PEDS Exam 4
Caring for a child in a Pavlik Harness pg. 1649 (SELECT ALL)
-Do not adjust the straps without checking with the physician or nurse practitioner first. -Until your physician or nurse practitioner instructs you to take the harness off for a period of time each day, it must be used continuously (for the first week or sometimes longer). -Change your baby's diaper while he or she is in the harness. -Place your baby to sleep on his or her back. -Check skin folds, especially behind the knees and diaper area, for redness, irritation, or breakdown. Keep these areas clean and dry. -Once the baby is permitted to be out of the harness for a short period, you may bathe your baby while the harness is off. -Long knee socks and an undershirt are recommended to prevent rubbing of the skin against the brace. -Note location of the markings on the straps for appropriate placement of the harness. -Wash the harness with mild detergent by hand and air dry. If using the dryer, use only the air fluffing setting (no heat). -Call the doctor if: Your baby's feet are swollen or bluish, the harness appears too small, skin is raw or a rash develops, your baby is unable to actively kick his or her legs. Used to keep the knees flexed and hips abducted to allow the hips to grow normally in a child with developmental dysplasia on the hip.
Osteogenesis imperfecta teaching guidelines 45.3 pg. 1647
-Never push or pull on an arm or leg. -Do not bend an arm or leg into an awkward position. -Lift a baby by placing one hand under the legs and buttocks and one hand under the shoulders, head, and neck. -Do not lift a baby's legs by the ankles to change the diaper. -Do not lift a baby or small child from under the arm-pits. -Provide supported positioning. -If fracture is suspected, handle the limb minimally.
Pin care pg. 1642
-Perform pin care daily or weekly after the first 48 to 72 hours. -*The most effective solution for pin site care may be chlorhexidine 2 mg/mL.* -Teach children and their families pin site care along with instructions on the signs and symptoms of infection before discharge.
Children's bones bend slide 5 MS powerpoint
-The infant's muscles account for approximately 25% of total body weight, as compared with the adult's muscle mass, which accounts for about 40% of total body weight. -The infant's skeleton is not fully ossified at birth. -The infant's and young child's bones are more flexible and porous with a lower mineral content than the adult's. -These structural differences of bones allow for greater shock absorption, so the bones will often bend rather than break when an injury occurs.
Child's level of consciousness- define and know levels pg. 1307
1. Full consciousness is defined as a state in which the child is awake and alert; is oriented to time, place, and person; and exhibits age-appropriate behaviors. 2. Confusion is defined as a state in which disorientation exists. The child may be alert but responds inappropriately to questions. 3. Obtunded is defined as a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided. 4. Stupor exists when the child only responds to vigorous stimulation. 5. Coma defines a state in which the child cannot be aroused, even with painful stimuli.
Cerebral palsy pg. 1612-1617 and baclofen read pages
Cerebral palsy is a term used to describe a range of non-specific clinical symptoms characterized by abnormal motor pattern and postures caused by non-progressive abnormal brain function. The majority of causes occur before delivery, but can also occur in the natal and post-natal period Primary signs include motor impairments such as spasticity, muscle weakness, and ataxia, which is lack of coordination of muscle movements during voluntary movements such as walking or picking up objects. Complications include mental impairments, seizures, growth problems, impaired vision or hearing, abnormal sensation or perception, and hydrocephalus. Most children can survive into adulthood, but function and quality of life can vary from near normal to substantial impairments -Electroencephalogram: usually abnormal but the pattern is highly variable -Cranial radiographs or ultrasound: may show cerebral asymmetry -MRI or CT: may show area of damage or abnormal development but may be normal -Screening for metabolic defects and genetic testing may be performed to help determine the cause of cerebral palsy -Most commonly a result of prenatal brain abnormalities -Most important risk factor is prematurity -Kernicterus- a result of high levels of bilirubin in the neonatal period See box 44.1 pg 1613 Review Neuromuscular ppt good info Baclofen acts on the spinal cord nerves and decreases the number and severity of muscle spasms caused by multiple sclerosis or spinal cord diseases.
Bucks traction pg. 1640 table 45.1
Description: Skin traction for hip and knee contractures, Legg-Calvé-Perthes disease, slipped capital femoral epiphysis. Used to rest an injured limb or to prevent spasms of injured muscles or joints Traction force delivered in straight line Nursing Implications: Remove traction boot every 8 hours to assess skin. Leg may be slightly abducted.
Ketogenic diet- high fat, low carbs and adequate protein intake pg. 1305
Diet involving high intake of fats, adequate protein, and a very low intake of carbohydrates, resulting in a ketosis state. Child is kept in a mild state of dehydration. Indication: Prevention, control, and reduction of seizures, in particular for children with difficult-to-control seizures Nursing Implications: Monitor input and output closely, for seizure activity, growth and nutritional status, the diet is time consuming and many children find it unpalatable; therefore, all families and children do not accept it.
Duchenne muscular dystrophy; Gower's sign pg. 1606-1610 (SELECT ALL) read pages
Early childhood (usually 3 to 6 years) X-linked recessive Generalized weakness, muscle wasting; limb and trunk first. Gowers' sign is a medical sign that indicates weakness of the proximal muscles, namely those of the lower limb. The sign describes a patient that has to use their hands and arms to "walk" up their own body from a squatting position due to lack of hip and thigh muscle strength. Duchenne muscular dystrophy, the most common neuromuscular disorder of childhood, is universally fatal (usually by age 20 to 25) . Absence of dystrophin leads to generalized weakness of voluntary muscles, and the weakness progresses over time. The hips, thighs, pelvis, and shoulders are affected initially; as the disease progresses, all voluntary muscles as well as cardiac and respiratory muscles are affected. Rarely, males with Duchenne muscular dystrophy may survive beyond the early 30s. Initial Stages: waddling gait frequent falls gower sign- pg. 1609 enlarged muscles Later Stages: profound muscular atrophy Confirmed: serum enzymes muscle biopsy electromyography Complications Respiratory cardiac failure contracture deformities disuse atrophy overweight No effective treatment Corticosteriods Goal - maintain function keep active range of motion exercises surgery for contractures Bracing Genetic Counseling autosomal dominant (X-linked)
Bacterial meningitis- Health history pg. 1336 (SELECT ALL)
Elicit a description of the present illness and chief com-plaint. Common signs and symptoms reported during the health history might include: -Sudden onset of symptoms -Preceding respiratory illness or sore throat-Presence of fever, chills -Headache -Vomiting -Photophobia -Stiff neck -Rash -Irritability -Drowsiness -Lethargy -Muscle rigidity -Seizures Symptoms in infants can be more subtle and atypical, but the history may reveal: -Poor sucking and feeding -Weak cry -Lethargy -Vomiting Explore the child's current and past medical history for risk factors such as: -Young age: 1 month to 5 years, with most cases in children younger than 1 year of age and young adults 15 to 24 years of age -Any fever or illness during pregnancy or around delivery (for infants younger than 3 months of age)-Exposure to ill persons -Exposure to tuberculosis -Travel history -History of maternal illness -Recent neurosurgical procedure or head trauma-Presence of a foreign body, such as a shunt or a cochlear implant -Immunocompromised status -Close-contact living spaces such as dormitories or military bases -Day care attendance
Osteomyelitis signs and symptoms pg. 1655
Explore the health history for risk factors and symptoms. Risk factors include impetigo, infected varicella lesions, furunculosis, recent trauma, infected burns, and prolonged intravenous line use. Obtain history of current or recent antibiotic therapy and response. Note history of irritability, lethargy, possible fever, and onset of pain or change in activity level. The child usually refuses to walk and demonstrates decreased range of motion in the affected extremity. Inspect the affected extremity for swelling. Palpate for local warmth and tenderness. Note point tenderness over affected bone. Laboratory and diagnostic testing may reveal: -Elevated white blood cell count, erythrocyte sedimentation rate, and C-reactive protein level -Positive blood cultures -Deep soft tissue swelling on radiography -Changes on ultrasound or CT scan
Effects of chemotherapy slide 46 neoplastic lecture (SELECT ALL)
Mucosal Ulceration • Oral - (compounds anorexia) • bland, moist, soft diet • soft toothrush • mouthwashes, local anesthetics, anti-microbials Rectal • hygiene • occlusive ointment/dressing • attention to bowel movements Anorexia • Nausea & Vomiting • administer anti-emetics BEFORE chemo • Zofran and dexamethasone attention to bowel movements
Nursing management fracture pg. 1663 (SELECT ALL)
Immediately after the injury, immobilize the limb above and below the site of injury in the most comfortable position with a splint. Use cold therapy to reduce swelling in the first 48 hours after injury. Elevate the injured extremity above the level of the heart. Perform frequent neurovascular checks. *Assess the injured, splinted, or casted extremity frequently for the "5 P's," which may indicate compartment syndrome: pain (increased out of proportion), pulselessness, pallor, paresthesia, and paralysis. Report these findings immediately.* Assess pain level and administer pain medications as needed. Utilize nonpharmacologic methods of pain relief as needed. Administer tetanus vaccine in the child with an open fracture if he or she has not received a tetanus booster within the past 5 years. Additional nursing interventions include providing family education and teaching on fracture prevention.
Table 50.2 stages of Leukemia treatment pg. 1839
Induction -Purpose: Rapid induction of complete remission -Length: 3-4 weeks -Usual medications: oral steroids, IV vincristine, IM L-asparaginase, daunomycin (high risk) Consolidation (intensification) -Purpose: strengthen remission, reduce leukemic cell burden -Length: varies -Usual medications: high-dose methotrexate, 6-mercaptopurine; possibly cyclophosphamide, cytarabine, asparaginase, thioguanine, epipodophyllotoxins Maintenance -Purpose: eliminate all residual leukemic cells -Length: 2-3 years -Usual medications: low dose: daily 6-mercaptopurine, weekly methotrexate, intermittent IV vincristine and oral steroids CNS prophylaxis -Purpose: reduce risk of development of CNS disease -Length: given periodically in all stages -Usual medications: intrathecal chemotherapy; cranial radiation is used infrequently
According to development age chart ATI pg. 98
Infants/toddlers (birth to 3 years) › Have little to no concept of death › Egocentric thinking prevents their understanding death (toddlers) › Mirror parental emotions (sadness, anger, depression, anxiety) › React in response to the changes brought about by being in the hospital (change of routine, painful procedures, immobilization, less independence, separation from family) › May regress to an earlier stage of behavior Preschool children (3 to 6 years) › Egocentric thinking › Magical thinking allows for the belief that thoughts can cause an event such as death (as a result, child may feel guilt and shame) › Interpret separation from parents as punishment for bad behavior › View dying as temporary because of the lack of a concept of time and because the dead person may still have attributes of the living (sleeping, eating, breathing) School-age children (6 to 12 years) › Start to respond to logical or factual explanations › Begin to have an adult concept of death (inevitable, irreversible, universal), which generally applies to older school-age children (9 to 12 years) › Experience fear of the disease process, the death process, the unknown, and loss of control › Fear often displayed through uncooperative behavior › May be curious about funeral services and what happens to the body after death Adolescents (12 to 20 years) › May have an adult like concept of death › May have difficulty accepting death because they are discovering who they are, establishing an identity, and dealing with issues of puberty › Rely more on peers than the influence of parents, which may result in the reality of a serious illness causing adolescents to feel isolated › May be unable to relate to peers and communicate with parents › May become increasingly stressed by changes in physical appearance due to medications or illness than the prospect of death › May experience guilt and shame
Adequate nutrition for child undergoing chemotherapy pg. 1828
NURSING DIAGNOSIS: Imbalanced nutrition: less than body requirements related to anorexia, nausea, vomiting, or mucosal irritation associated with chemotherapy or radiation as evidenced by decreased oral intake and weight, length/height, and/or body mass index (BMI) below average for age or individual child's usual measures. Outcome Identification and Evaluation: Child will improve nutritional intake, resulting in steady increase in weight and length/height. Interventions: Promoting Adequate Nutrition-Determine body weight and length/height norm for age or find out what the child's pretreatment measurements were to determine goal to work toward. -Determine child's food preferences and provide favorite foods as able to increase the likelihood that the child will consume adequate amounts of foods.-Administer antiemetics as ordered to increase the likelihood that the child will retain the food he or she ingests. -Weigh child daily or weekly (according to physician order or institutional standard) and measure length/height weekly to monitor for growth. -Offer highest-calorie meals at the time of day when the child's appetite is the greatest to increase likelihood of increased caloric intake. -Provide increased-calorie shakes or puddings within diet restriction: high-calorie foods increase weight gain. -Administer vitamin and mineral supplements as prescribed to attain/maintain vitamin and mineral balance in the body. -Administer total parenteral nutrition and intravenous lipids as ordered to provide adequate nutrition for healing.
Seizure precautions nursing care plan (preventing injury) pg. 1316 SELECT ALL
NURSING DIAGNOSIS: Risk for injury related to altered level of consciousness, weakness, dizziness, ataxia, loss of muscle coordination secondary to seizure activity. Outcome Identification and Evaluation: Child will remain free of injury as evidenced by no signs of aspiration or traumatic injury. Interventions: Preventing Injury -Ensure child has patent airway and adequate oxygenation (have suction, oxygen available at bedside) and place child in side-lying position if possible: a child with altered level of consciousness may not be able to manage his or her secretions and is at risk for aspiration and ineffective airway clearance; providing suction and oxygenation can help ensure an open airway and the side-lying position can help secretions drain and prevent obstruction of airway or aspiration. -Protect child from hurting self during seizures or changes in level of consciousness by removing environmental obstacles, easing child to lying position, and padding side rails: helps to keep environment safe. -Institute seizure precautions for any child at risk for seizure activity (see Box 38.2) to help prevent injury that can result from acute seizure activity. -With seizure activity do not insert a tongue blade or restrain child: can lead to injury to caregiver and child. -Administer anticonvulsant medications as ordered: will help to promote cessation and prevention of seizure activity. -Assist child with ambulation to help prevent injury in child with weakness, dizziness, or ataxia. -Allow for periods of rest to prevent fatigue and decrease risk of injury.
Neuroblastoma content pg. 1846 read
Neuroblastoma, a tumor that arises from embryonic neural crest cells, is the most common extracranial solid tumor in children. Occurs frequently in the abdomen, mainly in the adrenal gland, but it may occur anywhere along the paravertebral sympathetic chain in the chest or retroperitoneum. Metastasis to the bone is a worse prognostic factor than metastasis to the skin, liver, or bone marrow. Must be removed surgically. Radiation and chemotherapy are administered to all children except those with stage I disease, in whom the tumor is completely resected. Health history and physical examination: Often parents are the first to notice a swollen or asymmetric abdomen. Health history on bowel or bladder dysfunction, especially watery diarrhea, neurologic symptoms, bone pain, anorexia, vomiting, or weight loss. Note neck or facial swelling, bruising above the eyes, or edema around the eyes (metastasis to skull bones). Inspect skin for pallor or bruising (bone marrow metastasis) and document cough or difficulty breathing. Auscultate the lungs for wheezing. Palpate for lymphadenopathy, especially cervical. Palpate the abdomen, noting a firm, nontender mass. Palpate for and note hepatomegaly or splenomegaly if present. Laboratory and diagnostic testing: -CT scan or MRI to determine site of tumor and evidence of metastasis -Chest radiograph, bone scan, and skeletal survey to identify metastasis -Bone marrow aspiration and biopsy to determine metastasis to the bone marrow -24-hour urine collection for homovanillic acid (HVA) and vanillylmandelic acid (VMA); levels will be elevated
Visual impairment treatment ATI pg. 139-140
Nursing Care: -Maintain normal to bright lighting for the child when reading, writing, or participating in any activity that requires close vision. -Assess infants and children for visual impairments, and identify children that are high-risk. -Observe for behaviors that suggest vision loss or decrease. -Promote child's optimal development and parent-child attachment. -Identify safety hazards, and prevent injury to the eyes (helmets, safety glasses). -Provide information regarding laser surgery for clients who have myopia, hyperopia, or astigmatism. Inform the child and family about corrective measures: -Myopia: biconcave lenses, laser surgery -Hyperopia: convex lenses, laser surgery -Astigmatism: special lenses that compensate for refractive errors, laser surgery -Anisometropia: special lenses that compensate for the refractive errors, preferably corrective contacts, laser surgery -Amblyopia: treat primary visual defect -Strabismus: occlusion therapy (patch stronger eye), surgery -Cataracts and glaucoma: surgery Caring for a child who has lost her vision -Reassure the child and family. -Orient the child to the surroundings and provide a safe environment. -Promote independence and meeting developmental milestones while assisting with play and socialization. -Refer to educational services for visual impairment (Braille, audio tapes, special computers).
Neurovascular assessment MS power point slides 10-16
Pain: Does it occur with palpation? Does it occur with movement? Is it intermittent or constant? How does it rate on the pain scale? Does anything relieve it? Pallor: Color? Capillary refill? Paraesthesia: Pins and needles sensation Where is it? Does it come and go? Does anything relieve it? Does anything make it worse Pulses: Check above and below the fracture Full? Diminished? Absent? Paralysis: Can the patient move the affected part? Do NOT attempt to move the limb yourself Pressure: Does the patient complain of pressure? Is the skin taught? May indicate actual/impending compartment syndrome (a life/limb threatening condition)
Epilepsy- Dilantin (phenytoin) side effects
Pharmacology book pg. 158: -CNS effects (nystagmus, sedation, ataxia, double vision, cognitive impairment) -Gingival hyperplasia (softening and overgrowth of gum tissue, tenderness, and bleeding gums) -Skin rash -Teratogenic (cleft palate, heart defects) -Cardiovascular effects (dysrhythmias, hypotension) -Endocrine and other effects (coarsening of facial features, hirsutism, and interference with vitamin D metabolism) -Interference with vitamin K-dependent clotting factors causing bleeding in newborns Nursing consideration (Big Book) -Monitor serum levels to ensure therapeutic dosing. -Be aware that gingival hyperplasia appears most commonly in children and adolescents. -If on prolonged therapy, ensure adequate intake of vitamin D-containing foods. Monitor serum calcium and magnesium levels. -IV form given in normal saline to prevent precipitation
Reye's syndrome pg. 1340
Reye syndrome is a disease that primarily affects children younger than 15 years of age who are recovering from a viral illness. It has been found that Reye syndrome is a reaction that is triggered by the use of salicylates or salicylate-containing products to treat a viral infection. This reaction causes brain swelling, liver failure, and death in hours if treatment in not initiated. Common signs and symptoms reported during the health history might include: severe and continual vomiting, changes in mental status, lethargy, irritability, confusion, hyperreflexia. Explore the child's current and past medical history for risk factors such as: a prodromal viral illness, like chickenpox, croup, flu, or an upper respiratory infection; ingestion of salicylate-containing products within 3 weeks of the start of the viral illness. Elevated liver function tests and elevated serum ammonia levels can confirm diagnosis. Nursing management is aimed at maintaining cerebral perfusion, managing and preventing increased ICP, providing safety measures due to changes in LOC and risk for seizures, and monitoring fluid status to prevent dehydration and overhydration. Salicylates are found in many products, including many over-the-counter products such as AlkaSeltzer and Pepto-Bismol.
Care of a child in a spica cast pg. 1638
Slide 48 Musculoskeletal -Toys that are small enough to "hide" in the cast should not be given to the child. -It is important to meet everyday needs. -A special wagon, with pillows inside it for support, is one of the safest ways to transport a child in a spica cast. ATI pg. 311 -Keep the casts elevated until dry. -Encourage frequent position changes to allow for drying. -Handle the casts with the palm of the hand until dry. -Note color and temperature of toes on casted extremity. -Give sponge baths to avoid wetting the cast. -Use a waterproof barrier around the genital opening of spica cast to prevent soiling with urine or feces. -Educate regarding care after discharge with emphasis on using appropriate equipment (stroller, wagon, car seat) for maintaining mobility.
Neuroblastoma- staging table 50.5 and content pg. 1846
Stage I: Tumor confined to organ or structure of origin Stage II: Tumor extends beyond organ or structure, not beyond midline ("A" negative lymph nodes, "B" regional nodes on same side involved). Stage III: Tumor invasively extends beyond the midline with bilateral lymph node involvement. Stage IV: Metastasis to bone, bone marrow, other organs, distant lymph nodes Stage IV-S: Tumor would have been considered a stage I or II, but remote metastasis to one or more sites (liver, skin, or bone marrow) has occurred without metastasis to the bone.
Staging of Wilms Tumor
Stage I: unilateral, limited to kidney, completely resectable Stage II: unilateral, tumor extends beyond kidney but is completely resectable Stage III: unilateral, tumor has spread outside of kidney, located in abdominal cavity only, not fully removed Stage IV: unilateral with metastasis in liver, lung, bone, or brain Stage V: bilateral kidney involvement
Myelomeningocele discharge teaching pg. 1605 (SELECT ALL)
Teaching should begin immediately in the hospital. Teaching should include positioning, preventing infection, feeding, promoting urinary elimination through clean intermittent catheterization, preventing latex allergy, and identifying the signs and symptoms of complications such as increased ICP. Due to the chronic nature of this condition, long-term planning needs to begin in the hospital. These children usually require multiple surgical procedures and hospitalizations, and this can place stress on the family and their finances. The nurse has an important role in providing ongoing education about the illness and its treatments and the plan of care. As the family becomes more comfortable with the condition, they will become the experts in the child's care. Respect and recognize the family's changing needs. Providing intense daily care can take its toll on a family, and continual support and encouragement are needed. Myelomeningocele is a type of spina bifida cystica, and clinically the term "spina bifida" is often used to refer to myelomeningocele. It may be diagnosed in utero via ultrasound. Otherwise it is visually obvious at birth. The newborn with myelomeningocele is at increased risk for meningitis, hypoxia, and hemorrhage. In myelomeningocele, the spinal cord often ends at the point of the defect, resulting in absent motor and sensory function beyond that point .
Checklist for the patient in traction Slide 33 MS power point (SELECT ALL)
The checklist for a traction apparatus includes the following: -Weights are hanging freely -Weights are out of reach of the child -Ropes are on the pulleys -Knots are not resting against pulleys -Bed linens are not on traction ropes -Countertraction is in place -Apparatus does not touch foot of bed -Body in alignment -HOB no higher than 20 degrees -Heels of feet elevated from bed -ROM of unaffected parts checked at regular intervals -Antiembolism stockings or foot pumps in place as ordered -Neurovascular checks performed regularly and recorded -Skin integrity monitored regularly and recorded -Pain relieved by medication is recorded -Measures to prevent constipation are provided -Use of trapeze for change of position is encouraged
Bone growth and the epiphysis pg. 1626
The ends of the bones in young children are composed of the epiphysis, the end of a long bone, and the physis, in combination termed the growth plate. In infants, the epiphyses are cartilaginous and ossify over time. In children, the epiphysis is the secondary ossification center at the end of the bone. The physis is a cartilaginous area between the epiphysis and the metaphysis. Growth of the bones occurs primarily in the epiphyseal region. This area is vulnerable and structurally weak. Traumatic force applied to the epiphysis during injury may result in fracture in that area of the bone. Epiphyseal injury may result in early, incomplete, or partial closure of the growth plate, leading to deformity or shortening of the bone. Epiphyseal growth continues until skeletal maturity is reached during adolescence. Production of androgens in adolescence gradually causes the growth plates to fuse, and thus long bone growth is complete.
Head injury/ head size pg. 1303
The head of the infant and young child is large in proportion to the body. The head of an infant accounts for a quarter of the body height; in adults it accounts for one eighth of the body height (Fig. 38.1). In addition, the infant's and child's neck muscles are not well developed. Both of these differences lead to an increased incidence of head injury from falls. The head is the fastest growing body part during infancy and continues to grow until the child is 5 years old.
Scoliosis assessment pg. 1658 (SELECT ALL)
The physical assessment of a child with possible or actual scoliosis involves mainly inspection and observation. Auscultate the heart and lungs to determine compromise related to severe curvature. Observe the child at rest, sitting, and standing for evidence of poor posture. Inspect the child's back in a standing position. Note asymmetries such as shoulder elevation, prominence of one scapula, uneven curve at the waistline, or a rib hump on one side. Measure shoulder levels from the floor to the acromioclavicular joints. Note the difference between the height of the high and low shoulder in centimeters. Measure heights of anterior and posterior iliac spines and note the difference in centimeters. View the child from the side, noting abnormalities in the spinal curve. With the child bending forward, arms hanging freely, note asymmetry of the back (pronounced hump on one side). Note leg-length discrepancy if present. During the neurologic examination, balance, motor strength, sensation, and reflexes should all be normal.
Wilms tumor pg. 1849-1850 read
Wilms tumor is the most common renal tumor and the fourth most common solid tumor in children. It usually affects only one kidney. The etiology is unknown, but some cases occur via genetic inheritance. Wilms tumor demonstrates rapid growth and is usually large at diagnosis. Metastasis occurs via direct extension or through the bloodstream. Wilms tumor most commonly metastasizes to the perirenal tissues, liver, diaphragm, lungs, abdominal muscles, and lymph nodes. Complications include metastasis or complications from radiation therapy such as liver or renal damage, female sterility, bowel obstruction, pneumonia, or scoliosis. Therapeutic Management: Surgical removal of the tumor and affected kidney (nephrectomy) is the treatment of choice and also allows for accurate staging and assessment of tumor spread. Radiation or chemotherapy may be administered either before or after surgery. Parents typically initially observe the abdominal mass. Note abdominal pain, which may be related to rapid tumor growth. Document history of constipation, vomiting, anorexia, weight loss, or difficulty breathing. Determine risk factors such as hemihypertrophy of the spine, Beckwith-Wiedemann syndrome, genitourinary anomalies, absence of the iris, or family history of cancer. Measure blood pressure; hypertension occurs in 25% of children with Wilms tumor. Inspect the abdomen for asymmetry or a visible mass. Auscultate the lungs for adventitious breath sounds associated with tumor metastasis. Palpate for lymphadenopathy. *Avoid palpating the abdomen after the initial assessment preoperatively. Wilms tumor is highly vascular and soft, so excessive handling of the tumor may result in tumor seeding and metastasis.* Laboratory and diagnostic testing may include:-Renal or abdominal ultrasound to assess the tumor and the contralateral kidney -CT scan or MRI of the abdomen and chest to deter-mine local spread to lymph nodes or adjacent organs, as well as any distant metastasis -Complete blood count, BUN, and creatinine: usually within normal limits -Urinalysis: may reveal hematuria or leukocytes -24-hour urine collection for HVA and VMA to distinguish the tumor from neuroblastoma (levels will not be elevated with Wilms tumor) *To avoid injuring the remaining kidney, children with a single kidney should not play contact sports.*
Signs of increased intracranial pressure-teaching guidelines pg. 1343-1344 slides 9 Neuro power point (SELECT ALL)
• Stay with the child for the first 24 hours and be ready to take the child to the hospital if necessary. • Wake the child every 2 hours to ensure that he or she moves normally, wakes enough to recognize the caregiver, and responds to the caregiver appropriately. • Closely observe the child for a few days. • Call the medical provider or bring child to the emergency room if the child exhibits any of the following: -constant headache that gets worse -slurred speech -dizziness that does not go away or happens repeatedly -extreme irritability or other abnormal behavior -vomiting more than two times -clumsiness or difficulty walking -oozing blood or watery, fluid from ears or nose -difficulty waking up, unequal-sized pupils -unusual paleness that lasts longer than 1 hour -seizures -review signs and symptoms of increased intracranial pressure and provide parents with a number they can call if they have questions or concerns. Power point slide 9: Sunsetting is when the sclera of the eyes is showing over the top of the iris. Sunset eyes may indicate increased ICP as seen in hydrocephalus. Pupillary response is often abnormal when a neurologic disorder is present. Early Signs : headache, vomiting, possibly projectile, decreased motor and sensory responses, blurred vision, double vision (diplopia), bradycardia, dizziness, irregular respirations, decreased pulse and respirations, increased blood pressure or pulse pressure, pupil reaction time decreased and unequal, sunset eyes, changes in level of consciousness, irritability, seizure activity In infant will also see: bulging, tense fontanel, wide sutures and increased head circumference, dilated scalp veins, high-pitched cry Late signs: Lowered level of consciousness, decreased motor and sensory responses, bradycardia, irregular respirations, Cheyne-Stokes respirations, decerebrate or decorticate posturing, fixed and dilated pupils
Strabismus - Esotropia (inward deviation of eye); Exotropia (outward deviation of eye)
›› Abnormal corneal light reflex or cover test ›› Misaligned eyes ›› Frowning or squinting ›› Difficulty seeing print clearly ›› One eye closed to enable better vision ›› Head tilted to one side ›› Headache, dizziness, diplopia, photophobia, and crossed eyes
Cataracts
›› Decreased ability to see clearly ›› Possible loss of peripheral vision ›› Nystagmus ›› Strabismus ›› Gray opacity of the lens ›› Absence of red reflex
Anisometropia
›› Different refractive strength in each eye ›› Headache and vertigo ›› Excessive eye rubbing ›› Poor school performance
Glaucoma
›› Loss of peripheral vision ›› Perception of halos around objects ›› Red eye ›› Excessive tearing (epiphora) ›› Photophobia ›› Spasmodic winking (blepharospasm) ›› Corneal haziness ›› Enlargement of the eyeball (buphthalmos) ›› Possible pain
Amblyopia (lazy eye)
›› Reduced visual acuity in one eye
Myopia (nearsightedness)
›› Sees close objects clearly, but not objects in the distance ›› Headaches and vertigo ›› Eye rubbing ›› Difficulty reading ›› Clumsiness (frequently walking into objects) ›› Poor school performance
Hyperopia (farsightedness)
›› Sees distant objects clearly, but not objects that are close ›› Because of accommodation, not usually detected until age 7
Astigmatism
›› Uneven vision in which only parts of letters on a page may be seen ›› Headache and vertigo ›› The appearance of normal vision because tilting the head enables all letters to be seen
Cast care pg. 1638 Teaching guidelines- compartment syndrome
● For the first 48 hours, elevate the extremity above the level of the heart and apply cold therapy for 20 to 30 minutes, then off 1 hour, and repeat. ● Assess for swelling, and have the child wiggle the fingers or toes hourly. ● For itching inside the cast: -Never insert anything into the cast for the purposes of scratching. -Blow cool air in from a hair dryer set on the lowest setting or tap lightly on the cast. -Do not use lotions or powders. ● Protect the cast from wetness. -Apply a plastic bag around cast and tape securely for bathing or showering. -Continue to avoid placing the cast directly in water (unless it is Gore-Tex lined). -Cover it when your child eats or drinks. If a cast become soiled it can be wiped clean with a slightly damp clean cloth. -If the cast gets wet, dry it with a blow dryer on the cold setting (if warm setting is used the child could get burned). ● If the child has a large cast, change position every 2 hours during the day and while sleeping change position as often as possible. ●Check the skin for irritation. -Press the skin back around edges of the cast. -Use a flashlight to look for reddened or irritated areas. -Feel for blisters or sores. ● Call the physician or nurse practitioner if: -The casted extremity is cool to the touch, pale, blue, or very swollen. -The child cannot move the fingers or toes. -Severe pain occurs when the child attempts to move the fingers or toes. -Persistent numbness or tingling occurs. -Drainage or a foul smell comes from under the cast. -Severe itching occurs inside the cast. -The child runs a fever greater than 101.5°F for longer than 24 hours. -Skin edges are red and swollen or exhibit break-down. -Child complains of rubbing or burning under cast. -The cast gets wet or is cracked, split, or softened.
