What constitutes a family?

  How is a cultural assessment different for children?  Who does this involve?

Culture has visible and invisible layers.  The behaviors are visible and the history, beliefs, values and religion are not observed and have to be learned and expressed by the children or parent.

Requires knowledge of the target behavior, awareness of the principles that are related to behavioral change, and effective and consistent implantation of consequences.

Growth: refers to an increase in the physical size of a whole or any of its parts or an increase in the number and size of cells.

Development: a continuous, orderly series of conditions leading to activites and patterns of behavior.

Review the purpose of the Denver Developmental Test.

Provide a clinical impression of a child’s overall development and alerts the user to potential developmental difficulties.  125 tasks in 4 areas: Personal-social, Fine motor, Language, Gross motor

What are the functions of play?  

Children play to accomplish developmental task and master the environment.  It is also how children learn about shape, color, cause and effect and themselves.

Pros: Protection against infectious diseases such as diphtheria, tetanus, measles, mumps, etc.

Cons: Complexity of healthcare system, expenses, record keeping by parents and healthcare workers, lack of public awareness, reluctance to give more than 2 vaccines during the same visit.

Understand the components of communication including:

physical proximity, listening, visual communication, tone of voice, body language, and timing

a.     Physical Proximity: Children’s familiarity and comfort with their physical surroundings

b.     Listening: Active listening skills: attentiveness, clarification through reflection, empathy, and impartiality

c.     Visual Communication: Good eye contact

d.     Tone of voice: Soft, smooth voice to infants

e.     Body Language: Open body posture and positioning

f.       Timing: Recognize the appropriate time to communicate information

 Discuss communicating with children who have special needs.

a.     Visual impairment: Self help skills and abilities

b.     Hearing impairment: Identify family’s method of communicating

c.     Speaks another language: Interpreter

d.     Aphonic: Sign Language, writing board

List the special needs, infants birth to 6 mo's, when assessing children.

a. Infants birth to 6 mo’s: Responsive to human faces, do not mind being undressed.  Auscultate the baby’s heart, lungs and abdomen on parent’s lap or exam table without waking baby.  Check primitive reflexes: palmar grasp, plantar grasp, placing, stepping, and tonic neck reflexes.  Leave all uncomfortable procedures, such as abduction of the hips, speculum exam of tympanic membranes, and eliciting the moro reflex until last.  Refocus an unhappy baby by talking in a calm, soft, voice, distracting with a rattle or offering a pacifier.

Same as younger infant.  Distract with toys.  Leave uncomfortable procedures till last: ear, oral, etc.

Least likely to cooperate.  Begin by sitting or standing next to the parent to form a supportive relationship.  To facilitate relaxation: offer books or toys for child to explore.  Communicate with age appropriate words to describe what is  about to be done.  Reassure parent’s that child’s crying and response is normal and have parents help hold child during procedures if necessary.

To establish trust, ask the child questions the child can answer.  Children of school-age will talk about school, favorite friends and activities.  Older children might have to be encouraged to talk about their school performance and activities.  Children prefer a simple drape over their underpants or a colorful examination gown.  This exam is a good opportunity to teach the child about the body and personal care.  Answer questions openly and in simple terms.

Most comfortable with a straightforward, non-condescending approach.  Decisions about who should be present during the exam should be openly discussed with the adolescent.  The parent should be given an opportunity to talk to the nurse about any concerns.  It is best to incorporate the genital examination into the middle of the examination.  If possible proceed from the abdomen to the genital examination to allow ample time for questions and discussions about this part of the exam.  The adolescent is expected to undress and wear a gown and draped appropriately during the exam.

  Head circumference  

              Measured on all children from birth to age 36 months and plotted on a standard growth chart on all visits.  The nurse uses a non-stretching tape and measures in a hat-band position just above the eyebrows and around the occipital prominence in the back.

Growth charts  

The National Center for Health Statistics publishes growth charts: Infant charts for birth to age 3 years relate length, weight, and head circumference to age and relate weight to length.  Charts for ages 2-19 years relate stature, weight and BMI to age.  BMI is used to track overweight children and adolescents.  The 85^th percentile line helps identify children at risk for overweight.

Skin, hair and nails  

Includes inspection and palpation.  The entire skin surface is examined for color, texture, turgor, and presence of lesions.

Skin Color Terminology:

*Vitiligo: Areas of depigmentation

*Nevi: Areas of increased pigmentation

* Jaundice: A yellow discoloration of the skin, best seen in the sclera of the eyes

*Cyanosis: A blue discoloration of the skin, best seen  in all races in the mucous membranes of the mouth, particularly under the tongue

*Carotenemia: An orange color of the skin, best seen on the soles of the feet and palms of the hands.

*Pallor: Loss of skin color

*Erythema: Diffusely red

*Mottling: Discolored areas of the skin

 Lymph nodes  

Inspected and palpated.  Always assess for enlarged lymph nodes in the head and neck, supraclavicular area, and axillary region, the arms, and the inguinal area.  Use the distal portion of the fingers for palpation, gently but firmly in a circular motion.  Lymph nodes that are enlarged warm and firm and fluctuant are a sign of infection.  Lymph nodes that are palpable, small, firm, and shotty( Freely palpable and very small) are normal in healthy infants and children up to 12 y/o.  An enlarged supraclavicular lymph node on the left in young children is called the sentinel node because it may suggest a Wilm’s tumor or other neoplastic disease.

Heart

Inspection

Peripheral vascular system

 Abdomen

The abdomen is divided into four quadrants that correlate with underlying anatomic structures.  The abdomen is first inspected, the auscultated, then percussed, and last palpated.  The child’s comfort should be considered: an empty bladder, warm hands and position the child supine on the examination table with a pillow under the head and knees flexed  enhance abdominal relaxation.

 Inspect the abdomen for contour , symmetry, characteristics of the umbilicus and skin, pulsations, or movement and hair distribution.

Auscultate the abdomen for bowel sounds in all four quadrant (high-pitched, gurgling sounds).  They are irregular and can occur from 5-34 times per minute.  Begin in the lower right  and listen in  for up to 5 minutes to determine if there are no bowel sounds.  The bell of the stethoscope is used to listen for bruits over  the aortic, renal, iliac, and femoral arteries.  The examiner also listen in the epigastric region around the umbilicus for a venous hum- a soft, low-pitched continous sound.

Abdominal palpation can identify any mass or tenderness as well as determine the size, consistency, and location of certain organs. 

 Genitalia

Approaches depend of the child’s growth and development.  In an infant and toddler or young child, the nurse tells the child what will occur and then the parent/guardian concurs that the nurse  can examine the child’s genitalia.  Use a matter of fact approach with male adolescents because they are normally apprehensive about the genital exam.  It should be performed  during or immediately following the abdominal exam.  The cremasteric reflex in young boys may cause testes to withdraw into the inguinal canal making palpation more difficult. 

For females: inspect the labia minora(more prominent) and majora.  In an infant the hymen may protrude and may appear thick and vascular.  The clitoris may appear large.  Normally the Skene’s glands and Bartholin’s glands  should not be swollen or tender.

Observing the child climbing, jumping, hopping,  rising from a sitting postion, and manipulation toys and other objects provides evidence of  joint function, range of motion, bone stability,  and muscle strength.  Assessment of the the fine and gross motor ability is accomplished during the Denver II test for the child younger than 5 y/o.  General inspection begins with visual scanning  of the body with use of a cephalocaudal (head to toe) organization.  Compare the two sides of the body for symmetry, contour, size, and involuntary movement.  The examiner then inspects the two sides for areas of swelling and for ecchymoses.  Common deformities of the extremities are varus and valgus deformities.  A varus deformity is a medial adduction, or turning inward.  A valgus deformity is a deformity is a medial abduction or turning outward.  Deformities of the spine are scoliosis, kypohosis, and lordiosis. 

Palpation of the skull, extremities and ribs for tenderness, swelling, deformity,  or crepitus is performed on any child with a suspected injuries.

Infants: Symmetrical flexion of the arms and legs is noted.  By 2 months old the infant can lift the head while prone.  The examiner observes ROM as the infant spontaneously moves the extremities.  The examiner checks the hips for congenital dislocation by comparing leg lengths.  Look for the top of the knees to be the same height (Allis test).  The Ortolani and Barlow maneuvers are performed by a trained examiner on every visit until 1 y/o.

Toddler/Preschoolers/School-Aged: Start with child’s hand and arms by checking for range of motion and presence of pain.   Lordiosis is common in young children.  Inspect the feet for adduction (toeing in) and pronation (common btwn 12-30 mo’s ).  Adduction usually corrects itself by age 3 y/o as long as the foot is flexible.  Genu varum (bow leg) is present when a space of more than 2.5 cm is measured btwn the knees as the medial and malleoli are held together.  Genu varum is normal after a child begins to walk and may persist until 3 y/o.  Genu valgum means that more than 2.5 cm remains bwtn the medial malleoli when the knees are held together and is presented btwn age 2-3 ½.

Adolescents:  The examiner follows the same sequence as the child but pays special attention to the spine.  Adolescents frequently have kyphosis.  Children age 9-15 often are screened for scoliosis and the nurse needs to know the correct screening procedures.  Girls are the greatest risk from 10y/o-adolescents.  

For the child younger than 5: neurological function is best evaluated with the Denver II test or other reliable and valid developmental screening test.  For the child older than 5 y/o adapt the sequence of the neurological examination to the child’s ability to understand and cooperate. 

Specific Cerebral Function Tests:

1. Sound recognition: Can the child identify far sounds with the eyes closed?

2. Auditory and verbal comprehension: Does the child answer  questions and carry out instructions appropriate for age?

3. Recognition of body parts and sideness: Does the child know right from left?

4. Performance of skilled motor acts: Can the child drink from a cup, button clothes, use a common tool?

5. Visual object recognition: Can the child identify a familiar toy or object?

6. Visual and verbal comprehension: Can the child read appropriately and explain the meaning?

7. Motor speech: Does the child imitate different sounds and phrases?

8. Automatic speech: Can the child repeat series learned? (nursery rhymes, days of the week)

9. Volitional speech: Does the child answer questions relevantly?

10. Writing: Can the child write his or her name or the name of an object?

Tests of Balance and Coordination:

1. Finger to Nose test

2. Rapid Alternating movements: ask the child to rapidly pat his knee with the palms and backs of his hands by pronating and supinating the hands

3. Ask the child erect, first with the eyes open and then with the eyes closed. Stand with the child to prevent injury if the child begins to fall.

4. Ask the child to walk in tandem fashion, placing her heel immediately in front of her opposite foot’s toes and alternating while walking a straight line.

5. Ask the sitting child to run each heal down the opposite shin.  With the child lying down, ask the child to point to your hand with each big toe.

Infants: Allow the use of a pacifier, use a quiet, soothing voice, touch, rock, or cuddle the infant, keep the infant warm, use warming lights if the infant is undressed.  As much as possible, allay parents’ fears so they will not be communicated to the infant.  Remember that infants feel pain.

Toddlers: Give treatments and perform procedures with the toddler sitting up on the stretcher or examining table, or on the parent’s lap.  Perform the most distressing or intrusive parts of the examination last.  Reasssure parents.  Allow the child to have familiar objects with them such as a blanket or toy.  Keep frightening objects out of the child’s line of vision and machines that make loud noises away.  Praise and distraction will decrease anxiety and increase cooperation.

Pre-schoolers: Explain a procedure or treatment a few seconds rather minutes beforehand.  Talk them through procedures, describing the sensations they are feeling or will feel and telling them how they can help.  Distract the child with noises or bright objects.  Counting with some preschool children might help calm them down.  Avoid criticizing the preschool child forcrying, struggling,  or fighting during a procedure.  Reassuring  a child that the child did try his or her best to cooperate will help build a positive self image.  Encourage the preschool child to talk about how the illness or injury occurred.    Explain things in words the child understands.  Use positive terms such as, “make better” and “help” and avoid more frightening terms such as “shot” and “cut.”  Use bandaides over small wounds and injection sites.  Preschool children might imagine their blood  leaking out through puncture wounds.

School Aged during an emergency

School-Age: Offer simple choices whenever possible to help the child feel more in control.  The school-age child is capable of deciding in which arm to have an injection or in which hand to hold a nebulizer.  Talk directly to the child, explaining procedures in simple terms.  When explaining treatment options or care to the parent, include the child.  Ask the child about the level of understanding and allow time for questions.  Address the child’s fears or concerns directly rather than treating then as foolish or inconsequential.  Give rewards such as sticker or an inexpensive  toy, after a procedure regardless of the child’s behavior.

Adolescents: Preserve the adolescents modesty; offer a choice regarding whether they want their parents present when obtaining history and during the examination.  Consider the legal issues regarding the right to privacy for pregnant adolescents and adolescents with sexually transmitted diseases.  Provide an opportunity for questions.  Listen to the adolescents concerns non-judgmentally and without belittling the young person.  Refrain from developing a teasing relationship, the adolescent is easily embarrassed.  Explain procedures or treatments carefully and allow choices.  Adolescents are capable of complex abstract thinking and can make intelligent and reasoned decisions about their own care.

Must be rapid and accurate to identify abnormal findings quickly.  Three essential factors combine to form a first impression: respiratory rate and effort, skin color, and response to the environment

Use bag valve mask: stop inflating the lungs when the chest just begins to rise and allow enough time for exhalation.  Ventilations should be given at a rate of 12-20/min or 1 breath every 3-5 secs.  Each breath should be 1 sec.    Compression/breath ratio: 30/2  Compression rate: 100 per min.   1/3 to ½  depth of chest.

No longer do finger sweeps for choking child.

 Once the airway, breathing and circulation are established, the next priority is adequate vascular access.  A crystalloid infusion of warm normal saline or lactated ringers should be promptly instilled.  After 3  boluses, and hypovolemic shock persists, transfusions of typed and crossmatched packed red blood cells may be considered.

2. Distributive: restoring hemodynamic status with fluid resuscitation and promptly treating the underlying cause. 

Cardiogenic: Supplemental oxygen, vascular access, hemodynamic monitoring and frequent assessments are imperative in shock management.  Invasive monitoring of central venous pressure, arterial blood pressure, and pulmonary artery pressure helps identify hemodynamic changes and subtle clinical signs and symptoms.  Extracorporeal membrane oxygenation is a means of providing short-term circulatory and respiratory support for infants and children in whom other methods of treatment are not effective.

  Discuss the child in a trauma situation.  

Blunt: common cause is motor vehicle accidents.

Waddell’s triad: 1. After being struck by the bumper and hood of the car, the child sustains abdominal or thoracic injuries. 2. The child is then propelled into the air, lands on the ground, and sustains femur or other leg injury, as well as surface trauma. 3. As the child is propelled like a missile to the ground, the large size and weight of the child’s head result in skull fracture or closed head injury to the contralateral side of the head.

Penetrating: Stabbing, firearms, blasting, and impaling objects.

Multiple trauma: Incurs injuries to more than one body system.  Positive outcome depends on rapid assessment and intervention, which begins at the scene of the accident and continue through the trauma center ER. 

The goal of the primary survey is to assess and manage the life-threatening injuries.  The secondary survey is the head to toe assessment and obtains a history of the injury.

What can be done for the child who ingests poison?  

Assess  ABCDEs and stabilize the child.  Oxygen can be given and breathing supported with a bag-valve-mask if necessary.  When the child has ingested a sufficient amount of a substance to cause a rapid deterioration in mental status, an intubation tray should be at the bedside even when the child is awake and alert.  Several methods frequently used to treat toxic ingestions include removal of dermal and ocular toxins(remove contaminated clothes, brushing chemical powders from skin and liberal washing, irrigation of eyes with water and normal saline), dilution of the toxin(with water or milk), administration of activated charcoal, gastric lavage and administration of an antidote (mucomyst and narcan). 

What is the best way to handle a drowning?  

Rescue and removal from the water first.  Prompt iniation of CPR and activation of EMS.  After the childs airway is opened, the nurse suctions the orophaynx to remove mucus and fluid and delivers 100% oxygen by mask or by bag-valve-mask in the child with inadequate respiratory rate or effort.  Overinflation of the lungs must be avoided to prevent a pnemothorax.  Assessment of breath sounds, chest symmetry, and rise and fall central color are more reliable indicators of adequate respirations.  Elevating the head of the bed to 30 degrees may help lower intracranial pressure but should be done only if no spinal injury or shock is present.  A cardiac monitor is used for ongoing assessment of heart rate and rhythm.  V-fib or asystole that is unresponsive to resuscitative efforts can occur in the severely hypothermic child.  Continue resuscitating while warming.  Children have been successfully resuscitated  up to 40 min’s after a cold water immersion.  Two IV lines should be started immediately in critically ill children with submersion injuries.  Because of the electrolyte and fluid shift into the intracellular space, children can become hypovolemic.  A gastric tube  should be inserted to decompress the stomach, ensure full respiratory excursion , and prevent aspiration of stomach contents from vomiting.  If the child is in shock or has experienced significant trauma, typing and crossmatching of 2-4 units of blood should be included. 

What should be done if a child has a dental emergency?  

Time is of the essence in caring for dental injuries.  With injury to the child’s mouth, the nurse observes for missing teeth.  If a missing tooth cannot be found, possible aspiration should be considered in the presence of dyspnea.  A tooth that is loose should not be removed.  Emergency care by the dentist includes cleaning the tooth and socket, placing the tooth in the socket, and splinting the tooth.  Tetanus immunization is given if needed, and an antibiotic may be prescribed.  Parents should be instrcted to keep the tooth moist and can be immersed in saline, water, milk or a commercial tooth-preserving liquid.  The tooth should not be cleaned or scrubbed.  The child should go to the dentist or should go to an emergency facility for care without delay.

Fear of the unknown, separation anxiety, fear of pain or mutilation, loss of control, anger, guilt, regression.

The Infant and Toddler:

1. Separation Anxiety: Stages of separations: protest, despair, detachment

2. Fear of injury and pain: toddlers react to any intrusive procedure whether painful or not

3. Loss of Control: toddlers need routines

The Preschooler:

1. Seperation Anxiety: less direct than toddlers, may refuse to eat or take meds

2. Fear of Injury and Pain: they fear mutilation and intrusive procedures, does not understand body integrity

3. Loss of Control:  Like routines and independance

4. Guilt and Shame:  Their thinking is egocentrical and magical they may think their illness is somehow related to a thought or deed.

The School-Age Child:
1. Separation: related to combination of starting school and hospital

2. Fear of Injury and Pain: concerned with body disability and death , more relaxed about physical exams, understand cause and effect

3. Loss of Control: Movers and shakers: illness will disrupt their social life and self care and activities

The Adoloscent:

1. Separation: Unsure about whether they want parents with them or not, separation from friends causes anxiety

2. Fear of Injury and Pain: appearance is crucial: illness or injury that changes their perceptions of themselves can have a major impact

3. Loss of Control: Feel like they are losing control of their social lives; control conflicts with parents

    List some ways that the nurse can assist children during this stressful period.  

Breathing (blowing bubbles, pinwheels, party blowers) or singing helps with relaxation and offers a focus for the child.  Teaching coping mechanisms and practicing them before a procedure can help a child feel more in control and successful.  Distraction (water wheels, games, books) and imagery for older children are effective tolls for coping.  Parents and child life specialists may all serve as facilitators for these techniques.

What happens to parents when a child is hospitalized?  

May create a situational crisis for family.  Ill children become the parents’ central focus and they become very vigilant and committed to protecting the child and ensuring optimal care.  They may initially deny that their child is ill, especially if their illness is serious.  This period of denial is followed by anger.  Then they go through depression .  At this point, they are usually exhausted both physically and pshychologically.

 How are siblings affected?  

The illness or hospitalization of a brother or sister can be difficult for children.  It may bring jealousy, insecurity, resentment, confusion, and anxiety to the child’s sibling. 

 Identify the needs of families with children who have chronic illness or disorders.

Psychosocial support, reimbursement provisions, health care resources,

Discuss stress points for the parents.  

Unexpected physical setbacks, exacerbations, worsening, or relapse of the condition, as well as the time of death.

1. Establishing and accessing both internal and external sources of physical, social, and financial support.

2. Reframing the situation to identify positive rather than negative aspects

3. Successfully coping that increases family self-efficacy or the belief that the family can problem solve in new ways to meet the new challenges

4. Maintaining high-quality and open communication patterns

5. Being flexible

6. Maintaining social integration

7. Preserving family boundaries

Refer single parents to support groups,  put them in contact with other parents who have a child with a similar chronic condition, or organize group-sharing experiences between parents experienced in the care of the child with a particular chronic condition and parents of newly diagnosed children.

Children's View Illness:

Infants: Potential distortion of differentiation of self from parents or significant others

Toddlers: Perceives external, unrelated concrete phenomena as cause of illness; contagion: that occurs by “magic” (getting a cold because you are near someone who has a cold.

Preschooler: Phenomenism, contagion

School-Age Child: Contamination: perceives cause as a person, object, or an action external to the child that is bad or harmful to the body.  Internalization: perceives illness as having an external cause but being located inside the body.

Adolescent: Physiologic- perceives cause as malfunctiong or nonfunctiong organ or process; can explain illness in sequence of events.  Psychophysiologic-realizes that psychological actions and attitudes affect health and illness.

Children's View of Death:

Infants & toddlers: view death in relation to the loss of a caregiver and the subsequent emptiness in their lives

Preschoolers: view death as a separation or departure and believe it to be only temporary.  Death is also seen as reversible. 

School-Age Children: view death as a sad and irreversible event, yet still may be considered inevitable for only adults

Adolescents: Fully developed understanding of death as inevitable and irreversible

      What can be done to support families with chronically ill children?  Discuss how this affects the mood of the family.

1. Assist the family to achieve a positive, realistic view of the child in relation to the condition by providing appropriate information.  Describe ways the family can continue appropriate behavioral expectations for the ill child within the limits of the child’s condition.

2. Assist the family to identify fears and emotions pertaining to the child’s illness.  Emphasize that these feelings are normal and that appropriate verbalization is a positive and healthy part of coping.

3. Act as a role model for appropriate, accepting , positive attitudes and behaviors concerning the child.

4. Refer the family or child to additional resources (social worker, clergy, professional counselor) when necessary if problems are beyond the nurse’s scope or if the family requests referral.

5. Discuss with the family alternative approaches to maintaining usual routine.

 What are physical signs of impending death?

This phase may last a few hours or days.  The heart rate increases, with a concominant decrease in the strength and quality of peripheral pulses.  Blood pressure also decreases.  Pulses and blood pressure may become difficult or impossible to palpate, a state that can last for hours.  Cardiac changes generally occur before respiratory but not always.  The force of respiratory effort may decline, as evidenced by rapid, shallow breaths.  Cessation may occur after a period of Cheyne-Strokes respirations.  This is a cyclic period of slowing respiratons with apnea, followed by a speeding up speeding up to peak, and then slowing and becoming agonal.  Potentially most distressing is the noisy breathing caused by the rattling secretions in the upper airway.  This rattling often called the death rattle occurs when the child has lost the strength and ability to clear airway secretions. A final gasping noise may occur after respirations and heartbeat have stopped. 

Discuss how death affects families.  How can the nurse assist in this process? 

1. Explain the five stages of grief and their necessity for healthy grieving, including resolution to acceptance.

2. Identify the stage of grief being experienced and provide each family member with the opportunity to verbalize feelings corresponding to that stage.  Provide positive feedback for appropriate progression.

3. Offer all family members the opportunity to verbalize and act out as necessary, all emotions  in an appropriate manner.

4. Exhibit a nonjudgmental attitude toward and acceptance of verbalization and behaviors.

5. Encourage open, honest communication with the child to the degree requested.  Demonstrate appropriate communication techniques.

6. Offer family members the opportunity to participate in the child’s physical care, as desired by both parties.  Demonstrate care in a gentle supportive fashion.

What is informed consent and who can give it?

How can nurses help prepare children for procedures?

       Gather all equipment to be used and check that it functions before beginning procedure.  Explaining procedures includes demonstrating equipment and describing anything the child will feel, see, hear and smell.  Use words the child will understand. 

We have talked about why you need to have blood taken from your arm, but you need to know how important it is for you to hold your arm very still while we are doing this.  I will tell you everything that is going to happen so you can be prepared and know when to help.  Do you think you can help us, or do we need to ask someone to help you remember?

What are some ways that play can be used to help children understand hospital procedures.  Give some examples.

Play can be used to demonstrate what is involved for procedures.  For example, you can give a doll to a child and have the child to pretend to give the doll an IV as well as demonstrate the procedure done on the doll.

Bed baths are generally used for infants and children.  When bathing an infant, soap is not necessary because it dries the skin.  Newborns can be immersed in water after the umbilical stump and circumcision sites have healed.  The temperature of the bath should not exceed 100.0 F.  Before bathing any child, assess the family’s preference and home practices.  An infant who cannot sit unaided can be given either a sponge bath or tub bath while supporting the infant’s body and head at all times during the bath.  Older infants and toddlers can be bathed in either a bedside tub or a regular bath tub.  Older children can take showers if facilities are available.  Privacy is important for adolescents.  Document the type of bath, child or parent participation, procedure tolerance and any abnormal findings noted.

Treatment can consist of environmental measures, antipyretics, or a combination of interventions.  Dressing the child appropriately, providing adequate fluids, monitoring for signs of dehydration.

Prevent transmission of droplet nuclei, or dust particles, containing infectious agents (Measles, TB, Varicella, Zoster, SARS)

Droplet Precautions: Negative Pressure Room for TB, Private, Keep door closed, Orange (duckbill) mask required to enter room.

Mask In addition to wearing a mask as outlined under Standard Precautions, wear a mask when working within 3 ft of the patient. (Logistically, some hospitals may want to implement the wearing of a mask to enter the room.)

Patient Placement: Place the patient in a private room. If a private room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganism but with no other infection (cohorting). When a private room is not available and cohorting is not achievable, maintain spatial separation of at least 3 ft between the infected patient and other patients and visitors.

Vesicular rash, maculopapular rash with coryza and fever, cough and fever and upper lobe pulmonary infiltrate, cough and fever and any infiltrate and HIV infection.

Place the patient in a private room that has: 1) monitored negative air pressure in relation to the surrounding areas; 2) 6 to 12 air changes per hour; and 3) appropriate discharge of air outdoors or monitored high-efficiency filtration of room air before the air is circulated to other areas in the hospital. Keep the room door closed and the patient in the room. If a private room is not available, place the patient in a room with a patient who has active infection with the same microorganism but with no other infection.

Respiratory Protection:  Wear respiratory protection when entering the room of a patient with known or suspected infection.

Patient Transport: Limit the movement and transport of the patient from the room to essential purposes only. If transport or movement is necessary, minimize patient dispersal of droplet nuclei by placing a surgical mask on the patient, if possible.

Used to prevent transmission of epidemiologically important organisms from an infected or colonized patient through direct touch or indirect contact.

Place the patient in a private room. If a private room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganism but with no other infection.

In addition to wearing gloves as outlined under Standard Precautions, wear gloves  when entering the room. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and surfaces, and before going to another patient or leaving the room, and wash hands immediately. After glove removal and handwashing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient’s room to avoid transfer of microorganisms to other patients or environments.

In addition to wearing a gown as outlined under Standard Precautions, wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room. Remove the gown before leaving the patient's environment. After gown removal, ensure that

clothing does not contact potentially contaminated environmental surfaces to avoid transfer of microorganisms to other patients or environments.

Gastric lavage involves the passage of a tube via the mouth or nose down into the stomach, followed by sequential administration and removal of small volumes of liquid. The placement of the tube in the stomach must be confirmed either by air insufflation while listening to the stomach, by pH testing a small amount of aspirated stomach contents, or x-ray. This is to ensure the tube is not in the lungs. In adults, small amounts of warm water or saline are administered and via a siphoning action removed again. In children, normal saline is used, as children are more at risk of developing hyponatremia if lavaged with water. Because of the possibility of vomiting, a suction device is always on hand in case of pulmonary aspiration of stomach contents. Lavage is repeated until the returning fluid shows no further gastric contents. If the patient is unconscious or cannot protect their airway then the patient should be intubated before performing lavage.

Force-feeding, which in some circumstances is also called gavage, is the practice of feeding a person against their will.  Force-feeding is generally carried out by passing a feeding tube through the nose or mouth into the esophagus.  Neonatology Nasogastric feeding of Pts–eg, premature infants with weak sucking reflexes or nasogastric hyperalimentation

What principles need to be considered during oxygen therapy?

-The size of the equipment is smaller for children

-Teaching and emotional support needed for children and family

-A oxygen hood is used often for infants

-A nasal cannula, blow by oxygen, and a facemask is better tolerated by older  infants and toddlers

-Children experiencing difficulty breathing may be less cooperative when attempting to put on a mask

-Flow rate should not exceed 6L/per min for nasal cannula

      Discuss how children metabolize medications.

Most medications are metabolized in the liver.  Because the metabolic enzyme systems are less mature in newborn and premature infants, they might not be able to properly metabolize all the medication in a prescribed dosage.  Toddlers and preschoolers can have a much a greater metabolizing capacity than adults do for certain drugs.  For this reason, larger dosages or more frequent administration of certain drugs might be needed for young children to achieve therapeutic results. 

  List effective ways of administering medication to children.

 1. Adhere to the “six rights of medication administration: right child, right dose, right time, right route, and right documentation.

2. Check the orders to be sure that all information is correctly transcribed.  Note any allergies.

3. Always double-check medication calculations before administration.  Be sure the child’s weight is accurately recorded.

4. Double-check calculations of medications provided by the pharmacy  in a unit dose form.  Consult with the physician or pharmacist if there is any question about a dose. 

5.  Ask another nurse to double check the following medications and others required the following medications and any others required to be doubled checked by agency policy.

  How does one administer otic drops?

1. Explain procedure to child in age appropriate terms and describe how the child can help.  Assistance may be needed in holding a young child.

2. Gather the following equipment: otic drops and cotton pieces.  Use appropriate hand hygiene before and after procedure.

3. Position the child lying down with the affected ear up or sitting with the head turned so the affected ear is up.

4. Brace the administrating hand against the child’s head above the ear.

5. If the child is 3years or younger, pull the pinna of the ear back and down, holding near the lobe.  If the child is older than 3 years, pull the pinna back and up.

6. Insert the required number of drops.  Then gently massage the tragus (anterior portion) to ensure that the drops reach the tympanic membrane.

7.  Pack the cotton loosely into the canal, if ordered.  Instruct the child not to remove the cotton or place anything inside the ear.

8.  Keep the child on the unaffected side for several minutes after administration in both ears, the procedure should be repeated in the other ear after a wait of at least 1 minute.

9.  Document the medication.

Opthalmic Drops 

1. Explain the purpose for the medication.  Tell the child how to help with the procedure.  Explain that the child may have blurred vision for a short time afterward.

2. Gather needed equipment: eyedrops, gauze pads, and tissues.  Use appropriate hand hygiene before and after procedure.  Wear gloves if contact with exudates is expected.

3. Assist the child into a supine position with the neck slightly hyperextended (by placing a rolled towel or small blanket under the shoulder blades)

4. If the drops are to be instilled into an infant’s eyes, obtain assistance in holding the child’s arms and head or use a mummy wrap as necessary.

5. Instruct an older child to look upward and gently pull the lower lid down and away from the eye.

6. Place the drops or a ribbon of ointment into the space between the eye and lower lid, taking care not to contaminate the end of the dropper or tube.

7. If both drops and ointment are ordered, the drops should be administered first.  If they are placed after the ointment, they will not be absorbed.

8. Have the child look down as the lower lid is released.  Encourage the child to close both eyes and keep them closed for several seconds.  Hand the child a tissue to gently blot and excess medication.

9. As with any procedure, praise the child for cooperation and assistance.  Document the medication.

Nurses must consider the following:

1. Type of IV solution

2. Compatibility of the medication and the IV solution

3. Dilution volume of the medication

4. Amount of flush needed

5. Administration rate

To prevent fluid overload in children receiving IV therapy, IV fluids or medications are through an infusion pump that delivers a preset volume at an hourly rate.  Children also have smaller tubing and the IV sites are not changed every 72 hours like adults because of difficulty finding a site.

Myths:

-Neonates do not feel pain because of incomplete myelinization in peripheral nerves and the CNS

-Children have no memory of pain

-There is a correct or given amount of pain for a specific injury or procedure-induced pain.

-Children can easily become addicted to narcotic analgesics.

-Narcotic administration can easily cause respiratory depression.

 Tell how you would assess the pain level of a child.  

Neonate and Infant:

-Usually demonstrates changes in facial expression, including frowns, grimaces, wrinkled brow, expression of surprise, and facial flinching

-May demonstrate increases in BP and HR and decrease in arterial saturation.

-High-pitched, tense, harsh crying

-The neonate and young infant usually demonstrate a generalized or total body response that becomes more purposeful as the infant matures.

-May thrash extremities; may exhibit tremors

-Older infants may localize the pain, rubbing the painful area or pull away, or guard the involved part.

 Tell how you would assess the pain level of a child. 

Toddler:

-Likely to demonstrate loud crying

-Able to verbalize words that indicate discomfort such as “ouch, hurt or boo boo”

-May attempt to delay procedures perceived as painful

-May demonstrate generalized restlessness

-May guard the site

-May touch painful areas

-May run from the nurse

 Tell how you would assess the pain level of a child. 

Preschooler:

-May think the pain is punishment for something he or she has said or done

-Likely to cry and struggle

-Able to describe the location and intensity of pain (ear hurts bad)

-May demonstrate regression to earlier behaviors, such as loss of bladder and bowel control

-May deny pain to avoid a possible injection

-May have been told to “be brave” and deny pain, even though it is present

 Tell how you would assess the pain level of a child. 

School-Age Child:

-Able to describe pain and quantify pain intensity

-Fears bodily injury

-Has an awareness of death

-May demonstrate withdrawal

-May demonstrate stiff body posture

-May procrastinate or bargain to delay procedure

 Tell how you would assess the pain level of a child. 

Adolescent

-Perceives pain at a physical, emotional, and cognitive level.

-Understands cause and effect

-Able to describe pain and quantify pain intensity

-May have increased muscle tension

-May demonstrate withdrawal and decreased motor activity

-May use words such as “sore, ache, or pounding” to describe pain

Analgesics can be administered: oral, rectal, intranasal, topical, transdermal, intravenous (IV), intramuscular (IM), subcutaneous, and epidural.  The lease invasive route should be chosen and as soon as the child can tolerate, the medications should be given orally.  Older children (5 yr and up) may receive a PCA pump for pain control.  Frequent pain assessments should be done and if the pain is not controlled and the vitals are stable, more medication would be needed.

What opoiod is best for children and why?

Morphine: it can reach its peak effect 10-20 minutes after IV administration and 1 hr after oral administration.

Discuss transmission of pathogens.  

Direct: Droplets, Saliva, Blood, Urogenital, Fecal, Objects

Animal Insect: Bites, Scratches, Fecal

1. Live or attenuated vaccines: Viruses that have their virulence (potency) diminished so as to not produce  a full-blown clinical illness.

2. Killed or inactivated vaccines: Vaccines that contain pathogens made inactive by either chemicals or heat.

3. Toxoids: Bacterial toxins that have been made  inactive by either chemicals or heat.

4. Human immune globulin: pooled blood from many people

5. Animal serums: Vaccines derived from the serum of immunized animals.

Viral Infections:

Rubeola (measles)

Causative agent: RNA virus

Incubation period: 8-12 days from exposure to onset of symptoms

Infectious period: Ranges from 3-5 days before the appearance of the rash to 4 days after appearance of the rash.

Transmission: Transmitted between individuals by direct contact with infectious droplets or less frequently by airborne spread

Immunity: Natural disease or live attenuated vaccine

Season: Late winter and spring

  Viral Infection:

Rubella (three day measles)

Causative agent: RNA virus

Incubation period: 14-21 days

Infectious period: Ranges from 7 days before the onset of symptoms to 14 days after appearance of the rash.

Transmission: Airborne particles or direct contact with infectious droplets, transplacental transmission; small number of infants with congenital rubella continue to shed the virus for months after birth.

Immunity: Natural disease or live attenuated vaccine

Season: Late winter and early spring

Viral Infection:

Erythema Infectoiosum (fifths disease)

Causative agent: Parvovirus

Incubation period: 4-14 days but can be up to 21 days

Infectious period: Unknown but thought to extend from the prodromal period until the rash appears.

Transmission: Airborne particles, respiratory droplets, blood, blood products,  transplacental transmission

Immunity: Natural disease is thought to provide antibodies for immunity

Season: Winter and spring

Viral Infection:

Mumps

Causative agent: Paramyxovirus

Incubation period: 16-18 days but may extend to 25 days

Infectious period: From 7 days before swelling to 9 days after onset

Transmission: Airborne droplets, salivary secretions, possibly urine

Immunity: Natural disease or live attenuated vaccine

Season: Late winter and spring

Viral Infection:

    Varicella Zoster

Causative agent: Varicella-zoster virus

Incubation period: 10-21 days

Infectious period: 1-2 days before the onset of rash until all lesions all dried (crusted over), usually 5-7 days

Transmission: Direct contact, droplet, airborne particles

Immunity: Natural disease of varicella; same virus causes zoster, and child may contract zoster at a later time; varicella vaccine

Season: Late winter and early spring

Viral Infection

     Small pox

Causative agent: Smallpox (Variola virus)

Incubation period: Averages 12 days, with a range of 7 to 17 days

Infectious period: At the appearance of mouth lesions a skin rash becomes visible and the client is the most contagious during this time and remains contagious until all of the lesions have scabbed over have dried and fallen off.

Transmission: Transmitted through droplets via direct and prolonged face-to face contact with an infected person; less commonly, smallpox can be transmitted through contact with contaminated objects.

Immunity: Live vaccinia virus

Season: Not confined to a particular season

Viral Infection:

     Cytomegalovirus

Causative agent: Human cytomegalovirus (CMV)

Incubation period: Unknown, except for 3 to 12 weeks after blood transfusions and 4 weeks to 4 months after organ (tissue) transplantation.

Transmission: Saliva, urine, blood, semen, cervical secretions, breast milk, organ transplants

Immunity: None, although CMV immune globulin, used only in seronegative transplant clients, has had moderate effectiveness

Season: Can occur during any season.

Viral Infection

Epstein Barr

Causative agent: Epstein-Barr Virus (EBV, a herpeslike virus)

Incubation period: 4-7 weeks

Infectious period: Unknown; the virus is commonly shed before clinical onset of disease until 6 months or longer after recovery; asymptomatic carriers are common

Transmission: Saliva, intimate contact, blood

Immunity: Natural disease

Season: Can occur during any season

Viral Infection:

     Poliomyelitis

Causative agent: Poliovirus (an enterovirus)

Incubation period: 3 to 6 days for abortive poliomyelitis

Infectious period: Shortly before and after the onset of clinical illness when the virus is in the throat and in high concentration in feces; the virus is shed in the pharynx for 1 week after onset and in the feces for several weeks to months.

Transmission: Fecal-oral, oral-oral (respiratory)

Immunity: Inactivated poliovirus (IPV) and oral poliovirus (OPV) vaccines

Season: Summer and Fall

Bacterial Infection

 Diptheria:  

Causative agent: Cornynebacterium diphtheria (gram-positive, nonmotile bacillus)

Incubation period: 2-7 days

Infectious period: Ranges from 2 weeks or less to several months in an untreated individual

Transmission: Contact with carrier or disease, droplets

Immunity: Vaccine with boosters, passive immunity from maternal antibodies, natural disease

Season: Fall and Winter

Bacterial Infection

     Pertussis (Whooping Cough)

Causative agent: Bordetella pertussis (a gram-negative bacillus)

Incubation period: 6 to 20 days

Infectious period: Catarrhal stage (1-2 weeks) until the fourth week

Transmission: Direct contact or respiratory droplets from coughing

Immunity: Bacteria or vaccine, both of which provide varying degrees and duration of immunity against pertussis

Season: Can occur during any season

Bacterial Infection

     Scarlet Fever

Causative agent: Group A beta-hemolytic streptococci

Incubation period: 1 to 7 days (average of 3 days)

Infectious period: Acute stage until 24 hours after antimicrobial therapy has begun

Transmission: Airborne (inhalation or ingestion), direct contact

Immunity: None

Season: Late fall, winter, and spring

 Understand parasites and be able to identify the four most common ones.

Rickettsaie: small, parasitic bacteria that are transmitted to human beings by blood sucking arthropods.

Rocky Mountain spotted fever: rickettsaia rickettsii from wild rodents and dogs.

Borrelia: transmitted to humans by arthropods

Lyme Disease: Tick bites

Helminths: worms: roundworms, pinworms, tapeworms, hookworms

Granulocytes:

Neutrophils: First leukocytes to respond to tissue damage.  Ingest and destroy antigens, especially bacteria, by phagocytosis.  Increase in number during acute inflammation, bacterial infection, and necrosis.  Immature neutrophils are called bands.  Increased bands (shift to the left) indicate infection.

Eosinophils: Help control the inflammatory response.  Neutralize histamine.  Increase in number during hypersensitivity reactions and kill parasites directly.

Basophils: Secrete histamine, heparin, and serotonin in inflammation and immediate hypersensitivity reactions.  Basophils located in tissue rather than in blood are called mast cells, which activate the inflammatory allergic response.

Agranulocytes

Monocytes/macrophages: Monocytes, immature macrophages, are large phagocytic agranulocytes.  Monocytes ingest and introduce antigens into the circulation for recognition by B and T  lymphocytes.   Macrophages engulf bacteria and cellular debris to finish the clean up process started by the neutrophils.

Specific Immune Responses:

B Lymphocytes:

Non-circulating, short-lived cells responsible for humoral immunity.  B lymphocytes contain receptor sites that recognize specific foreign substances.   Differentiate into plasma cells capable of secreting antibodies against bacteria.  First responder to viral infection.  Some become memory cells for long-term recognition of specific antigens.

Responsible for cellular immunity.  Interact with specific antigens on cell surfaces and directly attack invading microorganisms.  Respond to viruses, fungi, parasites, and foreign tissue.  T cell regulatory functions mobilize or deactivate the other cells in the immune system.

Helper (CD4 +) T cells:

Recognize antigens that have been processed and presented to them by B cells or macrophages.  CD4 + cells secrete cytokines that stimulate B cells to manufacture antibodies.

Suppressor T cells:

Inhibit the actions of helper T cells and B cells.  Help keep the immune system cells in check.

Cytotoxic (CD8+) T cells:

Kill target cells directly.  Particularly effective with viruses and malignant cells.

Understand how HIV manifests itself in children.  What is the treatment?  

Clinical manifestations can be non-symptomatic.

 Mildy symptomatic: lymphanopathy, hepatomegaly, splenomegaly, dermatitis, parotitis, recurring or persistent upper respiratory infection, sinusitis, or otitis media.

 Moderately symptomatic: anemia, neutropenia, thrombocytopenia, diarrhea, fever for longer than 1 month, herpes simplex, oral candiasis in children older than 6 months, bacterial meningitis, pneumonia,  or sepsis, cardiomyopathy, complicated chickenpox, herpes zoster, hepatitis, nephropathy, LIP, and toxoplasmosis onset before age 1 month.

 Treatment: In addition to giving intravenous ZDV to the mother during labor, infants of known HIV-positive mothers should receive oral ZDV therapy within 6 to 12 hours after birth.  Treatment with trimethoprimsulfamethoxazole usually continues until the infant is 1 year old.  After 1 year of age, infected children receive prophylaxis according to CD4+ count. 

What are the s/s of lupus? 

-Malar butterfly rash: a fixed, red, flat, or raised rash over the cheeks and the bridge of the nose

-Discoid rash: red, round, raised patches that spread

-Photosensitivity: skin rash from sun exposure

-Oral and nasal ulcers

-Arthritis: painful, swollen joints with edema

-Pleuritis, pericariditis, or perinititis

-Renal disorder: protein, casts, or red blood cells in urine

-Neurological disorders: headaches, personality changes, seizures or psychosis

-Hematologic disorders: anemia, leucopenia, lymphopenia, or thrombocytopenia

-Immunologic disorders

-Positive antinuclear antibody (ANA) assay

Systematic corticosteroids are given to control the inflammatory response.  When steroid treatment is not effective or renal progression is rapid, Cyclophosphamide (Cytoxan) is considered.  Children with renal and neurological disorders generally receive anticonvulsant and antihypertensive therapy, whereas those with skin lesions and joint problems take antimalarial drugs suchas hydroxychloroquine (plaquenil).  Killed virus vaccines are used rather than live-virus vaccines.  A low-salt diet may reduce fluid retention and prevent elevated BUN levels; a low protein diet helps preserve renal function.  The 5 yr survival rate is in excess of 90%.

            Anaphylaxis occurs when an allergen binds with IgE on mast cells and basophils, causing degranulation and release of histamines and other chemical mediators. Histamine action precipitates respiratory signs of bronchoconstriction with bronchospasm and edema (especially laryngeal edema) from increased vascular permeability. Other systems most affected during an anaphylactic response include GI (itchiness and tingling along the GI tract, vomiting, diarrhea, pain) and integumentary (uritcaria). Anaphylaxis can lead to circulatory collapse and death if not promptly managed. An allergen that has previously provoked a response, or one that has not can cause anaphylaxis.

The onset is sudden, usually occurring within seconds to minutes after exposure to an allergen. Initial symptoms include: Sneezing , Tightness or tingling of the mouth or face, with subsequent swelling of the lips and tongue,  Severe flushing, urticaria, and itching of the skin, especially on the head and upper trunk, Rapid development of erythema , A sense of impending doom

These symptoms might be followed by GI and respiratory symptoms, which include N/V, diarrhea, and cramping, as well as rhinorrhea, stridor, wheezing, and hoarseness. The most serious features are laryngospasm, edema, cyanosis, hypotensive shock, vascular collapse, and cardiac arrest. Several hours after the initial phase resolve, a second, or biphasic, reaction can occur. This second reaction can be as severe as the initial reaction, affects similar body system, and can occur hours up to several days after the initial episode.

Should be transported by ambulance to an emergency facility and kept for observation at least 4 hours after the episode is resolved to ensure prompt intervention should a biphasic reaction occur.

 In a hospital or emergency setting:

 Ensure adequate airway, possible by endotracheal intubation

Administer epinephrine. If reaction is caused by an insect sting, place a tourniquet proximal to the site of the sting and administer epinephrine in the uninvolved extremity and in the area of reaction, with repeat dosing within 5 to 10 minutes.

Administer O2 if available.

Administer corticosteroids and antihistamines as ordered.

Keep the child warm and lying flat or with feet slightly elevated.

Start an IV line.

 Isonatremic dehydration – the most common type of dehydration in children, water and electrolytes are lost in approximately the same proportion as they exist in the body, and serum sodium levels remain  within the normal range of 138 to 145 mEq/L.

 Hyponatremic dehydration – the electrolyte loss is greater than the water loss, resulting in a serum sodium concentration of <135 mEq/L.

Hypernatremic dehydration – the water loss is greater than the electrolyte loss and the serum sodium concentration is >150 mEq/L

Explain diarrhea in reference to the pediatric population. 

Diarrhea, one of the most common disorders in childhood, is defined as an increase in the frequency, fluidity, and volume of stools. Diarrhea accompanies many childhood disorders. Diarrhea in children may be acute or chronic, inflammatory or non-inflammatory. Diarrhea caused by infection is usually called gastroenteritis. Viral gastroenteritis is the case of approximately 80% of all cases, making it the most common cause of diarrhea in children older than 1 year. Rotavirus infection, the most common type of infectious diarrhea, accounts for approximately one third of hospitalizations of children in industrialized countries due to the resulting fluid imbalances.

      If not treated, acute diarrhea can lead to dehydration, electrolyte imbalance, and hypovolemic shock. Acute diarrhea can be life threatening in infants and small children if GI fluid losses are not adequately replaced.

What can a nurse do for a child who is vomiting?

Place child in an upright or side-lying position to prevent aspiration.

Interventions are determined by the cause of the vomiting therefore maybe very specific. For example: if the vomiting is found to be caused by incorrect feeding techniques, the nurse’s role is to educate the family regarding appropriate feeding techniques.

Ensure continued reduction in the vomiting and preventing dehydration. Advice the parent to offer an ORS (table 42-3) in small, frequent feeding to avoid gastric distention and to continue age-appropriate diet as tolerated.

Educate the child and family about avoiding certain foods (e.g., fatty, acidified, or seasoned foods) and minimizing stimuli such as stress, anxiety, or unfavorable-smelling foods, which might lead to nausea and subsequent vomiting.

To rid the mouth of the hydrochloric acid, and to freshen the mouth, the parent should rinse the child’s mouth and brush the child’s teeth after each time the child vomits.