Common health problems that develop
during infancy
INTRODUCTION
Few
things
can
change
the
usually joyous tone of a birthing room
faster than the birth of a baby with
a
physical
or
developmental
challenge.
Physicians
or
nursemidwives, who are used to saying
“perfect boy” or “beautiful girl” and
holding up the infant for the parents’
first glance, are suddenly without
words. Words of congratulations hang
unsaid in the air. When a child is
born with an apparent physical or
developmental challenge, nurses must
play a major role in supporting and
educating the parents to help them
move forward from this point. Some
congenital disorders require surgery
but the prognosis is good, so this is
only a temporary concern. Other
disorders,
however,
represent
serious,
even
lifethreatening
concerns for infants and financially
draining long-term responsibilities
for parents. This part covers the
physical congenital disorders that
are apparent at birth or soon after.
Such disorders primarily involve the
gastrointestinal,
neurologic,
and
skeletal systems
●
Cleft lip occurs as a familial
tendency or most likely occurs from
the transmission of multiple genes.
●
Formation
may
be
aided
by
teratogenic factors present during
weeks 5 to 8 of intrauterine life eg.
Viral
infection
or
folic
acid
deficiency
Cleft palate
●
Failure of palatal process to
close at approximately weeks 9 to 12
of intrauterine life.
●
The opening of the palate is
usually on the midline and may involve
the
anterior
hard
palate,
the
posterior soft palate, or both
●
Usually occurs
with a cleft lip.
in
conjunction
●
occur more frequently in girls
than boys
●
it appears to be the, result of
polygenic
inheritance
or
environmental influences
ETHIOLOGY
-
Hereditary
Environmental factors- exposure
to radiation, ,
CLEFT LIP/ CLEFT PALATE
-
Cleft
lip
is
when
maxillary
and
median
nasal processes fail to
fuse
(normally
fuse
between weeks 5 and 8 of
intrauterine life).
Teratogenic
factors
present
during weeks 5 to 8 of intrauterine
life
●
Degrees of the disorder range
from a small notch in the upper lip to
total separation of the lip and facial
structure up into the floor of the
nose, with even the upper teeth and
gingiva absent.
●
Deviation may be unilateral or
bilateral.
●
Cleft lip is more
among boys than girls.
prevalent
-
Chromosomal abnormalities
Viral infection rubella virus
Folic acid deficiency
ASSESSMENT
a.
Cleft lip may be detected by a
sonogram while an infant is in utero
or is readily apparent upon inspection
at birth
Can range from a slight notch to
a complete separation from the floor
of the nose
b.
Cleft palate can include nasal
distortion,
midline
or
bilateral
cleft, and variable extension from the
uvula and soft and hard palate
a child with cleft palate must be
assessed
for
other
congenital
anomalies, cleft palate is a component
of many syndromes,
TREATMENT
1.
Surgical treatment
o
Cleft lip is repaired surgically
as early as possible Or between 2 and
10 weeks of age.
o
deviation of the lip interferes
with nutrition
o
revision of the original repair
or a nasal rhinoplasty to straighten
a
deviated
nasal
septum
may
be
necessary
when
the
child reaches 4 to 6
years of age.
o
Cleft-palate
needs
two-stage
palate repair, with
soft palate repair at
3 to 6 months of age
and
hard
palate
repair at 15 to 18 months of age
o
early repair increases speech
development but may result in a
necessary second-stage repair as the
child’s palate arch grows.
o
XXXX Do not use the older term
for this condition, harelip, when
talking with parents about the problem
XXXX
o
Follow up pedodontist- possible
for poor teeth alignment
o
Follow up to detect if speech or
hearing difficulty occurs.
NURSING INTERVENTION:
1.
Assess for imbalance nutrition
-assess the infants’ ability to suck,
swallow, handle normal secretions,
and breath without distress.
-assess fluid and calory intake daily
-monitor daily weight
-feeding the infant is
because the infant has
maintaining suction
a problem
difficulty
- it is important that the child does
not aspirate.
- best feeding method for the child
with cleft lip may be to support the
baby in an upright position and feed
the infant gently using a commercial
cleft lip nipple.
-feed small amounts gradually and burp
frequently.
- Offering small sips of fluid between
feedings can help keep the mucous
membranes moist and prevent cracks and
fissures
that
could
lead
to
infection.\
-ESSR Method of feeding: enlarge the
nipple, stimulate sucking reflex,
swallow, rest to allow the infant to
finish swallowing what has been placed
in the mouth.
- use a commercial cleft palate nipple
that has an extra flange of rubber to
close the roof of the mouth.
- If surgery is delayed beyond 6
months of age or the time solid food
would be introduced, teach parents to
be certain any food offered is soft.
2.
Assess for ineffective airway
clearance related to oral surgery
- maintain respiratory rate between 20
to 30 respirations per minute without
retractions or obvious distress.
- observe children closely in
immediate postoperative period
respiratory distress.
the
for
-suction secretion as needed
- After cleft lip surgery, place
infants on their side to allow mouth
secretions to drain.
Support them well so they do not turn
onto their abdomen, as this pressure
on the suture line, possibly tearing
3.
Promote tissue integrity at
incision line related to cleft lip or
cleft palate surgery
-keep incision line clean and intact
and free of erythema or drainage
during postoperative period
-avoid
cryingbecause
crying
increases tension on the sutures.
-Nothing hard or sharp must come in
contact with a recent cleft suture
line
Type of hydrocephalus
1.
Communicating
extraventricular hydrocephalus
or
●
If fluid can reach the spinal
cord
-elbow restraint should be used to
prevent infant from injuring or
traumatizing surgical site
●
Impaired
arachnoid space
4.
avoid
Infection
surgical incision.
●
Interference of CSF within the
ventricular system does not occur
- keep
after
suture
normal
related
to
surgical site clean and dry;
feeding gently cleanse the
line with a solution such as
saline.
- Use a smooth, gentle, rolling motion
to apply the solution. Do not rub,
because this can loosen sutures. high
incidence of middle
-high incidence of ear infection
(otitis
media)
in
cleft
palate
because organisms are more readily
able to reach this area from the oral
cavity due to changes the in slope of
the eustachian tube to the middle ear.
●
absorbtion
within
Non-obstructive
2.
Obstructive
hydrocephalus
intraventricular hydrocephalus.
●
If there is
passage of fluid
a
block
to
or
such
●
Obstruction of csf flow within
ventricular system
●
Non-communicating
ETHIOLOGY
Congenital
Hydrocephalus
usually
result from defects caused by
5.
Encourage parents to express
their feelings about the disorder
▪
InfectionRubella,Toxoplasmosis,
cytomegalovirus.
6.
Encourage
bonding
with
the
infants and calling the infant by name
▪
Congenital
brain
obstructing the CSF flow
HYDROCEPHALUS
▪
Congenital malformations like
aqueduct
stenosis,
Arnold-chiari
malformation
Hydrocephalus is
an excess of CSF
in the ventricles
or
the
subarachnoid
space.
this
excess
fluid
causes
enlargement
of
the skull in infants.
Normally, CSF is formed in the first
and second ventricles of the braincand
then passes through the aqueduct of
Sylvius and the fourth ventricle to
empty into the subarachnoid space of
the spinal cord, where it is absorbed.
CSF volume in Child is 60-100ml
▪
tumor
Malformations of arachnoid villi
Acquired hydrocephalus usually result
from
space-occupying
lesion,
hemorrhage, intracranial infections
and dormant development defects.
▪
InflammationEncephalitis, abscess
meningitis,
▪
Trauma:
Birth
injury,
intracranial
subdural hematoma
injury,head
hemorrhage,
▪
Neoplasmspace
occupying
lesions
like
tuberculosis,
or,gliomas,
ependymoma,astrocytoma,choroid plexus
papilloma, pseudotumor cerebri
▪
Chemical: Hypervitaminosis
▪
Connective
disorder:Hurler syndrome
tissue
▪
Setting sun signs
▪
Sluggish
and
unequal pupils
▪
Arteriovenous
malformation:reptured aneurysm
▪
Irritability ang
lethargy
with
varying LOC
An excess of CSF in the newborn occurs
for one of three main reasons:
▪
Abnormalitis
with
infanatile
reflexes
▪
Possible cranial nerve damage
▪
Signs of increased ICP
▪
Degenerative atrophy of brain
▪
Overproduction of fluid by a
choroid plexus in the first or second
ventricle, as could occur from a
growing tumor (rare).
o
▪
Obstruction of the passage of
fluid in the narrow aqueduct of
Sylvius (the most common cause).
▪
Meningitis or encephalitis may
leave adhesions behind that block
fluid flow.
▪
Hemorrhage from trauma
▪
Growing tumor
▪
Arnold-Chiari
disorder
(elongation of the lower brain stem
and
displacement
of
the
fourth
ventricle into the upper cervical
canal
▪
Interference with the absorption
of CSF from the subarachnoid space if
a portion of the subarachnoid membrane
is removed ( surgery for meningocele,
or
after
extensive
subarachnoid
hemorrhage, when portions of the
membrane absorption surface become
obscured)
ASSESSMENT
Clinical Manifestation:
▪
Abnormal rate of head growth
▪
Bulging fontanelle
▪
Tense anterior fontanelle (aften
buylging and non-pulsatile)
Headache on awakening with
improvement
following
emesis,
papilledema,
strabismus,
atxia,
irritability,
lethargy,
apathy and confusion.
DIAGNOSTIC
1.
Prenatal
sonogram
detects
hydrocephalus during pegnancy
2.
Physical examination
3.
Computed tomography (CT) Scan
4.
Cranial ultrasonography
5.
Magnetic resonance imaging (MRI)
6.
X-ray film will reveal the
separating sutures and thinning of the
skull.
7.
Transillumination
(holding
a
bright light such as a flashlight or
a specialized light [a Chun gun]
against the skull with the child in a
darkened room) will reveal the skull
is filled with fluid rather than solid
brain
8.
LUMBAR PUNCTURE Insertion of
spinal needle into subarachnoid space
between the lower lumbar vertebrae.
Modified sitting position for LP
CEREBRAL SPINAL FLUID
▪
Dilated scalp vein
o
Normal CSF
▪
Macewen’s sign cracked pot sound
on percussion of bones of the
head
o
Clear odorless
o
WBC’s 0 – 5
Frontal bossing
o
Protein 15 to 45
o
Glucose 50 – 80
▪
o
Pressure 50 to 180
o
Abnormal CSF
o
Turbid, cloudy
o
WBC’s 1000 – 2000
o
Protein 100 – 500
o
Glucose lower than blood sugar
o
Pressure 180 or greater
escape to the surface of the brain
where it can be absorbed, instead of
inserting a shunt.
b)
VENTRICULO-PERITONEAL SHUNT (VP SHUNT).
THERAPEUTIC MANAGEMENT
A VP shunt is a long, plastic tube
that allows fluid to drain from the
brain to another part of the body.
This drainage prevents the increase in
pressure on the brain caused by
hydrocephalus.
Goal of management:
VP shunt has at least three parts.
I.
o
The
first
part
is
the
ventricular catheter, which goes into
the brain.
Reducing intra cranial pressure
II. Prevention
complication
III. Managing
pathology
and
Management
problems
caused
of
by
Medical Management include the use of
osmotic diuretics and loop diuretics
to reduce CSF production medical
management is temporary relief but
main management is surgery
1.
SURGICAL MANAGEMENT
o
A shunt is made up of radio
plastic and has ventricular catheter,
pressure valve, pumping chamber, and
distal catheter that directs the flow
of CSF from the ventricles to other
areas of body from where it is
absorbed.
o
Endoscopic Third Ventriculostomy
o
Choroid plexectomy
o
Ventriculo-peritoneal shunt (VP shunt).
o
Ventriculoatrial shunt
o
Ventriculopleural shunt
o
Ventriculogallbladder shunt.
a)
ENDOSCOPIC THIRD VENTRICULOSTOMY
(ETV)
An alternative procedure to shunt
surgery
is
an
endoscopic
third
ventriculostomy (ETV). This procedure
involves making a hole in the floor of
the brain, allowing the trapped CSF to
o
The second part is the valve,
which controls the pressure within the
brain.
o
The third part is the distal
catheter, which is underneath the skin
and connects the other parts of the VP
shunt to a space within the body,
usually the abdominal cavity (also
called the peritoneal cavity).
WARNING SIGNS OF
WORKING PROPERLY
A
VP
SHUNT
NOT
o
A headache that hurts more as
time passes.
o
Child acts irritated ; this may
be the only sign of a headache in a
child who is young or cannot speak.
o
Vomiting (throwing up) with
little or no nausea (feeling sick to
his or her stomach)
o
Changes in personality. For
example, a child who is easy to deal
with becomes very hard to handle all
of a sudden or
is just not acting
right.”
o
Swelling of the skin that runs
along the path of the VP shunt
o
A bulging soft spot on child’s
head • Vision problems (blurry or
double vision, or loss of vision)
o
Loss of some mental and physical
abilities that he or she had already
mastered (milestones that fit your
child’s age)
SHUNT INFECTION
COMPLICATIONS
A shunt infection occurs when bacteria
infect the tissue around the VP shunt.
When the tissue is infected, it can
cause the VP shunt to stop working
properly. A shunt that does not work
well can cause an increase in pressure
within the brain. This increase in
pressure can damage the brain or
threaten child’s life.
●
Seizure
●
Herniation of brain
●
Developmental delay
Signs of a shunt infection
●
Depression.
• A fever that is equal to or higher
than 100.4 degrees F (38.0 degrees C)
NURSING MANAGEMENT
• Redness or swelling of the skin that
runs along the path of the VP shunt
• Pain around the shunt or around the
shunt tubing
c)
VENTRICULOATRIAL (VA) Shunt
A ventriculoatrial (VA) shunt also is
called a "vascular shunt." It shunts
the cerebral ventricles through the
jugular vein and superior vena cava
into the right cardiac atrium. It is
used when the patient has abdominal
abnormalities
(eg,
peritonitis,
morbid obesity, or after extensive
abdominal
surgery).
This
shunt
requires repeated lengthening in a
growing child.
d)
LUMBOPERITONEAL SHUNT
A lumboperitoneal shunt is used only
for communicating hydrocephalus, CSF
fistula, or pseudotumor cerebri.
e)
VENTRICULOPLEURAL SHUNT
A
ventriculopleural
shunt
is
considered second line. It is used if
other
shunt
types
are
contraindicated.
PROGNOSIS
Prognosis depends on early diagnosis
and prompt therapy.
With
improved
diagnostic
and
management techniques, the prognosis
is becoming considerably better.
Approximately two- thirds of patients
will die at an early age if they do
not receive surgical treatment.
●
Spontaneous
arrest
due
to
natural
compensatory
mechanisms,
persistent increased ICP and brain
herniation.
1. Explain the family about the
management required for the disorder.
2. Provide preoperative nursing care
a.
a.
Assess
head
circumference,
fontanelles, cranial sutures, and
LOC; check also for irritability,
altered feeding habits and a highpitched cry.
b.
Firmly support the head and neck
when holding the child.
c.
Provide skin care for the head
to prevent breakdown.
d.
. Give small, frequent feedings
to decrease the risk of vomiting.
3. Provide Postoperative nursing care
a.
Assess for signs of increased
ICP and check the following; head
circumference
(daily),
anterior
fontanelle for size.
b.
Administer
prescribed
medications
which
may
include
antibiotics to prevent infection and
analgesics for pain.
c.
Provide shunt care
1. Monitor for shunt infection and
malfunction
which
may
be
characterized by rapid onset of
vomiting,
severe
headache,
irritability,
lethargy,
fever,
redness along the shunt tract, and
fluid around the shunt valve.
2. Prevent infection
3. Monitor for shunt overdrainage
(headache, dizziness and nausea).
4. Teach home care

a.
Encourage
the
child
to
participate
in
ageappropriate
activities as tolerated. Encourage
the

b.
parents to provide
lifestyle as possible.
as
normal
c.
Explain how to recognize signs
and symptoms of increased ICP. Subtle
signs include changes in school
performance, intermittent headache,
and mild behavior changes.
d.
Arrange for the child to have
frequent developmental screenings and
routine medical checkups.
NEEDS IDENTIFIED
PHYSICAL NEEDS:










Need
to
maintain
personal
hygiene.
Prevention of skin breakdown
Prevention
or
reduction
of
deformities.
Maintenance of ideal weight.
Change the position frequently.
PHYSIOLOGICAL NEEDS:
Prevention
of
injury
and
infection of sac.
Provision of adequate nutrition.
Prevention
of
infection
of
urinary tract.
Regulation of bladder and bowel
function.
PSYCHOLOGICAL NEEDS:


Relieve anxiety of parents.
Maintain the psychology of the
parents
●
Risk
of
infection
related
to
introduction of infecting organism
through the shunt.
Ineffective
cerebral
tissue
perfusion related to increased ICP
maintaining cerebral perfusion
●
Observe
for
increased
ICP,
immediately.
evidence
of
and
report
●
Assist
with
diagnostic
procedures to determine cause of
hydrocephalus
and
administering
treatment schedule as indicated.
Imbalance nutrition less than body
requirement related to reduced oral
intake and vomiting. - providing
adequate nutrition
●
Be
aware
that
feeding
is
frequently
difficult
because
the
child may be listless, and prone to
vomiting.
●
Complete
nursing
care
and
treatments before feeding so the child
will not be disturbed after feeding.
●
Hold the infant in a semisitting position with head well
supported during feeding.
●
Offer
feedings.
small
and
frequent
●
Place the child on side with head
elevated after feeding to prevent
aspiration.
Risk for impaired skin integrity
related to alterations in LOC and
enlarged head-maintain skin integrity
●
Prevent pressure sore
NURSING DIAGNOSIS
●
Keep the scalp clean and dry.

●
Turn the child head frequently.
●
Give range of motion exercise.



Ineffective
cerebral
tissue
perfusion related to increased ICP
Imbalance nutrition less than body
requirement related to reduced oral
intake and vomiting.
Risk for impaired skin integrity
related to alterations in LOC and
enlarged head
Anxiety
related
to
abnormal
condition
and
surgical
intervention
NEURAL TUBE DISORDER
The neural tube forms in utero first
as a flat plate and then molds to form
the brain and spinal cord, thus making
it
susceptible
to
malformation.
Normally, the spinal cord and cauda
equina are encased in a protective
sheath of bone and meninges. Failure
of neural tube closure produces
defects of varying degrees. They may
involve the entire length of the
neural tube or may be restricted to a
small area.
Spina bifida cystica
visible defect with
saclike protrusion.
refers to a
an external
Two major forms of SB cystica
1.
Meningocelethe
meninges
covering the spinal cord herniate
through unformed vertebrae
-appears as a protruding mass, usually
approximately
the size of an orange, at the center
of the back
Types of disorder
Anencephalyis
absence
cerebral hemispheres.
-abnormal tufts of hair or discolored
skin
of
the
-underdeveloped head does not engage
the cervix well-DIFICULTY IN LABOR
-parents are offered the option of
abortion- ETHICAL PROBLEM
Microcephaly is a disorder in which
brain growth is so slow that it falls
more than three standard deviations
below normal on growth charts.
-caused by intrauterine infection
such as rubella, cytomegalovirus, or
toxoplasmosis.
-result from severe malnutrition or
anoxia in early infancy.
Spina bifida occulta- Spina bifida
occulta occurs when the posterior
laminae of the vertebrae fail to fuse
-refers to a defect that is not
visible
externally.
-It occurs most frequently in the
lumbosacral area (L5 and S1).
-SB occulta may not be apparent unless
there
are
associated
cutaneous
manifestations
or
neuromuscular
disturbances.
-noticeable as a dimpling at the point
of poor fusion
-not
associated
deficit
with
neurologic
2.
myelomeningocele
(or
meningomyelocele),
which
contains
meninges, spinal fluid, and nerves,
same as meningocele
-difference is that the spinal cord
ends at the point, so motor and
sensory function is absent beyond this
point
-Hydrocephalus
accompanies
myelomeningocele because of lack of an
adequate subarachnoid membrane for
CSF absorption
Encephalocele- an encephalocele is a
cranial
meningocele
or
myelomeningocele
-occurs most often in the occipital
area of the skull but may occur as a
nasal or nasopharyngeal disorder.
PATHOPHYSIOLOGY
At approximately 20 days of
gestation, a decided depression, the
neural groove, appears in the dorsal
ectoderm of the embryo. During the
fourth week of gestation, the groove
deepens rapidly, and its elevated
margins develop laterally and fuse
dorsally to form the neural tube.
Neural tube formation begins in the
cervical region near the center of the
embryo
and
advances
in
both
directions—caudally and cephalically—
until by the end of the fourth week of
gestation, the ends
tube, the anterior
neuropores, close.
of the neural
and posterior
Primary defect in neural tube
malformations is a failure of neural
tube closure. Some evidence indicates
that the defects are a result of
splitting of the already closed neural
tube as a result of an abnormal
increase in cerebrospinal fluid (CSF)
pressure during the first trimester
●
•
•
Ultrasound scan
Fetoscopy,
•
Amniocentesis
elevated
maternal concentrations of alphafetoprotein (AFP, or MSAFP)
fetal-specific
gamma-1-globulin in amniotic fluid
(between 16 and 18 weeks of pregnancy)
•
Chorionic villus sampling - not
recommended
before
10
weeks
of
gestation
ETHIOLOGY
●
Exposure
radiation
Prenatal Detection
to
drugs,
chemicals,
ASSESSMENT
Maternal factors
SPINA BIFIDA CYSTICA
-malnutrition
-maternal obesity
Sensory disturbances usually parallel
to motor dysfunction
-maternal diabetes mellitus
•
-low maternal
(FOLIC ACID)
vitamin
B12
status
-maternal hyperthermia
mutation
•
Flaccid, partial
lower extremities
•
Varying
deficit
-use of AEDs in pregnancy
●
genetic
pathways
Below second lumbar vertebra:
in
folate
●
genetic component- occurs in
association with trisomy 21, PHAVER
syndrome (limb pterygia, congenital
heart anomalies, vertebral defects,
ear anomalies, and radial defects),
Meckel-Gruber syndrome.
-risk of recurrence after one affected
child (3-4%)
-risk
of
recurrence
with
two
previously affected children (10%)
DIAGNOSIS
paralysis
degrees
of
of
sensory
•
Overflow
incontinence
constant dribbling of urine
with
•
Lack of bowel control
•
Rectal prolapse (sometimes)
•
Below third sacral vertebra:
•
No motor impairment
•
May have saddle anesthesia with
bladder and anal sphincter
-
paralysis
Joint deformities (sometimes produced
in utero):
•
Talipes
contractures
valgus
or
varus
The diagnosis of SB is made on the
basis of clinical manifestations and
examination of the meningeal sac.
•
Kyphosis
•
Lumbosacral scoliosis
To evaluate the brain and spinal cord
•
Hip dislocation or subluxation
•
MRI
•
Ultrasonography
•
CT SCAN
SPINA BIFIDA OCCULTA
•
Frequently
manifestations
no
observable
May be associated with one or more
cutaneous manifestations:
•
Skin depression or dimple
•
Port-wine angiomatous nevi
•
Dark tufts of hair
•
Soft, subcutaneous lipomas
(Ditropan)
(Detrol)
•
Progressive disturbance of gait
with foot weakness
and
bladder
sphincter
THERAPEUTIC MANAGEMENT
1.
Surgical closure within the
first 24 hours is recommended if the
sac is leaking
neurosurgical
and
plastic
surgical procedures are used for skin
closure without disturbing the neural
elements or removing any portion of
the sac.
satisfactory skin coverage
the lesion and meticulous closure
Clean
intermittent
catheterization
(CIC)-regular
emptying of the bladder is taught to
child and family
medications to improve bladder
storage and continence, such as
oxybutynin chloride
May have neuromuscular disturbances:
•
Bowel
disturbance
assessing of neurogenic bladder
dysfunction and prevent infection
of
to prevent injury to the exposed
spinal cord tissue and the improvement
of neurologic and urologic outcomes in
the affected child.
and
tolterodine
vesicostomy (bladder surgically
brought out to the abdominal wall,
allowing continuous urinary drainage)
and augmentation enterocystoplasty
(using a segment of bowel or stomach
to increase bladder capacity, thereby
reducing high bladder pressures).
5.
Bowel
control
management:
Dietary
fiber
supplements
(recommended 10 g/day), laxatives,
suppositories, or enemas aid in
producing regular evacuation
NURSING MANAGEMENT
Provide psychological support
Before surgery
●
Clean the defect gently
sterile normal saline solution
●
with
or other solutions, as ordered.
●
Handle the infant carefully, and
don’t apply pressure to the defect.
2.
Initial care of the newborn
involves
preventing
infection;
performing a neurologic assessment,
including observing for associated
anomalies; and dealing with the impact
of the anomaly on the family.
●
Provide
adequate
time
for
parent-child bonding, if possible.
3.
Orthopedic management includes
prevention of joint contractures,
correction
of
any
existing
deformities,
prevention
or
minimization of the effects of motor
and sensory deficits, prevention of
skin breakdown, and obtaining the best
possible function of affected lower
extremities
●
report signs of drainage, wound
rupture, and infection.
4.
Manage genito-urinary function
After surgery
●
Change the dressing regularly,
as ordered, and check and
●
Place
position.
the
infant
in
a
prone
●
If leg casts have been applied,
watch for signs that the child is
outgrowing the cast. Ensure adequate
circulation by regularly checking
distal pulses.
●
Before surgery, monitor the
patient’s neurologic status, feeding
ability, and nutritional status.
●
After
surgery,
monitor
the
patient’s intake and output, vital
signs, and for signs of infection or
increased intracranial pressure.
Common Health Problem in Toddlers
INTRODUCTION:
During the toddler period, the
age span from 1 to 3 years, enormous
changes take place in a child and,
consequently, in a family. During this
period, children accomplish a wide
array of developmental tasks and
change from largely immobile and
preverbal infants who are dependent on
caregivers for the fulfillment of most
needs to walking, talking young
children with a growing sense of
autonomy (independence). To match
this growth, parents must also change
during this period. If a parent
enjoyed being the parent to an infant
because time could be spent rocking or
singing to the child, they may not
enjoy being the parent of a toddler as
now their task is to support their
child’s growing independence with
patience and sensitivity and to learn
methods for handling the child’s
frustrations that arise from the quest
for
autonomy.
Because
healthy
children and families are constantly
being challenged by the process of
normal development, parents often
have questions about how to guide
their
children
in
different
situations and how to cope with
special needs and concerns relevant to
this age.
OTITIS MEDIA
–
Otitis media -Presence of a
middle ear infection or inflammation.
o
Acute Otitis Media: occurrence
of bacterial infection within the
middle ear cavity.
o
Otitis Media with Effusion:
presence of nonpurulent fluid within
the middle ear cavity (viral)
Otitis media is the second most common
clinical problem in childhood after
upper respiratory infection.
Otitis Media usually follows an URI in
which there is edema of the eustacian
tube, leading to blockage. Stasis of
these middle ear secretions lead to
infection and irritation
EPIDEMIOLOGY
✔
Peak incidence in the first two
years of life (esp. 6-12 months)
✔
Boys more affected girls
✔
50% of children 1 yr of age will
have at least 1 episode
✔
1/3 of children will have 3 or
more infections by age 3
✔
90% of children will have
least one infection by age 6
at
✔
Occurs more frequently in the
winter months
2.
Otitis Media with Effusion:
evidence of middle ear effusion on
pneumatic otoscopy
3.
Recurrent
Otitis
Media:
inability
to
clear
middle
ear
effusions
4.
Chronic Serous Otitis Media:
presents as ‘fullness in the ear’,
tinnitus, or another acute disease
ASSESSMENT
▪
Neonates/Infants:
change
in
behavior, irritability, tugging at
ears, decreased appetite, vomiting.
▪
Children(2-4years):
otalgia,
fever, noises in ears, cannot hear
properly, changes in personality.
▪
Children (>4years): complain of
ear pain, changes in personality.
ETHIOLOGY
●
Short length and horizontal
positioning of the eustachian tube
●
Bottle
position
●
fed
babies
in
supine
Passive smoker
●
Recurrent
infection
upper
respiratory
●
Infection
usually
associated
with the ff. microorganism






Streptococcus pneumoniae
Haemophilus
influenzae(nontypeable)
Moraxella catarrhalis
Group A Streptococcus
Staph aureus
Pseudomonas aeruginosa
RSV assoc. with Acute Otitis Media
●
Allergies
●
Craniofacial
(cleft palate)
●
abnormalities
Down’s Syndrome
Classification of Otitis Media
1.
Acute Otitis Media: presents
with fever, otalgia, and hearing loss
DIAGNOSIS
1.
Physical
exam
showsn
erythematic, opaque, bulging tympanic
membrane
with
loss
of
anatomic
landmarks including a dull/absent
light reflex.
2.
Pneumatic
Otoscopy:
standard
tool for diagnosis- shows decreased
tympanic membrane mobility
3.
Impedance Tympanometry: Measures
the resonance of the ear canal for a
fixed sound as the air pressure is
varied.
4.
Spectral
Gradient
Acoustic
Reflectometry: measures the condition
of the middle ear by assessing the
response of the TM to a sound
stimulus. Equivalent to tympanometry
for dx of middle ear effusions
5.
Diagnostic
tympanocentesis
&
myringotomy: involves puncturing the
tympanic
membrane
and
aspirating
middle ear fluid to relieve pressure.
Only used if the primary and secondary
line
treatment
fail.
With
the
increasing
incidence
of
drug
resistant strains of S. pneumoniae,
CDC
recommends
the
capacity
of
clinicians to be efficient in using
tympanocentesis.
INDICATIONS FOR TYMPANOCENTESIS
●
toxic appearing child
●
Failed
antibiotics
treatment
regimen
with
▪
tympanosclerosis
▪
Cholesteatoma
▪
Chronic suppurative OM
▪
Cholesterol
drum syndrome’
granuloma:
‘Blue
▪
Facial nerve paralysis
▪
Intracranial complications
▪
Bacterial meningitis
▪
Epidural abscess
▪
Subdural empyema
MANAGEMENT
▪
Brain abscess
1.
▪
Otitic hydrocephalus
▪
Amoxicillin: 20-40 mg/kg/day tid
for 10-14 days or,
▪
Lateral sinus thrombosis
▪
Augmentin: 45 mg/kg/day po bid
for 10-14 days
1.
Parent
teaching
prophylactic care
▪
Benzocaine
analgesic/adjunct
drops tid
2.
Position infants as upright as
possible during feeding to avoid
reflux of formula into eustachian
tube.
●
Suppurative complications
●
Immunosuppressed pt.
●
Newborn infant in which the
usual pathogens may not be the case.
Pharmacological treatment
for
(Auralgan):
ear pain 2-4
2nd Line Treatment Regimen: These
medications are used as secondary
agents if the primary antibiotic has
failed after 10 days and the symptoms
persists.
▪
Cefzil
Nursing Intervention
about
3.
Avoid smoking around infants and
children.
4.
Administer analgesics as ordered
to provide pain relief.
5.
Heat pack application over the
ear
may
relieve
pain
for
some
children.
▪
Pediazole
(erythromycin/sulfisoxazole)
▪
Bactrim
(trimethoprim/sulfamethoxazole
2.
Tympanocentesis & myringotomyincision in the posterior inferior
aspects of tympanic membrane for
draining exudates and pressure.
6.
Position child on the affected
side to promote drainage (if draining,
or
postoperatively
after
myringotomy).
7.
Assist in removal of drainage,
when possible
3.
Tympanoplasty- ventilating tubes
or pressure equalizer to create an
artificial
canal
that
equalize
pressure
8.
Postoperative
support
may
include wicks inserted loosely in the
ear to promote drainage but prevent
infection transfer to middle ear.
COMPLICATIONS
9.
Frequent cleansing of outer ear
and moisture barrier on ear to protect
from purulent drainage.
▪
Hearing
loss:
sensoneural, mixed
conductive,
▪
Acute mastoiditis:
advent of antibiotics
before
▪
the
Chronic perforation of the TM
10.
Family-centered care
a.
Educating the family in care of
child
b.
Analgesia for pain management
c.
Postoperative care to prevent
spread of infection and promote
healing
d.
Providing emotional support to
the child and family
e.
Explain
the
process
management of drainage.
for
f.
Encourage follow-up evaluation
of hearing to detect any loss of
hearing.
Resulting
edema
could
lead
respiratory tract obstruction
to
2.
Hand burns- if the fingers and
thumb are not positioned properly
during
healing,
adhesions
will
inhibit full range of motion in the
future.
3.
Genital burns- edema of the
urinary meatus may prevent a child
from voiding.
4.
Feet and genitalia - high risk
for secondary infection.
What caused the burn?
BURN
Burns are injuries to body tissue
caused by excessive heat (heat greater
than 104° F [40° C]).Second greatest
cause of unintentional injury in
children 1 to 4 years of age and the
third greatest cause in children age
5 to 14 years.
ETHIOLOGY
Because different materials
different degrees of burn.
cause
Where the fire happened?
Fires in closed spaces are apt to
cause more respiratory involvement
than fires in open areas.
Ask
whether
the
child
secondary health problem.
has
any
●
Toddlers are often burned by
pulling pans of scalding water
or grease off the stove and onto
themselves or from bath water
that is too hot.
In their anxiety over the present
burn, parents may forget to report
important facts, such as the child has
diabetes or is allergic to a common
drug.
●
They can bite into electrical
cords.
Ask who put out the fire.
●
●
Older children are more apt to
suffer burns from flames when
they move too close to a
campfire, heater, or fireplace;
touch a hot curling iron; or play
with matches or lighter candles
Eye
burns
can
occur
from
splashed chemicals in science
classes
Some burns (particularly scalding)
can be caused by child abuse
DETERMINATION OF EXTENT OF BURNS IN
CHILDREN.
Where is the burn and what is its
extent and depth?
1.
Face and throat burns- unseen
burns in the respiratory tract.
Were any other
animals hurt?
family
members
or
Does anyone else need care?
Depth of Burn
1.
Partial-thickness burns:
include
burns.
first-
and
second-degree
a.
first-degree burn involves only
the superficial epidermis.
●
area appears erythematous.
●
painful to touch
●
blanches on pressure
b.
second-degree burn involves the
entire epidermis.
●
Sweat glands and hair follicles
are left intact.
appears very erythematous
●
blistered,
exudate.
●
and
Minor Burns
▪
Pain management burn involve
pain and death of skin cells.
▪
Apply ice Immediately to cool
the skin and prevent further burning.
Scalds and sunburn are examples of
first-degree burns. Such burns heal by
simple regeneration and take only 1 to
10 days to heal.
●
1.
moist
from
It is extremely painful.
▪
Application of
antibiotic ointment
bandage to prevent
an analgesic–
and a gauze
▪
Follow-up visit in 2 days to have
the area inspected for a secondary
infection and to have the dressing
changed.
▪
Caution parents to keep the
dressing dry (no swimming or getting
the area wet while bathing for 1
week).
2.
Moderate Burns
▪
Do not rupture blisters because
doing so invites infection.
Scalds can cause second-degree burns
▪
Broken blisters may be débrided
(cut away) to remove possible necrotic
tissue as the burn heals.
Such burns heal by regeneration of
tissue but take 2 to 6 weeks to heal.
▪
topical
antibiotic
silver sulfadiazine
such
as
▪
dressing to prevent damage to
the denuded skin.
2.
Third-degree
thickness burn
burn
is
a
full-
Involving both skin layers, epidermis
and dermis.
It may also involve adipose tissue,
fascia, muscle, and bone.
Flames are a common cause of thirddegree burns.
▪
The burn
white or black
area
appear
either
▪
Not
painful
Because
the
nerves,
sweat
glands,
and
hair
follicles have been burned
▪
▪
assess that pain control is
adequate and there are no signs and
symptoms of infection.
3.
Severe burns.
▪
Critically injured
swift and ure care,
and
needs
▪
Including fluid therapy,
▪
Systemic antibiotic therapy,
▪
Pain management,
▪
Physical therapy, - survive the
injury without a disability caused by
scarring, infection, or contracture.
cannot heal by regeneration
▪
Skin
grafting
is
usually
necessary, and healing takes months.
▪
Scar tissue will cover the final
healed site
EMERGENCY MANAGEMENT OF BURN
4.
Electrical Burns of the Mouth
When a child puts the prongs of a
plugged-in extension cord into the
mouth or chews on an electric cord,
the mouth will be burned severely.
▪
unplug the
control bleeding
▪
applied
with gauze
electric
Pressure
to
cord
the
and
site
▪
admission to a hospital for at
least 24 hours in an observation unit
because edema in the mouth can lead to
airway obstruction.
▪
Supply adequate pain relief as
long as necessary.
▪
Clean the wound about four times
a day with an antiseptic solution
▪
Give bland fluids
THERAPY FOR BURN
Application of dressing
Second- and third-degree burns may
receive open treatment, leaving the
burned area exposed to the air, or a
closed treatment, in which the burned
area is covered with an antibacterial
cream and many layers of gauze.
1.
Apply dressings loosely for the
first 24 hours to prevent interference
with circulation as edema forms not to
allow two burned body surfaces ------- TO PREVENT WEBBING BETWEEN THESE
SURFACES
2.
Do not use adhesive tape to
anchor dressings to the skin; it is
painful to remove and can leave
excoriate
areas,
which
provide
additional entry for infection.
3.
Netting
is
useful
to
hold
dressings in place, because it expands
easily and needs no additional tape.
Povidone-iodine (Betadine)
▪
Antiseptic solutions as may also
be used to inhibit bacterial and
fungal growth.
Nitrofurazone
Pseudomonas
(Furacin)
cream
for
Escharotomy:
the eschar)
escharotomy (cut into
An eschar is the tough, leathery scab
that forms over moderately or severely
burned
areas.
Fluid
accumulates
rapidly
under
eschars,
putting
pressure on underlying blood vessels
and nerves.
▪
cutting
off
circulation
distal body portions.
to
▪
Distal parts feel cool to the
touch and appear pale.
▪
tingling or numbness.
▪
Pulses are difficult to palpate,
▪
capillary refill is slow (longer
than 5 seconds).
Débridement
o
The removal of necrotic tissue
from a burned area.
o
Reduces
the
possibility
of
infection, because it reduces the
amount of dead tissue present on which
microorganisms could thrive.
o
A
hydrotherapy
before
debridement is done to soften and
loosen eschar.
o
Débridement is painful, and some
bleeding occurs with it.
Topical Therapy.
▪
Premedicate the
prescribed analgesic,
Silver sulfadiazine (Silvadene) is
the drug of choice for burn therapy.
▪
use a distraction
during the procedure.
▪
applied as a paste to the burn,
and the area is then covered with a
few layers of mesh gauze.
▪
Transcutaneous electrical nerve
stimulation
(TENS)
therapy
or
patient-controlled analgesia may also
be helpful.
▪
Silver
sulfadiazine
is
an
effective agent against both gramnegative and gram-positive organisms
and even against secondary infectious
agents, such as Candida.
Grafting
child
witha
technique
Homografting
(also
called
allografting) is the placement of skin
(sterilized and frozen) from cadavers
or a
donor on the cleaned burn site.
These grafts do not grow but provide
a protective covering for the area.
Heterografts (also called xenografts)
from other sources, such a sporcine
(pig) skin, may be used.
Autografting is a process in which a
layer of skin of both epidermis and a
part of the dermis (called a splitthickness graft) is removed from a
distal, unburned portion of the
child’s body and placed at the
prepared burn site, where it will grow
and replace the burned skin
After grafting
1.
the area is covered by a bulky
dressing------growth of the newly
adhering cells will not be disrupted,
this should not be removed or changed.
2.
The donor site on the child’s
body (often the anterior thigh or
buttocks) is also covered by a gauze
dressing
3.
observed for fluid drainage and
odor. pain at either site, which might
indicate infection.
4.
Monitor the child’s temperature
every 4 hours.
5.
Autograft sites can be reused
every 7 to 10 days, so any one site
can provide a great deal of skin for
grafting.
NURSING DIAGNOSIS AND INTERVENTION
b.
Use
of
patient-controlled
analgesia before performing any burn
care such as débridement (the removal
of necrotic tissue from a burned area)
is also effective
c.
Proper positioning
contracture formation
to
prevent
2.
Nursing
Diagnosis:
Deficient
fluid volume related to fluid shifts
from severe burn
Outcome
Evaluation:
Skin
turgor
remains good; hourly urine output is
greater than 1 mL/kg, with specific
gravity between 1.003 and 1.030; vital
signs
are
within
acceptable
parameters.
Immediately
after
a
severe
burn,hypovolemia occurs , because of
a loss of plasma, which oozes from
blood
vessels into the burn site and then
sequesters
in
edematous
tissue
surrounding the site.
most marked during the first 6 hours
after a burn and extent for the first
24 hours.
a.
Monitor vital signs closely to
allow
early
detection
of
shock
(decrease CO ---- Hypotension)
b.
Monitor
for
severe
anemia
because of injury to red blood cells
caused by heat and loss of blood at
the wound site.
c.
Watch out for hyponatremia and
hyperkalemia - sodium lost with the
edematous burn fluid and the release
of potassium from damaged cells can
lead to an immediate hyponatremia and
hyperkalemia
Outcome Evaluation: Child states that
pain is at a tolerable level.
d.
Fluid replacement with LACTATED
RINGERS SOLUTION (most compatible
with extracellular fluid.), normal
saline,
plasma
replacement,
5%
dextrose in water.
a.
Morphine sulfate is commonly the
agent of choice and most effective in
IV or epidural administration.
This
fluid
is
administered
rapidly for the first 8 hours (half of
the 24-hour load)
1.
Nursing Diagnosis: Pain related
to trauma to body cells
slowly for the next 16 hours (the
second half
continued beyond the time of
increased capillary permeability (at
least the first 24 hours)
About 48 hours after the burn,
as
inflammation
decreases,
the
extracellular fluid at the burn site
begins to be reabsorbed into the
bloodstream.
(Diuresis,
temporary
hypervolemia,
hypokalemia,
low
hematocrit (dilution of RBC’S)
e.
Do not administer potassium
immediately after a burn until kidney
function is evaluated
3.
Nursing Diagnosis: Risk for
ineffective tissue perfusion related
to cardiovascular adjustments after
burn injury
Outcome Evaluation: Child’s vital
signs stay within normal limits;
hourly urine output remains greater
than 1 mL/kg.
a.
Monitor vital signs
until the
child passes the immediate danger of
shock (at least 24 hours) and at 48
hours after the injury, when fluid
returns to blood stream
4.
Nursing Diagnosis: Risk for
ineffective
breathing
patterns
related to respiratory edema from burn
injury
Outcome
Evaluation:
Child’s
respiratory rate remains within 16 to
20 breaths/minute; lung auscultation
reveals no rales.
d.
Administration of 100% oxygen is
the best therapy for displacing carbon
monoxide
and
providing
adequate
oxygenation to body cells. (possible
for endotracheal intubation or a
tracheostomy)
e.
Assess for the development of
infection.
5.
Nursing Diagnosis: Risk for
impaired urinary elimination related
to burn injury
Outcome Evaluation: Child’s urine
output is greater than 1 mL/kg of body
weight per hour.
a.
Facilitate indwelling urinary
(Foley) catheter should be inserted in
the emergency department, and an
immediateurine specimen should be
obtained for analysis.
b.
Administer diuretic, such as
mannitol, may be administered to flush
hemoglobin from the kidneys
c.
observing urinary output is a
major nursing responsibility.
6.
Nursing Diagnosis: Risk for
imbalanced nutrition, less than body
requirements, related to burn injury
Outcome Evaluation: Child’s weight
remains within normal age-appropriate
growth
percentiles;
skin
turgor
remains
normal;
urine
specific
gravity
remains
between1.003
and
1.030.
a.
supplement the child’s diet with
IV or parenteral nutrition solutions
or NG tube feeding
a.
Assess for burns of the face,
neck, or chest, which would indicate
that the fire was near the nose and
respiratory tract.
b.
supply adequate calories for
increased metabolic needs and spare
protein for repair of cells
b.
Assess the quality of the
child’s voice (it will be hoarse if
the throat is irritated from smoke).
c.
Closely observe NGT drainage for
a change to fresh bleeding, which can
be caused by a stress ulcer (Curling’s
ulcer).
c.
monitor the respiratory rate of
all
burned
children,
because
respiratory
rate
increases
with
respiratory obstruction.
d.
administering
a
histamine-2
receptor
antagonist,
such
as
cimetidine (Tagamet) or a proton pump
inhibitor
(Prilosec)
such
as
omeprazole
7.
Nursing Diagnosis: Risk for
injury related to effects of burn,
denuded skin surfaces, and lowered
resistance
to infection with burn injury
a.
Observe strict sterile aseptic
technique when providing care to
patient.
prescribed
●
most
commonly
in
children
between the ages of 2 and 3 years.
●
Common agents include soaps,
cosmetics, detergents or cleaners,
and plants.
●
Outcome
Evaluation:
Child’s
temperature remains at 98.6° F (37°
C); skin areas surrounding burned
areas show no signs of erythema or
warmth.
b.
Aminister
biotics.
POISONING
anti-
8.
Nursing
Diagnosis:
Social
isolation
related
to
infection
control
precautions
necessary
to
control spread of microorganisms
Outcome Evaluation: Child states that
he
understands
the
reason
for
infection control precautions; child
accepts it as a necessary part of
therapy.
9.
Nursing Diagnosis: Interrupted
family processes related to the
effects of severe burns in family
member
Outcome Evaluation: Family members
state that they
are able to cope
effectively with the degree of stress
to which they are subjected; family
demonstrates
positive
coping
mechanisms.
10. Nursing
Diagnosis:
Disturbed
body image related to changes in
physical appearance with burn injury
Outcome Evaluation: Child expresses
fears
about
physical
appearance;
demonstrates desire to resume ageappropriate activities.
poisoning isentirely preventable
Emergency Management of Poisoning at
Home
If poisoning occurs, parents should
telephone their local poison control
center to ask for advice.
Information parents need to provide
includes:
▪
Child’s name, telephone number,
address, weight, and age and what the
child swallowed
▪
How
occurred
long
ago
the
poisoning
▪
The route of poisoning (oral,
inhaled, sprayed on skin)
▪
How much of the poison the child
took (the bottle should say how many
pills or liquid it originally held).
▪
If the poison was in pill form,
whether there are pills scattered
under a chair or if they are all
missing and presumed swallowed
▪
What was swallowed; if the name
of a medicine is not known, what it
was prescribed for and a description
of it (color, size, shape of pills)
▪
The child’s present condition
(sleepy? hyperactive? comatose?) If
one child has swallowed a poison,
parents should investigate whether
other children have also poisoned
themselves as a preschooler often
shares “candy” with a younger sibling.
Emergency Management of Poisoning at
the Health Care Facility
▪
the best method to deactivate a
swallowed
poison
is
the
administration of activated charcoal,
either orally or by way of an NG tube.
▪
charcoal is excreted through the
bowel over the next 3 days, stools
will appear black
▪
assess
ordered.
2.
ALT
and
AST
levels
as
Activated charcoal
ACETHAMINOPHEN POISONING
Acetaminophen (Tylenol) is the drug
most frequently involved
CAUSTIC POISONING
in childhood poisoning today, because
parents use
Ingestion of a strong alkali, such as
lye (common in toilet bowl cleaners or
hair care products)
acetaminophen
fevers.
to
treat
childhood
parents may not be as careful about
putting this drug away as they were
with aspirin
Acetaminophen in large doses it can
cause extreme liver destruction
May cause burns and tissue necrosis in
the mouth, esophagus, and stomach
Do not try to make a child vomit after
ingestion because they can cause
additional burning as they are vomited
ASSESSMENT
▪
▪
drools saliva because of oral
edema
ASSESSMENT
▪
anorexia, nausea and vomiting
▪
▪
elevated
serum
aspartatetransaminase (AST [SGOT])
▪
elevated
Serum
transaminase (ALT [SGPT])
▪
alanine
elevated liver enzymes
▪
The liver may feel
liver toxicity occurs
pain in the mouth and throat
tender
as
inability to swallow
▪
Early: mouth turns white because
of burn
▪
Later: Mouth turns because of
edema and ulceration
▪
vomit blood, mucus, and necrotic
tissue
DIAGNOSTICS
MANAGEMENT
1.
Acetylcysteine
the
specific
antidote for acetaminophen poisoning
will be administered
Acetylcysteine
prevents
hepatotoxicity by binding with the
breakdown product of acetaminophen so
that it will not bind to liver cells.
▪
Administer it in a carbonated
beverage to help the child swallow it.
▪
Administer directly into an NG
tube to avoid for smaller children
▪
continue to observe for jaundice
and tenderness over the liver;
1.
chest radiograph may be ordered
to
determine
whether
pulmonary
involvement has occurred from any
aspirated
poison
or
whether
an
esophageal perforation has allowed
poison to seep into the mediastinum.
2.
barium swallow or esophagoscopy
AFTER 2 WEEKS may be performed to
reveal the final extent of the
esophageal burns
MANAGEMENT
1.
Check for airway obstruction due
to severe pharyngeal edema
2.
Assess
vital
signs
closely
especially the respiratory rate
3.
Watch
out
for
increasing
restlessness
an
important
accompanying sign of oxygen want
4.
Assist
in
intubation
necessary to provide a patent airway
5.
Assess the child also for the
degree of pain
MANAGEMENT
1.
Gastric Lavage- to remove any
pills not yet absorbed
Activated Charcoal- NOT GIVEN,
NOT EFFECTIVE
Very important to removed iron
load from the stomach in time so that
not all of it was absorbed.
Morphine - strong analgesic to achieve
pain relief
2.
Maalox or Mylanta (aluminum
hydroxide and magnesium hydroxide)
may be given to help decrease gastric
irritation and pain
IRON POISONING
3.
Deferoxamine
a
chelating
agent, combine with metals and allow
them to be excreted from the body.
Usually swallowed by children for it
is
an
ingredient
in
vitamin
preparations( pregnancy vitamin)
Iron
poisoning
occurs
frequently
because parents do not think of iron
pills or vitamins containing iron as
real medicine.
Children often think of vitamins as
candy because of its shape
Corrosive to the gastric mucosa
4.
Check for any signs of GI
bleeding (fecal occult for the next 3
days)
5.
Parent teaching – Over-doses can
be fatal to small children
-keep it out
reach of small children.
of
the
LEAD POISONING (Plumbism)
ASSESSMENT
o
nausea and vomiting
o
diarrhea and abdominal pain
Poisoning from lead has been a problem
throughout history and throughout the
world.
o
>6 Hours: hemorrhagic necrosis
of the lining of the GI tract
o
-Causes orange urine
At 12 hours:
▪
melena (blood in stool)
hematemesis (blood in emesis)
and
Lead interferes with red blood cell
function
by
blocking
the
incorporation
of
iron
into
the
protoporphyrin compound that makes up
the heme portion of hemoglobin in red
blood cell.
▪
Lethargy and coma, cyanosis, and
vasomotor collapse.
Occur most often in the toddler or
preschool child.
▪
Coagulation
hepatic injury
●
Poisoning
leads
hypochromic,
microcytic
kidney destruction
▪
defects
--------
Shock
o
Gastric scarring from fibrotic
tissue formation as long-term effects
to
a
anemia,
●
MOST
SERIOUS
EFFECT:
Lead
encephalitis- inflammation of brain
cell
Sources of Lead:
DIAGNOSTICS
serum iron level should
measured to establish a baseline.
o
Lead-based paint in deteriorating
condition
o
Lead paint chips or paint dust
be
o
fumes from burning or swallowed
batteries
o
Lead solder
o
Battery casings
o
Lead fishing sinkers
o
Lead curtain weights
o
Lead bullets
2.
Free Erythrocyte Protoporphyrinsimple
screening
procedure
that
involves only a fingerstick.
-elevated in a child with
lead poisoning
3.
Blood smear- shows basophilic
stippling
(an
odd
striation
of
basophils)
4.
XRAY- reveal paint chips in the
intestinal tract.
Some of these may contain lead:
• Ceramic ware
5.
Urine analysis - presence of
lead, proteinuria, ketonuria, and
glycosuria -KIDNEY DAMAGE
• Water
• Pottery
6.
CSF analysis- increased protein
level.
• Pewter
• Dyes
• Industrial factories
MANAGEMENT
• Vinyl mini-blinds
1.
Remove the source of lead.
• Playground equipment
2.
Advise hospital admission
• Collectible toys
3.
Succimer (Chemet)- A chelating
agents given for children with blood
lead levels greater than 20 ug/100 mL
• Some imported toys or children's metal jewelry
• Artists' paints
ASSESSMENT
▪
Asymptomatic – even fairly high
blood lead levels
▪
Anorexia and
lead in stomach
abdominal
pain-
▪
Lethargy,
impulsiveness,
and
learning difficulties – early signs of
encephalopathy
▪
Paralysis,
Seizures
permanent neurologic damage,
death – severe encephalopathy
and
coma,
DIAGNOSTICS
1.
Serum ferritin - most widely
used method of screening for lead
levels
of
atomic
spectrophotometry
procedure
-requires the use
absorption
---costly
4.
Chelation
therapy
with
dimercaprol (BAL) or edetate calcium
disodium (CaEDTA) – for lead levels of
greater than 45 ug/100 mL
EDTA - given IM injection into a large
muscle mass,
-may
be
combined with 0.5 mL of procaine for
pain
-removes calcium from the body ---CHECK SERUM CALCIUM LEVELS
-check adequacy of kidney function --- Can Cause NEPHROTOXYCITY or KIDNEY
DAMAGE
BAL - advantage of removing lead
from red blood cells
-possible
of
sever
toxicity
intoxication
severe
forms
5.
Parental education
risk of lead poisoning
of
about
lead
the
PESTICIDE POISONING
accidental ingestion or through
or respiratory tract contact
children play in an area that
recently
been
sprayed
pesticides.
skin
when
has
with
organophosphate
base
pesticides:
causes acetylcholine to accumulate at
neuromuscular junctions;
this accumulation
paralysis
leads
to
1.
Check electrolyte levels
2.
Toxicology screen
ASSESSMENT
▪
nausea and vomiting,
▪
diarrhea,
▪
excessive salivation,
▪
weakness of respiratory muscles,
▪
confusion,
▪
depressed reflexes,
▪
possibly seizures
▪
Avoid shouting or
when eliciting history
aggravating
▪
Approaching a child’s friends in
this way is more likely to result in
their naming the drug
▪
ask parents to have someone at
home check the child’s bedroom for
drugs or what could be missing from
the medicine cabinet
▪
Determine whether the ingestion
was an accident or the child was
actually attempting suicide.
MANAGEMENT
clothing
DIAGNOSTICS
muscle
ASSESSMENT
1.
remove
clothing
Typical
drugs
involved
include
codeine and antidepressant drugsprescription drugs removed from the
family medicine cabinet
contaminated
2.
administer Activated Charcoal if
swallowed
3.
wear gloves while bathing the
child’s skin and hair
4.
Pralidoxime (Protopam Chloride):
antidote to reverse symptoms.
PLANT POISONING
Plant poisoning (ingestion of a
growing plant) occurs because parents
commonly do not think of plants as
being poisonous
POISONING BY DRUG ABUSE
Adolescents and even grade-school
children are brought to health care
facilities by parents or friends
because of a drug overdose or a “bad
trip” caused by an unusual reaction or
the
effect
of
an
unfortunate
combination of drugs.
-All poisonings or drug ingestions in
children older than 7 years of age
should
be
considered
potential
suicides
ACCIDENTAL- need counseling to avoid
drug use or about which drugs do not
mix.
SUICIDALneed
observation
and
counseling
toward
more
effective
coping mechanisms in self-care
MANAGEMENT
1.
Supportive management- measures
for
their
specific
symptoms,
including
oxygen
administration,
electrolyte replacement (particularly
if there is accompanying nausea and
vomiting), and perhaps IV fluid
administration in an attempt to dilute
the drug.
2.
Reduction of fear and anxiety,
increased
coping
mechanisms,
knowledge of the effects of drug use,
and availability of referral sources
for a drug problem are areas need to
be addressed
CHILD ABUSE
●
Undiagnosed medical problems,
such as anemia, otitis media, lead
poisoning, or sexually transmitted
infections.
–
Abuse, defined as the “willful
injury
by
one
person
of
another”(Helfer & Kempe, 1987),
●
sexual abuse can have long-term
effects of depression, guilt, and
difficulty enjoying sexual relations
(Chartier, Walker, & Naimark, 2007)
–
Child
abuse
occurs
at
an
incidence of 2 per 100,000 children
per year in the United States.
●
they tend to rear their children
in basically the same way as they were
reared
–
It accounts for 1500 deaths per
year (DHHS, 2009).
●
they never form a basic sense of
trust, and this may cause them to have
parenting difficulties themselves
–
Abuse maybe physical (the child
is beaten or burned), or it may be
neglect (the child is not fed,
clothed,
supervised
properly,
or
offered medical care or educational
opportunities).
–
Abuse may also be psychological
or emotional (a child is made to feel
unintelligent or inadequate).
–
Women who threatened the health
of their fetus by drug abuse
–
Abuse is associated with stress
and has been linked to inability of a
family to handle external and internal
stressors.
–
Abuse
isolated
indication
needs care
in a family is rarely an
event
but
rather
an
of how much the family
overall
THEORIES OF CHILD ABUSE
Triad of circumstances
• A parent has the potential to abuse
a child (special parent).
• A child is seen as “different” in
some way by the parent (special
child).
• An event or
about
the
circumstance).
circumstance brings
abuse
(special
Special Parent: Parents Who Abuse
●
were abused as children
●
history of mental illness
The victim’s safety is paramount, but
ensuring this safety must be done with
sensitivity to the importance of
maintaining and improving overall
family functioning.
●
have less
other parents
Long term effects of child abuse
●
socially
isolated,
with
no
support people readily available, and
so
can
become
overwhelmed
by
childrearing
●
Physically abused children are
found to be more angry, noncompliant,
and hyperactive than others;
●
they
may
demonstrate
poor
selfcontrol and low self-esteem.
●
Children whose parents do not
interact with them (emotional abuse)
are apt to be more withdrawn and to
have a flatter affect than other
self-control
than
●
unfamiliar
with
the
normal
growth and development of children and
so have unrealistic expectations of a
child
●
Abuse is strongly associated
with
excessive
parental
use
of
alcohol, a substance that removes
inhibitions and self-control
Special Child: Children Who Are Abused
●
more or less intelligent than
other children in the family
●
they may have been unplanned
●
may have a birth defect;
●
they may have an attention span
deficit
frustrated when the child does not
respond in the way they expect.
Physical abuse is when a child has
been physically harmed due to some
interaction or lack of interaction by
another person, which could have been
prevented by any person in a position
of responsibility, trust or power.
●
born prematurely or who have an
illness at birth – separation during
time
of
hospitalization
causing
failure to establish bond
The following signs may indicate child
abuse or neglect.
●
assume a role reversal with the
parent or become the comforting,
solacing person (They learn to comfort
the parent and reduce the parent’s
stress and anxiety, thereby avoiding
the hurt)
CHILDREN
Special Circumstance: Stress
●
Stress which may be a response
to an event that would not necessarily
be stressful for an average parent
●
as common as a blocked toilet,
an illness in the family, a lost job,
a landlord asking for the rent, or a
rainstorm that cancels a picnic.
●
Stress generally has a greater
impact on individuals who do not have
strong support people around them.
●
Faulty family support system or
not formed outside support systems
have a higher incidence of abuse.
●
Show sudden changes in behavior
or school performance
●
Haven’t
received
help
for
physical or medical problems brought
to the parent’s
●
attention
●
Are always watchful, as if
preparing for something bad to happen
●
Lack adult supervision
●
Are overly compliant, passive,
or withdrawn
●
Come to school or activities
early, stay late, and don’t want to go
home
●
behavior problems in school because the constant stress under
which these children live frequently
results in disruptive school behavior
PARENTS
PHYSICAL ABUSE
Physical abuse is the action of a
caregiver that causes injury to a
child. It is commonly revealed by
burns or by injuries to the head or
hands.
Physical abuse may occur when the
caregiver is unfamiliar with normal
child
behaviour.
Inexperienced
caregivers may not know what is normal
behaviour for a child and become
●
Show
child
little
concern
for
the
●
Deny or blame the child for the
child’s problems in school or at home
●
Request
that
teachers
or
caregivers
use
harsh
physical
discipline if the child misbehaves
●
See the child as entirely bad,
worthless, or burdensome
●
Demand a level of physical or
academic performance the child can’t
achieve
●
Look primarily to the child for
care, attention, and satisfaction of
emotionaln needs
PARENTS AND CHILDREN
●
Rarely look at each other
●
Consider their relationship to
be entirely negative
o
fractures,
and
epiphyseal injuries.
metaphyseal-
o
Torn-periosteumradiograph
reveals a strange haziness along both
sides of the bone shaft, child is
shaken roughly
o
Tibial torsion (twisting)is also
often seen
●
Bruises
●
State that they don’t like each
other
1.
Abused child say something that
is inconsistent with the parent’s
explanation.
Assessment finding
●
Delay in growth (height
weight) – suggest neglect
and
●
higher incidence of hand injury
Most
parents
protect
their
children’s hands carefully.
●
peculiar circular and linear
lesion- electrical cords, belts, or
clotheslines have
●
curved lacerations and contusion
and (+) imprint of the belt buckle
●
Abrasions or ecchymotic areas on
the wrists or ankles – tied up to bed,
against the wall
●
Burns or scalds - peak age at
which
children
accidentally
burn
themselves is 2 years
related to abuse is closer to 3 years.
often on the dorsal surface.
●
Cigarette burnsdefinite circular scar
●
heal
with
a
Human bites
●
chunks of hair pulled off the
scalp
●
Head injury
●
Broken bones- a broken bone
during preschool and younger suggests
the child was thrown or struck so hard
that the bone broke
o
multiple fractures in different
stages of healing,
o
a single fracture with multiple
bruises, rib or occipital
2.
Cry little in response to a
painful procedure because they are not
used to receiving comfort for pain
3.
may draw back from an examiner
more than the average child would
because they are afraid of adults
4.
injury
is
usually
out
proportion to the history of
injury given by the parent
of
the
5.
parents may give conflicting
stories (the mother says that the
child fell, but the father says that
6.
the child broke his arm throwing
a baseball)
7.
they may give no reason for the
injury (“He woke up from his nap and
couldn’t move his arm; I don’t know
what could have happened”)
8.
abused children often repeat the
parent’s story; this loyalty to
parents seems misplaced, but they may
fear further beatings or simply
believe that living with such parents
is better than not having anyone.
9.
Always assume that the parents
have done the best they could under
the circumstances in which they found
themselves. The fact that they have
brought the child for care means they
are seeking help; this may be their
way of saying, “Help me; I don’t want
this to happen again.”
SHAKEN BABY SYNDROME
Shaken baby syndrome is caused by
repetitive, violent shaking of a small
infant by the arms or shoulders, which
causes a whiplash injury to the neck,
edema to the brainstem, and distinct
retinal hemorrhages
Loss of vision, mental retardation, or
even
death
may
occur
in
these
children.
This form of child abuse does not have
easily noted signs and can be missed
on examination of the child.
Clinical manifestations may include
●
Lethargy
●
irritability,
●
omiting,
●
seizures,
Internal symptoms are detected by the
use of computed tomography (CT) and
magnetic resonance imaging (MRI).
RITUAL ABUSE
Ritual
abuse
is
cult
based
or
religiously,
spiritually,
or
satanically motivated. It can involve
physical, sexual, or psychological
abuse with bizarre or ceremonial
activities. With this type of abuse,
multiple
perpetrators
may
abuse
multiple victims over an extended
period
PHYSICAL NEGLECT
–
Neglect or negligent treatment
is purposeful omission of some or all
developmental needs of the child by a
caregiver with the intention of
harming the child. This includes the
failure of protecting the child from
a harmful situation or environment
when feasible.
–
Child neglect is failure to
provide
adequate
hygiene,
health
care, nutrition, love, nurturing, and
supervision needed for growth and
development.
–
Neglect takes many forms and can
be classified broadly as physical or
emotional maltreatment.
1.
Physical neglect involves the
deprivation of necessities ; such as
food, clothing, shelter, supervision,
medical care, and education.
2.
Emotional
neglect
generally
refers to the failure to meet the
child’s
needs
for
attention,
affection, and emotional nurturance.
A neglected child may appear
●
Unwashed
●
Thin
●
malnourished
●
dressed inappropriately, such as
without mittens, a coat, or shoes in
cold weather.
Neglect may be willful, or it may
occur if parents simply do not realize
the normal needs of a child. Such
parents need guidance from health care
personnel to understand their child’s
needs.
MUNCHAUSEN SYNDROME BY PROXY
–
one person either fabricates or
induces illness in another to get
attention.
–
When
a
caregiver
has
this
syndrome, he or she frequently brings
the child to a health care facility
and reports symptoms of illness when
the child is actually well.
–
Child’s illness fabricated or
induced by the parent (usually the
mother) Mother develops a dependent
relationship with her child’s doctor
/ medical staff.
1.
the symptoms are not easily
detected by physical examination,
only by history;
2.
the symptoms are present only
when the abuser is providing care and
disappear when care is provided by
another person.
This situation is frustrating for
health care personnel because it is
difficult to catch the suspect in the
act of endangering the child.
Close observation of the caregiver’s
interactions
with
the
child
is
necessary.
To diagnose this disorder, covert
video surveillance may be necessary.
Because
this
syndrome
reveals
distorted perceptions on the part of
the parent, it is almost always
necessary to remove the child from the
home to protect the child, even if the
parent receives counseling.
FAILURE
TO
THRIVE
ATTACHMENT DISORDER)
(REACTIVE
NURSING INTERVENTIONS
a
●
Identification of instances of
suspected
abuse
or
neglect
is
essential
Assess injuries.
Recording
Assessment
Suspected Abuse
Data
in
History of Injury
●
Date,
occurrence
time,
or other play activities
●
Interview
with
parent,
witnesses,
and
other
significant
persons, including verbal quotations
●
Description
of
parent–child
interactions (verbal interactions,
eye contact, touching, parental
●
concern)
●
Name, age, and condition of
other children in home (if possible)
Physical Examination
●
Location, size, shape, and color
of bruises; approximate location,
size, and shape on drawing of body
outline
●
Distinguishing characteristics,
such as a bruise in the shape of a
hand or a round burn (possibly caused
by cigarette)
●
Symmetry or asymmetry of injury;
presence of other injuries
●
Degree
tenderness
1.
Support the child during
thorough physical assessment.
2.
●
and
place
of
●
Sequence of events with recorded
times
●
Presence
of
witnesses,
especially person caring for child at
time of incident
●
Time lapse between occurrence of
injury and initiation of treatment
●
Interview
with
child
when
appropriate,
including
verbal
quotations
and
information
from
drawing
of
pain;
any
bone
●
Evidence
of
past
injuries;
general state of health and hygiene
●
Developmental
screening test
3.
level
of
child;
Prevent Further Abuse.
●
Abuser’s behavior modification
and keep the family intact (ideal)
●
Remove the child or the abuser
from the home so that no more abuse
occurs.
●
it is impossible to reverse the
damage that has been done to the
child’s sense of trust and selfesteem.
4.
Provide Consistent Care
Support for the Abused Child.
and
●
A
major
nursing
role
is
supplying a consistent, caring adult
presence for an abused child or
furnishing a relationship that the
child has never enjoyed.
●
offer them consistency through
primary or case management type of
nursing care assignment
●
Allow an opportunity to express
their feeling (mourn the loss of their
parent)
●
one-to-one relationship promote
sense of security
●
Ensure
child
is
not
only
physically safe but also whether they
are developing self-esteem
●
nurse–child relationship is to
provide a role model for the parents
in helping them to relate positively
and constructively to their child and
to foster a therapeutic environment
for the child in his or her reprieve
from the abusing situation
●
Do not implying questions that
any one answer is the correct one, or
they will supply what they think you
want to hear rather than the truth.
(A question such as, “That feels
better, doesn’t it? may be followed by
an instant “yes” even though the child
feels no improvement in symptoms.)
AUTISTIC DISORDER
Autistic
Disorder,
pervasive
developmental disorder, characterized
by
impairment
in
social
and
communication skills and the display
of
stereotypical
behaviors
(APA,
2000)
Marked by severe deficits in language
perceptual, and motor development;
defective reality testing; and an
inability to function in social
settings.
Family
●
Occurring
in
16-40/10,000
children (Hagman & Dech, 2008).
●
help evaluate whether a child
would be safe in the parents’ care in
the future.
●
Occurs more often in boys than
in girls and may have a genetic
cause (Volkmar, 2008)
●
acts as a role model for parents
in helping them to relate positively
and constructively to their child
●
50%
of
children
disorder are also
challenged.
●
educate the parent
children's physical and
needs
●
20% may have coexistent mental
health diagnoses (Mouridsen et
al., 2008).
5.
Evaluate
Health.
and
Promote
regarding
emotional
●
Praise any competent parenting
abilities they demonstrate to promote
their sense of parental adequacy.
●
Proper
referral
of
abusive
parents
for
counseling,
and
to
appropriate social service agencies
●
careful
follow
up,
because
parents may revert to an abusive
pattern if stress occurs again
6.
Plan for discharge
Discharge planning should begin as
soon as the legal disposition for
placement has been decided,
which may be temporary foster home
placement, return to the parents, or
permanent termination of
parental rights.
with
the
cognitively
ETHIOLOGY
The
cause
of
ASD
is
unknown.
Researchers
are
investigating
a
number of theories, including a link
between hereditary, genetic, medical
problems,
immune
dysregulation/neuroinflammation,
oxidative stress (damage
to
cellular
tissue),
environmental factors
and
No link between vaccines containing
thimerosal.
ASSESSMENT
▪
is moved
room)
Failure to develop social
relationsthe
normal
attachment behavior does not
develop.
▪
infant failed to cuddle,
make eye contact, or
exhibit
facial
responsiveness
-
unable
to
cooperatively or
friendships
Impaired ability to initiate
or sustain a conversation
-
▪
Impairment
in
communication is shown
in
both
verbal
and
nonverbal skills.
-
Language may be totally
absent
-
Nominal
inability
objects
attachment
to
odd
objects such as always
carrying a string or a
shoe.
-
Over-responsiveness to
sensory stimuli, such as
light or sound, but then
be unaware
of a major event in the room, such as
the sound of a fire alarm
▪
Extreme resistance to change
in routine
▪
Decreased sensitivity to pain
-
▪
-
Echolalia:
repetition
of words or phrases
spoken by others
▪
-
Repetitive
hand
movements, rocking, and
rhythmic body movements
preoccupied by objects
that revolve, such as a
fan, the swirling water
in the toilet bowl,
or a spinning top.
▪
Abnormal responses to sensory
stimuli
-
intense
reactions
to
minor changes in the
environment
(perhaps
screaming if a toy box
Labile
mood
(crying
occurs suddenly and is
followed immediately by
giggling or laughing)
Specific,
intellectual
abilities
limited
problem-solving
-
long-term
memory
and
“savant”
skills
(exceptional
skills
such as virtuoso piano
playing)
may
be
excellent
-
Autistic children may be
able to recall dates and
spoken
words
from
conversations that took
place years before
-
majority
of
children
with autistic disorder
have an IQ of less than
70
Stereotyped behaviors such as
hand gestures
-
Hitting, head banging,
and biting also may be
present.
Inappropriate or decreased
emotional expressions
Aphasia:
to
name
Stereotyped or repetitive use
of language
-
▪
play
make
the
-
Parents report:
-
across
DIAGNOSIS
Diagnosis is often not made until 2 to
3 years after symptoms are first
recognized.
Parents of autistic children
reported their child showed
interest in social interaction
have
less
(e.g., abnormal eye contact, decrease
response
to
own
name,
decrease
imitation, usual repetitive
behavior) and had verbal and motor
delay.
Any child who does not display
language skills such as babbling
orgesturing by 12 months old, single
words by 16 months old, and two-word
phrases
by
24
months
old
is
recommended for immediate hearing and
language evaluation.
6. Speech
therapy,
sensory
integration therapy, exercise,
and physical therapy
7. No cure
NURSING INTERVENTIONS
1. Institute safety measures when
appropriate.
2. Provide positive reinforcement.
3. Encourage development of selfesteem.
4. Encourage self-care.
5. Prepare the child for change by
telling him about it.
MANAGEMENT
1. Structured treatment plan
A day care program can help to promote
social awareness.
Some children may eventually reach a
point where they can become passively
involved in loosely structured play
groups.
2. Behavioral, educational,
psychological techniques
and
Behavior modification therapy may be
effective in controlling some of the
bizarre mannerisms that accompany
autism, but, because the basic cause
of the disorder is not known, therapy
will not always succeed.
3. SSRIs
(selective
serotonin
reuptake inhibitors) have been
tried because of their potential
to alleviate anxiety and reduce
behavioral
rigidity
no
medications specific for autism
are
as
yet
effective.Pleasurable
sensory
and motor stimulation
4. Nutritional
therapy
(food
intolerance,
allergies,
or
vitamin
deficiencies
may
contribute
to
behavioral
issues)
5. Monitor activities (for safety
purposes)
6. Help family members to develop
strong one-on-one relationships
with the patient.
7. Monitor the patient’s response
to
treatment,
adversedrug
reactions, behavior patterns,
nutritional
status,
social
interaction,
communication
skills, and activity.
Health
Problems
Preschoolers
Common
In
INTRODUCTION
The preschool period traditionally
includes ages 3 to 6years. Although
physical growth slows considerably
during this period, personality and
cognitive growth continue at a rapid
rate. This is also an important period
of growth for parents. They may be
unsure about how much independence and
responsibility for self-care they
should allow their preschooler. Most
children of this age want to do things
for
themselves—choose
their
own
clothing and dress by themselves, feed
themselves completely, wash their own
hair, and so forth. As a result,
parents of a preschooler may find
their child dressed in one red sock
and one green sock, going to preschool
with unwashed ears, or trying to eat
soup
with
a
fork.
They
need
reassurance that this behavior is
typical as it is the way that children
adjust to new experiences. Parents may
also need some guidance in separating
those
tasks
a
preschooler
can
accomplish independently from those
that
still
require
some
adult
supervision so they can set sensible
limits. Setting limits this way
protects
children
from
harming
themselves
or
others
while
participating in all the interesting
experiences available to them
ASTHMA
Asthma
is
an
immediate
hypersensitivity (type I) response, a
non-communicable
chronic
lung
disease, characterized by the 1.)
Airway
inflammation.
2.)
Airway
obstruction mainly due to muscle
spasm, associated with mucosal edema
and stagnation of the mucus. 3.)
Airway
hyper-reactivity
to
aerobiological irritants.
●
It is the most common chronic
illness in children, accounting
for a large number of days of
absenteeism from school and many
hospital admissions each year.
●
Occur initially before 5 years
of age
●
Asthma
tends
to
occur
in
children with atopy or those who
tend to be hypersensitive to
allergens.
●
Mast cells release histamine and
leukotrienes that result in
diffuse
obstructive
and
restrictive
airway
disease
because
of
a
triad
of
inflammation,
bronchoconstriction,
and
increased mucus production.
ETHIOLOGY
1. Host factors
Genetic; Genes predisposing to airway
hyper responsiveness
Sex: More in males 2:1
2.
Environmental factors
a. Allergens
allergen.
Sensitization
to
Indoor – house dust, omestic mites,
furred animals (dogs, cats, mice),
cockroach allergens, fungi, molds,
yeasts.
Outdoor
yeasts.
–
Pollens,
fungi,
b. Seasonal factors:
to cold air
molds,
exposure
Seasonal variation of asthma attacks
is experienced by 35% of children.
c. Diet: certain foods also
trigger it ( peanuts, eggs,
wheat).
d. Pollutants
(particularly
environmental tobacco smoke,
mosquito coil smoke, sprays,
perfumes etc).
3. Respiratory (viral) infections
4. Psychosocial factors
5. Drugs (aspirin, beta blockers)
Older children sitting upright with
shoulders in a hunched-over position,
hands on the bed or chair,
Bronchial constriction occurs because
of stimulation of the parasympathetic
nervous system (cholinergic mediated
system),
which
initiates
smooth
muscle constriction.
and arms braced (tripod)
Chest
Inflammation and mucus production
occur because of mast cell activation
to release leukotrienes, histamine,
and prostaglandins.
ASSESSMENT
Clinical manifestations
▪
Hyperresonance
percussion
▪
Coarse, loud breath sounds
▪
Wheezes
throughout
lung fields
▪
Prolonged expiration
▪
Crackles
▪
Generalized
inspiratory
and expiratory wheezing;
increasingly high pitched
Classical manifestations are:
Cough
–
Hacking,
paroxysmal,
irritative, and nonproductive
Becomes rattling and productive
frothy, clear, gelatinous sputum
of
Copious secretion
Dyspnea
exhaling
-
Increasing
difficulty
Wheezing(+)
audible
wheezes
wheezing (the sound caused by air
being pushed forcibly past
obstructed
the
With Repeated Episodes
▪
Barrel chest
▪
Elevated shoulders
▪
Use of accessory muscles of
respiration
▪
Facial
appearance—
flattened malar bones, dark
circles beneath the eyes,
narrow
nose,
prominent
upper teeth
bronchioles)
Respiratory-Related Signs
on
DIAGNOSIS
1. HISTORY TAKING:
▪
Shortness of breath
▪
Prolonged expiratory phase
▪
Audible wheeze
▪
May have a malar flush and red
ears
●
What the child was doing at
the time of the attack
▪
Lips deep, dark red color
●
▪
May progress to cyanosis of nail
beds or circumoral cyanosis
What actions were taken by
the parents or child to
decrease
or
arrest
the
symptoms.
▪
Restlessness
●
▪
Apprehension
▪
Prominent sweating as the attack
progresses
Does the child have a
troublesome cough which is
particularly worse at night
or on waking?
Assessment should include a thorough
history of the development of a
child’s symptoms
●
Is the child awakened by
coughing
or
difficult
breathing?
●
Has the child had an attack
or recurrent episode of
wheezing
(high-pitched
whistling
sounds
when
breathing out)?
●
●
Does the child cough or
wheeze
after
physical
activity (like games and
exercise)
or
excessive
crying?
Does the child experience
breathin problems during a
particular season?
2. PHYSICAL ASSESSMENT:
●
Low vital capacity (air
that they are able to
exhale) or the capacity may
be normal, but, because of
narrowed bronchioles as a
result of bronchospasm
●
expiratory rate will be
abnormally long (more than
10 seconds, rather than the
normal 2 or 3 seconds).
●
Increased total lung
residual capacities.
●
Decreased peak flows and
forced expiratory volume in
1 second
and
●
PEAK FLOW METER
▪
Dyspnea,
▪
Expiratory wheeze
▪
Accessory muscle movement
▪
Difficulty
in
feeding,
talking, getting to sleep
▪
Irritability to Cough
▪
Eczema, Allergic Rhinitis
▪
Hyper-resonant
percussion
lungs
-child then places the meter in the
mouth and blows out as hard and fast
as possible
- repeats two more times and records
the highest number achieved as the
peak flow meter result
upon
3. CHEST X-RAY:
●
Chest
X-ray
may
show
hyperinflation with areas
of focal atelectasis.
●
It is needed only when the
diagnosis is not clear or
any
complications
are
suspected.
4. ARTERIAL
BLOOD
GAS
(ABG)
ANALYSIS reveals hypoxemia.
●
●
oxygen saturation monitored
by a pulse oximeter will
begin to decrease
increased PCO2 level
5. COMPLETE
BLOOD
COUNT
with
differential
shows
increased
eosinophil count.
6. PULMONARY FUNCTION STUDIES
MANAGEMENT
1.
Identification and avoidance of
precipitating factor
▪
avoidance of the
environmental control
allergen
▪
skin
testing
hyposensitization
to
allergen
by
and
identified
2.
Establishment and maintenance of
patent airway
Oxygen therapy : Give oxygen to keep
oxygen saturation > 95% in all
children with asthma who are cyanosed
(oxygen saturation ≤ 90%) or whose
difficulty in breathing interferes
with
talking,
eating
or
breastfeeding.
3.
PHARMACOTHERAPY
●
MILD PERSISTENT
COTICORSTERIODS
ASTHMA-
DAILY
Inhaled
anti-inflammatory
corticosteroid such as fluticasone
(Flovent) daily
●
MODERATE PERSISTENT symptomsDAILY CORTICOSTEROIDS + LONG-ACTING
BRONCHODILATORS
usually are prescribed a long-acting
bronchodilator at bedtime in addition
to
the
inhaled
anti-inflammatory
daily corticosteroid
●
SEVERE
PERSISTENT
asthma
symptom- DAILY CORTICOSTEROIDS + LONG
ACTING BRONCHODILATORS + SHORT-ACTING
BETA-2–AGONIST BRONCHODILATOR
take a high dose of both an oral
corticosteroid
and
an
inhaled
corticosteroid daily as well as a
long-acting
bronchodilator
at
bedtime.
albuterol or terbutaline - use if an
attack should begin
Cromolyn
sodium
prevent
bronchoconstriction
and
thereby
prevent the symptoms of asthma
Quick relievers: Used for acute
attacks to relieve bronchospasm as and
when needed.
▪
Salbutamol
▪
Terbutaline
▪
Adrenaline
▪
Aminophylline
Preventers: Used for long-term
control the inflammation and
prevent further attacks.
Long-term symptom relievers: Used to
relieve
bronchospasm
for
longer
hours.
▪
Salmeterol
▪
Formoterol
▪
Bambuterol
inhaled Steroids
Always
use
with
4.
IV THERAPY Intravenous line is
established
to
supply
continuous
fluid therapy to address dehydration
and also provide a route for emergency
drug administration
NURSING DIAGNOSIS
Nursing Diagnosis: Fear related
sudden onset of asthma attack
to
Outcome Evaluation: Parents and child
express confidence in their ability to
prevent
attacks
and
effectively
manage any that occur.
Nursing
Diagnosis:
Health-seeking
behaviors related to prevention of and
treatment for asthma attacks
Outcome Evaluation: Parents and child
accurately state triggers that cause
an
attack;
child
correctly
demonstrates breathing exercises, use
of inhaler, and peak expiratory flow
meter.
NURSING MANAGEMENT
1.
Educate patient and parents and
must
spend
time
to
clear
the
misconceptions about the disease,
sexual bias, non-communicability of
the
disease,
fear
of
inhalers,
steroids, etc.
to
to
2.
Educate
about
environment
Control - the most important factor in
the control of asthma.
▪
Steroids (Oral and Inhaled) like
prednisolone.
The aim should be to avoid allergens
and irritants:
▪
▪
Dust mites: Avoid carpets, use
plastic
covers
to
pillows
and
Theophylline
mattresses; and expose to sunlight
once
a
week;
wash
soft
toys
periodically;
and
wet
mop
the
floorings.
▪
Cockroach: Cover
unused food containers.
garbage
and
▪
Clear liquids in small amounts.
▪
Allergic foods to be avoided.
▪
Spicy and gas forming foods to
be avoided
▪
Balanced diet.
▪
Fungus: Attend to damp walls,
have good ventilation and clean the
shower curtains weekly.
7.
Maintenance
measures:
▪
Pets:
Keep
them
away
from
sleeping area, if possible outside the
house
▪
Dust
and
environment.
▪
Avoid
strong
odors,
smoke,
mosquito coil burning, and especially
tobacco smoke.
3.
Evaluate respiratory status and
patient’s general condition
▪
Frequent
assessment
respiratory pattern.
of
▪
▪
of
hygienic
Routine hygiene care.
allergen
free
Aseptic technique.
8.
Provide emotional support: Calm
and
quiet
approach,
trusting
relationship,
reassurance
and
maintain parental participations in
planning treatment and education
▪
Cyanosis
URINARY TRACT INFECTION
▪
Breath sounds
▪
vital signs
–
UTI occurs more often in females
than in males at a rate of about 8% to
2%.
▪
Cerebral functions
4.
Allow and assist patient in
proper
positioning
during
acute
attack
▪
Comfortable sitting position and
supporting with pillow.
▪
Leaning forward with support and
raise
their
shoulders
to
give
themselves more breathing space
▪
Do not urge children to “lie down
and relax,” as this can cause severe
anxiety and increased difficulty in
breathing.
▪
Administering oxygen
5.
Facilitate
fluid therapy:
Administration
of
–
Urethra is shorter in female,
and located close to the vagina.
vagina
(allowing
the
spread
of
vulvovaginitis) and close to the anus,
from which E. coli spread.
–
Pathogens enter
the urinary
tract most often as an ascending
infection from the perineum
–
E. coli most common pathogens, a
gram-negative rod.
ASSESSMENT
Typical symptoms that occur in older
children or in adults
▪
pain on urination
▪
frequency
▪
burning
▪
Vomiting and insensible loss due
to hyperventilation.
▪
hematuria—may not be present.
▪
▪
low-grade fever
▪
mild abdominal pain
▪
During
fluid.
asthma
they
take
less
Maintain input output chart
6.
Maintain
intake:
adequate
dietary
Cystitis
▪
enuresis (bedwetting).
clean-catch specimen for culture or
microscopicanalysis.
Pyelonephritis
▪
high fever,
▪
abdominal or flank pain
▪
Vomiting
▪
1.
2.
A
mild
analgesic,
acetaminophen (Tylenol),
reduce pain in voiding.
such
as
may help
NURSING INTERVENTION
Malaise
Any child with a
fever
and
no
demonstrable cause
on
physical
examination should
be evaluated for
UTI (Wan, Liu, &
Chen, 2007).
1.
Educate on the need to drink a
large quantity of fluid to “flush” the
infection out of the urinary tract.
DIAGNOSIS
3.
Emphasize
treatment
with
antibiotics must be continued for the
full prescription or the infection
will return.
Urine analysis
(+) BACTERIURIA - bacterial colony
count is more than 100,000/mL.
(+) Proteinuria - because
presence of bacteria.
of
the
(+) Red blood cells (hematuria)
because of mucosal irritation.
2.
If
the
child
experiences
moderate to severe pain on urination
that interferes with the ability to
void, suggest that the child sit in a
bathtub of warm water and void into
the water.
Prevention
1.
Changing diapers frequently can
help reduce the risk for infection in
infants.
Elevated pH- presence of red or white
blood cells and bacteria tends to make
urine more alkaline.
2.
Girls should be taught early
(when they are toilettrained) to wipe
themselves from front to back after
voiding
2.
Urine culture - collected by a
clean-catch
technique,
suprapubic
aspiration, or catheterization, so
that bacteria from the vulva or
foreskin do not contaminate the sample
and give a false reading.
and defecating to avoid contaminating
the urethra.
MANAGEMENT
1.
Anti-biotic
therapy:
oral
administration
of
an
antibiotic
specific to the causative organism
that is cultured
After recurrent UTIs, children may be
prescribed a prophylactic antibiotic
for 6 months
periodic health checkups for the next
few years, a child should void a
3.
Minimize use of bubble bath,
feminine hygiene sprays, and hot tubs
and UTI in girls
4.
Infection also often
occurs
after sexual intercourse. Teach both
adolescent males and females to void
after sexual intercourse.
5.
UTIs need vigorous treatment in
childhood so they do not spread to
involve the kidneys (pyelonephritis).
6.
Referral to a urologist to
determine
whether
they
have
a
congenital anomaly such as urethral
stenosis
or
bladder–ureter
for
recurrent UTI
ATTENTION
DISORDER
DEFICIT
HYPERACTIVITY
●
Behavioral problem characterized
by
difficulty
with
inattention,
impulsivity,
hyperactivity,
and
boredom
●
The most common neurobehavioral
disorder of childhood
●
Difficult to diagnose before age
4 or 5; some patients not diagnosed
until adulthood
●
Varied symptoms
●
Occurs in 3% to 7% of school-age
children
●
Affects males three
times more commonly than
to
●
females
●
Also called ADHD and ADD
four
The disorder is characterized by three
major
behaviors:
inattention,
impulsiveness, and hyperactivity
1.
Inattention
makes
children
unable to complete tasks effectively.
become easily distracted and often may
not seem to listen.
2.
Impulsieness causes them to act
before they think and therefore to
have difficulty with such tasks
as
awaiting turns at games
3.
Hyperactivity,
children
may
shift excessively from one activity to
another,
exhibiting
excessive
or
exaggerated muscular activity, such
as excessive climbing onto objects,
constant fidgeting, or aimless or
haphazard running.
Alleles of dopamine genes may alter
dopamine transmission in the neural
networks.
During fetal development, bouts of
hypoxia
and
hypotension
may
selectively damage neurons located in
some of the critical regions of the
anatomical networks.
ASSESSMENT FINDINGS
1.
Impulsive behavior
2.
Inattentiveness
3.
Disorganization in school
4.
Tendency to jump quickly from
one
partly
completed
project,
thought, or task to another
5.
Difficulty meeting deadlines and
keeping track of school or work tools
and materials
6.
Symptoms of inattention
–
Makes careless mistakes
–
Struggles to sustain attention
–
Fails to finish activities
–
Difficulty with organization
–
Avoids
tasks
that
sustained mental effort
require
–
Distracted or forgetful
7.
Symptoms of hyperactivity
–
Fidgets
–
Can’t sit still for sustained
period
–
Difficulty playing quietly
ETHIOLOGY
–
Talks excessively
Although the cause is unknown, it
occurs more frequently among some
families
than
in
the
general
population, indicating a possible
genetic etiologic component ADHD has
also been associated with child
neglect, lead poisoning, and drug
exposure in utero
8.
Symptoms of impulsivity
–
Interrupts
–
Can’t wait patiently
DIAGNOSIS
The Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition,
Text
Revision
criteria;
criteria confirming diagnosis:
these
●
Six symptoms or more from the
inattention or hyperactivity●
impulsivity categories
●
Symptoms present for at least 6
months
●
7
Some symptoms evident before age
●
Some impairment
present in two or
●
from
Pharmacologic therapy:
a.
Stimulants for core
(first-line treatment):
symptoms
clinically
Acts paradoxically in children with
ADHD,
possibly
by
stimulating
dopamine receptors to calm rather than
stimulate activity
or
●
Symptoms aren’t accounted for by
another mental disorder
Complete psychological, medical, and
neurologic evaluations rule out other
problems;
specific
tests
include
continuous performance test, behavior
rating
scales,
and
learning
disability.
TREATMENT
Treatment of ADHD depends on the
child's age and severity of symptoms.
Evidence supports behavioral therapy
as the first-line treatment, but other
approaches include family education
and counseling, medication, proper
classroom placement, environmental
manipulation, and psychotherapy for
the child.
Behavioral therapy:
–
focuses on the
undesired behavior.
2.
Methylphenidate
hydrochloride
(Ritalin,
Concerta)
and
dextroamphetamine
●
social,
academic,
occupational functioning
1.
–
Through collaborative teamwork
parents learn techniques to help the
child become more successful at home
and in school.
symptoms
more settings
●
Clear evidence of
significant impairment in
behaviors,
and
providing
ageappropriate consequences (e.g., timeout, response cost). \
prevention
of
–
Families are helped to identify
new appropriate contingencies and
reward systems to meet the child's
developing needs. They may also
receive
instruction
in
effective
parenting skills, such as delivering
positive
reinforcement,
rewarding
small
increments
of
desired
monitored carefully for side effects
of the medication:
–
appetite loss
–
abdominal pain
–
headaches
–
sleep disturbances
–
growth velocity.
DO NOT ADMINISTER: History
of tic-like behavior, family history
of Tourette syndrome and ADHD with TS
b.
Tricyclic
antidepressants
(second-line treatment)
Considered after the failure of two or
three stimulants
May be used as adjunct therapy for
ADHD, primarily for children with
coexisting conditions, such as sleep
disturbances
c.
Non-stimulant
medications,
including
norepinephrine
reuptake
inhibitors and adrenergic agonists,
have also shown to be effective with
fewer side effects in school-age and
adolescent children
3.
Environmental manipulation:
–
Encourage families to learn how
to modify the environment to allow the
child to be more successful.
–
Consistency
is
especially
important for children with ADHD.
–
Consistency between families and
teachers in terms of reinforcing the
same goals is essential.
–
Fostering
improved
organizational skills requires a more
highly structured environment than
most children need.
–
Use organizational charts (e.g.,
listing all activities that must be
performed before leaving for school)
and decrease distractions in the
environment
while
the
child
is
completing homework (e.g., turning
off
the
television,
having
a
consistent study area equipped with
needed supplies)
3.
Keep all instructions short and
simple—make one-step requests.---Realistic expectations
4.
Provide praise, rewards, and
positive feedback whenever possible
to reinforcement of good behavior
5.
Provide diversional activities
suited to a short attention span.
6.
Monitor the patient’s activity
level, nutritional status, adverse
drug
reactions,
response
to
treatment, and activity (for safety
purposes).
MENTAL RETARDATION
–
Mental retardation refers to
significantly subaverage general
intellectual
functioning
resulting in or associated with
concurrent
impairments
in
adaptive behavior & manifested
during the developmental period
–
About 3% of the world population
is estimated to be mentally
retarded.
–
Mental
retardation
is
more
common in boys than girls.
–
With severe & profound mental
retardation mortality is high
due
to
associated
physical
disease.
–
The child should be encouraged
to make more appropriate choices and
to take responsibility for their
actions.
4.
Appropriate classroom placement.
–
Children with ADHD need an
orderly, predictable, and consistent
classroom environment with clear and
consistent rules
5.
Education regarding the nature
and effect of the disorder
6.
Supportive psychotherapy
7.
Trial elimination of sugar,
dyes, and additives from diet may
result in change
8.
Monitor
purposes)
activity
(for
safety
9.
Mood
stabilizers
for
the
treatment of co-existing conditions
such as bipolar disorder
10.
Referral for family therapy
NURSING INTERVENTIONS
1.
Set realistic expectations and
limits.
2.
Maintain a calm and consistent
manner.
ETIOLOGY
Moderate Retardation (IQ 35-50) About
10% of mentally retarded come under
this group.
●
During preschool years, these
children learn to talk and
communicate, but they have only
poor
awareness
of
social
conventions.
●
They can learn some vocational
skills during adolescence or
young adulthood and can learn to
take care of themselves with
moderate supervision.
●
They are unlikely to progress
beyond the second-grade level in
academic subjects.
●
As adults, they may be able to
contribute to their own support
by
performing
unskilled
or
semiskilled work under close
supervision
in
a
sheltered
workshop setting.
●
They may learn to travel alone
to familiar places. They need
supervision and guidance when in
stressful settings.
Classification
Mild Retardation (IQ 50-70 This is
commonest type of mental retardation
accounting for 85-90% of all cases.
●
The category is equivalent to
the category “educable” used by
school systems.
●
During
early
years,
these
children
learn
social
and
communication skills and are
often not distinguishable from
average children.
●
They are able to learn academic
skills up to about the sixthgrade level.
●
●
As adults, they can usually
achieve
social
andvocational
skills adequate for minimum
self-support.
During the preschool period,
these children develop only
minimal speech and little or no
communicative speech.
●
They usually have accompanying
poor motor development.
Severe Retardation (IQ 20-35) Severe
mental
retardation
is
often
recognized early in life with poor
motor development & absent or markedly
delayed
speech
&
communication
skills.
●
They can live independently but
need guidance and assistance
when faced with new situations
or unusual stress.
●
During school years, they may
learn to talk and can be trained
in basic hygiene and dressing
skills.
●
These individuals have minimum
retardation
in
sensory-motor
areas.
●
As adults, they may be able to
perform simple work tasks under
close supervision, but as a
group they do not profit from
vocational training.
●
They need constant supervision
for safety.
Profound Retardation. The IQ of
children in this group is less than
20. Fewer than 1% of cognitively
challenged children fall into this
group.
●
●
●
During the preschool period,
these children show only minimal
capacity
for
sensorimotor
functioning.
They need a highly structured
environment and a constant level
of help and supervision.
Some
children
respond
to
training in minimal self-care,
such as toothbrushing, but only
very
limited
self-care
is
possible.
4. Assessing milestones development
5. Investigations
o
Urine & blood examination
for metabolic disorders
o
Culture for cytogenic
biochemical studies
o
Amniocentesis
in
infant
chromosomal disorders
o
chorionic villi sampling
o
Hearing & speech evaluation
6. EEG, especially if seizure is
present
7. CT scan or MRI brain, for
example, in tuberous sclerosis
8. Thyroid function tests
cretinism is suspected
Assessment
&
when
▪
Failure to achieve developmental
milestones
▪
Deficiency
in
cognitive
functioning such as inability to
follow commands or directions
▪
Failure to achieve intellectual
developmental markers
▪
Reduced ability to learn or to
meet academic demands
1. Behavior management
▪
Expressive or receptive language
▪
Psychomotor skill deficits
3. Monitoring
the
child’s
development needs & problems.
▪
Difficulty
esteem
▪
Irritability when frustrated or
upset
performing
▪
Depression or labile moods
▪
Acting-out behavior
▪
Persistence
behavior
▪
Lack of curiosity.
of
self-
infantile
DIAGNOSIS
1. History collection from parents
& caretakers
2. Physical examination
3. Neurological examination
9. Psychological
tests
like
Stanford
Binet
Intelligence
Scale & Wechsler Intelligence
Scale for Children’s (WISC), for
categorizing the child’s level
of disability.
TREATMENT MODALITIES
2. Environmental supervision
4. Programs that maximize speech,
language,
cognitive,
psychomotor, social, self-care,
& occupational skills.
5. Ongoing
evaluation
for
overlapping
psychiatric
disorders, such as depression,
bipolar disorder, & ADHD.
6. Family therapy to help parents
develop coping skills & deal
with guilt or anger.
7. Early intervention programs for
children younger than 3 with
mental retardation Provide day
schools to train the child in
basic skills, such as bathing
NURSING INTERVENTIONS
1. Determine the child’s strengths
& abilities & develop a plan of
care to maintain & enhance
capabilities.
2. Monitor
the
child’s
developmental levels & initiate
supportive interventions, such
as
speech,
language,
or
occupational skills as needed.
3. Teach him about natural & normal
feelings & emotions.
4. Provide for his safety needs.
5. Prevent self-injury. Be prepared
to intervene if self-injury
occurs.
6. Monitor the child for physical
or emotional distress.
7. Teach the child adaptive skills,
such
as
eating,
dressing,
grooming & toileting.
8. Demonstrate & help him practice
self-care skills.
9. Work to increase his compliance
with conventional social norms &
behaviors.
10.
Maintain a consistent
supervised environment.
&
11.
Maintain
adequate
environmental stimulation.
12.
et supportive
activities.
limits
on
13.
Work to maintain & enhance
his positive feelings about self
& daily accomplishments.
PROGNOSIS
The prognosis for children with metal
retardation
has
improved
&
institutional care is no longer
recommended.
These
children
are
whenever
feasible
&
survival skills.
mainstreamed
are
taught
A multidimensional orientation is
used when working with these children,
considering
their
psychological,
cognitive,
social
development.
&
emotional
Summary
Parent–infant
bonding
can
be
difficult to establish when a child is
hospitalized at birth. Assess family
relationships at health maintenance
visits
to
see
that
bonding
is
occurring.
Cleft lip and palate result from the
failure of the maxillary process to
fuse in intrauterine life. Surgical
repair is possible early in life, with
a good prognosis for both these
conditions.
Imperforate anus is stricture of the
anus, resulting in inability to pass
stool. The infant may have a temporary
colostomy created before a final
surgical correction can be completed.
Physical developmental disorders of
the
nervous
system
include
hydrocephalus (excess cerebrospinal
fluid in the ventricles) and spina
bifida (incomplete closure of the
spinal
cord).
Infants
with
hydrocephalus need surgery to relieve
a ventricular obstruction or have a
shunt implanted from their ventricles
to the peritoneal cavity to remove
excess cerebrospinal fluid. Children
with
myelomeningocele,
the
most
severe form of neural cord disorder,
face permanent loss of lower neuron
function
and
require
continued
rehabilitation.
Asthma, a type I hypersensitivity
reaction, is a diffuse and obstructive
airway disease with wheezing as the
most common symptom. Newer drugs such
as leukotriene receptor antagonists
and careful environmental control
have aided in the management of this
disorder
Urinary tract infection tends to occur
more often in girls than boys.
“Honeymoon cystitis” refers to a
urinary tract infection occurring
with first-time sexual intercourse
Otitis media (middle ear infection) is
a common childhood illness. Some
children who have otitis media with
effusion
have
myringotomy
tubes
inserted to relieve pressure and
supply air access to the middle ear.
Children need total body assessment
after
an
unintentional
injury,
because they may be unable to describe
other injuries besides the primary one
they have suffered
Common substances children swallow
that result in poisoning include
acetaminophen
(Tylenol),
caustic
substances, and hydrocarbons. Teach
parents to keep the number of the
local poison control center next to
their telephone and always to call
first
before
administering
an
antidote for poisoning.
Lead poisoning most frequently occurs
from the ingestion of paint chips in
older housing units. Preventing this
is a major nursing responsibility.
Burns
are
classified
as
mild,
moderate, and severe and can be
divided
into
three
types—first,
second, and third degree—depending on
the depth of the burn. Burns produce
systemic body reactions and require
long-term nursing care.
For children who are cognitively
challenged, a stigma still may be
present in many communities, although
less so than previously. Parents may
have a more difficult time accepting
this diagnosis in their child than
they would a physical illness. Help
parents to gain the insight that
cognitive challenges occur in a
proportion
of
infants
in
every
population and that having a child
with this problem merely reflects a
chance occurrence.
Child abuse can exist in many forms.
It may be physical,emotional, or
sexual and may encompass neglect. A
high suspicion for child abuse should
be present if burns,head injury, or
rib fractures are present or if the
history ofthe accident seems out of
proportion to the injury.
Mental health disorders often begin
subtly in children and are often first
manifested as behavior problems in
school. Assess thoroughly any child
who
is
referred
for
disruptive
behavior in a school class for the
possibility that the child has a
serious mental health problem.
Autistic disorder is a pervasive
developmental disorder that has a
syndrome
of
behaviors,
including
fascination with movement, impairment
of
communication
skills,
and
insensitivity to pain.
Attention-deficit
and
disruptive
behavior
disorders,
such
as
oppositional
defiant
and
conduct
disorders, may occur in childhood.
Children with ADHD may be treated with
methylphenidate
hydrochloride
(Ritalin, Concerta) to reduce the
hyperactivity and allow them to
achieve better in school and interact
successfully at home