PEDI Exam 1 Review .

Promoting Optimal Growth and Development

-Biological Development:Proportional changes *5-7 ounces weight gain per week *Double birth weight by age 6 months *Triple birth weight by age 1 year *Height increases by 1 inch per month *Growth in "spurts" rather than gradual pattern *Height increases 50% by 1 year *Head Circumference still exceeds chest circumference *Posterior fontanel closes by 6-8 weeks *Anterior fontanel closes by 12-18 months

Developing a Self Concept

-Children develop conscious awareness of a variety of self-perceptions (abilities, values, appearance) -Significant adults can help children experience success -Positive self-concept leads to feelings of self-respect, self-confidence, and happiness

Pathology of Hearing Impairments

-Conductive Hearing loss (Middle Ear) usually related to otitis media -Sensorineural Hearing Loss (Nerve Deafness) r/t ototoxic drugs or congenital defects -Mixed Conductive - Sensorineural Loss May Follow recurrent Otitis Media With Complications - Central Auditory Interception (Organic such as aphasia, etc. & Functional- the unconscious withdraw of hearing to block remembrance of traumatic events)

Developing sense of initiative (Erikson)

chief psychosocial task of preschool period. Feelings if guilt, anxiety, and fear may result from thoughts that differ from expected behavior. Development of superego (conscience). Learning right from wrong/moral development.

Nursing Assessment for Vision

infancy: response to visual stimuli, parental observations and concerns, expect binocularity by age 4 months. Childhood- visual acuity testing

Risk Factors That Increase Children's Vulnerability to the Stresses of Hospitalization

"Difficult" temperament Lack of fit between child and parent Age (especially between 6 months and 5 years of age) Male gender Below-average intelligence Multiple and continuing stresses (e.g., frequent hospitalizations)

Failure to Thrive

read in the book because this slide was trash

Breast/Bottle Weaning

should be gradual, replacing one feeding session at a time. Nighttime feeding usually last feeding to be discontinued. Do one feeding session at a time not all at once.

Sleep and Activity in Preschoolers

sleep 12 hours per night. Infrequent naps. Waking during the night is common. Motor activity levels remain high. Emphasize fun and safety. Readiness to participate in sports. Sedentary activity should be limited.

Loss of Control: Infant's Needs

trust, consistent loving caregivers, daily routines

Safety promotion (Toddler)

motor vehicle safety- car seat restraints Drowning- 12 months to 36 months Is highest risk Burns- fireplace, candles, irons, cigarettes, electrical outlets Aspiration and suffocation Falls Bodily Injury Anticipatory Guidance- education to families

Television, Video Games, Internet with School Age

includes cell phones, significant amount of time with media, media influences attitudes, violence can lead to desensitization.

Sexuality-Reproductive Pattern

(Answer questions that apply to your child's age group.) Has your child begun puberty (developing physical sexual characteristics, menstruation)? Have you or your child had any concerns? Does your daughter know how to do breast self-examination? Does your son know how to do testicular self-examination? How have you approached topics of sexuality with your child? Do you think you might need some help with some topics? Has your child's illness affected the way he or she feels about being a boy or a girl? If so, how? Do you have any concerns with behaviors in your child, such as masturbation, asking many questions or talking about sex, not respecting others' privacy, or wanting too much privacy? Initiate a conversation about an adolescent's sexual concerns with open-ended to more direct questions and using the terms "friends" or "partners" rather than "girlfriend" or "boyfriend": • Tell me about your social life. • Who are your closest friends? (If one friend is identified, could ask more about that relationship, such as how much time they spend together, how serious they are about each other, if the relationship is going the way the teenager hoped.) • Might ask about dating and sexual issues, such as the teenager's views on sexuality education, "going steady," "living together," or premarital sex. • Which friends would you like to have visit in the hospital?

Coping/Stress Tolerance Pattern

(Answer questions that apply to your child's age group.) What does your child do when tired or upset? • If upset, does your child want a special person or object? • If so, explain. If your child has temper tantrums, what causes them, and how do you handle them? Whom does your child talk to when worried about something? How does your child usually handle problems or disappointments? Have there been any big changes or problems in your family recently? If so, how have you handled them? Has your child ever had a problem with drugs or alcohol or tried to commit suicide? Do you think your child is "accident prone"? If so, explain.

Neonatal Infant Pain Scale (NIPS)

(Recommended for children less than 1 year old) - A score greater than 3 indicates pain. Pain AssessmentScore Facial Expression: 0 - Relaxed musclesRestful face, neutral expression 1 - GrimaceTight facial muscles; furrowed brow, chin, jaw, (negative facial expression - nose, mouth and brow) CRY: 0 - No CryQuiet, not crying 1 - WhimperMild moaning, intermittent 2 - Vigorous CryLoud scream; rising, shrill, continuous (Note: Silent cry may be scored if baby is intubated as evidenced by obvious mouth and facial movement. Breathing Patterns: 0 - RelaxedUsual pattern for this infant 1 - Change in BreathingIndrawing, irregular, faster than usual; gagging; breath holding Arms: 0 - Relaxed/RestrainedNo muscular rigidity; occasional random movements of arms 1 - Flexed/ExtendedTense, straight legs; rigid and/or rapid extension, flexion Legs: 0 - Relaxed/RestrainedNo muscular rigidity; occasional random leg movement 1 - Flexed/ExtendedTense, straight legs; rigid and/or rapid extension, flexion State of Arousal: 0 - Sleeping/AwakeQuiet, peaceful sleeping or alert random leg movement 1 - FussyAlert, restless, and thrashing

Review of Systems

(change of diet, illness, altered appetite), exercise tolerance, fevers (time of day), chills, night sweats (unrelated to climatic conditions), general ability to carry out activities of daily living Integument: Pruritus, pigment or other color changes (including birthmarks), acne, eruptions, rashes (location), bruises, petechiae, excessive dryness, general texture, tattoos or piercings, disorders or deformities of nails, hair growth or loss, hair color change (for adolescents, use of hair dyes or other potentially toxic substances, such as hair straighteners) Eyes: Visual problems (behaviors indicative of blurred vision, such as bumping into objects, clumsiness, sitting close to television, holding a book close to face, writing with head near desk, squinting, rubbing the eyes, bending head in an awkward position), cross-eyes (strabismus), eye infections, edema of lids, excessive tearing, use of glasses or contact lenses, date of last vision examination Ears/nose/mouth/throat: Earaches, ear discharge, evidence of hearing loss (ask about behaviors such as the need to repeat requests, loud speech, inattentive behavior), results of any previous auditory testing, nosebleeds (epistaxis), constant or frequent runny or stuffy nose, nasal obstruction (difficulty breathing), alteration or loss of sense of smell, mouth breathing, gum bleeding, number of teeth and pattern of eruption/loss, toothaches, tooth brushing, use of fluoride, difficulty with teething (symptoms), last visit to the dentist (especially if temporary dentition is complete), sore throats, difficulty swallowing, choking, hoarseness or other voice irregularities Neck: Pain, limitation of movement, stiffness, difficulty holding head straight (torticollis), thyroid enlargement, enlarged nodes or other masses Chest: Breast enlargement, discharge, masses; for adolescent girls, ask about breast self-examination Respiratory: Chronic cough, wheezing, shortness of breath at rest or on exertion, difficulty breathing, snoring, sputum production, infections (pneumonia, tuberculosis), skin reaction from tuberculin testing Cardiovascular: Cyanosis or fatigue on exertion, history of heart murmur or rheumatic fever, tachycardia, syncope, edema Gastrointestinal: Appetite, nausea, vomiting (not associated with eating; may be indicative of brain tumor or increased intracranial pressure), abdominal pain, jaundice or yellowing skin or sclera, belching, flatulence, distention, diarrhea, constipation, recent change in bowel habits, blood in stools Genitourinary: Pain on urination, frequency, hesitancy, urgency, hematuria, nocturia, polyuria, enuresis, unpleasant odor to urine, force of stream, discharge, change in size of scrotum, date and result of last urinalysis; for adolescents, sexually transmitted infection and type of treatment; for adolescent boys, ask about testicular self-examination Gynecologic: Menarche, date of last menstrual period, regularity or problems with menstruation, vaginal discharge, pruritus; if sexually active, type of contraception, sexually transmitted infection and type of treatment; if sexually active with weakened immune system or if 21 years of age and older, date and result of last Papanicolaou (Pap) smear; obstetric history (as discussed under birth history, when applicable) Musculoskeletal: Weakness, clumsiness, lack of coordination, unusual movements, scoliosis, back pain, joint pain or swelling, muscle pains or cramps, abnormal gait, deformity, fractures, serious sprains, activity level Neurologic: Headaches, seizures, tremors, tics, dizziness, loss of consciousness episodes, loss of memory, developmental delays or concerns Endocrine: Intolerance to heat or cold, excessive thirst or urination, excessive sweating, salt craving, rapid or slow growth, signs of early or late puberty Hematologic/lymphatic: Easy bruising or bleeding, anemia, date and result of last blood count, blood transfusions, swollen or painful lymph nodes (cervical, axillary, inguinal) Allergic/immunologic: Allergic responses, anaphylaxis, eczema, rhinitis, unusual sneezing, autoimmunity, recurrent infections, infections associated with unusual complications Psychiatric: General affect, anxiety, depression, mood changes, hallucinations, attention span, tantrums, behavior problems, suicidal ideation, substance abuse

Measures to Prevent Cognitive Impairment

* Counseling and education regarding nutrition and tobacco use. * Awareness of danger of chemicals, including prenatal exposure to alcohol. * Rubella immunization. * Genetic counseling. * Folic Acid supplementation during pregnancy *newborn screenings

Maximizing potential benefits of hospitalization

* Fostering parent-child relationships * Providing educational opportunities * Promoting self-mastery * Providing socialization

Establish Realistic Future Goals

- Cultivate realistic vocations for the child with chronic illness or disabilities such as music or art, employment, etc. - Prolonged survival leads to new decisions and problems: > Independent living > Marriage, employment, insurance coverage > Reproductive decisions

Perspectives on Care of Children at End of Life

- Principles of palliative care > Focus on symptom control and support, quality of life rather than cure > Distinction between palliative care and end-of-life care > Does not serve to hasten death Decision making at end of life- ethical considerations, physicians, health care team, DNR? pg. 1012 ANA Code of Ethics No cure just support them, and don't want them to feel pain, and relieve the symptoms. End of life: actively dying and keeping as peaceful as possible. Part of palliative care. Just helping to relieve the pain when death occur. Assisting them.

Family centered care for children with chronic and complex problems

- family is constant in kids' life. HCP are addicts to Childs care. - nurse must include family members in plan of care - share info and allow participation in care by family - collaborate with family to plan care

School Experience

-Entrance to school is a sharp break in the structure of the child's world -School is second only to the family as socializing agent -Values of the society are transmitted in school -Peer relationships become increasingly important Teachers Parents -"Latchkey children" -Limit setting and discipline -Dishonest behavior -Stress and fear-Changes in behavior or attitude may be a sign of stress. Fears at this age surround school activities and family

Spiritual Development

-Evolution of spirituality often parallels cognitive development -Family and environment influence a child's perception of the world Intuitive-projective phase is experienced -Fowler's faith construct -Spiritual routines can be comforting -Moral development: action is bad if they are punished for it

Development of Gender Identity

-Exploration of genitalia is common Genital fondling can occur Parental reaction should be accepting -Gender roles are understood by toddler Playing "house" -Gender identity is formed by age 3 years

Safe Pad

-Identify common pediatric injuries S: Suffocation, sleep position A: Asphyxia, animal bites F: Falls E: Electrical burns or burns P: Poisonings, ingestions A: Automobile safety D: Drowning

Symptom Severity of Hearing Impairment

-Measured In Decibels (dB) -Measured at varying frequencies - Hearing Threshold - Effect On Speech

Visual Impairment Classification

-Partially sighted (Acuity of 20/70 to 20/200 & Education is usually in the public school system) -Legal blindness (Acuity of 20/200 or less & Legal as well as medical term) -near sight is almost always better than far sight

Prepubescence

-Preadolescence is the period of 2 years before age 13 -Prepubescence typically occurs during preadolescence -Age at prepubescence varies from 9 to 12 (girls about 2 years earlier than boys) -Puberty begins at approximately age 10 in girls and age 12 in boys

Measures to Prevent Visual Impairment

-Prenatal care, prevention of prematurity -Rubella immunizations for all children -Safety counseling for preventing eye injuries -Periodic screening of children

Deaf-Blind Children

-Profound effects on development -Motor milestones are usually achieved at a slower rate -Other developmental achievements are often delayed -Finger spelling: spell words with one finger in the Childs hand -Developing future goals for the child: vocational training and preparation for home care

Hospitalization of the Visually Impaired Child

-Safe environment- stool right next to the bed -Reassurance -Orient the child to surroundings -Encourage independence- rope attached to the bathroom door -Consistency of team members

Emergency Admission

-essentials of admission counseling -postvention is counseling after the event -participation of the child and family as appropriate to situation

Ingestion of Injurious Agents

90% occur in the home Home immediate treatment Call Poison Control Center Syrup of ipecac is not recommended in the home Emergency department management Gastric lavage (not recommended in all cases) Activated charcoal Antidotes Cathartics

Emergency Treatment Poisoning

1. Assess the victim: • Initiate cardiorespiratory support if needed (circulation, airway, breathing). • Take vital signs; reevaluate routinely. • Evaluate for possibility of concomitant trauma or illness; treat prior to initiation of gastric decontamination. 2. Terminate exposure: • Empty mouth of pills, plant parts, or other material. • Flush any body surface (including the eyes) exposed to a toxin with large amounts of moderately warm water or saline. • Remove contaminated clothes, including socks, shoes, and jewelry. Ensure protection of rescuers and health care workers from exposure. • Bring victim of an inhalation poisoning into fresh air. 3. Identify the poison: • Question the victim and witnesses. • Look for environmental clues (empty container, nearby spill, odor on breath), and save all evidence of poison (container, vomitus, urine). • In absence of other evidence, be alert to signs and symptoms of potential poisoning in the absence of other evidence, including symptoms of ocular or dermal exposure. • Call the poison control center or other competent emergency facility for immediate advice regarding treatment. 4. Prevent poison absorption: • Place the child in a side-lying, sitting, or kneeling position with the head below the chest to prevent aspiration.

Discharge From Ambulatory Settings

1. Before beginning, explain that all instructions will also be presented in writing for the family to refer to later. 2. Provide an overview of the typical trajectory (expected pattern) of recovery. 3. Discuss expected progression of the child's activity level during the postdischarge period (e.g., "Mary will probably sleep for the rest of the day and feel kind of tired most of tomorrow but will be back to her usual activities the next day"). 4. Explain which activities the child is allowed and what is not permitted (e.g., bed rest, bathing). 5. Discuss dietary restrictions, being very specific and giving examples of "clear fluids" or what is meant by a "full liquid diet." 6. Discuss nausea and vomiting, if applicable, explaining how much is "normal" and what to do if more occurs (e.g., "Juan may be sick to his stomach and vomit. This is normal. However, if he vomits more than three times, please call us at this number right away"). 7. Discuss fever and appropriate comfort measures, explaining how much fever is considered "normal," and specifically what to do if the child goes beyond the range. 8. Explain the amount, location, and kind of pain or discomfort the child may experience. • Give any prescribed medication before leaving the facility. • Send a pain scale home with the family. • Explain how much pain and discomfort is "normal" and what to do if the child surpasses that level or if pain management interventions are unsuccessful. • Discuss pain management, including dosage for pain medications and details on how to administer them. • Describe appropriate nonpharmacologic comfort measures, such as holding, rocking, or swaddling. 9. Provide information about each medication that the child will be taking at home. • Review the details, including dose and route. • Demonstrate how to administer medications, if necessary (e.g., how to take outer packaging off suppositories, how to insert). • Discuss guidelines for requesting other medications. • Request that all prescriptions be filled and given to the family before discharge. 10. Make certain the family has all of the equipment and supplies (e.g., gauze and tape for dressing changes) that they will need at home. 11. Discuss complications that may occur and the steps to take if they do. 12. Ensure that appropriate measures are in place for safe transport home. • Remind family to use a seat belt or car seat for the child. • Determine if there will be one person whose sole responsibility is helping ensure the child's safety and comfort during transport. • Discuss measures the driver may need to take if this is impossible (e.g., be certain a basin is within the child's reach in case vomiting occurs; take a route that permits slower traffic and has places along the roadside to stop if necessary). • Determine the availability of a blanket, pillow, and cup with a lid and straw for the child's use in the car. 13. Provide emergency phone numbers for the family to call with any concerns. 14. Explain that the family will be contacted (give an approximate time) to follow up on the child but that they should not hesitate to call if concerns arise before then. 15. Ask the family and child, if appropriate, if they have any questions, and problem solve with family members to meet their unique needs.

Piaget Cognitive Development

1. sensorimotor 2. pre-operational 3. concrete operational 4. formal operational 1-4 months eating is the most important for the infant

Nutrition in Preschoolers

1000 to 1800 cals a day. 100mL/kg a day depending on activity and climate. Food fads and strong tastes are common. Amount of food varies greatly from day to day. Obesity in young children has increased dramatically.

Anticipatory Guidance—Sexuality

12 to 14 Years of Age Have adolescent identify a supportive adult with whom to discuss sexuality issues and concerns. Discuss the advantages of delaying sexual activity. Discuss making responsible decisions regarding normal sexual feelings. Discuss the roles of gender, peer pressure, and the media in sexual decision making. Discuss contraceptive options (advantages and disadvantages). Provide education regarding sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) infection; clarify risks, and discuss condoms. Discuss abuse prevention, including avoiding dangerous situations, the role of drugs and alcohol, and the use of self-defense. Have the adolescent clarify his or her values, needs, and ability to be assertive. If the adolescent is sexually active, discuss limiting partners, use of condoms, and contraceptive options. Have a confidential interview with the adolescent (including a sexual history). Discuss the evolution of sexual identity and expression. Discuss breast examination or testicular examination. 15 to 18 Years of Age Support delaying sexual activity. Discuss alternatives to intercourse. Discuss "When are you ready for sex?" Clarify values; encourage responsible decision making. Discuss consequences of unprotected sex: Early pregnancy; STIs, including HIV infection. Discuss negotiating with partners and barriers to safer sex. If the adolescent is sexually active, discuss limiting partners, use of condoms, and contraceptive options. Emphasize that sex should be safe and pleasurable for both partners. Have a confidential interview with the adolescent. Discuss concerns about sexual expression and identity.

Language Development

1st communication is crying, and is more of a reflex that represents physiological needs. At 5 weeks infants start making small throaty sounds. At 2 months they start making single vowel sounds. 3-4 months the conscious n,k,g,p are added. 8 months they imitate sounds but do not describe meaning until 10-11 months. By 9-10 months of age they can comprehend the meaning of the word no.

apparent life-threatening event (ALTE)

A sudden event in infants under the age of 1 year, during which the infant experiences a combination of symptoms including apnea, change in color, change in muscle tone and coughing or gagging. Aborted or near miss SIDS.

FLACC postoperative pain tool

2 months of age to 7 years of age Validity using analysis of variance for repeated measures to compare FLACC scores before and after analgesia; preanalgesia FLACC scores significantly higher than postanalgesia scores at 10, 30, and 60 minutes (p <0.001 for each time) Correlation coefficients used to compare FLACC pain scores and OPS pain scores; significant positive correlation between FLACC and OPS scores (r = 0.80; p <0.001); positive correlation also found between FLACC scores and nurses' global ratings of pain (r[47] = 0.41; p <0.005) Face (0-2) Legs (0-2) Activity (0-2) Cry (0-2) Consolability (0-2) 0 = no pain; 10 = worst pain

pre operational stage (Piaget)

2 - 7 years; rapid development of new language; egocentrism; sense of time and space; learning conservation and reversibility. Preconceptual phase ages 2 to 4 years. Intuitive thought phase ages 4 to 7 years. Shifting from egocentric thought to social awareness. Ability to consider other viewpoints.

Safety promotion and injury prevention

3 leading causes of deaths are from suffocation, drowning, and motor vehicle accidents. Rear facing car seat until 2 years of age or pass required height and weight. Must be in back seat because of the airbag.

Assessing the family

Assessment of the families coping. Are there any concurrent stressors. Table 36.3 pg 1006

Play in Preschoolers

Associative Play- loose rules Imitative Play Imaginative Play Dramatic Play- roles are assigned Mutual play- parent and child

Visual Impairment Trauma

A common cause of blindness in children. Injuries to eyeball or adnexa. Penetrating- start instruments, propulsive objects, blunt objects, motor vehicle accidents. Non-penetrating- lacerations, blows to the eyes or head, burns. Treatment is aimed at preventing further damage. Any time there is an injury to the eye, the child must see an ophthalmologist.

Autism Spectrum Disorder (ASD)

A complex neurodevelopmental disorder accompanied by intellectual and social defects. Includes Asperger's syndrome and pervasive developmental disorder. Risk is 1 in 166 children. Four times as common in males.

school refusal

A reluctance or refusal to go to school or to remain there, sometimes called school phobia because it often involves intense anxiety.

Education about the Disorder

ADLS Safe transportation- may need to be modifications such as car seats or wheelchairs. Primary health Care- like any other child. Stress the importance of communicating the Childs condition in a medical emergency such as a bracelet or card in the wallet.

Spiritual Development Preschoolers

Knowledge of Faith and religion is learned from significant others and from religious practices. Development of conscience is strongly linked to spiritual development. May misinterpret illness as punishment from God.

Organ or Tissue Donation and Autopsy

Requires a sensitive approach and should not be done during impeding death. For some families it may be meaningful to act to benefit another human being.

Safety in Preschoolers

Safety education is most important. Increase in pedestrian vehicle accidents. Protection such as helmets and protective equipment. Parents should practice what they preach. Preschoolers are great imitators.

Child Home Safety Checklist

Safety: Fire, Electrical, Burns • Guards in front of or around any heating appliance, fireplace, or furnace (including floor furnace)* • Electrical wires hidden or out of reach* • No frayed or broken wires; no overloaded sockets • Plastic guards or caps over electrical outlets; furniture in front of outlets* • Hanging tablecloths out of reach, away from open fires* • Smoke detectors tested and operating properly • Kitchen matches stored out of child's reach* • Large, deep ashtrays throughout house (if used) • Small stoves, heaters, and other hot objects (cigarettes, candles, coffee pots, slow cookers) placed where they cannot be tipped over or reached by children • Hot water heater set at 49° C (120° F) or lower • Pot handles turned toward back of stove, center of table • No loose clothing worn near stove • No cooking or eating hot foods or liquids with child standing nearby or sitting in lap • All small appliances, such as iron, turned off, disconnected, and placed out of reach when not in use • Cool, not hot, mist vaporizer if used • Fire extinguisher available on each floor and checked periodically • Electrical fuse box and gas shutoff accessible • Family escape plan in case of a fire practiced periodically; fire escape ladder available on upper-level floors • Telephone number of fire or rescue squad and address of home with nearest cross street posted near phone Safety: Suffocation and Aspiration • Small objects stored out of reach* • Toys inspected for small removable parts or long strings* • Hanging crib toys and mobiles placed out of reach • Plastic bags stored away from young child's reach; large plastic garment bags discarded after tying in knots* • Mattress or pillow not covered with plastic or in manner accessible to child* • Crib design according to federal regulations (crib slats less than 2.375 inches [6 cm] apart) with snug-fitting mattress* † • Crib positioned away from other furniture or windows* • Portable play yard gates up at all times while in use* • Accordion-style gates not used* • Bathroom doors kept closed and toilet lids down* • Faucets turned off firmly* • Pool fenced with locked gate • Proper safety equipment at poolside • Electronic garage door openers stored safely, and garage door adjusted to rise when door strikes object • Doors of ovens, trunks, dishwashers, refrigerators, and front-loading clothes washers and dryers kept closed* • Unused appliance, such as a refrigerator, securely closed with lock or doors removed* • Food served in small, non-cylindric pieces* • Toy chests without lids or with lids that securely lock in open position* • Buckets and wading pools kept empty when not in use* • Clothesline above head level • At least one member of household trained in basic life support (cardiopulmonary resuscitation), including first aid for choking Safety: Poisoning • Toxic substances, including batteries, placed on a high shelf, preferably in locked cabinet • Toxic plants hung or placed out of reach* • Excess quantities of cleaning fluid, paints, pesticides, drugs, and other toxic substances not stored in home • Used containers of poisonous substances discarded where child cannot obtain access • Telephone number of local poison control center (800-222-1222) and home address with nearest cross street posted near phone • Medicines clearly labeled in childproof containers and stored out of reach • Household cleaners, disinfectants, and insecticides kept in their original containers, separate from food and out of reach • Smoking in areas away from children Safety: Falls • Nonskid mats, strips, or surfaces in tubs and showers • Exits, halls, and passageways in rooms kept clear of toys, furniture, boxes, or other items that could be obstructive • Stairs and halls well lighted, with switches at both top and bottom • Sturdy handrails for all steps and stairways • Nothing stored on stairways • Treads, risers, and carpeting in good repair • Glass doors and walls marked with decals • Safety glass used in doors, windows, and on walls • Gates on top and bottom of staircases and elevated areas, such as porch, fire escape* • Guardrails on upstairs windows with locks that limit height of window opening and access to areas such as fire escape* • Crib side rails raised to full height; mattress lowered as child grows* • Restraints used in high chairs, walkers, or other baby furniture; preferably walkers not used* • Scatter rugs secured in place or used with nonskid backing • Walks, patios, and driveways in good repair Safety: Bodily Injury • Knives, power tools, and unloaded firearms stored safely or placed in locked cabinet • Garden tools returned to storage racks after use • Pets properly restrained and immunized for rabies • Swings, slides, and other outdoor play equipment kept in safe condition • Yard free of broken glass, nail-studded boards, other litter • Cement birdbaths placed where young child cannot tip them over* • Furniture anchored so child cannot pull down on top of self when climbing or pulling to stand

Prepubescence

period of approx 2 years before onset of puberty; preliminary physical changes occur

Medications for Fragile X Syndrome

Tegretol, Prozac (serotonin agents) to control violent outbursts. CNS stimulants for hyperactivity.

Fragile X Syndrome Therapeutic Management

Tegretol/Prozac for behavior Stimulants for hyperactivity (similar to ADHD) Referral to early intervention program Expected to live a normal life span Genetic counseling

onlooker play

During onlooker play, children watch what other children are doing but make no attempt to enter into the play activity. There is an active interest in observing the interaction of others but no movement toward participating. Watching an older sibling bounce a ball is a common example of the onlooker role.

Head Lag

when the infant is lifted from the bed, the head will fall back, because newborn cannot maintain neutral position of the head

Formal Operations Period (Piaget)

Abstract thinking: formal operations, thinking beyond present, mental manipulation of multiple variables. concern about others thoughts and needs.

Consequences of Untreated Pain in Infants Acute Consequences

Acute Consequences Periventricular-intraventricular hemorrhage Increased chemical and hormone release Breakdown of fat and carbohydrate stores Prolonged hyperglycemia Higher morbidity for neonatal intensive care unit patients Memory of painful events Hypersensitivity to pain Prolonged response to pain Inappropriate innervation of the spinal cord Inappropriate response to nonnoxious stimuli Lower pain threshold

The Divorce Process

Acute Phase • The married couple makes the decision to separate. • This phase includes the legal steps of filing for dissolution of the marriage and, usually, the departure of the father from the home. • This phase lasts from several months to more than 1 year and is accompanied by familial stress and a chaotic atmosphere. Transitional Phase • The adults and children assume unfamiliar roles and relationships within a new family structure. • This phase is often accompanied by a change of residence, a reduced standard of living and altered lifestyle, a larger share of the economic responsibility being shouldered by the mother, and radically altered parent-child relationships. Stabilizing Phase • The post-divorce family re-establishes a stable, functioning family unit. • Remarriage frequently occurs with concomitant changes in all areas of family life.

Isolation

Added stressor of hospitalization. Child may have limited understanding. Dealing with child's fears. Potential for sensory deprivation.

Preparation for Hospitalization

Admission assessment. Preparing child for admission. Preventing or minimizing separation. Minimizing loss of control: promoting freedom of movement, maintaining Childs routine, encouraging independence and industry. Prevent or minimize fear of bodily injury. Provide opportunities for play and expression: diversional activities, toys, expressive activities, dramatic play

head and neck abnormalities

After 6 months of age, significant head lag strongly indicates cerebral injury and is referred for further evaluation. Hyperextension of the head (opisthotonos) with pain on flexion is a serious indication of meningeal irritation and is referred for immediate medical evaluation. If any masses are detected in the neck, report them for further investigation. Large masses can block the airway.

skill play

After infants have developed the ability to grasp and manipulate, they persistently demonstrate and exercise their newly acquired abilities through skill play, repeating an action over and over again. The element of sense-pleasure play is often evident in the practicing of a new ability, but all too frequently, the determination to conquer the elusive skill produces pain and frustration (e.g., putting paper in and taking it out of a toy car)

The terrible twos

Ages 12 to 36 months. Intense period of environmental exploration. Temper tantrums/obstinacy/negatvisim.

The Preschool Period

Ages 3-5. Preparation for most significant lifestyle change- going to school. Cooperative interaction with other children. Experience brief and prolonged separation. Use of language for mental symbolization. Increased attention span and memory.

School Age

Ages 6 to 12 years. Physiologically begins with shredding of first deciduous teeth; ends at puberty with acquisition of final permanent teeth. Gradual growth and development. Progress with physical and emotional maturity.

Gross Motor Development: Standing, Walking

All children will not take first steps at the same age. Pediatric nurse should assess/ask if infant is pulling up to a standing position by the age of 11-12 months

Immunizations

All immunizations and "boosters" are listed, stating (1) the name of the specific disease, (2) the number of injections, (3) the dosage (sometimes lesser amounts are given if a reaction is anticipated), (4) the date when administered, and (5) the occurrence of any reaction following immunization.

Coping with Concerns Related to Normal Growth and Development

Alternative childcare arrangements Limit setting- time outs

head lag nursing alert

An infant who displays head lag at 6 months of age should have a developmental and neurologic evaluation.

hip dysplasia nursing alert

An infant who does not pull to a standing position by 11 to 12 months of age should be further evaluated for possible developmental dysplasia of the hi

Etiology of Hearing Impairments

Anatomic- malformation ear not formed Family History LBW- low birth weight Ototoxic drugs- Gentamicin - Chronic ear infections Perinatal asphyxia Perinatal infections Cerebral palsy

Communicating with Adolescence

Anticipating these shifts in identity allows the nurse to adjust the course of interaction to meet the needs of the moment. No single approach can be relied on consistently, and encountering cooperation, hostility, anger, bravado, and a variety of other behaviors and attitudes is common. It is as much a mistake to regard an adolescent as an adult with an adult's wisdom and control as it is to assume that a teenager has the concerns and expectations of a child. If the parents and teenager are together, talking with the adolescent first has the advantage of immediately identifying with the young person, thus fostering the interpersonal relationship. However, talking with the parents initially may provide insight into the family relationship. Privacy and confidentiality are of great importance when communicating with adolescents because it is consistent with developmental maturity and autonomy

Skin Disorders (Toddlers)

Arthropod bites and stings: remove stinger and observe for allergic reaction. Children should not approach a dog that is eating, sick, or injured and should never tease or surprise them. Most common animal bite is from dogs. Rinse round with saline and wash with mild soap then apply clean dressing. then seek medical care. Human bites- immediately seek medical attention. wash wound with soap and water and apply dressing.

Communicating With Parents

Assessing the child requires input from the child (verbal and nonverbal), information from the parent, and the nurse's own observations of the child and interpretation of the relationship between the child and the parent. When children are old enough to be active participants in their own health care, the parent becomes a collaborator.

ADHD

Attention Deficit Hyperactive Disorder presented with inattention, impulsiveness, and hyperactivity. Diagnosed by a multidisciplinary team. Therapeutic management consists of: Behavioral therapy, Pharmacologic Therapy, Multimodal treatment, Environmental manipulation, Appropriate classroom placement.

Facilitating Lipreading

Attract child's attention before speaking; use light touch to signal speaker's presence. Stand close to child. Face child directly, or move to a 45-degree angle. Stand still; do not walk back and forth or turn away to point or look elsewhere. Establish eye contact, and show interest. Speak at eye level and with good lighting on speaker's face. Be certain nothing interferes with speech patterns, such as chewing food or gum. Speak clearly and at a slow and even rate. Use facial expression to assist in conveying messages. Keep sentences short. Rephrase message if child does not understand the words.

Animism

Attributing lifelike qualities to inanimate objects Example: Child scolds stairs for making child fall down. Implication: Join child in the "scolding." Keep frightening objects out of view.

Blood Pressure

Auscultation remains the gold standard method of BP measurement in children, under most circumstances. Oscillometric devices measure mean arterial BP and then calculate systolic and diastolic values. The algorithms used by companies are proprietary and differ from company to company and device to device. These devices can yield results that vary widely when one is compared with another, and they do not always closely match BP values obtained by auscultation. An elevated BP reading obtained with an automated or oscillometric device should be repeated using auscultation. BP readings using oscillometry, such as Dinamap, are generally higher (10 mm Hg higher) than measurements using auscultation

Autism Family Support

Autism often becomes a family disease. Frequently parents express guilt and shame. Stress the importance of family counseling. Autism Society of American is a good source for information. Educate Managing clients at home or long term placement therapy.

Loss of Control: Toddler's Needs

Autonomy Daily routines and rituals Loss of control may contribute to: Regression of behavior Negativity Temper tantrums May cry louder when they see their parents, this is a sign of detachment,

solitary play

During solitary play, children play alone with toys different from those used by other children in the same area. They enjoy the presence of other children but make no effort to get close to or speak to them. Their interest is centered on their own activity, which they pursue with no reference to the activities of the others.

Speech Problems in Preschoolers

Most critical period is between 2 and 4 years of age. Failure to master sensorimotor integration may result in stuttering, stammering. Caregivers should speak slowly and calm and refrain from insult. Prevention and early detection are crucial. Causes could be from hearing loss, developmental delay, autism, or lack of environmental stimuli.

BMI

BMI for sex and age may be used to identify children and adolescents who are either underweight (<5th percentile), healthy weight (5th percentile to <85th percentile), overweight (≥85th percentile and <95th percentile), or obese (≥95th percentile).

Pre-conventional or Premoral Level (Kohlberg)

Basic level of moral judgement. Punishment and obedience orientation. Naive instrumental orientation- pleasing themselves not others. Very concrete sense of justice and fairness.

Drowning

Bath tub-NEVER leave infant unattended in tub or sink of water.Swimming pools, bird baths, decorative ponds of water, splash pads-Place fence around pools with gate lock that is out of child's reach. Supervise infants in water at ALL times; an infant may drown in as little as 2 inches of water. Swimming lessons are encouraged but are not foolproof for drowning if infant or child hits head on hard object and becomes unconscious as falling into the water.5-gal buckets-Keep 5-gal buckets empty of water and elevated out of child's reach.

Cultural Considerations Food Practices

Because cultural practices are prevalent in food preparation, consider carefully the kinds of questions that are asked and the judgments made during counseling. For example, some cultures, such as Hispanic, African-American, and Native American, include many vegetables, legumes, and starches in their diet that together provide sufficient essential amino acids even though the actual amount of meat or dairy protein is low. The most common and probably easiest method of assessing daily intake is the 24-hour recall. The child or parent recalls every item eaten in the past 24 hours and the approximate amounts. The 24-hour recall is most beneficial when it represents a typical day's intake. Some of the difficulties with a daily recall are the family's inability to remember exactly what was eaten and inaccurate estimation of portion size. To increase accuracy of reporting portion sizes, the use of food models and additional questions are recommended. In general, this method is most useful in providing qualitative information about the child's diet. To improve the reliability of the daily recall, the family can complete a food diary by recording every food and liquid consumed for a certain number of days. A 3-day record consisting of 2 weekdays and 1 weekend day is representative for most people. Providing specific charts to record intake can improve compliance. The family should record items immediately after eating.

Infant Assessment Prep

Before able to sit alone—supine or prone, preferably in parent's lap; before 4 to 6 months, can place on examining table After able to sit alone—sitting in parent's lap whenever possible; if on table, place with parent in full view If quiet, auscultate heart, lungs, and abdomen. Record heart and respiratory rates. Palpate and percuss same areas. Proceed in usual head-to-toe direction. Perform traumatic procedures last (eyes, ears, mouth [while crying]). Elicit reflexes as body part is examined. Elicit Moro reflex last. Completely undress if room temperature permits. Leave diaper on male infant. Gain cooperation with distraction, bright objects, rattles, talking. Smile at infant; use soft, gentle voice. Pacify with bottle of sugar water or feeding. Enlist parent's aid for restraining to examine ears, mouth. Avoid abrupt, jerky movements.

Immunizations

Begin at birth. Flu shot at 6 months. Important for the prevention of communicable diseases. Atraumatic care- pacifier or mom breast feeding when the immunization is being administered. Fewer Reactions with IM injections than sub q. IM tissue is more vascular.

peroperational stage

Begins about age 2 and last until age 4. It is the transition between self-satisfying behavior and socialized relationships.

Impetigo contagiosa: Staphylococci

Begins as a reddish macule then becomes vesicular Ruptures easily Exudate dries to form heavy, honey-colored crusts Pruritus common Systemic effects: Minimal or asymptomatic Topical bactericidal ointment (mupirocin) or triple antibiotic ointment Oral or parenteral antibiotics (penicillin) in cases of severe or extensive lesions Vancomycin for methicillin-resistant Staphylococcus aureus (MRSA) Tends to heal without scarring Autoinoculable and contagious May be superimposed on eczema

Dental Health

Begins with Maternal Dental Health Cleaning: Wipe with a clean damp cloth when primary teeth erupt. Fluoride at 6 months. Prevention of dental caries: no bottle propping, no milk in bed, no fruit juices.

Aggression in preschoolers

Behavior that attempts to hurt person or destroy property. May be influenced by biologic, sociocultural, and familiar variables. Factors that increase aggressive behavior: gender, frustration, modeling, and reinforcement.

Singling reactions to illness and hospitalization

Being younger and experiencing many changes. Being care for by non relatives or outside of the home. Receiving little information about their ill sibling Perceiving that parents will treat them differently

Magical Thinking

Believing that thoughts are all-powerful and can cause events Examples: Child wishes someone died; then if the person dies, child feels at fault because of the "bad" thought that made the death happen. • Calling children "bad" because they did something wrong makes them feel as if they are bad. Implications: Clarify that thoughts do not make things happen and that the child is not responsible. • Use "I" rather than "you" messages to communicate thoughts, feelings, expectations, or beliefs without imposing blame or criticism. Emphasize that the act is bad, not the child.

ambulatory or outpatient setting

Benefits: minimizes the stressors of the hospitalization, decreases change of infection, increase cost savings. Preparation of the child can be challenging Waiting can be stressful. Explicit written discharge and follow up instructions.

Recommended Temperature Screening Routes in Infants and Children

Birth to 2 Years of Age Axillary Rectal: if definitive temperature reading is needed for infants older than 1 month of age 2 to 5 Years of Age Axillary Tympanic Oral: when child can hold thermometer under tongue Rectal: if definitive temperature reading is needed Older Than 5 Years of Age Oral Axillary Tympanic

Maturation of systems in school age

Bladder capacity increases. Heart is smaller in relation to rest of body. Immune system is increasingly effective. Bones continue to ossify. Physical maturity is not necessarily correlated with emotional and social maturity.

Nutrition Second 6 months

Breastmilk or formula should continue to be the primary source of nutrition. Iron-fortified cereal is usually introduced first. Common sequence of introducing foods is shrined fruits followed by vegetables and then meats. Some recommend veggies then fruits. One item is introduced at an interval of 4-7 days to allow indication of food allergies. Introduction of solid foods is primarily for taste and chewing NOT growth.

Guidelines Communicating With Adolescents

Build a Foundation Spend time together. Encourage expression of ideas and feelings. Respect their views. Tolerate differences. Praise good points. Respect their privacy. Set a good example. Communicate Effectively Give undivided attention. Listen, listen, listen. Be courteous, calm, honest, and open-minded. Try not to overreact. If you do, take a break. Avoid judging or criticizing. Avoid the "third degree" of continuous questioning. Choose important issues when taking a stand. After taking a stand: • Think through all options. • Make expectations clear.

Automobile Safety

Car or truck and hot weather-An automobile-related hazard for infants is overheating (hyperthermia) and subsequent death when left in a vehicle in hot weather (>26.4° C [80° F]). Infants dissipate heat poorly, and an increase in body temperature may cause death in a few hours. Caution parents against leaving infants in a vehicle alone for any reason.Air bags-Avoid placing infant in a car restraint behind an air bag. Deactivate the air bag (available in certain models) or place the infant in the back seat in a proper car seat restraint.

Listening and Cultural Awareness

Careful listening relies on the use of clues, verbal leads, or signals from the interviewee to move the interview along. Frequent references to an area of concern, repetition of certain key words, or a special emphasis on something or someone serve as cues to the interviewer for the direction of inquiry. Concerns and anxieties are often mentioned in a casual, offhand manner. Even though they are casual, they are important and deserve careful scrutiny to identify problem areas. For example, a parent who is concerned about a child's habit of bedwetting may casually mention that the child's bed was "wet this morning."

Herpes zoster, shingles: Varicella zoster virus

Caused by same virus that causes varicella (chickenpox) Crops of vesicles usually confined to dermatome following along course of affected nerve Usually preceded by neuralgic pain, hyperesthesias, and itching Symptomatic treatment Analgesics for pain Ophthalmic variety: Systemic corticotropin or corticosteroids Acyclovir or valacyclovir Preventive vaccine is available for people >50 years of age Isolate affected child from other children in a hospital or school May occur in children with depressed immunity Can be fatal

Etiology and Patho of Eating Disorders

Causes unclear. Distinct psychologic component. common indicator: dieting. Relentless pursuit of thinness. Distorted body image. Media impact. Triggered by an adolescent crisis such as divorce, bullied, college, menstruation.

Growth Motor Development: Locomotion

Cephalocaudal direction of development Crawling: ages 6 to 7 monthd Creeping: Age 9 months Walking with assistance: Age 11 months Walking alone: Age 1 year

Developmental Nighttime Crying

Child 6-12 months of age with undisturbed nighttime sleep now awakens abruptly; may be accompanied by nightmares. Reassure parents that this phase is temporary. Enter room immediately to check on child, but keep reassurances brief. Avoid feeding, rocking, taking to parent's bed, or any other routine that may initiate trained nighttime crying

Development of Sexuality in Preschoolers

Child forms strong attachment to opposite sex parent while identifying with same sex parent. Modesty becomes a concern. Child evinces sex role limitation, dressing up like Mommy or Daddy. Sexual exploration is more pronounced. Questions arise about sexual reproduction.

Nighttime Feeding

Child has prolonged need for middle-of-night bottle or breastfeeding. Child goes to sleep at breast or with bottle. Awakenings are frequent (may be hourly). Child returns to sleep after feeding; other comfort measures (e.g., rocking or holding) are usually ineffective. Increase daytime feeding intervals to 4 hours or more (may need to be done gradually). Offer last feeding as late as possible at night; may need to gradually reduce amount of formula or length of breastfeeding. Offer no bottles in bed. Put to bed awake. When child is crying, check at progressively longer intervals each night; reassure child but do not hold, rock, take to parent's bed, or give bottle or pacifier.

Development of Body Image (Toddler)

Child refers to body parts by name Child recognizes words used to describe appearance -adults should avoid negative labels about physical appearance. Child recognizes gender differences by age 2. They can also recognize themselves in the mirror.

Refusal to go to Sleep

Child resists bedtime and comes out of room repeatedly. Nighttime sleep may be continuous, but frequent awakenings and refusal to return to sleep may occur and become a problem if parent allows child to deviate from usual sleep pattern. Evaluate if hour of sleep is too early (child may resist sleep if not tired). Help parents establish consistent before-bedtime routine and enforce consistent limits regarding child's bedtime behavior. If child persists in leaving bedroom, close door for progressively longer periods. Use reward system with child to provide motivation.

Nighttime Fears

Child resists going to bed or wakes during night because of fears. Child seeks parent's physical presence and falls asleep easily with parent nearby unless fear is overwhelming. Evaluate if hour of sleep is too early (child may fantasize when nothing to do but think in dark room). Calmly reassure frightened child; keeping night light on may be helpful. Use reward system with child to provide motivation to deal with fears. Avoid patterns that can lead to additional problems (e.g., sleeping with child or taking child to parent's room). If child's fear is overwhelming, consider desensitization (e.g., progressively spending longer periods of time alone; consult professional help for protracted fears). Distinguish between nightmares and sleep terrors (confused partial arousals).

Trained Nighttime Crying (Inapproproate Sleep Associations) Management:

Child typically falls asleep in place other than own bed (e.g., rocking chair or parent's bed) and is brought to own bed while asleep; on awakening, cries until usual routine is instituted (e.g., rocking). Put child in own bed when awake. If possible, arrange sleeping area separate from other family members. When child is crying, check at progressively longer intervals each night; reassure child, but do not resume usual routine.

Anticipatory Guidance Preschool Safety

Childcare focus shifts from protection to education- verbal explanations to avoid danger. Children begin questioning previous teachings of parents. Children begin to prefer companionship of peers. Children enter school.

games

Children in all cultures engage in games alone and with others. Solitary activity involving games begins as very small children participate in repetitive activities and progress to more complicated games that challenge their independent skills, such as puzzles, solitaire, and computer or video games. Very young children participate in simple, imitative games such as pat-a-cake and peek-a-boo. Preschool children learn and enjoy formal games, beginning with ritualistic, self-sustaining games, such as ring around the rosy and London Bridge. With the exception of some simple board games, preschool children do not engage in competitive games. Preschoolers hate to lose and try to cheat, want to change rules, or demand exceptions and opportunities to change their moves. School-age children and adolescents enjoy competitive games, including cards, checkers, and chess, and physically active games, such as baseball.

Spiritual Development School Age Children

Children think in very concrete terms. Children are avid Lerners with a desire to know their God. Children expect punishment for misbehavior. Children may view illness or injury as punishment for a real or imagined misdeed.

Communication with Early Childhood

Children younger than 5 years of age are egocentric. They see things only in relation to themselves and from their point of view. Therefore, focus communication on them. Tell them what they can do or how they will feel. Experiences of others are of no interest to them. It is futile to use another child's experience in an attempt to gain the cooperation of small children. Allow them to touch and examine articles they will come in contact with.

Diagnosing Eating Disorders

Clinical manifestations are HTN, bradycardia, and hypothermia are usually present.

Social Relationships and Cooperation in School Age

Clubs and Peer groups: formation of formalized groups, bullying. Relationships and Families: Parents are primary influence in shaping child's personality, behavior, and value system. Increasing independence from parents is primary goal of middle childhood. Parents need to be adults, not friends.

Blocks to Communication

Communication Barriers (Nurse) Socializing Giving unrestricted and sometimes unsought advice Offering premature or inappropriate reassurance Giving over-ready encouragement Defending a situation or opinion Using stereotyped comments or clichés Limiting expression of emotion by asking directed, closed-ended questions Interrupting and finishing the person's sentence Talking more than the interviewee Forming prejudged conclusions Deliberately changing the focus Signs of Information Overload (Patient) Long periods of silence Wide eyes and fixed facial expression Constant fidgeting or attempting to move away Nervous habits (e.g., tapping, playing with hair) Sudden interruptions (e.g., asking to go to the bathroom) Looking around Yawning, eyes drooping Frequently looking at a watch or clock Attempting to change the topic of discussion

Development of Body Image

Concept of object permanence By end of first year, recognize that they are distinct from parents. Development of body image parallels sensory motor development. (smiling at each other) Kinesthetic and tactile experiences are children's first perceptions of their bodies (putting things in mouth)

Coping with Ongoing Stress and Periodic Crises

Concurrent stresses (marital differences, financial burden) within the family which leads to decrease family resources and decreased recreation time. Coping mechanisms could be drugs or alcohol. Parental empowerment is a gradual process.

General Strategies for Pain Management

Consult child-life specialist. Use nonpharmacologic interventions to supplement, not replace, pharmacologic interventions, and use for mild pain and pain that is reasonably well controlled with analgesics. Form a trusting relationship with child and family. Express concern regarding their reports of pain, and intervene appropriately. Take an active role in seeking effective pain management strategies. Use general guidelines to prepare child for procedure. Prepare child before potentially painful procedures, but avoid "planting" the idea of pain. • For example, instead of saying, "This is going to (or may) hurt," say, "Sometimes this feels like pushing, sticking, or pinching, and sometimes it doesn't bother people. Tell me what it feels like to you." • Use "nonpain" descriptors when possible (e.g., "It feels like heat" rather than "It's a burning pain"). This allows for variation in sensory perception, avoids suggesting pain, and gives the child control in describing reactions. • Avoid evaluative statements or descriptions (e.g., "This is a terrible procedure" or "It really will hurt a lot"). Stay with child during a painful procedure. Allow parents to stay with child if child and parent desire; encourage parent to talk softly to child and to remain near child's head. Involve parents in learning specific nonpharmacologic strategies and in assisting child with their use. Educate child about the pain, especially when explanation may lessen anxiety (e.g., that pain may occur after surgery and does not indicate something is wrong); reassure the child that he or she is not responsible for the pain. For long-term pain control, offer the child a doll, which represents "the patient," and allow child to do everything to the doll that is done to him or her; emphasize pain control through the doll by stating, "Dolly feels better after the medicine."

Maturation of Systems

Continues abdominal breathing Respiratory rate slows Short, straight eustachian tube closely communicates with ear and opens the door for infection

Exercise and Activity School Age Children

Controversy regarding early participation in competitive sports. Concerns with physical and emotional maturity in competitive environment. Children generally like competition.

Cooperative play

Cooperative play is organized, and children play in a group with other children (Fig. 28.9). They discuss and plan activities for the purposes of accomplishing an end: to make something, attain a competitive goal, dramatize situations of adult or group life, or play formal games. The group is loosely formed, but there is a marked sense of belonging or not belonging. The goal and its attainment require organization of activities, division of labor, and role playing. The leader-follower relationship is definitely established, and the activity is controlled by one or two members who assign roles and direct the activity of the others. The activity is organized to allow one child to supplement another's function to complete the goal.

Counseling Nursing Alert

Counseling children whose parents are going through a divorce or separation should involve a discussion with the child about her or his role. Because of magical thinking the child may believe that she or he wished the other parent away. The child should be reassured that this is not the case.

Visual Impairment

General term that refers to visual loss that cannot be corrected with regular prescription lenses. Common problem during childhood. In the US, prevalence of blindness to serious visual impairment is 30 to 64/100,000. 5% to 10% of all preschoolers are VI.

Fragile X Syndrome Gender Differences

Most males are mentally deficient. 30% of females are mentally deficient. Males have only the nonfunctioning X. Females have one normally functioning X and one nonfunctioning X.

Proportional Changes in Toddlers

Weight gain slows to 4 to 6 pounds/year. Birth weight should be quadrupled by age 2.5 years. Heigh increased about 3 inches/year. Elongation of legs rather than trunk/ Growth is step-like rather than linear.

Fears of the Preschooler

Dark, being left alone, animals, ghosts, sexual matters (castration), objects or people associated with pain

Telephone Triage Guidelines

Date and time Background • Name, age, sex, contact information • Chronic illness • Allergies, current medications, treatments, or recent immunizations Chief complaint General symptoms • Severity • Duration • Other symptoms • Pain Systems review Steps taken • Advised to call emergency medical services (911) • Advised to go to emergency department • Advised to see practitioner (today, tomorrow, or later appointment) • Advised regarding home care • Advised to call back if symptoms worsen or fail to improve

Psychosocial Development in Toddlers

Developing a sense of autonomy (Erikson) Autonomy versus shame and doubt Negativism Ritualization that provides sense of comfort

Psychosocial Development

Developing a sense of trust (Erikson) Infants trust that their comfort needs will be met: feeding, stimulation Mistrust: occurs when gratification of needs is delayed Social modifications: grasping, biting

Moral Development (Kohlberg)

Development of conscience and moral standards. Ages 2 to 4 years: reward and punishment guide choices. Older school age: child is able to judge and act by the intentions that prompted it. Rules and judgements become more founded on needs and desires of others.

Moral Development (Kohlberg)

Development of conscience and moral standards. Ages 6 to 7 years reward and punishment guide choices. Older school age: child is able to judge an act by the intentions that prompted it. Rules and judgements become more founded on needs and desires of others.

The Child with Chronic/Complex Conditions

Developmental Aspects depend on the age on onset. table 36.2 pg 1003. Coping mechanisms: hopefulness, health education and self care. box 36.6 pg 1004. Children need info on their condition and the plan.

Concerns related to growth and development of preschoolers

Developmental Screening tool to assess readiness for school. Importance of infection control in school setting. Introduction of child to school and teachers.

dietary fats nursing alert

Dietary fat in infants younger than 6 months of age should not be restricted unless on specific medical advice. Substituting skim or low-fat milk is unacceptable, since the essential fatty acids are inadequate and the solute concentration of protein and electrolytes, such as sodium, is too high.

Individual Risk Factors for care during hospitalization

Difficult temperament, Age (esp. 6 mo-5yr), males, below average intelligence, multiple and continuing stresses (frequent hospitalizations)

Parental Reactions to illness and hospitalization

Disbelief, anger, guilt- especially is sudden illness. Fear, anxiety- related to Childs pain and seriousness of illness. Frustration- especially related to need for information. Depression

parallel play

During parallel activities, children play independently but among other children. They play with toys similar to those the children around them are using but as each child sees fit, neither influencing nor being influenced by the other children. Each plays beside, but not with, other children (Fig. 28.7). There is no group association. Parallel play is the characteristic play of toddlers, but it may also occur in other groups of any age. Individuals who are involved in a creative craft with each person separately working on an individual project are engaged in parallel play.

Appropriate Site, Technique, Needle Size, and Dose for Intramuscular Injections in Infants, Toddlers, and Small Children

Infants and Toddlers • A 16-mm needle was sufficient to penetrate the anterolateral thigh muscle if the needle is inserted at a 90-degree angle without pinching the muscle in children 2, 4, 6, and 18 months of age (Cook & Murtagh, 2002). • A 25-mm needle was necessary to penetrate the thigh muscle when a 45-degree injection technique was employed. Longer needle length is needed to fully deposit the medication into the muscle in children 2, 4, 6, and 18 months of age (Cook & Murtagh, 2002). • Vaccines containing adjuvant such as alum (e.g., DTaP, hepatitis A and hepatitis B, diphtheria-tetanus [DT or Td]) should be given deep into the muscle to prevent local reactions (American Academy of Pediatrics [AAP], 2012; Centers for Disease Control and Prevention [CDC], 2002; Petousis-Harris, 2008; Taddio, Ilersich, Ipp, et al., 2009). • Injecting adjuvant-containing vaccines into subcutaneous tissue increases the incidence of local reactions (Taddio et al., 2009). • 4-month-old infants experienced fewer local side effects (redness, tenderness, and swelling) when immunizations were administered into the anterior aspect of the thigh with a 25-mm (1-inch) needle versus shorter 16-mm (-inch) needle (Diggle & Deeks, 2000). • Localized vaccine reactions were significantly reduced when long needles (25 mm) were used for infant immunizations (Diggle, Deeks, & Pollard, 2006; Petousis-Harris, 2008). • A 16-mm needle may be adequate for injections in small infants, and a 22- to 25-mm (- to 1-inch) needle can be used in infants 2 months of age and older (AAP, 2012). • A 22- to 32-mm (- to -inch) needle is recommended for injections in toddlers if deltoid muscle size is adequate (CDC, 2002). • A minimum of 25-mm needle is recommended for anterolateral thigh injection in toddlers (CDC, 2002). • The dorsogluteal muscle should be avoided in infants and toddlers, and in smaller preschoolers with smaller muscle mass, because of the possibility of damaging the sciatic nerve (AAP, 2012). • In children older than 1 year of age, the deltoid muscle is recommended for IM injections. When multiple vaccines are given, two may be given in the thigh (anterior and lateral) because of its larger size (Diggle, 2003). • Injections in the anterolateral thigh should be given at least 2.5 cm (1 inch) apart so local reactions are less likely to overlap (AAP, 2012). • No research or supportive data were found regarding the amount of medication to be given at the different sites in infants and toddlers. Children and Adolescents • A 22- to 25-gauge needle for all IM childhood immunizations is recommended (AAP, 2012; CDC, 2002). • The deltoid muscle may be used for immunizations in toddlers, older children, and adolescents (AAP, 2012; CDC, 2002). • 16-mm needle for children who weigh less than 60 kg and a 25-mm needle for children 60-70 kg are appropriate for IM injections in the deltoid injection site (Koster, Stellato, Kohn, et al., 2009). • Needle length was found to be the most significant variable for local reactions in children after injection: A 25-mm needle was associated with fewer localized reactions versus a 16-mm needle (Davenport, 2004). • In children older than 1 year of age, the deltoid muscle is recommended for IM injections. When multiple vaccines are given, two may be given in the thigh (anterior and lateral) because of its larger size (Diggle, 2003). • Injections in the anterolateral thigh should be given at least 2.5 cm (1 inch) apart so local reactions are less likely to overlap (AAP, 2012). • IM injections in the buttocks with longer needles and a 90-degree angle are associated with less reactogenicity (Petousis-Harris, 2008).

Specific Strategies for pain Management

Distraction Involve parent and child in identifying strong distractors. Involve child in play; use radio, smartphone, tablet, or computer game; have child sing or use rhythmic breathing. Have child take a deep breath and blow it out until told to stop. Have child blow bubbles to "blow the hurt away." Have child concentrate on yelling or saying "ouch," with instructions to "yell as loud or soft as you feel it hurt; that way I know what's happening." Have child look through kaleidoscope (type with glitter suspended in fluid-filled tube) and encourage him or her to concentrate by asking, "Do you see the different designs?" Use humor, such as watching cartoons, telling jokes or funny stories, or acting silly with child. Have child read, play games, or visit with friends. Relaxation With an infant or young child: • Hold in a comfortable, well-supported position, such as vertically against the chest and shoulder. • Rock in a wide, rhythmic arc in a rocking chair, or sway back and forth, rather than bouncing child. • Repeat one or two words softly, such as "Mommy's here." With a slightly older child: • Ask child to take a deep breath and "go limp as a rag doll" while exhaling slowly; then ask child to yawn (demonstrate if needed). • Help child assume a comfortable position (e.g., pillow under neck and knees). • Begin progressive relaxation: starting with the toes, systematically instruct child to let each body part "go limp" or "feel heavy." If child has difficulty relaxing, instruct child to tense or tighten each body part and then relax it. • Allow child to keep eyes open, since children may respond better if eyes are open rather than closed during relaxation.

Role/Relationship Pattern

Does your child have a favorite nickname? What are the names of other family members or others who live in the home (relatives, friends, pets)? Who usually takes care of your child during the day and night (especially if other than parent, such as babysitter, relative)? What are the parents' occupations and work schedules? Are there any special family considerations (adoption, foster child, stepparent, divorce, single parent)? Have any major changes in the family occurred lately (death, divorce, separation, birth of a sibling, loss of a job, financial strain, mother beginning a career, other)? Describe child's reaction. Who are your child's play companions or social groups (peers, younger or older children, adults, or prefers to be alone)? Do things generally go well for your child in school or with friends? Does your child have "security" objects at home (pacifier, bottle, blanket, stuffed animal or doll)? Did you bring any of these to the hospital? How do you handle discipline problems at home? Are these methods always effective? Does your child have any condition that interferes with communication? If so, what are your suggestions for communicating with your child? Will your child's hospitalization affect the family's financial support or care of other family members (e.g., other children)? What concerns do you have about your child's illness and hospitalization? Who will be staying with your child while hospitalized? How can we contact you or another close family member outside of the hospital?

Cognitive/Perceptual Pattern

Does your child have any hearing difficulty? • Does the child use a hearing aid? • Have "tubes" been placed in your child's ears? Does your child have any vision problems? • Does the child wear glasses or contact lenses? Does your child have any learning difficulties? What is the child's grade in school?

Safety Alert Emergency Management of Anaphylaxis

Drug: Epinephrine 0.01 mg/kg of 1 mg/ml solution up to maximum of 0.3 mg Dose: • EpiPen Jr (0.15 mg) intramuscularly (IM) for child weighing 8 to 25 kg (17.5 to 55 lbs) • EpiPen (0.3 mg) IM for child weighing 25 kg (55 lbs) or more Observe for adverse reactions, such as tachycardia, hypertension, irritability, headaches, nausea, and tremors.

Promotion of Normal Development

Early childhood Basic trust, separation from parents, and beginning independence. May need more parental support, how to hold a rigid flaccid infant, tongue thruster, or dyspnea. School age Industry/activity. Prep could involve a tutor, role play, prepare classmates. Maintain or reestablish relationships with peers. They need the same socialization. Adolescence Developing independence/autonomy. Making decisions regarding their care.

Ears and Nose

Ears ➢External structures ➢Internal stuctures •Positioning the child •Otoscopic examination •Auditory testing Nose ➢External structures ➢Internal structures

Other Eating Disorders

Eating disorder not otherwise specified (EDNOS) Binge eating disorder (BED) Avoidance\restrictive food intake disorder (ARFID)

anorexia nervosa

Eating disorder: refusal to maintain normal body weight. Severe weight loss in the absence of obvious physical causes. Primarily in adolescent girls and young women. Mean age onset: 13 years, ranging from 10 to 25. Can be life threatening.

Nursing Care of the Child with Impaired Cognitive Function

Educate child and family. Positive reinforcement. Motivate the child. Teach child self care skills. Promote child's optimal development. Encourage play and exercise. Communication. Discipline. Socialization. Sexuality. Helping families adjust to future care, Care for the child during hospitalization.

Nurses Role in injury Prevention

Education Anticipatory guidance (an appreciation of the hazards or conflict of each developmental period) Ensuring safety in the home. Encourage infant CPR.

Effects of Hospitalization on the Child

Effects may be seen before admission, during hospitalization, or after discharge Child's concept of illness is more important than intellectual maturity in predicting anxiety

Enterobiasis (pinworms)

Eggs float in the air and are ingested. S/S: intense anal itching. Tape test performed by parent in the morning and before a BM or bath. Treated with pyrantel pamoate (Pin-Rid) and albendazole.

Loss of Control: Preschoolers

Egocentric and magical thinking typical of age May view illness or hospitalization as punishment for misdeeds Preoperational thought Separation anxiety demonstrated as refusal to eat, difficulty sleeping, breaking toys.

Electrical Burns or burns

Electrical outlets-Place safety cap over electrical outlets; infants may be burned by placing conductive object into outlet.Hot hair styling appliances (curlers, flat irons)Keep out of reach of infant and keep turned off when not in use.Water-Infants may turn on tap or faucet in bathtub and burn self. Lower the water heater to a safe temperature of 49° C (120° F). Before placing infant in tub, check temperature of water and completely turn off faucet so child cannot alter temperature of water. NEVER leave infant unattended in tub or sink of water.Fireplace-Place a childproof screen in front of fireplace.Stove, hot liquids-Keep top front burners off and keep pot handles turned toward back to avoid infant pulling hot pot onto self and causing burn injuries.Cigarettes-Avoid smoking and holding infant on lap while smoking cigar or cigarette.

Promoting optimum health during adolescence

Emotional well being Nutrition- dietary habits, Eating disorders, obesity Physical fitness- recommended 60 minutes 3 times per week Hypertension associated with obesity Hyperlipidemia- major risk factor for development Immunizations- stay current with meningitis, HPV, TB Sleep and rest- recommended 9 hours a night dental visits every 6 months. Frequent showering and bathing due to hyperactive sweat glands Body art help with identity formation. Tanning beds are not recommended and eye protection must be worn. Posture- scoliosis Stress Reduction 7% of students between 16-24 drop out

being empathetic

Empathy is the capacity to understand what another person is experiencing from within that person's frame of reference; it is often described as the ability to put oneself in another's shoes. The essence of empathic interaction is accurate understanding of another's feelings.

Teething

Eruption of deciduous (primary) teeth. The age varies among children, but the order is usually regular and predictable. The first primary teeth to erupt are lower central incisors. Usually 6 to 10 months of age. Infants may bite on hard objects, increase sucking, or hold their ear to show signs of discomfort. Topical ointments can be rubbed on the gums, but it can destroy the oxygen carrying component of the hemoglobin.

Dental Health in Preschoolers

Eruption of deciduous teeth is complete Professional care and prophylaxis Fluoride supplements Assistances and supervision of brushing, flossing by parents.

Neuroendocrine events of puberty

Estrogens and Androgens are produced

Child Maltreatment/Neglect

Everyone is responsible to report. Physical neglect- deprivation of food, housing, clothes, medical attention, School, etc. Emotional neglect- lack of affection, attention, and emotional nurturance. Emotional abuse or psychological maltreatment- destruction of a Childs self esteem intentionally.

Atopic Dermatitis

Excess inflammation; dry skin, redness, and itching from allergies and irritants. Hydrate skin and minimize flare ups by using a milk soap. Prevent secondary infection by prevent breaking the skin. Can put clean cotton or socks on the hands.

Seborrheic Dermatitis (Cradle Cap)

Excessive thick scaling on the scalp of younger infants. Treated by softening and removal of the thick scales on the scalp after soaking scalp a few hours (to overnight) with vegetable oil or mineral oil. Shampoo scalp and gently scrub scales with soft comb. Prevention is by frequent shampooing with mild baby shampoo and removing scales with soft brush or comb. Self-limiting condition and resolves spontaneously within a few months. Shampoo daily with mild soap or cradle shampoo.

Primary sex characteristics

External and internal organs necessary for reproduction

Eyes

External structures Internal structures •Preparing the child •Funduscopic examination ➢Vision testing •Occular alignment •Visual acuity in children •Visual acuity in infants and difficult to test children •Peripheral vision •Color vision

Scope of Problem for Families and Siblings

Families: additional tasks, responsibilities, and concerns Siblings: loss of attention. secondary losses: extracurricular and social events. Need info and knowledge on siblings disease or condition

family assessment

Family assessment is the collection of data about the composition of the family and the relationships among its members. In its broadest sense, family refers to all those individuals who are considered by the family member to be significant to the nuclear unit, including relatives, friends, and social groups (e.g., school and church). Although family assessment is not family therapy, it can and frequently is therapeutic. Involving family members in discussing family characteristics and activities can provide insight into family dynamics and relationships

Family Health History

Family health history is generally confined to first-degree relatives (parents, siblings, grandparents, and immediate aunts and uncles). Information includes age, marital status, health status, cause of death if deceased, and any evidence of conditions, such as early heart disease, stroke, sudden death from unknown cause, hypercholesterolemia, hypertension, cancer, diabetes mellitus, obesity, congenital anomalies, allergies, asthma, seizures, tuberculosis, abnormal bleeding, sickle cell disease, cognitive impairment, hearing or visual deficits, and psychiatric disorders (e.g., depression, psychosis, or emotional problems).

Fears for the Family

Fear of pain and suffering- Pain control is the highest priority. Death vigil- when the parent never leaves the child alone. Nurses suggest parents and family to take shifts. If the child is actively dying, give full access to the child at all times and maybe a pager. Fear of actual death. Scopolamine can be given for death rattle respirations. After death allow the parent to hold the child, bathe the child, etc.

Sex Education for Preschoolers

Find out what children know and think. Use correct anatomic words. Be honest. Masturbation is common at approximately 4 years of age- private act.

Tests for Cerebellar Function

Finger-to-nose test: With the child's arm extended, ask the child to touch the nose with the index finger with the eyes open and then closed. Heel-to-shin test: Have the child stand and run the heel of one foot down the shin or anterior aspect of the tibia of the other leg, both with the eyes opened and then closed. Romberg test: Have the child stand with the eyes closed and heels together; falling or leaning to one side is abnormal and is called the Romberg sign.

Guidance During the Infant's First Year

First 6 Months • Teach parents car safety with use of federally approved restraint, facing rearward, in the middle of the back seat—not in a front seat with an air bag. • Understand each parent's adjustment to the newborn, especially mother's emotional needs after birth. • Teach care of infant, and help parents understand his or her individual needs and temperament and that the infant expresses wants through crying. • Reassure parents that infant cannot be spoiled by too much attention during the first 4 to 6 months. • Encourage parents to establish a schedule that meets needs of child and themselves. • Help parents understand infant's need for stimulation in environment. • Support parents' pleasure in seeing child's growing friendliness and social response, especially smiling. • Plan anticipatory guidance for safety. • Stress need for childhood immunizations. • Prepare for introduction of solid foods. Second 6 Months • Prepare parents for child's "stranger anxiety." • Encourage parents to allow child to cling to them and avoid long separation from either. • Guide parents concerning discipline because of infant's increasing mobility. • Encourage use of negative voice and eye contact rather than physical punishment as a means of discipline. • Encourage showing most attention when infant is behaving well, rather than when infant is crying. • Teach injury prevention because of child's advancing motor skills and curiosity. • Encourage parents to leave child with suitable caregiver to allow some free time. • Discuss readiness for weaning. • Explore parents' feelings regarding infant's sleep patterns.

Nutrition

First 6 months. Whole milk is not an acceptable source of nutrition. Breast milk is the recommended source. Before 6 months the baby's digestive system is not ready to absorb foods. Breastfed babies reduce the risk of obesity and non breast fed predisposes the child for risk of allergies. Al infants receive daily supplement of 400 iu of vitamin D beginning the first few days to prevent Ricketts and vitamin D deficiency.

Developmental Focus in Care of Children with Chronic and Complex Problems

Focus on developmental (strengths and abilities) not chronological. Normalization- adapting environment, promoting coping skills. Family centered care: communication with HCP, establish a therapeutic relationship, the role of culture, shared decision making, normalization/home care.

Centration

Focusing on one aspect rather than considering all possible alternatives Example: Child refuses to eat a food because of its color, even though its taste and smell are acceptable. Implication: Accept child's reasoning.

Diphtheria Infection Control

Follow Standard and Droplet Precautions until two cultures are negative for C. diphtheriae; use Contact Precautions with cutaneous manifestations. Administer antibiotics in timely manner. Participate in sensitivity testing; have epinephrine available. Administer complete care to maintain bed rest. Use suctioning as needed. Observe respiration for signs of obstruction. Administer humidified oxygen as prescribed.

Asphyxia, animal bites

Food items: cylindric items such as hot dogs, hard candy, nuts. Cut hot dogs lengthwise; avoid hard candy in infants and toddlers. Infants should completely chew up each food item in mouth; do not feed more until item is swallowed. Toys: small toys such as Legos-As a general rule of thumb, if the toy fits into a toilet paper cardboard roll, it can be swallowed by a small child. Small objects: batteries, buttons, beads, dried beans, syringe caps, safety pins. Keep out of reach of infants, who are naturally inquisitive. Pacifiers-Pacifiers should be one piece .Baby (talc) powder-Avoid shaking powder over infant; if used, place on adult's hand and then place on infant's skin. Domestic dogs, cats-Supervise child around domestic animals; teach not to approach dog that is eating, has puppies, or is not feeling well. Animals that are "tame" can be unpredictable. Small children are the right size for most domesticated animals to come face to face. Closely supervise child around visiting pets.

Directing the Focus

For example, if the parent proceeds to list the other children by name, say, "Tell me their ages, too." If the parent continues to describe each child in depth, which is not the purpose of the interview, redirect the focus by stating, "Let's talk about the other children later. You were beginning to tell me about Paul's activities at school." This approach conveys interest in the other children but focuses the assessment on the patient.

Temperature

For rectal temperatures in children, a value of 37° to 37.5° C (98.6° to 99.5° F) is an acceptable range, where heat loss and heat production are balanced. For neonates, a core body temperature between 36.5° and 37.6° C (97.7° to 99.7° F) is a desirable range

Middle Childhood: 6 to 11 or 12 Years of Age

Frequently referred to as the school age, this period of development is one in which the child is directed away from the family group and centered around the wider world of peer relationships. There is steady advancement in physical, mental, and social development with emphasis on developing skill competencies. Social cooperation and early moral development take on more importance with relevance for later life stages. This is a critical period in the development of a self-concept.

Tinea corporis: Trichophyton rubrum, Trichophyton mentagrophytes, M. canis, Epidermophyton organisms

Generally round or oval, erythematous scaling patch that spreads peripherally and clears centrally; may involve nails (tinea unguium) Usually unilateral Diagnosis: Direct microscopic examination of scales Oral griseofulvin Local application of antifungal preparation, such as tolnaftate, naftifine, miconazole, terbinafine, clotrimazole; applied daily 2.5 cm (1 inch) beyond periphery of lesion; application continued 1 to 2 weeks after no sign of lesion Usually of animal origin from infected pets but may occur from human transmission, soil, or fomites; commonly seen in wrestlers

ASDs Etiology

Genetic disorder of prenatal and postnatal brain development. Immune and environmental factors that may interact with genetic susceptibility. Relatively high risk of recurrence of ASDs in families with one affected child.

Prenatal Period: Conception to Birth

Germinal: Conception to approximately 2 weeks of age Embryonic: 2 to 8 weeks of age Fetal: 8 to 40 weeks of age (birth) A rapid growth rate and total dependency make this one of the most crucial periods in the developmental process. The relationship between maternal health and certain manifestations in the newborn emphasizes the importance of adequate prenatal care to the health and well-being of the infant.

Usual Sequence of Maturational Changes

Girls • Breast changes • Rapid increase in height and weight • Growth of pubic hair • Appearance of axillary hair • Menstruation (usually begins 2 years after first signs noted above) • Abrupt deceleration of linear growth Boys • Enlargement of testicles • Growth of pubic hair, axillary hair, hair on upper lip, hair on face and elsewhere on body (facial hair usually appears about 2 years after appearance of pubic hair) • Rapid increase in height • Changes in the larynx and consequently the voice (usually take place along with growth of penis) • Nocturnal emissions • Abrupt deceleration of linear growth

Sexual maturation

Girls can take 1.5 to 6 years and boys 2 to 5 years. girls mature faster than boys. Tanner stages of sexual maturity is a way to tell where a child is in development.

Social Development in Adolescents

Goal: to define identity independently from parental authority Much ambivalence Intense sociability; intense loneliness Acceptance by peers is the most important to them

Fine Motor Development

Grasping object: ages 2 to 3 months Transferring object between hands: age 7 months Pincer grasp: age 10 months Removing objects from container: age 11 months Building tower of two blocks: age 1 year

Grief and Mourning

Grief is a process not an event and can take up to one year. Highly individualized. Anticipatory grief can manifest as denial, anger, or depression. The is a mourning process- it never goes away but it does lessen. The nurse needs to recognize when grief becomes complicated. Sibling grief is individual. Nurses are encouraged to attend the funeral service to be supportive. Pg 1020

Gross and Fine Motor Skills: Preschooler

Gross motor: walking running, climbing, and jumping well established. Fine motor: Refinement in eye-hand and muscle coordination. Skillful manipulation (dressing, drawing)

Physical Growth During Puberty

Growth spurt is very dramatic. Girls usually grow faster than boys. Heart increases in size and strength. HR decreases. BP increases. RR decreases. Response depends on stage of development. During this time girls will begin their menstrual cycle and boys will begin nocturnal emissions.

Guided Imagery

Have child identify some highly pleasurable real or imaginary experience. Have child describe details of the event, including as many senses as possible (e.g., "feel the cool breezes," "see the beautiful colors," "hear the pleasant music"). Have child write down or record script. Encourage child to concentrate only on the pleasurable event during the painful time; enhance the image by recalling specific details by reading the script or playing the tape. Combine with relaxation and rhythmic breathing.

Clinical Manifestations of Down Syndrome

Head and Eyes Separated sagittal suture Brachycephaly Rounded and small skull Flat occiput Enlarged anterior fontanel Oblique palpebral fissures (upward, outward slant)* Inner epicanthal folds Speckling of iris (Brushfield spots) Nose and Ears Small nose* Depressed nasal bridge (saddle nose)* Small ears and narrow canals Short pinna (vertical ear length) Overlapping upper helices Conductive hearing loss Mouth and Neck High, arched, narrow palate* Protruding tongue Hypoplastic mandible Delayed teeth eruption and microdontia Abnormal teeth alignment common Periodontal disease Neck skin excess and laxity* Short and broad neck Chest and Heart Shortened rib cage Twelfth rib anomalies Pectus excavatum or carinatum Congenital heart defects common (e.g., atrial septal defect, ventricular septal defect) Abdomen and Genitalia Protruding, lax, and flabby abdominal muscles Diastasis recti abdominis Umbilical hernia Small penis Cryptorchidism Bulbous vulva Hands and Feet Broad, short hands and stubby fingers Incurved little finger (clinodactyly) Transverse palmar crease Wide space between big and second toes* Plantar crease between big and second toes* Broad, short feet and stubby toes Musculoskeletal and Skin Short stature Hyperflexibility and muscle weakness* Hypotonia Atlantoaxial instability Dry, cracked, and frequent fissuring Cutis marmorata (mottling) Other Reduced birth weight Learning difficulty (average intelligence quotient [IQ] of 50) Hypothyroidism common Impaired immune function Increased risk for leukemia Early-onset dementia (in one-third)

Head Circumference

Head circumference is a reflection of brain growth. Measure head circumference in children up to 36 months of age and in any child whose head size is questionable. Measure the head at its greatest frontooccipital circumference, usually slightly above the eyebrows and pinna of the ears and around the occipital prominence at the back of the skull (Fig. 29.11). Use a paper or non-stretchable tape because a cloth tape can stretch and give a falsely small measurement Generally, head and chest circumferences are equal at about 1 to 2 years of age. During childhood, chest circumference exceeds head size by about 5 to 7 cm (2 to 2.75 inches).

Gross Motor Development

Head lag in first 2 months Head control at 4 months Parachute reflex by 7 months Sit alone by 7 months Move from prone to sitting position by 10 months Rolling over abdomen to back age 5 months Rolling over back to abdomen 6 months

Middle Childhood

Height increases by 2 inches/year Total height gained is 1 to 2 feet Weight Increases by 2 to 3 kg a year Weight almost doubles Boys and girls differ little in size.

Spoon Feeding

Helps prevent infant from pushing out food with their tongue.

Consequences of Untreated Pain in Infants Potential Long Term Consequences

Higher somatic complaints of unknown origin Greater physiologic and behavioral responses to pain Increased prevalence of neurologic deficits Psychosocial problems Neurobehavioral disorders Cognitive deficits Learning disorders Poor motor performance Behavioral problems Attention deficits Poor adaptive behavior Inability to cope with novel situations Problems with impulsivity and social control Learning deficits Emotional temperament changes in infancy or childhood Accentuated hormonal stress responses in adult life

Treatment options for the terminally ill child

Hospital- if child is unstable bring familiar items from when the child is at home. Be consistent with coordinated plan of care for the child and the family's comfort. Home Care- stable enough but still under care of physician. There will be periodic nurse visits to administer meds, etc. Hospice- specialized for dying patients. Principles of palliative care. Care involves physical, psychosocial, and spiritual needs.

Self Perception/Self Concept Pattern

How would you describe your child (e.g., takes time to adjust, settles in easily, shy, friendly, quiet, talkative, serious, playful, stubborn, easygoing)? What makes your child angry, annoyed, anxious, or sad? What helps? How does your child act when annoyed or upset? What have been your child's experiences with and reactions to temporary separation from you (parent)? Does your child have any fears (places, objects, animals, people, situations)? • How do you handle them? Do you think your child's illness has changed the way he or she thinks about himself or herself (e.g., more shy, embarrassed about appearance, less competitive with friends, stays at home more)?

A Child's Perception of Taking Ritalin at School

I feel embarrassed by having to leave class early to go take my medication. The other kids always ask where I'm going and why. It would be better if we could leave class at the same time as everyone else, go take the medication, and then just be a little late to the next class. Students don't ask why people are late for class, only why they leave early. It also bothers me when kids tell other kids, "Go take a pill" and other mean things just because someone is acting up. What could nurses and teachers do to help? Most kids do not understand why other kids have to take medication. I think it would help if a nurse or teacher talked with the other kids and explained why some children take the medication and how ADHD affects people. That way there would be more understanding among all the kids. Marissa White, Age 16 Years ADHD, Attention deficit hyperactivity disorder.

PTSD in children

I: Trauma Symptom Checklist for Children, Beck Anxiety Inventory DD: Depressive, bipolar, anxiety, substance use Tx: CBT, Exposure Therapy, Emotion Focused Cognitive-Behavioral, Trauma Focused CBT

Thought Stopping

Identify positive facts about the painful event (e.g., "It does not last long"). Identify reassuring information (e.g., "If I think about something else, it does not hurt as much"). Condense positive and reassuring facts into a set of brief statements, and have child memorize them (e.g., "Short procedure, good veins, little hurt, nice nurse, go home"). Have child repeat the memorized statements whenever thinking about or experiencing the painful event.

Outline of a Pediatric Health History

Identifying information 1. Name 2. Address 3. Telephone 4. Birth date and place 5. Race or ethnic group 6. Sex 7. Religion 8. Date of interview 9. Informant Chief complaint (CC): To establish the major specific reason for the child's and parents' seeking of health care Present illness (PI): To obtain all details related to the chief complaint Past history (PH): To elicit a profile of the child's previous illnesses, injuries, or surgeries 1. Birth history (pregnancy, labor and delivery, perinatal history) 2. Previous illnesses, injuries, or surgeries 3. Allergies 4. Current medications 5. Immunizations 6. Growth and development 7. Habits Review of systems (ROS): To elicit information concerning any potential health problem 1. Constitutional 2. Integument 3. Eyes 4. Ears/nose/mouth/throat 5. Neck 6. Chest 7. Respiratory 8. Cardiovascular 9. Gastrointestinal 10. Genitourinary 11. Gynecologic 12. Musculoskeletal 13. Neurologic 14. Genitourinary 15. Gynecologic 16. Musculoskeletal 17. Neurologic 18. Endocrine Family medical history: To identify genetic traits or diseases that have familial tendencies and to assess exposure to a communicable disease in a family member and family habits that may affect the child's health, such as smoking and chemical use Psychosocial history: To elicit information about the child's self-concept Sexual history: To elicit information concerning the child's sexual concerns or activities and any pertinent data regarding adults' sexual activity that influences the child Family history: To develop an understanding of the child as an individual and as a member of a family and a community 1. Family composition 2. Home and community environment 3. Occupation and education of family members 4. Cultural and religious traditions 5. Family function and relationships Nutritional assessment: To elicit information on the adequacy of the child's nutritional intake and needs 1. Dietary intake 2. Clinical examination

Reasons for tobacco use

Imitation of adult behavior. Peer pressure. A desire to control weight. Less likelihood of smoking is parents/family do not smoke. Less likelihood of smoking with high-performance sports activities.

Infections of the Skin in School Age

Impetigo, Herpes, Tinea, Scabies, Pediculosis capitis

Nutrition in the school age child

Importance of balanced diet to promote growth. Quality of diet related to family's pattern of eating. Developing a taste for a variety of foods. "Fast food" concerns. Know MyPlate recommendations

Associative play

In associative play, children play together and are engaged in a similar or even identical activity, but there is no organization, division of labor, leadership assignment, or mutual goal. Children borrow and lend play materials, follow each other with wagons and tricycles, and sometimes attempt to control who may or may not play in the group. Each child acts according to his or her own wishes; there is no group goal (Fig. 28.8). For example, two children play with dolls, borrowing articles of clothing from each other and engaging in similar conversation, but neither directs the other's actions or establishes rules regarding the limits of the play session. There is a great deal of behavioral contagion: When one child initiates an activity, the entire group follows the example.

bulimia nervosa

In older adolescents and young women. Eating disorder characterized by binge eating. May be followed by purging behaviors: laxative abuse, self induced vomiting, diuretic abuse, rigorous exercise regimens. As Many as eight or more cycles per day. Can lead to depression.

unoccupied behavior

In unoccupied behavior, children are not playful but focus their attention momentarily on anything that strikes their interest. Children daydream, fiddle with clothes or other objects, or walk aimlessly. This role differs from that of onlookers, who actively observe the activity of others.

Egocentrism

Inability to envision situations from perspectives other than one's own Example: If a person is positioned between the toddler and another child, the toddler, who is facing the person, will explain that both children can see the middle person's face. The young child is unable to realize that the other person views the middle person from a different perspective, the back. Implication: Avoid moralizing about "why" something is wrong if it requires an understanding of someone else's feelings or opinion. Telling a child to stop hitting because hitting hurts the other person is often ineffective because to the aggressor it feels good to hit someone else. Instead emphasize that hitting is not allowed.

Inability to Conserve

Inability to understand the idea that a mass can be changed in size, shape, volume, or length without losing or adding to the original mass (instead children judge what they see by the immediate perceptual clues given to them) Example: If two lines of equal length are presented in such a way that one appears longer than the other, child will state that one line is longer even if child measures both lines with a ruler or yardstick and finds that each has the same length. Implications: Change the most obvious perceptual clue to reorient child's view of what is seen. For example, give medicine in a small medicine cup rather than a large cup because child will imagine that the large vessel contains more liquid. If child refuses the medicine in the small cup, pour it into a large cup, because the liquid will appear to be less in a tall, wide container. • Give a large, flat cookie rather than a thick, small one, or do the reverse with meat or cheese; child will usually eat larger size of favorite food and smaller size of less favorite food.

Irreversibility

Inability to undo or reverse actions initiated physically Example: When told to stop doing something such as talking, child is unable to think of positive activity. Implication: State requests or instructions positively (e.g., "Be quiet.")

Pathophysiologic Causes of Failure to Thrive

Inadequate caloric intake: Incorrect formula preparation, neglect, food fads, excessive juice consumption, lack of food availability, breastfeeding problems, behavioral problems affecting eating, or central nervous system problems affecting intake Inadequate absorption: Food allergy, malabsorption, pyloric stenosis, GI atresia, inborn errors of metabolism Excessive caloric expenditure: Hyperthyroidism, malignancy, congenital heart disease, chronic pulmonary disease, or chronic immunodeficiency

Infectious Conditions Preschoolers

Incidence has declined r/t increase utilization of immunizations. Complications have decreased r/t use of antibiotics. Handwashing is the number one prevention

Epidemiology of Sudden Infant Death Syndrome

Incidence-1545 per 100,000 live births (2014)*Peak age2-3 months; 95% occur by 6 months; preterm infants die from sudden infant death syndrome (SIDS) at mean age of 6 weeks later than mean age of death from SIDS for term infants. Sex-Higher percentage of boys affected. Time of death-During sleep. Time of year-Increased incidence in winter. Racial-Greater incidence in African-Americans and Native Americans (see the "Sudden Infant Death Syndrome" section earlier in this chapter)Birth Higher incidence in the following: • Preterm infants, especially infants of extremely and very low birth weight • Multiple births† • Neonates with low Apgar scores • Infants with central nervous system disturbances and respiratory disorders such as bronchopulmonary dysplasia • Increasing birth order (subsequent siblings as opposed to firstborn child) Health status-Infants with a recent history of illness; lower incidence in immunized infants. Sleep habits- Highest risk associated with prone position; use of soft bedding; overheating (thermal stress); cosleeping with adult, especially on sofa or noninfant bed; higher incidence in cosleeping with adult smoker Infants cosleeping with adult at higher risk if younger than 11 weeks of age Feeding habits-Lower incidence in breastfed infants. Pacifier-Lower incidence in infants put to sleep with pacifier. Siblings-May have greater incidence in siblings of SIDS victims. Maternal-Young age; cigarette smoking, especially during pregnancy; poor prenatal care; substance abuse (heroin, methadone, cocaine). A few studies have shown an increased risk in infants exposed to second-hand environmental tobacco smoke.

Factors That Affect Iron Absorption

Increase • Acidity (low pH)—Administer iron between meals (gastric hydrochloric acid). • Ascorbic acid (vitamin C)—Administer iron with juice, fruit, or multivitamin preparation. • Vitamin A • Tissue (cellular) need • Meat, fish, poultry • Cooking in cast iron pots Decrease • Alkalinity (high pH)—Avoid any antacid preparation. • Phosphates—Milk is unfavorable vehicle for iron administration. • Phytates—Found in cereals • Oxalates—Found in many fruits and vegetables (plums, currants, green beans, spinach, sweet potatoes, tomatoes) • Tannins—Found in tea, coffee • Tissue (cellular) saturation • Malabsorptive disorders • Disturbances that cause diarrhea or steatorrhea • Infection

Intensive Care Unit

Increased stress for child and parents Emotional needs of the family are paramount Parents need for information- the unknown is worse than the known Perception of security from constant monitoring and individualized care. A major stressor is the Childs appearance- prepare the parents what to expect before they see the child

development of body image of preschooler

Increasing comprehension of desirable appearances. Aware of racial identity, differences in appearances, and biases. poorly defined body boundaries. Children fear that if skin is broken, all blood an insides can leak out. Band aids are crucial. Intrusive experience are frightening.

Feelings and Behaviors of Children Related to Divorce

Infancy • Effects of reduced mothering or lack of mothering • Increased irritability • Disturbance in eating, sleeping, and elimination • Interference with attachment process Early Preschool Children (2 to 3 Years of Age) • Frightened and confused • Blame themselves for the divorce • Fear of abandonment • Increased irritability, whining, tantrums • Regressive behaviors (e.g., thumb sucking, loss of elimination control) • Separation anxiety Later Preschool Children (3 to 5 Years of Age) • Fear of abandonment • Blame themselves for the divorce; decreased self-esteem • Bewilderment regarding all human relationships • Become more aggressive in relationships with others (e.g., siblings, peers) • Engage in fantasy to seek understanding of the divorce Early School-Age Children (5 to 6 Years of Age) • Depression and immature behavior • Loss of appetite and sleep disorders • May be able to verbalize some feelings and understand some divorce-related changes • Increased anxiety and aggression • Feelings of abandonment by departing parent Middle School-Age Children (6 to 8 Years of Age) • Panic reactions • Feelings of deprivation: loss of parent, attention, money, and secure future • Profound sadness, depression, fear, and insecurity • Feelings of abandonment and rejection • Fear regarding the future • Difficulty expressing anger at parents • Intense desire for reconciliation of parents • Impaired capacity to play and enjoy outside activities • Decline in school performance • Altered peer relationships: become bossy, irritable, demanding, and manipulative • Frequent crying, loss of appetite, sleep disorders • Disturbed routine, forgetfulness Later School-Age Children (9 to 12 Years of Age) • More realistic understanding of divorce • Intense anger directed at one or both parents • Divided loyalties • Ability to express feelings of anger • Ashamed of parental behavior • Desire for revenge; may wish to punish the parent they hold responsible • Feelings of loneliness, rejection, and abandonment • Altered peer relationships • Decline in school performance • May develop somatic complaints • May engage in aberrant behavior, such as lying, stealing • Temper tantrums • Dictatorial attitude Adolescents (12 to 18 Years of Age) • Able to disengage themselves from parental conflict • Feelings of a profound sense of loss: of family, childhood • Feelings of anxiety • Worry about themselves, parents, siblings • Expression of anger, sadness, shame, embarrassment • May withdraw from family and friends • Disturbed concept of sexuality • May engage in acting-out behaviors

Clinical Manifestations of Giardiasis

Infants and young children: Diarrhea Vomiting Anorexia Growth failure (failure to thrive)—if chronic exposure Children older than 5 years of age: Abdominal cramps Intermittent loose stools Constipation Stools that are malodorous, watery, pale, and greasy Spontaneous resolution of most infections in 4 to 6 weeks Rare, chronic form: Intermittent loose, foul-smelling stools Possibility of abdominal bloating, flatulence, sulfur-tasting belches, epigastric pain, vomiting, headache, and weight loss

Communication with Infancy

Infants communicate their needs and feelings through nonverbal behaviors and vocalizations that can be interpreted by someone who is around them for a sufficient time. Infants smile and coo when content and cry when distressed. Crying is provoked by unpleasant stimuli from inside or outside, such as hunger, pain, body restraint, or loneliness. Infants respond to adults' nonverbal behaviors. They become quiet when they are cuddled, rocked, or receive other forms of gentle physical contact. They receive comfort from the sound of a soft voice even though they do not understand the words that are spoken.

Behavioral Contracting

Informal: May be used with children as young as 4 or 5 years of age: • Use stars, tokens, or cartoon character stickers as rewards. • Give a child who is uncooperative or procrastinating during a procedure a limited time (measured by a visible timer) to complete the procedure. • Proceed as needed if child is unable to comply. • Reinforce cooperation with a reward if the procedure is accomplished within specified time. Formal: Use written contract, which includes the following: • Realistic (seems possible) goal or desired behavior • Measurable behavior (e.g., agrees not to hit anyone during procedures) • Contract written, dated, and signed by all people involved in any of the agreements • Identified rewards or consequences that are reinforcing • Goals that can be evaluated • Commitment and compromise requirements for both parties (e.g., while timer is used, nurse will not nag or prod child to complete procedure)

Poliomyelitis Infection Control

Institute Contact Precautions. Participate in physical therapy procedures (use of moist hot packs and range-of-motion exercises).. Position child to maintain body alignment and prevent contractures or skin breakdown; use footboard or appropriate orthoses to prevent footdrop; use pressure mattress for prolonged immobility. Encourage child to perform activities of daily living to capability, promote early ambulation with assistive devices; administer analgesics for maximum comfort during physical activity; give high-protein diet and bowel management for prolonged immobility. Observe for respiratory paralysis (difficulty in talking, ineffective cough, inability to hold breath, shallow and rapid respirations); report such signs and symptoms to practitioner.

Rubella Infection Control

Institute Droplet Precautions. Reassure parents of benign nature of illness in affected child. Use comfort measures as necessary. Avoid contact with pregnant woman. Monitor rubella titers in pregnant adolescent.

Scarlet Fever Infection Control

Institute Standard and Droplet Precautions until 24 hours after initiation of treatment. Ensure compliance with oral antibiotic therapy; intramuscular benzathine penicillin G (Bicillin) may be given. Encourage rest during febrile phase; provide quiet activity during convalescent period. Relieve discomfort of sore throat with analgesics, gargles, lozenges, antiseptic throat sprays, and inhalation of cool mist. Encourage oral fluids during febrile phase; avoid irritating liquids (certain citrus juices) or rough foods (chips); when child is able to eat, begin with soft diet. Advise parents to consult practitioner if fever persists after beginning therapy. Discuss procedures for preventing spread of infection; discard toothbrush; avoid sharing drinking and eating utensils.

Giardiasis

Intestinal Parasitic disease (protozoa) S/S are abdominal cramps and diarrhea. Transferred by food/animals, stagnate water in lakes/streams. Treated with metronidazole, tinidazole, or nitazoxanide. String test to diagnose.

Etiology of CI

Intrauterine infection and intoxication Trauma or Physical Agent Inadequate nutrition Postnatal brain disease Unknown prenatal influences (hydrocephalus) Chromosome disorders (down syndrome) Gestational disorders Psychiatric disorders (autism) Environmental influences

final sensorimotor stage

Invention of are means through mental combinations: 19-24 months -imitation of behaviors -domestic mimicry (cleaning) -Limited attention span Concept of time is still embryonic

Measles Infection Control

Isolate until fifth day of rash; if hospitalized, institute Airborne Precautions. Encourage rest during prodromal stage; provide quiet activity. Fever: Instruct parents to administer antipyretics; avoid chilling; if child is prone to seizures, institute appropriate precautions. Eye care: Dim lights if photophobia present; clean eyelids with warm saline solution to remove secretions or crusts; keep child from rubbing eyes. Coryza, cough: Use cool-mist vaporizer; protect skin around nares with layer of petrolatum; encourage fluids and soft, bland foods. Skin care: Keep skin clean; use tepid baths as necessary.

Erythema Infectiosum (Fifth Disease) Infection Control

Isolation of child is not necessary, except hospitalized child (immunosuppressed or with aplastic crises) suspected of human parvovirus infection is placed on Droplet and Standard Precautions. Pregnant women need not be excluded from workplace where parvovirus infection is present; they should not care for patients with aplastic crises. Explain low risk of fetal death to those in contact with affected children; assist with routine fetal ultrasound for detection of fetal hydrops.

Interviewing Without Judgment

It is easy to inject one's own attitudes and feelings into an interview. Often nurses' own prejudices and assumptions, which may include racial, religious, and cultural stereotypes, influence their perceptions of a parent's behavior. What the nurse may interpret as a parent's passive hostility or lack of interest may be shyness or an expression of anxiety. For example, in Western cultures, eye contact and directness are signs of paying attention. However, in many non-Western cultures, including that of Native Americans, directness (e.g., looking someone in the eye) is considered rude. Children are taught to avert their gaze and to look down when being addressed by an adult, especially one with authority (Ball, Dains, Flynn, et al., 2014). Therefore, nurses must make judgments about "listening," as well as verbal interactions, with an appreciation of cultural differences.

Controlling Diaper Rash

Keep skin dry.* Use superabsorbent disposable diapers to reduce skin wetness. Change diapers as soon as soiled—especially with stool—whenever possible, preferably once during the night. Expose healthy or only slightly irritated skin to air, not heat, to dry completely. Apply ointment, such as zinc oxide or petrolatum, to protect skin, especially if skin is very red or has moist, open areas. Avoid removing skin barrier cream with each diaper change; remove waste material and reapply skin barrier cream. To completely remove ointment, especially zinc oxide, use mineral oil; do not wash vigorously. Avoid overwashing the skin, especially with perfumed soaps or commercial wipes, which may be irritating. May use a moisturizer or non-soap cleanser, such as cold cream or Cetaphil, to wipe urine from skin. Gently wipe stool from skin using a soft cloth and warm water. Use disposable diaper wipes that are detergent- and alcohol-free.

Key Elements of Family-Centered Care

Key Elements of Family-Centered Care • Incorporating into policy and practice the recognition that the family is the constant in a child's life, whereas the service systems and support personnel within those systems fluctuate • Facilitating family-professional collaboration at all levels of hospital, home, and community care: • Care of an individual child • Program development, implementation, and evaluation • Policy formation • Exchanging complete and unbiased information between family members and professionals in a supportive manner at all times • Incorporating into policy and practice the recognition and honoring of cultural diversity, strengths, and individuality within and across all families, including ethnic, racial, spiritual, social, economic, educational, and geographic diversity • Recognizing and respecting different methods of coping and implementing comprehensive policies and programs that provide developmental, educational, emotional, environmental, and financial support to meet the diverse needs of families • Encouraging and facilitating family-to-family support and networking • Ensuring that home, hospital, and community service and support systems for children needing specialized health and developmental care and their families are flexible, accessible, and comprehensive in responding to diverse family-identified needs • Appreciating families as families and children as children, recognizing that they possess a wide range of strengths, concerns, emotions, and aspirations beyond their need for specialized health and developmental services and support

Manifestations of Hearing Impairment in Infancy

Lack of startle reflex Absence of babbling by age 7 months General indifference to sound Lack of response to spoken word Failure to be awakened by loud environmental noise Identify before 3 months of age and no longer than 6 months to improve language and educational development

language of preschooler

Language becomes more sophisticated. Language is the major role of communication and social interaction. Vocabulary increases dramatically between ages 2 and 5 years. Complexity of language use increases between ages 2 and 5.

Cognitive Development in Preschoolers

Language continues to develop. Concept of casualty begins to develop. Concept of time is incompletely understood. Magical thinking is used frequently.

Suffocation, Sleep Position

Latex balloons- Avoid latex balloons except with close adult supervision. Plastic bags- Tie unused plastic bags in a knot and dispose of in a safe container. Bed surface (noninfant) such as sofa or adult bed Avoid placing infants to sleep on sofas, soft bedding, or adult bed. Pillows-Avoid use of pillows for sleep. Soft cushions and blankets Clear bedding of soft cushions and blankets .Prone sleeping-Place infant to sleep on back at all times.

Sources of Lead

Lead-based paint in deteriorating condition Lead solder Lead crystal Battery casings Lead fishing sinkers Lead curtain weights Lead bullets The following may contain lead: • Ceramic ware • Water • Pottery • Pewter • Dyes • Industrial factories • Vinyl miniblinds • Playground equipment • Collectible toys • Artists' paints • Pool cue chalk • Some imported toys or children's metal jewelry Occupations and hobbies involving lead: • Battery and aircraft manufacturing • Lead smelting • Brass foundry work • Radiator repair • Construction work • Furniture refinishing • Bridge repair work • Painting contracting • Mining • Ceramics work • Stained-glass making • Jewelry making

Tinea capitis: Trichophyton tonsurans, Microsporum audouinii, Microsporum canis

Lesions in scalp but may extend to hairline or neck Characteristic configuration of scaly, circumscribed patches or patchy areas of alopecia Pruritic Diagnosis: Microscopic examination of scales Oral griseofulvin or terbinafine Oral ketoconazole for difficult cases Selenium sulfide shampoos, used twice a week Person-to-person or animal-to-person transmission Rarely, permanent loss of hair Atopic individuals more susceptible

Language Development (Toddler)

Level of comprehension and ability to understand increases. Comprehension is much greater than the number of words a toddler can say. At age 1 year, child uses one word sentences. By age 2 years, child uses multi word sentences.

Promoting Communication for Impaired Hearing

Lip reading Cued speech (use of hand signals) Sign language Speech language therapy, which is formed through a multi sensory approach with visual, tactile, kinesthetic, and auditory stimulations. Additional aids such as flashing lights, special type writers, therapy dog, closed captions. Socialization is very important.

Gross and Fine Motor Development: Toddler

Locomotion- begin to walk. 12 to 13 months wide stance. 2 to 3 years can grasp an object and release it, jump with both feet and tip toe. Improved manual dexterity between ages 12 to 15 months. Throwing a ball by age 18 months.

Fragile X Syndrome Clinical Manifestations

Long face with a prominent jaw (prognathism), large protruding ears, large testes (macroorchidism) In carrier females the manifestations are varied.

Maturation of Systems: Toddler

Most physiologic systems relatively mature by the end of toddlerhood Upper respiratory infections, otitis media, and tonsillitis are common among toddlers Voluntary control of elimination: Sphincter control age 18 to 24 months Body temperature is maintained Child is physiologically able to control elimination Defense mechanisms of skin are intact

Play

Magnifies psychical and psychosocial development. Interaction with others becomes more important. Parallel play, imitation, tactile play, selection of appropriate toys.

Pertussis Infection Control

Maintain isolatation during catarrhal stage; if hospitalized, institute Droplet and Standard Precautions. Obtain nasopharyngeal culture for diagnosis. Encourage oral fluids; offer small amount of fluids frequently. Ensure adequate oxygenation during paroxysms; position infant on side to decrease chance of aspiration with vomiting. Provide humidified oxygen; suction as needed to prevent choking on secretions. Observe for signs of airway obstruction, such as increased restlessness, apprehension, retractions, cyanosis. Encourage compliance with antibiotic therapy for household contacts. Encourage adolescents to obtain pertussis booster (Tdap). Use Standard and Droplet Precautions in health care workers exposed to children with persistent cough and high suspicion of pertussis.

Mumps Infection Control

Maintain isolation during period of communicability; institute Droplet and Contact Precautions during hospitalization. Encourage rest and decreased activity during prodromal phase until swelling subsides. Give analgesics for pain; if child is unable to swallow pills or tablets, use elixir form. Encourage fluids and soft, bland foods; avoid foods requiring chewing. Apply hot or cold compresses to neck, whichever is more comforting. To relieve orchitis, provide warmth and local support with tight-fitting underpants.

Safety Promotion 8 to 12 months

Major Developmental Accomplishments • Crawls or creeps • Stands, holding onto furniture • Stands alone • Cruises around furniture • Walks • Climbs • Pulls on objects • Throws objects • Is able to pick up small objects; has pincer grasp • Explores by putting objects in mouth • Dislikes being restrained • Explores away from parent • Increasingly understands simple commands and phrases Injury Prevention Aspiration • Keep small objects off floor, off furniture, and out of reach of children. • Take care in feeding solid table food to give very small pieces. • Do not use beanbag toys or allow child to play with dried beans. • See also under 4 to 7 Months of Age. Bodily Damage • See under 4 to 7 Months of Age. • Avoid placing televisions or other large objects on top of furniture, which may be overturned when infant pulls self to standing position. Falls • Avoid walkers, especially near stairs.* • Ensure that furniture is sturdy enough for child to pull self to standing position and cruise. • Fence stairways at top and bottom if child has access to either end.* • Dress infant in safe shoes and clothing (soles that do not "catch" on floor, tied shoelaces, pant legs that do not touch floor). Suffocation and Drowning • Keep doors of ovens, dishwashers, refrigerators, coolers, and front-loading clothes washers and dryers closed at all times. • If storing an unused large appliance, such as a refrigerator, remove the door. • Supervise contact with inflated balloons; immediately discard popped balloons, and keep uninflated balloons out of reach. • Fence swimming pools and other bodies of standing water such as decorative fountains; lock gate to swimming pools so only adult can access. • Always supervise when near any source of water, such as cleaning buckets, drainage areas, ponds, toilets. • Keep bathroom doors closed. • Eliminate unnecessary pools of water. • Keep one hand on child at all times when in bathtub. Poisoning • Administer medications as a drug, not as a candy. • Do not administer medications unless prescribed by a practitioner. • Return medications and poisons to safe storage area immediately after use; replace caps properly if a child-protector cap is used. • Have poison control center number (800-222-1222) on telephone and refrigerator. Burns • Place guards in front of or around any heating appliance, fireplace, or furnace. • Keep electrical wires hidden or out of reach. • Place plastic guards over electrical outlets; place furniture in front of outlets. • Keep hanging tablecloths out of reach (child may pull down hot liquids or heavy or sharp objects).

Safety Promotion and Injury Prevention During Infancy Birth to 4 months

Major Developmental Accomplishments • Exhibits involuntary reflexes (e.g., crawling reflex may propel infant forward or backward; startle reflex may cause the body to jerk) • May roll over • Has increasing eye-hand coordination and voluntary grasp reflex Injury Prevention Aspiration • Aspiration is not as great a danger to this age-group, but parents should begin practicing safeguarding early (see under 4 to 7 Months of Age). • Never shake baby powder directly on infant; place powder in hand and then on infant's skin; store container closed and out of infant's reach. • Hold infant for feeding; do not prop bottle. • Know emergency procedures for choking. • Use pacifier with one-piece construction and loop handle. Burns • Install smoke detectors in home. • Do not microwave infant formula or breast milk because this can cause burns because of uneven warming. • Check bathwater temperature. • Do not pour hot liquids when infant is close by, such as sitting on lap. • Beware of cigarette ashes that may fall on infant. • Do not leave infant in sun for more than a few minutes; keep skin covered. • Wash flame-retardant clothes according to label directions. • Use cool-mist vaporizers. • Do not leave child in parked car. • Check surface heat of car restraint before placing child in seat. Suffocation and Drowning • Keep all plastic bags stored out of infant's reach; discard large plastic garment bags after tying in a knot. • Do not cover mattress with plastic. • Use firm mattress and loose blankets, with no pillows. • Make certain crib design follows federal regulations and mattress fits snugly—crib slats 2.375 inches (6 cm) apart.* • Position crib away from other furniture and away from heat radiators. • Do not tie pacifier on a string around infant's neck. • Remove bibs at bedtime. • Never leave infant alone in bath. • Do not leave infant younger than 12 months of age alone on adult or youth mattress or "beanbag" type seats. • Install carbon monoxide monitor. Motor Vehicles • Transport infant in federally approved, rear-facing car seat, preferably in back seat. • Do not place infant on seat (of car) or in lap. • Do not place child in a carriage or stroller behind a parked car. • Do not place infant or child in front passenger seat with an air bag. • Do not leave infant unattended in car, especially in environmental temperatures above 70° F. Falls • Crib rails are fixed and firmly latched. As of 2011, only beds with fixed rails are recommended, but some older models may be in use (suggest purchasing a rail-latching mechanism for older models). • Never leave infant alone on a raised, unguarded surface. • When in doubt as to where to place child, use floor. • Restrain child in infant seat, and never leave child unattended while the seat is resting on a raised surface. • Avoid using a high chair until child can sit well with support. Poisoning • Poisoning is not as great a danger to this age-group, but parents should begin practicing safeguards early (see under 4 to 7 Months of Age). Bodily Damage • Keep sharp or jagged objects such as knives and broken glass out of child's reach. • Keep diaper pins closed and away from infant.

Safety and Injury Prevention in Adolescents

Motor vehicle are the #1 unintentional injury due to strong need for peer approval, indestructibility, and need for independence. Other vehicle related injuries such as a 4 wheeler. Firearms in the home increase risk for accidental shooting

Safety Promotion 4 to 7 months

Major Developmental Accomplishments • Rolls over • Sits momentarily • Grasps and manipulates small objects • Resecures a dropped object • Has well-developed eye-hand coordination • Can focus on and locate very small objects • Has prominent mouthing (oral fixation) • Can push up on hands and knees • Crawls backward Injury Prevention Aspiration • Keep buttons, beads, syringe caps, and other small objects out of infant's reach. • Keep floor free of any small objects. • Do not feed infant hard candy, nuts, food with pits or seeds, or whole or circular pieces of hot dog. • Exercise caution when giving teething biscuits, since large chunks may be broken off and aspirated. • Do not feed infant while he or she is lying down. • Inspect toys for removable parts. • Keep baby powder, if used, out of reach. • Avoid storing large quantities of cleaning fluid, paints, pesticides, and other toxic substances. • Discard used containers of poisonous substances. • Do not store toxic substances in food or drink containers. • Discard used button-size batteries; store new batteries in a safe area. • Know telephone number of local poison control center (800-222-1222). Suffocation • Keep all latex balloons out of reach. • Remove all crib toys that are strung across crib or play yard when child begins to push up on hands or knees or is 5 months of age. Burns • Keep water faucets out of reach. • Place hot objects (cigarettes, candles, incense) on high surface out of child's reach. • Limit exposure to sun; apply sunscreen. Falls • Restrain in a high chair. • Crib rails are fixed and firmly latched. As of 2011, only beds with fixed rails are recommended. Motor Vehicles • See under Birth to 4 Months of Age. Poisoning • Make certain that paint for furniture or toys does not contain lead. • Place toxic substances on a high shelf or in locked cabinet. • Hang plants, or place on high surface rather than on floor. • Know telephone number of local poison control center (800-222-1222). Bodily Damage • Give toys that are smooth and rounded, preferably made of wood or plastic. • Avoid long, pointed objects as toys. • Avoid toys that are excessively loud. • Keep sharp objects out of infant's reach.

Skinfold Thickness and Arm Circumference

Measure skinfold thickness with special calipers, such as the Lange calipers. The most common sites for measuring skinfold thickness are the triceps (most practical for routine clinical use), subscapular, suprailiac, abdomen, and upper thigh. For greatest reliability, follow the exact procedure for measurement and record the average of at least two measurements of one site. Arm circumference is an indirect measure of muscle mass. Measurement of arm circumference follows the same procedure as for skinfold thickness except the midpoint is measured with a paper or steel tape. Place the tape vertically along the posterior aspect of the upper arm from the acromial process and to the olecranon process; half of the measured length is the midpoint

Interpreting Blood Pressure

Measuring and interpreting BP in infants and children requires attention to correct procedure because (1) limb sizes vary and cuff selection must accommodate the circumference; (2) excessive pressure on the antecubital fossa affects the Korotkoff sounds; (3) children easily become anxious, which can elevate BP; and (4) BP values change with age and growth. In children and adolescents, determine the normal range of BP by body size and age. BP standards that are based on gender, age, and height provide a more precise classification of BP according to body size. This approach avoids misclassifying children who are very tall or very short.

Sexual Education and Guidance

Media influences are pervasive. Knowledge is often inaccurate. Adolescents whose parents limit television are less lily to engage in early sex. Factual information is available from these sources: parents, schools, nurses, planned parenthood.

Therapeutic Management of Hearing Impairments

Medical or Surgical Interventions: antibiotics for otitis media, tubes can be placed. Hearing aids Cochlear Implants

Poisoning, Ingestions

Medication, ointments, cream, lotions Medications left in purses or handbags or on a table top can often be ingested by the curious infant. Keep Poison Control Center number readily available ([800]-222-1222). Plants: household plants may be a source of accidental poisoning-Keep plants out of child's reach.Cleaning solutions-Store in locked cabinet or in top cabinet where there are no drawers or shelves for infant to climb on. Avoid storing cleaning and caustic solutions in containers such as a soda bottle or jar—infants and toddlers cannot differentiate a soda from a caustic drain cleaner.Inhalation or oral or nasal ingestion of poisonous or harmful chemicals such as methamphetamine, gasoline, turpentine-Keep gasoline and turpentine stored in a locked cabinet or closet out of child's reach. Avoid storing in containers that are also used to keep drinks or food.

Fragile X Syndrome Classic Behavioral Features

Mild to severe cognitive impairment/normal IQ with learning disabilities. Delayed speech and language. Hyperactivity. Autistic like behaviors. Aggressive behaviors. Fragile X syndrome is the most common cause of intellectual disability and the most common known genetic cause of autism spectrum disorders.

Stress in Preschoolers

Minimal amounts of stress can be beneficial. Parental awareness of signs of stress in Childs life could be regression. Anticipatory Guidance. Stressors can be birth of a sibling, divorce or separation, relocation, illness.

Changes in the Pediatric Population

More serious and complex problems Fragile newborns Children with severe injuries Children with Disabilities who have survived because of increased technology More frequent and lengthy stays in hospital.

Injury Prevention in School Age Children

Most common cause of severe injury and death in school age children is vehicle crashes: pedestrian and passenger. Educate on proper safety equipment

Physical Changes in School Age Children

Movements more graceful than preschoolers. Skeletal lengthening and fat diminution. Increased muscle tissue. Decrease in head circumference related to height. Change in facial proportions. The age of loose teeth.

Atraumatic Care Immunizations

Needle length is an important factor and must be considered for each individual child; fewer reactions to immunizations are observed when the vaccine is given deep into the muscle rather than into subcutaneous tissue. Deep intramuscular tissue has a better blood supply and fewer pain receptors than adipose tissue, thus providing an optimum site for immunizations with fewer side effects (Taddio, Ilersich, Ipp, et al., 2009).

Infancy Period: Birth to 12 Months of Age

Neonatal: Birth to 27 or 28 days of age Infancy: 1 to approximately 12 months of age The infancy period is one of rapid motor, cognitive, and social development. Through mutuality with the caregiver (parent), the infant establishes a basic trust in the world and the foundation for future interpersonal relationships. The critical first month of life, although part of the infancy period, is often differentiated from the remainder because of the major physical adjustments to extrauterine existence and the psychologic adjustment of the parent.

CRIES pain scale

Neonates (0-6 months)

Types of Drugs Abused

Nicotine Alcohol Cocaine Narcotics Central nervous system (CNS) depressants CNS stimulants Mind-altering drugs

Encouraging the Parents to Talk

Nurses need to be alert for clues and signals by which a parent communicates worries and anxieties. Careful phrasing with broad, open-ended questions (such as, "What is Jimmy eating now?") provides more information than several single-answer questions (such as, "Is Jimmy eating what the rest of the family eats?"). it may be necessary to direct another question on the basis of an observation, such as "Connie seems unhappy today," or "How do you feel when David cries?" If the parent appears to be tired or distraught, consider asking, "What do you do to relax?" or "What help do you have with the children?" A comment such as "You handle the baby very well. What kind of experience have you had with babies?" to new parents who appear comfortable with their first child gives positive reinforcement and provides an opening for questions they might have on the infant's care

Therapeutic Management of Eating Disorders

Nutrition Therapy: Refeeding Syndrome Cognitive behavioral therapy Pharmacotherapy Psychotherapy Care Managemt- side effects, ketones in urine. Be consistent with defined boundaries.

Obesity Nursing Alert

Obesity has increased significantly over the past three decades in young children. Efforts to provide a healthy diet and encourage physical activity should begin early to help children achieve optimal health

Tinea pedis ("athlete's foot"): T. rubrum, Trichophyton interdigitale, E. floccosum Tinea unguium: Nail infection

On intertriginous areas between toes or on plantar surface of feet Lesions vary: • Maceration and fissuring between toes • Patches with pinhead-sized vesicles on plantar surface Pruritic Diagnosis: Direct microscopic examination of scrapings Local application of terbinafine, ciclopirox, clotrimazole, miconazole, or ketoconazole Oral itraconazole, terbinafine, or griseofulvin for severe infections or not responsive to topical Elimination of conditions of heat and perspiration by use of clean, light socks and well-ventilated shoes Most frequent in adolescents and adults; rare in children, but common in locations such as showers, locker rooms and swimming pools where fungi proliferate

How to improve interviewing skills

One of the best methods for improving interviewing skills is audiotape or videotape feedback. With supervision and guidance, the interviewer can recognize the blocks and consciously avoid them

dramatic, or pretend play

One of the vital elements in children's process of identification is dramatic play, also known as symbolic or pretend play. It begins in late infancy (11 to 13 months of age) and is the predominant form of play in preschool children. After children begin to invest situations and people with meanings and to attribute affective significance to the world, they can pretend and fantasize almost anything. By acting out events of daily life, children learn and practice the roles and identities modeled by the members of their family and society. Children's toys, replicas of the tools of society, provide a medium for learning about adult roles and activities that may be puzzling and frustrating to them. Interacting with the world is one way children get to know it. The simple, imitative, dramatic play of toddlers, such as using the telephone, driving a car, or rocking a doll, evolves into more complex, sustained dramas of preschoolers, which extend beyond common domestic matters to the wider aspects of the world and the society, such as playing police officer, storekeeper, teacher, or nurse. Older children work out elaborate themes, act out stories, and compose plays.

Psychosexual Development (Freud)

Oral stage (birth to 1 year of age): During infancy, the major source of pleasure seeking is centered on oral activities, such as sucking, biting, chewing, and vocalizing. Children may prefer one of these over the others, and the preferred method of oral gratification can provide some indication of the personality they develop. Anal stage (1 to 3 years of age): Interest during the second year of life centers in the anal region as sphincter muscles develop and children are able to withhold or expel fecal material at will. At this stage, the climate surrounding toilet training can have lasting effects on children's personalities. Phallic stage (3 to 6 years of age): During the phallic stage, the genitalia become an interesting and sensitive area of the body. Children recognize differences between the sexes and become curious about the dissimilarities. This is the period around which the controversial issues of the Oedipus and Electra complexes, penis envy, and castration anxiety are centered. Latency period (6 to 12 years of age): During the latency period, children elaborate on previously acquired traits and skills. Physical and psychic energy are channeled into acquisition of knowledge and vigorous play. Genital stage (12 years of age and older): The last significant stage begins at puberty with maturation of the reproductive system and production of sex hormones. The genital organs become the major source of sexual tensions and pleasures, but energies are also invested in forming friendships and preparing for marriage.

Actions to Promote Positive Media

Parents • Follow American Academy of Pediatrics recommendations for 2 hours (total) of screen time daily for children 2 years of age and older. • Establish clear guidelines for Internet use, and provide direct supervision. Have frank discussions of what youth may encounter in viewing media. Be mindful of own media use in the home. • Encourage unstructured play in the home, and plan to help kids readjust to this change in family dynamic. Consider planned, deliberate use of media to experience the benefits (i.e., watching a television show together to bond or start a sensitive discussion). Nurses/Health Care Providers • Dedicate a few minutes of each visit to provide media screening and counseling. • Discourage presence of electronic devices in children's rooms. • Be sensitive to the challenges that parents face in carrying this out. Schools • Offer timely, accurate sexuality and drug education. • Promote resilience. • Develop programs to educate youth on wise use of technology. • Develop and implement policies on dealing with cyber-bullying and sexting.

Anticipatory Guidance for School Age Children

Parents adjust to Childs increasing independence. Parents provide support as unobtrusively as possible. Child moves from narrow family relationships to broader world of relationships.

Impact on Family

Parents may feel shock, hopelessness, fear, isolation, depression. Exacerbations lead to set backs. Take into consideration how the parents role may change and always keep siblings informed. siblings- may feel resentment and jealousy.

ASDs Clinical Manifestations

Peculiar and bizarre characteristics primarily in socialization, communication, behavior, difficulty with eye and body contact, language delay.

Relationships with Peers in adolescents

Peers assume an increasingly significant role in adolescence ("best friend") Peers provide a sense of belonging and a feeling of strength and power. Provide a measure of what is normal. School is essential. Work can lead to fatigue and lower grades. Peers form a transitional world between dependence and autonomy Role of social media and advanced technology. More to peer centered interests and activities.

Initiating a Comprehensive Family Assessment

Perform a comprehensive assessment on the following: • Children receiving comprehensive well-child care • Children experiencing major stressful life events (e.g., chronic illness, disability, parental divorce, death of a family member) • Children requiring extensive home care • Children with developmental delays • Children with repeated accidental injuries and those with suspected child abuse • Children with behavioral or physical problems that could be caused by family dysfunction

Guidelines Performing Pediatric Physical Examination

Perform the examination in an appropriate, nonthreatening area: • Have room well-lit and decorated with neutral colors. • Have room temperature comfortably warm. • Place all strange and potentially frightening equipment out of sight. • Have some toys, dolls, stuffed animals, and games available for the child. • If possible, have rooms decorated and equipped for different-age children. • Provide privacy, especially for school-age children and adolescents. • Provide time for play and becoming acquainted. Observe behaviors that signal the child's readiness to cooperate: • Talking to the nurse • Making eye contact • Accepting the offered equipment • Allowing physical touching • Choosing to sit on the examining table rather than the parent's lap If signs of readiness are not observed, use the following techniques: • Talk to the parent while essentially "ignoring" the child; gradually focus on the child or a favorite object, such as a doll. • Make complimentary remarks about the child, such as about his or her appearance, dress, or a favorite object. • Tell a funny story, or play a simple magic trick. • Have a nonthreatening "friend" available, such as a hand puppet, to "talk" to the child for the nurse (see Fig. 4.26, A). If the child refuses to cooperate, use the following techniques: • Assess reason for uncooperative behavior; consider that a child who is unduly afraid may have had a traumatic experience. • Try to involve the child and parent in the process. • Avoid prolonged explanations about the examining procedure. • Use a firm, direct approach regarding expected behavior. • Perform the examination as quickly as possible. • Have an attendant gently restrain the child. • Minimize any disruptions or stimulation. • Limit the number of people in the room. • Use an isolated room. • Use a quiet, calm, confident voice. Begin the examination in a nonthreatening manner for young children or children who are fearful: • Use activities that can be presented as games, such as test for cranial nerves (see Table 29.11 or parts of developmental screening tests (see Chapter 28). • Use approaches such as Simon Says to encourage the child to make a face, squeeze a hand, stand on one foot, and so on. • Use the paper-doll technique: 1. Lay the child supine on an examining table or floor that is covered with a large sheet of paper. 2. Trace around the child's body outline. 3. Use the body outline to demonstrate what will be examined, such as drawing a heart and listening with a stethoscope before performing activity on the child. If several children in the family will be examined, begin with the most cooperative child to model desired behavior. Involve the child in the examination process: • Provide choices, such as sitting on table or in parent's lap. • Allow the child to handle or hold equipment. • Encourage the child to use equipment on a doll, family member, or examiner. • Explain each step of the procedure in simple language. • Examine the child in a comfortable and secure position: • Sitting in parent's lap • Sitting upright if in respiratory distress Proceed to examine the body in an organized sequence (usually head to toe) with the following exceptions: • Alter sequence to accommodate needs of different-age children (see Table 29.2). • Examine painful areas last. • In an emergency situation, examine vital functions (airway, breathing, and circulation) and injured area first. Reassure the child throughout the examination, especially about bodily concerns that arise during puberty. Discuss findings with the family at the end of the examination. Praise the child for cooperation during the examination; give a reward such as a small toy or sticker.

Visual Impairment Etiology

Perinatal or postnatal infections: gonorrhea, Chlamydia, rubella, syphilis, toxoplasmosis. Retinopathy of prematurity. Perinatal or postnatal trauma. Other disorders such as sickle cell disease, juvenile rheumatoid arthritis, Tay Sachs disease.

Dental Health in School Age

Permanent teeth have erupted. Need to prevent dental caries. Peridontal disease- inflammation of gums and tissues and can cause tooth loss in adulthood. Malocclusion- arches don't have the proper relationships which can affect chewing and cosmetic appearance. Dental avulsion needs emergency treatment

Nutrition (Toddler)

Phenomenon of physiologic anorexia, picky eaters. Give planned frequent and nutritious snacks. Develop bedtime routines.

Clinical Manifestations of Fragile X Syndrome

Physical Features Increased head circumference Long, wide, or protruding ears Long, narrow face with prominent jaw Strabismus Mitral valve prolapse, aortic root dilation Hypotonia In postpubertal males, enlarged testicles Behavioral Features Mild to severe cognitive impairment (CI) Speech delay; may be rapid speech with stuttering and word repetition Short attention span, hyperactivity Hypersensitivity to taste, sounds, touch Intolerance to change in routine Autistic-like behaviors, such as social anxiety and gaze aversion Possible aggressive behavior

Assessing Toilet Training Readiness

Physical Readiness • Voluntary control of anal and urethral sphincters, usually by 24 to 30 months of age • Ability to stay dry for 2 hours; decreased number of wet diapers; waking dry from nap • Regular bowel movements • Gross motor skills of sitting, walking, and squatting • Fine motor skills to remove clothing Mental Readiness • Recognizing urge to defecate or urinate • Verbal or nonverbal communicative skills to indicate when wet or has urge to defecate or urinate • Cognitive skills to imitate appropriate behavior and follow directions Psychologic Readiness • Expressing willingness to please parent • Ability to sit on toilet for 5 to 8 minutes without fussing or getting off • Curiosity about adults' or older sibling's toilet habits • Impatience with soiled or wet diapers; desire to be changed immediately Parental Readiness • Recognizing child's level of readiness • Willingness to invest time required for toilet training • Absence of family stress or change such as a divorce, moving, new sibling, or imminent vacation

Smokeless tobacco

Place in mouth but not ignited. Increasing popularity. Serious hazards. Carcinogenic. Can cause periodontal disease, tooth erosion, soft tissue damage.

Varicella Infection Control

Precautions if hospitalized until all lesions are crusted; for immunized child with mild breakthrough varicella, isolate until no new lesions are seen. Keep child in home away from susceptible individuals until vesicles have dried (usually 1 week after onset of disease), and isolate high-risk children from infected children. Provide skin care; give bath and change clothes and linens daily; administer topical calamine lotion; keep child's fingernails short and clean; apply mittens if child scratches. Keep child cool (may decrease number of lesions). Lessen pruritus; keep child occupied; use oatmeal or baking soda baths to minimize pruritus. Remove loose crusts that rub and irritate skin. Teach child to apply pressure to pruritic area rather than scratching it. Avoid use of aspirin (possible association with Reye syndrome).

School Age Child Assessment Prep

Prefer sitting Cooperative in most positions Younger child prefers parent's presence Older child may prefer privacy Proceed in head-to-toe direction. May examine genitalia last in older child. Respect need for privacy. Request self-undressing. Allow to wear underpants. Give gown to wear. Explain purpose of equipment and significance of procedure, such as otoscope to see eardrum, which is necessary for hearing. Teach about body function and care.

Preschool Child Assessment Prep

Prefer standing or sitting Usually cooperative prone or supine Prefer parent's closeness If cooperative, proceed in head-to-toe direction. If uncooperative, proceed as with toddler. Request self-undressing. Allow to wear underpants if shy. Offer equipment for inspection; briefly demonstrate use. Make up story about procedure (e.g., "I'm seeing how strong your muscles are" [blood pressure]). Use paper-doll technique. Give choices when possible. Expect cooperation; use positive statements (e.g., "Open your mouth").

Later Childhood: 11 to 19 Years of Age

Prepubertal: 10 to 13 years of age Adolescence: 13 to approximately 18 years of age The tumultuous period of rapid maturation and change known as adolescence is considered to be a transitional period that begins at the onset of puberty and extends to the point of entry into the adult world—usually high school graduation. Biologic and personality maturation are accompanied by physical and emotional turmoil, and there is redefining of the self-concept. In the late adolescent period, the young person begins to internalize all previously learned values and to focus on an individual, rather than a group, identity.

Childhood Schizophrenia

Prevent relapse and provide social and occupational rehab

antismoking campaigns

Prevention is the most effective way to reduce incidence. Programs that focus on long term effects have been ineffective. Peer-led programs are more successful. Media are used in smoking prevention. School-based programs focus on prevention.

Child Maltreatment

Priority- remove the child from abusive situation to prevent further injury. Abused children that are taken from parents will still morn the loss of their parents. Nurse should be a role model to parent.

Nursing Care Management for Visually Impaired

Promote parent-child attachment. Promote Childs optimal development and independence. Play and socialization. Look for clues for infant responding- eyelids blinking, change in respirations. Discourage body rocking, finger flicking, arm twirling- related to lack of stimulation. Education: Braille on clothes, audiobooks and learning materials.

Separation Anxiety

Protest phase: cry and scream, cling to parent. Despair phase: crying stops, evidence of depression. Detachment Phase/Denial: Resignation but not contentment. May seriously affect attachment to parent after separation.

Feeding the Child With Failure to Thrive

Provide a primary core of staff to feed the child. The same nurses are able to learn the child's cues and respond consistently. Provide a quiet, unstimulating atmosphere. A number of children with failure to thrive (FTT) are very distractible, and their attention is diverted with minimal stimuli. Older children do well at a feeding table; bottle-fed infants and children should always be held. Maintain a calm, even temperament throughout the meal. Negative outbursts may be commonplace in this child's habit formation. Limits on eating behavior definitely need to be provided, but they should be stated in a firm, calm tone. If the nurse is hurried or anxious, the feeding process will not be optimized. Talk to the child by giving directions about eating. "Take a bite, Lisa" is appropriate and directive. The more distractible the child, the more directive the nurse should be to refocus attention on feeding. Positive comments about feeding are actively given. Be persistent. This is perhaps one of the most important guidelines. Parents often give up when the child begins negative feeding behavior. Calm perseverance through 10 to 15 minutes of food refusal will eventually diminish negative behavior. Although forced feeding is avoided, "strictly encouraged" feeding is essential. Maintain a face-to-face posture with the child when possible. Encourage eye contact, and remain with the child throughout the meal. Introduce new foods slowly. Often these children have been exclusively bottle-fed. If acceptance of solid foods is a problem, begin with pureed food and, after it is accepted, advance to junior and regular solid foods. Follow the child's rhythm of feeding. The child will set a rhythm when the previous conditions are met. Develop a structured routine. Disruption in other activities of daily living has great impact on feeding responses, so bathing, sleeping, dressing, playing, and feeding are structured. The nurse should feed the child in the same way and place as often as possible. The length of the feeding should also be established (usually 30 minutes).

Diagnosis Support

Provide support in a quiet, comfortable setting at time of diagnosis. Provide info that they desire. Never say that it will be okay. Focus on strengths of the child. Support families coping methods. Parents- discuss impact and their feelings. Parent to parent support (share experiences). Advocate for empowerment- meetings, conferences, committees, boards. Provide normalization for the child. Inform the siblings. pg 1008 guidelines for normalization.

Psychosocial Development (Erikson)

Psychosocial Theory emphasizes emotional development and interactions with the social environment. Stages are based on a series of crises that derive from conflicts between needs and social demands. 1. Trust v. Mistrust 2. Autonomy v. Shame & Doubt 3. Initiative v. Guilt 4. Industry v. Inferiority 5. Identity v. Role Confusion 6. Intimacy v. Isolation 7. Generativity v. Stagnation 8. Integrity v. Despair

Internalized set of Moral Principles (Kohlberg)

Questioning of existing moral values and relevance to society. Understanding of duty and obligation, reciprocal rights of others. Concepts of justice, separation.

Hearing Impairment

Ranges from mild to profound. Deaf: a person whose hearing disability precludes processing linguistic information with or without hearing aid. Hard of hearing: generally able to hear with hearing aid. The terms deaf and dumb, mute or deaf-mute are unacceptable.

Using Car safety Restraints

Read manufacturer directions, and follow them exactly. • Anchor safety seat securely to automobile seat, and apply harness snugly to child. • Do not start the car until everyone is properly restrained. • Always use the restraint, even for short trips. • If child begins to climb out or undo the harness, firmly say, "No." It may be necessary to stop the car to reinforce the expected behavior. Use rewards to encourage cooperative behavior. • Encourage child to help attach buckles, straps, and shields, but always double-check fastenings. • Decrease boredom on long trips. Keep soft toys in the car for quiet play; talk to child; point out objects, and teach child about them. Stop periodically. If child wishes to sleep, make certain that he or she stays in the restraint. • Insist that others who transport children also follow these safety rules.

Cognitive Development Preschool

Readiness for school, readiness for scholastic learning. Typically ages 5 to 6 years.

Car Seat Nursing Alert

Rear-facing infant safety seats must not be placed in the front seats of cars equipped with an air bag on the passenger side. If an infant safety seat is placed in the passenger seat with an air bag, the child could be seriously injured if the air bag is released, since rear-facing infant seats extend closer to the dashboard

Transductive Reasoning

Reasoning from the particular to the particular Example: Child refuses to eat a food because something previously eaten did not taste good. Implication: Accept child's reasoning; offer refused food at a different time.

Global Organization

Reasoning that changing any one part of the whole changes the entire whole Example: Child refuses to sleep in room because location of bed is changed. Implication: Accept child's reasoning; use same bed position or introduce change slowly.

Care for Hearing Impaired Child During Hospitalization

Reassess understanding of instructions given. Supplement with visual and tactile media. Communication devices: picture board, common words and needs.

Beneficial Effects of Hospitalization

Recovery from illness Increased coping skills Mastering of stress and feelings of being competent in coping New socialization experiences

What is the gold standard for temperature with infants and children?

Rectal measurement remains the clinical gold standard for the precise diagnosis of fever in infants and children compared with other methods

Diaper Dermatitis

Red, moist, maculopapular patch with poorly defined borders in diaper area, extending along inguinal and gluteal folds. History of infrequent diaper changes or occlusive coverings. Inflammatory disease caused by skin irritation from ammonia, heat, moisture, occlusive diapers. Greater incidence in bottle fed infants.

Visual Impairments

Refraction: bending of light rays through the lens of the eye, most common Myopia- near sight hyperopia- far sigh Stabismus (may or may not be refractive) Amblyopia- one eye is affected

Dental Health in Toddlers

Regular dental exams Removal of plague- brushing and flossing Fluoride Caries- education

Three major goals of eating disorder treatment

Reinstitution of normal nutrition and reversal of malnutrition. Resolution of the disturbed pattern of family interactions. Individual psychotherapy to correct deficits and distortions in psychologic functions.

Complex & Chronic disease/conditions

Require multiple specialists, technology, and community services to function to highest potential. This consists of frequent hospitalizations, complex and multi system health needs, developmental needs, reliance on technology, care that crosses hospital, clinic, and home settings. Health and Developmental Consequences: ongoing functional impairment, neurodevelopment disabilities, dependance on technology, need for on going skilled nursing, supportive care form all providers.

School Health

Responsibilities of parents, schools, and health departments. Routine services are health appraisal, education, communicable disease control, counseling, follow up care and referral.

Secondary Sex Characteristics

Result of hormonal changes: voice change, hair growth, breast enlargement, fat deposits. Play no role in reproduction.

Classification of Cognitive Impairment

Results of standardized test are used in making a diagnosis of cognitive impairment. Mildly impaired constitutes 85% of the population with CI. Moderately impaired about 10% of those with CI.

Personal-Social behavior of preschooler

Ritualism and negativism of toddlerhood diminish. Child can dress self. Child is willing to please. Child has internalized values and standards of family and culture. Child may begin to challenge families code of conduct.

Relationships with parents in adolescents

Roles change from "protection-dependency" to "mutual affection and equality" Process involves turmoil and ambiguity Struggle of privileges and responsibility Emancipation from parents may begin with rejection of parents by teen

play in school age children

Rules and Rituals. Team play. Quiet games and activities.

Adolescent Assessment Prep

Same as for school-age child Offer option of parent's presence Same as older school-age child. May examine genitalia last. Allow to undress in private. Give gown. Expose only area to be examined. Respect need for privacy. Explain findings during examination (e.g., "Your muscles are firm and strong"). Matter-of-factly comment about sexual development (e.g., "Your breasts are developing as they should be"). Emphasize normalcy of development. Examine genitalia as any other body part; may leave to end.

Fragile X Syndrome

Second most common genetic cause of cognitive impairment after down syndrome. 1 in 3600 affected males. 1 in 4000 to 6000 affected females. Abnormal gene on the lower end of the long arm of the X chromosome.

Sense pleasure play

Sense-pleasure play: Sense-pleasure play is a nonsocial stimulating experience that originates from without. Objects in the environment (light and color, tastes and odors, textures and consistencies) attract children's attention, stimulate their senses, and give pleasure. Pleasurable experiences are derived from handling raw materials (water, sand, food), body motion (swinging, bouncing, rocking), and other uses of senses and abilities (smelling, humming)

Cognitive Develop in Toddlers

Sensorimotor and preoperational phase (Piaget) Cognitive processes develop rapidly between ages 12 and 24 months. Tertiary circular reactions: active experimentation (to achieve previously unattainable goals), applying knowledge to new situations, learning spatial relationships. Aware of objects.

Cognitive Development (Piaget)

Sensorimotor-explores through the senses, gains object permanence Preoperational-can't see other people's point of view (egocentrism) Concrete operational-concept of conservation, logical thinking Formal operational-adult reasoning develops, abstract thinking, metacognition (thinking about thinking)

Down Syndrome Diagnostic Evaluation

Separated sagittal suture. Palpable sutures. Palmer creases. Flat nasal bridge. High arch palate. Excess skin and neck folds. Plantar crease between big and 2nd toe. Wide space between the big and 2nd toes. Hyperflexibility. Hypotonia and muscle weakness. Congenital heart disease is common. Hypothyroidism and increased incidence of leukemia are common.

Social Development Preschoolers

Separation-individuation process is completed. Stranger anxiety and fear of separation from parents are overcome. Parental security and guidance are still needed. Security is derived from familiar objects. Play therapy is beneficial for working through fears, anxieties, and fantasies.

Social Development (Toddler)

Separation: Differentiation of self from mother and significant others. Individualization: Achievements that mark the child's expression. Major achievements occur in the toddler years. Transitional objects can be a blanket or toy that proved security when separated from care givers.

Factors Affecting Parents' Reactions to Their Child's Illness

Seriousness of the threat to the child Previous experience with illness or hospitalization Medical procedures involved in diagnosis and treatment Available support systems Personal ego strengths Previous coping abilities Additional stresses on the family system Cultural and religious beliefs Communication patterns among family members

Autism Nursing Care Management

Severely disabling condition with no cure. Numerous therapies that have been used: behavior modification, provide a structured routine, decrease unacceptable behavior.

Sex Education: School Age

Sex play as part of normal curiosity during preadolescence Middle childhood is ideal time for formal sex education: Life span approach Information on sexual maturity and process of reproduction Effective communication with parents. Peers versus parents for primary source of information.

Child Physical Abuse

Shaken baby Syndrome- head trauma. Munchausen syndrome by proxy. Predisposing factors: young, single parents, unrelated partner, socially isolated, no support system, low income, low education.

Assisting Family Members in Managing Feelings

Shock and denial- 1st emotions Adjustment- open admission that the condition exists. Guilt, blaming self, punishment. Reintegration and acknowledgment- development of realistic expectations for the child. include relationships outside of the home. Establishing a support system early to enhance coping. pg 1001 top right

Use of Silence

Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. Silence can also be a cue for the interviewer to go more slowly, re-examine the approach, and not push too hard (Ball, Dains, Flynn, et al., 2014).

Toddler Assessment Prep

Sitting or standing on or near parent Prone or supine in parent's lap Inspect body area through play: "Count fingers," "tickle toes." Use minimum physical contact initially. Introduce equipment slowly. Auscultate, percuss, palpate whenever quiet. Perform traumatic procedures last (same as for infant). Have parent remove outer clothing. Remove underwear as body part is examined. Allow toddler to inspect equipment; demonstrating use of equipment is usually ineffective. If uncooperative, perform procedures quickly. Use restraint when appropriate; request parent's assistance. Talk about examination if cooperative; use short phrases. Praise for cooperative behavior.

Tinea cruris ("jock itch"): Epidermophyton floccosum, T. rubrum, T. mentagrophytes

Skin response similar to that in tinea corporis Localized to medial proximal aspect of thigh and crural fold; may involve scrotum in males Pruritic Diagnosis: Same as for tinea corporis Local application of tolnaftate liquid; terbinafine, clotrimazole, ciclopirox Rare in preadolescent children Health education regarding transmission via person-to-person (direct or indirect)

Sleep and Rest (school-aged children)

Sleep averages 9 to 11 hours a night during school age but is highly individualized. Children may resist going to bed ages 8 to 11. Children aged 12 years and up are generally less resistant to bedtimes.

Sleep and Activity

Sleep patterns vary among infants. By ages 3-4 months, nocturnal sleep lasts 9-11 hours. Breastfed awakened infants more often. Try to avoid excessive use if play pins or strollers because it prevents the infants from exploring by limiting excessive movement

Classification of Hearing Impairment Based on Symptom Severity

Slight: 16 to 25 Has difficulty hearing faint or distant speech Usually is unaware of hearing difficulty Likely to achieve in school but may have problems No speech defects Mild to moderate: 26 to 55 May have speech difficulties Understands face-to-face conversational speech at 0.9 to 1.5 m (3 to 5 ft) Moderately severe: 56 to 70 Unable to understand conversational speech unless loud Considerable difficulty with group or classroom discussion Requires special speech training Severe: 71 to 90 May hear a loud voice if nearby May be able to identify loud environmental noises Can distinguish vowels but not most consonants Requires speech training Profound: 91 May hear only loud sounds Requires extensive speech training

social affective play

Social-affective play: Play begins with social-affective play, wherein infants take pleasure in relationships with people. As adults talk, touch, nuzzle, and in various ways elicit responses from an infant, the infant soon learns to provoke parental emotions and responses with such behaviors as smiling, cooing, or initiating games and activities. The type and intensity of the adult behavior with children vary among cultures.

Spiritual development in adolescents

Some may question values and beliefs of family. Capable of understanding abstract concepts and of interpreting analogies and symbols. May fear that others will not understand their feelings. Greater levels of spirituality are associated with fewer risk behaviors.

Manifestations of Separation Anxiety in Young Children

Stage of Protest Behaviors observed during later infancy include the following: • Cries • Screams • Searches for parent with eyes • Clings to parent • Avoids and rejects contact with strangers Additional behaviors observed during toddlerhood include the following: • Verbally attacks strangers (e.g., "Go away") • Physically attacks strangers (e.g., kicks, bites, hits, pinches) • Attempts to escape to find parent • Attempts to physically force parent to stay Behaviors may last from hours to days. Protest, such as crying, may be continuous, ceasing only with physical exhaustion. Approach of stranger may precipitate increased protest. Stage of Despair Observed behaviors include the following: • Is inactive • Withdraws from others • Is depressed, sad • Lacks interest in environment • Is uncommunicative • Regresses to earlier behavior (e.g., thumb sucking, bed-wetting, use of pacifier, use of bottle) Behaviors may last for variable length of time. Child's physical condition may deteriorate from refusal to eat, drink, or move. Stage of Detachment Observed behaviors include the following: • Shows increased interest in surroundings • Interacts with strangers or familiar caregivers • Forms new but superficial relationships • Appears happy Detachment usually occurs after prolonged separation from parent; it is rarely seen in hospitalized children. Behaviors represent a superficial adjustment to loss.

A sense of industry (Erikson)

Stage of accomplishment. Eagerness to develop skills and participate in meaningful and socially useful work. Acquisition of sense of personal and interpersonal competence. Growing sense of independence. Peer approval: A strong motivator.

Falls

Stairs-Infants like to climb; place childproof gate at top and bottom of stairs.Diaper changing tableI-nfants do not have depth perception and cannot perceive a dangerous height from one that is safe. Never leave infants unattended on a flat surface, even if not rolling over. Crib, bed-crib sides can fall when infant leans on them.In 2011, a mandate was made to stop selling drop-side infant cribs.*Infant carriers-Never leave infant unattended in a carrier on top of a surface such as a shopping cart, clothes dryer, washer, kitchen cabinet; place carrier on floor.Car seat restraints-Secure infant in car seat restraint and never leave unattended if unrestrained.High chair-Restrain infant in high chair; avoid using high chair except for feeding and only if adult supervision is adequate; even restrained infants can squirm out of some restraints and fall.Infant walkers-Use only stationary walkers. There is no evidence that walkers help infants "walk" any sooner. Wheeled walkers can easily be propelled off stairs and other platforms such as porches or decks, causing significant injury.Windows, screens-Avoid placing furniture next to a window. Infants learn to climb and can fall out of open windows, even with screens. Television, stereos, sound systems-These must be secured to the stand; infants can pull the stand over, causing the TV or sound system to land on their heads, causing significant injury.

Loss of Control: School-Age Children

Striving for independence and productivity Fears of death, abandonment, permanent injury- important to be honest and explain.

Loss of Control: Adolescents

Struggle for independence and liberation Separation from peer group May respond with anger, frustration Need for information about their condition

Down Syndrome Therapeutic Management

Surgery to correct congenital abnormalities, evaluation of hearing and sight (strabismus), periodic testing of thyroid function. Support the family at time of diagnosis. Assist the family in preventing physical problems. Assist in prenatal diagnosis and genetic counseling.

Weight

Take measurements in a comfortably warm room. When the birth-to-2-year or birth-to-36-month growth charts are used, children should be weighed nude. Older children are usually weighed while wearing their underpants, a gown, or light clothing, depending on the setting. However, always respect the privacy of all children. If the child must be weighed wearing some type of special device, such as a prosthesis or an armboard for an intravenous device, note this when recording the weight. Children who are measured for recumbent length are usually weighed on an infant platform scale and placed in a lying or sitting position. When weighing a child, place your hand slightly above the infant to prevent him or her from accidentally falling off the scale (Fig. 29.10, A), or stand close to the toddler, ready to prevent a fall (see Fig. 29.10, B). For maximum asepsis, cover the scale with a clean sheet of paper between each child's weight measurement.

Positive Self Talk

Teach child positive statements to say when in pain (e.g., "I will be feeling better soon," or "When I go home, I will feel better, and we will eat ice cream").

Dietary Intake

The Dietary Reference Intakes (DRIs) are a set of four evidence-based nutrient reference values that provide quantitative estimates of nutrient intake for use in assessing and planning dietary intake (US Department of Agriculture, National Agricultural Library, 2014). The specific DRIs are as follows: Estimated Average Requirement (EAR): Estimated to meet the nutrient requirement of one-half of healthy individuals for a specific age and gender group Recommended Dietary Allowance (RDA): Sufficient to meet the nutrient requirement of nearly all healthy individuals for a specific age and gender group Adequate Intake (AI): Based on estimates of nutrient intake by healthy individuals Tolerable Upper Intake Level (UL): Highest nutrient intake level likely to pose no risk for adverse health effects

Tanner Stages

The Tanner stages were developed by Dr. J.M. Tanner and colleagues. Tanner stages describe the stages of pubertal growth and are numbered from stage 1 (immature) to stage 5 (mature) for both males and females. In girls and young women, the Tanner stages describe pubertal development based on breast size and the shape and distribution of pubic hair. In boys and young men, the Tanner stages describe pubertal development based on the size and shape of the penis and scrotum and the shape and distribution of pubic hair.

Birth History

The birth history includes all data concerning (1) the mother's health during pregnancy, (2) the labor and delivery, and (3) the infant's condition immediately after birth

Chief Complaint

The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. It may be the theme, with the present illness viewed as the description of the problem. Elicit the chief complaint by asking open-ended, neutral questions (such as, "What seems to be the matter?" "How may I help you?" or "Why did you come here today?"). Avoid labeling-type questions (such as, "How are you sick?" or "What is the problem?"). It is possible that the reason for the visit is not an illness or problem.

Down Syndrome

The most common chromosomal abnormality, (1 in 800 to 1000 live births) causing mental retardation, susceptibility to heart disease, and other health problems; and distinctive physical characteristics, such as slanted eyes and stocky build. Etiology unknown- likely multiple casualty. Most common genetic cause of cognitive impairment. Occurs more often in Caucasian than African Americans. Maternal age 35- risk is 1 in 400 births. Age 40- risk is 1 in 110 births.

Social Development in School Age Children

The peer group is extremely important. Identification with peers is a strong influence in achieving independence from parents. Sex roles are strongly influenced by peer relationships.

Assurance of Privacy and Confidentiality

The physical environment should allow for as much privacy as possible with distractions (such as, interruptions, noise, or other visible activity) kept to a minimum. The environment should also have some play provision for young children to keep them occupied during the parent-nurse interview

Length

The term length refers to measurements taken when children are supine (also referred to as recumbent length). Until children are 2 years of age and able to stand alone (or 36 months of age if using a chart for birth to 36 months), measure recumbent length using a length board and two measurers Because of the normally flexed position during infancy, fully extend the body by (1) holding the head in midline, (2) grasping the knees together gently, and (3) pushing down on the knees until the legs are fully extended and flat against the table. Place the head touching the headboard and the footboard firmly against the heels of the feet. A tape measure should not be used to measure the length of infants and children due to inaccuracy and unreliability (Foote, Brady, Burke, et al., 2014).

Immunization Nursing Alert

The use of meningococcal and diphtheria proteins in combination vaccines does not mean the child has received adequate immunization for meningococcal or diphtheria illnesses; the child must be given the appropriate vaccine for that specific disease.

vitamin D nursing alert

There are reports of accidental overdoses of liquid vitamin D in infants caused by packaging errors; the syringe for liquid administration may not be labeled clearly for 400 IU. Nurses should educate parents to read the syringe and to avoid administering more than 400 IU of vitamin D

Oucher Scale

This pain scale can be used with children 3-13. It is a visual scale with numbers (0-100) and pictures of children experiencing various levels of pain.

Sleep Problems in Preschoolers

Thorough assessment of sleep problems, nightmares, sleep terrors, encouragement of consistent bedtime ritual, slowdown activity before bedtime.

Psychosocial History

Through observation, obtain a general idea of how children handle themselves in terms of confidence in dealing with others, answering questions, and coping with new situations. Observe the parent-child relationship for the types of messages sent to children about their coping skills and self-worth. Do the parents treat the child with respect, focusing on strengths, or is the interaction one of constant reprimands with emphasis on weaknesses and faults? Do the parents help the child learn new coping strategies or support the ones the child uses?

Early Childhood: 1 to 6 Years of Age

Toddler: 1 to 3 years of age Preschool: 3 to 6 years of age This period, which extends from the time children attain upright locomotion until they enter school, is characterized by intense activity and discovery. It is a time of marked physical and personality development. Motor development advances steadily. Children at this age acquire language and wider social relationships, learn role standards, gain self-control and mastery, develop increasing awareness of dependence and independence, and begin to develop a self-concept.

Personal Social Behavior in Toddlers

Toddlers develop skills of independence. Skills for independence may result in determined, strong willed, volatile behaviors. Skills include feeding, playing, dressing, and undressing self. Toddlers develop concern for the feelings of others.

Concerns Related to Normal Growth and Development (Toddler)

Toilet training, sibling rivalry, temper tantrums, negativism, regression.

Adolescence

Transition between childhood and adulthood. Characterized by rapid physical, cognitive, social, and emotional maturation. Generally defines as beginning with the appearance of secondary sex characteristics and ending with cessation of body growth at ages 18 to 20 years.

Prevention of Hearing Loss

Treatment and management of recurrent otitis media Prenatal preventive measures: genetic testing, avoidance of oxytoxic drugs, testing to rule out syphilis, rubella, or blood incompatibility. Avoid exposure to noise pollution

Burn Safety

Turn pot handles toward back of stove. Place electrical appliances such as coffee maker and toaster toward back of counter. Place guardrails in front of radiators, fireplaces, or other heating elements. Store matches and cigarette lighters in locked or inaccessible area; discard carefully. Place burning candles, incense, hot foods, and cigarettes out of reach. Do not let tablecloth hang within child's reach. Do not let electric cord from iron, curling iron, or other appliance hang within child's reach. Cover electrical outlets with protective plastic caps. Keep electrical wires hidden or out of reach. Do not allow child to play with electrical appliance, wires, or lighters. Stress danger of open flames; teach what "hot" means. Always check bath-water temperature; adjust water heater temperature to 49° C (120° F) or lower; do not allow children to play with faucets. Apply sunscreen when child is exposed to sunlight (all year round).

Sleep/Rest Pattern

What is your child's usual hour of sleep and awakening? What is your child's schedule for naps; length of naps? Is there a special routine before sleeping (bottle, drink of water, bedtime story, night light, favorite blanket or toy, prayers)? Is there a special routine during sleep time, such as waking to go to the bathroom? What type of bed does your child sleep in? Does your child have a separate room or share a room; if shares, with whom? Does your child sleep with someone or alone (e.g., sibling, parent, other person)? What is your child's favorite sleeping position? Are there any sleeping problems (falling asleep, waking during night, nightmares, sleep walking)? Are there any problems in awakening and getting ready in the morning? • What do you do for these problems?

Value/Belief Pattern

What is your religion? How is religion or faith important in your child's life? What religious practices would you like continued in the hospital (e.g., prayers before meals or bedtime; visit by minister, priest, or rabbi; prayer group)?

Analyzing the Symptom: Pain

Type Be as specific as possible. With young children, asking the parents how they know the child is in pain may help describe its type, location, and severity. For example, a parent may state, "My child must have a severe earache because she pulls at her ears, rolls her head on the floor, and screams. Nothing seems to help." Help older children describe the "hurt" by asking them if it is sharp, throbbing, dull, or stabbing. Record whatever words they use in quotes. Location Be specific. "Stomach pain" is too general a description. Children can better localize the pain if they are asked to "point with one finger to where it hurts" or to "point to where mommy or daddy would put a Band-Aid." Determine if the pain radiates by asking, "Does the pain stay there or move? Show me with your finger where the pain goes." Severity Severity is best determined by finding out how it affects the child's usual behavior. Pain that prevents a child from playing, interacting with others, sleeping, and eating is most often severe. Assess pain intensity using a rating scale, such as a numeric or Wong-Baker FACES Pain Rating Scale (see Chapter 30). Duration Include the duration, onset, and frequency. Describe these in terms of activity and behavior, such as "pain reported to last all night; child refused to sleep and cried intermittently." Influencing Factors Include anything that causes a change in the type, location, severity, or duration of the pain: (1) precipitating events (those that cause or increase the pain), (2) relieving events (those that lessen the pain, such as medications), (3) temporal events (times when the pain is relieved or increased), (4) positional events (standing, sitting, lying down), and (5) associated events (meals, stress, coughing).

Exanthem Subitum (Roseola Infantum; Sixth Disease) Infection Control

Use Standard Precautions Teach parents measures for lowering temperature (antipyretic drugs); ensure adequate parental understanding of specific antipyretic dosage to prevent accidental overdose. If child is prone to seizures, discuss appropriate precautions and possibility of recurrent febrile seizures. Ensure adequate oral fluid intake.

Tobacco

Use has declined slowly since its peak in 1999. The use of available tobacco did not change from 2006 to 2009/ Secondhand smoke has deleterious effects on health. Although the rate of smoking has declined, smoking is still the chief avoidable cause of death.

Concrete Development (Piaget)

Uses thought processes to experience events and actions. Develops understanding of relationships between things and ideas. Is able to make judgements on the basis of conceptual thinking. Masters the concept of conservation. Develops classification skills.

Assessing the Child

Using developmental and chronologic age as the main criteria for assessing each body system accomplishes several goals: • Minimizes stress and anxiety associated with assessment of various body parts • Fosters a trusting nurse-child-parent relationship • Allows for maximum preparation of the child • Preserves the essential security of the parent-child relationship, especially with young children • Maximizes the accuracy and reliability of assessment findings

Media Effects on Children and Adolescents

Violence: Government, medical, and public health data show exposure to media violence as one factor in violent and aggressive behavior. Both adults and children become desensitized by violence witnessed through various media, including television (including children's programming), movies (including G-rated movies), music, and video games. In addition, cyber-bullying and harassment via text messages are a growing concern among middle school and high school students. Sex: A significant body of research shows that sexual content in the media can contribute to beliefs and attitudes about sex, sexual behavior, and initiation of intercourse. Teens access sexual content through a variety of media: television, movies, music, magazines, Internet, social media, and mobile devices. Current issues receiving attention for the role they play in adolescent sexual behavior include sending of sexual images via mobile devices (i.e., sexting), impact of violent media on youth views of women and forced sex/rape, and cyber-bullying LGBTQI youth. Media can also serve as a positive source of sexual information (i.e., information, apps, social media about sexually transmitted infections, adolescent pregnancy, and promoting acceptance and support of LGBTQI youth). Substance use and abuse: Although the causes of adolescent substance use and abuse are numerous, media plays a significant role. Alcohol and tobacco are still heavily marketed to adolescents/young adults. Television and movies featuring the use of these substances can influence initiation of use. Media also shows substance use to be pervasive and without consequences. Finally, content shared over social networking sites can serve as a form of peer pressure and can influence likelihood of use. Obesity: Obesity is a highly prevalent public health issue among children of all ages, and rates are increasing around the world. A number of studies have demonstrated a link between the amount of screen time and obesity. Advertising of unhealthy food to children is a long-standing marketing practice, which may increase snacking in the face of decreased activity. In addition, both increased screen time and unhealthy eating may also be related to unhealthy sleep. Body image: Media may play a significant role in the development of body image awareness, expectations, and body dissatisfaction among young and older adolescent girls. Their beliefs may be influenced by images on television, movies, and magazines. New media also contributes to this through Internet images, social network sites, and websites that encourage disordered eating (e.g., pro-Ana sites) (Strasburger, Jordan, & Donnerstein, 2012).

Chicken Pox

Viral Infection. Vaccination is important to prevent. Treat with cool baths, acetaminophen and ibuprofen. No aspirin because is associated with Rye syndrome. Benadryl for itching, throat lozenges. Apply thin coat of calamine lotion on open lesions. Thin because excessive absorptions can cause drug toxicity.

Sensory Changes in Toddlers

Visual acuity of 20/40 acceptable Hearing, smell, taste, and touch development increase Use all senses to explore environment

Manifestations of Acute Pain in the Neonate Physiologic Responses

Vital signs: Observe for variations • Increased heart rate • Increased blood pressure • Rapid, shallow respirations Oxygenation • Decreased transcutaneous oxygen saturation (TcPO2) • Decreased arterial oxygen saturation (SaO2) Skin: Observe color and character • Pallor or flushing • Diaphoresis • Palmar sweating Other observations • Increased muscle tone • Dilated pupils • Decreased vagal nerve tone • Increased intracranial pressure • Laboratory evidence of metabolic or endocrine changes: Hyperglycemia, lowered pH, elevated corticosteroids

Manifestations of Acute Pain in the Neonate Behavioral Responses

Vocalizations: Observe quality, timing, and duration • Crying • Whimpering • Groaning Facial expression: Observe characteristics, timing, orientation of eyes and mouth • Grimaces • Brow furrowed • Chin quivering • Eyes tightly closed • Mouth open and squarish Body movements and posture: Observe type, quality, and amount of movement or lack of movement; relationship to other factors • Limb withdrawal • Thrashing • Rigidity • Flaccidity • Fist clenching Changes in state: Observe sleep, appetite, activity level • Changes in sleep-wake cycles • Changes in feeding behavior • Changes in activity level • Fussiness, irritability • Listlessness SaO2, Arterial oxygen saturation; TcPO2, transcutaneous oxygen pressure.

Assessing Readiness for Toilet Training

Voluntary sphincter control Able to stay dry for 2 hours Fine motor skills to remove clothing Willingness to please parents Curiosity about adult's or sibling's toilet habits Impatient with wet or soiled diapers

Height

Wall charts and flip-up horizontal bars (floppy-arm devices) mounted to weighing scales should not be used to measure the height of children (Foote, Brady, Burke, et al., 2014). These devices are not steady and do not maintain a right angle to the vertical ruler, preventing an accurate and reliable height. Measure height by having the child, with the shoes removed, stand as tall and straight as possible with the head in midline and the line of vision parallel to the ceiling and floor. Be certain the child's back is to the wall or other vertical flat surface, with the head, shoulder blades, buttocks, and heels touching the vertical surface (see Fig. 29.9, B). Check for and correct slumping of the shoulders, positional lordosis, bending of the knees, or raising of the heels. Nursing Alert Normally height is less if measured in the afternoon than in the morning. The time of day should be recorded when measurements are taken (Foote, Brady, Burke, et al., 2014). For children in whom there are concerns about growth, serial measurements should be taken at the same time of day, when possible, to establish an accurate growth velocity (see Evidence-Based Practice box: Linear Growth Measurement in Pediatrics). For the most accurate measurement, use a wall-mounted unit (stadiometer; see Fig. 29.9). To improvise a flat, vertical surface for measuring height, attach a paper or metal tape or yardstick to the wall, position the child adjacent to the tape, and place a three-dimensional object, such as a thick book or box, on top of the head. Rest the side of the object firmly against the wall to form a right angle. Measure length or stature to the nearest 1 mm or inch.

milk nursing alert

Warming expressed milk in a microwave decreases the availability of anti-infective properties and nutrients (Labiner-Wolfe & Fein, 2013). To prevent oral burns from uneven warming of the milk, breast milk should never be thawed or rewarmed in a microwave oven. To thaw the frozen milk, either place the container under a lukewarm water bath (<40.5° C [105° F]), or place in a refrigerator overnight.

Dietary History

What are the family's usual mealtimes? Do family members eat together or at separate times? Who does the family grocery shopping and meal preparation? How much money is spent to buy food each week? How are most foods prepared (baked, broiled, fried, other)? How often does the family or your child eat out? • What kinds of restaurants do you go to? • What kinds of food does your child typically eat at restaurants? Does your child eat breakfast regularly? Where does your child eat lunch? What are your child's favorite foods, beverages, and snacks? • What are the average amounts eaten per day? • What foods are artificially sweetened? • What are your child's snacking habits? • When are sweet foods usually eaten? • What are your child's tooth brushing habits? What special cultural practices are followed? What ethnic foods are eaten? What foods and beverages does your child dislike? How would you describe your child's usual appetite (hearty eater, picky eater)? What are your child's feeding habits (breast, bottle, cup, spoon, eats by self, needs assistance, any special devices)? Does your child take vitamins or other supplements? Do they contain iron or fluoride? Does your child have any known or suspected food allergies? Is your child on a special diet? Has your child lost or gained weight recently? Are there any feeding problems (excessive fussiness, spitting up, colic, difficulty sucking or swallowing)? Are there any dental problems or appliances, such as braces, that affect eating? What types of exercise does your child do regularly? Is there a family history of cancer, diabetes, heart disease, high blood pressure, or obesity?

Elimination Pattern

What are your child's toileting habits (diaper, toilet trained—day only or day and night, use of word to communicate urination or defecation, potty chair, regular toilet, other routines)? What is your child's usual pattern of elimination (bowel movements)? Do you have any concerns about elimination (bed-wetting, constipation, diarrhea)? • What do you do for these problems? Have you ever noticed that your child sweats a lot?

Observing Behavior

What is the child's overall personality? • Does the child have a long attention span, or is he or she easily distracted? • Can the child follow two or three commands in succession without the need for repetition? • What is the child's response to delayed gratification or frustration? • Does the child use eye contact during conversation? • What is the child's reaction to the nurse and family members? • Is the child quick or slow to grasp explanations?

Nutrition/Metabolic Pattern

What is the family's usual mealtime? Do family members eat together or at separate times? What are your child's favorite foods, beverages, and snacks? • Average amounts consumed or usual size of portions • Special cultural practices, such as family eats only ethnic food What foods and beverages does your child dislike? What are your child's feeding habits (bottle, cup, spoon, eats by self, needs assistance, any special devices)? How does your child like the food served (warmed, cold, one item at a time)? How would you describe your child's usual appetite (hearty eater, picky eater)? • Has being sick affected your child's appetite? In what ways? Are there any known or suspected food allergies? Is your child on a special diet? Are there any feeding problems (excessive fussiness, spitting up, colic); any dental or gum problems that affect feeding? • What do you do for these problems?

Activity/Exercise Pattern

What is your child's schedule during the day (preschool, daycare center, regular school, extracurricular activities)? What are your child's favorite activities or toys (both active and quiet interests)? What is your child's usual television-viewing schedule at home? What are your child's favorite programs? Are there any television restrictions? Does your child have any illness or disabilities that limit activity? If so, how? What are your child's usual habits and schedule for bathing (bath in tub or shower, sponge bath, shampoo)? What are your child's dental habits (brushing, flossing, fluoride supplements or rinses, favorite toothpaste); schedule of daily dental care? Does your child need help with dressing or grooming, such as hair combing? Are there any problems with these patterns (dislike of or refusal to bathe, shampoo hair, or brush teeth)? • What do you do for these problems? Are there special devices that your child requires help in managing (eyeglasses, contact lenses, hearing aid, orthodontic appliances, artificial elimination appliances, orthopedic devices)? Note: Use the following code to assess functional self-care level for feeding, bathing and hygiene, dressing and grooming, toileting: 0: Full self-care I: Requires use of equipment or device II: Requires assistance or supervision from another person III: Requires assistance or supervision from another person and equipment or device IV: Is totally dependent and does not participate

Additional Dietary Questions for Infants

What was the infant's birth weight? When did it double? Triple? Was the infant premature? Are you breastfeeding, or have you breastfed your infant? For how long? If you use a formula, what is the brand? • How long has the infant been taking it? • How many ounces does the infant drink per day? Are you giving the infant cow's milk (whole, low-fat, skim)? • When did you start? • How many ounces does the infant drink per day? Do you give your infant extra fluids (water, juice)? If the infant takes a bottle to bed at nap or nighttime, what is in the bottle? At what age did the child start on cereal, vegetables, meat or other protein sources, fruit or juice, finger food, and table food? Do you make your own baby food or use commercial foods, such as infant cereal? Does the infant take a vitamin or mineral supplement? If so, what type? Has the infant had an allergic reaction to any food(s)? If so, list the foods and describe the reaction. Does the infant spit up frequently; have unusually loose stools; or have hard, dry stools? If so, how often? How often do you feed your infant? How would you describe your infant's appetite?

Using Children as Interpreters

When no one else is readily available to interpret, there may be temptation to use a bilingual child within the family as an interpreter. However, the use of children in health care interpreting is strongly discouraged, because they are often not mature enough to understand health care questions, answers, or messages (American Academy of Pediatrics, 2011). Children may inadvertently commit interpretive errors, such as inaccuracies, omissions, or substitutions. In addition, children can be adversely affected by serious or sensitive information that may be discussed. In some cultures, using a child as an interpreter is considered an insult to an adult because children are expected to show respect by not questioning their elders. Note that some institutions prohibit the use of children as interpreters; check institutional policy for compliance. If a trained on-site or community-based interpreter is not available, a language line using a telephonic interpreter may be an option.

Health Perception/Health Management Pattern

Why has your child been admitted? How has your child's general health been? What does your child know about this hospitalization? • Ask the child why he or she came to the hospital. • If the answer is "For an operation or for tests," ask the child to tell you about what will happen before, during, and after the operation or tests. Has your child ever been in the hospital before? • How was that hospital experience? • What things were important to you and your child during that hospitalization? How can we be most helpful now? What medications does your child take at home? • Why are they given? • When are they given? • How are they given (if a liquid, with a spoon; if a tablet, swallowed with water; or other)? • Does your child have any trouble taking medication? If so, what helps? • Is your child allergic to any medications? What, if any, forms of complementary medicine practices are being used?

Post-Hospital Behaviors in Children

Young Children They show initial aloofness toward parents; this may last from a few minutes (most common) to a few days. This is frequently followed by dependency behaviors: • Tendency to cling to parents • Demands for parents' attention • Vigorous opposition to any separation (e.g., staying at preschool or with a babysitter) Other negative behaviors include the following: • New fears (e.g., nightmares) • Resistance to going to bed, night waking • Withdrawal and shyness • Hyperactivity • Temper tantrums • Food peculiarities • Attachment to blanket or toy • Regression in newly learned skills (e.g., self-toileting) Older Children Negative behaviors include the following: • Emotional coldness followed by intense, demanding dependence on parents • Anger toward parents • Jealousy toward others (e.g., siblings)

Communication with School Age Years

Younger school-age children rely less on what they see and more on what they know when faced with new problems. They want explanations and reasons for everything but require no verification beyond that. They are interested in the functional aspect of all procedures, objects, and activities. They want to know why an object exists, why it is used, how it works, and the intent and purpose of its user. They need to know what is going to take place and why it is being done to them specifically. School-age children have a heightened concern about body integrity. Because of the special importance they place on their body, they are sensitive to anything that constitutes a threat or suggestion of injury to it. This concern extends to their possessions, so they may appear to overreact to loss or threatened loss of treasured objects. Encouraging children to communicate their needs and voice their concerns enables the nurse to provide reassurance, to dispel myths and fears, and to implement activities that reduce their anxiety.

conversion reaction

a form of hysteria characterized by the conversion of emotional difficulties into a loss of a specific body function

fetal alcohol syndrome (FAS)

a medical condition in which body deformation or facial development or mental ability of a fetus is impaired because the mother drank alcohol while pregnant

the most common problem with hearing aids

acoustic feedback- hearing a whistling noise. Have the child take it out then put it back in.

Anthropometry

an essential parameter of nutritional status, is the measurement of height, weight, head circumference, proportions, skinfold thickness, and arm circumference in children. Height and head circumference reflect past nutrition, whereas weight, skinfold thickness, and arm circumference reflect present nutritional status, especially of protein and fat reserves. Skinfold thickness is a measurement of the body's fat content because approximately one-half the body's total fat stores are directly beneath the skin. The upper arm muscle circumference is correlated with measurements of total muscle mass. Because muscle serves as the body's major protein reserve, this measurement is considered an index of the body's protein stores. Ideally, growth measurements are recorded over time, and comparisons are made regarding the velocity of growth and weight gain based on previous and present values.

Providing Anticipatory Guidance

anticipatory guidance focused on providing families information on normal growth and development and nurturing childrearing practices. For example, one of the most significant areas in pediatrics is injury prevention To achieve this level of anticipatory guidance, the nurse should do the following: • Base interventions on needs identified by the family, not by the professional • View the family as competent or as having the ability to be competent • Provide opportunities for the family to achieve competence

Social Development

attachment occurs between 4 to 8 months of age leading to separation anxiety 6 to 8 months the infant is able to discriminate between familiar and unfamiliar people known as strange fear

Suicide

can be the result of depression, bipolar disorder, substance abuse. Firemarms are the most common followed by overdose and hanging. No threat of suicide should be dismissed.

puberty

development of secondary sex characteristics

parasuicide

describes behaviors ranging from gestures to serious attempts

Legal blindness

determines tax status entry into special schools

Positional Plagiocephaly

flattening of one side of an infant's head from prolonged lying in one position. A helmet worn 23 hours a day for 3 months and exercises are used. Teach preventative measures.

Cognitive Impairment

general term that encompasses any type of mental difficulty or deficiency. Used synonymously with intellectual disability (cognitive impairment). Diagnosis: Made after a period of suspicion by family or health professionals. In some instances diagnosis is made at birth. (ex: down syndrome)

Developing a Sense of Identity (Erikson)

group identity: difference between self and parents. Individual identity: personal relationships. Develop of self concept and body image. Sex-role identity.

Cold sore, fever blister: Herpes simplex virus (HSV) type 1 Genital herpes: HSV type 2

inflammatory base, usually on or near mucocutaneous junctions (lips, nose, genitalia, buttocks) Vesicles dry, forming a crust, followed by exfoliation and spontaneous healing in 8 to 10 days May be accompanied by regional lymphadenopathy Burrow solution compresses during weeping stages Oral antiviral (acyclovir [Zovirax]) for treatment or prophylaxis Oral antiviral (valacyclovir [Valtrex]) for episodic treatment; primarily recommended for immunocompromised patients Heal without scarring unless secondary infection HSV-1 cold sores can be prevented by using sunscreens protecting against ultraviolet A and ultraviolet B light to prevent lip blisters Aggravated by corticosteroids May be fatal in children with depressed immunity

Appropriate Introduction

introduce yourself, and ask the name of each family member who is present. Address parents or other adults by their appropriate titles, such as "Mr." and "Mrs.," unless they specify a preferred name. Include children in the interaction by asking them their name, age, and other information

Heavy metal poisoning

lead poisoning- usually no signs or symptoms diagnosed with blood specimen screening for high risk children. Chelation therapy removes lead from the blood, organs and tissues Mostly reversible. Most effect is on the CNS. Identify sources of lead.

Childhood depression

mood disorder characterized by such symptoms as a prolonged sense of friendlessness, inability to have fun or concentrate, fatigue, extreme activity or apathy, feelings of worthlessness, weight change, physical complaints, and thoughts of death or suicide

Colic (Paroxysmal Abdominal Pain)

occurs in 5 to 20% of all infants Rule of threes- crying and fussing for more than 3 hours per day, more than 3 days per week, lasting more than 3 weeks per infant. Symptoms usually occur in the evening an dis most common in infants less than 3 months, Multifactorial Cause- too rapid of a feeding, overeating, swallowing excess air, poor feeding technique, stress. infants with cow and milk allergies have a higher risk. No specific treatment

conjuctivitis

ophthalmic antibiotics systemic antibiotics in some cases. Caution with steroids- may exacerbate viral infections. Infection control concerns. The child may return to school after taking antibiotics for 24 hours.

the dying child

parents may request not to tell the child. The RN should respond that terminally ill children know when they are seriously ill. Share the importance on honesty and shared decision making- they are important for emotional help.

Postpubescence

period of 1-2 years after puberty; skeletal growth is complete; reproductive functions become well established

biologic development of the preschooler

physical growth rate slows and stabilizes during preschool years; physical proportions change: slender but sturdy, graceful, agile, posture erect; males and females similar in size and proportion. Average weight gain remains about 5lbs/year. Average height increases 2 1/2 to 3 inches/year. Body systems mature and stabilize; can adjust to moderate stress and change.

Sucking

sucking is an infants chief pleasure. Thumb sucking and pacifiers are normal at this age. There is some evidence that suggest pacifiers reduce the incidence of SIDS, but are higher risk for otitis media (ear infections). Malocculsion can occur after permanent teeth are present with thumb sucking. Never put honey on a baby's pacifier, could result in botulism.

geographic location

the birthplace and travel to different areas in or outside of the country, for identification of possible exposure to endemic diseases. Include current and past housing, whether they rent or own, whether they reside in an urban or rural location, the age of the home, and whether there are significant threats such as molds or pests within the housing structure. Although the primary interest is the child's temporary residence in various localities, also inquire about close family members' travel, especially during tours of military service or business trips. Children are especially susceptible to parasitic infestation in areas of poor sanitary conditions and to vector-borne diseases, such as those from mosquitoes or ticks in warm and humid or heavily wooded regions.

sudden infant death syndrome (SIDS)

the unexplained death of a seemingly healthy baby cause is unknown: but there are hypothesis that there is a brain stem abnormality, sleep apnea, or a genetic link. There is a strong genetic link and high risk between siblings. Lower incidence with breastfed babies. Smoking causes increased risk.

Substance Abuse

usually begins with curiosity. Drug abuse, misuse, and addiction. Drug tolerance and physical dependence is an involuntary physical response. Can cause seizures.

Suggestions for breaking the silence include statements such as the following:

• "Is there anything else you wish to say?" • "I see you find it difficult to continue. How may I help?" • "I don't know what this silence means. Perhaps there is something you would like to put into words but find difficult to say."

Qualities of Strong Families

• A belief and sense of commitment toward promoting the well-being and growth of individual family members, as well as the family unit • Appreciation for the small and large things that individual family members do well and encouragement to do better • Concentrated effort to spend time and do things together, no matter how formal or informal the activity or event • A sense of purpose that permeates the reasons and basis for "going on" in both bad and good times • A sense of congruence among family members regarding the value and importance of assigning time and energy to meet needs • The ability to communicate with one another in a way that emphasizes positive interactions • A clear set of family rules, values, and beliefs that establishes expectations about acceptable and desired behavior • A varied repertoire of coping strategies that promote positive functioning in dealing with both normative and nonnormative life events • The ability to engage in problem-solving activities designed to evaluate options for meeting needs and procuring resources • The ability to be positive and see the positive in almost all aspects of their lives, including the ability to see crisis and problems as an opportunity to learn and grow • Flexibility and adaptability in the roles necessary to procure resources to meet needs • A balance between the use of internal and external family resources for coping and adapting to life events and planning for the future

Care Management for Injuries

• Accept adolescent as a unique individual. • Respect adolescent's ideas, likes and dislikes, and wishes • Be involved with school functions, and attend adolescent's performances, whether it be a sporting event or a school play. • Listen and try to be open to adolescent's views, even when they disagree with parental views. • Avoid criticism about no-win topics. • Provide opportunity for choosing options, and accept natural consequences of these choices. • Allow young person to learn by doing, even when choices and methods differ from those of adults. • Provide adolescent with clear, reasonable limits. • Clarify house rules and consequences for breaking them. Let society's rules and consequences teach responsibility outside the home. • Allow increasing independence within limitations of safety and well-being. • Be available, but avoid pressing adolescent too far. • Respect adolescent's privacy. • Share adolescent's feelings of joy or sorrow. • Respond to feelings, as well as words. • Be available to answer questions, give information, and provide companionship. • Make communication clear. • Avoid comparisons with siblings. • Assist adolescent in selecting appropriate career goals and preparing for adult role. • Welcome adolescent's friends into the home, and treat them with respect. • Provide unconditional love. • Be willing to apologize when mistaken. Be aware that adolescents: • Are subject to turbulent, unpredictable behavior • Are struggling for independence • Are extremely sensitive to feelings and behavior that affect them • May receive a different message from what was sent • Consider friends extremely important • Have a strong need to belong to a peer group of friends and not necessarily to family (except in certain circumstances)

Communicating With Children

• Allow children time to feel comfortable. • Avoid sudden or rapid advances, broad smiles, extended eye contact, and other gestures that may be seen as threatening. • Talk to the parent if the child is initially shy. • Communicate through transition objects (such as, dolls, puppets, and stuffed animals) before questioning a young child directly. • Give older children the opportunity to talk without the parents present. • Assume a position that is at eye level with the child (Fig. 29.2). • Speak in a quiet, unhurried, and confident voice. • Speak clearly, be specific, and use simple words and short sentences. • State directions and suggestions positively. • Offer a choice only when one exists. • Be honest with children. • Allow children to express their concerns and fears. • Use a variety of communication techniques.

Bicycle Safety

• Always wear a properly fitted bicycle helmet that is approved by the US Consumer Product Safety Commission (CPSC); replace a damaged or outgrown helmet. • Ride bicycles with traffic and away from parked cars. • Ride single file. • Walk bicycles through busy intersections only at crosswalks. • Give hand signals well in advance of turning or stopping. • Keep as close to the curb as practical. • Watch for drain grates, potholes, soft shoulders, loose dirt, and gravel. • Keep both hands on handlebars except with signaling. • Never ride double on a bicycle. • Do not carry packages that interfere with vision or control; do not drag objects behind a bike. • Watch for and yield to pedestrians. • Watch for cars backing up or pulling out of driveways; be especially careful at intersections. • Look left, right, and then left before turning into traffic or roadway. • Never hitch a ride on a truck or other vehicle. • Learn rules of the road and respect for traffic officers. • Obey all local ordinances. • Wear shoes that fit securely while riding. • Wear light colors at night, and attach fluorescent material to clothing and bicycle. • Equip the bicycle with proper lights and reflectors. • Be certain the bicycle is the correct size for rider (see Fig. 34.9). • Have the bicycle inspected to ensure good mechanical condition. • Children riding as passengers must wear appropriate-size helmets and sit in specially designed protective seats.

Negative Actions

• Are you overinvolved with children and their families? • Do you work overtime to care for the family? • Do you spend off-duty time with children's families, either in or out of the hospital? • Do you call frequently (either the hospital or home) to see how the family is doing? • Do you show favoritism toward certain patients? • Do you buy clothes, toys, food, or other items for the child and family? • Do you compete with other staff members for the affection of certain patients and families? • Do other staff members comment to you about your closeness to the family? • Do you attempt to influence families' decisions rather than facilitate their informed decision making? • Are you underinvolved with children and families? • Do you restrict parent or visitor access to children, using excuses such as the unit is too busy? • Do you focus on the technical aspects of care and lose sight of the person who is the patient? • Are you overinvolved with children and underinvolved with their parents? • Do you become critical when parents do not visit their children? • Do you compete with parents for their children's affection?

encouraging deep breaths

• Ask the child to "blow out" the light on an otoscope or pocket flashlight; discreetly turn off the light on the last try so the child feels successful. • Place a cotton ball in the child's palm; ask the child to blow the ball into the air and have parent catch it. • Place a small tissue on the top of a pencil, and ask the child to blow the tissue off. • Have child blow a pinwheel, a party horn, or bubbles.

Family Nursing Intervention

• Behavior modification • Case management and coordination • Collaborative strategies • Contracting • Counseling, including support, cognitive reappraisal, and reframing • Empowering families through active participation • Environmental modification • Family advocacy • Family crisis intervention • Networking, including use of self-help groups and social support • Providing information and technical expertise • Role modeling • Role supplementation • Teaching strategies, including stress management, lifestyle modifications, and anticipatory guidance

Habits to Explore During a Health Interview

• Behavior patterns, such as nail biting, thumb sucking, pica (habitual ingestion of nonfood substances), rituals ("security" blanket or toy), and unusual movements (head banging, rocking, overt masturbation, walking on toes) • Activities of daily living, such as hours of sleep and arising, duration of nighttime sleep and naps, type and duration of exercise, regularity of stools and urination, age of toilet training, and daytime or nighttime bedwetting • Unusual disposition; response to frustration • Use or abuse of alcohol, drugs, coffee, or tobacco

CAM therapies

• Biologically based: foods, special diets, herbal or plant preparations, vitamins, other supplements • Manipulative treatments: chiropractic, osteopathy, massage • Energy based: Reiki, bioelectric or magnetic treatments, pulsed fields, alternating and direct currents • Mind-body techniques: mental healing, expressive treatments, spiritual healing, hypnosis, relaxation • Alternative medical systems: homeopathy; naturopathy; ayurveda; traditional Chinese medicine, including acupuncture and moxibustion

Areas of Stress in Adolescents

• Body image • Sexuality conflicts • Academic pressures • Competitive pressures • Relationships with parents • Relationships with siblings • Relationships with peers • Finances • Decisions about present and future roles • Career planning • Ideologic conflicts

Children whose growth may be questionable include the following:

• Children whose height and weight percentiles are widely disparate (e.g., height in the 10th percentile and weight in the 90th percentile, especially with above-average skinfold thickness) • Children who fail to follow the expected growth velocity in height and weight, especially during the rapid growth periods of infancy and adolescence • Children who show a sudden increase (except during normal puberty) or decrease in a previously steady growth pattern (i.e., crossing two major percentile lines after 3 years of age) • Children who are short in the absence of short parents

Skating Safety

• Children younger than 5 years of age should not use skateboards or in-line skates because they are not developmentally prepared to protect themselves from injury. Children 6 to 10 years of age should use these only with close adult supervision. • The age when children are ready to use in-line skates safely is not known because of differences in the ability to acquire the skills needed to participate in the sport. Novice skaters should learn indoors on a flat, smooth surface. Children who ride skateboards, in-line skates, or scooters should wear helmets and other protective equipment, especially on their knees, wrists, and elbows, to prevent injury. • Skateboards, in-line skates, and scooters should never be used near traffic or in streets. Their use should be prohibited on streets and highways. Activities that bring skateboards together (e.g., "catching a ride") are especially dangerous. • Some types of use, such as riding homemade ramps on hard surfaces, may be particularly hazardous.

Implementing Discipline

• Consistency: Implement disciplinary action exactly as agreed on and for each infraction. • Timing: Initiate discipline as soon as child misbehaves; if delays are necessary, such as to avoid embarrassment, verbally disapprove of the behavior and state that disciplinary action will be implemented. • Commitment: Follow through with the details of the discipline, such as timing of minutes; avoid distractions that may interfere with the plan, such as telephone calls. • Unity: Make certain that all caregivers agree on the plan and are familiar with the details to prevent confusion and alliances between child and one parent. • Flexibility: Choose disciplinary strategies that are appropriate to child's age and temperament and the severity of the misbehavior. • Planning: Plan disciplinary strategies in advance, and prepare child if feasible (e.g., explain use of time-out); for unexpected misbehavior, try to discipline when you are calm. • Behavior orientation: Always disapprove of the behavior, not the child, with statements, such as "That was a wrong thing to do. I am unhappy when I see behavior like that." • Privacy: Administer discipline in private, especially with older children, who may feel ashamed in front of others. • Termination: After the discipline is administered, consider child as having a "clean slate," and avoid bringing up the incident or lecturing.

School Age Child Response to Pain

• Demonstrates behaviors of the young child, especially during actual painful procedure, but less before the procedure • Exhibits time-wasting behavior, such as "Wait a minute" or "I'm not ready" • Displays muscular rigidity, such as clenched fists, white knuckles, gritted teeth, contracted limbs, body stiffness, closed eyes, wrinkled forehead

Anticipatory Guidance 24 to 36 Months

• Discuss importance of imitation and domestic mimicry and need to include child in activities. • Discuss approaches toward toilet training, particularly realistic expectations and attitude toward accidents. • Stress uniqueness of toddlers' thought processes, especially through their use of language, poor understanding of time, causal relationships in terms of proximity of events, and inability to see events from another's perspective. • Stress that discipline still must be structured and concrete and that relying solely on verbal reasoning and explanation leads to injuries, confusion, and misunderstanding. • Discuss investigation of preschool or day care center toward completion of second year.

Positive Actions

• Do you strive to empower families? • Do you explore families' strengths and needs in an effort to increase family involvement? • Have you developed teaching skills to instruct families rather than doing everything for them? • Do you work with families to find ways to decrease their dependence on health care providers? • Can you separate families' needs from your own needs? • Do you strive to empower yourself? • Are you aware of your emotional responses to different people and situations? • Do you seek to understand how your own family experiences influence reactions to patients and families, especially as they affect tendencies toward overinvolvement or underinvolvement? • Do you have a calming influence, not one that will amplify emotionality? • Have you developed interpersonal skills in addition to technical skills? • Have you learned about ethnic and religious family patterns? • Do you communicate directly with people with whom you are upset or take issue? • Are you able to "step back" and withdraw emotionally, if not physically, when emotional overload occurs, yet remain committed? • Do you take care of yourself and your needs? • Do you periodically interview family members to determine their current issues (e.g., feelings, attitudes, responses, wishes), communicate these findings to peers, and update records? • Do you avoid relying on initial interview data, assumptions, or gossip regarding families? • Do you ask questions if families are not participating in care? • Do you assess families for feelings of anxiety, fear, intimidation, worry about making a mistake, a perceived lack of competence to care for their child, or fear of health care professionals overstepping their boundaries into family territory, or vice versa? • Do you explore these issues with family members and provide encouragement and support to enable families to help themselves? • Do you keep communication channels open among self, family, physicians, and other care providers? • Do you resolve conflicts and misunderstandings directly with those who are involved? • Do you clarify information for families or seek the appropriate person to do so? • Do you recognize that from time to time a therapeutic relationship can change to a social relationship or an intimate friendship? • Are you able to acknowledge the fact when it occurs and understand why it happened? • Can you ensure that there is someone else who is more objective who can take your place in the therapeutic relationship?

Interviewing Adolescents

• Ensure confidentiality and privacy; interview adolescent without parents present. • Explain the limits of confidentiality (e.g., legal duty to report physical or sexual abuse or to get others involved if patient is suicidal). • Show concern for adolescent's perspective: "First, I'd like to talk about your main concerns" and "I'd like to know what you think is happening." • Offer a nonthreatening explanation for the questions you ask: "I'm going to ask a number of questions to help me better understand your health." • Maintain objectivity; avoid assumptions, judgments, and lectures. • Ask open-ended questions when possible; move to more directive questions if necessary. • Begin with less sensitive issues, and proceed to more sensitive ones. • Use language that both the adolescent and you understand. Clarify terms, such as "having sex." • Restate or summarize: reflect back to adolescents what they have said, along with feelings that may be associated with their descriptions.

Using an Interpreter

• Explain to interpreter the reason for the interview and the type of questions that will be asked. • Clarify whether a detailed or brief answer is required and whether the translated response can be general or literal. • Introduce the interpreter to the family, and allow some time before the interview for them to become acquainted. • Communicate directly with family members when asking questions to reinforce interest in them and to observe nonverbal expressions, but do not ignore the interpreter. • Pose questions to elicit only one answer at a time, such as "Do you have pain?" rather than "Do you have any pain, tiredness, or loss of appetite?" • Refrain from interrupting family members and the interpreter while they are conversing. • Avoid commenting to the interpreter about family members, because they may understand some English. • Be aware that some medical words, such as allergy, may have no similar word in another language; avoid medical jargon whenever possible. • Be aware that cultural differences may exist regarding views on puberty, sex, marriage, or pregnancy. • Allow time after the interview for the interpreter to share something that he or she thought could not be said earlier; ask about the interpreter's impression of nonverbal clues to communication and family members' reliability or ease in revealing information. Arrange for the family to speak with the same interpreter on subsequent visits whenever possible.

Clinical Manifestations of Failure to Thrive

• Growth failure (see earlier in this chapter for definitions) • Developmental delays—social, motor, adaptive, language • Undernutrition • Apathy • Withdrawn behavior • Feeding or eating disorders, such as vomiting, feeding resistance, anorexia, pica, rumination • No fear of strangers (at age when stranger anxiety is normal) • Avoidance of eye contact • Wide-eyed gaze and continual scan of the environment ("radar gaze") • Stiff and unyielding or flaccid and unresponsive • Minimal smiling

Taking an Allergy History

• Has your child ever taken any prescription or over-the-counter medications that have disagreed with him or her or caused an allergic reaction? If yes, can you remember the name(s) of this medication(s)? • Can you describe the reaction? • Was the medication taken by mouth (as a tablet or syrup), or was it an injection? • How soon after starting the medication did the reaction happen? • How long ago did this happen? • Did anyone tell you it was an allergic reaction, or did you decide for yourself? • Has your child ever taken this medication, or a similar one, again? If yes, did your child experience the same problems? • Have you told the physicians or nurses about your child's reaction or allergy?

Administration of Oral Iron Supplements

• Ideally, iron supplements should be administered between meals for greater absorption. • Liquid iron supplements may stain the teeth; therefore administer with a dropper toward the back of the mouth (side). In older children, administer liquid iron supplements through a straw, or rinse mouth thoroughly after ingestion. • Avoid administration of liquid iron supplements with whole cow's milk or milk products because these bind free iron and prevent absorption. • Educate parents that iron supplements will turn stools black or tarry green. • Iron supplements may cause transient constipation. Caution parents not to switch to a low-iron-containing formula or whole milk, which are poor sources of iron and may lead to iron deficiency anemia (see the "Iron Deficiency Anemia" section in Chapter 43). • In older children, follow liquid iron supplement with a citrus fruit or juice drink (no more than 3-4 oz). • Avoid administration of iron supplements with foods or drinks that bind iron and prevent absorption (see information earlier in this chapter).

Anticipatory Guidance 5 Years

• Inform parents to expect tranquil period at 5 years of age. • Help parents prepare children for entrance into school environment. • Make certain that childhood immunizations are up to date before child enters school. • Suggest that unemployed parental caregivers consider own activities when children begin school.

Adolescent Response to pain

• Less vocal with less physical resistance • More verbal in expressions, such as "It hurts" or "You're hurting me" • Displays increased muscle tension and body control

Reducing Lead levels

• Make sure that child does not have access to peeling paint or chewable surfaces painted with lead-based paint, especially window sills and wells. • If a house was built before 1978 and has hard-surface floors, wet mop them at least once per week. Wipe other hard surfaces (e.g., window sills, baseboards). If there are loose paint chips in an area, such as a window well, use a wet disposable cloth to pick up and discard them. Do not vacuum hard-surfaced floors or windowsills or wells because this spreads dust. Use vacuum cleaners with agitators to remove dust from rugs rather than vacuum cleaners with suction only. If a rug is known to contain lead dust and cannot be washed, it should be discarded. • Wash and dry child's hands and face frequently, especially before eating. • Wash toys and pacifiers frequently. • Wipe your feet on mats before entering the home, especially if you work in occupations where lead is used. Removing your shoes when you are entering the home is a good practice to control lead. • If soil around home is or is likely to be contaminated with lead (e.g., if home was built before 1978 or is near a major highway), plant grass or other ground cover; plant bushes around outside of house so child cannot play there. • During remodeling of older homes, follow correct procedures. Be certain children and pregnant women are not in the home, day or night, until process is completed. After deleading, thoroughly clean house using cleaning solution to damp mop and dust before inhabitants return. • In areas where the lead content of water exceeds the drinking water standard and a particular faucet has not been used for 6 hours or more, "flush" the cold-water pipes by running the water until it becomes as cold as it will get (30 seconds to 2 minutes). The more time water has been sitting in pipes, the more lead it may contain. • Use only cold water for consumption (drinking, cooking, and especially for reconstituting powder infant formula). • Hot water dissolves lead more quickly than cold water and thus contains higher levels of lead. First-flush water may be used for nonconsumption uses (e.g., bathing). • Have water tested by a competent laboratory. This action is especially important for apartment dwellers; flushing may not be effective in high-rise buildings or other buildings with lead-soldered central piping. • Do not store food in open cans, particularly if cans are imported. • Do not use pottery or ceramic ware that was inadequately fired or is meant for decorative use for food storage or service. Do not store drinks or food in lead crystal. • Avoid folk remedies or cosmetics that contain lead. • Avoid candy imported from Mexico (e.g., tamarind hard candy). • Avoid imported toys and toy jewelry that may contain lead. • Make sure that home exposure is not occurring from parental occupations or hobbies. Household members employed in occupations such as lead smelting should shower and change into clean clothing before leaving work. Construction and lead abatement workers may also bring home lead contaminants. • Make sure that child eats regular meals because more lead is absorbed on an empty stomach. • Make sure that child's diet contains sufficient iron and calcium and not excessive fat. • Consider iron supplementation if the child does not regularly consume foods rich in iron.

Review the child's growth including the following:

• Measurements of weight, length, and head circumference at birth • Patterns of growth on the growth chart and any significant deviations from previous percentiles • Concerns about growth from the family or child • Developmental milestones include: • Age of holding up head steadily • Age of sitting alone without support • Age of walking without assistance • Age of saying first words with meaning • Age of achieving bladder and bowel control • Present grade in school • Scholastic performance • If the child has a best friend • Interactions with other children, peers, and adults

Temperature Nursing Implications

• No single site used for temperature assessment provides unequivocal estimates of core body temperature. • Studies show that the axillary and tympanic measures demonstrate poor agreement when these modes are compared with more accurate core temperature methods. The differences are more evident as temperature increases, regardless of age. • TAT is not predictable for fever and should be only used as a screening tool in young children. • When an accurate method for obtaining a correct reflection of core temperature is needed, the rectal temperature is recommended in younger children and the oral route in older children. For infants younger than 1 month of age, axillary temperatures are recommended for screening.

Length Quality Control Measures

• Personnel who measure the growth of infants, children, and adolescents need proper education. Competency should be demonstrated. Refresher sessions should occur when a lack of standardization occurs. • Length boards and stadiometers must be assembled and installed properly and calibrated at regular intervals (ideally daily, at least monthly, and every time they are moved) due to frequent inaccuracy and the variability between different instruments. Calibration can be performed by measuring a rod of known length and adjusting the instrument accordingly. • All children should be measured at least twice (ideally three times) during each encounter. The measurements should agree within 0.5 cm (ideally 0.3 cm). Use the mean value. If the variation exceeds the limit of agreement, measure again and use the mean of the measures in closest agreement. If none of the measures are within the limit of agreement, then (1) have another measurer assist, (2) check technique, and (3) consider another education session. • Children between 24 and 36 months of age may have length and/or height measured. Standing height is less than recumbent length due to gravity and compression of the spine. Plot length measurements on a length curve and height measurements on a height curve to avoid misinterpreting the growth pattern

Warning Signs of Abuse

• Physical evidence of abuse or neglect, including previous injuries • Conflicting stories about the "accident" or injury from the parents or others • Cause of injury blamed on sibling or other party • An injury inconsistent with the history such as a concussion and broken arm from falling off a bed • History inconsistent with child's developmental level such as a 6-month-old turning on the hot water • A complaint other than the one associated with signs of abuse (e.g., a chief complaint of a cold when there is evidence of first- and second-degree burns) • Inappropriate response of caregiver such as an exaggerated or absent emotional response, refusal to sign for additional tests or agree to necessary treatment, excessive delay in seeking treatment, or absence of parents for questioning • Inappropriate response of child such as little or no response to pain, fear of being touched, excessive or lack of separation anxiety, indiscriminate friendliness to strangers • Child's report of physical or sexual abuse • Previous reports of abuse in the family • Repeated visits to emergency facilities with injuries • Parent or caregiver report of being gone and finding the child unresponsive, indicating absence during the supposed event that resulted in harm

Managing Colic

• Place infant prone over a covered hot-water bottle or heated towel. • Massage infant's abdomen. • Respond immediately to the crying. • Change infant's position frequently; walk with child's face down and with body across parent's arm, with parent's hand under infant's abdomen, applying gentle pressure. • Use a front carrier for transporting infant. • Swaddle infant tightly with a soft, stretchy blanket. • Take infant for car rides or outside for a change in environment. • Use bottles that minimize air swallowing (curved bottle or inner collapsible bag). • Use a commercial device in the crib that stimulates the vibration and sound of a car ride or plays soothing "noise," in utero sounds, or music. • Provide smaller, frequent feedings; burp infant during and after feedings using the shoulder position or sitting upright, and place infant in an upright seat after feedings. • Introduce a pacifier for added sucking. • If household members smoke, avoid smoking near infant; preferably confine smoking activity to outside of home. • If nothing reduces the crying, place infant in crib and allow to cry; periodically hold and comfort child, and put down again. • Maintain a brief diary of the time of day the crying starts; events going on in household; time, amount, and type of last feeding; length of crying; and characteristics of cry. Although this will not stop the crying, it may help the practitioner identify a possible cause.

Promoting Relaxation During Abdominal Palpation

• Position the child comfortably, such as in a semireclining position in the parent's lap, with knees flexed. • Warm your hands before touching the skin. • Use distraction, such as telling stories or talking to the child. • Teach the child to use deep breathing and to concentrate on an object. • Give an infant a bottle or pacifier. • Begin with light, superficial palpation, and gradually progress to deeper palpation. • Palpate any tender or painful areas last. • Have the child hold the parent's hand and squeeze it if palpation is uncomfortable. • Use the nonpalpating hand to comfort the child, such as placing the free hand on the child's shoulder while palpating the abdomen. • To minimize the sensation of tickling during palpation: • Have the child "help" with palpation by placing a hand over the palpating hand. • Have the child place a hand on the abdomen with the fingers spread wide apart, and palpate between his or her fingers.

Characteristics of Children or Adolescents With Depression

• Predominantly sad facial expression with absence or diminished range of affective response (most of the day) • Solitary play or work; tendency to be alone; lack of interest in play with friends • Withdrawal from previously enjoyed activities and relationships • Lowered grades in school; lack of interest in doing homework or achieving in school; refuses to wake up for school • Diminished motor activity; tiredness • Tearfulness or crying • Inability to concentrate • Dependent and clinging or aggressive and disruptive • Recurrent suicidal thoughts or talk Internal States • Utterance of statements reflecting lowered self-esteem, sense of hopelessness, or guilt • Suicidal ideation Physiology • Constipation • Loss of energy; fatigue • Nonspecific complaints of not feeling well • Change in appetite resulting in weight loss or gain • Alterations in sleeping pattern, sleeplessness, or hypersomnia

Avulsed Permanent Tooth

• Recover tooth. • Hold tooth by crown; avoid touching root area. • If tooth is dirty, rinse it gently under running water or saline; be certain to insert stopper in sink or basin (to avoid tooth loss). To Reimplant the Tooth • Insert tooth into socket; be certain that the lip side (or convex surface) is facing front. • Have child maintain tooth in place by slowly biting down on a piece of gauze. • Transport child to dentist immediately. • Avoid sudden stops or sharp turns to prevent dislodging tooth. If Reluctant to Reimplant the Tooth • Place avulsed tooth in suitable medium for transport: • Cold milk • Saliva—under child's or parent's tongue • If child is holding tooth in the mouth, avoid sudden stops to prevent swallowing tooth. • DO NOT FORGET TO TAKE THE TOOTH.

Warning Signs of Suicide

• Preoccupation with themes of death—focuses on morbid thoughts • Wants to give away cherished possessions • Talks of own death, desire to die • Loss of energy, loss of interest, listlessness • Exhaustion without obvious cause • Changes in sleep patterns—too much or too little • Increased irritability, argumentativeness, or stubbornness • Physical complaints—recurrent stomachaches, headaches • Repeated visits to physician, nurse practitioner, or emergency department for treatment of injuries • Reckless behavior • Antisocial behavior—engages in drinking, uses drugs, fights, commits acts of vandalism, runs away from home, becomes sexually promiscuous • Sudden change in school performance—lowered grades, cutting classes, dropping out of activities • Resists or refuses to go to school • Remains distant, sad, remote—flat affect, frozen facial expression • Describes self as worthless • Sudden cheerfulness after deep depression • Social withdrawal from friends, activities, interests that were previously enjoyed • Impaired concentration • Dramatic change in appetite

Anticipatory Guidance 3 years

• Prepare parents for child's increasing interest in widening relationships. • Encourage enrollment in preschool. • Emphasize importance of setting limits. • Prepare parents to expect exaggerated tension-reduction behaviors such as need for a "security blanket." • Encourage parents to offer child choices. • Prepare parents to expect marked changes at years, when child becomes insecure and exhibits emotional extremes. • Prepare parents for normal dysfluency in speech, and advise them to avoid focusing on the pattern. • Prepare parents to expect extra demands on their attention as a reflection of child's emotional insecurity and fear of loss of love. • Warn parents that the equilibrium of a 3-year-old will change to the aggressive, out-of-bounds behavior of a 4-year-old. • Inform parents to anticipate a more stable appetite with more food selections. • Stress need for protection and education of child to prevent injury

Anticipatory Guidance 12 to 18 months

• Prepare parents for expected behavioral changes of toddler, especially negativism and ritualism. • Assess present feeding habits, and encourage gradual weaning from bottle and increased intake of solid foods. • Stress expected feeding changes of picky eating habits, food fads, and strong taste preferences; need for scheduled routine at mealtimes; inability to sit through an entire meal; and lack of table manners. • Assess sleep patterns at night, particularly habit of a bedtime bottle, which is a major cause of early childhood caries (ECC), and procrastination behaviors that delay hour of sleep. • Prepare parents for potential dangers of the home and motor vehicle environment, particularly motor vehicle injuries, drowning, accidental poisoning, and falling injuries; give appropriate suggestions for safety-proofing the home. • Discuss need for firm but gentle discipline and ways to deal with negativism and temper tantrums; stress positive benefits of appropriate discipline. • Emphasize importance for both child and parents of brief, periodic separations. • Discuss toys that use developing gross and fine motor, language, cognitive, and social skills. • Emphasize need for dental supervision, types of basic dental hygiene at home, and food habits that predispose to caries; stress importance of supplemental fluoride (according to age and fluoride content of local water supply).

Anticipatory Guidance 4 Years

• Prepare parents for more aggressive behavior, including motor activity and offensive language. • Prepare parents to expect resistance to parental authority. • Explore parental feelings regarding child's behavior. • Suggest some type of respite for primary caregivers, such as placing child in preschool for part of the day. • Prepare parents for child's increasing sexual curiosity. • Emphasize importance of realistic limit setting on behavior and appropriate disciplinary techniques. • Prepare parents for the highly imaginative 4-year-old who indulges in "tall tales" (to be differentiated from lies) and develops imaginary playmates. • Prepare parents to expect nightmares or an increase in them. • Provide reassurance that period of calmness begins at 5 years of age.

Talking With Children Who Reveal Abuse

• Provide a private time and place to talk. • Do not promise not to tell; tell them that you are required by law to report the abuse. • Do not express shock or criticize their family. • Use their vocabulary to discuss body parts. • Avoid using any leading statements that can distort their report. • Reassure them that they have done the right thing by telling. • Tell them that the abuse is not their fault, that they are not bad or to blame. • Determine their immediate need for safety. • Let the child know what will happen when you report.

Communicating with Parents about Immunizations

• Provide accurate and user-friendly information on vaccines (the necessity for each one, the disease each prevents, and potential adverse effects). • Realize that the parent is expressing concern for the child's health. • Acknowledge the parent's concerns in a genuine, empathetic manner. • Tailor the discussion to the needs of the parent. • Avoid judgmental or threatening language. • Be knowledgeable about the benefits of individual vaccines, the common adverse effects, and how to minimize those effects. • Give the parent the vaccine information statement (VIS) beforehand, and be prepared to answer any questions that may arise. • Help the parent make an informed decision regarding the administration of each vaccine. • Be flexible and provide parents with options regarding the administration of multiple vaccines, especially in infants, who must receive multiple injections at 2, 4, and 6 months of age (i.e., allow parents to space the vaccinations at different visits to decrease the total number of injections at each visit; make provisions for office visits for immunization purposes only [does not incur a practitioner fee except for administration of vaccine], provided the child is healthy). • Involve the parent in minimizing the potential adverse effects of the vaccine (e.g., administering an appropriate dose of acetaminophen 45 minutes before administering the vaccine [as warranted]; applying EMLA [lidocaine-prilocaine] or LMX4 [4% lidocaine] to the injection sites before administration; following up to check on the child if untoward reactions have occurred in the past or parent is especially anxious about the child's well-being). • Respect the parent's ultimate wishes.

Guidelines for Integrating Spiritual Care Into Pediatric Nursing Practice

• Respect the child and family's religious beliefs and practices. • Consider the child's development when talking about spiritual concerns. • Contact the institution's chaplaincy department for patients and families who have symptoms of spiritual distress, or ask for specific religious rituals. • Become knowledgeable about the religious worldviews of cultural groups found in the patients you care for. • Encourage visitation with family members, members of the patient's spiritual community, and spiritual leaders. • Allow children and families to teach you about the specifics of their religious beliefs. • Develop awareness of your own spiritual perspective. • Listen for understanding rather than agreement or disagreement.

Using Time Out

• Select an area for time-out that is safe, convenient, and unstimulating, but where the child can be monitored, such as the bathroom, hallway, or laundry room. • Determine what behaviors warrant a time-out. • Make certain children understand the "rules" and how they are expected to behave. • Explain to children the process of time-out: • When they misbehave, they will be given one warning. If they do not obey, they will be sent to the place designated for time-out. • They are to sit there for a specified period. • If they cry, refuse, or display any disruptive behavior, the time-out period will begin after they quiet down. • When they are quiet for the duration of the time, they can then leave the room. • A rule for the length of time-out is 1 minute per year of age; use a kitchen timer with an audible bell to record the time rather than a watch.

Minimizing Misbehavior

• Set realistic goals for acceptable behavior and expected achievements. • Structure opportunities for small successes to lessen feelings of inadequacy. • Praise children for desirable behavior with attention and verbal approval. • Structure the environment to prevent unnecessary difficulties (e.g., place fragile objects in an inaccessible area). • Set clear and reasonable rules; expect the same behavior regardless of the circumstances; if exceptions are made, clarify that the change is for one time only. • Teach desirable behavior through own example, such as using a quiet, calm voice rather than screaming. • Review expected behavior before special or unusual events, such as visiting a relative or having dinner in a restaurant. • Phrase requests for appropriate behavior positively, such as "Put the book down," rather than "Don't touch the book." • Call attention to unacceptable behavior as soon as it begins; use distraction to change the behavior or offer alternatives to annoying actions, such as exchanging a quiet toy for one that is too noisy. • Give advance notice or "friendly reminders," such as "When the TV program is over, it is time for dinner," or "I'll give you to the count of three, and then we have to go." • Be attentive to situations that increase the likelihood of misbehaving, such as overexcitement or fatigue, or decreased personal tolerance to minor infractions. • Offer sympathetic explanations for not granting a request, such as "I am sorry I can't read you a story now, but I have to finish dinner. Then we can spend time together." • Keep any promises made to children. • Avoid outright conflicts; temper discussions with statements, such as "Let's talk about it and see what we can decide together," or "I have to think about it first." • Provide children with opportunities for power and control.

Childhood Injuries: Risk Factors

• Sex—Preponderance of males; difference mainly the result of behavioral characteristics, especially aggression • Temperament—Children with difficult temperament profile, especially persistence, high activity level, and negative reactions to new situations • Stress—Predisposes children to increased risk-taking and self-destructive behavior; general lack of self-protection • Alcohol and drug use—Associated with higher incidence of motor vehicle injuries, drownings, homicides, and suicides • History of previous injury—Associated with increased likelihood of another injury, especially if initial injury required hospitalization • Developmental characteristics • Mismatch between child's developmental level and skill required for activity (e.g., all-terrain vehicles) • Natural curiosity to explore environment • Desire to assert self and challenge rules • In older child, desire for peer approval and acceptance • Cognitive characteristics (age-specific) • Infant—Sensorimotor: explores environment through taste and touch • Young child—Object permanence: actively searches for attractive object; cause and effect: lacks awareness of consequential dangers; transductive reasoning: may fail to learn from experiences (e.g., perceives falling from a step as a different type of danger from climbing a tree); magical and egocentric thinking: is unable to comprehend danger to self or others • School-age child—Transitional cognitive processes: is unable to fully comprehend causal relationships; attempts dangerous acts without detailed planning regarding consequences • Adolescent—Formal operations: is preoccupied with abstract thinking and loses sight of reality; may lead to feeling of invulnerability • Anatomic characteristics (especially in young children) • Large head—Predisposes to cranial injury • Large spleen and liver with wide costal arch—Predisposes to direct trauma to these organs • Small and light body—May be thrown easily, especially inside a moving vehicle • Other factors—Poverty, family stress (e.g., maternal illness, recent environmental change), substandard alternative child care, young maternal age, low maternal education, multiple siblings

The nurse who observes the following signs of stress in a child should explore the situation further:

• Stomach pains or headache • Changes in sleep patterns or nightmares • Bed-wetting • Changes in eating habits • Aggressive or stubborn behavior • Withdrawal or reluctance to participate • Regression to earlier behaviors (e.g., thumb-sucking) • Trouble concentrating or changes in academic performance

Anticipatory Guidance 18 to 24 Months

• Stress importance of peer companionship in play. • Explore need for preparation for additional sibling (as appropriate); stress importance of preparing child for new experiences. • Discuss present discipline methods, their effectiveness, and parents' feelings about child's negativism; stress that negativism is an important aspect of developing self-assertion and independence and is not a sign of spoiling. • Discuss signs of readiness for toilet training; emphasize importance of waiting for physical and psychologic readiness. • Discuss development of fears such as darkness or loud noises and habits, such as security blanket or thumb sucking; stress normalcy of these transient behaviors. • Prepare parents for signs of regression in time of stress. • Assess child's ability to separate easily from parents for brief periods under familiar circumstances. • Allow parents opportunity to express their feelings of weariness, frustration, and exasperation; be aware that it is often difficult to love toddlers when they are not asleep! • Point out some of the expected changes of the next year such as longer attention span, somewhat less negativism, and increased concern for pleasing others.

Methods Used to Pressure Children Into Sexual Activity

• The child is offered gifts or privileges. • The adult misrepresents moral standards by telling the child that it is "okay to do." • Isolated and emotionally and socially impoverished children are enticed by adults who meet their needs for warmth and human contact. • The offender asks the child for help in finding a favorite pet or object with which the child can easily identify. • The successful sex offender pressures the victim into secrecy regarding the activity by describing it as a "secret between us" that other people may take away if they find out. • The offender plays on the child's fears, including fear of punishment by the offender, fear of repercussions if the child tells, and fear of abandonment or rejection by the family.

Nurse's Role in Sex Education

• Treating sex as normal part of growth and development • Questions and answers • Differentiation between "sex" and "sexuality" • Values, problem-solving skills • Open communication with parents

Newborn and young infant response to pain

• Uses crying • Reveals facial appearance of pain (brows lowered and drawn together, eyes tightly closed, and mouth open and squarish) • Exhibits generalized body response of rigidity or thrashing, possibly with local reflex withdrawal from what is causing the pain • Shows no relationship between what is causing the pain and subsequent response

Older infant response to pain

• Uses crying • Shows a localized body response with deliberate withdrawal from what is causing the pain • Reveals expression of pain or anger • Demonstrates a physical struggle, especially pushing away from what is causing the pain

Young Child Response to pain

• Uses crying and screaming • Uses verbal expressions, such as "Ow," "Ouch," or "It hurts" • Uses thrashing of arms and legs to combat pain • Attempts to push what is causing the pain away before it is applied • Displays lack of cooperation; need for physical restraint • Begs for the procedure to end • Clings to parent, nurse, or other significant person • Requests physical comfort, such as hugs or other forms emotional support • Becomes restless and irritable with ongoing pain • Worries about the anticipation of the actual painful procedure

Exploring a Family's Culture, Illness, and Care

• What do you think caused your child's health problem? • Why do you think it started when it did? • How severe is your child's sickness? Will it have a short or long course? • How do you think your child's sickness affects your family? • What are the chief problems your child's sickness has caused? • What kind of treatment do you think your child should receive? • What are the most important results you hope to receive from your child's treatment? • What do you fear most about your child's sickness?