NCLEX: Caring for the Pediatric Client

Terms you’ll need to understand:
Aganglionic
Atresia
Autosomal recessive disorder
Congenital anomaly
Craniofacial
Dysplasia
Enteropathy
Extravasation
Fistula
Hyperpnea
Hyperpyrexia
Lordosis
Meconium ileus
Neural tube defect
Palliative
Polycythemia
Respiratory synctial virus
Sex-linked disorder
Steatorrhea
Stenosis
Stridor

Nursing skills you’ll need to master:
Performing sterile dressing changes
Calculating pediatric medication dosage
Administering medications to infants and children
Using intravenous pumps and burette
Applying pediatric urine collector
Instilling eye drops and ear drops
Determining intake and output
Applying mummy and clove hitch restraints
Providing care for the client with traction and casts

There are few areas in nursing more challenging or more rewarding than working with children and their families. Taking care of a sick child involves more than reading a bedtime story or making a balloon from a surgical glove. The pediatric nurse combines the knowledge of disease process with an understanding of how illness and injury affect normal growth and development and uses the best of her communication skills to help parents cope. This guide reviews normal growth and development and the most common alterations in child health. A. you review normal growth and development, you should consider ways in which nurses help children stay healthy through accident prevention and immunizations. Pediatric guides lists guidelines for accident prevention as well as the recommended schedule for childhood immunizations. 

Growth and Development
Growth and development refers to the numerous changes that take place over a lifetime. For the nurse, growth and development represents a guide for assessing and providing care to children from birth through adolescence.
Key elements include physical growth, the development of gross motor and fine motor skills, and socialization through play. There are individual differences in growth and development.

Infant (28 Days to 1 Year)
The infancy stage is marked by rapid changes in growth and development.
In fact, there is no other time in life when changes occur so quickly and dramatically. Body weight triples and length increases by 50% in the first year of life (Aren’t we glad that doesn’t continue!). Infant reflexes are replaced with fine motor and gross motor skills. These skills occur in an orderly fashion in a head-to-toe and center-to-peripheral sequence, which is referred to as cephalocaudal – proximodistal development.

Below is a summary of infant development elements that are important for you to know for the NCLEX exam.

Key Elements in the Development of Infants:

Physical growth and development
Weight: The birth weight (average is 7–9 pounds) doubles by approximately 6 months of age and triples by 1 year of age.
Length: The length at birth (average is 19–21 inches) increases by 1 inch per month during the first 6 months of life. By 1 year of age, the birth length has increased by 50%.
Head circumference: The head circumference at birth (13–14 inches) increases to an average of 17 inches by 6 months and 18 inches at 1 year of age. The posterior fontanel closes by approximately 2 months of age; the anterior fontanel closes by approximately 18 months of age. As the brain matures, the infant’s reflexes (Moro, tonic neck, Babinski, stepping, and rooting) are replaced by purposeful movements that influence motor development.
Chest circumference: The lateral diameter becomes greater than the anteroposterior diameter. By 1 year of age, the circumferences of the head and the chest are approximately the same.

Development of gross motor and fine motor skills
1–3 months: The infant can lift the head, grasp and hold objects for a brief period of time, and roll from side to back. The eyes become more coordinated, and the infant can focus on objects.
3–6 months: The infant gains head control, rolls from abdomen to back, sits with support, and can move her hand to her mouth. The lower central incisors erupt and, by 6 months of age, new foods are added to the infant’s diet, including crackers, melba toast, rice cereal, vegetables, fruits, meat, and egg yolk.
9 months: The infant can sit without support, transfer objects from hand to hand, bang cubes together, play patty-cake, creep on hands and knees, and pull herself to a standing position. Upper lateral incisors begin to appear.
12 months: The infant cruises well, can walk with one hand being held, begins to take her first steps alone, can sit down from a standing position unassisted, can turn pages in a book, and recognizes familiar pictures like animals (likes to make animal sounds). The use of a pincer grasp allows placement and retrieval of small objects. The 1-year-old has from six to eight deciduous teeth.

Socialization
1–3 months: The infant smiles, recognizes the primary caregiver, and vocalizes by cooing.
3–6 months: The infant now socializes by imitating sounds and laughing aloud.
9 months: The infant now reaches for familiar people, can say 'mama' and 'dada,' and responds to simple verbal requests.
12 months: The infant shows affection (blows kisses on request), explores away from parents, and seeks a security blanket or favorite toy when upset. The infant plays alone (solitary play) and enjoys mobiles, busy boxes, soft cuddle toys, and soft picture books.

Toddler (1–3 Years)
By the end of the first year of life, the infant has acquired the skills necessary for mobility. Sitting up and pulling to a standing position give rise to the more advanced gross motor skills of walking, running, and climbing. These skills, along with advancing fine motor development, allow the child to explore his environment as he tries to find out how things work. In the midst of toddlerdom is the stage known as the terrible twos, in which the most often-heard word from both parent and child is no. Everyday is a new adventure for the toddler and getting into things is a way of life. Parenting the toddler involves allowing exploration while setting limits, overcoming the struggles of toilet training, and (in some cases) managing sibling rivalry.

Key Elements in the Development of Toddlers:

Physical growth and development
Weight: On average the birth weight quadruples by the time the toddler is age 2 1/2 years. Weight gain slows to an average of 4–6 pounds per year.
Height: The toddler is approximately one half his adult height by the age of 2 1/2 years.
Head circumference: The head circumference is about 19 inches by 15 months of age and about 20 inches by 2 years of age. Brain growth increases to 90% of the adult size.
Chest circumference: The chest circumference is greater than the head circumference, giving the toddler a more adult appearance.

Development of gross motor and fine motor skills
12–18 months: The toddler can kick a ball forward, walk up steps, build a tower of two or four cubes, use a spoon, drink from a cup, push and pull toys, remove clothes, and scribble with crayons or pencils.
19–24 months: The toddler can jump in place, throw a ball overhand, kick a ball forward without falling, walk up and down steps with two feet on each step, build a tower of four or six cubes, copy a vertical line, wash and dry his hands, and help dress himself.
2–3 years: The toddler can balance on one foot, jump with both feet, take a few steps on tiptoe, ride a tricycle, build a tower of eight cubes, and copy vertical and horizontal lines. The toddler at this age can give his first and last name and name a friend and one color.

Socialization
12–18 months: At this age the toddler imitates housework, points to at least one named body part (nose, eyes, and so on), and can say three to six words other than mama or dada.
19–24 months: At this age the toddler has understandable speech, can combine three or four words, and can name pictures.
2–3 years: The toddler plays beside another child with little or no interaction in a fashion known as parallel play.
Toddlers enjoy nesting toys, picture books, push-pull toys, riding toys, pounding boards, sand, soap bubbles, talking toys, balls, dolls, and dress-up clothes.

Preschooler (3–5 Years)
If toddlers are best known for the terrible twos, then the preschooler should be known as a delightful paradox. He loves secrets and yet he will share all the family secrets with a total stranger. He can recite the sweetest of prayers and yet swear like a sailor. He can be brutally honest and yet invent the tallest of tales. He explores his world; imitates the adults in it; and yet lives in the fantasy world of adventure figures, becoming them from time to time. No one has more fun than the preschooler, who will run with total abandonment through the largest, muddiest puddle of water. Many of his baby features have given way to those of the older child. The potbelly of the toddler disappears and is replaced by a thinner, more athletic preschooler’s body.
Unfortunately, the potbelly will reappear when you least want it—and you can count on the preschooler to point it out to you in case you didn’t notice.
Although physical growth slows a bit, cognitive and language development continue at a rapid rate, preparing the child for a major life event: entering school.

Key Elements in the Development of Preschoolers:
A summary of important elements that are key to the development of preschoolers.

Physical growth and development
Weight: The average weight gain is about 5 pounds per year so that the 3-year-old weighs about 37 pounds, the 4-year-old about 42 pounds, and the 5-year-old about 47 pounds.
Height: The average increase in height is about 2–3 inches per year, which is mostly due to an elongation of the legs rather than the trunk. The average 3-year-old is 37 inches tall, the average 4-year-old is 40 inches tall, and the average 5-year-old is 43 inches tall.
Head and chest circumference: Unlike the squatty, potbellied appearance of the toddler, the physical proportions of the preschooler are more like that of the adult. The preschooler is usually slender and agile and takes great pride in showing off for others.

Development of gross motor and fine motor skills
3 years: The 3-year-old can pedal a tricycle, jump in place, broad jump, balance on one foot, walk up and down steps using alternating feet, build a tower of 9 or 10 cubes, copy a circle, put facial features on a circle, and feed and dress himself.
4 years: The 4-year-old can balance on one foot for 5 seconds, walk heel to toe, catch a ball, throw a ball overhand, skip and hop on one foot, use scissors, lace shoes, copy a square, and add three parts to a stick figure.
5 years: The 5-year-old can skip and hop on alternate feet, throw and catch a ball, jump rope, jump from a height of 12 inches, balance on alternate feet with eyes closed, tie shoelaces, use scissors, begin to print a few letters or numbers, copy a diamond and triangle, and draw a stick figure with from seven to nine parts.

Socialization
3 years: The 3-year-old has a vocabulary of about 900 words and can use complete sentences of 3–4 words, asks many questions, and begins to sing songs.
4 years: The 4-year-old prizes independence, takes pride in her accomplishments, enjoys entertaining others, shares family secrets with outsiders, and commonly has an imaginary friend.
5 years: The 5-year-old has a vocabulary of approximately 2,100 words and can use sentences with 6–8 words. At this age, the child can name the days of the week and the months of the year. The preschooler enjoys associative play, group play with similar or identical activities but without organization or rules. Preschoolers enjoy wading pools, tricycles, wagons, dolls, books with pictures, musical toys, finger paints, and toys that imitate objects used by adults.

School Age (6–12 Years)
School age begins with the child’s entrance into the school environment, which has a profound effect on the child’s development and relationship to the outside world. The freedom of expression enjoyed by the preschooler is less tolerated in the classroom, and the child learns to conform to social expectations. Associative play gives way to cooperative play in which following the rules is a must with little or no tolerance for those who do not. It is a time of leaders and followers as well as the emergence of in crowds and out crowds. Children with special learning needs, the overweight, those with physical limitations, and the poor often finds themselves in the out crowd, making the school years a time of loneliness and frustration. In many instances, this has later given way to school violence with tragic results.
Parents and teachers can help by making children more sensitive to the needs of others and by providing opportunities for all children to achieve their potential.

Key Elements in the Development of School-age Children:

Physical growth and development
Weight: During the period known as school age, the child gains an average of 6–8 pounds a year, reaching an average of 85–90 pounds by age 12 years.
Height: Between the ages of 6 and 12, children grow an average of 2 inches per year. By age 12, the child should be approximately 5 feet tall.
Head and waist circumference: Head and waist circumference decrease in relation to standing height. Leg length increases, and the child takes on a more mature appearance.

Development of gross motor and fine motor skills
6–8 years: The child has boundless energy, which is channeled into activities such as swimming, skating, biking, dancing, and sports. Fine motor skills become more developed as dexterity becomes more refined.
Among the skills acquired during the early school years the ability to read, tell time, and use simple math are important.
9–12 years: The child uses tools and equipment well, follows direction, is enthusiastic at work and at play, and looks for ways to earn money.

Socialization
9–12 years: The older school-age child loves secrets and might help organize secret clubs. The school-age child participates in cooperative play or activities that are organized with rules. Play activity is mostly with same-sex groups but with some mix in the later years. The schoolage child enjoys board games, video games, music, and sporting activities that are shared with others.

Adolescence (12–18 Years)
Adolescence is a time of rapid growth with the peak growth spurt spanning
24–36 months. Secondary sex characteristics appear, with physical and sexual maturity occurring in late adolescence.
Growth in height generally ceases by age 17 in girls and age 18–20 in boys.
Boys generally gain more in height and weight than girls. In early adolescence (12–15 years), the teen is usually uncoordinated with awkward movements due to the increasing length of the legs and the size of the feet. In later adolescence (16–18 years), the teen has increased coordination with more graceful movement. This no doubt accounts for the perfecting of athletic ability in high school and college.

The teen years represent a time of developmental crisis for the adolescent as well as the parents. The adolescent is usually on an emotional roller coaster, with highs and lows and periods of sociability and isolation. The desire for increased independence and changing roles within the family often lead to parent-child conflicts. Peer relationships are all-important and friendships can replace the influence parents have had during the childhood years.
Adolescents enjoy music, sports, video games, and activities where there are others of the same age.
You should review nursing textbooks for Erikson’s Theory of Psychosocial Development, Kohlberg’s Theory of Moral Development, and Piaget’s Theory of Cognitive Development as they relate to normal growth and development.

Congenital Anomalies
Congenital anomalies are also known as birth defects, and they refer to deviations in normal development that are evident at the time of birth or shortly thereafter. Congenital anomalies can be caused by genetic or environmental factors and include gastrointestinal, musculoskeletal, neurological, and cardiovascular defects. Some congenital defects are not physical malformations but are evident as inborn errors in metabolism and mental retardation. This section includes a review of the most common congenital anomalies, their management, and the reaction of parents to the birth of an infant with defects in physical development.

Anomalies of the Gastrointestinal System
These disorders can involve any portion of the gastrointestinal tract from the mouth to the anus. Incomplete development during embryonic development can result in atresia, malrotation, malposition, or failure of embryonic structures to close. The most common disorders of the gastrointestinal tract are
- Biliary atresia
- Cleft lip and cleft palate
- Esophageal atresia/tracheoesophageal atresia
- Hirschsprung disease
- Imperforate anus

Cleft Lip and Cleft Palate
Cleft lip and cleft palate are craniofacial deformities that involve the lip, hard palate, or soft palate. These can occur as separate malformations or occur together. Surgical repair of a cleft lip is generally performed between 1 and
3 months of age, while cleft palate repairs are performed between 6 months and 2 years of age depending on whether the defect involves the hard palate or soft palate.
Lip repair is performed earlier than palate repair to facilitate feeding and promote parental–infant bonding. The nurse should assess the amount and quality of parental interaction with the infant because the bonding process can be negatively affected by the infant’s appearance.

Preoperatively the nurse should teach the parents to feed the infant using a Breck feeder or flanged nipple. The infant should be fed slowly to prevent aspiration and should be burped more frequently to prevent gastric distention. The infant’s weight should be closely monitored.
Postoperatively the nurse should give priority to assessing the respiratory status of the infant. Surgical correction of the soft tissue of the mouth and palate can result in airway obstruction.

Additional postoperative care includes feeding the infant using a Breck feeder to prevent stress on the suture line caused by sucking. The mouth and suture line are cleansed of formula residue using sterile water. The suture line of the lip is cleaned using half-strength hydrogen peroxide. The suture line is reinforced with a Logan bar, which lessens stress on the suture line caused by crying. Elbow restraints prevent the infant placing his hands near his face or mouth.
A multidisciplinary team is involved in the care of the infant with cleft lip/cleft palate.
This team can include the physician, nurse, orthodontist, speech therapist, otolaryngologist, and social worker.

Esophageal Atresia or Tracheoesophageal Fistula
Esophageal atresia (EA) is a failure of the esophagus to develop a continuous passage, and tracheoesophageal fistula (TEF) is an abnormal opening between the trachea and esophagus. These can occur alone or in combination. Symptoms of EA and TEF include

- The presence of maternal polyhydramnios (excessive amniotic fluid)
- Excessive mucus and drooling in the newborn
- Coughing, choking, and cyanosis with the first feeding
- An x-ray of the esophagus that confirms the presence of a blind pouch at each end, widely separated with no connection (EA) or the presence of an abnormal connection between the trachea and esophagus (TEF)

Prior to surgical correction, intravenous fluids are started and the infant is positioned to facilitate drainage of secretions. Frequent suctioning of secretions from the mouth and pharynx decreases the likelihood of aspiration. A double lumen catheter placed in the esophageal pouch is attached to intermittent low suction. Keeping the infant’s head in an upright position makes it easier to remove collected secretions.
Aspiration pneumonia is so common that prophylactic antibiotics are usually started.

The surgical correction of esophageal atresia can be performed in one operation or staged in one or two operations. Surgical correction of TEF involves a thoracotomy, a division and ligation of the TEF, and an end-to end anastomosis. If the repair is to be done in stages, a gastrostomy tube is inserted to permit tube feedings. Prior to feeding, the gastrostomy tube is elevated and secured above the level of the infant’s stomach. This allows gastric contents to pass into the duodenum and lessens the likelihood of aspiration.
Gastrostomy feedings are continued until the esophageal anastomosis is healed. Oral feedings are begun about one week postoperatively and are started with sterile water followed by small, frequent feedings of formula.
Esophageal atresia and tracheoesophageal fistula are associated with several other anomalies, including congenital heart disease, anorectal malformations, and genitourinary anomalies. The prognosis depends on the preoperative weight, associated congenital anomalies, and prompt diagnosis.
Premature and low birth weight infants as well as those with severe respiratory complications have poorer prognoses.

Imperforate Anus
This deformity includes a number of malformations in which there is no obvious anal opening or where an abnormal opening exists between the anus and the perineum or genitourinary system. A routine part of neonatal assessment includes checking for patency of the anus and rectum and noting the passage of meconium.
Passage of meconium does not always indicate anal patency—particularly in females—because a fistula might be present, allowing evacuation of the meconium.
In males meconium might pass through a fistula in the midline. This can appear as ribbonlike meconium at the base of the scrotum or near the base of the penis.

Surgical repair depends on the extent of the malformation. The imperforate anal membrane is removed, followed by dilation. More extensive surgery is required for the infant with perineal defects. Postoperatively, the infant should be placed in a side-lying or prone position to prevent pressure on perineal sutures.

Hirschsprung Disease (Congenital Aganglionic Megacolon)
This anomaly refers to the absence of nerve stimulation to the bowel, which produces normal peristalsis. Although it accounts for about 25% of all cases of neonatal bowel obstruction, it might not be diagnosed until later in infancy or childhood. Hirschsprung disease is more common in males and is frequently associated with other congenital anomalies such as Down syndrome.
The symptoms of Hirschsprung disease depend on the amount of bowel involved, the occurrence of complications, and the age at time of diagnosis.
Symptoms in the newborn include failure to pass meconium within the first 24–48 hours, refusal to feed, abdominal distention, and intestinal obstruction. During infancy symptoms include the failure to gain weight, constipation, abdominal distention, and episodes of vomiting. In childhood the symptoms become chronic and include poor appetite; poor growth; abdominal distention; infrequent passage of foul smelling, ribbonlike stools; and palpable fecal masses.
The presence of fever, bloody diarrhea, and severe lethargy should alert the nurse to the possibility of enterocolitis, a potentially fatal condition.

The diagnosis of Hirschsprung disease is made using a barium enema, rectal biopsy, and anorectal manometry (a procedure that records the pressure response of the internal anal sphincter). In the case of Hirschsprung disease, the internal sphincter fails to relax.

In some cases the child with Hirschsprung disease can be managed with dietary modifications such as increasing fluid and fiber intake. Management also includes the administration of occasional enemas using isotonic or normal saline solutions. These solutions can be purchased without a prescription or can be prepared by adding 1 level measuring teaspoon of non-iodized salt to 1 pint of tap water.
The use of tap water, concentrated salt solutions, soap solutions, or phosphate preparations is discouraged because frequent use of nonisotonic solution can lead to water intoxication and the dilution of serum electrolytes.

Most children with Hirschsprung disease require surgical correction. The child’s fluid and electrolyte is stabilized, and a temporary colostomy is performed to relieve the obstruction and allow the bowel to return to normal.
Following the initial surgery, a complete corrective surgery is performed.
Several surgeries are used; however, one of the most common includes a pull-through procedure in which the end of the normal bowel is pulled through the muscular sleeve of the rectum. The temporary colostomy is closed at the same time. Postoperative nursing care includes assessing the client for abdominal distention and for the return of bowel sounds and the passage of stool. The abdominal wound is assessed and cared for the same as any abdominal wound.

Biliary Atresia
This problem causes fibrosis of the intrahepatic and extrahepatic bile ducts and gradually results in liver failure. Most affected infants are full term and appear healthy at birth. Jaundice, dark urine, clay-colored stools, and hepatomegaly occur early in the disease. Later symptoms are associated with the development of cirrhosis and spleenomegaly.
Treatment of biliary atresia includes surgical procedures that allow drainage of the bile (hepatic portoenterostomy or Kasai procedure) and orthotopic liver transplantation, now considered to be the definitive therapy for biliary atresia.
Jaundice that exists longer than 2 weeks of age accompanied by elevations in direct (conjugated) bilirubin points to the possibility of biliary atresia.

Anomalies of the Musculoskeltal System
These disorders affect the development and ossification of bones and joints.
The most common skeletal disorders are developmental dysplasia of the hip (DHD) and congenital clubfoot.

Developmental hip dysplasia most commonly involves subluxation or incomplete dislocation of the hip. The disorder can affect one or both hips; if only one hip is involved, it is most often the left hip. Although the cause is unknown, certain factors such as gender, family history, intrauterine position, method of delivery, and postnatal positioning affect the risk of DHD.
Females are affected more often than males, and there is an increased incidence if one of the parents or a sibling had the disorder. DHD is more common in the infant with frank breech presentation and delivery by Cesarean section.
DHD is found more often in groups that use cradle boards or papoose boards for carrying the infant (such as Native Americans) than those groups that carry the infant on the back or on the hips (such as Asians).

Symptoms of DHD in the infant 2–3 months of age include laxity in the hip joint and the presence of the Ortolani click—the audible sound that is made when the affected hip is abducted. Other signs include shortening of the affected limb (Allis sign) and asymmetrical thigh and gluteal folds.
Symptoms of DHD in the older child include delays in walking, the presence of extra gluteal folds, and a positive Trendelenburg sign when weight bearing. If both hips are affected, the child develops a waddling gait and lordosis.
Early diagnosis and correction of DHD are important because correction becomes more difficult as the child ages. Correction in the infant less than 6 months of age involves the use of a Pavlik harness. This device prevents hip extension or adduction and is worn continuously for about 3–6 months.
Failure to diagnose the condition before the child begins to stand results in apparent contractures of the hip adductor and flexor muscles. Correction at this point involves traction, open or closed reduction, and the application of a hip spica cast.
The infant is growing rapidly, so the straps of the Pavlik harness should be checked every 1–2 weeks for needed adjustments because vascular or nerve damage can occur with improper positioning.

Congenital Clubfoot
Also known as talipes equinovarus, this problem is a structural deformity in which the foot is turned inward, causing the child to walk on the outer border of the foot. Congenital clubfoot can be classified as positional (due to intrauterine crowding), teratologic (associated with other congenital anomalies), or true clubfoot (due to a bony abnormality). The affected foot is usually smaller and shorter than the unaffected foot. If the defect is unilateral, the affected limb is smaller with atrophy of the calf muscle.
Treatment begins in the nursery or shortly after birth with the application of casts. The cast is changed and the affected limb is manipulated weekly for the first 6–12 weeks. Surgical correction involves pin fixation and the release of tight joints and tendons followed by casting for 2–3 months. After the cast is removed, a varus-prevention brace is worn.

Anomalies of the Central Nervous System
Central nervous system (CNS), or neural tube defects, make up the largest group of congenital anomalies. The incidence of neural tube defects has been drastically reduced by supplementing the mother’s diet with folic acid prior to conception. Avoiding extremes of temperature during early fetal development has likewise reduced the risk of neural tube defects.
The pregnant client should avoid external heat exposure, such as hot tubs and saunas, because these have been identified as factors that increase the risk of neural tube defects.

Spina Bifida
This disordered is marked by a failure of the bony spine to close. It is the most common defect of the central nervous system. There are two types of spina bifida: spina bifida occulta and spina bifida cystica. Of these two types, spina bifida cystica, an external sac-like protrusion, causes the greatest CNS damage.
The major forms of spina bifida cystica are meningocele (the defect contains the meninges and spinal fluid) and myelomeningocele (the defect contains the meninges, nerve tissue, and spinal fluid). Unlike the child with a meningocele, who usually has no neurological deficit, the child with a myelomeningocele often has serious neurological deficit.
In most instances, myelomeningocele occurs in the lumbar or lumbosacral area. Regardless of where the defect is located, higher and larger defects result in more neurological damage.

The defect, which is usually enclosed in a thin membrane, should be protected from trauma as well as contamination with urine and stool, which can cause infection. Any stool or urine near the sac is gently removed using sterile saline, and the sac is examined for signs of leakage.
During the preoperative period, the nurse should give priority to preventing injury to or drying of the sac. The sac should be covered with a sterile, nonadherent dressing moistened with sterile normal saline. Dressings are changed every 2–4 hours. The newborn should be placed prone with the hips slightly flexed and elevated (low
Trendelenburg) to prevent stretching of involved nerves.

Surgical correction usually takes place within the first 24–72 hours of life to prevent local infection and trauma to the exposed tissues. Several neurosurgical and reconstructive procedures are used for skin closure. Complications of myelomeningocele include the development of hydrocephalus, urinary tract infection, meningitis, pressure sores, and contractures.
Symptoms of meningitis in the infant include temperature instability, poor feeding, a high-pitched cry, and bulging fontanels. Symptoms of meningitis in the child include fever, projectile vomiting, headache, and visual disturbances.

Anomalies of the Cardiovascular System
Cardiovascular disorders are classified as congenital heart defects and acquired heart disorders. Congenital heart defects involve structural defects in the anatomy of the heart and blood vessels that are apparent at birth or shortly thereafter. These affect the function of the heart and are evident in the development of congestive heart failure and hypoxemia. Acquired heart disorders refers to disease processes that affect the structure and function of the heart. Acquired heart disease can be the result of bacterial infection, autoimmune response, environmental factors, or heredity. This section focuses on two congenital heart defects: coarctation of the aorta and tetralogy of Fallot. A review of two acquired heart diseases—rheumatic fever and Kawasaki disease—follows later.

Congenital Heart Defects
Heart defects are the major cause of death during the first year of life, with the exception of those infants who die from prematurity. In most cases, the cause of congenital heart defects (CHD) remains unknown. However, certain maternal risk factors have been identified:

- Alcoholism
- Maternal age over 40
- Rubella during pregnancy
- Type 1 diabetes

CHD is more likely to be diagnosed when the infant is several weeks old than at the time of birth.
The rapid heart rate of the infant, the instability of the circulatory system, and the fact that many newborns have a benign murmur present for the first few days of life often delay diagnosis. It is more likely that a congenital heart defect will be diagnosed when the infant is several weeks old.

Symptoms of CHD in the infant and child depend on the type and severity of the defect but include
- Cyanosis with feeding and clubbing of the fingers and toes
- Dyspnea
- Failure to gain weight
- Fatigue
- Respiratory congestion

Complications of CHD include delayed growth and development, polycythemia, clot formation, and congestive heart failure.
Early signs of congestive heart failure include tachycardia while sleeping, profuse sweating (especially on the scalp), fatigue, irritability, respiratory distress, and weight gain.

Congenital heart disease is classified according to whether the defect is acyanotic (without cyanosis) or cyanotic (with cyanosis). Acyanotic defects include patent ductus arteriosus, atrial septal defect, ventricular septal defect, and coarctation of the aorta. Cyanotic defects include transposition of the major vessels, truncus arteriosus, and Tetralogy of Fallot. A. this point, you might want to review heart structure and normal circulation in a nursing textbook as well in an anatomy and physiology textbook. It is difficult to understand the abnormal if you don’t know the normal.

Aw you probably realize, the content area of congenital heart disease is quite large, so we’ll focus on two defects (one acyanotic and one cyanotic) because of the uniqueness of the symptoms associated with these two conditions.

Coarctation of the Aorta
This refers to a narrowing within the aorta that alters blood flow to the extremities. Symptoms of coarctation of the aorta (COA) include elevated blood pressure and bounding pulses in the upper extremities and diminished blood pressure and weak or absent pulses in the lower extremities. Infants who develop congestive heart failure require hospitalization for stabilization of the blood pressure and treatment of acidosis. Older children with COA might complain of dizziness; headache; fainting; and nosebleed, which can indicate that the blood pressure is higher than usual.
Correction of COA involves resection of the coarcted portion with an endto-end anastomosis of the aorta or by enlargement of the narrowed portion using either a prosthetic graft or a graft taken from the left subclavian artery.
The defect is outside the heart and pericardium so cardiopulmonary bypass is unnecessary.
Residual hypertension following surgery seems to be related to the age of the child at the time of repair, so elective surgery should be performed within the first 2 years of life. The prognosis is good with less than 5% mortality in children with no other defects.
Tetralogy of Fallot A. the name implies, this disorder involves four separate defects. These defects include pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Infants with tetralogy of Fallot (TOF) might have a history of acute cyanosis and heart murmur at birth that worsens over the first year of life. Acute episodes of cyanosis and anoxia, referred to as blue spells or tet attacks, occur during crying or feeding because the infant’s oxygen demands are greater than the blood supply. Children with TOF have noticeable cyanosis, clubbing of the fingers, and growth retardation. When oxygenation is compromised, the child with TOF assumes a squatting position. Children with TOF are at risk for developing emboli, seizures, loss of consciousness, or sudden death following an anoxic episode.
Nursing care for the infant or child with a tet attack involves placing the child in knee chest position and providing supplemental oxygen.

Surgical treatment for TOF involves a palliative shunt (Blalock-Taussig procedure) to increase blood flow to the lungs thereby providing for better oxygenation. Complete elective repair, involving correction of each of the four defects, is usually performed in the first year of life. Surgical repair requires the child to be placed on cardiopulmonary bypass. The operative mortality is less than 5% for total correction of TOF.

Inborn Errors of Metabolism
This refers to inherited diseases caused by the absence or deficiency of a substance, usually an enzyme that is essential to cellular metabolism. Most inborn errors in metabolism involve abnormal metabolism of protein, carbohydrate, or fat. Although many diseases are included in this category, we will focus on two of the most common: phenylketonuria (PKU) and galactosemia.

Phenylketonuria
Phenylketonuria (PKU) is a genetic disorder in which the child is unable to metabolize phenylalanine into tyrosine. Tyrosine is essential to the formation of melanin (responsible for hair, skin, and eye color) and the hormones epinephrine and thyroxine. Accumulation of phenylalanine affects the normal development of the brain and central nervous system. Without early detection and treatment, the child with PKU develops irreversible brain damage.
Clinical manifestations of PKU include irritability, frequent vomiting, failure to thrive, and seizures. Older children with PKU have bizarre behaviors such as head banging, screaming, arm biting, and other psychotic behaviors.
The most commonly used screening test for PKU is the Guthrie blood test.
All newborns are screened for PKU before discharge or within the first week of life because early detection and treatment are necessary to prevent mental retardation.
The Guthrie test is obtained from a heel stick. Remember to stick the newborn on the side of the heel to avoid nerve damage. The test is most reliable if the infant has ingested a source of protein. If the specimen is obtained before the infant is 24 hours old, a subsequent sample should be obtained before the infant is 2 weeks old.

The treatment for PKU consists of instituting a low-phenylalanine diet begun as soon as possible after diagnosis and continued through adolescence.
Specially prepared formulas include Lophenalac and ProPhree Total. Partial breast feeding can be allowed if phenylalanine levels are closely monitored.
Solid foods such as cereal, fruits, and vegetables are added according to the recommended schedule. Most high-protein foods are either eliminated or restricted to small amounts. Artificial sweeteners containing aspartame should be avoided because they are converted to phenylalanine.

Galactosemia
Galactosemia is a genetic disorder in which one of the three enzymes necessary to covert galactose to glucose is missing. The infant with galactosemia appears normal at birth, but within a few days of ingesting a formula containing lactose, she begins to vomit and lose weight. Additional symptoms arise from accumulations of galactose, which target the major organs.
Damage done to the liver and spleen results in jaundice, cirrhosis, and portal hypertension. Cataracts—opacities in the lens of the eyes—are usually evident by 1–2 months of age. Lethargy and hypotonia associated with brain damage are evident soon afterward.
Newborn screening for galactosemia is required in most states. Diagnosis is based on history, physical exam, and increased levels of serum galactose. The treatment of galactosemia is aimed at eliminating all milk- and lactosecontaining foods, including breast milk. Instead, the infant is fed a soyprotein formula.
Medications that contain lactose should also be avoided.

Respiratory Disorders
These disorders include infections of the upper airway and lower airway and as well as infections of the ears. Three points should be made about respiratory disorders in children. First, respiratory disorders are more common, and often more serious, in infants and children than adults. Some infections, such as otitis media, occur with greater frequency because of anatomical differences. Second, although all children are at risk, certain children are more vulnerable to respiratory disorders. This includes premature and low-birth weight infants and children with AIDS. Finally, children with respiratory disorders are more likely than adults to develop gastrointestinal symptoms such as vomiting and diarrhea, which increase the risk of dehydration and acidosis. This section focuses on the care of children with the most common pediatric respiratory disorders.

Acute Otitis Media
Acute otitis media (AOM) is one of the most common respiratory diseases in childhood. The incidence is highest in children 6 months to 3 years of age.
Otitis media is more prevalent in the young child because the eustachian tube is straighter, shorter, and wider than in older children or adults. Other factors that contribute to AOM are passive smoking, enlarged adenoids, attendance at day care, and supine positioning with bottle feeding. In AOM the child develops a high fever (103°–104° F), anorexia, vomiting, and pain.
The infant or young child might be seen rubbing or pulling at the affected ear or rolling her head from side to side. Increasing pressure can rupture the eardrum. If rupture occurs, pain and fever subside.
The organism responsible for AOM is usually H.influenza, although other organisms (such as S. pneumoniae and M. catarrhalis) can also produce an acute infection. Treatment of AOM involves the use of antibiotics, including oral amoxicillin, sulfonamides, erythromycin, or cephalosporins.
Antipyretics such as ibuprofen or acetaminophen can be given to reduce fever and pain.
Oral suspensions are usually administered for 7–10 days. It is important that parents comply by giving the medication for the full course of treatment. Single-dose injections of an appropriate antibiotic can be used if the child has poor absorption of the drug, the child refuses to take the medication, or the parents fail to comply with oral therapy.

Complications of AOM include mastoiditis, meningitis, and hearing loss.
Hearing evaluation is recommended for a child who has bilateral OM for a total of 3 months. Children with AOM should be seen after antibiotic therapy to check for any residual infection and to identify potential complications.
More information on otitis media, including myringotomy and insertion of PE tubes, is included in Chapter 8, 'Caring for the Client with Sensorineural Disorders.'

Tonsillitis
This problem often accompanies pharyngitis and is a major cause of illness in young children. The tissue referred to as tonsils is actually made up of several pairs of lymphoid tissue:
- Adenoids
- The lingual tonsils
- The palatine tonsils
- The pharyngeal tonsils

Symptoms of tonsillitis include
- Difficulty swallowing and breathing
- Enlargement of the tonsils
- Inability to smell and taste
- Mouth breathing
- Snoring

The condition can be viral or bacterial in origin.
Viral infections are usually self-limited, and management is aimed at relieving the symptoms of soreness and dryness of the throat.
Tonsillitis is usually caused by a virus; therefore, management focuses on the relief of symptoms. However, if the infection is caused by Group A beta hemolytic streptococcus, antibiotic therapy is ordered. A tonsillectomy— surgical removal of the palatine tonsils—is indicated if tonsillar enlargement interferes with eating or breathing, if there is a recurrent history of frequent streptococcal infection, or if there is a history of peritonsillar abscesses. An adenoidectomy—surgical removal of the adenoids—is recommended if enlarged adenoids block breathing. In most cases, the tonsils are not removed before 3 years of age because of the possible complications associated with blood loss in very young children and the possibility of the regrowth of lymphoid tissue.
Preoperative nursing care includes obtaining a detailed history (including a history of unusual bleeding), assessing for signs of upper respiratory infection, and noting whether any teeth are loose. Routine vital signs are obtained to serve as a baseline for postoperative comparison, and a bleeding and clotting time are requested.
Postoperatively the child should be closely observed for continual swallowing, which is an indication of bleeding. An ice collar can be applied to the throat to increase comfort, and analgesics can be given intravenously or rectally for the first 24 hours to decrease pain and promote rest. When the child is awake and responsive, ice chips and cool, clear liquids are given. Citrus foods, hot foods, and foods with rough textures should be avoided as well as foods that are red, orange, or brown in color. Upon discharge, the parents should be instructed to keep the child out of crowds for 1–2 weeks and to report any signs of new bleeding, which is most likely 7–10 days after surgery. The doctor should be notified immediately if bleeding occurs after discharge.

Laryngotracheobronchitis
This is the most common form of croup in hospitalized children and is a viral infection of the upper airway. It is most common in children between 3 months and 8 years of age. Unlike acute spasmodic croup, which appears suddenly at night, the onset of laryngotracheobronchitis (LTB) begins with an upper respiratory infection and low-grade fever. The child is restless and irritable, with noticeable hoarseness and a brassy cough.
The goal of care is to maintain the airway and ensure adequate oxygenation.
The child with mild croup is often managed at home and treated symptomatically. The symptoms of hoarseness, cough, and inspiratory stridor can be relieved by providing high humidity with cool mist. The child should be frequently offered fluids to maintain adequate hydration.
Immediate medical attention should be sought if the child develops labored respirations, continuous stridor, or intercostal retractions or refuses to take oral fluids.

If the respiratory condition worsens, treatment includes withholding oral intake and administering IV fluids until the respiratory condition improves.
Other measures include cool mist vaporizers, supplemental oxygen, and the administration of antibiotics to treat coexisting infections and steroids or epinephrine to reduce bronchial swelling.

Acute Epiglottitis
This is an upper airway infection that primarily affects children 2–5 years of age, but it can also occur at any age from infancy to adulthood. The primary cause of acute epiglottitis is H. influenza.
The American Academy of Pediatrics recommends that all children receive the H.influenza B conjugate vaccine beginning at 2 months of age as part of the routine childhood immunization series. This can account for the decline in the incidence of epiglottitis.

The child with epiglottitis is much sicker than symptoms suggest. Typically, the child goes to bed with no symptoms but awakens complaining of a sore throat and pain on swallowing. Additional symptoms include drooling, muffled phonation, inspiratory stridor, and sitting in a tripod position. Upon examination, the physician notes the appearance of a cherry red epiglottis.
Remember that only the physician should assess the child’s throat because visualization can precipitate immediate airway obstruction. A tracheostomy set should be readily available because emergency intervention might be necessary to support respiratory efforts.

Endotracheal intubation or tracheostomy is usually performed if the child has H. influenza epiglottitis. These procedures, as well as initiation of intravenous fluids and antibiotics, are usually carried out in the operating room.
Even if intubation and assisted ventilation are unnecessary, the child should be maintained in an intensive care area for continual observation for at least 24 hours. Dramatic improvement occurs in 24 hours with antibiotic therapy, and the epiglottis is almost normal within 2–3 days.

Bronchiolitis
This is a lower airway infection that occurs most often in infants and children under 2 years of age. The respiratory synctial virus (RSV) accounts for most cases of bronchiolitis; however, the condition is also caused by adenoviruses, parainfluenza viruses, and M. pneumoniae. Outbreaks occur most commonly in the winter and spring months.
Symptoms of bronchiolitis include dyspnea, nonproductive cough, wheezing, nasal flaring, intercostal and sternal retractions, and emphysema.
Management of the client with bronchiolitis depends on the age and presenting symptoms. Older children with bronchiolitis can be treated at home, but infants are more likely to need hospitalization. Treatment is aimed at maintaining the respiratory status, decreasing the chance of aspiration, treating the infection, and maintaining acid/base balance. Nursing care includes careful assessment of the vital signs and respiratory status as well as attention to intake and output. Oral fluids might be withheld until respiratory function improves. Additional measures include the use of cool mist vaporizers with or without supplemental oxygen and respiratory therapy with Virazole (ribavirin).

To be effective, ribavirin should be administered within 3 days of the infection.
Healthcare workers who are pregnant should avoid direct care of the client receiving aerosolized Virazole (ribavirin) because the medication can cause birth defects or death of the fetus. Surgical masks do not provide adequate filtration of the Virazole particles.
RSV-IGIV (Respigam) can be given to high-risk (premature or low-birth weight) infants. The medication, given IV over 3–4 hours, is administered monthly. Respigam interferes with the MMR vaccine and the varicella vaccine, so these vaccines should be deferred for 9 months after infusion. Palivizumab (Synagis) is preferred for use because it does not interfere with the MMR vaccine or varicella vaccine. Synagis is given IM in a monthly injection.

Cystic Fibrosis (Mucoviscidosis)
This is inherited as an autosomal recessive gene. The disease affects the exocrine system and produces abnormalities in the lungs, pancreas, and sweat glands. Although cystic fibrosis affects these systems, the prognosis depends on the degree of lung involvement. Lung function has been greatly improved with the use of Pulmozyme, an enzyme that improves respiratory function.
Symptoms of cystic fibrosis include meconium ileus, frequent upper respiratory infections, malabsorption, failure to gain weight, and heat prostration.
Additional health problems include reoccurring nasal polyps and rectal prolapse.
The diagnosis of cystic fibrosis is made by the sweat test, which reveals elevated sodium and chloride levels. The absence of pancreatic enzymes results in malabsorption and steatorrhea or undigested fat in stools. Chest x-ray reveals emphysematous changes in lungs.
The treatment of cystic fibrosis includes the use of antibiotics to treat respiratory infections and pancreatic enzyme replacement to improve absorption and decrease weight loss. The client’s diet should be high in carbohydrate, high in protein, and moderate in fat. Extra salt is allowed, and the diet is supplemented with water-soluble preparations of vitamins A, D, E, and K.
Pancreatic enzyme replacement is based on the client’s age and the consistency of the stools. These enzymes, which are given with each meal and snack, are best tolerated when given in applesauce because it disguises the taste.

Gastrointestinal Disorders
Gastrointestinal disorders include infections, malformations, and structural changes that affect the digestion and absorption of nutrients. When we think of the GI tract, and we seldom do unless there is a problem, we typically only think of its role in digestion and elimination. However, the GI tract plays a key role in maintaining fluid and electrolyte balance through its interaction with the kidneys and lungs. Gastrointestinal disorders are considered to be more severe in the infant and young child because of the danger of dehydration and metabolic acidosis.

Gastroenteritis
Gastroenteritis, or acute diarrheal disease, can be caused by an infection with rotavirus, salmonella, or another organism, or it can accompany another illness such as an upper respiratory or urinary tract infection. Additional causes include ingestion of sorbitol or fructose in juices. Regardless of the cause, acute diarrhea is a more severe illness in infants and very young children because they develop dehydration more quickly than adults. Untreated, the condition can quickly progress to a life-threatening situation.
Treatment focuses on determining the cause of the illness, assessing for signs of fluid and electrolyte imbalance, ensuring adequate hydration, and reintroducing adequate diet. Stool and urine cultures are ordered in addition to the routine lab studies.
Oral rehydration solutions such as Pedialyte and Infalyte replace formula feedings. Intravenous fluids with electrolytes are started on children with severe dehydration and shock. When symptoms improve, the child can begin to have clear liquids with progression to the BRAT diet (bananas, rice, applesauce, and toast). Infants can begin formula progression as follows: halfstrength soy formula, full-strength soy formula, and (if tolerated) a return to regular formula.
Potassium replacement should be instituted only after assessing for the presence of urinary output.

Pyloric Stenosis
This problem involves a narrowing of the sphincter at the outlet of the stomach, and it occurs most often in firstborn males. The signs and symptoms of pyloric stenosis include projectile vomiting and a palpable olive-shaped mass in the right upper quadrant of the abdomen. X-ray confirms the presences of hypertrophy and an elongation of the pylorus. The disorder is corrected surgically by a procedure known as a pyloromyotomy or Fredet-Ramstedt procedure. The prognosis following surgery is excellent.

Intussusception
This problem involves an invagination or telescoping of one portion of the bowel into another. The most common site for intussusception is the ileocecal valve or the point where the large and small intestines join. Symptoms associated with intussusception include colicky abdominal pain and the passage of 'currant jelly' stools by an otherwise healthy child. The use of air pressure or water-soluble contrast can be used to diagnose and reduce the intussusception. If conservative measures fail, surgical intervention is required to restore normal bowel function.

Celiac (Gluten-induced Enteropathy, Celiac Sprue)
This issue is a malabsorptive disorder of the proximal small intestine caused by an intolerance to gluten. Gluten is found in the grain of wheat, oats, barley, and rye. Digestive problems most often appear between the ages of 1 and 5 years when the child begins to ingest various foods containing gluten. Symptoms vary but generally include malabsorption, steatorrhea, abdominal distention, and muscle wasting (particularly in the buttocks and extremities). Diagnosis is based on jejunal biopsy, which reveals changes in the intestinal mucosa. The treatment of celiac involves the replacement of gluten-containing grains with corn, rice, and millet as well as avoiding hidden sources of gluten. Hydrolyzed vegetable protein, a common ingredient in many commercially prepared foods, contains gluten and can cause an exacerbation of symptoms. Associated problems include deficiencies in iron, folic acid, and fat soluble vitamins that are treated with vitamin and mineral supplements.

Strict adherence to dietary restrictions can help minimize the development of small intestine lymphoma, one of the most serious complications of celiac.

Cardiovascular Disorders
These are divided into two groups: acquired heart disorders and congenital heart disorders, which are sometimes referred to as congenital heart disease.
Congenital heart disease, which exists at the time of birth, was discussed earlier in this chapter. Acquired heart disease refers to disease processes that occur after birth and can be found in those with a normal heart and cardiovascular system. Two examples of acquired heart disease are rheumatic fever and Kawasaki disease.

Rheumatic Fever
This is an autoimmune response to Group A beta hemolytic streptococcal infection. The disease, which is self-limiting, affects the skin, joints, brain, serous surfaces, and heart. The most serious complication of rheumatic fever is damage to the valves of the heart, and the valve most often affected is the mitral valve.
The major clinical manifestations of rheumatic fever are the result of inflammation and the appearance of hemorrhagic lesions (Aschoff bodies) that are found in all the affected tissues. The symptoms associated with each of the major manifestations are
- Carditis (heart)—Includes the presence of an apical systolic murmur, aortic regurgitation, tachycardia, cardiomegaly, complaints of chest pain, and development of mitral stenosis.
- Polymigratory arthritis (joints)—Includes the presence of red, swollen, painful joints, particularly the larger joints (knees, elbows, hips, shoulders, and wrists). The symptoms move from one joint to another and are most common during the acute phase of illness.
- Erythema marginatum (skin)—Includes the presence of a distinct red macule with a clear center found on the trunk and on proximal extremities.
- Subcutaneous nodules (serous surfaces)—Include the presence of small, painless swellings located over the bony prominences of the feet, hands, elbows, vertebrae, scalp, and scapulae.
- Syndeham’s chorea (brain)—Includes the presence of aimless, jerking movements of the extremities; involuntary facial grimacing; speech disturbances; emotional lability; and muscle weakness.
In addition to the major manifestations, the client with rheumatic fever has minor manifestations that include fever, arthralgia, an elevated erythrocyte sedimentation rate, and a positive C-reactive protein. Supporting evidence of a preceding Group A beta hemolytic streptococcal infection includes a positive throat culture and a positive antistreptolysin-O (ASLO) titer.
The goals of treatment are eradicating the hemolytic streptococcal infection, preventing permanent cardiac damage, making the child more comfortable, and preventing recurrences of Group A beta hemolytic infection. Nursing interventions include administering prescribed medications (such as penicillin, salicylates, and steroids), promoting rest and proper nutrition, providing emotional support for the child and the family, and teaching regarding the need for periodic follow-up with the physician. In addition, the nurse plays a key role in emphasizing the need for good dental hygiene and regular dental visits.

Kawasaki’s Disease (Mucocutaneous LymphNode Syndrome)
This is an acute systemic vasculitis. The exact cause remains unknown, although it appears to be a problem with the immune system. The disease mainly affects children under 5 years of age with the peak incidence occurring in toddlers. The disease is best known for the damage done to the heart; however, it involves all the small- and medium-size blood vessels. The most common sequela of Kawasaki disease (KD) is the dilation of coronary arteries, which results in aneurysm formation. Infants under 1 year of age and those over 5 years of age appear to be at the greatest risk for developing coronary problems. KD is one of the major causes of acquired heart disease in children in the United States.
The child with KD develops a high fever that lasts 5 or more days and fails to respond to antipyretics or antibiotics. Other symptoms include redness of the bulbar conjunctiva, inflammation of the pharynx and oral mucosa, red cracked lips, 'strawberry tongue,' and swelling of the cervical lymph nodes.
One of the most notable symptoms is desquamation that begins at the fingertips and toes and gradually spreads, leaving the soles and palms red and swollen. Swelling is also noted in the weight-bearing joints. Additional findings include increased platelet counts and increased coagulation.
Most cases of KD are reported in the winter and early spring. There is also an increased incidence in children who are exposed to recently cleaned carpet, which suggests there is perhaps an immune response.

There is no specific test for KD. The diagnosis is based on the presence of symptoms and supporting lab work that reveals a decreased number of RBC, an increased number of immature WBC, and an increased erythrocyte sedimentation rate. Medical management includes the use of IV immunoglobulin and aspirin.

The nursing care of the child with KD focuses on relieving symptoms, providing emotional support, administering medications, and educating the family. The nurse should carefully monitor the vital signs and assess for signs of cardiac complications, which include congestive heart failure and myocardial infarction.
Signs of myocardial infarction in the infant or young child include abdominal pain, vomiting, restlessness, inconsolable crying, pallor, and shock. Sings of congestive heart failure include respiratory distress, tachycardia, and decreased urinary output.

Nursing interventions during the acute phase focus on the relief of symptoms. Inflammation of the skin and mucous membranes accounts for much of the child’s discomfort during the acute phase. The nurse can help minimize discomfort by applying soothing, unscented lotions to the skin. Mouth care with a soft-bristled toothbrush is followed by the application of lubricating ointment to the lips. Acetaminophen can be given for fever and to relieve joint pain. The child should be placed in a quiet environment to promote rest.
The administration of intravenous gamma globulin requires that the nurse carefully assess vital signs and observe for signs of an allergic reaction, which include chills, fever, dyspnea, and flank pain.
The nurse must ensure patency of the IV line before administering gamma globulin because extravasation can result in tissue damage.

The child with KD might be discharged on high doses of aspirin for an extended period of time. The nurse should teach parents the side effect signs and symptoms of aspirin toxicity, including tinnitus, dizziness, headache, and confusion. Low-dose aspirin can be continued indefinitely if the child has coronary abnormalities. The child with coronary abnormalities should avoid contact sports.
The nurse should instruct the parents to discontinue the aspirin and notify the physician if the child is exposed to influenza or chickenpox.

Musculoskeletal Disorders
These disorders involve alterations in bones, joints, muscles, or cartilaginous tissues. Musculoskeletal disorders, like fractures, are the result of trauma. Disorders such as congenital hip dysplasia and clubfoot involve prenatal or genetic factors. Other musculoskeletal disorders include scoliosis, Legg-Calve Perthes Disease, and muscular dystrophy.

Scoliosis
Scoliosis refers to a lateral curvature of the spine with rotation of the vertebrae. It is the most common spinal deformity and is associated with physiological alterations in the spine, chest, and pelvis. Idiopathic scoliosis is more prevalent in adolescent females, and there is some evidence that it might be genetically transmitted as an autosomal dominant trait. Routine scoliosis screening is often a part of the adolescent physical exam.
The Adams position is used to screen for scoliosis. With the examiner standing behind, the child is asked to bend from the waist while allowing the arms to hang freely. When viewed from behind, the child with scoliosis is noted to have a primary and compensatory curvature of the spine.

Conservative treatment includes the use of either the Milwaukee brace or Boston brace and exercise. Surgical correction consists of realignment and straightening the spine with internal fixation. Two surgical methods that can be used are Harrington rods and Luque wires. The Cotrel-Dubousset approach uses both Harrington rods and Luque wires.
Postoperative nursing care includes assessment of vital signs, medication administration for pain, assessment of operative site, and providing emotional support to the client and family.
Logrolling technique should be used when turning the client with Harrington rods.

Legg-Calve-Perthes Disease (Coxa Plana)
This disease is a self-limiting disorder in which there is an aseptic necrosis of the head of the femur. Although the exact cause is unknown, it occurs most often in males 4–8 years of age.
Symptoms include soreness, aching, stiffness, and the appearance of a limp on the affected side. Pain and joint dysfunction are most evident on arising or at the end of the day.
The goal of treatment is to keep the head of the femur within the acetabulum and to prevent microfractures of the epiphysis. Initial measures include bed rest and non-weight-bearing activity. An abduction brace, leg casts, or leather harness sling can be used to prevent weight bearing. Conservative therapy is continued for 2–4 years. Although the condition is self-limiting, the ultimate outcome depends on early recognition and effective treatment.

Muscular Dystrophies
Muscular dystrophies refer to a group of inherited degenerative diseases that affect the cells of specific muscle groups resulting in muscle atrophy and weakness. The most common type, Duchenne muscular dystrophy, is inherited as a sex-linked disorder; therefore, it affects only males. Clinical manifestations of muscular dystrophy include delayed walking; wide-based waddling gait; lordosis; weak, hypertrophied leg muscles; and the use of
Gower’s maneuver to stand erect. Children with Duchenne muscular dystrophy lose the ability to walk by 9–12 years of age.
With Gower’s maneuver, the child places his hands on his knees and moves his hands up his legs until he’s standing erect.

The goal of treatment is aimed at maintaining mobility and independence for as long as possible. Nursing interventions include dietary teaching to prevent obesity and complications associated with limited mobility, coordinating healthcare services provided by physical therapy, and providing emotional support to the child and family.

Childhood Cancer
Childhood cancer is a leading cause of death in children under 15 years of age. Although survival has increased for most types of cancer, few diagnoses present a greater challenge for the nurse as she cares for the child and his family. Refer to Chapter 9, 'Caring for the Client with Cancer,' for a detailed review of cancer, the treatment modalities, and nursing care. This section briefly reviews the key points of the following childhood cancers: Wilms tumor, leukemia, and osteosarcoma.

Wilms Tumor (Nephroblastoma)
This is the most common type of renal cancer. Parents usually find the tumor while diapering or bathing the infant. The tumor, which is confined to one side, is characteristically firm and nontender. The tumor is also usually encapsulated, so it is responsive to chemotherapy. Survival rates for Wilms tumor are the highest of all childhood cancers.
The nurse should post a DO NOT PALPATE THE ABDOMEN sign on the bed of the child suspected of having Wilms tumor.

Leukemia
Leukemia, a cancer of the blood-forming elements of the bone marrow, is the most common form of childhood cancer. Pathological changes are related to the rapid proliferation of immature white blood cells, and symptoms include anemia; fatigue; lethargy; fever; joint and bone pain; pallor; petechiae; and enlargement of the spleen, liver, and kidneys. Acute lymphoid leukemia, the most common form, is more prevalent in males 1–5 years of age.
Treatment involves a combination of cytotoxic drugs and possible bone marrow transplantation. Nursing interventions include preparing the child and family for diagnostic procedures, administering chemotherapy, observing for signs of infection, and providing continuous emotional support.

Osteogenic Sarcoma (Osteosarcoma)
This cancer type is the most common bone cancer found in children. Most of those affected are males, ages of 10–25. The most common site is the epiphyseal plate of long bones, particularly the femur. Traditional management involves amputation of the affected extremity and intensive chemotherapy.
Nursing interventions are the same as those for the child with other forms of cancer.

Ingestion of Hazardous Substances
Injuries and death related to accidental poisoning have declined over the past three decades. This is largely due to the Poison Prevention Packaging Act of 1970, which requires that potentially hazardous drugs and household products be sold in child-resistant containers. Still, poisoning remains a significant health concern for children under 6 years of age. Common sources of household poisoning are plants, cosmetics and perfumes, cleaning products, and petroleum distillates. Over-the-counter medications such as cough and cold remedies, laxatives, and dietary supplements are also frequently ingested by children.
Consultation with the physician or Poison Control Center should be done before administering any antidote.

Salicylate Overdose
Salicylate, or aspirin overdose, results in an acid/base imbalance. Symptoms include nausea, vomiting, dehydration, tinnitus, hyperpnea, hyperpyrexia, bleeding, convulsions, and coma. Treatment is aimed at removal through emesis, lavage, or the use of activated charcoal. Additional measures are sodium bicarbonate transfusions to correct metabolic acidosis, vitamin K to control bleeding, and diazepam to control seizures. Hemodialysis might be needed in the most severe cases.

Acetaminophen (Tylenol) Overdose
This results in severe and sometimes fatal damage to the liver. Initial drug levels for are drawn 4 hours after the drug is ingested, but treatment should begin before the lab results are obtained. Tylenol overdose is treated with IV acetylcysteine. Plasma levels of 300 mcg /ml occurring 4 hours after ingestion or 50 mcg /ml occurring 12 hours after ingestion are associated with hepatotoxicity. In spite of treatment, there can be continuing hepatic damage that makes liver transplantation a necessity.

Lead (Plumbism)
This poisoning results in irreversible damage to the brain. Sources of lead include lead-based paint, lead crystal, ceramic wares, dyes, playground equipment, stained glass, and collectible toys. Lead poisoning affects the hematopoietic, renal, and neurological systems. With low-dose exposure, the child might experience symptoms of impulsivity, hyperactivity, and distractability. With higher-dose exposure, the child can experience mental retardation, paralysis, blindness, convulsions, and death.

Chelation therapy is used to remove lead from the circulating blood.
Commonly used chelation agents include calcium disodium edetate (EDTA), calcium disodium versenate (Versenate), British anti-Lewisite (BAL/Dimercaprol), and Succimer (which can be given orally).
Nursing care includes the administration of medication, which is often painful. If renal function is adequate, Versenate can be given intravenously; otherwise, it is given by injection. The nurse should assess the client receiving Versenate for signs of cerebral edema. Cerebral edema is treated with intravenous mannitol or dexamethasone. The side effects of heavy metal antidotes include malaise, paresthesia, nausea, and vomiting.

Iron Poisoning
This poisoning is usually the result of ingesting vitamins or iron-containing medications intended for adults. Initial symptoms of iron poisoning include vomiting of blood and blood in the stools. If the condition is left untreated, the victim becomes restless, hypotensive, tachypneic, and cyanotic. Hepatic injury, coma, and death can occur within 48–96 hours after ingestion. The treatment of iron poisoning includes emesis or gastric lavage. In cases of severe intoxication, chelation therapy with deferoxamine is necessary.

Diagnostic Tests for Review
The following are routine tests done on most all hospital admissions.
Specific tests are ordered to confirm or rule out a particular illness. For example, an erythrocyte sedimentation rate and antisteptolysin titer are ordered for the client with symptoms of rheumatic fever. Positive results on these tests indicate inflammation caused by a preceding infection with Group
A beta hemolytic streptococcus. It is helpful if you have a text of laboratory and diagnostic tests with nursing implications as a reference while you review. The routine tests are as follows:
- CBC
- Urinalysis
- Chest x-ray

Pharmacology Categories for Review
The following drug classifications are most commonly ordered for the pediatric client. However, some situations require the nurse to know about drugs rarely given. You is helpful to have a pharmacology text with nursing implications available as you review. The following are the drug classifications most commonly ordered:
- Antibiotics
- Antipyretics
- Analgesics
- Vitamin supplements