Peds Unit 6: Nursing Care of Preschoolers (3-5 years of age)

Perry et.al. (In course packet)

 Chapter 33: pp. 904-915 – Preschooler Growth & Development
 Chapter 40: pp. 1133-1135 – Tonsillitis; pp. 1135-1137 – Otitis Medis; pp. 1152-1162 – Asthma
 Chapter 41: pp. 1208-1210 – Cleft Lip & Cleft Palate; pp. 1218-1219 – Celiac Disease
 Chapter 44: pp. 1342-1344 – Nephrotic Syndrome
 Chapter 45: pp. 1372-1375 – Bacterial Meningitis; pp. 1377-1387 – Seizure Disorders
Moodle
 Asthma Action Plan and Medication Guide, Tonsillectomy Teaching Sheet – Required
 Asthma Quiz – Resource

Preschoolers: Overview
 Children learn better control of bodily functions – potty trained
 Develop ability to tolerate prolonged periods of separation from parents – Getting ready to take their
biggest step: starting school
 Gain ability to interact cooperatively with other adults and children – sharing
 Obvious increase in vocabulary and language
 Attention span and memory increase dramatically
 Achievements in all of these areas gets them ready for enrollment in school

Preschool: Physiological – Gross and Fine Motor - p. 909-910, Table 33-1

 Biologic Development
o Growth slows – stabilizes
o Elongation of legs – start losing pot bellies, legs catching up with trunk
 Average weight gain 2-3 kg/year (about 5lbs.)
 Height increases by 6.5-9 cm/year (2.5-3.5 inches/ year)
 More slender appearance (not long trunk growing anymore, now legs)
o Most are potty trained
 Mostly BM accidents because they don’t want to stop playing
 Might have a few accidents
 Gross & Fine Motor Development
o Refinement of skills mastered during toddler years
 Skills they have established by age 3 are fine-tuned by age 5
 Now fine-tuned, balanced, doing without thinking (automatic), and part of play
o 3 years
 Gross motor
 Not just walking  running, climbing, jumping
 Riding tricycle (pedaling), walk on tippy toes, balance on one foot a few seconds
 Fine motor
 Draw a picture and explain to you (name what is being drawn),
 At the beginning of 3 years, can’t draw stick figure, but can make circles and
appendages with facial features, rudimentary drawing
 Build towers with blocks

o 4 years
 Gross motor

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  Skip/hop (refining walk to run), hop on one foot with good balance (can play hop
scotch), can catch a ball and throw overhand
 Fine motor
 Using scissors well (not enough to just glue things), adding 3+ parts to stick figure
(not at level of toes and fingers yet)
o 5 years
 Gross motor
 Skip well using alternate feet
 Usually can begin to skate/balance on skateboard
 Swimming
 Fine motor
 May or may not tie shoe laces (being lost due to Velcro) – “now research says by
8 years old they can tie their shoes – it is a little delayed now”
 Use pencils and crayons well
 Can jump rope (can play with 3 people)
 Print name/alphabet and write numbers (may not remember how to spell their
name, but they can write it if you help them)
 Draw hair, teeth, fingers, trunk, etc.

Psychosocial and Cognitive – p. 904-905

 Initiative vs. Guilt – Erikson’s
o Play, work, and live to the fullest; all about life
o Very active, work is their play (play/work hard)
o If they overstep boundaries or behave improperly – can develop sense of guilt or anxiety/fear
o Feel they might be responsible if something breaks; sense of responsibility
o Accomplished
 Task of acquiring initiative – sense of accomplishment and satisfaction in their actions,
have strong desire to please others like teacher and parents
 Like to do things that will illicit praise (when they draw, do art); they want to tell you
about their work. They look at you to make sure you are watching them draw, etc.
o Conscience – developing conscience, superego
 Major task is learning sense of right or wrong
 Superheroes can help – bad vs. good
 This is the time when we can help them learn right from wrong in a supportive/learning
environment
 Begins to learn about basic cultural values, ethics, beliefs, and prejudices
 Preoperational – Piaget
o 2 Stages of Preoperational
 Preconceptual (2-4 years)
 Intuitive thought (4-7 years) – can’t explain true definitions, just know it
 Explains in a way that makes you think they understand, although their
comprehension is not there yet
 Explain concepts as they were taught but may not really comprehend them
 Uses “absolute” in a sentence in the right context, but when you ask them what
it means, they don’t know – where intuitive thought comes in
o Shift from totally egocentric role (self-absorbed) to social awareness (able to consider others’
viewpoints) – however still somewhat egocentric

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  Not all about “me,” starting to understand others have an opinion too
 It’s okay for me to change my mind, accept what you want, or say “no”
o Concept of time not yet completely understood even at ladder of age 5; time still needs to be
explained in regard to an event (Ex.- going take a bath after supper)
 When are we going to read a book? – at bedtime
 Tomorrow – means something in the future – “everything in the future is tomorrow and
anything that happened before now is last night; weekends are always faraway”
 Understand how to use words, but don’t understand the defining concept of the word
 They explain concepts as they were taught but may not really comprehend – “may talk
abstractly but really are not totally comprehended the abstract (ex: like beyond the
trees)”
o Most don’t understand concept of left and right
o Egocentric behavior – age 3 – assumes everyone thinks like them
o By age 5 – understand people have different mindsets

Growth and Development

 Body Image
o Recognize desirable and undesirable appearances (pretty/ugly), skin color and racial identity
o Learning prejudices and biases
o By 5 years old: compare their size to others
o Formative years – teach benefits of physical exercise and healthy eating rather than focusing on
weight/size.
o Band-aide stage – if skin broken, need bandage to keep everything inside
 Sexuality
o Children are aware of their gender and related expected behavior by age 2.5 years of age
 By age of 5 – boys know how to act like boys, same with girls
o By 5 years – beyond gender recognition, modesty begins (girls want to wear shorts under skirt
to hide panties)
 Sexual exploration and playing with genitals is common (esp. in boys)
 Social Development
o Language
 Little scientists  Questions: “Why”
 Toddler was “no”
 Really want to listen and know why
 Rapid inc. in vocabulary
 By age 2 – 200-300 words
 By end of age 5 – over 2,100 words
 Love to tell exaggerated stories using all of their vocab that they know/heard; will talk
your ear off non-stop
 Use words without knowing their exact meaning; know how to use words in context
they heard them in, repeating
o Personal-Social Behavior
 Ritualism and Negativism gradually disappear – “they know what to do with their spoon
and cup – there is no more teaching”
 Sense of autonomy – independence is requested as well as many tasks can be
performed independently – dressing/eating
 Can be trusted to obey warnings of danger
 More social and willing to please
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  “We tell them the consequence of safety – ex: tell them the consequences of running in
the street”
o Play
 Communicate best through play – “they use play to communicate”
 Refinement of motor skills – gross and fine motor skills help them in the group play
(running, playing tag)
 Associative Play
 Group play is similar activities, yet without the rigid rules
 3 y.o.- wanting more group play, but with their rules
 Imaginative Play
 Dress up, may be dramatic, hand puppets, princess, light puppet shows
 Imaginary playmate- may develop an imaginary friend; appropriate at this age!
 TV and media play a big part in today’s preschoolers – caregivers should have
educational programs that teach lessons; know they can have P and PG
 They’ll mimic what they watch
 phone – know how to play games, download, knowing the rules
 Look for TV ratings (2+ vs. 7+ or 9+)
 Preschool Coping
o School Experience
 Opportunities for learning group cooperation, adjusting to sociocultural differences,
coping with frustration, dissatisfaction and anger.
 No absolute indicators for school readiness, yet social and emotional maturity and
attention span are just as important as the child’s cognitive level. – “attention span
needs to be their in order to be successful” – if the child is doing okay in school but their
maturation is not there, then the teacher may need to hold them back  it is the
parents decision”
 Children need preparation for the school experience, especially if coming from home
environment.
o Sex Education
 Ask many questions: “Where do babies come from?”
 2 Rules: 1. Find out what they know and think. And 2. Be truthful: answer what is ask
keeping it simple without long explanations.
 Handling sexual curiosity: “Playing doctor” and investigating the differences: neither
condone or condemn – ask questions to adults and respect body – “private’ parts
o Fears
 Begin to have fears, whether real or imaginary
 Decreases between end of year 5 and beginning of year 6
 Fears going away by end of this age
 Starting to know preventive and protection
 Not an overwhelming sense of fear
 May have the fear of:
 Darkness (biggest)
 Fear going into rooms by themselves
 Animals
 Loss of body parts
 The boogey man– tell them to separate movies and real life
o Able to separate magical thinking at about age 5 rather than age 3
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  Afraid of bleeding to death
 Best way to overcome fear: actively involving child in a practical method to deal with the
fear
 Seeing other people playing with the animal – if we show them, they will learn
and trust it
 Ex: night light or watch others play with a dog
o Stress
 Being aware of signs of stress and identify source
 Prevention is best approach: Inform of anticipated changes and structured schedules to
allow for rest usually are sufficient – “like a new baby coming”
o Aggression
 Defined as behavior that attempts to hurt others or destroy property
 Differs from anger which is a temporary state
 Hyper-aggression refers to unprovoked physical attacks – “ex: going out and just biting
someone b/c biting should be outgrown by this age”
 Boys exhibit more physical aggression than girls
 Exhibited from:
 Frustration – humiliation, insults to child – child takes out on others – usually at
school, esp. if fear parents
 Modeling – imitate behaviors of significant others. OR double standard –
aggression = masculinity
 Reinforcement – every time child acts out – child gets attention of adult
o “So if they get in trouble at home for it they may come to school and do it
b/c they think they can get away with it?”
 Problematic behavior based on quantity of behavior, severity, distribution (S &
S), onset and duration (when are they most vulnerable).
o Speech
 Tells exaggerated stories
 Love to talk
 Uses words without knowing exact meaning, yet they use them in the same context as
they’re hearing them
 Critical time of speech development – between 2 and 4 years of age
 Problems: Stuttering- most prominent problem if they’re going to stutter, this is the age
we’re going to see it.
 Affects boys more than girls
 Genetic link
 Usually resolves during childhood
 If it continues to a point where they aren’t articulating, then we need to look for
something like hearing loss, developmental delays, autism, or simply a lack of
environmental stimulation
 Best therapy: prevention and early detection
 Common causes: hearing loss, developmental delay, autism and lack of
environmental stimulation
o Magical thinking – superheroes
 Believe their thoughts are all-powerful
 If they’re thinking something and that event occurs, they believe they truly have
influence over the event
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  Blame themselves and think they’re the cause of events
 Divorce, death of a parent***
- must really look into how they are going to cope with this (say nothing you did
caused the death)
 Often accept the meaning of words literally
 “little stick in the arm” -> tree branch in arm
 Placing live-like qualities to inanimate objects
 Animism
 Fall and hit the chair hit the chair and says it’s being bad
 Promoting Optimal Health
o Nutrition
 Should include a variety of foods while avoiding obesity
 Esp. if parents tend to be obese, or not providing healthy foods
o Kids will either duplicate behaviors or do the opposite
o Want the pendulum to be somewhere in the middle
 Obesity depends on – what we eat and the amount
 Teach parents to slow down so sensation of fullness can kick in (happens 20
mins)
 Emphasize reduction in sugar sweetened beverages (juices)
 Increase whole grains, vegetables, and fruits – shown to decrease dental caries
 Fluid requirements dec. slightly & protein requirements inc. (building muscle mass)
 Research – developing healthy eating habits at this age reduces childhood obesity, adult
coronary heart disease, and diabetes
 Eating habits well established by 5 years of age – major contributing factor = family
(parents)/ home environment
o Safety
 Pedestrian accidents increase between 3-5 years of age
 Ball goes into street, running in parking lots/streets/driveway to retrieve them
 Less prone to falls – better balance and coordination
 Beginning to be aware of potential dangers *So, potential sense of safety developed by
age 5
 Pot on stove may be hot (starting to apply)
 Sharp objects (it’ll hurt if I touch the point)
 Accidental poisoning still exists even though outgrowing oral stage
 Poisoning is less common though
 Great time (age 3-5 years) to reinforce preventive safety – Ex. wearing helmet on bike

Tonsillitis - p. 1133, Figure 40-2

 4 pairs of tonsils – palatine (you can see on oral exam), pharyngeal (adenoids)
 Characteristics
o Tonsils: mass of lymphoid tissue – encircling the nasal and oropharynx
o Role of tonsils:
 Filter and protect respiratory system from invasion of pathogens
 and produce antibodies
o Larger in children than in adults
o Palatine tonsils – ones we can see on an oral exam - are the ones usually removed during T&A
o Pharyngeal tonsils - also called the adenoids. They are close to the nares and Eustachian tubes

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 Clinical Manifestations
o Inflammation of the tonsils
 Due to viral or bacterial agents
 Often occurs w/ pharyngitis
 Common morbidity in children
o Enlargement
 Due to edema of palatine tonsils
 May be so inflamed that they meet in the middle- called “kissing tonsils” – meet at the
uvula
 Causes difficulty swallowing and breathing (may cause drooling)
 Can obstruct passage of food and air
 Might talk very nasally
o Air by-passing mouth and going out through nose – so child breathes
through mouth
 Adenoids (pharyngeal tonsils)
 When they enlarge, air can’t pass from nose to throat
o As a result, child becomes a mouth breather
 Affects drainage of the Eustachian tubes, due to their close proximity
o Disordered breathing
 Due to enlargements of tonsils and adenoids
 Snoring – “Is your child snoring?” – this is how the doctor determines including both
palatine tonsils AND adenoids
 Sleep apnea – causes them to be irritable and tired the next day
o Trouble swallowing  causing increased drooling
o Ear infections – blockage of Eustachian tubes
 May notice infants pulling ears
 Child around 3 may be able to tell you it hurts
o Sinusitis – blockage of Eustachian tubes
 Therapeutic management
o Viral
 Treat the symptoms – symptomatic tx.
 Throat cultures
 Swab of tonsils - to rule out bacterial
 Rapid screens to confirm diagnosis to treat appropriately
 Antibiotics- don’t want to give them unnecessarily/inappropriately
o Bacterial
 If it is bacterial….. GABHS (this is your strep throat) – group A beta hemolytic strep
 Hence strep throat – very painful like knives in the back of throat, dries out
quickly
 Want child to drink, but it hurts every time they swallow
 Antibiotics necessary
 Do NOT give abx. unnecessarily
o Surgical treatment: with recurrent severe infections
 Will do if there is a risk like hearing loss or if they have sleep disruption due to breathing
patterns
 Rule of thumb: 3x3. More than 3 infections per year (x) 3 years
 T&A: Tonsillectomy and Adenoidectomy

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  Contraindications to surgery:
o Cleft palate (b/c T&A assist in speech)
o If acute infection at time of surgery - increase risk of bleeding – cancel
surgery
o Blood diseases like leukemia
o Poor anesthesia risk (benefits vs. risks) –“ like a cardiac defect”
 Other than contraindications – considered routine unless it’s you or your child
o Recurrent or severe infections – 3 or more in a year
- Includes complications: abscessed tonsils (with pus), airway obstruction (snoring), spike in
fever quickly (febrile seizure), or if presumed malignant they will be surgically removed

 Nursing Care
o Tonsillitis
 Pain relief
 Current infection: Motrin or Acetaminophen
 Throat lozenges – explain purpose (let it melt in mouth; don’t chew it)
 Warm salt water gargles
 Throat sprays
 Soft diet or something that will not scratch tonsils and inc. pain if VERY inflamed
– minimizes bleeding is inflamed
 Cool mist humidifier to reduce dryness of throat
 Opioid elixirs for severe pain if child refusing to drink/eat – so they can be able to
eat or drink -Dehydration is a risk
 Antipyretics – fever
 Minimize dryness – they dry up & will feel sharp pain when they swallow
o Pre-operative Teaching
 Honesty – throat will hurt (be honest in explaining post-op; a 5 y.o. will be able to
understand)
 Age appropriate, explain what will happen & post-op interventions (show in
mirror, Dr. will remove & they won’t be there anymore), will be asleep & won’t
remember, won’t wake up during surgery
 Reassure them that they will be asleep & won’t see or feel the removal
 Throat will hurt when they wake up
 Tell them what you want them to do at this point before they are waking up in
too much pain (b/c they don’t have the pain at this point)
o We will give you popsicles, drinks to keep throat wet & prevent it from
getting dry
o **anything you want them to know after surgery, tell them pre-op
 Tell parents throat will look bad
 Review post-op care
o Post-op care
 Usually outpatient so have little time post-op & they’ll go home after
 Make sure caregiver & child and all are on same page, so they do what they’re
supposed to do at home
 A lot of education
 Immediate post-op:
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  Place them on abdomen or on side to facilitate drainage
o They will drool and not want to swallow/still under effects of anesthesia
 Avoid routine suctioning - just let them drool it out
 Place ice collar on throat may help
 Analgesics for pain – either IV or rectal when child can’t swallow liquids yet
(anesthesia) “esp. if they have cognitive impairment like CP or Down’s
Syndrome”
 Antiemetics for N/V if this is a result of anesthesia or from the blood being
swallowed
o Old blood in stomach from surgery: #1 reason for the nausea
 When they become alert
 Sit up and encourage them to swallow their spit to moisten the back of throat
 If we see them increase their swallowing  might indicate bleeding (#1
complication)
 Instruct child not to cough or blow nose (will aggravate the tissue)
 Diet
 When tolerating: start with ice chips, progress to popsicles, then soft diet  Jell-
O, ice cream, cool foods to help with the pain
 Avoid brown or red colored fluids or popsicles so we can see the secretions and
watch for bright red blood
 #1 complication:
 Bleeding!!!
o Hemorrhage is rare, but sometimes bleeding can occur up to 7 to 10 (she
said 14 days) days after surgery
o May need surgery to ligate the vessels once scabs fall off – “esp. with
laser if they did not catch it”
o “However with current laser sx.  bleeding is less, faster healing”
o *required tonsillectomy sheet on Moodle*
Otitis Media – inflammation of the middle ear -- earache
 Etiology
o Non-infectious OM - Primary cause: malfunctioning EUSTACHIAN TUBE (blocked)
 Remember purpose of Eustachian tubes:
 Help drain secretions in middle ear
 Keep secretions in nasopharynx from going in middle ear
 Ventilates middle ear so pressure does not build up
o Middle ear has a pressure sensor that helps with equilibrium and
balance; Eustachian tubes help with this pressure and balance
 If tubes are not functioning properly (blocked by enlarged adenoids) can result in
accumulation of secretions and negative pressure in middle ear
 “T&A may also be needed with kids with chronic otitis media”
 “Viral now becomes bacterial b/c of the secretions staying in there”
 Swallow and ears does not pop like they are in a vacuum
 Secretions and fluid stay in the middle ear – can lead to colonization of bacteria (great
medium if fluid not released)
 Most common: strep pneumoniae, H. influenza

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 Diagnosis
o Tympanic Membrane inspection
 To decide if it’s acute otitis media (AOM) or otitis media with effusions (OME)
 Effusion = fluid in a body cavity
o Tympanic membrane is usually gray-pinkish (pearlish) pearl-like sphere that moves when air is
puffed into canal
o It “wobbles/quivers” when air is puffed through a tube  called insufflation  determines
normal middle ear pressure
o With AOM  tympanic membrane is red, bulging, and immobile with puff of air (no wobble)
o With OME we have an orange tympanic membrane. This is because of the fluid behind it,
which might have a yellowish hue. Also immobile
 Symptoms
o Acute onset of ear pain – “wake up during night with ear pain”
o Fever, but may not be present
o May or may not have ear discharge
 “If rupture – may see a drainage coming out of ear”
o Often proceeds from a virus or URI, allergic rhinitis
 Characteristics
o Middle ear inflammation
 70% of children experience this episode at least once in their life, preceded by virus or
URI
o Highest incidence
 First 2 years of life
 Inc. at age 5-6 when entering school, with children around them
 Dec. with age, very infrequent after age of 7
 Incidence peaks in Winter
 Dec. incidence in breastfed babies
o Recurrent OM can lead to speech and hearing problems; recurrent and chronic OM -> we’ll do
something about it
o Breastfeeding= protective measure
 Predisposing Factors
o URI’s
o Allergic Rhinitis (nasal congestion caused by allergies)
o Down Syndrome
o Cleft Palate
o Second hand smoke (babysitter, parents)
o Daycare attendance
o Propped bottle when feeding at an incline – milk backs up into Eustachian tubes when they
swallow
o Often preceded by a virus or URI
 Types
o Regular otitis media: inflammation of the ear without an etiology; just an earache
o Acute otitis media – AOM
 Rapid onset of symptoms; acute infection
 Acute ear pain, fever, irritability, poor feeding (don’t want to eat), infants up to 3 years
old pull on ears

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  Tympanic membrane is red and bulging – should look nice, grey, pearly, shiny, and not
dull
 IF TM Rupture – sharp pain at time of rupture (screams) then subsides “b/c pain
is gone and feel a lot better”
o Classic sign of ruptured membrane: purulent drainage
o Otitis media with effusion – OME
 Collection of fluid and inflammation in middle ear
 With or without acute symptoms of infection (may or may not have fever)
 Feeling of fullness with/without hearing loss – “cant pop ears?”
 Hearing loss depends on amount of fluid they have
 “WHAT I can’t hear you!” Like they’re in a drum because ears full of fluid
 TM not red – “may be a little orange”
 Might be a little bulging due to fluid behind it (convexed)
 There will be no quivering!!
 May lead to AOM (because fluid staying in middle ear) or resolve spontaneously
 If it remains unresolved or recurrent (chronic) > 4-6 months  put in PE tubes
(pressure equalizing tubes)
 If child is > 6 months of age, we do a waiting period for about 72 hours (3 days)
- dependent on symptom severity
- we want to see if it will heal on its own (some effusions do)
- also don’t want to inappropriately use antibiotics
 Acute Otitis Media
o Treatment  diagnosed by diagnosis of the tympanic membrane
 Oral antibiotics
 > 6 months: waiting period up to 72 hours for healing on own due to drug-
resistant concerns for less severe S&S; however for true diagnostic of AOM:
o 10 days for smaller child (0 - 5 y.o.)
o 5-7 days for (6 y.o. +)
 Amoxicillin first choice
 Don’t worry about admin specifics
 Analgesics
 Tylenol & ibuprofen for pain and fever
 Ear drops for topical pain relief – have prescription and non-prescription
 More aggressive Tx considered if causing speech or hearing problems
 Antipyretics
 Myringotomy – surgical incision of ear drum to alleviate pain from AOM/OME to allow
drainage, very painful/short in duration; blade visits tympanic membrane, pain relief
afterwards
 Tympanostomy tube (T tubes) or PE tubes (pressure equalizing tubes- equalizes
pressure in middle ear, often w/ adenoid removal)
 To treat recurrent episodes of AOM/OME
 Done to avoid long-term effects like hearing loss and speech difficulty
 More aggressive Tx with chronic otitis media (both types)
 Once procedure is done (either myringotomy or tubes) they need routine
hearing exams

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  “If they fall out, they may not have to put them back in if they were in there for a
long time enough and they grew out of the AOM”
 Tube allows for continuous drainage of fluid and ventilation of the middle ear
space
 Require regular ear exams & usually put on antibiotics initially
o Important to teach them finish the sequence completely – take until
empty!
o Prevention
 PCV13 – pneumococcal conjugate vaccine
 Protects against 13 different types of pneumococcal bacteria
 Routinely given at 2, 4, and 6 months of age and again at 12-15 months of age (4
injections)
 Annual flu vaccine – esp. if they are having chronic ear infectons
 Breastfeeding is a lower risk for OM, this can be a selling point for BF kid with less ear
infections  BF for at least 6 mo.
 Teach moms not to prop bottles esp. at an incline – can cause AOM and OME
 Can occur with exposure to second hand smoke; avoid passive tobacco smoking

Bronchial Asthma
 Characteristics
o Chronic inflammatory disorder of airways
o Long term dysfunction of the resp. system
o Inflammation causes: recurrent episodes of
expiratory wheezing, breathlessness, chest tightness,
and coughing (esp. early morning or night hours)
o Vary with degree of airway obstruction,
that is reversible… either spontaneously
or with treatment
 Classifications p. 1152, Box 14-13
o Usually classified in 4 categories based on severity of symptoms
o (i.e use of rescue inhaler, number of exacerbations, or interference with activities)
o The patient is placed in the corresponding category with the most severe symptom categories
may overlap because of the variability of the symptoms
o Severity Classification Categories may overlap due to variability of the symptoms
 1: Intermittent- no limitations
 2: Mild- mild limitations because the child has asthma
 3 or 4: Moderate- moderate- some limitation because of their asthma
 5 or 6: Severe persistent asthma- activity is extremely limited
o Symptoms increase in frequency as the number increases
o Interference with normal activity as indicator yet be familiar with what common
o The step system also helps provide an approach to the management of the asthma (meds, Tx
prevention)
o When looking at Categories: Be familiar with symptoms, time frame, influence on normal
activity, and medication usage
 Incidence

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 o Increased in U.S. due to air pollution, poor access to healthcare, rural farm communities with
dust, pollen
o Undiagnosed and untreated
o Increased incidence in non-Hispanic African Americans
o Increased incidence in boys than girls until adolescence around 12-14 years trend reverses:
more girls diagnosed and have asthma than boys
o Onset at any age, but majority have symptoms before 4 or 5 years of age
o Asthma – primary cause of school absences
 3rd leading cause of hospitalizations under age of 15
o Severity varies extremely – from very mild to respiratory arrest with severe asthma attack
o Some children resolve during puberty, but some continue into adulthood
 Now adult onset asthma
o No different between asthma and RAD
o Prognosis
 Deaths uncommon and most deaths occur in the home, school or community d/t
delayed lifesaving medical care
 2/3 of children with asthma continue to have symptoms into adulthood
 RAD (reactive airway disease) – just another term for asthma; interchangeable terms
o Started calling it RAD for insurance purposes to pay for MDI, etc.
o Usually initially diagnosed as RAD then eventually later may call it asthma
o Because of labeling risks
o ***Asthma quiz – see link on Moodle form – The American Academy of Asthma and
Immunology
 Etiology
o Allergens
 Allergies influence both persistence and severity of disease – how many attacks & how
severe attacks are each time is based on allergy or allergen response
 Often, the child has an allergic hypersensitivity reactions to foreign substance in air
 Plant pollens, mold, dust mites, pet dander – up to 80% of cases with asthma
and active asthma attacks
 20-40% of patients with asthma have no allergies when tested
o Other triggers – Box 40-14 p. 1153
 Cold air
 Being hot, sweating
 Viral infection – most common trigger!!! (RSV)
 Exercise-induced asthma
 Baby with GE reflux
 Foods: nuts, milk, and dairy
 Inhaled irritants: perfumes, candles
 Strong emotions, stress
 Pathophysiology:
o Inflammation of the bronchioles – causes intensified airway reactivity or hyper-responsiveness
to variety of stimuli (triggers)
 So, it’s a hyperactive response in bronchial tubes to antigen (to the triggers)
 It causes inflammation which causes most problems with asthma
o Inflammation causes mucosal edema
 Accumulation of thick secretions results in airway obstruction (overproduced)

13
  Bronchioles have bands of smooth muscle, don’t notice bands until it becomes
rigid and edematous, internal mucosa of bronchioles stretch out between the
bands so it constricts the airways because of the edema of the bands of the
bronchial tubes
 Becomes edematous / Inflamed -> exudate -> narrowing of airways
o Obstructions – leads to bronchospasms
o Bronchospams occur – spasms of smooth muscle of bronchi in bronchioles  Leads to
hyperinflation of alveoli and air trapping
o All causing permanent damage to airways narrowed air lumen called airway remodeling;
might be permanent with recurrence of asthma attacks  “this is all what causes the chronic
symptoms of asthma”

o Impaired respiratory function results due to bronchioles usually constricting in response to

foreign stimuli
 With asthma, this constriction is abnormally severe because of banding
 Air trapping – leads to difficult inspiration and expiration
 Normally, bronchioles dilate during inspiration to get the air in
 Because of narrowing, air doesn’t come out as easily during expiration causing
expiratory wheezing and air trapping
o Child begins to force expiration which causes air trapping between alveoli
and lumbar bronchi (because air won’t go up and out, but down into
alveoli)
o Causes child to breathe at higher and higher lung volume/ tidal volume:
 The amount of air we breathe at rest in normally
o End up fighting to inspire sufficient air or take a good breath in
o Increased effort to breathe  CO2 retention, hypoxemia, resp. acidosis
 severe - resp. failure
 Smooth muscle changes can be permanent  remodeling of bronchioles
 Signs and Symptoms
o Box 40-15, pg. 1154
o Expiratory wheezing, dyspnea, breathlessness (trying to inc. tidal volume)
o Chest tightness – due to air in lobar bronchioles being forced downwards into smaller
bronchioles
o Complains of prolonged expiratory phase
o May have cough at night or early morning that is non-productive
o SOB – along with apprehension, inc. anxiety; audible wheezing
o Might lead to cyanosis, pallor, retractions (inc. and higher retractions -> more severe)
o Infants (obligatory nose breathers) – nasal flaring (especially in younger children)
o May hear crackles, but mostly wheezing – auscultation

14
 o Increased HR as episode lingers
o With repeated episodes: Barrel chest (> in AP diameter) and elevated shoulders to expand
chest cavity as compensation.
o Might speak with short, panting phases because of prolonged expiratory phase
o May assume position for best breathing: tripod position
o With acute asthma attacks that are recurrent, shoulders stay in upright & forward (similar with
CF), body knows they’re able to breathe better in this position
o Impending Attack Symptoms:
 Ask mom and 5 year old patient -> educate mom, use diary to see pattern and to predict
when verge of attack
 Runny nose
 Cough
 Low grade fever
 Inc. irritability- frightened
 Itching of neck and chest – common complaint of child
 Loss of appetite – rather breathe than eat (also full stomach gets in the way of
breathing)
 Abdominal discomfort – air trapped in alveoli diaphragm stays flat; doesn’t come back
up
 Diagnosis
o Full History – before, during, and after attack
o Environmental triggers, if any
o Physical exam
 Clinical signs of dyspnea, chronic cough
 Expiratory wheezing is sufficient to establish diagnosis most of the time
 With positive history and physical, can usually say there is RAD or if they aren’t
conservative they will go straight into diagnosis of asthma
o Age significant factor – usually before age 5 that asthma will be Dx
o Might have allergy skin test – 20-40% don’t have all allergic responses to the antigens
o PFT – Pulmonary Function Tests
 Determines degree of lung disease/involvement
 Can follow directions enough for this test around 5 y.o.
o Also look at how child responds to meds (Ex.- give him albuterol and it works… you might have
asthma!)
o CBC – inc. WBCs during acute attack, or might indicate previous URI
o Chest x-ray – hyper-expansion of airways; see flat or less-rounded diaphragm
o Identify if GE Reflux is contributing factor
 Treatment p. 1227 Patient Teaching
o Goals
 Maintain normal activity levels for the child
 Maintain normal PFTs (pulmonary function tests) – determine the degree of lung
disease & response to tx
 Includes spirometry testing
 Prevent recurrent exacerbations, to prevent remodeling of smooth muscle
 Optimal drug therapy with few side effects
o Treatment Principles:
 Regular visits to monitor, evaluate and revise the plan of care if needed
15
  Appropriate use of medications – when to use each type of medication and by what
route
 Education to avoid allergens, triggers and use of medication
o Allergen control
 Nonpharmacologic Therapy aimed at the prevention and reduction of exposure to
airborne allergens and irritants:
 dust, cockroaches, mites, pets, tobacco smoke, pesticides, fire, wood-burning
stove
 Teach mom: decrease exposure to airborne irritants/illnesses in the home
If environmental: not so much rolling in the grass, etc.
Suggestions: exterminating the house, dehumidifiers or use A/C, clean vents & air filters
often, allergen-type pillow cases and mattress covers, remove carpets if possible, have
wipeable furniture (vinyl, leather), no stuffed animals, no pets in the house, wash hair
after playing outside, avoid perfumes & powders
o Pharmacological
 Prevent and control symptoms
 Reduce frequency and severity of exacerbations
 Reverse airflow obstruction
 Long-term suppression of inflammation
 Exercise
o Encouraged to participate in activities and sports provided asthma is under control
o For those children with exercise-induced bronchospasms (EIB) – appropriate prophylactic
treatment with medications before exercise usually permits full participation
 Breathing Exercises
o Strengthen respiratory musculature
o Prevents over-inflation and improves efficiency of the cough
o Not recommended during acute exacerbations
 Hypo-sensitization
o Typical allergy shots
o Limited to clinically significant allergens
o Successful treatment is continued for a minimum of 3 years and then stopped to check for
immunity: asymptomatic – immunity assumed
 Medications – see asthma medication sheet on moodle
o 2 general classes
 1. Long-term control (preventative meds) – to achieve and maintain control of the
inflammation of airways (anti-inflammatory drugs)
 Do not use this when sense of asthma attack approaching
 2. Quick relief (rescue meds) – to treat symptoms and exacerbations
 Often have drugs that are used in combination and we should watch for both drugs side
effects
 Antibiotics not used unless bacterial infection is a trigger (sinusitis, pneumonia, URI)
 Combinations, long acting bronchodilators, short acting bronchodilators, anti-
inflammatory
 Long term to control and prevent- inhaled corticosteroids
16
o Anti-inflammatories – Long term to control and prevent
o Corticosteroids - Fluticasone (Flovent) or Budesonide (Pulmicort)
o To treat reversible airflow obstruction, control symptoms and reduce bronchial
hyperresponsiveness in chronic asthma.
o Inhaled is 1st line therapy in children older than 5 years
o Child might have creamy white patches in mouth (oral thrush), hoarseness/dry mouth,
cough
 rinse mouth with water/brush teeth after treatment.
o Systemic corticosteroids – short term basis:
o Oral: Prednisolone (Prelone, Orapred) OR IV: Methylprednisolone (Solu-Medrol)
 Side effects: blurred vision, facial flushing, mood swings, weight gain, increased
appetite and stomach irritation
o Inhaled Short Acting Beta2Adrenergic agonists
o Albuterol (ProAir, Proventil, Ventolin) and levalbuterol (Xopenex)
o Quick response but short duration - for treatment of acute exacerbations and for
prevention of EIB
o Relaxes smooth muscles – helps eliminate bronchospasm
o Side effects include: increased HR (esp. w/ long term neb tx), irritability, nervousness,
tremor, insomnia
o Long Acting Beta2Adrenergic agonists
o Bronchodilator
o Salmeterol (Serevent)
o Used no more frequently than twice daily (every 12 hrs) – early am and pm d/t side
effects
o Long term prevention of symptoms, especially nighttime symptoms and EIB (exercise
induced bronchospasms
o Side effects: increased HR, palpitations, nervousness, headache and sleeplessness.
o Combined with corticosteroids for better control of asthma symptoms [error in book p.
1156 – should state long-term (says short term]
 salmeterol/fluticasone - Advair Diskus – side effects: same as each medication
ingredient discussed independently
o Mast Cell Stabilizers - works similar to an antihistamine
o Maintenance therapy: helps prevent allergy symptoms that cause allergy-induced
asthma attacks.
o Does not result in the immediate relief of symptoms  “not used in rescue”
o Cromolyn sodium (Intal) [dry powder]- Use in children over the age of 2 years
o Few side effects include multiple sneezing, stuffy nose, cough mostly d/t dry powder
inhalation
o Nedocromil (Tilade) [inhaler] – not used in children younger than 5 years
o Leukotriene Modifiers
o block inflammatory and bronchospasm effects
o Given orally in combination with inhaled medications to provide long-term control &
prevent symptoms in mild persistent asthma

17
 o Montelukast (Singulair) – approved for children 12 months and older; has been
associated with suicide tendencies in adolescents
o Zafirlukast (Accolate) – approved for children 5 years and older; can affect elimination of
cyp3a4 drugs: Biaxin (antibiotic drug of choice to treat strep throat)
o Long-acting Anticholinergics
o May relieve acute bronchospasm - prevents the muscle bands around the airways from
tightening.
o Atropine & Ipratropium (Atrovent) [MDI or inhalation solution]
o Side effects of ipratropium – usually dry mouth
o However atropine side effects are rare yet more serious: drying of respiratory secretions,
blurred vision, cardiac and CNS stimulation
 *** SEE CHART

ASTHMA MEDICATIONS
Type Class Example General Side Effects
Brand (Generic)name
Long Term Inhaled Corticosteroids Pulmicort (budesonide) Creamy white patches in mouth-
(Control/Prevent) (Anti-inflammatory) or rinsing out their mouth after use
Flovent (fluticasone) Hoarseness
Dry mouth
Inhaled Serevent (salmeterol) Increased heart rate
Long Acting Beta2 or Palpitations
Agonists Foradil (formoterol) Nervousness
(Bronchodilator) Headache
Sleeplessness
Inhaled Advair Same as each medication
Combined (salmeterol/fluticasone) (see above)
(Corticosteroid and Long or
Acting Beta2 Symbicort
Bronchodilator) (budesonide/ formoterol)

Long Acting Atrovent Rare

Anticholinergics (Ipratropium Bromide) Usual dry mouth
(Bronchodilator) or
Spiriva
(Tiotropium Bromide)

Mast Cell Stabilizers Intal Sneezing

(antihistamine) (Cromolyn Sodium) Stuffy nose
Help prevent allergy or Cough
symptoms that cause Alocril (Nedocromil)
allergy induced asthma
attacks

18
 Oral Singulair (Montelukast) Has been associated with suicide
Leukotriene Modifiers tendencies
Blocks inflammatory and or
bronchospasm effects Can affect elimination of other
Accolate (Zafirlukast) drugs

Quick Relief Inhaled Proventil or Ventolin Increased heart rate

Medications Short Acting Beta2 (Albuterol) Palpitations
(quick acting but Agonists Nervousness
short duration) (Bronchodilator) Xopenex Headache
Can be used in acute (Levalbuterol) Sleeplessness
exacerbation
(short term basis) Systemic Corticosteroids Prelone or Orapred Blurred vision
Oral (Prednisolone) Facial flushing
Mood swings
IV Weight gain
Solu-Medrol Increased appetite
(Methylprednisolone) Stomach irritation

10/27/15 RMM; revised 10/20/17 S

• Serevent (salmeterol)- given to ages 4 years and older
• Serevent (salmeterol) and Foradil (formoterol)- usually given twice a day, in the early am and early pm
to avoid the sleeplessness at night. Usually the side effects are worse when you start the med and then
lightens us
• Atrovent (Ipratropium Bromide)- metered dose inhaler
• Spiriva (Tiotropium Bromide)- prevent the muscle bands around the airways from tightening
o Delivery of Inhaled Medications
 We do this based on their chronological age as well as developmental age
 Nebulizer
 Medication is mixed with saline, compressed air turns liquid medication into gas
or vapor so it can be inhaled into the lungs, take droplet form to go into small
airways (aerosolized)
 Needed for young children and may work better when having an exacerbation
 Sometimes we need mask
 When using the pipe, do put a tube on the back for a reservoir so when they are
breathing in, whatever is still coming out can go into the reservoir – taking
breaths and stays in reservoir, stays full of med
 Hand held inhalers – Usually can use them correctly around age 5
 Metered dose inhaler (with and without a spacer)
o Older child can learn to puff straight from inhaler
o With or without spacers – for use with metered dose inhalers. Can be
attached to a mouthpiece or mask.
o Used to prevent oral yeast infections
 Diskus inhaler
o Dry powder – gives that white powder, film in mouth; moisture may help
with irritation from powder. Make sure they rise their mouth afterwards
19
  Turbo inhaler
o Dry powder
 Acute Care Management
o Short acting Beta2 agonists- albuterol
o Supplemental O2 with pulse ox – want to keep level at equal to or above 95%
o IV corticosteroids
o Close monitoring of increased respiratory distress (nasal flaring, tachypnea, retractions)
o Status asthmatics - can result in respiratory failure, those children who continue to exhibit S&S
despite the treatment
 Usually in children with other conditions like a respiratory infection, pneumonia
 Child on CR monitor, pulse oximetry to maintain 02 sat > 90%, oral fluid limited with IV
fluid replacement for adequate hydration,
 Additional nontraditional therapies may be necessary: IV MgS04 - improves pulmonary
function and peak flow rate and heliox - mixture of helium and oxygen may be used to
improve pulmonary function until albuterol and corticosteroids take effect.
o Acute Asthma:
 short acting Beta 2 agonists: inhaled albuterol/levalbuterol, supplemental O2 with pulse
oximetry, corticosteroids IV: methylprednisolone;
 close monitoring of increased respiratory distress: nasal flaring, tachypnea, retractions.
 parents remain with child to help calm child
 Antibiotics - not used to treat an acute attack except where bacteria infection triggers
asthma (pneumonia/sinusitis)
o IV fluid replacement for adequate hydration
 Long-term Care – EDUCATION is key!
o S/S
 Diary – learn triggers – ID and avoid triggers
 When to come into the hospital or when they can manage at home
 What to do with impending attack
 S/S of problems: impending attack, exacerbation
 runny nose, cough, low grade temp, irritability, itching neck and chest, loss of
appetite, abdominal discomfort
o Med compliance
 Usual therapies that go along with it and in acute exacerbations
 If they would take their medication as prescribed, they would be healthier overall
o Avoidance of allergens and other triggering factors
 Allergen control
 Is it exercise induced?
o Protect from infection
 Give flu shot, vaccination, etc.
o Exercise awareness
 Know when the intolerance can cause asthma attack
o Breathing exercise
 When they are well – to improve lung functions o that when they have an attack their
reserve will be greater to fight attack
20
o Asthma Action Plan – Joint Commission Core Meausre
 Written plan for what to do when peak flow meter is feeling green, yellow, red
 Determines if asthma is getting worse
 If you have asthma, it is recommended that you have a plan developed between you
and your healthcare provider that gives specific instructions for early treatment of
asthma symptoms. An asthma action plan is a written, individualized worksheet that
shows you the steps to take to prevent your asthma from getting worse. It also provides
guidance on when to call your healthcare provider or when to go to the emergency
room right away.
 Any setting that comes into contact with children who have asthma should have copy in
their facility on the child
 Given to the parents and help them fill it out if they don’t have one completed
o Peak Flow Meter- measures the maximum amount of air that can be forcibly exhaled in 1 sec.
 Helps pt.’s determine if their asthma symptoms are getting worse
 3 zones (red, yellow, green) – figure out personal best by history & we do the
percentages; teach parents how to look at percentages
 “Each child needs to establish what their baseline is and their baseline determines the
level of severity”
 Green is good
o 80-100% of personal best
o Asthma under good control
o Follow routine treatment plan
 Yellow is what’s going on
o 50-79% of personal best
o Not well controlled
o May need to inc. maintenance of treatment
 “If they are doing PRN schedule they may want to do them
regularly scheduled”
o Or if continued yellow, call doctor & may need med readjustment
 Red is do we need rescue inhaler
o Below 50% of personal best
o Medical alert
o Severe narrow airway
o Give short acting bronchodilator and call physician
 Sometimes if yellow, they wait too long and it becomes red & give quick inhaler
& ER visit
 Teach them how to use it

21
Cleft Lip and Palate p. 1208
 Info
o Remember when we talked about embryonic
development, and the 1st trimester is the most lethal to
the baby (structural, anatomical abnormalities)
o Occurs during embryonic development
o Most common congenital deformity in the U.S.
 Cleft Lip
o Result from failure of fusion of maxillary and median
nasal processes
 Can vary from a small notch on upper lip to
complete cleft extending to the base of the nose
 Can be unilateral or bilateral
 Cleft palate
o Failure of fusion or a fissure of palatal processes (hard and soft)
o Varies from a
 bifid uvula (mildest form) to a
 complete cleft -- extending from the soft to the hard palate
 Combination
o Occurs more often and more common in males
o Most often bilateral cleft lip and palate
 Etiology
o Can be isolated occurrence or can be with recognized syndrome
o Combination or singular factors
 Genetic disposition
 Environmental factors
 Teratogens of maternal exposure
 Diagnosis
o About 30% of infants are prenatally diagnosed because of advances of ultrasound, esp. cleft lip
as seen on ultrasound
 3D, 4D, more often ultrasounds are performed to know the sex and count gingers and
toes and that’s when we see it on ultrasound
o Cleft lip may be visible however cleft palate may not be
 Palate: Can be diagnosed upon newborn assessment when checking hard & soft palate
and suck reflex
 It is the most imp. assessment of the newborn after birth - use gloved finger
 Swallowing is not affected by the anatomical abnormal structures; baby can swallow
 Therapeutic Management
o Parental grief
 1st thing nurses should be aware of
 Even when prenatally diagnosed, it is a shock to the parents to see esp. with a
full cleft lip and palate (esp. if it a bilateral cleft lip and palate)
 They may be worried about what other people think when they see the baby
especially before repair
 Most of the time moms continue bonding, but dad & other caregivers are more
standoffish
22
  This is why we allow the parents to vent their emotions, because there must be
teaching before repairs and assist them with tasks to care for the infant once
home
 Before parents can learn what to do with this baby, they need to be allowed to
vent with the nurse or a counselor, what exactly it means for the baby, they
need support and encouragement that they can do this
 Multidiscipline team – Nurses, Peds, Plastic surgeons, orthodontics, ST,
audiology, social worker
 Goal: closure of the clefts, prevent complications (aspiration), facilitate normal G
& D in child.
 If mom wants to BF: BF is actually recommended with cleft lip
o Because it takes the anatomical opening and the breast confirms to the
structure and forms a better seal
o We should tell them that we encourage BF & it increases the bonding
 Good to show them before and after pictures to see the outcome after
reconstructive surgeries
o Surgical Correction
 Cleft Lip
 repair usually between 2-3 months of age
 techniques have minimized scar retraction and if no infection/trauma – little scar
formation
 Nasoalveolar molding device may be used to bring the cleft lip segments closer
prior to surgery – reduces need for revision
 Severe cases revision needed at a later age
 Cleft Palate
 Repair occurs before 12 months of age to help w/ speech development
 Secondary surgery may be needed to improve speech
o “Sometimes they will have an initial sx., they will tell parents depending
how they do with their speech depends on if there needs to be a second
sx.”
o Feeding difficulties
 An immediate problem for the infant
 Teach parents how to feed their child – high priority or baby will have growth failure

o Effect on growth and development
 Growth failure usually does occur prior to repair even bc baby is not getting proper
feeding, adequate nutrition even with proper teaching and feeding from mom or
caregiver
 After complete repair, baby usually regains weight, they become good feeders, and
catches up in height for age
o Pre-surgical Repair Treatment
 Breastfeeding recommended esp. for cleft lip due to the breast conforming to the clef
and allows the infant to create a good suction and – they can create a good seal to BF
properly
 If not breast feeding we can use a certain type of nipple on the bottles, we need to
regulate this
23
 Mothers & caregivers are taught to feed infant early as possible and do the 1st feeding
after the sx., so they will be comfortable doing it and will be doing it appropriately
 Child upright position
o BF: mom should not be lying down; should be upright
 Do skin to skin if baby is healthy and term with good first cry and tone, and
breastfeed
 If mom wants to bottle feed, she will initiate feeding with nurse present
o Baby held upright
o Needs to be slow and use gravity to take fluid down to avoid it going up
into nasal passageways
 Baby can swallow, but fluid can go up into nasal passages and
start coughing, sneezing
 Stop feeding, let baby catch breath, continue
 Earlier we do this, the better and more comfortable parents are for discharge
 If baby is healthy otherwise, usually not an extended stay if everything goes well, can go
home at usual time frame
 Other than if there is an issue with comfort level and feeding difficulty of baby
 Modifiers
 Mead Johnston cleft palate nurser – you can squeeze or stop to regulate volume
baby is getting so they don’t choke
o Used to be called the Hammerman
 Pigeon bottle
 Infant swallows excessive air – burping often required
 Special needs feeder
o All assist in forming a seal for effective sucking while positioning baby
upright, so milk can go down better
o So that we can feed with bottle upright and not at incline
o As baby sucks at upright position, the formula still goes into the mouth
o Elongated nipple bottle to bypass the nasopharyngeal access and goes
towards the uvula to swallow
 Especially if hard palate all the way at the front
 Teach mom and caregivers so they can help out
 Bottle feeding – ask who else is in going to be in house to teach; can help her
learn and remember the right way; inc. support and teaching
 Preoperative Care – Education
 Multiple surgeries planned for additional cosmetic results, etc.
 Parents may be taught alternative feeding options for after surgery: syringes,
etc.
 Always a craniofacial team involved
 Pediatrician will be the lead at birth and remain who will be consulted;
plan/overview said when baby is born; cranial facial team starts the plan after
the mom goes home
 Mom, baby, family brought back in clinic visits to make specific plan & teach
mom how to use the stretching thing
 At first visit they may use nasoalvelar molar to help stretch cleft lip together

24
 o Another teaching we must do
o Measure & adjust, get it right size
o Teach mom how to do it at home
 Post-Op Teaching
o Multiple surgeries are usually planned
o And then the cosmetic surgeries begin
 Not all cosmetic surgeries are done with initial lip closure
 Do their best but will have more cosmetic type craniofacial specialists after
 Post-Op Care
o Parents taught how to feed baby
 Breastfeeding can still be done
o Protection of surgical site
 Supine position and Petroleum jelly at site for Cleft Lip
o With all 3 combos (cleft lip, cleft palate, or combo)
 Surgical steps: put elbow restraints/immobilizers on the baby so baby doesn’t rub or
move incision, or put fingers in mouth with repair of palate
 Applied immediately after surgery
 Baby usually sent home with mom until 7-10 days until incision is healing, no infection
 Usually at post-visit, they will look at palate and incisions to see when to remove them
 Teach skin care with restraints
 How to remove them
 How to watch baby when restraints not on baby
 Holding hands, playing with baby, keeping hands away from mouth
o Using syringes for feeding after surgery
 With cleft lip, but esp. with cleft palate, don’t put anything in the lip
 Teach them how to drizzle it at the nook of the lip in the buccal cavity and baby
swallows
o Analgesia for pain management and to prevent restlessness
 Teach mom signs of babies (2-3 months for first repair) cues for pain in infant; use pain
scale what to look for
 Restless, irritability, waking from sound sleep, arching of the back
o Feedings are resumed like any surgery post-op as baby can tolerate it
 Once they are awake
 N/V subsides – it is usually d/t the anesthesia
 Once n/v subsides, start half strength Pedialyte, full strength Pedialyte, half
strength formula, to full strength formula (this is their regular as tolerated)
 Feed infant in upright position
 At this point, mom knows this from pre-op, so she can use same tactic
 Also helps to maintain secretions from being aspirated or going up into
nasopharyngeal if cleft palate has yet to be closed
 Avoid use of suctioning or any objects in the mouth: pacifiers, tongue depressors,
spoons etc.
 Older child: no eating of items that can damage the repaired palate: potato chips, hard
items, etc.
 No objects in mouths
25
 Pacifiers, spoons or things to help with feedings from trying to get inc. calories, tongue
depressors
o Prognosis/Long-Term Care - depending on severity of anomaly
 CL may require multiple surgeries, yet these children are not at risk for speech problems
 CP or CL/P – many children have some degree of speech impairments requiring ST
 CP – inefficient function of eustachian tube results in recurrent OM which may lead to
conductive hearing loss – preventive: PE tubes
 CP – Malposition of teeth may need extensive orthodontics
 Monitoring academic achievement, social adjustment and healthy self-esteem as child
grows.
 If they have orthodontic prosthesis
 (they probably will with severe cleft palate) – how to use, how to clean them
 Give them good self-esteem
 Keen observation of the nurse in clinic to see how caregivers and baby are
interacting
 Usually look at them in waiting room, how are they responding to questions,
etc.?
o How they respond in front of children will shape their self-esteem &
adjustment
Celiac Disease
 Info
o Permanent lifelong disorder, no cure
o Also called gluten-induced enteropathy
o Disease of proximal small intestine with an intolerance of the protein gluten
o Classified as malabsorption syndrome:
 Chronic diarrhea and malabsorption of nutrients
 Can lead to growth failure prior to knowing the diagnosis
o Gluten is a protein present in wheat, barley, rye and oats that damage the villi in the small
intestine - which can cause growth failure
o Second only to CF as cause of malabsorption in children
o Autoimmune disorder with genetic (inherited) predisposition
 Don’t need to know specifics of the genetic predisposition that book goes through
 Just know that it is a proximal small intestine intolerance to gluten protein,
autoimmune, lifelong, no cure
 Pathophysiology
o Immune response
o Can’t tolerate gluten
o Gluten ingested  body sees it as an antigen and infection  antibodies build up, inflamed
mucosa, process begins all in the proximal small intestines
 Causes intestinal damage to villi of small intestines
 Leads to atrophy and subsequent malabsorption
 Because the normal intestinal mucosa has a lot surface area to absorb nutrients
for growth and development
 In Celiac, gluten comes in, get inflammation, lesions, chronic damage; happens in
stages

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 o Villi getting shorter and fatter
o Reduction in surface area
o Intolerance to gluten and gluten proteins found in wheat, barley, rye, and oats
o Once we stop gluten, inflammation stops, and stages don’t progress
 So, we hope to catch it in stage 1;gets edematous all the way to it gets flatter

 Characteristics - Box 41.14

o Classic Symptoms
 GI manifestations
 Usually several months after introduction of gluten or gluten-containing grains
 For child who is an early feeder, this can be as early as 6 months of as age when
grains and cereal are introduced
 From 6 months all the way to 2 years of age
o Steatorrhea – MAIN characteristic
 Fatty, fowl-smelling bulky stools
 Chronic diarrhea
 Abdominal distention
o General malnutrition, wt. loss, FTT
 Not due to lack of eating; child is eating fine
 However, if it progresses and abd distention happens, pain causes child at early age
before age 1 to shy away from eating
 Behavioral changes  irritability
o Without diagnosis
 Leads to impaired growth
 Can lead to anemia
 Muscle wasting
 Hypotonia
 Poor appetite (association of pain with food)
o Without proper diet (secondary vitamin and iron deficiencies)
 Lack of energy s/t vitamin and iron deficiency (anemia)
 Can cause brittle nails
 Acne & eczema (skin irritation)
 Mouth ulcers with tooth enamel erosion
o Over time if still not diagnosed,
 Joint & muscle pain and swelling from malabsorption and chronic inflammation in small
intestine
27
  (Skin, mouth, joint, & muscle)
o Untreated can lead to  Celiac Crisis!!!
 Bloated abdominal distention
 Explosive watery diarrhea
 Dehydration – electrolyte imbalance
 Lethargy
 Hypovolemic shock
o (Skin, mouth, join, and muscle – teeth erosion, joint and muscle pain)
 Diagnostic evaluation
o 18 months of age or older – b/c this is when foods containing gluten are introduced and
sysmtpoms begin to appear
o Small intestine biopsy
 Since early diagnosis and detection can stop damage to mucosa and atrophy, we usually
do endoscopy with biopsy of small intestines
 See mucosal inflammation and classic intestinal atrophy
o Blood test to identify markers for tissue transglutaminase and antiendomysial antibodies
o Small intestine endoscopy with biopsy-shows mucosal inflammation and intestinal villia atrophy
o Genetic testing
 Usually with this we will do the antibody screens to determine if it is an allergic type
reaction with the antigens posing the IgA, IgG, IgEs, all the immune responses
o IgG and IgA antibody screenings
o Introduction of gluten free diet with rapid favorable response
 Good thing; usually see a good response
 If there is a suspicion, pediatrician will say “let’s cut of grains and come back in week”
 Normally, favorable response seen within 48 hours if mom is good at keeping
child as gluten-free as possible
 All of a sudden during the 5 or 7-day follow-up visit, it worked; it’s diet
o Then pediatrician starts next step
o Mom may not realize it’s necessary to do more lifelong
 After these 2 days, the baby might even have weight gain (1/2 pound) the
following 48 hours after they’re eating
 The next step is to do biopsy, endoscopy, and genetic testing to confirm
 Must explain to parents that it’s the diet change that led us to believe it was Celiac
disease
 Hard for parents & caregivers because they think it’s fine
 Teach about process of Celiac disease, reason behind it, make sure there is
definite diagnosis
 Management
o Dietary Management
 Gluten free (actually low gluten) diet
 Can’t take gluten out everything we eat
 Eliminate wheat, rye, barley, and oats
 Substitute with corn and rice
 May need to remove lactose to allow intestinal mucosa heal if lots of inflammation –
use lactose free diet at 1st
 Treat specific nutritional deficiency such as iron with anemia
28
  Take a CBC result – if H&H – temporary iron, temporary lactose free diet
 If failure growth – inc. calories
 Treat specific nutritional deficiencies with vitamins, iron, increased calories – especially
fat-soluble vitamins – A, D and K
 Reassure mom this is treatable with diet, but this is a lifelong chronic disorder
 Will occur with persistent intestinal damage
 With any intestinal damage, it weakens the mucosa & chance of lymphoma
(cancer) in small intestines is 7-12% occurrence
o Due to chronic inflammation and damage of mucosa
o Try to prevent by having a great diet with very little gluten, keeping the
damage away as much as possible
o Unfortunately, whatever stage it is at, it stays there (can’t grow
back/increase surface & reverse)
 This is why we want to catch at stage 1
 If stage 4/more severe case, want more aggressive treatment
 Reduce inflammation, and prevent further damage
 Can be successful with diet control
 Tell them there is a chance of cancer with damaged mucosa/gut and that is what
we want to prevent
o This may help them comply a lot of times
o It isn’t just diet control, it’s preventing severe cases of lymphoma
 Prognosis
o Chronic disorder
o Can lead to lymphoma of the small intestine
 Will occur with persistent intestinal damage, which weakens the mucosa
 Chance of lymphoma (cancer) at risk in small intestines due to inflammation and
damage to lining
 Does not grow or increase in surface – this is why we want to catch it in stage 1
 Will need more aggressive treatment in stage 4
 Nursing management
o Support with genetic counseling
o **Help child adhere to dietary management**
 Disease that gets better with diet control
 Many parents believe “no symptoms, no disease” – cheating will start the whole process
again
 Hard to maintain the diet when child doing well
 Temporary transgression results in no issues initially, but after that 1 piece of pizza then
add something else within 48 hours they can have a bout of diarrhea
 May not occur the very next day but when add more then it occurs
 Parents will think that they will reverse the diet if it happens twice, but the
parents need to train children how to be healthy adults
 By doing it the wrong way parents are teaching them how to beat the odds &
hope that they don’t have cancer in their teens & twenties from the Celiac
disease
 We should promote maintaining and continuing diet all the time
o **Help child adhere to dietary management**
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 o Hidden sources of gluten
 Read labels
 Teach what is on label that contains gluten
 Most found in cereals, baked goods, filler in processed foods
 Hidden sources of gluten: also is a filler in many processed foods. Often added as
“hydrolyzed veg protein” or “modified food starch”.
 Often added as hydrolyzed vegetable protein
 Other things: modified food starch (100% gluten protein)
 Usually have parents consult with dietician early on
 If child is 15 months-2 years, have child listen to everything and look at play
foods & teach what is bad
 Sometimes when child is 6,7,8 years old child is self-controlling because they
know what will hurt them
o “Favorite foods”
 Hard for school-aged children or adolescents as many favorite foods contain gluten-
pizza, spaghetti, hot dogs, lunch meats, instant soups
 Sleep-overs, must have training of parents of friends of diet
o Initially temporarily cut out certain foods that cause irritation
 Initially due to inflammation esp. with delayed diagnosis, anything that irritates the gut
(nuts, raw fruits with skin, vegetables, apple skins, popcorn, cuts, , etc.); anything that
will cause inflammation: will cut out temporarily
 Once inflammation under control, then all of these items can be put back into diet
o Recommended diet high in:
 Calories
 Protein
 Fruits
 Vegetables
o Support groups, recipes, websites
 It’s a family affair
 One way of eating for you, one way for eating for child (if they don’t take on same diet
as child)
 How they cook will change
 Holidays are especially trying
 Going out to eat is hard but is getting easier now because gluten free shift
Nephrotic Syndrome - p. 1342-1344
 Idiopathic Nephrosis
o AKA Minimal Change Nephrotic Syndrome (MCNS)
o Most common type of nephrotic syndrome
 What is it?
o Glomerular Disease – affects filtering units of kidneys called glomeruli
 Membranes responsible for filtration of urine
 Blood and waste enter the kidney via renal artery
 Glomeruli filtering the lining, removing waste and cleaning the blood, waste
excreted through urine
 Clean blood goes from kidney up into vein back to body
 Characteristics
30
 o This type responsible for 80% of cases (most common)
o Predominantly disease in 2 to 7 years of age – preschool children
o Male population – twice as common in boys than girls
o Exact etiology unknown
 Usually occurs in conjunction with viral or bacterial infection
 Could be as response to infection as body does an immune medicated response and
damages filtration of kidneys
 Remembers toxins of meds either go to kidney, liver, and spleen to clean body of
toxins
 Pathophysiology
o Normally the glomerular membrane is impermeable to plasma proteins. Proteins remain in the
plasma and do not escape into urine.
o With MCNS  increased glomerular permeability to plasma proteins which leads to:
 Proteinuria – massive protein loss -> inc. loss of albumin -> dec. serum albumin level in
blood -> accumulation of fluid in interstitial space (orbital area and abd cavity aka
ascites)
 Normally glomerular membrane is impermeable (including plasma protein)
o So albumin is not loss through the urine
 Albumin most abundant plasma protein
 Hypoalbuinemia
 Albumin is the most abundant plasma protein
 When becomes impermeable, there is increased amount of albumin lost in urine
o Proteinuria
 Decreased serum albumin level
 Leads to accumulation of fluid in interstitial face  edema – most common
around orbital area & abdominal cavity in the form of ascites
 Hyperlipidemia  leads to accumulation of fluid in interstitial spaces
 Edema
 Ascites – mostly abdominal
 P. 1343; Fig. 45-6
o Schematic for sequence of events for nephrotic syndrome/acute nephrosis
 Normally, oncotic pressure (type of osmotic pressures) in capillaries that is greater than
vascular hydrostatic pressure
 When protein is lost, capillary oncotic pressure decreases  fluid shift vascular
hydrostatic pressure is now greater
 Fluid shift from cell into interstitial spaces  edema & ascites
 Shift of fluid into interstitial spaces reduces vascular fluid volume  hypovolemia (so
we have glomerular damage, massive proteinuria, hypoproteinemia, decreased oncotic
pressure, vascular pressure greater so fluid shift, causes edema & hypovolemia)
decreased renal blood flow stimulates renin angiotensin system & secretion of ADH and
aldosterone  sodium & water retained bc hypovolemia  more edema (progression to
abdominal ascites)
 Elevation of serum lipids  don’t understand why, but may be body’s natural defense
mechanism attempting to make more proteins because we are losing in urine
 Signs and symptoms
o p. 1342; Box 45-2
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 o Diagnosis of MCNS is based on history and clinical manifestations as well as proteinuria (higher
than 2+ on dipstick)
o Weight gain
o Generalized edema initially, facial swelling
 Usually worse in mornings and subsides as day goes
o Abdominal distention, ascites with advanced or more severe
o Periorbital edema with:
 Puffy pale face
 Swollen lips
o Ankle/leg edema (lower extremities)
o  urine output
o With progression – pallor, fatigue -> dec. activity level
 If a 2 year old may become irritable
 If older child – anorexia, too tired to eat or to avoid weight gain (educate weight gain is
from edema)
 Respiratory difficulty – due to pleural effusion with progression
 Slight dec. in BP due to hypovolemia
o Irritability
 Diagnosis – check urine and labs
o Proteinuria
 on a dipstick = 2+
 KEY – hallmark sign for diagnosis
o Serum labs
 Dec. serum albumin level
 Inc. cholesterol level
 Dec. total protein level
 No hematuria or inc. BP – seen in acute glomerulonephritis
 Treatment
o 1. Dec. amount of protein excreted
o 2. Dec. fluid retention in tissues
o 3. Prevent infection  BIGGEST CHALLENGE and causes relapse with these children
 With a kidney that is not filtering toxins and waste adequately and ascites/edema –
infection can be fulminating & get very severe because of this
 Ex: Sniffle  pneumonia quickly
o 4. Min. complications
 Usually from the treatment & from massive edema & complications of infection
 Steroids - #1 drug of defense
 High doses given to child for 6-12 weeks & then tapered down over several
months
 If no crises, severe/progressive episodes taper off the steroids (prednisone)
 If asymptomatic they will try to not take them at all
 Educate s/s for use of steroids esp. when high doses in early weeks
o Weight gain, round moon face
o Behavioral changes – more aggression, moody
 2 year old – temper tantrums inc. in frequency & duration
o Increased appetite because of the steroids

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 o Long term use shows long term growth retardation
 This is why with lack of progression of the syndrome we will taper
off and stop the steroids
o Increased BP
o Increased GI bleeding with long term use
o Change in bone density complications
o Affects Hyperglycemia and effects of long-term can create hyperglycemia
and DM in these children
o Immunosuppressive response – inc. risk for infection
 2nd line – start cyclosporine as alternate to steroids
 If steroids are not working or if causing too many complications or
child has been on it too long
 Seeing that child growth chart is starting to decline or plateau,
might take off steroids and start cyclosporines
 Diuretics
 Given for severe edema
 Severe cases – albumin infusions are given
 Tend to limit fluids initially (with 1st crisis) or with more severe cases (with
subsequent crisis)
 Low salt diet
 Start on low salt diet esp. if on diuretics (not necessarily salt free)
 Try not to use added table salt
 Complications
o Peritonitis from the asities
o Infections  “MOST COMMON COMPLICATION with all of these”
o Cellulitis from facial edema
o Pleural effusions
o Pneumonia
o Can progress all the way to shock
 Prognosis
o 80% of these kids go on to have normal renal function without any type of long term kidney
disease.
 Better in this 80% will early detection and prompt treatment
 2/3 of children will have relapse after they are controlled
 Usually triggered by infection or if they have allergies  asthma
 Asthma is big deterrent in relapses in children with nephrotic syndrome
o Relapse may continue over many years, yet dec. over time
o Once tendency of relapse subsides, child has normal renal functions
 Nursing Care & Teaching
o Teaching
 Especially in early diagnostic phase
 Lifelong, lifestyle change usually for whole family
 Talk about their feelings, how compliant they will be
 Encourage them that they can do this

33
  Most children are treated in hospital but when have a relapse they are treated at home,
clinic visit, or call to nurse to get labs, visit, etc. to make sure it isn’t severe/crisis
 Not necessarily hospitalization all the time
 Home care is preferred even with relapses that are not severe
 Stay away from others who are sick; Infection protection: esp URI
 Vaccinations: Pneumococcal conjugate vaccine (PCV13) & pneumococcal
polysaccharide vaccine (PPSV23 or Pneumovax)
 Measuring urine protein – how to read a urine dipstick – early detection of relapses
 Support family and child- relapsed very taxing on both
o Strict I&O
 Teach how to do this at home
 Fluid restriction usually not indicated unless for short term period & if very severe
o Daily weights – with same scale, same amount of clothes and other things on
o Low sodium diet – consult with dietician
o Urine dipstick testing for protein
o Abdominal growth measurement
o Edema assessment – teach how to assess edema
 Daily weight
 Come in and calibrate scale with ours
 Can input high and low, see trends, etc. with scale
 Abdominal girths – show how to do at umbilical level
 May give parameters for weight gain & girth to call in for appointment
 Signs of advancing edema- teach about pitting edema and how to assess for it
o Vital signs
 When in hospital, signs of hypovolemia, infection, & early signs of shock
 circulatory insufficiency 2nd to hypovolemia) or infection
o Infection protection
 Proper handwashing, sneezing & coughing into crook of elbow
 Stay out of large crowds
o Checking dipstick
 Measuring urine protein at home, how to read dipstick
o Support family & child with each relapse
 With each relapse is always a concern about starting a cycle with more severity & long-
term complications, further kidney disease
Bacterial Meningitis – p. 1372
 Defining terms
o Encephalitis – brain infection
o Meninges – membranes covering brain & spinal cord
o Meningitis – infection of meninges
o Bacterial meningitis: much more serious than viral meningitis
o Considered a medical emergency!!
o Immediate action to identify causative agent and begin prompt tx with abx therapy is essential
o Inflammation of the meninges and CSF
 Etiology – varies with age groups
34
 o Newborns
 Culprit is group B strep
o Children (3 most common causes)
 H. influenza type b (Hib)
 Streptococcus pneumoniae (pneumococcal) 3mo. to 11 yrs.
 Neisseria meningitis (meningococcal) 11 y/o to 17 y/o
 Transmitted by droplet infection of nasopharyngeal secretions
 Can occur in epidemic forms because it is readily transmitted by droplet
infection from nasopharyngeal secretions
 Before the drop in this type of meningitis in school-age and universities, would
often get a piece of paper that said someone was diagnosed, and please be
aware of these certain symptoms & seek immediate medical attention
o Not as often now
 After the Hib vaccine that was introduced in 1990 & pneumococcal conjugate vaccines
in 2000, incidence of decline except from 0-2 months of age
 Because of the causative agent is GBS in that age group
 Characteristics
o Mortality rate = 6.9%
 Because of the meningococcal meningitis
 This percent includes all children
 Highest in age group of newborns to 2 months of age
 Risk increases in child with # of contacts – starting school, living in dorms (school-aged &
adolescents high risk)
 May 2017 CDC recommends vaccination for all preteens 11-12 years and then at 16
years old get a booster
 Hib and pneumococcal conjugate vaccines to children beginning at 2 months of age
 Survivors may experience long term effects: hearing loss, learning disabilities and
seizure disorder
 Pathophysiology
o Organism usually enters meninges through blood stream from other parts of the body (usually
nasopharynx, upper respiratory system area)
 Blood stream carries organism from infected area to meninges
o Less common: from puncture/penetrating wounds (brain trauma causing opening to meninges
or MVA), procedures (lumbar punctures), congenital defects like spina binfida where meninges
are exposed
o Meninges are inflamed, so they start having same s/s of any normal infection of mucosa  “it
starts in the meninges which is the lining of our brain in the CSF”
 Inflammation
 Exudate (pus)
 WBCs accumulation to fight infection
 Varying degrees of tissue damage
 Signs and symptoms p. 1373; Box 46-4
o Infants & young children
 Usually history of URI precedes the symptoms*
35
  3 months to 2 years of age
 Classic presentation rarely seen
 Low grade fever increasing to fever above 100.4
 Poor feeding & vomiting potentially
 Bulging fontanelle
 Nuchal rigidity but hard to tell
 Budinski and Kernig’s not helpful b/c can’t really elicit in these young children
 Major symptoms when bacterial meningitis resulting from Neisseria meningitis
(meningococcal)
 Fever, headache, stiff neck, progression to lethargy, drowsiness, & then coma
 Petechiae – most lethal state of meningitis when petechiae seen
o Medical attention immediately to prevent death
o “1st and foremost think of bacterial men of the worst kind”
 Meningococcemia – sepsis of meninges but also sepsis in the blood
o Older children & adolescents – ONLY WORRY ABOUT THIS CATEGORY
 S/S usually abrupt
 “Usually starts with a febrile sickness like an URI”
 Nuchal rigidity – “they will not want to have neck extension”?
 Spasms of muscles causing backward arching of head, neck, spine as in severe
meningitis (called opisthodomos)
 Positive Kernig’s sign (flex hip to 90 degrees toward trunk, attempt to extend knee and it
will not extend more than 135 degrees (it is positive here), pain felt in back of leg with
child – feeling pain in hamstring)
 Positive Budinski sign (take head at lying position and bring it forward, legs/knees flex
up) – we bring the head up  the knees come up toward the abdomen
 Symptoms
 Low-grade fever starts
 May have n/v, irritability, anorexia (don’t want to eat), headache, photophobia  light
sensitivity, confusion, back pain, neck pain, go to sleep & wake up in morning
nonresponsive
 Diagnosis
o Lumbar puncture is definitive diagnostic test
o Test fluid pressure measured in CSF
o Also obtain cultures for sensitivity
o Gram stain
o Blood cell count
o Glucose & protein counts
o Want to ID causative agent for definitive diagnosis so we can treat – after specimens are
obtained they will start abx. based on sensitivity report
 Cerebrospinal fluid analysis – chart – only know the normal & bacterial ones (don’t crowd ya brain
cells)
o Value: opening pressure
 Normal CSF: 50-180 mmH20
 Bacterial elevated
36
  Viral usually normal
o Value: glucose – will be Low
 Normal: 40-85
 B: marked decrease < 40
 V: moderate increase > 40
 “The lower the glucose the higher the severity”
o Value: protein – will be High
 Normal: 15-45
 B: marked increase > 250
 V: moderate increase > 100
o Value: WBCs – will have high WBC
 Normal: 0-5 for adults & children, up to 30 for newborns
 B: >500 (usually > 1000)
 V: < 100
o Value: culture
 Normal: Sterile
 B: positive
 V: negative
o Complications (depending on exact causative organisms)
 Edema
 Because brain becomes hyperemic (increased blood flow), it becomes
edematous
 Surface covered with pulse & can go into ventricles
 Causing obstruction of flow of CSF
o Medical emergency with early recognition & treatment are necessary to
prevent residual disabilities & death esp. in meningococcal
 Systemic complications
 Septic shock
 DIC – inappropriately clots
o Ischemia, tissue damage , loss of limbs
 RDS – respiratory distress syndrome
 Long term
 CNS involvement – impaired
o Recurrent seizures
 Hearing loss – common after effect & ranges from very mild to profound
deafness
 Treatment
o IV antimicrobial agents
 #1 treatment (IV antibiotics)
 Start them as soon as cultures are obtained – priority
 Don’t wait for sensitivity
 May alter what we give them based on sensitivity, but priority to start antibiotics
after culture is taken
o Isolation precautions
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  From other children in PICU – remember it can be a Droplet infection (resp. isolation)
 Take away droplet isolation after 24 hours of antibiotic coverage
 Nursing care/prevention
o Symptom monitor/relief
 Usually in PICU on CR monitor
 Check s/s of inc. increased ICP
 Fontanels for infants
 Lethargy for older children
 Pain Relief – Acetaminophen with codeine is most often used.
 Give appropriate hydration
 Correct fluid deficits & electrolyte imbalances
 Usually once we correct these, may do fluid restriction so we do not increase ICP
 If ICP already there, have fluid restriction
 Monitor for advancement of complications like RDS in smaller children, shock in older
ones
 Monitoring for advancement of complications:
 Systemic complications, such as disseminated intravascular coagulation (DIC), -
ischemic tissue damage – loss of digits/limb to save life; respiratory distress
syndrome, are usually the consequence of the bacteremia that frequently
accompanies meningitis and shock.
 Decrease stimuli at beginning, emotional support for caregivers
 Quick onset, rapid decline
 Long term: because of the CNS involvement: recurrent seizures and hearing loss is the
most common
o Routine vaccinations – BIGGEST prevention
Seizures
 Definition & Info
o Epilepsy
 When the child has 2 or more seizures
 Don’t have a quick diagnosis of epilepsy
 Does not include those occurring from an acute disease process that will stop when the
child recovers from the illness.
o Seizure is the result of a surge of electrical activity in the brain
 Most common pediatric neurologic disorders
 Most are from febrile seizures
 Seizure is a symptom of underlying disease process – it is NOT the disease
o Usually 1 seizure event is not treated with long term antiepileptic medications esp. if together
with fever
o If febrile seizure,
 Educate parents how to keep fever down
 With any slight infection, teach how to check fever, room temp. baths, cool rags in
axillary & neck region
 Causes p. 1378, box 46-6 resource DON’T need to know causes b/t acute & chronic
38
 o Unknown (#1)
 Sometimes never known & never reoccur
 After a seizure, an optimal prognosis relies on determining the cause if we get to the
epileptic stage (2 or more seizures)
o Acute symptomatic – acute insult: meningitis or head trauma
o Remote symptomatic – no immediate cause yet with prior brain injury – major head trauma,
meningitis, encephalitis, stroke, CP
o Cryptogenic seizures – unknown cause
o Idiopathic seizures – genetic in origin
o Infectious, Neurologic, Metabolic, Traumatic- after MVA, Toxin ingestion
 Types p. 1379-1380, box 46-7 & table 46-3 (more specific, be familiar); review main points of simple &
complex partial seizures, and the absent seizure under generalized classification)
o 1. Partial
 Have a local onset (focal point): Can ID in the brain where seizure stems from; have
location in brain
 Localized motor symptoms
 Most common is aversion (eyes & head turn away from side of the focus of the electrical
discharge in the brain, eyes look away from side that is affected)
 If on left side, child look and turn head to the right
 so turns head and looks to left side means right side of brain affected
o 2. Generalized
 Tonic-Clonic (formally known as Grand mal)
 Most common and occurs without warning
 Involves both hemispheres of the brain & without local onset; radiates (spirals)
o May know where it occurred to begin with but radiates
 See tonic-clonic most common and occurs without warning
 Tonic phase – usually is 10-20 seconds
o Eyes roll upward, arms flexed, legs & head & neck are extended
 Clonic phase – usually about 30 seconds but can vary up to half an hour (30 min.)
o Violent jerking movements as the body and extremities contract and
relax – “so it is like the brain is firing and both sides”
 Absence (Petit mal)
 Brief loss of consciousness, staring off into space
 Often mistaken as daydreaming or inattentiveness
 Less than 15 seconds
o Box 46-7: resource and Table 46-3 – more specific with what you should be familiar with to
have a broad sense of fundamental nursing: reviews main point of simple and complex partial
seizures and Absence seizure under the Generalized classification – tonic clonic with
manifestations – So, none on pg. 1380 – only learn what is most common
o 3. Unclassified (she didn’t go over this one, said only worry about partial and generalized)
 Unknown cause
 Used when seizure cannot be classified as either partial or generalized
 Usually inadequate information about the seizure
 May not have been witnessed
39
  Or unusual nature of the seizure
 Usually older child or adolescent – must rule out drug involvement
 Diagnosis (history followed by EEG)
o Once a child has 2 or more seizures, establish diagnosis of epilepsy – prognosis is better with
proper tx.
o Determine if seizures are epileptic or non-epileptic events and the underlying cause if possible.
o History
 Thorough history of family account of seizure activity
 Hopefully there are witnesses
 What was going on before, what was child doing when it occurred? What was
happening prior to seizure? What happened after it ended?
 How long, when did it stop/start, what types of movements, was there eye
involvement?
 Did they become incontinent?
o EEG – firing of the brain
 confirms the presence of abnormal electrical discharges in the brain and maybe able to
give seizure type and focus (location of brain)
 also identifies those children at risk for recurrent seizures.
 Treatment
o Goal – Control seizures, reduce severity and frequency
 ID cause, assist family and child to know what may preempt seizure & avoid it (triggers)
 “Teach them to live their lives without worrying about a seizure all the time”
 Help the family and patient cope
 If caused by epilepsy  lifelong
 If caused by triggers: Infection/trauma  treatment may be necessary to treat the
cause and then won’t have it as a lifestyle, lifelong problem
Seizure Drug Therapy
o Benzodiazepines / Anticonvulsants
 Reduces responsiveness of the neurons for sudden high frequency surges of nerve
impulses in the brain (reduces electricity in the brain)
 Benzodiazepines – drug of choice to tx. seizures
 Also given for anxiety, panic attacks, depression, insomnia
 Take blood levels to maintain a therapeutic range
o Titrate them according to presence or absence of seizure activity and
severity of seizures
 If reach max dose range for one benzodiazepine, may add a second one
 Names:
 Lorazepam (Ativan)- first choice in seizure control
 Clonazepam (Clonipine)
 Diazepam (Valium) - often used for a sudden seizure. RECTAL normally
 Midazolam (versed) – rarely used
 Phenobarbital (used on occasion in older children, but used most often infants
and newborns seizure drug of choice for them)

40
 Refractory/intractable seizures (drug-resistant seizures): drugs aren’t effective in reducing or
maintaining seizure control, so turn to other
measures….
o Put on Ketogenic diet
 May institute ketogenic diet
 High fat, low carb, adequate protein
 Forces body to burn fats rather than glucose and carbs  starvation mode of body
 Usually if they are not responding to meds  called refractory or intractable seizures or
drug-resistant seizures.
 Child develops state of ketosis there WILL be ketones in the urine
 B/c of this, need vitamin supplements when on this diet
 Initial side effects (short term and expected):
 Diarrhea
 Hypoglycemia
 Dehydration
 Acidosis, that is formed with ketoacidosis potentially
 Lethargy
 Long term:
o Dyslipidemia: increase in cholesterol & triglyceride levels
o Kidney stones
o Poor growth in height & weight with long-term diet
 Weigh benefits vs. risks from side effects of seizures vs. ketogenic diet long-term

o Vagus Nerve Stimulation

 Like pacemaker for the brain
 Surgically implanted device that stimulates left vagus nerve (CN 10) with electrical
impulses
 Implant gives constant impulses to a focal point in the brain, hoping that this constant
surge of electrical forces will cause the brain the slow down elsewhere and not have
sudden surges
 Programed according to each person’s needs
 New devices are programmed with a heart rate range - when it detects this certain
range it will give a bolus
 Activated by person or caregiver at feeling of onset of seizure, or when seizure starts
(run magnet over implant- a magnet that will give a higher-frequency surge)
 There is a basal rate of small surges and abrupt/bolus surges when necessary
 33%-50% effective at reducing seizures after 1 year of having implant – “so it is effective
in most children or adolescents that use it”
 Can input range of HR- device will work when it increases to prevent seizure
 Instead of having erratic brain electrical waveforms, it gets it more consolidated and
makes the seizure more focal instead of widespread thru the brain
 Clonic tonic seizures reduced

41
 o Surgery risks vs. benefits
 removal of the cause: when a hematoma, tumor or cerebral lesion is present and
determined to be the cause of seizure activity
 Most invasive
 May be recommended for refractory seizures for which medications and other
measures don’t work (or don’t want to use other measures like keto)
 Focal resection: when they ID where the abnormal brain activity is that causes the
seizures on an EEG, and remove that area
 Hemispherectomy: removal of all or most of the hemisphere affected.
• Improves quality of life, but there are long-term and permanent residuals
• Ex: paralysis  either partial or complete

Seizures: Status Epilepticus - p. 1383-1386, Box 46-8 & Box 46-9. Emergency Treatment p. 1386
 Seizure activity > 30 mins
 Single epileptic seizure > 30 minutes duration or series of epileptic seizures during which function of the
person is not regained between the ictal events for a 30 minute period
 Person may be conscious, yet they are still confused and not aware of what is going on between each
episode, for those 30 minutes – “they are looking gazed at you”
 The first time point (5 minutes), indicates the earliest time when treatment should be started.
 The second, time point (30 minutes) indicates when long-term consequences such as functional deficits,
are increasingly likely

 Need for Emergency Treatment Initially:

o Support and maintain the vital functions: CAB (circulation, airway, and breathing)
o O2 - can give it without an order if patient is declining or has a seizure
o Antiepileptic agents at high doses (IV Lorazepam is drug of choice at this time)
o 1st episode: 911 is called and they will give high doses of antiepileptics
 Nursing Care During Seizure, or care while in the community:
o Note events preceding onset of seizure:
 What is child doing at onset of seizure; can give history of triggers
o Observe and document events: (during the seizure)
 Time of onset
 How long did it last?
 Body movement descriptions - what is the child doing
 Incontinent during seizure?
o Position child on side
o Make sure airway is patent
o Protect child from injury
 Move objects from nearby (toys, etc.)
o Call for help
o Move others away and isolate child from sight of other kids (very scary)
o Insert rectal antiepileptic agent ASAP
 Nursing Care After Seizure (Postictal state)

42
 o Postictal State (state after the seizure): usually lasts 5-30 mins where child is drowsy, confused,
can get nauseated & vomit, complain of HA & HTN can result – common symptoms after
seizure
o Explain to them what happened if they are cognitively able to understand
o Monitor them
o Depending on how common seizures are for this child, parents may wish that 911 not even be
called
 They will tell you what they do at home, what the red flags are for calling 911
 Same thing if child is at school, may rest in nurse’s office & resume classes in about 30
mins
Box 46-8: Observations during a seizure p. 1383 and 46-9: Seizure Precautions and Emergency treatment box:
p1386

 Febrile Seizures
o Febrile seizure – associated with a febrile illness in a child who does not have a CNS infection
and does not have a history of neonatal or unprovoked seizures
o “Doesn’t have to be a high fever – but it is a spike in a fever – so if they are normally at 98 and
it spikes very fast to even if it’s a low grade”
o Most common seizure type in children between 1 month and 5 years of age
o Most require no treatment
o If continues longer than 5 minutes: treat with IV lorazepam; IV or rectal diazepam or IV, buccal
or intranasal midazolam.
o Antipyretic meds will not prevent a seizure and ineffective at lowering fever that leads to a
seizure  “so a lot of times if the seizure occurs and fever stays high, we want to tx. for the
fever but it may not stop or prevent the seizure”
o Tepid sponge baths are no longer recommended: ineffective, shivering increases metabolic
output and discomfort to the child.
o There is no indication for use of daily prophylactic antiepileptic med for febrile seizures  they
are usually treated acutely and then no more treatment
o Causes:
 Genetic – children with family history are at increased risk
 Environmental – factors include viral illness and age younger than 18 mo. of age

43
 Pediatric Unit 7 Part 1:
Nursing Care of the School Age Child: 6 to 12 years of age

G&D Fifth Disease, Diabetes Mellitus

Readings: Perry et.al: (Course Packet)
- Table 33-3: p. 920 – Fifth Disease
- Chapter 34: pp. 936-952 – Growth & Development
- Chapter 47: pp. 1407-1420 – Type 1 Diabetes Mellitus
Moodle: Fifth Disease – Kidshealth.org website – Resource
Kahoot.it
 Common characteristic of school-age: girls begin to surpass boys in wt. & ht.
 5th disease highly contagious at this point: prior to appearance of skin rash
 Diagnosis of diabetes type 1: 8 hour fasting blood sugar > 126 mg/dl
 Teaching concept for diabetes type 1: no special foods in dietary plan required

Growth & Development – p. 936-937; p. 943-944 Table 34.1

 School Age - AKA Middle Childhood
o Period of gradual growth and development
 Biological Development
o Physical Changes
 Height: grow 5 cm (2 in) per year
 Weight: 2-3 kg (4.4-6.6 lbs) per year
 Nearly double their weight within this period (from beginning of this stage: 6 years, to
end: age 12)
 By end of school-aged years, girls begin to surpass boys in height & weight
o Usually uncomfortable for both sexes
o “Ex: the boy wants to excel in sports but some girls are taller than the boys; but
the girls may feel embarrassed but still tease the boys”
 Although muscle strength increases, they are still immature in functioning compared to the
adolescent
 So, increased muscular injury is common due to overuse
o Especially sports – baseball, injury pitching arm muscles
o They are strong, but not as strong as in adolescence
o Maturation of Systems:
 Stomach capacity is larger
 Caloric needs are less as a result of HR and respirations steadily decreasing during this time
frame  less energy is used/needed for metabolism
 BP increases slowly as child ages (from the 6 y/o to the 12 y/o)
 Immune system is more competent to fight increased exposures of school (infections)
 Physical maturity does not necessarily correlate with emotional or social maturity
 Therefore: bigger kids that look 12 but they’re only 9 or 10, or child that’s 12 that looks 9 or 10 –
“still need to treat them like their actual age”
o Prepubescence – Preadolescence:
 2 year period that begins at end of middle childhood and ends with 13th b-day – enters puberty
 “B/c at 13 y/o – this is when puberty starts”

44
  Puberty may begin around 10 years for girls and 12 years for boys, therefore the period before
this time is considered prepubescence.

o Prepubescence- Preadolescence

 -2 year period that begins at end of middle childhood and ends with the 13th birthday – enters
puberty
 Puberty may begin around 10yrs for girls and 12yrs for boys, therefore, the period before this
time is considered prepubescence.
 Girls  Reliable early sign of sexual maturity is:
 Growth of axillary and pubic hair, which usually precedes menarche by about 2 years
 Start seeing blonde fuzz follicles in axillary and pubic area
 Boys  Little visible sexual maturation during preadolescence phase
 “12 or 13 will start seeing sexual tendencies”
 Psychosocial Development: Erickson Stage 4 – Industry vs. Inferiority
o Stage 4: Industry vs. Inferiority
 Growing sense of independence and want to engage in tasks they can successfully complete
 Acquired skills provide a way to gain success at social activities, sports, group play with peers,
intellect or physical coordination
 Reinforcement through grades, rewards, privileges become an important measurement
socially
 “Earlier in the stage they may not understand the responsibility that comes with the
chores and later in the stage they understand the responsibility and appreciate it”
 Have sense of accomplishment when completing a task, that will lead to more independence
and risk-taking as an adolescent
 Socially adaptable to events going on around them
 Sense of accomplishment is what they’re looking for in everything they do
 If they don’t get it, they may feel inferior to peers
 Reinforced with grades in school, rewards
 Get privileges part of being socially-accepted by peers. If their peers get a privilege, they want
to know what they did to get it
 Begin forming clubs, teams, groups
 Parents’ mindset is still most important to them though
 When not able to master a skill: As adults in their lives, to avoid this sense of inferiority, we need
to say “do your best, and that’s all you can do” and that’s all we ask, and praise if doing their
best (this is healthy development of Industry vs. Inferiority)
 “And ask them “Is this the best you can do? Did you study?”
 Important to give tasks (chores) to this age group that can be accomplished to be successful in
fulfilling a sense of industry – competent!

45
 Cognitive Development:
Concrete Operations
Concept of Conservation
Classification skills
Relational terms
Tell time
 Cognitive Development – Piaget – p. 937-939, Fig. 34.3 “Only Erikson and Piaget” Ability to read

o Concrete Operations
 Able to relate a series of events to mental images and can express them verbally and
symbolically
 Understanding symbols now
o Concept of Conservation
 Changing shape of object doesn’t mean it’s changing mass (or change how big it is)
 Ex: the shape when vertical is the same shape when it is horizontal
 Picture: horizontal object (longer) = vertical object (thinner) – “but they understand they
are the same”
o Classification Skills
 Can group and sort objects according to shared /liked attributes and putting them into
categories. Fine-tuned by age of 12
 “Collecting is big in this age group – they want to do collectables – want multiple of one
type/thing”
o Understand Relational Terms  Darker, heavier, lighter, more than, less than.
o Can tell time - using the hands of a clock and not just digital
 Understand events in relation to time (history)
 Understand locations in relation to space, distance (geography) - how far is our vacation, etc. –
“Ex: When we tell them we are going to BR they understand there will be 45 min to an hour to
get there”
o Ability to read
 Profusely reading now
 “Can read directions”
 Valuable tool to learn on their own to increase their independence
 If they have a question the “why” will disappear because now they have the independence to
learn on their own by reading
Normal Growth & Development -- p. 943-944 Table 34-1 – summarizes G&D during school age years
 Spirituality-family & religious people over peers
o Beliefs and ideals of family and religious people are moved/influential than those of their peers in matter
of faith
o Family and religious people are authority over peers
o May believe illness/hospitalization is a punishment for misbehavior
o But they are starting to listen to their peers and relate/compare to peers’ values
o “They are giving them this fear of I want to be good” and giving them an opportunity to be good and they
want to please and yet, their peers are starting to influence them in a few ways; and if they had impulse
problems they are getting better control”
 Social Development

46
 o Peer groups begin to develop at this stage
o Parents are primary influence
o Start telling secrets
o Develops a sense of belonging to a group other than the family unit
o Lessons learned from peers:
 1. Different view points
 2. Aware of social norms and pressures – “& hopefully how to approach/overcome these”
 3. Form relationships with same-sex peers
o Parents continue to be the primary influence in shaping child’s personality, setting behavior standards and
establishing value systems. If peer pressure overcomes their family values from what they were taught is
when they will deviate from family norms. Normally they will revert back to family values once they are
older. This is a challenging time for parents and youth.

o Family values take precedence over peer values – even when it seems the child rejects in testing value
system of parents (later school age child & adolescence) – usually the child retains family taught values as
they enter adulthood
o School-age children still want and need restrictions and they want controls; this gives them a sense of
security
o “By 11 years old they may think my friend may know more but still listening to the parents but start to test
the parents – Will say “Well Tom’s parents let him stay up till 11 as long as he is studying”

 Social Development

o Understand traditions in the family, codes of ethics - what is and isn’t appropriate socially, initiations into
the group, sense of belonging to group other than family unit
o Begin to gain independence from their parents as school-age years progress, but parents are still the main
influence in shaping child’s personality, setting behavior standards, and establishing the value systems
they are creating
o But they start seeking advice from peer group instead of just going to mom or dad
 Play and Physical Activity
o Sense of belonging
o Involves increased physical skill (coordination), intellectual ability (they know the rules and they don’t
mind the rules), and fantasy at some point in the early stages
o Understands the need for rules
o Develop a sense of belonging to a team, club, cliques and have some benefit w/ appropriate development
o Activities such as beginning collections of unrelated objects then progresses to collectables by end of
school-age years.

o Aware of rules and rituals and understand the need for them
 “boys more in athletic abilities and girl more in intellectual clubs, but still can have a mix”
o Beginning of stage: share same activities yet later differences in gender noticed in play preferences
 “Yet in the end, the differences in gender start to show in how they like to play and socialism”
o Highly active yet can enjoy sitting quietly with computer game (don’t mind solitaire play)
o May begin collections: collecting things, categorizing things
o Boys clicks are about sports and girls are more social.
 Body Image Development
o Influenced by significant others, close familiar members (ex: cousins) and peers they admire
o By the end of school-age, peers’ opinions are starting to come into play
o “They want to be accepted”
o Aware of deviations from the norm, especially if it interferes with their accomplishments
47
  Children with disabilities begin to realize they are different
 Intellect or cognitive delay: wonder why they can’t get it compared to peers
 Ex: weight becomes an issue, if they love basketball and are short
Coping with Concerns – p. 942-946
 School Experience
o Socialization for children outside the family unit
o Enforce standards of conduct
o Most children in this age group understand what school entails and like to go to school (they like school,
like the social aspect and the routine)
o “For the 1st time they are learning to introduce themselves – and depending on how they went through
inferiority vs industry – they may either approach them and say “hey I don’t know you who are you?” or
they may just avoid them”
o Teachers, like parents, enforce good behavior yet have the additional tasks of the child’s intellectual
development

 Discipline -this age group wants discipline, or they will act out to get that attention. (School bus bulling –
parent imposes consequences)
o Serves many purposes for the school-age child
 Assist child to stop a forbidden behavior/action
 Point out a more acceptable way to behave in the situation learning curve for this age group
 Give reason why certain actions are inappropriate, while others are more desirable
 “We need to give cause and effect – if they are going to get in trouble we need to tell them
what will cause the punishment and what to do instead”
 Stimulates child’s ability to empathize with victims of their mis-deeds (Ex: bullying)
 Concern and stress can be created here if home and school discipline isn’t the same
 “Ex: unhealthy fear -- so much fear that they are scared if they don’t do what their parents
want that they don’t know what they are going to do to them but at school they are getting
that nurturing”
 Mistakes are learning opportunities and they must learn from that.
 Stress and Fear
o Recognize signs > Evaluate situation > Educate both parents and child.
 “not enough food to eat, close quarters (extended family and friends living with them), eating
everything on their plate at school and asking other kids if they are going to eat their food?”
o Stress in school or home: Pressure to perform academically when not adjusting to school environment or
questionable home support is often noticed in grades/conduct - requires further evaluation. (ex: kid afraid
to come home after making a B on a test. Or Teachers might compare siblings)
o Fears of previous stage may continue into school age years – “Ex: boogey man fear but usually by the end
of this stage they understand that what they see on tv is not real and fears” Ex: fear of crowds, the dark or
empty rooms.
o “7 year old will say – “are we going to have a tornado?” and going to start having concern about it – they
start hearing what we say and start having a concern about it”
o Teach both parents and child how to reduce tension and anxiety – relaxation techniques, etc.
 “This also helps reduce stress when they get into adolescence years and may not have an option of
suicide” taking a break, imagery, deep breathing and relaxation.
Promoting Optimal Health – p. 946-952, Table 34.2 & Guidance During School Years
 Nutrition
o Caloric intake decreases in relation to body size
o Diet usually based on family habits early on

48
  Ask mom and caregiver what the family is eating, instead of asking child what they are eating (what
are you cooking, do you eat out, what are the meal plans?)
o Even though caloric intake decreases in relation to body size – promotion of a balanced diet is established
during these years -usually based on famly habits.
o Healthier foods in schools and now rules on what type of food brought to school from home for lunch
o Yet, obesity is on a rise within this age group along with Type 2 Diabetes – “esp. at the end of this stage”
 “So we need to start this at the beginning of this stage” beginning as early as 10-12 yo.
 Sleep, Exercise & Activity
o Sleep requirements vary
 Naps stop yet sleep requirements range from 11.5-12 hours at 5 years to 9 hours at 12 yrs.
o Possess the coordination, timing, and concentration to participate in an adult-type of activity
o But they may lack the strength, stamina, and control/coordination of an older aged adolescent
 “So the 7 yr. may want to keep up with their 11 or 12 yr. old but they can’t”
o Become involved in sports, enjoy competition, highly competitive
 Usually highly active yet can enjoy sitting quiet alone with a computer game
 Dental Health
o Beginning of stage: Loss of baby teeth-permanent teeth erupt.
o 6 to 12 years of age: begins with loss of the first baby tooth and ends with obtaining all permanent teeth
except for the wisdom teeth
o Usually independent oral hygiene yet occasional supervision for compliance necessary to prevent cavities
– main oral problem in this age group, may need supervision sometimes to make sure they are cleaning
properly.
o By the end: permanent teeth all present, except for wisdom teeth
o Orthodontic treatment may begin to correct malocclusions of the upper and lower teeth - if they are not
aligning properly (in the upper age group around 10-12) – “remember this is an expense; this is something
we need to look into in our community and this helps with their body image” bills may start coming in
from dentist and orthodontist, age for braces
 Sex Education (continuation of condom story – older brother of friend – make penis larger)
o Sexual curiosity should be viewed as normal to avoid adverse emotional consequences toward sexuality
o “Esp. at the end of this stage” – “make sure you make it as matter of fact”
o Usually visit the MD less so they have less of chance of learning about what happens with their bodies, sex
edu.
 “Need to start educating them so when they are 11 or 12 and they are bleeding and they think they
are hemorrhaging”
 Injury Prevention p. 951, Table 34-2 (know how to prevent these*)
o Family Centered Care Box: Guidance During School years – p. 952
o Number of injuries reduced due to refined muscle coordination and control & reasoning development
o Have a sense of safety now & are coordinated (not falling)
o #1 most common cause of severe injury and death: MVA (motor vehicle accidents) --- “whether they run
out into the street or if they are in the vehicle”
o At the earlier ages of this group they know rules & expected behaviors but they don’t understand the
reasons behind them but know that they need they need to follow rules & what is expected of them
o Older school-age: not only understand reason, yet begin they start to understand concept of “treat others
as you would want to be treated”
o Everyone has morals, teach what is acceptable

Erythema Infectiosum aka Fifth Disease - p. 920 Table 33-3

 E-ri-theme-ma In-fect-tio-sum

49
 Characteristics
o Common & highly contagious childhood ailment causing distinctive rash on face
o Often occurs in outbreaks among school-aged children
o Short term; resolves within days to weeks
o Contagious before rash appears
 Once rash appears, have already gone through contagious stage
 Etiology
o Causative agent  Human Parvovirus B19 – source is infected person
 Mainly in school-aged children
o Human transmission by:
 Respiratory secretions
 Blood or blood products
 Also can cross the placenta (mother to fetus)
 Signs & Symptoms
o Initially
 Has low-grade fever, HA, fatigue/general malaise, sore throat, maybe nausea - they are infected and
contagious at this point
 Enough that parents and caregiver may keep child home or will get call from school
 A lot of times the school will say it’s not above 100.4, so keep them in school
 Normally it’s on day 3 or 4 when rash comes they actually do something about it and go to
doctor; well contagious part is already gone
 “May not want to eat”
o Rash begins 1 week after exposure
 “Child is contagious before rash appears and this is when they are at school”
 3 Stage Rash:
 1: Erythema on face (redness)
o Mainly cheeks  called Slapped Face
o Disappears in 1-4 days
o When rash appears, the child is no longer contagious
 2: Maculopapular red spots
o About 1 day after rash appears these maculopapular red spots (raised bumps) appear
on trunk then extremities
o May last 1 week or more
 3: Subsiding
o Rash beings to subside but can reappear with irritation (sun, heat, hot shower/bath,
cold, friction)
o Can become more noticeable. Sometimes with playing and running around outside
o “So we tell parents to keep kid away from hot showers or heat otherwise it will come
up again”
 Incubation period  time between exposure to agent to infection and appearance of 1st symptom (fever)
o Typically 4 to 14 days but can be up to 21 days
o “Contagious part is when fever starts and ends with rash appearance”
 Duration  short term – resolves 1 to 3 weeks (7-21 days)
 Diagnosis
o Usually by visual inspection only – “and usually with hx. if child comes in with the raised bumps”
 With a history of low grade fever, headache, tired, fatigue, etc. and now rash
o “Child usually comes into doctor’s office with the rash”
o Blood test can test for parvovirus B19 and can tell you whether there has been a recent infection
50
  Usually reserved for people with compromised immune system or pregnant woman(rarely done for
the general population)
 Treatment
o Symptoms & Supportive
 Usually self-treatable-for healthy child no treatment is necessary
 Antipyretics, Analgesics
 For headache or fever: acetaminophen. Increase fluid intake and rest.

 Children can often return to school once the red rash appears since they’re no longer contagious.

 Supportive care if requiring hospitalization (immunosuppressed or aplastic crisis) Droplet precaution

isolation.

 For most healthy children, no treatment is necessary

 May give acetaminophen for HA and fever
 Increased fluid intake and let child rest b/c they’re tired and they don’t want to eat much so
we don’t want them to be dehydrated
 Children can often return to school once red rash appears b/c they are no longer contagious
o Hospitalization  supportive care is required
 Usually required if the child is immunosuppressed or aplastic crisis (this is a form of anemia with the
RBC’s)
 “Leukemia also – if they get the fifth disease they can have severe complications”
 Droplet precaution isolation for these children
 “If they come with a fever, HA and fatigue with leukemia – we will always do an antibody screen and
always think fifth disease”
 Normally the daycares don’t want child at school with rash, but disease is not contagious then. So
parent has to go to Dr. office and get a paper allowing them to go back to school.
 Complications
o Usually minimal
o Aplastic Crisis
o Low risk fetal death
o For children with healthy immune systems -- it is a common, mild illness that rarely presents lasting
consequences
o Children with underlying hemolytic disorders like sickle cell  can develop transient aplastic crisis
(bone marrow stop producing red blood cells)
 Bone marrow failure
 Abnormal decrease in reticulocytes in the body
 Invades and destroys RBC precursors and halts RBC production
 Children with underlying hemolytic disorders can develop transient aplastic crisis from fifth
disease infection
o Low risk fetal death
 If a pregnant mom gets exposed, can lead to fetal death and fetal anemia and hydrops
 “Hydrops  severe anemia in the fetus – RBC’s are not being produced by the mother and
then the fetus too and can produce a stillborn baby”
 Infection during pregnancy can lead to fetal death (fetal anemia/hydrops)
 Know there is higher complications with fetus and with an immunosuppressed child
 Prevention
o Minimize contact with people who are sneezing, coughing, blowing their noses
 “Teach when sneezing use the hook of the elbow”

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 o Wash your hands frequently can help prevent contracting the disease of fifth disease
o For a person with an intact immune system, once you’ve contracted this virus, you are considered
immune for life
o To limit spread among children at home or in childcare setting like a daycare
 Teach workers to wash hands often especially wiping/blowing noses of kids, changing diapers,
before preparing or eating food.
 Don’t let them share food, cups, drinking cups, plates, eating utensils, pacifiers, bottles between
children (in home or day care environment)
o Normally they’ll come in with rash and want to bring them to doctor
 Tell them they aren’t contagious anymore and hopefully we did well with prevention, so the others
don’t have it
 But if you see one slapped face then you will probably see others esp. in large school system;
may give parents notes and tell them to be aware

Diabetes Mellitus -- pp. 1407-1420

 Chronic disorder of metabolism characterized by partial or complete deficiency of the hormone insulin,
hyperglycemia, and insulin resistance
 Most common metabolic disorder in children. Can occur at any age in children
 Peak incidence between 10-14 years of age (40% diagnosed at these ages), and 60% are diagnosed b/w 15-19
years of age.
 School age and adolescence are the higher percentage of ages being diagnosed
 Classifications - according to type
o Type 1 Diabetes** (our focus)
 Characterized by the destruction of pancreatic Beta cells, which produce insulin  this leads to an
absolute insulin deficiency
 2 Forms by cause:
 1. Immune-mediated DM -- results from an autoimmune destruction of the beta cells
 2. Idiopathic -- refers to rare forms of the disease that have no known cause
 A lot of the times it is unknown
 It can be from an auto immune response
 Hereditary disposition
 Cystic fibrosis - we now know that children born with CF are usually diagnosed in their school
age, all the way to young adult years. It is called cystic fibrosis related diabetes (CFRD). It mimics
type 1 and they need to have insulin
o Type 2 Diabetes
 Insulin resistance
 occurs in those who are older than 45 yrs., overweight and sedentary and have a family history
of diabetes
 “It is becoming more common in kids b/c of sedentary lifestyle and obesity”
 More likely in girls (main thing we need to know)
 Body fails to use the insulin properly
 Relative (not absolute) insulin deficiency
 Acanthosis Nigricans -strong predictor to develop type 2 diabetes. (often a stronger predictor of
type 2 than family history)
 Hyperpigmentation of the skin that we see in this group very often esp. if have obesity
 Skin condition characterized by dark, thickened, velvety patches, esp. in the folds of skin (in
armpits & back of neck)

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 o “If a guy has shorter hair we look in the back of the neck and if it is there then we look at
the armpit”
 Can occur with endocrine diseases such as Type 2 Diabetes
 Commonly seen in AA population
 60-90% of these children will develop type 2 diabetes as adolescents or young adults
 Strong predictor of Type 2 Diabetes even more so than family history and heredity/history
(school nurses should be aware of this and screen especially if the child has an increase BMI)
 Diabetes Mellitus Type 1 - p. 1408; Table 47.1* & 47.13*
o Pathophysiology
 Insulin is needed to transport carbohydrates, fat, & protein into the cells to give the cells energy
 If there is a deficit of insulin, then glucose cannot enter the cells & the concentration of the glucose is
left in the blood rises  causing Hyperglycemia
 Increase of serum glucose produces osmotic gradient that causes movement of fluid from intracellular
space to extracellular space  causing Polyuria (increased urination)  which causes Polydipsia
(increased thirst)
 Without the use of carbohydrates for energy, fat & protein stores are depleted  results in weight
loss  which triggers the hunger mechanism  polyphagia-Results in weight loss which triggers the
hunger mechanism
 Reason for our 3 P’s. ^
 If the serum glucose exceeds the renal threshold, then glucose spills into the urine (glycosuria)
 Because glucose can’t enter the cells, protein is broken down & converted to glucose by the liver
(gluconeogenesis)  increases glucose level even more (vicious cycle)
 Resulting in hyperglycemia
 Insulin deficiency =  blood glucose
 Polyuria -  Urination – (ex: a mom may tell you “My son has so many wet diapers”)
 Polydipsia -  Thirst
 Glycosuria – Glucose in urine
 Polyphagia – Excessive hunger – (ex: Mom may say “My son is forever eating but not gaining weight”)
o Refer to p. 1408: Table 47.1 for type 1 Characteristics & Box 47.13 for Clinical Manifestations “don’t worry
about type 2 characteristics in that grid”
o - This increases the blood glucose level even more, resulting in hyperglycemia.
o Refer to p. 1408: Table 47.1 for Type 1 Characteristics and also Box 47.13 for Clinical Manifestations
o Type 1
o Onset  < 20 years of age (peak 10-15 years old); Sudden, abrupt onset
 “Everything going on is good and then all of a sudden something changes”
 Primarily in Caucasian race
 Males more than females (type 2 is females more than males)
 Presenting changes  3 P’s  Polyuria, Polydipsia, Polyphagia
 Usually lose weight and become underweight-
 Tx: Need insulin w/ Type 1
o Ketoacidosis: common w/ Type 1
 Without insulin, glucose is unavailable for cellular metabolism
and the body must choose an alternative source of energy –
primarily fat
 Source of energy = Fat
 Excess fat broken down into fatty acids & ketones in the
body

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 – Source of energy = Fat
– Ketonuria – Ketones in urine
– Ketones in lungs = acetone
breath
 & the excess ketones are eliminated in the: – Ketonemia – Ketones in
o urine  ketonuria blood
– Cellular Death > Coma >
o lungs  acetone breath Death
o blood stream  ketonemia
 Abnormally high concentration of ketone bodies in the blood leads to decrease in serum PH leading to
ketoacidosis (lower pH = acidosis)
 Cellular Death (if not recovered by insulin)  dehydration  electrolyte imbalances (decreased K
level)  increased acidosis  Coma  Death
 Insulin stops this cycle
 DKA – diabetic ketoacidosis – reversed by insulin therapy, correction of fluid deficiency and electrolyte
imbalance
 IVF with added KCl only after the child voids and the serum K+ level is known to be normal or low
o Long- term Complications:
 Generally, the injurious effects of hyperglycemia are separated into 2 long term complications
 Microvascular complications
o Diabetic nephropathy (kidney damage/failure)
o Neuropathy (nerve damage in fingers & toes; this is why we check diabetic feet because
they can’t feel them)
o Retinopathy (eye damage)
o “Usually starts in the 1st 10-15/30 years of diagnosis and this is what we can prevent by
maintaining a certain level in the blood stream – hopefully 80-120”
 Macrovascular
o Coronary Artery Disease (CAD), Stroke, Peripheral Arterial Disease (PAD)
o Develops after 25 years of the disease – also predominant complications of Type 2
Diabetes
 With poor control, vascular changes can occur within 3 years after diagnosis, yet with excellent
control, changes can be delayed for 20 or more years.
o Diagnostic Evaluation: based on any of the following 4 abnormal glucose metabolites
 Diabetic evaluation should be considered in 3 groups of children:
 1. Children who have glycosuria, polyuria, history of weight loss/failure to gain wt. despite good
appetite
 2. Children with transient or persistent glycosuria
 3. Children who display signs of metabolic acidosis, with or without coma – “these are the ones
that will come into ER”
As well as with all cases when glycosuria, with or without ketonuria and unexplained hyperglycemia.
– “Need to do a diabetic workup with these kids”
 When these four thing are present then further investigation needs to take place:
 Glycosuria alone is not diagnostic of diabetes.
 Diagnostic levels:
 1. 8 hour fasting blood sugar > 126 mg/dl
 2. Random blood glucose > 200 mg/dl with classic signs and symptoms of hyperglycemia/the
three P’s (a lot of times this is because of a pre-op when we notice this)
 3. Oral Glucose tolerance Test (OGTT) > 200 mg/dl in the 2 hour sample
 4. Hemoglobin A1C > 6.5
 Remember you can have transient increase in blood glucose levels with some medications, illness &
infection, and trauma

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  If these are not present and we have a reading of any of these that are greater than these
parameters, look at saying the child is diabetic
 It’s like if you’re pregnant: you’re either are or you’re not
o Not borderline anything
o Management of Type 1 DM - p. 1410; Box 47.14* – “only looking at school-aged”
 Replacement of insulin the child is unable to produce
 Dosage of insulin is tailored to each child’s home glucose monitoring
 Done before meals, bedtime, prn. At home and in school
o “May have 3 or 4 shots and we need to tell them the # of times we have to stick them
depends on their levels, the # varies”
 Goal: maintain near normal blood glucose levels between 80-120 as much as possible, while
avoiding frequent episodes of hypoglycemia
o “Ex: If they vomit after getting their insulin injection – we need to watch them for
hypoglycemia”
 Often hard to regulate blood sugar in children because insulin needs are affected by emotions,
nutritional intake, activity, growth, puberty, illness – a lot of this is going on within this age
group.
o Insulin requirements might be different for a girl starting menses, we need to monitor
 Blood Glucose Monitoring pg 1410 Box 47.2*(only worry about the 6-12 age group) for Plasma blood
glucose and hemoglobin A1c goals – school age child only.
 Self-monitoring of blood glucose is taught to children and their parents soon after diagnosis
 Normal range is 80-120mg/dL, yet goal range varies by child’s age, time of day and other factors
such as illness.
o “Might say we want it to be above 100 but not over 140”
 Continuous subcutaneous blood glucose monitoring is now available with a wireless monitor,
which alarms with increased & decreased trending of glucose levels
 Now, can communicate with insulin pump
 Glycosylated Hemoglobin (Hemoglobin A1C) Levels: assesses the control of the diabetes
 As RBCs circulate in the bloodstream, glucose molecules gradually attach to the hemoglobin
molecule and stay there for the life of the red blood cell (approximately 120 day life span) (this
range will let us know the last 2-3 months of glucose).
o This attachment is not reversible
 So the Hgb A1c reflects the average blood glucose over the previous 2-3 months.
 Goal for diabetic school-age children is a HgbA1c < 8% - which is slightly elevated but
acceptable because children with type 1 DM are susceptible to hypoglycemia.
 We want to manage glucose to where it is not to high and not too low. If A1c is low we need to ask
how many episodes of hypoglycemia have they had in the past few months.
 Nondiabetic range is 4-6%
 (if child is nauseated and can’t eat=hypoglycemia, often times insulin was given and not enough carbs
were eaten)
 Urine Testing – no longer used for diabetes management
 Urine testing for ketonuria is still performed using the glucose oxidase tapes – test for ketones
not glucose now – use (Keto-Diastix)
 Insulin Therapy
 Insulin dosing is specific to each child based on their individual home blood glucose monitoring.
 Goal: maintain near-normal blood glucose values and avoiding frequent episodes of
hypoglycemia with the least amount of insulin given to child as possible

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 Attempt to mimic our own body’s release of insulin to the blood glucose levels: our body
naturally maintains a steady level of insulin and releases a bolus in response to nutrient intake.
(we want to give a baseline as well as boluses when they eat, best way to mimic the body’s
natural production)
 Preference to have a twice-daily injection regimen, however multiple daily injection regimen
reduces microvascular complications.

o -Before breakfast and evening meal of rapid/short-acting (with meals) and

long/intermediate-acting (daily maintenance/baseline)

o - Requires a minimum of 4 blood glucose checks per day

o - Insulin needs vary according to child’s activity level, eating habits, growth spurts and
illness

 Methods of Administration:
o 1. Subcutaneous insulin injections-insulin pen
 Injections – 2 or more injections per day
 Preference to have a twice-daily injection regimen, however multiple daily
injection regimen reduces microvascular complications.
o Before breakfast and evening meal of rapid/short-acting and
long/intermediate-acting dose to have that basal rate in body
o Requires a minimum of 4 blood glucose checks per day – “tell them at
least 4 and maybe more if you are feeling funny”
o Insulin needs vary according to child’s activity level, eating habits, growth
spurts and illness
 Now we have insulin pens – can set the amount of insulin in the pen and then
inject themselves with it
o 2. Continuous Sub-q Infusion using a Portable Insulin Pump
 Also available : continuous subcutaneous blood glucose monitoring – transmitter -
wireless monitor alarms with increase or decrease trending of blood glucose –
Dexcom

 Recommended to test blood glucose level periodically or when unstable/erratic.

 Closely imitates release of insulin by pancreas; insulin injected subcutaneously

 Continuous dose (basal rate) and bolus dose – give on demand before meals and
high blood glucose levels
 Most pumps use rapid-acting insulins
 Child still needs to check CBGs & program the pump to deliver a bolus insulin dose
before a meal
 “Carb counting – so many carbs requires so much insulin”
 Tubing and needle need to be changed every 72 hours, but some models can last
up to a week
 Can get expensive
 Needs to remain connected at all times & according to the company you can be
off your pump for about 1 hour, can swim with it (waterproof)
 3.) Insulin pump
 - Closely imitates the release of insulin by the pancreas: continuous dose (basal rate) and
bolus dose – given on demand for meals and high blood glucose levels.

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  - Injected through a catheter and sub q needle

 - Most pumps use rapid-acting insulins.

 - The child still needs to check CBG’s and program pump to deliver a bolus insulin dose
before each meal.

 - Tubing and needle need to be changed every 72 hours; some models last for one week.

 - Requires compliance, commitment and can be expensive

 - Needs to remain connected all the times or only off for no longer than an one hour (is
waterproof for swimming)

 Latest and greatest: Artificial Pancreas or closed loop system: Medtronic

o System consists of a continuous glucose monitor (CGM) that measures the user’s glucose levels for up
to seven days, an insulin pump that delivers insulin to the user, and a glucose meter used to calibrate
the CGM.

o Insulin independence would not be achieved using this method, but it would help to reduce variability
in blood glucose readings (a major factor in avoiding diabetic complications).

o Reviews on it are up & down

o All have different onset, peak time, duration depending on insulin needs
o Insulin pump continuously monitors glucose (IGM) and not only monitors
insulin but gives glucagon as well
o “Has an update every 24 hrs.”
o Measures the user’s glucose levels for up to seven days, an insulin pump
that delivers insulin to the user, and a glucose meter used to calibrate the
CGM.
o Its response is real-time to adjust out of range blood sugars
o insulin independence will not be achieved using this method, but it can
help reduce variability in blood glucose readings
 It’s the trending of the glucose in your system going high or low or
always being high or always low that causes complications
 Want to prevent these complications by maintaining a regular level,
keeping it at a set range
 This system (artificial pancreas) promotes this
 4 Main Types of Insulin: Box 47.14* p. 1410 “know 4 types and know where their
peaks are and how they act”
o “A lot of these come in pens and are color coated so we need to teach the
kids the colors”
o Rapid-Acting: Lispro [Humalog], Aspart [NovoLog]
 Reaches blood within 15 minutes
 Peaks 30-90 minutes and lasts about 5 hours
 Usually is what is put in a pump – we can regulate this type of
insulin
o Short-Acting: Regular [Novolin R]
 Reaches blood within 30 minutes – “need to make sure you eat
something within 30 minutes after giving injection”
 Peaks 2-4 hours
 Lasts 4-8 hours
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 o Intermediate-Acting: NPH [Novolin N]
 Reaches blood 2-6 hours
 Peaks 4-14 hours
 Lasts 14-20 hours
o Long-Acting: Glargine [Lantus]
 Can’t be mixed with other insulins
 Takes 6-14 hours to begin working
 Has no peak, or minimal peak 10-16 hours after injection
 Lasts 20-24 hours.
 “Teach if they take it every evening it needs to be at the same time
and even if they take it every 12 hours they need to take it at the
same time”
o Premixed Insulins (Novolin 70/30) – Intermediate and short acting/rapid
acting mixed together – cannot adjust either one – not commonly used in
pediatrics.

o Nutrition
 No special foods or supplements are needed
 Carb counting
 Normally we do carb counting and increase fibers with meals to decrease the rise in blood
sugars (fiber will decrease rise in blood sugar)
 Want to promote healthy, balanced diet
 They learn quickly how to manipulate their diet so on occasion they can have what they want
 For this child we want them to eat their dessert with their meal
 1200 calorie diet is trending out now - consistency is key
 Concentrated sweets are discouraged esp. if eaten alone without protein or complex carb (simple &
complex CHO, protein)

 Timing of food consumption must be regulated to correspond with insulin administration

 Need consistency of diet -- enhances normal CBGs
 Consistency of how many carbs they each every day for each meal (ex: 90 grams of carbs for
every breakfast)
 Teaching body regular intake so it can adjust
 Challenging with sleepovers, etc.
 Extra food when active --- w/ increased activity
 At school, right before recess may need a cracker and cheese snack
 Sports (athletic practice) may need to eat before
o Exercise
 Encouraged, but may need snack to avoid hypoglycemic episodes
 Exercise can lower overall blood sugar levels and insulin requirements
 Also know that stress or infection can increase glucose
 An abrupt, sudden scare will drop sugar dramatically (Halloween, car crash)
 Lowers overall blood glucose levels
 Avoid hypoglycemia (may need a snack before to prevent hypo)

o Illness/Hospital Management
 Goals: maintain blood glucose within established range, treat urinary ketones, maintain hydration – to
flush out ketones.

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  Hard to control stable blood glucose levels when ill – usually remain elevated – will need more insulin
temporarily. Vomiting? - Risk of Hypo- or Hyper- glycemia?
o Hypoglycemia pg 1411-1412
 Episodes expected
 Occasional episodes expected with insulin therapy, so we need to teach moms, parents,
caregivers. Must tell them there is nothing wrong with these episodes happening. They aren’t
doing anything wrong
 Goal: reduce frequency of these episodes
 Usually before meals or when insulin is peaking –”If it peaks at 2-4 hours. They need to know not to do
exercise at this time”
 Need to know insulin onset and peak times of what insulin they’re taking
 Rapid acting (peaks from chart on moodle)
o Insulin glulisine (Apidra)- 1 hour
o Insulin Lispro (Humalog)- 1-1.5 hours
o Insulin aspart (Novolog)- 1-3 hours
 Short acting
o Insulin injection SQ (Novolin R, Humulin R U-500, Humulin R)- 2-4 hours
o Insulin IV (regular insulin only)- 15-30 minutes
 Intermediate acting
o Isophane insulin suspension (Novolin NPH, Humulin N)- 4-12 hours
 Long-acting
o Insulin glargine (Lantus) - Plateau
o Insulin detemir (Levemir)- 3-14 hours
 Signs and Symptoms
 Weakness, dizziness, tremors, nervousness, pale, sweaty, palpitations, HA, hunger, irritability
(emotions), drowsiness, loss of coordination, cannot talk sensibly
 hunger, headache, irritability, nervousness, dizziness, - tremors, sweating, weakness,
drowsiness, loss of coordination, cannot talk sensibly, palpitations.

 If severe, can lead to seizures & coma

 Sometimes hard to differentiate between hyperglycemia- need to check CBG. If unsure treat as
if hypoglycemic then check CBG to confirm.

 If unsure treat as if hypoglycemic

 Sometimes hard to differentiate between hyper and hypoglycemia, so we need to check the
CBG and see what’s happening. If unaware, treat as hypo then check CBG
 “B/c if it is really hypoglycemia and we treat it as hyperglycemia, we can put them into seizures”
 Treatment for Hypoglycemia:
 Give 10-15 grams of simple carb (juice, milk, candy, glucose gel, sugar tabs, cake icing)
o So go ahead and treat like hypo then check and see
o This is like short-acting insulin
o “Glucose gel is absorbed very quickly and can be put into the mouth”
 Always follow simple carb with complex carb (bread, crackers, protein like PB or milk)
o Helps maintain glucose level
o Avoids a big spike and residual effect of going down again (drop)
o This is like long-acting insulin
 Recheck CBG as early as 10 or 15 minutes after you give it to see if it’s going in right direction
(may have only gone up 2 or 3 points but at least we know we are having an effect)

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  Treatment for Hypoglycemia:

 If unconscious or incoherent and unable to consume a simple sugar, an emergency glucagon

injection should be injected . (glucagon is a hormone that stimulates the release of glucose from
the liver) side effect: nausea and vomiting.
o Stimulates glucose from liver
o Works like the simple sugar but occurs within the body
o N/V side effect that lasts until the glucagon gets out of their system
 Have parent always carry some form of sugar to give quickly if needed
 Monitoring effectiveness of treatment
 Need to see how insulin regimen and meal times/planning are working; check:
o Hyperglycemia:
 Most often occurs in the morning hours for 2 reasons:
 1. Dawn Phenomenon – gradual decline of insulin with a progressive rise in blood sugar from
bedtime to sunrise – usually after 3am
o Treated by increasing the nighttime insulin dose – “usually the intermediate or long-
acting”
 “If q24 we will start it at night”
o “And if they are having an increased level during the day (an increased basal rate CBg) –
then we will add the every 12 hours and start with a morning dose”
 2. Rebound Hyperglycemia (Somogyi Effect) – elevated blood glucose level at bedtime - There
is a drop in blood glucose around 2am which triggers hormones to be released that counteract
the remaining insulin in blood and elevated blood sugars result in the morning.
o Usually happens with too much insulin with nighttime dose or skipping bedtime snack.
o Treated by decreasing the nighttime insulin dose and/or consistently providing a bedtime
snack.
o “Will wake them up and see what the body is doing esp. if they have a pump”
o “Can manage symogyi effect very effectively with a pump”
o Type 1 DM Management – p. 1413-1420, Table 47.4
 Support with Diagnosis
 Before parents or caregivers or child can effectively learn what to do with diabetes, first must let
them vent their feelings about the diagnosis and once somewhat accepting then education can
begin.
 Many organizations assist in education w/ resource available to families
 Talk about their fears
 Everyone needs to learn; family affair - but don’t rush in, they need to somewhat accept the
diagnosis first
 Education
 Medical Identification  ID bracelet/chain or card in wallet
 Meal Planning
o Diet --- dietician/nutritionist, diabetic educator and as nurses we are just assisting them
o Adequate intake for age, consistent menus & eating times, complex CHO and CHO
counting/serving sizes
 “Ex: 1 slice of bread is 1 carb”

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 o Reading labels; sugar-free foods doesn’t mean no sugar (if eaten in access it can cause
diarrhea) – “could have other forms of sugar so they need to read the labels like the
carbs” – and then do how much sugar based on how many calories it is” means CHO free
o How to count carbs, size - must become a mini nutritionist
 Traveling  prepare supplies needed with extra quantity, time zones – “keep bag”
o “If going on plain  need a doctor’s note to be able to have needles on plane”

 Self-administration of Insulin/CBG checks

o When to check blood sugar, how to administer insulin, onset
o Rotate sites, absorption rates
o Mixing the insulin - clear (regular) before cloudy
o If they start on oral agent first, what should they look for advancing to injections (give
insight about what their future is potentially)
o At about age 9 they can usually give their own insulin
o At about age 4-5 they can learn to do their own CBG checks
o Always have two people check, even at home
 Signs & symptoms of hypo/hyperglycemia
o Teach signs and what to do (how to treat it)
o Treat like hypo if you don’t know
o Carry glucose tabs, insta-glucose gel, lifesavers at all times; glucagon ER kit
o Administration of insulin
o CBG checks
o How to work monitor
o When to check
 Hygiene  includes nails, foot care, eye and dental care
 Record Keeping  most valuable tool in effective management (#1 thing) – know hx.
o “What time it was, what you ate, how many carbs and how much insulin given”
 School considerations
o Meals, management and emergency treatment
o Work closely with school nurses
o This is another point with chronic illness that mom and caregivers become experts with
time
 They will know triggers, meal planning, what to do to avoid hypoglycemic
episodes, and how much insulin is needed with meals
 Noncompliance
o Be aware of potential noncompliance esp. in school-aged child and adolescents (peer
pressure, etc.)
o Explain to parents they will try things like taking pump off at night

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