Peds Exam 1 (NURA 403)

Phenylketonuria (PKU): disorder, clinical manifestations

Disorder/Explanation • Phenylketonuria (PKU): deficiency in a liver enzyme leading to inability to process the essential amino acid phenylalanine properly. • Phenylalanine accumulation can lead to brain damage unless PKU is detected soon after birth and treated Clinical Manifestations • No symptoms at birth. Most cases are identified before symptoms are present due to newborn screening (PKU is screened for in all states). Blood sample taken 2-3 days after birth to detect increased levels of phenylalanine and decreased levels of tyrosine. • If undiagnosed, most common sign is developmental delay along with vomiting, irritability, eczema-like rash, musty/mousy odor to urine, microcephaly, seizures and behavioral abnormalities. Osmosis adds early/late symptoms: failure to thrive, intellectual disability (ID), behavioral problems

Epiglottitis nursing interventions

Do not leave the child unattended. Keep the child and parents as calm as possible. Allow the child to assume a position of comfort. Do not place the child in a supine position, as airway occlusion may occur. Provide 100% oxygen in the least invasive manner that is acceptable to the child. If the child with epiglottitis experiences complete airway occlusion, an emergency tracheostomy (incision in trachea to permit breathing) may be necessary. Ensure that emergency equipment is available and that personnel trained in intubation of the pediatric occluded airway and percutaneous tracheostomy are notified of the child's presence in the facility.

Down syndrome parent education

Down syndrome is a lifelong disorder that can result in health problems and cognitive disability (range from mild to moderate). Prenatal or neonatal dx Parent needs support and education Variable parent response; plan around family experience, values and strengths Family members may have trouble meeting the demands of caring for a child with Down syndrome. These children have complex medical needs, which place strain on the family and its finances. Family must be heavily involved in care Needs will change over time Children with Down syndrome will need meaningful education programs. Many children with Down syndrome begin formal education in infancy and continue through high school. The outlook is brighter than it used to be: Many go on in adulthood to obtain jobs, to receive secondary education, and to live on their own or in semi-independent housing. Be familiar with local and national resources for families.

Clinical manifestations of conjunctivitis

Elicit a description of the present illness and chief complaint. Common signs and symptoms reported during the health history might include: Redness Edema Tearing Discharge Eye pain Itching of the eyes (usually with allergic conjunctivitis)

Temporal scanning

Temporal scanning uses infrared scanning on the skin over the temporal artery combined with a mathematical computation to determine the child's arterial temperature. Temporal artery thermometry may be used with any age child except infants younger than 90 days of age who are ill or have a fever for whom the rectal method should be used. Measure temperature on the exposed side of the head (not the side that has been lying on a pillow or covered by a hat). Depress the sensor button and slide the sensor tip externally in a horizontal line across the child's forehead, midway between the eyebrows and hairline and ending at the lateral hairline (Fig. 32.4). Continuing to depress the button, lift the sensor from the forehead and then place it on the soft spot behind the ear lobe. Hold it there until the device registers the temperature reading, which usually requires 1 second. Accuracy may be affected by excessive sweating.

Nursing implications for ID

When children with intellectual disability are admitted to the hospital (usually for some other physical or medical condition), it is important for the nurse to continue the child's usual home routine. Follow through with feeding and motor supports that the child uses. Ensure that the child is closely supervised and remains free from harm. Allow parents time to verbalize frustrations or fears. For some families, the caretaking burden is extensive and lifelong; arrange for respite care as available. Support the child's strengths and assist the child and family to follow through with therapy or treatment designed to enhance the child's functioning. Assist with the development of the child's IEP as appropriate.

Acute otitis media tx

antibiotics, sometimes observation with pain relief

ASD warning signs

• Does not imitate • Lack of interest in joint attention (Joint attention or shared attention is the shared focus of two individuals on an object. It is achieved when one individual alerts another to an object by means of eye-gazing, pointing or other verbal or non-verbal indications.) • Eye contact abnormalities (too little or very intense) • Using parent as a tool such as pulling them by the hand to fridge for juice (this is communication but is not SOCIAL in absence of eye contact, using words/gestures as developmentally appropriate. Autism is a SOCIAL communication disorder) • Not responding to their name when it's called, in the absence of hearing problems • Delayed language development • Failure to develop symbolic-imaginative play • Losing language or social skills at any age - (True regression is actually rare but if a child learns and uses words for a week and you never hear them again, that's unusual)

Immunizations: indications and contraindications Where to find schedule?

• Vaccines mimic the characteristics of the natural antigen. The immune system mounts a response and establishes an immunologic memory as it would for an infection. • The classification of vaccines is based on the characteristics of the antigen present. The antigen may be viral or bacterial. It may be live attenuated (weakened) or killed. It may be the whole antigen or a portion of it (fractional). • Contraindications are conditions that justify withholding an immunization either permanently or temporarily. The only permanent contraindication to all vaccines is an anaphylactic or systemic allergic reaction to a vaccine component https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf

Interprofessional collaboration - child life specialist

• individual specially trained in the developmental impact of illness, injury, and trauma • provides programs that prepare children for hospitalization, surgery, and other procedures that could be painful or distressing. • member of the multidisciplinary team and works in conjunction with the health care provider and parents • goal of the CLS is to decrease the child's anxiety and fear while improving and encouraging the child's understanding and cooperation. • considers the needs of siblings or other children who may be affected by the child's illness or trauma. • provides engaging and uplifting events by coordinating special entertainment and activities

HCP questions about neglect

- Are the child's needs being inadequately met? - Is there evidence of actual or potential harm? - Is there a pattern of neglect? - has child protective services been involved? - What factors are contributing to the neglect? (Is the parent aware of the problem? Does poverty play a role? Is there access to necessary services?) - What family strengths or resources are available? - What interventions have been tried in the past? What were the results? - Is the family motivated to make necessary changes? - Are the necessary resources available? - How much help is the family willing to accept on behalf of their child?

Nursing assessment with opioids

-Assessment is crucial when pharmacologic pain interventions are used. An initial assessment of pain provides a baseline from which options for relief can be chosen. -Factors that can affect the choice of analgesic, such as the child's age, pain intensity, physiologic status, or previous experiences with pain, also need to be considered. -The nurse acts as an advocate for the child and the family to ensure that the most appropriate pharmacologic agent is chosen for the situation. Assessment is ongoing once the agent is administered. - Monitor physiologic parameters such as LOC, vital signs, oxygen saturation levels, and urinary output for changes that might indicate an adverse reaction to the agent. - More intensive monitoring is needed when agents are administered intravenously or epidurally or by moderate sedation. For example, if the child is receiving moderate sedation, interventions include: · Ensuring that emergency equipment is readily available · Maintaining a patent airway · Monitoring the child's level of consciousness and responsiveness · Assessing the child's vital signs (especially heart rate, blood pressure, and respiratory rate) · Monitoring oxygen saturation levels

Tympanic temperature

. Note age of child. If younger than 3 years, pull the earlobe back and down. 2. Insert the tympanic thermometer gently into the ear canal with the infrared sensor beam directed toward the center of the tympanic membrane rather than the sides of the ear canal. 3. Push the button to take the temperature and hold until a reading is obtained. The length of time required for the temperature to register varies per manufacturer but is only a few seconds at most.

Clinical manifestations of potential child maltreatment/abuse

A delay in seeking medical treatment, a history that changes over time, or a history of trauma that is inconsistent with the observed injury all suggest child abuse.

Respiratory priority assessment/clinical manifestations

A slow or irregular respiratory rate in an acutely ill infant or child is an ominous sign. Seesaw (or paradoxical) respirations are very ineffective for ventilation (gas exchange) and oxygenation (binding of oxygen). The chest falls on inspiration and rises on expiration.

ADHD

ADHD is the most common neurodevelopmental disorder of childhood, affecting 8% to 11% of school-age children. ADHD is characterized by inattention, impulsivity, distractibility, and hyperactivity. Three subtypes of ADHD exist: hyperactive-impulsive, inattentive, and combined. The child with ADHD has a disruption in learning ability, socialization, and compliance, placing significant demands on the child, parents, teachers, and community. Children with ADHD often have a comorbidity (disorder accompanying the primary illness) such as oppositional defiant disorder, conduct disorder, an anxiety disorder, depression, a less severe developmental disorder, an auditory processing disorder, or learning or reading disabilities (Krull, 2019). Comparison Chart 50.1 gives information about oppositional defiant disorder and conduct disorder to distinguish them from ADHD.

Developmental theory

Addresses family change over time Duvall's family life cycle stages - Family is a semi-closed system that interacts with the larger social system. - The age of the oldest child marks stage transitions. - At each stage, the family faces certain developmental tasks. - At each stage, each family member must achieve individual developmental tasks. Nurse assesses family's life cycle adjustment

Family theories: Resiliency model of family stress and family adjustment, and adaptation response model

Addresses the way families adapt to stress and can rebound from adversity. Identified the elements of risks and protective factors that aid a family in achieving positive outcomes.

Family theories: Family stress theory

Addresses the way families respond to stress and how the family copes with the stress as a group and how each individual member copes. Described elements of stress as occurring internally within the family (e.g., values, beliefs, structure) that the family can control or change or externally from outside the family (e.g., culture of the surrounding community, genetics, the family's current time or place) over which the family has no control. Described mobilization of family resources resulting in either a positive response of constructive coping or negative response of a crisis. Identified the main determinant of adequate coping based on the meaning of the stressful event to the family and its individual members.

Pediatric variations in anatomy & physiology of the ears

Anatomy differences child will have relatively shorter, wider Eustachian tubes and horizontal positioning How do you examine the ears? Pull down and back <3, up and back if older What happens when fluid is in middle ear, how does it result in hearing loss? Three tiny bones in the middle ear carry sound vibrations from the eardrum to the inner ear. When fluid is present, the vibrations are not transmitted efficiently and sound energy is lost. The result may be mild or even moderate hearing loss. Therefore, speech sounds are muffled or inaudible. Generally, this type of hearing loss is conductive and is temporary. However when otitis media occurs over and over again, damage to the eardrum, the bones of the ear, or even the hearing nerve can occur and cause a permanent, sensorineural hearing loss. Interventions for ear infection: abx

Communicating: Toddlers

• Approach toddlers carefully; they are often not only fearful but also quite resistant. • Use the toddler's preferred words for objects or actions so he or she is better able to understand. • Toddlers enjoy stories, dolls, and books. • Participate in parallel play to help start communication. • Prepare toddlers for procedures just before they are about to occur.

Communicating: Preschoolers

• Use play, puppets, or storytelling via a third-party approach. • Speak honestly. • Use simple, concrete terms. • Ask specific questions. • Allow the child to have choices as appropriate. • Participate in imaginative play to help open communication. • Prepare preschoolers about 1 hour prior to a procedure.

Assessment of stages of separation anxiety

Protest phase: cry and scream, cling to parent Despair phase: crying stops, evidence of depression, uninterested in food and play Detachment phase: denial; resignation but not contentment may seriously affect attachment to parent after separation

Priority nursing assessment of pain

Assessment of pain in children consists of both subjective and objective data collection. The acronym QUESTT is an excellent way to remember the key principles of pain assessment (Baker & Wong, 1987): · Question the child. · Use a reliable and valid pain scale. · Evaluate the child's behavior and physiologic changes to establish a baseline and determine the effectiveness of the intervention. The child's behavior and motor activity may include irritability and protection as well as withdrawal of the affected painful area. · Secure the parent's involvement. · Take the cause of pain into account when intervening. · Take action. Observe for physical signs and symptoms of pain, keeping in mind the child's developmental level. Look for facial expressions of discomfort, grimacing, or crying. Be alert for movements that may suggest pain. For example, an infant or toddler may pull on the ear when experiencing ear pain. The child may move the head from side to side, suggesting head pain. Typically, children with abdominal pain will lie on one side and draw their knees up to the abdomen. Inspect the child's gait: a limp or avoidance of weight-bearing may suggest leg pain. Immobility, guarding of a particular body area, or refusal to move an area may be observed. Inspect the skin for flushing or diaphoresis, possible indicators of pain. Also monitor vital signs for changes. Pulse or heart rate, respiratory rate, and blood pressure may increase. Other physiologic parameters that suggest pain may include elevated intracranial pressure and pulmonary vascular resistance and decreased oxygen saturation levels.

Hypoxia assessment pediatric

Assessment of respiratory dysfunction in children includes health history, physical examination, and laboratory or diagnostic testing. Early signs: tachypnea, tachycardia, anxiety, restlessness, dehydration (tachypnea interferes with breastfeeding/drinking as does nasal congestion & mouth lesions, rapid RR means more fluids lost) Late: Pallor, cyanosis, bradypnea, advanced finger clubbing, weak peripheral pulses, nasal flaring, chest retractions, inability to feed, lethargy What's a good indicator? A slow or irregular respiratory rate in an acutely ill infant or child is an ominous sign

PKU management

Begin as early as possible, and treatment will be lifelong. Our text says: • Low-phenylalanine, high tyrosine diet. • Phenylalanine is found mostly in protein-containing foods such as meat and milk (including breast milk and formula). Osmosis adds: Avoid: meat, fish, dairy, eggs, bean, tofu, nuts, seeds Carbonated drinks, aspertame sweetener Most fruits and veggies are ok, small amounts of cereal ok Special formula and PKU medical food available For mild cases of PKU, pharmacological tx with synthetic BH4 is available to allow a less restrictive diet and better manage blood phenylalanine levels. Perform regular blood tests to monitor phenylalanine and tyrosine levels. Monitor growth- height, weight, BMI Go over food logs Observe child's mental status and behavior Report unusual skin rashes, behavioral abnormalities, growth outside regular parameters Provide parent referral for counseling and support groups

Behavioral vs physiologic pain indicators

Behavioral: grimacing, kicking legs, grabbing abdomen Physiologic: elevated RR, elevated HR, elevated BP Infants also demonstrate physiologic responses to pain. These may include: · Increased heart rate, usually averaging approximately 10 bpm; possibly bradycardia in preterm newborns · Decreased vagal tone · Decreased oxygen saturation · Palmar or plantar sweating (as measured by skin conductivity testing); not reliable in infants before 37 weeks' gestation Toddlers can react to painless procedures as intensely as painful ones, with intense emotional upset and physical resistance or aggression. They may bite, hit, scream, or kick. Other behaviors may include being very quiet, pointing to where it hurts, or saying such words as "owww." Facial grimacing and teeth clenching may be noted. They may also react with fear and try to hide or leave the room. They often have limited vocabularies, so it may be difficult for them to express pain. It is important to ask about and encourage the child to verbalize his or her pain. Ensure the use of words the toddler understands, such as "owie" or "boo-boo." Toddlers may demonstrate regressive behaviors, such as clinging to the parent or crying loudly.

What happens if blood pressure is strange?

Check bp manually

Varicella infection nursing implications

Chicken pox • Comfort measures, such as antipyretics and antipruritics • For those with exposure to susceptible persons, air-borne and contact precautions, from 8 to 21 days after exposure • Children may return to school or child care once all lesions have crusted. • Airborne and contact precautions in the hospitalized child for a minimum of 5 days after the onset of rash and as long as vesicular lesions are present. When is child contagious? • Incubation period: 10-21 days, usually 14-16 days • Communicable 1-2 days before the onset of rash until all vesicles have crusted over (about 3-7 days after the onset of rash) When can child go back to daycare or school? 7+ days after onset of rash, after all vesicles have crusted over

Myopia

Children who are nearsighted may see well at close range but have difficulty focusing on the blackboard or other objects at a distance. Therapeutic management for both hyperopia and myopia is prescription eyeglasses or contact lenses. Generally, a child of 12 years of age can demonstrate the responsibility necessary to wear and care for contact lenses. Contact lenses may be used in younger children but are lost or damaged more readily. Because of the continuing refractive development in the child's vision through adolescence, laser surgery for vision correction is not recommended for most children.

Assessment of hearing loss pediatric

Common symptoms reported during the health history might include: · Infant: o Wakes only to touch, not environmental noises o Does not startle to loud noises o Does not turn to sound by 4 months of age o Does not babble at 6 months of age o Does not progress with speech development · Young child: o Does not speak by 2 years of age o Communicates needs through gestures o Does not speak distinctly, as appropriate for his or her age o Displays developmental (cognitive) delays o Prefers solitary play o Displays immature emotional behavior o Does not respond to ringing of the telephone or doorbell o Focuses on facial expressions when communicating · Older child: o Often asks for statements to be repeated o Is inattentive or daydreams o Performs poorly at school o Displays monotone or other abnormal speech o Gives inappropriate answers to questions except when able to view face of speaker · At any age: o Speaks loudly o Sits very close to the TV or radio or turns volume up too loud o Responds only to moderate or loud voices Investigate signs of hearing loss as early as possible in order for appropriate intervention to begin. Explore the child's current and past medical history for risk factors such as congenital anomalies, genetic syndrome, infection, family history, kernicterus, neonatal ventilator use, ototoxic medication, or exposure to excess noise. Note whether newborn hearing screening was done and, if so, what the results were. Physical Examination and Diagnostic Testing Determine the child's level of interaction with the environment. For preschoolers and older children, administer the whisper test, keeping in mind that this is a gross screening test only. Perform the Weber and Rinne tests. If further evaluation is needed, the nurse may be responsible for administering an otoacoustic emissions test or auditory brain stem-evoked response test, either in the hospital or outpatient office.

Autism screening/Assessment

Developmental delays (not reaching milestones) Social communication problems Restrictive/repetitive behaviors Assess the child's functional status, including behavior, nutrition (are they eating what you would expect for their age including a variety of foods and textures) , sleep, speech and language, education needs, and developmental or neurologic limitations. Assist with screening, using an approved autism screening tool such as the MCHAT, which is recommended for administration at 18 months of age, and then again at 24 to 30 months of age. Additional screening tools include the Social Communication Questionnaire (SCQ) and the Pervasive Developmental Disorders Screening Test-II (PDDST-II). Perform a thorough physical examination. Look for red flags for ASD (not bothering with detail because I do this for a living) Measure growth parameters, in particular noting head circumference (macrocephaly or microcephaly may be associated with ASD). Note the presence of large, prominent, or posteriorly rotated ears. Examine the skin for hypo- or hyperpigmented lesions. Note asymmetry of nerve function or palsy, hypertonia, hypotonia, alterations in deep tendon reflexes, toe-walking, loose gait, or poor coordination. Obtain hearing screening results and ascertain that lead screening has been performed.

Physical assessment - child abuse

Elicit the health history, noting the chief complaint and timing of onset. Assess for appropriateness of the parent-child attachment (often altered in the case of neglect). Pay particular attention to statements made by the child's parent or caretaker. Is the history given consistent with the child's injury? Identify abuse and violence by screening all children and families using these questions: · Questions for children: o Are you afraid of anyone at home? o Who could you tell if someone hurt you or touched you in a way that made you uncomfortable? o Has anyone hurt you or touched you in that way? · Questions for parents: o Are you afraid of anyone at home? o Do you ever feel like you may hit or hurt your child when frustrated? Assess for risk factors in children and parents or caretakers. Risk factors for abuse in children include poverty, prematurity, cerebral palsy, chronic illness, or intellectual disability. Risk factors for being abusers in parents or caretakers include a history of being abused themselves, alcohol or substance abuse, or extreme stress. Determine if the child has a history of hurting self or others (e.g., cutting), running away, attempting suicide (taking one's own life), or being involved in high-risk behaviors. Note inappropriate sexual behavior for developmental age, such as seductiveness, as this may indicate sexual abuse. Note history of chronic sore throat or difficulty swallowing, which may occur with forced oral sex or sexually transmitted infections. Document history of genital burning or itching (associated with sexual abuse). Note nonspecific symptoms of emotional abuse such as low self-confidence, sleep disturbance, hypervigilance, headaches, or stomachaches.

Family theories: Duvall's developmental theory

Emphasizes the developmental stages that all families go through, beginning with marriage; the longitudinal career of the family is also known as the family life cycle. Described eight chronologic stages with specific predictable tasks that each family completes: • Marriage: beginning of family • Childbearing stage • Family with preschool children • Family with school-age children • Family with adolescents • Family with young adults • Middle-age parents • Family in later years

Family theories: Von Bertalanffy: general system theory applied to families

Emphasizes the family as a system with interdependent, interacting parts that endure over time to ensure the survival, continuity, and growth of its components; the family is not the sum of its parts but is characterized by wholeness and unity. Used to define how families interact with and are influenced by the members of their family and society and how to analyze the interrelationships of the members and the impact that change affecting one member will have on other members.

Family theories: Friedman's structural functional theory

Emphasizes the social system of family, such as the organization or structure of the family and how the structure relates to the function. Identified five functions of families: • Affective function: meeting the love and belonging needs of each member • Socialization and social placement function: teaching children how to function and assume adult roles in society • Reproductive role: continuing the family and society in general • Economic function: ensuring the family has necessary resources with appropriate allocation • Health care function: involving the provision of physical care to keep family healthy

Teaching regarding prevention of external otitis

Encourage breastfeeding Ask parents to stop smoking, or not to smoke in house/car Risk factors for OME include passive smoking, absence of breastfeeding, frequent viral upper respiratory infections, allergy, young age, male sex, adenoid hypertrophy, Eustachian tube dysfunction, and certain congenital disorders (Yoon et al., 2018). Complications of OME include AOM, hearing loss, and deafness. Educate the family about the natural history of OME and the anatomic differences in young children that contribute to OME. Inform parents that antihistamines, decongestants, antibiotics, and corticosteroids have not been proven to hasten the resolution of OME and thus are not recommended. OME usually resolves spontaneously, but children should be rechecked every 4 weeks while this resolution is occurring. Teach parents not to feed infants in a supine position and to avoid bottle propping.

Refractive errors medical management education

Encourage the child with newly prescribed eyeglasses to wear them by having the parent spend "special time" with the child doing an activity that requires the glasses (such as reading or drawing). Provide positive reinforcement for wearing the glasses. Teach the parent and child to remove eyeglasses with both hands and to lay them on their side (not directly on the lens on any surface). Instruct the child and family about cleaning the glasses daily with mild soap and water or a commercial cleansing agent provided by the optometrist. Use a soft cloth to clean the glasses. Teach the older child or adolescent how to care for the contact lenses properly, including lens hygiene and lens insertion and removal. Inform the child and parents that protective eyewear should be worn when the child is participating in contact sports. If the eye becomes inflamed, remove the contact lens and wear eyeglasses until the eye is improved. Consult with the child's eye care provider to determine if medications prescribed for an eye problem can be used while the contact lens is in. Encourage the family to complete visual assessments as scheduled. Since the child's vision is continuing to develop and refraction is not stable, the corrective lens prescription may change more frequently than it does in an adult. As the young child in particular is continuing to grow at a rapid rate, the head size is also changing. Eyeglass frames may hurt or pinch the child as the child's head becomes larger. Teach families to check the fit of the glasses monthly. Monitor for signs of ill fit, such as constant removal of the glasses in an older child or rubbing at the glasses or eyes in the very young child. Monitor for squinting, eye fatigue or strain, and complaints of headache or dizziness, which may indicate the need for a change in the lens prescription.

Psychosocial integrity considerations of isolation (due to infectious process) in hospital

Encourage the family to visit often, and help them to understand the reason for the isolation and any special procedures that are required. Introduce yourself before entering the room and allow the child to view your face before applying a mask, if possible. Continue to have contact with the child and hold or touch the child often, especially if the parents are not present.

Phenylketonuria nursing interventions

Ensure that the diet prescribed for the infant or child is followed. For amino acid disorders, nutritional therapy is the major intervention. Dietary intake of specific amino acids is restricted according to the disorder. Ensure that overall protein and calorie needs are still met. Supplementation with specific vitamins may also be important in the treatment of these disorders. Strict adherence to the diet is necessary and will require close supervision by registered dietitians, physicians, and nurses and the cooperation of both the parent and child. Teaching: Nursing management will focus on education and support for the family, who will need thorough knowledge about the child's disease and management. Refer the child and family to a dietitian and appropriate resources, including support groups. In addition, monitor the child's developmental progress and begin therapies as soon as a concern arises. When a previously healthy newborn presents with a history of deterioration, suspect an inborn error of metabolism. If an inborn error of metabolism is suspected, feedings will usually be stopped until the test results are received. Teach family how to read food labels and choose items with <2g protein per serving and talk about it with child Provide list of good/bad/sometimes food How to obtain low-protein specialty foods How to keep a food log

Age-appropriate pain scale (CRIES, FACES)

FACES Pain Rating Scale. The FACES pain rating scale is a self-report tool that is typically used in children 3 to 8 years of age. The scale consists of six illustrations of faces arranged horizontally with expressions ranging from smiling (indicating no hurt) to crying with frowning (indicating hurts worst). Under each face is a short description such as "hurts little bit" and a number. The number scale can be 0, 1, 2, 3, 4, and 5 or 0, 2, 4, 6, 8, and 10. The nurse explains the words associated with each face to the child. Then, the nurse asks the child to select the facial expression that best describes the level of pain he or she is feeling. CRIES Scale for Neonatal Postoperative Pain Assessment. The CRIES scale is a behavioral assessment tool that also includes measures of physiologic parameters. Great for newborns & infants. The tool assesses five parameters: cry, oxygen required for saturation levels less than 95%, increased vital signs, facial expression, and sleeplessness (Table 36.6). Each parameter is scored as 0, 1, or 2 and then totaled. As with other assessment tools, the higher the score, the greater the infant's pain. r-FLACC Behavioral Scale for Pain in Nonverbal Young Children and Children with Cognitive Impairment. The original FLACC behavioral scale is a behavioral assessment tool that is useful in assessing a child's pain when the child cannot report accurately his or her level of pain. It has been demonstrated to be a reliable tool for children from age 6 months to 7 years of age. This tool measures five parameters: facial expression, legs, activity, cry, and consolability. Observe the child with the legs and body uncovered. If the child is awake, observe him or her for 1 to 2 minutes; if sleeping, observe the child for 2 minutes or longer. Each parameter is scored as 0, 1, or 2. The scores are totaled, with a maximum achievable score of 10. As with other assessment tools, the higher the score, the greater the pain.

Family Stress Theory

Families encounter stressors, both predictable and unpredictable Multiple stressors in a short period of time can be overwhelming, cause inadequate coping, and lead to a state of crisis Adaptation requires a change in the family structure and/or interaction Nurse assesses the family's reaction and resiliency to stress

barriers to family centered care

Family role stress Negotiation failures Power struggles Incongruent definitions of family needs (patient/family vs. health care team members) Violence Safety

Family Systems Theory

General Systems Theory: family is a system in which interaction continually occurs among members and between the family unit and the environment Emphasis is on interaction Problems do not lie in any one member but in the type of interactions used by the family Makes the family the "patient" and the focus of care Nurse assesses the family's ability with health promotion, disease prevention, and/or hospitalization, etc.

Verbal and nonverbal communication

General guidelines for appropriate verbal communication include the following: · Use open-ended questions that do not restrict the child's or parents' answers. · Redirect the conversation to maintain focus. · Use reflection to clarify the parents' feelings. · Paraphrase the child's or parents' feelings to demonstrate empathy. · Acknowledge emotions. · Demonstrate active listening by using the child's or family's own words. Remember that most parents are laypersons, so avoid using medical jargon. Guidelines for appropriate nonverbal communication include the following: · Relax; maintain an open posture, with the arms uncrossed. · Sit opposite the family and lean forward slightly. · Maintain eye contact. · Nod your head to demonstrate interest. · Note the child's or parent's posture, eye contact, and facial expressions. Active listening is critical to the communication process. Listening may uncover fears or concerns that the nurse may not have discovered through questioning.

Therapeutic play to assess stressors

Health care professionals use therapeutic play to help the child deal with the physical and psychological challenges of illness and hospitalization. Supervised play with medical equipment in the hospital environment can help children work through their feelings about what has happened to them. CLS in large hospital will coordinate. In emotional outlet play or traumatic play, the child acts out or dramatizes real-life stressors. Allow the child to express anger over separation from family and friends. Commercial toys such as anatomically correct dolls and puppets have removable parts so children can see various organs of the body. Sometimes younger children "talk" to puppets and dolls, allowing them to express their feelings to a nonthreatening "person" about a specific situation or what they want from the health care provider. Other types of therapeutic play include drawing and supervised "needle play." Supervised "needle play" assists children who must undergo frequent blood work, injections, or intravenous procedures. A doll can receive an injection as the child works out his or her anger and anxiety.

Age-appropriate communication techniques

If the child is shy, talk to the parents first to give the child time to "warm up" to you. Use specific and clear phrases in an unhurried, quiet, yet confident manner. Communicate at the child's eye level. Spending time and incorporating play with younger children, even just a few moments, may help them feel more at ease with you and help open the door to communication. Instead of direct questioning, use dolls, puppets, or stuffed animals with younger children. The use of metaphors (e.g., referring to white blood cells as "bad guy fighters") and stories can help to illustrate concepts to young and school-age children. Older children need privacy. Provide the child or adolescent with honest answers at a developmentally appropriate level. Allow children to express their thoughts and feelings. Offer the child choices when possible, but only when they truly exist. Encourage children to write and draw about their experiences. This may increase their understanding and also draw attention to any misconceptions or fears. Children feel empowered when health care professionals communicate directly with them. Include children in discussions and avoid talking about them in their presence. Children may also desire advice about their health care and reassurance about their health status. · Infants primarily communicate through touch, sight, and hearing. Communication with the infant can occur by cuddling, holding, rocking, and singing to the infant. · When working with toddlers and preschoolers, allow them time to complete their thoughts. Though language acquisition at this age is exponential, it often takes longer for the young child to find the right words, particularly in response to a question. · School-age children are very interested in learning and appreciate simple but honest and straightforward responses. When addressed first and allowed to respond, the school-age child may be eager to communicate. The school-age child is beginning to utilize more sophisticated language and developing problem-solving and critical thinking skills. · Adolescents tend to experience strong feelings and emotions and perceive situations in extreme terms. Building a trusting, respectful rapport is essential.

Informed consent: special situations

If the parent is not available, then the person in charge (relative, babysitter, or teacher) may give consent for emergency treatment if that person has a signed form from the parent or legal guardian allowing him or her to do so. During an emergency situation, a verbal consent via the telephone may be obtained. Two witnesses must be listening simultaneously and will sign the consent form, indicating that consent was received via telephone. Health care providers can provide emergency treatment to a child without consent if they have made reasonable attempts to contact the child's parent or legal guardian. In urgent or emergent situations, appropriate medical care never should be delayed or withheld due to an inability to obtain consent. Certain federal laws, such as EMTALA, require that every client who presents at an emergency department is given a medical examination regardless of informed consent or reimbursement ability

What happens at a well-child appointment?

Immunizations Growth & Development screens (height & weight, mchat) Feeding discussion Safety discussions Blood draws Hearing assessment Discussing any concerns or prevention

Newborn and infant pain

In preterm and term newborns, behavioral and physiologic indicators are used for determining pain. Behavioral indicators include facial expression, such as brow contracting and chin quivering; body movements; and crying. Physiologic signs include changes in heart rate, respiratory rate, blood pressure, oxygen saturation levels, breathing pattern, skin color, pupillary size, intracranial pressure, vagal tone, and palmar sweating. In the younger infant, facial expression is the most common response to pain (Fig. 36.2). The brows may be lowered and drawn together, with the eyes tightly closed. The mouth is open, often forming a square. The body may be stiff, and thrashing may be seen. When the area is stimulated, the infant may demonstrate a generalized reflex withdrawal. The infant may exhibit a high-pitched, shrill cry. The older infant often displays similar behavioral manifestations of pain. The older infant may display an angry facial expression, but the eyes are open. He or she often demonstrates a definite withdrawal response when the area is stimulated. The older infant cries loudly and tries to push away the stimulus that is causing the pain. Other manifestations include irritability, restless sleeping, and poor feeding.

Normal range for HR and RR - pediatric

Infant HR: 80-150. RR: 25-55 Toddler HR: 70-120, RR: 20-30 Preschooler HR: 65-110, RR: 20-25 School-age HR: 60-100, RR: 14-26 Adolescent HR: 55-95, RR: 12-20

Communicating: Infants

Infants • Respond to crying in a timely fashion. • Allow the infant time to warm up to you. • Use a soothing and calming tone when speaking to the infant. • Talk to the infant directly. • Communication through play may be helpful with older infants. • Watch for signs of overstimulation such as closing eyes, turning away, yawning, and irritability.

Amblyopia- what is it, what does the nurse do

Lazy eye. (brain to eye connection problem) Refers to poor visual development in the otherwise structurally normal eye. It develops within the first decade of life and, if left untreated, is the most common cause of vision loss in children and young adults, occurring in about 1% to 4% of children. The vision in one eye is reduced because the eye and the brain are not working together properly. While the eyes are fighting to focus differently because of their differences in visual acuity, one eye is stronger than the other. Screen all preschoolers for amblyopia, as this one of the most important functions of the nurse in relation to the child's eyes. Begin visual acuity testing using an age-appropriate tool by 3 years of age. Observe for asymmetry of the corneal light reflex in the child of any age. This may be the only sign in the preverbal child. Support and encourage children and parents to comply with the patching protocol or atropine drop use. Promoting eye safety is extremely important for the child with amblyopia; if the better eye suffers a serious injury, both eyes may become blind.

Clinical manifestations of croup Nursing interventions, patient teaching

Scary sounding cough Can usually be managed at home Give moist, humidified air Cough peaks at night when pediatrician offices are closed Take child outside into cold night air Put in bathroom and run shower Cool mist humidifiers are preferred to cut down on burns Dexamethasone will help with swelling if croup is significant Monitor respiratory status for increased work of breathing and level of oxygenation

Nursing role in mandated reporting

Management of medical child abuse is complex. When abusive activity is identified, notify the social services and risk management departments of the hospital. Ensure that the local child protection team and the caregiver's family or support system are present when the caregiver is confronted. Inform the caregiver of the plan of care for the child and of the availability of psychiatric assistance for the caregiver. In addition to physical or palliative care needed for the injuries, abused children need to redevelop a sense of trust in adults. Provide consistent care to the abused child by assigning a core group of nurses. Child abuse requires a multidisciplinary approach that may include psychological therapy for the child and family. Role model appropriate caretaking activities to the parent or caregiver. Call attention to normal growth and development activities noted in the infant or child, as sometimes parents have expectations of child behavior that may be unrealistic based on the child's age, leading to the abuse. Praise parents and caretakers for taking appropriate steps toward getting help and for providing appropriate care to the child. Refer parents to Parents Anonymous, an organization dedicated to the prevention of child abuse through strengthening of the family (see https://parentsanonymous.org). When it is determined by the child protective team that the child would be in danger to continue living in the current situation, the child may be removed from the home. If the child is removed from the family temporarily or permanently, provide the foster or adoptive family with education necessary to assume the child's care.

Informed consent: exceptions to parental consent

Mature minor The health care provider must determine that the adolescent (usually over 14 years of age) is sufficiently mature and intelligent to make the decision for treatment. The provider also considers the complexity of the treatment, its risks and benefits, and whether the treatment is necessary or elective before obtaining consent from a mature minor Emancipated minor Emancipation may be considered in any of the following situations, depending on the state's laws: · Membership in a branch of the armed services · Marriage · Court-determined emancipation · Financial independence and living apart from parents · Pregnancy · Mother less than 18 years of age Depending on the state law, health care may be provided to minors for certain conditions, in a confidential manner, without including the parents. These types of care may include pregnancy counseling, prenatal care, contraception, testing for and treatment of sexually transmitted infections and communicable diseases (including HIV), substance abuse, and mental illness counseling and treatment. These exceptions allow children to seek help in a confidential manner in situations where they might otherwise avoid care if they were required to inform their parents or legal guardian.

Medical Child Abuse (Munchausen Syndrome by Proxy)

Medical child abuse was historically termed Munchausen syndrome by proxy. It is a type of child abuse in which the parent creates physical and/or psychological symptoms of illness or impairment in the child. The adult meets his or her own psychological needs by having an ill child. Medical child abuse is difficult to detect and may remain hidden for years. In most cases, the biologic mother is the perpetrator (Roesler & Jenny, 2018). Therapeutic management focuses on ensuring the safety and well-being of the child, as well providing psychotherapy for the perpetrator. Take a thorough and detailed health history of the child's illness or illnesses. Use quotations to document the parent's responses. Warning signs of medical child abuse include: · Child with one or more illnesses that do not respond to treatment or that follow a puzzling course; a similar history in siblings. · Symptoms that do not make sense or that disappear when the perpetrator is removed or not present; the symptoms are witnessed only by the caregiver (e.g., cyanosis, apnea, seizure). · Physical and laboratory findings that do not fit with the reported history. · Repeated hospitalizations failing to produce a medical diagnosis, transfers to other hospitals, discharges against medical advice. · Parent who refuses to accept that the diagnosis is not medical. Observe the mother's behavior with the child, spouse or partner, and staff. Use of covert video surveillance may reveal maternal actions causing illness in the child when the nurse, physician, or nurse practitioner is not in the room. Perform a thorough physical examination, noting where the physical examination findings differ from the reported health history.

Nursing implications for child with SI

Nursing management of children and adolescents with mood disorders focuses on education and support, and prevention of depression and suicide. Assess for risk factors for suicide, which include: Previous suicide attempt Change in school performance, sleep, or appetite Loss of interest in formerly favorite school or other activities Feelings of hopelessness or depression Statements about thoughts of suicide

Family composition/function

One broad definition of family is "two or more persons who are joined together by bonds of sharing and emotional closeness...who identify themselves as being part of the family" (Friedman, Bowden, & Jones, 2003, p. 10). This definition characterizes the range of families in 21st-century America and covers a wide range of relationships, including those outside the genetic and legal definitions of family. Another definition is that families decide who they are, and family boundaries are not limited to traditional definitions (Wright & Leahey, 1999, 2009). Although this definition might seem simplistic, it draws attention to individual group needs to affirm identity as family and establish connection to others within that group

Child abuse: predisposing factors

Parent: Age, Single parent, unrelated partner, low self-esteem, poor parenting knowledge, poor role model Child: Newborn to 1 year, physically disabled, hyperactive, premature Environmental factors: Social isolation, poor support system, chronic stress, poverty, substitute caregivers

Types of neglect

Physical: Deprivation of food, clothing, shelter, supervision, medical care, and education Emotional: Lack of affection, attention, and emotional nurturance Educational: Failure to enroll in school or ensure school attendance or home schooling Medical: Refusal to seek or delay in seeking medical care resulting in damage or risk of damage to the child's health

ADHD symptoms

Presence of six or more of the following in the child 17 years of age and younger: • Failure to pay close attention • Careless mistakes on schoolwork • Difficulty paying attention to tasks or play • Doesn't listen • Doesn't follow through • Doesn't complete tasks • Doesn't understand instructions • Poorly organized • Avoids, dislikes, or fails to engage in activities requiring mental effort • Loses things needed for task completion • Easily distracted • Forgetful • Fidgety or squirmy • Often out of seat • Activity inappropriate to the situation • Cannot engage in quiet play • Always on the go • Talks excessively • Blurts out answers • Has difficulty waiting his or her turn • Often interrupts or intrudes on others

Correct assessment of BP: nursing interventions

The NHLBI recommends that the cuff bladder width be at least 40% of the circumference of the upper arm at its midpoint. The cuff bladder length should cover 80% to 100% of the circumference of the upper arm. Various pediatric and infant cuffs are available, as well as larger thigh cuffs that may be used on an arm in an obese adolescent. Measure blood pressure in the upper arm, lower arm, thigh, or calf/ankle. The size of the cuff should match the extremity used. The measurement should be taken in the same limb, at the same place, and in the same position with each subsequent measurement to ensure consistency in tracking the blood pressure. To measure blood pressure using the upper arm, place the limb at the level of the heart, place the cuff around the upper arm, and auscultate at the brachial artery. When obtaining blood pressure in the lower arm, again, position the limb at the level of the heart, place the cuff above the wrist, and auscultate the radial artery. For measurement in the thigh, place the cuff above the knee and auscultate the popliteal artery. To obtain blood pressure on the calf or ankle, place the cuff above the malleolus or at the midcalf and auscultate the posterior tibial or dorsal pedal artery. Figure 32.7 shows appropriate cuff placement and auscultation points for the various sites. The NHLBI recommends auscultation as the preferred method of obtaining blood pressure readings in children. Systolic pressure in children is read at the moment the first Korotkoff sound is heard as the manometer pressure is lowered. The point at which the sound disappears is the diastolic pressure. The systolic blood pressure sometimes can be heard to a measurement of zero, so document the reading as systolic pressure over "P" for pulse. In children older than 1 year, the systolic pressure in the thigh tends to be 10 to 40 mm Hg higher than in the arm; the diastolic pressure remains the same. Refer to Appendix B for the NHLBI blood pressure levels based on gender and height. Systolic blood pressure increases if the child is crying or anxious, so measure the blood pressure with the child quiet and relaxed. If the reading is lower in the leg than in the arm, always consider coarctation of the aorta or inter

Child neglect

The failure of a parent or other persons legally responsible for the child's welfare to provide for the child's basic needs (physical, emotional, educational, or medical) and an adequate level of care. Can encompass both actual and potential harm (i.e., failure to use a child safety seat, even if the child is not injured)

Non-pharmacological pain interventions teaching: nurse's role

The nurse plays a major role in teaching the child and family about nonpharmacologic pain interventions. Help the child and family choose the most appropriate and most effective methods and ensure that the child and parents use the methods before pain occurs as well as before the pain increases. Teaching Guidelines 36.1 lists some helpful instructions for the parents and child about nonpharmacologic pain management. It is also important to assist the child and parents when using the technique in order to make sure that they are using the technique correctly. Offer suggestions for modifications or adaptations as necessary. Try: Distraction, relaxation, guided imagery, positive self-talk, TENS unit, acupuncture as appropriate for developmental level. Biophysical interventions: sucking, swaddling, holding, rocking, positioning

Consent for minors: nurse's role If 16 yo has a baby, who consents to what?

The nurse's responsibility related to informed consent includes the following: · Determining whether the client or parents or legal guardians understand what they are signing by asking them pertinent questions. · Ensuring that the consent form is completed with signatures from the client (or parents or legal guardians if the client is a child). · Serving as a witness to the signature process. Box 1.5 describes the key elements of informed consent, although laws vary from state to state. Nurses must become familiar with state laws as well as the policies and procedures of the health care agency. Treating children without obtaining proper informed consent violates their rights, and the physician and/or facility may be held liable for any damages • The decision maker must be of legal age in that state, with full civil rights, and must be competent (have the ability to make the decision). • Present information that is simple, concise, and appropriate to the level of education and language of the individual responsible for making the decision. • The decision must be voluntary, and without coercion, force, or influence of duress. • Have a witness to the process of informed consent. • Have the witness sign the consent form.

Prioritization of assessment: comprehensive vs. focused

The purpose of the examination will determine how comprehensive the history must be. If the physician or nurse practitioner rarely sees the child or if the child is critically ill, a complete and detailed history is in order, no matter what the setting. The child who has received routine health care and presents with a mild illness may need only a problem-focused history. In critical situations, some of the history taking must be delayed until after the child's condition is stabilized. Evaluate the situation to determine the best timing and the extent of the history. Also, be sensitive to repetitive interviews in hospital situations, and collaborate with physicians or other members of the health care team to ensure that a family already under stress does not need to undergo prolonged or repetitive questioning. A child in an emergent situation should have a health history that is focused on the child's most immediate need. On the other hand, a comprehensive health history is appropriate for the child who is having his first visit at a pediatrician's office, for example.

Atraumatic care

Therapeutic care that minimizes or eliminates the psychological and physical distress experienced by children and their families in the health care system. Prevent or minimize physical stressors, including pain, discomfort, immobility, sleep deprivation, inability to eat or drink, and changes in elimination. • Avoid or reduce intrusive and painful procedures, such as injections, multiple punctures, and urethral catheterization. • Avoid or reduce other kinds of physical distress, such as noise, smells, shivering, nausea and vomiting, sleeplessness, restraints, and skin trauma. • Control pain via frequent assessments and use of pharmacologic and nonpharmacologic interventions. • Prevent or minimize parent-child separation. • Promote family-centered care, treating the family as the patient. • Use core primary nursing. • Consider research findings related to preferences of parents and children and whether or not to be together. • Promote a sense of control. • Elicit the family's knowledge about the child and his or her health condition, promoting partnerships, empowerment, and enabling. • Reduce fear of the unknown through education, familiar articles, and decreasing the threat of the environment. • Provide opportunities for control, such as participating in care, attempting to normalize daily schedule, and providing direct suggestions.

response to hospitalization by a child

This is a change from routine They are more vulnerable to effects than adults They hav a limited repertoire of coping mechanisms Children react to the stresses of hospitalization before admission, during hospitalization, and after discharge. Anxiety, fear elated to the overall process and the potential for bodily injury, physical harm, and pain. Separation from familiar setting and people may result in separation anxiety in hospital -General loss of control over their lives and sometimes their emotions and behaviors, resulting in feelings of anger and guilt, developmental regression, acting out, and other types of defense mechanisms to cope with these effects.

Hearing loss tips

To communicate more effectively with children with OME who have hearing loss: · Turn off music or television. · Position yourself within 3 ft of the child before speaking. · Face the child while speaking. · Use visual cues. · Increase the volume of your speech only slightly. · Speak clearly. · Request preferential classroom seating.

Family structure

Traditional Nuclear Consists of a married couple and their biologic children Nuclear Composed of two parents and their children. The parent-child relationship may be biologic, step, adoptive, or foster. The parents are not necessarily married. Blended (reconstituted) Consists of at least one stepparent, stepsibling, or half-sibling Extended Consists of at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling. Parent-child and sibling relationships may be biologic, step, adoptive, or foster Single-parent Composed of a child or children living with a single-parent as a result of divorce, death, desertion, or single parenthood Binuclear (co-parenting) Refers to parents continuing the parenting role while terminating the spousal relationship Polygamous Refers to the conjugal unit being extended by the addition of spouses in polygamous relationships Communal Communal groups share common ownership of property. This family structure has a strong reliance on group members and material interdependence. LGBT Consists of a legal or common-law tie between two persons of the same sex who have children

Assessment and intervention of pain management

Various interventions can be used for pain management. These interventions include nonpharmacologic and pharmacologic measures. A guiding principle when caring for the child experiencing pain is the provision of atraumatic care. For example, cognitive and behavioral approaches are appropriate for pain management, including pain management related to procedures. In addition to nonpharmacologic measures, pharmacologic measures are appropriate for pain management. For example, apply a topical anesthetic cream to a site early enough before a venipuncture that it becomes effective. Another idea is to use an intermittent infusion device to obtain multiple blood specimen samples rather than perform repeated venipunctures. In addition, it is a good idea to consider the use of sedation for more painful procedures. Discuss specific goals and interventions with the child and family as appropriate. Include the family in developing appropriate interventions so they can continue to support the child. Education of the child and family about interventions, including various therapies, is key. Ongoing assessment is needed to determine the effectiveness of the pain relief measures in achieving the desired goals.

Patient teaching for conjunctivitis

Wash hands Keep child's things separate from family's Don't use same towels Don't share makeup; sanitize or throw away if cannot be sanitized Child will need to be home from daycare for 24 hours May be prescribed eye drops Bacterial/viral are considered communicable but not allergic Keep child from rubbing eyes then touching siblings, toys, or friends Children with viral conjunctivitis may return to school or day care when symptoms lessen. When mucopurulent drainage is no longer present (usually after 24 to 48 hours of treatment with a topical antibiotic), the child with bacterial conjunctivitis may safely return to day care or school

Tonsillectomy discharge teaching

What things lead up to a tonsillectomy? Recurring streptococcal tonsillitis, massive tonsillar hypertrophy. Palatine tonsils removed surgically. Hemorrhage is a big concern after surgery (think Jahi McMath) What signs indicate that something is going on like bleeding? fresh blood in secretions, continuous swallowing while awake or sleeping, emesis of bright red blood, tachycardia, pallor, restlessness, frequent throat clearing. What to avoid when they go home to prevent bleeding? Though unusual postoperatively, monitor for hemorrhage as it may occur any time from the immediate postoperative period to as late as 10 days after surgery. Inspect the throat for bleeding. To avoid trauma to the surgical site, discourage the child from coughing, clearing the throat, blowing the nose, and using straws. Upon discharge, instruct the parents to immediately report any sign of bleeding to the physician or nurse practitioner. To maintain fluid volume postoperatively, encourage children to take any fluids they desire; popsicles and ice chips are particularly soothing. Citrus juice and brown or red fluids should be avoided: the acid in citrus juice may irritate the throat, and red or brown fluids may be confused with blood if vomiting occurs. Educate families that for the first 24 hours after surgery, the throat is very sore. Provide adequate pain relief (may be with or without narcotics) in order to establish adequate oral fluid intake. Apply an ice collar if prescribed. Counsel parents to maintain pain control upon discharge from the facility, not only for the child's sake, but also to enable the child to continue to drink fluids.

strabismus

crossed eyes (muscular problem that may lead to amblyopia as brain uses less and less input from affected eye) Testing Parents may be the first persons to notice that the child's eyes do not face in the same direction. Question parents about the onset of the problem and whether it is continuous or intermittent. If intermittent, does it occur more often when the child is tired? Elicit the health history, noting complaints of blurred vision, tired eyes, squinting or closing one eye in bright sunlight, tilting the head to focus on an object, or a history of bumping into objects (depth perception may be limited). Observe the child's eyes for obvious exotropia or esotropia. In the absence of an obvious finding, assessment of the symmetry of the corneal light reflex is extremely helpful (Fig. 39.8). The "cover test" is also a useful tool for the identification of strabismus. True strabismus should not be confused with pseudostrabismus. In pseudostrabismus, the eyes may appear slightly crossed (as in the child with a wide nasal bridge and epicanthal folds), but the corneal light reflex remains symmetric Nursing intervention: When patching is prescribed, encourage the family to comply with this modality. Encourage eyeglass wearing if prescribed. Provide appropriate postoperative care by protecting the operative site with eye patching.

Amy's talk on ASD at 18mo

https://www.youtube.com/watch?v=4dXn-xNRemA

Family-centered care

is a philosophy of care that recognizes the family as the constant in the child's life and holds that systems and personnel must support, respect, encourage, and enhance the strengths and competence of the family involves a partnership between the child, family, and health care providers in planning, providing, and evaluating care

Assessment techniques for the ears:

look at placement on head (symmetric and no lower than eyes), earwax (soft and orangish-brown), what tympanic membrane looks like (pearly pink or gray, translucent). Drainage is abnormal. Doc or NP will generally look with otoscope.

Local anesthetic application: EMLA When is it appropriate, how it's used, what are time constraints

· A common choice for effective, painless local anesthesia is EMLA (eutectic mixture of local anesthetics [lidocaine and prilocaine]). · reduces pain of phlebotomy, venous cannulation, and intramuscular injections for up to 24 hours after the injection. · requires a 60- to 90-minute application time to intact skin using an occlusive dressing for superficial procedures and up to 2 to 3 hours for deeper, more invasive procedures · use in infants 37 weeks' gestation or older. · Maximum dosage and maximum area of application are based on the child's weight. · Parents can be taught how to apply the EMLA at home in preparation for a procedure. Sometimes, EMLA is not used due to the expense and the time needed to allow the drug to act.

Positive outcomes of family-centered care

· Anxiety is decreased. · Children are calmer and pain management is enhanced. · Recovery times are shortened. · Families' confidence and problem-solving skills are improved. · Communication between the health care team and the family is also improved, leading to greater satisfaction for both health care providers and health care consumers (families). A decrease in health care costs is seen and health care resources are used more effectively

Child life specialist service

· Nonmedical preparation for tests, surgeries, and other medical procedures · Support during medical procedures · Therapeutic play · Activities to support normal growth and development · Educate child and family about health conditions · Teach and support coping and pain management strategies · Sibling support · Advocacy for the child and family · Grief and bereavement support · Emergency room interventions for children and families · Hospital preadmission tours and information programs Outpatient consultation with families

Communicating: adolescents

• Always respect the teenager's need for privacy. • Ensure confidentiality. • Remain nonjudgmental. • Listen attentively and speak respectfully. • Use appropriate medical terminology, defining words as necessary. • Use creativity and humor. • Do not force the adolescent to talk as this may shut down communication. • Prepare the teen up to 1 week prior to a procedure.

Factors Affecting a Child's Response to Illness and Hospitalization

• Amount of separation from parent/caregiver • Age • Developmental level • Cognitive level • Previous experience with illness and hospitalization • Recent life stresses and changes • Type and amount of preparation • Temperament • Innate and acquired coping skills • Seriousness of the diagnosis/onset of illness or injury (e.g., acute or chronic) • Support systems available, including the family and health care professionals • Cultural background • Parents' reaction to illness and hospitalization

EMLA use

• Explain the purpose of the medication to the child and parents, reinforcing that it will help the pain go away. • Check the scheduled time for the procedure; plan to apply the cream 60 minutes before a superficial procedure such as an intramuscular injection or a venipuncture or 2 to 3 hours before a deeper procedure such as an LP or bone marrow aspiration. • Place a thick layer of the cream on the skin at the intended site of the procedure, on unbroken skin • Cover with transparent dressing • After the allotted time, remove the occlusive dressing and wipe the cream from the skin. Inspect the skin for a change in color (blanching or redness), which indicates that the medication has penetrated the skin adequately. • Verify that sensation is absent by lightly tapping or scratching the area. Use this technique also to demonstrate to the child that the anesthetic is effective. If sensation is present, reapply the cream. • Prepare the child for the procedure. Assess the child's pain after the procedure to evaluate for pain and to differentiate pain from fear and anxiety.

Risk factors for hearing assessment

• Family history of hearing loss • Prenatal infection • Anomalies of the head, face, or ears (craniofacial anomalies) • Low birthweight (<1.5 kg) • Hyperbilirubinemia requiring exchange transfusion • Ototoxic medications • Low Apgar scores: 4 or less at 1 minute, or 6 or less at 5 minutes • Mechanical ventilation lasting 5 days • Syndrome associated with hearing loss • Head trauma • Bacterial meningitis • Neurodegenerative disorders • Persistent pulmonary hypertension • Otitis media with effusion for 3 months

atraumatic interventions: preventing or minimizing physical stressors

• For painful injections, blood draws, or IV insertion, use numbing techniques (see Chapter 36). • During painful or invasive procedures, avoid traditional restraint or "holding down" of the child. Use alternative positioning such as "therapeutic hugging." • If the above-mentioned positions are not an option, have the parent stand near the child's head to provide comfort. • Insert a saline lock if the child requires multiple doses of parenteral medications. • Advocate for minimal laboratory blood draws. • Minimize intramuscular or subcutaneous injections. • Provide appropriate pain management (refer to Chapter 36).

Atraumatic care: distraction methods and preparation

• Have the child point toes inward and wiggle them. • Ask the child to squeeze your hand. • Encourage the child to count aloud. • Sing a song and have the child sing along. • Point out the pictures on the ceiling. • Have the child blow bubbles. • Play music appealing to the child. · Provide a description of and the reason for the procedure using age-appropriate language ("the doctor will look at your blood to see why you are sick"). · Describe where the procedure will occur ("the x-ray department has big machines that won't hurt you; it's a little cold there too"). · Introduce strange equipment the child may see ("you will lie on a special bed that moves in the big machine, but you can still see out"). · Describe how long the procedure will last ("you will be in the x-ray department until lunchtime"). · Identify unusual sensations that may occur during the procedure ("you may smell something different" [e.g., alcohol smell]; "the MRI machine makes loud noises"). · Inform the child if any pain is involved. · Tell the child it is OK to cry or yell. · Identify any special care required after the procedure ("you will need to lie quietly for 15 minutes afterward"). · Discuss ways that may help the child stay calm, such as using distraction methods or relaxation techniques ("during the procedure you may want to count from one to 100 or sing your favorite song").

Down Syndrome health guidelines

• Have your child evaluated by a pediatric cardiologist, including an echocardiogram. • Take your child for routine vision and hearing tests. By 6 months have your child seen by a pediatric ophthalmologist. • Make sure your child gets regular medical care, including recommended immunizations and a thyroid test at 6 and 12 months and then yearly. • Have your child follow a regular diet and exercise routine. • Make sure all family members perform proper hand hygiene to prevent infection. • Monitor for signs and symptoms of respiratory infections, such as pneumonia and otitis media. • Discuss with your physician the use of pneumococcal, respiratory syncytial virus, and influenza vaccines. • Begin early interventions, therapy, and education as soon as possible. • Make sure your child brushes his or her teeth regularly. He or she should visit the dentist every 6 months. • Make sure the child gets a cervical radiograph between 3 and 5 years of age to screen for atlantoaxial instability. Report any changes in gait or use of arms and hands, weakness, changes in bowel or bladder function, complaints of neck pain or stiffness, head tilt, torticollis, or generalized changes in function. Ensure cervical spine positioning precautions (to avoid overextending or flexing of the neck) are utilized during procedures, such as those involving anesthetic, surgery or radiographs.

Varicella additional nursing implications

• Institute airborne precautions and contact precautions until lesions have dried and crusted. • Consider susceptible patients who are exposed to the virus to be at risk and potentially infectious for 21 days. • Observe an immunocompromised patient for manifestations of complications, such as pneumonitis and meningitis; immediately report any manifestations. • Administer varicella zoster immune globulin, as ordered, within 10 days of exposure; administer the VZV vaccine within 72 hours of exposure. • Give an antipyretic and antihistamine, as ordered. Ensure the use of safety measures to reduce the risk of injury related to the sedative effects of antihistamines. • Group care activities to provide the patient with uninterrupted periods of rest. Assist with energy-conservation measures, as appropriate. Encourage frequent rest periods. • Provide diversionary activities. • Allow the patient to verbalize feelings and concerns related to the condition and the need for infection control precautions. Provide clear explanations, and answer any questions. • Assist with positive coping strategies, promote active participation in care and decision making, and point out positive aspects of the patient to foster feelings of control and self-esteem. • Encourage increased fluid intake. Frequently offer fluids based on the patient's preferences. • Ensure that the patient's nails are short to reduce the risk of scarring and secondary infection from scratching. • Provide skin care comfort measures, such as cool compresses, calamine lotion, cornstarch, oatmeal or colloidal baths, and showers. • Prevent exposure to pregnant women. • Monitoring vital signs, especially temperature • Skin integrity, including the status of lesions and severity of pruritus • Hydration status, including fluid balance • Signs and symptoms of secondary infection • Response to treatment • Interaction with others • Pain level and effectiveness of interventions • Sensory function

Basics for communicating with children

• Introduce yourself and explain your role. • Position yourself at the child's level. • Allow the child to remain near the parent if needed, so the child can remain comfortable and relaxed. • Smile and make eye contact with the child if culturally appropriate. • Direct your questions and explanations to the child. • Listen attentively and pause to allow time for the child to formulate his or her thoughts. • Use the child's or family's terms for body parts and medical care when possible. • Speak in a calm, quiet, confident, and unhurried voice. • Use positive, rather than negative, statements and directions. • Encourage the child to express his or her feelings and ask questions. • Observe for nonverbal cues. • Ask for permission if you need to approach the child to avoid appearing threatening.

Scarlet fever: clinical manifestations and tx

• It usually occurs with a group A streptococci throat infection (i.e., strep throat) or rarely streptococcal skin infection. However, in the case of scarlet fever, the bacteria produce a toxin that causes a rash. Not all children with a group A streptococci infection will develop the rash of scarlet fever. • Symptoms of scarlet fever begin abruptly. The health history may reveal a fever greater than 101°F, chills, body aches, loss of appetite, nausea, and vomiting. Inspect the pharynx, which is usually very red and swollen. The tonsils may have yellow or white specks of pus, and cervical lymph nodes may be swollen. Inspect the skin for the most striking symptom of scarlet fever, which is an erythematous rash appearing on the face, trunk, and extremities. • The rash is typically absent from the palms and soles of the feet. It looks like a sunburn but feels like sandpaper (Fig. 37.1A). The rash lasts approximately 5 days and is followed by desquamation, typically on the fingers and toes. Early in the illness the tongue develops a thick coat with a strawberry appearance. The tongue will later lose the coating and become bright red (Fig. 37.1B). • Diagnosis is made by identification of group A streptococcus on throat culture. Several rapid tests for group A streptococcal pharyngitis are available. The accuracy of these tests depends on the quality of the specimen. It is important that the secretions obtained are pharyngeal or tonsillar (see Common Medical Treatments 37.1 for more information on throat cultures). • Children with scarlet fever are usually cared for at home. Penicillin and amoxicillin are the antibiotics of choice (Shulman, 2016). In those sensitive to penicillin, erythromycin may be used. Educate the family on the importance of taking the antibiotic as directed and finishing all the medicine. • Encourage fluid intake to maintain adequate hydration due to fever. Teach parents ways to provide comfort for the child. A cool mist humidifier can soothe the child's sore throat. Soft foods, warm liquids like soup, or cold foods like popsicles may also be helpful. If the child is hospitalized, droplet precautions, along with standard precautions, are necessary.

Dysfunctional family

• Lack of empathy to family members • Lack of respect to family members • Borrowing or taking personal possessions without asking • Conflict and hostility (verbal or physical) • Isolation (not forming friendships or relationships outside the family) • Secrecy • Denial (Ignoring or pretending a problem exists) • Rigid or extreme rules • Perfectionism • Unreasonable expectations • Emotional or verbal abuse • Blaming and scapegoating • Using children as weapons • Stifled speech or emotions (not allowing children to express themselves) • Conditional love

atraumatic care: Promoting a sense of control

• Maintain the child's home routine related to activities of daily living. • In the hospital, use primary nursing. • Encourage the child to have a security item present, if desired. • Involve the child and family in planning care from the moment of the first encounter. • Empower the family and child by providing knowledge. • Allow the child and family choices when they are available. • Make the environment more inviting and less intimidating.

Healthy family

• Openness with and fondness for one another • Togetherness and resiliency in chaos and stress • Honest differences result in new understandings • Family members collaborate to meet each other's needs • Trust and cooperation with each other • Optimistic; hopeful in challenging situations • Contribute to community around them

atraumatic care: Preventing or minimizing child and family separation

• Promote family-centered care. • In the hospital, provide comfortable accommodations for the parent. • Allow the family the choice about whether to stay for an invasive procedure, and support them in their decision.

Non-pharmacological pain interventions teaching

• Review the methods available and choose the method(s) that your child and you find best for your situation. • Learn to identify the ways in which your child shows pain or demonstrates he or she is anxious about the possibility of pain. For example, does he or she get restless, make a face, or get flushed in the face? • Begin using the technique chosen before your child experiences pain or when your child first indicates he or she is anxious about, or beginning to experience, pain. • Practice the technique with your child and encourage the child to use the technique when he or she feels anxious about pain or anticipates that a procedure or experience will be painful. • Perform the technique with your child. For example, take the deep breath in and out or blow bubbles with him or her; listen to the music or play the game with your child. • Avoid using terms such as "hurt" or "pain" that suggest or cause your child to expect pain. • Use descriptive terms like "pushing," "pulling," "pinching," or "heat." • Avoid overly descriptive or judgmental statements such as, "This will really hurt a lot" or "This will be terrible." • Stay with your child as much as possible; speak softly and gently stroke or cuddle your child. • Offer praise, positive reinforcement, hugs, and support for using the technique even when it was not effective.

Pinworms prevention teaching

• Standard precautions are sufficient. • Reinfection occurs easily. • Infected people should bathe, preferably in a shower, in the morning, which will remove a large portion of the eggs. • Frequent changing of underclothes and bedding • Personal hygiene measures such as keeping fingernails short, avoiding scratching of perianal area and nail biting • Good hand hygiene is the most effective preventive measure, especially after using the bathroom and before eating. All family members should be treated since transmission from person to person is very easy.

Down Syndrome Care Developmental considerations Parent education Anticipatory guidance

• Trisomy 21 (Down syndrome) is a genetic disorder caused by the presence of all or part of an extra 21st chromosome. • most common chromosomal abnormality associated with intellectual disability • Multidisciplinary management including primary care, cardiology, opthalmology, gastro, RN, PT, OT, ST, dietician, teachers, early intervention staff • There is no standard treatment for all children, and there is no prevention or cure. • Treatment is mainly symptomatic and supportive. • Promote the child's optimal growth and development and function within the limits of the disease. • Skill progression order is normal but delayed For example, children with Down syndrome will learn to walk, but the average child with Down syndrome walks at 24 months (versus 12 months for a child without Down syndrome). They have their own set of growth charts. • Conditions such as hypotonia, ligament laxity, decreased strength, enlarged tongue, and short arms and legs are common in children with Down syndrome, and early intervention can help in the development of gross and fine motor skills, language, and social and self-care skills.

Communicating: school age children (6-12)

• Use diagrams, illustrations, books, and videos. • Allow the child to honestly express feelings. • Use third-party stories to elicit desired information (such as "some children feel anxious about...."). • Allow the child to ask questions related to care and treatment. Give the child adequate time for all of the questions to be answered. • Prepare the child a few days in advance for a procedure.