INTUSSUSCEPTION

Definition:

Intussusception is the invagination of one portion of the intestine into another. This
generally occurs in the second half of the first year of a child’s life.

Signs and Symptoms:

 Vomitus containing bile

 Blood in stool or "currant jelly" stool
 Abdomen becomes distended as the bowel above the intussusceptions distends.
 Elevated temperature
 Peritoneal irritation
 Increased white blood cell count
 Shock like state with rapid pulse, pallor, and marked sweating

Treatment:

Enemas. The enema increases the pressure in the child's intestine, which can often cause
the affected area to return to its normal position.
Surgery.

Sometimes surgery is needed for intussusception. Surgery may be needed if:

 Enemas have not corrected the problem after two or three attempts.
 Doctors suspect that the intestine has been damaged and needs to be repaired.
 The child is very ill or the intestine has ruptured, leaking stool into the abdomen.

Diagnostic Procedure:

 plain abdominal X-rays

 Ultrasound

Nursing Care:

 Monitor I.V. fluids and intake and output to guide in fluid balance.
 Be alert for respiratory distress due to abdominal distention.
 Monitor vital signs, urine output, pain, distention, and general behavior preoperatively
and postoperatively.
 Observe infant’s behavior as indicator of pain; may be irritable and very sensitive to
handling or lethargic or unresponsive. Handle the infant gently.
 Explain cause of pain to parents, and reassure them about purpose of diagnostic tests and
treatments.
 Administer analgesic as prescribed.
 Maintain NPO status as ordered.
 Insert nasogastric tube if ordered to decompress stomach.
 Continually reasses condition because increased pain and bloody stools may indicate
perforation.
 After reduction by hydrostatic enema, monitor vital signs and general condition –
especially abdominal tenderness, bowel sounds, lethargy, and tolerance to fluids – to
watch recurrence.
 Encourage follow up care.
 Provide anticipatory guidance for developmental age of child.

Medical Management:

 Surgery to straighten the invaginated portion

Nursing Diagnosis:

o Pain related to abnormal abdominal peristalsis

o Risk for deficient fluid volume related to bowel obstruction
o Risk for impaired parenting related to the infant’s illness

Pathophysiology

Pathophysiology

In simple mechanical obstruction, blockage occurs without vascular compromise. Ingested fluid
and food, digestive secretions, and gas accumulate above the obstruction. The proximal bowel
distends, and the distal segment collapses. The normal secretory and absorptive functions of the
mucosa are depressed, and the bowel wall becomes edematous and congested. Severe intestinal
distention is self-perpetuating and progressive, intensifying the peristaltic and secretory
derangements and increasing the risks of dehydration and progression to strangulating
obstruction.

Strangulating obstruction is obstruction with compromised blood flow; it occurs in nearly 25%
of patients with small-bowel obstruction. It is usually associated with hernia, volvulus, and
intussusception. Strangulating obstruction can progress to infarction and gangrene in as little as 6
h. Venous obstruction occurs first, followed by arterial occlusion, resulting in rapid ischemia of
the bowel wall. The ischemic bowel becomes edematous and infarcts, leading to gangrene and
perforation. In large-bowel obstruction, strangulation is rare (except with volvulus).

Perforation may occur in an ischemic segment (typically small bowel) or when marked dilation
occurs. The risk is high if the cecum is dilated to a diameter ≥ 13 cm. Perforation of a tumor or a
diverticulum may also occur at the obstruction site.
HYDROCEPHALUS

Definition:

Hydrocephalus is an excess of cerebrospinal fluid (CSF) in the ventricles and

subarachnoid spaces of the brain.

Signs and Symptoms:

 Prominent scalp veins

 Bossing of the forehead
 Enlarged fontanelles
 Sunset eyes
 Shrill cry
 Hyperactive reflexes
 Separated suture lines
 Increased head circumference
 Lethargy of irritability
 Signs of increases intracranial pressure
 decreased pulse rate
 increased temperature
 decreased respirations
 increased blood pressure

Treatment:

 Acetazolamide and furosemide - Decreasing CSF secretion by the choroid plexus

 Isosorbide (effectiveness is questionable) - Increasing CSF reabsorption

Diagnostic Procedure:

 Ultrasound
 computerized tomography (CT)
 magnetic resonance imaging (MRI)
 Lumbar puncture or tap
 Continuous lumbar CSF drainage
 Intracranial pressure (ICP) monitoring
 Measurement of cerebrospinal fluid outflow resistance or isotopic cisternography
 Neuropsychological testing.

Nursing Care:

1. Teach the family about the management required for the disorder

a. Treatment is surgical by direct removal of an obstruction and insertion of shunt to

provide primary drainage of the CSF to an extracranial compartment, usually
peritoneum (ventriculoperitoneal shunt)

1. The major complications of shunts are infections and malfunction

2. Other complications include subdural hematoma caused by a too rapid

reduction of CSF, peritonitis, abdominal abscess, perforation of organs,
fistulas, hernias and ileus.

b. A third ventriculostomy is a new nonshunting procedure used to treat children with

hydrocephalus.

2. Provide preoperative nursing care

a. Assess head circumference, fontanelles, cranial sutures, and LOC; check also for
irritability, altered feeding habits and a high-pitched cry.

b. Firmly support the head and neck when holding the child.

c. Provide skin care for the head to prevent breakdown.

d. Give small, frequent feedings to decrease the risk of vomiting.

e. Encourage parental-newborn bonding.

3. Provide Postoperative nursing care (nursing interventions are the same as those for increased
ICP)

a. Assess for signs of increased ICP and check the following; head circumference (daily),
anterior fontanelle for size and fullness and behavior.

b. Administer prescribed medications which may include antibiotics to prevent infection

and analgesics for pain.

c. Provide shunt care

1. Monitor for shunt infection and malfunction which may be characterized by
rapid onset of vomiting, severe headache, irritability, lethargy, fever, redness
along the shunt tract, and fluid around the shunt valve.

2. Prevent infection (usually from Staphylococcus epidermis or Staphylococcus

aureus)

3. Monitor for shunt overdrainage (headache, dizziness and nausea). Overdrainage

may lead to slit ventricle syndrome whereby the ventricle become accustomed
to a very small or slitlike configuration, limiting the buffering ability to
increased ICP variations.

4. Teach home care

a. Encourage the child to participate in age-appropriate activities as tolerated. Encourage

the parents to provide as normal lifestyle as possible. Remind both the child and
parents that contact sports are prohibited.

b. Explain how to recognize signs and symptoms of increased ICP. Subtle signs include
changes in school performance, intermittent headache, and mild behavior changes.

c. Arrange for the child to have frequent developmental screenings and routine medical
checkups.

Medical Management:

Surgical correction

Shunt placement. The hydrocephalus treatment of choice is the surgical placement of a

hydrocephalus shunt system. This system diverts the flow of cerebrospinal fluid (CSF)
from a site within the central nervous system (CNS) to another area of the body where it
can be absorbed as part of the circulatory process.

Third ventriculostomy. For a limited number of patients, hydrocephalus treatment can

be performed using an alternative procedure called third ventriculostomy. In this
hydrocephalus treatment, a neuroendoscope -- a small camera designed to visualize small
and difficult-to-reach surgical areas -- allows a doctor to view the ventricular surface
using fiber optic technology. The scope is guided into position so that a small hole can be
made in the floor of the third ventricle, allowing the CSF to bypass the obstruction and
flow toward the site of resorption around the surface of the brain. 
Nursing Diagnosis:

o Risk for ineffective cerebral tissue perfusion related to increased intracranial pressure
o Risk for imbalanced nutrition , less than body requirements related to increased
intracranial pressure
o Risk for impaired skin integrity related to weight and immobility of head
o Risk for delayed growth and development related to potential neurologic challenge
o Deficient parental knowledge related to hydrocephalus and shunt insertion
o Deficient knowledge related to home care needs of child with hydrocephalus

Pathophysiology
OTITIS MEDIA

Definition:

Otitis media is the inflammation of the middle ear (the cavity between the eardrum and
the inner ear).It is the most prevalent disease of childhood after respiratory tract infections.

Signs and Symptoms:

 Colds
 Rhinitis
 Low grade fever for a number of days
 Fever of about 102○F (38○C)
 Sharp, constant pain in one or both ears
 External canal generally free of wax
 Tympanic membrane appears inflamed bulging into the external canal

Treatment:

Antibiotics such as ampicillin or amoxicillin

Erythromycin and sulfonamide for increased organism resistant

Diagnostic Procedure:

 Tympanocentesis. To obtain fluid for culture at the time of assessment.

Nursing Care:

 Suggest alternative for comfort, such as gentle rocking and close cuddling.
 Caution mother to position to child on the unaffected ear
 Institute antibiotic therapy as ordered. Strongly reinforce need for completion of a full
course of a full course of therapy.
 Suggest use of saline nose drops or nasal spray.
 Encourage the mother to offer liquids and soft finger foods.

Medical Management:

 Prescription of decongestant nose drops to open eustachian tubes

 Surgery if the child's infection fails to respond to antibiotics, if the ear infections are
chronic or hearing loss is indicated. The most common type of surgery is myringotomy.

Nursing Diagnosis:
o Pain related to inflammation and erythema secondary to ear infection
o Powerlessness related to repeated episodes of otitis media

Pathophysiology
IMPERFORATED ANUS

Definition:

Imperforated anus is the stricture of the anus.

Signs and Symptoms:

 membrane filled with black meconium can be seen protruding from the anus
 abdominal distention evident
 Anal opening very near the vaginal opening in girls
 Missing or misplaced opening to the anus
 No passage of first stool within 24 - 48 hours after birth
 Stool passes out of the vagina, base of penis, scrotum, or urethra
 Swollen belly area

Treatment:

Surgical reconstruction of the anus is needed. If the rectum connects with other organs,
repair of these organs will also be necessary. A temporary colostomy is often required.

Diagnostic Procedure:

 Urinalysis
 X- ray
 Sonogram

Nursing Care:

 Before surgery, keep infant NPO to avoid further bowel distention.

 Administer intravenous therapy to maintain fluid and electrolyte imbalance
 Caution parents to avoid unrefined rice and grains, vegetables with fibers, or fruits with
peel.
 Take axillary or tympanic temperatures rather than rectal temperatures.
 Avoid enemas, suppositories, or any other intrusive rectal procedures.
 Clean suture line well after bowel movements by irrigating it with normal saline.
 Place diaper under, not on the infant so that bowel movements can be cleansed away as
soon as they occur
 Do not place infant on abdomen because in this position, newborns tend to pull their knees
under them, causing tension in the perineal area. A side lying is best.

Medical Management:

 Surgery. The degree of difficulty in repairing an imperforate anus depends on the extent
of the problem.

Nursing Diagnosis:

o Imbalanced nutrition, less than body requirements related to bowel obstruction and
inability for oral intake
o Impaired tissue integrity at rectum related to surgical incision
o Risk for impaired parenting related to difficulty bonding with infant ill at birth

Pathophysiology
FAILURE TO THRIVE

Definition:

Failure to thrive is a unique syndrome in which an infant falls below the fifth percentile
for weight and height on a standard growth chart or is falling in percentiles on a growth chart.

Signs and Symptoms:

 Lethargy with poor muscle tone

 A loss of subcutaneous fat
 Skin breakdown
 Inability to resist the examiner’s manipulation the way the average infant does
 Staring hungrily at people who approach them as if they are starved from human contact
 Little cuddling or conforming to being held by the second month life
 Achievement of development milestones in the prone position by third of fourth month,
but delays in other behaviors that should appear in later months
 Markedly delayed or absent speech
 Diminished or nonexistent crying

Treatment:

Diet appropriate for the ideal weight

Diagnostic Procedure:

 Routine admission blood work

 Urinalysis
 Fecalysis

Nursing Care:

 Ensure adequate nutrition. Keep a careful record of intake and output so that the number
of calories being consumed everyday can be evaluated. Assess stools for pH and reducing
substances (glucose) to be certain the child is absorbing nutrients.
 Nurture the child. Give effective parenting. Spend time rocking the child, giving a
leisurely bath, talking to the child, exposing the child to toys, and parenting the child
rather than just giving routine care.
 Support and encourage the parents. Encourage the parents to visit as much as possible
while the child hospitalized or in foster care. Encourage the parents to feed the child if
they want and interact with the child as they choose. Give some suggestions about how the
baby tries to communicate with them.
 Ensure evaluation and follow-up. Adequate follow up to ensure that the emotional and
physical needs continue to be met is a much larger issue, so big that the answer lies not in
treatment but in prevention. Give counseling and close follow up in the postnatal period.
Secure careful, thoughtful pregnancy histories to elicit information about physiologic
events that could lead to parenting breakdown.

Medical Management:

Nursing Diagnosis:

o Imbalanced nutrition, less than body requirement related to inadequate intake secondary
to emotional deprivation

Pathophysiology
FEBRILE SEIZURES

Definition:

Febrile seizures are seizures associated with high fever and are the most common in
preschool children, or between 5 months and 5 years of age, although seizures may occur as
early as 3 months and as late as 7 years.

Signs and Symptoms:

 Consistent high fever or a sudden spike of temperature

Treatment:

Antipyretic drugs to reduce the fever below seizure level

Antibiotic therapy

Diagnostic Procedure:

Nursing Care:

Medical Management:

Nursing Diagnosis:

Pathophysiology