NCLEX-RN: Pediatric Nursing

Pediatric Nursing: Cardiovascular System

Focus topic: Pediatric Nursing

The heart is the center of the cardiovascular system, which, by contracting rhythmically, pumps blood through the body to nourish all of the body tissues and cells. This is one of the most essential body systems because failure to function results in death of the client.

Pediatric Nursing:Obstructive Defects

Focus topic:  Pediatric Nursing

 Pediatric Nursing: Pulmonary Stenosis

Focus topic: Pediatric Nursing

Definition: Narrowing of the pulmonary artery proximally, at the valve, in the outflow tract or in the branch pulmonary arteries.

Assessment
A. Some children with pulmonary stenosis (PS) may be asymptomatic.
B. Evaluate for a decrease in exercise tolerance, evidence of tiring easily, and dyspnea.
C. Help facilitate diagnostic procedures to evaluate right ventricular pressure, hypertrophy, and degree of severity of PS (echocardiography, ECG, cardiac catheter).
D. Assess for signs of congestive heart failure.
E. Observe for cyanosis in critical pulmonary stenosis.

Implementation
A. Provide symptomatic nursing care. Children with mild or moderate stenosis may not need intervention.
B. Monitor drug and oxygen therapy if needed.
C. Provide preoperative nursing and monitor postop problems: reactive pulmonary hypertension, arrhythmias, and conduction problems.

Pediatric Nursing: Aortic Stenosis

Focus topic: Pediatric Nursing

Definition: The narrowing or the stricture of the aortic valve. Stenosis may occur in the valve itself or above or below the annulus.

Assessment
A. Infants can be asymptomatic, may present with critical aortic stenosis (AS) and congestive heart failure (CHF).
B. Evaluate child’s exercise tolerance.
C. Assess older children for chest pain during exercise. Be aware that in rare conditions sudden death may occur after exercise because of inadequate blood flow to the heart muscle.
D. Observe for episodes of syncope or vertigo, assist in obtaining detailed history of events.
E. Assist in preparation and obtaining diagnostic evaluations of left ventricular status and degree of AS (echocardiography, ECG, cardiac catheter).

Implementation
A. Teach children to evaluate their exercise tolerance and to not exceed their limit. Parents may be encouraged to limit child’s activity and minimize stress until corrective procedure is performed.
B. Provide preoperative and postoperative care for surgical intervention; possible prosthetic valve or Ross procedure.

Pediatric Nursing: Coarctation of Aorta

Focus topic: Pediatric Nursing

Definition: The constriction of the lumen of the aorta, usually occurring below the level of the ductus arteriosus, or occasionally above (infantile form or interrupted aortic arch).

Assessment
A. Assess for high blood pressure and bounding pulses in areas of the body that receive blood from vessels proximal to the constriction that may result in these conditions (upper extremities).
B. Evaluate for a diminished blood supply in areas of the body distal to the defect (legs and feet).
C. Infant diagnosis: Assess for discrepancies in pulses and blood pressure between upper and lower extremities and left–right sides.
D. Older child diagnosis: Assess for increased cerebral flow headache, dizziness, epistaxis, fainting.
E. Evaluate for possible complications (in untreated cases): intracranial hemorrhage, stroke, hypertension, or congestive heart failure.
F. Assess for leg pain after exertion.

Implementation
A. Provide symptomatic nursing care as necessary.
B. Monitor blood pressure and neurological signs in nonsurgical clients.
C. May be surgically repaired or some cases may be balloon dilated in cardiac catheter lab.
D. Provide preoperative and postoperative nursing care.
E. Observe for postsurgical signs of gastrointestinal disturbance and systemic hypertension (mesenteric irritation resulting from increased blood flow postoperatively).

Pediatric Nursing: Acquired Cardiac Conditions

Focus topic: Pediatric Nursing

Pediatric Nursing: Heart Failure

Focus topic: Pediatric Nursing

Definition: Cardiac output that is insufficient to meet the metabolic demands of the body, resulting in a series of sympathetic responses. The most common cause of heart failure (HF) in children is related to congenital anomalies.

Assessment
A. Observe for the following signs of pulmonary and systemic venous congestion:

  •  Tachycardia.
  •  Tachypnea, progressing to respiratory distress.
  •  Intercostal, supraclavicular, substernal retractions.
  •  Crackles, wheezing, or rhonchi.
  •  Fluid retention (weight gain), periorbital edema, hand and foot edema.
  •  Hepatic enlargement.

B. Infant signs and symptoms: increased respiratory rate and infections; crackles; enlarged liver and spleen, generally little edema, may see periorbital edema; babies do not display distended jugular veins, but fontanelles may be full or bulging.

Implementation
A. Increase oxygen supply and reduce oxygen demand.

  •  Ensure that child has secure airway.
  •  Administer oxygen via most appropriate route.
  •  Continuously monitor ventilation, respiratory effort, and SaO2.

B. Monitor medication administration.

  •  Afterload reducing medications (ACE inhibitors, e.g., Capoten [captopril] and Vasotec [enalapril]).
    a. Drugs inhibit renin-angiotensin system, producing vasodilation in pulmonary and systemic vasculature.
    b. Monitor I&O and heart rate (HR), and observe carefully for hypotension and renal dysfunction.
  •  Lanoxin (digoxin).
    a. Monitor vital signs every hour during digitalization. If pulse under 90–100, notify physician; may hold dose.
    b. Observe for Lanoxin toxicity; nausea, vomiting, and diarrhea (early signs seen most often in children); anorexia, dizziness and headaches, arrhythmias, and muscle weakness.
  • Diuretics important part of treatment.
    a. Observe for electrolyte abnormalities.
    b. Weigh child daily.
    c. Common diuretics: Lasix (furosemide) and Diuril (chlorothiazide) deplete potassium, and Aldactone (spironolactone) preserves potassium.
  • Seriously ill children require intensive care unit (ICU) monitoring and inotropic support.

C. Monitor for signs of complications other than medications.

  •  Fluid balance important to keep child adequately hydrated, dehydration may occur from vigorous fluid restriction; maintain strict I&O.
  • Electrolyte imbalance.
  •  Dysrhythmias.
  •  CNS complications from poor cardiac output and hypoxemia.
  •  Cardiovascular collapse pallor, cyanosis, shock.

D. Promote rest for child with heart failure.

  •  Provide outlets such as drawing, doll play, and reading for child with restricted activity.
  •  Organize care to promote child’s rest periods.

E. Supervise diet.

  •  Provide small, frequent feedings.
  •  Failure to thrive often present, so meals should be high calorie, attractive, and foods child will eat; may need  nasogastric tube to provide sufficient calories for growth and daily energy needs.

F. Prepare family for home care of infant or child.

  • Encourage family to participate in care.
    a. Administration of medications.
    b. Signs of medication toxicity.
    c. Techniques for conserving children’s energy.
    d. How to contact others for help and guidance.
  • Support family relationships.
    a. Reinforce positive coping mechanisms.
    b. Assist family to express feelings and fears.
    c. Support as normal a life as possible for child.

Pediatric Nursing: Rheumatic Fever

Focus topic: Pediatric Nursing

Definition: A systemic inflammatory (collagen) disease that usually follows a group A beta-hemolytic Streptococcus infection.

Assessment
A. Jones criteria utilized by healthcare professionals for diagnosis (there is no single clinical pattern).

B. Evaluate supporting evidence.

  •  Recent scarlet fever.
  •  Positive throat culture for group A streptococci.
  •  Increased streptococcal antibodies: ASO (antistreptolysin O) titer.

Implementation
A. Provide antibiotic therapy against any remaining streptococci.
B. Maintain fluid balance.
C. Ensure sufficient bed rest.
D. Prevent further infection.
E. Instruct on use of long-term antibacterial prophylaxis Permapen (penicillin).

Pediatric Nursing

 

 Pediatric Nursing: Infective (Bacterial) Endocarditis

Focus topic: Pediatric Nursing

Definition: An infectious disease involving abnormal heart tissue, particularly rheumatic lesions or congenital defects.

Assessment
A. Look for insidious onset of symptoms.
B. Assess for fever (unexplained, low-grade, intermittent).
C. Check for lethargic behavior and general malaise.
D. Assess for anorexia and weight loss.
E. Evaluate for splenomegaly.
F. Assess for splinter hemorrhages under the nails, and on the palms and the soles (Janeway spots), petechiae on oral mucous membranes.
G. A new murmur.

Implementation
A. Current practice for giving antibiotic therapy before surgery or dental procedures: no longer recommended (American Heart Association, 2007) except for clients with the highest risk of infective endocarditis.
B. Provide several weeks of IV antibiotic therapy for diagnosis of infective endocarditis, usually penicillin or cephalosporin, depending on organism.
C. Support cardiovascular function.
D. Ensure adequate bed rest.
E. Monitor erythrocyte sedimentation rate (ESR) and increased leukocytes.
F. Repeat blood cultures as ordered.

Pediatric Nursing: Kawasaki Disease

Focus topic: Pediatric Nursing

Definition: An acute systemic vasculitis a children’s disease, most frequently seen in boys under age 5 of Asian ancestry. It responds like a viral disease of lymph nodes; cause is suspected to be an immune-mediated vasculitis triggered by an acute infection or by a bacterial toxin. One in five children with Kawasaki disease develops coronary artery aneurysms.

Assessment
A. Assess for age, sex, and ancestry to determine if child fits usual profile.
B. Assess for acute symptoms: persistent high fever without a specific cause, generalized rash over the trunk, swollen hands and feet, redness of the conjunctivae, swollen lymph glands in the neck, cracking of lips, strawberry tongue. Subacute phase: fissures on skin, joint pain, thrombocytosis, and cardiac disease.
C. Assess for potential heart involvement (aneurysm, blocked coronary artery leading to a heart attack, myocarditis or pericarditis; arrhythmias, ST segment changes, and enzyme elevations can also occur).

D. Lab findings include: elevated ESR, elevated platelet count and elevated C-reactive protein level, elevated liver enzymes.
E. Thrombocytosis (peaks at 3–4 weeks; may go very high), anemia, or leukocytosis.

Implementation
A. Since cause is unknown, no specific treatment is ordered.

B. Intravenous immunoglobulin (IVIG) is administered to prevent coronary artery disease (must be given early).

  •  Commonly given initially in high doses for its anti-inflammatory effect.
  •  Later given in low doses for its anti-aggravation platelet action.

C. Monitor high doses of aspirin to reduce fever, pain, and inflammation high doses may be given to reduce inflammation.

  •  Dose: 80–100 mg/kg/day given when fever is high.
  •  Given until platelet count is normal (to prevent thrombocytosis).

D. Anticoagulation and thrombolytic therapy may be required.

E. Corticosteroids may be added if the child does not improve with IVIG and aspirin.

Pediatric Nursing: Cardiac Surgery

Focus topic: Pediatric Nursing

Assessment
A. Preoperative.

  •  Determine if child is physically prepared for surgery.
  •  Determine if child and family are psychologically prepared for surgery.
  •  Assess readiness of child and family to learn postoperative procedures; perform teaching.
  • Observe for signs of infection and CHF.
  •  Check that all laboratory tests are completed.

B. Postoperative.

  • Observe for patency of the airway, administer appropriate support to reduce respiratory work and maintain oxygenation and ventilation.
  • Evaluate cardiovascular function, vital signs, quality of pulses, temperature of extremities, and fluid balance. Manage invasive monitoring lines.
  • Evaluate chest tube drainage, clotting, and signs of postoperative bleeding.
  • Monitor cardiac rate and rhythm.
  •  Assess need for inotropic support as needed, vigilant monitoring of prescribed fluid balance.
  •  Evaluate child’s hydration and nutrition status frequently. Advance feedings carefully, when appropriate.
  • Ensure environment provides opportunity for rest.
  • Evaluate pain (efficacy of analgesics and sedation).
  • Observe for postoperative complications and HF.
  • Promote return to activity as indicated.

Implementation
A. Preoperative.

  •  Evaluate laboratory values for presence of infection or other abnormalities.
  •  Discuss with the parents of the child the extent of preparation that the child has received.
  • Plan with the parents the approach and timing of preoperative teaching.
  •  Ensure that written consent is obtained.
  •  Utilize dolls or models to explain the surgery and postoperative treatment.
  •  Conduct a tour of the intensive care unit for the parents and the child and introduce the child to the staff.
  •  Teach the child how to cough and deep breathe using blow bottles or other devices.

B. Postoperative.

  • Maintain adequate pulmonary function.
    a. Maintain patent airway.
    b. Maintain ventilator if required by child.
    c. Administer oxygen as ordered.
    d. Check rate and depth of respirations.
    e. Suction as necessary.
    f. Instruct child to deep-breathe and cough.
    g. Encourage use of incentive spirometry.
  • Maintain adequate circulatory functioning.
    a. Monitor hemodynamic status and check vital signs.
    b. Monitor rate of IV replacement fluids.
    c. Replace blood when required.
    d. Maintain very accurate hourly intake and output records.
  • Monitor chest tube drainage and patency.
  •  Provide adequate analgesia (and sedation if warranted).
  •  Provide for rest through organized care.
  •  Establish adequate hydration and nutrition.
  •  Encourage ambulation and activity as tolerated.
  •  Observe for complications of cardiac surgery.
    a. Pneumothorax.
    b. Hemothorax.
    c. Shock.
    d. Cardiac failure.

e. Heart block.
f. Cardiac tamponade.
g. Hemorrhage.
h. Hemolytic anemia.
i. Post cardiotomy syndrome: sudden fever, carditis, and pleurisy.
j. Post perfusion syndrome (3–12 weeks after surgery): fever, malaise, and splenomegaly.
k. Embolism, air or clot.

  • Observe for late complications.
    a. Respiratory: pneumonia.
    b. Infection: incision area.
    c. Congestive heart failure.
    d. Post pericardiotomy syndrome (assess for symptoms of fever, pericardial friction rub, and pleural effusion).
    e. Post perfusion syndrome (assess for fever, hepatosplenomegaly, leukocytosis, malaise, and maculopapular rash).
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Pediatric Nursing: Heart Failure

Focus topic: Pediatric Nursing

Definition: Heart failure (HF) occurs when cardiac output is insufficient to meet the body’s metabolic needs or when the heart cannot adequately pump venous return, causing pulmonary congestion (left ventricular failure), systemic edema (right ventricular failure), or both. HF in infants and children has many other causes. Acute severe HF in neonates or infants is a medical emergency. The increased volume of blood in the lungs decreases pulmonary compliance and increases the work of breathing. Fluid leaks into the interstitial space and alveoli and causes pulmonary edema.

Assessment
A. In infants, signs of HF include tachycardia, tachypnea, dyspnea with feeding, diaphoresis, chest retractions, nasal flaring, wheezing, and restlessness and irritability.
B. Dyspnea causes insufficient caloric intake and poor growth, which may be accentuated by increased metabolic demands in HF and frequent respiratory tract infections.
C. Hepatomegaly is common and liver is easily palpated.
D. Most infants do not have distended neck veins and dependent edema; occasionally have periorbital edema.
E. Findings in older children with HF are similar to those in adults.
F. Children with severe heart failure (cardiogenic shock) appear extremely ill and have cold extremities, diminished pulses, low BP, and reduced response to stimuli.
G. Diagnosis: HF is a clinical diagnosis based on auscultation, pulse oximetry, ECG, and chest x-ray. Echocardiography usually confirms the diagnosis.

Pediatric Nursing

 

Implementation
A. Medical treatment of HF is similar to that in adults.

B. Treatment may include a diuretic (e.g., Lasix) and ACE inhibitor (e.g., Capoten) and/or Lanoxin. (See Table 13-7.)

C. Nursing care.

  • Enhanced caloric content feedings are recommended. Some children require nasogastric or gastrostomy feedings to maintain growth.
  • Surgical repair of the anomaly is indicated if weight gain is not established, with appropriate postoperative nursing care.
  •  Cardiac monitoring and meticulous I&O monitoring.
  •  Humidified O2 should be given by mask, or nasal prongs with adequate FIO2 to prevent cyanosis and alleviate respiratory distress.
    a. When possible, FIO2 should be kept < 40% to prevent pulmonary epithelial damage in neonates.

Pediatric Nursing: Oral Digoxin Dosage in Children*

Focus topic: Pediatric Nursing

Pediatric Nursing

 

b. Upright position may benefit small infants and children, by reducing pressure in the thorax from abdominal organs and reducing work required for breathing.

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