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Bulacan State University
College of Nursing
COMMON PEDIATRIC DISORDERS
SIGNS OF DEVELOPMENTAL DELAY
Criteria For Referral
Communication and Feeding
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Feeding difficulties weak sucking or poor
coordination of suck-swallowing to sustain normal
weight gain
No social smile by age 4 months
No babbling (ga-ga, da-da) by age 9 months
No Mama, Dada (specific) by age 14 months
No name of object (one word) by age 14 months
At least 10 words by age 18 months (not just
repeating)
Combines words (eg, me outside, more milk) and
uses pronouns by age 24 months
Regression in language at any age
Unresponsive to his name
Motor Delay
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Not rolling over by age 6 months
Not sitting by age 9 months
Not walking by age 15 months
Not stair-climbing by age 2 years
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Nursing Diagnoses
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CARE OF THE CHILD WITH A DEVELOPMENTAL DISABILITY
Nursing Assessment
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Review the child's record to determine existing
health problems that may cause or affect the
developmental disability. Always rule out a vision
or hearing impairment.
Assess the family's understanding of the diagnosis
and its ramifications. The parents' experiences,
cultural biases, cognitive ability, stage of grief,
and physical condition affect their ability to
assimilate information provided. It will be
necessary to repeat the information. (For
example, a woman who has just given birth to a
child with Down syndrome will not be able to
retain much information until her body returns to
a state of homeostasis.)
Determine the developmental age of the child.
The pediatric nurse should be familiar with normal
developmental milestones (see Chapter 40,
page 1320), noting the child's strengths and
areas presenting challenges, for example, the
communication skills are at a 12-month level and
the gross motor skills are at a 36-month level.
Children who are found to be functioning at onehalf or less of their chronological age have a
moderate to severe developmental problem.
Administer the Clinical Adaptive Test-Clinical
Linguistic Auditory Milestone Scales (CAT-CLAMS).
It is a reliable tool that nurses can be trained to
use to assess cognitive and communicative
development in children at the 1- to 36-month
developmental level. It has been found tobe
more sensitive than the Denver Developmental
Screening Scale because language
development is the best early predictor of
cognitive abilities
Assess the functional level of the child. Functional
areas to assess include:
o Feeding.
o Grooming and bathing.
o Dressing.
o Mobility.
o Problem solving.
o Communication.
Assess parents' perception of the child's
development level and the appropriateness of
parental expectations. Use such questions as,
“Do you have any concerns regarding things
your child is doing or should be doing?―
“What age child does your child act like?―
Assess parent-child interaction. Observe and
explore bonding and attachment, ability to set
appropriate limits, management of behavioral
problems, and methods of discipline.
Assess the need for additional resources, such as
financial aid, transportation, and counseling, for
long-term support of child and family.
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Impaired Adjustment related to birth and
diagnosis of developmentally disabled child
Impaired Parenting related to multiple needs of
child and difficult bonding
Ineffective Infant Feeding Pattern related to
protruding tongue, poor muscle tone, and weak
sucking
Delayed Growth and Development related to
disability
Social Isolation related to developmental
differences from other children
Risk for Injury related to developmental age
Nursing Interventions
Promoting Adjustment
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Allow the parents access to the infant at all
possible times to promote bonding when parents
appear ready.
Focus on the positive aspects of the infant and
serve as a role model for handling and
stimulating.
Be cognizant of the grieving process (loss of the
anticipated and planned for normal child that
families experience when a diagnosis is made,
and be aware that spouses can be at different
stages.
Accept all questions and reactions
nonjudgmentally, offering verbal and written
explanations.
Provide the family a quiet place to discuss their
questions with each other and someone
knowledgeable about the condition (primary
care provider, clinical nurse specialist) to support
their concerns.
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Offer the family the option to take advantage of
counseling. A social worker or psychologist can
help families deal with immediate reactions.
Many parents benefit from continuous or
periodic support of counseling professionals.
Help the family to realize what strengths they
have in caring for their child. The role of the
parents is critical; a nurturing, loving environment
gives the child the best chance at maximizing
potential. An individual who grows up at home
has markedly higher adaptive abilities and an
increased life span compared with those raised
in institutions.
Enlist the help of family and siblings, who can
offer valuable support to the parents and child
and assist with stimulation activities. Including
siblings in the care can help them feel needed
and involved, thus strengthening the family.
If sibling issues arise, suggest family counseling to
address the needs of all family members.
Identify resources available to the family, such as
parent support groups, early intervention
programs, specialty clinics, pediatrician or
primary health care provider, financial support
programs, and advocacy groups for individuals
with developmental disabilities.
For those parents concerned with their ability to
care for the child, explore with them their options
of adoption or institutionalization in a
nonjudgmental manner.
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Providing Meaningful Social Interaction
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Establishing Effective Feeding Techniques
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Be aware that the presence of hypotonia, as in
children with Down syndrome; or hypertonia, as
in children at high risk for cerebral palsy, can
interfere with feeding by compromising sucking
and swallowing.
Demonstrate proper feeding positioning, with the
infant's head elevated, and encourage the
parents to always hold the infant during feedings
with his head elevated and supported in arms.
Try different nipples and bottles to find the easiest
for the infant to use without leakage or danger of
aspiration.
Allow adequate time for feeding, and increase
frequency of feedings if infant tires easily.
Offer support and guidance for breast-feeding.
Refer to lactation consultant if needed.
Consider referral for a feeding evaluation to a
speech therapist, or to an occupational therapist
who has experience working with children and
families.
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Refer parents to the Early Intervention Program
administered by their county so that they can
take advantage of the educational and support
services available for children from birth to age 3.
If the condition is identified after age 3, refer
parents to the school district in which they reside.
RESPIRATORY DISORDERS
Pneumonia
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The most
common
causative agent
is Streptococcus
pneumoniae.
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Responsible for the majority
of bacterial pneumonias in
ages 1 month through 6
years. However, it is seen in
all age groups.
The incidence has declined
due to the use of the
vaccine.
Make parents aware that recreational and
leisure-time experiences are valuable in building
social skills and self-esteem.
Offer suggestions that will be enjoyable and
developmentally appropriate for the child.
Interaction with developmentally delayed and
nondevelopmentally delayed peers is desirable.
The Special Olympics is one example of an
adaptive program. Local programs are also
available in many areas.
Praise the child for participation in activities,
regardless of whether the child succeeds.
Maintaining Safety
Promoting Optimum Growth and Development
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Help the parents to understand the concept of
developmental age, and identify the functional
level of the child.
Determine whether there is consistency between
the developmental age of the child and degree
of independence. Cognitive and physical
limitations may interfere with emerging
independence; however, parents may
“baby― or overindulge a child who has a
disability.
Work with parents to set reasonable expectations
and tobreak down tasks into simple, achievable
steps. Care should be taken not to address too
many areas at one time so as not to overwhelm
the family.
Use appropriate behavior modification
techniques, such as extinction, time-out, and
reward, to achieve cooperation and success.
Demonstrate and encourage play with the child
at the appropriate level to provide stimulation,
and work toward achieving developmental
milestones.
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When handling the infant, provide adequate
support with a firm grasp because the infant may
be floppy due to poor muscle tone.
If hypotonia is accompanied by poor head
control and neck strength, position the infant to
prevent aspiration should vomiting occur.
o Support the infant with a diaper roll, if
needed, to maintain position.
o Change the infant's position frequently.
o Continuously check the environment for
the safety needs of this child.
Advise the parents to:
o Maintain appropriate surveillance of the
child when cooking or exposing him to
other potential hazards that he may be
able to get into but not understand.
o Help the child to read words, such as
“danger― and “stop.―
o Teach the child how to call and ask for
help.
o Teach the child to say no to strangers.
o Provide sex education in a way the child
can understand.
Infants: Mild upper respiratory infection (URI) of
several days' duration, poor feeding, decreased
appetite.
Abrupt onset of fever 102.2° F (39° C) or higher;
restlessness, respiratory distress, air hunger, pallor,
cyanosis (common), nasal flaring, retractions,
grunting, tachypnea, tachycardia, irritability; may
see abdominal distention due to swallowed air or
ileus.
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Winter and spring.
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Older child: Mild URI, followed by fever up to
104.9° F (40.5°C), shaking chills, headache,
decreased appetite, vomiting, drowsiness,
restlessness, irritability, lethargy, rhonchi, fine
crackles, dry hacking cough, increased respirations,
anxiety, occasionally circumoral cyanosis, pleuritic
pain, diminished breath sounds, may develop a
pleural effusion, empyema.
Nursing Assessment
Determine the severity of the respiratory distress that the
child is experiencing. Make an initial nursing assessment.
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Observe the respiratory rate and pattern. Count
the respirations for 1 full minute, document and
note level of activity, such as awake or asleep.
Determine if the rate is appropriate for age
Observe respiratory rhythm and depth. Rhythm is
described as regular, irregular, or periodic. Depth
is normal, hypopnea or too shallow, hyperpnea
or too deep.
Auscultate breath sounds over all lung fields.
Note airflow and presence of adventitious sounds
such as crackles, wheeze, or stridor.
Observe degree of respiratory effort, normal,
difficult, or labored. Normal breathing is effortless
and easy.
Document character of dyspnea or labored
breathing; continuous, intermittent, worsening, or
sudden onset
Note presence of additional signs of respiratory
distress: nasal flaring, grunting, and retractions
Observe for head bobbing, usually noted in a
sleeping or exhausted infant. The infant is held by
caregiver with head supported on the
caregiver's arm at the suboccipital area. The
head bobs forward with each inspiration.
Observe the child's color. Note the presence and
location of cyanosis—peripheral, perioral,
facial, and trunk. Note degree of color changes,
duration, and association with activity such as
crying, feeding, and sleeping.
Observe the presence of cough, noting type and
duration, such as dry, barking, paroxysmal, or
productive. Note any pattern, such as time of
day, night, association with activity, physical
exertion, or feeding.
Note the presence of sputum, including color,
amount, consistency, and frequency.
Observe the child's fingernails and toenails for
cyanosis and the presence and degree of
clubbing, which indicate underlying chronic
respiratory disease
Nursing Diagnoses
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Ineffective Airway Clearance related to
inflammation, obstruction, secretions, or pain
Ineffective Breathing Pattern related to
inflammatory process or pain
Deficient Fluid Volume related to fever,
decreased appetite, and vomiting
Fatigue related to increased work of breathing
Anxiety related to respiratory distress and
hospitalization
Parental Role Conflict related to hospitalization of
the child
Tonsillitis and Adenoiditis
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In tonsillitis and adenoiditis, structures that are
already large become inflamed due to an
infectious agent and cause airway obstruction,
decreased appetite, and pain.
Clinical Manifestations
Obstructive Sleep Apnea
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Loud snoring or noisy breathing in sleep.
Excessive daytime sleepiness.
Mouth breathing.
Chronic Infection of Tonsils and Adenoids
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Mouth breathing or difficulty breathing.
Frequent sore throat.
Anorexia, decreased growth velocity.
Fever.
Obstruction to swallowing or breathing.
Nasal, muffled voice.
Night cough.
Offensive breath.
Chronic Otitis Media
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Ear pain or general irritability in young children.
Alterations in hearing.
Fever.
Enlarged lymph nodes.
Anorexia.
Diagnostic Evaluation
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Thorough ears, nose, and throat examination
and appropriate cultures to determine presence
and source of infection.
Preoperative blood studies to determine risk of
bleeding—clotting time, smear for platelets,
prothrombin time, and partial thromboplastin
time.
RESPIRATORY DISTRESS SYNDROME (HYALINE MEMBRANE
DISEASE)
Respiratory distress syndrome (RDS), formerly known as
hyaline membrane disease, is a syndrome of premature
neonates that is characterized by progressive and usually
fatal respiratory failure resulting from atelectasis and
immaturity of the lungs.
Primary Signs and Symptoms
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Expiratory grunting or whining (when the infant is
not crying).
Sternal, suprasternal, substernal, and intercostal
retractions progressing to paradoxical seesaw
respirations.
Inspiratory nasal flaring.
Tachypnea less than 60 breaths per minute.
Hypothermia.
Cyanosis when child is in room air (infants with
severe disease may be cyanotic even when
given oxygen), increasing need for oxygen.
Supportive Management
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Maintenance of oxygenation
Maintenance of respiration with ventilatory
support, if necessary
Maintenance of normal body temperature
Antibiotics as needed to treat infection.
PEDIATRIC RESPIRATORY PROCEDURES
OXYGEN THERAPY
Children with respiratory problems may receive oxygen
therapy via nasal cannula, mask, face tent, or
trachesotomy device.
MECHANICAL VENTILATION
Aggressive Management
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Administration of exogenous surfactant into lungs
early in the disease.
Surfactant Replacement Therapy
Nursing Diagnoses
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Impaired Gas Exchange related to disease
process
Imbalanced Nutrition: Less than Body
Requirements related to prematurity and
increased energy expenditure on breathing
Ineffective Thermoregulation related to
immaturity
Impaired Parenting related to separation from
the neonate due to hospitalization
Infants and children requiring mechanical ventilation
need specialized care. These patients are typically
treated in facilities that focus on providing a safe
environment for technology-dependent children, with
care provided by highly skilled nurses, respiratory
therapists, and pediatricians. Specific nursing procedures
and interventions and management of technologydependent infants and children are beyond the scope of
this text. General considerations are as follows.
Maintenance of a Patent Airway
Artificial airway options include nasotracheal,
orotracheal, and tracheostomy. ET and tracheostomy
tubes are available in several sizes, cuffed and uncuffed,
for the pediatric population. Several methods are
available to determine the appropriate size such as: ET
tube size = Age in years + 16 /divided by 4.
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CARDIOVASCULAR DISORDERS
CONGENITAL HEART DISEASE
Congenital heart disease (or defects) (CHD) is one of the most common forms of congenital anomalies. It involves the
chambers, valves, and great vessels arising from the heart
NURSING CARE OF THE CHILD WITH CONGENITAL HEART
DISEASE
Nursing Assessment
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Obtain a thorough nursing history.
Discuss the care plan with the health care team
(cardiologist, cardiac surgeon, nursing case
manager, social worker, nutritionist). Discuss the
care plan with the patient, parents, and other
caregivers.
Measure and record height and weight. Plot on
a growth chart.
Record vital signs and oxygen saturations.
o Measure vital signs at a time when the
infant/child is quiet.
o Choose appropriate-size blood pressure
(BP) cuff.
o Check four extremity BP
Assess and record:
o Skin color: pink, cyanotic, mottled.
o Mucous membranes: moist, dry,
cyanotic.
o Extremities: check peripheral pulses for
quality and symmetry; dependent
edema; capillary refill; color and
temperature.
Assess for clubbing (cyanotic heart disease).
Assess chest wall for deformities; prominent
precordial activity.
Assess respiratory pattern.
o Before disturbing the child, stand back
and count the respiratory rate.
Loosen or remove clothing to directly
observe chest movement.
o Assess for signs of respiratory distress:
increased respiratory rate, grunting,
retractions, nasal flaring.
o Auscultate for crackles, wheezing,
congestion, stridor.
Assess heart sounds.
o Determine rate (bradycardia,
tachycardia, or normal for age) and
rhythm (regular or irregular).
o Identify murmur (type, location, and
grade).
Assess fluid status.
o Daily weights.
o Strict intake and output (number of wet
diapers; urine output).
Assess and record the child's level of activity.
o Observe the infant while feeding. Does
the infant need frequent breaks or does
he or she fall asleep during feeding?
Assess for sweating, color change, or
respiratory distress while feeding.
o Observe the child at play. Is play
interrupted to rest? Ask the parent if the
child keeps up with peers while at play.
o Assess and record findings relevant to
the child's developmental level: ageappropriate behavior, cognitive skills,
gross and fine motor skills.
o
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Nursing Diagnoses
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Impaired Gas Exchange related to altered
pulmonary blood flow or pulmonary congestion
Decreased Cardiac Output related to
decreased myocardial function
Activity Intolerance related to hypoxia or
decreased myocardial function
Imbalanced Nutrition: Less Than Body
Requirements related to excessive energy
demands required by increased cardiac
workload
Risk for Infection related to chronic illness
Fear and Anxiety related to life-threatening illness
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Improving Oxygenation and Activity Tolerance
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Nursing Interventions
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Relieving Respiratory Distress
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Position the child in a reclining, semi-upright
position.
Suction oral and nasal secretions as needed.
Identify target oxygen saturations and administer
oxygen as prescribed.
Administer prescribed medications and
document response to medications (improved,
no change, or worsening respiratory status).
o Diuretics.
o Bronchodilators.
May need to change oral feedings to
nasogastric feedings because of increased risk of
aspiration with respiratory distress.
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Organize nursing care and medication schedule
to provide periods of uninterrupted rest.
Provide play or educational activities that can
be done in bed with minimal exertion.
Maintain normothermia.
Administer medications as prescribed.
o Diuretics (furosemide, spironolactone):
 Give the medication at the
same time each day. For older
children, do not give a dose
right before bedtime.
 Monitor the effectiveness of the
dose: measure and record urine
output.
o Digoxin:
 Check heart rate for 1 minute.
Withhold the dose and notify the
physician for bradycardia (heart
rate less than 90 beats/minute
[bpm]).
 Lead II rhythm strip may be
ordered for PR interval
monitoring. Prolonged PR
interval indicates first-degree
heart block (dose of digoxin
may be withheld).
 Give medication at the same
time each day. For infants and
children, digoxin is usually
divided and given twice per
day.
 Monitor serum electrolytes.
Increased incidence of digoxin
toxicity associated with
hypokalemia.
o Afterload-reducing medications
(captopril, enalapril):
 When initiating medication for
the first time: check BP
immediately before and 1 hour
after dose.
Place pulse oximeter probe (continuous
monitoring or measure with vital signs) on finger,
earlobe, or toe.
Administer oxygen as needed.
Titrate amount of oxygen to reach target oxygen
saturations.
Assess response to oxygen therapy: increase in
baseline oxygen saturations, improved work of
breathing, and change in patient comfort.
Explain to the child how oxygen will help. If
possible, give the child the choice for face mask
oxygen or nasal cannula oxygen.
Providing Adequate Nutrition
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Improving Cardiac Output
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Monitor for signs of hypotension:
syncope, light-headedness, faint
pulses.
Withhold medication and notify
the physician according to
ordered parameters.
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For the infant:
o Small, frequent feedings.
o Fortified formula or breast milk (up to 30
cal/oz).
o Limit oral feeding time to 15 to 20
minutes.
o Supplement oral feeds with nasogastric
feedings as needed to provide weight
gain (ie, continuous nasogastric feedings
at night with ad-lib by-mouth feeds
during the day).
For the child:
o Small, frequent meals.
o High-calorie, nutritional supplements.
o Determine child's likes and dislikes and
plan meals accordingly.
o Allow the parents to bring the child's
favorite foods to the hospital.
Report feeding intolerance: nausea, vomiting,
diarrhea.
Document daily weight (same time of day, same
scale, same clothing).
Record accurate inputs and outputs; assess for
fluid retention.
Fluid restriction not usually needed for children;
manage excess fluid with diuretics.
Preventing Infection
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Maintain routine childhood immunization
schedule. With the exception of RSV (Synagis)
and influenza, immunizations should not be given
for 6 weeks after cardiovascular surgery.
Administer yearly influenza vaccine.
Administer RSV immunization for children younger
than age 2 with complex CHD and those at risk
for CHF or pulmonary hypertension.
Prevent exposure to communicable diseases.
Good hand washing.
Report fevers.
Report signs of URI: runny nose, cough, increase
in nasal secretions.
Report signs of GI illness: diarrhea, abdominal
pain, irritability.
Evaluation: Expected Outcomes
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Improved oxygenation evidenced by easy,
comfortable respirations
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Improved cardiac output demonstrated by
stable vital signs, adequate peripheral perfusion,
and adequate urine output
Increased activity level
Maximal nutritional status demonstrated by
weight gain and increase in growth curve
percentile
No signs or symptoms of infection
Parents discuss diagnosis and treatment together
and with child
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COMMON PEDIATRIC GASTROINTESTINAL DISORDERS
CLEFT LIP AND PALATE
Cleft lip and palate are congenital anomalies resulting in
structural facial malformation. These defects are usually
present in early fetal development.
Pathophysiology and Etiology
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A failure of embryonic development, resulting in
defect syndromes associated with other
anomalies.
Genetic/hereditary predisposition; a fetus with an
affected parent or sibling has a 2% to 4% risk
compared to 0.15% risk of the general
population.
Environmental causes are suspected: antiepileptic medications taken during pregnancy,
other factors suspected include maternal
smoking, heavy alcohol intake, infections, folic
acid deficiency, and vitamin A intoxication.
Clinical Manifestations
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Physical appearance of cleft lip or palate:
o Incompletely formed lip—varies from
slight notch in vermilion to complete
separation of lip.
o Opening in roof of mouth felt with
examiner's finger on palate.
Eating difficulty:
o Suction cannot be created for effective
sucking.
o Food returns through the nose.
o Nasal speech.
Diagnostic Evaluation
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Prenatal ultrasonography enables many cleft lips
and some cleft palates to be identified in utero.
Magnetic resonance imaging (MRI) to evaluate
extent of abnormality before treatment.
Photography to document the abnormality.
Serial X-rays before and after treatment.
Dental impressions for expansion prosthesis.
Genetic evaluation to determine recurrence risk.
General management is focused on closure of
the clefts, prevention of complications,
habilitation, and facilitation of normal growth
and development of the child.
The cleft lip is generally repaired before the
palate defect.
o Immediate repair—several hours to
several weeks after birth.
o Intraoral or extraoral prosthesis to
prevent maxillary collapse, stimulate
body growth, and aid in feeding and
speech development; may be used
before surgical repair.
o Later repair when infant is 6 to 12 weeks
old, hemoglobin 10 g/dL, steady weight
gain seen—10 lb (4.5 kg) or white blood
cell (WBC) count normal.
Cleft palate repair may be done any time
between ages 6 months and 5 years; it is based
on degree of deformity, width of oropharynx,
neuromuscular function of palate and pharynx,
and surgeon's preference.
o Repair at age 9 to 18 months may be
preferred because speech patterns
have not been set, yet growth of
involved structures allows for improved
surgical repair.
o If repair is delayed to age 4 or 5, a
special denture palate is used to help
occlude the cleft and aid in establishing
speech patterns.
Nursing Assessment
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If the patient has a cleft lip, assess for cleft palate
by direct visualization and palpation with finger.
Obtain family history of cleft lip or palate.
Evaluate feeding abilities.
o Effectiveness of suck and swallow
o Amount taken
Observe for other syndromic features.
Nursing Diagnoses
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Ineffective Infant Feeding Pattern related to
defect
Risk for Infection related to open wound created
by malformation, ear infections
Risk for Impaired Parent/Infant Attachment
related to malformation and special care needs
Risk for Aspiration related to tongue and palate
deformities in Pierre Robin syndrome
Deficient Knowledge related to home
management of infant with cleft malformation
Fear related to surgery
Deficient Knowledge related to postoperative
care
COMMON ORTHOPEDIC DISORDERS IN CHILDREN
FRACTURES
A fracture is a break or disruption in the continuity of
bone
FIGURE: Common fractures in children. (A) Plastic
deformation (bend). (B) Buckle (torus). (C) Greenstick. (D)
Complete.
Epiphyseal Injuries
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Fifteen percent to 30% of all childhood fractures
involve the physis (growth plate).
The most frequent site of physeal injuries
(excluding phalangeal fractures) is the distal
radius and ulna.
The 11- to 15-year-old age-group tends to sustain
the majority of physeal injuries to the distal radius
and ulna.
The mechanism of injury is usually a fall on an
outstretched arm.
Clavicle Fractures
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Frequent site of fracture in children.
The shaft of the clavicle is the most common site
of injury.
A fall on the shoulder or excessive lateral
compression of the shoulder is usually the
mechanism of injury.
Treatment involves support in the form of
immobilization with a sling.
Reduction of clavicle fractures occurs only in
instances of extreme displacement.
Forearm and Wrist Fractures
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Most common site of fracture in children, with
most occurring in children older than age 5.
Account for 30% to 50% of all fractures in
children.
Seventy-five percent of forearm fractures occur
in the distal third of the radius and ulna and most
do not involve the physis.
Major categories of classification include fracture
dislocations, midshaft fractures, and distal
fractures.
Most common cause is from a fall on an
outstretched arm.
Humerus Fractures
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The mechanism of injury for the majority of
humeral fractures is a fall onto an outstretched
arm or hand.
Less than 1% of fractures occur at the proximal
humerus.
Ten percent of all humeral fractures occur at the
shaft of the humerus; they account for less than
2% of all pediatric fractures.
o Humeral shaft fractures are usually a
result of twisting injuries in infants and
toddlers (child abuse is a common cause
of these fractures in this age group).
o Direct trauma to the humeral shaft is the
most common mechanism of injury in
older children.
Supracondylar fractures account for 60% of all
elbow fractures in children. There is a high
incidence of neurovascular injury with
supracondylar fractures, 8% of which sustain a
neurologic injury.
Twenty percent of distal humeral injuries occur in
the lateral condyle; this ranks as the second most
common elbow fracture in children.
Medial epicondyle fractures are the third most
common elbow fracture in children, accounting
for 5% to 10% of all pediatric elbow fractures.
Spinal Fractures
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Rare in children they account for 1% to 2% of all
pediatric fractures.
Mechanism of injury is due to significant trauma,
such as an motor vehicle accident, fall from a
significant height, athletic activities, beatings, or
pedestrian-versus-motor-vehicle accident.
Most spinal fractures involve the cervical spine.
Pelvic Fractures
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Pelvic fractures are uncommon in children and
adolescents with an incidence of 1 per 100,000
children per year.
Pelvic fractures are commonly the result of highenergy trauma or a crush-type injury.
Associated injuries are present in approximately
75% of children with pelvic fractures and include
damage to the abdominal wall and pelvic
organs.
Hip Fractures
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Hip fractures account for less than 1% of all
fractures in children.
Seventy-five percent of hip fractures in children
result from high-energy trauma, such as motor
vehicle accidents, bicycle accidents, and falls
from significant heights.
Half of children who sustain a hip fracture have
been involved in a motor vehicle accident or
pedestrian-versus-motor-vehicle accident; these
children usually have other injuries.
Child abuse is the most common cause of hip
fracture in children under age 3.
Hip fractures can result in avascular necrosis of
the femoral head, damage to the physis resulting
in growth arrest, malunion, and nonunion.
Femur Fractures
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Common in children. Peak incidence occurs in
two age groups—children ages 2 to 3 and
adolescents.
The midshaft of the femur is the most common
location for femoral fractures in children and
accounts for 1% to 2% of all childhood fractures.
Usually the result of high-energy trauma, such as
a motor vehicle accident or fall from a significant
height.
Seventy percent of femur fractures in children
younger than age 1 are associated with child
abuse.
Tibial Fractures
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The most common lower extremity fracture in
children occurs in the tibial and fibular shaft
constitutes 10% to 15% of all pediatric fractures.
A rotational mechanism of injury to the lower leg
is the most common cause of tibial fractures in
children under age 3 (toddler's fracture).
Greater force is required to injure the tibia in
older children; motor vehicle accidents and
sports injuries are the most common causes of
tibial fractures in children and adolescents.
Ankle Fractures
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Common in children and adolescents
approximately 5% of all pediatric fractures.
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Involve the growth plate in approximately every
1 of 6 injuries.
Greatest incidence is in males ages 10 to 15.
Usually the result of direct trauma.
Foot Fractures
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Management
Treatment is dependent upon the type of fracture, its
location, and the age of the child.
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Metatarsal and phalangeal fractures make up
approximately 7% to 9% of all pediatric fractures.
Fractures of the tarsal bones are uncommon in
children.
Most metatarsal and phalangeal fractures are
nondisplaced.
Mechanism of injury is usually a direct or indirect
trauma such as falls, jumping from heights, and
twisting injuries.
Classification of Fractures
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Open fractures: underlying fracture in bone
communicates with an external wound.
o Usually the result of high-energy trauma
or penetrance wounds.
o The tibia is the most common site of
open fractures in children.
Closed fractures: underlying fracture with no
open wound.
Plastic deformation: a bending of the bone in
such a manner as to cause a microscopic
fracture line that does not cross the bone. When
the force is removed, the bone remains bent.
Unique to children, and most common in the
ulna.
Clinical Manifestations
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Inability to stand, walk, or use injured part
Limb deformity (visible or palpable)
Ecchymosis
Pain
History of injury or trauma (may not be the case
with pathologic fractures)
Spontaneous onset of pain (usually seen with
pathologic fractures).
Local swelling and marked tenderness
Movement between bone fragments
Crepitus or grating
Muscle spasm
Diagnostic Evaluation
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X-rays of suspected limb fractures should include
the joint above and below the injury.
o Should always include a minimum of two
views at 90-degree angles to each other
(anteroposterior and lateral).
o Comparison views of the opposite
extremity are frequently needed. They
help to distinguish the fracture line from
the growth plate.
o In some situations, oblique X-rays are
warranted in order to help identify a
fracture that is difficult to detect.
Further radiologic studies may be indicated in
certain instances to evaluate a fracture:
tomography, computed tomography (CT) scan,
magnetic resonance imaging (MRI), bone scan,
fluoroscopy.
Vascular assessment may include the use of:
o Doppler studies.
o Compartment pressure monitoring.
Angiography.
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Treatment may consist of:
o Immobilization by cast, splint, or brace.
o Closed reduction followed by a period of
immobilization in a cast or splint.
o Open reduction with or without internal
fixation and usually followed by a period
of immobilization in a cast or splint.
o Closed reduction and percutaneous
pinning followed by a period of
immobilization.
o Closed or open reduction and
application of an external fixator.
o Traction (skin, skeletal) followed by a
period of immobilization.
Most children's fractures heal in 12 weeks or less.
Simple fractures that are closed and
nondisplaced can heal enough to be free from
immobilization within 3 weeks.
Nursing Diagnoses
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Acute Pain related to tissue trauma and reflex
muscle spasms secondary to fracture
Ineffective Tissue Perfusion: Peripheral related to
swelling and immobilization
Impaired Skin Integrity related to mechanical
trauma (eg, fixation device, traction, casts, other
orthopedic devices)
Ineffective Coping related to separation from
family and home
Impaired Physical Mobility related to fracture and
external immobilization device (eg, cast, splint,
external fixator)
Bathing/Hygiene/Feeding/Toileting Self-Care
Deficit related to external devices (eg, cast,
splint)
Risk for Infection related to trauma (fracture) and
surgery
Risk for Peripheral Neurovascular Dysfunction
related to restrictive envelope secondary to cast
or splint
Promoting Comfort
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Monitor and assess pain level using an ageappropriate pain scale (eg, Oucher or FACES
scale).
Properly position, align, and support affected
body part.
Administer analgesics as indicated and monitor
effectiveness of analgesia.
Use nontraditional methods of pain
relief—music therapy, diversionary activities,
relaxation techniques, therapeutic touch, play
therapy.
Maintaining Tissue Perfusion
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Frequently assess perfusion of limb by checking
temperature, color, sensation, and pulses.
Elevate extremity above heart level to prevent
edema.
Encourage movement of digits on affected limb.
Remove compressive bandages (eg, elastic
bandages, splints) that restrict flow of circulation.
Maintaining Skin Integrity
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Assess for and relieve pressure caused by tight
bandages, casts, and splints.
Provide periodic cleaning, thorough drying, and
lubrication to pressure points if in traction.
Encourage frequent position changes as
allowed.
Assess skin condition on a regular basis.
Massage healthy skin around affected area to
stimulate circulation.
Protect skin at risk with special dressings or
products (eg, barrier cream, moisture-permeable
dressing).
Discourage the use of sticks, knitting needles, or
small toys to scratch itchy skin.
Promote a diet high in protein, carbohydrates,
and calcium.
Promoting Effective Coping
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Assess the child's and parents' response to
events.
Explain condition, treatment, and rehabilitation
goals as indicated.
Provide reassurance and emotional support
when needed.
Refer to community-based support agencies (eg,
social services, United Way) if indicated.
Structure the child's day with routine, activities,
and therapy to keep him or her busy.
Encourage the child and parents to verbalize
feelings.
Encourage child to express feelings and emotions
through writing (eg, journal), drawing, or play
therapy.
Promoting Mobility
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Encourage exercise of uninvolved limbs regularly
throughout day.
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Teach appropriate ambulation techniques using
aids, such as crutches, walkers, or wheelchairs, as
indicated.
Teach safety precautions when using an
ambulatory aid.
Attaining Independence
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Assess family situation for ability to care for child
at home.
Allow child to care for self when able.
Encourage parents and siblings to assist only as
needed.
Encourage child to participate in care as much
as possible.
Evaluate child's ability to participate in self-care
activities.
Preventing Infection
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Assess wounds frequently for warmth, erythema,
swelling, tenderness, or purulent drainage.
Report signs of infection.
Provide appropriate wound care for open injuries
and surgical wounds.
Administer antibiotics as ordered.
Encourage child to eat and maintain good
caloric and protein intake to promote healing.
Teach good hand-washing technique to child
and parents.
Preventing Peripheral Neurovascular Dysfunction
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Assess the neurovascular status of affected limb
every hour for the first 24 hours (or as indicated
by hospital protocol)—compare with
unaffected limb.
Assess for nerve injury (eg, abduct all fingers,
touch thumb to small finger, plantar flexion,
dorsiflexion).