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PEDIATRIC NURSING

Care of the Child


and Family

1
Developmental Theorists

 Maslow’s Hierarchy of Needs


(1954)
 Erik Erikson - Psychosocial
Theory
 Jean Piaget - Cognitive
Theory
2
Maslow’s Hierarchy of
Needs
ciples:
individual’s needs are depicted in ascending levels on the
erarchy
eds at one level must be met before one can focus on a hig
el need

ls of Maslow’s Hierarchy of Needs:


 Physiologic/Survival Needs
 Safety and Security Needs
 Affection or Belonging Needs
 Self-esteem/Respect Needs
 Self-actualization Needs
3
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

4
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

5
AUTONOMY VS.
SHAME & DOUBT
1 – 3 years
– Sense of control
– Exerts self/will
– Pride in self-
accomplishment
• Negativism
• Ritualism/Routines Photo Source: Del Mar Image Library; Used with
permission

• Parallel play

6
INITIATIVE VS. GUILT

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

criticism permission

7
INDUSTRY VS.
INFERIORITY
6 – 12 years
– Mastery of skills
– Peers in both play
and work
– Rules important
– Competition
Photo Source: Del Mar Image Library; Used with
– Predictability permission

8
IDENTITY VS. ROLE
CONFUSION
12 -18 years
– Sense of “I”
– Peers are very
important
– Independence
from parents
– Self-image Photo Source: Del Mar Image Library; Used with
permission

9
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

10
SENSORIMOTOR
Birth - 2 years
– Reflexive behavior
leads to intentional
behavior
– Egocentric view of
world
– Cognitive parallels
motor development
– Object Permanence

11
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

12
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

13
FORMAL OPERATIONS
11 years - Adult
– Abstract thinking
– Analyze
situations
– New ideas created
– Factors altering
this:
• Poor
comprehension
• Lack of
education Photo Source: Del Mar Image Library; Used with
permission
• Substance
abuse 14
Infant Physical Tasks
Physical Tasks: 0 - 6 months:
 Fastest growth period
 Gains 5-7 oz (142-198 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 15
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: 16
Can fixate on and follow objects
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* Photo Source: Del Mar Image Library; Used with
permission
• Separation anxiety develops at 9
months*

17
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

18
Toddler
Physical Tasks:
• Slow growth period
• Gains 11 lbs (5 kg)
• Grows 8 inches (20.3 cm)
• Anterior fontanel closes at
• 12 - 18 months*
• Primary dentition (20 teeth)
complete by 2½ years
• Develops sphincter control – toilet
training possible*

Motor Tasks:
• Walks alone by 12 - 18 months*
• Climbs and runs fairly well by 2
Photo Source: Del Mar Image Library; Used with
years permission
• Rides tricycle well by 3 years

19
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 20
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

TOYS = Push-pull toys,


21
large blocks
Preschooler
Physical Tasks:
• Slow growth rate continues
• Weight increases 4-6 lbs (1.8–2.7 kg)
a year
• Height increases 2½ inches (5-6.25 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

22
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

23
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


24
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*

25
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 Photo Source: Del Mar Image Library; Used with
permission
muscle coordination, stamina
& strength
26
 Has all permanent teeth by
age 12
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*

27
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 28
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
12-18 yrs
 Body shape changes:
Photo Source: Del Mar Image Library; Used with
Girls have fat deposits in permission

thighs, hips & breast, pelvis


broadens
Boys become leaner with a
29
broader chest
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

30
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 31
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 32
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

33
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. 34
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.
35
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.

36
Infant Nutrition
Birth – 6 months:
 Breast milk is most complete diet
 Iron-fortified formulas are acceptable
 No solid foods before 4 months*

6 - 12 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)

37
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*
Photo Source: Del Mar Image Library; Used with
 Choking is a hazard (no nuts,permission
hot dogs,
popcorn, grapes)* 38
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

39
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


40
integrated into
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
41
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.

42
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.

43
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.
44
D. Introduction of solid foods should begin at
Play is the work of
Children
 Enhances Motor
Skills
 Enhances Social
Skills
 Enhances Verbal
Skills
 Expresses
Creativity
45
 Decreases Stress
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, 46
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 Photo Source: Del Mar Image Library; Used with
• Praise/reward child when permission
finished
47
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


48
possible
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.

49
Health Promotion
Childhood Immunizations
Well child check-ups
Nutrition
Screenings throughout childhood
(APGARS, newborn screenings, lead poisoning,
vision/hearing, scoliosis)

Health Teaching

50
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
51
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!
52
 Safety education is the answer
Injury Prevention
 Methods of Injury Prevention
• Understanding and Applying Growth and

Developmental Principles
• Anticipatory Guidance
• Childproofing the environment
• Educating caregivers and children
• Legislation
 Precipitating Factors

 Potential Outcomes
53
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 54
available
Types of Poisonings

Lead
Poisoning

Salicylate
Poisoning

Acetaminophen
Ingestion

55
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 56
blood level ≥ 45, chelation therapy is
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 57
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! 58
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
59
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 60
Distract with soft voice, offer pacifier, music
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
61
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
Photo Source: Del Mar Image Library; Used with
permission
 If proceed as game, will gain cooperation 62
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
63
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
64
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
65
Pediatric Differences
Fluid & Electrolyte
Percent Body Water compared to Total
Body Weight:
• Premature infants: 90% water
• Infants: 75 - 80% 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 66
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, 67


potassium, chloride, carbon dioxide,
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
68
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!
69
Priorities: fluid replacement & assess
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
70
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 71
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.
72
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

73
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
74
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) 75
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
Photo Source: Del Mar Image Library; Used with
permission
76
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
77
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
78
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 79

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

80
Let’s Review

When assessing pain in an infant


it would be inappropriate to
assess for:
A. Facial expressions
B. Localization of pain
C. Crying
D. Extremity movement

81
Genetic Disorders
✗ Principles of Inheritance
γ Autosomal Dominant
γ Autosomal Recessive
γ Sex-linked (X-linked) Inheritance
γ Chromosome Alterations

✗Down’s Syndrome
✗Tay-Sachs Disease

Nursing intervention is supporting parents


and resources

82
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,
83
hypotonia
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

84
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

85
Pediatric Differences
Neurosensory System
Size and Structure:
Rapid head growth in early childhood
Bones are not fused until 18-24 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
86
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 87
The Neurosensory
System
Disorders of the Nervous System

✓ Hydrocephalus
✓ Spina Bifida
✓ Reyes Syndrome
✓ Seizures
✓ Cerebral Palsy (CP)
✓ Meningitis

88
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 89
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

90
General Nursing
Interventions
• Monitor Neuro • Decrease ICP
Status  Cluster care/ ⇓
 Determine stress
baseline  Quiet
 Assess LOC environment
 Assess  ⇑ HOB 30-45
motosensory degrees
 Pupil checks  Appropriate
 Vital signs, Head position (head
circ midline, no hip
flexion, no prone)
• Provide Patient  Medications(pain
Safety meds,corticostero
ids, diuretics,
 Seizure stool softeners,
precautions anti-infectives, 91
 Fall precautions anticonvulsants)
General Nursing
Interventions
• Maintain • Maintain
Adequate Nutritional &
Cerebral Fluid Needs
Perfusion  Determine
 Maintain airway swallow ability
 Monitor prior to PO’s
oxygenation and  NGT feedings may
apply O2 PRN be necessary
 Monitor  Dietary consult
temperature and PRN
administer  Daily weight
antipyretics PRN  Monitor lab
 Maintain results
normovolemia 92
 Monitor I/O • Psychosocial
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
Photo Source: Del Mar Image Library; Used with
permission
occur. 93
– Hydrocephalus (80-90%)
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
94
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.
95
• Therapeutic management is intensive nursing
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 96
occular movements or some extremity
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

97
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
98
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
99
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
100
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
101
Causes of Deafness
Conductive:
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

102
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

103
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).
104
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.
105
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. 106
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.

107
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 108
manifestations (S/S)
FETAL CIRCULATION

Photo Source: Del Mar Image Library; Used with 109


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 110
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

111
NORMAL HEART
ANATOMY BLOOD FLOW

Photo Source: Del Mar Image Library; Used with


permission

112
The Cardiovascular
System
Care of the Child with Congestive Heart Failure
Congenital Heart Defects
Increased Pulmonary Blood Flow
 Decreased Pulmonary Blood Flow
Obstruction to Systemic Blood Flow
Acquired Heart Disease 

113
Goals of Nursing Care with
Congenital Heart Disease
Reduce workload-Improve cardiac function
Improve respiratory function
Maintain nutrition to meet metabolic demands
and promote growth
Prevent infection and support/instruct parents

114
Congestive Heart Failure
Review
• COMPENSATORY
RESPONSES
– Tachycardia, especially at rest
– Diaphoresis
– Fatigue
– Poor Feeding
– Failure to Thrive (FTT)
– Exercise Intolerance
– Decreased Peripheral
Perfusion
115
– Pallor and/or Cyanosis
CLINICAL
MANIFESTATIONS-CHF
• PULMONARY • SYSTEMIC
– Tachypnea – Edema (facial)
– Dyspnea – Sudden weight
– Wheezes gain
– Crackles – Decreased Urine
Retractions Output
– Nasal Flaring – Hepatomegaly
– Cough – Splenomegaly
– Jugular Vein
Distention (JVD,
children)
116
– 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

117
GENERAL NURSING
INTERVENTIONS
• Improve Cardiac • Decrease Cardiac
Function Demands
– Medicate – Promote rest
• Cardiac – Minimize Stress
glycosides – Monitor VS (temp)
(Digoxin) • Reduce Respiratory
• Promote Fluid Loss Distress
– Medicate – HOB elevated
• Furosemide – Possible
• Spironolactone supplemental
• Clorothiazide oxygen
– Fluid Restriction • Maintain Nutrition
– Daily Weight – Nipple vs.
– Monitor I/O Gavage/GTT
– Higher-calorie 118
feeds (more than
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
119
lungs”
Photo Source: Del Mar
Image Library; Used with
permission

120
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

121
Decreased Pulmonary
Blood Flow (Cyanotic)

Photo Source: Del Mar


Image Library; Used 122
with permission
Obstruction to Systemic
Blood flow
• Aortic Stenosis
• Coarctation of the Aorta
• Think perfusion issues
-Diminished or unequal
pulses
-Poor color
-Delayed capillary refill
time
123
-Exercise intolerance
Obstruction to Systemic
Blood flow

Photo Source: Del Mar Image Library; Used with


permission
124
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 125

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


126
hemoglobin is
The Hematologic System
 Disorders of Red Blood Cells
 Iron Deficiency Anemia
 Sickle Cell Anemia

 Disorders of Platelets/Clotting
Factors
 Idiopathic Thrombocytopenia
Purpura (ITP)
 Hemophilia

127
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 128
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
129
Sickle Cell Disease

Photo Source: Del Mar Image Library; Used with

PATHOLOGY permission

 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 130
reticulocytes
Sickle Cell Disease
ACUTE FEBRILE SPLENIC
ILLNESS SEQUESTRATION
• High mortality rate • Highly vascular
<5 years old • Susceptible to
• Splenic dysfunction injury/infarction
begins at 6 mo old • Occurs 6 mo-3yrs
• Prophylactic PCN • Pallor, fatigue, abd
– BID at 2-3 mo old pain, splenomegaly,
• Monitor for CV compromise
Infection • Treatment: IV fluids,
– Temp > 101.5 PRBC’s
– Respiratory S/S 131
Sickle Cell Disease:
Nursing Interventions
GENERAL NURSING CARE HOME
• Hydration is Priority! MANAGEMENT
– Fluid Bolus & • Pain Control
maintenance + 1/2 • Fluids
• Oxygen - to decrease • Teaching
sickling of of cells • Early
• Pain Management Identification of
– Assess infection
frequently/appropriatel • Immunizations
y
– IV Morphine q3-4 hr,
• Avoid
PCA dehydration
– Non-pharmacological
methods 132
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 133
prednisone, IV immunoglobulin, or Anti-D
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
134
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

135
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.
D. Suspects the child may have coarctation
of the aorta.
C. Suspects the child may have Tetralogy of
Fallot. 136
D. Notifies the physician and alerts the
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%.
137
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.
138
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 139
choose foods he
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
140
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 141
 Abdominal muscles are used for inhalation
The Respiratory System
Upper Airway
Disorders
Tonsillitis
Croup
Epiglottis
Foreign Body
Aspiration

Lower Airway
Disorders
Bronchiolitis Photo Source: Del Mar Image Library; Used with
permission

Asthma 142
Cystic Fibrosis
Tonsillitis
CLINICAL MANIFESTATIONS IMPLEMENTATIONS
Sore throat  Ease Respiratory
Mouth breathing Efforts
Sleep Apnea  Provide Comfort
Difficulty swallowing Warm saline gargles
Fever Pain Medication
Throat C&S/Rapid Strep Throat lozenges
Reduce Fever
Promote Hydration
Administer
Antibiotics
Provide Rest
Patient Teaching
Tonsillectomy may
be necessary
143
Tonsillectomy
Pre-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
144
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 Photo Source: Del Mar Image Library; Used with
• LTB form most common permission

145
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
146
Croup/Epiglottitis
Nursing Nursing
Interventions Interventions
Maintain Patent  Administer Meds
Airway  Corticosteroids
Assess and  (HHN) Nebulizer
Monitor treatment of
Ease Respiratory Racemic
Epinephrine PRN
Efforts
stridor
Promote Hydration  Antibiotic for
Reduce Fever epiglottitis
Calm Environment 147
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
148
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
149
• Palivizumab (Synagis)
Bronchiolitis/RSV
CLINICAL IMPLEMENTATIONS
MANIFESTATIONS Suction – priority
Bronchodilator via
Nasal Congestion HHN
Cough CPT
Rhonchi, Crackles, Promote fluids
Wheezes Monitor VS , SaO2,
lung
Increased RR & SOB sounds &
Respiratory Distress respiratory effort
Fever Supplemental
oxygen
Poor Feeding Reduce fever
Promote rest
HANDWASHING! 150
Asthma
CLINICAL INTERVENTIONS
MANIFESTATIONS Monitor VS (HR,
Tachypnea RR)
SaO2 below 95% on RA Monitor SaO2
Wheezes, crackles Auscultate lung
Retractions, nasal sounds
flaring Monitor
Non-productive cough respiratory effort
Silent chest Humified oxygen
Restlessness, fatigue Calm environment
Orthopnea Ease respiratory
efforts
Abdominal pain
Promote hydration
CXR = hyperinflation
Promote rest
Monitor labs/x-
151
rays
Asthma
Administer Medications
 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)
 Mast cell inhibitor via HHN or MDI (Cromolyn
Sodium - Intal)
 Leukotriene modifiers PO for long-term
152
control - Singular
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
153
death: 32 years
Cystic Fibrosis
PULMONARY GI MANIFESTATIONS
MANIFESTATIONS • Large, loose, frothy
• Initial and foul-smelling
• Wheezing stools
• Dry, non-productive • Increased appetite
cough (early)
• Eventual & Progressive • Loss of appetite
• Repeated lung (later)
infections • Weight loss
• Wet & paroxysmal • FTT
cough • Distended abdomen
• Emphysema/Atelectasi •
s Thin extremities
• Barrel-chest • Deficiency of A,D, E,
- Clubbing
K
- Cyanosis • Anemia
154
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
155
Otitis Media
◊ 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

156
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 Photo Source: Del Mar Image Library; Used with
◊ Surgery prep if needed permission

157
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).

158
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.
E. Obtain a throat culture for respiratory
syncytial virus
(RSV).
G. Obtain vital signs and auscultate lung
sounds.
159
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.

160
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.

161
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 162
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! Photo Source: Del Mar Image Library; Used with
permission
• Assess hydration 163

status
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
164
vascular
The Gastrointestinal System
Altered Connections
✓ Esophageal
Atresia/Tracheoesophageal Fistula
✓ Cleft Lip and Palate

Gastrointestinal Disorders
✓ Gastroesophageal Reflux ✓ Pyloric
Stenosis
✓ Hirschsprung’s Disease ✓
Imperforate Anus
✓ Intussusception

Acquired Gastrointestinal Disorders


✓ Celiac Disease
✓ Appendicitis 165

 ✓ 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” -
Photo Source: Del Mar Image Library; Used with
coughing,choking,cyanosis
permission 166
ESOPHAGEAL ATRESIA &
TRACHEOESOPHAGEAL
FISTULA
SIGNS/SYMPTOM TREATMENT
• Copious, frothy • Surgery: either a
oral secretions one- or two-stage
• Abdominal repair
distension from • Pre-op care
air in stomach focuses on
• Look for 3 C’s preventing
• Confirmed with aspiration and
radiographic hydration
studies • Post-op care focus
is a patent airway,
prevent incisional 167
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 168
 Open communication between mouth
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
Photo Source: Del Mar Image Library; 169
 Altered bonding is aUsed 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
170
 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 12-18
mo old related to growth due Photo Source: Del Mar Image Library; Used with
permission
to elongation of esophagus
and the LES drops below the
diaphragm 171
GASTROESOPHAGEAL
REFLUX
SIGNS/SYMPTOMS DIAGNOSTIC EVAL
• Vomiting/spitting • History of
up feedings/PE
• Gagging during • Upper GI/Barium
feedings swallow to
• Irritability eliminate
• Arching/posturing anatomical
problems
• Frequent URI’s/OM •
Upper GI
• Anemia endoscopy to
• Bloody stools visualize
esophageal
mucosa
• pH probe study 172
GASTROESOPHAGEAL REFLUX:
Therapeutic Management
• Positioning • Medications
• Prokinetic agents:
• Prone HOB ⇑ 30°
⇑ LES pressure &
• Right side gastric motility
• Dietary • Histamine H-2
modifications antagonists are
• Small, frequent added if
feedings, burp esophagitis : ⇓
often acid
• Possibly thicken • Proton Pump
formula Inhibitors if H-2
ineffective:⇓acid
• Avoid fatty, spicy
foods caffeine, & • Mucosal
citrus Protectants
• Teach • Surgery: 173

fundoplication
HIRSHSPRUNG’S
• Aganglionic
megacolon
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- Photo Source: Del Mar Image Library; Used with
permission
step surgery
Colostomy with later pull-
174
through
HIRSHSPRUNG’S
SIGNS/SYMPTOMS NURSING
 Infants INTERVENTIONS
 Unable to pass • Surgery prep: bowel
meconium stool within cleansing,
24 hours of life antibiotics, NPO,
 Abdominal distention IVF’s, therapeutic
 Bilious vomiting play for surgery
preparation
 Refusal to feed
• Infection & Skin
 Failure to thrive
Integrity: monitor
 Children ostomy/anus
 Chronic constipation
• Nutrition &
 Pellet or ribbon-like
Hydration: NGT,
stools (foul-smelling)
NPO then advance
 Vomiting/FTT
to Diet as tolerated,
175
assess bowel
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 Photo Source: Del Mar Image Library; Used with
shock permission

176
INTUSSUSCEPTION
DIAGNOSTIC STUDY NURSING
• Barium or air enema INTERVENTIONS
• Abdominal • Monitor for infection,
ultrasound shock, pain
• Maintain hydration -
TREATMENT assess status!
• Hydrostatic • Prepare child/parent
reduction: force for hydrostatic
exerted using water- reduction - teach,
soluble contrast and consent, NPO, NGT
air to push the • Monitor stools pre &
affected intestine post procedure
apart
• If surgery: general
• Surgical reduction if pre & post-op care
hydrostatic
reduction is
unsuccessful 177
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
Photo Source: Del Mar Image Library; Used with
permission
hypochloremic metabolic alkalosis 178
 Weight loss
PYLORIC STENOSIS
DIAGNOSTIC EVAL INTERVENTIONS
• History/PE: “olive” • Pre-op: NPO, NGT
palpated in to LIS, hydration,
epigastrum I/O, monitor
• Upper GI (string electrolytes
sign) • Post-op: Start
• Abdominal feedings in 4-6
Ultrasound hrs. Progressive
feeding schedule
TREATMENT begin w/5cc GW ⇒
half strength
• Surgical
formula ⇒ Full
Intervention: strength formula
Pyloromyotomy
179
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-180
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

181
APPENDICITIS
• Inflammation and • Surgery is
infection of vermiform necessary
appendix, usually • If ruptured, often
related to an child will receive IV
obstruction antibiotics for 24
• Cause may be bacteria, hrs prior to OR
virus, trauma • Pre-op Care: NPO,
• Ischemia can result pain management,
from the obstruction, hydration, prep &
leading to necrosis teaching, consent
causing perforation • Post-op Care:
• S/S: periumbilical pain routine post-op
⇒RLQ pain care,
(McBurney’s point), IVF/antibiotics,
fever, vomiting, NPO⇒DAT,
diarrhea, lethargy, ambulation,
irritability, ⇑ WBC’s positioning, pain
management, 182
wound care,
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
183
*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.
184
Let’s Review
Which food choice by a parent of a
child with celiac disease indicates a
need for further teaching?
A. Oatmeal
B. Rice
C. Cornbread
D. Beef

185
Let’s Review
Which assessment finding
would the nurse find in a child
with Hirschsprung’s Disease?
C. Current jelly stool
D. Diarrhea
E. Constipation
• Foul-smelling, fatty stool

186
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.” 187
D. “The water in the IV goes into your veins
Let’s Review
The nurse caring for a child with
suspected appendicitis would
question which physician order?
C. NPO status
D. Start IV fluids of D5 ½ NS at 50
mls/hour
E. Complete Blood Count (CBC)
F. Apply heating pad to abdomen for
comfort
188
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
Photo Source: Del Mar Image Library; Used with
(and B/P) permission
• Kidneys produce
erythropoeitin which 189
stimulates RBC
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
190
padding & large size
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

191
The Genitourinary System

 Disorders of the Genitourinary


System
 Enuresis
Nephrotic Syndrome
Acute Glomerulonephritis
 Hemolytic Uremic Syndrome
(HUS)

192
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
193
Glomerulonephritis
PATHOPHYSIOLOGY

Streptococcal
Infection
Producing Antibodies

Bacterial Antigens
 plus Antibodies form
Immune Complexes
& trap in Glomerulus

Inflammatory
Response
Injury to Capillary Walls

Ineffective Filtration
Proteins Pass Through
Decreased GFR

Kidneys Enlarge
with sodium, water, waste
EDEMA

Photo Source: Teresa Simbro,


ACUTE RENAL RN, Santa Ana College, Used
FAILURE with permission. 194
Glomerulonephritis
ASSESSMENT INTERVENTIONS
• Hematuria • Monitor Urine
• Proteinuria (Dipstick)
• Edema: periorbital, • Monitor fluid
ankles overload
∀ ⇓ Urine Output • Assess lung
• Hypertension sounds/Resp effort
• Fatigue • Possible fluid & salt
• Possible fever restriction
• Abdominal • Monitor I/O, Daily
discomfort Weights
• Labs: +ASO, ⇓ • Monitor VS
Bicarb,⇑K ⇑BUN,⇑ • Antibiotic, diuretic &
Creat, ⇓ H & H antihypertensive
medications
• Promote & provide
rest 195
• Provide comfort
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
196
Nephrotic Syndrome PATHOPHYSIOLOGY

Alteration
in
Glomerulus

Damage to
Basement Membrane
of glomerulus
(increased permeability)

Proteinuria
(Hypoalbuminemia)

Fluid Shift
Intravascular to
Interstitial
HYPOVOLEMIA

 Decreased Renal Reabsorption of Sodium
Blood Flow and Water retention
Triggers Renin Production
Causing Increased Aldosterone Hyperlipidemia

Photo Source: Teresa Simbro,


EDEMA RN, Santa Ana College, Used
with permission. 197
Nephrotic Syndrome
ASSESSMENT INTERVENTIONS
• Proteinuria (3-4+), • Monitor Urine
frothy urine (Dipstick)
• Edema • Monitor
(pitting):periorbital, edema/dehydration
genitals, lower • Assess skin
extremities, abdominal integrity/turn often
∀ ⇓ Urine Output • Possible fluid & salt
(Hypovolemia) restriction
• Normotensive or • Monitor I/O, Daily
hypotensive Weights
• Fatigue • Monitor VS & S/S of
• Recent URI, Pneumonia infection
• Abdominal • Administer
Pain/Anorexia medications
• Labs: • Promote & provide
⇓Albumin rest
⇑ Platelets • Monitor labs
⇑H & H • HANDWASHING/monit 198
⇑ Cholesterol or 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
199
good renal function.
Hemolytic Uremic
Syndrome (HUS)
GASTROENTERITIS

e. coli #0157

Bacteria Adheres to
GI Mucosa
Multiplies
Releases Toxins

 Damages Capillary Walls

Collection of
Inflammatory Response Fibrin
Lipids
Platelet Fragments

Occlusion of Vessels Fragmented RBC's
Thrombocytopenia Causing Anemia
(Glomerular Vessels)

Decreased GFR
Photo Source: Teresa Simbro,
RN, Santa Ana College, Used
with permission. 200
Acute Renal Failure
Hemolytic Uremic
Syndrome (HUS)
ASSESSMENT INTERVENTIONS
• History: emesis, • Monitor I/O, Daily
bloody diarrhea, abd Weights
pain, ⇓ Urine • Evaluate for signs of
• Petechiae, bruises, bleeding
purpura • Monitor fluid
• Edema (possible CHF) overload/edema
• Hepatosplenomegaly • Assess for
• Altered LOC, seizure dehydration
• Hypertension • Monitor VS with neuro
• Fatigue checks
• Seizure Precautions,
• Abdominal discomfort
HOB ⇑
• Labs: Lytes may be • Diuretic &
abnormal antihypertensive
⇑ BUN medications
⇑ Creatinine • Provide rest/calm 201
⇓ H&H environment
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) 202
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. 203
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. 204
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

205
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.
206
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

207
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

208
The Musculoskeletal
System
✱Disorders of the
Musculoskeletal System
Developmental Dysplasia of the
Hip
Talipes (Clubfoot)
Osteogenesis Imperfecta
Scoliosis
Muscular Dystrophy
Juvenile Rheumatoid Arthritis
209
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 210
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
211
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

212
Scoliosis
o Abnormal curvature of the spine (lateral)
o Congenital or develops later, most
common during the growth spurt of early
adolescence (idiopathic)
o Diagnosis is made by physical exam and x-
rays
o Treatment for curvatures < 40 degrees is
bracing
o Surgical intervention is for severe
curvatures – internal fixation and
instrumentation (Harrington)
o Postoperative care includes logrolling,
neurologic assessments, pain
management, skin care, assessing for
213
paralytic ileus and possible mesenteric
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 214
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
215
(swimming), moist heat for pain and
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
216
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

217
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 218
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 219
maintain muscular
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 220
The Endocrine System

Disorders of the Endocrine


System
✘ Type 1 Diabetes Mellitus
✘ Congenital Hypothyroidism
✘ Growth Hormone Deficiency
✘ Precocious Puberty

221
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
222
Type 1 Diabetes Mellitus
Pediatric Considerations
• 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 223
Type 1 Diabetes Mellitus
Pediatric Considerations
EXERCISE
• Important for normal growth and
development
• Assists with daily utilization of dietary
intake
• Enhances insulin absorption, so may
decrease amount needed
• Add 15-30 grams of carbs for each 45-
60 minutes of exercise
• Watch for hypoglycemia with
strenuous exercise
224
Type 1 Diabetes Mellitus
Pediatric Considerations
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
225
• 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)
226
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 227
child at her appropriate developmental
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
228
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:
C. “That dose is too high, the doctor
needs to be notified.”
D. “You are doing a great job, that is the
correct dose for your child.”
E. “The injection should be given
intramuscular, not subcutaneous.”
229
F. “That dose is too low based on your
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
230
goes out to play
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 231
D. Assure the parents there is no
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

232
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

233
The Integumentary
System

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

234
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 Photo Source: Del Mar Image Library; Used with

& systemic permission

antibiotics, comfort
measures, teaching,
preventing comps 235
Roseola
• Transmission:
contact with
secretions (saliva)
• Virus
• 6 - 18 months
• Fever »flu
symptoms » rose-
pink macular rash
• Fades with
pressure Photo Source: Del Mar Image Library; Used with
permission

• Treatment is
supportive

236
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 237
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
238
tube
Factors to consider when
selecting IM sites
 Age
 Weight
 Muscle development
 Amount of subcutaneous fat
 Type of drug
 Drug’s absorption rate

239
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
240
into 2 injections depending on
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

241
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)
242
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

243
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
244
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.

245
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.
246
MDI with Spacer
MDI with Spacer and Mask

Photo Source: Del Mar Image Library; Used with


permission

247
Let’s Review
The nurse would prepare which
site for an intramuscular
injection to a 11 month-old?
C. Dorsogluteal
D. Deltoid
E. Vastus lateralis
F. Ventrogluteal

248
Pediatric Oncology
Cancer is the leading cause of death from
disease in children from 1 - 14 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
249
Leukemia is the most frequent type of
Oncology Stressful Events

“Treatment is worse than the disease.”


1. Diagnosis
2. Treatment - multimodal
3. Remission
4. Recurrence
5. Death

250
Oncology Interventions

✘ Surgery
✘ Radiation Therapy
✘ Chemotherapy
✘ Bone Marrow Transplant

251
Stages of
Cancer Treatment
1. Induction
2. Consolidation
3. Maintenance
4. Observation
5. Late Effects of Treatment
• Impaired growth & development
• CNS damage
• Psychological problems

252
Pediatric Oncology
Types of Childhood
Cancers
Leukemia
Brain Tumors
Wilm’s Tumor
Neuroblastoma
Osteogenic Sarcoma
Ewing’s Sarcoma

253
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: 254
prednisone, allupurinol, selected
Leukemias
CLINICAL LABS &
MANIFESTATIONS DIAGNOSTIC TESTS
• Purpura, Bruising ↑ WBC’s (50-100) or
• Pallor Very low WBC’s
• Fever Unknown ↓Hgb, Hct,
Origin Platelets
• Fatigue, Malaise Blast cells in
• Weight loss differential
• Bone pain BONE MARROW
• Hepatosplenomegaly ASPIRATION
• Lymphadenopathy LUMBAR PUNCTURE
BONE SCAN possible

255
Brain Tumors
econd most prevalent type of cancer in children
ales affected more often
eak age 3 - 7 years
ypes: Medulloblastoma
Astrocytoma
Brain Stem glioma
ook for S/S of increased ICP and area of brain affect

256
Wilm’s Tumor
 Also known as Nephroblastoma

 Large, encapsulated tumor that


develops in the renal parenchyma (do
not palpate abdomen!)
 Peak age of occurrence: 1 - 3 years
 Prognosis is good if no metastases-
lungs first
 Treatment is surgery, chemotherapy
and sometimes radiation
257
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
258
Bone Tumors
Osteogenic Sarcoma:
Occurs most often in boys between 10-20
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 5 - 15 years
Primary tumor arising from cells in bone
259
marrow
Pediatric Oncology:
Nursing Interventions
CHEMOTHERAPY NURSING
SIDE EFFECTS INTERVENTIONS
• Leukopenia • HANDWASHING!
(Nadir) • Monitor visitors
• Thrombocytopenia • Monitor for
• Stomatitis infection
• Nausea/Vomiting • Meticulous oral
• Alopecia care
• Hepatotoxicity • Antiemetics ATC
• Nephrotoxicity • Monitor Labs
• Support/Teaching
260
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

261
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

262
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.
E. Both surgery and chemotherapy are
indicated.
F. Only palliative measures are taken. 263
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.
264
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.

265
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
266
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 th

267
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
May wish to plan own funeral

268
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
269
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 270
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

271
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 272
fears and
Types of Child Abuse
Neglect:
Intentional or unintentional
omission of basic needs and
support
Physical Abuse:
Is non-accidental injury to a child
by an adult
Sexual Abuse:
Forced involvement of children in
sexual activities by an adult
Emotional Abuse:
273
Withholding of affection, use of
Child Abuse
Reports of violence against children
has almost
tripled since 1976.
Many of the abused children are
infants.

“Red Flags”
Fractures in infants
Spiral fractures
Injuries do not match story told

NURSES ARE MANDATED


274
REPORTERS
Child Abuse
Neglect
 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 275
 Impairs child’s self-esteem and competence
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 276


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:

C. Avoid touching the child.


D. Provide the child with play situations
that allow for
disclosure of event.
F. Discourage the child from speaking
about the event.
G. Give the child realistic choices to feel in
control. 277
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. 278
Photo Acknowledgement:
All unmarked photos and clip art
contained in this module were
obtained from the
2003 Microsoft Office Clip Art
Gallery.
279