SCHOOL OF NURSING AND MIDWIFERY

PAEDIATRIC NURSING: NURU 2104

CREDIT HOURS: 6 CREDITS
Course Purpose
By the end of the unit the student should be able to apply the concept of family centered care in
managing children suffering from childhood diseases/conditions
Expected Learning outcomes
At the end of the unit, the student will be able to:
1. Describe the principles and concepts of paediatric nursing
2. Describe child growth and development
3. Describe the paediatric variations of health assessment
4. Describe the nursing management of the hospitalized child
5. Manage children at health risk (vulnerable children)
6. Describe the nursing care of the dying child
7. Discuss fluid and electrolyte alterations in children
8. Describe the management of various systemic diseases/conditions affecting children
9. Describe the management of paediatric emergencies
WEEK TOPIC SUB-TOPIC METHOD

1. Introduction to - Definition of concepts; Lecture

paediatrics paediatrics, child health

- Principles and concepts of

paediatric nursing family
centered care

- A traumatic care

- Impacts of childhood illness

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 and hospitalization.

2. Theories - Casey’s model, Ahmann’s Lecture

theory
Discussion
- Growth and development

- theories of growth and

development

- developmental millstones

3. Paediatric health - Nutrition in children Lecture

assessment
- nutritional requirements Discussion

- nutritional disorders

4. Preventive - Immunization Lecture

Paediatrics
- dental care Discussion

- Safety paediatric
techniques/skills

5. Management of - Respiratory problems Lecture

conditions in infants
- hematological conditions
and children

6. Management of - cardio-vascular conditions Lecture

conditions in infants
- Gastro- intestinal disorders
and children
- Genito-urinary tract
disorders

7. Management of - Dermatological disorders Lecture

conditions in infants
- fungal, viral, bacterial Discussion
and children
- impetigo

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 - Parasitic

- Papulosquamal reactions
dermatitis/eczema

8. CAT

9. Management of - Dermatological disorders Lecture

conditions in infants
- disorders of pigmentation- Discussion
and children
albinism

- Burns

- metabolic disorders

10. Management of - Ophthalmologic disorders Lecture

conditions in infants
- Ear, nose & throat (ENT) Discussion
and children

11. Management of - connective tissue disorder Lecture

conditions in infants Discussion
- Neurologic disorders
and children
- Orthopaedic conditions

- Paediatric oncology

12. Paediatric - Integrated management of Lecture

emergencies childhood illnesses (IMCI)
Discussion
- At risk children

- Genetic counseling

- abused child

- Substance dependent
mother

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13. Paediatric - the dying child; family Lecture
emergencies influence on child health

- Care of the terminally ill

and end-of-life care

14. END OF TRIMESTER EXAMINATION

Instructional Material and /or Equipment

Overhead projector, Power point, Flip charts, Handouts, Books
Course Evaluation
Class presentation 5%
Continuous Assessment Tests (CAT) 15%
Course assignment 10%
Trimester examination 70%
Total 100%
Teaching / Learning Methodologies
Parthasarathy, et al. (1999) IAP Textbook of Pediatrics.
New Delhi, Jaypee Brothers.
Whaley L F and Wong D L (1999). Nursing Care of Infants and children (6thedn.), St.
Louis, Mosby.
Skale N (1992).
Manual of Pediatric Nursing Procedures.Philadelphia, J.B. Lippincott.
Parthasarathy, et al. (1999) IAP Textbook of Pediatrics. New Delhi, Jaypee Brothers.
Whaley L F and Wong D L (1999). Nursing Care of Infants and children (6thedn.),
St. Louis, Mosby. Skale N (1992).Manual of Pediatric Nursing Procedures.Philadelphia,
J.B. Lippincott.
APROVED
BY……………………………………………….DATE………………………………
REVISED SEPTEMBER 2022

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INTRODUCTION
Children are not small adults but special individuals with unique minds, bodies and needs.
Different children have different developmental needs ranging from communication, nutrition,
safety, sexuality and self-esteem, dental, sleep which the nurse ensures are maintained and
promoted. For this to happen the nurse should assume a holistic and family centered approach.
Health, as defined by WHO (1999) is a complete state of wellbeing in the body, mind and spirit.
Therefore, we emphasis on promotion of physical, emotional, psychosocial, mental and spiritual
well being
The child is an essential member of a family setting. Anything that affects the family affects the
child and vice versa. Nursing care is most effective when it is delivered with the belief that the
family is the patient. The child health is enhancing when the family is fully functioning, health
promoting system. The family has the potential to provide a caring and supportive environment
in which the child can grow, mature and maximize his/her human potential. Furthermore; you
will appreciate the challenges caring for children and their families at the dawn of 21st century.
Contemporary and cultural influences like technological advances, reform in the delivery of
health care, efforts to control costs, raising levels of poverty, social changes have greatly
impacted on children and their families. These calls for rethinking the structure and provision of
paediatric nursing services. Providing nursing to children will be more effective when you the
learner are aware of the pressure and problems confronting children and their families. For
example, there is emphasizing on solving medical and social problems using preventive
strategies.

INTROODUCTION TO PAEDIATRIC NURSING

Paediatric is concerned with health of infant, children and adolescents
It includes the five stages of development according to Eric Erickson. Thus, infancy, toddler,
pre-school, school and adolescent. It focusses on their growth and development to ensure they
are given the opportunities to achieve their full potential as adults.
The young are most vulnerable or disadvantaged in the society hence need special attention.
Children are individuals, not little adults who must be seen as part of the family. Child health
needs to be approached from a holistic and family centered approach. There are many challenges
to paediatric care in the system: costs, poverty – especially in 3rd world countries. Most causes
e.g. morbidity/mortality in these countries are preventable or easily treatable; drug abuse &
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alcohol abuse; physical, emotional and sexual abuse; and civil strife – many parts of sub-Saharan
Africa. May contemporary social changes have taken place and these have impacted on children
on different ways. Providing paediatric care to children and families requires knowledge of
different dynamics that influence it in contemporary society. Examples of such changes include:
parenting styles; nature and structure of families; break down of traditional family systems’
eating habits; level of activity; information acquisition means adoption of western cultures
technical advancement.
Remember
Child health has changed from curative approach to preventive & promotive model. Nurses play
a major role here to ensure that children are healthy i.e. health indictors e.g. nutrition,
immunization, access to healthcare, environmental quality, mental health, tobacco, injury and
violence. Therefore, care of children and their families is increasingly complex especially in the
21st century considering the above problems among others; which the paediatric nurse should be
ready to confront.
The child in the context of the family
No other factor in a child’s life has a greater influence than the family, which is the first and the
most important socializing agent in one’s life successful socialization is the process by which
`children acquire beliefs, values and behaviors deemed significant to the society , this is a
function of parenting and other familial interactions. The family’s organization, structure and
function have significant impact on children during growth and development, nurses caring for
the children should consider the entire family rather than just a child as a client. The nurse looks
at the family from two perspectives; one, the family is viewed as a context within which the
individuals are assessed and managed. The second, views is that of a family as a set of inter
related parts which should function harmoniously. The assessment is on the whole unit of family
as the client rather than as an individual. In either case, the nurse must grasp the interacting
aspects of the family, to understand the context within which the individual lives and to which he
or she reacts opt to work with the family as a client. Children are members of families,
community’s populations and society. This shapes their context, experiences and opportunities of
their lives. Their well-being is inextricably linked to the families, communities and the society
they live. Many familial factors impact as children. Divorce; family size, absent fathers, working
mother’s sibling position and sex.

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The nurse should always use different family assessment tools to do a comprehensive family
assessment to judge the extent to which the family is meeting its roles in child rearing: based on
its stage of development
Critical thinking activity/learning activity
a) Revisit theoretical foundations of family nursing, with particular attention on the
development/life-cycle theory.
b) Revisit the concept of family assessment, with particular emphasis on models of
family assessment
c) How the changes have in a family: structure, roles among family members, size of
family
d) Is there a significant different between children raised by lesbian/gay parents and
those raised by heterosexual parents?
Culture and paediatric care
Culture is defined as learned, shared and interpretive forces that guide human interactions
and are transmitted from one generation to next. There are many cultures of the world
that is complex way to interact with paediatric practice/ nurses work in culturally diverse
environments which may be a great challenge. Culture influences every human endeavor
and therefore impact on child rearing patterns. If you work in diverse (culturally)
environment you need to be culturally informed and competent (knowledge and skills
needed to transcend cultural boundaries). Culture is more relevant to paediatric nursing
because it has a great opportunity to shape an individual’s lifelong perceptions of health
care and use health services. Through children, the health of population can be changed.
The meaning of cultural competence
Refers to the acquisition of knowledge and skills needed to transcend cultural boundaries.
Some cultures are obvious or marked e.g. Maasai dress others are not. Health care
provider may share same culture with patient but health beliefs & behaviors cannot be
assumed. The patient’s symptom definition & etiological explanations can shed a lot of
light on cultural belief system. If the care giver has to give explanations and clarifications
to counter any cultural barrier to care. For parents to cooperate in the care of the child,
clear clarifications should be given where there is cultural conflict. Some positive cultural
practices can also be identified & encouraged e.g. good eating habits. Child rearing
practices are diverse depending on the culture.
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Nurses need to be aware of their own attitudes and values regarding a way of life and
how these influence their attitudes and actions, including health practices. Nurses also
ought to be non-judgmental when working with families whose behaviors and attitudes
differ from or conflict with their own. This means that for nurses working with families
from cultures other than their own, the development of cultural sensitivity is paramount
in order to respond accurately and sensitively is to their needs to provide care. Cultural
sensitivity means having an awareness and appreciation of cultural influences in health
care and being respect in health care and being respectful of differences in cultural belief
systems and values nurses can be more effective in their work if they adopt a
multicultural perspective, which means using appropriate aspects of the family cultural
orientation to develop health care interventions cultural beliefs and practices should be
included during assessment. This enables recognition of beliefs and practices that may
impede/facilitate nursing interventions. Nurses should make themselves aware of any
specific attitudes regarding the manner of approach to a child in a given culture e.g. the
concept of the “evil eye” is common to many cultures throughout the world and serves to
explain the onset of illness in infants/children. Majority culture/minority of the nurse and
the patient and the patient may bring suspicion because of underlying mistrust e.g. caste
system in India, the white Australians and the Aborigines of Australia. Nurses should
know the characteristics of the culture /subculture of the community in which they
practice. They should resect these cultures and work with the community leaders to
enhance delivery of healthcare to children.
Critical thinking activity/learning activity
a) How can you as a nurse enhance your cultural competence?
b) Identify several challenges you have experienced during you nursing practice as a
result of cultural diversity among different ethnic groups.
Principles of paediatric nursing
There are certain basics that act as the basis of paediatric nursing
 Growth and development
 Health promotion
 Focus on the family
 Child advocacy
 Communication
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 LEGAL AND ETHICAL ISSUES OF PAEDIATRICS
Nurses are confronted by difficult ethical/legal decisions especially for nurses taking care
of children in critical care conditions e.g. does one resuscitation a child or not? Hence the
need to understand some legal/ethical guidelines that can resolve these dilemma.
Different governments have different legal laws and regulations. Though children have
right to informed consent. Usually, it’s the legal guardian or parents who take the
consent. Children are said to “Assent” i.e. paediatric client has been informed about the
procedure and is willing to permit it being informed. However, assent is not legally
required but important for child cooperation. It may maximize success of procedure and
minimize trauma to child.
When is informed consent not required?
 Emergency situations – emergency lifesaving procedures. But should be after
attempts have been made to contact parent or legal guardian. Adolescents can
consent.
 Forensic examination –where evidence is required. May not require informed
consent but still is vital for child’s assent. Minors can consent for care in a
number of situations
 Where a child mammy avoid care of caregivers were informed e.g. pregnancy,
drug abuse treatment, contraception, treatment of STIs.
 If minor is considered to be emancipated i.e. legal recognition that a minor lives
independently and is legally responsible for his or her own support and decision
making.
Refusal of medical care by parent/caregiver
Usually, this occurs if health care conflicts parent’s religious beliefs. Parents may refuse
to act to the best interests of the child. In such cases, the government may take legal
decision of the child.
The theory of parents’ patrie is applied. This is legal rule allowing government to make
decision in place of parents when they are unable or unwilling e.g. to provide for the best
interest of the child.
Confidentiality
Also vital for paediatric care especially for; STI, contraception, mental healthcare, drug
abuse, alcoholism and HIV testing
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 Breaching Confidentiality
This can be done in a number of situations, thus:
 Reporting child abuse
 Mandatory injury by criminal act or weapon
 Reporting infectious (notifiable) diseases to the local public health department
 When there is duty to warn 3rd party. The duty to breach confidentiality by
warning a 3rd party is required when there is a specific threat to an identified
person e.g. psychiatric case – patient tells a psychiatrist that he shall kill his
girlfriend but the psychiatrist dent warn the patient’s girlfriend. Then the
psychiatrist is guilty of an offence since he had the duty to warn the 3rd party
N/B: Nurses are legally and ethically responsible for keeping medical records and other
types of client’s communication confidential e.g. giving information over phone or media
need to be treated carefully. For electronic medical records, passwords and screensavers
can be used well to prevent unauthorized access to compute medical records.
i. The nurse must breach that duty
ii. The breach of duty must the cause of the damage/injury
iii. There must be actual damage to the client.
Duty: -special relationship created when a person agrees to provide care to client –
during that specific time e.g. shift.
Child Safety: - is a big concern because children are very vulnerable to
accidents/injuries.
Ethics: study of the nature and justification of principles that guide human behaviour and
that are applied when moral problems arise. Knowledge of ethical principles assist the nurse to
make decisions when confronted by dilemmas in ethics e.g. justice, informed consent etc.
Examples of ethical principles influencing healthcare:
Autonomy: right to freedom and self-determination. Individuals are not interchangeable.
Beneficence: principle of “doing good” for another. Competent health care is primary
goal of nurses e.g. may emphasize child brushing teeth, though refusing and crying.
Non Maleficence: doing no harm to the client or protecting the client from doing no
harm to self-e.g. not leaving paediatric client in acute distress
Justice: treating client with fairness despite creed, ethnicity etc.

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 Veracity: telling the truth about healthcare e.g. diagnosis and treatment especially in
terminal illness.
Fidelity: keeping ones promise or word e.g. takes a child to playroom at promised time.
Research on children
Appropriate laws, regulation and requirements need to be followed
One or both parents usually consent to research – based on potential risk vs. benefit to the
child. Nurses are advocates of the study participants (children) hence need to ensure that
their rights are not violated.
Confidentiality
Also vital for paediatric care especially for: STI, contraception, mental healthcare, drug
abuse & alcoholism, HIV testing
Breaching confidentiality
This can be done in a number of situations. Thus:
 Reporting child abuse
 Mandatory injury by criminal act or weapon
 Reporting infectious (notifiable) diseases to the local public health department.
 When there is duty to warn3rd party. The duty to breach confidentiality by
warning 3rd party required when there’s a specific threat to an identified person
e.g. psychiatric case – patient tells a psychiatrist that he shall kill his girlfriend but
the psychiatrist doesn’t warn the patient’s girlfriend. Then the psychiatrist is
guilty of an offense since he had the duty to warn the 3rd party.
Remember
Nurses are legally and ethically responsible for keeping medical records and other types
of client’s communication confidential e.g. giving information over phone or media need
to be treated carefully. For electronic medical records, passwords and screensavers can be
used well to prevent unauthorized access to compute medical records.
Malpractice and negligence
For court to recognize a claim of malpractice/negligence.
For legal elements must be present:
i. There must be a duty to the client by nurse
ii. The nurse must breach that duty
iii. The breach of duty must be the cause of the damage/injury
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 iv. There must be actual damage to the client
Duty: - special relationship created when a person agrees to provide care to a client during that
specific time e.g. shift.
Child safety: - is a big concern because children are very vulnerable to accidents/injuries
N/B: What you leant in this course “Theories and professionalism” as regards “Ethics” in
healthcare. However, in summary, note the following
Ethics: study of the nature and justification of principles that guide human Behaviour and that
are applied when moral problems arise. Knowledge of ethical principles assist the nurse to make
decisions when confronted by dilemmas in ethics e.g. justice, informed consent etc.
Examples of ethical principles influencing health care:
Autonomy: right to freedom and self-determination. Individuals are not interchangeable.
Beneficence: principle of “doing god” for another. Competent health care is primary goal of
nurses e.g. may emphasize child brushing teeth, though refusing & crying
Non maleficence: Doing no harm to the client or protecting the client from doing harm to self-
e.g. not leaving paediatric client in acute distress.
Justice: treating client with fairness despite creed, ethnicity etc.
Veracity: Telling the truth about healthcare e.g. diagnosis and treatment especially in terminal
illness.
Fidelity: Keeping ones promise or word e.g. takes a child to playroom at promised time.

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Critical thinking/learning activity
a) What are the provisions in Kenyan law as regards malpractice and negligence?
b) Cases of malpractice and negligence are very common in Kenya. Identify some
recent cases and discuss how they were handled. Which of those cases identified
involved the nurse?
c) Which professional bodies do protect the patient from malpractice and negligence
in Kenya?
Ethical Decision Making
Process of thinking through what you out to do in an orderly systematic manner to
provide justification for your actions based on principles. It is a rational way of resolving
ethical dilemmas in nursing practices e.g. allocation of healthcare resources; euthanasia:
genetic engineering, abortion; research involving fatal life; conflict between duties and
outcomes e.g. resuscitating a terminally ill. Conflict rights parents’ unconsciousness child
without truth vs. informed consent client’s autonomy vs. safety welfare concerns. It is
used in situations in which the right decision is not clear or in which there are conflicts of
rights and duties. These are part of the nursing practice and all situations are unique and
should be given due consideration. Each case should be treated with its own merit.
Ethical decision making process
This is a model framework for resolving ethical issues. It’s made of the following steps:
i. Collect information about situation
ii. State the dilemma
iii. List all possible causes of action for resolution.
iv. Analyze the advantages and disadvantages of each action
v. Make decision

PERSPPECTIVE ON PAEDIATRIC NURSING

These are central issues in paediatric nursing.
Family Central care: paediatric care involves care of children and their entire family.
Family centered care considers family contributions and involvement in the plan and
delivery of child care. It is a healthcare delivery model that seeks to fully involve family
in the care of children. The concept gained prominence on 1987 when research showed

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that children cared together with their families responded better than those cared with
little involvement of their families.
Characteristics of family centered care
 Policy recognition of need for family in child’s life.
 Enhance professional family based collaboration at all levels of care.
 Exchange of unbiased and complete information between family and
professionals.
 Incorporate into policy recognition of uniqueness of each family in race,
education, creed, culture and economic situations.
 Enhance family to family networking- social support especially families of
children with chronic illness/aged caretakers.
 Ensure home, hospital and community child health services are of high standards.
 Family centered care empowers the family in relation to their child care.
 The nurse should always look at how the child functions within the family and
how this influences his or her health. Gaps/deficits of care should be noted and
addressed.
 A traumatic care: care that minimizes or eliminates physical or psychological
distress for children and other families in the care environment. Many interns are
traumatic, stressful; painful hence the nurse should recognize them and provide
care that minimizes them.
Principles for the basis for a traumatic care
 Identify stress for child and family
 Minimize separation of child and care givers.
 Minimize or prevent pain.
Examples of a traumatic interventions include: prepare child/family before every
procedure especially surgery e.g. allow the child to play with the equipment, visit the
hospital prior to the surgery and reassurance; involve care givers to support the child,
control pain by administering analgesics freely and provide social support to the family
Role of the paediatric Nurse
Nurses provide quality care in all settings e.g. clinics, physician’s offices, home health
agencies, rehabilitation centers, hospice programs, day care centers and schools. The

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 primary roles of a nurse include: care giver, patient advocacy, health education,
researcher and manager/leader. Secondary roles include: coordinator, collaborator,
communicator and consultant. There could be more specialized roles depending on
training and country. Nurses many also have some advanced practice roles such as
practitioner, clinical nurse specialist and care manager.
Challenges of paediatric care in twenty first century.
There are many challenges facing care in the 21st century: increasing cost of paediatric
care, embracing information technology, lifestyle diseases and technology associated
health problems e.g. computer addiction among others.
CHILD AND FAMILY COMUNICATION
Student learning objectives
At the end of the chapter the learner should be able to:
a) Define communication and explain its importance in developing positive
relationship with children and their families
b) Discuss elements of communication, including rapport/trust, respect, empathy and
listening, providing feedback and conflict management
c) Describe the impact and challenges that a child’s development has on
communication.
d) Describe effective communication strategies that assist nurse’s work with infant
children and adolescents.
e) Discuss the impact that a person’s cultural background may have on their
communication patterns
f) Explain the concept of communicating with children who have special needs.
Effective communication among staff, children, their care givers and their families can
lead to enhanced understanding of child’s condition and active participation of family
caregiver. Effective communication is very basic central component to delivering
effective care to children and caregivers. Therefore: nurses need to use effective
communication skills in every interaction to: enhance cooperation of family and ensure
interventions are likely to be optional because of good rapport.
There are two basic modes of communication; formal/informal and verbal/nonverbal formal is an
organized communication with particular agenda e.g. health education during discharge. While
informal is when one talks without particular agenda/protocol.
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Usually occurs in day to day interactions. On the other hand, verbal communication is messages
communication through words/language. Lastly, non-verbal communication and transcend the
literal content of the message. It’s more apparent when emotions cause observable body changes.
Observe for congruency between verbal and non-verbal communication. If there is a
contradiction, yet listener usually believes nonverbal message rather than verbal message.
Nurse, Child and family communication
Nurses’ child to establish a therapeutic relationship is related to her communication abilities i.e.
abilities for therapeutic communication. It’s a vital tool for history taking, physical examination,
health education and maintaining adequate rapport with child/caregiver. It is the basic
requirement for family or caregiver centered paediatric care. There are certain considerations that
are vital for effective communication; rapport and trust, respect, empathy and listening. Listening
is so important that it requires special further discussion
Listening
It is providing verbal/non-verbal clues that communicate interest. It requires actively attending to
what is verbalized, observed and created by entire communication context. Encourages
expression of feelings and inputs. It considers developmental level of children and their
emotional Behaviour. Use developmentally appropriate language
The four Bs for effective listening:
 Be attentive and eliminate distractions
 Be clear about the message, clarify if necessary
 Be empathetic, convey concerned caring
 Be open minded, avoid prejudices
Provide feedback e.g. by nodding, reflecting back to client what was said; ask questions to
clarify, seek validation from the client to ensure one is talking about the same thing and follow
one single idea and explore it further. Conflict management – nurse should strive for win
approach so that child and care giver feel in control and can likely adhere to decisions arrived at.
Physical boundaries nurse creates and maintains them avoid emotional over-involvement and
overprotection e.g. exchanging gifts, personal contacts, sharing personal information. Don’t
interfere with relationship between care giver and child. Other skills useful in communicating
with children include: observing- observation skills useful for what clients don’t say e.g. eyes,
mouth, body movement, posture etc. silence interpreted based on context e.g. silent caregiver

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after diagnosis may indicate the client is experiencing shock/disbelief,: environment –
environment should reduce psychological stresses and should facilitate therapeutic relationship.
Humour is a healing and helps child cope with illness used when communication is
feared/offensive. Enhances therapeutic interactions. Helps child cope with hospitalization and
illness. Use appropriate humours during interactions; play- puppets, dolls, stuffed animals,
drawing pictures, story telling, engage child with play-closer interaction increases trust in nurse.
It also helps child relax and shed inhibitions. Development stage should be considered for
appropriateness for choice of play e.g. writing and drawing is good for older children. If children
write thoughts, feelings, it becomes easier to discuss them later. Evaluation of drawing/ writing
enables nurse understand children inner self.
Communication principles based on development level
Incorporate knowledge of gender language development level critical to this endeavor,
Infants: allow warm up to strangers, respond to cries timely, use soothing and calm voice, talk
to infant directly, crying, cooing, whining or body movement, face.
Toddlers: Approach carefully not to cause fear, integrate familiar objects in care, use dolls,
storytelling and picture books in conservation
Pre-school: Allow choices as appropriate, use play, story telling, speak honestly, simple
language, concise, prepare procedure 1-3 hours before they are done.
School age: use books, diagrams and videos in preparing for procedure. Prepare the procedure
many days before. Allow the child to express feelings.
Adolescent: prepare them one week before the procedure, provide respect and privacy. Use
creative methods to explain experiences and procedures. The ideal that they construct should be
merged with the real world by listening to them, Attentiveness, acceptance and freedom is
important for adolescents and should be provided. Do not trivialize information they think is
important for them.
Communicating with the care giver
Explain equipment and procedures thoroughly. Address the question and concerns of caregivers
honestly. Teach caregivers what to expect the child will look like and feel like during treatment.
Help care givers to understand the bigger picture that is long term/short term effect of treatment
e.g. Orchitis. Teach and allow the care giver to carry out as many aspects of child’s care as
feasible. Make reassurance as part of family interactions, ask care givers how they are doing as
time passes.
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Principles of defective communication in paediatric setting
 Talk to caregivers of effective commutation in paediatric setting
 Use objects (toys, dolls, stuffed animals) instead of questioning child directly.
 Provide privacy for older child.
 Use clear, specific single phrases in confident, quiet and unhurried speech
 Position – eye level.
 Allow expression of thoughts feelings
 Provide honest answers
 Offer choices only if they exist
 Use a variety of age – appropriate methods/techniques
Cultural impact on communication: cultural perspective for the family/children should be
considered. Be non-judgmental of any cultural values, belief of children/family. If care is
planned and implemented with child/caregiver it should be congruent with values system. Nurse
elicits this information during assessment that many impact on care.

THEORETICAL APPROOACHES TO GROWTH AND DEVELOPPMENT OF

CHILDREN
Learning objectives
At the end of the chapter the learner should be able to:
a) Identify and describe principles of human development
b) Explain how these theories are applied to the various theories of human development
c) Compare and contrast the major theories of human development
d) Explain how the major developmental issues can be applied to the theories of human
development
e) Apply the theories of human development to paediatric nursing practice.
Growth and development of children
Understanding human development is part of the nursing process. Knowledge of normal
behavior for specific groups allow for individualizing assessment and care plans – identify
delays/abnormal, counseling needs and treatment.
It enables the nurses to emphasize on:
 Promoting and maintaining health

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  Ant participatory guidance related to human development i.e. understanding upcoming
developmental needs and teaches care givers how to handle them to eliminate/minimize
their impact on the child.
 Help families and children achieve optimal health through appropriate interventions.
Let us differentiate some terms related to growth and development.
Growth and development: sum total of numerous changes that take place during the
lifetime of an individual.
Growth: physiological increase in size through cell multiplication of differentiation.
Quantitative change. Differentiation cell structure changes to achieve specific
physical/chemical properties seen through weight and height changes.
Maturation: changes that are due genetic inheritance rather than experiences, illness or
injury. These changes enable children to function at increasingly higher and more
sophisticated levels as they get older. There is increase in competence/adaptability
Development: s physiological, psychological, cognitive changes occurring over one’s
lifetime due to growth, maturation and learning; and assumes that orderly and specific
situations lead to new activities and behavior patterns.
The different ages and stages relevant to paediatric nursing (Erik Erikson)
 Birth – 1 year infant
 Toddler (early childhood) 1-3 years
 Preschool (late childhood) 3-6 years
 School age 6-12 years
 Adolescents 12-19/21 years
Other stages of development according to Erikson include: 20-45 years – young adult/early
adulthood, 45 – 65 years middle age/middle adulthood, 65 years + - death later maturity/late
adulthood.
Principals of growth and development
Provide frameworks for studying human development. Not all are proven by research but they
are assumed to be true.
1. development is orderly and sequential maturation follows a predictable and universal
timetable e.g. crawl walk run very rapid in infancy
2. Development in directional: skills development proceeds through two pathways i.e.
cephalocaudal and proximodistal. Cephalocaudal development proceeds from head
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 downwards. Areas close to brain /head develop first trunk legs –feet e.g. head control
sitting crawling – walking.
3. Development is unique for each child: each child has a unique timetable for
physiological, psychosocial; cognitive and moral development e.g. walk, crawl at
different stages.
4. Development is interrelated
Physiological, cognitive and moral development affect and is affected by one another e.g.
nervous system maturation necessary for (language) cognitive development
5. Development becomes increasingly differentiated. Response to stimuli becomes more
specific and skillful as the child grows e.g. infant react with whose body to pain – cry and
withdrawal, while older children withdrawal specific part/extremely affected e.g.
throwing a ball up- younger children throw even the hand. Older ones throw the ball
only.
6. Development becomes increasingly integrated and complex. New skills gained and
more complex task leaned e.g. learning to drink, eat eye hand coordination grasping hand
mouth coordination.
7. Children are competent. Possess qualities/abilities ensuring their survival and providing
their development e.g. communicates their needs in an increasingly sophisticated way.
8. New skills predominate: occur because of strong drive to practice & perfect new
abilities. This is especially in early age when cannot cope with many skills. Pay attention/
effort to one skill at a time e.g. walk, talk and eat from utensils.
Theories of human development
Human development can be viewed from various perspectives. None of the/theories coves all
aspects of development hence for planning of care all these theories are important. Each looks at
a particular area of human development and has assumptions principles, strengths and
weaknesses that can help guide practice.
The electric nature of human development
There are many perspective of human growth and development and search perspective has
underlying theories as can be seen below.
 Psychoanalytic perspective: psychosexual (S. Freud): Psychosocial (E. Erikson)
interpersonal (Sullivan)
 Cognitive structural perspectives: Moral – Kohberg; cognitive –piaget
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  Behavioral perspective: social leading, bandura Albert; Behaviorism – Pavlov, skinner
 Contextual perspective: Ecology theory – Bronfenbrenner
Theories and their contribution to human growth and development.
Sigmond Freud (1856 -1939) and psychosexual development.
He was a Viennese physician who originated psychosexual theory. It focuses on importance of
unconsciousness motivation and early childhood experiences in influencing Behaviour. This
theory postulates two basic biological instincts always compete for supremacy. (Freud, 1993).
Life instincts aim for survival hence responsible for activities like eating, breathing, copulation
(life-sustaining) and self-preservation behavior e.g. love, constructive conduct. Death instinct is
the destructive force expressed as hate, self-centeredness, cruel behavior, aggression and
destructive conduct. These instincts are the source of psychic energy that drive human behavior.
They have 3 components; ID, ego and super ego.
As a child matures these components of personality become more rational & reality bound
(Freud, 1933). At infancy all psychic energy resides in ID with its selfish urges. It obeys
‘pleasure principle’ – maximize pleasure and immediate gratification of needs.
Late ego takes over where there is rational controlling of personality. Operates according to the
‘reality principal’ as a reality ways of gratifying needs are discovered. Characteristic of ego
include: memory, cognition, intelligence, problem solving, compromising, separating reality
from fantasy. Ego develops through out life. Supper ego/conscience emerge when one
internalizes caregivers or social value, role, morals. Start developing an infancy but become clear
in per/school age when child learns socially acceptable behavior. It strives for perfection not
pleasure/reality. Right verses wrong is distinguished. Acts as disciplinarian by creating feelings
of remorse/guilt for breaking rules and self-praise/pride for obeying rules.
Freud saw sexuality in form of genital manifestation and any other kind of pleasure seeking
behavior. As the sex instinct psychic energy (libido) shifts from one part of the body to another,
the child passes through five stages of development. Each stage is related to specific body part
(erogenous zone) that brings primary pleasure to the child during this stage. According to Freud:
adult personality is profound impacted by how each stage is managed. Body centered sexual
drives shifts with maturation. The following are stage of psychosocial development according to
S. Freud.
 Oral: Birth year – satisfaction from oral needs being met. Attachment to mother because
of breastfeeding
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  Anal: 1-3 years – learning to control body functions especially toileting
 Phallic: 3 years – fascinated by gender difference Oedipus/Electra complex develops
 Latency: 6-11 years – sexual drives submerged. Appropriate gender roles adopted.
Learning about society takes place.
 Genital: 12 years and older – sexual desires directed towards opposite urges in societally
approved ways.
Application of paediatric care
There are some lessons that can be learned about growth and development from this theory
It helps understand others in that every behavior is meaningful and many indelicate inner
needs/conflicts e.g. pacifiers can be used in infancy if infant is not taking anything per mouth,
after painful procedures since pleasure obtained through the mouth. Additionally, it helps
understand about training which should start at 1-3 years when you should provide potty chair.
The sexual behavior of pre-school, school age and adolescent can be understood in the light of
this theory e.g. Masturbation, sexual curiosity is normal. Social relationship and observing
privacy during examinations vital for school age and adolescence. For school age and
adolescence, encourage them to have contact with friends and answer their question honestly.
Erikson (1902-1994) and psychosocial development
Erikson recognized importance of biological factors to development. But felt that environment,
culture and society were also important. His psychosocial (epigenetic) theory of development
stresses the complexity of interrelationships existing between emotional of physical variables of
one’s lifetime. (Erikson, 1963). Erikson agreed with Freud’s idea of personality (ID, ego and
super ego) and about instinct. Believed that development was as stage like revolution of conflict
at each stage was necessary for one to move to the nest stage. Freud’s and Erikson’s stages of
development are closely linked.
Difference
Erikson differ with Freud in that he believes children actually adapt and explore their
environment instead of being passively controlled and modelled by care giver and society.
Erikson also believes that human beings are rational creatures whose action, feelings and thought
is controlled primarily by ego instead of id, super ego and conflicts between the three
components of personality. He thought that lifespan development is made of 8 sequential stages.
The five of them describes life from infants through to adolescents. Each stage dominated by
major development conflict/crises related to societal demands and expectations that must be
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addressed or resolved before the individual can prosper to the nest stage. The resolution of each
conflicts/crisis might be positive – favorable and growth enhancing or negative – unfavorable,
frustrating and making later later developments difficult. He believed that major conflicts
occurring each stage are rarely completely resolved. Instead, they are of primary or dominant
importance during a particular stage and then become less important/dominant as other conflicts
arise in later stages. Also suggest that conflicts are rarely completely resolved positively. Rather
a true resolution predominant over negative during a particular stage. Failure to successfully
master a crisis or developmental task doesn’t destine the child to failure since delayed mastery is
possible. But difficult at are stage may affect progress through later stages (Erikson, 1963)
The stages of psychosocial development according to Erikson are as follows:
1. Trust verses mistrust: (1m – 1 ½ years) (infancy) – characterized by basic task is
established trust rather than mistrust in relation to oneself and others. If infant’s needs of
food, warmth, comfort are well met, he learns that the world is predictable, safe, and
reliable and can be trusted. If caregiver don’t provide above, infant get confused and view
environment which mistrust. This is demonstrated as restlessness, crying, whining, sleeps
disturbance, vomiting diarrhea (Erikson 1963)
2. Autonomy verses shame and doubt: 1 ½ - 3 years) (toddlers) – characterized by
autonomy develops and children discover their new mental and physical abilities,
language and motor skills improve. They can also bath, toilet, dress and eat. Shame
occurs if assertiveness and independence are considered unacceptable in effective by
caregivers. Doubt occurs if children learn not to mistrust not only themselves but also
others in the immediate environment. If a child shows dependency and constant approval
for their action then they haven’t resolved this conflict. (Erikson 1963)
3. Initiative verse guilt (3-6 years) initiative occurs when the child tries out new ways of
combining activities, invents creative ways to use skills and abilities and imagines what
other people or things are like and takes responsibility for their own actions. Guilt occurs
when care givers frequently reprimand behaviors reflecting initiative. Children
experiencing severe restrictions and belittling feel guilty about their actions and thought
and may become passive reluctant or refuse to participate in activities (Erikson, 1963)
4. Industry vs. inferiority: 6-11 years industry is the mastery of social, physical and
intellectual skills and orientation towards and competition with others i.e. over school age
children want to be the beast in everything and constantly compare their efforts with
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 others. Attention and energy is focused to learning academic skills and social roles. A
child is more societal/peer focused that family focused. Inferiority occurs if the child is
ridiculed by peers, do not measure up to adult or their skills own expectations or lack
certain skills so that they are not always the best, fast, fastest or smartest (Erikson, 1963)
5. Adolescence (12-18 years): identity verses role confusion identity is achieving a sense of
who one is intellectually, cognitively, behaviorally & emotionally as emerging physical
and sexual maturity is integrated with the already existing skills and abilities. To achieve
identity, you also require to find your political, social, economic and religious ideology;
also adopting an appropriate gender identity making an occupation/vocational choice and
adopting behavior consistent with one’s own self –concept. It is a vital stage because
identity formation affects commitment and decision made alter in life. Role confusion
occurs when one is not able to acquire a sense of direction, self or place within the world.
Erikson identified other 3 stages that occur during adult hood as follows:
6. Intimacy verses isolation
7. Generativity verses stagnation
8. Integrity verses despair
Each of these stages has conflicts, which require resolution before the next stage.
Erikson’s theory covers lifespan & emphasizes the importance of taking responsibility for self-
development. Also suggests methods of resolving conflicts at each stage. However, it doesn’t
consider differences between men & women in relation to environmental & cultural influences.
Also doesn’t show how development in one stage affects development in the next stage.
Furthermore it doesn’t state the experiences required to resolve conflicts at each stage. He
describes development socially, emotionally and doesn’t say how and why development occurs.
He also doesn’t discuss observable behaviors indicating that trust, autonomy, initiative and
industry or identity has occurs. (Crain 1200, sige/man 1999)
Application in paediatric care: shows the developmental crisis that children/adolescents face &
and acts as basis of teaching caregivers but behavioral expectations. It also helps us realize the
importance of societal influences on health/behavior and that of psychological/social
development is a lifelong process. Caregiver can be taught how to facilitate resolution of each
stage e.g. meeting basic needs at infancy helps development of trust hence the need to meet these
needs promptly. When infant is sick, parents should spend as much time as possible with it. For
toddlers: 1-3 years, encourage independence with some activities e.g. feeding, bathing, dressing,
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toileting etc. if there is need for restraint explain why love approval and praise vital just like in
all other stages. And for preschool: 3-6 years, like initiative, are curious and interested in world
around them. Let them ask questions, explore and create as they wish. For school aged 6-11
years, involvement and success in some activities vital for self with/value. Nurses should provide
school- aged child with opportunities for continuing school work if hospitalized or ill,
maintaining hobbies or activities, interacting with their peers and adjusting to hospitalization.
Adolescents (12-18) should be allowed to be autonomous as possible, encourage them to take
responsibility for their actions, support their life choices and introduce them to their tens. Provide
them with a separate recreation or activity area if in an acute care setting.
Family teaching related to Erikson’s theory; Teach parents to meet infant’s basic needs in
timely & appropriate manner. Allow opportunities for toddlers to be independent. Provide
preschoolers with a variety of experiences where they can explore, ask questions and create.
Encourage school aged children to interact with peers. Support adolescent choices, be available
to listen and offer guidance.
BEHAVIOURAL PERSPECTIVE
Posits that human actions and interactions come from learned responses to environmental
stimuli. Behavioral theorist study behavior in the labs setting and then applies information to the
general population and look for ways for alter/control the environment to change, modify or
teach desired behaviors. Believe that the past or unconsciousness motives are not the root of
behavior and learning doesn’t depend on opposite friend maturation. Also believe that children
randomly respond to environment consistent with developmental capabilities and rewards or
punishment influence behavior. Behaviour relationship in punishment, pain, disappointment or
frustration often is discontinued while behavior that is rewarded or viewed positively is retained
and repeated in similar situations.
Behavioral perspective divided into: behaviorism (classified & operant conditioning) and social
learning.
Classical conditioning: Ivan Pavlov (1849 -1936). Russian physiologist who established
linkage between response and stimuli. Learnt that dog would salivate when saw food
(unconditioned stimuli) or saw person who fed it or heard bell ring just before food appeared
(conditioned stimulus). The dog had learnt that appearance of person or bell ringing meant that
food would follow. This learning to respond to a new stimulus the same way a familiar stimulus

25
was responded to is called classical conditioning,. It’s a sign that learning has takes place.
Another r example, is when an infant gets excited o seeing a spoon/cup used for feeding her.
Operant conditioning- B.F. Skinner (1904 -1990) – behavior changes achieved by positive
(reinforce) or negative (punishment) consequences other than occurrence of stimuli.
Example of positive rein forcers – smiles, praises and special treats/privileges while negative rein
forcers include criticism frown and withdrawal of privileges
Social learning by albert Bandura (1925-) suggest that other than stimuli, personality, past
experience, relationship with the model, situation itself and cognition impact on behavior
change(Bandura, 1977). You imitate what you see, remember and organize through cognition.
Children usually think about the behavior and the consequences (cognition). Bandura also
suggests observational learning is also important where children learn by observing others
(model) as they generally pursue their interest. In this case there is no punishment, reward or
active teaching is provided e.g. children who frequently watch through violence are more
aggressive than those children who do not watch much through violence. Bandura also find that
children tend to model behavior of children and adult of the same gender more often that of male
behavior of more than of female do.
Application in paediatric nursing care: reinforcement of positive behavior and
extinguishing/weakening negative ones is possible. The behavior can be reinforced by praise,
reward and weakened by punishment. On education to caregivers should emphasize on
reprimanding children for unacceptable behavior consistently and appropriately e.g. father and
mother. Children will model behavior they see in the parents, even if parents talk to children
about not modelling that same behavior.
Cognitive – structural perspective
Concerned with low children learn to reason, use language and think rather than what they learn.
These theorist believe that cognitive development is the result of interaction between CNS
maturation and active involvement with the environment. Children adapt by integrating new with
existing knowledge. Important theorist here include Jean Piaget and Lawrence Kohlberg. Let us
now look at the work of Jean Piaget as an example of a theory in this perspective.
Piaget Jean (1896-1980). Piaget started studying children in 1920s. Felt that from birth children
acted upon and transformed their environment and were shaped by consequences. This constant
interplay is responsible for intellectual growth. Believed that intellectual growth followed an
orderly progression based on children maturation level, experience with physical objects
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interaction with care givers, other adults/peers and an internal self-regulating mechanism that
responded to environmental stimuli. Stages if Piaget theory of cognitive development. According
to Piaget, cognitive development occurs gradually, sequentially and without regression e.g.
development moves from single to complex; concrete to abstraction. Has suggested 4 stages with
different phases. There is increased integration and organization as children pass through these
stages. Children pass through them at different rates.
1. Sensorimotor stage (B – 2 years) foundation for future cognitive functioning. Motor/
sensory abilities used to explore the world, learning of goal – directed behavior/cause
effect relationship takes place.
Phases
a) Reflective – (B – 1 month): Predictable, inmate survival reflexes like sucking,
grasping present
b) Primary circular reactions (1 - 4 moths): perform more complex, respective
actions. Look and reach 4 objects in environment. Initiate and repeat satisfying
behavior.
c) Secondary circular reactions (4-8m): learns from intentional behavior e.g.
shake something to hear the sound. Motor skills and vision more coordinated.
There is a lot of interest in environment. Recognize familiar objects
d) : Coordination of secondary schemes phase (8-12): Develop objects
performance. Differentiate familiar verses unfamiliar e.g. caregiver and stranger
direct action to an intended goal e.g. through objects, examines them etc.
individual habits of learning about world start to develop
e) Tertiary circular reactions (12-18m): interesting novelty. Also understands
casualty and seeks help. Increased explorations and new behaviors
f) Mental combinations (18-24m) children think before acting. Solving simple
problems by trial and error and imitate behavior. They can now predict effects
when observing causes. They can also name & locate familiar objects.
2. Pre operational stage: (2-7 years): this stage is characterized by better use of land
gauge. They also have a better understanding e.g. past, present and future. Egocentric
thought and are easily fooled. They also cannot understand the relationship among
phenomenon.

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 a. Pre-conceptual phase (2-4 years) increased use of language use, egocentric
thoughts; symbolic play e.g. woo ds made as car/trunks and mental imagery.
b. Intuitive phase (4-7 years): language more sophisticated, decreased
egocentrism; incessant questioning; more reality- based play; believed
inanimate things have human feelings.
3. Concrete operations and stage (7-11 years): Basic properties\ relationship between
objects events understood. Can classify objects into categories – shape, size, color.
Understands the principle of conversation i.e. things remain the same even through
shape or arrangement changes. See other viewpoints i.e. decrease in egocentrism. Use
trial and error to solve problems. Can focus on different dimensions (color, shape, size)
of an object. Understand others intentions
4. Formal operations stage (12 and above): Characterized by systematic and abstract
thought. May become idealistic because they think about hypothetical issues. Through
inductive reasoning the can the can construct theories about their ideas. Better
understanding of mathematical and principles e.g. proportional, variable etc. established
personal rules/ values.
 Piaget believed that interacts with the environment caused people to organized
patterns of thought (Schema) which they used to interpret or make sense of their
experienced e.g. children believed sun is alive its moving using schema. As they
grow, they regard other moving objects as alive as well as- demonstrate assimilation
i.e. interpret new information in terms of existing information. As they get older,
meet animated and in animated objects –accommodation i.e. revising, read
readjusting and realizing existing schema to accept new information. Assimilation
and accommodation result in equilibrium i.e. harmonious relationship between
thought processes and the environment. (Piaget, 1963, was worth, 1989). In
summary of the 4 stages but without phases include: sensorimotor B-2years; Pre-
operation 2-7; Concrete operation 7-11 years; formal operations 11- older
Today, most develop mentalists accept Piaget beliefs of cognitive development and have tested
most of his prepositions. They have demonstrated that development is:
 Discontinuous
 Increasingly complex through series of stages

28
However the theory is not without criticisms. It underestimates importance of emotions and
motivation to learning and important of adult interaction to learning. It also doesn’t acknowledge
that
 Cognitive development continuous to adult life
 People can advance in one area of cognition than others
 Some people never reach higher stages to abstract thought
Application in paediatric care; Piaget’s theory is vital when communicating/interacting with
children at home, school &community setting. Sensor motor: use sight and motor skills to learn
about environment. – Give manipulative objects, bright pictures etc. preoperative- more verbal &
limited thought process, hence you need to explain experiences in plain language. Concrete
operations-mature thought possible but needs you know how to work, relate, change or interact.
Formal operations - adolescence – provide complete & clear information - verbal/writing.
Caregivers’ needs to be educated that: children learn at different rates; adolescents may still use
concrete operations; Caregivers/family members need to use simple language when talking to
young children and may need to repeat directions several times. Be patient with children’s
questions for this is the way they learn the world. Children learn at different paces .
Learning activity; read about moral development by Kohlberg (1927-1987). This theory
describes changes in thinking about moral judgment and reflects societal norms and
values. Kohlberg was interested in rationale for moral decision than decision itself. Moral
development influenced by external and internal factors.
Contextual perspective
This perspective adopt a broader focus by viewing human development as life long process
affected by many factors; individuals/group of individuals; historical, cultural, political,
economic, context that one lives in. ecological theory (Bronfebrenner, 1917) is an example of
contextual perspective. He offers an organizational framework for examining systems influences
on human growth and development. Ecological theory considers relationship between
environments, individual and how this impacts on human development.
Change in environment results to change in the individual and vice versa. These interchange
occurs simultaneously and continuous. Children actively create their environment. This theory
emphasizes the importance of environment though biological factors are also vital. Urie offers an
organizational framework for examining the environmental systems influencing human
development. Family, peer, government, society impacts are impacted by the individuals.
29
The environment can be viewed as:
Macro system – large enduring systems has beliefs, resource, lifestyle e.g. poor slums vs. rich
suburbs.
Exosystem – middle system, social setting that individual do not directly experience e.g.
Caregiver work settings, social network – support system, educational level, community decision
making, one’s neighborhood.
Microsystems: immediate environment e.g. family, peer, teachers, neighbors religion leaders.
Importance of micro systems changes over time e.g. primary socialization is cared by family but
can be carried by school, church, teachers and neighbors
Mesosystems: interrelationship between 2 or 7 microsystems e.g. home, school and peer makes
a child mesosystem. For example for adult mesosystem – family. , employment situation and
friends.

GROWTH AND DEVELOPMENT OF THE NEWBORN

Learning objectives
At the end of the chapter the learner should be able to:
a. Identify the adaptive changes that occur during the transition to extra uterine life
b. Describe normal physiological development of the new born
c. Discuss the psychosexual, cognitive and psychosocial development of the newborn
d. Identify and explain aspects of health promotion and maintenance pertinent to the new
born
e. Describes family education needs regarding health promotion of the new born
f. Explain the etiology and treatment of high risk new born
g. Discuss the nurses’ role in caring for healthy and high risk newborns
We are now going to examine growth and development along the different stages that are a
concern to paediatrics as was indicated in the earlier discussion of Erikson’s theory of
development. Let us start with earliest stage of the first one month.

Note: Neonatal or newborn period – 1st 4 weeks/28 days of life.

Physical development: General appearance – Head – ¼ body size. May be molded due to
delivery process. Caput succedaneum may be present especially after long labour. Caput –
swelling of soft tissue of scalp evident within 24 hours after birth. Resolve within day and may
30
extend across future lines. Cephalhematoma – blood between skills and periosteum indicates
trauma during birth. Develops in 24 – 48 hours after birth and doesn’t cross future lines. May
take 1-3 weeks to resolve

Cord should be given appropriate care 70/ isopropyl alcohol or hydrogen peroxide applied next
to the skin. Never pull the cord off or attempt to loosen it. Skin may be mooted, acrocyanosis
bluish coloration of hand/ feet due to instability of peripheral circulation system. Fontanels occur
at junctions or future lines of the skull bones ---allow growth and delivery. They close at
different times, Posterior fontanel close in 3 months while anterior close within 8—18 months.
Asses neurological system by the neonates response to handling, new borns position and
gestational age .Gestation age is determined by use of handling, newborn‘s position and
gestational age. Gestational age is determined by use of Ballard score-within 12hours of life
using this score, you can classify newborns: Large for gestational age (LGA) 90th percentile;
Appropriate gestational age (AGA) (10-90th percentile) and small gestational age (SGA) (<10TH
percentile)

Newborns sleep most of the time- -- but need for decreased as it grows. Responds to
environment/stimulation is by changing expression - smiling, grimacing, and crying. Primitive,
inmate behavior seen in the newborn are called reflexes---which can localize or generalized.

Cardiorespiratory; has restricted space for lung expansion due to Horizontal ribs weak
intercostal, large abdomen, high diaphragm and small airways hence neonates are obligatory
nose breathers. Therefore, any obstruction will cause respiratory distress. Respiratory rate is
usually 30 x 60b/min. characteristics of breathing include: abdominal breathing. Shallow
irregular depth and rhythm and short periods of urea seen. Irregular breathing common in active
or light sleep state. Regular breathing common in deep sleep state during 1st breath, heart rates
accelerate to 180b/min(for 4 hrs.) then back to normal range i.e. 100 when a sleep to 150 when
awake.

Gastro intestinal system: slower in new born than adult. Mature slowly, stomach capacity of
newborn is 60ml--- increases later. Peristaltic waves rate decrease with time. Liver functionally
immature for 1year and pancrease works efficiently—hence poor fat absorption. In uterine life,
extra haemoglobin required to carry oxygen since oxygen tension available to the fetus is
decreased. After delivery extra HB not required hence excess cell destroyed by the

31
reticuloendothelial system and not replaced. Haemoglobin is broken to heme and Globin. Globin
is converted to unconjugated bilimbin leads to jaundice. Liver also not mature enough to
conjugate bilirubin (direct). Physiological or normal jaundice shows a gradual rise in bilimbin of
8mmg/dl at 3-5 days after birth. Later, it fails to normal level in the 2nd week of life – if persist
further investigation required. There are many causes for persisting jaundice: sepsis,
polycythemia, infant of diabetic mothers, fetal – maternal blood group incompatibility and
nonspecific hemolytic anaemia. Kernictems may result when new born jaundice causes nuclear
masses of the brain/s. cords to undergo pathological changes accompanied by deposition of the
bile pigments within them. Occurs at bilirubin toxic levels. Many lead to permanent brain
damage causing abnormalities in motor function. Phototherapy which use of special high density
fluorescent lights. It is used to prevent the above state. Phototherapy oxidizes the unconjugated
bilimbin in the skin, when it becomes soluble in water and excreted in stool and urine maximum
exposure newborn naked. However; you need to protect the gonads with surgical mask and eyes
using patches to prevent retinal damage.

May experience loose stools and increased urine output – possible dehydration and excoriation
of skin in the perianal area. Obtain serial bilirubin levels 8-12 hourly during phototherapy to
access treatment effectiveness.

Genital urinary system; renal tubules unable to concentrate urine because they cannot well
absorb H2O, glucose, Na +and other solutes back into blood. Full concentration possible at 3
months of age, Normal values for new born urine; output 1-2m/kg/hr. -2-6 voidings per day
.urine output increase .evaluate renal function if no voiding in the 1st 24 hrs. of life normal value
for new born urine ; color-pale yellow, glucose—ve;PH-4.5-8 protein > 5-10 mg/dl, RBC-
negative, specific gravit-1.001-1.020; and WBC-negative genitals –pendulous scrotum with
rugae, testes palpable in the lower portion of scrotal sac ,if scrotum is destended , use of transillu
minator may reveal hydrocele (collection of fluid between parietal & visceral layers of tunica
vaginalis).

No treatment required unless it goes beyond one year of life. .reassure caregivers that use
normal& will disappear. Circumcision – when done on a new born considered elective. May be
delayed or not performed in prematurity, illness distressed body at birth, hemophilia, genital
urinal deformation. Care of uncircumcised new born-wash outside the penis to decrease
odour/infections. Smegma –collection of cells that shed from outer layer of skin & yet gather
32
under fore skin remain intact possible till 3 years when it’s retractable. Attempt to retract fore
skin may cause damage. In female genitalia for term new born –clitoris and labia minora are
covered by labia majora. Vermix caseosa may be found between the labia. Blood may be
observed in the diaper due to maternal hormones withdrawal at the time of delivery -
pseudomenstruatron. Reassure care giver.

Musculoskeletal system: tem new born exhibits hypertonic flexion of all extremities muscle
tone not well developed, hence cannot support weight of lead .head lag seen if newborn pulled
from supine position. Hands should reach the upper thighs when extended. Intrauterine
positioning of newborns of feet may result in a talipes deformity or club-foot. Foot may easily be
manipulated to midline; otherwise orthopedic consult considered. Spina bifida should be ruled
lout examining the base of the spine. New born gain 5-7 ounces per week and head
circumference& length increase by one inch per month.

Integumentary system: skin delicate& mottled, acrocyanosis. Observe for milia:-small white
papules on nose, face, forehead & upper torso cause by plugging of the sebaceous gland;
petenchiea;-small pinpoint, non-raised, perfectly round, purplish red spots due to intradermal or
submuscosal hemorrhage. they are normal if found in area of presenting part .other area-
investigating cause e.g. sepsis; Mongolian spot-irregular dark pigmented area on posterior
lumbar region.no clinical signifance and are usually noted in newborns of various racial back
grounds; desquamation-peeling of skin and the degree depends on maturity. preterms peel less
while post term peel more ;telangiectatic nevi-capillary hemangiomas commonly called stork
bites found at nape of neck & bridge of nose .They disappear with time ; nevus flammeus –port
wine stain . Hemangioma or vascular tumor that will not disappear with time; erythema toxicum
– transient rash characterized by red mascular base with a white vesicular center.

Psychosexual development: Find satisfaction from oral stimuli, physical contact, being held and
cuddled.

Cognitive development: Can interact with environment and signal needs and gratitude when
those are met. Learning is by habituations and imitations. In twelve days newborns can imitate
facial and manual gestures of adults. Can respond to auditory stimuli turn head to find source.
Are sensitive to touch and handling. Newborns tend to habituate to noxious stimuli-protects it
from overstimulation and frees energy for physiologic demands

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Psychosocial development: As caregivers meet newborns needs it develops trust and form
attachment and relationships. Caregivers should interact with newborns as much as possible.
Health.

Promotes and maintenance: Ophthalmic drops or ointment administered. Hemorrhage disease

of newborn-is due vitamin k deficiency and you prevent by giving phytonadione within 1hr of
birth. Dose-1mg in –full term and 0.5mg-preterm. Before discharge screen: phenylketonuria
(PKU) and hypothyroidism. Ensure immunization is given and give a follow up care schedule.

Anticipatory guidance: Nutrition-breast feed for 6-to 12m. Cow’s milk is not good as it is
designed for rapidly growing animal- has more protein, fat, sugar, ca++, na+, mg+, sulphur ,
phosphorous than human milk . Baby milk does not come until second –fourth day until then ,
baby gets nutrients from colostrums a product breast produces before milk .Feeding should be on
demand feeds , not schedule.

Thermoregulations -controlled by hypothalamus. Not very effective hence vulnerable to

overheating/under heating. There are many reasons for this poor heat regulation: increased
surface area, poor thermal insulation, limited shivering response and increased metabolic rate.
Educate on this aspect above e.g. avoid overdressing, brown fat is the major source heat
production newborn.

Sleep- Term newborns have two sleep states deep and light. For deep, eyes closed, no eye
movement and no major activity except for occasional startles. Light state is featured by eye
movement in 10 seconds interval and motor activity e.g. stretching .newborns sleep for 16-
19hrs/day with cycles of 45-50 minutes. Usually it begins and ends with light sleep.

Position: Sulphine/side lying but newborns with craniofacial abnormalities and

gastroesophangeal reflux should be positioned prone. Sudden infant death syndrome (SIDS) has
been reported as commonly caused by prone sleeping, soft bedding e.g. pillows, blankets,
sheepskins, comforters etc.

Diaper care: when changing female new born, wipe from front to back. This control faces
contamination of vaginal area. Diaper rash – keep them clean, dry and use plain water and
absorbent cotton. There is no need to use commercial wipes, unless those used for babies not
adults contain alcohol & can dry baby’s skin. There are several causes of diaper rash: - too much

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moisture on skin, changing/rubbing, prolonged contact of skin with feaces/urine, use of
antibodies (year’s infection) and allergic reaction onto diaper material. Treatment for diaper rash
include: changing diaper often use of clean H2O to clean diaper area, apply thick layer of
protective ointment or cream e.g. Zinc oxide or petroleum, seek medical advice I it doesn’t go
within 48 – 72 hours or gets worse – open sore and blisters.

New born screening: depends on policies of countries/states. It could be for: - Phenylketonuria,

congenital hypothyroidism, galactosemia, sickle cell disease, and hearing (done at least within 3
months)

Safety-promotion & injury prevention: new born can wiggle themselves into a variety of
positions which can become a safety hazard. You can only leave newborns unattended in the crib
with side rails. The common sources of injury drowning, suffocation, burns, falls and motor
vehicle accidents. Prevention of accidents is very critical though. Never leave baby in bathwater,
vehicle – secure neonate in rear seat facing backward not front seat, cot/rib is put away from
heat, cover unused electrical outlets, don’t hold newborn while drinking hot drinks. Don’t smoke
near new born – has been associated with otitis media & respiratory infections

Nurse’s role in fostering healthy newborns is through health education on the care of newborns

.such topics as immunization, follow-up care, available community resources and breast feeding
& general nutrition should be covered

GROWTH AND DEVELOPMENT OF THE INFANT (1M-1YEAR)

Student learning objectives

At the end of the chapter the learner should be able to

a. Discuss physiological growth and developmental milestones of infants

b. Discuss the process of infant fine and gross motor development
c. Describe infant psychosexual, cognitive and psychosocial development
d. Describe health promotion and maintenance activities for infants
e. Discuss educational strategies for caregivers of infants as related to nutritional needs,
growth and development pat6erns, play, stranger and separation anxiety, and safety

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 There is rapid growth and development. There are rapid changes taking place that the
nurse needs to understand to ensure optimum health (for infant/ family is achieved) the
nurses assist the family to give all the care required to the infants.

Physiological development: very marked changes taking place. Physical growth, skills
development is taking place so that the child can cope with the worded. Physical growth in
terms of height, weight and head circumference. Gross & fine motor skills development
occurring in a cephalocaudal (head – toe) & proximal distal (central _ peripheral) fashion.
Weigh changes occur rapidly :1st 6m of life –weigh doubles , (next 6m 3-5-Oz/per week)
and in 12m – 0.5inches per month and at 12m – infant brain 2/3 that of adults . As head
grows fontanel close – posterior fontanel – by 2 months. Anterior fontanel by 12 – 18
months.

Motor development: Related to physical, cognitive & social development. Includes – gross
and fine motor development that helps infant explore environment. It’s marked by: voluntary
behaviors follow disappearance of primitive, reflexes, e. g to willingly grasps objects , the
infant must 1st lose the involuntary grasps reflex . Probation occurs before suspiration e.g.
Children pick up objects proceeds ability to release it

Gross motor: gross motor development – ability to use large muscle group For: - balance,
postural control e. g head control, k and loco motion e. g. By one mouth – infant can turn
head to one side while prone. Infant head control is judged by presence or absence of head
lag – amount determined when infant is pulled by the arms from the supine to a sitting
position. At 1m – a lot of head lag. 2m – partial had lag. 4m – no head lag & well head
control is achieved, infants can sit without support. as infant develops , other mile stones are
realized:- thus at 8-10 months the child can cruise ( deliberate steps while holding something
) once can stand alone , they will take 1st step

Fine motor: Hands and eyes get more used to manipulate environment. Fine motor
development – ability to coordinate hand – eye movement in any orderly and progressive
manner. This skills develop from primitive grasp reflex that enables infants to hold objects
with a tight clenched fist.
c(1m) to 10 -12 months when- Deliberate movements –put and remove objects from
containers ,hold and mark a paper turn pages of a book etc…..

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Psychosexual development; Base on a child need to seek pleasure .According to frued theory,
the infants (birth-1 year) are in oral stage and pleasure dominants life. Oral stimulation/ sucking
are major focus. Feeding or nutritive sucking vital source to pleasure .Feeding and cares touch
gets associated. Others some of pleasure-non – nutritive sucking e.g. objects /fingers, pacifiers –
may be used to calm the child.

Cognitive development; According to Piaget, the infant is in sensor motor stage (birth – 24
months). Knowledge about an object is acquired through interaction with the object and use of
the object .major task for the infant Is object permanence , where infants learn is not an
extension of self and that it continues to exit even if it cannot be seen .

Health promotion; Caregivers need to know the expected physical , emotional and
developmental growth patterns of the infant . nurse can help family to attain optimal level of
health This can be achieved through –education , counseling , anticipatory ,guidance ,
understanding family cultural needs .

Health screen; assessment and detection of any problems ;( PKU), iron, deficiency,
hypothryoism and lead poisoning. Advice care givers to contact health workers, in case of any
problem. ; fever , poor feeding , vomiting ,reducing of activities or alertness , appear restless ,
inconsolable crying , abdominal movement – unusual jerking of the body , unusual skin color
; bluish color around the lips , screening visit , medical activities , ; physical examination ,
growth indicator – height , weight and head circumference , anticipatory guidance . , parental
concern and immunization.

Vision: Even newborns have full visual arrays of acuity 20/100 to 20/200. Any problem with
vision may affect perception; hence development e.g. infant should be able to follow objects or
light. Possible vision problems include: Absent or poor hand – eye coordination by 7 months,
Inability to follow objects by 1m, Doesn’t fixate on object, Absence of doll’s eye reflex
(movement of head to the right or left in which eyes lag behind & do not immediately adjust to
the new position.

Hearing: To be detected early to prevent delay in speech development. Assess hearing regularly-
se paediatrics assessment. Signs of problems: Can’t follow verbal direction, No response to
human voice, absent babble or voice inflection by 7months. Can’t turn head towards a sounds by

37
7 months. Lack of startle reflex or blink with a loud sound. Failure to be awakened due to loud
noises in environment.

Dental care: teeth eruption begins in 3-4 months. Lower incisors – upper central incisors (4-
8m). Dental hygiene – start with eruption of deciduous teeth. Use: clean with wet cloth or soft
bristled brush. Establish routine early in life. Fluoride prevents dental carries. Give if local water
lacks adequate (0.3ppm) fluorides content. At concentrations of 0.3ppm of fluoride infant
doesn’t require supplements. If needed, they start at 6 months – 0.6ppm. Exercise i.e. beyond
0.6ppm causes tooth staining. Prolonged sugars exposure causes dental caries. Since caregivers
are concerned about teeth number of teeth at any given time, the formula is: Age of child -6=total
no. expected at 18 months. Routine visits the dentist are important. First visit – before 2 years of
age.

Teething: Eruption of deciduous teeth causes periodontal membrane to become swollen, tender
and red. There is also anorexia, fussiness, drooling and desire to bite. Low grade fever, vomiting
& diarrhea. Teaching on teething – to soothe swollen red gums you can do the

Following:-Apply frozen teething, or ice cube in a washcloth, give hard rubber toy biting for
biting. Also medications like topic unaesthetic and acetaminophen for irritability/ grade fever can
be given.

Nutrition: Since there`s rapid growth nutrition vital. Feeding assessment should e done.
Nutritional requirement based on physical activity & rate of growth needed to support life. After
birth 120kcal/kg day. Fluids also vital. Introduction of solid foods should be at 4-6m. If done
before it can use allergies. Self-feeding encouraged for autonomy development. Wean
appropriately. Use of pacifiers (non-nutritive) sucking helps calm. Should have a shape of a
nipple.

Communication: Helps express needs. Involve cognitive, social abilities. Crying & smiling used
by infants. Caregiver should give appropriate response based on need. At infancy receptive
language (ability to understand words) better than expensive language (ability to speak). Assess
language development during visit to clinic. Speak to the infants as much us possible when it
starts to vocalize.

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Temperament- Defined as the way a child interact with the surrounding environment. Children
are genetically endowed with temperamental characteristics e.g. adaptability, mood, attention
span and persistence. These should be understood for the caregiver to provide appropriate and
unique care for the child. When combined with caregiver personality, they produce a
characteristics pattern of social interaction. Temperament characteristics are behavioral
tendencies, not implications of ad behavior.

Sleep: Temperament, satisfaction and environment influences sleep pattern. The patterns of
being awake in day & sleep at night evolve as child matures. The infants also take 1-2 naps
during the day. Night waking occurs every 2-4 hours but disappears later.

Sooth child to sleep. Nurse should understand any concern of sleep patterns & counsel
appropriately. Measures to promote healthy sleep bedtime routine established. Room temperature
(comfortable). Don’t feed at night or make brief .Place infant in supine or side lying for sleep.
Don’t awaken infant to feed/change diapers. Sleeping position vital.

Some conditions common during infancy

Colic: Common problem in under 3 months. Defined as recurrent episodes of unexplained crying
and the inability to be consoled. Onset – 1-2 weeks of age. Subsides spotaneonly by approximate
16 week of age. It is not clear what causes colic but postulated that it could be due to excessive
air swallowing, improper feeding techniques e.g. feeding position, food allergies, and infant
behavior factors. Characteristics of colicky episodes: - Loud, persistent cry, flexing of hips
towards abdomen- thought to be due to paroxysmal abdominal cramping. The rule of 3 is used to
define colic so that is differentiated from other forms of crying. States that colic is present if
crying occurs during the first 3 months of life, lasts longer than 3 hours per day, occurs more
than 3 days in any one week and continues for at last 3 weeks. Though it resolves spontaneously,
it’s very stressful to the family (fatigued, frustrated, and helpless).

Management: Rule out other organic / infectious causes, feed slowly, right amount and upright
amount & upright position & burp frequently. Mother avoids gas-formed foods – onions,
cabbage, and dry beans. Swaddle infants to avoid jerky / sudden movements, responds favorable
to vibration & movement, hence car ride used. Walk or rock infant while applying some gentle
presence or the infant abdomen. Gentle back messages, Soft soothing music helps. Quiet; dark
room to avoid environment simulation. Let the infant cry it out in the crib when other measures
39
do not work. Sometimes only fatigue will make it fall asleep. Caregiver should remain calm, no
self-blame & positive attitude is necessary. Relaxation technique & sometime off is good for
caregiver.

Sudden infant death syndrome (SIDS): Unexplained, sudden death of infant under age of 1
(most 95% occur by 6 months), after all other causes have been rule out. Supline/ side lying is
the recommended position since 1992 as position is associated with SIDS. Other risks

Factors include Infants factors-Premature, LDW, Male gender, Asphyxia, Multiple birth, SIDS in
sibling and under 6m of age. Environmental factors include: Cigarette smoke, Prone sleeping,
Bottle feeding in crib, over building for sleeping, over heating soft sleep surface and loose
bedding.

Bathing: No much bathing is required. Do not leave infant unattended. Sponge bath till cord
falls off but keep diapers area clean to avoid diapers rash. Expose only those areas those areas
been washed because of cold. Use cotton ball for eyes. Perinieal areas are washed last. Clean all
body creases, especially neck fold and perineal area. To prevent cradle crap [seborrhea] a dry,
scaly scalp condition]. Hair should be washed every day using a body shampoo. If it occurs: use
soft-bristles tooth brush can be used to remove crusts and mineral oil or petroleum jelly can be
used to soften the patches.

Skin and nail care: Lotions and baby powder not required by infants. Nail clippers are used
immediately after bath-nails soft. Powder may cause aspiration pneumonia. Lotion may be hypo
allergic and warned by hand first.

Strangers and separation anxiety: Stranger appears in 8-12 months when a child develops
sense of object permanence. Mental image of caregiver enables child develops stranger anxiety
peaks at 15-18m and disappear at 2years. Separation anxiety: occurs when care giver moves
away. Occurs because child doesn’t know if caregiver will return. As separation episodes are
repeated, cognitive coping develops. Characteristic of these anxiety include: isolation, frowning,
whimpering, crying and clinging. The management includes: stranger anxiety-Visit by friend
increased, introduce stranger,-and keep safe distance from strangers, warm for strangers and
stranger should use smooth voice. Separation anxiety-leave child familiar place. Talk to child
before leave. Say goodbye. Leave security objects e.g. toy.

40
Play: Is described as the ‘work of the child’ It has many advantages. Skills are practiced learn
about environment and people and them. Able to develop sense of mastery, control and
predictability. Relationship is enhanced. Play is more purposeful and intended at this stage
caregiver should actively be involved in the play-enriches the interaction. Nurse should assist the
caregiver get involved in infant play as such as possible. Consideration in play: Toys should be
developmentally appropriate. As many senses as possible should be involved. Encourage use of
hands/feet’s. Expose too few new experiences each day. Praise often. Use age-appropriate toys
e.g. suffocations can be caused by large toys. During assessment, inquire about play e.g. safety
of environment that child plays-phone accidents avoided.

Play may help to detect: - Development delays, neurological problems-coordinative problems,

delayed social skills, learning disabilities and emotional disturbances.

Safety promotion and infant prevention: Infants have instable curiosity about environment.
Development and skills refinement is very rapid. Hence, they are at great risk of accident
especially at age 6-12 months. Accidental injury prevented by child-proofing the home.

Common injuries include falls, drowning, strangulation, burns, choking, suffocation, and
ingestion of poisonous substances.

GROWTH AND DEVELOPMENT OF THE TODDLER [12M-36M]

Student learning objectives

At the end of the chapter the student should be able to:

a. Describe the toddler’s physical, psychosexual, psychosocial, cognitive and moral

development.

b. Describe interventions for temper tantrums, negativism, regressions, and ritualism

c. Discuss strategies that caregivers can use when planning a disciplinary plan

d. Discuss sibling rivalry and appropriate interventions

e. Describe the physiological readiness for toilet training and the appropriate interventions

f. Discuss anticipatory guidance strategies for health promotion, including play, nutrition, sleep,
safety, development and dental hygiene

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Introduction: It takes 24 months. There is rapid, unprecedented maturation and change in the
life of child & family. The child is more independent, mobile, verbal & inquisitive. Autonomy,
sense of identity continues to develop. More exposed to danger because of increased activity.

Physiological Development: Different toddlers achieve different milestones variably – some

will achieve verbal milestones faster than motor skills. Developmental task achieved at different
paces. Growth rate is slower than infancy.

Average weight gains 5 pounds/year. Height increases by 3 inches/year. Slower growth rate
leads to physiology anorexia. This is due to erratic feeding behavior and decline in appetite.
Required caloric intake increased. Head more proportional to body. This reflects slower brain
growth, as extremities lengthen.

Chest circumference increased and exceeds abdominal girth. Pot bellied and toddling gait as
bones strengthen. Abdominal muscles replace a dispose tissue. Walking starts at 12-15 months.
Spend a lot of time practicing the newly learnt skills so that mastery can occur. All deciduous
teeth are erupted by 30 months of age. Improve eye-coordination enables self-feeding.

Psychosexual development: They recognize gender differences at 2 yrs. Explores body parts
during toilet training. According to Freud (1957) toddlers are at anal stage. Masturbation is
common & should be handled carefully to lessen the child’s anxiety & feeling of shame. They
imitate domestic/ role activities i.e. domestic mimicry e.g. takes role of daddy, mummy etc.
Gender-specific behaviors & role-related thinking patterns develop. Gender-identity formulated
during toddler hood & rewards for responding in a manner consistent with a specific gender
internalized that identity. Avoid using slung, baby talk or confusing terms. Teach child correct
anatomical terms. Provide positive reinforcement when the child experiment with gender related
roles. Accept manipulation/ masturbation of genitalia as natural, private behavior of toddler.
Respond to quiz with age-appropriate language-language should be under standable. Don’t make
toilet training a major confrontation issue in the house hold. Try to tie in educational aspects
when possible. Child usually learns at different times. Don’t compare children as they develop at
different rates.

Psychosocial development: Psychosocial tasks here include: - Gaining self-control, developing

autonomy, increasing independence. Progress toward mastery and development can be judged by
some indicators like tolerating separation from care givers, withstanding delayed gratification,
42
increased control of bowel/ bladder function, interact with others in a less id-centric / ego-
centric, utilizing socially acceptable behaviors., autonomy vs. shame/ doubt develops according
to Eric Erickson

Cognitive development: Speech skills develop faster. Depends on parent encouragement/

participation (environmental influence) – the impact of regular care taker (e.g. house help) can be
great. At 36 months can converse. Use of short sentences & following directions. Can recognize
shapes & classify objects based on their use. An object that looks alike have same function &
therefore treated equally e.g. everything round is a ball.

Health promotion: Nutrition- encourage self-feeding. Reassure for decrease food intake.
Frequent small meals are advisable. Acknowledge toddlers ritualistic needs e.g. same plate, same
spoon. Don’t force child to eat – provided praise and positive reinforcement. Sleep -2 year old –
12-14hrs sleep per day and a nap in the afternoon. Develop sleep routines. Waking up at night &
nightmares are common among toddlers. Dental health: Caregivers need to assist. Use toothpaste
sparingly since tendency to swallow – fluoridated. Otherwise use water only. Flossing also done
to prevent gingivitis.

Safety promotions & injury preventions: Follow traffic rules related to auto- safety prevent
falls – related injury e.g. screens to open window guards. Warned not to run with everything in
month etc. Prevent suffocation, burns, drowning, ingestion of medications, other poisonous
substances. Keep syrup ipecac at home. Promote gun safety. If gun in house: - keep gun locked
up & unloaded. Store bullets away from the gun. Supervise child while in bath tabs. Instruct
child never to go near water alone.

Etc. alcohol kept out of reach, smoking (passive) eliminated, adults have to smoke away from
children
Screening: immunization health, heart and weight, BP, Hb, vbision/hearing some behavior
issues common vital in toddlers.
Some common behaviors in toddler age
Negativism: an expression of toddlers search for autonomy. Resent given directions and or not
being allowed to explore what is desired in an expanding environment. Delights in doing
opposite and says no to what requested. Care giver is frustrated. Pass by the age of 30 months.

43
Ritualism: ritualism - need to maintain sameness routines formed that give security and safety;
child experiences stress when these are disrupted and may regress (return to earlier, safer more
familiar behaviors)
Discipline: limit setting and consistently (both parents) applied discipline is vital explain
the reason for discipline. Show love and support.
Sibling rivalry: intense feelings of jealousy between siblings. Often seen when an infant is born
into a family with a toddler. Toddler devastated because they complete for attention and fear loss
of love or abandonment. It should be manage by pay some attention to toddler, maintain toddlers
rituals, others e.g. grand parents can assist in care of toddler, movement from crib is made
several months in advance and set limits and apply them consistently etc.
Temper tantrums: outward explosive reactions to inward stressful or frustrating situations that
are a normal part of toddler life. Between 2-3 yrs. the child is faced with new rules, fears and
environments. They need to express their feelings, wishes, frustrations but have no language skill
to do this. This new experiences coupled with child’s quest for autonomy may erupt as tantrum.
It’s a way they say “I have needs; I am important, need some control” characteristics screaming,
crying, falling onto the floor. Banging the head, flailing the arms, breath holding which may
cause fainting, kicking the feet, ignore tantrums unless they pose danger e.g. head banging. You
can prevent by scheduling the toddler, allow choices, reward god behavior and stay calm.
Note: tantrums are a normal developmental response of toddler and disappear at four years,
therefore, the care giver need to be reassured.

Toilet training; accomplishing bowel/bladder control parts of the toddler’s achievement of

autonomy/independence. Myelinization of spinal cord and development of sphincter control
occurs at12-18 months hence toddler ready for toilet training between 18-24 months. Readiness
for toilet training indicated by; Cognitive awareness of elimination, e.g. diaper wetness. Follow
direction and communicate understanding of elimination needs to the caregiver (pulls on diaper,
ask for diaper change), remain dry for longer periods of time(more than 2 hours),independently
dresses and undresses, sit, squat and walk well, bladder control more difficult than bowel control.
Assume positive reinforcement/ praise when the child controls the bowels/ bladder and do not
scorn the when it wets itself. Both night/ day dryness should be achieved by 5 years, otherwise
look for pathological causes. Stress affects toilet training in that it interferes with toilet training

44
by precipitating regressive bowel/ bladder continence. These are temporary and reinforcement,
gentle support; encouragement will assist toddler regain a sense of independence and success.

Play; Described as “work of the childhood”. Important because the child learns about
environment, enhance fine and gross motor development. Toddlers play alongside, but not with
other children (parallel play). Demonstrate little attention to the feelings of play partners and
may grab toys etc. Play may serve the following functions; cognitive development – learn about
objects, solve problems; social development – fantasy play and acting roles; problem solving –
use of excess energy, assist in coping with anxieties. Select age – appropriate play objects that
cannot cause injury.

GROWTH AND DEVELOPMENT OF THE PRE- SCHOOLER (3-6 YEARS.

Student learning objectives

At the end of the chapter the learner should be able to;

A. Describe physiological, psychosexual, cognitive, psychosocial, moral and spiritual

development of the preschooler.
B. Discuss changes in fine and gross motor movements, and identify appropriate activities to
help develop these skills.
C. Identify activities of daily living (ADLS) that the preschooler is capable of independently
performing.
D. Explain ways of promoting and maintaining health through nutrition, activity, sleep/ rest,
and play and injury prevention.
E. Describe ways to evaluate readiness and preparation for school.
F. Identify appropriate means of discipline and limit – setting.
Introduction; The rate of physical growth and changes decrease. Cognitive/ social skills getting
refined. Developmental tasks here include;- establish control of body systems e.g. toilet, dress,
feed self, tolerate longer separation by the caregiver, closer interaction with adults/ other
children, language is more sophisticated.
Physiological development; Rate of growth slower than infant/ toddler, Weight gained at 2pds/
year, Height changes by 3 inches per year such that by 5 years the child is ½ adult heights.
Becomes slimmer, taller- reassure caregivers. Excessive activity/ overexertion- damage growing
tissue, hence adequate rest and nutrition is vital at this stage. Body systems continue to mature
45
and stabilize. By 3 yrs - all 20 deciduous teeth. Permanent teeth start erupting by 6 yrs. Muscles
and bone growth continues as maturity is not yet. Handedness established by end of pre-school.
Bladder bowel control achieved (including night control). But lack of concentration may cause
accidental self – soiling by the preschooler. Gross and fine motor skills like walking, running and
jumping well established. By 3 years can ride bicycle. Other motor skills well developed-
dancing, skating, dancing, and swimming etc. Eye- hand coordination refined. Fine motor like
lace shoes, do simple buttons, draw shapes e.g. square are more developed.
Psychosexual development; Distinguish boys’ and girls’ features. Freud described this period as
oedipal/ phallic – child experiences subconscious conflicts and intense attraction and love for
parent of the opposite sex. Child also feels competition with the same sex for the attraction/

Affection of the other parent. This called Oedipus preschool boy attraction to the mother. Electra
preschool girl attraction to the father

Its normal competition romance .Resolution comes as child identifies with the opposite sex
.They start to copy behavior of opposite sex .Sexual curiosity displayed and many questions are
asked related to gender. Answer questions correctly. Teach children about private parts which
should not be touched by strangers. Many caregivers fail to give the right information on
sexuality, hence confusion occurs as child grows.

Cognitive development: Continues to be seen in the ability to speak e.g. At 3 year’s vocabulary
of 500-900 words 3/9 of a sentence .At 4 years -1500 words-4/5 of a sentence. At 5 year-2100
words -6/8 of a sentence

Psychosocial development: Sense of initiative and guilt (Erickson) is a major achievement.

Conscience (superego) starts to take shape .Rewards/punishment vital for them to understand
acceptable/un-acceptable behavior .Limits set and followed closely .Play is more dramatic,
imaginative and creative. 3 years old want to please caregiver, less sibling rivalry with
older/younger sibling, Can run few errands, 5 years old –helps in house chores, Parent seen as
source of security and reassurance.

Moral development: Is in Kohlberg stage 3(convention level) of moral development. The child
tries to please others/seek approval. Has concern for others. Spiritual development: Imitate
religious practices of their parents. Doesn’t comprehend religious gestures. The child views God
has a friend.
46
Health promotion: Nutrition –At3 years the child can eat table foods. Maintain a balanced diet
.Children may be choosy (picky-eaters) as they explore the world. Caregivers shouldn’t make
meal time a powerful struggle, because preschoolers can go on “feeding strikes” and “food jags”.
Childhood obesity: It’s on the increase related to parental obesity before child is 3years. Has
many effects: Physical effects- hyperlipidemia, DM-type2, pancreatitis, gall bladder disease and
increased blood pressure. Psychological effects e.g. Low self- esteem especially for girls.
Components for treatment: Psychological activity, Nutrition diets and behavioral changes – teach
need for healthy life sleep/rest: Bedtime routine important. Avoid caffeine, sugar at night. May
provide a quiet activity e.g. reading a story. Common preschool sleep disturbances include:
Nightmares, sleep terrors, talking the sleep, sleep walking. These are self-limiting problems.

Play: Enjoy group play Engage in imitative, dramatic and imaginative play.3 year- still
egocentric play.4 years-interactive play. 5 years –impulse control is complete & group sports can
be useful. Establishes interest at this stage and most enjoy books with lots of pictures.

Television /media: Has positive and negative impact. Not a substance for education/play but
some programs can reinforce learning, Promote creativity and enhance cognitive growth.TV
watching should be controlled 1-2hrs/day .guidelines for TV viewing: viewing hours, control
what children watches. Watch with children especially new programs or select video with known
content. Provide feedbacks to networks about children programming. Establish good habits that
shall last lifetime. Major dental problem is dental carries. Primary teeth should be preserved so
that permanent teeth will have room to form correctly and the dental arch will not be narrowed.
Dental carries may lead to loss of primary teeth & dental arch alteration which compromises
permanent teeth development. Brushing and flossing vital. Surgery snacks avoid. Use fruit
fruits, vegetables or cheese instead .Rinse mouth in case sugary snack are used.

Dental health: night grinding some children rind their teeth at night, common in preschoolers-
thought to relieve tension, calm child to sleep. But inn cerebral palsy – grinding occurs due to
jaw muscle spasticity. If excessive, see health care provider

Safety and injury: less prone to falls than toddler’s sine they have better motor skills but
increased activity and skills, still pose a danger to them e.g. playing near streets. Are less
reckless and obey rules e.g. limits can be set and followed. But it’s time to imitate and adults

47
should show adequate modelling. Common health problems of preschoolers: otitis media, colds,
GIT disturbances

School: Prepare the child for school in a number of ways:-Show that school environment is
adventure & fun introduce child to social settings before, Set a “pseudo school routine” before
the actual start, Stay with child in the 1st day, if possible. There are no absolute indicators for
readiness to start school.

Affection of the other parent. This called Oedipus preschool boy attraction to the mother. Electra
preschool girl attraction to the father

Its normal competition romance .Resolution comes as child identifies with the opposite sex
.They start to copy behavior of opposite sex .Sexual curiosity displayed and many questions are
asked related to gender. Answer questions correctly. Teach children about private parts which
should not be touched by strangers. Many caregivers fail to give the right information on
sexuality, hence confusion occurs as child grows.

Cognitive development: Continues to be seen in the ability to speak e.g. At 3 year’s vocabulary
of 500-900 words 3/9 of a sentence .At 4 years -1500 words-4/5 of a sentence. At 5 year-2100
words -6/8 of a sentence

Psychosocial development: Sense of initiative and guilt (Erickson) is a major achievement.

Conscience (superego) starts to take shape .Rewards/punishment vital for them to understand
acceptable/un-acceptable behavior .Limits set and followed closely .Play is more dramatic,
imaginative and creative. 3 years old want to please caregiver, less sibling rivalry with
older/younger sibling, Can run few errands, 5 years old –helps in house chores, Parent seen as
source of security and reassurance.

Moral development: Is in Kohlberg stage 3(convention level) of moral development. The child
tries to please others/seek approval. Has concern for others. Spiritual development: Imitate
religious practices of their parents. Doesn’t comprehend religious gestures. The child views God
has a friend.

Health promotion: Nutrition –At3 years the child can eat table foods. Maintain a balanced diet
.Children may be choosy (picky-eaters) as they explore the world. Caregivers shouldn’t make
meal time a powerful struggle, because preschoolers can go on “feeding strikes” and “food jags”.

48
Childhood obesity: It’s on the increase related to parental obesity before child is 3years. Has
many effects: Physical effects- hyperlipidemia, DM-type2, pancreatitis, gall bladder disease and
increased blood pressure. Psychological effects e.g. Low self-esteem especially for girls.
Components for treatment: Psychological activity, Nutrition diets and behavioral changes – teach
need for healthy life sleep/rest: Bedtime routine important. Avoid caffeine, sugar at night. May
provide a quiet activity e.g. reading a story. Common preschool sleep disturbances include:
Nightmares, sleep terrors, talking the sleep, sleep walking. These are self-limiting problems.

Play: Enjoy group play Engage in imitative, dramatic and imaginative play.3 year- still
egocentric play.4 years-interactive play. 5 years –impulse control is complete & group sports can
be useful. Establishes interest at this stage and most enjoy books with lots of pictures.

Television /media: Has positive and negative impact. Not a substance for education/play but
some programs can reinforce learning, Promote creativity and enhance cognitive growth.TV
watching should be controlled 1-2hrs/day .guidelines for TV viewing: viewing hours, control
what children watches. Watch with children especially new programs or select video with known
content. Provide feedbacks to networks about children programming. Establish good habits that
shall last lifetime. Major dental problem is dental carries. Primary teeth should be preserved so
that permanent teeth will have room to form correctly and the dental arch will not be narrowed.
Dental carries may lead to loss of primary teeth & dental arch alteration which compromises
permanent teeth development. Brushing and flossing vital. Surgery snacks avoid. Use fruit
fruits, vegetables or cheese instead .Rinse mouth in case sugary snack are used.

Dental health: night grinding some children rind their teeth at night, common in preschoolers-
thought to relieve tension, calm child to sleep. But inn cerebral palsy – grinding occurs due to
jaw muscle spasticity. If excessive, see health care provider

Safety and injury: less prone to falls than toddler’s sine they have better motor skills but
increased activity and skills, still pose a danger to them e.g. playing near streets. Are less
reckless and obey rules e.g. limits can be set and followed. But it’s time to imitate and adults
should show adequate modelling. Common health problems of preschoolers: otitis media, colds,
GIT disturbances

School: Prepare the child for school in a number of ways:-Show that school environment is
adventure & fun introduce child to social settings before, Set a “pseudo school routine” before
49
the actual start, Stay with child in the 1st day, if possible. There are no absolute indicators for
readiness to start school.

Discipline and limit: Toddler use tantrum to get what they want .for pre-school; limits should be
set and enforced so that the child can learn acceptable behavior. Punishment should be applied if
a child crosses these limits.

GROWTH AND DEVELOPMENT OF THE SCHOOL-AGED CHILD (6-12 YEARS)

Student learning objectives

At the end of the chapter the learner should be able to:

a. Describe the normal physical growth pattern of the school-age child

b. Discuss psychosexual, psychosocial .cognitive and moral development of school-age
child
c. Explain the nurses role caring for the school-age child
d. Discuss the significance of school and peers for the school-age child
e. Identify common stressors of the school-aged child and the coping strategies to help
them manage

Introduction

It is an important stage for establishing self-esteem, sense of belonging, and feeling of

competence. Child moves from egocentric thought to experiencing world through peers and
school environment. Today’s child can experience the world beyond the classroom e.g through
internet, electronic mail, educational videotapes and cables television etc.

Physical development: Hormones are influencing a lot of physiological change taking place.
Brain and skull slow down growth. Weight increase by 5pds/year while height increases by 2
inches /year.

Note: Growing pains: Occur because long bones grow faster than attached muscles affects 15%
of schools aged children.

Motor skills e.g. balancing, catching, throwing, jumping, running are refined better .Girls tend to
have better dexterity of fingers and hands ( fine motor skills ) .While boys have great number of
muscles cells than females – hence better in gross motor skills e.g. throwing/running.
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Note: About 50% of schools aged (6-10yrs) have an innocent heart murmur not clinically
important. Heard because of the child’s thin chest wall. Respirations: 20 breaths/min.

Dental: Shed dental teeth and permanent appear. Start from 5yrs to adolescent except for 3rd
molars (wisdom teeth). 1ST permanent teeth appear by 6yrs – central incisors and first molars.
Replacement rate is 4 deciduous teeth /year. Boys loose teeth later than girls. Flossing and
brushing vital i.e. x2/day with soft bristled toothbrush which changed after every 2-3 months.
Immunity develop well due to exposure to microorganisms – healthiest days of one’s life.

Psychosexual development: Freud called this stage latency where there is identification with
same sex parent by modeling their roles and behaviors. Also observes and learns from media,
caregiver interactions and children of same gender. Last years of school-aged period called
prepubescence -2yrs before puberty. May be characterised with as breast tissue development and
menarche in females. In puberty secondary sexual characteristics begin.

Cognitive development: Less egocentric as was in pre-school age. Are more open and flexible
in thinking as they interact with the ideas of their peers. The child is in concrete operations stage
(Piaget) and portrays such characteristics as classification, conservation and reversibility.
Vocabulary expands from 2000-50000. Language becomes a tool for communication and
socialization.

Psychosocial Development; Peers become a great socializing agent from caregiver. Behavior is
confined to pleasing friends and much of the time spent with peers to give necessary support
.Erickson called this stage -, industry vs. inferiority where there is competition and the great
need to succeed .Child should be assisted to develop a positive sense of compentence especially
when he/she does not meet the expectations of peers ,teachers and care givers .Self-concept;
development of self-esteem critical now. It is influenced by; -physical appearance, athletic
activity academic achievement, approval from caregiver and comparison with peers. Caregiver
educated on how they should respond to failures on inadequacy of their children especially on
their weaknesses.

Health promotion & maintenance; Nutrition the following needs to be done no nutrition;
Balanced diet; breakfast is emphasized as very crucial for academic and physical performance;
nutrition education be part of curriculum; help them make choices for themselves but help them

51
build appropriate health eating habits which they can carry to adult life and lastly fast foods
should be avoided as obesity as possibility.

Sleep/rest: Promote adequate sleep. Thus for 6yrs -10 hrs ,12 yrs -8 /9hoursof sleep is adequate
fir good academic performance &physical growth. Lack of sleep may lead to irritability, night
mares/night terrors, less common in school aged children .But somnambulism /sleep- walking
occurs in 15%of school –aged. More in boys than girls. These experiences are usually not
remembered in the morning .Associated with nocturnal enuresis which the child out grows by
adolescence .somniloquy (sleep-talking) occurs at any age across life span .Not associated with
any healthy concern.

Dental health: Brush x2/day and at least floss once bed time. They should be assisted because
they lack dexterity. Dental checkup done by paediatric dentist

Malocclusion- where permanent upper and lower teeth do not approximate, leaving then
crowded or uneven. Referral to orthodontist is important. If braces are used, frequent flossing
/brushing necessary. Evulsed (teeth that has been knocked out tooth should be picked, rinsed in
water and placed in its socket and a dentist contacted immediately.

Safety and injury prevention: Major causes of death in this age is accident –hence the need for
accident prevention. The reasons for this increase are increased independence; desire to have
peer approval, increased involvement in physical challenging activities. Example accident of
include motor vehicles and firearm injuries. Safety rules: avoid talking to strangers ,don’t accept
rides from them ;avoid guns ,don’t assume a gun is not loaded ;medicine kept out of children
reach ;teach escape route in case of fire ;caution when crossing street ,obey traffic light and bikes
,skates board –wear helmet, elbow and knee pads

Immunization: Ensure that all appropriate immunization is received, including boosters

common include – dipheria, tetanus, pertussis, mumps, measles and rubella (MMR). MMR –
booster required at 4-6yrs or 11yrs. Some lose this immunity in later ages.

Homework: Caregivers should actively participate in their children home work.

Play: Appropriate plays should be formulated but avoid limit those that encourage sedentary life
e.g. computer games. Physical activities should be encouraged to sedentary life discourage .even
children with physical imitation should be encouraged to participate using his abilities

52
GROWTH AND DEVELOPMENT OF THE ADOLESCENT (12-21 YEARS)

Student learning objectives

At the end of the chapter the learner should be able to:

A. Discuss physiological ,psychosexual, psychosocial cognitive and moral development of

the adolescent
B. Discuss the impact that school, peers, work, and leisure have an adolescents’
development
C. Describe the major developmental tasks of adolescence
D. Discuss health promotion and screening activities related to adolescence and the
appropriate nursing interventions
E. Discuss issues or problems facing adolescents today and appropriate nursing
interventions.

Introduction; Adolescents start to focus on who they are; it’s time for exploration, excitement
and discovery, sometimes confusion and despair occur. Adolescents is second to infancy in terms
of infancy in terms of the amount of changes one experiencing both physically and
psychologically. This stage can be divided as;

 Early 12-14 pre-pubertal –middle school

 Middle 15-17-pubertal –high school
 Late 18-21- post-pubertal-post high school

These levels may also relate to educational levels as seen above

Physiological development; Extensive physiological changes are taking place which affect
psychosexual, social, cognitive development of the adolescent. These changes affect adolescent
experiences with families, peers, and others in social world. Body image and self esteem is also
affected. It is important to differentiate the term puberty and adolescence stages; Puberty –State
of physical development 12-16yrs for male and 10-14 yrs for females, when secondary sexual
characteristics begin to appear, sexual organ mature, reproduction possible, growth spurt begin .
Adolescent- begin with puberty and ends when individual is physically and psychologically
mature and able to assume adult responsibilities. The duration of this stage vary culturally and
individually.
53
NOTE; Puberty lies within adolescence period. Before puberty somatotropin growth hormones
regulates body function but after puberty, gonadol hormones responsible for most of the changes.
Adolescent growth spurt AGS last for four and half years when the body assumes an adult
appearance. Boys begin spurt at 13, Girls at 7.5-12 years.

These physiological changes may cause worry and embarrassment if they are not congruent with
the peers. They may comparatively come early/later in which case counseling needed.

Psychosexual development; According to Freud, physical changes in puberty re-waken the

sexual and aggressive energies felt toward parents during early child hood. To effectively cope,
adolescent need to re-direct these newly re-emerging energies from parental relationship to non-
familial relationship – friendship, love, interest, and career endeavous. Hence, they need
detachment or separation from parents and may result to conflict with parents. The psychological
changes in adolescence are attributable to physiological changes. They way an individual and
others respond to these adolescent changes is vital. The changing body appearance seriously
affects their self-concept –body image and selfesteem.

Health promotion ; General nursing interventions ; Many adolescent not willing to seek health
care because of financial concern, accessibility, characteristics of health care providers and
confidentiality issues. Hence show respect, compentence, warmth, compassion, and
understanding. Effective communication is vital to gain trust of the adolescent e.g. provides.
Caring environment, individualize care, strengths and weakness acknowledged, treat them with
dignity –know them indivually, assessment geared to promotion health improving it, relationship
with family vital to establish and maintain – hence the need to involve family. Involve them in
their care as much as possible. Help them take responsibility of their health as you guide them to
make appropriate decisions. May need teaching a decision making.0.

Environment and confidentiality are vital consideration when interacting with adolescent –e.g.

May seek health care away from home. Hence consent may not always be sought
from parent in case of underage (legally).T he goal for adolescence health
promotion: immunizations, nutritional, dental health, sleep or rest activities, risky
behavior, safety, violence, motor vehicles, sexual activities, homosexuality,
contraceptives, suicide, menstrual problems, pregnancy, chron ic fatigue syndrome,
STI, drug abuse and alcoholism and obesity.
54
PEDIATRIC ASSESSMENT

Student learning objectives

At the end of the chapter the learner should be able to:

a. Elicit a complete health history from a child and caregiver using standard components of
a pediatric health history.
b. Discuss the purpose of a nutritional assessment and its components.
c. Explain the purpose of nutritional assessment.
d. Identify various techniques of approaching children at different developmental levels
before initiating the physical assessment.
e. Describe inspection, palpation, percussion and auscultation in a head-toe-assessment of a
child.
f. Identify normal and abnormal findings obtained during the physical assessment.

INTRODUCTION: Children undergo physical cognitive and social changes as they

mature.-the nurses must be aware of these changes while continually reassessing what is
considered within normal limits
PHYSICAL GROWTH: Parameter indicative of physical growth include: weight,
length, height, and head circumference. The parameters can be normal/ abnormal
depending on age.
Learning activity: Refer to growth and development at different stages for normal
parameters.
Health history: In pediatric history, the historian is usually the caregiver, hence it’s
important to know the relationship with the child. Include child with Hx taking depending
on age/development e.g. adolescents, school age

Components of pediatrics health history

1. Biographical data: The following components are important: Name of child and
legal guardian care; Address and phone number-child or/and guardian. Source of
information-other than the care giver, other sources include: medical/school
records, diaries, clinic notes etc.

55
 2. Client complaint: usually given by care giver-for infants, toddler and pre-scholars
whose age and mental status prevent them from offering genuine information?
Older preschooler, school age and adolescent able to describe their complaint.
3. Past health history: Birth history: prenatal history – Planning, date of start of
clinic, number of children/ abortions, medication. Illnesses in pregnancy.
Labor/delivery-gestation, labor duration, C/S or virginal, ianalgesic age, birth
weight of neonate, Agpar score, where baby born i.e. home/hospital. Post natal: If
went home with baby together? Hospitalization days, Breathing/feeding problems
early in life, medicine received, bottle or breast feeding and fever after delivery.
Medical history: hospitalization or OPD treatments. Injuries/Accidents: e.g.
measles, mumps, rubella, chickenpox, pertussis. Immunizations status needs to be
confirmed.
4. Family health history: inquire about age and health status (if dead age, cause of
death) of child’s mother, father, siblings, grandparents, aunt and uncles. Family
disease –like alcoholism, asthma, congenital disorders, mental retardation, diabetes
mellitus, seizures sudden infant death syndrome need to be elicited etc.
5. Social history: work environment-schools, day care facilities-how much time
spent their academic performance. Home environment-potential exposure to lead-
pregnancy and young children. Note that lead affects brain development and
nervous system. Child ‘s personal habits
ADENOIDS IF ELARGED CAN BLOCK AIR FLOW THROUGH NASAL
PASSAGES.
We should be careful when chewing food or swallowing food to avoid accidents .like
(choking, coughing)
We should eat healthy to keep our body healthy, (protein, carbohydrates, and vitamins)
Check the activities that the child enjoys, stress coping temper tantrums and discipline
measures used.
Health maintenance activities: sleep naps, share, share bedroom etc. diet should be
tailored to child’s development level safety use methods used for child proofing the
environment
Nutritional assessment - good nutrition is vital for optimal health and disease prevention
appropriate nutrition habits should be built early in life.
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 Nutritional assessment the bases of anticipatory guidance, identification of at risk
individuals, referral as need be. There are various methods used to assess nutritional; status:
 History of dietary intake
 Laboratory data
 Anthropometric data
 Physical examination
Dietary intake and history: records of dietary intake e.g. food diary 24 hour recall.
Type and amount of food information gotten. Know about liquids given.
Dietary history depends on age. Questions relate to what is expected at that age e.g.
balance diet, fast/foods/ snacks, dental care, frequency, adequacy.
Note: remember the different nutritional needs are based on age of the child.
Lab evaluation: the tests are ordered usually are albumin & pre-albumin.
They reflects adequate calories and protein intake.
Serum albumin- reflect previous month’s food intake. Pre albumin reflects previous one
intake. Complete blood cell cont. (Hb, hematocint and RBC indeces, iron status and
cholesterol.
Anthropometric data:
Measurement of parameters e.g. height, weight, skin, folds etc. physical growth measured
by weight, ht/length, skinfold thickness, arm circumference which indicate body fat stores,
nutritional status and skeletal muscle mass.
Learning activity: read more on how the above test like skin fold thickness and arm
circumference is done.
Physical examination: physical examination of all systems can indicate nutritional status
e.g. in musculoskeletal system poor nutritional status will be indicated by reduced muscle
tone, flappy muscle, bowing lower extremes, frequent fractures and weakness, in
cardiovascular system palpitations, swelling, cardiac enlargement, changes in blood
pressure, edema heart murmurs and tachycardia
Development assessment: used to assess developmental functioning. The process is to: -
validate normal development, detect problems early. Basis for anticipatory guidance and
identify care givers’ concerns. Many tests can be used for developmental assessment e.g.
 Carey – revised infant (4-8m)for sleeping and temperament
 Denver articulation screening test 2.5 -6 years) – intelligent and articulation
57
  Denver II (Birth -3 years) expressive and receptive components of speech
 Good enough – Harris drawing test (5-17 years) drawing ability
 Developmental profile II(B-9 yrs.) physical, social and academic skills
Learning activity: read more on developmental test including how they are used
Caution: during testing: Childs performance can be affected by: current illness, fear/anxiety,
deafness and blindness. Early detection of abnormalities will lead to appropriate intervention
and assistance
How do you make paediatric assessment successful?
The following considerations are important in facilitating paediatric assessment
 Use game playing and distraction to increase cooperativeness e.g. small toys, wind up
musical toys, humming/whistling.
 Demonstrate produce on doll, stuffed toy or even the care giver prior to performing
them on the child
 Explain procedure
 Warm equipment
 Invasive procedures should be done last e.g. ear Inspection.
 Interview older children separately.
 Caregiver present during assessment.
 Room should be warm and quiet.
 Provide comfort measures after painful procedures etc.
Assessment of different aspects of the paediatric client.

Vital signs; obtain these parameters at beginning of assessment or during assessment of systems
i.e. blood pressure, pulse, respiratory, pulse-indicate the child’s basic physiological status.

Temperature; Oral, rectal, auxiliary& tympanic temperatures taken. Depends on age, condition,
development stage. Rectal temp-good for all ages but if diarrhea is there, no use <2yrs.Rectal
perforation is also possible. Axillary temp-all age but not very accurate & may not detect early
changes in temperature. Oral temperature requires cooperativeness of the child. Taking of
tympanic temperature is controversial.

58
Respiratory Rate: Obtain early in assessment when child is cooperative. If child crying,
measurement become inaccurate and you need to retake it. Observe the expansion of the
abdomen in infants and toddlers- chest must not be visible.

Pulse: An apical pulse is taken especially for children<2yrs, all those with cardiac problems and
those on digitals preparation. Place stethoscope on precordium. Children over 2yrs you can take
the radial pulse. Tachycardia is indicative of fever, anxiety, dysrhythmias or medication.

Blood pressure: Choose correct cuff size.

You can use the following formulae in determining normal blood pressure in children who are
one year above:

Systolic= normal (80mmHg) + (2x age in year). Normal diastolic is usually 2/3 of systolic
pressure.

Physical growth: Weight: Scale depends on age of the child. Neonates usually lose 10% of
between by 3rd-4th day after birth which they regain it by 2 weeks of age. This is called
physiological weight loss- This is due to loss of extracellular fluid & meconium. Length /
Height- Length is measured for children <2years. May place child on supine position &
measures head to heel. Other children height is measured just like in adult’s .Head circumference
– For children < 2yrs or child with known or suspected hydrocephalus. Tape measures is used .It
is placed anteriorly just above the eyebrows and around posteriorly to the capital protuberance.
Normal growth size—1-1.5cm/ mouth for 1st yrs. Small head circumference may indicate
prematurity. Other problems could be microcephalus and hydrocephalus. Chest circumference-
Measures till up to 1yr. Tape measures placed around chest at the nipple. Head circumference is
initially bigger than chest circumference, after wards its vice –versa.

FLUID AND ELECTROLYTE ALTERATIONS

Students learning objectives

At the end of the chapter the learner should be able to:

a) Identify differences among adults, children and infants related to fluid

requirement, fluid therapy and electrolytes.
b) Compare mild, moderate and severe dehydration.

59
 c) Describe the treatment of a child with gastroenteritis based on the degree of
dehydration.
d) Describe common types of burns, their management and prevention.

INTRODUCTION
Physiological factors responsible for fluid and electrolyte differences between children and
adults include: percentage and distribution of body water; body surface area; rate of basal
metabolism and status of kidney function. Infants and children have a higher amount of body
water than adults: infants (80%); children (65%); adult (50%) of body weight. Intracellular and
extracellular fluid distribution also differs: 40% body water in newborns is extracellular fluid.
Extracellular fluid is lost usually faster.
NOTE: Children reach adult water distribution at the age of 5years.
During vomiting, diarrhea ,hemorrhage ,ECF water is lost first .therefore ,children are more at
risk for fluid alterations beau case a higher percentage of their body weight is water and water
and more of that water is located in the extracellular comparing
Infants /children have a relatively grater body surface area than adults .Therefore ,insensible
water losses through the skin and lungs are higher in children .infants and children also have a
higher Basal Metabolic Rate (BMR).One to higher BMR ,fluid intake per kilogram of body
weight per day must exceed the per kilogram fluid requirement of an adult .father, their bodies
cannot regulate homes tic changes as quickly as adults due to immature liver /kidney , hence
more H2O / electrolytes has potential to cause imbalances .common alertation:DH2O , Age
,edam and burns
Dehydration

Due to the extracellular fluid loss. Large portion of child fluid in extracellular spaces (than adult)
hence more susceptible to dehydration .dehydration if not corrected can lead to hypovoiemic
shock and death .types

1. Hypotonic: an+ loss is greater than h2o loss hence serum an+ falls below 130MEq/l hence:
intracellular becomes more concentrated and body responds by moving fluid from
extracellular spaces to intracellular spaces. though this re stabilities osmotic
equilibrium , it increases fluid losses and can lead to shock .causes inappropriate IV
therapy ,gastric ,nephritis ,adrenal insufficiency ,not replacing gastric secretions.

60
 2. Isotonic DH2O: loss of na+ and h2o equal, hence serum na+ levels remain normal. Fluid
loss both extra and intracellular. Since there is no osmotic variation, much loss comes
through extracellular spaces .It is the most common type of DH2O in children .Reduces
plasma volume leading to hypovolemic shock.
3. Hypertonic DH2O: loss of H2O is greater than the loss of na+ .May develop in infants
who are treated for diarrhea with high concentration fluids .NA+ goes beyond 150
intracellular spaces to intravascular compartment, hence intravascular volume is
maintained and shock is less apparent .But it is the most dangerous type because the
fluid replacement strategy is much more difficult to determine and manage .May result
from sense vomiting and diabetes inspidus

Incidence and Etiology : Any procedure or illness that requires prolonged NPO status can result
in DH20.Infant or young children are the most vulnerable to DH20.Conditions
causingDH20:Vomiting,diarrhea,burns,hemmorrhage,nasogastric suctioning and drainage loss
(excessive),NPO status or inadequate fluid or food intake due to illness , over use of diuretics or
enemas Adrenal insuffiency - ADH.

Weight loss, Rapid, thready pulse, blood pressure, Peripheral circulation,urnary output, specific
gravity ,skin turgor - elasticity, dry mucous memberanes , absence of fear , sunkenfontanel in
infants. Clinical dehydration depends on weight loss. Thus:

 Mild-<5%weight loss
 Modarate-5-10%weight loss
 Severe->10%weight loss

Diagnostic evaluation: Based on clinical manifestation from physical examination, history and
laboratory test.

Therapeutic management: Depends on the degree. The aim is to correct fluid/electrolyte

imbalances and treat the underlying cause e.g. Gastroentreritis.

Oral rehydration therapy; for mild to moderate DH20. Should contain: Glucose (20g), Na+
(90MEq/L), K+ (80MEq/L), Bicarbonate-Chloride (30MEq/L).Caregivers need to know that the
fluids contain the above concentration. Don’t use fruits juices ,soft drinks etc since they have
high CHO and electrolyte .ORS can be made at home .Type of DH20 determine treatment e.g.

61
Isotonic dehydration five isotonic fluids e.g. normalsaline,ringer,(RL) actate ,Dextrose 5% in RL
Hypotonic H20. Oral route preferred but IV used if not possible or in severe state. Rate of fluid
replacement depends on degree of DH20.Itis basedon the child’s weight and clinical
manifestation .Calculating Fluid loss from weight loss

1kg of body weight loss= 1l of water

Therefore: 1kg of weight loss+1000mls of fluid losse.g. America Academy of paediatrics

recommends:

Minimal < 3% - 10ml /Kg ORS per stool

Mild 5% -50ml /kg ORS IN 4hours after each loose Movement

Moderate6-9%-100ml/ kg ORS

Severe >10% - a) Emergency

b) IV, 40m/s/kg/hr. until child improves then, 50-100ml/kg ORS

(c)Reassess often.

Nursing management. Assessment: Reduce perfusion- skin pale and fray, cold skin increased
capillary refill time. Also check heart rate ,BP and pulse (peripheral) .Skin-dry and loose i.e.
loss of skin turgor .This result in tenting of skin when pinched .Mucous membrane e.g. absence
of tears (5%of weight loss).If below 18m ,to check fontanel( anterior). Expressed/ sunken .intake
and output assessed – urine, stool, emesis, wound drainage etc. Semi- electrolyte result reviewed.
Family teaching is important –Sign and symptoms, administration of ORS. Judging the state and
knowing when to seek medical help e.g. after 4 hours re hydration with no improvement,
inability to retain fluids, urine output reduction and change in mental alertness

Acute frastroenteritis: Diarrhoea disease of rapid onset with or without accompanying

manifestations e.g. nausea, vomiting, fever, abdominal pain. Inflammation of the membrane of
stomach, intestines .Usually self-limiting but prolonged dx cause DH20 (Morbidity and
mortality)

Incidence and etiology: Common in children attending common facilities e.g. day care centers,
schools and others institutions. Etiology : Viruses, bacteria and parasites e.g. Rotavirus, Shigella

62
a) Criadia lamblia Norwalk virus, Salmonella Cryptosporidium, adenovirus , Camphylabacter,
entamoeba historical, eschrichia coli, clostridium difficle ,and yersinio.

Incidence and Etiology : Any procedure or illness that requires prolonged NPO status can result
in DH20.Infant or young children are the most vulnerable to DH20.Conditions
causingDH20:Vomiting,diarrhea,burns,hemmorrhage,nasogastric suctioning and drainage loss
(excessive),NPO status or inadequate fluid or food intake due to illness , over use of diuretics or
enemas Adrenal insuffiency - ADH.

Weight loss, Rapid, thready pulse, blood pressure, Peripheral circulation, urinary output,
specific gravity ,skin turgor - elasticity, dry mucous membranes , absence of fear , sunken
fontanel in infants. Clinical dehydration depends on weight loss. Thus:

 Mild-<5%weight loss
 Modarate-5-10%weight loss
 Severe->10%weight loss

Diagnostic evaluation: Based on clinical manifestation from physical examination, history and
laboratory test.

Therapeutic management: Depends on the degree. The aim is to correct fluid/electrolyte

imbalances and treat the underlying cause e.g. Gastroentreritis.

Path physiology: Viral-poorly understood, but thought to cause damage to the epithelial cells
lining intestines. Bacterial gastroenteritis: Destroy mucosal cells hence reduce SA for
fluid/electrolyte absorption; penetrate musoca and submcosa-necrosis, ulteration and may enter
systematic circulation; Organism produces enterotixins that stimulate secretion of fluid and
electrolyte from small intestines. Enterotoxins also interfere with surface are of upper intestine
e.g. shigella, enterotoxigenic, E.coli

Clinical manifestations: Depends on causative organism General Sign and symptoms include:
diarrhea, nausea, vomiting, abdominal pain, weight loss, fever, and DH20 and electrolyte
imbalances. Others; malaise and lethargy

Diagnostic revolution based on history and physical examination and lab tests. Hydration status
should be assessed.

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Therapeutic management: Depends on degree of dehydration. Aim is to replace fluid and
electrolyte. Therefore< adequate caloric intake and fluids are appropriate. Use of antiemetics is
not recommended because the vomiting/diarrhea are body’s means of eliminating infecting
organisms. Use of antibiotics, not necessary unless in <3 months e.g. who may get salmonella
bacteremia. Shigella and salmonella infections are self-limiting usually). Parasitic infections e.g.
metronidazole use.

Nursing interventions include: Administer oral rehydration solution to replace fluid and
electrolytes. administer and monitor IV fluids as prescribed – IV therapy based on degree of
DH20; check urine specific gravity shortly if increasing in DH20; weight taking, daily same
time, in order to monitor effectiveness of rehydration; maintain intake/output by evaluating
hydration status and effectiveness of fluid replacement. Evaluation: Child has signs of normal
hydration e.g. presence of tears, improved skin turgor, moist mucous membranes.

Family Teaching on: - preventing, most effective treatment – Careful hand washing after
diapering, toileting, before feeding, eating, food preparation; change diaper for acidic stool
frequently to prevent urination of skin; wash perineal area with soap and H20 after each diarrhea;
apply protective ointment to bottom; teach care giver about when to contact healthcare provider
e.g. blood in diarrhea, child doesn’t urinate for >6 hours, cries and produces no tears etc.

Burns: Great advances have been made with the treatment of burns in the last 50 years, hence
better survival of these children. Burns usually result from accidents that could prevented.
Hence, a nurse needs further teach care givers preventing measures.

Incidence and Etiology: depends on cause;

 Thermal most common in children; mostly from flames explosions/flash, scalds, contact
with hot objects

 Electrical

 Chemical

 Radiation- over-exposition to UV rays

Determination of cause of burn in vital because some result from child abuse.

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  Pathophysiology: Burns range from minor local injury to burns with multisystem
involvement All systems are affected. In the first 24-48 hours the following happens in
respective systems: Cardiovascular: decrease in CO due to increase in capillary
permeability and vasodilation, increase in metabolic acidosis hemacrotic.
 Renal system: decreased blood flow to the kidneys decreased acid production in 48-72
hours, later increases in production and the risk of stress ulcers, decreased GIT motility
Metabolism; rapid protein break down and muscle wasting , increased metabolic rate
from nitrogen loss and stress of injury , increased heat loss through damaged skin,
increased blood glucose levels due to insulin resistance and breakdown of glycogen
stores; delayed growth and maturation from need to use energy to repair burned tissues
 Note: Treatment should be targeted to each the above changes (and others) in each
system e.g. for cardiovascular system-increased fluid replacement, maintain vital signs
and especially BP and assess blood gases. GIT-monitor bowel sounds place NG tube for
decompression of stomach.
Metabolism maintain intake calories , give parental nutrition , increase protein diets and
increase vitamin C & A

Clinical manifestations: severity determined by depth and surface area categories of burns
based on depth of tissue destructions.

Superficial (1st degree): Epidermis, painful (very) red, heals easily in 5-10 days, no systemic
effects and no scarring

Partial thickness (2nd degree): upper layer of dermis, bright red, moist, painful (extremely),
sensitive to cold air, blistered, heals, heals in 14-21 days with some scarring if deep dermal layer
involved.

Full thickness (3rd and4th degree): Epidermis and dermis and subcutaneous tissue, form
Escher (thick leather-like dead skin), whitish, leathery.

Dry appearance, less painful, scarring, and contractures may form.

4th degree- tendons, bones and muscles involved.

Usually electrical burns. Requires skin grafting, skin flaps, possible amputation to fuel heal,

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Estimation of percentage burns

Adults (rule of nines) Child (rule of sevens)

Head: 9 28

Trunk: 36 28

Legs: 18 each 14 each

Arms: 9 each 7 each

Perineum: 1 2

The percentage of area burnt determines the fluid resuscitation needs. Usually refine hospital
except minor burnt.

Diagnostic evaluation: Clinical manifestation and physical examination.

Therapeutic management: The aim of the treatment targets: ABC: Fluid resuscitation and
respiratory management.

Respiratory management: Airways. Oxygen if needed especially in upper body burns, facial
bruises and smoke inhalation burns

Fluid resuscitation: Especially in1st treatment- prevent hypovolemic shock due to increased
capillary permeability. Ringers lactate usually used. Child body weight and% of burned area
determine fluid volume and rate of administration.

Parkland Formula for calculating resuscitation needs: 4mls of lactated Ringer solution x kg of
body weight x % total body surface area burned divided into one –half of total 1ST 8 hours post –
burn; quarter next 8 hours and then quarter the next 8 hours.

Note: Calculate the time from the time of sustaining burn not admission of the client

Foley Cather is inserted to determine urine output measurement. Signs of recovery; having
regained capillary permeability and urine output and decreased IV fluids to avoid fluid overload
and pulmonary edema.

Pain management: Burn pains – Acute and Chronic Pain compounded by performing
procedures on the wound e.g. dressing. Fears and anxiety increase pain perception. Major burns-
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narcotics e.g. morphine. Minor burns- acetaminophen. Given before any painful procedure.
Other pain –alleviating procedures – Behavioral interventions (imagery, relaxation, hypnosis,
music therapy)

Wound care; after stabilization. Aseptic technique .Clean and debrided- removal of dead tissue
(very painful). Wound soaked for 10 minutes and then washed from inner to outer edges using
firm, circular motion (cut dead tissue with forceps). Apply antimicrobial cream e.g. silver
sulfadicizine; others; silver nitrate, magenide acetate (suitamylon cream). Hydrotherapy can be
used to soften dead tissue. Dressing ded x 1\2 day. Grafting: 4 full thickness burns (auto graft)
taken from unburned area of child’s own skin. After graft heals, pressure dressing applied to

Avoid contractures formation and minimize scarring (uniform pressure important for these
dressings)

Prevention of impaired mobility: Contractures due to; Increase bed rest, Muscular atrophy and
shortening, stiffening of burned tissue, appropriate position and exercise to prevent the above ,
e.g.: Range of motion exercise e. g . Use toys perfumed X 3/ days. Analgesics also important.

Nutrition support: Burned child require2-3 times the normal calories .Diet: Increased proteins
23% of total calories

, Multivitamin leading to C&A increase.

Psychological support: Play therapy. Counseling leading to increased self-esteem and family
financial concern.

Family Education: Nutrition and diet; daily dressing and skin care; exercise (range of motion
exercise) elasticized garments.

Prevention of burning injury: Smoke detectors; escape route keep hot items away e.g. hot liquids
and chemicals kept out of reach.

GENITAL URINARY ALTERATIONS

Students learning objective

At the end of the chapter the learners should be able to

A. Review the anatomy and physiology of the urinary tract and pediatric variations.

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 B. Describe the etiology, clinical manifestations, treatment, and nursing management of
urinary tract infections in children.
C. Describe the etiology, treatment, nursing support and management of common genital
urinary alterations.
D. Describe the etiology, clinical manifestations, treatment and nursing, management of
common congenital malformations of the urinary tract and external genitalia of children.
E. Identify education needs of families and children with genitourinary alterations.
F. Explain the type of renal failure and their treatment

Urinary tract infections.

Classification of urinary tract infection (UTI)

Let us now classify urinary tract infections.

Lower urinary tract infection e.g. cystitis and urethritis and upper urinary tract infections e.g.
Pyelonephritis.

Incidence/ etiology of urinary tract infections.

Most common problem of genitourinary tract. UTI in newborns approximately is approximately

1%. At 1 year- more girls than boys are affected. More common in uncircumcised more than
circumcised boys. The bacteria commonly involved include Escherichia coli which is common in
GIT and perianal skin. Others include Klebsiella, Entero bacter, proeteus spp, and pseudomonas
. These later four are associated with complicated UTI, often in children with chronic conditions
that alter urinary tract e.g. neurogenic bladder in spinal bifida. Virus, fungi (e.g. candida) may
cause UTI.

Pathophysiology: short urethra in female increase vulnerability while long urethra in males
decrease vulnerability. Structural anomalies e.g. neurogenic bladder, vesico ureteral reflux
common in children with spinal bifida, urinary catheters, urinary stasis, and obstructions may
predispose to UTI.

Vague in young children, older child, malodorous urine, dysuria (diff& painful urination),
urinary frequency, fever, vomiting, irritability, poor feeding, loss of appetite, flank pain,
avoidance of urination and hematuria. Infants may property with the following features: malaise,

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malodorous urine, irritability/ colic, Jaundice neonates, fever, poor, feeding, poor weight gain,
vomiting & diarrhea.

Specific infections affecting the urinary system

Pyelonephritis

This can be acute or chronic. Pyelonephritis is a bacterial infection of the renal pelvis, tubules
and interstitial tissue of one or both kidneys. Let us now start with acute pyelonephritis.

Acute pyelonephritis: Upper UTIs are associated with the antibody coating of the bacteria in the
urine. Bacteria reach the bladder by means of the urethra and ascend to the kidney. Children with
acute pyelonephritis become chronic, the kidneys become scarred, contracted and
nonfunctioning.

Clinical manifestations: An ultra sound study or CT scan may be performed to locate any
obstruction in the urinary tract. Urine culture and sensitivity tests are performed to determine the
causative organisms so that appropriate antimicrobial agents can be prescribed.

Therapeutic management: Children with acute uncomplicated pyelonephritis are usually treated
as outpatient, if they are not dehydrated, not experiencing nausea or vomiting and not showing
any signs or symptoms of sepsis. Pharmacological therapy for outpatients, a 2 weeks course of
antibiotics is recommended because renal parenchymal diseases is more difficult to eradicate
than mucosal bladder infections. Commonly prescribed agents include: ciprofloxacin,
gentamicin, or a third- generation cephalosporin. These medication must be used with great
caution of the patients has renal or liver dysfunction. A possible problem in acute pyelonephritis
treatment is a chronic or recurring symptomless infection persisting for months or years. A
follow up urine culture is done 2 weeks after completion of antibiotic therapy to document
clearing of the infection.

Chronic pyelonephritis: The child with chronic pyelonephritis usually has no symptoms of
infection unless an acute exacerbation occurs. Noticeable signs and symptoms include: fatigue,
headache, poor appetite, polyuria, excusive thirst, weight loss. Persistent and recurring infection
may produce progressive scarring of the kidney, with renal failure.

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Complications: Complications of chronic pyelonephritis include: ESRD (end- stage renal
diseases) from progressive loss of nephrons secondary to chronic inflammation and scarring;
hypertension and formation of kidney stones.

Therapeutic management: The choice of antimicrobial agents is based on which pathogen is

identified through urine culture. If the urine cannot be made urine free, nitrofurantoin may be
used to suppress bacterial growth. Important nursing management.

The child may require hospitalization or may be treated as an outpatient. When the child is
hospitalized, fluid intake and output are carefully measured and recorded. Unless
contraindicated, fluids are encouraged (3 to 4 days) to dilute the urine, decreased burning on
urination, and prevent dehydration. Nurse assesses the child temperature every 4 hours and
administers antipyretic and antibiotic agents as prescribed. Nurse educates the parents or child on
prevention of UTIs by consuming adequate fluids, emptying the bladder regular and performing
perineal hygiene. Nurse emphasis the importance of taking antimicrobial medications exactly as
prescribed. Now let us discuss an example of lower urinary tract infections.

Cystitis

It’s the inflammation of the bladder.

Pathophysiology: Gram negative organisms that enter the urinary bladder, the major organism is
the Escherichia coli. Normal flora in the bladder initiates the inflammatory reaction that affects
the inner wall of the bladder. Depending on severity may cause hemorrhagic cystitis i.e. bleeding
through the bladder walls.

Clinical manifestations: Cystitis is characterized by severe irritable voiding symptoms (day and
night frequency. Nocturnal, urgency); Pain and discomfort (suprapubic pressure, pain with
bladder filling, supraubic or perneal pain and pressure) markedly diminished bladder and
capacity.

Assessment and diagnostic evaluation: The diagnosis is made by excluding other causes of the
symptoms. Urine culture and sensitivity is done. Urinalysis will also be done.

Therapeutic management: Treatment strategies includeuse of medications that target pain and
discomfort. Pharmacologic therapy involves Tricyclic antidepressant medications (doxepin and
amitriptyline) which have central and peripheral anticolinergic actions may decrease the
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excitability of smooth muscle in the bladder and reduce pain and discomfort. Use of the
appropriate antibiotics. Nursing management involves focus on health promotion. Ensure that the
child empty the bladder regularly. Wipe the perineal from front to back. Take adequate amount
of fluids. Avoid caffeine, chocolate, because they cause bladder irritation. Urethritis is also an
infection of the upper urinary tract.

Urethritis: It’s the inflammation of the urethra. It’s usually an ascending infection and may be
classified as gonogococcal or non-gonocal. Non-gonogococcal urethritis is usually caused by
Chlamydial trachomatis or unreaplasma urealyticum.

Diagnostic evaluation: It’s very difficult to diagnose since the bacteria is in the urethra tissue
and not in the urine. Culture of split urine collection is done.

Therapeutic management: Use of antibiotics like tetracycline, or doxycycline and

erythromycin. Nursing management is the same as in cystitis. Prevention of urinary tract
infections is very important. Educate on preventive measures

General patient education on preventing recurrent urinary tract infections

-Hygiene: Shower rather than bathe in tub because bacteria in the bath water may enter the
urethra. After each bowel movement, clean the perineum and urethral meatus from front to back.
This will help reduce concentration of pathogens at the urethral openings and in the girl’s vaginal
opening.

-Fluid intake: Drink liberal amount of fluids daily to flush out bacteria. Avoid coffee, tea, colas
and other fluids that are urinary irritants.

-Voiding habits: Void every 2-3 hours during the day and completely empty the bladder. This
prevents over distension of the bladder and compromised blood supply to the bladder wall.

-Drug therapy: Take medication exactly as prescribed.

Inguinal hernia & hydrocele: These conditions are similar in clinical manifestations and
treatment. Inguinal hernal is a scrotal or inguinal swelling or both that include abdominal
contents. This incidence is 10-20: live births. Common in boys than girls 4:1. Incidence increase
with prematurely & low birth weight. Those receiving dialysis due to increased abdominal

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pressure are also at higher risk. Infantile inguinal hernias diagnosed in first month of life.
Hydrocele occurs in 6% of full term boys.

Etiology: Inguinal hernia occurs when abdominal contents exit peritoneal cavity and protrude
into processus vaginalis (a fold of peritoneum that precedes the testicle as it descends through the
inguinal call into the scrotum. An incomplete or abnormal obliteration of the processus vaginalis
at birth allows peritoneal fluid/ abdominal contents to enter the scrotum which result in
hydrocele/ hernia. Processus vaginalis follows same descending pathway of the testes into the
scrotum. Common clinical manifestation include: K+ levels, burn and creatinine increase, low
grade fever and urine becomes blood tinged, smoky or tea color.

Diagnostic evaluation: based on clinical manifestations above, physical examination,

immunologic tests to detect streptozyne and serum complement.

Therapeutic treatment: depend on degree of kidney damage. The aim is to treat source of
inflammation, maintain fluid and electrolyte and maintain BP within normal range.

Norte: do thorough physical examination to know the source of inflammation

For a child with normal BP and urine outputs, you can manage at home, those with Oedema,
increase BP, olguria, and hematuria are hospitalized because acute renal failure may occur. If
there is generalized oedema diuretics need to be used.

Increase BP use antihypertensivenes. Dietary restrictions based on degree of BP & edema e.g.
Na+, K+, fluids

Nephrotic Syndrome

Clinical entity by massive proteinuria and hypoalbuminemia leading to edema and hypelidemia

Types

 Idiopathic (primary) – due to glomerular disease of kidney. The most common type

 Secondary – renal malfunctioning due to systematic disease, drugs or toxins e.g. hepatitis,
systematic lupus erythematosis, lead poisoning, child cancer therapies – put stress on the
renal system.

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Etiology: more common in males than females i.e. it is commonly affects those aged between 2-
6 years. Idiopathic type is thought to be immune response while the other is caused by infections,
drugs and toxins as discussed above.

 Inguinal hernia – cause bulge/swelling in scrotum/groin – size increase with increased

abdominal pressure.

 Pain strangulated – possible necrosis and perforation – irritability, vomiting, abdominal

distention, tachycardia

 If hydrocele is present: scrotal swelling is painless and doesn’t change in size/shape when
abdominal pressure increases with by cough, cry, not reducible and easily transilumited.

The diagnosis is made through physical examination of scrotum, angina area differentiated by:
hernia – boggy, reduced by pressure and reducible (usually) while hydrocele – fluid filed, feel
tense and not reducible.

Therapeutic management: inguinal hernia hemiorrhapy is done outpatient basis. For hydrocele
is resolved within 1 year of age spontaneously. If not, means hermia present and repair same –
hydocelectomy.

Acute glomerulonephritis

This is sudden inflammation of glomeruli within the kidney which result in acute renal failure.
Glomerulus gets damaged, hence referred as intarenal acute failure. It may affect glomerular
capillaries or membrane,

Incidence/etiology: rare in <3 years and peak at 7 years. More common boys: girls 2:1
infectious agent is usually in the body2-3 weeks before clinical manifestation. It could be
bacterial (streptococcus group a commonest) e.g acute post streptococcal glomemlonephrritis or
vital.

Pathophysiology: viral or bacterial agents invade body. Immune system produces antibodies
against them. Antibody antigen reaction in the kidney glomeruli forms immune complex and
inflammation occurs. End results is scared/damaged glomeruli membrane permeability altered by
immune response – protein leak into urine glomeruli filtration rate decreases. Sodium and water
are retained and edema occurs.

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Clinical manifestations: hematuria, dependent and periorbital oedema, diminished urinary out
proteinuria, increased BP, fatigue decreases glufiltration, increased serum Na+ level and increase

Pathophysiology: the inflammation process from immune response of disease makes glomeruli
to become [permeable to protein (proteinuria). Fluid shift from intravascular to intestinal space
which subsequently leads to odema/ascites, hypovalemia
Clinical manifestations: just as a child with renal failure it will cause edema, anorexia,
abdominal pain and tenderness due to inflammation of kidney, abdominal swelling and fatigue.
Diagnostic evaluation: dependent upon proteinuria. Urinalysis shows protein, red blood cells,
serum album, serum cholesterol, triglycerides, creatimine, hematocrit, placet count
Therapeutic management: the aim of management to reduce protein, oedema and prevent
infection. The mainstay of treatment is corticosteroids e.g. prednisolone with decrease
inflammation and loss of proteins hence restoring oncotic pressure and promoting diuresis. The
period of treatment is usually 4-8 weeks. Relapse is a possibility. Immuno suppressants e.g.
cyclophosphamide, chlorambucin and cyclosporine are used. Antibiotic may be required in case
infection due to excessive use of steroids. Diuretics like furosemide can be used but because they
can cause a decrease in N+, K+, and decrease hypovolemia monitoring electrolytes closely is
important. Decrease salt intake because of edema & increased blood pressure.
Nursing considerations: maintain fluid and electrolytes, administer medication and prevent
infection and skin breakdown.
Hemolytic uremic syndrome
Acute renal disease, often lead to acute renal failure
Incidence: uncommon and affect usually children aged 6m -3 years old. Around 80% of them
are under 4 years. The exact etiology is not determined but associated with: bacterial toxins,
viruses and chemicals. The common causative organisms are: E.coli, shigella, rickettsia,
coxsackievirus, echo virus, adenovirus, salmonella and pneumococci
Pathophysiology: it’s complex, bacterial invasion of GIT and maturity and multiply causing
vomiting diarrhea and peristalsis reduction. Endoxin produced by bacteria also damage capillary
walls through inflammation and surrounding vessels get occluded. This process can also occur in
renal system. Damage to endothelial lining of the affected tissue swell and platelets move there.
This causes clot formation and intravascular coagulation-decrease blood flow in renal system.
Renin produced which increased BP platelets, RBCs damaged causing thrombocytopenia.

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Involvement of the renal system causes decrease of glomerular filtration which decrease urine
output and acute renal failure with increased BP occurs. Note that inflammation & clot can occur
in any system but common in: gastrointestinal system, respiratory system and genitourinary as
examples.
Clinical manifestations: involves a triad of acute renal failure, thrombocytopenia and anaemia
(hemolytic). In the early stages of disease process there is diarrhea/vomiting, URTI, irritable,
lethargic, anorectic, anaemia, platelet decrease bleeding, bruising pumpura and high blood
pressure.
Diagnostic evaluation: physical examination will reveal hepatosplenosmegally, increase BP and
edema. Full heammogram also need to be done.
Therapeutic management: symptomatic is the main approach to management. If renal failure &
electrolyte imbalance has occurred, hemo or peritoneal dialysis especially for anuric children,
oliguria, high BP & experiencing seizures. Treat the increased blood pressure. Treat metabolic
acidosis with bicarbonate therapy as kidney is not able to buffer acids. Institute fluid restricting if
necessary.
Renal failure
Common condition that affects kidney and hence it’s functioning. It can be acute or chronic
Acute renal failure (ARF): Sudden onsets of impaired renal function. Most with ARF regain
function. ARF classified according to part or renal system affected, thus we have pre renal, intra-
renal and post renal failure.

Etiology/incidence: ARF is uncommon but can be life threatening. Pre-rental-sudden decrease

in rental blood flow or perfusion to kidney. Common cause include: DH2O, Hypovolemia,
Shock, Sepsis, Rental artery obstruction and parental asphyxia. Intra renal is due to damage of
kidney tissues. Causes of intrarenal ARF include: Antibiotics, e.g. amino glycosides and other
nephrotoxic medication, contrast dyes, ureterovesical obstruction. Hemolytic uremic syndrome,
glomerulonephritis, pyelonephritis and other injection. For post renal, it’s due to obstruction of
urine at some point between kid and urinary meats. It’s on outflow obstruction that cause “back-
up” of urine and put pressure on endothelial lining and ultimately diminishing renal function.
Causes can be utero or post natally e.g. posterior urethra valves, ureter vesicle obstruction-an
obstruction junction of the urethras into the bladder-without inervatins; wilms tumor-a
nephroblastoma or solid mass which is the common renal tumor in children and renal calculi.

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Clinical manifestations: Electro and fluid imbalance, metabolic acidosis, dehydration, pallor,
lethargic, anorexia, vomiting and seizures.

Diagnostic evaluation: through history, laboratory and physical environment.

Therapeutic evaluation: The aim is to restore renal perfusion and correct electrolyte and fluid
imbalance. Management modalities include: fluid and Na+ restriction if increased, dialysis if
there is congestive heart failure or severe increase bloom pressure. Metabolic acidosis and
hyperkalemia need to be corrected.

Chronic renal failure (crf): Progressive disease. Irreversible damage has taken place for 50%
renal function and the condition has lasted for at least several months. If considered permanent/
irreversible-end stage renal failure (ESRF) is diagnosed. Chronis renal failure first process to
uremia (where toxic nitrogenous) waste products, blood urea, cretonne build up in system)

Etiology: It is associated with prematurity, nephrotoxic medications e.g. amino glycosides, renal
obstructions, glomemlonrphritis and pyelonephritis. Immunological dysfunction may also cause
injury to renal system. Pathophysiology is variable and depend on cause.

Clinical manifestations: Fluid and electro imbalance, dehydration, edema, metabolic acidosis
and systemic increase in blood pressure, anemia, pallor, fatigue, anorexia, vomiting, slowed
linear growth, organic failure to thrive, and renal bone disease/osteodystrophy.

Diagnostic evaluation: Is through history, laboratory evaluation and X –rays of long bones to
detect any osteodystophy.

Therapeutic management: the aim is to restore and maintain fluid and electrolyte balance. For
edema restrict fluid and Use diuretics, increase in blood pressure use antihypertensive, restrict
proteins, vitamin D supplement used to boost ca ++ levels to deal with bone disease. If above
treatment fail renal transplantation is done.

Structural defects: Let us now look at one example of structural defect.

Cryptorchidism: Cryptorchidism or undescended testicles, is the failure of one or both of the

testes to descend into the scrotum. At full term birth, less than 3% of the male’s population is
affected. In utero; the movement of testes is initiated by androgenous hormones. Failure to

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descend may be related to hormonal deficiency or mechanical problems such as a narrow
inguinal canal, a short spermatic cord, or adhesions.

Clinical manifestation:

Since proper function of the testes depends upon a temperature cooler than 98.6F, failure to
descend leads to decreased function and eventually atrophy of cases with an inguinal hernia on
the involved side.

Therapeutic management: Orchiopexy is the preferred treatment.

The testis is surgically brought down into the scrotal sac and kept in position by any appropriate
different traction devices such as a button on the outer scrotal surface or an elastic band attached
to the thigh. Choice of the device is up to the surgeon.

If the testis cannot be positioned the surgeon may elect to remove it to minimize the risk of
malignancy. If cryptorchidism persists into adolescence,

Sterility may result. Risk of malignancy is elevated if atrophy occurs.

Nursing management involves: Preoperative assessment reveals an empty scrotum with

unilateral or bilateral testes palpable in the inguinal canal.

Preoperative prescription need to involve the user of a tension device.

Post-operatively the nurse checks the device for proper tautness.

Bed rest is maintained until the tension suture is moved, usually in a few days.

Analgesics, ice packs are often used to relieve pain and thus enable the child to tolerate keeping
his leg extended.

GASRTROINTESTINAL TRACT (GIT) ALTERATIONS

Student learning objectives

At the end of the chapter the learner should e able to:

a. Review the anatomy and physical of the GIT and predict variations
b. Describe the etiology, clinical manifestations, diagnosis and treatment of common GIT
conditions
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c. Discuss nursing management and interventions appropriate for children requiring
abdominal surgery
d. Identify the education needs for families and children
We begin this chapter by discussing some alterations affecting upper gastrointestinal
system.
Cleft lip & clef palate: Cleft is an elongated opening tissure. Cleft lip and palate is the
most common congenital anomalies of newborns. One may have one or both affected.
Development of lips, muscles & palate is affected. The degree to which these structures
are incomplete/ malformed depends on type, severity and placement of the clefts.
Prevalence and etiology: The incidence rate is 1:5:1000. Cleft of lip without palate
more common in males cleft of palate alone more common in females. The etiologies
include: genetical, environmental factors – alcohol (mother), maternal age, vitamin,
deficiencies, phenytoin, diazepam, and folic acid.
Pathophysiology: Cleft lip caused by failure of the nasal & maxillary process to fuse
between the 5th & 8th week of gestation. Cleft palate is due to failure of the palatine
plates to fuse between 7th -12th weeks gestation.
Clinical manifestation: Cleft lip can occur on one side or both sides. Cleft palates and
occur the hard or soft palate. Diagnosis is usually made at birth.
Therapeutic management: Surgery is done closure of lip at 3 months while palate at 1
year for effective feeding / speech development. Some long term difficulties may occur
e.g. speech difficulties, malocclusion i.e. abnormal teeth eruption, hearing problems
from recurrent, otitis media due to abnormalities of Eustachian tube. Nursing aspects of
the management include: imbalance nutrition- e.g. poor feeding./ BF ;interruption in
bonding ; risk of injury & infection ; pain related to surgical procedures: deficient
knowledge related to the disease , treatment and prognosis ; psychological care of the
giver; protect operative site after surgery ; small metal strip (Logan bow / butterfly
adhesive placed overs the upper lip & tapped to the infants cheek to prevent tension on
suture line. Pain medication given because of pain. Teaching is important on feeding,
care of operative site, offer small H20 after feeding to discourage bacterial growth and
inform caregiver that more surgeries might require as the child matures.
Alternations of the lower gastrointestinal system.

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Intussusception: It is where one segment of bowel telescopes/ invaginate into the lumen of an
adjacent segment of intestines. Most frequent cause is intestines obstruction in infants/ young
children. It peaks between 3rd – 9th months twice as common in boys as in girls.
Etiology: Usually not identifiable. Some times polpy, foreign body or viral infection.
Pathophysiology: Bowel telescoping? / Invagination causes walls of bowels to press on one
another compromising blood flow. Involved intestines get inflamed, edematous and bleeding
occur and appear in stool.
Later complete bowel obstruction occurs with subsequent abdominal distention and vomiting. If
not treated is instituted necrosis perforation occurs

Clinical manifestation: Four classical manifestations include: colic, intermittent abdominal pain
(sudden), vomiting – early and red currant jelly – like stool. But these are present only in 50% of
those with disease. Others present with sausage- shape mass felt right upper Quadrant. Later
other symptoms set in: listless, lethargic, weak, thread pulse, shallow respirations and increase
body temperature

Diagnostic evaluation: Barium or air contrast enema-but invasive& radiation exposure;

abdominal ultra sound and x- ray nonspecific but more show intra peritoneal air (perforation)

Therapeutic management: Non-surgical hydrostatic reduction using barium, a water soluble

contrast agent or air enema (air insufflations-blowing air into a cavity) air and H2o use safer
than bariun because of bowel perforation risk. Air is 90% successful while water or barium is 65
to 85% successfully. If there is perforation peritonitis, shock occurs. If the above does not work;
surgical intervention to reduce (manually) intussusceptions. Nursing management includes: NPO
status, monitor vital signs for worsening state, - reassure caregiver who may worry due to
sadness of disease onset and surgical care pre-operative care. Family teaching: Caregiver to
observe signs of intestinal obstruction / recurrent e.g. abdominal pain, abdominal distension,
blood in stool and bile stained vomiting.

Hirschsprung’s disease (HD): Also called congenital aganglionic mega colon. Motility disorder
due to absence e.g. parasymthetic gaglion cells in colon hence no peristalsis & feces accumulate
proxima to defect- bowel obstruction. Most common cause of distal bowel obstruction in the new
born that may not be diagnosed until infancy on child hood. Common in males X3 -4 than
females.

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Etiology: Has one genetical link in 7% of cases. Aganglionic segment located oftenly in recto
sigmoid area. Affected area unable to transmit coordinated peristalsis movement/ waves.

Proximal to the defect, fecal matter accumulates & distension occurs. This causes hypertrophy &
dilation (mega colon)

Clinical manifestation: In new born, failure to pass meconium, within 24 hrs – 48 hrs after
birth, abdominal distension, bile starved vomiting , refusal to feed intestinal obstruction in
infants and children you notice chronic constipation (initial) , Abdominal distension , Poor
weight gain episodes of explosive passage of stool, vomiting , ribbon-like or pellet shaped foul-
smelling stools. The major danger is development of enterocolitis i.e. the inflammation of small
and large intestines. Enterocolitis present with: on set of foul-smelling diarrhea, abdominal
distension, fever, may perforation and sepsis. It is a major cause of death in hours – 30% of cases

Diagnostic evaluation: History, physical extermination i.e. rectal exam shows no stools in
rectum & a tight sphincter. Rectal biopsy – absence of ganglionic cells confirms diagnosis.
Barium enema can also be done.

Therapeutic management: Client goes through two stages of operation. Temporary colostomy
in normal bowel. In the second stage the aginglionic segment is resected & normal boy
anastomose to the rectum. Temporarily colostomy is closed. The operation in is done at 6- 15
months of age. One stage correction has also been done with good results. Pre up & Post-
operative care just like any other patient undergoing GIT surgery. E.g. pre- operative care – clean
bowel- saline enema, NPO, NG tube insertion and antibiotics to decrease flora. Post-operative
care – NG tube care, Assess bowel sounds and observe abdominal distension

Anorecta malformations: Arrest of rectal descent result absence of an anal opening and occur
during 4th- 16th weeks of gestation. Examples of these malformations include: anorectic agenesis
(imperforate anus), rectal artesian and anal agenesis. More common in males.

Etiology Uncommon – associated with other congenital anomalies Of UT, esophagus &
intestines. Anus and rectum embryonic origin is cloaca (Precursor of anarectal & the urinary
tract.

Diagnostic evolution: Physical examination and radiological imaging of abdomen e.g. fistula
detected.

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Therapeutic management: Depends on degree of malformation e.g. Anal stenosis – will require
repeated manual dilation of arms. Other defects – require surgery e.g. create opening and anal
dilation to prevent stenosis. Other therapeutic approaches include; stool softeners, fiber, adequate
fluid which prevent constipation.

Gastro – esophangeal reflux (gef): Most common disorder of infants’. It’s defined as return of
gastric contents into the lower esophagus through the lower esophangeal sphincter. Physiological
GER is a common occurrence in many healthy infants. Improvement seen in 6-12m as the infant
matures. Esophagus elongates and lower esophangeal sphincter moves down the diaphragm
decreasing the chance of reflux. Pathological GER is one that manifests with esophagitis and its
complication (structures), malnutrition, Respiratory disorders – apnea, pneumonia, and
respiratory injections.

Etiology and prevalence; Occurrence is 5:1000. In boys its x3 than girls. Common in premature
babies and those with neurological impairment. The etiology is not well known. But postulated
to be delayed maturation of lower esophangeal neuromuscular junction. Impaired local hormone
control mechanisms are also implicated.

Pathophysiology: Loer esophangeal sphincter is a physical barrier to reflux. It’s inherited by

vagal nerve and any defect in nerve transmission results in appropriate relaxation Delay in
gastric emptying due to hypo motility in duodenum may enhance GER.

Clinical manifestations: Vomiting (non-biliuos material) and regurgitation- most common

clinical feature. Others include: esophagitis causing irritability and crying; bleeding-anemia-
meleana; refusal to feed as infants associate feeding with pain and malnourishment. Possible
complications include: apnea, chocking spells, recurrent aspirations pneumonia. Frequent
respiratory infections also occur.

Diagnostic evaluation: History, physical examination and observe feeding habits. Other tests
include: Upper GI barium- rule out anatomical abnormalities e.g. esophangeal structures, pyloric
stenosis, and intestinal mal rotation); Upper GI endoscopy; Esophangeal pH study-catheter
inserted via nostrils to distal episodes of reflux.

Therapeutic management: Dietary modifications, positioning and medication are used. Dietary
modifications involves small frequent feedings, thicken formula with cereal which will increase

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calorie and decrease times of emesis. Position- it’s controversial but flat prone or head elevated
prone position for infants with GER but puffy bedding materials should be eliminated from
infant’s bed. Supine the most appropriate position for infants. Medications can be used such as
antacids; prokinetic agents that increase gastric motility e.g. metoclopramide, cisapride; H2
antagists and proton pump inhibitors to reduce. Surgical intervention are not common because
drugs are usually effective. But it can be indicated in repeating pneumonia, poor wt gain,
recurrent esophagitis with structure, severe apnea, failure to respond in 4-6 weeks and operation
usually is usually called nissen fundoplication.

Constipation: Difficult passage of stool or infrequent passage of hard stool, associated with
straining, abdominal pain or withdrawal behavior. Frequency of bowel movement varies widely
among children. Hence, frequency not adequately diagnostic. Infants may stay for 3 days without
passing stools. Common in male children in early childhood female’s children in adolescents.

Etiology: It can be organic or non-organic/ functional.

Organic factors include: dietary e.g. decreased fiber, decreases fluid intake, increase dietary
intake. Structural disorders of GIT e.g. hirschsprung’s disease, intestinal structures; metabolic
and endocrine disorders e.g. Medications e.g. opiates, antidepressants, anticholinergic, antacids.
Non-organic/ functional.

Factors include: These are the most common. Examples of non-organic causes include: Fear of
bowel movement due to previously painful experience e.g. due to hard stool/ anal; strictures/
tissues; magical thinking-characteristic of toddler- because fear of toilet e.g. do pools have brain?
And suppression of defecation e.g. on staffing school-facilities may not be adequate or to the
standard expected.

Pathophysiology: constipation is self-perpetuating because when stool is retained the distension

& sensory feedback are less effective in defection. More water get re- absorbed, stools get harder
and bowel movement is pain full. Later, the two anal sphincters are compromised. Sensitivity to
rectal distension and control of rectal distension and control of rectal evacuation is diminishing
and child loses the urge to have bowel movement

Clinical manifestations: Hard stools pass at regular intervals or as large masses after days,

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Abdominal pains/distention, irritable, loss of appetite and pulp able fecal mass on physical
examination.

Diagnostic evaluation: Physical examination, history - rule out organic cause’s .Get information
about dietary history, stool pattern and medications x-ray – enlarged colon.

Therapeutic management: cleanse bowel using enemas orals & suppository; establish bowel
movement pattern and modify diet- increase fluid & fiber e. g. whole grain bread cereals,
fruits, whole grain bread cereals, fruits, vegetables, bran. Nursing management and family
teaching include: dietary modification, administration of enema and establishing regular
pattern of defecation e.g. a child sits on toilet after meal for 5-10 min.

Appendicitis: inflammation of vermiform appendix. Most common conditions requiring

abdomen surgery in children. Anatomical location of the appendix tends to vary

Prevalence and etiology: The prevalence is 4:1000. Increases in males than females
etiological factors include: poorly understood but thought may include obstruction of appendix,
enteric systemic infection, 30% of cases is due to infection and trauma. Rare in 3rd word, due to
high fiber diet

Clinical manifestation: Abdominal pain-initially vague and poorly localized , later settles at
right lower quadrant , anorexia , nausea , and vomiting that precedes abdominal pain is due to
gastro enteritis ,diarrhea , and constipation .

Diagnostic evaluation. Diagnosis is a major challenge because of vegueness of symptoms in

urinary tract. Challenging because symptoms can be typical, hence misdiagnosis which causes
increase in incident of perforation, absence, wound injection and morality. Rebound tender
men may be elicited through palpation though not good for children. Muscle rigidity-tenseness
of muscle of tender area. Guarding-involuntary contractions of abdominal muscle caused by
fear of impending pain. Others diagnostics indicators include Increase

WBCs. Rule out other causes of abdominal pains e.g., constipation UTI, acute gastroenteritis
and peptic ulcer disease. Delay in diagnosis cause 300/0-600/0 perforation. In younger children,
the thinner appendicular wall progress to inflammation faster than adults.

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Therapeutic management; Appendectomy is preferred intervention. Posturer-NPO status till
bowel sounds back, IV fluids, antibiotics 7-10 days’ and NG tube suction. Complications;
Peritonitis, Paralytic ileus, intestinal obstruction.

Inflammatory bowel disease; chronic disorders featured by inflammation and ulceration of

small and large intestines. Ulcerative colitis affects colon and rectum. Chrons disease involve
entire GIT especially ileum (regional enteritis)

Incident and etiology; increasingly becoming common. 200/0 of ulcerative colitis and 25/ 30
of those with chronic’ disease is below 20 years. Peak onset is late adolescence. Male and
female affected at the same rate. Etiology factors implicated include; unclear, implicated
factors include; infectious agents like virus, bacteria, autoimmune, genetical factors and
environmental factors e.g. smoke.

Pathophysiology; Bowels responds to an environmental trigger to release local mediator e.g.

histamine causing marked vasodilatation which may lead to raptures, ulceration and bleeding.
Deeper ulcers may lead to fistula into bladder and/or vagina. Healing lesion may lead to scar
tissue i.e. strictures and bowel obstruction.

Clinical manifestations; Ulcerative colitis; rectal bleeding, diarrhea, abdominal pain. Diarrhea
on set is insidious. Urgency to defecate, abdominal cramping and tenderness, anorexia, weight

Loss, low grade fever, mild anaemia. Some extra intestinal features especially with chrons
disease include growth failure, arthritis and skin lesions.

Diagnostic evaluation: Endoscopy – sigmoidoscopy, colonscopy, Radiological exam, Biopsies

and barium enema. Laboratory studies include: anemia, hypoproteinemia and fluid/ electrolyte
balance.

Therapeutic management: Pharmacotherapy to decrease inflammation and decreased immune

system. To decrease inflammation – corticosteroids, amino salicylate/ sulfasalazine.
Metronidazole given for perianal complications. Cyclosporine given for immunosuppressant
effect. Nutritional support: adequate calorie, restrict milk, fiber & highly seasoned food as they
are poor tolerated, vitamins & minerals replaced because in chron’s diseases fat soluble vit. ADE
K deficiency may result. TPN - sever cases, surgery especially in complications such perforation,
hemorrhage, conventional treatment has failed and there is an intractable bleeding. Colon/

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rectum removal – proctocolactomy provides a permanent cure. Permanent ileostomy is created at
same time. Remissions & exacerbations characterized the disease. Nursing considerations
include: Continued guidance of families in terms of dietary management; coping with those
factors that increase stress and emotional liability; when indicated preparing children and
children families to administer nasogastric feedings. The child and family member’s anxieties
should be acknowledged and they should be given adequate time to demonstrate the skills
necessary to continue the therapy at home needed.

Absorption of food substances may be disturbed and therefore our next session we look at some
alterations associated with absorption.

Celiac disease: This is also called glutten-sensitive-enteropathy. Which is a permanent intolerant

to glutten, the protein component of wheat, barley, rye and oats. Second to cystic fibrosis as the
most common cause of malabsorption in children?

Incidence and Etiology: Genetic disorder occurring among all races. Prevalence is 0.1: 1000
births coincides with introduction of food containing gluten

Pathophysiology: Exact mechanism by which glutten damages the mucosa is unclear. However,
it’s postulated that immunological response is involved. Glutten is made up of two proteins-
glutenin and gliadin. Gliadin, the harmful protein elicits an immune response. This causes the
villi to flatten out & artrophy leading to decrease in the absorptive surface area. The effect on
absorption is in this order: fat, protein, CHO & fat- soluble vitamins i.e. A D K.

Clinical manifestations: Anorexia, irritability, listlessness, weight loss, abdominal distension,

steatorrhea- large amount of unabsorbed foods with fats stools, bulky, foul smell, greasy, partly
colored & float because of fat. Later signs include: Protuberant abdomen, loss of subcutenous
fat, muscle wasting secondry to hypoproteinmia, growth retardation, osteoporosis, and delayed
menses/puberty.

Diagnostic evaluation: bowel biopsy reveal atrophy of villi deep cypts on intestinal mucosa.
These lesions return to normal after dietary restriction of glutten this confuses the diagnosis.
Serologic tests-defect antigliadin & antiendomysical antibodies.

Therapeutic treatment: Gluten- free diet. Education on this diet is the major management
modality. The nurse dietican caregivers need to get involved. Wheat, rye, barley, oats replaced

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with rice, corn and millet. Specific nutritional requirements may be used to correct deficiency
states e.g. fat soluble vit. Ca++, folate and iron.

Lactose intolerance: Inability to digest lactose (disaccharide) in human/ cow’s milk; formulas,
cheese, ice cream. May also be found in other baked foods, biscuits, pan cakes and cakes.

Etiology: Deficiency or absence of lactase enzyme in small intestine required for the digestion
and absorption of lactose. It can be congenital or acquired. Congenital is very while acquired
loss, low grade fever, mild anaemia. Some extra intestinal features especially with chrons disease
include growth failure, arthritis and skin lesions

Pathophysiology: Inability to digest lactose caused by absence of lactase .Undigested lactose

mowed into colon where its broken down by bacteria down by bacteria to release hydrogen,
methane, carbon dioxide. Salutes also increase in colon which increase osmotic pressure causing
watery diarrhea

Clinical manifestations: After ingestion of lactose you get explosive watery diarrhea, abdominal
distention, pain, and excessive flatus.

Diagnostic evaluation: hydrogen –breath test –Measures amount of hydrogen left after
fermentation of undigested /unabsorbed carbohydrates i.e. lactose

Therapeutic management: Reduce or eliminate lactose from child diet. Milk products may be
pre-treated with microbial lactase.

Poisoning: poison-substance that harm the body .Can occur through ingestion, inhalation, skin
exposure eye contact est. Ingestion –most common cause. Poisoning is the fourth cause of death
in toddlers/preschoolers due to curiosity. Children take it accidentally while adolescent
intentionally, hence have higher fatalities .Some substances ingested kerosene, gasoline , paint
thinner ,turpentine, perfume, cologne .After shave lotion etc

Clinical manifestation: Depends on specific poison. e.g. corrosives (toilet liven cleaners
ammonia burnt in the mouth, throat, stomach, edema of lips, pharynx, tongue vomiting etc)e.g.
panadol poisoning cause nausea, vomiting, jaundice, confusion, and somnolence right upper
quadrant upper abdominal pain

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Diagnostic evalution: Identify type /amount of exposure .Physical examination and history will
help identify the poison laboratory analysis of the emesis is critical

Therapeutic management: Vary according to type /amount; time elapsed since exposure to
poison. Priority paid to ABCE (Stabilization of the child) of life support. After which gastric
decontamination can be done.

Gastric emptying using lavage or emetic most effective when done within 1hr of ingestion.
Syrup of ipecac used for inducing vomiting occurs within 20 min and last several hrs. But its
contra indications in <6 months children , already vomiting individuals, decrease consciousness
patient, inpaired gag reflex and ingested acids, alkalis , sharp object, hydrocarbons. Gastric
lavage used within 1-2 hrs of ingests but contra indicated but contra indicated in corrosive and
gag reflex depressed patient. Complication may occur: aspirationand perforation .Normal saline
used. Activated charcoal: Effective in most oral poisoning. Major concern: Vomiting occurs, in
15% of children-increase risk of aspiration/ pneumothorax. Antidotes e.g. Nalaxone – narcotics,
N-acetylcysteine- parasol flumazenil- benzodiazepines, EDTA for lead, bicarbonate for –
antidepressants should be used as appropriate Nursing management is that the solution to
childhood poisoning in prevention.

Nurses discusses these prevention measures

 Store chemicals out of children;

 Return toxic substance immediately after use to safe storage.
 Store product in their original containers. Never put potentially harmful products in food/
beverage containers.
 Refer medications by their proper names.
 Buy products with child proof caps.
 Avoid having poisonous plants at home.
 Have symptoms of ipecac but administer consulting a health care practitioner/ poison
control center.
 Keep contact of poison control center.

Hepatitis is inflammation of the liver. Majority 90% of hepatitis is caused by five viruses;

Hepatitis A virus (HAV); Hepatitis B virus (HBV); Hepatitis C virus (HVC); Hepatitis D virus

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(HDV) and Hepatitis E virus (HEV). Cyclomegalovirus, Epstein Barr virus and Herpes simplex

Virus may occationary cause hepatitis. Hepatitis A: Highly contagious and is transmitted through

Fecal oral route .it usually acute and mind and has no carrier state .It affects under15 years old.
Hepatitis B transmission potential route through the exchange of blood or any bodily secretion of
fluid HBV. Infection occurs in children and adolescent in the following high risk situation
;infants of mothers who are chronic carriers ; those who have received transfusions , children
involved in intravenous drug abuse ,institutionalized children ,pre- school in endemic areas.
HEPATITIS C: A blood borne virus transmitted parentally .Cirrhosis and hepatocellular r
carcinoma may develop in children with HCV infection. HEPATITIS D

: Occurs in parents already infected with HBV it requires the infection of HBV.HDV infection
occurs primarily in hemophiliacs and intravenous drug users. HEPSTITIS E: It is epidemic or
externally transmitted .Transmission may occur through contaminated water and there is no
carrier state.

Clinical features: The clinical manifestation for most type of viral hepatitis are similar except
for a more rapid, acute in type A and slower, more insidious onset in type B, and A may
represent with flu like symptoms.

Diagnostic evaluation: Diagnosis of hepatitis is based on history, physical examination,

serologic markers, and liver function test. The diagnosis of hepatitis is confirmed by detection of
anti-bodies or antigens in response to the specific virus .No liver function test is specific for
HEPATITIS. Serum aminotransferase [AST, ALT] levels are elevated.

Therapeutic management: Management includes treatment of symptoms. Allow children

freedom to rest when they want –to regulate their own pace. Allow children to choose foods they
prefer especially during initial stage when anorexia is severe. Hospitalization is required if
coagulopathy or fulminant Hepatitis develop .nurses consideration: the emphasis is on
encourages a well-balanced diet and realistic schedule of rest and activity adjusted to the child
conditions. The parents are cautioned about administering any medication to the child since
normal doses of many drugs may become dangerous because of the liver inability to detoxify and
excrete them. Hand washing reduces the risk of hepatitis transmitted in any setting .In children

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with HBV infection who have a known or suspected history of illicit drug use, the nurse should
help them realize the association between drug use and HBV

RESPIRATORY ALTERATIONS

STUDENT LEARNING OBJECTIVES

At the end of the chapter the learner should be able to:

a. Review anatomy and physiology of the respiratory system

b. Describe the etiology, clinical manifestations, treatment and nursing management of
common acute respiratory: nasopharyngitis. Pharyngitis, tonsillitis, Otitis media, CROUP
bronchitis and pneumonia.
c. Describe the etiology, clinical manifestation, treatment and nursing management of
common chronic respiratory conditions: allergic rhinitis and asthma.
d. Discuss the clinical manifestation and treatment of foreign body aspiration smoke
inhalation, acute respiratory distress syndrome and apnea.
Respiratory alternative can be acute or chronic. We start this this chapter with an
examination of common acute conditions.
Nasopharyngitis: Common accountant for 80% school missed days.
Etiology: There are many infectious agents that can cause this diseases e.g. viruses
include respiratory syncytial viruses, adenovirus, influenza virus, coxsackievirus,
paraifluenza viruses. Bacteria e.g. streptococcal infections are the major causes of
nasopharyngitis.
Pathophysiology: Nasopharynx- positioned behind the nasal cavities and is bordered by
soft palate &the skull .tissue swelling and exudates formation occurs .Exudates – (fluids,
cells, other substance released from the body .Nasal congestion caused by edema
secretions impede flow through the nasal passages.

Clinical manifestation: Nasal stuffiness ,rhinitis, sneezing ,nasal discharge , coughing sore
through ,fever, irritability , malaise, nausea and vomiting and poor appetite.

Diagnostic evaluation: History and physical examination –Afebrile and normal WBC
seen.
Therapeutic management: Management is usually done at home. For viral

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nasopharynx there is no specific treatment. Require supportive management e.g. non-
Aspirin Analgesics; saline nasal drops every 3/4hrs particularly before feeding infants
to relieve nasal congestion. Decongestant nasal drops/cough suppressant for older
children e.g. dextromethorphan. Older children can gaggle saline solution. Note that
antibiotics are not effective. Health education is critical. Nasal congestion forces mouth
breathing which impedes coordination e.g. Breathing, sucking, swallowing. Hence
feeding is very challenging.

Tonsillitis &pharyngitis: Common co-morbidities of childhood. Tonsillitis is

inflammation of palatine tonsils.

Etiology: Viral infection but can also be bacterial. The bacteria involved include GPA
beta –Hemolytic streptococcal in 20% of the cases. If untreated – scarlet fever media and
streptococcal infection in the surrounding tissues occurs. Other complications of
untreated streptococcal infection include rheumatic fever, meningitis and
glomerulonephritis.

Pathophysiology: Tonsils are important for lymphoid tissues in oropharynx protection.

Tonsillitis are inflammation of palatine tonsils. Adenoiditis- inflammation of
pharyngeal tonsils/adenoids.

Note: Children are prone to tonsillitis because they have many lymphoid tissues in
pharyngeal cavity, and have frequent respiratory infection and cross infection from
other children.

Clinical manifestations: sore Throat difficult in swallowing, fever, nasal congestion-

mouth breathing and drying of mucus membranes aggravates pain associated
tonsillitis/pharyngitis. Others especially if beta- hemolytic streptococcal infection is
involved include: headache, abdominal pain, vomiting, diarrhea and cervical
adenopathy.

Diagnostic evaluation: Visual inspection of the throat. Throat culture& rapid

streptococcal screening specific etiology.

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Therapeutic management: For viral infection supportive care is instituted warm saline
gargles soothe inflamed mucus membrane, antipyretics which are non-Aspirin.
Bacterial infections antibiotics – e.g. penicillin/ cefuroxime. Tonsillectomy with/
without adenoidectomy can be done under the following conditions:

 Recurrent streptococcal infection.

 Hypertrophied tonsils to affect eating/breathing.
 The child should be 3yrs or older. Increased blood loss may occur in younger
children. Tonsils may also re-grow if child very young.
Note: Adenoids, if enlarged can block air flow through nasal passages

Nursing considerations: Postoperative care: Lie via abdomen or side which increases
drainage of secretions. No coughing or blowing nose oftenly as it may disrupt clot
formations. Examine secretions/ emesis for bleeding (fresh). Analgesic for pain
postoperative. Soft diet and non-carbonated/ acidic drinks.

Note: Frequent swallowing with is an indication of post-operative bleeding as the child

swallows the trickling blood.

Family teaching is important on- Promote increase fluid intake/ rest, administrator
analgesis/ antipyretics, seek medical attention if there signs of bacterial infection and
pre-operative and post-operative educating e.g. bleeding.

Otitis media: Is the inflammation of middle ear. Can occur as acute/ chronic/;
infectious/ noninfectious, occur with/without effusion. Bilateral OM is present in (50%)
of the cases. There are several types of Otitis media: cute, Otitis media with effusion
(Exudate arising from inflammation) and

Chronic Otitis media acute otitis media. Pathogens invade through Eustachian tubes. Has a
sudden onset and short duration and is painful. Om with effusion; inflammation with fluid
behind tympanic membrane and without signs of infections .It usually asymptomatic. Chronic
Om: inflammation go for >3 months with/without effusion.

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Incidence/etiology; Common childhood disease. Common in 6-18 months old children. Acute
OM is often caused by streptococcal pneumiae, haemophilus influenza and Moraxella catarrhal
is. Prevalent. Approximately 93% of children with acute Otitis media have sign and symptoms
of URTI...Also viruses can cause OM with effusion such as para –Influenza and rhino virus
.Allergic rhinitis and sinusitis also predispose .Also cleft palate and decreased immune function
;passive smoking are other predisposing factors.

Pathophysiology: Child below 3 years is more vulnerable to otitis media because have
Eustachian tube that are wider, shorter, straighter than those of older child and adults. Also
Eustachian tubes are horizontally positioned. Hence; these anatomical features allow
microorganisms and nasopharyngeal secretion easy 3] access to the middle ear. This lead to
inflammation with/without infection .Exudates /fluids produced and impede middle ears ability
to transmit sound. Enlarged lymphoid tissue may obstruct flow of drainage from middle ear
ability to transmit sound .Enlarged and rapture of tympanic membranes may occur.

Clinical manifestations: Children who are verbal will express pain. Non-verbal/preverbal
children will express pain by tuggling /pulling ear .Others include: fever, diarrhea, irritable,
vomiting, URTI may be present .If conductive hearing impaired is present, child in attentive to
voices /noises

Diagnostic evaluation: Orthoscopic exam in acute otitis media shows tympanic membranes as
red and bulging. Serous /purulent fluid visible behind tympanic membranes. Pneumatic
orthoscopic assessment of tympanic reveals decreased movement. Maybe absent with chronic
Otitis media Culture with sensitivity testing is conducted, if drainage in external canal is present
so that to institute appropriate antibiotic therapy identified.

THERAPEUTIC MANAGEMENT: For acute - Otitis media antibodies e.g. amoxil, cefaclor,
co-trimoxazole (bactrim) for 5- 10 days. If poor compliance expected, give single dose of IM
ceftriaxone (Rocephin). Response within 2- 3 days but effusion (serous fluid) takes
months/weeks to clear. There are possible complications: conducive hearing loss & related
speech problem; abscess formation in the tissues adjacent to the middle ear, meningitis and
septicemia. Follow-up for 2 to 4 weeks or earlier depending on the state is important. Recurrent
Otitis media. i.e. episodes occurring within 6m need prophylactic antibiotic treatment treat URTI
early and influenza/ pneumococcal immunizations.

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NOTE: Steroids may also be used especially for Otitis media with effusion.

Tympanostomy (surgical incision in the tympanic membrane to drain fluid) is indicated if an

episode of OM with effusion last longer than 3-4m & associated with loss of at least n20
decibels. These tubes that are used facilitate drainage / increase ventilation. Ear plugs used when
swimming to prevent water entry. Family education include avoiding second hand smoke
prevention irritates Eustachian tube; avoid horizontal position during bottle feeding and adequate
breast feeding.

Note: immunization and breast feeding are good preventive measures for otitis media.

Acute epiglottises: Acute epiglottitis or acute supraglotis is a serious obstructive inflammatory

process that occurs principally in children between 3 and 7 years of age, and can occur from
infancy to adulthood. The responsible organism is usually H.8Influenza; LBT and epiglottises do
not occur together.

Clinical manifestation: The onset epiglottises is abrupt rapidly progressive to serve respiratory
distress. The child usually goes to bed asymptomatic to awaken later complaining of sore throat
and pain on swallowing. The child generally insists on sitting upright and leaning forward, with
chin thrust out, mouth open and tongue protruding. Drooping of saliva is common.

Because of the difficult or pain on swallowing and excessive secretions. The child is irritable and
markedly with a froglike croaking sound in inspiration. The child seldom struggles to breathe,
and slow quiet breathing provides better air exchange. Edematous epiglottis is visible on careful
inspection.

Therapeutic management: The cause of epiglottises may be fulminate, with respiratory

obstruction appearing suddenly. End tracheal intubations or tracheotomy is usually considered
for h. Children with suspected bacterial epiglottis are given antibiotics intravenously followed by
oral administration to complete 7 to 10 days course. The epiglottal swelling usually decreases
after 24hrs of antibiotic therapy and epiglottis is near normal by the third day. Incubated children
are generally extubated at this time. It is important to act quickly but calmly and provide support
without unduly increasing anxiety. The child is allowed to remain in the position that provides
the most comfort and security and parents are reassured that everything possible is being done to
obtain relief for their child.

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Pneumonia: Acute inflammation of pulmonary parenchyma (functional tissue of an organ as
from supporting and connective tissue).Usually occurs in infancy or early childhood.

Etiology: Viruses like adenovirus; cytomegaloirusr and influenza are involved. If bacterial,
should be in order children, preceded with viral infection of upper respiratory system.

Pathophysiology: Toxins/ pathogens damage pulmonary mucus membranous and cause

accumulation of debris and exudate in airways. This leads to ventricular / perfusion ratio
Abnormalities.

Pneumonia can be: - lobar pneumonia where one or more lobes involved or interstitial
pneumonia. Involves and lastly bronchial- diffuse involvement of bronchi & lung fields.

Clinical manifestation: Cough, malaise, pleuritic pain, fever, anorexia, tachypnea, wheezing,
headache.

Therapeutic management: Depends etiology.

For viral causes supportive. For bacterial –Antibiotic required.

Treatment can be done at home. OXYGEN therapy & chest physiology may be needed pastoral
peas drainage.

Asthma: Characteristics by chronic information, bronchoconstriction & bronchial hyper

responsiveness.

Pathophysiology of the allergic type: antigens e.g. dust mites, medications, poles, dust,
emotional stress, and physical stress and food preservatives.

The cause IgE, mast cell and macrophage, basophils, esinophils.

Degranulation of mast cells causing release of histamine, interleukin II, SRSA, PGDs and
Bradykinin. Bronchoconstriction, mucosa, oedema and increase mucus production occurs.
Airway obstruction/air tapping follows and ventilation/perfusion alterations result.

The ultimate response is increase work of breathing, hyper capnia, hypoxemia, respiratory failure
and death.

Clinical main manifestation s: Expiratory wheezing, chronic cough, dyspnea (shortness of

breath and difficulty in breathing); recurrent chest tightness; tachypnea; the chest pain;
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Nasal flaring; Orthopnea.(Increase In difficult breathing when lying down) older child may sit
up with stimulator in hunched – over position with the hands braced.

Diagnostic evaluation; physical, history, plomunafy functions.

Expiratory flow rates /PEER determine extender of child asthma .

fastest speed of which air is forced out of the lungs during expiration .(peak flow meter )
used in liters / min in acute episodes it is lowered in impaired expiration and air trapping.

1. Therapeutic management: avoid triggers; regular peak flow; Monitoring egg.

(nebulizer); short acting B2 agonists that live ; terbutaline; systematic
corticosteroids;ipratropium bromide (atrovent) oxygen therapy ;
ant cholinergic bronchodilators; B2agonists antimuscarinic bronchodilators
Pham mgt depends on severity & frequency of symptoms; rapid access to healthcare vitals
in emergencies ;
FAMILY EDUCATION, sleep importan ,
avoid being with those with respiratory problems Nursing inversions include ;
identify child at risk , fax education e.g. use of PEFR meter and interpretation of data ,
Nebulizer - Metered dose inhaler – inhalation;
Exercise with asthma is under control;B2 agonist can be prophylacticlly before physical
exercise to decrease exacerbations; Triggers – child specific – avoid them – worsening of
symptoms should not be noted
Respiratory alterations are among the most common problem in paediatrics.
Preventive measures will play a big role in enhancing the wellbeing of children

General Preventive measures in respiratory alteration

Control environmental hazards e.g.2nd hand smoke, air pollution, allergies.

Minimize risk of infection by immunization and infection control practices e.g. contact control

Genetic counseling e.g. cystic fibrosis has 250/0 chance of getting a child with a similar problem

Prenatal care – decrease prematintyome conditions that which is highly vulnerable

Anticipatory guidance e.g. SIDS prevention

Health education – creates conductive environment for the child]

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CARDIOVASCULAR ALTERATIONS

Student learning objectives

At the end of the chapter the learner should be able to:

a) Reactive anatomy and physiology of the cardiovascular system and pediatric variations
b) Perform assessment of a child with a heart disease
c) Describe the manifestation of congenital heart failure and identify appropriate
interventions
d) Discuss the clinical manifestations, treatment and nursing management of various
congenital defects
e) Explain the management of a child who has undergone open heart surgery
f) Describe the etiology, clinical manifestations, treatment and nursing management of
rheumatic fever, Kawasaki and infectious endocarditic
g) Explain the cause, clinical manifestations and management of shock.

Conditions that arise due to disruption in normal development during intrauterine life are:

Congenital heart defects

Introduction

Congenial heart defects occur in approximately 8:1000 live birth (America heart association,
1999). There are minimum of 35 types of recognized defects. Range from mild e.g. patient
ductus arteriosus to complex anomalies e.g. hypoplastic left heart syndrome –a variety of
deformities characterized by lack of development of the left ventricle secondary to mitral value
artesia or aortic artesia. Left ventricle is small, hypoplastic &not capable of anycardic function.
An infant may have a combination of defects. Majority of the defects are repaired in the first year
of life .More complex defects require staged repairs – more than one surgery is required for final
correction. Even in staged repairs –done in 2-4 yrs. Mild isolated defects may never require
surgery e.g. slight vulvar incompetence. Because a heart of a child is the size of the child’s first,
intracardiac or open heart surgery can be complex. To support the child during surgery cardiac

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pulmonary by-pass (CPB) is implemented. CPB not a treatment used during open H+ surgery
only, for the repair of many congenital defects as it is a mechanical pump and artificial
oxygenator that provides for a short period, substitution of the heart and lungs. Unoxygenated
blood removed via venom cannula. The work of the heart is performed by the bypass pump. Let
now start discussing some congenital heart conditions.

Patent ductus Arteriosus (PDA):-Direct connection between the main pulmonary artery &
aorta. In fetus, ductus arteriosus needed for survival. In preterm, a PDA is a common feature
depending on developmental maturity. In term new born ductus begins to close within 12 hours
and closed by 2-3 wks. Thereafter, called PDA if not closed.

Incidence: In mature infant the rate is 5-10% while in premature infants its 45%.

Pathophysiology: There is left to right shutting of blood. High pressure aorta blood flow into
low pressure pulmonary artery/ pulmonary circulation. The size of PDA & pulmonary vascular
resistance is important to determine the degree of shutting. If resistance is low,-high shutting &
vice versa. Congestive heart failure may result from high pulmonary blood flow.

CLINICAL MANIFESTATIONS

Depend on size shut. For small PDA it may be asymptomatic .For large PDA signs of congestive
heart failure may be present .e.g. Tachycardia, diaphoresis, edema, decreased pulses, wheezing,
refractions, orthopnea, ascites, decreased urineoutput, exercise intolerance and poor weight gain.

Diagnostic evaluation; Auscultation reveals murmurs in lower left clavicle. Echo

/7cardiogramstudies structures and motion of the heartie sound waves are studied. Transducer
enables recording of waves on a strip chart.

Therapeutic management; NSAIDS e.g. indomethacin given as it inhibits synthesis of

prostaglandins which are responsible for a number of cellular connections. Maintain potency of
the dustus arterious in premature infants. Surgical closure for term symptomatic [CHF] infant if
indomethacin is not effective here. Prognosis is usually good.

Tetralogy of fallot (TOF)

Made of four components:

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 1. Ventricular septal defect [VSD]-abnormal connection between the right and left
ventricles. Defect can be located in various positions along the septum. Very common
congenital heart defect comprising of 20% overall. Small VSD (75-80%) close in 2 years.
2. Pulmonary stenosis- Narrowing of pulmonary valve and obstruction to blood flow from
the right ventricle to the lungs. Obstruction can be at valve (vulvar), just before
pulmonary valve itself (subvalvar), above valve (supravalvar), varying places along the
pulmonary artery.
3. Right ventricle hypertrophy-due to resistance to pumping blood through the pulmonary
artery which stenosed/narrowed.
4. The aorta overrides the ventricular septal defect (VSD) but this is of little clinical
significance but part of these anatomical features of this defect.

Incidence: Most common cyanotic defect accounting for approximately 10% of all congenital
heart disease.

Pathophysiology: large VSD lead to equal pressure in left and right side. Amount of pulmonary
blood flow (hence cyanosis) depend the degree of pulmonary stenosis. Minimal obstruction
described as “pink te”

Clinical manifestations: depend on degree of pulmonary stenosis. Varying degree of cyanosis.

Loud systolic murmur is noted at birth. Hypercyanotic episodes called “tet spells” occur due to
some activity e.g. crying, feeding and defecating.

Diagnostic evaluation: boot shaped heart caused by hypertrophy of right ventricle is observed
on x-ray. Echo cardiogram –demonstrates clinical features of TOF and is the beast diagnostic
tool.

Therapeutic management: surgical correction. Manage hyper cyanotic symptoms i.e. hyper
spell place infant in knee- chest position. For older children they can squat. This decrease
systemic vascular resistance is hope of decrease right-left shunt allowing blood to flow to the
lungs. Oxygen therapy, phenylephrine used to decrease vascular resistance. Surgical repair at 5-
12m widen right ventricular outflow tract and close VSD. There are some possible
complications; residual VSD – leaking, pulmonary regurgitation, arrhythmias, decrease cardiac
output, cardiac failure and sudden death.

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Acquired heart disease: disease process or disorders that develop after birth and affect
functioning of the heart and cardiovascular system e.g. Kawasaki disease, infective endocarditis
and acute rheumatic fever. We shall discuss one of these diseases.

Acute Rheumatoid (ARF): leading cause of acquired heart disease in developing countries.
Advent of penicillins have reduced the incidence.

Incidence and Etiology: approximately 10-20 million new cases occur yearly in developing
countries. Usually seen in age group susceptible to gp A streptococcal infection i.e. children aged
5-15 years. ARF follow an untreated or partially treated gp a streptococcal pharyngitis (sore
throat). Group a streptococcal can produce infection in any body tissue but rheumatoid
specifically follows throat infection. Incidence has been decreasing due timely identification and
availability of antibiotic therapy. But morbidity remains at risk factor due miral stenosis
(progressive) & chronic vulvar disease.

Pathophysiology: exact pathogenesis of ARF is unknown. Generally, it’s thought to be auto

immune response to untreated group a streptococci. Pharyngitis in genetically predisposed
individuals. Autoimmune response specifically affects heart, CNS, joints. In the heart it causes
pericarditis, myocarditis and vulvutis can occur. Valvulitis usually affects the mitral valve.
Valvulitis is responsible for mitral regurgitation. Aortic valve can also be affected and develop
insuffiency. However, aortic insufficiency without mitral regurgitation is uncommon in ARF.
Myocarditis and pericarditis in isolation shouldn’t be considered rheumatic in origin because
they are never encountered in the fever without vulvar involvement. Polyarthritis of ankles,
knees, hips, shoulders. This unlike other forms of arthritis doesn’t result in permanent disability.
Central nervous system manifestation present late even years after initial illness. Inflammation
changes in CNS result in chorea (Sydenham’s chorea) which is featured by involuntary,
purposeless movements of extremities. Vulvar regurgitation can progress to stenosis, hence
requiring replacement with artificial valve.

Clinical manifestation: there are variable. Non-descript febrile illness and antecedent GPA
streptococcal throat infection. But some children have no history of fabrille illness or
pharyngitis. Manifestation of valvulitis is the most significant feature – with miral regurgitation –
systoli murmur and aortic insufficiency – diastolic murmur. Others include: polyarthritis that is
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migratory i.e. moves from one joint to the next. It presents with tenderness, pain, swelling, heat,
limited movement on affected joints. Erythema marginatum i.e. a distinctive, fine, pink rash
noted on the trunk & extremities (never on face), pronounced with heat. It is seen with
carditis/polyarthritis. The subcutaneous nodules are firm, painless over the extensor surfaces of
the elbow, knees & wrists. These always occur with carditis, never in isolation. Arthralgia &
fever are present frequently present but are nonspecific for rheumatic fever.

Diagnostic evaluation: use clinical manifestation, lab studies – gp a streptococcal infection

through but throat culture might be –ve since the child might have recovered by the time the
fever is suspected. A symptomatic children might be carriers of strept hence +ve culture may
result. Blood tests also good to test strept infection i.e. Anti - streptolysin o-titer (ASO) and anti
DNAse B are obtained together.

Note: if ASO and anti DNAse tests are combined 92% of cases are diagnosed.

Echo cardiogram: good for vulvar disease e.g. miiral regurgitation. Echo should be obtained for
any child suspected to having rheumatic fever because mitral regurgitation and aortic
insufficiency might be silent

Therapeutic management: the aim of treatment in the acute phase is to eradicate organism and
decrease inflammation process. Use oral penicillin as an initial treatment. Aspirin inti-
flammation because polyarthritis is not responsive to ibuprofen/acetaminophen. High doses used
i.e. 100mg/kg day then reduced decrease 70mg/kg/day. After acute phase, disco ASA.
Administer antacids because of ASA gastric effects. Bed rest required till inflammation resolves.
Restrict activities because of aortic insuff/mitral regurgitation.

Note: repeat echoes used evaluate resolution of vulvar disease though most don’t completely
return to normal

Secondary prophylaxis

Oral penicillin 250mg BID or a monthly IM injection of penicillin. This is done for at least 10
years or more. It is important because of recurrence which can induce severe cardiac damage.
Compliance is very difficult as many clients feel it’s not necessary to continue the treatment.
Aortic and miral value replacement require in adulthood. Nursing management aspects include:
unless there is severe heart failure, acute rheumatic fever is managed as an output. Timely

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identification vital for recurrence prevention. Throat infection treated timely and full dose taken
avoid under treatment. Vigilance for sign and symptoms of the disease. Follow up is vital.

Note: education is the most important nursing intervention for this disease.

Psychosocial issues for children with heart disease

If a child is born with a heart problem, it may affect attachment and bolding as the child may be
taken away by health staff. Parents feel grief at their loss of an anticipated health baby. After
shock, the family thinks of incorporating that child to the society. However, faced by problems
of defining restriction on the child cause withdrawal from the peer. As the child leaves home to
school, there is the dilemma – do parents tell teachers? What is the reaction of teachers? Might
this mean limited capability of the child to the teacher? Teenagers may not disclose the condition
to the peers. As adolescents gain independence they must be able to assume their own care for
themselves in terms of taking medicine, limiting on activities, paying attention to their body’s
cues and being the primary historian during following clinics. Sibling rivalry – due to extra
attention the child with heart problem gets. Support (social) for the family should be identifiable
e.g. church, other families, social workers, therapists etc., and financial counselors – because of
financial problems. Multi-disciplinary team is best placed to develop appropriate care plan.
Approximately exercise that can be tolerated must be chosen. Some congenital develop defects
are minor and place no physical limitation.

Restriction is usually for children who have pulmonary hypertension, QT syndrome and exercise
induced ventricular tachycardia

The impact of parental stress, hospitalization and cyanosis and child temperament may affect
child’s development. May also have behavioral problem e.g. adolescents with heart problems
may not take it well that cannot do what peers can do.

Conclusion: Pediatric heart diseases imposes physiological.

Physiological & social &perceived severity of these concerns influence coping of outcome.

Nurses assist these families resolve and adjust to all these issues.

Problem need to identify early &intervention applied.

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IMMUNOLLOGIC ALTERATIONS.

Student learning objectives

At the end of the student should be able to:

A. Describe the etiology ,clinical manifestations, treatment and diagnosis of juvenile

arthritis,
B. systemic lupus Erythematous and allergic` drug reactions
C. Discuss the educational needs of families with children with immunological alteration.

Juvenile rheumatoid arthritis: This condition is also called juvenile chronic arthritis (JRA).
Inflammatory autoimmune diseases causing many forms of arthritis in children.

Incidence / etiology: Most common pediatric connective tissue disease with arthritis being the
principle manifestation. Incidence rate 1:1,000. Prognosis- 80-90% with JRA recovers and has
no functional limitation. 10% become adults with functional limitations. Increase risk for
functional limitations, in children with polyarthritis and prominent systemic manifestations. Peak
age of inset; between 2-4 years in girls; unknown. Thought that there is interaction of genetical,
environment and immunogenetic factors in susceptible individuals with a trigger factors being
viral/ bacterial infection.

Pathophysiology: T cells activation triggers development of antigen- antibody complexes,

which cause release of inflammatory substance called cytokines in targeted organs e.g. skins and
joint. Synovial membranes swell and joint effusion occurs. Chronic inflammatory evolves into
erosion of particular cartilage and other symptoms of inflammatory.

Classification: Classified according to symptoms at onset of disease: hence, systemic,

polyarticular and pauciarticular. System type: fever, rash that is migratory- macular/ popular,
Arthralia/ myalgia, arthritis – objective arthritis defined as joint swelling or effusion or two of
the following: warmth, pain on motion, limited range of motion. Fatigue and malaise:
lymphadenopathy: hepatosplenomegaly: tachycardia and carditis are other symptoms for
systemic type. Polyarticular onset: arthritis in many joints – or more especially knees, wrist,
ankles proximal interphalangeal joints of fingers neck and temporomandibular joints are
involved. Low grade occasional fever. Pauciarticular: arthritis in few joints (4-<) especially

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knees, ankles. There is also inflammation of eyes, especially in antinuclear antibody positive
preschool girls.

Diagnostic evaluation: characteristic features observed: onset before 16 years. Arthritis

observed objectively at 6 weeks duration. Defined subtype (by onset C/features) ensure you
exclude other conditions e.g. rheumatic disease, infections arthritis, inflammatory bowel; disease
and non-rheumatic conditions of bones/joints.

Note: objectively observed arthritis is defined as joint swelling or effusion of 2 of the following
warmth pain, limited range of motion.

No specific laboratory test for JRA. Tests reflecting inflammation are non-specific for JRA but
used to monitor disease e.g erythrocytes sedimentation rate (ESR) increase C- reactive proteins
(CRP), increase WBC, decrease Hb and increased plaletlet pauciarticular. Anti-nuclear antibody
(ANA) and rheumatoid factor (RF) are in the number of cases. ANA is also positive in systemic
lupus erythematous. Hence not specific for JRA. Positive RF- linked to adult rheumatoid
arthritis. In children associated with poor prognosis, rheumatoid nodules.

Note: Rheumatoid factor is positive in 70%of rheumatoid cases but it can also occur in TB
parasitic infection, leukemia and connective tissue disorders

X- Ray shows soft tissue swelling, joint effusion, Narrowing of joint spaces, Increase bone
destruction fusion, and Bone scans can rule out malignancies and MRI also used to evaluate
joint/ soft tissues

Therapeutic management: Multidisciplinary team- nurse, child/family physician, occupational

and physical therapists, social workers are requires in management. Drugs to decrease
inflammation given

E.g. NSAIDS Aspirin, corticosteroids, cytotoxics e.g. methotrexate [folic acid

antagonist].NSAID are 1st line in treatment [initially ASA and prednosnal] but many sides’
effects may result. NSAIDS- Decrease inflammatory and antiantipiretic e.g. Indomethacin,
tolmeting, ibuprofen, naproxen, NSAIDS usually cause GIT pain/bleeding, Reyes syndrome-
may in children exposed to flu virus, hence shouldn’t be administered if a child has got this
virus. Newer NSAID –Cox-2 inhibitor have fewer gastrointestinal side effects. Slow acting anti
rheumatic drugs (SAARDS) e.g. salfasala zone may be used in combination with NSAIDS.

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Etanercept (Enbrel) - works by blocking TNF – alpha (inflammatory substance) Cold/ heat
applied for pain... Exercise_ therapeutic exercise for increasing strength and endurance e.g.
swimming, walking, biking.N.B; Activity should not be very strenuous. Balanced diet and
healthy weight important. Increase calcium to [3-4] serving daily for strong bones. Decrease fat
and salt vital of child on corticosteroids

ENDOCRINE ALTERATION

Student learning objectives

At the end of the chapter the learner should be able to;

A. Review anatomy and physiology of the endocrine system

B. Describe the etiology, clinical manifestations, treatment and nursing managements of
common endocrine alterations
C. Discuss the etiology. Clinical manifestations, treatment and nursing interventions of
diabetes mellitus in children; with special emphasize on hypoglycemia and hypoglycemia

The endocrine system is one of the systems that regulate the body functions, the other being the
nervous system

We start by looking at one of the commonest and serious metabolic disorders.

Diabetes mellitus: islets of langerhans fail to produce adequate insulin hence carbohydrate and
lipid metabolism impaired. Type 1 DM (insulin dependent DM) is 2 nd most common chronic
disease of childhood within USA & Europe. Type 2 - usually affects those above 40 years old.

Incidence/etiology: type 1 is autoimmune disease that occurs in genetically predisposed

individuals. Environmental factors e.g viruses, chemicals, have been known to play some role.
Beta cells are damaged. Islet cell antibodies, insulin autoantibodies can be measured before
clinical appearance. Males and females equally affected. Peak onset at 11 years – girls and 13
years boys

Note: incidence of type 2DM has been increasing in those under 25 years old -16% of
children/adolescent have DM type 2

Features for these children suffering from type 2DM include: may have a relative DM; are
inactive and overweight/ obese. Mechanism and causative factors of type 2 DM in childhood not
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very clear. Median age for type 2 is 12-14. Years. If glucose exceeds 150-180mg/dl –renal
threshold- it’s excreted in urine (glycosuria) – polyuria due to osmotic shifts (DH2O). Polydipsia
– increase thirst. Polyphagia – increases anger due to less glucose use.

In type 2DM, pancreas produces enough insulin but for unknown reasons the body is unable to
use the insulin effectively-called insulin resistance. After several years, insulin production
decreases. The clinical results are the same as for type 1.

Clinical manifestation: Type 1-polyuria, polyphagia, weight loss, DH20. In some individuals-
abdominal pain and vomiting occurs misdiagnosis possible.

Diagnostic evaluation: Classic triad of symptoms i.e. polyuria, polydipsia, and polyphagia. The
glucose levels are usually great 200ml/dl. DKA-diabetic ketoacidosis may present. An acetone
odor to breath resembling nail polish remover to rotten apples.

Therapeutic management: Involves many parties-child, caregiver, health care practitioner,

nurse, nutritionist and mental health professional. The goals are to achieve normal growth and
development; optimal glucose control; minimal complications and positive adjustments to the
disease. Insulin management: SC or via portable pump. Usually 2-3 times/day. There many types
of insulin: short-acting-regular-onset-20-30min, peak 2-4hrs, and duration 12-20hrs. Ultra lente-
long u/kg/day greater 1yr child,1.7u/kg/day- adolescent. Blood glucose monitoring: Home based
glucose monitoring is common. Lancing (use lancet) finger tips or forearm, thigh to obtain blood
sample. Place blood sample on a testing strip in a glucose meter. Nutrition: Known as medical-
nutrition-management (MNT). No food, as previously thought is automatically excluded. Typical
mean plan include: 50-60% of the calories-from CHO (grains, breads, fruit, milk, vegetable); 10-
20%-protein (meat, egg, legumes); 20-30%-fat. Exercise: potentiates the hypoglycemic effect of
insulin and may assist to control glucose. Increased levels of activity-increase meals in the plan
or decrease dose of insulin.

Adequate education is needed for the client/child and the caregiver. The skills should be
understood if the child/family is to have adequate home self-management of the disease. The
goals for each client are highly specific-consider them. Consider developmental stages as you
teach skills to the child e.g urine testing-4-6 years, blood testing-4-8. Being different or
restrictions imposed by the disease can have devastating physiological impact. Hence
psychological care is extremely important. E.g future obstetric limitations.
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CELLULAR ALTERATIONS.

Student learning objectives

At the end of the chapter the learner should be able to:

a) Describe the etiology, clinical manifestations, treatments and nursing management of

common malignancies in children, including leukemia, brain tumors lymphomas,
neuroblastomas and wilm’s tumor.

b) Explain different cancer treatment modalities.

c) Discuss the nursing management of common effects of these treatment modalities.

d) Discuss the long term, late effects of childhood cancer therapy.

e) Identify the emotional and educational needs of families who have children with cancer.

Introduction: Cancers refer to group of diseases in which there is out of control growth and
spread of abnormal cells. The tumor/-mass can be –benign (slow noninvasive growth) or
malignant (progressive). The progressive one can be localized (mass) or disseminated e.g

Leukemia/lymphoma. Cancers are a leading cause of death of children 1-14yrs. Differences

between child and adult cancers; most carcinoma in adult is of epithelial origin while in children
the common lymphoma and sarcoma originated from primitive embryonic origin. Environ factor
vital in adult cancer while in child cancer they are not. Routine screening is critical e.g. in breast
cancer, in children it is not recommended unless there is genetical predisposition. Preventable in
adult while there are few preventive strategies in children. Often localized at first in adult while
metastatic disease is usually present at diagnosis. Less responsive to increase responsive
treatment for adults and good response in children. Less than 60% cure rate while a child will
have more than 70% cure rate.

Leukemia; Most common childhood malignancy in less than 15yrs. Describes SP of malignant
dxs in which normal bone marrow elements are replaced by abnormal immature
lymphocytes(blast cells). Types in children;

 Acute lymphocytes leukemia(ALL)

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  Acute myelogeneous leukemia(AML)

Acute lymphocytes leukemia (ALL)

Incidence\etiology; Account for 80% childhood leukemia & approximately 1\3 of all childhood
cancers. Approximately 3000 cases per year in USA with being at 2-5yrs.

Etiology; it is unknown but certain agent increase risk. Such agents include viruses, irradiations,
toxic chemicals exposure-benzene and genetical predisposition.

Pathophysiology; Single lymphoid cell undergoes malignant transformations & proliferation. In

the bone marrow of an individual with all the invasions of these malignant lymphoblasts or
immature white cells causes “growing out” of normal red blood cells, WBC pancytopenia
(WBCS, RBCs & platelets) and immunosuppression.

Clinical manifestations; Depends on affected organs but some include fever, bone pain, pallor,
bruising. Enlargement of organs infiltrated by blasts cells i.e. splenomegaly, hepatomegaly and
kidney enlargement; increased metabolism and weight loss: bone marrow suppression because of

“Crowding out” disturbance of WBCs lead to fever and increase infection while that of RBCs

Lead to oxygen carrying – tachycedic, weakness, malaise, dyspitea, anaemia and pallor. Platelets
are also affected leading to increase bruising/petechial, nose bleeding, bleeding gums and
hemorrhage

Therapeutic evaluation: bone marrow aspirates. Finding of 25% of abnormal lymphoblasts in

the bone narrow diagnostic. Childs WBC and count and age at diagnosis vital for prognosis. Best
–WBC<500/mm3 at age 2-10 years and worst at WBC – 5000/mm3 at 2>10 years. Lumbar
puncture done to asses CNS involvement. Chest x-ray for mediastinal mass detection. Laboratory
test for detection of liver & kidney involvement

Therapeutic management: systemic chemotherapy in three phases. Introduction phase aim to

reduce the tumor to an undetectable level- a state called remission. During remission there is no
evidence of leukemia on -95% achieve remission lasting few weeks then relapse if treatment is
stopped. This indicates existence of undetectable blasts and necessity of continuing with therapy.
Remission induction achieved by use of chemotherapeutic agents e.g. vincristine (oncovin), L-
asparaginase (Alpar), prednisone, anthracycline e.g doxorubicin. Treatment is done in OPD once

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stability achieved. Treat anaemia bleeding & infection. On starting chemotherapy, purines are
released from destroyed leukemia lymphoblasts – increase uric acid which can lead to renal
failure called tumor lysis syndrome. This complication prevented by IV Na= bicarbonate to
aikanalse urine to ph. 7-8. Allopurinol (zyloprin) given to aid excretion of uric acid through
kidneys, preventing obstruction & failure. Tumor lysis syndrome usually occur in children with
greater tumor burden i.e. WBC>500000/mm3 or extensive lymphadenopathy. Most
chemotherapeutic agents don’t cross BBB. Leukemia cells can cross. CNS prophylaxis given
intrathecally into CSF during lumbar puncture. Radiation to brain/spinal cord may be used. The
second phase is consolidation which aims at eradicating any residual leukemia cells. Starts
promptly once remission is achieved. Chemotherapy given in high doses and requires
hospitalization. Intrathecal therapy and radiation to other extramedillary sites done at this time.
Intense phase lasting six months. The third (maintenance phase) maintains control of the
leukemia with chemotherapy administered IV, ORAL, IM. Intrathecal may administration may
continue for 1 ½ - 3 years. If remissions maintained during this period treatment discontinued
electively. Remission achieved is 95% of children and 5 years survival rate are now 80%. Child

INTEGUMENTARY ALTERATIONS

Student learning objectives

At the end of the chapter he student should be able to:

a) Review the anatomy and physiology of the skin

b) Discuss the etiology, clinical manifestations, treatment and nursing management of
common integumentary disorders including cellulitis, candidiasis, and tinea infections.
Pediculosis, scabies, different dermatitis. Acne and, bites and stings.
c) Discuss educational need of a family which children with integumentary condition.

Diaper dermatitis: Also called “diaper rash”. Acute inflammation process occurring in the
diaper area. Usually due to primary irritant (contact dermatitis). Rashes may also appear due to
other conditions e.g. candidiasis.

Incidence & etiology: This is most common irritant dermatitis of childhood. Any child wearing
diaper is at risk but peaks at 9-12 months- this may be related to transition from breast feeding to
bottle feeding and introduction of solid foods. Increase acidity of urine/stools. In USA the

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incidence is7-35%. Introduction of ultra – obsolete disposable diaper has led to decrease in
incidence. Decrease use of diaper dermatitis. The etiological factors responsible include: exact
cause is unknown. Multiple factors thought to be involved: environmental factors e.g. urine pH,
stool consistency, frequency of urine and stool. Type of diaper used – cloth diapers that are
covered by tight fitting plastic pants reduce air circulation and create increased moisture within
the diaper area. Hygiene related factors: infrequent diaper changes, inadequate cleaning and
drying of diaper area, failure to use appropriate topical barriers to protect the skin, other
associated factors: bottle feeding, prematurity and intestinal carriage of candida albinos.
Presence of atopic dermatitis and biotin deficiency also predispose.

PH of urine and stool of BH infants is lower than those bottle-fed infants. This may explain the
decreased incidence of diaper dermatitis with these infants

Pathophysiology: skin breakdown due to prolonged exposure to chemical & physical irritants.
Wetness & warmth increase damage caused by friction. Stratum correum is damaged which
further increases the susceptibility to irritants. Increased pH, fecal enzymes & bile salts irritate
the skin e.g Candidad diaper dermatitis: - A cute onset of erythematons papules beginning in the
perennial area and progressing to cover the perineum. Papules coalesce & form a well-defined
area of erythema with scalloped borders

Diagnostic evaluation; characteristic rash in the dipper area.

Since rashes of another origin may appear in the dipper area. The specific appearance is
important in diagnosis.

Therapeutic management; keep the skin dry, protected and free from infection. Most cases
are minor and they respond quickly to this approach .change the dipper frequently. Good dipper
hygiene .Super absorbent and dispensable diapers (prevents wetness and provide ph care) are
better than the cotton diapers. Barrie powder is also used. Protect skin from moisture and
chemical irritants like white petroleum and zinc oxide products can be used . Note that baby
powder and other out products like baking soda and aortic acid not to be used because they cause
more irritation and they are toxic if they are inhaled. Low dose of steroid cream like 1% of
hydrocortisone for severe inflammation. (Do not use more than 2 times a week) DAIPER
dermatitis due to Candida albucans needs treatment with antifungal agent, typical misstating

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cream or ointment. Some products may have both of steroid and antifungal like clotimazole and
batemathasone.

Note that prevention is the best approach to diaper dermatitis.

Acne / acne vulgarism

Acne vulgarism (Acne) a common disease of adolescent .Its chronic and May persist-adulthood.
Result to skin lesions and emotional disturbance for the adolescent

Incidence/ Etiology: Approximately 85% of 12-25yrs old develops it. Highest incidence at age
16-17 yrs for girls and 17-18 in boys. More common in male’s .The etiology is not exactly clear.
Associated with increase androgens and sebum production occurring during puberty usually
.Family tenancy exits .Other associate Factors are ; emotional stress , heat , humidity ,
increased friction , oil cosmetics , menstrual cycle and steroid administration .

Note: No evidence exists suggesting that any special food is associated with development acne.

Pathophysiology: involves pilosebaceous follicles which are most abundant on the face, chest &
upper back. Acne associated with increased production of sebum (complex lipid that help to keep
skin hydration). Production peaks in adolescents & decreased by 20s due to adrenal cortical
maturation. In individuals with acne, epithelial cells lining the follicle change & become more
cohesive - leading to accumulation of sebum. Keratinized material develop from the lining cells.
Exact trigger of the process is not clear. If due to obstruction that the acne lesions develop.
Propionibacterium acnes (p. acnes) are anaerobic normal flora of skin that colonise the
pilosebaceous follicle. The bacterial use and sebum as nutrient and for growth.
Propionibacterium acnes believed to contribute to the development of acne by producing free
fatty acids/ enzymes that trigger inflammation response & damage to the follicle wall.

Clinical manifestos and types: there are two common classifications:

 Comedonal acne: obstructive & non-inflammatory comedones common.

 Inflammatory acne: characterized by inflammatory, papules, pustules & nodules.

Many individuaals with acne have both types. Comedone - characteristics lesion of non –
inflammation acne. Lesions closed (white heads) or open (black head due to oxidation of

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melainin). lesions may get inflamed when follicle wall ruptures, leaking sebum, hair, p. acnes &
cells into demis causing form action of papules, pustules, nodules & cysts.

Acne scars – pits/depression but hyperthyroid scars may results. Psychological aspects
accompanying acne – low self-esteem, decreased self-confidence, and depression.

Therapeutic management: Based on client’s age & appearance of lesions on face, neck &
back. Appearance of acne in pre-pubertal age may indicate an endocrine problem further
evaluation important. Topical – benzoyperoxide, retionoids, adapalene, azelaic acid, &
antibiotics. Oral – antibiotics, oral contraceptives & isotrtinoin. Improvement starts 4-6 weeks
after staring use. The severity of acne & the characteristic type determine the selection of
treatment. Adjunct therapies include: come done extraction and steroid infections. Treatment
should be individualized as much as possible. Psychological care vital. Nursing management
include:

Common myths associated with skin care need be dispelled e.g. acne is caused by dirt. Picking &
squeezing the lesions not advisable as can cause secondary infection & scaring. Support (fix
support & social/ support) are vital for adolescent, though the treatment regime take long.
Cosmetics & moisturizers containing oils should be avoided.

SENSORY ALTERATION

Student learning objectives.

At the end of the chapter the student should be able to:

a. Review normal language, vision and hearing development.

b. Discuss major type of language and speech disorders in children.
c. Describe common causes of hearing and visual impairment in children.
d. Explain how hearing or/and visual impairment affects the Childs development of speech
and language.
e. Discuss the nurse’s role in early detection of sensory impairments.
f. Describe the nurse’s role in promoting optimal development of a child with a sensory
impairment.
g. Describe the nurse’s role in preventing and treating traumatic injury to the sensory organ
in children.

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Hearing impairment: Hearing impairment is a general term indicating disability that may
range in severity. A deaf person is one whose hearing disability predates successful
processing of linguistic information through audition with or without a hearing aid.

Hard-of hearing person who generally with the use of a hearing aid, has residual hearing
sufficient to enable successful processing of linguistic information that condition where a
person cannot use aid? Hearing impairment may be classified according to etiology,
pathology, or symptom severity. An estimated 1 in 750 infants in the low-risk newborn
population is born with some degree of bilateral sensorneural hearing.

Etiology: Hearing loss may due to a number of prenatal and post natal conditions this
includes: family history of childhood hearing impairment, anatomic malformation of head or
neck, low birth weight, severe prenatal asphyxia. Perinatal infection (cytomegalovirus),
Rubella, herpes, syphilis, toxoplamosisos and bacterial meningitis, chronic ear infection,
cerebral palsy down syndrome, administration of toxics drugs.

Me i.e. sensorneural hearing loss could be due to continuous humming noises or high noise
levels associated with incubators, or intensive care units, especially when combined with the
use of potentially ototoxic antibiotics. Environment noise is a special concern, sounds loud
enough to damage sensitive hair cells of the inner ear can provide irreversible hearing loss.

Pathophysiology: Disorders of hearing are divided according to the location of defects.

Conductive or middle ear hearing loss is due to interference of transmission of sound to the
middle ear. It’s commonly a result of recurrent serious otitis media. Sensorinueral hearing
loss also called perceptive or nerve deafness involves damage to the inner ear structure and
the auditory nerve. Common causes include congenital defects of inner ear structure or
consequences of acquired conditions, that is, kernicterus, infection, administration of ototoxic
drugs, or exposure to excessive noise. This hearing loss results in distortion of sound and
problem in discrimination that is; there are sound distortion. Mixed conductive sensorineutral
results due to interference with the transmission of sound in the middle ear and along neural
pathocry. It results from recurrent otitis media and its complications. Central auditory
imperceptions – hearing loss that does not demonstrate defects in conductive or
sensorineutral.
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Structures normally divided into organs .In organs central auditory imperceptions, the defect
involves of auditory stimuli along the central pollutions and expression of the message into
meaningful communication. Example include: -inability to express ideas in any form either
written or verbally, anoxia inability to interpret sound correctly, dysacusis (difficulty in
processing detail or discrimination among sound). In functional type of conversion
hysteria(unconscious withdrawal from hearing to block remembrance of a traumatic event)
,infantile autism ,and childhood schizophrenia .Hearing impairment is expressed in terms of a
decibel (Db) , a unit of loudness and is measured at varies frequencies i.e. 500 , 1000 and 2000
cycles per second , the critical listening speech range . Hearing impairment can be classified
according to hearing threshold level (measurement of an individual hearing threshold by means
of an audiometer) and the degree of symptom seventy as it affects speech.

Clinical manifestation:

In infants the following clinical manifestations will feature

Lack of startle or blink reflex to a loud sound ; failure to be awakened by loud environmental
noises ; failure to localize a sense of sound of sound by 6 months of age ; absence of babble or
inflection in voice by 7 moths of age ; general different into sound ; lack of response to loud
noises as opposed to the voice .

In children the following signs and symptoms will feature

Use of gestures rather than verbalization to express desires, expect after 15 months of age.

Failure to develop intelligible speech by age 24 months ; vocal play , head banging or foot
stamping vibratory sensation ; frequent and gestures then verbal explanation ; inquiring
sometimes confused facial expression ; frequent stubborn because of lack of comprehension ;
irritable at not making themselves understood .

Therapy management: Treatment of this depends on the cause and of hearing impairment.
Conductive hearing loss mainly respond to medical or surgical treatment the antibiotic therapy
for acute otitis antibiotic therapy for acute otitis media or insertion of typmpanostroy tubes for
chromic otitis

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Media. When conductive hearing impairment is permanent can be improved if the use of a
hearing aid to amplify sound. Treatment for sensor neural hearing loss is less satisfactory;
hearing aids are of less value in this type of defect. Use of cochleare implants (surgical implanted
prosthetic device) provides hope for some affected children. Disorders of central auditor
imperceptions depend on the cause: Textual type i.e. conversion hysteria may require
psychologic interview but i.e. autism may not respond to any therapy

Nursing considerations

Assessment

 Discovery of hearing impairment within the 1st 6 – 12 months is essential.

 Hearing aids – Nurse should be familiar of this I.e. those worn in or behind the ear ,
models incorporated into an eyeglass frame or types worn by the body with a wire
connection to ear.
 Lip reading – child teams to supplements spoken words with sensitivity to visual cues,
primarily body language and facial expression.
 Sign language – Uses hand signals that roughly corresponds to specific words and
concepts in angling language
 Speech therapy - learned through a multisensory approach using visual, tactile,
kinesthetic and auditory stimulation.

Socialization – name should discuss on the method of fostering social contact with family
members i.e. with peers and with parents themselves. Assist in measures to prevent hearing
impairment. Appropriate measures are instituted to treat existing infections and prevent
recurrences. Periodic auditory testing should be done regularly for children with histories of ear
or respond infections or others known to increase the risk of hearing impairment.

Evaluation

Based on the following observational guidelines and expected outcomes.

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 Observe techniques used to communicate with child i.e. inquire if child is enrolled in
auditory training program, socialization opportunities for child (who are his friend, extra-
curricular activities).
 Interview family regarding their adjustment to the sensory impairment, observe family
members relation with child regarding feeling about sensory imperilments and the
effect on activates of daily living.
Nurse can observe neonates response to authority stimuli as evidence by startle reflex, head
turning, eye blinking and causation of body movement. Infant may vary in the intensively
of responsibly of responsible depending on state of alertness. Consistent absence of a
reaction should led to a suspicion of hearing loss. A nurse should assess and suspect
hearing impairment in any child who demonstrates the behaviors below, child with murk
conductive hearing impairment in any child fairly deadly but in a loud monotone voices,
child with sensormeural detect has a different articulation i.e. inability to hear highest
frequencies may result in the word spoon being pronounced’ pool.
Visual impairment: It refers to visual loss that cannot be corrected with regular
prescriptive lenses. Classifications is based on the type of activity in which the child can be
expected to engage in this may include; school vision(visual acuity between 20/200 and
20/200 also known as partially sighted; legal blindness (visual acuity 20/200 or else and or a
visual field of 20 degrees or else in better eye. It’s useful in only on legal definition not for
medical diagnosis; travel vision. (Visual acuity of 20/400. It allows the child to travel in
unfamiliar surroundings provided he is otherwise healthy; light perception, which are
primarily important for the child’s sense of wellbeing and may be an aid in mobility.

Etiology: Based on the following divisions;

 Familiar factor; including genetic diseases associated with visual defects, such as
teaches
Disease, albinism, galactosemia or retinoblastoma.
 Prenatal/ intrauterine factors; especially maternal infection, such as rubella syphilis,
herpes simplex or toxoplasmosis.
 Perinatal factors; including prematurity, maternal infection (ophthalmic, neonatorum),
and oxygen toxicity (retrolental fibroplasias.)

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  Postnatal factors; which are primarily trauma, infections (mumps, measles, rubella,
poliomyelitis and chicken pox), and disorders such as juvenile rheumatoid arthritis,
leukemia, and myasthenia gravis.

Types of visual impairments

Refractive errors: Which refers to those variations eye that prevent perfect focusing of light rays
on the retina? These refractive errors may result in: myopia or near sightedness and refers to the
ability to see near objects but not those in a distance. It results from an eye ball that’s too long.
Resulting in the focal point failing in front of retina. Correction: use of biconcave lenses which
cause the parallel rays to diverge thus permitting the lens of myopic eye to the two rays on the
retina.
Hyperopic (hypermetropia) or far sightedness: this results of short in length: as a result rays
are theoretically focused behind the retina. They see objects at a distance and because of their
accommodative ability they can see objects at close range. Correction: use of convex lenses
which bend the light rays so that the lens of the eye can focus them on the retina.
Astigmatism: refractive surfaces of the eye being rarely spheric. There’s unequal curvatures in
the cornea or lens such that rays are bent in different directions, producing a blurred image.
Correction: use of a specially ground lenses that compensate for errors in refraction.
Amblyopia which results when one eye does not receive sufficient visual stimulation during the
critical period of development of visual cortex. Amblyopia can be classified according to the
following; strabismus amblyopia; from prolonged fixation by the dominant eye and suppression
of the images in the deviating eye. Occlusion a myopia: from prolonged patching of an eye, such
as therapeutic patching after an injury in very young children.
Therapeutic management: Amlyopia treatment includes patching the good eye so that the child
can be forced to use the weaker eye. If refractive errors are present then corrective lenses are
worn

Strabismus. Referring to the misalignment of the eyes, and thus the visual axes do not parallel
causing the eye to see two separate images. The brain can suppress the images of the weaker or
deviating eye; amblyopic can result in children less than 9 years of age. Strabismus can be
classified as:

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  Paralytic strabismus; which is a deviation of the eye caused by a paralysis of an extra
ocular muscle (six eye muscles innervated by the 3, 4 and 6th cranial nerves.)
 Non paralytic strabismus; where there is no defect in the action of the individual of the
extra ocular muscles or in a specific nerve.
 Isotropic strabismus; an inward deviation of the eye, and be classified as infantile
isotropic or early onset isotropic; which begins at an early age of 6-12 months.
Accommodative isotropic which occurs between 6-7 years. And involves a large
hyperopic refraction error that requires excessive accommodation to bring the image into
clear focus.

Therapeutic management: Depend on the type of strabismus but may involve surgery, of the
affected muscles, lenses to correct refractive errors, occlusion therapy, and sometimes
administration of anticholinesterases agents to reduce the accommodative effort.

Cataracts; which is opacity of the crystalline lens. The lenses are normally transparent to allow
the light rays to enter the eye and refract them for a clear image of the retina. A cataract then
interferes with both of these functions. Cataract can be congenital, such as those caused by
maternal rubella during the first trimester, or acquired, most commonly as a result of penetrating
injuries or as a result of a disease complication i.e. galactosemia. Cataracts are identified as a
visible white clouding of the lens from absence of the red reflex on examination of the retina.

Therapeutic management: For children include glasses or removable lenses to provide sharp
vision at only one distance. As the child grows a bifocal system is required to correct both far
and near vision. Nursing interventions include general nursing goals focuses on prevention,
detection and rehabilitation. Prevention measures include:

 Prenatal screening for pregnant women at risk such as those with rubella or syphilis
infection and family histories of genetic disorders associated with visual loss
 Adequate prenatal or prenatal care to prevent Prematurity and iatrogenic damage from
excessive administration of oxygen.
 Periodic screening of children especially of newborns through preschoolers, for
congenital blindness and visual impairment caused by refractive errors and strabismus.
 Adequate immunization for all children.

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Most infants demonstrate specific orientation responses to visual impairment. Most infants
would exhibit the following response; failure to focus on or follow stimulus, with stimulus and
brightens.; tills, focuses on stimulus when present , little spontaneous interest, no following ;
stills, focuses on stimuli, and follows for 30 degree arc, jerky movements loses stimulus but finds
it again; Follows for 30- degree arch with eyes and head, eye movements are smooth; follows
with eyes and head at least 60 degrees horizontally, maybe briefly vertically, partially continuous
movement, loses stimulus occasionally, head turns to follow; follows with eyes and head 60
degrees horizontally and 30 degrees vertically; Focuses on stimulus and follows with smooth,
continuous head movement horizontally, vertically, and in a circle; follows 120 degree arch and
during infancy, the child should be tested for strabismus.

In childhood common problems are refractive errors. Testing for visual acuity is essential.
Nurses should be aware of signs and symptom indicating other ocular problems. Nurses should
also stress on continuity of periodic eye examinations. Glasses are necessary for visual
impairment. Safety counseling regarding common uses of ocular trauma. In rehabilitation nurses
goals include; helping the child and family to adjust to the impairment; promoting child- parent
attachment; fostering optimum development and independence; providing for play/socialization
and being aware of educational facilities.

NEUROLOGICAL ALTERRATIONS

Student learning objectives.

At the end of the chapter the learner should be able to:

a. Review the anatomy and physiology of the nervous system with pediatric considerations

B. Describe the etiology , clinical manifestations , treatment and nursing management of

seizures , hydrocephalus craniosytosis, arteriovenous malformations, neural tube defects,
mengitis, encephalitis, head injury, spinal injury, cerebral palsy, drowning and Reyes
syndrome.

C. Describe the intervention needed to help families cope with a child who has alteration in
neurological functioning.

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Introduction: neurological alteration can be structural, infections or injury. General clinical
manifestations: may be different levels of consciousness e.g. confusion, (e.g. disorientation),
delirium with anxiety, fear and agitation. Further deterioration of consciousness may lead to
stupor where the child can only react to deep stimulation. Lastly coma may result where the child
cannot respond even to deep painful stimulus. Assessment of level of consciousness by AVPU

A= alert and awake; V= Responsible to verbal stimuli; P= responsive to painful stimuli; U=

unresponsive. Ensure that you state the exact stimuli and reaction used.

Other methods used for assessing level of unconsciousness: Glasgow coma scale – consider the
age child e.g. 5 year old may not respond because have told by parent not to talk to strangers.
Presence or absence of posturing: - decorticate (flexor posturing) associated with bilateral
hemisphere injury while decerebrate (rigid extensor posturing) is associated with midbrain, pons
injury. Flaccid areflexia (absence of response) indicates server brain system injury-common in
terminal coma. Vital signs: Changes in the viral signs ca indicated pathophysiological changes
within the brain stem. CVS observations are important because of the close relationship between
cerebral haemodynamic and cerebral blood flow. Reduced cerebral blood flow result in
vasomotor response e.g. blood pressure increases.

Diagnostics procedures: Varies and depends on the child’s presentation. May include the
following:

 Blood profiling e.g. Urea and electrolytes, metabolic and immune assays and genetic
screening
 Lumbar puncture for CSf collection for bacterial/ tumor screening, measure CSF pressure
 Neuroimaging e.g. X-rays, computerized axial tomography (CT), MRI
 Specialized physiological imaging techniques e.g. PET, SPECT.
 Cerebrovascular studies e.g. angiography can detectaneurysms and anteriovenous
malformations.
 Electroencephalography (EMG) to detect seizures.
 Electromyography (EMG) conduction studies measures electrical activity and velocity in
muscular fibers.
 Muscule biopsies measures muscule enzymes to detect if a problem is neurogenic or
myogenicin origin.
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 Cerebral palsy (CP): Defined as non-progressive motor dysfunction caused by damage to
the motors areas of the brain

Incidence etiology: Incidence: 7:1000 live birth per year. Persons with CP may have
accompanying disabilities in cognition and language

Pathophysiology: Congenital malformation or brain damage from any of the above

factors

Clinical Manifestations: CP is an abnormality of muscle tone and movement clinical

features depends on muscle responses and area of body affected. Clinical features
according to muscle response: - Hypotonia: Manifested as floppiness, increase range of
motion of joints, increase reflex responses. Hypertonic: Manifested as rigidity, spasticity,
scissoring or crossing of lower extremities, reflex reactions [Babiski deep tendon reflexes
are exaggerated. Athetosis:-Constant involuntary writhing motions; affect entire body;
but more severe distally. Ataxia:-Irregularity in muscle action or coordination and wide
based giant. Clinical manifestations according to topographic response; Hemiplegic;
Manifested as upper extremities move involved, sensory deficits, asymmetric posture/
position , atypical response on affected side, alteration in muscle tone spasticity.
Diplegia: Involve similar sides of the body; lower extremity dysfunctional than the upper;
muscle tone altered – hypertonic/spasticity; delay in development of fine motor skills
usually at normal pace. Quadriplegia: Involvement of all 4 extremities with equal
involvement although arms are usually flexed & legs extended; delay in attaining those
developmental milestones dependent on motor ability; there are speech dysfunctions and
swallowing may be impaired; emotional liability not uncommon.

Diagnostic evaluation: Based on clinical findings

Note: Definite Diagnosis is not possible till age 18m—2years so that Signs & Symptoms
are not confused with delayed development

Any suspected case, keen observation is made on age of achieving specific motor skills.
See the above clinical manifestation as important diagnostic features.

Therapeutic management: There is no cure for cerebral palsy. Interventions are aimed
at: Enabling client achieve the best movement, Locomotion, communication possible &

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 be self- dependent as possible e.g. Occupational therapy to prevent complications of
immobility , Speech therapy , Wheel chairs , Walkers , Surgical intervention to reduce
spasms e.g. rhizotomy with small section of spinal cord is cut . Medication for older
child/adolescent e.g. muscle relaxants to decrease contractures. Anti-anxiety – reduce
excessive motions associated with athetosis.

Note: Botulinum toxin A has currently been to manage spasticity. Children receiving this
therapy have had significant improvement of muscle tone, range of motion and function motor
response.

Other important interventions include: Positioning vital e.g. pillows; protect any prominences- to
prevent bed sores; moving client & feeding is a big challenge for the nurse- seek support from
the family members ; social support extremely vital for the entire family ;family need to be
taught how to take care of child at home as much as possible,

Seizure: Episodic, stereotypic behavioral syndrome that have an abrupt onset. Generally not
provoked by external stimuli.

Etiology: Depends on the type of seizure. Incidence rate is 0.5-1.0%.

Partial: originate from a focal point .for comples partial, may cause by intracranial leisure,
tumours and cysts. Birth and other traumatic injury, arteriovenous malformations, prolonged
febrile seizures. Simple seizures – May be caused by tumours & other lesions, focal damaged to
brain arteriovenous mal function, brain abscess. Examples of simple seizures- Jacksonian,
Rolandic/ sylvian seizures.

Generalized: Tonic/ Clonic seizures, birth injury/ cerebral trauma, metabolic disorder, fever,
unknown .Absence seizures – possible genetic link. Myoclonic seizures - prenatal & perinatal
encephalopathy.

Pathophysiology: Spontaneous electrical discharge of hyper excited brain cell in epileptogenic

focus. May be triggered by emotional stress, Anxiety, Fatigue, infection, metabolic disturbance.
Location & number of epileptogenic foci determines the nature of seizures. Small area –
localized, if spread – generalized. Status epilepticus; prolonged seizures or series of convulsions
where loss of consciousness occurs for at least 30 minutes. Epilepsy: Chronic seizures disorders
that is often associated with CNS pathology. Clinical manifestation: Depends on the type e.g.

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Simple partial – local motor, sensory, psychic & somatic manifestations. E.g. Hallucinations,

Anxiety, paresthesias. Complex partial: Aura, Anxiety, fear, D`eja` vu, unusual tastes, visual/

Auditory hallucinations, disturbed consciousness. Automatism – repeated non- purposeful action

e.g. Lip smacking, chewing, sucking, uttering same word. Tonic/ clonic, Postictal/ post

Convulsive state. Absence/ petit mal: Appear around 6th birthday & disappearance in
adolescence transient loss of consciousness i.e. Cessation of current activity. Stare at space. Loss
of muscle tone – things drop from hand and head droop. Lip smacking occur. Febrile seizures:
Type of clonic/ tonic .Associated with increase temperature. 390C at 6m- 5yrs .The family
history vital .Frequently accompany infections e.g. URTL, pneumonia, otitis media etc. Infantile
spasm: Salaam seizures being at 3months of age. X2 in male’s .Infants head sudden drop forward
while arms & legs flexed, eyes roll upward / downward .Cry out turn pale or cyanotic/ flushed
and loss of consciousness may result.

Diagnostic Evaluation: Family history is vital. Investigate about infection about infection and
some metabolic disturbance. Neurological evaluation e.g. Level of consciousness, Reflexes,
Sensory and motor responses. CT/MRI – structural abnormalities. Angiography-vascular
abnormalities. Electro-once phalogram (EEG) – brain electrical activity. Positron emission
tomography (PET)-brain abnormality areas

Therapeutic management: Oxygen for tonic/clonic. Absence may be self- limiting.

Pharmacotherapy e.g. Benzodiazepines and barbiturates-Revise on pharmacology. Intractable

seizures require Surgery - epileptogenic focus if necessary e.g. temporal lobectomy or

Hemispherectomy. Nursing Management – Oxygen therapy & suction. Medication compliance is

Very important. Classify seizures to accurately determine right medication. Safe environment –

Family education. Destigmatise about epilepsy. Counseling. Social services and support groups
need be involved e.g. epilepsy association of Kenya. Medic alert bracelet – for legal and first aid
purposes.

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MUSCULOSKELETAL ALTERATIONS

Student learning objectives

At the end of the chapter the learner should be able to:

a. Review anatomy and physiology of the musculoskeletal systems with pediatric

considerations
b. Discuss the etiology , clinical manifestations , treatment and nursing management of
various musculoskeletal alterations, including injuries like sprains, strains contusions,
dislocations and fractures; Osteomyelitis, clubfoot, developmental dysphasia of the hip;
scoliosis, kyphosis. Lordosis
c. Identify the educational needs of the families of children with musculoskeletal alterations
Soft tissue injuries: Soft tissue injuries involve the skin and the underlying fat and
connective tissue and muscles. A closed wound is an injury to the soft tissue but without
a break in the skin. Closed wounds include: contusions (bruises) – bleeding beneath the
skin into the soft tissue. The bleeding can be a lot or a little. A lot of bleeding can cause
pain and swelling, and can lead to problems with vital structures. Hematomas – well –
defined pocket of blood and fluid beneath the skin. An open wound is an injury to soft
tissue with a break in the skin. Usually, they are more serious than closed injuries
because they can cause blood loss and infection. Open wounds include: Abrasions –
superficial loss of skin from rubbing or scraping the skin over a rough or uneven surface.
Lacerations – tears in the skin. The cut can have smooth or jagged edges. Punctures –
skin is penetrated by a pointed object. Can be penetrating (entrance wound only) or
Perforating (entrance and exit wound). Usually, puncture wounds do not cause a lot of
bleeding on the outside, but there may be a lot of bleeding on the insides and damage to
organs. Avulsions – involve a tearing off or loss of a flap of skin. Amputations –
traumatic cutting or tearing off of a finger, toe, arm or leg.

Sprains: These occur from overstretching and tearing of ligaments. Sprains vary from sparse
fibrous tears to complete disruption of a ligament complex. The results are pain, tenderness and
soft tissue swelling. Ligament sprains are traditionally graded into three types, although
distinguishing clinically between them may be difficult: First degree sprains involve minor
tearing of ligament fibers and are entirely stable. Second degree sprains are more severe partial

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sprains. There may be some resultant slight ligamentous laxity, but with a definite end - point on
stressing. Third degree sprains reflect completely torn ligaments causing significant laxity:
patients sometimes report hearing a snap at the time of injury. Ligament sprains are very
common, but there is a lack of reliable evidence about treatment. Prolonged immobilization
seems to be detrimental to recovery, because of muscles wasting and loss of proprioception.

Painful minor sprains do respond well to traditional measures: Ice, compression with elastic
support/ strapping, elevation and progressive mobilization as soon as symptoms allow.

Simple analgesics such as paracetamol or NSAID (e.g. ibuprofen) may help. Complete ligament
rupture can be relatively painless, but if associated with gross joint instability will require
surgical repair. Associated haemarthrosis require orthopaedic appraisal, aspiration and often
initially, protection and immobilization in Plaster of Paris.

Strains: Indirect injury involving muscles – tendon units may be classified in a similar fashion to
ligament sprains. Pain on palpation over the site of injury is also reproduced by passive stress or
active contraction of the affected muscle unit.

Diagnostic evaluation: palpable defect may be apparent in complete ruptures (which typically
occur at the musculotendinous junction). However, associated swelling may prevent any defect
from being easily palpable.

Therapeutic management: Minor strains similarly to sprains; consider specialist review for
complete ruptures, some of which may require surgical repair.

Direct muscle injuries: These results from direct impact to a limb, body surface or internal
organ causing local pain, bruising and soft tissue swelling. Note that associated bone contusions
can occur, such as the parimeniscal areas of the knee (these are visible on MRI). Treat minor
injuries with ice, analgesia and early mobilization within the limits of symptoms. For more
significant injuries, consider and treat according to possible risks of compartment and crush
syndromes with Rhabdomyolysis and large haematomas

Haematomas: Blood can accumulate as a result of traumatic disruption of the vascular structures
within bone, muscles and soft tissues. In the case of intracranial, intrathoracic, intraabdominal
and pelvic haematomas, this is potentially life – threatening. Deceptively large volumes of blood
can be accommodated within the soft tissue planes of the chest wall or thigh.

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Diagnosis: In the presence of massive visible bruising of the torso or a limb, check for shock and
measure Hb and Hct. Perform a coagulation screen. Blooding transfusion may be necessary.
Treat minor haematomas with compression dressings, ice and consider ultrasound therapy. Large
haematomas or supervening infection requires selective surgical drainage, haemostasis and
antibiotics.

Myositis ossificans: After some muscle or joint injuries, calcification can occur within a
haematoma leading to restriction of movement and loss of function. Frequent sites include
calcification within a quadriceps haematoma (e.g. following a rugby injury) where inability to
flex the knee >900 at 48hrs after injury indicates an increased risk of myositis ossificans. Other
sites include the elbow and femur. Passive stretching movements of joints may be implicated in
the development of myositis ossificans. This particularly applies at the shoulder, hip and knee
where passive exercises are performed for spasticity following paraplegia or head injury.

Therapeutic management: Involves immobilizing the limb or joint for a period of weeks, under
specialist supervision. Early excision is contraindicated, as it is invariably followed by massive
recurrence, but delayed excision (after 6-12 months) can improve function.

Tendonitisis/tenosynovitis: This includes a bewildering range of conditions, some of which may

have medicolegal implications (e.g. overuse or repetitive strain or injury). Example include:
classic tenosynovitis: - swelling along a tendon sheath, with pain on passive stretching or upon
attempted active movement against resistance. Chronic paratendonitis (e.g. affecting Achilles
tendon):- swelling around the tendon with localised pain and tenderness. Tendon insertion
inflammation causes epicondylitis in adults and traction apophysitis in children.

Threpeutic management: Appropriate initial treatment usually includes rest, immobilization

and NSAID. Later, consider involving an appropriate specialist (e.g. physiotherapist or hand
therapist).

Bursitis: Inflammation of bursae most frequently affects the subacromial, olecranon and
prepatellar bursae. There is localised swelling and tenderness: generalized joint effusion and/or
tenderness along the whole joint line suggest an alternative diagnosis.

Therapeutic management: In many instances, bursitis is non-infective and responds to rest and
NSAID. Signification warmth and erythema raise the possibility of an infective origin. In this

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case, consider aspiration for bacteriological culture and provide antibiotics (e.g. co – amoxiclav
or penicillin + flucloxacillin). Other problems: Other causes of joint or limb pain with no specific
history of trauma in the adult patient includes: stress fractures, cellulitis and other infections,
osteoarthritis and other forms of acute arthritis, nerve compression (e.g. carpal tunnel syndrome).
Apparently atraumatic limb pain in children may present with limping, likely underlying cause
vary according to the age.

Physiotherapy in Accident and Emergency (A&E) departments

The term physiotherapy in an A&E department includes the advice given to each patient
following minor injury. It encompasses the assessment and treatment of selected patients by
skilled, experienced physiotherapists. It is valuables for a department to have close links with a
physiotherapy unit, preferably with designated physiotherapy staff responsible for A&E referrals.

Everyday physiotherapy

Minor soft tissue injuries are amongst the most commonly seen problem in A&E departments.
Once bony injury has been excluded (clinically and/or radiologically) ensure that patients are
discharged with clear; consistent advice on how to manage their own injuries in every case:

 Be clear and specific about what the patient is to do

 Give a realistic time limit after which the patient should seek further attention if their
symptoms are not improving

 Give additional written instructions for reinforcement (e.g. ankle sprains, minor knee
injuries), as patients will forget much of the verbal advice given.

Formal physiotherapy: Physiotherapists are trained in the rehabilitation and treatment of injury,
based on a detailed knowledge of relevant limb and joint anatomy, biomechanics and
physiology. In A&E, physiotherapy staffs are valuable in assessment and treatment of acute soft
tissue injuries, patient education and advice and in the provision of appropriate mobility aids
(particularly in the elderly) after injury. In order to make the best use of physiotherapy services,
follow these guidelines:

 Refer early if required for acute injury. Aim for the patient to be seen for initial
assessment the same day, so treatment needs can be properly assessed.
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  Discus the problem and treatment options with the physiotherapy staff prior to referral.

 Use the physiotherapy service for selected cases, not as a general rule.

 Never use the physiotherapy department to simply offload difficult or problematic

patients.

Physiotherapists have a range of different treatments at their disposal, which typically focus upon
regaining range of movement and mobility, improving strength and proprioception.

Nursing management: Rest/ice/compression/elevation (RICE) forms the traditional basic

framework for management of most acute soft tissue injuries. Rest: With most acute injuries,
advise a period of 24 – 48h rest after an injury. Ice; this is often advocated both in the immediate
first aid of soft tissue injuries, and in their subsequent treatment. Crushed ice cubes wrapped in a
damp cloth (to avoid direct contact with the skin) placed against the injured joint may decrease
swelling and pain. Do not apply for more than 10 – 15mins at a time. Repeat treatment every few
hour initially. A cold pack or bag of frozen vegetables can also be used (do not refreeze if for
consumption!).

Compression: Despite a distinct lack of evidence, injured joints (particularly the ankle) are
frequently treated with some form of support. The easiest to use is an elasticated tubular bandage
(e.g. Tubigrip), either single or double over. If provided, advise the patient not to wear it in bed
and to discard as soon as convenient. If not provided, explain why, or the patient may feel
inadequately treated. Avoid providing support bandage s to patients with elbow and knee injuries
because the bandage tends to be uncomfortable & dig in and in the case of the knee, may affect
venous return and increase chance of DVT.

Elevation: Initially, advise elevation of injured limbs or extremities above horizontal to decrease
swelling and discomfort. This is particularly crucial in hand or foot injuries.

Exercise: Start gentle, controlled exercise for any injured joint as soon as symptoms allow.
Demonstrate what is expected and confirm that the patient understands what to do.

Nursing intervention: Nurse educate patient care of the injury and symptoms that you should
watch over at home. You should call the doctor if your child has a lot of pain that does not get
better after you give him/her pain medication. You should be looking at the wound for signs and

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symptoms of infection (redness, swelling, pus from the wound or fever). Get medical help if your
child has bleeding that will not stop after placing firm pressure with your fingers over the wound
for 15 minutes. Medication/pain: Nurse administers analgesics to reduce pain e.g. acetaminophen
as prescribed by the physician. Nurse also administers immunization e.g. tetanus toxoid.

Wound and Skin Care: The child may shower or take a bath, but may need help for several
days after going home. Advice patient and family about care when taking baths if yours child has
had surgery. If child has cuts or scrapes on the skin from other injuries, wash the areas with
warm soapy water and pat them dry. If child has stitches, follow the specific instructions on
caring for them. Prevention education: it is very important to teach the child about all types of
safety. The child watches the parent, so you should also always use proper safety precautions.
Child should learn to wear a helmet when riding a bike, rollerblading or skate boarding. Teach
your child to always wear a seatbelt when riding a car. Remember that children 12 years old and
younger should always use correct safety restraints in the back seat when the car has a passenger
side airbag.

Follow – up Care: Stitches on the face are taken out in 3-5 days and stitches on the rest of the
body are taken out in 7- 10 days. Stitches may be taken out by your or at Trauma Clinic. The
nurse will make an appointment to have the stitches taken out before you leave the hospital or
they will give you a number to call to make an appointment.

Nutrition: Educate family to feed the child on nutritious foods and drinks as much fluid as her or
she did before they were hurt. Activity: Activity limitations following a soft tissue injury depend
on where the child was injured and how bad the injury is. The nurse will talk to you about what
type of activity your child should stay away from after he/she leaves the hospital. The area that is
injured will heal faster if kept at rest. The child can usually go back to day care or school right
after your child is injured. Nurse will help you decide when it is time to send your child back to
school. If surgery was needed or your child has other injuries, he/she may be out of school
longer. The Trauma team will help you with your child returning to school. At school, child
should not be taking gym until the doctor says it’s okay.

Developmental dysplasia of the hip: DDH (e.g. his dislocation): 1.3% of neonates have
unstable hips or subluxation. A hip may be normal at birth, and become abnormal later.

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Incidence (UK): 2 per 1000 live births. Female/male is approximately 6:1; left hip/right hip.
Incidence approximately 4:1 (bilateral in1/3)

At – risk babies: Breech birth, Caesar for beach, other malformations, Positive family history,
Birth weight increase, Obligohydramnios, Post maturity, older mother/older primipara

Diagnosis: Examine hips of all babies in the 1st days of life and at 6 weeks. With well trained,
well supported staff this prevents later dysplasia. Be alert to DDH throughout child surveillance.

Click test of Ortolani: With the baby supine and relaxed, flex the hips to 900 and knees fully.
Place your middle finger over the greater trochanter, and thumb on inner high opposite the lesser.

Diagnose; a dislocated hip if slow abduction produces a palpable (often audible) jerk or jolt (i.e.
more than a click) as the femoral head slips back into the acetabulum.

The Barlow manoeuvre: With the pelvis stabilized by one hand, abduct each hip in turn by 450.
Forward pressure by the middle finger causes the femoral head to slip into the acetabulum if the
hip is dislocated. If the femoral head slips over the posterior lip of acetabulum and straight back
again when pressure is exerted by the thumb it is unstable (i.e. dislocatable not dislocated). Use
both test but avoid repetitions (may induce instability/dislocation)

Note: Both tests are problematic, missing up to 2/3 of those later needing surgery.

In older children signs may be: delay in walking, abnormal waddling gait (affected leg is
shorter), asymmetric thigh creases (extra crease on the affected side), and inability to fully
abduct the affect hip. With bilateral involvement the perineum appears wide and lumbar lordosis
is increased.

Ultrasound: Is the image of choice, as it is non – invasive and dynamic? Routine ultrasound
screening for DDH remains controversial.

Treatment: If neonatal examination suggests instability, use double nappies; reassess at 3

weeks. If still a problem, splint the hips in moderate abduction for 3 months (e.g. the Pavlik
harness). Excess abduction may case avascular necrosis of the head of femur. From 6 – 18
months and examination-underanaesthetic, arthrogram and closed reduction is performed
followed by a period of immobilization in a hip spica. Open reduction is sometimes required if
closed techniques fail. After 18 months (delayed presentation) open reduction is required with

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corrective femoral/pelvic osteotomies to maintain joint stability. Nursing management and
invention: The goal of treatment is to put the femoral head back into the socket of the hip so that
the hip can develop normally. The nurses therefore has a role in educating patients on the
treatment regimens and if possible describe the type of procedure, materials used need for
surgery which the surgeon should have explained. The nurse explains the following treatment
option: placement of a Pavlik harness. The Pavlik harness is used on babies up to 6 months of
age to hold the hip in place, while allowing the legs to move a little. The harness is put on by
physician and is usually worth full time for at least six weeks, then part-time (12 hours per day)
for six weeks.

The nurse organizes and informs parent and caretaker on return date. The baby is seen frequently
during this time so that the harness may be checked for proper fit and to examine the hip. At the
end of this treatment, x-rays (or an ultrasound) are used to check hip placement. The hip may be
successfully treated with the Pavlik harness, but sometimes, it may continue to be partially or
completely dislocated traction and casting. If the hip continues to be partially or completely
dislocated, traction, casting or surgery may be required. Traction is the application of a force to
stretch certain parts of the body in a specific direction. Traction consists of pulleys, strings,
weights, and a metal frame attached over or on the bed. The purpose of traction is to stretch the
soft tissue around the hip and to allow the femoral head to move back into the hip socket.
Traction is most often used for approximately 10 to 14 days. Traction can either be set up at
home or in the hospital, depending upon physician, hospital and the availability of the resources
of Surgery and casting. If the other methods are not successful or if DDH is diagnosed after the
age 2 years, surgery may be required to put the hip back into place manually, also known as a
“closed reduction”. If successful, a special cast (called a spica cast) is put on the baby to hold the
place. The spica cast is worn for approximately three to six months. The cast is changed from
time to time to accommodate the baby’s growth and to ensure the cast’s rigidity, as it may soften
with daily wear. The cast remain on the hip until the hip returns to normal placement. Following
casting, a special brace and physical therapy exercises may be necessary to make the muscles
around the hip and in the legs stronger. Nurse educates patients on the condition, what a short leg
hip spica cast is, and its general care until it is removed. A short leg hip spica cast is applied from
the chest to the thighs or knees. This type of cast is used to hold the hip in place after surgery to
allow healing. Cast care instructions:

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  Keep the cast clean and dry.

 Check for cracks or breaks in the cast

 Rough edges can be padded to protect the skin from scratches.

 Do not scratch the skin under the cast by inserting objects inside the cast.

 Use a hairdryer placed on a cool setting to blow air under the cast and cool down the hot,
itchy skin. Never blow warm or hot air into the cast.

 Do not put powders or lotion inside the cast.

 Cover the cast during feedings to preventing spills from entering the cast.

 Prevent small toys or objects from being put inside the cast.

 Elevate the cast above the level of the heart to decrease swelling.

 Do not use the abduction bar on the cast to lift or carry the baby.

Nurse educates patients on cast complications. Teach patient on signs that if observed he should
call the physician: contact your physician or healthcare provider if your baby develops one or
more of the following symptoms; fever, increased pain, increased swelling above or below the
cast, drainage or foul odor from the cast, cool or cold toes

Scoliosis; Increased lateral curvature of the spine. Above and below the scoliosis, secondary
curves develop to maintain normal position of head and pelvis. In all cases, refer to orthopaedics
for assessment. The chief cause is muscle spasm (e.g. with sciatica). Structural (true) scoliosis:
Fixed deformity (no correctible). Scoliosis is associated with rotation of the vertebrae with or
without ribs and wedging of the vertebrae. Causes: Idiopathic, neuromuscular (e.g. cerebral
palsy, muscular dystrophy, neurofibromatosis), trauma, osteoporosis, TB of the spine (rare),
spinal tumours (rare), congenital abnormalities of the spine (rare). Non – structural (mobile)
scoliosis:

Curvature is secondary to another condition outside the spine e.g. unequal leg length and
disappears when that is corrected e.g. leg length disparity (disappears on sitting). No rotation of
the vertebrae.
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Cause of true scoliosis

 Idiopathic (this is seen both in infants and adolescents)

 Congenital: (failure of formation or segmentation). Vertebral malformation produces

severe scoliosis which is rapidly progressive. Major cause: hemivertebra; Klippel-Feil
syndrome; congenital vertebral bar due to failure of segmentation.

 Neuromuscular imbalance e.g. polio, cerebral palsy, muscular dystrophy,

neurofibromatosis, syringomyelia.

 Trauma resulting in damage to the vertebral growth plate and uneven growth.

 Neoplasm: Primary: Osteoid Osteoma and esteoblastoma cause a painful scolios and
secondary: Lytic metastases

 Other (e.g. tumour, infection, trauma).

 Treatment of tumours (e.g. radiotherapy) may result in scoliosis.

 Metabolic Osteoporosis and crush fracture.

 Infection: TB of the spine (Potts’diseases).

Screening tests:

 <1y. Old: Place the child prone on his tummy and feel the shoulder and thoracic cage.
There should be no rib hump or shoulder hump.

 >1y. Old: Ask the child to bend forward whilst standing straight with both feet together
and holding both hands straight. Look for a shoulder, thoracic or lumbar hump, difference
in shoulder height, oblivious spinal curvature, and check the gap between arm and
waistline.

Clinical presentation: Usually found incidentally or on screening. Look for: Difference in

shoulder height; spinal curvature and difference in space between trunk and upper limbs:
Structural scoliosis is often made more obvious by asking the child to bend forwards. Scoliosis
which disappears on bending is postural and no clinical significance.

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Management

Refer children with structural scoliosis to orthopaedics.

If scoliosis is painful (especially at night) in a child or young person, consider spinal tumour and
refer for urgent orthopaedics assessment.

Complications: Deformity; pain and limitation of activities; respiratory restriction.

Idiopathic scoliosis

>100 of lateral curvature of the spine and thoracic curves tend to be more severe than lumbar.

Incidence: 1 – 3% greater in girls than in boys.

Divided into 3 groups depending on basis of onset i.e

 Infantile idiopathic scoliosis: (birth – 3yrs) 90% are left –sided convex scoliosis.
Associated with ipsilateral plagiocephaly (flattening of the skull). May resolve
spontaneously (more likely if male, onset at <1y. of age and/or the rib-vertebral angle is >
200) or progress as the child grows.

 Progressive/juvenile scoliosis: - (4 – 10 yrs) is treated with braces and surgery. As a

general rule the younger the child and the higher curve, the worse the prognosis.

 Late onset idiopathic/adolescent scoliosis: Affects children aged 10 – 15 yrs, Female:

Male [appropriate] 9:1. The scoliosis is usually right-sided convex. The condition always
gets worse without treatment as the child grows.

Treatment is with observation (if the scoliosis is mild and the child has nearly completed
growth), braces, and/or surgery.

Therapeutic management: Early treatment of scoliosis prevents progression. Early onset

scoliosis (<8y.) is responsible for cosmetic problems, pain, and cardiopulmonary disturbance.
Late onset scoliosis is less severe but also causes pain and significant deformity.

Scoliosis which disappears on bending is postural and of no clinical significance.

In all case, if scoliosis is suspended, refer for an orthopaedic opinion.

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Kyphosis (round back)

This is where the normal thoracic spine has a convex alignment in the sagital plane. The normal
radiographic range of kyphosis is 20 – 40 degrees. People with increased kyphotic alignment
have the clinical sign of round back. Round back may be flexible or structural

 Postural/flexible kyphosis (drooping shoulders or around back female) is common and

voluntarily correctable.

 Structural kyphosis cannot be corrected voluntarily. It may be idiopathic or congenital in

origin.

Flexible kyphosis: This is a common concern of parents of adolescents. The adolescent can
correct the round back appearance voluntarily in both standing and prone positions. The overall
angle of kyphosis may be increased on the standing lateral radiography, but no vertebral
abnormalities present.

Therapeutic management: a thoracic hyperextension exercise program may assists in

strengthening the extensor muscles of the spine, but the patient has the ultimate responsibility for
their posture. Orthopaedic treatment is not indicated for patients with flexible kyphosis.

Structural kyphosis

Idiopathic kyphosis/Scheuerman disease

This is a non flexible kyphosis that develops during adolescence in previously normal children.
Mild increases in structural kyphosis are equally normal in boys and girls; the condition may
worsen slightly in boys than in girls. It is an autosomal dominant. The normal ossification of ring
epiphyses of several thoracic vertebrae is affected. Deforming forces are greater at their anterior
border, so vertebrae are narrower here; causing kyphosis during the active phase, vertebrae may
be tender.

Radiographs

Irregular vertebral endplates, schmorl’s nodes and decreased disc space with or without anterior
wedging. Schmor’s nodes are herniations of inter vertebral disc through the vertebral end-plate.

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Treatment: If posture control (e.g. standing during lessons rather than sitting) and exercises (e.g.
swimming) fails, physiotherapy with or without spinal braces can help. Surgery may be tried for
several kyphosis (>750) with curve progression, refractory pain, or neurological deficit.

Congenital kyphosis/kyphotic deformity: This is the result of vertebral malformation that

occurs during the first trimester. The most common abnormalities are congenital failure of
formation of all or part of the vertebral Centrum and failure of anterior segmentation of the
spine. Severe deformities are usually recognized at birth and rapidly progress thereafter. The less
obvious deformities may not become obvious until later in childhood. Patients with congenital
Kyphosis should be referred for specially evaluation as soon as deformity is recognized.

Treatment: Brace treatment is not effective. Surgical intervention is often necessary, and the
results of surgery are best if performed before significant deformity has developed.

Common causes of kyphosis

 Osteoporosis

 Paget’s disease

 Ankylosing spondylitis

 Adolescent kyphosis (Scheuermann’s disease). May cause a restrictive ventilator defect.

 Spina bifida

 Cancer; wedge fractures

 Tuberculosis; polio

Congenital kyphosis is much less common than congenital scoliosis, but is more serious, as
cord compression and paraplegia sometimes develop rapidly, e.g. during adolescence.

Lordosis: In the antero posterior (frontal) plane, the vertebral of normal spine are stack squarely
on the other with little or no deviation from vertical alignment. The vertebral end plates are
parallel and inter-vertebral disks are symmetric in height. In the sagittal plane the spine has
normal curvatures that provide balance and stability. The cervical and lumber spine displays

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anterior convexity, termed lordosis, while sacrum and the thoracic spine display posterior
convexity and are kyphotic. Nursing care for Scoliosis, Kyphosis and Lordsis patients.

Surgical options: Several types of spinal fusion can be formed, including posterior and/or
anterior spinal fusion. The posterior spinal fusion (PSF) is performed on the back of the spine,
with an incision down the center of the patient’s back. The anterior spinal fusion (ASF) is
performed on the front half of the spine, which is reached through an incision on the side of the
chest. The ASF can also be performed by using a thoracoscope. A scope used for visualization,
with spinal fusion performed through small holes in the chest similar to knee arthroscopy.

Nursing interventions

Educating the family: The nurse supplies the family with written materials, including a
preoperative spinal fusion information packet; an activity list, which is a schedule of when the
patient may or may not resume activities she was involved in prior to her surgery; research
consents, if applicable; and name and phone number of a family whose child had a similar curve
and same procedure. No more information is given at the first visit because the family is usually
overwhelmed. It is suggested that they go home, further discuss the issues, consider a surgery
date, and follow up with the nurse the next week.

Pre surgical tests: Preparation for surgery begins with several tests. Consults are sent to the
family for pulmonary function test (PFT), ECG, and basic labs (CBC, electrolytes, creatine
kinase, send rate, PT, PTT, platelets, and urinalysis). PFTS evaluate respiratory status, and if the
results are abnormal, the patient will need surgical clearance from a pulmonologist. Rarely,
children with spinal deformities show moderate constrictive disease on their PFTs secondary to
asthma. If the results on the ECG are abnormal, an echocardiogram should be performed and
cardiology clearance obtained. Occasionally, the neurological exam by the physician is abnormal
and an MRI is done to ensure that the spine is free of tumors, intraspinal lesions, or syrinx (a cyst
in the spinal cord). A syrinx sometimes needs to be surgically drained or decompressed before
spinal fusion surgery. A consult with a neurosurgeon for surgical clearance must also be obtained
if MRI findings are abnormal. Somatosensory evoked potentials (SSEP) are a noninvasive
measurement of conduction in the central nervous system. Small electrodes are inserted onto the
patient’s scalp and extremities and connected to a monitor. SSEP monitoring is done during the
surgical procedure to pick up any neurological problems that occur when spinal instrumentation

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is inserted and when the spinal curve is being straightened. A pre – op baseline SSEP is used as a
comparison during surgery.

Blood units needed: Each patient undergoing this type of spinal surgery needs approximately
two to four units of blood available, an amount specifically determined by the surgeon. If able,
the patient can donate two units of autologous blood. Close family members can directly donate
other units. If the family is not able to provide the required amount of blood, the nurse can obtain
blood from a blood bank. The operating room uses a cell – saver machine, and most patients
receive at least one unit of cell – saver. The patient needs to start taking iron supplements one
week before donating blood, and then 7 – 10 days following surgery. Because the surgical team
prefers not to use frozen blood, patient donates her blood within five weeks before surgery so the
blood would not expire.

Informing the child’s school: Another pre surgical duty of the spine nurse is to contact patient’s
school gym teacher to inform him that, if she wouldn’t be able to participate in a full physical
education program for six months after surgery. After that period, the patient will be able to
participate in limited gym activities. The spine nurse also contacts the school nurse to initiate
homebound instruction for 6 to 8 weeks post – op. when child return to school, she should have
access to the elevator and be allowed to leave class 5 to 10 minutes early to avoid crowded
hallways. Because sick child will only be able to lift a limited amount of weight, she will need
two sets of books – one for school and the other for home.

Ongoing support: Completing the necessary testing and blood donation can be overwhelming
and confusing to the patient and family. Let the patient and the parents keep in close contact with
the care coordinator for spine patients at the hospital. To help the patient and her family deal
with anxiety about the upcoming surgery and recovery period, the spine nurse strongly suggests
that they attend one of the meetings of a support group.

Pre-op teaching: Pre – op teaching by the spine nurse starts from the initial consult through the
day of surgery. It begins with explaining the degree of the curve, the surgical procedure, the
length of incision, and duration of hospital stay. Estimated blood loss, prevention of paralysis,
and the risks and benefits of surgery are also emphasized. Post – op dressing changes, bracing
needs, pain management, activity levels, and homebound instruction are included, and the nurse

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promises to return calls the same or before noon the next day. After all the tests are completed,
the patient is ready for surgery.

Sedation and transport to operating room: Early on the morning of surgery, the patient
receives a sedative and sip of water. She and her family are escorted to the OR/PACU (Post
Anesthesia Care Unit), where they are greeted by the nurse and anesthesiolost. She will have a
peripheral IV started in the pre –op holding area and two more IVs and an A-line inserted after
she is asleep. A wake – up test, along with pre-op with SSEP monitoring during surgery, will
determine that no neurological damage has occurred. Toward the end of the surgery, after the
hardware has been placed, the anesthesiologist will decrease the amount of anesthesia and ask
patient to move her feet. After successful completion of the wake – up test, the anesthesia will be
resumed and the surgery will be completed. Patients have no recollection of this test nor do they
experience pain. The surgery usually takes 5 hours. A 12 to 16 inch incision is made down her
back and the spine exposed by peeling backs the muscles. Next, small (2-cm) pieces of rib are
resected to reduce the rib deformity. The hooks screw and rods are placed and the spine is
straightened. For the child, the surgeon may choose to use her ribs for bone graft. Some patients
will have small pieces of their pelvis used as bone graft. The rib pieces are placed against the
spine, under the rod, to facilitate the fusion. After surgery, the patient is taken to the PACU,
where she will be monitored for 2 to 3 hours. Routine PACU monitoring includes vital signs,
intake and output, neurovascular checks, dressing and skin checks, and labs, including ABGs,
hemoglobin, and hematocrit. Patients receive oxygen via face tent at 40% concentration to keep
oxygen saturation above 94%. Most patients have a hemovac in their back incision, a chest tube
or rib protector, and a Foley catheter along with two peripheral IVs and an A – line. A chest x-
ray is done to check for lung expansion and atelectasis (partial collapse of sections of the lung),
and the position of the hardware in the back can be seen. Pain is controlled by patient-controlled
anesthesia (PCA) using morphine. Immediately after surgery, most children rate their pain as “5”
on a severity scale of 1 – 5. By the first post-op day, the usual rating is 2 to 3. IV antibiotics are
given until the patient’s drains are removed. A posterior spinal is a big operation. The nurses and
doctors work very hard to make the patient as comfortable as possible. Six weeks after surgery,
most kids say they do not remember much of their first few days after surgery. The patient is
moved to the extended Post –Anesthesia Care Unit (EPACU) for two days. The two hemovac
drains and one chest tube are removed once drainage decreases to a minimal amount. She is

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taken off the PCA pump and put on oral medication. Her diet is advanced to clear liquids, and
she is allowed to sit in a chair. By day 4 the child will be transferred out of EPACU to continue
her recovery. Before she is discharged from the hospital, the patient will begin to build up her
strength and endurance by walking and performing some nonstrenuous activities of daily living.
Patient and her family are taught how to care for her wound, and she is given a prescription for
pain medication. The patient will return to the outpatient center for a wound check, and her
dressing will be taken off and any remaining steri-strips on her back will be removed. Her pain
level will also be assessed at this time. Patient will return to the outpatient center two and six
months post – surgery for x-rays and follow-up. After the six-month check – up, patient will
come to the outpatient center every six months three times and then yearly until she discharged
from the Hospital system age 21. The care coordinator is always available by phone to answer
any questions or handle any issues that may arise.

Leg – calve perthes disease: LCPD is idiopathic osteonecrosis or avascular necrosis of the
capital femoral epiphysis, and the associated complication thereof, occurring in an immature
growing child.

The osteochondrosis is caused by an interruption of the capital femoral epiphysis blood supply.

Etiology: Is unknown, but an association among protein C and protein S deficiency,

thrombophillia and hypofibrinolysis has been observed.

It is primarily a disorder affecting males (4 – 5:1) and is bilateral in approximately 20% of

children. Children with LCPD often have delayed bone age, disproportionate growth and mild
short stature.

Clinical manifestation: Onset occurs between 2 – 12 years of age. Mean is 7 years.

Most children present with mild or intermittent pain in the anterior thigh and a limb.

Radiographic evaluation:

Anteroposterior & Laue stein lateral radiographs of pelvic should be obtained to establish the
diagnosis.

Radiographic characteristics divide into 5 distinct stages representing a continuum of disease

process.

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 1. Cessation of capital femoral epiphysis growth; subchondral fracture

2. Resorption

3. Reossification

4. Healed or residual stage

Prognosis:

Usually the condition heals over 2-3yrs. Joint damage may lead to early arthritis. Young patients
do best. Shirt – term prognosis relates to the femoral head deformity at the completion of healing
stage. Adverse risk factors include;

 Older age at clinical onset

 Extensive capital femoral epiphysis involvement

 Loss of femoral head containment.

 Decreased range of hip motion

 Premature capital femoral epiphysis closure

Long term prognosis relates to potential for osteoarthritis of the hip in adulthood. Older children
with significant residual femoral head deformity are at risk for degenerative arthritis; incidence is
essentially 100% in children who are 10 years of age or older at onset and who have residual
head deformity.

Management: Treatment is with rest, X – ray surveillance, bracing, and /or surgery depending
on severity. The more severe the case, the greater the likelihood that the child may experience
limited hip motion, differences in leg lengths, and further hip problem in adulthood.

Nursing care: Assessment and history taking

Take past health history, intrauterine history its age, overall health and medical history. Child
tolerances for specific medication procedures or therapy assess the extent of the condition. The
goal of treatment is preserve the roundness of the femoral head and to prevent deformity while
the condition runs its course. Treatment options are dependent upon the amount of hip pain,
stiffness, and x – ray change over time, as well as how much of the femoral head has collapsed.
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The ultimate goal in Legg-Calve`-Perthes disease is to diagnose the condition early in order to
allow as much time as possible to let the femoral head remodel back into a round shape.
Typically, the first step of treatment and management is to regain his motion and eliminate pain
that results from the tight muscle around the hip and the hip and the inflammation inside the
joint.

Therapeutic management includes: - Rest: Nurse Advice’s patient on importance of rest and
orders bed rest.

Activity restrictions: Activity increases the movement and therefore worsening necrosis.

Bed rest and traction: This is important as it reduces movement of the limb allowing the bone
recovers. Casting or bracing: To hold the femoral head in the hip socket, permit limited joint
movement, and allow the femur to remold itself into a round shape again. Medications: Advice
patient on importance of adheherence of prescribed medication as it reduces pain and reduces
inflammation. Surgery: The nurse educates ensures that patient is aware of importance of
surgery. Surgery is done to hold the femoral head in the hip socket.

Physical therapy: The nurse collaborates with the physiotherapists to keep the hip muscles
strong and to promote hip movement. Aim is to maintain hip motion and preventing continued
hip deformity. Control of pain: Nurse administers prescribed analgesics e.g. paracetamol.

INTEGRATED MANAGEMENT OF CHILDHOOD ILLNESS (IMCI)

Problem statement

Every year, almost 11 million children under the age of five in developing countries die from
readily preventable and treatable illness such as;

 Diarrheal dehydration

 Acute respiratory infection (ARI)

 Measles

 Malaria

 In half of the cases, illness is complicated by malnutrition

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While improved medical treatment combined with greater access to health care has help children
in many parts of the world, in others huge numbers of children facility continue to die needlessly.
Many of these children were never seen at a health facility because; services don’t exist, their
families lack access to these services, or families and other caregivers do not recognize the
warning signs of life-threatening illness.

Introduction

Because most child deaths occur at home, before reaching health facilities, preventing fatalities
by improving child health through the community is at the core of IMCI

It offers simple and effective methods to prevent and manage the leading causes of serious
illness and mortality in young children.

The clinical guidelines promote evidence –based assessment and treatment, using a syndromic
approach that supports the rational, effective and affordable use of drugs.

The approach is designed for use in outpatient clinical settings with limited diagnostic tools,
limited medications and limited opportunities to practice complicated clinical procedures.

There are feasible and effective ways that health workers in clinics can care for children with
these illnesses and prevent most of these deaths.

WHO and UNICEF used updated technical findings to describe management of these illnesses as
a set of integrated instead of separate guidelines for each illness.

Effective case management needs to consider all of a child’s symptoms.

Guidelines address most but not all of the major reasons a child is brought to a clinical for
illness.

The case management process

The integrated case management process ensures priority, need for urgent referral is met and
treatment of child’s illness. Also mothers are counseled and follow up done. It is presented on a
series of charts, which show the sequences of steps and provide information for performing
them. It describes the following steps:

i. Assess the child or young infant

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 ii. Classify the illness

iii. Treat the child

iv. Counsel the mother

v. Give follow – up care

The case management process for sick children age 2 months up to 5 years is presented on three
charts titled:

Assess and classify the sick child

Treat the child

Counsel the mother

Management of the young infant age up to 2 months in different. It has a chart titled assess,
classify and treat the sick young infant.

Charts are designed to help health workers manage children correctly and efficiently.

THE COMPLETE IMCI CASE MANAGEMENT PROCESS INVOLVES THE

FOLLOWING ELEMENTS:

i. Assessment; Assess a child by checking first for danger signs (or possible bacterial
infection in a young infant), asking questions about common conditions, examining the
child, and checking nutrition and immunization status. Assessment includes checking the
child for other health problems

ii. Classification of illness; Classify a child’s illnesses using a colour-coded triage system.
Because many children have more than one condition, each illness is classified according
to whether it requires:

 Urgent pre – referral treatment and referral (red), or

 Specific medical treatment and advices (yellow) or

 Simple advice on home management (green)

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 iii. Treatment of the illness: Identify specific treatments for the child. If a child requires
urgent referral, give essential treatment before the patient is transferred. If a child needs
treatment at home, develop an integrated treatment plan for the child and give the first
dose of drugs in the clinic. If a child should be immunized, give immunizations.

iv. Counsel the mother/guardian; provide practical treatment instructions, including;

teaching the caretaker how to give oral drugs, how to feed and give fluids during illness,
and how to treat local infections at home. Assess feeding, including assessment of
breastfeeding practices, and counsel to solve any feeding problems found. Then counsel
the mother about her own health.

v. Give follow up care; ask the caretaker to return for follow – up on a specific date, and
teach her how to recognize signs that indicate the child should return immediately to the
health facility. When a child is brought back to the clinic as requested, give follow – up
care and, if necessary, reassess the child for new problems.

Purpose

Learn to manage sick children according to case management charts i.e.

 Assessing signs and symptoms of illness and nutritional, suspected HIV infection,
immunization and vitamin A supplementation status.

 Classifying illness

 Identifying treatments for the child’s classification, deciding on need for referral.

 Giving important pre-referral treatments (first close of antibiotic, vitamin A, quinine

injection, diazepam, treatment to prevent low blood sugar).

 Provide treatment e.g. ORS, vitamin A and immunizations.

 Teach mother to give treatment at home.

 Counsel mother on feeding and when to return

 During follow up visit, re asses the child’s problem and provide appropriate care.

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ASSESS & CLASSIFY THE SICK CHILD AGE 2 MONTHS UP TO 5 YEARS

INTRODUCTION

 The chart describes how to assess and classify sick children to ensure signs of diseases
are not overlooked.

 Ask child’s problem.

 Check the child for general danger sign

 Ask about four main symptoms: cough or difficult breathing, diarrhea, fever and ear
problem.

 When a main symptoms is present ask additional questions to help classify the illness

 Check the child for malnutrition and anemia

 Look for signs of suspected symptomatic HIV infection in a child with entry signs
suggesting HIV infection.

 Check child’s immunization and vitamin A supplementation status

 Assess other problem the mother has mentioned

Asking child’s problem

A mother brings the child to the clinic because the child is sick, for well-child visits,
immunization sessions or for treatment of injuries. The steps on assess and classify chart
describe what you should do when another brings her child to the clinic because he is sick;

 Great the mother appropriately and ask her to sit with her child.

 Determine the child’s age and choose the right case management chart

 Look at the child’s record to find if weight and temperature have been recorded. If not
taken weigh the child and measure temperature.

 Ask the mother what the child’s problems are and record.

 Determine if this is an initial or follow-up visit for the problem.

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 CHECK FOR GENERAL DANGER SIGNS

Check all sick children for general danger signs.

A general danger sign is present if;

1. The child is not able to drink or breastfeed – child cannot suck or swallow.

2. The child vomits everything

3. The child has had convulsions

4. The child is lethargic or unconscious

5. The child is convulsing now.

A child with general danger sign has a serious problem and may need urgent referral to hospital.

Complete the rest of the assessment immediately.

ASSESS AND CLASSIFY COUGH OR DIFFICULT BREATHING

Respiratory infections occur in any part of the respiratory tract e.g. nose, throat, larynx, trachea,
air passages or lungs.

A child with cough or difficult breathing may have pneumonia or another severe respiratory
infection.

The length care workers need to identify children who are very sick with cough or difficult
breathing requiring antibiotic therapy. This is done by assessing two clinical signs i.e. fast
breathing and chest indrawing.

Due to pneumonia the child’s lungs become stiff and hypoxia results. The child responds by fast
breathing.

When pneumonia becomes more severe, the lungs become even stiffer and chest indrawing may
develop. It is a sign of severe pneumonia.

A child with cough or difficult breathing is assessed for;

1. During of cough or difficult breathing, if more than 30 days the child has chronic cough.
If may be a sign of tuberculosis, asthma, whooping cough or another problem.
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 2. Fast breathing, count the child takes in one minute to decide if the child has fast
breathing. The cut – off for fast breathing depends on the child’s age. Normal rates are
higher in children age 2 months up to 12 months than in children age 12 months up to 5
years.

A child age 2 months up to 12 months has fast breathing if 50 breaths per minutes or more.

A child 12 months up to 5 years has fast breathing if 40 breaths per minutes or more.

Question

A child exactly 12 months with 40 breaths per minutes, does the child have fast breathing?

3. Chest indrawing: lift the child’s shirt and look for chest indrawing when the child
breathes in. Child has chest indrawing if the lower chest wall goes in when the child
breathes in. For chest indrawing to be present it must be clearly visible and present all
the time.

4. Stridor in a calm child. Look to see when the child breathes in and listen for stridor with
your ear near the child’s mouth (a harsh noise made when the child breathes in).

5. Wheeze; look to see when the child is breathing out and listen for a soft musical noise
(wheeze).

Classification

There are three possible classifications for a child with cough or difficult breathing;

1. Severe pneumonia or very severe disease

 Any general danger sign or

 Chest indrawing or

 Stridor in calm child

A child with this classification is seriously ill and needs urgent referral to hospital after giving
first dose of injectable antibiotics.

2. Pneumonia

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  Fast breathing

Treat with oral antibiotics

3. No pneumonia cough or cold

 No signs of pneumonia or

 Very severe disease.

Child does not need an antibiotic, teach the mother how to relieve cough with home remedy e.eg.
Warm tea with sugar

When using classification table, start with the top row. If the child has signs from more than one
row, always select the more serious classification.

Fast breathing and chest indrawing are entry signs for suspected symptomatic HIV infection.

For all sick children, ask about cough or difficult breathing. If present assess and classify, and if
absent ask about the next main symptoms, diarrhea.

EXERCISE

Aziz is 18 months old; he weighs 11.5Kg and has a temperature of 37.50C. The mother has
brought him to hospital because he has a cough and trouble breathing. This is the initial visit for
Aziz.

The health worker assessed Aziz for general danger signs; he is able to drink, he does not vomit
everything, no history of convulsion and he is not lethargic or unconscious.

The mother says Aziz has had a cough for 7 days. The health worker counted 41 breaths per
minutes, there was no chest indrawing no wheeze or stridor.

a) Classify Aziz’s problem;

b) Explain how you have arrived at the classification:

Wambui is 8 months old; she weighs 6Kg and has a temperature of 390C. The mother has
brought her to hospital because of cough and refusal to feed. She is not vomiting nor has she had
a convulsion. She did not look at the health worker or her mother as they were talking.

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The health worker counted 55 breaths per minute, she saw chest indrawing and heard a harsh
noise as the child breathed in.

 Classify Wambui’s problem;

 Explain how you have arrived at the classification;

ASSESS AND CLASSIFY DIARRHOEA

Diarrhoea is common in children between 6 months and 2 years of age.

Common in infants below 6 months who are not exclusively breastfed?

Diarrhoea is three or more watery stools in a 24 hour period.

Types of diarrhea

i. Loose or watery diarrhea e.g. diarrhea due to cholera.

ii. Acute diarrhea – it is diarrhea lasting less than 14 days. It causes dehydration and
contributes to malnutrition.

iii. Persistent diarrhea – it is diarrhea lasting 14 day and more. Up to 20% of diarrhea
episodes become persistent.

iv. Dysentery – diarrhea with blood in the stool, commonly caused by Shigella bacteria.

Ask the mother if the child has diarrhea, if yes assess child for signs of dehydration,
persistent diarrhea and dysentery, if no ask about the next main symptom fever.

Assess diarrhea

Assess the child for;

 How long the child has had diarrhea. Diarrhea lasting 14 days or more is persistent
diarrhea. Ask if the child has had two or more episodes of diarrhea lasting 14 days or
more, if yes check the child for suspected symptomatic HIV infection (entry sign for
suspected symptomatic HIV infection). Current episode of diarrhea lasting 14 days or
more is included in the two or more episodes.

 Ask if there is blood in stool to determine if the child has dysentery.

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  Sign of dehydration.

i. Look at the child’s general condition; is the child lethargic or unconscious? Is the child
restless and irritable? A child who is lethargic or unconscious has a general danger sign.

ii. Look for sunken eyes then ask the mother if she thinks her child’s eyes are unusual. A
child with malnutrition and is visibly wasted has eyes that always look sunken even if the
child is not dehydrated. Use the sign to classify the child’s dehydration.

iii. Offer child fluid; is the child not able to drink or drinking poorly? Drinking eagerly,
thirsty?

iv. Pinch the skin of the abdomen; located the area on the abdomen halfway between the
umbilicus and the side of abdomen and pinch the skin using thumb and first finger. Does
it go back very slowly (longer than 2 seconds)? Slowly? Immediately?

In a child with Marasmus the skin may go back slowly even if the child is not dehydrated.

In an overweigh child or a child with oedema, the skin may go back immediately even if the
child is dehydrated.

Even though skin pinch is less reliable in these children, still use it to classify the child’s
dehydration.

Classify diarrhea

There are three classifications for diarrhoea;

1. Severe dehydration

Two of the following signs;

 Lethargic or unconscious.

 Sunken eyes.

 Not able to drink or drinking poorly.

 Skin pinch goes back very slowly

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A child with severe dehydration needs intravenous fluids quickly (plan C).

2. Some dehydration

Two of the following signs;

 Restless, irritable.

 Sunken eyes.

 Drink eagerly, thirsty.

 Skin pinch goes back slowly.

The child is treated with ORS solution, in addition the needs food and should continue
breastfeeding (plan B)

3. No dehydration

Not enough signs to classify as some severe dehydration

The child needs home treatment. The three rules of home treatment are;

i. Give extra fluid.

ii. Continue feeding.

iii. When to return.

Plan A. treating diarrhoea at home

EXERCISE

Gratel 16 months old has had diarrhoea for 2 days. She does not have blood in stool, has had 2
episodes of diarrhea lasting 14 days previously and is not irritable or restless. Her eyes are
sunken, she is not able to drink and her skin pinch goes back very slowly.

a) Classify Gretal’s problems

b) Explain how you have arrived at the classification;

Classify persistent diarrhoea

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There are two classifications for persistent diarrhoea;

1. Severe persistent diarrhoea

Dehydration present (child with diarrhoea for 14 days or more and also has some or severe
dehydration).

The child needs referral to hospital, treat the child’s dehydration unless the child has another
severe classification.

2. Persistent diarrhoea

No dehydration

The child requires special feeding, give multivitamin supplement.

Classify dysentery

There is one classification for dysentery i.e. dysentery (child with diarrhoea and blood in the
stool).

Child is treated with an antibiotic.

EXERCISE

Rana is 14 months old, she weighs 12Kg and her temperature is 37.50c. Her mother has brought
her to the hospital because she has diarrhoea.

She does not have any general danger sign nor does she have cough or difficult breathing.

Rana has had diarrhoea for 21 days, her last diarrhoea lasting 15 days four months ago. There is
no blood in her stool, she is irritable, drinks eagerly and her skin pinch goes back immediately.

Classify Rana’s problem;

Explain how you have arrived at the classification;

ASSESS AND CLASSIFY FEVER

A child with fever may fever may have malaria, measles or another severe disease. The fever
could also be due to simple cough or cold or other viral infection.

Assess fever
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A child has the main symptom fever if;

1. The child has a history of fever or

2. The child feels hot (abdomen or underarm) or

3. The child has an axillary temperature of 37.50C or above.

Determine if child has fever, if fever is present assess child for fever if no fever ask about the
next main symptom ear problem.

If the child has fever assess for;

 During of fever, if fever has been present every day for more than 7 days the child may
be having typhoid fever.

 History of measles in the last 3 months; child could be having fever due to measles
complications such as eye intention.

 Stiff neck; a child with fever and stiff neck may be having meningitis.

 Runny nose; runny nose in a child with fever mean that the child has a common cold.

 Signs suggesting measles; generalized rash (cephalocaudal, no vesicles or pustules, does

not itch), cough, runny nose or red eyes.

 If the child has measles now or within the last 3 months, assess for signs of measles
complications; mouth ulcers – are they deep & extensive, pus draining from the eye (sign
of conjunctivitis) and clouding of the cornea.

Classify fever

1. Very severe febrile disease

 Any general danger sign or

 Stiff neck

Child could be having meningitis, severe malaria or sepsis; he/she needs urgent referral. Give pre
– referral treatment.

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2. Malaria

Fever

Classify measles

A child with fever and signs & symptoms of measles now or within the last 3 months is
classified both for fever and for measles.

First you classify the child’s fever, next you classify measles. If the child does not have measles
now or in the past 3 months, do not classify measles. Ask about the next main symptoms; ear
problem.

There are three possible classifications of measles;

1. Severe complicated measles

 Any general danger sign or

 Clouding of cornea or

 Deep or extensive mouth ulcers.

The child needs urgent treatment and referral to hospital.

2. Measles with eye or mouth complications

 Pus draining from the eye or

 Mouth ulcers

The child does not need referral; treat with vitamin A, TEO or gentian violet.

3. Measles

 Measles now or within the last 3 months and with no complications listed in the pink or
yellow rows.

Treat the child by giving vitamin A to help prevent measles complications.

NB. All children with measles should receive vitamin A.

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EXERCISE

Atika is 5 months old, she weighs 5Kg and her temperature is 36.50C. She has been brought to
hospital because she feels hot and has a cough.

She is not able to drink, there is not history of vomiting or convulsion and she is not lethargic or
unconscious.

The health worker counted 43 breaths per minute. No chest indrawing and no stridor.

Atika does not have history of diarrhoea.

She has had hotness of the body for 2 days, no stiff neck, she has a generalized rash, her eyes are
red and she has mouth ulcers that are not deep or extensive.

a) Classify Atira’s problems;

b) Explain how you have arrived at the classification;

ASSESS AND CLASSIFY EAR PROBLEM

A child with ear problem may have an ear infection.

When a child has ear infection, pus collects behind the ear and causes pain and often fever. If
infection is not treated, the ear drum may burst and pus discharges. Fever and other symptoms
may stop but the child suffers from poor hearing because the eardrum has a hole in it this could
eventually lead to deafness.

Assess ear problem

Ask the mother if the child has an ear problem, if yes assess child for ear problem and if no
check for malnutrition and anemia.

A child with ear problem is assessed for;

 Ear pain; ask the mother if the child has ear pain. If she is not sure ask if the child has
been irritable and rubbing his ear.

 Ears discharge and

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  If discharge is present; ask about its duration. An ear discharge that has been present for 2
weeks or more is treated as a chronic ear infection while one less than 2 weeks is treated
as acute ear infection.

 Look for pus draining from the ear which is a sign of infection.

 Tender swelling behind the ear (sign of mastoiditis).

 Feel behind both ears, compare them and decide if there is tender swelling of the mastoid
bone. Both tenderness and swelling must be present to classify mastoiditis.

Classify ear problem

There are four possible classifications for ear problem;

i. Mastoiditis

 Tender swelling behind the ear.

Child needs urgent referral to hospital.

ii. Acute ear infection

 Pus is seen draining from the ear and discharge is reported for less than 14 days or

 Ear pain

Child is treated with appropriate antibiotic and analgesic for pain, if pus is draining from the ear
dry the ear by wicking.

iii. Chronic ear infection

 Pus is seen draining from the ear and discharge is reported for 14 day or more. Teach
mother how to dry the ear by wicking.

iv. No ear infection

No ear pain and

No pus seen draining from the ear

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EXERCISE

Mbira is 3 years old. She weighs 13Kg and her temperature is 37.50C. Her mother has brought
her to hospital because she has felt last 2 days. She cries at night and complains her ear hurts.

She does not have a general danger sign, no cough or difficult breathing, or diarrhoea.

On assessment of the ear, there is discharge and ear pain and also swelling behind one ear.

a) Classify Mbira’s problem

b) Explain how you have arrived at the classification;

CHECK FOR MALNUTRITION AND ANAEMA

Check all sick children for signs suggesting malnutrition and anemia. Child with malnutrition has
a higher risk of many types of diseases and death.

Some malnutrition cases can be treated at home while severe cases referral to hospital for special
feeding, blood transfusion or specific treatment of a disease contribution to malnutrition.

Children with malnutrition may have TB; ask for history of TB contact when assessing children
for malnutrition and anemia.

Children with malnutrition may also have HIV infection; check any child who is very low weight
for age suspected symptomatic HIV infection.

Protein energy malnutrition results to;

 Severe wasting, a sign of marasmus.

 Oedena, a sign of kwashiorkor.

 Stunning

Child not eating foods that contain vitamin A can result in vitamin A deficiency. This makes the
child at risk of measles, diarrhoea and blindness.

Not eating foods rich in iron can lead to iron deficiency and anemia. Anemias can also result
from; infection, parasites, malaria, sickle cell disease and HIV infection.

Assess for malnutrition

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  Ask if there history of TB contact.

 Look for visible severe wasting; very thin, no fat and looks like skin and bones. Remove
child’s clothes; look for severe wasting of the muscles of the shoulders, arms, buttocks
and legs, look to see if the outline of the ribs is easily seen. Look at the child’s hips; they
may look small when compared to chest and abdomen. Look on the side to see if the fat
of the buttocks is missing. When wasting is extreme, there are many folds of skin on the
buttocks and thigh, the child has severe palmar pallor.

 Look and feel for pallor; look at the skin of the child’s palm. Hold the child’s open by
grasping it gently from the side compare the colour of the child’s with your own palm. If
the palm is pale, the child has some palmar pallor. If the skin of the palm is very pale or
so pale that it looks white, the child has severe palmar pallor.

 Look and feel for oedema of both feet, use a thumb to process gently for a few seconds
on the top side of each foot. The child has oedema if a dent remains in the child’s foot
when the thumb is lifted.

 Determine weight for age; identify children whose weight for age is below the bottom
curve of weight for age chart (child with very low weight). Identify if growth faltering is
present.

Classify nutritional status

There are three classifications for a child’s nutritional status;

1. Severe malnutrition or severe anemia

 Visible severe wasting or

 Severe palmar pallor or

 Oedema of both feet

Child needs urgent referral to hospital.

2. Anemia or very low weight

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  Some palmar pallor or

 Very low weight for age

Assess the child’s feeding and counsel the mother about feeding her child.

Check a child with very weight for suspected symptomatic HIV infection.

Child with palmar pallor is treated with iron. Also give mebendazole, if child with anemia is 2
years of age or older and has not had a dose of mebendazole in the last 6 months.

3. No anemia and not very low weight

 Not very low weight for age and other signs of malnutrition

 No pallor

If the child is less than 2 years assess the child’s feeding.

CHECK FOR SUSPECTED SYMPTOMATIC HIV INFECTION

Children with symptomatic HIV infection usually present with same illnesses that others have,
such as pneumonia, diarrhoea, malaria, ear infection and malnutrition. They may also present
with tuberculosis, very low weight, and failure to thrive. Enlarge lymph nodes or oral thrush.

IMCI helps in identifying children who are mostly likely to have HIV.

Entry signs;

 Chest indrawing

 Fast breathing

 Child has ever had two or more episodes of diarrhoea lasting 14days or more.

 Very low weight

 Growth faltering

A child with any of the above signs should be assessed for suspected symptomatic HIV infection.

Check for suspected symptomatic HIV infection.

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  Ask history of TB infections in any of the parents in the last 5 years.

 Find out if the child has fast breathing or chest indrawing.

 Ask if child has had two or more episodes of diarrhoea lasting 14 days or more.

 Look for growth faltering or weight below the “very low weight curve”.

 Feel for enlarge lymph nodes in two or more of the following sites; neck, axillae and
groin.

 Look for oral thrush

Classify suspected symptomatic HIV infection

There are two possible classifications;

1. Suspected symptomatic HIV infection

Presence of any three or more of the following;

 TB in any parent in the last 5 years.

 Fast breathing or chest indrawing

 Child has two or more episodes of diarrhoea lasting 14 days or more

 Growth faltering or weight below the “very low weight” curve.

 Enlarge lymph nodes in two or more of the following sites; neck, axillae, groin.

 Oral thrush.

2. NO suspected symptomatic HIV infection

Less than three of the above features

CHECK THE CHILD’S IMMUNIZATION & VITAMIN A SUPPLEMENTATION STATUS

Check the immunization status of all sick children. Identify if they have received all the
immunizations recommended for their age and whether there are due immunizations.

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  Give the recommended vaccine

 Contraindications to immunization

 Pentavalent is not given to a child who has had convulsions or shock.

 BCG and yellow fever to a child known to have AIDs/symptomatic HIV infection.

 If the child is going to be referred do not immunize the child before referral.

 Children with diarrhoea who are due for OPV should receive a dose of OPV during the
visit but do not count the dose. The child should return in 4 weeks for an extra does of
OPV.

CHECK THE CHILD’S VITAMIN A SUPPLEMENTATION STATUS

Give vitamin A supplement to children with the following;

 Persistent diarrhea

 Malnutrition

 Pneumonia

 Meascles

If the child is out of schedule give the nearest dose and give next dose as per schedule as long as
it is 1 month apart.

ASSESS OTHER PROBLEMS

Assess the child for other problems that the mother talked about and were not assessed needed,
IMCI.

IDENTIFY TREATMENT

Determine if urgent referral is needed, if yes identify urgent pre – referral treatment needed, give
pre – referral treatment and refer the child.

If the child does not require urgent referral identify treatment.

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Some children will have ore than one classification; identify treatment for the listed
classification. Some may be the same e.g. pneumonia and ear infection require an antibiotic. You
must notice which treatment are the same and can be used for both problems and which
treatment are different.

Classifications that require urgent referral to hospital

 Severe pneumonia or very severe disease

 Severe dehydration.

 Severe persistent diarrhoea

 Very severe febrile disease

 Severe complicated measles

 Mastoiditis

 Severe malnutrition or severe anemia

NB; For severe persistent diarrhoea refer the child to hospital. This means referral is needed
neither but nor urgently. Give all treatments before referral.

If the child’s only severe classification is severe dehydration, use plans C to decide whether to
refer the child.

If the child has another severe classification in addition to severe dehydration refers urgently to
hospital with mother giving frequent sips of ORS on the way. Advise mother to continue
breastfeeding.

Refer to treatment model to see the flow chart

A child with any general danger sign needs urgent attention, complete the assessment and any
pre – referral treatment immediately so referral is not delayed.

Refer the child for any other severe problem (fracture, gun shot wound, extensive burns) that
cannot be treated at the clinic.

While identifying treatment for a child that does not require referral include follow up.

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List non – urgent referrals for further assessment e.g. child with chronic cough, fever lasting
more than 7 days

NB; Advise mother when to return immediately. Teacher the mother has signs that mean she
should return immediately.

Anemia or very low weight; A child with palmar pallor should begin iron treatment fro anemia
and should also be given an oral antimalarial even if the child does not have a fever. If the child
is 2 years of age or older and has not had a dose of mebendazole in the last 6 months he/she
should be given.

When to return immediately;

Advice the mother to return immediately if the child has any of these signs;

1. Any sick child

 Not able to drink or breast feed

 Becomes sicker

 Develops a fever

2. If child has no pneumonia, cough or cold return if;

 Fast breathing

 Difficult breathing

 wheeze

3. If child has diarrhoea, also return if;

 Blood in stool

 Drinking poorly

 Vomiting everything

Urgent treatments

 Diazepam IV 0.3mg/kg for a child convulsing

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  Appropriate antibiotic; chloramphenicol 25mg/kg IV.

 Quinine for severe malaria; 15mg/kg IV (loading dose).

 Vitamin A in child with severe malnutrition or measles.

 Treatment to prevent low blood sugar.

 Oral antimalarial; coartem

 Paracetamol for high fever (38.50 C or above).

 TEO (tetracycline eye ointment) if cornea clouding or pus draining from the eye.

 Provide ORS solution for mother to give frequent sips on the way to hospital.

Refer the child

Steps to refer a child to the hospital;

a) Explain to the mother the need for referral and get her agreement to take the child.

b) Calm the mother’s fears and help her resolve any problems.

c) Write a referral note for the mother to take with her to the hospital. It should include;
name and age of the child, date and time of referral, description of the child’s problems,
the reason for referral, treatment given, any other important information, your name and
name of clinic.

d) Give the mother any supplies and instructions needed to care for her child on the way to
the hospital.

 Additional doses of antibiotic

 Keeping the child warm

 Continue breastfeeding.

 Give ORS for a child with some or severe dehydration

TREAT THE CHILD

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Select the appropriate oral drug and determine the dose and schedule.

Children with the following classifications need an antibiotic;

 Severe pneumonia or very severe disease

 Pneumonia

 Severe dehydration with cholera in the area.

 Dysentery

 Symptomatic HIV infection – long term prophylaxis with contrimoxazole

 Very severe febrile disease

 Severe complicated measles

 Mastoiditis

 Acute ear infection.

Severe pneumonia or very severe disease

i. Give first dose of appropriate antibiotic; ampicillin 50mg/kg or gentamycin 7.5mg/kg.

ii. Treat to prevent low blood sugar.

 If child is able to breastfeed ask the mother to breast feed the child.

 If the child is not able to breast feed but is able to feed; give expressed breast milk or
breast milk substitute.

 If neither of these is available give 30 – 50 ml sugar water. To make sugar water dissolve
4 level teaspoons of sugar (20 grams) in a 200ml cup of clean water.

 If the child not able to swallow give 50mls of milks or sugar water by nasogastric tube.

 For suspected low blood sugar give 10% glucose 10ml/kg by nasogastric tube or give the
same amount slowly intravenously.

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iii. Keep the child warm

iv. Treat wheeze if present; Give salbutamol metered dose inhaler using a spacer. Give 2
puffs. Repeat up to three times intravenously.

v. Refer urgently to hospital.

Convulsion

1. Turn the child to his/her side and clear the airway. Avoid putting things in the mouth.

2. Give 0.5mg diazepam injection solution per rectum using a small syringe or using a
catheter if convulsion lasts more than 5 minutes.

3. Check for low blood sugar, them treat to prevent

4. Refer

5. If convulsions have not stopped after 10 minutes repeat diazepam dose

Pneumonia

1. Give contrimoxazole BD for 5 days or amoxicillin TDS for 5 days.

2. Give vitamin A

3. Treat wheeze if present.

4. Soothe through throat and relieve the cough with a safe home remedy

5. Advise the mother when to return immediately.

6. Follow up in 2 days.

No pneumonia cough or cold

1. If coughing more than 14 days refer for assessment

2. Treat wheeze

3. Soothe the throat and relieve the cough with a safe remedy

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 4. Advice the mother when to return immediately

5. Follow up in 5 days if not improving

Severe dehydration

1. If the child has another severe classification refers urgently to hospital with mother
giving frequent sips of ORS on the way.

2. Advise mother to continue breastfeeding.

OR

If the child has no severe classification;

1. Give fluid plan B.

 Give ORS solution 75 X child weight for the first 4 hours.

 Give more if the child wants.

 For infants < 6 months who are not breast feed also give 100 – 200 mls clean water
during this period.

 Give frequent small sips from a cup. If the child vomits, wait 10 minutes the continue
breastfeeding whenever the child wants.

 After 4 hours reassess the child and classify for dehydration.

 Continue treatment

 Begin feeding the child in the clinic

 If the mother must leave before completing treatment; show her how to prepare ORS
solution at home, how much to give for finish 4 hours, instruct her how to prepare salt
and sugar solution for use at home and explain the four rules of home treatment.

2. Give vitamin A

3. Give zinc

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4. Advice mother when to return immediately

5. Follow up in 2 days if not improving

No dehydration

If the child has a severe classification refers urgently to hospital with mother giving frequent sips
of ORS on the way.

Advice mother to continue breastfeeding

OR

1. Give fluid and food to treat diarrhoea at home (Plan A)

 4 rules of home treatment; Give extra fluid, Give zinc supplements, Continue feeding and
Counsel mother when to return

 Give extra fluid;

 Tell mother to breast feed frequently and for longer at each feed

 If the child id EBF give ORS or clean water in addition to breast milk.

 If the child is not EBF give one more of the following food based fluids (soup, rice, water
and yoghurt) or ORS.

 Teach the mother how to mix and give ORS. Give the mother 2 packets of ORS to use at
home.

 Show the mother how much fluid to give in addition to the usual fluid intake.

 Up to 2 years; 50 to 100ml after each loose stool.

 2 years or more; 100 to 200mls after each loose stool.

 Tell the mother to give frequent small sips from a cup, if child vomits, wait 10 minutes
then continue but more slowly.

2. Give vitamin A

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 3. Give zinc

4. Advice mother when to return immediately.

5. Follow up in 2 days if not improving

Severe persistent diarrhoea

1. Treat dehydration before referral unless the child has another severe classification

2. Give vitamin A

3. Give Zinc

4. Give multivitamin/mineral supplements.

5. Follow up in 5 days

Dysentery

1. Treat with antibiotic, if child has not improved on ciprofloxation by second day change to
metronidazole.

2. Give vitamin A

3. Give zinc

4. Follow in 2 days.

Very severe febrile disease

1. Give quinine 15mg/kg IV/IM for severe malaria (first dose), maintenance 10mg/kg BD to
complete10 days.

2. Give first does of appropriate antibiotic

3. Treat to prevent low blood sugar

4. If fever is present give one dose paracetamol in the clinic

5. Refer urgently to hospital.

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Malaria

1. Treat with oral antimalarial co-artemether.

2. Stat, repeat after 8 hours next dose after 24 hours then 36, 48 and 60th hour.

For a child 5 months to 3 years 5 -<15Kg) give 1 tablet, if more than 3 years (15 - <
20kg) gives two tablets.

MANAGEMENT OF THE SICK YOUNG INFANT AGE 1 WEEK UP TO 2 MONTHS

INTRODUCTION

Young infants have special characteristics that must be considered when classifying their illness.
They can become sick and die very quickly from serious bacterial infections.

Mild chest indrawing is normal in young infants because their chest wall is soft.

This chart is not used for a sick newborn, i.e. a young infant less than 1 week of age.

Assess and classify the sick young infant

Ask the mother what the sick young infant’s problems are.

Determine if this is an initial or follow up visit for these problems.

Check the young infant for possible bacterial infection

Check all sick infant for the possible bacterial infection

Ask if the infant had convulsions.

Ask and look if the infant not able to feed or breastfed

Look for breathing, is the baby gasping or not breathing at all even when stimulated

Count the breaths in one minute/repeat the count if elevated (cut off 60 breaths per minute).

Look for severe chest indrawing.

Look for nasal flaring (widening of the nostril when the young infant breathes in)

Look and listen for grunting or wheezing.

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The above signs must be assessed when the child is calm

 Look for central cyanosis.

 Look and feel for bulging fontanelle.

 Look for pus draining from the ears.

 Look for pus draining from the eyes.

 Is there associated swelling or redness of the eyelids?

 Look at the umbilicus. Is it red or draining pus?

 Does the redness extend to the skin?

 Measure temperature (or feel for fever or low body temperature less than 35.50 C).

 Look for skin pustules. Are there many or severe pustules?

 See if the young infant is lethargic or unconscious.

 Look at the young infant’s movements, are they less than normal?

Classify all sick young infants for bacterial infection

There are four possible classifications.

1. Very severe disease

A child with any of the following signs;

 Gasping or

 Not breathing at all even when stimulated or

 Respiratory rate less than 20 breathes per minute

 Convulsions or convulsing now or

 Not able to feed or breastfeed

 Fast breathing

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  Severe chest indrawing

 Grunting or wheezing or

 Nasal flaring

 Central cyanosis

 Bulging fontanelle

 Pus draining from the ear

 Fever/low body temperature or

 Drowsy (lethargic) or unconscious or

 No movements even when stimulated.

Treatment

 Immediately resuscitate if;

- Child is not breathing at all even when stimulated or

- Is gasping or

- Has a respiratory rate less than 20 breaths per minute.

 If convulsing now, give anticonvulsants.

 Give first dose of intramuscular antibiotics.

 Treat to prevent low blood sugar

 Advise mother how to keep the infant warm on the way to the hospital.

 Refer urgently to hospital.

2. Local bacterial infection

 Red umbilicus or draining pus or

 Skin pustules
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Treatment

 Give an appropriate oral antibiotics

 Teach the mother to treat local infections at home.

 Advise mother to give home care from the young infant

 Follow up in 2 days

3. No very severe disease or local bacterial infection

None of the signs of every severe disease or local bacterial infection

4. Low body temperature

Temperature 35.5 – 36. 4

Treatment

 Rewarm the young infant and reassess after 1 hour

 Treat to prevent low blood sugar

 Advise mother to give home care for the young infant

 Advice mother when to return immediately

Check for jaundice

Yellow discoloration of skin is visible in a neonate when serum bilirubin is >5mg/dl.

Physiologic jaundice 48 – 72 hours disappear in 14 days does not extend to palm and soles and
does not need any treatment.

Assess for jaundice

Ask if the infant has yellow discoloration of the skin.

Look at the infants palms and soles for yellow discoloration.

Classification

1. Severe jaundice
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  Yellow palms and soles at any age

 Any jaundice if age less than 24 hours OR more than 14 days of age

Treatment

 Treat to prevent low blood sugar

 Advise mother how to keep the infant warm on the way to the hospital

2. Jaundice

No yellow palms and soles AND Jaundice appearing between 24 hours and 14 days.

Treatment

 Advise caregiver to expose the baby to the direct sunlight for at least an hour per day

 Advise the mother when to return immediately.

 Advise the mother to give home care for the young infant.

 Follow up in 2 days.

3. No jaundice

No signs to classify as severe jaundice or jaundice

Treatment

Advise mother to give home care for the young infant.

Check for eye infections

Ask the mother is there is eye discharge.

Enquire on duration of eye discharge.

Look at the infant’s eyes, are they draining pus?

Are they swollen?

Classify eye infections

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 1. Severe eye infection

Eyes swollen and draining pus

Treatment

Give first dose of intramuscular antibiotics

Apply first dose of local antibiotic.

Treat to prevent low blood sugar.

Refer urgently to hospital.

Advise mother how to keep the infant warm on the way to the hospital

2. Eye infection

Eyes draining pus

Treatment

Teach the mother to treat eye infection at home

Advise mother to give home care for the young infant

Follow up in 2 days.

3. No eye infection

No swollen eyes or

Eyes not draining pus

Treatment

Advise mother to give home care for the young infant

Assess and classify for diarrhoea

 Ask the mother if the young infant has diarrhoea

 Ask about duration of diarrhoea.

 Ask if there is blood in stool

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  Assess infant for lethargy or unconsciousness

 Assess for irritability or restlessness.

 Look at the eyes, are they sunken?

 Assess for skin turgor

Classify diarrhea

1. Severe dehydration

2. Two or more of the following signs;

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