Exam #5 Flashcards
Neural tube defects (NTDs) are a group of birth defects in which malformations of the __________ and __________ __________ occur and the structures lack protection of soft tissue and bone. NTDs develop when the neural tube fails to close during fetal development.
brain and spinal cord
Spina Bifida is a __________ __________ defect.
neural tube
Risk factors for Spina Bifida
o Poor nutrition
o Prolonged hyperthermia
o DM
o Seizure meds
Least severe form of Spina Bifida
Spina Bifida Occulta
CSF fluid filled sac w/ no nerve endings or spinal cord in it
Meningocele
May be a closed or open sac containing nerve endings and/or spinal cord. Most severe form of Spina Bifida.
Myelomeningocele
Spina Bifida management after delivery
o Keep patient prone
o Moist, sterile dressing on defect
o Laminectomy
Spina Bifida management in utero
surgical repair
Spina Bifida management after surgery
o Post-op care: wound, VS (NO RECTAL TEMPS), antibiotics, pain control
o Manage neurological deficits
▪ Bowel/bladder training- anticholinergics and antispasmodics to help with continence and spasms
▪ Constipation/impaction is common
▪ Straight cath
o Head circumference measurements (hydrocephalus)
o Skin care & mobility
Fluid and pressure buildup in the ventricles and intracranial vault due to
-increase of CSF production
-Impedance to absorption
-obstruction to flow
Hydrocephalus
S/sx of Hydrocephalus
-Increased ICP if disorder is severe enough
-Sun-setting eyes
-Prominent forehead/enlarged
-Difficulty holding head upright
Treatment for Hydrocephalus
Shunt
Usually ventriculoperitoneal
When does shunt infection or malfunction typically occur?
Can happen at any time
Most often 1-3 months after placement
Common s/sx of shunt infection/malfunction
NV
HA
Bulging fontanels
Change in customary behavior
Lethargy, unresponsiveness, sunset eyes
Elevated temp.
Shunt reminders
-do not allow child to lie on shunt side continuously
-no contact sports
-prophylactic antibiotics w/ dental & surgical procedures
How do we determine a child’s LOC?
-observation
-using the pediatric Glasgow Coma Scale
-subjective (caregiver history)
Patient answers appropriately while opening his eyes and responding fully.
What state of LOC?
alertness
Technique: speak in a normal tone of voice
Patient opens his eyes but appears drowsy; answers questions appropriately but falls asleep easily.
What state of LOC?
Lethargy
Technique: speak in a loud voice
Patient opens his eyes and looks at the stimuli; appears slightly confused; alertness & interest in surroundings are decreased.
What state of LOC?
Obtundation
Technique: shake gently to arouse
Patient only responds to painful stimuli; verbal responses are absent or slow. Responsiveness to painful stimuli ceases.
What state of LOC?
Stupor
Technique: use painful stimuli
Patient does not respond to internal or external stimuli; they remain in an unaroused state with eyes closed.
Coma
Technique: apply repeated painful stimuli
What are the three parts to the Glasgow Coma Scale?
▪ Eyes
▪ Verbal response
▪ Motor response
Glasgow Score 9-15
Unaltered Consciousness
Glasgow Score 4-8
Coma
Glasgow Score 3 or below
Deep coma
Early signs of ICP
- Headache
- Emesis
- Change in LOC
- Irritability
- Sunsetting eyes
- Decreased eye contact (infant)
Late signs of ICP
- Further decrease in LOC
- Bulging fontanelles
- Posturing
- Papilledema
- No pupil response
- Cushing’s Triad
Meds for ICP
- Antipyretics (no shivering)
- Barbiturates
- Anti-seizure/epileptics
- Mannitol*
Tx for ICP
- HOB at least 15 to 30 degrees
- PROM q2 hours
- O2 & Respiratory care: Intubate (VAP care), Suction only as needed
- Decompressive Craniectomy if
necessary
Progressive encephalopathy w/ hepatic dysfunction
Reye Syndrome
How is Reye Syndrome diagnosed?
-liver biopsy
-lumbar puncture
-CT/MRI
What is a risk factor for Reye Syndrome?
salicylate use (aspirin)
Treatment for Reye Syndrome is
symptom dependent
Rare immune system response that attacks myelin
Caused by:
-EBV
-Cytomegalovirus
-Varicella
-Campylobacter
Guillain-Barre Syndrome
S/sx of Guillain-Barre Syndrome
-muscle weakness or paralysis
-numbness or tingling
-resp. distress
-hypotension
-areflexia (lack of any reflexes)
How is Guillain-Barre Syndrome diagnosed?
-clinical signs
-lumbar puncture to evaluate protein in CSF
-electroyography
How to prepare before a seizure
-know the triggers (lights, certain noises or smells, temp. changes, etc. )
-look for alerts: seizure animal, mediAlert jewelry, behavioral responses or complaints
Things to do during a seizure
Safety is key
-protect for injury
-keep airway stable (pulse ox, oxygen, prepare suction)
-meds (valium or ativan)
Things to do after a seizure
-document how long and patient response
-monitor VS and behavior
-complete a focused neuro assessment
Caregiver education re: seizures
-med compliance
-safety @ home, school, community
-limiting certain sports
Inflammation of the meninges that is identified by an abnormal rise in WBC in the CSF
Can be viral or bacterial; Common after OM or URI, penetrating wounds, skull fractures, contaminated LP equipment
Meningitis
Acute febrile illness causing inflammation of the brain and meninges
Most commonly viral
Encephalopathy
S/sx of encephalopathy
High fever
Coma
Confusion
S/sx of meningitis
Positive Kernig and Brudzinski sign
S/sx shared by Meningitis & Encephalopathy
HA
Photophobia
Lethargy
Irritability
NV
Nuchal rigidity
Seizures
Tx options for Meningitis & Encephalopathy
Meds: antibiotics (bacterial), antivirals (acyclovir), anti-inflammatories, antipyretics, analgesics
Nursing care: decreased stimuli, seizure precautions, focused neuro assessment, ICP monitoring, droplet precautions, freq. VS, HOB elevated, fluid hydration, electrolyte monitoring
Disorder of muscle control or coordination caused from an injury to brain during early development; most common permanent physical disability of childhood
Caused by prematurity, perinatal infections, perinatal asphyxia, meningitis, non-traumatic brain injury, near drowning, hyperbilirubinemia
Cerebral palsy
S/sx of cerebral palsy
-difficulty w/ mobility & coordination, rigidity, spasticity, hyper/hypotonia, ataxia, poor posture
-decrease in vision, hearing, emotions & cognitive abilities
-seizure disorders
Meds for cerebral palsy
-reduce spasms (dantrium, baclofen)
-paralyze certain muscles w/ botox
-control seizures (Dilitan)
-control tension (Valium)
-control secretions
-control reflux
Child’s ability to walk indicates the severity of the disease. If the child can sit by 2 years of age, they will probably walk.
Death is usually due to
the related problems of immobility, malnutrition, and seizures
Important nursing care points for cerebral palsy
nutrition, mobility, skin integrity, safety, growth & development, parental knowledge, emotional support
Decreased circulating RBCs d/t
decreased, production, increased destruction, or acute/chronic blood loss
Anemia
General s/sx of anemia
-lethargy/fatigue
-SOB
-HA
-difficulty concentrating
-pale skin
-irritability
-tachycardia
-murmur
Decreased iron supply
Most common nutritional disorder in infants & young children worldwide
Microcytic, hypochromic
Iron is needed to make Hgb This type of anemia decreases oxygen carrying capacity of blood.
iron deficiency anemia
Causes of iron deficiency anemia
dietary, increased demands, blood loss, inability to form Hgb, impaired absorption, lead poisoning
S/sx of iron deficiency anemia
mild: asymptomatic, SOB, tachycardiac during exertion
moderate: SOB, tachycardic, palpitations, dizzy, fainting, irritability, & PICA
severe: murmur, CHF, enlarges spleen
Diet for iron deficiency anemia
-breast milk or Fe formula for 1st 12 months
-no cow’s milk until 1yr & limit to 18-24oz/day
-beans, whole grains, & cereals for vegetarian
Reminders for elemental Iron supplements
-give on empty stomach w/ vitamin C juices
-don’t give w/ milk or tea
-use straw/dropper & rinse mouth (can stain teeth)
-GI side effects such as constipation, GI upset, black tarry stools may be normal
Hereditary bleeding disorder. There is a deficiency in specific clotting factors.
Hemophilia
What type of hemophilia?
Factor VIII
Hemophilia A
What type of hemophilia?
Factor IX
Hemophilia B (Christmas)
What type of hemophilia?
Factor XI
Hemophilia C
What type of hemophilia?
Factor VIII & poor platelet aggregation
Von Willebrand’s disease
S/sx of hemophilia
-excessive & prolonged bleeding
-tingling, pain, swelling
-hemarthrosis
Tx and nursing care for hemophilia
-Recombinant Factor replacement therapy (IV)
-prophylactic use
-family teaching is paramount to outcomes
-focus on safety preventing, and promoting quality of life
-genetic counseling
Hemophilia pts should avoid
aspirin, IM Injections, and activities that may cause injury
Acquired hemorrhagic disorder causing excess destruction of circulating platelets (platelet count <100K) and/or shortened platelet life span from antiplatelet antibodies
No known cause
Diagnosed by exclusion & labs
Immune thrombocytopenia purpura (ITP)
S/sx of ITP
-petechiae/purpura
-epistaxis
-mucocutaneous bleeding
-rare: intracranial hemorrhage
Tx & nursing care for ITP
Steroids, IVIG, splenectomy
Restrict contact sports & high risk activities, lean forward & pinch for nosebleeds, bleeding precautions (avoid aspirin, straight edge razors, tampons, inserting items in rectum)
Autosomal recessive genetic trait in which globin chain in normal Hgb A replaced w/ Hgb S
Sickle cell disease
S/sx of sickle cell disease
Remember all organs are affected
PAIN! (cardinal symptom)
Weakness/fatigue, jaundice from hemolysis, chronic anemia, susceptible to infection, delayed growth & sexual maturation, avascular necrosis of shoulder or hip, cholelithiasis
All complications are r/t occlusion.
Pt education re: sickle cell anemia
-fevers require IMMEDIATE medical attention
-report worsening s/sx
-avoid strenuous activities
-avoid crisis w/ rest & adequate hydration
Prophylactic antibiotics and immunizations (Hib, pneumococcal) decrease the rates of _________ in sickle cell anemia patients.
sepsis
Emergency related to sickle cell anemia
Can occur anywhere in the body (hands/feet long bones, joints, and abd)
Soft tissue swelling and pain
Tx is hydration, pain management w/ opioids and NSAIDs
vaso-occlusive crisis
Pedi considerations for cancer
- Not strongly linked to lifestyle or environmental factors
- > 60% participate in clinical trials
- Originate in mesoderm/ectoderm
- Fast growing (80% mets at diagnosis)
skeletal, muscle, bone tissue formation
mesoderm
outer parts of the body- skin, spinal cord, eyes
ectoderm
major organs: liver, pancreas, lungs, etc.
endoderm
Childhood oncology diagnosis
Often presents w/ vague sx (which can delay diagnosis)
Tumor markers, bone marrow aspirate & biopsy, CSF analysis
X-rays, CT scans, MRI, bone scan, PET scan, nuclear med
S/sx of pedi cancer
Continued, unexplained pain
Headaches, unexplained weight loss
Increased swelling/persistent pain in bones, joints, back, legs
Lump or mass
Development of excessive bruising, bleeding, or rash
Constant infections
A whitish color behind pupil
Nausea that persists or vomiting w/o nausea
Constant tiredness or noticeable paleness
Eye or vision changes that occur suddenly or persist
Recurrent or persistent fevers of unknown origin
Tx options for cancer
surgery, radiation, chemo, stem cell transplant, biotherapy, complementary therapy
Multimodal treatments have shown increased success
Nursing care for a client with cancer (what to monitor, psychosocial considerations)
- Assess fear & anxiety
- Assess development
- Regression
- Body image disturbance
Side effects of cancer treatment & corresponding tx
NV related to chemotherapy; given antiemetics (Zofran)
Acute or chronic pain; give pain meds, rest & sleep, massage, heat, distraction, & social support
Mucositis- inflammation of mucosa in mouth caused by chemo & radiation; magic mouthwash and oral assessments
Impaired nutrition- higher nutrition needs with lack of appetite; can lead to irritability, susceptibility to infections, reduction in growth and development; offer food choices and small frequent feedings, may need enteral feedings or TPN
Proliferation of abnormal blood cells in the body. Stem cells in bone marrow produce immature WBC blasts
Most common cancer diagnosis in children under 14
Childhood Leukemia
S/sx of childhood leukemia
fever, bone pain (refusing to walk), enlarged liver or spleen, increase lymphadenopathy, cold or flu like sx
Persistence of symptoms is key
Bone marrow aspirate and biopsy
o Should show < 5% blasts
o Definitive if bone marrow reveals > 25% blasts
Pediatric Perceptions of Death
Based on degree of discomfort, reactions of parents
What age group?
infant
Pediatric Perceptions of Death
Separation from parents or disruption in routine
What age group?
toddler
Pediatric Perceptions of Death
Magical thinker: illness or injury viewed as punishment, death is temporary, death should not be described as “going to sleep”
What age group?
preschool
Pediatric Perceptions of Death
May feel responsible, at age 8/9 understand the permanence of death, preparation is helpful, important to feel some control
What age group?
school age
Pediatric Perceptions of Death
Understands at an adult level, difficulty accepting it as reality, more questions about death & afterlife, info about disease is important
What age group?
adolescent
Before death care
Facilitate communication and build trust:
o Family needs HONEST information about treatment options and potential outcomes
o Family care conferences
o Ethics committee for certain situations
o Maintain a consistent message from team
o Encourage the family to keep a log/journal
Aspects to consider:
o Palliative Care or Hospice
o DNR status
o Continue school
o Organ donation (Gift of Life)
o Autopsy
Address Physical and Emotional needs caregiver and patient:
- Spiritual support
- Sleep, food, hygiene, etc.
- Flexible visitation
During death care
Orient to routines, explain tubes/lines
Prepare family for changes in the child’s appearance such as:
o Respirations-noisy; Cheyne-Stokes
o Loss of senses
o Decreased vital signs
o Decreased appetite
o Confusion
o Incontinence
o Seizures
Comfort measures:
o Manage pain & anxiety
o Use of touch
o Peaceful environment
Continue talking to the child:
o Tell the child that it is OK to let go
o Reassure child that he is loved
After death care
- Allow family time with the child/hold child: Do NOT RUSH-allow family to dictate timeline
- Allow siblings to say good-bye
- Post-mortem care: Final bath
- Save all personal items
- Remembrance boxes (Locks of hair, footprints, etc..)
- Assist with contacting funeral home
- Offer information regarding support groups
Nurse stress
burnout, compassion fatigue, alarm fatigue, moral distress
Interventions for burnout
A multifactorial state of “being” in which the nurse experiences an emotional or physical disconnect w/ their working or professional environment
-take breaks
-limit overtime
-create a life outside of work environment
Interventions for compassion fatigue
Compassion fatigue exists as a result of a continuous display of empathetic feelings and behaviors w/o proper holistic replenishment
-support groups
-fair & equitable staff assignments
-attending memorial services (depends on individual)
Interventions for alarm fatigue
Delayed or non-existent responses to alarms
-hourly rounding*
-proactive planning
Interventions for moral distress
Nurse acts contrary to personal/professional values
-evaluate your personal judgements on situations
-ask for clarification
-understand your resources (ethics committee, supervisor)
Effects of illness (acute and chronic) on the patient & family system
Infant - trust
Toddler - autonomy
Preschooler - initiative
School age - industry
Adolescent - identity
Caregiver - burnout
Environment of Care
Sensory overload
- Minimize noise levels,
- Adequate sleep/rest times, when possible
- Day/night routine
- Cluster care
Patient response to chronic illness
-can produce extreme fear, anxiety
-children may appear withdrawn, feel powerless
-sleep affected
-regression
-growth and developmental delays
Family response to chronic illness
-sense of unknown
-loss of parental role, normal family functions, isolation from other family members
-financial concerns
-siblings may act out
Erickson’s theory of psychosocial development
Basic needs must be met, and trust must be learned
“Hold me, feed me, take care of me”
Trust vs. Mistrust
(Birth-1 year)
Erickson’s theory of psychosocial development
Controlling body excretions, “No”, balance independence and
self-sufficiency
“Watch me do this myself”
Autonomy vs. Shame & Doubt
(1-3 years)
Erickson’s theory of psychosocial development
Exploring world, creating, resourcefulness to achieve and learn new things
“I want to help you; I can do it too”
Initiative vs. Guilt
(3-6 years)
Erickson’s theory of psychosocial development
New activities, sports, school, sense of confidence
“I want to fit in”, “What are the rules?”
Industry vs. Inferiority
(6-12 years)
Erickson’s theory of psychosocial development
New sense of identity, clear sense of self
“I just want my friends”, “Who cares, so what”
Identity vs. Role Confusion
(12-18 years)
Piaget’s theory of cognitive development
- Learns from sensory input, language skills
- Looking hearing touching, mouthing, grasping
Sensorimotor (Infant-2 years)
Piaget’s theory of cognitive development
- Increasing verbal, limitations in thought. Development of motor skills.
- Talking, drawing,
- Using words and images to represent things. Gradually evolves to pretend play
Preoperational (2-6 years)
Piaget’s theory of cognitive development
- Mature, abstract thought and reasoning to handle difficult concepts
- Forming abstract thought and ask why in a different way
- Looking at moral reasoning
Formal operational (12-adulthood)
Piaget’s theory of cognitive development
- Organize thought in logical order. Manipulates objects
- Do math, basic word problems
- Grasping concrete analogies. Performing mathematical operation
Concrete operational (7-11 years)
Type of play for infants
solitary play
reflexive manner
grasps objects
Type of play for toddlers
Imitative behavior
copying of actions performed by another person
Type of play for preschoolers
Associative play
children play together, but have different ideas and goals
Type of play for school age
Cooperative play
- No cervical change (from previous dilation/effacement)
- CTX do not intensify and may space out
- Can walk/talk through CTX, walking does not make them stronger
- Pain medication may stop contractions (Braxton Hicks)
What type of labor?
False (latent) labor
- Cervical change
- CTX get longer, stronger, closer together, & demand attention
- Walking may make them stronger
- Pain med may slow or speed up labor, never stop
- Contractions that are increasing in frequency and duration and intensity along with
cervical change - “5-1-1”
▪ Occurring every 5 minutes
▪ Lasting 1 minute and happening for 1 hour
What type of labor?
True labor
Signs of impending labor
Labor is coming soon but doesn’t mean she is in labor
- Lightening: the baby dropped
- Irregular contractions
- Energy spurt “nesting”
- Urinary frequency- baby is pushing on the bladder
- Bloody show/vaginal discharge: mucus plug and can have blood and the baby is about to come
- Loss of mucous plug
- Pelvic pressure- may have to go have a bowel movement- tell your nurse because the baby’s head is coming down
Interventions for PPROM
o Hospitalization, bed rest PRN
o Fetal surveillance
o Antibiotics
o Tocolytics
o Corticosteroids
Delivery if there are signs of infection
Without intervention, 50% of patients who have ROM will go into labor within 33 hours
PPROM nursing care
– Obtain vaginal swab for fFN testing
– Collect cervical cultures
– Explain to the patient they will be on modified bedrest with VS checked every 4 hours
– Monitor FHR and contractions
– Explain that frequent US will be done to assess amniotic fluid levels
– Administer tocolytics and betamethasone as ordered
– Provide emotional support
Low levels of amniotic fluid –> higher risk of
cord compression
PPROM treatment
– STRICT STERILE TECHNIQUE (Fern/Nitrazine/Amnisure Test)
– No vaginal exams, unless delivery is imminent
– Expectant management (aka watch and wait) is recommended as long as there are no contraindications
PTL Prevention: Lifestyle Modifications
Avoid:
o Sexual activity
o Riding long distances
o Carrying heavy loads
o Standing for long periods
o Hard, physical labor
Barriers to mental health- late diagnosis, treatment, and resolution most often stems from societal stigmas and deflection
-negative opinion of psychosocial or cognitive conditions
-childhood is a “sacred” happy time, free of problems
-providers minimize or dismiss parental concerns
-child is going through a stage that “will pass”
-lack of access**
Nursing management of hospitalized client with a mental health condition
Safety, evaluating risk of harming self or others, liaison w/ family and therapist, support family-child, monitor when receiving antidepressants, vitals, side effects, and dietary intake
Discharge planning- educate s/sx of worsening depression, meds, suicide prevention, and support groups
Any type of physical or emotional uneasiness that impedes normal developmental and/or social growth
-generalized, separation, panic, agoraphobia, PTSD
Anxiety
Constant and consistent feelings of sadness and/or being “low”. Diagnosis requires manifestations in these five areas: persistent sad or irritable mood, changes in appetite/weight/sleep patterns, fatigue/loss of energy, feelings of worthlessness, inability to concentrate, recurrent thoughts of death/suicide, anhedonia (loss of ability to feel pleasure)
Can use PHQ-A or Beck Depression Inventory. No screening tool available to children under 12.
Depression
Characterized by extreme mood swings between feelings of sadness to hyper excitability and/or aggressiveness
Bipolar disorder
Bipolar disorder - what phase?
Happy, silly, irritable, wired, very little sleep, easily distracted, hyper-sexuality, risk-taking behaviors, impulsive
Manic phase
Bipolar disorder - what phase?
Persistent sadness, irritable, anhedonia, increase in amount of sleep, thoughts of death or suicide
Depression phase
Suicide is the 2nd leading cause of death for youth and young adults between the ages of 10-34. 90% dying by suicide had underlying mental illness.
Signs of suicide
Talk of being a burden, feeling trapped, experiencing unbearable pain, having no reason to live, and killing themselves
Mood- depression, loss of interest, rage, irritability, humiliation, anxiety
Behavior- acting recklessly, increased use of drugs/alcohol, withdrawing from activities, isolating, sleeping too much/too little, saying goodbye to love ones, giving away prized possessions
Suicide prevention includes
-remove or secure harmful objects (guns/weapons, poisons, medications) close
-constant supervision
-resources (crisis hotlines, counseling, inpatient facilities)
One of the most common neurodevelopmental disorders of childhood. Children with ADHD may have trouble paying attention, controlling impulsive behaviors (may act without thinking about what the result may be), or be overly active.
Diagnosis requires symptoms must be:
Present for at least 6 months
Present before 12 years of age
Occur in at least 2 settings (school, home, etc.)
Evidence of impaired social, academic functioning
ADHD
Presentation of ADHD
Inattention, hyperactivity, impulsivity
Inattention- distractibility, inability to complete projects, easily bored, disorganized, inattentiveness, avoidance of detailed tasks, forgetfulness
Hyperactivity & impulsivity- excessive energy and activity, restlessness, overactivity, inability to sit still, excessive talking, poor boundaries, interrupts, difficulty delaying
ADHD Tx
Environmental changes- decrease stimulation, structured routine, consistent limits
Behavior therapy- play & group therapy, reward for desired behaviors, consequences for undesired behaviors
Pharmacotherapy- stimulants and non-stimulants
Complementary therapy- elimination of processed foods, sugars, aspartame, and yeast from diet; supplements- melatonin, Omega-3, vitamins; “green time”/being out in nature
Abnormalities in neurodevelopmental processes resulting in altered sensory perceptions.
Schizophrenia
Schizophrenia
Safety is the main priority during an active episode.
Active episodes include:
Active episode includes hallucinations, delusions (false beliefs), disorganized speech & behavior, flat affect/speech/motivation
What eating disorder?
-Weight <85% of expected weight
-Distorted body image
-Absence of 3 consecutive menstrual cycles
Anorexia nervosa
What eating disorder?
-Lack of control overeating
-Recurrent inappropriate compensatory behavior
-Cycle of binge eating with purging (dental erosion & redness/irritation on fingers)
Bulimia nervosa
What eating disorder?
-binging w/o purging
binge eating
Management of eating disorders
*Highly structured environment
*Involve client in decision making
*Realistic weight goals
*Assist in changing negative perception to positive
*Monitor weight, VS, I&O, caloric intake, exercise
*Education/discharge instructions
Abnormalities in brain structure & function
Essential features:
Impaired socialization, communication, and behavior
Cognitive impairment varies
Characteristics:
Rigid, repetitive, machinelike movements, obsessive
-Head banging, twirling in circles, biting themselves, flapping hands, rocking back and forth
-Prefers to be alone
Abnormal response to stimuli
-extreme aversion to touch, noises, lights
-may not respond to pain
-resists attention and affection
-communication challenges, no eye contact
-difficulty interpreting feelings or gestures of others
Autism spectrum disorder
AAP recommends screening for Autism at the 18 and 24 month well child check ups.
Safety concerns for children w/ autism
Wandering/Elopement
Bullying
Sexual Abuse
Global delays in development functioning
-Encompasses number of disorders
-Affects mental and/or physical development
-Wide variability in classification
-May occur w/ variety of physical conditions
developmental disorders
Conditions responsible to for developmental disorders:
*Genetic-DS, FXS
*Metabolic-PKU
*Pregnancy-Fetal alcohol, Maternal Rubella, Birth asphyxia
*External-TBI, Poison, Hypoxia, Environmental deprivation
Hormones control
*Growth & Development
*Sexual Maturation
*Energy use and storage
*Control of levels of sugar, salt, fluids in the bloodstream
*Response to stress or physical trauma
Alterations in functioning significantly impact children!
Pituitary hypofunction causes
Growth Hormone Deficiency
■ Delayed growth of less than 2 in a yr needs to be evaluated
■ Delayed closure of the anterior fontanelle
■ Delayed dental eruption
■ Greater weight-to-height ratio
■ Increased abdominal (truncal) fat
■ Poor development of bridge of nose
■ Protrusion of the frontal skull bones
■ Delayed puberty, including a high-pitched voice and a small penis or testes in boys
■ Hypoglycemia in neonatal period
Secondary sex characteristics developing before age 8 in girls and age
9 in boys
Can be congenital or acquired
Pituitary hyperfunction AKA Precocious Puberty
- Hypofunction of posterior pituitary gland
- It can be Neurogenic or Nephrogenic
S/sx:
* Infants–> FTT, saturated diapers, fussy
* Older children–> Irritable, polydipsia (excessive
thirst), polyuria, enuresis
Diabetes Insipidus
How is DI diagnosed and treated?
Diagnosis:
* 24 hour urine (specific gravity < 1.005) [lots of dilute urine]
* Hypernatremia (can cause seizures and brain damage)
* Water Deprivation Test (lab testing during forced dehydration)
Tx:
* Monitor output (daily weights) & s/s of dehydration
* Neurogenic–> desmopressin (DDVAP)
* Nephrogenic–> Potassium sparing diuretic
Rare in children. Excessive levels of ADH are produced.
S/sx: N/V, seizures, headaches, cramping, changes in
LOC, fluid retention, decreased UOP
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
How is SIADH diagnosed and treated?
Diagnosis:
-High urine specific gravity > 1.030
-Hyponatremia (HA, lethargy, confusion, seizure precautions needed)
Tx:
-Strict I&Os
-Fluid restriction (2/3 maintenance)
-Increase sodium and protein in diet
-ADH receptor agonist (allows for reabsorption of water in kidneys)
Thyroid insufficiency can be congenital or acquired
(Hashimoto’s Thyroiditis- acquired 6+, autoimmune)
S/sx:
Congenital hypothyroidism –> Poor feeding, constipation, hypotonia, large fontanelles, large/thick tongue, delayed development
Older child–> Bradycardia, hypothermia, puffy face, delayed puberty, constipation, impaired memory
Hypothyroidism
How is hypothyroidism diagnosed and treated?
Diagnosis:
* Congenital hypothyroidism–> Newborn screening
* Low T4 and high TSH
Tx:
* Thyroid replacement therapy (levothyroxine [Synthroid])
* Adherence to follow-ups
An autoimmune disorder that is most frequent cause of hyperthyroidism in children (frequency increases in adolescence)
*Neonatal Graves Disease (born to women with Graves’)
S/sx:
Goiter, raised, thickened skin,
exophthalmos in addition to increased HR/BP,
increased sweating, tremor, poor concentration
Grave’s disease
How is Grave’s disease diagnosed and treated?
Diagnosis:
Low TSH, high T3 and T4
Tx:
Goal=remission
* Antithyroid drugs (methimazole)
* Radioactive iodine
* Thyroidectomy
* Calm environment
Often preceded by a stressful event or illness.
Can be life threatening if not treated.
Symptoms include hypermetabolic state, n/v, tremors, and psychosis
Thyroid storm
Rare. Occurs when there is an inadequate production of PTH. Can be inherited or acquired
S/sx:
Poor tooth development, headaches, seizures,
spasms of face/hands/feet, irritability, vomiting
Hypoparathyroidism
How is Hypoparathyroidism diagnosed and treated?
Diagnosis:
* Low calcium and magnesium
* High phosphates
* Low PTH
* Imaging (increased bone density)
Tx:
* Supplemental calcium and vitamin D
* Adherence to follow-ups
Rare in children. Overactive parathyroid glands produce high levels of PTH = increased levels of serum calcium
S/sx:
Bone/joint pain, bone loss (osteoporosis), weakness, n/v, kidney stones, psychiatric conditions
Hyperparathyroidism
How is Hyperparathyroidism diagnosed and treated?
Diagnosis:
* High PTH and calcium
* Imaging (bones may show rickets)
Tx:
* Reduce osteoclastic bone reabsorption (oral
phosphate)
* Diet low in calcium
* Parathyroidectomy
Caused by cell destruction resulting indefinite insulin dependency
Type I DM
Clinical presentation for Type I DM
- Three P’s: Polydipsia, Polyphagia, Polyuria*
- Fatigue
- Nausea and vomiting
- Yeast Infections
- Dehydration
- Muscle wasting/weight loss
- Tachycardia
- Blurred vision
Developmental considerations w/ diabetes
- Establish routines (Find specific place for glucose tests)
- Allow toddler to participate and predict activities- not able to do injections
- Preschooler can assist with cleaning their finger, holding still for injection, helping to choose foods
- School age child can perform site choosing, cleaning, fingerstick, injection
- School age recognizes needs to eat on time & signs of hypoglycemia and correction
- Adolescent is able to perform all tasks, can choose own foods, adds extra for increased activity, can treat/recognize hypoglycemia
Goals of DM management
*Optimal glycemic control
*Normal growth and development
*Minimizing complications
*Family and patient education
*Emotional adjustment to diabetes
*Caregivers know plan
Monitor for Hypoglycemia! < 70 mg/dL
S/sx include
Cold, pale skin
Light-headed
Shakey, tremors
Sudden hunger
Emotional outbursts
Anxiety
Fainting
Interventions for hypoglycemia
Can give 10-15 grams of: juice, glucose gel, hard candy, gumdrops, honey,
raisins, regular soda, cake icing and recheck in 15 mins (may need to give
again)
If unconscious = glucagon
Caused by insulin resistance in which the body fails to recognize and use insulin properly
Type II DM
Risk factors for Type II DM
*Black, Hispanic, Native American, Asian/Pacific Islander American
*Obesity
*Sedentary Lifestyles
*High calorie/high fat diet
*Family History
*Maternal hx of GDM
S/sx of Type II DM
- Numbness or tingling in feet, ankles, legs
- Complaints of blurry or poor vision
- Fatigue
- Weight gain or weight loss
- Headache
- Polyuria, polydipsia
- Enuresis, nocturia
- Acanthosis Nigricans
- HTN, dyslipidemia
Tx for Type II DM
- Lifestyle modifications
- Oral hypoglycemic agent (metformin)
- Insulin
- Education
Breath smells like fruity gum, Kussmaul resp, thirsty, dehydrated, tachy, hypotension, acidosis, high blood sugar (greater than 240mg/dl), hyperkalemia, polyuria
diabetic ketoacidosis
DKA Tx
Hydration, insulin, and electrolyte replacement
Goals of DKA management
*Restore fluid volume
*Return child to a glucose utilization state by inhibiting lipolysis
*Replace the child’s body electrolytes
*Correct acidosis and restore acid-base balance
Diabetes education
-Teach how to count carbs
-Monitor glucose around exercise
-Monitor glucose 3-6 times/day
-See HCP every 3 months for follow-up and monitoring
-Teach about DKA
-Giving insulin (rotate sites, room temperature, exact dosing, 45-90° angle for subcutaneous in children, safe needle disposal, don’t reuse syringes)
