an immature immune system contributes to an increased risk of respiratory
infection, collapse, and failure
why are Premature babies, infants, and toddlers until the age of 2 years more vulnerable to infection and airway collapse
fragility of pulmonary structures and ease of occlusion from secretions
what can acute respiratory failure lead to?
before calcification what airway structures are vulnerable to collapse and occlusion with an acute respiratory infection
soft cartilaginous larynx and trachea
what type of breathers are infants
obligate nose breathers
how long are infants obligate breathers
first five months of life
how long are infant apnea episodes (ones that are considered non life threatening)
what do younger children use for respiration until the age of 5-6 years
diaphragm and abdominal muscles
what is an early indication of increased work of breathing
Nasal flaring and accessory muscle movement during an acute illness
lung alveoli are immature in number exponentially increasing from
birth to 3 years
Metabolic processes create a higher demand for
oxygen consumption during infancy
what age do the lungs start to normalize to more adult levels
7-8 years old
the Eustachian tubes of children are smaller and more horizontal until the age of
Arterial Blood Gas (ABG)
ABG's assist the evaluation of acid-base balance measuring the PH, PaO2, PaCO2, HCO3- during symptoms of respiratory distress
Chest (anterior and posterior) Lung Fields Radiography
Views of the airways, lungs provide structural views of the lung fields in order to determine the presence of disease.
Computed Tomography (CT)
Shows a cross section of the lung tissue identifying questionable lesions or alterations, a tumor or mass, also shows specific tissue response to therapies.
Scope procedure to assess lesions and foreign body presence in the tracheobronchial tree. Can be curative in the removal of mucoid obstructions as needed.
rast for IgE
Radioimmunoassay test to measure specific IgE antibodies, and systemic response during exposure to a particular trigger allergen.
Pilocarpine Iontophoresis (Sweat Chloride)
Golden standard diagnostic exam to determine the diagnosis of Cystic Fibrosis. Normal findings are <40mEq/L, Suggestive findings: 40 - 60mEq/L, Postive findings: >60mEq/L.
test is not reliable in children younger than 2 weeks related to immaturity of the
A standard skin test to evaluate for tuberculosis. Testing the cutaneous surface consists of injecting a wheal of recominant purified protein derivative (PPD) medium intradermally and monitoring for a reaction over 48 - 72 hours. Negative results are: <15
End-Tidal CO2 Monitoring
A non-invasive monitor of exhaled breath for the presence of carbon dioxide. Tidal volumes can be used to evaluate response to asthma treatment, indicate impending respiratory failure, and an indication of endotracheal (ET) tube placement.
acute otitis media (AOM): patho
infection involving the eustachian tube
otitis media with effusion (OME): Patho
effusion (fluid behind the tympanic membrane) of the middle ear after an acute infection
what is the most common childhood illness treated by physicians
ear infection: symptoms
Ear pain, tugging and pulling at ear
Popping, or tinnitus
Difficulty sleeping, irritability and/or crying
Febrile > 102�F or 38.8�C
Loss of hearing
Yellow, green and/or foul smelling drainage
ear infection: lab/diagnostic
exam of child's ear using a pneumatic otoscope, the child's tympanic membrane can appear red, swollen or bulging, with limited movement of the eardrum. Injection of air into auditory canal is performed to determine presence of accumulation of fluid behind
T or F Otitis media infections can spontaneously resolve without the need for aggressive therapies
acute otitis media (AOM): treatment
generally conservative for the first 48 - 72 hrs administering analgesics and anti-inflammatories for pain/discomfort, especially at bedtime. If spontaneous resolution of symptoms doesn't occur after 72 hrs of close observation, child will be placed on or
what is substituted in children with a penicillin allergy
Cephalosporin, clindamycin, Erythromycin
Priority nursing interventions for AOM or Otitis Media with Effusion (OME)
focuses on treating any worsening infection, acute pain, and fever
Anticipatory guidance provided to parents about otitis media
proper med administration techniques stress the importance of completing the entire antibiotic therapy as prescribed and safe dosing for pain control per 24 hours; Parents can be at risk for administering too much Tylenol or ibuprofen med if not given as
When OME lasts longer than three months and/ or the fluid accumulation in the eustachian tube risks
hearing loss in the child, the surgical procedure tympanostomy is performed
placement of a small tube in the child's tympanic membrane to help equalize the pressure in the middle ear and allow fluid drainage. The tube is designed to remain in the tympanic membrane for 6 - 12 months and naturally fall out with the growth of ear ti
Nurses should advise parents that if a tube falls out, it's not a
medical emergency, however, should contact their physician or specialist as soon as possible.
post procedure tube. and ear care
keeping ears dry during bathing include the placement of a cotton ball with petroleum jelly, ear putty or age-appropriate sized earplugs to help keep them dry and reduce the risk of introducing a bacterial infection in the middle ear. Children should neve
Pharyngitis viral or bacterial infections are usually spread by
children exposed to each other in close settings such as daycare or early childhood school settings
pharyngitis and tonsilitis: patho
both viral and bacterial
an inflammation of the back of the child's throat, with redness.
swelling of the adjacent tonsillar tissue in response to the infection as part of the immune system
tonsillar tissue is enlarged, red and may have white spots, crypts and/or exudate present; child will breathe with their mouth open exposing foul breath, dry mucous membranes and some difficulty with swallowing
Nurses grade the swelling of tonsils
scale from 0+ (normal presentation) to 4+ (as they approach the uvula)
priority concern with pharyngotonsillitis at 4+
the adenoids can also become swollen creating
nasal congestion characteristic to the child's voice and contribute to the development of otitis media, and/or symptoms of sleep apnea.
pharyngitis and tonsilitis: labs/diagnostics
Throat swab for rapid strep and culture obtained at same time depending on presenting symptoms of infection in child; mild symptoms receive a rapid strep test that renders quick results in a ruling out of the bacterial type of the infection. A culture for
pharyngitis and tonsilitis: treatment
Penicillin V is the antibiotic of choice with Group A beta-hemolytic streptococcal pharyngeal infections, Treatment for a 10-day course is standard, with an initial IM injection given in cases when children are likely to be non-compliant with recommended
pharyngitis or tonsillitis infection: prioritized nursing interventions
focused on the ass. and management of a patent airway. Pain is controlled with oral analgesic and anti-inflammatory meds and by encouraging intake of oral fluids to aid in preventing dehydration. Instructions on when to notify the physician with worsening
tonsillectomy: pre operative care
instruction for post-procedure care of tonsillectomy begins when child is diagnosed as an outpatient; children should schedule a tour of surgical center and meet care providers to ask Q's and begin the initial connections of trust. should be taught how to
what builds self-esteem resulting in better surgical outcomes overall
Helping children understand their role and responsibility in recovery; Praise and reward are given to children who demonstrate an interest in their recovery, pre-operatively.
focused on airway maintenance and close monitoring for any symptoms of bleeding. The nurse must be alerted to any subtle change in the child's condition and notify the physician immediately of any worsening symptoms.
Symptoms of bleeding in children after tonsillectomy (Emergency Condition)
Frequent Swallowing, choking, or signs of fresh bleeding in the back of the throat
Vomiting bright red blood
Tachycardia with decreasing blood pressure
how long should parents be monitoring for active bleeding after a tonsillectomy?
what helps maintain adequate hydration and facilitates healing of the postoperative tonsillar membrane after a tonsillectomy
soft foods and plenty of liquids
viral illness that manifests as a narrowing of the upper airway, laryngeal and subglottic area of the throat from inflammation and edema
the three types of croup
acute spasmodic, acute laryngotracheobronchitis (LTB) and acute epiglottitis
the most common cause of croup
parainfluenza, influenza A and B, and respiratory syncytial virus (RSV)
what is a positive sign of viral croup
steeple sign (narrowing in the subglottic area of the throat)
bacterial infection of subglottic tissue commonly caused by H. Influenzae. rapid onset and quick progression to complete airway obstruction.
A radiologic soft tissue of the neck exam positive for epiglottitis shows
a positive thumb sign (airway occlusion) from severe swelling of the pharyngeal tissues
what is imminent with epiglottitis
complete airway. obstruction
when should an oropharyngeal exam be done
when a secure airway is established
when is intubation done with epiglottitis
mmediately with confirmation of this diagnosis
symptoms of viral croup and epiglottitis
experienced at night when child awakens with sudden-onset of harsh bark-like cough, stridor on inspiration, increased work of breathing, rapid onset fever, anxious, assuming tripod sitting position, drooling, difficulty talking, difficulty swallowing, use
clinical presentation and radiological evidence of narrowing in the airway. a complete blood count is done to confirm presence of bacterial antigen. a thorough history of childhood vaccines help determine immunity from H. Influenzae.
laryngotracheobronchitis (LTB): treatment
two-fold pharmacologic of corticosteroids and nebulized racemic epinephrine treatment and encouraging oral intake or IV fluids and close monitoring for resolution of symptoms of distress.
emergency intubation and stabilization of the airway. Admission to the ICU environment for treatment of IV antibiotics until extubation. Resolution of severe symptoms and extubation typically occurs after 48 hrs. The child will receive oral antibiotics fo
Croup and Laryngotracheobronchitis (LTB) nursing interventions
Maintaining patent airway is highest priority a croup infection, stabilize/support adequate O2 with administration of supplemental O2 to maintain saturation levels >95%.
Monitoring for increased accessory muscle use or a change in LOC is crucial for ident
respiratory condition resulting in increased inflammation and mucus occlusion of the small airways
what is the significant cause of bronchiolitis infection in children
Respiratory Syncytial Virus (RSV)
who is at an increased risk for hospitalization from the harmful effects of RSV related to complications of hypoxia, dehydration, and atelectasis
children younger than two years
Respiratory Syncytial Virus (RSV): symptoms
Thick, tenacious secretions contribute to hyperinflation of lungs from air becoming trapped due to child's inability to exhale fully. Progressive hyperinflation of the lungs increases risk of atelectasis. Severe hypoxia results as retained CO2 and diminis
Nasal Pharyngeal Aspirate
Nasal Pharyngeal Aspirate
common way to obtain a respiratory specimen in children under five yrs. Although uncomfortable, is relatively painless and produces more live virus specimen sample than a nasal swab. A nasal wash is generally considered collection method of choice when is
how to perform a Nasal Pharyngeal Aspirate
tilt head back. Instill small amount of sterile saline into nostril (1 ml). Instill saline into small catheter and insert tubing into nostril curving downwards. Aspirate nasopharyngeal secretions into catheter tubing. Remove and flush contents into steril
focused on O2 and hydration management during the acute illness. Palivizumab preventative injections are administered to premature babies, immunocompromised or cardiac infants at risk, once a month throughout the cold and flu season. Routine removal of se
Priority nursing care for children with RSV is to
facilitate gas exchange, maintain adequate hydration, prevention through education
how to facilitate gas exchange in children with RSV
cardiopulmonary monitoring of VS and O2. Administration and regulation of supplemental O2 with sat levels <94%. Routine suctioning of secretions to free the airway of mucus is performed before meals and as needed, noting that overuse of suctioning can cre
how to maintain adequate hydration in children with RSV
oral or IV fluid admin. collect I&O data for accurate assess of child's hydration status.
education prevention of RSV
proper handwashing; can live on surfaces for up to 6 hours; avoid infant exposure in crowded buildings during peak cold/flu season and make sure children are up to date on all recommended vaccines.
Accumulation of fluid and cellular debris begin to block the child's air passages. Consolidation of mucous in these areas results in dyspnea, increased respiratory rate and work of breathing.
viral pneumonia (parainfluenza, RSV, Influenza): symptoms
Febrile, low or progressively increasing to higher levels; Adventitious lung sounds, cough, abdominal pain
Infiltrate of perihilar tissue may be noted on chest radiography
Non-elevated white blood cell count (<20,000/mm3)
Duration of illness approximately
Bacterial Pneumonia (Streptococcus pneumonia, Mycoplasma, and Hemophilus Influenza): symptoms
Rapid onset of high fever, usually after an initial upper respiratory illness
Cough, general malaise or anxiety, chest pain
GI symptoms and abdominal pain
White blood cell count elevation ( >20,000/mm3)
Chest radiography shows consolidation
pneumonia: labs and diagnostics
Chest Radiography, Serum studies (CBC), Sputum Cultures, Ultrasound
pneumonia treatment with air
facilitation of airway clearance and correction of impaired gas exchange. Oxygenation is supported with humidified supplemental O2 to keep saturation levels ?91% or according to physician orders.
pneumonia treatment with hydration
Oral/IV fluid interventions are admin in efforts to keep child hydrated and lung secretions thin and liquefied for ease in removal. Accurate I&O data is an essential assess to determine adequate hydration levels in children.
pneumonia treatment with comfort
antipyretics, antibiotics, and analgesics to facilitate child's ability to receive adequate rest and ambulate as directed to facilitate normal respiratory mechanisms and secretion removal. Teaching child to splint their cough using a towel roll, pillow or
pneumonia: priority nursing interventions
support airway clearance, acute pain control, maintain normal breathing patterns, maintain adequate hydration
immaturity of brainstem's functional capacity to regulate autonomic cardiopulmonary function. The other, apnea as a secondary result of a primary medical condition such as gastrointestinal reflux, seizures, metabolic disorders, childhood obesity and other
during sleep when the brain or heart signals for normal respiration are interrupted creating periods of cessation of breathing. Cessation of respirations for >15 seconds is commonly caused by central apnea.
obstructive (OSA) apnea
When soft tissues in the posterior pharyngeal area relax and occlude the airway during sleep.
a combination of both types when the absence of air movement and obstruction of the airway are present.
obstructive sleep apnea symptoms
periods of cessation of breathing for more than 20 seconds. This type of apnea presents as very loud snoring with pausing for > than 20 seconds multiple times. Restlessness during sleep that results in daytime neurobehavioral complications
what is a known complication of obstructive apnea
sleep apnea labs/diagnostics
polysomnogram (sleep study) is performed on children to monitor their brain wave patterns, oxygenation and heart rate during sleep. Other physical manifestations such as eye and movement of extremities are recorded as well giving clues as to the type of a
traditional pharmacologic interventions for apnea
Methylxanthines (Theophylline) and caffeine
children receiving pharmacologic treatment for sleep apnea show fewer complications with
bradycardia and frequency of periodic breathing until the maturing of systems occurs when the condition spontaneously subsides
Continuous positive airway pressure (CPAP)
machines that force oxygen into the airways when sleeping may be prescribed along with medications
obstructive sleep apnea treatment
children may undergo a surgical adenoidectomy to remove tissue that contributes to airway obstruction
what can help reduce the symptoms of complication associated with OSA.
reducing childhood obesity
sleep apnea nursing interventions
requires management of meds, an adequate breathing pattern and sleep position while hospitalized. Teaching parents about importance of adherence to newly prescribed med regimen and how to perform emergency life-saving steps of CPR before discharge
Exercise-induced bronchoconstriction / Asthma
bronchoconstrictive condition occurring with vigorous exercise in children who have asthma
exercise induced asthma causes
cough, shortness of breath and wheezing
Bronchoconstriction associated with exercise can be managed by
using a short-acting beta-agonists (SABA) or Ipratropium 30 minutes before the activity as directed by the physician in accordance with long-term control medications taken regularly.
peak expiratory flow rate (PEFR) meter
peak expiratory flow rate (PEFR) meter
used to objectively measure airflow of the lungs
asthma action plan
individualized plan helps manage acute exacerbations and becomes an objective historical tool to recall any precipitating symptoms.
meds that give quick relief of acute symptoms in asthma
short acting. beta2-agaonist (SABA's)
long term management of asthma symptoms: meds
long acting beta agonist (LABA's)
prioritized interventions with an acute asthma episode
Teaching the child to use the SABA's before exercise and with acute exacerbation is a priority intervention. Instructing parents and children in how to follow the asthma action plan using the PEFR meter as prescribed, can help reduce emergency room visits
a severe, life-threatening asthma attack that is refractory to usual treatment and places the patient at risk for developing respiratory failure.
long term management of asthma is designed to
Minimize impairment in child's life with prevention of severe exacerbation with accurate daily assess. monitor symptoms.
Reduce need to use SABA for relief of symptoms to ?2 days per week using PEFR to regularly monitor lung status and evaluate pharmacolo
cystic fibrosis: patho
genetic autosomal-recessive complication in children when the gene cystic fibrosis transmembrane regulator (CFTR) responsible for movement of fluid across cell membrane is altered and exocrine gland regulation of salt and water removal from the body malfu
what is the overall life expectancy of those with cystic fibrosis
30 - 40 years but growing with the advancement of medical treatment
Parents of children with CF must receive
genetic counseling to understand better the potential risk for other children to be born with the disease.
cystic fibrosis: symptoms
Thickened mucus is a complication affecting the normal function of the digestive, respiratory, reproductive and skin systems.
cystic fibrosis prevents the pancreas from releasing what vitamins that are essential for digestion?
A, D, E, K
cystic fibrosis causes mucous buildup in the intestine and prevents
absorption of fats and proteins resulting in Failure to Thrive and malnutrition
type of stool characteristic prominent in CF children that can also be used as an indication for medication management when symptomatic.
fat in the feces
Children with CF are at risk of developing frequent serious respiratory infections because
thick, sticky mucous traps harmful germs in the lungs and provides a medium for robust growth.
lung infections are predominantely
cystic fibrosis affects the reproductive system
in both girls and boys contributes to delay in development or other complications with sex organs
why are boys with CF sterile
abnormal or no development of the vas deferens
what complications do girls with CF face in the reproductive system
thick cervical mucus that interrupts regular menstrual cycles and/or prevents pregnancy
why are CF children's skin salty
abnormal function of sweat glands releasing high amounts of NaCl. Glands carry salt and water to surface of skin. water evaporates while the cell's inability to reabsorb sodium creates a hyponatremic metabolic condition and abnormally salty skin identifie
what is the gold standard test for diagnosing CF?
sweat chloride test
sweat chloride test
non-invasive, painless test is performed by placing electrodes on the child's skin to produce minimal amounts of sweat for levels of measurable chloride
what level is considered a positive for CF when performing a sweat chloride test
why does the sweat chloride test not work on infants less than 2 weeks old
do not produce adequate amounts of sweat for accurate diagnosis using the sweat test.
what is the earliest clinical symptom of CF in newborns
meconium ileum during the first 48 hours of life
multi-specialty individualized care based on their specific conditions. Pancreatic enzyme supplementation to support healthy growth/development and respiratory system maintenance therapies are essential to providing opportunities for the child to live a q
prioritized nursing interventions for CF
facilitate gas exchange
prevent/minimize risk of infection
promote adequate absorption of nutrients
Prioritized Nursing Interventions: facilitate gas exchange in children with CF
removal of secretions rom respiratory tract using chest percussion therapy, mucolytics, bronchodilators, and preventative antibiotics to prevent bacterial growth, high frequency chest wall oscillation
Prioritized Nursing Interventions: Prevent and Minimize Risk of Infection in children with CF
obtain recommended childhood vaccinations, proper hand washing techniques Children encouraged to develop an exercise routine to facilitate lung function.
calorie intake of those with CF
150% of recommended daily intake
how is pancreatic enzyme replacement regulated and when is it given
according to the child's weight and administered with all snacks and meals
what should parents avoid doing with pancreatic enzymes
avoid mixing enzymes with hot or acidic foods for maximum effectiveness.
Persistent murmurs associated with left-to-right shunting lesions may not be detected or diagnosed until
after the first six weeks
Innocuous murmurs detected with auscultation can be
a normal finding and resolve within the first few weeks of extrauterine life
turbulent blood flow causes
pathologic murmurs through an opening in the heart
what type of murmur requires referral to a pediatric cardiologist
what is the most effective way to identify cardiac murmurs in children during the physical assessment.
Heart lesions in children are the result of a
congenital or acquired complication
Congenital Heart lesions are the result of
genetic alterations (Down Syndrome, Atrial Septal Defect, Patent Ductus Arteriosis, Tetralogy of Fallot)
A congenital heart condition is classified by
he lesion's effect on the body's ability to oxygenate the blood and a shift in the normal direction of blood flow.
Acquired heart disease is the result of
a child contracting a severe illness that attacks the heart muscle itself. Kawasaki disease and Rheumatic fever are two examples of conditions that cause coronary and cardiac tissue injury.
children who have undergone repair of a congenital heart anomalies are also at risk for
contracting infective endocarditis (IE).
Shunting is a cardiac condition when the
blood travels through the heart abnormally related to holes or areas of communication between the heart chambers
Shunting allows for
mixing of oxygenated and unoxygenated or backflow of blood through the heart
Cardiac shunts are identified by
the abnormality in the heart and associated blood flow changes
The most common congenital heart defects in children are
left to right shunting lesions. that reverse the normal pressure gradient from them being higher on the left side of the heart to higher on the right
non-invasive examination of the heart's electrical activity. This test can record arrhythmias, rate irregularities, or damage to the cardiac muscle.
holter (event) monitor
non-invasive continuous monitoring of cardiac activity during activities of daily living for an extended period. capture and record hr, rhythm irregularities, palpitations or other symptoms on demand to thoroughly assess for cardiac irregularities.
performed by a sonographer using a transducer device to scan the precordium. Ultrasonic beams bounce sound waves through the skin against the heart and become converted into computer images on a monitor Blood flow, valve competence, measurement of chamber
screening of newborn babies can help providers monitor for O2 complications during the first 24 - 48 hrs of life. Critical congenital heart disorders are detected using this non-invasive method of assess for early identification
Cardiac Catheterization-based procedure
gold standard for confirmation of congenital heart disorders; invasive procedure performed by inserting a catheter into the brachial or femoral artery leading to the heart, to assess the function of cardiac chambers, measure
CO, diagnose complications wit
heart failure is the result of
two primary physiologic complications of congenital heart disease (CHD), hypoxia and volume overload
who are predominately affected by congenital structural abnormalities creating right-sided HF affecting systemic circulation and oxygenation
Newborns and young infants
who commonly experience heart failure from left-sided complications and pressure overload related to obstruction, damage to the heart muscle or renal disorders causing cardiac hypertrophy and development of inefficient pumping mechanisms
Characteristics of HF in children are identified during
the child's physical assess as fluid overload in lungs w/adventitious sounds upon auscultation, edema of extremities and dependent sites from the interstitial fluid shift, failure to thrive related to high metabolic demand, dyspnea and exercise intoleranc
Clinical recommendations for feeding the child with HF are focused on
helping the infant to conserve energy and maintain steady growth and weight gain. Caloric recommendations for infants ranges from 140 - 200 kilocalories/day. Breastfed infants unable to meet weight gain goals receive caloric supplement through intermitten
priority intervention for feeding the child with HF are focused on
symptoms of intolerance such as irritability, rapid respiratory rate, vomiting or sweating
secondary condition resulting from hypoxia. primary cause is an absolute increase in RBC mass related to increased production. CHD shunting lesions that alter systemic O2 stimulate the body to increase its O2 carrying capacity to the tissues and over prod
Polycythemia in the ill child with dehydration is at an increased risk for
stroke and pulmonary thrombosis that can lead to cardiac arrest
Hypercyanotic (TET) Spells are associated with
cyanotic heart lesions namely Tetralogy of Fallot (TOF)
Hypercyanotic (TET) Spells occur
randomly with right ventricular outflow obstruction drastically reducing the blood flow to the lungs causing a systemic cyanotic condition that's evident in the child's outward bluish appearance
Teaching parents how to resolve the cyanosis requires putting the infant in the
knee-chest position or having an ambulatory child squat during an acute event to increase peripheral vascular resistance and force more blood through the pulmonary system helps to resolve the cyanosis.
Chest radiography and Echocardiogram help to diagnose
electroconductivity, pulmonary flow, and structural deviations.
Serum studies include
complete blood counts, metabolic panels, cardiac enzymatic and hormonal studies
Pulse oximetry indicates complications with
room air oxygenation
heart failure treatment: Pharmacologic
Pharmacologic therapy is aimed at reducing systemic fluid congestion and edema with diuretics, increasing cardiac contractility with inotropes and reducing increased afterload with vasodilators.
heart failure treatment: conventional therapies
Conventional therapies include the use of a combination of diuretics, inotropic (digoxin), beta-blockers, angiotensin-converting enzymes (ACE) inhibitors and spironolactone medications
cardiac glycoside that helps to increase cardiac output and aid in diuresis. requires strict I&O measurements
when do you hold digoxin
apical heart rate of <100 in infants and <70 in older children.
Diuretics and Thiazides
facilitate the removal of excess water and Na+ to prevent fluid volume overload and systemic edema
loop diuretics (lasix)
very potent and potassium wasting
have less of the K+ wasting effect than the loop forms of diuretic but are also less potent
Prevention of hyponatremia or hypokalemia is monitored through
serum studies and strict collection of I&O data.
Vasodilators or Angioconverting Enzyme (ACE) Inhibitors
help relax smooth muscle and reduce afterload caused by obstruction affecting left-side cardiac output. The action of the drug prevents the conversion of angiotensin I to angiotensin II in the kidneys reducing the release of aldosterone. Less aldosterone
potent loop diuretic
potassium sparing diuretic
acts on distal renal tubules
increases cardiac output has positive inotropic and negative chronotropic effects
relaxes smooth muscle; decreases afterload
nursing care interventions for children with HF
Monitor VS; watch O2 sat levels and report complications of developing hypoxia to the physician.
Support hydration and wt gain by implementing dietary supplementation interventions, performing strict daily wt, I&O assess.
Administer pharmacotherapies as o
ineffective endocarditis (IE)
can be caused by bacterial, fungal or viral antigens that invade the endocardium and heart valves. Exposure to dental procedures, deep cuts, and interventional procedures increases the risk of bacterial invasion by either staphylococcus or streptococcal p
ineffective endocarditis (IE): symptoms
Fever and sweating
Headache, muscle aches, and pain in the joints
Loss of appetite
Exacerbation of a preexisting murmur
IE: labs and diagnostics
serum studies including a complete blood count and blood cultures, CRP, ESR and rheumatoid factor. A urinalysis and radiologic studies such as echocardiography and MRI also provide essential data for diagnosis.
eliminate all infective bacterial vegetation from the cardiac tissues completely. This intervention is a difficult task that requires long-term antibiotic treatment typically lasting 6 - 8 weeks. In cases of severe persistent vegetation surgical excision
IE: prioritized nursing interventions
Instruct parents to practice daily oral hygiene.
Comply with AHA recommendations for dental prophylaxis
Practice safety by having the child wear a medical alert bracelet or activate other forms of medical alert notification systems in case of an emergency
rheumatic fever: causes
by an untreated or poorly treated infection caused by. streptococcus group A bacteria
rheumatic fever: patho
a complication with strep throat; inflammatory disorder caused by group A streptococcus; causes inflammation throughout the body and can derive from scarlet fever
rheumatic fever: symptoms
occur 2-4 weeks after strep throat; noodles/bums non the. skin, nosebleeds, and fatigue, heart palpations/flutters, joint pain, swelling, fever, shortness of breath, stomach ache, vomiting, rash,
rheumatic fever treatment
antibiotics, pain meds, corticosteroids, anticonvulsants, bed rest
common meds used to treat rheumatic fever
Penicillin G benzathine (PCN-G)
Penicillin VK (Pen VK)
Erythromycin ethylsuccinate (EES) *used with PCN allergy
Kawasaki disease patho
auto-immune complication of unknown etiology primarily affecting children <5 years of age
what is the leading cause of acquired heart disease in children
acute symptoms of Kawasaki disease
high fever >102�F for a period of at least 5 days and lasts up to 14 days. Persistent high fever of >5 days along with 4 of the 5 manifestations confirms diagnosis
Kawasaki: diagnostic manifestations
Oral alterations (strawberry tongue, dry, red and cracked lips) Pharyngeal erythema
Rash over body surfaces
Redness of upper and lower extremities
Cervical lymphadenopathy and enlarged lymph nodes
Absence of other infectious disea
subacute phase of kawasaki
disease begins when the fevers are no longer present, around the fourth to sixth week of illness. Conjunctivitis and desquamation of the skin on the fingers and toes begin along with increased risk for thrombocytosis and development of coronary aneurysms.
convalescent phase of kawasaki
time when most other manifestations of complication have resolved leaving behind the markers known as Beau's lines in the nail beds.
what stage does Kawasaki disease present itself
admitted during acute phase of infection and given a high 2g/kg 1-time dose of IV immunoglobulin or gamma-globulin (IVIG) delivered over 10 - 12 hours and high dose aspirin; o prevent complications of high fever and continued until afebrile for 72 hours.
Kawasaki: nursing interventions
prioritize cardiac assess during acute phase of hospital admission closely monitoring for changes in VS, or LOC that may indicate cardiac compromise, implement and evaluate pain control measures, and maintain adequate hydration
Hypertension (HTN) in children
defined as BP that is greater than the 95th percentile for height and weight
defined as BP levels between the 90th and 95th percentile
defined as BP readings less than the 90th percentile
what is the main complication associated with Essential HTN
what is the result of renal complications from underlying physical disorders that create situations of volume overload such as HF
when does Diagnostic evaluation of blood pressures begin
at 3 years old
how many times must high BP readings be recorded to be considered a diagnostic for HTN
3 separate occassions
HTN prioritized nursing
correcting the underlying condition of obesity in children with essential and secondary HTN. Weight reduction is a primary goal for complete resolution of an essential disorde
(high cholesterol) is the result of a build-up of arterial plaque that creates a significant risk for heart, cerebral and other systemic complications
hyperlipidemia: treatment/nursing interventions
dietary modifications of restricting daily consumption of foods to recommended daily allowances, and balancing proper nutrients fats, proteins and carbs are essential to lowering cholesterol and triglyceride levels in children. Encouraging physical activi
Three types of circulating cell formed to help fight infection and inflammation (neutrophil, eosinophil, basophil)
Five types of cell that together work to prompt immune reaction and inflammatory response. (monocytes, lymphocytes, T cell, B cell)
red blood cells
carry OO2 the tissues in the body concentrated in hemoglobin for transport throughout the systems. Iron stores determine the body's ability to produce an adequate supply of hemoglobin. The lifespan of an RBC is 90 - 120 days.
regulate the blood's clotting process in order to prevent loss (hemostasis).
Which diagnostic test confirms aplastic anemia
bone marrow aspiration
iron deficiency anemia (IDA): patho
can be attributed to prematurity, low socioeconomic status and limited access to iron-rich food, excessive intake of cow's milk, and insensible blood loss from the GI tract and menstruation in some girls.
recommended amounts of iron for full-term infants from birth to 6 months is
recommended amounts of iron for infants 7 months to 1 year
Toddler: recommended amounts of daily iron intake
iron intake for children 4 -8 years of age is
iron deficiency anemia: symptoms
Pallor of skin, nail beds and gingival tissue
Lightheadedness or vertigo
Symptoms of Pica: Eating inanimate objects such as paint chips, dirt, or chalk which also correlates with lead poisoning.
iron deficiency anemia: labs/diagnostics
serum study of the complete blood count is the determinate of anemia.
Acceptable levels of hemoglobin should be no less than
levels of hemoglobin in children with mild anemia is
complications of ID/IDA can be attributed to
prematurity, low birth wt, breastfeeding as only form of nutrition beyond 4 mths w/o Fe supplementation, overfeeding of cow's milk w/o dietary solid food supplement of iron-rich or fortified foods, and exposure to lead.
modification of dietary intake and supplementation of iron with oral forms of ferrous salts; Oral iron should be taken on empty stomach and admin through a straw to avoid staining the teeth and given with OJ to enhance absorption. Parents should expect ir
Priority nursing goals for the anemic child are to
evaluate child's cognitive baseline for developmental delay and accessing necessary resources for intervention. Teach parents about significance of dietary nutrient, and how to incorporate natural forms of iron in daily diets such as encouraging child to
Sickle cell disease (SCD) is an
autosomal recessive inherited genetic abnormality that alters the shape of an average round red blood cell (HbA
do both parents need to carry the recessive sickle cell gene for the child to have sickle cell anemia
Sickled RBC's are composed of
thick strands that force the abnormal shape of the cell.
overwhelming about of sickled cells begin to block vessel passageways. This complication can happen anywhere in the body but is frequently reported as pain in the chest, joints upper and lower extremities including symptoms of dactylitis.
Acute Splenic Sequestration
complication for children with SCD. The spleen's reticuloendothelial system designed to filter and prevent harmful bacterial infection, cannot function as its intended because of the obstruction created by sickling blood cells
related to infection from Parvovirus B19. Parvo completely shuts down hematopoiesis in the bone marrow with acute symptoms lasting up to 10 days. infections such as this create a tremendous deficiency in the amount of available hemoglobin to carry O2 to t
Diagnosis of SCD is now performed with the
newborn screening test done at birth. Serum studies such as the complete blood count assessment are used to determine the significance of the illness and guide treatment when symptomatic.
Standard treatment for SCD children is
prophylactic penicillin 2x daily for the first 5 yrs of life Hydroxyurea is an oral form of fetal hemoglobin (HbF) that prevents adhesions of the sickled RBC to the vessels and stimulates the production of normal RBC's (erythropoiesis) and increases the c
SCD: Prioritized Nursing Interventions
assess VS, adequate hydration, I&O data, IV/oral antibiotics, manage pain, support psychosocial development
This condition is a result of a lack in clotting factor VIII. 9/10 children have this type of hemophilia.
lack of clotting factor IX, and is also known as the Christmas disease; symptoms of this complication are similar to Hemophilia A.
mild form of the condition where minimal bleeding is noted from a lack of clotting factor XI
lifelong x-linked autosomal recessive disorder that affects male children of women who carry the genetic trait; bleeding out into the tissues and joints
bleeding into the knee joint; arthritis and crippling deformities can result from painful, recurrent bleeding episodes. Bleeding under the skin from normal childhood accidents, no matter how small, can cause the development of a hematoma.
recommended triage treatment for hemophiliacs to stabilize an acute bleeding condition.
Serum studies include prothrombin (PT) and partial thromboplastin (PTT) clotting time tests, along with specific tests for factors VIII and IX to confirm the diagnosis
recombinant anti-hemophilic factor allow children to receive factor VIII and IX replacement therapies without risks of blood-borne disease.
antidiuretic; (hemophilia) helps the tissues in the blood vessels release stored factor VIII. is given as a prophylactic for invasive procedures or minor surgeries and any dental intervention.
hemophilia prioritized interventions
Preventing Bleeding and reducing the risk of Injury
Immune Thrombocytopenic Purpura (ITP): patho
acquired hematologic disorder when the platelet count falls abnormally low <150,000/mm3
A pinpoint rash commonly seen with mild capillary bleeding under the tissue, or as the result of a low platelet count
pooling of blood under the skin as a result of low platelet levels in the blood.
symptoms of ITP
petechial, purpura, bleeding gum with brushing or blood in the stool
A purpuric rash is noted with platelet counts
Children show symptoms if ITP with a platelet count of
A normal platelet count is
150,000 to 450,000
pharmacologic interventions of steroids and IVIG to block the attack of the platelets
Children with chronic complications of ITP will be considered for
splenectomy to stop the destruction of the cells.
ITP nursing interventions
prevent bleeding, safe environment,
full bladder control by the age of
Bladder capacity at birth is
The child's bladder capacity is determined by
age + plus two, totals capacity (i.e., a 3-year-old, plus two would have a 5-ounce capacity)
Urine output averages for children
Control over emptying the bladder is dependent upon
maturation of the CNS
Children are generally not able to potty train until
18 -36 months of age when myelination of the spinal cord is complete.
Blood Urea Nitrogen (BUN)
assess the amount of urea nitrogen is in the blood. The normal range is from 7 - 20, the BUN level increases with the worsening condition of the kidney.
Normal creatinine levels for children ? 12 years is 0.0 - 0.7 mg/dL. This level indicates renal function as increased levels suggest the worsening condition of the kidney.
show levels of concentration of urine, the presence of urinary tract infection (UTI), or results of therapeutic management of chronic renal disease or disorder. A culture may also be ordered on the specimen to determine pathogen associated with UTI sympto
level of protein in the urine. Chemstrip results of albumin >1+ require further diagnostic testing and comparison ratios with the creatinine.
Glomerular Filtration Rate (GFR)-
indicator of renal function in children and adults. It is the calculation of the clearance of waste from the blood with the child's age and gender.
Kidney, Ureter, Bladder (KUB)
radiograph is used in the first steps of diagnosing a complication with the genitourinary organs. The KUB helps to assess the size, position and any obstructions or stones of the kidneys and bladder abnormalities, or confirmation of ascites.
Voiding Cystourethrogram (VCUG)
uses fluoroscopy to exam the child's urinary tract and bladder assess for structural deviations that contribute to symptoms of obstruction and backflow of urine. The test itself is considered invasive
ultrasound is a non-invasive painless intervention that shows the internal structures of the renal system. The ultrasound images help to assess the size, position and any mass or stones of the kidneys and bladder abnormalities.
wetting from a child who has never experienced a time of urinary control or continence for > 6 months
return to wetting after having experienced urinary continence for longer than 6 months
wetting while awake
mono symptomatic enuresis
uncomplicated, no lower tract symptoms or bladder dysfunction
complications of lower abdominal pain and symptoms of urgency, hesitancy, and inability to empty the bladder resulting in post void dribbling.
Sleep issues, patterns, behaviors during sleep including history of nightmares or night terrors, History of normal patterns of oral fluid intake and typical time of day the most consumption takes place, History of any emotional/ psychosocial complications
minimize their feelings of guilt and inferiority
enuresis prioritized nursing interventions
monitor for symptoms of skin breakdown and increased risk of infection
Teaching related to behavioral conditioning and establishing reward programs for compliance in working toward goals of control
Supporting the child's self-esteem and encouraging social
Urinary tract infections occur when
colonization of bacteria manifests in the renal structures whether, urethra, bladder or ureters that can worsen and travel backward infecting the kidneys (pyelonephritis) causing sepsis or bacteremia
most common cause of UTI in children is an
E coli bacterial infection
UTI symptoms: Infants > 2months and Preschool Children up to 2 years
Fever and irritability
Strong smelling urine
Abdominal pain and vomiting
UTI symptoms: Preschool and Young School Age Children aged 2-6 years
Urinary symptoms of frequency, urgency, and dysuria
Fever and irritability
Strong smelling urine
Abdominal pain and vomiting
UTI symptoms:Older School Age Children > 6 years and Adolescents
Urinary symptoms of frequency, urgency, and dysuria
Fever and irritability
Strong smelling urine
Abdominal pain and vomiting
Enuresis and Incontinence
urine flows from bladder up to the kidneys
vesicoureteral reflux: symptoms
swelling of kidneys and ureters, febrile UTI
vesicoureteral reflux: treatment
surgery to increase tunnel length of ureter
vesicoureteral reflux: labs/diagnostics
Urinalysis and urine culture, VCUG, bladder catheterization or suprapubic aspiration and ultrasound imaging are performed in severe cases.
Nursing care of the child with a UTI includes
manage/prevent worsen of condition, monitor VS, timely antibiotic administration, adequate hydration, strict I&O, daily WT, avoid bubble baths, change out of wet clothes, routinely relieve bladder
dilation of the renal pelvis
inflammation of the bladder
Incomplete development of the urethra causes the opening of the urethral meatus to form on the ventral side of the penile shaft
development of the opening of the urethral meatus on the dorsal side of the penile shaft. commonly diagnosed with other structural complications such as bladder exstrophy.
excess of fluid collection in the scrotal sac related to a dysfunction in the drainage of the scrotum.
emergency condition involving the spermatic cord and scrotum. Sudden onset of severe swelling and pain felt in the scrotum as a result of twisting of the spermatic cord forcing a rotation of the testicle. Blood supply to the testicle is obstructed risking
Treatment for hypospadias repair requires
surgical correction between the ages of 6 - 18 months. Parents are advised to abstain from circumcising their infant as the extra skin can be used for surgical repair if necessary
Acute Post-Streptococcal Glomerulonephritis
kidney disease that develops after infection with certain strains of group A streptococcus bacteria, autoimmune disorder
Acute Post-Streptococcal Glomerulonephritis can cause
inflammation of the glomeruli, causes kidney less able to filter urine
Acute Post-Streptococcal Glomerulonephritis: symptoms
fatigue, blood in urine, fever, headache, nausea, dark urine, edema in face hands and feet, high BP, protein in the urine, less urine frequency,
Acute Post-Streptococcal Glomerulonephritis: diagnosis
based on symptoms, physical exam, and if person has recently had a bacterial infection, ultrasound of kidney, biopsy of kidney, protein analysis
Acute Post-Streptococcal Glomerulonephritis: treatment
treat bacterial infection, treat symptoms, monitor/support kidney function
nephrotic syndrome (MCNS): symptoms
Severe proteinuria +3 - +4
Fatigue and weakness
nephrotic syndrome (MCNS): patho
renal injury in which large amounts of protein are lost in the urine
nephrotic syndrome (MCNS): labs/diagnostics
Serum studies of albumin, cholesterol, and triglycerides, complete blood count, hemoglobin, and hematocrit, electrolytes (BUN, Creatinine), - ASO titer, urinalysis, and culture if indicated.
nephrotic syndrome (MCNS): treatment
corticosteroid therapy, oral prednisone (2mg/kg/day)
nephrotic syndrome (MCNS): intterventions
strict sodium intake, diuretics, I&O data, hydration, skin integrity, ascites, no live virus vaccines for 30 days
PET scan (positron emission tomography scan)
views the internal tissues. PET scans involve the injection of radioactive glucose into the veins, assessing for uptake of the sugar by cancer cells throughout the body. Malignancies in the tissue become enhanced in scans showing up as brighter images ove
implemented using one drug, or a combination of drugs to kill cancer cells. Various types of cells act differently from each other; therefore children may require multiple medications. Unfortunately, chemotherapeutic drugs do not differentiate healthy cel
administering medications before surgically debulking a mass
administration of chemotherapy after surgical removal of a mass to eradicate any remaining cells not removed.
sed to direct energy particle waves into cancer cells to interrupting their DNA and cellular division causing them to die, does not differentiate between healthy and unhealthy cells
shrink the size of the tumor prior to surgical removal
side effects of chemotherapy and radiation
low WBC count, anemia, low platelet count, nausea, vomiting, diarrhea, wt gain/loss. mucositis, alopecia
mouth sores are prevalent during therapy as the tissues are vulnerable to break down. Oral infections can be prevented, and lesions managed with good oral hygiene practices, by keeping the membranes moist and staying well hydrated
performed to remove a tumor, and tumor margins in combination with chemotherapy, or radiation to eradicate any remaining microscopic traces of cancer cells possibly left behind
Hematopoietic Stem Cell Transplant (HSCT):
replace stem cells in the bone marrow that have been depleted by cancer treatment. Radiation and Chemotherapy kill normal stem cells in the bone marrow responsible for cell production.
HSCT can either be
autologous using the child's disease-free stem cells or allogeneic using the stem cells of a family member, or another person who is not related to the family.
what does HSCT help children with
greater tolerance of the higher doses of chemotherapy and suffer less adverse effects of treatment.
cancer arising from the bone marrow that spreads throughout the body as blood delivered to the tissue of organs becomes affected by the disease.
what s a fast-growing cancer that requires immediate treatment upon diagnosis.
Acute Lymphoblastic Leukemia (ALL)
symptoms of ALL
Bone and joint pain, fatigue, fever, weight loss and bleeding, thrombocytopenia, and anemia
ALL labs and diagnostics
Serum studies, bone marrow aspiration, CT, radiography and lumbar puncture
Acute lymphoblastic anemia: cause
blast cells interfere with development and function of healthy WBCs , RBCs, and platelets
induction of remission
first phase of in the cycle of reducing immature blast cells with the goal of inducing a state of remission that should occur in the first 28 days for the best prognosis.
Once remission is achieved, therapy is aimed at removing any remaining abnormal cells from sites where chemotherapy cannot cross the blood-brain barrier such as the CNS and gonads (sanctuary sites)
phase of chemotherapy is aimed at preventing any regrowth of cells. Cycles during this phase are lower dose and extended over many months to years.
used throughout these phases of treatment as an adjunct to chemotherapy and to control symptoms of nausea and vomiting. High doses of corticosteroid therapy create conditions of immunosuppression and Cushing syndrome.
children using a steroid therapy need strict monitoring of
temperature and routine serum glucose checks
monitor neuro fonction, VS, standard precautions, prevent injury, monitor for bleeding, hydration, nutritional status, provide support, involve family members in decisions
brain tumors affecting children begin as
gliomas in the lower parts of the brain stem and cerebellum. Astrocytoma spread throughout brain tissue mixing in with healthy brain tissue making it difficult to remove surgically. This type of cancer also affects the spinal cord.
brain tumor: symptoms
manifest in relation to the location of the tumor
Tumors that obstruct the normal flow of CSF create
visual disturbances, uncoordinated movements, unstable balance, gait, and increased ICP
brani tumor: labs/diagnostics
Radiography exams such as MRI, CT and PET scans are used to evaluate the status of tissue and assess for metastasis. Lumbar puncture is performed to assess for the presence of abnormal cells in the spinal fluid.
brain tumor treatment
surgical craniotomies are performed to eradicate the tumor or reduce its size as an adjunct to chemotherapy treatment. Combinations of treatment are dependent on the type of tumor and location. Not all tumors are operable such as those in the brain stem
Children whose tumors block the flow of CSF in the CNS often receive a
VP shunt or endoscopic third ventriculostomy to restore and maintain proper cranial ventricular pressures
Radiation is also withheld from children with a brain tumor younger than five years related to
potential for damage to developing tissue and cognitive sequelae later in life.
brain tumor: interventions
monitor for infection and ICP post op, LOC, VS, temperature, assess surgical site, treat pain, psychosocial support
Non-Hodgkins Lymphoma (NHL)
malignancy of the lymphatic system; three main types affecting B or T cells lymphocytes, Burkitt and Burkitt-like lymphoma/leukemia, Diffuse large B-cell lymphoma, Primary mediastinal B-cell lymphoma. Children with NHL can experience rapid onset and progr
hodgkin lymphoma (HL)
malignancy of the lymphatic system;commonly occurring in teens and adolescents age 15 - 19 years. Studies show that commonly, the Epstein Barr Virus (EBV) can activate abnormal growth of tissues and colonization of large Reed-Sternberg cells
what is considered the hallmark indication of HL
reed Sternberg cells
HL and NHL symptoms
Painless swelling of axillary, neck and groin lymph nodes
Mediastinal pain, cough, or respiratory distress
Gastrointestinal complications, abdominal pain, weight loss or ascites.
Fever with no cause
HL and NHL labs/diagnostics
Serum blood studies are performed to evaluate complete blood count, metabolic status, and liver function. Tissue biopsy, radiologic exams (MRI, CT, PET scan, x-ray), and bone marrow aspiration.
HL and NHL treatment
Chemotherapy, radiation, HSCT and supportive pharmacologic therapies are all specific to the lymphoma
Nursing care of the child receiving chemotherapy for any tumor, but specifically NHL includes monitoring for
tumor lysis syndrome
tumor lysis syndrome
occurs from the massive amount of large tumor cell destruction releasing considerable amounts of electrolytes into the vascular system overwhelming renal filtration
arises from the immature nerve cells (neuroblasts) and rapidly developing cells in children. The condition is isolated to infants and children under five years. These tumors develop in the nerve cells of the adrenal glands that sit atop of both kidneys
Surgical removal of the tumor, chemotherapy, radiation, HSCT, immunotherapy and supportive pharmacologic therapies are all specific to the lymphoma.
Symptoms of occur in areas where tumor puts pressure on surrounding tissue and structures.
Tumors of abdomen result in significant distention, pain, and loss of appetite
Bone marrow involvement results in pallor, ecchymosis, and bone pain
Spinal cord comp
Diagnostic testing includes radiologic studies (CT, MRI), bone marrow aspiration, tissue biopsy, serum studies and urine testing.
Nurses caring for neuroblastoma children is given according to the system specific manifestations and /or type of interventional procedure.
Administer prescribed treatment for pain and assess for resolution of symptoms.
mainly found in adolescent to young adult, affects long bones of the axial skeleton; The smaller and more distal the development of the tumor mass, the better the prognosis
the primary sites for osteosarcoma development is
in the metaphysic of the long bones of the knee and the second is near the shoulder on the upper arm
is a challenge b/c symptoms mimick normal developmental growth pains. Pain and swelling at the tumor site often get overlooked during adolescent growth spurt. In some cases, pathologic fracture follows extended bouts of pain. reports of symptoms lasting f
radiologic studies (x-ray, CT, MRI, Bone Scan, PET scan), Needle or Surgical biopsy, serum studies including alkaline phosphatase (ALP) and lactate dehydrogenase (LDH).
Chemotherapeutic agents are used during the initial phases of treatment to shrink the tumor in anticipation of surgical removal. After this phase, the tumor is excised, and multi-agent chemotherapy is continued to kill any microscopic cells left in the ti
Practice standard precautions prevent /monitor for sign of infection.treat acute pain. Increased levels of pain and anxiety can interfere with healing and acceptance.
Access resources for impaired physical mobility needs and facilitate outpatient services
cancer that affects small children ages 3 - 5 years of age, also referred to as nephroblastoma
wilms tumor symptoms
most have no symptoms. Parents complain about palpable mass in the abdomen while bathing child
wilms tumor labs/diagnostics
serum including a metabolic panel and complete blood count, clotting studies and urinalysis are analyzed along with genetic marker testing. Radiology and scanning exams (X-ray, CT, MRI, and ultrasound) help determine the extent of disease and staging.
wilms tumor treatment
Surgical nephrectomy followed by chemotherapy and radiation to fully eradicate any remaining cells is the standard treatment.
what should you never do with a wills tumor
never palpate the abdominal mass as rupture can disrupt the protective membrane around the tumor allowing cancer cells to spread throughout the entire abdomen