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Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:44:26 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=2 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 1 - GROWTH AND DEVELOPMENT OF CHILDREN CHAPTER 1.0 - GROWTH AND DEVELOPMENT Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 8 of 8 12/22/2006 7:14 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=3&FxId=123&Sessio. CHAPTER 1.1 - BASIC CARE PLAN: WELL CHILD INTRODUCTION Healthy children are assessed at regular intervals to monitor growth and development, prevent disease through immunization, promote wellness, and provide families with anticipatory guidance. The nursing care plan for a well child is based on a thorough nursing history, assessment, and review of medical and laboratory findings. The child's parent (or caretaker) is included in all aspects of the child's care. Specific client-related data should be inserted within parentheses and whenever possible. NURSING DIAGNOSES HEALTH-SEEKING BEHAVIORS: WELL-CHILD VISIT Related to: Parent's belief in the benefits of health screening and health promotion for the child. Defining Characteristics: Child is brought in for routinely scheduled well-child office visits (specify). Parent appears interested and asks appropriate questions related to the child's health and growth and development. (Specify, using quotes whenever possible.) Goal: Parent will continue health-seeking behaviors. Outcome Criteria √ The parent keeps all scheduled well-child appointments. √ The parent calls the health care provider for concerns related to the child's health and well-being. NOC: Knowledge: Health Promotion INTERVENTIONS RATIONALES Establish a comfortable environment Promoting comfort and a sense of for the child and parent: provide safety for the child decreases privacy, assume a position at the the stress of health care child's level without approaching visits. too suddenly, listen attentively, and allow adequate time to address the parent and child's concerns. Establish the reason for health care Provides the framework for the visit (specify, e.g., 6-month well- health care experience and baby checkup; high school physical encourages information-sharing exam). Elicit and address any and giving. concerns the parent or child (if age appropriate) might have. Assess the child's growth and physical The nurse's knowledge of growth well-being based on developmental and development allows the exam level (specify, e.g., an infant may to be structured to cause the 1 of 8 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=3&FxId=123&Sessio. be examined sitting in the parent's least stress for the child. lap with auscultation the first technique. An adolescent may benefit from having the parent wait outside during the physical exam.) Provide health teaching as appropriate Teaching helps the parent and during and after the exam. child to maintain optimal health. Evaluate the child's competence on More than one measure is several appropriate developmental necessary to gain an accurate milestones (specify which parameters evaluation of development. are appropriate for individual child). Provide the parent (and child if Anticipatory guidance helps the appropriate) with anticipatory parent to support the child's guidance related to expected development. development in the near future (specify). Offer praise to parent and child for Positive reinforcement may help attempts to maintain a healthy maintain the desired behavior. lifestyle, including keeping health care appointments. Provide written information about Written information can be read growth and development. at leisure and provides reinforcement of teaching. Encourage parent to call health care Encouragement helps the parent to provider for concerns about the seek information and care in a child's health and well-being. timely manner. Provide appropriate phone numbers. Make referrals as needed (specify, Describe rationale for specific e.g., WIC, social services, etc.). referral. NIC: Health Screening; Health Education Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Has the parent kept all scheduled well-child appointments?) (Has the parent called the health care provider for concerns related to the child's health and well-being?) (Revisions to care plan? D/C care plan? Continue care plan?) READINESS FOR ENHANCED ORGANIZED INFANT BEHAVIOR Related to: Increasing stability of autonomic, motor, and state responses to environmental cues. 2 of 8 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=3&FxId=123&Sessio. Defining Characteristics: (Specify, e.g., parent reports that the infant has established a sleep/wake pattern; infant responds to visual and auditory cues; infant demonstrates ability to console self, etc.) Goal: The infant will continue to adapt appropriately to environmental stimuli by (date/time to evaluate goal). Outcome Criteria √ Infant exhibits smooth movements (specify, e.g., hand-to-mouth, suck, swallow). √ Infant exhibits organized behaviors (specify, e.g., maintains quiet alert states, engages in reciprocal interaction with parent; self-consoling, etc.) NOC: Child Development INTERVENTIONS RATIONALES Assess parent(s)' understanding of Assessment provides baseline infant's current behavioral states information. and cues (specify). Provide parents with information Recognizing the infant's about expected infant development individual behaviors enhances (specify if verbal discussion, the parent-infant written information, or video will relationship. be used). Help parents to identify their infant's behavioral states and individual cues. Assist parents to identify when the Identifying infant behaviors infant's behavior indicates stress helps the parent to modify caused by excess environmental stressors. stimuli (specify). Encourage parents to decrease stimuli Promotes infant development when infant appears overstimulated. without excessive stress. Teach parents to provide Interventions foster developmental interventions for development and enhance their infant (specify interventions parent-infant relationship. based on infant's age and ability). Provide parents with referrals or Provides parents with additional information as indicated additional information to (specify for clients). foster infant development. NIC: Infant Care Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Does infant exhibit smooth movements? (Specify) 3 of 8 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=3&FxId=123&Sessio. (Describe infant's behavior organization; specify as listed in outcome criteria) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: Lack of completed immunizations. Defining Characteristics: Infant/child has not received all immunizations against childhood illnesses (specify age and appropriate immunizations for age). Goal: Infant/child will not experience infection with preventable childhood illnesses by (date/time to evaluate). Outcome Criteria √ Infant/child receives all immunizations appropriate for age (specify which immunizations and when they should be completed). √ Infant/child does not experience infection with preventable childhood illnesses. NOC: Immunization Behavior INTERVENTIONS RATIONALES Assess infant/child's current Provides baseline data about immunization status. immunization needs. Teach parent about the benefits of Informed parents are able to make childhood immunization against good decisions for their child. preventable illnesses. Provide written information about immunization. Administer immunizations as ordered Specify action of particular agent by the caregiver (specify drug, in preventing infection. Relate dose, route, and timing) providing principles of growth and the least traumatic care (specify development to method of giving based on developmental level). immunization. Observe for side effects and teach Specify side effects of particular parent to provide relief as ordered agent and action of Tylenol or by caregiver (specify, e.g., other relief measures. Tylenol as ordered for discomfort). Teach parent (and child if age- Teaching empowers the parent and appropriate) to practice good child to take responsibility for hygiene (specify, e.g., health. Specify how infection is handwashing, bathing, kitchen prevented by specific teachings. hygiene, etc.). Encourage parent to provide optimal A well-nourished and rested infant/ nutrition and a balance between child is less susceptible to rest and activity for the infant/ infection and better able to child (specify). respond effectively. Offer praise and encouragement to Positive reinforcement helps ensure parent and child for taking good that behavior will continue. 4 of 8 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=3&FxId=123&Sessio. care of the child's health. NIC: Immunization/Vaccination Administration Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Has infant/child received all immunizations appropriate for age? Specify) (Has infant/child experienced infection with preventable childhood illnesses? Specify) (Revisions to care plan? D/C care plan? Continue care plan?) DELAYED GROWTH AND DEVELOPMENT Related to: Separation from significant others (specify, parents, siblings, peers and/or primary caretaker). Defining Characteristics: Ages 6 to 30 months (specify, crying, screaming, withdraws from others, inactive, sad, detachment behaviors, regressive behaviors); 3 to 6 yrs. (specify, temper tantrums, refusal to comply with hospital routine/treatments, crying, refusal to eat); 6 to 12 yrs. (specify, express feelings of loneliness, boredom, isolation, depression, worry about absence from school); 13 to 18 yrs. (specify, may react with dependency, uncooperativeness, withdrawal behaviors, fear of loss of peer status/acceptance at school). Related to: Decreased or increased environmental stimulation. Defining Characteristics: Inability to perform self-care or self-control activities appropriate for age, decreased responses, listlessness, flat affect; delay or difficulty in performing developmental tasks/skills (specify, motor, social or language) typical for age group. Related to: Chronic illness or disability, repeated hospitalizations. Defining Characteristics: Inability to perform gross and fine motor tasks appropriate to age, altered physical growth (specify). Goal: Child will exhibit age-appropriate growth and development by (date/time to evaluate). Outcome Criteria √ Child exhibits age-appropriate growth and development activities (specify). NOC: Child Development INTERVENTIONS RATIONALES Provide or arrange for growth and Identifies developmental level or development assessment with the any lag in development to assist administration of tools in plan of care or therapy; 5 of 8 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=3&FxId=123&Sessio. such as Washington Guide, Denver information should include age- Developmental Screening Test expected gross and fine motor (DDST), Denver Developmental development, language and social Screening Test Revised (DDST-R), development, psychosocial and Denver II, Revised Denver psychosexual development, Prescreening Developmental interpersonal skills, cognitive Questionnaire (R-PDQ), Denver and moral and spiritual Articulation Screening Exam (DASE) development. (specify). Reassess developmental levels at Provides evidence of progress to intervals appropriate for illness evaluate program to correct any or other problem (specify). growth and developmental deficit. Provide consistent caretaker and Promotes trust and progress in care. development. Depending on age and abilities, Promotes independence needed for encourage to participate in goal- control and development. setting decision-making, participation in care (specify). Provide visual, auditory, tactile Promotes stimulation needed to stimulation, including mobiles with maintain developmental status. or without color, music, toys, books, television, games or other age-related activities; hold child and rock or pat on back, talk to child. Provide time for child, either quiet Promotes independence and or talking, to play with other development or maintenance of children, time for parents that motor skills to prevent remain in hospital to interact with regression. child. Provide developmentally appropriate To enhance child's adjustment to activities based on child's age- hospitalization and treatment and related abilities (specify). to enhance child's maximum growth and developmental abilities. Explore the family's and child's Promotes family communication and feelings regarding child's health attitude of acceptance and status and required treatments. adaptation to child's health status and abilities. Encourage independence and choices in Fosters child's sense of control, as many areas as possible (i.e., adaptation, and developmental dressing, feeding, type of foods/ growth during their altered drinks, or BandAids). health state and hospitalization. Encourage socialization (i.e., in the To foster child's ability to play room, with siblings, peers, develop and maintain peer phone calls, if possible). relationships. Recognize and support ritualistic Fosters child's need for autonomy. behaviors (especially in the young child). Encourage mastery of self-care Fosters child's need for initiative activities, required health care and purpose; fosters child's equipment, if appropriate. self-esteem. Instruct parents on growth and Provides information about age- 6 of 8 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=3&FxId=123&Sessio. development for child's age related growth and development to (specify). ensure realistic expectations. Inform of age-related play and other Provides guidance for proper, safe activities that enhance growth and activities and stimulation to development and provide needed prevent frustration of child and stimulation; include those that to promote normal development. encourage gross and fine motor development, sensory and cognitive development, others as determined by testing and needs. Teach parents whether developmental Promotes understanding and relief and growth lag is the result of the from anxiety and guilt. child's illness (acute or chronic) or some other reason. Discuss test results with child and Promotes understanding of special parents and possible plan to needs and formulation of goals resolve any deficits, both and actions based on findings. short-term during hospitalization and long-term during convalescence. Initiate referral

to child Provides source of assistance to development expert if appropriate. ensure proper age-related development. NIC: Developmental Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Does child exhibit age-appropriate growth and developmental activities? Describe) (Revisions to care plan? D/C care plan? Continue care plan?) COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: 7 of 8 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=3&FxId=123&Sessio. Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:44:51 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=3 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 1 - GROWTH AND DEVELOPMENT OF CHILDREN CHAPTER 1.1 - BASIC CARE PLAN: WELL CHILD Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 8 of 8 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=4&FxId=123&Sessio. CHAPTER 1.2 - HOSPITALIZED CHILD INTRODUCTION Hospitalization of the child, whether it involves a short-term hospital admission, surgery, a follow-up evaluation, or repeated hospitalizations for a chronic illness or episode, creates a crisis for the child and family. Responses to hospitalization are related to the developmental level of the child but generally include fear of separation, loss of control, injury, and pain. The ease of transition from home to the hospital depends on how well the child has been prepared for it and how the child's physical and emotional needs have been met. Supporting the family, providing them with information, and encouraging their participation in the child's care contributes to the adjustment and well-being of all concerned. COMMON NURSING DIAGNOSES See DISTURBED SLEEP PATTERN Related to: Physiologic factors related to illness and psychological stress, external factors of environmental changes. Defining Characteristics: Interrupted sleep, irritability, restlessness, lethargy, disorientation, fatigue, pain, separation anxiety, side effects of medication (nausea, vomiting, diarrhea) (specify for child). See IMPAIRED PHYSICAL MOBILITY Related to: Pain and discomfort; neuro or musculoskeletal impairment (specify). Defining Characteristics: Imposed restrictions of movement or activity, imposed bed rest, limited strength, endurance, weakness, fatigue, drainage tubes and IV catheters; disturbances in gait, vision, equilibrium (specify). See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Loss of appetite; lack of interest in food; alteration in taste; inability to ingest, digest or absorb nutrients; nausea; vomiting; diarrhea; constipation; abdominal pain; oral ulcers (specify). Defining Characteristics: Weakness, fatigue, anxiety, anorexia, illness, lack of interest in eating (specify behavior). See DELAYED GROWTH AND DEVELOPMENT Related to: Separation from significant others; environmental and stimulation deficiencies; effects of repeated hospitalizations; social isolation; sensory and/or motor delays (specify). Defining Characteristics: (Specify, e.g., inability to perform self-care or self-control activities appropriate for age; regressive behavior; fear of unfamiliar environment and treatments; feelings of inferiority; low self-esteem, or alterations to body image.) ADDITIONAL NURSING DIAGNOSES 1 of 11 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=4&FxId=123&Sessio. ANXIETY Related to: Change in health status; change in environment; threat to self-concept; situational crisis (specify). Defining Characteristics: Increased apprehension; fear; helplessness; uncertainty; distress over hospitalization; restlessness; expressed concern over procedures, pain, loss of control, separation from significant others; crying; clinging; refusal to interact with staff, changes in VS, financial stresses caused by required absence from employment (specify child's behavior). Goal: Child and family will experience decreased anxiety by (date/time to evaluate). Outcome Criteria √ Reduced anxiety expressed by child and family. √ (Specify behaviors to look for: e.g., child is not crying or clinging, facial features are relaxed, parents verbalize understanding of procedures and plan of care, etc.) NOC: Anxiety Control INTERVENTIONS RATIONALES Assess child's and parents' level of Provides information about sources anxiety, child's developmental and level of anxiety related to level, understanding of illness, and illness and hospitalization; reason for hospitalization, and sources of anxiety and responses responses to this and previous vary with age of child and hospitalizations during admission. include separation, pain and bodily injury, loss of control, enforced dependence, fear of unknown, fear of equipment, unfamiliar environment and routines, guilt, fear and concern for child's recovery, feelings of powerlessness. Assess social and emotional history of Provides information about child and family for strengths and strengths and about weaknesses to successful coping ability. draw upon to cope with hospitalization. Allow expression of feelings and Provides opportunity to vent concerns about illness and feelings and fears to reduce procedures and listen individually anxiety and promote adaptation to to child and parents. hospitalization. Provide a calm, accepting environment Assists child and family in and avoid rushing through establishing trust and obtaining interactions and care. emotional stability. Provide orientation to hospital Familiarizes child and family with environment and room, routines, meal environment, promotes secure and play time, introduction to staff feeling, and reduces fear of members, forms to sign and hospital unknown. policies. 2 of 11 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=4&FxId=123&Sessio. Have same personnel following written Promotes continuity and consistency care plan, care for child; schedule of care to support trusting personal contact with child within relationship. work day (specify). Encourage involvement of child and Promotes participation in and parents in planning and adaptation to hospitalization, interventions of care; allow reduces anxiety; allows parents to remain with child; demonstration of love and allow to hold and cuddle the child. affection for child. Allow child and parents to incorporate Promotes security and reduces home routines as much as possible; anxiety associated with new bring toys, tapes, photographs and experiences. favorite foods from home as appropriate (specify). Maintain a quiet environment, control Decreases stimuli that increase visitors and interactions. anxiety. Allow child to play out feelings. Permits child to express feelings Accept feelings and responses without fear of punishment. expressed by the child. Approach child in a positive way; use Promotes rapport and trust and child's proper name; avoid maintains identity. communicating, either verbally or nonverbally, any rejection, judgments, or negativism. Identify and recognize regressive Allows for behaviors common to behavior as a part of the illness hospitalizations and loss of and assist child in dealing with control. dependency associated with the hospitalization. Provide support to child during any Reduces anxiety and fear caused by procedures or distressing features possible bodily injury. associated with care, including intrusive procedures, exposure of body parts, need for personal privacy and privacy of others. Inform and explain all treatments and Provides easily understood procedures in simple, understandable information, which decreases language to child and parents anxiety. according to their intellectual level and age; pace information according to child/parental needs. Inform parents and child that behavior Prevents feeling of inadequacy and caused by anxiety and fear is normal fear of punishment. and expected. Use therapeutic play to explain and Permits child to understand and prepare child for procedures; repeat become familiar with articles any teaching as needed. used for care or procedure. If surgery planned (specify) instruct Prepares child for surgical in preoperative and postoperative intervention with minimal care, surgical procedure to be anxiety. done, reason for surgery, and length of hospitalization; 3 of 11 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=4&FxId=123&Sessio. answer questions about surgery. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did child or family express decreased anxiety? Use quotes. Describe behavioral change associated with decreased anxiety, e.g., child is no longer clinging to parent.) (Revisions to care plan? D/C care plan? Continue care plan?) SELF-CARE DEFICIT, BATHING/HYGIENE, DRESSING/GROOMING, FEEDING, TOILETING Related to: Impaired ability to perform ADL; pain and discomfort (specify). Defining Characteristics: Inability to wash body, take off or put on clothing, feed self, positioning or mechanical restrictions, weakness, fatigue, imposed bed rest, inability to carry out toileting with use of bedpan or go to bathroom (specify for child). Goal: Child will demonstrate increased ability to care for self by (date/time to evaluate). Outcome Criteria √ Maximum self-care capability with or without use of aids (specify for child). NOC: Self-Care: Activities of Daily Living INTERVENTIONS RATIONALES Assess physical tolerance and Provides information about abilities to perform ADL, and play amount of energy and effect of activities and restrictions imposed illness on activity level. by the illness and medical protocol. Anticipate child's needs for Prevents embarrassing toileting, feeding, brushing teeth, experiences with toileting and bathing and other care if unable to maintains comfort with manage on own; allow child to do as personal cleanliness and much as possible (specify). appearance. Provide personal care for infant and Provides needed assistance where small child; assist child and using patterns and articles Adjust times and methods to fit that encourage parent to home routine. assist child. child is accustomed to using and doing. Praise child for participation in own Promotes self-esteem and care according to age, independence. 4 of 11 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=4&FxId=123&Sessio. developmental level, and energy (specify). Provide assistive aids or devices to Assists child in performing perform ADL, allow choices when self-care for ADL. possible (specify for child). Balance activities with rest as Prevents fatigue by conserving needed; place needed articles and energy and promoting rest. call light within reach if appropriate. Instruct child in toileting, feeding, Promotes performance of ADL bathing, hygiene, dressing while in skills already known by child. hospital environment and inform of differences from home care and methods as needed (specify). Inform to rest when tired and to Ensures proper rest and prevents request quiet times. fatigue. Inform parents to assist child in ADL Promotes independence and some but to allow child as much control by the child without independence as condition permits; separating child from parents. inform parents that a place is provided for their personal needs in order to allow them to remain with the child. Instruct parents to interpret child's Provides anticipatory care for needs if child too young to talk. child. NIC: Self-Care Assistance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe child's ability to attain behaviors specified under outcome criteria.) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT DIVERSIONAL ACTIVITY Related to: Environmental lack of diversion, long-term hospitalization. Defining Characteristics: Boredom, desire for something to do because usual hobbies and activities cannot be done in hospital (specify, use quotes). Goal: Child will engage in diversional activity by (date/time to evaluate). Outcome Criteria 5 of 11 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=4&FxId=123&Sessio. √ Participation in age-appropriate activities within limitations imposed by illness (specify activity). NOC: Play Participation INTERVENTIONS RATIONALES Assess type of activities allowed Provides information about and desired and amount of motor type of activities and play activity needed; check medical to suggest. protocol for bed rest or limitations imposed by illness. Show playroom to child and introduce Provides a familiar child and family to other children environment for child. and families with similar illness (specify). Place child in a room with another Promotes interaction and child of same age if possible diversion while (specify). hospitalized. Schedule care and treatments to Provides opportunity for play allow for play activities. and diversion. Provide age-appropriate play Prevents fatigue resulting activities according to amount of from overactivity while ill energy of child and activity and in need of rest and allowed, including quiet play with quiet. games, television, reading, soft toys, favorite toys. Encourage family to play with child Promotes diversion for child. or interact with child. Provide play activities that include Promotes therapy that educational needs for school-age includes educational needs. child; bring school-work from home if appropriate (specify). Suggest parents bring child's Promotes diversionary favorite toys or articles for activity. play. Teach parents and child of need to Prevents fatigue during acute monitor activities and rest phase of illness. although still allowing for play and interactions with others. Consult a play therapist for Promotes age-appropriate assistance in planning activities diversionary activities. and assessing child's play needs as needed. NIC:

Activity Therapy Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 6 of 11 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=4&FxId=123&Sessio. (Did child participate in diversional activity? Describe.) (Revisions to care plan? D/C care plan? Continue care plan?) POWERLESSNESS Related to: Health care environment, illness-related regimen. Defining Characteristics: Expression of loss of control over situation, expression or behavior indicating dissatisfaction with inability to perform activities and dependence on others, reluctance to express true feelings, fear of alienation from others in the hospital environment (specify). Goal: Client will experience less powerlessness by (date/time to evaluate). Outcome Criteria √ Gains sense of control over situation √ (Specify how child and/or parent participates in plan of care: e.g., goal-setting, scheduling of treatments.) √ (Specify how child or parent verbalize increased sense of control—use quotes.) NOC: Family Participation in Professional Care INTERVENTIONS RATIONALES Encourage parents and child to Allows for venting of feelings verbalize feelings in an accepting about loss of control and environment. frustrations over loss of ability to perform activities. Allow for input from child and Allows for as much control as parents in care goals, care plan, possible for child and family. and scheduling of activities, and integrate this input into routines as much as possible. Encourage parents to participate in Promotes support of child and child's care as much as desired; allows family some control and to visit or remains with child over the situation. continuously. Provide encouragement and praise to Promotes positive feedback and child and parents for their reduces fear of rejection by participation; encourage and defend staff because of their expression of their true feelings. behavior. Allow child to perform simple tasks Promotes independence and in hospital unit and for own care, control of the environment. such as pouring own water and marking amounts on record at bedside. Inform parents and child of tasks Accommodates need for sense of that they can perform in care plan control. (specify). 7 of 11 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=4&FxId=123&Sessio. NIC: Security Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Have child/parents participated in care? Specify how. Use quotes as applicable.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR TRAUMA Related to: Developmental age, deficient knowledge and cognitive immaturity predisposing the child to safety hazards in the environment. Defining Characteristics: Developmental age, developmental delays, disturbances in gait, vision, hearing, perceptual or cognitive functioning (specify). Goal: Child will not experience any trauma by (date/time to evaluate). Outcome Criteria √ Child engages in appropriate play (specify) without injury. √ Parents verbalize safety considerations related to toys/games (specify according to developmental level). NOC: Knowledge: Personal Safety INTERVENTIONS RATIONALES Assess age of child and reason for Provides information needed to select particular selection of type and appropriate toy or activity for play article of play, and intended purpose based on age: infants grasp and hold of play (enjoyment, development, articles and stuffed toys; young therapy). child plays with replicas of adult tools and other toys, plays pretend, and later moves from toys to games, hobbies, sports; older child continues with games and sports and begins to daydream; play provides fun, diversion, and learning about procedures for the child who is hospitalized. Select safe toys appropriate for age Provides guidelines for quiet play or and amount of activity allowed play that involves motor activity. (active or passive plays) and that suit the skills and interest of 8 of 11 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=4&FxId=123&Sessio. the child. Encourage play and allow parents to Promotes learning and skill bring favorite toy, game or other development, and facilitates play materials from home. expression of feelings. In a quiet environment, plan and Promotes therapeutic play with a implement an age-appropriate play selection of toys and articles that activity to prepare the child for all include dolls or puppets (nurse, invasive procedures, to observe doctor, child, family members); child's behavior, or to allow child hospital supplies (syringe, to reveal fears and concerns with or dressings, tape, tubes); paper, without someone in attendance crayons, and paints; stuffed toys, (specify). toy telephone; prepares the child emotionally and cognitively for invasive procedures; fosters appropriate coping strategies. Remove all unsafe, sharp, broken toys, Prevents trauma or injury to the toys with small parts that can be child. swallowed, toys inappropriate for age (specify). Allow child to communicate type of toy Promotes independence and control over desired and to assist in the play situation. selection of toys and play activities. Teach parents to select toys, play Promotes safe play for the child. equipment, and supplies that are labeled for intended age group; nontoxic and flame resistant with directions for use; that are durable and do not have sharp edges or points; that do not have small parts that can be swallowed; that do not contain any parts to be ejected; and that are not broken, rusted, or weak and need repairs. Teach parents to store play materials Prevents accidents caused by toys in meant for older children away from pathways or by toys meant for older, young child to provide a safe place more mature play. for toys, to discard or repair broken toys. Teach parent(s) to select play activity Provides the enjoyment of active or based on child's energy and tolerance passive play that is geared to level during an illness, and to child's condition. evaluate toys given as gifts to the child. NIC: Parent Education: Child-Rearing Family Evaluation (Date/time of evaluation of goal) 9 of 11 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=4&FxId=123&Sessio. (Has goal been met? Not met? Partially met?) (List appropriate play child engaged in without injury. Provide quotes from parents verbalization of safety considerations.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR HOSPITALIZED CHILD COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: 10 of 11 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=4&FxId=123&Sessio. STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:45:23 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=4 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 1 - GROWTH AND DEVELOPMENT OF CHILDREN CHAPTER 1.2 - HOSPITALIZED CHILD Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 11 of 11 12/22/2006 7:15 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=5&FxId=123&Sessio. CHAPTER 1.3 - CHILD ABUSE INTRODUCTION The term child abuse is used to describe any neglect or mistreatment of infants or children including infliction of emotional pain, physical injury, or sexual exploitation. Neglect or abuse is most often inflicted by the child's biologic parents. Others who have been implicated include foster parents, babysitters, boyfriends, friends, and daycare workers. Nurses are legally and morally responsible to identify children who may be maltreated and to report findings to protect the child from further abuse. Neglect is the most common form of abuse and may include deprivation of basic physical or emotional needs: food, clothing, shelter, health care, education, affection, love, and nurturing. Emotional abuse stems from rejection, isolation, and/or terrorizing the child. Physical abuse may result in burns, bruises, fractures, lacerations, or poisoning. Infants may suffer from "shaken baby syndrome" with severe or fatal neurologic injuries caused by violent shaking of the infant. Signs of shaken baby syndrome include retinal and subarachnoid hemorrhage. Signs of sexual abuse include bruising or bleeding of the anus or genitals, genital discharge, odor, severe itching or pain, and sexually transmitted diseases. A discrepancy between the nature of the child's injuries and the reported cause of injury is a frequent clue that abuse has occurred. MEDICAL CARE Complete Blood Count (CBC): reveals changes resulting from infection (increased WBC), blood loss (decreased RBC, Hgb). Urinalysis: reveals blood, pus in urinary tract. Vaginal/Anal Cultures: reveal sexually-transmitted disease. X-ray: child abuse long bone series of X-rays are required to detect evidence of or to rule out healed fractures/current fractures. C-scan: to rule out central nervous system damage caused by shaken baby syndrome. COMMON NURSING DIAGNOSES See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food. Defining Characteristics: (Specify, e.g., withholding of food by parent/caretaker, weight loss, malnutrition, lack of subcutaneous fat, failure to thrive, provides inadequate amount of food; knowledge of deficit regarding appropriate food preparations [i.e., cleaning bottles].) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: External factor of trauma. Defining Characteristics: (Specify, e.g., lacerations, burns, abrasions, skin trauma in different stages of healing, unclean skin, teeth, hair.) 1 of 8 12/22/2006 7:16 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=5&FxId=123&Sessio. See DELAYED GROWTH AND DEVELOPMENT Related to: Inadequate caretaking, indifference, environmental and stimulation deficiencies. Defining Characteristics: (Specify, e.g., delay or difficulty in performing skills [motor, social, or expressive] typical of age group, altered physical growth, inability to perform self-care or self-control activities appropriate for age, flat affect, decreased responses, withdrawal, antisocial behavior, fearfulness, poor relationships with peers, regressive behavior, acting out behavior.) ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: Threat to self-concept, change in health status, change in interaction patterns, situational crisis. Defining Characteristics: Increased apprehension and uncertainty, fearfulness, feeling of powerlessness, fear of consequences, repeated episodes of maltreatment, mistrust, trembling, quivering voice, poor eye contact, lacks appropriate pain response, frozen watchfulness, developmental delays/regressive behaviors (specify). Goal: Child will experience less anxiety by (date/time to evaluate). Outcome Criteria √ (Specify measurable criteria, e.g., child makes eye contact, has relaxed facial features, reports decreased anxiety if age-appropriate.) NOC: Coping INTERVENTIONS RATIONALES Assess level of anxiety and fear in Provides information about the child and how it is manifested; source and level of anxiety and identify the source of anxiety and what might relieve it and basis observe reactions to staff and to judge improvement. parents at each encounter. Demonstrate affection and acceptance Promotes trust of staff and of the child even if not returned positive behavior of the child. or ignored; avoid reinforcing any negative behavior. Provide a play program with other Modifies negative behavior by children; set aside time to be promoting interactions with alone with child or quiet time for others and rewarding desired child as well; praise child or behaviors; promotes self-esteem. reward with a special treat when appropriate (specify). Provide consistent staffing for Promotes familiarity and trusting child, preferably those who seem to relationship with staff. relate well to child. Allow expression of concerns and Provides opportunity to vent fears of child about treatments, feelings, which reduces anxiety. environment; allow questions 2 of 8 12/22/2006 7:16 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=5&FxId=123&Sessio. and provide honest explanations and communication at child's age level. Provide treatment of injuries; avoid Prevents increased anxiety and treating child as a victim, asking stress in child by discussion of too many questions, or forcing any abuse. discussion. Explain all treatments and procedures Provides preparation and to be done and the purpose for them information that will assist in and that someone will accompany preventing fear or anxiety. them to a different department if needed (specify). Use therapeutic play kit to instruct Reduces anxiety by familiarizing child in any procedure to be done child with what to expect to (dolls, syringe, tubing, dressing, reduce anxiety. other articles, specify). Refer for counseling services for the Reduces anxiety and supports child child as indicated. in dealing with abuse and negative behavior. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide data about outcome criteria, e.g., does child make eye contact? Are facial features relaxed, does child report feeling "calmer," use quotes if possible.) (Revisions to care plan? D/C care plan? Continue care plan?) IMPAIRED PARENTING Related to: (Specify: unmet social and emotional maturation needs of parental figures, ineffective role modeling, lack

of knowledge, situational crisis or incident.) Defining Characteristics: (Specify: lack of parental attachment behaviors, verbalization of resentment toward child and of role inadequacy, inattention to needs of child, noncompliance with health practices and medical care, inappropriate discipline practices, frequent accidents and illness of child, growth and development lag in child, history of child abuse or abandonment, multiple caretakers without regard for needs of child, evidence of physical and psychological trauma, actual abandonment of child.) Goal: Parents will exhibit improved parenting skills by (date/time to evaluate). Outcome Criteria √ Demonstration of appropriate parenting behaviors. 3 of 8 12/22/2006 7:16 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=5&FxId=123&Sessio. √ Maintenance of safe environment for child. √ Establishment of positive relationship with child and realistic expectations for self and child. √ Acceptance of support for achievement of desirable parenting skills. NOC: Parenting INTERVENTIONS RATIONALES Assess parents for achievement of Provides information about parent- developmental tasks of self and child relationship and parenting understanding of child's growth and styles that may lead to child development; how they are bonded and abuse; identifies parents at attached to child; how they interpret risk for violence or other and respond to child; how they accept abusive behavior. and support child; how they meet child's social, psycho-logical and physical needs. Provide a child nurturing role model Promotes development of parenting for parents to emulate. skills by imitation. Praise parents for their participation Reinforces positive parenting in child's care, tell them that they behaviors and increases feeling are giving good care to child. of adequacy. Include parents in planning care and Promotes participation of parents setting goals. in meeting child's needs. Provide an opportunity for parents to Supports parents in meeting their express their feelings, personal own needs. needs, and goals; avoid making judgmental remarks or comparing them to other parents. Teach parents developmental tasks for Provides information that assists child and parents, difference in parents in responding developmental level between child and realistically and appropriately parents, and appropriate tasks for to child's needs at different age levels. age levels. Discuss with parents methods to reduce Promotes a more positive child- conflict, to be consistent in parent relationship. approach to child's behavior and needs, to avoid siding with child or other parent. Instruct parents to maintain their own Provides information on importance health by getting adequate rest, of parents meeting their own nutrition, and exercise; and to needs to enable them to better participate in leisure activities and care for and cope with their make social contacts. children. Refer to community agencies that offer Provides education in parenting parenting classes and support groups. skills. Initiate referrals to social services, Provides options if parenting is parenting classes, or counseling as unsatisfactory or inadequate. appropriate. Inform parents that 4 of 8 12/22/2006 7:16 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=5&FxId=123&Sessio. child protection services have been contacted to investigate the child's health status and safety; keep the parents informed of the child's health status (unless or until custody of the child is removed from the parents. NIC: Parent Education: Child-Rearing Family Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide data about outcome criteria, e.g., parent attends to child's crying; feeds child; plays game with child; attends parenting classes or self-help groups; verbalizes child's developmental needs, etc., use quotes if possible.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR TRAUMA Related to: Characteristics of child, caregivers, environment. Defining Characteristics: (Specify: sexual assault of child, evidence of physical abuse of child, history of abuse of abuser, social isolation of family, low self-esteem of caretaker, inadequate support systems, violence against other members of the family.) Goal: Child will not experience trauma by (date/time to evaluate). Outcome Criteria √ Absence of violence or maltreatment of the child by parents or other offenders. NOC: Risk Detection INTERVENTIONS RATIONALES Assess the abuser for violent behavior Provides information to determine or other abusive patterns, use of warning signs of child abuse. alcohol or drugs, or other psychosocial problems. Assess behavior of parents toward Reveals characteristics that may child, including responses to the indicate risk for abuse. child's behavior, ability to comfort the child, feelings and perceptions toward the child, expectations for the child, over-protective or concern for the 5 of 8 12/22/2006 7:16 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=5&FxId=123&Sessio. child. Communicate information and needs of Provides care plan for child based child to those on the abuse team (or on court decision to caretakers to new caretakers if child being working with the family based on placed with a foster parent or court decision for child's care. someone other than parents); provide written instruction for care and child's needs (specify). Maintain factual and objective Provides information that may be documentation of all observations, used in legal action regarding including: child's physical abuse. condition, child's behavioral response to parents, health care workers, other visitors, parent's response to child, and interviews with family members. Inform parents of follow-up care and Promotes emphasis on child's care needs of child, need to evaluate and prevention of recurrence of child's progress. abuse. Instruct parents in identifying events Prevents further abusive behavior that lead to child abuse and in directed at the child. methods to deal with behavior without harming the child. Inform of Parents Anonymous and other Provides self-help group child protective groups to contact activities, information, and for assistance. support based on type of abuse and parental needs. Inform parents of child's placement in Prepares parents for court order a foster home, allow them to meet of alternate placement to ensure and speak to new caretaker. a safe environment. Initiate referral to social worker, Provides support to child and public health nurse, psychological family, and monitors behaviors counselor before discharge to home following discharge. (specify). NIC: Risk Identification Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Has the child suffered maltreatment or violence? Provide specifics if indicated.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR CHILD ABUSE 6 of 8 12/22/2006 7:16 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=5&FxId=123&Sessio. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY 7 of 8 12/22/2006 7:16 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=5&FxId=123&Sessio. Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:46:29 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=5 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 1 - GROWTH AND DEVELOPMENT OF CHILDREN CHAPTER 1.3 - CHILD ABUSE Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 8 of 8 12/22/2006 7:16 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=6&FxId=123&Sessio. CHAPTER 1.4 - DYING CHILD INTRODUCTION Care of the dying child includes the physical and emotional interventions necessary to support the totally dependent child and grieving family. Nursing considerations involve the dissemination of information to the child, whose perceptions of death and responses to death and dying are age-related, and family with sensitivity, caring, and honesty. The nurse also helps the child move through the stages of awareness and acceptance, and helps the family move through the stages of grieving. An additional role of the pediatric nurse, when caring for dying children, is to direct the child and family to appropriate age-related information about death and dying. MEDICAL CARE Medications that promote comfort, prevent/manage pain, rest and proper body functions specific to the child's needs. COMMON NURSING DIAGNOSES See DISTURBED SLEEP PATTERN Related to: Illness and stressors, side effects of medications. Defining Characteristics: (Specify: fatigue, lethargy, irritability, restlessness, pain, psychological stress [anxiety, fear], nausea and vomiting, increased voiding patterns.) See IMPAIRED PHYSICAL MOBILITY Related to: Pain and discomfort, side effects of medications. Defining Characteristics: (Specify: weakness, inability to purposefully move, fatigue, limited strength, changes in consciousness, neuropathy, foot drop, amputation, gait disturbances; muscle wasting; contractures.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Loss of appetite, fatigue, oral ulcers, (specify). Defining Characteristics: (Specify: weakness, anorexia, poor feeding, lack of interest in food, anorexia-cachexia syndrome, nausea and vomiting, chronic constipation or diarrhea; dryness and cracking of lips; alterations in taste.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Immobilization, side effects of medications; invasive procedures/IV infiltration; radiation treatments (specify). Defining Characteristics: (Specify: redness, disruption of skin surface.) 1 of 11 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=6&FxId=123&Sessio. See DISTURBED THOUGHT PROCESSES Related to: Physiologic changes, side effects of medication (specify). Defining Characteristics: (Describe: disorientation, changes in consciousness, fatigue, hallucinations, mood changes.) See INEFFECTIVE AIRWAY CLEARANCE Related to: (Specify) decreased energy and fatigue, tracheobronchial secretions, oral ulcers; decreased gag reflex. Defining Characteristics: (Describe: increasing secretions, changes in respiratory rate or depth [stridor, irregularity], inability to cough and remove secretions, shortness of breath.) See CONSTIPATION Related to: Less than adequate physical activity and intake, side effects of medications, food allergy, secondary to disease process (specify). Defining Characteristics: (Specify: frequency less than usual pattern, hard-formed stool, decreased bowel sounds, abdominal pain, firm/hard abdomen; fecal impaction.) ADDITIONAL NURSING DIAGNOSES PAIN Related to: Biologic, physical, psychological injuring agents (specify). Defining Characteristics: (Specify, e.g., communication [verbal or coded] of pain descriptors, guarding, protective behavior, facial mask of pain, crying, moaning, withdrawal, changes in VS, irritability, restlessness, age-related expression of pain behaviors, facial grimacing, tension or flexion of muscles.) Goal: Child will experience less pain by (date/time to evaluate). Outcome Criteria √ Child verbalizes decreased pain (use a pain scale appropriate for age). √ VS return to baseline (provide range). √ Child appears relaxed and is not crying, grimacing, moaning. NOC: Pain Control INTERVENTIONS RATIONALES Assess severity of pain, fear of Provides information as a basis for receiving pain medication, anxiety analgesic administration. 2 of 11 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=6&FxId=123&Sessio. and coping mechanisms associated Developmentally-based pain scales with pain, ability to rest and sleep provide accurate assessment of (specify frequency and pain scale child's discomfort. used). Administer analgesic intermittently or Provides coverage of pain continuously as ordered, depending medications to ensure freedom on pain severity, and administer from any type of pain and before any painful procedure or care discomfort including is performed(specify drugs, route, administration of analgesic for times). prompt relief if given intermittently. Teach child and parents of route of Provides assurance that pain will medication administration and effect be controlled continuously to expect; that pain will be whether or not child is able to assessed continuously and medication express pain. adjusted as needed to control pain. Provide position changes as tolerated, Reduces pain by nonpharmacologic use pillows to support position, measures. move slowly with gentle handling, give backrub. Provide companionship for child, Reduces fear and supports comfort familiar toys (specify). of child. Support coping mechanisms of child and Promotes child's comfort, supports family and adjust analgesic coping abilities, and includes accordingly, with input from child, parents and child in decision parents, and physician. making regarding care. Dim lights, avoid noise, maintain Provides environment free of clean, comfortable bed with loose stimuli that increases anxiety sheets and clothing, disturb for and pain. care only when needed to promote comfort. Provide nonpharmacologic pain Reduces pain perceptions and may management strategies: soothing foster a sense of control. baths; massage therapy to painful areas; education on possible (and encourage parent/child to use) distraction techniques (i.e., music, aroma, humor, reading, journal writing, art work, pets, prayer, hypnosis, relaxation techniques. Specify). Discuss with child and parents that Reduces anxiety by recognizing fear fear of pain is common and that it of pain and encouraging to vent is all right to express fear and feelings and concerns about feelings about pain and its control. methods of control. Teach parents and child that only Reduces anxiety and stress caused palliative care and treatments will by anticipation of painful be administered. interventions.

NIC: Medication Management Evaluation 3 of 11 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=6&FxId=123&Sessio. (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide data on pain scale rating, vital signs, muscle tension, and behavior such as crying, grimacing, or moaning.) (Revisions to care plan? D/C care plan? Continue care plan?) ANTICIPATORY GRIEVING Related to: Potential loss of a child. Defining Characteristics: (Specify: expression of distress at potential loss of child, denial of loss, guilt, anger, sorrow, choked feelings, change in need fulfillment, crying, self-blame, shock and disbelief, overprotectiveness, loss of hope and depression, withdrawal and avoidance of ill child.) Goal: Clients will begin the grief process by (date/time to evaluate). Outcome Criteria √ Child, parents, and family are able to verbalize feelings about their grief in a culturally relevant manner. √ Clients are able to share their grief with each other. NOC: Family Coping INTERVENTIONS RATIONALES Assess stage of grief process, Provides information about need problems encountered, feelings for grieving, which varies with regarding terminal nature of illness individual members of a family and potential loss of child. when child's death is expected. Provide emotional and spiritual Provides for emotional need of comfort in an accepting environment, parents and family and helps and avoid conversations that cause them to cope with dying child guilt or anger. without adding stressors that are difficult to resolve. Provide opportunities for family to Promotes progression through express feelings and respond to grieving and ability to express child commensurate with stage of desires for themselves and their grieving. child. Allow parents and family members to be Promotes feeling that they are with child as much as they feel a helping and supporting their need to, and help them understand child. the child's behavior and needs. Assist child and family in identifying Promotes effective coping that is and use effective coping mechanisms positive for the family. and in under-standing situation over which they have no control. 4 of 11 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=6&FxId=123&Sessio. Provide privacy when needed, while Promotes a helping relationship being available to the family. with the family. Arrange for clergy, social services, Provides for and assists with hospice care, or return to home for alternative care and preferences dying as appropriate; support for that care. choices made by the family (specify). Encourage parents to express their Promotes parent coping, acceptance thoughts and feelings about the of grief process, and may possible death of their child; to minimize sense of guilt. share memories of their child's life; to create memories (now, if possible); to take family pictures, and create a memory box of their child's memory. Encourage parents to be involved with Reduces parent feelings of child's care (i.e., procedures, how powerlessness and helplessness. to help with nausea, pain control). Reassure child, parents, and family Promotes understanding of grief that their grief response is normal. reaction and may enhance coping abilities. Educate parents regarding child's Promotes family communication; developmental understanding of promotes family coping death; educate and encourage parents abilities. to utilize children's books to aid in a discussion about the child's understanding/fears of death. Inform (child, if appropriate) Promotes understanding of feeling parents, and family of stages of and behaviors manifested by the grieving and acceptable behaviors grieving process. during the grief process. Provide information about child's Allows parents to follow course of condition, including appearance of terminal condition and change to the child, and reactions to expect. expect. Instruct parents in care and Involves parents involvement in procedures they want to participate child's care and allows them to in and in those they will carry out share their sadness with child. if the child is taken home to die; suggest resources to contact for assistance. Encourage family to ask questions and Promotes honest and realistic view to be honest about their feelings of situation to enhance and acceptance of information about grieving. death and dying. Teach family to maintain own needs and Allows family to better cope with health during this difficult time. child's needs if own needs are fulfilled, since terminal period may be prolonged. NIC: Grief-Work Facilitation Evaluation 5 of 11 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=6&FxId=123&Sessio. (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Specify, e.g., parents and child are able to verbalize the grief process, use quotes; parents and child identify coping mechanisms to assist with grief work (specify); parents and child make decisions regarding care, death, and funeral.) (Revisions to care plan? D/C care plan? Continue care plan?) ANXIETY Related to: Specify: diagnosis, tests, treatments, pain, side effects of medication and prognosis. Defining Characteristics: (Specify, e.g., states: fear of death, loss of control, loneliness; increased feelings of helplessness and hopelessness; poor prognosis of terminal illness.) Goal: Client will experience lessened anxiety by (date/time to evaluate). Outcome Criteria √ Specify, e.g., child and parents verbalize decreased anxiety. √ Child and parents identify at least two coping mechanisms for anxiety. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess anxiety level, fears and Reveals information needed for concerns, ability to express needs, interventions to relieve anxiety and how anxiety is manifested. and increased comfort. Ask clients to rank their anxiety as Ranking allows assessment of mild, moderate, severe, or improved or worsening levels of incapacitating. anxiety. Assist child and family to identify Coping mechanisms help relieve the at least two coping mechanisms to stress of anxiety. Humor is not use for coping with anxiety always out of place and may be (specify suggestions such as music, helpful to diffuse tension if exercise, talking to spiritual judiciously used. advisor, use of humor). Allow family friend to stay with Promotes comfort of child and child or remain with child during provides support during anxious stressful periods if family not and fearful times. able to be there. Allow expressions of fears and Provides opportunity to vent concerns about terminal stage of feelings and fears to reduce illness, answer all questions anxiety. honestly based on what family has 6 of 11 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=6&FxId=123&Sessio. been told about prognosis. Provide appropriate pain control and Promotes comfort and minimizes preparation prior to invasive emotional distress related to procedures (specify, i.e., invasive procedures (action of application of EMLA cream before EMLA). bone marrow aspiration, or before restarting IV sites). Provide calm reassurance and Promotes comfort and love of child kindness, be available to child at to reduce anxiety. all times as needed for support. Involve child and parents in as much Promotes interactions and attitude planning and care as possible of caring within family. without forcing participation. Inform child and parents of all Promotes understanding of physical anticipated care and activities. needs of dying child, limiting activities to those that are essential. Inform family members, with honesty Prepares them for the changes and and openness, of physical changes assists in the recognition of in child as death nears. impending death. Reassure child and parents that they Reduces fear and guilt caused by are not to blame for illness and terminal nature of the illness. its consequences. Encourage parents to talk to the Reduces possibility of additional child and sit or lie near the child stress for child; reduces as desired. child's fear of being alone. Provide parents and family members Provides a source of communication telephone numbers and methods of about the child's condition. acquiring information about the child. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Specify, e.g., are parents and child able to verbalize lessened anxiety? use quotes. List coping mechanisms parents and child identified to assist with anxiety. Have parents and child made decisions regarding terminal illness?) (Revisions to care plan? D/C care plan? Continue care plan?) DYSFUNCTIONAL GRIEVING Related to: Loss of child as result of (specify: accident, SIDS, absence of anticipatory grieving). Defining Characteristics: (Specify: expressed distress; anger; guilt over loss; difficulty in expressing loss; sadness; crying; sudden, unexplained 7 of 11 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=6&FxId=123&Sessio. and unexpected death of infant; shock; grief; denial; social isolation.) Goal: Parents will resolve dysfunctional grieving. Outcome Criteria √ Parents verbalize understanding about the cause of the death (specify). √ Parents acknowledge that their grief is unresolved and seek assistance. NOC: Psychosocial Adjustment: Life Change INTERVENTIONS RATIONALES Assess feelings of parents and what Allows feelings of anger, guilt, they perceive happened to infant; and sorrow to be expressed listen to any feelings expressed. following death of infant. Provide privacy and remain with Provides support without adding to parents; avoid conversation and grief and feelings of guilt. questions that may place any blame or cause guilt; (explain cause of death; reinforce that the cause of SIDS is unknown, with no absolute means to prevent or predict it). Prepare child for parents to view and Allows parents to say good-bye to hold; stay with parents during this their child. experience. Allow parent to determine the length Promotes positive grief resolution of time they hold their infant or if parents hold/see the infant child; this varies by culture and and spend time saying good-bye individual parent needs. on their own terms. Notify clergy or other support if Provides support and comfort. requested; offer baptism/prayer to parents; arrange for clergy to be present, if applicable. Provide parents the opportunity to Presence of other family members call significant others; if unable, and significant others often staff member should call. serves as support for grieving family. (Answer any questions about SIDS and Reinforces physician's explanation explain need for autopsy to verify of disorder. diagnosis.) Take pictures of infant and offer to Promotes positive grief parents; saving clothing infant was resolution. wearing, ID bracelets, hats, as part of a "memento packet" to be given to parents; if parents refuse packet, save for future retrieval (if appropriate). Assist parents to inform and help Children's concept of death siblings understand loss; answer develops with age, and help is children's questions honestly and needed to avoid feelings of 8 of 11 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=6&FxId=123&Sessio. appropriately for age level. blame and guilt by siblings. Assist to identify and use effective Promotes movement through grieving coping mechanisms applicable to process by utilizing defense situation. mechanisms that have worked in the past. Reassure parents that they are not Reinforces that SIDS is an responsible for the death of their unpreventable, unexplainable child. sudden death of an infant and that no one can be blamed. Obtain thorough history from parents, Provides optimal level of accurate including parental resuscitation information for medical efforts and illness history examiner. (experienced or trained member of staff recommended because of sensitive nature of information). Contact the infant's primary care Enhances the parental support provider. system and enhances communication. Inform of stages and importance of Allows, in a nonjudgmental grieving and of behavior that is environment, for the initial expected in resolving grief. shock and disbelief that are expected behaviors of grief. Use therapeutic communication Therapeutic communication assists techniques, especially active the parents to express their listening. Encourage parents to feelings and identify verbalize their understanding of dysfunctional aspects of their the cause of death, their feelings grief. of grief, and any concerns about seeking assistance with grieving. Refer family to counseling services, Provides support and assistance local SIDS chapter, community during bereavement or chronic health nursing agency, grief grief which may affect family support groups. relationships, presence of infertility or other problems. Correct any misinformation or Assists with resolution of guilt misconceptions regarding the death. and grieving. NIC: Grief Work Facilitation Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What are the parents' understandings about the cause of death? Did parents acknowledge their grief and seek assistance? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR DYING CHILD 9 of 11 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=6&FxId=123&Sessio. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title:

STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 10 of 11 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=6&FxId=123&Sessio. 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:46:56 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=6 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 1 - GROWTH AND DEVELOPMENT OF CHILDREN CHAPTER 1.4 - DYING CHILD Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 11 of 11 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=7&FxId=123&Sessio. UNIT 2 - CARDIOVASCULAR SYSTEM CHAPTER 2.0 - CARDIOVASCULAR SYSTEM: BASIC CARE PLAN INTRODUCTION The cardiovascular system consists of the heart and a network of blood vessels: arteries, veins, and capillaries. The heart is an efficient pumping mechanism that circulates oxygenated blood and nutrients to all parts of the body and provides a path for removal of wastes. Alteration in the function of the system may interfere with the client's well-being, thereby causing physical and psychosocial problems for both the affected child and family. Diseases of the cardiovascular system are classified as either congenital malformations or acquired disorders that result from infection, autoimmune responses, or environmental insult. The degree of alteration in function determines the acuity or chronicity of the condition, the interference with growth and development, and the preferred treatment. Before birth, fetal structures allow the blood to by-pass the nonfunctional lungs and circulate through the placenta for gas, nutrient, and waste exchange. Shortly after birth, fetal circulation converts to postnatal circulation, which continues throughout life. CARDIOVASCULAR GROWTH AND DEVELOPMENT HEART AND BLOOD VESSEL STRUCTURE • Circulation changes at birth involve the closure of the fetal shunts (foremen ovale at birth, ductus arteriosus by the fourth day after birth, and eventually the ductus venosus). • Size of the heart in the infant is large in relation to total body size and occupies more space in the chest surrounded by the lungs. • The heart lies at a transverse angle in infancy and gradually changes to a lower and more oblique angle as the lungs grow until maturity is reached. • The weight of the heart doubles by 1 year of age, and increases four times by 5 years of age. • The walls of the ventricle are of equal thickness at birth but become thicker on the left side as the demand of peripheral circulation increases. • Arteries and veins become longer as the body grows, and the walls of the vessels thicken as blood pressure increases. • The apical pulse is located laterally and to the left of the fourth intercostal space and to the right of the midclavicular line in infants and small children; it changes laterally to the left of the fifth intercostal space and midclavicular line after 7 years of age; the point of maximal intensity (PMI) may be noted at these same areas. CARDIOVASCULAR ASSESSMENT • Blood pressure increases and pulse decreases with growth in heart size. • Heart rate (pulse), resting and awake: 1 of 10 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=7&FxId=123&Sessio. 1 to 3 months: 100 to 180/min 3 months to 2 years: 80 to 120/min 2 to 4 years: 80 to 110/min 4 to school-aged: 75 to 100/min Adolescents: 60 to 90/min • Pulse pressure: 10 to 15 mm Hg during infancy; 20 to 50 mm Hg throughout childhood. • Blood pressure (varies with age and position): Systolic Diastolic (average) (average) Infant 65 to 90 mm Hg 55 to 56 mm Hg 1 to 5 years 90 to 95 mm Hg 54 to 56 mm Hg 5 to 10 years 14 to 102 mm Hg 56 to 62 mm Hg Over 10 years 102 to 121 mm Hg 62 to 70 mm Hg COMMON NURSING DIAGNOSES DECREASED CARDIAC OUTPUT Related to: Mechanical factors—alterations in preload; alterations in afterload; alterations in inotropic function of heart. Defining Characteristics: Variations in hemodynamic readings (BP, CVP); hypovolemia; jugular vein distention; oliguria; decreased peripheral pulses; cold, clammy skin; crackles; dyspnea (specify). Related to: Electrical factors—alterations in rate; alterations in rhythm; alterations in conduction. Defining Characteristics: Arrhythmias, ECG changes, bradycardia, changes in contractility resulting from preload or afterload abnormalities (specify). Related to: Structural factors. Defining Characteristics: Murmurs, fatigue, cyanosis, pallor of skin and mucous membranes, dyspnea, clubbing, activity intolerance (specify). 2 of 10 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=7&FxId=123&Sessio. Goal: Client will experience increased cardiac output by (specify date and time to evaluate). Outcome Criteria √ Client's BP, heart rate, and respirations will return to or remain within (specify appropriate ranges for each). √ Absence of cardiac dysrhythmias. √ Skin color and mucous membranes pink; tolerates activity (specify level). NOC: Cardiac Pump Effectiveness INTERVENTIONS RATIONALES Assess cardiac output by monitor—heart Cardiac output is the amount of blood rate (apical and peripheral pulses) pumped from the heart in 1 minute and for 1 minute, noting quality, rate, is determined by multiplying the rhythm, intensity; pulse deficiency; heart rate by the stroke volume use radial site with gentle palpation (amount of blood ejected with 1 in child over 2 years of age, and use contraction), which depends on heart apical site with stethoscope and contractility, preload and afterload; correct size diaphragm in infant and pulse easily obliterated by young child; grade pulse on a range compression. from 0 to +4 (specify). Assess blood pressure using proper size Doppler method transmits audible sounds cuff; diaphragm on stethoscope of through a transducer in the cuff proper size; and aneroid or mercury caused by ultrasound frequency caused instrument, Doppler method, or by blood flow in the artery; the use electronic device. Approximate cuff of oscillometry transmits pressure width sizes are 4 to 6 cm for infant, changes through the arterial wall to 8 to 9 cm for child 2 to 10 years of the pressure cuff which are detected age; BP cuff bladder should completely by an indicator that prints out the encircle extremity circumference and readings for BP and pulse. cuff width should cover 2/3 of upper arm/thigh. Take BP of infant with infant supine; take child BP with child sitting and arm supported at heart level; sites for BP determinations may be (radial), leg (popliteal), or ankle (dorsalis pedis) (specify). Assess BP when infant/child is at rest Crying or other activity can increase (give expected range). BP 5 to 10 mm Hg; BP elevations that are considered abnormal are: >110/70 in 3 to 6 year olds, >120/75 in 6 to 9 year olds, and >130/80 in 10 to 13 year olds. Assess existence of dysrhythmias per ECG Device that measures and records the tracings. heart's electrical activity and provides information about heart rate and rhythm, hypertrophy, effects of electrolyte imbalances, conduction problems and cardiac ischemia. 3 of 10 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=7&FxId=123&Sessio. Administer cardiac (specify drug, dose, Vasodilators decrease pulmonary and route, and times as ordered) systemic vascular resistance, which glycosides, vasodilators; monitor for decrease afterload and BP; cardiac digoxin toxicity by symptoms of glycoside strengthens and decreases anorexia, nausea, vomiting, the heart rate, which decreases the bradycardia, arrhythmias and digoxin workload of the heart by more level within 0.8 to 2.0 mcg/L range efficient cardiac performance; (therapeutic level) potassium level; decreased potassium level enhances take apical pulse for 1 minute before risk for digoxin toxicity. administering digoxin, and withhold if pulse below desired level for age of child. Position for comfort and chest expansion Promotes ease of breathing and rest; in Fowler's, provide quiet reduces stress and workload of the environment, pace any activity to heart. allow for rest. Monitor temperature for increases q 4 Pulse increased at rate of 8 to 10/ hours. minute with every degree of elevation on F scale. Attach cardiac monitor to infant/ child Reveals changes in heart rate and if prescribed. respirations. Inform about heart condition's effect on Provides information to promote pulse and blood pressure, and the need compliance with medical regimen and for rest and reduction of stress. realization of importance of reducing workload of the heart. Instruct in correct taking of peripheral Encourages caretaker, parents to and apical pulses and when to take correctly monitor changes in heart them. function. Instruct in administration of cardiac Ensures correct administration of glycoside (specify form, dosage, how cardiac glycoside to prevent toxicity to take, frequency and time of day), and improve cardiac performance. to give 1 hour before or after feedings and not with food, to avoid second dose if child vomits, to avoid making up missed doses when less than 4 hours have passed, and to maintain careful records of administration and effects or adverse signs/symptoms. Inform to report changes in pulse, blood Allows for prompt treatment to prevent pressure, digoxin toxicity, change in complications like dysrhythmias or breathing pattern, edema, presence of heart failure. infection. Instruct in application, settings and Monitoring may be advised and alarms in use of cardiac monitor. prescribed for cardiac and respiratory changes. NIC: Cardiac Care Evaluation (Date/time of evaluation of goal) 4 of 10 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=7&FxId=123&Sessio. (Has goal been met? Not met? Partially met?) (What are BP, heart rate, and respirations?) (Describe cardiac rhythm.) (What color are skin and mucous membranes? What activity does the child tolerate?) (Revisions to care plan? D/C care plan? Continue care plan?) EXCESS FLUID VOLUME Related to: Compromised regulatory mechanisms. Defining Characteristics: (Specify: periorbital usually but may be dependent on weight gain, effusion, shortness of breath, orthopnea, crackles, change in respiratory pattern dyspnea, tachypnea, oliguria, specific gravity changes, altered electrolytes. Goal: Client will return to a state of fluid balance by (date/time to evaluate). Outcome Criteria √ Intake equals output. √ Lung sounds clear. √ Absence of periorbital edema. √ (Specify others if appropriate for client.) NOC: Fluid Balance INTERVENTIONS RATIONALES Assess presence of edema in periorbital Increased sodium and water retention tissue or dependent areas, such as result in increased systemic extremities when standing; in sacrum vascular pressure and fluid and scrotum when in lying position; overload, which lead to edema; or generalized in an infant; neck gravity determines the site of vein distension in child (specify dependent edema. frequency). Weigh (specify: daily BID or as needed) Weight gain from fluid retention is on same scale, at same time, and with an early sign of fluid retention. same clothing. Assess for plueral effusion by presence Indication of gross fluid retention of dyspnea, tachypnea, crackles, which causes impaired organ orthopnea, acites; for hepatomegaly function (pulmonary and system by measuring abdominal girth (specify venous congestion) is associated frequency). with some cardiac or renal 5 of 10 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=7&FxId=123&Sessio. conditions. Assess for oliguria, increased specific Indicates decreased renal perfusion, gravity, electrolyte imbalances. which activates the renin- angiotensin and aldosterone mechanism, resulting in water, sodium, and potassium retention. Administer diuretic therapy early in Diuretics prevent reabsorption of the day (specify drug, dose, route, water, sodium and potassium by and times for client), and monitor tubules in the kidneys, resulting resulting diuresis by accurate I&O in excretion of excess. and weight. Note and document I&O (including losses Intake and output ratio should from breathing and diaphoresis) and normally be 2:1 or 1 to 2 ml/kg/h. intake from all fluids IV or orally taken with medications and meals (if child not toilet trained, weigh diaper to calculate output at 1 gm = 1 ml). Restrict fluid intake as ordered Supports possible need for (specify amount calculated for this additional loss of fluid based on child); schedule over 24 hours with age and using possible limit of 65 most given during the day hours; use ml/kg/24 hrs as a guideline. small cups and allowing older child to keep track of daily amounts. Limit sodium intake as ordered by Sodium intake is necessary for removing salt shaker, foods high in normal growth and development, and salt. to offset diuretic therapy. Maintain bed rest, and position and Protects and supports edematous

support edematous body parts; change parts from pressure and trauma. position (q 2h or specify) provide sheepskin, egg crate mattress. Instruct caregiver in taking weights, Monitors weight to determine fluid noting and reporting gains and accumulation and I&O to prevent losses; and in measuring I&O, and imbalances (fluid overload or reporting excessive outputs from dehydration). diuretic therapy or decreases in comparison or intake. Instruct caregiver in correct Promotes excretion of fluid to administration of diuretic early in prevent accumulation. the day for a child (specify amount, frequency, side effects, and amount of output to expect in relation to intake). Instruct and assist caregiver to Promotes compliance if fluids are schedule fluid intake over 24 hours, restricted. with major portion administered during day hours. NIC: Fluid Management Evaluation 6 of 10 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=7&FxId=123&Sessio. (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Specify intake and output and time frame.) (Are lung sounds clear?) (Is there any periorbital edema?) (Provide data released to other outcomes criteria that were identified.) (Revisions to care plan? D/C care plan? Continue care plan?) INEFFECTIVE TISSUE PERFUSION: (CARDIOPULMONARY, CEREBRAL, GASTROINTESTINAL, RENAL, PERIPHERAL) Related to: Interruption of arterial or venous flow, exchange problems, hypovolemia. Defining Characteristics: (Specify: Cardiopulmonary—BP and pulse changes, dyspnea, tachypnea, changes in ABGs, cyanosis, changes in cardiac output, ventilation perfusion imbalances, crackles; Cerebral—changes in mentation, restlessness, lethargy; Gastrointestinal—vomiting, inability to digest and absorb nutrients, gastric distention; Renal—oliguria, anuria, periorbital edema, electrolyte imbalance; Peripheral—skin cold, mottled, or pale; decreased peripheral pulses). Goal: Client will exhibit effective tissue perfusion by (date/time to evaluate). Outcome Criteria √ Based on specific defining characteristics. Specify for client: (ABG values—specify ranges). √ Client is alert, not restless or lethargic. √ Bowel sounds present, abdomen soft, nondistended. √ Urine output > (specify cc/hr). √ Skin warm, pink, and dry, without edema. NOC: Tissue Perfusion 7 of 10 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=7&FxId=123&Sessio. INTERVENTIONS RATIONALES Assess organ functional abilities in Interrelationships of systems cause relation to disease and its effect an overlapping of signs and on a particular system (specify symptoms associated with tissue how). perfusion causing changes in elimination, oxygenation, nutrition, and mental function. Assess pulse, blood pressure, Provides information about cardiac presence of peripheral pulses, output, which, if decreased, will capillary refill time, skin color reduce blood flow and tissue and temperature; oxygenation perfusion. saturation as measured by pulse oximetry; urinary output, mentation, anorexia, gastric distention (specify when). Provide O2 by hood, cannula, or face Provides oxygen to organs for mask, depending on age and at rate proper functioning. determined by ABGs as ordered (specify route and rate). Administer vasodilator, cardiac Promotes cardiac output and slows glycoside as ordered (specify and strengthens heart rate for a drugs, doses, routes, and times). more efficient pump action and increased return flow of blood to the heart and decreased heart workload Position change q 2-4h (specify) to Promotes circulation and prevents avoid pressure on susceptible body breakdown of tissue from further parts, perform ROM if needed. perfusion decreases associated with pressure. Position in Fowler's at height of Decreases blood volume returning to comfort if respiratory status heart by pooling of blood in compromised by pulmonary perfusion. lower dependent parts of the body. Inform caregiver of causes of Promotes understanding of condition decreased circulation and its and risk to organ function. effect on body organs. Demonstrate positions that enhance Promotes comfort and prevents comfort and circulation, such as tissue breakdown. cardiac chair or infant seat (specify), which alleviate pressure on body parts; use of pillows to maintain Fowler's position. Inform caregiver to avoid tight and Constricts circulation. restrictive clothing, such as belts, elastic waists on pajamas, diapers. NIC: Cardiac Care Evaluation 8 of 10 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=7&FxId=123&Sessio. (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What are ABG values?) (Is client alert, not restless or lethargic?) (Are bowel sounds present? Is abdomen soft and nondistended?) (Specify cc/hr of urine output/time frame.) (Is skin warm, pink, and dry, without edema?) (Revisions to care plan? D/C care plan? Continue care plan?) COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:47:11 PM PST (GMT -08:00) 9 of 10 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=7&FxId=123&Sessio. Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=7 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 2 - CARDIOVASCULAR SYSTEM CHAPTER 2.0 - CARDIOVASCULAR SYSTEM: BASIC CARE PLAN Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 10 of 10 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=8&FxId=123&Sessio. CHAPTER 2.1 - CARDIAC CATHETERIZATION INTRODUCTION Cardiac catheterization is the insertion of a flexible catheter through a blood vessel (most often the femoral vein) into the heart for diagnostic and therapeutic purposes. It is usually combined with angiography when radiopaque contrast media is injected through the catheter and circulation is visualized on fluoroscopic monitors. Catheterization allows measurement of blood gases and pressures within chambers and great vessels; measurement of cardiac output; and detection of anatomic defects such as septal defects or obstruction to blood flow. Therapeutic, or interventional, cardiac catheterizations use balloon angioplasty to correct such defects as stenotic valves or vessels, aortic obstruction (particularly recoarctation of the aorta), and closure of patent ductus arteriosus. MEDICAL CARE Chest X-ray: to determine condition of lung fields and cardiac size. ECG: to detect any cardiac conduction changes or abnormalities. Complete Blood Count: to provide baseline data and ensure the child is not in an infectious state. Blood Coagulation Time: to provide baseline data for comparison after the procedure. Type and Cross-match: obtained for interventional cardiac catheterizations as risk of hemorrhage is greater; not usually obtained for diagnostic procedures. Analgesics: precatheterization sedation given on-call to the catheterization laboratory. Intravenous Fluids: IV access is essential for additional medications during catheterization and may be started on the nursing unit or after arrival at the laboratory. Ringer's lactate or 5% Ringer's lactate are routine. COMMON NURSING DIAGNOSES See DEFICIENT FLUID VOLUME Related to: NPO status, blood loss during the catheterization, and diuretic effect of the contrast media. Defining Characteristics: Elevated temperature, increased heart rate and respiratory rate, decreased blood pressure, decreased skin turgor, pallor, dry mucous membranes (specify). See PAIN Related to: Percutaneous puncture site, numerous needle sticks from local anesthesia during procedure, positioning during procedure. Defining Characteristics: Crying, guarding or refusal to move, verbal expression of pain, increased heart rate and respiratory rate. Cardiac 1 of 8 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=8&FxId=123&Sessio. catheterization is described by most children as painful, but there should be minimal pain postcatheterization (puncture site described as sore). Severe pain needs further investigation (specify). ADDITIONAL NURSING DIAGNOSES FEAR Related to: Invasive, painful procedure, risk of harm, separation from parents, fear of needles, and fear of exposure. Defining Characteristics: (Specify: Apprehension, expressed concern over impending procedure. In children: increased motor activity, inattention, withdrawal, crying, clinging to parent(s), verbal protests). Goal: Child (and parents) will exhibit decreased anxiety by (date/time to evaluate). Outcome Criteria √ Child will not cry, cling to parents, or protest. √ Parent(s) will verbalize decreased anxiety/concern. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess parents' and child's Provides information on parents' and understanding of catheterization and child's knowledge, misunderstanding any special fears. and particular concerns; sources of anxiety for the parents include fear and uncertainty over the procedure, fear of complications, guilt and anxiety over the child's pain, and uncertainty over the outcome; for the child, fears may include: fear of mutilation and death, separation from parents, fear of the unknown (if the first catheterization), or remembered fear and pain (if repeat catheterization). Allow expression of fears, clarify any Allows parents and child to express misconceptions or lack of knowledge. feelings and provides them correct, complete information. Encourage the child to take along a A familiar object provides comfort and familiar, comforting item (specify security to the child experiencing stuffed animal, pillow, taped unfamiliar events and surroundings. music). Encourage parents to accompany child Children cope with stressful events and be with child immediately best when in the presence of their following the procedure. parents. Prepare the child using age- Age-appropriate information given to 2 of 8 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=8&FxId=123&Sessio. appropriate guidelines; (specify) the child allows for greater use concrete explanations just prior understanding and reassurance; young to an event for younger children. children process information through Include information on what the all their senses and need to know child will experience through all what to expect to better cope. senses (sights, smells, sounds, feel). Explain reason for each pre- and Knowledge of rationale for all postcatheterization procedure. treatments provides greater understanding and acceptance. Inform parents that the child may Stressful events may cause the child to temporarily act differently at home: need extra reassurance and may cause may need to stay close to parents, a temporary regression in development have nightmares, and be less as the child reverts to comfortable, independent; encourage parents to familiar "safe" activities; children, comfort and reassure child, to allow like adults, have a need to replay child to "re-live" the experience stressful events in order to understand through stories or play, and to and cope, and this is often accept temporary setbacks in accomplished through play activities. development. Inform parents about, and demonstrate Information provides parents the how to care for the child's knowledge they need to feel catheterization site; leave Steri- comfortable and confident in caring Strips in place until they fall off, for their child. do not place child in a tub bath for 3 days; immediately report any bleeding, bruising, redness or swelling to physician. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe child's behavior: does child cry, cling to parents, or protest?) (Specify what parents said to indicate decreased anxiety/concern; use quotes whenever possible.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: Altered hemostasis and trauma from percutaneous puncture. Defining Characteristics: Increased apical heart rate and decreased blood pressure, bleeding from catheterization site, bruising, decreased level of consciousness (specify). 3 of 8 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=8&FxId=123&Sessio. Goal: Child will not experience injury by (date and time to evaluate). Outcome Criteria √ No bleeding from puncture site. √ BP and heart rate remain within (specify ranges appropriate for child). NOC: Risk Control INTERVENTIONS RATIONALES Obtain baseline laboratory values Provides comparative data for from precatheterization assessment. postcatheterization assessment. Assess vital signs (apical HR, Changes in vital signs may indicate respiratory rate and BP) every 15 blood loss and with internal minutes × 4, every 30 minutes × 3 bleeding may be the first hours, then every 4 hours. indicator of problems. Maintain pressure dressing on Constant pressure on site is needed catheterization site and check to prevent bleeding; no bleeding, every 30 minutes for bleeding. If even oozing, should occur. bleeding does occur, apply continuous direct pressure 1″ above puncture site and notify physician immediately. Maintain bed rest for 6 hours Bed rest prevents strain to postcatheterization as ordered. catheterization site which otherwise might precipitate bleeding; a 45-degree head elevation and slight bend at the knees are acceptable; young children may be held by parents: this is beneficial in decreasing agitation. Inform parents and child of need for Promotes understanding and frequent assessments and for bed cooperation. rest. Encourage parents and child to engage Allows for expression and inter- in quiet activities (i.e., reading action without physical stress; stories, music). provides distraction for comfort. Encourage parents of infants and Allows parents to touch and comfort young

children to hold their their child in a more normal children as an acceptable manner; this decreases the child's alternative to resting in bed. agitation, thereby promoting more rest. Instruct parents to immediately Increases close monitoring of the report any sign of bleeding. Teach site. parents that pressure dressing will be removed after 24 hours and that they should continue to monitor the site and report to the physician if 4 of 8 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=8&FxId=123&Sessio. any bleeding is seen. NIC: Bleeding Precautions Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Is there any bleeding from puncture site?) (Specify child's BP and heart rate.) (Revisions to care plan? D/C care plan? Continue care plan?) INEFFECTIVE TISSUE PERFUSION: PERIPHERAL Related to: Clot formation at puncture site. Defining Characteristics: Cool, mottled appearance of involved extremity, decreased or absent pulses distal to catheterization site, pain, tingling or numbness in involved extremity (specify). Goal: Child will experience adequate peripheral tissue perfusion. Outcome Criteria √ Affected extremity will be pink and warm. √ Pulses present distal to the catheterization site and equal bilaterally. √ Child responds to sensation in extremities equally bilaterally. NOC: Tissue Perfusion: Peripheral INTERVENTIONS RATIONALES Assess temperature, color and Clots form at puncture site and the capillary refill of affected child is at risk of the clots extremity and assess distal seriously obstructing distal pulses by palpation and Doppler blood and resulting in tissue every 15 minutes × 4, every 30 damage. Assessing the extremity minutes × 3 hours, then every 4 frequently for adequate perfusion hours. allows for early intervention as needed. Maintain bed rest with extremity Bed rest and slight, or no flexion, straight or slight bend in knee allows for greater blood flow and (10 degrees) for 6 hours. decreases risk of further trauma 5 of 8 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=8&FxId=123&Sessio. which could increase clot formation. Apply warmth to the opposite Improves circulation without extremity. causing risk of increased bleeding at site. Inform parents and child of need Promotes understanding and for frequent assessment of vital cooperation. signs and need for bed rest with extremity extension. Teach parents and child to avoid May help decrease risk of tub baths for three days after infection. procedure. NIC: Bleeding Precautions Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe pulses distal to the catheterization site and compared to other extremity.) (Describe how child responds to sensation in extremities bilaterally.) (Revisions to care plan? D/C care plan? Continue care plan?) HYPERTHERMIA Related to: Reaction to radiopaque contrast material used in catheterization. Defining Characteristics: Elevated body temperature (specify) within a few hours of procedure. Goal: Child will not be hyperthermic by (date and time to evaluate). Outcome Criteria √ Child's axillary temperature will be <100° F. NOC: Thermoregulation INTERVENTIONS RATIONALES Assess body temperature every Provides information on which hour × 6 hours and then action to take. routine (specify route). Continue IV fluids (specify) Increased fluid intake promotes while child is drowsy, and more rapid excretion of the when fully awake, encourage PO dye. 6 of 8 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=8&FxId=123&Sessio. intake (specify fluids). Administer age-appropriate dose Acetaminophen will help of acetaminophen every 4 hours decrease fever and associated (specify dose). discomfort. Record hourly I&O. Assesses routine adequacy of fluid intake and elimination. Instruct parents to encourage PO Involving parents in care fluids. increases the likelihood of achieving the goal. Teach parents to take child's Teaching empowers parents to temperature and report any care for child and helps elevations after discharge. monitor for hyperthermia. NIC: Fever Treatment Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Specify child's temperature.) (Revisions to care plan? D/C care plan? Continue care plan?) COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: 7 of 8 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=8&FxId=123&Sessio. Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:47:33 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=8 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 2 - CARDIOVASCULAR SYSTEM CHAPTER 2.1 - CARDIAC CATHETERIZATION Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 8 of 8 12/22/2006 7:17 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=9&FxId=123&Sessio. CHAPTER 2.2 - CONGENITAL HEART DISEASE INTRODUCTION Congenital heart disease results from malformations of the heart that involve the septums, valves, and large arteries. They are classified as acyanotic or cyanotic defects. Acyanotic defects occur when a left-to-right shunt is present that allows a mixture of oxygenated and unoxygenated blood to enter the systemic circulation. The most common consequences of these defects in children are growth retardation and congestive heart failure (CHF). Common cyanotic defects include tetralogy of Fallot and transposition of the great vessels. Tetralogy of Fallot involves four defects that include pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy, and an aorta that overrides the ventricular septal defect. Transposition of the great vessels is a condition in which the aorta arises from the right ventricle instead of the left ventricle, and the pulmonary artery arises from the left ventricle instead of the right ventricle, thereby causing a reversal of the normal position of these arteries. Transposition of the great vessels is incompatible with life unless septal defects are also present to allow mixing of blood from the two circulations. Acyanotic defects include coarctation of aorta, patent ductus arteriosus, and ventricular septal defect. Coarctation of the aorta is the narrowing of the aorta proximal to the ductus arteriosus (preductal), distal to the ductus arteriosus (postductal), or level with the ductus arteriosus (auxtaductal). The position of the narrowing during fetal development determines circulation to the lower body and development of collateral circulation. Patent ductus arteriosus is the failure of the structure needed for fetal circulation to close after birth. Ventricular septal defect is the incomplete development of the septum that separates the right and left ventricles, and it often accompanies other defects. Congenital heart defects vary in severity, symptoms, and complications, many of which depend on the age of the infant/child and the size of the defect. Treatment may include management with medications, open heart surgery to repair or resect, or to temporarily correct the defect until the child is older and growth takes place. MEDICAL CARE Diuretics: chlorothiazide (Diuril), spironolactone (Aldactone) PO, or furosemide (Lasix) PO or IV, depending on acuity of condition and need to promote fluid excretion by decreasing reabsorption of water, potassium, and sodium by the kidneys. Cardiac Glycosides: digoxin (Lanoxin) tablets or elixir PO or IV-form; administered to prevent or treat congestive heart failure resulting from congenital heart defect by increasing the force of and decreasing the rate of cardiac contractions. Antibiotics: penicillin G potassium (Pentids solution or tablets) PO, or erythromycin (Ilosone tablets, chewables, suspension) PO if patient is penicillin-sensitive as prophylaxis for bacterial endocarditis. Prostaglandin Synthesis Inhibitors: indomethacin (Indocin) IV to close PDA. Prostaglandin Hormones: alprostadil (Prostin VR Pediatric) IV to maintain open PDA when needed for blood flow. Electrolytes: potassium chloride tablet (Klorvess), elixir (Pan-Kloride) PO as potassium replacement with use of diuretic therapy. Chest X-ray: reveals cardiomegaly involving left side of heart, no enlargement depending on defect or cardiomegaly involving right ventricle, increased pulmonary blood flow or congested lungs, egg-shaped heart and narrowed mediastinum. 1 of 11 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=9&FxId=123&Sessio. Electrocardiography (ECG): reveals abnormal changes associated with right ventricular and/or atrial hypertrophy, possible abnormal changes associated with left ventricular hypertrophy in older children, may not reveal any abnormality depending on specific defect; identifies arrhythmias. Echocardiography (contrast, two-dimensional or real time, M-mode): reveals cardiomegaly, atrial or ventricular changes and location and size, great vessel location and size, valve function and any abnormalities or obstructions of the valves, increase in left atrial to aortic ratio, location of shunting in heart. Doppler: reveals circulation abnormalities and congested lung areas, done with or without echocardiography. Cardiac Catheterization: reveals abnormalities in communication between chambers, oxygen, and pressure levels in the chambers; location and number of septal defects. Angiography: reveals cardiac defect by revealing detailed heart structure. Electrolyte Panel: reveals possible decreased potassium and increased sodium. Complete Blood Count (CBC): increased WBC with infection, decreased Hgb and Hct with anemia, increased RBC, decreased platelet count. Prothrombin or Partial Thromboplastin Times (PT, APPT): reveals bleeding tendency and evaluates components of the blood-clotting mechanisms. Blood Urea Nitrogen (BUN): reveals increase when heart is not able to perfuse kidneys. Arterial Blood Gases (ABG): reveals decreased pH and PO2 and increased PCO2 resulting from changes in pulmonary blood flow. Surgical Shunt: increases blood flow to the lungs for severely hypoxic newborns creating an artificial connection between the right or left subclavian artery and the pulmonary artery on the same side (modified Blalock-Taussig shunt). COMMON NURSING DIAGNOSES See DECREASED CARDIAC OUTPUT Related to: Structural factors of congenital heart defect. Defining Characteristics: Variations in hemodynamic readings (hypertension, bounding, pulses, tachycardia, specify values), ECG changes, arrhythmias, fatigue, dyspnea, oliguria, cyanosis or absence of cyanosis, murmur, decreased peripheral pulses, widened pulse pressure, squatting or knee-chest position. See INEFFECTIVE BREATHING PATTERN Related to: Decreased energy and fatigue, pulmonary complications. Defining Characteristics: Dyspnea, hypoxia (blue baby), tachypnea, abnormal ABGs, cyanosis (specify). 2 of 11 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=9&FxId=123&Sessio. See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest, digest, or absorb nutrients because of biologic factors. Defining Characteristics: Poor feeding, fatigue, slow growth, lack of interest in food, prolonged impaired cardiac function, decreasing perfusion to gastrointestinal organs (specify). See DELAYED GROWTH AND DEVELOPMENT Related to: Effects of acute or chronic illness or disability (specify). Defining Characteristics: Altered physical growth, delay or difficulty in performing motor or social skills typical of age, dependence and isolation (specify). ADDITIONAL NURSING DIAGNOSES ACTIVITY INTOLERANCE Related to: Generalized weakness. Defining Characteristics: (Specify: presence of circulatory/respiratory problem, verbal complaint of fatigue or weakness, needs to rest after short period of play.) Related to: Imbalance between oxygen supply and demand. Defining Characteristics: Abnormal heart rate or blood pressure response to activity, exertional dyspnea (specify). Goal: Child will tolerate increased activity. Outcome Criteria √ (Specify for this child the activity level that is optimal within the limitations of the congenital heart disease.) NOC: Activity Tolerance INTERVENTIONS RATIONALES Assess level of fatigue, ability to Provides information about perform ADL and other activities energy reserves and response in relation to severity of to activity. condition. Assess dyspnea on exertion, skin Indicates hypoxia and increased color changes during rest and when oxygen need during energy active. expenditure. Allow for rest periods between care; Promotes rest and conserves disturb only when necessary for energy. care and procedures. 3 of 11 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=9&FxId=123&Sessio. Avoid allowing infant to cry for Conserves energy. Cross-cut long periods of time, use soft nipple requires less energy nipple for feeding; cross-cut for infant to feed. nipple; if unable for infant to ingest sufficient calories by mouth,gavage-feed infant. Provide toys and games for quiet Promotes growth, diversion, and play and diversion appropriate for physical and mental age of child (specify), allow to development. limit own activities as much as possible. Provide neutral environmental Avoids hot or cold extremes temperature; when bathing infant, which increase oxygen and expose only the area being bathed energy needs. and keep the infant covered to prevent heat loss. Explain to parents need to conserve Avoids fatigue. energy and encourage rest. Inform of activity or exercise Prevents fatigue while engaging restrictions and to set own limits in activities as nearly for exercise and activity (specify normal as possible. for child). Inform to request assistance when Prevents overtiring and needed for

daily activities. fatigue. Assist parents to plan for care and Provides for rest and prevents rest schedule. overexertion, minimizes energy expenditure. NIC: Cardiac Precautions Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe child's ability to engage in the activity level that was specified as criteria.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: Chronic illness. Defining Characteristics: Debilitated condition, IV-site contamination, susceptibility to bacterial endocarditis, immobility, change in VS (specify). Goal: Child will not experience any infection by (date and time to evaluate). Outcome Criteria 4 of 11 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=9&FxId=123&Sessio. √ Temperature <100° F √ Absence of inflammation of IV site: no swelling, redness, or increased tenderness. NOC: Risk Control INTERVENTIONS RATIONALES Assess temperature, IV site if Provides information indicating present, increased WBC, potential infection. increased pulse and respirations (specify when). Provide adequate rest and Protects against potential nutritional needs for age infection by increasing body (specify for child). resistance and defenses. Wash hands before giving care. Prevents transmission of microorganisms to infant/ child. Avoid allowing those with Prevents transmission of infections to have contact with infectious agents to infant/ infant/ child. child with compromised defense. Administer antibiotics as ordered Describe action of specific (specify drug, dose, route, and antibiotic ordered. times). Use sterile technique for IV Prevents contamination, which maintenance if present. causes infection. Inform to avoid contact with Infections are easily those in family or friends that transmitted to a debilitated have an infection. child. Instruct parents and child in Prevents reduced defenses or personal hygiene and practices exposure to possible (rest, nutrition, activity, contaminants. bathroom for elimination, bathing). NIC: Infection Protection Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is temperature?) (Describe assessment of IV site.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY 5 of 11 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=9&FxId=123&Sessio. Related to: Cardiac function compromised by congenital defects and medication administration. Defining Characteristics: (Specify: digoxin toxicity (vomiting, dysrhythmia), hypokalemia (muscle weakness, hypotension, irritability, drowsiness), congestive heart failure (tachycardia, dyspnea fatigue, restlessness, cough, cyanosis, orthopnea, edema, weight gain, neck vein distention, decreased BP, cardiomegaly), hypoxemia, possible cardiac surgery.) Goal: Child will not experience injury by (date/time to evaluate). Outcome Criteria √ Specify, e.g., digoxin level <2.5 ng/mL. √ Parent correctly administers medications. √ Parent verbalizes signs and symptoms of complications to report (specify). NOC: Risk Control INTERVENTIONS RATIONALES Assess for risk of drug toxicity, Early identification of signs and cardiac complication of heart symptoms of complications allows failure. preventive measures and adjustments to be made. Monitor orders for diagnostic tests Allows for preparation and support and procedures. of parents and infant/child. Administer digoxin or indomethacin in Promotes safe administration of correct dosages (specify), check cardiotonic to decrease and dosages, take apical pulse for a strengthen heart rate (digoxin), full minute before administering or to promote closing of ductus digoxin, assess for drug responses. (indomethacin). Assist and support family's feelings Provides needed support to allay and decision regarding surgery. anxiety and promote caring attitude. Instruct in administration of Ensures safe and accurate cardiotonic, taking apical pulse, administration of cardiac when to withhold (less than 70-80 in glycoside. child and 90-100 in infant), to notify physician of low pulse or irregular pulse, signs of toxicity. Prepare parents and child (use play Assists in allaying anxiety and doll) for diagnostic procedures and/ understanding that diagnostic or surgery; should be extensive, tests are usually done before consistent, and comprehensive, surgery. including surgical procedure to be performed and expected results, prognosis and whether corrective, palliative, temporary, or permanent. Teach actions to take if child becomes Encourages calmness during attack cyanotic (knee-chest or squatting and teaches actions that will 6 of 11 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=9&FxId=123&Sessio. position, elevating head and chest), relieve episode and associated when to call physician. fear. NIC: Medication Administration Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is digoxin level? Describe parent ability to administer medication safely. Did parent verbalize complications signs to report? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) COMPROMISED FAMILY COPING Related to: Situational and developmental crises of family and child. Defining Characteristics: (Specify: family expresses concern and fear about infant/child's disease and condition, displays protective behavior disproportionate to need to grow and develop, chronic anxiety and possible hospitalization and surgery.) Goal: Family will cope more effectively by (date/time to evaluate). Outcome Criteria √ (Specify signs of increased development of coping skills with infant/child's illness and changes in family coping.) NOC: Family Coping INTERVENTIONS RATIONALES Observe for erratic behaviors Information affecting ability of (anger, tension, family to cope with infant/ disorganization), perception of child's cardiac condition. crisis situation. Assess usual family coping methods Identifies need to develop new and effectiveness. coping skills if existing methods are ineffective in changing behaviors exhibited. Assess need for information and Provides information about need support. for interventions to relieve anxiety and concern. Encourage expression of feelings Reduces anxiety and enhances and provide factual information family's understanding of about infant/child. condition. Assist in identifying and using Provides support for problem techniques to cope with and solve solving and management of problems and gain control over situation. 7 of 11 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=9&FxId=123&Sessio. the situation (specify). Provide anticipatory guidance for Assists family in adapting to crisis resolution and allow for situation and developing new grieving process. coping mechanisms. Suggest and reinforce appropriate Promotes behavior change and coping behaviors, support family adaptation to care of infant/ decisions. child. Teach that overprotective behaviors Knowledge will enhance family may hinder growth and development understanding of condition and during infancy/ childhood. of adverse effects of behaviors. Encourage to maintain health of Chronic anxiety, fatigue, and family members and social isolation as result of infant contacts. care will affect health and care capabilities of family. Teach family about the disease Relieves tension when they know process and behaviors, physical what to expect. effects, and symptoms of condition. Clarify any misinformation and Prevents unnecessary anxiety answer questions regarding resulting from inaccurate disease process. knowledge or beliefs. Encourage parents to include ill Promotes normal growth and infant/child in family activities development of family and rather than family revolving infant/child. around needs of infant/child. Encourage to maintain consistent Prevents behavioral problems and behavior limits and modification child control over family, which techniques. interfere with child's growth and family relationships. Instruct parents in nutritional and Assists in coping with effects and activity needs and/or limitations special needs of infant/child and approaches that will assist with cardiac defect. in establishing an effective pattern. Refer family for additional support Referral supplies more assistance and counseling if indicated with coping than is available (specify where to refer family). from nursing personnel. NIC: Family Therapy Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe increased coping skills of family.) (Revisions to care plan? D/C care plan? Continue care plan?) 8 of 11 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=9&FxId=123&Sessio. FLOW CHART FOR CONGENITAL HEART DISEASE 9 of 11 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=9&FxId=123&Sessio. 10 of 11 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=9&FxId=123&Sessio. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:47:48 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=9 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 2 - CARDIOVASCULAR SYSTEM CHAPTER 2.2 - CONGENITAL HEART DISEASE Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 11 of 11 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=10&FxId=123&Sessi. CHAPTER 2.3 - CONGESTIVE HEART FAILURE INTRODUCTION Congestive heart failure is the inability of the heart to maintain the workload necessary to pump blood throughout the circulatory system of the body because of ineffective contractions. In children, cardiac heart failure occurs as a result of changes associated with congenital heart defects, such as those resulting in left-to-right shunts (volume overload) or obstructive lesions within the heart (pressure overload), of cardiomyopathy affecting the myocardium or dysrhythmias (decreased contractility), or of disorders such as anemia or sepsis (high cardiac output needs). In infants and children, failure of one side of the heart generally causes failure in the other side. Normally, any predisposing problem that blocks the effective flow of blood causes the heart to respond by compensatory mechanisms that maintain the workload of the heart. Congestive heart failure occurs when the compensatory mechanisms are not able to maintain the workload of the heart, and the body tissues and organs are deprived of the oxygen and nutrients they need to function properly. MEDICAL CARE Diuretics: chlorothiazide (Diuril), spironolactone (Aldactone) PO, which promotes fluid excretion by acting on the distal and proximal tubules or blocks action of aldosterone to decrease water, sodium chloride, and potassium absorption; furosemide (Lasix) PO or IV for acute failure, which acts to block reabsorption of water and sodium in the proximal, distal tubules and loop of Henle. Cardiac Glycosides: digoxin (Lanoxin) tablets or elixir PO or IV form, depending on treatment, for acute or maintenance therapy to increase the force of and decrease the rate of cardiac contractions. Digoxin has a narrow therapeutic serum level of 0.8 to 2.0 g/L. Angiotensin-Converting Enzyme (ACE) Inhibitors: captopril (Capoten), enalapril (Vasotec), PO to inhibit conversion of angiotensin I to II by reducing the production of renin; ultimately the result is to reduce vasoconstriction and aldosterone secretion, which lowers blood pressure and the work of the heart. Electrolytes: potassium chloride tablet (Klorvess), elixir (Pan-Kloride) PO as a potassium replacement with use of diuretic therapy. Humidified Oxygen: relaxes pulmonary vasculature and decreases cardiac workload. Analgesics/Sedatives: morphine sulfate SC or IV to relax smooth muscle. Chest X-ray: for cardiac dilatation and hypertrophy. Electrocardiography: reveals ventricular hypertrophy and arrhythmias. Echocardiography: for abnormal valve function via ultrasound. Digoxin Level: for serum level, to prevent toxicity, and regulate dosage. Electrolyte Panel: for hypokalemia caused by diuretics or hyperkalemia resulting from K+ supplements and/or Vasotec. May result in cardiac dysrhythmias. Complete Blood Count: decreased Hgb and Hct in anemia. 1 of 9 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=10&FxId=123&Sessi. Arterial Blood Gases: for decreased PO2 and pH and increased PCO2 leading to acidosis with pulmonary changes. COMMON NURSING DIAGNOSES See DECREASED CARDIAC OUTPUT Related to: Mechanical factors with alterations in (specify: preload, afterload, and inotropic changes in heart). Defining Characteristics: (Specify: fatigue; oliguria; decreased peripheral pulses; pale, cool extremities; tachycardia; decreased BP; dyspnea, crackles.) See INEFFECTIVE BREATHING PATTERN Related to: Decreased lung expansion; pulmonary congestion. Defining Characteristics: (Specify: dyspnea, tachypnea, orthopnea, cough, nasal flaring, respiratory depth changes, altered chest excursion, use of accessory muscles with retractions, abnormal arterial blood gases, wheezing, crackles, grunting, cyanosis.) See FLUID VOLUME EXCESS Related to: Compromised regulatory mechanisms. Defining Characteristics: (Specify: edema [periorbital, peripheral], effusion, weight gain, dyspnea, orthopnea, crackles, blood pressure changes, oliguria, jugular vein distention, hepatomegaly, restlessness and anxiety, altered electrolytes, change in mental status.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: (Specify, e.g., fatigue.) Defining Characteristics: (Specify, e.g., percentage of meals eaten, weight loss, weight percentile, laboratory values.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Medication (diuretics). Defining Characteristics: (Specify, give values: output greater than intake, weight loss, hypokalemia, hypernatremia.) See INEFFECTIVE TISSUE PERFUSION: CARDIOPULMONARY, PERIPHERAL Related to: Hypervolemia, prolonged cardiac failure Defining Characteristics: (Specify: edema, dyspnea, change in color, temperature of extremities [mottled, cold], decreased peripheral pulses, 2 of 9 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=10&FxId=123&Sessi. effusion, changes in

BP (specify), tachypnea, orthopnea, tachycardia, cough.) ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: (Specify: threat of death, threat of or change in health status, threat of change in environment [hospitalization].) Defining Characteristics: (Specify: parent—increased apprehension that condition might worsen into life-threatening situation, increased concern and worry about possible hospitalization, increased tension and uncertainty, chronic worry. Child—unhappy and sad attitude; withdrawn or aggressive behavior; somatic and fatigue complaints; failure to thrive and participate in school, play, or social activities.) Goal: Client will experience decreased anxiety by (date/time to evaluate). Outcome Criteria √ (Specify, e.g., display relaxed facial features, engage in relaxation exercises, express feeling in control of anxiety.) NOC: Anxiety Control INTERVENTIONS RATIONALES Assess level and manifestations of Provides information needed for anxiety in parents and child at interventions and clues to each visit. severity of anxiety. Allow expression of fears and Provides opportunity to vent concerns and time to ask feelings and secure information questions about disorder and what to reduce anxiety. to expect. Provide supportive, nonjudgmental Promotes trust and reduces environment and individualized, anxiety. consistent care. Hold and cuddle infant when crying/ Promotes comfort and security. tense. Inform parents and child of all Relieves anxiety caused by fear procedures and treatments, of the unknown. anticipate needs. Allow parents to stay and provide Reduces anxiety by allowing open visitation and telephone presence and involvement in communication; encourage to care and provides familiar participate in care and to plan persons and routine for child. care similar to usual home patterns. Keep parents informed of changes in Promotes understanding and condition, progress made. reduces anxiety about whether child is improving. Explain why hospitalization became Promotes understanding of necessary (specify). disorder and underlying disease that causes this complication. Clarify any misinformation with Promotes knowledge and prevents 3 of 9 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=10&FxId=123&Sessi. simple, understandable language anxiety caused by inaccurate and honesty. information or beliefs. Instruct in signs and symptoms Provides information of what indicating possible heart failure might be expected and what to (fatigue, tachycardia, anorexia, report in order to allay dyspnea, tachypnea) and measures anxiety. to take (specify). NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parent/child verbalize decreased anxiety? Describe facial tension; did parent/child do relaxation exercises? What did parent/child say about feeling in control? Use quotes whenever possible.) (Revisions to care plan? D/C care plan? Continue care plan?) ACTIVITY INTOLERANCE Related to: Imbalance between oxygen supply and demand. Defining Characteristics: (Specify: abnormal heart rate or blood pressure response to activity, exertional dyspnea, fatigue, weakness, respiratory/circulatory problem, provide data.) Goal: Child will engage in tolerable levels of activity by (date/time to evaluate). Outcome Criteria √ Engages in stimulating activities appropriate for developmental needs and energy level (specify). Balances periods of activity and rest. √ Controls level of activity to prevent fatigue or cardiac symptoms. NOC: Activity Tolerance INTERVENTIONS RATIONALES Assess level of fatigue, v/s, and Provides information about responses to activity. change in vital signs and energy level. Allow for rest periods between Promotes rest, conserves energy care, disturb only when and reduces heart workload. necessary and then perform care and treatments during one period of time. Avoid allowing infant to cry for Conserves energy and prevents 4 of 9 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=10&FxId=123&Sessi. long periods of time; use soft fatigue. nipple with large opening for feeding and feed frequently, slowly, and in small amounts (specify). Provide small, frequent meals for Conserves energy. child. Provide toys and quiet, age- Allows for play without appropriate play (specify). depleting energy reserves. Provide neutral environmental Extremes of temperature temperature. increase oxygen and energy needs, which increase work of heart. Explain reason for need to Promotes compliance with conserve energy and encourage activity restrictions. rest. Discuss activities allowed, type Prevents fatigue while still of play recommended, and allowing activities as near rationale. normal as possible. Assist in planning for rest and Provides for rest, prevents activity schedule. overexertion and symptoms, minimizes energy expenditure. Inform of continued stimulation- Promotes normal growth and type activities (visual, development. auditory, tactile, mental, and physical; Specify). NIC: Activity Therapy Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe activity child engaged in; provide information about balance of activity and rest; describe how child controls activity in response to fatigue or cardiac symptoms.) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE Related to: Lack of information about disorder and treatments/care. Defining Characteristics: (Specify: verbalization of need for information about disease, medications, dietary restrictions.) Goal: Parents will gain knowledge about disorder and treatment by (date/time to evaluate). Outcome Criteria 5 of 9 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=10&FxId=123&Sessi. √ Parents verbalize understanding of child's disorder, causes, and risk factors. √ Parents participate in treatment planning. √ Parents correctly administer medications to child. √ Parent verbalizes signs of medication side effects and signs of congestive heart failure to report. NOC: Knowledge: Diseases Process INTERVENTIONS RATIONALES Assess knowledge of disease, causes Promotes plan of instruction that and methods to prevent or control is realistic to ensure compliance condition, willingness and interest of medical regimen, prevents to implement care to reduce work of repetition of information. heart, ability and readiness to learn. Provide information about disorder Ensures understanding and aids in causes and risk factors; use clear, reinforcement of learning. understandable language, pictures, pamphlets, models, video tapes, anatomic doll in teaching (specify). Teach to plan menus that include Allows input, control over planning sodium restriction, fluids if for sodium; fluid restriction may prescribed, additional calories be needed to prevent fluid (specify for child). retention; additional calories provided for higher metabolic needs. Teach about administration of cardiac Ensures correct administration of glycosides and diuretics, including drugs to prevent heart failure dosage, frequency, route, side and drug toxicity. effects to report, expected results (specify). Instruct in taking pulse for 1 minute Apical pulse taken before and allow return demonstration. administration of cardiac glycoside. Discuss effects of disorder on Disorder slows growth and infant/child (growth and physical development for age. development). Teach to report infection or changes Reduction in body defenses in breathing, pulse, irritability, predisposes to infectious restlessness, edema, temperature process, signs and symptoms (increase), or weight. reported to prevent progressive heart failure. Ask parent to verbalize or return- Parents may be overwhelmed with too demonstrate all teaching that has much information. Allows the been done. nurse to identify areas for additional instruction. Provide additional written or video Allows parent to review information 6 of 9 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=10&FxId=123&Sessi. information for parents. at home; allows for varied learning styles. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents verbalize understanding of child's disorder, causes, and risk factors? Did parents participate in treatment planning? Do parents correctly administer medications? Can parent verbalize signs of medication side effects and signs of congestive heart failure to report?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR CONGESTIVE HEART FAILURE 7 of 9 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=10&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library 8 of 9 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=10&FxId=123&Sessi. ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:48:02 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=10 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 2 - CARDIOVASCULAR SYSTEM CHAPTER 2.3 - CONGESTIVE HEART FAILURE Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 9 of 9 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=11&FxId=123&Sessi. CHAPTER 2.4 - CARDIAC DYSRHYTHMIAS INTRODUCTION Dysrhythmia is a term used to describe cardiac rate and rhythm abnormalities or irregularities. They may originate from any site in the heart, as any cell in the myocardium has the ability to discharge an impulse. In children, they may occur as the result of cardiac surgery or congenital heart defects and are less common than in adults. Treatment consists of medications, and in some cases, a permanent pacemaker to manage conduction disturbances in the heart. MEDICAL CARE Antidysrhythmics: verapamil (Isoptin) PO or IV, depending on acuteness of condition, to slow SA and AV node conduction in tachyarrhythmias. Cardiac Glycosides: digoxin (Lanoxin) PO to slow and strengthen heart beat. Cardiac Pacemaker: to initiate or supplement conduction in the myocardium. Chest X-ray: reveals correct placement of pacemaker catheter. Electrocardiography/Holter Monitoring: reveals deviations suggesting dysrhythmias that assist in diagnosis of cardiac conditions and provide rhythm strips to monitor pacer function; test to determine pharmacologic treatment of dysrhythmias; similar to cardiac catheterization, which artificially induces a dysrhythmia and administers different drugs IV to see which will terminate the dysrhythmia. COMMON NURSING DIAGNOSES See DECREASED CARDIAC OUTPUT Related to: Electrical factors with alteration in rate, rhythm, and conduction. Defining Characteristics: (Specify: dysrhythmias, ECG changes, changes in apical and peripheral pulses, failing batteries or break in pacemaker catheter, provide data.) ADDITIONAL NURSING DIAGNOSES RISK FOR INFECTION Related to: Inadequate primary defenses (broken skin) (specify where). Defining Characteristics: (None, as this is a potential diagnoses.) Goal: Child will not experience any infection by (date/time to evaluate). Outcome Criteria 1 of 6 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=11&FxId=123&Sessi. √ Site will be clean and dry, without redness, edema, drainage, or odor. √ Child's temperature will be <101° F. NOC: Risk Detection INTERVENTIONS RATIONALES Assess temperature q 4 hours. Temperature >101° F or WBC Monitor lab work as obtained. may indicate development of an infection. Wash hands before and after Handwashing prevents the spread providing care for patient. of microorganisms that may Teach family and child to wash cause infection. hands frequently. Assess site for warmth, redness, Indicates infectious process at pain, drainage, and odor q 4 site of wound. hours. Assess IV site for edema, Indicates phlebitis or infiltration, redness, and dislodgement of infusion warmth q hour. catheter for administration of fluids and IV medications. Assess skin under ECG electrodes Infection can result from skin for erythema, irritation, or irritation and breakdown rash (if cardiac monitoring caused by electrode gel and present). adhesive pads. Maintain sterile technique for Prevents contamination by dressing changes, IV site pathogenic microorganisms. changes, and care of any breaks in skin. Change IV site and tubing every Prevents bacterial growth and 24 to 72 hours according to prolonged irritation to vein. protocol. Gently wash and dry electrode Prevents prolonged irritation sites when removed and before to skin. reapplication. Administer antibiotic therapy as Prevents irritation to vein and ordered by physician (specify). phlebitis (action of drug). Teach parents to take oral or Monitors for infection. axillary temperature. Instruct on care of site during Maintains sterility or and after healing. cleanliness of site. NIC: Infection Control Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 2 of 6 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=11&FxId=123&Sessi. (Describe wound. What is child's temperature?) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: Chemical or mechanical insult. Defining Characteristics: (Specify: negative response to medications [digoxin toxicity]; pacemaker or catheter malfunction; failure of pacemaker to capture or sense arrhythmias.) Goal: Child will not experience any injury by (date/time to evaluate). Outcome Criteria √ Proper functioning and maintenance of pacemaker system with pulse rate, rhythm, and duration occurring as programmed. √ Digoxin level maintained at therapeutic level (specify); K+ levels within normal ranges (specify). NOC: Risk Detection INTERVENTIONS RATIONALES Assess pulse, changes in cardiac Decreases in pulse and cardiac output, changes in ECG (specify output indicate battery when). depletion; ECG changes may indicate loss of

capture, arrhythmias from malpositioning of pacing catheter. Assess digoxin, potassium and Electrolyte imbalance may result in calcium levels as obtained. arrhythmias, too high or too low dosages, or cardiotonic causes arrhythmias. Monitor effect of antidysrhythmics Ensures desired effect of by taking pulse rate and rhythm; medications (action of drugs). carefully administer correct dosage at correct rate (specify). Instruct parents in administration Ensures proper dosage, frequency, of antidysrhythmics; cardiac and knowledge of when to report glycosides; diuretics, including side effects. name, actions, dosage, frequency, side effects, how to take, expected results. Describe to parents and child the Provides understanding of type and device and its parts, how it function of pacemaker; parts functions, and type of lead used; include the generator with the use manufacturer's instruction battery and electronic circuitry, pamphlet, drawing, and models. of which produces the impulse to the the impulse to the heart; lead may heart, and a lead, which operates be epicardial or transvenous. as a conductor 3 of 6 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=11&FxId=123&Sessi. Teach parents the method of taking Monitors effect of medication and pulse (apical) for 1 minute. changes to report. Describe procedure for transmission Transmits ECG strips by phone to of ECG by telephone to parents. monitor for dysrhythmias, pacemaker function, and battery depletion. Review activity limitations, types Activity tolerance usually improved of activities to avoid that might with pacemaker. affect pacemaker function (contact sports). Stress the importance of wearing Provides information for emergency identification with pacemaker care. type, site of insertion, physician name and number. Inform to avoid electrical Some pacemakers are still affected interferences, microwave ovens, by electrical interference of and to request hand scanner at current leakage. airports. Stress the importance of follow-up Ensures monitoring of condition and visits to physician. pacemaker function. Refer to cardiopulmonary May be needed as an emergency resuscitation (CPR) classes. measure to maintain normal rhythm. NIC: Dysrhythmia Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Is pacemaker functioning properly? Specify; what is digoxin level? What is potassium level?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR CARDIAC DYSRHYTHMIAS 4 of 6 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=11&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:48:17 PM PST (GMT -08:00) 5 of 6 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=11&FxId=123&Sessi. Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=11 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 2 - CARDIOVASCULAR SYSTEM CHAPTER 2.4 - CARDIAC DYSRHYTHMIAS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 6 of 6 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=12&FxId=123&Sessi. CHAPTER 2.5 - HYPERTENSION INTRODUCTION Hypertension in children is reflected by the consistent readings of the systolic and/or diastolic blood pressure at the level of or above the 95th percentile for age and sex. It may be primary or secondary. Fifty to 80% of secondary hypertension is caused by renal parenchymal disease; therefore, infants and children with hypertension and adolescents with severe hypertension need to be evaluated for renal pathology. Hypertension in children is of particular concern because of its close association with adult hypertension. Children with increased blood pressure usually do not display any overt symptoms. Blood pressure determinations are a part of routine examination in children 3 years and older. Children under 3 who have been diagnosed with a heart condition are also screened for hypertension. MEDICAL CARE Diagnosis and Treatment of Underlying Cause: preferred over use of drug therapy in children. Chest X-ray: hypertrophy of left ventricle in sustained hypertension. Electrocardiography: cardiac abnormalities. Urinalysis: renal disease or infection. Electrolytes: hypokalemia, hypernatremia during diuretic therapy. Lipid Panel: increases in lipoproteins, cholesterol, and triglyceride levels. Blood Urea Nitrogen: increases in impaired renal function in secondary hypertension. Creatinine: increases in impaired renal function in secondary hypertension. Complete Blood Count: increased WBC in presence of infection. Diuretics: chlorothiazide (Diuril and Hydrochlorothiazide Chydrodiuril) PO promotes diuresis and elimination of sodium by preventing reabsorption; it also decreases cardiac output, which reduces peripheral vascular resistance. Beta-Blockers: propranolol (Inderal), PO to lower cardiac output, which decreases blood pressure. Angiotension-Converting Enzyme (ACE) Inhibitors: captopril (Capoten), PO to lower total peripheral resistance by inhibiting angiotensin-converting enzyme. Vasodilators: hydralazine (Apresoline), PO to relax smooth muscle of arterioles, resulting in reduced peripheral resistance. COMMON NURSING DIAGNOSES See FLUID VOLUME EXCESS 1 of 7 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=12&FxId=123&Sessi. Related to: (Specify: compromised regulatory mechanisms, excessive sodium intake.) Defining Characteristics: (Specify: edema, weight gain, intake greater than output, blood pressure changes, altered electrolytes—give data.) See IMBALANCED NUTRITION: MORE THAN BODY REQUIREMENTS Related to: Excessive intake in relationship to metabolic need. Defining Characteristics: (Specify: weight 10% over ideal for height and frame, dysfunctional eating pattern, hereditary predisposition—provide data.) See INEFFECTIVE TISSUE PERFUSION: RENAL Related to: (Specify: interruption in renal, arterial, or venous flow.) Defining Characteristics: (Specify: edema, oliguria, hypertension.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Medications (diuretic). Defining Characteristics: (Specify: increased urinary output, sudden weight loss, hypokalemia, dry skin and mucous membranes.) ADDITIONAL NURSING DIAGNOSES RISK FOR INJURY Related to: Internal regulatory function. Defining Characteristics: (Specify: uncontrolled hypertension; neurologic status [blurred vision, headache, irritability, dizziness, papilledema]; future renal, heart, circulatory problems.) Goal: Child will not experience injury by (date/time to evaluate). Outcome Criteria √ Blood pressure will remain within appropriate range for child (specify range). √ Child denies headache, dizziness, or visual changes. NOC: Symptom Control INTERVENTIONS RATIONALES 2 of 7 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=12&FxId=123&Sessi. Assess BP (using a Doppler method on Provides accurate systolic and an infant and proper size cuff on diastolic readings to establish a child). Use a cuff that covers 2/3 pattern of elevations, although no of the upper arm and inflatable definite readings are used to bladder that encircles the child's diagnose hypertension in children. arm circumference (take an infant's BP in a supine position; take a child's BP with the child seated and the arm supported at the level of the heart); obtain readings when infant/child is at rest q 2h. Assess for headache, dizziness, nose- Indicates increased BP, although bleed, visual changes. symptoms in children are varied and some or none of the symptoms may be present. Provide quiet environment and reduce May increase BP by sympathetic activities, stress and stimuli. stimulation. Administer antihypertensives and Drug therapy is given diuretics as diuretics as prescribed (specify prescribed when BP does not respond drug, dose, route, and time). to nonpharmacologic methods of reducing it; control is managed with the use of one drug and cautious addition of another drug, depending on side effects produced and achieved reduction of BP (action). Teach medication administration Pharmacologic intervention to control including action, dosage, hypertension. frequency, side effects, importance of long-term therapy, physical and behavioral changes to report (specify). Demonstrate and have parents return Offers correct monitoring of BP for the demonstration of taking BP changes that might indicate need correctly and of maintaining a log for initiation and/or changes in of readings. treatments for children with chronic hypertension. Instruct parents to report any Provides opportunity to prevent sustained elevation of BP or neurologic impairment or other neurologic symptoms. complications. Reinforce that therapy is long term Provides realistic support and and of consequences of rationale to encourage compliance noncompliance (specify). of drug therapy. Praise child and family for Positive reinforcement enhances compliance with regimen. compliance and self-esteem. NIC: Teaching: Prescribed Medication Evaluation (Date/time of evaluation of goal) 3 of 7 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=12&FxId=123&Sessi. (Has goal been met? Not met? Partially met?) (What is child's BP? Does child deny headache, dizziness, and visual disturbances?) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE: HYPERTENSION Related to: Lack of information or experience about disease and treatment. Defining Characteristics: (Specify: parents, child verbalize need for information about nonpharmacologic treatments for hypertension.) Goal: Parents (and child) will gain information about hypertension. Outcome Criteria √ Parents (and child) verbalize correct understanding of underlying cause of hypertension. √ Parents (and child) verbalize understanding of treatment plan for hypertension (specify, e.g., drugs, diet, etc.). NOC: Knowledge: Treatment Regimen INTERVENTIONS RATIONALES Assess knowledge of disease, causes Provides baseline information. and methods to control disease. Provide information and Ensures understanding based on explanations in clear language; readiness, aids reinforce use pictures, pamphlets, video learning. tapes, models in teaching about disorder, causes and risk factors. Instruct and assist in planning Weight reduction and restricted dietary menu that includes sodium, fat, and cholesterol restrictions that help reduce BP intake may be part of the (specify). medical regimen. Suggest activity and exercise plan Assists in weight reduction and specific to child's needs and contributes to lowering BP. interests (swimming, cycling). Teach relaxation techniques, such Reduces stress that raises BP. as breathing, biofeedback (specify). Reinforce importance of follow-up Provides early detection of visits to physician. complication and evaluation therapy. Discuss long-term nature of medical Provides rationale for regimen and potential for acceptance of long-term care. cardiac, cerebral, and renal damage or complications that 4 of 7 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=12&FxId=123&Sessi. result from htn. Refer to stress, weight reduction, Provides specialized guidance nutritional or support groups or if needed to ensure counseling as needed (specify). compliance and success. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Specify what parents/child said about understanding of the cause and treatment of the hypertension. Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR HYPERTENSION 5 of 7 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=12&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: 6 of 7 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=12&FxId=123&Sessi. Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:48:31 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=12 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 2 - CARDIOVASCULAR SYSTEM CHAPTER 2.5 - HYPERTENSION Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 7 of 7 12/22/2006 7:18 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=13&FxId=123&Sessi. CHAPTER 2.6 - KAWASAKI DISEASE INTRODUCTION Kawasaki Disease, or mucocutaneous lymph node syndrome, is an acute vasculitis of unknown cause. Most cases occur in children less than 5 years of age. The disease is self-limiting, but about 20% of those affected will develop cardiac sequelae (most commonly dilatation of the coronary arteries resulting in coronary aneurysms). The disease occurs in 3 phases: the acute phase is characterized by progressive inflammation of small blood vessels accompanied by high fever, inflammation of the pharynx, dry, reddened eyes, swollen hands and feet, rash, and cervical lymphadenopathy. In the subacute phase, the manifestations disappear, but there is inflammation of larger vessels and the child is at greatest risk for the development of coronary aneurysms. In the convalescent phase (6-8 weeks after onset), the clinical signs are resolved, but lab values are not completely normal. There are no diagnostic tests for Kawasaki disease, so the diagnosis is made on the basis of the child exhibiting at least 5 of 6 criterion manifestations. MEDICAL CARE Hgb/Hct: the child with KD is often anemic

at the time of diagnosis. WBC: may show leukocytosis with a "shift to the left" (increased immature white blood cells during the acute phase). Sedimentation Rate: elevated, reflecting inflammation, and lasts 6 to 8 weeks. Platelet Count: thrombocytosis and hypercoagulability occur in the subacute phase and gradually return to normal. Liver Enzymes: usually elevated during the acute phase. Echocardiogram: baseline and to monitor changes in myocardium and coronary arteries. Gamma Globulin: IV gamma globulin is given during the first 10 days of the illness; usually given as a single dose of 2g/kg over 10 to 12 hours. Aspirin (ASA): used for its anti-inflammatory and anticoagulant actions; given in large doses (80 to 100 mg/kg/day) while the child is febrile, and then 3 to 5 mg/kg/day until the platelet count returns to normal. COMMON NURSING DIAGNOSES See HYPERTHERMIA Related to: Inflammatory disease process. Defining Characteristics: High fever (specify degrees, not responsive to antipyretics or antibiotics.) See RISK FOR DEFICIENT FLUID VOLUME Related to: (Specify: decreased PO intake during uncomfortable acute phase, fluid losses through fever and increased metabolic rate.) 1 of 6 12/22/2006 7:19 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=13&FxId=123&Sessi. Defining Characteristics: (Specify, e.g., refusal to take PO fluids, oliguria, poor skin turgor, dry mucous membranes, weight loss, provide data.) ADDITIONAL NURSING DIAGNOSES PAIN Related to: Inflammatory process (dry mucous membranes, conjunctivitis, pharyngitis, fever, joint pain, swollen hands and feet). Defining Characteristics: (Specify: crying, extreme irritability, refusal to play, cries when being touched or moved, increased rating on pain scale.) Goal: Child will experience less pain by (date/time to evaluate). Outcome Criteria √ (Specify, e.g., client is not crying, is playing, has relaxed facial features, allows touch, pain rating is less than before interventions [give number].) NOC: Pain Control INTERVENTIONS RATIONALES Assess level of pain by observation Provides information upon which (crying, grimacing, vocal accurate assessments of pain expressions of pain), using pain and treatment effectiveness assessment scales, and by obtaining can be based. relevant pain information from parents about child's expression of pain. Apply cool cloths to skin, lotion, Decreases skin discomfort. and soft, loose clothing on child. Apply lubricating lip ointments and Moistens dry oral mucosa to glycerin swabs to the oral mucosa; decrease discomfort and offer cool liquids and soft foods. promote oral intake. Keep child's room quiet and semidark. Promotes rest; darkness decreases eye discomfort caused by conjunctivitis. Disturb child as little as possible; Movement causes discomfort. when necessary, handle gently and avoid unnecessary handling. Administer IV gamma globulin and high Decreases inflammatory process dose ASA therapy as directed and helps decrease fever. (specify doses, routes times). Explain to parents reason for child's Promotes understanding and discomfort/irritability; ask cooperation; provides parents for information on child's valuable assessment data. expression of pain. Explain to parents that irritability Promotes understanding and may persist for up to 2 months; allows parents to anticipate that peeling skin on hands and feet needs. is normal and not painful. 2 of 6 12/22/2006 7:19 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=13&FxId=123&Sessi. If child has joint pain, explain to Persistent joint pain is not parents that it may persist for uncommon; ROM with heat helps several weeks; passive ROM increase flexibility. exercises in a warm bath may help. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Specify: Is child crying? Describe activity of child; what is pain ranking? Use quotes if possible.) (Revisions to care plan? D/C care plan? Continue care plan?) ANXIETY Related to: Acute, serious illness of unknown origin with possible cardiac sequelae. Defining Characteristics: (Specify: verbalization of anxiety, use quotes.) Goal: Client will experience decreased anxiety by (date/time). Outcome Criteria √ Parents verbalize decreased anxiety levels. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess anxiety level of parents. Ask Assessment provides baseline them to rank their anxiety on a information for the design of scale from 1 to 5 with 1 being no interventions. anxiety. Encourage parents to express their Encouragement and reassurance help feelings freely. Reassure parents the parents to identify and that some anxiety is appropriate regain control of their when their child is ill. emotions. Provide information about the disease Ensures understanding; the unknown (the unknown etiology, the disease etiology helps allay any guilt phases and manifestations, parents may have concerning the diagnostic tests and treatments). child contracting the disease. Support parents in their efforts to Provides support to parents during comfort their irritable child; a stressful event. encourage them to "take a break" while the nurse cares for the child; 3 of 6 12/22/2006 7:19 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=13&FxId=123&Sessi. reassure parents that irritability is a manifestation of Kawasaki disease and that they should not feel embarrassed or guilty. Monitor child closely during IV gamma Gamma globulin is a blood product globulin administration and requires the same close (temperature, pulse, BP). Stop the observation for safe infusion and report immediately any administration to prevent a signs of reaction (chills, fever, reaction; this reassures parents dyspnea, nausea/vomiting). that their child is receiving appropriate care. Explain to parents that touching the Provides information parents need child may cause pain; demonstrate to give comfort to their child. gentle handling of child as needed. Explain to parents that the child may Helps ensure child will receive have recurrent fever at home and needed care at home. Empowers demonstrate how to take the child's the parent and decreases anxiety temperature and when to notify associated with uncertainty. physician (temp. greater than 38.4° C/101° F). Demonstrate ASA administration to Helps ensure safe, proper parents and instruct them to report administration of ASA at home. any signs of toxicity (tinnitus, Empowers parents. headache, dizziness, or confusion). Explain that ASA may cause easy bruising and that the ASA should be stopped and the physician notified if child exposed to chickenpox or influenza (risk of Reye's syndrome). Assist parents to make any referral Assistance helps decrease anxiety. (specify) and follow-up appointments for child. NIC: Anticipatory Guidance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents specify decreased levels of anxiety? Use quotes if possible.) (Revisions to care plan? D/C care plan? Continue care plan? FLOW CHART FOR KAWASAKI DISEASE 4 of 6 12/22/2006 7:19 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=13&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. 5 of 6 12/22/2006 7:19 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=13&FxId=123&Sessi. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:49:01 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=13 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 2 - CARDIOVASCULAR SYSTEM CHAPTER 2.6 - KAWASAKI DISEASE Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 6 of 6 12/22/2006 7:19 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=14&FxId=123&Sessi. CHAPTER 2.7 - ACUTE RHEUMATIC FEVER INTRODUCTION Acute rheumatic fever is an autoimmune disease responsible for cardiac valve disease or rheumatic heart disease. It is associated with infections caused by the group A streptococcus and occurs about 2 to 6 weeks following a streptococcal upper respiratory infection. It is prevented by adequate treatment of the infection with appropriate antibiotic therapy within 9 days of onset of streptococcal infection before further complications can occur. Because rheumatic heart disease does not occur after only one attack and children are susceptible to recurrent attacks of rheumatic fever, it is vital that an initial episode is diagnosed and treated, and that long-term prophylactic therapy (5 years or more) is given following the acute phase. There is no specific test for rheumatic fever; the diagnosis is based upon the manifestations using the revised Jones criteria as a guideline. Jones criteria consist of major manifestations (polyarthritis, carditis, chorea, subcutaneous nodules, and erythema marginatum) and minor manifestations (fever, arthralgia, ECG and laboratory changes). The presence of 2 major manifestations, or 1 major and 2 minor manifestations, supported by evidence of a preceding group a streptococcal infection is indicative of acute rheumatic fever. MEDICAL CARE Antibiotics: benzathine penicillin G IM, penicillin G potassium (Pentids solution), ampicillin (Amcill tablets, suspension or pediatric drops) PO or erythromycin (Ilosone tablets, chewables, suspension PO if penicillin-sensitive). Followed by: penicillin G benzathine (Bicillin) IM monthly or penicillin G potassium (Pentids) PO daily as long-term therapy. Anti-inflammatory/Antipyretic/Analgesic: aspirin (acetylsalicylic acid tablets, suspension or liquid) PO to reduce temperature and reduce inflammatory process by inactivitating the enzyme required for prostaglandin synthesis, that contributes to inflammatory process. Electrocardiogram: reveals prolonged P-R interval. Antistreptolysin-O Titer: reveals increase 7 days after streptococcal infection with elevation above 330 Todd units, indicating recent infection. Complete Blood Count: reveals increased WBC in presence of infectious process. Erythrocyte Sedimentation Rate: reveals increase in presence of inflammatory process in rheumatoid disease. C-reactive Protein: reveals increase during inflammatory process and may be done in place of ESR. Throat Culture: reveals presence of streptococci, Group A. COMMON NURSING DIAGNOSES See HYPERTHERMIA Related to: Illness or inflammatory disease. Defining Characteristics: (Low-grade increase in body temperature above normal range, temperature tends to spike in late afternoon, specify for child.) 1 of 7 12/22/2006 7:19 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=14&FxId=123&Sessi. See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food because of anorexia, increased metabolic rate and/or chores (specify). Defining Characteristics: (Specify: anorexia, fatigue, weight loss, abdominal pain, give figures.) See IMPAIRED PHYSICAL MOBILITY Related to: Pain and discomfort. Defining Characteristics: (Specify: verbalizes joint pain of polyarthritis.) Related to: Neuromuscular impairment from chorea. Defining Characteristics: Decreased muscle control and strength, clumsiness, uncoordination, sudden and aimless movement of extremities, bed rest protocol (describe activity). ADDITIONAL NURSING DIAGNOSES PAIN Related to: Inflammation, arthralgia. Defining Characteristics: (Specify: verbal description of pain, use scale, guarding and protective behavior of painful joints, edema, redness, heat at affected joints.) Goal: Child will experience less pain by (date/time to evaluate). Outcome Criteria √ Child verbalizes pain less than (specify) on scale of 1 to 10. √ Child appears relaxed without guarding. √ Joints are not swollen, red, or warm. NOC: Pain Control INTERVENTIONS RATIONALES Assess child's perception of pain Provides data about degree of using an appropriate scale pain the child is experiencing. (specify) q 2 to 3 hours. Assess behavior changes, such as Nonverbal responses to pain that crying, restlessness, refusal to are age-related as child or move, irritability, aggressive or infant may be unable to dependent behavior. describe pain; fear and anxiety 2 of 7 12/22/2006 7:19 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=14&FxId=123&Sessi. associated with pain causes changes in behavioral responses. Assess severity of pain, joints Provides information regarding involved, level of joint pathologic changes in joints; movement. joint involvement is reversible, usually affecting large joints, such as knees, hips, wrists, and elbows; an increase in numbers of affected joints occurs over a period of time. Administer analgesic and anti- Relieves pain, edema in joints inflammatory agents as ordered and promotes rest and comfort (specify drugs, dose, route, and (action of drugs). times), and inform child that the medication will decrease the pain; administer a sustained- action analgesic before bedtime or 1 hour before anticipated movement. Maintain bed rest during the acute Promotes comfort and reduces stage of disease. joint pain caused by movement. Elevate affected extremities above Promotes circulation to the heart level of heart. to relieve edema. Change position q 2h while Prevents contractures and maintaining body alignment. promotes comfort. Move gently and support body parts; Prevents additional pain to minimize handling of affected affected parts. parts as much as possible. Apply bed cradle under outside Prevents pressure on painful covers over painful parts. joints. Provide toys, games for quiet, Provides diversionary activity to sedentary play (specify for distract from pain. child). Use nonpharmacologic measures to Provides additional measures to decrease pain (distraction, decrease pain perception. cutaneous stimulation, imagery, relaxation,

heat application). Inform of limited activity or Prevents increase or exacerbation amount of joint movement allowed. of pain. Teach parents and child of need for Controls pain, and allows for analgesia and that it will help uninterrupted sleep and him/her to feel better. activity within tolerance level. Reassure parents and child that Reduces anxiety associated with joint involvement is temporary, fear of permanent damage. that pain and edema will subside, and that joints will return to normal size. Teach parents in body positioning Promotes comfort and prevents and handling of affected parts. pain and contractures while on 3 of 7 12/22/2006 7:19 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=14&FxId=123&Sessi. enforced bed rest. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Specify pain-rating on scale of 1 to 10; does child appear relaxed without guarding? Are joints not swollen, red, or warm? Describe.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: Chronic recurrence of disease. Defining Characteristics: None, as this is a potential diagnosis. Goal: Child will not experience recurrence of infection. Outcome Criteria √ Absence of occurrence of reinfection. √ Child is afebrile; no complaints of discomfort. √ Child takes medications as ordered. NOC: Risk Control INTERVENTIONS RATIONALES Assess parents' ability to provide Long-term antibiotic therapy (as long long-term treatment with prescribed as 5 years) as a preventive measure antimicrobials; daily oral may be difficult. administration or monthly intra- muscular injections. Assess for chest pain, dyspnea, Signs and symptoms of carditis, which cough, tachycardia during sleep, may lead to endocarditis causing friction rub, gallop during acute vegetation that becomes fibrous at stage of disease. the valve areas that is at increased risk with repeated infections. Administer antibiotic therapy during Inhibits cell wall synthesis of acute phase of disease as ordered microorganisms, destroying (specify drugs, dose, route, and causative agent. times). 4 of 7 12/22/2006 7:19 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=14&FxId=123&Sessi. Instruct in long-term antibiotic Therapy starts after acute phase and regimen, need for protection before medical supervision is needed for dental work or any invasive life as rheumatic fever may recur; procedure, and inform of importance a large percentage of children who to prevent recurrence. have had the disease have heart disease later in life. Teach to report to physician any May indicate recurrence of the upper respiratory infections, disease or need to change or adjust elevated temperature, joint pain, medication. or inability to continue antibiotic therapy. NIC: Infection Protection Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is child's temperature? Does child complain of discomfort? Is child taking the medications as ordered?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR ACUTE RHEUMATIC FEVER 5 of 7 12/22/2006 7:19 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=14&FxId=123&Sessi. 6 of 7 12/22/2006 7:19 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=14&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:49:24 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=14 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 2 - CARDIOVASCULAR SYSTEM CHAPTER 2.7 - ACUTE RHEUMATIC FEVER Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 7 of 7 12/22/2006 7:19 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=15&FxId=123&Sessi. UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.0 - RESPIRATORY SYSTEM: BASIC CARE PLAN INTRODUCTION The respiratory tract is a common site of major and minor disorders in infants and children, and any alteration in respiratory structure or function has a profound effect on the ability to supply the body with oxygen and remove carbon dioxide. A constant supply of oxygen is necessary to sustain organ function and survival, and any decrease in or cessation, obstruction, and infection, can compromise airway patency and pattern. This in turn changes the respiratory rate and efficiency. This tendency gradually decreases after the age of five. Each stage of life and its associated changes resulting from growth and developmental patterns establish different pulmonary parameters and susceptibility to diseases. Although the system generally functions the same as in an adult, anatomic changes that occur with growth influence the way that the infant or child responds to acute or chronic illnesses related to this system. GROWTH AND DEVELOPMENT CHEST STRUCTURE AND BRONCHOPULMONARY MOVEMENT • Chest shape and anteroposterior diameter: Infant: rounded chest where diameter equals transverse diameter; School-age: changes gradually to lateral diameter ratio of 1:2 or 5:7 as chest assumes a more flattened anteroposterior diameter with growth. • Narrow, smaller lumen of airway system with increased airway resistance until age of five years. • Ability to respond to irritating stimuli by age 4 to 5 months as smooth muscle develops in airways, gradually reaching smooth muscle development of an adult by age of one year. • Glottis has more cephalad location in the infant than in the child; epiglottis is longer, and the narrowest part of the larynx located at the same level as the cricoid cartilage; larynx grows slowly during infancy and childhood, with a spurt of growth after childhood phase during preadolescence (voice change). • Airways grow faster than cervical and thoracic spine, causing a descent of the larynx and trachea; the tracheal bifurcation gradually descends from opposite T3 in the infant to T4 by the end of the growth period, and the cricoid cartilage descends from C4 in the infant to C6 by the end of the growth period. • Diaphragm in the infant is attached higher in front and is longer, causing a decreased ability to contract with the same force of an older infant or child. • Lung growth changes from globular to lobular shape by 12 years of age. • Lung growth produces an increase in alveoli numbers and size as septa in the alveoli develop, divide, and increase their numbers at each terminal 1 of 13 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=15&FxId=123&Sessi. airway. • Branching of terminal bronchioles is increased as alveoli are increased as the child grows. • Collateral pathways develop between bronchioles and growth pores in alveolar walls during child's growth. BREATHING PATTERN AND VENTILATORY FUNCTION • Respiratory rate (ratio to pulse is 1:4) Infant: 30 to 60/minute Toddler: 25 to 40/minute Preschool: 22 to 34/minute School age: 18 to 30/minute Rate decreases as metabolic needs decrease. • Respiratory depth (chest expansion) Infant: 2 to 4 inches Toddler: 4 to 6 inches Preschool: 6 to 8 inches School age: 9 to 10 inches • Respiratory pattern: Infant: obligate nasal and diaphragmatic breathing during first year of life; School age: changes gradually from infancy through childhood to a more thoracic breathing for girls and a more abdominal breathing for boys—volume of inspired air increases as lungs grow in size, which results in a decreased amount of oxygen taken in and an increased amount of carbon dioxide expired. • Increased surface area available for gas exchange as alveoli increase in numbers and size. • Changes in compliance with age, from high compliance in the infant with a more pliant rib cage to gradually decreasing to normal compliance level; chest structure changes with growth. • Arterial blood gas values: pH: 7.35 to 7.45 2 of 13 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=15&FxId=123&Sessi. pO2: 80 to 100 mm Hg (pressure of dissolved oxygen in the blood) pCO2: 35 to 45 mm Hg (pressure of dissolved carbon dioxide in the blood) HCO3: 22 to 28 mEq/L (bicarbonate level in the blood to reveal buffering effect on acid) NURSING DIAGNOSES INEFFECTIVE AIRWAY CLEARANCE Related to: (Specify: tracheobronchial infection, obstruction, secretions.) Defining Characteristics: (Specify, e.g., abnormal breath sounds: fine or coarse crackles, rhonchi, wheezes, changes in rate or depth of respirations, tachypnea, cyanosis, fever, provide data.) Related to: Decreased energy and fatigue. Defining Characteristics: (Specify, e.g., ineffective cough with or without sputum, labored respirations, inability to feed self, sleeplessness, lack of activity, weakness.) Goal: Infant/child will experience improved airway clearance by (date/time to evaluate). Outcome Criteria √ Return of respiratory status to baseline parameters for rate, depth and ease (specify). √ Breath sounds clear bilaterally. √ Ability to cough up and remove secretions that are thin and clear. NOC: Respiratory Status: Airway Patency, Ventilation INTERVENTIONS RATIONALES Assess respirations for rate (count for Reveals rate and type of respirations one full minute), depth and ease, (baselines or deviations) that are presence of tachypnea (specify), related to age and size of the dyspnea and if it occurs during sleep infant/child, changes that indicate or quiet time; note panting, nasal obstruction and consolidation of flaring, grunting, retracting, airways and lungs resulting in a slowing, deep (hyperpnea) or shallow decrease in lung surface for gas (hypopnea) breathing, stridor on diffusion, extreme changes in depth inspiration, head bobbing during sleep are abnormal, head bobbing indicates (specify frequency). dyspnea in the infant and fatigue causing neck flexion, grunting indicates respiratory distress. Assess breath sounds by auscultation, Provides indication of patent airways 3 of 13 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=15&FxId=123&Sessi. consolidation by percussion and by auscultation, revealing crackles fremitus (specify when). heard in the presence of secretions (fine and coarse), rhonchi (audible and palpable) in larger airway obstruction and wheezes in small bronchiolar narrowing (inspiration and expiration), diminished breath sounds in presence of decreased airflow and lung consolidation; indication of consolidation by presence of dullness on percussion and increased fremitus, decreased functional lung area by presence of tympany on percussion. Assess skin color changes, distribution Reveals presence and degree of and duration of cyanosis (nail beds, cyanosis, indicating an uneven skin, mucous membranes, circumoral) or distribution of gas and blood in the pallor (specify frequency). lungs, and alveolar hypoventilation resulting from airway obstruction, the weakness of muscles used in respiration or respiratory center depression. Assess cough (moist, dry, hacking, Reveals characteristics of cough as an paroxysmal, brassy, or croupy): onset, indication of a respiratory condition duration, frequency, if occurs at that may be produced by infection or night, during day, or during activity; inflammation; small and narrow mucus production: when produced, airways of an infant/child and the amount, color (clear, yellow , green), difficulty to cough up secretions cause consistency (thick, tenacious, obstruction from the stasis of secretions, frothy); ability to expectorate or if which lead to infection and change in swallowing secretions, stuffy nose or respiratory status. nasal drainage. Elevate head of bed at least 30° for Positioning facilitates chest expansion child and hold infant and young child and respiratory efficiency by in lap or in an upright position with reducing pressure of abdominal organs head on shoulder; older child may sit on diaphragm. up and rest head on a pillow on overbed table (specify); check child's position frequently to ensure child does not slide down in bed. Reposition on sides q 2h; position child Prevents accumulation and pooling of in proper body alignment. secretions. Provide fluids at frequent intervals Maintains hydration status, and clear over 24-h time periods, specify liquids liquefy and mobilize amounts; encourage clear liquids, and secretions; milk tends to thicken avoid milk. secretions. Provide for periods of rest by Prevents unnecessary energy expenditure organizing procedures and care and resulting in fatigue. disturbing infant/child as little as possible in acute stages of illness. Perform postural drainage between meals Promotes removal of secretions and using gravity, percussion, and sputum from airways; percussion and 4 of 13 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=15&FxId=123&Sessi. vibration unless contraindicated; hold vibration loosen and dislodge infant on lap; support child with secretions, and gravity drains the pillows. Teach parents. positioning. airways and lung segments through Assist to perform deep breathing and Promotes deeper breathing by enlarging

coughing exercises in child when in a tracheobronchial tree and initiating relaxed position for postural drainage cough reflex to remove secretions. unless procedures are contraindicated; use incentive spirometer in older child, blowing up balloon, blowing bubbles, blowing a pinwheel or blowing cotton balls across the table in younger child (specify). Suction nasal and/or oropharyngeal Removes secretions when cough is passages, if needed and appropriate, nonproductive (older child if unable using correct catheter and method, to regulate cough or breathe through amount of negative pressure, and time mouth); if nose obstructed by mucus limits (specify); orotracheal with the (infant or young child); type of administration of oxygen before suctioning dependent on amount, and after suctioning if needed; use bulb ability to drain or cough up, breath syringe to suction mucus from infant's sounds in upper airways; prolonged nose; catheter size is age dependent suctioning causes vagal stimulation, (specify), maximum negative pressure oxygen desaturation, and bradycardia, of 60 to 90 cm H2O with time limit of and the use of high pressure damages 5 seconds for infant, and 90 to 110 cm the mucous membrane lining of airways. H2O with 5 second time limit for child. Administer pain medications as ordered Promotes comfort during deep breathing (specify drug, dose, route, and time); exercises and coughing to aid in the assess level of pain using appropriate removal of secretions. pain assessment tools (specify). Provide mouth care qid and after Prevents drying of oral mucous suctioning. membranes. Provide toys, games for quiet play, and Prevents excessive energy expenditure a quiet environment (specify). and need for additional oxygen consumption, which changes respiratory status while still providing moderate activity and diversion of play. Place airway maintenance equipment and Provides immediate access to emergency supplies at bedside (resuscitation equipment for interventions to treat bag, oxygen and suction equipment, airway obstruction if needed. endotracheal tube, tracheostomy tube, and supplies). Administer medications (mucolytics, (Specify drug action, e.g., treats bronchodilators, antibiotics, conditions affecting secretions, expectorants, decongestants, and/or infection by liquefying secretions antihistamines) orally, parenterally, and enhancing outflow and removal of via aerosol therapy with hand-held secretions (mucolytics, measured-dose inhaler, small volume expectorants), relieving nebulizer, IPPB according to physician bronchospasms (bronchodilators), order (provides specifics). destroying infectious agents by interfering with cell way synthesis 5 of 13 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=15&FxId=123&Sessi. (antibiotics), reducing allergic responses and discomfort of nose stuffiness (decongestant, antihistamines), and by suppressing cough (cough suppressants) unless cough is desired to bring up secretions.) Instruct parents/child in handwashing Prevents transmission of microorganisms techniques. from touching or handling supplies, touching face of child by parent(s)/ child without handwashing. Instruct parents/child to avoid contact Prevents transmission of microorganisms with those who have respiratory via airborne droplets. infections. Inform parents of need to maintain or Maintains hydration. increase fluids, type of fluids to include and avoid, to offer small amounts (q 1h to infant and 50 to 100 ml to child q 2h) during waking hours using small cup or straw. Teach the importance of physical Promotes better tolerance than exercise; activities with short burst endurance exercises. of energy (baseball, sprinting, skiing) are recommended. Recommend swimming as a form of physical Promotes saturation of inhaled air with exercise. moisture; exhaling underwater prolongs expiration and improves end expiratory pressures. Teach parents to use bulb syringe to Removes secretions in those too weak or remove mucus from infant's nose, unable to cough up secretions, demonstrate and instruct in removing mucus from nose of infant oropharyogeal suctioning if enhances breathing (obligate appropriate; allow return breather). demonstration. Teach parents and possibly older child Ensures compliance with correct drug (specify) administration of dosage and other considerations for medications via proper route with name administrations for desired results, and action of each drug: dosage; why and what to do if side effects occur. given; frequency; time of day or night; side effects to report; how to administer in food—crushed, chewable, by measured dropper, or other recommended form; and method (nose drops, inhaler). Instruct parents and child to administer Promotes proper administration and aerosols with use of hand-held independence of child depending on inhaler, small volume nebulizer using age and ability. oral or mask breathing apparatus; assembling of devices, cleaning and care of reusable supplies and equipment (specify). 6 of 13 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=15&FxId=123&Sessi. NIC: Airway Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is respiratory rate, depth, and ease? Are breath sounds clear bilaterally? Is child able to cough, are secretions thin and clear?) (Revisions to care plan? D/C care plan? Continue care plan?) INEFFECTIVE BREATHING PATTERN Related to: Inflammatory process. Defining Characteristics: (Specify: shortness of breath, tachypnea, fremitus.) Related to: Decreased lung expansion. Defining Characteristics: (Specify: apnea, dyspnea, respiratory depth changes.) Related to: Tracheobronchial obstruction. Defining Characteristics: (Specify: dyspnea, head bobbing in infant, drooling, tachypnea, abnormal arterial blood gases, cyanosis (skin, circumoral, mucous membranes), nasal flaring, respiratory depth changes, use of accessory muscles and retractions, altered chest excursion, prolonged expiratory phase, grunting, apnea during sleep, anxiety, air hunger, sitting up with mouth open to breathe, stridor on inspiration, persistent cough, throat edema.) Goal: Infant/child will experience an effective breathing pattern by (date/time to evaluate). Outcome Criteria √ Return of respiratory status to baseline parameters for pattern rate, depth, and ease (specify). √ Effective breathing effort and improved chest expansion. NOC: Respiratory Status: Airway Patency, Ventilation INTERVENTIONS RATIONALES Assess respirations for rate (count for Reveals rate and type of respirations one full minute), pattern, depth, and (baselines or deviations) that are ease; presence of tachypnea related to age and size of the (specify), dyspnea and use of infant/child and presence of anxiety accessory muscles and retractions and disease processes, changes in (intercostal, subcostal, substernal, patterns indicate the acuteness of a suprasternal), nasal flaring; note condition and the respiratory 7 of 13 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=15&FxId=123&Sessi. expiratory phase, chest expansion, function that result from infection periods of apnea, head bobbing in and obstruction; retractions that infant during sleep. become severe are responses to a decrease in intrathoracic pressure that may extend to suprasternal area if lung consolidation is severe, nasal flaring occurs as the work of breathing increases, head bobbing occurs with dyspnea in infants. Assess configuration of chest by Reveals an increased anteroposterior palpation; auscultate for breath ratio common in children with sounds that indicate a movement chronic respiratory disease that restriction (absent or diminished, results from hyperexpansion of the crackles or rhonchi). airways. Assess skin for pallor or cyanosis, Reveals presence of hypoxemia causing distribution and duration of cyanosis cyanosis from an uneven distribution (nail beds, skin, mucous membranes, of gases and blood in the lungs, and circumoral). alveolar hypoventilation caused by airway obstruction, weakness of muscles used in respirations. Assess for cough, pain when coughing, Cough is an indication of a characteristics of cough and sputum, respiratory condition and if ability to mobilize and bring up excessive may cause chest pain and secretions when amounts increase. interfere with respirations, accumulation of mucus in airways affects respiration if obstruction is present. Position with head elevated at least Facilitates chest expansion and 30° or seated upright with head on respiratory efficiency by reducing pillows; position on side if more pressure of abdominal organs on comfortable; tripod position for the diaphragm; position of comfort is child with epiglottitis; avoid tight age-related and dependent on degree clothing or bedding; for child with of dyspnea. low muscle tone, use pillows and/or padding to maintain positioning. Perform deep breathing exercises and Strengthens intercostal and abdominal upper body exercises (isometric). muscles, and diaphragm, which enhances breathing and prolongs expiratory phase. Assess child's pain and administer Promotes improved oxygenation. analgesics as prescribed (specify drug, dose, route, and time); use a pain assessment tool appropriate to the child's age (specify) and developmental level; assess and record child's response to pain control measures; provide age- appropriate diversional activities as tolerated (specify). Pace activities and exercises, and Prevents changes in respiratory allow for rest periods and energy pattern brought about from exertion conservation. and fatigue. 8 of 13 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=15&FxId=123&Sessi. Monitor blood gas levels and provide Maintains oxygen level in blood to supplemental oxygen via hood, tent, maintain tissue and organ function, cannula, or face mask as needed if amount and type of oxygen hypoxia results from inadequate administration dependent on hypoxia breathing pattern and ventilation; if and changes in mentation. an infant is apneic, provide access at bedside at all times. Administer bronchodilators via oral, Relieves bronchospasms that affect subcutaneous, or aerosol therapy; respirations (tachypnea, rhonchi), antibiotics, or sedatives prevents or treats infection, (cautiously) via oral therapy if promotes rest and reduces anxiety to respiratory efficiency is not enhance breathing; prevents reduced; antiasthmatics and steroids asthmatic attack and reinforces body via oral or aerosol therapy as defenses against allergic reactions ordered (specify). (action of drug). Assess family's responses to child's Parents know their child's behaviors, illness and/or hospitalization; temperament, and reactions to utilize the principles of family- previous illnesses and treatments centered caregiving, which encourages better than the health care the parents to participate in their professionals; utilizing the child's illness within their comfort parent's knowledge will promote level. understanding and improved caregiving. Teach parents and child in handwashing Prevents transmission of and when to perform; disposal of microorganisms to child from tissues; covering mouth and nose when inanimate objects or airborne coughing to avoid those with droplets. respiratory infections. Demonstrate and instruct to parents and Facilitates ease of breathing. child in possible positions for comfort and ventilation during activities and sleep. Inform parents and child of activity Reduces potential dyspnea and fatigue. restrictions and to avoid any activities beyond tolerance and energy level. Instruct child in relaxation exercises, Reduces anxiety in older child which quiet play, and controlled breathing. increases respiratory rate. Inform parents and child to avoid Prevents responses that change allergens, changes in environmental respiratory pattern. temperatures, humidity, and pollutants, effect of pets, dust, dirty filters, plant odors, and other irritants in the home. Teach parents about oxygen Supplies oxygen when needed in a administration (correct rate and correct and safe manner. method specify) and safety measures (fire prevention). Instruct and demonstrate medication Ensures accurate and safe regimen to parents (and older child) administration for medications for and include route, dosage, time, optimal effect. action, what to expect, and how to 9 of 13 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=15&FxId=123&Sessi. administer according to form prescribed (specify). Teach parents to avoid giving child Prevents any undesirable interactions over-the-counter medications unless with prescribed drugs. advised by physician. Instruct parents in disinfection, care Reduces potential for infection and of reusable supplies, and care of preserves equipment and supplies for equipment used to administer long-term use. medications. (Teach and demonstrate use of apnea Provides alert system for parents to monitor to parents (application, monitor changes in respirations and setting, alarms, electric source) and heart rate of infant with apnea how to perform cardiopulmonary episodes. resuscitation on infant if needed). NIC: Airway Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is respiratory rate, depth, and ease? Are breath sounds clear bilaterally? Is child able to cough, are secretions thin and clear?) (Revisions to care plan? D/C care plan? Continue care plan?) IMPAIRED GAS EXCHANGE Related to: Ventilation perfusion imbalance. Defining Characteristics: (Specify: ABGs.) Goal: Child will experience improved gas exchange by (date/time to evaluate). Outcome Criteria √ Arterial blood gases within normal ranges for age (specify). NOC: Respiratory Status: Gas Exchange INTERVENTIONS RATIONALES Assess respiratory rate, depth, and Reveals respiratory effort, rate and ease, (count for one minute), depth (baselines or deviations), presence of dyspnea, tachypnea, chest symmetry of movements, and use of movement, periods of apnea (specify accessory muscles, which affect the frequency). amount of air that reaches the alveoli for ventilation process and 10 of 13 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=15&FxId=123&Sessi. diffusion of oxygen (external respiration). Monitor SaO2 continuously with pulse Reveals status of hypoxemia and oximeter alarms turned on (specify if hypercapnia and potential for using TCM to obtain TcPaO2 and respiratory failure: cyanosis

in TcPaCO2 levels). Assess ABGs for children results from hypoventilation pH, PaO2, PaCO2 as obtained. or an uneven distribution of gas and Observe nail beds, circumoral area, circulation through the lungs, and mucous membranes for development usually caused by disease and of cyanosis. breathing abnormalities; gas levels provide the basis for oxygen administration adjustment, need for position change; continuous monitoring by oximetry or transcutaneous electrode reduces need for arterial punctures to determine hypoxemia and hypercapnia. Assess for changes in consciousness and Reveals hypoxic state as oxygen level activity, presence of irritability in blood reduces, causing decrease of and restlessness. oxygen to brain. Place child in semi- or high Fowler's Promotes chest expansion and ease of position; orthopenic position for breathing, gas distribution, and older child unless contraindicated pulmonary blood flow, all of which (specify). enhance gas exchange. Administer humidified oxygen via hood Ensures adequate oxygen intake to (infant), tent (young child), maintain desired level; a PO2 of less cannula, or face mask (older child) than 60 mm Hg and PCO2 of more than at rate prescribed, and adjust 50 to 55 mm Hg may indicate need for according to blood gas levels repositioning, stimulation, (specify). suctioning, or ventilator support. Provide sedation for restlessness, Promotes rest and ease of respiratory irritability as ordered unless effort to support ventilation, respirations are depressed (specify especially if anxiety present (action drug, dose, route, and times). of drug). Observe for early stages of hypoxemia Promotes careful evaluation of early and effects on nervous system (mood signs and symptoms of insufficient changes, anxiety, confusion), alveolar ventilation and prevention circulatory system (tachycardia, of respiratory failure or arrest. hypertension), respiratory system (altered depth and pattern, dyspnea, retractions, grunting, prolonged expiration), gastro- intestinal system (anorexia). Discuss disease process, causes, signs Provides information about reason for and symptoms with parents and child how to control symptoms and promote appropriate to age. general health. Explain all procedures and use of Reduces anxiety, which reduces oxygen equipment to parents and child requirements in the child. appropriate to age. Teach and demonstrate oxygen Maintains oxygen levels with amounts administration showing correct device given, preventing hypoxia as well as to deliver O2, amount to deliver, oxygen, toxicity methods and amounts 11 of 13 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=15&FxId=123&Sessi. frequency, type of oxygen system, vary with age and condition of safety factors to parents; allow for infant/child. return demonstration. Instruct and demonstrate use of apnea Alerts parents to presence of prolonged monitor to parents; allow for return periods of apnea in infant in order demonstration of application, to prevent hypoxia and possible setting, alarms, power source, inform death. of when and how to respond to changes in respiration and heart rate. Teach parents of respiratory signs and Assessing and reporting prevents symptoms that must be reported potential for hypoxemia, hypercapnia, indicating blood gas imbalance: and more serious complications of fatigue, mental confusion, increasing respiratory failure. dyspnea and tachypnea. NIC: Respiratory Monitoring Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What are ABG values?) (Revisions to care plan? D/C care plan? Continue care plan?) COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning 12 of 13 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=15&FxId=123&Sessi. Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:49:48 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=15 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.0 - RESPIRATORY SYSTEM: BASIC CARE PLAN Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 13 of 13 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=16&FxId=123&Sessi. CHAPTER 3.1 - APNEA INTRODUCTION Apnea in the infant is the periodic absence of breathing for more than 15 seconds in the full-term or more than 20 seconds in the preterm infant. It may be associated with gastroesophageal reflux, seizures, sepsis or the impairment of breathing during sleep in the infant, although it is not uncommon to find no apparent causative factor. Apnea occurs during infancy and is usually resolved by one year of age without resulting in the death of the infant. The apparent life-threatening event (ALTE) that is indicative of apnea is not considered a cause of SIDS (sudden infant death syndrome), although the infant with apnea is at slightly higher risk. Both apnea and high-risk SIDS infants may be monitored by an apnea-monitoring device as a preventive measure. MEDICAL CARE Apnea Monitor: a device attached to the infant by electrodes placed on a belt that is wrapped around the infant's chest; alarms sound when respiratory or heart rate changes occur that are more or less than the rates set revealing apneic episodes. Oxygen Therapy: treats hypoxia during apneic periods. Chest X-ray: reveals respiratory infection if present. Electrocardiogram: reveals presence of arrhythmias caused by bradycardia associated with apnea. Electroencephalogram: reveals changes associated with seizures. Pneumocardiogram: reveals cardiorespiratory patterns of heart and breathing rates, nasal airflow, and oxygen saturation. Polysomnography: measures brain waves, eye movement, esophageal manometry, and end-tidal CO2 levels during sleep. pH Probe Study: 24-hour measurements of pH from a probe in the esophagus to reveal reflux. Upper Gastrointestinal X-ray: reveals reflux associated with apnea. Arterial Blood Gases: monitors respiratory function for pO2 and pCO2 changes resulting from abnormal ventilatory drive. Methylxanthines: a drug used to stimulate respiration; theophyline or caffeine. Metoclopramine (Cisapride): drug used to increase emptying a duodenum and tone of esophageal sphincter. Nasal CPAP: continuous positive airway pressure may be used for preterm-birth apnea thought to be related to collapse of airway. COMMON NURSING DIAGNOSES See INEFFECTIVE BREATHING PATTERN 1 of 7 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=16&FxId=123&Sessi. Related to: Impaired regulation. Defining Characteristics: (Specify: respiratory depth changes, apnea during sleep, cyanosis, abnormal arterial blood gases. See IMPAIRED GAS EXCHANGE Related to: Ventilation perfusion imbalance. Defining Characteristics: (Specify: preterm birth, hypoxia, apnea, bradycardia, hypercapnia, pallor.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food because of biologic factors. Defining Characteristics: Choking and gasping during feeding, apneic or cyanotic episodes, reflux. ADDITIONAL NURSING DIAGNOSES RISK FOR ALTERED PARENTING Related to: (Specify, e.g., adolescent parent.) Defining Characteristics: Verbalization of role inadequacy, inappropriate caretaking behaviors (use of apnea monitoring device, cardiopulmonary resuscitation), request for information about care of infant and parenting skills (specify). Goal: Parents will demonstrate necessary skills for caring for their child by (date/time to evaluate). Outcome Criteria √ Verbalized readiness to deal with apneic episodes of infant. √ Demonstrates correct application and operation of apnea monitor. √ Becomes proficient at infant cardiopulmonary resuscitation (CPR). NOC: Role Performance INTERVENTIONS RATIONALES Assess history of apnea, life- Reveals risk factors associated with threatening event of infant, SIDS of condition as basis for further siblings or cousins. evaluation. Assess for presence of apneic or Identifies apneic episodes of more cyanotic episodes, bradycardia, than 15 seconds in preterm or more upper respiratory infection, poor than 20 seconds in full-term feeding with choking during infant, associated factors, or feedings. potential for SIDS and need for 2 of 7 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=16&FxId=123&Sessi. monitoring. Assess parents' ability to participate Fear and anxiety common to parents of in apnea monitoring and/or CPR as an apneic infant; feelings of guilt intervention in event of episode. and inadequacy, fear of death of child presents obstacle to learning and interventions necessary for child's survival. Encourage and allow parents to express Identifies potential for isolation feelings about unmet needs and and social deprivation of mother, ability to meet and develop self- strategies to achieve realistic expectations. expectations. Encourage touching and play activities Enhances bonding process and positive between parents and infant. parental behaviors. Provide calm, supportive and positive Reduces anxiety for enhanced learning environment; encourage and praise of infant care procedures. positive parental behaviors. Provide written and/or pictorial Provides reference as reinforcement instructions for parents of step-by- of learning. step procedures for apnea monitoring and resuscitation. Demonstrate for parents, and allow for Apnea monitor may be prescribed by return demonstration, attaching physician for use in home for electrodes to belt and monitor, apneic and "near-miss" infants, applying belt to infant's chest, although use is controversial; setting monitor, testing monitor monitors cardiac and respiratory alarms, turning monitor on, removal activity with an alarm system that and care of monitor after use (add wakes parents when rates are not details). within prescribed boundaries; electrodes, lead wires, and cable pick up on breathing and heart activity signals and limit apnea time by sounding alarm. Teach parents safety issues of home Prevent electrical accidents related apnea monitoring: remove leads from to home monitor. infant when not attached to monitor; unplug power cord when cord is not plugged into monitor; use safety covers on electrical outlets to discourage siblings from inserting other objects. Demonstrate for parents and allow for CPR done to resuscitate infant with return demonstration of CPR on cessation of breathing and presence infant model; instruct both parents of cyanosis. and a family member in assessment of infant and need for CPR, correct mouth-to-mouth and cardiac compression techniques; supply written and pictorial instructions or booklet for review. Instruct parents to notify electric Provides for emergency services if company and nearest 911 unit that and when needed, including monitor is being used; provide alternate electric sources. 3 of 7 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=16&FxId=123&Sessi. telephone numbers for emergency services and instruct to keep near phone. Instruct other significant family Promotes positive coping as parents members (grandparents) and support can lessen continuous persons as to care for the child responsibility of home apnea with a home monitor, including CPR monitoring. (specify). Provide praise and support for parents Positive reinforcement and support as they learn to use the monitor and help the parents develop new develop skill in CPR. parenting skills and feel confident in their abilities as parents. Explain the difference between apnea Parental perception of the and SIDS. relationship between these conditions is often the basis for their fear of child's possible survival. Instruct parents to place healthy Decreases the risk of SIDS, according infants on their back during sleep; to research; the American Academy avoid soft surfaces and soft objects of Pediatrics recommends that (pillows) in the sleep environment. healthy infants be placed on their backs to sleep. Infants placed on their sides may roll to the prone position. Suggest referral to home care agency, Provides range of support and contact with family members and assistance, which helps to reduce friends, other support services anxiety and promote social (specify). activities. NIC: Role Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents verbalize readiness to handle apnea? Provide quotes. Did parents demonstrate correct application of apnea monitor? Are parents proficient at infant CPR?) (Revisions to care plan? D/C care plan? Continue care plan?) COMPROMISED FAMILY COPING Related to: Situational crisis. Defining Characteristics: (Specify: family expresses concern and fear about infant's apnea episodes, displays protective behavior disproportionate to infant's need to grow and develop, describes a preoccupation with monitoring of infant apnea, chronic anxiety.) 4 of 7 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=16&FxId=123&Sessi. Goal: Family will demonstrate adequate coping by (date/time to evaluate). Outcome Criteria √ Family members are able to express feelings and needs to each other. √ Family members identify three healthy coping mechanisms. NOC: Family Coping INTERVENTIONS RATIONALES Assess family anxiety level, Identifies information affecting erratic behaviors (anger, ability of family to cope with tension, disorganization) infant apnea and monitoring. perception of crisis situation. Assess family coping methods used Identifies need to develop new and perceived effectiveness. coping skills if existing methods are ineffective in changing exhibited behaviors. Encourage expression of feelings Reduces anxiety and enhances and provide factual information family's

understanding of about infant apnea. condition. Assist family to identify and use 3 Provides support for problem techniques to cope with and solve solving and management of problems and gain control over situation. the situation (specify suggestions). Reinforce appropriate coping Promote behavior change and behaviors. adaptation to care of infant during apnea. Suggest to parents that over- Enhances family understanding of protective behaviors may hinder condition and adverse effects of growth and development during behaviors. infancy. Reinforce need to maintain health Provides information about chronic of family members and social anxiety, fatigue, and isolation contacts. as result of infant care and about their effects on health and care capabilities of family. NIC: Family Integrity Promotion Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did family members express feelings and needs to each other? Specify. Which three healthy coping mechanisms did family members identify?) 5 of 7 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=16&FxId=123&Sessi. (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR APNEA COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. 6 of 7 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=16&FxId=123&Sessi. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:50:15 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=16 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.1 - APNEA Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 7 of 7 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=17&FxId=123&Sessi. CHAPTER 3.2 - ASTHMA INTRODUCTION Asthma in children is a reversible airway-reactive disease characterized by bronchospasm, increased mucus production, and edema of the mucosa of the bronchioles. The result is obstruction, air trapping, and respiratory distress. Asthma is the leading chronic disorder in children. Most children experience their first attacks between 2 and 7 years of age with the onset of the most severe cases occurring after the age of 7. The onset of an attack may be gradual or immediate; continuous, with wheezing present at all times; or spasmodic, with intermittent attacks separated by intervals without symptoms. As an attack progresses, alveoli that are hyperinflated and poorly ventilated may lead to impaired gas exchange, hypoxemia, hypercapnia, and eventual respiratory acidosis and failure. The two types of asthma are extrinsic (immune mechanisms) and intrinsic (imbalance in the autonomic nervous system), both of which affect the bronchial tissue and mast cell function that produce the characteristics symptoms of the disease. Status asthmaticus is an acute condition characterized by an asthma attack that fails to respond to treatment and continues and increases in severity. It requires hospitalization of the child. MEDICAL CARE Preventive Medications: cromolyn sodium (Intel), PO or inhalation for children >5 years old: an NSAID that inhibits release of bronchoconstrictors from mast cells; beta-adrenergic agonists: PO, (albuterol, terbutaline) or inhaled (salmetrol) as prophylaxis for exercise-induced asthma. Rescue Medications: corticosteroids: IV or possibly PO for short-term use to inflammation and airway obstruction; beta-adrenergic agonists: PO, IV (albuterol, terbutaline) or inhaled (salmetrol); methylxanthines (theophylline) PO, IV not usually used because of side effects and narrow margin of safety (toxicity at serum level >20 g/mL). Antibiotics: given PO or IV specific to organism identified in culture and in sensitivity test of sputum. Oxygen Therapy: treats hypoxemia as indicated by ABGs and is administered by tent, cannula, or face mask; use is usually reserved for status asthmaticus. Chest X-ray: may reveal hyperinflation, infiltrates, or other pulmonary conditions such as atelectasis or pneumonia. Pulmonary Function Testing; spirometry, peak expiratory flow rate (PEFR) compared with child's personal best flow rate. Measured in green (80-100% of personal best), yellow (50-80%), and red zones (<50% of personal best). Sputum Culture: reveals large numbers of eosinophils and crystalloid fragments. Arterial Blood Gases: reveals decreased pH, decreased pO2, and increased pCO2 as attack continues and ventilation perfusion imbalance occurs. Complete Blood Count: reveals increased WBC if infection present, increased eosinophils in differential count of more than 5%, increased Hgb and Hct. Skin Tests: done by scratch or intradermal to identify specific allergens for hypersensitization injection therapy for an older child. Provocative Inhalation Test: reveals specific allergens and level that precipitates symptoms. 1 of 11 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=17&FxId=123&Sessi. COMMON NURSING DIAGNOSES See INEFFECTIVE AIRWAY CLEARANCE Related to: Tracheobronchial obstruction, secretions. Defining Characteristics: (Specify: dyspnea; tachypnea; cough with or without sputum; uncontrollable cough that is hacking and paroxysmal, becomes rattling, and produces a clear, frothy sputum; abnormal breath sounds [wheezing on expiration and inspiration, fine and coarse crackles]; circumoral and nail bed cyanosis; fever; assuming orthopneic position.) See INEFFECTIVE BREATHING PATTERN Related to: Inflammatory process, tracheobronchial obstruction, anxiety. Defining Characteristics: (Specify: dyspnea, tachypnea, cough, nasal flaring, prolonged expiratory phase, intercostal and suprasternal retractions in infant, hyperresonance on percussion, shallow and irregular respirations, barrel chest configuration, abnormal ABGs, cyanosis, anxiety, restlessness, apprehension, speaks in short, broken phrases or unable to speak.) See IMPAIRED GAS EXCHANGE Related to: Ventilation perfusion imbalance. Defining Characteristics: (Specify: restlessness, irritability, hypoxemia, hypercapnia, confusion, somnolence.) See RISK FOR DEFICIENT FLUID VOLUME Related to: intake. Defining Characteristics: (Specify: difficulty in drinking during panting, tachypnea, and dyspnea; thirst; dry skin and mucous membranes; diaphoresis; insensible loss.) See SLEEP PATTERN DISTURBANCE Related to: Interrupted sleep. Defining Characteristics: (Specify: dyspnea, tachypnea, irritability, restlessness, inability to remain in prone or supine positions.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Chronic illness. Defining Characteristics: (Specify: anorexia, nausea, vomiting, weight loss, dyspnea and tachypnea preventing intake of food.) 2 of 11 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=17&FxId=123&Sessi. ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: Threat of or change in health status (specify). Defining Characteristics: (Specify: increased apprehension, fear with asthma attack, change in respiratory status, exposure to known or unknown allergens, tension and uncertainty about possible hospitalization for acute attack.) Goal: Client will experience decreased anxiety by (date/time to evaluate). Outcome Criteria √ Child verbalizes decreased anxiety. √ Child uses breathing exercises and relaxation techniques. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess level of anxiety before, Provides information about anxiety during, and after attack. level of child and parents as respirations become more difficult and fear of suffocation is present, and about fear of subsequent attacks. Provide calm, supportive, and Reduces anxiety and calming effect nonjudgmental environment, allows and eases respirations for especially during an attack. improved ventilation. Allow parents and child to express Provides opportunity to vent fears and concerns and to ask feelings and secure information questions about disease and what to reduce anxiety, especially if to expect. they know how to prevent or reduce frequency of attacks. Prepare parents and child before all Relieves anxiety caused by fear of procedures and treatment. unknown. Stay with child during acute attack. Provides comfort and support to the child. Encourage quiet play and avoid any Provides distractions from changes emotional stress. difficulty or in breathing pattern and prevents may initiate an acute attack. emotional upsets, that increase respiratory If hospitalized, allow open Relieves anxiety for parents and visitation, and telephoning; child when familiar people and encourage parents to stay with routines are available. child if possible, to bring toy or blanket from home, and to maintain home schedules for sleep, feeding, play as appropriate. 3 of 11 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=17&FxId=123&Sessi. Explain to parents and child the Promotes understanding of what is reason for and what to expect happening during attack and the before and/or during attack; use possible causes in order to allay drawings, pictures, models, and anxiety. video tapes for child. Inform parents and child of the Reduces anxiety caused by fear of reversibility of the disease, how suffocation. the medications and treatment resolve the attack. Clarify any misinformation and Prevents unnecessary anxiety that answer all questions honestly in results from inaccurate simple understandable language for information or beliefs. the parents and child. Instruct parents and child in Provides anticipatory teaching that environmental control and exercise assists parents and child in limitations. preventing attacks. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did child verbalize decreased anxiety? Use quotes. Did child engage in breathing and relaxation exercises?) (Revisions to care plan? D/C care plan? Continue care plan?) ACTIVITY INTOLERANCE Related to: (Specify: respiratory problem, fatigue.) Defining Characteristics: (Specify: prolonged dyspnea from asthma attack; lethargy; exhausted appearance, inability to eat, speak, play.) Goal: Child will experience increased tolerance for activity by (date and time to evaluate). Outcome Criteria √ Child participates in usual activities (specify). √ Child verbalizes feeling less fatigued (specify). NOC: Activity Tolerance INTERVENTIONS RATIONALES Assess presence of weakness and Provides information about fatigue caused by respiratory energy reserves as dyspnea and 4 of 11 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=17&FxId=123&Sessi. changes. work of breathing over period of time exhausts these reserves. Schedule and provide rest periods in Promotes adequate rest and a quiet environment. reduces stimuli. Disturb only when necessary, perform Conserves energy and prevents all care at one time instead of interruption in rest. spreading over a long period of time, avoid performing any care or procedures during an attack. Provide for quiet play, reading, TV, Prevents alteration in games while at rest. respiratory status and energy depletion caused by excessive activity. Explain reason for need to conserve Promotes understanding of effect energy and avoid fatigue to of activity on breathing and parents and child. need for rest to prevent fatigue. Instruct in planning a schedule for Provides care while promoting bathing, feeding, rest that will activities of daily care. conserve energy and prevent attack or promote resolution of an attack. Inform of activity or exercise Provides preventive measures to restrictions if these trigger offset possible attack. attack; suggest medically approved activities (swimming, bicycling). NIC: Energy Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe activities in which child participated. Use quotes for child's verbalization of energy level) (Revisions to care plan? D/C care plan? Continue care plan?) HEALTH-SEEKING BEHAVIORS: PREVENTION OF ASTHMA ATTACK Related to: Desire for information of preventive measures and behavior changes. Defining Characteristics: (Specify: expressed desire for increased control of health practices and effect of current environmental conditions and behaviors on health status, increased frequency of attacks use quotes.) Goal: Clients will obtain information about asthma. 5 of 11 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=17&FxId=123&Sessi. Outcome Criteria √ Parents (and child if age-appropriate) verbalize understanding of triggering agents and prevention measures for asthma attacks. NOC: Knowledge: Health Promotion INTERVENTIONS RATIONALES Assess for knowledge of factors Provides basis for information related to attacks, past history of needed for health maintenance, as respiratory infections and measures respiratory changes or infection taken to maintain health of child. can trigger an asthma attack. Assess for use of over-the-counter Identifies whether products medications, type used and effects. available for treatment of respiratory diseases should or should not be used, as they may interact with prescribed medications, causing attack to become more severe. Assess health history of allergies in Identifies familial tendency to family members, what does or does airway reactive disease or not precipitate attack, and what history of allergic rhinitis, behaviors result from the attack. eczema, urticaria. Teach parents/child handwashing Prevents transmission of technique, allow for demonstration. microorganisms from touching or handling supplies, touching face of child by parents or child without handwash. Instruct child to avoid contact with Prevents transmission of those who have respiratory microorganisms by airborne infections, how to cover mouth and droplets. nose when coughing or sneezing, and to dispose of tissues. Teach parents and child about Provides information that will physiology and signs and symptoms enhance performance of preventive of the disease and

possible measures and compliance to precipitating factors influencing medical regimen. an attack (specify). Discuss with parents and child the Teach actions to be taken to signs and symptoms indicating the prevent a severe attack and when onset of an attack (change in to notify physician. respirations, wheezing, dyspnea). Instruct child to avoid excessive Provides information on how to activity, stressful situations. avoid situations that may provoke an attack. Teach parents of effect of allergens Reduces exposure to factors that and how to avoid exposure to precipitate an attack. offending environmental factors (cold air, humidity, air pollution, sprays, plants). Suggest to parents actions to change Reduces exposure to factors that home environment to reduce dust, precipitate an attack. 6 of 11 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=17&FxId=123&Sessi. exposure to pets and indoor plants, changing of filters, avoidance of foods (yellow dye), drugs (aspirin). Teach child breathing exercises and Prevents attack before it begins controlled breathing and and increases ventilation. relaxation. Teach parents and child about Promotes compliance in order to medication administration as prevent attack and maintain ordered (specify drug, dose, route, wellness (action of drug). and times to be given) and how to manage method of administration; advise to avoid over-the-counter drugs without physician advice. Inform parents of skin testing for Identifies allergies for sensitivities to allergens. hypersensitization regimen. Suggest community agencies to contact Offers support to families with for information and support. child suffering from asthma. NIC: Health Education Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents/child verbalize understanding of triggering agents and prevention measures for asthma attacks? Provide quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) INTERRUPTED FAMILY PROCESSES Related to: (Ill child.) Defining Characteristics: (Specify: parental stress, which may result in parental dysfunction; stress may be manifested by excessive worry, withdrawal, denial, difficulty in making child-rearing decisions, overprotectiveness; alterations in the parent-child relationship which may hinder adjustment and decrease parent's ability to maximize child's growth and development potential.) Goal: Family will resume supportive interaction by (date/time to evaluate). Outcome Criteria √ Parents verbalize feelings and concerns related to the implications of the disease on the entire family. √ Family demonstrates acceptance, adjustment, and coping behaviors related to the symptoms and effects of asthma. NOC: Family Coping 7 of 11 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=17&FxId=123&Sessi. INTERVENTIONS RATIONALES Provide an opportunity for the family Reaction may occur in the early to adjust to the diagnosis; adjustment phase, after the anticipate the normal grief reaction diagnosis of a chronic disease, of "loss of the perfect child." depending on the severity. Explore the family's feelings regarding Indicators of family-related the child and the diagnosis. psychologic stress often are obtained during open discussions as part of a history-taking; family stressors, if found early, can be the focus of preventive services to promote adaptation. Assist the family to explore specific Validates the normalcy of their feelings regarding: guilt, anger, feelings which promotes stress disappointment, irritation, and fear; reduction and positive coping discuss with parents their fears: skills. dealing with the child's anxiety, fear of complications, fear of death, fear of tests and procedures, fear of treatments, and the child's potential inability to feel "normal" as compared to peers; help family to identify realistic and unrealistic fears. Assess the family's coping skills and Promotes reinforcement of positive resources. coping skills. Foster positive family relationships; Promotes the family's ability to serve as a role model regarding cope in a positive manner. attitudes and behaviors towards the child. Assess interpersonal relationships Promotes early identification of within the family and support interpersonal problems, systems, with emphasis on the especially within the parent- family's relationship with the child child relationship. diagnosed with asthma; intervene appropriately with evidence of maladaptation; refer to counseling if appropriate (specify). Provide support to the family; assess Promotes positive adaptation within family's support systems and the family. encourage their appropriate use; refer to community agencies and support groups, as applicable (specify). Assess siblings and peers at intervals, Promotes positive relationships as appropriate, providing time for within siblings and peers, which questions and feelings. can be altered by chronic illness that requires increased parental attention, and so forth. Provide information to the family Promotes a sense of control and regarding the disorder, treatments, alleviates stress; reinforcement 8 of 11 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=17&FxId=123&Sessi. and implications; reinforce all and individualizing the approach information given; provide accurate promotes better understanding. information, paced at a rate appropriate for the family (specify). Encourage family in methods to promote Provides parents accurate the child's physical, psychological, information on growth and and cognitive development, based on development. child's current developmental level (specify). Assist family in the development and Provides for an optimal level of implementation of a home plan of care at home; parental input into care, utilizing age-appropriate goals that plan of care may serve to consistent with activity tolerance. increase compliance and foster positive adaptation. Explain to child/family the possible Prevents potential asthma benefits of hyposensitization therapy exacerbation when allergen where allergies cannot be avoided, as induced. applicable. Teach child and family correct use of Prevents and/or minimizes asthma metered dose inhaler, nebulizer, and exacerbation by early peak flow meter; emphasize identification. understanding of equipment usage, cleaning, and strategies for compliance. Instruct child and family on preventive Prevents and/or minimizes asthma treatment when applicable (specify, exacerbations. i.e., prevention of exercise-induced asthma can be accomplished by use of certain medications prophylactically). Encourage child and family to engage in Promotes the body's own natural good health practices, such as defenses. balanced nutritional diet, adequate rest, good hygiene, and follow-up care. Reinforce methods to prevent Prevention of infection may infections: good handwashing, minimize asthma exacerbations. cleaning and care of equipment used, and avoidance of exposures. Review with parents the signs of Promotes timely communication depression, especially in the between parent and healthcare adolescent; make appropriate provider if concerns arise. referrals as needed (specify). NIC: Family Integrity Promotion Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 9 of 11 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=17&FxId=123&Sessi. (Did parents verbalize feelings and concerns? Provide quotes. Did family demonstrate acceptance, adjustment, and coping behaviors? Describe.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR ASTHMA 10 of 11 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=17&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:50:34 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=17 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.2 - ASTHMA Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 11 of 11 12/22/2006 7:20 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=18&FxId=123&Sessi. CHAPTER 3.3 - BRONCHIOLITIS INTRODUCTION Bronchiolitis is an acute viral inflammation of the lower respiratory tract involving the bronchioles and alveoli. Accumulated thick mucus, exudate, and cellular debris and the mucosal edema from the inflammatory process obstruct the smaller airways (bronchioles). This causes a reduction in expiration, air trapping, and hyperinflation of the alveoli. The obstruction interferes with gas exchange, and in severe cases causes hypoxemia and hypercapnia, which can lead to respiratory acidosis. Children in a debilitated state who experience this disorder with other serious diseases are hospitalized. MEDICAL CARE Prevention: synagis IM monthly or RespiGam IV × 3 to 4 hours monthly. Drugs are reserved for high-risk infants (preterm, immune-compromised, <2 years old with chronic lung disease) during RSV season only. Antipyretics: acetaminophen (Tylenol tablets, Pedric wafers or elixir, Liquiprin drops) PO to reduce fever. Ibuprofen (nonsteroidal anti-inflammatory) for children 6 months to 12 years; Motrin or Advil liquid suspension or tablets PO to reduce fever and inflammation. Antivirals: ribavirin (Vilena, Viramid) via aerosol inhalation (hood, tent, or mask) during first 3 days of illness to prevent replication of the syncytial virus; controversial, usually reserved for use in those with or at risk for severe illnesses or complications. Chest X-ray: reveals hyperinflation, atelectasis and areas of collapse, flattened diaphragm indicating air trapping; areas of consolidation may need differentiation from pneumonia. Nasal/Nasopharyngeal Culture: reveals respiratory synctial virus by enzyme-linked immunosorbent assay method. Arterial Blood Gases: reveals decreased pH, pO2 under 60 mm Hg, pCO2 over 45 mm Hg, indicating respiratory compromise and potential failure. Complete Blood Count: reveals increased WBC, indicating infectious process. COMMON NURSING DIAGNOSES See INEFFECTIVE AIRWAY CLEARANCE Related to: Tracheobronchial infection, obstruction, secretions. Defining Characteristics: (Specify: abnormal breath sounds [diminished or absent, crackles, wheezes]; audible and palpable rhonchi; hyperresonance; change in rate and depth of respirations; tachypnea (50-80/min); paroxysmal, nonproductive, and harsh, hacking cough; dyspnea and shallow respiratory excursion; fever; increased mucus and nasal discharge.) See INEFFECTIVE BREATHING PATTERN Related to: Inflammatory process, tracheobronchial obstruction. 1 of 9 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=18&FxId=123&Sessi. Defining Characteristics: (Specify: dyspnea, tachypnea, cough, nasal flaring, shallow respiratory excursion, suprasternal and subcostal retractions, abnormal ABGs.) See IMPAIRED GAS EXCHANGE Related to: Ventilation perfusion imbalance. Defining Characteristics: (Specify: hypoxia, hypercapnia, irritability, restlessness, fatigue, inability to move secretions.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food because of fatigue. Defining Characteristics: (Specify: dyspnea, fatigue, and weakness, causing difficulty in feeding, anorexia, weight loss.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Excessive losses, altered fluid intake. Defining Characteristics: (Specify: increased temperature, dry skin and mucous membranes, poor turgor.) See HYPERTHERMIA Related to: Respiratory infection. Defining Characteristics (Specify: low-grade, moderate fever; give data, malaise.) ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: (Specify: change in health status of infant or small child, threat of or actual hospitalization of infant/small child.) Defining Characteristics: (Specify: increased apprehension that condition might worsen; expressed concern and worry about impending hospitalization, need for treatment such as mist tent, IV therapy while hospitalized.) Goal: Clients will experience decreased anxiety by (date/time to evaluate). Outcome Criteria √ Client verbalizes decreased anxiety. √ Client appears relaxed. 2 of 9 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=18&FxId=123&Sessi. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess source and level of anxiety, Provides information about anxiety how anxiety is manifested, and need level and the need for for information that will relieve interventions to relieve it; anxiety. sources of anxiety may include fear and uncertainty about treatment and recovery, guilt for presence of illness, possible loss of parental role, and loss of responsibility if hospitalized. Allow expression of concerns and Provides opportunity to vent opportunity to ask questions about feelings, and to secure condition and recovery of ill information needed to reduce infant/small child. anxiety. Communicate openly with parents and Promotes calm and supportive answer questions calmly and environment. honestly. Encourage parents to remain calm and Promotes constant monitoring of involved in care and decision- infant/small child for improvement making regarding infant/small child or worsening of symptoms. noting any improvement that results. Encourage parents to stay with Allows parents to care for and infant/small child or allow open support infant/small child; visitation and telephoning, have absence and wondering about parents assist in care (holding, condition of infant/small child feeding, diapering) and suggest may increase anxiety. routines and methods of treatment. Teach parents about disease process Provides information to relieve and physical effects and symptoms anxiety by informing parents of of disease. what to expect. Explain reason for each procedure or Prevents anxiety by reducing fear of type of therapy, effects of any unknown. diagnostic tests to parents (specify). Clarify any misinformation and answer Prevents unnecessary anxiety questions in lay terms when parents resulting from inaccurate are able to listen, give same knowledge or beliefs, or explanation other staff and/or inconsistencies in information. physician gave regarding disease process and transmission. NIC: Anxiety

Reduction Evaluation (Date/time of evaluation of goal) 3 of 9 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=18&FxId=123&Sessi. (Has goal been met? Not met? Partially met?) (Did parents verbalize decreased anxiety? Use quotes. Do parents appear more relaxed? Describe appearance contrasted to initial assessment of tension.) (Revisions to care plan? D/C care plan? Continue care plan?) FATIGUE Related to: Respiratory effort. Defining Characteristics: (Specify: lethargy or listlessness, emotional liability or irritability, exhausted appearance, inability to eat, limpness.) Goal: Infant/child will experience increased energy level by (date/time to evaluate) Outcome Criteria √ Infant/child is able to eat, drink, and play quietly. NOC: Activity Tolerance INTERVENTIONS RATIONALES Assess for extreme weakness and Provides information to determine fatigue; ability to rest, sleep, effects of dyspnea and work of and amount; movement in bed. breathing over period of time, which becomes exhaustive and depletes infant/small child energy reserves and ability to rest, eat, drink. Disturb infant/small child only when Conserves energy and prevents necessary, perform all care at one interruptions in rest. time instead of spreading over a long period of time. Schedule and provide rest periods in Promotes adequate rest and reduces a quiet, comfortable environment stimuli in order to decrease (temperature and humidity). risk for fatigue. Allow quiet play with familiar toy Rest decreases fatigue and while maintaining bed rest. respiratory distress; quiet play prevents excessive activity, that depletes energy and increases respirations. Encourage parents to use measures to Provides support to infant/small prevent fatigue in infant/small child and conserves energy. child (holding and/or rocking, feeding in small amounts, playing with child, offering diversions such as TV, toys). Teach parents to pick up infant/ Prevents fatigue, as prolonged small child if crying longer than crying is exhaustive. 4 of 9 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=18&FxId=123&Sessi. 1 to 2 minutes. Assist parents to develop a plan to Prevents interruption in rest and provide feeding, bathing, changing sleep. diaper around rest periods. NIC: Energy Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide data about child's eating and drinking including amounts taken. Describe child's play activity.) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE: RSV Related to: Lack of information about respiratory syncytial virus. Defining Characteristics: Parents verbalize lack of understanding about RSV. Goal: Parents will obtain knowledge about RSV. Outcome Criteria √ Parents verbalize methods of prevention and treatment of RSV. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess existing knowledge of disease Provides baseline for type of prevention, transmission, and information needed to prevent treatment. infection transmission to child. Teach that the virus is transmitted by Explains that kissing and cuddling direct and indirect contact via the infant/small child, and fomites nose and eyes, and that hands should that are on hard, smooth be kept away from these areas. surfaces are sources of contact with the virus. Teach good handwashing technique for Prevents transmission by the child and family members. hands, which are the main sources of contamination and carriers of organisms to the face area. Suggest that plastic goggles may be Prevents risk of contact with worn when caring for infant/small virus via the eyes. child. 5 of 9 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=18&FxId=123&Sessi. Teach of potential for spread of virus Explains that virus is easily to other family members and need for transmitted, with an incidence segregation of infant/small child as high as half of family from others. members acquiring viral infections. If hospitalized, adhere to infection Protects from exposure to control policies for clients with secretions and transmission of RSV (specify). virus to other patients. Teach parents about the administration Improves consistency of medication of medications prescribed (specify). administration and the recognition of adverse side effects. Teach parents on the signs and Encourages parents to seek prompt symptoms of respiratory distress and medical attention, as needed. infection, including fever, dyspnea, tachypnea, and expectoration of yellow/green sputum. Encourage parents to provide good Promotes liquification of nutrition and hydration, emphasizing secretions and replaces calories a high-calorie balanced diet and used to fight infection, thereby increased fluids (specify amounts). boosting the child's own natural body defense. Encourage and teach parents to provide Promotes parental identity and care for the hospitalized child at a control; may lessen anxiety and level they are comfortable with and stress. within the constraints of necessary treatments. Teach parents about the prophylactic drugs (if ordered) of RespiGam or Synagis (specify) • These drugs are given to high- risk infants only during the RSV season to prevent RSV infection of compromised infants. • RespiGam is RSV immune globulin that is administered once a month during RSV season by IV infusion lasting several hours. The drug interferes with vaccine effectiveness. • Synagis is a synthetic monoclonal antibody that is administered IM once a month during RSV season. The drug does not interfere with vaccines. It is very expensive. (Instruct parents regarding the drug Promotes understanding which may Ribavirin if used during lessen anxiety; prevents hospitalization: accidental exposures to the • Side effects drug. • Type and purposes of isolation, including use of masks, gloves, and/or gowns as applicable (specify) • Precautions utilized for parents, staff, and visitors, including 6 of 9 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=18&FxId=123&Sessi. information regarding potential risks of environmental exposure; advise pregnant women not to directly care for child; decrease potential exposure by temporarily stop-ping the aerosols when tent/ hood is opened and administer drug in well-ventilated rooms (at least 6 air exchanges per hour) • Strict handwashing before and after leaving the child's room) Teach family members about the Prevent the transmission of the appropriate disposal of soiled disease. tissues, and so forth. Instruct parents on the importance of Prevent transmission of the limiting the number of visitors and disease to others; prevent screening them for recent illness. further complications in the child with RSV. NIC: Parent Education Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents verbalize methods of prevention and treatment of RSV? Provide quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR BRONCHIOLITIS 7 of 9 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=18&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: 8 of 9 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=18&FxId=123&Sessi. KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:50:51 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=18 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.3 - BRONCHIOLITIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 9 of 9 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=19&FxId=123&Sessi. CHAPTER 3.4 - BRONCHOPULMONARY DYSPLASIA INTRODUCTION Bronchopulmonary dysplasia (BPD) is a chronic lung condition most common in infants that were preterm or small for gestational age (SGA) at birth. It is characterized by varying degrees of lung damage past the age of 1 month. BPD is caused by the use of assistive ventilation with the administration of high concentrations of oxygen to treat respiratory distress syndrome (RDS) or other serious disorders of the neonate. The lung and airway damage affects pulmonary function which leads to oxygen dependence, abnormal ABGs, and chest findings on X-ray examination, as well as susceptibility to pulmonary infections resulting in frequent and/or lengthy hospitalizations. BPD may resolve by the time the child is 3 to 4 years of age. MEDICAL CARE Prevention: prenatal glucocorticoid therapy given to mothers expected to deliver premature infants, and exogenous surfactant replacement therapy at birth. Bronchodialators: albuterol, terbutaline, theophylline to relax bronchial smooth muscle. Antimicrobials: cefaclor, amoxicillin, ampicillin sodium, carbenicillin disodium, vancomycin, third generation cephalosporins or other antibiotics to treat infection based on culture results and severity of infection. Diuretics: furosemide, spironolactone to promote fluid removal and excretion which will reduce edema if heart failure present. Cardiac Glycosides: digitalis to increase force and strength of heart contractions if heart failure or pulmonary hypertension present. Corticosteroids: dexamethasone given to decrease the inflammation of the lung tissue. Oxygen Therapy: treats hypoxemia as indicated by ABGs or transcutaneous O2 monitoring or oximetry; oxygen level delivered varies according to severity of disease, per nasal cannula or endotracheal tube. Pulmonary Toilet: chest physiotherapy, postural drainage, and suction timed to allow maximum rest for the infant. Chest X-ray: reveals bilateral infiltration, with areas of hyperaeration and cystic areas at base of lungs as disease progresses; "whiteout" and consolidation visible if condition worsens or increases in healing tissue visible if improving. Serial Echocardiograms: reveal right ventricular hypertrophy and possible failure. Pulmonary Function: reveals prolonged ratio between inspiratory and expiratory phases. Throat/Tracheal Cultures: reveal and identify infectious agent and sensitivity to specific antimicrobial treatment if infection present. Arterial Blood Gases: reveal hypoxemic state by decreases in pO2 of less than 55 to 60 mm Hg and increases in pCO2 of more than 45 to 65 mm Hg which determine oxygen administration adjustments based on chronic hypoxemia associated with this condition; increased HCO3 in presence of respiratory failure (chronic or acute). 1 of 10 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=19&FxId=123&Sessi. Electrolyte Panel: reveals hypokalemia if diuretics given, calcium and phosphorus deficits if nutrition inadequate. Complete Blood Count: reveals increased WBC if infection is present. COMMON NURSING DIAGNOSES See INEFFECTIVE BREATHING PATTERN Related to: Inflammatory process. Defining Characteristics: (Specify: dyspnea, tachypnea, use of accessory muscles, increased anteroposterior diameter, abnormal ABGs, cyanosis, recurrent wheezing, crackles and presence of respiratory infections [bronchitis, bronchiolitis, pneumonia].) See IMPAIRED GAS EXCHANGE Related to: Tissue damage. Defining Characteristics: (Specify: hypoxemia, hypercapnia, restlessness, confusion, irritability, somnolence.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food. Defining Characteristics: (Specify: hypoxia during feeding, poor feeder, decreased weight gain, increased energy/metabolic need for work of breathing, altered physical growth.) See EXCESS FLUID VOLUME Related to: Compromised regulatory mechanisms (presence of right heart failure). Defining Characteristics: (Specify: edema, pulmonary effusion, weight gain, dyspnea, crackles, change in respiratory pattern, pulmonary congestion.) See DELAYED GROWTH AND DEVELOPMENT Related to: Separation from significant others. Defining Characteristics: (Specify: frequent or prolonged hospitalizations.) Related to: Environmental and stimulation deficiencies. Defining Characteristics: (Specify: isolation, listlessness, decreased responses.) 2 of 10 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=19&FxId=123&Sessi. Related to: Effects of physical disability/chronic illness. Defining Characteristics: (Specify: delay or difficulty in performing motor, mental, social skills typical of age group.) ADDITIONAL NURSING DIAGNOSES RISK FOR INFECTION Related to: Chronic respiratory disease. Defining Characteristics: (Specify: reduced ciliary activity, lung damage, decreased lung capacity and accessory muscles' inability to move secretions, increased temperature, yellow or green sputum in increased amounts, diminished breath sounds; presence of respiratory and suction of family membranes.) Goal: Infant will not experience a respiratory infection by (date/time to evaluate). Outcome Criteria √ Temperature <101° F, clear respiratory secretions, breath sounds consistent for infant (specify). √ Behavior is consistent for infant. NOC: Risk Control INTERVENTIONS RATIONALES Assess for change in breathing Indicates presence or potential pattern, color of mucus, rise in for infection, which may be temperature, diminished breath life threatening in infants sounds; presence of respiratory with this disease. infection of family members. Avoid exposure to persons with Infants have a low respiratory respiratory infections; isolate reserve and are prone to from infectious patients. infection transmission from others. Utilize and teach good handwashing Prevents transmission of technique before giving care to microorganisms to infant. infant. Remove secretions by CP and PD and Stasis of secretions provide suctioning via sterile technique medium for infection. as needed. Obtain sputum for culture as Identifies presence of needed. pathogenic organisms. Teach parents about infant's Any illness, even a minor one susceptibility to infection and will compromise the infant's

to avoid contact with anyone respiratory status. with a respiratory infection. Reinforce to parents to maintain Avoids irritation of airways an environment free of smoke, that might increase risk of 3 of 10 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=19&FxId=123&Sessi. sprays, or other irritating infection. substances. Encourage parents to provide Maintains fluid and nutritional adequate fluid and nutritional requirements of infant to intake. provide adequate defenses. Refer parents for cardiopulmonary Provides anticipatory knowledge resuscitation (CPR) class. to perform life-saving measure if needed. Teach parents of need to have Monitors progress of disease. periodic X-rays and laboratory tests. Instruct parents to report any Provides for immediate changes in mucus or respiratory interventions, if needed, to distress to physician. control infection. NIC: Infection Control Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is temperature? Are respiratory secretions clear? Describe. Describe breath sounds and infant behavior and compare to usual parameters.) (Revisions to care plan? D/C care plan? Continue care plan?) COMPROMISED FAMILY COPING Related to: (Specify, e.g., prolonged disease that exhausts supportive capacity of significant people; lack of coping skills.) Defining Characteristics: (Specify: preoccupation of significant persons with anxiety, guilt, fear regardless of infant/child illness; display of protective behaviors by significant persons that are disproportionate to infant/child needs (too much or too little), frequent hospitalizations, prolonged hospitalization.) Goal: Family will improve coping skills by (date/time to evaluate). Outcome Criteria √ Family expresses major stressors accompanying infant's illness. √ Family identifies 3 coping mechanisms/support systems they can use. NOC: Family Coping INTERVENTIONS RATIONALES Assess anxiety, fear, erratic Provides information affecting behavior, perception of crisis family ability to cope with 4 of 10 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=19&FxId=123&Sessi. situation by family members. infant/child prolonged illness. Assist family to discuss coping Identifies coping methods that methods used and effectiveness. work and need to develop new coping skills. Encourage expression of feelings Reduces anxiety and enhances and questions in accepting, family's understanding of nonjudgmental environment. infant's condition. Encourage family involvement in Provides for reduction of anxiety care during and after and fear of equipment used in hospitalization. care. Allow for open visitation, Encourages bonding and assists in encourage telephone calls to coping with infant/child hospital by family members. hospitalization if family unable to stay. Provide place for family members Promotes comfort of family. to rest, freshen up. Suggest social worker referral as Provides support and resources needed (specify). for financial or infant/child care relief. Give positive feedback and praise Encourages parents and family to family efforts in developing participate in care and gain coping and problem-solving some control over the techniques and caring for situation. infant. Suggest and reinforce appropriate Promotes behavior change and coping behaviors (provide adaptation to care of infant examples). with oxygen dependence. Reinforce need to maintain health Chronic anxiety, fatigue will of family members and emotional affect health and care status of parents. capabilities of family. Provide information regarding Reduces anxiety of parents and infant's condition and progress, family and anticipates need for oxygen dependence needs, and knowledge about disease and reason for care and medications. care. Suggest that assistance may be Provides family with resource in secured by telephoning hospital crisis situation. after discharge. Arrange education about Empowers family to manage cardiopulmonary resuscitation emergency situation and (CPR), oxygen administration, maintain safe oxygen and safety measures to eliminate administration. fire hazards. NIC: Family Integrity Promotion Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 5 of 10 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=19&FxId=123&Sessi. (What stressors did the family identify? List at least three coping mechanisms or support systems the family plans to use.) (Revisions to care plan? D/C care plan? Continue care plan?) DISORGANIZED INFANT BEHAVIOR Related to: Environmental stimulation. Defining Characteristics: (Specify, e.g., alterations in heart rate, respirations, color changes, erratic body movements, difficulty with feedings or prolonged periods of wakefulness. Goal: Infant will display increased organization of behavior by (date/time to evaluate). Outcome Criteria √ Infant demonstrates quiet alert state and ability to habituate to environmental stimuli. √ Color changes with handling and movement are decreased. √ Demonstrates smoother transitions between sleeping and waking (specify how to measure). NOC: Child Development: Infant INTERVENTIONS RATIONALES Assess behavioral states of the infant Assessment provides information about including: periods of quiet and active the infant's unique abilities to sleep, habituation, orientation, and cope with environmental self-consoling ability. stimulation. Allows planning of individualized supportive care. Introduce one caregiving intervention at Prevents overstimulation and further a time, observing responses; allow for maladaptation to the environment. "time out" if infant displays stress signals, such as finger splaying, grimacing, tongue extension, worried alertness, spitting up, back arching, gaze aversion, yawning, hiccuping, color changes, or changes in cardiac or respiratory functioning. Cluster caregiving, while not Promotes longer periods of alert and/ overstimulating infant; continuously or deep sleep which will enhance monitor infant for signs of stress the body's own natural defenses; during caregiving, providing rest providing rest periods will allow periods as needed. infant to recover prior to initiation of additional caregiving; prevents sudden disruptions in sleep; promotes stability and adaptive behaviors. Remain at bedside after procedures/ Prevents or minimizes maladaptive caregiving to assess infant's responses which often occurs up to 6 of 10 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=19&FxId=123&Sessi. response; if maladaptive responses 20 minutes after caregiving is occur, use "time-out" to allow infant completed. to adapt. Alter physical environment by decreasing Prevents or decreases maladaptive light and sound. physiological behaviors; both light and sound functioning. levels in the NICU have been implicated in interfering with sleep and stable Facilitate handling by providing Promotes flexion and stabilizes containment: holding infant's arms and infant's motor and physiologic legs in a flexed position, close to systems. their midline using the caregiver's hands and/or positioning aids such as rolled blankets; premature or ill infants should be positioned prone or side-lying, maintaining soft flexion. Place the infant in a flexed position Promotes self-consoling/soothing with hands to midline, or swaddled behaviors which facilitate with hands free; providing pacifier organization and adaptive and/or fingers to suck on; providing behaviors. objects to encourage hand grasping such as blankets, tubing, and fingers during caregiving. Provide a primary care team to work Promotes element of trust for both collaboratively with the parents in the infant and family, improving developing an individualized plan of parent-infant relationships; allows care reviewed daily and discussed at caregivers to identify infant's intervals with the parents. behavioral cues. Provide individualized feeding support Promotes positive feeding determined by the infant's own needs experiences, that facilitate weight and strengths; feeding focus should be gain and feeding competency. positive and pleasurable, with attention to infant's cues or signals. Provide optimal level of family support Promotes feelings of belonging and through utilization of family centered control which enhances parent- caregiving principles: enhanced infant relationship. parental involvement in all aspects of caregiving and decision-making; promote family comfort with homelike environment. Assist parents in learning their Promotes positive parenting role and infant's signals or cues and minimizes infant's maladaptive interpreting them appropriately. behaviors, promoting improved long- term growth and development. Instruct and encourage parents in Promotes improved parental caregiving activities throughout the confidence, enhances parenting NICU stay, at a level parents are skills, and improves parent-infant comfortable with (specify). relationship/interactions. Teach and assist parents in promoting Promotes positive adaptive behaviors infant adaptive behaviors through use in the infant and increases of containment, swaddling, promotion parental participation and feelings and maintenance of flexion, non- of control. 7 of 10 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=19&FxId=123&Sessi. nutritive sucking, and finger grasping. Encourage parents to personalize infant Promotes positive parental identity bed space by bringing in clothes, and feelings of control. Decreases blankets to be used over isolettes/ NICU stimulation. cribs, and pictures from home. Teach and encourage parental Promotes stable physiologic participation in Kangaroo care or functioning, maintains skin-to-skin holding when infant is thermoregulation, improves quiet/ medically stable; this method is alert sleep periods, improves accomplished by placing infant on weight gain, promotes positive parent's chest under their clothing. parent/infant relationship and improves parental confidence. Support parents in making the difficult Promotes feelings of control and transition from hospital to home; mastery through education and allow ample time for teaching and open communication; this will enhance communication of needs and feelings; the parent-infant relationship and validate feelings of anxiety as foster the child's growth and normal; give brief and accurate development. information, with time for clarification and provide supplemental written materials; allow parents permission to be in control of decisions and maintain structure in their own lives; discuss feelings of anger and guilt openly; adapt teaching and communication techniques to different family styles, customs, and cultures. NIC: Developmental Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did infant demonstrate quiet alert state and ability to habituate to environmental stimuli? Describe. Were color changes with handling and movement decreased? How was this measured? Did infant demonstrate smoother transitions between sleeping and waking? How was the change measured?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR BRONCHOPULMONARY DYSPLASIA 8 of 10 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=19&FxId=123&Sessi. 9 of 10 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=19&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:51:09 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=19 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.4 - BRONCHOPULMONARY DYSPLASIA Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 10 of 10 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. CHAPTER 3.5 - CYSTIC FIBROSIS INTRODUCTION Cystic fibrosis (mucoviscidosis) is the most common life-shortening hereditary illness in children. It is an autosomal-recessive trait disorder affecting the exocrine glands. The disease produces abnormal ion transport in epithelial tissues, which results in dehydration of secretions causing mucus to become thick and tenacious and causing mechanical obstruction in ducts and glands. Organs affected are the pancreas, small intestine, liver, lungs, and reproductive organs. Severity of the disease varies. Although an increased survival rate has been evident in recent years, death is the final result as progressive pulmonary complications occur and create a serious threat to the child's life. Children with cystic fibrosis and their families are continuously faced with the daily implementation of a medical regimen that may deplete their physical, emotional, and financial resources. As the disease is chronic, hospitalization may be frequent. MEDICAL CARE Bronchodilators/Adrenergic Agonists: via nebulizer, or hand-held inhalator to relieve bronchospasms and facilitate removal of pulmonary secretions by bronchial dilatation and smooth muscle relaxation. Mucolytics: acetylcysteine (Mucomyst) used in the nebulizing solution for mist tent, face mask to liquefy mucus; recombinant human deoxyribonuclease (Pulmozyme) used as an aerosolized medication to decrease the viscosity of mucus. Vitamins: if liver involved, vitamin A, D, E, and K given as replacement in water-miscible preparations. Pancreatic Enzymes: given to replace enzyme deficiency in powder, granules, packet, or tablet form to assist in digestion and bowel elimination. Antibiotics: selection dependent on identification and sensitivity to organism revealed by culture, whether therapy is prophylactic, and term of treatment. Oxygen Therapy: continuous, low-volume oxygen administered with caution for acute respiratory distress. Pulmonary Toilet: chest PT and postural drainage and aerobic exercise enhances movement of secretions. Chest X-ray: reveals patchy areas of atelectasis and generalized obstructive emphysema, with later infiltratives and dissemination of bronchopneumonia evident. Pulmonary Function: reveals severity of lung involvement and general condition. Iontophoresis of Pilocarpine Sweat Test: reveals sweat chloride content greater than 60 mEq/L, obtained by electrode stimulation of the sweat glands

and measurement of the chloride content in the laboratory, is the most definitive test for cystic fibrosis. Stool Test: reveals fecal fat (steatorrhea) in a 5-day stool collection specimen and calculated to determine impaired fat absorption. Alanine Aminotransferase (ALT)/Aspartate Aminotransferase (AST): reveals elevation of these enzymes in liver damage. COMMON NURSING DIAGNOSES 1 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. See INEFFECTIVE AIRWAY CLEARANCE Related to: Tracheobronchial secretions and obstruction. Defining Characteristics: (Specify: dyspnea; tachypnea; increasing amount of thick, tenacious sputum; nonproductive cough; wheezy respirations with expiratory obstruction.) See INEFFECTIVE BREATHING PATTERN Related to: Tracheobronchial obstruction; decreased energy and fatigue. Defining Characteristics: (Specify: dyspnea, tachypnea, cough, increased anteroposterior diameter (barrel chest), cyanosis, prolonged expiratory phase, finger and toe clubbing with continued ventilatory impairment.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to digest food or absorb nutrients. Defining Characteristics: (Specify: reduced weight gain; failure to thrive; weight loss with adequate food intake and increased appetite; vomiting; thin and wasted appearance of extremities and buttocks; absence of pancreatic enzymes, causing increased amount of stool; foul-smelling loosely formed bulky stools; steatorrhea, prolapse of the rectum.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Excessive losses through normal routes. Defining Characteristics: Tachypnea, vomiting, diarrhea, profuse sweating, loss of sodium and chloride. See DECREASED CARDIAC OUTPUT Related to: Electrical factors. Defining Characteristics: (Specify: dysrhythmias; ECG changes; variations in hemodynamic readings [VS and BP]; dyspnea; pale, cold, clammy skin; cyanosis; edema; complication of heart failure.) See DISTURBED SLEEP PATTERN Related to: Interrupted sleep. Defining Characteristics: (Specify: cough, dyspnea, fatigue, increasing irritability, restlessness, lethargy, listlessness, average number of hours.) See RISK FOR IMPAIRED SKIN INTEGRITY 2 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. Related to: Bed rest. Defining Characteristics: (Specify: disruption of skin surface, redness or rash on genitalia and buttocks, redness and irritation at bony prominences; describe.) See DELAYED GROWTH AND DEVELOPMENT Related to: Effects of physical illness and disability. Defining Characteristics: (Specify: altered physical growth, delay or difficulty in performing motor, social skills typical of age group; describe.) ADDITIONAL NURSING DIAGNOSES RISK FOR ACTIVITY INTOLERANCE Related to: Deconditioned status. Defining Characteristics: (Specify: weakness, fatigue, inability to participate in self-care, physical and social activities.) Related to: Respiratory problems. Defining Characteristics: (Specify: dyspnea, tachypnea, exertional discomfort.) Goal: Infant/child will maintain usual activity levels by (date/time to evaluate). Outcome Criteria √ Infant/child engages in activities (specify) without fatigue or respiratory distress. NOC: Energy Conservation INTERVENTIONS RATIONALES Assess level of fatigue and activity Provides information about energy in relation to respiratory status reserves as dyspnea and work of (specify frequency). breathing over period of time exhausts these reserves. Schedule care and provide rest Promotes adequate rest and periods in a quiet environment. reduces stimuli. Disturb only when necessary for care Conserves energy and prevents and procedures; provide quiet play interruption in rest; prevents appropriate for age (specify), alteration in respiratory interests, and energy level. status and energy depletion caused by excessive activity. Perform respiratory physiotherapy Reduces work while promoting (specify when); avoid treatment effectiveness of breathing. before or after meals. Assist to perform breathing Improves ventilation and 3 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. exercises. strengthens chest muscles. Explain to parents and child the Promotes understanding of effect reasons for need to conserve of activity on breathing and energy and to rest to avoid importance of rest to prevent fatigue. fatigue. Discuss with parents and child any Measures to prevent fatigue while activity or exercise restrictions, engaging in as near normal how to engage in activities participation as possible. without tiring or affecting respiratory status; discuss types of activities child enjoys. Instruct child to ask for assistance Prevents overtiring and fatigue. if needed for daily activities; assist to plan a schedule for ADL that will conserve energy. NIC: Energy Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did infant/child engage in the activity specified without fatigue or respiratory difficulty? Describe behavior.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: Chronic pulmonary disease. Defining Characteristics: Presence of and stasis of mucus in respiratory tract, increased environmental exposure, change in respiratory pattern and mucus color, temperature, steroid administration (specify). Goal: Client will not experience any infection by (date/time to evaluate). Outcome Criteria √ Absence of infection. √ (Specify individual parameters to monitor for infection, e.g., behavioral, VS, lab values, changes in secretions and breathing.) NOC: Risk Control INTERVENTIONS RATIONALES Assess for change in breathing Indicates presence of respiratory pattern, color of mucus, infection. 4 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. diminished breath sounds, ability to cough and raise secretions (specify frequency). Teach to avoid exposure to persons Prevents transmission of with respiratory infections; microorganisms as disease isolate from infectious patients. increases susceptibility to infection. Teach and use good handwashing Prevents transmission of technique before giving care. microorganisms to child. Assist to cough or remove secretions Stasis of secretions provide by suctioning. medium for infection. Use medical asepsis techniques or Prevents exposure to infectious sterile techniques when agents. administering respiratory care (specify). Administer antibiotics as ordered Provides prophylactic (specify drug, dose, route, and antibiotics, that are often times). prescribed as a preventive measure. Specify drug action. Instruct parents of child's high Prevents any infection that will susceptibility to infection and to compromise respiratory status avoid contact of child with and that could be life- persons or family members with threatening. respiratory infections. Teach parents about antibiotic Promotes use of preventive regimen (specify) and inform of measures to control possible need to have influenza infection, cough suppressants immunization and to avoid cough prevent cough needed to bring suppressants. up secretions. Teach parents to report any changes Provides for immediate in mucus or respiratory status to interventions to control physician. infection. NIC: Infection Control Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide evaluative data on parameters specified in outcome criteria, e.g., VS, behavior, etc.) (Revisions to care plan? D/C care plan? Continue care plan?) ANTICIPATORY GRIEVING Related to: Potential loss of significant other by parents, perceived potential loss of physiopsychosocial well-being by child. 5 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. Defining Characteristics: (Specify: expression of distress at potential loss, poor prognosis for child [premature death], anger, guilt, sadness, fear, long-term chronic illness of child; use quotes.) Goal: Clients will express their grief by (date/time to evaluate). Outcome Criteria √ Clients express concerns about the future. √ Clients verbalize the stages of grieving. √ Clients identify support systems available to them. NOC: Family Coping INTERVENTIONS RATIONALES Assess stage of grief process, Allows for information regarding problems encountered, feelings stage of grieving, as time to regarding potential loss. work through grieving varies with individuals and the longer the illness, the better able the parents and family will be able to move through the stages towards acceptance. Provide emotional and spiritual Provides for emotional needs of comfort in an accepting parents; assists them in coping environment. with ill child. Answer all questions honestly, Promotes trust and reduces clarify any misconceptions. parental anxiety. Accept parental and child's Allows for reactions necessary to responses and allow for their work through grieving. expression of feelings. Assist in identifying and using Promotes use of defense mechanisms effective coping mechanisms and to progress through grief. in accepting situations over which they have no control. Encourage parents to assist child Promotes sense of normalcy and with normal development and well-being for child. discipline. Allow child to talk about any Promotes expression of feelings concerns regarding death and and concerns for understanding respond to questions honestly. grieving process and behaviors. Provide information to child based Ensures that child receives on age and developmental level information he or she can (specify). understand. Promotes trust. Inform parents and child of stages Promotes understanding of feelings of grieving and of behaviors that and behaviors that are are common in resolving grief. manifested by grief. Suggest to parents coping skills Promotes coping ability over and approaches that may be used prolonged period of illness. 6 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. (give examples). Refer to (specify) counseling Provides support and assistance in services, clergy, local support adapting to chronic illness and agencies for cystic fibrosis, potential early death of child. Cystic Fibrosis Foundation. Discuss with parents and child the Provides a realistic view of the disease process and what can be child's illness. expected from chronic nature and systems involved with the illness. NIC: Grief-Work Facilitation Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did clients express concerns about the future? Did clients verbalize the stages of grieving? What support systems did clients identify as available to them? Provide quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) ANXIETY Related to: (Specify: threat of or change in health status; threat of or change in environment (hospitalization), threat of death, threat of illness occurring in healthy children or future children.) Defining Characteristics: (Specify, e.g., parent—increased apprehension that condition might worsen or infection develop, expressed concern and worry about possible hospitalization, fear of consequences of disease, increased tension and uncertainty; child—unhappy and sad attitude, withdrawal or aggressive behavior, somatic and fatigue complaints, poor school attendance and performance.) Goal: Clients will experience decreased anxiety by (date/time to evaluate). Outcome Criteria √ Clients identify cause of anxiety and 3 coping mechanisms. √ Clients verbalize decreased feelings of anxiety. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess source and level of anxiety, Provides information about anxiety how anxiety is manifested, and level and the need for need for information that will interventions to relieve it, relieve anxiety of client. and sources may include fear and 7 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. loss of responsibility if uncertainty about treatment and hospitalized. recovery, guilt for presence of illness, possible loss of parental role, Allow parents and child to express Provides opportunity to vent fears and concerns and to ask feelings and secure information questions about disease and what to reduce anxiety. to expect. Assist clients to identify effective Promotes clients' active coping mechanisms they may use for participation in decreasing anxiety (suggest possibilities as anxiety. needed, e.g., relaxation techniques, listening to music, playing with clay). Communicate with parents and answer Promotes calm and supportive questions calmly and honestly. environment. Provide supportive and nonjudgmental Promotes trust and reduces environment. anxiety. Inform parents and child of all Relieves anxiety caused by fear of procedures and treatments. the unknown. Allow parents to stay with child, Reduces anxiety for child by allow open visitation and allowing presence and telephone communications; involvement in care, and encourage to participate in care familiar routines and persons. that is planned around usual home routines. If hospitalization is frequent, Promotes trust and comfort and assign same personnel to care for reduces anxiety when cared for child if appropriate. by familiar persons. Explain changes in condition and Promotes understanding of disease need for hospitalization. complications and nature of chronic disease. Explain to parents and child as Prevents anxiety by reducing fear appropriate for age, reason for of unknown. each procedure or type of therapy, effects of any diagnostic tests. Clarify any misinformation with Prevents unnecessary anxiety honesty and in simple, resulting from inaccurate understandable language. information or beliefs. Refer to counseling, community Provides support to parents and groups for cystic fibrosis (as child, and information from needed; specify). those with similar problems, which reduces anxiety. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 8 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. (Which causes of anxiety did clients identify? Did clients verbalize decreased anxiety? Provide quotes. Specify 3 coping mechanisms identified by clients.) (Revisions to care plan? D/C care plan? Continue care plan?) INTERRUPTED FAMILY PROCESSES Related to: Chronic illness. Defining Characteristics: (Specify: family system unable to meet physical, emotional needs of its members; inability to express or accept wide range of feelings; family unable

to deal with or adapt to chronic illness of child in a constructive manner; excessive involvement with ill child by parents/siblings; evidence of marital and social discord exhibited by parents; guilt expressed by parents/siblings; irritability as a response to the ill child; lack of support from family/friends.) Goal: Family will regain a functional family system by (date/time to evaluate). Outcome Criteria √ Family members display supportive behaviors to one another. √ Family members report open discussions to solve problems. √ Family members identify how ill child will be cared for. NOC: Family Functioning INTERVENTIONS RATIONALES Assess family ability to cope with Provides information about family ill child, strain on family attitudes and coping abilities, relationships, developmental level that directly affect the child's of family, response of siblings, health and feeling of wellbeing; knowledge of health practices, chronic illness of a child in a family rule behavior and attitude family may strengthen a family or toward long-term care, economic strain family relationships; pressures and resources to care for members may develop emotional long-term illness. problems when family is under stress. Assist individual family members to Individual problems that are identify stressors and behaviors defined and explored have meaning and to define them in positive for the entire family. terms. Assist family members in expressing Provides opportunity to express problems and exploring solutions, feelings, problems, and problem- responsibilities. solving strategies by whole family. Assist in establishing short- and Promotes inclusion of ill child in long-term goals in maintaining family routines and activities. 9 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. child care and family integration of child into home routine. Support and encourage parental Reinforces roles and reduces stress caretaking efforts. in family members. Discuss family dynamics and need to Provides knowledge and assists in tolerate conflict and individual understanding family behaviors behaviors. leading to problem resolution. Discuss needs of all family members Allows for ongoing responsibility and inform of methods to provide for care of all family members. care and attention to all members. Inform parents of local agencies, Provides information, economic and respite care, support groups for emotional support for family as a family assistance, Cystic Fibrosis group or individual. Foundation (specify). Suggest to family methods to maintain Ensures acceptance of child into child's independence and role in family routines. the family and that discipline of child and well children should be the same. Encourage that family health must be Health and attitude of family maintained and social contacts promotes ill child's coping encouraged. ability. Provide referrals to parents about Ensures ongoing health care for where health care may be secured child with chronic illness. (dentist, physical therapy, pulmonary physiotherapy (specify). NIC: Family Mobilization Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe family members' behavior toward each other. Did family members report open discussions? Use quotes. Specify the plan family members identified to care for ill child.) (Revisions to care plan? D/C care plan? Continue care plan?) IMPAIRED HOME MAINTENANCE Related to: Complexity of home care management of cystic fibrosis patient. Defining Characteristics: (Specify: frequent exacerbations of respiratory infections; inadequate understanding of illness and home care components; child not functioning up to full potential in terms of growth and development, independence issues; stressors within family relationships.) Goal: Family will provide a safe, hygienic home for ill child by (date/time to evaluate). 10 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. Outcome Criteria √ Parents obtain and learn to operate equipment needed to care for child (specify). √ Family provides appropriate care for ill child (specify parameters to evaluate). NOC: Family Functioning INTERVENTIONS RATIONALES Assess home environment and families' Provides baseline data on which to ability to maintain a safe, clean home plan interventions. for the ill child. Develop a flexible home plan of care, Promotes less disruption to family with input from all family members. routines. Assist parents in locating the Promotes feelings of control; may appropriate equipment and supplies decrease anxiety and stressors. necessary for home care; provide opportunities to learn and practice use prior to discharge; anticipate problems. Instruct parents in all aspects of home Promotes understanding of care care; reinforce teaching with written needed for child at home to materials; return demonstrations, as provide optimal health and promote applicable: oral hygiene chest normal growth and development; physiotherapy (CPT)—parents adjust promotes body's own natural frequency based on individual child's defenses. Use of play will needs; use of games and childhood increase the likelihood of activities can be incorporated into success. the therapy (somersaults, wheelbarrow); antibiotic therapy for respiratory exacerbations; facilitate arrangements with home health nursing (as applicable), nutrition management including pancreatic enzyme replacement, health practices—adequate rest, good hygiene, importance of follow-up care, exercise, prevention of illness. Instruct parents on the signs of Promotes good communication between depression, especially in adolescents; parent and health professional if make appropriate referral as needed a concern arises. (specify). Organize and coordinate services from Promotes family support which is health professionals involved in the crucial for a positive adaptation home care of the child, including home to care at home; may lessen health nursing, respiratory therapy, anxiety and stressors. physicians, social services (as applicable). Discuss impact of caregiving at home Promotes improved communication with family members to assess between family members and health 11 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. potential problems; include siblings. professionals; promotes positive relationships between parent-child and child-sibling. Provide support and praise for family Positive reinforcement empowers the members as they take over the care of family to provide optimum care. their child. NIC: Family Mobilization Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did family obtain and demonstrate use of equipment? Did family care for child as indicated in specified outcome parameters?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR CYSTIC FIBROSIS 12 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. 13 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=20&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:51:23 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=20 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.5 - CYSTIC FIBROSIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 14 of 14 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=21&FxId=123&Sessi. CHAPTER 3.6 - EPIGLOTTITIS INTRODUCTION Epiglottitis is the acute inflammation of the epiglottis and surrounding laryngeal area with the associated edema that constitutes an emergency situation as the supraglottic area becomes obstructed. The child characteristically appears very ill with a fever, severe sore throat, muffled voice, and insists on sitting upright with the chin extended and mouth open. Drooling is common because of inability to swallow, and respiratory distress is progressive as the obstruction advances. No examination of the oropharynx is performed until emergency equipment and personnel are readily available. Respiratory distress must be relieved by endotracheal intubation or tracheostomy in severe cases. Onset is rapid (over 4-12 hours) and breathing pattern usually re-established within 72 hours following intubation and antimicrobial therapy. Children most commonly affected are between 2 and 7 years of age. MEDICAL CARE Immunization: hemophilus, type B vaccination, to protect against the Hemophilus influenzae, type B, the most common cause of epiglottitis. Antipyretics/Analgesics: acetaminophen to reduce fever and relieve throat pain. Ibuprofen (nonsteroidal anti-inflammatory) for children 6 months to 12 years; to reduce fever and inflammation. Antibiotics: ampicillin; chloramphenicol (Chloromycetin Palmitate suspension); cefuroxime sodium. Corticosteroids: reduces inflammation of the epiglottis, improving oxygenation; dexamethasone. Oxygen Therapy: treats potential hypoxia; administered by tent, mask, cannula or via endotrachial tube. Neck X-ray: may be done to view lateral neck to diagnose condition. Throat Culture: reveals and identifies causative agent and sensitivity to specific antimicrobial therapy. Done only under direct supervision of a physician, emergency equipment for intubation should be readily available. Blood Culture: reveals and identifies causative agent or presence of other infectious agent. Arterial Blood Gases: reveals decreased pH, pO2; increased pCO2 as respiratory distress becomes more acute and ventilation perfusion disturbance occurs. COMMON NURSING DIAGNOSES See INEFFECTIVE AIRWAY CLEARANCE Related to: Obstruction. Defining Characteristics: (Specify: sudden increase in temperature, dyspnea, tachypnea, drooling, difficulty in swallowing, bright red epiglottis with edema, decreased breath sounds, muffled voice, sore throat, neck X-ray results.) 1 of 7 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=21&FxId=123&Sessi. See INEFFECTIVE BREATHING PATTERN Related to: Inflammatory process, obstruction. Defining Characteristics: (Specify: air hunger, dyspnea, tachypnea, use of accessory muscles [intercostal, sub or suprasternal retractions], assumption of three-point position, sitting up with mouth open and chin forward, stridor or croaking sound on inspiration.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Loss of fluid through respirations and temperature, altered intake. Defining Characteristics: (Specify: increased body temperature, dry skin and mucous membranes, decreased skin turgor, increased pulse and respirations, sore throat and difficulty in swallowing, refusal to drink fluids.) See HYPERTHERMIA Related to: Inflammation/infection of epiglottis. Defining Characteristics: (Specify: sudden increase in body temperature above normal range, specify, warm to touch, increased pulse and respirations, positive culture.) ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: Specify: change in health status of child; change in environment (hospitalization); change in role functioning (parenting). Defining Characteristics: (Specify: verbalization of extreme fear and apprehension by parents; agitation, crying, irritability, air hunger and extreme expression of fear [child].) Goal: Clients will experience decreased levels of anxiety by (date/time to evaluate). Outcome Criteria √ Clients verbalize decreased anxiety. √ Child appears calm without crying or irritability. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess severity of fear and anxiety Provides information about of parents and child. presence of extreme anxiety as symptoms of disease become more acute and breathing more 2 of 7 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=21&FxId=123&Sessi. difficult. Provide calm and supportive Provides reassurance and environment and reassure parents reduces anxiety of parents. that best care is being given to child. Allow child to assume position of Promotes comfort and security comfort, provide familiar object for child. (toy, blanket); tripod position may offer the most comfort. Remain with child at all times Provides constant assessment during acute stages. for emergency interventions and reassurance for parents. Encourage parents to stay with Promotes security needs for child, provide a place for rest. child and assists in reducing parental anxiety. Teach parents about all procedures, Reduces anxiety caused by fear care, and changes in the child's of the unknown. condition. Avoid any care or procedures that Prevents increase of anxiety are not necessary during acute which increases respiratory stage. distress. Allow child to remain seated on Reduces child's anxiety and parent's lap during all care, avoids precipitating a including lateral neck X-ray if complete obstruction. ordered. Allow for expression of fears and Reduces anxiety and feelings of parents and child and embarrassment. for behaviors caused by severe anxiety. Orient parents and child to room, Familiarizes them to hospital equipment, supplies and policies. environment. Teach parents that swelling Provides confirmation of subsides 24 hours after positive outcome and reduces antibiotic therapy is initiated anxiety. and epiglottis usually returns to normal in about 3 days. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did client verbalize decreased anxiety? Use quotes. Describe child's behavior.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR SUFFOCATION 3 of 7 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=21&FxId=123&Sessi. Related to: Disease process. Defining Characteristics: (Specify: supraglottic edema; obstruction; dysphasia; hypoxia; cyanosis; extreme anxiety, with struggle to breathe.) Goal: Child will not experience suffocation by (date/time

to evaluate). Outcome Criteria √ Preventive measures taken to ensure patent airway. √ Child's airway remains open either naturally or by means of ET tube or tracheostomy. NOC: Risk Control INTERVENTIONS RATIONALES Assess for changes in skin color from Provides information about pallor to cyanosis, severe dyspnea increasing airway and sternal and intercostal obstruction. retractions, lethargy, increased pulse (specify when). Allow to sit up and avoid forcing Lying down may cause epiglottis child to lie down. to fall backward, causing airway obstruction. Avoid inspecting throat with tongue Leads to airway spasms and blade or obtaining throat culture obstruction. unless immediate emergency equipment and personnel at hand. Administer O2 and monitor via pulse Promotes oxygenation of tissues oximeter. and prevents hypoxemia. Have emergency intubation equipment Establishes airway if at hand and assist with obstruction present and endotracheal intubation or respiratory failure and tracheostomy if necessary, or asphyxia imminent. prepare for procedure in surgery. Provide parents with explanation of Explanations provide care and all procedures and reason information and support for and procedure for emergency parents who are not familiar intubation or tracheostomy if with procedures. needed while hospitalized. Inform parents of reason for Prepares parents with restraints if emergency procedure information of what to done, that swelling is reduced expect. after 24 hours of therapy and tube will probably be removed after 3 days. NIC: Airway Management Evaluation 4 of 7 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=21&FxId=123&Sessi. (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe status of child's airway.) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE (PREVENTIVE CARE) Related to: The promotion of health-seeking behaviors within the hospital and/or home to prevent complications and speed recovery (specify). Defining Characteristics: (Specify: parents request information about caregiving and preventive measures; child readmitted to hospital with complications.) Goal: Parents will gain understanding of preventive care by (date/time to evaluate). Outcome Criteria √ Parents verbalize signs and symptoms to report to the physician. √ Parents demonstrate correct medication administration for the child. NOC: Knowledge: Treatment Regimen INTERVENTIONS RATIONALES Teach parents on the administration Promotes understanding that may of prescribed medications improve consistency of (specify). medication administration and recognition of adverse effects. Teach parents the signs and symptoms Encourages parents to seek prompt of respiratory distress (specify). medical treatment as necessary. Instruct parents on the importance Prevents secondary infections; of rest and good nutrition, to promotes body's own natural prevent illness. defenses. Encourage and teach parents to Promotes parental identity and provide care for the hospitalized control; may lessen anxiety and child at a level they are stress. comfortable with and within the constraints of necessary treatments. Teach parents, child, and family Prevents transmission of illness. members, as applicable, on good handwashing techniques and the proper disposal of soiled tissues, and so forth. Evaluate parents' understanding of Provides information about 5 of 7 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=21&FxId=123&Sessi. teaching and reinforce as needed. additional teaching needs. Offer praise for efforts. Positive reinforcement promotes self-esteem and pride in caring for the child properly. NIC: Teaching: Prescribed Medication Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents verbalize understanding of signs to report? Provide quotes. Did parents demonstrate medication administration?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR EPIGLOTTITIS 6 of 7 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=21&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:51:38 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=21 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.6 - EPIGLOTTITIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 7 of 7 12/22/2006 7:21 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=22&FxId=123&Sessi. CHAPTER 3.7 - CROUP INTRODUCTION Laryngotracheobronchitis (LTB) is the most common form of croup. It is characterized by an acute viral infection of the larynx, trachea, and bronchi which causes obstruction below the level of the vocal cords. Spasmodic croup is croup of sudden onset, occurring mainly at night and characterized by laryngeal obstruction at the level of the vocal cords caused by viral infections or allergens. Both occur as a result of upper respiratory infection, edema, and spasms that cause respiratory distress in varying degrees depending on the amount of obstruction. The disease most commonly affects infants and small children between 3 months and 3 years of age and occurs in the winter months. Hospitalization is reserved for those with severe symptoms and compromised respiratory function caused by the obstruction. MEDICAL CARE Antipyretics: acetaminophen to reduce fever; Ibuprofen (nonsteroidal anti-inflammatory) for children 6 months to 12 years; to decrease fever and inflammation. Bronchodilators: racemic epinephrine inhalant given by nebulizer or intermittent positive pressure breathing device (IPPB) to relax respiratory smooth muscle and relieve stridor respirations. Corticosteroids: to reduce inflammation and edema around the vocal cords. Antibiotics: antibiotic selection dependent on culture sensitivity results. Oxygen Therapy: treats hypoxemia based on reduced pO2 levels of ABGs, administered by tent or hood. Chest/Neck X-rays: differentiate between croup disorders and epiglottitis. Throat Culture: reveals and identifies infectious agent and sensitivity to specific antimicrobial therapy. Arterial Blood Gases: reveal hypoxemic states that require oxygen therapy; decreased pH, and changes in oxygen and carbon dioxide levels, indicating respiratory acidosis or failure in severe cases. Complete Blood Count: reveals increased WBC if infection present. COMMON NURSING DIAGNOSES See INEFFECTIVE AIRWAY CLEARANCE Related to: Tracheobronchial obstruction. Defining Characteristics: (Specify: dyspnea; thick secretions; tachypnea; hoarseness; persistent barking cough; diminished breath sounds, with scattered crackles and rhonchi; cyanosis; restlessness; tachycardia; hypoxemia; hypercapnia.) 1 of 8 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=22&FxId=123&Sessi. See INEFFECTIVE BREATHING PATTERN Related to: Inflammatory process, laryngotracheobronchial obstruction. Defining Characteristics: (Specify: dyspnea, tachypnea, abnormal ABGs, barking, metallic sounding cough, nasal flaring, inspiratory stridor, subclavicular and substernal retractions, cyanosis or pallor, restlessness, irritability.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Loss of fluid through normal routes (respirations and temperature), altered intake. Defining Characteristics: (Specify: low grade temperature, dry skin and mucous membranes, increased pulse and respiration, difficult swallowing, poor skin turgor, sunken fontanels, and absence of tears.) See DISTURBED SLEEP PATTERN Related to: Difficult breathing. Defining Characteristics: Interrupted sleep caused by cough, restlessness, irritability (describe). ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: Change in health status of infant/small child; threat to or change in environment (hospitalization). Defining Characteristics: (Specify: increased apprehension that condition might worsen and hospitalization might be necessary [parental]; crying and clinging behaviors, refusal to eat or play [infant or small child]; persistent cough and breathing difficulty [infant/small child].) Goal: Client will experience decreased anxiety by (date/time to evaluate). Outcome Criteria √ Parent verbalizes decreased anxiety. √ Child is calm, not crying. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess level and sources of anxiety Provides information about need of parents and child and identify for interventions to relieve behaviors caused by anxiety. anxiety and concern. Allow parents to express concerns Provides opportunity to vent and to ask questions about course feelings, secure information 2 of 8 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=22&FxId=123&Sessi. of disease and what to expect. needed to reduce anxiety. Encourage parents and child to Anxiety affects respirations and remain calm and provide a quiet calm environment reduces environment. anxiety. Inform parents and child of all Relieves anxiety resulting from procedures, especially use of fear of the unknown. croup tent, care and any changes in condition. Encourage parents to stay with Allows parents to care for and infant/small child if support child and provide hospitalized, bring toy, blanket familiar objects and people to from home; allow visits from reduce child's anxiety. siblings. If hospitalized, carry out home Prevents anxiety associated with routines for feeding, sleep. changes in daily rituals. Explain course of disease to parents Reduces anxiety caused by the and child, that recovery is fairly sound of the breathing and prompt with proper therapy, and appearance of the infant/small that cough may persist for a week child. or more after recovery. Clarify any misinformation and Prevents unnecessary anxiety answer all questions regarding the resulting from inaccurate disease process and manifestations. information or beliefs. If tent is used, instruct and assist Promotes support to child and parents in interacting with child. relieves anxiety. Inform and discuss signs and Reduces anxiety caused by symptoms indicating increasing increasing acuteness of severity of disease and actions to condition by knowledge of what take. to do and when to report to physician. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did parent say about anxiety level? Describe child's behavior) (Revisions to care plan? D/C care plan? Continue care plan?) FATIGUE Related to: Dyspnea. Defining Characteristics: (Specify: lethargy or listlessness, emotional lability or irritability, exhausted appearance, inability to eat.) 3 of 8 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=22&FxId=123&Sessi. Goal: Child will experience increased energy by (date/time to evaluate). Outcome Criteria √ Child sleeps (specify number of hours) without interruption. √ Child eats and drinks (specify amount or percentage). NOC: Energy Conservation INTERVENTIONS RATIONALES Assess for weakness and fatigue, Dyspnea and work of breathing over ability to rest, sleep, and eat. period of time exhausts the infant/child's energy reserves affecting ability to rest, eat, drink. Disturb only when necessary, Conserves energy and prevents perform all care at one time interruptions in rest. instead of spreading over a long period of time. Schedule and provide rest periods Promotes adequate rest and reduces in a quiet, comfortable stimuli to decrease fatigue. environment (temperature and humidity). Allow quiet play while maintaining Rest decreases fatigue and bed rest. respiratory distress; quiet play prevents excessive activity, which depletes energy and increases respirations. Explain need to conserve energy and Promotes understanding of infant/ avoid fatigue to parents and young child's response to child. respiratory distress and importance of rest and support to prevent fatigue. Suggest measures to take to prevent Provides support to infant/small fatigue (holding and/or rocking child and conserves energy. infant/young child, feeding slowly in small amounts, playing with child, offer TV and other diversions). Teach parents to decrease crying Prevents fatigue, as prolonged and not allow infant to cry crying exhausts infant. longer than 1 to 2 minutes. Assist parents to make a plan for Prevents interruption in rest or providing bathing, feeding, sleep. changing diaper around rest periods. NIC: Energy Management 4 of 8 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=22&FxId=123&Sessi. Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Specify how long child sleeps and describe how much child is eating.) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE OF PARENTS: CARETAKER Related to: Caregiving to prevent complications and speed recovery. Defining Characteristics: (Specify, use quotes: parents request information about the home care of the child and/or preventive measures.) Goal: Parents will understand how to care for ill child by (date/time to evaluate). Outcome Criteria √ Parents verbalize how to provide warm mist for spasmodic croup. √ Parents identify when to seek medical care for their child. NOC: Knowledge: Treatment Regimen INTERVENTIONS RATIONALES Assess parent's understanding of Provides baseline data for child's illness. teaching. Teach parents to seek medical care if Provides parents with guidelines their child has a high fever (>101° to obtain health care when F) or any signs of respiratory needed. distress. Instruct parents on the Improves consistency of administration of prescribed medication administration and medications (specify). recognition of adverse side effects. Teach parents the importance of rest Prevents secondary infections (specify quantity). and/or relapses. Teach parents to provide good Promotes liquification of nutrition and

hydration, secretions, and replaces emphasizing a high calorie balanced calories used to fight diet and increased fluids infections, boosting the (specify). child's own natural defenses. Teach parents how to provide humidity Decreases bronchial spasms and by sitting in the bathroom with the inflammation. door closed and a hot shower running, while holding the child. 5 of 8 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=22&FxId=123&Sessi. Protect the child from burns. Also, teach that taking the child out into the cool night air when taking child to the hospital, may decrease the symptoms. Encourage and teach parents to Promotes parental identity and provide care for the hospitalized control; may lessen anxiety child at a level they are and stress. comfortable with, and within the constraints of necessary treatments (specify). Teach good handwashing techniques, Prevents transmission of and the appropriate disposal of illness. soiled tissues. Encourage parents to limit visitors Prevents transmission of and screen them for recent illness. illness; prevents or minimizes risk of complications for the infected child. Teach parents that spasmodic croup Provides anticipatory guidance may reoccur for 1 or 2 nights. to parents. NIC: Teaching: Individual Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Using quotes, what did parents say about how to provide warm mist for spasmodic croup? When did they say they would seek medical care for their child?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR CROUP 6 of 8 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=22&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 7 of 8 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=22&FxId=123&Sessi. 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:51:55 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=22 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.7 - CROUP Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 8 of 8 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=23&FxId=123&Sessi. CHAPTER 3.8 - OTITIS MEDIA INTRODUCTION Otitis Media (OM) is an infection of the middle ear most common in infants and toddlers during the winter months. It may be either viral or bacterial. Inflammatory obstruction of the eustachian tube causes accumulation of secretions in the middle ear and negative pressure from lack of ventilation. The negative pressure pulls fluid and microorganisms into the middle ear through the eustachian tube resulting in otitis media with effusion. The illness usually follows a URI or cold. The older child runs a fever, is irritable, and complains of severe earache, while a neonate may be afebrile and appear lethargic. The child may or may not have a purulent discharge from the affected ear. Myringotomy is a surgical procedure performed to equalize the pressure by inserting tubes through the tympanic membrane. The tympanostomy tubes remain in place until they spontaneously fall out. Most children outgrow the tendency for OM by the age of 6. There is a higher incidence in children exposed to passive tobacco smoke and decreased incidence in breast-fed infants. MEDICAL CARE Antipyretics and Analgesics: to decrease fever and pain. Antibiotics: when indicated for bacterial infection, a full 10 day course of an appropriate antibiotic: amoxicillin-clavulanate, trimethorprim-sulfamethoxazole, erythromycin, sulfonamides, cephalosporins, and so forth. Tympanometry: provides information about pressure on the tympanic membrane. Otoscopy: reveals a red, bulging tympanic membrane. COMMON NURSING DIAGNOSES See HYPERTHERMIA Related to: Acute illness. Defining Characteristics: (Specify infant/child's temperature.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Inadequate intake. Defining Characteristics: (Specify client's intake and output; describe feeding behavior of infant, e.g., begins to suck and pulls away crying; poor skin turgor, dark urine, etc.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inadequate intake for age and size. 1 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=23&FxId=123&Sessi. Defining Characteristics: (Specify: e.g., refusal to eat; picks at food; cries that ear hurts when swallowing; low percentage of meals eaten [specify]; weight loss.) See DISTURBED SLEEP PATTERN Related to: Ear discomfort. Defining Characteristics: (Specify: child wakes crying; sleeps fitfully.) ADDITIONAL NURSING DIAGNOSES PAIN Related to: Increased pressure in the middle ear. Defining Characteristics: (Specify: e.g., infant is pulling at ear and crying, child states "my ear hurts"; rate pain on an appropriate pain scale for age and development.) Goal: Client will experience relief from pain by (date/time to evaluate). Outcome Criteria √ Child rates pain < (specify for scale used). √ Infant does not pull at ear, is calm and not crying, pain rating is < (use a pain scale designed for infants). NOC: Comfort Level INTERVENTIONS RATIONALES Assess client's pain (specify how Use of a pain scale allows frequently) using the (specify) pain measurement of changes in level scale. Note if infant is irritable of pain by different providers. or pulling or rubbing an ear. Preverbal infants frequently pull or rub the affected ear and appear irritable. Assess vital signs (specify which, Pain may cause tachycardia and e.g., TPR or TPR or BO) q 4h and as tachypnea; fever may increase indicated by client's condition. discomfort. Administer pain medication (specify Specify the action of the drug, dose, route, and times) as medication to decrease pain. ordered. Monitor child for relief of pain Provides information about the (specify appropriate time frame for effectiveness of the medication drug) and any side effects of and prevents complications. medication (specify). Encourage and assist the parent to Provides tactile comfort and hold and comfort the client. distraction for the ill child. 2 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=23&FxId=123&Sessi. (Specify: e.g., holding, rocking, or kangaroo care for an infant.) Suggest that a warm heating pad or an Heat may facilitate vasodilation ice pack might provide comfort. and drainage if the child lies on (Specify if the child is old enough the affected side. Cold may to choose.) Ensure safety by turning reduce edema and pain. the heating pad only to low and covering it with a towel. Teach parents to check for overheating and to never turn the control higher than low. Reassure parents that the discomfort Parents may be concerned about usually subsides within a day on their child's pain but may not antibiotics but reinforce that the know to continue the antibiotic whole prescription should be taken. after symptoms subside. NIC: Kangaroo Care Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Using quotes when possible, what is pain rating after implementation of care plan? Describe infant's behavior.) (Revisions to care plan? D/C care plan? Continue care plan?) DISTURBED SENSORY PERCEPTION: AUDITORY Related to: Inflammation and edema of middle ear. Defining Characteristics: (Specify: child complains of not being able to hear; does not respond when spoken to; infant does not respond to sounds as usual.) Goal: Client will regain usual hearing level by (date/time to evaluate). Outcome Criteria √ Specify, e.g., child states that hearing has returned to "normal." √ Infant responds to sounds made behind him or her. NOC: Anxiety Control INTERVENTIONS RATIONALES Observe the client's response to Provides baseline assessment sound. Ask an older child to data about degree of hearing 3 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=23&FxId=123&Sessi. describe hearing loss (e.g., do loss. things sound muffled, or is there no sound in the affected ear?). Reassure parents and child that Decreases anxiety over sensory hearing loss is temporary and will loss. resolve with treatment. Provide information about OM and answer any questions. Speak in a loud and clear voice and Assists the client to hear what face child when talking. Encourage is being said. parents also to do this. Administer medications as ordered Describe action of drug that (specify drugs, doses, routes, will resolve OM and restore times). hearing. Decrease unnecessary environmental The child may be confused and noise (specify, e.g., TV, alarms, frightened by sounds he or staff noise, etc.) she cannot hear properly. Notify caregiver of changes in Complications of OM may include hearing ability or drainage from conductive hearing loss or a affected ear. perforated tympanic membrane. NIC: Communication Enhancement: Hearing Deficit Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did child report that hearing was improved? Use quotes. Describe infant's behavior related to sounds—compare to before interventions.) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE: PARENTS, PREVENTION OF OM Related to: (Specify, e.g., lack of information; lack of recall of information; misinterpreted information.) Defining Characteristics: (Specify, e.g., parents allow smoking in the home so child is exposed to passive smoke; infant is bottle-fed and sometimes the infant lies flat with the bottle propped.) Goal: Parents will gain knowledge about prevention of OM by (date/time to evaluate). Outcome Criteria √ Parents verbalize understanding of OM. √ Parents verbalize understanding of 3 factors that may contribute to OM. 4 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=23&FxId=123&Sessi. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Provide privacy for discussion, Shows respect for the parents promote trust, remain nonjudgmental, and opens communication. and support parents. Assess parent's current understanding Provides baseline information of OM, the risks of exposing the about current knowledge. infant/child to passive smoking, feeding activities with infant, and exposure to illness. Teach parents (and child if age- Provides information by appropriate) about OM using an ear auditory and visual means and model for demonstration. Ask parents assesses understanding. to verbalize their understanding of teaching. Discuss possible causes of OM: Provides information about exposure to illness of others, health promotion. irritation from environmental smoke, and/or formula entering the eustachian tube when the infant is fed in a supine position. Assist parents to plan ways to Empower parents to make good decrease the chances of recurrent parenting decisions for their OM. Make suggestions as needed: take child to help prevent OM. entire course of antibiotic; avoid sick people; maintain a smoke-free home; feed the infant while being held in a sitting position. Provide praise for decisions that will Positive reinforcement supports promote wellness for the child and decision to improve family. lifestyle. Refer parents to (specify, e.g., Encourages follow-up and caregiver, smoking cessation, or gaining additional knowledge parenting skills class) as needed. and skills. NIC: Health Education Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents verbalize understanding of OM? What 3 factors did parents identify that may contribute to OM? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR OTITIS MEDIA 5 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=23&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: 6 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=23&FxId=123&Sessi. Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:52:11 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=23 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.8 - OTITIS MEDIA Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 7 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=24&FxId=123&Sessi. CHAPTER 3.9 - PNEUMONIA INTRODUCTION Pneumonia is a lower respiratory condition characterized by the inflammation or infection of the pulmonary parenchyma. It

is caused by bacteria, viruses, or fungi, or by the aspiration of a foreign substance. It may occur as a primary infection or secondary to another illness or infection. Pneumonia is most common in infants and small children, but it can occur throughout childhood. Signs and symptoms of the disease depend on the age, causative agent, extent of the disease, and the degree of obstruction it causes and the systemic reaction to the infection. The treatment and care is similar for all types of pneumonia. MEDICAL CARE Antipyretics: acetaminophen to reduce fever; Ibuprofen (nonsteroidal anti-inflammatory) for children 6 months to 12 years; to reduce fever and inflammation. Antibiotics: penicillin G to treat pneumococcal, streptococcal, or staphylococcal pneumonia; Erythromycin, Trimethoprimsulfamethoxazole, Climadycin, Chloramphenicol, or cephalosporins for penicillin-allergic children. Oxygen Therapy: treats hypoxemia, administered by oxygen tent or hood. Chest X-ray: reveals patchy areas of consolidation in one lobe or throughout lung, varying sizes of pneumatoceles or disseminated infiltration dependent on causative agent. Sputum Culture: reveals and identifies infectious agent and sensitivity to specific antimicrobial therapy. Blood Culture: reveals positive reaction for causative agent. Complete Blood Count: increased WBC of 15,000 or over 20,000/cu mm. Antistreptolysin-O Titer: elevation indicates recent streptococcal infection if above 333 Todd units. COMMON NURSING DIAGNOSES See INEFFECTIVE BREATHING PATTERN Related to: Inflammatory process. Defining Characteristics: (Specify: dyspnea, tachypnea, grunting and nonproductive cough in small child, nasal flaring, decreased dull breath sounds, crackles, productive cough in older child, use of accessory muscles with retractions, circumoral cyanosis, shallow respirations, increased fremitus.) See RISK FOR DEFICIENT FLUID VOLUME 1 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=24&FxId=123&Sessi. Related to: Excessive losses through normal routes, fluid intake. Defining Characteristics: (Specify: increased temperature and pulse rate tachypnea, vomiting and diarrhea in young child, reduced fluids in proportion to output, provide I&O.). See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food or digest food. Defining Characteristics: (Specify: lack of interest in food, anorexia, cough, abdominal pain, vomiting and diarrhea in younger child.) ADDITIONAL DIAGNOSES HYPERTHERMIA Related to: Illness of lower respiratory tract infection. Defining Characteristics: (Specify: abrupt onset of high body temperature, tachycardia, tachypnea, chills, myalgia, warm to touch, flushed cheeks, convulsions in infant/young child.) Goal: Client will be normothermic by (date/time to evaluate). Outcome Criteria √ Temperature between 97 and 100° F. NOC: Thermoregulation INTERVENTIONS RATIONALES Assess temperature (specify route Provides information about the and frequency). effectiveness of care. Administer antipyretic medications Specify action of drug in as ordered (specify drug, dose, lowering temperature. Specify route, and times) and reassess timing until peak action of temperature (state when). specific medication. Remove any extra clothing or covers Helps reduce skin temperature the child may have on after the by convection after the set antipyretic has taken effect. point has been lowered. Encourage fluids (specify if IV Additional fluids help prevent running or PO amounts—at least 30 elevated temperature cc/hr) that child likes associated with dehydration. (specify). Teach parents how to take the Teaching empowers parents to child's temperature (specify). care for their child. Teach parents about possible side Information helps prevent effects of antipyretic adverse effects from medications (specify). medications. 2 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=24&FxId=123&Sessi. Provide parents with instructions Empowers parents to care for about management of childhood their child. fever per caregiver preference (specify, e.g., when to use antipyretics, when to call the caregiver, etc.). NIC: Fever Treatment Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is client's temperature?) (Revisions to care plan? D/C care plan? Continue care plan?') RISK FOR INJURY Related to: Pulmonary complications. Defining Characteristics: (Specify: fluid accumulation in the pleural cavity, dyspnea, pneumothorax, empyema, decreased breath sounds with crackles, seizure activity with high temperature, staphylococcal-type pneumonia in infant, pneumococcal-type pneumonia in child.) Goal: Client will not experience injury by (date/time to evaluate). Outcome Criteria √ Breath sounds clear. √ Temperature <100° F. NOC: Risk Control INTERVENTIONS RATIONALES Assess vital signs and breath Changes revealed in early stages of sounds, cough and ability to cough complications and reveals airway up secretions (specify when). patency and dyspnea caused by fluid accumulation in pleural cavity and secretion accumulation in airways. Prepare (infant/child) for procedure Performed to drain fluid to be and assist with thoracentesis; use cultured or to instill therapeutic play to prepare child. antibiotics if infection present. Monitor temperature for sudden rise Reveals a sudden, rapid rise in (specify frequency). temperature which may trigger a 3 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=24&FxId=123&Sessi. febrile seizure. Report detection of possible Allows for immediate preventive respiratory complications (chest measures to be taken during pain, dyspnea, cyanosis, abdominal course of disease. distention), to physician. Reassure parents that complications Promotes a positive feeling in are uncommon because of parents for recovery of child. effectiveness of antibiotic therapy. Inform parents that recovery from Promotes awareness and compliance the disease is usually rapid and of parents to note respiratory uneventful if symptoms are changes and report them reported early for proper immediately to prevent treatment. complications. Teach parents and child to report Indicates possible pulmonary changes in respirations, sputum, infection. temperature elevation. NIC: Infection Control Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe breath sounds; what is client's temperature?) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE: PNEUMONIA Related to: Unfamiliarity with disease and complications, measures to control and prevent transmission of respiratory disease. Defining Characteristics: (Specify: use quotes, verbalization of need for information about medications, activity and rest, nutritional and fluid requirements and medical asepsis techniques to prevent spread of infection.) Goal: Parents will obtain knowledge about pneumonia by (date/time to evaluate). Outcome Criteria √ Parents verbalize understanding about disease and treatment methods. √ Parents verbalize signs of respiratory distress to report (specify). √ Parents demonstrate correct handwashing and disposal of used tissues. NOC: Knowledge: Treatment Regimen 4 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=24&FxId=123&Sessi. INTERVENTIONS RATIONALES Assess parents' knowledge of disease Promotes plan of instruction that is and methods to control and resolve realistic and prevents repetition disease. of information. Provide information and explanations Ensures understanding based on in clear, understandable language; readiness and ability to learn; use pictures, pamphlets, video visual aids reinforce learning. tapes, model in teaching about disease (specify). Instruct in administration of Provides information about drug medications including action of therapy, which is the most drugs, dosages, times, frequency, important treatment for the cure side effects, expected results, of pneumonia, and about prevention methods to give medications; provide of lung complications resulting written instructions and schedule to from the disease; bacterial follow and inform to administer full pneumonia is treated with course of antibiotic to child antibiotic therapy. (provide specifics). Instruct and assist to plan feedings Promotes proper diet, which enhances and/or develop menus for appropriate health status, and adequate fluid inclusion of nourishing fluids, intake, which prevents daily caloric and basic four dehydration. requirements for age group (specify). Teach about any activity restrictions Promotes more rest and possible and of adequate rest during illness restriction of activity needed and convalescence. during more acute stages of disease. Teach about care of used tissues and Prevents transmission of to cover mouth and nose when microorganisms by droplets coughing or blowing nose; proper dispersed into the air or by handwashing technique for parents hands. and child. Instruct parents on the signs and Encourages parents to seek prompt symptoms of impending respiratory medical treatment as necessary. distress (specify). NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents verbalize understanding about the disease and treatment and signs of respiratory distress to report? Provide quotes. Did parents wash hands and dispose of used tissues correctly or indicate that they would?) (Revisions to care plan? D/C care plan? Continue care plan?) 5 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=24&FxId=123&Sessi. FLOW CHART FOR PNEUMONIA COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. 6 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=24&FxId=123&Sessi. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:52:25 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=24 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.9 - PNEUMONIA Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 7 of 7 12/22/2006 7:22 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=25&FxId=123&Sessi. CHAPTER 3.10 - TONSILLITIS INTRODUCTION Tonsillitis is an infection of the tonsils, which consist of pairs of lymph tissue in the nasal and oropharyngeal passages. Bacterial or viral pharyngitis usually precedes infection of the tonsils. Inflammation and edema of the tonsillar tissue creates difficulty swallowing and talking, and forces the child to breathe through the mouth. Advanced infection can lead to cellulitis in adjacent tissue or formation of an abscess which may require drainage. The tonsils removed during a tonsillectomy are the palatine tonsils located in the oropharynx. The adenoids are tonsils located in the nasopharynx and also sometimes removed by adenoidectomy. MEDICAL CARE Rapid Strep Test/Throat Culture: to identify streptococcal tonsillitis requiring antibiotic treatment. Antibiotics: for streptococcal tonsillitis: penicillin, erythromycin, amoxicillin, azithromycin, cephalosporins. Antipyretics/Analgesics: acetaminophen to reduce fever and discomfort; throat lozenges. Tonsillectomy, Possibly with Adenoidectomy (T & A): may be done for recurrent bouts of tonsillitis or severe inflammation leading to obstruction. Surgery is delayed for 6 weeks after an acute infection. COMMON NURSING DIAGNOSES See INEFFECTIVE AIRWAY CLEARANCE Related to: Obstruction by inflamed lymphoid tissue. Defining Characteristics: (Specify, e.g., child complains of difficulty swallowing; breathes through mouth only.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Discomfort associated with swallowing. Defining Characteristics: (Specify: e.g., child refuses to eat, states "throat hurts"; give percentages of meals eaten.) See ANXIETY Related to: Perceived threat to biologic integrity of child secondary to invasive procedures. Defining Characteristics: (Specify, e.g., parents state they are anxious, confused about indications for surgery; parent is crying or irritable; describe behaviors.) ADDITIONAL NURSING DIAGNOSES 1 of 7 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=25&FxId=123&Sessi. RISK FOR DEFICIENT FLUID VOLUME Related to: Inadequate oral intake, excessive losses through abnormal route. Defining Characteristics: (Specify, e.g., child states it hurts to drink, decreased intake [specify amount]; post-tonsillectomy risk for hemorrhage.) Goal: Child will not experience deficient fluid volume by (date/time to evaluate). Outcome Criteria √ Intake equals output. √ No signs of bleeding from operative site. NOC: Fluid Balance INTERVENTIONS RATIONALES Assess hourly intake and output. Provides information about Monitor skin turgor and moisture of physiologic fluid balance and mucous membranes. signs of dehydration. Observe post-tonsillectomy client for Provides information about the signs of bleeding: assess operative integrity of the surgical site. site using a flashlight (specify Bleeding from the operative site frequency), monitor child for may cause the child to swallow excessive swallowing, even during frequently. sleep. Monitor vital signs per protocol Tachycardia and hypotension are (specify which parameters and physiologic responses to deficient frequency). fluid volume. Monitor and maintain IV fluids via Replaces losses from surgery and pump as ordered (specify fluid and maintains hydration if child is rate). Evaluate IV site hourly. unable to drink. Encourage child to drink small Small amounts may be more easily amounts of favorite clear liquids tolerated. Red or brown may be (specify, e.g., 30 cc per hour of confused with bleeding if child apple juice). Avoid red or brown- vomits. Suction created by sucking colored liquids or citrus. Do not could disrupt operative site, allow use of a straw. avoids risk for injury. Use creative, developmentally Child's desire to play or to gain appropriate techniques to make a approval can help promote game of

drinking (specify, e.g., increased intake. placing stars or coloring in blocks on a chart or earning stickers. Teach child to avoid excessive Excessive coughing, clearing the coughing or clearing of throat. throat, or vomiting may disrupt Administer antiemetics as ordered the operative site. (specify) to prevent vomiting. Provide parents with discharge Teaching ensures that parents will teaching regarding fluid intake, continue to monitor fluid balance. 2 of 7 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=25&FxId=123&Sessi. activity, and when to seek medical care (specify caregiver's orders). NIC: Fluid Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide intake and output specifying time frame. Is there any bleeding from operative site?) (Revisions to care plan? D/C care plan? Continue care plan?) PAIN Related to: Invasive procedure. Defining Characteristics: (Specify date/type of surgery; client statements about pain [use quotes], pain rating on a scale [specify which scale is used]; nonverbal indications of discomfort such as grimacing, crying, clinging to parent.) Goal: Child will experience decreased pain by (date/time to evaluate). Outcome Criteria √ (Specify, e.g., child states pain is less; rates pain lower on same scale; child not grimacing, crying, or clinging to parent.) NOC: Pain Level INTERVENTIONS RATIONALES Assess pain using appropriate pain Use of a pain scale allows scale for child's age and objective measurement of development (specify). subjective pain perception. Observe child for nonverbal Provides additional information indications of pain such as about pain. Child may find crying, grimacing, irritability. speaking causes discomfort. Administer pain medications as Specify action of medication in ordered (specify drug, dose, relieving pain. route, and time). Monitor for effectiveness and side effects (specify when). Encourage child to try placing an Cold causes vasoconstriction ice collar on the neck or to eat and reduces edema that frozen pops. contributes to pain. Suggest quiet activity such as Provides distraction from listening to music, watching TV discomfort. (specify). 3 of 7 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=25&FxId=123&Sessi. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did child report decreased pain? How did child rate pain? Describe nonverbal behavior.) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE: POSTOPERATIVE HOME CARE Related to: Lack of information about tonsillectomy and postoperative care. Defining Characteristics: (Specify, e.g., parents state or demonstrate lack of understanding of how to care for child after surgery.) Goal: Parents will gain the knowledge to care for the postoperative child safely at home by (date/time to evaluate). Outcome Criteria √ Parents verbalize understanding of postoperative care information. √ Parents demonstrate appropriate postoperative care of child (specify, e.g., encouraging child to drink 30 cc/hr). NOC: Knowledge: Treatment Regimen INTERVENTIONS RATIONALES Assess parents' understanding of the Provides baseline information illness and treatment. about parents' comprehension of illness. Allow time for teaching, use a variety Facilitates learning by ensuring of methods (specify, e.g., written parents' comfort. A variety of instructions, pictures, verbal methods ensures that even instruction), encourage questions and illiterate parents will reassure parents about child's receive appropriate teaching. condition. Provide information about the surgery Provides necessary information as needed. Teach parents that an for parents to recognize and important risk after a tonsillectomy prevent complications. is excessive bleeding from the operative site. Teach to observe for excessive swallowing and to encourage the child to avoid putting anything in the mouth, and to avoid excess coughing and clearing the throat. 4 of 7 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=25&FxId=123&Sessi. Provide physician's instructions regarding any bleeding (specify). Instruct parents to keep the child Provides information to prevent quiet for the first few days (specify complications. physician's orders) and inform when the child may return to school (specify). Teach parents to encourage child to Provides information to prevent drink clear liquids the first day, dehydration. advance to soft foods as per physician's preference (specify). Show parents how to evaluate for dehydration; how to monitor intake and output and test skin turgor. Provide medication teaching as needed Specify action of medications. (specify drug, dose, route, and times Aspirin may interfere with ordered) and instruct parents to blood clotting. avoid giving the child aspirin. Provide phone numbers in case parents Provides additional information have additional questions after as needed. discharge. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents verbalize understanding of care? Provide quotes. Describe parental behavior which indicates understanding of teaching.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR TONSILLITIS 5 of 7 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=25&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: 6 of 7 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=25&FxId=123&Sessi. Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:52:48 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=25 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.10 - TONSILLITIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 7 of 7 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=26&FxId=123&Sessi. CHAPTER 3.11 - TRACHEOSTOMY INTRODUCTION The surgical creation of an opening in the trachea between the second and fourth rings is known as a tracheostomy. In children, it may be done to provide an airway to by-pass an acute upper airway obstruction (subglottic stenosis, vocal cord paralysis, epiglottitis, croup) or for long-term mechanical ventilation administration. A plastic tube that softens at body temperature, usually without an inner cannula, is inserted in place and anchored with long sutures taped to the chest during surgery. These sutures remain in place for five days to hold the stoma open until a tract is formed in the trachea and skin. Routine care includes suctioning, cleaning and changing the tracheostomy tube, changing the ties that hold the tube in place, and dressing changes. Temporary tubes are removed when the condition permits and they are no longer needed. Long-term tubes are removed by weaning to the smallest tube with subsequent occlusion of the tube for a day and then final removal. MEDICAL CARE Cleansing Agents: hydrogen peroxide at half strength to cleanse around the stoma. Oxygen Therapy: supplements oxygen when ventilator removed for procedures to prevent hypoxemia, administered with humidication. Emergency Endotracheal Intubation: procedure done to provide airway in an emergency situation until crisis is resolved or tracheostomy is performed. COMMON NURSING DIAGNOSES See INEFFECTIVE AIRWAY CLEARANCE Related to: Tracheobronchial secretion, obstruction. Defining Characteristics: (Specify: abnormal breath sounds [crackles, wheezes], change in rate or depth of respirations, dyspnea, cyanosis, tube dislodgement or decannulation, tube occlusion, viscous secretion.) See IMPAIRED GAS EXCHANGE Related to: Altered oxygen supply. Defining Characteristics: (Specify: hypoxia, hypercapnia, inability to move secretions, improper suctioning procedure.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Presence of tracheostomy. Defining Characteristics: (Specify: secretions around tracheostomy tube; rash or redness around site; low environmental humidity; dry, crusting secretions around site; mechanical factor of pressure and irritation of tube movement.) 1 of 12 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=26&FxId=123&Sessi. See INEFFECTIVE BREATHING PATTERN Related to: Tracheobronchial obstruction, anxiety. Defining Characteristics: (Specify: tube occlusion or accidental decannulation, dyspnea, tachypnea, respiratory depth changes, viscous secretions, nasal flaring, accessory muscle retractions.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENT Related to: Inability to ingest food. Defining Characteristics: (Specify: poor feeding with tube in place, difficulty swallowing, choking.) ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: Threat to self-concept (tracheostomy); change in health status. Defining Characteristics: (Specify: increased apprehension, fear of procedures to care for tracheostomy, uncertainty about possible respiratory status changes, expressed feelings of distress over presence of tracheostomy.) Goal: Clients will experience decreased anxiety by (date/time to evaluate). Outcome Criteria √ Reduced parental and child anxiety verbalized. NOC: Coping INTERVENTIONS RATIONALES Assess level and manifestations of Provides information needed for anxiety in parents and child. interventions and clues to severity of anxiety. Allow parents and child to express Provides opportunity to vent fears and concerns and to ask feelings and secure information questions about disease and what to reduce anxiety. to expect. Provide supportive and nonjudgmental Promotes trust and reduces environment. anxiety. Encourage parents to stay with Reduces anxiety by allowing child, allow open visitation and presence and involvement in telephone communications; care, familiar routines and encourage to participate in care persons for child. that is planned around usual home routines. Inform of all procedures and care Reduces anxiety caused by fear of 2 of 12 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=26&FxId=123&Sessi. and any changes in the child's the unknown. condition. Provide child with pencil and paper, Provides means of communication pictures, slate as age allows and interaction with the child. (specify). Provide child with medical play Provides child the opportunity to objects such as a doll with a have hands on experience with tracheostomy, suction catheters, supplies; improves their tracheostomy tubes and ties, as understanding of procedures; applicable (specify). gives health care professionals some insight into the child's understanding of the procedure. Allow child to assume position of Promotes comfort and security. comfort, provide familiar object (toy or blanket). Provide child/parents tours of the Promotes understanding of what to PICU and the floor prior to the expect which may help to surgical procedures as applicable. decrease anxiety. Inform of disease process and Relieves anxiety by knowing what behaviors and physical effects and to expect, especially if symptoms of tracheostomy; assure tracheostomy is long-term. parents that tracheostomy will facilitate breathing. Explain to parents and child in age- Reduces anxiety caused by fear of related fashion reason for unknown. tracheostomy procedure or therapy, effects of presence of tracheostomy, how procedures are performed (specify). Clarify any misinformation with Prevents any unnecessary anxiety honesty and in simple resulting from inaccurate understandable language. information or beliefs. Refer to counseling, community Reduces anxiety by providing to groups or agencies (specify). parents and child support and information from those with similar problems. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did clients verbalize decreased anxiety? Provide quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION 3 of 12 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=26&FxId=123&Sessi. Related to: Invasive procedures (tracheostomy and care). Defining Characteristics: (Specify: stasis of secretions, suctioning tracheostomy, redness, excoriation, swelling and drainage at tracheostomy site, change in breath sounds and sputum, increased temperature, presence of infection of family members.) Goal: Client will not experience infection by (date/time to evaluate). Outcome Criteria √ Client's temperature remains <100° F. √ Breath sounds and secretions remain clear. NOC: Risk Control INTERVENTIONS RATIONALES Assess for change in breathing Indicates presence of pattern, color of mucus, respiratory infection. diminished breath sounds, ability to cough and raise secretions (specify when). Avoid exposure to persons with Prevents increased respiratory infection, isolate susceptibility and risk for from infectious patients or family infection. members. Utilize good handwashing technique Prevents transmission of before giving care or performing microorganisms to child. procedures. Demonstrate handwashing technique to Prevents cross-contamination by parents and child and allow for hands. return demonstration. Assist to cough or remove secretions Stasis of secretions provide by suctioning via sterile medium for infection. technique. Use medical asepsis techniques or Prevents exposure to infectious sterile technique when agents. administering tracheostomy and site care (specify). Change tracheostomy dressing, tube, Maintains cleanliness of wound and ties when soiled, wet, or and removes risk of contact encrusted with secretions as with infectious agents. needed. Administer antibiotic therapy if Provides protection from or ordered. (Specify drug, dose, treatment of infection by route, and times ordered.) destroying or inhibiting growth of microorganisms (specify). Obtain sputum or wound drainage Identifies

presence of culture, send to lab. pathogenic organisms. 4 of 12 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=26&FxId=123&Sessi. Teach parents of child's Provides information that any susceptibility to infection and to infection will compromise avoid contact of child with respiratory status and could persons or family members with be life-threatening. respiratory infections. Encourage parents to provide Provides humidity normally humidity to environment by obtained through mouth and vaporizer. pharynx. Inform parents to provide adequate Maintains fluid and nutritional fluid and nutritional intake based requirements of infant/child. on age (specify). Teach parents to report any changes Provides for immediate in sputum, respiratory status, interventions to control skin at tracheostomy site to infection. physician. Instruct parents and allow for Promotes sterility or demonstration of sterile or clean cleanliness of procedures technique. based on healing of tracheostomy site. NIC: Infection Protection Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is temperature? Describe breath sounds and secretions.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR ASPIRATION Related to: Presence of tracheostomy or endotracheal tube. Defining Characteristics: (Specify: impaired swallowing, vomiting, choking.) Goal: Client will not aspirate by (date/time to evaluate). Outcome Criteria √ Client swallows meals without choking, coughing, or changing color. NOC: Risk Control INTERVENTIONS RATIONALES Assess ability to swallow, type of Provides information about 5 of 12 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=26&FxId=123&Sessi. food consistency (solid or potential for choking or formula), age of child. aspiration. Offer small amounts of liquids Provides fluids and nutrients of initially and follow with a consistency that is best increases as tolerated; add cereal managed and swallowed to to infant formula or offer thick prevent choking. milkshakes to child (specify). Place in upright or sitting position Promotes flow of fluids and for feedings (or place on lap or foods by gravity. in infant seat); allow to remain in position for 30 minutes afterwards. If choking occurs, suction fluids Removes fluid or food from from mouth and airway; avoid airway to prevent aspiration; suctioning procedure after suctioning after feedings may feedings. cause nausea or vomiting. Instruct parents in types of foods Promotes nutrition requirements and liquids to offer infant/child. that are easier to tolerate and swallow with tube in place. Teach parents actions to take when Prevents aspiration of fluid or choking occurs; positions that are food into airway. most effective, procedure for feeding (specify). Teach parents to suction airway if Removes fluid or feedings from choking, perform after other airway. measures have failed. Inform parents to notify physician Prevents life-threatening in presence of respiratory situation caused by distress. suffocation. NIC: Aspiration Precautions Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did client swallow meal without choking, coughing, or changing color?) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: Tracheostomy complications. Defining Characteristics: (Specify: damage to tracheal mucosa by inappropriate suctioning, excessive movement or dislodgement of tube, accidental decannulation.) 6 of 12 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=26&FxId=123&Sessi. Goal: Client will not experience injury related to tracheostomy by (date/time to evaluate). Outcome Criteria √ Absence of respiratory distress (define). √ Tracheostomy tube remains in place and patent. NOC: Risk Control INTERVENTIONS RATIONALES Assess for proper tube placement, Ensures effective tube function to presence of an air leak around tube, provide airway for ventilation. patency of tube (specify when/how). Assess security of tapes and knots, Promotes safe use of ties to tightness of tapes by inserting stabilize tube, which should not small finger between tape and neck be frayed and should fit snugly (when?). circulation. without compromising Assess need for suctioning by noting Allows for removal of secretions change in breath sounds and to prevent obstruction and respiratory rate, depth, and ease. respiratory distress. Assess stay sutures if new Ensures safe placement of tracheostomy by noting security of tracheostomy tube and prevents tapes on side of neck, any movement dislodgement. or dislodgement of tube. Hold tube in place when dressing Prevents manipulation of tube that changed, ointment applied under causes mechanical irritation and wings of tube, changing tapes, or may dislodge tube. suctioning tube. Restrain if appropriate Prevents child from pulling tube developmentally and if needed; out accidentally; prevents inform parents and child of reason. injury. Monitor skin under restraints per protocol (specify). Suction carefully and intermittently, Clears airway and tube of use proper catheter size and secretions without damage to technique (specify). trachea, prolonged suctioning causes vagal stimulation and bradycardia and high pressure may damage mucosa of trachea. Provide spare tracheostomy tube, Provides for emergency scissors, bag, and proper sized mask interventions for airway and adaptor, oxygen source, and obstruction or decannulation. suctioning equipment at bedside. Change tapes 3 days after surgery and Ensures safety of procedures with tube 2 weeks after surgery per help at hand if needed. physician order, with 2 nurses present or respiratory therapist. Change tube if obstructed, reinsert Maintains effective tube new tube if dislodged; have 2 people functioning and airway patency. 7 of 12 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=26&FxId=123&Sessi. present. Teach, demonstrate, and allow parents Promotes continuity of care by to return demonstration of the tube parents if able to perform change (insertion and removal) to be skills and approved by done every month or as needed, tube physician; promotes independence ties change, suctioning and and control of family in child's cleansing of tube if long-term care care. needed. Teach parents of positive effects of Provides emotional support to tracheostomy, such as ease of parents and family. breathing, improved rest and feeding, progress in developmental tasks. Teach parents of equipment and Provides support for any supplies to have on hand. Assist emergency. family to obtain needed equipment. Inform parents to clothe child in Prevents obstruction of tube or loose-fitting clothing around neck entry of foreign materials. with no loose threads or frayed material, remove crumbs, beads or dangerous toys, careful bathing with elimination of water near tube; cover tube with bib when drinking or eating meals. Instruct parents to report any Prevents complications that may swelling or bleeding around tube, compromise respiratory status. increased respiratory effort, change in skin color, absence of air moving in and out of tube, inability to insert suction tube, excessive choking during feeding. NIC: Airway Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide data about respiratory status. Is tracheostomy tube in place and patent?) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE Related to: Lack of understanding of the care necessary for a child at home with a tracheostomy; impending discharge of child to home. Defining Characteristics: (Specify: parents request information regarding care of the child at home; child returns to the hospital because of 8 of 12 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=26&FxId=123&Sessi. problems encountered during/with caregiving at home. Goal: Parents will gain knowledge about caring for the child with a tracheostomy by (date/time to evaluate). Outcome Criteria √ Parents verbalize and demonstrate proper care of tracheostomy: site assessment, suctioning techniques, site care, tube changes, and emergency protocols (specify). NOC: Knowledge: Treatment Regimen INTERVENTIONS RATIONALES Instructions should be in short Understanding will be improved when sessions, tailored to parents' sessions are short and specific learning styles and needs; individualized; written materials written materials should be given reinforce learning and improve after each session if literate. comprehension. Notify local utilities and EMS Response time may be heightened if the regarding the child's condition. appropriate personnel are notified in advance. Facilitate the acquisition of Ensures appropriate supplies and necessary supplies and equipment equipment are available at needed at home, including suction discharge; promotes understanding of apparatus, oxygen, pulse oximetry, how equipment works. and so forth; coordinate the necessary teaching regarding the equipment as applicable. Contact local home health nursing Promotes feelings of control and agencies, as applicable; facilitate decreases anxiety within parents; arrangements. discharge is often a time of higher stress for parents, and they can become easily overwhelmed. Demonstrate all aspects of Including all family members and tracheostomy care for the child (if significant others may help expand applicable), family, and other the level of support felt by the significant caregivers; observe immediate family; stress will be return demonstrations; teaching decreased if they have a sense that should include: tracheostomy site they can have some time away, while assessment, suctioning techniques, still leaving the child in good tracheostomy site care, tracheostomy hands. changes, and emergency protocols. Instruct all caregivers on CPR, with Promotes increased understanding of return demonstrations encouraged; emergency resuscitation needs of reinforce with written materials or patient; prior knowledge of CPR may video. reduce stress felt by the family. Teach and encourage the family to Promotes normalcy within the family treat the child as normally as which facilitates positive possible, including information on adaptation; lessens anxiety and growth and development, discipline, stress. school, sibling reactions, the importance of play, and trips 9 of 12 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=26&FxId=123&Sessi. outside the home. Teach child and parents vocalization Promotes communication which enhances techniques as applicable. self-esteem and facilitates normal growth and development. NIC: Teaching: Procedure/Treatment Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents verbalize and demonstrate proper care of tracheostomy: site assessment, suctioning techniques, site care, tube changes, and emergency protocols?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR TRACHEOSTOMY 10 of 12 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=26&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 11 of 12 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=26&FxId=123&Sessi. 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:53:30 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=26 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.11 - TRACHEOSTOMY Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 12 of 12 12/22/2006 7:23 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=27&FxId=123&Sessi. CHAPTER 3.12 - TUBERCULOSIS INTRODUCTION Tuberculosis (TB) in children is usually contracted from an infected adult by droplets expelled from the respiratory tract and dispersed into the air. Although the incidence and death rate from TB are greater in other parts of the world, there has been an increase of cases in the United States. Rates are high among migrant workers, the homeless, and those who are HIV-positive. Most cases are managed at home with drug therapy. Only patients with more serious forms of the disease or who need special diagnostic tests are hospitalized. MEDICAL CARE Anti-infectives/Antituberculosis: isoniazid (INH) in combination with rifampin or pyrazinamide to inhibit bacterial growth (bacteriostatic action). Skin Tests: intradermal Mantoux test (purified protein derivative (PPD)) to screen for sensitivity to the bacillus as a result of past exposure, or to test for suspected tuberculosis. The American Academy of Pediatrics (2000) does not recommend tuberculin skin testing of children with no TB risk factors who live in communities with a low prevalence of TB. Sputum or Gastric Washing Culture: identifies causative agent in sputum coughed up from lower respiratory tract in children or fasting gastric contents in infants or young children who swallow sputum. Chest X-ray: reveals tuberculosis lesion if disease is suspected, but radiography results are difficult to differentiate from other diseases. COMMON NURSING DIAGNOSES See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food because of biologic, economic factors. Defining Characteristics: Inadequate food intake, lack of food availability, pyridoxine deficiency as result of drug therapy. ADDITIONAL NURSING DIAGNOSES DEFICIENT KNOWLEDGE: DISEASE PROCESS Related to: Unfamiliarity with disease and treatment. Defining

Characteristics: (Specify: verbalization of need for information about medications, activity and rest, nutritional requirements, and infection transmission prevention.) Goal: Parents will obtain knowledge about tuberculosis by (date/time to evaluate). Outcome Criteria 1 of 5 12/22/2006 7:24 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=27&FxId=123&Sessi. √ Parents verbalize understanding about tuberculosis and planned treatment. √ Parents demonstrate correct medication administration (specify drugs, dose, routes, and times). NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess knowledge of disease and Promotes plan of instruction that is methods to control and resolve realistic; prevents repetition of disease. information. Provide information and explanations Ensures understanding based on in clear, understandable language; readiness and ability to learn; use pictures, pamphlets, video visual aids reinforce learning. tapes, model in teaching about disease. Teach about administration of Provides information about drug medications, including action of therapy which is the most important drugs, dosages, times, frequency, treatment for the cure of side effects, expected results, tuberculosis and is methods to give medications; provide administered for at least 9 months written instructions and schedule during the course of the disease to follow (specify). and for 6 months after negative cultures secured; isoniazid alone or in combination with other antituberculosis drugs administered for active tuberculosis and conversion from negative to positive skin testing. Instruct and assist in planning Ensures proper diet that enhances feedings and/or developing menus health status, and adequate amounts for appropriate inclusions of meat of meat and milk supply vitamin B6 and milk and daily caloric and (pyridoxine) in those receiving basic four requirements for age isoniazid to prevent peripheral group. neuritis. Teach about activity or activity More rest and possible restrictions restrictions and adequate rest of activity needed during active during convalescence (specify). stage of disease, but school or nursery school attendance is encouraged if asymptomatic. Provide information about limiting Promotion of optimal health without competitive and contact sport injury will enhance complete activities when the disease is recovery. active. Teach about care of used tissues and Prevents transmission of to cover mouth and nose when microorganisms by droplets coughing or blowing nose, proper dispersed into the air. handwashing technique. Teach parents about prevention of Promotes the body's own defenses; unnecessary exposure to other prevents secondary infection and/or infectious diseases, including complications. maintaining the appropriate 2 of 5 12/22/2006 7:24 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=27&FxId=123&Sessi. immunizations as applicable (specify). Provide information about testing Provides early detection of disease family members and follow-up skin and possible source of disease, and tests for exposed contacts. prevents potential spread of disease. Provide parents information on Prevents transmission of the disease. isolation procedures, as needed, during the active stage of the illness (specify). Reinforce to parents the importance Recovery requires extended period of of maintaining the treatment time and support helps to ensure regimen over long period of time; compliance with regimen. offer information and support for continued care. Teach parents about protecting the Promotes body's own use of natural child from stressors, including defenses; stress may further weaken parental anxieties. those defenses. Encourage parents to verbalize and Reinforces teaching and promotes demonstrate understanding of optimal caregiving. teaching. Provide praise and support to family. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents verbalize understanding about tuberculosis and planned treatment? Provide quotes. Did parents demonstrate correct medication administration?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR TUBERCULOSIS 3 of 5 12/22/2006 7:24 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=27&FxId=123&Sessi. 4 of 5 12/22/2006 7:24 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=27&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:53:46 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=27 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.12 - TUBERCULOSIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 5 of 5 12/22/2006 7:24 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=28&FxId=123&Sessi. CHAPTER 3.13 - ALLERGIC RHINITIS INTRODUCTION Allergic rhinitis is an episodic or perennial upper respiratory tract condition characterized by sneezing, itching nose and eyes, and discharge from the nose and throat. Chronic nasal stuffiness and obstruction to airflow cause mouth breathing, otitis media, and eustachian tube abnormalities. Allergic rhinitis may manifest itself at any age in childhood. MEDICAL CARE Antihistamines (H1 receptor antagonist): given alone or in combination with a decongestant for nasal congestion and cough. Antihistamines (phenothiazine derivatives): given to prevent action of histamine, which provides relief from allergic conditions. Decongestants: nose drops or spray for older infants (over 6 months) and children; pseudoephedrine given for children over 2 years of age to relieve nasal congestion and clear passages; nose drops reduce swelling by vasoconstriction resulting from topical application. Skin Tests: identify allergic responses and sensitivities to antigens as a basis for desensitization therapy. Nasal Culture: reveals presence of eosinophils. Biopsy of Nasal Mucous Membrane: reveals eosinophils and abnormal mucosa. RAST Test: reveals and measures the immunoglobulin. COMMON NURSING DIAGNOSES See INEFFECTIVE BREATHING PATTERN Related to: Inflammatory process, obstruction. Defining Characteristics: Nasal stuffiness and obstruction, mouth breathing, mucus secretion and drainage, respiratory changes, breathing difficulty. See DISTURBED SLEEP PATTERN Related to: Internal factors of illness. Defining Characteristics: (Specify: interrupted sleep, irritability, restlessness, inability to breathe through nose). ADDITIONAL NURSING DIAGNOSES RISK FOR INFECTION 1 of 5 12/22/2006 7:26 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=28&FxId=123&Sessi. Related to: Chronic disease (allergy). Defining Characteristics: (Specify: nasal discharge; red, itchy conjunctiva; purulent discharge from nose or eyes; allergic shiners [dark areas under eyes], frequent colds, otitis media with pain and temperature elevation; pharyngitis.) Goal: Client will not experience an infection by (date/time to evaluate). Outcome Criteria √ Temperature <100° F. √ Secretions remain clear. NOC: Risk Control INTERVENTIONS RATIONALES Assess for rubbing of nose, nasal Provides information about physical discharge and its characteristics and behavioral effects of (clear, amount, purulent), dark allergic rhinitis; chronic nasal areas around eye, nose itching and obstruction causes edema and pushing hand up and back of nose, discoloration of the eyes and frequent sneezing, red and itchy mouth breathing, wrinkling of eyes and drainage or watering face is caused by attempt to (specify when). avoid rubbing or scratching of nose. Inspect nasal passages and throat Reveals inflammation and risk of with penlight for redness, infection spread. swelling, and presence of mucus and/or exudate; check skin around nares for redness, irritation (when). Assess for knowledge and use of Provides basis for information preventive measures needed to avoid needed for health maintenance. spread of microorganisms. Assess for frequency of upper Persistent reinfection usually the respiratory infections among family result of repeated exposures to members; attendance at school, microorganisms. daycare, nursery school. Assess use of over-the-counter Combination products are not medications and type used. particularly useful; symptomatic treatment more effective in controlling upper respiratory responses; overuse of some medications may cause undesirable side effects (drowsiness) or rebound effects (return of symptoms). Provide vaporizer or humidifier if Maintains moist mucous membranes to nasal and oral mucous membranes are prevent breaks and soreness. 2 of 5 12/22/2006 7:26 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=28&FxId=123&Sessi. dry. Administer antihistamines and Provides control of the symptoms immunotherapy if ordered alone or when exposed to allergens. in combination with decongestants (specify). Teach handwashing technique after Hands found to be most common exposure to nasopharyngeal carrier of microorganisms. secretions (sneezing, blowing nose). Instruct in disposal of tissues used Prevents transmission of for cough or nose wiping. microorganisms. Inform to avoid contact with infected Prevents exposure to the infectious people or family members, although agent, although isolation is not transmission commonly occurs in realistic within a family. families, schools, nursery schools, recreational gatherings. Instruct parents in administration of Ensures compliance with medication medications via oral and inhalation regimen to control symptoms and routes (specify). prevent infection. Instruct to administer all of the Ensures effective treatment of antibiotic prescribed for infection bacterial infection for prompt (if present). response within 24 hours after antibiotic administration. Teach about desensitization injection Allays child's anxiety and fear schedule. caused by injections. Teach parents measures to control Supports environment free of environment (air conditioning; allergens or irritants that cause removal of dust, pets, smoke). attacks. Inform to notify physician if the Allows for immediate interventions temperature increases, ear hurts, to treat at complications. throat is sore or nose has purulent drainage. NIC: Infection Prevention Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is temperature? Describe secretions.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR ALLERGIC RHINITIS 3 of 5 12/22/2006 7:26 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=28&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. 4 of 5 12/22/2006 7:26 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=28&FxId=123&Sessi. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:55:05 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=28 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 3 - RESPIRATORY SYSTEM CHAPTER 3.13 - ALLERGIC RHINITIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 5 of 5 12/22/2006 7:26 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. UNIT 4 - GASTROINTESTINAL SYSTEM CHAPTER 4.0 - GASTROINTESTINAL SYSTEM: BASIC CARE PLAN INTRODUCTION The gastrointestinal (GI) tract is a long passageway that functions to allow ingestion, digestion, and absorption of nutrients and fluids, and elimination of solid wastes from the body. The components of the GI tract are the mouth, teeth, salivary glands, esophagus, stomach, small intestine, pancreas, liver, gallbladder, large intestine, and anus. Inherited defects in structure or function, or infection, physiologic and psychological factors may affect ingestion, digestion, or elimination. The system is a common site of minor disorders in infants and children. GASTROINTESTINAL GROWTH AND DEVELOPMENT • Tooth eruption in infancy at 6 to 8 months with the primary set of teeth completed by approximately 2 years of age. • Striated muscles in the throat develop by 6 weeks of age and cerebral connections are developed at 6 months of age to assist in swallowing, which is a reflex activity up to 3 months of age and is stimulated by the flow of milk into the mouth. A coordinated muscular action of swallowing and sucking is necessary. • Sucking pads present in cheeks to assist sucking and remain until sucking not needed to obtain nutrition. • Stomach is round in shape until 2 years of age, elongates until 7 years of age when it assumes shape and position of an adult. • Stomach capacity increases: Newborn: 10 to 20 ml 1 to 3 weeks: 30 to 100 ml 1 to 3 months: 90 to 200 ml 1 to 2 years: 200 to 500 ml 10 years: 750 to 900 ml • Cardiac sphincter is immature and relaxed in infant causing regurgitation; as digestive system matures, this "spitting up" is outgrown by 6 to 7 months of age. • The intestinal tract in the infant and young child is longer than in the older child and the musculature and sphincters are underdeveloped with a deficiency of elastin fibers in the very young child. • Growth of the intestines increases between 1 to 3 years of age. • Digestive and absorptive surfaces are completely developed at birth. 1

of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. • The liver may sometimes be palpated 1 to 2 cm below the right costal margin in infants and young children. Palpation of the liver 3 cm or more below the costal margin indicates abnormal enlargement. • Sucking and swallowing are reflex activities without voluntary control until 3 months of age. Infants are capable of swallowing, holding food in the mouth and spitting food out of mouth by 6 months of age; swallowing becomes more coordinated and solid foods more acceptable with growth. • Chewing begins with eruption of primary teeth at about 6 months; a sense of taste with response to sweet and sour solutions is present at birth; sweet taste increases sucking and other tastes decrease sucking. • Stomach empties in 3 to 4 hours (breast milk faster than formula) in infant and 3 to 6 hours in older infant and child; begins to enter small intestine in 1 to 2 minutes after ingestion. • Immature system allows food to be propelled through system rapidly resulting in bowel elimination frequency and watery stools as water not absorbed as well as in older child; stool less frequent and more regular and becoming firmer as system becomes more efficient during the first year. • Intestinal flora introduced through the mouth and established by 2 days of life. • Stool changes from meconium to greenish black, greenish brown, greenish yellow (transitional stools) and then become yellowish and pasty in breast-fed infants and paler yellow in infants fed formula. • Salivary glands increase in size and mature in function by 3 years of age. • Gastric secretions increase in acidity with composition the same as an adult by 10 years of age. • Pancreatic amylase and lipase are deficient in infant and affect utilization of complex carbohydrates, and absorption of fats. • Liver function increases as growth takes place and liver matures; limited ability to conjugate bilirubin which may result in jaundice, but able to conjugate bilirubin and secrete bile by 2 weeks of age with bile composition mature at 6 months of age. • Gluconeogenesis, formation of plasma proteins and ketones, storage of vitamins and the breakdown of amino acids by the liver achieved by 1 year of age. • Basal metabolism rate is highest in infant and decreases as body increases in size; usually higher in boys than girls. • Appetite decreases by 2 years of age as growth and metabolic rate slows and food requirements are reduced. • Caloric requirements of child: Infant: 110 to 120 cal/kg/day Toddler: 1300 cal/day Preschool: 1800 cal/day School-age: 2400 cal/day 2 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. • Approximate weights (varies with sex, age frame, height): Birth: 51/2 to 10 lb (2500-4600 gm) at full term Birth weight doubled by 5 months, tripled by 1 year Gains approximately 30 gm/day • Length at birth for full-term infant: 18 to 22 in (45-55 cm) Growth rate/year: 2nd year: 11 cm 3rd year: 8 cm 4th year: 7 cm up to 10 years: 5 to 6 cm NURSING DIAGNOSES IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: (Specify: inability to ingest or digest food or absorb nutrients because of biologic or psychological factors.) Defining Characteristics: (Specify: loss of weight with adequate intake, lack of interest in food, anorexia, nausea, vomiting, diarrhea, congenital defect of gastrointestinal system, regurgitation, abdominal pain, dysphagia, inability in infant to suck and swallow, failure to thrive, malabsorption syndromes, growth and developmental changes [food jags, fads, ritualisms, rejection of solid foods], vitamin deficiency, increased metabolic demand, chronic illness, poor nutrient quality of food.) Goal: Client will experience balanced nutrition by (date/time to evaluate). Outcome Criteria √ Adequate intake of appropriate nutrients for normal growth and development (specify). √ Height and weight parameters met and maintained based on individual determinations (specify). NOC: Nutritional Status: Nutrient Intake INTERVENTIONS RATIONALES Assess history of food intake (24-hour Provides information needed to recall, amounts of food and formula evaluate nutritional pattern, habits 3 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. or breast milk; financial and and adequacy (deficiency or excess). cultural influences; vitamin/mineral supplement; food allergies. Assess appetite changes (poor or Indicates health status and effect of excessive), presence of illness and illness which requires an increase diagnosis, effect of nutrition on in nutritional needs and appetite skin, hair, eyes, mouth, head, that is affected by illness and may muscles, behavior. result in malnutrition. Assess height and weight, head Provides anthropometric information circumference, skinfold thickness about body's fat and protein content and arm circumference and compare and general nutritional status. with previous values and standard charts. Assess difficulty in sucking, Provides information about ability to swallowing, chewing, gag reflex, ingest foods or formula necessary teeth, oral mucous membrane, lips, for normal growth and development; and palate for abnormalities, inadequate dental care, oral presence of oral pain or infection. inflammatory disorders, congenital feeding. defects (cleft lip/palate) interferes with Assess presence of nausea, vomiting Provides information about emesis and if spitting up, projectile; which affects nutrition and is related to activity or intake or controlled by the vomiting center in tension/stress; characteristics of the medulla; causes include: vomits (bloody, bile, digested or blockage of the pylorus, reflex from undigested food), frequency and incompetent esophageal sphincter, persistence, amount, associated gastroenteritis, duodenal and conditions (diarrhea, fever, gastric spasm, increased ICP, bowel headache, motion sickness, anger, obstruction, drugs and allergens; conflict with parent). persistent losses may lead to fluid and electrolyte imbalance. Assess abdominal girth, stool Provides information about ability to characteristics (odor, appearance), absorb foods; stool may be bulky and presence of diarrhea, bowel sounds fatty in cystic fibrosis if bile for increased motility. flow obstructed and fats are not digested; diarrhea may cause carbohydrate malabsorption as motility increases and moves nutrients through the bowel before absorption takes place. Place infant/child in position of Provides most appropriate position to comfort for feeding/meals: hold enhance movement of formula/solid infant in arms or upright as food by gravity and peristalsis and condition indicates (cleft defect); to prevent vomiting and/or child in sitting position at table aspiration. within easy reach of food and with appropriate sized utensils (specify). Offer feedings/meals as near usual to Promotes feedings/meals that are normal routine as possible; provide similar to established pattern and amounts (small when indicated) and adjusted to special needs caused by frequency (infant feedings q 4h and specific illness or increased 4 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. progress to 3 meals/day with metabolic demand (fever, infection, introduction of solid foods at chronic illness, malnutrition). proper age); if ill, spread over 6 meals/day (specify). Request parent to bring foods from Promotes appetite and increased home if desired and serve in age independence and familiar types and appropriate quantities; allow child preparation of foods. to eat in a community setting with other children. Offer age appropriate food consistency Promotes ingestion and retention of and foods that are not irritating to foods and prevents exacerbation or oral, stomach, bowel mucosa; thicken increased severity of formula with cereal when necessary; gastrointestinal disorders. modify other foods specific to disorder (specify). Maintain NPO status (if prescribed), Provides rest for gastrointestinal provide infant with non-nutritional tract needed because of vomiting, sucking. diarrhea, preoperative preparation. Initiate and monitor IV administration Provides short-term fluid and of nutrients as prescribed (specify nutritional support via peripheral fluid, rate and site and use of vein in those who are unable to pump). ingest or retain nourishment (vomiting, diarrhea postoperative care). Initiate and monitor IV total Provides long-term fluid and parenteral nutrition as prescribed nutritional support via a right (specify). atrial catheter in a large vein in those who are nutritionally deficient as a result of a chronic disease (Crohn's disease) or negative nitrogen balance. Insert nasogastric tube and initiate Provides nutritional support for those and monitor tube feedings as with persistent weight loss; unable prescribed; initiate and monitor to chew, swallow, suck; who need an feedings and insertion site of increase in nutrients while ill, but gastrostomy if present (provide with intact digestive and absorption specifics). activity. Avoid excessive handling of an infant Prevents possible vomiting from after feeding. increased stimuli. Administer vitamin/mineral Provides or replaces necessary supplements, digestive enzymes, substances that may be deficient if antispasmodics, antibiotics absorption impaired, or be the cause (specify). of impaired digestion absorption; reduces peristalsis and infectious process affective nutritional status. Consult or refer with nutritionist as Provides support for the infant/ needed. child's special dietary needs. Instruct parents in the different food Promotes knowledge of needs that will intake at different ages, the amount ensure nutritional adequacy of and types of foods appropriate to child. age using the food guide pyramid, 5 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. how food intake relates to growth and development. Teach parents to avoid including sugar Maintains and promotes health status. and salt in diet; offer nutritious between-meal snacks. Teach parents about caloric needs for Promotes knowledge to ensure stable age of child and in weight and weight and gains proportionate to height measurement techniques growth. (specify). Teach about proper preparation and Prevents spoiling and contamination of storage of foods; handwash before foods that may cause preparing or handling food. gastrointestinal symptoms. Instruct parents in use of special Promotes food intake. devices or utensils for feeding or for self-feeding by child (specify). Inform parents of need for food Ensures nutritional status and supplements and that the quality of provides parents with realistic food is more important than the information about food intake. quantity of food ingested. Explain method of providing nutrition Reduces anxiety by understanding of via IV or NG or gastrostomy tube (if alternate method of supplying used). nutrients to infant/child. Discuss with parents how to wean child Provides information if needed about from breast or bottle, when to add infant's diet changes. solid foods to diet (specify). Instruct parents in menu planning that Encourages inclusion of necessary is age appropriate, acknowledging foods and acceptance of foods food preferences, consistency and offered. texture, finger and raw foods, and allow child to participate in planning. NIC: Nutrition Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe intake based on outcome criteria. What is height and weight?) (Revisions to care plan? D/C care plan? Continue care plan?) DIARRHEA Related to: Dietary intake. Defining Characteristics: (Specify: abdominal pain, cramping, increased frequency of bowel elimination and bowel sounds, loose, liquid stools, 6 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. urgency, intake of high fiber, spicy foods.) Related to: Inflammation, irritation or malabsorption of bowel. Defining Characteristics: (Specify: abdominal pain and cramping, increased frequency of bowel elimination and bowel sounds, loose, liquid, unformed stools, urgency, blood, mucus or pus in stools.) Related to: Toxins, contaminants. Defining Characteristics: (Specify: abdominal pain, increased frequency of bowel elimination and bowel sounds, loose, liquid stools, urgency, fever and malaise.) Related to: Medications, radiation. Defining Characteristics: (Specify: abdominal pain, increased frequency of bowel elimination and bowel sounds, loose, liquid stools, urgency, chemotherapeutic agents, external radiation treatments.) Goal: Client will be relieved of diarrhea by (date and time to evaluate). Outcome Criteria √ Resolution of diarrhea with establishment of pattern of soft formed stool elimination (specify). √ Absence of precipitating factors causing diarrheal episodes (specify). NOC: Bowel Elimination INTERVENTIONS RATIONALES Assess normal pattern of bowel Provides information about baseline elimination and characteristics of parameters for comparison, reason stool (frequency, amount, for changes; diarrhea may be acute consistency, presence of blood, pus, caused by an inflammation, toxin or mucus, color change), presence of a systemic disease and last about diseases or contact with 72 hours, or chronic caused by contaminants, infective organisms, inflammation, allergy, medications being taken. malabsorption, bowel motility changes or disease and last longer than 72 hours; antibiotic therapy may cause diarrhea as it destroys the normal flora in the bowel. Assess abdomen for distention palpation Indicates a distended bowel with and bowel sounds for increases in fluid and hypermotility of bowel auscultation (specify when). which reduces the amount of material that is absorbed by the

bowel mucosa. Assess for temperature elevation, Provides information about signs and irritability, flaccidity, lack of symptoms associated with diarrhea. expression, whiny cry, lethargy, anorexia, vomiting, eyes lackluster. 7 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. Assess for fluid loss with a light Indicates possible dehydration weight loss, dry skin and mucous associated with fluid/electrolyte membranes, poor skin turgor, serum loss from frequent watery stools potassium, sodium for decreases and vomiting and insensible fluid (specify when). loss from fever that leads to metabolic acidosis. Obtain stool specimen for laboratory Indicates possible cause of diarrhea. examination for toxins, ova and parasites, number of calories of infective organisms present; fecal analysis for occult blood, fat content; repeat specimen examination as needed to confirm presence of organism. Place on enteric isolation and explain Prevents undue anxiety and reasons why this is necessary until transmission of disease to others diagnosis is confirmed; maintain since bacterial and viral precautions if cause is identified as infections are the most common an infective organism. causes of diarrhea in children. Place on NPO, administer and monitor IV Allows bowel to rest and IV replaces fluids and electrolytes (specify). lost fluids and electrolytes. Administer oral rehydration fluids q 4 Provides therapy of choice for milk to 6 hours and increase or decrease or moderate dehydration in infants. depending on hydration status; volume should equal stool losses and as prescribed, and maintenance therapy includes the addition of breast milk or plain water for every 2 bottles of rehydration fluid (specify). Encourage continuation or A regular diet provides the nutrients reintroduction of the child's regular the child needs and has been shown diet as soon as possible. to have no adverse effects according to the American Academy of Pediatrics. Administer anti-infective therapy and Specify drug action. antidiarrheals as ordered (specify drug, dose, route, and times; include therapeutic and side effects to monitor for. Change diaper frequently as needed (in Protects skin from excretions and infant), expose buttocks to air and secretions that are irritating and apply skin protective ointment to cause excoriation and skin buttocks and perianal area in infants breakdown. and anal area in children if irritated and sore; wash area with warm water after each diarrhea episode (commercial wipes may be used if skin not irritated). Teach parents and child about enteric Prevents transmission or spread of precautions including handwashing microorganisms causing diarrhea to technique after bowel movement and others. before meals, disposal of and 8 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. laundering of linens and articles contaminated by excrement, demonstrate and allow for return demonstration of handwashing. Teach parents signs and symptoms of Provides for immediate treatment and dehydration or changes in prevention of severe complication characteristics of diarrhea and to of acidosis; diarrhea that persists report them to physician; diarrhea longer than 12 to 24 hours in that becomes chronic or returns or infant or longer than 48 hours in diet that is not tolerated should be child should be reported. reported. Discuss proper refrigeration and Preserves foods properly to prevent handling of foods. spoiling and possible source of diarrhea. Instruct parents on procedure to Provides specimen examination to collect stool specimen and take to identify cause of diarrhea. laboratory labeled properly. Instruct parents to stop milk and solid Prevents recurrence of severe foods if diarrhea starts again and diarrhea or chronic type caused by begin with sips of fluid and advance intolerance to foods or effect of diet as before. foods on diseased bowel. Instruct parents in medication Promotes correct administration of administration if prescribed and antibiotics for some types of avoidance of medications in children diarrhea and avoidance of under 12 years of age (absorbents, medications that may cause toxicity antidiarrheals). or mask fluid losses and prolong diarrhea caused by infectious agents by decreasing motility. NIC: Fluid and Electrolyte Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe pattern and consistency of bowel movements. Have precipitating factors been eliminated? Describe.) (Revisions to care plan? D/C care plan? Continue care plan?) CONSTIPATION Related to: Less than adequate dietary intake and bulk. Defining Characteristics: (Specify: frequency less than usual pattern, hard, dry formed stool, decreased bowel sounds, straining at stool, decreased amount of stool, change from human to cow's milk in infancy.) Related to: Personal habits. 9 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. Defining Characteristics: (Specify: environmental changes [school], stool withholding in young children, lack of privacy, inability of leisurely use of bathroom, not using bathroom when urge is felt by school-age children.) Related to: Less than adequate physical activity or immobility. Defining Characteristics: (Specify: frequency less than usual pattern, hard, dry formed stool, decreased bowel sounds, absence of stool, abdominal distention or rigidity or cramping, postoperative bed rest and immobility, bed rest status.) Related to: Medications. Defining Characteristics: (Specify: administration of diuretics, antacids, anticonvulsives, iron preparation to treat other conditions, diagnostic procedure using barium, hard, dry, less frequent stools.) Related to: Neuromuscular or musculoskeletal impairment. Defining Characteristics: (Specify: inability to feel urge to defecate, fecal impaction, hard, dry formed stool, locomotion impairment, inability to exert force necessary to defecate, painful defecation, mental retardation, poor and sphincter tone, paralysis, autonomic dysreflexia.) Related to: Gastrointestinal obstructive lesions. Defining Characteristics: (Specify: ribbon-like stools, less frequent or absence of stools, abdominal distention and pain, diminished or absence of bowel sounds.) Goal: Client will obtain relief from constipation by (date and time to evaluate). Outcome Criteria √ Resolution of constipation with establishment of pattern of soft formed stool elimination depending on age (specify). √ Bowel elimination alteration (constipation) relieved and return of preoperative or prehospitalization pattern (describe). NOC: Bowel Elimination INTERVENTIONS RATIONALES Assess normal pattern of bowel Provides information that indicates elimination and characteristics of baseline parameters for comparison; stool (frequency, amount, shape and frequency varies among children consistency), presence of diseases, depending on age and foods abnormalities of the bowel caused by ingested, but may be as few as 3 to congenital defects. 5/day in infant, as few as 6/week in child less than 3 years of age, and few as 4/week in older child; presence of constipation may be associated with disorders in children that lead to obstruction. Assess abdomen for hard mass or Indicates accumulation of stool in distention, measure abdominal girth, bowel or reduction in peristalsis. 10 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. auscultate for bowel sounds that are diminished or absent (specify frequency). Assess for toilet training techniques, Provides information that may lead to change in diet, change in reasons for constipation. environment. Assess for intentional stool Provides information about reason withholding, discomfort in child might have for suppressing defecation, word the child uses to the urge to defecate. indicate need to defecate. Assess parents' feelings about bowel Provides information about child's habits and toilet training. reaction to parental attitudes and may cause bowel elimination suppression. Provide privacy during bowel Promotes elimination by preserving elimination. privacy that a child considers important for a very private and intimate activity. Allow child to sit up during bowel Provides a normal position for easier elimination on a bedpan if necessary bowel elimination; a bedpan may or on a commode or toilet if eliminate possibility of possible. elimination. Encourage fluid intake and activity Provides fluid and exercise for bowel within limitations imposed by motility and prevents hard, dry illness; add fruit, fiber, prune stool if water is reabsorbed juice to diet (specify amounts). because of lack of fluids, bulk in stool provided by fiber in the diet promotes motility. Administer stool softeners, Preparation by explanation encourages suppositories or isotonic enema as cooperation (specify action of ordered for child (specify), explain drug). procedure and what to expect to the child before administering. Teach parents that daily bowel Provides accurate information to elimination is not necessary for a replace beliefs or misinformation child and that straining is not by expecting results that will always a symptom of constipation; frustrate child. that changes in bowel elimination pattern may be caused by illness. Discuss with parents that child may Provides information about behavior suppress defecation as a result of common to toddlers and preschool bad experiences during toilet age children and constipation is training; if punished for accidental developed and perpetuated when soiling of clothing; that an illness bowel contents are retained. or discomfort when defecating may cause a child to suppress defecation. Teach parents and child in dietary Provides bulk to increase motility in inclusion of high fiber foods child; fiber absorbs water to including cereals, grains, fruit, soften stool. and vegetables, or add fiber to foods for child. 11 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. Instruct parents and child to avoid Provides information about foods that excessive milk products, rice, prevent resolution of constipation. apples and apple juice, bananas, gelatin which are constipating foods. Teach parents and child to increase Provides adequate fluid intake to fluids, age appropriate, and as soften stool and maintain bowel child gets older and milk amount is elimination. reduced, replace with other fluids. Teach parents and child to maintain Promotes peristalsis and muscle activity and instruct child in strength involved in bowel abdominal and rectal exercises. elimination especially if child is ill and on bed rest or has poor anal sphincter control. NIC: Constipation Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe pattern and consistency of bowel movements. Has constipation been relieved and the elimination pattern returned to prehospitalization or preoperative patterns? Describe.) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT FLUID VOLUME Related to: (Specify: chemosensitive triggers medication, anesthesia, chemotherapy, toxins, increased ICP, inner ear disturbances, cerebral hypoxia, food intolerances, allergens, motion sickness.) Defining Characteristics: (Specify: nausea, vomiting, perspiration, weight loss or gain, pallor, dehydration, fluid and electrolyte imbalance, anxiety, hopelessness, loss of control, tachycardia, abdominal cramping, early morning vomiting (ICP and metabolic disease), fever and diarrhea (infection), decreased urine output, fatigue, hypotension, thirst.) Related to: Emotional stimuli triggers (unpleasant sights, odors, fright, anorexia, eating disorders). Defining Characteristics: (Specify: weight loss, change in level of consciousness or headache, malnutrition, weight gain [overeating], psychogenic vomiting [after meals], nausea, perspiration, pallor, dehydration, fluid and electrolyte imbalance, anxiety, tachycardia.) Related to: Visceral stimuli triggers (specify: irritation, inflammation, mechanical disturbance in GI tract or other related viscera, or GI pain). Defining Characteristics: (Specify: chronic intermittent vomiting [malrotation], green bilious vomiting [bowel obstruction], curdled mucus or food, vomiting many hours after eating [poor gastric emptying or high intestinal obstruction], constipation [anatomic or functional obstruction], forceful vomiting [pyloric stenosis], localized abdominal pain, vomiting soon after meals [peptic ulcer disease], weight loss, nausea, perspiration, 12 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. tachycardia, anxiety, pallor, dehydration, fluid and electrolyte imbalance, fatigue, decreased urinary output.) Goal: Client will experience adequate fluid volume by (date/time to evaluate). Outcome Criteria √ Denies nausea and vomiting. √ Intake increased to (specify). √ Elastic skin turgor and capillary refill <2 seconds. NOC: Fluid Balance INTERVENTIONS RATIONALES Assess food frequency and 24 hour Provides information to evaluate recall, oral fluids, medications, nutritional status, patterns, food likes and dislikes, financial habits, and environmental and cultural influences, food influences on diet. allergies, food preparation methods. Assess onset of nausea and vomiting, Provides information about emesis quality, quantity and presence of and defining characteristics. blood, bile, food, and odor. Assess relationship of nausea and Provides information to identify vomiting to meals, time of day or factors related to time of fluid activities, and associated deficit. triggers. Assess for presence of associated Provides information to identify symptoms: diarrhea, fever, ear associated medical conditions; pain, UGI symptoms, vision changes, indicates fluid status; increased headache, seizures, high pitched output and decreased intake cry, polydipsia, polyuria, indicate a fluid deficit and need polyphagia, anorexia, and so forth; for replacement. record intake and output, including all body fluid losses, IVs and oral fluids (specify frequency). Assess skin turgor, mucous membranes, Provides information about weight, fontanelles of an infant, hydration status; including last void, and behavior changes. extracellular fluid losses, decreased activity levels, malaise, weight loss, poor

skin turgor, concentrated urine. Maintain NPO status, if prescribed Provides rest for the (specify). gastrointestinal tract because of nausea and vomiting and associated medical conditions. Initiate and monitor IV Provides fluid and nutritional administration of nutrients as support to replace active fluid prescribed (specify). loss and prevention of fluid 13 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. overload. Assess vital signs, including apical Provides monitoring of pulse (specify when). cardiovascular response to dehydration (weak, thready pulse, drop in blood pressure). Increased respiratory rate may contribute to fluid loss. Initiate small amounts of clear Provides fluids in minimal amounts liquids, as tolerated when nausea until nausea and vomiting and vomiting subside; offer oral resolved. hydration fluids; breast-fed babies need frequent short feedings at the breast:Infant: 70 to 100 ml/kg in 24 hours, toddler: 50 to 70 ml/kg in 24 hours, school-age: 20 to 50 ml/kg in 24 hours. Gradually reintroduce other fluids Allows for the gradual return to and regular diet. the expected dietary intake. Monitor urine specific gravity, Concentrated urine with an color, and amount every voiding or increased specific gravity as ordered. indicates lack of fluids to dilute urine. Monitor laboratory data results, as Allows identification of fluid ordered (electrolytes, BUN, CBC, losses and electrolyte pH, etc.). imbalances. Administer medications (specify drug, Specify action. dose, route, and times) as ordered and evaluate effects/side effects. Position child on side or sitting up Avoids aspiration of emesis. when vomiting; keep suction available. Provide comfort measures (e.g., cool Promotes comfort level and cloth, clean linens, etc.). distraction. Administer or assist with good oral Provides moisture and comfort for hygiene (brushing teeth, mouthwash drying oral mucosa. or oral swabs). Explain all interventions to child Provides comfort, information, and parents and provide relieves anxiety, and decreases psychological support. feeling of powerlessness. Assist child with activity and Prevents injury and provides safety position changes. because of possible postural hypertension. Instruct parents regarding causes of Provides information for immediate nausea and vomiting, signs of treatment of excessive loss of dehydration, and when to report fluids and electrolytes caused by them to the physician (specify). nausea and vomiting. Teach parents to position child Provides information to promote safely during vomiting episodes and safety, oral hydration and to provide oral hygiene. hygiene. NIC: Fluid Management 14 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Does client/parent deny nausea and vomiting? What is intake in time frame criteria? Is skin turgor elastic? What is capillary refill time?) (Revisions to care plan? D/C care plan? Continue care plan?) COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:58:47 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=29 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 4 - GASTROINTESTINAL SYSTEM CHAPTER 4.0 - GASTROINTESTINAL SYSTEM: BASIC CARE PLAN 15 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=29&FxId=123&Sessi. Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 16 of 16 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=30&FxId=123&Sessi. CHAPTER 4.1 - APPENDICITIS INTRODUCTION Appendicitis is the inflammation of the appendix, a blind sac connected to the end of the cecum. It is caused most commonly by a fecalith (hard feces) and may result in obstruction which leads to ischemia, necrosis, perforation, and peritonitis. Surgical removal of the appendix (appendectomy) is performed as treatment for this disorder, preferably before rupture for a positive outcome. Surgery after rupture requires external drainage and management to reduce the spread of peritonitis. The condition commonly occurs in children over 2 years of age. MEDICAL CARE Narcotic Analgesics: after diagnosis has been made and postoperatively. Analgesics (non-narcotic analgesics): acetaminophen given postoperatively to control moderate pain. Antibiotics: ampicillin or other anti-infectives to prevent or treat peritonitis. Abdominal X-ray: reveals presence of fecalith or other material in the appendix. Abdominal Ultrasound: reveals abscess location if present. Complete Blood Count: reveals increased WBC of 15,000 to 20,000/cu mm and increased neutrophils. COMMON NURSING DIAGNOSES See RISK FOR DEFICIENT FLUID VOLUME Related to: (Specify: excessive losses, NPO status postoperatively.) Defining Characteristics: (Specify: vomiting, deviations affecting intake of fluids, elevated temperature, reduced urinary output, diaphoresis.) See HYPERTHERMIA Related to: Illness. Defining Characteristics: (Specify: increase in body temperature above normal range, warm to touch, increased pulse and respiratory rate, flushing, abrupt rise in temperature with rupture of appendix.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food. Defining Characteristics: (Specify: vomiting, anorexia, nausea, abdominal pain, presence of nasogastric function postoperative.) 1 of 8 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=30&FxId=123&Sessi. See CONSTIPATION Related to: Less than adequate physical activity. Defining Characteristics: (Specify: bed rest following surgery, decreased or absent bowel sounds, frequency less than usual pattern, hard formed stool, abdominal pain.) ADDITIONAL NURSING DIAGNOSES PAIN Related to: Biologic injuring agents, inflammation. Defining Characteristics: (Specify: verbal descriptor of pain, guarding and protective behavior of painful area, irritability, refusal to move or change position, crying, muscular rigidity, clinging behavior, side-lying position with knees flexed.) Goal: The client will experience less pain by (date/time to evaluate). Outcome Criteria √ Client rates pain less than (specify using an appropriate rating scale for age and development). NOC: Pain Level INTERVENTIONS RATIONALES Assess severity of pain, generalized Provides information symptomatic of abdominal pain descending to lower appendicitis with pain being the right quadrant and localized at most common presenting complaint; McBurney's point with rebound behaviors manifested by pain vary tenderness, reduced bowel sounds; with age with infant responding behaviors indicating pain with with crying, facial expression of psoas and/or obturator signs pain and physical resistance; positive. Ask child to rate the young children responding with pain using an appropriate scale for crying loudly, clinging, the child's age and development. irritability, uncooperation, rigid position, side-lying position with knees flexed up to abdomen, refusal to move. Assess for severity of postoperative Provides information needed to pain (specify when). administer most effective analgesic therapy. Assess for acuteness of abdominal Indicates rupture of appendix and pain that progresses to abdominal peritonitis. rigidity, abdominal distention, tachycardia, shallow respirations, fever, pallor. Administer narcotic or non-narcotic Promotes relief of pain depending on 2 of 8 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=30&FxId=123&Sessi. analgesic preoperatively or severity, age and general postoperatively as ordered (specify condition (action of drug). drug, dose, route, and times). Avoid palpation of abdomen and Prevents increased pain and possible unnecessary movements and care rupture of appendix. procedures of child. Apply ice packs to abdomen. Provides relief of pain. Place in position of comfort; right Promotes comfort to reduce pain; side-lying or low to semi-Fowler's. postoperatively will facilitate drainage if appendix has ruptured and prevent spread of infection. Provide toys, games for quiet play. Promotes diversionary activity to detract from pain. Inform child that palpation will Warns child of discomfort to expect cause some pain and inform of any and promotes trust of caretaker. other procedures that cause pain. Explain cause of pain to parents and Promotes understanding of condition child and measures that are taken and reasons for treatments and to relieve pain. medication. Inform parents of behavioral Promotes understanding of behavior responses to pain that child is changes common to an age group in manifesting and that as pain presence of pain. subsides, child will return to usual behavior patterns. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is pain rating?) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: Inadequate primary defenses (e.g., ruptured appendix), invasive procedure (surgery). Defining Characteristics: (Specify: spread of infection in peritoneal cavity, absent bowel sounds, diffuse abdominal pain followed by an absence of pain, abdominal distention, vomiting, increased pulse and respirations, fever, redness, swelling, drainage at incision site whether closed by primary intension (appendectomy) or open and draining (ruptured appendix). Goal: Client will not experience infection by (date and time to evaluate). Outcome Criteria 3 of 8 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=30&FxId=123&Sessi. √ Incision will be clean and dry, without redness, edema, or odor. NOC: Risk Control INTERVENTIONS RATIONALES Assess closed incision site for Provides information indicating redness, swelling pain, incision infection. drainage, approximation of edges, healing (specify when). (Assess open incision site for (Provides information about drainage and characteristics, effectiveness of wound drainage drain placement and patency, to prevent abscess formation and need for dressing change, spread of peritonitis.) specify when.) Administer antibiotic therapy IV Destroys infectious agent with as ordered (specify). selection of medications based on culture and sensitivities of wound drainage. Position in side-lying or semi- Facilitates drainage through wound Fowler's. drain and prevents spread of infection upward in abdomen. Redress incision wound using Promotes cleanliness of wound and sterile technique as ordered. prevents introduction of pathogens. (Change dressings on open wound or (Maintains clean, dry dressings reinforce as needed, use and allows for frequent changes Montgomery straps to hold without removing tape.) dressings in place.) (Apply warm, wet pack to open (Promotes circulation to the area incision as ordered; specify.) and reduces inflammation.) (Irrigate open wound with (Cleanses wound and destroys antibiotic solution as ordered; pathogens.) specify.) Initiate wound isolation Prevents transmission of precautions. infectious agents to or from the child. Inform parents and child of reason Promotes understanding and for infection and risk of spread cooperation in treatments to of infection. prevent spread of existing infection or risk of infection of appendectomy incision. Teach parents about incision care, Promotes understanding of wound dressing changes, removal of healing and progression to drainage, healing process. infection resolution. Teach parents and child that Promotes understanding of isolation is needed to prevent isolation techniques. spread of infection and length of time isolation is carried out. NIC: Incision Site Care 4 of 8 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=30&FxId=123&Sessi. Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe incision for: redness, edema, odor. Is incision clean and dry?) (Revisions to care plan? D/C care plan? Continue care plan?) ANXIETY Related to: Change in health status of child, hospitalization of child, possible surgery of child (specify). Defining Characteristics: (Specify: increased apprehension that condition might worsen and appendix rupture, expressed concern and worry about impending surgery, need for IV, NPO and NG tube and other treatments and procedures while hospitalized, lack of information about postoperative care.) Goal: Clients will experience less anxiety by (date and time to evaluate). Outcome Criteria √ Clients report decreased anxiety (specify, e.g., no anxiety or mild anxiety only). NOC: Anxiety Control INTERVENTIONS RATIONALES Assess source and level of anxiety Provides information about anxiety and how anxiety is manifested; need level and need for interventions for information that will relieve to relieve it; sources for the anxiety. Ask parents and child to parents include fear and rank their feelings of anxiety as uncertainty about treatment and none, mild, moderate, severe, or recovery, guilt for presence of feelings of panic. illness; sources for child include separation from parents, procedures, fear of mutilation or death, unfamiliar environment; anxiety in the child may be manifested by crying, inability to play or sleep or eat, clinging aggression. Encourage expression of concerns and Provides opportunity to vent questions about condition, feelings and fears and secure procedures, recovery surgery by information to reduce anxiety. parents and child. Communicate with parents and answer Promotes calm and supportive questions calmly and honestly; use trusting environment (development 5 of 8 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=30&FxId=123&Sessi. pictures, drawings, and models for level). explanations to child (specify). Allow parents to stay with

child and Allows parents to care for and encourage to assist in care or open support child and continue visitation. parental role. Give parents and child as much input Allows for more control over in decisions about care and situation. routines as possible. Teach parents and child about disease Provides information to relieve process, physical effects and anxiety by knowledge of what to symptoms of illness. expect. Explain reason for each pre and Reduces fear which decreases postoperative procedure or type of anxiety. therapy, diagnostic tests, surgical procedure and rationales including IV, NG tube and dressings to parents and child as appropriate for age (specify). Demonstrate and teach about wound Ensures wound healing without care and dressing changes; allow complication of infection or for return demonstration; inform to recurrence of infection. protect dressing from diaper. Inform parents and child of activity Ensures wound healing without restrictions and length of time complication of infection or before returning to school. recurrence of infection. Teach to report changes in wound Allows for immediate treatment in indicating infection (redness, presence of infectious process. swelling, pain, drainage). Teach parents about dietary Promotes return to nutritional progression following removal of NG baseline and bowel elimination. tube (specify). NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (How does client rank feelings of anxiety?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR APPENDICITIS 6 of 8 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=30&FxId=123&Sessi. 7 of 8 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=30&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:59:05 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=30 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 4 - GASTROINTESTINAL SYSTEM CHAPTER 4.1 - APPENDICITIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 8 of 8 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=31&FxId=123&Sessi. CHAPTER 4.2 - CLEFT LIP/PALATE INTRODUCTION Cleft lip and/or palate is a defect caused by failure of the soft and bony tissue to fuse in utero. They may occur singly or together and often occur with other congenital anomalies such as spina bifida, hydrocephalus, or cardiac defects. Treatment consists of surgical repair, usually of the lip first between 6 and 10 weeks of age, followed by the palate between 12 and 18 months of age. The surgical procedures are dependent on condition of the child and physician preference. Management involves a multidisciplinary approach that includes the surgeon, pediatrician, nurse, orthodontist, propthodontist, otolaryingologist, and speech therapist. MEDICAL CARE Surgical Repair: Cleft lip: Z-plasty between 6 to 10 weeks with Logan bow taped to cheeks to protect incision. Cleft palate: repair between 12 to 18 months of age. Analgesics (narcotic analgesics): codeine or morphine sulfate postoperatively to control pain. Analgesics (non-narcotic analgesics): acetaminophen given postoperatively to control moderate pain. Complete Blood Count (CBC): done as a routine preoperative examination. Urinalysis: done as a routine preoperative examination. Follow-up: speech therapy, orthodontia, prosthodontia. COMMON NURSING DIAGNOSES See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food. Defining Characteristics: (Specify: presence of cleft lip/palate, sore, inflamed buccal cavity, inability to suck, weakness of sucking and swallowing muscles.) See INEFFECTIVE AIRWAY CLEARANCE Related to: Tracheobronchial aspiration of feedings, trauma of surgery. Defining Characteristics: (Specify, e.g., abnormal breath sounds, dyspnea, tachypnea, cyanosis, changes in rate or depth of respirations, cough with or without sputum, postoperative edema.) ADDITIONAL NURSING DIAGNOSES 1 of 10 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=31&FxId=123&Sessi. ANXIETY Related to: Situational crisis of congenital defect of infant. Defining Characteristics: (Specify: severe reaction to appearance of infant with a facial defect, responses to imperfect infant [shock, denial and grief], expression of guilt, blame and helplessness, feelings of inadequacy and uncertainty, worried and anxious about impending surgery.) Goal: Clients will experience decreased anxiety by (date and time to evaluate). Outcome Criteria √ Clients report decreased anxiety (specify, e.g., no anxiety or mild anxiety only). NOC: Anxiety Control INTERVENTIONS RATIONALES Assess level of anxiety and need for Provides information to allay information that will relieve anxiety manifested by the anxiety. Ask parents to rank their infant's appearance at birth feelings of anxiety as none, mild, with level increased with the moderate, severe, or feelings of location and extent of the panic. defect (lip and/ or palate defect). Encourage expression of concerns and Provides an environment conducive questions about condition, to to venting of feelings to discuss feelings about appearance facilitate adjustment to the of infant. infant's defect. Provide an accepting environment and Promotes trust and conveys to attitude and handle the infant in a parents that infant is a gentle, caring way. valuable human baby deserving of love and caring. Communicate with parents in a calm, Promotes a calm and supportive honest, way, discuss the surgical environment to reduce anxiety procedures for correction of the and instill hope. defects using pictures and models, and allow to view pictures of children with successful defect repair. Allow parents to stay with infant and Reduces anxiety and promotes encourage to assist in care as bonding that may be blocked by appropriate. infant's appearance. Emphasize the infant's positive Promotes positive feelings for features when providing infant. information. Suggest visits with parents who have Provides support and information a child with a similar defect. to reduce anxiety. Inform parents of usual ages for Provides information to reduce cleft lip repair and/or cleft fear and anxiety and to know palate, stages of surgery and type what to expect. of procedure performed. 2 of 10 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=31&FxId=123&Sessi. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (How do parents rank feelings of anxiety?) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE Related to: Lack of information about preoperative care. Defining Characteristics: (Specify: request for information about cause of defects, feeding techniques, prevention of complications caused by defects preoperatively.) Goal: Clients will obtain knowledge about preoperative care by (date and time to evaluate). Outcome Criteria √ Clients verbalize understanding of preoperative care and demonstrate proper feeding techniques for their infant (specify). NOC: Knowledge: Infant Care INTERVENTIONS RATIONALES Assess parents' ability to feed infant Provides information about defect that with a defect and acceptance of may be inherited or congenital, methods used, knowledge, cause and partial or complete, unilateral or type of defects, preoperative needs bilateral cleft of lip and/or and care, ability of infant to swallow palate; adequate nutritional status (specify). and freedom from infection before surgery done. Teach and observe parents to hold infant Holding head upright reduces while feeding with the head in an possibility of aspiration, pressure upright position, use a nipple or at the base of the bottle prevents feeding device, allow feeder to choking or coughing, special nipples control the flow or the infant to or devices are used because the express the formula, apply gentle, cleft interferes with the ability to steady pressure on the bottom of the suck and liquid often flows into the bottle and avoid removing the nipple nose when taken into the mouth, use frequently; instruct in feeding method of a nipple encourages development that will be used postoperatively of sucking muscles. (specify). Teach and observe to feed slowly and in Prevents choking, abdominal 3 of 10 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=31&FxId=123&Sessi. small amounts, burping frequently distention, possible flow of liquid (tends to swallow air), and extend into nose or aspirated into lungs nipple or feeding device well back causing pneumonia or otitis media or into the mouth. upper respiratory infections. Inform parents that feeding should not Prolonged feedings may deplete an last any longer than 20 to 30 minutes. infant's energy and cause fatigue. (Instruct in use and care of Promotes the alignment of maxilla and preoperative orthodontic device more normal speech sounds and [plastic palate mold] for infant with prevents food from entering nasal cleft palate including removing and cavity. cleaning daily, replacing, preventing infant from removing palate.) Instruct parents to cleanse lip, oral Prevents infection or skin breakdown cavity and nose with water before and with cleft lip or palate. after feeding. Teach parents to avoid prone position Prepares the child to treatments that and place child on back or side (use will be done postoperatively. arm restraints, use cup for feeding if palate repair to be done, feed upright if lip repair is to be done for the period preoperatively). Inform parents of procedure for Prepares parents for surgical correction of defect(s), medications correction of defect(s) and what to and procedures done to prepare infant expect during convalescence. for surgery, what to expect postoperatively. NIC: Teaching: Infant Care Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did clients verbalize understanding of preoperative care? Use quotes. Describe how parents feed their infant.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: Surgery (broken skin). Defining Characteristics: (Specify: trauma to suture line, use of protective device, formula or drainage at suture site, improper mouth care and teeth brushing, hands or other objects in mouth, redness, swelling and drainage from incision site, crying caused by pain of incision, improper feeding method.) Goal: Infant will not experience injury to incision by (date and time to evaluate). 4 of 10 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=31&FxId=123&Sessi. Outcome Criteria √ Suture line free of trauma, accumulation of substances, infection. √ Sutures intact and healing with protective device in place. NOC: Risk Control INTERVENTIONS RATIONALES Assess suture line for cleanliness, Provides information indicating redness, swelling or drainage possible infection and need (frequency). for cleansing away formula or drainage. Assess for respiratory distress Monitors breathing through a following palate surgery (specify smaller airway caused by edema frequency). and breathing through nose. Cleanse suture site of lip repair Removes material to prevent with gauze or cotton tipped inflammation or sloughing and applicator with saline, apply final cosmetic result ointment after cleansing as expected. prescribed (specify); rinse mouth with water before and after each feeding. Provide air humidification or place Decreases dry mouth and nose in mist tent for a short time mucous membranes. following surgery, as ordered. Monitor lip protective device taped Relaxes the site and prevents on operative site. tension on sutures caused by facial movement or crying. Provide ordered analgesics (specify) Promotes comfort and prevents for pain, hold, cuddle or rock crying caused by pain which child, anticipate needs to prevent creates tension on suture crying. line. Apply soft elbow restraints and Prevents child from touching or remove periodically to perform ROM injuring operative site. on arms and allow for some movement and holding; a child may need a jacket restraint to prevent rolling over. Remove sharp objects or toys, avoid Prevents trauma to mouth and use of forks, straws or other suture line. pointed objects. Feed with a cup or spoon if palate Prevents damage to suture line. repair done; avoid placing spoon in mouth. Accompany child when playing or Prevents trauma caused by ambulating. accidental falls. Teach parents about cleansing suture Prevents infection and enhances site and to apply antibiotic comfort and healing. ointment. Teach parents in feeding method of Promotes nutrition following 5 of 10 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=31&FxId=123&Sessi. infant and allow to practice surgery without sucking on a appropriate technique using a nipple. syringe soft tube in mouth away from any suture line or using a cup for older child (specify). Instruct parents in soft diet Provides nutritional needs until inclusions and avoidance of

toast, incision heals completely. hard cookies or foods, as ordered. Explain to parents and child to keep Prevents trauma to suture line. hands and objects away from mouth or to maintain use of restraints with removal until incision is healed. Advise parents not to allow child to Removes possibility of placing play with small toys or those that toy in mouth or damage are sharp or require sucking or incision. blowing; suggest soft, stuffed toys for infant. Explain to parents that usual feeding Provides estimated times based patterns may be resumed in 2 weeks on suture removal and healing for lip repair or in 4 to 6 weeks to resume regular bottle for palate repair. feeding or return to baseline dietary status. NIC: Wound Care Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe suture line) (Revisions to care plan? D/C care plan? Continue care plan?) COMPROMISED FAMILY COPING Related to: Inadequate information and temporary family disorganization caused by defect(s) and future correction. Defining Characteristics: (Specify: expression of concern about defect(s), long-term care required for successful outcome, confirmation of worry about normal growth and development, limited family support and assistance.) Goal: Family will increase coping ability by (date and time to evaluate). Outcome Criteria √ Family will identify short term and long-term goals (specify number). 6 of 10 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=31&FxId=123&Sessi. √ Family members will work together to identify 3 coping mechanisms. NOC: Family Coping INTERVENTIONS RATIONALES Assess family coping methods used and Provides information identifying their effectiveness; family ability coping methods that work and need to cope with child that needs long- to develop new coping skills, term care and guidance; stress on family attitudes directly affect family relationships; developmental child's feeling of self-worth, level of family; perception of child with special needs may crisis situation by family, strengthen or strain family response of siblings. relationships. Encourage family members to express Reduces anxiety and enhances problem areas and explore solutions understanding; provides together. opportunity to identify problems and problem solving strategies. Assist family members to identify 3 Empowers the family to find healthy coping mechanisms they can solutions appropriate for them. use. Assist family to establish short- and Promotes involvement and control long-term goals for child and over situations and maintains importance of integrating child parental role. into family activities. Encourage to follow home routines and Increases child's sense of security meet child's needs with and sense of belonging. participation of family members. Give positive feedback to family and Encourages family to continue praise family efforts in involvement in long-term care. development of coping and problem solving techniques in caring for child. Teach family that overprotective Enhances family understanding of behavior may hinder growth and importance of making child one of development and to treat the child the family and adverse effects of as normally as it is possible. overprotection of child. Discuss the long-term treatment of Promotes a positive outcome when speech therapy, hearing impairment family collaborates with the preventions, dental corrections for health team. crossbite or malocclusion or other therapies. Inform parents to observe for hearing Provides preventive therapy for deficits and to schedule hearing permanent changes in ear caused tests as prescribed. by frequent otitis media. Teach parents to stimulate speech Promotes speech development. after sutures removed by playing games, encourage use of words beginning with F, P, S, T, and encourage chewing and swallowing of foods. Refer family to community agencies, Provides information and support 7 of 10 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=31&FxId=123&Sessi. March of Dimes, American Cleft services for families of children Palate Association (specify). with cleft defect. NIC: Coping Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What goals did family identify? What coping mechanisms?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR CLEFT LIP/PALATE 8 of 10 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=31&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 9 of 10 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=31&FxId=123&Sessi. 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:59:25 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=31 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 4 - GASTROINTESTINAL SYSTEM CHAPTER 4.2 - CLEFT LIP/PALATE Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 10 of 10 12/22/2006 7:29 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=32&FxId=123&Sessi. CHAPTER 4.3 - GASTROENTERITIS INTRODUCTION Gastroenteritis is an acute infectious process affecting the gastrointestinal tract caused by bacteria or viruses. Younger children are most commonly affected with specific organisms found in different age groups. At highest risk are those in daycare centers and schools, and those with immune system abnormalities. The disease is transmitted by ingestion of contaminated food, water, or by contaminated hands, linens, equipment, and supplies. Its most serious complication is dehydration and electrolyte losses which may lead to metabolic acidosis and death. MEDICAL CARE Antibiotics: selection depends on identification and sensitivity to organism revealed by culture, whether therapy is prophylactic and term of treatment with use of doxycycline (Vibramycin) in children over 8 years of age. Stool Examination: reveals toxins, culture reveals ova and parasites, specific pathogen for treatment mode. Electrolyte Panel: reveals decreases in electrolyte levels (K) in persistent diarrhea. Complete Blood Count: reveals decreased RBC, Act, Hgb with blood loss in persistent diarrhea, and inflammation of bowel mucosa; increased WBC in severe infectious process of tract. COMMON NURSING DIAGNOSES See RISK FOR DEFICIENT FLUID VOLUME Related to: Excessive losses through normal routes, NPO status. Defining Characteristics: (Specify: vomiting, diarrhea, decreased skin turgor, dry skin and mucous membranes, weakness, fever, decreased urinary output, decreased pulse volume, increased pulse rate.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: External factor of excretions and secretions. Defining Characteristics: (Specify: redness, excoriation at anal site and perineum, presence of persistent diarrhea.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest and digest foods. Defining Characteristics: (Specify: NPO status, nausea, vomiting, diarrhea, weight loss, anorexia, abdominal cramps.) See HYPERTHERMIA 1 of 5 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=32&FxId=123&Sessi. Related to: Illness (infectious process). Defining Characteristics: (Specify: increase in body temperature above normal range, warm to touch, increased pulse and respirations.) See DIARRHEA Related to: (Specify: dietary intake, contaminants, toxins, inflammation and irritation of bowel.) Defining Characteristics: (Specify: abdominal pain, cramping, increased frequency of bowel sounds, increased frequency, loose, liquid stools, changes in color, urgency.) ADDITIONAL NURSING DIAGNOSES DEFICIENT KNOWLEDGE Related to: Lack of information about disease and treatment. Defining Characteristics: (Specify: request for information about effect and treatment of the disease and preventions of transmission of disease.) Goal: Clients will obtain information about gastroenteritis by (date and time to evaluate). Outcome Criteria √ Parents verbalize understanding of the cause and treatment (specify). √ Clients demonstrate proper handwashing techniques. NOC: Knowledge: Treatment Regimen INTERVENTIONS RATIONALES Assess knowledge of causes of types Promotes effective plan of of enteritis, methods to treat and instruction that is realistic, control disease. information. prevents repetition of Provide parents and child with Ensures understanding based on information and clear explanations interest and need to know to in understandable language, promote compliance. include teaching aids and encourage questions. Instruct to offer rehydration fluids Provides and replaces fluids and (Pedialyte) and avoid those fluids electrolytes lost in frequent high in Na+ (milk, broth). diarrheal stools, Na+ increases Encourage to reintroduce normal removal of fluid from cells by diet of easily-digested foods as osmosis. child tolerates. Instruct in collection of stool Reveals identification of specimens for culture: collect specific organism responsible 2 of 5 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=32&FxId=123&Sessi. stool specimens from other family for enteritis as a basis for members and inform to take to treatment; reveals occult blood laboratory for examination in stool in severe inflammation (specify). of bowel. Teach about enteric precautions and Prevents transmission of effective handwashing. organisms. Inform to take temperature by Prevents additional irritation to axillary method. rectum. Instruct to avoid over-the-counter Prevents use of medications that drugs to treat diarrhea or may exacerbate condition. vomiting. Demonstrate and instruct to insert Treats vomiting and additional antiemetic or sedative suppository fluid loss and promotes rest. (specify). Instruct to measure I&O and Prevents possible fluid imbalance determine imbalance to report complication which leads to (specify). dehydration. Instruct in antibiotic or other (Action of drug.) medication administration (specify). NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did parents verbalize about the cause and treatment of the illness? Did clients demonstrate proper handwashing techniques?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR GASTROENTERITIS 3 of 5 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=32&FxId=123&Sessi. 4 of 5 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=32&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 5:59:50 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=32 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 4 - GASTROINTESTINAL SYSTEM CHAPTER 4.3 - GASTROENTERITIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 5 of 5 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=33&FxId=123&Sessi. CHAPTER 4.4 - GASTROESOPHAGEAL REFLUX DISEASE (GERD) INTRODUCTION Gastroesophageal reflux (chalasia, cardiochalasia) is the return of gastric contents into the esophagus and possibly the pharynx. It is caused by dysfunction of the cardiac sphincter at the esophagus-stomach juncture. Reasons for this incompetence include an increase of pressure on the lower esophageal sphincter; following esophageal surgery; or immature lower esophageal neuromuscular function. The result of the persistent reflux is inflammation, esophagitis, and bleeding causing possible anemia and damage to the structure of the esophagus as scarring occurs. It also may predispose to aspiration of stomach contents causing aspiration pneumonia and chronic pulmonary conditions. Most commonly affected are infants and young children. As the condition becomes more severe or does not respond to medical treatment and the child experiences failure to thrive, surgical fundoplication to create a valve mechanism or other procedures may be done to correct the condition. MEDICAL CARE Proton Pump Inhibitors: lansoprazole (Previcid) or omeprazole (Prilosec) to suppress gastric acid secretion. H2 Receptor Antagonists: cimetidine (Tagamet), or ranitidine (Zantac) to reduce gastric acidity and pepsin secretion. Barium Esophagram: reveals reflux of barium into the esophagus under fluoroscopy if done at time reflux occurs. Manometry: reveals esophageal sphincter pressure of less than 6 mm Hg. Intraesophageal pH Monitoring: reveals pH measurements of the distal esophagus reflux contents. Gastroesophageal Scintigraphy: reveals reflux or aspiration following ingestion of a radioactive compound and scanning the esophagus. Gastroscopy: endoscopic examination that reveals view of esophagus to note esophagitis or to remove tissue for biopsy. Complete Blood Count: reveals decreased RBC, Hgb, Hct in persistent blood loss. COMMON NURSING DIAGNOSES See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest or digest food because of biologic factors. Defining Characteristics: (Specify: weight loss, vomiting, increased appetite, heartburn (older child), failure to thrive, gastric bloating.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Excessive losses through normal route. Defining Characteristics: (Specify: vomiting, diarrhea (postoperatively), decreased urine output, dehydration.) 1 of 8 12/22/2006

7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=33&FxId=123&Sessi. See INEFFECTIVE AIRWAY CLEARANCE Related to: Tracheobronchial aspiration and infection. Defining Characteristics: (Specify: abnormal breath sounds, dyspnea, changes in rate or depth of respirations, fever, cough that is effective or ineffective and with or without sputum.) ADDITIONAL NURSING DIAGNOSES RISK FOR ASPIRATION Related to: Increased intragastric pressure with an incompetent cardiac sphincter. Defining Characteristics: (Specify: laryngospasm, choking, coughing, apnea, cyanosis, wheezing, pneumonitis.) Goal: Client will not aspirate by (date and time to evaluate). Outcome Criteria √ Absence of aspiration with breathing pattern maintained at baseline parameters (specify). √ Absence of recurrent pulmonary infection. NOC: Risk Control INTERVENTIONS RATIONALES Assess respiratory status for Provides information about rate, depth and ease, breath respiratory pattern changes sounds before and after caused by aspiration. feedings. Assess vomiting, activity, and Predisposes to aspiration of position before and after contents of reflux which is feeding. precipitated by factors associated with feeding. Place in prone position (flat Maintains prone position to prone or with head elevated 30 prevent reflux and risk of degrees) or in an infant seat. reflux. Offer frequent, small feedings (of Prevents reflux and minimizes thickened formula, if ordered). symptoms. Administer medications ordered (Action of drug.) (specify). Maintain suction and O2 equipment Removes aspirate and promotes at hand. airway patency and tissue oxygenation. Inform parents of risk for Provides information about aspiration and consequences of potential for complications. 2 of 8 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=33&FxId=123&Sessi. recurring aspiration associated with the condition. Instruct parents in feeding Minimizes risk for reflux and modifications, positions before aspiration. and after feedings. Reassure parentst hat it is best for their child to sleep prone, not on the back like others. Reassure parents that most Reassurance and praise provide children outgrow GERD. Praise positive reinforcement to parents' efforts to prevent parents. complications. NIC: Airway Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe breathing pattern. Has child experienced any respiratory infection?) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: (Specify: malnutrition, abnormal blood profile.) Defining Characteristics: (Specify: decreased Hgb with esophageal bleeding leading to anemia, severe reflux disorder leading to failure to thrive.) Goal: Client will not experience injury by (date and time to evaluate). Outcome Criteria √ No esophageal bleeding (negative Guaiac tests) is found. √ Child exhibits appropriate growth (specify). NOC: Risk Detection INTERVENTIONS RATIONALES Assess for severity of reflux, Provides information about weight loss or gain, failure to complication of esophagitis or thrive, stool and vomit for occult esophageal structure, anemia or blood (specify when). failure to thrive. Prepare parents and infant for Reveals severity of reflux and diagnostic procedures and possible need for surgical 3 of 8 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=33&FxId=123&Sessi. surgical procedure (specify). interventions. Inform parents that infant usually Provides reassurance to parents outgrows the disorder and achieves that medical regimen may be normal function by 6 weeks of age successful and complication may and those with a continuing not occur. problem of reflux usually improve by 6 months of age. Teach to perform Guaiac test on Reveals presence of occult blood stool and vomitus and allow to in esophagitis. return demonstration. Inform that severe reflux may Prevents distention and require NPO status and nasogastric continuing reflux activity of tube insertion with suction. stomach contents. NIC: Bleeding Precautions Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What are results of Guaiac testing? What is child's weight gain? Is that appropriate for age?) (Revisions to care plan? D/C care plan? Continue care plan?) ANXIETY Related to: Change in health status of infant, possible surgery of infant. Defining Characteristics: (Specify: increased apprehension that condition might worsen and that surgery be required, expressed concern and worry about impending surgery, pre and postoperative care, gastrostomy and treatments while hospitalized and complications following surgery.) Goal: Clients will experience less anxiety by (date and time to evaluate). Outcome Criteria √ Clients report a decrease in their anxiety level to none or mild. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess source of level of anxiety and Provides information about how anxiety is manifested: need for anxiety level and need for information that will relieve interventions to relieve it; anxiety. Ask clients to rate sources for the parents include anxiety from none, to mild, fear and uncertainty about moderate, severe, or panic level. treatment and recovery, guilt 4 of 8 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=33&FxId=123&Sessi. for presence of illness. Encourage expression of concerns and Provides opportunity to vent to ask questions about condition, feelings and fears and secure procedures, recovery surgery by information to reduce anxiety. parents. Communicate frequently with parents Promotes calm and supportive and answer questions calmly and trusting environment. honestly; use pictures, drawings, and models for explanations. Encourage parents to stay with child Allows parents to care for and and to assist in care. support child and continue parental role. Give parents as much input in Allows for more control over decisions about care and routines situation. as possible. Provide consistent care of infant Promotes trust and reduces with familiar staff assigned for anxiety. care. Inform parents of disease process, Provides information to relieve physical effects, and symptoms of anxiety by knowledge of what to illness. expect. Explain reason for each pre and Reduces fear which decreases postoperative procedure or type of anxiety. therapy, diagnostic test, surgical procedure and rationales including IV, NG tube, dressings and gastrostomy tube (specify). (Inform parents that NG tube is Reduces anxiety that the tube removed when postoperative ileus is placements and care evokes. resolved and gastrostomy tube is removed 2 or more weeks after surgery.) (Instruct in care of and feeding via Information of what to expect gastrostomy tube and inform of will reduce anxiety. complications of choking, delayed gastric emptying, inability to vomit, gas bloating that may occur following surgery; specify.) (Demonstrate and instruct in wound Ensures wound healing without care and dressing changes; allow complication of infection or for return demonstration, inform to recurrence of infection. protect dressing from diaper.) Instruct parents in feeding Familiarizes parents with changes techniques, allowing infant to take in feeding patterns to prevent a long time to feed and to report complications of choking, any feeding problems. aspiration. Instruct to report changes in wound Allows for immediate treatment in indicating infection (redness, presence of infectious swelling, pain, drainage). procedure. NIC: Anxiety Reduction 5 of 8 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=33&FxId=123&Sessi. Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (How do parents rate their anxiety?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR GASTROESOPHAGEAL REFLUX DISEASE (GERD) 6 of 8 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=33&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library 7 of 8 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=33&FxId=123&Sessi. ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:00:18 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=33 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 4 - GASTROINTESTINAL SYSTEM CHAPTER 4.4 - GASTROESOPHAGEAL REFLUX DISEASE (GERD) Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 8 of 8 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=34&FxId=123&Sessi. CHAPTER 4.5 - HEPATITIS INTRODUCTION Hepatitis is the inflammation of the liver usually caused by a virus. Four viruses that may cause it are: hepatitis A (HAV), hepatitis B (HBV), hepatitis D (HDV) and hepatitis non-A, non-B (NANB). Most common of the types found in children is hepatitis A which is transmitted by the fecal-oral route. The incidence in children is increased in those living in crowded housing. The disorder is usually self-limiting with resolution within 2 to 3 months or may develop into chronic hepatitis. Symptomology varies with severity of the disease. MEDICAL CARE Immunizing Agents: immune globulin (Gamma globulin) given IM as prophylaxis to provide passive immunity or modify severity of hepatitis A; hepatitis B immune globulin (H-BIG) given IM as prophylaxis after exposure to hepatitis B or to provide passive immunity if exposed to contaminated materials (blood serum); hepatitis B vaccine given to newborns IM to immunize against hepatitis B. Metabolic Enzymes: alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactic dehydrogenase (LDH) reveal increases as liver damage occurs and cells release enzymes; alkaline phosphatase reveals increase in liver disease. Immunoglobulins: reveal IgM antibodies indicating hepatitis A virus antibodies for diagnosis of hepatitis A, IgG indicates susceptibility or past exposure to hepatitis A. Hepatitis B surface antigen (HBsAg); titer that reveals antibodies or antigens that are produced in response to hepatitis B and indicates chronic hepatitis B if present longer than 6 months or improvement as the antigen is decreased or disappears. Bilirubin: reveals increases in indirect bilirubin if liver damaged. Ammonia: reveals increases in poorly functioning liver. Protein: reveals increased globulins and decreased albunin. Prothrombin Time: reveals increases in severe liver disease. Urine Urobilinogen: reveals increases in liver disease whether the serum bilirubin level changes or not. Stool: reveals changes in color if bile is not produced as a result of liver disease. COMMON NURSING DIAGNOSES See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest, digest food. Defining Characteristics: (Specify: anorexia, nausea, vomiting, weight loss, fatigue, abdominal discomfort.) See RISK FOR DEFICIENT FLUID VOLUME 1 of 6 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=34&FxId=123&Sessi. Related to: Excessive losses through normal routes. Defining Characteristics: (Specify: vomiting, diarrhea, reduced intake of fluids, reduced urinary output, signs and symptoms of dehydration, gastrointestinal bleeding.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: External factors of excretions and secretions, internal factor of altered pigmentation. Defining Characteristics: (Specify: redness, irritation of perianal area with diarrhea, jaundice with pruritis.) ADDITIONAL NURSING DIAGNOSES RISK FOR ACTIVITY INTOLERANCE Related to: Generalized weakness, bed rest. Defining Characteristics: Easy fatigue, malaise, preference for inactivity, deconditioning with bed rest. Goal: Client will tolerate appropriate levels of activity by (date and time to evaluate). Outcome Criteria √ (Specify level of activity for client, e.g., quiet play in bed.) NOC: Energy Conservation INTERVENTIONS RATIONALES Assess intolerance to activity and Provides information about manifestations. extent of fatigue. Maintain bed rest while illness is Allows for time for liver to in acute stage but allow for heal and prevents any further quiet play and progress as damage. condition allows. Provide access to needed articles Preserves energy which improves within reach, aids to assist in endurance. performing ADL. Provide increasing activity Promotes recovery without participation as tolerated on a compromising energy or daily basis (specify). causing fatigue. Help parents devise a rest and Provides information to improve activity schedule which can be activity tolerance without adjusted to child's tolerance and causing fatigue or remission allow child to regular activity or disease. at own pace (specify). Inform parents and child of level Permits return to normal 2 of 6 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=34&FxId=123&Sessi. of activity necessary to return activity when possible. to school. NIC: Activity Therapy Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe client's activity) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE Related to: Lack of information about transmission of disease. Defining Characteristics: (Specify: request for information about spread of disease, measures to take to prevent spread of disease and possible relapse of condition.) Goal: Parents will obtain information about hepatitis by (date and time to evaluate). Outcome Criteria √ Parents verbalize understanding of the cause and treatment of hepatitis. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess knowledge of disease and Promotes knowledge

and isolation precautions to take to understanding of disease. prevent transmission. Instruct parents and child in proper Prevents transmission of handwashing and teach to perform microorganisms for type A before meals, after using bathroom. which is carried via the oral-fecal route. Teach parents and child that toys may Prevents transmission to become contaminated and that they others via handling of toys. should not be shared. Instruct to use disposable gloves when Prevents transmission of handling blood, excrete any other microorganisms. body fluids. Instruct parents to use disposable Prevents transmission of dishes, wash linens in hot soapy microorganisms to others. water and rinse well and dry, separate child's personal hygiene 3 of 6 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=34&FxId=123&Sessi. articles from other members of household. Teach parents and child of signs and Provides information about symptoms of disease, how disease is disease and treatments to transmitted, dietary inclusions of prevent transmission or protein and carbohydrate, activity relapse. program and signs, symptoms of disease recurrence (pain, anorexic fever, nausea and vomiting, jaundice) to report. Inform parents of immune globulins Provides information about available (for hepatitis A if given prophylactic measures before exposure or after exposure if available. during early incubation period, or hyper-immune gamma globulin for hepatitis B if given after exposure but reserved for those at risk). Teach parents and child to avoid over- Provides information. the-counter drugs without physician advice to prevent toxicity if liver is unable to detoxify drugs. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What do parents verbalize about hepatitis?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR HEPATITIS 4 of 6 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=34&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. 5 of 6 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=34&FxId=123&Sessi. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:00:33 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=34 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 4 - GASTROINTESTINAL SYSTEM CHAPTER 4.5 - HEPATITIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 6 of 6 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=35&FxId=123&Sessi. CHAPTER 4.6 - HERNIA INTRODUCTION A hernia results from a protrusion of abdominal contents through an opening in a weakened musculature. An umbilical hernia is the protrusion of intestine and omentum through the umbilical ring caused by a failure of complete closure after birth. Inguinal hernia is the protrusion of intestine through the inguinal ring caused by a failure of the processus vaginalis to atrophy to close before birth allowing for a hernial sac to form along the inguinal canal. Umbilical hernia usually resolves by 4 years of age; those that do not by school age are corrected by surgery. Inguinal hernia becomes apparent in the infant by 2 to 3 months of age when intra-abdominal pressure increases enough to open the sac. It is usually associated with a hydrocele. Both are corrected by surgical repair (herniorrhaphy) to prevent obstruction and eventual incarceration of a loop of bowel. MEDICAL CARE Surgical reduction and repair of defect. COMMON NURSING DIAGNOSES See INEFFECTIVE BREATHING PATTERN Related to: Pain, decreased lung expansion. Defining Characteristics: (Specify: dyspnea, tachypnea, respiratory depth changes, altered chest excursion.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Postoperative status. Defining Characteristics: (Specify: NPO status, altered intake, signs and symptoms of dehydration, I&O imbalance.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Surgical incision. Defining Characteristics: (Specify: disruption of skin surface, invasion of body structures, excreta in diaper contaminating the incision area.) ADDITIONAL NURSING DIAGNOSES RISK FOR INJURY Related to: Intestinal obstruction. Defining Characteristics: (Specify: irreducible loop of bowel, incarceration of the bowel with complete obstruction.) 1 of 7 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=35&FxId=123&Sessi. Goal: Client will not experience injury by (date and time to evaluate). Outcome Criteria √ Child appears comfortable, denies pain (specify). NOC: Risk Detection INTERVENTIONS RATIONALES Assess by palpation for umbilical or Reveals hernia that is inguinal swelling that appears when reducible. infant cries or when child strains or coughs, and ability to reduce swelling with gentle compression if bowel forced into sac. Assess tenderness at hernia site with Indicates partial or complete abdominal distention, anorexia, obstruction caused by irritability and defecation incarceration and changes. strangulation. Instruct parents to report signs and Prevents more severe symptoms to physician; inform of complication of eventual reason for disorder and what signs gangrene of bowel. are expected and those that indicate obstruction. Teach parents of surgical procedure Corrects and repairs hernia and to repair hernia and possible hydrocele if present before hydrocele and course of progress to complication arises. expect. Encourage parents to prevent infant Prevents bowel from being forced from crying as much as possible; into sac. hold and feed when hungry as preventive measures. Teach about dietary inclusions and Modification of diet to prevent restrictions to prevent straining constipation, decreased (specify). straining and increased intra- abdominal pressure that forces bowel into sac. Reassure parents that hernia usually Provides information regarding resolves itself and if not, surgery prognosis of disorder. may be required to repair. NIC: Teaching: Prescribed Activity Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 2 of 7 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=35&FxId=123&Sessi. (What did parents verbalize about caring for their child?) (Revisions to care plan? D/C care plan? Continue care plan?) PAIN Related to: Surgical repair. Defining Characteristics: (Specify: irritability in infant, crying, moaning, guarding behavior, verbal descriptor of pain, refusal to move, change in facial expression in child.) Goal: Client will experience less pain by (date and time to evaluate). Outcome Criteria √ Client rates pain less than (specify) on the (specify scale used for developmental level). NOC: Pain Level INTERVENTIONS RATIONALES Assess incision pain and Provides information about associated symptoms. need for analgesic therapy. Administer analgesic appropriate Relieves pain and discomfort for severity of pain and age caused by incision. (Specify as ordered (specify drug, action of drug.) route, dose, and time). Maintain position of comfort. Promotes comfort and reduces pain caused by strain on incision. Support buttocks when lifting or Prevents strain and pull on changing position. incision site. Apply ice bag to scrotal area if Promotes comfort by decreasing hydrocele corrected and apply edema. scrotal support if applicable (specify). Provide toys, games for quiet Promotes diversionary activity play (specify). to detract from pain. Teach parents to hold infant Reduces strain on incision and when feeding or when promotes comfort. irritable, burp frequently to remove swallowed air. Encourage parents to change Prevents irritation and pain diapers frequently. at incision area caused by damp diapers. Explain cause of pain to parents Promotes understanding of and child and measures taken treatments for pain to relieve it. postoperatively. NIC: Pain Reduction 3 of 7 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=35&FxId=123&Sessi. Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (How does child rate pain (or use infant scale and report findings)?) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE Related to: Lack of knowledge about postoperative care. Defining Characteristics: (Specify: request for information about activity allowed, wound care, diet, bathing and comfort measures.) Goal: Parents will obtain knowledge about postoperative care by (date and time to evaluate). Outcome Criteria √ Parents verbalize understanding of postoperative care for their child. NOC: Knowledge: Treatment Procedure INTERVENTIONS RATIONALES Assess knowledge of causes of hernia, Promotes effective plan of surgical procedure performed, instruction to ensure willingness and interest to compliance. implement treatment regimen. Provide parents and child as Ensures understanding based on appropriate with information and learning ability and age. clear explanations in understand- able language, include teaching aids and encourage questions. Inform to maintain incision dressing Maintains dry and clean until it peels off and to apply incision site. diaper so that it does not cover incision. Teach to give sponge baths until Maintains incision integrity. incision heals. Encourage to hold infant when crying Reduces strain on incision and and to feed; activity is not possible recurrence of usually restricted; advise child to hernia. refrain from lifting, pushing, or engaging in strenuous play or gym classes at school. Advise parents to increase diet and Promotes return to nutritional fluids as ordered (specify). status without causing 4 of 7 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=35&FxId=123&Sessi. gastrointestinal strain on incision. Reassure parents that infant usually Provides assurance and comfort tolerates surgery well and to parents in giving care. progresses to wellness without incident and that this condition is one of the most common surgeries in infancy. NIC: Teaching Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Does child appear comfortable? Does child deny abdominal discomfort?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR HERNIA 5 of 7 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=35&FxId=123&Sessi. 6 of 7 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=35&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:00:48 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=35 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 4 - GASTROINTESTINAL SYSTEM CHAPTER 4.6 - HERNIA Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 7 of 7 12/22/2006 7:30 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=36&FxId=123&Sessi. CHAPTER 4.7 - INFLAMMATORY BOWEL DISEASE INTRODUCTION Inflammatory bowel disease includes Crohn's disease and ulcerative colitis with similar signs and symptoms but with different intestinal pathology. Actual cause of either disease is unknown but they are associated with immunologic, nutritional, and infectious disturbances with psychogenic factors responsible for severity and exacerbation of the disease. Crohn's disease affects the small and/or large intestine with the terminal ileus the most common site. It involves all layers of the bowel and results in a thickening and eventual obstruction. Lesions from this disease are patchy with areas of normal tissue while lesions from ulcerative colitis are continuous in the affected bowel. Ulcerative colitis also affects the mucosa and submucosa of the large intestine and rectum in a hyperemia and edema of which effects absorption of nutrients and eventually a narrowed, inflexible, scarred bowel. Both diseases are characterized by remissions and exacerbations and occur in children of school age but are most commonly found in the adolescent age group. MEDICAL CARE Anti-inflammatories: corticosteroids, azathioprine, mercaptopurine. Anti-infectives: sulfasalazine (Azulfidine) to prevent recurrences administered with folic acid supplement as it interferes with utilization of this substance; metronidazole (Flagyl) given to treat perianal condition, intestinal amebiasis. Analgesics: codeine given to control pain. Gastrointestinal X-ray (Barium enema): reveals colon abnormalities. Gastrointestinal X-ray (Barium swallow): reveals small intestine abnormalities. Colonoscopy: reveals view of colon abnormalities such as intermittent mucosa involvement, mucusal erosion, cobblestoning, granularity. Bowel biopsy: taken during colonoscopy or sigmoidoscopy at different sites reveals bowel pathology especially in Crohn's. Sigmoidoscopy: reveals abnormalities in rectum, sigmoid colon. Erythrocyte sedimentation rate (ESR): reveals increases in Crohn's disease. Protein: reveals decreases in albumin. Immunoglobulins: reveal decreases in IgG, IgA. C-Reactive protein (CRP): reveals increases in presence of inflammatory disorder, especially Crohn's

disease. Electrolyte Panel: reveals decreased K+ with diarrhea. Complete Blood Count (CBC): reveals increased with inflammation WBC, decreased RBC, Hct with blood loss and anemia. 1 of 10 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=36&FxId=123&Sessi. Stool: fecal culture reveals presence of pathologic organisms that may cause diarrhea; fecal analysis for fat content reveals absorption defect; fecal occult blood reveals bleeding from intestinal tract. COMMON NURSING DIAGNOSES See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest and digest food, absorb nutrients. Defining Characteristics: (Specify: anorexia, diarrhea, abdominal cramping, weight loss, growth retardation, abdominal distention, possible vomiting.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Excessive losses through normal routes. Defining Characteristics: (Specify: diarrhea, output greater than intake, signs and symptoms of dehydration, electrolyte imbalance (K+). See DIARRHEA Related to: Irritation, or malabsorption of bowel, dietary intake. Defining Characteristics: (Specify: abdominal pain, cramping, increased frequency, increased frequency of bowel sounds, loose, liquid, watery stools, urgency, changes in color and constituents (blood, mucus), ingestion of high fiber foods.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: External factor of secretions and excretions, internal factor of extra-intestinal skin lesions. Defining Characteristics: (Specify: irritation, redness, pain at perianal area, disruption of skin surfaces, chronic and excessive diarrhea.) See DELAYED GROWTH AND DEVELOPMENT Related to: Effects of physical disability. Defining Characteristics: (Specify: altered physical growth, delay in sexual maturation, delay in bone age, weight loss, school absences during exacerbations.) ADDITIONAL NURSING DIAGNOSES PAIN Related to: Biologic injuring agents, inflammation and irritation of the bowel. 2 of 10 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=36&FxId=123&Sessi. Defining Characteristics: (Specify: abdominal cramping, abdominal distention, intermittent pain aggravated by eating or pain that is constant and aching, verbalization of other pain descriptors, guarding and protective behavior towards abdomen.) Goal: Child will experience less pain by (date and time to evaluate). Outcome Criteria √ Child rates pain less than (specify) on a scale of (specify). NOC: Pain Level INTERVENTIONS RATIONALES Assess severity of pain, onset and Provides information symptomatic precipitating factors, location, of inflammatory bowel disease duration, remissions and with pain common in Crohn's exacerbations (specify when). disease and less frequent in ulcerative colitis; pain is associated with dietary intake in both diseases. Administer medications as ordered (Action of drug) (specify drug, dose, route,and times); assess effect of medications in relieving discomfort. Assist to assume position of Promotes comfort to reduce comfort. pain. Provide toys, TV, book, games for Promotes diversionary activity to quiet play during painful detract from pain. episodes (specify). Teach child relaxation exercises Provides child with methods to and guided imagery, use of music control discomfort by diversion. for relaxation. Explain cause of pain to child and Provides information for measures taken to relieve pain. understanding of condition and reasons for treatments and medication. Teach child about factors that Promotes opportunity to avoid exacerbate pain episodes and to those foods or stressful express presence of pain at situations that contribute to onset. pain and provides for immediate relief. NIC: Pain Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 3 of 10 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=36&FxId=123&Sessi. (How does child rate pain?) (Revisions to care plan? D/C care plan? Continue care plan?) ANXIETY Related to: Threat to self-concept (body image), change in health status. Defining Characteristics: (Specify: expressed fear and uncertainty, feelings of inadequacy among peer group, feeling of helplessness about consequences, delayed growth and sexual maturation, feeling of being different or frequency of being ill, school absences, ongoing dietary restrictions, presence of a colostomy if colectomy performed.) Goal: Child will experience decreased anxiety by (date and time to evaluate). Outcome Criteria √ Verbalized reduction in anxiety. √ Child verbalizes reduction of anxiety to (specify level, e.g., none, mild, moderate, severe, or panic level). NOC: Anxiety Control INTERVENTIONS RATIONALES Assess level of anxiety of child Provides information about source and how it is manifested; the and level of anxiety and need for need for information that will interventions to relieve it; relieve anxiety (specify when). sources for the child may be procedures, fear of mutilation or death, unfamiliar environment of hospital and may be manifested by restlessness, inability to play or sleep or eat, clinging, aggression, withdrawal. Assess possible need for special Reduces anxiety and supports child counseling services for child. dealing with a long-term illness and promotes adjustment to lifestyle changes. Encourage expression of concerns Provides opportunity to vent about illness and procedures and feelings and fears to reduce treatments. anxiety. Communicate with child at Promotes understanding and trust. appropriate age level and answer questions calmly and honestly; use pictures, models and drawings for explanations. Encourage child's input in Allows for more control and decisions about care and routines independence in situations. as possible. 4 of 10 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=36&FxId=123&Sessi. Teach child disease process, Provides information to promote physical effects, signs and understanding and relieve symptoms of disease. anxiety. Explain reason for each procedure Reduces fear of unknown which or type of therapy, diagnostic evokes anxiety. tests and what to expect. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (How does child rank anxiety?) (Revisions to care plan? D/C care plan? Continue care plan?) IMPAIRED ADJUSTMENT Related to: Disability requiring change in lifestyle, inadequate support systems. Defining Characteristics: (Specify: verbalization of nonacceptance of health status change, unsuccessful in ability to be involved in problem solving, lack of movement towards independence.) Goal: Child will adapt to lifestyle changes by (date and time to evaluate). Outcome Criteria √ Child and family verbalize strengths. √ Child and family identify 3 ways to cope with illness. NOC: Acceptance: Health Status INTERVENTIONS RATIONALES Assess for ability of child and family Provides information about ability to adapt, willingness of family and of family and child to modify child to support medical regimen and lifestyle, make plans for a need to change lifestyle, ability to constructive lifestyle within problem solve and utilize coping limits imposed by change in mechanisms. health status. Encourage to identify strengths and Allows for support needed to roles of family and child, coping manage long-term illness of mechanisms that have been successful child. in the past, resources and support groups available. 5 of 10 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=36&FxId=123&Sessi. Assist child and family to develop a Promotes independence and control health care regimen by making over care and situations. decisions regarding care, sharing goals and progress, accepting accountability for specific aspects of care. Assist child and family to deal with Permits realistic lifestyle denial behavior and to differentiate changes that are congruent with between denial of change in health health status changes. status and denial of limits imposed by change in health status. Maintain a positive, hopeful attitude Promotes maximal use of personal about lifestyle changes accomplished resources and acceptance of to promote health. support systems. Provide information about disease Promotes understanding of disease process, treatment, potential and effect on lifestyle. disability, prognosis. Prepare child and family for colostomy Provides information that may or ileostomy surgery if indicated begin to lead to acceptance of and emphasize the positive aspects change in bowel elimination. of such a surgery and possibility of fairly normal life regardless of bowel diversion (permanent recovery, normal growth and sexual development). Refer to resources such as insurance Assists family and child to seek assistance (government and private, out support and information over support groups, social services, long period of time for current colitis and Ileitis Foundation, treatment development and United Ostomy Association). research and economic and psychological assistance. NIC: Self-Awareness Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What strengths did child and family identify? How do child and family plan to cope with illness?) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE Related to: Lack of information about long-term medical regimen. Defining Characteristics: (Specify: request for information about medication, dietary regimen, care of colostomy or ileostomy.) 6 of 10 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=36&FxId=123&Sessi. Goal: Clients will obtain knowledge about care by (date and time to evaluate). Outcome Criteria √ Clients verbalize plan of care for child. NOC: Knowledge: Treatment Regimen INTERVENTIONS RATIONALES Assess parents and child for knowledge Provides information of learning of prescribed medical regimen and needs of parents and/or child. postoperative care if applicable. Instruct in special nutritional needs Provides replacement of including diet that is high in nutritional losses caused by protein and calories and low in fat the disease and to promote and fiber. metabolic function and energy levels. Inform that mouth care before meals Promotes comfort if stomatitis and bland foods should be encouraged present. if mouth pain is present. Teach about long-term administration Provides information. of medications, folic acid supplement including actions, dosages during acute and chronic stages, frequency, times, side effects, (specify) effect of discontinuing a steroid without tapering, signs and symptoms to report. (Teach, demonstrate, and allow for Promotes independence in ostomy return demonstration for ostomy care care with as normal a return to including, application and removal activities as possible; of appliance peristomal skin care, procedure done if child does emptying and cleansing of ostomy not respond to medical bag, odor control; continent treatment. ileostomy care and catheterization of the pouch.) (Inform of nasogastric tube feedings Provides information about or total parenteral nutrition if alternate methods of required.) nutritional support during acute state of disease. Provide praise and encouragement to Positive reinforcement enhances child and family as they learn new understanding and skill. skills. NIC: Teaching: Disease Process Evaluation 7 of 10 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=36&FxId=123&Sessi. (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did clients verbalize about child's plan of care?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR INFLAMMATORY BOWEL DISEASE 8 of 10 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=36&FxId=123&Sessi. 9 of 10 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=36&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:01:08 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=36 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 4 - GASTROINTESTINAL SYSTEM CHAPTER 4.7 - INFLAMMATORY BOWEL DISEASE Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 10 of 10 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=37&FxId=123&Sessi. CHAPTER 4.8 - INTUSSUSCEPTION INTRODUCTION Intussusception is a telescoping of one section of the bowel into another section which results in obstruction to passage of the intestinal contents and inflammation and decreased blood flow to the parts of the intestinal walls that are pressing against one another. If left untreated, eventual necrosis, perforation, and peritonitis occurs. It occurs in infants most commonly between 3 to 12 months of age or in children 12 to 24 months of age. The actual cause is unknown but risk for the condition increased in children with Meckel's diverticulum, celiac disease, cystic fibrosis, diarrhea, or constipation. Surgical correction is indicated if the obstruction of the involved segment cannot be reduced manually or by hydrostatic pressure or if bowel becomes necrotic. MEDICAL CARE Analgesics (narcotic analgesics): codeine, morphine sulfate preoperatively before diagnostic test or postoperatively for pain. Analgesics (non-narcotic analgesics): acetaminophen given for pain postoperatively. Antibiotics: given to prevent or treat peritonitis. Lower Gastrointestinal X-ray, Ultrasound: barium enema reveals an obstruction which prevents the flow of barium into the colon. Reduction of the Intussusception: usually occurs as a result of the pressure of the barium enema, or may

be accomplished by other methods of hydrostatic or air pressure reduction. Surgical Reduction of the Intussusception: with possible resection for necrotic bowel. COMMON NURSING DIAGNOSES See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest and digest foods. Defining Characteristics: (Specify: vomiting, abdominal pain, NPO status, NG tube pre and postoperatively.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Excessive losses through normal routes. Defining Characteristics: (Specify: vomiting, decreased urine output, altered intake with NPO status, signs and symptoms of dehydration or electrolyte imbalance.) See CONSTIPATION 1 of 6 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=37&FxId=123&Sessi. Related to: (Specify: medications, diagnostic procedure using barium enema.) Defining Characteristics: (Specify: hard formed, barium colored stools, decreased bowel sounds, less frequent passage of stools and flatus, abdominal discomfort.) ADDITIONAL NURSING DIAGNOSES RISK FOR INJURY Related to: Bowel dysfunction. Defining Characteristics: (Specify: severe abdominal pain, bowel obstruction.) Goal: Client will not experience injury by (date and time to evaluate). Outcome Criteria √ Intussusception is reduced by hydrostatic pressure. √ Client passes normal brown stool. NOC: Symptom Control INTERVENTIONS RATIONALES Assess presence of acute abdominal Provides information that pain with loud crying and drawing indicates that intussusception knees up to chest which may be is present which may lead to episodic, vomiting, passage of a obstruction and signs of brown stool followed by red, peritonitis if not treated. currant jelly-like stool, pallor, irritability. Assess presence of diarrhea, Indicates presence of constipation, episodes of vomiting intussusception and need for and colic in older child. further evaluation. Provide NG tube attached to suction, Prevents vomiting and dehydration IV fluids to decompress bowel and and prepares child for barium maintain hydration status and enema procedure to diagnose and maintain patency of therapy as reduce the invagination. ordered (specify). Note bowel elimination and stool Indicates success of the procedure characteristics and ability to in reducing the affected bowel eliminate barium following the as the condition may recur procedure. within 36 hours. Provide reassurance to parents and Promotes trust and reduces allow to accompany child during anxiety. procedure. Provide information about all care Reduces anxiety. given and allow for opportunity to 2 of 6 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=37&FxId=123&Sessi. ask questions about procedures. Teach parents about reasons for IV Provides information about and NG tube, NPO status (specify). treatments for understanding and reduction of anxiety. Inform parents that surgical Prepares parents for possibility reduction may be necessary if of surgical correction. barium enema does not reduce the invagination. Reinforce information given by Provides information about surgery physician. intervention if barium enema reduction not successful or if bowel obstruction and gangrene is present. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Was intussusception reduced by hydrostatic pressure? Did client pass a normal brown stool?) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE Related to: Lack of information about condition. Defining Characteristics: (Specify: request for information about causes of condition, postoperative or postprocedural care.) Goal: Parents will obtain information about intussusception by (date and time to evaluate). Outcome Criteria √ Parents verbalize understanding of intussusception, the need for a barium enema, and possibility of surgical intervention. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess knowledge of condition, Promotes development of effective causes, treatment regimen plan of instruction. following procedure(s). Provide parents with information and Ensures understanding of care clear explanation in needs based on ability to understandable language, include learn. aids in teaching and encourage 3 of 6 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=37&FxId=123&Sessi. questions (specify). (Inform parents of signs and Promotes awareness of signs and symptoms of incision infection and symptoms to report to treat demonstrate and allow for return complication of wound demonstration of dressing change.) infection. Teach to report any blood in stool, Indicates gastrointestinal change in stool characteristics or bleeding and possible diarrhea or constipation or recurrence or chronicity of absence of stools. condition. Teach parents about preparation Provides information regarding procedures for reduction by barium care to expect during enema or surgery and antibiotic hospitalization. and postoperative care given to child. Teach parents that child will be NPO Prevents vomiting or abdominal and when advisable, will be distention until condition offered clear fluids and slowly resolved. progress to usual diet. Inform parents of activity Allows condition and/or wound to restrictions (specify). heal and resolve itself without complications. Inform parents that bowel Provides parents with baseline elimination of brown stools expected with successful indicate that condition has been resolution of problem. corrected. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did parents verbalize about intussusception, barium enema, and possibility of surgery? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR INTUSSUSCEPTION 4 of 6 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=37&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 5 of 6 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=37&FxId=123&Sessi. Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:01:29 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=37 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 4 - GASTROINTESTINAL SYSTEM CHAPTER 4.8 - INTUSSUSCEPTION Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 6 of 6 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=38&FxId=123&Sessi. CHAPTER 4.9 - PYLORIC STENOSIS INTRODUCTION Pyloric stenosis is a hypertrophic disorder of the circular muscle of the pylorus in which the pylorus is greatly enlarged and hyperplasic and causes progressive narrowing of the canal between the stomach and duodenum. As the canal becomes obstructed over time, associated inflammation and edema result in complete obstruction. The enlarged pylorus muscle may be felt as an "olive-like" mass in the upper abdomen. The infant appears very hungry but exhibits projectile vomiting soon after eating and fails to gain appropriate weight. Metabolic alkalosis is a possibility from loss of hydrochloric acid. The exact cause is unknown although heredity is suspected. The abnormality is most common in young children between 1 to 6 months of age. Pyloric obstruction is treated successfully with surgical correction. MEDICAL CARE Pyloromyotomy: surgical enlargement of the pyloric lumen. Analgesics (narcotic analgesics): postoperatively for pain control. Analgesics (non-narcotic analgesics): acetaminophen postoperatively for moderate pain. Upper Gastrointestinal X-ray: reveals delayed gastric emptying with an elongated canal between stomach and duodenum. Ultrasound: reveals narrowed canal between stomach and duodenum without the use of barium swallow. Electrolyte Panel: reveals increased Hgb, Hct as hemoconcentration occurs with fluid depletion. COMMON NURSING DIAGNOSES See RISK FOR DEFICIENT FLUID VOLUME Related to: (Specify: excessive losses through normal routes, NPO status pre and postoperatively.) Defining Characteristics: (Specify: vomiting with an eventual projectile character, electrolyte losses, signs and symptoms of dehydration, hemoconcentration, decreased urine output.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest, digest food. Defining Characteristics: (Specify: excessive vomiting especially after eating, chronic hunger, weight loss, failure to gain weight, diminished stools, abdominal distention, NG tube pre and postoperatively for stomach decompression.) 1 of 6 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=38&FxId=123&Sessi. ADDITIONAL NURSING DIAGNOSES RISK FOR INJURY Related to: GI obstruction. Defining Characteristics: (Specify: vomiting that increases in severity leading to dehydration, hunger, and weight loss.) Goal: Infant will not experience injury by (date and time to evaluate). Outcome Criteria √ Absence of vomiting, weight gain (specify for infant) per week. √ Skin turgor elastic, mucous membranes moist, intake equals output. NOC: Risk Control INTERVENTIONS RATIONALES Assess pattern of vomiting, Provides information about development of projectile presence of hypertrophic vomiting, vomiting that occurs pyloric stenosis causing after feeding or hours after obstruction as the canal feeding, weight loss, diminished to the duodenum narrows. stools, palpable mass in the epigastrium to the right of the umbilicus, presence of visible gastric peristaltic waves across the epigastrium. Maintain NPO status and NG tube Decompresses stomach for 24 to connected to suction, position 36 hours in preparation for with head slightly elevated. surgery. Assess skin for decreased turgor, Provides information about the elasticity, loss of subcutaneous presence of dehydration caused tissue, sunken eyeballs, urinary by excessive vomiting. output (specify frequency). Maintain IV fluids and electrolytes Provides hydration and replaces (Na+, K+, CA-, Cl-), glucose for lost glycogen stores and nutritional support (specify fluid electrolytes for 24 to 36 and rate). hours in preparation for surgery or when needed. Weigh daily at same time on same Reveals losses or gains related scale. to fluid and nutritional. Teach parents about diagnostic tests Provides information needed to and procedures done and reason for reduce anxiety. them. NIC: Surveillance 2 of 6 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=38&FxId=123&Sessi. Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Has infant vomited? What is weight gain per week? What is intake and output? Describe skin turgor and mucous membranes.) (Revisions to care plan? D/C care plan? Continue care plan?) ANXIETY Related to: Change in health status of infant, surgical correction of condition. Defining Characteristics: (Specify: increased apprehension and expressed concern and worry about impending surgery, pre and postoperative care, treatments while hospitalized and complications following surgery.) Goal: Clients will experience decreased anxiety by (date and time to evaluate). Outcome Criteria √ Parents verbalize decreased anxiety (use a scale; specify). NOC: Anxiety Control INTERVENTIONS RATIONALES Assess source and level of anxiety Provides information about and how anxiety is manifested; need anxiety level and need for for information that will relieve interventions to relieve it; anxiety (use a scale). sources for the parent(s) include fear and uncertainty about treatment and recovery, guilt for presence of illness. Encourage expression of concerns and Provides opportunity to vent questions about condition, feelings and fears and secure procedures, and surgery. information to reduce anxiety. Communicate with parents and answer Promotes calm and supportive questions calmly and honestly; use trusting environment. pictures, drawings, and models for explanations. Encourage parents to stay with child Allows parents to care for and and assist in care and feeding. support child and continue parental role. Give parents as much input in Allows for more control over decisions about care and routines situation. as possible. Provide consistent care of infant Promotes trust and reduces 3 of 6 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=38&FxId=123&Sessi. with familiar staff assigned for anxiety. care. Inform parents of disease process, Provides information to relieve physical effects and symptoms of anxiety by knowledge of what to illness. expect. Explain reason for each pre and Reduces fear which decreases postoperative procedure or type of anxiety. therapy, diagnostic tests, surgical procedure and rationales including IV, NG tube, dressings that will be in place. Teach parents about surgical Reduces anxiety and concern about procedure (pyloromyotomy). surgery and outcome. Demonstrate and teach parents about Ensures wound healing without wound care and dressing changes and complication of infection. allow for return demonstration; apply and pin diaper low or use a urine collecting system to maintain dry dressing and wound. Teach parents to report redness, Indication that infectious swelling, or drainage at wound process is present. site. Teach parents about feeding after NG Promotes comfort and bonding with tube removed and allow to feed infant with continuation of clear liquids slowly and frequently parenting role until feeding and progress to formula or breast pattern returns; prevents milk expressed by mother or to overdistention of stomach and limit nursing to 5 minutes and vomiting. gradually increase until previous pattern established, as ordered. Instruct parents to hold infant Facilitates feeding upright and use nipple that does postoperatively and prevents not flow too rapidly, burp vomiting and possible frequently, and place on right side aspiration. or

abdomen after feeding. Inform parents to sponge bathe infant Promotes comfort and cleanliness until incision heals. of infant. Reassure parents and offer praise for Positive reinforcement reduces their care of infant. anxiety associated with learning new skills. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What do parents verbalize about their feelings of anxiety?) 4 of 6 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=38&FxId=123&Sessi. (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR PYLORIC STENOSIS COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 5 of 6 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=38&FxId=123&Sessi. Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:01:43 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=38 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 4 - GASTROINTESTINAL SYSTEM CHAPTER 4.9 - PYLORIC STENOSIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 6 of 6 12/22/2006 7:31 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=39&FxId=123&Sessi. UNIT 5 - GENITOURINARYSYSTEM CHAPTER 5.0 - GENITOURINARY SYSTEM: BASIC CARE PLAN INTRODUCTION The genitourinary system is made up of the reproductive organs, the kidneys, ureters, urethra, and bladder. The kidneys regulate fluid and electrolyte balance, maintain the pH of the body, and provide for the excretion of the end product of protein metabolism in the form of urea. Fluid and electrolyte balance is controlled by filtration, reabsorption, and secretion of these substances during urine formation in the glomeruli and renal tubules. The kidneys produce erythropoietin-stimulating factor in response to lowered oxygen levels, which increases red blood cell production in the bone marrow. They also release renin in response to hypotension, which initiates the renin-angiotensin pathway to increase blood pressure. Urine descends through the ureters to the bladder, where it is stored until it is excreted via the urethra. Disease processes may cause inflammation, tissue damage, and scarring with resultant dysfunction of the organs or structures of the genitourinary system. Structural defects may be either congenital or acquired and can obstruct urine flow causing renal damage and possibly lead to kidney failure. The kidneys of infants and children are immature in regard to fluid and electrolyte balance because of their limited ability to concentrate urine. This creates increased risk for fluid and electrolyte fluctuations and the possibility of dehydration during illness. Renal function matures as the child grows. GENITOURINARY GROWTH AND DEVELOPMENT ORGAN STRUCTURE • Infant kidney size is, proportionately, three times larger than adult size • The number of nephrons increase until 1 year of age with continued maturation of the nephrons throughout development of the young child. • Tubules and glomeruli continue to form and enlarge after birth; tubular length is highly variable but glomeruli size is less variable; tubular length increases until 3 months of age. • The loop of Henle is short in the infant which affects ability to reabsorb water and sodium causing urine to be dilute. • The length of the urethra in children is proportionately shorter according to their growth and age. • The urinary bladder increases in size with growth and development and is considered an abdominal organ in infancy; it becomes a pelvic organ with growth. • Urinary output and bladder capacity increase with growth: Infant: 350 to 550 ml/24 hr Child: 500 to 1000 ml/24 hr Adolescent: 700 to 1400 ml/24 hr 1 of 7 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=39&FxId=123&Sessi. GROWTH AND DEVELOPMENTAL CHANGES • Glomerular filtration and absorption values are reached between 1 to 2 years of age. • The kidneys' ability to concentrate urine increases at 3 months of age with urea synthesis and excretion reaching adult levels by this time; by age 2, urine is concentrated at the adult level. • Excretion of water and hydrogen ion is reduced during infancy and excretion of sodium is also reduced during the first month of life with an inefficient reabsorption of sodium. • The volume of urinary output varies with age: Infant: 5 to 10 ml/hr 10 yr old: 10 to 25 ml/hr • The number of voidings/day vary but decrease with age as urine becomes more concentrated. • Voluntary control of the urethral sphincter is achieved between 18 to 24 months of age with night control of bladder usually achieved by 3 years of age; by 4 years of age, bladder capacity reaches 250 ml which allows the child to remain dry at night. • The amount of total body water varies with age, growth, and sex and decreases as the child grows and develops Birth: 75 to 80% of weight 3 yr old: 63% of weight 12 yr old: 58% of weight • Extracellular fluid levels decrease within the first year. Intracellular fluid volume increases with the growth of muscles and organs. • The infant and young child have greater intake and output relative to size than older children, and water loss or decreased intake are more likely to cause dehydration as this age group is more vulnerable to fluid and electrolyte alterations. • The increased amount of extracellular fluid results in a high water turnover (50% of the extracellular fluid is exchanged daily) and higher tendency to develop dehydration. • Water loss through respirations, increased metabolism is greater in children; the greater surface area increases water loss through the skin. • Acid-base balance is maintained by a buffer system that is less mature in children. • The newborn is at risk of developing severe metabolic acidosis because hydrogen ion excretion is reduced, immature kidneys cannot conserve water efficiently, high metabolic levels produce increased acid, and plasma bicarbonate levels are low. • Sodium excretion is reduced in the immediate newborn period, and the kidneys are less able to adapt to deficiencies and excesses of sodium. 2 of 7 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=39&FxId=123&Sessi. • Infants have a diminished capacity to reabsorb glucose and, during the first few days of life, to produce ammonium ions. NURSING DIAGNOSES RISK FOR DEFICIENT FLUID VOLUME Related to: Excessive losses. Defining Characteristics: (Specify: vomiting, diarrhea, excessive renal excretion, dry skin and mucous membranes, weight loss, decreased urinary output, altered intake, sunken fontanels in infant, decrease of tears and saliva, sunken soft eyeballs, nasogastric suction, fistula.) Related to: Factors influencing fluid needs. Defining Characteristics: (Specify: hypermetabolic states, temperature elevation [diaphoresis], increased insensible loss [respirations, perspirations], failure to absorb or reabsorb water, excessive renal excretion, extremes of age, water output exceeds intake.) Related to: Medications. Defining Characteristics: (Specify: use of diuretics, administration of IV fluids containing NaCl.) Goal: Client will maintain fluid balance by (date and time to evaluate). Outcome Criteria √ Intake equals output. √ Mucous membranes are moist, elastic skin turgor (specify for infant: fontanels flat). NOC: Fluid Balance INTERVENTIONS RATIONALES Assess fluid losses, sources, amounts, Provides information about body fluid and effects; urinary output (should losses and depletion which can lead be 1-2 ml/kg/hr; weigh diapers for to serious consequences in the infant and calculate as 1 ml/gm); infant/child; include output analysis vomiting (include spitting up); when comparing to intake; causes diarrhea (include watery or bloody); include failure to absorb or reabsorb stoma drainage (liquid); nasogastric water, reduced intake or NPO status, aspirate (suctioning); insensible excessive renal excretion, losses (respirations, diaphoresis inappropriate ADH secretion, from body temperature or ambient increased temperature or temperature); wound damage hemorrhage respirations, over-use of diuretic (fluid volume reduced); injury therapy, improper fluid replacement. (burns). Assess intake and accurately compare to Provides strict I&O to determine losses (q 2-8h) for I&O determination positive or negative balance and 3 of 7 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=39&FxId=123&Sessi. and balance; oral intake (liquids, potential for fluid deficit/ fluid content of foods/formula, foods dehydration; mild dehydration: less that become liquid at body than 50 ml/kg fluid loss; moderate temperature, fluids given with dehydration: 50 to 90 ml/kg; severe medications); parenteral (IV, IM, dehydration: about 100 ml/kg. TPN); enteral (NG, gastrostomy tube feedings). Assess infant's weight (undressed Determines losses related to fluid without diaper) on the same scale. deficit and potential for dehydration; mild dehydration: loss of 5% in infant, 3% in older child; moderate: loss of 10% in infant, 6% in older child; severe: loss of 15% in infant, 9% in older child. Assess for presence of dehydration (q Reveals signs and symptoms of 2-8h) including decreased urinary dehydration and hydration status; output, poor skin turgor, dry skin dehydration occurs when output and mucous membranes, gray or mottled exceeds intake and is classified as color to skin, reduced or absent isotonic dehydration (water and tears and saliva, sunken, soft electrolyte deficits equal); eyeballs (sunken fontanels in hypertonic dehydration (water loss is infants), increased sp. gr. and serum greater than sodium loss); hypotonic osmolality, blood urea nitrogen dehydration (sodium loss is greater (BUN), creatinine, hemoglobin, than water loss). creatinine hematocrit, thirst in the older child, vital signs changes (tachycardia, lowered blood pressure, postural changes in blood pressure). Assess (and teach parents) for presence Reveals signs and symptoms of of electrolyte depletion (specify). electrolyte imbalance which are related to specific diseases; provides information regarding fluid/ electrolyte imbalances, kidney function and risk for acidosis or alkalosis. Potassium (K+): muscle weakness and K+: excessive urinary output, diuretic cramping, irritability, fatigue, therapy, vomiting, diarrhea, NG hypotension, arrhythmias. aspirate (functions in neural transmission in smooth, skeletal and cardiac muscle). Sodium (Na+): nausea, abdominal cramps, Na+: excessive water loss via any weakness, dizziness, apathy. route, fever, diaphoresis, vomiting, diarrhea, NG aspirate, fistula or wounds (functions to control movement of fluid between fluid compartments). Calcium (Ca++): tingling of fingertips, Ca++: renal insufficiency, loss through toes, hypotension, muscle gastrointestinal route, inadequate irritability, tetany. Ca++ intake or vitamin D deficiency (functions to prevent metabolic acidosis). Assess urinalysis, electrolyte panel, Provides information regarding fluid/ 4 of 7 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=39&FxId=123&Sessi. serum and urine osmolality, blood electrolyte imbalances, kidney urea nitrogen, creatinine, arterial function and risk for acidosis or blood gases, as indicated. alkalosis. Encourage increased oral fluid intake Provides replacement of lost fluids if in proportion to losses; provide a able to retain PO; child requires 750 varied selection of beverages to 2000 ml/day fluids depending on (specify); if the fluid volume age and weight and calculation of deficit is caused by diarrhea, allow losses; fluids with a high child to request oral fluid carbonation content, usually have a preferences or provide ORT solutions; low electrolyte content; the caffeine start with rapid replacement for 4 to in caffeinated soft drinks acts as a 6 hours and continue over 24 hours mild diuretic and may lead to for maintenance therapy as tolerated: increased loss of water and sodium; Infant: 150 ml/kg/day Toddler: 120 chicken or beef broth contains ml/kg/day Preschool: 100 ml/kg/day excessive sodium and inadequate School-age: 75 ml/kg/day carbohydrates. Provide oral rehydration therapy (i.e., Promotes fluid and electrolyte Pedialyte, Rehydralyte, Infalyte) for replacement and prevents risk of infant. dehydration and electrolyte deficits. Prepare child and initiate IV fluid Provides immediate replacement and therapy with (specify: solution rate ongoing prevention of losses for and amount). those who are unable to ingest fluids PO. Teach parents (and child) about need Teaching helps parents and child cope for IV fluids, how the pump works, with IV therapy. what alarms mean. Reassure the child that the IV is not a punishment. Use infusion pump or volume control Provides regulated and accurate fluid chamber for IV with a pediatric rate and volume with a microdrip IV infusion set with long tubing and infusion set (60 gtt/ml); long tubing restrain body parts as needed. allows for movement in bed, and proper restraining and monitoring provides safe IV administration. Monitor IV hourly for amount, site Ensures safe fluid administration; infiltration, tube patency

or allows for ROM of restrained parts, displacement; change fluid bag and prevents complication of IV therapy. tubing (q 24h), use a transparent occlusive dressing over IV site. Provide non-nutritive sucking for Provides support and comfort to infant/ infant, hold and cuddle child, mouth child. care (spray water into mouth) for oral dryness. During IV therapy, note presence of Indicates overhydration. headache, cramps, vomiting, crackles, muscle twitching, lethargy, decreased urine output. Discontinue IV when fluids are Resumes oral fluid intake when tolerated orally; begin with small condition improves; oral intake may amounts of clear fluids, gradually be resumed as soon as 5 to 50 hours increase in amounts and frequency as after surgery. tolerated to regular diet; baby food for infants. 5 of 7 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=39&FxId=123&Sessi. Employ play at developmental level Promotes oral intake of fluids when including games, use of straws, small child is ill and doesn't fulfill cup (medicine or animal image cup, fluid goals. specify). Place water and cup in room and allow Promotes adequate intake of fluids and to take frequent sips; praise child promotes independence. for drinking fluids. Allow child to participate in the fluid Promotes independence and control over selection and scheduling, to record the situations and enhances intake using symbols or checks with compliance. colors. Teach parents and child the amount of Provides information about fluid needs fluid needed by the infant/child as a basic need and increase of fluid daily and therapeutic need based on need as treatment for deficit. disorder or illness. Teach to measure I&O and allow for Permits accurate monitoring of I&O to return demonstration by calculating determine risk for dehydration. and measuring for 24 hours. Suggest referral to a nutritionist for Provides information and instruction administration of electrolyte and support to parents for safe fluid formula, dilution of fluids, caloric administration PO. and sodium content of commercial fluids. NIC: Fluid and Electrolyte Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What has been intake [specify time]? What has the output been [time]? Describe moisture of mucous membranes and skin turgor. Describe infant's fontanels.) (Revisions to care plan? D/C care plan? Continue care plan?) COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 6 of 7 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=39&FxId=123&Sessi. 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:02:03 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=39 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 5 - GENITOURINARYSYSTEM CHAPTER 5.0 - GENITOURINARY SYSTEM: BASIC CARE PLAN Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 7 of 7 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=40&FxId=123&Sessi. CHAPTER 5.1 - CHRONIC RENAL FAILURE INTRODUCTION Chronic renal failure (CRF) is the progressive deterioration of kidney function that reaches 50% or more loss or a creatinine level of less than 2 mg/dl. Causes include congenital kidney and urinary tract abnormalities in children less than 5 years of age, and glomerular and hereditary kidney disorders in children 5 to 15 years of age. The disease involves all body systems as abnormalities include water, Na+, Ca++ losses, K+, HPO2- 4, Mg++ increases, and reduced Hgb and Hct that result in metabolic acidosis, anemia, growth retardation, hypertension, and bone demineralization. Eventually, if untreated, uremic syndrome develops as the kidneys are not able to maintain fluid and electrolyte balance. End stage renal disease (ESRD) is defined as loss of kidney function at 90% or greater. ESRD is the term applied when the kidneys are no longer able to clear wastes from the body. Eventually the disease terminates in death unless kidney transplantation or dialysis is performed. MEDICAL CARE Electrolyte Panel: at diagnosis lab results will reveal decreased Ca++, Cl-, CO2, and increased K+, HPO2- 4, Na+, and hydrogen ions. With diuretic therapy and increased K+ intake, lab results may display decreased K+ and Na+. Diuretics: furosemide, or hydrochlorothiazide to promote excretion of water and electrolytes to reduce edema associated with renal failure. Antihypertensives: for severe hypertension. Alkalizing Agents: metabolic acidosis is treated with oral alkalizing agents, such as sodium bicarbonate or a combination of sodium and potassium citrate (Bicitra). Antibiotics: specific to identified microorganisms and sensitivity to specific antimicrobials to prevent or treat infection with dosage adjusted to renal function to prevent toxicity. Vitamins/Minerals: water-soluble vitamins may be prescribed (B, C, folic acid, niacin) and vitamin D is prescribed. Folic acid (and sometimes ferrous sulfate) is prescribed to enhance iron absorption. Renal Scan/Renal Ultrasound: may reveal renal abnormality. Calcium Carbonate Preparations: used as phosphate binders, also act as a calcium supplement and as an alkalizing agent. Aluminum Hydroxide Gels: are effective phosphorus binders. Only used for severe or unresponsive hyperphosphatemia due to risk of aluminum toxicity. Epogen: recombinant human erythropoietin (rHuEPO) is prescribed to treat anemia. Growth Hormone: recombinant human growth hormone is used to treat growth retardation secondary to CRF and following renal transplant. Blood Urea Nitrogen (BUN): reveals increases as renal failure progresses and protein catabolism increases. Serum Creatinine: reveals increases as renal failure progresses and glomerular filtration rate is reduced. 1 of 11 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=40&FxId=123&Sessi. Electrolyte Panel: reveals decreased Na+, Ca++, Cl- and increased K+, CO2. Complete Blood Count: reveals decreased RBC, Hct, Hgb, WBC, reticulocyte count. Prothrombin Time (PT): Activated Partial Thromboplastin Time (APPT): reveals prolonged time as erythropoietin production is reduced. COMMON NURSING DIAGNOSES See EXCESS FLUID VOLUME Related to: Compromised regulatory mechanism. Defining Characteristics: (Specify: edema, water and Na retention, weight gain, clothes begin to feel tight, decreased urine output, facial puffiness, altered electrolyte, shortness of breath, crackles, hypertension, vascular congestion.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Loss of appetite. Defining Characteristics: (Specify: anorexia, nausea, fatigue, weight loss, limited K+, HPO2- 4 and protein food intake, poor absorption of Ca++, iron by intestines, growth retardation; may observe weight gain [caused by fluid retention and oliguria] or weight loss (caused by anorexia and electrolyte disturbances].) See HYPERTHERMIA Related to: Renal failure. Defining Characteristics: (Specify: frequent infections, increase in body temperature malaise.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Chronic renal failure. Defining Characteristics: (Specify: dryness, pruritis, uremic frost, sallow color, disruption of skin surfaces from scratching secondary skin breakdown [caused by edema].) See DELAYED GROWTH AND DEVELOPMENT Related to: (Specify: loss of appetite, depletion of body protein, decreased erythropoietin production, and related metabolic disturbances.) Defining Characteristics: (Specify: altered physical growth, delay in sexual maturation, frequent absences from school and disruptions in socialization, inability to participate in activities, frequent hospitalizations.) 2 of 11 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=40&FxId=123&Sessi. ADDITIONAL NURSING DIAGNOSES ACTIVITY INTOLERANCE Related to: Weakness. Defining Characteristics: (Specify: complaints of fatigue on exertion, preference for quiet play, lack of energy.) Goal: Child will progress to increased tolerance for activity by (date and time to evaluate). Outcome Criteria √ (Specify an activity level appropriate for child; e.g., child will go to playroom for 15 minutes each afternoon.) NOC: Activity Tolerance INTERVENTIONS RATIONALES Assess degree of weakness, fatigue, Provides information about effect ability to participate in of activities on fatigue and activities (active and passive). energy reserves. Schedule care and provide rest Promotes independence and control periods following an activity; of situations as the presence encourage child to set own limits of a chronic disease may in amount of exertion tolerated. encourage independence. Provide for quiet play, reading, TV, Provides diversion, stimulation games during times of fatigue. and requires minimal energy expenditure. Explain to child reason for Promotes understanding of the restrictions; explain when to stop need to conserve energy and activity and rest to child. rest. Teach parents and child that full Promotes an active and normal participation in activities is life for the child with a important and should be encouraged chronic illness. for as long as possible (within capabilities and disease restriction). NIC: Activity Therapy Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What has been child's activity level? How does it compare with the outcome criteria?) 3 of 11 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=40&FxId=123&Sessi. (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: (Specify: pulmonary edema, metabolic acidosis, uremia, loss of appetite.) Defining Characteristics: (Specify: changes in respiratory pattern, productive cough with yellow or other abnormal color, adventitious sounds, elevated temperature, cloudy, foul smelling urine, dysuria, urgency, frequency.) Goal: Child will not experience infection by (date and time to evaluate). Outcome Criteria √ Temperature remains <99° F, WBC count < (specify for age), urine and/or blood cultures negative. NOC: Risk Control INTERVENTIONS RATIONALES Assess lab results for infection To prevent and treat infection. (elevated WBC and positive blood cultures). Assess temperature, respiratory and Provides information about urinary system changes as disease presence of infection caused progresses (specify frequency). by progressive chronic disease and its deteriorating effect on all systems. Administer antibiotic therapy as Prevents or treats infection ordered (specify drug, dose, (action of drug). route, and times). Perform handwashing, medical or Prevents transmission of surgical asepsis during procedures pathogens to child. or care as appropriate. Instruct child and parents in handwashing technique, proper disposal of tissues and used articles. Secure urine or sputum cultures for Identifies presence and type of analysis. microorganism responsible for infection and specific sensitivities to antibiotic therapy. Teach parents and child to decrease Information empowers parents and growth of microorganisms by child to help prevent bathing daily, wiping from front infection. to back after toileting, and wearing loose cotton underwear. Teach child to avoid contact with Prevents transmission of persons with upper respiratory infectious agents that may infections. lead to pneumonia. 4 of 11 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=40&FxId=123&Sessi. NIC: Infection Control Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is child's temperature and WBC count? What are results of any urine/blood cultures?) (Revisions to care plan? D/C care plan? Continue care plan?) DISTURBED BODY IMAGE Related to: Biophysical and psychosocial factors. Defining Characteristics: (Specify: verbal and nonverbal responses to change in body appearance, disruptions in school attendance and participation in school activities and socialization, negative feelings about body, multiple stressors and change in daily living, severe growth retardation [in height and weight]; dry skin, facial puffiness.) Goal: Child will experience improved body image by (date and time to evaluate). Outcome Criteria √ Verbalization of positive feelings about self. NOC: Self-Esteem INTERVENTIONS RATIONALES Assess child for feelings about Provides information about status abilities, chronic illness, of self-concept and special difficulty in school and social needs. situations, short stature, inability to keep up with peers. Encourage expression of feelings Provides opportunity to vent and concerns and support feelings and reduce negative communication with parents, feelings about change in teachers, and peers. appearance. Stress positive activities and Enhances sense of positive body accomplishments, avoid negative image, confidence, self-esteem. comments. Teach parents to maintain support Encourages acceptance of the for child. child with special needs (dialysis, dietary requirements, urinary device, medications). Encourage parents to be flexible in Promotes well-being of child and care of child and to integrate sense of belonging. 5 of 11 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=40&FxId=123&Sessi. care and routines into family routines. Teach child and parents about food Promotes social interactions with selections which can be tolerated peers within limitations when eating out with friends. imposed by disease. NIC: Self-Esteem Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did child verbalize about self?) (Revisions to care plan? D/C care plan? Continue care plan?) ANTICIPATORY GRIEVING Related to: (Specify: perceived potential loss of child by

parents; perceived potential loss of physiopsychosocial well-being by child.) Defining Characteristics: (Specify: expression of distress of potential loss, inevitable kidney failure, kidney dialysis, premature death of child.) Goal: Parents and child will begin to work through the grief process by (date and time to evaluate). Outcome Criteria √ Parents will verbalize stages of grief. √ Parents and child will identify 3 positive coping methods. NOC: Family Coping INTERVENTIONS RATIONALES Assess stage of grief process, Provides information about stage of problems encountered, feelings grieving as time to work through regarding long-term illness and the process varies with potential loss of child. individuals; the longer the illness, the better able the parents and family will be able to move towards acceptance. Provide emotional and spiritual Provides for emotional needs of comfort in an accepting parents and assists them to cope environment and avoid with ill child without adding conversations that will cause stressors that are difficult to guilt or anger. resolve. Allow for parental and child Allows for reactions necessary to 6 of 11 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=40&FxId=123&Sessi. responses and expression of work through grieving. feelings. Assist to identify and use effective Promotes use of coping mechanisms coping mechanisms and to over long period of time of understand situations over which illness; chronic disease causes they have no control. physical and emotional stress on family members which may be positive or negative. Refer to social worker and/or Offers information and support to counseling as appropriate parents and family in need of (specify). assistance. psychologic, economic Teach parents of stages of grieving Promotes understanding of feelings and behaviors that are common in and behaviors that are manifested resolving grief. by grief. Assist parents and child to develop Promotes coping ability over coping skills, problem solving prolonged period of illness and skills and approaches that may be assists in resolution of family used. stress. Refer to clergy, local support Provides support and assistance in groups for kidney diseases, adapting and accepting chronic National Kidney Foundation illness and services and (specify). information for care. NIC: Grief-Work Facilitation Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did parents say about the stages of grief? What 3 coping mechanisms were identified? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: Renal failure. Defining Characteristics: (Specify: complications of impaired renal function, hypertension, anemia, metabolic acidosis, osteodystrophy, neurologic manifestations, uremic syndrome if disorder untreated.) Goal: Child will not experience injury by (date and time to evaluate). Outcome Criteria √ BP remains (specify range for child). 7 of 11 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=40&FxId=123&Sessi. √ Hgb and Hct remain > (specify lower limit). √ Child denies bone pain or sensory loss. NOC: Risk Control INTERVENTIONS RATIONALES Assess blood pressure for Provides data regarding hypertension alterations; administer evident in advanced renal disease antihypertensives ordered (action of drug). (specify). Assess I&O, electrolyte panel, and Provides indication of renal function creatinine; administer diuretics as affecting output with water and ordered (specify). electrolyte retention as disease progresses and nephrons are destroyed (action of drug). Assess RBC, Hct, Hgb and administer Provides indication of anemia caused by iron and transfusion of packed red the reduced production of blood cells, as ordered (specify). erythropoietin by the failing kidneys and inadequate intake of iron in a restricted diet. Assess bone pain and deformities Provides indication of osteodystrophy affecting ambulation and caused by a calcium phosphorus activities; administer supplemental imbalance resulting in bone vitamin D, calcium and alkalizing demineralization and growth agents, as ordered. retardation; kidney disease results in the inability to synthesize vitamin D needed to absorb Ca++; acidosis causes dissolution of alkaline salts of bone, phosphate is increased, and calcium decreased as glomerular filtration is reduced. Assess presence of acidosis by pH, Provides indication of impending bicarbonate losses and administer metabolic acidosis caused by the alkalizing agents (specify). inability of the failing kidneys to excrete metabolic acids that are byproducts of metabolism; the hydrogen ion is retained and bicarbonate is lost as the tubules are unable to reabsorb it. Assess for sensory loss, confusion Reveals possible changes in neurologic and changes in consciousness. status as kidney function deteriorates and uremic syndrome appears. Teach parents medication Ensures compliance of correct administration including actions, medication administration; long-term dosage, frequency, side effects to of many medications are given for report. syndrome. disease to prevent complications and uremic Instruct parents and child in dietary Promotes compliance with dietary regimen, to restrict Na+, K+, HOP2-4 inclusions or restrictions depending 8 of 11 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=40&FxId=123&Sessi. and include Ca++, iron in diet, on degree of renal failure. to restrict protein and water intake if appropriate and amounts allowed; offer lists of foods and sample menus for planning (specify). Teach parents and child of dialysis Provides information if renal dialysis procedure and frequency if is needed; usually based on appropriate; include biologic, creatinine level which indicated the psychological and social effects. ability of the kidneys to excrete waste materials and the degree of renal failure. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is BP? Hgb and Hct? What does child say about bone pain? Give examples of sensory ability.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR CHRONIC RENAL FAILURE 9 of 11 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=40&FxId=123&Sessi. 10 of 11 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=40&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:02:28 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=40 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 5 - GENITOURINARYSYSTEM CHAPTER 5.1 - CHRONIC RENAL FAILURE Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 11 of 11 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=41&FxId=123&Sessi. CHAPTER 5.2 - GLOMERULONEPHRITIS INTRODUCTION Acute glomerulonephritis (AGN) is an alteration in renal function caused by glomerular injury, which is displayed by the classic symptoms of gross hematuria, mild proteinuria, edema (usually periorbital), hypertension, and oliguria. AGN is also classified as either: a primary disease, associated with group A, beta-hemolytic streptococcal infection; or a secondary disease, associated with various systemic diseases (i.e., systemic lupus erythema, sickle cell disease, Henoch's chorea purpura). The most common type of AGN is the primary disease, described as an immune-complex disease (or an antigen-antibody complex formed during the streptococcal infection which becomes entrapped in the glomerular membrane, causing inflammation 8 to 14 days after the onset of this infection). AGN is primarily observed in the early school-age child, with a peak age of onset of 6 to 7 years. The onset of the classic symptoms of AGN is usually abrupt, self-limiting (unpredictable), and prolonged hematuria and proteinuria may occur. AGN results in decreased glomerular filtration rate causing retention of water and sodium (edema); expanded plasma and interstitial fluid volumes that lead to circulatory congestion and edema (hypervolemia); hypertension (cause is unexplained; plasma renin activity is low during the acute phase, hypervolemia is suspected to be the cause). MEDICAL CARE DIAGNOSTIC EVALUATION Urinalysis: reveals gross hematuria, and some proteinuria, increased specific gravity. Microscopic examination of the urine sediment will reveal: red blood cells, leukocytes, epithelial cells, granular and red blood cast cells. Bacteria not present, urine cultures negative. Creatinine Clearance: reveals increase in AGN. Determines presence of severe renal impairment. Blood Urea Nitrogen (BUN): determines presence of renal disease, dehydration, hemorrhage, high protein intake, corticosteroids therapy. Electrolyte Panel: will reveal normal electrolytes (sodium, potassium, and chloride ions) and carbon dioxide levels (unless the AGN has progressed to renal failure). Complete Blood Count: reveals decreased RBC, Hct, Hgb and increased WBC. Throat Culture: positive cultures of the pharynx (occur in only a few cases). Antistreptolysin O (ASO): an ASO titer of 250 Todd units or higher is diagnostic for AGN, as is a rising titer in 2 samples taken a week apart. Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), and Serum Mucoprotein Test: are all elevated during the early stages of AGN and then gradually return to normal as healing occurs. MEDICAL MANAGEMENT Diuretics: to treat edema and fluid overload. Antihypertensives: with diuretics to decrease blood pressure. 1 of 8 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=41&FxId=123&Sessi. Hyperkalemia Treatment: if hyperkalemia is present, administration of calcium, glucose and insulin, or a sodium polystyrene sulfonate (Kayexalate) enema may be required. COMMON NURSING DIAGNOSES See EXCESS FLUID VOLUME Related to: Compromised regulatory mechanism. Defining Characteristics: (Specify: dependent edema, periorbital edema, pleural effusion, puffiness in the face, moderate blood pressure increases, intake greater than output, weight gain, azotemia, crackles and pleural effusion (occasionally is seen if pulmonary congestion occurs), decreased Hgb and Hct, altered electrolytes, decreased urinary output.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Loss of appetite. Defining Characteristics: (Specify: anorexia fatigue, nausea, vomiting, malaise, no added-salt diet, lethargy, abdominal discomfort.) See INEFFECTIVE TISSUE PERFUSION: CEREBRAL Related to: (Specify: hypervolemia, hypertensive encephalopathy, cerebral ischemia.) Defining Characteristics: (Specify: early signs of hypertensive encephalopathy: headache, dizziness, abdominal discomfort, and vomiting; if hypertensive encephalopathy worsens: transient loss of vision and/or hemiparesis, disorientation, generalized convulsions (tonic/clonic type), coma.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Edema, altered circulation. Defining Characteristics: (Specify: bed rest, impaired tissue perfusion, pressure on skin and bony prominences, pink or redness of skin, disruption of skin from IV infusions.) ADDITIONAL NURSING DIAGNOSES ACTIVITY INTOLERANCE Related to: Generalized weakness, bed rest. Defining Characteristics: (Specify: expressed weakness and fatigue, anemia, lethargy.) Goal: Child will progress to increased tolerance for activity by (date and time to evaluate). 2 of 8 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=41&FxId=123&Sessi. Outcome Criteria √ (Specify an activity level appropriate for child; e.g., child will play with a puzzle.) NOC: Activity Tolerance INTERVENTIONS RATIONALES Assess weakness, fatigue, Provides information about ability to move about in bed energy reserves during the and participate in play acute phase of the disease and activities. acceptance of bed rest status. Schedule care and provide rest Provides adequate rest and periods following any activity reduces stimuli and fatigue. in a quiet environment. Maintain bed rest during the Conserves energy and decreases acute stage, disturb only when production of waste materials necessary. which increases work of the kidneys. Provide for quiet play, reading, Provides diversion, stimulation TV, games as symptoms subside. and requires minimal energy expenditures. Explain reason for activity Promotes understanding of the restriction to parents and need to conserve energy and child. rest to promote recovery. Inform parents and child to rest Prevents fatigue and conserves following ambulation or any energy during recovery. activity. Instruct parents and child to Prevents fatigue and promotes rest when feeling tired. recovery. NIC: Activity Therapy Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What has been child's activity level? How does it compare with the outcome criteria?) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: Chronic disease. Defining Characteristics: (Specify: persistent streptococcal infections.) 3 of 8 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=41&FxId=123&Sessi. Goal: Child will not experience infection by (date and time to evaluate). Outcome Criteria √ Child denies sore throat. √ Throat cultures are negative. NOC: Risk Detection INTERVENTIONS RATIONALES Assess temperature, chills, sore Indicates persistence of throat, cough (presence or streptococcal infection. recurrence). Obtain throat culture for Identifies streptococcal analysis and sensitivities. microorganism and sensitivity to specific antibiotic therapy. Administer antibiotic therapy to Destroys microbial agents by child and to family members if preventing cell wall ordered (specify). synthesis

and prevents transmission to family members. Instruct parents about antibiotic Promotes parental understanding therapy and to administer full and prevents development of course of medication. super-infection. Provide for disposal of used Prevents transmission of tissues and articles properly. microorganisms to others or reinfection. Instruct child and family to wash Prevents spread of disease. hands after sneezing/coughing and to dispose of used tissues. Instruct parents to avoid Prevents respiratory infections exposure of child to others in the susceptible child. with upper respiratory infection. Inform parents to report fever, Indicates infection and cough, sore throat. provides for early intervention. NIC: Infection Control Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 4 of 8 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=41&FxId=123&Sessi. (Does child deny sore throat? What are results of throat cultures?) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: Impaired renal function. Defining Characteristics: (Specify: complications of impaired renal function, hypertension, cardiac failure, renal failure; risk of complications (i.e., encephalopathy, congestive heart failure, acute renal failure).) Goal: Child will not experience injury by (date and time to evaluate). Outcome Criteria √ BP remains (specify range for child). √ Child denies headache, appears calm. NOC: Risk Detection INTERVENTIONS RATIONALES Assess BP, pulse, respirations q 4h Provides information about (monitor BP q 1h if diastolic is complication of hypertension more than 90, pulse and respirations which may lead to encephalopathy, q 1h if tachycardia, tachypnea or pulse and respirations that dyspnea present). change with heart failure and pulmonary edema. Assess changes in I&O, extent of Indicates signs and symptoms of edema, decreased urinary output, possible renal failure. headache, pallor, electrolyte balance. Administer antihypertensives, diuretic Provides therapy for complications therapy, cardiac glycoside (specify) if a more severe renal impairment and monitor for expected results is present (action of drugs). (specify). Limit fluids as ordered; allow intake Prevents further fluid retention of the amount lost via urine and and edema in the presence of insensible losses (specify). renal damage. Limit foods high in Na+, K+ and Provides nutrition during the acute protein during the acute phase of period with limitation of K+ AGN; encourage a diet with the during oliguria, Na+ with increased carbohydrates and fats presence of edema, protein (only during acute phase of AGN), as limitation if oliguria is ordered. prolonged. Note behavior changes including Indicates need for safety lethargy, irritability, restlessness precautions associated with associated with hypertension and seizure activity as a result of 5 of 8 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=41&FxId=123&Sessi. administer anticonvulsives if cerebral changes. ordered (specify). Teach parents about potential for Provides for early intervention to complications and signs and symptoms prevent severe renal impairment. to report (increased weight, blood in urine with decreased amount of output, complaints of headache and anorexia). Teach about dietary inclusions and Provides nutrition while disease is restrictions; offer a list of foods being resolved. to include and avoid that comply with Na+, K+, protein allowances. Encourage to allow activity/rest Prevents fatigue and conserves periods as energy and fatigue energy during acute stage and requires; progressively increase as convalescence. condition warrants. Reinforce to parents the need for Ensures ongoing monitoring of child follow-up care and supervision. for chronic renal disease or infection. persistent streptococcal NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is child's BP? Describe child's behavior. Does child deny headache?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR GLOMERULONEPHRITIS 6 of 8 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=41&FxId=123&Sessi. 7 of 8 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=41&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:02:47 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=41 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 5 - GENITOURINARYSYSTEM CHAPTER 5.2 - GLOMERULONEPHRITIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 8 of 8 12/22/2006 7:32 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=42&FxId=123&Sessi. CHAPTER 5.3 - HYPOSPADIAS/EPISPADIAS INTRODUCTION Hypospadias and epispadias are congenital defects of the penis that result in incomplete development of the anterior urethra. The congenital defect results in an abnormal urethral opening at any place along the shaft of the penis and may even open onto the scrotum or perineum. The incidence of this defect in the United States is approximately 3.2 in 1,000 live male births or about 1 in every 300 male children. The etiology of this defect is unknown but is associated with a higher familial tendency and by race/ethnic background (more common in whites, Italians, and Jews). Chordee, an abnormal curvature of the penis, is frequently associated with hypospadias. Other associated anomalies/diseases include: undescended testes (9%-32%); inguinal hernia (9%-17%); and Wilms' tumor. The goal of treatment of this defect is to reconstruct a straight penis with a meatus close to the normal anatomic location. Repair is being performed at progressively younger ages to avoid emotional distress in the young child. Currently, the recommended age for repair is between 3 and 12 months (for hypospadias/epispadias or urethroplasty); and during the first year (for chordee repair or orthoplasty). Three objectives of surgical correction of this defect are: to ensure the child's ability to void in the standing position with a straight stream (will minimize child and parent anxiety); to improve the child's physical appearance and ensure a positive body image; and to preserve sexual function. MEDICAL CARE Analgesics: postoperatively to control pain. Antibiotics: to prevent infection or treat infection postoperatively. Complete Blood Count: reveals increased WBC if infection present. Chromosome Analysis: testosterone level reveals male hormone if ambiguous genitalia is present. COMMON NURSING DIAGNOSES See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Surgical incision. Defining Characteristics: (Specify: disruption of skin surface, surgical correction of defect, catheter site irritation, poor wound healing or wound infection, edema within the urethra.) See RISK FOR DEFICIENT FLUID VOLUME Related to: (Specify.) Defining Characteristics: (Specify: NPO preoperatively, temperature elevation with infection, decreased urinary output, inadequate fluid replacement postoperatively, risk of intraoperative hemorrhage and postoperative bleeding.) 1 of 9 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=42&FxId=123&Sessi. See HYPERTHERMIA Related to: Presence of postoperative wound infection or UTI (specify). Defining Characteristics: (Specify: increase in body temperature above normal range, warm to touch, increased pulse and respiratory rate, evidence of infection at surgical site, evidence of lower urinary tract infection.) ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: (Specify: threat to self-concept, change in health status, change in environment [hospitalization].) Defining Characteristics: (Specify: expressed apprehension and concern about correction of defect by surgery and the imperfect appearance of the penis following surgery, preoperative and postoperative care.) Goal: Parents will experience less anxiety by (date and time to evaluate). Outcome Criteria √ Parents state they feel less anxious. NOC: Coping INTERVENTIONS RATIONALES Assess source and level of anxiety and Provides information about anxiety need for information that will level and need to relieve it; relieve anxiety. of procedure and concerns include the type appearance of penis after surgery; whether the penis will be sexually adequate; possibility that correction may need to be done in stages if child is old enough; fear of castration and change in body image. Encourage expression of concerns and Provides opportunity to vent time for parents (and child) to ask feelings and fears and secure questions about condition, environment. procedures, recovery. Answer questions calmly and honestly; Promotes trust and a calm, use pictures, drawings, and models supportive environment. for information. Encourage parents to stay with child Allows parents to care for and during hospitalizations and to support child and continue assist in care. parental role. Ask for parents' input into decisions Allows for control over situations about care and usual routines. and maintains familiar routines for care. 2 of 9 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=42&FxId=123&Sessi. Inform parents of cause of defect, and Provides information that will extent of defect to be corrected, enhance understanding of the whether a mild defect or severe defect to relieve anxiety. defect, that correction is best done between 3 to 9 months, placement of meatus on penis, and possible number of procedures necessary to correct defect (specify). Teach parents of reason for surgery Provides rationale for surgery (urethroplasty), type of procedure, which includes voiding in a appearance of penis following standing position with ability surgery and cosmetic results to to direct stream, improve expect; inform older child that appearance of penis and preserve penis will not be cut off and self-image, and to develop a that procedure is not a form of sexually adequate penis. punishment. Teach parents about postoperative care Provides information about (indwelling meatal or suprapubic postoperative care and what to catheter or stents will be in place; expect following surgery. restraints maybe in place; medications will be administered to control pain and promote sedation; specify). Teach parents relaxation techniques. Reduces anxiety and promotes ability to provide calm and supportive care. Reassure parents and child (if Relieves anxiety produced by fear appropriate) that defect or surgery caused by misinformation. will not affect sexual activity or orientation and will not affect reproductive ability. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (How do parents evaluate their anxiety now?) (Revisions to care plan? D/C care plan? Continue care plan?) PAIN Related to: Surgery. Defining Characteristics: (Specify: communication of pain descriptors, crying, irritability, restlessness, withdrawal, increased P, increased R, 3 of 9 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=42&FxId=123&Sessi. increased BP.) Goal: Infant will experience decreased pain by (date and time to evaluate). Outcome Criteria √ Infant will score less than (specify pain scale to be used and expected score after interventions). NOC: Comfort Level INTERVENTIONS RATIONALES Assess verbal and nonverbal Provides information about pain behavior; type, location and as basis for analgesic severity of pain depending on therapy. child's age. (Specify pain scale to be used.) Administer analgesic and Reduces pain and promotes rest sedative, as ordered which reduces stimuli and (specify). pain (action). Place in position of comfort; Promotes comfort and prevents position catheter to avoid pain from pulling on or tension and kinking. manipulating catheter. Apply ice pack if ordered. Reduces edema and pain. Inform parents that medications Provides information about need will prevent pain and for pain medications for restlessness and allow for child's comfort. healing. NIC: Pain Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is score on pain scale now?) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: (Specify: inadequate primary defenses [surgical incision]; invasive procedure [catheter].) Defining Characteristics: (Specify: redness, swelling, drainage at incision site; cloudy, foul-smelling urine, elevated temperature, positive urine or wound culture.) Goal: Infant will not become infected by (date and time to evaluate). 4 of 9 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=42&FxId=123&Sessi. Outcome Criteria √ Wound is clean and intact without redness, edema, odor or drainage. √ Urine culture negative. NOC: Risk Control INTERVENTIONS RATIONALES Assess wound for redness, swelling, Provides information indicating drainage on dressing, healing presence of infection or poor (specify when). healing. Assess catheter insertion site for Indicates infectious process at redness, irritation, swelling; catheter site or in urinary assess urine collected in drainage bladder. system for cloudiness, foul odor, sediment (specify frequency). Collect urine specimen for culture Provides information about specific and sensitivities (as ordered). organism and sensitivity to antibiotic. Administer anti-infective if culture Treats specific organism causing results are 100,000 ml/mm or more urinary infection or prevents as ordered (specify). infection when catheter is

in place. Use sterile technique when changing Prevents contamination by dressings or giving catheter care introducing organisms into or emptying drainage bag. sterile wound or cavity. Encourage to increase fluid intake Promotes dilution of urine to according to age needs (specify). prevent urinary infection and after catheter removed will encourage voiding. Maintain catheter and collection bag Provides information that will below level of bladder and a closed enhance understanding of the drainage system free of kinks in defect to relieve anxiety. the tubing (if a drainage device is used) then maintain catheter and collection bag—marked in red. Immobilize arms and legs with Prevents accidental removal or restraints, remove periodically; disturbance of catheter or use a bed cradle following surgery. contamination of wound if surgical correction done for a more severe defect. Avoid change of dressing, reinforce Promotes comfort and prevents as needed, and secure catheter to infection and catheter penis with dressing and tape, and displacement. to leg or abdomen with tape. Note urinary output of at least 1 ml/ Indicates that catheter obstruction kg/hr and report if less. may be present with urinary retention which leads to infection. 5 of 9 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=42&FxId=123&Sessi. Demonstrate to parents catheter care, Provides information and skill in irrigation, emptying of drainage caring and maintaining patency bag or use of diaper for urine for catheter as child may be drainage, how to tape catheter and discharged with a catheter or bag to leg; allow for return stent in place. demonstration. Teach parents to avoid allowing child Prevents trauma to or dislodging of to straddle toys, play in a catheter or infection. sandbox, swim, or engage in rough activities until advised by physician. Teach parents to sponge bathe the Promotes cleanliness and comfort child and use loose fitting without constriction. clothing, avoiding contact of feces with wound, and instruct in cleansing after each bowel elimination. Teach parents in signs and symptoms Provides information about need for of infection to report. reporting to allow for early treatment. NIC: Infection Control Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe wound. What are results of urine culture?) (Revisions to care plan? D/C care plan? Continue care plan?) IMPAIRED URINARY ELIMINATION Related to: (Specify: mechanical trauma [urethroplasty].) Defining Characteristics: (Specify: dysuria, frequency, urgency, retention, bladder spasms, inadequate output, edema of the urethra.) Goal: Client will experience improved urinary elimination by (date and time to evaluate). Outcome Criteria √ Client voids through new or corrected urinary meatus after catheter is removed. √ Unable to palpate bladder after voiding. NOC: Urinary Elimination 6 of 9 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=42&FxId=123&Sessi. INTERVENTIONS RATIONALES Assess I&O ratio, voiding stream, Provides information about color and amount of urine on voiding pattern after first voiding and each clamping or removal of subsequent voiding. catheter. Assess for pain, abdominal Indicates urinary dysfunction distention, inability to void and possible obstruction or for 8 hours after catheter. continuing edema of meatus. Support child after catheter is Prevents embarrassment which removed and provide privacy for is common in an older child. voiding. Encourage increased fluid intake Promotes micturition. after catheter removed, offer preferred liquids q 1h. Instruct parents to notify Allows for early intervention physician if urinary pattern to prevent complications. changes or if child is unable to void. NIC: Urinary Elimination Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe client's ability to void through new or corrected meatus. Is bladder palpable above symphysis after voiding?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR HYPOSPADIAS/EPISPADIAS 7 of 9 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=42&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 8 of 9 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=42&FxId=123&Sessi. Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:03:02 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=42 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 5 - GENITOURINARYSYSTEM CHAPTER 5.3 - HYPOSPADIAS/EPISPADIAS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 9 of 9 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=43&FxId=123&Sessi. CHAPTER 5.4 - NEPHROTIC SYNDROME INTRODUCTION Nephrotic syndrome is an alteration of renal function caused by increased glomerular basement membrane permeability to plasma protein (albumin). Alterations to the glomerulus result in classic symptoms of gross proteinuria, hypoalbuminemia, generalized edema (anasarca), oliguria, and hyperlipidemia. Nephrotic syndrome is classified either by etiology or the histologic changes in the glomerulus. Nephrotic syndrome is also classified into 3 types: primary minimal change nephrotic syndrome (MCNS), secondary nephrotic syndrome, and congenital nephrotic syndrome. The most common type of nephrotic syndrome is MCNS (idiopathic type) and it accounts for 80% of cases of nephrotic syndrome. MCNS can occur at any age but usually the age of onset is during the preschool years. MCNS is also seen more in male children than in female children. Secondary nephrotic syndrome is frequently associated with secondary renal involvement from systemic diseases. Congenital nephrotic syndrome (CNS) is caused by a rare autosomal recessive gene which is localized on the long arm of chromosome 19. Currently, CNS has a better prognosis because of early treatment of protein deficiency, nutritional support, continuous cycling peritoneal dialysis (CCPD), and renal transplantation. The prognosis for MCNS is usually good, but relapses are common, and most children respond to treatment. MEDICAL CARE Diagnostic Evaluation: Evaluation is based on the history and the presence of classic clinical manifestations of MCNS. Urinalysis: reveals great increases of protein (proteinuria) of 3+ to 4+ or 300 to 1000 mg/dl; increased sp. gr.; hyaline-casts and few RBC. Renal Biopsy: provides information regarding the glomerulus status, type of nephrotic syndrome, expected response to steroids and prognosis. Creatinine Clearance: reveals increase in MCNS. It will determine presence of severe renal impairment. Blood Urea Nitrogen (BUN): determines presence of renal disease, dehydration, hemorrhage, high protein intake, corticosteroids therapy. Serum Protein: reveals decreases in total proteins (albumin and globulin) with electrophoresis revealing a great decrease in albumin. Serum Lipids: reveals increases with a great increase in cholesterol to 450 to 1500 mg/dl. Electrolyte Panel: reveals decreased Na+ and Ca++ and K+ at normal level. Complete Blood Count: reveals normal Hct and Hgb and increased platelet count of 500,000 to 1,000,000 cu/mm resulting from hemoconcentration. MEDICAL MANAGEMENT Corticosteroid Therapy: continues until the urine is free from protein and remains normal for 10 days to 2 weeks. A positive response to therapy usually occurs in 1 to 3 weeks. Plasma Expanders: human albumin for severe edema to increase plasma protein level and promote diuresis. Diuretics: typically not used; used for edema which interferes with respirations or results in secondary skin breakdown. 1 of 8 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=43&FxId=123&Sessi. Diet: salt is restricted by a no-added salt diet and a diet generous in protein. A high-protein diet is a contraindication with the presence of azotemia and renal failure. COMMON NURSING DIAGNOSES See EXCESS FLUID VOLUME Related to: Compromised regulatory mechanism. Defining Characteristics: (Specify: edema [pitting], periorbital and facial puffiness in morning and dependent in the evening, abdominal ascites, scrotal or labial edema, edema of mucous membranes of intestines, anasarca, slow weight gain, decreased urine output, altered electrolytes, sp. gr., BP, R.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: (Specify: inability to ingest and digest foods and absorb nutrients.) Defining Characteristics: (Specify: anorexia, edema of intestinal tract affecting absorption, weight loss, loss of protein [negative nitrogen balance], rejection of low salt diet.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Edema. Defining Characteristics: (Specify: disruption of skin surface, waxy pallor, stretched and shiny appearance, muscle wasting, decreased tissue perfusion, pressure on edematous area, irritation of anal area with diarrhea.) See DIARRHEA Related to: Inflammation, edema, malabsorption. Defining Characteristics: (Specify: increased frequency, loose, liquid stools, abdominal discomfort.) See RISK FOR DEFICIENT FLUID VOLUME Related to: (Specify: medications, intravascular fluid loss.) Defining Characteristics: (Specify: diuretic therapy, increased fluid output, urinary frequency, rapid weight loss, hypotension, hypovolemia, protein and fluid loss, edema.) ADDITIONAL NURSING DIAGNOSES 2 of 8 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=43&FxId=123&Sessi. FATIGUE Related to: Discomfort. Defining Characteristics: (Specify: extreme edema, lethargy, easily fatigued with any activity.) Goal: Child will conserve energy by (date and time to evaluate). Outcome Criteria √ Child alternates activity with rest periods (specify). NOC: Energy Conservation INTERVENTIONS RATIONALES Assess degree of weakness, Provides information about fatigue, extent of edema and fatigue and tendency of lying difficult movement or activity in prone position and not in bed. moving or changing position. Maintain bed rest during most Prevents energy expenditure when acute stage. edema is severe. Provide selected play activities Provides stimulation and as tolerated and adjust schedule activity within endurance to allow for rest periods and level as edema is relieved. after activity. Plan activities with discretion Prevents fatigue while improving and observe for behavior changes endurance; inactivity and after activity. steroid therapy and disease result in mood swings and irritability in the child. Allow for quiet play followed by Promotes independence and unrestricted activity and control of situations. encourage child to set own limits when feasible. Inform child to rest when feeling Reduces fatigue and conserves tired. energy. Inform parents and child that full Promotes return to active life participation in activities will for child. be allowed as the disease is resolved. NIC: Energy Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 3 of 8 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=43&FxId=123&Sessi. (Describe child's activity and rest pattern.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: Inadequate secondary defenses. Defining Characteristics: (Specify: fluid overload, edema, elevated temperature, immunosuppression, suppressed inflammatory response, leukopenia.) Goal: Child will not become infected by (date and time to evaluate). Outcome Criteria √ Temperature remains <99° F. √ Breath sounds clear bilaterally. √ Urine is clear without foul odor. NOC: Risk Detection INTERVENTIONS RATIONALES Assess temperature elevation, Indicates presence of infectious respiratory changes (dyspnea, process resulting from steroid productive cough with yellow and immunosuppressant therapy sputum), urinary changes (cloudy, given to enhance body defenses foul-smelling urine), skin and reduce relapse rate. changes (redness, swelling, pain in an area) (specify when). Provide private room or share room Protects child from pathogen with children who are free from transmission. infections. Maintain and teach medical aseptic Promotes measures to prevent techniques and handwashing when infection. giving care. Maintain warmth for child, regulate Prevents chilling and room environmental temperature predisposition to upper and humidity. respiratory infection. Administer antibiotic therapy if Prevents or treats infection ordered (specify). based on culture and sensitivities (action of drug). Instruct parents and child to avoid Provides understanding of exposure to those with susceptibility to infections. infections. Instruct parents to report any sign Allows for immediate medical or symptom of infection to intervention to prevent 4 of 8 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=43&FxId=123&Sessi. physician immediately. relapse. NIC: Infection Control Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is temperature? Describe breath sounds and urine) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE Related to: Lack of exposure to information about disease. Defining Characteristics: (Specify: expressed need for information about disease, medication administration, follow-up care and procedures, anxiety associated with relapse of disease.) Goal: Parents will obtain information about child's illness by (date and time to evaluate). Outcome Criteria √ Parents verbalize understanding of cause and treatment for illness. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess knowledge of disease, signs Provides information about and symptoms of relapse, dietary

teaching needs for follow-up and activity aspects of care, care. medication administration and side effects, monitoring urine and VS. Assess level of anxiety and need for Anxiety will interfere with support in care of ill child and learning process. possible relapse. Teach parents and child about the Teaching provides needed cause of the child's illness and information about the disease treatment to expect. Encourage and treatment. questions and allow time for discussion. Teach about medication administration Promotes compliance of accurate including side effects of steroids medication administration and and immunosuppressives; that these what can be expected from drug are reversible when discontinued therapy. and must be discontinued gradually. 5 of 8 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=43&FxId=123&Sessi. Inform parents that immunizations may Provides safety measure to be postponed. prevent complications in a child that is immunosuppressive. Teach parents and child of potential Prevents risk of infection that for relapse to avoid infection. may precipitate a relapse. Demonstrate and allow for parents to Allows for monitoring of return demonstrate urine testing by possible relapse of disease. dipstick for albumin, monitor for edema, taking daily weights and BP, and to report changes of increased weight or presence of albumin in urine to physician immediately. Offer praise and encouragement to Positive reinforcement enhances parents and child as they learn desire to learn new skills. skills. Reinforce physician instructions Promotes return to usual about Na+ restriction, activity patterns of living. progression and pacing. Provide information about disease, Promotes understanding of its causes, need for frequent disease process and importance hospitalizations if disease becomes of compliance with therapy to prolonged or is a relapsing type prevent exacerbation. with remissions and exacerbations. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did parents verbalize about the cause and treatment of the child's illness? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR NEPHROTIC SYNDROME 6 of 8 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=43&FxId=123&Sessi. 7 of 8 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=43&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:03:47 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=43 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 5 - GENITOURINARYSYSTEM CHAPTER 5.4 - NEPHROTIC SYNDROME Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 8 of 8 12/22/2006 7:33 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=44&FxId=123&Sessi. CHAPTER 5.5 - SEXUALLY TRANSMITTED DISEASES INTRODUCTION Sexually transmitted diseases (STD) are a diverse group of viral, bacterial, protozoal, and ectoparasitic infections that have a common route of transmission through sexual intercourse. Infectious organisms associated with STDs include: Chlamydia trachomatis; Neisseria gonorrhoeae; bacterial vaginosis, vulvovaginal candidiasis, trichomoniasis; syphilis; herpes simplex; papillomavirus (genital warts); genital herpes and HIV. Infection by each of the above organisms has its own pattern of clinical patterns; medications/treatments; prognosis; transmission dynamics/host response to infection; and patterns of sexual contact. STDs are identified as one of the major causes of morbidity during adolescence. MEDICAL CARE DIAGNOSTIC EVALUATION Diagnosis is completed by identification of the organism from direct smear or culture techniques. Venereal Disease Research Laboratory (VDRL): reveals presence of Treponema pallidum (syphilis) by antibody tests (FTA-ABS and TPI). Cultures: Urethral and/or cervical smears for microorganism identification in gonorrhea, Chlamydia, urethritis; lesion smear to detect herpes, syphilis. MEDICAL MANAGEMENT Antibiotics: specific for the infectious organism. Anti-viral Medications: to decrease severity and possible prevent recurrent outbreaks. COMMON NURSING DIAGNOSES See RISK FOR IMPAIRED SKIN INTEGRITY Related to: External factor of excretions and secretions, internal factor of infectious agent invasion. Defining Characteristics: Disruption of skin surface, invasion of body structures, pus from urethra or cervix, vesicles on genitalia, buttocks, thighs, penile or vaginal discharge, chancre lesion on penis or female genitalia, skin rash, popupapules on skin, blisters and ulcerations on genitalia, itching and burning of lesions or sores, conjunctivitis, pharyngitis, dermatitis. See HYPERTHERMIA Related to: Pelvic inflammatory disease. 1 of 5 12/22/2006 7:34 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=44&FxId=123&Sessi. Defining Characteristics: (Specify: increase in body temperature above normal range, warm to touch, increased pulse and respiratory rate, evidence of infectious process.) ADDITIONAL NURSING DIAGNOSES DEFICIENT KNOWLEDGE Related to: Lack of information about disease. Defining Characteristics: (Specify: expressed need for information about treatment and prevention of recurrence of sexually transmitted disease.) Goal: Child will obtain information about sexually transmitted diseases and how to prevent them by (date and time to evaluate). Outcome Criteria √ Client verbalizes understanding of mode of transmission for STDs and identifies 2 ways to avoid becoming infected. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess knowledge of signs and symptoms Provides information about the of specific diseases, risk factors disease causes, treatment and in acquiring or transmitting preventive measures. disease, and potential complications. Teach about type of culture and blood Provides information about need to testing done for diagnosis of identify specific organisms by disease. culture of discharge from lesions, urethra, vagina, and cervix. Teach to report pain, tingling, Indicates active disease caused by burning, dysuria, frequency, lesion, inflammation. purulent discharge or leukorrhea, itching of genitalia. Teach about treatment: antibiotics, Provides treatment of choice for analgesics, topical agents as specific disease and instructions ordered (specify); emphasize need to for administration (action of take full course of ordered drug). antibiotic and follow-up exam for syphilis, gonorrhea, pelvic inflammation, chlamydial infection; (application of topical chemical agent and removing the drug by washing off in 4-6 hours to remove warts); (topical application of topical antiviral to treat herpes) (specify). Inform that disease is contracted and Prevents spread of the disease to transmitted by sexual contact and to others and recurrence in the 2 of 5 12/22/2006 7:34 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=44&FxId=123&Sessi. avoid sexual contact with an infected person. infected partner and during active phase of the disease; instruct to use male or female condom protection if sexually active. Instruct in handwashing technique to Prevents transmission of infectious be used following toileting and to agents to genitalia or other body avoid touching face with hands. parts. Explain consequences of disease if Prevents progression or left untreated or follow-up complications of the disease; may evaluation avoided. lead to infertility or second stage syphilis. Reassure that information will be kept Promotes environment conducive to confidential according to state instruction and that is laws. nonjudgmental and accepting. Teach about causes of flare-ups of Prevents recurrence of herpes herpes and to avoid changes in lesions that commonly occur with environment extremes, tight illnesses, trauma, or changes clothing, colds, exposure to sun. that may lower resistance. Encourage to report the disease and Promotes control of disease by inform contacts. tracing and treating contacts as well as the infected person. Teach about the recommended use of Usage helps prevent transmission of spermicide-coated latex condoms. infections (action of spermicide). Reinforce that the best form of This information may decrease prevention is avoiding exposure (by incidence and reoccurrence of sexual activity). STDs in the adolescent. Provide education to the adolescent Adolescents are often uninformed or that STDs are not contracted from lack accurate information toilet seats, drinking glasses or regarding how STDs are bath towels; also, that hormonal contracted. contraceptive methods do not provide protection against STDs. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did client say about the mode of transmission of STDs? What 2 methods to prevent STDs did the client identify?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR SEXUALLY TRANSMITTED DISEASES 3 of 5 12/22/2006 7:34 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=44&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 4 of 5 12/22/2006 7:34 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=44&FxId=123&Sessi. Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:04:15 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=44 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 5 - GENITOURINARYSYSTEM CHAPTER 5.5 - SEXUALLY TRANSMITTED DISEASES Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 5 of 5 12/22/2006 7:34 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=45&FxId=123&Sessi. CHAPTER 5.6 - CRYPTORCHIDISM INTRODUCTION Undescended testes (cryptorchidism) is a condition present at birth in which one or both testes fail to descend through the inguinal canal into the scrotal sac. The testes usually descend spontaneously by 1 year of age. If not, a child may receive human chorionic gonadotropin therapy or surgery (orchiopexy) performed between 1 to 2 years of age. Surgery prevents damage to the testes that may be affected by exposure to a higher temperature in the abdomen. Repair at a younger age also prevents the adverse effect on body image and embarrassment caused by the difference in the appearance of the empty smaller scrotal sac. Undescended testes that are associated with the presence of an inguinal hernia are repaired at the time of herniorrhaphy. Failure of the testes to descend can occur at any point along the normal path of descent into the scrotum. Symptoms of undescended testes rarely cause discomfort. The entire scrotum, or one side, will appear smaller than normal and may appear incompletely developed. Congenital inguinal hernias are frequently present with this defect. MEDICAL CARE DIAGNOSTIC EVALUATION Retractile Testes: testes can be manually pushed back down (or milked) into the scrotum. True undescended testes cannot be manually pushed back down into the scrotum. Cremasteric Reflex: (after 6 months of age and peaks by 4 to 5 years of age). Procedure: drawing up of the scrotum and testicle when the skin over the front and inside thigh is stimulated; will result in spontaneous retraction of testes back into the pelvic cavity. Diagnostic Tests, may include: testicular ultrasonography, computed tomography, and laparoscopy. All can be performed to confirm undescended testes prior to surgical intervention and to rule out masses, tumors, or cysts. MEDICAL MANAGEMENT By 1 year of age, the undescended testes will spontaneously descend into the scrotum in 75% of cases. Surgical Intervention (Orchiopexy): recommended for undescended testes repair before the child's second birthday. Analgesics: postoperatively to control pain. Antibiotics: to prevent infection at operative site. Hormones: chorionic gonadotropin to enhance testicular descent in the absence of an anatomic impediment. Complete Blood Count: reveals increased WBC if infection present. COMMON NURSING DIAGNOSES See RISK FOR IMPAIRED SKIN INTEGRITY 1 of 6 12/22/2006 7:34 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=45&FxId=123&Sessi. Related to: External factor of surgical incision. Defining Characteristics: (Specify: disruption of skin surface, surgical invasion.) ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: (Specify: threat to self-concept, change in health status of child, hospitalization and surgery of child.) Defining Characteristics: (Specify: increased apprehension and expressed concern about future infertility and effect on body image, presence of empty scrotum and smaller size, expressed concern about impending surgery or need for future surgery and procedure performed to correct abnormality.) Goal: Client will experience decreased anxiety by (date and time to evaluate). Outcome Criteria √ Parents verbalize decreased anxiety about child's undescended testes. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess source and level of anxiety Provides information about anxiety and how it is manifested; need for level and need for interventions information that will relieve to relieve it; source for the anxiety. parents

include fear and uncertainty about treatment and recovery; source for child include embarrassment by different shape and size of scrotum after school age. Allow expression of concerns and Provides opportunity to vent opportunity to ask questions about feelings and fears and secure diagnosis, procedures, effect of information to reduce anxiety. abnormal placement on testes and future fertility. Communicate with parents (and child) Promotes calm and supportive and answer questions calmly and trusting environment. honestly; use pictures, models and drawings as aids where helpful in explanations. Give parents (and child) as much Allows for more control over input in decisions about care and situation. routines as possible. Provide as much privacy to the child Promotes comfort and prevents as possible during assessments. embarrassment. 2 of 6 12/22/2006 7:34 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=45&FxId=123&Sessi. Inform parents that surgery is Provides information about need for usually performed after the age of surgical correction before school 1 but may be done during the age to prevent psychological and preschool years by the age of 5 if cosmetic embarrassment to the testes have not spontaneously child and that exposure to the descended on their own. higher temperature in the abdomen infertility. may damage testes and predispose to formation of tumor and Teach about procedure to the parents Explains the surgical procedure to (and child). correct the deformity (orchiopexy). (Reassure child that his penis will Alleviates any fear that the penis remain in place and that the may be cut off. surgery will not affect the penis in any way.) Instruct parents and child in Provides information about return to activity restrictions and play normal activity without injury to appropriate to age and trauma of operative area or disconnect the surgery (as ordered, specify). suture which may lead to testes again returning into inguinal canal. (Demonstrate and teach self- Allows for early detection of a examination of testes and allow for neoplasm. return demonstration; inform to report any change felt.) NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents report decreased anxiety? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: Inadequate primary defenses (broken skin). Defining Characteristics: (Specify: surgical incision proximity to urine and feces.) Goal: Client will not experience infection by (date and time to evaluate). Outcome Criteria √ Temperature remains <99° F. 3 of 6 12/22/2006 7:34 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=45&FxId=123&Sessi. √ Incision is clean and dry without redness, edema, drainage, or odor. NOC: Risk Control INTERVENTIONS RATIONALES Assess wound for redness, Indicates infection at site. warmth, swelling, discharge or odor (specify frequency). Apply ice to wound Reduces swelling. postoperatively as ordered. Carefully cleanse perineal area Prevents contamination of of any urine or stool as wound and risk of needed; teach parents. infection. Administer antibiotic therapy as Prevents or treats infection ordered (specify). by preventing synthesis of cell wall of microorganisms. Reinforce completion of course Prevents recurrence of of antibiotic therapy. infection. Teach child to wear clean Maintains cleanliness of undergarments or parents to surgical area and prevents change child's diaper contamination. frequently and not leave child in soiled diaper. NIC: Infection Control Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is temperature? Describe wound assessment relative to outcome criteria.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR CRYPTORCHIDISM 4 of 6 12/22/2006 7:34 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=45&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 5 of 6 12/22/2006 7:34 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=45&FxId=123&Sessi. Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:04:46 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=45 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 5 - GENITOURINARYSYSTEM CHAPTER 5.6 - CRYPTORCHIDISM Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 6 of 6 12/22/2006 7:34 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=46&FxId=123&Sessi. CHAPTER 5.7 - URINARY TRACT INFECTION INTRODUCTION Urinary tract infection (UTI) is defined as infection located in the lower tract (bladder or urethra) or in the upper tract (ureters or kidneys). The peak incidence of UTI observed in children occurs between 2 and 6 years of age, but can be observed at any age. The incidence of UTI in children also varies by gender: females have a 10% to 30% greater risk of developing a UTI; males have a 50% greater risk of developing a recurrent UTI; and during the newborn-age range only, male infants are at a greater risk of developing a UTI. Etiologic factors associated with UTI in children include: 75% to 80% of bacterial infections are caused by Escherichia coli. Bacterial organisms occur more frequently than viral or fungal organisms which are more frequent in low-birth weight and preterm infants. The higher incidence in female children is attributed to the female child's anatomic differences from the male child (shorter urethra with an increased chance of contamination caused by the close proximity to the anus), other factors include: urinary stasis, poor hygiene practices, and external factors (i.e., Foley catheter, tight fitting diapers, exposure to bubble baths). Diagnosis of UTI can be made by a urine culture from a clean-catch or a catheterized specimen. However, there is a high risk for contamination with clean-catch specimens. Lab result criteria for a UTI diagnosis: colony counts of 100,000 colonies in a clean-catch urine; and any urine culture greater than 5,000 colonies from urine obtained on a suprapubic puncture or catheterized specimen. Signs and symptoms of UTI in pediatric patients are age-related. For example, unique symptoms of UTI displayed by the infant: failure to thrive and fever; by the preschooler: anorexia and somnolence; by the school-ager: enuresis and personality changes; and those by the adolescent: fatigue and flank pain. MEDICAL CARE DIAGNOSTIC EVALUATION Diagnosis Is Dependent Upon: age-related symptoms of UTI; an accurate and thorough history of UTI symptoms, patterns of voiding, health practices at home, recurrent treatment of UTI, physical growth and examination, and urine culture lab results. Urine Culture and Sensitivity: the gold standard for the diagnosis of UTI, to determine the presence of bacteria in the urine and the drugs to which they are sensitive. UTI will have >100,000 colony formation units/ml (CFU/ml) in the first urine specimen in the morning. Evidence of a contaminated urine sample will reveal a report of fewer than 10,000 CFU/ml. Low colony formation may also occur because of very dilute or acidic urine, frequent voiding, chronic infection, or antibacterial therapy. Urinalysis: may show elevated protein, leukocytes, casts, pus cells. The urinalysis may be normal, with a positive urine culture. Radiographic Studies: (may be performed to identify any structural or functional renal abnormalities). These may include: renal ultrasound (RUS), voiding cystourethrogram (VCUG), intravenous pyelogram (IVP), and dimercaptosuccinic acid (DSMA). Voiding Cystourethrogram (VCUG): reveals anatomic abnormality of bladder and urethra and reflux of urine into ureters which predisposes to recurrent infection. Intravenous Pyelogram (IVP): reveals abnormalities in renal or bladder function caused by recurrent infections. Renal Ultrasound (RUS): radiologic test to determine renal obstructions and structural abnormalities; renal size; renal calculit; and polycystic 1 of 6 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=46&FxId=123&Sessi. kidney. MEDICAL MANAGEMENT Is directed at early diagnosis, elimination of infection, identification of causative factors to prevent infection and preservation of renal function. Anti-infectives: dependent on identification of the microorganism and sensitivity to specific anti-infectives. Urine Culture: reveals colonization of bacteria and identification of specific organism and sensitivity to antimicrobials. Follow-up Management: urine cultures should be repeated monthly for 3 months, every 3 months for 6 months, and annually thereafter to ensure early detection of any recurrent symptoms. The relapse rate of UTI is high in children and tends to occur within 1-2 months after termination of antibiotic therapy. COMMON NURSING DIAGNOSES See HYPERTHERMIA Related to: Illness (urinary tract infections). Defining Characteristics: (Specify: age-related symptoms of UTI in the pediatric patient, fever [temperature greater than 38.5° C], positive urine culture and sensitivity for bacteria in the urine.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Abnormal loss of fluids and deviations affecting intake of fluids. Defining Characteristics: (Specify: fever and chills; vomiting and diarrhea; anorexia, abdominal pain; reluctance of child to drink fluids; attempts to hold urine for long periods; enuresis; urgency and dysuria with voiding.) ADDITIONAL NURSING DIAGNOSES DEFICIENT KNOWLEDGE Related to: UTI. Defining Characteristics: (Specify: lacks accurate information related to diagnosis; treatment of current UTI and prevention or recurrent UTI; age-related signs and symptoms of UTI; home management and follow-up needs.) Goal: Client will obtain information about UTIs by (date and time to evaluate). Outcome Criteria √ Client verbalizes signs and symptoms of UTI and expected treatment regimen. 2 of 6 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=46&FxId=123&Sessi. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess parents' knowledge of age- Provides information needed to related signs and symptoms of UTI, develop plan of instruction to associated anatomy effects related ensure compliance of medical to UTI (girls vs. boys); assess regimen; UTI commonly occur in history and past treatments for UTI, females and are prone to recurrent compliance of previous UTI episodes; vesicoureteral reflux management. predisposes to UTI. Teach parents about causes of the Provides information that indicates infection and predisposing factors; lower or upper urinary tract to be alert to dysuria, frequency, infection. urgency, fever, foul odor to urine, cloudiness of urine, enuresis in the toilet trained child or flank pain, chills and fever, abdominal distention; and to report the presence of these signs and symptoms to physician. Teach parents how to collect a mid- Reveals presence of infection and stream urine specimen for laboratory identifies organism responsible and analysis before and after antibiotic if treatment is effective or needs therapy. changing. Teach parents (and child) in Provides information about medication antibiotic therapy and to take full therapy for effective resolution of course of medication. infection and prevention of relapse. Teach parents and child to avoid Provides information about prevention bubble baths and tub baths and take of recurrence of infection and showers; to wipe female from front irritation to the urethra. to back and instruct child to do same after toileting. Instruct child to void frequently and Prevents retention and stasis of increase daily fluids according to urine which predisposes to age (specify), include fluids that infection; fluids flush out are acidic (citrus and cranberry bacteria and acidic fluids change juice). pH of urine from alkaline to acid. Teach parents and child to avoid Predisposes to harboring of bacteria, wearing tight nonabsorbable entry and ascending into urinary undergarments. tract. If diagnostic tests are to be Prepares child and parents for performed, provide information about procedures to diagnosis anatomic type of procedure, reason for abnormalities that may be the procedure to be done, what to expect source of UTI. during procedure, after care following procedure. Instruct parents to obtain urine for The first morning void is considered analysis from the first morning the most accurate for assessing void. growth of organisms; urine specimens will show a decline in 3 of 6 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=46&FxId=123&Sessi. colonization throughout the day from diuresis and frequent voiding. Teach parents to avoid giving the Caffeine and carbonated beverages may child caffeine beverages and cause irritation to the bladder carbonated beverages. mucosa. Instruct sexually active adolescents This measure is associated with to void immediately after sexual decreasing the risk of exposure to intercourse. UTI; it may also help prevent recurrence of UTI; this measure will aid in flushing out bacteria. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did clients verbalize about

the signs and symptoms and treatment of UTIs? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR URINARY TRACT INFECTION 4 of 6 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=46&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library 5 of 6 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=46&FxId=123&Sessi. ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:05:21 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=46 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 5 - GENITOURINARYSYSTEM CHAPTER 5.7 - URINARY TRACT INFECTION Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 6 of 6 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=47&FxId=123&Sessi. CHAPTER 5.8 - VESICOURETERAL REFLUX INTRODUCTION Vesicoureteral reflux is defined as a retrograde (or backflow) of urine into the ureters. The diagnosis for VUR rarely occurs after 5 years of age. The etiology of VUR is categorized into two types, primary and secondary reflux. Primary reflux is caused by an inadequate valvular mechanism at the ureterovesical junction and is not associated with any obstruction or neurogenic bladder. The inadequate valve in primary reflux is caused by the shortened submucosal tunnel that shortens bladder filling. Secondary reflux occurs secondary to obstruction (50% of cases in infants are caused by posterior urethral valves) or neurogenic bladder. Important risk factors associated with VUR include: age, urinary tract infection (UTI), and reflux. The following effects of unrepaired reflux have been identified: urine concentration ability is inversely proportional to the grade of reflux; renal scarring; lower-weight percentiles (in physical growth); hypertension; proteinuria; and those with bilateral scarring and an increased risk of developing end stage renal failure (as high as 30%). In the majority of children, the problem will disappear spontaneously without surgical intervention if infection is controlled. Management of reflux includes antibacterial therapy for infection control. MEDICAL CARE DIAGNOSTIC EVALUATION Ultrasound: to identify anatomic abnormalities and measure renal growth. Voiding Cystourethrography (VCUG): visualizes bladder outline and urethra, reveals reflux of urine into ureters, and shows complications of bladder emptying. Intravenous Pyelogram (IVP): provides information about the integrity of the kidneys, ureters and bladder. It is recommended after an abnormal ultrasound, especially if anatomy is poorly defined. MEDICAL MANAGEMENT Antibacterial Therapy: may be administered for short-term or long-term usage. Ureteral Reimplantation Surgery: antireflux surgery, consists of reimplantation of ureters into the bladder. Follow-up Evaluation: children with reflux should be evaluated at a clinic at 3-month intervals. VCUG: is recommended again, at 2 to 6 months postoperatively. Analgesics: to control pain postoperatively. Antispasmodics: flavoxate hydrochloride (Urispas), propantheline (Banlin), PO, belladonna and opium (BSO) suppository to relax smooth muscle of bladder and reduce discomfort caused by bladder irritation and spasms. Urine Culture: reveals infectious agent and basis for antibacterial therapy or need for modification of therapy. 1 of 11 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=47&FxId=123&Sessi. COMMON NURSING DIAGNOSES See RISK FOR DEFICIENT FLUID VOLUME Related to: Loss of fluid through abnormal routes, deviations affecting intake of fluid. Defining Characteristics: (Specify: NPO status pre and postoperatively, urinary catheter [Foley or suprapubic], dry skin and mucous membranes, poor skin turgor, decreased urinary output via catheter or stents, temperature elevation.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Surgical incision. Defining Characteristics: (Specify: disruption of skin surface, catheter site irritation and discomfort.) See HYPERTHERMIA Related to: Illness. Defining Characteristics: (Specify: increase in body temperature above normal range, evidence of infection at surgical or catheter site, or renal/urinary infection.) ADDITIONAL NURSING DIAGNOSES DEFICIENT KNOWLEDGE Related to: Lack of exposure to information about disorder. Defining Characteristics: (Specify: expressed need for information about continuous medical regimen to control renal/bladder infection and measures to prevent infection.) Goal: Clients will obtain information about child's illness and treatment by (date and time to evaluate). Outcome Criteria √ Clients verbalize understanding of illness and treatment regimen. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess parents' and child's Provides basic understanding of the understanding of vesicoureteral condition without repeating reflux. Provide necessary information information the clients already and allow time for questions. Use know. 2 of 11 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=47&FxId=123&Sessi. teaching aids as needed (specify). Instruct parents and child in Promotes understanding of the antibacterial administration medication regimen for long-term including information on action, therapy to prevent recurrent or dose, form, time, frequency, how to relapse of urinary infection. take, side effects to report (specify). Teach parents and child to develop Empowers the parents and child to strategies for administration of take control of medication medications including the development administration on a long-term of an organized plan using pill basis. dispensers, alarms on a clock or watch, check-off list, reminder notes to prevent omissions (specify). Teach parents and child of need to Reveals presence of urinary obtain urine cultures by midstream infection and assists to regulate and taking to a laboratory or use of antibacterial therapy. dip-slide or strip to use at home (specify). NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did clients verbalize about the illness and treatment regimen? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) ANXIETY Related to: Change in health status, change in environment (hospitalization for surgery). Defining Characteristics: (Specify: expressed apprehension and concern about surgery [ureteral reimplantation] and pre and postoperative procedures and care.) Goal: Clients will experience decreased anxiety by (date and time to evaluate). Outcome Criteria √ Clients verbalize decreased anxiety. NOC: Anxiety Control INTERVENTIONS RATIONALES 3 of 11 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=47&FxId=123&Sessi. Assess source and level of anxiety and Provides information about anxiety need for information and level and need to relieve it; interventions that will relieve it. source for parent includes the procedure and care of child pre and postoperatively; source for child includes separation from parents, unfamiliar environment, and painful procedures. Allow expression of concerns and time Provides opportunity to vent to ask questions about need of feelings and fears and to feel surgery, procedure to be done, secure in the environment. procedures to prepare for surgery, procedures, care and recovery after surgery. Answer questions calmly and honestly, Promotes trust and a calm and use pictures, drawings, models and supportive environment. therapeutic play. Encourage parents to stay with child Allows parents to care for and and assist in care. support child and continue parental role and increases child's comfort by having a familiar caretaker. Allow as much input into decisions Allows for more control over about care and usual routines as situations and maintains a possible by parents. familiar routine for care. Orient and introduce child to the Reduces anxiety caused by fear of surgical unit preoperatively. the unknown. Teach parents and child about abnormal Provides information that will functioning ureter and reason for enhance understanding about surgical repair, that the ureter surgery to reduce anxiety. will be reimplanted to prevent urine from backing up in the ureter and continuing problems with infections. Teach about and prepare for Allays anxiety and provides preoperative procedures and tests accurate information of what to necessary for visualization and expect. diagnosis (specify). Teach parents and child that catheter Provides information of what to and/or stent will be in place and expect following surgery. where they will be placed, that they will be irrigated and receive special care, that urine output will be noted and measured for any abnormalities or complications, that a surgical dressing will be in place to protect the incision, and, in case of young child, restraints may be in place on arms and legs, and that medications will be given to control pain. Reassure parents and child that Provides information that may cause surgery and catheters will not anxiety. 4 of 11 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=47&FxId=123&Sessi. affect sterility or sexual orientation. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did clients report decreased anxiety? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) PAIN Related to: Surgery. Defining Characteristics: (Specify: communication of pain descriptors, crying, irritability, restlessness, withdrawal, flank pain, ureteral edema from surgery, bladder spasms.) Goal: Client will experience decreased pain by (date and time to evaluate). Outcome Criteria √ Client rates pain as less than (specify for child, indicate which pain scale is used). NOC: Comfort Level INTERVENTIONS RATIONALES Assess verbal and nonverbal Provides information about pain behavior, type and location and as a basis for analgesic severity of pain depending on age therapy. (specify pain scale and frequency). Administer analgesic based on pain Reduces pain and promotes rest assessment and before pain becomes to reduce stimuli and severe (specify). restlessness (action of drug). Place in a comfortable position; Promotes comfort and decreases avoid unnecessary movement or bladder spasms that cause manipulation of suprapubic pain. catheter. Administer antispasmodic as ordered Reduces bladder spasms caused (specify). by irritation of suprapubic catheter. Maintain catheter patency by Reduces pain caused by 5 of 11 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=47&FxId=123&Sessi. ensuring placement, checking flow distention as a result of and presence of kinks or catheter clogging or obstruction (specify when). displacement. Provide distractions and reassurance Reduces anxiety which tends to when spasms occur and stay with increase pain. child when they occur to inform the child that the pain is temporary. Inform parents and child that pain Provides knowledge about will subside 24 to 48 hours duration of pain and causes following surgery and teach of pain. measures taken to control pain. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is pain rating? Specify scale used.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: (Specify: urinary tract infection [acute, chronic or postoperative]; invasive postoperative drainage tubes (i.e., Silastic stents, urethral Foley or suprapubic tube].) Defining Characteristics: (Specify: redness, abnormal drainage, and/or swelling at incision site; UTI symptoms [burning on voiding, cloudy and foul-smelling urine]; positive urine or wound culture; temperature elevation [38.5° C or higher].) Goal: Client will not experience an infection by (date and time to evaluate). Outcome Criteria √ Surgical incision remains clean and dry without redness, edema, odor, or drainage. NOC: Risk Control INTERVENTIONS RATIONALES Assess wound for redness, swelling, Indicates presence of infectious purulent drainage on dressing, process or poor healing. healing. Assess catheter site for redness, Indicates infectious process at edema, irritation; urine collected catheter site or in urinary in drainage system for cloudiness bladder. 6 of 11 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=47&FxId=123&Sessi. and foul odor. Collect urine for culture and Reveals presence of urinary sensitivities. infection and sensitivity to specific antibacterial agent. Administer antibacterial as ordered Treats specific microorganism or (specify). prevents infection when catheter is in place. Encourage increased fluid intake Promotes dilution of urine to daily depending on age prevent infection and encourage requirements when PO fluids are voiding after catheter is allowed (specify). removed. Use sterile technique when changing Prevents contamination of wound or dressings, giving catheter care or urinary tract by the emptying drainage bag. introduction of pathogens. Maintain catheter and collection bag Prevents backflow of urine into below level of bladder and bladder or retention of urine maintain a closed, patent system which predisposes to infection. free of kinks or obstructions. Provide suprapubic catheter care by Promotes comfort and prevents cleansing with peroxide solution infection at suprapubic or after removing any meatal meatal site. crusting, catheter care by washing perineum with mild soap and water, rinsing and applying antiseptic ointment. Change dressings when soiled or wet Promotes comfort and allows for 24 hours after

surgery. wound assessment. Instruct and demonstrate catheter Provides information and skill in care, irrigation, emptying of caring for and maintaining drainage system using sterile catheter patency to prevent technique and allow for return infection if child is to be demonstration. discharged with catheter in place. Inform parents of signs and symptoms Allows for early intervention if of infection to report. infection is present. NIC: Infection Control Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe incision) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY 7 of 11 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=47&FxId=123&Sessi. Related to: (Specify: catheter displacement; internal factor of complications of surgical trauma.) Defining Characteristics: (Specify: catheter obstruction, postoperative bleeding catheter dislodgement, bladder distention, reduced urine output, dysuria, frequency, retention following removal of catheter.) Goal: Client will not experience injury by (date and time to evaluate). Outcome Criteria √ Urine is clear without blood or clots. √ Bladder is not distended. √ Client able to urinate after catheter is removed. NOC: Risk Control INTERVENTIONS RATIONALES Assess output via catheter and note Provides information about characteristics of urine, passage possible complication of of blood clots, color of urine and bleeding or obstruction. return to clear color; and if clots or return to red color occurs after a period of normal characteristics. Notify physician immediately if red Allows for immediate color returns. interventions to treat hemorrhage. Immobilize arms and legs with Prevents accidental restraints, remove periodically; dislodgement or removal of use bed cradle following surgery. catheter. Secure catheter to abdomen or leg Prevents movement or with tape stents to catheter and manipulation of catheter avoid placing tension on the that may cause displacement. catheter when in place by gently holding it when performing care. If catheter becomes displaced, notify Ensures continued drainage of physician for replacement (have a urine. suprapubic catheter on hand at all times). Measure I&O q h for an output of 1 Provides information to ensure ml/kg/hr and notify physician if adequate output via less. catheters. Note first voiding after catheter Provides information about removed, time of voiding and return of urinary pattern, amount, difficulty, presence of presence of retention. abdominal distention. Support during first voiding (warm Prevents embarrassment and water over perineum, sitting or promotes voiding. standing position) and privacy. Encourage increase in fluid intake Promotes voiding. 8 of 11 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=47&FxId=123&Sessi. according to age requirements. Inform parents and child that Allows for early interventions physician should be notified if if needed. urinary pattern or characteristics change or if unable to void after catheter is removed. Teach parents about measures taken to Informs parents of need for ensure that catheters remain in measures to prevent place and patent (use of displacement of catheter. restraints, anchoring catheters, irrigations) and that this is a temporary situation. Teach child to void frequently after Prevents stasis of urine catheter removal. leading to urinary infection. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe urine. Is ladder distended?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR VESICOURETERAL REFLUX 9 of 11 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=47&FxId=123&Sessi. 10 of 11 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=47&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:05:35 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=47 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 5 - GENITOURINARYSYSTEM CHAPTER 5.8 - VESICOURETERAL REFLUX Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 11 of 11 12/22/2006 7:35 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=48&FxId=123&Sessi. CHAPTER 5.9 - WILMS' TUMOR INTRODUCTION Wilms' tumor (or nephroblastoma) is identified as the most common pediatric malignant renal tumor in children. Incidence of Wilms' tumor is slightly less frequent in boys than in girls. The average age at diagnosis with unilateral tumors is 41.5 months and with bilateral tumors is 29.5 months. Children with Wilms' tumor may have associated anomalies and chromosomal abnormalities, such as: aniridia (congenital absence of the iris); hypospadias; cryptorchidism; Beckwith-Wiedemann syndrome; Denys-Drash syndrome; Perlman and Sotos' syndrome. The appearance of the Wilms' tumor is usually referred to as the "pushing type" (or adjacent renal parenchyma, enclosed by a distinct intrarenal pseudocapsule). The most frequent initial clinical presentation for most children with Wilms' tumor is abdominal swelling or the presence of an abdominal mass. This initial presentation is usually first noticed by a parent while bathing or dressing the child. Other frequent findings at diagnosis include: abdominal pain, gross hematuria, fever, and hypertension. The most common sites of metastases of Wilms' tumor are the lungs, the regional lymph nodes, and the liver. Histology classifies the tumor into: (1) favorable or unfavorable histology; (2) 3 cell types: triphasic or biphasic; with blastemal, stromal, and epithelial elements; and (3) 10% have anaplastic or unfavorable histologic findings, including anaplastic Wilms' tumor, clear cell sarcoma of the kidney, rhabdoid tumor of the kidney. Other histologic patterns include: nephrogenic rests, congenital mesoblastic nephroma, and renal cell carcinoma. An unfavorable histology is associated with a poor prognosis and more extensive chemotherapy. Prognosis is determined by the pathologic staging of Wilms' tumor, defined by the National Wilms' Tumor Study Group. Both the histology classification and the pathologic staging of Wilms' tumor determine the type and length of time for administration of chemotherapy agents and radiation treatments. MEDICAL CARE Diagnostic Evaluation: complete peripheral blood count (including a differential white blood cell count platelet count); liver function test (SGOT, SGPT, bilirubin); urinalysis, renal functions tests (BUN, creatinine) and serum calcium determination. Elevated serum calcium is associated with a rhabdoid tumor of the kidney or congenital mesoblastic nephroma. Abdominal Ultrasound Examination: can distinguish whether the abdominal mass is intrarenal or extrarenal; unilateral or bilateral; unifocal or multifocal; or solid or cystic. Contrast-Enhanced Computed Tomography of the Abdomen: to evaluate the nature and extent of the mass; and whether the tumor has extended into adjacent structures such as the liver, spleen, or colon. Supine X-ray Film of the Abdomen: is necessary for planning and review of radiation therapy. Real-Time Ultrasonography: determines the patency of the inferior vena cava vessel (when the tumor is identified within this vessel, the proximal extent of the thrombus must be established before the operation). Chest X-ray and Chest CT scan: to determine whether pulmonary metastases are present (are only performed if an unfavorable histology of the tumor is identified). Radionuclide Bone Scan and X-ray Skeletal Survey: should be performed on all postoperative children with clear cell sarcoma of the kidney, presence of pulmonary or hepatic metastases. 1 of 11 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=48&FxId=123&Sessi. Brain Imaging: should be obtained on all children with clear cell sarcoma of the kidney or with rhabdoid tumor of the kidney; both of these tumors are associated with intracranial metastases. Bone Marrow Aspiration and Biopsy: usually not performed as bone marrow involvement is rare. THERAPEUTIC MANAGEMENT Chemotherapy and Radiation Therapy Protocol: Favorable Histology: vincristine and actinomycin-D (no radiation). Unfavorable Histology: vincristine, actinomycin-D, cyclophosphamide, with radiation. Renal Angiogram: reveals renal function and extent of involvement. Scans of Kidney, Liver, Bone: reveals involvement of these organs if metastasis is present. Inferior Venacavagram: reveals involvement adjacent to the vena cava if the tumor has grown to a large size. Erythrocyte Sedimentation Rate (ESR): reveals increases as serum protein levels change. Albumin: reveals decreases with renal involvement. Enzymes: reveals increases in alanine aminotransferase (ALT), aspartate aminotransferase (AST), lactic dehydrogenase (LDH) with liver involvement; alkaline phosphatase (ALP) with bone involvement. Complete Blood Count: reveals increases in RBC as tumor excretes more erythropoietin. Urinalysis: reveals characteristics that indicate change in renal function caused by tumor, uric acid, erythropoietin increases. COMMON NURSING DIAGNOSES See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: (Specify: inability to ingest and digest food, side effects from therapy.) Defining Characteristics: (Specify: anorexia, nausea and vomiting from chemotherapy, obstruction postoperatively from chemotherapy causing adynamic ileus stomatitis [rare], abdominal cramping.) See RISK FOR DEFICIENT FLUID VOLUME Related to: (Specify: altered intake, excessive losses through normal routes, nausea and vomiting caused by chemotherapy and radiation therapy.) Defining Characteristics: (Specify: diarrhea, vomiting from radiation.) See DIARRHEA 2 of 11 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=48&FxId=123&Sessi. Related to: Side effects. Defining Characteristics: (Specify: increased frequency of bowel sounds and loose, liquid stools.) See CONSTIPATION Related to: (Specify: gastrointestinal obstructive lesions postoperatively, side effects.) Defining Characteristics: (Specify: adynamicileus, decreased bowel sounds, abdominal distention, frequency less than usual pattern.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: (Specify: side effects and radiation therapy; secondary effects of chronic diarrhea.) Defining Characteristics: (Specify: erythema or hyperpigmentation of previously irradiated skin; local phlebitis; transverse ridging of nails; redness and excoriation of perianal area from chronic diarrhea.) ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: (Specify: change in health status, threat of death, threat to self-concept.) Defining Characteristics: (Specify: increased apprehension and fear of diagnosis, expressed concern and worry about preoperative procedures and preparation, postoperative care and effects of therapy, possible metastasis of disease.) Goal: Clients will experience decreased anxiety by (date and time to evaluate). Outcome Criteria √ Clients verbalize decreased anxiety. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess source and level of anxiety Provides information about degree of and need for information and anxiety and need for interventions support that will relieve it. and support; sources for parents may be guilt and uncertainty about surgery, treatments and recovery, possible loss of child; sources for the child may be the multiple procedures of diagnosis and surgery and the effects of postoperative treatments. 3 of 11 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=48&FxId=123&Sessi. Allow expression of concerns and Provides opportunity to vent inquiries about disease and feelings, secure information needed possible consequences of surgery to reduce anxiety. and prognosis. Encourage parents to stay with the Promotes care and support of child by child or open visitation, provide a parents. telephone number to call for information about condition of child. Provide continuing nurse assignment Promotes trust and comfort and with the same personnel; encourage familiarity with staff giving care. parents to participate in care. Orient child to the surgical and ICU Reduces anxiety caused by fear of unit, equipment, noises and staff. unknown. Teach parents and child about the Promotes knowledge and understanding disease process, surgical of pre and postoperative treatments procedure, what to expect with and effect on disease and self- procedures done preoperatively, and image. what will be experienced postoperatively including radiation and chemotherapy and its benefits and effects (alopecia, stomatitis, nausea, vomiting, diarrhea are possible but temporary). Explain all procedures and care in Prevents overwhelming child and simple, direct, honest terms and parents with information in small repeat as often as necessary; amount of time as diagnosis and reinforce physician information if procedures usually carried out needed and provide specific within a short period of time and information as needed. anxiety will prevent ability to comprehend. Teach parents and child the extent of Reduces anxiety when knowledge and surgery with the removal of a support is given and child and kidney and the staging process; parents will not feel betrayed by discuss their understanding of the inadequate preparation of pathology report postoperatively procedures and treatments. and clarify information as needed. Utilize therapeutic play, drawings, Provides aids to assist child to models for instruction of child. understand what will be experienced and to express their feelings. Provide parents and child with Provides emotional support by those information about community who have experiences with the agencies and support groups. effects of the disease. NIC: Anxiety Reduction Evaluation (Date/time of

evaluation of goal) (Has goal been met? Not met? Partially met?) 4 of 11 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=48&FxId=123&Sessi. (Did parents report decreased anxiety? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: (Specify: side effects, complications.) Defining Characteristics: Intestinal obstruction; edema; adhesion formation; stomatitis. Goal: Child will not experience injury by (date and time to evaluate). Outcome Criteria √ BP remains within (specify range for child). √ Tumor capsule remains intact. √ Surgical incision remains clean and dry without redness, edema, odor, or drainage. NOC: Risk Control INTERVENTIONS RATIONALES Assess blood pressure for increases Provides information about vital pre and postoperatively q 2h, signs caused by renal function changes in pulse and respirations. abnormality preoperatively or by nephrectomy postoperatively, postoperative atelectasis. Avoid any palpation of abdominal Prevents trauma to tumor site and mass; post sign on bed stating not possible metastasis by to palpate preoperatively. dissemination of cancer cells. Assess bowel activity postoperatively Provides information about possible for elimination pattern, bowel adynamic ileus from chemotherapy sounds, bowel distention. causing bowel obstruction. Assess incision site for redness, Indicates infectious process swelling, drainage, intactness, and resulting from invasive procedure healing and change dressing when or inflammation resulting from soiled or wet; assess oral and immunosuppressive therapy for perineal area. stomatitis or skin breakdown or inflammation; provides oral care and anal care after elimination; provides postoperative pulmonary care. Assess urinary output for presence of Indicates possible renal impairment cloudy, foul-smelling urine; and/or urinary bladder infection; collect specimen for culture renal involvement alters renin analysis and report any change in excretion which increases BP and renal function (hypertension, immunosuppressive therapy leads to 5 of 11 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=48&FxId=123&Sessi. headache irritability, weight gain, infection. behavior changes). Maintain reverse isolation if Prevents transmission of infective leukopenia present or according to agents to the immunosuppressed agency dictate. child. Assess and document frequency of To assess potential intestinal bowel movements; document a obstruction from vincristine- description of all bowel movements; induced adynamic ileus. measure abdominal girth. Give stool softeners (as prescribed). To prevent straining with bowel movements. Teach parents and child about all Promotes understanding and assessments and procedures and cooperation. reason for isolation precautions. Teach parents to avoid exposing child Prevents exposure to possible to infectious agents; limit pathogens in the immunosuppressed visitors. child. Advise parents to dress child Prevents respiratory infections appropriate to weather conditions associated with exposure or trauma and to avoid rough activities or to the abdominal site sports. preoperatively and surgical site postoperatively. Instruct parents and child in mouth Prevents or treats skin and mucous care (rinsing and swabbing with membrane damage as a result of solutions, cleansing and drying therapy. after bowel elimination). Teach parents and child to report any Allows for immediate attention to changes in urinary pattern or any genitourinary problems in characteristics or renal function remaining kidney. promptly. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is BP? Is tumor capsule intact? Describe postoperative incision.) (Revisions to care plan? D/C care plan? Continue care plan?) IMPAIRED ORAL MUCOUS MEMBRANE Related to: Chemotherapy. Defining Characteristics: (Specify: stomatitis, oral ulcers, hyperemia, oral pain or discomfort, oral plaque.) 6 of 11 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=48&FxId=123&Sessi. Goal: Child will be free of oral mucous membrane irritation by (date and time to evaluate). Outcome Criteria √ No oral mucous membrane lesions present. NOC: Oral Health INTERVENTIONS RATIONALES Assess oral cavity for pain Provides information about ulcers, lesions, gingivitis, effect of chemotherapy. mucositis or stomatitis and effect on ability to ingest food and fluids (specify frequency). Administer medication (specify) Permits eating with more before meals and offer bland, comfort. smooth foods that are not hot or spicy. Administer an antiseptic mouth Promotes comfort of oral mucosa rinse 30 minutes before any food and maintains integrity or fluid intake as ordered (action of drug). (specify). Provide oral hygiene (30 minutes To prevent oral mucositis. before or after meals): mouth- washes (specify); instruct patient not to eat or drink for 30 minutes after oral hygiene is completed. Use soft-sponge toothbrush or To avoid oral trauma. sponge toothette or gauze to provide mouth rinse. Administer local anesthetics to May be effective in temporary oral area as ordered; administer pain relief from oral these before meals. lesions; permits eating with decreased oral pain. Avoid oral temperatures. To avoid oral trauma. Avoid use of lemon glycerin swabs Lemon may increase irritation to oral lesions. to oral lesions. Offer moist, soft, bland foods. To minimize irritation to oral ulcers; it may also be better tolerated by the child. Avoid foods which are hot, spicy, To minimize irritation to oral or which include ascorbic acid. ulcers; these foods may increase pain and irritation to oral areas. Teach parents about effect of Promotes understanding of side chemotherapy on oral mucosa and effects that occur and in treatments to decrease temporary nature of the side discomfort in oral cavity. effects. Teach parents in mouth care. Promotes effective care of oral cavity to relieve discomfort 7 of 11 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=48&FxId=123&Sessi. and prevent mucosa breakdown and increased inflammation. NIC: Oral Health Maintenance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Does child have any oral mucous membrane lesions?) (Revisions to care plan? D/C care plan? Continue care plan?) INEFFECTIVE PROTECTION Related to: (Specify: drug therapy [antineoplastics]: abnormal blood profile [leukopenia, thrombocytopenia, anemia, coagulation]; treatments [radiation].) Defining Characteristics: (Specify: altered clotting, bone marrow suppression, deficient immunity against infection, petechiae, bleeding from nose, gums, hematuria [25% of cases will display preoperatively], hemorrhagic cystitis [a common side effect of cyclophosphamide].) Goal: Child will be protected from illness or injury by (date and time to evaluate). Outcome Criteria √ Child does not experience bleeding. √ Temperature remains <100° F. NOC: Infection Status INTERVENTIONS RATIONALES Assess for bleeding from any site, Provides information about frank WBC, platelet count, Hct, absolute bleeding or blood profile neutrophil, count and febrile abnormalities that predispose to episodes (specify when). bleeding caused by bone marrow suppression and immunosuppression resulting from chemotherapy. Administer blood transfusion as Replaces blood loss when symptoms of ordered for severe blood loss, anemia appear (dizziness, pallor, monitor patency, vital signs, fatigue, increased pulse and chills, fever, urticaria, rash, respirations) or when Hct is less dyspnea, diaphoresis, headache than 20% or platelet count less throughout transfusion, and than 20,000/cu mm. terminate if any of these changes occur. 8 of 11 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=48&FxId=123&Sessi. Pad sides of bed, avoid trauma with Prevents bleeding caused by trauma use of hard toothbrush or dental during chemotherapy administration floss, apply pressure for 5 minutes which alters platelets and after IV administration, discontinue clotting factor. taking rectal temperatures or performing unnecessary invasive procedures. Carry out handwashing technique before Prevents transmission of pathogens giving care, use mask and gown when to a compromised immune system appropriate, provide a private room, during chemotherapy if the monitor for any signs and symptoms absolute neutrophil count is less of infection. than 1,000/cu mm. Teach parents and child to avoid rough Prevents trauma that causes play or sports, straining at bleeding. defecation, blowing nose hard. Caution parents and child to avoid Prevents risk for infection in the persons with upper respiratory highly susceptible child. infection or any illness. Instruct parents to report any fever, Indicates a complication associated behavior changes, headache, with abnormal blood profile. dizziness, fatigue, pallor, slow oozing of blood from any area, exposure to communicable diseases. Teach and allow for return Identifies presence of bleeding in demonstration of urine and stool gastrointestinal or urinary tract. testing for blood using dipstick and hematest. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Are there any indications of bleeding? What is child's temperature?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR WILMS' TUMOR 9 of 11 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=48&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. 10 of 11 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=48&FxId=123&Sessi. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:05:56 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=48 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 5 - GENITOURINARYSYSTEM CHAPTER 5.9 - WILMS' TUMOR Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 11 of 11 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=49&FxId=123&Sessi. UNIT 6 - MUSCULOSKELETAL SYSTEM CHAPTER 6.0 - MUSCULOSKELETAL SYSTEM: BASIC CARE PLAN INTRODUCTION The musculoskeletal system includes components that are needed for the supportive and protective framework of the body. The system functions to provide the movement that is essential for interacting and adapting to the child's environment and is especially vulnerable to forces in the environment. The system includes bones which compose the skeletal system, muscles which compose the muscular system, joints which compose the articular system, tendons, and ligaments. Tendons and ligaments with muscle attach to the surfaces of bones and the combination of all of the components allows for ambulation, personal care, and play. The problems encountered in these systems are classified as traumatic (most common) and long-term disability (degenerative disease). Any problem or abnormality that affects this system commonly affects the function of one or more other organ systems. The functional disruption that occurs as a result of a musculoskeletal problem that requires immobilization leads to physical and emotional alterations in a child who is usually active and curious. With growth and development of the system structures and gross and fine motor development, the child progressively functions within adult parameters for movements and activities of daily living. MUSCULOSKELETAL GROWTH AND DEVELOPMENT BONE, MUSCLE, JOINT, TENDON, LIGAMENT STRUCTURE • The spine in the newborn is rounded or has a convex curvature with the lumbar curve developed by 12 to 18 months of age; cervical spine is concave; thoracic spine is convex; and lumbar spine is concave after 18 months of age with the double S curve developed in the older child. • Muscles are completely formed at birth with size increasing by hypertrophy and strength increasing with muscular functions of walking, climbing, running, and jumping which is well established by 3 years of age. • Muscle development and bone growth continue to mature with skeletal lengthening and muscle strengthening increases throughout childhood. • Bone ossification is continuous with 25 new ossification centers appearing during the second year and bones continue to ossify until maturity is reached. • Bone growth occurs in the epiphysis at the end of long bones until it closes, at which time growth ceases. • Height and rate of skeletal growth increases at a slower rate with age with the toddler increasing 3 to 5 inches/year. • Feet of the infant and toddler appear flat and an arch develops with walking. • Height averages vary with age and sex. Boys Girls 6 mo 26 3/4 in 26 in 1 yr 30 in 29 1/4 in 2 yr 34 1/4 in 34 1/4 in 1 of 6 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=49&FxId=123&Sessi. 3 yr 37 1/4 in 37 in 4 yr 40 1/2 in 40 in 6 yr 45 3/4 in 45 in 8 yr 50 in 49 3/4 in 10 yr 54 1/4 in 54 1/2 in 12 yr 59 in 59 3/4 in MUSCULOSKELETAL FUNCTION • Development of gross and fine motor function and muscle strength and refinement continue in the preschool and school-age child. • From the beginning of walking through toddler stage, legs

are usually bowlegged until back and leg muscles develop and wide stance and waddle or toddling gait is apparent until 2 to 21/2 years of age; by school-age the legs become closer together and walking and posture is sturdy and balanced. • Bones in the child resist pressure and muscle pull less than the adult, so injury by trauma is common. • Bones heal faster in children as the bones are still in the process of ossification and growth. NURSING DIAGNOSES IMPAIRED PHYSICAL MOBILITY Related to: (Specify: intolerance to activity; decreased strength and endurance.) Defining Characteristics: (Specify: inability to purposefully move within physical environment, including bed mobility, transfer and ambulation, limited range of motion, decreased muscle strength, control and/or mass, fatigue, bed rest.) Related to: Pain and discomfort. Defining Characteristics: (Specify: reluctance to attempt movement, limited range of movement, painful and/or swollen joints, fracture, surgical procedure, infectious process.) Related to: Neuromuscular impairment. Defining Characteristics: (Specify: inability to purposefully move within physical environment, including bed mobility, transfer and ambulation, decreased muscle strength, control and/or mass, impaired coordination, paralysis [paraplegia or quadraplegia], progressive deterioration, inadequate gross and fine motor skills, diminished musculoskeletal responses.) Related to: Musculoskeletal impairment. Defining Characteristics: (Specify: inability to purposefully move within physical environment, including bed mobility, transfer and ambulation, reluctance to attempt movement, limited range of motion, decreased muscle strength, control and/or mass, imposed restrictions of movement 2 of 6 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=49&FxId=123&Sessi. including mechanical [cast, traction, splint, brace, or bed rest], contractures, fracture, joint disease and destruction inflammation, congenital disorders.) Goal: Client will gain improved physical mobility by (date and time to evaluate). Outcome Criteria √ (Specify, e.g., child will move self in bed with traction bar; walk the length of the hallway and back twice a day; etc.) NOC: Mobility Level INTERVENTIONS RATIONALES Assess muscle tone, strength, mass; Provides information about joint mobility, pain, stiffness, musculoskeletal condition and swelling; ability to move and function. activity level in performing ADL (specify when). Assess bed rest status, activity Maintains rest during acute stages restrictions, imposed immobility by to promote healing and braces, casts, traction, splints. restoration of health. Assess sensory (diminished sensation Provides information about and numbness) and motor (gait and conditions or treatments that balance) function of extremities; affect mobility. presence of paralysis, fracture, surgical correction of musculoskeletal abnormalities. Assess physical effects of Prevents complications of immobilization on body systems; immobility by monitoring and constipation, skin breakdown, intervening when needed; mobility urinary retention, hypercalcemia, provides important contributions loss of muscle strength, to development and physical contractures, circulatory stasis, health. stasis of pulmonary secretions, anorexia, renal calculi, decreased metabolism and energy, loss of nerve innervation. Assess psychologic effect of Provides information about behavior immobilization; reduced body image, and deprivation resulting from inability to reduce stress, loss of immobilization that prevents stimuli, loss of independence and children from dealing with mastery, anxiety, regressive feelings and expression of behavior, anger and aggression, anxiety and tensions. passive and submissive behavior, crying, irritability, temper tantrums. Avoid restriction in activities unless Promotes mobility and activity ordered; encourage and allow for as synonymous with health and life; much movement as possible in allows for autonomy and control performing daily activities; for normal development. administer analgesic before activity. 3 of 6 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=49&FxId=123&Sessi. Encourage all age-appropriate Promotes mobility according to activities that facilitate mobility, limitations of illness and allow infant to crawl (specify). provides outlet for frustration of imposed immobility. Provide quiet play and progress in Maintains large and small muscle ambulation by scheduling dangling at strength as condition permits. bedside, standing with support, ambulation with support with increases daily and praise for all attempts regardless of progress. Transport/transfer infant/child by Provides stimulation by interacting Hoyer lift, stroller, wheelchair, in a different environment in bed outside of room/hospital. absence of mobility. Provide and apply brace, splint; use Promotes independence and support of aids including wheelchair, in mobility and activities. crutches, supportive reading, eating, and other aids for ADL as needed (specify). Maintain body alignment on bed rest, Prevents contractures and physical reposition q 2h or as needed; use a deformity and preserves joint drawing for child to follow for function. position and where to lie in bed. Coordinate rest with periods of Prevents fatigue and conserves mobility. energy. Perform muscle strengthening Preserves muscle strength or exercises, passive stretching prepares for use of crutches or exercises, joint mobilizing other mobility aids. exercises if ordered or as appropriate (specify). Apply special shoes, splint or Maintains position at night and appliance for day or night use prevents deformity and allows for (specify). locomotion by increasing gait efficiency during day use. Prepare for physical and/or Promotes and maintains optimal occupational therapy during function and mobility of child. recuperative period as ordered (specify how). Inform parents and child of hazards of Promotes compliance with program to immobility (specify). maintain mobility and understanding of effects of immobility. Teach parents and child to use devices Promotes safe use of aids and or aids for mobility and ADL apparatus and increased security. (specify). Teach parents to provide clear Provides safe environment for pathways, remove rugs, make mobility. environmental modifications as needed. Teach parents and child about Promotes strengthening of muscles activities for large muscle as condition improvement. strengthening (tricycle, swimming, running, skipping rope), and small 4 of 6 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=49&FxId=123&Sessi. muscle strength-ening (games, puzzles, crayons, coloring books). Encourage child with progress in Provides child with a goal to ambulation and ADL. strive for and achieve. Teach parents and child ROM, Maintains muscle and joint strengthening exercises as function. appropriate. Reinforce parents and child of Promotes compliance with prescribed importance of therapy and follow-up therapy especially if needed to care, short- or long-term depending ensure mobility or health on need. maintenance in chronic disorders. NIC: Activity Therapy Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What has been child's activity level? How does it compare with the outcome criteria?) (Revisions to care plan? D/C care plan? Continue care plan?) COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) 5 of 6 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=49&FxId=123&Sessi. Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:06:29 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=49 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 6 - MUSCULOSKELETAL SYSTEM CHAPTER 6.0 - MUSCULOSKELETAL SYSTEM: BASIC CARE PLAN Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 6 of 6 12/22/2006 7:36 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=50&FxId=123&Sessi. CHAPTER 6.1 - FRACTURES INTRODUCTION A fracture is a break in a bone which is usually caused by a fall or injury. Fractures are common in children because of their activity and continual changes and growth in gross motor function. Injury of this type in an infant or very small child is often the result of physical abuse. The most common type of fracture in children under 3 years of age is the greenstick which is an incomplete fracture and results in a compression of one side causing it to bend and the other side to fail. A bend fracture is the result of the bone bending and straightening on its own because of the flexibility of the bone at a young age. A buckle fracture is raised bulging of the bone resulting from compression of the bone near its most porous part. A complete fracture is a division in the bone with or without attachment of a periosteal hinge remaining. The most common sites of fractures in children are the femur, humerus, clavicle, ulna, radius, tibia, and fibula. Treatment includes reduction (open or closed), and immobilization by casting and/or traction depending on the type and severity of the fracture. Healing is faster in the child and takes place within 3 to 4 weeks. Remodeling is usually completed within 9 months depending on the type and site on the fracture, amount of fragmentation, and the age of the child. MEDICAL CARE Analgesics: for pain control depending on severity. Bone X-ray: reveals trauma site, separation of the epiphysis in older child. Enzymes: reveals increases in alkaline phosphatase (ALP), lactic dehydrogenase (LDH), creatine phosphokinase (CPK), aspartate aminotransferase (AST) with bone, and muscle damage. Complete Blood Count (CBC): reveals increased WBC and neutrophils if infection present, decreased RBC, Hct, Hgb with destruction of RBC caused by muscle, bone and soft tissue injury. COMMON NURSING DIAGNOSES See IMPAIRED PHYSICAL MOBILITY Related to: Pain and discomfort, musculoskeletal impairment (fracture). Defining Characteristics: (Specify: intolerance to activity, decreased strength and endurance, inability to purposefully move within physical environment including bed mobility, transfer and ambulation, reluctance to attempt movement, imposed restrictions of movement including mechanical medical protocol [cast, traction], inability to participate in activities and socializing.) See INEFFECTIVE TISSUE PERFUSION, PERIPHERAL Related to: Interruption in arterial and venous flow. Defining Characteristics: (Specify: cold, pallor or blue color of extremity, decreased peripheral pulse, cast tightness.) See RISK FOR IMPAIRED SKIN INTEGRITY 1 of 9 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=50&FxId=123&Sessi. Related to: (Specify: external factor of physical immobilization, pressure of cast, traction apparatus, presence of surgical incision from open reduction; internal factors of altered circulation and sensation.) Defining Characteristics: (Specify: disruption of skin surface, invasion of bony structures, redness, irritation of skin at cast edges or pressure areas, numbness or tingling of casted extremities.) See CONSTIPATION Related to: Inadequate physical activity or immobility. Defining Characteristics: (Specify: frequency less than usual, hard formed stool, decreased bowel sounds, straining at defecation.) ADDITIONAL NURSING DIAGNOSES PAIN Related to: Physical injuring agents (bone fracture); surgery to realign fracture. Defining Characteristics: Communication of pain descriptors, guarding and protective behavior to injured part, crying, irritability, restlessness, swelling of part, muscle spasms. Goal: Child will experience less pain by (date and time to evaluate). Outcome Criteria √ Child rates pain as less than (specify desired level and pain scale used). NOC: Pain Level INTERVENTIONS RATIONALES Assess site for pain including type, Provides information about pain severity, and duration using a pain as a basis for analgesic and scale if appropriate; pain as a muscle relaxant therapy. result of surgical open reduction (specify frequency). Administer analgesic, muscle Reduces pain and promotes rest relaxant, or both as ordered and following injury or surgery note response (specify drug, dose, (action of drug). etc.). Apply ice to fracture if ordered. Treats pain and edema by vasoconstriction. Apply splint or Jones dressing Relieves pain and prevents (cotton wrapping over area covered further damage by protecting by an Ace bandage). and immobilizing limb. Elevate limb above heart level, Promotes venous return to maintain alignment of limb when relieve edema which causes 2 of 9 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=50&FxId=123&Sessi. positioning. pain and prevents contractures. Support limb above and below injured Prevents pain caused by area when moving and positioning; movement. use smooth movements and avoid abrupt movement of limb. Teach parents and child about pain Provides information about medications and expected results expected effects of analgesic and importance of reporting pain therapy during acute stages of before it becomes too severe. pain and as pain subsides with healing. Show parents and child ways to move Prevents undue pain caused by and position limb, maintaining movement of limb. immobilization of extremity, and to avoid weight-bearing exercise until advised by physician. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is pain rating? Specify scale used) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: (Specify: sensory dysfunction, tissue hypoxia, altered mobility resulting from cast application.) Defining Characteristics: (Specify: change in color, temperature, edema, movement of fingers/toes; tingling or

numbness of fingers/toes; drainage or musty odor from under cast; skin irritation at cast edges; moist, wet, or broken cast, foreign objects inserted between cast and skin.) Goal: Child will not experience injury by (date and time to evaluate). Outcome Criteria √ Affected area (specify remains pink and warm). √ Child reports sensation and is able to move affected area (specify). NOC: Risk Detection INTERVENTIONS RATIONALES Assess pulses in casted upper or Provides information about the 3 of 9 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=50&FxId=123&Sessi. lower extremity, swelling, neurovascular status of an coolness, inability to move digits, extremity following cast pallor or cyanosis, numbness of application as swelling continues areas distal to the cast q 2h. causing the cast to become tight and compromise circulation; a bivalved cast treats excessive edema to prevent tissue damage. Allow cast to dry thoroughly using a Prevents indentations in the cast fan, turning q 2h, support on that may cause pressure areas, pillows and use palm of hands to allows cast to dry from inside lift or handle cast exposing as out for 1/2 hour or more much of the cast to the air as depending on substance used for possible. cast and type of cast. Do not use a heated fan or dryer. Heat causes the cast to dry on the outside but stay wet underneath, or may cause burns from heat conduction through the cast. Elevate casted part on pillow until Promotes venous return to reduce completely dry and when at rest for swelling. a few days. Provide quiet play for a few days and Maintains muscle and joint exercise muscle and joints above function. and below. Remove small articles or food that Prevents pressure to injury and may be put into the cast. infection if skin is broken under the cast. Clean plaster cast with vinegar and Maintains cleanliness of the cast. water; fiberglass casts are cleaned with mild soap and water. Petal cast if rough edges are Protects skin from irritation and present; massage skin near cast breakdown. edges and note any reddened or abrasive areas. Outline area of drainage on cast with Monitors increases in drainage pen; and include date and time. under the cast. Provide muscle strengthening Prepares for crutch walking if exercises, ROM of unaffected parts, appropriate and maintains joint isometric exercises appropriate. and muscle mobility. Teach parents and child about type of Provides information about injury cast, type of fracture and how it and type of immobilization to heals. allow for healing process. Reinforce to parents and child to Prevents damage to the cast and restrict activities according to skin that may lead to infection physician advice, to avoid placing or impair the desired effect of articles, such as a coat hanger for the cast. scratching, into the cast. Teach parents and child to avoid Maintains return venous flow and allowing limb to hang down and prevents fatigue from heavy cast. maintain elevation of the limb when sitting and support limb with a sling when standing; avoid standing for prolonged periods of time. 4 of 9 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=50&FxId=123&Sessi. Instruct parents to note and report Indicates presence of infection or any pain, swelling, musty odor from neurovascular compromise that may cast; changes in neurovascular require a cast change. status in casted extremity, tightness or looseness of cast. Teach parents to massage skin at cast Toughens skin to prevent breakdown edges, avoid use of lotions and and prevents infection by powder in these areas, and pad cast providing media for bacterial edges if needed. growth. Instruct child in use of crutches or Allows for mobility and application of sling (specify). participation in activities. Teach parents and child about length Permits planning for continuing of cast presence, need for physical care if appropriate. therapy if appropriate, and method of maintaining clean cast (plaster or plastic). NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe color, temperature, sensation, and movement of affected area. What does child say?) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: (Specify: sensory dysfunction, altered mobility resulting from skin or skeletal traction.) Defining Characteristics: (Specify: redness, swelling, pain at pin site, change in neurovascular status of extremity, malfunction of traction apparatus, ineffective traction, contractures or weakness of joint and muscles.) Goal: Child will not experience injury by (date and time to evaluate). Outcome Criteria √ Traction is maintained. √ Child remains in correct body alignment. (Pin sites are not red or swollen.) NOC: Risk Control INTERVENTIONS RATIONALES Assess type and purpose of traction, Provides information about use of 5 of 9 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=50&FxId=123&Sessi. extremity or body part involved traction to realign bone ends, (specify). provide immobilization of a part, reduce muscle spasms, correct a deformity, provide rest for an extremity; traction may be manual as in cast application, skin in which the pull is attached to the skin with bandages or straps, or skeletal in which the pull is attached to a pin, wire, or tongs inserted into the bone at a distal position to the fracture. Assess functioning part of the Provides information needed to traction apparatus including ensure correct traction applied correct weight amount and hanging, to body part. ropes in tract with secure knots, pulleys in original site with movable wheels, position of frames, splints. Assess skin color, pulses, numbness, Indicates neurovascular changes or changes in movement of body resulting from traction; muscular part; weakness or contractures of changes resulting from uninvolved muscles and joints: immobilization. neurochecks q 2 to 4h. Assess pressure points noting any Prevents prolonged pressure on skin redness or breakdown and reposition that results in breakdown and if possible; massage uninjured skin decreased blood flow to area. areas. Maintain bed position as ordered with Provides desired amount of pull and head or foot elevated. countertraction. Maintain correct body alignment Promotes comfort and prevents especially in hips, legs, arms, and deformity. shoulders; realign after the child has moved or changed position. Perform ROM to unaffected joints, Prevents contractures and foot apply foot plate if appropriate. drop. Maintain nonadhesive straps or Supplies attachment for pull in bandages used; do not remove or skin traction. change unless permitted while someone maintains traction; note tightness or looseness that may cause ineffective traction. Cleanse and dress pin site daily; Supplies attachment for pull in apply antiseptic ointment if skeletal traction and treats pin ordered; check skin for infection site to prevent infection. at site; examine screws within metal clamp for proper attach-ment of clamp to traction; do not remove traction. Assist child to perform ADL Promotes independence in self-care activities independently as much as within limitations of age and possible; facilitate self-care with immobilization. 6 of 9 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=50&FxId=123&Sessi. assistive aids. Suggest activities such as hobbies, Allows for movement without TV, reading, games while in disturbing traction. traction. Provide diversionary activities and Provides and promotes social encourage visits from family and interactions. friends, move bed to area of activity with peers. Teach parents and child as Provides information to assist with appropriate for age about reason coping with immobility. for traction and length of time traction must be in place. Teach child of amount and type of Ensures that amount of activity is movement allowed while in traction. not exceeded and will not affect traction. Reassure parents that traction will Promotes positive response to assist in the healing of fracture. treatment. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Has traction been maintained? Describe child's body alignment. Describe pin assessment.) (Revision to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR FRACTURES 7 of 9 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=50&FxId=123&Sessi. 8 of 9 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=50&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:06:50 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=50 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 6 - MUSCULOSKELETAL SYSTEM CHAPTER 6.1 - FRACTURES Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 9 of 9 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=51&FxId=123&Sessi. CHAPTER 6.2 - CONGENITAL HIP DYSPLASIA INTRODUCTION Congenital hip dysplasia is related to abnormal hip development. The abnormalities include hip instability, preluxation (shallow acetabulum), subluxation (incomplete dislocation of the hip), and dislocation (femoral head not in contact with the acetabulum). It usually involves one hip, but may involve both. It occurs 6 times more often in females than males. It is usually identified in the newborn period and responds to treatment best if initiated before 2 months of age. Therefore, it is important to examine every infant from birth to 12 months of age. Treatment is dependent on the age of the child and the degree of abnormality, and ranges from application of a reduction device, to traction and casting, to surgical open reduction. Casting and splinting with correction is usually impossible after 6 years of age. MEDICAL CARE Pelvic X-ray: reveals outward femoral displacement with upward slope of the roof of the acetabulum in infant/child over 4 months of age. Ultrasound: reveals cartilaginous head displacement in infant under 1 to 4 months of age. Ortolani Test: a maneuver abducting the infant's leg that, in the event of hip dysplasia, causes the femoral head to enter the acetabulum and is identified by a click as this occurs. Barlow's Test: a maneuver adducting the infant's leg that, in the event of hip dysplasia, causes the femoral head to exit the acetabulum and is palpable by the examiner. COMMON NURSING DIAGNOSES See IMPAIRED PHYSICAL MOBILITY Related to: Musculoskeletal impairment (hip defect). Defining Characteristics: (Specify: imposed restriction of movement by harness, cast, traction, or splint; inability to purposefully move within physical environment including bed mobility; ambulation. See RISK FOR IMPAIRED SKIN INTEGRITY Related to: External factor of physical immobilization; internal factor of altered circulation; sensation by pressure of device, cast, traction. Defining Characteristics: Edema, tight appliance or cast, change in skin color and temperature proximal to spica cast or device or pin site, skin irritation at pin site or cast edges, numbness proximal to cast. See CONSTIPATION Related to: Musculoskeletal impairment, inadequate physical activity or immobility. 1 of 7 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=51&FxId=123&Sessi. Defining Characteristics: Frequency less than usual, hard formed stool, decreased bowel sounds, straining at defecation. See DELAYED GROWTH AND DEVELOPMENT Related to: Effects of physical disability (immobilization). Defining Characteristics: Environmental and stimulation deficiencies, inability to perform self-care activities appropriate for age, isolation with long-term immobilization. ADDITIONAL NURSING DIAGNOSES RISK FOR INJURY Related to: (Specify: untreated or improper treatment for dislocation.) Defining Characteristics: (Specify: late onset dislocation, absence of early recognition and intervention for correction, muscle contracture, muscle shortening, femoral and acetabulum deformity, tight spica cast, inappropriate traction or malfunctioning traction.) Goal: Infant will not experience injury by (date and time to evaluate). Outcome Criteria √ (Specify outcome criteria based on treatment mode, e.g., traction is maintained; Pavlik harness is applied properly; skin is free of irritation in spica cast.) NOC: Risk Detection INTERVENTIONS RATIONALES Assess infant up to 2 months of age for Provides information about the presence frank breech birth, cesarean birth, hip and degree of dysplasia; may be joint laxity or dislocation (Ortolani preluxation, subluxation, or or Barlow test), degree of dysplasia or dislocation (luxation) and involve a dislocation, shortened limb on the laxity of the capsule or an abnormal affected side (telescoping), broadened acetabulum; identification of the perineum, asymmetry of thigh

and presence of the deformity at this age gluteal folds with increased number of results in the highest success rate folds and flattened buttocks. in complete correction. Assess child's shortened leg affected Provides information about the presence with telescoping; palpation of femur of deformity in one or both hips in when thigh is extended and pushed the older infant or toddler and toward the head and pulled in distal preschool age group; usually direction; delayed walking and a limp identified when the child begins to that causes lurching toward affected walk or stand, and limb is shortened side; downward tilt of pelvis toward and adductor and flexor muscle unaffected side if weight-bearing on contracture has occurred; requires affected side when standing closed reduction (traction and cast) (Trendelenberg sign); lordosis and or open reduction (surgery, cast 2 of 7 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=51&FxId=123&Sessi. waddling gait if both hips affected. splint) to correct. (Apply Pavlik harness splinting device to Maintains abducted, reduced position infant up to 6 months of age to be worn for maintaining the femur in the continuously for 3 to 6 months to acetabulum; other methods to correct ensure hip stability; apply double or unstable hip may be used to stretch triple diapers or Frejka pillow if this legs and maintain abducted position is treatment ordered.) deformity. depending on degree of (Maintain skin traction in presence of Promotes hip abduction until stable; abduction contracture in the infant up applies with a spica cast if unable to 6 months of age and spica cast if to maintain stable reduction of the applied following the traction; hip for 3 to 6 months; removal of the maintain skin traction for gradual spica cast is followed by an reduction of the hip adductor and abduction brace for protection. flexor muscles with a spica cast application for immobilization in child 6 to 10 months of age.) (Provide traction care including correct Maintains safe, effective traction to alignment of extremity, correct amount affected hip(s) with child's response of weights, free hang of weights, to traction monitored. correctly functioning pulleys with secure knots, neurologic and circulatory checks q 4h for color, warmth, sensation.) (Provide spica cast care including Maintains safe, effective support of cast when moving, removing immobilization to ensure permanent crumbs and small articles that may get stability of hip with child's into cast, petal cast edges, avoiding response to cast monitored for cast insertion of anything into cast to syndrome caused by tight spica cast scratch, clean cast when needed, allow compressing the superior mesenteric to dry completely, protect cast from artery of the duodenum. soiling and dampness from elimination or bathing; neurologic and circulatory checks q 4h for color, peripheral pulse, warmth, capillary refill, sensation; nausea and vomiting resulting from cast syndrome.) (Provide diaper change frequently and as Maintains clean harness brace, or cast. needed; use disposable diapers or plastic protection over diaper.) (Teach parents about type and degree of Provides information about abnormality, deformity and cause and treatment plan its classification, medical and/or for correc- tion and prognosis by surgical regimen that is determined reinforcing physician information; by age and severity of the deformity. inform of proposed operative reduction in older child or if obstruction of joint development by soft tissue is present in the young child.) (Teach parents to apply splint or harness Promotes and maintains reduction of hip correctly over the diaper and shirt, to correct deformity. use disposable diapers or waterproof undergarment to protect appliance; on removal of harness for bathing if 3 of 7 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=51&FxId=123&Sessi. allowed or sponge bathing child with harness in place, padding shoulder straps, changing position q 2h; to avoid adjusting the harness.) (Teach parents about traction care Ensures correct traction for gradual including reason and purpose for reduction of the hip and/or traction, amount of movement that the preoperative if surgery anticipated. child is allowed, performing neurovas- cular assessment and what to report, correct weight for amount and hanging with pulleys and knots if present, maintaining body alignment.) (Teach parents in spica cast care Ensures correct cast care for including reason and purpose; support immobilization of hip following of the cast during movement; reduction of the hip; traction or maintaining clean, dry cast and surgical correction may be used for protecting it from stool and urine with reduction or reconstruction of the waterproof tape or plastic cover; acetabulum. padding cast edges; avoid lifting by crossbar; disallowing small objects or crumbs to enter cast; cast signatures without leaving white space between writing; instruct in diapering or bedpan/toilet use; use of a diaper tucked into the perineal opening on cast; feeding infant in supine position [head elevated propped with pillows or while being held in upright position on lap or in a car seat]; inform parents that specially made car seats for infants with casts/harness are available and must be used if the child rides in a car; refer to social worker if cost prevents access to the seats.) Refer parents to crippled children or Provides information and support other community agencies available. services to the child and family. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide data related to outcome criteria, e.g., Has traction been maintained? Is Pavlik harness correctly applied? Describe skin around spica cast.) (Revisions to care plan? D/C care plan? Continue care plan?) IMPAIRED SOCIAL INTERACTION 4 of 7 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=51&FxId=123&Sessi. Related to: Limited physical mobility. Defining Characteristics: (Specify: change in pattern of interaction, lengthy treatment and immobilization, boredom, inability to engage in usual activities for age group, environment that lacks diversion.) Goal: Infant will experience adequate social interaction by (date and time to evaluate). Outcome Criteria √ Parent stays with infant and provides social interaction. √ Infant responds positively to parental interaction. √ Infant is included in family activities. NOC: Social Involvement INTERVENTIONS RATIONALES Assess infant's social interaction Provides information about infant with parents. stimulation. Provide age appropriate toys to be Promotes social and developmental used in bed while in a prone or activities and reduces boredom sitting position depending on during long-term treatment. type of treatment and degree of immobilization. Provide exposure to other children Provides environmental by moving bed near areas of stimulation and social activity or near a window; wheel interaction; promotes social on a stretcher, wheelchair, or interaction with others during stroller; allow to walk with cast long-term treatment and reduces or brace if permitted. boredom. Encourage family and friends to Promotes social interaction with visit or stay with child. others during long-term boredom. treatment and reduces Place toys and other articles Provides access to diversion within reach. activities when needed. Teach parents to include infant/ Promotes feeling of acceptance child in family activities. and well-being as part of the family. Assist parents with devices Promotes exposure to a variety of available or methods of activities and changes of converting aids used for mobility environmental stimuli. to fill needs of child with a cast or appliance. Encourage parents to allow as much Promotes independence and allows independence if self-care by some control over the child as possible. situation. NIC: Socialization Enhancement 5 of 7 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=51&FxId=123&Sessi. Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Do parents provide social interaction for infant? Does infant respond positively? Is infant included in family activities?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR CONGENITAL HIP DYSPLASIA 6 of 7 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=51&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:07:04 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=51 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 6 - MUSCULOSKELETAL SYSTEM CHAPTER 6.2 - CONGENITAL HIP DYSPLASIA Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 7 of 7 12/22/2006 7:37 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=52&FxId=123&Sessi. CHAPTER 6.3 - LUPUS ERYTHEMATOSUS INTRODUCTION Lupus erythematosus is a chronic systemic inflammatory disease of the collagen or supporting tissues and affects any organ in the body. It is classified into a transient type affecting neonates and a type with an onset after infancy that is the same as systemic lupus erythematosus affecting adults. The disease is characterized by remissions and exacerbations and may appear in children as young as 6 years of age but is most commonly seen in those 10 years of age and older. Disease manifestations include lesions or rash on face, neck, trunk and extremities; pleurisy; pericarditis; kidney failure; arthritis; anemia; gastrointestinal abnormalities; and enlarged lymph nodes. Prognosis is dependent on the response to the medical regimen and prevention of exacerbations and severe complications of the renal system. MEDICAL CARE Anti-inflammatories (Nonsteroidal): aspirin given to relieve joint pain by decreasing inflammation. Anti-inflammatories (Steroidal): prednisone given to relieve severe manifestations of the disease; oral dose is tapered to lowest effective amount to control symptoms. Immunosuppressants: azathioprine (Imuran) given in combination with an anti-inflammatory to reduce amount of steroids. Antimalarials: hydroxychloroquine sulfate, chloroquine given as second line therapy to relieve symptoms caused by skin, joint, and renal complications and to reduce amounts of steroids needed. Antibiotics: given specific to identified microorganisms and sensitivity to tested antibiotics. Anticonvulsants: phenytoin given to control or prevent seizure activity if central nervous system affected. Antihypertensives: given with a diuretic to lower blood pressure if needed. Diuretics: given to promote diuresis and elimination of sodium by preventing reabsorption if renal function affected or if blood pressure elevated. Electrocardiogram: reveals changes and arrhythmias if cardiac output decreased. Blood Urea Nitrogen (BUN): reveals increases in impaired renal function. Creatinine: reveals increases in impaired renal function. Complete Blood Count: reveals increased WBC in presence of infection, decreased Hgb, and platelet and RBC decreases. Urinalysis: reveals protein, RBC with renal impairment. Guaiac Test: reveals occult blood in stool. COMMON NURSING DIAGNOSES 1 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=52&FxId=123&Sessi. See RISK FOR IMPAIRED SKIN INTEGRITY Related to: (Specify: altered pigmentation, circulation, immunologic.) Defining Characteristics: (Specify: disruption in skin surface; scaly erythematmous blush or patchy area over nose and cheeks in the shape of a butterfly; sensitivity to cold in hands and feet with or without cyanosis; dry, cracked skin; alopecia.) See IMPAIRED PHYSICAL MOBILITY Related to: (Specify: intolerance to activity, decreased strength and endurance, pain and discomfort.) Defining Characteristics: (Specify: generalized weakness; joint swelling, stiffness, and pain; limited range of motion; generalized aching; arthralgia; fatigue.) See HYPERTHERMIA Related to: Inflammation. Defining Characteristics: (Specify: increase in body temperature above normal range, low grade elevation.) See DISTURBED THOUGHT PROCESSES Related to: Physiologic changes. Defining Characteristics: (Specify: forgetfulness, changes in consciousness, excitability, seizures, psychosis, irritability, nystagmus, diplopia, disorientation.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Renal failure. Defining Characteristics: (Specify: increased urine output, altered intake, weight loss or gain, edema, dry skin and mucous membranes, thirst, hypotension, increased pulse rate, proteinuria.) See DECREASED CARDIAC OUTPUT Related to: (Specify: alteration in preload, electrical factor of altered conduction.) Defining Characteristics: (Specify: variations in hemodynamic readings, arrhythmias, ECG changes, cyanosis, skin and mucous membrane pallor, decreased peripheral pulses, rales, dyspnea, orthopnea, restlessness.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS 2 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=52&FxId=123&Sessi. Related to: Inability to ingest, digest, and absorb nutrients. Defining Characteristics: Anorexia, nausea, vomiting, diarrhea, abdominal discomfort. ADDITIONAL NURSING DIAGNOSES DISTURBED BODY IMAGE Related to: Biophysical and psychosocial factors. Defining Characteristics: (Specify: verbal and nonverbal responses to change in body appearance [alopecia, skin rashes, steroid side effects], negative feelings about body,

multiple stressors and change in daily living limitations and social relationships.) Goal: Child will gain improved body image by (date and time to evaluate). Outcome Criteria √ Child verbalizes positive feelings about self. √ Participates in social gatherings. NOC: Body Image INTERVENTIONS RATIONALES Assess child for feelings about Provides information about status multiple restrictions in of self-concept and body image lifestyle, chronic illness, that require special attention. difficulty in school and social situations, inability to keep up with peers and participate in activities. Encourage expression of feelings and Provides opportunity to vent concerns and support feelings and reduce negative communications with parents, feelings about changes in teachers, and peers. appearance. Avoid negative comments and stress Enhances body image and confidence. positive activities and accomplishments. Note withdrawal behavior and signs Reveals responses to body image of depression. changes and possible poor adjustment to changes. Note hair loss, skin rashes or Reveals side effects of steroid changes, weight gain and shift in therapy and disease body fat distribution, hirsutism, manifestations that affect body edema and effect on child. image. Show support and acceptance of Promotes trust and demonstrates changes in appearance of child; respect for child. provide privacy as needed. 3 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=52&FxId=123&Sessi. Teach parents to maintain support Encourages acceptance of the child for child. with special needs (long-term steroid therapy and side effects, risk for infection and bleeding tendency, lifelong activity restrictions). Suggest use of wig, scarf, makeup, Supports child during body image clothing selection as indicated. changes involving skin, hair, hirsutism. edema, weight gain, Encourage parents to be flexible in Promotes well-being of child and care of child and to integrate sense of belonging and control of care and routines so child may life events. participate in peer activity. Assist parents and child to deal Prevents stigmatization of child by with peer and school perceptions those who are not apprised of the of appearance and to tell others child's disease; attitudes of about change in appearance. others will affect child's body image. NIC: Socialization Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did child say about self? Use quotes. Does child participate in social gatherings? Specify.) (Revisions to care plan? D/C care plan? Continue care plan?) PAIN Related to: Inflammatory process. Defining Characteristics: (Specify: communication of pain descriptors, joint pain, achiness, joint swelling and stiffness.) Goal: Child will experience decreased pain by (date and time to evaluate). Outcome Criteria √ Child rates pain as less than (specify expected level and pain scale used). NOC: Pain Level INTERVENTIONS RATIONALES Assess severity of joint pain, Provides information symptomatic location, duration, remissions, of the effect of the disease on 4 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=52&FxId=123&Sessi. and exacerbations and what the musculoskeletal system; precipitates pain such as weight allows for analgesic selection gain, activity; affect on and better management of mobility and participation in activity involvement. ADL; presence of joint deformity. Administer analgesic (specify) and (Action of drugs.) anti-inflammatories (specify) and assess effect of medications in relieving pain. Apply warm compresses or packs to Promotes circulation to the area painful areas. by vasodilation to relieve pain. Provide 1 to 2 rest periods during Decreases stimulation that day and quiet environment for increases pain, and promotes sleep. rest. Encourage to assume position of Promotes comfort and rest for comfort. joints to reduce pain. Provide toys, TV, books, games, for Promotes diversionary activity to quiet play during painful detract from pain. episodes. Explain cause of pain to child and Provides reasons for treatments measures that should be taken to and medications. relieve pain (specify). Inform child of factors that Promotes opportunity to avoid exacerbate pain episodes and to those situations or activities express or report presence of that contribute to pain and to pain at the onset. provide for immediate relief. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is pain rating? Specify scale used.) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE Related to: Lack of information about chronic illness. Defining Characteristics: (Specify: request for information about disease and the special needs associated with the disease; prevention of exacerbation and complications of the disease; risk of noncompliance with multiple preventive precautions.) Goal: Clients will gain knowledge about lupus erythematosus by (date and time to evaluate). 5 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=52&FxId=123&Sessi. Outcome Criteria √ Clients verbalize how lupus affect each body system. √ Clients identify 3 ways to avoid exacerbations of the condition. √ Clients verbalize understanding of treatment regimen. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess knowledge of disease, type of Provides information needed to treatments, effect on all systems, understand this complex disease and medical regimen. and adjust long-term treatment and restrictions. Teach parents and child about the Provides information about known disease process, effect on connective facts related to the disease to tissue and all systems, and treatment enhance knowledge of potential for regimen needed to maintain remission. exacerbations that may lead to early death. Teach parents and child about the Promotes understanding of long-term administration and side effects of medication regimen even when anti-inflammatories and affected by undesirable side immunosuppressant drugs (specify), effects; an abrupt withdrawal of not to decrease or skip the dose if the medication may cause a serious side effects appear, and the need to physiologic complication. adjust dosage during stressful situations. Teach parents and child about activity Prevents exacerbation of the restrictions or moderate activities symptoms while considering the allowed and to weigh one activity long-term difficulty the child against another as appropriate for faces when activities are the child. restricted. Teach child to avoid sun exposure Prevents skin eruptions/reactions directly, through clouds, or common to this disease when reflected from water or snow; to use exposed to the sun. special sun screen or brimmed or visored hat to protect face. Teach clients about child's need to Prevents exacerbations of the take naps and have 8 hours of sleep/ disease symptoms. night; avoid fatigue or stressful situations; avoid medica-tions such as sulfonamides, tetracyclines, anticonvulsants, and others that cause an exacerbation. Teach parents and child to report Provides for early interventions if bruising, petechiae, elevated complications occur. temperature, blood in urine or stool, increased irritability, vomiting, inability or remission in taking medications, respiratory or urinary 6 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=52&FxId=123&Sessi. changes. Refer to community agencies or American Provides information and support for Lupus Society for contact and families and children to assist in support. adjusting to the disease and its lifelong limitation. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did clients verbalize about lupus? What 3 ways to avoid problems did clients identify? What did clients verbalize about treatment regimen? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) INEFFECTIVE COPING Related to: (Specify: multiple life changes, personal vulnerability.) Defining Characteristics: (Specify: alteration in social participation, inappropriate use of defense mechanisms [denial, regression, projection], withdrawal, intolerance of new experiences, lifelong hardships of medical regimen and limitations.) Goal: Child will cope effectively with illness by (date and time to evaluate). Outcome Criteria √ Child expresses feelings about chronic illness. √ Child identifies 3 effective coping mechanisms to use. NOC: Coping INTERVENTIONS RATIONALES Assess coping behaviors of child and Provides information about child's factors that induce use of defense coping mechanisms and pattern mechanisms, response to stressful and use of coping strategies. situations (avoidance behavior, cooperation or resistance, aggression, regression, delaying tactics, inappropriate humor). Allow child to express feeling and Promotes independence and control provide outlet for release of over a situation. feeling in an accepting environment. 7 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=52&FxId=123&Sessi. Provide therapeutic play including Provides expression of feelings throwing ball or balloons, pounding and outlet to release board, hand painting, water play. aggression. Involve child in care decisions and Promotes active participation in encourage independence in as much care with assistance as needed. of the care as possible. Assist child to identify at least 3 Allows for experiences which gives coping mechanisms to use during the child an opportunity to play, social interactions, painful practice successful coping procedures, restrictions, and bed behaviors that enhance rest. development of one's self- esteem. Encourage parents to participate in Increases feelings of security child's care and support. when the child must deal with new situations. Assist child to identify behaviors Promotes understanding of coping that are positive and negative and pattern and reasons for discuss the factors that influence behavior. coping pattern (age, development, past experiences, ability to adapt, support, perception of what is happening, inner resources). Teach child about any procedures well Promotes coping with new and before scheduling and that support painful experiences. will be given to assist through the event. Suggest psychological consultation if Assists child to deal appropriate. constructively with frustration and compliance with medical regimen for lifelong illness. NIC: Self-Esteem Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What feelings about chronic illness did child verbalize? What 3 ways to cope did child identify? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR LUPUS ERYTHEMATOSUS 8 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=52&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 9 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=52&FxId=123&Sessi. Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:07:21 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=52 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 6 - MUSCULOSKELETAL SYSTEM CHAPTER 6.3 - LUPUS ERYTHEMATOSUS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 10 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=53&FxId=123&Sessi. CHAPTER 6.4 - LEGG-CALVE-PERTHES DISEASE INTRODUCTION Legg-Calve-Perthes disease (osteochondritis deformans), is a disease of the femoral head occurring in children between 3 to 12 years of age. Its cause is unknown but the disease is characterized by a necrosis of the femoral head which results from an impaired circulation of the femoral epiphysis extending to the acetabulum. Joint dysfunction with hip pain or ache and a limp that is continuous or intermittent are common signs and symptoms of the condition. Early treatment to maintain the femoral head in the acetabulum determines the prognosis. The disease progression and resolution is classified into four stages: stage I is the necrosis and degeneration of the femoral head (avascular); stage II is the bone absorption and vascularization (revascularization); stage III is the new bone formation with ossification (reparative); and stage IV is the reformation of the femoral head to a sphere (regenerative). MEDICAL CARE X-ray: reveals changes in the femoral head and hip from a flattened appearance (stage I) to a mottled appearance and progressing to increased bone density and normalization of the rounded appearance of the femoral head (stage IV). Magnetic Resonance Imaging (MRI): useful early in the disease to detect changes as radiographic changes are not present for several months after onset. MRIs are useful later in assessing containment of the femoral head in the acetabulum. Abduction Traction: used to increase the range of motion in a child who has developed limited hip motion from pain and spasm. Abduction traction is gradually increased on a daily basis to a point comfortably tolerated by the child. Traction may be used prior to surgical intervention and may be used in a home-based program. Serial Casting: casting of the hips in an abducted position with weekly cast

changes using a progressively longer bar until full range of abduction is achieved. Casting also contains the femoral head in the acetabulum. The cast may be bivalved later and used as a splint. Osteotomy: surgical realignment of the femur so that the head of the femur is securely contained within the acetabulum. Requires 6 to 8 weeks of a hip spica cast after surgery and may be preceded by traction. COMMON NURSING DIAGNOSES See IMPAIRED PHYSICAL MOBILITY Related to: Musculoskeletal impairment (femoral head). Defining Characteristics: (Specify: imposed restrictions of movement by medical protocol of corrective device [cast, brace, traction], reluctance to attempt movement, restriction in weight-bearing, limited ROM, bed rest.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: (Specify: physical immobilization, pressure of cast or appliance and altered circulation, sensation.) 1 of 6 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=53&FxId=123&Sessi. Defining Characteristics: (Specify: change in skin color and temperature proximately to cast, skin irritation at cast edges, numbness or tingling distal to cast, redness on skin from prolonged pressure, break in skin from surgical correction.) See DELAYED GROWTH AND DEVELOPMENT Related to: Effects of immobilization. Defining Characteristics: (Specify: environmental and stimulation deficiencies, inability to perform self-care activities appropriate for age, inability to participate in school and social activities.) ADDITIONAL NURSING DIAGNOSES DEFICIENT KNOWLEDGE Related to: Lack of information about the disease. Defining Characteristics: (Specify: request for information about initial and long-term treatment, management of the therapy, and modification of activities.) Goal: Clients will obtain knowledge about the illness by (date and time to evaluate). Outcome Criteria √ Parents verbalize understanding of the four stages of the disease. √ Parents and child (if applicable) verbalize understanding of treatment plan (specify). NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess knowledge of pathology of the Provides information needed to disease and its four stages, develop a plan of instruction to treatment and prognosis, signs and ensure compliance of the medical symptoms. Provide information as regimen for correction; usually needed. of age with each stage lasts 1 to 4 years and affects lasting approximately 9 to 12 months; children 3 to 12 years the younger the child at the time of diagnosis, the more positive the results and prognosis. Teach parents and child that hip pain Reveals signs and symptoms of the or stiffness that is constant or disease usually noted in the second intermittent with involvement of the stage. knee or thigh, limited ROM of the hip joint, a limp on the affected side may indicate aseptic necrosis of the femoral capital epiphysis with degenerative changes in the femoral 2 of 6 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=53&FxId=123&Sessi. head. Teach parents and child about use and Applied to stretch adductor muscles purpose of traction if used. before abduction cast is used, or before surgery. (If home traction is used, refer Home traction allows child to be in parents to a home health agency.) comfortable, familiar surroundings while maintaining therapeutic regimen; visits from home nurse allow evaluation of treatment and provision of family support and education. (For surgical correction, inform Decreases anxiety about the surgical parents that child will need procedure through knowledge of prophylactic antibiotics, will postoperative care. receive IV narcotics for pain for 2 to 3 days after surgery, will have a hip spica cast applied, and will be discharged to home 4 to 5 days after surgery.) (Teach parents about purpose and Provides containment of the position application of an abduction splint; of the femur while allowing for after ROM achieved, demonstrate and supported weight-bearing during allow for return demonstration of healing, and is removable for application.) bathing. Teach child to avoid weight-bearing on Prevents degeneration of the hip the affected limb (except as joint caused by femoral damage prescribed by physician) and to be resulting from weight-bearing relatively inactive; advise activities; prolonged bed rest is activities suitable to stage of no longer required. condition such as hobbies, crafts, games, museums, events of interest. Encourage parents to advise school of Provides special needs of child in activities that are allowed for order to continue school attendance learning and peer interactions. and activities that may be adapted to appliance to promote feeling of acceptance. Teach parents about care of cast or Promotes proper function of appliance splint including cleaning, tightness, used and prevents complications and alignment with joints. associated with its use. Instruct parents and child in use and Promotes safe use of crutches for care of crutches if used including mobility. swing through gait; monitor for repair needs as presence of loose screws and worn tips. Encourage parents to maintain pathways Prevents falls and injury. clear of clutter or toys in home. Suggest to parents to prepare for Provides for participation in outside attendance at special activities by activities to enhance growth and calling in advance for special development needs in long-term transportation, use of wheelchairs or therapy. other aids. 3 of 6 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=53&FxId=123&Sessi. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did clients verbalize about the four stages of Legg-Calve-Perthes disease? What did clients verbalize about treatment regimen? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR LEGG-CALVE-PERTHES DISEASE 4 of 6 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=53&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 5 of 6 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=53&FxId=123&Sessi. Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:08:19 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=53 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 6 - MUSCULOSKELETAL SYSTEM CHAPTER 6.4 - LEGG-CALVE-PERTHES DISEASE Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 6 of 6 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=54&FxId=123&Sessi. CHAPTER 6.5 - OSTEOGENIC SARCOMA INTRODUCTION Osteogenic sarcoma is a primary malignancy of the bone with the metaphysics of the long bones most commonly affected. These include the femur, humerus, and tibia. Metastasis most commonly affects the lungs but may involve other organs. The disease most commonly occurs in children over 10 years of age. Treatment consists of amputation of the limb with chemotherapy before and/or following surgery, or a bone and joint replacement in selected children to salvage the limb with chemotherapy before the surgery. MEDICAL CARE Analgesics: to control postoperative pain. Chemotherapy Protocol: methotrexate with leucovorin calcium, doxorubicin, dactinomycin cyclophosphamide, cisplatin. Antigout Agent: allopurinol to reduce the severity of hyperuricemia caused by chemotherapy which promotes nucleic acid degradation causing increased plasma uric acid levels. Bone X-ray: reveals bone lesion, fracture caused by tumor invasion. Bone Scan: reveals presence of bone lesions and size. Bone Biopsy: reveals presence of malignant tumor. Computerized Tomography (CT): reveals metastasis of bone and other organs. Enzymes: alkaline phosphatase (ALP): reveals increased level caused by abnormal osteoblastic activity or bone cell production; also reveals presence of isoenzymes (ALP2) of bone origin. COMMON NURSING DIAGNOSES See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: (Specify: inability to ingest and digest food, chemotherapy.) Defining Characteristics: (Specify: anorexia, nausea, vomiting from chemotherapy, anxiety, grieving, weight loss, NPO status before and after surgery.) See RISK FOR DEFICIENT FLUID VOLUME Related to: (Specify: altered intake; excessive losses through normal routes.) Defining Characteristics: (Specify: diarrhea, vomiting from chemotherapy, NPO status before and after surgery.) 1 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=54&FxId=123&Sessi. See RISK FOR IMPAIRED SKIN INTEGRITY Related to: (Specify: chemotherapy, IV, surgical site, and use of prosthesis.) Defining Characteristics: (Specify: disruption of skin surfaces, destruction of skin surfaces, redness, edema, excoriation of stump site, improper fit or application of prosthesis, extravasation of IV site with swelling skin, redness, and tissue necrosis.) See IMPAIRED PHYSICAL MOBILITY Related to: Amputation. Defining Characteristics: (Specify: inability to move within physical environment, reluctance to attempt movement, imposed restrictions of movement with loss of limb, inability to adapt to prosthesis or brace, use of crutches or wheelchair.) See DIARRHEA Related to: Chemotherapy. Defining Characteristics: (Specify: increased frequency of bowel sounds and loose, liquid stools.) ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: Change in health status, threat of death, threat to self-concept. Defining Characteristics: (Specify: increased apprehension and fear of diagnosis; expressed concern and worry about preoperative procedures and preparation, postoperative effects of therapy on physical and emotional status, possible metastasis of disease, loss of limb and use of prosthesis.) Goal: Clients will experience decreased anxiety by (date and time to evaluate). Outcome Criteria √ Parents and child express feelings about illness. √ Clients verbalize feeling less anxious. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess level of anxiety of parents Provides information about source and child and how it is manifested; and level of anxiety and need for the need for information that will interventions to relieve it; 2 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=54&FxId=123&Sessi. relieve anxiety. sources for the child may be procedures, fear of mutilation or death, unfamiliar environment of hospital and may be manifested by restlessness, inability to play, sleep, or eat. Assess possible need for special Reduces anxiety and supports child counseling services for child. dealing with illness and promotes adjustment to lifestyle changes. Allow open expression of concerns Provides opportunity to vent about illness, procedures, feelings and fears to reduce treatments, and possible anxiety. consequences of surgery. Communicate with child at appropriate Promotes understanding and trust. age level and answer questions calmly and honestly; use pictures, models, and drawings for explanations. Provide child with as much input in Allows for more control and decisions about care and routines independence in situations. as possible. Encourage parents to stay with child; Promotes care and support by provide a telephone number to call parents. for information. Provide continuing nurse assignment Promotes trust and comfort and with the same personnel. familiarity with staff giving care. Orient child to surgical and ICU Reduces anxiety caused by fear of unit, equipment, noises, and staff. unknown. Teach parents and child about the Provides information to promote disease process, surgical understanding that will relieve procedure, what to expect fear and anxiety; understanding of preoperatively and postoperatively preoperative and postoperative including chemotherapy and its treatments and effect on body benefits and side effects (nausea, image. vomiting, diarrhea, stomatitis, alopecia, and others are possibilities but are temporary; phantom pain). Explain all procedures and care in Supplies information about all simple, direct, honest terms and diagnostic procedures and tests repeat as often as necessary; such as CBC, platelets with reinforce physician information if chemotherapy and scans, and X-rays needed and provide specific for diagnosis. information as requested. Inform parents and child of the Reduces anxiety when knowledge and extent of surgery planned with the support is given, and child and removal of a limb (that a temporary parents will not feel betrayed by prosthesis will be fitted inadequate preparation of immediately following surgery, and procedures and treatments. a permanent one will be fitted in 6 to 8 weeks; that recreational and 3 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=54&FxId=123&Sessi. physical therapy will be undertaken following amputation). Introduce child to another who has Provides information and support same disease and amputation. from a peer with the same condition and who would have empathy. Refer to American Cancer Society. Provide resource for information and support groups. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents and child express feelings about the illness? Did clients verbalize decreased anxiety? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) IMPAIRED ORAL MUCOUS MEMBRANE Related to: Chemotherapy. Defining Characteristics: (Specify: stomatitis, oral ulcers, hyperemia, oral pain

or discomfort, oral plaque.) Goal: Child will be free of oral mucous membrane irritation by (date and time to evaluate). Outcome Criteria √ No oral mucous membrane lesions present. NOC: Oral Health INTERVENTIONS RATIONALES Assess oral cavity for pain ulcers, Provides information about lesions, gingivitis, mucositis or effect of chemotherapy. stomatitis and effect on ability to ingest food and fluids. Provide mouth rinses, cleansing Provides mouth care without with swabs or soft toothbrush. irritating oral mucosa. Administer medication topically as Permits eating with more ordered (specify) before meals comfort (action of drug). and offer bland, smooth foods that are not hot or spicy. Administer an antiseptic mouth Promotes comfort of oral mucosa rinse (specify) 30 minutes before and maintains integrity. 4 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=54&FxId=123&Sessi. any food or fluid intake, as ordered. Encourage child to select foods Allows for independence and they prefer from list. nutrition. control over situation to reduce helplessness and increase Teach parents about the effect of Promotes understanding of side chemotherapy on oral mucosa and effects that occur and in treatment to decrease temporary nature of the side discomfort in oral cavity. effects. Teach parents about mouth rinses Promotes effective care of oral and topical application of cavity to relieve discomfort medications. and prevent mucosa breakdown and increased inflammation. Instruct to use soft brush or swabs Prevents trauma to mucosa. to clean mouth. NIC: Oral Health Maintenance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Does child have any oral mucous membrane lesions?) (Revisions to care plan? D/C care plan? Continue care plan?) INEFFECTIVE PROTECTION Related to: (Specify: drug therapy [antineoplastics]: abnormal blood profile [leukopenia, thrombocytopenia, anemia, coagulation].) Defining Characteristics: (Specify: altered clotting, bone marrow suppression, deficient immunity against infection, hematoma, petechiae, bleeding from nose or gums, hematemesis, blood in stool.) Goal: Child will be protected by (date and time to evaluate). Outcome Criteria √ Child does not experience bleeding. √ Temperature remains <100° F. √ Breath sounds clear bilaterally. NOC: Infection Status 5 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=54&FxId=123&Sessi. INTERVENTIONS RATIONALES Assess for bleeding from any site, Provides information about frank WBC, platelet count, Hct, absolute bleeding or blood profile neutrophil count, and febrile abnormalities that predispose to episodes. bleeding caused by bone marrow suppression and immunosuppression resulting from chemotherapy. Avoid trauma by use of hard Prevents bleeding caused by trauma toothbrush or dental floss, taking during chemotherapy which alters rectal temperatures, performing platelet and clotting factors. unnecessary invasive procedures. Carry out handwashing technique Prevents transmission of pathogens before giving care, use mask and to a compromised immune system gown when appropriate, provide a during chemotherapy if neutrophil private room, monitor for any signs count is less than 1,000/cu mm. and symptoms of infections, especially pulmonary. Teach parents and child to avoid Prevents trauma that causes rough play or sports, straining at bleeding. defecation, forcefully blowing nose. Teach parents and child to avoid Prevents risk for infection in the people with upper respiratory highly susceptible child. infection or any illness. Teach parents to report any fever, Indicates a complication associated behavior changes, headache, with an abnormal blood profile. dizziness, fatigue, pallor, slow oozing of blood from any area, exposure to a communicable disease. Instruct and allow for return Identifies presence of bleeding in demonstration of urine and stool gastrointestinal or urinary testing for blood using dipstick tract. and hematest. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Is there any sign of bleeding? What has been looked for? What is temperature? Describe breath sounds.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: (Specify: broken skin and altered mobility; prosthesis use.) 6 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=54&FxId=123&Sessi. Defining Characteristics: (Specify: amputation of a limb, changes in stump incision [redness, irritation, swelling, drainage], improper fit of prosthesis and failure to adapt to it, improper positioning and alignment of the stump, psychosocial maladaption to prosthesis.) Goal: Child will not experience injury by (date and time to evaluate). Outcome Criteria √ Stump is clean and dry without redness, odor, or drainage. √ Child and parents begin to care for stump (specify). NOC: Risk Control INTERVENTIONS RATIONALES Assess child for type of surgery and Provides information about condition and healing of the stump, amputation needed to provide type of bandaging or cast, presence specific care of stump and of drains, type of prosthetic rehabilitation. device and fit. Assess dressing for bleeding, Indicates infection or risk of redness, pain, drainage at stump hemorrhage at amputation. area q 2 to 4h; maintain dressing (pressure) or wrapping of stump as ordered; change dressing only if ordered. Maintain Trendelenburg and prone Prevents deformities and position as ordered; avoid contractures caused by hip elevation (with pillow), external flexion. rotation, or abduction of stump. Perform ROM daily and exercises Promotes mobility and healing of recommended by physical therapist. the stump and prevents contractures. Cleanse stump and socket daily with Promotes adaptation to device mild soap and warm water, rinse and and prevents infection caused pat dry. by pathogens transmitted via the prosthetic device. Support expressions about loss of Promotes venting of feelings and lifestyle and permanent disability assists to cope with change in adjustment difficulties (age body image. appropriate). Instruct parents and child in stump Promotes adaptation to loss and care, toughening exercises, correct care of stump and application of stocking and prosthesis. prosthesis, care of device. Instruct child in stump positioning Prevents muscle or joint and exercising, ROM of muscles and complications and enhances joints. mobility. Inform child of importance of daily Promotes mobility and return to activities to perform and those to former activities within 7 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=54&FxId=123&Sessi. avoid and explain reasons for limitation imposed by restrictions. amputation and use of prosthetic device. Teach parents and child to continue Promotes healing. chemotherapy and rehabilitation therapy. Discuss modification of clothing and Enhances body image and return instruct in crutch walking and how to limited activities. to get around in room, at home, and at school. Reassure child that feelings of Promotes acceptance of child anger, denial, and hostility are while grieving for loss. normal following such a loss. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe stump. Describe stump care provided by parents and child.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR OSTEOGENIC SARCOMA 8 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=54&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. 9 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=54&FxId=123&Sessi. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:08:33 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=54 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 6 - MUSCULOSKELETAL SYSTEM CHAPTER 6.5 - OSTEOGENIC SARCOMA Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 10 of 10 12/22/2006 7:38 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=55&FxId=123&Sessi. CHAPTER 6.6 - OSTEOMYELITIS INTRODUCTION Osteomyelitis is an infection of the bone caused by any infectious agent, but most commonly by Staphylococcus aureus, hemolytic streptococci, E. coli, or Haemophilus influenzae. In children, the metaphyses of long bones (tibia, femur) are the sites most frequently involved. The infectious agent usually enters the bone through the blood (hematogenous) after trauma or an upper respiratory infection. Less commonly, the infection can spread to the bone secondary to a contiguous focus of infection. The disease can be acute, with a rapidly destructive pyogenic infection of the bone and marrow and signs of systemic infection as well as local pain, swelling, and redness of the involved area. In subacute osteomyelitis, the disease is insidious in onset and the child has pain and dysfunction without systemic infection. The subacute form may be caused by children receiving antibiotics during a presymptomatic period. Osteomyelitis most commonly occurs in children 5 to 14 years of age. The disease can usually be treated with antibiotics, but may require surgical drainage as well. MEDICAL CARE Analgesics/Antipyretics: acetaminophen for pain and to reduce fever. Antibiotics: dependent on identification of infective agent and sensitivity to the antibiotic. Bone X-ray: shows changes in the involved area after the first 2 weeks. Computerized Tomography (CT): reveals bone changes early in the disease. Bone Scan: reveals infectious process in bone by increased uptake of radionucleotides. Erythrocyte Sedimentation Rate (ESR): reveals increases in acute stage. Complete Blood Count (CBC): reveals increased WBC during infectious process. Blood/Wound Cultures: reveals organisms responsible for infection by culture of site. COMMON NURSING DIAGNOSES See HYPERTHERMIA Related to: Infection. Defining Characteristics: (Specify: increase in body temperature above normal range, warm to touch, increased respiratory and pulse rate.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Excessive losses. 1 of 10 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=55&FxId=123&Sessi. Defining Characteristics: (Specify: elevated temperature, diaphoresis, thirst, altered intake, insensitive losses.) See IMPAIRED PHYSICAL MOBILITY Related to: Pain and discomfort, musculoskeletal impairment. Defining Characteristics: (Specify: reluctance to attempt movement, imposed restrictions of movement by immobilization of part by cast and/or bed rest, restriction in weight-bearing.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food. Defining Characteristics: (Specify: anorexia, irritability, restlessness, weight loss, inadequate food intake.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: (Specify: physical immobilization, pressure of cast and altered circulation, sensation.) Defining Characteristics: (Specify: change in color and temperature of skin proximal to cast or device, skin irritation at cast edges, numbness distal cast, prolonged pressure on an area with redness present, break in skin from surgical wound.) ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: Change in health status, change in environment (hospitalization). Defining Characteristics: (Specify: expressed apprehension and concern about prolonged hospitalization resulting from spread of infection, possible surgical drainage of infected area.) Goal: Clients will experience decreased anxiety by (date and time to evaluate). Outcome Criteria √ Clients identify source of anxiety. √ Clients verbalize decreased anxiety. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess source and level of anxiety Provides information about anxiety, and need for information that will its effect and need to relieve it; relieve anxiety. sources may include prolonged 2 of 10 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=55&FxId=123&Sessi. immobilization and hospitalization, long-term IV antibiotic therapy, possible surgical drainage and antibiotic instillation into wound, risk of complications from disease and high-dose medication therapy. Encourage expression of concerns and Provides opportunity to vent feelings time to ask questions about and fears to reduce anxiety. condition, procedures, prognosis, recovery time by parents or child. Answer questions calmly and honestly; Promotes trust and secure, supportive use pictures, drawings, and models environment. for information about demonstrations. Encourage parents to stay with child Allows parents to care for and during hospitalization, and to support child, continue parental assist in care; encourage visits role and promote security for the from friends and relatives. child. Give parents and child as much input Allows for more control over into decisions about care and usual situation and maintains familiar routines as possible. routines for care. Teach parents and child about cause Provides information that will and course of the disease, extent enhance understanding of the of the infectious process, and disease to relieve anxiety. treatment modalities. Inform parents and child of tests and Provides rationale for diagnostic procedures to be done and the procedures and surgery to prepare reasons for them; include surgical for these experiences and reduce procedure if planned. fear of unknown that increases anxiety. Teach parents and child of reason for Provides rationale for long-term antibiotic therapy.

therapy to control infectious process and prevent its spread to reduce anxiety. Teach parents and child about Provides information about treatment to expect following postoperative care to reduce surgery including presence of cast anxiety. on the affected extremity, antibiotic therapy instillation into the wound, and continuous removal of drainage from the wound by low suction. Teach parents and child that although Promotes comfort and positive weight-bearing will be disallowed attitude and reduces anxiety level until healing is well established, when expectations are known. appetite, quiet activity, and improved sense of well-being will be increased as acuity of the disease is reduced. (Inform parents that physical therapy Permits optimal function of affected may be prescribed after infection extremity and allows for feeling of subsides, acute healing assured.) positive outcome. 3 of 10 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=55&FxId=123&Sessi. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents and child identify source of anxiety? Did clients verbalize decreased anxiety? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) PAIN Related to: Inflammation/infection. Defining Characteristics: (Specify: communication of pain descriptors, crying, irritability, restlessness, withdrawal, reluctance to use or move affected limb, tenderness.) Goal: Child will experience decreased pain by (date and time to evaluate). Outcome Criteria √ Child rates pain as a (specify using a pain scale. Identify scale used). NOC: Pain Level INTERVENTIONS RATIONALES Assess site for pain on movement of Provides information about pain extremity; resistance of muscles as a basis for analgesic to passive movement, holding therapy. extremity in semi-flexion; severity, type, and duration of pain using a pain scale if appropriate. Administer analgesic and sedative as Reduces pain and promotes rest to ordered (specify drug, dose, reduce stimuli that cause pain route) and note response. (action of drug). Place extremity in position of Promotes comfort and reduces or comfort and support with pillows prevents pain by reducing edema at 30 degrees elevation. when venous return is enhanced. Move extremity with smoothness and Prevents pain caused by careless care. handling or abrupt movement of affected part. Provide diversionary activities and Diverts attention from the pain. quiet play during acute stage (specify). 4 of 10 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=55&FxId=123&Sessi. Teach parents and child about Provides information about analgesic medications and expected effects expected from analgesic results. therapy to relieve pain until acute stage subsides or healing is underway. Suggest to parents and child ways to Prevents undue pain caused by move, position extremity; movement of affected area. importance of maintaining immobilization of the extremity and avoiding any weight-bearing activity until advised. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is pain rating? Specify scale used) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: (Specify: infection spread, immobilization, effects of cast application.) Defining Characteristics: (Specify: changes in color and temperature, tactile perception of casted extremity, increased body temperature, purulent drainage, edema, erythematic infection site, musty odor under cast, increased WBC, positive wound culture.) Goal: Child will not experience injury by (date and time to evaluate). Outcome Criteria √ Child denies increased pain. WBC levels remain < (specify). NOC: Risk Control INTERVENTIONS RATIONALES Assess presence of localized pain, Provides information about site of swelling, and warmth over the infection(s) which may be open affected bone; purulent drainage wound, bone, or surgical with a musty odor from open wound, drainage wound; inadequate under cast, or over the infected treatment may result in chronic area that is left open for osteomyelitis or persistence and observation. spread of infection. Administer antibiotics based on (Action of drug.) 5 of 10 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=55&FxId=123&Sessi. physician orders (specify). Administer antibiotic solution Treats open wound infections and (specify) into the wound, as ensures continuous wound ordered, via an IV administration drainage. set at a regulated rate; provide wound drainage by connecting tubes from wound to low suction. Place child in isolation and maintain Prevents wound contamination or body fluid precautions (wound and spread of infection; agency skin) if wound is open and policy dictates measures for draining. precautions. Maintain sterile technique for all Prevents introduction of procedures and dressing changes; infectious organisms. cleanse, pack wound as ordered. Measure limb circumference when Reveals changes caused by edema. assessing infectious process. Monitor WBC, ESR, and antibiotic Increases in WBC and ESR found in levels as appropriate. infections and antibiotic levels reveal if therapeutic levels are maintained for effective treatment. Provide immobilization of limb by Maintains limb alignment, limits maintaining cast, splint, and bed spread of infection, and rest status; monitor color, prevents possible fraction or temperature, sensation, and motion complications resulting from of digits. neurovascular problems. Teach parents and child about proper Prevents transmission of technique for handwashing, wound microorganisms to or from child. care and han-dling contaminated articles/supplies. Instruct parents about antibiotic Promotes long-term therapy to administration including action, ensure effective results. dose, time, frequency, side effects, and expected results; length of time that antibiotic therapy may last. Teach parents and child about Prevents further spread of measures to maintain immobility and infection and possible damage to reason for isolation precautions. affected area and surrounding tissue. Teach parents to care for cast or Ensures effective immobilization splint including petaling edges, and prevents complications maintaining dry and clean cast or caused by whole or bivalve cast splint, preventing small particles or splint. or objects from entering cast or splint. Inform parents and child that Ensures optimal functioning of physical therapy may follow healing affected limb. and resolution of infection. NIC: Surveillance 6 of 10 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=55&FxId=123&Sessi. Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Does child complain of increased pain? What is WBC level—include date and time of test.) (Revisions to care plan? D/C care plan? Continue care plan?) IMPAIRED SOCIAL INTERACTION Related to: (Specify: limited physical mobility, therapeutic isolation.) Defining Characteristics: (Specify: change in pattern of interaction, lengthy treatment and immobilization, boredom, inability to engage in usual activities for age group, environment that lacks diversion.) Goal: Child will increase social interaction by (date and time to evaluate). Outcome Criteria √ Child participates in family activities. √ Child socializes with friends. NOC: Social Involvement INTERVENTIONS RATIONALES Provide age-appropriate toys that Promotes social and can be used in bed while in a developmental activities and prone or sitting position reduces boredom during long- depending on type of treatment and term treatment. degree of immobilization. Provide exposure to other children Provides environmental by moving bed near areas of stimulation and social activity or near a window; wheel interaction. on a stretcher or in a wheelchair or stroller, allow to walk with cast or splint when permitted. Encourage family and friends to Promotes social interaction with visit, call, or stay with child; others during long-term if in isolation provide frequent treatment and reduces boredom. interactions or someone to stay with child. Place toys and other articles within Provides access to diversion reach. activities when needed. Inform parents to include infant/ Promotes feeling of acceptance child in family activities. and well-being as part of the 7 of 10 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=55&FxId=123&Sessi. family. Inform of devices available or Promotes exposure to various methods used for mobility to fit activities and changes of needs of child with a cast or environmental stimuli. splint. Encourage parents to allow as much Promotes independence and allows independence in self-care by child some control over the as possible. situation. NIC: Socialization Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Does child participate in family activities? Does child socialize with friends? Specify.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR OSTEOMYELITIS 8 of 10 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=55&FxId=123&Sessi. 9 of 10 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=55&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:08:48 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=55 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 6 - MUSCULOSKELETAL SYSTEM CHAPTER 6.6 - OSTEOMYELITIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 10 of 10 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=56&FxId=123&Sessi. CHAPTER 6.7 - JUVENILE RHEUMATOID ARTHRITIS INTRODUCTION Juvenile rheumatoid arthritis (JRA) is a chronic inflammatory disease that involves the synovium of the joints resulting in effusion and eventual erosion and destruction of the joint cartilage. It is classified into different types and characterized by remissions and exacerbations with the onset most common between 2 to 5 and 9 to 12 years of age. Pauciarticular arthritis involves only a few joints, usually under five; polyarticular arthritis involves many joints, usually more than four. Systemic arthritis involves the presence of arthritis and associated high temperature, rash, and effects on other organs such as the heart, lungs, eyes, and those located in the abdominal cavity. Prognosis is based on the severity of the disease, type of arthritis, and response to treatment with the most severe complications of permanent deformity, hip disease, and iridocyclitis with visual loss. MEDICAL CARE Anti-inflammatories (Nonsteroidal): for analgesia, antipyretic action as well as anti-inflammatory and antirheumatic effects; may be used in combination with steroids and gold salts; action thought to be the inhibition of prostaglandin synthesis. Anti-inflammatories (Steroidal): prednisone (Deltasone) given PO to suppress inflammatory responses and reactions, also reduces antibody titers and inhibits phagocytosis and release of allergic substances. Antirheumatics (Slow acting): to inhibit collagen formation or alter immune responses and inhibit prostaglandin synthesis in the treatment of rheumatic diseases. Cytotoxics: to treat rheumatoid arthritis when response to other anti-inflammatory drugs are not effective if the disease is severe and debilitating; usually used in combination with other drugs. Joint X-ray: reveals widened joint spaces with later joint destruction and fusion, evidence of osteoporosis and inflammation at affected joint sites. Erythrocyte Sedimentation Rate (ESR): reveals increases in systemic type but may be increased or decreased depending on the degree of inflammation. Antinuclear Antibodies: reveals presence in 75% of rheumatoid factor with a positive result in 25%; positive or negative result depending on type of arthritis. Rheumatoid Factor: reveals presence in those with later onset type with a positive result in pauciarticular type. Complete Blood Count: reveals increased WBC in early stages. Synovial Fluid Culture: reveals absence of infectious process and confirms absence of other conditions by joint aspiration of fluid for examination. COMMON NURSING DIAGNOSES See IMPAIRED PHYSICAL MOBILITY Related to: Musculoskeletal impairment, pain, and discomfort. 1 of 11 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=56&FxId=123&Sessi. Defining Characteristics: (Specify: reluctance to attempt movement, limited range of motion, imposed restrictions of movement by medical protocol, resting or immobilization of joint(s) by splinting and positioning, fatigue, malaise.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: (Specify: external factor or physical immobilization.) Defining Characteristics: (Specify: skin irritation under splint(s), redness from prolonged pressure, break in skin from surgery if done, macular rash on extremities and trunk areas.) See DELAYED GROWTH AND DEVELOPMENT Related to: Effects of physical disability. Defining Characteristics: (Specify: environmental and stimulation deficiencies, inability to perform self-care activities appropriate for age, growth retardation during active disease, reduced peer relationships.) See HYPERTHERMIA Related to: Illness of inflammation. Defining Characteristics: (Specify: increase in body temperature above normal range, chills, low-grade temperatures or high elevation late in day or twice a day.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food. Defining Characteristics: (Specify: anorexia, weight

loss or poor gain, weakness, fatigue, irritability.) ADDITIONAL NURSING DIAGNOSES CHRONIC PAIN Related to: Chronic physical disability. Defining Characteristics: Verbalization or observed evidence of pain experienced for more than 6 months, guarded movement, fear of reinjury, altered ability to continue activities, physical and social withdrawal. Single or multiple joint involvement, joint stiffness, loss of motion, edema, and warmth in joint(s) and painful to touch. Goal: Child will experience decreased chronic pain by (date and time to evaluate). Outcome Criteria 2 of 11 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=56&FxId=123&Sessi. √ Child rates pain as less than (specify using a scale. Specify scale.). NOC: Comfort Level INTERVENTIONS RATIONALES Assess severity of joint pain, Provides information symptomatic of location, duration, remissions and the effect of the disease on the exacerbations, stiffness and musculoskeletal system: what precipitates pain such as allows for analgesic/ anti- weight gain, activity, fatigue; inflammatories selection and better effect on mobility and management of activity involvement; participation in ADL; presence of inflammatory process cause pain joint deformity. with the edema resulting from joint effusion and synovial thickening and limited motion resulting from muscle spasms; joint deformity results from joint destruction. Administer medications (specify) as (Action of drugs: relieves pain and ordered and assess effect of the inflammatory process associated medications in relieving pain. with the pain; drugs may be administered alone or in combination including the nonsteroidal anti-inflammatory drugs that act as analgesic, antipyretic and anti-inflammatory; slower acting antirheumatic drugs which may be added for optimal effect if NSAIDs are ineffective; corticosteroid drugs in lowest effective dose for short period of time especially in the presence of a life-threatening situation.) Apply warm compresses, packs, or Promotes circulation to the area by soaks to painful areas; paraffin vasodilation to relieve pain; moist baths and whirlpool as ordered. heat relieves painful, stiff areas. Provide 1 to 2 rest periods during Decreases stimulation that increases day and quiet environment for pain, and it promotes rest, sleep. especially during acute episodes. Encourage child to assume position Promotes diversionary activity to of comfort; elevate and support detract from pain. painful joints when changing position. Apply splints if ordered for night Provides immobilization of joints to use. ease pain during movement. Explain cause of pain to child and Provides reasons for treatments and measures that should be taken to medications. relieve pain. Teach child and parents about Promotes opportunity to avoid those factors (stress, climate movement) situations or activities that that exacerbate pain episodes, and contribute to exacerbations of pain to express or report presence of and to provide for immediate 3 of 11 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=56&FxId=123&Sessi. pain at the onset. relief. Instruct parents and child in Promotes compliance with medical accurate administration of regimen to control pain and medications including side effects inflammation. and importance of compliance with regimen whether taken qid, h.s., or bid and side effects to report (specify). Teach parents to give warm bath Supplies heat to affected joints to daily for 10 minutes or warm wet relieve pain and stiffness. packs with a towel bath to painful areas. Instruct parents and child to avoid Prevents injury to affected joints overactivity or movement of during the acute episode when affected joints. immobilization is important. Teach child relaxation techniques, Provides nonpharmacologic music therapy and diversionary interventions to relieve pain. activities such as TV, reading, games. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is pain rating? Specify scale used.) (Revisions to care plan? D/C care plan? Continue care plan?) DISTURBED BODY IMAGE Related to: Biophysical and psychosocial factors. Defining Characteristics: (Specify: verbal and nonverbal responses to change in body appearance [joint deformity, steroid side effects], negative feelings about body, multiple stressors and change in daily living limitations and social relationships.) Goal: Child will experience improved body image by (date and time to evaluate). Outcome Criteria √ Child expresses feelings about illness. √ Child identifies at least 1 positive thing about his or her body. NOC: Body Image 4 of 11 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=56&FxId=123&Sessi. INTERVENTIONS RATIONALES Assess child for feelings about Provides information about status multiple restrictions in lifestyle, of self-concept and body image chronic illness, difficulty in that require special attention. school and social situations, inability to keep up with peers and participate in activities. Encourage expression of feelings and Provides opportunity to vent concerns, and support feelings and reduce negative communications with parents, feelings about changes in teachers, and peers. appearance. Avoid negative comments and stress Enhances body image and confidence. positive activities and accomplishments. Note withdrawal behavior and signs of Reveals responses to body image depression. changes and possible poor adjustment to changes. Note presence of joint deformities, Reveals side effects of steroid need to use splints, weight gain, therapy and disease shift in fat distribution, edema manifestations that affect body and effect on child. image. Show support and acceptance of Promotes trust and demonstrates changes in appearance of child; respect for child. provide privacy as needed. Teach parents about maintaining Encourages acceptance of the child support for child. with special needs (long-term steroid therapy and side effects, lifelong activity restrictions). Discuss with parents and child the Provides correct information to impact of the disease on body assist in dealing with negative systems and risk for deformity and feelings about body. disabilities; correct misinformation and inform of ways to cope with body changes. Encourage parents to be flexible in Promotes well-being of child and care of child and to integrate care sense of belonging and control of and routines into family life events by participating in activities; to allow child to normal activities for age and participate in peer activity. enhancing developmental task achievement. Discuss with parents and child how to Prevents stigmatization of child by deal with peer perceptions of those who are not apprised of the appearance and how to tell others child's disease; attitude of about change in appearance. others will affect child's body image. Suggest psychological counseling or Assists to improve self-esteem and child life worker and inform of to learn coping and problem functions performed by these solving skills. professionals. Refer to Juvenile Arthritis Promotes support from others and Foundation. how they handle the changes. 5 of 11 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=56&FxId=123&Sessi. NIC: Self-Esteem Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What feelings about chronic illness did child verbalize? What positive thing about their body did child identify? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) SELF-CARE DEFICIT: BATHING/HYGIENE, DRESSING/GROOMING, FEEDING, TOILETING Related to: Pain, discomfort, and musculoskeletal impairment. Defining Characteristics: (Specify: impaired ability in performance of ADL and maintenance of complete physical care; pain and weakness of joints and intolerance to activity; immobility status; joint deformity and/or contractures.) Goal: Child will perform self care within limits of illness by (date and time to evaluate). Outcome Criteria √ (Specify several self-care activities the child is capable of.) NOC: Self-Care: Bathing/Hygiene, Dressing/Grooming, Feeding, Toileting INTERVENTIONS RATIONALES Assess abilities and level of care Provides information about and assistance. child's ability to perform self-care and to monitor progress. Allow as much independence in ADL as Promotes independence and control possible but assist when needed. over daily personal care needs without damage to joints. Encourage to perform own care and Promotes sense of accomplishment praise all accomplishments. and independence; motivates to continue progress in ADL. Position articles needed for care Promotes independence and allows within reach; provide physical child access to aids to enhance aids/devices to assist in independence. performance of ADL (crutches, wheel-chair, utensils that are easy to handle, hand bars, handles that are easy to open, clothing that is easy to put on and take off with zippers, Velcro, etc.). 6 of 11 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=56&FxId=123&Sessi. Assist parents and child to develop Promotes independence and plan and goals for daily ADL and compliance in self-care. suggest inclusions of actions taught by physical and occupational therapist. Teach parents and child about Promotes independence in ADL and application and use of aids and self-confidence. devices to accommodate self-care activities. Discuss possible changes or Allows for safe participation in adjustments in home and school activities that are usually environment to accommodate child's carried out by child on a daily independence in meeting physical basis. needs (pathways, furniture, doors). NIC: Self-Care Assistance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What self-care activities did the child perform relative to the outcome criteria?) (Revisions to care plan? D/C care plan? Continue care plan?) COMPROMISED FAMILY COPING Related to: (Specify: inadequate or incorrect information or understanding, prolonged disease or disability progression that exhausts the physical and emotional supportive capacity of caretakers.) Defining Characteristics: (Specify: expression and/or confirmation of concern and inadequate knowledge about long-term care needs, problems and complications, anxiety and guilt, overprotection of child.) Goal: Family will cope more effectively by (date and time to evaluate). Outcome Criteria √ Clients express feelings about child's chronic illness. √ Clients identify 3 positive coping mechanisms to implement. NOC: Family Coping INTERVENTIONS RATIONALES Assist family to assess coping methods Provides information identifying used and effectiveness, family coping methods that work and the 7 of 11 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=56&FxId=123&Sessi. interactions and expectations related need to develop new coping skills to long-term care, developmental and behaviors, family attitudes; level of family, response of child with special long-term needs siblings, knowledge and use of may strengthen or strain family support systems and resources, relationships and an undue degree presence of guilt and anxiety, of overprotection may be overprotection and/or overindulgence detrimental to child's growth and behaviors. development (disallow school attendance and peer activities, avoiding discipline of child, and allowing child to assume responsibilities for ADL). Encourage family members to express Reduces anxiety and enhances problem areas and explore solutions understanding; provides family an responsibly. opportunity to identify problems and develop problem solving strategies. Assist family to establish short- and Promotes involvement and control over long-term goals for child and to situations and maintains role of integrate child into family family members and parents. activities, include participation of all family members in care routines. Refer to assistance of social worker, Provides support to the family faced counselor, clergy, or other as with long-term care of child with a needed. chronic illness. Refer to community agencies and contact Provides information and support to with the Arthritis Foundation or child and family. other families with a child with arthritis. Assist family members to express Allows for venting of feelings to feelings, how they deal with the determine need for information and chronic needs of family member and support, and to relieve guilt and coping patterns that help or hinder anxiety. adjustment to the problems. Inform family that overprotective Promotes understanding of importance behavior may hinder growth and of making child one of the family development, and to treat child as and the adverse affects of normally as possible. overprotection of the child. Teach family about remissions and Provides a realistic view of the exacerbations of the disease and that chronic nature of the disease. an exacerbation may last for long periods of time (over a period of months); that exacerbations may be precipitated by overactivity, stress, presence of other illnesses, climate changes. Inform parents and child of suggestions Prevents injury as well as of unorthodox cures for the disease disappointment when cures do not by friends, and the harmful effects measure up to expectations. caused by some of them. Assist family to identify positive Promotes ownership of solutions to coping mechanisms they may use (e.g., coping difficulty. 8 of 11 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=56&FxId=123&Sessi. discussing feelings and issues openly, hiring a baby-sitter once a week, family movie nights, etc.). NIC: Family Involvement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did clients discuss feelings about child's chronic illness? Provide quotes. List 3 positive coping mechanisms the family plans to implement.) (Revisions

to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR JUVENILE RHEUMATOID ARTHRITIS 9 of 11 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=56&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: 10 of 11 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=56&FxId=123&Sessi. STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:09:08 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=56 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 6 - MUSCULOSKELETAL SYSTEM CHAPTER 6.7 - JUVENILE RHEUMATOID ARTHRITIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 11 of 11 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=57&FxId=123&Sessi. CHAPTER 6.8 - SCOLIOSIS INTRODUCTION Scoliosis is a lateral curvature of the spine with the thoracic area being the most commonly affected. It can be classified as functional or structural. Functional scoliosis is the result of another deformity and is corrected by treating the underlying problem. Structural scoliosis is most often idiopathic although it may be congenital or secondary to another disorder. There is a growing body of evidence that idiopathic scoliosis is probably genetic but the etiology is not completely understood. Structural scoliosis is more progressive and causes changes in supporting structures, such as the ribs. Management includes observation, bracing, and surgical fusion. Patients with idiopathic curves of less than 25 degrees are observed for progress until they have reached skeletal maturity. Bracing is recommended for adolescents with curves between 30 and 45 degrees, while curves greater than 45 degrees usually require surgery. The deformity may occur at any age, from infancy through adolescence, but the best prognosis belongs to those who are almost fully grown and whose curvature is of a mild degree. Idiopathic scoliosis most commonly occurs in adolescent girls. MEDICAL CARE Analgesics: to control postoperative pain depending on severity. Spinal X-ray: reveals curvature of the spine via different views (A, P, and lateral) with head and hips unaligned. Myelogram: reveals presence of neurologic abnormalities of muscle function. Scoliometer: reveals deformity of back when in a forward bending position. Thoracolumbosacral brace (TLSO): an underarm brace of molded plastic fitting from below the rib cage to the lower pelvis to correct thoracolumbar and lumbar curves. This brace is also worn 23 hours per day until skeletal maturity. Boston brace: a type of corset with metal stays that is a more comfortable type of brace for scoliosis than molded plastic. Surgical Fusion: includes the use of instrumentation and bone grafts to maintain internal fixation to correct severe deformities (greater than 45 degrees). The newer instruments no longer require postoperative casting, but immobility after surgery is maintained through bracing. The instruments include: Harrington rods: metal rods connected by wires to the vertebrae. Luque rods: flexible L-shaped metal rods fixed by wires to the bases of the spinous processes. Dwyer instrumentation: a titanium cable fixed by screws to the vertebrae. Cotrel-Dubousset (CD) procedure: bilateral segmental fixation using 2 rods and multiple hooks. Electrical Stimulation: an electrical pulse transmitted to muscles on the convex side of the curve causing muscles to contract to straighten the spine. May be used for mild to moderate curves, but the effectiveness of this treatment is not well documented. COMMON NURSING DIAGNOSES 1 of 7 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=57&FxId=123&Sessi. See IMPAIRED PHYSICAL MOBILITY Related to: Musculoskeletal impairment (curvature of spine). Defining Characteristics: (Specify: imposed restrictions of movement by medical protocol of corrective device [brace, traction], bed rest and inability to purposefully move within the physical environment following surgery or with halo traction.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: (Specify: physical immobilization, traction, or brace and altered sensation and circulation, surface electrical stimulation.) Defining Characteristics: (Specify: change in skin color and temperature, skin irritation at stimulation, brace, redness on areas from prolonged pressure, break in skin from surgical correction or implantation of stimulators.) See DELAYED GROWTH AND DEVELOPMENT Related to: Effects of immobilization and restricted movement from spinal curvature. Defining Characteristics: (Specify: environmental and stimulation deficiencies, difficulty participating in self-care and social activities with long-term continuous brace use.) ADDITIONAL NURSING DIAGNOSES DEFICIENT KNOWLEDGE Related to: Lack of information about correction of functional or structural scoliosis. Defining Characteristics: (Specify: request for information about treatments for scoliosis, application of brace and surgical procedure to correct scoliosis.) Goal: Clients will obtain information about scoliosis by (date and time to evaluate). Outcome Criteria √ Clients verbalize understanding of scoliosis and the treatment plan. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess knowledge of deformity, cause Provides information about teaching and treatments. needs. Teach parents and child about Promotes understanding of type of functional or structural defect and defect and treatment protocol to methods of treatment modalities relieve anxiety; functional 2 of 7 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=57&FxId=123&Sessi. specific to age of child and scoliosis is corrected by treating severity of the deformity. the underlying problem, and structural scoliosis is treated with long-term bracing and exercising or surgical fixation to straighten and realign spine. Teach parents and child about Provides nonoperative bracing to application, care, and removal of prevent progressive curvatures; brace or orthoplast jacket, and higher curves are treated with the inform that appliance must be worn Milwaukee brace and lower curves for 23 hours/day and may be removed with the TLSO brace and both are for bathing and exercise. worn until growth is complete. Teach child exercises to be performed Prevents atrophy of muscle of spine in and out of the brace or other and abdomen. appliance and to perform them daily. Teach child to maintain proper Corrects functional scoliosis which posture, use shoe lifts, exercises, is usually caused by poor posture and other prescribed treatments for or unequal length of legs. functional scoliosis. (Teach parents and child to use Provides stimulation to the muscles electrical stimulation, application to prevent progression of of electrodes, skin protection, curvature. connection of leads, operation of machine to be used at night.) (Teach parents and child of operative Provides information about option procedure planned and preoperative for internal surgical preparation required; reinforce instrumentation of curves over 45 physician information and use degrees or those which are rapidly pictures, models and drawings to aid progressing to 45 degrees. in teaching.) (Prepare parents and child for Provides information about what to postoperative care, especially expect following surgery depending activity restrictions, log rolling, on the type of procedure. progression to ambulation, use of pillows for proper support, maintaining flat position, and possible use of special bed such as Stryker frame.) (Teach parents and child of use of Prevents trauma caused by fall from safety belt and walker when postoperative weakness, unassisted ambulating; instruct in safety ambulation, or wearing of brace precautions to take for child causing awkwardness in ambulation wearing brace [clear pathways, and ADL performance. handrails, performing ADL using aids].) (Reassure parents and child that Provides information and support physical and occupational therapy services. will be prescribed after surgery.) Refer to agencies for assistance such Promotes optimal physical activity. as National Scoliosis Foundation, community support groups. 3 of 7 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=57&FxId=123&Sessi. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did clients verbalize about scoliosis and the treatment plan? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) DISTURBED BODY IMAGE Related to: Biophysical and psychosocial factors of spinal deformity Defining Characteristics: (Specify: verbal response to actual change in structure of spine, negative feelings about body, dependence on long-term use of brace, feeling of rejection by peers, inability to participate in some activities.) Goal: Child will experience improved body image by (date and time to evaluate). Outcome Criteria √ Child expresses feelings about scoliosis and long-term treatment. √ Child identifies at least 1 positive thing about his or her body. NOC: Self-Esteem INTERVENTIONS RATIONALES Assess child for feelings about Provides information about status wearing brace, long-term of self-concept and changes in treatments, restrictions in appearance. lifestyle, inability to keep up with peers and participate in activities. Encourage expression of feelings and Provides opportunity to vent and concerns and support child's reduce negative feelings about communications with parents, peers changes in appearance and and teachers. appliance. continuing wearing of an Maintain positive environment and Enhances body image and promote activities that are allowed confidence, and promotes trust (sports, play, games). and respect of child. Assist with plan for independence in Promotes independence and ADL, application and removal of adjustment to appliance. appliance, selection of shoes and clothing to wear such as T-shirt. Assist child to adjust to self- Promotes positive self-image and 4 of 7 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=57&FxId=123&Sessi. perception of short leg, use of realistic view of appearance. appliance and effect on appearance. Suggest open communication with Promotes adaptation to school school nurse and teacher. within activity limitations. Reassure parents and child that most Promotes positive feelings about activities are allowed with use of treatment and restrictions appliance. imposed by the deformity. Assist child to type of clothing to Enhances appearance and body cover appliance that is stylish and image. has peer acceptance. Help child find ways to inform others Assist child in dealing with about wearing appliance. questions and curiosity of others about differences caused by deformity. Teach child of activity restrictions Prevents injury following that include progression from quiet surgical correction of the activities to involvement in those deformity. to avoid: contact sports, bike riding, driving, skating, or those that may result in a fall if surgery has been done. NIC: Self-Esteem Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What feelings about scoliosis and treatment did child verbalize? What positive thing about body did child identify? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR SCOLIOSIS 5 of 7 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=57&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library 6 of 7 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=57&FxId=123&Sessi. ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:09:25 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=57 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 6 - MUSCULOSKELETAL SYSTEM CHAPTER 6.8 - SCOLIOSIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 7 of 7 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=58&FxId=123&Sessi. CHAPTER 6.9 - TALIPES INTRODUCTION Talipes (club foot) is a congenital disorder of the foot usually with ankle involvement characterized by a twisting out of a normal position that is unable to be manipulated into a different position. The deformity is typed and named according to the position of the foot and includes talipes varus (foot inversion), talipes valgus (foot eversion), talipes equinus (plantar flexion), and talipes calcaneus (dorsiflexion). Most are a combination of these with the most common deformity known as talipes equinovarus (inversion and plantar flexion of the foot). The defect may occur alone or in association with other congenital syndromes or defects. MEDICAL CARE Foot/Ankle X-ray: reveals abnormal bone deformity or distortion. Casting Surgical Correction COMMON NURSING DIAGNOSES See IMPAIRED PHYSICAL MOBILITY Related to: Musculoskeletal impairment (talipes deformity). Defining Characteristics: (Specify: imposed restrictions of movement by medical protocol

of corrective device, serial cast application.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: (Specify: physical immobilization by cast(s), internal factors of altered circulation, sensation by cast pressure.) Defining Characteristics: (Specify: edema, rapid growth rate, tight cast or appliance, color change and cool skin proximal to cast.) See DELAYED GROWTH AND DEVELOPMENT Related to: Effects of physical disability (immobilization). Defining Characteristics: (Specify: delay in performing motor skills typical of age group during cast applications, lack of stimulation while cast is present.) ADDITIONAL DIAGNOSES DEFICIENT KNOWLEDGE Related to: Lack of information about condition. 1 of 5 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=58&FxId=123&Sessi. Defining Characteristics: (Specify: request for information about disorder, its cause and treatment for correction, follow-up care.) Goal: Parents will gain information about talipes by (date and time to evaluate). Outcome Criteria √ Parents verbalize understanding of condition of infant. √ Parents state the planned corrective treatment. NOC: Knowledge: Treatment Procedures INTERVENTIONS RATIONALES Assess knowledge of disorder, type of Provides information needed to deformity, and if one or both feet develop plan of instruction to are involved; type of immobilization ensure compliance to medical and application and/or care; presence regimen for correction; usually of associated congenital disorders or begins in infancy and lasts for 3 syndromes. to 5 months, and most commonly occurs in males. Teach parents about type of talipes Provides information about how the deformity and describe the position correction is accomplished, of the foot and ankle and the stages maintained, and re-evaluated to of corrective treatment. ensure the correction and prevent recurrence of the deformity. Instruct parents in manipulation of Ensures correct positioning of the feet in one smooth motion, feet in preparation for demonstrate and allow for return immobilization. demonstration. Teach parents about casting procedure Ensures correction by the most and type of cast applied (midthigh reliable method of manipulation and long led) and that new successive serial casting to stretch tight casts will be applied q 2 to 3 days structures and contract lax for 1 to 2 weeks and then q 1 to 2 structures; frequent castings allow weeks with the final cast remaining for rapid growth in infant. in place for 4 to 8 weeks. Teach parents to monitor extremities Prevents circulation and neurologic for color, peripheral pulses, and impairment from tight casts. coolness, and report changes in these circulatory parameters. Teach parents that if conservative Prepares parents for possibility of treatment fails or child is older, surgical correction if manipulation surgery may be needed to correct is ineffective after 5 months of deformity by releasing ligaments, treatment. lengthening tendons, or correcting bone deformity with casting following immobilization of the feet. Encourage parents to plan for follow-up Ensures compliance over long-term physician evaluations and cast correction of deformity by casting changes. or appliance. 2 of 5 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=58&FxId=123&Sessi. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did clients verbalize about infant's condition and the treatment plan? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR TALIPES 3 of 5 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=58&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 4 of 5 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=58&FxId=123&Sessi. Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:09:42 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=58 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 6 - MUSCULOSKELETAL SYSTEM CHAPTER 6.9 - TALIPES Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 5 of 5 12/22/2006 7:39 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=59&FxId=123&Sessi. UNIT 7 - NEUROLOGIC SYSTEM CHAPTER 7.0 - NEUROLOGIC SYSTEM: BASIC CARE PLAN INTRODUCTION The neurologic system includes the central nervous system (CNS) consisting of the cerebrum, cerebellum, brain stem, and the spinal cord; the peripheral nervous system consisting of the motor (efferent) and sensory (afferent) nerves; and the autonomic nervous system (ANS) consisting of the sympathetic and parasympathetic systems that provide control of vital body functions. Alterations in the neurologic system affect the process of receiving, integrating, and responding to stimuli that enter the system. This results in disturbances with signs and symptoms dependent on the type and site of the impairment and the normal functioning of the system. The disturbances may be manifested by alterations in consciousness, sensation, or muscle function. Changes in the system also occur as the child develops neurologically and completes the growth and development requirements for adulthood; this system is one of the last to complete development after birth. NEUROLOGIC GROWTH AND DEVELOPMENT BRAIN AND SPINAL CORD STRUCTURE • Skull structure is expansible during infancy and young childhood and becomes rigid with growth in older child. • Head circumference at birth is 13 to 14 inches in size, increases to 17 inches at 6 months of age, and 18 inches at 12 months. • Cranial sutures close during infancy (by 6 months), posterior fontanel at 6 to 8 weeks, and anterior fontanel at 12 to 18 months. • Increases in brain size and cell numbers occur between birth and 1 year of age; growth continues with increases primarily in size from 1 year of age until maturity. Weight of the brain at birth is approximately 350 g or 12% of total body weight, doubles by 1 year of age, and is approximately 1,000 g or 2/3 of adult size by 2 years of age, a continual slower pace until adulthood follows with a final size of 2% of total body weight. • Cortex is 1/2 the thickness of the adult brain at birth and continues to develop and mature with growth. • Myelinization of nerves and fiber tracts develops rapidly after birth with sensory pathways before motor pathways; continue to develop with growth of the child until reaching completion in late adolescence. • Myelinization of nerve tracts follows a cephalocaudal and proximodistal sequence that allows for progressive neuromotor function; begins with cranial nerve fibers and spinal cord nerve fibers and then proceeds to brain stem and corticospinal nerve tracts. • At birth, spinal nerves are attached to the cord in a horizontal position in relation to the vertebral column; with growth, lower nerves are directed more downward, and sacral and coccygeal nerves are directed in a vertical direction while cervical nerves remain in a horizontal position. SENSORY AND MOTOR FUNCTION • As the neurologic system develops, integrated functions of consciousness, mentation, language, motor function, sensory function, and bowel and bladder function develop to completion. 1 of 10 12/22/2006 7:42 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=59&FxId=123&Sessi. • Infant has reflexive responses and learns to bring responses under conscious control with growth and development of cortex—areas of cerebral development correspond to the development of intellect, control of attention span, and responses to stimuli. • Neuromuscular maturity and myelinization of spinal cord promote walking by the age of 2 with skills perfected through preschool years. • Gross and fine motor development and coordination develop by age 3 for most activities and continue with growth; physical strength and endurance continue to develop throughout school age. • At birth, response to sound is present with ability to locate and identify sounds as myelinization of auditory pathways beyond the midbrain occurs; curvature of the external equal develops to adult position by 3 years of age. • Hearing fully developed by 5 months of age; child proceeds to listen and react to sounds and understand words by 1 year of age. • Sense of taste, smell, and touch are present at birth; responses to strong odors, sour solutions, pin prick apparent. • In the infant, ciliary muscles are immature, which limits accommodation and the ability of the eye to fixate on an object for a period of time. • Macula and muscles develop with growth. • Response to color by 1 to 2 months, color vision at 6 months. • Eye movement coordination by 3 months, function matures at 6 months. • Binocular vision by 4 months, tear glands function by 4 months. • Depth perception by 6 to 9 months, detail perception by 8 months. • Peripheral vision by 1 year of age. • Permanent iris color by 18 months of age. • Visual acuity matures at 6 years of age. Infant: 20/100 to 20/400 (technique dependent) 2 years: 20/40 4 years: 20/30 School-age: 20/20 • Body temperature regulation unstable at birth with decrements and improved regulation taking place with maturity Infant: 99.4 to 99.5 degrees F 2 of 10 12/22/2006 7:42 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=59&FxId=123&Sessi. Toddler: 99.7 to 99 degrees F Preschool: 99 to 98.6 degrees F School-age: 98.6 to 97.8 degrees F • Length of sleep time decreases from infancy throughout childhood; amount of REM sleep is 20% compared to 50% in infancy, non-REM sleep increases with age; length of the sleep cycle increases from 50 minutes in the infant to 90 minutes in later childhood, number of hours decrease with age. NURSING DIAGNOSES HYPERTHERMIA Related to: Illness or trauma. Defining Characteristics: (Specify: increase in body temperature above normal range, flushed skin, warm to touch, increased respiratory rate, tachycardia, seizures/convulsions.) Related to: Dehydration. Defining Characteristics: (Specify: increase in body temperature above normal range, flushed, dry skin, warm to touch, increased respirations, pulse, oliguria, poor skin turgor, sunken eyeballs.) Goal: Child's temperature will be decreased by (date and time to evaluate). Outcome Criteria √ Return of body temperature to (specify). √ Child's temperature will remain < (specify for child). NOC: Thermoregulation INTERVENTIONS RATIONALES Assess temperature via axillary method Provides information about temperature in infants and children to age 5 changes caused by high susceptibility years, oral in children 5 to 6 years to fluctuations in infants and young and older, depending on the individual children as their regulatory function child's ability to safely and is unstable (regulated in the accurately keep the thermometer in hypothalamus); temperature in infant their mouth; check for malaise or and young child responds to infection lethargy and compare to normal ranges with higher and more rapid elevations for age or low grade or high and may become overheated as elevations associated with specific environmental temperatures change or microorganisms or diseases. from activity, crying and emotional upsets since regulating mechanism 3 of 10 12/22/2006 7:42 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=59&FxId=123&Sessi. immature until age 8. Assess temperature q 1 to 2h for sudden Sudden temperature elevation may induce increase in presence of any a seizure. temperature elevation or illness. Teach parents that the main reason for Reduces temperature; (lowers set treating a fever is discomfort; two point); prevents possible toxicity antipyretic drugs of choice: caused by accumulation if given too Acetaminophen and nonsteroidal anti- often, may be administered by tablet, inflammatory drugs such as Ibuprofen; liquid, chewable, suppository (action administer as ordered in the form of drugs). (liquid, tablet) that is appropriate for the age of the child and illness severity. Teach that cooling measures such as Antipyretics lower the set point, lightweight clothing, skin exposure, enabling cooling measures to be decreasing room temperature and cool, effective. wet compresses to skin are only effective if given one hour after antipyretic. Instruct that sponging/tepid baths are Utilized only for child with not recommended for children with hyperthermia caused by elevated set fever. point; hyperthermia is a condition where body temperature exceeds set point—more heat created than eliminated caused by internal factors such as hyperthyroidism, cerebral dysfunction, "malignant hyperthermia" (a reaction to anesthesia), or external factors (heat stroke). Encourage parents to provide additional Maintains hydration when fluids are fluid. lost through fever or hyperthermia. Treat shivering by warming the body with Shivering increases metabolic demands clothing (especially extremities),

that produce more heat; it is the increasing room temperature, and warm body's natural mechanism to maintain baths. the higher set point by producing more heat. Promote rest and provide a stress-free Decreases metabolic requirements. environment, hold and rock infant/ child if needed. For hyperthermia only: cooling measures Cooling measures are effective because such as cooling blankets/mattresses of normal set point in hyperthermia; and tepid tub baths are utilized; antipyretics are not effective. water temperature should be 1 to 2 degrees less than the child's temperature; recheck temperature 30 minutes after intervention; discontinue if shivering occurs. Teach parents to take oral and axillary Allows parents to monitor temperature temperature and allow for return for elevation when child feels warm. demonstration; instruct in use of digital thermometers and plastic strips. 4 of 10 12/22/2006 7:42 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=59&FxId=123&Sessi. Teach parents of the difference between Antipyretics given to control fever fever and hyperthermia and use of which is an elevation in set point, antipyretics to reduce fever and and cooling measures given to control cooling baths to treat hyperthermia; hyperthermia which is a temperature instruct in safe use of antipyretics that exceeds the set point. including type, dosage, frequency, form and limitations in 24-hour administration and sponging without use of cold water or alcohol. Teach parents to report to physician Prevents severe complications from immediately if: child is less than 2 elevated temperature that persists months old with any fever; fever and is not relieved by medications; greater than 40.5° C. (105° F); physician intervention to initiate or presence of excessive crying; change treatment may be necessary. decreased level of consciousness; seizures; stiff neck; difficulty breathing; or if child has underlying illness. Inform parents that temperature may Reduces parental anxiety if unduly become elevated without the presence concerned about fever. of a serious illness. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is child's temperature?) (Revisions to care plan? D/C care plan? Continue care plan?) DISTURBED SLEEP PATTERN Related to: Illness. Defining Characteristics: (Specify: interrupted sleep, temperature elevation, irritability, restlessness, listlessness, fatigue, weakness, nightmares.) Related to: Environmental changes. Defining Characteristics: (Specify: hospitalization, interrupted sleep, separation anxiety, stimuli overload, lack of privacy, breaks in bedtime rituals or routines.) Goal: Client will be able to sleep without interruption by (date and time to evaluate). Outcome Criteria 5 of 10 12/22/2006 7:42 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=59&FxId=123&Sessi. √ Client goes to bed without difficulty. √ Client sleeps (specify number of hours) without waking. √ Client appears rested. NOC: Sleep INTERVENTIONS RATIONALES Assess sleep patterns and changes, nap Provides information about times and frequency, sleep problems, fulfillment of sleep needs related pattern of awakenings and reason. to age requirements: infants need 10 to 20 hours/24 hours with a routine and sleep through the night by 5 months of age; toddlers need 12 hours/night and 2 naps which gradually changes to 10 hours/night and 1 nap; preschoolers need 10 hours/night with or without a nap; school-age children need 10 hours/night; wakenings may be caused by anxiety; nightmares and the absence of good sleep habits may create sleep problems. Assess presence of temperature Provides possible reasons for elevation, restlessness caused by restlessness, wakenings, and pain, dyspnea, other signs and sleep/rest deficit. symptoms of an illness. Assess for fatigue, irritability, Results of sleep deficit or weakness, lability, yawning. deprivation, overactivity. Place infant (0-6 months) on back or Recent research has led the American side-lying position for sleep, Academy of Pediatrics to recommend utilizing positioning aids such as these positions which have shown rolled blankets to maintain desired to decrease the incidence of SIDS position; infants with (sudden infant death syndrome). gastroesophageal reflex, premature infants, and infants with specific upper airway problems may sleep in prone position; premature infants benefit developmentally from the prone position as it often facilitates flexion, and is soothing. Avoid waking/interrupting sleep for Provides comfort for sleep without feedings or caregiving. interruptions. Offer snack and preferred toy at Promotes comfort and familiar bedtime for child, follow home bedtime pattern. routines for time, night light, reading a story at bedtime, playing, 6 of 10 12/22/2006 7:42 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=59&FxId=123&Sessi. tapes of music. Allow time for quiet play before Avoids overstimulation before bedtime. bedtime. Provide soothing comfort if child has a Provides security and explanation to nightmare and explain bad dream, stay encourage child to sleep without until child returns to sleep. fear. Promote naps during day if such a Follows usual age dependent nap/rest routine has been established. pattern. Provide environment that is quiet, calm Promotes sleep and/or rest periods. and warm; proper clothing, covers, and diaper change as needed. Try to avoid painful procedures prior Decreases stimuli that prevent rest to bedtime when possible. and sleep. Encourage parent to stay with child at Promotes sleep and relaxation with a night if possible or hold, rock, or familiar person giving care. stroke child "until" asleep. Discuss with parents the amount of Promotes parental understanding of sleep needed by infant/child. sleep needs which are age dependent. Teach parents: Infant: feed, change Provides suggestions that may assist diaper, dress appropriately, place in to establish bedtime rituals. side-lying or supine position.Toddler: remind of bedtime or nap in advance, offer snack, allow preferred toy in bed, can assist to prepare for bed.Preschool: provide own sleeping area, night light, story or music.School-age: provide time before sleep for talk, review activities of day. Teach parents to maintain same sleep Promotes sleep pattern and avoids schedule, set limits, reinforce sleep problems. appropriate behaviors. Teach child relaxation techniques such Promotes rest and induces sleep. as tensing each part of the body and slowly relaxing each part, taking deep breaths, repeating a word that the child associates with relaxation (specify). Assist parents to solve chronic sleep Routines greatly promote the child's problems after acute illness is sleep quality and quantity; resolved and child is at home; promote the child's feelings of suggestions may include: a bedtime security; improve the quality of ritual; a consistent bedtime and the parent-child relationship; location; use of a favorite blanket promote the child's own natural or toy to increase feelings of body defenses. security; avoid use of bed as punishment; avoid feedings/drinks at night; if child consistently awakens at night, implement strategies which promote gradual change such as: entering room without picking up the 7 of 10 12/22/2006 7:42 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=59&FxId=123&Sessi. child, then leaving for progressively longer periods of time until the child falls asleep by him/herself. NIC: Sleep Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did child go to bed without problems? How long did client sleep? Does client appear rested? Describe.) (Revisions to care plan? D/C care plan? Continue care plan?) DISTURBED THOUGHT PROCESSES Related to: Physiologic changes. Defining Characteristics: (Specify: altered attention span, disorientation to time, place, person, circumstances and events, changes in consciousness, hallucination, cognitive dissonance, inappropriate affect, memory deficit.) Goal: Client will experience improved thought processes by (date and time to evaluate). Outcome Criteria √ (Specify for client, e.g., will have decreased ICP; will be alert and oriented × 3; will deny hallucinations, etc.) NOC: Cognitive Orientation INTERVENTIONS RATIONALES Assess history for neurologic Provides information about conditions or infection, cognitive reason for mentation changes. functioning. Assess for increased ICP and effects Provides information about on orientation mentation, increased ICP which results intellectual function, motor from brain edema, shift or function. distortion and brain hypoxia. Perform neurologic checks q 2h Provides data about changes in including PERL, orientation, grip thought processes that and grasp and pain response, indicate serious pathology. presence of irritability, confusion, memory loss; include cranial nerve function if indicated. Elevate head of bed 30 degrees and Promotes blood flow to brain and maintain proper head and neck prevents hypoxia. 8 of 10 12/22/2006 7:42 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=59&FxId=123&Sessi. alignment. Provide toys and stimulation that Promotes developmental level are age-appropriate and modified within prescribed limitations for illness. to improve orientation and attention span. Limit sensory and motor expectations Prevents frustration and if unable to maintain thought insecure feelings. processes and independence in activities. (Inform parents of reason for loss Relieves doubts and anxiety of thought processes and temporary about mental status of infant/ nature of this condition.) child. Encourage parents to expose infant/ Promotes developmental task child to stimulation, toys, and achievement. play activities and praise desired behaviors indicating orientation. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide information related to the outcome criteria chosen, e.g., what is ICP? Describe level of alertness and orientation, etc.) (Revisions to care plan? D/C care plan? Continue care plan?) COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: 9 of 10 12/22/2006 7:42 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=59&FxId=123&Sessi. Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:10:00 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=59 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 7 - NEUROLOGIC SYSTEM CHAPTER 7.0 - NEUROLOGIC SYSTEM: BASIC CARE PLAN Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 10 of 10 12/22/2006 7:42 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=60&FxId=123&Sessi. CHAPTER 7.1 - HYDROCEPHALUS INTRODUCTION Hydrocephalus is the enlargement of the intracranial cavity caused by the accumulation of cerebrospinal fluid in the ventricular system. This results from an imbalance in the production and absorption of the fluid which causes an increase in intracranial pressure as the fluid builds up. Fluid may accumulate as a result of blockage of the flow (noncommunicating hydrocephalus) or impaired absorption (communicating hydrocephalus). As the head enlarges to an abnormal size, the infant experiences lethargy, changes in level of consciousness, lower extremity spasticity and opisthotonos and, if the hydrocephalus is allowed to progress, the infant experiences difficulty in sucking and feeding, emesis, seizures, sunset eyes, and cardiopulmonary complications as lower brain stem and cortical function are disrupted or destroyed. In the child, increased intracranial pressure (ICP) focal manifestations are experienced related to space-occupying focal lesions and include headache, emesis, ataxia, irritability, lethargy, and confusion. Treatment may include surgery to provide shunting for drainage of the excess fluid from the ventricles to an extracranial space such as the peritoneum or right atrium (in older children) or management with medications to reduce IC if progression is slow or surgery is contraindicated. MEDICAL CARE Anticonvulsants: to interfere with impulse transmission of cerebral cortex and prevent seizures. Antibiotics: culture and sensitivity dependent for shunt infections such as septicemia, meningitis, ventriculitis or given as prophylactic treatment. Skull X-ray: reveals increasing head enlargement, widening of suture lines and fontanelles. Magnetic Resonance Imaging: reveals presence of hydrocephalus. Echoencephalogram: reveals comparison of ratio of ventricle to cortex. Ventriculogram: reveals size of ventricles and patency of a shunt if present. Surgical Management: therapy of choice in almost all cases. Includes use of ventriculo-peritoneal shunt (VP), ventriculo-atrial shunt (VA), temporary ventriculostomy. Electrolyte Panel: reveals changes indicating dehydration or losses from diuretic therapy. Complete Blood Count: reveals increased WBC if infection, presence of dehydration. COMMON NURSING DIAGNOSES See EXCESS FLUID VOLUME Related to: Compromised regulatory mechanism shunt placement—ventriculoatrial or VP. Defining Characteristics: (Specify: decreased cardiac output, change in respiratory pattern, tachycardia, tachypnea, dyspnea, weight gain, chest pain, cardiac arrhythmias, pulmonary congestion.) 1 of 10 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=60&FxId=123&Sessi. See RISK FOR DEFICIENT FLUID VOLUME Related to: Excessive losses. Defining Characteristics: (Specify: postoperative vomiting or diarrhea, use of diuretics, altered intake, thirst, dry skin and mucous membranes.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food/feedings. Defining Characteristics: (Specify: advanced stage of hydrocephalus, postoperative vomiting, NPO status.) See

RISK FOR IMPAIRED SKIN INTEGRITY Related to: Physical immobilization. Defining Characteristics: (Specify: decreased movement of head, disruption of skin surface by surgical procedure [shunt insertion] or diagnostic procedure.) See HYPERTHERMIA Related to: Illness (infection). Defining Characteristics: (Specify: increase in body temperature above normal range.) See DELAYED GROWTH AND DEVELOPMENT Related to: Effects of disorder or disability. Defining Characteristics: (Specify: altered physical growth, mental retardation, delay or difficulty in performing motor, social skills typical of age, dependence.) ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: (Specify: threat to or change in health status; threat to or change in environment [hospitalization].) Defining Characteristics: (Specify: increased apprehension that condition of infant might worsen or condition may develop in child as a complication, expressed concern and worry about preoperative preparation and the surgical procedure, possible or actual physical, neurologic and mental deficits.) Goal: Client will experience decreased anxiety by (date and time to evaluate). 2 of 10 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=60&FxId=123&Sessi. Outcome Criteria √ Clients verbalize feeling better. √ Anxiety is decreased. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess source and level of anxiety Provides information about severity and need for information and of anxiety and need for support about condition and interventions and support; allows impending surgery. for identification of fear and uncertainty about condition and/or surgery and treatments and recovery; guilt about condition, possible loss of infant/child or of parental responsibility. Allow expressions of concern and Provides opportunity to vent opportunity to ask questions about feelings, secure information needed condition and recovery of ill to reduce anxiety. infant/child. Communicate therapeutically with Promotes calm and supportive parents and answer questions calmly environment. and honestly. Encourage parents to remain involved Promotes constant monitoring of in care and decision-making infant/child for improvement or regarding infant/ child. worsening of symptoms. Encourage parents to stay with Allows parents to care for and infant/child or visit when able if support child instead of becoming hospitalized, assist in care (hold, increasingly anxious because of feed, diaper) and make suggestions absence from child and wondering for routines and methods of about infant/ child's condition. treatment. When surgery is planned, answer all Promotes supportive environment and questions from parents and child reduces anxiety caused by fear of with honesty; refer to physician unknown. for answers and explanations if needed. Prepare child/parents for diagnostic Promotes reduction in anxiety if they tests and potential surgical have knowledge of expectations. procedures. Explain reason for and what to expect Reduces fear which causes anxiety. for each procedure or type of therapy; use drawings and pictures, video tapes for child. Teach parents and child (age Provides information about surgery dependent) about reason for and and desired effects as well as type of surgery to be done, site possible residual effects. and dressings, time of surgery and 3 of 10 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=60&FxId=123&Sessi. length of time of procedure, preoperative care and treatments. Clarify any misinformation and answer Prevents unnecessary anxiety all questions honestly and in resulting from inaccurate simple understandable language. information or beliefs. Teach about shunt placement and Shunt is placed to by-pass an reason; possible future revision of obstruction or remove excess shunt placement, signs and symptoms cerebrospinal fluid that of shunt complication or predisposes to increased ICP; a malfunction. shunt revision may be done to treat shunt complication such as infection or obstruction or as a result of child growth. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents and child verbalize feeling better? Did clients verbalize decreased anxiety? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: (Specify: sensory, integrative and effector dysfunction preoperatively.) Defining Characteristics: (Specify: neuromuscular changes, neurosensory changes, behavioral changes, increased ICP, CSF accumulation, vital signs changes, seizure activity.) Goal: Client will not experience any injury by (date and time to evaluate). Outcome Criteria √ Head circumference remains (specify cm). √ Client will not demonstrate (specify several signs of increased ICP to observe for, e.g., irritability, bulging fontanels, sunset sign, vomiting, headache, seizures). NOC: Risk Detection INTERVENTIONS RATIONALES Assess for rapidly increased Indicates increasing ICP in circumference of head, tense, bulging infant/ small child. fontanels, widening suture lines, 4 of 10 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=60&FxId=123&Sessi. irritability, lethargy, "cracked pot" sound percussion, sunset sign, opisthotonos, spasticity of lower extremities, seizures, high-pitched cry, distended scalp veins, changes in normal feeding patterns. Assess for early signs including: Indicates increasing ICP in headache, nausea, vomiting, diplopia, children with symptoms related blurred vision, seizures, to cause of hydrocephalus. irritability, restlessness, decrease in school performance, decreased motor performance, sleep loss, weight loss, memory loss progressing to lethargy and drowsiness. Late signs: decreased level of consciousness, decreased motor response to commands, decreased response to pain, change in pupils, posturing, papilledema. Perform neurologic and vital sign Provides data indicating an assessment q 4h or as needed increasing ICP causing decreased (specify). respirations, increased blood pressure and pulse. Position with head elevated 30 degrees Promotes drainage of CSF and and support head when handling or reduces accumulation of CSF; changing position; monitor skin infant may not be able to lift integrity with position change. and move head. Carry out seizure precautions including Prevents injury to self during padding of crib/bed, remove toys and seizure activity caused by objects from bed, maintain suction increased ICP and to treat apnea and oxygen at bedside, note and during seizure activity. report characteristics of seizure. Support an enlarged head by cradling it Protects infant's head from trauma in an arm when holding, place infant and neck from strain. on a pillow when moving, move head and body of infant at the same time. Teach parents signs and symptoms of Promotes knowledge of risk of increased ICP and changes to report developing increased ICP and to physician (specify). encourages preventive measures. Inform parents that condition is life- Provides realistic and honest long and monitoring and follow-up information that promotes care on a regular basis is required. optimal health and function for the infant/child. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 5 of 10 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=60&FxId=123&Sessi. (Provide information related to the outcome criteria chosen, e.g., is child irritable? Are fontanels of infant bulging? Does child exhibit sunset sign? Complain of headache? Has there been any vomiting or seizure activity?) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: (Specify: shunt placement and potential complications of shunt functioning.) Defining Characteristics: (Specify: increased ICP, kinking or plugging of shunt tubing, separation of tubing, changing of position of tubing, obstruction of shunt, displacement with growth.) Goal: Client will not experience any injury by (date and time to evaluate). Outcome Criteria √ Client will remain alert without signs of increased ICP. NOC: Risk Control INTERVENTIONS RATIONALES Assess for signs and symptoms of Provides data that indicates increased ICP, swelling along shunt shunt malfunction. tract; note presence/severity of headache and neck pain; behavior changes (lethargy, irritability), physical changes (full fontanel, nausea, vomiting, edematous eyes, tender, swollen abdomen). Note vomiting, drowsiness, irritability, Indicates shunt blockage. swelling at pump site, redness, exudate and temperature of child. Position carefully on nonoperative side Prevents trauma to surgical postoperatively; maintain bed position site; maintain shunt patency. and activity level as ordered depending on shunt dynamics. Instruct parent on hydrocephalus and Promotes understanding of shunt placement; teaching should illness/treatments which may include: definition of hydrocephalus decrease anxiety; knowledge (brain anatomy), causes, diagnostic of prompt treatment of tests, treatments, signs of shunt complications often life- malfunction and infection, saving. interventions and proper notification of health professionals, and documentation; supplemental written materials are important; emphasize the importance of early identification of infection/malfunction and prompt notification. 6 of 10 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=60&FxId=123&Sessi. Teach parents about need for bowel Prevents complications elimination at least every 2 days and associated with ventriculo- steps to take to ensure bowel peritoneal shunt. movement. Inform parents of agencies for guidance Provides assistance with and support such as National management of child with Hydrocephalus Foundation. hydrocephalus. Discuss and encourage parents to treat Promotes growth and development child as member of family and instruct and feeling of belonging. in activities to be avoided such as rough contact sports. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide information related to the outcome criteria chosen, e.g., is child irritable? Are fontanels of infant bulging? Does child exhibit sunset sign? Complain of headache? Has there been any vomiting or seizure activity?) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: Invasive procedure of shunt insertion. Defining Characteristics: (Specify: elevated temperature, swelling, redness at shunt tract or operative site, nausea, vomiting, lethargy, excessive drainage on dressing, poor feeding.) Goal: Client will not experience any infection by (date and time to evaluate). Outcome Criteria √ Temperature remains <99° F. √ WBC levels (specify maximum for age). NOC: Risk Detection INTERVENTIONS RATIONALES Assess site for inflammatory Provides data indicating process, temperature for presence or potential for elevation, WBC for increases, infection which affects shunt characteristics of drainage on function. dressings. 7 of 10 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=60&FxId=123&Sessi. Follow principles of asepsis when Prevents transmission of performing procedures such as microorganisms to shunt site. dressing changes. Monitor temperature q 4h. Elevation of temperature indicates infection. Avoid positioning head of valve Alleviates the risk of site for at least 2 days infection. postoperatively. Teach about signs and symptoms of Promotes early detection of infection of site and shunt infection that may occur for tract and to notify physician if up to 1 to 2 months after noted. shunt insertion. Teach parents about wound care and Provides clean, sterile dressing change, emphasize dressings when soiled or wet. importance of good handwashing techniques. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is temperature? What is WBC level—include date and time of test.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR HYDROCEPHALUS 8 of 10 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=60&FxId=123&Sessi. 9 of 10 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=60&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:12:54 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=60 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 7 - NEUROLOGIC SYSTEM CHAPTER 7.1 - HYDROCEPHALUS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 10 of 10 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=61&FxId=123&Sessi. CHAPTER 7.2 - BRAIN TUMOR INTRODUCTION A brain tumor is a solid tumor that may be benign, malignant, or a metastatic growth from a tumor in another part of the body. Most central nervous system tumors occur in the cerebellum or brain stem and cause increased intracranial pressure and the symptoms associated with it. Other tumors occur in the cerebrum. A malignant brain tumor is the second most common type of cancer in children and has a poor prognosis as the tumor usually enlarges and becomes advanced before signs and symptoms appear or are detected as they are easily missed. Signs and symptoms are site and size dependent. Brain tumors are most prevalent in children 3 to 7 years of age. Treatment includes surgery, although total removal is not usually possible, chemotherapy, and radiation, which may be done to decrease the size of the tumor before surgery. One or a combination of these procedures

may be done with each resulting in possible residual neurologic deficits. MEDICAL CARE Analgesics/Antipyretics: for headache to reduce fever and to decrease pain. Diuretics (Osmotic): mannitol to induce diuresis with a hypertonic solution to prevent reabsorption of water by the glomeruli and decrease cerebral edema. Antibiotics: specific to microorganisms identified by culture and sensitivities to treat infection or given to prevent infection. Anti-inflammatories: cortisone to reduce the inflammation process in brain. Saline Solution: given as eye drops or eye irrigation to prevent corneal ulceration. Stool Softeners: for easier elimination to prevent constipation and Valsalva's maneuver which increase intracranial pressure. Computerized Tomography Scan (CT): reveals changes in position of brain parenchyma, ventricles, and subarachnoid space caused by tumor growth. Stereotactic Surgery: use of CT/MRI to reconstruct brain tumor three-dimensionally to accurately remove it surgically. Laser Therapy: vaporization of tumor tissue. Radiotherapy: use of radiation to shrink tumor size. Chemotherapy: used to treat malignant tumors. Cerebral Angiogram: reveals vascularity and blood supply to the tumor before surgery. Magnetic Resonance Imaging (MRI): reveals tumor growth and size before, during, and after treatment. Electrolyte Panel: reveals changes indicating dehydration or losses from diuretic therapy. Complete Blood Count: reveals increased WBC if infection present. 1 of 9 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=61&FxId=123&Sessi. Urinalysis: reveals increased sp.gr. in presence of dehydration. COMMON NURSING DIAGNOSES See HYPERTHERMIA Related to: Illness. Defining Characteristics: (Specify: increase in body temperature above normal range, presence of infection [meningitis or upper respiratory], surgical procedure [anesthesia, brain stem or hypothalamus area].) See DISTURBED SLEEP PATTERN Related to: Sensory alternations. Defining Characteristics: (Specify: lethargy, restlessness, irritability, disorientation, coma, frequent napping.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Excessive losses. Defining Characteristics: (Specify: vomiting, altered intake, diuresis with use of diuretic, diabetes insipidus development, thirst, dry skin and mucous membranes.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food. Defining Characteristics: (Specify: vomiting, nausea, choking and possible aspiration with facial paralysis or edema, refusal to eat or drink, gavage feedings, depressed gag reflex.) See IMPAIRED PHYSICAL MOBILITY Related to: Neuromuscular impairment. Defining Characteristics: (Specify: inability to purposefully move within physical environment, impaired coordination, loss of balance, decreased muscle strength and control spasticity, hypo or hyperreflexia, paralysis, general weakness, ataxia following surgery.) See DELAYED GROWTH AND DEVELOPMENT Related to: Effects of disorder following surgery/other. 2 of 9 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=61&FxId=123&Sessi. Defining Characteristics: (Specify: delay or difficulty in performing skills typical of age group [motor, social or expressive], inability to perform self-control activities appropriate for age behavior and/or intellectual deficits, presence of somnolence syndrome.) ADDITIONAL NURSING DIAGNOSES PAIN Related to: Biologic injuring agents. Defining Characteristics: (Specify: verbal descriptor of pain, headache in frontal or occipital area that is worse in the morning and becomes worse if head lowered or with straining, increased VS, restlessness, hostility, inability to relax.) Goal: Child will experience decreased pain by (date and time to evaluate). Outcome Criteria √ Child rates pain as less than (specify pain rating and scale used). NOC: Pain Level INTERVENTIONS RATIONALES Assess severity of headache, Provides information regarding recurrence and progressive presence of tumor as headache characteristics, precipitating is a most common symptom in factors and length of headache. child. Administer analgesic (specify) to (Action of drug.) treat or anticipate headache based on assessment. Provide toys, games for quiet play Provides diversionary activity (specify). to detract from pain. Apply cool compress to head for low Provides comfort and relief to moderate pain. from headache, decreases facial swelling, if present. After surgical intervention, opioids Side effects occur rarely, (morphine sulfate) may be initially opioids can be given safely used. Assess for side effects such with appropriate monitoring. as sedation and respiratory depression; use Naloxone to reverse. Determine the child's understanding Promotes better communication of the word "pain" and ask family between child/family and what word the child normally uses. nurse. Use a pain assessment tool appropriate for age and developmental level to identify intensity of pain. Plan a preventive approach to pain Promotes early identification management around the clock; of pain which enhances pain observe for signs of pain, both relief measures. 3 of 9 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=61&FxId=123&Sessi. physiologic and behavioral. Teach parents and child about Controls pain before it becomes analgesics, to administer in severe (action of drug). anticipation of headache and type to give (sustained release) (specify) and that it will help to control headache. Encourage child to restrain from Prevents straining that coughing, sneezing, or straining precipitates or intensifies during defecation. headache. Assist parents to develop activities Promotes stimulation for that will not precipitate or child's development needs. increase headache pain. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is pain rating? Specify scale used.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: Sensory, integrative, and effector dysfunction. Defining Characteristics: (Specify: neuromuscular changes, neurosensory changes, behavioral changes, increased ICP, seizure activity, vital signs changes.) Goal: Child will not experience injury by (date and time to evaluate). Outcome Criteria √ Child does not exhibit increased ICP. Participates in teaching about treatment options (specify for child). NOC: Risk Detection INTERVENTIONS RATIONALES Assess head circumference in the Provides data indicating an infant/small child for increases as increase in ICP as tumor grows fluid obstruction caused by tumor with a poorer prognosis because will increase head size. tumor size becomes large before diagnosis is made. Assess vital signs including Provides changes indicating 4 of 9 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=61&FxId=123&Sessi. increased BP, decreased pulse presence of brain tumor depending pressure, pulse and respirations; on type and location of tumor. take for 1 full minute when monitoring pulse and respirations. Assess changes in gross and fine Provides changes in neuromuscular motor control, weakness, ataxia, status indicating presence of spasticity, paralysis or change in brain tumor. balance, coordination. Assess changes in vision (visual Provides changes in neurosensory acuity, strabismus, diplopia, status indicating presence of nystagmus), head tilt, papilledema. brain tumor. Assess for irritability, lethargy, Provides changes in behavior loss of consciousness or coma, indicating presence of brain fatigue, napping. tumor. Assess for increased ICP including Provides information about ICP irritability, poor feeding, change caused by brain distortion vomiting, head enlargement, or shifting caused by tumor. lethargy, high-pitched cry (infant) or vomiting, diplopia, behavioral changes, change in VS, seizure activity. Alter environment by padding bed or Prevents injury if seizure activity crib, reduce light and stimulation. possible. Place in position of comfort with Promotes comfort and decreases head elevated. increased ICP by gravity. Teach parents and child about Promotes understanding of diagnostic procedures done to procedures to reduce. evaluate tumor presence; base information on child's age and past experiences (specify). Inform parents that surgery may be Prepared for surgery and possible performed to remove the tumor as a postoperative therapy with reinforcement of physician information limited to sensitive, information and that radiation and hopeful explanation; information chemotherapy may be administered about postoperative therapy after surgery. should be postponed until this decision is made after surgery. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide data about signs of increased ICP. Did child participate in teaching? Describe.) (Revisions to care plan? D/C care plan? Continue care plan?) 5 of 9 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=61&FxId=123&Sessi. ANXIETY Related to: Change in health status and threat to self-concept. Defining Characteristics: (Specify: increased apprehension as diagnosis is confirmed and condition worsens, expressed concern and worry about postoperative residual tumor and effects, hair removal before surgery, insomnia, social isolation.) Goal: Clients will experience decreased anxiety by (date and time to evaluate). Outcome Criteria √ Parents verbalize decreased anxiety. √ Child appears calm, without crying or irritability. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess level of anxiety and need for Provides information about degree information that will relieve it of anxiety and need for following surgery. interventions and support; allow for identification of fear and uncertainty about surgery and treatments and recovery, guilt about illness, possible loss of child, parental role and responsibility. Encourage expression of concerns and Provides opportunity to vent inquire about condition of ill child feelings, secure information and possible consequences and needed to reduce anxiety. prognosis. Prepare family and/or child for Promotes understanding which diagnostic tests and surgery. decreases anxiety; may clarify Encourage child to draw a picture of misconceptions and increase the brain to clarify any feelings of control. misconceptions; encourage use of medical play (dolls, puppets, equipment) after procedures (specify for child). Encourage parents to stay with infant/ Promotes care and support of child child; encourage participation in by parents. care of infant/child. If surgery planned, orient to special Reduces anxiety caused by fear of care unit, equipment and staff unknown. (specify how). Teach parents and child about hair Promotes understanding of clipping and that hair will grow postoperative appearance to back in short period of time, to maintain self-image; support cover head with cap or scarf self-concept. temporarily; that there is edema of 6 of 9 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=61&FxId=123&Sessi. the face and eyes after surgery; that a dressing will be applied that completely covers the head; use of a doll with head wrapped in a bandage may be useful in explaining the post-surgical dressing. Teach parents and child that after Provides an explanation of what to surgery a headache and sleepy expect after surgery. feeling may be present for a few days or even lethargy and coma may be present. Clarify any information in lay terms Prevents unnecessary anxiety and use aids that are age related if resulting from misunderstanding helpful to child (specify). or inconsistencies in information. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents verbalize decreased anxiety? Use quotes. Is child calm and not irritable? Describe behavior.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR BRAIN TUMOR 7 of 9 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=61&FxId=123&Sessi. 8 of 9 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=61&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:13:20 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=61 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 7 - NEUROLOGIC SYSTEM CHAPTER 7.2 - BRAIN TUMOR Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 9 of 9 12/22/2006 7:43 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=62&FxId=123&Sessi. CHAPTER 7.3 - GUILLAIN-BARRE SYNDROME INTRODUCTION Guillain-Barre syndrome (infectious polyneuritis) is an acute inflammation of the spinal and cranial nerves manifested by motor dysfunction that predominates over sensory dysfunction. The actual cause is unknown, but it is associated with a previously existing viral infection or vaccine administration. Neurologic symptoms include muscle cramps and paresthesia with weakness progressing to paralysis. The severity of the disease ranges from mild to severe with the course of the disease dependent on the degree of paralysis present at the peak of the condition. Recovery is usually complete and may take weeks or months. The disease most commonly occurs in children between 4 and 10 years of age. Treatment is symptom-dependent with hospitalization required in the acute phase of the disease to observe and intervene for respiratory or swallowing complications. MEDICAL CARE Anti-inflammatory (Corticosteroids): to reduce inflammation process and immune responses; Ibuprofen may or may not be helpful in early stages of disease. Analgesics/Antipyretics: acetaminophen to relieve pain in muscles or elevated temperature if present. Stool Softeners: given for easier elimination to prevent constipation and

Valsalva's maneuver. Oxygen Therapy: given with ventilatory support depending on ABGs revealing decreased PO2 level. Arterial Blood Gases: reveals O2 and CO2 and pH levels as indication of acidosis or respiratory failure or need for oxygen therapy. Cerebrospinal Fluid Analysis: reveals protein concentration of more than 60 mg/dl and white blood cells of fewer than 10/cu mm. Plasmapheresis: may be used to shorten length of illness and/or to lessen long-term disability. COMMON NURSING DIAGNOSES See DECREASED CARDIAC OUTPUT Related to: Effects of autonomic dysfunction on cardiac activity. Defining Characteristics: (Specify: variations in hemodynamic readings [tachycardia, bradycardia, hypotension, hypertension] decreased peripheral pulses, oliguria, cyanosis, pallor of skin and mucous membranes, ECG changes [arrhythmias], diaphoresis, dizziness, orthostatic hypotension.) See INEFFECTIVE BREATHING PATTERN Related to: Neuromuscular impairment. 1 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=62&FxId=123&Sessi. Defining Characteristics: (Specify: altered chest expansion, respiratory depth changes, cyanosis, abnormal ABGs.) See INEFFECTIVE AIRWAY CLEARANCE Related to: Tracheobronchial obstruction. Defining Characteristics: (Specify: abnormal breath sounds [crackles, wheezes], changes in rate or depth of respiration, paralysis in chest muscles, tachypnea, cough, dyspnea, inability to clear secretions from airway, inability to swallow secretions, weakness in speech, gag reflex, aspiration.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food, absorb nutrients. Defining Characteristics: (Specify: anorexia, diarrhea, weakness of chewing and swallowing muscles, dysesthesia of hands with inability to feed self, weight loss, loss of muscle tone, paralysis [ascending].) See DIARRHEA Related to: Neuromuscular impairment. Defining Characteristics: (Specify: increased frequency, loose, liquid stools, increased bowel sounds.) See IMPAIRED PHYSICAL MOBILITY Related to: Neuromuscular impairment. Defining Characteristics: (Specify: paralysis, inability to purposefully move within physical environment including bed mobility, transfer and ambulation, limited ROM, decreased muscle strength and control, trauma from falls.) See HYPERTHERMIA Related to: Illness causing autonomic instability. Defining Characteristics: (Specify: increase in body temperature above normal range or decrease below normal range, warm or cool to touch.) ADDITIONAL NURSING DIAGNOSES IMPAIRED URINARY ELIMINATION Related to: Neuromuscular impairment. Defining Characteristics: (Specify: paralysis, retention.) 2 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=62&FxId=123&Sessi. Goal: Child will have improved urinary elimination by (date and time to evaluate). Outcome Criteria √ Bladder is not palpable. √ Intake equals output. NOC: Urinary Elimination INTERVENTIONS RATIONALES Assess continuing extent of Provides information about effect paralysis and effect on urinary of motor weakness that travels elimination. upward from extremities. Assess for I&O q 4 to 8h and Provides monitoring for I&O ratio palpate bladder q 2h; assess for and presence of urinary cloudy, foul-smelling urine. retention, UTI as paralysis progresses. Provide urinary elimination Promotes urine elimination and rehabilitation program; perform return to normal pattern as soon Crede's maneuver in gentle as possible. fashion if indicated. Catheterize as last resort; Relieves distention and retention. maintain indwelling catheter if needed to maintain elimination. Instruct parents in program to Promotes urinary elimination and rehabilitate urinary function return to baseline pattern (specify). without retention and possible urinary bladder infection. Teach parents to maintain fluid Maintains I&O balance and enough intake and monitor output in intake to encourage urinary relation to intake. output. Inform to report any reduction or Prevents complication of absence of urinary elimination. neuromuscular impairment of disease and effect on urinary bladder function. NIC: Urinary Elimination Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Is bladder palpable above symphysis after voiding? What is intake and output? Provide cc's and amount of time.) (Revisions to care plan? D/C care plan? Continue care plan?) 3 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=62&FxId=123&Sessi. PAIN Related to: Biologic injuring agent (inflammation of nerves). Defining Characteristics: (Specify: communication of pain descriptors of discomfort in hands and feet, guarding behavior, alteration in muscle tone, autonomic responses of diaphoresis, VS changes.) Goal: Child will experience decreased pain by (date and time to evaluate). Outcome Criteria √ Child rates pain as less than (specify pain rating and scale used). NOC: Pain Level INTERVENTIONS RATIONALES Assess pain and ability to Provides information about participate in activities. degree of pain or presence of progressive paralysis. Reposition q 2h, support extremities Promotes comfort and reduces and maintain clean, comfortable bed risks for skin impairment. with eggcrate mattress and padding to bony prominences as needed; use good postural alignment, provide passive ROM. Administer analgesics (specify) based Eliminates or controls pain and on pain assessment and respiratory promotes comfort (action of status; evaluate effect. drug). Apply moist heat to painful areas as Promotes circulation to area ordered. and relieves pain. Reassure parents and child that pain Provides information about decreases as motor changes become length of time pain might be resolved or improve. expected to continue. Determine the child's understanding Promotes better communication of the word "pain" and ask family between the child/family and members what word the child uses at nurse. home; use pain assessment tool appropriate for the child's age and develop-mental level to identify the intensity of pain. Plan a preventive approach to pain Promotes early identification around the clock; observe for signs of pain which enhances of pain, physiologic and effective pain relief. behavioral. NIC: Pain Management Evaluation 4 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=62&FxId=123&Sessi. (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is pain rating? Specify scale used) (Revisions to care plan? D/C care plan? Continue care plan?) ANXIETY Related to: Change in health status and threat to self-concept. Defining Characteristics: (Specify: increased apprehension as condition worsens and paralysis spreads, expressed concern and worry about permanent effects of disease, treatments during hospitalization, expressed feeling of increased helplessness and uncertainty.) Goal: Clients will experience decreased anxiety by (date and time to evaluate). Outcome Criteria √ Parents and child verbalize decreased feelings of anxiety. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess source and level of anxiety, Provides information about degree how anxiety is manifested and need of anxiety and need for for information that will relieve interventions, sources may it. include fear and uncertainty about treatment and recovery, guilt about presence of illness, possible loss of parental role and responsibility while hospitalized. Encourage expression of concerns and Provides opportunity to vent opportunity to ask questions about feelings, secure information condition and recovery of ill needed to reduce anxiety. child. Communicate therapeutically with Promotes supportive environment. parents and child and answer questions calmly and honestly. Assist parents and child to note Promotes positive attitude and improvements resulting from optimistic outlook for recovery. treatments. Encourage parents to stay with child Allows for care and support of and assist in care of child. child instead of increasing anxiety that is caused by absence and lack of knowledge about child's condition. 5 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=62&FxId=123&Sessi. Encourage child to participate in Promotes independence and control own care depending on ability and/ and preserves developmental or paralysis; allow to make status. choices about ADL as soon as possible. Teach parents and child about Provides information to relieve disease process and behaviors, anxiety by knowledge of what to physical effects. expect. Discuss each procedure or type of Reduces fear of unknown which may therapy, effects of any diagnostic increase anxiety. tests to parents and child as appropriate to age. Teach parents and child that degree Provides information about usual of severity varies but motor course of disease and length of weakness and paralysis start with illness. extremities and move upward with the peak reached in 3 weeks and improvement seen by 4 to 8 weeks. Clarify any information and answer Prevents unnecessary anxiety questions in lay terms and use resulting from inaccurate aids for visual reinforcement if knowledge or beliefs or helpful. inconsistencies in information. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents and child verbalize decreased feelings of anxiety? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR IMPAIRED PARENTING Related to: Illness. Defining Characteristics: (Specify: verbalization of decreased interactions with hospitalized child and inability to provide care, lack of control over situation, request for information about parenting skills for long recovery period or permanent residual disability.) Goal: Child will receive appropriate parenting by (date and time to evaluate). Outcome Criteria √ Parents participate in child's care. 6 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=62&FxId=123&Sessi. √ Parents identify agencies that offer assistance and support. NOC: Parenting INTERVENTIONS RATIONALES Assess for presence of permanent Identifies factors associated with disability or possibility of long recovery period. long-term recovery and effect on parents. Encourage parents to express Identifies potential for social feelings and unmet needs and deprivation of parents and ability to meet and develop self- development of strategies to expectations. achieve realistic expectations. Encourage touching and play Enhances comfort and positive activities between parents and parental behaviors. child. Encourage and praise positive Reduces anxiety for and enhances parental behaviors; support any learning about child's needs and participation in care or care. decision-making on behalf of the child. Teach parenting skills needed for Promotes parental knowledge and long-term recovery period awareness of skills to be (specify). learned and implemented. Teach about physical therapy Facilitates muscle recovery and program including ROM, exercises, prevents contractures and gait training, bracing (refer as permanent disability, promotes indicated). sense of confidence and control. Continue to inform and support Provides reassurance that recovery parents during recovery period is slow and conserves parental (provide telephone numbers). emotional reserves. Refer to Guillain-Barre Syndrome Provides information and support Support Group for assistance or from those with experience with community agencies for support. the disease. NIC: Support System Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents participate in child's care? Describe. Which agencies did parents identify?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR GUILLAIN-BARRE SYNDROME 7 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=62&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: 8 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=62&FxId=123&Sessi. KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:13:58 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=62 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 7 - NEUROLOGIC SYSTEM CHAPTER 7.3 - GUILLAIN-BARRE SYNDROME Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 9 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=63&FxId=123&Sessi. CHAPTER 7.4 - MENINGITIS INTRODUCTION Meningitis is the inflammation of the meninges and is the most common infection of the central nervous system (CNS). It may be bacterial or viral in origin. Bacterial infections may be caused by Haemophilus influenzae (type B), Streptococcus pneumoniae, Neisseria meningitidis, or Staphlococcus aureus. Those at greatest risk for this disease are infants between 6 and 12 months of age with most cases occurring between 1 month and 5 years of age. The most common route of infection is vascular dissemination from an infection in the nasopharynx or sinuses, or one implanted as a result of wounds, skull fracture, lumbar puncture, or surgical procedure. Viral (aseptic) meningitis is caused by a variety of viral agents and usually associated with measles, mumps, herpes, or enteritis. This form of meningitis is self-limiting and treated symptomatically for 3 to 10 days. Treatment includes hospitalization to differentiate between the two types of meningitis, isolation and management of symptoms, and prevention of complications. MEDICAL CARE Antipyretics: given to reduce fever. Antibiotics: given to treat the infection, or specific to identified microorganisms as a result of culture and sensitivity tests. Anticonvulsants: to prevent seizure activity. Computerized Tomography Scan: reveals subdural effusion. Cultures of Blood, Urine, Cerebrospinal Fluid, Nasopharynx: reveal

causative organism. Lumbar Puncture: reveals cloudy or purulent appearance, increased WBC predominant polymorphonuclear leukocytes, increased protein, decreased glucose in bacterial type; clear, normal or slight elevation of WBC with predominant lymphocytes, slight increased glucose, slight protein, normal lactate dehydrogenase in viral type. Electrolyte Panel: reveals decreased K+ and increased Na+, changes indicating dehydration. Serum Osmolality: reveals increase if antidiuretic hormone secretion increased. Complete Blood Count: reveals increased WBC. Urinalysis: increased osmolarity if antidiuretic hormone secretion increased, increased sp. gr. COMMON NURSING DIAGNOSES See HYPERTHERMIA Related to: Illness. Defining Characteristics: (Specify: increase in body temperature above normal range, warm to touch, increased respiratory and pulse rate.) 1 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=63&FxId=123&Sessi. See RISK FOR DEFICIENT FLUID VOLUME Related to: Excessive losses. Defining Characteristics: (Specify: vomiting, diarrhea.) Related to: Deviations affecting intake of fluids. Defining Characteristics: (Specify: decreased intake, fluid restrictions, change in level of consciousness.) Related to: Failure of regulatory mechanisms. Defining Characteristics: (Specify: secretion of antidiuretic hormone, increased sp. gr. and osmolality, reduced output, dehydration.) See DISTURBED THOUGHT PROCESSES Related to: Physiologic changes. Defining Characteristics: (Specify: disorientation to time, place, persons, events, changes in consciousness, behavior changes also important to monitor fluids and ventilation.) ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: (Specify: threat to or change in health status of child; threat to or change in environment [hospitalization of child].) Defining Characteristics: (Specify: increased apprehension that condition of child might worsen, expressed concern and worry about actual hospitalization of child and seriousness of illness.) Goal: Parents will experience decreased anxiety by (date and time to evaluate) Outcome Criteria √ Parents verbalize decreased anxiety. NOC: Anxiety Reduction INTERVENTIONS RATIONALES Assess sources and level of anxiety, Provides information about the need how anxiety is manifested, and need for interventions to relieve for information and support. anxiety and concern; sources may include fear and uncertainty about treatment and recovery, guilt for 2 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=63&FxId=123&Sessi. presence of illness, possible loss of parental role, and loss of responsibility when hospitalization necessary. Encourage to express concerns and ask Provides opportunity to vent questions regarding condition of feelings, secure information ill child. needed to reduce anxiety. Encourage to be involved in care and Promotes constant monitoring of decision-making regarding child's child's condition for improvements needs. symptoms. or worsening of Encourage parent to stay with child Allows parent to care for and or visit when able and call when support child instead of concerned if hospitalized; assist increasing anxiety if not with in care (hold, feed, bathe, clothe child. and diaper), and provide information about child's daily routines. Assess parental feelings of guilt Prevents or minimizes feelings of from not suspecting the seriousness blame or guilt. of the illness sooner; encourage them to openly discuss feelings. Teach about disease process and Relieves anxiety of parents. behaviors, physical effects and symptoms of disease (specify). Explain reason for procedures or type Reduces fear of unknown which of therapy, effects of any increases anxiety. diagnostic tests (specify). Teach parents about isolation Provides opportunity to validate precautions for at least 24 hours type of meningitis and to take or until diagnosis is made and measures to prevent transmission antibiotic therapy begins to take to others in contact with child. effect. Clarify any misinformation and answer Prevents unnecessary anxiety questions in lay terms when parents resulting from inaccurate able to listen, give same knowledge or beliefs or explanation as other staff and/or inconsistencies in information. physician gave regarding disease process and transmission. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents verbalize decreased anxiety? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) 3 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=63&FxId=123&Sessi. RISK FOR INJURY Related to: Internal factor of altered neurologic regulatory function. Defining Characteristics: (Specify: increased intracranial pressure; early signs of lethargy, restlessness, increased head circumference, headache, vomiting, personality changes or late signs of decreased level of consciousness, change in posturing, widening of pulse pressure, projectile vomiting, decreased pulse and respirations, seizure, abnormal PERL, shrill cry, bulging fontanel, changes in vision.) Goal: Child will not experience injury by (date and time to evaluate). Outcome Criteria √ (Specify for child, e.g., no decrease in LOC; no vomiting or seizures.) NOC: Risk Detection INTERVENTIONS RATIONALES Assess neurologic status to include VS Provides information that offers pattern, changes in consciousness, clues to possible change in behavior patterns and pupillary/ intracranial pressure caused by ocular responses appropriate for age inflammation of the brain and (measure head circumference in associated edema. infant) (specify when). Attach cardiac and respiratory monitor Increased intracranial pressure will to assess for bradycardia and decrease pulse and respirations, hypoxia. widen the pulse pressure with pulse becoming irregular and respirations rapid and shallow as ICP progresses and the body attempts to decrease blood flow to brain. Reposition q 2h, positioning child to Maintains airway patency and optimize comfort with HOB slightly prevents obstruction by secretion elevated, no pillow in bed, side- which increases CO2 retention and lying position if nuchal rigidity ICP. present; avoid sudden movements such as lifting the head; have oxygen and suctioning equipment on hand to be administered when needed. Provide quiet environment free from Promotes comfort and rest and bright lighting, minimize gentle reduces irritability. handling and care of infant/child, allow for rest periods between care or procedures, restrict visiting if irritable. Administer antibiotics as prescribed Manages existing infection and (specify) as soon as ordered based prevents further spread of on analysis of CSF, throat cultures. infection (action of drug). Note any seizure activity including Prevents injury during seizure which 4 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=63&FxId=123&Sessi. onset, frequency, duration and type is a complication of meningitis. of movements before, during, or after seizure; pad bed and remove objects/toys from bed and administer any ordered anticonvulsants. Administer stool softeners, avoid use Prevents Valsalva's maneuver that of restraints and prevent or reduce will increase ICP. crying episodes. Position with head elevated up to 30 Decreases intracranial pressure by degrees and maintain head alignment allowing blood flow from brain by with sandbag. gravity or any obstruction of jugular drainage. Stay with infant/child and sit near Provides limited stimulation to and speak in a low voice. infant/child during acute stage of disease. Inform parents of changes in Promotes knowledge about possible condition, reasons for physical and manifestations of the disease and mental changes and effects of the causes. disease. Explain causes of increased ICP and Allows for understanding of importance of preventing any further increased ICP and life-threatening increases in ICP. nature of such a complication. Inform of reason for seizure activity Provides knowledge of seizure and other signs and symptoms of the complications and actions and disease and treatment necessitated responsibility in prevention and/ by them. or treatment of this activity. Inform parents of risk for Allows for ongoing care and complications and need for responsibility in preventing monitoring for increased ICP; review change in neurologic status. signs and symptoms of increased ICP. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide data about outcome criteria chosen. What is LOC? Did child vomit? Are there signs of increased ICP? Describe.) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE Related to: Lack of exposure to information. Defining Characteristics: (Specify: request for information about medications, signs and symptoms and behaviors to report, general care during convalescence of infant/child.) 5 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=63&FxId=123&Sessi. Goal: Parents will obtain information about meningitis by (date and time to evaluate). Outcome Criteria √ Parents verbalize understanding of cause and treatment plan. NOC: Knowledge: Treatment Regimen INTERVENTIONS RATIONALES Assess knowledge of disease and method Promotes plan of instruction that is to control and resolve disease; realistic to ensure compliance of willingness and interest of parents medical regimen; prevents to implement care. repetition of information. Provide information and explanations Ensures understanding based on in clear language that is readiness and ability to learn; understandable; use pictures, visual aids reinforce learning. pamphlets, video tapes, model in teaching about disease. Teach about administration of Provides information for compliance medications including (specify: in medication therapy to prevent or action of drugs, dosages times treat infection and seizure frequency, side effects, expected activity resulting from the results, methods to give disease; bacterial meningitis is medications); provide written treated with antibiotics, and viral instructions and schedule to follow meningitis may be treated with and inform to administer full course antibiotics until diagnosis is of antibiotic to child. established. Assist to plan feedings and/or develop Promotes optimal nutrition in a menus to include nourishing fluids, progressive manner as tolerable. caloric and basic four groups for age group. Reinforce to parents follow up to Promotes identification of hearing assess for potential hearing loss (injury to 8th cranial nerve impairment. caused by meningitis). Inform parents as to the benefits of May prevent the disease; data routine immunizations with H. suggests the incidence of this form influenzae (type B) vaccine, of meningitis has decreased since beginning at 2 months of age for a the vaccine was introduced; may total of 3 doses. decrease the spread of infection to unvaccinated infants. Teach to promote adequate rest and Rest important for convalescence and activities that provide age stimulating activities needed for appropriate play and stimulation continued development or to promote (specify). stimulation if developmental lag is present. Teach to isolate other children in Prevents transmission of bacteria to family for 24 hours if respiratory others in family. infection present or until culture is negative. Teach to report elevated temperature, Reveals signs and symptoms of 6 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=63&FxId=123&Sessi. poor feeding or anorexia, presence of or spread of infection. irritability or other changes in behavior or level of consciousness, decrease in hearing acuity. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did clients verbalize about the cause of meningitis and the treatment plan? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR MENINGITIS 7 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=63&FxId=123&Sessi. 8 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=63&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:14:16 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=63 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 7 - NEUROLOGIC SYSTEM CHAPTER 7.4 - MENINGITIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 9 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=64&FxId=123&Sessi. CHAPTER 7.5 - SENSORY DEFICITS INTRODUCTION Sensory deficits can lead to auditory or visual deprivation and affect the child's ability to interact with the environment. Cognitive, perceptive, communicative, and social skills may all be affected. Vision disorders are common in children with the most prevalent problems of a refractive type (myopia or hyperopia) and others that include amblyopia, strabismus, cataracts, and glaucoma. Eye injury may occur as a result of trauma from blunt or sharp objects, or from infection resulting in conjunctivitis, keratitis, or even blindness or loss of the eye. Auditory disorders are classified as conductive, sensorineural or mixed conductive-sensorineural hearing loss. Causes include damage to the inner ear structures or the auditory nerve from congenital defects, infection, ototoxic drugs, long-term excessive exposure to noises (sensorineural) or middle ear infection such as otitis media (conductive). Hearing and vision screenings vary with the age of the infant/child and are performed

as part of physical assessment of all children. Treatment focuses on the correction and rehabilitation of any actual or potential impairment. MEDICAL CARE Anti-inflammatories: to eye to reduce inflammation if present. Antibiotics: to treat infection. Vision Tests: Lighthouse Vision test or Blackbird Preschool Vision Test for children 3 to 4 years of age; Snellen E vision chart for children 5 to 6 years of age; Snellen vision chart for children 7 years and older who are familiar with the alphabet; Corneal Light Reflex test and Cover/Uncover test to reveal malalignment; visual tracking to identify muscle movement abnormalities; test for peripheral vision and amblyopia reveal objection to cover over eye or inability to see at a 90-degree angle from straight line of vision. Hearing Tests: audiometry reveals degree of hearing loss and possible locale of defect in child 2 to 5 years of age based on behavior modification and over 5 years if child is able to cooperate; reaction to noise in infant; conductive tests (Rinne and Weber) in children of school-age reveals auditory acuity; tympanometry reveals middle ear air pressure and abnormalities but not reliable in young children; brain stem-evoked audiometry reveals hearing acuity in the infant or child by computer analysis of electrical or brain wave potentials that are initiated by the hearing process. COMMON NURSING DIAGNOSES See DELAYED GROWTH AND DEVELOPMENT Related to: Effects of physical disability. Defining Characteristics: (Specify: delay or difficulty in performing skills [motor, social, expressive] typical of age group, behavior and/or intellectual deficits, poor academic performance, reduced independence in performance of ADL.) 1 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=64&FxId=123&Sessi. ADDITIONAL NURSING DIAGNOSES DISTURBED SENSORY PERCEPTION: AUDITORY Related to: (Specify: altered sensory reception, transmission and/or integration of neurologic disease or deficit, altered state of sense organ, inability to hear [partial or complete deafness].) Defining Characteristics: (Specify: change in behavior pattern, anxiety, change in usual response to stimuli, altered communication pattern, auditory distortions, reduced auditory acuity, inappropriate responses.) Goal: Client will experience improved hearing by (date and time to evaluate). Outcome Criteria √ (Specify outcome criteria appropriate for individual child.) NOC: Risk Control: Hearing Impairment INTERVENTIONS RATIONALES Assess history of chronic otitis Provides information about media, brain infection, use of possible risks for conductive ototoxic drugs, rubella or other or sensorineural hearing loss. intrauterine infections (viral), congenital defects of ear or nose, presence of deafness in family members, hypoxemia and increased bilirubin levels in low-birth weight infants. Assess for auditory acuity: Infant: Provides information of infant/ failure to waken to sounds; no child ability to hear using response to loud noise; no response techniques that are age to sound made out of visual field; dependent. lack of startle and blink reflexes; failure to turn head to localize sound by 6 months; absence of babble by 7 months; lack of response to spoken words/failure to follow simple commands (older infant). Child: failure to respond to name or to locate sound; failure to respond to being read to or to sound of music; failure to respond to verbal speech; requesting repeat of message; gesturing instead of speech; shy, timid, inattentive; poor performance in school; failure to develop understandable language by 24 months; vocal play, head banging for increased vibratory 2 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=64&FxId=123&Sessi. sensation; stubborn attitude related to decreased comprehension; appear to be "in their own world." Perform audiometry or other tests Evaluates degree of hearing depending on age and preparation of acuity and/or loss and type of technician. hearing loss. Face infant/child when speaking, Provides opportunity to develop speak distinctly and slowly without lip reading. shouting to gain child's attention. Assist with use of hearing aid. Promotes maximum benefit from aid hearing. Encourage use of sign language, lip Promotes communication with reading, cued speech, speech others. therapy and as much verbal communication as possible. Provide for play and social Promotes independence for age interactions, self-care in all group and security in activities for age group, continued interacting with peers. attendance at school. Anticipate grief reaction after the Grief reaction is normal part of diagnosis; facilitate expression of early adjustment phase; feelings and concerns. promotes adjustment to diagnosis. Help child focus on sounds in the Maximizes child's hearing environment. potential. Recommend closed-captioned TV. Provides enjoyment for the child; facilitates feelings of normalcy. Encourage child to read books and Promotes effective communication practice responding to cues with and corrects or prevents language development or use of aids impairments. or methods. Encourage child to take Promotes independence and self responsibility for the care and use esteem. of the aid as soon as possible. Teach parents and child about type of Prevents anxiety caused by test tests to be performed and procedure and possible results if not to be followed by child. done as part of normal child assessment and screening. Alert parents to behavioral cues Promotes identification of indicating hearing impairment. hearing loss for correction before development is affected. Teach parents about hearing aid Assists with hearing aid resources, types available and selection if loss is instruct in cleaning and care of conductive type. aid and the proper adjustment for optimal benefit. Instruct child in methods to conceal Prevents negative effect of hearing aid (specify). self-concept and image. Refer parents and child of resources Promotes a method of to learn lip reading or signing or communication with others and 3 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=64&FxId=123&Sessi. speaking (specify). especially those with hearing impairment. Encourage parents and family to Promotes developmental process provide stimulation through and language use. language. Refer to appropriate community Provides support to parents. resources and support groups, as needed (specify). Encourage parents to promote Promotes feelings of normalcy socialization with peers. and self-esteem. Assist parents to arrange for vision Poor sight may decrease the testing. ability to learn lip reading or sign language. Discuss with the family to maintain Promotes normal growth and normalcy, including discipline and development. limit setting. Assist parents and child to adjust Encourages social interactions, environment and select toys that development of friendships, promote social interactions and and sense of belonging. increase hearing potential. Encourage parents to notify school Provides information that nurse and teacher of degree of encourages a positive school hearing loss and methods of experience and opportunity for communications used by child. learning in a regular classroom and socialization with classmates. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide data about the outcome criteria selected.) (Revisions to care plan? D/C care plan? Continue care plan?) DISTURBED SENSORY PERCEPTION: VISUAL Related to: (Specify: altered sensory reception, transmission and/or integration of neurologic disease or deficit, altered state of sense organ, inability to see [partial or complete loss of sight].) Defining Characteristics: (Specify: change in behavior pattern, anxiety, change in usual responses to stimuli, visual distortions, reduced visual acuity, myopia, hyperopia, lazy eye, cross-eye, cataracts, glaucoma, trauma to eye, frequent injury by walking into objects.) Goal: Client will experience improved vision by (date and time to evaluate). 4 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=64&FxId=123&Sessi. Outcome Criteria √ (Specify outcome criteria appropriate for individual child.) NOC: Risk Control: Visual Impairment INTERVENTIONS RATIONALES Assess history of rubella or syphilis Provides information about risks of mother before birth of child, for or presence of sight presence of genetic disorders in the impairment or blindness. family, excessive oxygen given to infant, congenital conditions that cause blindness, impairment caused by strabismus, cataract or glaucoma. Assess for risk of trauma to an eye Eye trauma caused by accidents is from toys, missiles or projectiles most common cause of blindness into eye during games or play, in children and information excessive sunlight to eyes. provides safety education plan to prevent eye injury. Assess for visual acuity: Infant: Provides information of infant/ failure to follow light or object child ability to see using with eye movement and cessation of techniques that are age body movement; failure to fixate on dependent. mother's face; delay in posture and in developmental tasks; absence of binocularity; failure to move eyes together.Child: failure to respond to visual stimuli; squinting, blinking, rubbing of eyes; eye crossing after 6 months of age; headache after using eyes; failure to initiate eye contact, nystagmus, head tilt, holding reading material close to face, bumps into objects when walking or crawling; poor performance in school. Perform visual tests for acuity Evaluates degree of acuity and/or peripheral vision and muscle balance loss and possible causes with depending on age and intellectual consideration for improving development level; include tests for visual acuity with age. strabismus, amblyopia. Face infant/child when speaking, Promotes comfort and security explain sounds and what is happening with environment. in the environment. State name when approaching and Reduces anxiety and sudden explain any procedure before contact that is unexpected. starting, use touch if acceptable. Assist with use and care of glasses or Promotes independence in use of patching one eye and encourage aids for refractive disorders wearing of these as prescribed. and strabismus. Provide for age related toys and Promotes stimulation and 5 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=64&FxId=123&Sessi. social interactions within secure development. environment. Provide well lit environment and Promotes safety and security in familiar placement of objects to the environment and prevents orient child to environment. possible trauma from bumping into furniture or falling. Emphasize the abilities and praise Promotes self-esteem of child. attempts and/or accomplishments. Talk softly to infant before contact; Promotes association of human learn to read total body cues, not voice with anticipated changes; just eyes and visual cues; use prepares infant for changes. gentleness of touch when interacting with infant. Tell the child exactly what you will Promotes understanding and be doing before you do anything; feelings of security and trust. reinforce this as you perform the procedure; warn of discomfort. Allow the child to touch instruments Promotes increased understanding and equipment whenever possible. through speech. Use the child's name specifically when Promotes communication since you want a response from him/her. visually impaired children lack the input of visual cues. Teach parents and child about tests to Prevents anxiety and promotes be performed, what is being tested cooperation. and procedure to be followed by child. Discuss with parents the child's Provides a realistic appraisal of abilities and impairment and what visual ability of the child. might be expected of child; behaviors that might indicate a decrease in visual acuity. Assist parents to explore the Provides assistance to gain possibility of rehabilitation to independence for the child. accomplish ADL skills, use of Braille, mobility aids, trained dogs. Encourage parents to treat child as Promotes integration into the others in family, setting limits, family and creates a sense of encouraging play and relationships belonging. with family members. Instruct in eye care, administration Promotes health of eye and of eye medications (specify). compliance with medical regimen. Encourage parents to notify school of Encourages learning with optimal sight deficit and to place in a consideration for impairment. front row, use large printed materials, proper lighting. Teach parents to plan for regular Monitors visual acuity for vision screening. improvements or need for change in treatment; screening is often done in schools. Initiate referral to an Permits thorough examination of 6 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=64&FxId=123&Sessi. ophthalmologist for evaluation if eyes to identify and treat any acuity is not normal for age or if disorder. indication of a disorder is present. Refer to national and community Provides information and support agencies and associations that for families of child with supply educational materials, impaired vision. services for blind or partially sighted children. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide data about the outcome criteria selected.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR SENSORY DEFICITS 7 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=64&FxId=123&Sessi. 8 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=64&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning.

All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:14:36 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=64 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 7 - NEUROLOGIC SYSTEM CHAPTER 7.5 - SENSORY DEFICITS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 9 of 9 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=65&FxId=123&Sessi. CHAPTER 7.6 - REYE'S SYNDROME INTRODUCTION Reye's syndrome is an acute encephalopathy, often including fatty infiltration of organs such as the liver, heart, lungs, pancreas, and skeletal muscle. It has been associated with a viral condition such as influenza or varicella and the use of aspirin as an analgesic/antipyretic, but the exact cause is not known. Serious complications of the disorder can include increased intracranial pressure from cerebral edema, high levels of ammonia from organ involvement, and mental dysfunction from progressive coma. Recovery is complete in most depending on severity of the condition but some neurologic and mental residual disability may occur. The most common group affected by this condition are those between 6 to 11 years of age although all ages are susceptible. Hospitalization with close observation is required with therapy to monitor and treat all vital functions affected by the condition and state of consciousness. MEDICAL CARE Sedatives/Anticonvulsants: promote CNS depression for sedation or to prevent or treat seizures. Muscle Relaxants: induce sedation and relax muscles if mechanical assistive ventilation used. Diuretics (Osmotic): mannitol (Osmitrol) to induce diuresis by increasing osmotic pressure of glomerular filtrate to prevent reabsorption of water. Antibiotics: treat infection if present or specific antibiotic dependent on culture and sensitivities. Anti-inflammatories: (corticosteroids) reduce inflammatory process, capillary dilation, and permeability. Antacids: via nasogastric tube to maintain pH of over 4.0 to prevent gastrointestinal bleeding. Liver Biopsy: reveals histologic results of impaired liver or pathology. Enzymes: reveal increased glutamic oxaloacetic transaminase (SGOT), glutamic pyruvic transaminase (SGPT), lactic dehydrogenase (LDH), creatine phosphokinase (CPK), amylase, and lipase. Ammonia: reveals increases of twice the normal level (hyperammonimia). Glucose: reveals decreases with this disease (hypoglycemia) that may lead to brain damage. Prothrombin/Partial Thromboplastin Times (PT, APPT): reveals prolonged times. Cholesterol: reveals decreased level. Uric acid: reveals increased level. Arterial Blood Gases (ABGs): reveal levels that may indicate possible increases in cerebral edema or respiratory distress. COMMON NURSING DIAGNOSES 1 of 8 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=65&FxId=123&Sessi. See DECREASED CARDIAC OUTPUT Related to: Mechanical or electrical effect on the heart. Defining Characteristics: (Specify: variations in hemodynamic readings, ECG changes, arrhythmias, decreased peripheral pulses, oliguria, diuretic therapy, changes in perfusion of vital organs.) See IMPAIRED GAS EXCHANGE Related to: Assistive ventilatory use and oxygen supply. Defining Characteristics: (Specify: hypercapnia, hypoxia, confusion, restlessness, irritability, inability to move secretions, cyanosis, retractions, changes in ABGs.) See DISTURBED THOUGHT PROCESSES Related to: Physiologic changes, encephalopathy. Defining Characteristics: (Specify: cognitive dissonance, disorientation, changes in consciousness, hallucination, altered sleep patterns, coma, altered attention span and memory, lethargy, drowsiness.) See HYPERTHERMIA Related to: Illness. Defining Characteristics: (Specify: increase in body temperature above normal range, increased respiratory and pulse rate, warm to touch.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Medications. Defining Characteristics: (Specify: diuretic therapy, altered intake, NPO status, increased urinary output, loss via nasogastric tube suctioning.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Physical immobilization, hypothermia blanket, invasive procedures. Defining Characteristics: (Specify: disruption of skin surfaces, redness, edema, discharge, warmth at insertion sites for IV, monitoring devices, redness or excoration at pressure points.) ADDITIONAL NURSING DIAGNOSES 2 of 8 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=65&FxId=123&Sessi. ANXIETY Related to: Threat of death; change in health status; change in environment (hospitalization). Defining Characteristics: (Specify: apprehension and uncertainty about child's condition, feelings of inadequacy and increased helplessness about child cared for in intensive care unit, fear associated with severe acuity of condition, possible sequelae as a result of the disorder.) Goal: Parents will experience decreased anxiety by (date and time to evaluate). Outcome Criteria √ Parents verbalize decreased anxiety. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess level of anxiety, need for Provides information about information and support about severity of stress and anxiety, severity and life threatening guilt about responsibility of nature of the illness. delay in diagnosis and loss of parental role, fears and feelings about possible complications. Allow expression of concerns and Provides opportunity to vent opportunity to ask questions about feelings, secure information condition and recovery of child. needed to reduce anxiety. Encourage parents to remain with Promotes parent involvement and child and participate in care if interaction with the child. appropriate; if parents unable to stay, allow open visitation and frequent telephoning. Encourage parents to bring a Promotes contact with familiar favorite toy, book or other items. objects outside the hospital environment. Provide for space to rest, bathe and Promotes emotional support to relax if staying with child; parents to reduce anxiety. provide quiet room if desired. Refer to clergy or social services Provides support and assistance as appropriate. in dealing with severely ill child. Explain reason for and what to Reduces fear and promotes expect for each procedure or type understanding. of therapy (lumbar puncture, IV lines, urinary catheter, NG tube, respirator). Provide honest information in Prevents unnecessary anxiety understandable language and resulting from inaccurate reinforce physician. information or beliefs. Teach parents about state of Reduces fear and anxiety. consciousness of child, stage of 3 of 8 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=65&FxId=123&Sessi. disease and signs and symptoms to expect. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did parents verbalize decreased anxiety? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: Illness. Defining Characteristics: (Specify: altered clotting factors, changes in orientation and consciousness, increased ICP, altered sleep pattern, cognitive dissonance, inability to close or blink eyes, hypoglycemic seizure activity, coma.) Goal: Child will not experience injury by (date and time to evaluate). Outcome Criteria √ (Specify appropriate outcome criteria based on individual child's condition.) NOC: Risk Detection INTERVENTIONS RATIONALES Assess for stage by noting signs and Indicate stage as a basis for symptoms associated with the expected behaviors and need for condition which range from vomiting, specific care and preventive lethargy, and liver dysfunction to measures. disorientation, deepening coma, loss of reflexes, and seizures. Assess vomiting, papilledema, ataxia, Indicates increasing ICP caused by irritability, lethargy, apathy, cerebral edema and advancing confusion, change in level of stage of disease. consciousness, increased pulse, and decreased BP q 1h; if ICP monitor in place, note elevation above 20 mm Hg or any gradual increases for physician. Elevate head of bed 30 degrees and Promotes cerebral circulation and maintain head and neck alignment. reduces venous pressure; prevents neck flexion. 4 of 8 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=65&FxId=123&Sessi. Administer osmotic diuretic, diretic, Administered to promote fluid sedative, anticonvulsants, output to reduce edema, prevent neuromuscular blocking agent IV seizure activity, and induce separately or in combination as sedation to reduce agitation and ordered (specify). activity that increase ICP. Provide clustering of care and Promotes rest. procedures. Carry out seizure precautions of Prevents injury during seizure and padding bed, removing objects from treats apnea if it occurs. bed, maintain suction and oxygen at bedside. Monitor laboratory tests of increased Provides information about prothrombin or partial thrombin coagulation defects from liver time, fibrin split products, dysfunction, hypoglycemia decreased platelets and serum metabolic dysfunction, and loss glucose, decreased electrolyte of electrolytes from diuretic levels (K+). therapy. Monitor for occult blood in stool, Provides information about possible gastric aspirate, skin for bleeding from impaired liver petechiae, hematoma, oozing or frank function. bleeding from any orifice or mucous membranes. Administer antacid, vitamin K and/or Replaces blood loss and increases blood as ordered. blood clotting capabilities; antacids are given to discourage gastrointestinal irritation and bleeding. Instill eye drops (as ordered) or tape Provides moisture to eyes if unable eyelids closed if paralyzed to blink or close eyes to prevent (specify). corneal damage. Teach parents of every aspect of care Assist parents to deal with their and equipment used including child that is acutely ill. comatosed status, effects of medications, IV therapy, NG tube care, use of catheter, use of monitoring devices (ICP, cardiac, CVP), intubation and ventilation. Reassure parents that mild stimulation Provides stimulation as child may is allowed and that speaking and be able to perceive tactile and touching child is permitted. auditory stimuli when unresponsive. Teach parents that child will be Child may not be aware of the reoriented to person, time and place environment and realize that he when awakened from the coma. or she has been hospitalized. Assist parents to read labels for Promotes prevention of syndrome as aspirin (salicylate) content and to aspirin considered to be a avoid using these drugs (e.g., causative factor. Pepto-Bismol) when child is ill. Teach parents that deficits usually Provides guidance as to what to improve and resolve in 6 to 12 expect as child progresses to months during recovery and wellness. evaluation and rehabilitation may be 5 of 8 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=65&FxId=123&Sessi. needed. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide data about outcome criteria chosen.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR REYE'S SYNDROME 6 of 8 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=65&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: 7 of 8 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=65&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:14:47 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=65 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 7 - NEUROLOGIC SYSTEM CHAPTER 7.6 - REYE'S SYNDROME Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 8 of 8 12/22/2006 7:44 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=66&FxId=123&Sessi. CHAPTER 7.7 - SEIZURES INTRODUCTION A seizure is a central nervous system (CNS) event characterized by an excessive level of neuronal electrical discharges in the brain. Seizures may be idiopathic or chronic and recurrent (epilepsy or acute acquired and nonrecurrent). Seizures can be partial or generalized with signs and symptoms dependent on the areas involved and range from varying degrees of motor, sensory and sensorimotor changes, and altered consciousness. Partial seizures may be classified as partial or complex partial and generalized seizures as tonic-clonic, absence, atonic or akinetic, myoclonic, and infantile spasms. Seizures occur at any age in children with epilepsy, but mostly in children over 3 years of age. Infantile spasms occur in infants between 3 to 9 months of age. Treatment focuses on prevention of subsequent seizure activity with medication regimen or surgical removal of a focal lesion, tumor, or hemorrhage. Febrile seizures occur in children between 3 and 5 months. The younger the age of the first episode, the more likely there will be recurrence. Status epilepticus is characterized by a seizure lasting more than 30 minutes or repeated seizures without regaining consciousness and is viewed as a medical emergency with a prognosis dependent on the length of the seizure activity and the effect on the brain. MEDICAL CARE Anticonvulsants: decrease or limit impulses and spread of electrical discharges in the brain. Amphetamines: stimulate CNS and counteract

drowsiness caused by anticonvulsant therapy. Electroencephalogram (EEG): reveals abnormal electrical impulses to the brain in initial stage of seizure and characteristic patterns identifying type of seizure. Skull X-rays: reveal head trauma if present. Computerized Tomography Scan (CT): reveals abnormalities such as brain tumor, trauma, or infection as causes of seizure. Ultrasound: reveals intraventricular hemorrhage if present as cause of seizure. Brain Scan: reveals abnormality as source of seizure if present. Lumbar Puncture: reveals abnormality in cerebrospinal fluid caused by bleeding trauma or infection responsible for seizure activity. Complete Blood Count: reveals increased WBC if infection present. Electrolyte Panel: reveals abnormal levels of calcium or phosphorus as cause of seizure if levels decreased. Blood Glucose: reveals metabolic cause for seizure if decreased. Lead Level: reveals increased level as cause of seizure. COMMON NURSING DIAGNOSES See INEFFECTIVE BREATHING PATTERN 1 of 9 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=66&FxId=123&Sessi. Related to: (Specify: neuromuscular impairment, perception or cognitive impairment.) Defining Characteristics: (Specify: dyspnea, tachypnea, changes in respiratory depth, cyanosis, cessation of breathing in status epilepticus, obstruction of airway by secretions during a seizure.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Rejection of diet. Defining Characteristics: (Specify: weight under ideal for height and frame, poor eating patterns, anorexia, rejection of decrease in protein and carbohydrate and increase of fat in dietary intake.) ADDITIONAL NURSING DIAGNOSES RISK FOR INJURY Related to: (Specify: internal factors of biochemical regulatory function [seizure, tissue hypoxia], physical trauma [broken skin, altered mobility], psychological changes [orientation].) Defining Characteristics: (Specify: seizure activity with change in consciousness, falls, muscle flaccidity or rigidity, aspiration of secretions, cyanosis, change in sensation in a body part, muscle weakness, presence of aura before seizure.) Goal: Client will not experience injury by (date and time to evaluate). Outcome Criteria √ Client sustains no physical injury from seizure. NOC: Risk Detection INTERVENTIONS RATIONALES Assess seizure activity including Provides information that type of activity before, during, prepares environment for and after seizure, movements and prevention of trauma or parts of body involved (tonic and complications as a result of clonic), site of onset and seizure. progression of seizure, duration of seizure, pupillary changes, bowel or bladder incontinence, paralysis, sleep, alertness, or confusion after seizure, presence of aura. Assess skin for color (pallor, Provides information about flushed or cyanosis), respiratory possible obstruction or rate, depth, and ease for signs of aspiration of secretions if distress; have oxygen, suctioning seizures are prolonged and equipment on hand. affect ventilation. 2 of 9 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=66&FxId=123&Sessi. Maintain sidelying position with side Allows for secretions to drain rails up, bed or crib padded, and and maintains airway patency; articles removed from area near padding protects child from child. injury during seizure. Avoid attempts to restrain any Restraint may result in fracture movements or putting anything in and inserting object in mouth child's mouth; provide gentle increases stimuli. support to head and arms if harm might result. Loosen clothing, assist child to Prevents injury from fall. floor if not in bed and place pad under head. Stay with child during seizure, Provides support and prevents any reorient when awake, and allow to injury to child. rest or sleep after seizure. Administer and evaluate (Action of drugs.) anticonvulsants obtaining blood levels as ordered (specify). Assist parents to remain calm during Allows parents to function seizure activity of child. appropriately to protect the child from injury. Teach about information to record Provides physician with important about seizure activity should it information needed to prescribe occur (specify). medical regimen. Teach parents about care of child Ensures safe and effective during seizure and precautions to actions to prevent injury. take. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did client have a seizure? Was any injury sustained?) (Revisions to care plan? D/C care plan? Continue care plan?) COMPROMISED FAMILY COPING Related to: Situational crisis. Defining Characteristics: (Specify: preoccupation of significant persons with anxiety, guilt, fear regarding child's disorder, display of protective behaviors by significant persons that are disproportionate to child's needs [too much or too little], recurrence of seizure activity, lack of support by family members to child.) Related to: (Specify: inadequate or incorrect information or understanding by a primary person and/or significant persons.) 3 of 9 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=66&FxId=123&Sessi. Defining Characteristics: (Specify: verbalizations by significant persons of inadequate knowledge base that interferes with care and support of infant/child.) Goal: Family will cope effectively by (date and time to evaluate). Outcome Criteria √ Family members identify stressors of child's illness. √ Family identifies 3 effective ways to cope with child's illness. NOC: Family Coping INTERVENTIONS RATIONALES Assess anxiety, fear, erratic Provides information affecting behavior, perception of crisis family ability to cope with situation by family members. infant/ child's recurring disorder. Assess coping methods used and Identifies coping methods that work effectiveness; family ability to and need to develop new coping cope with ill member of family, skills; family attitudes and stress on family relationships, coping abilities directly affect developmental level of family, child's health and feeling of response of siblings, knowledge wellness, members of family may and attitudes about disorder and develop emotional problems when health practices. stressed, and ill member may strengthen or strain family relationships. Encourage expression of feelings and Reduces anxiety and enhances questions in accepting, family's understanding of infant/ nonjudgmental environment and child's condition and provides assist family members to express opportunity to express feelings, problems and explore solutions problems, and problem-solving responsibly. strategies by whole family. Encourage family involvement in care Provides for reduction of anxiety during hospitalization and after and fear. discharge. Allow for open visitation, encourage Encourages bonding and assists in telephone calls to hospital by coping with infant/child's family members. hospitalization. Provide place for family members to Promotes comfort of family. rest, freshen up. Suggest social worker referral if Provides support and resources for needed. financial or infant/child's care relief. Give positive feedback and praise Encourages parents and family to family efforts in developing participate in care and gain some coping and problem-solving control over the situation. techniques and caring for infant/ 4 of 9 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=66&FxId=123&Sessi. child. Assist to establish short- and long- Promotes inclusion of ill child in term goals in maintaining child family routines and activities. care and family integration of child into home routine. Reinforce appropriate coping Promotes behavior change and behavior. adaptation to care of infant/ child prone to seizures. Teach that overprotective behaviors Knowledge will enhance family may hinder growth and development. understanding of condition and adverse effects of behavior. Encourage to maintain health of Chronic anxiety, fatigue will family members and discuss needs affect health and care of all family members; inform of capabilities of family. methods to provide care and attention to all members. Suggest methods to maintain child's Ensures acceptance of child into independence and role in the family routines. family. Reassure parents that they do not Explodes the many myths associated pass this disorder directly onto with the disorder. their offspring, that intellectual functioning is not affected, that the child is not considered violent or insane, that the disorder is not contagious. Reinforce to parents that child Normalizes life of child as much as should attend school and possible. participate in activities with friends and peers. Teach parents that child needs to Provides information that may be wear or carry identification and needed in an emergency. treatment information. Refer to Epilepsy Foundation. Provides information and support to family for chronic, long-term care. NIC: Support System Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What stressors did family identify? Which 3 coping mechanisms did family identify?) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE 5 of 9 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=66&FxId=123&Sessi. Related to: Lack of exposure to information about ongoing care. Defining Characteristics: (Specify: expressed request for information about medication regimen, causes of seizures and when to report to physician.) Goal: Parents will obtain information about care of child by (date and time to evaluate). Outcome Criteria √ Parents verbalize understanding of cause of seizures. √ Parents verbalize correct medication plan for child. NOC: Knowledge: Treatment Regimen INTERVENTIONS RATIONALES Assess parents' and child's perceptions Provides information regarding and knowledge about disorder, fears long-term care of child with a and misconceptions about disorder, seizure disorder and how to deal nature and frequency of seizures, and with seizures and the stigma factors that initiate seizures. attached to this disorder. Teach about administration of Promotes compliance to drug regimen anticonvulsants (specify name of which is the most important drug(s), action of drug(s) and when treatment to prevent seizure. given in combination, times, frequency, side effects, expected results, methods to give drugs) and provide written instructions to follow related to age group and a schedule to follow; give at most convenient times with meals or at bedtime with as few disruptions in routines and activities as possible; give in tablets, liquid extracts, emulsions, or crushed in syrup or jelly; avoid milk if giving phenytoin or phenobarbital and supplement vitamin D; replace prescription before running out of drug(s) and avoid skipping doses (specify). Teach parents and child to report Indicates side effects of sedatives lethargy, ataxia, nausea, vomiting, and anticonvulsants. hyperactivity, blood dyscrasia, stomatitis, tremor, nystagmus. Teach parents about blood testing for Prevents toxicity and other severe therapeutic levels, blood count, liver side effects of drug therapy by function tests when instructed. adjusting dosage or changing medications. Inform that seizures may be provoked by Promotes knowledge and 6 of 9 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=66&FxId=123&Sessi. omission of medication administration, understanding of causes of an illness or infection, too much increased frequency of seizures. activity, lack of sleep, excessive alcohol or drug intake, emotional stress, or other causes specific to child. Teach parents to supervise child in Provides precautions to prevent bathroom, avoid dangerous play and injury as a result of a seizure. toys, avoid exposure to incidents that trigger seizure, pad areas in bed, or wear protective clothing if needed. Encourage parents to notify school nurse Promotes knowledge and and teacher of disorder and actions to understanding to prevent injury take including telephone number to and embarrassment to child. call. Discuss any activity restrictions such Promotes knowledge of activity as sports, rough play, need for based on individual child and someone in attendance. seizure activity and response to therapy. Alert parents of possible changes in Indicates effects of behavior, activity, or personality or anticonvulsants on behavior and changes in school performance or learning. interactions with family and peers. Refer to resources offering assistance Provides educational materials, such as Epilepsy Foundation of employment, legal services, America, community support groups. support, and counseling to families and children. NIC: Teaching: Prescribed Medication Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did parents say about the cause of the seizures? What did parents verbalize about medications for child?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR SEIZURES 7 of 9 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=66&FxId=123&Sessi. 8 of 9 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=66&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:14:59 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=66 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 7 - NEUROLOGIC SYSTEM CHAPTER 7.7 - SEIZURES Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 9 of 9 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care

Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. CHAPTER 7.8 - SPINA BIFIDA INTRODUCTION Spina bifida is a defect of the central nervous system that involves the failure of neural tube closure during embryonic development. There are two types of spina bifida: spina bifida occulta and spina bifida cystica. Spina bifida occulta is a defect in the closure without the herniation and exposure of the spinal cord or meninges at the surface of the skin in the lumbosacral area. Spina bifida cystica (meningocele or myelomeningocele) is a defect in the closure with a sac and herniated protrusion of meninges, spinal fluid and possibly some part of the spinal cord and nerves at the surface of the skin in the lumbosacral or sacral area. Hydrocephalus is often associated with spina bifida cystica. The neurologic effects are related to the anatomic level and nerves involved in the defect and range from varying degrees of sensory deficits, to partial or total motor impairment resulting in flaccidity, partial paralysis of lower extremities, and loss of bladder and bowel control. Children with spina bifida cystica, especially myelomeningocele, are commonly afflicted with orthopedic abnormalities that may include hip dislocation, spinal curvatures, or clubfeet and may require assistive devices such as braces, special crutches, or wheelchairs for mobility. Treatment includes surgical repair of defect as well as other anomalies depending on severity of the neurologic deficit and may be done during infancy or later. Other treatment focuses on prevention of complications, bowel and urinary management, and promotion of optimal growth and development. MEDICAL CARE Stool Softeners: prevent constipation and promote bowel rehabilitation. Antispasmodics: increase capacity or urinary bladder in treatment of bladder spasticity. Cholinergics: increase urinary bladder tone and prevent retention. COMMON NURSING DIAGNOSES See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Excretions and secretions. Defining Characteristics: (Specify: urinary and/or fecal incontinence, redness and irritation of perineal and anal areas, disruption of skin in perineal and anal areas, leakage of CSF from sac, rupture of sac, use of diapers.) Related to: Physical immobilization and pressure. Defining Characteristics: (Specify: redness, excoriation at bony prominences or other pressure areas, skin breakdown at pressure points, inability to change position, paralysis.) Related to: Altered sensation, circulation and skeletal prominence. 1 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. Defining Characteristics: (Specify: loss of tactile perception in extremities, pressure on bony prominences, lack of padded protection and massage of bony prominences, improper application of hot or cold.) See IMPAIRED PHYSICAL MOBILITY Related to: Neuromuscular impairment. Defining Characteristics: (Specify: inability to purposefully move within physical environment, including bed mobility, transfer, and ambulation, imbalance, impaired coordination, partial or complete paralysis of lower extremities, flaccidity, spasticity, skeletal abnormalities [hip, feet, spine].) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest food. Defining Characteristics: (Specify: NPO status following surgery, inadequate swallowing or sucking in presence of ICP, reduced muscle tone, abnormal eating pattern development.) See CONSTIPATION Related to: Neuromuscular impairment. Defining Characteristics: (Specify: frequency less than usual, hard, formed stool, palpable mass, inability to maintain normal bowel elimination pattern, poor anal sphincter tone and ability to feel urge to defecate.) See RISK FOR TRAUMA Related to: (Specify: weakness, balancing difficulties, lack of safety precautions, cognitive or emotional difficulties, reduced muscle coordination, skeletal abnormalities.) Defining Characteristics: (Specify: injury from falls, improper use of assistive aids, fractures, mental impairment, loss of tactile sensation, paralysis of extremities.) See DELAYED GROWTH AND DEVELOPMENT Related to: Effects of disorder or disability before of after surgery. Defining Characteristics: (Specify: frequent hospitalizations, delay or difficulty in performing skills typical of age group [motor, social or expressive], inability to perform self-care or self-control activities appropriate for age, behavior and/or intellectual deficits.) ADDITIONAL NURSING DIAGNOSES RISK FOR INFECTION 2 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. Related to: Inadequate primary defenses [broken skin, inadequate bladder emptying]. Defining Characteristics: (Specify: breaks or leaks in meningeal sac, abrasion or irritation of sac, contamination of sac or surgical repair by urinary or stool incontinence.) Goal: Client will not experience infection by (date and time to evaluate). Outcome Criteria √ (Specify, e.g., sac is intact and moist. Incision clean, dry, and intact without redness, edema, odor, or drainage; temperature <99° F, WBC < [specify for age].) NOC: Risk Detection INTERVENTIONS RATIONALES Assess sac for breaks or leakage of Provides information about CSF, irritation of sac redness, potential for infection of the swelling, purulent drainage at or sac site, meningitis if sac is around sac area, fever, ruptured, or is present. irritability, nuchal rigidity, cloudy, foul-smelling urine. Maintain the infant in prone position Reduces pressure on the sac to or side-lying, as permitted, with prevent possible rupture and head lower than buttocks or hips prevents rolling on side or slightly flexed with a pad between back. the knees; anchor position with sandbags. Apply a moist sterile dressing over Prevents drying of sac membrane the sac, use sterile saline or that could predispose to antibiotic solution; ointment if break, or rupture of sac and ordered may be applied. contamination. Reinforce moist dressing with dry Prevents contamination by sterile dressing and change when capillary action through needed being careful to avoid damage moisture. to sac by removing moist dressing after it has dried. Apply a shield over the sac dressing Protects the sac from and tape a plastic sheet below the contamination by urine or defect; following surgical closure feces. on the defect, apply a transparent occlusive dressing over the area below the sac site. Alter routine nursing care activities Prevents trauma to sac. such as feedings, changing linens and comforting as needed. Perform handwashing before any care or Prevents transmission of procedure involving the site before microorganisms to site. or after surgery and carry out sterile technique for all sac and wound care. 3 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. Maintain cleanliness of anal area and Prevents contamination by feces apply a sterile shield between anus caused by poor anal sphincter and sac or wound site. control which allows for dribbling and incontinence of stool. Administer antibiotics as ordered (Action of drug.) (specify drug, dose, route, and time). Following surgical repair of defect, Indicates wound infection. note any changes in wound including redness, swelling, warmth, drainage, fever. Following surgery, cleanse wound with Promotes cleanliness of wound antiseptic as ordered (specify) and and prevents infection (action change dressings when needed using of drug). sterile technique for at least 24 hours. Avoid ureteral contamination with Prevents urinary tract stool, perform thorough perianal infection. hygiene as needed. Teach parents about positioning Prevents damage to the sac and infant, application of protection possible infection. around sac (shield, foam rubber doughnut). Teach parents to cleanse the sac Protects sac from contaminants gently with moist cotton balls if and maintains cleanliness. soiled, avoid diapering the infant until after surgery and healing has taken place. Handle infant gently, hold and support Prevents pressure on the sac back above the defect, or place on area. pillow in prone position to move from place to place. Inform parents of signs and symptoms Promotes early detection of of infection of sac or surgical infectious process for early site, whichever is applicable, that treatment. should be reported. Teach handwashing technique, dressing Prevents transmission of change, use of clean or sterile infectious organisms; sterile linens, gloves, supplies when caring technique may not be needed in for sac area. giving care after surgery is performed. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 4 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. (Provide data about outcome criteria, e.g., describe sac or incision; what is temperature? WBCs?) (Revisions to care plan? D/C care plan? Continue care plan?) HYPOTHERMIA Related to: Illness. Defining Characteristics: (Specify: fluid and heat loss from large area of exposed sac, cool skin, body temperature lower than normal range.) Goal: Infant will maintain temperature by (date and time to evaluate). Outcome Criteria √ Temperature remains above (specify, e.g., 97.8° F). NOC: Thermoregulation INTERVENTIONS RATIONALES Assess temperature q 2 to 4h and Provides information as to note lack of stability; assess source of temperature changes temperature of extremity. which may be low if infection present. is Place infant in an isolette or Provides warmth and reduces the provide radiant warmer based on heat loss causing hypothermia evaluation keeping hypothermia. sac moist postoperatively. Teach parents to take temperature Monitors for temperature and report any decreases or instability detection for increases. early intervention. Teach parents in proper amount of Provides optimal environmental clothing and room temperature temperature. for infant/child (specify). NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is temperature?) (Revisions to care plan? D/C care plan? Continue care plan?) BOWEL INCONTINENCE 5 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. Related to: Neuromuscular involvement. Defining Characteristics: (Specify: constant dribbling or involuntary passage of stool, reduced anal sphincter tone and control, skin integrity breakdown caused by continuous contact with liquid stool.) Goal: Child will have decreased episodes of bowel incontinence by (date and time to evaluate). Outcome Criteria √ Child participates in bowel control regimen. √ Child is able to control bowel elimination. NOC: Bowel Continence INTERVENTIONS RATIONALES Assess presence of neurogenic Provides information about bowel, degree of incontinence, condition for use in plan of potential for rehabilitation. establishing bowel elimination routine. Change diapers as quickly as Dry, clean skin resists feasible; cleanse perianal area breakdown. carefully. Apply barrier creams (specify) as Prevents skin breakdown ordered to perianal area during (action). diapering. Place child on a toilet or potty Establishes a routine for chair at the same time each day; elimination to empty bowel. use stimulation and suppository if helpful. Maintain fluid intake of up to 2, Promotes bulk for easier and 000 ml/day depending on age; more manageable passage. include fiber and roughage in diet at regular times of the day. Apply padding in waterproof Prevents embarrassment for the undergarments but avoid use of child if bowel elimination diapers. not controlled. Teach parents and child about Promotes success in bowel program for control of bowel training. incontinence (fluids, diet, routine toileting, use of stimulation). Teach about behavior modification Promotes compliance with as a method to be used for bowel routine to control bowel rehabilitation. incontinence. Suggest clothing and undergarments Promotes self-image and to protect from staining prevents embarrassing accidents. incidents. Instruct parents on proper Promotes understanding to 6 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. cleansing and diapering maintain good skin techniques of infant/toddler. integrity. NIC: Bowel Incontinence Care Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Does child participate in bowel control regimen? Has child achieved control? Provide data.) (Revisions to care plan? D/C care plan? Continue care plan?) IMPAIRED URINARY ELIMINATION Related to: Neuromuscular defect. Defining Characteristics: (Specify: incontinence, retention, neurogenic bladder with increased or decreased tone [flaccid or spastic], absence of awareness of bladder fullness, passing of urine or ability to stop flow of urine [reflex incontinence].) Goal: Child will have improved urinary elimination by (date and time to evaluate). Outcome Criteria √ (Specify outcome criteria appropriate for individual child: e.g., learns to perform self-catheterization or maintains a daily urinary elimination pattern.) NOC: Urinary Elimination INTERVENTIONS RATIONALES Assess presence of neurogenic Provides information about bladder, degree of incontinence, condition for use in plan of potential for rehabilitation, age establishing urinary elimination of child. routine. Assess urine for cloudiness, foul Indicates urinary bladder odor, fever, lethargy, dysuria, infection caused by urinary retention. retention or residual resulting in urinary stasis and medium for bacterial growth. Offer and encourage intake of 30 ml/ Promotes renal blood flow and lb/day including acid-containing acidifies urine to prevent beverages and dietary inclusion of infection. foods high in acid content. Maintain clean genital and anal area Controls introduction of after each elimination episode or microorganisms into urethra and as needed if incontinent. urinary bladder. 7 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. Catheterize after urination if Moves residual urine if unable to indicated and ordered. empty bladder completely.

Perform scheduled rehabilitation Establishes a routine for urinary program of placing child on toilet elimination if this is a or potty chair at same times each possibility. day. Perform intermittent catheterization Ensures emptying of bladder to q 3 to 4h if indicated to resolve prevent incontinence and incontinence. infection. Perform Crede's maneuver if Promotes emptying of bladder. indicated. Administer antispasmodic, smooth Improves bladder storage and muscle relaxant, anticholinergic as continence by increasing bladder ordered (specify drug, dose, route, (action). and time). Teach parents and child (age Provides method for emptying dependent) in use of external bladder routinely or managing urinary device or procedure for incontinence by use of intermittent self-catheterization; collecting device connected to a demonstrate and allow for return closed system. demonstration. Teach about rehabilitative program of Provides an alternate method of toileting and using Crede's method. controlling incontinence although may be temporary. Encourage parents to avoid use of Causes embarrassment for child. diapers for child over 3 years of age; suggest pad and water-proof undergarment as an alternative. Inform parents of other methods Provides information about available including implantation of procedures that can be done if an artificial sphincter, creation intermittent catheterization is of an artificial reservoir, or not successful. creation of a urinary diversion to control incontinence. Teach parents and child about changes Allows for early interventions to in urine characteristics indicating control infection and eventual bladder infection and measures to renal complications. take to prevent this complication. Encourage to monitor fluid intake/ Maintains a monitoring system to day, weights and changes to report, ensure control of possible foods and fluids that are acidic complications. including citrus fruits, meat, eggs, cheese, prunes, breads. NIC: Urinary Elimination Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 8 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. (Provide data about specific outcome criteria for child; e.g., did child learn self-catheterization or maintain a bladder elimination pattern?) (Revisions to care plan? D/C care plan? Continue care plan?) DISTURBED BODY IMAGE Related to: Biophysical, psychosocial factor of child. Defining Characteristics: (Specify: urinary/bowel incontinence, partial or complete paralysis, recurring hospitalizations, change in social, verbal expression of negative feelings about body and functional disabilities, feelings of helplessness and hopelessness, inability in performing ADL.) Goal: Child will experience improved body image by (date and time to evaluate). Outcome Criteria √ Child expresses feelings about disability. √ Child identifies at least 1 positive thing about own body. NOC: Body Image INTERVENTIONS RATIONALES Assess child for feelings about Provides information about abilities and disabilities in potential for independence ADL, social interaction, effect in thinking and functioning. on self-concept. Encourage independence and maximize Promotes ADL capability by use functioning with use of aids for of assistive aids as needed bathing, grooming, dressing, depending on disability. eating, mobility, toileting, and praise any attempts at self-care activities. Encourage expression of feelings Provides opportunity to vent and concerns and support feelings to reduce anxiety communication of child with and negative feelings. parents and peers. Provide touch and hugging, age- Conveys caring and concern for appropriate activities with other child and enhances children. socialization. Stress and mention positive Enhances body image and accomplishment; avoid negative confidence. comment. Instruct in use of assistive aids Promotes independence and for ADL. enhances body image. Encourage parents to maintain Encourages acceptance of support and care for child. child. Advise parents to maintain same Provides sense of belonging to behavior rules for child as other family. 9 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. children in family and to integrate care and activities into family routines. NIC: Self-Esteem Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What feelings about disability did child verbalize? What positive thing about body did child identify? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) INTERRUPTED FAMILY PROCESSES Related to: Situational crisis of long-term condition of child. Defining Characteristics: (Specify: family system unable to meet physical, emotional needs of its members, inability to express or accept wide range of feelings, family unable to deal with or adapt to chronic condition and disabilities of child in a constructive manner, excessive involvement with child by family members, guilt expressed by family members, lack of support from family and friends, irritability and impatience as a response by family members to child.) Goal: Family will adapt to child's disability and begin to move forward by (date and time to evaluate). Outcome Criteria √ Family discusses disability and effect on individuals and the family system. √ Family identifies ways to cope with chronic illness. √ Family members exhibit positive feelings for each other. NOC: Family Normalization INTERVENTIONS RATIONALES Assess family ability to cope with Provides information about family child, stress on family attitudes and coping abilities relationships, developmental level that directly affect the child's of family, response of siblings, health and feeling of wellbeing; knowledge of health practices, chronic condition affecting a family role behavior and attitude child in a family may strengthen about long-term care, economic or strain relationships and pressures, resources to care for members may develop emotional long-term condition and grieving problems when family is stressed. 10 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. process, signs of depression, feelings of powerlessness and hopelessness. Assess anxiety level of family and Identifies need to develop new child, perception of crisis coping skills and realistic situation, coping and problem- behaviors in goal setting and solving methods used and interventions necessary for effectiveness. family and child to adapt to crisis. Encourage expression of feelings and Allows reduction in anxiety and provide factual, honest information enhances family understanding of about care with or without surgical condition and child's needs. repair, abilities and disabilities. Assist to identify helpful techniques Provides support for problem to use to problem solve and cope solving and management of with problem and gain control over situation. the situation. Provide anticipatory guidance for Assists family to adapt to crisis resolution. situation and develop new coping mechanisms. If hospitalizations frequent, assign Promotes trust and communication same personnel to care for child if with family members. appropriate. Support and encourage parental and Provides positive reinforcement of family caretaking efforts. roles and reduces stress in family members. Encourage family members to express Relieves anxiety and concern and feelings and reaction to appearance allows a show of acceptance for and condition of infant/child. their responses. Communicate empathy for patient and Promotes coping and positive family. adjustment to illness. Be aware of cultural differences in Promotes cultural and developmental coping behaviors; needs differ normalcy. according to cultural and ethnic backgrounds. Assist family with identifying Provides support, information and realities of disabilities and assistance. suggest contact with community agencies, clergy, social services, physical and occupational therapy including Spina Bifida Association of America. Assist to discuss family dynamics and Assists to understand the family need to tolerate conflict and behaviors leading to resolution. individual behaviors. Reinforce positive coping behaviors. Promotes behavior change and adaptation to care of child. Teach that overprotective behavior may Enhances family understanding of hinder growth and development and condition and need for that child should have limits and integration of child into family rules to live by. activities. Encourage to maintain health of family Prevents adverse effect of chronic 11 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. members and social contacts. anxiety, fatigue, and isolation on health and care capabilities of family. Explain causes, treatment and Reduces guilt and provides prognosis of condition; inform information about condition. parents that they are not at fault for development of the congenital defect. Inform parents that surgery may be Provides information to assist performed within 48 hours after family in decision about surgical birth or be delayed to age of 3 procedure. months or until further neurologic function is assessed, to allow for better epithelialization to occur, and to reduce the possibility of the development of hydrocephalus; use this information as reinforcement of physician information. Inform need for follow-up appointments Ensures compliance with medical with physician and therapists. regimen. NIC: Family Involvement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did family discuss disability and the effect on the family? Provide quotes. What ways did the family identify to cope with illness? Describe family behaviors towards each other.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: Repeated exposure to latex products and development of latex allergy. Defining Characteristics: (Specify: child exhibits symptoms such as: sneezing, coughing, rashes, hives, wheezing when handling products made of rubber (balloons, tennis balls, Band-Aids) or when exposed to hospital products that contain latex such as gloves, catheters, and so forth.) Goal: Child will not experience injury by (date and time to evaluate). Outcome Criteria √ Child will not be exposed to latex in any form. NOC: Risk Detection 12 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. INTERVENTIONS RATIONALES Identify children with latex allergy; Promote expediency in treatment children with this allergy should if a reaction occurs; may wear a form of identification such prevent an allergic reaction. as a medical bracelet. Maintain an environment that is Prevent development of latex latex-free, especially with high- allergy; prevent allergic risk populations (children with reaction in those who are spina bifida, for example). Do not already sensitized. allow latex balloons in hospital environment. Keep emergency equipment nearby, Promote prompt emergency including equipment needed to treat treatment. an anaphylactic reaction. Ask all patients admitted about Promotes screening of all reactions to latex allergy during patients which may prevent all initial interviews. severe allergic reactions in otherwise low-risk patients. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Was child exposed to latex?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR SPINA BIFIDA 13 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: 14 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=67&FxId=123&Sessi. STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:15:17 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=67 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 7 - NEUROLOGIC SYSTEM CHAPTER 7.8 - SPINA BIFIDA Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 15 of 15 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=68&FxId=123&Sessi. UNIT 8 - HEMATOLOGIC SYSTEM CHAPTER 8.0 - HEMATOLOGIC GROWTH AND DEVELOPMENT INTRODUCTION The hematologic system includes the blood (plasma and cells) and the blood-forming tissues/organs (red bone marrow, lymph, lymph nodes, spleen, thymus, and tonsils). The cellular portion of the blood contains the erythrocytes (RBC), leukocytes (WBC), and thrombocytes (platelets). The plasma portion contains water and solutes, which include albumin, electrolytes, and proteins (clotting factors, fibrinogen, globulins, and antibodies). The system provides the body with specialized cells to transport oxygen, nutrients, and other substances to all the tissues; assist in clotting to prevent blood loss; and provide protection to the body from infectious agents (immunologic function). Children are vulnerable to disorders common to the system such as anemia, immunologic disorders, hemostatic problems, and malignancies involving the lymphatic system and blood cell production. GROWTH AND DEVELOPMENT • Blood volume of full-term newborn averages 300 ml. • Fetal hemoglobin is present for 5 months; adult hemoglobin forms at 13 weeks of age. • Hemoglobin is at its lowest between 4 and 6 months of age because maternal iron stores in the infant have been used up and this accounts for the lower hemoglobin at 6 months of age. • Erythrocyte production increases rapidly after birth

and results in an increase in reticulocytes (immature RBC). • The life span of a RBC is 120 days, of a granulocyte 4 to 5 days, of an agranulocyte a half-life is 60 to 90 days, and of a platelet 8 to 10 days. • Cell-mediated immune responses are deficient in the infant; immunoglobulin A (IgA) appears in the blood serum at 1 month of age and adult levels are reached at 10 years of age. • Phagocytic action of neutrophils and monocytes is not at full strength in the newborn, so inflammatory response is less effective than in an older infant or child. • By 5 months of age, immunoglobulin level is based on antibodies made by the infant's own system, but the child/adult level is not attained until 1 year of age. • Lymphoid tissue (thymus, tonsils, adenoids, spleen, lymph nodes) grows rapidly during infancy and reaches peak growth at 12 years of age; it filters and traps pathogens before they enter the bloodstream. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: 1 of 2 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=68&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:15:40 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=68 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 8 - HEMATOLOGIC SYSTEM CHAPTER 8.0 - HEMATOLOGIC GROWTH AND DEVELOPMENT Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 2 of 2 12/22/2006 7:45 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=69&FxId=123&Sessi. CHAPTER 8.1 - HIV/AIDS INTRODUCTION Acquired immunodeficiency syndrome (AIDS) is caused by HIV (human immunodeficiency virus). HIV has been found in blood and bodily fluids (semen, saliva, vaginal secretions, urine, breast milk, and tears). Transmission of HIV can occur by 3 primary modes: exposure by sexual contact, IV exposure to blood, or perinatal exposure from an HIV-infected mother to her infant. In children and adolescent age groups 3 populations have been identified: 1) children exposed in utero from an infected mother; 2) children who have received blood products, especially children treated with hemophilia (before testing of blood products began in 1985); and 3) adolescents who are infected after engaging in high-risk behaviors (i.e., sharing of needles for injection of drug use; accidental needle sticks; unprotected sex and multiple sexual partners). Polymerase chain reaction (PCR) tests are very accurate in detecting HIV in infected infants (95% by 1 month). Diagnosis of AIDS in children under 13 years of age, based on the Centers of Disease Control (CDC) criteria, include the presence of one of the following: 1) confirmed HIV in blood or tissues; 2) symptoms meeting the CDC criteria; or 3) HIV antibody and one or more of the following disorders: secondary infectious diseases, recurrent bacterial infections, or secondary cancers. Diagnosis of AIDS in children over 13 years of age and above is based on the CDC adult criteria. Children with HIV infection usually have detectable HIV antibody 6 to 12 months after exposure (except for infants of HIV-positive mothers). The diagnosis process for infants of HIV seropositive mothers, in the first 15 months of life, is difficult because of the presence of maternal antibody. Infants with perinatal acquired AIDS are normal at birth but may develop symptoms within the first 18 months of life. Clinical manifestations in children include: fever; decreased CD4 count; anemia; decreased WBC count (less than 3,000 cells/mm3); neutropenia (absolute neutrophil count of less than 1,500 cells/mm3); thrombocytopenia; myelosuppression; vitamin K deficiency; hepatitis; pancreatitis; stomatitis and esophagitis; meningitis; retinitis (common with low CD4 counts); otitis media and sinusitis (chronic or recurrent); lymphadenopathy; hepatosplenomegaly; recurrent bacterial infections (especially, Streptococcus pneumoniae and Haemophilus influenzae); Mycobacterium infections (MAC) or tuberculosis; cytomegalovirus (CMV); failure to thrive (in infants); chronic diarrhea; neurologic involvement, (developmental delays and microcephaly in infants, or loss of motor skills in the older child); and pulmonary infections (Pneumocystis carinii [PCP], lymphocytic interstitial pneumonitis [LIP], and pulmonary lymphoid hyperplasia [PLH]). Kaposi sarcoma, a hallmark of adults with HIV, is rare in children with HIV. A major success in pediatric HIV is the recognition that a majority (from 25% to 8%) of perinatal transmissions can be prevented with prophylactic zidovudine therapy. MEDICAL CARE Diagnostic Tests for HIV in Children: enzyme-linked immunosorbent assay (ELISA) detects HIV antibodies; Western blot (detects serum antibody bound to specific HIV antigens); immunofluorescence assays. Because of the presence of maternal antibodies for newborns, the polymerase chain reaction (PCR assay) is required. Medical Management: there is no cure for HIV. Medical care is directed at slowing the virus, preventing and treating the opportunistic infections, nutritional support, and symptomatic treatment. Combination drug therapy with antiviral therapy is recommended, with at least two antiviral drugs. Antiretroviral Medications: drugs and treatment regimens are continually evolving. Currently recommended drugs include nucleoside analogue reverse transcriptase inhibitors (NRTIs, e.g., zidovudine), non-nucleoside analogue reverse transcriptase inhibitors (NNRTIs), and protease inhibitors (PIs). IVIG (intravenous gamma globulin): may be helpful to decrease opportunistic infections. 1 of 11 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=69&FxId=123&Sessi. Trimethoprim-Sulfamethoxasole: used for prevention/treatment of Pneumoncystis carinii. Immunizations: Immunizations should be given as recommended for all children, except no chickenpox (varicella) vaccine, inactivated poliovirus (IPV) instead of oral poliovirus (OPV); and pneumococcal and influenza vaccine are recommended; Varicella zoster immune globulin should be given within 96 hours of chickenpox exposure. Acyclovir: as prophylaxis for herpes infections. Complete Blood Count (CBC): reveals increased WBC in infections, decreased T-helper lymphocytes. Immunoglobulins (Ig): reveal increased levels. COMMON NURSING DIAGNOSES See INEFFECTIVE AIRWAY CLEARANCE Related to: (Specify: infection, obstruction, secretions, decreased energy, and fatigue.) Defining Characteristics: (Specify: abnormal breath sounds; changes in rate, ease, and depth of respirations; tachypnea; fever; weakness; ineffective cough with or without sputum.) See INEFFECTIVE BREATHING PATTERN Related to: Illness. Defining Characteristics: (Specify: increase in body temperature above normal range, increased respiratory rate, tachycardia.) See DIARRHEA Related to: Inflammation, irritation of bowel. Defining Characteristics: (Specify: chronic, increased frequency of loose, liquid stools; cramping; abdominal pain.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: (Specify: inability to ingest, digest, or absorb nutrients.) Defining Characteristics: (Specify: anorexia, weight loss, lack of interest in feeding, failure to thrive, child's growth begins to slow or weight begins to decrease.) See DELAYED GROWTH AND DEVELOPMENT Related to: Neurologic involvement (75% to 90% of HIV infected children). 2 of 11 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=69&FxId=123&Sessi. Defining Characteristics: Developmental delays or, after achieving normal development, loss of motor milestones; microcephaly (in HIV infected infants); and abnormal neurologic examination findings. ADDITIONAL NURSING DIAGNOSES ANXIETY Related to: (Specify: change in health status, threat of death, threat to self-concept, fear of interpersonal transmission and contagion.) Defining Characteristics: (Specify: increased apprehension and fear of diagnosis; expressed concern and worry about early death, effect of lifestyle changes on physical and emotional status, possible opportunistic infections.) Goal: Clients will experience decreased anxiety by (date and time to evaluate). Outcome Criteria √ Clients explore feelings about the child's illness. √ Clients report decreased anxiety. NOC: Anxiety Control INTERVENTIONS RATIONALES Assess level of anxiety of parents Provides information about source and child and how it is and level of anxiety and need manifested; and need for for interventions to relieve it; information that will relieve sources for the child may be anxiety. procedures, fear of mutilation or death, unfamiliar environment of hospital, and may be manifested by restlessness and inability to play, sleep, or eat. Refer for special counseling or Reduces anxiety, supports family social services as needed. coping with illness, and promotes adjustment to lifestyle changes. Encourage open expression of Provides opportunity to vent concerns about illness, feelings and fears to reduce procedures, treatments, and anxiety. prognosis. Communicate with child at Promotes understanding and trust. appropriate age level and answer questions calmly and honestly; use pictures, models, and drawings for explanations. Allow child as much input in Allows child more control and decisions about care and routines independence in situations. 3 of 11 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=69&FxId=123&Sessi. as possible. Encourage parents to stay with child Promotes parental care and and have open visitation, provide support. a telephone number to call for information. Teach parents and child about the Promotes understanding that will disease process, treatments, and relieve fear and anxiety. therapy. Explain all procedures, treatments, Supplies information about all and care in simple, direct, honest diagnostic procedures and tests. terms, and repeat as often as necessary; reinforce physician information if needed; provide specific information as needed. Reassure parents and child that all Decreases anxiety associated information about the disease will social attitudes about the be kept confidential. disease and those infected with it. Refer to local and national AIDS Provides information and support groups and agencies to contact for from those in similar assistance. circumstances. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did clients explore feelings about child's illness? Did clients report decreased anxiety? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) ANTICIPATORY GRIEVING Related to: (Specify: perceived potential loss of infant/child by parents, perceived loss of physiopsychosocial well-being by child.) Defining Characteristics: (Specify: expression of distress at potential loss, fatal prognosis of the disease, premature death of child.) Goal: Clients will begin the grieving process by (date and time to evaluate). Outcome Criteria √ Clients verbalize the stages of the grieving process. √ Clients identify support systems they may use for grief. 4 of 11 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=69&FxId=123&Sessi. NOC: Family Coping INTERVENTIONS RATIONALES Assess stage of grief process, Provides information about stage problems encountered, feelings of grieving; time to work regarding long-term illness and through the process varies with potential loss. individuals as they move toward acceptance. Provide emotional and spiritual Provides for emotional needs of comfort in an accepting environment parents and child as and avoid conversations that will appropriate, and helps them to cause guilt or anger. cope with illness and its implications without adding stressors that are difficult to resolve. Encourage parents' and child's Promotes ventilation of feelings. responses and expressions of feelings such as concern, fear, anxiety, or guilt. Assist in identifying and using Promotes constructive use of effective coping mechanisms and in coping skills. understanding situations over which they have no control. Allow for discussion of likelihood of Presents realistic view of child's death with parents and probable outcome of illness. child, if appropriate, and encourage them to discuss this with family members, friends. Refer to social, psychological, Provides support and information clergy services, or counseling as to child and family if need appropriate. assistance. Teach parents about stage of grieving Promotes understanding of feelings process and of behaviors that are and behaviors that are common in resolving grief. manifested by grief. Assist parents and child to identify Promotes coping ability over coping skills, problem-solving period of prolonged illness and skills, and approaches that may be assists in resolving family used. stress. Refer to AIDS groups and agencies for Provides support for family and social, economic, legal aid; family child as needed. and friends for support. NIC: Grief-Work Facilitation Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did clients verbalize the stages of grieving? Did clients identify support systems? Use quotes.) 5 of 11 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=69&FxId=123&Sessi. (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: Inadequate secondary defenses (immunosuppression). Defining Characteristics: (Specify: presence of infective organism, opportunistic infectious process and malignancy, expressed need for information about transmission prevention.) Goal: Client will not experience opportunistic infection by (date and time to evaluate). Outcome Criteria √ Temperature remains (specify for child). √ WBC level remains > (specify for child). √ CD4 T-lymphocyte level remains

> (specify). NOC: Risk Control INTERVENTIONS RATIONALES Assess CBC lab values; assess CD4 T- To identify abnormal range of lab lymphocyte counts; assess blood values related to infection or culture for opportunistic anemia; early recognition of infections; assess vital signs, as organisms will expedite ordered, to identify changes in appropriate treatment of respirations or lung sounds. infections; early recognition of signs of pulmonary infections will expedite treatment for pulmonary changes. Assess for fever, malaise, fatigue, Provides information about signs and night sweats, weight loss, chronic symptoms of infection during the diarrhea, oral infection or lesions, (prodromal) stage of AIDS with pain in joints and muscles, responses that are age-dependent lymphadenopathy, upper and lower at onset of AIDS in infants/ respiratory infections. children: long-term opportunistic infections, including Pneumocystis carinii pneumonia, Kaposi's sarcoma, and lymphoma. Provide protective isolation for Protects child from contact with immunosuppressed child; use gloves, infectious process in others. mask, and gown for visitors; and during care, proper handwashing when needed. Wear gloves for all care, when in Prevents transmission of virus to contact with body fluids (changing personnel or caretaker; follows diapers, handling any secretions or guidelines published by the 6 of 11 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=69&FxId=123&Sessi. excretions); do not recap needles; Centers for Disease Control. clean all spills and disinfect article or area; use bleach solution in home; wash, disinfect, or dispose of all contaminated articles used; double bag all linens and specimens with proper precautionary labeling. Use medical or surgical asepsis for Prevents transmission of pathogens all procedures and care as to child. appropriate. Administer medications as ordered to Prevents or treats infectious control disease progression or treat process, compensates for any infection as ordered (specify). immunosuppression by improving functioning of immune system (action of drug). Restrict contact with persons with Prevents transmission of infection infections or illnesses, have child to child. to share room with another child who does not have an infection. Teach parents and child of possible Promotes understanding and source for infection and risk of cooperation in treatments and spread or transmission of infection. procedure, prevents spread of existing infection or risk of new infection. Teach parents and child about Promotes compliance with isolation isolation to prevent contact with techniques. sources of potential infections (i.e., infected persons or contaminated articles). Inform parents and child of diagnostic Provides information about the and reporting methods, signs and disease causes, treatment, and symptoms of specific diseases, risk preventive measures. factors in acquiring or transmitting disease and potential complications. Teach parents and child about high- Assists in maintaining nutritional calorie protein diet with food status necessary to fight selections and sample menus. infection. Teach parents and child to avoid Prevents exposure to others with family members, friends, peers, or infection that may be transmitted others with infections or illnesses. to child with a compromised immune system. Teach parents and child handwashing Prevents transmission of pathogens technique. via the hands. Using written guidelines offered by Prevents transmission of virus to Centers for Disease Control, others. instruct in care of bodily fluids, use of gloves, cleansing and care of articles used, disposal methods, care of linens, clothing, specimens, mode of transmission to others. Encourage parents to contact school Promotes safety of child and nurse and discuss child's needs and possible contacts; attendance is 7 of 11 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=69&FxId=123&Sessi. guidelines for school attendance. recommended by physician as long as child has control of body secretions, and does not bite or have open lesions. Teach parents and child about Protects child from infectious immunization needed to prevent diseases (pneumonia and infectious disease. influenza). (If appropriate, inform child of Prevents transmission of virus to precautions to take if sexually others by taking appropriate active [condom use] or if using precautions. drugs [not sharing needles].) NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is temperature? What is WBC level? CD4 T-lymphocyte level?) (Revisions to care plan? D/C care plan? Continue care plan?) SOCIAL ISOLATION Related to: (Specify: altered state of wellness, unaccepted social behavior, low blood count precautions, repeated hospitalizations, social stigma of HIV, physical limitations.) Defining Characteristics: (Specify: protective isolation; absence of support by family, friends, others; seeks to be alone; expresses feelings of rejection, indifference of others; aloneness; withdrawal; displays behavior unaccepted by dominant culture; evidence of altered state of wellness.) Goal: Clients will experience increased social support by (date and time to evaluate). Outcome Criteria √ (Specify for clients, e.g., child returns to school, family reports support from friends, etc.) NOC: Social Involvement INTERVENTIONS RATIONALES Assist child to identify personal To increase child's strengths to facilitate enhanced self competence and increase coping. child's self-esteem. Assess child and family for feelings Provides information about extent about stigma associated with the of isolation felt by the family disease, rejection by others. and child. Provide accepting, warm environment Promotes trust and comfort to 8 of 11 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=69&FxId=123&Sessi. for child and parents to express enhance adaptation to presence their feelings. of positive testing or actual symptoms of the disease. Encourage child to interact with Promotes feeling of belonging, peers, attend school and and provides growth and activities. development. Reinforce peers, school nurse and Provides information and personnel about AIDS and safe education about AIDS. activities for child and other children. Discuss with child and parents Promotes correct information misconceptions that the public has dissemination and dispels myths and ways to correct the situation about the disease, thereby by providing information about reducing fear and rejection by causes and mode of transmission others. and by answering questions and concerns. Reassure parents and child that Protects child from stigma confidentiality will be maintained associated with the disease. at school and elsewhere if needed. NIC: Support System Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide data based on the outcome criteria selected, e.g., did child return to school? Did family report support of friends? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR HIV/AIDS 9 of 11 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=69&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library 10 of 11 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=69&FxId=123&Sessi. ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:15:54 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=69 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 8 - HEMATOLOGIC SYSTEM CHAPTER 8.1 - HIV/AIDS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 11 of 11 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=70&FxId=123&Sessi. CHAPTER 8.2 - ANEMIA INTRODUCTION Anemia is the most common group of hematologic disorders of infancy and childhood. The term anemia refers to a reduction in either the total number of circulating red blood cells (RBC) or a decrease in the concentration of hemoglobin (Hgb). The etiology of anemia is divided into 3 categories: 1) excessive blood loss (acute or chronic hemorrhage), 2) increased destruction of RBCs (or hemolysis), or 3) impaired or decreased rate of production (or bone marrow failure). The following three types of anemia are included here: iron deficiency, sickle cell anemia, and aplastic anemia. Iron deficiency anemia is primarily caused by an inadequate intake of dietary iron. The iron stores of the full-term infant normally meet the infant's nutritional needs until 6 months of age. In comparison, the iron stores for the premature infant normally is depleted by 2 to 3 months of age (milk is iron-poor). Treatment consists of iron supplementation and optimum nutrition. Sickle cell anemia (Hgb SS) is referred to as a genetic disease of autosomal dominant inheritance (and a sickling hemoglobinopathy syndrome). Hgb SS is caused by the substitution of a single amino acid (valine replaces glutamic acid) at the sixth position of the B-chain. It occurs primarily in the black race and symptoms appear usually after 4 to 6 months of age because of the presence of fetal hemoglobin earlier. Treatment consists of prevention/treatment of sickle cell pain crisis; and supportive/symptomatic measures. Aplastic anemia is defined as bone marrow failure characterized by the reduction or absence of the solid elements of the blood (red cells, white cells, and platelets). There are two types: primary (congenital or Fanconi anemia, an inherited autosomal recessive trait) or secondary (acquired, caused by exposure to toxins in the environment or a complication of an infection). Symptoms occur in the acquired type after exposure to a toxin or infection and in the congenital type usually after 17 months of age. Treatment is directed at restoration of bone marrow function, by two approaches: immunosuppressive therapy and replacement of the bone marrow through bone marrow transplantation. MEDICAL CARE DIAGNOSTIC EVALUATION FOR IRON DEFICIENCY ANEMIA Red Cell Smear: examines the red cell shape and content (i.e., MVC and MCH). Free Erythrocyte Protoporphyrin (FEP): elevated FEP is associated with an inadequate iron supply. Serum-Iron Concentration (SIC): measures circulating iron (normal: 70% ug/dl in infants). Total Iron-Binding Capacity (TIBC): measures transferrin (iron-binding globulin) for iron transport. Transferrin saturation: divide the SIC by the TIBC and multiplying by 100; (10%—suggests anemia). TREATMENT FOR IRON DEFICIENCY ANEMIA Iron Supplements: ferrous sulfate for prevention/treatment of iron deficiency. Vitamin C Supplements: may enhance iron absorption. 1 of 12 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=70&FxId=123&Sessi. DIAGNOSTIC EVALUATION FOR SICKLE CELL ANEMIA Stained Blood Smear: will reveal a few sickled RBCs; it is not 100% accurate. Sickle-Turbidity Test (Sickledex): a reliable screening method for the sickle cell trait or disease. Hemoglobin Electrophoresis: is an accurate, rapid, and specific test for detecting the homozygous and heterozygous forms of sickle cell anemia. TREATMENT FOR SICKLE CELL ANEMIA Hydration: given for hemodilution to treat/prevent sickle cell crisis. Analgesics: to prevent/treat pain crisis. Immunizations: should receive all recommended childhood immunizations; should also receive: pneumococcal (at 2 years of age and a booster at 5 years of age); Haemophilus influenzae, type B (is given to all infants at 2 months of age); and meningococcal vaccine (at 2 years of age). Folate Replacement: is given for the treatment of aplastic type of sickle cell crisis. Blood Transfusions: packed RBC transfusions are used to replace prematurely destroyed red cells and to diminish the percentage of hemoglobin S (sickled hemoglobin). It is primarily used with severe complications (i.e., stroke, progressive hypoxia, pulmonary disease, or in severe hemolysis). DIAGNOSTIC EVALUATION FOR APLASTIC ANEMIA Red Cell Indices: examine an elevated MCV (mean corpuscular volume of the RBC). Hgb Electrophoresis: will reveal an abnormally high fetal hemoglobin. Chromosomal Studies: will reveal multiple chromosomal abnormalities. CBC: evaluation of lab values characteristic of anemia, leukopenia, and decreased platelet count. Bone Marrow Aspiration: examination confirms hypocellularity and fatty replacement of bone marrow (conversion of red bone marrow to yellow, fatty bone marrow). TREATMENT FOR APLASTIC ANEMIA Anti-Lymphocyte Globulin (ALG) or antithymocyte globulin (ATG): suppresses T-cell-dependent autoimmune responses, (based on theory that aplastic anemia is caused by an autoimmune response). Androgens: may be used with ATG, may stimulate erythropoiesis. Immunoglobulin: (IV) has been successful in the acquired type of aplastic anemia (of infectious origin). Bone Marrow Transplantation: is the treatment of choice for severe aplastic anemia. It is the only mode of treatment which may result in a cure 2 of 12 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=70&FxId=123&Sessi. of this disease. Prognosis is highly correlated with the number of pretransplant transfusions (better to consider early in the course of the disease). COMMON NURSING DIAGNOSES See INEFFECTIVE TISSUE PERFUSION Related to: Impaired oxygen-carrying capacity of the blood. Defining Characteristics: (Specify: in iron deficiency anemia: irritability, anxiety, blood loss in the stool, hypochronic RBCs,

normal or near normal RBC count, decreased serum ferritin and iron; in sickle cell anemia: pallor, weakness, anorexia, easy fatigability, jaundice and developmental delays; in aplastic anemia: pallor, fatigue, weakness, loss of appetite, normochromic, normocytic RBCs in reduced numbers, leukopenia, thrombocytopenia [risk of spontaneous bleeding or bleeding after mild to severe trauma].) See RISK FOR DEFICIENT FLUID VOLUME Related to: Impaired kidney function to concentrate urine (in the sickle cell patient). Defining Characteristics: (Specify: dilute urine or low specific gravity; diuresis; enuresis; dehydration [dry mucous membranes; dry diapers and sunken fontanel in the infant]; prone to dehydration from environmental factors [i.e., overheating].) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inadequate ingestion of iron. Defining Characteristics: (Specify: in iron deficiency: underweight or may be overweight [because of excessive cow's milk ingestion]; fecal loss of blood; pallor; poor muscle development; prone to infections; inadequate intake of iron-rich foods; weakness.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Allergic response. Defining Characteristics: (Specify: itching, rash, urticaria, face and lymph node swelling; sclerosing from extravasation at venous access when receiving ATG.) ADDITIONAL NURSING DIAGNOSES PAIN Related to: Tissue anoxia. Defining Characteristics: (Specify: communication of pain descriptors, guarding and protective behavior of area, soft tissue swelling, warmth over painful area, crying, clinging behavior.) 3 of 12 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=70&FxId=123&Sessi. Goal: Client will experience decreased pain by (date and time to evaluate). Outcome Criteria √ Pain rating is decreased to (specify level and pain scale used). NOC: Pain Level INTERVENTIONS RATIONALES Assess for location, severity, and Provides information about pain duration of pain (specify caused by vasoocclusion frequency). resulting from RBC sickling, ischemia, and necrosis in soft tissue, joints, abdomen, back, or wherever occlusion occurs. Administer analgesics as ordered Controls pain and promotes (specify); administer comfort. intermittently over 24-hour period before pain becomes severe rather than wait for request or complaint from child. Provide rest periods, refrain from Decreases stimuli that increase disturbing child unless pain and promotes rest, necessary. decreases oxygen expenditure. Apply dry heat to area and note Promotes vasodilation and response of pain decrease. circulation to area to reduce pain. Maintain position of comfort, Promotes comfort and prevents handle painful areas gently, and pain from movement. support with pillows. Inform parents and child of cause Provides information and of pain, methods to control it. rationale for treatment. Teach parents to avoid situations Provides measures to control that cause stress for the child, sickling, which results in and clothing or positions that pain. restrict and impede blood flow. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is pain rating? Specify scale used.) (Revisions to care plan? D/C care plan? Continue care plan?) 4 of 12 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=70&FxId=123&Sessi. ACTIVITY INTOLERANCE Related to: Generalized weakness, imbalance between oxygen supply and demand. Defining Characteristics: (Specify: reduced oxygen delivery to tissues from reduced RBC or RBC sickling; fatigue; verbalization of weakness; changes in respiratory rate, depth, and ease; irritability; low tolerance to activity; increased pulse.) Goal: Child will increase activity to (specify level and date and time to evaluate). Outcome Criteria √ (Specify for child, e.g., is able to play a game; feed self, etc.) NOC: Activity Tolerance INTERVENTIONS RATIONALES Assess temperature, respirations, Provides information about VS and pulse; changes in behavior changes caused by hypoxia and (irritability, lightheadedness, about behavior changes caused short attention span); if easily by reduced oxygenation of the fatigued, unable to sleep, or brain. weak; ability to tolerate any activity or ADL. Assist with activities that require Minimizes physical exertion, exertion and are beyond tolerance which increases oxygen to and ability. tissues. Provide rest periods, plan care and Decreases oxygen expenditure to activities around rest/sleep. enhance tissue oxygenation. Provide appropriate quiet play and Promotes diversionary activity activities, and allow interaction and prevents withdrawal. with child of same age, if possible (specify). Administer oxygen therapy as ordered Provides supplemental oxygen, if (specify). needed, to treat hypoxia. Administer transfusion of blood, Replaces blood or blood packed RBC, platelets as ordered components depending on type (specify). of anemia and need. Teach parents and child how to Provides information to prevent conserve energy and increase fatigue by minimizing physical endurance of child, including activity or exertion, which placing articles within reach, utilizes more oxygen. anticipating needs and assisting before child attempts activity, allowing for rest; remain with child as needed. Encourage parents to avoid stressful Promotes quiet environment for situations. child. NIC: Energy Management 5 of 12 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=70&FxId=123&Sessi. Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is child able to do? Provide data related to outcome criteria.) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: (Specify: decreased Hgb and decreased immune system functions; in aplastic anemia: immunosuppressive therapy, ATG, and steroids; in sickle cell anemia: splenic dysfunction.) Defining Characteristics: (Specify: temperature elevation [greater than or equal to a temperature of 101° F or 38.5° C]; elevated WBC counts; positive cultures for bacterial organisms; positive throat, urine or blood culture; changes in respirations and sputum characteristics; cloudy, foul-smelling urine.) Goal: Child will not experience infection by (date and time to evaluate). Outcome Criteria √ Temperature remains <99° F. √ Child denies pain or swelling in any area. NOC: Risk Control INTERVENTIONS RATIONALES Assess temperature, signs, symptoms, Provides information about and laboratory tests indicating infection in a child made infectious process, irritability susceptible by steroid and and malaise, swelling in soft globulin therapy, particularly in tissue or lymph nodes. aplastic anemia, or pneumococcal and salmonella infections in child with sickle cell anemia. Provide protective isolation if Prevents transmission of pathogens neutrophil count is less than 500/ to a susceptible child. cu mm; use mask and gown and good handwashing when caring for child. Obtain culture of body fluid for Identifies pathogens and examination. sensitivity to antibiotic therapy if an infection is present. Teach parents and child to limit Prevents exposure to those with contact with persons who are ill or infections or illness that may be have respiratory infections. transmitted to child with anemia. 6 of 12 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=70&FxId=123&Sessi. Instruct in handwashing technique and Prevents exposure to infectious when to use it, including before agents transmitted by hands or meals, after using bathroom. hard surfaces. Inform parents of recommended Prevents infectious disease in the childhood immunizations; and of susceptible child. acquiring the following vaccines when the child is 2 years of age or older: meningococcal and pneumococcal. Teach parents to report any Indicates possible infection that temperature elevation, changes in may be controlled with early respirations and pulse, pain or intervention. swelling in any area. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is temperature? Does child deny pain or swelling?) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: (Specify: abnormal blood profile [thrombocytopenia] reaction to transfusion or ATG administration.) Defining Characteristics: (Specify: fever; restlessness; chills; shortness of breath; chest pain; tachycardia; hypotension; headache; thrombocytopenia at 20,000/cu mm level; bruising; petechiae; bleeding from mucous membranes; blood in urine, sputum, stool; nosebleed; blood in vomitus; stomatitis.) Goal: Client will not experience injury by (date and time to evaluate). Outcome Criteria √ No evidence of bleeding. NOC: Risk Detection INTERVENTIONS RATIONALES Assess for signs of bleeding from any Provides information indicating site as manifested in skin changes; blood loss as tendency also, blood from nose, oral cavity, increases with therapy for urinary or gastrointestinal tract, aplastic anemia. and factors that precipitate or 7 of 12 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=70&FxId=123&Sessi. increase bleeding. Assess blood in urine with dipsticks Identifies occult blood in urine and hematests (specify when). or stool. Protect child from trauma by padding Prevents bleeding in skin bed and toys, using soft toothbrush layers, deeper tissues, or and towels or swabs for cleaning mucous membranes. mouth, avoiding rectal temperature and injections. Discontinue transfusion if allergic Prevents irreversible reaction reaction occurs, notify physician. to blood or blood products. If ordered, perform skin test for ATG Alerts to possible sensitivity before dose, administer steroid to horse serum and protects daily 30 minutes before ATG, which from allergic reaction to ATG. is given in normal saline IV. Teach parents and child about Prevents trauma, which causes activities to avoid while on bleeding when tendency is therapy, such as contact sports or present. activities that cause falls. Advise parents to avoid aspirin and Encourages bleeding by its aspirin products. effect on platelet aggregation. Instruct parents to report any Provides for early interventions bleeding from any site, nosebleed to control bleeding. that will not stop, blood in urine or stool. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Is there any evidence of bleeding? What was looked for?) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE Related to: Lack of information about anemia. Defining Characteristics: (Specify: request for information about pathophysiology of anemia, changes that occur, preventive measures and treatments.) Goal: Clients will obtain information about anemia by (date and time to evaluate). Outcome Criteria 8 of 12 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=70&FxId=123&Sessi. √ Parents verbalize understanding of (specify type of anemia) and treatment plan. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess for knowledge level of type of Provides information needed for anemia, cause, treatment, appropriate teaching content prevention. for parents and child. Teach about RBC physiology and the Promotes understanding of RBC changes that occur in the anemia function to provide a rationale the child has. treatments. for signs, symptoms, and Teach parents about genetic Provides information about risk counseling for sickle cell anemia. of offspring having the disease. Teach parents and child about bone Provides information of this marrow transplant treatment if therapy if child has aplastic appropriate. anemia. Instruct child to carry or wear Provides information in the event identification information, of an emergency. including condition, treatments, and physician's name and telephone number. Teach parents and child about dietary Provides iron intake or intake of iron, including foods replacement in iron-deficiency such as iron-rich formula for anemia. infant, meats, whole grains, green leafy vegetables, dried fruits. Administer oral iron replacement Provides iron replacement (specify dose) as ordered, and therapy. instruct to take with orange juice to promote absorption; give iron preparation between meals, avoid administering with milk, use straw or dropper, and have child rinse mouth after ingestion. Refer parents and child to National Provides information and support Association for Sickle Cell Disease for child and family with and other community agencies and sickle cell or aplastic anemia. groups for family, parents or child. Reinforce to parents importance of Treats child as member of family child attending school and and integrates him or her into participating in family activities. social, mental, and physical activities, that will enhance growth and development needs. Teach risks to avoid, including signs Prevents complications of and symptoms of infection, disease. bleeding, hypoxia, malnutrition, immunizations, high altitudes, side effects of steroid therapy, emotional and physical stress. 9 of 12 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=70&FxId=123&Sessi. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did parents say about the cause of the child's anemia? What did parents verbalize about treatment for child?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR ANEMIA 10 of 12 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=70&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library 11 of 12 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=70&FxId=123&Sessi. ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00)

Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:16:12 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=70 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 8 - HEMATOLOGIC SYSTEM CHAPTER 8.2 - ANEMIA Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 12 of 12 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=71&FxId=123&Sessi. CHAPTER 8.3 - HEMOPHILIA INTRODUCTION Hemophilia, an X-linked disorder, is a congenital hereditary bleeding disorder caused by an abnormal gene that produces a defective clotting factor protein with little or no clotting ability. The two most common forms of this disorder are: 1) factor VIII deficiency (hemophilia A, or classic hemophilia) and 2) factor IX deficiency (hemophilia B, or Christmas disease). Because both of these disorders are X-linked, the female is the carrier and the disorder is manifested only in males. Hemophilia is classified into the following three groups, based on the severity of factor deficiency, mild (5-50%), moderate (1-5%) and severe (1%). Hemophiliacs are at risk for prolonged bleeding or hemorrhage as a result of minor trauma. Individuals with severe hemophilia, or less than 1% clotting factor, are also at risk to suffer from spontaneous bleeding without trauma or more severe prolonged bleeding after trauma. Bleeding can occur at any part of the body. Hemarthrosis, or bleeding into the joint spaces, is the most common complication of severe hemophilia. The knee joint is the most frequent joint involved. MEDICAL CARE DIAGNOSTIC EVALUATION In the hemophilia patient, the following tests will be within the normal range: prothrombin time, fibrinogen level, thrombin level, and platelet count; the following tests will be abnormal: prolonged PTT and low levels of clotting factor (for factor VIII or IX). Partial Thromboplastin Time Test (PTT): measures activity of thromboplastin. Thromboplastin Generation Test (TGT): measures blood's ability to generate thromboplastin. Specific for determination of specific factor deficiencies, especially factor VIII and IX. Prothrombin Test (PT): measures activity of prothrombin and detects deficiencies only for factor V, VII, X, fibrinogen, and prothrombin. Platelet Test: total number of circulating platelets. Bleeding Time: measures time interval for bleeding from small superficial wound to cease. Factor VIII: antihemophilic factor A or antihemophilic globulin (AHG). Factor IX: antihemophilic factor B or plasma thromboplastin component (PTC). THERAPEUTIC MANAGEMENT Replacement of the Deficient Clotting Factor: Factor VIII and Factor IX (IV): (monoclonal), (reconstituted with sterile water immediately before use); DDAVP: (1-deamino-8-D-arginine vasopressin), a synthetic form of vasopressin that is the treatment of choice for hemophilia. Corticosteroids: are used to treat inflammation in the joints; Ibuprofen is used for pain management. 1 of 10 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=71&FxId=123&Sessi. Oral Use of EACA or Amicar (Epsilon aminocaproic acid): promotes clotting, it is used in children (>1 year of age) for mucous membrane bleeding; also for preprocedural and postprocedural oral surgery (a dose of factor replacement must be given first). Porcine Preparations: prevents inhibitor antibodies (30% will develop inhibitor antibodies against factor replacements). Regular Program of Exercise: active range-of-motion is recommended to strengthen muscles around joints and may decrease the number of spontaneous bleeding episodes. TREATMENTS NOT CURRENTLY RECOMMENDED Cryoprecipitate: has not been recommended (since 1988) because it cannot be treated to safely eliminate hepatitis or HIV viruses. NSAIDS: (such as aspirin, Indocin, or Butazolidin) are not recommended because they inhibit platelet function. COMMON NURSING DIAGNOSES See IMPAIRED PHYSICAL MOBILITY Related to: Pain and discomfort with the onset of bleeding episodes; and hemarthrosis. Defining Characteristics: (Specify: pain in affected joint, and decreased ability to move the joint; immobilized joints [first 24 to 48 hours after a bleeding episode], potential contractures in affected joints.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Spontaneous bleeding episodes or bleeding episodes related to trauma. Defining Characteristics: (Specify: bleeding into soft tissue, muscles, and most frequently, joint capsules.) ADDITIONAL NURSING DIAGNOSES PAIN Related to: Hemarthrosis. Defining Characteristics: (Specify: a feeling of stiffness, tingling or aching in the affected joint, followed by a decrease in the ability to move a joint, verbal descriptors of pain, irritability, crying, restlessness.) Goal: Client will experience decreased pain by (date and time to evaluate). Outcome Criteria √ Pain rating is decreased to (specify level and pain scale used). 2 of 10 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=71&FxId=123&Sessi. NOC: Pain Level INTERVENTIONS RATIONALES Assess for joint pain, swelling and Bleeding episodes should be treated limited ROM. at the onset of discomfort, which requires replacement of the deficient factor. Immobilize joints and apply elastic Immobilization is mandatory for bandages to the affected joint if comfort and to avoid further prescribed; elevate affected bleeding; elastic bandage most extremity/joint; avoid heat often prevents muscle bleeding; application. that may prolong elevation of affected extremity/ bleeding time; ice packs promote joint will minimize swelling; heat vasoconstriction to active bleeding application will promote sites, but must be used cautiously vasodilatation and to prevent skin damage in young children. Administer analgesics for pain Administer ibuprofen for pain (specify as ordered). management; avoid NSAIDS (aspirin), as they may inhibit platelet function. Provide bed cradle over painful Prevents pressure of linens on joints and/or other sites of affected sites, especially joints bleeding. (i.e., hemarthrosis). Maintain immobilization of the Prevents increase of pain and affected extremity during the acute potential increased bleeding time phase (24 to 48 hours); apply a caused by movement. splint or sling to the affected extremity if prescribed. Inform child of cause of pain and Promotes understanding of pain interventions to relieve it; how responses and methods to reduce medications must be administered it. via mouth, while injections are avoided; to avoid taking aspirin or aspirin product for pain. Instruct child to support and protect Promotes comfort and prevents painful areas and in the importance further bleeding into joints. of immobilization. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is pain rating? Specify scale used.) (Revisions to care plan? D/C care plan? Continue care plan?) 3 of 10 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=71&FxId=123&Sessi. RISK FOR INJURY Related to: Decreased clotting factor (VIII or IX). Defining Characteristics: (Specify: prolonged bleeding anywhere from or in the body; spontaneous bleeding episodes; mild to severe bleeding episodes after trauma; hemarthrosis [bleeding to the joint and swelling of the joint]; affected bleeding site will display warmth, redness, swelling, and pain with limited movement.) Goal: Client will not experience injury by (date and time to evaluate). Outcome Criteria √ No evidence of bleeding. √ Joints are not swollen, warm, or red. NOC: Risk Control INTERVENTIONS RATIONALES Assess signs and symptoms of bleeding; Early detection of bleeding episodes hemarthrosis (stiffness, tingling, or will delay initiation of factor pain); subcutaneous and intramuscular replacement therapy and will hemorrhage; oral bleeding; epistaxis minimize complications; oral (is not a frequent sign); petechiae bleeding is often caused by trauma (are uncommon). to the gums; petechiae is caused by low platelet function versus a deficient clotting factor. Provide appropriate oral hygiene (use of Implementation of appropriate oral a water irrigating device; use of a hygiene will minimize trauma to the soft toothbrush or softening the gums. toothbrush with warm water before brushing; use of sponge-tipped toothbrush). Advise adolescents to use an electric High risk of bleeding is related to shaver versus manual razor devices use of razor blades; minimal risk of (with blades). bleeding is associated with use of electric shaver. Substitute the subcutaneous route for Both of these measures are associated intramuscular injections; utilize with less bleeding after venipuncture blood drawing technique implementing a subcutaneous for all required blood testing samples injection or venipuncture blood versus use of a finger or heel sample. puncture. Utilize appropriate toys (soft, not All of these recommendations will pointed or small sharp objects); for minimize and/or prevent bleeding infants, may need to use padded bed episodes due to trauma. rail sides on crib; avoid rectal temperatures. 4 of 10 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=71&FxId=123&Sessi. Implement the following measures to To allow clot formation. To decrease control and stop all bleeding blood flow to control bleeding. To episodes: 1) apply pressure (10 to 15 promote vasoconstriction, but use mins); 2) immobilize and elevate caution with small children to avoid affected extremity above the heart; 3) tissue damage. To control and stop application of cold pack (if bleeding episode and to prevent prescribed); 4) institute factor crippling effects from joint replacement therapy (based on medical bleeding. protocol); 5) institute DDAVP (it can be given IV or intranasally). Other recommended adjunct measures: 1) To minimize hemorrhage in muscles of complete bed rest for intramuscular lower spine (i.e., attaching to hemorrhage of lower spine area and trochanter or femur). These values non-weight bearing support; 2) assess determine current hemodynamic status laboratory values for blood clotting and factor replacement therapy factors (VIII or IX) and vital signs; guidelines or protocols. To avoid 3) stop passive range-of-motion injury to the affected extremity or exercises after an acute episode of joint and to avoid recurrence of bleeding. bleeding to these. Teach to wear appropriate medical To prepare medical personnel, family identification and to notify medical members and others of accurate personnel of diagnosis. information in the event of an emergency. Teach parents, family members and Empowers others with accurate affected child: signs and symptoms of information to recognize and control bleeding; and appropriate measures to bleeding episodes; to prevent control bleeding at home. bleeding; and to prevent crippling effects of bleeding. Limit use of helmets and padding of Daily use of these measures may cause joints during participation in contact the child to feel ostracized or may sports activities. discomfort. create emotional Recommend non-contact sports activities These activities are considered a safe such as swimming, hiking, or activity by the Hemophilia bicycling. Foundation. Avoid contact sports such as football, Contact sports will predispose the soccer, ice hockey, karate. child to injury and bleeding episodes. Maintain close supervision during play To prevent bleeding related to trauma time to minimize injuries. in the child's environment (i.e., school or park). Teach parents related to home health To protect the child from childhood maintenance: 1) the affected child communicable diseases (but use should receive all routine subcutaneous route administration to immunizations (use subcutaneous route, prevent prolonged bleeding). To recommend pressure and elastic bandage minimize oral trauma. To minimize after injections); 2) reinforce emotional distress importance of appropriate dental during the child's progression through hygiene program; 3) reinforce the the different developmental stages. provision of a safe but normal home To minimize risk of trauma in the environment, such as safety measures home by falls; infants and toddlers that are employed for all children of frequently fall or sustain injuries. different ages are recommended; 5 of 10 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=71&FxId=123&Sessi. example: for the toddler, gates over stairs but avoid restraining the toddler's attempt to master motor skills; for the older child, participating in sports activities (use helmets and padding); 4) provide a home environment free of hazards, including clear pathways, and supervise child during ambulation and play without being overprotective. Instruct parents and child, if age Prevents or manages bleeding by factor appropriate, to administer factor VIII replacement. via IV if signs and symptoms appear, or before dental visits or other possible invasive procedures; instruct in mixing the precipitate, drawing into syringe, venipuncture, and application of pressure following IV, and allow for return demonstration. Teach parents to include iron-rich foods Maintains iron level to prevent in diet; provide list of foods and anemia. sample menus. Teach parents and child of possible Reduces anxiety caused by risk of reactions to IV concentrate infections such as hepatitis and administration and that blood is AIDS from replacement products. tested for AIDS. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Is there any evidence of bleeding? Are joints red, swollen, or warm?) (Revisions to care plan? D/C care plan? Continue care plan?) COMPROMISED FAMILY COPING Related to: (Specify: inadequate or incorrect information or understanding, prolonged disease or disability progression that

exhausts the physical and emotional supportive capacity of caretakers.) Defining Characteristics: (Specify: expression and/or confirmation of concern and inadequate knowledge about long-term care needs, problems and complications, anxiety and guilt, overprotection of child.) Goal: Family will cope effectively with child's illness by (date and time to evaluate). 6 of 10 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=71&FxId=123&Sessi. Outcome Criteria √ Family identifies 3 effective coping mechanisms related to chronic illness of child. √ Family members establish short term and long-term goals for family. NOC: Family Coping INTERVENTIONS RATIONALES Assess family's coping methods and Identifies coping methods that work their effectiveness; family and the need to develop new coping interactions and expectations skills and behaviors, family related to long-term care, attitudes; child with special long- developmental level of family; term needs may strengthen or strain response of siblings; knowledge and family relationships and an undue use of support systems and degree of overprotection may be resources; presence of guilt and detrimental to child's growth and anxiety; overprotection and/or development (disallowing school overindulgent behaviors. attendance or peer activities, avoiding discipline of child, and disallowing child to assume responsibility for ADL. Encourage family members to express Reduces anxiety and enhances problem areas and explore solutions understanding; provides family an responsibly. opportunity to identify problems and develop problem solving strategies. Help family establish short- and long- Promotes involvement and control over term goals for child and integrate situations and maintains role of child into family activities, family members and parents. include participation of all family members in care routines. Provide assistance of social worker, Gives support to the family faced with counselor, or other as needed. long-term care of child with a serious illness. Suggest community agencies and contact Provides information and support to with the National Hemophilia child and family. Foundation or other families with a child with hemophilia. Encourage family members to express Allows for venting of feelings, which feelings, such as how they deal with relieves guilt and anxiety and helps the chronic needs of family member determine need for information and and coping patterns that help or support. hinder adjustment to the problems. Provide information regarding long- Enhances family understanding of term care and treatments. medical regimen and responsibilities of family members. Teach family that overprotective Promotes understanding of importance behavior may hinder growth and of making child one of the family development and that child should be and the adverse effects of treated as normally as possible. overprotection of the child. 7 of 10 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=71&FxId=123&Sessi. NIC: Family Involvement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What 3 coping mechanisms did the family identify? What are the short- and long-term goals established by the family? Provide quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR HEMOPHILIA 8 of 10 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=71&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: 9 of 10 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=71&FxId=123&Sessi. Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:16:32 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=71 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 8 - HEMATOLOGIC SYSTEM CHAPTER 8.3 - HEMOPHILIA Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 10 of 10 12/22/2006 7:46 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=72&FxId=123&Sessi. CHAPTER 8.4 - ITP INTRODUCTION Idiopathic thrombocytopenic purpura (ITP) is an acquired hemorrhagic blood disorder. It is characterized by excessive destruction of platelets (thrombocytopenia) and purpura (a discoloration caused by petechiae beneath the skin). Etiology is unknown but it is believed to be an autoimmune response to disease-related antigens. ITP is classified into two forms: 1) acute form, which arises usually after an upper respiratory infection, measles, mumps, or chickenpox; and 2) chronic form, which is unresponsive to treatment (with persistent thrombocytopenia) beyond 6 months of diagnosis. Classic signs and symptoms of ITP may include: easy bruising with petechiae, and/or ecchymosis over bony prominences; bleeding from mucous membranes (i.e., epistaxis, bleeding gums); hematuria; hematemesis; hemarthrosis; hematomas over the lower extremities. ITP is seen most frequently between the ages of 2 and 10 years in children. It is rarely seen in infants less than 6 months of age. Treatment is primarily supportive as the course of this disease is self-limiting. MEDICAL CARE Diagnostic Evaluation of ITP: Platelet count (below 20,000 mm3 to 30,000 mm3); bone marrow aspiration (to rule out malignant infiltration of the marrow); abnormal platelet function (prolonged bleeding time, tourniquet test, and clot retraction); higher than normal levels of megakaryocytes; all other blood studies are typically normal. Also, lab studies are performed to rule out systemic lupus erythematosus, lymphoma, and leukemia. Gamma Globulin (IVIG) (IV): can be expensive. Corticosteroids: sometimes helpful in increasing the platelet count. Anti-D Antibody Therapy: may increase platelet count after 48 hours. Blood Transfusions: packed red blood cells are given to replace blood lost in symptomatic children with ITP. Platelet transfusions are seldom administered. Splenectomy: reserved for symptomatic children with the chronic form of ITP or used as an emergency treatment when life-threatening hemorrhage occurs. Usually only performed in children older than 5 years. Pain Control: acetaminophen products are substituted for salicylates. COMMON NURSING DIAGNOSES See RISK FOR INJURY Related to: Autoimmune destruction of platelets. Defining Characteristics: (Specify: petechiae, ecchymoses, hematomas, damage from trauma.) See HYPERTHERMIA 1 of 5 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=72&FxId=123&Sessi. Related to: Infection. Defining Characteristics: (Specify: elevated temperature (above 38.5° C); elevated WBC counts indicating infection; and/or the presence of a positive culture for a bacterial organism.) ADDITIONAL NURSING DIAGNOSES ALTERED PROTECTION Related to: Abnormal blood profile (thrombocytopenia). Defining Characteristics: (Specify: platelet count below 20,000 cu mm/dL, petechiae, ecchymoses, bleeding from any mucous membrane area, hematomas on legs.) Goal: Child will be protected from effects of thrombocytopenia by (date and time to evaluate). Outcome Criteria √ No bleeding from any source. NOC: Abuse Protection INTERVENTIONS RATIONALES Assess for bleeding from gums, Provides information and data hematemesis, hematuria, indicating low platelet level hemathrosis, hematomas, epistaxis, and increased tendency for or evidence of easy bruising, bleeding. petechial rash. Avoid trauma to tissues by avoiding Prevents bleeding caused by use of hard toothbrush or dental trauma to sensitive areas. floss, taking rectal temperatures, performing unnecessary invasive procedures, and if administering an IM injection, applying pressure for 5 minutes to site. Administer medications (specify) as Administered to children who are ordered. at highest risk for excessive bleeding. Administer packed RBCs as ordered and Administered to replace blood monitor for responses, expected and loss or increase platelets. adverse reactions. Provide support in a warm, accepting Promotes trust and comfort environment for parents and child. during periods of stress. Teach parents and child about cause Provides information about the of disorder, reason for treatment disease needed to understand and signs and symptoms indicating treatments and care. presence or relapse of disease. 2 of 5 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=72&FxId=123&Sessi. Inform parents and child to avoid Prevents trauma that causes rough contact play; blowing nose bleeding. hard; straining at defecation; toys with sharp edges; using hard toothbrush; eating hard, rough foods. Teach parents and child about Promotes compliance in drug medications and to avoid aspirin therapy to prevent relapses in and aspirin over-the-counter bleeding; aspirin prevents products. platelet aggregation. Teach child to avoid those with upper Prevents risk for infection in respiratory infections or any susceptible child. illness. Teach about and allow return Identifies presence of bleeding demonstration of urine and stool in gastrointestinal or urinary testing for blood using dipstick tract or any other area. and hematest; inform to report other signs of bleeding including fatigue, pallor, headache, and blood in sputum or vomitus. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Is there any evidence of bleeding? What types of bleeding were ruled out?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR ITP 3 of 5 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=72&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library 4 of 5 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=72&FxId=123&Sessi. ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:16:52 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=72 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 8 - HEMATOLOGIC SYSTEM CHAPTER 8.4 - ITP Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 5 of 5 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. CHAPTER 8.5 - LEUKEMIA AND LYMPHOMA INTRODUCTION Leukemia is a malignant hemopoietic disease which is characterized by an unrestricted proliferation of poorly differentiated lymphocytes called blast cells that replace normal blood marrow elements. It occurs more frequently in male children after age 1 year. The peak age of onset is between 2 and 6 years. In children, the two most common forms of leukemia are: acute lymphoid leukemia (ALL) and acute myelogenous leukemia (AML). Pathologic effects of leukemia include the replacement of normal bone marrow elements by leukemic cells which results in clinical manifestations of anemia, neutropenia, and thrombocytopenia. Symptoms related to anemia may result in fatigue, weakness, pallor, and lethargy. Neutropenia predisposes the child to febrile episodes and infection. Symptoms related to thrombocytopenia may result in cutaneous bruises or purpura, petechiae, epistaxis, melena, and gingival bleeding. Other common symptoms related to leukemic infiltration include: hepatosplenomegaly and lymphadenopathy; bone and joint pain; anorexia; abdominal pain; weight loss. Other symptoms, that are very rare, may include: hematuria, gastrointestinal bleeding, or central nervous system (CNS) bleeding. Prognosis is based on age and initial WBC at diagnosis, sex, histologic type of the disease, number of chromosomes, the DNA-index, morphology and cell-surface immunologic markers. Lymphoma encompasses a group of neoplastic diseases that arise from the lymphoid and hemopoietic systems. There are two types: Hodgkin's disease and non-Hodgkin's lymphoma (NHL). NHL occurs more frequently and is the third most common childhood malignancy. In both types, it is observed in children under 15 years of age, and boys are affected more than girls. The peak incidence of NHL is between the ages of 7 and 11 years. Characteristics of Hodgkin's disease include: differentiated cells; pattern of infiltration is specific; subacute and a prolonged onset; and localized disease is present at the time of diagnosis. Characteristics of NHL include: undifferentiated cells; pattern of infiltration is diffuse; rapid onset; and widespread involvement at the time of diagnosis. Clinical manifestations of Hodgkin's disease exhibit: 60% to 90% of cases presenting with cervical or supraclavicular adenopathy; the enlarged lymph node will be painless, firm, and movable; 50% of cases will also have mediastinal involvement with symptoms of airway obstruction; anorexia; weight loss; malaise; lethargy, and fever. Clinical manifestations of NHL depend on site of involvement: 1/3 of cases, intra-abdominal site, with mediastinal, peripheral nodal, right quadrant pain, with or without fever, 1/4 of cases, mediastinal site, with respiratory symptoms. MEDICAL CARE FOR LEUKEMIA Treatment of leukemia involves multimodal therapy, including the use of chemotherapeutic agents with or without cranial irradiation in 3 phases. 1) Remission Induction Therapy includes corticosteroids (usually prednisone), vincristine (Oncovin), L-asparaginase, with or without doxorubicin; 2) CNS Prophylactic Therapy

includes intrathecal methotrexate; 3) Maintenance Therapy (or Consolidation) includes weekly methotrexate and daily 6-mercaptopurine. Supportive Therapies: for the treatment of side effects induced by the chemotherapy agents. Prophylactic Antibiotic Therapy: to reduce the incidence of infections. Infection is a frequent threat resulting from immunosuppression effects of chemotherapy agents. Granulocyte Colony-Stimulating Factors (GCSF): filgrastim (Neupogen) IV or subcutaneously 24 hours after chemotherapy is discontinued and is given for 10 to 14 days. GCSF directs granulocyte development, which decreases the duration of the neutropenia. 1 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. Replacement of Blood Elements: for the treatment of anemia, agranulocytopenia, and thrombocytopenia. Prevention and Treatment of Oral Ulcers (Stomatitis): Peridex is the most commonly used mouth rinse to prevent or treat Candida and bacterial infections. Other mouth rinses that can be used include normal saline or baking soda solutions. Antifungal and antibacterial mouthwashes (nystatin) are used after mouth rinses 30 minutes after using Peridex. Use a soft sponge toothbrush (Toothette). Severe Oral Infections: Acyclovir may be used to treat severe oral lesions. Treatment of Oral Ulcer Pain: utilization of analgesics such as Chloraseptic lozenges, Orabase, or opiates. Prevention and Management of Nausea and Vomiting: administration of antiemetic before the chemotherapy begins (30 minutes to 1 hour) and every 2, 4, or 6 hours for at least 24 hours after chemotherapy. Diagnostic Evaluation of Leukemia (includes the following): Complete Blood Count: decreased white blood cells, red blood cells, and platelets. Physical Examination: liver, spleen, lymph nodes and the mediastinal area; weight loss; bone or joint pain; petechiae; abdominal pain. Bone Marrow Aspiration: reveals hypercellularity with 60% to 100% blast cells. Lumbar Puncture: evaluates the presence of central nervous system (CNS) leukemia. Number of Chromosomes: number of chromosomes (ploidy or the DNA index) in the lymphoblasts. Better prognosis: DNA index of more than 1.16 and more than 46 chromosomes. Cytogenic Abnormalities: presence of translocation of portions of one chromosome (e.g., the Philadelphia chromosome). Presence of the Philadelphia chromosome is least favorable. Enzymes: lactic dehydrogenase (LDH), serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvic transaminase (SGPT). Monoclonal Antibodies: used to detect the presence of the common ALL antigen (CALLA) on leukemic cells. A positive CALLA is associated with a good prognosis. Cell-Surface Immunologic Markers: B-cell (early pre B-cell, pre B-cell or B-cell) or T-cell. Urine Tests: blood urea nitrogen (BUN), creatinine, and uric acid may be elevated. Computerized Tomography Scans (CT): may reveal infiltrated sites with leukemic cells, such as the kidneys, testes, prostrate, ovaries, gastrointestinal tract, and lungs. FOR LYMPHOMA Medical Care for Hodgkin's Disease and NHL: 2 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. Diagnostic Evaluation for Hodgkin's Disease: Laboratory Studies: CBC, erythrocyte sedimentation rate (ESR), serum copper and iron levels, serum ferritin and transferrin, renal and liver function tests, baseline thyroid function tests, T and B lymphocyte levels, PPD skin test. Evaluation Includes: chest X-ray; CT scan of the mediastinal, pulmonary and upper abdominal area; ultrasound of neck and abdomen; isotope scanning; MRI; lymphangiogram (LAG); lymph node biopsy. Diagnostic Evaluation for Non-Hodgkin's Disease: Laboratory Studies: CBC with differential, liver and renal function studies, electrolyte, calcium, phosphorus, magnesium, lactate dehydrogenase (LDH), uric acid, EBV titers and urinalysis. Evaluation Includes: bone marrow aspiration, lumbar puncture, lymph node biopsy, radiographic studies, CT scans of the lungs and gastrointestinal tract. Supportive Therapies for Both Types: are similar to the care discussed in the leukemia child. Treatment for Hodgkin's Disease: radiation and chemotherapy. Chemotherapy Agents for Hodgkin's Disease: (2 regimens) 1) MOPP: mechlorethamine, vincristine, prednisone, and procarbazine; 2) ABVD: (for advanced disease) adriamycin, bleomycin, vinblastine, and dacarbazine. Treatment for Non-Hodgkin's Disease: chemotherapy and radiation therapy. Chemotherapy Agents for NHL: similar to leukemia. COMMON NURSING DIAGNOSES See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: (Specify: loss of appetite; and/or pain in mouth; induced malabsorption or enteropathy [caused by abdominal radiation, chemotherapy, abdominal surgery, or frequent antibiotic use]; and anorexia-inducing substances [secreted by tumor cells]; xerostomia (irreversible dryness of mouth], destruction of microvilli of taste buds and/or lining of salivary glands [all can be caused by radiation therapy].) Defining Characteristics: (Specify: anorexia, nausea, vomiting, stomatitis, mucositis, decreased salivation, cachexia, fatigue, diarrhea, alterations in taste, gustatory changes, weight loss, abdominal pain, psychologic and sociocultural factors.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Excessive losses. Defining Characteristics: (Specify: vomiting and diarrhea; blood losses (i.e., hemorrhagic cystitis, epistaxis, hemoptysis.) See DIARRHEA 3 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. Related to: (Specify: surgery, radiation, chemotherapy, increased emotional stress, use of nutritional supplements, lactose intolerance, fecal impaction, tumor growth, infection or antibiotics.) Defining Characteristics: (Specify: abnormal increase in quantity, frequency, and fluid content of stool.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: (Specify: delayed wound healing, immobility, external exposure to radiation, administration of chemotherapy and antibiotics.) Defining Characteristics: (Specify: radiation effects: erythema, dryness, itching, increased pigmentation, dry desquamation, necrotic tissue; chemotherapy and antibiotic induced side effects: local phlebitis, stomatitis, mucositis, maculopapular rash, hyperpigmentation, nail changes, pruritus, dermatitis, alopecia, photosensitivity, acne, erythema, poor wound healing.) See RISK FOR INFECTION Related to: (Specify: disease process; immunosuppression caused by required chemotherapy; prolonged antibiotic and prednisone therapy; skin breakdown, serious bacterial, viral fungal, and protozoan infections; surgery and/or splenectomy; invasive procedures; GI obstruction; malnutrition, inadequate serum protein level.) Defining Characteristics: (Specify: increase in body temperature above normal range [>38.3° C or 101° F], neutropenia; inadequate number of neutrophils: severe risk of infection [<500/mm3] or moderate risk of infection [<1000 mm3]; presence of pathogens may or may not be identified from blood cultures.) ADDITIONAL NURSING DIAGNOSES FEAR Related to: Diagnostic tests, procedures, treatments, diagnosis and prognosis. Defining Characteristics: (Specify: child: crying, screaming, combative behaviors, anger, withdrawn behaviors, and verbalized fears; parents: fear, guilt, depression, anxiety.) Goal: Child will experience decreased fear by (date and time to evaluate). Outcome Criteria √ Child is calm. √ Child reports feeling less afraid. NOC: Fear Control INTERVENTIONS RATIONALES Assess child and parents' level of Provides information about fears. 4 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. anxiety and fear. Explain to the child what will take To increase the child's sense of place and what the child will control before and during feel, see, and hear during various procedures. procedures. Encourage child and parents to be To promote the child's and involved with procedure (specify). parents' sense of control. Remain nonjudgmental regarding the Encourages supportive child's behaviors and fears. relationship child's behavior. Teach parents and child about the Provides information that will disease process and treatments, relieve fear and anxiety; including radiation chemotherapy understanding of treatments and and its benefits and side effects effect on body image. (nausea, vomiting, diarrhea, stomatitis, alopecia are possibilities but are temporary). Explain all procedures, treatments, Supplies information about and care in simple, direct, honest diagnostic procedures and terms and repeat as often as tests, such as CBC, platelets necessary; reinforce physician with chemotherapy; and scans information if necessary and and X-rays for diagnosis. provide specific information as needed. Introduce child to another who has Provides information and support same disease. from a peer with the same condition and who has empathy. NIC: Anxiety Reduction Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Describe child's behavior. Did child report feeling less fearful? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) PAIN Related to: (Specify: disease-related, treatment-related and procedure-related.) Defining Characteristics: (Specify: multidimensional aspects of the cancer pain experience in children with cancer include components of assessment of cognitive of self-report, physiologic responses, behavioral manifestations, and the child's developmental level.) Goal: Child will experience less pain by (date and time to evaluate). Outcome Criteria 5 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. √ Ranks pain as less than (specify level and pain scale being used). NOC: Pain Level INTERVENTIONS RATIONALES Assess the following three areas: 1) Provides information about pain self-report responses of the child's that varies with age, pain (use words and pain assessment developmental level of child and tools that help the child to is unique to a particular child's describe pain (specify); learned emotional responses; 2) behavioral manifestations (i.e., degree of pain and fatigue crying, facial expressions, muscle influence ability of child to tension, screaming, pain perceive and identify discomfort. verbalization, physical resistance, favors affected body parts, more common to observe during procedure- related pain or acute episodes); and 3) physiologic responses (evaluation of sweating palms, increased heart and respiratory rates, increased blood pressure, use along with self- report and behavioral assessments). Assess need for pain management. Ensures consistency of pain management strategies. Administer analgesics as prescribed Ensures effective pain management; (specify), on a preventive pain promotes comfort and rest; schedule, and monitor side effects fosters a trusting and caring of analgesics. relationship between the child, family, and health care team. Apply EMLA cream to sites to be used Minimizes pain related to intrusive for intrusive painful procedures procedures; ensures child's (i.e., venipuncture, bone marrow safety during scheduled intrusive aspiration, lumbar puncture, procedures. implanted port access, subcutaneous and intramuscular injections); it must be applied 1 hour before the procedure to be effective. Evaluate effectiveness of pain relief Ensures effective pain control and from all pain medication used. management. Promote rest and avoid disturbing Decreases stimuli that increase child unnecessarily. pain, and promotes rest to conserve energy. Maintain body alignment and support, Promotes comfort and prevents and immobilize limbs with pillows contractures. and sand bags. Apply heat (moist or dry) to painful Relieves pain by promoting areas. circulation to the area. Provide toys and activities for quiet Provides diversion and distraction play appropriate for age; use music, from pain. relaxation techniques; remain with child when pain is most acute. 6 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. Inform child of cause of pain and Promotes understanding of pain interventions to relieve it, of how response and methods to reduce medications are administered and it. actions to expect; to report pain before it becomes severe. Educate child and parents on various Enhances trust between the nurse, distraction techniques (i.e., child and the family; also, may counting, music, imagery, deep minimize the child's pain breathing, self-talk, positioning, perceptions and foster a sense of reassurance, prayer, massage, control during intrusive therapeutic touch, relaxation). procedures. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is pain rating? Specify scale used.) (Revisions to care plan? D/C care plan? Continue care plan?) IMPAIRED ORAL MUCOUS MEMBRANES Related to: (Specify: administration of chemotherapy agents, side effect of radiotherapy, long-term administration of antibiotics.) Defining Characteristics: (Specify: oral ulcers [stomatitis] are red, eroded, painful areas in the mouth and pharynx; and similar lesions [as stomatitis] that may extend along the esophagus and in the rectal area.) Goal: Child will experience healing mucous membranes by (date and time to evaluate). Outcome Criteria √ Mucous membranes are intact without lesions. NOC: Tissue Integrity: Skin and Mucous Membrane INTERVENTIONS RATIONALES Assess mouth daily for oral ulcers, To effectively treat oral ulcers pain, ability to ingest foods; and to promote healing; to provide meticulous oral hygiene, to prevent bacterial and Candida prevent oral breakdown and to infections; to prevent trauma promote healing (start as soon as a to oral mucosa. drug is used that causes oral ulcers): use a soft sponge toothbrush or toothette, administer 7 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. frequent mouth rinses, at least every 4 hours and after meals; mouth rinses commonly used include Peridex, normal saline with or without sodium bicarbonate solution. Administer nystatin mouthwashes as To maintain oral integrity; to ordered after mouth rinses; treat bacterial and fungal restrict oral intake for 30 minutes infections. after taking this mouthwash. Administer Acyclovir (topically or To prevent or treat herpetic IV) for oral herpes lesions as infections. ordered. Apply local anesthetics to ulcerated To relieve pain associated with areas before meals and as needed to oral ulcers. relieve pain; topical agents include: Ora-base; can be applied directly to oral lesions as ordered or swished and spit. Apply lip balm (daily). To

prevent cracking and fissuring of lips; to maintain lip integrity. Encourage a bland, soft diet and To minimize oral discomfort and selection of foods by child. irritation; enhances sense of control, independence, decreases sense of helplessness; may increase child's level of nutrition. Avoid using lemon glycerin swabs. To prevent irritation of mouth ulcers decay of teeth. Avoid juices containing ascorbic To prevent discomfort to oral acid, hot, cold, or spicy foods. ulcers. Avoid use of hydrogen peroxide as a It will delay healing of oral mouth rinse. ulcers by breaking down protein. Avoid use of milk of magnesia. To prevent drying of oral mucosa. Provide education to parents and Promotes understanding of oral child: 1) chemotherapy and stomatitis, significance of radiation may cause oral ulcers; 2) daily oral hygiene, and pain effective oral hygiene strategies control for oral ulcers. to prevent and treat oral ulcers; 3) child may require hospitalization (for hydration, parental nutrition, pain control of oral ulcers) if stomatitis interferes with food or fluid intake. NIC: Surveillance Evaluation 8 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Is there any evidence of mucous membrane impairment or new lesions?) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INJURY Related to: (Specify: disease process; immunosuppression, thrombocytopenia and other side effects from chemotherapy and radiation treatments.) Defining Characteristics: (Specify: fever [>38.3° C or 101° F], secondary infections; fatigue; anemia [hemoglobin level <11 g]; neutropenia [absolute neutrophil count <1000/mm3]; risk of hemorrhage or bleeding tendencies [platelet count of 20,000/mm3]; side effects of chemotherapy.) Goal: Child will not experience injury by (date and time to evaluate). Outcome Criteria √ Temperature remains <101° F. √ No evidence of bleeding. NOC: Risk Detection INTERVENTIONS RATIONALES Assess for bleeding from any site, Provides information about frank WBC, platelet count, Hct, absolute bleeding or blood profile neutrophil count, and febrile abnormalities that predispose to episodes. bleeding caused by bone marrow suppression and immunosuppression resulting from chemotherapy or radiation therapy. Avoid trauma by not using hard Prevents bleeding during toothbrush or dental floss, not chemotherapy regimen, which taking rectal temperatures, not alters platelet and clotting performing unnecessary invasive factors. procedures. Carry out handwashing technique Prevents transmission of pathogens before giving care, use mask and to a compromised immune system gown when appropriate, provide a during chemotherapy if neutrophil private room, monitor for any signs count is less than 1000/cu mm. and symptoms of infection, especially pulmonary. Teach parents and child to avoid Prevents trauma that causes rough play or sports, straining at bleeding. defecation, blowing nose hard. Teach parents and child to avoid Prevents risk for infection in the 9 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. those with upper respiratory highly susceptible child. infection or any illness. Teach parents to report any fever, Indicate complications associated behavior changes, headache, with an abnormal blood profile. dizziness, fatigue, pallor, slow oozing of blood from any area, exposure to a communicable disease. Show and allow for return Identifies presence of bleeding in demonstration of urine and stool gastrointestinal or urinary testing for blood using dipstick tract. and hematest. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is temperature? Is there any evidence of bleeding?) (Revisions to care plan? D/C care plan? Continue care plan?) DISTURBED BODY IMAGE Related to: Side effects of chemotherapy and radiation therapy. Defining Characteristics: (Specify: loss of hair; moon face; weight loss or gain; hyperpigmentation; skin rash or erythema; acne; skin thickening; or peeling of skin.) Goal: Child will experience improved body image by (date and time to evaluate). Outcome Criteria √ Child expresses feelings about how he or she looks. √ Child identifies at least 1 positive thing about own body. NOC: Body Image INTERVENTIONS RATIONALES Assess child for feelings about Provides information about status of multiple restrictions in self-concept and body image, that lifestyle, chronic illness, may require special attention. difficulty in school and social situations, inability to keep up with peers and participate in 10 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. activities. Encourage expression of feelings and Provides opportunity to vent concerns and support communication feelings and reduce negative with parents, teachers and peers. feelings about changes in appearance. Avoid negative comment and stress Enhances body image and confidence. positive activities and accomplishments. Note withdrawal behavior and signs Reveals responses to body image of depression. changes and possible poor adjustment to chances. Show support and acceptance of Promotes trust and demonstrates changes in appearance of child; respect for child. provide privacy as needed. Encourage parents to maintain Encourages acceptance of the child support for child. with special needs (must deal with long-term steroid therapy and its side effects, lifelong activity restrictions). Teach parents and child about the Provides correct information to risk for hair loss; correct assist in dealing with negative misinformation and suggest ways to feelings about body. cope with body changes. Encourage parents to be flexible in Promotes child's sense of wellbeing care of child; to integrate care and of belonging and having and routines into family control of life events by allowing activities, and allow child to participation in normal activities participate in peer activities. for age and enhancing developmental task achievement. Assist parents and child to deal Prevents stigmatization of child by with peers and perceptions of those who are not apprised of the appearance and how to tell others child's disease; attitude of about change in appearance. others will affect child's body image. Suggest a cap, scarf, or other head Preserves body image by covering covering. head if alopecia is present. Suggest psychological counseling or Assists in improving self-esteem and child-life worker, and inform of in learning, coping and problem functions performed by these solving skills. professionals. NIC: Self-Esteem Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What feelings about disability did child verbalize? What positive thing about their body did child identify? Use quotes.) 11 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. (Revisions to care plan? D/C care plan? Continue care plan?) INEFFECTIVE COPING AND COMPROMISED FAMILY COPING Related to: (Specify: for the child: separation from family, friends, home, and school activities; loss of control, altered self-image, altered body image, altered self-esteem, and altered sense of self-confidence. For the parents: uncertainty of child's future, sense of helplessness and powerlessness, multiple family stressors and demands [related to child's health care needs].) Defining Characteristics: (Specify: for the child: depression, anxiety, withdrawn, excessive outbursts of temper, insecurity, sleep and/or eating disturbances, regressive behaviors, behavioral problems [acting out], denial, difficulties in interpersonal relationships, nonadherence with treatment. For parents: shock, disbelief, anger, guilt, numbness, denial, ambivalence, bargaining, overprotectiveness, grief for the loss of their healthy child, anticipatory grief for the potential loss of their child.) Goal: Family and child will cope more effectively by (date and time to evaluate). Outcome Criteria √ Family and child identify stressors. √ Family and child verbalize 3 effective coping mechanisms to use. NOC: Coping INTERVENTIONS RATIONALES Assess effectiveness of family coping Provides information identifying methods; family interactions and successful coping methods or the expectations related to long-term, need to develop new coping skills, developmental level of family; behaviors and family attitudes; response of siblings; knowledge child with overprotection (e.g., and use of support systems and not allowing child to attend resources; presence of guilt, school, participate in activities anxiety, overprotective and/or with peers, or assume overindulgent behaviors. responsibilities for ADL; avoiding disciplining of child) may be at risk in growth and development. Encourage family members to express Reduces anxiety and enhances stressors and explore solutions understanding; allows family to responsibly. identify problems and develop problem solving strategies. Assist family in establishing short- Promotes involvement and control over and long-term goals for child and situations, and maintains role of in integrating child into family family members and parents. activities; include participation of all family members in care routines. Provide assistance of social worker, Provides support to the family faced counselor, clergy, or other as with long-term care of child with a needed. threatening illness. serious, life Suggest community agencies and the Provides information and support to 12 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. American Cancer Society, that can child and family. provide contacts with families that have a child with leukemia or lymphoma. Allow family members to express Allows for venting of feelings to feelings on how they deal with the determine need for information and chronic needs of family member and support, and relieves guilt and on coping patterns that help or anxiety. hinder adjustment to the problems. Inform family of requested and needed Enhances family understanding of information regarding long-term medical regimen and care and treatments. responsibilities of family members. Inform family that overprotective Promotes understanding of importance behavior may hinder growth and of making child one of the family development and that child should and the adverse effects of be treated as normally as possible. overprotection of the child. Assist child and family to identify Empowers the clients to take control at least 3 coping mechanisms they of coping methods and find can use to cope with the stressors alternatives. of the child's illness. NIC: Family Involvement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What stressors did the child and family identify? What 3 coping mechanisms did the child and family verbalize? Provide quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR LEUKEMIA AND LYMPHOMA 13 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. 14 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=73&FxId=123&Sessi. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:17:06 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=73 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 8 - HEMATOLOGIC SYSTEM CHAPTER 8.5 - LEUKEMIA AND LYMPHOMA Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 15 of 15 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=74&FxId=123&Sessi. UNIT 9 - ENDOCRINE SYSTEM CHAPTER 9.0 - ENDOCRINE GROWTH AND DEVELOPMENT INTRODUCTION The endocrine system includes the cells of certain glands that produce hormones; the organ or tissue sites that receive the hormone; and the transport system of the blood, lymph, and extracellular fluids that move the hormones from the point of origin to the point of utilization. Hormones may regulate general cell physiologic activities or may affect specific cells of the body. Glands included in this system are the pituitary, thyroid, parathyroid, adrenal, isles of Langerhans, ovaries, and testes. The system regulates and integrates functions with the neurologic system that assist the body to adjust behavior, growth, development, and sexual reproduction. In children, abnormal conditions involving these glands are caused by oversecretion or undersecretion of hormones or by a problem in the response to these hormones by the receiving organ or tissue. These abnormalities may result from congenital or acquired factors. They are usually treated by partial or complete surgical removal of the gland and/or drug therapy to replace hormone deficiencies. GROWTH AND DEVELOPMENT • Endocrine glands are well developed at birth, but their functions are immature. • Secondary sex characteristics usually develop between 10 and 18 years of age in girls and between 12 and 20 years of age in boys; menarche usually occurs between 12 and 13 years of age. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar

Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 1 of 2 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=74&FxId=123&Sessi. 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:17:23 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=74 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 9 - ENDOCRINE SYSTEM CHAPTER 9.0 - ENDOCRINE GROWTH AND DEVELOPMENT Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 2 of 2 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=75&FxId=123&Sessi. CHAPTER 9.1 - INSULIN-DEPENDENT DIABETES MELLITUS INTRODUCTION Insulin-dependent diabetes mellitus (IDDM) is a metabolic disorder caused by a deficiency of insulin. The deficiency is thought to occur in those individuals who are genetically predisposed to the disease and who have experienced a precipitating event, commonly a viral infection or environmental change, that causes an autoimmune condition affecting the beta cells of the pancreas. It is treated by injection of insulin and regulation of diet and activity that maintain body functions. Complications that occur from improper coordination of these include hypoglycemia and hyperglycemia which, if untreated, lead to insulin shock or ketoacidosis. Long-term effects of the disease include neuropathy, nephropathy, retinopathy, atherosclerosis, and microangiopathy. MEDICAL CARE Insulin Replacement: given to control blood glucose concentrations; administered one, two, or more times/day individually prescribed for child. Blood Glucose: reveals levels greater than 120 mg/dL in a fasting specimen and 200 mg/dL or greater in a random specimen; 300 mg/dL level in ketoacidosis. Ketones: reveal increase in the blood and urine. Urine Glucose: reveals glycosuria. COMMON NURSING DIAGNOSES See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to metabolize glucose. Defining Characteristics: (Specify: loss of weight with adequate food intake, lack of interest in food, inadequate intake, insufficient insulin, too much insulin.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: (Specify: injections and blood glucose monitoring, altered metabolic state, sensation, nutritional state.) Defining Characteristics: (Specify: disruption of skin surfaces with daily injections [lipodystrophy], failure to rotate sites, weight loss, poor wound healing, dry skin.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Osmotic diuresis. Defining Characteristics: (Specify: output greater than intake, decreased urine output, dry skin and mucous membranes, poor skin turgor, 1 of 10 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=75&FxId=123&Sessi. dehydration with electrolyte depletion [K+, Na+, Cl-, Mg2+, PO3-] with ketoacidosis, polyuria, polydipsia.) ADDITIONAL NURSING DIAGNOSES RISK FOR INJURY Related to: (Specify: hyperglycemia or hypoglycemia.) Defining Characteristics: (Specify: hyperglycemia—fatigue, irritability, headache, abdominal discomfort, weight loss, polyuria, polydipsia, polyphagia, dehydration, blurred vision; hypoglycemia—nervousness, sweating, hunger, palpitations, weakness, dizziness, pallor, behavior changes, uncoordinated gait.) Goal: Client will not experience injury from hyperglycemia or hypoglycemia. Outcome Criteria √ Blood glucose levels remain between 60 mg/dL and 120 mg/dL. √ Urine is free of ketones and glucose. NOC: Risk Detection INTERVENTIONS RATIONALES Assess for signs and symptoms of Provides information about complication hyperglycemia, blood glucose level, caused by increased glucose levels urinary glucose and ketones, pH and resulting from improper diet, an electrolyte levels. illness, or omission of insulin administration; glucose is unable to enter the cells, and protein is broken down and converted to glucose by the liver, causing the hyperglycemia; fat and protein stores are depleted to provide energy for the body when carbohydrates are not able to be used for energy. Administer insulin SC as ordered Provides insulin replacement to maintain (specify), rotate sites, increase normal blood glucose levels without dosage as indicated by glucose levels; causing hypoglycemia; two or more decrease food intake during an injections may be given daily SC with a infection or illness and adjust portable syringe pump or by insulin dosage during an illness. intermittent bolus injections with a syringe and needle. Provide diet with calories that balance Provides child's nutritional needs for expenditure for energy (specify) and proper growth and development using the correspond to type and action of exchange system developed and approved insulin, and snacks between meals and by the American Diabetic Association at bedtime as appropriate. (ADA), or by carbohydrate counting—monitoring carbohydrate intake 2 of 10 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=75&FxId=123&Sessi. only, maintaining consistent level at meals and snacks, and adjusting insulin as needed (requires close collaboration with physician). Promote exercise program consistent with Aids in the utilization of dietary dietary and insulin regimen; teach to intake, regular activity may reduce increase carbohydrate intake before amount of insulin required; a decrease vigorous activities. hypoglycemia. in insulin and increased carbohydrate intake before vigorous exercise or activity may prevent Assess for signs and symptoms of Provides information about episodes of hypoglycemia, blood-glucose level. hypoglycemia resulting from increased activity without additional food intake or omission or incomplete ingestion of meals, incorrect insulin administration, illness. Provide rest and immediate source of a Alleviates the symptoms of hypoglycemia simple carbohydrate such as honey, as soon as symptoms are noted; glucagon milk, or fruit juice followed by a releases the glycogen stored in the complex carbohydrate such as bread in liver to assist in restoring glucose amounts of 15 gm; repeat intake in 10 levels; IV glucose is administered when minutes for expected response of a condition is severe and child is unable reduced pulse rate; administer IV 50 to take glucose source PO. Glucagon, a percent glucose or glucagon IM if hormone, releases stored glycogen from hypoglycemia is severe. the liver and raises blood glucose in 5 to 15 minutes. Teach parents and child signs and Provides information about abnormal blood symptoms to note, reasons why they glucose levels causing complications of occur, and interventions to correct hyperglycemia, hypoglycemia, and the the complication. consequences. Teach parents and child to regulate Maintains child's growth and development insulin, manage dietary intake, and needs while preventing complications. exercise to accommodate needs of individual child. Teach parents and child to adjust Prevents and/or treats hyperglycemia; insulin administration based on blood- avoids serious complication of glucose testing and glycosuria, during ketoacidosis. an illness or after changes in food intake or activities. Teach parents and child to administer a Prevents and/or treats hypoglycemia. quick-acting carbohydrate followed by a longer-acting carbohydrate and to have Lifesavers, sugar cubes, Insta- glucose on hand at all times; instruct parents that, in the case of severe hypoglycemia, if the child is unconscious or unable to take oral fluids, to rub honey or syrup on the child's buccal surface until alert enough to take fluids/foods by mouth. Inform parents and child to report Prevents more serious complications and erratic blood and urine test results, long-term effects of the disease; poor 3 of 10 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=75&FxId=123&Sessi. difficulty in controlling blood control leads to serious and severe glucose levels, presence of an consequences in a few hours. infection or illness. NIC: Surveillance Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is blood-glucose level? Is there any evidence of ketonuria or glucosuria?) (Revisions to care plan? D/C care plan? Continue care plan?) DEFICIENT KNOWLEDGE Related to: Lack of information about disease. Defining Characteristics: (Specify: new diagnosis of IDDM; request for information about pathology, insulin therapy, dietary requirements, activity/exercise needs, blood and urine testing, personal hygiene and health promotion.) Goal: Clients will obtain information about child's illness and treatment by (date and time to evaluate). Outcome Criteria √ Clients verbalize understanding of IDDM. √ Clients demonstrate correct blood-glucose monitoring insulin administration, dietary management, and exercise planning. √ Clients identify signs and symptoms of hypo- and hyperglycemia and correct response. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess parents and child for knowledge Provides information needed to of disease and ability to perform plan teaching program; children procedures and care, for educational 8 to 10 years of age may be able level and learning capacity, and for to take responsibility for some developmental level. of the care. Teach about cause of disease, disease Provides basic information that process and pathology; use pamphlets may be used as a rationale for and other aids appropriate for age of treatments and care and allows child and level of comprehension of for different teaching parents. strategies. Provide a quiet, comfortable Prevents distractions and environment; allow time for teaching facilitates learning. 4 of 10 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=75&FxId=123&Sessi. small amounts at a time and for reinforcement, demonstrations and return demonstrations; start teaching 1 day following diagnosis and limit sessions to 30 to 60 minutes. Include as many family members in Promotes understanding and support teaching sessions as possible. of family and feeling of security for child. Instruct parents and child in insulin Promotes accurate administration administration including storing of insulin, which prevents insulin, drawing up insulin into complications. syringe, rotating vial instead of shaking, drawing clear insulin first if mixing 2 types in same syringe, injecting SC, rotating sites, adjusting dosages, reusing syringe, and needle, and disposing of them. (Instruct in use of syringe-loaded Provides temporary method of injector.) insulin administration if child is afraid to puncture skin. (Instruct parents and child in operation Provides continuous subcutaneous and use of a portable insulin pump to insulin infusion. adjust insulin delivery.) Teach parents and child about collection Monitors glucose and ketone levels and testing of blood for glucose 4 in blood and urine. times a day (before meals and before bed), with a lancet and blood-testing meter or a reagent strip compared to a color chart; collection and testing of urine with ketostix or Clinitest (specify). Teach parents and child about dietary Provides information about an planning with emphasis on proper meal important aspect of total care times and adequate caloric intake of the child with diabetes according to age as ordered (offer according to the American food lists for free foods and Diabetic Association guidelines. exchanges according to the basic four groups and assist in preparing sample menus). Teach that food intake depends on activity, and describe methods to judge amounts of foods; provide list of acceptable food items from "fast food" restaurants, published by the ADA. Teach parents and child about role of Provides information about usual exercise and alterations needed in activity pattern and effect on food and insulin intake with increased dietary intake and insulin or decreased activity. needs. Teach parents and child about skin Provides information about common problems associated with diabetes, problems resulting from long- need for regular dental examinations, term effects of the disease. foot care, protection of and proper 5 of 10 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=75&FxId=123&Sessi. care of nails, prevention of infections and exposure to infections, eye examinations, immunizations. Instruct parents and child in record- Provides a method to enhance self- keeping for insulin, test results, care and demonstrates the need responses to diet and exercise, to notify physician for noncompliance in medical regimen and treatment evaluation and effects. possible change. Encourage child to wear or carry Provides information in event of identification and information about emergency. the disease, treatment, and physician name. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did clients verbalize understanding of IDDM? Did clients demonstrate correct glucose monitoring, insulin administration, diet management, and exercise planning? Did clients identify signs and symptoms of hypo- and hyperglycemia and correct response? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) COMPROMISED FAMILY COPING Related to: (Specify: inadequate or incorrect information or understanding, prolonged disease or disability progression that exhausts the physical and emotional supportive capacity of caretakers.) Defining Characteristics: (Specify: expression and/or confirmation of concern and inadequate knowledge about long-term care needs, problems and complications, anxiety and guilt, overprotection of child.) Goal: Family will cope effectively by (date and time to evaluate). Outcome Criteria √ Family explores feelings about long-term needs of child. √ Family identifies support systems and coping skills. NOC: Family Coping INTERVENTIONS RATIONALES Assess family coping methods and Identifies coping methods that work effectiveness, family interactions and the

need to develop new coping and expectations related to long- skills and behaviors, family 6 of 10 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=75&FxId=123&Sessi. term care, developmental level of attitudes; child with special long- family, response of siblings, term needs may strengthen or strain knowledge and use of support systems family relationships, and that over- and resources, presence of guilt and protection may be detrimental to anxiety, overprotection and/or child's growth and development overindulgence behaviors. (e.g., not allowing child to attend school or participate in peer activities; avoiding discipline of child; and not allowing child to assume responsibilities for care). Encourage family members and child to Reduces anxiety and enhances express problem areas, anxiety and understanding; provides family an explore solutions responsibly. opportunity to identify problems and develop problem-solving strategies. Assist family to establish short- and Promotes involvement in and control long-term goals for child and to over situations and maintains role integrate child into family of family members and parents. activities, include participation of all family members in care routines. Provide assistance of social worker, Provides support to the family faced counselor, clergy, or other as with long-term care of child with a needed. chronic illness. Suggest community agencies and contact Provides information and support to with the American Diabetic child and family. Association or other families with a diabetic child. Allow family members to express Allows for venting of feelings to feelings, to tell how they deal with determine need for information and the chronic needs of family member, support and to relieve guilt and and to describe coping patterns that anxiety. help or hinder adjustment to the problems. Teach family about long-term care and Enhances family understanding of treatments. medical regimen and responsibilities of family. Teach family that overprotective Promotes understanding of importance behavior may hinder growth and of making child one of the family development so they should treat and demonstrates the adverse effects child as normally as possible. of overprotection of the child. Discuss importance of follow-up Promotes positive outcome when family appointments for physical collaborates with the physician and examinations, laboratory tests. health team to monitor disease. NIC: Family Involvement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 7 of 10 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=75&FxId=123&Sessi. (Did family explore feelings about long-term needs of child? What support systems and coping mechanisms did the family identify? Provide quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR INSULIN-DEPENDENT DIABETES MELLITUS 8 of 10 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=75&FxId=123&Sessi. 9 of 10 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=75&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:17:38 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=75 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 9 - ENDOCRINE SYSTEM CHAPTER 9.1 - INSULIN-DEPENDENT DIABETES MELLITUS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 10 of 10 12/22/2006 7:47 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=76&FxId=123&Sessi. CHAPTER 9.2 - HYPOTHYROIDISM INTRODUCTION Hypothyroidism is the result of inadequate thyroid hormone production to maintain body processes. It may be the result of congenital thyroid abnormality and therefore present in infancy or it may become notable during the first two years of life. It appears later when production is inadequate to maintain body processes as rapid growth increases the need for hormones. Acquired causes of the condition may be thyrotoxicosis, thyroidectomy, irradiation, infections, and dietary deficiency of iodine. Secretions of the thyroid gland include thyroid hormone (thyroxine, T4 and triiodothyronine, T3) which are bound to proteins in the blood (thyroxine-binding globulin, TBG) and thyrocalcitonin (maintains calcium levels in blood). The hormones are controlled by the thyroid-stimulating hormone (TSH) that is secreted by the anterior pituitary gland. Treatment of hypothyroidism is by thyroid hormone replacement, which involves prompt intervention in the infant and gradually increasing amounts of hormone administration in the child. Treatment is maintained throughout life to ensure restoration of thyroid deficiency. MEDICAL CARE Hormones: levothyroxine sodium (Synthroid) as replacement therapy for diminished or absent thyroid function. Vitamins: vitamin D to ensure calcium levels during periods of growth requiring increased demands. Lab Tests: T3 (triodothyronine), T4 (thyroxine), TBG (thyroxine-binding globulin), TSH (thyroid-stimulating hormone) by RIA (radioimmunoassay testing) reveals decreases indicating hormone deficiency. Protein-Bound Iodine: reveals increases after 2 months of age. Bone X-ray: reveals bone age and effect of thyroid deficiency or treatment. Scan: reveals presence of gland with location, size, and shape of the organ; radioactive iodine uptake by thyroid gland is scanned and displayed on a screen for examination. COMMON NURSING DIAGNOSES See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Internal factor of altered metabolic state (hypothyroidism). Defining Characteristics: Skin pale, cool, dry, and scaly. See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: Inability to ingest or digest food; decreased body processes. Defining Characteristics: Poor feeding, choking, thick tongue in infant; lethargy, reduced metabolic process, anorexia in child. 1 of 4 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=76&FxId=123&Sessi. See CONSTIPATION Related to: Less than adequate physical activity, decreased body process. Defining Characteristics: Lethargy, decreased peristalsis, fatigue, reduced activity level. ADDITIONAL NURSING DIAGNOSES DEFICIENT KNOWLEDGE Related to: Lack of information about disorder. Defining Characteristics: Request for information about cause and treatment of the disorder, thyroid replacement. Goal: Clients will obtain information about child's illness and treatment by (date and time to evaluate). Outcome Criteria √ Clients verbalize understanding of cause and treatment for hypothyroidism. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess knowledge of disorder, signs Provides information needed to and symptoms for infant or child as develop plan of instruction to appropriate, replacement therapy. ensure compliance with medical regimen. Teach parents and child about cause Provides thyroid replacement over 4 of thyroid deficiency and need for to 8 weeks in the child without prompt treatment in infants and for causing hyperthyroidism. gradual increases in thyroxine in children to achieve euthyroidism. Teach parents and child about thyroid Ensures compliance with correct replacement including administering administration of thyroid daily for life without missing replacement via oral route. doses, crushing and mixing with food, giving at breakfast time. Teach parents and child to report Indicates an excess of thyroid nervousness, irritability, hormone and need for and tachycardia, diarrhea. adjustment in dosage. Reassure parents and child that Promotes comfort and reduces improvement will be gradual as anxiety caused by physical and hormone levels are achieved and mental changes brought about by sleep, elimination, appetite, the disorder, maintains realistic growth, and activity levels will expectations from the treatment. improve. NIC: Teaching: Disease Process 2 of 4 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=76&FxId=123&Sessi. Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What did clients say about the cause and treatment of hypothyroidism?) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR HYPOTHYROIDISM COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND 3 of 4 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=76&FxId=123&Sessi. Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:17:51 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=76 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 9 - ENDOCRINE SYSTEM CHAPTER 9.2 - HYPOTHYROIDISM Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 4 of 4 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=77&FxId=123&Sessi. UNIT 10 - INTEGUMENTARY SYSTEM CHAPTER 10.0 - INTEGUMENTARY SYSTEM: BASIC CARE PLAN INTRODUCTION The integumentary system includes the skin and associated structures or appendages, which are hair, nails, and sensory skin receptors. Skin acts as a barrier to retain body fluids and electrolytes, a regulator of body heat, and a receptor of sensory stimuli (tactile, pain, heat and cold). It is made up of three layers including the epidermis (outer layer), the dermis (thicker layer directly under the epidermis), and the subcutaneous (fat and connective tissue under the dermis). Its appearance reflects the general health of an infant or child. Changes in the skin that alter appearance are a source of psychological stress and embarrassment to children. Common integumentary conditions of childhood are infections, lesions, wounds, and dermatitis disorders. INTEGUMENTARY GROWTH AND DEVELOPMENT Integumentary component structure and function: • Skin is 1 mm thick at birth and increases to twice this thickness by maturity. • Perspiration is present in the child over 1 month of age. • Lanugo disappears by 3 months of age. • Hair is soft and fine in texture in the young child and takes on adult characteristics with growth. • Nails are soft in infant and young child and become hardened with growth and development. • Pubic and axillary hair appear between 8 to 12 years of age, with axillary hair occurring 6 months later than pubic hair and facial hair in males occurring 6 months later than pubic hair; texture becomes coarse and curly with growth and development. NURSING DIAGNOSES RISK FOR IMPAIRED SKIN INTEGRITY Related to: (Specify: external mechanical factors of shearing, pressure, restraint forces; external factor of radiation; external factor of immobilization; external factors of excretions, secretions, humidity, infection.) Defining Characteristics: (Specify: redness; edema; irritation of skin, perianal area, buttocks; excoriation or maceration of skin; enforced bed rest; induration or fissure in skin; scratching; rash; scales; crusting disruption of skin surface; destruction of skin layers with or without necrosis; open wound with drainage; pressure from cast, splint, brace, or other appliance/device; prolonged placement in one position.) Related to: (Specify: internal factors of altered nutrition, circulation, sensation, skin turgor, metabolic rate, pigmentation and internal factors of medications, skeletal prominence, immunosuppression, developmental status, communicable disease.) 1 of 6 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=77&FxId=123&Sessi. Defining Characteristics: (Specify: thin, fragile skin; temperature elevation; dryness; flakiness; pruritus; pallor; cyanosis; redness; jaundice; allergic response to food, medication; dermatitis; rash; muscle tissue wasting; weakness; decreased muscle strength; edema; disruption of skin surface; eruptions [papule, macule, vesicle]; loss of tactile perception in extremities.) Goal: Client's skin will remain intact by (date and time to evaluate). Outcome Criteria √ (Specify outcome criteria based on potential problems, e.g., no redness, edema, healed lesion.) NOC: Risk Control INTERVENTIONS RATIONALES Assess skin and mucous membranes for Provides information about potential color changes, warmth, dryness, for disruption of skin integrity firmness, swelling or edema, lesions in any part of the body to ensure or breaks, and infection or identification and intervention inflammation of the oral cavity, before impairment becomes too nose, eyes, ears, and scalp. severe or extensive. Assess mobility status, ability to Reveals ability for movement, move in bed, use of restraints and external factors that produce length of time restraint used, pressure leading to skin breakdown enforced bed rest as part of medical as circulation of oxygen and regimen, presence of any nutrients is reduced. immobilization device. Assess for any skin rashes, Reveals skin conditions that lead to dermatitis, pruritis, and impairment. scratching. Assess for open wounds and type of Reveals presence of secretions and drainage (serosanguineous or excretions that lead to skin purulent), peristomal skin, diarrhea impairment especially in infants and effect on perianal area, diaper and young children who have rash from prolonged exposure to thinner, more sensitive skin. ammonia

from urine decomposition. (Assess skin under cast edges, Reveals skin impairment causes and tightness of cast, color and neurocirculatory effects of cast, sensation in toes or fingers, splint, brace application. redness and fit discomfort under any immobilization or assistive [prosthetic] device.) Assess nutritional and hydration Reveals information regarding status including dehydration or ability to maintain healthy skin fluid imbalances and obesity or and mucous membranes with proper emaciation with muscle wasting and nutrition and circulation to weakness. tissues and the preservation of muscle mass and strength needed to pad bony prominences and allow movement and position change. (Assess effect of radiation therapy, Provides rationale for preventive presence and extent of burns, measures to treat risk for burns, 2 of 6 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=77&FxId=123&Sessi. chemotherapy on skin, mucous stomatitis, impairment, and membranes, and areas of infection caused by vulnerability.) immunosuppression. Assess skin cleanliness and examine Provides information about removal bony prominences for changes, of dirt, irritants, bacteria, condition of hair and nails, use of sweat, urine, feces to promote cleansing products, and skin skin integrity and offers an response; include assessment of assessment opportunity. effect of contact allergens that cause skin changes. Provide bathing in bed, tub, or shower Promotes health and cleanliness of (specify); use warm water and mild skin, reduces accumulation of body soap and rinse well, with a soft secretions and excretions, and towel pat dry and (avoid rubbing) reduces bacteria in skin folds including all folds, crevices, and where bacterial growth is creases. enhanced. Provide careful cleansing of eyes with Promotes intact mucous membranes either warm, sterile water or saline from irritation and breakdown and soft cloth from inner to outer caused by pressure or inflammation aspect of eye; nasal mucosa with from tubes or by suctioning, warm water and application of a chemotherapy, or NPO status; protective lubricant; oral mucosa rapidly dividing epithelial tissue with a peroxide solution mouthwash. of oral and nasal mucosa leads to breakdown when receiving chemotherapeutic agents. Provide hair shampooing, nail trimming Promotes cleanliness and prevents as ordered; cut nails straight skin irritation or breaking caused across with round-tipped scissors; by scratching with long nails. dry hair well, rubbing gently with soft towel. Apply emollients, lotions to skin, Protects and softens skin and bony prominences with gentle massage promotes circulation to vulnerable using fingers and/or hands as parts. ordered. (Apply skin adhesive barrier to Protects skin that is exposed to peristomal area including secretions and excretion or tracheostomy, urinary or bowel pressure. diversion, and over bony prominences if immobilized or too weak or ill to move in bed.) Provide position change q 1 to 2h as Prevents prolonged pressure on any indicated with prone, supine, side one area leading to skin and or elevated position utilized; if tissue breakdown. child is able, encourage to change positions on own. Maintain body alignment and encourage Promotes even pressure on body to maintain correct posture when parts. sitting, lying, and walking. Pad bony prominences and susceptible Protects vulnerable parts from parts with sheepskin, foam rubber, pressure and redistribution weight pillows, alternating pads and and improves circulation. mattress, special apparatus such as 3 of 6 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=77&FxId=123&Sessi. Stryker frame. Maintain tight, wrinkle-free linens Prevents irritation and excoriation and bed free of crumbs, sharp toys, of skin. and dampness from urine or feces. (Correct tight dressings by loosening Reduces external sources of pressure tape, correct dry and sticking that decrease circulation or dressings with saline solution irritate skin. before removing, secure tubing away from skin contact, correct fit of any prosthesis or immobilization device, petal edges of cast with soft adhesive material.) Apply topical skin medications Promotes healing and prevents (ointments, solutions) as ordered infection (action). (specify); bathe or soak area or extremity. Provide bath with oatmeal or other Soothes pruritis and prevents emollients, mitts on hands, scratching. temporary soft restraints as needed. Provide nutritional diet that is high Promotes tissue healing with in protein and calories and includes synthesis of protein to meet vitamins A and C. metabolic needs and formation of collagen and connective tissue by vitamins A and C. (If wound present, provide dressing Promotes healing and prevents change, irrigations, debridement, infection and further skin wet or dry dressing, Op-site as breakdown. ordered specific to wound.) Teach parents to remove environmental Prevents or controls skin rashes or irritants, chemical agents, and eruptions caused by contact with allergens that have an outward offending substances. effect on the child's skin (fabrics, soaps, lotions, toys, dust, pollens, plants, animals, others). Teach parents and child about bathing Promotes cleanliness and removes and personal hygiene measures infectious agents from the skin. regarding toileting, mouth and teeth care, nail and hair care, and to avoid wearing tight-fitting clothing. Teach parents and child about Promotes healing of any skin wound nutritional diet and fluids to or breakdown. provide or replenish needed intake if skin disruption is present. (Instruct parents in dressing change Promotes wound cleanliness and using sterile technique, allow for healing. return demonstration.) (Inform parents to maintain mobility Promotes circulation to skin and of child, avoid allowing child to tissues. remain in same position over 1 hour.) Teach parents to report any changes in Allows for adjustment of device 4 of 6 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=77&FxId=123&Sessi. skin color, irritation, pain or prosthesis or appliance. absence of sensations, breaks in skin. Teach parents to report any redness, Provides early interventions if skin swelling, pain, purulent drainage infection present. from skin or mucous membrane, lesions or open wounds. Instruct in application of lotions or Protects skin and promotes comfort. ointments (antiseptic, antibiotic, or palliative) to skin and irritated areas as ordered (specify). Advise child to avoid scratching or Prevents further damage to skin and picking at skin or squeezing risk for infection. eruptions. Teach parents about safety to prevent Provides information for protective burn injuries (specify). measures. Teach parents on first aid measures Provides information for early for skin insults (e.g., burns, intervention. insect bites) (specify). NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Provide data related to the outcome criteria for the specific client.) (Revisions to care plan? D/C care plan? Continue care plan?) COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 5 of 6 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=77&FxId=123&Sessi. 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:18:07 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=77 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 10 - INTEGUMENTARY SYSTEM CHAPTER 10.0 - INTEGUMENTARY SYSTEM: BASIC CARE PLAN Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 6 of 6 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=78&FxId=123&Sessi. CHAPTER 10.1 - BURNS INTRODUCTION Burns are injuries to the skin and underlying tissues caused by flames, electricity, contact with hot articles or water, or radiation therapy. Burns affect children of all ages. They are classified according to severity, source, and extent of surface involved. Most burn injuries occur in children under 5 years of age. Severe burns affect all systems with local responses that include edema, circulatory stasis, and fluid loss. Systemic responses include circulation alteration, anemia, fluid loss, metabolic alteration, acidosis, and stress response. Burns that involve over 10% of body surface require hospitalization with management of ventilation, fluid and electrolyte imbalance, pain control, nutrition, wound care, infection prevention, skin grafting, and rehabilitation. MEDICAL CARE Analgesics: for pain relief. Antimicrobials: applied topically as ointment to affected areas. Vitamins/Minerals: to facilitate growth and replace depleted stores. Complete Blood Count (CBC): reveals decreased RBC, Hgb, HCT. Electrolyte Panel: reveals decreases because of loss from burned areas. Proteins: reveals decreases with protein breakdown and losses. Blood Urea Nitrogen/Creatinine: reveals increases as tissue is destroyed and in presence of oliguria. Wound Culture: reveals and identifies infectious organism if present and sensitivity to anti-infective treatment. COMMON NURSING DIAGNOSES See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Burn. Defining Characteristics: (Specify: disruption of skin surface or layers, destruction of skin layers, edema, altered circulation, altered nutritional state, altered metabolic state.) See IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Related to: (Specify: inability to ingest, metabolize nutrients.) Defining Characteristics: (Specify: catabolism, protein and fat wasting, anorexia, diarrhea, weight loss.) 1 of 8 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=78&FxId=123&Sessi. See IMPAIRED PHYSICAL MOBILITY Related to: (Specify: pain and discomfort, musculoskeletal impairment.) Defining Characteristics: (Specify: limited range of motion, impaired joint flexibility, scar formation, reluctance to attempt movement.) See INEFFECTIVE BREATHING PATTERN Related to: Musculoskeletal impairment. Defining Characteristics: (Specify: trauma/edema of airway, oral or nasal membranes, restlessness, tachypnea, dyspnea.) See RISK FOR DEFICIENT FLUID VOLUME Related to: Excessive losses. Defining Characteristics: (Specify: loss of protective skin, blood loss from stress ulcer, electrolyte imbalance, reduced cardiac output with reduced plasma and blood volume.) See DELAYED GROWTH AND DEVELOPMENT Related to: Effects of long-term disability. Defining Characteristics: (Specify: altered physical growth, inability to perform self-care or self-control activities appropriate for age.) ADDITIONAL NURSING DIAGNOSES PAIN Related to: Burn injury. Defining Characteristics: (Specify: communication [verbal or nonverbal] of pain descriptors depending on severity and type of burn, moaning, crying, restlessness, guarding of injured area.) Goal: Client will experience decreased pain by (date and time to evaluate). Outcome Criteria √ Pain is rated as less than (specify level and pain scale used). NOC: Pain Level INTERVENTIONS RATIONALES 2 of 8 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=78&FxId=123&Sessi. Assess pain in burned area for Provides information about pain severity and degree of burn that varies in severity with (specify frequency). extent and depth of burn, cause of burn injury (chemical, thermal). Administer analgesic as ordered Relieves and controls pain (specify) depending on severity of response caused by injury to pain and status of other systems; superficial nerve endings administer before procedures and (action of drug). care are performed; anticipate need before pain becomes severe. Provide relaxation, diversionary Provides nonpharmacologic relief activities (specify). of pain. Place in position of comfort, change Promotes comfort and prevents q 2h, and handle injured parts additional pain caused by rough gently. handling or pressure on injured body parts. Avoid touching painful parts, use Prevents contact with linens of bed cradle over injured, painful hard surfaces that cause pain. parts. Apply ointment to healing skin that Provides relief from discomfort of is itchy and flaking, as ordered itching with use of an (specify). antihistamine cream. Teach parents about methods to Provides information about relieve pain including quiet play, interventions that may distract reading to child, television, child from any discomfort music, games, soft toys, other experienced. activities to interest to child. Instruct parents and child to Prevents further injury and pain. protect injured areas from contact with pain including stimuli. NIC: Pain Management Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is pain rating? Specify scale used) (Revisions to care plan? D/C care plan? Continue care plan?) RISK FOR INFECTION Related to: Inadequate primary defenses. Defining Characteristics: (Specify: broken skin, traumatized tissue, new skin graft, fever, purulent drainage from open wound or under eschar, 3 of 8 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=78&FxId=123&Sessi. positive wound culture.) Goal: Client will not experience infection by (date and time to evaluate). Outcome Criteria √ Temperature remains <101° F. √ Wound is without redness, edema, odor, or purulent drainage. NOC: Risk Detection INTERVENTIONS RATIONALES Assess healing wounds for changes in Provides information indicating color, odor and drainage. Assess infection of wound or skin VS and temperature elevation. graft area. Administer antibiotics, as ordered (Action of drug.) (specify). Perform protective isolation as Protects child from exposure to appropriate including mask, gown, infectious

organisms. gloves; perform hand-washing before giving any care; discourage visits from those who are suffering from an infection or who are ill. Apply antimicrobial wet dressings to Destroys infectious agents and wound or antimicrobial ointment as protects wound from ordered when performing a dressing infection. change. Use sterile technique to perform all Protects wound from pathogens dressing changes and wound care. and reduces risk of infection. Instruct parents in handwashing Provides method of controlling technique and importance of exposure to infectious procedure in caring for child. agents. Instruct parents in healing process Provides information about and expected changes in skin process of healing and during healing; how to assess changes to note that should wound and graft for signs of be reported. infection that should be reported. Instruct parents to avoid any Prevents transmission of contact with family, friends, infectious agents to the visitors that are ill with an child. infection. Instruct parents in administration Promotes compliance with of antimicrobial therapy via PO or medication regimen to prevent topical application. or treat infection. NIC: Surveillance 4 of 8 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=78&FxId=123&Sessi. Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What is temperature? Describe wound. Is there any redness, edema, odor, or purulent drainage?) (Revisions to care plan? D/C care plan? Continue care plan?) DISTURBED BODY IMAGE Related to: Biophysical and psychosocial factors. Defining Characteristics: (Specify: verbal and nonverbal responses to change in body appearance [scarring, deformity], loss of control, dependence, negative feelings about body, multiple stressors and change in daily living limitations and social relationships.) Goal: Child will experience improved body image by (date and time to evaluate). Outcome Criteria √ Child expresses feelings about how they look. √ Child identifies at least 1 positive thing about self. NOC: Body Image INTERVENTIONS RATIONALES Assess child for feelings about Provides information about status multiple restrictions in lifestyle, of self-concept and body image change in appearance, difficulty in that require special attention. school and social situations, inability to keep up with peers and participate in activities. Encourage expression of feelings and Provides opportunity to vent concerns and support communications feelings and reduce negative with parents, teachers, and peers. feelings about changes in appearance. Avoid negative comments and stress Enhances body image and confidence. positive aspect of activities and accomplishments. Note withdrawal behavior and signs of Reveals responses to body image depression. changes and possible poor adjustment to changes. Show support and acceptance of Promotes trust and demonstrates changes in appearance of child; respect for child. provide privacy as needed. Allow as much control and decision Promotes independence and gives 5 of 8 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=78&FxId=123&Sessi. making by child as possible. child some control over the situation. Allow and encourage parental and peer Promotes social acceptance by peers visits when possible. and support by parents. Inform parents of importance of Encourages acceptance of the child maintaining support for child with special needs, long-term regardless of their needs. rehabilitation needs, lifelong activity restrictions. Inform parents and child of impact of Provides correct information to the disease on body systems and assist in dealing with negative risk of scarring, physical feelings about body. disability; correct any misinformation and inform of ways to cope with body changes. Instruct parents of need for Promotes well-being of child and flexibility in care of child and sense of belonging and control of need to integrate care and routines life events by participating in into family activities; to allow normal activities for age and child to participate in peer enhancing developmental task activities. achievement. Inform parents and child about how to Prevents stigmatization of child by deal with peer and school those who are not apprised of the perceptions of appearance and how child's disease; attitude of to tell others about change in others will affect child's body appearance. image. Inform of clothing, wigs, scarves, Provides suggestions for aids that makeup that may assist in will camouflage scarring or preserving body image. disfigurement. Suggest psychological counseling or Assists to improve self-esteem and child life worker and inform of to learn coping and problem functions performed by these solving skills. professionals. NIC: Self-Esteem Enhancement Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (What feelings did child verbalize about how he or she looks? What positive thing about self did child identify? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR BURNS 6 of 8 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=78&FxId=123&Sessi. 7 of 8 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=78&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:18:24 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=78 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 10 - INTEGUMENTARY SYSTEM CHAPTER 10.1 - BURNS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 8 of 8 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=79&FxId=123&Sessi. CHAPTER 10.2 - CELLULITIS INTRODUCTION Cellulitis is an infection of the skin and underlying subcutaneous tissue affecting the lymph nodes within the area of inflammation. It may follow an upper respiratory infection and become systemic in its symptomology. The most common areas affected are the face, periorbital area, and extremities. Treatment includes antibiotic therapy. MEDICAL CARE Antipyretics/Analgesics: to reduce fever and/or control pain. Antibiotics: based on culture identification of organism and sensitivity to drugs. Wound Aspirate/Blood Culture: reveals and identifies infectious agent if present and sensitivity to specific antimicrobial treatment. COMMON NURSING DIAGNOSES See HYPERTHERMIA Related to: Illness (infection). Defining Characteristics: Increase in body temperature above normal range, flushed skin that is warm to touch, increased pulse and respiration rate. See RISK FOR DEFICIENT FLUID VOLUME Related to: (Specify: altered intake; excessive losses through normal routes.) Defining Characteristics: (Specify: temperature elevation, diaphoresis, insensible losses, dry, hot skin and mucous membranes.) See RISK FOR IMPAIRED SKIN INTEGRITY Related to: Infection of skin layers. Defining Characteristics: (Specify: redness, swelling, induration, warmth, pain at affected areas, destruction of skin layers.) ADDITIONAL NURSING DIAGNOSES DEFICIENT KNOWLEDGE Related to: Lack of information about condition. 1 of 4 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=79&FxId=123&Sessi. Defining Characteristics: (Specify: request for information about cause and treatment of the condition, measures to prevent spread of the infection.) Goal: Clients will obtain information about cellulitis by (date and time to evaluate). Outcome Criteria √ Clients verbalize understanding about the cause and treatment of cellulitis. NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES Assess knowledge of treatment of an Provides information needed to infection, possible complications, plan teaching that will assist extent of infection, and risk of parents in caring for child spread. with an infection involving skin layers. Inform parents of cause of the Provides information indicating infection and manifestations to cellulitis and spreading of note including pain, redness, infection systemically. swelling, warmth of a localized infection and to report increasing temperature, enlarged lymph nodes in the region, and a red streak along the lymph pathway in a systemic infection. Administer antibiotics as ordered Provides treatment to destroy (specify), teaching parents about causative agent by inhibiting administration with dose, time, cell wall synthesis; route is frequency, side effects, and dependent upon site and instruct to take until entire severity of the infection. prescription is ingested. Inform parents that culture is done Provides identification of to determine treatment. microorganism and sensitivity to specific antibiotics. Instruct parents to apply warm Promotes vasodilation and compresses or soaks to affected circulation to the area to area or limb. promote healing. Instruct parents in dressing change Promotes wound cleanliness and using sterile technique if an prevents introduction of incision and drainage has been done additional pathogens. at infection site, and instruct in proper disposal of soiled dressing. Instruct parents and child in Prevents transmission of handwashing technique and instruct infectious agents. them to perform this before and after giving care to the child. Inform parents to immobilize limb and Promotes healing and reduces pain maintain bed rest for the child. caused by movement if an extremity is involved. 2 of 4 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=79&FxId=123&Sessi. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) (Did clients verbalize understanding about cause and treatment for cellulitis? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR CELLULITIS COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: 3 of 4 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=79&FxId=123&Sessi. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:18:43 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=79 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 10 - INTEGUMENTARY SYSTEM CHAPTER 10.2 - CELLULITIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 4 of 4 12/22/2006 7:48 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=80&FxId=123&Sessi. CHAPTER 10.3 - DERMATITIS INTRODUCTION Dermatitis is an inflammatory condition of the superficial layer of the skin. It may be caused by contact with an allergen, urine, or feces, and it may cause irritation characterized by erythema, papules, or vesicles. Treatment includes actions to prevent infection and skin breakdown. MEDICAL CARE Anti-inflammatories: hydrocortisone in cream, lotion, ointment forms to apply topically to suppress inflammatory process and modify immune response to hypersensitivities. Antihistamines: to relieve allergic response and promote rest. Antipruritics: applied topically as compresses, lotion, or for bathing to allay itching. Skin Protectors: applied topically to protect skin against contact with irritants. COMMON NURSING DIAGNOSES See RISK FOR IMPAIRED SKIN INTEGRITY Related to: (Specify: excretions and secretions, contact with allergens or irritants.) Defining Characteristics: (Specify: rash, erythema, papule, vesicle, lesions, disruptions of skin surface, itching.) ADDITIONAL NURSING DIAGNOSES DEFICIENT KNOWLEDGE Related to: Lack of information about disorder. Defining Characteristics: (Specify: request for information about cause and treatments of dermatitis and measures to prevent recurrence.) Goal: Clients will obtain information about dermatitis by (date and time to evaluate). Outcome Criteria √ Clients verbalize understanding of cause and treatment for dermatitis (specify for individual child). NOC: Knowledge: Disease Process INTERVENTIONS RATIONALES 1 of 4 12/22/2006 7:49 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=80&FxId=123&Sessi. Assess type and extent of dermatitis Provides information about rash including site and offending resulting from contact that may irritant, presence of redness, be chemical or physical and most papules, vesicles, breaks in skin, commonly is caused by ammonia excoriation, itching. from diaper, plant, animal, cloth, soap, or sun exposure. Inform of potential factors causing Provides information to assist in eruptions/dermatitis and how to avoid avoiding contact with substances contact with offending agents that cause dermatitis. (specify: e.g., clothing covering all part of body, to wash after contact with substance, to use hypoallergic soaps, proper use of skin applications, and proper changing and laundering of diapers). (Teach about application of ointment or Promotes healing of skin lotion as ordered to treat diaper irritation caused by ammonia in rash, to cleanse and dry area well diapers. during diaper change, to expose irritated area to the air; laundering diapers by soaking, using mild soap, double rinsing, and drying well in clothes dryer or in sun.) Teach parents about palliative Promotes comfort

and healing, treatments (specify: such as allays pruritis, and prevents application of warm, wet compresses infection if skin is broken and lotion or paste to the affected down. areas, and baths; discourage child from scratching the areas.) Instruct parents in administration of Reduces allergic reactions and antibiotics, anti-inflammatories, prevents complications antihistamines as ordered. associated with dermatitis. Inform parents to avoid dressing child Promotes comfort and prevents risk in tight clothing, to wash new of contact with substance that clothing before wearing, to rinse may cause rash. clothing well during laundering. Inform parents to use sun protection Protects skin from sunburn by with a minimum sun protection factor blocking or absorbing of 15 such as PABA. ultraviolet rays. Suggest toys, games, television, and Provides diversion to prevent activities preferred by child; scratching. maintain short, smooth nails. NIC: Teaching: Disease Process Evaluation (Date/time of evaluation of goal) (Has goal been met? Not met? Partially met?) 2 of 4 12/22/2006 7:49 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=80&FxId=123&Sessi. (Did clients verbalize understanding about cause and treatment for dermatitis? Use quotes.) (Revisions to care plan? D/C care plan? Continue care plan?) FLOW CHART FOR DERMATITIS COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 3 of 4 12/22/2006 7:49 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=80&FxId=123&Sessi. 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:18:56 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=80 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) UNIT 10 - INTEGUMENTARY SYSTEM CHAPTER 10.3 - DERMATITIS Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 4 of 4 12/22/2006 7:49 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=82&FxId=123&Sessi. APPENDIX ABBREVIATIONS : increase : decrease →: leads to >: greater than <: less than °: degree AAP: American Academy of Pediatrics ABO: refers to the blood types A, B, or O ABG: arterial blood gas ADHD: attention deficit hyperactivity disorder AFDC: Aid to Families with Dependent Children AIDS: acquired immunodeficiency syndrome ALT: alanine aminotransferase (also SGPT) APTT: activated partial thromboplastin time ARDS: adult respiratory distress syndrome AROM: artificial rupture of membranes ASD: atrial septal defect AST: aspartate aminotransferase (also SGOT) BBT: basal body temperature BM: bowel movement BP: blood pressure 1 of 9 12/22/2006 7:50 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=82&FxId=123&Sessi. BRP: bathroom privileges BUN: blood urea nitrogen C: centigrade cal: calories CBC: complete blood count cc: cubic centimeters CD & I: clean, dry, and intact CHF: congestive heart failure Cl-: chloride CNS: central nervous system c/o: complains of CO: cardiac output CO2: carbon dioxide CPAP: continuous positive airway pressure CPT: chest physiotherapy CRP: C-reactive protein CSF: cerebral spinal fluid CT: computerized axial tomography CVP: central venous pressure CVA: cerebral vascular accident DAT: diet as tolerated D/C: discharge DCFS: Department of Children and Family Services 2 of 9 12/22/2006 7:50 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=82&FxId=123&Sessi. DIC: disseminating intravascular coagulation dL: deciliter DNA: deoxyribonucleic acid dsg: dressing DtaP: diptheria, tetanus, activated pertussis DTR: deep tendon reflexes EBL: estimated blood loss ECMO: extracorporeal membrane oxygenation ECT: electroconvulsive therapy EEG: electroencephalogram e.g.: for example ELISA: enzyme-linked immunosorbent assay F: Fahrenheit FFP: fresh frozen plasma FiO2: fraction of inspired oxygen FVE: fluid volume excess FVD: fluid volume deficit GBS: group B streptococcus GC: gonorrhea GFR: glomerular filtration rate GI: gastrointestinal gm: gram GTT: glucose tolerance test 3 of 9 12/22/2006 7:50 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=82&FxId=123&Sessi. GU: genitourinary H+: hydrogen ion Hct: hematocrit Hgb: hemoglobin Hib: Haemophilus influenzae, type b HIE: hypoxic-ischemic encephalopathy HIV: human immunodeficiency virus H2O: water HOB: head of bed hr: hour HR: heart rate Ht: height HTN: hypertension hx: history I&O: intake & output ICP: intracranial pressure ID: identification IDDM: insulin-dependent diabetes mellitus Ig: immune globulin IM: intramuscular IMV: intermittent mechanical ventilation IPPB: intermittent positive pressure breathing IPV: inactivated poliovirus vaccine 4 of 9 12/22/2006 7:50 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=82&FxId=123&Sessi. IV: intravenous IVP: intravenous push K+: potassium KVO: keep vein open kcal: kilo calories kg: kilogram L: liter LOC: level of consciousness LR: lactated Ringer's MAE: moves all extremities mEq: milliequivalent mg: milligram mL: milliliter mm Hg: millimeters of mercury MRI: magnetic resonance imaging Mg2+: magnesium MMR: measles, mumps, rubella vaccine Na+: sodium NIC: nursing interventions classification NPO: nothing by mouth NTD: neural tube defect N&V: nausea and vomiting 5 of 9 12/22/2006 7:50 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=82&FxId=123&Sessi. O2: oxygen OG: orogastric OTC: over-the-counter OR: operating room oz: ounce P: pulse PaCO2: arterial carbon dioxide pressure PaO2: arterial oxygen pressure PCA: patient controlled analgesia PEEP: positive end expiratory pressure PO: by mouth PO2: partial pressure of oxygen PO 3- 4 : phosphorus PPV: positive pressure ventilation prn: as needed PT: prothrombin time PTT: partial thromboplastin time PVC: premature ventricular contraction PVR: pulmonary vascular resistance q: every R: respirations RBC: red blood cell REEDA: redness, edema, echymosis, approximation 6 of 9 12/22/2006 7:50 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=82&FxId=123&Sessi. RN: registered nurse SaO2: oxygen saturation SC: subcutaneous SGOT: serum glutamic-oxaloacetic transaminase (AST) SGPT: serum glutamic-pyruvic transaminase (ALT) sp. gr.: specific gravity SR: side rails s/s: signs and symptoms STD: sexually transmitted disease SVR: systemic vascular resistance T: temperature TCDB: turn, cough, and deep breathe TCM: transcutaneous monitoring TcPaO2: transcutaneous partial pressure of oxygen TcPaCO2: transcutaneous partial pressure of carbon dioxide Td: tetanus toxid vaccine TEF: tracheoesophageal fistula TGV: transposition of the great vessels TPN: total parenteral nutrition TPR: temperature, pulse, respirations TSH: thyroid stimulating hormone UA: urinalysis URI: upper respiratory infection 7 of 9 12/22/2006 7:50 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=82&FxId=123&Sessi. UTI: urinary tract infection VP: ventriculoperitoneal VS: vital signs VSD: ventricular septal defect WBC: white blood cell WIC: women, infants, and children program WNL: within normal limits Wt: weight w/o: without ZDT: zidovudine COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: 8 of 9 12/22/2006 7:50 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=82&FxId=123&Sessi. Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:19:25 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=82 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) APPENDIX Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Customer Service Send Us Your Comments User Responsibilities 800.901.5494 Training Center What's New 9 of 9 12/22/2006 7:50 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=81&FxId=123&Sessi. BIBLIOGRAPHY Alfaro-LaFevre, R. (2004). Critical thinking in nursing: A practical approach (3rd ed.). Philadelphia: W.B. Saunders Co. American Academy of Pediatrics. (2000). Pickering, L. (Ed.). 2000 Red book: Report of the committee on infectious diseases (25th ed.). Elk Grove, IL: Author. Ball, J. W., & Binder, R. C. (2002). Pediatric nursing: Caring for children (3rd ed.). Upper Saddle River, NJ: Prentice Hall. Barnum, B.S. (1999). Teaching nursing in the era of managed care. New York: Springer Publishing. Behrman, R. E., Kleigman, R. M., Jenson, H. B. (2004). Nelson's textbook of pediatrics (17th ed.). Philadelphia: W.B. Saunders. Betz, C., Snowden, L. A., & Betz, L. (2004). Mosby's pediatric nursing reference (5th ed.). St. Louis: Mosby. Brazelton, T. B. (1984). Neonatal behavioral assessment scale (2nd ed.). London: Heinemann. Burns, C., Barber, N., Brady, M., & Dunn, A. (2000). Pediatric primary care: A handbook for nurse practitioners. Philadelphia: W.B. Saunders. Carpenito, L. J. (2004). Handbook of nursing diagnosis (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Carpenito, L. J. (2004). Nursing diagnosis: Application to clinical practice (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Daly, K. A., Selvius, R. E., & Lindgren, M. S. (1997). Knowledge and attitudes about otitis media risk: Implications for prevention. Pediatrics, 100(6), 931-936. DeLaune, S.C., & Ladner, P.K. (2002). Fundamentals of nursing: Standards and practice (2nd ed.). Clifton Park, NY: Thomson Delmar Learning. Dochterman, J. M., & Bulechek, G.M. (2004). Nursing Interventions Classificaton (NIC) (4th ed.). St. Louis: Mosby, Inc. Fischbach, F. T. (2004). A manual of laboratory and diagnostic tests (7th ed.). Philadelphia: Lippincott Williams & Wilkins. Fleming, D. F. (1999). Challenging traditional insulin injection practices. American Journal of Nursing, 99(2), 72-74. Foley, G. V., Fochtman, D., & Mooney, K. H. (1997). Nursing care of the child with cancer (3rd ed.). Philadelphia: W.B. Saunders. Gardner, P. (2003). Nursing process in action. Clifton Park, NY: Thomson Delmar Learning. Harkreader, H. (2004). Fundamentals of nursing: Caring and clinical judgment (2nd ed.). Philadelphia: W.B. Saunders Co. Hazinski, M. F. (1999). Manual of pediatric critical care. St. Louis: Mosby. Jackson, P. L., & Vessey, J. A. (2000). Primary care of the child with a chronic condition (3rd ed.). St. Louis: Mosby. Kaditis, A. G., & Wald, E. R. (1999). Viral group: Current diagnosis and treatment. Contemporary Pediatrics, 16(2), 139-153. 1 of 4 12/22/2006 7:49 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=81&FxId=123&Sessi. Kee, J. L. (2001). Laboratory and diagnostic tests with nursing implications (6th ed.). Norwalk, CT: Appleton & Lange. Kelly-Heidenthal, P. (2003). Nursing leadership and management. Clifton Park, NY: Thomson Delmar Learning. Kozier, B., Erb, G., Blais, K., & Wilkinson, J. (2004). Fundamentals of nursing: Concepts process and practice (7th ed.). Upper Saddle River, NJ: Pearson Education. McCance, K. L., & Huether, S. E. (2002). Pathophysiology: The biologic basis for disease in adults and children (4th ed.). St. Louis: Mosby. Meyers, T. A., Eichhorn, D. J., Guzzetta, C. E., Clark, A. P., Klein, J. D., Taliaferro, E., & Calvin, A. (2000). Family presence during invasive procedures and resuscitation. American Journal of Nursing, 100(2), 32-42. Moorhead, S., Johnson, M., & Maas, M. (2004). Nursing outcomes classifications (NOC) (3rd ed.). St. Louis: Mosby, Inc. Nettina, S. (2001). The Lippincott manual of nursing practice (7th ed.). Philadelphia: Lippincott Williams & Wilkins. North American Nursing Diagnosis Association. (2003). Nursing diagnoses: Definitions & classification 2003-2004. Philadelphia: Author. Olds, S. B., London, M. L., & Ladewig, P. A. (2000). Maternal-newborn nursing: A family and community-based approach (6th ed.). Upper Saddle River, NJ: Prentice Hall. Pasero, C. (1999). Pain control: Epidural analgesia in children. American Journal of Nursing, (99)5, 20. Pizzo, P. A., & Poplack, D. G. (2001). Principle and practice of pediatric oncology (4th ed., pp. 1343-1355). Philadelphia: Lippincott Williams & Wilkins. Porth, C. M. (2002). Pathophysiology. Concepts of altered health states (6th ed.). Philadelphia: Lippincott Williams & Wilkins. Rudolph, C. D., Hostetter, M. K., Siegel, N. J., & Lister, G. E. (2002). Rudolph's pediatrics (21st ed.). Stamford, CT: Appleton & Lange. Smeltzer, S., & Bare, B. (2004). Brunner and Suddarth's textbook of medical-surgical nursing (10th ed.). Philadelphia: Lippincott Williams & Wilkins. Ulrich, S., & Canale, W. (2001). Nursing care planning guides: For adults in acute, extended and home care settings (5th ed.). Philadelphia: W. B. Saunders Co. Whaley, L. F., & Wong, D. L. (1999). Nursing care of infants and children (6th ed.). St. Louis: Mosby Year Book. White, L. (2003). Documentation and the Nursing Process. Clifton Park, NY: Thomson Delmar Learning. Wilkinson, J. M. (2000). Nursing diagnosis handbook (7th ed.). Upper Saddle River, NJ: Prentice Hall. Wilson, B. A., Shannon, M. T., & Stand, C. L. (2000). Nurse's drug guide 2000. Stamford, CT: Appleton & Lange. Wolfe, J., Grier, H. E., Klar, N., Levin, S. B., Ellenbogen, J. M., Salem-Schaltz, S., Emanuel, E. J., & Weeks, J. C. (2000). Symptoms and suffering at the end of life in children with cancer. New England Journal of Medicine, 342(5), 326-333. 2 of 4 12/22/2006 7:49 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=81&FxId=123&Sessi. Wong, D. L., Hockenberry-Easton, M., Wilson, D., Winkelstein, M., & Schwartz, P.

(2001). Wong's Essentials of Pediatric Nursing (6th ed.). St. Louis: Mosby. Yoos, H. L., & McMullen, A. (1999). Symptom perception and evaluation in childhood asthma. Nursing Research, 48(1), 2-8. COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Author: KARLA L. LUXNER, RNC, ND Copyright: COPYRIGHT © 2005 by Thomson Delmar Learning. All Rights Reserved. Database Title: STAT!Ref Online Electronic Medical Library ISBN: 0-7668-5994-0 Publication City: Clifton Park, NY Publication Year: 2005 Publisher: Thomson Delmar Learning Date Posted: 5/5/2006 6:51:38 AM PST (GMT -08:00) Book Title: Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) Date Accessed: 12/21/2006 6:19:11 PM PST (GMT -08:00) Electronic Address: http://online.statref.com/document.aspx?fxid=123&docid=81 Location In Book: DELMAR'S PEDIATRIC NURSING CARE PLANS - 3rd Ed. (2005) BIBLIOGRAPHY Send Feedback Teton Server (4.5.0) - ©2006 Teton Data Systems Title Updates Send Us Your Comments 3 of 4 12/22/2006 7:49 AM Delmar's Pediatric Nursing Care Plans - 3rd Ed. (2005) http://online.statref.com/Document/DocumentBodyContent.aspx?DocId=81&FxId=123&Sessi. C ustomer Service User Responsibilities 800.901.5494 Training Center What's New 4 of 4 12/22/2006 7:49 AM

Drug Metabolism Current Concepts Edited by CORINA IONESCU “I. HaĠieganu ” University of Medicine and Pharmacy, Cluj-Napoca, Romania and MINO R. CAIRA University of Cape Town, South Africa A C.I.P. Catalogue record for this book is available from the Library of Congress. ISBN-10 1-4020-4141-1 (HB) ISBN-13 978-1-4020-4141-9 (HB) ISBN-10 1-4020-4142-X ( e-book) ISBN-13 978-1-4020-4142-6 (e-book) Published by Springer, P.O. Box 17, 3300 AA Dordrecht, The Netherlands. www.springeronline.com Printed on acid-free paper All Rights Reserved © 2005 Springer No part of this work may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission from the Publisher, with the exception of any material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Printed in the Netherlands. Dedication To the memory of my parents To my beloved husband and son, for their continuous support, understanding and encouragement. Corina Ionescu CONTENTS PREFACE . xi ACKNOWLEDGEMENTS . xiii CHAPTER 1. DRUG METABOLISM IN CONTEXT. 1 1.1 INTRODUCTION. 1 1.2 ABSORPTION. 3 1.2.1 Basic mechanisms of transport through membranes. 17 1.3 DRUG DISTRIBUTION. 21 1.3.1 Qualitative aspects . 21 1.3.2 Kinetic aspects. 22 1.4 DYNAMICS OF DRUG ACTION. 25 1.4.1 Drug-receptor interaction . 25 1.4.2 Mechanisms. 27 1.4.3 Further aspects. 28 1.5 DRUG CLEARANCE. 29 1.5.1 Drug metabolism. 29 1.5.2 Excretion . 32 1.6 DYNAMICS OF DRUG CLEARANCE . 33 1.6.1 Basic pharmacokinetic parameters . 34 References . 37 CHAPTER 2. PATHWAYS OF BIOTRANSFORMATION – PHASE I REACTIONS. 41 2.1 INTRODUCTION. 41 2.2 PHASE I AND PHASE II METABOLISM: GENERAL CONSIDERATIONS . 42 2.3 OXIDATIONS INVOLVING THE MICROSOMAL MIXED-FUNCTION OXIDASE SYSTEM. 48 2.3.1 Components of the enzyme system and selected miscellaneous oxidative reactions (mechanisms of action). 48 2.3.2 Oxidations at carbon atom centres. 58 2.3.3 Oxidations at hetero-atoms . 82 2.4 OXIDATIONS INVOLVING OTHER ENZYMATIC SYSTEMS. 94 2.4.1 The monoamine oxidase and other systems. 94 2.4.2 Other representative examples . 100 2.5 METABOLIC REACTIONS INVOLVING REDUCTION. 102 viii Contents 2.5.1 Components of the enzyme system. 102 2.5.2 Compounds undergoing reduction . 103 2.6 HYDROLYSIS. 107 2.6.1 Hydrolysis of esters . 108 2.6.2 Hydrolysis of amides . 115 2.6.3 Hydrolysis of compounds in other classes. 116 2.7 MISCELLANOUS PHASE I REACTIONS. 116 2.8 THE FATE OF PHASE I REACTION PRODUCTS. 117 References . 118 CHAPTER 3. PATHWAYS OF BIOTRANSFORMATION – PHASE II REACTIONS. 129 3.1 INTRODUCTION. 129 3.2 GLUCURONIDATION . 129 3.2.1 Enzymes involved and general mechanism . 130 3.2.2 Glucuronidation at various atomic centres (O, S, N). 134 3.3 ACETYLATION. 138 3.3.1 Role of acetyl-coenzyme A. 138 3.3.2 Acetylation of amines, sulphonamides, carboxylic acids, alcohols and thiols . 141 3.4 GLUTATHIONE CONJUGATION. 144 3.5 OTHER CONJUGATIVE REACTIONS . 147 3.6 CONCLUDING REMARKS. 165 References. 167 CHAPTER 4. ENZYMATIC SYSTEMS INVOLVED IN DRUG BIOTRANSFORMATION. 171 4.1 INTRODUCTION. 171 4.2 INTERACTION BETWEEN A DRUG SUBSTRATE AND AN ENZYME . 172 4.3 ENZYME SYSTEMS WITH SPECIFIC ROLES . 189 4.3.1 Phase I enzyme systems. 189 4.3.2. Phase II enzymes . 202 4.4 FINAL REMARKS. 204 References . 204 CHAPTER 5. INDUCTION AND INHIBITION OF DRUG-METABOLISING ENZYMES . 209 5.1 INTRODUCTION. 209 5.2 INDUCTION. 210 5.2.1 Induction of the Cytochrome P450 system . 210 5.2.2 Induction of other enzyme systems . 213 5.3 INHIBITION. 214 5.3.1 Inhibition of the Cytochrome P450 system. 214 5.4 CONSEQUENCES OF THE ABOVE PHENOMENA. 219 Contents ix 5.5 DIETARY AND NON-DIETARY FACTORS IN ENZYME INDUCTION AND INHIBITION . 220 References . 234 CHAPTER 6. FACTORS THAT INFLUENCE DRUG BIOTRANSFORMATION. 243 6.1 INTRODUCTION. 243 6.2 INTRINSIC FACTORS . 244 6.2.1 Species. 244 6.2.2 Sex . 253 6.2.3 Age . 254 6.2.4 Pathological status. 258 6.2.5 Hormonal control of drug metabolism – selected examples. 261 6.3 ENVIRONMENTAL FACTORS. 262 6.4 FURTHER OBSERVATIONS. 263 References . 264 CHAPTER 7. IMPACT OF GENE VARIABILITY ON DRUG METABOLISM. 269 7.1 INTRODUCTION. 269 7.2 BASIC PRINCIPLES OF PHARMACOGENETICS. 269 7.2.1 Species-dependent biotransformations and their genetic control . 274 7.3 PHARMACO-INFORMATICS. 287 7.4 IMPLICATIONS FOR THIRD MILLENNIUM MEDICINE. 288 References . 289 CHAPTER 8. DRUG INTERACTIONS AND ADVERSE REACTIONS. 295 8.1 INTRODUCTION. 295 8.2 DRUG-DRUG INTERACTIONS. 295 8.2.1 Definitions, concepts, general aspects . 295 8.2.2 Interactions associated with the pharmacodynamic phase . 297 8.2.3 Pharmacokinetic interactions: incidence and prediction. 300 8.2.4 Interaction during the biotransformation phase . 305 8.2.5 Other selected, miscellaneous recent examples . 308 8.2.6 Other frequent and relevant interactions . 314 8.3 INTERACTIONS BETWEEN DRUGS AND OTHER ENTITIES . 325 8.3.1 Drug-food interactions . 325 8.3.2 Interactions with alcohol. 327 8.3.3 Influence of tobacco smoke . 328 8.4 ADVERSE REACTIONS . 329 8.4.1 Classification criteria. 329 8.4.2 Selected examples. 333 8.5 SUMMARY . 348 CONCLUDING REMARKS . 351 References . 351 x Contents CHAPTER 9. STRATEGIES FOR DRUG DESIGN. 369 9.1 INTRODUCTION. 369 9.2 PHARMACOKINETICS AND METABOLISM IN DRUG RESEARCH. 369 9.2.1 General overview . 369 9.2.2 The prodrug approach. 372 9.2.3 The hard drug approach. 385 9.2.4 The soft drug approach . 390 9.2.5 Strategies based on Chemical Delivery Systems . 394 9.3 THE ROLE OF FORMULATION. 405 9.4 CONCLUDING REMARKS . 407 References . 408 INDEX. 415 PREFACE This book is intended to serve a wide audience, including students of chemistry, pharmacy, pharmacology, medicine, biochemistry and related fields, as well as health professionals and medicinal chemists. Our aim in preparing it has been threefold: to introduce essential concepts in drug metabolism (drug biotransformation), to illustrate the wide-ranging medical implications of such biological processes and to provide the reader with a perspective on current research in this area. The general intention is to demonstrate that the metabolism of a drug is a primary concern throughout its lifetime, from its inception (chemical design and optimisation) to its final clinical use, and that for any given drug, the multiple factors influencing its metabolism necessitate on-going studies of its biotransformation. In the first chapter, the principles underlying drug absorption, distribution, metabolism and elimination are described, with drug metabolism highlighted within the context of these fundamental processes. Chapters 2 and 3 deal with the chemistry of drug biotransformation, describing both Phase I (‘asynthetic’) and Phase II (‘synthetic’) biotransformations and the enzymes that mediate them. Further details of the structural features, mechanisms of action in biotransformation, and regulation of enzymes appear in Chapter 4. Enzyme induction and inhibition, with special reference to the cytochrome P450 system, are examined in Chapter 5. This is followed, in Chapter 6, by a discussion of the influence of sex, age, hormonal status and disease state on drug biotransformation. An introduction to the relatively new discipline of pharmacogenetics, probing the effects of gene variability on drug biotransformation, is the subject of Chapter 7. This includes commentary on the implications of pharmacogenetics for the future dispensing of medicines. Chapter 8 treats two special topics that have significant clinical implications, namely drug-drug interactions and adverse reactions. Included in this chapter is an extensive tabulation of drug-drug interactions and their biological consequences. Finally, Chapter 9 attempts to demonstrate how considerations based on a sound understanding of the principles of drug metabolism (described in the earlier chapters) are incorporated into the drug design process in order to maximise the therapeutic efficacy of candidate drugs. This is of paramount interest to the medicinal chemist whose aim is to design safe and effective drugs with predictable and controllable metabolism. The text is supported extensively by pertinent examples to illustrate the principles discussed and a special effort has been made to include frequent literature references to recent studies and reviews in order to justify the term ‘current’ in the title of this work. Corina Ionescu Mino Caira ACKNOWLEDGEMENTS Prof. dr. Marius BojiĠă, Rector of “I.HaĠieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania, for facilitating this collaboration, his understanding and support; Prof. dr. Felicia Loghin, Dean of the Faculty of Pharmacy, for her continuous support and encouragement; Prof. dr. Jacques Marchand (Univ. of Rouen, France) and Prof. George C Rodgers Jr. (Univ. of Louisville, Kentucky, USA) for their encouragement and recommendations; Prof. dr. Dan Florin Irimie, the first reader of the Romanian version of my book, for his helpful comments. MRC expresses his gratitude to Fiona, Renata and Ariella for their infinite patience and unflagging loyalty. Thanks are due to the University of Cape Town and the NRF (Pretoria) for supporting drug-related research projects. We are indebted to Richard A Paselk, Abby Parrill and numerous other sources for granting us permission to reproduce numerous figures. A special token of thanks is due to our colleagues who have assisted with technical aspects of the production of this work. They include Senior Lecturer Dr. Adrian Florea, from the Department of Cellular Biology, “I.HaĠieganu” University of Medicine and Pharmacy, as well as Mr Vincent Smith and Mr Paul Dempers (both of the Department of Chemistry, University of Cape Town). Chapter 1 DRUG METABOLISM IN CONTEXT 1.1 INTRODUCTION There are four discrete processes in the pharmacokinetic phase during the biological disposition of a drug (or other xenobiotic), namely its absorption, distribution, metabolism and excretion – the ADME concept (Figure 1.1). B io tr a n s f o r m a t io n A d m in is tr a t io n P L A S M A b o u n d A b s o r p t io n f r e e A c t io n f re e b o u n d D e p o t S e c r e t io n f re e E x c r e t io n b o u n d Fig.1.1 Schematic representation of the interrelationship of the four main processes 1 2 Chapter 1 The importance of ADME in modern drug development cannot be understated. Optimisation of the performance of new drug candidates, with respect to increasing their bioavailability and controlling their duration of action, depends critically on investigation and proper exploitation of their metabolism and pharmacokinetics (PK), an activity referred to as ‘early ADME studies’. Studies of metabolism and PK have accordingly evolved to be in step with innovations in modern drug-discovery, such as automated combinatorial synthetic developments, high-throughput pharmacological testing and the compilation of extensive databases. The reader is referred to a recent review highlighting a particular category of ADME investigation, namely ‘metabolic stability’ studies [1]. In addition to explaining the theoretical basis of metabolic stability and its relationship to metabolic clearance, the review presents some fundamental relationships between drug structure and metabolism, as well as providing examples of how metabolic stability studies have contributed to the design of drugs with improved bioavailabilities and favourable half-lives. In the final chapter of this book dealing with drug design, we return to this topic and describe further examples of the incorporation of metabolism and PK data into various strategies for increasing the therapeutic indices of new candidate drugs. Before dealing in detail with the individual items comprising ADME, another modern aspect of drug discovery and development that merits mention here is ‘ADME prediction’, whose aim is to forecast the ADME behaviour of candidate drugs from their chemical structures with a view to selecting suitable compounds for further development. A recent account of the biophore concept describes its particular application in the important area of ADME prediction [2]. An overview of ADME is useful at this point. Drugs are introduced into the body by several routes. They may be taken by mouth (orally); given by injection into a vein (intravenously), into a muscle (intramuscularly), into the space around the spinal cord (intrathecally), or beneath the skin (subcutaneously); placed under the tongue (sublingually); inserted in the rectum (rectally) or vagina (vaginally); instilled in the eye (by the ocular route); sprayed into the nose and absorbed through the nasal membranes (nasally); breathed into the lungs, usually through the mouth (by inhalation); applied to the skin (cutaneously) for a local (topical) or bodywide (systemic) effect; or delivered through the skin by a patch (transdermally) for a systemic effect. Each route has specific purposes, advantages, and disadvantages. After the drug is absorbed, it is then distributed to various organs of the body. Distribution is influenced by how well each organ is supplied by blood, organ size, binding of the drug to various components of blood and tissues, and permeability of tissue

membranes. The more fat-soluble a drug Drug metabolism in context 3 is, the higher its ability to cross the cell membrane. The blood-brain-barrier restricts passage of drugs from the blood into the central nervous system and cerebrospinal fluid. Protein binding (attachment of the drug to blood proteins) is an important factor influencing drug distribution. Many drugs are bound to blood proteins such as serum albumin (the main blood protein) and are not available as active drugs. Metabolism occurs via two types of reaction: phase I and phase II. The goal of metabolism is to change the active part of medications (also referred to as the functional group), making them more water-soluble and more readily excreted by the kidney (i.e. the body attempts to get rid of the “foreign” drug). Appropriate structural modification of drugs increases their water solubility and decreases their fat solubility, which speeds up the excretion of the drug in the urine. Excretion occurs primarily through the urine. Fecal excretion is seen with drugs that are not absorbed from the intestines or have been secreted in the bile (which is discharged into the intestines). Drugs may also be excreted in the expired air through the lungs, in perspiration, or in breast milk. There are three processes by which drugs are eliminated through the urine: by pressure filtration of the drug through the kidney component called the Glomerulus, through active tubular secretion (like the shuttle system), and by passive diffusion from areas of high drug concentration to areas of lower concentration. While the four processes comprising ADME were formally separated above, it should be noted that, depending on their respective pharmacokinetics, a given dose of drug may be undergoing more than one of these processes simultaneously, so that e.g. metabolism of absorbed drug may commence while part of the administered dose is still being absorbed. 1.2 ABSORPTION Medicines may be administered to the patient in a variety of ways, but the desired therapeutic effect will be achieved only if the pharmacologically active substance reaches its site of action (the target cells in the body) in a concentration sufficient for the appropriate effect and remains there for an adequate period of time before being excreted [3-8]. Thus, to produce its characteristic effects, a drug must undergo a process of movement from the site of application into the extracellular compartment of the body and be present in appropriate concentrations at its sites of action. Absorption may therefore be defined as the sum of all processes that a drug substance may undergo after its administration before reaching the systemic circulation. Consequently, it is evident that the 4 Chapter 1 concentration of active drug attained depends primarily upon the extent and rate of absorption. The extent (completeness) of absorption into the systemic circulation is sometimes defined by another parameter, designated as bioavailability. Generally, the term is used to indicate the fractional extent to which a dose of drug reaches its site of action, or a biological fluid from which the drug has access to its site of action. The amount of drug absorbed is determined by measuring the plasma concentration at intervals after dosing and integrating by estimating the area under the plasma concentration versus time curve (AUC) [3,4,7,8]. Bioavailability may vary not only between different drugs and different pharmaceutical formulations of the same drug, but also from one individual to another, depending on various factors, described in a following subsection. The rate of absorption, expressed as the time to peak plasma concentration (Tmax), determines the onset of pharmacological action, and also influences the intensity and sometimes the duration of drug action, and is important in addition to the extent (completeness) of absorption. Moreover, we can define the concept of absolute bioavailability as the percentage of the drug substance contained in a defined drug formulation that enters the systemic circulation intact after initial administration of the product via the selected route. Nevertheless, it is noted that while the absolute bioavailability of two drugs may be the same (as indicated by the same AUC), the kinetics may be very different (e.g. one may have a much higher peak plasma concentration than the other, but a shorter duration) [4]. As already mentioned, drugs may be administered by many different routes, the choice of which depends upon both convenience and necessity. Under the circumstances, it is evident that knowing the advantages and disadvantages of the different routes of administration is of primary importance [3-8]. The most common, generally safe, convenient for access to the systemic circulation and most economical method of drug administration is the oral route, applicable for achieving either local or systemic effects. A number of recent reviews treat various aspects that are relevant to drug administration via this route. For example, an account has been given of the structure of oral mucosa and the factors that affect drug oral mucosal absorption and drug formulation [9]. In the case of hydrophilic drugs, the structure of the intestinal epithelium, characterised by the presence of tight junctions (‘zona occludens’) significantly reduces their permeability. Design of agents that are capable of increasing paracellular permeability via modulation of tight junctions has been reviewed [10]. Efflux proteins, expressed by intestinal epithelium, may limit the absorption of drugs and secrete intracellularly formed metabolites back into the intestinal lumen. Drug metabolism in context 5 The clinical significance of the carrier-mediated efflux on intestinal absorption as well as first-pass gut wall metabolism of drugs has been highlighted [11]. Computational approaches to questions of drug absorption are also topical. We mention here a recent review that features simulation of gastrointestinal absorption and bioavailability and its application to prediction of oral drug absorption [12]. Statistical and mathematical methods were used to obtain models from which parameters for common drugs (e.g. the fraction absorbed, bioavailability, concentration-time profiles) could be predicted. Regarding oral administration, we must mention that this route does not always give rise to sufficiently high plasma concentrations to be effective: some drugs may be absorbed unpredictably or erratically [8], or patients occasionally may have an absorption malfunction. Disadvantages of this route include also limited absorption of some drugs, determined by their physical characteristics (e.g. water solubility), destruction of some drugs by digestive enzymes or low gastric pH, irritation to the gastrointestinal mucosa, irregularities in absorption in the presence of food (or other drugs, polytherapy still being very common), as well as necessity for patient compliance. In addition, drugs in the gastrointestinal tract may be metabolised by the enzymes of the intestinal flora, mucosa, or, especially, the liver (the main location of biotransformations) before they gain access to the general circulation; so, it can be said that most orally administered drugs undergo first-pass metabolism. The extent of the latter is usually determined from a comparison of the difference in the areas under the blood concentration-time curves (AUCs) observed for oral versus i.v. drug administration, and is accurate only when drug clearance obeys first-order kinetics. Complications arising from clearance that is not first- order (e.g. that of ethanol) and errors that could result in measurements of first-pass metabolism have been reviewed recently [13]. Experimental strategies have been developed for the in vivo evaluation of factors affecting oral bioavailability; these can lead to estimation of the individual contributions attributable to drug absorption, losses in the gut lumen, and first-pass metabolism in the gut wall and liver [14]. The methods assume linear pharmacokinetics and constant clearance between treatments and are also appropriate for assessing metabolite bioavailability and probable sites of metabolism. The effects of food on drug absorption also merit consideration in a discussion of oral bioavailability, since these may be quite complex. One classification of drug-food interactions includes those that cause reduced, delayed, increased and accelerated drug absorption, and those in which food does not play a role [15]. According to this account, the drug 6 Chapter 1 formulation is evidently also an important factor, so that ‘formulation-food interactions’ may be a more appropriate term than ‘drug-food interactions’. For some drugs it is sometimes assumed that parenteral administration is superior to oral administration as the latter may be impaired due to e.g. poor lipid solubility of the drug, its high molecular weight, or strongly anionic nature. This applies to the antithrombotic heparin. However, one study has shown that heparin is taken up by endothelial cells not only parenterally, but also following oral administration, despite low plasma concentrations [16]. Thus, animal experiments with unfractionated heparins (bovine and porcine) or low molecular weight heparins have yielded results supporting the thesis that heparin may well be effective when administered orally. Drug metabolism by intestinal flora may also affect drug activity. Alteration of bowel flora (e.g. by concomitant use of antibiotics) can interrupt enterohepatic recycling and result in loss of activity of some drugs (e.g. the low oestrogen contraceptive pill). The oral route is usually precluded only in patients with gastrointestinal (GI) intolerance or who are in preparation for anaesthesia or who have had GI surgery, as well as in situations of coma. It is worth emphasising here that several common disorders may have an influence on the ability of the body to handle drugs. As a result, individualized therapy may become necessary for patients when e.g. gastrointestinal, cardiac, renal, liver and thyroid disorders influence drug pharmacokinetics. To avoid therapeutic failure, altering the route of administration or favourable drug co-administration (see Chapter 8) may be considered. The rate and extent of absorption of orally administered drugs may be affected by numerous pathological factors that alter gastric emptying in instances where patients have GI diseases. Factors such as trauma, pain, labour, migraine, intestinal obstruction and gastric ulcer have been associated with decreased absorption rate, whereas conditions such as coeliac disease and duodenal ulcer may result in enhanced absorption. More specific cases include the following: reduction in the absorption of lipophilic molecules (e.g. fat-soluble vitamins) due to steatorrhoea induced by pancreatic disease; poor absorption in cardiac failure as a result of reduced GI blood flow; reduction in the absorption of ferrous sulphate and other drugs in chronic renal failure due to the buffering effect of ammonia generated by cleavage of urea; alteration in drug absorption in liver disease due to associated mucosal oedema. In the latter case, hepatic pre-systemic metabolism of drugs administered orally is impaired, resulting in significantly increased bioavailability. Drugs that are not absorbed can have a systemic effect via an indirect action. Cholestyramine, a bile acid binding resin that lowers Drug metabolism in context 7 plasma concentrations of low-density lipoprotein cholesterol and reduces the risk of myocardial infarction in men with hypercholesterolaemia, is an example of this [6]. For systemic effects there are two main mechanisms of drug absorption by the gut: passive diffusion and active transport (a specific, carrier-mediated, energy-consuming mechanism). Particular cases to be mentioned are controlled-release preparations [7,8,17], the Positive Higher Structures (PHS) [18], and the use of proliposomes [19], nanoparticles [20], chitosan microspheres [21], and erythrocytes [22], as potential carriers for drugs. Controlled-release preparations are most suitable for drugs with short half-lives (< ~ 4 h) and are designed to produce slow, uniform absorption of the drug for 8 hours or longer with the obvious advantages of reduced dose frequency (improved compliance), maintenance of a therapeutic effect overnight, and lower incidence and/or intensity of undesired effects (by elimination of the peaks in drug concentration). Opioids in a range of controlled-release preparations for oral, rectal and transdermal administration in a wide variety of pain states have been reviewed [17]. The first of these on the market (MS Contin tablets) has been in use for nearly twenty years. In contrast to short-acting immediate- release opioid preparations, which are typically administered after 4 or 6 h intervals, controlled-release preparations require considerably lower dosing frequency (e.g. once- or twice-daily doses for oral/rectal preparations, up to 7 days for transdermal preparations). With some newer preparations, analgesic therapy can begin without initial stabilisation with an immediate- release product. The primary advantages are thus sustained pain relief and patient compliance. Nevertheless, absorption of such preparations is likely to be incomplete, so it is especially important that bioavailability be established before their general introduction. Other problems associated with slow- release preparations include the following: overdose is difficult to treat (because large amounts of drug continue to be absorbed several hours after the tablets have left the stomach); there is reduced flexibility

of dosing (since sustained-release tablets should not be divided); high cost [4-8]. The PHS are bio-systems which return the enlarged molecules of a drug, resulting from attracted water molecules, to their ‘normal’ size, and thus restore their initial bioactivity [18]. Oral preparations based on liposomes as enteric-coated products can have improved in vivo stability. Reduction of toxicity and improvement in therapeutic efficacy have also resulted from the use of liposomes. Conventional liposomes may, however, present problems of stability (e.g. aggregation, susceptibility to hydrolysis, oxidation). Instead, proliposomes, 8 Chapter 1 which are dry, free-flowing materials that form a multi-lamellar suspension on addition of water, are devoid of such problems [19]. Pre-systemic metabolism reduces drug bioavailability. This may sometimes be overcome by using nanoparticles, in particular those that are bioadhesive (e.g. poly(methylvinylether-co-maleic anhydride) nanoparticles, that are either coated with albumin, or treated with albumin and 1,3-diaminopropane) [20]. Chitosan microspheres have been explored as carriers for drugs owing to their biocompatibility [21]. This stems from the fact that chitosan (a deacylated chitin) is a natural, non-toxic biodegradable polymer with mucoadhesive properties. Interaction with counterions such as sulphates and polysulphates, and crosslinking with glutyraldehyde lead to gel formation, a phenomenon that lends itself to pharmaceutical application. Thus, the performance of certain poorly soluble drugs has been significantly improved using this approach. Drug pharmacokinetics can be altered significantly by encapsulation in biocompatible erythrocytes, which have been employed for delivery of drugs, enzymes and peptides [22]. Advantages include modification of release rate, enhancement of liver uptake and targeting of the reticulo- endothelial system. Targeting of particular drugs (e.g. antineoplastics such as methotrexate and carboplatin, anti-HIV peptides and nucleoside analogues) to specific organs or tissues is another important application that employs erythrocytes. (See also Chapter 9 for drug targeting using ‘chemical delivery systems’). Enteric-coated formulations may also be employed in an attempt to reduce high first-pass metabolism, to achieve tissue targeting and to improve the overall safety profile of a drug, as has recently been reported for budesonide [23]. Important routes of administration that circumvent pre-systemic metabolism, providing direct and rapid access to the systemic circulation, and bypassing the intestine and liver are the buccal and sublingual routes. The sublingual route provides a very rapid onset of action (necessary, for example, in the treatment of angina attacks with nitroglycerine), while for the buccal route, the formulation ensures drug release over a prolonged period, thus giving an extended absorption and providing more sustained plasma concentrations. The drug substance must be relatively potent since the dose administered is necessarily low, and its taste must be masked (otherwise, it would result in salivation with subsequent loss of drug). Frequently, drugs administered by these routes provide improved bioavailability compared with that from the oral route (because of the direct, rapid access to the systemic circulation). Nevertheless, we have to mention that only a few drugs may be administered successfully by these routes. Major limitations are the prerequisite for low dosage levels Drug metabolism in context 9 (generally limited to around 10 mg), the masking of taste and the risk of irritation to the mucosa, especially with prolonged treatment. Useful especially in paediatrics (as well as in patients who are unconscious or when vomiting) is the rectal route, drugs administered in this way displaying either local or systemic effects. Currently there is considerable interest in exploring alternative routes of administration of narcotics for the management of pain due to cancer [24]. The rectal, buccal or sublingual routes for management of acute pain syndromes have been considered as alternatives to the oral, intramuscular, intravenous and subcutaneous routes. Thus, rectal administration of morphine sulphate and chlorhydrate can lead to acceptable absorption, albeit subject to interpersonal variation. Further studies are warranted in view of the meagre pharmacokinetic data currently available for administration of narcotics via the buccal and sublingual routes in particular. The mucosal membrane of the rectum is well supplied with blood and lymph vessels and consequently this route of drug absorption is usually high. Other advantages include avoidance of exposure to the acidity of the gastric juice and digestive enzymes, prolonged duration of action, as well as partly bypassing the portal circulation, and thus reducing pre-systemic metabolism. Usually, approximately 50% of a drug that is absorbed from the rectum will bypass the liver; the potential for hepatic first-pass metabolism is consequently less than that for an oral dose. Disadvantages are that drugs administered rectally can cause severe local irritation; in addition, rectal absorption is often irregular and incomplete. The reader is referred to a recent review on suppositories [25] describing both the pharmaceutical agents employed in rectal and/or vaginal preparations as well as novel suppositories with specific functions (e.g. suppositories that are foaming, those having localised effect, hollow suppositories). The topical route is employed to deliver a drug at (or immediately beneath) the point of application. Therefore, this route is of limited utility. However, some success has been reported with transdermal preparations of certain drugs for systemic use (e.g. those of nitroglycerine and clonidine). The aprotic solvent dimethyl sulphoxide (DMSO) is a well-known penetrant used to enhance absorption. Topical administration using DMSO as a vehicle for systemic effects has also been investigated [26]. Other substances that enhance penetration of drugs include surface-active agents and several amides [6]. Nevertheless, it should be mentioned that systemic absorption may sometimes cause undesirable effects, as in the case of potent glucocorticoids, especially if applied to large areas (and under occlusive dressings) [6]. 10 Chapter 1 As with injection or buccal administration, transdermal administration bypasses pre-systemic metabolism in the gut wall or liver. The inhalation route is one of the oldest methods of effective treatment and has been used by asthmatics for their self-medication with natural products for centuries. However, administration of drugs to the bloodstream with inhalation aerosols may be hindered by several factors. These include the limitations of dry powder inhalers, drug-excipient interactions and biological loss of the active substance in lung tissue. This subject has been reviewed recently [27]. Inhalation may be employed for delivering gaseous or volatile substances into the systemic circulation, as with most general anaesthetics or nebulised antibiotics sometimes used in children with cystic fibrosis and recurrent Pseudomonas infections. The major advantage is that the drug substance can be targeted directly to its sites of action in the lower respiratory tract with the potential for significantly reduced systemic side effects. At the same time, the large surface area of the alveoli, together with the excellent local blood supply, ensure rapid absorption, with subsequent rapid onset of action of the administered drug. More recently this route has been applied to the administration of drugs such as steroids and peptides, which are inactivated after oral administration, another major advantage of the inhalation route being avoidance of hepatic first-pass loss. Various types of inhalers for pulmonary administration of glucocorticoids have been reviewed [28]. Details of their contents, construction and principles of operation are discussed. With inhalers, disadvantages may include incorrect use of the device itself, the existence of a high degree of coordination between breathing and activation of the device, the possibility of causing bronchoconstriction in certain cases, and toxicity of aerosol propellants. Pulmonary absorption is also an important route of entry of certain drugs of abuse and of toxic environmental substances of varied composition and physical states. Both local and systemic reactions to allergens may occur subsequent to inhalation. The use of liposomes in drug delivery was mentioned briefly above. A comprehensive review on the development of liposomes for local administration and its efficacy against local inflammation has appeared [29]. Topics covered include local administration to treat a number of conditions including arthritis (by intra-articular injection), pancreatitis and inflammation (of skin, airway, eye, ear, rectum, burn wounds). Parenteral administration, currently referring to the administration of drug substances via injection, include the intravenous, intramuscular, and subcutaneous routes. These routes may be employed whenever enteral routes are contraindicated or inadequate and present main advantages such as: rapid onset of action; possibility of administration in the case of Drug metabolism in context 11 unconscious, uncooperative or uncontrollable patients; avoiding preliminary metabolism in the GI tract or liver (first-pass effect e.g. in i.v. injection) and especially in the case of intravenous infusion, facile control, enabling precise titration of drugs with short half-lives. For parenteral formulations, that most commonly used in medical care is the intravenous route, which avoids all natural barriers of the body for absorption, and therapeutic levels are reached almost instantaneously. Other advantages of this route include the greater predictability of the peak plasma concentration, as well as the generally smaller doses required. The principal adverse effect can be a depression of cardiovascular function, often called drug shock (see also Chapter 8). Intramuscular injection is a very convenient, more practicable route for routine administration, and inherently safer for the patient. Subcutaneous injections are administered into the loose connective and adipose tissue immediately beneath the skin. This route is particularly useful in the case of drugs that are not effective after oral administration and it permits self-medication by the patient on a regular basis as, for example, in the case of insulin for diabetics. Local routes of injection can also be used for specific purposes and conditions. In this context, intrathecal (specialised route for anaesthetics) and intra-arterial (directly into an artery for local effect in a particular tissue or organ) injections can be mentioned. Disadvantages include: the need for qualified medical staff; not very good patient compliance; difficulty in counteracting the effects of the drug substance in the case of overdose; continuous care to avoid the injection of air or particulate matter into the body; severe allergic reactions; haematoma formation can occur, especially after fibrinolytic therapy. From the above presentation of the main routes of drug administration, some conclusions can be drawn concerning oral versus parenteral administration: oral ingestion is more common, safer, convenient and economical, but its main disadvantages include: limited absorption of some drugs (because of their physicochemical characteristics), irritation to the GI mucosa, destruction of some drugs by low gastric pH or digestive enzymes, irregularities in absorption in the presence of food or other drugs, extensive deactivation of many drugs as a result of the ‘first-pass effect’, and necessity for cooperation on the part of the patient. Over oral administration, the parenteral injection of drugs has certain distinct advantages: availability is usually more rapid, extensive, and predictable; the effective dose can be more accurately delivered; in emergency therapy and when a patient is unconscious or unable to retain anything given by mouth; avoidance of preliminary metabolism in the GI tract or liver; by use of electric pumps, facilitation for controlled 12 Chapter 1 intravenous infusion. Disadvantages include: asepsis must be maintained; pain may accompany the injection; difficulty for patients to perform the injections themselves if self-medication is necessary; high cost. Bioequivalence The chemical substance which is a pharmacologically active ingredient synthesised by the medicinal chemist is not per se the medicine which is administered to the patient. That is, drugs are not administered as such, but formulated into drug dosage forms. Typically only ~10% of modern dosage forms comprises the active ingredient (drug), which is mixed with a variety of pharmacologically inert ingredients or excipients that perform a number of functions (as bulking agents, colourants, antioxidants, preservers, binders, enhancers). It is important to emphasise that the manufacturing process, or changes in the excipients contained in a medicine, may have a profound effect on the bioavailability of a drug substance, and it is important to bear in mind that it is never the isolated drug substance, but a dosage form which is administered to the patient. In this context, a new concept appeared, namely that of bioequivalence [30]. It is assumed that drug products are pharmaceutically equivalent if they contain the same active ingredients and are identical in strength or concentration, dosage form and route of administration. Furthermore, such pharmaceutically equivalent drug products are considered to be bioequivalent when the rates and extents of bioavailability of the active ingredient in the respective products are not significantly different under suitable test conditions. As noted in a recent report [31], the regulatory bioequivalence requirements of drug products have undergone major changes. The biopharmaceutics drug classification system (BCS) has been introduced into the guidelines of the FDA. The BCS is based on mechanistic approaches to drug

absorption and dissolution, simplifying the drug approval process by regulatory bodies. This system is also useful for the formulation scientist who may now base development of optimised dosage forms on mechanistic rather than empirical approaches. Factors affecting absorption These may be subdivided into: • factors depending on the physicochemical properties of the drug molecule and characteristics of dosage formulations, and • biological factors (usually specific for the route of administration, surface area at the site, blood flow to the site, acid-base properties surrounding the absorbing surface), including genetically determined inter- individual variability. Drug metabolism in context 13 Absorption from the GI tract is governed by factors such as surface area for absorption, blood flow to the site of absorption, the GI transit time (of major importance since the extent of absorption is very dependent on time spent in the small intestine with its very large surface area), the presence of food or liquid in the stomach (affecting especially the emptying time of the stomach), as well as co-administration of, for example, two drug substances, which may influence the absorption rate and extension of one of them, thus accelerating or delaying gastric emptying. For example, if salicylate (a weak acid) is administered with propantheline (which slows gastric emptying) its absorption will be retarded, whereas, co-administered with metoclopramide (which speeds up gastric emptying) its absorption is accelerated [6]. The physical properties of the formulation may also have a dramatic effect on the absorption of a selected drug substance. Poor absorption characteristics may be improved by the use of lipid adjuvants which form oil/water emulsions to achieve higher concentrations of lipophilic drugs that would not otherwise be possible. Usually, unsaturated fatty acids enhance absorption more than the saturated analogues. In this context, we should also mention current interest in the use of absorption enhancers (for particular routes of administration). A recent review on the development of intestinal absorption enhancers [32] describes appropriate research methodology, the effects of the drug delivery system and physiological factors on absorption enhancing performance, the classification of enhancers, and issues of safety. Absorption enhancers include e.g. L-lysophosphatidylcholine, N-trimethyl chitosan, chitosan chloride, and cyclodextrins (CDs). An example of the use of CD technology is the recent achievement of improved solubility and skin permeation of bupranolol in the form of its CD complex by the transdermal route [33]. Commercial preparations based on CD inclusion complexes are available for oral, sublingual, intranasal and intracavernosal administration. Some examples are piroxicam betadex (based on the inclusion complex between β-CD and the drug and displaying more rapid absorption than uncomplexed piroxicam), benexate betadex and nimesulide betadex (based on their respective β-CD complexes), itraconazole in an oral liquid formulation with hydroxypropyl- β-CD (displaying good bioavailability, with absorption independent of local acidity), clonazepam contained in dimethyl-β-CD as a nasal formulation (a useful alternative to buccal administration for patients with serial seizures), alprostadil alfadex (based on the α-CD complex of the drug, for intracavernosal delivery) and nicotine (as the β-CD inclusion complex in a sublingual tablet) [34] (See also Chapter 9). 14 Chapter 1 On the other hand, it should be noted that diffusion of some drug substances may be reduced by their association with a cyclodextrin molecule [35], as it represents an average of ~20-fold increase in the molecular weight. This point is mentioned because the influence of CDs on diffusion through a semi-permeable membrane is very important, the absorption of biologically active molecules always occurring through such a membrane. The diffusion rate of a complex in homogenous solutions is always lower than that of the free guest. Also, the partition coefficient of lipophilic drugs in an octanol/water system is considerably reduced when CD is dissolved in the aqueous phase. Therefore, CDs can be used as reverse phase-transfer catalysts: the poorly soluble guest can be transferred to the aqueous phase, where its nucleophilic reactions, for example, can be accelerated. Whilst rapid bioavailability of the drug substance from the dosage form is usually required, suitable sustained-release forms can be formulated to deliver effective levels of a medicine over long periods when this is appropriate. For drugs given in solid form, the rate of dissolution may be the limiting factor in their absorption, especially if they have low water solubility. Since most drug absorption from the GI tract occurs via passive processes, absorption will be favoured when the drug is in the non-ionised and more lipophilic form. On the other hand, the particle size of the drug substance is a major consideration in virtually all formulation for oral and, notably, aerosol administration. The surface area per unit weight is increased by size-reduction, which aids both dissolution and the potential systemic bioavailability. The existence of polymorphism, or the ability of a compound to exist in more than one crystalline state with different internal structures, will also have significance for the development of a suitable dosage form. Metastable polymorphs will tend to have an increased solubility, and consequently faster dissolution than a stable polymorph. This property may become important for a drug substance with an inherently poor initial dissolution rate profile, provided that the metastable form does not convert to the stable modification during storage or in the GI tract. An example is provided by ampicillin, where the anhydrous and trihydrated forms result in significantly different serum levels in human subjects after oral administration, the more soluble anhydrous polymorph producing higher and earlier blood levels (see also Chapter 9). Another important factor that will be discussed in the following subchapter is the pH of the drug substance administered. Other factors that influence absorption from the GI tract include: disease of the GI tract, surgical interference with gastric function, and drug metabolism by intestinal flora [5-8]. Drug metabolism in context 15 In the case of buccal and sublingual administration, absorption is dependent on the fraction of unionised material available at the buccal membranes and on the partition coefficient of the drug. A careful balance between these properties is necessary, because buccal absorption is more dependent on lipid solubility than is absorption across the mucosa of the GI tract. In the case of the rectal route, the mucosal membrane of the rectum being well supplied with blood and lymph vessels, drug absorption is usually high. However, it can be significantly increased by using enhancers such as chelating agents (e.g. EDTA), non-steroidal anti-inflammatory agents (NSAIDs), and surfactants [6]. Also, the particle size of the drug substance, as well as the base used in the suppository will play a significant role in drug absorption. Factors affecting percutaneous drug absorption include: skin condition (inflammation and other conditions that increase cutaneous blood flow may enhance absorption), age, region, hydration of the stratum corneum, surface area to which the drug is applied, physical properties of the drug, and vehicle [3-8]. The most important physicochemical properties of a drug affecting its transdermal permeability are its partition coefficient and molecular weight. To reach the systemic circulation the drug substance must cross both the lipophilic stratum corneum and the hydrophilic viable epidermis. Although no direct correlation between percutaneous absorption and molecular weight of the drug substance can be demonstrated, it is obvious that macromolecules will penetrate the skin very slowly, if at all (peptides and proteins are not effectively absorbed through the skin). Increasing drug concentration in the dosage form generally increases absorption via the skin until the vehicle is saturated. The pH of the formulation will also affect its penetration, the drug molecule ideally being in its unionised form. The skin presents a major barrier to the absorption of drugs. Challenges and progress in transdermal drug delivery have recently been reviewed [36], as have the clinical aspects [37]. The physicochemical constraints severely limit the number of molecules that can be considered as realistic candidates for transdermal delivery. Nonetheless, absorption through the skin can be enhanced by suspending the drug in an oily vehicle and rubbing the resulting preparation into the skin. Hydration of the skin for absorption is extremely important and many topical formulations simply increase hydration of the stratum corneum by reducing water loss with an impermeable layer of a paraffin or wax base, or with a high water content in the formulations. Thus, the dosage form may be modified or an occlusive dressing may be used to facilitate absorption. The use of a surface-active agent frequently enhances penetration of drug substances. Use of penetration enhancers such as DMSO (mentioned earlier) and urea may also dramatically increase transdermal drug absorption [26]. 16 Chapter 1 To increase the range of drugs available for transdermal delivery, several chemical and physical enhancement techniques have been developed. One such procedure aimed at enhancing penetration of hydrophilic and charged molecules across the skin is iontophoresis, which is an electrical stimulation modality primarily noted for affording control and the ability to individualise therapy [38]. The latter issue may achieve more significance as knowledge about inter-individual variations in protein expression and their effect on drug metabolism and drug efficacy accumulates. The components of an iontophoretic device include a power source and two electrode compartments. The drug formulation that contains the ionised molecule is placed in the electrode compartment having the same charge while the indifferent electrode is placed at a distal side on the skin. This technique not only has applications in pain management (for local pain relief or local anaesthesia), but significantly improves transdermal delivery of certain classes of drugs such as NSAIDs (e.g. piroxicam, diclofenac), opioids, local anaesthetics, anti-emetics, antivirals, cardiovascular agents, steroids, various peptides and proteins (e.g. insulin, human parathyroid hormone, luteinising hormone-releasing hormone (LHRH) and its analogues). A related technique is phonophoresis (or sonophoresis), which employs ultrasound to increase percutaneous absorption of a drug. The method has been used extensively in sports medicine for the last forty years. With the typical parameters used (frequency 1-3 MHz, intensity 1-2 W/cm2, duration 5-10 min, continuous or pulse mode), controlled human in vivo studies have shown either insignificant or only mild effects of this procedure. There has been renewed interest in the technique during the last decade, owing to the finding that administration of macromolecules with conserved biological activity was possible with low frequency ultrasound in animals. The status of the technique has been reviewed [39]. Recent use of both low and high frequency ultrasound is discussed, as are the roles of thermal, cavitational and non-cavitational effects on the reduction of the skin barrier. As regards pulmonary absorption, it is obvious that the particle size of the drug substance is critical for optimum delivery in inhalation devices. If the particles are larger than 10 µm they impact the walls of the respiratory tract and never reach the alveolar sacs. If they are smaller than 1 µm then they are likely to be exhaled from the lungs before impact. Only 10-20% of the administered drug substance will reach the alveolar sacs owing to these particle size constraints, which are therefore critical for obtaining the desired, expected therapeutic effects. As previously indicated, in the case of the parenteral route, especially from subcutaneous and intramuscular injection, absorption occurs by simple diffusion along the gradient from drug depot to plasma. Drug metabolism in context 17 The rate of absorption is governed by the total surface area available for diffusion (area of the absorbing capillary membranes) and by the solubility of the drug substance in the interstitial fluid (lipid-soluble drugs generally diffusing freely through capillary walls). Transport away from the injection site is governed by muscle blood flow, and this varies from site to site (deltoid > vastus lateralis > gluteus maximus); blood flow to muscle can be increased by exercise (or massage) and thus absorption rates can be increased as well. Conversely, shock, heart failure or other conditions that decrease muscular blood flow reduce absorption. The incorporation of a vasoconstrictor agent in a solution of a drug to be injected subcutaneously also retards absorption. As mentioned earlier, by intravenous injection of drugs in aqueous solution, bioavailability being complete and rapid, the factors relevant to absorption are circumvented. 1.2.1 Basic mechanisms of transport through membranes The absorption of a drug (as well as the rest of the processes involved in the fate of a drug formulation in the body, namely distribution, biotransformation and excretion) involves its passage across cell membranes [40]. When a drug permeates a cell, it must obviously traverse cellular plasma membrane. Important in the process

of transfer through membranes are both the mechanisms by which drugs cross membranes as well as the physicochemical properties of both the drug molecules and membranes. Cell membranes consist of a bilayer of amphipathic lipids, with their hydrocarbon chains oriented inward to form a continuous hydrophobic phase and their polar groups oriented outward. Individual lipid molecules in the bilayer can move laterally, conferring on the membrane fluidity, flexibility, high electrical resistance, and relative impermeability to highly polar molecules. The membrane proteins embedded in the bilayer serve as receptors, ion channels, or carriers and provide selective targets for drug action. There are two main mechanisms of drug absorption: passive diffusion and active transport. Considered to be the more important mechanism, passive diffusion ensures good absorption of non-polar, lipid- soluble agents from the gut (mainly from the small intestine) because of its enormous absorptive area. The drug molecule usually penetrates by passive diffusion along a concentration gradient by virtue of its solubility in the lipid bilayer. This transfer is directly proportional to the magnitude of the concentration gradient across the membrane, the lipid: water partition 18 Chapter 1 coefficient of the drug, and the cell surface area. The concentration gradient across the membrane becomes the driving force that establishes the rate of diffusion, with the direction from high towards lower drug concentration. In the case of weak acids or weak bases, the non-ionised form of the drug is relatively fat-soluble and thus diffuses easily. Thus, the greater the partition coefficient, the higher the concentration of the drug in the membrane and the faster is its diffusion. Many drugs, because of their chemical structures (which determine their physicochemical properties), behave as acids or bases in that they can take up or release a hydrogen ion. Within certain ranges of pH, these drugs will carry an electrical charge, whereas in other pH ranges the compounds will be uncharged. It is this uncharged form of a drug that is lipid-soluble and therefore crosses biological membranes readily. Absorption is therefore influenced by the pKa of the drug and the pH at the absorption site. For example, consider the distribution of a drug substance acting like a weak acid (pKa = 4.4), and its partitioning between plasma (pH = 7.4) and gastric juice (pH = 1.4). It is assumed that the gastric mucosal membrane behaves as a simple lipid barrier, permeable only to the lipid-soluble, non-ionised form of the acid (Figure 1.2). The ratio of non-ionised to ionised drug at each pH can be calculated from the Henderson-Hasselbalch equation. In the case of weak acid, the total concentration ratio between the plasma and the gastric juice calculated by the above equation is 1000:1 (if the system comes to a steady state). In the case of a drug substance acting like a weak base with the same pKa, the ratio would be reversed. HA A- + H+ pH = 1.4 pH = 7.4 HA A- + H+ Fig.1.2 Equilibrium distribution from one side to the other of the cell membrane (Reproduced from ref. 4 (Fig. 1-2) with permission of The McGraw-Hill Companies) Drug metabolism in context 19 Thus, it is assumed that, at steady state, an acidic drug will accumulate on the more basic site of the membrane, and a basic drug on the more acidic site. This phenomenon is termed ion trapping [4]. Based on the pH-partition concept presented, it would be predicted that drugs that are weak acids would be better absorbed from the stomach (pH 1 to 2) than from the upper intestine (pH 3 to 6), and vice versa for weak bases. On the other hand, it should be noted that since the drug is ionised to a very small extent in the stomach but appreciably so in blood, the drug substance should cross readily in the stomach-to-plasma direction but hardly at all in the reverse direction [41]. A summary of the effect of pH on degree of ionization of several acidic and basic drugs is presented in Figure 1.3. While passive diffusion through the bilayer dominates in the disposition of most drugs, carrier-mediated mechanisms can also play an important role. Active transport requires energy, movement against an electrochemical gradient, saturability, selectivity, and competitive inhibition by co-transported compounds [42]. The specific carriers, transporter proteins (Figure 1.4), are often expressed within the cell membranes in a domain- specific fashion. pKa=1 antipyrine ACIDS BASES salicylic acid diazepam phenylbutazone warfarin aminopyrine phenobarbital procainamide amphetamine mecamylamine pKa=11 Fig.1.3 Prediction where drugs with certain pKa values will be absorbed (Data from ref. [41]) 20 Chapter 1 Fig.1.4 Comparative drug absorption via active (carrier) transport (the black arrow) and via passive diffusion (the white arrow) across a cellular membrane [41] An example of such an important efflux transporter is the P-glycoprotein. Nevertheless, it should be emphasised that this special protein, localised in the enterocyte, limits the oral absorption of transported drugs since it exports the compound back into the intestinal tract subsequent to its absorption by passive diffusion. Other mechanisms of transmembrane drug transport such as facilitated diffusion, or pinocytosis may also occur, but attempting to predict the type of transport expected for a specific drug and across a specific membrane type is not straightforward. Measurement and prediction of membrane permeabilities of candidate drugs are important topics in drug development. The Caco-2 cell model that allows estimates of apparent permeabilities of drugs through membranes is well-established and widely employed, but other, non- biological techniques such as PAMPA (parallel artificial membrane permeability assay) are receiving increasing attention [43]. In vitro and in silico approaches to predicting biological permeation have recently been reviewed [44]. Drug metabolism in context 21 1.3 DRUG DISTRIBUTION In section 1.2, the various routes of drug administration, as well as the factors that affect drug absorption in each case, were described. The present section addresses the subsequent phase, namely distribution of the drug to the various ‘compartments’ or ‘volumes of distribution’ that may be considered to comprise the human body. Following absorption or injection of the drug into the bloodstream, it is distributed into interstitial and cellular fluids, and interacts with macromolecules present in the various body fluids and tissues. The processes of drug diffusion into the fluids and drug binding to macromolecules affect both drug pharmacodynamics and pharmacokinetics. Distribution is thus effected by interaction of the drug with body components and the pattern of distribution depends on both the physicochemical properties of the drug in question (e.g. its lipid solubility, degree of ionisation, pKa, molecular weight) and physiological parameters (e.g. pH, extent of plasma protein binding, permeability of membranes, blood flow, nature of the tissue) [45]. Following a qualitative overview of drug distribution, kinetic aspects are described that serve to introduce a basic pharmacokinetic parameter, the apparent volume of distribution, which is of crucial importance in optimising the dosage regimen. 1.3.1 Qualitative aspects Following absorption of the drug into the general circulation, it is transported via the bloodstream and diffusion to the various tissues of the body (e.g. adipose tissue, muscle, brain) and body fluids. This distribution is aided by the rapidity of blood flow, the average circulation time being of the order of one minute. Drug distribution continues during blood recirculation. It is noted here that certain disease states can alter drug distribution. For example, in patients with congestive cardiac failure, the apparent volume of distribution (defined below) of certain drugs may be approximately only one-third that of the normal, so that regular doses give rise to elevated plasma concentrations, with concomitant toxicity. Renal impairment can result in accumulation of several acidic compounds that compete with drugs for binding sites on plasma proteins. In liver disease, the lower than normal plasma albumin concentration will lead to reduced drug plasma protein binding. In addition, bilirubin and other endogenous 22 Chapter 1 compounds that accumulate in liver disease may also displace drugs from binding sites, thus altering drug distribution. All drugs are bound to some extent to either plasma proteins (serum albumin primarily), tissue proteins, or both, and it is the unbound fraction that initially undergoes distribution. In the case of drugs such as propranolol, verapamil and aspirin, since more than 90% of the absorbed drug is bound in plasma, drug available to reach the site of action is limited. Owing to the equilibrium that is set up between bound drug and free drug, as distribution proceeds, the reduced concentration of drug in the bloodstream results in the blood-proteins releasing more bound drug. More polar drugs, such as atenolol, tend to remain within the blood and interstitial fluids, whereas apolar drugs, such as the anaesthetic halothane, primarily concentrate in fatty tissues. The nature and extent of tissue distribution depends on numerous factors including e.g. the blood flow to specific tissues and the lipid-solubility of the drug. The anaesthetic thiopental, for example, is highly lipid-soluble, rapidly entering brain tissue, whereas penicillin is generally unable to do so due to its relatively high aqueous solubility. However, tissue distribution may be altered by disease state and increased penetration of penicillin into brain tissue in patients affected by pneumococcal and meningococcal meningitis occurs due to increased permeability of the inflamed meninges [46]. Just as the bound drug in the bloodstream acts as a reservoir, replenishing distributed drug, so too do many tissues in which drugs concentrate act as storage sites, slowly releasing the drug, thus maintaining high concentrations and prolonging drug efficacy. From the above, it should be evident that the overall process of drug distribution is dynamic and very complex, involving release of the drug from the drug-plasma protein complex and its movement to major organs such as the liver, lungs, and kidneys, as well as to peripheral tissues. Pharmacokinetic modelling attempts to quantify not only this distribution phase but also simultaneous clearance of the drug (by metabolism and excretion). Depending on the drug and the level of accuracy required, models of different degrees of sophistication are employed to formulate mathematical equations describing these processes. 1.3.2 Kinetic aspects For the purposes of modelling drug distribution, it is convenient to consider the body as being divided into discrete ‘compartments’, separated by boundaries. Superficially, this resembles a multiphase system in which a chemical component partitions itself among the distinct, non-miscible Drug metabolism in context 23 phases to an extent depending on its affinity for each, as dictated by relative solubilities. However, whereas in such a system an equilibrium distribution is eventually attained, the nature of drug distribution is much more complicated because the human body is not a simple receptacle and it is not always possible to associate a specific pharmacokinetic compartment with an actual tissue or organ, Furthermore, there is a dynamic distribution of the drug into and out of many peripheral tissue compartments while drug elimination proceeds simultaneously. Because drug distribution and elimination can overlap in time, they are usually treated together in any mathematical model that seeks to map the complete drug concentration- time profile in the phases following drug absorption. In practice, the essential experimental parameter that is available to mirror the distribution and subsequent elimination of the drug is its concentration in whatever biological fluid is chosen for sampling. Most commonly, this is the blood plasma, since its composition resembles that of the extracellular fluid, which in turn is in contact with tissue cells containing the drug receptor sites. The blood plasma level of the drug is therefore taken as a measure of the drug concentration that reflects therapeutic efficacy. The discussion that follows is based mainly on the use of drug plasma concentration as the available experimental parameter. The simplest of the pharmacokinetic models is the ‘one- compartment model’, for which it is assumed that the initially administered drug dose, after entering a central compartment (the bloodstream in the case of administration as an intravenous bolus), rapidly equilibrates with the peripheral compartments, leading to a constant drug concentration throughout. It is stressed that such a simplified model implies that the entire body is a single compartment and that distribution is instantaneous and uniform. In this case, the volume in which the drug dose is distributed is referred to as the ‘apparent volume of distribution’, denoted Vd. This represents the apparent volume of body fluid which yields the measured concentration of drug in plasma for a given drug dosage and it may be calculated from eqn.

1.1: Vd = A / C 1.1 where A is the amount of drug in the body (measured in e.g. mg) and C is the measured drug concentration in the blood or plasma (measured in e.g. mg L-1). Thus, if a 10 mg dose of a drug that is 100% bioavailable results in a measured plasma concentration of 4 mg L-1, the apparent volume of distribution is 2.5 L. The value of Vd is generally regarded as a constant for a given drug and effectively represents the volume of body fluid that would be required to dissolve all of the drug present in the body at the same concentration as that found in the plasma. 24 Chapter 1 That the apparent volume of distribution is actually a hypothetical volume is easily seen from the following illustration. If we consider three drugs, X, Y and Z, present in equal total amounts in the body, but e.g. appearing in plasma to different extents, then the apparent volumes of distribution may be calculated using equation 1.1, with C being the measured concentration in the plasma (assumed volume 3 L). The results are shown in the Table below. Table 1.1 Vd calculated for drugs with varying fractions in plasma Mass in the Fraction in Measured drug Vd (L) body (mg) plasma concentration in plasma (mg L-1) Drug X 15 0.95 4.75 3.2 Drug Y 15 0.50 2.50 6.0 Drug Z 15 0.05 0.25 60.0 Although constant amounts of drugs X, Y, and Z in the body are involved, a wide range of apparent volumes of distribution is evident. For drug X, which is almost completely confined to the plasma, and hence has a very high concentration in this phase, the apparent volume of distribution is similar to that of the assumed plasma volume of 3 L. In contrast, for drug Y, only one-half of the total amount is present in the plasma, yielding a lower concentration in this phase compared with drug X; drug Y has a correspondingly higher Vd. In the case of drug Z, most of it is evidently distributed in the peripheral tissues (its relative concentration in the plasma being very low) and Vd is ten times that for drug Y. It follows that in general, higher apparent volumes of distribution must be associated with drugs that are either distributed extensively to tissue constituents or are dissolved in lipids, or both. In the case of the tricyclic antidepressant amitryptiline, Vd calculated for a 70 kg male is 1400 L, which exceeds the total body-water by a factor of ~30 [46]. Extensive distribution into tissues leaves a low measured concentration of drug in plasma, hence yielding a large Vd. The illustrations above emphasise that Vd is not a real volume. It is, nevertheless, an important pharmacokinetic parameter for a drug. One of its primary uses in drug therapy is in the estimation of the loading dose. Knowing the desired plasma concentration C, and the apparent volume of distribution Vd, the required dose D (mg kg-1) may be calculated from equation 1.2: D = VdC / f 1.2 Drug metabolism in context 25 where f is the bioavailability factor (the fraction of the drug dosage reaching the systemic circulation) and D is expressed in units of drug mass per unit of body mass [46]. While the one-compartment model is satisfactory for describing the dynamic behaviour of a drug that does, in practice, equilibrate rapidly between the central compartment (the bloodstream) and peripheral tissues (as in the case of e.g. aminoglycosides, with a distribution time of less than 30 min), the behaviour of many drugs requires simulation using a multi- compartmental or a physiological model. The two-compartmental model, for example, assumes that the drug displays a slow equilibration with the peripheral tissues. Here there is a clear distinction between the central compartment and the peripheral compartment in the sense that the mathematical treatment must take into account the finite values of the rate constants for transfer of the drug from the first to the second, and the reverse process. The use of simple pharmacokinetic models is resumed in section 1.5.1 where their relevance in analysing the process of drug elimination is considered. 1.4 DYNAMICS OF DRUG ACTION 1.4.1 Drug-receptor interaction After absorption and distribution, a drug reaches its site of action to produce an effect. The means by which a drug elicits such an effect is known as the mechanism of action [3-8, 47-50]. The effect of a drug results from its interaction with its site of action in the biological system; this takes place during the pharmacodynamic phase (pharmaco – referring to drugs and dynamics – referring to what happens when two things meet and interact). This interaction, usually with macromolecular components of the body, alters the function of the relevant component and thereby initiates the biochemical and physiological changes that are characteristic of the response to the drug. Those specific macromolecular components are referred to as receptive substances or drug receptors and denote the components of the body with which the chemical agent is presumed to interact. Besides drug- receptor interaction (stimulation or blockade), drugs may also produce effects via drug-enzyme interactions, or non-specific drug interactions. Receptors are specific biological sites located on a cell surface or within a cell; they can be thought of as keyholes into which specific keys (drugs) may fit. Identification of the two functions of a receptor, ligand binding and message propagation, correctly suggests the existence of 26 Chapter 1 functional domains within the receptor, namely a ligand-binding domain and an effector domain. Certainly from a numerical viewpoint, proteins comprise the most important class of drug receptors. Being proteic in nature, an important property of physiological receptors that renders them excellent targets for drugs, is that they act catalytically and hence function as biochemical signal amplifiers. The largest group of receptors with intrinsic enzymatic activity are cell surface protein kinases, which exert their regulatory effects by phosphorylating various effector proteins at the inner face of the plasma membrane. Another large family of receptors uses distinct heterotrimeric GTP-binding regulatory proteins, known as G proteins, as transducers to convey signals to their effector proteins. However, although often regarded as drug receptors, they are in fact receptors for endogenous substances that mediate normal biological and physiological regulatory processes. A special group of receptors – acting as dimers with homologous cellular proteins – forms part of a larger family of transcription factors. These are soluble DNA-binding proteins that regulate transcription of specific genes and include receptors for steroid hormones, thyroid hormone, vitamin D and the retinoids. The types of chemical bonds by which drugs bind to their receptors are (in decreasing order of strength): covalent, ionic, hydrogen, hydrophobic and van der Waals bonds. For the binding of a ligand (drug substance) to a receptor to be a genuine physiological phenomenon (and not just non-specific binding), the ligand binding should: • be saturable (in which case a plot of amount of drug bound against drug concentration will level off and reach a plateau); • be characterised by high affinity (binding constants less than 10-6M); • be linked to a pharmacological response characteristic of the particular ligand. The so-called occupation theory defines that only when the receptor is actually occupied by the drug molecule is its function transformed in such a way as to elicit a response. In the classical occupation theory, two attributes of the drug are required: a) affinity, a measure of the equilibrium constant of the drug-receptor interaction, and b) intrinsic activity (or efficacy), a measure of the ability of the drug to induce a positive change in the function of the receptor. The probability that a molecule of drug will react with a receptor is a function of the concentrations of both drug and receptor. Regulation of receptors Receptors not only initiate regulation of physiological and biochemical function, but are also themselves subject to many regulatory and homeostatic Drug metabolism in context 27 controls. These controls include regulation of the synthesis and degradation of the receptor (by multiple mechanisms), covalent modification, association with other regulatory proteins, and/or re-localisation within the cell. Modulating inputs may come from other receptors, directly or indirectly, and receptors are almost always subject to feedback regulation by their own signalling outputs. 1.4.2 Mechanisms Drugs have specific affinities for their specific receptors. Strong affinity for a receptor will allow a drug to elicit an agonist, antagonist, or mixed agonist/antagonist interaction. The organ on, or in which, the desired effect occurs is generally called the ‘target organ’. The target organ can represent any organ or system in the body. Drugs that bind to physiological receptors and mimic the regulatory effects of the endogenous signalling compounds are termed agonists (Figure 1.5). The physiological response is usually predictable: a drug agonist simply stimulates or enhances the body′s natural response to stimulation. In contrast, drugs with antagonistic activity will block receptors for which they have affinity. Such compounds may, however, produce desired effects by inhibiting the action of an agonist (i.e. by competition for agonist binding sites). Agents that do not elicit maximum response even at apparently maximum receptor occupancy are termed partial agonists, and those that stabilise the receptor in its inactive conformation are termed inverse agonists. Thus, antagonists are agents designed to inhibit or counteract effects produced by other drugs or undesired effects caused by cellular components during illness. Antagonists can be competitive or non- competitive. Tissue cell Fig.1.5 Schematic of drug-receptor interaction. The drug molecule (in black) has a high affinity for the receptor with which it makes the best fit 28 Chapter 1 Competitive antagonists are agents with an affinity for the same receptor site as an agonist. Features of their action include the following: the competition with the agonist for the site inhibits the action of the agonist; increasing the concentration of the agonist tends to overcome the inhibition; competitive inhibition responses are usually reversible. In contrast, non- competitive antagonists are agents that combine with different parts of the receptor mechanism and inactivate the receptor so that the agonist cannot be effective regardless of its concentration; their effects are considered to be irreversible or nearly so. Antagonists often share some structural similarities with their agonists. 1.4.3 Further aspects An important aspect to underline is that not all drugs work via receptors for endogenous mediators, and many drugs exert their effects by combining with an enzyme, transport protein or other cellular macromolecule (e.g. DNA) and interfering with its function. Drug-enzyme interaction Enzymes are generally considered as catalysts responsible for mediating biochemical reactions. Many enzymes begin working after becoming attached to a particular substrate; this is analogous to a drug attaching to a receptor. A drug/enzyme interaction occurs when a drug resembles the substrate that usually interacts with that enzyme. Stimulation or blockade of the enzyme will then be produced by the drug, and a pharmacodynamic reaction (effect) follows. On the other hand, many very useful therapeutic drugs are enzyme inhibitors, which selectively inhibit the normal activity of only one type of enzyme, thereby reducing the ability of the enzyme to act on its normal biochemical substrate. Of particular relevance and importance, frequently seen in medicine, are the interactions between cytochrome P450 enzyme and various drug substances. As is well known, cytochrome P450 enzyme is responsible for metabolism of many drugs. Consequently, any interference with this enzyme can lead to decreased metabolism with concomitant drug accumulation (and appearance of adverse reactions – e.g. combining cimetidine and theophylline without close monitoring can lead to theophylline poisoning). Finally, some drugs may elicit pharmacologic effects via non-specific drug interactions. For example, ointments and emollients may physically block underlying tissues from the outside environment. In other instances, Drug metabolism in context 29 drugs may penetrate cell membranes or accumulate within a cell or cavity so that interference with normal cell biochemical function occurs. Drug-response relationships Two other terms need to be introduced : efficacy and potency. Efficacy is the degree to which a drug is able to produce the desired effect. Potency is the relative concentration required to produce that effect. 1.5 DRUG CLEARANCE 1.5.1 Drug metabolism At this point, we introduce the topic which is the focus of this book, namely drug metabolism. As implied in the title of this introductory chapter, the intention here is to describe

its role in the context of the chain of events following ingestion of a drug or xenobiotic. As outlined below, all subsequent chapters will elaborate on the most important aspects and implications of drug metabolism in therapy and in the design of new medicinal agents. The concept of clearance of a drug substance includes all elimination processes which act to remove it from the physiological areas; drugs may be eliminated from the body either unchanged (by the process of excretion – see following sub-chapter), or converted to metabolites with lower affinity characteristics (which obviously increase their elimination rate). The process of conversion is called biotransformation. Drug biotransformation reactions are classified as either phase I – functionalisation reactions, or phase II, – biosynthetic (conjugation) reactions [51, 52]. Phase I reactions introduce (or expose) a functional group on the parent compound, generally resulting in loss of pharmacological activity; however, active and chemically reactive intermediates may be also generated. Phase I reactions are especially important in the case of pro-drugs, which are rapidly converted to biologically active metabolites, often by hydrolysis of an ester or amide linkage (see Chapters 2 and 9). In rare instances, phase I metabolism is associated with an altered pharmacological activity. Phase II conjugation reactions lead to the formation of a covalent linkage between a functional group on the parent compound (or on a phase I metabolite) with endogenously derived glucuronic acid, sulphate, glutathione, amino acids or acetate. These highly polar conjugates are generally inactive and are excreted rapidly in the urine and faeces. 30 Chapter 1 Therefore, the usual net effect of biotransformation may be said to be one of inactivation or detoxification. Biotransformations may be placed into four categories: oxidation, reduction, hydrolysis and conjugation. The first three comprise Phase I, whilst the last one comprises Phase II. Oxidation – is the most common type of biotransformation; it includes side-chain hydroxylation, aromatic hydroxylation, deamination, N-, O-, and S-dealkylation, sulphoxide formation, dehydrogenations, and deamination of mono- and diamines. Reduction – is relatively uncommon; it includes reduction of nitro, nitroso, and azo groups. Hydrolysis – is a common biotransformation route for esters and amides. Conjugation – represents the biosynthetic process of combining a chemical compound with a highly polar and water-soluble natural compound to yield a water-soluble, usually inactive and rapidly excreted product (details in Chapter 3). Biotransformations take place principally in the liver, although the kidney, skeletal muscle, intestine, or even plasma may be important sites of metabolism. Within a given cell, most drug metabolising activity is found in the endoplasmic reticulum or cytosol, although drug biotransformations also occur in the mitochondria, nuclear envelope and plasma membrane. It is emphasised that the metabolic conversion of drugs is generally enzymatic in nature. The most important group of drug metabolising enzymes is the Cytochrome P450 (‘CYP450’) Monooxygenase System represented by a superfamily of heme-thiolate proteins widely distributed across all living systems. These enzymes are involved in the metabolism of a very large range of diverse chemical structures, endo- and exogenous compounds including drugs, environmental chemicals and other xenobiotics (details in Chapter 4). Hydrolytic enzymes include a number of non-specific esterases and amidases (identified in the endoplasmic reticulum of human liver, intestine and other tissues). We emphasise, as being of particular importance, the microsomal epoxide hydrolase, found in the endoplasmic reticulum of essentially all tissues and in close proximity to the cytochrome P450 enzymes; it is generally considered a detoxification enzyme, hydrolysing highly reactive arene oxides (generated from CYP450 oxidation reactions) to inactive, water-soluble trans-dihydrodiol metabolites (details in Chapter 4). Of the conjugation enzymes the most important are considered to be the uridine diphosphate glucuronosyltransferases (‘UGTs’, microsomal enzymes), catalysing the transfer of glucuronic acid to aromatic and Drug metabolism in context 31 aliphatic compounds. Other important enzymes involved in this type of metabolic reaction include sulphotransferases and N-acetyltransferases. Details of these enzyme systems are also discussed in Chapter 4. Some of the most important and common enzyme systems involved in drug biotransformation are presented in Figure 1.6. This figure is a significantly extended version of a similar representation in ref. 4. The biotransformation of a drug may present large inter-individual variability that often results in significant differences in the extent of the process, and consequently in the rate of elimination of the drug, as well as in other characteristics of its concentration-time profile. The most important factors affecting drug metabolism include: genetic variation, environmental determinants and disease-state factors. It is crucial to know and if possible, to control these factors in optimising a dosage regimen for a particular individual. CYP2E1 CYP2D6 CYP3A4/5/7 CYP2C19 Phase I enzymes CYP2C9 ALDH CYP1B1 ADH DPD others epoxide CYP1A1/2 esterases NQ01 hydroxilases COMT HMT TPMT STs Phase II enzymes UGTs GST-A GST-P GST-T GST-M NAT2 NAT1 others Fig.1.6 The relative proportions of Phase I and Phase II metabolising enzymes 32 Chapter 1 Genetic variation. Existence of genetic polymorphisms leads to altered drug metabolising ability; differences involve a variety of molecular mechanisms leading to a complete lack of activity, a reduction in catalytic ability, or, in the case of gene duplication, enhanced activity (details in Chapter 4). Environmental determinants can up- or down-regulate the enzymes; such modulation, termed induction and inhibition, respectively, is thought to be another major contributor to inter-individual variability in the metabolism of many drugs. Disease factors. In renal failure, the metabolism of several drugs is reduced, but such effects are considered to be of relatively minor practical consequence. Since the liver is the major location of drug-metabolising enzymes, any dysfunction in this organ can potentially lead to impaired drug biotransformation (in general, the severity of the liver damage determining the extent of reduced metabolism). In patients with very severe liver disease, cytochrome P450 levels are reduced, but moderate liver disease does not impair drug metabolism very significantly. In addition, in cases of very severe liver disease, the metabolism of different drugs is affected to different extents, probably owing to the altered composition of the multiple CYTP450 forms resulting from hepatocellular dysfunction. Thyroid dysfunction is also known to affect drug metabolism. In hyperthyroid patients, unusual prolongation of prothrombin time may be produced by oral anti-coagulants due to increased metabolic decomposition of vitamin K-dependent clotting factors. For patients with this condition, acute sensitivity to opioid analgesics can cause significant respiratory depression. The above topics are treated in detail in Chapters 5-7. Further aspects of drug metabolism addressed in this book include drug interactions and adverse reactions (Chapter 8) and strategies for the design of drugs, based on metabolism as a directing principle (Chapter 9). 1.5.2 Excretion As already mentioned at the beginning of the subchapter, some drugs are not biotransformed in the body, thus being eliminated from the body unchanged. The most important organ of excretion is the kidney, although some substances are excreted in bile, sweat, saliva, and gastric juice or from the lungs. Renal excretion takes place principally by glomerular filtration; as the glomerular filtrate passes through the proximal tubule, some solute may be resorbed (tubular resorption) through the tubular epithelium and returned to the blood. Resorption occurs in part by passive diffusion and in part by Drug metabolism in context 33 active transport (especially with sodium and glucose). Also noteworthy here is the active transport of organic cations and anions into the lumen (tubular secretion), these active transport systems being extremely important in the excretion of a number of drugs. Drugs also may be resorbed in the distal tubule, in which case the pH of the urine is extremely important in determining the rate of resorption (in accord with the principle of non-ionic diffusion and pH partition). It should be borne in mind that the urinary pH, and hence drug excretion, may fluctuate widely according to the diet, exercise level, drugs, time of day and other factors. Biliary excretion and faecal elimination: Drugs that are secreted into the bile usually pass into the intestine; from here, they may be re-absorbed (and thus retained in the body) and this cycle is known as enterohepatic circulation (the system providing a reservoir for the drug). Examples of drugs that are enterohepatically circulated include morphine and the penicillins. If a drug is not absorbed completely from the intestine, the unabsorbed fraction will be eliminated in the feces (such elimination being called fecal excretion). Alveolar excretion: Due to the large alveolar area and high blood flow at this level, lungs are ideal for the excretion of appropriate substances such as gaseous and volatile anaesthetics. Various disease states can alter drug excretion. Elimination of several drugs by the liver and/or kidneys is reduced in heart failure. Decreased hepatic perfusion attends reduced cardiac output and drug elimination is reduced. This increases the risk of toxicity from certain drugs or their metabolites (e.g. lignocaine). In patients with renal failure, glomerular filtration and tubular secretion of drugs usually fall at the same rate. The drop in glomerular filtration rate (GFR) is directly linked to the decline in drug excretion, which is why correct dosing relies on accurate GFR estimates for such patients. Thyroid dysfunction is another condition that may affect drug disposition, partly through its effects on drug metabolism (as mentioned earlier) and partly through changes in renal elimination. GFR is increased in thyrotoxicosis and decreased in myxoedema. 1.6 DYNAMICS OF DRUG CLEARANCE It should be evident that the rate of elimination of the drug from the body is a crucial factor in its efficacy: if this is too rapid, frequent drug dosing is required to maintain the therapeutic efficacy, whereas too long a residence time in the body could lead to toxic effects. 34 Chapter 1 1.6.1 Basic pharmacokinetic parameters As indicated above, drug elimination occurs primarily by excretion of the original drug, its metabolites, or a combination of these, via many routes. Kinetically, this composite and irreversible process is conveniently characterised by an elimination rate constant (ke) which takes all contributing processes into account and which can be related to other parameters reflecting drug elimination. One of these is drug clearance (CL), which can now be defined quantitatively as the volume of plasma that is completely emptied of the drug in unit time, measured in units of e.g. L h-1 [4]. The rate of elimination of a drug (measured as mass of drug eliminated per unit time e.g. mg h-1) can be related to the clearance through the drug concentration Ct (measured in e.g. mg L-1) at any time t as follows: Elimination rate (mg h-1) = CL (L h-1) x Ct (mg L-1) 1.3 where the total clearance CL may be considered to represent the sum of the clearances effected by metabolism and excretion. As CL is constant for most drugs, elimination rate is proportional to concentration i.e. the higher the plasma drug concentration Ct at a particular time t, the faster the rate of drug elimination. Kinetically, this represents first-order behaviour, according to -dCt / dt = ke Ct 1.4 reflecting the linear relation between the rate of decrease in drug concentration and the instantaneous drug concentration. The significance of the elimination rate constant ke is that it represents the constant fraction of the amount of drug that is eliminated in unit time. On integration of eqn. 1.4 over the lapsed time period from t = 0 (corresponding to initial concentration Co) up to some arbitrary time (t), one obtains the expression Ct = Co exp(-ke t) 1.5 showing that Ct decreases exponentially with time, as in Figure 1.7 (left). The rate law 1.5 can be cast into a linear form by taking natural logarithms on both sides, which gives eqn. 1.6: ln Ct = - ke t + ln Co 1.6 so that a plot of ln Ct versus time yields a straight line with slope –ke , as shown in Figure 1.7 (right). Drug metabolism in context 35 1n Co Co slope=– ke Ct In Ct t t Fig.1.7 First-order kinetic behaviour showing (left) exponential decrease in concentration with time and (right) linear behaviour of the lnCt versus time plot and determination of the elimination rate constant Measurements of the plasma drug concentration at various times after drug administration are thus made and the data treated graphically as shown above. The value of the elimination rate constant ke is then obtained from the slope of the linear graph. The half-life (t½) of the drug

is defined as the time taken for concentration of the drug in the plasma to decrease to one-half of its initial value. Thus, at the time t½, the value of Ct in equation 1.6 becomes Co/2, and further manipulation leads to the relationship 1.7: t½ = 0.693 / ke 1.7 The inverse relationship between t½ and ke is expected and simply indicates that e.g. the longer the half-life of a drug, the smaller the rate constant for its elimination. Either the half-life or the elimination rate constant may thus be used to express the rate of clearance of the drug. The rate of elimination of the drug was given in expression 1.3 above. An alternative way to express the rate of elimination is: elimination rate = ke x A 1.8 where A is the amount of drug present. Equating expressions 1.3 and 1.8, we obtain CL (L h-1) x Ct (mg L-1) = ke (h-1) x A (mg) 1.9 36 Chapter 1 Finally, substitution of A = Vd Ct (from eqn. 1.1) into the above expression and simplification yields 1.10: CL = ke Vd 1.10 This provides an alternative way to calculate drug clearance. The above discussion relates to the one-compartment model, characterised by rapid and uniform distribution of the drug throughout the body. For some drugs, this model is unsatisfactory because equilibration between the central compartment (e.g. the bloodstream for i.v. injection) and the peripheral tissues may be a relatively slow process. As mentioned earlier, such a situation requires modelling by the two-compartment model shown in Figure 1.8, together with the corresponding profile for the drug concentration in the plasma. Here, two distinct curves are evident, the one with the steeper initial slope representing drug distribution and elimination (the α-phase) while the second exponential curve, commencing after equilibrium is attained between the plasma and tissue, reflects the elimination of drug from the plasma (the β - phase). As an example, in a recent study investigating the ADME of triethanolamine (TEA) in mice [53], it was found that the concentration-time profile of TEA in the blood following intravenous injection closely resembled that of Figure 1.8. The initial phase of the bi-exponential curve was characterised by a short half-life of only 0.3 h (corresponding to kα = 2.3 h-1 from eqn. 1.7) that was followed by a slower, terminal phase with a half- life of 10 h (kβ = 0.07 h-1). Such biphasic elimination is consistent with a two-compartmental model. ka peripheral drug central compartment compartment Į kb Ct ke ȕ elimination T (post-dosing) Fig.1.8 Two-compartment model (left) and the biphasic concentration-time profile (right) Drug metabolism in context 37 With reference to the biphasic plot in Figure 1.8, we note that if distribution were instead to be complete in a very short period, the first part of the curve in Figure 1.8 (α -phase) would not be evident and the kinetics would reduce to that of a one-compartmental model. In this chapter, only elementary aspects of pharmacokinetics were introduced, but these are adequate for following the remaining chapters. For more advanced treatments of pharmacokinetics, including clinical aspects, the reader is referred to the references above. In the next chapter, the chemistry of Phase I and Phase II biotransformations outlined in section 1.5.1 is discussed in detail. References 1. Thompson TN. 2001. Optimization of metabolic stability as a goal of modern drug design. Med Res Rev 21:412-449. 2. Pickett S. 2003. The biophore concept. Methods and Principles in Medicinal Chemistry 19:73-105. 3. Balant LP, Gex-Fabry M, Balant-Gorgia EA. 2000. Pharmacokinetics: from genes to therapeutic drug monitoring. In: Sirtori CR, Kuhlmann J, Tillement J-P, Vrhovac B, editors. Clinical Pharmacology. London: McGraw-Hill International Ltd., pp 9-24. 4. Wilkinson GR. 2001. Pharmacokinetics: The Dynamics of Drug Absorption, Distribution, and Elimination. In: Hardman JG, Limbird LE, Gilman GA, editors. Goodman&Gilman’s The pharmacological Basis of Therapeutics, 10th ed. New York: McGraw-Hill International Ltd. (Medical Publishing Division), pp 3-29. 5. The Merck Manual – Second Home Edition. 2004. Section 2. Drugs, Chapter 11, Drug Administration and Kinetics, available at www.merckhomeedition.com/home.html. 6. Taylor JB, Kennewell PD. 1993. The Pharmaceutical phase. Routes of administration of medicines. In: Modern Medicinal Chemistry, New York: Ellis Horwood Ltd, pp 58-71. 7. Benet LZ, Perotti BYT. 1995. Drug Absorption, Distribution and Elimination. In: Woolf ME, editor. Burger’s Medicinal Chemistry and Drug Discovery, 5th ed., Vol. I: Principles and Practice. New York: John Wiley & Sons, Inc.(A Wiley-Interscience Publication), pp 113-128. 8. Franklin MR, Franz DN. 2000. Drug Absorption, Action, and Disposition. In: Gennaro AR, editor. Remington: The Science and Practice of Pharmacy, 20th ed. Philadelphia: Lippincott Williams&Wilkins, pp 1098-1126. 9. Ying J, Zhiqiang J. 2003. Advances on oral mucosal drug delivery system. Zhongguo Shenghua Yaowu Zazhi 24:150-152. 10. Ward PD, Tippin TK, Thakker DR. 2000. Enhancing paracellular permeability by modulating epithelial tight junctions. Pharm Sci Technol To 3: 346-358. 38 Chapter 1 11. Lennernas H. 2003. Intestinal drug absorption and bioavailability: Beyond involvement of single transport function. 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Nanoparticles with specific bioadhesive properties to circumvent the pre-systemic degradation of fluorinated pyrimidines. J Control Release 96:55-65. 21. Sinha VR, Singla AK, Wadhawan S, Kaushik R, Kumria R, Bansal K, Dhawan S. 2004. Chitosan microspheres as a potential carrier for drugs. Int J Pharm 274:1-33. 22. Gutiérrez Millán C, Sayalero Marinero ML, Castañeda AZ, Lanao JM. 2004. Drug, enzyme and peptide delivery using erythrocytes as carriers. J Control Release 95:27-49. 23. Fedorak RN, Bistritz L. 2005. Targeted delivery, safety, and efficacy of oral enteric- coated formulations of budesonide. Adv Drug Deliver Rev 57:303-316. 24. Ripamonti C , Bruera E. 1991. Rectal, bucal, and sublingual narcotics for the management of cancer pain. J Palliative Care 7:30-35. 25. Watanabe Y. 2000. A review of recent pharmaceutical preparations for rectal and vaginal administrations. Pharm Tech Japan 16:1767-1770, 1773-1776. 26. Casali F, Burgat V, Guerre P. 1999. Dimethyl sulfoxide (DMSO): properties and permitted uses. Rev Med Vet-Toulouse 150:207-220. 27. Vanbever R. 2003. Optimization of dry powder aerosols for systemic drug delivery. Optim Aerosol Drug Deliv 91-103. 28. Steckel H. 2003. Drug delivery systems for inhalable glucocorticoids. Pharmazie in Unserer Zeit 32:314-322. 29. Guofeng L, Jianhai C, Kang Z. 2003. Development of liposome for local administration and its efficacy against local inflammation. Zhongguo Yaoxue Zazhi (Beijing, China) 38:825-828. 30. Wilkinson GR. 2001. Pharmacokinetics: The Dynamics of Drug Absorption, Distribution, and Elimination. In: Hardman JG, Limbird LE, Gilman GA, editors. Drug metabolism in context 39 Goodman & Gilman’s The pharmacological Basis of Therapeutics, 10th ed. New York: McGraw-Hill International Ltd. (Medical Publishing Division), p 8. 31 . Lodenberg R, Amidon GL. 2000. Modern bioavailability, bioequivalence and biopharmaceutics classification system. New scientific approaches to international regulatory standards. Eur J Pharm Biopharm 50:3-12. 32. Shen T, Huinan X. 2003. Development of intestinal absorption enhancers. Zhongguo Yiayao Gongye Zazhi 34:476-480. 33. Babu RJ, Pandit JK. 2004. Effect of cyclodextrins on the complexation and transdermal delivery of bupranolol through rat skin. Int J Pharm 271:155-165. 34. 2002. In: Sweetman SC, editor. Martindale: The Complete Drug Reference,33rded. London: Pharmaceutical Press, electronic version (prepared by the editorial staff of the Royal Pharmaceutical Society of Great Britain). 35 . Frömming K-H, Szejtli J. 1994. Pharmacokinetics and Biopharmaceutics. In: Cyclodextrins in Pharmacy. Dordrecht: Kluwer Academic Publishers pp 105-126. 36. Naik A, Kalia YN. Guy RH. 2000. Transdermal drug delivery: overcoming the skin’s barrier function. Pharm Sci Technol To 3:318-326. 37. Kalia YN, Merino V, Guy RH. 1998. Transdermal drug delivery. Clinical aspects. Dermatol Clin 16:289-299. 38. Yogeshvar NK, Naik A, Garrison J, Guy RH. Iontophoretic drug delivery. 2004. Adv Drug Deliv Rev 56:619-658. 39. Machet L, Boucad A. 2002. Phonophoresis: efficiency, mechanisms and skin tolerance. Int J Pharm 243:1-15. 40. Bergelson LD. 1988, New Views on Lipid Dynamics: A Non-Equilibrium Model of Ligand-Receptor Interaction, Part I, Chapter 1, Basic Mechanisms of Medical Significance in Membrane Structure and Function. In: Benga Gh, Tager JM, editors. Biomembranes – Basic and Medical Research. Berlin: Springer-Verlag pp 1-12. 41. Jensen SC, Peppers MP. 1998. Biopharmaceutics and Pharmacokinetics. In: Rowland J, editor. Pharmacology and Drug Administration for Imaging Technologists. St. Louis (Missouri, USA): Mosby Inc., pp 30-38. 42. Winstanley P, Walley T. 1999. Basic principles. In: Simons B, editor. Churchill’s Pharmacology, A clinical core text for integrated curricula with self-assessment. Edinburgh: Horne T Publisher, pp 4-15. 43. Kansy M, Avdeef A, Fischer H. 2004. Advances in screening for membrane permeability: high resolution PAMPA for medicinal chemists. Drug Discov Today Technol 1:349-355. 44. Mälkiä A, Murtomäki L, Urtti A, Konturri K. 2004. Drug permeation in biomembranes: In vitro and in silico prediction and influence of physicochemical properties. Eur J Pharm Sci 23:13-47. 45. Barre J, Urien S. 2000. Distribution of drugs. In: Sirtori CR, Kuhlmann J, Tillement J-P, Vrhovac B, editors. Clinical Pharmacology. London: McGraw-Hill International Ltd. pp 37-43. 40 Chapter 1 46. Galinsky RE, Svensson CK. 2000. Basic Pharmacokinetics. In: Gennaro AR editor. Remington: The Science and Practice of Pharmacy, 20th ed. Philadelphia: Lippincott Williams&Wilkins, pp 1027-1144. 47. Rang HP, Dale MM, Ritter JM. 1999. Absorption, distribution and fate of drugs. In: Pharmacology, 4th ed. Edinburgh: Churchill Livingstone, pp 57-89. 48. Wingard LB Jr, Brody TM, Larner J, Schwartz A. 1991. Pharmacodynamics. In : Kist K, Steinborn E, Salway J, editors. Human Pharmacology, Molecular-to-Clinical. St. Louis, Missouri: Mosby Year Book Inc., pp 42-45. 49 . Ritter JM, Lewis LD, Mant T.GK. 1999. Mechanisms of Drug Action (Pharmacodynamics). In: Radojicic R, Goodgame F, editors. A Textbook of Clinical Pharmacology, 4th ed. Oxford University Press Inc., pp 8-16. 50. Ross EM, Kenakin TP. 2001. Pharmacodynamics: Mechanism of Drug Action and the Relationship Between Drug Concentration and Effect. In: Hardman JG, Limbird LE, Gilman GA, editors. Goodman&Gilman’s The pharmacological Basis of Therapeutics, 10th ed. New York: McGraw-Hill International Ltd. (Medical Publishing Division), pp 31-44. 51 . Gibson GG, Skett P. 1994. Introduction to Drug Metabolism. London: Blackie Academic & Professional, An Imprint of Chapman & Hall, pp 1-2. 52. Correia MA. 2001. Drug Biotransformation. In: Katzung GB, editor. Basic & Clinical Pharmacology, 8th ed. New York: Lange Medical Books/Mc Graw Hill Medical Publishing Division, pp 51-63. 53. Stott WT, Waechter Jr JM, Rick DL, Mendrala AL. 2000. Absorption, distribution, metabolism and excretion of intravenously and dermally administered triethanolamine in mice. Food Chem Toxicol 38:1043-1051. Chapter 2 PATHWAYS OF BIOTRANSFORMATION – PHASE I REACTIONS 2.1 INTRODUCTION Drug metabolism is a complex and important part of biochemical pharmacology. The pharmacological activity of many drugs is reduced or nullified by enzymatic processes, and drug metabolism is one of the main mechanisms by which drugs may be inactivated. Metabolism, or the biotransformation of a drug, is the process whereby living organisms effect chemical changes to a molecule [1-8]. The product of such a chemical change is called a “metabolite”. In practice, all xenobiotics undergo transformations in living organisms. In general, biotransformation converts a lipophilic xenobiotic to a polar compound, promoting a decline in its re-absorption by kidney tubules, thus allowing its excretion into the urine (the formation of polar metabolites from a non-polar drug facilitates efficient urinary excretion). Implications for drug metabolism include drug interactions, carcinogenesis, toxication (bioactivation), substrate inhibition, enzyme induction, as well as termination of drug action. Metabolism might convert an inactive agent (a prodrug) into the active agent that is responsible for producing the therapeutic effect. However, an important aspect to emphasise in this context is that delayed effects that manifest themselves many days after starting regular treatment with certain drugs can result from accumulation of long-lived metabolites that are at the same time the

main cause of overdosing and the appearance of secondary or even adverse reactions. It is convenient to divide drug metabolism into two phases (I and II) which sometimes, but not always, occur sequentially. Products of phase I reactions may be either pharmacologically active or inactive species and usually represent substrates for Phase II enzymes. Phase II reactions are 41 42 Chapter 2 synthetic conjugation reactions between a drug and an endogenous molecule (or between a phase I metabolite and an endogenous molecule). The resulting products have increased polarity compared to the parent drugs, being therefore more readily excreted in the urine (or, less often, in bile), and they are usually (but not always) pharmacologically inactive. The principal organs of metabolism include the liver, kidneys and the GI tract, but drugs may be metabolised at other sites, including the lungs and the plasma. The microbial flora present in the gut play a role in the biotransformation of certain drugs (e.g. reduction of nitro- and azo- compounds). Many of the enzymatic systems involved in drug metabolism are embedded in the membrane of smooth endoplasmic reticulum (sER), this being consequently the site of metabolism of many drugs. An important factor that contributes to drug metabolism at the microsomal site is the lipophilicity of the drug. In contrast to a polar compound, a lipophilic compound will dissolve in the membrane of the sER, consequently serving as a substrate for the microsomal enzymes. Some endogenous compounds (steroids, thyroxine and bilirubin) are metabolised in the sER as well. Genetic variation in drug metabolising enzymes is a factor that influences drug disposition; the implications of variations in the activity of an enzyme relate to blood levels of the drug, which in turn can result in either undesirable, unexpected toxic effects or expected therapeutic effects. 2.2 PHASE I AND PHASE II METABOLISM: GENERAL CONSIDERATIONS Biotransformation reactions affecting drugs (as well as other xenobiotics) are traditionally separated (or, conveniently divided) into Phase I and Phase II reactions (see also Chapter 1, subchapter 1.5.1). The reactions of Phase I are thought to act as a preparation of the drug for phase II, i.e. phase I “functionalises” the parent drug molecule by producing or uncovering a chemically reactive group on which the phase II reactions can occur. For example, a –CH3 moiety can be functionalized to become a –CH2OH or even a –COOH group. Through introduction of oxygen into the molecule or following hydrolysis of esters or amides, the resulting metabolites are usually more polar (subsequently, less lipid-soluble) than the parent drug, therefore presenting reduced ability to penetrate tissues and less renal tubular resorption than the parent drug. These primary metabolites are then further converted to secondary metabolites, involving a process of conjugation of an endogenous molecule or fragment to the substrate, yielding a metabolite known as a conjugate. Conjugates are usually more hydrophilic than the Pathways of biotransformation – phase I reactions 43 parent compound, and subsequently much more easily excreted via the kidney. This is the concept of sequential metabolism (Figure 2.1.) [9]. There is a third class of metabolites, recognized as xenobiotic- macromolecule adducts (also called macromolecular conjugates), formed when a xenobiotic binds covalently to a biological macromolecule [9]. As a very recent example of sequential metabolism, we mention that of 2,3,7-trichlorodibenzo-p-dioxin (2,3,7-triCDD) by cytochrome P450 and UDP-glucuronosyltransferase in human liver microsomes [10]. This study investigated the glucuronidation of 2,3,7-triCDD by rat CYP1A1 and human UGT. The ability of ten human liver microsomes to metabolise this polychlorinated compound was assessed. As another representative example of sequential metabolism, we present the biotransformation of propranolol, a process that leads to two metabolites, as shown in Figure 2.2. Propranolol is first oxidised to 4- hydroxypropranolol, which then undergoes sequential metabolism to 4-hydroxypropranolol glucuronide [11]. Other biotransformation reactions of propranolol will be presented later. 44 Chapter 2 OH H OH H OH H O N O N O N 8 8 8 7 2 7 2 7 2 6 3 6 3 6 3 5 4 5 4 5 4 propranolol OH O-glucuronide Fig.2.2 Sequential metabolism of propranolol Another possibility, occurring frequently, is that of parallel metabolism leading to a common metabolite (Figure 2.3) [9]. Fig.2.3 Scheme of parallel metabolism: the drug may undergo biotransformation to the primary metabolite, and be subsequently eliminated by excretion (as a Phase II metabolite), or it may follow other elimination (metabolic or excretion) routes We give as a representative example of parallel metabolism, the biotransformation of dextromethorphan [9], via two CYTP450 isoforms; both pathways involve N- and O-demethylation steps, but in reverse order, leading to a common metabolite (Figure 2.4). Pathways of biotransformation – phase I reactions 45 CH3 N H CYP3A CYP2D6 O H dextromethorphan N CH CH 3 3 N H H O 3-methoxymorphinan HO dextrorphan H3C H N H HO 3-hydroxymorphinan Fig.2.4 Parallel biotransformation pathways of dextromethorphan Reversible metabolism may occur when a metabolite or biotransformation product and the parent drug undergo interconversion. Although reversible metabolism is less common, there are examples occurring across a variety of compounds, including phase I metabolic pathways (for some amines, corticosteroids, lactones and sulphides/sulphoxides), as well as phase II metabolic pathways (including reactions of glucuronidation, sulphation, acetylation etc.) [9]. A recently published, detailed account of the subject of reversible metabolism of drugs [12] highlights the complexity of the pharmacokinetic treatment of such processes as well as the fact that two compounds undergoing metabolic interconversion may have different activities. Thus, for example, in the well-known prednisone-prednisolone system, both compounds are active but in the case of the reversible metabolism involving 46 Chapter 2 haloperidol and it metabolite, reduced haloperidol, the latter compound is an inactive, and possibly toxic species. Clinical implications of this system are discussed in depth. Thus, an aspect worth stressing from the outset is that in the case of a xenobiotic having a single metabolite, the following scenarios present themselves: • neither the xenobiotic nor its metabolite exerts a biological effect (within the concentration range of interest) • both of the above species are biologically active • only the xenobiotic exerts biological effects • only the metabolite exerts biological effects [8]. Generally, the usual net effect of biotransformation may be said to be one of inactivation or detoxication, the duration and intensity of a xenobiotic’s actions being influenced (sometimes predominantly) by its rate and extent of metabolism. There are, however, numerous examples in which biotransformation does not result in inactivation; many drugs generate active metabolites and moreover, in a few instances activity derives entirely from the metabolite. The production of an active metabolite may therefore be beneficial, or it may be detrimental when it is the origin of undesirable (adverse) effects (see also Chapter 8). There are also examples in which the parent drug has little or no activity of its own but is instead converted to an active metabolite. A particular case of ‘inactive’ drugs that yield active metabolites is represented by the well-known prodrugs (See Chapter 9). When a delayed or prolonged response to a drug is desired (or an unpleasant taste or local reaction is to be avoided), it is a common pharmaceutical practice to prepare an inactive (or non-offending) precursor, such that the active form may be generated in the body. This practice has been termed drug latentiation [9]. Examples of such precursors include chloramphenicol palmitate, dichlorphenazone and the estolates of various steroid hormones. Transformation of a drug, or other xenobiotic, into a toxic metabolite, on the other hand, is effected by a toxication reaction. Toxic responses from such a metabolite may manifest at a number of levels, ranging from the molecular to that of an organ or organism, with the former not necessarily implying the latter. What can be stated is that metabolic toxication processes are always counterbalanced by competitive and/or sequential detoxication processes that may lead to inactivation of the toxic metabolite. Pathways of biotransformation – phase I reactions 47 Factors affecting drug metabolism A great number of physiological and pathological factors affecting drug metabolism have been characterized; these are of importance both in drug research and toxicology (details in Chapter 6). Among the inter-individual factors we stress the species differences determined by genetic differences; the consequences of this genetic polymorphism are a greatly impaired metabolism of drugs (or prodrugs), and a marked risk of adverse reactions (see also Chapter 8). Pharmacogenetics has thus become in recent years a major issue in clinical pharmacology and pharmacotherapy [13] (see also Chapter 7). Intra-individual factors are related to physiological changes or pathological states (affecting for example the hormonal balance and immunological mechanisms of individuals). Biological rhythms (still not always duly recognized) are of the utmost importance and their study is the realm of chronopharmacology [14]. There are, however, factors from outside the body (intimately connected with the intra-individual factors) that can also have a profound influence on drug metabolism. Physical exposure to these factors can be either deliberate (e.g. alcohol, tobacco smoke, substances taken as food) or accidental (from air, water, different pollutants). Usually, the first group falls into the category of dietary factors while the second group comprises environmental factors. Factors of even greater significance (as far as drug therapy and toxicology are concerned) are enzyme induction and enzyme inhibition [15]. Enzyme inducers act by increasing the concentration and subsequently, the activity of some enzymes (or isoenzymes), while inhibitors decrease the activity of some enzymes (or isoenzymes) by reversible or irreversible inactivation (for details see Chapter 5). A given drug may induce and/or inhibit its own metabolism, thus acting respectively as an auto-inducer and/or auto-inhibitor; still, the vast majority of available data document the influence of one drug on the biotransformation of another, pre- or, co-administered, this being one of the major causes of drug-drug interactions [16] (details in Chapter 8, subchapter 8.1, subsubchaper 8.1.3). The influence of drug molecular configurational and conformational factors is a well-known and common phenomenon, resulting in substrate stereoselectivity and product stereoselectivity (enantio- and diastereo selectivity) [8]. In conceiving and preparing this monograph we have followed two approaches: • the molecular level – which covers the biochemistry of drug metabolism (e.g. enzymes and their properties, catalytic reactions and their 48 Chapter 2 mechanisms, structure-metabolism relationships) and, • the systemic level – which covers the physiology of drug metabolism (e.g. enzymes and their regulation, factors affecting drug metabolism, its pharmacological and toxicological consequences, and different related aspects). In the following subsections, we describe the principal Phase I metabolic reactions including illustrative examples with their mechanisms. 2.3 OXIDATIONS INVOLVING THE MICROSOMAL MIXED-FUNCTION OXIDASE SYSTEM 2.3.1 Components of the enzyme system and selected miscellaneous oxidative reactions (mechanisms of action) Phase I metabolism is dominated by the microsomal mixed-function oxidase (MMFO) system and this is known to be involved both in the metabolism of endogenous compounds (steroid hormones, thyroid hormones, fatty acids, prostaglandins and derivatives) as well as in the biotransformation of drugs (or other xenobiotics) [6,8,17]. The mixed-function oxidase system (found in microsomes of many cells – notably those of liver, kidney, lung and intestine) performs many different functionalisation reactions. The most important Phase I reaction is that of oxidation – by incorporation of oxygen into the substrate; therefore, this reaction characterizes oxygenases. Most frequently, these reactions are mono- oxygenation reactions (incorporating only one of the two atoms of molecular oxygen – see reaction below), the corresponding enzymes thus being categorised as monooxygenases [6,17]. The presence of such enzymes in the kidney can result both in the formation of toxic compounds leading to nephrotoxicity, and to the detoxification of metabolites generated elsewhere e.g. in the liver. The potential roles of renal flavin-containing monooxygenases and cytochrome P450s in the metabolism and toxicity of the model industrial compounds 1, 3-butadiene, trichloroethylene, and tetrachloroethylene have been the subject of a recent publication [18]. A feature highlighted there is the strong dependence of particular metabolic reactions on factors such as species-, tissue-, and sex-related differences. The phase I oxidative enzymes are almost exclusively localised in the endoplasmic reticulum (by contrast, most phase II enzymes being found predominantly in the cytoplasm). They differ markedly in structure and Pathways of biotransformation – phase I reactions 49 properties; among them, the most intensively studied both for drug and endogenous compound metabolism is the cytochrome P450. Cytochrome P450-mediated oxidations are unique in their ability to introduce polar functionalities into systems that are as unreactive

as saturated or aromatic hydrocarbons, being at the same time critical for the metabolism of lipophilic compounds without functional groups suitable for conjugation reactions. On the other hand, we have to stress that reactions catalysed by cytochrome P450 sometimes transform relatively innocuous substrates to chemically reactive toxic or carcinogenic species [8,19] (details in Ch.4). The general cytochrome P450-catalysed reaction is: cytochrome P450 NADPH + H+ + O2 + RH NADP+ + H2O + ROH 2.1 where RH represents an oxidisable drug substance and ROH, the hydroxylated metabolite. As can be seen from the above reaction, reducing equivalents (derived from NADPH + H+) are consumed and only one atom of the molecular oxygen is incorporated into the substrate (generating the hydroxylated metabolite), whereas the other oxygen atom is reduced to water (the reaction is actually a hydroxylation rather than a genuine oxidation). In addition to hydroxylation reactions, cytochrome P450 also catalyses the N-, O- and S-dealkylation of many drugs (details in further subsections); these types of reactions can be considered as a special form of hydroxylation reaction in that the initial event is a carbon hydroxylation (followed by heteroatom elimination). Components of the M.F.O. system include [17,20]: • the cytochrome P450 • the NADPH- cytochrome P450 reductase and • lipids Cytochrome P450 is the terminal oxidase component of an electron transfer system present in the endoplasmic reticulum responsible for many drug oxidation reactions. It is a haemoprotein having unusual properties (with iron protoporphyrin IX as the prosthetic group) and is found in almost all living organisms. Mammalian cytochromes P450 are found in almost all organs and tissues, located as already mentioned, mostly in the endoplasmic reticulum but also in mitochondria. It is important to note that in contrast to the porphyrin moiety, which is constant, the protein part of the enzyme varies markedly from one isoenzyme to the other (as a consequence 50 Chapter 2 of genetic polymorphism) [21], subsequently determining differences in their properties, substrate and product specificities, and sensitivity to inhibitors (details in Ch.4). This explains the great number (more than 500) of P450 isoenzymes identified and characterised and their resemblance in the so-called cytochrome P450 superfamily. NADPH-cytochrome P450 reductase is a flavin-containing enzyme, consisting of one mole of FAD (flavin adenine dinucleotide) and one mole of FMN (flavin mononucleotide) per mole of apoprotein; this is quite unusual as most other flavoproteins contain only FAD or FMN as their prosthetic group. The enzyme exists in close association with cytochrome P450 in the endoplasmic reticulum membrane and represents an essential component of the M.F.O. system in that the flavoprotein transfers reducing equivalents from NADPH + H+ to cytochrome P450 as shown in Eq. 2.2: NADPH-cyt.P450- NADPH + H+(FAD FMN)  cytochrome P450 2.2 reductase According to Eq.2.2, NADPH-cytochrome P450 reductase is thought to act as “transducer” of reducing equivalents by accepting electrons from NADPH and transferring them sequentially to cytochrome P450. The lipid component was originally identified as phosphatidylcholine and later studies showed that fatty acid composition of the phospholipids could be critical in determining functional reconstitution of M.F.O. activity. It has been suggested that lipid may be required for substrate building, facilitation of electron transfer or even providing a “template” for the interaction of cytochrome P450 and NADPH- cytochrome P450 reductase molecules. Nevertheless, it must be stressed that the precise mode of action of lipids is still unknown. Among the most important non-P450 oxidative enzymes participating in phase I reactions, the following are noteworthy: microsomal flavin- containing monooxygenase (FMO), the xanthine-dehydrogenase and the aldehyde oxidase (details appear in subchapter 2.4 and Chapter 4). Reactions catalysed specifically by the bacterial cytochromes P450 and the potential for applying the oxidising power of these enzymes have been discussed recently [22]. Oxidative reactions described include aliphatic and aromatic hydroxylation, alkene epoxidation, oxidative phenolic coupling, heteroatom oxidation and dealkylation, as well as multiple oxidations. Some of the most common CYTP450-catalysed reactions are summarised in Figure 2.5: Pathways of biotransformation – phase I reactions 51 NH C CH3 NH C CH3 O [OH] O OH Aromatic hydroxylation [OH] R CH3 R CH2 OH + H+ Aliphatic hydroxylation [OH] R NH CH3 [R NH CH2 OH] R NH2 + CH2O N-Dealkylation [OH] R O CH3 [R O CH2 OH] R OH + CH2O O-Dealkylation OH [OH] R CH CH3 R C CH3 R C CH3 + NH3 NH2 NH2 O Deamination CH3 CH3 CH [OH] 3 CH3 N [CH3 N OH] + CH3 NO + H+ CH3 CH3 CH3 Oxidation [OH] R S R' [R S R'] R S R' + H+ OH O Sulphoxidation Fig.2.5 Common reactions catalysed by CYTP450; note the hydroxyl intermediates commonly occurring in these reactions 52 Chapter 2 However, it ought to be stressed that the majority of oxidations are carbon oxidations, with carbon atoms in organic compounds greatly differing in their hybridisation and molecular environment, and consequently yielding a variety of oxidised intermediates (primary and secondary alcohols, phenols, epoxides) as presented in Figure 2.6: R CH2 R CH OH R R OH R R R' CH2 R R' CH R OH R O R R' R R' R O O R CH2 R' R CH R' OH R CH2 X R' R CH X R' OH Fig.2.6 General P450-catalysed oxidation reactions at carbon centres The general mechanism for aromatic hydroxylation involves an epoxide intermediate, illustrated in Figure 2.7, with naphthalene as substrate [23]. The formation of the epoxide involves the so-called NIH shift (NIH stands for U.S. National Institute of Health where the shift was discovered). Pathways of biotransformation – phase I reactions 53 OH 1-naphthol OH naphthalene 2-naphthol OH O OH 1,2-dihydroxy-naphthol OH OH 1,2-dihydroxy-1,2-dihydro-naphthol Fig.2.7 Epoxide intermediate in the biotransformation of naphthalene (Reproduced from ref. 25 with permission from R Paselk, Humboldt State University) Degradation of naphthalene by specific Pseudomonas putida bacteria in soils has been reported [24] together with an assessment of the metabolites formed and their toxicities. The survival of the bacteria in non- sterile soil samples was measured in the presence and in the absence of naphthalene. The results of the study suggested that the metabolites catechol, related compounds and their condensation products may reach toxic levels in the stationary phase of the bacterial cells. Oxidative metabolism of benzene gives a variety of products, with phenol as the major metabolite, as well as di- or even tri-hydroxylated metabolites [25], as indicated in Figure 2.8: 54 Chapter 2 OH OH OH OH catechol OH 1,2,4 trihydroxybenzene benzene OH OH OH OH phenol (major metabolite) resorcinol OH quinol Fig.2.8 Benzene hydroxylation yielding mono-, di-, and tri-hydroxylated metabolites (Reproduced from ref. 25 with permission from R Paselk, Humboldt State University) The carcinogenicity of benzene is related to the production of reactive oxygen species from its metabolites. A recent study of the mechanism of antiapoptotic effects (i.e. leading to prolonged cell survival) by benzene metabolites p-benzoquinone and hydroquinone in relation to carcinogenesis was reported [26]. Both metabolites were found to inhibit the apoptotic death of NIH3T3 cells induced by serum starvation as well as lack of an extracellular matrix. This inhibiting effect was reduced in the presence of an antioxidant, implicating the role of reactive oxygen species derived from the benzene metabolites. Further experiments suggested that the metabolites contribute to carcinogenesis by inducing dysregulation of apoptosis due to caspase-3 inhibition. Reactions of the type shown in Figure 2.8 are important, because by a similar mechanism, aromatic hydroxylations can become metabolically activating, as seen in benzopyrenes, where the epoxide is a potent carcinogen [27] (Figure 2.9): Pathways of biotransformation – phase I reactions 55 O HO OH Fig.2.9 Example of toxic activation, yielding a potent carcinogen + O Fe4+ + H O H H Fe3+ O NIH shift 1,2-hydride shift H OH H O Fig.2.10 CYTP450-catalysed aromatic hydroxylations; radical iron-oxo species delivering oxygen. (Reproduced from ref. 23 with permission from Abby L. Parrill, University of Memphis) 56 Chapter 2 As the aromatic hydroxylation mechanism involved, we present the radical iron-oxo species delivering oxygen (Figure 2.10), as well as details of the NIH shift mechanism (Figure 2.11) [23]: R R 4 H D O labelled substrate, with D D R substituent in the para -position R + H NIH 3 R O D D OH major product H competing has the D atom D base pathway in meta position O H+ R R H O H OH H+ none of product has D atom Fig.2.11 NIH shift mechanism (Reproduced from ref. 23 with permission from Abby L. Parrill, University of Memphis) The NIH shift is an intramolecular 1,2-hydride migration which can be observed in enzymatic and chemical hydroxylations of aromatic rings [23]. In enzymatic reactions the NIH shift is generally thought to derive from the rearrangement of arene oxide intermediates, but other pathways Pathways of biotransformation – phase I reactions 57 have been suggested. The mechanism was first documented for a number of substrate molecules containing deuterium substituents (“D” in Figure 2.11) on their aromatic rings. Studies showed that hydroxylation at the labelled position will cause either migration (see the major intermediate in the figure), or loss, of the labelled substituent (the competing pathway, leading to the product without “D”, in the figure presented). In addition, oxidative attack and hydroxylation ortho- to the label will also lead to both retention and loss of the label. Besides deuterium, the NIH shift may also affect halogenated substituents such as fluoro-, chloro- and bromo-. Aliphatic compounds are not readily oxidised or metabolised unless there is an aromatic side chain; primary and secondary alcohols are formed (Figure 2.12). CH2 CH2 CH3 OH CH CH CH n-propylbenzene 2 3 α-oxidation CH2 CH2 CH2 OH 3-phenylpropan-3-ol ϖ-oxidation OH CH CH CH 3-phenylpropan-1-ol 2 3 ϖ-1-oxidation 3-phenylpropan-2-ol Fig.2.12 Aliphatic hydroxylations: preferred positions yielding primary or secondary alcohols (Reproduced from ref. 25 with permission from R Paselk, Humboldt State University) 58 Chapter 2 Heterocyclic compounds are hydroxylated at the 3-position (Figure 2.13): OH HO OH N N Fig.2.13 Preferred positions of hydroxylation for heterocyclic species (Reproduced from ref. 25 with permission from R Paselk, Humboldt State University) Aromatic ring-hydroxylating dioxygenases (ARHD) are enzymes that effect reactions such as those shown above on aromatic hydrocarbons and heterocyclic molecules bearing various substituents. Aspects of their discovery, classification, enzymology, structure and properties have recently been reviewed [28]. 2.3.2 Oxidations at carbon atom centres Oxidations at carbon atoms represent the most common metabolic pathway for “attacking” the drug molecule. The major redox system catalyses the reductive cleavage of molecular oxygen, transferring one of the oxygen atoms to the substrate (resulting in the hydroxylated metabolite) and forming with the other one a molecule of water (see Eq. 2.1) [8,17,20]. Carbon atoms in organic compounds differ greatly in their hybridisation and molecular environment, and these characteristics are quite relevant as far as reactivity towards monooxygenases is concerned. Therefore, it is correct to distinguish the saturated carbon atoms (sp3 hybridisation) from the unsaturated ones (sp2 or sp). Targets for such reactions are represented by methyl (CH3-), methylene (-CH2-), and methine (-CH=) groups respectively, and the resulting products are primary, secondary, and tertiary alcohols respectively. The resulting metabolites may undergo further biotransformations (dehydrogenations, oxygenations and/or conjugations) serving therefore as examples of sequential metabolism. Primary alcohols are oxidised first to aldehydes. In aqueous solution, aldehydes being more easily oxidised than alcohols, oxidation usually continues until the carboxylic acid is formed (a metabolite that may further undergo conjugations). Secondary alcohols are oxidised to ketones, which in alkaline solution can be oxidised further (the same situation as above). Pathways of biotransformation – phase I reactions 59 Tertiary alcohols are not oxidised under alkaline conditions. In acidic solution, the tertiary alcohol undergoes dehydration and then the resulting alkene is oxidised. Oxidations of sp3-hybridised carbon atoms Reaction mechanism of C-sp3 hydroxylation The general CytP450-mediated hydroxylation reaction of sp3-hybridised carbons is described by Eq.2.3 and represents the overall substitution of a hydrogen atom by a hydroxyl group. RR’R’’C-H + [O] RR’R’’C-OH 2.3 The mechanism of hydrogen radical abstraction is known as the oxygen rebound mechanism [29], and has been extensively studied and finally understood at the molecular level (Figure 2.14): R H R I V F e O H R I I R I I I R H O R I H R I I a R I I I F e I V O H a R . R I

F e I I I H R I I I I I .F e O H R I I I b H 2 O R R I b R I I I R I I Fig.2.14 Mechanism of sp3-carbon atom oxidation involving the CYTP450 system (Reprinted from ref. 29, p.125, with permission from Elsevier) It is assumed that the perferryl-oxygen intermediate is responsible for homolytic cleavage of the C-H bond, the substrate consequently being transformed into a carbon-centred free radical. The enzyme thence becomes 60 Chapter 2 an iron-hydroxide intermediate to which the hydroxyl radical can be bound with variable strength. Following hydrogen abstraction, two outcomes are possible, namely oxygen rebound (reaction a, leading to the corresponding hydroxylated metabolite), or abstraction of a second hydrogen atom (reaction b), eliminating water and producing an olefin. Trapping of the carbon-radical intermediate by the iron-coordinated hydroxyl radical (before it can rearrange or break out of the solvent cage) is a point of crucial significance, since it explains why CytP450-mediated C-sp3 hydroxylations are usually not toxication reactions liberating carbon-centred free radicals [29]. Reaction mechanism of C-sp3 desaturation: From Figure 2.14 an additional reaction of the carbon-centred radical intermediate is evident, namely desaturation, with consequent formation of an olefin (reaction b); the implicit condition is the presence in the substrate of two vicinal hydrogen atoms. This type of reaction is of particular interest in the toxicological context of potent carcinogenic compounds/intermediates that undergo oxidative biotransformations to yield epoxides, as the latter can react with important biological macromolecules such as nucleic acids [30]. Methyl groups undergoing CytP450-mediated hydroxylation may present a variety of positions (e.g. in branched alkyl groups and on alicyclic compounds). In the case of the antihistaminic terfenadine the first biotransformation reaction is one of hydroxylation (Figure 2.15). The resulting metabolite may be further oxidised to the corresponding acid (documented also for finasteride and some other drugs). Moreover, in the case of terfenadine, the acid formed by oxidation of a methyl group has been identified as the major metabolite in human urine. As regards enzyme involvement, it has been proven that the first oxidation step is mediated by CYP3A isoenzymes [31]. Under certain circumstances, the resulting carboxylic acid may react further, undergoing decarboxylation. In a study aimed at explaining and predicting adverse drug interactions associated with terfenadine, its extensive metabolism in a variety of intact hepatocytes from human and rat cultures was investigated recently [32], the rates and routes of metabolism being established by HPLC. Metabolites identified included products of C-oxidation and the N- dealkylation product azacyclonol. Various substrates and inhibitors of cytochrome P 4503A (CYP3A) were then tested for their ability to inhibit terfenadine metabolism, with a range of outcomes depending on the inhibitor and the type of hepatocyte. Human hepatocytes were suggested as having potential as a screening system for such inhibitors. Pathways of biotransformation – phase I reactions 61 OH CH3 HO C N (CH2)3 CH C CH3 CH3 OH CH3 HO C N (CH2)3 CH C CH2OH CH3 OH CH3 HO C N (CH2)3 CH C COOH CH3 the major metabolite in human urine CO2 OH CH3 HO C N (CH2)3 CH C H CH3 Fig.2.15 Steps in the biotransformation of terfenadine A case of particular biochemical and physiological significance is offered by metabolism at the 10-methyl group in androgens. The methyl group being adjacent to a quaternary C-sp3 centre in fact undergoes a reaction of C-demethylation, leading subsequently to ring A aromatization and estrogen formation. The enzymatic system involved is a CYTP450 aromatase (CYP19, also known as estrogen synthetase) [33] and the methyl group is oxidised to formic acid. Nevertheless, the reaction partly resembles the usual C-sp3 hydroxylation, being initiated by a hydrogen 62 Chapter 2 abstraction and consequently yielding a carbon-centred radical. It is noteworthy that a similar mechanism might be involved in the oxidative breakdown of cardiac glycosides, involving sequential loss of two digitoxose units and finally resulting in the formation of a monodigitoxoside [34]. Several recent studies relating to androgen metabolising enzymes have appeared in the literature. One study relates aromatase activity to clinical effects associated with osteoporosis [35]. Evidence was found suggesting that in postmenopausal women, circulating adrenal androgen may be transformed into estrogen in peripheral tissues and may contribute to maintenance of bone mineral density, thus resulting in a protective effect against osteoporosis. Dehydroepiandrosterone (DHEA) can be converted sequentially into androstenedione and estrone in cultured human osteoblast apparently through aromatase activity. Localisation and function of androgen metabolising enzymes in the brain has been reviewed [36], as has the role of aromatase in the neuroprotective properties of estradiol [37]. In the latter work, neuroprotective effects of precursors of estradiol (e.g. testosterone) are described as being mediated by aromatase, suggesting that formation of estradiol in the brain is neuroprotective. Aromatase, described as a neuroprotective enzyme, was thus suggested as an important pharmacological target for therapies aimed at prevention of neurodegenerative disorders. Rapid changes in brain aromatase activity are evidently mediated by phosphorylation processes, as described in a recent review [37], where it was shown that such activity in hypothalamic homogenates is rapidly down-regulated by addition of Ca2+, Mg2+ and ATP. Another interesting case of oxidation of non-activated sp3-hybridized carbon atoms is represented by barbiturates [38], which bearing alkyl side- chains attached to a quaternary C-sp3 centre, will experience only limited activation. Barbiturates are metabolised primarily by the hepatic microsomal enzyme system and the metabolic products are excreted in the urine, and less commonly, in the faeces. Approximately 25 to 50% of a dose of aprobarbital or phenobarbital is eliminated unchanged in the urine, whereas the amount of other barbiturates excreted unchanged in the urine is negligible. The excretion of unmetabolised barbiturate is one feature that distinguishes the long-acting category from those belonging to other categories that are almost entirely metabolised. The inactive metabolites of the barbiturates are excreted as conjugates of glucuronic acid. In the case of 3-carbon chains, hydroxylation occurs preferentially at the terminal carbon, while for side-chains of four or more carbon atoms, the antepenultimate carbon is preferred (position 3’) [39] (Figure 2.16). In the case of pentobarbital, hydroxylation occurs on the pentyl side chain, the main metabolite (~40%) in human urine being the 3’-hydroxy derivative [40]. Pathways of biotransformation – phase I reactions 63 H O H O N C2H N 5 C2H5 O O N CH (CH2)2 CH3 N CH CH CH2 CH3 H O CH H 3 O CH3 OH Fig.2.16 Hydroxylation of pentobarbital Hydroxylations on ethyl groups may occur at either of the carbon atoms; a minor but very interesting metabolic reaction involves phenacetin [41] (Figure 2.17): CH3 CH2 O NH C CH3 O CH2 O NH C CH3 COOH O 4-acetamidophenoxyacetic acid Fig.2.17 ȕ-hydroxylation of phenacetin The resulting acid is the main urinary metabolite. A fact of particular relevance is that the reaction is strongly dependent on biological factors as well as pre-or co-administration of phenobarbital, which markedly increases the metabolite formation by enzyme induction. Also noteworthy is that phenacetin may undergo two other types of biotransformation: an N-hydroxylation (mediated by CYP1A enzymes), a reaction of great toxicological significance, yielding reactive electrophile intermediates which can form adducts with biological nucleophiles, and O-deethylation, mediated by two specific enzymes, CYP1A1 (aryl hydrocarbon hydroxylase) and CYP1A2, known as phenacetin O-deethylase. The O-deethylated metabolite resulted in the well-known acetaminophen (paracetamol). It is important to note that both enzymes are inducible by PAHs [42]. 64 Chapter 2 An in vivo and in vitro study of the metabolism of phenacetin in rats revealed its disappearance rate from blood and the activity of the enzyme phenacetin O-deethylase in liver to be at maximum in the morning and at a minimum in the evening [43]. However, these circadian variations are not completely responsible for previously observed rhythmical variations in the antipyretic action of phenacetin. A study was undertaken to determine the in vivo role of the enzyme CYP1A2 in phenacetin-induced toxicity in mice [44], this enzyme being known to metabolise phenacetin in vitro. From experiments involving long- term feeding of phenacetin, the drug was found to be more toxic for mice lacking the enzyme than for controls, substantiating the conclusions that metabolism of phenacetin by this enzyme does alter in vivo toxicity and that alternate metabolic pathways contribute to its toxicity. As in the case of phenacetin above, similar behaviour was demonstrated in the case of chlorpropamide undergoing hydroxylations at either of the carbon atoms on the n-propyl group (Figure 2.18), with the β-hydroxylation as the major metabolic route in humans [45]. We may stress here species differences in this drug biotransformation, the main pathway in rats being for instance Į-hydroxylation. O Cl S NH C NH CH2 CH2 CH3 O O O β Cl S NH C NH CH2 CH CH3 O O OH major metabolic route in humans O α Cl S NH C NH CH2 CH2 CH2 OH O O O the major metabolite in rats γ Cl S NH C NH CH CH2 CH3 O O OH Fig.2.18 ȕ-hydroxylation on the n-propyl group of chlorpropamide Pathways of biotransformation – phase I reactions 65 As seen in Figure 2.18, we note that both Į- and Ȗ-hydroxylations occur in humans as well, but these represent only minor routes of biotransformation. Non-activated C-sp3 atoms in cycloalkyl groups are of particular interest because they appear as substituents in a number of drugs. At least two groups of cycloalkane derivatives warrant mention here, namely steroid hormones (Figure 2.19) and terpenes. OH OH 16 O 6 OH OH O 7 6 O 7 6 Fig.2.19 Hydroxylation and desaturation reactions on the molecule of testosterone (Reprinted from ref. 29, p.133, with permission from Elsevier) They indeed deserve special mention due to the physiological and toxicological significance of their regio- and stereoselective CYTP450- catalysed hydroxylations [46]. Of relevance in the above example is the allylic oxidation at the 6-position, although hydroxylated metabolites may occur with the –OH group at other positions too, in particular 2ȕ, 15ȕ, 16Į and 16ȕ. When incubated with liver microsomes (of dexamethasone-treated rats), the hormone yields two metabolites: the 6ȕ-hydroxylated and the 6,7- desaturated. It is emphasised that it has been proven that desaturation in this case does not result from dehydration of corresponding 6ȕ- or 7ȕ- hydroxytestosterone, but occurs simultaneously with the 6ȕ-hydroxylation, under the action of the same isozymes. Studies using CYP2A1 confirmed a double hydrogen abstraction mechanism, with the first abstraction involving the 6Į-hydrogen [47]. Of clinical relevance, a report postulating the induction of testosterone metabolism by esomeprazole recently appeared [48]. This was based on an unusual episode in which a female patient gradually developed loss of libido 66 Chapter 2 while being treated with esomeprazole; testosterone supplementation or discontinuation of esomeprazole treatment reversed the effect. Another interesting compound in the present context – due to its cyclohexyl and piperidyl groups, is phencyclidine (PCP) [49]. The drug presents two monohydroxylated metabolites with the –OH group in the 4-and 4’-positions, both appearing as major urinary metabolites; the ratio of the two products is species dependent, being 2:1 in humans and 4:1 in dogs (Figure 2.20). 4 OH N 4 N 4' 4 N 4' 4' OH Fig.2.20 Major urinary metabolites of phencyclidine A study of the in vitro metabolism of PCP using rabbit liver preparations [50] revealed the formation of four metabolites originating from oxidative metabolism of the piperidine ring, namely 5-(1-phenylcyclohexylamino)valeraldehyde,N-(1-phenylcyclohexyl)- 1,2,3,4-tetrahydropyridine, 5-(1-phenylcyclohexylamino)valeric acid, and 1-phenylcyclohexylamine. The second of these was proposed as a work-up elimination product of the carbinolamine α-hydroxy-N- (1-phenylcyclohexyl)piperidine. Microsomal enzymes were necessary for the formation of all observed metabolites. Another study of PCP metabolism revealed that the cytochrome P450 3A plays a major role in the biotransformation of this drug [51]. Concurrent administration of potential inhibitors of cytochrome P450 3A could reduce the PCP elimination rate whereas potential inducers were able to accelerate it. Quantitative analysis of PCP and its main metabolites and analogues has been the subject of a recent review [52]. The report discusses (inter alia) analytical methodology and presents a scheme of PCP metabolism. Several more complex saturated cyclic systems have also been investigated. Among them a well-studied example is that of tolazamide (with the methyl group in a toluyl moiety) which undergoes only one specific Pathways of biotransformation – phase I reactions 67 hydroxylation in humans [53], the 4’-hydroxylated derivative (Figure 2.21) being demonstrated

to be the major urinary metabolite; no other ring- hydroxylated products were identified. O 4' CH3 S NH C NH N O O O OH CH3 S NH C NH N O O Fig.2.21 Specific hydroxylation of tolazamide in humans The study of tolazamide metabolism in humans and rats employed tritium-labelled drug to identify metabolites [54]. Following administration of tritiated tolazamide to human subjects, 85% of the radioactivity was excreted in urine after several days in the form of both unchanged tolazamide and as many as six of its metabolites. The structure of one of these [1-(4-hydroxyhexahydroazepin-1-yl)-3-p-tolylsulfonylurea)] (Figure 2.21) was established by X-ray analysis. The other metabolites identified included 1-(hexahydroazepin-1-yl)-3-p-carboxyphenyl sulphonylurea, p-toluenesulphonamide,1-(hexahydroazepin-1-yl)-3-p-ydroxymethylphenyl) sulphonylurea, 1 - (4 - hydroxyhexa - hydroazepin - 1- yl) - 3 - p - tolylsulphonylurea, as well as a labile, unidentified metabolite. Relative amounts of these species present in urine of humans and rats were also reported [54]. Among other drugs undergoing similar specific hydroxylations we may mention also gliclazide and zolpidem. Regarding enzyme involvement, participation of the CYTP450 isoforms CYP2C8, CYP2C9 and CYP2C10 has been proven [55]. In an account of the metabolism of benzodiazepines [56] the extensive metabolism that the hypnotic zolpidem undergoes is mentioned. This includes oxidation of methyl groups and hydroxylation at a site on the imidazolepyridine ring. The CYP3A4 isoform is also known to be involved in the metabolism of zolpidem, indicating that interactions could occur 68 Chapter 2 between this drug and those that may be inhibitors or substrates of this isoform. In another study of the metabolism of zolpidem [57], the kinetics of biotransformation to its three hydroxylated metabolites was determined in vitro using human liver microsomes. Microsomes that contained the human cytochrome P450 isoforms CYP1A2, 2C9, 2C19, 2D6, and 3A4 mediated zolpidem biotransformation. Inhibition of zolpidem metabolism in liver microsomes by ketoconazole and sulphaphenazole was established. An interesting reaction is given by compounds containing unsaturated functional groups; it was observed that these groups direct hydroxylation to adjacent sp3 carbons. Moreover, depending on a number of chemical and biological factors, it was noticed that the resulting regioselectivity may be either high or low. We may mention the following unsaturated systems as having been found to activate adjacent carbon atoms: aromatic rings, carbon- carbon double bonds, carbon-carbon triple bonds, carbonyl groups in ketones and amides, as well as cyano groups. A shared characteristic displayed by the Į-positions in such compounds is a common, larger electron density in the C-H bonds, and smaller electron densities on the C atoms. These results (from molecular orbital calculations) appear as important electronic indices for prediction of regioselective aliphatic hydroxylations. Midazolam is an example of therapeutic relevance, containing methyl groups adjacent to several aromatic heterocycles. The methyl group undergoes hydroxylation yielding 1’- hydroxymidazolam, found as the major metabolite in human plasma (Figure 2.22) [58]. The principal isoenzyme involved has been proven to be the CYTP3A4. In another investigation, midazolam was used as a substance probe to determine the ability of hepatocytes from a whole adult human liver to serve as a model for studying xenobiotic metabolism [59]. O H H N H N 3C 2C N N Cl N Cl N F F Fig.2.22 CYTP3A4-mediated hydroxylation of midazolam Pathways of biotransformation – phase I reactions 69 Both Phase I and Phase II reactions were investigated. The hepatocytes resulted in the metabolism of midazolam to various hydroxylated metabolites, mainly 1-hydroxymidazolam, as such and as its glucuronide conjugate. The metabolism of midazolam in microsomal fractions obtained from human livers was found to be extensive and mediated primarily by a single cytochrome P450 enzyme. A very recent study aimed at quantitative prediction of in vivo drug interactions with macrolide antibiotics in humans [60] centred around the metabolism of midazolam. Using human liver microsomes, α- and 4-hydroxylation of midazolam were evaluated as CYP3A-mediated reactions. This metabolism was found to be inhibited following pre-incubation with macrolides such as erythromycin and azithromycin, in the presence of NADPH. (Kinetic data for enzyme inactivation were subsequently used in a simulation of in vivo interactions based on a physiological flow model, yielding results that were consistent with experimental in vivo data). In the case of reactions of side-chains longer than a methyl group, we may mention benzylic hydroxylation, which is also a significant reaction in the biotransformation of a number of drugs. We illustrate an interesting example, namely the hydroxylation of metoprolol (Figure 2.23); it undergoes 1’-hydroxylation (in rats), with the diastereomeric benzylic metabolites predominantly in the 1’-(R-) configuration [61]: OH O NH 1' OCH3 OH O NH HO 1' OCH3 Fig.2.23 Stereospecific 1’-hydroxylation of metoprolol yielding mainly the 1’-(R-) product 70 Chapter 2 A report on the frequency distribution of the 8h urinary ratio metoprolol/hydroxymetoprolol in a specific population has appeared [62] showing that age may be a factor. Interesting oxidations of C-sp3 atoms adjacent to other unsaturated systems involve hydroxylation of allylic positions (in side-chains) or cycloalkenyl groups. An example of medical relevance is hexobarbital; its major metabolic route involves 3’-hydroxylation (Figure 2.24), followed by dehydrogenation yielding the corresponding 3’-keto metabolite: O CH O H3C 3 H C CH3 3 3' 3 ' N N OH O N O O N O H H Fig. 2.24 Hydroxylation of hexobarbital An important point to stress is that this hydroxylation reaction displays a complex array of substrate and product stereoselectivities, since the molecule is chiral and the 3’-carbon is prochiral. The phenomenon has been proven to be markedly influenced by biological factors [63]. With an even higher selectivity with respect to hydroxylation, glutethimide deserves mention as an important pharmacological example in view of the properties of the resulting metabolite (Figure 2.25): CH2 CH3 4 O N O H HO CH 4 2 CH3 O N O H Fig.2.25 Hydroxylation of glutethimide Pathways of biotransformation – phase I reactions 71 It is an interesting example illustrating the case of carbons adjacent to carbonyl groups, with the Į-position having high selectivity. From a range of resulting hydroxylated intermediates, the 4-hydroxy derivative (either free or in conjugated form) has been shown to be the major plasmatic and urinary metabolite [64]. The reason for highlighting this case is that this particular metabolite is a more active sedative-hypnotic agent than the parent drug, while, on the other hand it is believed to be responsible for most of the severe symptoms displayed by intoxicated patients [64]. As an aside, the fine structural line dividing e.g. convulsant/anticonvulsant or sedative/stimulant properties was some years ago indicated as potentially exploitable for generating drugs of abuse. Glutethimide was specifically mentioned in this context [65]. Hydroxylations of carbon atoms adjacent to acetylenic or cyano groups are not very specific, nor relevant for drug metabolism. Such reactions have been studied for e.g. acetonitrile (or higher nitriles), which clearly are not drug substances; nevertheless, the reaction mechanism, the enzymatic systems involved, as well as the Į-hydroxylation regioselectivity are well known and explained at the molecular level [66]. As previously mentioned in this subchapter, carbon atoms undergoing oxidations may be unsaturated as well, thus presenting either sp2- or, sp- hybridisation. We present briefly the CYTP450-mediated oxidation of C-sp2 atoms in aromatic rings, as a highly complex metabolic route leading to a variety of products; these can be either unstable intermediates or stable metabolites. A noteworthy feature here is the heavy dependence of the chemical reactivity of the intermediates (e.g. epoxides) on the chemical nature of the target group and molecular properties of the substrate. This reactivity also determines the nature and the relative amounts of stable metabolites produced. A well-documented example concerns the mechanism of ring oxygenation (Figure 2.26) [67]. The reaction results in loss of aromaticity, due to the formation of tetrahedral transition states following the activation of the CYTP450-oxygen complex (reaction a). Three oxygenated intermediates may be formed, through alternative reactions c, d and/or e and f. The essence of the entire pathway is the formation of the cation-radical (reaction b) that will bind the activated oxygen (reaction a). The products of this phase are a biradical and a cationic oxygenated intermediate. The second phase subsequently provides two possible rearrangement pathways, leading to the stable phenolic metabolites. An interesting aspect to emphasise is that while the biradical pathways show little (or even no) substituent effects, quite the opposite applies to the cationic pathways. 72 Chapter 2 The arene oxide intermediates (reaction g) are usually highly unstable, easily undergoing ring opening by a mechanism of general acid catalysis, leading ultimately to the stable phenols [68]. More stable epoxides are those of polycyclic aromatic hydrocarbons and olefins. . O a O F eV F eIV b . c . + H H O H F eIV O e F eIV F eIII . d + . O H f HO H H+ h . g . O X H H X f H+ O O X H+ i H+ m j + X+ HO X k l X H+ H X+ OH Fig.2.26 Mechanism of ring oxygenation, leading ultimately to the stable phenols (Reprinted from ref. 67 with permission from Elsevier) Pathways of biotransformation – phase I reactions 73 Other interesting examples in this context refer to NIH shift (displacement involving migration of the geminal hydrogen atom), regio- and stereoselectivity in aryl oxidation of certain drugs. Regioselectivity is well-documented for diclofenac (only three of the seven possible positions being hydroxylated [69]), while in the case of (S)- mephenytoin, the substrate regioselectivity as well as enantioselectivity are evident. Cytochromes P450 from the CYP2C subfamily catalyse the para- hydroxylation of mephenytoin with high efficacy and a marked preference for the (S-)-enantiomer [70]. Biotransformation of mephenytoin to its two major metabolites, 4-hydroxymephenytoin and 5-phenyl-5-ethylhydantoin in human liver microsomes has been investigated [71]. Metabolism was found to be stereoselective, (S-)-mephenytoin being preferentially converted to the 4-hydroxy derivative at low substrate concentrations while the (R-)- enantiomer was demethylated to 5-phenyl-5-ethylhydantoin over a wide concentration range. Mediation by cytochrome P450-type monooxygenases was established. A more complex situation, combining product regioselectivity with substrate enantioselectivity, is encountered in the metabolism of propranolol [72]. Figure 2.27 illustrates the regioselective aspects. In mammals, oxidative metabolic pathways include hydroxylations of the naphthalene ring at the 4-, 5-, and 7-positions as well as side-chain N-desisopropylation [73]. Cytochrome P450 isozymes are involved in propranolol metabolism in human liver microsomes, where the 4-OH, 5-OH and N-desisopropyl derivatives occur as primary metabolites and the 7-OH species is present in trace quantities. The main route in humans is the CYP2D6-mediated 4-hydroxylation; alternatively, 5-, 2-, and 7-hydroxylations may also occur. Among the four monohydroxylated metabolites, the 4- and 5-hydroxy species are poor substrates for a second hydroxylation. In contrast, the 2- and the 7-hydroxylated metabolites may subsequently be easily hydroxylated at the preferred 3-position, yielding the corresponding dihydroxylated metabolites, shown in the central part of the figure. Three other dihydroxylated metabolites can be also found in human urine, though in very small amounts, namely the 4,6-, 4,8- and 3,4-derivatives. While 4-hydroxylation showed no apparent substrate stereoselectivity, the 7-hydroxylation has been proven to be selective for (+)-(R-)-propranolol (in a ratio of about 20:1), while the 5-hydroxylation was selective for (-)-(S-)-propranolol, in a 3:1 ratio [72]. 74 Chapter 2 OH H OH H O N O N 8 8 7 2 7 2 6 3 6 3 5 4 5 4 OH OH 66% 7% CYP2D6 OH H O N 8 7 2 OH H OH H 6 3 O N 5 4 O N 8 8 7 7 2 OH HO 2 6 6 3 5 4 3 OH 5 4 OH OH H OH H O N O N 8 8 7 2 OH HO 7 2 6 3 6 3 5 4 5 4 1% 26% Fig.2.27 Complex regioselective biotransformation reactions of propranolol and the corresponding relative amounts of the monophenolic metabolites Concerning product enantioselectivity in aryl oxidation, the traditional example for illustrating this is phenytoin (Figure 2.28). In humans this phenyl hydroxylation is mediated by the isoform CYTP450C and occurs almost exclusively at the para-position, with the ratio of the two enantiomeric metabolites (S-/R-) about 10:1 [73]. Again, it is important to stress the species differences: in contrast to humans, the meta- phenol is formed preferentially in dogs and is the pure (R-)-enantiomer. Another interesting aspect to note is that both meta- and para-phenols are formed from the same intermediate –

the 3,4-epoxide [74]. Pathways of biotransformation – phase I reactions 75 OH pro-R HN O N O pro-S H HN O N O H HN O N OH O H Fig.2.28 Enantioselectivity in the biotransformation of phenytoin The 5-(p-hydroxyphenyl)-5-phenylhydantoin may be further metabolised to a catechol. Spontaneous oxidation of the catechol then leads to semiquinone and quinone species that modify proteins by forming covalent linkages [75]. The hydroxylation of phenols is of particular interest. As a rule, it has been demonstrated that when the position para- to the first hydroxyl group is free, it will generally be hydroxylated more rapidly than the ortho-position. An important example of a drug following this pattern is given by salicylamide (Figure 2.29) [76]; about 50% of an oral dose of salicylamide administered to mice was recovered as the 5-hydroxylated metabolite, while only about 20% of the dose underwent 3-hydroxylation. HO 5 CONH2 5 CONH OH 2 3 OH 3 5 CONH2 3 OH OH Fig.2.29 The two preferred positions of hydroxylation of salicylamide 76 Chapter 2 Polycyclic aromatic hydrocarbons (PAHs) have been the subject of intensive study due to their toxicological significance. Representatives of these compounds display high carcinogenic potencies following their toxication to reactive metabolites - ultimately called carcinogens [77]. One of the most carcinogenic PAHs is benzo[Į]pyrene, present in tobacco smoke. Figure 2.30 presents the three major epoxide metabolites, their hydration to dihydrodiols (by epoxide hydrolase), as well as the epoxidation of the M-region (which is the most electron-rich region in the molecule) dihydrodiol to a dihydrodiolepoxide, considered to be the ultimate carcinogen: OH OH O 4R; 5R 4S; 5R B K 12 1 O 11 2 7R; 8S 10 3 9 HO OH 8 4 7R; 8R M 7 6 5 K O O OH HO HO OH 7R; 8S; 9S; 10R 9S; 10R 9R; 10R Fig.2.30 Major epoxide metabolites of PAHs (Reprinted from ref. 27 with permission from Elsevier) Diol-epoxides rearrange to a triol carbonium ion (Figure 2.31) which will then react covalently with e.g. nucleophilic sites in nucleic acids [78]. Pathways of biotransformation – phase I reactions 77 HO + HO OH Fig.2.31 The triol carbonium ion Oxidation of sp2-hybridised carbon atoms Apart from their presence in carbon-carbon bonds of aromatic systems, sp2- hybridised carbon atoms occur, either isolated or conjugated, in olefinic bonds. Bonds of this type are found in a large variety of xenobiotics, as well as in various endogenous substrates (e.g. arachidonic acid) [79]. They usually undergo CYTP450-catalysed oxidation to epoxides and a few other products. The mechanism of olefin oxidation involves two distinct formations of C-O bonds (pathways a and b) shown in Figure 2.32. O a R R + FeV R CH CH R' CH CHR' CH CHR' O O FeIV FeIII R O R' b R H H H H O FeIII FeV R' c d H R H R H CH CHRR' FeIII H O O HO H + R R R N N Fe N N CH CH2R' N N N N O Fig.2.32 CYTP450-mediated oxidation of olefinic bonds (Reprinted from ref. 8, p.149, with permission from Elsevier) 78 Chapter 2 After the first C-O bond forms (reaction a), at least three intermediates arise: a radical, a carbocation and a cyclic intermediate.These highly reactive intermediates can subsequently follow three alternative pathways: formation of the second C-O bond (reaction b), generation of carbonyl derivatives (reaction c) and covalent binding to heme (reaction d) with the subsequent formation of abnormal N-alkylporphyrins (“green pigments”). It is this last reaction by which some compounds (called “suicide-substrates”) can act as irreversible mechanism-based enzyme inhibitors [80]. Further information appears in Chapter 5, section 5.2. A number of drugs (or metabolites) form olefinic epoxides which can either be stable or rearrange intramolecularly. An example is given by carbamazepine (Figure 2.33). This tricyclic drug yields more then 30 metabolites, among which appears the 10-11-epoxide, not as a predominant one, but a nevertheless pharmacologically active species [81]. O 10 11 10 11 N N CO NH2 CO NH2 Fig.2.33 Olefinic type epoxidation of carbamazepine Actually, in humans, epoxidation followed by enzymatic hydration is a major pathway of biotransformation of tricyclic drugs of this type. From a study of the metabolism and covalent binding of carbamazepine with the MPO/H2O2/Cl- system and neutrophils, a common pathway was identified [82]. Metabolites detected included an intermediate aldehyde, 9-acridine carboxaldehyde, acridine, acridone, chloracridone and dichloroacridone. To account for the observed ring contraction, it was suggested that reaction of hypochlorous acid with the 10,11-double bond of carbamazepine yields a carbonium ion as the first intermediate in its metabolism. This pathway is similar to that for the metabolism of iminostilbene, a metabolite of carbamazepine, but differs in rate and details of mechanism. The reader is also referred to a recent review describing the variable metabolism of several anti-epileptics and their implications for therapy [83]. Pathways of biotransformation – phase I reactions 79 Epoxide rearrangement reactions generally include formation of a lactone. Such an intramolecular nucleophilic reaction occurs during the metabolism of hexobarbital (see Figure 2.24 above). The major metabolic route involves 3’-hydroxylation followed by dehydrogenation to the corresponding 3’-keto metabolite. Through an alternative pathway (species dependent) the epoxide intermediate may arise, followed by cyclisation, involving an intramolecular rearrangement. In contrast, olefinic epoxidation in allylic chains, such as occurs in alclofenac, was found to represent only a very minor biotransformation, the resulting metabolite accounting for 0.01% or even less of a dose in humans [84] (Figure 2.34). Cl CH2 CH CH2 O CH2 COOH Cl O CH2 CH CH2 O CH2 COOH Fig.2.34 Epoxidation of a double bond in an allylic chain illustrated for alclofenac Alclofenac underwent no metabolism in control mouse hepatic microsomes, but in microsomes induced by phenobarbitone or 3-methylcholanthrene, it was found to biotransform to its dihydroxy and phenolic derivatives [85]. These metabolites did not destroy cytochrome P450 in vitro but formation of the reactive epoxide intermedate was cited as partly mediating destruction of the enzyme. Oxidation of sp-hybridised carbon atoms sp-hybridised carbon atoms, found in carbon-carbon triple bonds (e.g. in alkynes) undergoCYTP450-mediated oxidation to a number of products. The mechanism is very similar to that applying to oxidation of olefinic bonds and it is postulated that several reactive intermediates are generated (Figure 2.35). 80 Chapter 2 O a R R + FeV + R C C R' C C R' C C R' O O FeIV FeIII O R R' b R O R' FeIII FeV c - R=H d O + R R'=aril R R' O C C H R H2O O R N Fe N HOOC CH2 R' N N FeIII O R R H N N N N Fig.2.35 CYTP450-mediated oxidation of sp-hybridised carbon atoms (Reprinted from ref. 8, p.153, with permission from Elsevier) In the above scheme, similar intermediates and derivatives as in the case of oxidation of olefinic bonds can be observed. Reactions include heme alkylation and consecutive destruction of CYTP450 with subsequent appearance of abnormal “green pigments” [86]. An interesting example of acetylenic oxidation yielding D- homosteroids (steroids with a six-membered D-ring) is afforded by the 17Į- ethynyl steroids (Figure 2.36). The reactions are illustrated for norethindrone, derived from hydrolysis of its acetate in most tissues including skin and blood. The site of primary metabolism of norethindrone is the liver, but the first-pass effect may be significantly reduced by administering the drug transdermally. Pathways of biotransformation – phase I reactions 81 The main reactive intermediate, the epoxide, following successive oxidations and a decarboxylation, will finally yield the rearranged, six- membered D-ring [87]. OH C CH O [O] OH O OH+ O O O O O OH [O] . O O CO2 Fig.2.36 Mechanism of D-homoannulation of norethindrone 82 Chapter 2 2.3.3 Oxidations at hetero-atoms A large variety of drugs known to contain hetero-atoms such as O, N, S or P are substrates for reactions of oxidation, reduction and hydrolysis. We may mention from the outset the diversity of these reactions, including principally nitrogen oxidations, N-C cleavage, oxidation of oxygen and sulphur-containing compounds, oxidative dehalogenations and dealkylations. From the numerous examples of drugs undergoing such types of biotransformations we give some representative cases: • the group of primary amines: e.g. phentermine [88] (Figure 2.37) (Ar = Ph): CH3 Ar CH2 C NHOH CH3 CH3 Ar CH2 C NH2 CH3 CH3 Ar CH2 C N O CH3 CH3 Ar CH2 C NO2 CH3 Fig.2.37 N-oxidation of primary amines, partially MFO- and CYTP450-catalysed Oral and intraperitoneal dosing of phentermine yielded a p-hydroxy phentermine conjugate as the major metabolite in urine; N-hydroxy phentermine yielded a p-hydroxyphentermine conjugate [89]. Pathways of biotransformation – phase I reactions 83 • the group of primary arylamines : procainamide [90] (Figure 2.38): H2N CONHCH2CH2N(CH2CH3)2 HO HN CONHCH2CH2N(CH2CH3)2 Fig.2.38 Procainamide hydroxylation (common pathway of metabolism in rat and human liver microsomes) The resulting hydroxylamine is very reactive, undergoing non- enzymatic oxidation (autoxidation) to the corresponding nitroso-compound, which may covalently react with glutathione and thiol groups in proteins yielding sulphinamide adducts. It is assumed that this reaction may be responsible for procainamide-induced lupus [91]. Yet another noteworthy possibility is the coupling of the hydroxylamine and nitroso intermediates to form an azoxy derivative. Alternatively, either of the intermediates can react with the “parent” primary amine to yield an azo derivative (C-N=N-C). O CH3 O CH N CH3 O H O CH2 O CH N NO2 CH3 O O CH NH CH3 NO2 + HCHO NO2 Fig.2.39 The dealkylation of N,N-dimethyl-p-nitrophenylcarbamate (Reproduced from ref. 25 with permission from R Paselk, Humboldt State University) 84 Chapter 2 • the group of N,N-dimethylamino derivatives: methyl groups attached to a nitrogen atom are hydroxylated and rearrange to release an aldehyde, as shown in Figure 2.39 for the dealkylation of N,N-dimethyl- p-nitrophenylcarbamate. An interesting alternative is that of di-dealkylation, as presented in Figure 2.40, yielding a primary amine: H3C CH N 3 H3C CH O N 2 H NH2 CH2O CH2O H3C H N HO H2C H N Fig.2.40 The di-dealkylation of N,N-dimethylaniline (Reproduced from ref. 25 with permission from R Paselk, Humboldt State University) • the group of N,N-diethylamino derivatives. For a long time it was believed that N,N-diethylamino derivatives, could not yield N-oxide metabolites due to steric hindrance [92]. Generally, N,N-dimethylamino derivatives are better substrates for N-oxygenation than their N,N- diethylamino homologues, although some xenobiotics belonging to the latter class are known to yield small amounts of N-oxides. Examples include clomiphene and lidocaine [93] (Figure 2.41): Pathways of biotransformation – phase I reactions 85 CH3 C2H5 NHCO CH2 N CH C 3 2H5 CH3 C2H5 NHCO CH2 N O C CH 2H5 3 Fig.2.41 Formation of lidocaine N-oxide The metabolism of lidocaine to its major metabolite monoethylglycinexylidide (MEGX) has been studied in human liver microsomes [94]. At least two distinct enzymatic activities were identified. A review describing the advantages and disadvantages of using MEGX as a probe of hepatic function in liver transplantation has appeared [95]. Transformation of lidocaine to MEGX in the liver is the basis of a flow-dependent test of liver function. This test, though still subject to limitations, is significant in the context of assessing risk in liver transplantation as it reflects ‘real-time’ hepatic metabolising activity. • the group of tertiary alicyclic amines: morphine [96] (Figure 2.42): R O R O O O N CH3 NH HO HO Fig.2.42 N-demethylation of morphine (R = H) 86 Chapter 2 This N-demethylation is well established both in animals and humans. It was shown that the value of the Michaelis constant, Km, for the reaction decreased with increasing chain length from 1 to 9 carbon atoms; the decyl and dodecyl analogues were not N-demethylated. However, morphine, as a good example of a complex molecule enclosing a piperidine ring, may also be oxidized, yielding an N-oxide of particular relevance. A detailed account of features of opioid pharmacology, including the metabolism of morphine, is available [97]. Some emphasis is given to morphine glucuronides, and in particular to morphine 6-glucuronide owing to its clinical importance. Though this is a product of Phase II metabolism, it is introduced here and discussed further in Chapter 3. These compounds are formed in the liver and their fate is excretion in the bile and urine. Depending on the enzymes involved, different conjugates may form. In the case of morphine, the process is stereospecific and dependent on the body

region. The biotransformation of morphine-3-glucuronide to the active morphine-6-glucuronide is well known. A review of this topic also describes the discovery of a unique opioid receptor for morphine-6-glucuronide [98]. More recently, a review on the clinical implications of this metabolite appeared [99]. • the group of 1,4-dihydropyridines: their aromatization to the corresponding pyridine metabolites has been extensively studied, both in vitro and in vivo. The most common example is given by felodipine, which undergoes biotransformation in a CYP3A4-mediated reaction yielding a metabolite that contains the pyridine moiety (Figure 2.43): 4' 5' 3' Cl 4' 5' 3' Cl 6' 2' H Cl 6' 2' Cl CH3OOC COOC2H5 CH3OOC COOC2H5 CH N 3 CH3 N H Fig.2.43 Structure of felodipine undergoing aromatization The fastest rate of aromatization was observed for the 2’,6’- disubstituted derivatives, variations being correlated with electronic properties of the substrates. The slowest rates were associated with the 2’,3’-,2’,4’-,3’,4’- and 3’,5’-disubstituted derivatives [100]. Pathways of biotransformation – phase I reactions 87 This biotransformation was studied in rat-liver microsomes [101], kinetic data indicating it as a major metabolic pathway and cytochrome P450 was implicated in the aromatization of felodipine. • the group of amino azaheterocyclic compounds: trimethoprim is not N-hydroxylated, but forms two isomeric N-oxides, oxidation occurring at the 1- and 3- positions [102] (Figure 2.44). In the specific case of this antibacterial drug, hydroxylamine formation (considered as a route of toxication) is limited by the amine-imine tautomerism, which controls the metabolic processes, preventing the N-hydroxylation, and instead favouring the appearance of the isomeric N-oxides shown below. O CH 1 3 N H2N CH2 O CH3 3N NH2 O CH3 O O CH3 O CH 1 3 N 1N H2N CH2 O CH3 H2N CH2 O CH3 N N 3 NH 3 2 O CH3 O NH2 O CH3 Fig.2.44 Formation of the two isomeric N-oxides of trimethoprim Another example from this group relates to the N-hydroxylation of the purine base adenine to 6-N-hydroxyaminopurine [103], a compound with genotoxic and carcinogenic properties (Figure 2.45): NH2 NHOH 6 1 5 7 6 N N N N 8 2 N 4 N 9 N N 3 H H Fig.2.45 6-N-hydroxylation of adenine 88 Chapter 2 The 6-substituent was also found to play a role in influencing N-oxide formation [104]. For such compounds (heterocyclic hydroxylamines), it is assumed that the formation of a nitrenium ion is the step leading to the ultimate carcinogen or mutagen [105]. In a study of the effect of oxygen on adenine hydroxylation by the hydroxyl radical in aqueous solution, the 8-hydroxyadenine derivative was isolated [106]. • the group of hydrazines (1-substituted, 1,1-disubstituted, 1,2-di- substituted and azo derivatives): hydralazine (a 1-substituted hydrazine) [107] (Figure 2.46). The reaction of biotransformation in this case proceeds via radical pathways, with loss of the hydrazine moiety to yield phthalazine. NH NH2 N N N N Fig.2.46 Metabolism of hydralazine From the same group, we refer to procarbazine (a 1,1-disubstituted hydrazine , Figure 2.47) for which azo formation and subsequent N-C cleavage reactions are well documented. However, the mechanism of N-dealkylation may involve Į-carbon hydroxylation rather than hydrazone hydrolysis [108]. CH3 NH NH CH2 CONHCH(CH3)2 Fig.2.47 Structure of procarbazine The intermediate derived from N-oxidation may be either a diazene or a nitrene resonance form, existing in tautomeric equilibrium with an azomethinimine. The nitrene intermediate may form an iron-nitrene complex with CYTP450, while the azomethinimine can rearrange to a hydrazone. Particular examples are the N-dealkylations. They represent the simplest case of N-C cleavage; see the example of morphine above (Figure 2.42). Pathways of biotransformation – phase I reactions 89 Another interesting example is given by a seven-membered azaheterocycle, belonging to the group of benzodiazepines, namely diazepam (Figure 2.48). In humans, its N-demethylation [109] to the long- acting desmethyldiazepam is a major route of metabolism. Diazepam displays competition with the structurally related pinazepam, for the same metabolic route. N-dealkylation of these drugs occurs at markedly different rates; in rat liver microsomes for example, the N-depropargylation of pinazepam is eightfold faster than the N-demethylation of diazepam [110,111]. CH3 O N Cl N Fig.2.48 N-demethylation of diazepam Environmental and genetic factors may influence interindividual metabolism of diazepam and these have been discussed [112]. The benzodiazepine pinazepam contains an unsaturated bond (the propargyl group) at the N1-position and its metabolism involves N1- dealkylation and C3-hydroxylation. N-desmethyldiazepam is the main metabolite in dogs. Both pinazepam and N-desmethyldiazepam are converted to the inactive oxazepam [113]. N-demethylation of caffeine is another well-studied case [114] (Figure 2.49). As can be observed from the figure a preferred position for dealkylation is the N(3) atom, the reaction yielding para-xanthine; indeed, this metabolite was shown to predominate markedly over N(1)-, and N(7)- demethylated metabolites (theobromine and theophylline respectively). For the N(3)-demethylation of caffeine in human liver, the enzyme found to be primarily responsible is the isoform CYP1A2 (while other P450 enzymes, at least in part, are involved in the formation of the N(1)-, and N(7)- demethylated metabolites). An alternative biotransformation pathway for caffeine involves a non- P450 enzyme system, namely the xanthine oxidase; in particular, this 90 Chapter 2 enzymatic system catalyses the 8-hydroxylation of certain N-demethylated metabolites of caffeine, such as theophylline and 1-methylxanthine. O CH H 3 3C N N 1 7 3 O N N H p-xanthine O CH O CH H 3 3 3C H N N 1 7 N N 1 7 3 3 O N N O N N CH3 CH3 caffeine theobromine O H H3C N N1 7 3 O N N CH3 theophylline Fig.2.49 The three main metabolites of caffeine occurring in human liver microsomes In higher plants, demethylation of caffeine leads to xanthine and further catabolism takes place via the purine catabolism pathway. Theophylline is a catabolite of caffeine [115]. An interesting case is that of propranolol, which can undergo not only hydroxylations (Figure 2.27), but also N-dealkylation and deamination, these in fact being its major metabolic routes [116] (Figure 2.50): Pathways of biotransformation – phase I reactions 91 O NH2 OH a O b NHCH(CH ) OH 3 2 propranolol b O CHO OH O OH OH O COOH OH 3-(1-naphthoxy)-1,2-propanediol naphthoxylactic acid Fig.2.50 Alternative biotransformation reactions of propranolol yielding a diol and an acid metabolite (Reprinted from ref. 8, p.213, with permission from Elsevier) Most of the administered dose is dealkylated (path a) and then deaminated (path b), the dashed arrow indicating that the deamination of the “parent” drug is minor compared to that of deisopropylpropranolol. The aldehyde produced by deamination is either rapidly reduced – yielding the diol, or oxidised to the corresponding acid. This oxidative degradation of the side-chain of propranolol is assumed to be an important process in humans, accounting for some 15-30% of a dose on chronic administration of the drug [117]. 92 Chapter 2 Deamination is an important pathway of metabolism for certain other drugs with a basic side-chain such as ȕ-blockers, antihistamines and antipsychotics. These drugs usually being arylalkylamines with a secondary or tertiary amino group, deamination will involve either the parent drug and/or its N-dealkylated metabolite(s). Oxidative dehalogenation is another particular case of CYTP450- catalysed oxidation. One of the most important examples involves halothane [118] (Figure 2.51): H CF3 C Br CF3 CH2 OH CF3 COOH Cl Fig.2.51 Oxidative dehalogenation of halothane The compound can induce post-anaesthetic jaundice or hepatitis, its reductive metabolism partly and perhaps mainly accounting for such unwanted effects (see also subchapter 8.3). It undergoes CYTP450-catalysed dehalogenation by both oxidative and reductive routes. Its oxidative biotransformation occurs at the –CHClBr group, leading eventually to trifluoroacetic acid. The metabolism of polyhalogenated compounds used as anaesthetics is a subject with important toxicological implications. Metabolism of the compounds occurs mainly in the liver and hepatotoxicity is not unusual. Molecular processes underlying such adverse reactions have been reviewed [119]. Finally, we present another example of a specific oxidation (albeit not involving a drug), namely the CYTP450-catalysed oxidative ester cleavage. Not many years ago, a few isolated observations of such a reaction were published; they referred to the oxidative de-esterification of flampropisopropyl (a herbicide) to the corresponding acid, the proposed mechanism involving the formation of a hydroxylated intermediate, followed by its post-enzymatic breakdown to the acid and acetone [120] (Figure 2.52): Pathways of biotransformation – phase I reactions 93 CH3 CH3 CON CH COO CH CH3 Cl F flampropisopropyl CH3 CH3 CON CH COO C OH CH3 Cl F CH3 CH3 CON CH COOH + C O CH3 Cl F Fig.2.52 Oxidative ester cleavage of flampropisopropyl Another interesting group of dealkylations is that of O-alkylated compounds: alkyl groups are hydroxylated adjacent to oxygen and rearrange to release an aldehyde, as shown for p-nitroanisole (Figure 2.53): O H O CH3 O CH2 OH + CH2O NO2 NO2 NO2 Fig.2.53 Hydroxylation of p-nitroanisole occurring adjacent to oxygen (Reproduced from ref. 25 with permission from R Paselk, Humboldt State University) 94 Chapter 2 S-dealkylations, analogous to O-dealkylations, may also occur. They are likewise CYTP450-catalysed reactions, the intermediate undergoing S-C cleavage, yielding a thiol and a carbonyl compound (Figure 2.54): S CH3 N N OH N N S CH2 H N N 6-methylthiopurine N N H SH N N + CH2O N N H 6-mercaptopurine Fig.2.54 Dealkylation of 6-methylthiopurine, with a hydroxylated intermediate and final demethylation and formation of an aldehyde (Reproduced from ref. 25 with permission from R Paselk, Humboldt State University) 2.4 OXIDATIONS INVOLVING OTHER ENZYMATIC SYSTEMS 2.4.1 The monoamine oxidase and other systems Monoamine oxidase (MAO), widely distributed in most tissues of mammals is a membrane-bound, FAD-containing enzyme, mainly located in the mitochondria. However, some activity has also been detected in microsomes, cytosol and even in the extracellular space. Its presence in the brain is of particular importance in connection with the therapeutic profile of its inhibitors and its role as an activator of xenobiotics [121-126]. Protein sequencing, as well as cloning and sequencing cDNA coding for humans, have proven the existence of two different forms of the enzyme, Pathways of biotransformation – phase I reactions 95 conventionally designated as MAO-A and MAO-B. Physiological substrates of MAO are predominantly primary amines; they are oxidatively deaminated according to the following reaction: RCH2NH2 + O2 + H2O RCHO + NH3 + H2O2 2.4 Normally, this is a two-step reaction, producing first the aldehyde, the amine and the enzyme in the reduced form; subsequently, the reduced enzyme is re-oxidised by molecular oxygen, with concomitant production of hydrogen peroxide (Eq. 2.5 and 2.6): [FAD] + RCH2NH2 + H2O [FADH2] + RCHO + NH3 2.5 [FADH2] + O2 [FAD] + H2O2 2.6 If the resulting hydrogen peroxide is not quickly decomposed by peroxidases, it may activate some neurotoxins, which is of potential toxicological significance. The MAO catalytic mechanism is understood at the molecular level [124]. Usually, reaction begins with a single-electron oxidation (of the nitrogen atom), yielding an amine radical cation and thus facilitating the next step, namely abstraction of a hydrogen atom followed by fast electronic loss. Then, a second oxidation step occurs, generating an imine or its iminium ion. The reduced enzyme binds molecular oxygen and undergoes re-oxidation with release of hydrogen peroxide. A typical, endogenous substrate is represented by histamine (Figure 2.55). Histamine (in the small amounts normally ingested or formed by bacteria in the GI tract) is rapidly metabolised and eliminated in the urine. There are two major pathways of histamine metabolism in humans [127]. The more important involves ring methylation, with subsequent formation of N-methylhistamine (under the catalytic action of the well distributed N-methyltransferases). Most of this intermediate is then converted by MAO to the corresponding N-methylimidazoleacetic acid (reaction may be blocked by MAO inhibitors). An alternative pathway involves oxidative deamination catalysed mainly by the non-specific enzyme diamine oxidase (DAO), yielding imidazoleacetic acid, subsequently converted to imidazoleacetic riboside, (metabolites that display little or no activity and are readily excreted in the urine). An account of the biological role of histamine and its relation to development of antihistamines recently appeared [128]. 96 Chapter 2 CH2 CH2 NH2 HN N N-methyltransferase diamine oxidase histamine CH2 CH2 NH2 CH2 COOH H3C N N HN N N-methylhistamine imidazoleacetic acid monoamine riboside oxidase B CH2 COOH CH2 COOH H3C N N ribose N N N-methylimidazoleacetic acid imidazoleacetic acid riboside Fig.2.55 Alternative pathways in the biotransformation of histamine; note the participation of the B-form of MAO, yielding an acid that subsequently may be conjugated It is

important to mention the existence of two classes of MAO inactivators, depending on whether covalent binding occurs to FAD or to an amino side-chain in the active site. The flavin-containing monooxygenase The so-called FMOs are NADPH-dependent and oxygen-dependent microsomal FAD-containing enzyme systems, functioning as sulphur, nitrogen and phosphorus oxygenases. The proposed mechanism of action involves the sequential binding of NADPH and oxygen to the enzyme to generate an FAD C-4Į-hydroperoxide. The general mechanism of action will be detailed in Chapter 4. Nucleophilic substrates (organic nitrogen and sulphur compounds, including drugs such as phenothiazines, ephedrine, N-methylamphetamine, norcocaine) attack the distal oxygen of this hydroperoxide generating a hydroxyflavin species (the resultant oxygen being transferred to the substrate). The wide tissue distribution of the enzyme suggests that this enzymatic system plays a major role in the oxidative biotransformation of drugs while the broad substrate specificity is associated with the presence of Pathways of biotransformation – phase I reactions 97 multiple forms (sustained by the cloning and sequencing of distinct genes from several species and tissues) [129-131]. The prototypical FMO xenobiotic reaction pathway is considered to be the conversion of tertiary amines to highly polar N-oxides. Thus, the implication of FMOs is obvious in the metabolism of a variety of tertiary amine central nervous system-active agents (e.g. nicotine, olanzapine, clozapine). Consequently, it is readily understandable that there is considerable interest and advantage in identifying brain FMO isoforms capable of attenuating the pharmacological activity of such tertiary amines directly at their sites of action. Prostaglandin synthetase Present in all mammalian cells, this enzyme catalyses the oxidation of arachidonic acid to prostaglandin H2, an important precursor in the arachidonate cascade. However, what is most important is that this fatty acid cyclooxygenase activity is coupled with a hydroperoxidase activity, resulting in some drugs being co-oxidised during arachidonic acid metabolism [132- 134]. Drugs capable of undergoing such co-oxidation biotransformations include aminopyrine, benzphetamine, oxyphenbutazone and paracetamol. It is emphasised here that the same biotransformation mechanism occurs with certain carcinogens such as benzidine or the well-known benzo[Į]pyrene, a component of tobacco smoke. Further details appear in Chapter 4. However one can conclude that the prostaglandin synthetase-dependent co-oxidation of certain drugs may represent a significant metabolic pathway, playing a major role in drug biotransformation, particularly in those tissues that are low in M.F.O. activity, but rich in prostaglandin synthetase (such as the kidney, renal medulla, skin and lung) [130]. Xanthine dehydrogenase – Xanthine oxidase These enzymes, denoted XDH and XO respectively, represent two forms of a homodimeric enzyme, the two component subunits being of equal size [135-139]. These enzymes are sometimes designated as the molybdenum hydroxylases, XO being a xanthine-oxygen oxidoreductase (or hypoxanthine oxidase), and XDH, a xanthine NAD+ dependent oxidoreductase. They are cytosolic enzymes with complementary roles to those of monooxygenases in the metabolism of both endogenous and exogenous (xenobiotic) compounds. Each subunit of XD/XO contains as cofactors: • one atom of molybdenum in the form of a molybdopterin cofactor, whose oxidised form can be written as [MoVI (=S)(=O)]2+, • one FAD molecule, and 98 Chapter 2 • four non-heme iron atoms in the form of two Fe2/S2 centres. The general reaction catalysed by this unique combination of prosthetic groups obeys the general equation; SH + H2O SOH + 2e- + 2H+ 2.7 where SH is a reduced substrate, and SOH, the resulting hydroxylated metabolite. From the equation, two conclusions can be drawn: 1) the oxygen atom transferred to the substrate is derived from water, and 2), as the reaction liberates two electrons, an electron acceptor must also be present. In the case of XO, this electron acceptor is represented by molecular oxygen; the reaction generates uric acid (in the form of urate), plus hydrogen peroxide and superoxide (reactive oxygen species that can cause lipid peroxidation and general oxidative damage in cells). In contrast to XO, XDH uses as electron acceptor, oxidised NAD+; urate is again generated, plus the reduced form of NAD (NADH + H+). Specific substrates of the molybdenum hydroxylases are characterized by having electron-deficient sp2-hybridised carbon atoms, and belong to the following chemical classes: • aromatic azaheterocycles (mono-, bi-, or polycyclic), containing the –CH=N- moiety • aromatic or non-aromatic charged azaheterocycles, that contain the moiety –CH=N+<, and • aldehydes, containing the –CH=O moiety. It is interesting to note that conversion of XDH to XO may occur in vivo under the influence of different metabolic states such as hypoxia and ischemia. This conversion is associated with a variety of toxicities, a consequence of increased production of reactive oxygen species and amplification of oxidative cellular damage; this explains the continued interest in the regulation of the two forms of the enzyme. Details of this aspect appear in Chapter 4. Aldehyde oxidase This enzyme is also known as aldehyde oxygen oxidoreductase and is designated as AO [140-142]. Human AO has a limited tissue distribution, with significant levels detected only in the liver. It is noteworthy that human AO activity appears to be rather unstable; this may be due to substrate- dependence, being at the same time an indication of the presence of multiple forms that exhibit differences in substrate specificities and stability. Aldehyde oxidase (existing solely in its oxidase form) is a cytosolic enzyme, which although completely unrelated to the molybdenum Pathways of biotransformation – phase I reactions 99 hydroxylases, shares much similarity with the XO/XDH enzymes, yet does not participate in a dehydrogenase-oxidase transition. The electrons received from a reducing substrate are used by the flavin to reduce dioxygen. As an electron acceptor, AO uses molecular oxygen, to yield the corresponding acid and superoxide. Despite the fact that the dehydrogenase-oxidase transition does not occur with AO, the same pathophysiological implications that were mentioned for XO exist for AO as well (we refer especially to the reactive oxygen species generated during metabolism by AO). Details are given in Chapter 4. Copper-containing amine oxidases In this group are included amine oxygen oxidoreductases, diamine oxidases and histaminase [143, 144]. These enzymes are found in many tissues as well as in the plasma, the distribution being species-dependent. They are associated as an inorganic cofactor with copper, but also contain a covalently bound organic cofactor at the catalytic site (details in Chapter 4). A common reaction that they catalyse is the oxidative deamination of primary amines: RCH2NH2 + H2O + O2 RCHO + NH3 + H2O2 2.8 Unfortunately, not many drugs have been investigated for their biotransformation by copper-containing amine oxidases, but at least one interesting finding suggests that the phenomenon deserves more attention. This is the deamination of the calcium channel blocker amlodipine [145] (Figure 2.56). H Cl CH3OOC COOC2H5 O CH N 3 NH2 H Fig.2.56 Oxidative deamination of amlodipine 100 Chapter 2 The reaction is species-dependent, occurring in humans and dogs but not in rats, for instance. The reaction was shown to occur on incubation of the drug in dog plasma, and the involvement of plasma amine oxidases was suggested. Deamination leads to an aldehyde assumed to be the precursor of valproic acid, an important drug whose metabolism is of particular biochemical and toxicological interest [146]. 2.4.2 Other representative examples Phenelzine is a representative hydrazine that undergoes MAO-catalysed oxidation, yielding in the first step a diazene; this metabolite may rearrange to a hydrazone, which hydrolyses to hydrazine and an aldehyde (phenylacetaldehyde) that subsequently will yield the corresponding acid (phenylacetic acid), as the major urinary metabolite. NH NH2 [O] N NH E N NH2 S R N N O H2O NH N H O O H + H2N NH2 Fig.2.57 MAO-catalysed oxidation of phenelzine: formation of hydrazine and phenylacetaldehyde (right) and enzyme covalent binding of the phenylethyl radical (left) (Reprinted from ref. 8, p.322, with permission from Elsevier) Pathways of biotransformation – phase I reactions 101 An aspect worth stressing is that phenelzine is not only an MAO substrate, but also an inactivator of the enzyme; it facilitates the breakdown of diazene to N2 and the phenylethyl radical, which is capable of forming covalent adducts with the enzyme at the specific position C4 of the flavin. Under these circumstances, the enzyme will be inactivated by alkylation (“suicide substrate” behaviour) [147] (Figure 2.57). An interesting example is provided by the endogenous compound purine [148]. In the form of the N(9)-H tautomer, it undergoes xanthine- oxidase-catalysed oxidation with high affinity for different regions, as follows: at C(6), yielding hypoxanthine, then at C(2), generating xanthine, and finally at C(8), with corresponding formation of uric acid that is excreted in the urine (Figure 2.58): O H N N 6 1 5 7 N N O N N 8 H H 2 N 4 N 9 3 H O HN N OH O O N N H H H HN N O O N N H H Fig.2.58 The regiospecific XO metabolization of purine The hypoglycaemic drug, tolbutamide, affords a good example of the complexity of biotransformations in the in vivo metabolic context: it undergoes an initial oxidation yielding the corresponding aldehyde, which is subsequently oxidised by both XO and an NAD-linked aldehyde dehydrogenase [149] (Figure 2.59). The aldehyde metabolite is generated by the sequential action of CYTP450 and an alcohol dehydrogenase). 102 Chapter 2 O C4H9 NH C NH S CH3 O O O O C4H9 NH C NH S C O O H O O C4H9 NH C NH S C O O OH Fig.2.59 Tolbutamide metabolites 2.5 METABOLIC REACTIONS INVOLVING REDUCTION 2.5.1 Components of the enzyme system Generally, reductive processes involve two separate enzyme systems: one is represented by the already well-known cytochrome P450, while the other involves an NADH H+ dependent system. The latter is assumed to be a flavoprotein containing a molecule of FAD as the prosthetic group, and NADH H+, as preferred source of the necessary reducing equivalents. This system is known as the NADH-cytochrome b5 reductase system and its participation in physiological processes involves two main steps: acceptance of two electrons, to reach a reduced state, followed by the reduction of two equivalents of cytochrome b5 in successive one-electron steps [150-152]. Pathways of biotransformation – phase I reactions 103 It is assumed as well that this system is also responsible for the reductive denitrosation of nitrosourea anti-tumor drugs, consequently representing an important deactivation pathway [152]. NADPH-cytochrome P450 reductase, a ferrihemoprotein oxidoreductase, also known as NADPH- cytochrome c reductase, is considered to be the major oxidoreductase transferring electrons to microsomal cytochrome P450. The system contains one molecule each of FAD and FMN per polypeptide chain, and the NADPH (resulting from the pentose phosphate pathway), represents the preferred source of reducing equivalents. The electron acceptors are the cytochrome P450 and a small metalloprotein, the soluble cytochrome c, that acts as an electron carrier in the respiratory chain of all aerobic organisms [151,153]. 2.5.2 Compounds undergoing reduction Although relatively uncommon, metabolic reduction is also an important pathway in the biotransformation of drugs. Actually, it represents the major route of metabolism for aromatic nitro- and nitroso- groups (as in chloramphenicol, nitroglycerine and organic nitrites), for the azo- group (as in prontosil) as well as for a wide variety of aliphatic and aromatic N-oxides. Rreduction of azo- and nitro-compounds usually leads to primary amines. However, a number of azo-compounds (such as sulfasalazine) are converted to aromatic primary amines by azoreductase, an NADPH- dependent enzyme system present in the liver microsomes. The colonic metabolites of sulfasalazine are 5-aminosalicylic acid and sulfapyridine. Inflammatory bowel disease results in increase in the production of prostaglandins and leukotrienes. Consequently, the effects of sulfasalazine on the metabolism of the precursor arachidonic have attracted wide interest [154]. Nitro- compounds (chloramphenicol, for example) are reduced to aromatic primary amines by a nitroreductase, presumably through nitrosoamine and hydroxylamine intermediates. It is important to stress that these enzymes are not solely responsible for the reduction of azo- and nitro- compounds, probably because of reduction by the bacterial flora in the anaerobic environment of the intestine. Steps in the mechanism of reduction of an aromatic nitro- group are represented in Figure 2.60 [155]. 104 Chapter 2 2e NO2 2H+ NO2 2 2 H2O NO NO2 + 2H+ 2e NHOH NH H O 2 2 2H+ 2e Fig.2.60 Reduction steps for an aromatic nitro-group (Reproduced with the permission of Nelson Thornes from ‘Introduction to Drug Metabolism’, 2001, 3rd Ed., isbn 0 7487 6011 3 - Gibson & Skett - first published in 1986) Examples of

this type of biotransformation also include certain aldehydes which are reduced to the corresponding alcohols, as well as sulphoxides and sulphones. However, in these cases reduction is not considered to be the major metabolic pathway. Metabolic reduction has been shown to occur mainly in liver microsomes, but occasionally takes place in other tissues as well. Some general reactions are presented in Figure 2.61: Pathways of biotransformation – phase I reactions 105 R1 R1 OH C O C R2 R2 H R1 R3 R1 R3 C C CH. CH R2 C O R2 C O R4 R4 . O O OH OH O OH Fig. 2.61 Some representative types of reductive reactions at carbon atoms Aldehydes and ketones are reduced to the corresponding respective primary and secondary, alcohols, while quinones may be reduced to the corresponding hydroquinones. Some of the radical species formed as intermediates may have significant toxicological potencies. Aldehydes and ketones are widely distributed and have several biological functions. In addition to alcohol dehydrogenase (ADH), there are several enzymes in the aldo-keto reductase family that may participate in the metabolism of aldehydes and ketones in the kidney [156]. Dehalogenations may also proceed in a reductive manner, as in the case of halothane, with the intermediate formation of a radical (1-chloro- 2,2,2-trifluoroethyl) [157] (Figure 2.62): H H+ F H CF3 C Br CF3 C Br CF2 C Cl Cl Cl Fig.2.62 Reductive metabolism of halothane (Reproduced with the permission of Nelson Thornes from ‘Introduction to Drug Metabolism’, 2001, 3rd Ed., isbn 0 7487 6011 3 - Gibson & Skett - first published in 1986) 106 Chapter 2 Fluorocarbons of the halothane type can be defluorinated by liver microsomes in anaerobic conditions as shown above. Some aromatic compounds such as nitro-, nitroso- and hydroxylamines, as well as imines and oximes, are reduced to the corresponding primary amines. Some of the azo-aromatic compounds yield by reductive metabolism primary aromatic amines that are potentially toxic. Disulphides are reduced to the corresponding thiols (Figure 2.63): CH3 CH3 R N O R N CH CH 3 3 Aryl-NO2 Aryl-NO Aryl-NHOH Aryl-NH2 O Aryl N N Aryl Aryl N N Aryl 2Aryl NH2 Aryl NH. NH. Aryl R1 S S R2 R1 SH + R2 SH R1 S O R1 S R2 R2 Fig.2.63 Some representative reductive reactions involving heteroatoms nitrogen and sulphur Some non-microsomal metabolic reductions have also been found to occur, but relatively little is known concerning either the nature of the enzymatic systems involved or their location. Usually, such reductions refer to the double bond, especially in unsaturated monocyclic terpenes. Pathways of biotransformation – phase I reactions 107 2.6 HYDROLYSIS Hydrolysis occurs especially with esters and amides in reactions catalysed by various enzymes located in hepatic microsomes, kidneys and other tissues. Other compounds susceptible to such a biotransformation pathway are carbamates and hydrazides. Usually, esters and amides are rapidly hydrolysed under the catalytic action of specialised carboxylesterases. Some of the resulting metabolites may be subsequently conjugated, as glucuronides for example, and so, rapidly eliminated. Carboxylesterases include cholinesterases, pseudocholinesterases, arylcarboxylesterases, hepatic microsomal carboxylesterases and other unclassified hepatic analogues. Besides the important group of carboxylesterases, in the category of hydrolyses involved in xenobiotic metabolism, we should also mention arylsulphatases, epoxide hydroxylases, cysteine endopeptidases and serine endopeptidases as examples. Carboxylesterases/amidases catalyse hydrolysis of carboxylesters, carboxyamides and carboxythioesters, as seen in the equations below. The specificity of their action depends on the nature of the groups R, R’, R’’: carboxylester: R(CO)OR’ + H2O R(CO)OH + HOR’ 2.9 carboxylamide: R(CO)NR’R’’ + H2O R(CO)OH + HNR’R’’ 2.10 carboxythioether: R(CO)SR’ + H2O R(CO)OH + HSR’ 2.11 108 Chapter 2 The main reactions of hydrolytic cleavage are summarised in Figure 2.64: R1 CO2 R2 R1 CO2H + R2 OH R ONO2 R OH + HNO3 R1 CONH R2 R1 CO2H + R2 NH2 R1 R1 N CO2R3 N CO2H + R3 OH R2 R2 R1 N H + CO R 2 2 Fig.2.64 Representative types of hydrolytic reactions 2.6.1 Hydrolysis of esters This type of reaction can take place either in the plasma (non-specific acetylcholinesterases, pseudocholinesterases and other esterases) or in the liver (specific esterases for particular groups of compounds). A well-known example is the hydrolysis of procaine, catalysed by a plasma esterase (Figure 2.65): NH H 2 2O NH2 + HO (CH2)2 N(C2H5)2 CO O (CH2)2 N(C2H5)2 COOH Fig.2.65 Hydrolysis of procaine (Reproduced with the permission of Nelson Thornes from ‘Introduction to Drug Metabolism’, 2001, 3rd Ed., isbn 0 7487 6011 3 - Gibson & Skett - first published in 1986) Pathways of biotransformation – phase I reactions 109 Procaine is rapidly hydrolysed, while in the case of its amide, about 60% of the administered dose has been recovered unchanged in human urine, the rest being primarily N-acetylated [158]. Of particular pharmacological interest, we mention here the hydrolysis of several prodrugs. It is emphasised that the rate of hydrolysis of such compounds is structure-dependent, sterically masked esters being more slowly hydrolysed and sometimes occurring totally unchanged in urine. Pivampicillin is a prodrug that is enzymatically cleaved in the organism with subsequent formation of ampicillin (Figure 2.66). It is synthesised by esterification of the carboxyl group of ampicillin with a pivaloyl-oxymethyl function. Upon oral administration, pivampicillin displays a better absorption than ampicillin, ensuring superior plasma concentrations, at equivalent doses [159, 160] (See also Chapter 9). CH C NH CH S 3 NH2 O CH O N 3 H CH3 COO CH2 O C C CH3 O pivampicillin CH3 enzymatic cleavage CH C NH CH S 3 NH2O CH O N 3 H COOH ampicillin Fig.2.66 Enzymatic cleavage of pivampicillin, yielding the active drug ampicillin 110 Chapter 2 Analogously, the ester of piroxicam with pivalic acid is an effective prodrug with activity comparable to that of the parent drug but with fewer of the ulcerogenic effects that are associated with the carboxyl group of the parent compound [161]. Another, but older example of a prodrug in this drug class is ampiroxicam derived by conversion of the parent drug to an ethyl carbonate ester [162]. This compound generally displayed potencies that were similar to or greater than those of the parent drug, but (as with piroxicam pivalate) with reduced tendency to form gastrointestinal lesions. Cefuroxime axetil is a cefalosporine prodrug obtained by esterification of the carboxyl group of the parent compound with a complex group, namely 1-acetoxyethyl (designated as “axetil”); this esterification improves the lipohilicity of the parent molecule with consequent improvement in intestinal absorption [160]. The reaction of enzymatic conversion is presented in Figure 2.67: O H O C C NH S O N O N CH2 CH2 C NH2 CH COO CH O C 2 O CH CH 3 3 CH3 O cefuroxime axetil (axetil = methyl-oxy-carbonyl-oxy-ethyl) enzymatic conversion O H O C C NH S O N O N CH2 CH2 C NH2 H COO CH O C CH3 CH O cefuroxime 3 Fig.2.67 Activation of cefuroxime axetil, one of the most common prodrugs of cefuroxime Pathways of biotransformation – phase I reactions 111 When tested in animals, low toxicity was registered for cefuroxime axetil [163]. Ritipenem acoxyl is a representative prodrug for the class of penems (synthetic ȕ-lactamines) displaying a wide spectrum of activity and, in contrast to the un-esterified drug, can be administered orally [160]. In the organism, it is enzymatically deacetylated (Figure 2.68), yielding the parent, active drug, ritipenem. CH3 CH S CH2 O C NH2 HO O O N COO CH2 O C CH3 O ritipenem acoxyl (acoxyl =acetoxy-methyl) deacylation CH3 CH S CH2 O C NH2 HO O O N COOH ritipenem Fig.2.68 Biotransformation of ritipenem acoxyl, yielding the corresponding active form Quantitation of ritipinem in human plasma and urine can be performed by HPLC analysis [164]. Erythromycin salts, such as the laurylsulphate or the stearate (Figure 2.69) are more lipophilic and consequently more easily absorbable than the parent drug. In these salts the dimethyl amino N atom of the desosamine residue is protonated. When other salts are used (lactobionate or glucoheptonate), water-soluble erythromycin prodrugs are obtained, 112 Chapter 2 allowing parenteral administration. By esterification of the hydroxyl group in position 2- of the desosamine moiety, the propionate and ethyl-succinate esters of erythromycin have been obtained. Through enzymatic cleavage, the active erythromycin is liberated. As well as displaying improved absorption relative to the parent, these prodrugs are more robust in the acidic gastric juice [160]. O desosamine H3C CH 9 3 H3C CH3 HO OH RO CH 2 N H3C OH 3 O 3 4 H 1 3C 5 O H3C H2C O 5 1 2 3 O 6 CH O O CH 3 3 CH CH 3 3 OH O CH3 erythromycin esters (e.g. R = propionate, ethylsuccinate) enzymatic cleavage O desosamine H3C CH3 H3C CH 9 3 HO OH HO CH N H3C 3 2 OH 4 O 3 H3C 5 1 O H3C H2C O 5 1 2 3 O O O CH 6 CH3 3 CH CH 3 3 OH O CH3 erythromycin Fig.2.69 Esters of erythromycin displaying prodrug properties Pathways of biotransformation – phase I reactions 113 Of a series of erythromycin esters assessed for bioavailability, the 3,4,5-trimethoxybenzoate ester was reported to perform similarly to the stearate salt and the estolate of the parent antibiotic [165]. Esterification of chloramphenicol at the primary alcohol group yielded a more lipophilic product, devoid of the bitter taste of the parent compound [160]. These prodrugs, through enzymatic cleavage, are converted in vivo, into the active chloramphenicol, as presented in Figure 2.70. NO2 HO C H CH2 O CO (CH2)14 CH3 chloramphenicol palmitate [ CO (CH2)16 CH3] -stearate [ CO CH2 O CO (CH2)14 CH3] -palmitoyl glycolate enzymatic cleavage NO2 HO C H CH2 OH chloramphenicol Fig.2.70 Enzymatic conversion of some esters of chloramphenicol to the parent, active drug 114 Chapter 2 Moreover, the absorption of these products is slower, consequently ensuring a therapeutic plasma level of the drug for a longer period. In the organism, the esters are cleaved by specific lipases, liberating the active, parent drug. Water-solubility improvement for chloramphenicol can be realized by esterification with dicarboxylic acids and conversion of the acid function to the salt [160]. An example of such a prodrug, that can be administered intravenously, is the sodium salt of chloramphenicol hemisuccinate, hydrolysed in vivo under the action of specific esterases (Figure 2.71): NO2 HO C H H C NHCOCHCl2 CH2 O CO (CH2)2 COONa chloramphenicol-hemisuccinate sodium salt enzymatic cleavage NO2 HO C H H C NHCOCHCl2 CH2 OH chloramphenicol Fig.2.71 Biotransformation of chloramphenicol hemisuccinate sodium salt to the parent, active chloramphenicol Pathways of biotransformation – phase I reactions 115 2.6.2 Hydrolysis of amides Most amides are hydrolysed by the liver amidases. Theoretically, amides may be hydrolysed by plasma esterases too, but such reactions proceed more slowly. The deacylated metabolite of indomethacin (a tertiary amide) has been detected in human urine as one of the major metabolites of this compound [166] (Figure 2.72). Cl C O N CH3 H3CO CH2 COOH Indomethacin primarily inactive metabolites including O-demethylation (about 50%) conjugation with glucuronic acid (10%) N-deacylation Fig.2.72 Biotransformation routes for indomethacin Some of these metabolites are detectable in plasma, and the free and conjugated metabolites are eliminated in the urine, bile and faeces. The occurrence of enterohepatic cycling of the conjugates and probably of indomethacin itself is an important feature of the metabolism of this drug. Between 10 and 20% of the drug is excreted unchanged in the urine (in part by tubular secretion). On the other hand, it is important to emphasise that in certain cases, the reaction of hydrolysis may liberate the active metabolite of a parent drug; a case in point is that of phthalylsulphathiazole, which, under the action of bacterial enzymes in the colon, liberates the antibacterial agent, sulphathiazole. 116 Chapter 2 2.6.3 Hydrolysis of compounds in other classes Less common functional groups in drugs, such as hydrazide and carbamate, can also be hydrolysed. A well-known example is the hydrolysis of the hydrazide group of isoniazid (Figure 2.73): CO NH NH H2O 2 COOH + NH2 NH2 N N Fig.2.73 Hydrolysis of isoniazid (Reproduced with the permission of Nelson Thornes from ‘Introduction to Drug Metabolism’, 2001, 3rd Ed., isbn 0 7487 6011 3 - Gibson & Skett - first published in 1986) In this context, hydrolysis of proteins and peptides by enzymes can also

be mentioned, with the qualification that these enzymes are mainly found in gut secretions and are usually involved only to a small extent in drug metabolism. Exceptions occur in the further metabolism of glutathione conjugates as well as in the metabolism of orally administered peptide/protein drugs. 2.7 MISCELLANOUS PHASE I REACTIONS Regarded as a specialised form of hydrolysis, we can mention here the hydration reaction, where water is added to the compound without causing its dissociation. Particular substrates for this type of reaction are epoxides, yielding the corresponding dihydrodiols. The reaction is catalysed by epoxide hydratases, which are substrate-specific. In particular, this type of biotransformation occurs with the pre- carcinogenic polycyclic hydrocarbon epoxides and forms a trans-diol [167], (Figure 2.74): H2O H O OH H OH Fig.2.74 Hydration of benzo[Į]pyrene-4,5-epoxide (Reproduced with the permission of Nelson Thornes from ‘Introduction to Drug Metabolism’, 2001, 3rd Ed., isbn 0 7487 6011 3 - Gibson & Skett -first published in 1986) Pathways of biotransformation – phase I reactions 117 Many other reactions that do not fall within the above-mentioned groups have indeed been proposed as possible routes of biotransformation for specific drugs. These include e.g. isomerisations, dimerisations, transamidations, N-carboxylations and ring cyclisations. 2.8 THE FATE OF PHASE I REACTION PRODUCTS The main function of Phase I metabolism is to prepare the compound for phase II metabolism and not to prepare the drug for excretion. All the various types of reactions are classified under the three major groups of oxidation, reduction and hydrolysis. Virtually every possible chemical reaction that a compound can undergo is catalysed by the drug- metabolising enzyme systems, yielding final products containing chemically reactive functional groups that will represent targets for the enzymes of phase II metabolism. Phase II generally represents the true “detoxication” of drugs, giving more water-soluble, and thus more easily excreted, metabolites. Another important concluding remark of the present chapter is that many drugs can undergo a number of the reactions listed, being able to pass along several of the routes of biotransformation described above. The following points are also noteworthy in this context: • the significance of a particular pathway varies with many factors (details in Chapters 6 and 7). • the general difficulty of predicting the biotransformation pathways that a given drug will undergo in the human organism (see also Chapter 9). • Finally, we have to stress that during the Phase I metabolism, potential pharmacologically toxic intermediates may occur (e.g. free radicals, superoxides, epoxides). Taking this into account, a major concern in current drug design and the development of new therapeutic agents is the metabolism-mediated toxicity of xenobiotics. The importance of gaining more knowledge and understanding of biotransformation pathways and the factors that influence them is obvious. The increasing understanding of the metabolic fates of biologically active compounds will continue to aid identification of latent functionalities that may mediate toxic effects following bioactivation; at the same time, anticipation of the enzyme systems involved in the metabolic reactions leading to structural modifications (resulting either in bioactivation or in detoxication), as well as the factors that might influence these processes, represent other important challenges whose solution could be highly beneficial. 118 Chapter 2 The culmination of this ever-expanding knowledge base should be the improvement of strategies for designing needed drugs with appropriate therapeutic effects and devoid of toxicities mediated by reactive metabolites, so that the ratio of therapeutic effect to toxic risk is maximised in the interest of providing real benefit to the patient. References 1. Taylor JB, Kennewell PD. 1993. Biotransformation. Metabolic pathways. 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Pivampicillin, a new orally active ampicillin ester. Antimicrob Agents Ch Vol 1971:431-437. 160. Ovidiu O, Tiperciuc B. 2003. Antibiotice antibacteriene, In: “I. HaĠieganu” Universitary Medical Printing House, Cluj-Napoca, Romania, pp 58, 83-84, 97, 121-125, 208-212. 128 Chapter 2 161. Caira MR, Zanol M, Peveri T, Gazzaniga A, Giordano F. 1998. Structural Characterization of Two Polymorphic Forms of Piroxicam Pivalate. J Pharm Sci 87:1608-1614. 162. Yamanaka K, Munehasu S, Suzuki M, Ishiko J. 1991. Pharmacological actions of ampiroxicam, a new prodrug of nonsteroidal anti-inflammatory agent. Oyo Yakuri 41:597-612. 163. Spurling NW, Harcourt RA, Hyde JJ. 1986. An evaluation of the safety of cefuroxime axetil during six months oral administration to beagle dogs. J Toxicol Sci 11:237-77. 164. Matsuoka M, Hosomi R, Maki T, Banno K, Sato T. 1995. Determination of ritipenem in human plasma and urine by high performance liquid chromatography. Nippon Kagaku Ryoho Gakkai 43:91-96. 165. Dall’Asta L, Comini A, Garegnani E, Alberti D, Coppi G, Quadro G. 1988. Studies on the bioavailability of some new erythromycin esters. J Antibiot 41:139-141. 166. 2000. In: Gennaro AR editor. Remington: The Science and Practice of Pharmacy, 20th ed. Philadelphia: Lippincott Williams & Wilkins, p 1457. 167. Gibson GG, Skett P. 1994. Pathways of drug metabolism. In: Introduction to Drug Metabolism. London: Blackie Academic & Professional, An Imprint of Chapman & Hall, pp 9-10. Chapter 3 PATHWAYS OF BIOTRANSFORMATION – PHASE II REACTIONS 3.1 INTRODUCTION This chapter addresses the Phase II biotransformation reactions that a drug or its metabolite typically undergo. In these so-called ‘conjugation reactions’, mediated by the appropriate enzymes, the drug becomes linked to an endogenous moiety through one or more functional groups, that may either be present on the parent drug, or which may have resulted from a phase I reaction of oxidation, reduction or hydrolysis. A characteristic of most conjugation reactions is the replacement of a hydrogen atom present in a hydroxyl, amino or carboxyl group, by the conjugating agent. In general, the resulting conjugated metabolites have no pharmacological activity, are highly water-soluble and therefore subsequently readily excreted in the urine. These reactions are usually considered as detoxication reactions, but in certain cases, toxication has been recorded, and examples of both are treated below. Major phase II reactions include glucuronidation, sulphation, acetylation, and conjugation with glutathione or amino acids. Detailed examples of all of these are provided below, with an account of the relevant enzymes involved. 3.2 GLUCURONIDATION Glucuronidation represents the major route of sugar conjugation, although conjugation with xylulose and ribose are also possible [1-12]. Quantitatively, glucuronide formation is the most important form of conjugation both for drugs and endogenous compounds and can occur with 129 130 Chapter 3 very different substrates. The synthesis of ether, ester, carboxyl, carbamoyl, carbonyl, sulphuryl and nitrogenyl glucuronides generally leads to an increase in their polarity, and consequently their aqueous solubility and thus suitability for excretion. Mechanistically, glucuronidation is an SN2 reaction in which an acceptor nucleophilic group on the substrate attacks an electrophilic C-1 atom of the pyranose acid ring of UDPGA (uridine 5 ' -diphosphate- glucuronic acid) which results in the formation of a glucuronide, a ȕ-D- glucopyranosiduronic acid conjugate [5]. Thus, many electrophilic groups such as hydroxyl, carboxyl, sulphhydryl (thiol), or phenol can serve as acceptors. N-glucuronides may be formed by certain nitrogen containing groups such those in tertiary or aromatic amines. Esterification of the hemiacetyl hydroxyl group of glucuronic acid to organic acids forms acyl or ester glucuronides. The acyl glucuronides, unlike glucuronides formed with alcohols and phenols, have a great susceptibility to nucleophilic substitution and intramolecular rearrangement. It has even been proposed that the formed acyl glucuronides, acting as electrophiles and reacting with thiol and hydroxyl groups of cell macromolecules, might be responsible for toxicity of some compounds [5]. Renewed interest in this process from pharmaceutical companies has focused on development of drugs that avoid glucuronidation as a biotransformation pathway, thereby improving bioavailability. Glucuronidation is conjugation with Į-D-glucuronic acid and is indeed the most widespread of the conjugation reactions, probably due to the relative abundance of the cofactor for the reaction, UDP-glucuronic acid. 3.2.1 Enzymes involved and general mechanism The transfer of glucuronic acid from UDP- glucuronic acid (UDPGA) to an aglycone is catalysed by a family of enzymes generally designated as UDP- glucuronosyltransferases (UGTs) [5,7,9]. These ubiquitous microsomal enzymes are present principally in the liver, but also occur in a variety of extrahepatic tissues. Their location in the endoplasmic reticulum has important physiological effects in the neutralisation of reactive intermediates generated by the CYTP450 enzyme system and in controlling the levels of reactive metabolites present in these tissues. There are more then 50 known microsomal membrane-bound isoenzymes in humans, found in liver, lung, skin, intestine, brain and olfactory epithelium; however, the major site of glucuronidation is the liver. Thus the liver, being the central organ for a variety of anabolic and catabolic Pathways of biotransformation – phase II reactions 131 functions, plays a significant role in drug metabolism, toxicity and especially in detoxication processes [12]. Structural and functional aspects of human UDP- glucuronosyltransferases (UGTs) have been reviewed with details of the mechanisms of glucuronidation of both drugs and endogenous compounds [13]. Characterization of the active site in terms of amino acids and peptide domains that bind substrates and effectors in such reactions is also discussed. Genetic differences in the expression of UDP- glucuronosyltransferases in humans result in interindividual variations. This topic has also been reviewed recently [14]. Characterization of genetic multiplicity and regulatory patterns of UGTs is being aided by new developments in the field of genetics. An account of recent findings relating to this topic has appeared [15]. The different isoenzymes of the UGT family have high organ specificity locations: for example, bilirubin UGT is highly expressed in human liver, but is absent in human kidney, whereas phenol UGT is highly expressed in both organs. Individual UGTs are subject to differential induction by hormones, leading to tissue-specific regulated expression. In addition, the spectrum of UGTs in different tissues can be differentially altered by exposure to drugs and other xenobiotics. Glucuronidation requires an adequate supply of UDPGA and its concentration in cytosol may determine the transferase activity. This may be more critical in extrahepatic tissues than in the liver. The concentration of UDPGA in the kidney has been estimated to be one-fifteenth that in the liver in humans [8]. As mentioned above, the glucuronidation mechanism involves a nucleophilic substitution [5], illustrated in Figure 3.1 for a phenol as substrate. The resultant glucuronide has the ȕ-configuration at the C-1 atom of the glucuronic acid. With the attachment of the hydrophilic carbohydrate moiety, containing an easily ionisable carboxyl group, a lipid-soluble compound is thus converted into a conjugate that is poorly reabsorbed by the renal tubules from the urine, and therefore more rapidly excreted, predominantly via the kidneys. Nonetheless, it should be noted that certain high molecular weight glucuronides are excreted via the bile into the gastrointestinal tract where subsequent hydrolysis may result in reabsorption of drug or metabolites (biliary recirculation) or excretion in the faeces. 132 Chapter 3 α O OH O C O O O OH HN OH OH O N O P O P O 2NADH O O- O- OH HO OH R 2NAD+ UDPG- dehydrogenase UDP-glucuronosyl O OH transferase O HN O O OH OH OH O N O P O P O UDP O O- O- + PO - 4H β O OH C HO OH O O OH UDPG R OH OH phosphorylase OH O OH + UTP OH OH PO3H Fig.3.1 The general mechanism of glucuronidation Functional groups susceptible to glucuronidation are presented in Figure 3.2 with GLU representing glucuronic acid. As seen from the latter figure, alcohols and phenols form ether glucuronides; aromatic and some aliphatic carboxylic acids form ester (acyl) glucuronides; aromatic amines form N-glucuronides, and thiol compounds form S-glucuronides, both of these being more labile to acid than are the O-glucuronides. Some tertiary amines have been found to form quaternary ammonium N-glucuronides. Pathways of biotransformation – phase II reactions 133 OH O GLU R R GLU = glucuronic acid R1 R1 R1 R1 R2 C OH R2 C O GLU N CH3 N O GLU R3 R3 R2 R2 O O R2 C R2 C OH R O GLU 1 O R1 O N C N C O O R2 OH R2 O GLU R1 C R1 C N H N GLU R2 R2 R1 R1 N N GLU N H N GLU R R R2 R2 R1 R1 CH + 3 N CH3 N R SH R S GLU R2 R2 GLU O O R1 C H R1 C H C C R2 C H R GLU 2 C O O Fig.3.2 The most common functional groups undergoing glucuronidation Compounds containing a 1,3-dicarbonyl system (e.g. phenylbutazone) can form C-glucuronides by direct conjugation, bypassing

prior metabolism. The degree of C-glucuronide formation is determined by the acidity of the functional group separating the carbonyl groups. Drug-acyl glucuronides are reactive conjugates at physiological pH. The acyl group of the C1-acyl glucuronide can migrate via transesterification from the original C-1 position of the glucuronic acid to the C-2, C-3, or C-4 positions. The resulting positional isomers are not 134 Chapter 3 hydrolysable by ȕ-glucuronidase. Under physiological or weakly alkaline conditions, however, the C1-acyl glucuronide can hydrolyse in the urine to the parent compound (aglycone) or effect acyl migration to an acceptor macromolecule. The pH-catalysed migration of the acyl group from the drug C1-O- acyl glucuronide to a protein or other cellular constituent occurs with the formation of a covalent bond to the protein [5]. Further details of this process are given below. Endogenous compounds undergoing glucuronoconjugation include steroids, bilirubin and thyroxine. In the case of bilirubin, this pathway of detoxification is a major one, mediated by UGTs located in numerous tissues [16]. It should be noted that not all glucuronide conjugates are excreted by the kidneys; some may be excreted in the intestinal tract together with bile (they undergo enterohepatic cycling). Under the action of ȕ-glucuronidase present in the intestinal flora, the C1-O-acyl glucuronide will be hydrolysed back to the aglycone (drug or its metabolite) for re-absorption into the portal circulation. A very important aspect that merits emphasis is that, besides leading to “detoxication” for many drugs, glucuronidation is also capable of promoting cellular injury (hepatotoxicity, carcinogenesis) by facilitating the formation of reactive electrophilic intermediates and their transport into target tissues [17-20] (details in Chapter 8). 3.2.2 Glucuronidation at various atomic centres (O, S, N) Drugs from almost all therapeutic classes are glucuronidated. For those having narrow therapeutic indices (e.g. morphine, chloramphenicol), glucuronidation is therefore likely to have important consequences in their clinical use. O-glucuronidation of phenolic drugs (or other xenobiotics) is often in competition with O-sulphation, which has been demonstrated to be predominant at low doses of the administered drug, while glucuronidation prevails only with high doses. It is well established that sulphation and glucuronidation occur in parallel, often competing for the same substrate (most commonly phenols) the balance between sulphation and glucuronidation being influenced by different factors such as species, doses, availability of co-substrates, and inhibition or induction of the respective transferases. Pathways of biotransformation – phase II reactions 135 Another major group of substrates for glucuronidation is represented by alcohols (primary, secondary and tertiary). An interesting example is given by codeine (Figure 3.3) which, following demethylation to morphine, can undergo glucuronidation either at the phenolic, or at the secondary alcohol group, with concomitant formation of two distinct metabolites with different pharmacological activities. The pharmacokinetics of morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G) in newborn infants receiving diamorphine infusions was reported earlier [21]. A very recent study concludes that both compounds display opiate agonistic behaviour [22]. These metabolites and further references to them were introduced in Chapter 2. H3C O N CH3 HO GLU O HO O O N CH3 N CH3 HO GLU O Fig.3.3 Specific positions in glucuronidation of codeine: the phenolic hydroxyl (after demethylation to yield morphine) and the secondary alcohol group Another major pathway of O-glucuronidation is represented by the formation of acylglucuronides [23], the ideal substrates for this alternative pathway being aliphatic and aromatic acids (acidic drugs, such as NSAIDs). However, as already stressed, drug-acyl glucuronides are reactive conjugates at physiological pH, able to undergo different intramolecular rearrangements. This rearrangement of the glucuronide is actually an acyl 136 Chapter 3 migration, a process whereby the aglycone moves from the 1-hydroxyl group of the glucuronic acid sugar to the 2, 3-, or 4-hydroxyl groups. The rate of acyl migration differs from one compound to the next, and their stabilities are also highly variable [23]. Since the resulting positional isomers are not hydrolysable by ȕ-glucuronidase, acyl migration to an acceptor macromolecule (e.g. protein in plasma or in tissue) may occur, resulting in covalent bond formation. Acylated proteins (usually designated ‘haptens’) thus formed, can stimulate an immune response against the drug, resulting in hypersensitivity reaction or other forms of immunotoxicity. For this reason, conjugation of this type is not, in the strict sense, a process of inactivation and so cannot necessarily be considered a safe detoxification pathway. In recent years, the potential toxicity of certain glucuronides, such as the morphine metabolite M6G mentioned above, has been well recognized [24]. Interestingly, although several drug glucuronides bind irreversibly to proteins both in vitro and in vivo (Figure 3.4 [5]), the parent drug alone has been ineffective. Other relatively common substrates undergoing glucuronoconjugation are hydroxylamines and hydroxylamides. A recent example in the former category refers to the identification of an O-glucuronide metabolite of an aryl piperazine oral hypoglycaemic agent [25]. A relatively small number of aromatic amines are first N-hydroxylated, and then undergo O-glucuronidation. The reactivity of the resulting N-O-glucuronides and their potential for hydrolytic cleavage with subsequent formation of nitrenium ions are, however, still subjects of on-going investigation. N-glucuronidations are considered to be of secondary importance; substrates undergoing this type of reaction are carboxyamides, sulphonamides, as well as different types of amines. The special relevance of this reaction in the case of antibacterial sulphonamides (particularly the older ones) is that because of the consequent production of highly water-soluble metabolites, crystallization of the parent compound at renal level (crystalluria) is avoided. N-glucuronidation of aliphatic and aromatic amines as well as of some compounds with pyrimidynic structure has also been mentioned. Special significance was attributed to N-glucuronidation of lipophilic, basic tertiary amines, containing one or two methyl groups in their structure. Aliphatic and aromatic thiols, as well as dithiocarboxylic acids undergo S-glucuronidation. In the case of some 1,3-dicarbonyl compounds, such as sulphinpyrazone, C-glucuronidation has been reported [26]. Pathways of biotransformation – phase II reactions 137 imine formation COOH O HO O HO OH C O R COOH OH HO HO C O O R C O COOH OH HO HO C N Protein O R C O nucleophilic displacement COOH O HO O HO OH C O R COOH O HO OH HO OH + O Protein NH C R Fig.3.4 Irreversible binding of glucuronides to proteins by two main mechanisms: imine formation and nucleophilic displacement 138 Chapter 3 Polymorphism of drug glucuronidation in humans Various mutations within the UGT-1 gene and consequently, within the corresponding encoded isoforms, give rise to the hereditary hyperbilirubinemias. The in vitro analyses of hepatic samples from patients with severe hyperbilirubinemia revealed that UGT activities toward certain drugs (e.g. propofol, ethinylestradiol, phenols) are severely reduced. Gilbert’s disease, a mild familial hyperbilirubinemia, is a well-known syndrome associated with decreased clearance of several drugs such as rifamycin, acetaminophen and tolbutamide; it is assumed that a decreased rate of glucuronidation for this condition occurs as well [27, 28]. 3.3 ACETYLATION Acetylation is a Phase II reaction of amino groups and it involves the transfer of acetyl-coenzyme A (acetyl CoA) to an aromatic primary or aliphatic amine, amino acid, hydrazine, or sulphonamide group. The primary site of acetylation is the liver, although extrahepatic sites have been identified as well (e.g. spleen, lung and gut). Acetylation reactions require a specific co-factor, acetyl-CoA, which is obtained mainly from the glycolysis pathway (breakdown of glucose yielding pyruvate and its subsequent oxidative decarboxylation), or from catabolism of fatty acids or amino acids, or via direct interaction of acetate and coenzyme A [29] (Eq.3.1): CoA-S-acetyltransferase CH3-COO- + CoASH CH3-CO-S-CoA 3.1 Genetic polymorphism affecting the rate of acetylation has important consequences in drug therapy and tumorigenicity of certain xenobiotics (details in Chapter 7, subchapter 7.1.1). 3.3.1 Role of acetyl-coenzyme A Coenzyme A (A standing for ‘acyl’) participates in activation of acyl groups in general, including the acetyl group derived from pyruvate (by oxidative decarboxylation)[29,30]. The coenzyme is derived metabolically from the vitamin pantothenic acid, ȕ-mercaptoethylamine and ATP (Figure 3.5). Pathways of biotransformation – phase II reactions 139 O O H CH3 O O HS CH2 CH2 NH C CH2 CH2 NH C C C CH2 O P O P O CH2 HO CH O- O- 3 Adenine O OH O P β-mercaptoethylamine pantothenic acid adenosine 3'-phosphate 5'-diphosphate Fig.3.5 Structure of CoA Initially, the 4-phosphopantethine is formed under the catalytic action of a specific kinase and consumption of an ATP molecule. Then follows a sequence of reactions, with the consumption of two more ATP molecules, yielding finally CoA. This molecule is an important coenzymatic factor, participating in both biosynthetic and biodegradative reactions. The functionally significant part of the coenzyme molecule is the free thiol on the ȕ-mercaptoethylamine moiety, the rest of the molecule providing enzyme binding sites. In acylated derivatives, such as acetyl-coenzyme A, the acyl group is linked to the thiol group, with consequent formation of an ‘energy-rich’ thioester (Figure 3.6): O O CoA SH + C CH3 CoA S C CH3 coenzyme A acetyl group acetyl-CoA Fig.3.6 Formation of the energy-rich thioester Usually, the unbranched form is designated as CoA-SH, and the acylated forms as acyl-CoA or, 140 Chapter 3 O R C S CoA The energy-rich nature of thioesters, as compared with ordinary esters, is related primarily to resonance stabilisation [30], shown in Figure 3.7: thioesters O δO X δ+ R C SR' R C SR' esters O δO δ+ ∆Gresonance R C OR' R C OR' destabilisation ∆Ghydrolysis ∆Ghydrolysis O O R C + R' OH R C + R' SH O O Fig.3.7 Resonance stabilisation explaining the energy-rich nature of thioesters (Fig.14.9, p.494 from BIOCHEMISTRY, 3rd ed. by Christopher K. Mathews, K.E. van Holde and Kevin G. Ahern. Copyright © 2000 by Addison Wesley Longman, Inc. Reprinted by permission of Pearson Education, Inc.) Ordinary esters have two resonance forms, their stabilisation involving ʌ-electron overlap, giving partial double-bond character to the C-O link. However, in thioesters, because of the larger atomic size of S vs O, there is reduced ʌ-electron overlap and the C-S structure does not significantly contribute to resonance stabilisation. The thioester is thus destabilised relative to an ester and consequently the free energy change for its hydrolysis is enhanced. The chemical consequences are important: the lack of double-bond character in the C-S bond of acyl-CoAs makes this bond weaker than the corresponding C-O bond in ordinary esters. This renders the thioalkoxide ion (R-S-) a good leaving group in nucleophilic displacement reactions, allowing the acyl group to be consequently readily transferred to other metabolites in so-called ‘transacylation reactions’. Pathways of biotransformation – phase II reactions 141 Because of the important biological roles played by acetyl-CoA and related species, studies probing their structure and function are ongoing. Mechanistic aspects of the action of acetyl-CoA in modulating protein structure have been discussed in a recent paper [31]. The crystal structure of the ȕ-subunit of the enzyme acyl-CoA carboxylase has been reported [32] with the aim of understanding its substrate specificity; this would assist in the development of therapeutics against diseases such as obesity and diabetes. Another recent crystallographic study investigated the carboxyltransferase domain of acetyl-coenzyme A carboxylase in complexed form with an inhibitor [33]. Regions for drug binding in the active site were established in this way. The catalytic action of acetyl-CoA synthase, a bifunctional Ni-Fe-S containing enzyme that catalyses the synthesis of acetyl-CoA, has been reviewed [34]. The possibility of involvement of zero- valent Ni (unusual in biology) in the catalytic action of this enzyme was raised. 3.3.2 Acetylation of amines, sulphonamides, carboxylic acids, alcohols and thiols The general mechanism of acetyl transfer catalysed by N-acetyltransferases involves a double displacement – a so-called ‘ping-pong’ mechanism: Ac-CoA + isoniazid Ac-isoniazid + CoA 3.2 The reaction actually proceeds in two steps, namely transfer of the acetyl group from Ac-CoA with formation of an acetyl-enzyme intermediate and the subsequent acetylation of the arylamine with regeneration of the enzyme [6]. Because of their structural similarities to the substrates, some compounds act as reversible inhibitors towards N-acetyltransferases whereas others, such as iodoacetate and p-chloromercurybenzoate, are irreversible inhibitors. 142 Chapter 3 The principal types of acetylation are summarised in Figure 3.8: R1 R1 N H N CO CH3 R2 R2 NH2 NH CO CH3 R R R NH NH2 R NH NH CO CH3 NHOH R NH O CO CH3 OH R N R COCH3 Fig.3.8 Major types of acetylations As representative examples we illustrate the N-acetylation of sulphanilamide and isoniazid (Figure 3.9):

NH2 Acetyl-CoA NH2 (a) SO2NH2 CoA-SH SO2 NH CO CH3 CO NH NH2 Acetyl-CoA CO NH NH CO CH3 (b) N N CoA-SH Fig.3.9 N-acetylation of (a) sulphanilamide and (b) isoniazid (Reproduced with the permission of Nelson Thornes from ‘Introduction to Drug Metabolism’, 2001, 3rd Ed., isbn 0 7487 6011 3 - Gibson & Skett - first published in 1986) Pathways of biotransformation – phase II reactions 143 Sulphanilamide may also undergo acetylation on the amine nitrogen atom, with consequent formation of a diacetylated metabolite. The formation of acetyl-sulphonamides is of particular toxicological interest as these metabolites are less soluble in water than the parent drug and the renal toxicity of sulphonamides has been directly attributed to precipitation of these conjugates in the kidney. Secondary amines are not acetylated. Acetylation may produce conjugates that retain the pharmacological activity of the parent drug (e.g. N-acetylprocainamide). Variability in human drug acetylation was noted many years ago [14] with individuals designated as ‘rapid’ or ‘slow’ acetylators, based on their blood levels after administration of isoniazid. Only recently, however, has it been demonstrated that such differences are caused by genetic variability. The relevant human arylamine acetyltransferases are termed NAT1 and NAT2. Details concerning isoforms appear in Chapters 4 and 7. The role of genetic polymorphism in the rate of acetylation has important consequences in drug therapy and tumorigenity of certain xenobiotics, including drugs. The two acetylator phenotypes may determine significant differences in human drug toxicity, as follows: • Slow acetylators accumulate higher blood concentrations of the unacetylated drug than rapid acetylators. Such individuals are thus more prone to drug-induced toxicities such as sulphasalazine-induced hematologic disorders, procainamide-induced lupus erythematosus and isoniazid-induced peripheral nerve damage. • Fast acetylators eliminate certain drugs more rapidly, which presents a greater risk of liver toxicity. As a current example we mention the hepatotoxic monoacetylhydrazine metabolite formed by acetylation of isoniazid (Figure 3.9 above). Another noteworthy aspect is the difference in susceptibility to chemical carcinogenicity from arylamines directly related to differences in acetylating capacity resulting from genetic polymorphism. Apparently, the tumorigenity of arylamines may be the result of a complex series of sequential metabolic reactions beginning with N-acetylation. By the end of the sequence, an arylnitrenium ion is formed; this is a reactive species capable of covalent binding to proteins and even nucleic acids [5]. For the rapid acetylator phenotype, the rate of forming the acetoxyarylamine metabolite and consequent loss of the acetoxy group to form the reactive species, is greater than for slow acetylators, thereby presenting a greater risk for the development of bladder and liver tumors [5,10,14]. 144 Chapter 3 3.4 GLUTATHIONE CONJUGATION Glutathione [N-(N-L-γ-glutamyl-L-cysteinyl)glycine], an atypical tripeptide (Figure 3.10), is an endogenous compound, recognized as playing a protective role within the body in removal of potentially toxic electrophilic compounds. O O + H3N CH CH2 CH2 C NH CH C NH CH2 COO COO CH2 SH γ-Glu Cys Gly Fig.3.10 Structure of glutathione Glutathione (GSH) is present at highest concentration in the liver, with higher values in the cortex than in the medulla, but is also present in cytosol, mitochondria and nucleus [29,30]. In the blood, it is present at a relative concentration of about 20 µM. GSH conjugation involves the formation of a thioether link between the GSH and electrophilic compounds. The reaction can be considered as the result of nucleophilic attack by GSH on electrophilic carbon atoms, with leaving functional groups such as halogen, sulphate and nitro, ring opening (in the case of small ring ethers – epoxides, ȕ-lactones), and the addition to the activated ȕ-carbon of an Į,ȕ-unsaturated carbonyl compound. Thus, conjugation with glutathione usually results in detoxication of the electrophilic compounds by preventing their reaction with nucleophilic centres in macromolecules such as proteins and nucleic acids. The electrophilic substrates for glutathione are commonly generated by prior metabolism of the xenobiotics, or by displacement of suitable electron withdrawing groups in nitro or halo-alkanes, benzenes and sulphonic acid esters by the sulphur atoms of glutathione, and it is usually eliminated as mercapturic acid after further metabolism of the S-substituted glutathione. Pathways of biotransformation – phase II reactions 145 Major types of reaction are summarised in Figure 3.11: H R R SG O H O OH OH OH SG O OH OH R1 H SG R CH2 X R CH2 SG , C C R1 C CH2 X R2 X R2 (X=Cl, Br .) X X C C R X X X X X R C C SG C C H X R SG (X = halogen) X SG R R (X = halogen) O O R X R C R C , R N C X N C Cl SG H SG (X = O, S) R ONO2 GS NO2 + R OH Fig.3.11 Representative types of glutathione conjugation 146 Chapter 3 Two specific examples [6] are shown in Figure 3.12: Cl S Glutathione NO2 NO2 + H+ + Cl- (a) NO2 NO2 H COOR C CH2 COOR C Glutathione S CH COOR (b) H COOR Fig.3.12 Glutathione conjugation of (a) 2,4-dinitro-1-chlorobenzene and (b) maleic acid esters (Reproduced with the permission of Nelson Thornes from ‘Introduction to Drug Metabolism’, 2001, 3rd Ed., isbn 0 7487 6011 3 - Gibson & Skett - first published in 1986) The glutathione conjugates may be excreted directly in urine (or more usually in bile) but more commonly undergo further metabolism (Figure 3.13): Gly R S Cys transpeptidase Glu Glu Gly R S Cys NH2 R S Cys NH CO CH3 Gly N-acetylase peptidase R S Cys NH2 Fig.3.13 Further possible biotransformation pathways of glutathione conjugates (Reproduced with the permission of Nelson Thornes from ‘Introduction to Drug Metabolism’, 2001, 3rd Ed., isbn 0 7487 6011 3 - Gibson & Skett - first published in 1986) Pathways of biotransformation – phase II reactions 147 Many GSH conjugates undergo further enzymatic modification by hydrolysis of the glutathione-S-conjugate at the Ȗ-glutamyl bond. This specific reaction is catalysed by the enzyme Ȗ-glutamyl transferase, well known in the clinical laboratory as Ȗ-GT. As can be seen from the above figure, the tripeptide glutathione (Gly-Cys-Glu), once attached to the acceptor molecule, can be attacked by this specific enzyme, which removes the glutamate yielding a dipeptide; the latter may be further attacked by a peptidase which removes the glycine, thus forming the cysteine conjugate of the xenobiotic. In the final step, mediated by specific N-acetylases, the cysteine conjugate previously formed may undergo N-acetylation (via the normal acetylation pathway already described), yielding the N-acetylcysteine conjugate of mercapturic acid. The first two enzymes involved are most commonly found in the liver and kidney cytosol, while the highest N-acetyltransferase (NAT) activity is found in the proximal tubules. Depending on the nature of the substrate and the species investigated, each of the three conjugated metabolites (glycylcysteine, cysteine and mercapturic acid conjugates) may appear as excretion products. Conjugation reactions of GSH were reviewed earlier [35] as was the role of GSH S-transferases in the detoxification of reactive metabolites of benzo[a]pyrene-7,8-dihydrodiol [36]. 3.5 OTHER CONJUGATIVE REACTIONS Methylation O-and N-methylation are common biochemical reactions but appear to be of greater significance in the metabolism of endogenous compounds than for drugs or other xenobiotics. However, some drugs may also undergo methylation by non-specific methyltransferases found in the lung, or by the physiological methyltransferases. For example, histamine N-methyltransferase, (HMT), is a primary enzyme effecting degradation of histamine in the body. Its role in the regulation of airway functions has been discussed [37]. Another example is phenylethanolamine N-methyltransferase (PNMT), found in the adrenal medulla and many other tissues. This enzyme methylates noradrenaline yielding the product adrenaline. An account of the location and activity of extra-adrenal PNMT has appeared recently [38]. High levels of PNMT in the adrenal depend critically on glucocorticoids [39]. The three-dimensional structures of rabbit and human indolethylamine N-methyltransferases (INMTs) have been predicted from their amino acid sequences to bridge the gap between structure and pharmacogenetic aspects of their function [40]. 148 Chapter 3 The co-factor required to form methyl conjugates is S- adenosylmethionine (SAM), produced from L-methionine and ATP under the influence of the enzyme L-methionine adenosyltransferase, as presented in Figure 3.14: NH2 ATP N N + PPi + N N + S CH CH2 S CH2 CH2 CH COOH 3 OH HO CH2 O CH3 NH2 CH2 SAM + H C NH3 COO methionine Fig.3.14 The formation of S-adenosylmethionine (SAM) As can be seen from the above figure, methionine is involved in the methylation of endogenous and exogenous substrates, by transferral of its methyl group via the activated, high-energy intermediate SAM, to different substrates under the influence of specific methyl transferases. The general mechanism can be presented as follows (Figure 3.15): H2N CO2H H2N CO2H H N H N N NH H3C 2 N NH2 S+ S O N N O N N . R X H methyl transferase HO OH HO OH + R X CH3 Fig.3.15 The general mechanism of methylation involving participation of SAM and specific methyl transferases Pathways of biotransformation – phase II reactions 149 Reaction results mainly in the formation of O-methylated, N- methylated, and S-methylated products. This differs from other conjugation processes in that the O-methyl metabolites that form may, in certain instances, possess equal, or even enhanced pharmacological activity and lipophilicity, than the parent molecule. The process of O-methylation is catalysed by a magnesium-dependent enzyme, generically designated as catechol-O-methyltransferase (COMT). The reaction involves the transfer of a methyl group to either the meta- or less frequently, to the para-phenolic hydroxyl group of catecholamines, and their deaminated metabolites. O-methylation of phenolic groups is important in the metabolism of neurotransmitters such as the catecholamines and structurally related drugs. The most representative example is afforded by norepinephrine (Figure 3.16). It must be stressed that the meta/para product ratio is greatly dependent on the type of substituent attached to the catechol ring. Specific substrates for COMT include: • the catecholamines: norepinephrine, epinephrine and dopamine; • some specific aminoacids: L-DOPA, and Į-methyl-DOPA, as well as, • the 2- and 4-hydroxy- metabolites of estradiol. Monohydric or other dihydric phenols are not methylated. COMT is present both in kidney and liver, with the kidney activity present at about a quarter of the level found in the liver. Pharmacogenetic studies have revealed differences in inherited phenotype activities (details in Chapter 7, subchapter 7.1); at the same time, ageing has been associated with a decrease in COMT affinity for a particular substrate (details in Chapter 6). The N-methylation of various amines is among several conjugate pathways for metabolising amines. The transfer of active methyl groups from SAM to the acceptor substrate is catalysed by specific N-methyl- transferases. There are three important N-methyltransferases, namely: • histamine N-methyltransferase (HMT), a cytoplasmic enzyme that methylates histamine and similar amine compounds in which positions 3- and 12- are unsubstituted and there is a positive charge on the side chain. Methylation of histamine leads to the inactive metabolite N1-methyl- histamine. In this context, it is important to mention the existence of a great number of HMT inhibitors, including H1 and H2 receptor antagonists, diuretics and some local anaesthetics. Details regarding this enzyme appear in Chapter 4. • phenylethanolamine N-methyltransferase (PNMT), requiring the presence of phenylethanolamine compounds as substrate acceptors for the methyl group; endogenous substrates include norepinephrine and epinephrine (see again Figure 3.16); further details regarding the enzyme are given in Chapter 4; 150 Chapter 3 NH2 CH3 N N OOC S+ N N O H2N OH OH S-adenosylmethionine + HO NH2 HO OH norepinephrine COMT PNMT HO HO NH2 NH CH3 HO HO O CH3 OH 3-methoxynorepinephrine epinephrine Fig.3.16 Methylation pathways for norepinephrine (PNMT = phenylethanolamine N-methyltransferase) • amine-N-methyltransferases (also known as indolethylamine N-methyltransferases), which catalyse the transfer of a methyl group from SAM to the amino group of indoleamines; these enzymes will N-methylate a variety of primary and secondary amines, including endogenous biogenic Pathways of biotransformation – phase II reactions 151 amines (e.g. serotonin, tyramine, dopamine) and drugs such as amphetamine, normorphine and desmethylimipramine. Amine-N-methyltransferases evidently have a role in recycling N-demethylated drugs (Figure 3.17): S-adenosyl- SAM N homocysteine N H CH (CH2)3 N (CH2)3 N 3 CH CH 3 imipramine 3 Fig.3.17 The recycling of demethylated imipramine Other substrates for methylation reactions include thiols, which are generally considered as toxic. Thiol S-methyl transferases thus play a role among other detoxication pathways for these compounds. In this