Exam 2 Study Guide
Chapter 26 – Respiratory Condi3ons of Childhood
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Distinguish between clinical manifestations of various respiratory conditions
Respiratory system overview
Normal physiology
Essential functions
o Ventilation
o Oxygenation
o Removal of waste gases
o Protection of airway from harm, infections
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Nursing assessment (Box 26.1)
o Review of systems: Cough, Wheeze, Cyanosis, Chest Pain, Sputum Production, Halitosis
Respiratory distress identification, management (Box 26.1)
Anatomical differences in childhood
o Normal 4 mm in diameter
o Edema 1 mm significant closer
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Respiratory infec3ons
-
Very common in childhood
Infectious agents
o Most infections caused by viruses
Age
o Characteristics of infection often vary by age
Size
o Anatomic differences
Resistance
Seasonal variations
Clinical manifesta3ons (esp. Box 26.1)
- Fevers:
o May be absent in neonates (<28 days)
o Greatest at ages 6 months to 3 years
o Temperature may reach 103° to 105 °F (39.5° to 40.5°C) even with mild infecOons
o OQen appears as first sign of infecOon
o May leave child listless and irritable or somewhat euphoric and more acOve than
normal, temporarily; leads some children to talk with unaccustomed rapidity
o Tendency to develop high temperatures with infecOon in certain families
o May precipitate febrile seizures (see Chapter 30)
- Meningismus:
o
o
o
Meningeal signs without infection of the meninges
Occurs with abrupt onset of fever
Accompanied by
• Headache
o
-
Anorexia:
o
o
o
-
Small nasal passages of infants easily blocked by mucosal swelling and exudation
Can interfere with respiration and feeding in infants
May contribute to the development of otitis media and sinusitis
Nasal Discharge
Common feature
May be thin and watery (rhinorrhea) or thick and purulent
Depends on the type and stage of infection
Associated with itching
May irritate upper lip and skin surrounding the nose
Cough:
o
o
o
-
Common complaint
Sometimes indistinguishable from pain of appendicitis in older child
May be caused by mesenteric lymphadenitis
May represent referred pain (e.g., chest pain associated with pneumonia)
May be related to muscle spasms from vomiting, especially in nervous, tense children
Nasal congesOon / rhinorrhea:
o
o
o
o
o
o
o
o
o
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Usually mild, transient diarrhea, but may become severe
Often accompanies viral respiratory tract infections
Abdominal pain:
o
o
o
o
o
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Occurs readily in small children with illness
A clue to the onset of infection
May precede other signs by several hours
Usually short lived but may persist during the illness
Is frequent cause of dehydration
Diarrhea:
o
o
-
Common with most childhood illnesses
Frequently the initial evidence of illness
Persists to a greater or lesser degree throughout febrile stage of illness; often extends
into convalescence
VomiOng:
o
o
o
o
o
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• Pain and stiffness in the back and neck
• Presence of Kernig and Brudzinski signs
Subsides as the temperature drops
Common feature
May be evident only during the acute phase
May persist several months after a disease
Respiratory sounds:
o
Sounds associated with respiratory disease:
• Cough
o
-
• Hoarseness
• Grunting
• Stridor
• Wheezing
Findings on auscultation:
• Wheezing
• Crackles
• Absence of air movement
Sore throat:
o
o
o
o
Frequent complaint of older children
Young children (unable to describe symptoms) may not complain even when highly
inflamed
Increased drooling noted by parents
Refusal by child to take oral fluids or solids
Nursing care of child with respiratory tract infec3on (pp. 875 – 877)
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Ease respiratory efforts
• oxygen supplementation, HUMIDIFICATION- soothe inflamed mucosa, suctioning
Promote rest and comfort
• hydration, pain relief, fever support
Prevent infection spread
Reduce body temperature
Promote hydration and nutrition
Provide family support and teaching
Observe for deterioration
NO cold remedies should be used in children
Acute Viral Nasopharyngi3s (common cold)
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-
-
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Pathophysiology (common causes)
o Rhinovirus
o Respiratory syncytial virus (RSV)
o Adenovirus
o Influenza / Parainfluenza
Diagnostic evaluation
Clinical manifestations
o Based on age
o Cough is Protective*
Therapeutic management
o Promote hydration, rest, comfort
o Symptom management (e.g., fevers)
o Avoid OTC cough suppressants
• Limited evidence of effectiveness of OTC cough/cold preps for <6 years old
Nursing care management
§ Evidence of early complications (Box 26.3)
Pharyngi3s
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-
-
-
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Pathophysiology (common causes)
o Group A beta-hemolytic streptococci (GABHS)
o
Diagnostic evaluation
o Diagnosed by rapid swab or culture
• 80-90% of cases of acute pharyngitis are viral
Clinical manifestations
o Sore throat
o Cervical lymphadenopathy
o Headache
o Fever
o Abdominal pain
o Exudate
o Palatal petechiae
o Strawberry tongue
o Scarlet fever is a sand papery rash
o Brief illness varying in severity from asymptomatic to severe
o Complications: sinusitis, abscess
Therapeutic management
o PCN x 10days
o Analgesics
o Antipyretics
o Saline gargles
Nursing care management
o Carriers may have +culture in setting of another virus, rarely need therapy; minimal
transmission to others
o
Tonsilli3s
- InflammaOon of the tonsils
- TonsilliOs oQen occurs with pharyngiOs
- ManifestaOons
o Edema, enlargement of the tonsils
o Sore throat
o Difficulty swallowing and breathing
o Tender lymph nodes
o May be viral or bacterial in eOology
- Treatments include anObioOcs for GABHS, analgesia, surgery in some cases
Tonsillectomy and adenoidectomy (Post-op care)
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Assessment
o Inspect secreOons and emesis
o S/S of bleeding (tachycardia, pallor, bright red blood in emesis, frequent
swallowing or throat clearing)
o S&S of respiratory distress (agitaOon, stridor, drooling)
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Intervention
o
o
o
o
o
o
Abdomen/side lying unOl fully awake
Avoid/limit sucOon
Discourage coughing/clearing throat/blowing nose
Ice collar
Administer: analgesics, anOemeOcs
SucOon & O2 at bedside
o Restart clears when awake, not bleeding
§ SoQ diet
§ Avoid red foods, straws, cream based unOl toleraOng clears
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Discharge Teaching
o ***Bleeding risk 5-10 days post-op
o Proper fluid and foods
o Rest
o Nothing in the mouth, straws etc.
o Pain control
Influenza
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-
-
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Pathophysiology
o Influenza (flu) is a contagious respiratory illness spread by droplets and contact
o Two main types of influenza viruses: A & B
o Influenza type C: asymptomatic or mild respiratory illness
o Antigenic shift/drift
Diagnostic evaluation
o Diagnosed by nasal swab
Clinical manifestations (compared to cold, COVID, allergies)
o Range of severity from asymptomatic to severe disease
o Sudden onset
o Complications in children Young children are at higher risk for developing serious flu
related complications, Children <5years, Especially infants and toddlers (<2years old)
o Pneumonia (often hemorrhagic)
o Febrile seizures
o Exacerbation of known health conditions like heart disease or asthma
o Encephalopathy / Encephalitis
o Secondary bacterial infections (OM, myocarditis, sinusitis)
Therapeutic management
o Treatment depends on age and severity
o Rest, hydration, ease symptoms
o Antipyretics
o Analgesics
o Antiviral medication
o Oseltamivir (>2wks old) most effective when given within 48 hours of symptom onset
o 5-day course
o Ibuprofen more helpful d/t muscle aches
o Oseltamivir – for infants and children
o Yearly vaccine reduce risk
Nursing care management (Important considerations)
o Special care is needed to prevent flu infections in infants ≤6 months
o Avoid contact (including feeding) with anyone with flu or flu-like symptoms
o If exposure occurs, notify provider
o Breastfeeding considerations:
o Mother is not infected – direct breastfeeding encouraged
o
o
Mother is infected – pumping, bottle-feeding by healthy caregiver is ok
No flu vaccine under 6 months
Ear infec3ons
The most common trigger of ear infecOons in children is an upper respiratory infecOon such as a
cold, the flu, or strep throat
In infants and children, the eustachian tube is prone to becoming obstructed due to swelling
and inflammaOon that accompanies URIs and other respiratory condiOons (like allergies) à
poor venOlaOon of middle ear à moist, warm environment à infecOon
Middle Ear infec3on (O33s Media)
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Pathophysiology
o Otitis media is the presence of fluid within the middle ear along with s/s of middle ear
inflammation
o Often preceded by viral respiratory illness
o Acute otitis media (AOM) vs. otitis media with effusion (OME)
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§ AOM is fluid in middle ear with presenting signs and symptoms of illness
§ OME is middle ear fluid without signs of acute infection
Risk factors AOM
o Young age
o Genetic or familial history of AOM
o Craniofacial anomalies (e.g., cleft lip, palate)
o Poor access to primary healthcare
o Low socioeconomic status
o Exposure to tobacco smoke
o Having older siblings
o Day-care attendance
o Use of a pacifier
o Protective factor: breastmilk fed
-
Diagnostic evaluation
Clinical manifestations
o Acute otitis media
§ Preceded by upper respiratory infection
§ Otalgia (earache)
§ ± Fever
§ ± Otorrhea (purulent discharge)
o Chronic otitis media
§ Hearing loss
§ Difficulty communicating
§ Fullness sensation, tinnitus, or vertigo
-
Therapeutic management
o Guidelines emphasize need for accurate diagnosis, pain management, and watchful
waiting in children with non-severe AOM, i.e. delayed prescription for those >6mos with
mild/mod unilateral OM
o Exceptions include:
§ Infants <6 months old
§ Infants 6 months and older with drainage, fever >39, pain for >48 hours,
mod/severe ear pain
§ Bilateral AOM in child 6-23 months old
o Amoxicillin 80-90mg/kg/day divided twice daily for up to 10 days
§ Children 2 years and older: 5 to 7 days
§ Children <2 years and high-risk comorbidities: 10 days
o Supportive care and symptom management includes:
§ Fever reduction
§ Pain management (may include benzocaine ear drops)
§ Decongestants/antihistamines NOT recommended
o Other interventions include external application of heat or cold, promote rest and
hydration
-
-
Complications
o Hearing loss
§ Speech, language, cognitive development impairment
o Tympanic membrane perforation
o Chronic suppurative otitis media
o Cholesteatoma
o Tympanosclerosis
o Mastoiditis
o Labyrinthitis
o Facial paralysis
Nursing care management
§ Medical vs surgical
o Myringotomy – surgical incision of the eardrum to alleviate severe pain, and
drainage of fluid built up in middle ear
o Tympanostomy tube placement (oQen with adenoidectomy)
§ Pressure-equalizing tubes facilitate drainage from middle ear & promote
venOlaOon
Outer ear infec3ons (O3s Externa)
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-
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Pathophysiology
o Infection of the external ear canal most commonly caused by Pseudomonas aeruginosa,
Staphylococcus epidermidis or Staphylococcus aureus
o External ear canal becomes inflamed, irritated, and macerated when exposed during
swimming or increased environmental humidity
o More frequently occurring in 5- to 14-year-olds, esp. in the summer
§ Risk factors
Diagnostic evaluation
Clinical manifestations
o Ear pain with manipulation of the pinna (esp. pressure on the tragus)
o Pain out of proportion with degree of inflammation
o Conductive hearing loss may be present
o Itching
o Edema
o Erythema
o Cheesy green-blue-gray discharge
o Tenderness
o Fever
o Pain can progress to jaw, ear
Treatment
o
o
o
Relieve symptoms, restore normal flora, cerumen, tissue
External ear canal cleaning
Otic medications used to treat infection
-
§ Antibiotics and steroids
o Sterile gauze wick inserted if edema present to help facilitate ear drops to
penetrate deep enough into external ear canal
Prevention and Education
o Use well-fitting ear plugs while swimming
o Thoroughly drying ears after swimming
o Consider ear drop solution with 1-part white vinegar to 1-part isopropyl alcohol (only if
tympanic membrane is intact)
o Avoid temptation to itch or pick affected ear with cotton swab or other objects which
can lead to further damage
Croup syndromes (Table 26.4)
- Croup is a general term applied to a cluster of symptoms characterized by:
o Hoarseness
o Resonant cough (“barky” “brassy” “croupy”)
o Inspiratory stridor (varying degrees)
o Respiratory distress (varying degrees)
o Swelling or obstrucOon in larynx and subglois of upper airway
- Most cases are caused by viruses
Acute epigloQ3s
Medical emergency
Serious obstructive inflammatory process
Most common in children 2- to 5-years-old
Historically caused by H. influenzae
§ Incidence has declined due to availability of Hib conjugate vaccine
§ Now often caused by viruses
Clinical Manifestations
o Abrupt onset, rapidly progressive
o Asymptomatic at bedtime, then…
o Awakened with painful swallowing, sore throat, absent URI symptoms
o Febrile, appears suddenly very sick
o Tripod positioning
o Drooling
o Irritable, restless, anxious/apprehensive, frightened
o “Froglike” croaking on inspiration
o May lead to complete airway obstruction rapidly
o Child does not sound hoarse (unlike with LTB)
o Suprasternal and substernal retractions may be visible
o Better air exchange achieved with slow, quiet breaths
o Mild hypoxia will progress to cyanosis without immediate treatment
o Throat appears red, inflamed
o Epiglottis appears enlarged, cherry red, and swollen
Predictive Signs of Epiglottitis
o
o
o
o
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-
-
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o Absence of spontaneous cough
o Presence of drooling
o Agitation
Key Assessment Considerations
o When epiglottitis is suspected, throat inspection should be performed only when
immediate endotracheal intubation or an emergency tracheotomy can be performed if
needed.
o Don’t do anything that upsets them
o Separate from parents
o IV placement
o Look in the mouth
o Lie them flat
o Cry**
Therapeutic Management
o
o
o
o
o
Priority intervention
o Protect or re-establish airway
o Deliver supplemental oxygen
Diagnostic evaluation to determine underlying cause (e.g., throat culture, once airway
secured)
Administer antibiotics
Administer supportive medications (e.g., corticosteroids) and IV fluids
Prevention with routine immunizations; HiB
Laryngotracheobronchi3s
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Pathophysiology
o Caused by viral infection (esp. parainfluenza viruses, adenoviruses, RSV) and sometimes
bacteria (esp. M. pneumoniae)
o Most common croup syndrome
o Common age 6 mos-3 yrs; rare after age 6 yrs
o
o
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Usually preceded by an upper airway infection, which descends to adjacent structures
Inflammation of mucosal lining of larynx and trachea...leads to narrowing airway
Diagnostic evaluation
Clinical manifestations
o Gradual onset of low-grade fever
o “Barky” “Brassy” “Croupy” cough (see video #2)
o Inspiratory stridor
o Suprasternal retractions
o Hoarseness
o Worse at night and with agitation/crying
o Respiratory distress symptoms:
o Nasal flaring, intercostal retractions, tachypnea, continuous stridor
o Progresses to obstruction, impaired ventilation and respiratory failure
-
• Warning signs
Therapeutic management
Cool mist humidified air – no evidence
Not indicated: Anti-tussive or decongestant · Antibiotics
D/C no stridor at rest
-
Nursing care management
Bronchi3s - esp. respiratory syncy3al virus
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Pathophysiology
o Inflammation of the large airways (trachea and bronchi)
o Frequently associated with URIs
o Most commonly caused by viruses
§ Flu, parainfluenza, coronavirus, rhinovirus, RSV, human
metapneumovirus
§ Bacterial causes include pertussis, M. pnuemoniae, Chlamydia
pneumoniae
Diagnostic evaluation
Clinical manifestations (Box 26.6)
o Usually mild, self-limiting symptoms
o Cough
§ Dry
§ Hacking
§ Nonproductive
§ Worsened at night
§ Lasting > 5 days
§ May persistent for 1 to 3 weeks
-
Therapeutic management
o Symptom management
§ Analgesics
§ Antipyretics
§ Humidified air
§ No other medications are effective
o Consider evaluating teens for vaping, marijuana
-
Nursing care management
§ Oxygen delivery devices
Bronchioli3s
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Pathophysiology
o Acute viral infection mostly caused by respiratory syncytial virus (RSV)
o Also, adenovirus, parainfluenza, human metapneumovirus
o Occurs less frequently in breastfed infants, more frequently in crowded conditions
o
o
o
o
-
Most common cause of hospitalization in children < 2 yrs
Severe RSV in first year sig risk factor for asthma
Spread via direct contact with respiratory droplets
Peak incidence younger than 3 mos
Disease process
o Disease progression leads to inflammation of epithelial lining the small airways
(bronchioles) causing...
§ ↑ Mucus production
§ ↑ Inflammation
§ ↑ Cellular necrosis
RSV
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Hospitalization
o Children younger than 6 months of age with RSV infection may need to be hospitalized
o Likely admission <1 mos
o Poor feeding, lethargy, dehydration, moderate to severe distress, apnea, cyanosis
o Underlying conditions
-
o
o Lung or heart disease
o Prematurity
Hospital Management
o Oxygen (often high flow nasal cannula)
o Frequent oral, nasal, nasopharyngeal suction
o Noninvasive positive pressure ventilation (e.g. CPAP, BiPAP)
o Intubation and mechanical ventilation
o Nasogastric feeds or
o IV fluid / NPO
o AAP does not recommend use of nebulizers (Albuterol, Racemic Epi) or steroids
Home Treatment
Most RSV infections are self-limiting and can be managed at home
o Manage fever and discomfort
o Maintain hydration
o Watch for respiratory distress
SARS-COV-2/COVID-19/MISC
o Clinical manifestaOons similar to other viruses, i.e. flu
o Fever, sore throat, muscle aches, GI upset, headache, malaise
o Also loss of taste/smell, progression to dyspnea
o Severe cases include coagulopathy, cardiac impairment, liver or renal disease,
increased WBC counts
o More likely with preexisOng condiOons, < 1yr, asthma, CLD, oncology,
immunosuppression, anemia, low platelets, CV disease
o TherapeuOc management (hospital-based)
o Remdesivir (MAB therapy) & Dexamethasone
o Key is prevenOon: vaccines, hygiene
MIS-C (MulOsystem Inflammatory Syndrome in Children)
o Hyperinflammatory system occurring 2-4 weeks post COVID-19 infecOon
o Clinical manifestaOons
o Fever plus…any of the following:
o Abd, chest, or neck pain; V/D; injected conjuncOva, redness or swelling of
lips, tongue
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Therapeutic Management
o Vasoactive medications (50%)
o Oxygen/ventilation support (20%)
o Anticoagulation agents
o Steroids
o Immunoglobulin
o Immunosuppressants
o
Antibiotics
Pneumonia
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Pathophysiology
o Viral (most common)
o COVID-19, flu, adenovirus, parainfluenza
o Bacterial
o S. pnuemoniae, M. catarrhalis
o Atypical
o Aspiration (stay tuned)
o Occurs more frequently in infancy and early childhood
o Different pathogens based on age
o May be primary or secondary illness
-
-
Diagnostic evaluation
o Covid Test, Nasal Swab
Clinical manifestations (Box 26.8)
Therapeutic management
o Viral pneumonia is self-limiting, symptom management
o Oxygen, analgesics, antipyretics, monitoring fluid intake
o Bacterial pneumonia is treated with antibiotics and symptom management
o High dose amoxicillin or 2nd/3rd generation cephalosporin
o Atypical pneumonia is treated is with antibiotics and symptom management
-
o Azithromycin, erythromycin
§ Complications: Pleural effusions, Emphysema, Pneumothorax, and AOM
Nursing care management
o Symptom Management
Pertussis (whooping cough)
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-
-
-
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Pathophysiology
o Acute respiratory tract infection caused by Bordatella pertussis
o Primarily in children <4 years old who are not immunized
o Highly contagious
o Highest morbidity, mortality for young infants
Diagnostic evaluation
Clinical manifestations
o Classic whoop
o Apnea (young infants)
o Cough
o Coryza (rhinitis - inflammation of mucosal lining of nose)
o Sneezing
Therapeutic management
o Antibiotics
o Supportive care
o Complications include encephalopathy, seizures, pneumonia, hypoxia, rib
fractures, bleeding into conjunctiva, hernia
o Death risk higher for infants (particularly unimmunized)
Nursing care management
Non-infec3ous respiratory dysfunc3on
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Aspiration - esp. foreign body
Pathophysiology
o Two common types of aspiration in children:
o Foreign body aspiration
o Aspiration pneumonia
Foreign Body Aspira3on
o
o
o
o
o
o
o
80% of FBA occurs in children younger than 3 years
o Peak age: 1-2 years
Majority of FBA are lodged in bronchi
Larynx and trachea less common, higher morbidity and mortality
S/S depend on site of obstruction and time elapsed
Almost 50% of children will be asymptomatic
Able to stand, explore world via oral route, have fine motor skills to put objects in mouth, do
not yet have molars to chew adequately
Small airway diameter prone to obstruction
Laryngotracheal ObstrucOon
o
o
o
o
o
Dyspnea
Cough
Stridor
Hoarseness
Cyanosis
Bronchial ObstrucOon
o
o
o
o
o
Cough (frequently paroxysmal)
Wheezing
Asymmetrical breath sounds
Decreased air entry
Dyspnea
-
Diagnostic evaluation
o Witnessed or reported event
o Onset of coughing
o Unilateral wheezing or decreased aeration
o FB aspiration in mainstem or lower bronchi
o Witnessed event using choking or gagging
o Complete obstruction of trachea or larynx can occur from mechanical blockage
or induced laryngospasm
o History of choking, when asked specifically, found in 80-90% of confirmed
choking cases
o
Clinical Pearls
o Many aspiration events are unwitnessed
o Consider FBA in any infant/toddler with acute onset respiratory distress
o Safest removal is in the OR with appropriate personnel & resources
o Reflexive coughing is likely the most successful mechanism to clear FB
o Minimize interventions
Therapeutic management
Nursing care management
-
-
Aspira3on pneumonia
o An inflammaOon of the lungs due to aspiraOon of a foreign substance
such as food, liquid, vomit, or mucus
o Clinical manifestaOons include
o Increased cough or fever with foul-smelling sputum
o Other signs of lower airway involvement
o Treatment
o AnObioOcs
o Resp support
Conditions that increase risk
ARDS, or Acute Respiratory Distress Syndrome, is an inflammatory lung condiOon involving both
lungs that may complicate severe pneumonia (including influenza), trauma, sepsis, aspiraOon of
gastric contents, and many other condiOons. InflammaOon leads to injury of lung Ossue and
leakage of blood and plasma into the airspaces resulOng in low oxygen levels in the blood.
Mechanical venOlaOon is required both to deliver higher concentraOons of oxygen to and
provide venOlaOon to remove carbon dioxide from the body. InflammaOon in the lung may lead
to inflammaOon elsewhere causing shock and injury or dysfuncOon in the kidneys, heart, and
muscles.
There is no proven drug treatment for ARDS per se. Current management of ARDS begins with
treatment and stabilizaOon of the underlying disease that caused ARDS, such as early and
effecOve anObioOcs for pneumonia or sepsis. The injured lung should be managed gently with
small breaths and low pressures from the venOlator (so called low Odal volume and pressure
venOlaOon). In addiOon, conservaOve use of intravenous fluids combined with removal of excess
fluids with diureOcs lessens the need for mechanical venOlaOon. With these supporOve
measures, the lung may heal quickly and the paOent can return to normal breathing in days; in
severe cases ARDS may enter a prolonged phase of healing that may require weeks to resolve.
In even more severe cases, devastaOng lung injury cannot support life or other organs fail along
with the lung (a condiOon known as mulOple organ failure). Death may occur in up to 40
percent of cases in this severe form.
Congenital Diaphragma3c Hernia
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-
-
Pathophysiology
o Diaphragm does not form completely, resulting in an opening between the
thorax and the abdominal cavity
o Lung hypoplasia (underdevelopment) occurs on affected side
o Ventilation compromised by hypoplasia and compression; pulmonary
hypertension
o High mortality
o Prenatally diagnosed with appropriate prenatal care; otherwise, severe resp
distress at birth with scaphoid abdomen
Diagnostic evaluation
Clinical manifestations
Therapeutic management (big picture items)
o Fetal surgery
o Post birth
o Immediate intubation
o Gastric decompression
o Transfer to ECMO center
o Surgery
o Long term complications
o Chronic lung disease, gastroesophageal reflux, feeding problems,
recurrent diaphragmatic herniation, intestinal obstruction, pneumonia,
FTT, hearing loss, scoliosis, and impaired motor and cognitive function
o
Nursing care management
Asthma
-
Pathophysiology
o Inflammation in response to a trigger
o Airway edema and accumulation of mucus
o Smooth muscle spasm of the bronchi and bronchioles
o Airway remodeling leading to permanent changes
Airway impact
o
o
Airway lumen is narrowed, so expiration is forced
Air trapping occurs
o
o
o
o
o
o
§
Results in fatigue, poor ventilation, and poor oxygenation
Chronic inflammatory disorder
o Recurrent wheezing, breathlessness, chest tightness, and cough
Most have first symptoms before 4-5 years of age
Most common chronic disease of childhoods, primary cause of school absences,
3rd leading cause of hospitalizations
SES, geography, pollution, prematurity, limited access to health care, under
diagnosis, under treatment all increased risk, morbidity, and mortality
Ask about time of onset/exacerbation, potential causes, triggers, severity of
symptoms, response to treatments at home, all current medications, last doses,
Triggers (Box 26.16)
-
Diagnostic evaluation
o Symptoms are critical part of asthma diagnosis (Classification Box 26.15)
o Pulmonary function tests (PFTs)
o Children need to follow instructions
o Conduct at initial diagnosis, when treatment is started, when stable on
treatment, and then every 1-2 years
o Peak expiratory flow rates (PEFR; p. 923)
o Maximum forced expiration
o Allergen testing
o CXR not routinely indicated
-
Clinical manifestations
o May be associated with URI symptoms
o Cough: hacking, paroxysmal, may be productive, can be chronic
Dyspnea, SOB, prolonged expiration, cyanosis, restless, nervousness, sweating,
panting
o Wheezing, hyperresonance, coarse breath sounds, crackles
o Positioning to maintain a patent airway (tripod, on next slide)
Therapeutic management
o Anti-inflammatory
o Can be given IV, enterally, and inhalation
o Onset varies depending on route
o Used in children > 5 y/o
o Can lead to improved asthma symptoms
o S/E
o Cough, dysphonia, and oral thrush
o Growth needs to be monitored
o Ex. budesonide and fluticasone
o
-
o
o
Long term: Inhaled steroids, long acting β2 agonists, and leukotriene modifiers
Short acting: β2 agonists, anticholinergics, systemic corticosteroids
B2 Adrenergic Agonists
o
o
o
o
Allows smooth muscles to relax by reducing availability of calcium
Eliminate bronchospasms
S/E: tachycardia, GI disturbances, irritability, tremors, nervousness, and
insomnia
Ex. Albuterol, levalbuterol, terbutaline
Other MedicaOons
§
-
o Long-acting beta agonists (single and combo products with steroids)
o Leukotrienes
o Anticholinergics
o Monoclonal antibodies
Asthma exacerbation emergency management
Nursing care management
Status asthmaticus
o Goal is to improve ventilation and oxygenation
o Decrease airway resistance, relieve bronchospasm, correct
dehydration and acidosis, relieve anxiety
o Treatment
o Humidified O2
o Medication
§ Inhaled short acting β agonist: initially q20-30 min or
continuous
§ Systemic corticosteroid
§ Ipratropium bromide
§ IV fluids
o Other medications
o
o
o
IV magnesium
Inhaled heliox
Ketamine: smooth muscle relaxant
Cys3c fibrosis
-
Pathophysiology (Fig 26.15)
o Exocrine gland dysfunction that produces multisystem involvement
o Pulmonary sequelae
o Digestive sequelae
o Autosomal recessive trait
-
Diagnostic evaluation
o At least one of the typical features of CF: chronic sinusitis, GI and nutritional
abnormalities, salt-loss syndromes, obstructive azoospermia
o Sibling with CF
o Positive newborn screening
o Plus at least one of the following:
o Elevated sweat chloride
o
o
-
-
Two known CFTR gene mutations on separate alleles
Abnormal testing for nasal epithelial ion transport
Clinical manifestations
o Progressive chronic obstructive lung disease associated with infection
o Initial wheezing, dry, non-productive cough
o Maldigestion from exocrine pancreatic insufficiency
o Initial meconium ileus
o Growth failure from malabsorption and anorexia
o Diabetes symptoms of hyperglycemia, polyuria, glycosuria, and weight loss
from pancreatic insufficiency
o Salty kiss
- Therapeutic management
Pulmonary
o Typical findings could be absent
o Fever
o Tachypnea
o Chest pain
o Eval for anorexia, weight loss, and decreased activity
o Send respiratory culture and other appropriate studies
o Use of inhaled antibiotics (Tobramycin)
o Secretions are very viscous and thick,
o Dornase thins secretions
o 7% hydrate and thin sections
o Streaking incr pulm infection or advanced lung disease
o Hemoptysis – greater than 250mL/24 hr is life threatening
Management of Pulmonary InfecOons
o
o
o
o
-
Typical findings could be absent
o Fever
o Tachypnea
o Chest pain
Eval for anorexia, weight loss, and decreased activity
Send respiratory culture and other appropriate studies
Use of inhaled antibiotics (Tobramycin)
GI
o
o
Replace pancreatic enzymes
o Administer with meals and snacks, or within 30 min
§ Varying dose, depending on child’s response and meal (less capsules for
a snack, for example)
§ If dosage of pancreatic enzymes is correct, the patient’s stools should
not float
Well balanced, high protein, high calorie diet for growth
o
o
-
Reflux management
Constipation/rectal prolapse
o MiraLAX
o Other laxatives, stool softeners, rectal gastrografin
Endocrine
o
o
o
Unstable glucose homeostasis, insulin deficiency, insulin resistance
o Will discuss these issues more generally in the Endocrine lecture
95% chance of reproductive issues
Osteoporosis and osteopenia
o Chronic steroids and pancreatic insufficiency lead to poor bone growth
o Need monitoring of bone mass density
o Nutrition optimization, exercise, bisphosphonates
Chapter 19 – Children with Special Needs
-
Scope of the problem
-
Considerations
o Care in the home
o Supplies, backup plans
o Subspecialist involvement
o PT, OT, speech therapy, skilled nursing, etc
o School
o Social/emotional growth
o Impact on family
o Caregiver stress
o Siblings
Family-centered care
o
o
o
o
o
o
Importance of the family as the “consistent” unit
Parents become the expert à form partnerships with healthcare team
Family-Health Care Provider Communication
Establishing Therapeutic Relationships
Shared Decision Making
Normalization
-
Communication
Shared decision making (Box 19.1)
Normalization
Impact (Box 19.3)
-
Family, siblings
Times of crisis
o
o
o
o
o
Diagnosis of the condition
Exacerbations of the condition
Developmental milestones/recognizing limitations
Start of school
Death of child
Pallia3ve care in childhood
-
Ethical dilemmas
o Pain control
o Chemotherapy/experimental therapies
o Supplemental nutrition/hydration
o Resuscitation
o Autopsy
Chapter 10 – Infant Health Promo3on
Biologic development in infancy (Table 10.3)
-
-
-
Proportional changes (e.g., weight, height, head circumference)
Sensory changes
o Visual acuity improves
o Binocular vision established
o Depth perception develops 7-9 months
o Visual preference for human face
Maturation of systems
o Respiratory – rate slows, abd breathing, short trachea-lung distance, short straight
eustachian tubes
o CV- rate slow, increased BP
o Hematopoietic- transition from fetal Hb to adult Hb, 6 mos physiologic anemia (nadir),
maternal iron stores deplete
o GI- immature processes, stomach grow, amylase/lipase limited early on for fat
absorption, solids may be incompletely digested
o Immunologic– higher risk for infection due to low Ig, breastmilk helps in IgA
o Thermoregulation- becomes more efficient, vernix plays role in thermoregulation and
immune properties (protects skin/barrier), capillaries learn to respond to changes in
temperature
o Renal- 78% term infants body is water, decreases over time, void frequently and dilute
urine
o Sensory- every sense is present at birth, auditory is most advanced and adult levels at
birth, vision least mature, binocular vision and depth perception take time to develop
o
Gross motor milestones
o Head lag in first 2 months
o Head control at 4 months
o Rolling over (from abdomen to back) at 5 to 6 month
o
o
o
o
o
o
o
o
-
Parachute reflex by 7 months (Parachute reflex – arms out in anticipation of falling)
Sit alone by 7 months
Move from prone to sitting position by 10 months
Movement and Activity
Cephalocaudal direction of development
Increased coordination of extremities at 4 months
Crawling at 6 to 7 months (usually backward)
Walk with assistance at 11 months
Walk alone at 12 months
Fine motor milestones
o From palmar to pincer grasp
o Grasping object at 2 to 3 months
o Palmar grasp at 6 months
o Transfer object between hands at 7 months
o Pincer grasp at 10 months
o Remove objects from container at 11 months
o Build tower of two blocks at 12 months
Psychosocial development (Erikson)
-
Trust vs mistrust
o Infants learn basic trust if the world is a secure place where their basic needs are met.
Cogni3ve development (Piaget)
-
Sensorimotor phase
o Piaget's term for the way infants think—by using their senses and motor skills—during
the first period of cognitive development.
Stage One
o Reflexes- suck to drink from a bottle (Birth to 1 month)
o Stage Two (1 to 4 months) – Primary circular reactions – replaced reflexes with
voluntary behavior
o Stage of first habits- suck in some ways for hunger, others for comfort
o Stage Three (4 to 8 months)– primary circular actions become prolonged
o
Responding to people and objects- clapping when mom says patty-cake
o Stage Four(8 to 12 months)- Means to the end; more attuned to goals of others;
increased social understanding-putting mom’s hands together to get her to play patty
cake, waving bye bye,
o Object permanence
o
o
o
o
o
Stage Five - toddler
Little scientists; trial and error- putting teddy in toilet and flushing. No hesitation
Stage Six - toddler
Mental combination use; intellectual experimentation via imagination; deferred
imitation
Hesitation before acting
o
Remembering mom’s reaction to teddy flushed in toilet
Social development
-
-
Attachment
o The connection between one person and another, measured by how they respond to
one another
Attachment – 2 components required – ability to discriminate mother from others and
object permanence
o Begins to form in early infancy and influences a person's close relationships throughout
life.
o Remember trust vs. mistrust
Secure attachment (Type B)
o An infant obtains both comfort and confidence from the presence of his or her
caregiver. (~ 50-70% toddlers
o Disorders – result from abuse/ neglect …develop lack of warmth, do not response to
comfort, lack of emotional regulation
Separation anxiety, stranger fear
o Separation anxiety – 4-8 months
o Stranger – 6-8 months
Language development
o
o
o
o
o
o
o
Crying is the first verbal communication
Vocalizations by 6 weeks
Coo, gurgle, laugh aloud at 3 to 4 months
Imitate sounds and add consonants at 8 months
Comprehend “No”; follow commands at 9 to 10 months
Ascribe meaning to a word at 10 to 11 months
Three to five words with meaning by age 1 year
Temperament dimensions
o
o
o
Effortful control (regulating attention and emotion, self-soothing)
Negative mood (fearful, angry, unhappy)
Exuberant (active, social, not shy)
Coping with common concerns of infant growth / development
-
Separation/stranger fear
Limits/discipline
Childcare
Teething
o Pacifier use – no absolute certainty – sids, nipple confusion, incr OM,
Promo3ng op3mal health during infancy
-
Nutrition
o First 6 months
o
o
o
o
o Human milk is first choice
o No need for additional fluids in the first 4 months
o Daily supplements (vitamin D, iron)
Second 6 months
o Selection and preparation of solid foods
o Introduction of solid foods, progression
§ intervals of 4 to 7 days to allow for identification of food allergies
o May need fluoride supplements
o NO honey in the first year of life
Weaning
o Weaning from breast or bottle to cup after 1 year
Dental health
Introduction of Solids
o Rice or oatmeal cereal starting at 4-6 mo (iron)
o Then move to vegetables & fruit (roughly at 6-8 mo, depending on baby and
family)
o One new food every few days
o If no known allergy or high risk for allergy, introduce peanuts, eggs in the 4-6
months range
o Meat, fish, poultry: start at 8-10 months
o NO honey before 12 mo (botulism)
Weaning from breast or bottle à easiest if child decides; substitute one bottle
or sippy cup at a time for a feeding, gradually increase
Sleeping patterns
o Sleep duration changes
o Total daily sleep: 16-18 hours (newborn); 15 hours (2 mos); 13 hours (6-12 mos)
o Nocturnal pattern of 9 to 11 hours by 3 to 4 months
o As nighttime sleep increases, daytime sleep decreases
o Sleeping through the night Usually between 3-4 months
o Back to Sleep campaign
o Sleep problems
o Sleeping arrangements
o Anticipatory Guidance:
o Sleeping habits may change/become disrupted during attachment/separation
anxiety phase
o Sleep training: routine is important!
o
-
Safety and injury preven3on
-
Family-Centered Care Box Child Safety Home Checklist
o Suffocation
o Aspiration, asphyxia, animal bites
o Falls
o Electrical & other burns
o Poisoning and Ingestions
o
o
Automobile Safety
Drowning
Chapter 11 – Common Health Problems of Infancy
Health problems related to nutriOon
-
-
-
Nutritional imbalance
o Vitamin imbalances Vit D- exclusively breastfed, for longer than 6 mos, poor diets
without milk products
o Specific d/o or diets- fat soluble vitamins A & D
o Iron Calcium
o Mineral imbalances
o Protein- energy malnutrition
o Kwashiorkor- protein deficiency
o Marasmus- calorie deficiency
o Nursing care management- education, immunizations, well visits, appropriate nutrition
per age
Food sensitivity
o Immunoglobulin E (IgE)–mediated immune response (e.g., cow’s milk allergy)
o Food intolerance
o Non- IGE- mediated immune response (E.G, Lactose intolerance)
o Diagnosis and therapeutic management
o Nursing care management - advising for breastfeeding, do not delay highly allergic food
introduction, safety in day care (then school), what to do when allergic rxn
o Mgmt- Avoiding offender, sensitization therapy
Failure to thrive (FTT)
o Deceleration of growth in both height and weight
o < 5th%tile weight
o Z-score -2
o Crosses 2+ growth curve lines (down)
o Multifactorial, Dianosis of exclusion
o Classifications- Previous classification of organic or nonorganic may be too simple
because most cases of FTT are complex and have mixed causes.
o Inadequate caloric intake – incorrect formula prep, neglect, lack
o Inadequate absorption – CF, celiac, crohns, allergy
o Increased metabolism – hyperthyroid, heart disease
o Defective utilization – various genetic anomalies, metabolic storage dx
o Dx- diet hx, labs,
o Reverse cause, diets , medication
o Diagnostic evaluation
o Diagnostics focus on ruling out underlying causes (history, labs, environmental
& dietary assessments)
o Therapeutic management
o Treatment involves treating underlying cause plus:
o High caloric density feedings
o Vitamin & mineral supplements
o
o Family intervention if indicated
Chronic Disease
o Cardiac
§ Cardiac Failure
o Neoplasia
o Pulmonary
§ Bronchopulmonary Dysplasia
§ Cystic Fibrosis
o Renal
§ Renal Failure
§ Renal Tubular Acidosis
o Rheumatology
§ Systemic Lupus Erythematosus
o Congenital/Genetic/Neurological Disease
§ Cerebral Palsy
§ Craniofacial Abnormalities
§ Fetal Alcohol Syndrome
§ Intrauterine Growth Retardation
§ Mental Retardation
§ Myopathies
§ Neurocutaneous Syndromes
• Neurofibromatosis
§ Prematurity
§ Primary CNS abnormality
§ Genetic Syndromes
• Cystic Fibrosis
• Russell-Silver Syndrome
• Williams Syndrome
§ Muscle weakness
• Prader Willi Syndrome
§ Inborn Error of Metabolism
o Endocrinological Disease
§ Diabetes Mellitus
§ Hypopituitarism
§ Hyperthyroidism
§ Growth hormone Deficiency
o Gastrointestinal Disease
§ Celiac Disease
§ Chronic Diarrhea
§ Chronic Emesis
§ Esophagitis
§ Gastrointestinal Reflux
§ Inflammatory Bowel Disease
§ Malabsorption
o
o
o
o
o
o
o
o
o
§ Protein Losing Enteropathies
Infectious Disease
§ Congenital infections
§ HIV/AIDS
§ Recurrent infections
§ Parasites
§ Tuberculosis
Immunological/Rheumagological Disease
§ Immunodeficiencies
Other
§ Anemia
§ Heavy Metals
• Lead
• Drugs
o Amphetamine
o Cocaine
o Hydantoin
o Phenobarbital
§ Dental Caries
Nutritional Problems
§ Inadequate Calories
§ Inadequate Protein
§ Poor Appetite
§ Maternal Malnutrition
Psychiatric Problems
§ Depression
§ Eating Disorders in Patient or Mother
§ Munchausen’s Disease by Proxy
§ Psychosis
Social Problems
§ Child Abuse
§ Caregiver/Child Interaction Abnormalities
• Emotional Deprivation
• Difficult Child
§ Family Stress
§ Parenting, Ineffective
§ Poverty
Nursing Care Management:
Assessment & observation: anthropometrics, 3-5 day food record, family
interactions, mealtime behaviors, signs of disordered eating
Planning & Intervention: Provide accepting, caring, positive environment;
provide continuity of care for establishment of trust & rapport; actively feed
child; referral to social work and/or counseling
o
Colic
o
o
o
o
o
-
-
Reassessment & discharge: continued anthropometrics, signs of improved
behavior, education on feeding child
Excessive crying (rule of 3s) thought to be caused by abdominal pain in infants
o Most common in infants <3 mo, no other consistent risk factors but many proposed
o <5% have identified organic cause
o Self-limiting, usually resolves by 12-16 wks
Rule out potential causes
Most management = supportive
Feeding too rapidly, excessive air, improper feeding technique, emotion distress
Determining feeding characteristics, breast milk – mother’s diet
Nursing Assessment
o Circumstances of crying
§ Onset, location, duration, characteristics, aggravating factors, relieving factors,
treatment
o Family situation: who’s around, how they respond
Nursing Intervention:
o Parental reassurance – not doing anything wrong, very unlikely child will experience
negative long-term outcomes
o Parental education – changing positions, rocking swing, massaging, soothing sounds,
pacifier for sucking, swaddling, trial off foods or cows milk products, air-minimizing
bottles
Sleep problems
o
o
o
Nighttime feeding
Developmental night crying
o Awaken abruptly newly
Trained night crying (inappropriate sleep association)
o Falling asleep outside of own bed
Sudden Infant Death Syndrome (SIDS)
o
o
o
o
o
o
o
o
o
Death during sleep unexplained after postmortem exam and history taking
Likely multifactorial, environmental & genetic risk
#1 cause of death among infants 1-12 months
#1 Goal: Prevention
Back-to-Sleep (or Safe-to-Sleep) campaign, 1994
Genetic predisposition new research area
Brainstem abnormalities and cardio resp control,
Infant Risk Factors SIDS
Male, African American, American Indian, Preterm labor (LBW), Low APGARs, Sibling of SIDS
victim
Risk factors
Maternal Smoking, Co-sleeping, Prone sleeping, Soft bedding, Substance use, Recent illness,
Prolonged QT
Protective Factors
o
Sleeping in supine, Flat, alone space, breastfeeding, Pacifier use, Up-to date Immunizations
Brief Resolved Unexplained Event (BRUE)
o
o
o
o
o
o
Infant exhibits a combination of:
o Apnea, irregular respirations
o Change in color or muscle tone, mental status
o Choking, gagging, or coughing
o Usually involves significant intervention
Diagnostic evaluation
o Assess for underlying cause (GERD, arrhythmia, seizure disorder, sepsis, other
infections)
o History
o Monitoring
o Infection evaluation, chemistries
o +/- EKG, chest xray, cranial imaging
o Further evaluation depending on signs/symptoms
Therapeutic management
Educate regarding evaluation
Provide emotional support to the parents (fear, anxiety, uncertainty, frustration, depression)
Discharge teaching:
o CPR
o At-home apnea monitors: not routinely used
Skin disorders
o
o
o
-
-
Common conditions:
o Diaper dermatitis
o Atopic dermatitis (eczema)
o Seborrheic dermatitis
o Urticaria (HIVES)
Clinical manifestations
Nursing care management
Diaper dermatitis treatment
o Basic Irritant:
o Keep skin dry/change diaper as soon as wet
o Leave open to air if possible
o Use barrier cream (zinc oxide, petrolatum) 2-4 times a day
§ Clean and dry skin prior to application
o Do not use diaper wipes on open areas
o Avoid over-washing
§ Soft cloth, warm water, gentle non-soap cleanser
o Candidiasis:
o Nystatin diaper cream - topical 3-4 times/day
Atopic dermatitis (eczema)
o Usually in the context of fam hx eczema, asthma, allergies, allergic rhinitis
o Major treatment goals:
o
o
o
o
o
o
o
o
o Rehydrate
o Relieve itching
o Prevent/treat 2° infection
Treatments: topical treatment (aquaphoR, hydrolateum, eucerin, cetaphil,
corticosteriod) for inflammation, antibiotics for infections, oral antihistamine for itching
Therapeutic treatments: Baths, moisture locking lotions, cool compresses
Education:
Use nondrying soaps
Use lotions immediately after bath
Keep nails short, don’t scratch
Wear soft cotton pajamas, avoid itchy fabrics/stuffed animals
Sign of infection (impetigo): Assess for honey colored crusting on top of rash, or red
edged pustules – contact provider
Administration of medical ointments: appropriate amount, frequency, contact MD if
reoccurs/doesn’t resolve
Seborrheic DermaOOs
Chronic, recurrent inflammatory reaction of skin
o Usually of scalp
o Thick, yellow, adherent scaly patches
o Scalp Hygiene
o Shampoo and physical removal
Food allergies
o Oral Allergy Syndrome: Swelling & itching of lips, tongue, throat
o Immediate GI Hypersensitivity: Nausea, cyclic vomiting, diarrhea, abdominal cramping
o Cutaneous Symptoms: Hives, red rash, flushing
o Anaphylaxis: facial or throat swelling of any kind, uticaria, wheeze or noisy breathing,
croupy cough, difficulty swallowing, excessive drool, dizziness
o
-
Intervening on Food Alergies
Pharmacological and Medical TesOng
o
o
o
o
Diphenhydramine, <2yr old only w/ MD supervision
Cetirizine, Fexofenadine, Loratadine
Epinephrine 0.01mg/kg, max 0.5mg
Pin-prick testing, food challenges
Non- pharmacological and Nursing IntervenOons
o
o
Education for families & professionals working with kids on recognition, medical
intervention, avoidance
Advocacy & policy-making for allergy awareness, allergen-free zones, action plans
Chapter 12 – Toddler Health Promo3on
Biologic development in toddlers (Table 12.2)
-
Proportional changes
Sensory changes
-
-
-
o Visual acuity of 20/40 is acceptable
o Full binocular vision well developed
o Still gaining depth perception
o Development of hearing, smell, taste, and touch increases
o Uses all senses to explore the environment
Maturation of systems
o Neuro - All brain cells present, but continue to grow in size, brain 75% of adult size by
age 2 yrs, myelination almost complete by age 2 yr
o Resp – Volume of resp tract grows; inner ear structures are short and straight, tonsils
are large and therefore, upper respiratory tract infections, otitis media, and tonsillitis
are common; decr RR, still have abd breathing
o CV – decrease in HR, Inc BP
o GI – voluntary control of elimination key change in this age group, bladder capacity
increases
o Immune- defense mechanisms of skin and blood far more efficient, exposure to new
pathogens
o Thermo- rarely issues in mod temp regulation- capillaries fully functioning
Gross motor milestones
o Locomotion
o Walks by 12-13 months; runs by 18 months
o Climbs stairs by 2 yrs
o Jump, stand on one foot, tiptoe
o Improved coordination between 2 and 3 yrs
Fine motor milestones
o Has improved manual dexterity at 12 to 15 months
o Throws a ball by 18 months
o Building growing towers of blocks
o Scribble at 15 months
o Draws circles by age 3 years
Psychosocial development (Erikson)
-
-
Autonomy vs self-shame and doubt
o Developing a sense of personal control over physical skills and a sense of independence
o If children in this stage are encouraged and supported in their increased independence,
they become more confident and secure in their own abilities
o If children are criticized, overly controlled, or not given the opportunity to assert
themselves, they begin to feel inadequate in their ability to survive, and may then
become overly dependent upon others, lack self-esteem, and feel a sense of shame or
doubt in their abilities
Negativism, ritualism
o Negativism: giving negative response to requests
o "No" or "me do"
o Asserting independence and autonomy
o Emotional liability
o "Terrible Twos"
o
Ritualism the need to maintain sameness and reliability
o Provides sense of comfort
CogniOve development (Piaget)
-
-
Sensorimotor phase (12 – 24 months)
o Sensorimotor phases
o Tertiary circular reactions at 13 to 18 months (5th stage)
§ Causal relationships, trial and error; problem solving and operations
o Invention of new means through mental combinations at 19 to 24 months (6th
stage)
§ Symbolic thought and imagination; hesitating before acting; spatial
relationships; objective permanence
o Increasing awareness of others' actions and copy
§ Imitation gestures and words
§ Domestic mimicry
o Stage Five - toddler
o Liple scienOsts; trial and error- puing teddy in toilet and flushing. No
hesitaOon
o Stage Six - toddler
o Mental combinaOon use; intellectual experimentaOon via imaginaOon;
deferred imitaOon
o HesitaOon before acOng
o Remembering mom’s reacOon to teddy flushed in toilet
Preoperational – preconceptual phase (2 – 4 years) – Table/Box 12.1
o Preoperational Stage (2-7 yrs)
o Divided into two stages
§ Preconceptual phase at 2 to 4 years
§ Intuitive thought phase at 4 to 7 years
o Children do not use operations (logical reasoning)
o Transition between self-satisfying behaviors of infancy and socialized relationships
o Increased use of language
o Concern with “why” and “how”
o Prelogical thinking
CharacterisOcs of PreoperaOonal Thought
o
o
o
o
o
o
Obstacles to Logic
Animism – belief that natural objects and phenomena are alive with sensations and
abilities like humans
Egocentrism - self-centeredness, contemplating the world from personal perspective
Transductive reasoning – applying a connection to unrelated things, not inductive or
deductive
Global organization -Reasoning that changing any one part of the whole will changes the
whole (move bed, won’t sleep in room)
Centration -Tendency to focus on one aspect of a situation to the exclusion of all others
o
Irreversibility - Fail to recognize that reversing a process may restore what existed
before; nothing can be undone
Social development
o
o
o
o
o
Differentiation of self from mother and from significant others is a major task
o Separation
o Individuation
Increased understanding and awareness of object permanence
Some ability to tolerate frustration à diminished stranger fear
Some ability to delay gratification
Transitional objects provide security
Language development
o
o
o
o
o
o
Increasing level of comprehension
Increasing ability to understand
Comprehension of 300 words by age 2 yrs
At age 2 yrs, can use two- or three-word phrases
At age 3 yrs, can use simple sentences and acquires five to six new words a day
Gestures precede each language milestone up to 30 months of age (putting phone to ear;
pointing)
Personal-social behavior
o
o
o
o
Play
o
o
o
o
o
o
o
o
Toddler develop skills of independence
Sudden mood swings are common
Skills of independence may result in tyrannical, strong willed, volatile Behavior
Skills include feeding, playing, dressing, and undressing self
Parallel play
Imitation
Little emphasis on gender-stereotyped toys
Increased locomotive skills
Educational toys and books
Tactile play
Appropriate safety in relation to size, shape, risk for toxins, and sturdiness of toys
AAP- no screen time until 2 yrs; then <1 hr educational programming per day
Coping with common concerns of toddlerhood
-
-
-
Toilet training – a major task of toddlerhood; 3 markers include: aware of urge,
interest/motivation, dry at least 2 hours during day; also fine motor skills to remove clothing,
impatience with wet or soiled diapers; daytime dryness occurs long before nighttime
Temper tantrums – linked to anger and distress; asserting independence, set clear boundaries
and expectations, *consistency and routine and developmentally appropriate expectations and
rewards, offering choices
Negativism – reduce the opportunity for a no answer
-
Stress – small amounts beneficial to develop coping strategies, excess is destructive; best
approach is prevention
Regressive behavior – often response to stress; best approach is to ignore and praise
appropriate behavior
Sibling rivalry – typically when new baby enters family, jealousy, dethronement
PromoOng opOmal health
-
Nutrition
o Growth rate slows, decreasing need for calories, protein, fluid
o Physiologic anorexia
o Ritualism
o Lifetime habits are developed early
o Avoid food as reward
o MyPlate recommendations (replaced food pyramid)
o Transition to whole milk at 1 yr and low-fat milk at 2 yrs
o Need for iron, calcium and vit D
o Picky, fussy eaters with strong taste preferences
o Same dish, same cup, same seat at table
Specialized Diets/ AlternaOve Medicine
Vegetarian diets increasing in US
Adequate vegetarian diet can be achieved
Strict (vegan) diets are often inadequate in protein, calories for growth and energy;
iron deficiency anemia and rickets
o Supplements not always safe for children
Sleep/activity
o Average sleep of 11 to 12 hours per day
o One nap typically distinguishes by age 2 or 3 yrs
o Bedtime resistance, nighttime waking
o Transition from crib to bed
o Activity is very high
o Newer concern with decreased activity and increased screen time
o
o
o
-
Safety and injury prevenOon
-
Motor vehicle safety (e.g., use of car seats)
Accidental ingestions, burns, aspiration, drowning, etc.
o Unintentional injuries leading cause of death age 1-4 yrs
o MVC deaths are caused by improper car restraints or lack of; children in front seat
highest risk for injury
o Recs: children up to age 2 in rear facing seat until outgrow seat’s recommendations,
then forward facing in back seat – never in bulky jackets or clothing, then booster seats,
o Children should be in a car seat until 4’9”, or 8-12 yrs old
o Children with disabilities may require specialized restraint system
o Also concern for children in open beds of pick ups trucks, left in hot cars, children
crawling in trunks and asphyxiating
o
o
o
o
o
o
o
Drowning: males have higher rate of drowning, infants in buckets and tubs; toddlers in
pools, tubs, ponds/lakes, hot tubs
Burns: scald burns most common type of thermal injury, water heaters should be
adjusted, sunburns, keeping things out of reach, covers on electric sockets
Poisoning: toddlers highest risk, innate curiosity; major reason is improper storage
Falls: most non lethal injuries, from stairs, jungle gyms
Aspiration: new foods, toys
Bodily harm (ped vs car, bites, knives, scissors, firearms)
Anticipatory guidance
AnOcipatory guidance for family of toddler
-
Family-Centered Care Box – Guidance During Toddler Years (p. 422)
Chapter 13 – Preschooler Health Promo3on
Biologic development of preschool-age children (Table 13.1)
-
-
-
Proportional changes
o Physical growth slows and stabilizes
o Average weight gain remains about 5 lbs/yr
o Average height increases 2½ to 3 in/yr
o Physical proportions slender and sturdy
o Body systems mature and stabilize; can adjust to moderate stress and change
Gross motor milestones
o Gross motor skills should be well-established
o Walking
o Running
o Climbing
o Jumping, skipping
o Ride tricycle
o Balance
o Catch ball
Fine motor milestones
o Fine motor skills include refinement in eye–hand and muscle coordination
o Drawing, dressing, artwork, skillful manipulation
o Readiness for learning and independence in school
Psychosocial development (Erikson)
-
Initiation vs. guilt
o Chief psychosocial task of the preschool period
o Initiative includes saying something new, beginning a new project, or expressing an
emotion
o Feelings of guilt, anxiety, and fear may result from thoughts that differ from expected
behavior
o Development of superego (conscience)
o Learning right from wrong; moral development
CogniOve development (Piaget)
-
-
Preoperational – preconceptual phase (2 – 4 years)
o Preoperational phase spans age 2 to 7 years
o Divided into two stages
o Preconceptual phase at 2 to 4 years
Preoperational – intuitive thought phase (4 – 7 years)
o Shifts from egocentric thought to social awareness
o Able to consider other viewpoints
o Egocentricity is still evident
Development of body image
o
o
o
Increasing comprehension of “desirable” appearances
Aware of racial identity, differences in appearances, and biases
Poorly defined body boundaries
o Fear that if the skin is “broken,” all one’s blood and “insides” can leak out
o Frightened by intrusive experiences
Social development
o
o
o
o
o
Individuation–separation process is completed
Overcomes stranger anxiety and fear of separation from the parents
Still needs parental security and guidance
Security from familiar objects
Play therapy is beneficial for working through fears, anxieties, and fantasies
Language development
o
o
o
o
o
Major mode of communication and social interaction
Vocabulary increases dramatically between age 2 and 5 yrs
Complexity of language use increases between age 2 and 5 yrs
Form 3-4 word sentence between ages 3-4 yr olds; 4-5 word sentences for 4-5 yr olds
2 yrs – 300 words, 5 yrs – 2100 words
Personal-social behavior
o
o
o
o
Play
o
o
o
o
o
Less help with toileting, eating, or dressing
More sociable and willing to please
Has internalized values and standards of family and culture
May begin to challenge parental values
Associative play- interact, sharing toys, but not taking turns
Imitative play
Imaginative play and imaginative playmates
Dramatic play- Dress up clothes, props, dolls, housekeeping toys
Manipulative, constructive, creative, educations toys good for this age
Coping with common concerns of preschool-age children
-
School experience: Preschool and kindergarten – adjustment to school, peer experiences, social
emotional physical development
Sex – find out what the children know and think/ be honest
-
-
Gifted children can present unique challenges, require increased attention and stimulation
Aggression – Behavior that attempts to hurt another person or destroy property, avoiding media
exposure, using appropriate behavior to reply- non-negative appropriate discipline,
May be influenced by biologic, sociocultural, and familial variables, Factors that affect aggressive
behavior include gender, frustration, modeling, and reinforcement
Speech- most critical period for speech development occurs between 2-4 yrs; early detection,
prevention, an intervention; Stuttering Stammering
Stress – especially vulnerable because of inability to cope, best approach is prevention,
Minimum amounts of stress can be beneficial, Parental awareness of signs of stress in the child’s
life
Schedule adequate rest, Prepare the child for upcoming changes to maximize coping strategies
Fears – greatest during school age years; dark, alone, animals, ghosts, sexual matters…concept
of animism. Actively involve children in finding solutions, practical desensitization
PromoOng opOmal health
-
-
-
Nutrition
o Caloric requirements are approximately 1200-1400 calories
o Fluid requirements depend on activity, climate, state of health
o Total fat should be reduced (30-40% total caloric intake) > 2 yrs
o Limiting sugar sweetened beverages and juices
o MyPlate (USDA recs)
o Food fads and strong tastes still common
o Finicky eaters
o Help prepare meals
o Obesity, DM, metabolic syndrome, CV dx
Sleep/activity
o Patterns vary widely
o Sleeps 10-13 hrs (including naps)
o Nighttime waking still common
o Consistency is key
o Free active play is encouraged
o Emphasis is on fun and safety
Injury prevention/education
o Slightly less prone to injury/falls due to matured motor skills, coordination and balance
o Safety education and setting good examples
o Development of long-term safety behaviors
o Bike helmets
AnOcipatory guidance for families of preschoolers
-
Family-Centered Care Box - Guidance During Preschool Years (p. 440)
o Injury prevention shifts from protection to education
o Children begin questioning previous teachings of parents
o Children begin to prefer the companionship of peers
o Entry into school marks separation for parents and children
Chapter 14 – Common Health Problems of Early Childhood
Sleep problems
-
Nightmares vs night terrors (Table 14.1)
o Prime time for sleep disturbances
o Going to sleep
o Waking during the night
o Nightmares/sleep terrors
o Prolong bedtime
o Interventions based on cause
o Increasing autonomy, negative sleep associations, nighttime fears, inconsistent
sleep routines, lack of limits, media exposure
o Avoid violent media at all times, limit media in evening
o Consistent bedtime routines, do not take into parents bed or stay up too late, night
lights, comfort object
o Start wind down time early
o If they’re having a night terror, though, your child won’t really be awake. They may try
to talk or yell, but they probably won’t be forming full sentences or even words.
o Other signs of a night terror include:
o Appearing frightened.
o Being difficult to console.
o Moving wildly or erratically.
o Screaming, shouting or wailing.
o Staring blankly.
o Sweating
It’s best to allow a sleep terror to run its course. Trying to awaken your child in the midst of a
sleep terror probably won’t work. If you do rouse your child, they’ll probably be confused or
frightened to wake up so suddenly. Remember, they were sleeping during the night terror, so
waking up to you in their room worrying about them will likely be concerning for them. That
means more Ome and consoling to get back to sleep.
Accidental / injurious ingesOons
-
-
Emergent management (p. 446)
o Poison control center
o Call first, before initiating any interventions
o Assessment
o Vitals, mental status, resp & circ support
o Gastric decontamination
o Induce vomiting, activated charcoal, absorb toxin, or use gastric lavage,
depending on the agent ingested
o Prevention of recurrence
o Passive vs active measures
o Passive – no active participation, child safety caps on meds
Prevention (Nursing Care Guidelines Box)
Lead poisoning
o
o
o
o
o
o
o
o
o
o
o
o
Lead-based paint in older homes
o Impoverished, urban area; older rental homes
Microparticles of lead contaminate bare soil
Food and water contamination
o Pottery and dishes
Folk remedies
Can be inhaled or ingested
Rarely symptomatic (even at high levels) but affects renal, neurologic, and hematologic systems
(bone marrow)
Highly problematic for growing brain and nervous system
Diagnosis
o Anemia
o Blood lead level >5 μg/dl (venous sample)
Screening for lead poisoning at age 1 and 2 years
Chelation therapy
Prognosis
o Permanent CNS damage
Nursing priorities of care
o Prevent
o Identify (iron deficiency)
o Lead settles in teeth and bones
o Children who are iron deficient absorb more readily
Child maltreatment (Box 14.5, 14.6)
-
-
Neglect
o Failure to provide for basic needs and adequate level of care
o Physical neglect
o Emotional neglect
Physical abuse
o Deliberate infliction of injury
o Minor injuries more frequently reported
o Major injuries lead to more death
o Abusive head trauma
o AKA shaken baby syndrome
o 1300 children affected per yr, 25% die, 80% severe sequelae
o Violent shaking and shearing forces of blood vessels and neurons
• Intracranial bleeds, retinal hemorrhages
o Rib fractures, long bone fractures
o Often no outward signs of injury and presents with non-specific symptoms
o Poor outcomes – seizure d/o, visual impairments, hearing loss, cerebral palsy, mental,
cognitive, motor impairments
o large head, weak neck muscles
o Vomiting, irritability, poor feeding, listlessness
o Severe – seizures, alterations in LOC, apnea, bradycardia
Risk factors:
Parental characteristics
• Young parent, single parent
• Socially isolated/few supportive relationships
• Low income/little education
• Substance abuse
• Low self-esteem
• Limited parenting skills
• Hx of abuse
o Child characteristics
• Birth - 1 yr
• Need for constant attention
• Unplanned, unwanted
• Hyperactive
• Disabled
o Environmental characteristics
• Chronic stress
• Divorce
• Poverty
• Unemployment
• Poor housing
• Alcoholism/drug addiction
• Substitute caregivers
Sexual abuse
o Most devastating
o Increasing over past decade
Clinical manifestations
o Growth failure/signs of malnutrition
o Poor hygiene
o Enuresis
o Sleep disorders
o Bruising in various stages of healing
o Burns
o Patterns of objects in bruising/burns
o Specific types/location of fractures
o Multiple
o Spiral, twisting
o Skull, face, nose
o Recurrent UTI
o Rash/bleeding genitals
o Abnormal affect
o Withdrawn
o Self-stimulating behaviors
o Lack of social smiles in infants
o
-
-
-
o Antisocial behavior
o Inappropriate reactions (no response to scary stimuli)
o Fear of parents/home
o Age-inappropriate sexual play
o Sudden change in behavior
o Regressive behavior
o Decline in school performance
Nursing Care
o Physical assessment documentation
o Identify all injuries
o Ensure whole body is evaluated
§ Scalp, behind ears, frenulum
o Very clear and detailed description
o Genital exam findings may be normal in sexual abuse
§ Consider bed linens, clothing
o Strict adherence to evidence collection guidelines
o Assess behavioral indicators
Chapter 15 - Health Promo3on of the School-Age Child
Biologic development (Table 15.1)
-
Maturation of systems
o GI- Fewer stomach upsets, stable glucose levels, increased capacity; caloric needs less
than preschool
o GU- Larger bladder capacity (girls>boys)
o CV- Steady increase in BP and decrease in HR
o Immune- More competence in localizing infections & producing antibody response
o MS- Bones continue to ossify, but still yield to pressure and muscle pulls
Psychosocial development (Erikson)
-
Industry vs inferiority
o
o
o
o
Crisis between productivity (competence) and inadequacy (incompetence)
Attempt to master many skills; simply trying new things is insufficient
Sustained activity leading to accomplishment is the goal
Self-pride as well as peer feedback
CogniOve development (Piaget)
-
Concrete operational stage (7 – 11 years)
o Concrete thought arises from what is visible, tangible and real, not abstract and
theoretical
o Grounded in actual experiences
o New, logical thought
o Classification – organization into groups according to some characteristic they have in
common
o Seriation – concept that things can be arranged in a logical series
o Master concept of conservation
Social development
-
-
Play
o
o
o
o
Peers
o Social relationships and cooperation
o Peer groups have own culture
o Appreciate multiple viewpoints
o Sensitive to social norms
o Forming friendships
o Formalized groups
o Peer pressure/bullying
Relationship with families
o Parents still primary influence
o Transition to prefer peers
Rules and rituals
Team play
Quiet games and activities
Ego mastery
Coping with common concerns of school-age children
-
-
-
School experience, teacher, and parent roles
o Important socializing agent
o Role of teachers
o Role of parents
Latchkey children
o Increased risk for injury & delinquency, social/ emotional issues
o After school programs
Discipline
o Effective in positive, supportive environment; guide desired behaviors
Dishonest behavior
-
o Lying, cheating, stealing
Stress and fear
o Significant from many sources
o Risk factors and solutions
PromoOng opOmal health
-
-
-
-
Nutrition
o Importance of balanced diet to promote growth
o Quality of the diet related to the family’s pattern of eating
o Quality of dietary choices in the school cafeteria
Sleep/rest
o Total sleep varies
o Depends upon age, activity levels, health status
o Naps extinguished
o Average at 5 yrs: 10-13 hrs
o Average at 11 yrs: 9-12 hrs
o Bedtime resistance
o Common until age 12
Exercise/ activity
o Sports and injury prevention
o Essential for muscle development and tone, balance and coordination, strength and
endurance
o Sports
o Controversy regarding early participation in competitive sports
o Concerns with physical and emotional maturity in competitive
environment
o Acquisition of skills
o Generally, like competition
o Limit media/screen time
Injury prevention (Table 15.2)
o Motor vehicle accidents
o Bicycle safety
o Skateboard, in-line skating, scooter, ATVs
o Trampolines
o Drowning
AnOcipatory guidance for families of school-age children
-
Family-Centered Care Box - Guidance During School Years (p. 480)
o Education, proper equipment
o Account for child’s increasing independence
Chapter 16 – Health Problems of the School-Age Child
Obesity
o
o
Increase in body weight from excessive accumulation of body fat relative to lean body mass
o > 95th BMI for age, per CDC
Overweight: weighing more than average for height and body build
o
o
o
o
-
-
Significant number of overweight/obese children in US (1 in 3)
Disproportionately high among non-Hispanic black and Hispanic youth
Also affected by parent education
<5% cases attributed to underlying disease
Complications
o Low self-esteem
o Social isolation
o Anxiety
o Depression
o Eating disorders
o Hypercholesterolemia
o HTN
o Respiratory disorders (OSA)
o Orthopedic conditions (SCFE)
o Cholelithiasis
o Cancer
o Non-alcoholic fatty liver disease
o T2DM
o Metabolic syndrome
Recommendations for prevention (Box 16.1)
Dental care
o
o
o
o
o
Caries
one of most common chronic diseases affecting all children
Periodontal disease
Malocclusion
Trauma
EliminaOon
-
-
ADHD
o
o
o
o
-
-
Enuresis
o Repeated inappropriate voiding in a child who has reached an age where bladder
control is expected (5 yrs)
o Primary: has never obtained bladder control for extended periods
o Ex. Maturational delay, functionally small bladder
o Secondary: onset of wetting after established urinary continence
o Ex. Stress, infection, sleep disorder
o Monosymptomatic (only at night) or non-monosymptomatic (daytime with emotional
stressors)
Etiology
o Sleep theory – deep sleepers
o Functional bladder capacity theory – maximum volume of urine voided following
micturition
o Failure to concentrate urine, insufficient ADH
o Dysfunctional detrusor activity
Encopresis
o Repeated inappropriate stooling in a child who has reached an age where bowel control
is expected (4 yrs)
o Primary: has never obtained bowel control (>4yrs)
o Ex. Autism spectrum, spina bifida, neglect, lax training
o Secondary: had reliably had bowel control for 6+ months before onset
o Ex. Emotional or psychological concerns, stress
o More common males
Etiologies
o Most common cause is constipation
o Often precipitated by environment change
o Impairs usual movement and contraction of colon
o Abnormalities in digestive tract
o Medical conditions
o Psychogenic encopresis
3 Subtypes, per APA
Combined
Predominantly inattentive
Predominantly hyperactive-impulsive
Clinical manifestations (Box 16.5)
o Poor impulse control, difficulty sitting still, fidgeting, difficulty sustaining attention,
disorganized
Therapeutic management
o Based on age and severity
o Behavioral
o Collaboration between home, school, and other environments
Medications- Other medications may be used if comorbidities exist Ritaline
(methyphenidate), Concerta, Vyvanse
o Pharmacologic: stimulants vs nonstimulants
• Dose based on response
• Common side effects
o Appetite loss
o Abd pain
o Headaches
o Sleep disturbance
o Growth velocity issues
o Avoid in Tourette syndrome
Nursing care management
o School nurses particularly involved in management
o Instituting behavioral modifications & environmental manipulation
o Classroom placement
o Medication education
o Diet monitoring
o
-
Learning disabiliOes
o
o
o
o
Tics
o
o
o
o
o
o
3 characteristics
o Lower intellectual ability
o Childhood onset
o Significant impairment of social functioning or adaptation
Dyslexia, Dysgraphia, Dyscalculia
Multiple tests to diagnose
Therapeutic management depends on which type
Involuntary, recurrent, random, rapid stereotypes movement of vocalization
1 in 5 children
PANDAS
Most resolve by late childhood/adolescence without intervention
Support to child and famil
* Pediatric autoimmune neuropsychiatric d/o with strep infections
Stress
-
-
Functional abdominal pain
o Often attributed to psychogenic causes, organic cause in very few cases; real pain
o Assess risk factors – somatic predisposition, lifestyle, routines, diet, learned behaviors
o Tend to be high achievers with high expectations
o Reassurance and reduce symptoms
o High fiber diet, bowel regimen, CBT
Conversion reaction
o Psychophysiologic disorder with sudden onset often related to major family crisis
o May experience physical manifestations
o Abd pain, pseudoseizures, fating, paralysis, h/a, visual field deficits
o Nursing care includes education and support
o Conversion – dealing with the stressor, ruling out other etiologies
o Schizo – requires highly specialized care, education on medications (multiple side
effects), clarify abnormal perceptions
Mood and affect
-
-
Depression (Box 16.7)
o Low self-esteem, hopelessness, poor social engagement; manifests differently
o Assess need for inpatient care
o Can interrupt normal G&D, must be recognized, assess for suicide risk, adherence to
care plans, detection as it can affect normal G&D
o Medications can take time to work, close monitoring during initial medication
Schizophrenia- rare, genetic, gestational and birth complications
Anxiety
o Most common mental health d/o
o Excessive worry, fearfulness; difficulty functioning
o Often unrecognized
Chapter 17 – Health Promo3on of the Adolescent
Biologic development (Table 17.1)
o
o
Physical growth
o Dramatic increase in growth
§ Second only to the infant period
o Final 20-25% of linear growth achieved
o Up to 50% of ideal body weight gained – in growth spurt
o Height spurt follows a weight spurt, and then a muscle spurt occurs
Neuroendocrine events of puberty
o Hypothalamus> pituitary> gonads> estrogen/testosterone
o Gonads- paired sex glands (ovaries in female, testicles in males produce hormones and
gamates
o Estradiol- Sex hormone considered the chief estrogen, Females produce more estradiol
than males
o Testosterone- Sex hormone, the best known of the androgens (male hormones).
Secreted in far greater amounts by males than by females
o
o
o * Hypothalamus produces GnRH à ant pituitary gland à FSH/LH --> gonadsm
Sexual Maturation
o Orderly sequence
o Age of onset varies; genetics important in determining timing
o Primary sex characteristics
§ Parts of the body that are directly involved in reproduction, including the
vagina, uterus, ovaries, testicles, and penis
o Secondary sex characteristics
§ Observable physical traits that are not directly involved in reproduction but that
indicate sexual maturity, such as a man's beard and a woman's breasts
o Precocious puberty is a concern if occurs before age 8
Other physiologic changes
o Size and strength of heart increase
o HR decreases
o Blood volume and BP increases
o Adult blood values achieved
o Lung volume increases
o RR reaches adult rates
o Frontal cortex still not fully developed
CogniOve development (Piaget)
-
-
-
-
Formal operational thought
o Fourth and final stage of cognitive development
o Characterized by:
o Systematic logic
o Ability to think abstractly
o Consider consequences to actions
o Hypothesize possibilities
Deductive reasoning- Reasoning from a general statement, premise, or principle, through logical
steps to figure out, Top-down reasoning
§ Deductive- all students in the class like pizza, Jane is in the class, Therefore, Jane
likes pizza, At the conference, all those presenting have a PhD, Maria is
presenting at the conference, Therefore, Maria has. PhD
Inductive reasoning- Reasoning from one or more specific experiences or facts to a general
conclusion; maybe less cognitively advanced than deduction, bottom-up reasoning
§ Inductive – every quiz has been easy…the exam should be easy teacher used ppt
in the last few lectures, therefore the teacher will use PowerPoint tomorrow
Hypothetical thought- Reasoning that includes propositions and possibilities that may not reflet
reality, If-then propositions
Hallmark of formal operational thought is capacity to think of possibility not just reality
Psychosocial development (Erikson)
-
Identity vs role confusion
o Fifth stage of development/psychosocial crisis
o Finding one’s own identity but confused by many possible roles to adopt
o
o
o
“Who am I?”
Identity
Consistent definition of one's self as a unique individual, in terms of roles, attitudes,
beliefs, and aspirations
Identity achievement
Erikson's term for the attainment of identity, or the point at which a person understands
who they are as a unique individual, in accord with past experiences and future plans
Social environments
-
-
Families
o Changes in family microsystems lead to more unsupervised time
o Increase in risk taking behaviors, poor diet, more screen time, substance use,
sexual intercourse, etc
o Decrease opportunities for communication and intimacy with parents
o Adolescents who eat meals together 5-7 times/week are more connected with family,
perform better academically, participate in fewer risky behaviors
o Family belonging leads to less susceptibility to peer pressure
o Parenting style affects development
o Authoritative is preferred
o Microsystems – more divorce, remarriage, single parents, older parents, working
parents
o Roles change from “protection–dependency” to “mutual affection and equality”
o Conflicts with parents
o Parent–adolescent conflict typically peaks in early adolescence and is more a
sign of attachment than of distance
o Most often mothers & daughters
o Bickering- Repeated petty arguments (more nagging than fighting) about routine, dayto-day concerns
o Neglect- Although teenagers may act as if they no longer need their parents, neglect can
have adverse effects.
More important that conflict -- family closeness and cohesiveness
o Communication: Do family members talk openly and honestly?
o Support: Do they rely on each other?
o Connectedness: How emotionally close are family members?
o Control: Do parents undermine independence?
Peer groups
o Critically important in adolescence, may have positive and negative effects
o Adolescents spend more time with peers than children
o Peers serve as credible source of information, role models of social behaviors, social
reinforcement
o Help navigate physical changes of puberty, the intellectual challenges of high school &
the social changes of leaving childhood
o Do not negate the need for parental support
o Tech may bring peers together- provide outlet for those who feel alone
o
o
o
o
-
-
Encouragement to conform to one’s friends in behavior, dress and attitude, usually
considered a negative force
Deviancy training – destructive peer support in which one person shows another how to
rebel against authority
Controlling for environment and genes, if one twin is delinquent, the other will likely
follow
Study showed twins - controlling for genes and environment, if one is delinquent, the
other will likely be as well
Romantic Partners
First romance typically occurs in high school with steady relationships
Exclusive commitment is ideal, but often difficult; breakups are common
More closely related to emotional state than actual interactions
Sexual intercourse more or less likely dependent upon peer support
o
o
o
o
School
o Essential for successful future
o Failure to complete high school reduces employment opportunities and probability to
earning adequate income
o Lack of parental involvement in school
o Social environment, practices and conditions impact outcomes
o Smaller classes and school size
o Foster positive peer group relationships
o Promote health and fitness
o Encourage family involvement
Work
o Media, technology use
o Most adolescents employed
o Mostly restricted jobs, but some may promote social skills, autonomy
o May have detrimental effects (esp working >20 hrs/wk)
o Jobs that link to adults who serve as vocational mentors are valuable
Technology
o 95% of teens have smart phones; 45% online on constant basis
o Provide a connection, but have many downsides
o Cyberbullying, sexting
o Multitasking with technology
• Unclear how this will affect the brain
o Increased concern for distracted driving
• 59.5% of 12th graders report texting/emailing while driving
PromoOng opOmal health
o
o
o
Comprehensive approach
o Individuals, families, communities
o Physical, cognitive, emotional, social
Focus based on morbidity and mortality of age group
Mortality:
o MVC, accidental injuries, homicide, suicide
o
o
-
-
-
Morbidity
o Motor and recreational vehicles, sexual and physical abuse, unwanted pregnancy, STIs,
substance use, mental health issues
Inequities exist
o Gap in life expectancy between African American and white adolescents
o African American and native American males have highest risk of premature death
Adolescent perspective
o To be effective, health promotion must include adolescent perspective and involvement
o Many are reluctant to seek services for social and psychologic problems
o Unwilling to seek health care for fear parents will find out
Context
o Schools
o Health promotion and disease prevention
§ Healthy eating, fitness, assignments
o School-based and school-linked health services
o Communities
o Media campaigns, raise awareness
o Health care settings
o Internet and other technologies
Parenting/family adjustment
Psychosocial adjustment
Intentional and unintentional injury
Dietary habits/ eating disorders
Physical fitness
Sexual health
Substance use
Mental health and suicide
Sleep deprivation
LGBTQ++
o Unique considerations for care
o Higher prevalence of bullying, dating violence, eating disorders, suicidal behaviors
o Ensuring safety in disclosure, sensitive care
AnOcipatory guidance for adolescents and their families
-
Family-Centered Care Box – Guidance During Adolescence (p. 534)
Chapter 18 – Health Problems of the Adolescent
Varicocele
-
Enlarged veins of spermatic cord, may impair fertility (impaired spermatogenesis)
Palpated as worm like mass above the testicle
Surgery (if growth of testicle is arrested)
EpididymiOs
-
Inflammatory response of epididymis; may be infectious (viral or bacterial)
Urethral d/c, pyuria, dysuria, fever
-
Most common causes Chalmydia and Gonorrhea
Abx, rest, analgesics, scrotal support
GynecomasOa
-
Breast enlargement; unilateral or bilateral
Normally occurs transiently; may be pathologic
May also be drug-induced
Prepubertal should be evaluated for rare tumors, Klinefelter
Plastic surgery in severe cases
Drugs: spironolactone, cimeOdine, ketoconazole, estrogens,
TesOcular torsion
-
Occurs when a testicle rotates, twisting the spermatic cord that brings blood to the scrotum
Reduced blood flow causes sudden and often severe pain and swelling, redness, absent
cremasteric reflex
Fever and urinary symptoms typically absent
Most common between ages 12 and 18, but it can occur at any age, even before birth
Surgical emergency
Menstrual disorders
-
-
Amenorrhea
o Absence of menstruation
o Primary - age 14 w/o secondary sexual characteristics or 16 w/ secondary sex
characteristics
o Secondary- absence of menses after menstruation was previously established for more
than 3 menstrual cycles or irregular menses for 6 months after the establishment of
normal menses
o Female athlete triad – reduced calorie intake, amenorrhea, low bone mineral density
Dysmenorrhea
o Pain during or shortly before menstruation
o May be primary or secondary (pathological)
o Therapeutic management
§ NSAIDs
§ Estrogen therapy
§ Oral contraceptives
§ Dietary changes
§ Exercises, comfort measures
Sexually transmiped infecOons (Box 18.2)
-
Gonorrhea
Symptoms
Males: yellow discharge, painful urination, urinary frequency/urgency/nocturia
Females: may be asymptomatic or yellow discharge, painful urination, pain with intercourse
Rectal pain, purulent discharge, bloody stool
Treatment
-
Drug resistant strains increasing
Single dose IM ceftriaxone plus single dose PO azithromycin
Treat for concomitant chlamydia
Chlamydia (Most common bacterial)
Symptoms
Males: may be asymptomatic, or redness of urethral meatus, tenderness, itching, discharge
Females: may be asymptomatic, or purulent discharge, cervical redness, edema, pelvic
congestion
Increased risk of HIV if damage to cervix
Treatment
Single dose PO azithromycin or 7 days PO doxycycline BID
Abstain for 7 days
Notify partners
Syphilis
Symptoms
Increasing in MSM population
Primary – painless chancre
Secondary – (6wks-mos) widespread rash and generalized LAD, fever, h/a, malaise, wart like
lesions
Tertiary – Neuro, CV, MS effects
Treatment
Penicillin G
Human papillomavirus Most common viral
Symptoms
Types 16, 18 can lead to cervical cancer
Types 6, 11 cause genital warts (may appear cauliflower like)
Males: lesions on penis, anus
Females: lesions posterior to genitals, anus, buttocks
Treatment
Palliate, not curative
Topical medications
Cryotherapy
Surgery
Herpes Simplex Virus
Symptoms
May be asymptomatic or painful lesions, fever, chills, malaise, LAD, headaches
Lesions: vesicles, pustules, ulcers
Females have more severe symptoms, cervix involvement
May be passed form motheràinfant
Treatment
Palliative not curative
Oral antivirals
Oral analgesic
Consistent condom use
-
Flares trigger with stress
Trichomoniasis (protozoa)
Symptoms
Males: asymptomatic or urethritis
Females: yellow/green frothy, malodorous discharge, cervix with “strawberry spots”, acute
inflammation
Treatment
Metronidazole (flagyl) oral
Pelvic inflammatory disease
Pregnancy
o
o
o
Adolescent pregnancy
o Slight rate decline in US
o Considered socially, educationally, psychologically, and economically disadvantageous
to both mother and child
o Delayed or inadequate prenatal care common
Contraception
o Methods should be safe, effective, and suited to the individual
o Contraception use is variable
o Less familiar with partner less likely to use contraception
o Dissatisfaction with conception side effects
Nursing care management
Sexual assault
o
o
o
o
o
o
Unwanted sexual activity by force or manipulation
High risk population
Often committed by known perpetrator
Diagnostic evaluation
o Consider pediatric SANE
Therapeutic management
Nursing care management
EaOng Disorders (Table 18.5)
o
o
o
o
o
o
o
o
Multifactorial etiology
Genetic predisposition
Psychological: Fear, anxiety, obsessive compulsiveness, depression, other disorders
Sociocultural: Body dissatisfaction, family dysfunction
Environmental: Involvement with sports or activities with aesthetic or athletic
expectations
Anorexia/Bulimia
Anorexia nervosa (AN) characterized by:
§ Refusal to maintain a minimally normal body weight
§ Intense fear of weight gain
§ Disturbed body perception and denial of the problem
Bulimia nervosa (BN) characterized by:
Binge eating followed by inappropriate compensatory behaviors such as selfinduced vomiting, misuse of laxatives, diuretics, fasting, exercise
§ Secretive frenzied consumptions large amounts high-calorie food
Eating disorder NOS (EDNOS)
Binge eating disorder
§ Similar to BN, but no purging
§
o
o
Substance abuse
-
Self-harm
Suicide
Motivation – often initial experimentation, curiosity
Goal is often peer acceptance
Two broad categories often – experimenters and compulsive users, or recreational
users
Abused drugs
o Tobacco and smokeless tobacco
o Alcohol
o Cocaine
o Narcotics
o CNS depressants, stimulants
o Mind-altering drugs
- By age 18, 80-90% of adolescents have tried alcohol
- CNS depressants: hypnotic drugs, barbiturates, non-barbiturates, alcohol, Rohypnol
(10x more powerful than Valium)
- CNS stimulants: amphetamines, cocaine
- Mind-altering – cannabis included, LSD
-
Self-injury or self-mutilation, without intent to die
Excludes eating disorders, drug abuse & socially accepted behaviors (piercing & tattoos)
Peaks age 15-16 years, declines at 18 yrs
Prominent in females, those with sexual
orientation confusion, hx of physical/sexual abuse
Rarely seek treatment
Therapeutic management
Nursing Alert
The S.A.F.E. Alternatives offers a helpline, (1-800-DON'T-CUT [366-8288]) & hosts a
website (http://www.selfinjury.com) with information about treatment programs &
other resources
-
Terms: Suicide/Suicidal ideation/ Suicide attempt
Methods
• Firearms – most commonly used instrument for completed suicide by
males
• Cutting/piercing – by females
• Hanging
-
-
Depression
-
•
Overdose – most common method for attempt
•
•
Most important indicator is active psychiatric d/o
Individual, family, social, environmental factors
•
•
•
•
•
•
•
•
Fantasy based
Relief from suffering, gain comfort and sympathy, revenge
Return and witness grief
Therapeutic management
Threats require immediate action
Medications
SSRIs
Therapy
Etiology
Motivation
Dip in self-esteem occurs at puberty
Common for every ethnicity and gender
Less confidence, sadness
Family and cultural norms are protective
Feelings of hopelessness, lethargy, and worthlessness that last two weeks or more
Disrupts normal activities
Girls have much higher rates than boys (2x)
Biological and cultural difference
Rumination - repeatedly thinking and talking about past experiences
o Can contribute to depression
o More common in girls