PEDIATRIC
NURSING
Care of the Child and
Family
1
Developmental Theorists
 Maslow’s Hierarchy of Needs (1954)
 Erik Erikson - Psychosocial Theory
 Jean Piaget - Cognitive Theory
2
Maslow’s Hierarchy of
Needs
Principles:
 An individual’s needs are depicted in ascending levels on the
hierarchy
 Needs at one level must be met before one can focus on a higher
level need
Levels of Maslow’s Hierarchy of Needs:

Physiologic/Survival Needs
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Safety and Security Needs
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Affection or Belonging Needs
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Self-esteem/Respect Needs
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Self-actualization Needs
3
TRUST VS. MISTRUST
• Birth - 1 year
– World/Self is good
– Basic needs met
• Met = happy baby
• Unmet = crying, tense, clinging
• Stranger Anxiety
• Separation Anxiety
Photo Source: Del Mar Image Library; Used with
permission
5
AUTONOMY VS.
SHAME & DOUBT
1 – 3 years
– Sense of control
– Exerts self/will
– Pride in self-accomplishment
• Negativism
• Ritualism/Routines
• Parallel play
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permission
6
INITIATIVE VS. GUILT
3 – 6 years
– “Can-do” attitude
– Behavior is goal-directed
and imaginative
– Play is work
– Be careful with criticism
Photo Source: Del Mar Image Library; Used with
permission
7
INDUSTRY VS.
INFERIORITY
6 – 12 years
– Mastery of skills
– Peers in both play and
work
– Rules important
– Competition
– Predictability
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permission
8
IDENTITY VS. ROLE
CONFUSION
12 -18 years
– Sense of “I”
– Peers are very
important
– Independence from
parents
– Self-image
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permission
9
Piaget’s Cognitive
Theory
Development of Thought Processes:
30 – 2 years:
Sensorimotor
32 – 7 years:
Preoperational
37 – 11 years:
Concrete Operations
311 years + :
Formal Operations
10
SENSORIMOTOR
Birth - 2 years
– Reflexive behavior leads
to intentional behavior
– Egocentric view of world
– Cognitive parallels motor
development
– Object Permanence
11
PREOPERATIONAL
THOUGHT
2 - 7 years
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Egocentric thinking
Magical thinking
Dominated by self-perception
Animism
No irreversibility
Thoughts cause actions
Photo Source: Del Mar Image Library; Used with
permission
12
CONCRETE
OPERATIONS
7 - 11 years
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Systematic/logical
Fact from fantasy
Sense of time
Problem solve
Reversibility
Cause & effect
Humor
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permission
13
FORMAL OPERATIONS
11 years - Adult
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Abstract thinking
Analyze situations
New ideas created
Factors altering this:
• Poor
comprehension
• Lack of education
• Substance abuse
Photo Source: Del Mar Image Library; Used with
permission
14
Infant Physical Tasks
Physical Tasks: 0 - 6 months:
 Fastest growth period
 Gains 5-7 oz (142-198 g) weekly for 6 months
 Grows 1 inch (2.5 cm) monthly for 6 months
 Head circumference is equal to or larger than chest circumference
 Posterior fontanel closes at 2-3 months*
 Obligate nose breathers*
 Vital signs: HR and RR faster and irregular*
 Motor: behavior is reflex controlled
sits with or without support at 6 mo*
rolls from abdomen to back
 Sensory: able to differentiate between light and dark
hearing and touch well developed
TOYS = Mirror, Music, Mobile
15
Infant Physical Tasks
Physical Tasks 6 - 12 months:
 Gains 3-5 oz (84-140g) weekly for next 6 months
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* triples weight by 12 months
Gains 1/2 in (1.25 cm) monthly for next 6 months
Teeth begin to come in
Motor:
Intentional rolling over from back to abdomen*
Starts crawling and pulling to a stand*
Develops pincer grasp*
Sits without support by 9 months*
Sensory:
Can fixate on and follow objects
Localizes sounds
16
Infant Psychosocial
Tasks
Vocalizations:
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Distinction in cry at 1 month
Coos at 3 months
Begins to imitate sound at 6 months –
babbles
Verbalizes all vowels at 9 months
Can say 4–5 words at 12 months
Socialization:
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Social smile at 2 months
Demands attention & social interaction at 4
months
Stranger anxiety & comfort habits begin at 6
months*
Separation anxiety develops at 9 months*
Photo Source: Del Mar Image Library; Used with
permission
17
Infant Cognitive Tasks
Neonates
Reflexes only
1-4 months
Recognizes faces
Smiles and shows pleasure
Discovers own body and surroundings
5-6 months
Begins to imitate
7-9 months
Searches for dropped objects
*Object Permanence begins
Responds to simple commands
Responds to adult anger
10-12 months
Recognizes objects by name
Looks at and follows pictures in books
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Physical Tasks:
•
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•
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Toddler
Slow growth period
Gains 11 lbs (5 kg)
Grows 8 inches (20.3 cm)
Anterior fontanel closes at
12 - 18 months*
Primary dentition (20 teeth) complete by 2½
years
Develops sphincter control – toilet training
possible*
Motor Tasks:
•
•
•
Walks alone by 12 - 18 months*
Climbs and runs fairly well by 2 years
Rides tricycle well by 3 years
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permission
19
Toddler Cognitive Tasks
 Follows simple directions by 2 years
 Uses short sentences by 18 months
*favorite words “no” and “mine” = Autonomy
 Knows own name by 12 months, refers to self
 Achieves object permanence
 Uses “magical” thinking
 Uses ritualistic behavior
 Repeats skills to master them and decrease anxiety
 Egocentric thinking - thoughts cause actions
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Toddler Psychosocial Tasks
 Increases independence
 Able to help with dressing self
 Temper tantrums (autonomy)
 Beginning awareness of ownership (me and mine)
 Shares possessions by 3 years
 Vocabulary increases to over 900 words
 Toilet training
 Fears: separation anxiety, loss of control
TOYS = Push-pull toys, large blocks
21
Preschooler
Physical Tasks:
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•
•
Slow growth rate continues
Weight increases 4-6 lbs (1.8–2.7 kg)
a year
Height increases 2½ inches (5-6.25 cm)
a year
Permanent teeth appear
Motor Tasks:
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•
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•
•
Walks up & down stairs
Skips and hops on alternate feet
Throws and catches ball, jumps rope
Hand dominance appears
Ties shoes and handles scissors well
Builds tower of blocks
Photo Source: Del Mar Image Library; Used with
permission
22
Preschooler Cognitive
Tasks
 Can only focus on one idea at a time
 Begins awareness of racial and sexual differences
 Develops an understanding of time
• Learns sequence of daily events
• Able to understand some time-oriented words
 Begins to understand the concept of causality
 Has 2,000 word vocabulary
 Is very inquisitive and curious
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Preschooler Psychosocial
Tasks
 Becomes independent
 Gender-specific behavior is evident by 5 years
 Egocentricity changes to awareness of others
 Understands sharing
 Aggressiveness and impatience peak at 4 years
 Eager to please and shows more manners by 5 years
 Behavior is goal-directed and imaginative
 Play is work*
TOYS = Dolls, Dress-up, Imagination
24
Preschooler Psychosocial
Tasks
Fears: about body integrity (Fear & Injury) are common
Magical and animistic thinking allows illogical fears to develop*
Observing injuries or pain of others can precipitate fear
Able to imagine an event without experiencing it
Guilt and shame are common*
25
School-age
Physical Tasks:
Slow growth continues
Weight doubles over this period
Gains 2 inches (5 cm) per year
At age 9, both sexes are the same size
At age 12, girls are bigger than boys
Very limber but susceptible to bone
fractures
 Develops smoothness & speed in fine
motor skills
 Energetic, developing large muscle
coordination, stamina & strength
 Has all permanent teeth by age 12
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Photo Source: Del Mar Image Library; Used with
permission
26
School-Age Cognitive Tasks
Period of Industry:
• Likes to accomplish or produce
• Interested in exploration & adventure
• Develops confidence
• Rules become important*
Concepts of time and space develop:
• Understands causality, permanence of mass & volume
• Masters the concepts of conservation, reversibility,
arithmetic and reading
• Develops classification skills
• Begins to understand cause and effect*
27
School-Age Psychosocial
Tasks
 School occupies half of waking hours; has cognitive and
social impact on child
 Morality develops
 Peer relationships start to be developed
 Enjoys family activities
 Has increased self-direction - tasks are important
 Has some ability to evaluate own strengths & weaknesses
 Enjoys organizational activities (sports, scouts, etc.)*
 Modesty develops as child becomes aware of own body*
TOYS = Board games, computer games,
learning activities
28
Adolescent
Physical tasks:
Period of rapid growth
Puberty starts
Girls: height increases 3 inches/year
Boys: growth spurt around 13-yrs-old
height increases 4 inches/year
weight doubles between 12-18 yrs
 Body shape changes:
Girls have fat deposits in thighs, hips
& breast, pelvis broadens
Boys become leaner with a broader
chest
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Photo Source: Del Mar Image Library; Used with
permission
29
Adolescent
Sexual Development
Girls
Boys
Breasts develop
Facial Hair growth
Menses begins
Voice changes
First 1 –2 years infertile
Enlargement of testes at 13 yrs
Nocturnal emission during sleep
Reaches reproductive maturity
with viable sperm at 17 yrs
30
Adolescent Cognitive
Tasks
 Develops abstract thinking abilities
 Often unrealistic
 Sense of invincibility = risk taking behavior*
 Capable of scientific reasoning and formal logic
 Enjoys intellectual abilities
 Able to view problems comprehensively
ACTIVITIES = Music, video games,
communication with peers
31
Adolescent Psychosocial
Tasks
Early Adolescent: Prone to mood swings
Needs limits and consistent discipline
Changes in body alter self-concept
Fantasy life, daydreams, crushes are normal
Middle Adolescent: Separate from parents
Identify own values and define self*
Partakes/conforms to peer group/values*
Increased sexual interest
May form a “love” relationship
Formal sex education begins
32
Adolescent Psychosocial
Tasks
Late Adolescent: Achieves greater independence*
Chooses a vocation
Finds an identity*
Finds a mate
Develops own morality
Completes physical and emotional maturity
Fears:
Threats to body image – acne, obesity
Rejection
Injury or death, but have sense of “invincibility”
The unknown
33
Let’s Review
A 10 month-old baby was admitted to the pediatric unit.
Each time the nurse enters the room the baby begins to
cry. The most appropriate action by the nurse would be to:
A. Complete all procedures quickly in order to decrease the
amount of time the baby will cry.
B. Ask another nurse to assist you with the baby’s care.
C. Distract the baby.
D. Encourage the parent to stay by the bedside and assist with
the care.
34
Let’s Review
A 6 month-old is admitted to the pediatric unit for a 3 week
course of treatment. The infant’s parents cannot visit
except on weekends. Which action by the nurse indicates
an understanding of the emotional needs of an infant?
A. Telling the parents that frequent visits are unnecessary.
B. Placing the infant in a room away from other children.
C. Assigning the infant to different nurses for varied contacts.
D. Assigning the infant to the same nurse as much as possible.
35
Let’s Review
Which child is most likely to be frightened by hospitalization?
A. 4 month-old admitted with a diagnosis of bronchiolitis.
B. 2 year-old admitted with a diagnosis of cystic fibrosis.
C. 9 year-old admitted with a diagnosis of abdominal pain.
D. 15 year-old admitted with a diagnosis of a fractured femur.
36
Infant Nutrition
Birth – 6 months:
 Breast milk is most complete diet
 Iron-fortified formulas are acceptable
 No solid foods before 4 months*
6 - 12 months:
Breast milk or formula continues*
Diluted juices can be introduced
Introduction of solid foods*(4-6 mo): cereal, vegetables, fruits, meats
Finger foods at 9-10 months
 Chopped table foods at 12 months
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 Gradual weaning from bottle/breast
 No honey (risk for botulism)
37
Toddler Nutrition
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Able to feed self – autonomy & messy!
Appetite decreases- physiologic anorexia
Negativism may interfere with eating
Needs 16 – 20 oz. milk/day
Increased need for calcium, iron, and phosphorus – risk
for iron deficiency anemia
Caloric requirements is 100 calories/kg/day
No peanuts under 3 years of age (allergies)*
Do not restrict fats less than 2 years of age*
Choking is a hazard (no nuts, hot dogs, popcorn, grapes)*
Photo Source: Del Mar Image Library; Used with
permission
38
Preschooler Nutrition
 Caloric requirements is 90 calories/kg/day
 May demonstrate strong taste preferences
• 4 years old – picky eaters
• 5 years old – influenced by food habits of others
 Able to start social side of eating
 More likely to try new foods if they assist in food preparation
 Establish good eating habits - obesity
39
School-Age Nutrition
 Caloric needs diminish, only need 85 kcal/kg
 Foundation laid for increased growth needs
 Likes and dislikes are well established
 “Junk” food becomes a problem
 Busy schedules – breakfast is important
 Obesity continues to be a risk
 Nutrition education should be integrated into
the school program
40
Adolescent Nutrition
Nutritional requirements peak during years of maximum growth:
Age 10 – 12 in girls
Age 14 – 16 in boys
Food intake needs to be balanced with energy expenditures
Increased needs for:
Calcium for skeletal growth
Iron for increased muscle mass and blood cell development
Zinc for development of skeletal, muscle tissue and sexual maturation
Photo Source: Del Mar Image Library; Used with
permission
41
Adolescent Nutrition
(continued)
Eating and attitudes towards food are primarily
family/peer centered
Skipping breakfast, increased junk food, decreased fruits,
veggies, milk
Boys eat foods high in calories. Girls under-eat or have
inadequate nutrient intake.
42
Let’s Review
The nurse recommends to parents that popcorn
and peanuts are not good snacks for toddlers.
The nurse’s rationale for this action is:
A.
B.
C.
D.
They are low in nutritive value.
They cannot be entirely digested.
They can be easily aspirated.
They are high in sodium.
43
Let’s Review
Nutrition is an important aspect of health promotion
for the infant. Priority information to give the parents
concerning infant nutrition would include (check all
that apply):
A. Restrict the fat intake of the infant to help reduce the
chances of an obese child.
B. Breast or infant formula must be continued for the first
year.
C. Encourage the use of a pacifier for non-nutritive sucking
needs.
D. Introduction of solid foods should begin at 4-6 months.
44
Play is the work of
Children
 Enhances Motor Skills
 Enhances Social Skills
 Enhances Verbal Skills
 Expresses Creativity
 Decreases Stress
 Helps Solve Problems
45
Appropriate Play
Activities
Infants - Solitary Play, stimulation of senses (music, mirror)
Toddler - Parallel Play, make believe, locomotion (push-pull toys),
gross & fine motor, outlet for aggression & autonomy
Preschooler - Associative Play, Imaginary Playmate, dramatic &
imitative, gross & fine motor
School Age - Cooperative Play, rules dominate play, team
games/sports, quiet games/activities, joke books
Adolescent - Group activities predominate, activities involving the
opposite sex in later years
46
Preparation for
Procedures
• Allow child to play with equipment
• Demonstrate procedure on doll for
young child
• Use age-appropriate teaching
activities
• Describe expected sensations
• Use simple explanations
• Clarify any misconceptions
• Involve parents in comforting child
• Praise/reward child when finished
Photo Source: Del Mar Image Library; Used with
permission
47
Communicating with
Children
 Provide a trusting environment
 Get down to child’s eye level
 Use words appropriate for age
 Always explain what you are doing
 Always be honest
 Allow choices when possible
 Allow child to show feelings/talk
48
Let’s Review
The single most important factor for the nurse to
recognize when communicating with a child is:
A.
B.
C.
D.
The child’s chronological age.
Presence or absence of the child’s parents.
Developmental level of the child.
Nonverbal behaviors of the child.
49
Health Promotion
Childhood Immunizations
Well child check-ups
Nutrition
Screenings throughout childhood
(APGARS, newborn screenings, lead poisoning, vision/hearing,
scoliosis)
Health Teaching
50
Immunizations
 Primary prevention of many communicable diseases
 Vaccines safety
• MMR vaccine and autism (no correlation)
• Reactions (pre-medicate with Tylenol)
 Live attenuated vaccines (MMR, Varicella)
• Weakened form of disease
• Body produces immune response
• Contraindicated in immunosupressed individuals
 Inactivated (killed virus/bacteria or synthetic)
• 1st dose only “primes” system- immunity develops after
3rd
51
Injury Prevention
& Safety Issues
 Accidents are the leading cause of death in
infants and toddlers (falls, burns, poisons)
 Toddlers and Preschoolers – drowning
 School-age and adolescents – motor vehicle
accidents and firearms
 90% of all accidents are preventable!
 Safety education is the answer
52
Injury Prevention
 Methods of Injury Prevention
• Understanding and Applying Growth and
Developmental Principles
• Anticipatory Guidance
• Childproofing the environment
• Educating caregivers and children
• Legislation
 Precipitating Factors
 Potential Outcomes
53
Pediatric Poisonings
Highest incidence occurs in children in 2-year-old age
group and under 6 years of age
Major contributing factor – improper storage, allowing
children to play with “bottles” – rattling of pills,
“drink” syrups, toxic portion of plants.
Teach parents about proper storage
Knowledge of plants in household, and keep away from infants
and children who might “chew”
Emergency treatment depends on agent ingested
Teach parents to have poison control number available
Refer to appropriate method according to substance ingested
First Intervention is to call POISON CONTROL CENTER
54
Types of Poisonings
Lead Poisoning
Salicylate Poisoning
Acetaminophen Ingestion
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Lead Poisoning
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Major environmental health concern
Found in older homes (built before 1978), leadcontaminated soil, water through lead pipes, lead-based
paint in ceramics products, Mexican candies made in lead
containers
Body rapidly absorbs lead – specially in periods of rapid
growth – most harmful to children under 6 years
Absorbed in GI tract and accumulates in bones, brain,
kidneys
Low levels in blood can cause behavioral/learning
problems, mid-levels anemia-like symptoms and skeletal
growth interference, and high levels can be fatal from CNS
edema and encephalopathy
Diet high in fat, low in iron & calcium can increase lead
absorption
Intervention=teaching for prevention. If blood level ≥ 45,
chelation therapy is needed – monitor kidney function
during treatment.
56
Salicylate Poisoning
 Can be acute or chronic ingestion
 S/S = nausea, disorientation, vomiting, dehydration,
hyperpyrexia, oliguria, coma, bleeding tendencies,
tinnitus, seizures
 Nursing interventions = activated charcoal, sodium
bicarbonate for metabolic acidosis, external cooling
measures for hyperpyrexia, anticonvulsant and
seizure precautions (think patient safety!), vitamin K
for bleeding, possible hemo (NOT peritoneal)
dialysis
57
Acetaminophen Poisoning
 Most common drug poisoning in children
 Acute ingestion
 S/S start as nausea, vomiting, pallor, sweating »
hepatic involvement (jaundice, confusion, coagulation
problems, RUQ pain)
 Treatment is activated charcoal first, then the antidote
N-acetylcysteine (Mucomyst) PO every 4 hours for 17
doses after a loading dose given
Always assess Level of Consciousness (LOC) before
administering PO med!
58
Let’s Review
Which would be the best approach for gastric
emptying in a lethargic 18-month-old who
ingested antihistamine tablets an hour ago?
A.
B.
C.
D.
Diluting toxic substance with water or milk
Administering naloxone (Narcan)
Gastric lavage
Administering ipecac syrup
59
Physical Assessment of
Infant
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Assessment is NOT in the head-to-toe manner
When quiet, auscultate heart, lungs, abdomen
Assess heart & respiratory rates before temperature
Palpate and percuss same areas
Perform traumatic procedures last
Elicit reflexes as body part examined
Elicit Moro reflex last
Encourage caretaker to hold infant during exam
Distract with soft voice, offer pacifier, music or toy
60
Physical Assessment of
Toddler
 Inspect body areas through play – “count fingers and
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toes”
Allow toddler to handle equipment during assessment
and distract with toys and bubbles
Use minimal physical contact initially
Perform traumatic procedures last
Introduce equipment slowly
Auscultate, percuss, palpate when quiet
Give choices whenever possible
Photo Source: Del Mar Image Library; Used with
permission
61
Physical Assessment of
Preschooler
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If cooperative, proceed with head-to-toe
If uncooperative, proceed as with toddler
Request self undressing and allow to wear underpants
Allow child to handle equipment used in assessment
Don’t forget “magical thinking”
Make up “story” about steps of the procedure
Give choices when possible
If proceed as game, will gain cooperation
Photo Source: Del Mar Image Library; Used with
permission
62
Physical Assessment of
School-Age Child
 Proceed in head-to-toe
 May examine genitalia last in older children
 Respect need for privacy – remember modesty!
 Explain purpose of equipment and significance
 Teach about body function and care of body
63
Physical Assessment of
the Adolescent
 Ask adolescent if he/she would like parent/caretaker
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present during interview/assessment
Provide privacy
Head-to-toe assessment appropriate
Incorporate questions/assessment related to
genitals/sexuality in middle of exam
Answer questions in a straightforward, noncondescending manner
Include the adolescent in planning their care
64
Fever
 Causes – Often unknown, may be due to dehydration,
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most often viral induced
Danger in infants is febrile seizures – most common
between 3 months to five years. The seizure is a result
of how quickly the temperature rises.
Hydration (20mls/kg is formula for bolus)
Antipyretics – acetaminophen or ibuprofen
Cooling measures – avoid shivering
• Tepid bath
• Remove excess clothing and blankets
• Cooling blankets/mattresses
NO ICE PACKS!
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Pediatric Differences
Fluid & Electrolyte
Percent Body Water compared to Total Body Weight:
• Premature infants: 90% water
• Infants: 75 - 80% water
• Child: 64% water
Higher percentage of water in extracellular fluid in infants
Infants and toddlers more vulnerable to fluid and electrolyte
disturbances
Concentrating abilities of kidneys not fully mature until 2 years
Metabolic rate is 2-3 times higher than an adult
Greater body surface area per kg body weight than adults;
dehydrates more quickly
66
Dehydration
• Types:
 Isotonic – Most common; salt and water lost.
Greatest threat – Hypovolemic Shock
 Hypotonic – Electrolyte deficit exceeds water deficitphysical signs more severe with smaller fluid losses
 Hypertonic – Water loss higher than electrolyte
Vomiting leads to metabolic alkalosis
Diarrhea leads to metabolic acidosis
LAB WATCH: monitor sodium, potassium, chloride,
carbon dioxide, BUN, and creatinine
67
Assessment of
Dehydration
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Skin gray, cold, mottled, poor to fair, dry or clammy
Delayed capillary refill
Mucous membranes/lips dry
Eyes and fontanels sunken
No tears present when crying
Pulse and respirations rapid
Irritability to lethargy depending on cause and severity,
not responsive to parent and/or environment
68
Dehydration:
Nursing Interventions
Daily weight, I/O
Assess hydration status
Assess neurological status
Monitor labs (electrolytes)
Rehydrate with fluids both PO and IV (20 mls/kg of
NS)
 Diet progression: Pedialyte modified Bread-RiceApple Juice-Toast (BRAT)  Diet-for-age (DFA)
 Skin care for diaper rash
 Stool output (Amount, Color, Consistency, Texture ACCT)
 HANDWASHING!
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Priorities: fluid replacement & assess for S/S of69
shock
Diarrhea
• Often specific etiology unknown, but rotavirus is most
common cause of gastroenteritis in infants and kids
• Don’t forget contact precautions!!
• Leading cause of illness in children younger than 5
• May result in fatality if not treated properly
• History very important
• Treatment aimed at correcting fluid imbalance and
treating underlying cause
• Metabolic acidosis = blood pH < 7.35
70
Vomiting
• Often result of infections, improper
feeding techniques, GI blockage (pyloric
stenosis), emotional factors
• Management directed toward detection,
treatment of cause and prevention of
complications
• Metabolic alkalosis = blood pH >7.45
71
Let’s Review
The most appropriate type of IV fluid to
infuse in treatment of extra-cellular
dehydration in children is:
A.
B.
C.
D.
Isotonic solution.
Hypotonic solution.
Hypertonic solution.
Colloid solution.
72
Let’s Review
Which laboratory finding would help to
identify that a child experiencing metabolic
acidosis?
A.
B.
C.
D.
Serum potassium of 3.8
Arterial pH of 7.32
Serum carbon dioxide of 24
Serum sodium of 136
73
Pain Assessment: Infants
Assessment of pain includes the use of
pain scales that usually evaluate indicators
of pain such as cry, breathing patterns,
facial expressions, position of extremities,
and state of alertness
Examples: FLACC scale,
NIPS scale
74
Pain Assessment:
Toddlers
Toddlers may have a word that is
used for pain (“owie,” “booboo,” “ouch” or “no”); be sure
to use term that toddler is
familiar with when assessing.
Can also use FLACC scale, or
Oucher scale (for older toddlers)
75
Pain Assessment:
Preschoolers
Think pain will magically go
away
May deny pain to avoid
medicine/injections
Able to describe location
and intensity of pain
FACES scale, poker chips
and Oucher scale may be
used
Photo Source: Del Mar Image Library; Used with
permission
76
Pain Assessment:
Older Children
Older children can describe pain
with location and intensity
Nonverbal cues important, may
become quiet or withdrawn
Can use scales like Wong’s
FACES scale, poker chips, visual
analog scales, and numeric rating
scales
77
Let’s Review
The nurse begins a full assessment on a 10 yearold patient. To ensure full cooperation from this
patient it is most important for the nurse to:
A. Approach the assessment as a game to play.
B. Provide privacy for the patient.
C. Encourage the friend visiting to stay at the
bedside to observe.
D. Instruct the child to assist the nurse in the
assessment.
78
Let’s Review
During a routine health care visit a parent asks the
nurse why her 10 month-old infant is not walking as
her older child did at the same age. Which response
by the nurse best demonstrates an understanding of
child development?
A. “Babies progress at different rates. Your infant’s
development is within normal limits.”
B. “If she is pulling up, you can help her by holding her
hand.”
C. “She’s a little behind in her physical milestones.”
D. “You can strengthen her leg muscles with special
exercises to make her stronger.”
79
Let’s Review
When assessing a toddler identify the order in
which you would complete the assessment:
1.
2.
3.
4.
Ear exam with otoscope
Vital signs
Lung assessment
Abdominal assessment
80
Let’s Review
When assessing pain in an infant it would be
inappropriate to assess for:
A.
B.
C.
D.
Facial expressions
Localization of pain
Crying
Extremity movement
81
Genetic Disorders
7 Principles of Inheritance
g Autosomal Dominant
g Autosomal Recessive
g Sex-linked (X-linked) Inheritance
g Chromosome Alterations
7Down’s Syndrome
7Tay-Sachs Disease
Nursing intervention is supporting parents and resources
82
Down’s Syndrome
• Most common cause of cognitive impairment (moderate to severe)
• 1 in 600 live births
• Risk factor- pregnancy in women over 35 yrs old
• Cause - extra chromosome 21 (faulty cell division)
• Causes change in normal embryogenesis process resulting in:
Cardiac defects, GI conditions, Endocrine disorders, Hematologic
abnormalities, Dermatologic changes
• Physical features: small head, flat facial profile, broad flat nose,
small
mouth, protruding tongue, low set ears, transverse palmar creases,
hypotonia
* Feeding is often a problem in infancy *
83
Tay-Sachs Disease
 Occurs predominately in children of Eastern European Jewish ancestry
 Fatal Disease - death usually occurs before age 4
 Autosomal recessive inheritance
 Degenerative brain disease
 Caused by absence of hexosainidase A from body tissue
 Symptoms: progressive lethargy in previously healthy 2-6 months old
infants, loss of milestones, visual acuity, seizures, hyper-reflexia,
posturing, malnutrition, dysphagia
 Diagnosis: Classic cherry red spot on macula, enzyme measurement in
serum, amniotic fluid, white cells
84
Let’s Review
The infant with Down’s Syndrome is
closely monitored during the first year of
life for which condition?
A.
B.
C.
D.
Thyroid complications
Orthopedic malformations
Cardiac abnormalities
Dental malformations
85
Pediatric Differences
Neurosensory System
Size and Structure:
Rapid head growth in early childhood
Bones are not fused until 18-24 months
Function:
Autonomic Nervous System is intact - neurons are
completely myelinized by 1 year
Infants behavior initially reflexive, but are replaced with
purposeful movement by 1 year
Infants demonstrate a dominance of flexor muscles
Motor development occurs constantly in head to toe
progression
86
Pediatric Differences
Neurosensory System
Eye and Vision:
Changes in development of eye and eye muscles
*strabismus normal until 6 months
Vision function becomes more organized
Papilledema rarely occurs in infants due to expansion of
fontanels with increased ICP
Ear and Hearing:
Hearing fully developed at birth
Abnormal physical structures may indicate genetic problems
87
The Neurosensory
System
Disorders of the Nervous System
3
3
3
3
3
3
Hydrocephalus
Spina Bifida
Reyes Syndrome
Seizures
Cerebral Palsy (CP)
Meningitis
88
Hydrocephalus
• Develops as a result of an imbalance of production and
absorption of CSF
• The increase of CSF causes increased ventricular pressure,
leading to dilation of the ventricles, pressing on skull
• Signs/Symptoms of Increased ICP:
• Poor feeding and vomiting
• Bulging fontanel, head enlargement, separation of sutures
• Lethargy, irritability, restlessness, not responsive to parents
• CHILD - Headache, vomiting, diplopia, ataxia, papilledema
• Seizures
A child’s head with an open fontanel (under 2 years old) has the
ability to expand and better compensate for the increased
intracranial pressure.
89
Ventriculoperitoneal
(VP) Shunts
• Relief of hydrocephalus
• Prevention/treatment of
complications
• Management of problems related to
psychomotor development
• Surgical intervention:
ventriculoperitoneal (VP) shunt
• One-way pressure valve releasing
CSF into peritoneal cavity where it
is reabsorbed
Photo Source: Del Mar Image Library; Used with
permission
90
General Nursing
Interventions
• Monitor Neuro Status





Determine baseline
Assess LOC
Assess motosensory
Pupil checks
Vital signs, Head circ
• Provide Patient Safety




Seizure precautions
Fall precautions
Possible restraints
Determine LOC ac
• Decrease ICP
Cluster care/  stress
Quiet environment
 HOB 30-45 degrees
Appropriate position
(head midline, no hip
flexion, no prone)
 Medications(pain
meds,corticosteroids,
diuretics, stool
softeners, antiinfectives,
anticonvulsants)




91
General Nursing
Interventions
• Maintain Adequate
Cerebral Perfusion
 Maintain airway
 Monitor oxygenation
and apply O2 PRN
 Monitor temperature
and administer
antipyretics PRN
 Maintain normovolemia
 Monitor I/O
 Assess perfusion
• Maintain Nutritional
& Fluid Needs
 Determine swallow
ability prior to PO’s
 NGT feedings may be
necessary
 Dietary consult PRN
 Daily weight
 Monitor lab results
• Psychosocial Support
 Child Life consult
 Teaching
92
Spina Bifida:
Occulta and Cystica
(meningocele and myelomeningocele)
Photo Source: Del Mar Image Library; Used with
permission
• Etilogy is unknown, but genetic &
environmental factors considered.
– Maternal intake of folic acid
– Exposure of fetus to teratogenic drugs
• The severity of clinical manifestations
depend on the location of the lesion.
– T12 - flaccid lower extremities, 
sensation, lack of bowel control and
dribbling urine
– S 3 and lower - no motor impairment
• Other complications may occur.
– Hydrocephalus (80-90%)
– Orthopedic issues such as scoliosis,
kyphosis, club foot
– Urinary retention
– Skin breakdown/Trauma
93
Spina Bifida
Nursing Interventions
•
•
•
•
•
•
•
•
Sterile dressing pre/post-op
Monitor VS, S/S infection
Use latex free items
Avoid stress on sac - prone position only,
especially pre-op; no supine until incision healed
Monitor for S/S  intracranial pressure (ICP)
Interventions to  ICP
Encourage touch & talk
Social service consult
94
Reye’s Syndrome
• A true pediatric emergency - cerebral complications may
reach
an irreversible state. Vomiting & change in LOC to coma
• Acute encephalopathy with fatty degeneration of the liver
causing fluid & electrolyte imbalances, metabolic acidosis,
hypoglycemia, dehydration, and coagulopathies.
• Most frequently seen in children recovering from a
viral illness during which salicylates were given.
• Therapeutic management is intensive nursing care and
maintaining adequate cerebral perfusion, &↓ICP.
Increased ICP secondary to cerebral edema is major
contributing factor to morbidity and mortality.
95
Seizures
• Febrile seizures are the most common in children, caused by
by a RAPID elevation in temperature, usually above 102°.
• Most children do not have a second febrile seizure episode
and only about 3% develop epilepsy.
• Focus of care is on patient safety, cause of fever and
education of parents for home care.
• Remember basic CPR during seizures – airway before oxygen
• Seizure precautions: Suction, oxygen, padded rails
• Infants often have subtle seizures with only occular
movements or some extremity movements.
96
Cerebral Palsy (CP)
1.5 - 5 in 1,000 live births
Neuromuscular disorder resulting from damage or
altered structure of part of the brain
Caused by a variety of factors:
• Prenatally - genetic, trauma, anoxia
• Perinatally - fetal distress, drugs at delivery, precepitate
or breech delivery with delay
• Postnatally - kernicterus or head trauma
97
Cerebral Palsy
(continued)
Spasticity - exaggerated hyperactive reflexes
Athetosis - constant involuntary, purposeless, slow writhing
motions
Ataxia - disturbances in equilibrium
Tremor - repetitive rhythmic involuntary contractions of
flexor and extensor muscles
Rigidity - resistance to flexion and extension
Associated Problems: Mental retardation, hearing loss, speech
defect, dental & orthopedic anomalies, GI problems and visual
changes
98
Cerebral Palsy:
Nursing Interventions
• Safety
Feed in upright position
Seizure precautions
Ambulate with assistance if able
Medication administration
• Special Needs
Nutritional needs include increased calories, assist
with feeds, possible GT feeds.
Speech, Occupational and Physical therapies
99
Bacterial Meningitis
• Infectious process of CNS causing inflammation of meninges and
spinal cord.
• ISOLATION IS MANDATORY
• Signs and symptoms include those of increased ICP plus
photophobia, nuchal rigidity, joint pain, malaise, purpura rash,
Kernig’s and Brudinski’s signs
• Can occur at any age, but often between 1 month-5 years
• Most common sequele: hearing and/or visual impairments,
seizures, cognitive changes
• Diagnostic confirmation is done by lumbar puncture and CSF is
cloudy with increased WBCs, increased protein, and low glucose
• Nursing Interventions include: appropriate IV antibiotics and
meds for increased ICP as well as interventions to decrease ICP
100
Causes of Blindness
Genetic Disorders:
Tay-Sach’s disease
Inborn errors of metabolism
Perinatal: prematurity, retrolental fibroplasia
Postnatal: trauma, childhood infections,
Juvenile Arthritis
101
Causes of Deafness
Conductive:
Interference in transmission from outer ear to
middle ear from chronic OM
Sensorineural:
Dysfunction of the inner ear
Damage to cranial nerve VIII from rubella,
meningitis or drugs
102
Let’s Review
Which test would confirm a diagnosis of
meningitis in children?
A.
B.
C.
D.
Complete blood count
Bone marrow biopsy
Lumbar puncture
Computerized Tomography (CT) scan
103
Let’s Review
In performing a neurological assessment
on a patient which data would be most
important to obtain?
A.
B.
C.
D.
Vital signs.
Head circumference.
Neurologic “soft signs”.
Level of consciousness (LOC).
104
Let’s Review
A neonate born with myelomeningocele
should be maintained in which position
pre-operatively?
A.
B.
C.
D.
Prone.
Supine.
Trendelenberg.
Semi-Fowler.
105
Let’s Review
The nurse witnesses a pediatric patient
experiencing a seizure. The primary
nursing intervention would be:
A. Careful observation and documentation of the
seizure activity.
B. Maintain patient safety.
C. Minimize the patient’s anxiety.
D. Avoid over stimulation and promote rest.
106
Let’s Review
Which assessment finding in an infant first day
post-op placement of a ventriculoperitoneal
(VP) shunt is indicative of surgical
complications?
A.
B.
C.
D.
Hypoactive bowel sounds.
Congestion in upper airways.
Increasing lethargy.
Incisional pain.
107
Cardiovascular System:
Pediatric Variances
 Cardiac arrest is related to prolonged hypoxemia
 Heart Rate (HR) higher
 Cardiac Output depends on HR until heart muscle is fully
developed (around 5 years of age)
 Innocuous (benign) murmurs
 Sinus arrhythmias normal in infants
 Congenital defects present at birth – the greater the
defect,
the more severe the clinical manifestations (S/S)
108
FETAL CIRCULATION
Photo Source: Del Mar Image Library; Used with
permission
109
Cardiovascular System:
Changes from Fetal Circulation
Fetal Circulation - Pattern of Altered Blood Flow
Normal Circulatory Changes at Birth:
Oxygenation takes place in Lungs
Structural changes occur:
* Ductus venosus constricts by 3-7 days
becomes ligamentum venosum
* Foramen ovale closes within first weeks
* Ductus arteriosus functional closure at
24 hours, anatomic closure 1-3 weeks
110
Cardiovascular System:
Changes from Fetal Circulation
Abnormal Circulatory Patterns After Birth
Abnormal openings between the pulmonary
and systemic circulations can disrupt blood flow.
♥Blood will follow the path of least resistance
-Left side of heart has greater pressure, so . . .
♥Blood normally shunted from left to right
Obstructions to pulmonary blood flow may cause right
to left shunting of blood
111
NORMAL HEART
ANATOMY BLOOD FLOW
Photo Source: Del Mar Image Library; Used with
permission
112
The Cardiovascular
System
Y Care of the Child with Congestive Heart Failure
Y Congenital Heart Defects
Increased Pulmonary Blood Flow
Decreased Pulmonary Blood Flow
Obstruction to Systemic Blood Flow
Y Acquired Heart Disease
113
Goals of Nursing Care with
Congenital Heart Disease
Y Reduce workload-Improve cardiac function
Y Improve respiratory function
Y Maintain nutrition to meet metabolic demands
and promote growth
Y Prevent infection and support/instruct parents
114
Congestive Heart Failure
Review
• COMPENSATORY RESPONSES
–
–
–
–
–
–
–
–
–
Tachycardia, especially at rest
Diaphoresis
Fatigue
Poor Feeding
Failure to Thrive (FTT)
Exercise Intolerance
Decreased Peripheral Perfusion
Pallor and/or Cyanosis
Cardiomegaly
115
CLINICAL
MANIFESTATIONS-CHF
• PULMONARY
–
–
–
–
–
–
Tachypnea
Dyspnea
Wheezes
Crackles Retractions
Nasal Flaring
Cough
• SYSTEMIC
– Edema (facial)
– Sudden weight gain
– Decreased Urine
Output
– Hepatomegaly
– Splenomegaly
– Jugular Vein Distention
(JVD, children)
– Ascites
116
CHF: Focused Review
Nursing Interventions
Therapeutic Management
Improve cardiac function – Digitalization; Infant
dose calculated 1000micrograms=1mg, ACE
inhibitors
Diuretics, fluid restrictions, daily weights, I/O
Decrease tissue demands – Promote rest, minimize
stress
Increase tissue oxygenation – Oxygen
Nutrition – Nipple feeds vs. gavage or GT, highercalorie feeds
117
GENERAL NURSING
INTERVENTIONS
• Improve Cardiac Function • Decrease Cardiac Demands
– Medicate
– Promote rest
• Cardiac glycosides
– Minimize Stress
(Digoxin)
– Monitor VS (temp)
• Promote Fluid Loss
• Reduce Respiratory Distress
– Medicate
– HOB elevated
• Furosemide
– Possible supplemental
• Spironolactone
oxygen
• Clorothiazide
• Maintain Nutrition
– Fluid Restriction
– Nipple vs. Gavage/GTT
– Daily Weight
– Higher-calorie feeds
(more than 20 cals/oz)
– Monitor I/O
118
Increased Pulmonary
Blood Flow (Acyanotic)
• Atrial Septal Defect (ASD)
• Ventricular Septal Defect (VSD)
• Patent Ductus Arteriosus (PDA)
• CHF
• Feeding intolerance
• Activity intolerance
• Poor growth, failure to thrive
• Frequent Pulmonary Infections due to “boggy
lungs”
119
Photo Source: Del Mar
Image Library; Used with
permission
120
Decreased Pulmonary
Blood Flow (Cyanotic)
• Pulmonary Stenosis
• Tetralogy of Fallot
• Transposition of the Great Vessels
Assessment findings/Compensatory mechanisms
• Oxygen desaturation
• Varying degrees of cyanosis
• Polycythemia
121
Decreased Pulmonary
Blood Flow (Cyanotic)
Photo Source: Del Mar
Image Library; Used
with permission
122
Obstruction to Systemic
Blood flow
• Aortic Stenosis
• Coarctation of the Aorta
• Think perfusion issues
-Diminished or unequal pulses
-Poor color
-Delayed capillary refill time
-Exercise intolerance
123
Obstruction to Systemic
Blood flow
Photo Source: Del Mar Image Library; Used with
permission
124
Rheumatic Fever
Acquired Heart Disease
Inflammatory disorder involving heart, joints, connective tissue,
and the CNS
Peaks in school-age children
Linked to environmental factors and family history
Thought to be an autoimmune disorder:
Commonly preceded by a Strep Throat
Prognosis depends upon the degree of heart damage
Rest important in recovery – priority intervention in acute stage
Strep prophylaxis for 5 years or throughout adolescence
125
Hematologic System:
Pediatric Variances
All bone marrow in a young child is involved in the
formation of blood cells.
By puberty, only the sternum, ribs, pelvis, vertebrae,
skill, and proximal epiphyses of femur and
humerus are involved in blood cell formation.
During the first 6 months of life, fetal hemoglobin is
gradually replaced by adult hemoglobin.
126
The Hematologic System
 Disorders of Red Blood Cells
 Iron Deficiency Anemia
 Sickle Cell Anemia
 Disorders of Platelets/Clotting Factors
 Idiopathic Thrombocytopenia Purpura (ITP)
 Hemophilia
127
IRON DEFICIENCY
ANEMIA
• Most common nutritional anemia in childhood
• Severe depletion of iron stores resulting in a low
HGB level
• Decreased O2 to tissues = fatigue, headache,
pallor, increased heart rate
• Occurs after depletion of iron stores in body
(6-9 mo of age)
• Most likely to occur during rapid physical growth
and low iron intake
128
IRON DEFICIENCY
ANEMIA
• Often occurs as a result of increased
milk intake
• Lab results show low HGB, HCT,
MCV, MCH, MCHC, iron, ferritin
• Teach parents proper nutrition
• Meat, spinach, legumes, sweet potatoes,
egg yolks, seafood
• Calcium inhibits iron, Vitamin C
enhances iron absorption
129
Sickle Cell Disease
PATHOLOGY
Photo Source: Del Mar Image Library; Used with
permission
 Normal RBC has a flexible, round shape
 RBC w/HbS has a normal shape until it’s O2 delivered to
tissue, then sickle shape occurs
 Stiff, non-pliable – can’t flow freely
 Trapped in small vessels = causes vaso-occlusions, tissue
ischemia and infarctions – painful episodes, most common
area is joints
 Hemolysis of RBC- lifespan down to 20 days
 Compensatory mechanism is increased reticulocytes
130
Sickle Cell Disease
ACUTE FEBRILE ILLNESS
• High mortality rate
<5 years old
• Splenic dysfunction begins
at 6 mo old
• Prophylactic PCN
– BID at 2-3 mo old
• Monitor for Infection
– Temp > 101.5
– Respiratory S/S
SPLENIC
SEQUESTRATION
• Highly vascular
• Susceptible to
injury/infarction
• Occurs 6 mo-3yrs
• Pallor, fatigue, abd pain,
splenomegaly, CV
compromise
• Treatment: IV fluids,
PRBC’s
131
Sickle Cell Disease:
Nursing Interventions
GENERAL NURSING CARE
• Hydration is Priority!
HOME MANAGEMENT
• Pain Control
– Fluid Bolus & maintenance +
• Fluids
1/2
• Teaching
• Oxygen - to decrease sickling of • Early Identification of
of cells
infection
• Pain Management
• Immunizations
– Assess frequently/appropriately
• Avoid dehydration
– IV Morphine q3-4 hr, PCA
– Non-pharmacological methods
132
Idiopathic
Thrombocytopenic Purpura
(ITP)
 Acquired hemorrhagic disorder characterized by
thrombocytopenia and purpura
 Cause is unknown, but is to believed to be an auto-immune
response to disease-related antigens
 Usually follows an URI, measles, rubella, mumps,
chickenpox
 Greatest frequency is between 2-8 years of age
 Platelet count is below 20,000
 Therapeutic management is supportive with safety
concerns. Activity is usually restricted.
 Acute presentation therapy can include prednisone, IV
immunoglobulin, or Anti-D antibody (causes a hemolytic
anemia to rid the body of the antibody-coated RBC’s)
 Chronic ITP will involve a splenectomy.
133
Hemophilia
• Group of genetic bleeding disorders of which there is a
deficiency of a clotting factor
• Most common are Factor VIII (A) & Factor IX (B)
• Bleed LONGER not faster
• Clinical manifestations: prolonged bleeding, bruising,
spontaneous hematuria
• Management: replacement of missing clotting factor
(recombinant factor VIII concentrate), cryoprecipitate,
DDAVP
• NSAIDS (aspirin, Indocin) are contraindicated, they inhibit
platelet function
• Regular non-contact exercise/physical therapy is
encouraged
134
Hemophilia
COMPLICATIONS
• Bleeding into muscle tissue
• Hemarthrosis can cause joint
pain & destruction
• Acute Treatment is rest, ice,
elevation, ROM
Photo Source: Del Mar Image Library; Used with
permission
135
Let’s Review
When assessing a child for any possible cardiac
anomalies, the nurse takes the right arm blood
pressure (BP) and the BP in one of the legs. She
finds that the right arm BP is much greater than
that found in the child’s leg. The nurse reacts to
these findings in which way?
A.
B.
C.
D.
Charts the findings and realizes they are normal.
Suspects the child may have coarctation of the aorta.
Suspects the child may have Tetralogy of Fallot.
Notifies the physician and alerts the surgery team.
136
Let’s Review
A 1-month-old infant is being admitted for
complications related to a diagnosed ventricular
septal defect (VSD). Which physician’s order
should be questioned by the nurse?
A. Blood pressure every 4 hours.
B. Serum digoxin level.
C. Diet: Enfamil 20, nipple 6 oz q2H.
D. Supplemental oxygen via nasal cannula prn maintain
SaO2 >92%.
137
Let’s Review
A nursing intervention most pertinent for the
child with hemophilia is:
A. Sedentary activities to prevent bleeding episodes.
B. Meticulous oral care with dental floss to prevent
infection.
C. Warm compresses to bleeding areas to increase
absorption.
D. Active range of motion exercises for joint mobility.
138
Let’s Review
Which is the most appropriate information to
teach a parent of a 14 month-old child with iron
deficiency anemia?
A. Increase the child’s daily milk intake to a minimum of
24 ounces.
B. Administer oral iron supplement for the child to drink
in a small cup.
C. Increase the amount of dark green, leafy vegetables
and eggs in the child’s diet.
D. Encourage the parents to let the child choose foods he
prefers.
139
Let’s Review
Which strategy is appropriate when feeding the
infant in congestive heart failure?
A. Continue the feeding until a sufficient amount of
formula is taken
B. Bottle feed no longer than 30 minutes
C. Feed the infant every 2 hours
D. Rock and comfort the infant during feedings
140
Respiratory System
Pediatric Variances
 The airway is smaller and more flexible.
 The larynx is more flexible and more susceptible to spasm.
 The lower airways are smaller with underdeveloped








cartilage.
The tongue is large.
Infants < 6 months old are obligate nose breathers.
Chest muscles are not well developed
The diaphragm is the neonate’s major respiratory muscle.
Irregular breathing pattern and brief periods of apnea (10 15 secs) are common
Abdominal muscles are used for inhalation until age 5-6 yrs.
Respiratory rate is higher
Increased BMR raises oxygen needs
141
The Respiratory System
Upper Airway Disorders
Tonsillitis
Croup
Epiglottis
Foreign Body Aspiration
Lower Airway Disorders
Bronchiolitis
Asthma
Cystic Fibrosis
Photo Source: Del Mar Image Library; Used with
permission
142
Tonsillitis
CLINICAL MANIFESTATIONS






Sore throat
Mouth breathing
Sleep Apnea
Difficulty swallowing
Fever
Throat C&S/Rapid Strep
IMPLEMENTATIONS
 Ease Respiratory Efforts
 Provide Comfort
Warm saline gargles
Pain Medication
Throat lozenges
 Reduce Fever
 Promote Hydration
 Administer Antibiotics
 Provide Rest
 Patient Teaching
 Tonsillectomy may be
necessary
143
Tonsillectomy
Pre-operative Nursing Care
Monitor Labs (CBC, PT, PTT)
Age-appropriate Preparation/Teaching
Surgical Consent
Post-operative Nursing Care
Frequent site assessment - visualize!
Monitor for S/S of Complications
Pain Management
Diet (push fluids-no citrus juices or red, advance diet)
Patient Teaching
144
Croup/Epiglottitis
• Infection and swelling of larynx,
trachea, epiglottis, bronchi
• Often preceded by URI traveling
downward
• Causative agent: Viral
• Characterized by hoarseness,
barky cough, inspiratory stridor,
and respiratory distress
• Most common ages 6 mo-3 yrs
• LTB form most common
Photo Source: Del Mar Image Library; Used with
permission
145
Acute Epiglottitis
•
•
•
•
•
•
•
•
Bacterial form of croup affecting epiglottis
LIFE-THREATENING EMERGENCY
Wellness to complete obstruction in 2-6 hours
Most common in ages 2-5 years
Do not examine throat!
Have functional emergency equipment at bedside - Priority!
Often the child is intubated
4 D’s - Drooling, Dysphagia, Dysphonia, Distressed
Inspiratory Effort
• Lateral Neck X-ray shows “thumb sign”
• HIB vaccine has reduced the cases dramatically
146
Croup/Epiglottitis
Nursing Interventions
 Maintain Patent Airway
 Assess and Monitor
 Ease Respiratory Efforts
 Promote Hydration
 Reduce Fever
 Calm Environment
Nursing Interventions
 Administer Meds
 Corticosteroids
 (HHN) Nebulizer
treatment of Racemic
Epinephrine PRN stridor
 Antibiotic for epiglottitis
 Promote Rest
147
Foreign Body Aspiration
• Occurs most often in small children
• Choking, coughing, wheezing, respiratory
difficulty
• Often it is round food, such as hot dogs, grapes,
nuts, popcorn
• Bronchoscopy often needed for removal
• Age-appropriate preparation needed for procedure
• Prevention and parent education is very important
148
Bronchiolitis/RSV
• Acute viral infection of the bronchioles causing an
inflammatory/obstructive process to occur
• Increased amount of mucus and exudates preventing
expiration of air and overinflation of lungs
• Causative agent in 85% of cases is Respiratory Syncytial
Virus (RSV). It is highly contagious - contact isolation
must be enforced.
• Nasal swab or nasal washing obtained for viral panel,
including RSV
• CXR shows hyperinflation and consolidation if
atelectasis present
• Primarily seen in children under 2 years of age
• Most common in winter and early spring
• Palivizumab (Synagis)
149
Bronchiolitis/RSV
CLINICAL MANIFESTATIONS
 Nasal Congestion
 Cough
 Rhonchi, Crackles, Wheezes
 Increased RR & SOB
 Respiratory Distress
 Fever
 Poor Feeding
IMPLEMENTATIONS
 Suction – priority
 Bronchodilator via HHN
 CPT
 Promote fluids
 Monitor VS , SaO2, lung
sounds & respiratory effort
 Supplemental oxygen
 Reduce fever
 Promote rest
 HANDWASHING!
150
Asthma
CLINICAL MANIFESTATIONS
 Tachypnea
 SaO2 below 95% on RA
 Wheezes, crackles
 Retractions, nasal flaring
 Non-productive cough
 Silent chest
 Restlessness, fatigue
 Orthopnea
 Abdominal pain
 CXR = hyperinflation
INTERVENTIONS
 Monitor VS (HR, RR)
 Monitor SaO2
 Auscultate lung sounds
 Monitor respiratory
effort
 Humified oxygen
 Calm environment
 Ease respiratory efforts
 Promote hydration
 Promote rest
 Monitor labs/x-rays
 Patient teaching
151
Asthma
Administer Medications
 Bronchodilator via HHN or MDI with spacer (Albuterol) Peak flows should always be done before and after Tx
 Mast cell inhibitor via HHN or MDI (Cromolyn Sodium Intal)
 Corticosteroid IV or PO (Solu-medrol or Decadron)
 Antibiotic if precipitated from a respiratory infection
Home Medication Management
 Bronchodilator via HHN or MDI with spacer (Albuterol Proventil, Levalbuterol - Xopenex)
 Inhaled steroids (Beclamethasone - Vanceril)
 Mast cell inhibitor via HHN or MDI (Cromolyn Sodium Intal)
 Leukotriene modifiers PO for long-term control - Singular
152
Cystic Fibrosis
1 in 1,500-2,000 live births
Dysfunction of the exocrine gland (mucus producing)
Multi-system disorder
Secretions are thick and cause obstruction and fibrosis of
tissue.
The clinical manifestations are the result of the obstructive
process.
Sweat has a characteristic high sodium- Sweat Chloride Test
Pancreatic involvement in 85% of CF patients
Disease is ultimately fatal. Average age at death: 32 years
153
Cystic Fibrosis
PULMONARY MANIFESTATIONS
• Initial
• Wheezing
• Dry, non-productive cough
• Eventual & Progressive
•
•
•
•
Repeated lung infections
Wet & paroxysmal cough
Emphysema/Atelectasis
Barrel-chest
- Clubbing
- Cyanosis
GI MANIFESTATIONS
• Large, loose, frothy and
foul-smelling stools
• Increased appetite (early)
• Loss of appetite (later)
• Weight loss
• FTT
• Distended abdomen
• Thin extremities
• Deficiency of A,D, E, K
• Anemia
154
Cystic Fibrosis
MANAGEMENT/INTERVENTIONS
– Airway Clearance - Chest physiotherapy (CPT) Priority
– Drug Therapy
•
•
•
•
Bronchodilators - via HHN
Mucolytic Agent (Dnase-Pulmozyme) - via HHN
Antibiotics - via HHN, IV, or PO
Digestive enzymes
 Nutrition - needs are at 150%
• Increased calories and protein - TPN or GT feedings at night
• Additional fat soluble vitamins
• Additional salt with vigorous exercise and hot weather
 Exercise
 Patient Teaching
155
Otitis Media



Most common childhood illness
Inflammation of middle ear
Impaired eustachian tube causes
decreased ventilation and drainage
 Acute otitis media (AOM)
 Infectious process by pathogen
 Infection can spread leading to meningitis
 S/S: pain, pulling on ears, fever, irritability, vomiting, diarrhea, ear
drainage, full/bulging tympanic membrane
 Otitis media with effusion (OME)
 Inflammation of middle ear with fluid behind tympanic membrane-no
infection
 Peaks spring and fall (allergies)
 Chronic otitis media
 Inflammation of middle ear > 3 mo
 Can lead to hearing loss/delayed speech
Photo Source: Del Mar Image Library; Used with
permission
156
Otitis Media
RISK FACTORS
 Secondary smoke
 Formula feeding (positioning)
 Day care
 Pacifier > 6 mo old
TREATMENT
 Antibiotics (for AOM)
 Myringotomy with Pressure
Equalizing (PE) tubes
INTERVENTIONS
 Teaching
 No bottle propping
 Feeding techniques
 Medication regimen
PAIN MANAGEMENT
 Fever management
 Surgery prep if needed
Photo Source: Del Mar Image Library; Used with
permission
157
Let’s Review
The nurse’s first action in responding to a child
with tachypnea, grunting, and retractions is to:
A. Place the child in an upright, semi-fowler’s position.
B. Apply a pulse oximeter to determine oxygen
saturation.
C. Assess for further symptoms.
D. Call for a stat respiratory nebulizer treatment (HHN).
158
Let’s Review
A 3-year-old child is brought to the emergency
room with a sore throat, anxiety, and drooling.
The priority nursing action is to:
A. Inspect the child’s throat for infection.
B. Prepare intubation equipment and call the physician.
C. Obtain a throat culture for respiratory syncytial virus
(RSV).
C. Obtain vital signs and auscultate lung sounds.
159
Let’s Review
An assessment finding in a child with
asthma requiring immediate action by the
nurse is:
A.
B.
C.
D.
Diminished breath sounds.
Wheezing in bronchi.
Crackles in lungs.
Refusal to take PO fluids.
160
Let’s Review
Which sign is indicative of air hunger in an
infant?
A. Nasal flaring.
B. Periods of apnea lasting 15 seconds.
C. Irregular respiratory pattern.
D. Abdominal breathing.
161
Let’s Review
The priority nursing intervention in caring for
the infant with Respiratory Syncytial Virus
(RSV) induced bronchiolitis is:
A. Nasopharyngeal suctioning.
B. Coughing and deep breathing exercises.
C. Administration of intravenous antibiotic.
D. Administration of antipyretics for fever.
162
Gastrointestinal System
• Many GI issues require
surgical intervention
• Nursing interventions will
often include general pre
and post-op care
• Bilious vomiting is a sign
of GI obstruction and
requires immediate
intervention
• Assess stools!
• Assess hydration status
Photo Source: Del Mar Image Library; Used with
permission
163
Gastrointestinal System
Pediatric Variances
• Mechanical functions of digestion are immature at
birth
• Liver functions are immature throughout infancy
• Production of mucosal-lining antibodies is decreased
• Infants have decreased saliva
• Infant’s stomach lies transversely
• Peristalsis is faster in infants
• Digestive processes are mature as a toddler
• The child’s liver and spleen are large and vascular
• Infants and children who vomit bile-colored emesis
require immediate attention
• Gastric acidity is low at birth
164
The Gastrointestinal System
8 Altered Connections
3 Esophageal Atresia/Tracheoesophageal Fistula
3 Cleft Lip and Palate
8 Gastrointestinal Disorders
3
3
3
8
Gastroesophageal Reflux
Hirschsprung’s Disease
Intussusception
3 Pyloric Stenosis
3 Imperforate Anus
Acquired Gastrointestinal Disorders
3 Celiac Disease
3 Appendicitis
3 Parasitic Worms
165
ESOPHAGEAL ATRESIA &
TRACHEOESOPHAGEAL
FISTULA
•
•
•
•
Congenital defects of esophagus
EA is an incomplete formation of esophagus
TEF is a fistula between the trachea and esophagus
Classic 3 “C’s” - coughing,choking,cyanosis
Photo Source: Del Mar Image Library; Used with
permission
166
ESOPHAGEAL ATRESIA &
TRACHEOESOPHAGEAL
FISTULA
SIGNS/SYMPTOM
• Copious, frothy oral
secretions
• Abdominal distension
from air in stomach
• Look for 3 C’s
• Confirmed with
radiographic studies
TREATMENT
• Surgery: either a one- or
two-stage repair
• Pre-op care focuses on
preventing aspiration
and hydration
• Post-op care focus is a
patent airway, prevent
incisional trauma
167
Cleft Lip/Palate
 May present as single defect or combined
 Non-union of tissue and bone of upper lip and




hard/soft palate during fetal development
CL-failure of nasal & maxillary processes to fuse
at 5-8 weeks gestation
CP-failure of palatine planes to fuse 7-12 weeks
gestation
Cleft interferes with normal anatomic structure of
lips, nose, palate, muscles – depending on severity
and placement
Open communication between mouth and nose with
cleft palate
168
Cleft Lip/Palate
 Multidisciplinary care throughout
childhood and early adulthood
 Nutrition is a challenge in infancy
 ESSR method (enlarge, stimulate,
swallow, rest)
 Risk for aspiration
 Respiratory distress
 Altered bonding is a possibility
Photo Source: Del Mar Image Library;
Used with permission
169
CLEFT LIP & CLEFT PALATE:
Operative Care
 Cleft lip surgery by 4 weeks & again at 4-5 yrs
 Cleft palate surgery at 6-24 months of age, usually
done by 1 year so speech will not be affected
 Protect suture lines- priority
 Monitor for infection
 Clean Cleft Lip incision
 Pain Management
 Cleft Palate starts feedings 48-hour post-op:
 Clear and advance to soft diet
 No straws, pacifiers, spouted cups
 Rinse mouth after feeding
170
GASTROESOPHAGEAL
REFLUX
 Regurgitation of gastric contents back




into esophagus - 50% healthy term babies
affected
Related to inappropriate relaxation of
Lower Esophageal Sphincter (LES)
making the LES pressure less than the
intra abdominal pressure
GER may predispose patient to
aspiration and pneumonia
Apnea has been associated with GER
 chance of GER after 12-18 mo old
related to growth due to elongation of
esophagus and the LES drops below the
diaphragm
Photo Source: Del Mar Image Library; Used with
permission
171
GASTROESOPHAGEAL
REFLUX
SIGNS/SYMPTOMS
•
•
•
•
•
•
•
Vomiting/spitting up
Gagging during feedings
Irritability
Arching/posturing
Frequent URI’s/OM
Anemia
Bloody stools
DIAGNOSTIC EVAL
• History of feedings/PE
• Upper GI/Barium
swallow to eliminate
anatomical problems
• Upper GI endoscopy to
visualize esophageal
mucosa
• pH probe study
172
GASTROESOPHAGEAL REFLUX:
Therapeutic Management
• Positioning
• Prone HOB  30°
• Right side
• Dietary modifications
• Medications
• Prokinetic agents: 
LES pressure & gastric
motility
• Histamine H-2
antagonists are added if
esophagitis :  acid
• Proton Pump Inhibitors
if H-2 ineffective:acid
• Mucosal Protectants
• Small, frequent
feedings, burp often
• Possibly thicken
formula
• Avoid fatty, spicy foods
caffeine, & citrus
• Surgery: fundoplication
• Teach
173
HIRSHSPRUNG’S
• Aganglionic megacolon
No ganglion cells at affected area
usually at rectum/proximal
portion of lower intestine
Absence of peristalsis leads to
intestinal distension, ischemia &
maybe enterocolitis
• Treatment
Mild-mod: stool softeners & rectal
irrigations
Mod-severe: single or 2-step
surgery
Colostomy with later pull-through
Photo Source: Del Mar Image Library; Used with
permission
174
HIRSHSPRUNG’S
SIGNS/SYMPTOMS
 Infants
 Unable to pass meconium stool
within 24 hours of life
 Abdominal distention
 Bilious vomiting
 Refusal to feed
 Failure to thrive
 Children
 Chronic constipation
 Pellet or ribbon-like stools (foul-
smelling)
 Vomiting/FTT
NURSING
INTERVENTIONS
• Surgery prep: bowel
cleansing, antibiotics,
NPO, IVF’s, therapeutic
play for surgery
preparation
• Infection & Skin Integrity:
monitor ostomy/anus
• Nutrition & Hydration:
NGT, NPO then advance
to Diet as tolerated, assess
bowel function and
abdominal status
175
INTUSSUSCEPTION
• Prolapse or “telescoping” of
one portion of the intestine
into another
• Abrupt onset
• Usually occurs in 3-24 months
of age
• Sudden abdominal pain
• Vomiting
• Red, current jelly stool
• Abd distention/tender
• Lethargy
• Can lead to septic shock
Photo Source: Del Mar Image Library; Used with
permission
176
INTUSSUSCEPTION
DIAGNOSTIC STUDY
• Barium or air enema
• Abdominal ultrasound
TREATMENT
• Hydrostatic reduction: force
exerted using water-soluble
contrast and air to push the
affected intestine apart
• Surgical reduction if
hydrostatic reduction is
unsuccessful
•
•
•
•
•
NURSING
INTERVENTIONS
Monitor for infection, shock,
pain
Maintain hydration - assess
status!
Prepare child/parent for
hydrostatic reduction teach, consent, NPO, NGT
Monitor stools pre & post
procedure
If surgery: general pre &
post-op care
177
PYLORIC STENOSIS
 Hypertrophy of pyloric sphincter, causing a
narrowing/ obstruction (bands pylorus)
 Usually occurs between 2-8 weeks of age
 Infant presents with non-bilious projectile
vomiting, and is “always hungry”
 Can lead to dehydration and hypochloremic
metabolic alkalosis
 Weight loss
Photo Source: Del Mar Image Library; Used with
permission
178
PYLORIC STENOSIS
DIAGNOSTIC EVAL
• History/PE: “olive”
palpated in epigastrum
• Upper GI (string sign)
• Abdominal Ultrasound
TREATMENT
• Surgical Intervention:
Pyloromyotomy
INTERVENTIONS
• Pre-op: NPO, NGT to
LIS, hydration, I/O,
monitor electrolytes
• Post-op: Start feedings
in 4-6 hrs. Progressive
feeding schedule begin
w/5cc GW half
strength formula  Full
strength formula
179
IMPERFERATE ANUS
• Anorectal malformations
• No obvious anal opening
• Fistula may be present from distal rectum to perineum or
GU system
• Diagnostic Eval: patency of anus in newborn, passage of
meconium; ultrasound is suspected
• Therapeutic Management: manual dilatation for anal
stenosis, surgical treatment for malformations
• Nursing Implementations: pre and post-op care – IV fluids,
consent, assessing surgical site for infection and monitoring
for complications, possible NGT, diet progression, possible
colostomy and teaching; preferred post-op condition is sidelying.
180
Celiac Disease
• Malabsorption syndrome characterized by intolerance of
gluten (rye, oats, wheat and barley)
• Familial disease - more common in Caucasians
• Thought to be an inborn error of metabolism or an
immunological disorder
• Reduced absorptive surfaces in small intestine which causes
marked malabsorption of fats (frothy, foul-smelling stools)
• Child has diarrhea, abdominal distention, failure to thrive
• Treatment is lifelong low-gluten diet; corn and rice are
substituted grain foods
181
APPENDICITIS
• Inflammation and infection of
vermiform appendix, usually
related to an obstruction
• Cause may be bacteria, virus,
trauma
• Ischemia can result from the
obstruction, leading to
necrosis causing perforation
• S/S: periumbilical painRLQ
pain (McBurney’s point), fever,
vomiting, diarrhea, lethargy,
irritability,  WBC’s
• Surgery is necessary
• If ruptured, often child
will receive IV antibiotics
for 24 hrs prior to OR
• Pre-op Care: NPO, pain
management, hydration,
prep & teaching, consent
• Post-op Care: routine
post-op care,
IVF/antibiotics,
NPODAT, ambulation,
positioning, pain
management, wound
care, possible drains.
182
PINWORM
(enterobiasis)
 Transmission: oral-fecal
 Persist in indoors for up to 3 weeks contaminating anything
they contact (toilets, bed linens)
 S/S: intense perianal itch, sleeplessness, abd pain, vomiting
 Scotch tape test – collects eggs laid by female outside of
anus. Must be obtained in am prior to bath or BM.
 Treatment:
*mebendazole (Vermox) for over 2 years of age. Under
2 years of age treatment may be pyrvinium pamoate
(Povan) which stains stool and emesis red
*All family members must be treated.
183
Let’s Review
Which intervention would have the highest priority
for the nurse assisting in the feeding of a child post
cleft palate repair?
A. Permiting the child to choose the liquids desired.
B. Providing diversional activities during feeding.
C. Applying wrist restraints.
D. Cleansing the mouth with water after each feeding.
184
Let’s Review
Which food choice by a parent of a child with
celiac disease indicates a need for further
teaching?
A.
B.
C.
D.
Oatmeal
Rice
Cornbread
Beef
185
Let’s Review
Which assessment finding would the
nurse find in a child with
Hirschsprung’s Disease?
A. Current jelly stool
B. Diarrhea
C. Constipation
D. Foul-smelling, fatty stool
186
Let’s Review
Children with gastroenteritis often receive intravenous
fluids to correct dehydration. How would you explain the
need for IV fluids to a 3 year-old child?
A. “The doctor wants you to get more water, and this is the
best way to get it.”
B. “Your stomach is sick and won’t let you drink anything.
The water going through the tube will help you feel
better.”
C. “See how much better your roommate is feeling with his
IV! You will get better, too.”
D. “The water in the IV goes into your veins and replaces
the water you have lost from vomiting and diarrhea.”
187
Let’s Review
The nurse caring for a child with suspected
appendicitis would question which
physician order?
A. NPO status
B. Start IV fluids of D5 ½ NS at 50 mls/hour
C. Complete Blood Count (CBC)
D. Apply heating pad to abdomen for comfort
188
Genitourinary System
Anatomy & Physiology Review
• The GU system maintains
homeostasis of the body
(water & electrolytes)
• Responsible for the excretion
of waste products
• Nephron is the workhorse of
the kidney (filter blood at the
rate of 125mL/minute)-GFR
• Renin helps maintain Na &
water balance (and B/P)
• Kidneys produce
erythropoeitin which
stimulates RBC production in
marrow
Photo Source: Del Mar Image Library; Used with
permission
189
Pediatric Variances
Genitourinary System
• Infants & young children excrete urine at a higher
rate related to the increased BMR producing more
waste
• Infant kidneys have  function if under stress
• Infant can’t concentrate urine well until 3-6 mo
• In infants, kidney & bladder are abdominal organs
• Infant kidneys are less protected because of
unossified ribs, less fat padding & large size
• Young children have shorter urethras
• Nephrons continue to develop after birth
190
The Genitourinary System
Minimum urine outputs by age groups:
• INFANTS & TODDLERS
– 2-3 ml/kg/hr
• PRESCHOOLERS & YOUNG SCHOOL-AGE
– 1-2 ml/kg/hr
• SCHOOL-AGE & ADOLESCENTS
– 0.5-1 ml/kg/hr
• TIP: Bladder capacity in ounces: AGE in years + 2
Example: a 2-year-old’s bladder can hold up to 4 ounces or 120 mls
191
The Genitourinary System
d Disorders of the Genitourinary System
F
F
F
F
Enuresis
Nephrotic Syndrome
Acute Glomerulonephritis
Hemolytic Uremic Syndrome (HUS)
192
Glomerulonephritis
• Group of kidney disorders that show main focus
of injury is the glomerulus
• It is characterized by inflammation of the
glomerular capillaries
• Acute disorders occur suddenly and resolve
completely
• Acute poststreptococcal glomerulonephritis
(APSGN) is the most common type
• History, presenting symptoms, and lab results
establishes the diagnosis of APSGN
193
Glomerulonephritis
PA THOPHYSIOLOGY
Strep tococcal
Infection
Pro du cing A n tib od ie s
Ba cte ria l A ntige ns
p lu s A n tibo dies f orm
Immu ne Co mplex es
& t rap in Glome rulus
Inflamm atory
R espo nse
In ju ry to Cap illa ry Wa lls
Ine ffective Filtratio n
Pro te in s Pas s Th rou gh
De cre as ed GFR
Kidn eys Enl arge
w ith so dium, w a te r, w as te
ED EMA
AC U TE R EN AL
FAILU RE
Photo Source: Teresa Simbro,
RN, Santa Ana College, Used
with permission.
194
Glomerulonephritis
ASSESSMENT
• Hematuria
• Proteinuria
• Edema: periorbital, ankles
•  Urine Output
• Hypertension
• Fatigue
• Possible fever
• Abdominal discomfort
• Labs: +ASO,  Bicarb,K
BUN, Creat,  H & H
INTERVENTIONS
• Monitor Urine (Dipstick)
• Monitor fluid overload
• Assess lung sounds/Resp
effort
• Possible fluid & salt
restriction
• Monitor I/O, Daily Weights
• Monitor VS
• Antibiotic, diuretic &
antihypertensive
medications
• Promote & provide rest
• Provide comfort measures
• Monitor labs
195
Nephrotic Syndrome
• Kidney disorder characterized by proteinuria, hypoalbuminemia,
and edema.
• There is primary (involving kidney only) and secondary (caused
by systemic disease or heavy metal poisoning) NS. Primary is the
most common (MCNS).
• Cause not fully understood-may have an immunologic component.
• Primary age affected is 2-6 years (boys 2:1)
• There is no occlusion of glomerular vessels.
• Loss of immunoglobulins also occur (IgG)
• Hypovolemia and the severe proteinuria put the child in a
hypercoagulable state
• Treatment is prednisone (2mg/kg/day) for about 4-6 weeks.
Remission is obtained when the urine protein is 0-tr for 5-7 days
• Albumin followed by furosemide may be given for the edema
196
Nephrotic Syndrome
PATHOPHYSIOLOGY
Alteration
in
Glomerulus
Damage to
Basement Membrane
of glomerulus
(inc reased permeabilit y)
Proteinuria
(Hy poalbuminemia)
Fluid Shif t
Intravasc ular to
Interst itial
HYPOVOLEMIA
Dec reased Renal
Blood Flow
Triggers Renin Product ion
Caus ing Increas ed Aldos terone
Reabsorpt ion of Sodium
and Water ret ention
Hy perlipidemia
EDEMA
Photo Source: Teresa Simbro,
RN, Santa Ana College, Used
with permission.
197
Nephrotic Syndrome
ASSESSMENT
INTERVENTIONS
• Proteinuria (3-4+), frothy urine
• Edema (pitting):periorbital,
genitals, lower extremities,
abdominal
•  Urine Output (Hypovolemia)
• Normotensive or hypotensive
• Fatigue
• Recent URI, Pneumonia
• Abdominal Pain/Anorexia
• Labs:
• Monitor Urine (Dipstick)
• Monitor edema/dehydration
• Assess skin integrity/turn
often
• Possible fluid & salt
restriction
• Monitor I/O, Daily Weights
• Monitor VS & S/S of
infection
• Administer medications
• Promote & provide rest
• Monitor labs
• HANDWASHING/monitor
visitors
Albumin
 Platelets
H & H
 Cholesterol
 Triglycerides
198
Hemolytic Uremic
Syndrome (HUS)
• It is the most common cause of acute renal failure (ARF) in
children.
• HUS is characterized by the triad of anemia,
thrombocytopenia, and ARF.
• Most children have associated GI symptoms- almost all are
caused by e. coli 0157.
• Treatment is supportive and based on symptoms.
• No antibiotics are given; more damage can be caused.
• Serum electrolytes may be outside of normal limits.
• Blood transfusions and/or dialysis may be necessary.
• More than 90% of the children recover with good renal
function.
199
Hemolytic Uremic
Syndrome (HUS)
GASTROENTER ITIS
e. coli #0157
Bacteria Adher es t o
GI Mucosa
Mult iplies
Releases Toxins
Damages C apillar y Walls
Inf lammatory Response
Occlusion of Vessels
Thr ombocytopenia
Collect ion of
Fibrin
Lipids
Platelet F ragments
Fr agmented RBC 's
Causing Anemia
(Glomer ular Vessels)
Decreased GF R
Photo Source: Teresa Simbro,
RN, Santa Ana College, Used
with permission.
Acute Renal F ailur e
200
Hemolytic Uremic
Syndrome (HUS)
ASSESSMENT
• History: emesis, bloody
diarrhea, abd pain,  Urine
• Petechiae, bruises, purpura
• Edema (possible CHF)
• Hepatosplenomegaly
• Altered LOC, seizure
• Hypertension
• Fatigue
• Abdominal discomfort
• Labs: Lytes may be abnormal
 BUN
 Creatinine
 H&H
 Platelets
INTERVENTIONS
• Monitor I/O, Daily Weights
• Evaluate for signs of bleeding
• Monitor fluid
overload/edema
• Assess for dehydration
• Monitor VS with neuro
checks
• Seizure Precautions, HOB 
• Diuretic & antihypertensive
medications
• Provide rest/calm
environment
• Provide comfort measures
• Monitor labs closely
201
Enuresis
• Involuntary passage of urine in children whose
chronological or developmental age is at least 5 years of age
• Voiding occurs at least twice a week for minimum 3 months
• More common in boys
• Alteration in neuromuscular bladder function
• Often benign and self-limiting
• Organic factor could be the cause
• Familial tendency
• Emotional factor could be considered
• Therapeutic techniques include: bladder training, night
fluid restriction, drugs (imipramine, oxybutynin, DDAVP)
202
Let’s Review
A clinical finding that warrants further
intervention for a child with acute poststreptococcal glomerulonephritis is:
A.
B.
C.
D.
Weight loss to 1 pound of pre-illness weight.
Urine output of 1 ml/kg per hour.
A normal blood pressure.
Inspiratory crackles.
203
Let’s Review
A 3 year-old is scheduled for surgery to remove a
Wilms tumor from one kidney. The parents ask
the nurse what treatments, if any, will be
necessary after recovery from surgery. The
nurse’s explanation is based on knowledge that:
A.
B.
C.
D.
No additional treatments are necessary.
Chemotherapy may be necessary.
Chemotherapy is indicated.
Kidney transplant is indicated.
204
Let’s Review
Fluid balance in the child who has acute
glomerulonephritis is best estimated by
assessing:
A.
B.
C.
D.
Intake and output
Abdominal circumference
Daily weights
Degree of edema
205
Let’s Review
In evaluating the effectiveness of nursing
actions when caring for a child with
nephrotic syndrome, the nurse expects to
find:
A.
B.
C.
D.
A recurrence of pneumonia.
Weight gain.
Increased edema.
Decreased edema.
206
Pediatric Variances
Musculoskeletal System
Bone Growth:
Linear growth results from skeletal development
Bone circumference growth occurs as new bone tissue is formed
beneath the periosteum
Skeletal maturity is reached by age 17 in boys and 2 years after
menarche in girls (14 yrs)
Bone growth affected by Wolff’s Law - bone grows in the direction
in which stress is placed on it
Certain characteristics of bone affect injury and healing
Children’s bones are softer and are easily fractured
207
Pediatric Variances
Musculoskeletal System
Muscle Growth:
Responsible for a large part of increased body weight
The number of muscle fibers is constant throughout life
Results from increase in size of fibers and increased
number of nuclei per fiber
Most apparent in adolescent period
208
The Musculoskeletal
System
QDisorders of the Musculoskeletal System
m
m
m
m
m
m
Developmental Dysplasia of the Hip
Talipes (Clubfoot)
Osteogenesis Imperfecta
Scoliosis
Muscular Dystrophy
Juvenile Rheumatoid Arthritis
209
Developmental Dysplasia
of the Hip (DDH)
Variety of hip abnormalities – shallow acetabulum,
subluxation or dislocation
Often made in newborn period – often appears as hip joint
laxity rather than dislocation
Ortolani click if < 4 weeks old, older ultrasound needed to
diagnose
Treatment is Pavlik Harness (abducted position) for newborn
to 6 months old – monitor for Avascular Necrosis
6-18 months – traction followed by spica cast
Older children – operative reduction
Priority nursing interventions are skin care and facilitating
normal growth and development
210
Talipes (Clubfoot)
 Most common type is when foot is pointed
downward and inward
 Often associated with other disorders
 May be due to decreased movement in utero
 Treatment requires surgical intervention
 Serial casting is begun shortly after birth and usually
lasts for 8-12 weeks
 Priority nursing interventions are skin care and
facilitating normal growth and development
211
Osteogenesis
Imperfecta (OI)
 Inherited disorder of connective tissue and excessive
fragility of bones
 Pathologic fractures occur easily
 Incidence of fractures decrease at puberty related to
increased hormones making bones stronger
 Treatment is supportive: careful handling of extremities,
braces, physical therapy, weight control diet, stress on home
safety
 Surgical techniques for correcting deformities and for
intermedullary rodding
212
Scoliosis
o Abnormal curvature of the spine (lateral)
o Congenital or develops later, most common during the
growth spurt of early adolescence (idiopathic)
o Diagnosis is made by physical exam and x-rays
o Treatment for curvatures < 40 degrees is bracing
o Surgical intervention is for severe curvatures – internal
fixation and instrumentation (Harrington)
o Postoperative care includes logrolling, neurologic
assessments, pain management, skin care, assessing for
paralytic ileus and possible mesenteric artery syndrome
o Don’t forget the developmental needs of the adolescent
213
Muscular Dystrophy
• Duchenne’s Muscular Dystrophy most common
• Gradual degeneration of muscle fibers
• S/S begin to show about 3 years of age – difficulties in running
and climbing stairs
• Changes to having difficulty moving from a sitting/supine
position
• Profound muscular atrophy continues, wheelchair by 12 yrs
• Respiratory and cardiac muscles affected and death is usually
respiratory or cardiac in nature
• Diagnosis made with physical exam, muscle biopsy, EMG,
serum studies: AST (SGOT), aldolase, creatine phosphokinase
high first 2 years of life
• Nursing care is to maintain optimal level of functioning and to
help the child and family cope with the progression and
limitations of the disease
214
Juvenile (Rheumatoid)
Arthritis
• Inflammatory disease with an unknown cause
• Occurs in children < 16 years; lasts > 6 weeks
• Clinical manifestations: stiffness, swelling, and loss of
motion in affected joints, tender to touch
• Therapeutic management includes drug therapy
(NSAID’s, SAARD’s, cytoxic drugs, corticosterioids),
physical and occupational therapy, exercise
(swimming), moist heat for pain and stiffness, general
comfort measures
215
General Nursing Interventions
for Children with Musculoskeletal
Dysfunctions (immobility)
•
•
•
•
•
•
•
•
Maintain optimal level of functioning
Promote general good health
Facilitate compliance
Facilitate optimal growth and development
Maintain skin integrity
Safety considerations at home
Pain management
Support child and family
216
Let’s Review
An infant is being treated non-surgically
for clubfoot. Which describes a major goal
of care for this patient? Prevention of:
A.
B.
C.
D.
Skin breakdown
Calf atrophy
Structural ankle deformities
Thigh atrophy
217
Let’s Review
The nurse is helping parents create a plan
of care for their child with osteogenesis
imperfecta. A realistic outcome is for this
child to:
A. Have a decreased number of fractures
B. Demonstrate normal growth patterns
C. Participate in contact sports
D. Have no fractures after infancy
218
Let’s Review
During acute, painful episodes of juvenile
arthritis, a priority intervention is initiating:
A. A weight-control diet to decrease stress on the
joints.
B. Proper positioning of the affected joints to
prevent musculo-skeletal complications.
C. Complete bedrest to decrease stress to the joints.
D. High-resistance exercises to maintain muscular
tone in the affected joints.
219
Pediatric Variances
Endocrine System
Growth Hormone:
Does not effect prenatal growth
Main effect on linear growth
Maintains rate of body protein synthesis
Thyroid-stimulating hormone (TSH):
Important for growth of bones, teeth, brain
Secretion decreases throughout childhood and
increases at puberty
Adrenocorticotrophic Hormone (ACTH):
Activated in adolescent
Stimulates adrenals to secrete sex hormones
Influences production of gonadotropic hormone
220
The Endocrine System
Disorders of the Endocrine System
8
8
8
8
Type 1 Diabetes Mellitus
Congenital Hypothyroidism
Growth Hormone Deficiency
Precocious Puberty
221
Type 1 Diabetes Mellitus
Pediatric Considerations
INSULIN
• Most children are well-controlled with BID dosing of
fast acting (Lispro) short acting (regular) and
intermediate acting (NPH, Lente) insulin. There is also
Lantis, an insulin that acts a “basal.”
• U-20 insulin is also available for infants
• Insulin pump, pen
• “Honeymoon” phase
• Stress, infection, illness and growth at puberty can
increase insulin needs
222
Type 1 Diabetes Mellitus
Pediatric Considerations
• HYPOGLYCEMIC EPISODES
• In small children it is more difficult to determine and may
just be a behavior change.
• Treatment is the same – simple sugar – assess LOC first!
• NUTRITION
• Carb counting – most children’s calories should not be
restricted; meal plan might change as child grows.
• Some sweets may be incorporated into the diet and may
help with compliance.
• 3meals with 3 snacks per day
223
Type 1 Diabetes Mellitus
Pediatric Considerations
EXERCISE
• Important for normal growth and development
• Assists with daily utilization of dietary intake
• Enhances insulin absorption, so may decrease
amount needed
• Add 15-30 grams of carbs for each 45-60 minutes of
exercise
• Watch for hypoglycemia with strenuous exercise
224
Type 1 Diabetes Mellitus
Pediatric Considerations
DEVELOPMENTAL ISSUES
• Infant/Toddler
• Autonomy & choices, rituals, hypoglycemia identification difficult
• Preschooler
•
•
•
•
Magical thinking-let them know they did not cause it
Use dolls for teaching
Urine testing may be done
Can choose finger to use for testing
• School-age
• Very busy with school and activities
• Likes tasks and explanations
• Can do self blood testing; injections at age 8-10 years
• Adolescents
• Peers and body image preoccupation
• High risk for non-compliance
• Collaborative health care with parent involvement very important
225
Congenital
Hypothyroidism
• Thyroid is not producing enough thyroid hormone to meet
needs of the body (resulting in↓oxygen consumption, BMR
and protein synthesis)
• Clinical manifestations: cool, mottled skin, bradycardia,
large tongue, large fontanel, hypothermic, hypotonia,
lethargy, feeding problems - THINK SLOW!
• Labs: High TSH, low T4
• Decreased brain development will result with cognitive
impairments
• Part of newborn screening
• Therapeutic management is life-long thyroid hormone
replacement (levothyroxine)
226
Growth Hormone (GH)
Deficiency
• Deficient secretion of growth hormone
• Definitive diagnosis is made with GH levels (using
stimulation testing) under 10mg/ml and x-rays of hand
and wrist for ossification levels
• Treatment is replacement of GH (subcutaneous daily
injections) until goals met
• Nursing care is directed at child and family support
• Remember to interact and speak to the child at her
appropriate developmental level!
227
Precocious Puberty
• Manifestations of sexual development in boys younger
than 9 years and girls younger that 8 yrs
• Causes also an early acceleration of growth with closure
of growth plates
• Therapeutic management is directed toward the specific
cause, if known
• The early secretion of sex hormones will be treated with
monthly subcutaneous injections of leuteinizing
hormone-releasing hormone (LHRH)
• Priority interventions are directed at psychological
support of child and family – encourage play with same
age peers
228
Let’s Review
A child weighing 25 kilograms is being treated with
synthetic growth hormone. The recommended
dosage range is 0.3 – 0.7 mg/kg/week. The
mother informs the nurse that her child receives
1.25 mg subcutaneously at bedtime 6 times per
week. The proper response from the nurse would
be:
A. “That dose is too high, the doctor needs to be
notified.”
B. “You are doing a great job, that is the correct dose for
your child.”
C. “The injection should be given intramuscular, not
subcutaneous.”
D. “That dose is too low based on your child’s new
weight.”
229
Let’s Review
The nurse should include which information in
teaching the parents of a recently diagnosed
toddler with Type 1 diabetes mellitus?
A. Allow the toddler to choose which finger to use for
blood glucose monitoring
B. Allow the toddler to assist with the daily insulin
injections
C. Test the toddler’s blood glucose every time she
goes out to play
D. Let the toddler determine meal times
230
Let’s Review
Which is the most appropriate teaching
intervention for a nurse to give parents of a 6year-old with precocious puberty?
A. Advise the parents to consider birth control for their
child
B. Inform the parents there is no treatment currently
available
C. Explain the importance for the child to foster
relationships with peers
D. Assure the parents there is no increased risk for
sexual abuse.
231
Let’s Review
Number in order of priority the following
interventions needed while caring for a patient in
diabetic ketoacidosis.
_____ Hydration
_____ Electrolyte replacement
_____ Dietary intake
_____ IV Insulin
_____ Subcutaneous insulin
232
Pediatric Variances
Integumentary System
Evaporative water loss is greater in infants/small children
Skin more susceptible to bacterial infections
More prone to toxic erythema
More susceptible to sweat retention and maceration
233
The Integumentary
System
Disorders of the Integumentary System
 Impetigo
 Roseola
 Diaper Rash
234
Impetigo
• Superficial bacterial skin
infection, often secondary
from insect bite
• Highly contagious
• Late summer outbreak
• Toddlers & preschoolers
• Rash is bullous or honeycolored crusted lesions
• Treatment: topical &
systemic antibiotics,
comfort measures,
teaching, preventing
comps
Photo Source: Del Mar Image Library; Used with
permission
235
Roseola
• Transmission: contact
with secretions (saliva)
• Virus
• 6 - 18 months
• Fever »flu symptoms »
rose-pink macular rash
• Fades with pressure
• Treatment is supportive
Photo Source: Del Mar Image Library; Used with
permission
236
Diaper Rash
• Cause could be fungal in nature; assess
mucous membranes for thrush
• Cause could be due to infrequent diaper
changes, an allergic reaction to the diaper
product or diarrhea
• Skin care includes appropriate skin barrier
cream/ointment, keeping area dry
• Teach parents appropriate skin care
237
Medication Administration
Oral Medication
Hold infant with head elevated to prevent
aspiration
Slowly instill liquid meds by dropper along
side of the tongue
Crush pills and mix with sweet-tasting liquid
if permitted, but don’t add too much liquid!
Allow choices for the child such as which
med to take first
Flush following gastrostomy or NG tube
238
Factors to consider when
selecting IM sites
 Age
 Weight
 Muscle development
 Amount of subcutaneous fat
 Type of drug
 Drug’s absorption rate
239
IM and SQ Meds
Select needle length according to muscle size for IM
 Infant - should use 1 inch needle
 Preemies can use 5/8 inch needle
• Use Z-track for iron and tissue-toxic meds
• Apply EMLA or other topical anesthetic 45-60
minutes prior to injection
• May mix medication with lidocaine
• Some medications may be need to be separated
into 2 injections depending on amount
240
Peds IM Injection Sites
 Vastus lateralis for infants
 Ventrogluteal and dorsogluteal
Don’t inject into dorsogluteal until age 3 years - muscle not
well developed until child walks and sciatic occupies a
larger portion of the area.
 Deltoid after 3 years
241
IV Meds
 Site may be peripheral or central
 Administer IV fluids cautiously
 Always use infusion pumps with infants and small
children
 Inspect sites frequently (q 1-2 hours) for signs of
infiltration
 Cool blanched skin, puffiness( infiltration)
 Warm and reddened skin (inflammation)
242
Nose Drops
 Instill in one nare at a time in infants because they are
obligate nose breathers.
 Suction nare with bulb syringe prior to administration
if nasal congestion present
243
Ear Meds
Pull the ear down and back to instill eardrops
in infants/toddler (↓3 years pull ↓)
Pull the ear up and out to instill in older
children (↑ 3 years pull ↑)
Have medication at room temperature
244
Rectal Medication
 Insert the suppository past the anal sphincter
 Hold buttocks together for a few seconds after
insertion to prevent expulsion of medication
It is a very stressful route for children, and the school-age and
adolescent have issues with modesty.
245
Inhalers and Spacers
 Shake the inhaler for 2-5 seconds.
 Position inhaler into spacer (with mask or mouthpiece).
 After normal exhale, place mask on face or mouthpiece in
mouth – both with a good seal.
 Have child inhale slowly after canister is pressed down .
 Have child take a few breaths with a spacer and without a
spacer have them hold breath for few seconds after
medication released.
 Inhalers without spacers aren’t placed in the mouth because
spacers require a seal around mouthpiece; masks with
spacers can be used for infants.
246
MDI with Spacer
MDI with Spacer and Mask
Photo Source: Del Mar Image Library; Used with
permission
247
Let’s Review
The nurse would prepare which site for an
intramuscular injection to a 11 month-old?
A.
B.
C.
D.
Dorsogluteal
Deltoid
Vastus lateralis
Ventrogluteal
248
Pediatric Oncology
Cancer is the leading cause of death from disease in
children from 1 - 14 years.
Incidence: 6,000 children develop cancer per year
2,500 children die from cancer annually
Boys are affected more frequently
Etiologic factors: environmental agents, viruses, host
factors, familial/genetic factors
Leukemia is the most frequent type of childhood cancer
followed by tumors of the CNS system.
249
Oncology Stressful Events
“Treatment is worse than the disease.”
1. Diagnosis
2. Treatment - multimodal
3. Remission
4. Recurrence
5. Death
250
Oncology Interventions
8 Surgery
8 Radiation Therapy
8 Chemotherapy
8 Bone Marrow Transplant
251
Stages of
Cancer Treatment
1.
Induction
2.
Consolidation
3.
Maintenance
4. Observation
5. Late Effects of Treatment
• Impaired growth & development
• CNS damage
• Psychological problems
252
Pediatric Oncology
Types of Childhood Cancers
D
D
D
D
D
D
Leukemia
Brain Tumors
Wilm’s Tumor
Neuroblastoma
Osteogenic Sarcoma
Ewing’s Sarcoma
253
Leukemias
Most common form of childhood cancer
Peak incidence is 3 to 5 years of age
Proliferation of immature WBCs (blasts)
May spread to other sites (CNS, testes)
Types of Leukemia:
 Acute lymphocytic leukemia (ALL)
• 80-85% of childhood leukemia
• 95% chance of remission
 Acute nonlymphocytic Leukemia (ANLL)
• 60-80 % chance of remission
Treatment is chemotherapy: prednisone, allupurinol,
selected chemotherapeutic agents
254
Leukemias
CLINICAL
MANIFESTATIONS
•
•
•
•
•
•
•
•
Purpura, Bruising
Pallor
Fever Unknown Origin
Fatigue, Malaise
Weight loss
Bone pain
Hepatosplenomegaly
Lymphadenopathy
LABS &
DIAGNOSTIC TESTS
↑ WBC’s (50-100) or
Very low WBC’s
↓Hgb, Hct, Platelets
Blast cells in differential
BONE MARROW
ASPIRATION
LUMBAR PUNCTURE
BONE SCAN possible
255
Brain Tumors
Second most prevalent type of cancer in children
Males affected more often
Peak age 3 - 7 years
Types:
Medulloblastoma
Astrocytoma
Brain Stem glioma
Look for S/S of increased ICP and area of brain affected
256
Wilm’s Tumor
 Also known as Nephroblastoma
 Large, encapsulated tumor that develops in the renal
parenchyma (do not palpate abdomen!)
 Peak age of occurrence: 1 - 3 years
 Prognosis is good if no metastases- lungs first
 Treatment is surgery, chemotherapy and sometimes
radiation
257
Neuroblastoma
Highly malignant tumor – extracranial
Often develop in adrenal gland, also found in head, neck,
chest, pelvis
Incidence: One in 10,000
Males slightly more affected
From infancy to age 4
Often diagnosed after metastasis occurs
Treatment includes surgery, chemotherapy and radiation
258
Bone Tumors
Osteogenic Sarcoma:
Occurs most often in boys between 10-20 yrs
10-20% 5 year survival rate
Primary bone tumor of mesenchymal cell
Treatment:surgery (amputation or salvage) and chemo
Ewing’s Sarcoma:
Occurs in boys between 5 - 15 years
Primary tumor arising from cells in bone marrow
Treatment is radiation and chemotherapy
259
Pediatric Oncology:
Nursing Interventions
CHEMOTHERAPY SIDE
EFFECTS
• Leukopenia (Nadir)
• Thrombocytopenia
• Stomatitis
• Nausea/Vomiting
• Alopecia
• Hepatotoxicity
• Nephrotoxicity
NURSING
INTERVENTIONS
• HANDWASHING!
• Monitor visitors
• Monitor for infection
• Meticulous oral care
• Antiemetics ATC
• Monitor Labs
• Support/Teaching
260
Pediatric Oncology:
Nursing Interventions
• Supportive care for radiation treatment,
focusing on skin care
• Surgical interventions are based on location
and type of surgery
• Basic pre and postoperative care
• Psychosocial care for patient and family –
utilize Child Life and Social Services
261
Pediatric Oncology
• Teach, teach, teach!
• Support the child and
family
• Provide resources
• Be honest
• Include the child in the
care planning
Photo Source: Del Mar Image Library; Used with
permission
262
Let’s Review
In caring for the child with osteosarcoma, it is
important for the nurse to inform the child and
family of the treatment plan. Which would be
appropriate?
A.
B.
C.
D.
The affected extremity will have to be amputated.
The child will only need chemotherapy.
Both surgery and chemotherapy are indicated.
Only palliative measures are taken.
263
Let’s Review
The nurse assessing a child who is undergoing
chemotherapy finds the child to be suffering from
mucositis. Which intervention would be the
highest priority?
A. Meticulous oral care.
B. Obtain dietician consult.
C. Place the child on a full liquid diet only.
D. Medicate for pain around the clock.
264
Let’s Review
The priority nursing intervention in caring for
a child with acute lymphocytic leukemia (ALL)
during the child’s nadir period is:
A.
B.
C.
D.
Handwashing.
Monitoring lab results.
Administering antiemetics.
Monitoring visitors.
265
Death & Dying
Child’s Response to Death:
 Infants & Toddlers:
Do not understand
Viewed as a form of separation
Can sense sadness in others
 Preschooler:
Death is temporary
Viewed as sleep or separation
Feel guilty and blames self
Dying children may regress in behavior
266
Death & Dying
School-Age:
Have concept of irreversibility of death
Fear, pain, mutilation and abandonment
Ask many questions
Feel death is a punishment
May personify death (bogeyman)
Will ask directly if they are dying
Interested in the death ceremony
Comforted by having parents and loved ones with them
267
Death & Dying
Adolescent:
Have an accurate understanding of death
Death as inevitable and irreversible
May express anger at impending death
May find it difficult to talk about death
May wish to leave something behind to remember them by
May wish to plan own funeral
268
Death & Dying
Parental responses to death:
Major life stress
Experience grief at potential loss of child
Related to circumstances regarding child’s death (denial,
shock, disbelief, guilt)
Confronted with major decisions regarding care
May have long term disruptive effects on family
Bereaved parents experience intense grief of long
duration
269
Communicating with the Dying
Child and Family
•Use child’s own language
•Don’t use euphemisms
•Don’t expect an immediate response
•Communicate through touch
•Encourage questions and expressions of
feelings
•Strengthen positive memories
•Listen, touch, cry
270
Impending Death Care
Guidelines
Do not leave child alone
Do not whisper in the room
Touching the child is very important
Let the child and family talk and cry
Let parents participate in care as much as they are
emotionally capable of doing
Continue to read favorite stories or play the child’s favorite
music
Be aware of the needs of the siblings
271
Let’s Review
Which intervention would be most helpful in
supporting a dying child’s family as they cope with the
various decision-making periods of a lengthy terminal
illness?
A. Encouraging the parents to take their child home to die.
B. Encouraging the parents to go through all of the KublerRoss stages of dying as quickly as possible.
C. Referring the child’s family to the hospital clergy service
as soon as possible.
D. Using active listening to identify specific fears and
concerns of the child’s family members.
272
Types of Child Abuse
M Neglect:
Intentional or unintentional omission of basic
needs and support
M Physical Abuse:
Is non-accidental injury to a child by an adult
M Sexual Abuse:
Forced involvement of children in sexual
activities by an adult
M Emotional Abuse:
Withholding of affection, use of cruel and
degrading language towards a child by an adult
273
Child Abuse
M Reports of
violence against children has almost
tripled since 1976.
M Many of
the abused children are infants.
“Red Flags”
Fractures in infants
Spiral fractures
Injuries do not match story told
NURSES ARE MANDATED REPORTERS
274
Child Abuse
Neglect



Physical or emotional maltreatment
Failure to thrive
Contributing factors may be ignorance or lack of resources
Physical Abuse




Minor or major physical injury (bruising, burns, fractures)
May cause death
Munchausen by Proxy (MSP)
Shaken baby syndrome (SBS)
Sexual

Incest, molestation, child porn, child prostitution
Emotional


May be suspected, but difficult to substantiate
Impairs child’s self-esteem and competence
275
Child Abuse
Warning Signs





Incompatibility between history of event and injuries
Conflicting stories from various people involved
History inconsistent with developmental level of child
Repeated visits to emergency rooms
Inappropriate response from child and/or caregiver
Nursing Interventions



Assess: Physical assessment and history of event, observe and listen
to caregiver’s and child’s verbal and non-verbal communication
Documentation: Complete CAR form and contact Child Protective
Services, hospital documentation
Support family and child: Social services, resources, teaching
THE CHILD’S SAFETY COMES FIRST
AND IS THE PRIORITY!
276
Let’s Review
In caring for a 4 year-old with a diagnosis of
suspected child abuse, the most appropriate
intervention for the nurse is:
A. Avoid touching the child.
B. Provide the child with play situations that allow for
disclosure of event.
C. Discourage the child from speaking about the event.
D. Give the child realistic choices to feel in control.
277
Let’s Review
Which pediatric patient would most necessitate
further investigation by the community-based
nurse?
A. An adolescent who prefers to spend time with
friends rather than family.
B. A toddler with dark bruises located on both legs.
C. An infant with numerous insect bite marks and
diaper rash.
D. A preschooler with dirty knees and torn pants.
278
Photo Acknowledgement:
All unmarked photos and clip art
contained in this module were
obtained from the
2003 Microsoft Office Clip Art
Gallery.
279