154 terms

Pediatrics Exam 3

GU, Cancer, Integumentary, Abuse (doesn't include Cardiovascular)
STUDY
PLAY
ENURESIS
- Common in boys
- Expect nocturnal enuresis to stop by 6-8 years of age
- Serious psychologic consequences
ENURESIS: Clinical Manifestations
- Urgency that is immediate, or urgency may be absent
- Increased urinary frequency
- If nocturnal, may have difficulty awakening to urinate
ENURESIS: Dx
- Hx: details about bed-wetting behavior and toilet-training process, parental attitudes toward bed-wetting behavior
- Complete physical assessment to rule out other causes
ENURESIS: Therapeutic Management
- Conditioning therapy
- Retention control training
- Waking schedule tx
- Medication (anticholinergic effect)
- PUNISHMENT IS NOT A TX!
- Supportive therapy: child's role; fluid restriction; behavior modification
ENURESIS: Nursing Care Management
- Education for child and parents
- Anticipatory guidance
- Encouragement, patience, support
- Child's active participation
- SE of meds
- Avoid diapering
- Positive reinforcement
URINARY TRACT INFECTION (UTI)
- Inflammation
- May present with or without sx
- Peak incidence: 2-6 years of age
- Females have 10-30x greater risk
- Prognosis: often good with prompt tx, but can vary when associated with congenital renal malformations and reflux
UTI: Etiology
- Bacteria: E. coli and other gram-negative enteric organisms responsible for 80% of cases; common to anal, perianal, and perineal areas; pseudomonas, staphylococcus aureus, haemophilius, and others
- Anatomic and physical factors/barriers: short urethra (females); longer urethra and antibacterial properties of prostatic secretions (males)
- Altered urine and bladder chemistry
- Urinary stasis: urine is normally sterile but is an excellent medium for bacterial growth when it reaches body temp; can be d/t reflux, anatomic abnormalities, extrinsic bladder compression, dysfunctional voiding; normally, completely and repeatedly emptying bladder flushes away microorganisms
- Promotions of urine sterility: adequate fluid intake, cranberry juice as preventative measure (controversial)
UTI: Clinical Manifestations--Children <2 Years of Age
- May be vague
- Fever
- Hypothermia
- FTT
- Feeding problems
- Abdominal distension
- Jaundice
- Vomiting/diarrhea
- Frequent or infrequent voiding
- Constant squirming/irritability
- Strong-smelling urine
- Abnormal stream
- Persistent diaper rash
UTI: Clinical Manifestations--Children >2 Years of Age
- Enuresis
- Fever
- Strong or foul-smelling urine
- Increased frequency
- Dysuria
- Abdominal pain
- CVA tenderness
- Hematuria
- Vomiting
PYELONEPHRITIS
- UTI that involves upper urinary tract and kidneys
- Rapid onset
- Sx: UTI sx plus fever, chills, and flank pain
UTI/PYELONEPHRITIS: Dx
- Evaluation of hx and physical exam
- UA and culture: cloudy urine; pyuria (5-8 WBC/mL of uncentrifuged urine); leukocyte esterate = positive; nitrite = positive; hematuria (RBC >2); bacteria
- UA specimen collection: previously gold standard was suprapubic aspiration; other methods = catheterization, clean catch, urinary bag; risk for specimen contamination
UTI/PYELONEPHRITIS: Therapeutic Management
- Eliminate current infection
- Identify contributing factors to prevent reoccurrance
- Prevent urosepsis
- Preserve renal fx
- Risk for renal scarring
- Common antiinfectives: penicillins, sulfonamides, cephalosporins, nitrofurantoin, tetracyclines; pyelonephritis = hospitalization for 48 hours for IV abx
UTI/PYELONEPHRITIS: Nursing Care Management
- Promote adequate fluid intake
- Good hygiene
- Good potty training (wipe front to back)
- Investigate sx of intestinal parasites (i.e. scratching around anal area)
- Urinate ASAP following sexual intercourse, sexual contact, and masturbation
- Avoid bubble baths, public hot tubs, etc.
VESICOURETERAL REFLUX (VUR)
- Retrograde flow of urine into the ureters
- Increases chance for urinary infection
- Primary: results from congenital anomaly; has familial pattern
- Secondary: results from acquired condition (i.e. UTI, obstruction)
- 30-60% of pediatric cases with VUR have renal scarring
VUR: Therapeutic Management
- Conservative, nonoperative therapy is effective in most cases
- High incidence of spontaneous resolution over time
- Low-dose abx therapy with frequent urine cultures
- Possible surgery with recurrent UTIs, intolerance to abx, noncompliance with therapy, or VUR after puberty in females; ultrasound postop to evaluate renal growth
VUR: Nursing Care Management
- Encourage compliance of medication therapy
- Encourage parents to have other children screened
ACUTE GLOMERULONEPHRITIS (AGN)
- Immune-complex disease
- Commonly follows strep infection (i.e. URI, throat, skin)
- Commonly affect school-age children
- Occurs 10-14 days after initial infection
- Decreased filtration of plasma --> excessive H2O and Na+ retention
AGN: Clinical Manifestations
- Periorbital edema
- Anorexia
- Cola-colored urine
- Decreased urine output
- Pallor, irritability, lethargy
- HA, abdominal discomfort, dysuria
- Increased BP
- Hematuria
AGN: Clinical Course
- May persist from 4 days to 3 weeks
- Weight fluctuates
- Urine remains brown
- BP can reach dangerous levels
- Improvement indicated by increased urinary output with decrease in body weight; as child feels better, appetite will improve
- Most have complete recovery; deaths from complications are rare
AGN: Complications
- ARF
- Hypertensive encephalopathy
- Acute cardiac decompensation
AGN: Dx
- Hematuria
- Proteinuria
- Increased SpGr
- Discolored urine
- No bacteria in urine (urine culture = negative)
AGN: Therapeutic Management
- No specific tx
- Recovery often spontaneous
- Supportive measures
- Hospitalization for substantial edema, HTN, or significant oliguria
- Rest PRN
- Assess VS: BP q 4 hours
- Daily weight
- Strict I&O
- Possible Na+ and H2O restriction; K+ restriction for oliguria; protein restriction for severe azotemia
- Dialysis for severe cases
AGN: Medication Therapy
- Loop diuretics (i.e. Lasix)
- Calcium channel blockers, beta blockers, ACE inhibitors
- Abx
- Anticonvulsants if seizures are present
AGN: Nursing Care Management
- Thorough assessments: urine volume, color, and character; child's appearance and behavior
- Advise family against bringing in salty foods and eating salty foods in front of child
- Disperse amount of fluid evenly throughout day (serve in several small cups to give illusion of quantity)
- Activity: need for frequent rest periods
- Infection prevention
- Frequent health supervision when at home (weekly to monthly)
NEPHROTIC SYNDROME
- Most common glomerular injury in children
- Increased glomerular permeability to plasma proteins --> massive urinary protein loss --> massive proteinuria, hypoalbuminemia, hyperlipidemia, and edema
- Prognosis: with early detection and tx, membrane damage is minimal and full renal fx is often restored; 50% relapse, 20% relapse after 20 years
NEPHROTIC SYNDROME: Clinical Manifestations
- Weight gain
- Edema (face and eyes [worse in AM], legs, abdomen, labia/scrotum); can obscure weight loss
- Diarrhea, loss of appetite, malabsorption
- Decreased urinary output
- Dark and frothy urine
- Pallor
- Skin breakdown
- Irritable
- Fatigued, lethargic
- White nails
- Normal to decreased BP
- Susceptible to infection
NEPHROTIC SYNDROME: Dx
- Based on hx and clinical manifestations
- Massive proteinuria
- High SpGr
- Low serum protein concentration
- Normal to elevated H&H
- Elevated platelets
NEPHROTIC SYNDROME: Therapeutic Management Goals
- Reduce excretion of urinary protein; maintain protein-free urine
- Prevent/tx acute infection
- Control edema
- Good nutrition
NEPHROTIC SYNDROME: Therapeutic Management
- Diet: regular with restricted salt; no fluid restriction; regular protein intake
- Corticosteroid therapy: prednisone daily for 6 weeks, then tapered for 6 weeks; expect improvement 7-21 days after initiating steroids; can mask sx of infection
- Immunosuppressant therapy: indicated with frequent relapsing or steroid resistance; use oral alkylating agents (i.e. cyclophosphamide)
- Loop diuretics (i.e. Lasix)
- Plasma expander (i.e. human albumin)
NEPHROTIC SYNDROME: Nursing Care Management
- Daily weight
- I&O
- Urine albumin
- Abdominal girth (monitor for ascites)
- Edema
- Skin condition
- Shock and infection
- Skin care
- Infection prevention
- Nutrition
- Diversion
- Family anticipatory guidance and support
- Relapses often treated at home
- Teach parents S/S of relapse, how to test urine for albumin, how to give meds, and general care
RENAL FAILURE (ARF/CRF)
Inability of kidneys to excrete waste material, concentrate urine, and conserve electrolytes; mortality rate <20%
AZOTEMIA
Accumulation of nitrogenous waste products in the blood
UREMIA
Retention of nitrogenous waste products that produce toxic sx; very serious condition that involves other body systems
ARF: Etiology
- Prerenal causes: reduction of renal perfusion in otherwise normal kidneys; most common in first years of life; caused by dehydration, surgical shock and trauma, hypovolemia, hypoperfusion secondary to cardiac surgery, and sepsis
- Intrinsic renal causes: diseases and nephrotoxic agents that damage the glomeruli, tubules, or renal vasculature
- Postrenal causes: obstructive uropathy
ARF: Pathophysiology
- Usually reversible
- Severe reduction in GFR (best indicator = creatinine clearance) --> elevated BUN --> RAA is activated --> reduces renal blood flow
ARF: Clinical Course
- Severe oliguria (low output phase) --> abrupt onset of diuresis (high output phase) --> gradual return to normal urine volume
- Oliguria phase is 10-14 days in school-age children and adolescents; may be 3-5 days in infants and young children
- Diuretic phase may last a few days but is variable
ARF: Clinical Manifestations
- By the time child is seen, he is usually critically ill--underlying illness often overshadows renal failure (i.e. shock, gastroenteritis causing severe dehydration)
- Oliguria (<1 mL/kg/hr); possible anuria (uncommon)
- Edema
- Drowsiness
- Circulatory congestion
- Cardiac arrhythmias d/t hyperkalemia
ARF: Dx
- Thorough hx if no obvious cause
- Labs that indicate ARF: hyperK+, hypoNa+, metabolic acidosis, hypoCa+, anemia, azotemia
ARF: Therapeutic Management
- Prevention is #1! Avoid dehydration, shock, etc.
- Recognize when ARF is a known risk
- Fluid therapy when hypovolemic
- Use caution with nephrotoxic meds and take necessary precautions (i.e. generous fluid intake with chemo)
- Treat underlying cause
- Manage complications of renal failure
- Supportive therapy
- Fluid and calories: maintain zero water balance (at risk for FE imbalance)--keep intake and output equal; food high in carbs/fats and low in protein, K+, Na+, and phosphorus
- Possible Foley to rule out urinary retention, collect specimens, and monitor output (risk of infection makes this controversial)
Hyperkalemia Management
- Immediate threat = cardiac problems
- Eliminate K+ from foods and fluids
- Reduce tissue catabolism
- Correct acidosis
- Meds: Ca+ gluconate IV; Na+ bicarb IV; D50 and insulin; Kayexelate
- Dialysis
HTN Management
- Monitor BP q 4-6 hours
- Prevent hypertensive encephalopathy and overtaxing cardiovascular system; anticipate IV drips and boluses (i.e. beta blockers) and oral meds (for BP)
ARF: Complications
- Hyperkalemia
- HTN
- Anemia
- Seizures and coma
- Cardiac failure
- Pulmonary edema
ARF: Diuretic Phase Management
- Monitor intake of fluid, K+, and Na+
- Monitor electrolytes
- Provide adequate fluid replacement to prevent dehydration
ARF: Nursing Care Management
- Address underlying cause
- Monitor and manage renal status
- Monitor F&E balance
- Monitor for complications (i.e. anemia, infection)
- Provide support, comfort, and stability to pt and family
CHRONIC RENAL FAILURE (CRF)
- Diseased kidneys can no longer maintain normal chemical structure of body fluids
- Generally >50% of renal capacity has been destroyed by disease or injury; we often don't detect it until it's very advanced
- Irreversible
- Dialysis or transplant required when GFR is 10-15% below normal
CRF: Etiology
- <5 years of age: congenital renal and urinary tract malformations; VUR
- 5-15 years of age: glomerular and hereditary renal disease (i.e. chronic pyelonephritis, chronic glomerulonephritis, glomerulonephropathy r/t lupus)
Advanced Renal Damage: S/S
- Retention of waste products
- H2O and Na+ retention
- HyperK+
- Acidosis
- Decrease in Ca+ and phosphorus
- Elevated BUN/creatinine
- Anemia
- Growth and other disturbances
CRF: Clinical Manifestations
- Fatigue, low energy
- Pallor
- Elevated BP
- Decreased growth d/t decreased Ca+
- Poor eating
- Decreased interest in school and play
- Decreased or increased urinary output
- HA, muscle cramps, nausea
- Facial edema
- Malaise
- Bone pain
- Dry, itchy skin; bruising
- Amenorrhea (older girls)
- Changes in breathing pattern
CRF: Dx
- Based on clinical manifestations, hx of prior renal disease, and/or biochemical findings
- Lab values and other tests may assess extent of renal damage
CRF: Therapeutic Management Goals
- Promote effective renal fx
- Maintain F&E imbalance
- Treat systemic complications
- Promote active and normal life for as long as possible
CRF: Therapeutic Management
- Activity
- Diet
- Osteodystrophy
- Acidosis
- Anemia
- HTN
- Growth retardation
CRF: Nursing Care Management
- ESRD involves progressive deterioration
- Team support (medicine, nursing, social services, child life, PT/OT, dietary, psychology)
- Anticipatory guidance (i.e. procedures and frequent hospitalizations, clinical course, diet therapy, loss of healthy child)
- Renal replacement therapy
- Hemodialysis; peritoneal dialysis (PD)
HEMODIALYSIS
- Preferred method for acute infections
- Protein loss less extensive than PD
- Must come to clinic 3x/week for 3-5 hours
- Requires blood access via graft, fistula, or external access device
- Blood is dialyzed through external device
- F&E restricted diet
- Provide diversional activities
PERITONEAL DIALYSIS (PD)
- Slow, gentle process that decreases stress on body
- Indicated for neonates, children with severe CV disease, or those with poor vascular access
- Often performed at home by parents
- Requires surgically-placed cath
CONTINUOUS CYCLING PD (CCPD) PROCEDURE
- PD machine warms dialysis fluid and automates the cycles of inflow of dialysis fluid and outflow of dialysate
- Done overnight while pt sleeps (takes 6-8 hours); allows child and parents freedom during the day
DIALYSIS: Nursing Care Management
- Address feelings of loss of control/dependence on dialysis
- Explain different types
- If doing home dialysis, teach: how to take VS and interpret them (increased BP = change in dosage needed); how to perform procedure; S/S of infection (i.e. fever)
INGUINAL HERNIA
- Protrusion of the bowel into the groin region that causes an observable and palpable bulge
- 80% of all hernias in children
- More common in males (5:1)
- 10-20:1000 live births
- 30% increase in preemies
- Develops during 8th month gestation
- Usually asymptomatic; disappears with rest or reduced with gentle compression; appears with crying, straining, coughing
- Concern if intestine becomes obstructed or incarcerated (--> necrosis); most common in infants <10 months
INGUINAL HERNIA: Surgical Management
- Indicated to avoid incarceration
- Usually outpatient or discharged 12-24 hours postop
- Complications: intestinal obstruction, strangulation, gangrene
INGUINAL HERNIA: Postop Nursing Care
- Prevent infection: sponge bath for 3-5 days; frequent diaper changes (infants)
- Promote comfort: acetaminophen, ibuprofen
- Activity restrictions: school-age--return to class as soon as comfortable but don't go to PE class for 3 weeks; older--restrict heavy lifting, pushing, wrestling, fighting, bike riding, and sports for 3 weeks
PHIMOSIS
Narrowing or stenosis of foreskin opening; provide anticipatory guidelines on hygiene to parents
BALANITIS
Inflammation or infection of the phimotic foreskin; provide anticipatory guidelines on hygiene to parents
HYDROCELE
- Fluctuant mass of fluid within the processus vaginalis that presents as scrotal swelling, communicating or noncommunicating
- Management: surgery
- Nursing care: parent teaching, general principles of postop care
CRYPTORCHIDISM
- Failure of one or both testes to descend into the scrotal sac
- 30% occurrence in preemies
- 3-4% occurrence in term babies
CRYPTORCHIDISM: Surgical Management
- "Orchioplexy": surgical placement of testes in scrotum
- Done if testes haven't descended by 1 year of age; psychologically best to do it b/t 1-2 years; may do earlier if hernia is also present
- Usually outpatient
CRYPTORCHIDISM: Physical Risks
- Reduced fertility d/t higher degree of body heat in abdomen --> damage to testes
- Testicular malignancy: risk increases 20-40%; usually occurs in 3rd or 4th decade; greater risk if untreated or if surgery is done during/after puberty
CRYPTORCHIDISM: Nursing Care Management
- Prevent infection
- Promote comfort
- Teach self-exam of testes
- Teach importance of long-term F/U
HYPOSPADIAS
- Urethral opening located below glans of penis or anywhere along the ventral surface (underside) of penile shaft
- Incidence = 1:300
CHORDEE
- Ventral curvature of the penis
- D/t replacement of normal skin with fibrous band of tissue causing curvature --> constriction of penis
- Surgery done at 6-12 months of age, before development of body image
HYPOSPADIAS/CHORDEE: Nursing Care Management
- Examine every NB male
- Possible urinary diversion after surgery to promote optimal healing
- Teach parents to care for cath/stent
- Avoid baths until stent removed
- Increase fluid intake
- Avoid straddle toys, swimming, and sandboxes until allowed by surgeon
EPISPADIAS
- Extrophy of the bladder d/t failure of abdominal wall and underlying structure to fuse in utero
- More common in males (2:1)
- Severity varies
- Part of a complex of congenital anomalies
- Body image concerns
EPISPADIAS: Clinical Manifestations
- Widened pubic bones
- Outwardly-rotated hands and feet
- Triangle-shaped defect in abdomen
- Displacement of umbilicus; possible hernia
EPISPADIAS: Therapeutic Management
- Multiple surgical procedures
- Ongoing management of urinary systems
- Initial surgery: urine drains freely from urethra, regular UA and US; teach sx of UTI
- Second phase of surgery: repair of epispadias and creation of urethral sphincter mechanism
- Additional surgeries for sexual fx and body image improvement
EPISPADIAS: Nursing Care Management
- Meticulous hygiene
- Sterile, nonadherent moist dressing placed over exposed bladder
- Moist barrier ointment for surrounding skin
- Fluid management
- Postop care: decrease pain and agitation; decrease crying; pelvic immobility; maintain cath patency; maintain operative site
- Family care: explain appearance of defect and realistic outcomes; teach S/S of infection; sponge baths, do not immerse in water
CAPTA
Child Abuse Prevention and Treatment Act; finally defined child abuse
NAT
Non-accidental trauma
CHILD MALTREATMENT
- Sexual abuse (8%)
- Emotional abuse (4%)
- Intentional physical abuse (22%) or neglect (54%)
- Affects all ages
- 41% of deaths are under 1 year of age
- 76% of deaths are under 4 years of age
CHILD NEGLECT
- Not providing for basic needs
- Can be physical or emotional
- Most common form of maltreatment
- About 1/2 of reported cases
- >1/3 of deaths
PHYSICAL NEGLECT
Deprivation of food, clothing, shelter, supervision, medical care, and education; may present as FTT
EMOTIONAL NEGLECT
Lack of affection, attention, and emotional nurturing; "emotional abuse"--destroy or impair child's self-esteem
PHYSICAL ABUSE
- Deliberate infliction of physical injury on a child
- i.e. pinch marks, grab marks, strap marks, tie marks, bruising, burns, subdural hematoma (from hitting head against wall), intraabdominal injuries, shaken baby syndrome
- 15% of burns are from hot water (no splash marks); 3/4 includes injury to head, face, mouth, neck
BRUISING: Stages
- Stage 1: 1-2 days; swelling, red, black, blue
- Stage 2: 5-7 days; green
- Stage 3: 7-10 days; yellow
- Stage 4: 10-14 days; brown
MUNCHAUSEN'S SYNDROME BY PROXY (MSBP)
- Caregiver fabricates S/S of illness in the child (proxy) to gain attention from medical staff
- Child may undergo needless and painful procedures and tx; 10% of cases may be fatal to child
Parental Factors Predisposing to Physical Abuse
- Parental characteristics
- Social isolation; poor support systems
- Parental low self-esteem and less adequate maternal fx
Child Characteristics Predisposing to Physical Abuse
- Compatibility b/t child's and parent's temperament; parent's ability to deal with behavioral style
- Removing the child victim from the home may place other siblings at risk
Environmental Characteristics Predisposing to Physical Abuse
- Chronic stress
- Divorce
- Poverty, unemployment, poor housing, crowded living conditions
- Frequent relocation
- Can occur in any socioeconomic population
- Crosses all racial, economic, and religious lines
SEXUAL ABUSE
The use, persuasion, or coercion of any child to engage in sexually explicit conduct or stimulation of such conduct for producing visual depiction of such conduct, or rape, molestation, prostitution, or incest with children
Characteristics of Sexual Abusers
- Typical abuser is a male the victim knows, but it could be ANYONE
- Occurs in all socioeconomic backgrounds
- Often incest is tied to maladjustment b/t husband and wife
SEXUAL ABUSE: Risk Factors
- Female
- Absence of father/stepfather
- Poor relationship with parents
- Substance abuse
- Social isolation
- Conflict
- Mother working outside of home
Nursing Care of the Maltreated Child
- Identify abusive situations as early as possible
- Obtain hx pertaining to the incident
- Be the first to see child and parent
- Document evidence of maltreatment
- Monitor for pattern or combination of indicators that arouse suspicion and further investigation
- Protect child from further abuse
- Referral for investigation by social worker
- Child may be temporarily removed or hospitalized to care for injuries
- Family support: be a role model for the parents by showing genuine concern; encourage child's relationship with parents; establish therapeutic relationship with parents
Reporting Child Abuse
- Missouri: Division of Family Services (DFS)
- Kansas: State Department of Social Rehab Services
- All health care workers, teachers, and law enforcement officers are mandated to report suspected abuse
Abuse Prevention
- Professional counseling for abuser and victim
- Anger control
- Education in childrearing techniques
- Early identification of high risk populations
- Support: Parents Anonymous; Parents United International Inc., Child Abuse Prevention Association (CAPA)
RAD
Formation of indiscrimate relationships; child usually rejects comfort, no stranger anxiety
Abuse Red Flags
- Hx inconsistent with injury (most important indicator)
- No explanation offered for injury
- Hx inconsistent with child's developmental level
- Injury is blamed on sibling or other child
Purposes of the Skin
- Protection
- Impermeability
- Heat regulation
- Sensation
SKIN LESIONS: Origin
- Contact with injurious agents
- Hereditary factors
- External factor that produces a rxn in the skin
- Systemic disease in which lesions are a manifestation
- Age-related: birthmarks (infants); atopic dermatitis (early childhood); ringworm (school-age); acne (adolescents)
Types of Lesions
- Papule
- Macule
- Vesicle/bulla
- Pustule
- Cyst
- Patch
- Plaque
- Wheal
- Striae
- Scale
- Crust
- Keloid
- Fissure
- Ulcer
- Petechiae
- Purpura
- Ecchymosis
PETECHIAE
Pinpoint, tiny, sharply circumscribed spots that are superficial
Skin Assessment
- Inspect and palpate with gloves on
- Character of skin (describe deviations)
- Color, shape, and distribution of lesions or pattern
- Configuration and arrangement; size; clustered or confluent
- Wounds assessed for depth, evidence of healing, and sx of infection
Infant Skin Disorders
- Seborrhea dermatitis
- Diaper dermatitis
- Atopic dermatitis (eczema)
- Candidiasis
- Candida diaper rash
- Cradle cap
SEBORRHEA DERMATITIS
- Chronic recurrent inflammation of skin
- Cause unknown
- Tx: shampoo daily with mild soap
DIAPER DERMATITIS
- Occurs in 35% of children
- Caused by prolonged contact with irritants (i.e. feces, urine, soap, detergents) or friction; AKA candida albicans
- Tx: protective barrier (i.e. zinc oxide); dry area and change diapers often
ATOPIC DERMATITIS (ECZEMA)
- Redness, scaling, vesicles, and crusting
- Common and recurring
- Cause unknown; may be associated with family hx, asthma, food allergies, and allergic rhinitis
- 3 types: infantile (2-6 months); childhood (2-3 years, 90% manifest by 5 years); adolescent (begins at 12 years)
- Tx: no cure, but can manage; goals--hydrate skin, relieve pruritis (itching), reduce flare-ups, prevent and control infection; topical corticosteroids are tx of choice
ATOPIC DERMATITIS: Nursing Care Management
- Control intense pruritis through clothing and skin care
- Prevent infection by avoiding scratching
- Diet modification
Middle Childhood Skin Disorders
- Impetigo
- Herpes Simplex
- Ringworm
- Scabies
- Lice
- Contact dermatitis (i.e. poison ivy)
- Bites and stings
IMPETIGO
- Common, very contagious superficial skin disorder
- Caused by group A hemolytic strep or staph
- Tx: remove skin crusts and apply topical bactericidal ointment, possible systemic abx
TINEA FUNGUS: Types
- Tinea capitis (hair)
- Tinea corporis (trunk, legs, and arms)
- Tinea cruris (groin, pubic area, thighs)
- Tinea pedis (AKA athlete's foot)
- When in hair and on body, referred to as "ringworm"
FUNGAL INFECTIONS
- Fungi release an enzyme that digests and hydralizes the keratin in hair, nails, etc.--fungi will be on the border of the lesion
- Dx: skin scrapings
- Tx: topical antifungal ointments; good hygiene; shampoo with selenium sulfide; possible oral griseofluvin; no sharing of personal items
SCABIES
- Caused by mite (sarcoptes scabiei); impregnated female burrows into skin and lays eggs
- Inflammatory response at 30-60 days
- Manifests by intense itching
- Tx: Permethrin 5% cream (Elimite); apply to entire body; wash clothing in hot water
PEDICULOSIS (Lice)
- Transmitted by direct contact
- More common in school-age children and white females
- Tx: Permethrin 1% cream (Nix) and daily removal of nits with comb; psychological effect
Skin Disorders: Relief of Sx
- Pruritis = most common complaint with skin lesions
- Prevent scratching: mittens/covering for younger children; short nails; antipruritic meds
- Cooling baths or compresses
POISON IVY: Clinical Course
- Day 1: contact
- Day 2: little bumps, itching
- Day 3: inflammation, itching
- Day 4: inflammation, weeping
- Day 5: less weeping and itching
- Day 6: bright red color
- Day 7: same as day 6
- Day 8: same as day 6/7 with mild itching
- 1 week later: hard scaliness and return to natural color
POISON IVY: Tx
- Wash with cool water right away
- Wash clothing in hot water with detergent
- Tx: topical meds unless severe, then need oral corticosteroids
ARTHROPOD BITES AND STINGS
- Venom injected into skin may contain proteins that cause a rxn --> pain, local wheal, and erythema; itching that lasts <24 hours
- Prevention: use repellants with DEET
- Tx: symptomatic measures, cool compress, calamine lotion, prevention of infection; remove stinger quickly
LEUKEMIA: Patho
Starts in bone marrow --> unrestricted proliferation of immature WBCs in blood-forming tissues --> replacement of normal nonfunctioning cells with leukemic cells; liver and spleen most severely affected
LEUKEMIA: Manifestations
- Lymphadenopathy: >1 cm, firm/matted; regional or localized; epitrochlear (elbow) or supraclavicular node involvement usually = pathologic
LEUKEMIA: Dx
- H&P
- Peripheral blood smear for immature leukocytes and blood counts
- Bone marrow aspiration for large numbers of immature cells
- LP for CNS involvement
- CXR
- Testicular exam
LEUKEMIA: Tx
- Chemo combined with drugs per protocol
- Radiation sparingly if high-risk
- CNS prophylaxis: intrathecal chemo, high-dose methotrexate and/or cytarabine, cranial radiation (high-risk only)
- AML: short and intense therapy
- ALL: long and mild therapy
HODGKIN'S LYMPHOMA: Manifestations
- Systemic "B" sx (30% of cases)
- Unexplained fever >38C for 3 days
- Drenching night sweats
- Weight loss >10% in 6 months
- Possible mediastinal mass with resulting respiratory compromise
- Classical presentation = painless swelling
HODGKIN'S LYMPHOMA: Dx
- Presence of Reed-Sternberg cells
- Physical
- Blood work-up
- CT of neck, chest, abdomen, & pelvis
- Gallium or PET scan
- Bone marrow aspiration & bx
- Surgical lymph node bx
HODGKIN'S LYMPHOMA: Tx
- Multimodal therapy (chemo + radiation in some cases)
- Curative intent with goal of minimizing effects
- Transplant in relapse & refractory
NON-HODGKIN'S LYMPHOMA: Manifestations
- Classical presentation = painless swelling
NON-HODGKIN'S LYMPHOMA: Dx
- Presence of Reed-Sternberg cells
- Physical
- Blood work-up
- CT of neck, chest, abdomen, & pelvis
- Bone marrow aspiration & bx
- Surgical lymph node bx
- Bilateral bone marrow aspiration & bx
- CSF for cytology
- Nuclear med scans (bone scan 1st, gallium/PET scan 2nd)
NON-HODGKIN'S LYMPHOMA: Tx
- Chemo (depends on type and stage); 6-24 months
- Radiation
- Emergency mgmt of airway or CNS disease
- Palliative care
- Transplant in relapsed/recovery
BRAIN TUMORS: Patho
Abnormal DNA and uncontrolled cell division --> death to surrounding tissue d/t infiltration and compression --> cerebral edema --> ↑ ICP --> focal neuro deficits, obstruction of CSF flow, pituitary dysfunction, & brain stem herniation
BRAIN TUMORS: Manifestations
- R/t location, size, and pt's age
- HA
- Vomiting with position changes
- Neuro changes (i.e. uncoordination, clumsiness, loss of balance, loss of developmental milestones)
- Behavioral changes (i.e. irritability, lethargy, bizarre behaviors)
- Cranial nerve neuropathy (i.e. head tilt, facial weakness, visual deficits)
- VS disturbances (i.e. ↓ HR & RR, ↑ BP, hypo/hyperthermia)
- Seizures
- Nuchal rigidity
- Papilledema
- Cranial enlargement; bulging fontanel
BRAIN TUMORS: Dx
- Careful and thorough hx
- Physical and neuro exam
- MRI, CT, LP
- Definitive dx = tissue specimens obtained during surgery
BRAIN TUMORS: Tx
- Chemotherapy: can cross BBB to tx tumors or used in combination with radiotherapy & surgery
- Stereotactic surgery with MRI & CT
- Radiotherapy: used to shrink tumor before surgery
- Supportive meds: corticosteroids (to ↓ cerebral edema), anticonvulsants (for seizures), pain meds, abx, antiemetics, histamine blockers
NEUROBLASTOMA: Patho
Originates in embryonic neural crest cells; most tumors arise from adrenal glands, retroperitoneal sympathetic chain, head, neck, chest, & pelvis
NEUROBLASTOMA: Manifestations
- Fever
- HTN (d/t presence on adrenal gland)
- Anemia, fatigue
- Anorexia, weight loss
- Limp or refusal to walk d/t bone pain
- "Blueberry muffin" spots
- Horner's Syndrome (orbital ecchymosis)
- Opsoclonus/myoclonus (jerking movement)—rare
- Head/neck/chest/perispinal involvement = resp. distress, cord compression, wkns/paralysis, incontinence or urinary retention, constipation or diarrhea
- Abdominal/pelvis involvement: pain, distension, visible/palpable mass
NEUROBLASTOMA: Dx
- Radiological studies: CT, bone scan, MIBG
- Bone marrow aspiration & biopsy
- Surgical biopsy
- UA for catecholamines HVA & VMA
NEUROBLASTOMA: Tx
- Surgical resection
- Chemotherapy
- HCT
- XRT
- MIBG therapy
- Biological therapy/retinoids
- Focus on minimal residual disease
WILM'S TUMOR: Manifestations
- Most common: abdominal swelling or mass—firm, non-tender, unilateral, & deep, doesn't cross midline
- Hematuria
- Anemia
- HTN
- Weight loss
- Fever
- Lung mets: pain, dyspnea, SOB, cough
WILM'S TUMOR: Dx
- Abdominal ultrasound
- CT, MRI
- Hematological studies
- Kidney fx tests
- UA
- Bone marrow aspiration & biopsy
- Physical exam for congenital anomalies
- Inferior venacavogram to look for vena cava involvement
WILM'S TUMOR: Tx
- Combined surgery and chemo with or w/o radiation; depends on stage and histologic pattern
- Surgery to remove kidney, adrenal gland, involved structures and lymph nodes; if bilateral kidney involvement, may do partial nephrectomy on least affected and total removal on most affected
- All pts have chemo for 6-15 months postop
- Radiotherapy: reserved for large tumors, mets, or recurrence
RHABDOMYOSARCOMA: Manifestations
- Depend on location and compression of other organs
- Soft or hard, non-tender, immobile mass
- Eye changes (visual changes, ptosis)
- Nasal changes (congestion, obstruction, drainage, pain)
- Ear changes (otitis media, pain, drainage)
- Affected ROM
- GI/GU complaints
RHABDOMYOSARCOMA: Dx
- Radiographic studies
- CXR
- CT, MRI
- Bone scan
- Bone marrow aspiration & biopsy
- Possible LP
RHABDOMYOSARCOMA: Tx
- Aggressive multimodal therapy (usually malignant @ time of dx)
- Complete removal of primary tumor with chemo/radiation for 1-2 years
OSTEOGENIC SARCOMA: Manifestations
- Localized pain & swelling at tumor site
- Palpable mass
- Limp or ↓ ROM
OSTEOGENIC SARCOMA: Dx
- Rule out trauma or infection
- Radiologic studies (CT, bone scan) and bone bx
- MRI for neuro & soft tissue involvement
- Labs: possible ↑ alkaline phosphatase
OSTEOGENIC SARCOMA: Tx
- Traditional approach: radical surgical resection or amputation of affected limb
- Limb-salvage procedures: resection of bone with prosthetic
- Aggressive chemo postop
- Nursing Considerations: pain mgmt (i.e. phantom limb pain, stump care, prosthesis, rehab); anger and depression; preop prep (support, body image concerns)
EWING'S SARCOMA: Manifestations
- Localized pain & swelling at tumor site
- Palpable mass
- Limp or ↓ ROM
EWING'S SARCOMA: Dx
- Rule out trauma or infection
- Radiologic studies (CT, bone scan) and bone bx
- MRI for neuro & soft tissue involvement
- Labs: possible ↑ alkaline phosphatase
EWING'S SARCOMA: Tx
- Chemo to reduce tumor size
- Surgical removal or high-dose irradiation of entire bone
- Limb-sparing procedures preferred
- Chemo postop
- Nursing Considerations: pain mgmt (i.e. phantom limb pain, stump care, prosthesis, rehab); anger and depression; preop prep (support, body image concerns)
RETINOBLASTOMA: Patho
Arises from retina; bilateral = inherited (autosomal recessive gene); unilateral = inherited or nonhereditary
RETINOBLASTOMA: Manifestations
- "Cat's eye" reflex (leukokoria): most common sx; whitish glow seen in pupil
- Strabismus: 2nd most common sx
- Redness, pain
- Possible glaucoma
- Nystagmus
- Orbital cellulitis
- Blindness (late sx)
RETINOBLASTOMA: Dx
- Ophthalmologist exam under anesthesia
- Enucleation if optic nerve involved
RETINOBLASTOMA: Tx
- Radiotherapy = standard of care
- Other options: surgical implant of Iodine 125 applicator on sclera; photocoagulation with laser to destroy tumor's blood vessels; cryotherapy (freeze tumor); chemo
ALL: Favorable Prognostic Factors
- WBC <50K
- Age >1 year and <10 years
Effectiveness of Chemo
- Chemo drugs work only on cells that are actively reproducing (not cells that are in the resting phase), may specifically attack cells that are in a particular phase of reproducing cycle—targets the cell cycle
- Oncologists can predict which chemo drugs work best together
CHEMO: Common Side Effects
- Effects of myelosuppression (i.e. neutropenia, thrombocytopenia, anemia)
- N/V
- Altered nutrition
- Mucosal ulceration
- Neuro problems (i.e. constipation, foot drop, weakness, numbness)
- Hemorrhagic cystitis
- Alopecia
- Steroid effects (i.e. increased appetite, puffy face, weight gain, mood changes)
ALL: Phases of Chemo
Long, mild therapy; more common; best cure rate
- Induction
- Consolidation
- Interim maintenance (break in tx q 10 days for 2 months)
- Intensification
- Maintenance
AML: Phases of Chemo
Short (usually <1 year), intense therapy; timing is crucial; requires intense supportive care and length hospitalizations
- Induction
- Post-remission therapy: intensive chemo & hematopoietic cell transplant
CHEMO: Management of Side Effects
- N/V: prophylactic antiemetic 30 min to 1 hour before chemo and q 2/4/6 hours for 24 hours after; avoid development of anticipatory sx; may give chemo at night with sedative
- Anorexia/nutrition: thorough evaluation initially and throughout tx; oral supplements with high-protein and high-calorie food; calorie counts; possible supplemental enteral feedings (i.e. NG) or parenteral hyperalimentation; favorite foods and new foods; small, frequent meals; don't pressure; appetite stimulant meds (Periactin, Megace)
- Alopecia: prepare pt and family; warn that hair falls out in clumps; may choose to cut short or shave; consider purchase of wig; use mild shampoos and soft brushes; protect scalp (wigs/sunscreen); may wear hats or wigs to school
- Mucosal ulceration: bland, soft, moist diet; cold or room temp foods; fluids through straw; avoid acidic foods; sponge toothbrush or cotton-tipped applicator to brush teeth before and after eating; NS rinses; local anesthetics without alcohol; systemic pain meds; meticulous toilet hygiene & stool softeners; monitor stool
- Steroid SE: assure that SE are temporary; encourage sharing of feelings and sense of well-being
8 Cardinal Cancer Sx
- Pallor, bleeding
- Fatigue
- Persistent fever
- HA, visual changes
- Lymphadenopathy
- Bone/joint pain, limp
- Abdominal mass
- Cough, resp. difficulties