NCLEX: Health Promotion and Maintenance

Health Promotion and Maintenance : GASTROINTESTINAL SYSTEM

Focus topic: Health Promotion and Maintenance

Structural Defects

Focus topic: Health Promotion and Maintenance

I. CLEFT LIP AND CLEFT PALATE

Focus topic: Health Promotion and Maintenance

A. Introduction: Cleft lip and cleft palate are congenital facial malformations resulting from faulty embryonic development; there appear to be multiple factors involved in the exact etiology: mutant genes, chromosomal abnormalities, teratogenic agents, etc. The infant may be born with cleft lip alone, cleft palate alone, or with both cleft lip and cleft palate. Cleft lip and palate may occur unilaterally or bilaterally. Comparison of Cleft Lip and Cleft Palate compares these conditions.

 

Health Promotion and Maintenance

 

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B. Assessment:

Focus topic: Health Promotion and Maintenance

  • Cleft lip—obvious facial defect, readily detectable at time of birth.
  • Cleft palate—must feel inside infant’s mouth to check for presence of palatal defect and to note extent of defect: soft palate only or soft palate and hard palate.
  • Both—major problems with feeding: difficult to feed, noisy sucking, swallows excessive amounts of air, prone to aspiration.
  • Parent-infant attachment (bonding) may be adversely affected due to “loss of perfect infant,” multiple hospitalizations; note amount and quality of parent-infant interaction.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Altered nutrition, less than body requirements, related to physical defect.
  • Impaired physical mobility (postoperative) related to postoperative care requirements.
  • Altered parenting related to birth of child with obvious facial defect.
  • Knowledge deficit, actual or risk for, potential, related to treatment and follow-up.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: maintain adequate nutrition.

a. Preoperative: first encourage parents to watch nurse feed infant, then teach parents proper feeding techniques:

  • Use Breck feeder or Asepto syringe.
  • Deposit formula on back of tongue to facilitate swallowing and to prevent aspiration.
  • Rinse mouth with sterile water after feedings, to prevent infection.
  • Feed slowly, with child in sitting position, to prevent aspiration.
  • Burp frequently, because infant will swallow air along with formula due to the defect.
  • Monitor weight.

b. Postoperative

  • Begin with clear liquids when child has fully recovered from anesthesia Comparison of Cleft Lip and Cleft Palate—cont’d.
  • Monitor weight gain carefully, to ensure adequate rate of growth.
  • No sucking for either cleft lip or palate repair until incision is healed.
  • Avoid stretching or pulling at incision site; metal “Logan bow” may be used as external brace for cleft lip repair.

2. Goal: promote parent-infant attachment.

  • Show no discomfort handling infant; convey acceptance.
  • Stay with parents the first time they see/hold infant.
  • Offer positive comments about infant.
  • Give positive reinforcement to parents’ initial attempts at parenting.
  • Encourage parents to assume increasing independence in care of their infant.
  • Allow rooming-in on subsequent hospitalizations.

3. Goal: teach parents particulars of feeding and need for long-term follow-up care.

a. Teach parents regarding long-term concerns Comparison of Cleft Lip and Cleft Palate—cont’d .
b. Make necessary referrals before discharge:

  • Specialists: speech, dentition, hearing.
  • Home health nurse.
  • Social service.
  • Disabled children’s services for financial assistance.
  • Local craniofacial malformations support group.

c. Refer parents to genetic counseling services because of mixed genetic/environmental etiology.
d. Encourage parents to promote self-esteem in infant/child as child grows and develops.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Adequate nutrition is provided, and infant grows at “normal” rate for age.
  • Parent-infant attachment is formed.
  • Parents verbalize confidence in their ability to care for infant.

II. TRACHEOESOPHAGEAL FISTULA

Focus topic: Health Promotion and Maintenance

A. Introduction: Tracheoesophageal fistula (TEF) is a congenital anomaly resulting from faulty embryonic development; although there are numerous “types” of TEF, the major problem is an anatomical defect that results in an abnormal connection between the trachea (respiratory tract) and the esophagus (GI system) Esophageal malformations. No exact cause has been identified; however, infants born with TEF are often premature, with a maternal history
of polyhydramnios. Diagnosis should be made immediately, within hours after birth, and preferably before feeding (to avoid aspiration pneumonia).
Associated anomalies include: CHD, anorectal malformations, and genitourinary anomalies.

B. Assessment:

Focus topic: Health Promotion and Maintenance

1. Perinatal history: maternal polyhydramnios, premature birth.
2. Most important system affected is respiratory:

  • Shortly after birth, infant has excessive amounts of mucus.
  • Mucus bubbles or froths out of nose and mouth as infant literally “exhales” mucus.
  • The “3 Cs”: coughing, choking, cyanosis— because mucus accumulates in respiratory tract.
  • “Pinks up” with suctioning, only to experience repeated respiratory distress within a short time as mucus builds up again.
  • Aspiration pneumonia occurs early.
  • Respiratory arrest may occur.

3. Second system affected is GI:

  • Abdominal distention because excessive air enters stomach with each breath infant takes.
  • Inability to aspirate stomach contents when attempting to pass NG tube.
  • If all these signs are not correctly interpreted and feeding is attempted, infant takes two to three mouthfuls, coughs and gags, and forcefully “exhales” formula through nostrils.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Ineffective breathing pattern/ineffective airway clearance related to excess mucus.
  • Altered nutrition, less than body requirements, related to inability to take fluids by mouth.
  • Anxiety related to surgery, condition, preterm delivery, and uncertain prognosis.
  • Knowledge deficit regarding discharge care of infant related to gastrostomy tube, feeding.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: prepare neonate for surgery.

  • Stress to parents that surgery is only possible treatment.
  • Allow parents to see neonate before surgery to promote bonding and attachment.
  • Maintain NPO—provide IV fluids, monitor I&O, gastrostomy tube.
  • Position: elevate HOB 20 to 30 degrees to prevent aspiration.
  • Administer warmed, humidified oxygen, as ordered, to relieve hypoxia and to prevent cold stress.

 

Health Promotion and Maintenance

 

2. Goal (postoperative): maintain patent airway.

  • Position: elevate HOB 20 to 30 degrees.
  • Care of chest tubes (open-chest procedure).
  • Care of endotracheal tube/ventilator (neonate frequently requires ventilatory assistance for 24 to 48 hours postoperatively).
  • Monitor for symptoms and signs of pneumonia (most common postoperative complication):
    (1) Aspiration.
    (2)Hypostatic, secondary to anesthesia.
  • Monitor for symptoms and signs of respiratory distress syndrome (preterm infant).
  • Use special precautions when suctioning: “suction with marked catheter” to avoid exerting undue pressure on newly sutured trachea.
  • Administer prophylactic/therapeutic antibiotics, as ordered.
  • Administer warmed, humidified oxygen, as ordered; monitor arterial blood gases (ABGs).

3. Goal: maintain adequate nutrition.

  • 48 to 72 hours postoperatively: IV fluids only.
  • Maintain NPO for 10 to 14 days, until esophagus is fully healed (offer pacifier).
  • When condition is stable: begin gastrostomy tube (G-tube) feedings, as ordered.
    (1)Start with small amounts of clear liquids.
    (2)Gradually increase to full-strength formula.
    (3) Postoperative: leave G-tube open and elevated slightly above level of stomach to prevent aspiration if infant vomits.
    (4)Offer pacifier ad lib.
  • Between 10th and 14th postoperative day: begin oral feedings.
    (1)Start with clear liquids again.
    (2)Note ability to suck and swallow.
    (3)Offer small amounts at frequent intervals.
    (4)May need to supplement postop feeding with G-tube feeding prn.
  • Monitor weight, I&O.

4. Goal: prepare parents to successfully care for the infant after discharge.

  • Teach parents that infant will probably be discharged with G-tube in place; teach care of G-tube at home.
  • Teach parents symptoms and signs of most common long-term problems (i.e., esophageal reflux, stricture formation).
    (1)Refusal to eat solids or swallow liquids.
    (2) Dysphagia.
    (3) Increased coughing or choking.
  • Stress need for long-term follow-up care.
  • Offer realistic encouragement, because prognosis is generally good.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Neonate survives immediate surgical repair without untoward difficulties.
  • Patent airway is maintained; adequate oxygenation is provided.
  • Adequate nutrition is maintained; infant begins to gain weight and grow.
  • Parents verbalize confidence in ability to care for infant on discharge.

Health Promotion and Maintenance : Obstructive Disorders

Focus topic: Health Promotion and Maintenance

I. HYPERTROPHIC PYLORIC STENOSIS

Focus topic: Health Promotion and Maintenance

A.Introduction: Hypertrophic pyloric stenosis (HPS) causes obstruction of the upper GI tract, but the infant frequently does not have symptoms until 2 to 4 weeks of age. HPS results in thickening, or hypertrophy, of the pyloric sphincter located at the distal end of the stomach; this causes a mechanical intestinal
obstruction that becomes increasingly evident as the infant begins to consume larger amounts of formula during the early weeks of life. Pyloric stenosis
is five times more common in boys than girls and is most often found in full-term Caucasian infants. The exact etiology remains unknown; however, there does seem to be a genetic predisposition.

B. Assessment:

Focus topic: Health Promotion and Maintenance

1. Classic symptom is vomiting:

  • Begins as nonprojectile at age 2 to 4 weeks.
  • Advances to projectile at age 4 to 6 weeks.
  • Vomitus is non–bile stained (stomach contents only).
  • Most often occurs shortly after a feeding.
  • Major problem is the mechanical obstruction of the flow of stomach contents to the small intestine due to the anatomical defect of stenosis of the pyloric sphincter.
  • No apparent nausea or pain, as evidenced by the fact that infant eagerly accepts a second feeding after episode of vomiting.
  • Metabolic alkalosis develops due to loss of hydrochloric acid.

2. Inspection of abdomen reveals:

  • Palpable olive-shaped mass in right upper quadrant.
  • Visible peristaltic waves, moving from left to right across upper abdomen.

3. Weight: fails to gain or loses.

4. Stools: constipated, diminished in number and size—due to loss of fluids with vomiting.

5. Signs of dehydration may become evident Signs and Symptoms of Dehydration in Infants and Young Children .

6. Upper GI series and ultrasonography reveal:

  • Delayed gastric emptying.
  • Elongated and narrowed pyloric canal.

 

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C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Fluid volume deficit related to vomiting.
  • Altered nutrition, less than body requirements, related to vomiting.
  • Risk for injury/infection related to altered nutritional state.
  • Impaired skin integrity related to dehydration and altered nutritional state.
  • Knowledge deficit related to cause of disease, treatment and surgery, prognosis, and follow-up care.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal (preoperative): restore fluid and electrolyte balance.

  • Generally NPO, with IVs preoperatively to provide fluids and electrolytes.
  • Observe and record I&O, including vomiting and stool.
  • Weight: check every 8 hours or daily.
  • Monitor laboratory data.

2. Goal (postoperative): provide adequate nutrition.

  • Maintain NPO with IVs for 4 to 6 hours postoperatively, as ordered (can offer pacifier).
  • Follow specific feeding regimen ordered by doctor—generally start with clear fluids in small amounts hourly, increasing slowly as tolerated. Full feeding schedule reinstated within 48 hours. Offer pacifier between feedings.
  • Fed only by RN for 24 to 48 hours, because vomiting tends to continue in immediate postoperative period.
  • Burp well—before, during, and after feeding.
  • Position after feeding: high Fowler’s turned to right side; minimal handling after feeding to prevent vomiting.

3. Goal (preoperative and postoperative): institute preventive measures to avoid infection or skin breakdown.

  • Use good hand-washing technique.
  • Administer good skin care, especially in diaper area (urine is highly concentrated); give special care to any reddened areas.
  • Give mouth care when NPO or after vomiting.
  • Tuck diaper down below suture line to prevent contamination with urine (postoperatively).
  • Note condition of suture line—report any redness or discharge immediately.
  • Screen staff and visitors for any sign of infection.

4. Goal: do discharge teaching to prepare parents to care for infant at home.

  • Teach parents that defect is anatomical and unrelated to their parenting behavior/skill.
  • Demonstrate feeding techniques, and remind parents that vomiting may still occur.
  • Stress that repair is complete; this condition will never recur.
  • Instruct parents in care of the suture line: no baths for 10 days, tuck diaper down, report any signs of infection promptly.
  • Offer follow-up referrals as indicated.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Infant survives surgical repair without untoward difficulties (including infection/skin breakdown).
  • Adequate nutrition is maintained, and infant begins to grow and gain weight.
  • Parents verbalize confidence in their ability to care for their infant on discharge.

II. HIRSCHSPRUNG’S DISEASE (congenital aganglionic megacolon)

A. Introduction: Hirschsprung’s disease is a congenital anomaly of the lower GI tract, but the diagnosis often is not established until the infant is 6 to 12 months old. The major problem is a functional obstruction of the colon caused by the congenital anatomical defect of lack of nerve cells in the walls of the colon, resulting in the absence of peristalsis. Hirschsprung’s disease is four times more common in boys than girls and is frequently noted in children with Down syndrome.

B. Assessment:

Focus topic: Health Promotion and Maintenance

  • In the newborn, failure to pass meconium (in addition to other signs and symptoms of intestinal obstruction).
  • Obstinate constipation—history of inability to pass stool without stool softeners, laxatives, or enemas; persists despite all attempts to treat medically.
  • Stools are infrequent and tend to be thin and ribbon like.
  • Vomiting: bile stained, flecked with bits of stool (breath has fecal odor), due to GI obstruction and eventual backing up of stools.
  • Abdominal distention can be severe enough to impinge on respirations, due to GI obstruction and retention of stools.
  • Anorexia, nausea, irritability due to severe constipation.
  • Malabsorption results in anemia, hypoproteinemia, and loss of subcutaneous fat.
  • Visible peristalsis and palpable fecal masses may also be detected.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Constipation related to impaired bowel functioning.
  • Altered nutrition, less than body requirements, related to poor absorption of nutrients.
  • Risk for injury/infection related to malnutrition.
  • Pain related to surgery and treatments.
  • Knowledge deficit regarding care of the child with a colostomy and follow-up care.

D. Nursing care plan/implementation:
1. Goal (preoperative): promote optimum nutritional status, fluid and electrolyte balance.

  • Monitor for signs and symptoms of progressive intestinal obstruction: measure abdominal girth daily.
  • Administer IV fluids, as ordered—may include total parenteral nutrition (TPN) or intravenous lipids.
  • Daily weights, I&O, urine specific gravity.
  • Monitor for possible dehydration.
  • Diet: low residue.

2. Goal (preoperative): assist in preparing bowel for surgery.

  • Teach parents what will be done and why—enlist their cooperation as much as possible.
  •  Insert NG tube, connect to low suction to achieve and maintain gastric decompression.
  • Position: semi-Fowler’s.
  • Bowel is cleansed with a series of isotonic saline (0.9%) enemas.
  • Administer oral antibiotics and colonic irrigations to decrease bacteria.
  • Take axillary temperatures only.
  • If child can understand, prepare for probable colostomy using pictures, dolls (usual age at surgery is 10 to 16 months).
  • Postoperative goals: same as for adult having major abdominal surgery or a colostomy (see Chapter 6).

4. Goal (postoperative): discharge teaching to prepare parents to care at home for infant with a colostomy.

  • Home care of colostomy of infant is essentially same as for adult (see Chapter 6).
  • Teach parents to keep written records of stools: number, frequency, consistency.
  • Teach parents to tape diaper below colostomy to prevent irritation.
  • Because colostomy is usually temporary, discuss:
    (1)Second-stage repair (closure and pull through) done when the child weighs approximately 20 lb.
    (2)Possible difficulties in toilet training.
  • Stress need for long-term follow-up care.
  • Make referral to home care if indicated.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Infant is prepared for surgery and tolerates procedure well.
  • Postoperative recovery is uneventful.
  • Parents verbalize confidence in ability to care at home for infant with a colostomy and verbalize their understanding that second surgery will be needed to close the colostomy.

III. INTUSSUSCEPTION

Focus topic: Health Promotion and Maintenance

A. Introduction: Intussusception is the apparently spontaneous telescoping of one portion of the intestine into another, resulting in a mechanical obstruction of the lower GI tract. There is no known cause, and intussusception is three times more common in boys than girls; the child with intussusception is usually
between 3 and 36 months of age.

B. Assessment:

Focus topic: Health Promotion and Maintenance

  • Typically presents with sudden onset in child who is healthy, thriving.
  • Pain: paroxysmal, colicky, abdominal, with intervals when the child appears normal and comfortable.
  •  Stools: “currant-jelly,” bloody, mixed with mucus.
  • Vomiting due to intestinal obstruction.
  • Abdomen: distended, tender, with palpable, sausage-shaped mass in right upper quadrant (RUQ).
  • Late signs: fever, shock, signs of peritonitis as the compressed bowel wall becomes necrotic and perforates.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Fluid volume deficit related to diarrhea and vomiting.
  • Pain related to bowel-wall ischemia, necrosis, and death.
  • Risk for injury/infection related to bowel-wall perforation and peritonitis.
  • Knowledge deficit regarding the disease, medical or surgical treatment, and prognosis.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: assist with attempts at medical treatment.

  • Explain to parents that a barium enema will be given to the child in an attempt to reduce the telescoping through hydrostatic pressure (succeeds in 75% of cases).
  • Stress that if this treatment is not successful, or if perforation of the bowel wall has already occurred, surgery will be necessary.
  • If medical treatment is apparently successful, monitor child for 24 to 36 hours for recurrence before discharge.

2. Preoperative and postoperative goals: same as for adult with major abdominal surgery (see Chapter 6).

3. Goal: discharge teaching to prepare parents for care of the child at home.

  • Stress that recurrence is rare (10%) and most often occurs within the first 24 to 36 hours after reduction.
  • Other teaching: same as for adult going home after bowel surgery (see Chapter 6).

E. Evaluation/outcome criteria:

  • Infant tolerates medical-surgical treatment and completely recovers.
  • Parents verbalize confidence in ability to care for infant after discharge.

Health Promotion and Maintenance : Disorders of Motility

Focus topic: Health Promotion and Maintenance

I. ACUTE GASTROENTERITIS (AGE)

Focus topic: Health Promotion and Maintenance

A. Introduction: In infants and young children, gastroenteritis is a common acute illness that can rapidly progress to dehydration, hypovolemic shock, and severe electrolyte disturbances.

B. Assessment:

  • Diarrhea: often watery, green, explosive, contains mucus and blood.
  • Abdominal cramping and pain, often accompanied by bouts of diarrhea.
  • Dehydration: Signs and Symptoms of Dehydration in Infants and Young Children .
  • Irritability, restlessness, alterations in level of consciousness.
  • Electrolyte disturbances: see Chapter 6.

C. Analysis/nursing diagnosis:

  • Fluid volume deficit related to vomiting and diarrhea.
  • Altered nutrition, less than body requirements, related to AGE and its treatment (i.e., dietary restrictions).
  • Pain related to abdominal cramping, diarrhea.
  • Impaired skin integrity related to diarrhea.
  • Altered tissue perfusion related to dehydration and hypovolemia.
  • Knowledge deficit regarding diagnosis, dietary restrictions, treatment.

D. Nursing care plan/implementation:

1. Goal: prevent spread of infection.

  • Standard precautions to prevent infection.
  • Enforce strict hand washing.
  • Institute and maintain enteric precautions— follow policies regarding linens, excretions, specimens (“double-bag, special tag”).
  • Tape diapers snugly; keep hands out of mouth.
  • Obtain stool culture to identify causative organism; then administer antibiotics as ordered.
  • Identify family members and others at high risk, obtain cultures.

2. Goal: restore fluid and electrolyte balance.

  • Administer IV fluids and electrolytes as ordered.
  • Monitor for appropriate response to therapy: decreased specific gravity, good skin turgor, normal vital signs.
  • Monitor weight, I&O, specific gravity.
  • Oral feedings—oral rehydration therapy (ORT) with Pedialyte or comparable solution; resume normal diet as quickly as possible.
  • Ongoing assessment of stools: note Amount, Color, Consistency, Timing (ACCT).

3. Goal: maintain or restore skin integrity.

  • Frequent diaper changes.
  • Keep perineal area clean and dry.
  • Apply protective ointments (e.g., petroleum jelly, A and D emollient ointment).
  • If feasible, expose reddened buttocks to air (but not with explosive diarrhea).

4. Goal: provide discharge teaching to parents.

  • Careful review of diet to be followed at home.
  • Review principles of food preparation and storage to prevent infection.
  • Instruct in disposal of stools at home.
  • Emphasize importance of good hygiene.

E. Evaluation/outcome criteria:

  • No spread of infection noted.
  • Fluid and electrolyte balance normal.
  • No skin breakdown noted.
  • Parents verbalize understanding of home care.

Health Promotion and Maintenance : GENITOURINARY SYSTEM

Focus topic: Health Promotion and Maintenance

Health Promotion and Maintenance : Genitourinary Tract Disorder

Focus topic: Health Promotion and Maintenance

I. HYPOSPADIAS

Focus topic: Health Promotion and Maintenance

A. Introduction: Hypospadias is a congenital anatomical defect of the male genitourinary tract, readily detected at birth through simple visual examination.
In hypospadias, the urethral opening is located on the ventral surface of the penile shaft; this makes voiding in the standing position virtually impossible, which creates potential for serious psychological problems. Ideally, staged surgical repair should be completed by 6 to 18 months of age, before body image is developed or castration fears are evident.

B. Assessment:

  • Urethral opening is located on ventral surface of penis.
  • May be accompanied by “chordee”—ventral curvature of the penis due to a fibrous band of tissue.
  • Rare: ambiguous genitalia, resulting in need for chromosomal studies to determine sex of neonate.

C. Analysis/nursing diagnosis:

  • Altered urinary elimination related to congenital anatomical defect of penis.
  • Pain related to surgery and treatments.
  • Self-esteem disturbance related to anatomical defect in penis and resulting disturbance in ability to void standing up.
  • Knowledge deficit related to condition, surgeries, outcome.

D. Nursing care plan/implementation:

1. Goal: promote normal urinary function.

  • Teach family that surgery is done in several stages, beginning in the early months of life and finishing by age 18 months.
  • Provide age-appropriate information to child regarding condition, surgery.
  • Preoperative teaching with child: simulate anticipated postoperative urinary drainage apparatus and dressings on dolls; allow child to handle and play with them now, but stress need not to touch postoperatively.
  • Postoperatively: Monitor urinary drainage apparatus; note hourly urine output, color, appearance (should be clear yellow, no blood).

2. Goal: promote self-esteem.

  • Do not scold child if he exposes penis, dressings, catheters, etc.
  • Reassure parents that preoccupation with penis is normal and will pass.
  • Encourage calm, matter-of-fact acceptance of, and avoid strict discipline for this behavior, which could affect the child negatively.

E. Evaluation/outcome criteria:

  • Child is able to void in normal male pattern.
  • Child does not experience disturbances in self-concept and has normal self-esteem.

Health Promotion and Maintenance : Kidney Tumor

Focus topic: Health Promotion and Maintenance

I. WILMS’ TUMOR (NEPHROBLASTOMA)

Focus topic: Health Promotion and Maintenance

A. Introduction: Wilms’ tumor, a malignant tumor of the kidney, is the most common form of renal cancer in children. Peak incidence occurs at 3 years of age, with a slightly higher incidence in boys than girls. Ninety percent of the cases occur unilaterally; the treatment of choice is nephrectomy (and adrenalectomy) followed by chemotherapy and radiation.

B. Assessment:

  • Most common sign: abdominal mass (firm, nontender).
  • Most often first found by parent changing diaper; felt as a mass over the kidney area.
  • Intravenous pyelogram (IVP), abdominal ultrasound, and CT confirm the diagnosis.
  • Metastasis occurs most frequently to the lungs: pain in chest, cough, dyspnea.

C. Analysis/nursing diagnosis: altered urinary elimination (other diagnoses depend on stage of tumor and presence of metastasis—similar to adult with cancer).

D. Nursing care plan/implementation:

1. Goal: promote normal urinary function.

  • Inform family that surgery is scheduled as soon as possible after confirmed diagnosis (within 24–48 hours).
  • Explain to family that the preferred surgical approach is nephrectomy (and adrenalectomy).
  • Preoperative: do not palpate abdomen because the tumor is highly friable, and palpation increases the risk of metastasis.
  • Postoperative nursing care: similar to care of adult with nephrectomy.
  • Postoperative care also includes long-term radiation therapy and chemotherapy (actinomycin D, vincristine, Adriamycin;.

2. Goal: discharge teaching to prepare parents to care for child at home.

  • Teach parents need for long-term follow-up care with specialists: oncologist, urologist.
  • Answer questions regarding prognosis, offering realistic hope.
    (1) Children with localized tumor: 90% survival rate.
    (2) Children with metastasis: 50% survival rate.

E. Evaluation/outcome criteria:

  • Child is able to maintain normal urinary elimination.
  • Parents verbalize their understanding of home care for the child.

Health Promotion and Maintenance : Glomerular Diseases

Focus topic: Health Promotion and Maintenance

I. NEPHROSIS

Focus topic: Health Promotion and Maintenance

Nephrosis (idiopathic nephrotic syndrome) is a chronic renal disease having no known cause, variable pathology, and no known cure. It is thought that several different pathophysiological processes adversely affect the glomerular membranes of the kidneys, resulting in increased permeability to protein. This “leakage” of protein into the urine results in massive proteinuria, severe hypoproteinemia, and total body edema. A chronic disease, nephrosis often has its onset during the preschool years but is characterized by periods of exacerbation and remission throughout the childhood years.

The nursing care plan for the child with nephrosis is very similar to that for the adult with compromised renal functioning. Refer to Chapters 8 and 9 for additional information about dietary restrictions and medications; refer to Comparison of Nephrosis and Acute Poststreptococcal Glomerulonephritis for a chart comparing nephrosis and nephritis.

II. ACUTE POSTSTREPTOCOCCAL GLOMERULONEPHRITIS

Focus topic: Health Promotion and Maintenance

A. Introduction: Acute poststreptococcal glomerulonephritis (APSGN) is a bilateral inflammation of the glomeruli of the kidneys and is the most common noninfectious renal disease of childhood. It occurs most frequently in early school-age children, with a peak age of onset of 6 to 7 years; it is twice as common in boys as in girls. Like rheumatic fever, acute glomerulonephritis is thought to be the result of an antigen-antibody reaction to a streptococcus infection however, unlike rheumatic fever, it does not tend to recur, because specific immunity is conferred following the first episode of APSGN. (Further information about APSGN is found in Comparison of Nephrosis and Acute Poststreptococcal Glomerulonephritis.

 

Health Promotion and Maintenance

Health Promotion and Maintenance

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B. Assessment:

  • Typical concerns from family about urine: change in color/appearance of urine (thick, reddish brown; decreased amounts).
  • Acute edematous phase—usually lasts 4 to 10 days.
  • Laboratory examination of urine:

(1) Severe hematuria.
(2) Mild proteinuria.
(3) Increased specific gravity.

  • Hypertension

(1) Headache.
(2) Potential hypertensive encephalopathy leading to seizures, increased intracranial pressure.

  • Mild-moderate edema: chiefly periorbital; increased weight due to fluid retention.
  • General:

(1) Abdominal pain.
(2) Malaise.
(3) Anorexia.
(4) Vomiting.
(5) Pallor.
(6) Irritability.
(7) Lethargy.
(8) Fever.

3. Diuresis phase:

  • Copious diuresis.
  • Decreased body weight.
  • Marked clinical improvement.
  • Decrease in gross hematuria, but microscopic hematuria may persist for weeks/months.

C. Analysis/nursing diagnosis:

  • Fluid volume excess related to decreased urine output.
  • Pain related to fluid retention.
  • Altered nutrition, less than body requirements, related to anorexia and vomiting.
  • Impaired skin integrity related to immobility.
  • Activity intolerance related to fatigue.
  • Knowledge deficit related to disease process, treatment, and follow-up care.

D. Nursing care plan/implementation:

1. Goal: monitor fluid balance, observing carefully for complications.

  • Check and record blood pressure at least every 4 hours to monitor hypertension.
  • Monitor daily weights.
  • Urine: strict I&O; specific gravity and dipstick for blood every void.
  • Note edema: extent, location, progression.
  • Adhere to fluid restrictions if ordered.
  • Monitor for possible development of hypertensive encephalopathy (seizures, increased intracranial pressure); report any changes STAT to physician.
  • Administer medications as ordered:
    (1)Antibiotics—eradicate any lingering streptococcus infection; controversial.
    (2)Antihypertensives (e.g., Apresoline).
    (3)Rarely use diuretics—limited value.
    (4) If CHF develops—may use digoxin.
    (5)Refer to Chapter 8 for additional information on medications.

2. Goal: provide adequate nutrition.

  • Diet: low sodium, low potassium—to prevent fluid retention and hyperkalemia; decrease protein (if azotemia develops). Refer to Chapter 9 for additional information on diets.
  • Stimulate appetite: offer small portions, attractively prepared; meals with family or other children; offer preferred foods, if possible; encourage parents to bring in special foods (e.g., culturally related preferences).

3. Goal: provide reasonable measure of comfort.

  • Encourage parental visiting.
  • Provide for positional changes, give good skin care.
  • Provide appropriate diversion, as tolerated

4. Goal: prevent further infection.

  • Use good hand washing technique.
  • Screen staff, other clients, visitors (especially children) to limit contact with people who are infectious.
  • Administer antibiotics if ordered (usually only for children with positive cultures).
  • Keep warm and dry, stress good hygiene.
  • Note possible sites of infection: increased skin breakdown secondary to edema.

5. Goal: teach child and family about APSGN/ discharge planning.

  • Teach how to check urine at home: dipstick for protein and blood. (Note: occult hematuria may persist for months.)
  • Teach activity restriction: no strenuous activity until hematuria is completely resolved.
  • Teach family how to prepare low-sodium, low-potassium diet.
  • Arrange for follow-up care: physician, home health nurse.
  • Stress: subsequent recurrences are rare because specific immunity is conferred.

E. Evaluation/outcome criteria:

  • No permanent renal damage occurs.
  • Normal fluid balance is maintained/restored.
  • Adequate nutrition is maintained.
  • No secondary infections occur.
  • Child/family verbalize their understanding of the disease, its treatment, and its prognosis.

Health Promotion and Maintenance : ENDOCRINE SYSTEM

Focus topic: Health Promotion and Maintenance

I. DIABETES MELLITUS TYPE 1

Focus topic: Health Promotion and Maintenance

Diabetes mellitus type 1 was formerly called insulindependent diabetes mellitus (IDDM) and juvenile-onset diabetes. Diabetes mellitus is fully covered in Chapter 6. Only the differences between adults and children are covered in Differences Between Type 1 and Type 2 Diabetes Mellitus.

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FURTHER READING/STUDY:

Resources:

 

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