Transcript NURS 2410 unit 6 and 7x

Nancy Pares, RN, MSN
Metro Community College
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Identify pathophysiology and nursing process
of selected sensory/neurological system
alterations inclusive of:
◦ Visual, hearing, retinoblastoma (covered in onco
unit), hydrocephalus, cerebral palsy, spina bifida,
muscular dystrophies, spinal cord injuries and
systemic lupus
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Visual disorders
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Myopia
Astigmatism
Strabismus
Amblyopia
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Visual disorders
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Cataracts
Glaucoma
Retinoblastoma
Color blindness
Retinopathy of prematurity (ROP)
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Otitis media
Otitis externa
Hearing impairment
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Epistaxis
Nasopharyngitis
Sinusitis
Pharyngitis
Tonsillitis
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20/20 by age 6 or 7 (visual acuity)
Screening starts at well-child exams when
cooperative (screening timing and frequency)
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Infant in hospital
◦ Screening timing and frequency
◦ Many states mandate
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Observation for cues to hearing
Clinical manifestations
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Chronic ear infections
Chronic fluid/effusion
Follow-up needed for hearing deficit
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Conjunctivitis
◦ Bacterial
 Antibiotic eye drops
◦ Viral and allergic
 Supportive care
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Periorbital cellulitis
◦ Oral or intravenous antibiotics
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Other disorders
◦ Multiple types of treatments based on etiology
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Occlusion therapy
Compensatory lenses
Surgery
Vision therapy
◦ Refer to eye specialist
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Otitis media
◦ Antibiotic usage
◦ Supportive care
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Recurrent otitis media or effusion
◦ ENT referral for possible tympanostomy tube
placement
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Otitis externa
◦ Antibiotic ear drops
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Hearing loss
◦ Sensorineural
 Cochlear implant
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Collaborative care includes antibiotics if
bacterial in etiology
◦ Nasopharyngitis
◦ Pharyngitis
◦ Tonsillitis
 Tonsillectomy
 Criteria for surgery
◦ Sinusitis
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Primary intervention is prevention
◦ ROP interventions and prevention strategies
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Protective eyewear
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Prevention focus
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Decrease otitis media
Increase access to care
Increase frequency of hearing screens
Reduce noise-induced hearing loss
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Prevention measures
Education to prevent communicable diseases
Home care for common communicable
diseases
Injury prevention
Dental emergencies
◦ Tooth avulsion
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Avoid triggers
Long-term planning for chronic illness
Maintain fluid balance
Promote adequate and appropriate nutrition
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Promote skin integrity
Promote rest and comfort
Emotional support
Community activities and support groups
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Plan care
◦ Age and developmentally appropriate
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Medication regimen
◦ Education on importance of regimen
◦ Education on side effects
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Promotion of general health
◦ Avoid infectious individuals
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Promotion of growth and development
◦ Proper food
◦ Proper atmosphere, toys, friends
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Emotional support
◦ Caregiver
◦ Child
 Support groups
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Increasingly common
Children at risk for allergy
Testing for latex allergy
Latex allergy questionnaire
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Alternative products
Medical-alert ID bracelet
Epinephrine kit at home and school
Education of caregivers related to
hypersensitivity reactions
◦ Preparation to provide care
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Type I
◦ Definition
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Type II
◦ Definition
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Type III
◦ Definition
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Type IV
◦ Definition
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History
Assessment
◦ Type I and Type II carry EpiPen
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Cranial bones are not completely ossified
◦ Allows for brain growth
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The posterior fontanel closes at 3-4 months
The anterior fontanel closes at 18 months
Increases risk for brain and spinal cord injury
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Levels of consciousness—most important
indicator of neurological dysfunction
Consciousness—receptiveness to stimuli
Alertness—arousal, ability to react
Cognitive power—ability to process data and
respond
Altered levels of consciousness
◦ Causes
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Levels of consciousness assessment
◦ Categories: confusion, delirium, lethargy,
obtunded, stupor, and coma
◦ Decorticate and decerebrate posturing
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Increased intracranial pressure
◦ Scales for responsiveness
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Increased intracranial pressure
◦ Glasgow coma scale
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An acute seizure that lasts over 30 minutes
Electrolytes, glucose, blood gases,
temperature, and blood pressure need
monitoring if a seizure occurs for longer than
10 minutes
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Maintain airway
Ensure safety
Administer medications
Provide emotional support
Provide education
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Malformation of the spinal cord and canal
Impaired physical mobility related to
neuromuscular impairment
Impaired urinary elimination related to
sensory impairment
Risk for latex allergy response related to
multiple surgical procedures
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Imbalance between production and
absorption of CSF
Leads to increased CSF volume in brain
Commonly associated with
myelomeningocele (spinal-fluid-filled sac
protruding through vertebrae)
Treatment may include placement of a shunt
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Risk for infection related to the presence of
shunt
Risk for caregiver role strain related to care of
a child with a chronic condition
Risk for delayed development related to
compression of brain tissue with excess
cerebral spinal fluid
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Group of permanent disorders of movement
and posture
Causes activity limitations
Nonprogressive in nature
May have additional sensory, cognition,
communication and behavior problems
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Community care
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Case manager
Early intervention
Financial needs
School assistance and IEP needed
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Multidiscipline care
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Orthopedic surgeon care
Speech therapy
Regular eye exams
Pediatric nurse practitioner or pediatrician
Support groups
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Traumatic brain injuries
◦ Falls are a major cause
◦ Primary vs. secondary
◦ Cushing’s triad
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Nursing management of mild vs. severe brain
injury
◦ Emergency care
◦ Long-term care
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Explain the pathophysiology and nursing
process of congenital defects of the
musculoskeletal system inclusive of:
◦ Cranial malformations, club foot,
kyphosis/scoliosis, hip dysplasia,
 Bone tumors covered in oncology (unit 7)
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Child’s bones
◦ More porous and pliable
◦ Less dense
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Infant skull
◦ Fontanel closure: 18 months
◦ Overall growth completion: 2 years
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Child bone growth from epiphyseal plate
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Muscles
◦ Number same as adult
◦ Only length and circumference grow
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Ligaments and tendons
◦ Stronger than bone until puberty
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Feet and legs
◦ Metatarsus adductus (intoeing)
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Feet and legs
◦ Talipes equinovarus (clubfoot)
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Feet and legs
◦ Genu valgum (knock-knees)
◦ Genu varum (bowlegs)
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Hip
◦ Dysplasia
◦ Legg-Calvé-Perthes
◦ Slipped capital femoral epiphysis (SCFE)
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Spine
◦ Scoliosis, kyphosis, lordosis
◦ Torticollis
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Prevent complications of immobility
Assist coping with treatment
◦ Support long-term adaptation
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Facilitate pain control
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Bone infection
Etiology: idiopathic or nosocomial
◦ Due to trauma, pins
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Symptoms
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Bone pain
Edema
Joint pain
Fever
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Skeletal tuberculosis
◦ Pain, spasms, muscle atrophy
◦ “Doughy” swelling over joints, limited mobility
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Septic arthritis
◦ Pain, fever, local inflammation, joint tenderness,
loss of spontaneous movement
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Pain relief
Maintain joint mobility
Prevent deformities
Promote self-care
Well-balanced diet
Hydration
Medication management
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Achondroplasia
◦ Short stature, prominent forehead
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Marfan syndrome
◦ Connective tissue disorder
◦ Skeletal changes
◦ Cardiac, respiratory, vision changes
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Osteogenesis imperfecta
◦ Brittle-bone disease, collagen defect
◦ Thin, soft skin; increased flexibility; short
stature;weak muscles; hearing loss
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Muscular dystrophies
◦ Muscle degeneration and wasting
◦ Early signs:weakness and hypotonia
◦ Life-threatening
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Limit movement
◦ Snug but do not impair circulation
◦ No direct contact with skin
◦ Assess neurovascular and skin status
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Prevention
◦ Greater risk for children
◦ Teach use of protective equipment, safe play
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Types
◦ Closed
 Casting
◦ Open
 Surgery and casting
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Describe pathophysiology and nursing
process of inflammatory diseases of
childhood
◦ Meningitis, Reyes syndrome, tetanus, Kawasaki
disease
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An inflammation of the meninges covering
the brain and spinal cord
Caused by either viral or bacterial agents
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Acute inflammation of the brain
Symptoms include nuchal rigidity or positive
Kernig or Brudzinski
Symptoms depend on the causative organism
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Discuss the psychopathology and nursing
process of alterations in the psycho-social
functions of the childrearing period
◦ Learning disabilities
◦ ADHD
◦ Mental health
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Developmental and behavioral disorders
◦ Pervasive developmental disorders
◦ Nursing management
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Stabilize environmental stimuli
Provide supportive care
Enhance communication
Maintain a safe environment
Provide anticipatory guidance
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Attention deficit disorder (ADD) and attention
deficit hyperactivity disorder (ADHD)
◦ Nursing management
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Administer medication
Minimize environmental distractions
Implement behavior management plans
Provide emotional support
Promote self-esteem
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Attention deficit disorder (ADD) and attention
deficit hyperactivity disorder (ADHD)
◦ School issues
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Suicide
◦ Nursing management:
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Safety
24-hour monitoring
Medication
Care in community
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Effects up to 5 of school children
Children do not process information correctly
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Individual education plan (IEP)
◦ Developed through an interdisciplinary approach
◦ Specific goals are included
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Limitations in adaptive and intellectual
functioning
Conditions associated:
◦ Down syndrome
◦ Fragile X syndrome
◦ Fetal alcohol syndrome
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Nursing management
◦ Maintain safe environment
◦ Provide assistance with adaptive functioning
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Evaluation depends on needs and
developmental level
First evaluation needs to assess the family’s
understanding of the disorder
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Discuss pathophysiology and nursing process
associated with blood dyscrasias inclusive of:
◦ Sickle cell anemia, iron deficiency anemia, von
willenbrand disease, thalassemias
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Objective 2
◦ Describe nursing process and procedure for
pediatric blood transfusions (covered in NURS 2520)
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Iron deficiency anemia
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Lack of iron
Anemia of prematurity
Affects production of RBCs
RBCs appear hypochromic, decreased hemoglobin
synthesis
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Iron deficiency anemia
◦ Manifestations based on severity
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Pallor
Fatigue
Irritability
Pica
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Normocytic anemia
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Decreased number of RBCs
Normal size with pale center
Associated with multiple causes
Manifestations similar to iron deficiency anemia
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Sickle-cell anemia
◦ Genetic mutation
◦ Hemoglobin S replaces normal hemoglobin
◦ RBCs lose doughnut shape, become sickleshaped
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Sickle-cell anemia
◦ Manifestations appear in multiple body systems
◦ Severity based on pathologic changes
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Thalassemias
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Groups of hereditary disorders
Hemoglobin synthesis abnormal
Range from mild to severe
Three types
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Thalassemias
◦ Clinical manifestations based on type and severity
 Pallor
 Fatigue
 Failure to thrive
◦ Severe anemia leads to chronic hypoxia
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Hereditary spherocytosis
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Congenital hemolytic anemia
No abnormality of hemoglobin
Cells have unusual structure
Manifestations appear in neonatal period or infancy
Severity varies
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Goals of Care
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Adequate nutrition
Hydration and fluid balance
Promotion of adequate tissue perfusion
Promotion of growth and development
Family and patient education
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Failure of bone marrow to produce blood
cells
Disorder is idiopathic or acquired
Clinical presentation varies depending on
degree
Most common is bleeding secondary to
thrombocytopenia
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Hereditary bleeding disorder
X-linked—expressed in males, females have
carrier status
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Manifestations range from mild to moderate
to severe
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Spontaneous bleeding
Hemarthrosis
Deep tissue hemorrhage
Nosebleeds
Hematuria
Easy bruising
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Autosomal dominant trait
Equal expressivity in males and females
Manifestations
◦ Easy bruising
◦ Epistaxis
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Disseminated intravascular coagulation (DIC)
◦ Complication from another illness
◦ Most common following infection in children
◦ Manifestation range
 Minor oozing
 Frank hemorrhage
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Idiopathic thrombocytopenic purpura (ITP)
◦ Autoimmune disorder
◦ After a viral illness
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Idiopathic thrombocytopenic purpura (ITP)
◦ Manifestations
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Ecchymoses
Petechiae
Purpura
Bleeding from gums
Nosebleeds
Blood in urine
Blood in stools
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HSP
◦ Vasculitis
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Raised purpuric lesions
Joint pain
Colicky abdominal pain
GI bleeding
Renal involvement
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RBCs
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Oxygenation
Circulation
Fluid
Nutrition
Pain management
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WBCs
◦ Infection
◦ Oxygenation
◦ Nutrition
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Platelets and bleeding disorders
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Bleeding
Oxygenation
Circulation
Injury prevention
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Team approach
Family involved
◦ Decisions with family and child
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Discuss the pathophysiology and nursing
process of pediatric oncology
◦ Leukemia, Hodgkins disease, Wilm’s tumor
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Therapy may be singular or combination of
treatments
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Surgery
Chemotherapy
Radiation
Biotherapy
HSCT
Complementary therapies
Palliative care
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Based on type of cancer and therapy
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Infection control
Pain
Nutrition
Growth and development
Emotional needs
Spiritual needs
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Metabolic
◦ Tumor lysis syndrome
◦ Septic shock
◦ Hypercalcemia
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Hematologic
◦ Caused by bone marrow suppression
◦ Require transfusion and careful RBC and WBC
assessment
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Space-occupying lesions: tumors with
extensive growth
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Spinal cord compression
Increased ICP
Brain herniation
Seizures
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Space-occupying lesions: tumors with
extensive growth
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Hepatomegaly
Gastrointestinal obstruction
Cardiac and respiratory complications
SVC syndrome
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Brain and central nervous system
◦ Most common malignancy in children, next to
leukemia
◦ Treatment depends on type and location of tumor
◦ Surgery
◦ Radiation
◦ Chemotherapy
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Neuroblastoma
◦ Definition
◦ Treatment based on protocol
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Surgical
Chemotherapy
Radiation
HSCT
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Wilms’ tumor
◦ Define
◦ Treatment based on stage
 Requires surgical removal
 Radiation
 Chemotherapy
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Bone tumors (osteosarcomas)
◦ Definition
◦ Treatment
 Surgery required
 Chemotherapy
 Radiation
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Ewing’s sarcoma
◦ Similar to osteosarcoma
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Most commonly diagnosed malignancy in
children under 14
Definition
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Difficult due to multisystem effect
Long period of treatment required
Assessment complete and thorough
◦ Observe for signs of bleeding
◦ Observe for signs of infection
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Monitor for toxic side effects of
chemotherapy or tumor cell lysis
◦ Renal function
◦ Special attention for children on cyclophosphamide
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Nutrition
CNS infiltration
Pain
Bone marrow suppression
◦ Isolation and transmission precautions
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Education of family and child
◦ Careful handwashing
◦ Prevention of spread of infection
◦ Oral care
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Hodgkin’s disease
◦ Definition
◦ Treatment based on staging
 Outpatient setting
 Chemotherapy
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Non-Hodgkin lymphoma
◦ Definition
◦ Three types
◦ Treatment tailored to stage
 Stages I and II treat with drugs
 Stages III and IV treat with additional drugs and longer
period
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Rhabdomyosarcoma
◦ Definition
◦ Locations
◦ Treatment
 Surgical when possible
 Widefield radiation
 Chemotherapy
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Retinoblastoma
◦ Definition
◦ Treatment
 Radiation almost always used
 Chemotherapy sometimes used, but often ineffective
 Removal of eye if other treatment fails
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Similar to other cancers
Physiologic assessment
Psychosocial assessment
Collaboration with family
Collaboration with medical team
Intervention based on assessment and side
effects of therapy
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Cancer affects all areas of function
Effects of therapy
◦ Surgery
 External and internal body changes
◦ Radiation
 Long-term effects
 Growth
 Secondary cancers
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Effects of therapy
◦ Chemotherapy
 Effects immediate
 May present years later
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Long-term planning
◦ Family stressors
 Questions regarding outcomes
 Financial concerns
◦ Frequent follow-up
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Physical
Physiological
Developmental
Cognitive
Interventions started as soon as deficit noted
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Team members
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Nurses
Primary and specialty care providers
Social workers
Case managers
Child life therapist
Psychologist
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For the school-age child
◦ Encourage maintenance of learning
◦ Involvement of school appropriate with permission
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Spiritual and emotional needs
◦ Encourage participation in support groups
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Treatment for disorders unresponsive to
other therapy
Pretransplant phase
◦ Total body irradiation
◦ Strict isolation
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Transplant phase
◦ Intravenous transfusion of donor stem cells
◦ Transplant starts to grow in 2 to 4 weeks
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Posttransplant phase
◦ Lasts several weeks
◦ Major risk is infection
◦ Immunosuppressive agents prevent graftversushost disease
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Nursing care
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Prevent infections
Injury prevention
Growth and development
Nutrition
Physical activity limits
Oral health
Mental and spiritual health
Family and social relationships