStructures for tenderness,Masses, lesions
Palpate spine to assess curvature
Assess, muscle mass, tone
Disorders of Musculoskeletal Function
A spinal deformity that usuallyInvolves lateral curvature of theSpine, spinal rotation, and thoracic Kyphosis (hunch back)
Surgery to correct
A disorder caused by decreased blood supply to the femoral head; results in epiphyseal necrosis and degeneration
Legg-Calvé-Perthes Disease • Developmental Dysplasia of the Hip
A developmental abnormality
of the femoral head, the acetabulum,
or both; subluxation of the hip
Scoliosis
Disorders of Musculoskeletal Function
• Congenital deformity of the foot and ankle• Varies in severity; may involve one
foot or both feet• Manipulation and application of a
series of short leg casts; changed weekly to allow for further manipulation
Talipes (Clubfoot)
Osteomyelitis
• Infection within the bone• In children, the metaphysis of the femur,
the tibia, and the humerus are the areas most affected.
• It can occur at any age; the peak incidence in children is between ages 3 and 15 years, and boys are affected twice as often as girls.
Disorders of Musculoskeletal Function
• Duchenne’s Muscular DystrophyA sex-linked inherited
disorder characterized by gradually progressive
skeletal muscle wasting and
weakness
No effective treatment
Septic Arthritis
An infection of a joint,
which can occur from
bacteria in the blood or
as a direct extension of
an existing infection
Joint aspiration and surgical irrigationBroad-spectrum
IV antibiotics
Fractures
Most common sites in children are
long bones, clavicles, wrists, fingers,
and skull.
Assessment of the Neurological SystemMeasure head size, Palpate fontanels
TachycardiaIncreased ICP
HypertensionIncreased ICP
Assess LOC,Cerebullar status- gait Balance and coordination
Cranial nerve functionEsp pupillary response,Taste, olfaction, and tactile sense
Assess muscle tone and strength
Assess reflexes
Disorders of Neurological FunctionAn infection of the meninges that is usually caused by bacterial invasion and less Common by viruses. The bacteria Enter the meniges through the blood stream and spread through the csf.
Children under 2- poor feeding, irritability And lethargy, high pitched cry, bulging
Fontanel, fever, resistance to being held,Opisthotonos (hyperextension of the Neck)
Older children- respiratory or GI problems, nuchal rigidity (stiff neck), HA, kernigs sign,
bruzinski sign, petichial rash• Check for neurolical signs
and monitor LOC• Administer prescribed meds(antibiotic, steroid for cerebral
Edema, anticonvulsant)• Keep room quite and decrease
Environmental stimuli
Meningitis
Disorders of Neurological FunctionA condition caused by an imbalance in the production and absorption of CSF In the ventricular system. When production exceeds absorption, CSF Accumulates, usually under pressure andProduces a dilation of the ventricles.
Occurs with a number
of anomalies
Communicating hydrocephalus- an impaired Absorption of CSF in the arachnoid space
Noncommunicationg hydrocephalus- obstruction to the flow of CSF through the ventricular system
Increased ICP- HA, emesis, irritability, Lethargy, apathy, and confusion
Disorders of Neurological Function
Surgical treatment- removal of obstruction and insertion of shunts to provide primary drainage of the CSF to an extracranial compartment, usually the peritoneum (ventriculperitonel shunt or VP shunt)
Disorders of Neurological FunctionSpina Bifida
Defective closure of the vertebral Column that may occur anywhereBut usually occurs in the lumbosacral area.
• Occulta- does not affect spinal cordMay be dimpling of the skin, nevi,
hair tuft
• Meningocele- sac consisting of meninges and CSF protruding
outside the vertebrae. The spinalcord is not involved
Myelomeningocele (most common)-Similar to meningocele but spinal Cord and nerve roots are involved Resulting in sensorimotor deficits,
Urinary and bowel problems
No cure. Surgery to minimize infection. Preoperatively- apply a sterile dressingTo the lesion and constantly moisten it
With saline. Use protective devicesAnd handle infant with care.
Disorders of Neurological Function• Encephalitis- An inflammation of the CNS, mainly the brain and spinal cord
• Cerebral palsy- group of disabilities caused by injury or insult to the brain either before or during birth
• Seizure disorders- disturbances in normal brain function that result in abnormal electrical discharges in the brain, which can cause LOC, uncontrolled body movements, changes in behaviors and sensation, and changes in the autonomic system.
Many underlying causes:• Prenatal or perinatal hypoxia
• Infection• Congenital malformaiton• Metobolic disturbances
• Lead poisoning• Head injury
• Tumor• Medication
• Toxin exposure
• Administer prescribed meds• Prevent injury
• Document all seizure activity
Disorders of IntegumentaryFunction
• Contact – inflammation of the skin• Diaper- form of contact dermatitis, exposure
to feces and urine
• Atopic (eczema)- a pruritic response
• Seborrheic – cradle cap
resulting from contact with environmental antigens
AntihistaminesClip fingernails
Keep the diaper area clean and dry; change diapers as soon as possible;
cleanse area with mild soap and water, pat dry.
Hydration of the skin; control pruritus;
decrease inflammation; and prevent secondary infections.
Crusts should be soaked with warm water and compresses until loosened; shampoo and rinse.
Disorders of Integumentary Function• Acne Vulgaris – inflammatory process of the skin commonly seem in adolescents
• Psoriasis- a chronic proliferative skin disorder characterized by thick, scaly patches and inflammation
• Herpes Simplex – a common infection, transmitted by direct contact of infected body fliuds with nonintact skin or mucous membranes• Candidiasis (thrush)-white patches of candida frequently found on moist tissues, tongue, buccal cavity, vagina
meticulous skin careis emphasized
Nystatin suspension; administer after
feedings.Inform parents that the
full 7-day course of nystatin is to
be completed.Teach parents to sterilize
bottles, nipples, pacifiers, and teethers
Disorders of Integumentary Function• Parasitic infections –scabies, head lice
• Bacterial Infections- impetigo, folliculitis, and cellulitis
The assessment of systemic
signs and symptoms, areas involved, and appearance
of lesions are helpful in establishing the type of infection.
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