Care of the Child and Family

Care of the Child and Family
PEDIATRIC NURSING Care of the Child and Family

Developmental Theorists
Maslow’s Hierarchy of Needs (1954) Erik Erikson - Psychosocial Theory Jean Piaget - Cognitive Theory

Maslow’s Hierarchy of Needs
Principles: An individual’s needs are depicted in ascending levels on the hierarchy Needs at one level must be met before one can focus on a higher level need Levels of Maslow’s Hierarchy of Needs: Physiologic/Survival Needs Safety and Security Needs Affection or Belonging Needs Self-esteem/Respect Needs Self-actualization Needs Physiologic/Survival Needs: Basic human needs for food, water, elimination, oxygen, physical and mental rest, activity and avoidance of pain. Safety and Security Needs: Protection from physical harm (mechanical, thermal, chemical, infectious) Interpersonal, economic and emotional security Affection or Belonging Needs: Giving and receiving affection Sense of belonging in a family or group Self-esteem/Respect Needs: Feelings of self-worth Need for recognition/Rewards Self-actualization Needs: Highest level of the Hierarchy – not achieved by all Feeling of achievement or competency Independence

Erikson’s Psychosocial Theory
Birth to 1 year: Trust vs. Mistrust 1 – 3 years: Autonomy vs. Shame & Doubt 3 – 6 years: Initiative vs Guilt 6 – 12 years: Industry vs. Inferiority 12 – 18 years: Identity vs. Role Confusion Young Adults: Intimacy vs. Isolation These are the issues which are to be resolved. (example resolve to trust vs. mistrusting) The goals are for the child to develop the positive traits (Trust, Autonomy, Initiative, Industry, Identity and Intimacy)

TRUST VS. MISTRUST Birth - 1 year World/Self is good Basic needs met
Met = happy baby Unmet = crying, tense, clinging Stranger Anxiety Separation Anxiety Photo Source: Del Mar Image Library; Used with permission

AUTONOMY VS. SHAME & DOUBT
1 – 3 years Sense of control Exerts self/will Pride in self-accomplishment Negativism Ritualism/Routines Parallel play Photo Source: Del Mar Image Library; Used with permission

INITIATIVE VS. GUILT 3 – 6 years “Can-do” attitude
Behavior is goal-directed and imaginative Play is work Be careful with criticism Photo Source: Del Mar Image Library; Used with permission

INDUSTRY VS. INFERIORITY
6 – 12 years Mastery of skills Peers in both play and work Rules important Competition Predictability Photo Source: Del Mar Image Library; Used with permission

IDENTITY VS. ROLE CONFUSION
years Sense of “I” Peers are very important Independence from parents Self-image Photo Source: Del Mar Image Library; Used with permission

Piaget’s Cognitive Theory
Development of Thought Processes: 30 – 2 years: Sensorimotor 32 – 7 years: Preoperational 37 – 11 years: Concrete Operations 311 years + : Formal Operations Sensorimotor: Reflexes, repetition of acts Preconceptual: No cause and effect reasoning; egocentrism; use of symbols; magical thinking Intuitive/Preoperational: Beginning to understand cause and effect (causation) Concrete Operations: Judgment that a quantity is the same despite a difference in its appearance. Formal Operations: Abstract thought, reality

SENSORIMOTOR Reflexive behavior leads to intentional behavior
Birth - 2 years Reflexive behavior leads to intentional behavior Egocentric view of world Cognitive parallels motor development Object Permanence

PREOPERATIONAL THOUGHT
2 - 7 years Egocentric thinking Magical thinking Dominated by self-perception Animism No irreversibility Thoughts cause actions Photo Source: Del Mar Image Library; Used with permission

CONCRETE OPERATIONS 7 - 11 years Systematic/logical Fact from fantasy
Sense of time Problem solve Reversibility Cause & effect Humor Photo Source: Del Mar Image Library; Used with permission

FORMAL OPERATIONS Abstract thinking Analyze situations
11 years - Adult Abstract thinking Analyze situations New ideas created Factors altering this: Poor comprehension Lack of education Substance abuse Photo Source: Del Mar Image Library; Used with permission

TOYS = Mirror, Music, Mobile
Infant Physical Tasks Physical Tasks: months: Fastest growth period Gains 5-7 oz ( g) weekly for 6 months Grows 1 inch (2.5 cm) monthly for 6 months Head circumference is equal to or larger than chest circumference Posterior fontanel closes at 2-3 months* Obligate nose breathers* Vital signs: HR and RR faster and irregular* Motor: behavior is reflex controlled sits with or without support at 6 mo* rolls from abdomen to back Sensory: able to differentiate between light and dark hearing and touch well developed TOYS = Mirror, Music, Mobile

Infant Physical Tasks Physical Tasks 6 - 12 months:
Gains 3-5 oz (84-140g) weekly for next 6 months * triples weight by 12 months Gains 1/2 in (1.25 cm) monthly for next 6 months Teeth begin to come in Motor: Intentional rolling over from back to abdomen* Starts crawling and pulling to a stand* Develops pincer grasp* Sits without support by 9 months* Sensory: Can fixate on and follow objects Localizes sounds

Infant Psychosocial Tasks
Vocalizations: Distinction in cry at 1 month Coos at 3 months Begins to imitate sound at 6 months – babbles Verbalizes all vowels at 9 months Can say 4–5 words at 12 months Socialization: Social smile at 2 months Demands attention & social interaction at 4 months Stranger anxiety & comfort habits begin at 6 months* Separation anxiety develops at 9 months* Photo Source: Del Mar Image Library; Used with permission

Infant Cognitive Tasks
Neonates Reflexes only 1-4 months Recognizes faces Smiles and shows pleasure Discovers own body and surroundings 5-6 months Begins to imitate 7-9 months Searches for dropped objects *Object Permanence begins Responds to simple commands Responds to adult anger 10-12 months Recognizes objects by name Looks at and follows pictures in books

Toddler Physical Tasks: Motor Tasks: Slow growth period
Gains 11 lbs (5 kg) Grows 8 inches (20.3 cm) Anterior fontanel closes at months* Primary dentition (20 teeth) complete by 2½ years Develops sphincter control – toilet training possible* Motor Tasks: Walks alone by months* Climbs and runs fairly well by 2 years Rides tricycle well by 3 years Photo Source: Del Mar Image Library; Used with permission

Toddler Cognitive Tasks
Follows simple directions by 2 years Uses short sentences by 18 months *favorite words “no” and “mine” = Autonomy Knows own name by 12 months, refers to self Achieves object permanence Uses “magical” thinking Uses ritualistic behavior Repeats skills to master them and decrease anxiety Egocentric thinking - thoughts cause actions

Toddler Psychosocial Tasks
Increases independence Able to help with dressing self Temper tantrums (autonomy) Beginning awareness of ownership (me and mine) Shares possessions by 3 years Vocabulary increases to over 900 words Toilet training Fears: separation anxiety, loss of control Toilet training usually completed by 3 years: 18 months: bowel control 2 – 3 years: daytime bladder control 3 – 4 years: nighttime bladder control Separation Anxiety: Fears strangers less Bedtime might be looked upon as desertion. Learning to tolerate and master brief periods of separation, increased understanding of object permanence helps decrease anxiety Typical patterns of response to separation: Protest: screams and cries when caregiver leaves,attempts to call caregiver back Despair: whimpers, clutches at transitional object, curls up in bed, decreased activity, rocking Denial: Resumes normal activity but does not form psychosocial relationships, ignores caregiver when caregiver returns TOYS = Push-pull toys, large blocks

Preschooler Physical Tasks: Motor Tasks: Slow growth rate continues
Weight increases 4-6 lbs (1.8–2.7 kg) a year Height increases 2½ inches ( cm) a year Permanent teeth appear Motor Tasks: Walks up & down stairs Skips and hops on alternate feet Throws and catches ball, jumps rope Hand dominance appears Ties shoes and handles scissors well Builds tower of blocks Photo Source: Del Mar Image Library; Used with permission

Preschooler Cognitive Tasks
Can only focus on one idea at a time Begins awareness of racial and sexual differences Develops an understanding of time Learns sequence of daily events Able to understand some time-oriented words Begins to understand the concept of causality Has 2,000 word vocabulary Is very inquisitive and curious

Preschooler Psychosocial Tasks
Becomes independent Gender-specific behavior is evident by 5 years Egocentricity changes to awareness of others Understands sharing Aggressiveness and impatience peak at 4 years Eager to please and shows more manners by 5 years Behavior is goal-directed and imaginative Play is work* TOYS = Dolls, Dress-up, Imagination

Preschooler Psychosocial Tasks
Fears: about body integrity (Fear & Injury) are common Magical and animistic thinking allows illogical fears to develop* Observing injuries or pain of others can precipitate fear Able to imagine an event without experiencing it Guilt and shame are common*

School-age Physical Tasks: Slow growth continues
Weight doubles over this period Gains 2 inches (5 cm) per year At age 9, both sexes are the same size At age 12, girls are bigger than boys Very limber but susceptible to bone fractures Develops smoothness & speed in fine motor skills Energetic, developing large muscle coordination, stamina & strength Has all permanent teeth by age 12 Photo Source: Del Mar Image Library; Used with permission

School-Age Cognitive Tasks
Period of Industry: Likes to accomplish or produce Interested in exploration & adventure Develops confidence Rules become important* Concepts of time and space develop: Understands causality, permanence of mass & volume Masters the concepts of conservation, reversibility, arithmetic and reading Develops classification skills Begins to understand cause and effect*

School-Age Psychosocial Tasks
School occupies half of waking hours; has cognitive and social impact on child Morality develops Peer relationships start to be developed Enjoys family activities Has increased self-direction - tasks are important Has some ability to evaluate own strengths & weaknesses Enjoys organizational activities (sports, scouts, etc.)* Modesty develops as child becomes aware of own body* TOYS = Board games, computer games, learning activities

Adolescent Physical tasks: Period of rapid growth Puberty starts
Girls: height increases 3 inches/year Boys: growth spurt around 13-yrs-old height increases 4 inches/year weight doubles between yrs Body shape changes: Girls have fat deposits in thighs, hips & breast, pelvis broadens Boys become leaner with a broader chest Photo Source: Del Mar Image Library; Used with permission

Adolescent Sexual Development Girls Boys
Breasts develop Facial Hair growth Menses begins Voice changes First 1 –2 years infertile Enlargement of testes at 13 yrs Nocturnal emission during sleep Reaches reproductive maturity with viable sperm at 17 yrs

Adolescent Cognitive Tasks
Develops abstract thinking abilities Often unrealistic Sense of invincibility = risk taking behavior* Capable of scientific reasoning and formal logic Enjoys intellectual abilities Able to view problems comprehensively ACTIVITIES = Music, video games, communication with peers

Adolescent Psychosocial Tasks
Early Adolescent: Prone to mood swings Needs limits and consistent discipline Changes in body alter self-concept Fantasy life, daydreams, crushes are normal Middle Adolescent: Separate from parents Identify own values and define self* Partakes/conforms to peer group/values* Increased sexual interest May form a “love” relationship Formal sex education begins

Adolescent Psychosocial Tasks
Late Adolescent: Achieves greater independence* Chooses a vocation Finds an identity* Finds a mate Develops own morality Completes physical and emotional maturity Fears: Threats to body image – acne, obesity Rejection Injury or death, but have sense of “invincibility” The unknown

Let’s Review A 10 month-old baby was admitted to the pediatric unit. Each time the nurse enters the room the baby begins to cry. The most appropriate action by the nurse would be to: A. Complete all procedures quickly in order to decrease the amount of time the baby will cry. B. Ask another nurse to assist you with the baby’s care. C. Distract the baby. D. Encourage the parent to stay by the bedside and assist with the care.

Let’s Review A 6 month-old is admitted to the pediatric unit for a 3 week course of treatment. The infant’s parents cannot visit except on weekends. Which action by the nurse indicates an understanding of the emotional needs of an infant? A. Telling the parents that frequent visits are unnecessary. B. Placing the infant in a room away from other children. C. Assigning the infant to different nurses for varied contacts. D. Assigning the infant to the same nurse as much as possible.

Let’s Review Which child is most likely to be frightened by hospitalization? A. 4 month-old admitted with a diagnosis of bronchiolitis. B. 2 year-old admitted with a diagnosis of cystic fibrosis. C. 9 year-old admitted with a diagnosis of abdominal pain. D. 15 year-old admitted with a diagnosis of a fractured femur.

Infant Nutrition Birth – 6 months: 6 - 12 months:
Breast milk is most complete diet Iron-fortified formulas are acceptable No solid foods before 4 months* months: Breast milk or formula continues* Diluted juices can be introduced Introduction of solid foods*(4-6 mo): cereal, vegetables, fruits, meats Finger foods at 9-10 months Chopped table foods at 12 months Gradual weaning from bottle/breast No honey (risk for botulism)

Toddler Nutrition Able to feed self – autonomy & messy!
Appetite decreases- physiologic anorexia Negativism may interfere with eating Needs 16 – 20 oz. milk/day Increased need for calcium, iron, and phosphorus – risk for iron deficiency anemia Caloric requirements is 100 calories/kg/day No peanuts under 3 years of age (allergies)* Do not restrict fats less than 2 years of age* Choking is a hazard (no nuts, hot dogs, popcorn, grapes)* Photo Source: Del Mar Image Library; Used with permission

Preschooler Nutrition
Caloric requirements is 90 calories/kg/day May demonstrate strong taste preferences 4 years old – picky eaters 5 years old – influenced by food habits of others Able to start social side of eating More likely to try new foods if they assist in food preparation Establish good eating habits - obesity

School-Age Nutrition Caloric needs diminish, only need 85 kcal/kg
Foundation laid for increased growth needs Likes and dislikes are well established “Junk” food becomes a problem Busy schedules – breakfast is important Obesity continues to be a risk Nutrition education should be integrated into the school program

Adolescent Nutrition Nutritional requirements peak during years of maximum growth: Age 10 – 12 in girls Age 14 – 16 in boys Food intake needs to be balanced with energy expenditures Increased needs for: Calcium for skeletal growth Iron for increased muscle mass and blood cell development Zinc for development of skeletal, muscle tissue and sexual maturation Photo Source: Del Mar Image Library; Used with permission

Adolescent Nutrition (continued)
Eating and attitudes towards food are primarily family/peer centered Skipping breakfast, increased junk food, decreased fruits, veggies, milk Boys eat foods high in calories. Girls under-eat or have inadequate nutrient intake.

Let’s Review The nurse recommends to parents that popcorn and peanuts are not good snacks for toddlers. The nurse’s rationale for this action is: A. They are low in nutritive value. B. They cannot be entirely digested. C. They can be easily aspirated. D. They are high in sodium.

Let’s Review Nutrition is an important aspect of health promotion for the infant. Priority information to give the parents concerning infant nutrition would include (check all that apply): A. Restrict the fat intake of the infant to help reduce the chances of an obese child. B. Breast or infant formula must be continued for the first year. C. Encourage the use of a pacifier for non-nutritive sucking needs. D. Introduction of solid foods should begin at 4-6 months.

Play is the work of Children
Enhances Motor Skills Enhances Social Skills Enhances Verbal Skills Expresses Creativity Decreases Stress Helps Solve Problems

Appropriate Play Activities
Infants - Solitary Play, stimulation of senses (music, mirror) Toddler - Parallel Play, make believe, locomotion (push-pull toys), gross & fine motor, outlet for aggression & autonomy Preschooler - Associative Play, Imaginary Playmate, dramatic & imitative, gross & fine motor School Age - Cooperative Play, rules dominate play, team games/sports, quiet games/activities, joke books Adolescent - Group activities predominate, activities involving the opposite sex in later years

Preparation for Procedures
Allow child to play with equipment Demonstrate procedure on doll for young child Use age-appropriate teaching activities Describe expected sensations Use simple explanations Clarify any misconceptions Involve parents in comforting child Praise/reward child when finished Photo Source: Del Mar Image Library; Used with permission

Communicating with Children
Provide a trusting environment Get down to child’s eye level Use words appropriate for age Always explain what you are doing Always be honest Allow choices when possible Allow child to show feelings/talk

Let’s Review The single most important factor for the nurse to recognize when communicating with a child is: A. The child’s chronological age. B. Presence or absence of the child’s parents. C. Developmental level of the child. D. Nonverbal behaviors of the child.

Health Promotion Childhood Immunizations Well child check-ups
Nutrition Screenings throughout childhood (APGARS, newborn screenings, lead poisoning, vision/hearing, scoliosis) Health Teaching Immunizations developed to prevent serious life threatening communicable diseases such as small pox, diphtheria and polio. Immunity is the ability to fight or conquer infections. Natural immunity is present from birth and is the most basic form of resistance to disease. Acquired immunity occurs after birth and it takes time to be protected against disease. Active immunity is when the body actively manufactures antibodies against antigens. It takes time but can be considered permanent immunity. Antigens are introduced via a vaccine or by having a specific disease. Passive immunity involves receiving antibodies against antigens that were manufactured somewhere other than the person’s body. It is effective immediately but short- lived. It is acquired through injections of serums obtaining antibodies and must be repeated at timed intervals to continue immunity. Immunosuppressed means the body is not able to manufacture antibodies against antigens and therefore is more susceptible to becoming infected with a disease. Immunizations of live or weakened virus should not be administered. Considerations for immunization schedule: started at birth and continued until about 7th grade if schedule is interrupted it is not necessary to repeat, just continue with the next dose when seen by the doctor. if immunization status is unknown, start appropriate immunizations series – the child is considered susceptible until series is completed if NOT IMMUNIZED during the first year of life and who are less than 7 yrs the same schedule is given but with different time intervals For children greater than 7 who are not immunized Td, Adult Tetanus Toxoid and Diphtheria Toxoid is adminstered. Pertusssis is not given to children greater than 7 due to increase complications from the vaccine Contraindications for immunizations: Severe allergic reaction to a vaccine Anaphylactic reaction to a component of the vaccine (ie eggs, neomycin, streptomycin) mmunocompromised persons (HIV, chemotherapy, steroids, radiation) Pregnant female-Tuberculin testing: skin test is the only practical tool to diagnose tuberculosis. Routine testing is no longer recommended. Positive reaction signifies infection with Mycobacterium Tuberculosis indicates further need for evaluation and treatment

Immunizations Primary prevention of many communicable diseases
Vaccines safety MMR vaccine and autism (no correlation) Reactions (pre-medicate with Tylenol) Live attenuated vaccines (MMR, Varicella) Weakened form of disease Body produces immune response Contraindicated in immunosupressed individuals Inactivated (killed virus/bacteria or synthetic) 1st dose only “primes” system- immunity develops after 3rd

Injury Prevention & Safety Issues
Accidents are the leading cause of death in infants and toddlers (falls, burns, poisons) Toddlers and Preschoolers – drowning School-age and adolescents – motor vehicle accidents and firearms 90% of all accidents are preventable! Safety education is the answer

Injury Prevention Methods of Injury Prevention Precipitating Factors
Understanding and Applying Growth and Developmental Principles Anticipatory Guidance Childproofing the environment Educating caregivers and children Legislation Precipitating Factors Potential Outcomes Infants: totally dependent on adults for maintenance of a safe environment Toddler: more mobile/active, impatient, urge to investigate, imitate; likes climbing, jumping, running, uncoordinated Preschooler: very curious, exploring neighborhood, likes running, climbing, riding bikes; can accept and respond to teaching but still needs supervision/guidance School-Age and Adolescent: taking chances/dares, sports injuries, peer pressure to learn to drive, take drugs, drink. Safety issues: Infants: Use of car seats prevent suffocation – no fluffy pillows, stuffed animals, or soft mattresses to prevent choking – keep cords and small objects away from baby. Prevent burns – check hot water temperature, cover electrical sockets, hide electrical wires prevent falls – make sure crib rails up at all times, Secure child in high chair or infant seats, gate all stairwells, secure all window screens and windows prevent ingestions – lock up cleaners and medicines, Check and remove all lead paints from house Toddlers: Use car seats – greater than 20 lb (9kg) should be forward facing now prevent burns – turn pot handles inward, don’t leave hot liquids on tables. Prevent drownings – supervise near water, teach water safety/swimming prevent choking – avoid large chunks of food. Prevent accidents – supervise play outdoors Preschooler: May need to use booster seat with lap and shoulder restraint systems until 6 years of age and 60 lbs Similar issues as toddler Education of potential dangers/injury prevention with children starts. School age child: Incidence of accidents decrease. Motor Vehicle Crashes are the most common cause of serious death and injury. Safety issues regarding common sports activities – riding bikes, rollerblading, skateboarding, surfing, soccer, football, baseball, skiing, snowboarding. Education and supervision are key elements to prevention. Adolescent: Accidents are the leading cause of death – sports injuries, firearms accidents, motor vehicle crashes ,gangs, drug and alcohol use may be a serious problem during this period. Adolescent characteristics of poor impulse control and recklessness make prevention complex. Safety measures include education about proper use of equipment and caution concerning risk taking behavior. Suicidal behaviors have increased over the last several years. Proper use of equipment/machinery. Identification of risk-taking behaviors . Legislation: Government can help prevent injuries by passing laws to safeguard our children – seat belt laws, safe toys, riding unrestrained in back of pick up trucks. Precipitating Factors: Arguments or tension in the home, changes in routine Tired child/tired parents inadequate babysitting hungry child, illness in immediate family member. Potential Outcomes: temporary incapacitation, permanent disfigurement. DEATH

First Intervention is to call POISON CONTROL CENTER
Pediatric Poisonings Highest incidence occurs in children in 2-year-old age group and under 6 years of age Major contributing factor – improper storage, allowing children to play with “bottles” – rattling of pills, “drink” syrups, toxic portion of plants. Teach parents about proper storage Knowledge of plants in household, and keep away from infants and children who might “chew” Emergency treatment depends on agent ingested Teach parents to have poison control number available Refer to appropriate method according to substance ingested First Intervention is to call POISON CONTROL CENTER

Types of Poisonings Lead Poisoning Salicylate Poisoning
Acetaminophen Ingestion

Lead Poisoning Major environmental health concern
Found in older homes (built before 1978), lead-contaminated soil, water through lead pipes, lead-based paint in ceramics products, Mexican candies made in lead containers Body rapidly absorbs lead – specially in periods of rapid growth – most harmful to children under 6 years Absorbed in GI tract and accumulates in bones, brain, kidneys Low levels in blood can cause behavioral/learning problems, mid-levels anemia-like symptoms and skeletal growth interference, and high levels can be fatal from CNS edema and encephalopathy Diet high in fat, low in iron & calcium can increase lead absorption Intervention=teaching for prevention. If blood level ≥ 45, chelation therapy is needed – monitor kidney function during treatment.

Salicylate Poisoning Can be acute or chronic ingestion
S/S = nausea, disorientation, vomiting, dehydration, hyperpyrexia, oliguria, coma, bleeding tendencies, tinnitus, seizures Nursing interventions = activated charcoal, sodium bicarbonate for metabolic acidosis, external cooling measures for hyperpyrexia, anticonvulsant and seizure precautions (think patient safety!), vitamin K for bleeding, possible hemo (NOT peritoneal) dialysis

Acetaminophen Poisoning
Most common drug poisoning in children Acute ingestion S/S start as nausea, vomiting, pallor, sweating » hepatic involvement (jaundice, confusion, coagulation problems, RUQ pain) Treatment is activated charcoal first, then the antidote N-acetylcysteine (Mucomyst) PO every 4 hours for 17 doses after a loading dose given Always assess Level of Consciousness (LOC) before administering PO med!

Let’s Review Which would be the best approach for gastric emptying in a lethargic 18-month-old who ingested antihistamine tablets an hour ago? A. Diluting toxic substance with water or milk B. Administering naloxone (Narcan) C. Gastric lavage D. Administering ipecac syrup

Physical Assessment of Infant
Assessment is NOT in the head-to-toe manner When quiet, auscultate heart, lungs, abdomen Assess heart & respiratory rates before temperature Palpate and percuss same areas Perform traumatic procedures last Elicit reflexes as body part examined Elicit Moro reflex last Encourage caretaker to hold infant during exam Distract with soft voice, offer pacifier, music or toy Rooting-Touch/stroke cheek side of mouth-3-4 months; Extrusion-touch tongue force outward-4 months, plantar, Grasp-touch palms of hand/soles of feet/flexion 3-8months, Babinski-Stroke outer sole of foot upward from heel and across ball of foot- 1 yr, Tonic neck on back-1 arm and leg flexed on one side of body, other extended; Dance – Hold under arms and let feet touch hard surface-3-4 months, Crawl- place on abdomen-6 weeks, Moro-Sudden jarring/change in equilibrium causes sudden extension and abduction of extremities and fanning of fingers ; 3-4 months; “startle”-Sudden loud noise causes abduction of arms with flexion of elbows/hands clenched – 4months

Physical Assessment of Toddler
Inspect body areas through play – “count fingers and toes” Allow toddler to handle equipment during assessment and distract with toys and bubbles Use minimal physical contact initially Perform traumatic procedures last Introduce equipment slowly Auscultate, percuss, palpate when quiet Give choices whenever possible Photo Source: Del Mar Image Library; Used with permission

Physical Assessment of Preschooler
If cooperative, proceed with head-to-toe If uncooperative, proceed as with toddler Request self undressing and allow to wear underpants Allow child to handle equipment used in assessment Don’t forget “magical thinking” Make up “story” about steps of the procedure Give choices when possible If proceed as game, will gain cooperation Photo Source: Del Mar Image Library; Used with permission

Physical Assessment of School-Age Child
Proceed in head-to-toe May examine genitalia last in older children Respect need for privacy – remember modesty! Explain purpose of equipment and significance Teach about body function and care of body

Physical Assessment of the Adolescent
Ask adolescent if he/she would like parent/caretaker present during interview/assessment Provide privacy Head-to-toe assessment appropriate Incorporate questions/assessment related to genitals/sexuality in middle of exam Answer questions in a straightforward, non- condescending manner Include the adolescent in planning their care

Fever Causes – Often unknown, may be due to dehydration, most often viral induced Danger in infants is febrile seizures – most common between 3 months to five years. The seizure is a result of how quickly the temperature rises. Hydration (20mls/kg is formula for bolus) Antipyretics – acetaminophen or ibuprofen Cooling measures – avoid shivering Tepid bath Remove excess clothing and blankets Cooling blankets/mattresses NO ICE PACKS! Metabolic rate increases 10% for every 1 centimeter increase in temperature – 3-5 times during shivering. - Increases Oxygen, fluid and caloric requirements. Especially hazardous if cardiovascular/neuro system already compromised Shivering is the body’s way of maintaining the elevated set point by producing heat-Compensatory shivering greatly increases metabolic requirements above those already caused by the fever.

Pediatric Differences Fluid & Electrolyte
Percent Body Water compared to Total Body Weight: Premature infants: 90% water Infants: % water Child: 64% water Higher percentage of water in extracellular fluid in infants Infants and toddlers more vulnerable to fluid and electrolyte disturbances Concentrating abilities of kidneys not fully mature until 2 years Metabolic rate is 2-3 times higher than an adult Greater body surface area per kg body weight than adults; dehydrates more quickly

Dehydration Types: Isotonic – Most common; salt and water lost. Greatest threat – Hypovolemic Shock Hypotonic – Electrolyte deficit exceeds water deficit- physical signs more severe with smaller fluid losses Hypertonic – Water loss higher than electrolyte Vomiting leads to metabolic alkalosis Diarrhea leads to metabolic acidosis LAB WATCH: monitor sodium, potassium, chloride, carbon dioxide, BUN, and creatinine ECF constitutes more than ½ body water and thus greater relative content of sodium and chloride- birth to 2 yrs. Infant’s greater body surface allows larger quantities of fluid loss thru skin. BMR higher to support growth. Kidneys unable to concentrate or dilute urine to conserve or excrete sodium and acidify urine – more prone to dehydration with concentrated formulas or overhydrated with excessive fluids. Nursing Tip: 1 g wet diaper = 1 ml urine

Assessment of Dehydration
Skin gray, cold, mottled, poor to fair, dry or clammy Delayed capillary refill Mucous membranes/lips dry Eyes and fontanels sunken No tears present when crying Pulse and respirations rapid Irritability to lethargy depending on cause and severity, not responsive to parent and/or environment

Dehydration: Nursing Interventions
Daily weight, I/O Assess hydration status Assess neurological status Monitor labs (electrolytes) Rehydrate with fluids both PO and IV (20 mls/kg of NS) Diet progression: Pedialyte modified Bread-Rice-Apple Juice-Toast (BRAT)  Diet-for-age (DFA) Skin care for diaper rash Stool output (Amount, Color, Consistency, Texture - ACCT) HANDWASHING! Priorities: fluid replacement & assess for S/S of shock

Diarrhea Often specific etiology unknown, but rotavirus is most common cause of gastroenteritis in infants and kids Don’t forget contact precautions!! Leading cause of illness in children younger than 5 May result in fatality if not treated properly History very important Treatment aimed at correcting fluid imbalance and treating underlying cause Metabolic acidosis = blood pH < 7.35 NPO to see if diarrhea limits itself; ORT treatment of choice – avoid sweetened beverages, carbonated soft drinks and chicken or beef broth initially. If this doesn’t work and diarrhea continues, IV fluids and NPO. Oral Rehydration Sols (ORS) Approx 10ml/kg or ¼-1 cup ORS for each diarrhea stool

Vomiting Often result of infections, improper feeding techniques, GI blockage (pyloric stenosis), emotional factors Management directed toward detection, treatment of cause and prevention of complications Metabolic alkalosis = blood pH >7.45 Teaching for proper positioning during and after feeding; blockage – NPO or special feeding techniques; maintain hydration-prevent dehydration; proper treatment of infection; administer antiemetics

Let’s Review The most appropriate type of IV fluid to infuse in treatment of extra-cellular dehydration in children is: A. Isotonic solution. B. Hypotonic solution. C. Hypertonic solution. D. Colloid solution.

Let’s Review Which laboratory finding would help to identify that a child experiencing metabolic acidosis? A. Serum potassium of 3.8 B. Arterial pH of 7.32 C. Serum carbon dioxide of 24 D. Serum sodium of 136

Pain Assessment: Infants
Assessment of pain includes the use of pain scales that usually evaluate indicators of pain such as cry, breathing patterns, facial expressions, position of extremities, and state of alertness Examples: FLACC scale, NIPS scale

Pain Assessment: Toddlers
Toddlers may have a word that is used for pain (“owie,” “boo-boo,” “ouch” or “no”); be sure to use term that toddler is familiar with when assessing. Can also use FLACC scale, or Oucher scale (for older toddlers)

Pain Assessment: Preschoolers
Think pain will magically go away May deny pain to avoid medicine/injections Able to describe location and intensity of pain FACES scale, poker chips and Oucher scale may be used Photo Source: Del Mar Image Library; Used with permission

Pain Assessment: Older Children
Older children can describe pain with location and intensity Nonverbal cues important, may become quiet or withdrawn Can use scales like Wong’s FACES scale, poker chips, visual analog scales, and numeric rating scales

Let’s Review The nurse begins a full assessment on a 10 year-old patient. To ensure full cooperation from this patient it is most important for the nurse to: A. Approach the assessment as a game to play. B. Provide privacy for the patient. C. Encourage the friend visiting to stay at the bedside to observe. D. Instruct the child to assist the nurse in the assessment.

Let’s Review During a routine health care visit a parent asks the nurse why her 10 month-old infant is not walking as her older child did at the same age. Which response by the nurse best demonstrates an understanding of child development? A. “Babies progress at different rates. Your infant’s development is within normal limits.” B. “If she is pulling up, you can help her by holding her hand.” C. “She’s a little behind in her physical milestones.” D. “You can strengthen her leg muscles with special exercises to make her stronger.”

Let’s Review When assessing a toddler identify the order in which you would complete the assessment: Ear exam with otoscope Vital signs Lung assessment Abdominal assessment

Let’s Review When assessing pain in an infant it would be inappropriate to assess for: Facial expressions Localization of pain Crying Extremity movement

Nursing intervention is supporting parents and resources
Genetic Disorders 7 Principles of Inheritance g Autosomal Dominant g Autosomal Recessive g Sex-linked (X-linked) Inheritance g Chromosome Alterations 7Down’s Syndrome 7Tay-Sachs Disease Nursing intervention is supporting parents and resources

* Feeding is often a problem in infancy *
Down’s Syndrome Most common cause of cognitive impairment (moderate to severe) 1 in 600 live births Risk factor- pregnancy in women over 35 yrs old Cause - extra chromosome 21 (faulty cell division) Causes change in normal embryogenesis process resulting in: Cardiac defects, GI conditions, Endocrine disorders, Hematologic abnormalities, Dermatologic changes Physical features: small head, flat facial profile, broad flat nose, small mouth, protruding tongue, low set ears, transverse palmar creases, hypotonia * Feeding is often a problem in infancy *

Tay-Sachs Disease Occurs predominately in children of Eastern European Jewish ancestry Fatal Disease - death usually occurs before age 4 Autosomal recessive inheritance Degenerative brain disease Caused by absence of hexosainidase A from body tissue Symptoms: progressive lethargy in previously healthy 2-6 months old infants, loss of milestones, visual acuity, seizures, hyper-reflexia, posturing, malnutrition, dysphagia Diagnosis: Classic cherry red spot on macula, enzyme measurement in serum, amniotic fluid, white cells

Let’s Review The infant with Down’s Syndrome is closely monitored during the first year of life for which condition? A. Thyroid complications B. Orthopedic malformations C. Cardiac abnormalities D. Dental malformations

Pediatric Differences Neurosensory System
Size and Structure: Rapid head growth in early childhood Bones are not fused until months Function: Autonomic Nervous System is intact - neurons are completely myelinized by 1 year Infants behavior initially reflexive, but are replaced with purposeful movement by 1 year Infants demonstrate a dominance of flexor muscles Motor development occurs constantly in head to toe progression

Pediatric Differences Neurosensory System
Eye and Vision: Changes in development of eye and eye muscles *strabismus normal until 6 months Vision function becomes more organized Papilledema rarely occurs in infants due to expansion of fontanels with increased ICP Ear and Hearing: Hearing fully developed at birth Abnormal physical structures may indicate genetic problems

The Neurosensory System
Disorders of the Nervous System 3 Hydrocephalus 3 Spina Bifida 3 Reyes Syndrome 3 Seizures 3 Cerebral Palsy (CP) 3 Meningitis

Hydrocephalus Develops as a result of an imbalance of production and absorption of CSF The increase of CSF causes increased ventricular pressure, leading to dilation of the ventricles, pressing on skull Signs/Symptoms of Increased ICP: Poor feeding and vomiting Bulging fontanel, head enlargement, separation of sutures Lethargy, irritability, restlessness, not responsive to parents CHILD - Headache, vomiting, diplopia, ataxia, papilledema Seizures A child’s head with an open fontanel (under 2 years old) has the ability to expand and better compensate for the increased intracranial pressure.

Ventriculoperitoneal (VP) Shunts
Relief of hydrocephalus Prevention/treatment of complications Management of problems related to psychomotor development Surgical intervention: ventriculoperitoneal (VP) shunt One-way pressure valve releasing CSF into peritoneal cavity where it is reabsorbed Photo Source: Del Mar Image Library; Used with permission

General Nursing Interventions
Monitor Neuro Status Determine baseline Assess LOC Assess motosensory Pupil checks Vital signs, Head circ Provide Patient Safety Seizure precautions Fall precautions Possible restraints Determine LOC ac Decrease ICP Cluster care/  stress Quiet environment  HOB degrees Appropriate position (head midline, no hip flexion, no prone) Medications(pain meds,corticosteroids, diuretics, stool softeners, anti-infectives, anticonvulsants)

General Nursing Interventions
Maintain Adequate Cerebral Perfusion Maintain airway Monitor oxygenation and apply O2 PRN Monitor temperature and administer antipyretics PRN Maintain normovolemia Monitor I/O Assess perfusion Maintain Nutritional & Fluid Needs Determine swallow ability prior to PO’s NGT feedings may be necessary Dietary consult PRN Daily weight Monitor lab results Psychosocial Support Child Life consult Teaching

Spina Bifida: Occulta and Cystica (meningocele and myelomeningocele)
Etilogy is unknown, but genetic & environmental factors considered. Maternal intake of folic acid Exposure of fetus to teratogenic drugs The severity of clinical manifestations depend on the location of the lesion. T12 - flaccid lower extremities,  sensation, lack of bowel control and dribbling urine S 3 and lower - no motor impairment Other complications may occur. Hydrocephalus (80-90%) Orthopedic issues such as scoliosis, kyphosis, club foot Urinary retention Skin breakdown/Trauma Photo Source: Del Mar Image Library; Used with permission

Spina Bifida Nursing Interventions Sterile dressing pre/post-op
Monitor VS, S/S infection Use latex free items Avoid stress on sac - prone position only, especially pre-op; no supine until incision healed Monitor for S/S  intracranial pressure (ICP) Interventions to  ICP Encourage touch & talk Social service consult

Reye’s Syndrome A true pediatric emergency - cerebral complications may reach an irreversible state. Vomiting & change in LOC to coma Acute encephalopathy with fatty degeneration of the liver causing fluid & electrolyte imbalances, metabolic acidosis, hypoglycemia, dehydration, and coagulopathies. Most frequently seen in children recovering from a viral illness during which salicylates were given. Therapeutic management is intensive nursing care and maintaining adequate cerebral perfusion, &↓ICP. Increased ICP secondary to cerebral edema is major contributing factor to morbidity and mortality.

Seizures Febrile seizures are the most common in children, caused by by a RAPID elevation in temperature, usually above 102°. Most children do not have a second febrile seizure episode and only about 3% develop epilepsy. Focus of care is on patient safety, cause of fever and education of parents for home care. Remember basic CPR during seizures – airway before oxygen Seizure precautions: Suction, oxygen, padded rails Infants often have subtle seizures with only occular movements or some extremity movements.

Cerebral Palsy (CP) 1.5 - 5 in 1,000 live births
Neuromuscular disorder resulting from damage or altered structure of part of the brain Caused by a variety of factors: Prenatally - genetic, trauma, anoxia Perinatally - fetal distress, drugs at delivery, precepitate or breech delivery with delay Postnatally - kernicterus or head trauma

Cerebral Palsy (continued)
Spasticity - exaggerated hyperactive reflexes Athetosis - constant involuntary, purposeless, slow writhing motions Ataxia - disturbances in equilibrium Tremor - repetitive rhythmic involuntary contractions of flexor and extensor muscles Rigidity - resistance to flexion and extension Associated Problems: Mental retardation, hearing loss, speech defect, dental & orthopedic anomalies, GI problems and visual changes

Cerebral Palsy: Nursing Interventions
Safety Feed in upright position Seizure precautions Ambulate with assistance if able Medication administration Special Needs Nutritional needs include increased calories, assist with feeds, possible GT feeds. Speech, Occupational and Physical therapies

Bacterial Meningitis Infectious process of CNS causing inflammation of meninges and spinal cord. ISOLATION IS MANDATORY Signs and symptoms include those of increased ICP plus photophobia, nuchal rigidity, joint pain, malaise, purpura rash, Kernig’s and Brudinski’s signs Can occur at any age, but often between 1 month-5 years Most common sequele: hearing and/or visual impairments, seizures, cognitive changes Diagnostic confirmation is done by lumbar puncture and CSF is cloudy with increased WBCs, increased protein, and low glucose Nursing Interventions include: appropriate IV antibiotics and meds for increased ICP as well as interventions to decrease ICP

Causes of Blindness Genetic Disorders: Tay-Sach’s disease
Inborn errors of metabolism Perinatal: prematurity, retrolental fibroplasia Postnatal: trauma, childhood infections, Juvenile Arthritis

Causes of Deafness Conductive: Sensorineural:
Interference in transmission from outer ear to middle ear from chronic OM Sensorineural: Dysfunction of the inner ear Damage to cranial nerve VIII from rubella, meningitis or drugs

Let’s Review Which test would confirm a diagnosis of meningitis in children? A. Complete blood count B. Bone marrow biopsy C. Lumbar puncture D. Computerized Tomography (CT) scan

Let’s Review In performing a neurological assessment on a patient which data would be most important to obtain? A. Vital signs. B. Head circumference. C. Neurologic “soft signs”. D. Level of consciousness (LOC).

Let’s Review A neonate born with myelomeningocele should be maintained in which position pre-operatively? A. Prone. B. Supine. C. Trendelenberg. D. Semi-Fowler.

Let’s Review The nurse witnesses a pediatric patient experiencing a seizure. The primary nursing intervention would be: A. Careful observation and documentation of the seizure activity. B. Maintain patient safety. C. Minimize the patient’s anxiety. D. Avoid over stimulation and promote rest.

Let’s Review Which assessment finding in an infant first day post-op placement of a ventriculoperitoneal (VP) shunt is indicative of surgical complications? A. Hypoactive bowel sounds. B. Congestion in upper airways. C. Increasing lethargy. D. Incisional pain.

Cardiovascular System: Pediatric Variances
Cardiac arrest is related to prolonged hypoxemia Heart Rate (HR) higher Cardiac Output depends on HR until heart muscle is fully developed (around 5 years of age) Innocuous (benign) murmurs Sinus arrhythmias normal in infants Congenital defects present at birth – the greater the defect, the more severe the clinical manifestations (S/S)

FETAL CIRCULATION Photo Source: Del Mar Image Library; Used with permission

Cardiovascular System: Changes from Fetal Circulation
Fetal Circulation - Pattern of Altered Blood Flow Normal Circulatory Changes at Birth: Oxygenation takes place in Lungs Structural changes occur: * Ductus venosus constricts by 3-7 days becomes ligamentum venosum * Foramen ovale closes within first weeks * Ductus arteriosus functional closure at 24 hours, anatomic closure 1-3 weeks

Cardiovascular System: Changes from Fetal Circulation
Abnormal Circulatory Patterns After Birth Abnormal openings between the pulmonary and systemic circulations can disrupt blood flow. Blood will follow the path of least resistance -Left side of heart has greater pressure, so . . . Blood normally shunted from left to right Obstructions to pulmonary blood flow may cause right to left shunting of blood

NORMAL HEART ANATOMY BLOOD FLOW
Photo Source: Del Mar Image Library; Used with permission

The Cardiovascular System
Y Care of the Child with Congestive Heart Failure Y Congenital Heart Defects Increased Pulmonary Blood Flow Decreased Pulmonary Blood Flow Obstruction to Systemic Blood Flow Y Acquired Heart Disease

Goals of Nursing Care with Congenital Heart Disease
Y Reduce workload-Improve cardiac function Y Improve respiratory function Y Maintain nutrition to meet metabolic demands and promote growth Y Prevent infection and support/instruct parents

Congestive Heart Failure Review
COMPENSATORY RESPONSES Tachycardia, especially at rest Diaphoresis Fatigue Poor Feeding Failure to Thrive (FTT) Exercise Intolerance Decreased Peripheral Perfusion Pallor and/or Cyanosis Cardiomegaly

CLINICAL MANIFESTATIONS-CHF
PULMONARY Tachypnea Dyspnea Wheezes Crackles Retractions Nasal Flaring Cough SYSTEMIC Edema (facial) Sudden weight gain Decreased Urine Output Hepatomegaly Splenomegaly Jugular Vein Distention (JVD, children) Ascites

CHF: Focused Review Nursing Interventions
Therapeutic Management Improve cardiac function – Digitalization; Infant dose calculated 1000micrograms=1mg, ACE inhibitors Diuretics, fluid restrictions, daily weights, I/O Decrease tissue demands – Promote rest, minimize stress Increase tissue oxygenation – Oxygen Nutrition – Nipple feeds vs. gavage or GT, higher-calorie feeds Fall in K enhances dig increasing dig toxicity-carefully monitor K levels Cool humidity carefully regulated to prevent chilling

GENERAL NURSING INTERVENTIONS
Improve Cardiac Function Medicate Cardiac glycosides (Digoxin) Promote Fluid Loss Furosemide Spironolactone Clorothiazide Fluid Restriction Daily Weight Monitor I/O Decrease Cardiac Demands Promote rest Minimize Stress Monitor VS (temp) Reduce Respiratory Distress HOB elevated Possible supplemental oxygen Maintain Nutrition Nipple vs. Gavage/GTT Higher-calorie feeds (more than 20 cals/oz)

Increased Pulmonary Blood Flow (Acyanotic)
Atrial Septal Defect (ASD) Ventricular Septal Defect (VSD) Patent Ductus Arteriosus (PDA) CHF Feeding intolerance Activity intolerance Poor growth, failure to thrive Frequent Pulmonary Infections due to “boggy lungs” ASD – hole between 2 atria- Loud harsh murmur, enlarged R heart, may be asymptomatic VSD – hole between 2 ventricles – Loud, harsh murmur occurring about 4-8 wks of age-Failure to thrive PDA – accessory fetal vess between pul artery and aorta. Common in prematurity Coarctation of aorta – narrowing due to constricting band. Surgical repair/reconstruction Pul Stenosis – Narrowing of pul valve or artery – Opened with balloon or surgery; Aortic - same

Photo Source: Del Mar Image Library; Used with permission

Decreased Pulmonary Blood Flow (Cyanotic)
Pulmonary Stenosis Tetralogy of Fallot Transposition of the Great Vessels Assessment findings/Compensatory mechanisms Oxygen desaturation Varying degrees of cyanosis Polycythemia

Decreased Pulmonary Blood Flow (Cyanotic)

Obstruction to Systemic Blood flow
Aortic Stenosis Coarctation of the Aorta Think perfusion issues -Diminished or unequal pulses -Poor color -Delayed capillary refill time -Exercise intolerance TF – 4 anomalies;pul stenosis, VSD, destroposition of aorta, enlargement of R vent- Shunt may be placed until able to tolerate surgery. Murmur, cyanosis, polycythemia TGA – Aorta from Right ventricle instead of Left, pulmonary artery from Left vs Right, Incompatible with life. Must be repaired stat after birth

Obstruction to Systemic Blood flow

Rheumatic Fever Acquired Heart Disease
Inflammatory disorder involving heart, joints, connective tissue, and the CNS Peaks in school-age children Linked to environmental factors and family history Thought to be an autoimmune disorder: Commonly preceded by a Strep Throat Prognosis depends upon the degree of heart damage Rest important in recovery – priority intervention in acute stage Strep prophylaxis for 5 years or throughout adolescence

Hematologic System: Pediatric Variances
All bone marrow in a young child is involved in the formation of blood cells. By puberty, only the sternum, ribs, pelvis, vertebrae, skill, and proximal epiphyses of femur and humerus are involved in blood cell formation. During the first 6 months of life, fetal hemoglobin is gradually replaced by adult hemoglobin.

The Hematologic System
Disorders of Red Blood Cells Iron Deficiency Anemia Sickle Cell Anemia Disorders of Platelets/Clotting Factors Idiopathic Thrombocytopenia Purpura (ITP) Hemophilia

IRON DEFICIENCY ANEMIA
Most common nutritional anemia in childhood Severe depletion of iron stores resulting in a low HGB level Decreased O2 to tissues = fatigue, headache, pallor, increased heart rate Occurs after depletion of iron stores in body (6-9 mo of age) Most likely to occur during rapid physical growth and low iron intake

IRON DEFICIENCY ANEMIA
Often occurs as a result of increased milk intake Lab results show low HGB, HCT, MCV, MCH, MCHC, iron, ferritin Teach parents proper nutrition Meat, spinach, legumes, sweet potatoes, egg yolks, seafood Calcium inhibits iron, Vitamin C enhances iron absorption

Sickle Cell Disease PATHOLOGY Normal RBC has a flexible, round shape
Photo Source: Del Mar Image Library; Used with permission PATHOLOGY Normal RBC has a flexible, round shape RBC w/HbS has a normal shape until it’s O2 delivered to tissue, then sickle shape occurs Stiff, non-pliable – can’t flow freely Trapped in small vessels = causes vaso-occlusions, tissue ischemia and infarctions – painful episodes, most common area is joints Hemolysis of RBC- lifespan down to 20 days Compensatory mechanism is increased reticulocytes

Sickle Cell Disease ACUTE FEBRILE ILLNESS High mortality rate
<5 years old Splenic dysfunction begins at 6 mo old Prophylactic PCN BID at 2-3 mo old Monitor for Infection Temp > 101.5 Respiratory S/S SPLENIC SEQUESTRATION Highly vascular Susceptible to injury/infarction Occurs 6 mo-3yrs Pallor, fatigue, abd pain, splenomegaly, CV compromise Treatment: IV fluids, PRBC’s

Sickle Cell Disease: Nursing Interventions
GENERAL NURSING CARE Hydration is Priority! Fluid Bolus & maintenance + 1/2 Oxygen - to decrease sickling of of cells Pain Management Assess frequently/appropriately IV Morphine q3-4 hr, PCA Non-pharmacological methods HOME MANAGEMENT Pain Control Fluids Teaching Early Identification of infection Immunizations Avoid dehydration

Idiopathic Thrombocytopenic Purpura (ITP)
Acquired hemorrhagic disorder characterized by thrombocytopenia and purpura Cause is unknown, but is to believed to be an auto-immune response to disease-related antigens Usually follows an URI, measles, rubella, mumps, chickenpox Greatest frequency is between 2-8 years of age Platelet count is below 20,000 Therapeutic management is supportive with safety concerns. Activity is usually restricted. Acute presentation therapy can include prednisone, IV immunoglobulin, or Anti-D antibody (causes a hemolytic anemia to rid the body of the antibody-coated RBC’s) Chronic ITP will involve a splenectomy.

Hemophilia Group of genetic bleeding disorders of which there is a deficiency of a clotting factor Most common are Factor VIII (A) & Factor IX (B) Bleed LONGER not faster Clinical manifestations: prolonged bleeding, bruising, spontaneous hematuria Management: replacement of missing clotting factor (recombinant factor VIII concentrate), cryoprecipitate, DDAVP NSAIDS (aspirin, Indocin) are contraindicated, they inhibit platelet function Regular non-contact exercise/physical therapy is encouraged

Hemophilia COMPLICATIONS Bleeding into muscle tissue
Hemarthrosis can cause joint pain & destruction Acute Treatment is rest, ice, elevation, ROM Photo Source: Del Mar Image Library; Used with permission

Let’s Review When assessing a child for any possible cardiac anomalies, the nurse takes the right arm blood pressure (BP) and the BP in one of the legs. She finds that the right arm BP is much greater than that found in the child’s leg. The nurse reacts to these findings in which way? A. Charts the findings and realizes they are normal. Suspects the child may have coarctation of the aorta. C. Suspects the child may have Tetralogy of Fallot. D. Notifies the physician and alerts the surgery team.

Let’s Review A 1-month-old infant is being admitted for complications related to a diagnosed ventricular septal defect (VSD). Which physician’s order should be questioned by the nurse? A. Blood pressure every 4 hours. B. Serum digoxin level. C. Diet: Enfamil 20, nipple 6 oz q2H. D. Supplemental oxygen via nasal cannula prn maintain SaO2 >92%.

Let’s Review A nursing intervention most pertinent for the child with hemophilia is: A. Sedentary activities to prevent bleeding episodes. B. Meticulous oral care with dental floss to prevent infection. C. Warm compresses to bleeding areas to increase absorption. D. Active range of motion exercises for joint mobility.

Let’s Review Which is the most appropriate information to teach a parent of a 14 month-old child with iron deficiency anemia? A. Increase the child’s daily milk intake to a minimum of 24 ounces. B. Administer oral iron supplement for the child to drink in a small cup. C. Increase the amount of dark green, leafy vegetables and eggs in the child’s diet. D. Encourage the parents to let the child choose foods he prefers.

Let’s Review Which strategy is appropriate when feeding the infant in congestive heart failure? A. Continue the feeding until a sufficient amount of formula is taken B. Bottle feed no longer than 30 minutes C. Feed the infant every 2 hours D. Rock and comfort the infant during feedings

Respiratory System Pediatric Variances
The airway is smaller and more flexible. The larynx is more flexible and more susceptible to spasm. The lower airways are smaller with underdeveloped cartilage. The tongue is large. Infants < 6 months old are obligate nose breathers. Chest muscles are not well developed The diaphragm is the neonate’s major respiratory muscle. Irregular breathing pattern and brief periods of apnea (10 - 15 secs) are common Abdominal muscles are used for inhalation until age 5-6 yrs. Respiratory rate is higher Increased BMR raises oxygen needs

The Respiratory System
Upper Airway Disorders Tonsillitis Croup Epiglottis Foreign Body Aspiration Lower Airway Disorders Bronchiolitis Asthma Cystic Fibrosis Photo Source: Del Mar Image Library; Used with permission

Tonsillitis CLINICAL MANIFESTATIONS Sore throat Mouth breathing
Sleep Apnea Difficulty swallowing Fever Throat C&S/Rapid Strep IMPLEMENTATIONS Ease Respiratory Efforts Provide Comfort Warm saline gargles Pain Medication Throat lozenges Reduce Fever Promote Hydration Administer Antibiotics Provide Rest Patient Teaching Tonsillectomy may be necessary

Tonsillectomy Pre-operative Nursing Care Post-operative Nursing Care
Monitor Labs (CBC, PT, PTT) Age-appropriate Preparation/Teaching Surgical Consent Post-operative Nursing Care Frequent site assessment - visualize! Monitor for S/S of Complications Pain Management Diet (push fluids-no citrus juices or red, advance diet) Patient Teaching

Croup/Epiglottitis Infection and swelling of larynx, trachea, epiglottis, bronchi Often preceded by URI traveling downward Causative agent: Viral Characterized by hoarseness, barky cough, inspiratory stridor, and respiratory distress Most common ages 6 mo-3 yrs LTB form most common Photo Source: Del Mar Image Library; Used with permission

Acute Epiglottitis Bacterial form of croup affecting epiglottis
LIFE-THREATENING EMERGENCY Wellness to complete obstruction in 2-6 hours Most common in ages 2-5 years Do not examine throat! Have functional emergency equipment at bedside - Priority! Often the child is intubated 4 D’s - Drooling, Dysphagia, Dysphonia, Distressed Inspiratory Effort Lateral Neck X-ray shows “thumb sign” HIB vaccine has reduced the cases dramatically

Croup/Epiglottitis Nursing Interventions Nursing Interventions
Maintain Patent Airway Assess and Monitor Ease Respiratory Efforts Promote Hydration Reduce Fever Calm Environment Promote Rest Nursing Interventions Administer Meds Corticosteroids (HHN) Nebulizer treatment of Racemic Epinephrine PRN stridor Antibiotic for epiglottitis

Foreign Body Aspiration
Occurs most often in small children Choking, coughing, wheezing, respiratory difficulty Often it is round food, such as hot dogs, grapes, nuts, popcorn Bronchoscopy often needed for removal Age-appropriate preparation needed for procedure Prevention and parent education is very important

Bronchiolitis/RSV Acute viral infection of the bronchioles causing an inflammatory/obstructive process to occur Increased amount of mucus and exudates preventing expiration of air and overinflation of lungs Causative agent in 85% of cases is Respiratory Syncytial Virus (RSV). It is highly contagious - contact isolation must be enforced. Nasal swab or nasal washing obtained for viral panel, including RSV CXR shows hyperinflation and consolidation if atelectasis present Primarily seen in children under 2 years of age Most common in winter and early spring Palivizumab (Synagis)

CLINICAL MANIFESTATIONS
Bronchiolitis/RSV CLINICAL MANIFESTATIONS Nasal Congestion Cough Rhonchi, Crackles, Wheezes Increased RR & SOB Respiratory Distress Fever Poor Feeding IMPLEMENTATIONS Suction – priority Bronchodilator via HHN CPT Promote fluids Monitor VS , SaO2, lung sounds & respiratory effort Supplemental oxygen Reduce fever Promote rest HANDWASHING!

CLINICAL MANIFESTATIONS
Asthma CLINICAL MANIFESTATIONS Tachypnea SaO2 below 95% on RA Wheezes, crackles Retractions, nasal flaring Non-productive cough Silent chest Restlessness, fatigue Orthopnea Abdominal pain CXR = hyperinflation INTERVENTIONS Monitor VS (HR, RR) Monitor SaO2 Auscultate lung sounds Monitor respiratory effort Humified oxygen Calm environment Ease respiratory efforts Promote hydration Promote rest Monitor labs/x-rays Patient teaching

Asthma Administer Medications Home Medication Management
Bronchodilator via HHN or MDI with spacer (Albuterol) -Peak flows should always be done before and after Tx Mast cell inhibitor via HHN or MDI (Cromolyn Sodium - Intal) Corticosteroid IV or PO (Solu-medrol or Decadron) Antibiotic if precipitated from a respiratory infection Home Medication Management Bronchodilator via HHN or MDI with spacer (Albuterol -Proventil, Levalbuterol - Xopenex) Inhaled steroids (Beclamethasone - Vanceril) Leukotriene modifiers PO for long-term control - Singular Complications – Status asthmaticus, atelectasis, pneumothorax, respiratory failure and/or arrest, dehydration

Cystic Fibrosis 1 in 1,500-2,000 live births
Dysfunction of the exocrine gland (mucus producing) Multi-system disorder Secretions are thick and cause obstruction and fibrosis of tissue. The clinical manifestations are the result of the obstructive process. Sweat has a characteristic high sodium- Sweat Chloride Test Pancreatic involvement in 85% of CF patients Disease is ultimately fatal. Average age at death: 32 years

PULMONARY MANIFESTATIONS
Cystic Fibrosis PULMONARY MANIFESTATIONS Initial Wheezing Dry, non-productive cough Eventual & Progressive Repeated lung infections Wet & paroxysmal cough Emphysema/Atelectasis Barrel-chest - Clubbing - Cyanosis GI MANIFESTATIONS Large, loose, frothy and foul-smelling stools Increased appetite (early) Loss of appetite (later) Weight loss FTT Distended abdomen Thin extremities Deficiency of A,D, E, K Anemia

MANAGEMENT/INTERVENTIONS
Cystic Fibrosis MANAGEMENT/INTERVENTIONS Airway Clearance - Chest physiotherapy (CPT) Priority Drug Therapy Bronchodilators - via HHN Mucolytic Agent (Dnase-Pulmozyme) - via HHN Antibiotics - via HHN, IV, or PO Digestive enzymes Nutrition - needs are at 150% Increased calories and protein - TPN or GT feedings at night Additional fat soluble vitamins Additional salt with vigorous exercise and hot weather Exercise Patient Teaching

Otitis Media Acute otitis media (AOM) Infectious process by pathogen
Most common childhood illness Inflammation of middle ear Impaired eustachian tube causes decreased ventilation and drainage Acute otitis media (AOM) Infectious process by pathogen Infection can spread leading to meningitis S/S: pain, pulling on ears, fever, irritability, vomiting, diarrhea, ear drainage, full/bulging tympanic membrane Otitis media with effusion (OME) Inflammation of middle ear with fluid behind tympanic membrane-no infection Peaks spring and fall (allergies) Chronic otitis media Inflammation of middle ear > 3 mo Can lead to hearing loss/delayed speech Photo Source: Del Mar Image Library; Used with permission

Otitis Media RISK FACTORS Secondary smoke
Formula feeding (positioning) Day care Pacifier > 6 mo old TREATMENT Antibiotics (for AOM) Myringotomy with Pressure Equalizing (PE) tubes INTERVENTIONS Teaching No bottle propping Feeding techniques Medication regimen PAIN MANAGEMENT Fever management Surgery prep if needed Photo Source: Del Mar Image Library; Used with permission

Let’s Review The nurse’s first action in responding to a child with tachypnea, grunting, and retractions is to: A. Place the child in an upright, semi-fowler’s position. B. Apply a pulse oximeter to determine oxygen saturation. C. Assess for further symptoms. D. Call for a stat respiratory nebulizer treatment (HHN).

Let’s Review A 3-year-old child is brought to the emergency room with a sore throat, anxiety, and drooling. The priority nursing action is to: A. Inspect the child’s throat for infection. B. Prepare intubation equipment and call the physician. Obtain a throat culture for respiratory syncytial virus (RSV). Obtain vital signs and auscultate lung sounds.

Let’s Review An assessment finding in a child with asthma requiring immediate action by the nurse is: A. Diminished breath sounds. B. Wheezing in bronchi. C. Crackles in lungs. D. Refusal to take PO fluids.

Let’s Review Which sign is indicative of air hunger in an infant?
A. Nasal flaring. B. Periods of apnea lasting 15 seconds. C. Irregular respiratory pattern. D. Abdominal breathing.

Let’s Review The priority nursing intervention in caring for the infant with Respiratory Syncytial Virus (RSV) induced bronchiolitis is: A. Nasopharyngeal suctioning. B. Coughing and deep breathing exercises. C. Administration of intravenous antibiotic. D. Administration of antipyretics for fever.

Gastrointestinal System
Many GI issues require surgical intervention Nursing interventions will often include general pre and post-op care Bilious vomiting is a sign of GI obstruction and requires immediate intervention Assess stools! Assess hydration status Photo Source: Del Mar Image Library; Used with permission

Gastrointestinal System Pediatric Variances
Mechanical functions of digestion are immature at birth Liver functions are immature throughout infancy Production of mucosal-lining antibodies is decreased Infants have decreased saliva Infant’s stomach lies transversely Peristalsis is faster in infants Digestive processes are mature as a toddler The child’s liver and spleen are large and vascular Infants and children who vomit bile-colored emesis require immediate attention Gastric acidity is low at birth

The Gastrointestinal System
8 Altered Connections 3 Esophageal Atresia/Tracheoesophageal Fistula 3 Cleft Lip and Palate 8 Gastrointestinal Disorders 3 Gastroesophageal Reflux Pyloric Stenosis 3 Hirschsprung’s Disease Imperforate Anus 3 Intussusception 8 Acquired Gastrointestinal Disorders 3 Celiac Disease 3 Appendicitis 3 Parasitic Worms

ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA
Congenital defects of esophagus EA is an incomplete formation of esophagus TEF is a fistula between the trachea and esophagus Classic 3 “C’s” - coughing,choking,cyanosis Photo Source: Del Mar Image Library; Used with permission

ESOPHAGEAL ATRESIA & TRACHEOESOPHAGEAL FISTULA
SIGNS/SYMPTOM Copious, frothy oral secretions Abdominal distension from air in stomach Look for 3 C’s Confirmed with radiographic studies TREATMENT Surgery: either a one- or two-stage repair Pre-op care focuses on preventing aspiration and hydration Post-op care focus is a patent airway, prevent incisional trauma

Cleft Lip/Palate May present as single defect or combined
Non-union of tissue and bone of upper lip and hard/soft palate during fetal development CL-failure of nasal & maxillary processes to fuse at 5-8 weeks gestation CP-failure of palatine planes to fuse 7-12 weeks gestation Cleft interferes with normal anatomic structure of lips, nose, palate, muscles – depending on severity and placement Open communication between mouth and nose with cleft palate

Cleft Lip/Palate Multidisciplinary care throughout childhood and early adulthood Nutrition is a challenge in infancy ESSR method (enlarge, stimulate, swallow, rest) Risk for aspiration Respiratory distress Altered bonding is a possibility Photo Source: Del Mar Image Library; Used with permission

CLEFT LIP & CLEFT PALATE: Operative Care
Cleft lip surgery by 4 weeks & again at 4-5 yrs Cleft palate surgery at 6-24 months of age, usually done by 1 year so speech will not be affected Protect suture lines- priority Monitor for infection Clean Cleft Lip incision Pain Management Cleft Palate starts feedings 48-hour post-op: Clear and advance to soft diet No straws, pacifiers, spouted cups Rinse mouth after feeding

GASTROESOPHAGEAL REFLUX
Regurgitation of gastric contents back into esophagus - 50% healthy term babies affected Related to inappropriate relaxation of Lower Esophageal Sphincter (LES) making the LES pressure less than the intra abdominal pressure GER may predispose patient to aspiration and pneumonia Apnea has been associated with GER  chance of GER after mo old related to growth due to elongation of esophagus and the LES drops below the diaphragm Photo Source: Del Mar Image Library; Used with permission

GASTROESOPHAGEAL REFLUX
SIGNS/SYMPTOMS Vomiting/spitting up Gagging during feedings Irritability Arching/posturing Frequent URI’s/OM Anemia Bloody stools DIAGNOSTIC EVAL History of feedings/PE Upper GI/Barium swallow to eliminate anatomical problems Upper GI endoscopy to visualize esophageal mucosa pH probe study

GASTROESOPHAGEAL REFLUX: Therapeutic Management
Medications Prokinetic agents:  LES pressure & gastric motility Histamine H-2 antagonists are added if esophagitis :  acid Proton Pump Inhibitors if H-2 ineffective:acid Mucosal Protectants Surgery: fundoplication Positioning Prone HOB  30° Right side Dietary modifications Small, frequent feedings, burp often Possibly thicken formula Avoid fatty, spicy foods caffeine, & citrus Teach

HIRSHSPRUNG’S Aganglionic megacolon Treatment
No ganglion cells at affected area usually at rectum/proximal portion of lower intestine Absence of peristalsis leads to intestinal distension, ischemia & maybe enterocolitis Treatment Mild-mod: stool softeners & rectal irrigations Mod-severe: single or 2-step surgery Colostomy with later pull-through Photo Source: Del Mar Image Library; Used with permission

NURSING INTERVENTIONS
HIRSHSPRUNG’S SIGNS/SYMPTOMS Infants Unable to pass meconium stool within 24 hours of life Abdominal distention Bilious vomiting Refusal to feed Failure to thrive Children Chronic constipation Pellet or ribbon-like stools (foul-smelling) Vomiting/FTT NURSING INTERVENTIONS Surgery prep: bowel cleansing, antibiotics, NPO, IVF’s, therapeutic play for surgery preparation Infection & Skin Integrity: monitor ostomy/anus Nutrition & Hydration: NGT, NPO then advance to Diet as tolerated, assess bowel function and abdominal status

INTUSSUSCEPTION Prolapse or “telescoping” of one portion of the intestine into another Abrupt onset Usually occurs in 3-24 months of age Sudden abdominal pain Vomiting Red, current jelly stool Abd distention/tender Lethargy Can lead to septic shock Photo Source: Del Mar Image Library; Used with permission

INTUSSUSCEPTION DIAGNOSTIC STUDY TREATMENT NURSING INTERVENTIONS
Barium or air enema Abdominal ultrasound TREATMENT Hydrostatic reduction: force exerted using water-soluble contrast and air to push the affected intestine apart Surgical reduction if hydrostatic reduction is unsuccessful NURSING INTERVENTIONS Monitor for infection, shock, pain Maintain hydration - assess status! Prepare child/parent for hydrostatic reduction - teach, consent, NPO, NGT Monitor stools pre & post procedure If surgery: general pre & post-op care

PYLORIC STENOSIS Hypertrophy of pyloric sphincter, causing a narrowing/ obstruction (bands pylorus) Usually occurs between 2-8 weeks of age Infant presents with non-bilious projectile vomiting, and is “always hungry” Can lead to dehydration and hypochloremic metabolic alkalosis Weight loss Photo Source: Del Mar Image Library; Used with permission

PYLORIC STENOSIS DIAGNOSTIC EVAL TREATMENT INTERVENTIONS
History/PE: “olive” palpated in epigastrum Upper GI (string sign) Abdominal Ultrasound TREATMENT Surgical Intervention: Pyloromyotomy INTERVENTIONS Pre-op: NPO, NGT to LIS, hydration, I/O, monitor electrolytes Post-op: Start feedings in 4-6 hrs. Progressive feeding schedule begin w/5cc GW half strength formula  Full strength formula

IMPERFERATE ANUS Anorectal malformations No obvious anal opening
Fistula may be present from distal rectum to perineum or GU system Diagnostic Eval: patency of anus in newborn, passage of meconium; ultrasound is suspected Therapeutic Management: manual dilatation for anal stenosis, surgical treatment for malformations Nursing Implementations: pre and post-op care – IV fluids, consent, assessing surgical site for infection and monitoring for complications, possible NGT, diet progression, possible colostomy and teaching; preferred post-op condition is side-lying.

Celiac Disease Malabsorption syndrome characterized by intolerance of gluten (rye, oats, wheat and barley) Familial disease - more common in Caucasians Thought to be an inborn error of metabolism or an immunological disorder Reduced absorptive surfaces in small intestine which causes marked malabsorption of fats (frothy, foul-smelling stools) Child has diarrhea, abdominal distention, failure to thrive Treatment is lifelong low-gluten diet; corn and rice are substituted grain foods

APPENDICITIS Inflammation and infection of vermiform appendix, usually related to an obstruction Cause may be bacteria, virus, trauma Ischemia can result from the obstruction, leading to necrosis causing perforation S/S: periumbilical painRLQ pain (McBurney’s point), fever, vomiting, diarrhea, lethargy, irritability,  WBC’s Surgery is necessary If ruptured, often child will receive IV antibiotics for 24 hrs prior to OR Pre-op Care: NPO, pain management, hydration, prep & teaching, consent Post-op Care: routine post-op care, IVF/antibiotics, NPODAT, ambulation, positioning, pain management, wound care, possible drains.

PINWORM (enterobiasis)
Transmission: oral-fecal Persist in indoors for up to 3 weeks contaminating anything they contact (toilets, bed linens) S/S: intense perianal itch, sleeplessness, abd pain, vomiting Scotch tape test – collects eggs laid by female outside of anus. Must be obtained in am prior to bath or BM. Treatment: *mebendazole (Vermox) for over 2 years of age. Under 2 years of age treatment may be pyrvinium pamoate (Povan) which stains stool and emesis red *All family members must be treated.

Let’s Review Which intervention would have the highest priority for the nurse assisting in the feeding of a child post cleft palate repair? A. Permiting the child to choose the liquids desired. B. Providing diversional activities during feeding. C. Applying wrist restraints. D. Cleansing the mouth with water after each feeding.

Let’s Review Which food choice by a parent of a child with celiac disease indicates a need for further teaching? Oatmeal Rice Cornbread Beef

Let’s Review Which assessment finding would the nurse find in a child with Hirschsprung’s Disease? Current jelly stool Diarrhea Constipation Foul-smelling, fatty stool

Let’s Review Children with gastroenteritis often receive intravenous fluids to correct dehydration. How would you explain the need for IV fluids to a 3 year-old child? A. “The doctor wants you to get more water, and this is the best way to get it.” B. “Your stomach is sick and won’t let you drink anything. The water going through the tube will help you feel better.” C. “See how much better your roommate is feeling with his IV! You will get better, too.” D. “The water in the IV goes into your veins and replaces the water you have lost from vomiting and diarrhea.”

Let’s Review The nurse caring for a child with suspected appendicitis would question which physician order? NPO status Start IV fluids of D5 ½ NS at 50 mls/hour Complete Blood Count (CBC) Apply heating pad to abdomen for comfort

Genitourinary System Anatomy & Physiology Review
The GU system maintains homeostasis of the body (water & electrolytes) Responsible for the excretion of waste products Nephron is the workhorse of the kidney (filter blood at the rate of 125mL/minute)-GFR Renin helps maintain Na & water balance (and B/P) Kidneys produce erythropoeitin which stimulates RBC production in marrow Photo Source: Del Mar Image Library; Used with permission

Pediatric Variances Genitourinary System
Infants & young children excrete urine at a higher rate related to the increased BMR producing more waste Infant kidneys have  function if under stress Infant can’t concentrate urine well until 3-6 mo In infants, kidney & bladder are abdominal organs Infant kidneys are less protected because of unossified ribs, less fat padding & large size Young children have shorter urethras Nephrons continue to develop after birth

The Genitourinary System
Minimum urine outputs by age groups: INFANTS & TODDLERS 2-3 ml/kg/hr PRESCHOOLERS & YOUNG SCHOOL-AGE 1-2 ml/kg/hr SCHOOL-AGE & ADOLESCENTS 0.5-1 ml/kg/hr TIP: Bladder capacity in ounces: AGE in years + 2 Example: a 2-year-old’s bladder can hold up to 4 ounces or 120 mls

The Genitourinary System
d Disorders of the Genitourinary System F Enuresis F Nephrotic Syndrome F Acute Glomerulonephritis F Hemolytic Uremic Syndrome (HUS)

Glomerulonephritis Group of kidney disorders that show main focus of injury is the glomerulus It is characterized by inflammation of the glomerular capillaries Acute disorders occur suddenly and resolve completely Acute poststreptococcal glomerulonephritis (APSGN) is the most common type History, presenting symptoms, and lab results establishes the diagnosis of APSGN

Glomerulonephritis Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.

Glomerulonephritis ASSESSMENT INTERVENTIONS Hematuria
Proteinuria Edema: periorbital, ankles  Urine Output Hypertension Fatigue Possible fever Abdominal discomfort Labs: +ASO,  Bicarb,K BUN, Creat,  H & H INTERVENTIONS Monitor Urine (Dipstick) Monitor fluid overload Assess lung sounds/Resp effort Possible fluid & salt restriction Monitor I/O, Daily Weights Monitor VS Antibiotic, diuretic & antihypertensive medications Promote & provide rest Provide comfort measures Monitor labs

Nephrotic Syndrome Kidney disorder characterized by proteinuria, hypoalbuminemia, and edema. There is primary (involving kidney only) and secondary (caused by systemic disease or heavy metal poisoning) NS. Primary is the most common (MCNS). Cause not fully understood-may have an immunologic component. Primary age affected is 2-6 years (boys 2:1) There is no occlusion of glomerular vessels. Loss of immunoglobulins also occur (IgG) Hypovolemia and the severe proteinuria put the child in a hypercoagulable state Treatment is prednisone (2mg/kg/day) for about 4-6 weeks. Remission is obtained when the urine protein is 0-tr for 5-7 days Albumin followed by furosemide may be given for the edema

Nephrotic Syndrome Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.

Nephrotic Syndrome ASSESSMENT INTERVENTIONS
Proteinuria (3-4+), frothy urine Edema (pitting):periorbital, genitals, lower extremities, abdominal  Urine Output (Hypovolemia) Normotensive or hypotensive Fatigue Recent URI, Pneumonia Abdominal Pain/Anorexia Labs: Albumin  Platelets H & H  Cholesterol  Triglycerides INTERVENTIONS Monitor Urine (Dipstick) Monitor edema/dehydration Assess skin integrity/turn often Possible fluid & salt restriction Monitor I/O, Daily Weights Monitor VS & S/S of infection Administer medications Promote & provide rest Monitor labs HANDWASHING/monitor visitors

Hemolytic Uremic Syndrome (HUS)
It is the most common cause of acute renal failure (ARF) in children. HUS is characterized by the triad of anemia, thrombocytopenia, and ARF. Most children have associated GI symptoms- almost all are caused by e. coli 0157. Treatment is supportive and based on symptoms. No antibiotics are given; more damage can be caused. Serum electrolytes may be outside of normal limits. Blood transfusions and/or dialysis may be necessary. More than 90% of the children recover with good renal function.

Photo Source: Teresa Simbro, RN, Santa Ana College, Used with permission.

ASSESSMENT History: emesis, bloody diarrhea, abd pain,  Urine Petechiae, bruises, purpura Edema (possible CHF) Hepatosplenomegaly Altered LOC, seizure Hypertension Fatigue Abdominal discomfort Labs: Lytes may be abnormal  BUN  Creatinine  H & H  Platelets INTERVENTIONS Monitor I/O, Daily Weights Evaluate for signs of bleeding Monitor fluid overload/edema Assess for dehydration Monitor VS with neuro checks Seizure Precautions, HOB  Diuretic & antihypertensive medications Provide rest/calm environment Provide comfort measures Monitor labs closely

Enuresis Involuntary passage of urine in children whose chronological or developmental age is at least 5 years of age Voiding occurs at least twice a week for minimum 3 months More common in boys Alteration in neuromuscular bladder function Often benign and self-limiting Organic factor could be the cause Familial tendency Emotional factor could be considered Therapeutic techniques include: bladder training, night fluid restriction, drugs (imipramine, oxybutynin, DDAVP)

Let’s Review A clinical finding that warrants further intervention for a child with acute post-streptococcal glomerulonephritis is: A. Weight loss to 1 pound of pre-illness weight. B. Urine output of 1 ml/kg per hour. C. A normal blood pressure. D. Inspiratory crackles.

Let’s Review A 3 year-old is scheduled for surgery to remove a Wilms tumor from one kidney. The parents ask the nurse what treatments, if any, will be necessary after recovery from surgery. The nurse’s explanation is based on knowledge that: A. No additional treatments are necessary. B. Chemotherapy may be necessary. C. Chemotherapy is indicated. D. Kidney transplant is indicated.

Let’s Review Fluid balance in the child who has acute glomerulonephritis is best estimated by assessing: A. Intake and output B. Abdominal circumference C. Daily weights D. Degree of edema

Let’s Review In evaluating the effectiveness of nursing actions when caring for a child with nephrotic syndrome, the nurse expects to find: A. A recurrence of pneumonia. B. Weight gain. C. Increased edema. D. Decreased edema.

Pediatric Variances Musculoskeletal System
Bone Growth: Linear growth results from skeletal development Bone circumference growth occurs as new bone tissue is formed beneath the periosteum Skeletal maturity is reached by age 17 in boys and 2 years after menarche in girls (14 yrs) Bone growth affected by Wolff’s Law - bone grows in the direction in which stress is placed on it Certain characteristics of bone affect injury and healing Children’s bones are softer and are easily fractured

Pediatric Variances Musculoskeletal System
Muscle Growth: Responsible for a large part of increased body weight The number of muscle fibers is constant throughout life Results from increase in size of fibers and increased number of nuclei per fiber Most apparent in adolescent period

The Musculoskeletal System
QDisorders of the Musculoskeletal System m Developmental Dysplasia of the Hip m Talipes (Clubfoot) m Osteogenesis Imperfecta m Scoliosis m Muscular Dystrophy m Juvenile Rheumatoid Arthritis

Developmental Dysplasia of the Hip (DDH)
Variety of hip abnormalities – shallow acetabulum, subluxation or dislocation Often made in newborn period – often appears as hip joint laxity rather than dislocation Ortolani click if < 4 weeks old, older ultrasound needed to diagnose Treatment is Pavlik Harness (abducted position) for newborn to 6 months old – monitor for Avascular Necrosis 6-18 months – traction followed by spica cast Older children – operative reduction Priority nursing interventions are skin care and facilitating normal growth and development

Talipes (Clubfoot) Most common type is when foot is pointed downward and inward Often associated with other disorders May be due to decreased movement in utero Treatment requires surgical intervention Serial casting is begun shortly after birth and usually lasts for 8-12 weeks Priority nursing interventions are skin care and facilitating normal growth and development

Osteogenesis Imperfecta (OI)
Inherited disorder of connective tissue and excessive fragility of bones Pathologic fractures occur easily Incidence of fractures decrease at puberty related to increased hormones making bones stronger Treatment is supportive: careful handling of extremities, braces, physical therapy, weight control diet, stress on home safety Surgical techniques for correcting deformities and for intermedullary rodding

Scoliosis Abnormal curvature of the spine (lateral)
Congenital or develops later, most common during the growth spurt of early adolescence (idiopathic) Diagnosis is made by physical exam and x-rays Treatment for curvatures < 40 degrees is bracing Surgical intervention is for severe curvatures – internal fixation and instrumentation (Harrington) Postoperative care includes logrolling, neurologic assessments, pain management, skin care, assessing for paralytic ileus and possible mesenteric artery syndrome Don’t forget the developmental needs of the adolescent Braces are the Boston brace or the TLSO (thoracolumbosacralorthotic)

Muscular Dystrophy Duchenne’s Muscular Dystrophy most common
Gradual degeneration of muscle fibers S/S begin to show about 3 years of age – difficulties in running and climbing stairs Changes to having difficulty moving from a sitting/supine position Profound muscular atrophy continues, wheelchair by 12 yrs Respiratory and cardiac muscles affected and death is usually respiratory or cardiac in nature Diagnosis made with physical exam, muscle biopsy, EMG, serum studies: AST (SGOT), aldolase, creatine phosphokinase high first 2 years of life Nursing care is to maintain optimal level of functioning and to help the child and family cope with the progression and limitations of the disease

Juvenile (Rheumatoid) Arthritis
Inflammatory disease with an unknown cause Occurs in children < 16 years; lasts > 6 weeks Clinical manifestations: stiffness, swelling, and loss of motion in affected joints, tender to touch Therapeutic management includes drug therapy (NSAID’s, SAARD’s, cytoxic drugs, corticosterioids), physical and occupational therapy, exercise (swimming), moist heat for pain and stiffness, general comfort measures

General Nursing Interventions for Children with Musculoskeletal Dysfunctions (immobility)
Maintain optimal level of functioning Promote general good health Facilitate compliance Facilitate optimal growth and development Maintain skin integrity Safety considerations at home Pain management Support child and family

Let’s Review An infant is being treated non-surgically for clubfoot. Which describes a major goal of care for this patient? Prevention of: A. Skin breakdown B. Calf atrophy C. Structural ankle deformities D. Thigh atrophy

Let’s Review The nurse is helping parents create a plan of care for their child with osteogenesis imperfecta. A realistic outcome is for this child to: A. Have a decreased number of fractures B. Demonstrate normal growth patterns C. Participate in contact sports D. Have no fractures after infancy

Let’s Review During acute, painful episodes of juvenile arthritis, a priority intervention is initiating: A. A weight-control diet to decrease stress on the joints. B. Proper positioning of the affected joints to prevent musculo-skeletal complications. C. Complete bedrest to decrease stress to the joints. D. High-resistance exercises to maintain muscular tone in the affected joints.

Pediatric Variances Endocrine System
Growth Hormone: Does not effect prenatal growth Main effect on linear growth Maintains rate of body protein synthesis Thyroid-stimulating hormone (TSH): Important for growth of bones, teeth, brain Secretion decreases throughout childhood and increases at puberty Adrenocorticotrophic Hormone (ACTH): Activated in adolescent Stimulates adrenals to secrete sex hormones Influences production of gonadotropic hormone

The Endocrine System Disorders of the Endocrine System
8 Type 1 Diabetes Mellitus 8 Congenital Hypothyroidism 8 Growth Hormone Deficiency 8 Precocious Puberty

Type 1 Diabetes Mellitus Pediatric Considerations
INSULIN Most children are well-controlled with BID dosing of fast acting (Lispro) short acting (regular) and intermediate acting (NPH, Lente) insulin. There is also Lantis, an insulin that acts a “basal.” U-20 insulin is also available for infants Insulin pump, pen “Honeymoon” phase Stress, infection, illness and growth at puberty can increase insulin needs

HYPOGLYCEMIC EPISODES In small children it is more difficult to determine and may just be a behavior change. Treatment is the same – simple sugar – assess LOC first! NUTRITION Carb counting – most children’s calories should not be restricted; meal plan might change as child grows. Some sweets may be incorporated into the diet and may help with compliance. 3meals with 3 snacks per day

EXERCISE Important for normal growth and development Assists with daily utilization of dietary intake Enhances insulin absorption, so may decrease amount needed Add grams of carbs for each minutes of exercise Watch for hypoglycemia with strenuous exercise

DEVELOPMENTAL ISSUES Infant/Toddler Autonomy & choices, rituals, hypoglycemia identification difficult Preschooler Magical thinking-let them know they did not cause it Use dolls for teaching Urine testing may be done Can choose finger to use for testing School-age Very busy with school and activities Likes tasks and explanations Can do self blood testing; injections at age 8-10 years Adolescents Peers and body image preoccupation High risk for non-compliance Collaborative health care with parent involvement very important

Congenital Hypothyroidism
Thyroid is not producing enough thyroid hormone to meet needs of the body (resulting in↓oxygen consumption, BMR and protein synthesis) Clinical manifestations: cool, mottled skin, bradycardia, large tongue, large fontanel, hypothermic, hypotonia, lethargy, feeding problems - THINK SLOW! Labs: High TSH, low T4 Decreased brain development will result with cognitive impairments Part of newborn screening Therapeutic management is life-long thyroid hormone replacement (levothyroxine) Ideal time for newborn screening would be 3-6 days, but most often done much earlier. Results may be falsely interpreted due to an increase in TSH immediately after birth, which is part of the normal newborn transition.

Growth Hormone (GH) Deficiency
Deficient secretion of growth hormone Definitive diagnosis is made with GH levels (using stimulation testing) under 10mg/ml and x-rays of hand and wrist for ossification levels Treatment is replacement of GH (subcutaneous daily injections) until goals met Nursing care is directed at child and family support Remember to interact and speak to the child at her appropriate developmental level!

Precocious Puberty Manifestations of sexual development in boys younger than 9 years and girls younger that 8 yrs Causes also an early acceleration of growth with closure of growth plates Therapeutic management is directed toward the specific cause, if known The early secretion of sex hormones will be treated with monthly subcutaneous injections of leuteinizing hormone-releasing hormone (LHRH) Priority interventions are directed at psychological support of child and family – encourage play with same age peers

Let’s Review A child weighing 25 kilograms is being treated with synthetic growth hormone. The recommended dosage range is 0.3 – 0.7 mg/kg/week. The mother informs the nurse that her child receives 1.25 mg subcutaneously at bedtime 6 times per week. The proper response from the nurse would be: “That dose is too high, the doctor needs to be notified.” “You are doing a great job, that is the correct dose for your child.” “The injection should be given intramuscular, not subcutaneous.” “That dose is too low based on your child’s new weight.”

Let’s Review The nurse should include which information in teaching the parents of a recently diagnosed toddler with Type 1 diabetes mellitus? A. Allow the toddler to choose which finger to use for blood glucose monitoring B. Allow the toddler to assist with the daily insulin injections C. Test the toddler’s blood glucose every time she goes out to play D. Let the toddler determine meal times

Let’s Review Which is the most appropriate teaching intervention for a nurse to give parents of a 6-year-old with precocious puberty? A. Advise the parents to consider birth control for their child B. Inform the parents there is no treatment currently available C. Explain the importance for the child to foster relationships with peers D. Assure the parents there is no increased risk for sexual abuse.

Let’s Review Number in order of priority the following interventions needed while caring for a patient in diabetic ketoacidosis. _____ Hydration _____ Electrolyte replacement _____ Dietary intake _____ IV Insulin _____ Subcutaneous insulin

Pediatric Variances Integumentary System
Evaporative water loss is greater in infants/small children Skin more susceptible to bacterial infections More prone to toxic erythema More susceptible to sweat retention and maceration

The Integumentary System
Disorders of the Integumentary System Impetigo Roseola Diaper Rash

Impetigo Superficial bacterial skin infection, often secondary from insect bite Highly contagious Late summer outbreak Toddlers & preschoolers Rash is bullous or honey-colored crusted lesions Treatment: topical & systemic antibiotics, comfort measures, teaching, preventing comps Photo Source: Del Mar Image Library; Used with permission

Roseola Transmission: contact with secretions (saliva) Virus
months Fever »flu symptoms » rose-pink macular rash Fades with pressure Treatment is supportive Photo Source: Del Mar Image Library; Used with permission

Diaper Rash Cause could be fungal in nature; assess mucous membranes for thrush Cause could be due to infrequent diaper changes, an allergic reaction to the diaper product or diarrhea Skin care includes appropriate skin barrier cream/ointment, keeping area dry Teach parents appropriate skin care

Medication Administration
Oral Medication Hold infant with head elevated to prevent aspiration Slowly instill liquid meds by dropper along side of the tongue Crush pills and mix with sweet-tasting liquid if permitted, but don’t add too much liquid! Allow choices for the child such as which med to take first Flush following gastrostomy or NG tube

Factors to consider when selecting IM sites
Age Weight Muscle development Amount of subcutaneous fat Type of drug Drug’s absorption rate

IM and SQ Meds Select needle length according to muscle size for IM
Infant - should use 1 inch needle Preemies can use 5/8 inch needle Use Z-track for iron and tissue-toxic meds Apply EMLA or other topical anesthetic 45-60 minutes prior to injection May mix medication with lidocaine Some medications may be need to be separated into 2 injections depending on amount

Peds IM Injection Sites
Vastus lateralis for infants Ventrogluteal and dorsogluteal Don’t inject into dorsogluteal until age 3 years - muscle not well developed until child walks and sciatic occupies a larger portion of the area. Deltoid after 3 years

IV Meds Site may be peripheral or central
Administer IV fluids cautiously Always use infusion pumps with infants and small children Inspect sites frequently (q 1-2 hours) for signs of infiltration Cool blanched skin, puffiness( infiltration) Warm and reddened skin (inflammation)

Nose Drops Instill in one nare at a time in infants because they are
obligate nose breathers. Suction nare with bulb syringe prior to administration if nasal congestion present

Ear Meds Pull the ear down and back to instill eardrops
in infants/toddler (↓3 years pull ↓) Pull the ear up and out to instill in older children (↑ 3 years pull ↑) Have medication at room temperature

Rectal Medication Insert the suppository past the anal sphincter
Hold buttocks together for a few seconds after insertion to prevent expulsion of medication It is a very stressful route for children, and the school-age and adolescent have issues with modesty.

Inhalers and Spacers Shake the inhaler for 2-5 seconds.
Position inhaler into spacer (with mask or mouthpiece). After normal exhale, place mask on face or mouthpiece in mouth – both with a good seal. Have child inhale slowly after canister is pressed down . Have child take a few breaths with a spacer and without a spacer have them hold breath for few seconds after medication released. Inhalers without spacers aren’t placed in the mouth because spacers require a seal around mouthpiece; masks with spacers can be used for infants.

MDI with Spacer MDI with Spacer and Mask

Let’s Review The nurse would prepare which site for an intramuscular injection to a 11 month-old? Dorsogluteal Deltoid Vastus lateralis Ventrogluteal

Pediatric Oncology Cancer is the leading cause of death from disease in children from years. Incidence: 6,000 children develop cancer per year 2,500 children die from cancer annually Boys are affected more frequently Etiologic factors: environmental agents, viruses, host factors, familial/genetic factors Leukemia is the most frequent type of childhood cancer followed by tumors of the CNS system.

Oncology Stressful Events
“Treatment is worse than the disease.” 1. Diagnosis 2. Treatment - multimodal 3. Remission 4. Recurrence 5. Death

Oncology Interventions
8 Surgery 8 Radiation Therapy 8 Chemotherapy 8 Bone Marrow Transplant

Stages of Cancer Treatment
1. Induction 2. Consolidation 3. Maintenance 4. Observation 5. Late Effects of Treatment Impaired growth & development CNS damage Psychological problems

Types of Childhood Cancers
Pediatric Oncology Types of Childhood Cancers D Leukemia D Brain Tumors D Wilm’s Tumor D Neuroblastoma D Osteogenic Sarcoma D Ewing’s Sarcoma

Leukemias Most common form of childhood cancer
Peak incidence is 3 to 5 years of age Proliferation of immature WBCs (blasts) May spread to other sites (CNS, testes) Types of Leukemia: Acute lymphocytic leukemia (ALL) 80-85% of childhood leukemia 95% chance of remission Acute nonlymphocytic Leukemia (ANLL) 60-80 % chance of remission Treatment is chemotherapy: prednisone, allupurinol, selected chemotherapeutic agents

Leukemias CLINICAL MANIFESTATIONS LABS & DIAGNOSTIC TESTS
Purpura, Bruising Pallor Fever Unknown Origin Fatigue, Malaise Weight loss Bone pain Hepatosplenomegaly Lymphadenopathy LABS & DIAGNOSTIC TESTS ↑ WBC’s (50-100) or Very low WBC’s ↓Hgb, Hct, Platelets Blast cells in differential BONE MARROW ASPIRATION LUMBAR PUNCTURE BONE SCAN possible

Brain Tumors Second most prevalent type of cancer in children
Males affected more often Peak age years Types: Medulloblastoma Astrocytoma Brain Stem glioma Look for S/S of increased ICP and area of brain affected

Wilm’s Tumor Also known as Nephroblastoma
Large, encapsulated tumor that develops in the renal parenchyma (do not palpate abdomen!) Peak age of occurrence: years Prognosis is good if no metastases- lungs first Treatment is surgery, chemotherapy and sometimes radiation

Neuroblastoma Highly malignant tumor – extracranial
Often develop in adrenal gland, also found in head, neck, chest, pelvis Incidence: One in 10,000 Males slightly more affected From infancy to age 4 Often diagnosed after metastasis occurs Treatment includes surgery, chemotherapy and radiation

Bone Tumors Osteogenic Sarcoma:
Occurs most often in boys between yrs 10-20% 5 year survival rate Primary bone tumor of mesenchymal cell Treatment:surgery (amputation or salvage) and chemo Ewing’s Sarcoma: Occurs in boys between years Primary tumor arising from cells in bone marrow Treatment is radiation and chemotherapy

Pediatric Oncology: Nursing Interventions
CHEMOTHERAPY SIDE EFFECTS Leukopenia (Nadir) Thrombocytopenia Stomatitis Nausea/Vomiting Alopecia Hepatotoxicity Nephrotoxicity NURSING INTERVENTIONS HANDWASHING! Monitor visitors Monitor for infection Meticulous oral care Antiemetics ATC Monitor Labs Support/Teaching

Pediatric Oncology: Nursing Interventions
Supportive care for radiation treatment, focusing on skin care Surgical interventions are based on location and type of surgery Basic pre and postoperative care Psychosocial care for patient and family – utilize Child Life and Social Services

Pediatric Oncology Teach, teach, teach! Support the child and family
Provide resources Be honest Include the child in the care planning Photo Source: Del Mar Image Library; Used with permission

Let’s Review In caring for the child with osteosarcoma, it is important for the nurse to inform the child and family of the treatment plan. Which would be appropriate? A. The affected extremity will have to be amputated. B. The child will only need chemotherapy. Both surgery and chemotherapy are indicated. Only palliative measures are taken.

Let’s Review The nurse assessing a child who is undergoing chemotherapy finds the child to be suffering from mucositis. Which intervention would be the highest priority? A. Meticulous oral care. B. Obtain dietician consult. C. Place the child on a full liquid diet only. D. Medicate for pain around the clock.

Let’s Review The priority nursing intervention in caring for a child with acute lymphocytic leukemia (ALL) during the child’s nadir period is: A. Handwashing. B. Monitoring lab results. C. Administering antiemetics. D. Monitoring visitors.

Child’s Response to Death:
Death & Dying Child’s Response to Death: Infants & Toddlers: Do not understand Viewed as a form of separation Can sense sadness in others Preschooler: Death is temporary Viewed as sleep or separation Feel guilty and blames self Dying children may regress in behavior

Death & Dying School-Age: Have concept of irreversibility of death
Fear, pain, mutilation and abandonment Ask many questions Feel death is a punishment May personify death (bogeyman) Will ask directly if they are dying Interested in the death ceremony Comforted by having parents and loved ones with them

Death & Dying Adolescent: Have an accurate understanding of death
Death as inevitable and irreversible May express anger at impending death May find it difficult to talk about death May wish to leave something behind to remember them by May wish to plan own funeral

Death & Dying Parental responses to death: Major life stress
Experience grief at potential loss of child Related to circumstances regarding child’s death (denial, shock, disbelief, guilt) Confronted with major decisions regarding care May have long term disruptive effects on family Bereaved parents experience intense grief of long duration

Communicating with the Dying Child and Family
Use child’s own language Don’t use euphemisms Don’t expect an immediate response Communicate through touch Encourage questions and expressions of feelings Strengthen positive memories Listen, touch, cry

Impending Death Care Guidelines
Do not leave child alone Do not whisper in the room Touching the child is very important Let the child and family talk and cry Let parents participate in care as much as they are emotionally capable of doing Continue to read favorite stories or play the child’s favorite music Be aware of the needs of the siblings

Let’s Review Which intervention would be most helpful in supporting a dying child’s family as they cope with the various decision-making periods of a lengthy terminal illness? A. Encouraging the parents to take their child home to die. B. Encouraging the parents to go through all of the Kubler- Ross stages of dying as quickly as possible. C. Referring the child’s family to the hospital clergy service as soon as possible. D. Using active listening to identify specific fears and concerns of the child’s family members.

Types of Child Abuse M Neglect: Intentional or unintentional omission of basic needs and support M Physical Abuse: Is non-accidental injury to a child by an adult M Sexual Abuse: Forced involvement of children in sexual activities by an adult M Emotional Abuse: Withholding of affection, use of cruel and degrading language towards a child by an adult Neglect – Failure to provide adequate physical protection, nutrition, or health care as well as lack of human contact love. Currently 45% of all abuse cases involve neglect. Identification of neglect must take into consideration a parents attempt to meet the essential needs of a child despite limited resources. Psychosocial causes of failure to thrive are often linked to and reported as neglect. Physical abuse is characterized by injury, torture, maiming, or use of unreasonable force. Typically a pattern of behavior Is repeated over time but it can also be a single attack. Abuse can result from harsh discipline or severe punishment. Two patterns of physical abuse seen with increasing frequency is the shaken baby syndrome and Munchausen’s Syndrome by Proxy. Children rarely tell anyone about the abuse because of feelings of shame and confusion. Sexual abuse includes fondling, digital manipulation, exhibitionism, pornography, and actual or attempted oral, vaginal, or anal intercourse. In 1995, over 300,000 cases of suspected child sexual abuse were reported to child protective services (CPS). 80% of Children are sexually abused by someone they know. Most victims are identified when they start displaying inappropriate sexual behaviors or have a dramatic change in behavior – excessive masturbation, depression, suicidal gestures, delinquency, sleep disturbances, drug or alcohol abuse or with increased non-specific physical symptoms - headache, anxiety, fatigue, abdominal pain or complaints related to the anogenital area – bleeding, pain, discharge, swelling, etc. Emotional abuse is hard to prove and is not usually thought of as a form of abuse. Yet it is just as detrimental to a young child’s sense of worth as any other form of abuse. Typical abusers were often victims of child abuse themselves, most often they have low self-esteem, little confidence, and low tolerance for frustration. Only 10% of abusers have any serious psychological disturbances. Problems usually are related to a parent’s limited capacity to cope with, provide for or relate to a child. That is probably why toddlers are the most commonly abused – since they are exercising their autonomy and independence which can lead a parent to feel a sense of loss of power. Child abuse also occurs in all socioeconomic groups.

NURSES ARE MANDATED REPORTERS
Child Abuse M Reports of violence against children has almost tripled since 1976. M Many of the abused children are infants. “Red Flags” Fractures in infants Spiral fractures Injuries do not match story told NURSES ARE MANDATED REPORTERS Mandated reporting

Child Abuse Neglect Physical Abuse Sexual Emotional
Physical or emotional maltreatment Failure to thrive Contributing factors may be ignorance or lack of resources Physical Abuse Minor or major physical injury (bruising, burns, fractures) May cause death Munchausen by Proxy (MSP) Shaken baby syndrome (SBS) Sexual Incest, molestation, child porn, child prostitution Emotional May be suspected, but difficult to substantiate Impairs child’s self-esteem and competence

THE CHILD’S SAFETY COMES FIRST
Child Abuse Warning Signs Incompatibility between history of event and injuries Conflicting stories from various people involved History inconsistent with developmental level of child Repeated visits to emergency rooms Inappropriate response from child and/or caregiver Nursing Interventions Assess: Physical assessment and history of event, observe and listen to caregiver’s and child’s verbal and non-verbal communication Documentation: Complete CAR form and contact Child Protective Services, hospital documentation Support family and child: Social services, resources, teaching THE CHILD’S SAFETY COMES FIRST AND IS THE PRIORITY!

Let’s Review In caring for a 4 year-old with a diagnosis of suspected child abuse, the most appropriate intervention for the nurse is: Avoid touching the child. Provide the child with play situations that allow for disclosure of event. Discourage the child from speaking about the event. Give the child realistic choices to feel in control.

Let’s Review Which pediatric patient would most necessitate further investigation by the community-based nurse? A. An adolescent who prefers to spend time with friends rather than family. B. A toddler with dark bruises located on both legs. C. An infant with numerous insect bite marks and diaper rash. D. A preschooler with dirty knees and torn pants.

Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the Microsoft Office Clip Art Gallery.

Care of the Child and Family

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