NCLEX - Child Health (UWorld)

Fifth disease

("slapped face," or erythema infectiosum) is a viral illness caused by the human parvovirus and affects mainly school-age children. The virus spreads via respiratory secretions, and the period of communicability occurs before onset of symptoms. The child will have a distinctive red rash on the cheeks that gives the appearance of having been slapped. The rash spreads to the extremities and a maculopapular rash develops, which then progresses from the proximal to distal surfaces. The child may have general malaise and joint pain that are typically well controlled with nonsteroidal anti-inflammatory drugs such as ibuprofen. Affected children typically recover quickly, within 7-10 days. Once these children develop symptoms (eg, rash, joint pains), they are no longer infectious. Isolation is not usually required unless the child is hospitalized with aplastic crisis or immunocompromising condition.

Strabismus

(crossed eyes) is a disorder involving misalignment of the eyes caused by a congenital defect or acquired weakness of an eye muscle. One eye may appear deviated inward (esotropia) or outward (exotropia). When the visual axes are not in alignment, the brain perceives 2 images (diplopia) and suppresses the weaker image to compensate. If left untreated by age 4-6, permanent reduction or loss of visual acuity in the affected eye (amblyopia) can occur. Initial treatments vary depending on the underlying cause. One common treatment is to strengthen the muscles of the weaker eye by wearing a patch over the stronger eye or using special corrective lenses. If nonsurgical methods are unsuccessful, surgical intervention to shorten or reposition an eye muscle for more effective movement may be required.

Hospitalization for toddlers

(ie, 12-36 months) is particularly difficult due to separation anxiety and a limited ability to cope with stress. Toddlers thrive on home rituals and routines, which bring stability and reassurance. Hospitalization can severely disrupt these routines, triggering frustration and temper tantrums. Caregivers should maintain as many home routines as possible (eg, sleeping, eating) to help the child cope with unfamiliar hospital surroundings and procedures (Option 1). Parents should also stay with the child as much as possible, including overnight (ie, rooming-in), to provide consistency and alleviate separation anxiety. Play, an important part of a child's emotional and social well-being, is an effective coping mechanism for children of all ages to deal with the stress of being away from home. The playroom is a safe place for children to act out their fears and anxieties related to illness and hospitalization.

Wilms tumor

(nephroblastoma) is a kidney tumor that usually occurs in children age <5. Most often it involves only one kidney, and the prognosis is good if the tumor has not metastasized. An unusual contour in the child's abdomen is suggestive of Wilms tumor and confirmatory diagnosis is made by ultrasound. Once the diagnosis is suspected or confirmed, the abdomen should not be palpated, as this can disrupt the encapsulated tumor. It is important to post the sign "DO NOT PALPATE ABDOMEN" at the bedside. It is also essential that the child be handled carefully during bathing.

School Age Children (Eriksons Stages)

According to Erikson's stages of psychosocial development, school-age children deal with the conflict of industry versus inferiority. Attaining a sense of industry (competence) is the most significant developmental goal for children age 6-12. Parents should therefore be encouraged to provide a hospitalized child with missed school work on a regular basis. This will help the child keep up with school demands, learn new skills, cope with the stressors of hospitalization, and avoid a sense of inferiority.

Enhance Child's Cooperation during Examination

Always complete the assessment by performing the least invasive parts first and then progressing to the most invasive. By first establishing a rapport with the parent, the nurse will elicit the child's trust and cooperation. Playing with the child will help the child relax and perceive the nurse as less of a threat. Examining the child while in the parent's lap and explaining procedures in simple terms will provide a sense of security for the child. Measuring the child's height and weight should be performed next. Auscultation of the heart and lungs should then be performed. Allowing the child to play with the equipment first will make this part of the assessment easier. Praising the child throughout the assessment will enhance cooperation.

Scarlet fever with type 1 diabetes

An acute illness (eg, scarlet fever) in clients with type 1 diabetes may trigger the release of stress hormones, which leads to higher blood glucose and ketone levels (sometimes leading to ketoacidosis). Clients with type 1 diabetes do not produce any insulin (unlike those with type 2 diabetes), so clients should not skip administration of external insulin even if not eating. Insulin therapy should be continued as prescribed during an acute illness. Additional sick-day management includes: Increasing frequency of blood glucose level checks (every 1-4 hours) Increasing or decreasing the dose of insulin as needed based on blood glucose levels Maintaining adequate hydration Testing for urinary ketones frequently.

Bacterial meningitis clinical manifestations

Bacterial meningitis is an inflammation of the meninges in the brain and spinal cord that is caused by specific types of bacteria, including group B streptococcal, meningococcal, or pneumococcal pathogens. Clinical manifestations of bacterial meningitis in infants age <2 include: Fever or possible hypothermia Irritability, frequent seizures High-pitched cry Poor feeding and vomiting Nuchal rigidity Bulging fontanelle possible but not always present One of the most common acute complications of bacterial meningitis in children is hydrocephalus. Long-term complications include hearing loss, learning disabilities, and brain damage. Due to the severity of potential complications, prompt identification and immediate treatment are vital for any client with suspected bacterial meningitis.

Weight Loss Plan

Before initiating a treatment plan for weight loss, it is most important to make certain that the child and family are ready for change. Attempting to engage the family and child in weight loss strategies and dietary changes before they are ready could easily result in frustration, treatment failure, and reluctance to try new approaches in the future. The nurse needs to explore the reasons and desire for weight loss by assessing: Motivation and confidence Willingness to change behaviors and food choices Perceived importance of a weight loss treatment plan Confidence in ability to take on healthier eating habits.

Nutrients Provided by Milk

Calcium and vitamin D are nutrients in cow's milk that are essential for proper bone development in children and adolescents. To obtain the recommended 500 mg of daily calcium (for ages 1-3 years), the parents should serve foods such as beans, dark green vegetables, and calcium-fortified cereals and juices. Vitamin D, which enhances the absorption of calcium, is synthesized in the skin by exposure to direct sunlight. Alternate dietary sources include fish oils, egg yolks, and vitamin D-fortified foods (eg, orange juice).

Adolescence in psychosocial development

Certain behaviors are common in the adolescent period, ages 11 (early adolescence) to 20 (late adolescence). Teenagers engage in risk-taking behaviors and want to be just like their peers. Adolescents with chronic disease may have difficulty managing their illness due to a false sense of security and the belief that they are invincible.

Piaget's preoperational stage

Children age 3-6 (preschool) are in Piaget's preoperational stage of cognitive development. Children in the preoperational stage are developmentally capable of understanding adoption on a basic level; however, it may be difficult for them to understand the concept of having another family. At age 5, children may be unable to fully understand cause and effect and therefore ascribe inappropriate causes to phenomena (eg, scraped knee was caused by earlier misbehavior). Preschoolers who are adopted may believe they are responsible for being adopted and can develop separation anxiety and a fear of abandonment.

Attention-deficit hyperactivity disorder (ADHD)

Children with attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type, have trouble holding attention on tasks or play activities, experience difficulty organizing tasks and activities, and are easily distracted/side-tracked. They cannot give close attention to detail and dislike and/or avoid tasks that require mental effort over a long period. The key nursing intervention to help the child with ADHD adjust to hospitalization is providing a calm, structured, organized, and consistent environment. A written chart or list of daily activities will help remind the child of what to expect and what will happen at any given time. A structured environment helps these children organize their thoughts and activities.

autism spectrum disorder (ASD)

Children with autism spectrum disorder (ASD) often exhibit sensory processing problems; they may be hyper- or hypo-sensitive to sounds, lights, movement, touch, taste, and smells. A calming environment with minimal stimulation should be provided; a private room away from the nurses' station is the best location. The nurse can also facilitate a calming environment by: Using a quiet or monotone voice when speaking to the child Using eye contact and gestures carefully Moving slowly Limiting visual clutter Maintaining minimal lighting Providing the child with a single object to focus on.

Immunizations Side Effects

Common side effects of immunizations include a mild fever and soreness and redness at the injection site. Caregivers should be instructed to apply a cool compress to the injection site and taught how to correctly calculate the dose of acetaminophen or ibuprofen needed for these symptoms.

Left to right cardiac shunt

Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary blood flow. Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include: Tachypnea Tachycardia, even at rest Diaphoresis during feeding or exertion. Heart murmur or extra heart sounds. Signs of congestive heart failure. Increased metabolic rate with poor weight gain.

Dental avulsion

Dental avulsion (ie, tooth separated from the mouth) of a permanent tooth is a dental emergency. The priority nursing action is to rinse and reinsert the tooth into the gingival socket and hold it in place (eg, with a finger) until stabilized by a dentist (Option 1). Reimplantation within 15 minutes of injury re-establishes blood supply, increasing the probability of tooth survival. If the tooth cannot be reinserted it should be kept moist by submerging it in commercially prepared solution (eg, Hanks Balanced Salt Solution), cold milk, sterile saline, or as a last resort—due to bacteria—saliva (eg, holding it under the tongue). Scrubbing the root would damage it. The tooth should be gently rinsed with sterile saline or clean, running water. Placing the tooth in water (a hypotonic solution) would lyse the cells, killing the tooth. Wrapping the tooth in sterile gauze would dry it out. In addition, the nurse should arrange for immediate transfer to a dentist rather than advise the parent to schedule an appointment that might not be available for days.

Bullying

Despite increased media coverage, articles, and discussion about school bullying, myths and "old" attitudes toward school bullying persist. A number of parents and teachers continue to perceive bullying as a normal part of childhood, with the attitude of "kid will be kids." Some may even believe that bullying is "fun" and will help make those who are bullied stronger over time. These beliefs are one of the most common reasons why teachers and parents may ignore bullying behavior. The consequences of bullying are lasting harm and distress, including anxiety, depression, school adjustment problems, sleep difficulties, and even death.

Esophageal atresia (EA) and tracheoesophageal fistula (TEF)

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) consist of a variety of congenital malformations that occur when the esophagus and trachea do not properly separate or develop. In the most common form of EA/TEF, the upper esophagus ends in a blind pouch and the lower esophagus connects to the primary bronchus or the trachea through a small fistula. EA/TEF can usually be corrected with surgery. Clinical manifestations of EA/TEF include frothy saliva, coughing, choking, and drooling. Clients may also develop apnea and cyanosis during feeding. Aspiration is the greatest risk for clients with EA/TEF, and newborns who demonstrate signs of the condition are immediately placed on nothing by mouth (NPO) status. A newborn with EA/TEF may have a distended abdomen due to the buildup of air in the stomach via the fistula from the trachea to the lower esophagus. A concave (ie, scaphoid) abdomen is associated with a congenital diaphragmatic hernia due to the migration of abdominal organs to the thoracic space.

Assessment of school-age children (age 6-12)

Factors to consider during the physical assessment of school-age children (age 6-12) include the following: Clients (even those as young as age 3) can tell and/or show the examiner where they hurt or how they feel in their own terms Clients are capable of understanding and assisting in their physical examination. In fact, school-age clients are usually quite interested in medical equipment and how it works. Clients develop modesty during this period and some do not want a parent, especially of the opposite sex, in the room with them during a physical examination. This request should be honored. A head-to-toe sequence is appropriate for this age group.

Hearing impairment

Hearing impairment in children may be related to family history, an infection, use of certain medications, or a congenital disorder. Toddlers with hearing deficits may appear shy, timid, or withdrawn, often avoiding social interaction. They may seem extremely inattentive when given directions and appear "dreamy." Speech is usually monotone, difficult to understand, and loud. Increased use of gestures and facial expressions is also common. Children typically begin to use well-formed syllables such as "mama" and "dada" by approximately age 7 months. A referral for a hearing test should be made if there is an absence of well-formed syllables by age 11 months or intelligible speech is not present by 24 months. Lack of attentiveness and appropriate response when given a direction is characteristic of a toddler who has a hearing impairment.

Hirschsprung disease colostomy

In Hirschsprung disease, a portion of the colon has no innervation and must be removed. Some children require a temporary colostomy. The stoma created from the surgery should remain beefy red in the immediate postoperative period. Any paleness or graying of the stoma indicates decreased blood supply to that area. Blood-tinged mucus would be expected the first few days after surgery due to irritation of the intestinal mucosa during the procedure. By postoperative day 6, non-formed stool would be expected from the colostomy due to removal of part of the fluid-absorbing portion of the large intestine. It is not uncommon for a stoma to bleed a small amount with manipulation in the postoperative period.

Cystic fibrosis (CF) Diet

In cystic fibrosis (CF), a protein responsible for transporting sodium and chloride is defective and causes the secretions from the exocrine glands to be thicker and stickier than normal. These abnormal secretions plug smaller airway passages and ducts in the gastrointestinal (GI) tract. The thick secretions block pancreatic ducts, resulting in a deficient amount of pancreatic enzymes entering the bowel to aid in digestion and nutrient absorption. Clients require multiple vitamin supplements and supplemental pancreatic enzymes that are administered with meals. To meet the growth needs of clients with CF, a diet high in calories, fat, and protein is required.

Epiglottitis/Vaccination

It is essential for the nurse to present a calm, soothing, and reassuring attitude toward the parent and child while discussing the parents' concern. The parents will need further teaching about the importance of vaccinations, but the nurse should first address their concerns. The nurse discusses the topic with the parents without placing blame or guilt on the parents for choosing to decline vaccinations for their child. The majority of cases of epiglottitis are caused by Haemophilus influenzae type B (HiB) but may also be caused by other viruses, bacteria, fungi, or trauma. The prevalence of epiglottitis has decreased since the HiB vaccine has been routinely administered beginning at age 2 months.

Kawasaki disease Immunizations

Kawasaki disease is treated with aspirin and IVIG to prevent coronary artery aneurysms. Antibodies acquired from the IVIG therapy will remain in the body for up to 11 months and may interfere with the desired immune response to live vaccines. Therefore, live vaccines (eg, varicella, MMR) should be delayed for 11 months after IVIG administration as this therapy may decrease the child's ability to produce the appropriate amount of antibodies to provide lifelong immunity

Benign transient findings commonly seen in newborns

Mammary gland enlargement, non-purulent vaginal discharge (leukorrhea), and mild uterine withdrawal bleeding (pseudomenstruation) are benign transient findings commonly seen in newborns; these are physiologic responses to transplacental maternal estrogen exposure. Reassurance should be provided. Monitoring the amount, color, and consistency is the appropriate action.

Intussusception

Most cases of intussusception are treated successfully without surgery using hydrostatic (saline) or pneumatic (air) enema. The nurse will monitor for passage of normal brown stool, indicating reduction of intussusception. If this occurs, the supervisory registered nurse should be notified immediately to modify the plan of care and stop all plans for surgery. In intussusception, the stools are mixed with blood and mucus, giving a characteristic "currant jelly" appearance. This is an expected finding. Pain in intussusception is typically intermittent, occurs every 15-20 minutes, and is accompanied by screaming and drawing up of the knees. Therefore, if a child stops crying, it may due to a short-term intermission from painful spasms rather than reduction of intussusception. Intense pain causes spasms of the pyloric muscle that lead to vomiting after each episode. Vomiting tends to resolve once the intussusception is reduced. *****is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen, which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly"). Initially, some infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently, episodes of sudden abdominal pain (cramping), drawing the knees up to the chest, and inconsolable crying are seen. After an episode, the infant may vomit and then appear otherwise normal. Assessment may show a sausage-shaped abdominal mass.

Nasopharyngitis (common cold) Clinical Manifestations

Nasal congestion and discharge. Sneezing Cough and sore throat.

Meningococcal meningitis

Nursing care for a child with known or suspected meningococcal meningitis includes key safety and comfort measures. Droplet precautions are initiated because this form of meningitis is easily transferred through secretions. Precautions should be continued for 24 hours after initiation of antibiotic therapy. Clients with somnolence or other altered level of consciousness should be kept on NPO status to prevent aspiration. Comfort measures include promoting a quiet environment, minimizing stimuli in the room, and allowing the client to self-position. Due to nuchal rigidity, most clients prefer to lie with the head of the bed slightly raised and without a pillow, or in a side-lying position. Under droplet precautions, the nurse should wear a mask when caring for the client. However, the client does not need to wear a mask unless transportation outside the room (eg, to perform an imaging study) is necessary.

Osteogenesis imperfecta (OI)

Osteogenesis imperfecta (OI) (brittle bone disease) is a rare genetic condition resulting in impaired synthesis of collagen by osteoblasts. Collagen allows bone to be somewhat flexible while still maintaining strength. Impaired collagen causes bones to be frail and easily fractured. Clinical manifestations can range from mild defects to lethal disease in utero. OI is usually transmitted by autosomal dominant inheritance. The nurse's priority for a client with OI is careful handling to minimize additional fractures. Care of the infant with OI includes: Checking blood pressure manually to avoid cuff over-tightening, which may occur with automatic blood pressure cuffs. Lifting the infant by slipping a hand under the broadest areas of the body (eg, back, buttocks) so the pressure is distributed Repositioning the infant frequently using supportive devices and gel padding to avoid molding of the soft bones of the skull. Lifting by the ankles or under the arms puts too much pressure on the delicate bones (eg, legs, ribcage).

MMRV vaccine

Some children have a mild reaction to the MMRV vaccine within 5-12 days after the first dose. Problems include low-grade fever, mild rash, swelling and erythema at the injection site, irritability, and restlessness. Although rare, fever after MMRV vaccination can lead to febrile seizures. Therefore, it is important for the nurse to determine the child's temperature to evaluate the risk for a febrile convulsion. It would also be important for the nurse to instruct the parent to monitor the child's temperature and administer acetaminophen for a fever above 102 F (38.9 C). Children with a history of seizures should be vaccinated with separate MMR and varicella vaccines instead of the combination MMRV vaccine.

Epiglottitis Clinical Manifestations

Sore throat. Dysphagia. Drooling Respiratory distress seating up and leaning forward.

Aspiration of a foreign body

occurs most often in the toddler age group. Swallowing of objects such as buttons, small parts of toys, or food particles can be life-threatening and result in airway obstruction due to the small diameter of the airway. Manifestations include choking, gagging, cyanosis, and inability to speak when the object is lodged in the larynx.

Accidents associated with child walkers

Due to the relatively high incidence of injuries associated with child walkers, the American Academy of Pediatrics has recommended a ban on the manufacture and sale of mobile infant walkers. Accidents associated with child walkers include: Rolling down stairs (the most common cause of injury) Burns - children can reach high in a walker, enabling them to grab hot pot handles, reach heaters and fireplaces, or grab a hot cup of liquid off a counter or table Drowning - a child can fall into a bathtub or pool while in a mobile walker Poisoning - the child can reach higher objects Even if a parent is close by and watching a child in a walker, an accident may not be preventable. Children can move quickly and the parent or caregiver may not be able to respond quickly enough. Safer alternatives to mobile baby walkers include stationary walkers (no wheels) and play areas. If parents or caregivers insist on using a baby walker, they should be advised to choose one that meets the American Society for Testing and Materials safety standards. Walkers with braking mechanisms stop if at least one wheel drops off the riding surface.

Developmental Milestones of Infants

1 Month - Attempts to hold head up when prone. Maintains fisted hands. Cries when upset. Gazes at parents face when parent speaks. 2-3 Months - Gains head control when held. Holds rattle when placed in hand. Makes cooing sounds. Smiles in response to smiling and talking. 4-5 Months - Rolls front to back then back to front. Sits with support. Holds objects with palmar grasp. Puts things in mouth. Begins to laugh. Makes some consonant sounds. Becomes calmed by parents voice. 6-9 Months - Sits without help. Begins to crawl. May pull to a stand. Moves objects between hands. Uses crude pincer grasp. Babbles & imitates sounds. May say mama. Recognizes familiar faces. May have stranger anxiety. 10-12 Months - May walk with help or take independent steps. Crawls upstairs. Uses 2 finger grasps. Hits 2 objects together. Says 3-5 words. Uses non verbal gestures. May have separation anxiety. Searches for hidden objects.

Developmental milestones of toddlers

12 months - Walks first steps independently. Crawls upstairs. Uses 2 finger pincer grasp. Hits 2 objects together. Says 3-5 words. Uses non-verbal gestures. May have separation anxiety. Searches for hidden objects. 18 months - Walks up/down stairs with help. Throws a ball overhand. Jumps in place. Builds 3-4 block tower. Scribbles. Uses cup and spoon. 10+ word vocabulary. Identifies common objects. Has temper tantrums. Understands ownership. Imitates others. 2 years - Walk up/down stairs alone 1 step at a time. Runs without falling. Kicks balls. Builds 6-7 block tower. Turns 1 book page. Draws line. 300+ word vocabulary. 2-3 word phrases. States own name. Begins to parallel play. Begins to gain independence from parents. 3 years - Walks upstairs with alternating feet. Pedals a tricycle. Jumps forward. Draws a circle. Feeds self without help. Grips a crayon with fingers instead of fists. 3-4 word sentences. Asks why questions. States own age. Begins associate play. Toilet trained except wiping.

Growth Hormone Replacement

A child who demonstrates a slow growth pattern will undergo diagnostic evaluation to determine the cause. If the cause is found to be growth hormone deficiency, the child may undergo growth hormone replacement therapy. The biosynthetic hormone is administered via subcutaneous injection on a daily basis. Despite replacement therapy, the child may still have a final height less than "normal." Treatment is most successful when diagnosis and replacement therapy begin early in the child's life. When to stop therapy is decided by the client, family, and provider. However, growth less than 1 inch (2.5 cm) per year and bone age of 14 years in girls and 16 years in boys are the criteria often used to stop therapy. Growth hormone replacement does not guarantee that a child will grow at a rate equal to peers. Treated children often remain shorter than their peers.

Acute Appendicitis

A child with acute-onset right lower quadrant abdominal pain, nausea, and vomiting and a high white blood cell count likely has acute appendicitis. Appendicitis is a serious condition that usually requires emergency surgery due to the risk of appendix rupture. The pain results from swelling and inflammation of the appendix. However, once the appendix ruptures, pain is relieved only temporarily and will return with full-blown peritonitis and sepsis.

Separation anxiety

Around 6 months of age, infants begin to experience separation anxiety. This anxiety may be heightened during hospitalization because of exposure to many unfamiliar stressors. Appropriate nursing care can play a significant role in reducing the infant's physiologic and psychologic stress. Key interventions include: Adhering to the infant's home routine (eg, meal and sleep times) as closely as possible. Providing a favorite toy or pacifier. Encouraging caregivers to remain whenever possible during hospitalization Providing a quiet sleep environment with reduced stimulation to promote restful sleep. Offering a familiar object (eg, caregiver's shirt, blanket, voice recording) during stressful situations

Asthma Treatment

Asthma is a chronic condition characterized by inflammation, swelling, and narrowing of the airways in the lungs. The client having an acute attack will experience chest tightness, wheezing, uncontrollable coughing, rapid respirations, retractions, and anxiety and panic. Treatment of an acute attack can include nebulized breathing treatment with a short-acting beta-agonist medication such as albuterol, and oral or IV corticosteroids. Oxygen saturation is the best indicator of treatment effectiveness as it reflects gas exchange. Decreased coughing may indicate improvement, but it is more subjective than measurement of oxygen saturation. In addition, it may be a sign of client exhaustion and worsening asthma. The absence of wheezes may indicate resolution of the attack or progression of airway swelling to the point of little air flowing through the lungs. Peak expiratory flow rate, by measuring how much air a person can exhale, indicates the amount of airway obstruction. Following treatment for an acute asthma attack, an increase, not a decrease, in peak expiratory flow would be expected.

Liquid Iron Supplement

At birth, a newborn has enough iron (received during the last trimester of pregnancy) to last until approximately age 4 months. After this age, formula-fed infants usually receive adequate iron intake from iron-fortified formula, whereas breastfed infants may require supplementation until they begin eating iron-rich foods. Iron supplements should be given on an empty stomach between meals for best absorption. If gastric irritation occurs, iron may be given with meals; however, this decreases absorption. If the child is old enough, supplements with citrus fruit juice should be offered as an abundance of vitamin C increases absorption. Milk products and antacids should be avoided for 2 hours following oral iron administration as these will decrease absorption. Iron supplements may cause constipation and black or dark green, tarry stools; therefore, parents should be taught not to be alarmed if these expected findings occur. Liquid iron supplements can stain teeth; to reduce this risk, parents should use a medicine dropper to administer the dose at the back of the infant's cheek. The dose may also be diluted with water or juice to prevent staining and improve flavor. An older child should use a straw to take the supplement and drink water or juice after each dose.

Tracheostomy Tubes

In the event of an accidental decannulation or another urgent need to change a tracheostomy tube, the most important action is to quickly replace the tube as it is the client's only means to ventilate. Clients should always carry two spare tracheostomy tubes, one the same size and one a size smaller. If the tube is not easily replaced or is meeting resistance, the smaller tube should be used. Changing a tracheostomy tube is a high-risk procedure that should be done only if respiratory distress is noted and other interventions (eg, suctioning) have failed. Mucus plugs (ie, thickening and buildup of mucus due to dehydration) are one of the most common causes of respiratory distress. A tracheostomy should be suctioned frequently to maintain airway patency. However, deep suctioning should be reserved for clients in respiratory distress due to the risk of injury. Tracheostomy tubes should be suctioned to the specified depth using a measurement marked on the tube, to provide safe, effective suctioning. Humidification is crucial for clients with a tracheostomy as the upper airway, which provides natural humidity for inhaled air, is bypassed. Humidification helps keep secretions thin and reduces formation of mucus plugs. The humidifier should not be removed if the child develops more secretions as this is the intended effect.

Esophageal Atresia (EA) and Tracheoesophageal Fistula (TEF)

In the most common form of EA/TEF, the upper esophagus ends in a blind pouch and the lower esophagus connects to the primary bronchus or the trachea through a small fistula. EA/TEF can usually be corrected surgically. Clinical manifestations include frothy saliva, choking, coughing, and drooling. Clients may also develop apnea and cyanosis when feeding. Aspiration is the greatest risk for clients with EA/TEF. Priority nursing interventions for infants with suspected EA/TEF include maintaining NPO status, positioning the client supine, elevating the head at least 30 degrees, and keeping suction equipment by the bed to clear secretions from the mouth. If surgery must be staged or delayed due to the infant's condition, the priority is to maintain a clear airway and prevent aspiration. This client will likely require parenteral nutrition prior to surgery. A gastrostomy tube may be placed to allow for release of air and drainage of gastric contents to prevent aspiration; however, feedings or irrigations through the tube are contraindicated until after surgical correction of the TEF. The initial nursing action for a client experiencing cyanosis and excess oral secretions is suctioning the mouth (ie, oropharynx) to clear the airway. Excessive frothy mucus and cyanosis in a newborn could be due to esophageal atresia (EA) and tracheoesophageal fistula (TEF). If EA/TEF is suspected, the infant should be kept supine with the head elevated at least 30 degrees to prevent aspiration. A nasogastric tube should be inserted and connected to continuous or intermittent suction until surgical repair.

Nocturnal Enuresis

Involuntary bed-wetting at night in children beyond the age of expected bladder control is known as nocturnal enuresis. Primary enuresis is bed-wetting in a child who has never had bladder control. Secondary enuresis occurs in a child who has had a previous period of bladder control. Pharmacologic and nonpharmacologic interventions can be used in the treatment of enuresis. Parents should be educated on the following therapeutic techniques for nocturnal enuresis: Encourage fluids during the day but restrict after the evening meal. Have the child void before going to bed. Use enuresis alarms (attached to the child's underwear), which waken the child when voiding begins. Use positive reinforcement and motivation (eg, a calendar showing wet and dry nights). Avoid punishing, scolding, or ridiculing the child. Avoid the use of Pull-Ups and diapers at bedtime. Awaken the child at a specified time each night to void.

Iron Supplementation

Iron is necessary for adequate hemoglobin production. Chronic iron deficiency can lead to anemia, decreased immune function, and delays in growth and development. During gestation, iron received from the mother is stored in the hemoglobin, liver, spleen, and bone marrow of the fetus. Although iron stores typically last 5-6 months in term infants, preterm infants and infants born in multiples exhaust their iron stores by 2-3 months. Iron must then be acquired through dietary sources (eg, iron-fortified formula) or oral supplements. Exclusively breast-fed infants can receive supplements of oral iron drops as breast milk contains low levels of iron. After transitioning to solid foods, infants can obtain iron from fortified infant cereal and iron-rich foods.

Pediatric clients psychosocial integrity

Pediatric clients are at increased risk for impaired psychosocial integrity during stressful experiences (eg, hospitalization, surgical procedures, medical treatment) and require developmentally appropriate care based on their age to assist with managing stress. Unaddressed or ineffectively managed developmental needs may lead to or worsen the client's anxiety, disobedient behavior, and/or social withdrawal. Developmentally appropriate nursing care for an adolescent client includes: Encouraging interaction with peers (eg, hospital visits, internet communication), which supports the developmental need for social connection and support and reduces stress and anxiety. Involving the client in care planning to address the developmental needs for control and independence. Assisting the client to discuss emotions or fears related to treatment (eg, changes in body image, disability, possibility of death) to improve coping, support the developmental need for understanding, and decrease anxiety. Strict scheduling by the nurse reduces the adolescent's perception of control and independence, which may increase stress. Adolescents should be allowed to determine their daily schedule when possible. (Loss of privacy (eg, forced parental presence) can increase anxiety in the adolescent client. Adolescents should be asked if they want parents present for procedures and what level of parental involvement they prefer.

Nocturnal Enuresis Intervention

Pharmacological interventions are often used as second-line treatment for nocturnal enuresis in children age >5 years; this is done when there has been little or no response to behavioral approaches and/or when short-term improvement of enuresis is desired for attending sleepovers or overnight camp. A trial run is usually done at least 6 weeks before camp to determine the appropriate drug dose and effectiveness. However, there is a high risk of relapse once the drug is discontinued. Medications used to treat nocturnal enuresis include the following: Desmopressin reduces urine production during sleep. Tricyclic antidepressants such as imipramine, amitriptyline, and desipramine improve functional bladder capacity.

Magical thinkers.

Preschool children (age 3-6) are magical thinkers. Night fears are common during this period, and distinguishing between reality and fantasy is difficult. It is appropriate for parents to acknowledge their child's fears. A preschooler would be comforted and fears would be allayed if the parents looked under the bed and reassured the child that no tigers were there.

Pediculosis Capitis

Preventing the spread of pediculosis capitis (head lice) may be accomplished by using hot water to launder clothing, sheets, and towels in the washing machine; these items should then be placed in a hot dryer for 20 minutes. Treatment of head lice consists of pediculicide use and removal of nits (eggs). Head lice are not spread by oral contact with eating utensils. Instead, they are spread by direct person-to-person contact or by nits that remain on clothing, combs, pillows, and other surfaces and then hatch in the environment. Spraying insecticides around children and pets in the home is not recommended due to the risk of inhalation or skin contact. Items that cannot be washed or dry cleaned may be placed in sealed plastic bags for 14 days to kill active lice or lice that hatch from nits in 7-10 days. Vacuuming furniture, carpets, stuffed toys, rugs, and mattresses is also recommended to prevent the spread of lice and nits.

Regression

Regression during hospitalization is a normal response to the stress of an unfamiliar environment, the fear and pain of invasive procedures, and the change in a child's normal routine. Toilet-trained children may start bed-wetting, and children who gave up the bottle or pacifier may ask for it. It is important for the nurse to explain that this behavior is completely normal and that the child will gain back previous milestones after discharge.

Thumb Sucking

Rooting and sucking are a part of an infant's natural reflexes. Nonnutritive sucking assists in helping the infant to feel secure. Some parents become very concerned about their infants sucking fingers, thumbs, or a pacifier and try to stop the behavior. As a rule, if thumb sucking stops before the permanent teeth begin to erupt, misalignment of the teeth and malocclusion can be avoided. Parents should be taught that teasing and punishing a child for using a pacifier or sucking the thumb is not an effective method for getting the child to stop. This can increase the child's anxiety and cause the child to increase the behavior.

HIV Positive Immunizations

Routine immunization is particularly beneficial to children who are HIV-positive as they are more susceptible to preventable diseases due to a compromised immune system. The standard vaccine schedule for a 12-month-old includes Hib, PCV (PVC13), MMR, varicella, and Hep A. HIV-positive children who are asymptomatic and not extremely immunocompromised can receive the appropriate age-specific immunizations as recommended. However, live vaccine preparations (eg, MMR, varicella) are contraindicated in the presence of marked immunosuppression, as determined by CD4 lymphocyte percentages and/or counts. An individual with a CD4 lymphocyte percentage <15% is considered to be severely immunocompromised. Low CD4 lymphocyte counts vary slightly by age due to the normal occurrence of elevated CD4 counts during infancy and early childhood. Low CD4 counts are defined as <750/mm3 for infants 12 months or younger, <500/mm3 for children between age 1-5 years, and <200/mm3 for children age >5 years and adults.

SBAR

SBAR (situation, background, assessment, recommendation/read-back) is an established reporting format used to communicate with the health care provider (HCP). Use of SBAR ensures that the HCP receives the necessary information to make a clinical judgment regarding treatment or need for immediate assessment.

Separation Anxiety

Separation or stranger anxiety occurs when the primary caregivers leave the child in the care of others who are not familiar to the child. This behavior starts around age 6 months, peaks at age 10-18 months, and can last until age 3 years. Separation anxiety produces more stress than any other factor (eg, pain, injury, change in surroundings) for children in this age range. However, this reaction is normal and resolves as the child approaches age 3 years. A 3-month-old is too young to experience separation anxiety and can be soothed by any comforting voice.

Allergic Rhinitis

Symptoms of allergic rhinitis include sneezing, nasal drainage, nasal congestion, and pruritus of the eyes or nose. Clients and their families can help prevent these symptoms by identifying individual triggers (eg, dust, mold, pollen, dander) and implementing strategies to reduce or avoid exposure to known allergens. Key measures to reduce exposure to household and environmental allergens include the following: Installing high-efficiency particulate air filters in the home air conditioning system Keeping windows closed and staying indoors, particularly during times of heavy pollen Using hypoallergenic pillow and mattress covers to prevent exposure to dust mites. Reducing or eliminating carpet and area rugs from the home. Regularly mopping hard floors and damp-dusting furniture (at least weekly). If the client is not allergic to animal dander, keeping a household pet may be acceptable. However, to prevent pets from bringing environmental allergens into the home, further precautions may need to be implemented, such as more frequent baths or placement of additional doormats. Open windows allow environmental allergens, such as pollen, to enter the home. To prevent exposure to these particles, susceptible clients should keep exterior windows closed and avoid spending long periods of time outdoors.

First Manifestation of Puverty

Testicular enlargement, including scrotal changes, is the first manifestation of puberty and sexual maturation. This typically occurs at age 9½-14. It is followed by the appearance of pubic, axillary, facial, and body hair. The penis increases in size and the voice changes. Some boys also experience an increase in breast size. Growth spurt changes of increased height and weight may not be apparent until mid-puberty.

Infant CPR Test

The American Heart Association's guidelines for infant cardiopulmonary resuscitation (CPR) are used on children age <1 year. To check a pulse on an infant, the nurse should palpate the brachial artery by placing 2 or 3 fingers halfway between the shoulder and elbow on the medial aspect of the arm. The pulse should be assessed for 5-10 seconds to determine its presence and quality before CPR is initiated. The brachial pulse is preferred in infants as the brachial artery is close to the surface and is easily palpable. The carotid pulse can be difficult to assess due to a child's shorter neck. Extending an infant's neck to attempt to palpate the carotid pulse can cause injury. This pulse is recommended for clients age >1 year. The femoral pulse may be used for all clients; however, it is often not easily accessible for palpation due to diapers and clothing. The radial pulse is used in responsive clients age >1 year. It is not a recommended method of pulse detection in an unresponsive client as a weak or thready pulse is difficult to palpate at this location.

Cold Injury

The clinical indications of a cold injury include redness and swelling of the skin (chilblains or pernio) and blanched skin with hardness of the affected area (frostbite). For any cold injury, it is important to re-warm the area as soon as possible to restore blood flow and reduce the risk of permanent tissue damage. The recommendation for re-warming is immersion of the affected area in warm water (104 F [40 C]) for about 30 minutes or until the area turns pink in cases of frostbite. The face and ears can be re-warmed with the application of warm facecloths. Once re-warming has been effective, the child should be seen by an HCP as soon as possible.

Pulse Plethysmographic

The first action of the nursing process is assessment. The nurse should first evaluate the accuracy of the reading by evaluating the pulse plethysmographic waveform. Waveforms that are irregular or erratic may contain artifact caused by a loose, misapplied, or damaged pulse oximeter or by client movement. After ensuring that the probe has been properly applied and positioned to provide an accurate reading, the nurse should perform a thorough physical assessment and intervene as appropriate.

Establishing rapport

The first step in effective communication is to establish trust between the nurse, the child, and the parent. By actively including a school-age child in the health history interview, the nurse shows respect to that child and obtains valuable insight into their health status. Allowing the child to describe how they feel or where they hurt gives the nurse a better understanding of the issue. Using clear, age-appropriate explanations will enhance communication with the child while maintaining the participation of the caregiver. Open-ended questions allow the child or caregiver to elaborate on the question, giving the nurse detailed information to guide further assessment. Non-verbal cues also play an important role in communication (eg, staying at eye level with the child to ease any potential nervousness). Closed-ended questions usually result in a "yes" or "no" answer. There are times in an interview that closed-ended questions are appropriate to gather specific information, but broader, more descriptive answers are generally desired when conducting a health history interview. The nurse should interview a school-age child together with their caregiver unless there is an indication of child abuse. The child may feel more at ease, and a more complete assessment may be obtained through answers from both the child and caregiver.

Celiac Disease

The following are important principles to teach clients with celiac disease: All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats. Rice, corn, and potatoes are gluten free and are allowed on the diet. Deficient vitamins (mainly fat-soluble vitamins), iron, and folic acid should be replaced. Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten free. Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from the diet reduces the risk of nutritional deficiencies and intestinal cancer (lymphoma). Eating even small amounts of gluten will damage the intestinal villi although the client may have no clinical symptoms. All sources of gluten must be eliminated from the diet.

Introduction of Solid Foods

The introduction of solid foods generally occurs at 4-6 months. The process usually starts with a form of iron-fortified infant cereal, such as rice or oatmeal. Cereal can be mixed with breast milk, formula, or water. When introducing new foods, it is important to allow 5-7 days between foods to observe for any allergies to a particular food. Allergic responses often worsen with subsequent exposure, so it is a priority to identify food triggers as soon as possible. When an infant reaches age 6-8 months, pureed fruits and vegetables are introduced to provide needed vitamins. After introducing purees, it is also appropriate to begin offering simple finger foods, such as teething crackers and small pieces of fruit, soft vegetables, or cheese. These foods help children develop motor skills and learn to chew, even before they have teeth. Cow's milk is not introduced until after the first year because it lacks crucial vitamins and minerals for appropriate growth and is also more difficult for an infant to digest.

Pinworm Infection

The most common worm infection in the United States is pinworm, which is easily spread by inhaling or swallowing microscopic pinworm eggs, which can be found on contaminated food, drink, toys, and linens. Once eggs are ingested, they hatch in the intestines. During the night, the female pinworm lays thousands of microscopic eggs in the skinfolds around the anus, resulting in anal itching and troubled sleep. When the infected person scratches, eggs are transferred from the fingers and fingernails to other surfaces. Pinworm infection is treated with anti-parasitic medications.

Hemoglobin Levels for 1 Month Old

The normal range for hemoglobin in a 1-month-old is 12.5-20.5 g/dL (125-205 g/L). Hemoglobin of 24.9 g/dL (249 g/L) is diagnostic of polycythemia (elevated hemoglobin levels). Infants with cyanotic cardiac defects can develop polycythemia as a compensatory mechanism due to prolonged tissue hypoxia. Polycythemia will increase blood viscosity, placing an infant at risk for stroke or thromboembolism. Clubbing is another manifestation of prolonged hypoxia.

Atrial Septal Defect sounds

The nurse would expect to hear a murmur with an atrial septal defect. This defect is an abnormal opening between the right and left atria, allowing blood from the higher pressure left atrium to flow into the lower pressure right atrium. The back-and-forth flow of blood between the 2 chambers causes a vibration that is heard as a murmur on auscultation. ASD has a characteristic systolic murmur with a fixed split second heart sound. Some clients may also have a diastolic murmur.

Lumbar Puncture on a Child

The optimal position for access during a lumbar puncture is to have the client's head and knees tucked in and the back rounded out. This provides the most room for the health care provider (HCP) to perform the procedure and allows for a good hold to keep the client still. A lumbar puncture is a sensitive procedure, and it is important to keep the child from moving during needle insertion.

Pincer Grasp

The pincer grasp, a thumb to forefinger movement, develops at age 8-10 months. This is the time to start offering small finger foods, such as crackers or cut-up pieces of nutritious foods. Caregivers should inform their health care provider if the infant does not achieve this significant milestone in fine motor development. Formula should never be sweetened. Honey (especially raw or wild) should not be offered to children age <12 months because their immature gut systems are susceptible to Clostridium botulinum (botulism) infection. Common allergenic foods (eg, eggs, fish, peanut products) may be introduced along with other foods starting at age 4-6 months. Previous guidelines recommended delaying introduction of these foods until age 12 months. However, recent evidence suggests that delaying introduction of these foods may actually increase the risk for food allergy. Infants should be transitioned to whole milk, not low-fat milk, at age 12 months. Due to rapid growth, a child's brain requires the nutrition from the fat found in whole milk.

Varicella immunization

The varicella immunization is administered to prevent infection of varicella zoster, commonly known as chickenpox. Side effects of the immunization include discomfort, redness, and a few vesicles at the injection site. Covering the vesicles with clothing or a small bandage will reduce the risk of transmission from any exudate. Once the vesicles have dried, or crusted, a dressing is no longer necessary.

Sickle Cell Crisis

This client is exhibiting signs and symptoms of sickle cell crisis, which occurs when the client's sickle-shaped cells block blood flow through the vessels. These clients tend to have a small spleen due to repeated small splenic infarctions (autosplenectomy). Splenic sequestration crisis occurs when a large number of "sickled" cells get trapped in the spleen, causing splenomegaly. This is a life-threatening emergency as it can lead to severe hypovolemic (hypotensive) shock. The classic assessment finding is a rapidly enlarging spleen.

Toddlers and Hospitalization

Toddlers (age 1-3) display an egocentric approach as they strive for autonomy. They attempt to control their experiences through intense emotional displays, such as temper tantrums or forceful negative responses (eg, "no!"). Hospitalization causes loss of a toddler's usual routines and rituals, often resulting in regressive behavior. The toddler may also be frequently separated from the parents, leading to separation anxiety. Nursing care activities should be similar to the toddler's home routines and include providing preferred snacks and anticipating nap time. The toddler should be given options rather than asked yes/no questions to limit any potential negative responses. It is also important to encourage participation and parental presence whenever possible.

Toddlers Behaviors

Toddlers exhibit behaviors associated with negativism and ritualism as they seek autonomy. Limiting opportunities for children to express a negative response ("no") helps them learn self-control and behavior modification. For example, the parent can avoid asking, "Do you want to have dinner?" and instead offer food options or say, "It's time for dinner". If the child refuses a meal, the parents should wait to offer food until the next snack time or mealtime; days of low intake are common as toddlers experience a slowing growth rate. It is important not to force the child to eat. When toddlers have been physically active immediately before mealtime, they may have difficulty sitting at the table and can be disruptive. Offering a 15- to 30-minute period to calm down promotes better eating habits. Bedtime temper tantrums are common in toddlers as they become more independent. Parents should learn to ignore the behavior, remain in the child's presence, and consider using time-outs as a management technique.

Chest Compressions on a Newborn or Infant

Two techniques are acceptable for performing chest compressions on a newborn or infant. In the first, two thumbs are placed on the middle third of the sternum, with the fingers encircling the chest and supporting the back. The thumbs should be positioned side by side, just below the nipple line. This technique is preferred because it may result in improved cardiac perfusion. If the newborn or infant is extremely small or the rescuer's thumbs are extremely large, the thumbs may be superimposed (one on top of the other). The xiphoid portion of the sternum should not be compressed because this may damage the liver. The alternate method, especially if the resuscitator's hands are too small to encircle the chest, is to place only the index and middle fingers of one hand on the sternum just below the nipple line. The other hand should support the back. This technique is preferred if umbilical cord access is needed or in single rescuer situations. During compressions, the sternum is compressed approximately one-third of the anteroposterior chest diameter at a rate of 100-120/min (compression-ventilation ratio: 30:2 for 1 rescuer and 15:2 for 2 rescuers). The thumbs or fingers should not be lifted from the sternum during the relaxation phase.

Laryngotracheitis Clinical Manifestations

Upper respiratory tract symptoms followed by hoarseness, barking, cough, stridor and respiratory distress.

Toddler years

Weight gain slows during the toddler years with an average yearly weight gain of 4-6 lb (1.8-2.7 kg). By age 30 months, current weight should be approximately 4 times greater than birth weight. A toddler weighing 6 times the initial birth weight requires further evaluation. Family nutrition and meal habits should be discussed. A toddler achieves bowel and bladder sphincter control by age 24 months as bladder capacity increases. Head circumference increases by 1 in (2.5 cm) during the second year and then slows to a growth rate of 0.5 in (1.25 cm) per year until age 5. A normal pulse in a 30 month old may range from 80 to 140.

Kawasaki disease (KD)

also known as mucocutaneous lymph node syndrome, is characterized by ≥5 days of fever, bilateral nonexudative conjunctivitis, mucositis, cervical lymphadenopathy, rash, and extremity swelling. Coronary artery aneurysms are the most serious potential sequelae in untreated clients, leading to complications such as myocardial infarction and death. Echocardiography is used to monitor these cardiovascular complications. Intravenous immunoglobulin (IVIG) along with aspirin is used to prevent coronary aneurysms and subsequent occlusion. KD is one of the few pediatric illnesses in which aspirin therapy is warranted due to its antiplatelet and anti-inflammatory properties. However, parents should be cautioned about the risk of Reye syndrome. Cardiopulmonary resuscitation should also be taught to parents of children with coronary artery aneurysms. KD is a vasculitis of unknown etiology, but it is not an infectious process. Because the child will often have a similar clinical presentation to that of an infection (eg, persistent fever, inflammatory immune response), KD may be mistaken for a bacterial or viral illness. Polymorphous rash of the trunk and extremities is an expected finding in a child with KD. Cool compresses, unscented lotions, and loose-fitting clothing can minimize discomfort. IVIG is not given to control rash. When children with KD are discharged home, parents are instructed to monitor them for fever by checking the temperature (orally or rectally) every 6 hours for the first 48 hours following the last fever. Temperature should also be checked daily until the follow-up appointment. If the child develops a fever, the health care provider should be notified as this may indicate the acute phase of KD recurrence. The child may require additional treatment with IV immunoglobulin to prevent development of coronary artery aneurysms and occlusions. *****a childhood condition that causes inflammation of arterial walls (vasculitis). The coronary arteries are affected in KD, and some children develop coronary aneurysms. The etiology of KD is unknown; there are no diagnostic tests to confirm the disease, and it is not contagious. KD has the following 3 phases: Acute - sudden onset of high fever that does not respond to antibiotics or antipyretics. The child becomes very irritable and develops swollen red feet and hands. The lips become swollen and cracked, and the tongue can also become red (strawberry tongue). Subacute - skin begins to peel from the hands and feet. The child remains very irritable. Convalescent - symptoms disappear slowly. The child's temperament returns to normal. Initial treatment consists of IV immune globulin (IVIG) and aspirin. IVIG creates high plasma oncotic pressure; signs of fluid overload and pulmonary edema develop if it is given in large quantities. Therefore, the child should be monitored for symptoms of heart failure (eg, decreased urinary output, additional heart sounds, tachycardia, difficulty breathing).

Juvenile idiopathic arthritis (JIA)

an autoimmune disorder that begins before age 16, causes chronic inflammation of the joints. JIA can lead to deformed joints with decreased range of motion. Interventions focus on preventing joint deformity, maintaining range of motion, controlling pain, and providing for normal growth and development. Clients with JIA should: Avoid excess weight to prevent joint strain. Exercise daily to promote bone and muscle growth and avoid weight gain. Use moist heat to ease pain and stiffness. Rest for brief periods throughout the day to combat fatigue. Perform activities of daily living independently as tolerated.

Insulin pumps

are devices used to control blood glucose by delivering a continuous (basal) infusion of subcutaneous insulin in addition to intermittent, client-controlled bolus insulin doses. Insulin pumps, when used correctly, increase the client's autonomy and are believed to provide better glycemic control over time than the traditional, intermittent, subcutaneous insulin injections.

Acute glomerulonephritis (AGN)

in children is an immune complex disease most commonly induced by prior group A beta-hemolytic streptococcal infection of the skin or throat. A latent period of 2-3 weeks occurs between the streptococcal infection (eg, pharyngitis) and the symptoms of AGN. Clinical manifestations include periorbital and facial/generalized edema, hypertension, and oliguria, which are primarily due to fluid retention (decreased kidney filtration). The urine is tea-colored and cloudy due to the presence of protein and blood. Although most clients recover spontaneously within days, severe hypertension is an anticipated complication that must be identified early. Monitoring and control of blood pressure are most important as they prevent further progression of kidney injury and development of hypertensive encephalopathy or pulmonary edema. Hematuria is common with AGN. It is usually minimal and resolves spontaneously. Monitoring is important but not a priority. The most important measure of fluid status is a daily weight as it identifies fluid retention and response to treatment. Monitoring intake and output is important but is not the priority action over hypertension monitoring and control. Monitoring for edema is important but not the priority. Moderate sodium restriction is needed, especially if hypertension and edema are present. Otherwise, avoiding high-sodium foods and having no added salt in the diet may be adequate measures.

Hemophilia Long Term Complication

is a bleeding disorder caused by a deficiency in coagulation proteins. Clients with classic hemophilia, or hemophilia A, lack factor VIII. Clients with hemophilia B (Christmas disease) lack factor IX. When injured, clients with hemophilia should be monitored closely for external as well as internal bleeding. The most frequent sites of bleeding are the joints (80%), especially the knee. Hemarthrosis can occur with minimal or no trauma, with episodes beginning during toddlerhood when the child is active and ambulatory. Over time, chronic swelling and deformity can occur.

Nephrotic syndrome

is a collection of symptoms resulting from various causes of glomerular injury. The 4 classic manifestations of nephrotic syndrome are as follows: Edema - periorbital edema is usually the first sign; peripheral edema and ascites develop later due to fluid shifts Massive proteinuria - caused by increased glomerular permeability Hypoalbuminemia - resulting from excess protein loss in the urine Hyperlipidemia - related to increased compensatory protein and lipid production by the liver Additional symptoms include decreased urine output, fatigue, pallor, and weight gain. The most common cause of nephrotic syndrome in children is minimal change nephrotic syndrome, which is generally considered idiopathic. Less common secondary causes may be related to systemic disease or infection, such as glomerulonephritis, drug toxicity, or acquired immunodeficiency syndrome. *****An autoimmune disease, affects children age 2-7 and is characterized by increased permeability of the glomerulus to proteins (eg, albumin, immunoglobulins, natural anticoagulants). Loss of albumin in urine leads to hypoalbuminemia; this causes decreased plasma oncotic pressure, which allows fluid to leak out of the vascular spaces. Reduced plasma volume (hypovolemia) activates kidneys to retain salt and water (via the renin-angiotensin-aldosterone system). Clients experience generalized edema, weight gain, loss of appetite (from ascites), and decreased urine output. The loss of immunoglobulins causes increased susceptibility to infection. Caregivers should minimize the risk of infection during relapses (eg, limiting visitors). Treatment typically includes: Corticosteroids and other immunosuppressants (eg, cyclosporine) Loss of appetite management (eg, making foods fun and attractive) Infection prevention (eg, limiting social interaction until the child is in remission)

Tetralogy of Fallot

is a congenital cardiac defect that typically has 4 characteristics: pulmonary stenosis, right ventricular hypertrophy, overriding aorta, and ventricular septal defect. This infant is experiencing a hypercyanotic episode, or "tet spell," which is an exacerbation of tetralogy of Fallot that can happen when a child cries, becomes upset, or is feeding. The child should first be placed in a knee-to-chest position. Flexion of the legs provides relief of dyspnea as this angle improves oxygenation by reducing the volume of blood that is shunted through the overriding aorta and the ventricular septal defect.

Tetralogy of Fallot (TOF)

is a cyanotic cardiac defect. Infants with TOF will normally maintain oxygen saturation of 65%-85% until the defect is surgically corrected.

Hemophilia

is a hereditary bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention, including: Avoid medications such as ibuprofen and aspirin that have platelet inhibition properties. Avoid intramuscular injections; subcutaneous injections are preferred. The smallest gauge needle is used, and firm, continuous pressure is applied at the site for 5 minutes. Avoid contact sports and safety hazards; noncontact activities (eg, swimming, jogging, tennis) and use of protective equipment (eg, helmets, padding) are encouraged. Dental hygiene is necessary to prevent gum bleeding, and soft toothbrushes should be used. MedicAlert bracelets should be worn at all times.

Pertussis

is a highly contagious bacterial respiratory infection that can be deadly, especially if contracted during infancy. Pertussis is spread by contact with respiratory droplets. Therefore, nurses should implement standard precautions (eg, performing hand hygiene) and droplet precautions (eg, wearing a surgical mask) to prevent transmission. Clients requiring droplet precautions should be assigned to a private room to reduce the risk of transmission to other clients.

Measles, or rubeola

is a highly contagious disease that can affect people of all ages. The disease starts with fever, cough, runny nose, and conjunctivitis, soon after which a rash appears on the face and slowly spreads downward. Measles is spread through the air when infected persons cough and sneeze, and the virus remains in the air for up to 2 hours. Clients with measles are placed on airborne precautions in a negative-pressure single occupant room. Nursing care includes the following: Administering antipyretics Placing the child with high fevers on seizure precautions Providing a quiet, dimly lit atmosphere. The measles vaccine drastically decreased the disease incidence in the United States; however, with increased foreign travel and greater numbers of nonvaccinated children, there has been a resurgence of cases. Postexposure vaccination is recommended in exposed persons who have not been vaccinated or had the disease previously. Limiting exposure is not necessary with proper use of personal protective equipment. Restricting a child from eating raw fruits and vegetables is needed for neutropenic precautions; it is not appropriate for the client with measles. Clients with measles are placed on airborne precautions in a negative-pressure room. Masks (ideally N95 respirators) are required. Gown, gloves, and face shield are required only if substantial spraying of respiratory fluids is anticipated.

Shaken baby syndrome (SBS)

is a type of abusive head injury and is defined by the Centers for Disease Control and Prevention (CDC) as severe physical child abuse resulting from violent shaking of an infant by the arms, legs, or shoulders. The impact of the shaking causes bleeding within the brain or the eyes. It is not uncommon for the diagnosis of SBS to be missed as the clinical findings are often vague and nonspecific—vomiting, irritability, lethargy, inability to suck or eat, seizures, and inconsolable crying. Usually, there are no external signs of trauma except for occasional small bruises on the chest or upper arms where the child was held during the shaking episode. The most common reasons that caregivers seek medical attention for children with SBS are breathing difficulty, apnea, seizures, and lifelessness. Caregivers typically do not offer a history of trauma nor do they report the episodes of shaking. By contrast, children who have sustained unintentional head injury are typically brought for treatment out of concern by their caregivers even when the children are asymptomatic.

Patent ductus arteriosus (PDA)

is an acyanotic congenital defect more common in premature infants. When fetal circulation changes to pulmonary circulation outside the womb, the ductus arteriosus should close spontaneously. This closure is caused by increased oxygenation after birth. If a PDA is present, blood will shunt from the aorta back to the pulmonary arteries via the opened ductus arteriosus. Many newborns are asymptomatic except for a loud, machine-like systolic and diastolic murmur. The PDA will be treated with surgical ligation or IV indomethacin to stimulate duct closure.

Acute otitis media AOM

is an infection of the middle ear. Potential complications of AOM include hearing loss and spread of the infection. To prevent permanent damage, severe cases of AOM are treated with antibiotics. Amoxicillin is the standard treatment in most cases. However, if AOM symptoms do not improve within 48-72 hours of initiating antibiotic therapy, the client should return for further assessment. The HCP will then assess for other causes of persistent symptoms and determine if a different antibiotic is required to treat drug-resistant organisms. Following treatment with antibiotics, clients with AOM should be evaluated for complete infection resolution and screened for hearing impairment. Diarrhea is a frequent side effect of amoxicillin therapy that does not warrant treatment discontinuation. If the client develops fever and abdominal pain associated with diarrhea, it may indicate Clostridium difficile superinfection; this should be reported to the HCP. The medication is stopped immediately if the child develops an allergic reaction (eg, rash, shortness of breath, throat tightness). Ear pain and fever often subside within the first few days of antibiotic treatment. However, the entire course should be completed as prescribed to treat the infection completely and prevent antibiotic resistance. Over-the-counter decongestants are ineffective for AOM treatment and may even delay the recovery process.

Bacterial meningitis

is an inflammation of the membranes covering the brain and spinal cord that can lead to severe complications (eg, hearing loss, brain damage) or death without treatment. To reduce the risk of complications, the nurse should prioritize initiation of prescribed antibiotic therapy as soon as possible. example: ceftriaxone 400 mg IV every 12 hours

Gastroesophageal reflux (GER)

is attributed to an immature lower esophageal sphincter. It is common in infants age ≤3 months and results in spitting up after feeds. If an infant is gaining weight and meeting developmental milestones, treatment is aimed at controlling the symptoms. Because infants with GER are at risk for aspiration and apnea, caregivers should be instructed in cardiopulmonary resuscitation. For at least 30 minutes after feeding, these infants should not be rocked or agitated by active play but should be kept calm and upright. Infants with GER should be offered small frequent feedings and not be pushed to complete a feeding when demonstrating satiety. To minimize reflux, the feedings should be interrupted after every 1-2 ounces for burping the infant as waiting until the feeding is complete will increase the chance of regurgitation. Maintaining the infant in an upright position during and after feedings will minimize spitting up. Infants should not be placed in a car seat after feedings as this can increase intra-abdominal pressure, causing reflux. An infant's head should be elevated 30 degrees when placed in an infant seat.

Infant growth

is fast paced during the first year of life, with birth weight doubling by age 6 months and tripling by age 12 months. In addition, birth length increases by approximately 50% during the first year. An infant who does not meet expected length/weight milestones should be reported to the registered nurse for further assessment.

Failure to thrive (FTT)

is generally defined as weight less than 80% of ideal for age and/or depressed weight for length/height after correcting for gestational age, sex, and special medical conditions. The underlying cause of FTT is inadequate dietary intake, and contributing factors include a disturbance in feeding behavior and psychosocial factors. Observing the child feeding or when hungry will allow the nurse to identify potential factors contributing to insufficient intake. The nurse can observe the type of food being offered, the quantity of food consumed, how the child is held or positioned while being fed, the amount of time for feeding, the parent's response to the child's cues, the tone of the feeding, and the interaction between the child and parent.

Bacterial conjunctivitis (pink eye)

is highly contagious. The hands must be washed properly before and after instilling eye drops and after cleaning away eye drainage or crusting; this is the single best method to prevent the spread of infection to the other eye, the parents, other family members, or anyone else. Therefore, parents should ensure that affected children wash their hands frequently and discourage them from rubbing their eyes. Tissues used to clean the eye should be discarded. The child's washcloths and towels should be kept separate. Many schools and day care centers require that children be kept at home during the time when they are most contagious.

Bacterial meningitis

is inflammation of the meninges of the brain and spinal cord caused by infection. General manifestations in infants and children age <2 include fever, restlessness, and a high-pitched cry. One common acute complication of bacterial meningitis is hydrocephalus, an increase in intracranial pressure (ICP) resulting from obstruction of cerebrospinal fluid flow. Increased ICP can progress to permanent hearing loss, learning disabilities, and brain damage. Bulging/tense fontanels and increasing head circumference are important early indicators of increased ICP in children. Frequent assessment for developing complications is vital for any client with suspected bacterial meningitis.

Parallel play

is typical behavior of a toddler and involves activities focused on improving motor skills, imitative efforts, and the use of multiple senses. Toddlers play alongside, rather than with, other children. Having a variety of different balls for a group of children allows each child to be present with others and participate as they desire. Other examples of parallel play activities include pushing and pulling large toys; smearing paint; playing with dolls or toy cars; and digging in a sandbox.

Tonsillectomy

is usually performed as an outpatient procedure. Postoperative bleeding is an uncommon but important complication and it can last up to 2 weeks. It manifests with frequent or continuous swallowing and/or cough from the trickling blood; some clients may also develop restlessness. Discharge teaching includes: Avoid coughing, clearing the throat, and blowing the nose to prevent hemorrhage Limit physical activity Milk products are discouraged due to their coating effect, which can prompt clearing of the throat Oral mouth rinses, gargling, and vigorous tooth brushing should be avoided to prevent irritation. The presence of slight ear pain, a low-grade fever, and objectionable mouth odor are common findings during the first 5-10 days after the procedure. Persistent moderate-to-severe earache, fever, or cough requires further evaluation.

Hirschsprung disease

or congenital aganglionic megacolon, a child is born with a lack of specialized nerve cells in some sections of the distal large intestine; this renders the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. Newborns exhibit symptoms of distal intestinal obstruction (eg, distended abdomen, difficulty feeding, vomiting green bile) and do not pass meconium within the expected 24-48 hours. In less severe cases of the disease, the diagnosis may not be made until the child is older. Clinical manifestations include chronic constipation that is not psychogenic in nature and ribbon- or pellet-like stools.

FTT (failure to thrive)

or growth failure, is a state of undernutrition and inadequate growth in infants and young children. Most cases of FTT are related to an inadequate intake of calories, which can be tied to many different etiologies. Physiologic risk factors for FTT include preterm birth, breastfeeding difficulties, gastroesophageal reflux, and cleft palate. Socioeconomic risk factors include: Poverty - most common Social or emotional isolation - parents may lack the support system needed to assist them with the problems of child rearing Cognitive disability or mental health disorder Lack of nutritional education - parents may not have knowledge of proper feeding techniques or appropriate calorie intake based on age and size of the child.

Epiglottitis

should be considered first in a 3- to 7-year-old with acute respiratory distress, toxic appearance (eg, sitting up, leaning forward, drooling), stridor, and high-grade fever. Tachycardia and tachypnea are also present. The complications of epiglottitis are serious and include sudden airway obstruction. Epiglottitis is a pediatric emergency and should be managed with endotracheal intubation. However, intubating such clients is difficult, and as a result, preparation for possible tracheostomy is also standard.

Lead poisoning

still occurs in the United States, although not as often as in previous decades. A common source of exposure is lead-based paints found in houses built before 1978, when such paint was banned. Blood lead level (BLL) screenings are recommended at ages 1 and 2, and up to age 6 if not previously tested. Because lead poisoning particularly affects the neurological system, elevated BLLs (≥5 mcg/dL [0.24 µmol/L]) are dangerous in young children due to immature development of the brain and nervous system. A mild to moderate increase in BLL can manifest with hyperactivity and impulsiveness; prolonged low-level exposure can cause developmental delays, reading difficulties, and visual-motor issues. Extremely elevated BLLs can lead to permanent cognitive impairment, seizures, blindness, or even death.