Chapter 49 nursing care of a family when a child has a neurologic disorderastereognosis inability to judge the form of an object by touch automatism the performance of acti autonomic dysreflexia involves uncontrolled activation of autonomic neurons chorcoathetosis, movement disorder with features of both chorea and athetosis chorcoid irregular and jerking movements decerebrate posturing posturing in which the neck is extended with jaw clenched: arms are pronated, extended, and close to the sides; legs are extended straight out; more ominous sign of brain stem damage. Most Severe. decorticate posturing characterized by upper extremities flexed at the elbows and held closely to the body and lower extremities that are externally rotated and extended. occurs when the brainstem is not inhibited by the motor function of the cerebral cortex diplegia paralysis affecting like parts on both sides of the body dyskinetic difficult movement graphesthesia ability to "read" a number by having it traced on the skin hemiplegia paralysis of one side of the body infantile spasms Sudden, rapid flexion of neck and truck, adduction of shoulders and outstretched arms, variable flexion of lower extrem Tx: vigabatrin kinesthesia system for sensing the position and movement of individual body parts, without conscious thought or intention. paralysis from the waist down pulse pressure difference between systolic and diastolic pressure quadriplegia paralysis of all four limbs of the body status epilepticus condition in which seizures recur every few minutes or last more than 30 minutes stercognosis ability to recognize objects by feeling their form, size, and weight while the eyes are closed d) Use a doll with electrodes attached to the head Pg. 1383 Scanned with CamScannerAn clectroencephalogram (EEG) is a test to measure the electrical activity of the brai |. It is conducted by attached electrodes over sections of the head and obtains an electrical reading via a monitor. There is no pain involved in the procedure, but the child must lie still. The best way for the nurse to explain the procedure to the child is via a doll with attached electrodes that the child can play with, feel, and manipulate. This helps to reduce the child's anxiety and aids in cooperation. Videos can help with the education process but they do not allow for interaction and physical touching. The child can take anap during the procedure but this does not prepare the child for the procedure. Assuring the child that the procedure will not hurt is not the best way to prepare the child. 1, The nurse is preparing a child experiencing new-onset seizures for an eleciroencephalogram (EEG) test. How can the nurse best explain this procedure to the child? a) Show the child a video of the procedure b) Tell the child he or she can take a nap durin; c) Assure the child the procedure will net hurt ) Use a doll with electrodes attached to the head d) "Use this information to teach family and friends" e procedure Pg. 1399 Families need and want information they can share with relatives, child care providers, and teachers. Wearing a helmet and having a monitor in the room are precautions that may need to be modified as the child matures. The child may be able to bike ride and swim with proper precautions. 2. The nurse is educating the family of a 7-year-old with epilepsy about care and safety forthis child. What comment will be most valuable in helping the parent and the child cope? a) “If he is out of bed. the helmet's on the head” b) “You'll always need a monitor in his room” c) "Bike riding and swimming are just too dangerous" 4d) "Use this information to teach family and friends" ¢) While assessing the child's pupils, there is no change in diameter in response to alight Pg. 1384 ‘To perform the child’s eye reflex examination, the nurse will shine a pentight into the eyes and observe if the pupils constrict, which is a normal response. Lack of pupillary light reflex can indicate increased intracranial pressure (ICP). To perform the "doll’s eye” reflex examination, the nurse will place the child in a supine position and move the head gently but rapidly to one side. During this movement, it is normal for the child's eye to move to the opposite side. If the child has increased ICP, this response will be absent. While the other options are potential signs of increased ICP, they donot demonstrate the child's eye reflex examination. 3. The nurse is caring for a child with a suspected head injury. The nurse observes for ‘what response to the child's eye reflex examination that would indicate potential Scanned with CamScannerincreased intracranial pressure (ICP)? a) While calling the child's name, the child stares straij ad and does not turn to the sound by Whit outward ©) While assessing the child's pupils, there is no change in diameter in response to a light d) While turning the child's head to the left, the eyes turn to the right a) Loss of motor activity accompanied by a blank stare imulating the child's foot, the big toe points upward and other toes fan Pg. 1397 Anabsence seizure consists of a sudden, brief arrest of the child’s motor activity accompanied by a blank stare and loss of awareness. A tonic seizure consists of a brief onsct of increased tone or muscle. A myoclonic seizure is characterized by sudden, brief jerks of muscle groups. An atonic seizure involves a sudden loss of muscle tone and loss of consciousness. 4, Absence seizures are marked by what clinical manifestation? a) Loss of motor activity accompanied by a blank stare by Sudden, brief jerks ofa muscle group. ¢) Loss of muscle tone and loss of consciousness 4d) Bricf, sudden onset of increased tone of the extensor muscle b) As the child grows, the gross and fine motor skills Increase Pg. 1377 As the child grows, the quality of the nerve impulses sent through the nervous system develops and matures. As these nerve impulses become more mature, the child's gross and fine motor skills increase in complexity. The child becomes more coordinated and able to develop motor skills. 5. What information is most correct regarding the nervous system of the child? a) The child has underdeveloped fine motor skills and well-developed gross motor skills b) As the child grows, the gross and fine motor skills increase ) The child has underdeveloped gross motor skills and well-developed fine motor Sh 4) The child's nervous system is fully developed at birth a) Clonie P 397 ‘The inldial rigidity of the tonte phase changes rapidly to generalized Jerking muscle movements in the clonic phase. The child may bite the tongue or lose control of bladder and bowel functions. The jerking movements gradually diminish and then disappear, and the child relaxes. 6. The nurse is in the room when a child witha seizure disorder is having a seizure. ‘The child is exhibiting generalized jerking muscle movement, and the nurse notes the Scanned with CamScannerbed appears to be wet with urine, The child is in which stage of the generalized seizure? a) Clonic b) Tonic ©) Prodromal 4) Postictal ©) "You look funny. Well, both of you do. Isee two of you" Pg. 1379 ‘The caregiver should notify the health care provider immediately if the child vomits more than three times, has pupillary changes, has double or blurred vision, has a change in level of consciousness, acts strange or confused, has trouble walking, or has a headache that becomes more severe or wakes him or her from sleep. These instructions should be provided in written form to the caregiver. Just feeling nauseated is not a reason to notify the provider. 7. A child is home with the caregivers following a treatment for a head inju caregiver should contact the care provider if the child makes which statement? a) "My stomach is upset. I feel like I might throw up" b) "Tam glad that my headache is getting better” ¢) "You look funny. Well, both of you do. I see two of you" 4) "Itwill be nice when you will let me take a long nap. 1am sleepy” ©) Cerebral edema Pg. 1391 The child with meningitis is already at increased risk for cerebral edema and increased intracranial pressure due to inflammation of the meningeal membranes; therefore, the nurse should carefully monitor fluid intake and output to avoid fluid volume overload, Renal failure and cardi aren't complications of IV therapy. The child with a healthy heart wouldn't be expected to develop left-sided heart failure. 8. To detect complications as early as possible in a child with meningitis who's receiving IV fluids. monitoring for which condition should be the nurse's priority? a) Cardiogenic shock b) Left-sided heart failure ©) Cerebral edema 4) Renal failure © Trigeminal Pe. 1380 To test the trigeminal nerve, the nurse would note the strength of the infant's suck on a pacifier, thumb, or bottle. The olfactory nerve is not assessed in infants and young children. The facial nerve is assessed by noting the symmetry of facial expressions. For the infant, this would be assessed during spontaneous erying or Scanned with CamScannersmiling. The accessory nerve is assessed when the infant is in the sitting position and symmetry of the head position is noted. 9. During a well-child visit, the nurse assesses an infant's ability to suck on a paci! The nurse is assessing which cranial nerve? a) Ac ) Facial ¢) Trigeminal 4) Oliactory ©) "hate to think that I will need to be worried about my child having seizures for the rest of his life” ory Pg. 1395-1396 Febrile seizures occur most often in preschool children but can occur as late as 7 years of age. They occur when the child has a rapid rise in temperature and are not associated with the development of seizures later in life. Administering correct dosages of acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures. 10. The nurse is caring fora child who has suffered a febrile seizure, While speaking with the child's parents, which statement by a parent indicates a nced for further education? a) "The next time he has a fever, Ineed to make sure I read the dosage on the acetaminophen bottle carefully” b) “When he gets his next set of immunizations, I need to make sure I give him some ibuprofen so he doesn't spike a fever" ¢) "Thats to think that I will need to be worried about my child having seizures for the rest of his life" 4) “Tneed to set an alarm to wake up and check his temperature during the night when he is sick” ©) Reassure the mother that her partner's reaction is a normal stage in the grieving process Pg. 1407 The family's first reaetion to learning that the child may have cognitive impairment is grief because this is not the perfect child of their dreams. A parent may feel shame, assuming that he or she cannot produce a perfect child. Some rejection of the child is almost inevitable at least in the initial stages, but this must be worked through for the family to cope. 11, The mother of a child newly diagnosed with an intellectual disability tells the nurse that her partner disagrees with the diagnosis and believes that the child is perfectly normal. The mother shares with the nurse that she finds this reaction frustrating and confusing. Which action by the nurse would be appropriate in supporting this mother? a) Recommend that the couple consider placing the child in foster care until they adjust to the diagnosis, Scanned with CamScannerb) Suggest that the couple get a second opinion about the child's condition c) Reassure the mother that her partner's reaction is a normal stage in the grieving process ) Offer to speak with the partner to explain how the diagnosis was reached b) Bulging fontanels (fontanelles) Pg. 1384 Infants with increased ICP exhibit bulging fontanels (fontanelles). They typically have a decreased appetite, are restless, and have trouble sleeping. 12, What finding is consistent with increased intracranial pressure (ICP) in an infant? a) Narcolepsy b) Bulging fontanels (fontanelles) ) Increased appetite 4) Emotional lability a) Positive Kernig sign Pg. 1391 A positive Kernig sign can indicate irritation of the meninges. A positive Brudzinski sign also is indicative of the condition. A positive Chadwick sign is a bluish discoloration of the cervix indicating pregnancy. 13. A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges? a) Positive Kernig sign b) Negative Kernig s c) Negative Brud, 4) Positive Chadwick sign d)"For a lumbar puncture, the child will be placed in a side-tying position with knees bent and neck flexed to assist with arching the back” Pg. 1381 Correct positioning for a lumbar puncture /s to place the child on his or her side with the neck flexed and knees bent and drawn up to their chest. This helps to keep the back arched as much as possible. Newborns may be seated upright with their head bent forward. The child is not placed prone; this does not allow the back to be arched. 14, The nurse helps position a child for a lumbar puncture, Which statement describes the correct positioning for this procedure? a) "The child will be placed in the prone position with the nurse holding the child stil b) "When positioning the child, the nurse needs to a position and keep his back as flat as much as possible’ ¢) "The child will be held by the mother on her lap with his back toward the health care provider" ist the child to a side-lying Scanned with CamScanner4d) "For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back" ©) Collection of cerebrospinal fluid (CSF) and blood for culture Pg. 1391 Antibiotic therapy should always begin immediately after the collection of CSF and blood cultures. After the specific organism is Identified, hacterla-specific antibiotics can be administered if the initial choice of antibiotic therapy isn’t appropriate. Admission and initiation of IV therapy aren't, by themselves, appropriate times to begin antibiotic therapy. 15. Antibiotic therapy to treat meningitis should be instituted immediately after which event? a) Identification of the causative organism b) Admission to the nursing unit ¢) Collection of cerebrospinal fluid (CSF) and blood for culture 4) Initiation of IV therapy b) "She has been irritable for the last hour...seems like she is just upset for some reason" Pg. 1384 Irritability in an infant can be a sign of declining neurological function, Because infants are not able to answer questions pertaining to person, place and time, their neurological assessment must be catered to their level of development. The other responses would be typical and normal for an infant. 16. The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse fo further assess the child's neurological status? a) "She typically breastfeeds, but lately we have had to supplement with some rice cereal” b) "She has been irritable for the last hout....seems like she is just upset for some reason” c) "She is a pretty happy baby, unless her diaper is wet, then she cries until we change her diaper" 4) "She always cries when the person holding her has on glasses...I guess glasses seare her" b) Check the child's neurologic status every 2 hours Pg. 1391-1392 The nursing interventions for the child with meningitis are related to the goals for this child, which include monitoring for complications related to neurologic compromise, preventing aspiration, keeping the child safe from injury during a seizure, and monitoring fluid balance. During a seizure, stay with the child, protect the child from injury, but do not restrain him or her. To prevent aspiration, position the child in a side-lying position, watch for and remove excessive mucus as much as possible, and use suction sparingly. Every 2 hours, Scanned with CamScannerobserve the child for setzure activity, vital signs, neurologic changes, and change in level of consciousness. The child is placed on fluid restrictions if he or she has decreased urinary output, hyponatremia, increased weight, nausea, and Irritability. 17, When caring for an infant who is hospitalized with Haemophilus influenzae meningitis, an important nursing intervention for the child would be for the nurse to: a) Restrain the child before and during a seizure b) Check the child's neurologic status every 2 hours c) Monitor intake and output and increase fluid intake every 4 hours d) Place the child ina side-lying position and keep the position using pillows ¢) Risk for injury related to seizure activity Pg. 1398 ‘The child's risk for injury would be an appropriate nursing diagnosis. Surgery is not indicated for the child with meningitis, and if the child has a history of seizures, it would specifically impact airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis. 18. In caring for the child with meningitis, the nurse recognizes that which nurs diagnosis would be most important to include in this child's plan of care? a) Ineffective airway clearance related to history of seizures b) Risk for acute pain related to surgical procedure ) Risk for injury related to seizure activity ) Delayed growth and development related to physical res 4) High-pitched ery and nuchal rigidity Pg. 1391 Children with meningitis may have a characteristic high-pitched cry, fever, and irritability. Other symptoms include headache, nuchal rigidity (stiff neck) that may progress to opisthotonos (arching of the back), and delirium. 19. The nurse is caring for a 12-month-old infant diagnosed with Haemophilus influenzae meningitis. Which clinical manifestation would likely have been noted in this child? a) Shaking the head and pulling the ear b) Body stiffening and loss of consciousness ¢) Severe vomiting and confusion 4) High-pitched ery and nuchal rigidity @) Lo or LS Pg. 1381 Lumbar puncture, the introduction of a needle into the subarachnoid space (under the arachnoid membrane) at the level of LA or LS to withdraw CSF for analysis, is used most frequently with children to diagnose hemorrhage or Infection In the CNS or to diagnose an obstruction of CSF flow, Scanned with CamScanner20. A9-year-old girl who is suspected of having an infection of the central nervous system (CNS) is undergoing a lumbar puncture to withdraw cerebrospinal fluid (CSF) for analysis. The nurse knows that the needle will be introduced into the subarachnoid space at the level of which of the following vertebrae? a) Ll or L2 b) T3 or T4 ©) Cl or C2 d) L4or LS d) Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Pg. 1397 Absence seizures are characterized by a brief loss of responsiveness with minimal or no alteration in muscle tone. They may go unrecognized because the child's behavior changes very little. A sudden loss of muscle tone describes atonic A frozen position describes the appearance of someone having akinetic A brief, sudden contraction of muscles deseribes a myoclonic seizure, 21. The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure? a) Sudden, momentary loss of muscle tone, with a brief loss of consciousness b) Brief, sudden contracture of a musele or musele group ©) Muscle tone mainiained and child frozen in position 4) Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention b) Teach the child and his parents to keep a headache diary Pg. 1402 A headache diary can help identify any triggers so that the child can avoid them. ‘Triggers can include foods eaten, amount of sleep the night before, or activities at home or school that might be causing stress. Reviewing signs of increased intracranial pressure would be inappropriate because increased intracranial pressure is not associated with headaches. Having the child sleep without a pillow is an intervention to reduce pain from meningitis. Vomiting more than twice is an indication that the parents should notify the physician or nurse practitioner when the child has a head injury. 22..A9-year-old boy is suffering from headaches but has no signs of physical or neurologic illness. Which intervention would be most appropriate? a) Have the parents call the doctor if the child vomits more than twice b) Teach the child and his parents to keep a headache diary ©) Review the signs of increased intracranial pressure with parents 4) Have the child sleep without a pillow under his head a) Decrease environmental stimulation Pg. 1391 Scanned with CamScannerA child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lic flat because this position docsn't eause increased meningeal irritation. 23. A preschool-age child has just been admitted to the pediatric unit with a diagnosis ‘of bacterial meningitis. The nurse would include which recommendation in the nursing plan? a) Decrease environmental stimulation b) Take vital signs every 4 hours ) Encourage the parents to hold the child d) Monitor temperature every 4 hours a) Port-wine birthmark om the upper part of the face Pg. 1386 A congenital port-wine birthmark on the upper part of the fuce that follows the trigeminal nerve is an indication of Sturge-Weber syndrome. Soft cutancous tumors, irregular but excessive skin pigmentation, and pigmented nevi are all symptoms of neurofibromatosis (von Reeklinghausen disease 24, The nurse is eating for a child diagnosed with Sturge-Weber syndrome, Which, sment finding supports this diagnos a) Port-wine birthmark on the upper part of the fice ‘b) Soft cutaneous tumors on the child's skin along nerve pathways c) Pigmented nevi or café-au-lait spots on the child's chest and arms 4d) Irregular but excessive skin pigmentation all over the child's body b) Sunsetting Pg. 1384 Sunsetting is when the sclera of the eyes is showing over the top of the iris. Decorticate posturing includes adduction of the arms, flexion at the elbows with the arms held over the chest, and flexion of the wrists with both hands fisted and the lower extremities adducted and extended. Nystagmus is manifested by involuntary rapid rhythmic eye movements. Doll's eye is a mancuver that tests for symmetric eye movement to the opposite side when the head is turned in the other direction. 25, The nurse inspects the eyes of a child and observes that the scler: the top of the iris. The nurse documents this finding as: showing over a) Decorticate posturing b) Sunsetting ©) Doll's eye d) Nystagmus b) Institute droplet precautions in addition to standard precautions Scanned with CamScannerPg. 1391 Bacterial meningitis is a medical emergency. The child must be placed on droplet Precautions until 24 hours of antibiotics have been given, Encouraging the mother to hold and comfort the child is an intervention but not the priority one; the focus is to get the infant the appropriate medications to fight the infection and to prevent its spread. Educating the family about preventing bacterial meningitis would be appropriate later once the initial infection has been controlled. Palpating the fontanels (fontanclles) is used to as: for hydrocephalus. 26. A 6-month-old infant is admitted with suspected bacterial meningitis. She is crying. irritable, and lying in the opisthotonic position. Which intervention should the nurse take initially? a) Encourage the mother to hold and comfort the infant b) Institute droplet precautions in addition to standard precautions c) Palpate the child's fontanels (fontanelles) 4) Educate the family about preventing bacterial meningitis a) Monitor the child's breathing closely Pg. 1397 ‘Tonic-clonic seizures consist of four stages: the prodromal period, when the child may be drowsy or dizzy; the aura, which is sensory event that serves as a warning immediately before the selzure; the tonic-clonic movements, when the child's muscles contract, the child may fall, and the child’s extremities may stiffen. The contraction of respiratory muscles during the tonle phase may cause the child to become cyanotic and appear briefly to have respiratory arrest. During the postictal period, the child may sleep soundly and may have a period of confusion or stupor. 27. The nurse is providing education to the caregivers of a child recently diagnosed ‘with tonic-clonic seizure disorder. What instructions should the nurse provide related to the tonic stage of this type of seizure? a) Monitor the child's breathing closely b) Be prepared for the child to be temporarily confused ¢) Ask the child whether he or she is experiencing any unusual sensory sensations d) Be prepared for the child to report being dizzy 4d) "This might or might not bea problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome” Pg. 1393 Reye syndrome usually occurs after a viral illness, particularly after an upper respiratory infection or varicella (chickenpox). Administration of aspirin during the viral iliness has been implicated as a contributing factor. As a result, the American Academy of Pediatrics recommends that aspirin or aspirin compounds not be given to children with viral infections. The symptoms appear within 3 to 5 Scanned with CamScannerdays after the initial illness: The child is recuperating unremarkably when symptoms of severe vomiting, irritability, lethargy, and confusion oc Immediate intervention is needed (o prevent serious insult to the brain, including, respiratory arrest. 28. A T-year-old client has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when she first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse? a) “This is unlikely to be a problem. Half.an aspirin is not enough to cause harm, Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus" b) "This is a scrious problem. Aspirin is likely to cause Reye syndrome, and she should be admitted to the hospital for observation as a precaution” ©) “This might or might not be a problem. Watch your daughter for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome” 4) "This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting, If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome" a) "Did you use any medications, like aspirin, for the fever?" Pg, 1393 Severe and continual vomiting, changes in mental status, lethargy, and irritability are some of the signs and symptoms of Reye syndrome, which can occur as a result of ingesting aspirin or aspirin-containing products during a viral infection. Tylenol (acetaminophen) is allowed for viral infections in the school-age child. The type of fluids consumed during the illness has nothing to do with Reye syndrome. The temperature rise would be important for 2 much younger child because of the chance of febrile seizures, but not in this age child. 29. A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question? a) "Did youuse any medications, like aspirin, for the fever?" b) "How high did his temperature rise when he was ill?" ©) "What type of fluids did your child take when he had a fever?" 4d) "Did you give your child any acetaminophen, such as Tylenol?” b) Support for maintaining self-esteem because of his altered lifestyle Pg. 1399 The effects of living with a seizure disorder can be devastating, and it is essential for the child to receive support to maintain self-esteem. While corrective surgery is possible. it would only be performed once. Physical, occupational, speech, and hyperventilation therapy are not indicated for treatment of epileps: Scanned with CamScanner30. The nurse is caring for an 8-year-old boy who has chronic epilepsy. What would be most important to address when teaching the child and parents about living with this condition? a) Physical, occupational, and speech therapy to ma his potential b) Support for maintaining self-esteem because of his altered lifestyle ©) Multiple corrective surgeries to slowly remove diseased parts of his brain 4) Hyperventilation therapy to counteract the periods of decreased oxygenation d) Assess the client's respiratory status Pe. ‘The nurse would place priority on monitoring the client's respiratory status since the client is on a ventilator and at risk for intracranial pressure. The nurse would educate the family on the shunt, monitor for infection, and measure head circumference; however, these actions are not priority over ensuring the client maintains a patent airway. 31. The nurse is caring for a child diagnosed with hydrocephalus following ventriculoperitoneal shunt placement. The child is currently on a ventilator. Which nursing action is priority? a) Measure the client's head circumference b) Monitor the client for signs of infection c) Educate the family on the shunt 4) Assess the client's respiratory status 4d) "Lalways keep phenobarbital with mein case of a fever" Pg. 1395 Anticonvulsants, such as phenobarbital, are administered to children with prolonged seizures or neurologic abnormalities. Ibuprofen, not phenobarbital, is given for fever. Febrile seizures usually occur after age 6 months and are unusual after age 5. Treatment is to decrease the temperature because seizures accur as the temperature rises. 32. An otherwise healthy 18-month-old child with a history of febrile seizures is in the well-child clinic. Which statement by the father would indicate to the nurse that additional teaching should be done? a) "My child will likely outgrow these seizures by age 5" b) "Ihave ibuprofen available in case it's needed" ©) "The most likely time for a seizure is when the fever is rising” d) “Ialways keep phenobarbital with me in case of a fever" ¢) Semi-Fowler position with a parent at the bedside Pg. 1382 Proper positioning for an infant after a ventricular (ap is to place the child in a semi-Fowler position to prevent additional drainage from the puncture site. Allow the parents or caregivers to comfort the child, Placing the child in the Scanned with CamScannerprone or supine position could allow for additional drainage from the puncture site. High-Fowler position is contraindicated immediately after this procedure. 33. A nurse is caring for an infant who has just undergone a ventricular lap. In what position should the nurse place the infant immediately after the procedure? of the bed 4) "I need to watch for any new bruises or bleeding and let my health care provider know about it” Pg. 1396 Carbamazepine is an antiseizure medication. It can cause bone marrow depression, so parents need to wateh for any signs of bruising, bleed, or infection and notify their health care provider if this happens. Administer this medication with foad to minimize GI upset. This medication can cause drowsiness, so do not give any sleep-inducing or other sedative type medications. Antiseizure medication does not cure seizures; it only controls the seizures. Lifelong antiseizure medication may be needed. 34. The nurse is providing teaching to the parents of a child recently prescribed ‘carbamazepine for a seizure disorder. Which statement by a parent indicates successful teaching? a) “L will give the medication to him when | first wake him up in the moming” b) "This medication may cause him to have trouble sleeping. He may need something else to help him sleep” c) "I'm glad to know he will only need this medication for a short time to stop his seizures” 4) "I need to watch for any new bruises or bleeding and let my health care provider know about it” a) Avoid making noise when in the child's room Pg. 1392 Meningeal irritation may cause seizures and heightens a child's sensitivity to all g noise, lights, movement, and touch. Frequent rocking, presence of a younger sibling, and bright lights would increase stimulation, 35. Which nursing action should be included in the care plan to promote comfort ina 4-year-old child hospitalized with meningitis? b) Rock the child frequently c} Keep the lights on brightly so that he can see his mother 4) Have the child's 2-year-old brother stay in the room c) Ataxie cerebral palsy Pg. 1389 Scanned with CamScannerAtaxie cerebral palsy is essentially a lack of coordination caused by disturbances enses; it is characterized by an awkward and wide-based gait. Athetoid cerebral palsy is marked by involuntary, uncoordinated motion with varying degrees of muscle tension. Children with this disorder are constantly in motion; the whole body is in a state of slow, writhing muscle contractions whenever voluntary movement is attempted. Rigidity cerebral palsy is uncommon and is characterized by rigid postures and lack of active movement. Spastic cerebral palsy is characterized by scissoring caused by severe hip adduction. 36. The nurse is observing a group of children diagnosed with various types of cerebral palsy. One of the children has an awkward and wide-based gait. The nurse recognizes this characteristic as common in which type of cerebral palsy? in the kinesthetic and balance a) Athetoid cerebral palsy b) Spastic cerebral palsy ¢) Ataxic cerebral palsy 4) Rigidity cerebral palsy Scanned with CamScannerChapter 48 nursing care of a family when a child has an endocrine or metabolic disorder 2020 National Health Goals -Reduce the diabetes-related death rate from a baseline of 77 per 100,000 to no more than 46 per 100,000 people. -Increase the proportion of persons with education from a baseline of 56.8% to a target of 62.5%. -Reduce the proportion of children aged 3 to 10 years diagnosed with a disorder through newborn blood spot screening who experience developmental delay requiring special education services from 15.1% to a target level of 13.5%. -Increase the proportion of children with long-term illnesses who have access to a medical home from 57.5% of children under 18 years to 63.3% First symptom of t1DM in children -anacute loss of weight pituitary difficulties -may be revealed by unusually short or tall stature Assessment -to obtain info on activity in the child, take a day history by asking a parent or child to describe all of the child’s actions on a typical day Bribing children to take medicine -is never a good practice with any child Hypothalamus located in the center of the brain “serves as the regulator of the autonomic nervous system -directs the work of the pituitary gland Sella turcica -a depression in the sphenoid bone. where the pituitary gland rests pituitary gland -anterior lobe(adenohypophy' -posterior lobe(neurohyposis) ~intermediate lobe(pars intermedia) -store and release eight different hormones -ADH, thyrotropin, corticotropin, somatotropin-> prominently involved in childhood illness Ilnesses caused by pituitary dysfunction -can result from a tumor growing in either the pituitary gland or the hypothalamus Hypopituitarism clack of GH Hyperpituitarianism cess secretion of GH Growth hormone deficiency assessment -first few years of life—> child begins to fall below the third percentile of height and weight on growth charts -face appears infantile—> immature mandible, nose is usually small -child’s teeth may be crowded in a small jaw child's voice may be high pitched onset of pubic, facial, and axillary hair and genital growth will be delayed -funduscopic examination, neurologic testing, and blood analysis-> for hypothyroidism, hypoadrenalism, hypoaldosteronism, and growth factor-binding yctes who receive formal diabetes. s) Scanned with CamScannerproteins--> helpful in ruling out a lesion or tumor Bone age is established by a wrist X-ray -to detect enlargement of the sella turcia—> skull series, CT, MRI, ultrasound ADH Secreted by the neurohypophysis Target organ: kidney helps regulate fluid volume by regulating urine output trauma, pain, anxiety, and exposure to high temperatures inc release -secretion is low- urine output increases Corticotropin (ACTH) -Secreted by the adenohypophysis Target organ: adrenal glands -stimulates the adrenal gland to produce glucocorticoid and mineralocorticoid hormones -Inc production of adrenal gland secretions—> dec ACTH production Somatotropin (growth hormone [GH)) ~Secreted by the adenohypophysis Target organ: none; acts on all body cells ine bone and cartilage growth by inc the gastrointestinal absorption of calcium ‘Thyrotropin (TSH) -Secreted by the adenohypophysis Target ongan: thyroid gland -stimulates the thyroid gland to produce thyroid hormones ~to0 little--> atrophy and inactivity of the thyroid gland ~fo0 much-> hypertrophy and hyperplasia of the gland Signs of a pituitary tumor sudden halted growth -hx vision loss. headache, inc head circumference, nausea, vomiting, ‘Therapeutic Management of GH deficiency treated by the administration of intramuscular recombinant human growth hormone (thGH)-> given at bedtime(GH nermally peaks at -may need suppression of luteinizing hommone-releasing hormone (LHRH, or gonadotropin-releasing hormone [GnRH]}—> delays epiphyseal closure -supplements of gonadotropin or other pituitary hormones cH -has been used irresponsibly by athletes -children have delayed epiphyseal closure—> tx begun too early--> children can expect to reach a height individually targeted for them -epiphyseal lines of long bones elose—> GH tapered and stopped Cause of GH excess -benign tumor of the anterior pituitary (an adenoma) Ifthe overproduction occurs before the closure of epiphyseal lines of the long, bones have closed, excessive or overgrowth will result Signs of GH excess excessive weight but itis ine skull circumference -fontanels may close late or not at all after epiphyseal lines close--> acromegaly (enlargement of the bones of the head and soft parts of the hands and feet) roportional to height Scanned with CamScannerenlarged and thickened tongue -remains untreated--> may reach a height of more than & ft Diagnosis of GH excess -X-rays or ultrasounds of the skull tumor is present Tx of growth hormone excess -laser surgery to remove tumor -primary tx--> cryosurgery (freezing of tissue) -no tumor present--> GH antagonist--> bromocriptine (Parlodel) taken orally or octreotide (Sandostatin) taken by injection -more permanent therapy-> irradiation or radioactive implants of the pituitary gland When GH sceretion is halted in this way, other hormones may also be affected; therefore, the child may need to receive supplemental thyroid extract, cortisol, and gonadotropin hormones in later life diabetes insipidus -may reflect an X-linked dominant ait, or it may be transmitted by an autosomal recessive gene -dec release of ADH by the pituitary gland -less reabsorption of fluid in the kidney tubules extremely dilute urine great deal of fluid is lost from the body -may result from a lesion, tumor, or injury to the posterior pituitary, or it may have an unknown cause -rare type-> pituitary function i toADH DI assessment -polydipsia -polyuria—> noticed as bedwetting -low urine specific gravity(1.001 to 1.005) -Urine output may reach 4 to 10 Lina 24-hour period -hypernatremia(irritability, weakness, lethargy, fever, headache, and seizures) -if untreated—> danger of losing such a large quantity of water that dehydration and death can result -MRI. CT scanning, or an ultrasound study of the skull—> reveals whether a lesion or tumor is present administration of vasopressin (Pitressin) -used to rule out kidney disease -child's urine output has been measured to establish a baseline, vasopressin is administered -vasopressin decreases BP, alerting the kidney to retain more fluid in order to maintain vascular pressure ffthe fault that is causing the dilute urine is with the pituitary gland, not the eys--> child's urine output will dec -if the fault is with the kidneys~> urine will remain dilute and excessive in amount be the diseased kidneys cannot concentrate fluid Therapeutic management of DI -surgery is 1x of choice for a present tumor -idiopathic cause--> admin of of desmopressin (DDAVP) desmopressin (DDAVP) > reveal that the sella turcica enlarged or that a adequate, but the kidneys’ nephrons are not sensitive Scanned with CamScanner-an arginine vasopressin -can be given IV in an emergency long term use-> intranasally or orally tranasal admin can cause nasal irritation intranasal route is not effective if child develops URT infection w swollen mucous membranes -Caution children that they will notice an increasing urine output just before the next dose is due ‘Thyroid gland -responsible for controlling the rate of metabolism in the body through the hormones thyroxine (T4) and triiodothyronine (13) Radioimmunoassay of T4 and T3 -a specific blood study to determine how much protein-bound iodine (PBI) is present in serum -Ask if'a child has recently taken large amounts of cough medicine containing iodide or underwent a study using an iodine-based contrast medium recently levels may be abnormally elevated -The small amount of iodine ingested from iodized salt~—> does not effect levels Children who have low circulating albumin levels -can have abnormally low PBI levels be iodine is carried bound to protein Phenytoin (Dilantin) -common anticonvulsant medication prescribed for children with recurrent seizures -may displace T4 from binding globulin and further contribute to low PBI levels radioactive iodine uptake test child is given an oral dose of a solution containing radioactive iodine thyroid gland "traps" this iodine -24 hours later, after the maximum amount has been trapped, the amount of radioactive iodine present can be determined important that child swallows all the solution -in infants-> usually is given as a gavage feeding, accuracy of the dose can be censured -uptake of less than 10% of the test dose-—> suggests hypothyroidism -Be certain that the child does not receive iodine or thyroid extract in any other form during the 24-hour test time be this would compete with uptake of the radioactive iodine—> produce a falsely low value Congenital hypothyroidism ~causes reduced production of both T4 and T3 occurs as a result of an absent or nonfunctioning thyroid gland ina newbom. -may not be noticeable at birth be the mother’s thyroid hormones (unless she ingested Jess than usual amounts of iodine) maintain adequate levels in the fetus during pregnancy symptoms occur 3m in formula fed, 6m in breastied arly diagnosis is crucial -can lead to progressive physical and cogniti screening test for hypothyroidism -mandatory at birth in the United States in all 50 states Assessment of congenital hypothyro -excessive sleeping -enlarged tongue ifficulty, noisy respirations, or cbstruction challenges Scanned with CamScanner-may suck poorly -child does not perspire -skin of extremities—> cold, dry, and perhaps scaly -prolonged jaundice—> immature liver's inability to conjugate bilirubin Anemia may inc the child's lethargy and fatigue -hair-> brittle and dry -short and thick neck extremities appear short and fat-—> muscles become hypotonic, deep tendon reflexes dec and the infant develops a floppy, rag-doll appearance -generalized obesity -delayed dentition -hypotonia of intesti -umbilical hernia -low radioactive iodine uptake levels, low serum T4 and T3 levels, and elevated thyroid-stimulating factor inc blood lipids -delayed bone growth therapeutic management of congenital hypothyroidism -oral administration of synthetic thyroid hormone (sodium levothyroxine)—> start small then gradually ine ~do not put med in a large amount of food ipplemental Vit D--> prevent development of rickets -T4 tablets must be erushed and added to food or a small amount of formula or breast milk Acquired hypothyroi -the mo -onset I tract chronic constipation, enlarged abdomen ism(Hashimoto Thyrviditis) common form of acquired hypothyroidism in childhood most often 10 to If years -may be a family history of thyroid disease -more often in girls than boys dec in thyroid secretion is caused by the development of an autoimmune phenomenon that interferes with thyroid production Assessment of hashimoto thyroiditis, -xcretion of TSH from pituitary inc whea thyroid hormone dec in an attempt by the pituitary gland to ine thyroid function inc levels of TSH--> hypertrophy of thyroid(goiter)-> body growth impaired by lack of T4—> obesity, lethargy, delayed sexual development ~Antithyroid antibodies -nnust investigate if thyroid enlargement is malignant or night Diagnosis of Hashimoto's Thyroi -children are administered radioactive iodine -if nodules are benign—> generally a rapid uptake of radioactive iodine (“hot nodes") -no uptake (“cold nodes"}-> carcinoma is a much more likely diagnosis (which is rare at this age) ‘Therapeutic management of hashimotos thyroiditis -administration of synthetic thyroid hommone (sodium levothyroxine) Hyperthyroidism(graves disease) Wer secretion of thyroid hormones by the thyroid gland infants > usually resolves btwn 3 to 12 weeks of age with no long-term resulls as the maternal antibodies are cleared -older children—> can occur from the glands being overstimulated by TSH from the Scanned with CamScannerpituitary gland duc to a pituitary tumor -most frequent cause in older children—> caused by an autoimmune reaction that results in overproduction of immunoglobulin G (IgG)--> stimulates the thyroid gland to overproduce T4 -during pregnancy can lead to neonatal hyperthyroidism in a fetus Assessment of hyperthyroidism -may have a genetic predisposition -often follows a viral illness or a period of stress. -hervousness, tremors, loss of muscle strength, and easy fai increased basal metabolic rate, BP, and pulse -moist skin -perspire frecly -always hungry -eat constantly and do not gain w -may even lose weight because of the increased basal metabolic rate -bone age will appear advanced beyond the chronologic age of the child -not likely to reach adult height( epiphyseal lines of long bones will close before full height can be attained), unless condition is treated ye globes become prominent (exophthalmia) -elevated T4 and T3 levels and increased radioactive iodine uptake 1 is low or absent-> thyroid is being stimulated by antibodies, not by the pituitary gland ‘Therapeutic ement of hyperthyroidism -propranolol--> f}-adrenergic blocking agent--> dec antibody response antithyroid drugs--> propylthiouracil (PTU) or methimazole (Tapazole)--> suppresses the formation of T4—> must monitor for leukopenia tthyroid drugs take 2wks to work, needs to continue to take the drug for2 to 3 years before the condition "burns itself out.” “toxic rxn to medical management--> radioiodine ablative therapy or thyroid surgery to reduce the size of the thyroid gland Adrenal glands located retroperitoneally. just above the kidneys -protect the body against acute and chronic forms of stress. -cortisol (a glucocorticoid responsible for glucose and protein metabolism and preventing inflammation), androgen (a steroid hormone responsible for muscle development), and aldosterone (a mineralocorticoid hormone necessary for sodium and fluid balance)—> important in childhood illnesses Acute adrenocortical insufficiency can occur in either an acute or chronic form function of the entire gland suddenly becomes nonproductive -usually occurs following a severe overwhelming body infection (such as meningococcemia) -occur when corticosteroid therapy is abruptly stopped and gland does not return to usual function Assessment of acute adrenocortical insufficiency -BP drops extremely low child appears ashen gray -weak pulse gradually elevated temp -dehydration Scanned with CamScannerhypoglycemia--> be cortisol is no longer present to regulate it ine potassium ~child appears prostrate izures may occur -untreated-+> death can occur abruptly ‘Therapeutic management of acute adrenal corticoid insufficiency -immediate replacement of cortisol (with IV hydrocortisone sodium succinate [Solu- Cortef]) -admin of deoxycorticosterone acetate (DOCA)-> the synthetic equivalent of aldosterone -IV 5% glucose in normal saline solution—> restores BP, sodium, and blood glucose levels -vasoconstrictor may be necessary to elevate the BP congenital adrenal hyperplasia inherited as an autosomal recessive trait causes the adrenal glands to not be able to synthesize cortisol—> the level of adrenocorticotropic hormone (ACTH) secreted by the pituitary inc in an attempt to stimulate the glané to ine function. -adrenal glands enlarge under effect of ACTH, but cannot produce cortisol, overproducing androgen instead Ascessment of congenital adrenal hyperplasia -genital organs in 2 male fetus overgrow -masculinizes a female fetu: sinus btwn the urethra and vagina may be present -untreated--> bone age will advance so the epiphyseal lin close early -pubic and axillary hair, acne, and a deep masct -no breast development or menstruation at puberty Diagnosing congenital adrenal hyperplasia -possible to identify adrenogenital hyperplasia as early as 6 to 8 weeks of pregnancy trough serum analysis -1Swks by amniocenteses usually diagnosed during pregnancy, if not infant serum analysis shows elevated androgen Dextramethasone -controversial tx of congenital adrenal hyperplasia can prevent masculinization in the fetus for the remainder of the pregnancy, newborn will then need hydrocortisone admin after birth for continuing therapy ‘Therapeutic management of congenital hyperplasia -replace the cortisol that is missing by suppressing ACTH concentrations and normalizing adrenal size and androgen production -infants--> corticosteroid needs periodic analysis of serum cortisol levels and growth measurements to estimate the effectiveness of the therapy Salt-Losing Form of congenital adrenogenital hyperplasia -complete blockage of cortisol formation—> deficient aldosterone production—-> salt and fluid are not retained in the body Assessment of the Salt-Losing Form of congenital adrenogenital hyperplasia -almost immediately after birth--> affected infants begin to have vomiting, diarthea, anorexia, loss of weight, and extreme dehydration :s of the long bones will 1 voice will appear Scanned with CamScanner-boys w syndrome appear normal at birth--> may be incorrectly diagnosed as infection or as failure to thrive -in girls—> ambiguous genitalia, correct diagnosis can be made more easily -reason newborns are weighed at birth and again at 24 hours is to detect this condition ‘Therapeutic management of Salt-Losing Form of congenital adrenogenital hyperplasia -supplemented with hydrocortison aldosterone) -long-acting form of DOCA can be given once a month IM -long acting form of DOCA capsules can be implanted subq older child-> fludrocortisone (mineralocorticoid), may be given orally to aid salt retention Cushing syndrome -overproduction of the adrenal hormone cortisol usually results from increased ACTH production due to either a pituitary or adrenal cortex tumor -can occur in infancy, peak age is 6-7 -possible cause—> inappropriate use of hie dermatitis Cushing syndrome assessment findings -ine cortisol-> ine glucose--> causes fat to accumulate on the cheeks, chi causing a moon-faced, stocky appearance protein wasting--> muscle wasting--> extremities appear thin in contrast to the trunk, and loss of calcium in bones (osteoporosis) -dce in humoral immunity, susceptible to infections -vasoconstriction, extreme HTN may occur -hyperpigmentation(red appearance) occurs from the melanin.stimulating properties of ACTH -purple striae -poor wound healing -abnormal masculinization or feminization from ine androgen or estrogen polyuria -growth ceases -short stature if condition is not reversed b4 closure of epiphyseal lines Diagnosing Cushing syndrome -reveals an elevated plasma cortisol and increased urinary free-cortisol levels -dexamethasone suppression test -CT scan or ultrasound reveals the enlarged adrenal or pituitary gland, confirming the diagnosis dexamethasone suppression test if the child has the syndrome, the plasma level of adrenal cortisol will fall vill not fall in children with adrenocortical tumors be the tumor continues to stimulate the adrenal glands to oversecretion -If cosyntropin (Cortrosyn), a synthetic corticotropin, or ACTH is administered—> plasma cortisol levels will normally rise In children with an adrenal tumor--> gland is already functioning at full capacity no cortisol elevation occurs Therapeutic management of Cushing syndrome ¢, an ine salt intake, and DOCA(synthetic -potency steroid ereams for diaper and trunk, Scanned with CamScanner-surgical removal of the causative tumor prognosis depends on whether the tumor is benign or malignant -If a major part of the adrenal glands are surgically removed—> child will need replacement cortisol therapy -Ifa major portion of the pituitary gland is removed be the problem was overproduction of ACTH--> replacement of all pituitary hormones may be necessary Post adrenal surgery observe the child carefully for signs of shock -w/o epinephrine also produced by the gland—> body's ability to maintain BP is severely compromised-> severe hypotension can result Pancreas -both endocrine (ductless) and exocrine (with duct) types of tissue islets of Langerhans form the endocrine portion -alpha islet cells have the responsibility to secrete glucagon, and beta islet cells, secrete insulin Tasulin -essential for carbohydrate metabolism. ~important in the metabolism of both fats and protein -When serum glucose that passes through the pancreas exceeds 100 mg/dl-> beta cells immediately begin insulin production -low serum glucose levels—> production dec Insulin production Iso stimulated by gastrin -gastrin--> rises when the stomach is full as well as the levels of glucagon, cortisol, GH, progesterone, and estrogen -Inc levels of epinephrine or norepinephrine--> inhibit secretion of insulin in order to eserve glucose for "light or fight." Type 1 diabetes mellitus -an absolute or relative deficiency of insulin equal in incidence in boys and girls affects approximately 1 of every 500 children and adolescents T2DM ~insulin production is only reduced Etiology of TIDM -apparently results from immunologic damage to islet cells in susceptible individuals -reason for autoimmune destruction of islet cells occurs is unknown children have a high frequency of certain human leukocyte antigens (HLAs), particularly HLA-DR3 and HLA-DR4, located on chromosome 6--> may lead to susceptibility ‘When the kidneys detect hyperglycemia -they attempt to lowerit to by excreting excess glucose into the urine—-> glucosuria and polyuria excess fluid loss~> polydipsia Three cardinal symptoms of diabetes -polyuria -polydipsia -hyperglycemia parents usually notice inc thirst and urination(may be recognized first as bed-wetting [enuresis] in a previously toilet-trained child) Untreated diabetic children Scanned with CamScannerlose weight -acidotic due to buildup of ketone bodies in blood ~dchydrated be of loss of water electrolyte imbalance be of loss of potassium and phosphate in urine -femain short in stature and underweight be they lack necessary components for growth TIDM assessment -age of onset: 5-7yrs or at puberty -type of onset: abrupt -weight changes: Marked weight loss often initial sign -symptoms: Polydipsia and polyphazia, Polyuria , Fatigue, Blurred vision, Mood changes therapy: hypoglycemia agents never effective, need insulin, should count carbohydrates plus evaluate blood glucose levels to help determine insulin dosage, footcare -period of remission: 1-12 months (“honeymoon period") generally after initial diagnosis T2DM assessment -age of onset:40-65 years (may occur in adolescents as maturity-onset diabetes of youth [MODY]) “ype of onset: gradual -weight changes: obesity -symptoms: Polydipsia, Polyuria, , Fatigue, Blurred vision, Mood changes -therapy: diet, oral hypog gents, or insulin, meticulous skin and foot eare -period of remission: not demonstrable acceptable BG ranges for children w TIDM -before a meal: 70-110 -Lhr after a meal: 90-180 -2hr after a meal: 80-150 -between 2am and 4am: 70-120 A diagnosis of diabetes is established if one of the following three criteria is, present on two separate occasions: -Symptoms of diabetes plus a random blood glucose level greater than 200 mg/dl -A fasting blood glucose level greater than 126 mg/dl -A 2-hour plasma glucose level greater than 200 mg/dl during a 75-g oral glucose tolerance test (GTT) GIT involves the oral ingestion of a concentrated glucose solution followed by blood glucose levels drawn at fasting (baseline), after 1 hour, and after 2 hours “requires children to fast for § hours, drink an overly sweet solution, and submit to painful, intrusive procedures (routine application of lidocaine’prilocaine [EMLA] cream to finger stick or venipuncture sites and use of intermittent infusion devices greatly reduces this problem) Do not take blood for glucose analysis from functioning IV tubing to try to help with pain -the glucose in the IV solution will eause the serum reading to be abnormally high Other diagnostic tests for diabetes -analysis of blood samples for pH, partial pressure of carbon dioxide (PCO2), sodium, and potassium levels; a white blood cell count, glycosylated hemoglobin (HbA 1c) Scanned with CamScannerevaluation -if potassium level is low--> child may need an electrocardiogram to observe for T- wave abnormalities HbAle -usual value for non diabetic children: 1.8-4.0 ~greater than 6,0--> reflects an excessive level of serum glucose The white blood cell count of a child with diabetes may be elevated even though no infection is present, apparently as a response to: the ketoacidosis When children are first diagnosed with diabetes, they are usually hyperglycemic and perhaps ketoacidotic -t0 correct the metabolic imbalance-> given insulin administered IV at a dose of 0.1 to 0.2 units per kilogram of body weight per hour ideally within 12hrs the acidosis is considerably less and within 24hrs the Childs serum glucose retums to normal ‘Typical insulin regimen for children combined insulin dose of 0.4 to 0.7 units per kilogram of body w' divided doses (one before breakfast and one before dinner) ‘Typical insulin regimen for adolescents -may need as much as 1.2 units per kilogram daily divided into two doses ‘The most common mixture of insulin used with children -combo of an intermediate-acting insulin and a regular insulin, usually in a 2:1 ratio or 0.75 units of the intermediate-acting insulin to 0.33 units regular insulin, given in the same syringe -moming dose is two thirds of the total daily dose; the evening dose is the remaining one third Lispro(Humalog) -onset: immediate : 30min-1hr ight daily in two -peak effect: 30-40min duration: 3-Shr Regular (Humulin R) ~onset:0.5-1.Shr ~peak effect:24hr -duration:5-7hr Lantus ~onset: Ihr -peak effect: Shr -duration: 24hr Humulin-» wonset: 1-2hr -peak effect: 4-12hr ~duration: 24+hr Humulin-L -onset:1-3hr -peak effect:6-I4hr -duration:24+hr Scanned with CamScannerHumulia-U -onset6hr -peak effect:16-18hr -duration:36+hr “thinking scales" -Part of the education of parents is to allow them to vary their child's insulin doses based on an insulin algorithm or protocol influenced by the child's level of activity and the size of meals consumed for that day Lag time -time between the insulin injection and a meal Ifitis anticipated that the child will eat an unusually large meal such as at a special birthday dinner, parents can: inc the size of the premeal regular insulin injection Ifthe child is to participate in a strenuous sport in the afternoon that will use glucose, the regular insulin injection: can be decreased Insulin glargine injection (Lantus) -anew long-acting insulin that is supplied in an injectable pen and lasts 24 hours -disadvantage—> its pH, which is so low it cannot be mixed in a syringe with other insulins Mixing insulins in one syringe ~the regular or short-acting insulin should be drawn into the syringe first Insulin admin route -always injected SC except in emergencies, when half the required dose may be given Iv Subcutaneous tissue injection sites used most frequently in children -upper outer arms and the outer aspects of the thighs ‘The abdominal subcutaneous tissue injection sites -commonly used in adults can be adequate sites, but most children dislike this site because abdominal skin is tender Lipohypertrophy -buildup of subcutaneous fat at the site of repeated injections insulin no longer absorbs well from the site teach parents to rotate injection sites Insulin storage -parents should keep additional bottles of insulin in the refrigerator to increase the insulin's shelf life -insulin should be admin at 100m temp--> this diminishes subcutaneous atrophy and ensures peak effectiveness Insulin pump. -automatic device approximately the size ofan iPhone -delivers insulin at a constant rate--> regulates serum glucose levels better than periodic injections ~a syringe of regular insulin is placed in the pump chamber; a length of thin polyethylene tubing Ieads to the child's abdomen, where it is implanted into the subq tissue of the abdomen by a small-gauge needle -most children prefer pump over daily injections Women who develop gestational diabetes use insulin pumps Inhalation insulin Scanned with CamScanner-not available as yet but may be in the future -production of it is in experimental trials -difficulties w development-—> constructing an accurate delivery system and determining how the development of a cold or allergies that cause edema of the nasal membrane will affect drug absorption Nutrition -parents need to leam to count the total carbohydrate amount in food by carefully reading food labels -three spaced meals that are high in fiber plus a snack in the midmomning, midafternoon, and evening to keep carbohydrate amounts as level as possible during the day insulin-to-carbohydrate ratio ~calculated individually for each child depending on age and activity to guide insulin administration Children are adolescents, however, before they can be counted on to: -independently monitor their serum glucose levels on a daily basis Urine testing -not used routinely but is used to test for ketonuria if the child develops a gastrointestinal "flu" and is nat able to eat -Acetone revealed by a test strip is a sign fat is being used for energy or that the child is becoming acidotic honeymoon period -curing which only ar regulation -apparently occurs be the exogenous insulin stimulates the islet cells to produce a small amount of natural insulin, as if they are being reminded of their function -after a month-Lyr--> islet cells will begin to fail once again» diabetic symptoms will recur children inimal amount of insulin, or none at all, is needed for glucose diabetes undergo a stressful situation(emotionally or physically) -may need increased insulin to maintain glucose homeostasis Complications of diabetes -arteriosclerosis (hardening of artery walls}—> general poor circulation and kidney disease, thickening of retinal capillaries and cataract formation-> blindness Pancreas transplantation -may be considered in children who develop severe kidney disease or arteriosclerosis -pancreas is not removed entirely» portion that supplies digestive enzymes is still functioning and so is left in place digestive enzymes of the new pancreas» diverted into the intestine or bladder, or the pancreatic ducts can be sclerosed, so the digestive enzymes do not leave the transplanted ongan grafts may be taken from cadavers or from live donors -last resort be it involves major surgery continuous immunosuppressive meds for life -some pancreatic transplant recipients have a recurrence of diabetes If rejection of the transplanted pancreas occurs -patient is given monoclonal T-cell antibodies (OKT3) to try to reverse this process From about 8yrs of age ~children can be taught to administer their own insulin ‘Somogyi phenomenon Scanned with CamScannerinsulin overuse and persistent hypoglycemia cause a rebound hyperglycemic response -suspected when children have nighttime (2 AM or 3 AM) hypoglycemia followed by high carly-moming hyperglycemia -need to be referred to their HCP be they actually need less insulin rather than more to correct the problem diabetic ketoacidosis (DKA) -occurs when the body produces high levels of blood acids called ketones -develops when the body can't produce enough insulia and begins to break down fat as fuel -If ketoacidosis is not relieved when it first begins-> deep and rapid respirations (Kussmaul breathing) as the body attempts to "blow off" carbon dioxide and lessen the acidotic state -breath smells sweet -Signs of dehydration, including dry mucous membranes and skin, sunken eyeballs, and no tears Hypoglycemia -cause: Excessive insulin injection, limited food intake, excessive exercise -symptoms: Hunger, Lethargy and sensorial changes, Sweating, Pollor, Seizures, Coma -danger: Brain cells need glucose for function and survival -major nursing interventions: Administration of source of glucose by oral or intravenous route, Education to prevent recurrences Hyperglycemia -cause: inadequate insuli infection etc. symptoms: glucosuria, ketonuria, polytria, polydipsia, vomiting, kussmaul respirations, coma, flushing and dehydration, sweet breath, dec sodium, potassium, bicarb, chloride, phosphate, CO2 danger: Fatty acids used and ketoacidosis develops -major nursing interventions: Reestablishment of electrolyte balance and hydration, Education to prevent recurrences Influencing factors of T2DM -strong family history of diabet Indian descent: those who eat a di not exercise regularly Development of polycystic ovary syndrome (PCOS) -strongly associated with T2DM acanthosis nigricans -dark shiny patches on the skin -seen in T2DM four parathyroid glands -located posterior and adjacent to the thyroid gland regulate serum levels of calcium in the body by controlling the rate of bone metabolism through the secretion of PTH -~not under the control of the pituitary gland—> controlled by a negative feedback from the circulating serum levels of calcium and how much vitamin D is present to allow absorption of calcium from the GI tract into the bloodstream Hypocalcemia ¢ food intake, stress from surgery, hildren from African, Hispanic, Asian, or Native high in fats and carbohydrates; and those who do Scanned with CamScanner