N356- Exam #3 final

Shaken Baby Syndrome

-Serious form of child abuse caused by violent shaking of infants and young children which results in a TBI -Period of PURPLE Crying program approaches SBS and infant abuse prevention by helping parents and caregivers understand the frustrating features of crying in normal infants that can lead to shaking or abuse...more information can be found at: www.PURPLEcrying.info

Characteristics of Childhood Cancer

-Usually affects deep tissues -Related to peak growth periods (adolescence or toddlerhood) -Usually disseminated at Dx -No screening or early detection -Prevention unlikely -Very responsive to therapy -80% overall cure rate

Leukemia Diagnostic Workup: CBC

-WBC: May be inc, dec or normal -Platelets: Often dec -Hemoglobin: Often dec -Diff: Often neutropenia & blasts -10% with "normal" CBC -Cannot diagnose type of leukemia from CBC

DMD Clinical Manifestations

-Waddling gait, frequent falls, Gower sign -Lordosis -Enlarged muscles, especially thighs and upper arms -Profound muscular atrophy in later stages -Mental deficiency common

Hemophilia

-X linked recessive -Either clotting factor VIII deficiency (A) or factor IX deficiency (B) -Females are almost always asymptomatic carriers of disorder -Affected persons bleed for a much longer amount of time -Controlled through giving deficient clotting factor -Occurs in 1 in 5,000 male births (A)

Single Gene: X-Linked Dominant

-X-Linked Dominant- twice as common in females, an affected male transmits gene to all of his daughters and none of his sons. -Hypophosphatemia- Vitamin D resistant rickets- twice as common in females. But they have a milder disease (if heterozygous)

Single Gene: X-Linked Recessive

-X-Linked Recessive- expressed in all males and in homozygous females. -Hemophilia A- 1:10,000 male births. Factor VIII deficiency- Queen Victoria -Duchenne Muscular Dystrophy- Symptom onset 3-5 yrs, progresses, wheelchair by 7- 12 y/o

Benign Tumor Grading

-histologically are typical of cell of origin -minimal/no mitosis/necrosis -slow growing/low grade -do not invade areas outside the site of origin -may be considered malignant by location (metastatic tumors-->if we know we usually find these tumor types in the liver and now were seeing in the brain)

CA: Central Lines

-if getting chemo need CL -type depends on the amount of med/ chemo needed -pro's and con's to the various types

CA: PICCs

-love/hate relationship -placed at the bedside -one or two lumen -very small lumens -more temporary -awkward area -require a lot of care and can be easily pulled out so they require nursing home care

Childrens Concepts of Death: Adolescents

-mature understanding of death -still influenced by the remnants of magical thinking and subject to feelings of shame and guilt -likely to see deviations from their normal behavior as cause of illness

Who are the abusers?

-mostly parents 81.5% -3.9% other relatives

Nursing Education with Families in Children with CA:

-must know when to call, who to call -when to come in immediately (fever) -medication education (when, why, have parents demonstrate how they draw up meds and have them do teach back/ quizzes before going home) -social status (divorce, grandparents= barriers to learning) -fever is on oncological emergency (must be admitted immediately because this is life threatening= sepsis immune system cannot mount a response)

Types of Childhood Leukemia:

-myeloid (AML) -lymphoid (ALL) ALL= 75% more common and more treatable AML= 25% less common and more difficult to treat

Adjustments in Parenting:

-new birth present challenge of proving total care 24/7 for a new member of the family. -role changes and modifcation of former relationships: a move from husband/wife to father/mother Family must cope with: -inc financial resp. -loss of income -changes in sleeping habits -less time for parents to spend with each other -less time for parents to spend with other children

Top three priorities in a post op spinal fusion pt with an elevated HR:

-pain -fluid volume -hyperthermia

Death and Dying: Which decisions should be made by the family prior to the final dying process of a child?

-pallative care options -dnr status -funeral -cremation -whether to tell the child -what type of care to give -hospice -where the child will die: home vs institution -sibling involvement

What affects quality of life?

-physical -psychological -social -spiritual

Child Maltreatment:

-physical, emotional, or sexual abuse and/or neglect -intentional

Buckman's Six Steps for Breaking Bad News: Getting Started

-private physical setting -physician and pt comfortably seated -let the patient decide -Start with a question like "how are you feeling right now?" to indicate this conversation is a two way street.

Role of the Nurse: Communication

-pt and family (conferences) -education: honest/ current -preparation: procedures/ informed consent -support to team

CA: Aseptic Care of CL

-routine care needed to prevent infection -aseptic technique even needed at home -education with patient about not twisting lines

Long-term Outcomes of Abusive Head Truama:

-seizure disorders -visual impairment -developmental delays -hearing loss -cerebral palsy -mild to profound mental, cognitive, or motor impairments

Death and Dying: What are the common reactions of family members of a dying child?

-shock/disbelief -expression of grief -disorganization and despair -reorganization

Turner Syndrome: S/S

-short stature -low hairline -shield shaped thorax -widely spaced nipples -shortened metecarpal IV -small fingernails -brown spots -characteristic facial features -fold of skin -constriction of aorta -poor breast development -elbow deformity -rudimentary ovaries/ gonadal streak (underdeveloped) -no menstruation

CA: Broviac or Hickman

-single/double lumen -good for incompatible meds -AML therapy ideal -needed for BMT -higher risk for infection -lots of teaching required

Mid S/S of Inc ICP

-sleepy -arousable -ataxic -sluggish pupils -dec awareness

Definition of Pediatric Cancer

"A group of chronic diseases characterized by uncontrolled growth and spread of abnormal cells which, if not adequately treated, results in the death of the patient."

Factors Predisposing to Physical Abuse: Characteristics of the Child

-Children from birth to one year of age are at highest risk for being abused -Premature infants may be at risk for maltreatment due to failure of parent-child bonding during early infancy, increase physical need or irritability -The physical and emotional demands placed on parents or caregiver or a child who is: -Unwanted -Brain-damaged -Hyperactive -Physically disabled

Screening for Type 2 Diabetes

-Children older than 10 yrs or at onset of puberty if occurs earlier -BMI > 85th percentile for age and sex -Weight >120% of ideal for height -Screened every 2 years Two of the following: -Family history of Type 2 in 1st or 2nd degree relative -Ethnic Background -Signs of insulin resistance -Presence of condition associated with insulin resistance

Factors Predisposing to Physical Abuse: Environmental Characteristics

-Chronic stress -Divorce -Poverty -Unemployment -Poor housing -Crowded living conditions -Frequent relocation -Alcoholism and drug addiction

Cerebral Palsy

-Chronic, non-progressive neuromuscular disorder causing abnormal motor function -Etiology: Abnormal CNS development or injuries in prenatal and perinatal period -2.4-3.6:1000 live births -Prematurity, ELBW, VLBW -Perinatal hypoxia, anoxia -Perinatal infection

Trisomy 13 (Patau Syndrome)

-Cleft lip or palate -Decreased muscle tone -Extra fingers or toes (polydactyly) -Hernias: umbilical hernia, inguinal hernia -Small, poorly developed eyes -Low-set ears -Severe Mental Retardation -Brain or spinal cord abnormalities

What are some of the reasons for improved childhood CA survival?

-Clinical trials -Multimodality therapy -Intense supportive care -Multidisciplinary approach -Integrative Medicine

Scoliosis Nursing Considerations

-Concerns of body image -Concerns of prolonged treatment of condition -Preoperative care -Postoperative care -Support of adolescent development -Family issues

Children's Concepts of Death: School Age 7-10+ yo

-Concrete operational thought (beginning of logical thought but tend to be literal) May feel guilt about illness. Death is permanent. May view death as violent-‐ want details about what will happen.

Etiology of Immobilization in Children:

-Congential defects -Neuromuscular conditions -Infections or injuries

Torticollis

-Contracture of sternocleidomastoid muscle -Congenital or acquired -Head is tilted toward involved side, chin is rotated to opposite side -20% associated with DDH -Treatment: Stretching exercises, positioning, brace -Surgery options: release or resection

Chromosome Disorders: Deletions

-Cri du Chat Syndrome- short arm of #5 deleted. characteristic cry, MR, microcephaly, LBW -Turner Syndrome- 45 XO -DiGeorge Syndrome- #22 deletion

CA: Pallative Care

-DIPG -focuses of comfort rather than care -bring in coordinator well before end of life to establish relationship -respect battle already fought (battle fought plus comfortable death is honorable) -child life involvement -sibling awareness

Developmental Dysplasia of Hip

-Definition: abnormal development of the hip that may develop at any time during fetal life, infancy, or childhood Etiology: -Physiologic= maternal hormone, positioning -Mechanical=breech, multiples, LGA -Genetic=positive family hx -Incidence: 1-1.5 per 1,000 live births, 80% occurring in females

Primary CNS Tumors

-Develop when normal or abnormal cells within the brain and/or spinal cord multiply when not needed *Primary* -arise from normal cells within the brain -tumor name includes cell of origin +/- location -may be "benign" or malignant

CP Geographic Findings

-Diplegia -Hemiparesis -Quadriparesis -Monoplegia -Triplegia -Paraplegia

Hodgkins Disease Characteristics

-Rare before age five -Peaks in young adulthood -In US, more common in homes with higher SES and fewer siblings -Etiology unknown -Possible association with EBV -Occasionally occurs in siblings and multiple family members -Males > females

Type 2 (Insulin Resistance) Diabetes in Children

-Recent sharp increase -Overweight at diagnosis (hallmark) -Undergoing pubertal changes -74-100% have a 1st or 2nd degree relative with diabetes -Higher prevalence in non-white populations

Role of Nurse with New Parents: Educate

-Regular visits to child's health care provider -Vaccinations -Safety (in and out of home) -Normal growth and development **especially important in first time parents**

Midbrain

-Relay station for visual/auditory pathways -Maintains constant internal environment

Childhood ALL: Remission

-Remission=Absence of clinical signs of disease -<5% blasts in marrow with normal cellularity (M1 marrow) -Near normal peripheral blood counts -ANC >500 -Plts >100K *Absence of clinical signs doesn't necessarily mean we will need to stop tx, should continue treatments to completely irradicate CA* -chemo is non selective and will destroy healthy cells as well

Childhood ALL: Maintaining Normalcy

-School -Play -Growth, development -Discipline

Etiology of Childhood Cancer

Cause is unknown! maybe r/t: -peak growth -EM Fields -chemicals -viruses

Sexual Abuse

Includes: -Incest: any physical sexual activity between family members: -Molestation: indecent liberties such as fondling, kissing, inappropriate touching of genitals -Exhibitionism: indecent exposure -Child pornography: arranging and photographing sexual acts involving children -Child prostitution: involving children in sex acts for profit -Pedophilia: the preference of an adult for pre-pubertal children as a means of achieving sexual excitement

Mitosis vs Meiosis

cell division vs germ cell division where we get 23 from each parent

Hindbrain

-Cerebellum -Pons -Medulla oblongata -Brain stem= comprised of midbrain, medulla, & pons. Control of involuntary functions

Common Types of Childhood Brain Tumors

-Cerebral tumor- 8% -Optic nerve glioma- 6% -Supratentorial Ependymomas- 6% -Infrantentorial Ependymomas- 13% -Brainstem glioma- 10% -Medulloblastoma- 18%

Hodgkins Tx

-Chemo -Irradiation

Treatment Modalities of Childhood CA

-Chemotherapy -Radiotherapy -Surgery -Hematopoietic stem cell transplant -Biotherapy

Goals of Parenting

-Promote physical survival and health -Nurture skills and abilities to become a successful adult -Foster capabilities for maximizing cultural values and beliefs

Childhood ALL: Emotional Care

-Providing information -Caring for child/family -Preserving child's uniqueness and normalcy -Conquering fears

Childhood Brain Tumors: PNET/Medulloblastoma

-20% of tumors -Peak incidence 4-7 years -Males > Females -Highly malignant -Deep in the brain and difficult to treat -high rate of mets -receive such high doses of chemo that you have to bank their white blood cell prior to tx and give back later Treatment: -Surgery -Radiation -Chemotherapy Prognosis: -Average risk about 80% -High risk 50%

Klinefelter's Syndrome

-47 XXY -1 in 500-1000 males -not inherited

What is your first priority as the emergency room nurse for the child with a musculoskeletal injury?

-5 P's -Pain assessment and control

Site of Pediatric Death

-75-85% in institutional setting -most in PICU

Genetic Counseling: Prevention

1. Public Education 2. Identification of Families a. First affected child b. Family pedigree c. Carrier screening d. Birth control, if desired

ALL: Consolidation/Intensification

-Intensified treatment (to solidify remission) -Agents with varying mechanisms of action L-Asparaginase, MTX, vincristine, steroids, Cytarabine, 6-MP, Doxorubicin -"Delayed Intensification"=short, intensive spikes -Goal = eradicate remaining leukemia

ALL: CNS Prophylaxis

-Intrathecal chemo= all treatment phases -MTX or triple -Cranial radiation= high risk patients only (have a ton of CA in CNS) -CA likes to hide in CNS, testicles, and eyes so we will give chemo intrathecally

California la defines child abuse as any of the following:

-A child who is physically injured by other than accidental means -A child who is subjected to willful cruelty or unjustifiable punishment -A child is abused or exploited sexually -A child is neglected by a parent or caretaker who fails to provide adequate food, clothing, shelter, medical care or supervision

Leading Causes of Death in Infants:

-LBW -SIDS -maternal complications -accidents -cord/placenta complications -RDS -sepsis -circulatory diseases

Mandated Reporter: Failure to Report

-A misdemeanor with 6 to 12 months incarceration -A fine of 1,000 to 5,000 dollars -Both incarceration and a fine -May be liable for damages if further harm occurs -May loose nursing license or risk disciplinary actions from the California State Board of Nursing

Osteomyelitis: Assessment

-Abrupt onset of pain in extremity -Fever, tachycardia, dehydration, irritability -Guarding - +/- Local inflammation

Reasonable Suspicion and Reporting

-According to the California Department of Social Services Office of Child Abuse Prevention: "It is reasonable for the person to entertain such a suspicion based upon the facts, that could cause a reasonable person in a like position, drawing, when appropriate, on his or her training and experience, to suspect child abuse" -Any reasonable suspicion is sufficient! -Always believe the child if they disclose abuse

Duchenne Muscular Dystrophy (DMD)

-Also called pseudohypertrophic muscular dystrophy -Most severe and most common of the MDs in childhood -X-linked inheritance pattern; one third are fresh mutations -Incidence—1 in 3500 male births

Role of the Nurse:

-Anticipate: Pain and Symptom Management -Prevent: Suffering-plan ahead -Promote: opportunity between parents/child/siblings -Advocate: child and family's goals/preferences -Presence: compassionate caring -Realistic perspective: hope -COMMUNICATION

Muscular Dystrophies

-Largest group of muscular diseases in children -All have genetic origin with gradual degeneration of muscle fibers, progressive weakness, and wasting of skeletal muscles -All have increasing disability and deformity with loss of strength

Definition of Emotional Abuse:

-Any situation where any person willfully causes any child to suffer or inflicts on any child unjustifiable mental suffering -A child that is physically or sexually abused or neglected is also emotionally abused -Emotional abuse refers to failure to meet the child's needs for affection, attention, and emotional nurturance

What are the most common forms of childhood CA?

-Leukemia -CNS tumors -Lymphoma

Parenting Skills and Discipline Strategies:

-Listen, be honest, give positive attention -Set limits (be consistent) -Disapprove behavior, not the child Discipline: -Reasoning (older children= mid- to older preschool) -Behavior Modification -Consequences -Time out -Corporal Punishment

Lymphatic System

-Lymphocytes -Lymphatic vessels -Lymph nodes -Lymphatic tissues/organs

CSF

-Produced by choroid plexus in ventricles (small fluid filled cavities in center of brain) -Protects brain/SC from jolts/blows -~600 mls produced/day 125-150 mls circulating at a time -Obstruction within pathway leads to inc ICP/hydrocephalus -may require shunting

Palliative and EOL: Pediatric Stats

-Population of children under 18 is approximately 82 million -Children with complex chronic conditions are approximately 644,000-1.5 million -Almost 900,000 perinatal "birth tragedies" per year (800,000 miscarriages and 33,000 stillbirths) -53,000 children die each year in the United States

Cultural Considerations:

-Positive cultural orientation -Socialization within a culture -Coping styles -Male and female family roles -Differences in appropriate displays of affectionate to children -Importance of family

Do parents have the right to physically discipline their children?

-As previously mentioned, parents do have the right to discipline their children physically (otherwise known as corporal punishment on a child)...so long as the discipline is reasonable and causes no bodily injury -As a result, "spanking" (with your hand or an object) when used as a means of disciplining a child is not considered child abuse under California law unless it becomes unreasonable or excessive

Causes of Misbehavior in Children:

-Attention -Power -Defiance -Display of inadequacy -Rules are not clear -Rules are not consistently enforced -Uncontrolled frustration, anger, depression, pain (temper tantrum)

Sickle Cell Anemia

-Autosomal Recessive -Red blood cells assume abnormal rigid sickle shape -Occurs more commonly in people from Africa, India, -Mediterranean, Saudi Arabia, Caribbean, South & Central America -Person's with one allele of sickle cell disease protective of malaria -In US 1 in 5,000

Tay Sachs

-Autosomal recessive -1 in every 27 Jews, French-Canadian, Cajun community of LA is carrier -Deterioration of mental and physical abilities -Symptoms appear by 6 months and death by 5 years

Phenylketonuria

-Autosomal recessive genetic disorder -Deficiency in hepatic enzyme phenylalanine hydroxylase -If untreated, leads to mental retardation, seizures and brain damage -Low phenylalanine diet (low protein)

Things to Consider about Suspected Abuse:

-Be aware of cultural practices, such as cupping or coin rubbing -Understand that some situations such as with a bleeding disorder, osteogenesis imperfecta or sudden infant death syndrome may be misinterpreted as abuse -Unintentional injuries may also be wrongly diagnosed as abuse -Normal variations, such as mongolian spots or congenital anomalies, may be mistaken for abuse

Childhood ALL: Maintaining Hope

-Belief in future= realistic hope -Living fullest life possible -Coping with survival

What is the difference between a child's bone and an adults?

-Bones are still cartilagenous -Epiphyseal plates are still open -Ligaments are stronger than bone -Sprains less common

CA: Long Term Survivorship

-CA pt mindset -discipline not always present -only child at the hospital (siblings at home) -physical long tx deficits -meds for every s/s long after tx -integrating back into regular school system -**treat pts like survivors from day one** -teach teenagers that their livers have been through hell and cannot possibly take any more abuse or damage-->cannot drink and party

Other Genetic Inheritance Patterns for Autosomal Recessive Disorders

-CF -PKU -Sickle Cell

Goals of Parenting

*ensuring child can be a capable and self sufficient adult* -promote survival/health -nurture skills -foster capabilities to maximize cultural values and beliefs

What is Leukemia?

-"leuk" = white, "emia" = blood -Malignancy of blood-forming tissue Malignant blasts: --fail to mature --crowd normal cells

Acute Myelogenous Leukemia

-1 in 4 cases of childhood leukemia -Usually shorter, more intense treatment than for ALL - ~45% cure rate -6-8mths of therapy -tx may take over a year d/t complications

Incidence of Childhood CA in the US

-15,100 cases of childhood cancer diagnosed annually (ages 0-20) -1 in 285 children will have cancer prior to reaching adulthood (www.cancer.org) -1,300 cancer-related deaths per year

Discipline and Limit Setting

-Discipline should be based on love and should be carried out with conviction and confidence -Consistency in discipline is considered the most important aspect of a healthy parent-child relationship -Limit setting is establishing rules or guidelines for behavior -The clearer the limits that are set and the more consistently they are enforced, the less need there is for disciplinary action -Limit setting and discipline are positive, necessary components of childrearing

Chromosome Disorders: Numerical or Structural Duplication

-Duplication- can be whole gene or a part of one -Trisomy 21 -Down Syndrome- variable expressivity, MR, 2 have congenital heart defects, 15 time increased risk of leukemia, hypotonia, low set ears, large tongue, simian fold -Trisomy 13 and 18- usually fatal at or soon after birth -Klinefelter Syndrome- XXY- not identified until puberty- small testes, gynecomastia, sterile, tall, long limbs -XYY- 3% of men in prisons, aggressive -XXX- may go undetected

Type 2 Diabetes Treatment

-Education at diagnosis -Goal to maintain blood sugar levels close to normal -Prevent complications -Healthy eating and exercise -Metformin only oral drug FDA approved in children

For the pt receiving a cast what will your pt and family teaching consist of?

-Elevate limb -Keep dry -Don't stick anything in the cast, including powders, lotions, and sticks -Loose fitting clothes -Okay to decorate -When to call or visit the doctor

The Brain and CNS Tumors

-Enables individuals to: reason, function intellectually, express personality/mood, & interact with environment -Full size by 3 years/development by 7-8 years -Receives 15-20% of cardiac output -Three major divisions: forebrain, midbrain, hindbrain (posterior fossa)

Promoting Positive Parenting Skills:

-Encourage involvement: Foster attachment from birth -Provide resources- guidebooks, someone with experience, professional help -Demonstrate interest and expertise in child development and behavior -Teach growth and development -Be flexible, and give praise when indicated -Foster confidence -Be a role model in behavior and communication -Maintain cultural competence

Father Involvement

-Father interaction is often different than mother interaction -Fathers tend to be more boisterous and engage in more physically stimulating activities -Mothers are more likely to hold, soothe, care for or play quietly with their infants -A secure attachment to the father can offset the consequences of an insecure attachment of the mother

Clinical Presentation of Leukemia: S/S

-Fatigue, pallor, anorexia -Bruising, bleeding -Fever, infection -Bone/joint pain -Abdominal pain -Headache, vomiting, visual disturbances -Tachycardia -Lymphadenopathy -Hepatosplenomegaly -Pallor -Petechiae/purpura -Evidence of infection -Testicular involvement

ALL: Induction

-First phase of treatment (4-5 weeks) -Goal = remission -99% cell kill Agents: -Corticosteroids, VCR, L-Asparaginase, + anthracycline -97% achieve remission by end of month

Accidental Sites of Injury on Children:

-Forehead -brachial arm region -knees -shins -nothing really on the back

Genetic Counseling: Treatment and Referral

-Genetic Counselor- makes accurate diagnosis, determines risk or probability of it happening again, discusses options with family. What are some factors affecting the family's decision? -Refer to appropriate health care team -Community Resources

Pathophysiology of Leukemia

-Genetic damage to single bone marrow cell -Uncontrolled growth of blasts -Decreased production of normal cells -Accumulation of blasts in body organs/tissues

ALL: Maintenance

-Goal = to "maintain" remission -Usually antimetabolite based * Daily 6-MP * Weekly MTX -Intermittent vincristine + steroid -2-1/2 to 3 years total tx

DDH Treatment:

-Goal: Reduce the hip, ensure stability, resolve displastic features of hip and femur -0-6 months: Pavlik Harness-holds hip in flexion and abduction until stable -6-18 months: Not manually reducible *Traction x3 weeks *Closed surgical reduction *f/b hip spica in abducted flex 2-4 months *f/b flexion-abduction brace ->18 months *Open reduction, acetabuloplasty, derotation osteotomy, soft tissue release *No weight bearing *Difficult after age 4, not advised after 6y/o

Osteogenesis Imperfecta

-Group of inherited disorders, autosomal dominant or recessive -Abnormal collagen types causing brittle bones, easily fractured, progressive bone deformities -Assessment: *Soft, fragile bones, multiple fractures, slender bone shafts, reduced cortical thickness *Thin skin, blue sclera, bluish gray teeth, bruising

DMD Nursing Considerations

-Help child and family cope with chronic, progressive, debilitating disease -Help design a program to foster independence and activity as long as possible -Teach child self-help skills -Arrange for appropriate health care assistance as child's needs intensify (home health, skilled nursing facility, respite care for family, etc.)

CP Diagnosis

-History -Neurologic and MS exam of newborn -Refer "floppy" baby, not reaching milestones -Developmental screening -MRI -Metabolic disease screening -Genetic testing

Signs of Sexual Abuse

-Hostility of aggression -Withdrawn -Self-mutilation -Alcoholism/drug abuse -Running away -Promiscuity -Sexually explicit behavior -Trouble walking or sitting -Displays knowledge or interest in sexual acts inappropriate to his or her age -Doesn't want to change clothes in front of others or participate in physical activity -An STD or pregnancy, especially under the age of 14

OSteomyelitis: Treatment

-IV antibiotics until CRP normal, then PO -Bedrest, immobilization -Surgical incision and drainage -Long term: May need home IV antibiotics

The Immobilized Child

-Immobilization was once thought to be restorative from illness and injury -We know now that immobilization has serious consequences: Physical, Social, Psychologic, Emotional

Role of Nurse with New Parents: Be an active listener

-Improve overall family communication -Encourage parents to spend quality time with the child

Disease Related Disorders: Osteomyelitis

-Infection of the bone -May lead to bone destruction, abscess, dead bone -Typically bacteremic in origin

Munchausen Syndrome by Proxy

-MSBP is also known as medical child abuse or factitious disorder by proxy -This is a rare but serious form of child abuse in which caregivers deliberately exaggerate or fabricate histories and symptoms or induce symptoms -Can come in form of physical, emotional or psychological abuse for the gratification of the caregiver -Most cases perpetrator is the biologic mother with some degree of health care knowledge and training -Because of the history of symptoms provided by the caregiver, the child endures painful and unnecessary medical testing and procedures -Common symptoms presented are seizures, nausea and vomiting, diarrhea, and altered mental status that are usually witnessed only by the perpetrator

Acute Lymphoblastic Leukemia (ALL)

-Most common childhood malignancy -Peaks in preschool years -Intensity of therapy varies -Overall cure rate >80% -cure rate can widely vary based on region, pt initial presentation, etc. -universally fatal only 50 years ago

CNS Tumors

-Most common solid tumor of childhood -Peak in early school years (ages 5-10 years) -Multimodality therapy -Overall cure rate 72% -Significant late effects

Osteomyelitis: Etiology

-Most often metaphysis of long bones -Staph Aureus in children -Group B strep in neonates -Bacteria that is circulating in the blood get lodged in the capillary bed and starts the bone infection

Three Types of Consequences:

-Natural: those that occur without any intervention -Logical: those that are directly related to the rule -Unrelated: those that are imposed deliberately (time out)

Factors Influencing Parental Behavior:

-No amount of preparation can fully prepare prospective parents for an infant's constant and immediate needs -Parent's parenting style -Understanding growth and development -Parental age (18-35) -Support systems -Family dynamic -Conformity with societal expectations (public vs private) -Cultural expectations -Individual differences -Marital relationship -Economic influences

Therapeutic Management of DMD

-No effective treatment has been established -Primary goal—maintain function in unaffected muscles as long as possible -Keep child as active as possible -ROM, bracing, performance of ADLs, surgical release of contractures prn -Genetic counseling for family

Nursing Interventions for ICP

-Observe/evaluate fine & gross motor movements -Evaluate LOC/Check pupillary response -Listen to family members assessment -elevate head of bed -Quiet environment (dim lights) -Limited/gentle movements -Assess pain needs

Trisomy 18 (Edwards Syndrome)

-Occurs 1 in 6,000 births -Mental retardation, seizures -Microcephaly -Small wide set eyes -Small lower jaw -Severe growth retardation -Clenched hands with 2nd and 5th fingers on top of the other, other defects of hands and feet -Malformations of the digestive and urinary tract -Genital malformations -Pulmonary hypoplasia, apnea -Cardiac defects (VSD, ASD, Coarc) -Only 10% or more survive there first year -80% occur in females

What is included in the multidisciplinary supportive care for pediatric cancer pts?

-Oncology -Radiation -Surgery -Nursing -Rehab -Pharmacy -Diagnostics -Social Work -Psychology -Dietary -Chaplains -Educators -Child Life -Volunteers

Characteristics of DMD

-Onset between ages 3 and 5 years -Progressive muscle weakness, wasting, and contractures -Calf muscles hypertrophy in most patients -Progressive generalized weakness in adolescence -Death from respiratory or cardiac failure

General Postop Orthopedic Care Priorities:

-Pain related to surgery -Risk, Ineffective Airway Clearance / Impaired Gas Exchange related to pain, anesthesia -Risk, Body Image Disturbance related to surgery, impaired functioning -Risk, Hyperthermia -Risk for Infection -Risk, Constipation -Disuse Syndrome related to immobility / cast -Risk, Developmental Delay related to hospitalization, missing school, immobility -Interrupted family processes -Risk, Fluid Volume deficit related to NPO status, gastric suction, blood loss -Risk for Injury related to altered mobility, cast, crutches etc -Risk for peripheral neurovascular dysfunction related to surgery / cast -Risk for Nausea related to anesthesia / medications -Impaired Skin Integrity related to wound -Sleep Pattern Disturbance -Risk, Ineffective peripheral Tissue Perfusion

Initial School Nurse Assessment of a Musculoskeletal Injury:

-Pain, using pain scale -Closed vs. compound -Edema -Bruising -Point tenderness -Mobility -Position/Deformity -Guarding -5 P's

Hodgkins Disease Presentation

-Painless lymphadenopathy (60-90% in lower cervical chain) -Nodes often firm, rubbery -Extension to contiguous areas -Mediastinal mass -Hepatosplenomegaly

Types of Discipline: Reasoning

-Parents explain why an act is wrong -This is usually appropriate for older children, especially when moral issues are involved -Think developmentally; children in the preoperative stage of cognitive development (toddlers and preschoolers) are egocentric

Bone Tumors

-Peak onset in teen years (15 yrs) -Types -Osteogenic sarcoma -Ewing's sarcoma -Multimodality therapy -Limb salvage -70% cure

Self Awareness and Self Care

-Personal death awareness -Find own meaning and purpose -Self care activities: exercise, journaling, hobbies, relaxation, PLAY, ask for help!!

Mandated Reporter

-Persons mandated by law to report known or suspected child abuse -Nurses ARE mandated reporters -Your identity in the report is confidential -You have immunity from civil and criminal liability (PC 11172-A) if you report in good faith -DO NOT WAIT TO REPORT. OUR DUTY IS TO REPORT, NOT TO INVESTIGATE -Do not rely on someone else to report; reporting is your duty! -A mandated reporter must make a report whenever, in his/her professional capacity or within the scope of his/her employment, he/she has knowledge of, or observes a child (a person under 18) whom the mandated reporter knows or reasonably suspects has been the victim of child abuse or neglect -Always err on the side of caution! -No supervisor or administrator may impede or inhibit the reporting duties of a mandated reporter

CA: Ports

-Placed in OR -completely internalized when not accessed= more normalcy, less risk for infection, less teaching -long needle need to access the port= frightening -patient has to sit still -possibility of accidental de-access (maybe don't place a port in ADHD kids) -long term not really always a good thing

How to Handle Misbehavior in Children:

-Set realistic goals for acceptable behavior and expected achievements -Praise children for desirable behavior with attention and verbal approval -Set clear, realistic rules and BE CONSISTENT -Structure the environment to prevent unnecessary difficulties (fragile objects up) -Teach desirable behavior through own example -Call attention to undesirable behavior as soon as it starts -Offer alternatives to annoying actions -Know your child...know the triggers for misbehavior (fatigue, overexcitement)

Trisomy 13: S/S

-Severe Scalp defects (absent skin) -Seizures, apneic spells -Single palmar crease -Skeletal (limb) abnormalities -Small eyes -Small head (microcephaly) -Small lower jaw (micrognathia) -Septal defects -Urogenital Defects

Down Syndrome: S/S

-Severe mental retardation to low average intelligence -40-50% have septal defects -Other defects include renal agenesis, duodenal atresia, Hirchsprung disease, TE fistula, patella dislocation, hip subluxation, and instability of 1st and 2nd vertebrae -Ocular problems -Altered immune system -Growth reduced -Sexual development altered

CP Motor Findings

-Spasticity -Ataxia -Hypotonia -Delayed gross motor -Neuromotor -Primitive reflexes -Mixed-most common

Diagnostic Evaluation of Scoliosis

-Standing radiographs to determine degree of curvature -Asymmetry of shoulder height, scapular or flank shape, or hip height -Often have a primary curve and a compensatory curve to align head with gluteal cleft

Osteogenisis Imperfecta Treatment

-Supportive: preventing contractures, deformities, muscle weakness, malalignment of extremities -Braces, splints, PT, exercises -Surgical: Correct deformity -Nursing considerations: gentle handling, support limbs, no traction. *Assess body image and coping *Parental support groups (OI Foundation)

Diagnostic Evaluation of DMD

-Suspected based on clinical appearance -Confirmation by EMG, muscle biopsy, and serum enzyme measurement -Serum CPK and AST levels high in first -2 years of life, before onset of weakness; levels diminish as muscle deterioration continues

Nursing Care of the Maltreated Child

-Take a careful, detailed history and interview -Conduct a thorough physical examination -If a child discloses just ask: who, when, what and how...then call CPS! -Nurses are often the first person to see the child and parent in the hospital or community setting -Pay attention to how the child responds to his/her parents AND how the parents respond to their child -Evaluate how the child responds during care of the injury -Supporting the child and the parents is also part of nursing care -After treating the injury, the priority is to remove the child from the abusive situation to prevent further injury

Therapeutic Management of Scoliosis:

-Team approach to treatment -Bracing -Exercise -Surgical intervention for severe curvature (various systems of instrumentation and fusion)

How does discipline and limit setting help children?

-Test their limits of control (promotes learning) -Achieve in areas appropriate for mastery at their level -Channel undesirable feelings into constructive activity -Protect themselves from danger -Learn socially acceptable behavior -REMEMBER: children want and need limits...unrestricted freedom is a threat to their security and safety

Methods Used to Pressure Children into Sexual Activity:

-The child is offered gifts or privileges or has privileges withheld -The adult tells the child it is "okay to do" -Children who are isolated or emotionally and socially impoverished are targeted -The offender pressures the victim into secrecy -The offender plays on the child's fears

Definition of Physical Abuse:

-The deliberate infliction of physical injury on a child, usually by the child's caregiver -Involves a child receiving a non-accidental physical injury -Includes severe corporal punishment or unjustifiable punishment

Scoliosis

-The most common spinal deformity -Complex spinal deformity in three planes *Lateral curvature *Spinal rotation causing rib asymmetry *Thoracic hypokyphosis -May be congenital or develop during childhood -Multiple potential causes; most cases idiopathic -Generally becomes noticeable after preadolescent growth spurt -May have complaint of "ill-fitting clothes" -School screening controversial

Types of Discipline: Behavior Modification

-The theory is that behavior that is rewarded is repeated and behavior that is not rewarded is not repeated -Using rewards is a positive approach; when planning a reward system, parents must explain expected behaviors to the child and establish rewards that are reinforcing

Chromosome Disorders: Translocation

-Translocation- transfer of segment of one chromosome to another chromosome -Occur in many types of cancer

Sprains and Strains

-Trauma to a joint from ligament partially or completely torn or stretched by force -May have associated damage to blood vessels, muscles, tendons, and nerves -Presence of joint laxity as indicator of severity -Rapid onset of swelling with disability

ALL: Management of Relapse

-Treatment depends on timing of relapse -Early: On therapy or < 6 mos off therapy--> poor prognosis -Late: >6 mos off therapy -BMT/Stem cell transplant often indicated -1/3 of patients w/late relapse may survive with chemotherapy alone (but we will sometimes do a transplant to boost efforts)

Down Syndrome

-Trisomy 21 -Occurs about 1 in 700 births -Increase risk for older women -Genetic counseling

Childhood ALL: Nursing Care

-Tumor Lysis Syndrome -Leukostasis -Bleeding -Fever and Infection -Tumor Lysis Syndrome= cell contents are released and can cause acidosis and organ failure. IV fluid resuscitation is crucial during this period to avoid acidotic state/organ failure. Make sure fluids aren't stopped in imaging/ labs

Wilms Tumor

-Tumor of renal parenchyma -Early childhood onset Treatment -Nephrectomy -Chemotherapy -+ Radiation -90% cure

Retinoblastoma

-Tumor of retina -Infants/toddlers -Therapy depends on extent of disease at diagnosis -97% cure

Bone healing and Remodeling in Children

-Typically rapid healing in children -Neonatal period—2 to 3 weeks -Early childhood—4 weeks -Later childhood—6 to 8 weeks -Adolescence—8 to 12 weeks

Factors Predisposing to Physical Abuse: Parent Characteristics

-Younger parents -Single parent families -In single parent families that include an unrelated partner -Abusive families are often socially isolated and have few supportive relationships -Education < high school -Low income -Low self-esteem -Substance abusers -Lack knowledge of appropriate parenting skills -Victims of domestic violence, are drug and alcohol abusers or have an untreated mental illness -Approximately one third of parents who were maltreated as children will subject their children to similar maltreatment

Leading Causes of Death in Children 1-19 yo:

-accidents -assaults -CA -suicide

Buckman's Six Steps for Breaking Bad News: Finding Out How much the Patient Wants to Know

-ask: "Some patients want to know every medical detail, others just want the big picture-- what would you prefer now?" -establishes that there is no right answer -acknowledges the pts individuality -establishes that the patient can change their request in the future.

Buckman's Six Steps for Breaking Bad News: Finding Out How Much the Patient Knows

-ask: "What have you already been told about your illness?" From this you can determine: -level of underwstanding -knowledge of situation -level of technical sophistication -emotional state

Interventions for the Adolescent in the Presence of Death

-avoid alliances with either parents or child -structure hospital admission to allow for maximum self control and independence -answer questions honestly -respect their needs for privacy, solitude, and personal expression -help parents understand their reactions especially present focus on the physical (loss of hair, etc)

Childrens Concepts of Death: Preschoolers

-believe their thoughts are sufficient to cause death, may feel guilt, shame, and punishment -egocentricity imparts a tremendous sense of self power and omnipotence -have some sense of meaning regarding death -death is viewed as a departure or a kind of sleep -may recognize fact of physical death but cannot seperate it from living abilities -death is temporary and gradual can be reversible -no understanding of the universality and inevitability of death

Principles of Hospice and Palliative Care for Children

-child and family as unit of care -attention to physical, psychological, social, and spiritual needs -quality of life -interdisciplinary team approach

Who does the interdisciplinary team include?

-child/ family -physician -Social work -chaplain -CNA -Nurse -PT/OT -pharmacy -dietician -speech therapy -art therapy -child life -music therapy -child psychiatry

Development Issues in Pediatric Palliative Care

-comprehension -communication -fears -development theories and tools

Disease/Dying Trajectories

-death from lethal congenital anomaly -progressive conditions with intermittent crisis -death from potentially curable disease

Children's Concepts of Death: Infants and Toddlers

-death has least significance to children <6mo -after parent-child attachment the loss is profound even if temporary -seperation from parents is profound in the first years of life -toddlers are ego centric and can only think about terms in their own frame of reference:living -egocentricity and vague seperation of fact and fantasy make it difficult to comprehend the absence of life -instead of understanding death, this age group is affected more by any change in lifestyle

Early S/S of Inc ICP

-dec activity -restless -irritable -aware of surroundings

Buckman's Six Steps for Breaking Bad News: Sharing the Information

-decide on an agenda before the sit down -include dx, tx, prognosis, support, or coping -give info in small chunks and stop to check for understanding -translate medical terms into english -don't teach pathophysiology

Late S/S of Inc ICP

-difficult to arouse -dec HR and inc PP -pupils fixed -decorticate -decerebrate -death

Custody Arrangements in Divorce/Seperation:

-divided custody/split custody: siblings separated between parents -joint physical custody: parents alternate physical custody and responsibilities on a scheduled basis -joint legal custody: children reside with one parent but both parents are legal guardians and participate in child rearing

Interventions for Infants and Toddlers in the Presence of Death

-encourage parent to remain as near to the child as possible -maintain a normal environment to maintain ritualism -establish a consistent caregiver if parent has died -promote primary nursing

Who is the unit of care in pediatric pallative care?

-family and child

Likely causes of an elevated HR in a post op spinal fusion pt:

-fever -pain -bleeding -hypovolemia

Childhood Brain Tumors S/S

-flu like s/s -AM HA/vomiting -ataxia -CNS deficits -impaired vision -mental status changes -loss of developmental milestones -inc head circumfrence -seizures (10-15%)

What are the clinical manifestations of fracture?

-generalized swelling -pain or tenderness -diminished functional use -may have bruising, severe muscular rigidity, crepitus

S/S of Sepsis

-generally not doing well -poor thermoregulation -pallor -cyanosis -mottling -cold/clammy -hypotension -edema -irregular HR/RR -full fontanel -increased or decreased tone -abnormal eye movements -poor feeding vomiting -diarrehea -abd distention -hepatomegaly -occult guiac -jaundice -petechiae -ecchymosis -splenomegaly

Death and Dying: What are the developmental issues surrounding death for a teenager?

-have a mature understanding of death -may have remnants of magical thinking -may be in denial or have difficulty accepting death -may feel alienated from peers -very present oriented and may be more concern with appearance than dx -may experience guilt and shame

Interventions for Preschoolers in the Presence of Death

-help parents understand beh reactions of their child -encourage parents to remain near to their child -establish constant caregiver if parent has died -promote primary nursing

What are the 4 goals of fracture management?

1. Regain alignment and length of bony fragments by reduction 2. Retain alignment and length of bony fragments by immobilization 3. Restore function to injured part 4. Prevent further injury

Childrens Concepts of Death: School Age

-still feel guilt and associate bad behavior with negative outcomes -respond well to logical explanations and can comprehend the figurative meaning of words -have a deeper understanding of death in a concrete sense -particularly fear mutilation and punishment that they associate with death -personify death (devil, etc) -have naturalistic-physiologic explanations of death -by age 9 or 10 children have an adult concept of death, realizing that it is inevitable, irreversible, and universal

Reactions to Death: Adolescents

-straddle the transition from childhood to adulthood -have the most difficulty accepting death -least likely to accept the cessation of life particularly their own -concern for the present is much greater than concern for the past/ future -consider themselves alienated -worry more about physical changes even mor than the prognosis -idealistic views may lead them to criticize funeral rites/ ceremonies

Pediatric Deaths

-sudden, unexpected -ED, PICU

Buckman's Six Steps for Breaking Bad News: Planning and Follow Through

-synthesize patient concerns/dx into a concrete plan -step by step planning -be explict about your next contact with the pt -be sure pt has contact info of provider

Buckman's Six Steps for Breaking Bad News: Responding to the Patients Feelings

-understand your patients response -identifying and acknowledging a patients reaction is something that will improve with time -can always ask: "Could you tell me a bit about what you are feeling?"

Non-accidental Sites of Injury on Children

-upper back -buttocks -front and back of thighs -back of calfs -nose

Reactions to Death: Preschoolers

-view illness as a punishment for bad beh. -feel responsible or guilty for a siblings death -greatest fear concerning death is seperation -may exhibit strange or abnormal beh. (giggling, joking, attracting attention, regression) -may react more outwardly to a less significant loss (toy, pet) than to the loss of parent/ sibling -may deny the loss because of deep intense feelings

Reactions to Death: Infants and Toddlers

-with the death of someone else they may continue to act as though the person is alive -as children grow older they will be increasingly able and willing to let go of the dead person. -ritualism is important; lifestyle change may be upsetting -more focused on pain and discomfort of an illness than of a poor prognosis -also reacts to parent saddness

Childhood Brain Tumors: Brain Stem Glioma

-~10-20% of brain tumors -May be high or low grade (determines lifespan) -Peak incidence 5-10 years of age -cannot resect d/t location -can happen at any age -fatal Treatment: -Surgery not of value -Radiation -+/- Chemotherapy Prognosis: -<5% long term survival

Late-Onset Sepsis

1-3 wks after birth. Primarily noscomial infections (HAI). Organisms: -staphylococci -klebsiella -enterococci -e.coli -canidida

What are your priorities as the school nurse for the child with a musculoskeletal injury?

1. Assessment 2. Notify parents 3. Decide whether to call 911 4. Splint

How to talk to children about a death in the family:

1. Be prepared: start talking matter of factly about subject long before a death occurs. When a family member does die explain the procedures and rituals the child will witness (funerals, cemeteries, wakes...) 2. Be brief: Keep it simple and give the child plenty of time to talk. Give your child a concrete and straightforward explanation to hold on to (cancer, died, heart attack, dead NOT: passed away, expired)--> kids can handle it. 3. Listen Carefully: After providing the explanation listen to your childs reaction it may vary. Children process differently so just remind them they can talk to you whenever. 4. Be reassuring: Reassure the child that they had nothing to do with the death. Don't tell your child that you will be around forever, but do reassure them that you are healthy and plan to be around for a long time. 5. Be yourself: Show your own feelings.

How To's of a Neuro Assessment

1. Check level of consciousness: -awake, alert, oriented, -attention, irritability -activity level -deviation from baseline 2. VS assessment -monitor RR, depth, rhythm -dec HR & widened pulse pressure occur with inc ICP

Death and Dying: What are the stages of death and dying according to Kubler- Ross?

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

5 effects that prolonged immobilization or disability of the child may have on the family?

1. Financial strains may decrease or eliminate family resources 2. Attention is focused on the affected child and other family needs may not be met 3. Family members may have difficulty accepting the affected members altered body image 4. Family may be unable to express feelings and have difficulty coping 5. Parents feel guilty and have perception that they were unable to protect their child

What are the Robert Buckman's Six Step Protocol for Breaking Bad News?

1. Getting started 2. Finding out how much the patient knows. 3. Finding out how much the patient wants to know. 4. Sharing the information 5. Responding to the patients feelings. 6. Planning and follow through.

Assessment of Fractures: The 5 P's

1. Pain and point of tenderness 2. Pulse—distal to the fracture site 3. Pallor 4. Paresthesia—sensation distal to the fracture site 5. Paralysis—movement distal to the fracture site

Continuum of Palliative Care:

1. Presentation: Therapy to modify disease 2. EOL Care (Hospice) 3. Death: Beravement Care Palliative Care: End of #1, all of #2 & 3

What are the risks of casting on the same day of injury?

1. Swelling 2. Increased pain 3. Compartment syndrome

What subjective information do you want to gather for a child who presents to the school nurse with a musculoskeletal injury?

1. Where is the pain? 2. Is there anything else hurting? 3. Did he/she hit their head? 4. What was the mechanism of injury?

In order for the ignoring method to be effective parents should:

1. understand the process 2. record the undesired behavior prior to ignoring to determine whether a problem exists and requires intervention 3. determine if attention results in reinforcement of the behavior 4. be aware of response burst

California Child Abuse Statistics:

CA had the highest number of substantiated cases. 2012: -81,740 subst. -297,082 unsubst.

Lymphoma

=Malignancy of lymphatic system Two main types: -Hodgkin's disease -Non-Hodgkin's lymphoma Treatment depends on diagnostic subtype -85-80% survival at 5, 10 yrs

Tumor Grading

=determines degree of malignancy, treatment, and predicts outcome

Mandated Reporter: Making a Report

A mandated reporter that reasonably suspects abuse has occurred, must make two reports: 1. Telephone (verbal) immediately or as soon as possible to the Child Abuse Hotline at 1-800-344-6000 or in San Diego 858-560-2191 2. After verbal report, a written report, form DOJ SS 8572 (by fax, mail or electronically) must be submitted within 36 hours of receiving the information concerning the incident

Definition of Pediatric Pallative Care:

A philosophy of care that "seeks to enhance quality of life in the face of an ultimately terminal condition... includes the control of pain and other symptoms and addresses the psychological, social and spiritual problems of children and their families living with life-‐threatening or terminal conditions." Encompasses: -prevention and relief of suffering through ealy identification, vigilant assessment, and proactive treatment of pain and physical, psychosocial and spiritual problems.

Does palliative care hasten death?

No, its purpose is to relieve suffering through pain and symptom management

When should palliative care begin?

AAP & IOM state it should begin with life threatening diagnosis until resolution

Early- Onset Sepsis

Acquired in the perinatal period. Infection can occur from direct contact with organism from maternal GI and GU tracts. Organisms: -GBS -E. coli -other gram neg orgs

Parental Divorce:

Additional childhood adversity that contributes to poor mental health outcomes esp. when combined with child abuse.

What is the priority in suspected child abuse cases?

After treating the injury, the priority is to remove the child from the abusive situation to prevent further injury

What is the immediate treatment of sprains and strains?

a. Rest and cold application b. Disregarding the pain and "working out" the sprain or strain c. Rest, elevation, and pain medication d. Compression of the area and heat application Answer: A

Single Gene: Autosomal Recessive

Autosomal Recessive- expressed if homozygous- When both parents are carriers, offspring have a 50% chance of being a carrier, 25% chance of being affected, and 25% chance of being normal. -Cystic Fibrosis- 1 in 31 persons are carriers, most common in whites w/European ancestry. -Tay Sachs disease -Sickle Cell Anemia -Phenylketonuria

Corporal Punishment or Physical Discipline:

Based on the principles of aversive therapy, inflicting pain through spanking causes a dramatic short-term decrease in the behavior. However, this approach: -Teaches children that violence is acceptable -May physically harm a child if it is the result of parental rage -Interferes in the parent-child interaction -When parents aren't around, children tend to misbehave since they have not learned to behave well for their own sake -May interfere with the child's development of moral reasoning -Is not an effective form of discipline

Leukemia Diagnostic Workup: Bone Marrow Biopsy and Analysis

Best means. -steroids are effective for ALL so initially we will put them on steroids and fluids before obtaining the bone marrow biopsy this can lead to hungry and grumpys kids (placed on NPO + steroids= yikes) -wake kid up at 11pm and give them food the evening before biopsy Analysis: -Morphology -Cytochemistry -Immunophenotyping -Cytogenetics

Which age group has the highest rate of child abuse victimization?

Birth to one year

Cultural Practices the Dominant Culture may Consider Abusive:

Coining: vietnamese practice producing welt-like lesionson the childs back. done to rid the body of disease. Cupping: old world practice heated container is placed on the back to rid the body of poison or evil. Burning: southeast asian practice where small areas of the skin are burned to tx enuresis and temper tantrums Female Circumcision: removal of any part of the femal genitalia (africa, middle east, latin and north america, india, australia, and western europe) forced kneeling: carribean groups form of discipline where the child is forced to knee for a long period of time topical garlic application: yemenite jew practice where garlic is applied to the wrist to treat infectious disease-- can result in blisters of burns traditional remedies may contain lead: greta and azarcon for digestive problems (mexico), paylooah for rash and fever (southeast asia), and surma cosmetic to improve eyesight (india)

Signs of Physical Abuse:

Consider possibility when: -Has unexplained burns, bruises, bites, broken bones, lacerations, or black eyes -Has fading bruises or other marks noticeable -Child or caregiver changes the story about how those injuries occurs -History of injury is incompatible with the injury -Child is watchful and "on alert" as if waiting for something bad to happen -Child shies away from touch, flinches at sudden movement or seems afraid to go home

Warning Signs of Emotional Abuse in Children:

Consider the possibility when a child: -Shows extremes in behavior, such as overly compliant or aggressive -Is delayed in physical or emotional development -Has attempted suicide -Is withdrawn, depressed, apathetic -Reports a lack of attachment to the parent or caregiver

Possible Signs of Physical Neglect:

Consider the possibility when the child: -Clothes are ill-fitting, filthy, or inappropriate for the weather -Begs or steals food or money -Consistently is dirty, sleepy or hungry -Abuses alcohol or drugs -States there is no one at home to provide care -Lacks adequate medical or dental care -Is frequently late or missing from school

Complicated Grief Reactions

Continue for more than a year post loss. -intense intrusive thoughts -severe emotion -distressing yearnings -feelings of excessive loneliness/emptiness -unusual sleep disturbances Risk Factor: unexpected loss TX: refer to a bereavement and grief counselor

Musculoskeletal Definitions: Contusion

Damage to the soft tissue, subcutaneous structures, and muscle

SIDS

Defined as the sudden unexplained death of an infant younger than 1 year. -third leading cause of death in infants -etiology is unknown Risk Factors Include: -maternal smoking -etoh use -cosleeping -prone sleeping -side- lying position -prolonged QT interval -soft bedding -LBW/preterm -low APGAR -URI -two or more siblings who died of SIDS -males -minorities Protective Factors: -breastfeeding -pacifiers -back to sleep -UTD immunizations

Parenting Styles: Authoritative

Democratic: -Combines both extremes -Standards and boundaries -Emphasizes reason for rules, punishes deviations -Respect: allow individual opinion and objections -Consistent, reasonable

Parenting Styles: Authoritarian

Dictatorial: -Mandates behavior -Control -Rigid rules -Value absolute obedience

Psychologic Effects of Immobility

Diminished environmental stimuli Altered perception of self and environment Increased feelings of frustration, helplessness, anxiety Depression, anger, aggressive behavior Developmental regression

Definition of Discipline:

Discipline means to teach and refers to a set of rules that govern conduct

In the brain what is the tentorium?

Divides brain into upper and lower sections.

When is parenting most difficult?

During the first year due to rapid growth and developmental changes

How to determine if corporal punishment has crossed the line to abuse:

Each case of alleged child abuse will involve two questions: (1) Was the punishment "necessary" or warranted? and (2) Was it reasonable or excessive? If your California child abuse defense lawyer can convince the prosecutor, judge and/or jury that the alleged corporal punishment was justified as a reasonable means of discipline, you must be acquitted of this charge.

How can the nurse reduce the risk of SBS?

Educating the parents of the risk of shaken baby syndrome. This education must include coping mechanisms for caring for children with inconsolable crying

Children's Concepts of Death: Adolescent 11+ years

Formal operational thought (beginning of ability to think abstractly) Question life/death-‐why? Encourage participation in decision making-‐maintain contact with peers.

What is Cancer?

Genetic mutation: -Permanent DNA alteration -Begins in single cell (clonal) Mutation results in: -Lack of differentiation -Loss of contact inhibition -Unregulated growth -Cellular immortality

What places children at increased risk for childhood cancer?

Genetic predisposition: -Down syndrome -Retinoblastoma gene Immunodeficiency: -congenital / acquired -treatment-related History of cancer Prior cancer treatment

CP Long Term Management

Goals: -Early Recognition -Maximize mobility -Improve communication -Improve self care ability, caregiver ability Spasticity Management: -PO meds: Dantrolene, low dose benzodiazipines -Botulinum Toxin A -Baclofen-PO or intrathecal -Surgical-Selective dorsal rhizotomy (id the nerve roots that are causing the spasticity and cut them out -PT

What is anticipatory grief?

Grief expressed in anticipation of loss. May be characterized by: -denial -anger -depression -othe psych/physcical sxs

Survival in Childhoood Lymphoma

Hodgkin's -95% survival if localized -80% if disseminated Non-Hodgkin's -80-100% survival if localized -60-85% if disseminated

Definition of Hospice Care:

Hospice= a form of pallative care focused exclusively on comfort and support for terminally ill patients when a life limiting illness no longer responds to curative treatments.

Children's Concepts of Death: Infants 0-2yo

Sensorimotor Stage (awareness of being separate from others) No concept of illness/ death. Stranger anxiety-‐provide "safe place" and consistent caregivers.

Chromosome Disorders: Insertions vs Inversions

Insertions- part of arm of chromosome inserted to another Inversions- reversed end to end

Different types of Conflict

Interpersonal=between two indiv Intrapersonal= within

Wong Definition of Palliative Care:

Involves an interdisciplinary approach to the management of a childs life threatening of life limiting illness from diagnosis through death and focuses on preventing or relieving the childs symptoms and support of the child and family.

What factor largely contributes to neglect?

Lack of education

Parenting Styles: Permissive

Laissez faire: -Exert little or no control of actions -Avoids rules and standards -Parent is a resource -Elicit children's opinions in decision making

Effects of Immobility on Neurosensory System

Loss of innervation: -If nerve tissue is damaged by pressure -If circulation to nerve tissue is interrupted -Effects of improper positioning -Range of motion Sensory and perceptual deprivation

Malignant Tumor Grading

Malignant (brain cancer) -histologically have greater differentiation/anaplasia -inc mitosis/necrosis -faster growing/high grade -invade surrounding brain tissues -may metastasize to other areas of CNS or body

Reactions to Death: School Age

May have more fears d/t increased comprehension: -reason for illness -communicability of disease -consequences of disease -process of dying -fear of the unknown (greater than their fear of the known) -realisation of impending death is a tremendous threat to their sense of security and ego strength -likely to exhibit fear through verbal uncooperativeness -interested in post death services -may be inquisitive about what happens to the body

Why is reasoning as a form or discipline often ineffective?

May involve scolding which can criticize and shame the child

Musculoskeletal Definitions: Strain

Microscopic tear to the musculotendinous unit

Multifactorial Disorders

Multifactorial Disorders- No one error but combination of small variations that together produce a serious defect. Genetic problem but may have environments influence. 1. Cleft Palate -some types 2. Pyloric Stenosis 3. Neural Tube Deficits- influence of folic acid deficiency 4. Some cancers- retinoblastoma, Wilm's Tumor 5. Coronary Heart Disease 6. Diabetes Mellitus 7. Gout 8. Bi-polar disorder 9. Schizophrenia- some

Physiologic Effects of Immobilization

Muscular system: -Decreased muscle strength and endurance -Atrophy -Loss of joint mobility Skeletal system: -Bone demineralization -Negative calcium balance Cardiovascular system: -Orthostatic intolerance -Increased workload of the heart -Thrombus formation Respiratory system: -Decreased respiratory effort -Reduction in normal movement of secretions Gastrointestinal system: -Decreased mobility of the bowel -Risk for aspiration Renal system: -Renal statis -Hypercalcemia (renal calculi) Metabolism: -Decreased metabolic rate -Decreased production of stress hormones Integumentary system: -Decreased circulation and pressure leading to decreased healing capacity -Risk for ischemia and damage Urinary system: -Alteration of gravitational force -Difficulty voiding in supine position -Urinary retention -Impaired ureteral peristalsis

Definition of Neglect:

Neglect is defined as failure of a parent of other person legally responsible for the child's welfare to provide for the child's basic needs and an adequate level of care including deprivation of necessities, such as food, clothing, shelter, supervision, medical care and education

Realities of Parenting:

New Parents: -have limited experience and knowledge -can learn by trial and error -have a basic understanding of childhood growth and development (bathing, feeding, play, etc) -parents rear their children in the same way they were reared

Therapuetic Ways to Communicate with Bereaved Families:

Nonjudgemental Questions: -Can i be of any help? -Have you decided who the pallbearers will be? Clarification: -Correct me if I'm wrong, but you intend to make all the arrangements. -You believe the accident was your husbands fault? -I'm not sure I understand. Tell me more about... Explanations: -You can touch her and hold her if you wish Concern, Support, Empathy: -Your daughters birthday is near, that must be painful to deal with -It's okay to cry -It sounds like you have been doing some painful thinking Support, Silence: -I'm here if you want to talk Assessment of Coping and Support: -Do you have friends or family that can help you now? -You have been through a lot. How are you doing now? -Is there someone who can drive you home? Validation of Loss: -You have been through a very tough time. -He was a special boy to all the staff. I will miss him.

Death and Dying: What are nursing interventions for the dying child?

Nurses can minimize suffering/anxiety by explaining all proceedures, therapies, physical effects they will like experience, answering questions frank/honestly.

Musculoskeletal Definitions: Stress Fracture

Occurs as a result of repeated muscle contraction from repetitive weight-bearing sports

Musculoskeletal Definitions: Dislocation

Occurs when the force of stress on the ligament is so great that it displaces the normal position of the opposing bone ends or the bone in r/t its socket

Musculoskeletal Definitions: Sprain

Occurs when trauma to a joint is so severe that a ligament is either stretched or partially or completely torn by the force created as a joint is twisted or wrenched

Results of Authoritative Parenting Style:

Often results in children with high self-esteem, self-reliant, assertive, inquisitive, content, highly interactive with other children

Results of Permissive Parenting Style:

Often results in disobedient, irresponsible, self-involved and demanding, insecure, unruly in school, less academic motivation, risky behavior taking But...good interpersonal skills and communicate well -people pleasers

Result of Authoritarian Parenting Style:

Often results in shy, sensitive, self-conscious, submissive, loyal, honest, & dependable children

PURPLE Accronym:

P: peak of crying U: unexpected R: resistes soothing P: pain-like face L: long lasting E: evening

Generational Continuity:

Parents rear their own children in much the same way that they themselves were reared

The Differences in How Siblings and Parents Grieve:

Parents: continuous grief that lessens with time Siblings: Grieving in spurts that vary intensity as they grow

DDH Screening and Diagnosis

Physical Exam: -Limited abduction of affected hip (Barlow Test) for newborns -Asymmetry of gluteal folds -Unequal knee heights - Positive trendelenburg -Ortolani clunk

Genetic Counseling: Early Detection

Prenatal diagnosis- primarily amniocentesis and chorionic villi. Not all defects are detectable. When found family needs counseling. Newborn screening: a. Criteria- -Disease occurs with significant frequency -Serious effects from abnormality -Easy & inexpensive testing -Treatable problem b. Examples- PKU

Children's Concepts of Death: Toddlers/Preschoolers 2-7 yo

Preoperational thought (egocentric, magical thinking) Fear of separation-‐death is reversible. May feel it is their "fault". Provide simple, brief explanations. Encourage play therapy, maintain consistent limits.

Primary vs Secondary Losses Parents Face During the Death of a Child:

Primary= death of child Secondary: -loss of one's self -loss of ones hopes and dreams -loss of the family unit -loss of social and community supports -sometimes spousal support

Therapeutic Management of Sports Injuries

RICE: Rest, Ice (up to 30 min), compression, elevation ICES: Ice, Compression, ELevation, Support Immobilization and support (casts or splints as app)

The surgical technique for the correction of scoliosis consists of:

Realignment and straightening with internal fixation and instrumentation, along with bony fusion of the realigned spine

Child Abuse Prevention and Treatment Act Reauthorization of 2010:

Retained the existing definition of child abuse and neglect as, at a minimum: Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act, which presents an imminent risk of serious harm

Symptoms of Inc ICP

S/S of inc ICP initially subtle: -HA increasing in severity -dec in LOC -restlessness/irritability -bradycardia/HTN -Papilledema (seen by provider with opthalmascope) Evaluation/Assessment -close observation -verify findings -practice, practice, practice

Hodgkins Disease Staging (Ann Arbor System)

Stage I - single area Stage II - > 2 areas, same side diaphragm Stage III - both sides diaphragm Stage IV - diffuse involvement of organ or tissue (lung, bone, liver, marrow) A= no systemic s/s B= >1 systemic symptom E= extra lymphatic dz S= involves spleen

Death and Dying: What is the child's concept or meaning of death?

The child's concept and meaning of death varies greatly but largely depends on their cognitive stage of development. infants and toddlers: have no concept of death, may parrot expressions but don't really understand them. 3-5yo: may recognize the fact of physical death but don't separate it from living abilities. the dead person still breaths, eats, and sleeps= death is temporary and reversible. Children in this group are literal avoid euphemisms. school age: similar to the 3-5yo age group however this group tends to have a deeper understanding. May personify death (boogeyman, devil, etc). Concrete thinkers and may have an understanding of more facts (when you die your body decays...). **by 7yo most kids have a more adult understanding of death=universal, irreversible, and nonfunctional** adolescents: have a mature understanding of death but think they won't die. least likely to accept cessation of life.

Types of Discipline: Consequences

The strategy of consequences involves allowing children to experience the results of their misbehavior

When should an adoptive child be made aware of their adoptive status?

Theories vary but most agree that as early as possible is best, that way as children grow up they cannot remember a time when they didn't know. -inc trust -help form self- identity

Using Time-Out

Time-out places a child in an unstimulating, isolating place and gives both the parent and the child a cooling off time. To be effective, time-out must be planned in advance: 1. Select an area for time-out that is safe, convenient, and unstimulating but where the child can be monitored 2. Determine what behaviors warrant time-out 3. Make certain all family members understand the rules and how they are expected to behave 4. A rule for time-out is one minute per year of age...use a timer with an audible bell to record the time rather than a watch

Death and Dying: Should the child be able to make decisions regarding care and treatment?

Traditionally minors do not have the legal right to consent or refuse tx. Parents should be consulted with how much they want their child to know and participate in their care. At the minimum children deserve the truth.

Is cure a realistic goal for childhood CA?

Yes. Childhood cancer is a treatable disease and cure is a realistic goal

Etiology of Leukemia

Usually unknown

Childhood ALL: Prognostic Factors

WBC at diagnosis: -<50K is better high indication of going into remission at end of the tx Age at diagnosis: -2-10 years is best Early response to therapy: -Rapid response is best Cytogenetic features: -Immunologic Subtype (give better tx options) Gender (females have a better prognosis)

What effect does consistently ignoring unwanted behavior in children do?

Will eventually extinguish or minimize the act. Difficult to carry out consistently.

Sex Chromosomes

XX or XY

Julie, age 10, has been placed in a long leg cast for an open fracture. The nurse immediately notifies the physician if assessment findings include:

a. Appearance of blood-stained area the size of a quarter on the cast b. 2+ pedal pulse c. Inability to move the toes d. Ability of the nurse to insert one finger under the edge of the cast Answer: C

Bone healing is characteristically more rapid in children because:

a. Children have less constant muscle contraction associated with the fracture. b. Children's fractures are less severe than adult's c. Children have an active growth plate that helps speed repair with less likelihood of deformity d. Children have thickened periosteum and a more generous blood supply Answer: D

To reduce anxiety in the child undergoing cast removal, which of the following nursing interventions would the nurse expect to be least effective?

a. Demonstrate how the cast cutter works to the child before beginning the procedure b. Use the analogy of having fingernails or hair cut c. Explain that it will take only a few minutes d. Continue to reassure that all is going well and that their behavior is acceptable during the removal process Answer: C

Johnny, a 12-year-old with fracture of the femur, has developed chest pain and shortness of breath. The nurse suspects a pulmonary embolism. The priority nursing action is to:

a. Elevate the affected extremity b. Administer oxygen c. Administer pain medication d. Start an intravenous (IV) infusion of heparin Answer: B

What does CA law say about phsyical discipline?

a. If physical discipline is excessive or forceful enough to leave injuries, physical abuse has occurred. b. Reasonable and age appropriate spanking to the buttocks where there is no evidence of serious physical injury does not constitute abuse. c. a and b d. All forms of physical discipline is prohibited by CA law. C??

Emergency treatment for the child with a fracture includes:

a. Moving the child to allow removal of clothing from the area of injury b. Immobilization of the limb, including joints above and below the injury site c. Pushing the protruding bone under the skin d. Keeping the area of injury in a dependent position Answer: B

Nursing implementation directed toward nonsurgical management in a teenager with scoliosis primarily includes:

a. Promoting self-esteem and positive body image b. Preventing immobility c. Promoting adequate nutrition d. Preventing infection Answer: A

The method of fracture reduction is not determined by:

a. The child's age b. The manner in which the fracture occurred c. The degree of displacement d. The amount of edema Answer: B

Diagnostic evaluation is important for early recognition of scoliosis. Which of the following is the correct procedure for the school nurse conducting this examination?

a. View the child, who is standing and walking fully clothed, to look for uneven hanging of clothing b. View all children from the left and right side to look mainly for asymmetry of the hip height c. Completely undress all children before the examination d. View the child, who is wearing underpants, from behind when the child bends forward Answer: D

Autosome

first 22 pairs of chromosomes

Sepsis

generalized bacterial infection in the blood stream. -neonates are at a higher risk -premature withdrawl of the placental barrier increases risk -antibiotic therapy is the treatment and is usually initiate after cultures are drawn but before a definitive dx.

Death and Dying: What is the child's reaction to dying?

infants & toddlers: regression, may precieve the seriousness of their condition. provide physical comfort, consistency in care, and familiar objects 3-5: shame and guilt, may perceive dying as a punishment. Fear separation from parents. Nurses should clarify misconceptions, use simple accurate language and provide the opportunity to play. School age= have a greater fear of the unknown than the finality of death. may exhibit fear through verbal uncooperativeness as a fight or flight response. help give children a sense of control in this group. adolescents= greatest understanding of death but the most likely group to struggle with this and face denial/anger. may feel alienated from peer groups. Present orientation may cause them to be more concerned with changes in physical appearance than eventual death. Structure care to provide them maximum control/independence.

Homozygous

pair of chromosomes (1 from each parent) having the same gene loci in the same order. May be normal or affected.

Inherited/Hereditary vs Congenital

passed in genes vs present at birth

Heterozygous

two different alleles- one is normal one affected

What is the primary diagnostic proceedure for a musculoskeletal injury?

x-ray