Peds Notes

1364-FM_i-xxxvi 02/03/11 3:16 PM Page viii

2178_FM_ii-vi.qxd

10/21/09

1:03 PM

Page iii

Peds

Notes Luanne Linnard-Palmer, RN, MSN, EdD

Purchase additional copies of this book at your health science bookstore or directly from F.A. Davis by shopping online at www.fadavis.com or by calling 800-323-3555 (US) or 800-665-1148 (CAN) A Davis’s Notes Book

2178_FM_ii-vi.qxd

10/21/09

1:03 PM

Page iv

F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2010 by F. A. Davis Company All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in China by Imago Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher, Nursing: Lisa B. Deitch Senior Developmental Editor: William Welsh Director of Content Development: Darlene D. Pedersen Senior Project Editor: Padraic J. Maroney Cover Design: Carolyn O’ Brien Consultants: Kathleen Barta, EdD, RN; Jacqueline Brandwein, RN, MA, CPNP; Tammy Bryant, RN, BSN; Sandra Brzoza, MSN, RN; Nathania Bush, MSN, APRN, BC; Stephanie C. Butkus, MSN, RN, CPNP; Kathleen M. Cahill, MS, RN; Anne Citarella, RN, MSN; Jennifer J. Coleman, PhD, RN, CNE; Thomas W. Connelly, Jr., Ph.D, RN; JoAnn Crownover, RN, MSN, CNE; Christy Davidson, RNC, MSN; Cynthia A. Dyson, MSN, RN, BC, CNE; Emily Gilmore Fite, RN, MSN, CFNP; Betty Fruend, MSN, RN-BC; Linda Nicholson Grinstead, PhD, RN, CPN, CNE; Laura M.J. Kerr, RN, MSc, CON(C); Leslie Guthrie, RN, MS, BSN, NRP; Michele Hinds, PhD, RN, CNE; Marita B. Hoffart, RN, MS, PhD; Jill Holmstrom, RN, MS; Deborah Kramer, EdD, CPNP, FNP; Sarah Kulinski, MA, MSN; Patti Luttrell, MS, RN; Cherie L. McCann, MSN, RN, BC, CPN; Donna Miles Curry, RN, Ph.D; Carol Murphy Moore, MSN, RN, CRNP; Jean Rodgers, RN, MSN; Bridget Parsh, RN, MSN, CNS; Susan Perkins, MSN, RN; Susan Scholtz, RN, PhD; Laurel R. Talabere, PhD, RN, AE-C; Catherine Webb, RN, MA; Jeannie Weston, MS, BSN, CNS. As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.2510 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-2178-71169-2/1004 0 + $.2510.

2178_FM_ii-vi.qxd

10/21/09

1:03 PM

Page v

Place 27⁄8 ⫻ 27⁄8 Sticky Notes here for a convenient and refillable note pad

✓ HIPAA Compliant ✓ OSHA Compliant

BASICS

SAFETY

PLAY

ASSESS

PAIN

NUTRI

CLIN SKILLS

EMERG

PATHO A–G

PATHO H–Q

PATHO R–Z

TOOLS

TRANS

MEDS

2178_FM_ii-vi.qxd

10/21/09

1:03 PM

Page vi

Look for our other Davis’s Notes titles available now!

RNotes®: Nurse’s Clinical Pocket Guide, 2nd edition ISBN-13: 978-0-8036-1335-5

MedSurg Notes: Nurse’s Clinical Pocket Guide, 2nd edition ISBN-13: 978-0-8036-1868-8

LPN Notes: Nurse’s Clinical Pocket Guide, 2nd edition ISBN-13: 978-0-8036-1767-4

NCLEX-RN® Notes: Core Review & Exam Prep ISBN-13: 978-0-8036-1570-0

DocuNotes: Nurse’s Clinical Pocket Guide to Effective Documenting and Reporting ISBN-13: 978-0-8036-2092-6

NutriNotes: Nutrition & Diet Therapy Pocket Guide ISBN-13: 978-0-8036-1114-6

IV Med Notes: IV Administration Pocket Guide ISBN-13: 978-0-8036-1446-8 IV Therapy Notes: Nurse’s Clinical Pocket Guide ISBN-13: 978-0-8036-1288-4 LabNotes: Guide to Lab & Diagnostic Tests, 2nd edition ISBN-13: 978-0-8036-2138-1 MedNotes: Nurse’s Pharmacology Pocket Guide, 3rd Edition ISBN-13: 978-0-8036-1531-1

OB Peds Women’s Health Notes: Nurse’s Clinical Pocket Guide ISBN-13: 978-0-8036-1466-6 PsychNotes: Clinical Pocket Guide, 2nd edition ISBN-13: 978-0-8036-1853-4 Critical Care Notes: Clinical Pocket Guide ISBN-13: 978-0-8036-2084-1 Assess Notes: Assessment and Diagnostic Reasoning ISBN-13: 978-0-8036-1749-0

For a complete list of Davis’s Notes and other titles for health care providers, visit www.fadavis.com.

2178_FM_ii-vi.qxd

10/21/09

1:03 PM

Contacts • Phone/E-Mail Name Ph:

e-mail:

Name Ph:

e-mail:

Name Ph:

e-mail:

Name Ph:

e-mail:

Name Ph:

e-mail:

Name Ph:

e-mail:

Name Ph:

e-mail:

Name Ph:

e-mail:

Name Ph:

e-mail:

Name Ph:

e-mail:

Name Ph:

e-mail:

Name Ph:

e-mail:

Page ii

1364-FM_i-xxxvi 02/03/11 3:16 PM Page viii

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 1

1 Unique Aspects of Pediatric Nursing ■ Number of children in America (2009): 73.7 million ■ Percentage of children without health insurance (2009): 11.2% overall, including 12% to 28% of poor children ■ Percentage of children living at or below poverty level in United States: 13 million, ranging from 7% in New Hampshire to 27% in Mississippi ■ Ethnic breakdown of poverty levels: ■ African American: 35% ■ Native American: 29% ■ Latino: 28% ■ Asian: 11% ■ White: 10% ■ 16% of American children report the experience of food insecurity ■ 26.3% of American children are covered exclusively by Public Health Insurance (32.1% age 0–3 yr old) Source: Centers for Disease Control and Prevention, www.cdc.gov/nchs/fastats/children.htm; Health, United States (2008–2009) at www.cdc.gov/hus.htm

Society of Pediatric Nurses The mission of the Society of Pediatric Nurses is to promote excellence in nursing care of children and families through support of its members via clinical practice, education, research and advocacy. Their Web site, www.spn.org, is a resource for conferences, regional meetings, policy updates, clinical information and guidelines, professional support, and numerous Web links.

Adult Nurses Caring for Children Adult nurses need specific competencies to adequately provide safe care to children whose ages range from neonate to adolescent. Competencies include medication dosage calculations; pediatric-specific skills; neonatal, infant and child resuscitation techniques; play therapy; family-centered care principles; and developmentally appropriate care/ communication.

BASICS

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 2

BASICS Follow institutional policy concerning required competencies and do not perform pediatric patient care duties that you are not competent to perform. Read national documents concerning scope of pediatric nursing practice, standards of care, and required competencies (National Council of State Boards of Nursing). Seek nationally recognized pediatric nursing certification to attain a core body of knowledge and enhance practice. The two national certification boards that offer nationally recognized certification are the Pediatric Nursing Certification Board (PNCB) and the American Nurses Credentialing Center (www.pncb.org or www.nursingworld.org).

Common Acute Care Hospitalization Diagnoses ■ ■ ■ ■ ■ ■

Treatment for infectious diseases Treatment for consequences of injuries/accidents Surgical procedures Treatment for acute exacerbations of chronic childhood conditions Treatment of congenital heart defects Treatment of hematological, and oncological diagnoses

Critical Pediatric Nursing Issues ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Societal violence and unsafe neighborhoods Divorce rate, drug and alcohol abuse Lack of prenatal care, screenings through childhood Numbers of medically uninsured children in nation Violence and bullying in school settings Injury and accident rates across childhood Poor nutrition and increasing obesity rates Exposure to peer pressure with drugs, alcohol, and early sex Rates of STDs Mental health issues and depression Eating disorders Teen pregnancy rates School dropout rates Child abuse and neglect

2

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 3

3 Roles of the Pediatric Nurse ■ Health promotion through education, screening, and prevention measures ■ Disease prevention through rapid assessments and early interventions ■ Health restoration via acute, critical, and outpatient care ■ Community health nursing focusing on communities and client groups ■ Complex care coordination for children with multiple morbidities or complex chronic diseases requiring a multidisciplinary approach ■ Death and dying care, symptom management at end of life

Education concerning all aspects of children’s health.

Pediatric Care Locations ■ ■ ■ ■ ■ ■ ■ ■ ■

Acute care hospital units Critical care hospital units Specialty clinics for children with special needs Outpatient clinics Public health departments Home care Hospice care Private primary care provider offices Schools

Definition of Family Biological, legal and/or emotional relation between two or more persons. May have a variety of constellations including nuclear, alternative, adoptive, foster, and group. A family is who they say they are.

BASICS

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 4

BASICS

Differences Between Children and Adults Anatomical, Physiological, Metabolic, and Biochemical Differences ■ ■ ■ ■ ■ ■ ■

Medication pharmacodynamics and pharmacokinetics Anatomy and physiology Cognitive, motor, and psychosocial aspects Developmental processes and milestones Immune status Responses to illness Need for health promotion, frequent regularly scheduled screenings

Body System Differences ■ Respiratory ■ Tongue is disproportionally larger ■ Obligate nose breather for first 8–12 weeks ■ Underdeveloped intercostal muscles ■ Airway diameter approximate size of infant’s little finger ■ Less tidal volume ■ With respiratory compromise, rapid development of distress ■ Skin: Proportionally larger body surface area leading to body fluid loss and less temperature regulation ■ Cardiac: Higher heart rates, potential for congenital anomalies, lower blood pressures, higher oxygen demands ■ Fluids: Less ability to regulate body fluids and concentrate urine; higher specific gravity of urine in younger years ■ Electrolytes: Values differ in age groups, narrow fluctuations in values result in display of symptoms ■ Neurological: Primitive reflexes in infancy replaced slowly with gross to fine motor movements ■ Sensory: Born with all sensory organs intact except for vision (approximate visual acuity for a newborn is 20/100 to 20/200) ■ Immune system: Need acquired immunity to build adequate immune response; breast milk provides passive immunity

4

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 5

5 ■ Hematology: Fetal hemoglobin present at birth; rapid heart rate and higher hematocrit assists with oxygen delivery ■ Musculoskeletal: ■ Sequencing of growth is patterned by “spurts” and “lulls” ■ Mastery of motor skills is influenced by environment and for each child is highly individualized ■ Genital/urinary: ■ Smaller bladder capacity, must learn toileting skills and hygiene to prevent UTI: girls need to learn wiping front to back ■ Urine output at birth is 1–2 cc per hour per kg of body weight; newborn bladder capacity is 15 cc ■ Expectation of newborn and young infant is 6 to 8 wet diapers per day ■ Gastrointestinal: Feces change from newborn meconium to milk stools adjusting thereafter to eating habits, toileting capacities, and diet; first meal of protein beyond breast milk or formula may lead to rash ■ Endocrine: Inability to regulate blood glucose levels for first few years; newborns may demonstrate pseudomenstruation, “witches milk”

Stages of Childhood ■ ■ ■ ■ ■ ■ ■ ■

Premature infant: Born prior to 36 weeks’ gestation Newborn: First 28 to 30 days of life Infant: 30 days to first birthday Toddler: One year old to 3 years old Preschooler: Three years old to fifth birthday Early school age: 6 to 10 years old Late school age: 10 to 12 years old Adolescent: 13 to 18 years old

Family-Centered Care The philosophy of family-centered care recognizes the family as the constant in the child’s life and the need to provide support based on respect, encouragement, enhancement of strengths, and encouragement of competence.

BASICS

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 6

BASICS

Principles ■ Respect that the family is the constant in a child’s life ■ Treat the family as a unit because the entire family is affected by the child’s illness ■ Enforce that service systems and personnel support, respect, encourage, and enhance the family’s competence and strengths ■ Support natural care giving ■ Support decision-making roles within the family ■ Build unique strengths as individuals and families ■ Promote living at home and in the family’s community ■ Consider the needs of all family members and their role in the family structure ■ Include siblings and extended family members in care provision ■ Acknowledge diversity among structures and promote cultural practices ■ Promote normalization and encourage identities beyond the illness state ■ Support family goals, dreams, strategies, and activities ■ Locate support systems, services, education, and information for all members

Overarching Concepts ■ Empowerment: The interaction between the family and health providers is such that a sense of control over their family lives continues while members are supported to foster their own strengths, abilities, and actions through the caregiving/helping role ■ Enabling: Professionals provide opportunities for family members to master child’s care

Implementation ■ ■ ■ ■ ■ ■

Incorporate the philosophy into institutional policy Facilitate collaboration at all levels Exchange complete and unbiased information Incorporate the respect for cultural diversity into all aspects of care Provide opportunities for family-to-family support and networking Ensure that flexible, accessible and comprehensive services, support and care is given in all areas of specialized health ■ Appreciate that families have a wide range of strengths, emotions, concerns, and aspirations beyond their need for pediatric health care

6

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 7

7 Examples ■ Collaborative care conferences ■ Involvement in child’s care from the beginning of care ■ Teaching various members of the family to provide needed skills and care

Developmental Theorists Defined Erikson’s Developmental Theory Cognitive ■ Infant ■ Trust versus mistrust ■ Consistency of care is essential for an infant to develop trust Attend to expressed needs immediately and consistently ■ Need to learn object permanence (9–10 months) ■ Need to learn they are separate from primary caregiver ■ Toddler ■ Autonomy versus shame and doubt ■ Begin to tolerate some separation from primary caregiver ■ Temper tantrums are normal and negativism is common Egotistical at this time ■ Enjoy rituals, consistency, learning toileting skills and locomotion ■ Preschooler ■ Initiative versus guilt ■ May talk incessantly ■ Evolving from egocentrity to seeing other’s viewpoints ■ May have magical thinking to solve problems and make sense of their environment. Most at risk for effective symptom management as they may deny pain, nausea through their magical thinking ■ May be dependent on security objects and items (handle with care in the hospital and do not lose) ■ School-age ■ Industry versus inferiority ■ Acquisition of skills achieves a sense of competency, failure to do this leads to a sense of inferiority ■ The conscience is forming and peer group interactions are highly influential

BASICS

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 8

BASICS ■ Adolescent ■ Identity versus role confusion ■ Think beyond the present, are logical and use reasoning ■ Group identity is paramount and risk taking is common secondary to peer pressures

Kohlberg Theory of Moral Development ■ Infant: NA ■ Toddler: Preconventional, oriented toward obedience and punishment, discipline patterns affect moral development, praise appropriate behaviors ■ Preschooler: Preconventional, conscience emerges, emphasis on external control, moral standards are those of others ■ School age: Increased desire to please others and be seen as “good” ■ Adolescent: Postconventional, defined set of morals

Piaget ■ Infant: Sensorimotor stage, intellect develops, gains knowledge via environment through senses. Predictable survival reflexes (sucking and grasping), own body is point of central anxiety ■ Toddler: Sensorimotor to preconceptual and preoperational, egocentric, expressive jargon, 300 words ■ Preschooler: Preconceptual phase, intuitive phase, cannot see other’s viewpoints, magical thinkers, average 900 words ■ School age: Concrete operations, inductive reasoning, logical operation ■ Adolescent: Formal operations, abstract reasoning

Freud ■ Infant: Oral stage, sucks for enjoyment, meets the world orally ■ Toddler: Anal stage, experiences frustrations and satisfaction as she/he gains control ■ Preschooler: Phallic stage, masturbation, oedipal conflict where jealousy/rivalry with same sex person, strong bonding with opposite sex ■ School age: Latency period, relative sexual indifferences ■ Adolescent: Genital stage, masturbation, sexual relations, body image concerns

8

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 9

9 Principles of Growth and Development Infant Physical ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Ht increases 1 in. per month Wt doubles by 5–6 months Wt increases by 1.5 lb/month Teeth: 6–8 first year Head circumference (HC) increases by 0.5 in./month Gross/fine motor Rolls back to side at 3 months Hold head erect at 4 months Voluntary grasp at 5 months Rolls from front to back at 5–6 months Language Coos at 1–2 months Laughs at 2–4 months Makes consonant sounds at 3–4 months Imitative sounds at 6 months

Personal-Social ■ ■ ■ ■

Regards a person’s face at 1 month Displays social smile and follows object 180 degrees at 2 months Recognizes familiar faces at 3 months Stranger anxiety begins at 6 months

Older Infant Physical ■ ■ ■ ■ ■ ■ ■ ■

Ht increases 50% of birth ht by 1 year Wt increases 1 lb/month Triples wt by 1 year HC increases by 33% Posterior fontanel closes by 2–3 months Anterior fontanel closes by 12–18 months Central incisors erupt at 5–7 months Gross/fine motor

BASICS

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 10

BASICS ■ ■ ■ ■ ■ ■

Begins to crawl at 7 months Sits unsupported at 8 months Pulls up to stand at 9 months Drinks from cup at 9 months Builds two-block tower at 12 months Walks alone or holding onto one hand at 12 months

Language ■ ■ ■ ■ ■

Pronounces syllables (dada, mama) at 8 months Says 4–10 words at 12 months Personal–social Marked stranger anxiety at 8 months Emotions such as jealousy at 12 months

Toddler Physical ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Ht increases 3 in. a year Wt increases 5 lb a year Weighs about 4 times birth wt HC equals chest circumference at 1–2 years 10–14 temporary teeth erupt Gross/fine motor Walks without help at 15 months Walks up and down stairs placing both feet on each step at 24 months Scribbles spontaneously at 15 months Builds 3–4 block tower at 18 months Jumps with both feet at 30 months

Language ■ ■ ■ ■ ■ ■ ■ ■ ■

Says 300 words at 2 years old Uses 2- to 3-word phrases and pronouns Understands speech at 2 years old States first and last name at 2.5 years old Personal–social Separation anxiety peaks Ritualism is very important to child Negativism occurs (favorite word is no) Striving for independence but very unsafe and needs supervision at all times

10

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

11 Preschooler Physical ■ ■ ■ ■

Ht increases by 2.5 to 3 in. per year Wt increases by 4–6 lb per year HC increases by 0.5 in. per year Vision is 20/20 with color vision intact at 5–6 years old

Gross/Fine Motor ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Rides tricycle at 3 years old Climbs stairs using alternate feet at 3 years old Stands on one foot at 3 years old Has broad jump at 3 years old Builds 9–10 block tower by 3 years old Skips by 4 years old Catches a ball by 4 years old Laces shoes by 4 years old Ties shoelaces by 5 years old Uses scissors well by 5 years old Prints letters and numbers and name by 5 years old

Language ■ ■ ■ ■ ■ ■ ■

Says 900 words by 3 years old Speaks in 3- to 4-word sentences Says 1500 words by 4 years old Asks “why” questions at 4 years old Says more than 2000 words by 5 years old Knows and names colors by 5 years old Names days of the week by 5 years old

Personal-Social ■ Shares toys with others ■ Imitates caregivers ■ Enjoys domestic role-playing

BASICS

Page 11

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 12

BASICS

Early School Age Physical ■ ■ ■ ■

Ht increases by 2–3 in. a year Wt increases by 4.5–6.5 lb/year Secondary teeth erupt and deciduous teeth are shed Tanner stage 3 may begin

Gross/Fine Motor ■ Rides bike ■ Roller skates (needs lessons on safety and use of protective equipments ■ Runs, jumps, and swims ■ Cursive writing at 8 years old ■ Computer and craft skills become important

Language ■ Develops ability to read at grade level

Personal-Social ■ School relationships and work important ■ Separating from family ■ Best friends” develop

Later School Age and Adolescent Physical ■ ■ ■ ■

Puberty begins in girls at 8–14 years old Puberty begins with boys at 9–16 years old Ht and Wt increases are highly varied Progressive Tanner stages of development

Gross/Fine Motor ■ Gross motor reaches adult level although takes risks with sense of invincibility ■ Fine motor continues to be refined

Language ■ Develops formal thought including idealism, egocentrism, and ability to consider abstract possibilities

12

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 13

13 Personal/Social ■ Works through identity issues, status, and relationships

Emotional Factors Associated with Care of Children Separation Anxiety ■ Manifests in toddlerhood ■ Becomes clingy ■ Three phases: ■ Protest: Cries for caregiver ■ Despair: Disinterested in play and environment, show passivity ■ Detachment: Adjustment is superficial, detached but shows shallow interest, occurs after prolonged separation ■ Try short periods of separation in the beginning

Stranger Anxiety ■ ■ ■ ■ ■

Peaks at 9 months of age Unfamiliar situations and people set off child Cuddling can ease fears May need security object from home Try to plan care of child by same providers

■ ■ ■ ■ ■ ■ ■ ■

Peaks at 24 months Common in toddlers and an expected form of behavior in all children Considered normal, healthy way to deal with frustrations Avoid situations that are triggers Do not give in: Remain calm, gentle but firm Offer choices whenever possible Reward desired behavior with attention and praise Do not overcontrol and be flexible when able

Tantrums

BASICS

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 14

BASICS

Communicating with Children Infants ■ ■ ■ ■ ■

Direct eye contact: Get to their level Imitation sounds Emphasizing vowels and consonants Close contact with primary caregiver Promotion of security through contact and immediate needs gratification

Toddlers ■ Playing of age-appropriate games such as large balls, simple games, reading picture books ■ Simple conversations that encourage autonomy ■ Praise for desired behaviors ■ Inclusion in conversations ■ Only make promises you can keep!

Preschoolers ■ ■ ■ ■

Imaginative play Introduction to group play and conversations Learning how to take turns in conversation Preschoolers are very aware of surroundings, include child in conversations within earshot

Early School Age ■ Engage about schoolwork and accomplishments ■ Talk during shared crafts and art projects ■ Encourage and praise efforts: “You are doing a great job”

Later School Age ■ Enjoys competitive games, support sports by being actively involved ■ Enjoys mastering technology/computer games, engage child while playing

14

2178_Tab01_001-015.qxd

10/21/09

1:04 PM

Page 15

15 Adolescent ■ ■ ■ ■ ■ ■ ■

Engage in conversations about teen’s goals and life plans Ask about peer group members Provide time with peers, cell phones, and computer social groups Provide Internet access if appropriate Discuss family structure and home life Provide ample times of privacy Ask family to step out when interviewing

BASICS

2178_Tab02_016-023.qxd

10/21/09

1:18 PM

Page 16

SAFETY

Environmental Safety ■ Never leave a child unattended in a treatment room, on a scale, in a stroller, swing, highchair, bouncy seat, or wagon ■ Double-check that bed side rails or crib rails are up and locked in place ■ Use crib top covers to prevent a child from climbing out ■ Do not use cribs with greater than 35/8-in. gap between bars as child may place head between bars and suffocate ■ Do not allow helium- or air-filled latex or plastic balloons into the hospital or clinic; they pose a risk for aspiration as well as a risk for latex allergy ■ Always use security straps on every product/device according to manufacturer’s recommendation ■ Never leave a child alone during a procedure: Prevent injuries and falls ■ Follow all institutional policies concerning wrist or ankle alarms: Prevent abductions ■ Learn the institution’s infant or child abduction policy and procedure ■ Wash hands before and after all patient contact to prevent infection; wash as well between going from a dirty area to a clean area in the same patient ■ Monitor adolescents for evidence of high-risk behaviors: Educate ■ Prevent hypoglycemia and hypothermia in the newborn: Monitor nutritional intake and check child’s temperature and environmental temperature frequently. Keep infant wrapped and prevent cold stress ■ Place infants on their backs for sleep unless medically contraindicated: Prevent SIDS. Do not allow parents to sleep in the same bed as infant ■ Inspect toys brought from home for buttons, sharp edges, removable pieces, or defective parts ■ Never prop bottles in infant’s mouth: Prevent choking. Do not allow parents or caregivers to do so either as this is an aspiration hazard

Equipment Safety ■ Never leave scissors, hemostats, syringes, gloves, or any other medical equipment within reach of young children ■ Always cover electrical outlets: Prevent electrical injuries

16

2178_Tab02_016-023.qxd

10/21/09

1:18 PM

Page 17

17 ■ Never place heating pads or water-based warm packs in the microwave because they can cause burns: Use commercially prepared products ■ Do not leave ice packs on a child’s skin for longer than a few minutes ■ Do not microwave formula or baby food as there is uneven heating and can lead to burns; use water baths to heat formula bottles or baby food jars, or frozen/chilled breast milk

Medication Safety ■ Always use two patient identifiers before administering medications ■ Double-check with your institution to see which medications require two nurses for verification ■ Do not administer oral medications to a crying child as this poses a risk for aspiration ■ Include family members in medication administration: Teach and role-model safety ■ Never place medications in an alternative container. Leave in original container with safety caps and administration guidelines

Anticipatory Guidance: Accident and Injury Prevention ■ Teach parents about developmental issues that contribute to childhood injuries: ■ Newborn fall prevention safety practices ■ Choking prevention ■ SIDS prevention: “Back to Sleep” practices only (www.nichd.nih. gov/sids/) ■ Stair safety for toddlers ■ Water burns and kitchen burns prevention ■ Use of safety gates ■ Drowning safety for toddlers: Never leave child alone in or near any size body of water ■ Monitoring of play/interaction with animals, especially dogs ■ Car restraint safety: Appropriate car seat use ■ Use of sports safety devices: Wrist, elbow, knee protectors

SAFETY

2178_Tab02_016-023.qxd

10/21/09

1:18 PM

Page 18

SAFETY ■ ■ ■ ■ ■ ■ ■ ■

Prevention of drowning Hand gun/firearms storage guidelines Fireworks safety and prevention of burn injuries Teach children stranger danger Fire safety in the home ATV safety for school-age children and teens Sun exposure safety including keeping infants out of the direct sun Personal safety at the appropriate developmental level: Internet safety, never give out personal information, say no to drugs and smoking

Teaching Families to Prevent Childhood Injuries: Risk Factors Anticipatory Care Guidelines for All Parents, Caregivers, and Guardians ■ Gender: Behavioral characteristics of males cause them to experience large number of childhood injuries ■ Difficult temperaments lead to increased injuries ■ Stress increases risk of self-destructive behaviors ■ Natural curiosity leads to exploration and potential dangers in the home ■ Parents should see the home environment at the child’s level; crawl around on floor to see what dangers are present at the child’s level of vision and access ■ Developmental ages: ■ Infants explore through their mouths, leading to ingestions • Prevent aspiration and choking by inspecting toys • Keep cribs safe: No soft pillows, prevent suffocation • Car seat safety: Backward facing until 20 lb and 12 months • Prevent falls: Never leave infant alone on high surfaces • Prevent injury: Never leave infant alone with pets or young siblings. Never shake a baby • Check temperatures of warmed formula • Constantly hold on to infant in a bath tub • Use baby gates • Pad coffee tables or furniture with sharp edges • Lock cabinets with breakables and poisons

18

2178_Tab02_016-023.qxd

10/21/09

1:18 PM

Page 19

19 ■

Toddler’s and preschooler’s magical thinking means they cannot comprehend danger • Think crib safety as toddlers will climb over rails • Car seat safety: Forward-facing when >20 lb and older than 1 year for toddlers and forward-facing, backseat until 4 years old and 40 lb for preschoolers until they use a booster seat • Use safety gates, lock cabinets • Never leave toddler alone in the bathtub • Never keep buckets of standing water • Keep toilet bowl lids closed • Cover electrical outlets • Do not cook around toddler, cook on back stove top burners, prevent toddler from playing with stove controls • Cut foods in very small pieces to prevent choking • Do not allow young siblings to feed infants and toddlers • Keep matches, candles, fireplaces out of reach • Use helmets when riding tricycles, skates, and scooters (or any mobility toy) ■ Young child may not learn from experience and may repeat dangerous behavior ■ School-age children are still learning causal relationships, may attempt dangerous act without realizing consequences • Use helmets at all times • Use booster seats for children between 4 and 8 years of age and up to 80 lb (state laws vary) • Supervise children in pools, while swimming • Teach stranger safety; never approach cars • Keep guns, swords locked (avoid their storage in homes with children) ■ Adolescents may feel invulnerable and invincible • Provide appropriate sex education • Teach about decreasing risk-taking behaviors • Talk about risks of drugs, smoking, joy riding, alcohol

SAFETY

2178_Tab02_016-023.qxd

10/21/09

1:18 PM

Page 20

SAFETY

Use of Restraints A restraint is “any method, physical or mechanical, that restricts a person’s movement, physical activity, or normal access to his or her body” (Joint Commission on Accreditation of Healthcare Organizations, 2001, www.jointcommission.org/).

Restrictions ■ Policy must be clear and consistent ■ Need for restraint must be documented ■ At least one alternative method must be attempted before restraint is applied ■ Least restrictive method must be used ■ Order must be written and evaluated within 1 hour of application ■ Order must include start and stop time, date, reason for use, type, and signature of person ordering restraint

Nursing Tips ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Always obtain an order before using restraints Follow institutional policy carefully Assess child very frequently while using restraints Prevent injury or death from restraint use Document order, method, assessments, interventions, and child’s response frequently Remove restraints as soon as possible Never leave a restrained child alone Involve and educate parents and caregivers on need for restraint Exhaust all other forms of assisting child and situation before restraining child Restraint use is very frightening for the child: Use developmentally appropriate communication to explain indication

Behavioral Restraints ■ Wrist and ankle restraints ■ Jacket restraints tied to bed and sheets/straps tied to wheelchairs

20

2178_Tab02_016-023.qxd

10/21/09

1:18 PM

Page 21

21 ■ Blanket/sheet restraints used during procedures ■ Mummy wraps or tight swaddles

Guidelines for Using Behavioral Restraints ■ ■ ■ ■ ■ ■

Must use caution to ensure patent airway Needs either continuous supervision or frequent assessment: Follow policy Assess need for physical restraints every 2 hours Ensure correct and current physician’s order Give supervised rest periods from restraints Assess skin color and integrity, pulses below restraint site

Safety Alerts ■ ■ ■ ■ ■

Never tie restraint to side rails, tie only to bed or crib frames Leave one finger width between skin and device Tie knots for quick release Try to place restraint over clothing Use “No-No’s” when possible as a choice above wrist restraints. “No-No’s” are soft cotton wraparound devices with a Velco closure that covers PICC lines or IV devices. They prevent a young child from picking, chewing or otherwise dislodging bandages or devices. When wrapped around a child’s elbow, they prevent bending the extremity and therefore the child cannot reach up and pull out NG tubes or touch their faces after head, neck, or mouth surgery ■ “No-No’s” and other postoperative devices that are worn 100% of the time do not have the same standards: Assess skin frequently for breakdown and discomfort

Chemical Restraints ■ Medications include: ■ Haldol ■ Lorazepam ■ Diazepam

Guidelines for Using Chemical Restraints ■ ■ ■ ■

Use as a last resort Always check institutional policy Secure sitter or support person to monitor child during use Chemical restraints are a pharmacological means of decreasing combative, self-destructive behaviors

SAFETY

2178_Tab02_016-023.qxd

10/21/09

1:18 PM

Page 22

SAFETY

Restraining Methods During Procedures ■ It is sometimes necessary to restrain a child during a medical procedure. The techniques used involve close physical contact ■ Types: ■ Modified side-lying for lumbar puncture

■

Leg restraint for femoral vein puncture

22

2178_Tab02_016-023.qxd

10/21/09

1:18 PM

Page 23

23 ■

Mummy wraps for nasogastric tube insertion

Utilize child life specialists/therapists when available if restraints are indicated for a child of any age!

SAFETY

2178_Tab03_024-027.qxd

10/21/09

6:04 PM

Page 24

PLAY

Play Therapy What Is Play? Play is “work of the child.”All children need opportunities to play. It is sometimes a challenge to provide appropriate play to match a child’s interests and skills.

Why Provide Play? ■ ■ ■ ■ ■ ■

Play Play Play Play Play Play

is pleasurable has no extrinsic goal is spontaneous involves active engagement promotes social, emotional, and physical development provides learning

Types of Play ■ Unoccupied behavior: The child does not seem to be playing. Instead, he or she is watching whatever is going on that is most interesting (Parteri 1932) ■ Onlooker play: The child focuses on play activity of others and remains close by but does not participate ■ Solitary independent play: The child plays alone, using different materials from other children in the vicinity. The child makes no effort to interact with others. Considered intellectually advanced type of play across childhood and should be encouraged. ■ Parallel activity: Two children play in same area with others, using like materials, but they play independently. Often the children play back to back and have minimal interaction. Sharing infrequently happens during parallel play ■ Associative play: Children interact and engage in a common activity. Materials are exchanged. The play is not organized, although the children may attempt to control or limit participation. The children do not have a common goal ■ Cooperative or organized supplemental play: Play with a recognized group goal, often directed by 1 or 2 players and characterized by sets of different roles. Members control entry

24

2178_Tab03_024-027.qxd

10/21/09

6:04 PM

Page 25

25 Distraction Distraction can be used as a form of play for intellectual and motor development, but is also effective when prepping a child for a procedure, or to help relieve pain. Distractions include: ■ ■ ■ ■ ■

Music Videos Puzzles Books or stories read to the child Infant mobiles, mirrors, rattles

Child Life What Are Child Life Interventions? Child life interventions assist with the serious and long-term consequences of a child’s adverse emotional reaction to hospitalization and other medical encounters. Having a child life specialist provide play allows expression, education, and development for the child and siblings through deliberate interventions that minimize stress and anxiety (Thompson & Stanford, 1981).

Indications for Child Life Interventions ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Help the child cope with stress and anxiety Provide materials for play activities Prepare the child for hospitalization, surgery, or medical procedures Lend emotional support to siblings Maintain receptive environment for family members Advocate a child’s point of view to hospital personnel Promote physical, social, intellectual, and emotional development Prevent aggressive and hostile behaviors Provide stimulating environment and prevent solitude and boredom Encourage self-expression (feelings, emotions, vehicle of communication) Prevent regression by advocating for group participation and preventing isolation and independent play

PLAY

2178_Tab03_024-027.qxd

10/21/09

6:04 PM

Page 26

PLAY

Types of Play by Developmental Group Premature Infants ■ Allow uninterrupted sleep ■ Give soft touch with warm palms ■ If the infant is demonstrating signs of stress (decreased O2 sat, increased HR and RR) give rest periods

Newborns ■ Promote attachment to parents/caregiver ■ Demonstrate and encourage En Face positions (close eye/face contact) ■ Provide soothing soft music

Young Infants ■ ■ ■ ■

Hang mobiles above infant Infants enjoy contrasting colors such as black and white Toys with mirrors hold infants’ attention Infant may need breaks: Do not overstimulate

Older Infants ■ Encourage activities that promote development of crude pincer grasp at 8–10 months ■ Challenge infant to pick up items to continue development of pincer grasp at 11 months ■ Enjoys banging objects and making sounds ■ Play hide and seek to encourage development of object permanence ■ Play ball by rolling ball back and forth ■ Enjoys nesting cubes, stacking challenges ■ Large toys with music, variations in sound ■ Encourage child to hold toys

Toddlers ■ Dress-up games provide practice in putting clothes on and off ■ Push-pull toys, low slides promote development of motor skills ■ Toddlers enjoy toy phones, picture books, pail and shovel, safe water play, stacking cubes

26

2178_Tab03_024-027.qxd

10/21/09

6:04 PM

Page 27

27 Preschoolers ■ Play kitchens, tool chest, medical and nursing kits, and work surfaces allow children to pretend-play adult work roles ■ Tricycles, wagons, trucks, car, puzzles, drawing, crafts of all sorts

School-Age Children ■ Team play, making up new games with rules ■ Secret clubs ■ Board games, card games, computer technology/games

Adolescents ■ Activities that represent adult behavior: Studying drivers training manual ■ Access to peer group members; phones, computers, letter writing ■ Journal writing, challenging arts and crafts (jewelry making, clay) ■ Social clubs, dances, movies ■ Activities that discourage tobacco alcohol, drug use, and early sex

Children with Special Needs ■ Work with child life specialists and primary caregivers to determine appropriate activities ■ Always provide a slight challenge with support and encouragement to promote physical, intellectual, emotional, and social development

See Tab 14 for resources for play, play therapy, safe toys, toy safety regulations and suggestions.

PLAY

2178_Tab04_028-052.qxd

10/21/09

1:19 PM

Page 28

ASSESS

Vital signs Normal Vital Signs, by Age Group VS HR RR SBP DBP Temp (C) O2 sat

Newborn 100–180 35 65 41 36.5° 95%

Infant 80–120 30 65–100 45–65 37.5° 100%

Toddler 80–110 23–25 90–105 55–70 37.2° 100%

School Age 70–110 17–21 100–120 60–75 36.7° 100%

Adolescent 55–90 17–18 110–135 65–85 36.6° 100%

Tips on Assessment of Vital Signs Temperature ■ Temperature-regulating mechanisms are not well developed in infants and young children, so temperature may fluctuate as much as 3°F in 1 day ■ Young infants do not shiver and lack adequate adipose tissue to insulate against heat loss ■ Factors that influence body temperature include exercise, stress, crying, environmental temperature, and diurnal variations (lowest temp occurs between 1 a.m. and 4 a.m., highest between 4 p.m. and 6 p.m.) ■ When recording temperature, always include route (oral, axilla, rectal, tympanic) on documentation form ■ Always use least traumatic site

Temperature Conversion Chart C 36° 36.5° 37° 37.5° 38°

F 96.8° 97.7° 98.6° 99.5° 100.4°

C 38.5° 39° 39.5° 40° 40.5°

28

F 101.3° 102.2° 103.1° 104° 104.9°

2178_Tab04_028-052.qxd

10/21/09

1:19 PM

Page 29

29 Respirations ■ Count respirations for one full minute, especially when child has a respiratory illness ■ Assess for irregularities in respiratory patterns ■ Place hand on chest of infant to assess rate accurately

Respiration Patterns Eupnea

Bradypnea

Tachypnea

Apnea Hyperpnea

Kussmaul’s Respirations

Biot’s (Ataxic) Breathing

ASSESS

2178_Tab04_028-052.qxd

10/21/09

1:19 PM

Page 30

ASSESS Cheyne-Stokes (Periodic) Breathing

Blood Pressure ■ Assess BP on upper arm when child is quiet ■ Select cuff that is correct size (approx. 2/3 of area between shoulder and AC or knee and ankle) ■ Assess BP on thigh as needed ■ For child between 1–5, blood pressure can be determined by: approx. 90 + age in years for systolic over diastolic of 56 ■ For child between 6–18, approx. 83 + (2 X age in years) systolic over diastolic of 52 + age in years

Appropriate Sizing of BP Cuff

Popliteal artery

Brachial artery Radial artery

Dorsalis pedis artery

30

Posterior tibial artery

2178_Tab04_028-052.qxd

10/21/09

1:19 PM

Page 31

31 Pulse ■ Pulse is an accessible indicator of cardiovascular status ■ Variations in HR are much more dramatic in children than in adults ■ Factors that influence HR are medications, activity, pain, hemorrhage, hypoxia, fever ■ Measure pulse when child is quiet, document child’s activity level ■ Count for one full minute ■ Apical pulse is recommended for assessment across childhood

O2 Saturation

■ Oxygen saturation drops slightly when child is asleep ■ Cold fingers or toes will lower readings regardless of type of probe ■ Use self-adhering probes for young children: See packaging for placement

ASSESS

2178_Tab04_028-052.qxd

10/21/09

1:19 PM

Page 32

ASSESS

Normal Weight and Growth Rates Approximate Normal Weight per Age Age Newborn 6 months 1 yr 2–3 yr 4–5 yr 6–8 yr 8–10 yr 10–14 yr 14+ yr

Weight (in kg) 5 7 10 12–14 16–18 20–25 26–32 32–50 50+

Source: From Wong, D. (1991). Pediatric quick reference guide. St. Louis: Mosby.

Average Growth Newborn ■ Height (Ht): 50.5 cm average (50 percentile) at birth ■ Weight (Wt): 3.27 kg; expect up to 10% wt loss by third or fourth day due to loss of extracellular fluids and meconium ■ Head circumference: Increases by 0.5 cm per month

Younger Infant ■ Ht: Increases 18–22 cm/year ■ Wt: Almost doubles birth weight within first 6–8 months ■ Head circumference: Increases by 0.5 cm per month

Older Infant ■ Ht: Increases 14–18 cm/year ■ Wt: Triples birth weight within first year

Toddler ■ Ht: Increases 11 cm/year ■ Wt: Increases 1.8–2.6 kg/year

32

2178_Tab04_028-052.qxd

10/21/09

1:19 PM

Page 33

33 Preschooler ■ Ht: Increases 8 cm/year ■ Wt: Increases 2.3 kg/year

School age ■ Ht: Increases 5–6 cm/year ■ Wt: increases 2–3 kg/year

Adolescents ■ Rapid accelerating growth; reaches 95% of adult ht by age 17

Adolescent Girls ■ Ht: 5–20 cm total growth ■ Wt: Gains 7–25 kg

Adolescent Boys ■ Ht: 10–30 cm total growth ■ Wt: Gains 7–30 kg

Assessment Principles Across Childhood Following are essential components to include in a health assessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Sleep patterns Diet Dentition Immunizations Emotional health/family support and involvement Symptom assessment Discomfort/pain Nausea Sleep disorders Emotional distress Fatigue Dyspnea Hygiene Environmental safety: Car seats/restraints (varies by state) ■ Four steps for kids program (www.ca.gov)

ASSESS

2178_Tab04_028-052.qxd

10/21/09

1:19 PM

Page 34

ASSESS ■

Rear-facing seats • Newborns and infants up to 20–35 lb • Until 1 year AND at least 20 lb • Never forward facing ■ Forward-facing seats • Children older than 1 year and at least 20 lb • After 40 lb, most can be converted to belt positioning booster ■ Booster seats • More than 40 lb • Use with lap and shoulder belts ■ Seat belt • Age 6 or older or over 60 lb • Back seat only • All children 12 and younger should be in back seat ■ Smoking in the home ■ Toxins remain in home for up to 10 days ■ Smoke on clothes or residual in car can influence the development of respiratory distress syndrome ■ Home safety measures for young children: ■ Crib slats spaced 1 year 6 Obeys 5 Localizes pain 4 Flexion withdrawal 3 Flexion abnormal (decorticate) 2 Extension (decerebrate) 1 No response

0–1 year 6 Normal spontaneous movements 5 Localizes pain 4 Flexion withdrawal 3 Flexion abnormal (decorticate) 2 Extension (decerebrate) 1 No response

Best Verbal Behavior 0–2 years 2–5 years 5 years 5 Coos, babbles 5 Appropriate words 5 Oriented, converses 4 Irritable 4 Inappropriate words 4 Disoriented 3 Cries to pain 3 Cries/screams 3 Inappropriate words 2 Moans to pain 2 Nonspecific sounds 2 Incomprehensible sounds 1 None 1 None 1 No response Scoring: • 13-15: mild head injury • 9-12: moderate head injury • 45 consider respiratory acidosis ■ If 20 seconds)

Common Causes of Respiratory Distress Lower Airway RSV bronchiolitis Asthma Pneumonia Foreign body in airway Bronchospasm Copious mucus

Upper Airway Tracheal stenosis Foreign body in airway Croup Epiglottitis Tongue swelling (allergic responses)

Cardiopulmonary Resuscitation ■ The majority of pediatric cardiopulmonary arrests are respiratory in origin and follow a significant respiratory event ■ Because an infant and a young child’s airway is much smaller anatomically than an adult’s, a small amount of edema, mucus, or obstruction will significantly increase the airway’s resistance to airflow, and the young child will demonstrate respiratory distress rapidly

ABCs of Pediatric CPR Airway ■ ■ ■ ■ ■

Check responsiveness Assess for obstruction of airway Remove secretions/vomitus Open airway with head tilt/chin lift (or secure C-spine) In the event of an actual or suspected cervical injury, use jaw thrust

Breathing ■ Look, listen, and feel for breath ■ Determine breathlessness

132

2178_Tab10_131-142.qxd

10/21/09

1:21 PM

Page 133

133 ■ ■ ■ ■

Use bag-valve-mask device Give two slow breaths If rescue breaths are unsuccessful, reposition airway, reattempt If unsuccessful, give 5 abdominal thrusts (>1 yr old) or 5 back blows if (8 yr old); if 1 yr old, use automated defibrillator device Consider child’s blood glucose level Draw ABGs Do not leave child unattended

Choking/Obstruction by Foreign Object ■ Aspiration and obstruction of airway by foreign object is the numberone cause of death in children 1 yr old, perform Heimlich maneuver (abdominal thrusts) ■ Continue until successful or child loses consciousness; then begin cardiopulmonary resuscitation (CPR) ■ Monitor respiratory status continuously after removal of object ■ Position child for adequate ventilation ■ Provide low-dose oxygen as required after event ■ Call for medical personnel to assess child after episode

Adolescent ■ Do not perform blind finger sweep: remove foreign object via finger sweep only if visible ■ Perform Heimlich maneuver (abdominal thrusts) ■ Continue until successful or patient loses consciousness, then begin CPR ■ Monitor respiratory status continuously after removal of object ■ Position child for adequate ventilation ■ Provide low-dose oxygen as required after event ■ Call for medical personnel to assess adolescent after episode

Expect continued airway symptoms after removal of obstruction due to residual edema, inflammation, and irritation.

134

2178_Tab10_131-142.qxd

10/21/09

1:21 PM

Page 135

135 Shock Shock is a state of inadequate delivery of oxygenated blood flow and metabolic chemicals to meet the demands of the child’s tissues.

Clinical Signs ■ Low cardiac output ■ Decreased BP ■ Poor perfusion

Types of Shock ■ Hypovolemic: Severe blood or body fluid loss ■ Septic: Overwhelming bloodstream bacterial infection ■ Neurogenic: Sudden loss of autonomic nervous system signals to smooth muscle in vessel walls and sudden decrease in peripheral vascular resistance. Associated with severe brain and spinal cord damage ■ Cardiogenic: Primary failure of the heart’s ventricles to function effectively leading to inadequate circulation of the blood ■ Anaphylactic: Systemic response to an allergy exposure leading to laryngospasm, hypotension, bronchoconstriction

Shock may be compensated or uncompensated.

Presentation Compensated Shock ■ Normal BP ■ Tachycardia ■ Poor perfusion

Uncompensated Shock ■ ■ ■ ■ ■ ■

Low BP Weak or absent central pulses Increasing metabolic acidosis Increased CRT Decreased UOP Altered level of consciousness (LOC)

Begin cardiopulmonary resuscitation with uncompensated shock.

EMERG

2178_Tab10_131-142.qxd

10/21/09

1:21 PM

Page 136

EMERG

Interventions ■ GET INTERDISCIPLINARY HELP IMMEDIATELY! ■ Provide IV fluid resuscitation with isotonic boluses (20 cc/kg repeated as needed) ■ Draw ABGs and laboratory test ■ Provide oxygenation at 100% ■ Provide inotropic support, including epi ■ Reverse metabolic acidosis with sodium bicarbonate ■ Monitor patient closely ■ Make sure a crash cart with appropriate airway equipment for rapid intubation is available

Intraosseous Needle An intraosseous needle is used if traditional peripheral or central IV access is not possible or unsuccessful during the care of a critically ill child. ■ Place an intraosseous needle directly into the marrow of child’s long bones ■ Vascular network of long bones is sufficient to administer meds, fluids, and blood ■ This site has been found to be as effective as IV injections for medication distribution

Guidelines for Insertion of Intraosseous Needle ■ Clean site with appropriate antiseptic solution, use sterile technique ■ If able, use local anesthetic ■ Ensure proper landmarks on child’s anatomy: 1–2 cm distal of tibial tuberosity and insert perpendicular to the bone at an angle away from the foot ■ Successful placement will feel like a “pop” with sudden absence of resistance ■ Secure needle at site immediately even though needle will stand unsupported

136

2178_Tab10_131-142.qxd

10/21/09

1:21 PM

Page 137

137 ■ Remove inner stylet ■ Flush well after each med, transfusion

Intraosseous needle

Infant

Intraosseous needle inserted in bone

Neonatal Resuscitation ■ Always remember ABCs: Airway, breathing, and circulation ■ Conduct an APGAR score at 1 and 5 minutes after birth (1–2 score on HR, respiratory effort, muscle tone, reflex irritability and color) ■ If APGAR score is less than 7, intervene with ABCs and continue to assess every 5 min: ■ Stimulate ■ Dry ■ Warm ■ Suction ■ Position

EMERG

2178_Tab10_131-142.qxd

10/21/09

1:21 PM

Page 138

EMERG ■

Administer oxygen Ventilate carefully with correct size (newborn) bag-valve/mask ■ Intubate ■ Resuscitate (ventilate 40–60/min and chest compressions 120/min with ratio of 1 ventilation to 5 compressions) ■

Newborn Normal Vital Signs ■ Heart rate: 100–180 ■ Respiratory rate: 30–60 ■ Systolic blood pressure: 50–70

■ Diastolic blood pressure: 25–45 ■ O2 sat: 95% ■ Blood glucose: 35–40 mg/dL

Miscellaneous Emergency Skills Quick Mental Status Examination A quick mental status examination gives a rapid determination of neurological status. Serves as a quick communication for pediatric brain traumas (Davies & Hassell, 2001). ■ ■ ■ ■

A: Awake V: Voice P: Pain U: Unresponsive

For Pediatric Glasgow Coma Scale see Tab 4 under assessments.

Increased Intracranial Pressure Increased intracranial pressure (ICP) is a sudden or gradual increase in pressure within the bony cranium. Causes include brain injury, hemorrhage, contusions, edema, tumors, foreign bodies such as bullet, or intracranial hypertension.

Clinical Signs ■ ■ ■ ■

Headaches Vomiting Seizures Irritability, agitation

138

2178_Tab10_131-142.qxd

10/21/09

1:21 PM

Page 139

139 ■ Loss of consciousness ■ Dilation of one pupil

Severe ICP may lead to decreased cerebral perfusion, irreversible brain dysfunction, herniation, and death.

Treatment ■ Stabilize ABCs ■ Maintain patent airway ■ Monitor Pediatric Glasgow Coma Scores (less than 8 indicates severe brain injuries) ■ Elevate head of bed (HOB) (>30 degree angle) ■ Provide oxygen and suction ■ Treat seizures ■ Provide low-stimulation environment ■ Transfer to a pediatric critical care unit as required ■ Prepare for rapid diagnostics such as CT and MRI

Hypoglycemia Neonate ■ Blood glucose levels naturally drop in first 1–3 hours of life, and then spontaneously increase in healthy newborns ■ Expected values not less than: ■ Birth to 3 hours of life: 35 mg/dL ■ 3–24 hours of life: 40 mg/dL ■ >24 hours of life: 45 mg/dL ■ Treatment: 2 cc/kg of D10 water IV followed by continuous infusion of 6–8 mg/kg/min IV infusion, adjusting rates based on response (Behrman, Kleigman, & Jenson, 2001)

Any newborn with blood glucose levels lower than 40 after 3 hours should be treated and closely monitored. ■ High-risk neonate groups: ■ Very immature neonates ■ Severely ill neonates ■ Infants born to mothers with diabetes or gestational diabetes

EMERG

2178_Tab10_131-142.qxd

10/21/09

1:21 PM

Page 140

EMERG ■ ■

Infants with intrauterine growth retardation Newborns with intrauterine malnutrition and subsequent reduced hepatic glycogen stores

Children ■ Blood glucose levels should always be >40 ■ Normal range: 70–120 mg/dL ■ High-risk groups include children with: ■ Diabetes ■ Sepsis ■ Reye’s syndrome ■ Hepatoma ■ Malabsorption/malnutrition ■ Diarrhea ■ Shock ■ Burns

Hyperglycemia: Diabetic Ketoacidosis (DKA) Diabetic ketoacidosis is a consequence of highly elevated blood glucose levels.

Early Clinical Signs ■ ■ ■ ■ ■ ■

Polyuria, polydipsia and polyphagia Fatigue Headaches Fruity breath odor Dehydration (usually 10% loss of total body fluid) Change in LOC

Late Clinical Signs ■ ■ ■ ■ ■

Kussmaul respirations Metabolic acidosis Ketonuria Ketonemia Possible death

Treatment ■ Immediate expansion of intravascular fluid space with administration of isotonic saline (0.9%) ■ Continuous infusion of IV insulin therapy of 0.1 U/kg/hr

140

2178_Tab10_131-142.qxd

10/21/09

1:21 PM

Page 141

141 ■ Correction of electrolyte and acid/base imbalances ■ For children, after IV therapy is completed, SQ injections of fast-acting insulin

Near Drowning Near drowning refers to survival (even if temporary) beyond 24 hours after a submersion episode; it is considered the single leading cause of injury death in children 24–32 ounces of milk ■ Adolescents with poor nutrition and dietary habits

Assessment ■ ■ ■ ■ ■

Tachycardia and tachypnea Pale skin and pallid mucous membranes Poor appetite and anorexia Poor muscle tone Exercise intolerance

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 144

PATHO A–G ■ Cardiomegaly ■ Splenomegaly ■ Diagnostics

Diagnostic Testing All children should be screened for anemia during infancy. The American Academy of Pediatrics suggests three assessments: During infancy, during early childhood between 1 and 5 years old, and during adolescence between 14 and 20 years old. ■ Health history and physical examination ■ Complete blood count (CBC) with reticulocyte count (indicates body’s response to the increased demand of low circulating RBCs)

Treatment The most effective treatment is early recognition and change in diet to include iron-rich foods. Oral supplementation of iron may be necessary and in severe cases, intramuscular (IM) injections of iron may be required. Last resort treatment of anemia is the administration of blood products Treat early and consistently, and ensure adherence to oral treatments to prevent long-term complications, such as poor growth, developmental delays, and learning difficulties.

Nursing Care and Concerns ■ Teach family members exact dosing of oral iron supplements, as overdosing will cause complications ■ Give child straw to drink oral iron solutions to minimize discoloration of teeth by medication ■ Give oral preparation on an empty stomach or with orange juice as an acidic environment increases absorption of iron solution ■ Warn family that child’s stool may appear dark in color and tarry ■ Support the use of iron-rich formulas for infants who are not breastfed ■ Teach all family members examples of iron-rich foods, such as muscle meats, wheat, green and green-leafy vegetables, eggs, iron-rich cereals and breads

144

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 145

145 Evidence-Based Practice Tips ■ Children with anemia may develop pagophagia (pica), the desireto ingest noningestible substances such as twigs, dirt, houseplants, or carpet. Teach families to observe for this behavior and discourage it ■ Since concomitant plumbism (lead poisoning) can occur, blood levels of lead should be monitored along with hemoglobin levels ■ The three effective forms of orally administered iron solutions are ferrous sulfate, ferrous fumarate, and ferrous gluconate ■ The incidence and prevalence of iron deficiency anemia are not declining. The incidence rate among adolescent girls is between 11% and 17%. Girls must be encouraged to eat a well-balanced, ironrich diet when menstruation begins ■ The loss of as little as 7 cc of blood a day may lead to iron deficiency anemia. This occurs mostly in the GI tract and may be unnoticed for a long period of time

Anxiety ■ Normal child development includes feelings of fear, mild anxiety, and worry ■ Stranger anxiety and separation anxiety are normal and expected during infancy and young childhood ■ When the anxiety is unattached to an event or becomes disabling, interventions are warranted ■ Anxiety may be manifested as an unexpected panic attack or as a phobia ■ A mental health professional should differentiate between true anxiety and post-traumatic stress disorders in childhood ■ Panic attacks may include any of the following symptoms: ■ Dizziness ■ Faintness ■ Palpitations ■ Tachycardia ■ Nausea, GI distress ■ Flushing ■ Chest pain ■ Fear of losing control or fear of dying

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 146

PATHO A–G

Treatment ■ Evaluation by a mental health professional ■ If obsessive-compulsive disorder (OCD) accompanies the anxiety disorder, specific behavior therapy is indicated

Nursing Care and Concerns ■ ■ ■ ■ ■

Do not leave a child alone during a panic attack Provide support and comfort Involve parents and family members Try to identify the trigger of the feelings of anxiety or panic attack Assess for a previous pattern of anxiety, phobias, OCD, or panic attacks

Asthma Pathology Asthma is a chronic inflammatory lung disease of the large and small airways associated with exacerbations. It is the most common cause of acute and chronic illness in children. First episodes may be called reactive airway disease. Many children demonstrate an allergic component to their asthma. Immunological factors include an immediate hypersensitivity in the bronchial mucosa from IgE attachment to mast cells and basophils. As the IgE responds to the presence of an allergen, chemical mediators are released that cause significant clinical symptoms. The inflammation has three main consequences: 1. Bronchial constriction of the smooth muscle fibers surrounding the airways 2. Edema of the inner lumen, leading to thickening of the tracheobronchial mucosa 3. Copious mucus production that can lead to plugging

146

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 147

147 The resulting clinical picture includes: ■ Airway obstruction ■ Airway inflammation ■ Airway hyperresponsiveness

Bronchospasm may develop; complete airway obstruction by mucus plugging may lead to insufficient oxygenation and ventilation caused by air trapping and lung hyperinflation, resulting in acute respiratory distress. During periods of acute exacerbation of asthma, the child may demonstrate anxious behavior and signs of air hunger. The edema, bronchospasms, and mucus production are a result of a complex interaction of chemical mediators (acetylcholine, leukotrienes, prostaglandins, and histamine) and inflammatory cells (mast cells, T lymphocytes, and eosinophils). Autonomic neural regulation of airway is disrupted and clinical symptoms occur. Status asthmaticus is a complication, whereas in an acute, unresolving asthma attack, symptoms continue despite treatment. Aggressive emergency medical attention must be sought to prevent death. Atelectasis and pneumothorax should be considered in acute presentations. Triggers are often identified to help the family prevent exposure leading to acute exacerbation of asthma symptoms. Common triggers include: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Mold Animal dander Cold Airway irritants Pollen Cold air and wind Exercise Stress Respiratory infection Emotional distress GI reflux Allergens Aerosols Fragrances Tobacco smoke Fumes

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 148

PATHO A–G ■ ■ ■ ■

Strong odors Inhaled illegal drugs Fireplace or wood stove smoke Cockroach remains

Phases of an Asthma Attack Early asthma reactions (EAR) occur within minutes of exposure to allergen or trigger. Mast cells degranulate; histamine, leukotrienes, and prostaglandins are released; and edema, bronchoconstriction, and mucus production leads to wheezing and symptoms. EARs should respond to rapid-acting bronchodilators. Late asthma reactions (LAR) are the result of continued release of inflammatory chemicals leading to hyperresponsive airway and further edema. This phase may cause desquamation of the airway epithelium. Generally LAR responds to steroid anti-inflammatory drugs.

Incidence ■ 5%–10% of the population has asthma and is growing ■ 50% of new cases are diagnosed in the first year of life, 80% by the fifth year of life ■ The majority of children diagnosed with asthma have recurrent mild symptoms with the minority of children experiencing severe and/or intractable asthma ■ Prevalence and mortality associated with asthma have increased dramatically in the past three decades ■ 25% of school absences in childhood can be attributed to asthma ■ Mortality rates for asthma are increasing by 6% per year

Assessment In general, the younger the child, the more severe the symptoms. Assess for gradual or sudden onset of the following: ■ ■ ■ ■ ■

Cough; hacking, productive or nonproductive Use of accessory muscles for breathing Retraction Nasal flaring Dyspnea with prolonged expiration

148

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 149

149 ■ Expiratory wheezing progressing to inspiratory wheezing as well ■ Anxious and/or anxiety behaviors and the inability to speak from shortness of breath ■ Exercise intolerance

Severe Symptoms ■ Cyanosis ■ Decreased level of consciousness (LOC)

Death occurs due to complete respiratory obstruction.

Diagnostic Testing ■ Continuous or intermittent oxygen saturation levels to determine O2 needs ■ Chest x-ray ■ White blood cell (WBC) count ■ Peak flow meter monitoring ■ Arterial blood gases (ABGs) for severe exacerbation of symptoms; increased PaCO2 ■ Pulmonary function tests ■ Ruling out respiratory infections

Treatment Basic Principles ■ Identify and avoid allergens by modifying child’s environment and exposure ■ Daily management is essential ■ Have children use Aerochamber or other devices, with or without masks, to maximize amount of inhaled medication that reaches the upper and lower airways ■ Treatments prevent both acute asthma attacks as well as the development of the long-term consequence of chronic emphysema ■ Treat exercise-induced asthma by premedicating child prophylactically with short-acting bronchodilator

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 150

PATHO A–G Medications ■ Short-acting rescue meds: ■ Inhaled beta-2 agonists for rapid bronchodilation (e.g., albuterol) ■ Inhaled anticholinergics for reduction of smooth muscle construction ■ IV corticosteroids for rapid reduction of inflammation, such as beclomethasone, prednisone, and methylprednisolone ■ Long-acting prevention meds: ■ Corticosteroids ■ Cromolyn sodium and nedocromil ■ Long-acting beta-2 agonists ■ Methylxanthine ■ Leukotriene modifiers ■ Emergency meds for severe attacks: ■ Epinephrine ■ Antibiotics, if infection is present

Nursing Care and Concerns ■ Raise head of bed, stay with child and provide a quiet environment ■ Monitor closely for sudden change in clinical status: Get help, do not leave child alone. Secure help rapidly if child’s condition worsens. Prevent a transfer to intensive care and avoid need for ventilation if possible ■ Never administer sedatives to a child experiencing respiratory distress ■ Encourage adherence to preventive medication regimen; include family members in teaching ■ Young children with shortness of breath and sensations of air hunger often become dehydrated; provide favorite liquids and encourage child to take frequent small sips ■ May require IV therapy for dehydration. Assess UOP, mucous membranes ■ Teaching for the entire family should include: ■ Pathology ■ Clinical symptoms ■ Short-acting rescue meds ■ Long-acting prevention meds ■ Need for daily monitoring of peak-flow level measurements ■ Exercise and rest balancing ■ Follow-up care with pediatric health-care team

150

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 151

151 ■ Encourage pulmonary toileting of secretions and respiratory expansion via creative activities such as bubble-blowing, blowing a cotton ball across a table, blowing out a penlight ■ Provide family teaching: ■ Keep medications readily available ■ Ensure that medications are not expired ■ Teach breathing exercises to improve lung function ■ Teach side effects of rapid-acting bronchodilators, including increased HR, tremors, nervousness, and possible headache ■ Prevent status asthmaticus by aggressive management ■ Carefully document teaching. Use asthma action plans that cover prevention, symptoms, treatments, and when to call for help

Evidence-Based Practice Tips ■ If developmentally appropriate, child should perform daily peak flow measurements and document them in a place where all family members can see them, such as on the refrigerator door. This allows the family to determine if a child is experiencing the beginning of an asthma attack and to provide rapid-acting bronchodilators as needed ■ Teach child and family about the green, yellow, and red zones. The child’s baseline peak flow values are used to determine these values: ■ Green zone (above 80% of normal peak flow values) means no interventions other than prescribed daily preventive meds are needed ■ Yellow zone (between 50% and 80% of normal peak flow values) means use extra precautions that day, including rapid-acting bronchodilators and whatever else is prescribed. Rest and fluids ■ Red zone (at or below 50% of normal peak flow values) means the child needs immediate medical care and should be transported to medical center for further diagnostics and emergency interventions ■ Aggressive daily prevention activities and early interventions can prevent complications such as respiratory failure, respiratory arrest, and cardiopulmonary diseases, such as chronic bronchitis, emphysema, pneumonia, and cor pulmonale. Aggressive treatments may prevent death ■ Heliox (helium and oxygen mixed) has shown to be effective in oxygenating children in moderate asthma attacks with airway obstruction during status asthmaticus

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 152

PATHO A–G

Attention-Deficit Hyperactivity Disorder ■ Most children exhibit both inattention and hyperactive-impulsive behaviors with a poor ability to attend to a task ■ Children typically are diagnosed during the early school-age period ■ Adolescents with untreated attention-deficit hyperactivity disorder (ADHD) typically demonstrate great difficulty complying with academic, social, and work expectations ■ Six times as many males as females are affected ■ Oppositional and aggressive behaviors may coexist with the symptoms of ADHD ■ The cause of ADHD is unknown, but some experts agree that there may be a neurological etiology, because so many children with the disorder respond to central nervous system stimulants ■ Estimates of prevalence ranged from 1% to 20% of children. Different behavioral expectations in various cultural groups may play a large role in the range of estimates

Assessment ■ ■ ■ ■ ■ ■ ■

Inattention to rules, poor listener Inability to sustain attention to tasks, games, or play activities Inability to complete tasks Distractibility Fidgety on-the-go, busy, difficulty with quiet time or leisure activities Excessive talking Impulsivity demonstrated by blurting out answers, inability to take turns, and frequent interruptions of others

Diagnostic criteria for ADHD can be found in the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders (DSM-V)

Treatment ■ Administration of stimulants (before 4 pm to avoid interrupting the sleep cycle) ■ Tricyclic antidepressants

152

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 153

153 ■ ■ ■ ■

Biofeedback Parenting support Highly structured environment Collaboration with teachers

Psychological interventions with pharmacology have been deemed the most efficacious. Family counseling assists with the efforts to improve home social interactional problems.

Nursing Care and Concerns ■ Provide support for child and family during the stressful period of diagnosis ■ Assist with screening and testing ■ Educate parents and caregivers on administration times of stimulants and need to keep medications in safe place

Evidence-Based Practice Tips ■ Teach parents that some of the ADHD medications such as pemoline (Cylert) may require up to 3 weeks to demonstrate the desired effect. Other medications may be started at a low dose and then increased slowly until the desired effect takes place ■ Most of the central nervous system medications given to children with ADHD cause anorexia. Small and frequent nutritious meals may help prevent weight loss ■ Tricyclic antidepressants are known to increase incidence of dental caries. Teach parents to reinforce meticulous dental care

Autism Autism generally presents before the child reaches 36 months of age. It can be severely disabling. The key indicators are impaired nonverbal and verbal communication and reciprocal social interactions. Parents report considerable delays in communication patterns and social play compared with other children of the same age and development. The child may display stereotypical body movements and preoccupation with body parts. Autistic children often fall into the functionally retarded range of the intelligence scale. Autism is more common in males than in females and may be associated with other neurological disorders. The cause is unknown at this time.

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 154

PATHO A–G

Assessment ■ ■ ■ ■

Impaired social interactions Impaired communication Repetitive patterns of behavior Lack of interests and activities expected at the child’s age and level of development ■ Abnormal EEGs and seizures may be found

Treatment Younger Children ■ Treatment focuses on speech and language ■ The child may require special education

Older Children and Adolescents ■ Treatment focuses on their poor social skills and associated psychiatric symptoms, such as depression, anxiety, and obsessive compulsive behaviors

Nursing Care and Concerns ■ Assess and provide support for families. Refer families to support groups for caregivers of autistic children ■ Physical contact should be minimized or avoided whenever possible during nursing care, as it may cause anxiety and distress for the autistic child

Evidence-Based Practice Tips ■ Researchers have demonstrated no connection between autism and childhood immunizations

Child Abuse Child abuse, also called child maltreatment, is a nonaccidental injury or trauma that leads to sexual violation, emotional trauma, physical harm, or death. Child abuse is considered an intentional act of abuse or neglect.

154

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 155

155 Infants, toddlers, and preschoolers are the most common victims of physical abuse, whereas school-age children and adolescents encounter emotional abuse and sexual abuse more often.

Categories of Child Abuse ■ ■ ■ ■ ■ ■

Physical abuse Physical neglect Emotional abuse Emotional neglect Verbal abuse Sexual abuse

Contributing Factors Child Factors ■ ■ ■ ■ ■ ■ ■

Special needs Difficult or demanding personality Learning disabilities Chronic disease Prematurity Congenital anomaly Frequent illnesses

Parental/Abuser Factors ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Substance abuse or addiction Unemployment Social isolation Adolescent parent age Frequent family moves History of use of violence Multiple stressors Poor impulse control Lack of parenting skills Anger control issues and low tolerance for frustration Experiences of abuse in their own life Low self-esteem, low confidence

Environmental Factors ■ Unsafe neighborhoods ■ Low economic status

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 156

PATHO A–G ■ Low employment rates ■ Crowded living conditions ■ Lack of education of adults present

The highest risk group includes parents who are low-income adolescents with a high-stress environment. Emotional abuse almost always occurs in the presence of physical or sexual abuse.

Prevention Strategies ■ Parenting classes and parenting support via mentoring and rolemodeling from other family members ■ Encouraging respite care for stressed parents/caregivers ■ Education to prevent shaken baby syndrome ■ Support groups for parents who are socially isolated ■ Comprehensive media coverage of prevention strategies ■ Education about mandatory reporting of child abuse

Diagnostic Testing ■ Radiography for presence of fractures ■ Professional collection of secretions to rule out the presence of semen and blood ■ Computed tomography (CT) scan or magnetic resonance imaging (MRI) to rule out neurological consequences of shaken baby syndrome ■ Assessment of retina for detachment and evidence of bleeding from head trauma, blunt force trauma, or shaken baby syndrome ■ Sexually transmitted disease (STD) screening, pregnancy tests

Assessment ■ Incompatibility between injury and history given by parent/ guardian/caregiver, or inconsistent account of how and when the injury occurred ■ Nonaccidental trauma and suspicious injuries

156

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 157

157 ■ Unusual bruises with definitive shapes, bruises in various stages of healing (various colors such as red, purple, yellow), or bilateral black eyes without trauma, fracture, or bruising of the nose ■ Behavioral signs such as fear, irritability, aggression, withdrawal, apathy, or “radar gaze” (child is constantly surveying the environment) ■ Infected wounds or infections/injuries/disease processes where there was a delay in seeking treatment or no treatment sought ■ Facial fractures, multiple rib fractures, and spinal fractures ■ Unusual burns: Glove or sock burns that are well demarcated, symmetrical, or circumferential; cigarette burns; burns with distinct shapes, such as iron, doughnut, knife ■ Unexplained, traumatic hair loss (presence of bleeding from broken blood vessels under hair loss area is indicative of abuse) ■ Neglect in any area of child’s life (food, fluids, medications, seasonappropriate clothing, supervision, school attendance, or protection from dangerous/inappropriate situations) ■ Failure to thrive (FTT) syndrome ■ STDs, genital irritation and/or trauma, difficulty walking, or underwear stained with blood or feces ■ Age-specific abuse/neglect signs, such as severe diaper rash with ammonia burns, slap marks on young children, blunt force trauma in adolescents

Follow state and institutional policies carefully concerning the assessment of an abused child. Some institutions will not want you to initially assess the child alone. You do not want to be implicated as the one who caused the abuse. Some institutions require photographs of injuries.

Nursing Care and Concerns ■ Provide immediate ABCs in the presence of trauma ■ Provide safe environment for the child: Security/police holds/presence of other staff members ■ Document exactly what the parent/caregiver said about the history of injury and the time the injury took place ■ Understand that child abuse can consist of acts of commission or acts of omission; assess for both

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 158

PATHO A–G ■ Call child protection agency personnel or hospital social services for a social worker to assist in the situation per institutional policy ■ Do not leave child alone with parent/caregiver ■ Do not give opportunity for parent/caregiver to take child away from the health-care setting against medical advice (AMA) ■ Provide play, comfort, soothing support for child to establish a rapport and a sense of calmness and safety

Evidence-Based Practice Tips ■ Witnessing violence is highly detrimental for children of all ages; professionals now realize the need to intervene rapidly ■ Media violence can desensitize children to the meaning of violence and the effect of violent behavior ■ Children who experience or witness violence in their homes tend to be aggressive to their peers ■ Critical facts to consider when evaluating possible abuse: ■ More than 2 million reports are filed each year ■ Approximately 35% are substantiated ■ Approximately 90% of parents suspected of abusing their child have neither criminal records nor a psychotic personality/psychological disturbance ■ Unrealistic expectations of a child from lack of education and understanding of normal growth and development can lead to a level of frustration that influences abuse

Unusual Cases Munchausen Syndrome by Proxy A form of child abuse where a proxy (usually the biological mother) causes, simulates, or fabricates an illness that is often not compatible with the recognized disease or clinical presentation of the child. The proxy may cause the symptoms or actual disease by altering laboratory specimens, exposing child to a toxin or infectious agent, suffocating a child, or administering a medication that makes the child acutely ill. The child is either too young to report the offender, unwilling to expose the proxy, or unable based on the proxy’s protective behaviors. The clinical presentation of a seizure disorder or apnea is common with Munchausen syndrome by proxy. High levels of suspicion should provoke

158

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 159

159 an attempt to diagnose. When suspicion exists, rapid diagnosis should occur in order to avoid unnecessary diagnostics, laboratory specimen collection, and unpleasant, or painful procedures performed on the child. When the suspicion is confirmed, the parent should be confronted and child protective services contacted. The child’s safety should be the highest priority.

Cleft Lip Pathology Cleft lip is a congenital anomaly caused by a malformation that occurs during fetal development. The cleft may extend from the child’s lip up to or through the nasal anatomy and may be either unilateral or bilateral.

Assessment ■ Cleft lip can be identified in utero via ultrasound ■ Considered a congenital anomaly ranging in severity: May extend from child’s lip up to or through the nasal anatomy and can be either a small anomaly or a large fissure ■ Assessment should include the effectiveness of the child’s sucking ability and need for support devices

Treatment ■ Early surgical intervention to repair a cleft lip is usually performed between 1 and 3 months of age ■ Immediate postoperative care should include the protection of the suture line: Limbs should be restrained with “No-No’s,” and every effort should be taken to reduce crying ■ Postoperative care should include placing the child in a car seat to keep the head elevated ■ Apply antibacterial ointment to minimize scaring and prevent infection ■ Manage pain

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 160

PATHO A–G

Nursing Care ■ Young child will need to use special nipples/feeding devices that provide a seal to increase sucking adequacy ■ Family will need role modeling and encouragement to accept the child with the anomaly and bond effectively with the child

Cleft Palate Pathology Cleft palate is a congenital anomaly that affects the soft palate or the soft and hard palate, resulting in an abnormal opening between the mouth structures and the nasal cavity. Condition is associated with dental malformations, otitis media, and delayed speech development. Exposure to drugs, environment factors, and genetic disorders may all be associated with the development of cleft palate. Malocclusion of dentition, dental decay, speech difficulties, hearing impairments and altered self-esteem may occur if surgical treatment is delayed during childhood.

Assessment ■ ■ ■ ■

Assess roof of mouth to determine severity of condition Assess for choking and coughing during feedings Assess for family’s adjustment to condition Assess for frequent otitis media and need for frequent hearing assessments

Treatment Surgical repair is usually performed after the infant is 6 months old. More than one surgical intervention may be required to complete the fusion of the open palate.

160

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 161

161 Nursing Care and Concerns Preoperative Care Until surgical repair, the primary goal is to prevent aspiration during feedings: ■ Hold infant upright ■ Provide special feeding devices and nipples that promote adequate sucking ■ Burp infant frequently, and assess for feeding distress

Postoperative Care ■ Make sure child does not gain access to the suture line; place elbow restraints (No-No’s) on older infants and young children ■ Assess for bleeding and rupture of suture line ■ Do not allow young infants and children to have access to toys with pointed edges or shapes that could cause damage to the suture line while healing ■ Provide pain control ■ Every attempt should be made to reduce crying

Evidence-Based Practice Tips ■ After cleft palate repair, the surgical site will be without sensation until the nerves regenerate. Make sure the child’s lack of sensation does not lead to injury or burns ■ Child with repaired cleft palate may need to be referred to long-term hearing and speech follow-up care

Congenital Heart Disease Pathology Childhood congenital heart disease (CHD) can be divided into two main categories: those that produce cyanosis and those that do not (acyanotic). Acyanotic CHD is further subdivided into conditions that produce a volume load and those that produce a pressure load.

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 162

PATHO A–G Cardinal Signs of Childhood CHD ■ Congestive heart failure ■ Hypoxia ■ Decreased cardiac output

Acyanotic CHD ■ Results in left to right shunting of blood

Lesions That Cause Increased Volume Load These lesions cause oxygenated blood to shunt back to the lungs.

VSD

Ventricular septal defect: Opening between ventricles

ASD

Atrial septal defect: Opening between atriums

162

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 163

163

AVC

Atrioventricular septal defect (atrioventricular canal): Low ASD continuous with high VSD and cleft of mitral and tricuspid valves

PDA

Patent ductus arteriosus: Fetal ductus does not close at birth

Lesions That Cause Increased Pressure Load These lesions obstruct blood flow.

AS

Aortic valve stenosis: Narrowing or stricture of the aortic valve

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 164

PATHO A–G CoA

Coarctation of the aorta: Narrowing of aorta at the insertion of the ductus arteriosus

PVS

Pulmonic valve stenosis: Narrowing of the entrance of the pulmonary artery

Right atrium

Left atrium

Tricuspid valve

Left ventricle

Right ventricle

Tricuspid stenosis: Failure of the tricuspid valve to develop

164

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 165

165

Mitral valve

Mitral stenosis: Failure of the mitral valve to develop

Cyanotic CHD Results in right to left shunting of blood.

Lesions That Cause Decreased Pulmonary Blood Flow Degree of cyanosis depends on the degree of obstruction to the pulmonary blood flow.

ToF

Tetralogy of Fallot: Includes VSD, PS, overriding aorta, and right ventricular hypertrophy

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 166

PATHO A–G

PA

Pulmonary atresia

TA

Tricuspid atresia

Lesions That Cause Increased Pulmonary Blood Flow Degree of cyanosis depends on degree of mixing of oxygenated (pulmonary venous) with deoxygenated (systemic) blood or on the degree of the ventriculoarterial connections. Transposition of the great vessels (TGV): The aorta arises from the right ventricle, and the pulmonary artery arises from the left ventricle. As a result, there is no communication between pulmonary and systemic circulation. Associated mixed defects include patent ductus arteriosus, ventricular septal defect and atrial septal defect.

166

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 167

167

TGV

AO

AO PA

PA LA

LA

RA

RA

RV

LV

Normal

Single ventricle

Aorticpulmonic trunk

Truncus arteriosus

PATHO A–G

SV

Single ventricle

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 168

PATHO A–G

Assessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Degree of cyanosis Tachycardia Tachypnea Murmurs Palpable thrills Decreased peripheral perfusion (delayed CRT, weak pulses, decreased temps) Polycythemia Poor feeding behaviors Diaphoresis Desaturations Weight loss Sweating on brow Decreased exercise tolerance Frequent respiratory infections Headache, fatigue, and dyspnea in patients with cyanotic heart disease may indicate a state of increasing hypoxemia Acidosis Kidney failure Cardiac dysrhythmias Heart failure

Report Immediately ■ ■ ■ ■

Weight gain RR over 60 Decreased perfusion Nonadherence to medication regimen

Treatment Treatments for CHD are focused on: ■ Reducing cardiac workload ■ Preventing and treating congestive heart disease ■ Supporting maximal growth, development, and nutrition ■ Providing shunts and/or bands to protect the lungs by decreasing pulmonary blood flow

168

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 169

169 ■ Cardiac surgery may be performed to repair area of congenital anomaly ■ Some mild congenital heart defects may not require intervention ■ Symptoms of fluid overload are treated with diuretics

Nursing Care and Concerns ■ Educate parent/caregivers on signs and symptoms of respiratory distress and early signs of congestive heart failure ■ Educate family on need to report early signs and symptoms of infection ■ Secure a supportive relationship to increase adherence to treatment plans and optimize follow-up care ■ Teach family how to administer medications (e.g., accurate digoxin administration with predosing apical heart rate). Make sure the primary caregiver return demonstrates the accurate drawing up of all medications

Evidence-Based Practice Tips ■ Prophylactic antibiotics must be administered prior to dental procedures to prevent endocarditis ■ Avoid sudden temperature or altitude changes. Avoid dehydration

Croup Pathology Croup is a complex syndrome characterized by “barky” or “brassy” cough (croupy), hoarseness, inspiratory stridor, and respiratory distress from swelling and obstruction in larynx. The small airway diameter of infants and young children exacerbates symptoms. Croup syndrome includes epiglottitis, laryngitis, laryngotracheobronchitis (LTB), and tracheitis. Two predominate conditions are spasmodic croup and LTB.

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 170

PATHO A–G

Assessment Mild Croup ■ Barky cough without stridor or respiratory distress.

Severe Croup ■ Symptoms of respiratory distress: ■ Stridor ■ Cough ■ Retractions ■ Nasal flaring ■ Assess for symptoms progressing to cyanosis and complete obstruction

Treatment ■ Cool mist tent or humidified oxygen mask placed near child’s face. ■ Minimal disturbance to avoid anxiety and crying that might aggravate symptoms ■ Racemic epinephrine (nebulized) ■ Dexamethasone ■ Nebulized steroids ■ Heliox ■ If symptoms do not respond to treatment, consider bacterial tracheitis or retropharyngeal abscess

Nursing Care and Concerns ■ Keep child comfortable, reassure, provide support, prevent crying and agitation ■ Maintain cool mist and progress to humidified oxygen as needed ■ Keep child in position of comfort with head of bed elevated at least 30 degrees ■ Use a published croup scoring system to accurately document severity ■ Be vigilant with assessments and intervene if respiratory distress develops or if child begins to become fatigued by difficult breathing possibly requiring intubation ■ Educate family on the possibility of a long-lasting barky cough at night

170

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 171

171 Evidence-Based Practice Tips ■ Stridor at rest indicates the need to seek medical care.

Cystic Fibrosis Pathology Cystic fibrosis is a genetic defect in the gene that produces the protein that regulates the movement of salt in and out of the cells. This results in thick, sticky secretions. The triad of clinical phenomena includes severe pulmonary disease, pancreatic disease, and infertility in women.

Respiratory Effects ■ Acute respiratory failure can occur with pneumonia ■ CF patients tend to have nasal polyps that can cause a triggering of infections of the sinus tracts ■ Air trapping of the lower airways leads to destruction of pulmonary parenchyma ■ CF may lead to decreased levels of the natural anti-inflammatory interleukin-10 (a cytokine), leading to severe lung inflammation after an infection ■ Hemoptysis can occur with coagulopathies from decreased absorption of vit K

Gastrointestinal Effects ■ Proteins and fat-soluble vitamins cannot be absorbed ■ With the faulty secretion of salt and water, stool material can become dehydrated

Assessment ■ ■ ■ ■ ■

Presence of thick, tenacious mucus and sputum Chronic sinusitis Weight loss Clubbing of fingers Steatorrhea

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 172

PATHO A–G ■ Signs of respiratory distress: ■ Increased work of breathing ■ Tachypnea ■ Irregular breathing patterns ■ Pursed-lip breathing ■ Nasal flaring ■ Intercostal retractions ■ Use of accessory muscles ■ Clubbing of fingers respiratory acidosis

Treatment ■ Consistent and thorough pulmonary toileting: ■ Postural draining ■ Percussion or use of electronic vibrating vest device to produce and expectorate pulmonary secretions ■ Supplementary vitamins (A, D, E, K) ■ High-calorie diet ■ Prophylactic antibiotics, oral or aerosol ■ Pancreatic enzyme supplements ■ Possible lung transplantation with severe disease

Nursing Care and Concerns ■ Teach patient to prevent respiratory infections ■ Encourage patient to continue taking pancreatic enzymes to prevent wt loss ■ Meticulous pulmonary toileting ■ Emotional support with chronic disease

Evidence-Based Practice Tips ■ After six months of therapy, recombinant human deoxyribonuclease has been found to be associated with improvement in lung function ■ Stagnant mucus promotes bacterial infections in the lungs of children with cystic fibrosis. Since chronic infections produce lung disease, scarring, and fibrosis, aggressive removal of secretions is imperative

172

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 173

173 Depression Depression during childhood has many known etiologies. Refer the child and family to appropriate mental health professionals for evaluation, intervention, and follow-up. Genetic factors play a role in more than 50% of diagnosed mood disorders. There are three types: 1. Major depressive disorders 2. Dysthymic disorders 3. Bipolar disorders

Assessment ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Energy level Racing thoughts Family history of mental illness School history Physical appearance, dress, grooming, hygiene, general health condition Play activities and level of involvement in comparison to peers in general Orientation to time, place, person, environment, and situation Attention, concentration, memory Substance abuse, alcohol, smoking Dysphoria Sleep disorders ranging from insomnia to hypersomnia Severe feelings of worthlessness

Pediatric Rapid Assessment for Depression Symptoms ■ Changes in sleep habits ■ Declining interest in activities of daily living (school, play, and hobbies) ■ Feelings of guilt ■ Changes in energy such as hyperactivity and fatigue ■ Poor concentration ■ Changes in appetite ■ Agitation or psychomotor retardation ■ Attempts or ideations of suicide

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 174

PATHO A–G

Treatment ■ Treatment for mood disorders such as depression is based on severity, safety needs of the child, risk of suicide, and level of family involvement ■ Treatment includes antidepressant such as selective serotonin reuptake inhibitors

Nursing Care and Concerns ■ Provide support to families. Cultural factors play a large role in the family’s acknowledgment and acceptance of the diagnosis and compliance with the treatment regimen ■ It is imperative to maintain stable serum levels of mood disorder medications such as lithium. Educate the family on all aspects of medication administration, adherence, and lab studies

Evidence-Based Practice Tips ■ State laws vary on the requirement that parents or legal guardians must sign consent or offer verbal consent for a child of any age to undergo a psychiatric assessment. Check with state law. ■ If it is difficult to engage the child in conversation, use a topic such as “your top three wishes in the world,” or “future plans.” Asking the child to make drawings of his or her life, home, family, friends, school, and self may be helpful ■ Research has shown that 90% of teens who commit suicide have a diagnosis of depression, substance abuse, or another mental disorder. Early identification of depression and suicide risk, plus early interventions that include building resiliency, have been successful ■ Talking to or asking teens about suicide does not put the idea in their heads or lead to an increased risk that they will commit suicide or attempt suicide ■ The benefits of antidepressants are much greater than the risk of suicide ideation or attempt

174

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 175

175 Developmental Hip Dysplasia Pathology Hip dysplasia is an abnormal connection between the femoral head and the acetabulum, leading to instability and abnormal movement. Three patterns of abnormal structuring can occur: 1. Preluxation: The hip joint is shallow and structures slip 2. Subluxation: Incomplete hip dislocation and partial dislocation of the femoral head 3. Dislocation: Complete dislocation of the hip joint In one-sided dysplasia, the left hip is more frequently affected than the right.

Assessment ■ Ortolani’s sign: Movement to reduce dislocated hip by flexing the thigh then abducting the thigh while lifting the femoral head into place ■ Barlow’s sign: Considered the most important test to examine the newborn hip. While stabilizing the opposite hip, the affected hip is flexed and adducted to assess for a dislocation while feeling the movement ■ Unequal gluteal folds in infants while lying supine ■ Shortening of limb on affected side while older child is standing up ■ Waddling gait in ambulatory child indicates a bilateral condition ■ Ultrasound and/or radiography definitively determine a dislocation and its severity

Treatment Treatment is based on interventions that provide abduction and flexion of the hip. If bracing/traction/corrective devices, such as a Pavlik harness, are not warranted, surgical interventions will be required to secure hip structures into place. Hip spica casting will be required postoperatively. Young infants are usually braced, while older infants require surgical reduction. Older children require open reduction with pelvic or femoral osteotomy.

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 176

PATHO A–G

Nursing Care and Concerns ■ Provide education to family concerning the need to maintain young child in abduction position to encourage repair and healing ■ Assess skin every 2 hours for breakdown at sites of braces/harnesses or any corrective devices

Evidence-Based Practice Tip ■ The earlier the interventions are initiated to reduce the hip dysplasia, the greater the chance of preventing progressive deformities

Diabetes Insipidus and Syndrome of Inappropriate Antidiuretic Hormone Pathology These two conditions produce opposite symptoms. Diabetes insipidus (DI) is caused by a lack of antidiuretic hormone. Syndrome of inappropriate antidiuretic hormone (SIADH) is a condition of the excessive production of vasopressin or antidiuretic hormone (ADH).

Diabetes Insipidus May result from head trauma or space-occupying brain lesions. With the reduced secretion of ADH, DI leads to extreme dehydration as there is a tremendous loss of body fluids. The child exhibits large amounts of urine output.

Labs with DI ■ ■ ■ ■ ■

Increased serum sodium Increased serum osmolality Low urine sodium and potassium Low urine osmolality Low urine specific gravity (1.020) with low UOP

Assessment ■ Decreased urine output ■ Weight gain ■ Hyponatremia with weakness, irritability, and lethargy

Treatment ■ Administration of prescribed medications

Nursing Care and Concerns ■ Ensure adherence to fluid restrictions if ordered ■ Implement seizure precautions when electrolyte imbalances are present

Diabetes Type 1 Pathology Type 1 diabetes mellitus is thought to be an autoimmune disease that results in insulin deficiency (insulinopenia) and hyperglycemia. Cardinal signs are polyuria, polydipsia, polyphagia (the 3 Ps), and fatigue. Treatment consists of stabilizing blood glucose levels, preventing weight loss, promoting optimal growth and development, and preventing hypoglycemia and diabetic ketoacidosis.

Assessment ■ Blood glucose checks at regular intervals: before meals and at bedtime ■ Three Ps ■ Anorexia

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 178

PATHO A–G ■ ■ ■ ■ ■ ■ ■

Fatigue Wt loss Dehydration Frequent infections Nausea Weakness Urinalysis for glucose, pH, and ketones

Treatment ■ Maintain stable blood glucose levels by the administration of insulins as ordered: ■ Rapid acting: Such as Lispro-H (Humalog) ■ Intermediate acting: Such as NPH or Lente ■ Long acting: Such as Ultralente ■ Some newly diagnosed cases will need a continuous IV infusion of regular insulin at 0.1 U/kg/hour. Institutional policies may dictate that this infusion take place in an intensive care unit ■ Treat periods of dehydration and electrolyte imbalances ■ Low sugar diets ■ American Diabetes Association (ADA) carbohydrate-counting diets with corresponding insulin administration (check institutional policy on diets for type 1 diabetic children)

Nursing Care and Concerns ■ Educate child (if developmentally appropriate) to understand the disease process and to assess blood glucose levels ■ Teach family signs and symptoms of hyperglycemia and hypoglycemia ■ Demonstrate insulin administration and rotation of subcutaneous (SQ) sites for injection ■ Refer patient and family to diabetic clinical to be followed by diabetic educator ■ Teach family to carry quick source of carbohydrate for periods of hypoglycemia

178

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 179

179 Evidence-Based Practice Tips ■ Approximately 25% of children with type 1 diabetes will initially present with ketoacidosis (DKA). ■ The course of treatment for a newly diagnosed child typically includes recovery from DKA, followed by transitional period to stabilize blood glucose levels, followed by aggressive teaching and follow-up care

Diabetes Type 2 Pathology In type 2 diabetes mellitus, either the body does not produce enough insulin, or the cells do not use the insulin that is produced. Also called non-insulin-dependent diabetes mellitus (NIDDM). Associated with the rise of childhood obesity rates, type 2 DM is on the rise. Treatment centers on increasing exercise and reducing the child’s weight. Some children require insulin injections to stabilize hyperglycemia during infections and illnesses.

Assessment ■ See Diabetes type 1 ■ Assess child’s blood glucose history for need for oral meds versus SQ insulin injections

Treatment ■ Oral hypoglycemic meds ■ Low-sugar diet/ADA diet ■ Weight loss programs, exercise

Nursing Care and Concerns ■ Assess child for signs of hyperglycemia and hypoglycemia ■ Create a supportive relationship with family to encourage adherence to weight loss plan ■ Encourage family to carry source of carbohydrate for periods of sudden hypoglycemia

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 180

PATHO A–G ■ Be aggressive with teaching and follow-up care. With increasing obesity rates, children with type 2 DM are moving to type 1 and requiring insulin

Epiglottitis Pathology Epiglottitis is an inflammation of the epiglottis. It is considered a pediatric emergency because the child is at risk for complete airway obstruction. Edema may progress rapidly if bacterial cause is not treated promptly. Most frequent etiology is Haemophilus influenzae type b (HIB). Onset is usually abrupt and child presents as acutely ill with severe respiratory distress.

Assessment ■ Drooling with inability to swallow from edema ■ Tripod breathing positions (jaw thrusted out and leaning forward on hands) ■ Hoarse voice ■ Stridor

Treatment ■ Prepare emergency intubation equipment and be prepared for complete airway obstruction ■ IV antibiotics such as cephalosporins (blood cultures should be drawn) ■ IV hydration ■ NPO status ■ Rest and careful observation

180

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 181

181 Nursing Care and Concerns Epiglottitis is a life-threatening condition: Do not leave child. ■ Do not use tongue blade to assess throat as this may lead to immediate increase in swelling and complete respiratory obstruction ■ Delay invasive diagnostic procedures until all emergency support and equipment are prepared ■ Have endotracheal intubation and cricothyroidotomy emergency equipment set up ■ Assess gas exchange and support child with oxygen therapy as needed ■ Assist family in controlling for fear, anxiety, and crying as this will increase symptoms and feelings of distress ■ Administer first dose of antibiotic immediately after airway is secured

Evidence-Based Practice Tips ■ Corticosteroids can help reduce airway edema in the first 24 hours after diagnosis ■ Any manipulation of the child (airway assessment, IV placement, venipuncture) may lead to complete airway obstruction. Intubate immediately ■ Keeping parents with child at all times alleviates anxiety during acute epiglottitis and may decrease the chance of complete obstruction ■ Blow-by oxygen less obtrusive and causes less anxiety than other delivery methods

Failure to Thrive Pathology Failure to thrive (FTT) exists when a child’s measured weight and height (physical growth) is considered significantly less than normal. Growth retardation may be accompanied by delayed developmental and emotional functioning. FTT is associated with families living in poverty. There are two main types:

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 182

PATHO A–G 1. Organic FTT: There is an identifiable underlying medical condition 2. Nonorganic FTT: There is no identifiable underlying medical condition, and the condition is therefore associated with psychosocial factors. Typically found in children less than 20 calories per oz ■ Rule out medical conditions leading to FTT ■ Prevent associated complications such as vitamin deficiencies, dehydration, electrolyte imbalances, and anemia

Nursing Care and Concerns ■ Secure assistance from nutritionist for screening, education, and support ■ Attempt to use consistent nursing caregivers who learn the child’s routines and feeding needs ■ Provide calm, persistent, face-to-face feeding environments; smile at child and show how relaxed you are. Never communicate disappointment regarding intake, never scold or punish. Include parents/caregivers in creating a plan of care ■ Provide nasogastric (NG), nasojejunal (NJ) or gastrostomy feeds as ordered

Evidence-Based Practice Tips ■ FTT has been found to be associated with maternal depression. Mothers should be screened for this condition and referred for treatment if necessary ■ Following the child’s eating rhythms (movements from plate to spoon, to mouth, to chewing and swallowing) assists with increased consumption

Gastroenteritis Pathology Gastroenteritis is an inflammation of the mucous membranes lining the stomach and intestines resulting from viral or bacterial infections or toxins. The enterotoxins produced by infectious agents or the cytotoxins damage the intestinal lining, producing inflammation. Fluid loss and electrolyte losses result from decreased intake, vomiting, and diarrhea.

PATHO A–G

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 184

PATHO A–G Major Causes ■ ■ ■ ■ ■ ■ ■ ■ ■

Rotavirus Norwalk virus Enteric adenovirus Salmonella Shigella Escherichia coli Yersinia Cryptosporidium Giardia lamblia

Assessment ■ Severity of dehydration: ■ Sunken eyes ■ Skin turgor ■ Wt loss ■ Dry mucous membranes ■ Decreased UOP ■ Electrolyte imbalances ■ Fever ■ Diarrhea ■ Vomiting ■ Stool characteristics: ■ Watery ■ Bloody ■ Profuse amounts ■ Explosiveness ■ Pus ■ Abnormal color or odor ■ Abdominal pain and cramping ■ Febrile seizures

Treatment ■ Rehydration orally or via IV if unable to hold down fluids ■ Use of oral electrolyte solutions (Pedialyte) in frequent small volumes ■ Continue breastfeedings as tolerated

184

2178_Tab11_143-185.qxd

10/21/09

1:21 PM

Page 185

185 ■ In the presence of shock, fluid resuscitation via IV boluses (20 cc/kg repeated) ■ Advance diet as tolerated with easily digested foods ■ BRAT diet may be ordered (bananas, rice, applesauce, and toast) ■ Antibiotics and antiemetics are rarely used unless there is a definitive diagnosis of Shigella, E. coli, or Salmonella

Nursing Care and Concerns ■ ■ ■ ■ ■

Maintain strict universal precautions Dispose of excreta carefully to prevent contamination Daily weights Assess skin breakdown around anus; may require ointments Change diapers frequently and maintain strict I & 0 calculations

Evidence-Based Practice Tips ■ Complex carbohydrates are best tolerated as child’s diet is advanced from NPO to clear liquids to regular food

PATHO A–G

2178_Tab12_186-220.qxd

10/21/09

1:22 PM

Page 186

PATHO H–Q

Hemophilia Pathology Hemophilia is a term used for a group of genetic disorders leading to a deficiency of blood-clotting factors, primarily in males. This places the child at risk for uncontrolled bleeding. Factor VIII deficiency (hemophilia A) and factor IX deficiency (hemophilia B or Christmas disease) are the two most common. Severity of the bleeding condition is dependent on the actual amount of the factor produced. In all conditions there is an impaired ability to form a fibrin clot leading to abnormal and unexpected bleeding. The condition may be identified as early as in the newborn period, with bleeding from circumcision, severe cephalohematoma, or even during the cutting of the umbilical cord. Children present with easy bruising, bleeding from cuts and wounds, epistaxis, and hemarthrosis. There are three types of hemophilia: 1. Mild: Bleeding is only associated with severe trauma 2. Moderate: Bleeding is associated with minor trauma 3. Severe: Bleeding occurs spontaneously

Assessment ■ Assess child for painful joints, bruising, bleeding in mouth, nose, or rectum ■ Assess child with severe hemophilia for symptoms of intracranial bleeds ■ Assess teen girls for excessive menstrual flow

Diagnostic Testing ■ Laboratory diagnostics of complete blood count (CBC), DNA testing, and coagulation studies will reveal condition ■ Assess PT, PTT, platelets, thrombin clotting time, and bleeding times

186

2178_Tab12_186-220.qxd

10/21/09

1:22 PM

Page 187

187 Treatment ■ Administration of missing clotting factors for severe cases and desmopressin (DDAVP) for mild to moderate hemophilia A ■ Cryoprecipitate and fresh frozen plasma may be administered ■ Children should continue to have regular immunizations

Nursing Care and Concerns Educating all family members on the prevention of injuries and the presence of bleeding is essential. Clinical signs and symptoms of bleeding should be taught, including headaches, blurred vision, swelling of joints, tenderness, vomiting, lethargy, and seizures. Immediate joint immobilization, administration of ice packs, elevation and pressure should be reinforced. ■ Child’s school nurse and teachers must be involved with care and able to intervene if injury occurs. Child should be included in physical activity but rigorous contact sports must be avoided ■ Teaching all caregivers, and child if developmentally appropriate, to accurately administer clotting factors after injury to stop bleeding is life saving. This includes storage, reconstitution, and administration of the factor ■ Recommend using soft toothbrushes. Do not take rectal temps or perform digital rectal examinations. Avoid IM injections and pad side rails to prevent injury ■ Refer family to the National Hemophilia Foundation (www.infonhf.org)

Evidence-Based Practice Tips ■ Avoid all aspirin or aspirin-containing medicines ■ Childhood obesity is associated with joint stress and should be avoided via teaching, support, and interventions ■ Aggressive treatments of bleeding episodes prevent permanent crippling from hemarthrosis

PATHO H–Q

2178_Tab12_186-220.qxd

10/21/09

1:22 PM

Page 188

PATHO H–Q

Hirschsprung’s Disease Pathology Hirschsprung’s disease is considered a congenital aganglionic megacolon of the rectum or rectosigmoid, presenting as the absence of peristalsis and, therefore, absence of normal bowel evacuation. The aganglionic section of the bowel is due to the absence of autonomic parasympathetic ganglion cells, leading to the lack of nerve interventions and lack of propulsive movements of bowel. Feces accumulate directly above the area of the aganglionic segment, and the bowel above the aganglionic section then dilates. Etiology is unknown but may be associated with viral infections, intestinal polyps, or lymphoma. The condition typically presents in the newborn. Hirschsprung’s disease can be life threatening if intestinal distention and ischemia leads to enterocolitis. Transverse colon

Aganglionic portion of colon Rectum

Sigmoid colon, proximal to lesion, greatly distended

188

2178_Tab12_186-220.qxd

10/21/09

1:22 PM

Page 189

189 Assessment The neonate presents with lack of stool passage or explosive stools that may be ribbon-like. Possible findings include: ■ ■ ■ ■ ■ ■

Abdominal distention Bilious vomiting Liquid or ribbon-like stools Palpable fecal mass Failure to thrive and weight loss Constipation

Assess for signs of dehydration: Pallor, dry mucous membranes, sunken eyes, and increased capillary refill time. Assess for presence of enterocolitis: Explosive, bloody diarrhea; lethargy; temperature instability; metabolic acidosis; and hypovolemic shock.

Treatment Surgical procedures may be performed in two or three steps; a temporary colostomy to divert fecal contents and allow the bowel to resume expected tone, then a rectal pull-through procedure is performed to remove the entire aganglionic segment of bowel along with the reversal of the temporary colostomy. Reversal of colostomy may not occur for 3 to 4 months after pull through.

Nursing Care and Concerns ■ Preoperatively assess child for nutritional status, weigh patient daily, and monitor I & O. Provide family emotional support and educate on the plan of care. Do not take rectal temperatures or use suppositories ■ Prepare child and family for surgery. Treat symptoms of pain and discomfort. Monitor for complications such as perforation ■ Provide postoperative care, which includes monitoring strict intake and output, including the nasogastric (NG) tube; monitor for pain, keep wound clean and dry to prevent infection. Do not use a rectal thermometer or suppositories. Educate the parents on procedures and care

PATHO H–Q

2178_Tab12_186-220.qxd

10/21/09

1:22 PM

Page 190

PATHO H–Q

HIV/AIDS Pathology AIDS is caused by the human immunodeficiency virus (HIV). The virus targets the immune system CD4+ T-helper lymphocytes as well as macrophages and B-lymphocytes. AIDS is considered a multisystem disease producing gradual immunodeficiency. The virus is transmitted only via direct contact with blood, blood products, body fluids (semen, vaginal secretions, and breast milk), sexual contact, IV drug use, and prenatal vertical transmission from mother to child prenatally. Casual contact does not spread the virus. Most infected children become symptomatic within the first 6 to 9 months of life. Clinical findings include: ■ ■ ■ ■ ■

Lymphadenopathy Low birth weight Failure to thrive Oral thrush Recurring upper respiratory infections

Classification of AIDS Patients ■ Category N: No symptoms present ■ Category A: Mild symptoms including dermatitis, parotitis, otitis media, and lymphadenopathy ■ Category B: Moderate symptoms including cardiomyopathy, hepatitis, chronic diarrhea, meningitis, pneumonia, sepsis ■ Category C: Severe symptoms including multiple or recurrent bacterial infections, cytomegalovirus (CMV), HIV encephalopathy, lymphoma, sarcoma, and wasting syndrome

See CDC.org or further information.

Assessment ■ ■ ■ ■

Fever Fatigue Myalgia Night sweats

190

2178_Tab12_186-220.qxd

10/21/09

1:22 PM

Page 191

191 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Wt loss Diarrhea Respiratory infections Skin lesions/infections/inflammations Oral thrush Diaper rashes FTT Neutropenia Thrombocytopenia Anemia Developmental delays

Diagnostic Testing In pediatrics, the following tests are used to diagnose HIV: ■ ■ ■ ■ ■ ■ ■

ELISA Western blot HIV antigens HIV cultures CD4/CD8 ratios Polymerase chain reactions CBC

Treatment ■ Supportive care to treat infections ■ Combinations of antiviral drugs are used to slow the replication of the virus ■ Prophylactic antibiotics are used to prevent infections

Nursing Care and Concerns ■ Assess family’s knowledge of HIV/AIDS and provide several forms of education, including conference sessions, handouts, educational movies ■ AIDS is considered life threatening. Families need lots of support, education, and follow-up care

PATHO H–Q

2178_Tab12_186-220.qxd

10/21/09

1:22 PM

Page 192

PATHO H–Q ■ Prevent the child from being exposed to infectious agents in the hospital, clinic, and at home and use strict hand washing for patient encounters ■ Assess adherence to medication regimen ■ Assess child’s pain on a regular basis and provide interventions to increase comfort ■ Provide nutritional support to prevent wt loss ■ Assess for opportunistic infections ■ Educate family on transmission of the virus and use of appropriate universal precautions to reduce spread of the virus ■ Children should attend school ■ Support child’s developmental milestones and achievements ■ Refer family for child life, social services, and spiritual care ■ Since there is no cure, support child’s quality of life

Evidence-Based Practice Tips ■ All scheduled immunizations should be administered, but live vaccines should be replaced by attenuated ■ Administration of AZT to a pregnant woman before birth has been shown to reduce transmission of virus to the newborn during delivery

Hydrocephalus Pathology Hydrocephalus is a condition that results from the increased production, lack of reabsorption, or lack of outflow of cerebral spinal fluid (CSF) within the cranial vault. With the obstructed outflow, the child experiences a rise in intracranial pressure and a dilatation of the ventricular system proximal to the obstruction. The condition leads to ventricular dilatation and enlargement of child’s head circumference. Hydrocephalus is associated with tumor, vascular malformations, abscesses, cysts, hemorrhages, meningitis and trauma. There are two types: 1. Communicating hydrocephalus: Obstructed arachnoid villa with resulting lack of reabsorption of the CSF. 2. Noncommunicating hydrocephalus: Obstructed flow of CSF within the ventricular system from the presence of tumor or a congenital malformation.

192

2178_Tab12_186-220.qxd

10/21/09

1:22 PM

Page 193

193 Assessment ■ Head circumference that is out of the expected range for a child’s age (>95th percentile) ■ Bulging fontanels ■ Distended scalp veins ■ Sunset eyes (appears downturned) ■ Poor feeding behaviors ■ Vomiting (may be projectile) ■ Irritability ■ Lethargy ■ Seizure ■ High-pitched cry

Treatment Treatment of hydrocephalus involves the placement of a temporary or permanent shunt to provide an exit for flow of CSF. Typically, the shunt is placed to drain excessive or obstructed CSF from ventricles to the peritoneal cavity from which it is then reabsorbed and excreted. The shunt is a straight, Silastic catheter placed in the right ventricle via a burr hole. The drainage is then either managed via a permanent extraventricular shunt or temporary shunt via a connection system to an external collecting system (child will be in the pediatric ICU).

PATHO H–Q

2178_Tab12_186-220.qxd

10/21/09

1:22 PM

Page 194

PATHO H–Q

Nursing Care and Concerns ■ Provide meticulous postoperative care: Child is placed in a flat position on the nonoperative side; prevent pain or discomfort that would induce crying; assess for seizures ■ Assess for complications with the shunt system, such as sudden change in child’s clinical symptoms associated with sudden increase in intracranial pressure (ICP) ■ Assess for and prevent infections to shunt ■ Follow orders for shunt maintenance ■ Measure head circumference ■ Teach the parents signs and symptoms of ICP

Hyperbilirubinemia Pathology Hyperbilirubinemia is a condition of the neonate in which there is an increase in the breakdown of red blood cells (RBCs) releasing bilirubin. Child presents with jaundice from lipid-soluble unconjugated or indirect bilirubin in tissues. If there is a decrease of lipid-soluble bilirubin binding with albumin that should travel to liver for processing, then jaundice occurs. Conjugated bilirubin is water-soluble and has been processed by the enzyme glucuronyl transferase and is typically excreted through the infant’s urine and bile. Hyperbilirubinemia of the newborn most often occurs when there is a physiological immaturity of the liver functions or when there is an increased destruction of the RBCs. Typical onset is by 3 days of age. For normal newborns without a diagnosis of hyperbilirubinemia, slightly elevated levels decrease without interventions by the 10th day of life. Jaundice can be identified not only in the tissues but also the sclera, mucous membranes, and by the presence of dark urine. There are two types of hyperbilirubinemia: 1. Indirect hyperbilirubinemia: Transient, physiological, or breastfeeding jaundice 2. Direct hyperbilirubinemia: Biliary obstruction, metabolic disorders, neonatal hepatitis syndrome

194

2178_Tab12_186-220.qxd

10/21/09

1:22 PM

Page 195

195 Assessment ■ Jaundice: Apply light pressure over bony prominences to blanch the skin. The yellow color of the jaundiced tissues will be evident. ■ Poor feeding behaviors, poor breastfeeding ■ Lethargy ■ Encephalopathy, which is the deposition of unconjugated bilirubin in the brain tissues; also called kernicterus

Diagnostic Testing ■ Laboratory values are followed on a regular basis as part of ongoing assessment of the child’s status: Elevated indirect bilirubin levels will dictate length of stay under bili lights (can be drawn by heel stick) ■ Hyperbilirubinemia is determined by values that exceed the expected ■ Many institutions determine values over 13 mg/dL to be elevated

Expected Bilirubin Values ■ ■ ■ ■

Cord: