SCHOOLAGERS
WEEK 8
2008
Resources used
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Adam PC Image resouces
Hockenberry & Wilson 8th ed. Text
Hockenberry & Wilson Text CD
Mosby’s Electronic Image Collection
Partners’ powerpoint contributions
Past Powerpoints by S.McMahon
RNAO Best Practices
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Topics
Preparatory reading:
Growth & development for schoolagers and
presdolescence
Normal variations for the neurological and musculoskeletal
systems
Milestones
Play activities , equipment & toys
School – phobia, nutrition, dental care, obesity, latchkey,
relationships, injuries, bullying,
Immobilization Syndrome
Classroom Focus:
Neurological variations– Injury, IICP, coup-contecoup, fractures,
Unconscious child, Epileps,ADD/ADHD, pharmacology
Spinal cord injuries, infections, MD
Communicable diseases- Varicella, 5th disease, roseola, rubella,
mumps, conjunctivitis, scarlet fever, Group A strep(GABHS) and
sequelae
Kawasaki Disease
Biologic Development
Slower but steady ht & wt increase
 6 to 12 yrs – 2” per yr & 2-3 kg per yr
 Boys & girls differ very little in size
 Lower center of gravity – better
co-ordination (climbing, bike riding)
 Fat decreases & muscle increases
 Muscles are immature – more prone to overuse
injuries
 “Loose tooth” stage
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Biologic Cont’d
HR & RR decrease, BP increases
 Rapid growth towards end of middle
childhood
 May have striking differences between
children
 See pages 726-727 for
summary on G & D
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Prepubescence
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Begins toward end of middle childhood and
ends with 13th birthday
Boys & girls differ greatly in ht/wt
Onset of secondary sex characteristics
Changes may be cause of embarrassment &
lower self-esteem
Psychosocial Development
Erikson
 “Sense of Industry”
 Goal: technolgic & social skills
 Important to build on a sense of
accomplishment with tasks
 Need to learn that they can’t “master” every
skill
 Need to co-operate & compete with others
Temperament
 3 categories: easy,
slow to warm up, &
difficult
 “Slow to warm up” –
need time to adjust to
new
situations/environments
 “Difficult” – benefit from
practice sessions
Cognitive Development
Piaget
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Mental representations – expressed verbally
& symbolically
“Concrete Operations” stage
Able to conceptualize ideas
Able to recognize other points of view
Master conservation – “things don’t disappear
by magic”
3 Concepts:
 Identity
 Reversibility
 Reciprocity
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Conservation of numbers
occurs before conservation
of substance
Able to think through an
action, stop, anticipate the
consequences and then
return to the beginning to
make adjustments
Able to classify & group
objects
“Collections” start – shells,
dolls, cars, etc.
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Able to serialize – arrange objects according
to some ordinal scale
Able to state relations – bigger vs. smaller,
darker vs. paler
Develop combinatorial skills – simple
mathematical skills
Develop the ability to read
Moral Development
Kohlberg
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Rewards & punishment guide their acts
“Bad” vs. “good”
Feel guilty when they don’t follow the rules
Older children – able to judge an act by
intentions rather than just consequences
Older children – able to take into account
another point of view
“Treat others as you want to be treated.”
Spiritual Development
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Desire to learn about their
“God”
See God as human
View illness or injury as a
punishment for a real or
imagined misdeed
Expect to be punished for
wrong-doings
Learn difference between
“natural” and
“supernatural”
Language Development
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More complex grammar
(past tenses, plurals,
etc.)
By 10 -12 yrs should
use factitive words
(know, think, believe)
Grammatically correct
sentences
Appreciate jokes,
riddles, puns
Social Development
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Increased curiosity of
the world
Gaining independence
from parents & identify
with peers
Start to learn sex-roles
Relationships
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Group activities, one or several peer groups
Learn how to argue, persuade, co-operate
Groups teach acceptance & rejection
Learn norms & pressures of the group
“Best friends” are developed
Clubs & Peer Groups
 Rigid rules in groups: code word, privilege of
joining
 Children with disabilities may feel left out
 Bullying behaviour: “infliction of repetitive
physical, verbal or emotional abuse by one or
more individuals on another when there is a
perceived imbalance of power”
Bullying
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Children who bully may be at risk for longterm psychologic disturbances & psychiatric
symptoms
Often defiant, anti-social & likely to break
rules
Children who are bullied often seek medical
attention for headaches, stomach complaints,
etc.
Self-Concept
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Compare bodies to parents and others
Head is most noticeable
Aware of physical disabilities & “differences”
in others
May shy away from activities that show their
own “differences” ie. Bedwetting
Self-Concept Cont’d
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“Social worth” develops - what they are good
at and what they struggle with
Self-confidence vs. self-doubt
Internalize outside opinions
Pets have positive affect on physical &
emotional health
Rely on cues from adults regarding self-worth
& accomplishments
Sexuality
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Sexual curiosity is transient
Many children are “shamed” by parents for
sexual curiosity – may have lasting negative
effects
Teach proper terminology for sex organs
Ideal time for formal sexual education controversial
Nurses’ Role in Sex Education
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Emphasize physiologic aspects of sexual
reproduction, awareness of children’s
attitudes, beliefs & misconceptions
Answer questions honestly
Differentiate between sex & sexuality
Address with parents sex play &
masturbation as normal behaviours
Play
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Sense of “belonging” during
play
Fixed & rigid rules
Conformity & rituals
Team play: division of
labour, competition,
increases cognitive learning
thru complex rules ie.
baseball
Play Cont’d
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Still enjoy quiet, solitary
activities
Collections become more
organized
Strict adherence to rules ie.
Monopoly
Increase interest in reading
“Hero worship”
Love to learn new skills
School Experience
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Socializing agent only 2nd to
the family
Attitudes are influenced by
parents
Anticipatory socialization by
parents
Teachers “surrogate parent”
Approval by teacher is
important to child
May experience “Hero
worship”
Limit Setting & Discipline
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1.
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3.
4.
Purposes:
To stop
dangerous/forbidden
actions
Convey a more
acceptable action for
future
To help child understand
why action is
unacceptable
To help child empathize
with victim of action
Discipline Cont’d
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Techniques should help children control their
behaviours/actions
Corporal punishment linked with increased
aggression
Withholding privileges, compensation for
broken items, penalties & contracting are
beneficial
“I didn’t do it!”
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Why do children lie?
Can’t distinguish between fact & fantasy
To escape punishment
Low self-esteem or wanting to “get ahead”
with little effort
Lying is more common in families where
punishment is harsh for misbehaving
Stress
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School
Domestic violence
“Yelling” by teachers
Too many adult
responsibilities
School performance
Social threats “teasing”
See Pg. 732
Fears
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Fear of failing, bullies, harm
to parents
S/S: anxiety, stomach
pains, bed-wetting, change
in eating habits, regression
to earlier behaviours
Reluctance to participate
Latchkey Children
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Greater risk of injury and
delinquent behaviour
Coping with fear of being
left along: playing TV/radio
loud, hiding in small spaces,
bonding with pets
See Family Home Care Box
pg. 733
Nutrition
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Parents lack control of meals at school
Single-food preferences begin to end
Childhood obesity prevalent health problem
Parents/nurses need to work with schools to
promote good nutrition ie. Eliminating pop
machines, offering nutritious meals
Co critical thinking exercise on Text CD – Obesity :
Also – look up nursing care plan
for obesity on text CD
Sleep & Rest
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Generally, naps are not required
11 hours at age 5, 9.25 hrs at age 12
Children may be unaware that they are tired
– need bedtime rituals – consistency
Don’t use bedtime as reward or punishment
ie. Staying up late for behaving or going to
bed early for misbehaving
Sleep Problems
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Night Terrors in
preschool replaced by
sleepwalking/talking
Sleepwalking – 1st 3-4 hrs of sleep
No memory of event, movements are clumsy, rarely
perform purposeful acts
Leave along unless in danger
If waking is a must – quiet, soft tone of voice and
orient to surroundings
Do the Case Studies on Text CD- Sleep
Physical Activity
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Less emphasis on outdoor activity in past 10
years d/t computers & video games
Leading to increase in diabetes & obesity
Need to know limits d/t bone growth & muscle
development
Weight training is discouraged due to lack of
muscle/tendon stability
Dental Health
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Secondary teeth begin
to erupt at 6 yrs of age
Regular dental
evaluation
May lack fine motor
skills to brush molars
Injuries
Boys > girls
 Incidence of burns and poisonings decrease
 Transportation related injuries is higher
 Developmental: easily distracted, increasing
independence, strong allegiance to friends,
confidence > physical ability
See Table 17-2 page 744
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Injury Prevention
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MVA – seat belts, helmets,
pedestrians, bike safety
rules
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Drowning – water safety
rules, teach to swim,
flotation device, check
water depth for diving
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Burns – smoke
detectors, fire hazards
(fireworks, matches,
chemistry sets), teach
safe cooking
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Bodily damage – power
tools, window guards,
stranger safety,
trampolines
Neurological System
Overview & Episodic Variations
Assessment
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General: history, physical exam
Level of Consciousness
Vital Signs, eyes, motor function, posturing,
reflexes
Diagnostic Tests
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EEG (Electroencephalography)
CT
MRI
Lumbar Puncture (LP)
PET Scan (Positive Emission Tomography)
Nursing Care
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CT/MRI
Lumbar Puncture
EEG
Look up Nursing Care Plan for The
Unconscious Child and the Child with a Head
Injury on the text CD
The Unconscious Child
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Continual observation of LOC, pupillary
reaction, vital signs
Meticulous skin care
Pain assessment & Mgt
Respiratory management
Intracranial Pressure Monitoring
Nutrition & Hydration
Elimination
Positioning & Exercise
Stimulation
Family Support
Monitoring ICP
Closed Head Injuries
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Brain injury – concussion, contusion, laceration
Skull fractures
Hematomas (epidural, subdural)
Causes: falls, MVA’s, bicycle accidents, seizure
disorders, gait instability, cognitive delays, poor
judgment, alcohol & drug use
Skull Fractures
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Severity depends on velocity, force, mass,
area of skull & age
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Linear
Comminuted
Compound
Depressed
Basilar
Diastatic
Acceleration/Deceleration & shearing
results in damage
Brain Injury: Hemorrhage
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Epidural - rapid deterioration  dilated &
fixed pupils, seizures, paralysis,  deep
tendon reflexes, coma & brain herniation
Subdural-within 48 hrs, more common than
epidural - headache, agitation, confusion,
drowsiness
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Post-traumatic syndromes (seizures,
focal deficits, hydrocephalus) &
metabolic complications (eg. diabetes
insipidus) can occur up to 2 yrs after
injury
Subdural & subarachnoid
hemorrhages may be sign of child
abuse
Nursing Measure for Head Injury
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Emergency care – ABC, check LOC, assess
for other injury (pg. 1636)
Monitor neuro-status
Teaching – monitoring at home, signs of IICP
(Box 37-1 pg. 1617)
Prevention – safety measures – e.g. bicycle
helmets, seat beltssee text CD Nursing Care Plan for child with
Head Injury
Cerebral Edema
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Often with head injury
Pressure causes tissue anoxia
If unchecked leads to fatal anoxia or
herniation
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Brain Death
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Complete cessation of clinical
evidence of brain function &
irreversibility of condition
Treatment
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Surgery – insertion/ of shunt
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VA shunt
VP shunt (shown)
Periodic revisions of shunt
Management of long-term
problems
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Developmental delay
Learning disabilities
Sensory problems
Nursing Care
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Monitor neuro-status, head circumference,
fontanels
Pre-operative - prevent injury
Post-operative - shunt care, neuro-status,
complications
Support & teaching – developmental
screening, shunt care
Nursing Care Plan for Hydrocephalus on Text
CD
 SPINAL
CORD INJURIES
Look up the Text CD for Animation about
Cranial nerves,
cranial neural examination,
seizure,
spine structure,
ventriculoperitoneal shunt
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Spinal Cord Injuries
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Generally result of indirect trauma
Especially in MVC without child restraints
Vertebral compression from blows to the
head or buttocks (diving, surfing, falls from
horses)
Birth injuries from traction force on spinal
cord during breech delivery
Birth defects – congenital anomalies
Levels of Spinal Cord Injuries
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Higher injury—more extensive damage
Paraplegia: complete or partial paralysis of
lower extremities
Tetraplegia: lacking functional use of all four
extremities (formerly called quadriplegia)
High cervical cord injury affects phrenic
nerve, paralyzes diaphragm → ventilatory
dependency
Relationships of
Spinal Cord
Segments and Spinal
Nerves to Vertebral
Bodies
Spinal Cord Injury
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Therapeutic management: stabilization and
transport to pediatric trauma center
environment
Management is complex and controversial
Nursing considerations
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Stabilization, careful assessment, prevention of
complications, maintain maximum function
Nursing Management
of Spinal Cord Injuries
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Respiratory care
Temperature regulation
Skin care
Physiotherapy
Neurogenic bladder
Bowel training
Autonomic dysreflexia
Myelomeningocele
(Spina Bifida)
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Usually also have Arnold-Chiari with
hydrocephalus
Impairment of lumbar and sacral nerves
Level of defect influences degree of
impairment
Paralysis; bladder, bowel complications;
orthopedic problems
Tethered cord can occur later
Look up Nursing Care Plans for The Child
with Myelominingocele and The Child with
Immobility On Text CD
Fetal Surgery for Spina Bifida
Myelodysplasias
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Spinal canal and
cord defects
Types:
Occulta
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Meningocele
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Myelomeningocele
Level of Defect & Mobility
Dermotomes
and
Innervation of
Major
Muscles
Nursing Diagnoses
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Risk for injury/infection r/t spinal defect
Impaired physical mobility r/t lower extremity impairment
Impaired urinary elimination r/t neurogenic bladder
Altered bowel elimination r/t neurological impairment
Risk for impaired skin integrity r/t sensory impairment &
paralysis
Altered family process r/t demands of care for child
Management
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Initial – protect site from injury infection;
monitor neuro-status
Surgery – closure of defect, shunt if
necessary
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Can be done in utero
Ongoing management of mobility, bowel,
bladder, neuromuscular problems
Rehabilitation- ongoing
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Evaluation and support
Remobilization
Physical rehabilitation
Psychosocial rehabilitation
Sexuality issues
Look up Nursing Care plan on Text CD for
Rehabilitation
Seizure Disorders
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Abnormal electrical discharge in brain, causing
paroxysmal, uncontrolled behaviour
( View Generalized seizure animation on Text CD)
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Causes: idiopathic, IICP, infection, head injury,
metabolic disturbances
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Seizures are the indispensable characteristic of
epilepsy; however, not every seizure is epileptic
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(see evidenced-base practice box p. 1684)
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Look up Nursing Care Plan foe Seizures on Text CD
Anti-seizure Medications
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Phenobarbital
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Diazepam – Valium
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Phenytoin – Dilantin
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Carbamazepine – Tegretol
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Valproic acid - Depakene
Classification of Seizures
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Generalized
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Convulsive – tonic, clonic, tonic-clonic
Non-convulsive – petit mal
Partial
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Simple partial
Complex partial - psychomotor
Myotonic
Atonic – “drop attacks”
Management of Seizure
Disorders
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Seizure precautions
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Observe & document seizure activity
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Prevent injury
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Medications
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Teaching – meds, protection, legal issues
Later Manifestations
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Child
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Headache on awakening
Lethargy, irritability
Ataxia
Confusion
Long term effects: impaired vision,
headaches, seizures, hormonal effects,
destruction of cerebral cortex
 MUSCULAR
DYSTROPHY
Muscular Dystrophies (MDs)
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Largest group of muscular diseases in
children
All have genetic origin with gradual
degeneration of muscle fibers, progressive
weakness, and wasting of skeletal muscles
All have increasing disability and deformity
with loss of strength
Initial Muscle Groups Involved in
MDs
Duchenne Muscular Dystrophy
(DMD)
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Also called pseudohypertrophic muscular
dystrophy
Most severe and most common of the MDs in
childhood
X-linked inheritance pattern; one third are
fresh mutations
Incidence: 1 in 3500 male births
Characteristics of DMD
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Onset between ages 3 and 5 years
Progressive muscle weakness, wasting, and
contractures; often obesity
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Loss of ambulation by age 9-12 yrs
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Calf muscles hypertrophy in most patients
Progressive generalized weakness in
adolescence
Death from respiratory or cardiac failure
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Diagnostic Evaluation of DMD
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Suspected based on clinical appearance
Confirmation by EMG, muscle biopsy, and
serum enzyme measurement
Serum CPK and AST levels high in first
2 years of life, before onset of weakness;
levels diminish as muscle deterioration
continues
DMD: Clinical Manifestations
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Waddling gait, frequent falls, Gower sign
Lordosis
Enlarged muscles, especially thighs and
upper arms
Profound muscular atrophy in later stages
Mental deficiency common
Nursing Diagnoses
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Risk for injury/infection r/t spinal defect
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Impaired physical mobility r/t lower extremity impairment
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Impaired urinary elimination r/t neurogenic bladder
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Altered bowel elimination r/t neurological impairment
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Risk for impaired skin integrity r/t sensory impairment &
paralysis
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Altered family process r/t demands of care for child
Therapeutic Management of
DMD
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No effective treatment has been established
Primary goal: maintain function in unaffected
muscles as long as possible
Keep child as active as possible
ROM, bracing, performance of ADLs, surgical
release of contractures prn
Genetic counseling for family
Look up Nursing Care Plan for Chronic
Illness & Disability on Text CD
DMD: Nursing Considerations
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Help child and family cope with chronic,
progressive, debilitating disease
Help design a program to foster
independence and activity as long as
possible
Teach child self-help skills
Arrange for appropriate health care
assistance as child’s needs intensify (home
health, skilled nursing facility, respite care for
family, etc.)
A child with potential and
actual tissue breakdown
COMMUNICABLE DISEASES
Look up Nursing Care plan on Text CD
Communicable Diseases
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Have declined since immunizations
Assessment (see p 652-660)
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Recent exposure
Prodromal symptoms – fever or rash
Immunization hx
Previous history
Goals
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Avoid spreading infection to others
No complications
Child will have minimal discomfort
Child & family will receive adequate support
Nursing Care for
Communicable Diseases
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Prevent spread
Minimize complications
Provide comfort
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Pruritis
Fever management
Family education & support
Guillain - Barre Paralysis: Ascending
paralysis
do Critical thinking exercise on text
CD
Other causes of unexpected paralysis
and IICP -encephalitis from fleas, tics,
Mosquito bites, other insect bites,
stings + Arachnids, scorpions
as children travel or come from different
countries, we must remember to think
of vectors and other sources of toxins
and infections

Erythema Infectiosum[ 5th Disease]
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Human parvovirus
Possible transmission by resp. secretions
and blood
Contagious before onset of S&S and up to 1
week after onset
Incubation period 4-14 days or longer
S&S
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Reddened cheeks [slapped cheek]
Rash spreads to upper and lower extremities
After rash, skin remains reddened
Danger of fetal death if mother infected
during pregnancy
May cause chronic arthralgia or arthritis
Varicella [Chickenpox]
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Vaccinate after age 12 months
Transmitted by direct contact, droplet & objects
Incubation – 2-3 wks
Contagious from 1 day prior to eruption until all
lesions crusted
Strict isolation in hospital, keep home until all
vesicles crusted
Complications-pneumonia, encephalitis, Reye’s
syndrome
Varicella

DO Case studies from Text CD
Varicella in spite of immunization
Impetigo
Measles (rubeola)
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Transmitted by direct contact with droplets
Incubation: 10 to 20 days
***Koplik spots appear before rash
Fever management – spikes 4th-5th day
Eye care
Cough
Skin Care
Pertussis “Whooping Cough”
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Begins with URI symptoms, low-grade fever
Hacking cough becomes more severe
Transmission: direct contact or droplet
DX: nasal swab sent for C & S
Strict isolation
Monitor for airway obstruction
Group A B-hemolytic Strep
(GABHS)

Streptococcus pyogenes

Strep throat, scarlet fever, skin infection
(impetigo, cellulitis)

Complications – other strep infections,
rheumatic fever, glomerulonephritis
Strep Throat
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Red, sore throat with white patches
Swollen lymph nodes in neck
Incubation 2-4 days
Tx – antibiotic – Penicillin
– must finish course
Group A Beta Hemolytic Strep
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Sequelae
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Strep throat
Otitis media
Scarlet fever
Rheumatic heart disease- follows URI (p.1479)
Acute glomerulonephritis
Kawasaki disease
Juvenile rheumatoid arthritis
CNS – tics
Medications for Tx of GABHS
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Penicillin, Rifampin, Pen G, Biaxin, Azithromycin,
Clindamycin, Amoxicillin Cephalosporin
Emla cream for IV or IM
Check for allergies
Acetaminophen
Avoid ASA –Reye’s syndrome
Immune globulin for Kawasaki disease &
glomerulonephritis
Rheumatic Fever
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Complication of strep infection – 2-3 wks after
Jones criteria – (Box 34-7) pg. 1512
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Ashcoff bodies, polyarthritis, rash, fever
Carditis – can lead to rheumatic heart disease –
damaged mitral valve
Scarlet Fever
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Sore throat, fever and
red rash
Strawberry tongue
Skin desquamates
ADHD
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Behavioural disorder: inattention,
impulsiveness, hyperactivity
Criteria - Box 18-2, pg. 798
Family education & counseling
Medications: Ritalin [75%], Tofranil
Behavioural & psychotherapy
Environment – reduce distractions
Nursing Care
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Medications: usually given 2x a day –
breakfast & noon – begin at low doses
Side effects: wt loss, sleeplessness, nervous
stimulation
Caffeine will decrease effectiveness
Dental caries increase with tricyclics
Effects are OPPOSITE in ADHD than in
regular children – still possible for abuse
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Environment: Consistency is essential
Very structured/routine schedules
Decrease distractions with homework
Improve organizational skills: ie. Charts/lists
of things that need to be done
Do case study from Text CD on Attention
Deficit

Do the NCLEX QUESTIONS on the Text CD
for chapters 16,17, 18, 37, 39, 40