Pathophysiology
Airway stimuli result in spasms and edema of the bronchi and bronchioles with increased production and viscosity of mucus. Air is trapped distal to the resulting obstruction. Alveolar gas exchange is impaired. There is a familial predisposition to asthma.
Possible Causes of Acute Exacerbation
- Respiratory infection
- Allergens
- Respiratory irritants such as smoke, dust, or cold air
- Exercise
- Emotional stress
Signs and Symptoms
Medical Treatment
- Bronchodilators (such as Albuterol)
- Epinephrine
- Corticosteroids
- Expectorants
- Antibiotics if infection is present
Nursing Diagnoses
- Ineffective airway clearance
- Impaired gas exchange
- Activity intolerance
- Anxiety
Nursing Implications
- Wash hands before and after care
- Monitor vital signs and report marked changes
- Monitor oxygen saturation (O2 sat)
- Monitor oral intake
- Monitor hydration
- Encourage oral fluid intake
- Administer ordered medications and monitor for side effects
- Monitor IV fluids type and rate
- Administer prescribed medications and monitor for side effects and adverse reactions
- Auscultate respiratory sounds, listening for failure to move air and for adventitious sounds
- Report change in intensity or duration of breath sounds
- Plan care to allow for uninterrupted periods of rest
- Educate regarding avoidance of exacerbations and known triggers
Prognosis
About half of children will outgrow exacerbations. Persistent asthma may lead to development of chronic obstructive pulmonary disease (COPD).
Pathophysiology
Swelling of the small airways leads to hyperinflations distal to the obstructions. Resultant pneumonitis and patchy areas of atelectasis may be present. Most common in children younger than 2 years. Prematurity increases the risk for condition.
Possible Causes
- Respiratory infection
- RSV infection in most cases
- Adenovirus
- Parainfluenza virus
Signs and Symptoms
- Barrel-shaped chest
- Retractions
- Nasal flaring
- Tachypnea
- Cough
- Wheezing (mimics asthma)
- Anorexia
- Fever
Medical Treatment
- Supportive and typically managed at home
- Severe cases may require hospitalization and the following therapies:
- Supplemental oxygen
- IV fluids
- High-humidity, cool mist air
- Bronchodilators
- Corticosteroids
- High humidity air (croup tent)
- Supplemental oxygen to maintain SaO2
95% - Increased fluid intake at 1½ times maintenance (see Pediatric Fluid Calculation)
Nursing Diagnoses
- Ineffective breathing pattern
- Ineffective airway clearance
- Impaired gas exchange
- Potential fluid volume deficit
- Anxiety
Nursing Implications
- Hand washing is the most effective prevention against RSV and its spread
- Suction as needed
- Monitor and maintain hydration
- Monitor oxygen saturation
- Provide supplemental oxygen if indicated
- Pregnant women should be warned that RSV may be teratogenic
- Educate all visitors regarding hand washing
Prognosis
Normal lung function is usually recovered after several weeks. Lung problems may persist for years. There is an increased incidence of asthma.
Croup (Laryngotracheobronchitis)
Pathophysiology
Inflammation and spasm of the larynx, trachea, and bronchi.
Cause
Viral infection, usually parainfluenza, but may also be caused by RSV, influenza, or bacterial infection.
Signs and Symptoms
Seal-like barking cough and inspiratory stridor, x-ray may show narrowing of the trachea (subglottic) or the “steeple sign.”
Medical Treatment
- Hydration
- Humidified air
- Corticosteroids
- Oxygen
- Racemic epinephrine
Nursing Diagnoses
- Ineffective airway clearance
- Fluid volume deficit
- Fear
Nursing Implications
- Wash hands before and after care
- Close monitoring of vital signs
- Monitor respiratory effort
- Monitor oxygen saturation (pulse oximeter)
- Keep environment calm
- Ensure adequate fluid intake
- Explain all procedures to family
- If possible, allow a parent or caregiver to room in with child
Prognosis
- Good with prompt treatment
Cystic Fibrosis
Pathophysiology
Inherited autosomal recessive disease of the lungs, pancreas, urogenital system, skeleton, and skin. Mucus secretions are thick, leading to respiratory infections, poor food absorption, and constipation. Excess salt is lost via sweat. There is progressive lung dysfunction.
Diagnosis
- Physical exam, review of symptoms and several tests
- Sweat chloride
- Newborn screening
Common Causes of Acute Illness
- Respiratory infection
- GI malfunction such as constipation
Signs and Symptoms
- Nasal polyps
- Failure to thrive
- Voracious appetite
- Dyspnea, cough
- Excess salt in sweat
- Thick mucus secretions
- Frequent respiratory infections
- Bulky, foul-smelling stools
- Constipation
- Meconium ileus (failure to pass meconium) in newborns
- Rectal prolapse
Medical Treatment
- Annual influenza immunization
- Pneumococcal vaccination
- Oral pancreatic enzymes
- Antibiotics during infections
- Anti-inflammatory medications
- Mucus thinning agents
- Bronchodilators
- Stool softeners
- Acid-reducing medications
- Transmembrane conductance regulator modulators
- Humidified air
- Chest physiotherapy (percussion and postural drainage)
Nursing Diagnoses
- Ineffective airway clearance
- Potential for infection
- Altered nutrition, less than body requirements
- Risk for electrolyte imbalance
- Risk for constipation
- Knowledge deficit
- Fear
- Diversional activity deficit
- Sleep pattern disturbance
Nursing Implications
- Wash hands before and after care
- Administer medications and monitor for side effects
- Note: Frequent and prolonged use of antibiotics may decrease intestinal bacterial synthesis of vitamin K and impair blood clotting
- IV fluids as ordered
- Ensure compatibility of IV antibiotics
- Encourage oral fluid intake
- Plan care, including chest physiotherapy, to allow for uninterrupted periods of rest
- Plan chest physiotherapy so that it does not occur near meal times (cough and mucus expectoration may decrease appetite)
- Offer extra snacks with salt to taste; as a result of poor food absorption, extra calories are needed
- Referral to support groups
Prognosis
Average life span is 35 years. Males generally survive longer than females.
Pathology
Children have less body fluid reserve than adults and have a larger body surface area that allows more fluid to be lost through perspiration. The GI tract is proportionately longer in children, leading to relatively greater fluid loss. Immature kidneys mean that a child is less able to conserve electrolytes. In early dehydration, fluid loss is both intracellular and extracellular. In chronic dehydration, fluid loss is predominantly cellular. Fluid loss may result in shock, acidosis, or alkalosis, kidney and brain damage, and death.
Common Causes of Dehydration
- Viral or bacterial infection that results in vomiting and/or diarrhea
- Extensive burns
- Diabetic ketoacidosis
| Severity of Dehydration | Assessing for Dehydration |
|---|---|
| |
| Mild |
|
| Moderate |
|
| Severe |
|
Medical Treatment
May include the following:
- Oral rehydration solutions (ORS)
- IV fluids and electrolytes if fluids cannot be ingested or retained
- IV fluid formula:
- First 8 hours = maintenance fluids + half the estimated fluid deficit. Use 1 kg of weight loss to represent 1000 mL of fluid loss (see Pediatric Maintenance Fluid Calculation)
- Next 24–48 hours = maintenance fluids + remaining estimated fluid deficit is added to maintenance fluid
Nursing Care
May include the following:
- Wash hands before and after care
- Weigh on admission to estimate severity of dehydration (see table)
- Continue to assess hydration status, e.g., turgor, mucous membranes
- Wear gloves when changing diapers
- Adhere to ordered feeding type and times
- If oral feedings induce vomiting most of ingested fluids, or if volume of stools is increased with feeding, notify physician so that IV fluids may be initiated or appropriate rate of IV flow may be determined
- Monitor IV fluids type and control appropriate rate of flow
- Note: Potassium (K+) is not added to IV fluids until after the child voids (voiding indicates presence of kidney function)
- Assess and record size, color, and consistency of all vomitus and stools
- Weigh diapers using gram scale (subtract weight of dry diaper)
- 1 gram in wt equals 1 mL of urine or liquid stool
- Goal is to achieve 0.5 to 1 mL/h urinary output for each kilogram of body wt
- Keep diaper area clean and inspect for skin breakdown with each diaper change
- Be aware that in children blood vessels adapt quickly to intravascular fluid loss, so decreased blood pressure is not a reliable indication of early shock in young children
- Communicate to family and other caregivers that the nurse needs to be made aware of all elimination
- Educate all visitors regarding hand washing
- Notify physician of acute change in condition
Prognosis
Good with rehydration.
Diabetes Mellitus (DM)
Pathophysiology
A group of syndromes characterized by the inability to metabolize carbohydrates.
- Type 1 DM is caused by autoimmune destruction of the insulin-secreting cells of the pancreas and results in failure of the pancreas to produce insulin
- Type 2 DM may result from insufficient insulin production and/or body cellular resistance to the effects of insulin; excess body weight increases the risk for type 2 DM
- Diagnosis requires at least one of the following: If a diagnosis of Diabetes is suspected, the child will be given 2 different tests on separate days to confirm diagnosis. Additional testing may also be required to distinguish between Type 1 or Type 2.
- Fasting plasma glucose level exceeds 126 mg/dL on two occasions
- Random glucose levels exceed 200 mg/dL
- 2-hour oral glucose tolerance test is 200 mg/dL or higher
- Glycated hemoglobin (A1C) test of 6.5% or higher on two separate tests
Signs and Symptoms
May include the following:
- Hyperglycemia
- Polydipsia (excessive thirst)
- Polyuria (excessive urination)
- Polyphagia (excessive hunger)
- Anorexia (loss of appetite)
- Weight loss (type 1)
- Ketones in urine
Medical Treatment
May include the following:
- Medications that replace insulin, stimulate insulin secretion, or decrease insulin resistance (given acutely in the hospital as IV therapy, subcutaneously, or delivered through a pump that is worn continuously by the patient)
- Monitor for complications
- Monitor blood glucose and A1C
- In patients with type 1 diabetes, regular laboratory testing for other autoimmune conditions, e.g., Graves’ disease and celiac disease, or genetic testing
- Regular dilated eye examinations
- ACE inhibitor for blood pressure and to preserve renal function
Nursing Diagnoses
May include the following:
- Refer to American Diabetes Association guidance by typing ADA Child Diabetes 2020 in the search box
- Altered nutrition, less than or more than body requirements
- Unstable blood glucose
- Alteration in elimination
- Potential fluid volume deficit
- Fatigue
- Risk for infection
- Knowledge deficit
- Multiple psychosocial diagnoses
Nursing Implications
- Wash hands before and after care
- Monitor blood glucose
- Monitor for the following:
- Signs of Hypoglycemia—low blood sugar
- Signs of Hyperglycemia—high blood sugar
- Blurring of vision
- Drowsiness
- Frequent urination
- Polydipsia
- Signs of Ketoacidosis—(most common in patients with type 1 diabetes) when the body does not have enough insulin to use glucose or if insufficient glucose is consumed for energy, it may respond by burning fat for energy; fat breakdown results in ketones, which are acids, building up in the blood and appearing in the urine; ketoacidosis can result in diabetic coma and death
- High level of urine ketones
- High level of blood glucose and urine ketones
- Vomiting when urine ketones are high
- Abdominal pain
- Fatigue
- Dry or flushed skin
- Respirations that are short and shallow, followed by respirations that are deep and labored (Kussmaul respirations) as body attempts to “blow off” CO2
- Fruity odor on breath
- Confusion
- Signs of Hyperosmolar Nonketotic Coma—(most common in type 2 diabetes) occurs most often when the patient is stressed or ill with an infection or after a myocardial infarction or other illness; insulin deficiency leads to elevated blood glucose that may result in diabetic coma without ketosis (fat breakdown); this is different from diabetic ketoacidosis in which there is no insulin
- Polydipsia (excess thirst)
- Polyuria (excess urination)
- Dehydration
- Shock
- Thoroughly assess feet, including soles and between toes
- Assess hydration
- Teach patient and family regarding:
- Diet
- Monitoring of blood glucose
- Signs, symptoms, management of hypoglycemia
- Importance of regular exercise
- Signs and symptoms of infection
- Foot care
- Compliance with medical regimen
- Medication side effects
- Importance of eye exams
- Home blood pressure monitoring
- How and when to check for ketones
- When to contact the health-care provider
- Teach signs of hypoglycemia and hyperglycemia and treatment of each
- Provide encouragement and emotional support for patient and family
Prognosis
Varies with type of diabetes, age of onset, compliance, and complicating factors. Poor glucose and blood pressure control increase the risk for complications and early mortality. Excess body weight increases the risk for complications in patients with type 2 diabetes.
Pathophysiology
Inflammation of the meninges (covering) of the spinal cord and/or brain, usually caused by an infection, either viral or bacterial.
Usual Causes
- Infection
- Viral
- Bacterial (bacterial meningitis is a medical emergency that may result in death if not quickly treated with antibiotics)
- Fungal
- Parasitic
Signs and Symptoms
May include the following:
- Fever
- Vomiting
- Headache
- Nuchal (neck) rigidity to flexion
- Positive Kernig sign (see Assessment of Acutely Ill or Hospitalized Child)
- Positive Brudzinski sign (see Assessment of Acutely Ill or Hospitalized Child)
- Irritability
- Photosensitivity
- Seizures
- Bulging fontanel in infants
- Altered mental status
- Purpuric rash may be associated with Neisseria meningitidis
Medical Treatment
May include the following:
- IV antibiotics
- IV dexamethasone
- Antipyretics
Nursing Diagnoses
May include the following:
- Pain
- Sensory perception alteration
- Risk for ineffective cerebral tissue perfusion
- Hyperthermia
- Risk for trauma/suffocation (related to alternations in consciousness and risk for seizures)
Nursing Implications
May include the following:
- Frequent vital sign and neuro checks
- Administer medications as ordered, including prn medications for fever and discomfort
- Monitor for side effects and adverse reactions to medications
- Assess compatibility of IV medications
- Monitor I&O—watch for signs of inappropriate secretion of antidiuretic hormone (ISADH) caused by excess release of diuretic hormone (vasopressin) from the posterior pituitary, which may result in hyponatremia and fluid overload
- Prevention of bacterial meningitis by encouraging routine immunization for Haemophilus influenzae (Hib) and pneumococcus (Prevnar) (use of this immunization has also resulted in a decrease in the incidence of epiglottitis)
- Airborne or droplet precautions are indicated for 24 hours after antibiotic medications started
Prognosis
Varies depending on type and age of child; brain damage and hearing impairment may occur; bacterial meningitis has a mortality rate of 10% to 40%.
Pathophysiology
Infection and inflammation of the lungs lead to alveolar edema that promotes spread of the infecting organism. Solidification of the infected lobe(s) is caused by exudates (referred to as consolidation in radiology reports).
Usual Causes
- Aspiration
- Fluid stasis
- Infection
- Bacterial
- Viral
Signs and Symptoms
May include the following:
- Fever
- Chills
- Cough
- Dyspnea
- Tachypnea
- Tachycardia
- Chest pain
- Rales and crackles
- Increased fremitus
- Egophony
- Dullness on percussion of affected lobes
Medical Treatment
May include the following:
- Prevention via pneumococcal vaccination for children with chronic respiratory illnesses
- Antimicrobial agents
- Supplemental oxygen
- Incentive spirometry
- Hydration
- Arterial blood gas (ABG) assessment
Nursing Diagnoses
May include the following:
- Impaired gas exchange
- Ineffective breathing pattern
- Hyperthermia
- Fluid volume deficit
- Pain
- Anxiety
- Knowledge deficit
Nursing Implications
May include the following:
- Wash hands before and after care
- Encourage prevention via pneumococcal vaccination for children with chronic respiratory illnesses
- Monitor vital signs
- Monitor ABG reports and notify physician of significant change
- Administer antibiotics and monitor for side effects
- Administer prescribed analgesics with attention to respiratory response
- Encourage coughing and deep breathing
Prognosis
Varies depending on cause, age of child, coexisting illnesses, and complications.
Sickle Cell Crisis
Pathophysiology
Sickle cell disease is an autosomal recessive disorder. About 1 in 12 African Americans in the United States carries the gene. Normal hemoglobin is partly or completely replaced by abnormal hemoglobin. Under conditions of dehydration or decreased oxygenation or infection, increased numbers of red blood cells (RBCs) assume irregular shapes (some are sickle shaped). Fragile, sickled cells are poor transporters of oxygen. Sickled cells easily become enmeshed with one another, resulting in early cell destruction, clogging of small blood vessels, and tissue necrosis. “Pain crisis” or vaso-occlusive crisis occurs. Organs such as the liver, spleen, kidneys, and brain may be damaged.
Signs and Symptoms
May include the following:
- Hemoglobin S in blood
- Anorexia
- Increased susceptibility to infection
- Delayed growth or puberty
- Pain—frequently in the abdomen
- Anemia
- Swelling of hands and feet
- Vision problems
Common Causes of Hospital Admission
- Infection resulting in increased sickling and resultant pain crisis
- Dehydration resulting in increased sickling and resultant pain crisis
- Cerebral vascular accident (vaso-occlusion of blood vessels in brain)
- Acute chest syndrome causing pulmonary infiltrate with chest pain, fever, cough, tachypnea, hypoxia, and wheezing
- Fever
- Pain in the abdomen, chest, bones, or joints
- Abdominal swelling
- Pale skin or nail beds or yellow tint to the skin
Medical Treatment
May include the following:
- Supplemental oxygen
- Analgesics
- IV fluids
- Fluids are encouraged to be at least 1½ times maintenance (see Pediatric Maintenance Fluid Calculation)
- Prevention: Decrease risk for infection and dehydration to decrease risk for sickling
- Prophylactic antibiotics may be ordered
- Supplemental folic acid, B6, and B12 to support RBC production
- Medications include:
- Hydroxyurea, L-glutamine, crizanlizumab, voxelotor
- Surgical procedures
- Blood transfusions
- Stem cell transplant
Nursing Diagnoses
May include the following:
- Pain
- Altered tissue perfusion
- Altered growth and development
- Potential for infection
- Constipation related to analgesic use
- Knowledge deficit
Nursing Implications
- Hand washing before and after care to decrease risk for infection
- Teach child and family the role of infection and hydration in pain crisis prevention
- Encourage fluids to 1½ times usual maintenance amount
- Monitor need for and administer analgesics as needed
- Monitor for and provide ordered medication for analgesic-induced constipation
- Provide emotional support for chronic illness
- Refer to support groups
Prognosis
Varies depending on age of child, coexisting illnesses, and complications
Pathophysiology
- Cerebral palsy is a nonprogressive motor (movement) impairment that occurs as a result of brain injury, prenatally, perinatally, or postnatally up to age 2 yrs when cerebral development is completed. It affects varying degrees of motor development ranging from mild to severe and is classified by the extremities involved and type of neurological dysfunction.
- Diagnosis of a child with CP is supported by clinical presentation of any of the following:
- Hypotonia (decreased muscle tone)
- Hypertonia (increased muscle tone)
- Early hand preference by 6 months of age
- Persistence of primitive infant reflexes (Moro, crossed extensor)
| Prenatal | Perinatal | Postnatal | |
|---|---|---|---|
| Common Causes |
|
|
|
Signs & Symptoms
- Vary depending on the specific area of the brain involved and severity of the damage. There are four types of CP:
| Spastic | Ataxic | Athetoid or Dyskinetic | Mixed |
|---|---|---|---|
|
|
|
|
Medical Treatment
Aimed at maximizing function to prevent secondary complications. May include the following:
- Splints and braces
- Assistive devices
- Medications such as muscle relaxers, neurolytic agent nerve blocks, antianxiety and anticonvulsant drugs
- Surgeries such as joint stabilization, tendon lengthening, release of flexor muscle
- Feeding tubes
- Passive range of motion exercises
- Technical aids
- Physical therapy
- Speech therapy
Nursing Diagnosis
May include the following:
- Altered growth and development
- Imbalanced nutrition: Less than body requirements
- Impaired physical mobility
- Impaired verbal communication
- Risk for injury
- Risk for self-care deficit
Nursing Implications
May include the following:
- Encourage age-related play therapy
- Perform a developmental assessment and note milestones
- Facilitate activities using fine and gross motor skills
- Wash hands before and after care
- Educate the family on any assistive devices
- Administer medications and monitor for side effects
- Provide a safe environment
- Institute seizure precautions if warranted
- Encourage children to perform activities at their own pace
- Promote rest periods as necessary
- Perform range-of-motion exercises every 4 hours if the child is unable to move own body parts
- Referral to support group
Prognosis
Varies with severity.
Seizures
Pathophysiology
A convulsion caused by a sudden discharge of electrical activity in the brain. Generalized seizures are caused by abnormal electrical activity throughout the brain. Partial seizures are caused by abnormal electrical activity in a limited area of the brain.
Diagnosis may include any of the following tests:
- Neurological exam
- Blood tests
- Lumbar puncture
- Electroencephalogram (EEG)
- Computed tomography
- MRI
Common Causes
- Fever
- Increased intracranial pressure from:
- Hydrocephaly
- Infection (encephalitis or meningitis)
- Tumor
- Head trauma
- Electrolyte imbalances
- Hypoglycemia
- Drug overdose
Signs and Symptoms
Depend on seizure type. Two main types are partial and generalized.
| Partial seizures begin in a discreet or “focal” area of the brain | |
| Simple partial seizure |
|
| Complex partial seizure |
|
| Generalized seizures involve large areas of the brain—often both hemispheres | |
| Grand mal seizure |
|
| Absence seizure |
|
| Myoclonic seizure |
|
- Seizure terminology
- Atonic: Loss of muscle tone
- Clonic: Repetitive, jerking movement
- Febrile seizures: Seizure caused by fever; usually in children younger than 5 years when the seizure threshold is low; more common in boys
- Lennox-Gastaut: Severe form of epilepsy that may be associated with intellectual disability; type of seizure activity varies
- Neonatal seizures: Symmetrical flexion of the limbs or repeated smacking or chewing movements of the mouth
- Post-ictal: Period following a seizure
- Status epilepticus: Continuous seizures that cannot be controlled
- Tonic: Stiffening and rigidity of muscles
Medical Treatment
May include the following:
- Treatment of underlying causes of increased intracranial pressure
- Medications to prevent seizure activity
- Ketogenic diet: A diet high in fat and low in carbohydrates may be recommended (resulting elevated ketones in the blood reduces seizure rate in some children; note that this diet may lead to dehydration, constipation, renal calculi, elevated cholesterol, and slow growth)
- Neurostimulation
- Surgery after at least two anticonvulsants have failed to bring about improvement
Nursing Diagnoses
May include the following:
- Risk for trauma/suffocation
- Impaired social interaction
- Chronic low self-esteem
- Knowledge deficit
Nursing Implications
May include the following:
- Remove sharp objects from environment
- Roll child onto side after seizure activity
- Assess airway and breathing after seizure activity
- Young children with frequent seizures may need to wear a helmet to prevent head injury
- Educate child and family regarding safety
- Do not force objects into mouth during seizure activity
Prognosis
Varies with type of seizure and age of onset.