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Nursing Peds Exam 4 Study Guide
Acute glomerulonephritis
Chapter 25 The Child with Renal Dysfunction
- Immunologic disorder in the kidney proper; did not begin in the bladder and ascend
- Causes: o Primary event (Generally follows other bacterial illness such as Pneumococcal, streptococcal, or viral but especially strep) o Evidence of systemic disorder such as SLE and Sickle
- Range from minimal to severe
- Common features o Oliguria/Hematuria/Proteinuria o Edema d/t decrease Glomerular filtration rate o Begins with periorbital moves to lower extremities then ascites o Hypertension d/t increase ECF o circulatory congestion
- Treatment o
- s/s o
- nursing interventions o - Acute Poststreptococcal Glomerulonephritis (APSG) o Is a noninfectious renal disease (autoimmune) o Onset 5 to 12 days after other type of infection o Often group A β-hemolytic streptococci o Most common in children 6 to 7 years old o Uncommon in children younger than 2 years old o Can occur at any age o Management: ▪ Manage edema - Daily weights - Accurate I&O - Daily abdominal girth ▪ Nutrition - Low sodium - low to moderate protein ▪ Susceptibility to infections ▪ Bed rest is not necessary, but most children will restrict activity due to malaise
Hypospadias
- Urethral opening is located below the glans penis or anywhere along the underside of the penile shaft
- Requires surgical correction
- Nursing assessment of every male newborn
- Reasons to repair early? o
Causes of acute renal failure in kids UTI’s
- Definition—kidneys suddenly unable to regulate the volume and composition of urine
- Not common in children
- Most common pathologic cause transient renal failure resulting from severe dehydration
- Classic presenting symptoms o oliguria Associated with ▪ azotemia ▪ metabolic acidosis ▪ electrolyte disturbances
- nontraditional presenting signs/symptoms o
- dietary management o
- Complications: o Hyperkalemia o Hypertension o Anemia o Seizures o Hypervolemia o Cardiac failure with pulmonary edema Nephrotic Syndrome
- Most common presentation of glomerular injury in children
- Self-limiting
- Early detection and treatment to decrease proteinuria, and permanent renal damage
- Types of Nephrotic Syndrome o Minimal change nephrotic syndrome (MCNS) (most common) ▪ Also called Idiopathic nephrosis, Nil disease, Uncomplicated nephrosis, Childhood nephrosis, and Minimal lesion nephrosis o Congenital nephrotic syndrome o Secondary nephrotic syndrome
- Signs/Symptoms o Proteinuria o Hypoalbuminemia o Hyperlipidemia o Edema o Massive urinary protein loss o Glomerular membrane ▪ Normally impermeable to large proteins, but Becomes permeable to proteins, especially albumin ▪ Albumin lost in urine (hyperalbumin uria ), so Serum albumin decreases (hypoalbumin emia ) ▪ Fluid shifts from plasma to interstitial spaces
- Hypovolemia and Ascites
- Treatment o If child responds to steroids, usually will do OK o Supportive care o Diet ▪ Low to moderate protein ▪ Sodium restrictions if large amount of edema ▪ Avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods ▪ Encourage adequate fluids even after infection o Steroids ▪ 2 mg/kg divided into BID doses ▪ Prednisone drug of choice (cheapest and safest)
- Complicated infections o Stones o Obstruction o Catheters o Diabetes or neurologic disease o Recurrent infections
- signs/symptoms o Most common in kids: ▪ Pediatric patients with significant bacteriuria may have no symptoms or nonspecific symptoms like fatigue or anorexia ▪ Frequency (>2hr) ▪ Fever (upper) in some cases ▪ Odiferous urine ▪ Blood or blood-tinged urine ▪ Sometimes no symptoms except generalized sepsis, This is why urine culture is done as part of the septic workup when a child is admitted with FUO. o Nausea/vomiting o Chills o Nocturia/ urgency/bladder spasms/dysuria/burning on urination o Foul-smelling urine/tender and enlarged kidney/ cloudy appearance o Suprapubic or lower back pain (flank pain) o Leukocytosis, positive findings for bacteria, WBCs, RBCs, pyuria, ultrasound, CT scan, IVP
- Causes o Escherichia coli most common pathogen o Streptococci o Staphylococcus saprophyticus o Occasionally fungal and parasitic pathogens ▪ Gram-negative bacilli from GI tract common cause ▪ Fungal generally after multiple antibiotic courses o More common w/ immunosuppressed patients or diabetics
- Diagnosis: o Clean-catch is preferred o U-bag for collection from child o Specimen obtained by catheterization or suprapubic needle aspiration has more accurate results ▪ May be necessary when clean-catch cannot be obtained o Dipstick - to identify presence of nitrates, WBCs, and leukocyte esterase o Confirm w/ micro UA o Microscopic urinalysis o Culture - indicated in complicated or nosocomial, persistent bacteria, or frequently recurring (>2 episodes) ▪ May be cultured if infection is unresponsive to empiric therapy or diagnosis is questionable o Sensitivity testing determines susceptibility to antibiotics o Imaging studies for suspected obstruction (IVP or abdominal CT)
- Treatment o Uncomplicated cystitis—short-term course of antibiotics o Complicated UTIs—long-term treatment o Trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin ▪ TMP-SMX administered every day to prevent recurrence or single dose before events likely to cause UTI o Amoxicillin o Suppressive therapy often effective on short-term basis
▪ Limited because of antibiotic resistance ultimately leading to breakthrough infections
Chapter 29: The Child with Cardiovascular
Dysfunction Cardiac Defects (This is just a lead into the defects not on SG)
- Acquired-Disease process o Infection o Autoimmune response o Environmental factors o Familial tendencies
- Congenital-Anatomic → abnormal function o Causes:
- Maternal drug use
- Fetal alcohol syndrome—50% have CHD
- Maternal illness
- Rubella in first 7 weeks of pregnancy → 50% risk of defects including PDA and pulmonary branch stenosis
- CMV, toxoplasmosis, other viral illnesses → cardiac defects
- IDMs = 10% risk of CHD (VSD, cardiomyopathy, TGA most common) o Hemodynamic characteristics (4 types)
- Increased pulmonary blood flow →(CHF)
- Abnormal connection between two sides of heart o Either the septum or the great vessels such as: ▪ ASD ▪ ASD ▪ Patent Ductus Arteriosus
- Increased blood volume on right side of heart
- Increased pulmonary blood flow
- Decreased systemic blood flow
- Decreased pulmonary blood flow →(cyanosis)
- Tetralogy of Fallot
- Tricuspid atresia
- Obstructive defect decreases blood flow from ventricles
- Obstructed left heart >> CHF o Coarctation of the aorta o Aortic stenosis
- Obstructed right heart >> cyanosis o Pulmonic stenosis
- Mixed blood flow
- Depends on the degree of mixing o Relative desaturation of blood in systemic blood flow. o Cardiac output decreases because of volume load on ventricle.
- May have hypoxemia with or without cyanosis but May also have CHF o Transposition of great vessels o Total anomalous pulmonary venous connection o Hypoplastic heart syndrome (Right and/or Left)
▪ Emboli ▪ LOC ▪ sudden death ▪ seizures
- Treatments: o REPAIRS: usually indicated when TET spells and hyper cyanotic spells increase. ▪ Stage 1: Blalock or modified Blalock shunt >> blood to pulmonary arteries from L or R subclavian artery ▪ Complete repair: Usually in first yr of life. Repair of VSD, resect stenosed area, and patch R ventricular outflow. o Digoxin administration see dig for tox o Chest tubes in children o Cardiac catheterization: ▪ pre-procedure ▪ post procedure care o Knee-Chest Position can help with blood flow
Atrial septal defects (Increased pulmonary blood flow →CHF)
- Opening between the atria
- Because L atrial pressure is slightly higher than R atrial pressure, blood flows from L to R.
- Causes increased flow of oxygenated blood into the R atria. R atria becomes distended.
- Because there is low pulmonary vascular resistance, blood backs up into the pulmonary vessels and the R ventricle becomes distended as well.
- Signs/symptoms: o Because it is under low pressure this is often tolerated very well and the child may be asymptomatic. o Minimal symptoms of pulmonary vascular changes until several decades of unrepaired ASD. o Can here murmur o Atrial enlargment o Risk for.. if not corrected: ▪ Atrial dysrhythmias ▪ Emboli formation
- Medications
- Management: o Can be closed in cardiac cath procedure o Surgical repair w/ patch (usually before age 6)
Rheumatic fever (Acquired-Disease process) 5-15 years old
- Inflammatory disease occurs after group A β-hemolytic streptococcal pharyngitis o Can be asymptotic and go untreated
- Infrequently seen in United States; big problem in Third World
- Self-limiting but complications lead to Rheumatic heart disease. o Affects: ▪ Joints ▪ Skin ▪ Brain ▪ Serous surfaces ▪ Heart (Damage to valves)
- Signs/symptoms: o Carditis - involves endocardium, pericardium, and myocardium; most commonly the mitral valve o Polyarthritis especially in large joints (knees, elbows, hips, shoulders, wrists), edema
▪ Swollen, red, and warm joints for 1-2 days ▪ Fever 1-2 weeks o Erythema marginatum -Transitory rash on trunk and proximal extremities ▪ Red macule w/ clear center and wavy, well-demarcated border and usually on trunk and proximal portion of extremities. o Subcutaneous nodules - small, nontender nodules appear over bony prominences (hands, feet, elbows, scalp, scapulae, vertebrae), persist indefinitely after onset of the disease, and resolve w/ no resulting damage o Chorea which affect CNS MOST disturbing and frustration manifestation ▪ Sudden aimless irregular movement of the extremities ▪ Involuntary facial grimaces ▪ Speech problems ▪ Muscle weakness ▪ Relived by rest o Aschoff bodies -Inflamed hemorrhagic bullous lesions that cause swelling, fragmentation, and alterations in connective tissue. Found in the heart, blood vessels, brain, and on serous surfaces of joints and pleura.
- Management/medication: o Recurrent is a issue so prophylactic is started after the recurrence o Salicylates used to reduce fever and control inflammation ▪ DO NOT give before diagnosis can mask polyarthritis symptoms o Prednisone in some HF o Limit activity or BR
- Prevention is key (prevent RHD) o Treatment of streptococcal tonsillitis/pharyngitis ▪ Penicillin G—IM ×1 Monthly ▪ Penicillin V—oral ×10 days 2Xd ▪ Sulfa—oral ×10 days 1Xd - Erythromycin (if allergic to above)—oral ×10 days o Sore Throat see doctor
- Nursing management o Encourage drug regimens, if complice is issue will do daily dose of oral antibiotics o Rest and nutrient at home o After fever gone return to actives and appetite increase o
Congestive heart failure (Acquired-Disease process)
- Underlying Defect usually
- Impaired myocardial function o MOST COMMON: Tachycardia, decrease BP, and Decrease urine output o fatigue; weakness; restlessness; pale, cool extremities
- Pulmonary congestion o MOST COMMON: whezzing o Tachypnea, dyspnea, respiratory distress, exercise intolerance, cyanosis
- Systemic venous congestion o Peripheral and periorbital edema, weight gain, ascites, hepatomegaly, neck vein distention
- signs/symptoms in pediatrics o Polycythemia o Clubbing o Hypercyanotic spells (TET spells)
- Treatment Goal is decrease demands on the heart
- Tachypnea/tachycardia
- Failure to thrive/poor weight gain/activity intolerance- bc not eating
- Developmental delays- genetic conditions and not thriving
- Prenatal history- no access to care or not seeking care
o Preterm birth; IDM; IUGR more likely to have congenital anomalies than gen pop
- Family history of cardiac disease
o Frequent fetal loss; sudden infant deaths; sudden deaths in adults >> Heart disease
o congenital heart defects
Different in pre/post for kids
o Preparation/explanation geared towards developmental level
o Sedation
o NPO
o Cardiac and pulse oximetry monitoring
o Monitor pulses, temperature, color of extremity
o Vital signs q15, Apical HR
o Intraarterial monitoring of BP
o Dressing for bleeding/hematoma
o Change dressing every day after a heart cath for 2 days
o I&O
o Hypoglycemia
o Allow mom to hold baby but keep affected extremity flat for 4-6 hours
o Tight pressure dressings with med that has a type of coagulant in it
o blood loss- apply pressure above site
o Rest, comfort, and pain management
o Fluid management
o Progression of activity- can return to school but NO strenuous exercise
o NO tube bathing
- Postoperative Complications:
o CHF
o Dysrhythmias
o Decreased cardiac output syndrome
o Decreased peripheral perfusion
o Pulmonary changes
o Neurologic changes
VSD (CHF)
- Defect in ventricular septum—Error in early fetal development
- Can occur anywhere in muscle or membranous ventricular septum
- 20-25% of all CHDs are VSD
- Manifestations o Depends on size of VSD and degree of shunting. o Can be pinhole size to absence of entire septum. o Small to moderate defects may close spontaneously within first yr of life.
- Pathophysiology:
o Pressure is higher in L ventricle than in the R ventricle, so you get shunting of blood o Systemic arterial circulation offers more resistance than the pulmonary circulation; blood flows through the defect and into the pulmonary artery. o R ventricle becomes enlarged (hypertrophied); over time the R atria may also become distended. ▪ Cardiomegaly ▪ Increase pulmonary flow ▪ Leading to pulmonary HTN
- Symptoms: o characteristic murmur o decrease appetite o fever o central cynosis
- Severe cases: o Eisenmenger syndrome: very severe; resistance in pulm blood flow is >> than systemic circulation. Reversal of blood flow through ventricles.
- REPAIRS: o Cath repairs in clinical trials o Surgical repair w/ bypass; pulmonary artery banding (if not too large) or patch
PDA (CHF)
- Increase pulmonary, pulmonary vascular congestion
- Ductus SHOULD close by about 15 hours after birth. Some shunting of blood may occur up to 24 hours of life. DUCTUS closes because increase in arterial oxygen concentration that follows initiation of pulmonary function.
- 5%-10% of all CHDs are PDA. More common in females (about 3:1)
- Patent DA allows blood to flow from left to right.
- Manifestations: o Small PDA may be asymptomatic o Large PDA may be CHF w/ tachypnea, dyspnea, and hoarse cry.
- Symptoms: o BOUNDING peripheral pulses o Widened pulse pressure (>25) o Murmur (“machinery murmur”) at upper left sternal border or in L infraclavicular area. o Murmur audible throughout cardiac cycle
- Management of PDA: o Medical>>Preterm children = INDOMETHACIN to close PDAs; surgical ligation if meds fail o Prophylactic antibx to prevent bacterial endocarditis o Surgery between age 1 and 2 years
Coarctation of the Aorta (COA)
- The aorta is narrowed near the insertion of the ductus arteriosus.
- Increased pressure proximal to the defect.
- Causes: o high BP and bounding pulses in arms o Weak or absent femoral pulses o Cool lower extremities with low BP.
- Signs of CHF in infants. Condition can deteriorate rapidly.
- Older children may c/o: o Dizziness o HA o Fainting
- Mixing of oxygenated and unoxygenated blood in L side of heart o Systemic desaturation o Pulmonary obstruction.
- Treatment: o Need to keep open the PDA or VSD. Kept open with prostaglandin E (continuous infusion) until surgery o Surgery #1 Shunt to increase blood flow to lungs. (Create atrial septotomy if ASD is small) o Surgery #2 Bidirectional Glenn shunt (cavopulmonary anastomosis) at 6-9 months of age o Surgery #3 Fontan (or modified Fontan) Pt must have normal ventricular function and a low pulmonary vascular resistance for the procedure to be successful. Separates mixed blood, but does not restore normal anatomy or hemodynamics. High surgical mortality rate (<10% survival in some centers).
Transposition of Great Vessels
- Pulmonary artery leaves the L ventricle and the aorta exits from the R ventricle.
- No communication between the systemic and pulmonary circulations.
- Must have PDA or septal defect to permit blood flow.
- Surgical TX of choice is arterial switch procedure to resect and reanastomose great vessels. Coronary arteries have to be reimplanted to supply myocardial circulation. Other procedures possible, depending on defect.
- Prior to surgery keep open the PDA and septal defect. admin prostagldins E
Total Anomalous Pulmonary Venous Connection
- Rare defect. Pulmonary veins fail to join L atrium. Pulm. veins drain into L atrium. Results in mixed blood.
- Clinical manifestations: o Usually cyanotic early o Condition rapidly deteriorates as pulmonary blood flow increases o SURG TX: Common pulmonary vein is anastomosed to the L atrium, ASD is closed, and anomalous venous connections ligated. Success depends on specifics of anomalies.
Hypoplastic Left Heart
- Left side of heart is underdeveloped. Left ventricle is small and aortic atresia. Most blood flows across patent foramen ovale to right atrium to right ventricle and out the pulmonary artery. Descending aorta receives blood from the PDA to supply the systemic circulation. PDA closure >> rapid deterioration and CHF.
- TX: Keep ductus open w/ prostaglandin E infusion.
- SURG TX: o #1 is Norwood procedure to create a new aorta using the main pulmonary artery and creation of large ASD. o #2 is bidrectional Glenn shunt at 6-9 months age to reduce volume load on the R ventricle. o #3 is modified Fontan procedure, similar to tricuspid atresia repair. Transplant may be option for some patients. Mortality rate very high (30%-50% mortality rates).
Endocarditis
- Bacterial endocarditis (BE), infective endocarditis (IE), or subacute BE (SBE) o Infection in valves and endocardium o Usually sequelae of sepsis in child w/ cardiac disease or congenital anomaly
- Streptococci, Staphylococci, and Fungal infections
- S/S: o Insidious, malaise, low-grade fever o New murmur or change in previous murmur o Splenomegaly o Osler nodes—red, painful nodes on pads of fingers o Janeway spots—painless hemorrhagic spots on palms and soles
- Prevention: o Prophylactic antibiotics ONLY for highest-risk CHD patients o Recent changes in prophylaxis guidelines o Prophylaxis before dental work, invasive respiratory treatment, or procedures on soft tissue infections o No prophylaxis for GI/GU procedures o Administer prophylaxis 1 hour before procedure o Meticulous dental hygiene
- Treatment: o High-dose ANTBX: Penicillin, ampicillin, methicillin, cloxacillin, streptomycin, or gentamicin o Amphotericin or flucytosine for fungal infections o Treat 2-8 weeks. If unsuccessful → CHF develops, valvular damage
Most common cardiac dysrhythmia is SVT
Chapter 30
Hemophilia: sports, treatment for joint injuries, patho, signs/symptoms
Effect- prolonged bleeding anywhere from or in the body due to clotting deficiencies. Hemorrhage can occur with minor trauma. Sports- physical limitations in regard to sports may be a difficult adjustment and activity restrictions must be tempered with sensitivity to the child’s emotional and physical needs. PT should use protective equipment like helmets, face masks, shin/wrist/forearm guards, kneepads, and other equipment appropriate to the activity to prevent activity. If severe, pt should not participate in contact sports like hockey, football, soccer, or rugby. Risk of injury outweighs social benefit. Pt can participate in sports like swimming, golf, walking, jogging, fishing, and bowling. Tx for joint injury- rest, ice, elevation, splint, elastic wrap, crutches and physical therapy Patho- deficiency of clotting factor 8 produced by the liver and is necessary for the formation of the thromboplastin in the first phase of blood coagulation. The less factor 8 found in the blood, the more severe the disease. It is classified into three groups according to the severity of the factor deficiency. S/S- o subcutaneous and intramuscular hemorrhages o hemarthrosis (bleeding into joint cavities) is most common form of internal bleeding o joint stiffness o tingling o ache in joints o warmth o swelling o redness o severe pain o loss of movement o spontaneous hematuria o epistaxis (nose bleeds) but less common
Aplastic anemia: patho, signs/symptoms, treatment
- Hematopoietic stem cell transplantation (HSCT) is the only potential cure of SCD but it has a high risk of neurologic complications. Quality Patient Outcomes:
- Early recognition of S/S of SCA
- Tissue deoxygenation minimized
- SC crisis prevented or quickly managed
- Pain appropriately managed
- Stroke prevention
- Prophylactic penicillin regimen followed
- Hypoxia prevented when surgery is necessary
- Immunizations administered- pneumonia, flu, and meningococcal Iron deficiency Anemia: s/s, treatment, patient education S/S- severity r/t duration of the severity of the dietary deficiency o Underweight (or overweight if given cows milk) o Pale o Poor muscle development o Edema o Stunted growth o Decreased serum concentration of: albumin, gamma globulin, transferrin o Irritability o Tachycardia o Fatigue o Glossitis o Angular stomatitis o Koilonychia (concave/ spoon fingernails) Tx- optimum nutrition and appropriate iron supplementation Infant tx guidelines:
- Use only breastmilk or formula with 10-12 mg/L for full term or 15 mg/L for preterm
- Iron supplementation of 1mg/kg/d by four to six months of age in full term or 2mg/kg/d for preterm
- Iron drops 2-3mg/kg/d to max 15mg/d after two months of age and iron fortified cereal when food is intro
- Limit formula to 1 L/d to encourage intake of iron fortified foods
- Screening for anemia at 12 months Patient Education-
- Infants younger than 12 months should not be given fresh cows milk (decrease GI blood loss from intolerance of the milk protein)
- Give iron supplements with meals to prevent GI upset
- Give iron supplements with vitamin C to facilitate absorption
- Side effects of iron include- nausea, GI irritation, diarrhea/constipation, and anorexia Quality Patient Outcomes:
- Early recognition of S/S
- Appropriate quantity of milk, use of iron-fortified infant formula, and introduction of solid foods
- Adherence to oral iron supplement and appropriate admin
- Hemoglobin increases within 1 month an anemia resolved within 6 months
DIC: signs/symptoms, treatment S/S- often confused with many other diseases d/t similar s/s when figuring out dx o Petechiae o Purpura o Bleeding from openings in the skin- venipuncture site, surgical incision o Bleeding from umbilicus, trachea (newborn) o Evidence of GI bleed o Hypotension o Organ dysfunction from infarction or ischemia Tx- o Treat the underlying cause, which in most instances stops the coagulation problem spontaneously. o Platelets and fresh plasma may be necessary to replace plasma components o Ill newborns may need a blood transfusion o No response to treatment = heparin therapy may be initiated Chapter 31 Signs and symptoms of cancer in kids: generalized (box 31-1) S/S- o Unusual mass or swelling o Unexplained paleness and loss of energy o Sudden tendency to bruise o Persistent, localized pain or limping o Prolonged, unexplained fever or illness o Frequent headaches, often with vomiting o Sudden eye or vision changes o Excessive, rapid weight loss Wilms Tumor: Nx interventions Abdominal tumor- usually r/t kidney Management- similar to other cancers treated with surgery, irradiation, and chemo Preoperative care- o Care for family’s emotional needs regarding dx o Surgery scheduled within 24-48 hr once admitted o Labs o Monitor vitals (HTN from excess renin production is possible) o DO NOT PALPATE THE TUMOR UNLESS ABSOLUTELY NECESSARY= MAY CAUSE DISSEMINATION OF CANCER CELLS ELSEWHERE o Post caution sign on pt door “Do not palpate abdomen” o Parent education on what to expect with tx- s/e, benefits, risks, cautions Postoperative care-
- Head
- Do not use lotion/ creams
- Consult provider for specific care o Parotitis, sore throat, loss of taste, dry mouth
- Analgesics
- Regular dental care
- Urinary bladder o Rarely cystitis - Encourage liberal fluid intake and frequent voiding
- Bone Marrow o Myelosuppression - Admin abx - Sepsis workup - No rectal temps - Observe for bleeding and anemia Activities to avoid in myelosuppression - No fresh fruit or flowers
- Positive pressure precaution/ isolation
- Monitor for signs of infection Bone Marrow Transplants
- Remove marrow and use growth factors to promote engraftment of transplanted stem cells
- Usually hospitalized for several weeks
- Procedures: o Insertion of the venous access device (port) o Chemo and/or radiation o Strict infection precaution (hygiene and limited visitors)
- Prevent GVHD – if severe and organ involvement occurs, death can ensue
- Meds to prevent include- cyclosporine, tacrolimus, and methotrexate (all can increase risk of infection- monitor closely)
- Monitor for skin breakdown and delayed wound healing- give sitz baths and use protective skin barrriers
- Support the family Retinoblastoma: Signs/symptoms, treatments S/S- o Glow in pupil (cats reflex/ leukocoria) o White glow if tumor is small o Strabismus (cross eyed) o Heterochromia (different color iris) o Glaucoma o Pain o Blindness (late sign) Tx- o Enucleation (no salvage of vision) o Irradiation used when there’s vitreous seeding o Chemotherapy to shrink tumor before plaque brachytherapy o Photocoagulation- laser beam used to destroy retinal blood vessels that supply to tumor o Cryotherapy- freeze and destroy tumor o Meds- vincristine, carboplatin, etoposide most common
** IF they have to take eyeball out, show picture of other children with implants to make them feel more comfortable, reassure that the affected eye likely wouldn’t have vision anyway, and explain procedure- take eye out (gentle and doesn’t damage tissue or tear ducts, it’s like “taking a nut out of the shell”, placing a sphere to keep the shape then once implant is made and ready, implantation.
