CHILD HEALTH NURSING
CHILD HEALTH NURSING
CHILD HEALTH NURSING
Child Health Nursing
• Focuses on protecting children from illness and injury
• Assists children to obtain optimal levels of wellness
Primary roles of the Pediatric Nurse
• Care provider
• Educator
• Advocate
Pediatric Health Statistics
• Infant Mortality
o Number of deaths per 1000 live births during 1st year of life.
o Infant mortality rate is an indicator of how healthy the nation is.
o This rate is used to compare national health care to previous years and to other countries.
o There has been a great decrease in the number of deaths over the past century.
In 1997, 6.9 per 100 live births.
Childhood Mortality
• For children older than one year, death rates have always been less than those for infants.
• In later adolescence, there is a sharp rise in deaths.
Injuries; the leading killer in childhood
• Injuries cause more death and disabilities in children than any diseases.
• Some examples include:
o Motor vehicle accidents are the leading cause of death in children over 1 year of age.
o Majority of deaths are due to no use of seatbelts.
• Drowning is 2nd leading cause of death in boys 1-14; both sexes 15-24 years old. Drowning is the 3rd leading cause of death for girls 1-14.
• Burns are the 2nd leading cause of death from injury in girls and the 3rd in boys from 1-14 years old.
Childhood Morbidity (Illness)
• An illness or injury that limits activity, requires medical attention or hospitalization, or results in a chronic condition.
• Examples:
o Congenital heart defects
o Asthma
o Cerebral Palsy
o Cystic Fibrosis
• Concerned with helping to decrease these statistics as children miss school and other activities when ill.
Advanced Practice roles for nurses in Child health nursing
• Family nurse practitioner
• Neonatal nurse practitioner
• Pediatric nurse practitioner
• Nurse midwife
Growth and Development
• Growth: used to show an increase in physical size or a significant change.
• Includes:
o Height
o Weight
o Head circumference
• Development: Used to denote an increase in skill or ability to finction.
• Measured by:
o Observing child do specific tasks
o Parents description of child’s ability
o Using standardized testing (Denver II screening test)
Principles of Growth and development
• G & D is a continuous process from birth to death
o Rate of growth varies at different times
• G & D proceeds in an orderly manner
o Growth from smaller to larger
o Development: from sitting to crawling to walking
• Different children pass through the predictable stages at different rates
• All body systems do not develop at the same time.
• CNS, Cardiac develops quickly.
• Lungs are typically the last to develop.
Development is Cephalicaudal, which is the 3rd principle of G & D. “Head to toe”.
Development goes from proximal to distal, which is the 4th principle.
• Example: Development proceeds from gross to refined.
• A child cannot learn tasks until the nervous system is ready.
• Neonatal reflexes must be lost before development can proceed.
Factors that influence growth and development
• Genetics
• Gender
• Health
• Intelligence
Temperament
• Inborn in all of us
• A way of reacting to the world around us
Reaction Patterns:
• Activity level
o Level of activity differs widely among children
• Rhythmicity
o Have a regular rhythm is physiologic terms
• Approach
o Child’s response to a new situation
• Adaptability
o Is the child able to adapt to new situations?
• Intensity of reaction
• Distractibility
• Attention span and persistence
• Mood quality
Categories of temperament
• The “Easy” Child
o Easy to care for if they have predictable rhythmicity, approach and easily adapt to new situations, have a mild to moderate intensity of reaction, and an overall positive mood quality.
o 40-50% of children fall into this category
• The “Difficult” child
o Children are “difficult” if irregular in habits, have negative mood quality, and withdraw from new situations
o 10% of children fit this image.
• “Slow to warm up” child
o Describes children who are overall fairly inactive, respond only mildly, adapt slowly to new situations, and have a general negative mood.
o 15% of children display this pattern.
Other factors that impact growth and development
• Environment
• Socioeconomic level
• Parent-child relationship
• Position of birth in the family
• Health
• Nutrition
• As a child normally develops somewhat predictably in growth and physical development, he also matures emotionally, intellectually, and spiritually along certain paths.
Review:
• Erikson’s theory of Psychosocial development
• Piaget’s theory of cognitive development
• Kohlberg’s theory of Moral development
ASSESSMENT OF THE CHILD
Basic Principles
• Know norms; child vs. adult
• A & P variations are farthest from adult norms at birth
o Most of these variations mature quickly in the first year
o By 5-7 years of age, body is that of a “Small adult”; however, a child is not a miniature adult and should not be treated as such.
• As a child normally develops somewhat predictably in growth and physical development, he also matures emotionally, intellectually, and spiritually along certain paths.
• Try to see the child’s world and body through his/her mind. If you do this, you will connect with the child.
Approach to exam
• Always think of where the child is developmentally.
• Approach must be individualized
• Usually the child will be frightened and anxious. May lack verbal skills to express fear or ask for information.
• Use both hands on child when possible – comforting touch.
o Place left hand on shoulder while auscultating the heart.
o Move unhesitatingly, firmly, and gracefully.
o Talk pleasantly and reassuringly.
• Instructions to the child:
o Use a directive voice
o Have specific instructions
o Do not ask, but instead tell a child
Example: Say “Roll over on your belly” rather than “Will you roll over on your belly?”
Physical Exam
• Can take place almost anywhere
o On parents lap
o On the floor
o Examiners lap
Conducting the exam
• Perform the least distressing procedures first and the most distressing last.
o Heart and lungs; have the child lie down.
o Abdomen, throat, and ears (throat and ears are the worst)
o Genitalia and rectum
Physical exam technique
• Inspection
o Observe before you touch
• Auscultation
o Use diaphragm of stethoscope for high pitched sounds (bowel sounds)
o Use bell of stethoscope to help localize sounds for infant
• Palpation
o Use pads of fingers to determine tenderness and pulsations
o Use palmar surface of fingers to determine masses and organ enlargement
o Observe reaction to palpation rather than to ask if it hurts (don’t suggest that it does)
• Percussion
o A more advanced technique usually done by physicians and advanced practice nurses.
The general survey
• Vital signs
• General appearance
• Mental status
• Body measurements
Vital signs
• Temperature
o Body temperature in infants is less constant than in adults
o Use ax/tympanic for children less than 4 years of age
o Values are the same as in adults
• Axillary: hold child’s arm firmly
• Tympanic:
o Less than 3 years of age
Insert gently into ear
Pull down on ear
o Over 3 years of age
Pull up on ear
• Rectal temperature
o Most hospitals are done only with doctors order, or there is a standing order.
o Lubricate tip well
o Insert 1 inch
• Pulse
o Apical is best
o May use femoral arteries, brachial arteries
o Radials only in older children (at least 2 years old)
• Respirations
o The younger the child, the more abdominal breathing
o Observe the abdomen instead of the chest in infants and small children
o May need to auscultate the chest or put the stethoscope in front of the mouth and nose.
• Oxygen saturations
• Blood pressure
o Wide enough to over 75% of the upper arm
o Narrow cuff elevates reading, wide cuff lowers reading
o In infants less than 1 year:
Thigh BP = arm BP
o Older than 1 year:
Systolic in thigh is 10-40 mm Hg higher than in arm
Diastolic is same in thigh and arm
o If BP in thigh is less than in arm:
Cardiac anomaly or decreased circulation to extremities
Be sure to use correct size cuff
Use the same extremities, the same size cuff, and same position whenever possible when trending values for an individual patient.
o Diastolic BP
Diastolic pressure reaches about 55 mm Hg at one year of age
Gradually increases to 70 throughout childhood
o The most common cause of hypertension in children are:
Anxiety (increases BP in children)
Renal disease (78%)
Coarctation of the aorta (2%)
General appearance
• To form a general impression of child’s health and well-being
• To pin-point specific areas that may require more detailed assessment
Initial observations
• Degree of illness or wellness
• Mood
• State of nutrition
• Speech, cry, facial expression, posture
• Apparent chronological and emotional age
• Respiratory pattern
• Parent and child interaction
Parent and child interaction
• Amount of separation tolerated
• Displays of affection
• Response to discipline
• Look for signs of:
o Anxious parents
o Disengaged parents
o Stressed families
o Possible abusive parents (no separation anxiety when removed from parent, or over-affectionate)
Child cries or clings to parent
• Ignore the child temporarily
• Engage the parents in conversation, then place a small game, toy, or your stethoscope within reach of the child while continuing your discussion
Mental status
• Is the child alert?
• Able to respond to questions easily?
• Assess appropriateness of behavior
• Assess memory
Assessing Growth/Body measurements
• Height, weight, head circumference—important indicators of growth
• Measured and plotted on standard growth charts
• These charts are used to determine if the baby/child’s growth is falling within the accepted percentile for age
Length
• Birth to 36 months
o Fully extend the body by:
Holding the head midline
Grasping the knees together gently
Pushing down on the knees until the legs are fully extended and flat against the table.
o Hold pencil at right angle to the table and mark the head and toes (which are pointed toward the ceiling)
Height
• Child’s back is to the wall, with heels, buttocks, and back of the shoulders touching the wall and the medial melleoli touching if possible.
• Check for bending of the knees, slumping of the shoulders, or raising the heels of the feet
Weight
• Birth to 36 months, weigh nude
• Older children with panties and light gown
• Balance (or zero) scale prior to weighing
Head circumference
• Measure at greatest circumference
• Slightly above the eyebrows and pinna of the ears
o Around the occipital prominence at the back of the skull
o Compare to 36 months
Denver Developmental
• The standard for measuring the attainment of developmental milestones throughout infancy and childhood.
• Designed for birth to 6 years
• Includes screening for:
o Personal social skills
o Fine motor adaptive
o Language
o Gross motor
• Denver screening for articulation and eyes
Example of DDST for One year of age:
• Personal/Social
o Drink from a cup, imitate activities, play ball with examiner, indicate wants, play pat-a-cake
• Fine motor/adaptive
o Scribbles, puts block in cup
• Language
o Dada/Mama specific, one word
• Gross motor
o Stands alone
More on DDST:
• Only a measure of developmental attainment—not a measure of intelligence
• Not a highly specific test
o Most normal children score as normal
• Not very sensitive
o Many children with mild developmental delays also score normal
• Only a screening test
• Other more sophisticated tests are available if delay is suspected even when DDST is normal.
Heart Murmurs
• 50% of all children develop an innocent heart murmur at some point during childhood. It is usually not something to be overly concerned about unless there are other symptoms. Must be determines if murmur is normal; therefore always report when one is heard.
Abdomen
• Protuberant abdomen is typical in most children until adolescence.
• If child is ticklish on palpation, hold his/her hand over yours to reduce apprehension and increase relaxation of the abdominal musculature.
Neuromuscular
• If possible, watch the child standing upright. Have them walk, stoop, and touch their toes
• Checking for scoliosis.
More tidbits:
• Always think of child’s development when assessing
• Know the BP and pulse variations
• When there is an abnormal finding – ALWAYS gather more data
• Weight is a huge concern for children. Many medications are weight dependent.
• The Denver Developmental is not very precise; it’s more of a screening tool
• As it says, the Denver Developmental is only developmental—not a cognitive or an IQ test.
• For breath sounds:
o Encourage the child to “blow out” your light, in your pen light or flashlight. This will almost always produce full inspiration.
CARE FOR THE HOSPITALIZED CHILD
General communication guidelines
• Pay attention to infants and younger children through play or by occasionally directing questions or remarks to them.
• Include older children as active participants.
• With children of all ages, the nonverbal components of the message conveys the most.
• Communicate at the child’s level
o Developmentally and physically
Communication Guidelines
• Allow children time to feel comfortable
• Avoid sudden or rapid movements, extended eye contact, or other gestures that may be seen as threatening.
• Talk to the parent if the child is initially shy
• Communicate through puppets, dolls, or stuffed animals before questioning a young child directly.
• Give older children the opportunity to talk without the parents present
• Speak in a quiet, unhurried, and confident voice.
• Speak clearly, be specific, and use simple words and short sentences.
• Be honest with children
• Offer a choice only when one exists.
• Allow them to express their concerns and fears
• Use a variety of communication techniques; if one technique doesn’t work, try another.
Infant
• One month to one year old
• Erikson’s developmental task: Trust vs. Mistrust
o Task: Attachment to the mother
o Resolution of crisis: Trust in persons; faith and hope about the environment and future.
o Unsuccessful resolution of crisis: General difficulties relating to person’s effectively; suspicion; trust-fear conflict, fear of the future.
Infant: communication
• Forms first social relationships
• Communicates needs and feelings through nonverbal behaviors and vocalizations
o Smile and coo when content
o Cry when distressed—hunger, pain, body restraint, loneliness
• Respond to adults’ nonverbal behaviors
o Become quiet when cuddled, patted, or receive other forms of gentle, physical contact.
o Get comfort from the sound of voice—usually respond to any gentle firm handling until they reach the age of stranger anxiety (5-8 months).
Infant: Stressors of Hospitalization
• Separation anxiety
• Stranger anxiety
• Painful, invasive procedures
• Immobilization
Separation Anxiety
• Occurs as early as 4 months old; infants face shows disapproval as primary caregiver walks away.
• Three stages of separation anxiety:
o Protest
Cries loudly; rejects attempt to be comforted by anyone but the caregiver
o Despair
Crying stops and depression is evident
Much less active
Uninterested in food or play
Withdraws from others
o Detachment (denial)
Shows increased interests in surroundings
Interacts with strangers or familiar caregivers
Forms new but superficial relationships
Appears happy
Detachment usually occurs after prolonged separation from parents; rarely seem in hospitalized children.
Behaviors represent a superficial adjustment to loss.
• Interventions for separation anxiety:
o Encourage parents to room-in with infant
o Involve parents in child’s care whenever possible
o Keep parent in infant’s line of vision
o If parent is unable to be with infant, place familiar object with infant (stuffed toy, etc.)
o Support sibling and grandparent visitation
Stranger anxiety
• Occurs as early as 5 months
• Usually peaks at 8 months
• Behaviors exhibited by infant:
o Cries
o Screams
o Searches for parent with eyes
o Clings to parent
o Avoids and rejects contact with strangers
• Interventions for stranger anxiety:
o Holding out hands and asking the child to “come” will usually not work. If infant must be handled, better to pick up firmly without gestures.
o Observe position in which parents hold infant and imitate this.
o Hold infants where they can see their parents
o Are usually more at ease upright than horizontal.
Fear of procedures—interventions
• During procedure, use sensory soothing measures (Stroking skin, talking softly, giving pacifier)
• Cuddle and hug after stressful procedure or encourage parent to do so if present.
• Older infants may associate objects, places, or persons with prior painful experiences and will cry and resist at the sight of them
o Keep frightful objects out of view
o Perform painful procedures in separate room, not in crib,
o Use non-intrusive procedures whenever possible.
Immobilization
• Infants explore life through activity and mobility. If taken away:
o Feel helpless
o May have difficulty with language skills
o May have problems mastering developmental tasks
o Problems with motor skills
o Immobility impacts development.
• Immobilization interventions:
o Play therapy
o Transport infant outside of room by wagon of by carrying
o Spend time interacting with infant
o Encourage caregivers to do the same
Toddler
• Ages one to three years old
• Erikson’s developmental task: Autonomy vs. shame and doubt.
o Task: Gaining some basic control over self and environment
o Resolution of Crisis: Sense of self-control and adequacy; will power
o Unsuccessful resolution of crisis: Independence-fear conflict; severe feelings of self-doubt.
• Developing a sense of autonomy
• He wants to make choices and like the word “No!”
• Is egocentric
• Focus communication on toddler
o Toddler not interested in the experiences of others
Stressors of hospitalization
• Separation anxiety
• Loss of control
• Painful, invasive procedures
• Bodily injury
• Fear of dark
Separation anxiety
• Verbally attack stranger (“Go away!”)
• May physically attack stranger (kicks, bites, hits)
• Tries to escape to find parent
• Tries to physically force parent to stay (clings)
• May have temper tantrums or refuse care
• Behaviors may last from hours to days
Separation anxiety—interventions
• Child’s reaction to separation
o Toddler might ignore parent.
• Other strategies are same as for infant.
• Feels more secure with familiar item
• Allow them to touch and examine articles that will come into contact with them
• Be direct and concrete
• They interpret words literally.
Loss of control
• Very threatening to the toddler
• Many hospital situations decrease amount of control a child feels
• Loss of control occurs due to:
o Restriction or limitation of movement
o Altered routines and rituals
Eating
Toileting
Sleeping
Bathing
Play
o When routines are disrupted, problems can occur in these areas
• Interventions
o Promote freedom of movement
Encourage parent-child contact
Transport in carriage, wheelchair, carts, etc.
Maintain child’s routine
Encourage as much independence as possible (allow child to wear clothes from home, etc.)
Bodily Injury/Invasive procedures
• Concept of body very poor
• Intrusive procedures (examining ears) create much anxiety
• React with intense emotional upset and physical resistance
• Interventions:
o Tell child it’s ok to yell, cry, or do whatever is needed during procedure
o Explain procedure in relation to child’s senses
o Ignore temper tantrums
o Use distraction techniques (Sing song with a child)
Fear of the dark
• Keep night light on in room at all times
• Encourage parents to room-in with child
Preschool
• 3-6 years of age
• Erikson’s developmental task: Initiative vs. Guilt
o Task: Becoming purposeful and directive
o Resolution of Crisis: ability to initiate one’s own activities; sense of purpose.
o Unsuccessful resolution of crisis: aggression-fear conflict; sense of inadequacy or guilt
• Developing a sense of initiative
• Preschooler is:
o Egocentric
o Has increased language skills
o Concept of time and frustration tolerance is limited
o Illness and hospitalization may be viewed as punishment
Fears of hospitalization
• Separation anxiety and fear of abandonment
• Loss of control
• Bodily injury
• Painful, invasive procedures
• Fears of the dark, ghosts, monsters
Separation anxiety- preschooler
• Tolerate separation better than toddlers; may develop substitute trust in other significant adults
• However, they may show other behaviors:
o Refuse to eat
o Have difficulty sleeping
o Cry quietly for parents
o Constantly ask when parent will be visiting
o May express anger
• Interventions:
o Have parents bring in familiar articles from home—pictures/radio
o If child has attachment to special item, have it brought in
o Same strategies for toddlers
Loss of control
• Egocentric and magical thinking; perception of actual events are more frightening
o Typical fantasy: Illness is a punishment for their misdeeds
• Purely verbal instructions do not help them, have them practice on doll or toy.
Bodily injury
• Differentiate poorly between themselves and outside world.
• Fear of mutilation
• Take things literally “Stick for blood”
• Fear if when given a shot, when needle is removed, their insides will leak everywhere (put a band aid in place).
Interventions:
• Point out on drawing, doll, or child where procedure is performed
• Emphasize that no other body part will be involved
• Use non-intrusive procedures when possible
• Apply adhesive bandage over puncture site
• Encourage parental presence
• Allow child to wear underpants with gown
• Explain unfamiliar situations, especially noise or lights
• Involve child in care whenever possible (hold equipment, remove dressing)
• Praise child for helping and attempting to cooperate
• Never shame child for lack of cooperation
School age child
• 6-12 years old
• Erikson’s developmental task: Industry vs. Inferiority
o Task: developing social, physical, and school skills
o Resolution of Crisis: competence, ability to learn and work
o Unsuccessful resolution of crisis: Sense of inferiority; difficulty learning and working
• Developing a sense of industry and concrete thought
• Has increased language skill
o Interest in acquiring knowledge
o Improved concept of time
o Increased self-control
o Developing relationships with peers; peers are very important at this stage.
• Usually will want explanations and reasons for why things are being done
• Want to know more about procedures, activities, and objects
• Have a greater concern for privacy and body integrity
• Usually easier to communicate with than previous age groups
o Concrete thinkers; no abstract thought
Stressors of hospitalization
• Separation anxiety
• Loss of control
• Bodily injury
• Painful, invasive procedures
• Fear of death
Separation anxiety
• Younger school age children miss their parents more than older children
• Middle/late react more to separation from peers and usual activities
o May feel lonely, bored, isolated, depressed due to separation, not the illness.
o May try to be “brave and strong”.
o May be irritable with parents
• Interventions
o Make environment as home-like as possible
Continue school lessons
Have friends visit or call on phone
Decorate walls with cards
Bodily injury
• Less concerned with pain, more concerned about disability or death
• Take very active interest in their health
• Request facts
Invasive procedures
• Want to know about a procedure (will it hurt? What’s it for?)
• Tolerate intrusive procedures well
• By age 9 or 10 should less fright to pain
Adolescent
• Ages 12-20 years
• Erikson’s developmental task: Identity vs. Role confusion
o Task: developing sense of identity
o Resolution of Crisis: sense of personal identity
o Unsuccessful resolution of crisis: confusion about who one is; identity submerged in relationships or group memberships
• Developing a sense of identity and abstract thought
• Fluctuate between child and adult thinking and behavior
o Need to express their feelings, for some this comes easily, for others it does not.
o Major sources of concern for this age group are attitudes and feelings toward sex, substance abuse, relationships with parents, peer-group acceptance, and developing a sense of identity.
Stressors of hospitalization
• Loss of control
• Altered body image, disfigurement
o Do not want to look different
• Separation from peer group
• Loss of control
o Anything that interferes with sense of independence
o Patient role fosters dependency
o May withdraw, be uncooperative, angry, frustrated.
• Altered body image
o Very relevant at this stage
o Any change that makes them different from peers is seen as a major tragedy
o Insecure with their bodies due to the many changes
o May react with “know it all” attitude (but may be afraid, deep down)
o Privacy is very important—may need to give them some time alone.
CYSTIC FIBROSIS
Epidemiology
• Affects approximately 30,000 children and adults in the US today or 1 in 2500 live births
• Occurs most commonly in whites, rarely in blacks and Asians
• More than 10 million Americans (1 in 31 or 3.3%) are symptom free carriers of the defective CF gene
Survival
• In 1955, few children with CF lived to attend elementary school. Today, the median age of survival is 32 years.
• In this decade, many CF survive into their 40’s.
Etiology
• An inherited (genetic) disease
• CF is an autosomal-recessive disease (this means an individual must inherit 2 defective CF genes, one from each parent)
• The defective gene in CF occurs in Chromosome 7
• The gene causes the dysfunction of the exocrine glands
What are exocrine glands?
• Glands that secrete things such as:
o Lungs
o Pancreas
o Sweat glands
o Salivary glands
o Digestive glands
Pathophysiology
• CF causes the body to produce an abnormally thick, sticky mucus which:
o Clogs the lungs and leads to life-threatening lung infections;
o Obstructs the pancreas, preventing enzymes from reaching the intestine to help break down and digest food
• Primary symptoms:
o Thick, sticky mucus
o Salty taste on skin
• Marked electrolyte changes in sweat glands
o Chloride in sweat is 2-5X above normal
Lung involvement
• Thick tenacious mucus polls in the bronchial tree and obstructs bronchioles
• Results in:
o Bronchiectasis: Chronic dilation of the bronchi. Involves a chronic cough that produces mucopurulent sputum. Over time results in destruction of the bronchial walls.
o Pneumonia: Staph Aureus, pseudomona’s, and H. Influenzae
• Symptoms over time include:
o Clubbing of fingers
Clubbing is related to lack of tissue perfusion
Symptoms over time:
• Easily fatigued
• Physical growth stunted
• Chest may become enlarged from over inflation of alveoli because air cannot be pushed past the thick mucus on expiration (barrel chested)
• Increased carbon dioxide in blood (hypercapnia and/or chronic acidosis)
Pancreas involvement
• Thick secretions mix with pancreatic enzymes and block the pancreatic duct.
• Therefore:
o Essential pancreatic enzymes cannot flow into the duodenum to aid with digestion (lipase, trypsin, and amylase)
o Fats, proteins, and some sugars cannot be digested—are excreted in stools:
o Stools (The 4 F’s in CF)
Frothy (bulky/large)
Foul smelling (comparable to a cats stool)
Fat containing “greasy” Steatorrhea
Floaters
• Clogged ducts causes back pressure on the acinar cells (they make the enzymes)
• The cell lining of pancreas is damaged
• Over time the acinar cells atrophy and no longer produce the enzymes
Symptoms related to Pancreatic Involvement
• Protuberant abdomen because bulk of stool is setting in the intestines
• Signs of malnutrition—only benefit from 50% of food taken in
• Fat soluble vitamins are not absorbed A, D, E, K
• In infants, thick, sticky stools (meconium) which may cause intestinal obstruction
o One of the first signs of CF in infants
Sweat gland involvement
• The structure of the sweat glands is not changed, however:
• Level of chloride to sodium in the perspiration is increased 2 – 5 times above normal
• Some parents report they knew their newborn had the disease because when they kissed their child they could taste such strong salt in their perspiration
How is CF diagnosed?
• By the history (cough, stool, abdomen, hx. of pneumonia)
• The abnormal concentration of chloride in sweat
• The absence of pancreatic enzymes in duodenum (can be tested through NG tube)
• Pulmonary involvement
Common complaints that bring these patient to the doctor
• Newborn that loses 5-10% of weight after birth but does not gain it back
• Feeding problems—kids are always hungry because of their poor digestive function
• Frequent respiratory infections
• Cough
Diagnostic tests
• A sweat test is a test for the chloride content of sweat
• Infants may not be tested until 6-8 weeks of age. (they don’t sweat a great deal)
o Normal concentration of Chloride in sweat is 20 mEq/L
o A level of 50-60 mEq/L suggests CF—test is repeated
o A level >60 mEq/L = CF
• Duodenal analysis of secretions for detection of pancreatic enzymes
• Stool analysis: for fat content (although appearance may be enough)
• Pulmonary testing—chest x-rays or PFT’s
Therapeutic management
• Maintain respiratory function
o Keep bronchial secretions as moist as possible to facilitate drainage:
Moistened oxygen: Oxygen is supplied to children by mask, prongs, ventilators, or neubulizers, and rarely by tent
Aerosol therapy- 3-4 times/day via neubulizer to provide antibiotics and bronchodilators
o Never give cough syrups or codeine
• Aggressive chest physiotherapy- usually needed 3-4 times a day
• Activity- need frequent position changes, especially when in bed. Helps facilitate drainage of various lobes, as well as prevent skin breakdown.
• Respiratory hygiene: frequent mouth care, toothbrushing and good-tasting mouthwash.
• Need frequent check-ups and current immunizations/vaccines
• Adequate rest and comfort
o Dyspnea can lead to exhaustion
o Need periods of rest during the day:
Rest period before meals so not too tired to eat
Rest periods before chest physiotherapy
• Promote optimal nutrition
o Pancreatic enzyme supplements with meals and snacks
Pancreatic enzyme: Cotazym or pancrease
Comes in large capsule which can be opened and dissolved in a tsp. of food
Children usually begin to gain weight, and stools decrease in size and foul odor.
o High calorie, high protein, moderate fat diet
o Multivitamins and E, others when deficient.
• During hot months, extra salt may be added to food to replace that which is lost through perspiration
• Keep room temp at 72 degrees and have water available at all times. Parents need to supervise kids playing outdoors to prevent overheating.
• Keep well hydrated all of the time!
Complications
• Infertility in males related to blocking of vas deferens from tenacious seminal fluid
• Infertility in females related to tenacious cervical secretions that block sperm penetration
• Rectal prolapse in infants from straining to pass hard stool. Loss of blood supply to prolapsed rectal mucosa can occur if not replaced promptly and properly.
• Hypercapnia/respiratory acidosis from inability to adequately exhale carbon dioxide
• Exhaustion, slow growth patterns
• Skin irritation in diaper area from stool that is irritating due to acidic nature of stools
• Socialization and peer acceptance difficulties
• Cor Pulmonale (right sided heart failure) from increased respiratory resistance
• Anemia and bruising
• Frequent respiratory infections and compromised immunity
• Portal hypertension related to obstruction of bile ducts area of biliary fibrosis biliary cirrhosis
• Pneumothorax related to rupture of pulmonary blebs
Parental involvement
• Parents assume a great deal of responsibility when taking care of a CF child.
o Need to encourage a balance of work, the child, and the rest of the family
o Encourage involvement of support group
o Requires extensive involvement of the discharge planner
Nursing Diagnoses
• Ineffective airway clearance r/t thick mucus in the lungs
• Ineffective breathing pattern r/t thick tracheobronchial secretions and airway obstruction
• High risk for infection r/t presence of mucus secretions conductive to bacterial growth
• Altered nutrition: Less than body requirements r/t inability to digest nutrients
• Fear/Anxiety (parent or child) r/t prognosis and effect of illness on growth and development
• Knowledge Deficit (parent or child)
Summary
• CF is an inherited genetic disorder
• Causes the exocrine glands to produce thick secretions
• Primary body organs involved are lungs and pancreas.
• Prone to respiratory infections r/t mucus.
• Digestion problems r/t pancreatic enzymes.
• Treatment centers around control and management. No cure for the disease.
ERIKSONS STAGES
Infant
• One month to one year old
• Erikson’s developmental task: Trust vs. Mistrust
o Task: Attachment to the mother
o Resolution of crisis: Trust in persons; faith and hope about the environment and future.
o Unsuccessful resolution of crisis: General difficulties relating to person’s effectively; suspicion; trust-fear conflict, fear of the future.
o Developmental tasks: Learning to eat solid foods
Toddler
• Ages one to three years old
• Erikson’s developmental task: Autonomy vs. shame and doubt.
o Task: Gaining some basic control over self and environment
o Resolution of Crisis: Sense of self-control and adequacy; will power
o Unsuccessful resolution of crisis: Independence-fear conflict; severe feelings of self-doubt.
o Developmental tasks:
Learning to walk
Learning to use fine muscles
Toilet training
Learning to communicate
Preschool
• 3-6 years of age
• Erikson’s developmental task: Initiative vs. Guilt
o Task: Becoming purposeful and directive
o Resolution of Crisis: ability to initiate one’s own activities; sense of purpose.
o Unsuccessful resolution of crisis: aggression-fear conflict; sense of inadequacy or guilt
o Developmental tasks:
Independence of self-care
Learning sexual role identity
Forming reality concepts
Internalizing concepts of right and wrong
Learning to identify with family members and others.
School age child
• 6-12 years old
• Erikson’s developmental task: Industry vs. Inferiority
o Task: developing social, physical, and school skills
o Resolution of Crisis: competence, ability to learn and work
o Unsuccessful resolution of crisis: Sense of inferiority; difficulty learning and working
o Developmental tasks:
Acquiring game skills
Learning to relate positively with peers
Building a wholesome self-concept
Refining communication skills
Adolescent
• Ages 12-20 years
• Erikson’s developmental task: Identity vs. Role confusion
o Task: developing sense of identity
o Resolution of Crisis: sense of personal identity
o Unsuccessful resolution of crisis: confusion about who one is; identity submerged in relationships or group memberships
o Developmental tasks:
Forming peer relationships
Responding to an appropriate sexual role
Attaining emotional independence
Achieving a sense of economic independence
CARDIAC DEFECTS IN CHILDREN
ALTERATION IN FLUID-GAS TRANSPORT
Cardiac Defects in children:
• Divided into two major groups:
o Congenital cardiac defects
o Acquired heart disease
Congenital Heart Disease
• Anatomic abnormality present at birth; the heart has not developed as it should in utero.
• Thus, the heart is unable to adjust to life outside of mom
• Results in abnormal cardiac function
Acquired Cardiac disease
• Abnormalities that occur after birth
o Can occur by self
o Can occur with other congenital heart defects
o Example; Rheumatic disease is the 2nd largest cause of cardiac problems in children over 5)
Both congenital and acquired heart disorders can lead to heart failure
Assessment of cardiac function
• History
o History of heart disease in the family
o Contact with known teratogens, such as rubella during pregnancy
o Presence of chromosomal abnormalities (Down’s)
o Poor weight gain and/or feeding behavior
o Exercise intolerance and/or fatigue during feeds
o Sweating during feeding
o Frequent respiratory infections
o Respiratory difficulties, such as tachypnea, dyspnea, and shortness of breath.
o Recent streptococcal infection (may lead to valve damage)
• Physical exam
o Begins with observation of general appearance, then the specifics
o Use general assessment techniques but look specifically for the following:
o Inspection:
Nutritional state: failure to thrive or poor weight gain
Skin color: cyanosis and pallor
Chest deformities- enlarged heart
Unusual pulsations of neck veins seen in some patients
Respiratory pattern- tachypnea, dyspnea, presense of expiratory grunt
Clubbing of fingers (now rarely seen in children d/t advances in surgical techniques)
o Palpation
Quality and symmetry of pulses
o Auscultation
Heart rate and rhythm
Presence of murmurs
o Height and weight
o Position of comfort
Remember, squatting/fetal positions are often comfortable for a child with a CHD.
• Tests of cardiac function
o Electrocardiography
Records electricity generated by the beating heart
Painless but scary, child must be still
o Exercise stress test
Monitoring of heart rate, BP, ECG, and oxygen consumption at rest and during exercise on a tread mill or bicycle
o Chest x-ray
Shows accurate picture of heart size and contour; size of the heart chambers
Used more as a screening tool
o Echocardiography
Ultrasound (high frequency sound waves produce an image of heart structures)
The primary diagnostic test for heart disease.
Cardiac catherization
• Radiopaque catheter is inserted through peripheral blood vessel into heart
o Contrast material is injected and films taken (called angiography)
• Reasons for performing:
o Diagnose specific heart disease
o Measure pressures and O2 sats
o Visualize heart structures
o Determine blood flow patterns
Preparation for Cardiac cath
• Although done frequently, there are some risks. Typical reactions include:
o Acute hemorrhage from entry site (usually femoral artery)
o Low grade fever (reaction to contrast media)
o Nausea
o Vomiting
o Loss of pulse in the catheterized extremity
o Transient dysrhythmia’s (d/t ventricular irritability)
• Done on an outpatient basis
• NPO for 2-4 hours before
• Older children should see the cath lab before procedure
• Accurate height and weight (for medications)
• Most children are sedated to decrease anxiety
Post catheterization care
• Are usually on a cardiac monitor and pulse oximeter for the first few hours of recovery.
• Know the baseline pulse/BP before the procedure to compare
• Most important nursing responsibility is observation of the following for signs of complications:
o Pulses, especially below the catheterization site, for equality and symmetry (pulse just distal to site may be weaker for the first few hours but gradually increase in strength.
Observations of:
• Temperature and color of the affected extremity. Coolness or blanching may indicate arterial obstruction.
• Vital signs are taken every 15 minutes. Special emphasis on heart rate. Must take for one full minute.
• Assess blood pressure, especially for hypotension.
o Hypotension could indicate:
Hemorrhage
Too much medication
Dehydration
• Dressing, for evidence of bleeding.
• Fluid intake, both IV and oral, to ensure adequate hydration.
o Remember sensible and insensible fluid loss (breathing too quick!).
• Hypoglycemia, especially in infants.
Interventions
• Child must keep extremity straight 4-6 hours after venous catheterization and 6-8 hours for arterial cath.
• Child’s diet can be resumed as soon as tolerating sips of clear liquid
• Keep site clean and dry
• Encourage child to void.
Congenital heart disease
• Incidence: 4-10 per 1000 live births
• The major cause of death in the first year of life
o Other than prematurity/low birth weight
• More than 35 well recognized defects
• Statistics improving due to more surgeries/treatments that help prevent death.
Etiology
• Not known in 90% of cases
• Factors associated:
o Maternal rubella during pregnancy
o Maternal alcoholism
o Maternal age over 40
o Maternal insulin-dependent diabetes
• More likely to have other defects such as Down syndrome.
Circulatory changes at birth
• In order to understand the pathophysiology of cardiac defects, it is important to understand fetal circulation and the changes that occur at birth.
Review of prenatal circulation- 3 essential structures
• Ductus venosus (DV): opening between umbilical vein and inferior vena cava.
o The ductus venosus is a vessel that allows blood to bypass the fetus's liver. It carries blood with oxygen and nutrients from the umbilical cord straight to the right side (right atrium) of the fetus's heart. The ductus venosus closes shortly after birth, when the umbilical cord is cut and blood flowing between the mother and fetus stops.
• Foramen ovale: opening between the right and left atrium—bypasses fetal lungs.
o The foramen ovale is an opening in the wall that separates the upper right and left heart chambers (atria). This opening allows blood to flow to the left side of the heart without going to the lungs. Before birth, the foramen ovale is kept open by the pressure of blood that passes through it. When the baby takes the first breath, blood begins to flow through the lungs, and the foramen ovale closes
• Ductus arteriosis (DA): Opening between pulmonary artery and descending aorta; allows fetal blood to bypass the lungs.
o There is still very little blood getting into the fetal lungs—just enough to help it grow in utero, even though they are collapsed until birth.
Purpose of these structures
• Allow most of blood to bypass the liver and lungs.
Fetal circulation
• Oxygenated blood from placenta to ductus venosus inferior vena cava right atrium.
• Blood then shunts over to the left atrium through the foramen ovale.
• Then over to the left ventricle aorta head/extremities.
• The unoxygenated blood returns to the right atrium via the superior vena cava flows into the right ventricle exits thought the pulmonary artery (which is connected to the aorta).
• Most of this blood shunts through the ductus arteriosis into descending aorta, and back into the placenta.
Birth changes
• Infant cries, lungs expand
• Ductus arteriosis closes as resistance decreases though the pulmonary vasculature (infants now need to use their own lungs)
• Clamping cord causes ductus venosus to clot (infant needs to use own liver)
• Venous return from lungs causes increase in left atrium pressure.
• Increased left atrium pressure causes left to right blood flow through patent foramen ovale (which is a bad thing—we no longer want to bypass the lungs)
• The foramen ovale is a one way valve so it closes permanently.
Birth changes, summary
• Ductus venosus
o Clots to form ligamentus teres
• Foramen ovale
o Closes to form interatrial septum
• Ductus arteriosis
o Closes to form ligamentum arteriosus
Altered hemodynamics
• Important to remember pressure gradients as blood will always flow (or shunt) from an area of higher to lower pressure.
• Heart defects cause a change in the direction of this normal flow of blood; create symptoms, especially those associated with congestive heart failure.
Congenital heart defects
• Usual cause—heart structure fails to progress beyond earlier
• Was once classified as “Cyanotic” and “Acyanotic”
• New classifications below
Classification of Congenital heart disease
• Increase in pulmonary blood flow
• Decrease in pulmonary blood flow
• Obstruction to blood flow from ventricles
• Mixed blood flow
Defects with increased pulmonary blood flow
• Ventricular septal defect
o Hole between the ventricles
• Atrial septal defect
o Hole between the atria’s
• Patent Ductus Arteriosis (PDA)
o Allows blood to flow from higher pressure aorta to the lower pressure pulmonary artery, causing a left to right shunt.
• Atrialventricular septal defect
o Most likely to be a low artrial and a high ventricular defect.
• More blood to the lungs than needed.
• These defects allow blood to flow from area of higher pressure (left side of the heart), to area of lower pressure (right side of the heart).
• This creates increased blood volume on the right side of the heart which increases pulmonary blood flow.
• Usually results in CHF.
o Pulmonary hypertension and cor pulmonae are frequent disorders associated with this.
Defects causing Decreased pulmonary blood flow
• Tetralogy of the Fallot
o Pulmonic Stenosis: Narrowing of the pulmonary artery or valve
o Ventricular septal defect
o Overriding of the aorta: position of the aorta is not correct. Blood may be shunted from both ventricles.
o Hypertrophy of the right ventricle
Clinical symptoms:
O2 sats below 80%
Clubbing of fingers and toes
Polycythemia (increased hct)
Anoxia aeb: dizziness & convulsions
Squatting
Stunted growth
• Tricupsid Atresia
o Extremely serious.
o Tricupsid valve is completely closed.
o No blood flow from the right atrium to the right ventricle
o Blood passes through patent foramen ovale into the left atrium and through a ventricular septal defect to the right ventricle and out to the lungs.
Defects causing obstruction to blood flow from ventricles
• Coarctation of the aorta
o A segment of the aorta is too narrow, near the insertion of the ductus arterious.
o High blood pressure develops
o Left ventricle is enlarged
o Oxygenated blood to the body is reduced.
• Pulmonary stenosis
o Narrowing of the pulmonary artery or pulmonary valve just distal (under/below) to the valve.
o Eventually causes right ventricular enlargement (hypertrophy)
• Aortic stenosis
o Narrowing of the aortic valve
o Prevents blood from passing freely from left ventricle unto aorta.
o Causes left ventricular hypertrophy from increased pressure in the left ventricle.
Mixed blood flow
• Cardiac anomalies that involve the mixing of blood from the pulmonary and systemic circulation in the heart chambers.
• Results in deoxygenation of systemic blood flow.
• Cyanosis is not always visible.
Mixed blood flow involves:
• Transpositions of the Great Arteries
o Aorta arises from the right ventricle instead of the left
o Pulmonary artery arises from the left ventricle
o Blood enters the heart from the vena cava.
o Goes to the right atrium to the right ventricle then goes out the aorta to the body completely deoxygenated.
o Very incompatible with life
o Surgery indicated
• Total Anomalous Pulmonary Venous Return
o Pulmonary veins return to the right atrium or the superior vena cava instead of to the left atrium as they normally would. (The oxygenated blood keeps going back into the lungs)
o Blood must be shunted across a patent foramen ovale or ductus arteriosus in order to reach the systemic circulation.
• Truncus Arteriosus
o One major artery or “trunk” arises from the left and right ventricles in place of a separate aorta and pulmonary artery.
o Usually accompanied by a VSD.
o Restructure common trunk to create two separate vessels (2 separate trunks)
• Hypoplastic left heart syndrome
o Left ventricle of the heart is non-functional.
o Unable to effectively pump blood into the systemic circulation.
o Right ventricle enlarges as it tries to do all of the work.
o Transplant or the 3 Staged Norwood procedures performed.
Two principle clinical consequences of defects
• Heart failure
• Hypoxemia
Heart Failure
• Results when myocardium of heart cannot circulate and pump enough blood to supply oxygen and nutrients to body cells
• Blood pools in the heart or in pulmonary or venous systems
• To increase cardiac output, the heart compensates in several ways:
o Muscle fibers lengthen, causing ventricles to increase and handle more blood with each stroke (ventricular hypertrophy).
o Heart rate can also increase
• Eventually the heart can no longer compensate—blood pools, unable to be pushed forward effectively.
First signs of CHF
• Tachycardia, at rest and on slight exertion
• Tachypnea
• Scalp sweating, especially in infants
• Fatigue and irritability
• Sudden weight gain
• Respiratory distress
Implementation in CHF
• Reduce workload of the heart:
o Decrease extra fluid (diuretics)
o Strengthen cardiac function (digoxin)
o Decrease afterload with vasodilators
Afterload is the amount of force needed for left ventricle to push blood through the body.
• Decrease cardiac demands
o Allow for uninterrupted sleep periods
o Small frequent feedings or gavage
The more food in the stomach, the more cardiac work it is to digest.
• Reduce respiratory distress
o Count respirations carefully
o Humidified O2
o Semi or high Fowlers
Hypoxemia
• Color is not a great indicator
• SaO2 of 80-85%-- Saturation of Oxygen (arterial blood/Hemoglobin)
• Polycythemia (increase of the RBC’s d/t chronically low oxygen saturations)
• Clubbing
• Squatting to increase venous return
• Hypercyanotic spells
Surgical intervention
• Early intervention prior to hypoxic episodes preferred
• Mortality rates vary from 2% to 25%
• Surgery should be done in major centers
ALTERATION IN NUTRITION AND ELIMINATION
Overview of function of GI system
• Responsible for taking in and processing nutrients for all parts of the body.
• Any problems can quickly affect other systems of the body
• In children, can affect overall health, growth, and development
Overview of nutrition
• Infants
o First 6 months can live off of breast milk or commercially prepared formula with iron added
o May need to have Fluoride added if not already in the water.
• Cows milk is not recommended until 1 year of age d/t allergies
• First year is one of rapid growth
o High protein
o High calories
• A little about obesity
o A baby who is overweight by the age of one will usually struggle with weight as an adult.
Introducing solid foods
• 5-6 months: iron-fortified infant cereal mixed with breast milk, orange juice, or formula.
• 7 months: vegetables
• 8 months: fruit
• 9 months: meat
• 10 months: egg yolk
Toddler Nutrition
• Appetite is usually smaller than infant because they are growing at a less rapid rate
• Tend to play with their food
• Want to feed themselves. Do not want to be fed.
• May also choose the same foods over and over.
Preschooler and Nutrition
• Still not very big eaters at this age
• Parents should attempt to make meal times a pleasant experience for children.
School age children and nutrition
• Good appetites
• Should begin the day with breakfast
• Usually hungry after school
Adolescents and nutrition
• Growing so fast that they may always feel hungry
• May tend to eat faddish foods or those not very nutritious.
• May rebel against a parents wishes for them to eat good food
• This is a time when binging and unhealthy dieting may occur (even with athletes)
• Tend to not eat enough iron, calcium, and zinc
Physiological differences: Adults vs. Children
• Internal distribution of water
o Fluid is a greater fraction of their total body weight as compared to adults
Infants: 75-80% TBW
2 years: 60% TBW
Amounts stay approximately the same through later childhood and adult life
o Body water is also distributed differently in infants than older children.
Infants have more interstitial fluids
Extracellular fluid compartment in infants includes 35-45% body water
• Insensible water loss
o Loss of fluid through lungs and skin
o Insensible water losses per unit of body weight are higher for an infant and younger child than an adult.
Total body surface is larger in infants/children
Body surface is the percentage of skin compared to total body weight.
Infants have more skin for their size. The more skin, the more fluid loss through skin
Infants and children have rapid respiratory rate and metabolic rate
o All of these factors contribute to greater fluid loss through evaporation.
o In addition, treatments or other conditions may increase fluid output
Activity, fever, diarrhea, vomiting
• Kidney function
o During the first 2 years, kidneys are not mature
Do not excrete waste products efficiently
Difficulty concentrating or diluting urine
Sodium regulation mechanisms are not mature
o Nurses want to make sure that kidneys are working before adding potassium to I.V. fluids.
• Other imbalances
o Children are also more readily susceptible to imbalances in:
Serum glucose
Calcium
Potassium
Glucose
• Infants and children have
o Higher glucose needs due to high metabolic rate
o Low glycogen stores
o Hypoglycemia a threat under periods of stress
Calcium
• Infants and children have:
o Regulation of calcium less exact in infant than in older child or adult
o When stressed, more growth hormone (GH) is secreted
GH increases result in increased calcium deposits in bone
Infant unable to keep up with these increased demands
Hypocalcemia results.
Potassium
• Potassium concentration easily affected by decreased intake or intestinal illne
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CHILD HEALTH NURSING www.webs.comCHILD HEALTH NURSING Child Health Nursing • Focuses on protecting children from illness and injury • Assists children to obtain optimal levels of wellness Primary roles of the Pediatric Nurse • Care provider • Educator • Advocate Pediatric Health Statistics • Infant Mortality o Number of deaths per 1000 live births during 1st year of life. o Infant mortality rate is an indicator of how healthy the nation is. o This rate is used to compare national health care to previous years and to other countries. o There has been a great decrease in the number of deaths over the past century. In 1997, 6.9 per 100 live births. Childhood Mortality • For children older than one year, death rates have always been less than those for infants. • In later adolescence, there is a sharp rise in deaths. Injuries; the leading killer in childhood • Injuries cause more death and disabilities in children than any diseases. • Some examples include: o Motor vehicle accidents are the leading cause of death in children over 1 year of age. o Majority of deaths are due to no use of seatbelts. • Drowning is 2nd leading cause of death in boys 1-14; both sexes 15-24 years old. Drowning is the 3rd leading cause of death for girls 1-14. • Burns are the 2nd leading cause of death from injury in girls and the 3rd in boys from 1-14 years old. Childhood Morbidity (Illness) • An illness or injury that limits activity, requires medical attention or hospitalization, or results in a chronic condition. • Examples: o Congenital heart defects o Asthma o Cerebral Palsy o Cystic Fibrosis • Concerned with helping to decrease these statistics as children miss school and other activities when ill. Advanced Practice roles for nurses in Child health nursing • Family nurse practitioner • Neonatal nurse practitioner • Pediatric nurse practitioner • Nurse midwife Growth and Development • Growth: used to show an increase in physical size or a significant change. • Includes: o Height o Weight o Head circumference • Development: Used to denote an increase in skill or ability to finction. • Measured by: o Observing child do specific tasks o Parents description of child’s ability o Using standardized testing (Denver II screening test) Principles of Growth and development • G & D is a continuous process from birth to death o Rate of growth varies at different times • G & D proceeds in an orderly manner o Growth from smaller to larger o Development: from sitting to crawling to walking • Different children pass through the predictable stages at different rates • All body systems do not develop at the same time. • CNS, Cardiac develops quickly. • Lungs are typically the last to develop. Development is Cephalicaudal, which is the 3rd principle of G & D. “Head to toe”. Development goes from proximal to distal, which is the 4th principle. • Example: Development proceeds from gross to refined. • A child cannot learn tasks until the nervous system is ready. • Neonatal reflexes must be lost before development can proceed. Factors that influence growth and development • Genetics • Gender • Health • Intelligence Temperament • Inborn in all of us • A way of reacting to the world around us Reaction Patterns: • Activity level o Level of activity differs widely among children • Rhythmicity o Have a regular rhythm is physiologic terms • Approach o Child’s response to a new situation • Adaptability o Is the child able to adapt to new situations? • Intensity of reaction • Distractibility • Attention span and persistence • Mood quality Categories of temperament • The “Easy” Child o Easy to care for if they have predictable rhythmicity, approach and easily adapt to new situations, have a mild to moderate intensity of reaction, and an overall positive mood quality. o 40-50% of children fall into this category • The “Difficult” child o Children are “difficult” if irregular in habits, have negative mood quality, and withdraw from new situations o 10% of children fit this image. • “Slow to warm up” child o Describes children who are overall fairly inactive, respond only mildly, adapt slowly to new situations, and have a general negative mood. o 15% of children display this pattern. Other factors that impact growth and development • Environment • Socioeconomic level • Parent-child relationship • Position of birth in the family • Health • Nutrition • As a child normally develops somewhat predictably in growth and physical development, he also matures emotionally, intellectually, and spiritually along certain paths. Review: • Erikson’s theory of Psychosocial development • Piaget’s theory of cognitive development • Kohlberg’s theory of Moral development ASSESSMENT OF THE CHILD Basic Principles • Know norms; child vs. adult • A & P variations are farthest from adult norms at birth o Most of these variations mature quickly in the first year o By 5-7 years of age, body is that of a “Small adult”; however, a child is not a miniature adult and should not be treated as such. • As a child normally develops somewhat predictably in growth and physical development, he also matures emotionally, intellectually, and spiritually along certain paths. • Try to see the child’s world and body through his/her mind. If you do this, you will connect with the child. Approach to exam • Always think of where the child is developmentally. • Approach must be individualized • Usually the child will be frightened and anxious. May lack verbal skills to express fear or ask for information. • Use both hands on child when possible – comforting touch. o Place left hand on shoulder while auscultating the heart. o Move unhesitatingly, firmly, and gracefully. o Talk pleasantly and reassuringly. • Instructions to the child: o Use a directive voice o Have specific instructions o Do not ask, but instead tell a child Example: Say “Roll over on your belly” rather than “Will you roll over on your belly?” Physical Exam • Can take place almost anywhere o On parents lap o On the floor o Examiners lap Conducting the exam • Perform the least distressing procedures first and the most distressing last. o Heart and lungs; have the child lie down. o Abdomen, throat, and ears (throat and ears are the worst) o Genitalia and rectum Physical exam technique • Inspection o Observe before you touch • Auscultation o Use diaphragm of stethoscope for high pitched sounds (bowel sounds) o Use bell of stethoscope to help localize sounds for infant • Palpation o Use pads of fingers to determine tenderness and pulsations o Use palmar surface of fingers to determine masses and organ enlargement o Observe reaction to palpation rather than to ask if it hurts (don’t suggest that it does) • Percussion o A more advanced technique usually done by physicians and advanced practice nurses. The general survey • Vital signs • General appearance • Mental status • Body measurements Vital signs • Temperature o Body temperature in infants is less constant than in adults o Use ax/tympanic for children less than 4 years of age o Values are the same as in adults • Axillary: hold child’s arm firmly • Tympanic: o Less than 3 years of age Insert gently into ear Pull down on ear o Over 3 years of age Pull up on ear • Rectal temperature o Most hospitals are done only with doctors order, or there is a standing order. o Lubricate tip well o Insert 1 inch • Pulse o Apical is best o May use femoral arteries, brachial arteries o Radials only in older children (at least 2 years old) • Respirations o The younger the child, the more abdominal breathing o Observe the abdomen instead of the chest in infants and small children o May need to auscultate the chest or put the stethoscope in front of the mouth and nose. • Oxygen saturations • Blood pressure o Wide enough to over 75% of the upper arm o Narrow cuff elevates reading, wide cuff lowers reading o In infants less than 1 year: Thigh BP = arm BP o Older than 1 year: Systolic in thigh is 10-40 mm Hg higher than in arm Diastolic is same in thigh and arm o If BP in thigh is less than in arm: Cardiac anomaly or decreased circulation to extremities Be sure to use correct size cuff Use the same extremities, the same size cuff, and same position whenever possible when trending values for an individual patient. o Diastolic BP Diastolic pressure reaches about 55 mm Hg at one year of age Gradually increases to 70 throughout childhood o The most common cause of hypertension in children are: Anxiety (increases BP in children) Renal disease (78%) Coarctation of the aorta (2%) General appearance • To form a general impression of child’s health and well-being • To pin-point specific areas that may require more detailed assessment Initial observations • Degree of illness or wellness • Mood • State of nutrition • Speech, cry, facial expression, posture • Apparent chronological and emotional age • Respiratory pattern • Parent and child interaction Parent and child interaction • Amount of separation tolerated • Displays of affection • Response to discipline • Look for signs of: o Anxious parents o Disengaged parents o Stressed families o Possible abusive parents (no separation anxiety when removed from parent, or over-affectionate) Child cries or clings to parent • Ignore the child temporarily • Engage the parents in conversation, then place a small game, toy, or your stethoscope within reach of the child while continuing your discussion Mental status • Is the child alert? • Able to respond to questions easily? • Assess appropriateness of behavior • Assess memory Assessing Growth/Body measurements • Height, weight, head circumference—important indicators of growth • Measured and plotted on standard growth charts • These charts are used to determine if the baby/child’s growth is falling within the accepted percentile for age Length • Birth to 36 months o Fully extend the body by: Holding the head midline Grasping the knees together gently Pushing down on the knees until the legs are fully extended and flat against the table. o Hold pencil at right angle to the table and mark the head and toes (which are pointed toward the ceiling) Height • Child’s back is to the wall, with heels, buttocks, and back of the shoulders touching the wall and the medial melleoli touching if possible. • Check for bending of the knees, slumping of the shoulders, or raising the heels of the feet Weight • Birth to 36 months, weigh nude • Older children with panties and light gown • Balance (or zero) scale prior to weighing Head circumference • Measure at greatest circumference • Slightly above the eyebrows and pinna of the ears o Around the occipital prominence at the back of the skull o Compare to 36 months Denver Developmental • The standard for measuring the attainment of developmental milestones throughout infancy and childhood. • Designed for birth to 6 years • Includes screening for: o Personal social skills o Fine motor adaptive o Language o Gross motor • Denver screening for articulation and eyes Example of DDST for One year of age: • Personal/Social o Drink from a cup, imitate activities, play ball with examiner, indicate wants, play pat-a-cake • Fine motor/adaptive o Scribbles, puts block in cup • Language o Dada/Mama specific, one word • Gross motor o Stands alone More on DDST: • Only a measure of developmental attainment—not a measure of intelligence • Not a highly specific test o Most normal children score as normal • Not very sensitive o Many children with mild developmental delays also score normal • Only a screening test • Other more sophisticated tests are available if delay is suspected even when DDST is normal. Heart Murmurs • 50% of all children develop an innocent heart murmur at some point during childhood. It is usually not something to be overly concerned about unless there are other symptoms. Must be determines if murmur is normal; therefore always report when one is heard. Abdomen • Protuberant abdomen is typical in most children until adolescence. • If child is ticklish on palpation, hold his/her hand over yours to reduce apprehension and increase relaxation of the abdominal musculature. Neuromuscular • If possible, watch the child standing upright. Have them walk, stoop, and touch their toes • Checking for scoliosis. More tidbits: • Always think of child’s development when assessing • Know the BP and pulse variations • When there is an abnormal finding – ALWAYS gather more data • Weight is a huge concern for children. Many medications are weight dependent. • The Denver Developmental is not very precise; it’s more of a screening tool • As it says, the Denver Developmental is only developmental—not a cognitive or an IQ test. • For breath sounds: o Encourage the child to “blow out” your light, in your pen light or flashlight. This will almost always produce full inspiration. CARE FOR THE HOSPITALIZED CHILD General communication guidelines • Pay attention to infants and younger children through play or by occasionally directing questions or remarks to them. • Include older children as active participants. • With children of all ages, the nonverbal components of the message conveys the most. • Communicate at the child’s level o Developmentally and physically Communication Guidelines • Allow children time to feel comfortable • Avoid sudden or rapid movements, extended eye contact, or other gestures that may be seen as threatening. • Talk to the parent if the child is initially shy • Communicate through puppets, dolls, or stuffed animals before questioning a young child directly. • Give older children the opportunity to talk without the parents present • Speak in a quiet, unhurried, and confident voice. • Speak clearly, be specific, and use simple words and short sentences. • Be honest with children • Offer a choice only when one exists. • Allow them to express their concerns and fears • Use a variety of communication techniques; if one technique doesn’t work, try another. Infant • One month to one year old • Erikson’s developmental task: Trust vs. Mistrust o Task: Attachment to the mother o Resolution of crisis: Trust in persons; faith and hope about the environment and future. o Unsuccessful resolution of crisis: General difficulties relating to person’s effectively; suspicion; trust-fear conflict, fear of the future. Infant: communication • Forms first social relationships • Communicates needs and feelings through nonverbal behaviors and vocalizations o Smile and coo when content o Cry when distressed—hunger, pain, body restraint, loneliness • Respond to adults’ nonverbal behaviors o Become quiet when cuddled, patted, or receive other forms of gentle, physical contact. o Get comfort from the sound of voice—usually respond to any gentle firm handling until they reach the age of stranger anxiety (5-8 months). Infant: Stressors of Hospitalization • Separation anxiety • Stranger anxiety • Painful, invasive procedures • Immobilization Separation Anxiety • Occurs as early as 4 months old; infants face shows disapproval as primary caregiver walks away. • Three stages of separation anxiety: o Protest Cries loudly; rejects attempt to be comforted by anyone but the caregiver o Despair Crying stops and depression is evident Much less active Uninterested in food or play Withdraws from others o Detachment (denial) Shows increased interests in surroundings Interacts with strangers or familiar caregivers Forms new but superficial relationships Appears happy Detachment usually occurs after prolonged separation from parents; rarely seem in hospitalized children. Behaviors represent a superficial adjustment to loss. • Interventions for separation anxiety: o Encourage parents to room-in with infant o Involve parents in child’s care whenever possible o Keep parent in infant’s line of vision o If parent is unable to be with infant, place familiar object with infant (stuffed toy, etc.) o Support sibling and grandparent visitation Stranger anxiety • Occurs as early as 5 months • Usually peaks at 8 months • Behaviors exhibited by infant: o Cries o Screams o Searches for parent with eyes o Clings to parent o Avoids and rejects contact with strangers • Interventions for stranger anxiety: o Holding out hands and asking the child to “come” will usually not work. If infant must be handled, better to pick up firmly without gestures. o Observe position in which parents hold infant and imitate this. o Hold infants where they can see their parents o Are usually more at ease upright than horizontal. Fear of procedures—interventions • During procedure, use sensory soothing measures (Stroking skin, talking softly, giving pacifier) • Cuddle and hug after stressful procedure or encourage parent to do so if present. • Older infants may associate objects, places, or persons with prior painful experiences and will cry and resist at the sight of them o Keep frightful objects out of view o Perform painful procedures in separate room, not in crib, o Use non-intrusive procedures whenever possible. Immobilization • Infants explore life through activity and mobility. If taken away: o Feel helpless o May have difficulty with language skills o May have problems mastering developmental tasks o Problems with motor skills o Immobility impacts development. • Immobilization interventions: o Play therapy o Transport infant outside of room by wagon of by carrying o Spend time interacting with infant o Encourage caregivers to do the same Toddler • Ages one to three years old • Erikson’s developmental task: Autonomy vs. shame and doubt. o Task: Gaining some basic control over self and environment o Resolution of Crisis: Sense of self-control and adequacy; will power o Unsuccessful resolution of crisis: Independence-fear conflict; severe feelings of self-doubt. • Developing a sense of autonomy • He wants to make choices and like the word “No!” • Is egocentric • Focus communication on toddler o Toddler not interested in the experiences of others Stressors of hospitalization • Separation anxiety • Loss of control • Painful, invasive procedures • Bodily injury • Fear of dark Separation anxiety • Verbally attack stranger (“Go away!”) • May physically attack stranger (kicks, bites, hits) • Tries to escape to find parent • Tries to physically force parent to stay (clings) • May have temper tantrums or refuse care • Behaviors may last from hours to days Separation anxiety—interventions • Child’s reaction to separation o Toddler might ignore parent. • Other strategies are same as for infant. • Feels more secure with familiar item • Allow them to touch and examine articles that will come into contact with them • Be direct and concrete • They interpret words literally. Loss of control • Very threatening to the toddler • Many hospital situations decrease amount of control a child feels • Loss of control occurs due to: o Restriction or limitation of movement o Altered routines and rituals Eating Toileting Sleeping Bathing Play o When routines are disrupted, problems can occur in these areas • Interventions o Promote freedom of movement Encourage parent-child contact Transport in carriage, wheelchair, carts, etc. Maintain child’s routine Encourage as much independence as possible (allow child to wear clothes from home, etc.) Bodily Injury/Invasive procedures • Concept of body very poor • Intrusive procedures (examining ears) create much anxiety • React with intense emotional upset and physical resistance • Interventions: o Tell child it’s ok to yell, cry, or do whatever is needed during procedure o Explain procedure in relation to child’s senses o Ignore temper tantrums o Use distraction techniques (Sing song with a child) Fear of the dark • Keep night light on in room at all times • Encourage parents to room-in with child Preschool • 3-6 years of age • Erikson’s developmental task: Initiative vs. Guilt o Task: Becoming purposeful and directive o Resolution of Crisis: ability to initiate one’s own activities; sense of purpose. o Unsuccessful resolution of crisis: aggression-fear conflict; sense of inadequacy or guilt • Developing a sense of initiative • Preschooler is: o Egocentric o Has increased language skills o Concept of time and frustration tolerance is limited o Illness and hospitalization may be viewed as punishment Fears of hospitalization • Separation anxiety and fear of abandonment • Loss of control • Bodily injury • Painful, invasive procedures • Fears of the dark, ghosts, monsters Separation anxiety- preschooler • Tolerate separation better than toddlers; may develop substitute trust in other significant adults • However, they may show other behaviors: o Refuse to eat o Have difficulty sleeping o Cry quietly for parents o Constantly ask when parent will be visiting o May express anger • Interventions: o Have parents bring in familiar articles from home—pictures/radio o If child has attachment to special item, have it brought in o Same strategies for toddlers Loss of control • Egocentric and magical thinking; perception of actual events are more frightening o Typical fantasy: Illness is a punishment for their misdeeds • Purely verbal instructions do not help them, have them practice on doll or toy. Bodily injury • Differentiate poorly between themselves and outside world. • Fear of mutilation • Take things literally “Stick for blood” • Fear if when given a shot, when needle is removed, their insides will leak everywhere (put a band aid in place). Interventions: • Point out on drawing, doll, or child where procedure is performed • Emphasize that no other body part will be involved • Use non-intrusive procedures when possible • Apply adhesive bandage over puncture site • Encourage parental presence • Allow child to wear underpants with gown • Explain unfamiliar situations, especially noise or lights • Involve child in care whenever possible (hold equipment, remove dressing) • Praise child for helping and attempting to cooperate • Never shame child for lack of cooperation School age child • 6-12 years old • Erikson’s developmental task: Industry vs. Inferiority o Task: developing social, physical, and school skills o Resolution of Crisis: competence, ability to learn and work o Unsuccessful resolution of crisis: Sense of inferiority; difficulty learning and working • Developing a sense of industry and concrete thought • Has increased language skill o Interest in acquiring knowledge o Improved concept of time o Increased self-control o Developing relationships with peers; peers are very important at this stage. • Usually will want explanations and reasons for why things are being done • Want to know more about procedures, activities, and objects • Have a greater concern for privacy and body integrity • Usually easier to communicate with than previous age groups o Concrete thinkers; no abstract thought Stressors of hospitalization • Separation anxiety • Loss of control • Bodily injury • Painful, invasive procedures • Fear of death Separation anxiety • Younger school age children miss their parents more than older children • Middle/late react more to separation from peers and usual activities o May feel lonely, bored, isolated, depressed due to separation, not the illness. o May try to be “brave and strong”. o May be irritable with parents • Interventions o Make environment as home-like as possible Continue school lessons Have friends visit or call on phone Decorate walls with cards Bodily injury • Less concerned with pain, more concerned about disability or death • Take very active interest in their health • Request facts Invasive procedures • Want to know about a procedure (will it hurt? What’s it for?) • Tolerate intrusive procedures well • By age 9 or 10 should less fright to pain Adolescent • Ages 12-20 years • Erikson’s developmental task: Identity vs. Role confusion o Task: developing sense of identity o Resolution of Crisis: sense of personal identity o Unsuccessful resolution of crisis: confusion about who one is; identity submerged in relationships or group memberships • Developing a sense of identity and abstract thought • Fluctuate between child and adult thinking and behavior o Need to express their feelings, for some this comes easily, for others it does not. o Major sources of concern for this age group are attitudes and feelings toward sex, substance abuse, relationships with parents, peer-group acceptance, and developing a sense of identity. Stressors of hospitalization • Loss of control • Altered body image, disfigurement o Do not want to look different • Separation from peer group • Loss of control o Anything that interferes with sense of independence o Patient role fosters dependency o May withdraw, be uncooperative, angry, frustrated. • Altered body image o Very relevant at this stage o Any change that makes them different from peers is seen as a major tragedy o Insecure with their bodies due to the many changes o May react with “know it all” attitude (but may be afraid, deep down) o Privacy is very important—may need to give them some time alone. CYSTIC FIBROSIS Epidemiology • Affects approximately 30,000 children and adults in the US today or 1 in 2500 live births • Occurs most commonly in whites, rarely in blacks and Asians • More than 10 million Americans (1 in 31 or 3.3%) are symptom free carriers of the defective CF gene Survival • In 1955, few children with CF lived to attend elementary school. Today, the median age of survival is 32 years. • In this decade, many CF survive into their 40’s. Etiology • An inherited (genetic) disease • CF is an autosomal-recessive disease (this means an individual must inherit 2 defective CF genes, one from each parent) • The defective gene in CF occurs in Chromosome 7 • The gene causes the dysfunction of the exocrine glands What are exocrine glands? • Glands that secrete things such as: o Lungs o Pancreas o Sweat glands o Salivary glands o Digestive glands Pathophysiology • CF causes the body to produce an abnormally thick, sticky mucus which: o Clogs the lungs and leads to life-threatening lung infections; o Obstructs the pancreas, preventing enzymes from reaching the intestine to help break down and digest food • Primary symptoms: o Thick, sticky mucus o Salty taste on skin • Marked electrolyte changes in sweat glands o Chloride in sweat is 2-5X above normal Lung involvement • Thick tenacious mucus polls in the bronchial tree and obstructs bronchioles • Results in: o Bronchiectasis: Chronic dilation of the bronchi. Involves a chronic cough that produces mucopurulent sputum. Over time results in destruction of the bronchial walls. o Pneumonia: Staph Aureus, pseudomona’s, and H. Influenzae • Symptoms over time include: o Clubbing of fingers Clubbing is related to lack of tissue perfusion Symptoms over time: • Easily fatigued • Physical growth stunted • Chest may become enlarged from over inflation of alveoli because air cannot be pushed past the thick mucus on expiration (barrel chested) • Increased carbon dioxide in blood (hypercapnia and/or chronic acidosis) Pancreas involvement • Thick secretions mix with pancreatic enzymes and block the pancreatic duct. • Therefore: o Essential pancreatic enzymes cannot flow into the duodenum to aid with digestion (lipase, trypsin, and amylase) o Fats, proteins, and some sugars cannot be digested—are excreted in stools: o Stools (The 4 F’s in CF) Frothy (bulky/large) Foul smelling (comparable to a cats stool) Fat containing “greasy” Steatorrhea Floaters • Clogged ducts causes back pressure on the acinar cells (they make the enzymes) • The cell lining of pancreas is damaged • Over time the acinar cells atrophy and no longer produce the enzymes Symptoms related to Pancreatic Involvement • Protuberant abdomen because bulk of stool is setting in the intestines • Signs of malnutrition—only benefit from 50% of food taken in • Fat soluble vitamins are not absorbed A, D, E, K • In infants, thick, sticky stools (meconium) which may cause intestinal obstruction o One of the first signs of CF in infants Sweat gland involvement • The structure of the sweat glands is not changed, however: • Level of chloride to sodium in the perspiration is increased 2 – 5 times above normal • Some parents report they knew their newborn had the disease because when they kissed their child they could taste such strong salt in their perspiration How is CF diagnosed? • By the history (cough, stool, abdomen, hx. of pneumonia) • The abnormal concentration of chloride in sweat • The absence of pancreatic enzymes in duodenum (can be tested through NG tube) • Pulmonary involvement Common complaints that bring these patient to the doctor • Newborn that loses 5-10% of weight after birth but does not gain it back • Feeding problems—kids are always hungry because of their poor digestive function • Frequent respiratory infections • Cough Diagnostic tests • A sweat test is a test for the chloride content of sweat • Infants may not be tested until 6-8 weeks of age. (they don’t sweat a great deal) o Normal concentration of Chloride in sweat is 20 mEq/L o A level of 50-60 mEq/L suggests CF—test is repeated o A level >60 mEq/L = CF • Duodenal analysis of secretions for detection of pancreatic enzymes • Stool analysis: for fat content (although appearance may be enough) • Pulmonary testing—chest x-rays or PFT’s Therapeutic management • Maintain respiratory function o Keep bronchial secretions as moist as possible to facilitate drainage: Moistened oxygen: Oxygen is supplied to children by mask, prongs, ventilators, or neubulizers, and rarely by tent Aerosol therapy- 3-4 times/day via neubulizer to provide antibiotics and bronchodilators o Never give cough syrups or codeine • Aggressive chest physiotherapy- usually needed 3-4 times a day • Activity- need frequent position changes, especially when in bed. Helps facilitate drainage of various lobes, as well as prevent skin breakdown. • Respiratory hygiene: frequent mouth care, toothbrushing and good-tasting mouthwash. • Need frequent check-ups and current immunizations/vaccines • Adequate rest and comfort o Dyspnea can lead to exhaustion o Need periods of rest during the day: Rest period before meals so not too tired to eat Rest periods before chest physiotherapy • Promote optimal nutrition o Pancreatic enzyme supplements with meals and snacks Pancreatic enzyme: Cotazym or pancrease Comes in large capsule which can be opened and dissolved in a tsp. of food Children usually begin to gain weight, and stools decrease in size and foul odor. o High calorie, high protein, moderate fat diet o Multivitamins and E, others when deficient. • During hot months, extra salt may be added to food to replace that which is lost through perspiration • Keep room temp at 72 degrees and have water available at all times. Parents need to supervise kids playing outdoors to prevent overheating. • Keep well hydrated all of the time! Complications • Infertility in males related to blocking of vas deferens from tenacious seminal fluid • Infertility in females related to tenacious cervical secretions that block sperm penetration • Rectal prolapse in infants from straining to pass hard stool. Loss of blood supply to prolapsed rectal mucosa can occur if not replaced promptly and properly. • Hypercapnia/respiratory acidosis from inability to adequately exhale carbon dioxide • Exhaustion, slow growth patterns • Skin irritation in diaper area from stool that is irritating due to acidic nature of stools • Socialization and peer acceptance difficulties • Cor Pulmonale (right sided heart failure) from increased respiratory resistance • Anemia and bruising • Frequent respiratory infections and compromised immunity • Portal hypertension related to obstruction of bile ducts area of biliary fibrosis biliary cirrhosis • Pneumothorax related to rupture of pulmonary blebs Parental involvement • Parents assume a great deal of responsibility when taking care of a CF child. o Need to encourage a balance of work, the child, and the rest of the family o Encourage involvement of support group o Requires extensive involvement of the discharge planner Nursing Diagnoses • Ineffective airway clearance r/t thick mucus in the lungs • Ineffective breathing pattern r/t thick tracheobronchial secretions and airway obstruction • High risk for infection r/t presence of mucus secretions conductive to bacterial growth • Altered nutrition: Less than body requirements r/t inability to digest nutrients • Fear/Anxiety (parent or child) r/t prognosis and effect of illness on growth and development • Knowledge Deficit (parent or child) Summary • CF is an inherited genetic disorder • Causes the exocrine glands to produce thick secretions • Primary body organs involved are lungs and pancreas. • Prone to respiratory infections r/t mucus. • Digestion problems r/t pancreatic enzymes. • Treatment centers around control and management. No cure for the disease. ERIKSONS STAGES Infant • One month to one year old • Erikson’s developmental task: Trust vs. Mistrust o Task: Attachment to the mother o Resolution of crisis: Trust in persons; faith and hope about the environment and future. o Unsuccessful resolution of crisis: General difficulties relating to person’s effectively; suspicion; trust-fear conflict, fear of the future. o Developmental tasks: Learning to eat solid foods Toddler • Ages one to three years old • Erikson’s developmental task: Autonomy vs. shame and doubt. o Task: Gaining some basic control over self and environment o Resolution of Crisis: Sense of self-control and adequacy; will power o Unsuccessful resolution of crisis: Independence-fear conflict; severe feelings of self-doubt. o Developmental tasks: Learning to walk Learning to use fine muscles Toilet training Learning to communicate Preschool • 3-6 years of age • Erikson’s developmental task: Initiative vs. Guilt o Task: Becoming purposeful and directive o Resolution of Crisis: ability to initiate one’s own activities; sense of purpose. o Unsuccessful resolution of crisis: aggression-fear conflict; sense of inadequacy or guilt o Developmental tasks: Independence of self-care Learning sexual role identity Forming reality concepts Internalizing concepts of right and wrong Learning to identify with family members and others. School age child • 6-12 years old • Erikson’s developmental task: Industry vs. Inferiority o Task: developing social, physical, and school skills o Resolution of Crisis: competence, ability to learn and work o Unsuccessful resolution of crisis: Sense of inferiority; difficulty learning and working o Developmental tasks: Acquiring game skills Learning to relate positively with peers Building a wholesome self-concept Refining communication skills Adolescent • Ages 12-20 years • Erikson’s developmental task: Identity vs. Role confusion o Task: developing sense of identity o Resolution of Crisis: sense of personal identity o Unsuccessful resolution of crisis: confusion about who one is; identity submerged in relationships or group memberships o Developmental tasks: Forming peer relationships Responding to an appropriate sexual role Attaining emotional independence Achieving a sense of economic independence CARDIAC DEFECTS IN CHILDREN ALTERATION IN FLUID-GAS TRANSPORT Cardiac Defects in children: • Divided into two major groups: o Congenital cardiac defects o Acquired heart disease Congenital Heart Disease • Anatomic abnormality present at birth; the heart has not developed as it should in utero. • Thus, the heart is unable to adjust to life outside of mom • Results in abnormal cardiac function Acquired Cardiac disease • Abnormalities that occur after birth o Can occur by self o Can occur with other congenital heart defects o Example; Rheumatic disease is the 2nd largest cause of cardiac problems in children over 5) Both congenital and acquired heart disorders can lead to heart failure Assessment of cardiac function • History o History of heart disease in the family o Contact with known teratogens, such as rubella during pregnancy o Presence of chromosomal abnormalities (Down’s) o Poor weight gain and/or feeding behavior o Exercise intolerance and/or fatigue during feeds o Sweating during feeding o Frequent respiratory infections o Respiratory difficulties, such as tachypnea, dyspnea, and shortness of breath. o Recent streptococcal infection (may lead to valve damage) • Physical exam o Begins with observation of general appearance, then the specifics o Use general assessment techniques but look specifically for the following: o Inspection: Nutritional state: failure to thrive or poor weight gain Skin color: cyanosis and pallor Chest deformities- enlarged heart Unusual pulsations of neck veins seen in some patients Respiratory pattern- tachypnea, dyspnea, presense of expiratory grunt Clubbing of fingers (now rarely seen in children d/t advances in surgical techniques) o Palpation Quality and symmetry of pulses o Auscultation Heart rate and rhythm Presence of murmurs o Height and weight o Position of comfort Remember, squatting/fetal positions are often comfortable for a child with a CHD. • Tests of cardiac function o Electrocardiography Records electricity generated by the beating heart Painless but scary, child must be still o Exercise stress test Monitoring of heart rate, BP, ECG, and oxygen consumption at rest and during exercise on a tread mill or bicycle o Chest x-ray Shows accurate picture of heart size and contour; size of the heart chambers Used more as a screening tool o Echocardiography Ultrasound (high frequency sound waves produce an image of heart structures) The primary diagnostic test for heart disease. Cardiac catherization • Radiopaque catheter is inserted through peripheral blood vessel into heart o Contrast material is injected and films taken (called angiography) • Reasons for performing: o Diagnose specific heart disease o Measure pressures and O2 sats o Visualize heart structures o Determine blood flow patterns Preparation for Cardiac cath • Although done frequently, there are some risks. Typical reactions include: o Acute hemorrhage from entry site (usually femoral artery) o Low grade fever (reaction to contrast media) o Nausea o Vomiting o Loss of pulse in the catheterized extremity o Transient dysrhythmia’s (d/t ventricular irritability) • Done on an outpatient basis • NPO for 2-4 hours before • Older children should see the cath lab before procedure • Accurate height and weight (for medications) • Most children are sedated to decrease anxiety Post catheterization care • Are usually on a cardiac monitor and pulse oximeter for the first few hours of recovery. • Know the baseline pulse/BP before the procedure to compare • Most important nursing responsibility is observation of the following for signs of complications: o Pulses, especially below the catheterization site, for equality and symmetry (pulse just distal to site may be weaker for the first few hours but gradually increase in strength. Observations of: • Temperature and color of the affected extremity. Coolness or blanching may indicate arterial obstruction. • Vital signs are taken every 15 minutes. Special emphasis on heart rate. Must take for one full minute. • Assess blood pressure, especially for hypotension. o Hypotension could indicate: Hemorrhage Too much medication Dehydration • Dressing, for evidence of bleeding. • Fluid intake, both IV and oral, to ensure adequate hydration. o Remember sensible and insensible fluid loss (breathing too quick!). • Hypoglycemia, especially in infants. Interventions • Child must keep extremity straight 4-6 hours after venous catheterization and 6-8 hours for arterial cath. • Child’s diet can be resumed as soon as tolerating sips of clear liquid • Keep site clean and dry • Encourage child to void. Congenital heart disease • Incidence: 4-10 per 1000 live births • The major cause of death in the first year of life o Other than prematurity/low birth weight • More than 35 well recognized defects • Statistics improving due to more surgeries/treatments that help prevent death. Etiology • Not known in 90% of cases • Factors associated: o Maternal rubella during pregnancy o Maternal alcoholism o Maternal age over 40 o Maternal insulin-dependent diabetes • More likely to have other defects such as Down syndrome. Circulatory changes at birth • In order to understand the pathophysiology of cardiac defects, it is important to understand fetal circulation and the changes that occur at birth. Review of prenatal circulation- 3 essential structures • Ductus venosus (DV): opening between umbilical vein and inferior vena cava. o The ductus venosus is a vessel that allows blood to bypass the fetus's liver. It carries blood with oxygen and nutrients from the umbilical cord straight to the right side (right atrium) of the fetus's heart. The ductus venosus closes shortly after birth, when the umbilical cord is cut and blood flowing between the mother and fetus stops. • Foramen ovale: opening between the right and left atrium—bypasses fetal lungs. o The foramen ovale is an opening in the wall that separates the upper right and left heart chambers (atria). This opening allows blood to flow to the left side of the heart without going to the lungs. Before birth, the foramen ovale is kept open by the pressure of blood that passes through it. When the baby takes the first breath, blood begins to flow through the lungs, and the foramen ovale closes • Ductus arteriosis (DA): Opening between pulmonary artery and descending aorta; allows fetal blood to bypass the lungs. o There is still very little blood getting into the fetal lungs—just enough to help it grow in utero, even though they are collapsed until birth. Purpose of these structures • Allow most of blood to bypass the liver and lungs. Fetal circulation • Oxygenated blood from placenta to ductus venosus inferior vena cava right atrium. • Blood then shunts over to the left atrium through the foramen ovale. • Then over to the left ventricle aorta head/extremities. • The unoxygenated blood returns to the right atrium via the superior vena cava flows into the right ventricle exits thought the pulmonary artery (which is connected to the aorta). • Most of this blood shunts through the ductus arteriosis into descending aorta, and back into the placenta. Birth changes • Infant cries, lungs expand • Ductus arteriosis closes as resistance decreases though the pulmonary vasculature (infants now need to use their own lungs) • Clamping cord causes ductus venosus to clot (infant needs to use own liver) • Venous return from lungs causes increase in left atrium pressure. • Increased left atrium pressure causes left to right blood flow through patent foramen ovale (which is a bad thing—we no longer want to bypass the lungs) • The foramen ovale is a one way valve so it closes permanently. Birth changes, summary • Ductus venosus o Clots to form ligamentus teres • Foramen ovale o Closes to form interatrial septum • Ductus arteriosis o Closes to form ligamentum arteriosus Altered hemodynamics • Important to remember pressure gradients as blood will always flow (or shunt) from an area of higher to lower pressure. • Heart defects cause a change in the direction of this normal flow of blood; create symptoms, especially those associated with congestive heart failure. Congenital heart defects • Usual cause—heart structure fails to progress beyond earlier • Was once classified as “Cyanotic” and “Acyanotic” • New classifications below Classification of Congenital heart disease • Increase in pulmonary blood flow • Decrease in pulmonary blood flow • Obstruction to blood flow from ventricles • Mixed blood flow Defects with increased pulmonary blood flow • Ventricular septal defect o Hole between the ventricles • Atrial septal defect o Hole between the atria’s • Patent Ductus Arteriosis (PDA) o Allows blood to flow from higher pressure aorta to the lower pressure pulmonary artery, causing a left to right shunt. • Atrialventricular septal defect o Most likely to be a low artrial and a high ventricular defect. • More blood to the lungs than needed. • These defects allow blood to flow from area of higher pressure (left side of the heart), to area of lower pressure (right side of the heart). • This creates increased blood volume on the right side of the heart which increases pulmonary blood flow. • Usually results in CHF. o Pulmonary hypertension and cor pulmonae are frequent disorders associated with this. Defects causing Decreased pulmonary blood flow • Tetralogy of the Fallot o Pulmonic Stenosis: Narrowing of the pulmonary artery or valve o Ventricular septal defect o Overriding of the aorta: position of the aorta is not correct. Blood may be shunted from both ventricles. o Hypertrophy of the right ventricle Clinical symptoms: O2 sats below 80% Clubbing of fingers and toes Polycythemia (increased hct) Anoxia aeb: dizziness & convulsions Squatting Stunted growth • Tricupsid Atresia o Extremely serious. o Tricupsid valve is completely closed. o No blood flow from the right atrium to the right ventricle o Blood passes through patent foramen ovale into the left atrium and through a ventricular septal defect to the right ventricle and out to the lungs. Defects causing obstruction to blood flow from ventricles • Coarctation of the aorta o A segment of the aorta is too narrow, near the insertion of the ductus arterious. o High blood pressure develops o Left ventricle is enlarged o Oxygenated blood to the body is reduced. • Pulmonary stenosis o Narrowing of the pulmonary artery or pulmonary valve just distal (under/below) to the valve. o Eventually causes right ventricular enlargement (hypertrophy) • Aortic stenosis o Narrowing of the aortic valve o Prevents blood from passing freely from left ventricle unto aorta. o Causes left ventricular hypertrophy from increased pressure in the left ventricle. Mixed blood flow • Cardiac anomalies that involve the mixing of blood from the pulmonary and systemic circulation in the heart chambers. • Results in deoxygenation of systemic blood flow. • Cyanosis is not always visible. Mixed blood flow involves: • Transpositions of the Great Arteries o Aorta arises from the right ventricle instead of the left o Pulmonary artery arises from the left ventricle o Blood enters the heart from the vena cava. o Goes to the right atrium to the right ventricle then goes out the aorta to the body completely deoxygenated. o Very incompatible with life o Surgery indicated • Total Anomalous Pulmonary Venous Return o Pulmonary veins return to the right atrium or the superior vena cava instead of to the left atrium as they normally would. (The oxygenated blood keeps going back into the lungs) o Blood must be shunted across a patent foramen ovale or ductus arteriosus in order to reach the systemic circulation. • Truncus Arteriosus o One major artery or “trunk” arises from the left and right ventricles in place of a separate aorta and pulmonary artery. o Usually accompanied by a VSD. o Restructure common trunk to create two separate vessels (2 separate trunks) • Hypoplastic left heart syndrome o Left ventricle of the heart is non-functional. o Unable to effectively pump blood into the systemic circulation. o Right ventricle enlarges as it tries to do all of the work. o Transplant or the 3 Staged Norwood procedures performed. Two principle clinical consequences of defects • Heart failure • Hypoxemia Heart Failure • Results when myocardium of heart cannot circulate and pump enough blood to supply oxygen and nutrients to body cells • Blood pools in the heart or in pulmonary or venous systems • To increase cardiac output, the heart compensates in several ways: o Muscle fibers lengthen, causing ventricles to increase and handle more blood with each stroke (ventricular hypertrophy). o Heart rate can also increase • Eventually the heart can no longer compensate—blood pools, unable to be pushed forward effectively. First signs of CHF • Tachycardia, at rest and on slight exertion • Tachypnea • Scalp sweating, especially in infants • Fatigue and irritability • Sudden weight gain • Respiratory distress Implementation in CHF • Reduce workload of the heart: o Decrease extra fluid (diuretics) o Strengthen cardiac function (digoxin) o Decrease afterload with vasodilators Afterload is the amount of force needed for left ventricle to push blood through the body. • Decrease cardiac demands o Allow for uninterrupted sleep periods o Small frequent feedings or gavage The more food in the stomach, the more cardiac work it is to digest. • Reduce respiratory distress o Count respirations carefully o Humidified O2 o Semi or high Fowlers Hypoxemia • Color is not a great indicator • SaO2 of 80-85%-- Saturation of Oxygen (arterial blood/Hemoglobin) • Polycythemia (increase of the RBC’s d/t chronically low oxygen saturations) • Clubbing • Squatting to increase venous return • Hypercyanotic spells Surgical intervention • Early intervention prior to hypoxic episodes preferred • Mortality rates vary from 2% to 25% • Surgery should be done in major centers ALTERATION IN NUTRITION AND ELIMINATION Overview of function of GI system • Responsible for taking in and processing nutrients for all parts of the body. • Any problems can quickly affect other systems of the body • In children, can affect overall health, growth, and development Overview of nutrition • Infants o First 6 months can live off of breast milk or commercially prepared formula with iron added o May need to have Fluoride added if not already in the water. • Cows milk is not recommended until 1 year of age d/t allergies • First year is one of rapid growth o High protein o High calories • A little about obesity o A baby who is overweight by the age of one will usually struggle with weight as an adult. Introducing solid foods • 5-6 months: iron-fortified infant cereal mixed with breast milk, orange juice, or formula. • 7 months: vegetables • 8 months: fruit • 9 months: meat • 10 months: egg yolk Toddler Nutrition • Appetite is usually smaller than infant because they are growing at a less rapid rate • Tend to play with their food • Want to feed themselves. Do not want to be fed. • May also choose the same foods over and over. Preschooler and Nutrition • Still not very big eaters at this age • Parents should attempt to make meal times a pleasant experience for children. School age children and nutrition • Good appetites • Should begin the day with breakfast • Usually hungry after school Adolescents and nutrition • Growing so fast that they may always feel hungry • May tend to eat faddish foods or those not very nutritious. • May rebel against a parents wishes for them to eat good food • This is a time when binging and unhealthy dieting may occur (even with athletes) • Tend to not eat enough iron, calcium, and zinc Physiological differences: Adults vs. Children • Internal distribution of water o Fluid is a greater fraction of their total body weight as compared to adults Infants: 75-80% TBW 2 years: 60% TBW Amounts stay approximately the same through later childhood and adult life o Body water is also distributed differently in infants than older children. Infants have more interstitial fluids Extracellular fluid compartment in infants includes 35-45% body water • Insensible water loss o Loss of fluid through lungs and skin o Insensible water losses per unit of body weight are higher for an infant and younger child than an adult. Total body surface is larger in infants/children Body surface is the percentage of skin compared to total body weight. Infants have more skin for their size. The more skin, the more fluid loss through skin Infants and children have rapid respiratory rate and metabolic rate o All of these factors contribute to greater fluid loss through evaporation. o In addition, treatments or other conditions may increase fluid output Activity, fever, diarrhea, vomiting • Kidney function o During the first 2 years, kidneys are not mature Do not excrete waste products efficiently Difficulty concentrating or diluting urine Sodium regulation mechanisms are not mature o Nurses want to make sure that kidneys are working before adding potassium to I.V. fluids. • Other imbalances o Children are also more readily susceptible to imbalances in: Serum glucose Calcium Potassium Glucose • Infants and children have o Higher glucose needs due to high metabolic rate o Low glycogen stores o Hypoglycemia a threat under periods of stress Calcium • Infants and children have: o Regulation of calcium less exact in infant than in older child or adult o When stressed, more growth hormone (GH) is secreted GH increases result in increased calcium deposits in bone Infant unable to keep up with these increased demands Hypocalcemia results. Potassium • Potassium concentration easily affected by decreased intake or intestinal illnesses (diarrhea) • Decreased K can lead to cardiac arrhythmias • K must fall below 3 mEq/L before symptoms show Critical! • Any condition that interferes with normal water and electrolyte intake or causes excessive losses will produce a more rapid depletion of fluid and electrolyte stores in the infant and child than it will in the adult. Example: • Adults, when they do not eat for a day due to GI upset, and whose kidneys are normal, will have 14% less body fluid by the end of the day • Infants who do not eat for a day, and whose kidney function is normal, will be 40% short of fluid by the end of the day! Urine output norms • Infants: 2-3ml/kg/hr • Toddlers/preschoolers 2ml/kg/hr • School age: 1-2ml/kg/hr • Adolescents: 0.5-1ml/kg/hr Physical assessment • Skin o Color indicates the state of perfusion o As extracellular fluid volume decreases (as with dehydration), peripheral circulation decreases. o Note the following: Warmth Skin color: from pink to pale as peripheral circulation decreases (cyanosis is a late sign) Hands will get cold before core temperature Cap refill increases <2 seconds • Turgor: o In dehydrated states: Skin is unusually dry Tenting of skin (is a later sign) The best place to check skin turgor is the abdomen and medial area of the thighs • Skin temperature o Decreases in fluid status; results in vasoconstriction of small arterioles o Vasoconstriction causes a decrease in skin temperature o Extremities usually remain cold even if the child has a fever • Mucous membrane o Mouth is the most mucous membrane to assess for fluid deficit. o Note: Amount of saliva in mouth Lips and nares may be dry Mucous membranes may be cracked. Wrinkled tongue can indicate dehydration Be sure dryness is not due to excessive mouth breathing—look at other variables as well. • Head Assessment o Eyes Usually lack luster May appear sunken and dark After 4 months—if the infant does not produce tears, could indicate dehydration o Fontanels Should be soft and flat Sunken can represent dehydration (especially anterior) • Vital signs o Pulse: Usually the most sensitive index of fluid status Pulse over 160 for infants and 120 for children could indicate hypovolemia Pulse will usually be weak and thready o Respirations When fluid volume is decreased, children tend to compensate for changes in the blood by hyperventilating. This can lead to the development of cherry red lips o Blood pressure Usually the last vital sign to show any changes. When it falls, it’s usually hours after changes in pulse and respiration o Weight The single most important variable to follow in planning treatment of fluid imbalances o Intake and output Record all intake Output – usually a decrease in urine output and an increase in specific gravity (the higher the specific gravity, the more dehydrated the person is). Every hour is documented o Output Weigh diapers 1 gm = 1 ml document all stools, vomiting, wound drainage, perspiration o Behavioral assessment Changes seen with fluid volume deficit usually include: Anorexia Drawn, flaccid expressions Decreased levels of activity Increased seeking of comfort and attention Diarrhea • Increase in stool frequency and content of water • Caused by abnormal intestinal water and electrolyte transport • More water in the intestines Acute diarrhea • Major cause of infant mortality in developing countries • Most cases caused by infectious agents, viral or bacterial, and parasites • Chronic diarrhea is more likely related to malabsorption or inflammatory cause Infectious causes of acute diarrhea • Viruses o Rotavirus is responsible for 50% of hospital admissions for dehydration and diarrhea Also a nosocomial infection • Bacteria o Salmonella o Campylobacter (ingested by contaminated food) o Clostridium difficile (C-Diff) Food poisoning • Staphylococcus • Clostridium perfringens • Clostridium botulinum Parasites • Giardia lamblia • Cryptosporidium Etiology • Spread by contaminated food or water • Also from person to person • More common in crowded conditions, such as day care centers and schools • Infants immune system plays a role (the younger the infant, the less developed the immune system). Assessment of mild diarrhea • Fever of 101-102 degrees F may be present • Anorexia • Irritable • Appear unwell • Episodes of diarrhea consist of 2-10 stools per day • Mucous membranes are dry • Pulse rapid • Skin feels warm • Skin turgor is not yet decreased at this time • Urine output usually normal • Skin color is pale Therapeutic management of mild diarrhea • Is not serious at this stage—children can be treated at home • Rest the GI tract for at least one hour; then offer water or oral hydration solutions such as pedialye. o Approximately 1 tablespoon every 15 minutes x 4 o Then 2 tablespoons every ½ hour x 4 o If retained, give small sips of fluid; avoid giving large amounts of fluid. Give in small doses o Do not give OTC drugs such as Imodium or Kaopectate because they’re too strong for little tummies o Depended on developmental age of child; instruct on good handwashing technique. Severe diarrhea • May result from mild or may appear on it’s own • Temp: 103-104F • Pulse and respirations are weak and rapid • Skin is pale and cool • Infants may appear apprehensive, listless, lethargic (appears as a hypovolemic state) • Obvious signs of dehydration o Depressed fontanel o Poor skin turgor o Sunken eyes • Bowel movement every few minutes • Stool is liquid green, may be mixed with mucus and blood (because the intestines are inflamed and irritated) • Stool may be passed with explosive force • Urine output scanty and concentrated • Lab findings: o Increased hematocrit, hemoglobin, serum protein levels o Falsely high because the percentage is low • Loss of 2.5-5% of body weight- mild dehydration • Severe diarrhea can cause of loss of 5-15% of body weight quickly • Any infant who has lost more than 10% if body weight requires immediate treatment Therapeutic measures • Assessment of the fluid and electrolyte imbalance • Rehydration • Maintenance of fluid therapy • Reintroduction of adequate diet • Antimicrobial agents if necessary Nursing considerations: assessment • Observe general appearance and behavior • Assess for dehydration o Decreased urine output o Decrease in weight o Dry mucous membranes o Poor skin turgor o Sunken fontanel in infant • More severe dehydration o Increase in pulse o Increase in respirations o Decreased blood pressure o Prolonged cap refill time o All signs of impending hypovolemic shock o Also assess for septic shock Nursing goals • Urine output is more than 1ml/kg/hr • Bowel movements are formed and fewer than 4 per day • Stool tests negative • Blood pH more than 7 (to prevent metabolic acidosis) • Specific gravity < 1.030 Malabsorption syndromes • Celiac Disease • Short bowel syndrome Celiac Disease • Sensitivity or immunological response to the gluten factor of protein • When gluten is ingested, a autoimmune response destroys part of the small intestine mucosal • Body is unable to properly digest food and absorb nutrients, especially fats • As a result, these children develop: o Steatorrhea (bulky, foul-smelling, fatty stools) o Deficiency of fat-soluble vitamins (A, D, E, K) o Protuberant abdomen o Rickets (disease in bone formation) due to a loss of vitamin D o Hypoprothrombinemia may occur due to loss of vitamin K (need Vitamin K to make prothrombin in the liver) o May also have iron deficiency anemia and low albumin (blood carrier molecule that helps maintain blood volume and blood pressure) levels. Assessment of Celiac disease: • These children may be anorexic and irritable • A “typical” celiac baby: o Would be fit and well until after the ingestion of gluten-containing solids (usually between 6 and 18 months of age) o Then the baby would develop pale, bulky, offensive smelling stools (steatorrhea), become miserable and lethargic • They gradually fall behind other children in their age in height and weight • Appear skinny with spindly extremities and wasted buttocks • Face, however, may be plump and well-appearing Diagnosis of Celiac disease: • History • Clinical symptoms
Posted January 10, 2011 at 6:37 AM
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