Peds Study Guide

8/10/2019 Peds Study Guide

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Pediatric Exam 1 Study Guide

Pediatric Nursing -Chapter 1 and Chapter 22 Pg 636-658

1. Based on age development what are the major causes of mortality and morbidity

Neonates and postneo- Congenital anomalies, low birth weight, sudden infant death

syndrome, newborn affected by maternal complications during pregnancy, accidents,affected by complications of placenta, umbilical cord, and membranes; bacterial sepsis of

newborn; respiratory distress of newborn; diseases of circulatory system; neonatal

hemorrhage

1-4 years-mobile vehicle accidents, other accidents, congenital anomalies, homicide, cancer,

heart disease

5-9 years-accidents, cancer, congenital anomalies, homicide, influenza and pneumonia

10-14 years- accidents, cancer, suicide, homicide, congenital anomalies

15-19 years- accidents, homicide, suicide, cancer, heart disease

2. What is and how do you apply family centered and atraumatic care

Family centered care- It recognizes the family as the constant in a childs life. When

providing care, the nurse must consider the needs of all the family members in relation to

the care of the child.

Its important for the nurse to enablefamilies by creating opportunities for all

members to display their current abilities and competencies and to acquire new ones

to meet the needs of both the child and family

Empowermentis the interaction b/w the nurse and family, where families have that

sense of control over their family lives and acknowledge positive changes that results

from helping behaviors that foster their own strengths, abilities, and actions.

Atraumatic care-The provision of therapeutic care in settings, by personnel, and through the

use of interventions that eliminate or minimize the psychologic and physical distressexperienced by children and their families health care system.

Therapeutic care includes the prevention, dx, tx, or palliation of acute or chronic

conditions.

Personnel include anyone directly involved in providing therapeutic care.

Interventions range from psychologic approaches (preparing children for procedures),

to physical interventions (providing space for a parent to room in with child).

GOAL- first, do no harm by:

(1) Prevent or minimize child from being away from family;

(2) promote a sense of control;

(3) prevent or minimize bodily injury and pain.

3. Role of pediatric nurse

Therapeutic relationship

o Essential for providing high-quality nursing care

o Must have meaningful relationships with child and parents BUT also have

boundaries


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Family advocacy and caring

o Work with family members and identify their goals and needs, plan interventions

o Make sure child and family are aware of all health services, tx, procedures, etc

o Nurses must ensure that every child receives optimum care

o Must demonstrate caring, compassion, and empathy for others

Disease prevention and health promotiono Education and anticipatory guidance

oAnticipatory guidance: hazards or conflicts of each developmental period

o These guidelines enables nurses to guide parents regarding childbearing practices

aimed at preventing potential problems

Health teaching

o Nurses direct goal

o Includes teaching about a dx, tx, etc.

o Must transmit information at the childs and familys level of understanding

Injury prevention

o Safety!!o Must discuss injury prevention with parents and children routinely

Support and counseling

o Support by listening, touching, and being physically present

Coordination and collaboration

o With other professionals to provide high quality care

Ethical decision making (not in exam)

4. Consent issues of when and how to obtain when a minor is involved

Must be obtained for:

Major surgeryMinor surgery (ex. Cutdown biopsy, dental extraction, suturing a laceration, removal of

cyst, closed reduction of a fracture)

Diagnostic test with an element of risk (bronchoscopy, lumbar puncture, bone marrow

aspiration)

Medical treatments with an element of risk (e.g. blood transfusion, radiotherapy)

Photographs for medical, educational, or public use

Removal of the child from the health care institution against medical advice

Postmortem examination, except in unexplained deaths (SIDS, violent death, or

suspected suicide)

Assent: Child of teen has been informed about the tx, procedure, or research and is willing

to permit a health care provider to perform it.

How to obtain:

Parents or legal guardians required to give informed consent if child is a minor

If parents are married, either one can for non-urgent care.

If divorced, usually from the parent who has legal custody

Parent must be over 18 and competent


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5. Developmental considerations in procedure preparations

Psychologic preparation- decrease anxiety and promote cooperation, support coping skills

and teach new ones, facilitate a feeling of mastery in experiencing a stressful event

Establish trust and provide support-easier to gain cooperation

Parental presence and support

Provide an explanation- short, simple, and appropriate Physical preparation

Performance of procedure

Expect success- approach with confidence

Involve the child

Provide distraction

Allow expression of feelings

Use play in procedures

Infant- Developing trust and sensorimotor thought

Attachment to

Parent

-Involve parent in

procedure if desired

-Keep parent in

infants line of vision

-if parent is unable to

be there, place

familiar object such

as a stuffed toy.

Strange anxiety

-Make advances

slowly and in a

nonthreatening

manner

-Limit # of strangers

in room

Sensorimotor phase

of learning

-Use sensory

soothing measures

-Use analgesics

-cuddle and hug

infant after stressful

procedure

Increased muscle

control

-Restrain adequately

-Keep harmful objects

out of reach

Memory for pastexperiences

-Keep frightening

objects out of view

-Use non intrusive

procedures whenever

possible

Imitation ofgestures

-Model desire

behavior


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Egocentric

-Same as toddler plus,

-demonstrate equipment

-allow child to play with doll or equipment

-Use neutral words

Increased language skills

-use verbal explanations

-encourage child to verbalize ideas & feelings

Limited concept of time and frustration

tolerance

-Same as toddler but may play longer

teaching session

Illness and hospitalization viewed as

punishment

-clarify why procedure is done

Animism

-Keep equipment out of view until used

Fears of bodily harm, intrusion, and

castration

-point out on doll or child where it will be done

-emphasize that no other body part will be

involved

Striving for initiative

-involve child in care

-Praise child for helping

School-aged child- developing industry and concrete thought

Increased language

skills; interest in

acquiringknowledge

-Explain procedure

using scientific and

medical term

-explain procedure

using pictures

-Discuss why its

being done

-explain function and

operation ofequipment

Improved concept

of time

-Plan for longerteaching

-prepare up to 1 day

in advance of

procedure

Increased self-

control

-Gain childs

cooperation

-Tell child what is

Striving for industry

-Allow responsibility

for simple task

-include child in

decision making


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expected -encourage active

participation

Developing

relationships with

peers-prepare 2+ children

for same procedure

or encourage to help

each other

-privacy from peers

Adolescent- developing identity and abstract thought

Increasing abstractthought and

reasoning

-Discuss why its

being done

-Explain long-term

consequences of

procedures

-Realize they might

fear death, disability,

risks-encourage

questioning

Consciousness andappearance

-Provide privacy

-Discuss how

procedure may affect

appearance

-Emphasize physical

benefits of procedure

Concern more with

present than with

future

-immediate effects of

procedure more

significant than future

benefits

Striving for

independence

-involve in decision

making and planning

-explore coping

strategies

-have difficulty

accepting newauthority figures

Developing peer

relationships and

group identity

-same as school


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aged child

6. Preparation for procedures and pre-operative procedures (include play related)

For preparation for procedures see tables and information above Pre-op care

Psychologic and physical preparation

Similar as preparing for procedures (play, tours, videos)

Let children wear underpants under the hospital gown

Include a family centered preop preparation such as a tour of the

perioperative areas, a video to take home, a mark to take home and practice,

pamphlets, phone calls before surgery

Restriction of food and liquids

Different than adults.

Fasting: clear liquids- >2 hours

Breast milk: 4 hours

Infant formula: 6 hrs

Nonhuman milk: 6 hrs (amount ingested must be considered)

Light meal 6 hrs (toast and clear liquids; amount must be considered)

Parental presence

Appropriate education is important for parents to understand the stages of

anesthesia

When parents are not allowed or dont want to be near the child during the

induction of anesthesia, leaving a favorite possession with the child and uniting the

child and parents as soon as possible after surgery are important interventions

PLAY ACTIVITIES for specific procedures Fluid Intake

Ice pops using favorite juice

Cut gelatin into fun shapes

Tea party

Let child fill a syringe and squirt into mouth

Use crazy straw

Deep breathing

Blow bubbles with bubble blower, straw (no soap)

Blow on a pinwheel, feather, balloon, etc

Blowing contest using balloons, boats, feathers, etc

Straw-blowing painting

Take a deep breath and blow out the candles

Range of motion and use of extremities

Play simon says or twister game

Play pretend and guessing game (imitate a bird, butterfly, horse)

Play kickball or throw ball

Play video games or pinball


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Hide and seek

Clay to mold with fingers

Painting

Soaks

Play with small toys

Wash dolls or toys Read to child during soaks

Sitz bath

Punch holes in bottom of plastic cup, fill with water, and let it rain on child

Injections

Let child handle syringe, vial, alcohol swab and give injection to a doll

Use syringes to decorate cookies with frosting

Draw a magic circle on area before injections and smiling face after

Progress poster

Ambulation

Give child something to push (toddler: push pull toy; school aged: wagon or

doll in a stroller; adolescent: decorated iv stand)

Have a parade

Extending environment

Make bed into a pirate ship or airplane with decorations

Put up mirrors so patient can see around room

Move bed frequently to playroom, hallway, or outside

7. Feeding the sick child

Loss of appetite is a common sx to most childhood illnesses

Refusing food can also be one way children can exert power and control

Encourage parents to relax any pressure during an acute illness- dont force them to eat Dehydration is always a risk

Nurses should present food in the usual order, such as soup first followed by small

portions of meat, potatoes, and vegetables and ending with dessert

When child is hungry, take advantage by serving high quality foods and snacks

Parents can bring food items from home (esp. if cultural eating habits differ from the

hospital food)

Charting amount of food/liquid consumed is important

Nursing care guidelines

Take dietary hx and make eating time as similar to eating at home as possible

Encourage parents to feed child

Make mealtimes pleasant; avoid any procedures before or after eating

Serve small, frequent meals rather than 3 large meals

Provide finger foods for young children

Involve children in food selection when possible

Serve each course of food separately, not all plates at the same time

Provide food and fluid selections that are favorites of most children

Avoid food thats highly seasoned, have strong odors, or are mixed


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Offer nutritious snacks

Make food attractive and different (serve picnic lunch in a paper bag, put a face or

flower on a hamburger with pieces of veggies, use cookie cutter to shape a sandwich,

add food coloring to milk or water, etc)

DONT punish children for not eating by removing their dessert

Praise children for what they do eat

8. Fever

During febrile, shivering and vasoconstriction generate and conserve heat during the chill

phase of fever, raising central temperatures

Fever has physiologic benefits which include increased in wbc activity, interferon

production and effectiveness, and antibody production and enhancement of some

antibiotic effects

Important terms

Set point- Temp. around which body temp is regulated by a thermpstat-like

mechanism in the hypothalamus

Fever(hyperpyrexia)- an elevation in set point. Above 38 C

Hyperthermia- body tempt exceeding the set point

Therapeutic management

To relieve discomfort

Fever

Acetaminophen is the preferred drug

Aspirin should not be used

Ibuprofen should be 5mg/kg of body wt for temp less than 39.2C or 10mg/kg for

greater than 39.2C

Acetaminophen dosage should never be exceeded

Cooling measures such as wearing minimal clothing, exposing skin to air, reducingroom temp, increasing air circulation, and applying cool moist compresses to the

skin

Sponging or tepid baths are ineffective

Hyperthermia

Antipyretics are no value bc the set point is already normal

Cooling measures are used such as applications to the skin

Cooling devices and cooling blankets can reduce body temp

Tepid baths are effective to reduce body temp. Water should be 1C less than childs

body temp and left in there for 15-20 mins while water is gently squeezed from

washcloth over the back and chest of body

9. Safety

Responsibility of everyone who comes into contact with small children to maintain

protective measures throughout their hospital stay

Each age level and how each child is operating is important in guiding a safety plan

Identification bands are important for children

Infants and unconscious parties are unable to respond to their names


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Toddlers might only answer to nicknames or will respond to any name

Older children may exchange places, give an erroneous name, or choose not to

respond

Environmental Factors

All safety measures applied to adults are used with children

Windows secured, electronic equipment in good order, practice proper disposalof syringes, and other small medical devices

Check bathwater before placing child in bathtub and never leaving child in

bathtub alone

Furniture scaled to childs height

Danger of entrapment when electronically controlled bed when they are

activated and descended

Baby walkers should not be used

Safest sleeping position is wholly supineno pillows placed in a young infants

crib when infant is sleeping

Toys

Nurses must assess the safety of toys when brining them from home to

the hospital setting

Toys should be appropriate to the childs age, condition, and tx

Toys should also be non allergic and have nonbreakable/removable small

parts

Pass the choke tube test

Toy should not fit into the cylinder of a toilet paper roll

Latex balloons are never permitted in the hospital setting

Preventing Falls

Identify which children are at most risk by using a fall risk assessment

Risk Factors for Falls Medication effects: post anesthesia or sedation

Altered mental Status

Altered or limited mobility: reduced skill at ambulation, new

assistive walking devices

Postoperative children: risk for hypotension, extended bed

rest

History of Falls

Side rails down when family members are present

Once identified alert staff by posting signs on the door, bedside, and chart

Alter the environment

Bed in lowest position

Call bell within reach

All necessary items (toiletries, snacks, glasses, tissues, water ,etc)

are within reach

Offer toileting on regular basis

Lock wheelchairs before transferring pts

Keep lights on at all times


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Keep room free of clutter

Educate parents and patients with age appropriate teachings about

prevention

Call the nursing staff if assistance is necessary and do not allow

patient up independently

Keep side rails up Do not leave infants on day bed

When all family members leave the bedside notify the staff and

ensure the patients is in bed with all rails up

Transporting Infants and Children

Infants and small children can be carried for short distances but for extended

trips, child should be securely transported in a suitable conveyance

Horizontal position with the back supported and the thigh grasped firmly

by the carrying arm which leave one arm free for activity

Football hold is when the infant carried on the nurses arm with the head

supported by the hand and the body held securely between the nurses

body and elbow which leaves one arm free for activity

Upright position with the buttocks on the nurses forearm and the fron t of

the body resting against the nurses chest infants head and shoulders

supported by the nurses other arms in case the infant moves suddenly

Method of transporting depends on the childs age, condition, and destination

Younger children= crib

Older children= wheelchair with safety belt

Critically ill children= Stretchers/bed equipped with high sides and a

safety belt

Two staff members with monitoring continue during transport

Airway equipment and medication should accompany the patient10. Appropriate restraining

Therapeutic holdings: use of a secure, comfortable, temporary holding position that

provides close physical contact with the parent or caregiver for 30 minutes or less

Use of restraints avoided with the adequate preparation of the child, staff supervision of

the child, adequate protection of the vulnerable site

Medical Surgical Restraints

Used for children with an artificial airway or adjunct airway for oxygen, indwelling

catheters, tubes, drains, lines, pacemaker wires, or suture sites

Ensure safe care is given to the patient

Risks of the restraint are offset by the potential benefit of providing safer care

Can be initiated by an individual order or by protocol

Protocol must be authorized by an individual order

Order for continued use must be renewed each day

Patients monitored at least every 2 hours

Behavioral Restraints


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Limited to situations with a significant risk of patient physically harming

themselves or other behavior reasons where non physical interventions not

effective

Assess patientsmental, physical, and behavioral status

Collaborative approach used when implementing restraints with the help of the

medical staff and family Order must be obtained as soon as possible but no longer than 1 hour after

initiation

Must be renewed every 1 to 2 hours

Licensed independent practitioner must conduct an in person evaluation within 1

hour and again every 4 hours until restraints discontinued

Children must be assessed every 15 minutes for signs of injury, nutrition,

hydration, circulation, and ROM exercises, vital signs, hygiene, and readiness for

elimination

Restraints with ties must be secured to bed or crib frame not the side rails

One finger space between the skin and the restraint device

Should be tied with slip knots that can easily be quick released

Types of Restraints

Mummy Restraint/Swaddle

Short term restraint for examination or tx that involves the head and neck

A pappose board with straps or a mummy board controls the childs

movements

Child is placed on a blanket opened in the bed or crib with one corner

folded to the center so the childs shoulder lines up with the fold and the

feet are toward the opposite corner

Infants right arm is straight down against the body with the right side of

the blanket beneath the left side of the body Left arm placed straight against the shoulder and chest locked beneath

the body on the right side

Safety pins secure the blanket

To modify the mummy restraint for chest examination bring the folded

edge of the blanked over each arm and under the back and then fold the

loose edge over and secure it at a point below the chest

Jacket Restraint

Used to keep a child safe in various chairs

Put on the child with the ties in back so the ties cannot be manipulated

Help maintain the child in a desired horizontal position

Long tapes, secured to the understructure of the crib, keep the child

inside the crib

Arm and Leg Restraint

Restrain one or more extremities to limit movement

Must be right size and padded to prevent undue pressure, constriction, or

tissue injury


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Extremity must be observed frequently for signs of irritation or impaired

circulation

Ends of restraints never tied to the side rails because lowering the rail can

injure the child

Elbow Restraint

Prevents child from reaching head or face Fits from just below the axilla to wrist with a number of vertical pockets

into which tongue depressors are inserted

Restraint wrapped around the arm and secured with tapes or pins

Legal issues, family centered care and role of family on child health - Chapter 3 and 21

1. Family general concepts, theories

Family General Concepts:

No universal definition of family

Biology: perpetuation of the species

Psychology: intrapersonal aspects of the family and its responsibility for

personality development

Economics: productive unit providing for material needs

Sociology: social unit interactions with the larger society, creating the

context within which cultural values and identity are formed

Family structure and dynamics have a huge influence on the child that affects the childs

health and well being

Nursing care of infants and children is involved with the care of the child and the

family

Family defined by the relationship of the persons who make up the family unit

Consanguineous= blood relationships

Affinal=marital relationships

Family of origin=family unit a person born into Newer Concepts of family household

Single parent

Communal

Homosexual families

Theories: describes families and how the family unit responds to events both within and

outside the family

Family Systems

Family viewed as system that continually interacts with its members and

the environment with emphasis on the interactions between the family

members

A change in one part of the system affects all other parts of the family

where there are periods of rapid growth and change and then periods of

stability

Strengths and Limitations

Strengths

Applicable for family in normal everyday lifefamily dysfunction


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Can be used for family in varying structures and stage of the life

cycle

Limitations

Difficult to determine cause and effect relationships due to

circular causality

Applications Mate selection, courtship processes, family communication, power

and control within family, parent-child relationships, teenage

pregnancy and parenthood

Family Stress

Explains how families react to stressful events and suggests factors that

promote adaptation to stress

Family encounters both normative (parenthood) and unexpected ( illness,

unemployment, etc.) stressors throughout the life cycle

Too many stressors in a short time (1 year) can overwhelm the family and

its ability to cope causing breakdown or additional stressors that can lead

to a family crisis


Strengths

Explain and predict how a family will react to stressors and

develop into effective interventions to promote family

adaptations

Focuses on positive coping, resources, and social support

Limitations

Not yet known if there are certain resources and coping

strategies are applicable to all stressful events

Applications Transition to parenthood hood, single parent families, families with

work related issues, acute or chronic childhood

illnesses/disabilities, infertility, death of child, divorce, teenage

pregnancy and parenthood

Developmental

Addresses family change over time using Duvalls eight developmental

tasks of the family based on predictable changes in the familys structure,

function, and roles with the age of the oldest child as the marker for stage

transition

Each family member must achieve individual developmental tasks as part

of each family life cycle stage within the family and broader society

Family role performance at one stage of the family life cycle influences

familys behavioral options at the next stage

Family is in a stage of equilibrium when entering a new life cycle stage

and strives towards homeostasis within stages


Strengths


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Provides a dynamic view of the family

Addresses both changes within the family and the family

as a social system over its life history

Anticipates potential stressors with transitions over various

stages in life and when the problems may peak because of

lack of resources Limitations

Geared towards two parent families with children

Uses age of oldest child and marital duration as marker of

stage transition sometimes problematic with step families

and single parent families

Applications

Anticipatory guidance, education for developing or strengthening

family resources for management of transition to parenthood,

family adjustment to children entering school, becoming

adolescents, leaving home, managing empty nest and retirement

2. Family nursing intervention

Nurses choice of intervention depends on the theoretic family model that is used

Family system: group dynamics, anticipatory guidance

Family stress: crisis intervention

Developmental: anticipatory guidance

Family involvement is essential to be included in the care of children

General Nursing Interventions

Behavior modification

Case management and coordination

Collaborative strategies Contracting

Counseling, including support, cognitive reappraisal, and reframing

Empowering families through active participation

Environmental modification

Family advocacy

Family crisis intervention

Networking, including use of self helps groups, and social support

Providing information and technical expertise

Role modeling

Role supplementation

Teaching strategies (including stress management, lifestyle modification, and

anticipatory guidance)

3. Family roles

Each individual has a position in each family structure with a culturally and socially

defined interactions and roles in the family


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Conflicts arise when members do not fulfill their roles according to other family members

expectations or because they choose not to fulfill them

Parental Roles

Socially recognized mother and father with socially sanctioned roles that

define the sexual behavior and childrearing responsibilities in a family

structureall based upon parents social experience Roles have evolved immensely with changing times fathers are more active in

child rearing and household tasks

More conflicts arise in families due to cultural lag and persisting of

traditional role definitions

Siblings

Narrower the spacing between siblings, the more the children influence one

another

Wider spacing between siblings, the greater the influence from parents

Siblings exert power, exchange services, and express feelings in a reciprocal

way

Family Size

Small families emphasize individual development of the children

Children have a say in the family

Adolescents indentify more strongly with their parents and rely on them

for advice

Large Families emphasis on the group and less than the individuals

All members learn to cooperate

Dominant member either the parent or an older sibling emerges

Children adopt specialized roles to gain recognition in the family

Older children administer discipline and assumes responsibility for the

security of the other children when a parent is either ill or dies Ordinal Position/Birth Order

Affects personalities and how parents treat their children as well as how sibling

interact with one another

Firstborn

Achievement oriented, dominant, self discipline

Identify with parents more than peer group

Begin to speak earlier in life

Plan better and experience fewer frustrations

Subject to greater parental expectations

Middle children

More demands made on them to help with the household

Praised less often and receive less of parents attention

Good at compromising and adapting to new situations

Difficult to characterize due to variety of positions it assumes in the family

Youngest

Less dependent and less intense than the firstborn

Identify more with peer group than parentspopular among classmates


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Fewer demands to help household

Flexible with thinking

Only children

Similar to firstborn child

More mature

Experience greater parental pressure for mature behavior andachievement

Rarely develop into the sterotype of spoiled, selfish child

Enjoy a rich fantasy life as a result of isolation

Multiple Births

Twins

Develop a capacity for cooperative play and considerable loyalty and

generosity between each other

One member tends to be more dominant, outgoing, and assertive than

the other

The more passive twin tends to accomplish as much and get his or her

way more frequently than the assertive twin

Fraternal vs Identical

Identical or near unison in the actions of twinsalternate between

leadership

Differ in response to treating twins like some thrive best when in

each others company or when separated

Early years of togetherness is basis of the childrens

security and separating to early can be a stressor

Should foster differences when they become evident to

ease separation

Fraternal have no real unison in actions, sibling rivalry often found

4. Transition to parenting

No amount of preparation can fully prepare prospective parents for an infants constant

and immediate needs

Factors affecting transition

Parental age

Physiological standpoint best age for childbearing 18-35 years old

Childbearing age increased to 30-44 years old

Father involvement

Fathers with little initial contact with newborns will become involved with

them over the next few months

Fathers engage in more physically stimulating activities, successful at

soothing infants

Secure attachment to the father can help offset the consequences of an

insecure attachment to the mother

Parenting education


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Programs are designed to take place near the time of birth or soon after

can be more helpful in easing transitional stress than earlier programs

Nurses offer suggestions and education in helping become a better

parent

Support systems

Need to have at least two types of family resources Internal Resources

Adaptability: learning to be patient, becoming better

organized, and becoming more flexible

Integration: couples attempt to continue some activities

they engaged in before they becoming parents

Time away from the child is essential

Coping Strategies

Use of social support systems and community resources

Interpersonal supportrelationship with family, friends, and

the community

Provides opportunities to be away from the child

Brings reassurance that others experience the

same fears of parenthood as you

5. Discipline and limits

Discipline: the action taken to enforce the rules of noncompliance

Types of Discipline

Reasoning

Explaining why an act is wrong

Appropriate for older children especially with moral issues

Does not work well for children because of egocentrism or they cannot

see the other side Used by children to gain attention

Scolding

Often combined with reasoning

A form of shame or criticism

Believe that theyare bad not necessarily that their action is bad

Behavior Modification

Consistency and timing are essential

Positive and negative reinforcement

Rewarded for positive behavior to minimize the tendency to want to

misbehave

Older Children use a token system

Certain number of stars or points add up to a special reward

Parents need to plan and explain expected behavior to the child and

establish a reward system that is reinforcing

Verbal approval should accompany extrinsic rewards

Ignoring

Extinguish or minimize the act


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Difficult to implement consistently

Behavior actually reinforced because the child learns that persistence

gains parental attention

In order to be effective

Understand the process

Record the undesired behavior before ignoring to determinewhether a problem exists and to compare results after ignoring

begun

Determine whether parental action acts as a reinforce

Be aware of response burst

Response burst is when the undesired behavior increased

after ignoring the child because the child is testing the

parents to see if they are serious

Consequence

Involves allowing the child to experience the results of their misbehavior

Three Types

Natural

Occur without any intervention

Being late to the table and having to clean up the

dinner table

Preferred type and most effective

Logical

Directly related to the rule

Not being allowed to the play with another toy until the

used ones are put away

Preferred type and effective

Unrelated Imposed deliberately

No playing until homework is completed

Using time out

Withdrawing privileges

After a child experience the consequence, parents should

not say anything since the child will try to place blame for

imposing the rule

Time Out

Refinement of the common practice of sending the child to his or her

room

Type of unrelated consequence

If done in an un stimulating environment, child will become bored and try

to behave in order to renter the family group

Avoids many of the problems of other disciplinary approaches

Allows both child and parents to have a cooling off period

Corporal or Physical Punishment

Most often takes the form of spanking


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Inflicting pain causes a dramatic short term decrease in behavior

Serious Flaws

Teaches violence is acceptable

Physical harm the child if it results in parental rage

Children become used to spanking and require more severe punishment

over time Can result in severe physical and psychological injury

Interfere with the childs developmental theory of moral reasoning

When parents not around children are likely to misbehave because they have not

learned to behave well for their own sake

Limit Setting:establishing rules or guidance for behavior the clearer the limits, the

more consistently they will be enforced, and then the less need for discipline to be used

Minimizing Behavior

Reasons for misbehavior attention, power, defiance, and a display of

inadequacy, rules not clearly established

Set realistic goals

Praise children for desirable behavior

Teach desirable behavior by own example

Call attention to unacceptable behavior as soon as it appears

Off sympathetic explanations for not granting a request

Keep all promises made to children

Avoid outright conflict

Provide children with opportunity for power and control

Nurses help parents establish concrete and realistic rules

Test their limits of control

Children learn how they can manipulate their environment and gain reassurance

knowing that there are others to protect them from potential harm Achieve in area appropriate mastery at their level

Channel undesirable feelings into constructive activity

Protect themselves from damage

Learn socially acceptable behavior

Children need limits and unrestricted freedom is a threat to their safety and security

6. Parenting and divorce

Function of parenthood is to provide for the security and the emotional wellfar of children

Disruption of the family structure often leads to guilt on the childs part for the divorcing

parents

Stages of the Divorce Process

Acute

Decision to separate made

Legal steps for filing divorce and most likely departure of father from the

home

New caregiver put in place, new home environment, possibly new school

Lasts from several months to more than 1 year


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Causes familial stress and chaotic atmosphere

parents preoccupied with own feelings and needs leaving them

unavailable to help support the children through this process

sometimes parents begin to feel frightened and alone and starts

depending on the child to substitute for the absent parent causing a huge

burden to be placed on the child Transitional

Adults and children assume unfamiliar roles and relationships within the

new family structure

Inflammable tempers in both parents and children

Reduced parental competence

Greater sense of parental helplessness

Poorly enforced discipline

Diminished regularity in household routines

Noncustodial parents become the role of the visitor or the fun

parent

Change of residence, a reduced standard of living and lifestyle, larger

share of economic responsibility by the mother, radically altered parent

child relationships

Stabilizing

Post divorce family reestablished a stable, functioning family unit

Remarriage frequently occurs with concomitant change is all areas of

family life

Impact of Divorce on Children

Causes poor mental health outcomes

Possible relationship between child abuse, parental divorce, and

psychiatric disorder, and suicide attempts Children recall parental separation with the same emotional felt by victims of

natural disasters

Impact depends on age, gender, outcome of the divorce, and quality of parent-

child relationship

Children feel like they are caught in the middle

Feel a sense of shame and embarrassed concerning the family situation

A successful post divorce family can improve the quality of life for both the adults

and children

Greater stability in the home system

Conflict resolved= a better relationship with one or both the parents

results

Have less contact with a disturbed parent

Telling the Children

Hesitant to tell children

Initial discussion should include both parents and siblings followed with individual

discussions with each child


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Discussion should include the reason for the divorce and reassurance that the

divorce is not the fault of the children a

Acknowledge feelings of fear and abandonment

Need love and reassurance that their lives will try and remain as consistent and

orderly as possible

Physically comfort the children can help provide them with warmth andreassurance

Custody and Parenting Partnerships

Past belief is mother gets custody with visitation agreements for the father

Current belief is neither mother nor father should be awarded custody

automaticallyshould be awarded to the parent who is best able to provide for the

childrens welfare

Grandparents on the side of the parent with custody are increasingly involved in

the care of young children of divorced parents

Non custodial grandparents are kept away from their grandchildren

Divided/Split Custody

Each parent is awarded custody of one or more of the childrenseparated

siblings

Sons live with the father and daughters with the mother

Joint Physical Custody

Parents alternate the physical care and control of the children on an

agreed on basis while maintain shared parenting responsibilities legally

Works well with families who live close to each other and whose

occupations permit an active role in the care and rearing the children

Joint Legal Custody

The children reside with one parent but both parents are the childrens

legal guardians and both participate in childrearing Co parenting allows children to be close to both parents and life with each parent

can be more normal

For a successful co parenting relationship, parents have to be committed

to providing normal parenting and to separate their marital conflicts from

their parenting roles

Primary consideration is welfare of the children

7. Major hospital stressors

Separation from caregiver*: inability to go home, to be separated from family

If parents stay with child sleep issues, work concerns

Dont want pt too separated but consider caregivers need time to address

personal issues

Separation anxiety:major stressor middle infancy throughout pre-school years

Protest* stage: pt with be in flight/fight mode physically try to get out

and find parents

Despair: regression (may regress toilet trainingneed diapers; refuse

food), withdrawal, may refuse food


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Detachment: us. after prolonged separation (long hospitalizations),

appear happyignore parents when they visit (hurtful to parents)but

may be so detached that theyre not really happy can make separation

even worse

Stranger anxiety: level varies depending on developmental level of child

Fear of unknown: for parent and child; important to address parent fears b/c children cansense parent anxiety, worryfeelings transfer to child unintentionally

Fantasy thinking: child might hear/observe something and think about it in ways adults

wouldnt consider; sometimes kids live in cartoon worlds where anything is possible;

maybe I am here because my parents are trying to get rid of me orbeing punished for

having done something wrong

Need to be aware of common fantasies to help kids dealing with anxiety

Loss of control: children get routine set by hospital; e.g. IV, cant run around like normal

For parents: need to negotiate scheduling things to give them back some control

and give kid control backe.g. do so by giving children limited* choices [having

a procedure, like receiving oral meds, ask with frequency]

Painfulpast experiences

Fear of death

Invasion of privacy: younger roommate, hospital gown

Parental anxiety transferred to patient

Isolated: isolating both child and family; PPE can frighten/intimidate patients; so

encourage pt and family to put on isolation gown and experience it, understand it a little

better to decrease anxiety

Waiting times

Procedures involving pain

Rectal/Genital exams: e.g. vaginal examgo to general anesthesia rather than

explaining procedure/traumatizing Large number of adults: young boys having to show genitals to adults, nurses

uncomfortable

Explain circumstances as far as examinationsits ok for nurses, doctors but not

strangers

Explain rounds

Unfamiliar equipment, sounds and settings: allow pts to feel stethoscope to better

understand what were doing

8. Nursing interventions to decrease stressors

Admission Assessmentaddress

Address needs, concerns, routines, transitional objects: e.g. childs fave blanket,

animal; continue routines e.g. nighttime prayer

Environment safety: rails up, help pt/family understand about IV/maintain

Communication

Physical: e.g. explain NPO, addressing concerns

Hospital/Unit regulations: smoking, amount of ppl in roomsconserve quiet

Unit Orientation: let family know specificsnutrition room, playroom


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Minimize Separation

Rooming In: parents/family stays with child

Telephone: communication with family

Nursing Presence: play with patient

Parent Education

How to leave*: leave without saying goodbye is difficult; encourageparents to have discussion with child (I may leave when you fall asleep,

the nurses can call me at home)

Explaining time: frequent short visit are good- quality*

Limit Physical Restriction/Changed Routines

Help parent maintain routine

Take out of room: noisy room

Provide visual, auditory, tactile diversion: games, videos, books, cards

Maintain certain routines: e.g. pray before bed

Familiar food

Promote self-care if appropriate: wagon instead of wheelchair

Help child understand

Carefully consider how much information: little tube in your hand to give your

body medicine

Timing of information varies: 3 yo will normally be combative regarding a Foley

tell them a new min before

Prevent Fear of Bodily Injury

Pre-procedure preparation

Parental presence: encourage pts to be present for most thingseven

anesthesia in OR; can be relief to parents who think its worse than it is

Clear communication: IV stick (not a stick like found in woods), CAT -SCAN

(cat? big camera thats taking a lot of pictures its going to get loud but it will beok; headphones), Stretcher (bed on wheels), Flush (explainnot bathroom)

Explain wording!

9. Providing developmentally appropriate diversion

School: 14+ days in hospital before schools provide schooling; go on computer/on

phone to attend classes and continue

Play*: appropriate time and types of play

Peer interaction* and developmentally appropriate play: unless C/I like isolation,

encourage interaction

Many young pts on unit arent patients to encourage socialization (siblings,

friends from school, etc);playroom on unit with infantile games

Adolescents: separate teenroomappropriate for their age (video games, etc)

Volunteers: story telling, playing games with pts, performe.g. Halloween, Christmas

activities

Toys

Safety considerations

Play is a childs work provide with age appropriate, safe toys


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Infection control: e.g. soft, plush toy becomes pts permanently (cant

wash for another kid)

10. Dealing with Isolated patients

Isolated: isolating both child and family; PPE can frighten/intimidate patients; so

encourage pt and family to put on isolation gown and experience it, understand it a little

better to decrease anxiety

Communication and Physical Assessment- Chapter 6

1. Concentrate on content pp 99-131

2. Appropriate ways to obtain vitals (equipment, size, method)

Order is important!

Look, listen, than feel*

Look: RR (chest, nasal flare)can count, color

Listen: apicalheart rate, lung sounds for FULL minute

Lung sounds are loudcan overbear heart rate

Feel: BP, thermometer, cap refill

Vary by age: ranges via table*

Temperature:

Birth to 2 years: axillary, rectal

2-5 Years: axillary, tympanic, oral, rectal

5+ years: oral, axillary, tympanic

Pulse:

Radially: 2+ years old

Apical impulse: under 2; heard with stethoscope; count for full minute

Grading: 0not palpable; +1difficult to palpate, thready, weak; +2

difficult to palpate, may ne obliterated with pressure; +3easy to palpate,

normal; +4strong, bounding, not obliterated with pressure Compare with femoral pulse at least once during infancy to detect presence

of circulatory impairment e.g. aorta coarctation

Respiration:

Count like you would for adult

Observe* abdominal movementssince they are primarily diaphragmatic

Movements are irregular so count for a full minute

Breath Sounds: R/T low fat and because it is such a small area and most you

dont even need a stethoscope for (wheezing, stridor can be loud)

Can hear referred sounds (bowel, heart)

Almost always uncooperative: do before child get active/upset, while

parents hold

Can us. hear when patients cry

Blood Pressure

Annually in children 3+ years of age with sx of HTN, in the ER or ICU, and high-

risk infants

Compare in upper and lower extremities to detect abnormalities


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Use appropriately sized cuff OR a largerone if appropriate size if not available:

cuff bladder should be about 40% of circumference of arm measured at a point

midway between olecranon and acromion (shoulder, elbow); cuff bladder should

cover 80-100% of arm circumference; measure at the level of the heart with arm

supported; stethoscope bell placed over brachial artery pulse

3. Order of assessment

Do full exam: patient may not be able verbalize problems and some dont want to tell

Prior to exam, look at general appearance: appear well, sick, or very sick?

Observation: kids associate nurses with shots

First thing to do*: once touch child, assessment may change e.g. crying

increases RR; start with least invasive assessment first

General appearance

Assessment order: usually cannotgo in ordergo as body part becomes available

Listen when child is calmest: hate BP (do at end)

Toe to head

Infant: listen to heart, lungs, and abdomen if quiet; palpate and percuss the

areas; head to toe direction; traumatic procedures laste.g. ears, eyes, mouth

(while crying); elicit reflexes as body part is examined; elicit moro last

Toddler: use play to inspect areas (tickle toes); minimum physical contact

initially; introduce equipment slowly; auscultate, percuss, palpare whenever

quiet; perform traumatic procedures last

Pre-school child and up: if cooperative, head-to-toe fashion and genitalia last

Assessment Tips

Play with kids

Lighting

Inspect the entire body Parent assist: good!

Listen to history

DO NOT ASSUME ANYTHING

4. How to communicate with the child and family

Interview: parent/caregiverbe open minded with or without patient (R/T age)

Assume truth of parentusually dont question parent

Communication: many meanings for one word utilize parents

Injurybooboo, ouchie

Bottlebaba

Difficult neuro assessment R/T it being so dependent on verbal

Not necessarily A&Ox3

Alert: eye movement

Oriented: time of day, know who mom or cartoon character is

Family dependency

Listen to familys story


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5. Steps in general assessment of various systems (i.e capillary refill time, apical pulse)

Go from toe to head

General appearance-if a significant finding sticks out, it may direct how assessment is

done

Facial expressions, posture, position, body movements, hygiene, behavior

Growth measurements Length- fully extend the body of the infant, children can stand upright

Weight

Skin fold thickness and/or arm circumference may be used to distinguish

between fat and muscle

Head circumference-up to 36 months or if childs head size is questionable

Vitals

Apical pulse-listen for 1 minute

RR-count for 1 minute

Blood Pressure (mean averages)- Newborn-> 65/41, 1month-2years -> 95/58, 2-

5years-> 101/57

Temperature- for children a value of 37-37.5 C (97.7-99.7 F), for neonates 36.5-

37.6 C (97.7-99.7 F)

Skin-texture, color, hair distribution, nail quality

Lymph nodes-palpate for enlargement and/or tenderness

Head and neck-shape, symmetry, head control, palpate skull for patent sutures,

depressed fontanels, fractures, and swelling

Eyes-PERRLA, inspect conjunctiva, vision testing

Ears- inspect external structures and see if ears are level with eyes, inspect internal ear

with otoscope, auditory testing

Nose/throat/mouth-inspect mucous membranes, internal and external structures

Chest-inspect for barrel or pigeon chest Lungs- note breathing mechanism (nose breather?), assess

rate/rhythm/depth/quality/breath sounds

Heart-S1 and S2 present, S3 may be normal in some children but S4 is abnormal

Abdomen- inspect contour (distension, respiratory involvement), umbilicus for

abnormalities, check for hernias (umbilical, inguinal, femoral), auscultate for BS, palpate

for abnormal masses, tenderness, muscle tone, internal organs

Genitalia

Boys-note the external appearance of the glans and shaft of the penis, inspect

urethral meatus, note location and size of scrotum and identify two testes

Girls- limited to inspection and palpation of external structures (prepuce, clitoris,

labias, urethral meatus, vaginal orifice)

Anus-inspect skin, gluteal folds, anal reflex (assess tone of anal sphincter)

Back and Extremities- Curvature of spine, assess mobility, shape of bones (Bowleg

(knees outward) or Knock knee (knees inward)), pigeon toe, plantar/grasp reflex,

babinski reflex, assess range of motion, tone/strength of muscles

Neuro- assess cranial nerves, reflexes, cerebellar function (balance and coordination)


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Health Promotion of Infants- Chapter 9.10 and 11

1. Injury prevention for infants

The top leading causes for injury to infants were falls, ingestion, injuries, and burns

The three leading causes of accidental death injury in infants were suffocation, motor

vehicle-related injuries, and drowning

Box 10-1 on pages 345-346 of textbook has all the safety promotion and injuryprevention during infancy

2. Play during infancy r/t development

Play during infancy represents the various social modalities observed during cognitive

development

The activity of infants is primarily narcissistic and revolves around their own bodies

Birth-3months

Infants responses to the environment are global and large ly undifferentiated

Pleasure is demonstrated by a quieting attitude (1 month), a smile (2 months), or

a squeal (3 months)

3-6months

infants show more discriminate interest in stimuli and begin to play alone with

rattles or soft stuffed toys

by 4 months, infants laugh a loud, show preference for certain toys, and become

excited when their favorite toy is brought to them

6 months-1 year

play involves sensorimotor skills

peek-a-boo and pat-a-cake are played

at 6-8months, infants refuse to play with strngers

at 6 months, they extend their arms to be picked up

at 7 months, they cough to make their presence known at 10 months, they pull their parents clothing

at 12 months, they call their parents by name

stimulation is as important for psychosocial growth as food is for physical growth

infants need to be played with, not merely allowed to play

3. Infant growth and physical development, gross and fine motor

Table 10-1 on pages 310-314 of textbook (it literally has everything laid out in the

chart!!!)

4. Nutrition and feeding promotion

Birth to 6 months: Breastfeeding or bottle feeding

Breastfeeding more desirable

Iron-fortif ied commercial formula is a complete food for the first 6 months

4-12 months:

may begin to add solids

first foods are strained, pureed, or finely mashed


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introduce one food at a time, usually at intervals of 4 to 7 days, to identify

allergies

introduce solids when the infant is hungry

never introduce foods by mixing them with formula in the bottle

4-6 months: cereal (low allergenic potential)

6-8 months: fruit and vegetables 8-10 months: meat, fish, and poultry (avoid fatty meats)

12 months: eggs and cheese

feeding is a learning process--- taste and chewing experience

weaning- relinquishing the breast or bottle for a cup

regarded as a major task

infants are required to give up a major source of oral pleasure and gratification

5. Feeding difficulty and sensitivity

Infants are highly prone to aspiration and its attendant dangers

The amount and method of feeding are determined by the infants size and condition

Infants who are ELBW, VLBW, or critically ill often obtain the majority of their nutrients

by the parental route because of their inability to digest and absorb enteral nutrition

Preterm infants should be carefully evaluated for their readiness to breastfeed

Time , patience, and dedication on the part of the mom and nursing staff are needed to

help infants with breastfeeding

Feeding readiness is determined by each infants medical status, energy level, ability to

sustain a brief quiet alert state, gag reflex, spontaneous rooting and sucking behaviors,

and hand-to-mouth behaviors

A preterm infant may have difficulty coordinating sucking, swallowing, and breathing

When infants are unable to tolerate bottle feedings, intermittent feedings by gavage are

instituted until they gain enough strength and coordination Gavage feedings may be provided by continuous drip regulated via infusion pump or by

intermittent bolus feeding

Nonnutritive sucking on a pacifier may help bring the infant to a quiet alert state in

preparation for feeding

The longer the period of nonoral feeding, the more severe the feeding problem

Infants identified as being at risk for feeding resistance should be provided with regular

oral stimulation

6. Vegetarian diets

Lacto-ovo-vegetarian: exclude meat from diet but consume dairy products and rarely fish

Lactovegetarian: exclude meat and eggs but drink milk

Pure vegetarians (vegans): eliminate all foods of animal origin, including milk and eggs

Macrobiotics: allowing only a few types of fruits, vegetables, and legumes (more strict

than vegans)

Semi vegetarians: consume lacto-ovo-vegetarian diet with some fish and poultry


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The major deficiencies that may occur are inadequate protein for growth, inadequate

calories, poor digestibility of many of the bulky natural, unprocessed foods (especially for

infants), and deficiencies in vitamins and minerals

May need supplementation of vitamins and minerals

Achieving a nutritionally adequate vegetarian diet is not difficult but requires careful

planning and knowledge of nutrient sources (especially to ensure sufficient protein in thediet)

7. Malnutrition

Primary cause is not always lack of food

Diarrhea is a major factor

Additional factors are bottle feeding in poor sanitary conditions, inadequate knowledge,

economic and political factors

Poverty is leading cause of malnutrition

Most extreme form of malnutrition is protein-energy malnutrition (PEM)

Causes of PEM in U.S. are cystic fibrosis, renal dialysis, cancer, and GI malabsorption

Treatment of PEM includes providing a diet with high-quality proteins, carbohydrates,

vitamins, and minerals

If malnutrition is due to underlying disease and/or infection, must treat that as well

8. Nutrition problems such as kwashiorkor, failure to thrive

Kwashikor:A deficiency of protein with an adequate supply of calories.

Often occurs in children who are weaned off of breast milk after a younger sibling is

born.

Thin wasted extremities, prominent abdomen because of ascites (edema).

Edema masks severe muscular atrophy.

Skin is scaly and dry. Mineral deficiencies, diarrhea, infection. Failure to Thrive (FTT):Also known as growth failure, pediatric undernutrition.

Inability to maintain or use calories for growth.

Diagnosed with a pattern of persistent deviation from established growth parameters,

usually the weight and/or height is below the 5th percentile.

Categories includes organic, non-organic, or idiopathic. (More specifically, from

inadequate caloric intake, inadequate absorption, increased metabolism, or an

inability to use the calories they take in.)

Lots of factors can contribute, goal is to get child to have correct nutritional intake and

to catch up with growth.

9. Problems such as SIDS, ALTE, Plagiocephaly

SIDS: Sudden infant death syndrome.Unexplained sudden death of an infant younger

than 1 year of age.

Happens during sleep.

Put babies on their back to sleep!!!

Other risk factors include maternal smoking, co-sleeping, and soft-bedding.


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ALTE: Apparent life-threatening event. Infant exhibits a combination of apnea, change

in color, change in muscle tone, choking, gagging, or coughing.

Require significant intervention.

Needs diagnostic evaluation and sleep monitoring at home.

Plagiocephly: Misshapen head. When babies are put on their back to sleep, the back of

their head (posterior occiput) flattens over time. This can lead to a bald spot that goes away, can also lead to mild facial asymmetry.

Prevention includes changing babys head position frequently and giving them

tummy time when they are awake.

In more severe cases a specialized helmet can be worn during sleep, or they can

have surgery.

10. Newborn rash, thrush, herpes

Newborn rash: ERYTHEMA TOXICUM. Benign, self limiting.

Usually appears within first 2 days of life.

Lesions are firm, small, and white or yellow. Look like flea bites.

Can be located everywhere on the body except for the hands and soles.

Usually lasts 5-7 days.

Thrush: Oral candidiasis. It is due to a yeast-like fungus.

White patches on the tongue that can hurt when the infant feeds.

When scraped with a tongue blade it will cause bleeding.

Can apply anti-fungal to the mouth and diaper area. (There can be transmission

when babies put their hand in their diaper and then their mouth.)

Herpes:Neonatal herpes is a serious viral infection.

Usually transmission occurs during birth.

Manifests itself in either 1. skin, eye, mouth infection, 2. as a CNS disease, or 3. as

a disseminated disease involving multiple organs.

11. What is a high risk newborn what are major nursing concerns-temp, infection,

nutrition, feeding methods

A high risk newborn is a newborn who has a greater-than-average chance of morbidity

or mortality. A newborn can be considered high-risk regardless of their gestational age

or weight.

Primary objective for high-risk newborns is to establish and maintain respiration.

Thermoregulation is important to control in newborns. It is important to make sure that

they stay warm. In healthy term infants, axillary temps should be 36.5-37.5.

A fever in a newborn warrants immediate attention.

Less than 3 months old, a fever is 100.4 (38)

3-36 months, fever is 102 (38.9)

For children of any age, immediate attention for anything over 104

Watch BEHAVIOR though. (Restlessness and refusal to feed are two red

flags)


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Infection: High-risk newborns are particularly susceptible to infection. Use standard

precautions

Nutrition: Best way to determine nutrition is through their growth and physical

development.

Breastmilk is best source of nutrition, but some preterm infants need extra nutrients in

addition to breast milk. Breastfeeding, Nipple/bottle feeding. Best to have oral feedings

12. Hyperbili, RDS

Hyperbili:Excessive bilirubin in the blood, characterized by jaundice.

Common, usually benign, but can also be pathologic.

Treated with breastfeeding and with phototherapy.Can lead to bilirubin

encephalopathy, you see CNS effects.

Lethargy, irritability, hypotonia, seizures, deafness.

Delayed motor skills.

RDS: Respiratory distress syndrome.

It is a severe lung disorder, results in many deaths.

Self-limiting, but requires respiratory support to get through it.

Often in preterm infants who are born before lungs are fully developed.

Signs include tachypnea, dyspnea, retractions, crackles, grunting, flaring, cyanosis,

pallor.

Treatment: surfactant, respiratory equipment,

13. Necrotizing Enterocolitis

NEC: Necrotizing Enterocolitis. Acute inflammatory disease of the bowel.

Prematurity is the highest risk factor.

Diminished blood supply to intestines, cell damage and death. Signs: distention, blood in stool, gastric retention, abdominal redness, vomit, lethargy,

poor feeding, unstable temp, jaundice.

Treatment: Prevention! It is infectious so hand wash. Breastmilk can help to treat it,

surgery may be necessary sometimes.

14. Role of nurse in genetic counseling

Be alert for situations where a family may benefit from genetic counseling

Suggest it at an appropriate time.

Maintain contact with the family or refer them to an agency that can provide a sustained

relationship.

GI Dysfunction - Chapter 24, Chapter 22 694-703; GI Medications on Pediatric Pharm List

1. Dehydration signs for different types (mild, moderate, severe)

Weight loss is most important determinant of total body fluid loss.

Mild dehydration:

3-5% or 50 ml/kg weight loss over 48 hours.

HR 10-20% higher than baseline


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Dry mucus membranes

Concentrated urine

Poor tear production.

Moderate dehydration:

6-9% or 75 ml/kg weight loss over 48 hours.

Increased severity of above signs. Oliguria (low amounts of urine)

Sunken eyes

Sunken anterior fontanel

Severe dehydration

Decreased BP

Delayed capillary refill ltime

Acidosis

2. Motility disorders

- Diarrhea:

Caused by abnormal intestinal water and electrolyte transport

Involves digestive, absorptive, and secretory functions

Involves stomach and intestines, small intestine, colon, colon and intestines

Classified as acute or chronic

Acute: leading cause of illness in children younger than 5

Sudden increase in frequency and change in consistency of stools, often

caused by infectious agent in GI

May be associated with upper respiratory, antibiotic therapy or laxative use

Self limiting (


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Salmonella among infants

Pathophysiology

Invasion = increased intestinal secretion

Most serious issues for severe diarrhea

Dehydration

Acid-base imbalance with acidosis Shock when dehydration progresses

Diagnostic

Careful historyrecent travel, etc.

Presence absence of vomit, fever, freq./character of stool

Lab tests only for severely dehydrated

Neutrophils/RBC in stool indicate bacterial gastroenteritis or IBD

pH


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Avoid taking temperature to avoid bowel stimulation

3. Rehydration how much, methods

information is above

4. -Hirschsprung Disease Congenital anomaly results in mechanical obstruction frominadequate motility of part of the intestine

Familial pattern

Males and females

Patho

Absence of ganglion cells

Decreases internal sphincters ability to relax

Diagnostic

Neonate with distended abdomen, feeding intolerance and bilious vomiting, delay in

passage of meconium

Radiographs, unprepped barium enema, and anorectal manometric exams

Management

Most require surgery - stabilize first with fluid and electrolyte replacement

Transanal Soave endorectal pull through

Constipation and fecal incontinence are chronic problems in most patients

Perioperative care

Low fiber, high protein dietsometimes TPN for malnourished patients

Empty bowels with saline enemas and decrease bacterial flora with antibiotics

Enterocolitis is most serious complication

Monitor vitals and BP, fluid and electrolyte

Watch for symptoms of bowel perforation: fever, abdominal distention, vomit,

tenderness Measure abdominal distension with tape measure

Explain to preschool age with visual age

Colostomy is temporary

Postoperative care

Stoma care: diaper placed below dressing

Nursing Care

Help parents adjust

Foster infant parent bonding

Prepare them for medical surgical intervention

Assist them in colostomy care

- Vomiting

Well-defined, complex, coordinated process under CNS control

Nausea and retching

Nonbilious vs. bilious

Nonbilious: if obstruction present suggests a more proximal obstruction


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Causes: infectious, inflammatory, metabolic, or endocrinology, neurolic and

psychological causes, pyloric stenosis

Bilious: implies disorder of motility or distal physical blockage

Causes: intestinal atresia, stenosis, malrotation, ileus, intussusception, intestinal

duplication, appendicitis

Also associated with infectious disease Self-limiting

Watch for

Acute volume loss (dehydration)

Electrolyte disturbances

Malnutrition

Aspiration

Mallory-Weiss syndrome (small tears in distal esophageal mucosa

Management

Administer fluids

Antiemetic (Zofran)

For vomiting related to obstruction, withhold food

Ad libitum administration of a glucose electrolyte solution to an alert child to restore

water and electrolytes

Small frequent feedings of fluids and foods

For infant or child: position on side or semi reclining

Have child brush teeth or rinse mouth after vomiting

- GER/GERD

GER: Transfer of gastric contents into the esophagus: physiologic

Physiologic GER resolves by 1 year of age

Predisposition: neurologic impairment, hiatal hernia, morbid obesity, premature infant Symptoms:

Infants: Spitting up, vomit, excessive crying, weight loss, silent, respiratory

problems, apnea

Children: heartburn, abdominal pain, noncardiac chest pain, chronic cough,

dysphagia, nocturnal asthma

GERD: symptoms of tissue damage as a result of GER

Diagnostic

24 hour intra esophageal pH monitoring study is gold standard for diagnosis

Management

No therapy needed for thriving infants (could fix itself by 1 year)

Avoidance of certain foods (citrus, tomatoes, caffeine)

Small, more frequent meals

Thickened feeding, upright positioning

For severe: NG tube

Elevate HOB 30 degrees for 1 hour after feedings

Drugs: H2 receptor antagonists, proton pump inhibitors

Surgery: Nissen fundoplication


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Nursing Care

Identifying children with symptoms

Educate parents regarding home care

Care for children undergoing surgery

Supine positioning for feeding

Avoid vigorous play after feeding PPIs are most effective when administered 30 minutes before breakfast

- Acute Appendicitis Inflammation of the vermiform appendix

Symptoms:

Periumbilical pain followed by nausea, right lower quadrant pain, and later vomiting with

fever

Perforation of appendix can occur within 48 hours

Phlegmon: acute supportive inflammation of subcutaneous connective tissue that

spreads

Cause: obstruction of the lumen of the appendix

Diagnosis

Fever, vomiting, abdominal pain, and elevated WBC counts (greater than 10,000)

Lower right quadrant

McBurney point

Referred pain, elicited by light percussion

CBC, urinalysis (to rule out UTI)

Peritonitis: sudden relief from pain after perforation, subsequent increase in pain, progressive

abdominal distention, tachy, rapid shallow breathing, pallor, chills, and irritability

Management

Rehydration, antibiotics, surgical removal of appendix (laparoscopic normally)

Postoperative IV fluids, NPO, NG tube

Listen for bowel sounds

Meticulous skin care

Ruptured: preoperative IV administration of fluid and electrolytes, continued administration of

antibiotics, NG abdominal, Penrose drain post op

Nursing Care

If appendicitis suspected avoid laxatives or exams and applying heat to the site

- Meckel Diverticulum Remnant of the fetal omphalomesenteric duct

Failure of obliteration may result in an omphalomesenteric fistula

Complication: bleeding (due to peptic ulceration), obstruction or inflammation

Diagnosis

History, physical exam, radiographic studies, often hard to diagnose

Painless rectal bleeding in children, abdominal pain, signs of intestinal obstruction, dark

red or jelly stool

Management

Surgical removal of diverticulum


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Antibiotics

Reverse electrolyte imbalances and prevent abdominal distention

Nursing Care

Frequent monitoring of vital signs including BP

Keeping the child on bed rest

Recording the approximate amount of blood lost in stools

-Cirrhosis

End stage of many chronic liver diseases

Irreversibly damaged

Jaundice, poor growth, anorexia, muscle weakness, and lethargy, ascites, edema, GI bleed,

anemia, and abdominal pain

Management

Monitoring liver function

Combination of immunosuppressive medication

Nutritional support: supplements of fat-soluble vitamins

Sodium restriction and diuretics for ascites

Drugs to reduce ammonia formation (neomycin and lactulose)

- Biliary Atresia Progressive inflammatory process that causes both intrahepatic and

extrahepatic bile duct fibrosis

If untreated usually leads to cirrhosis, liver failure and death if first 2 years of life

Acquired late in gestation or in perinatal period and is manifested a few weeks after birth

Jaundice, manifesting with yellow discoloration of skin and sclera, pale stool, dark urine

Direct bilirubin greater than 1 ml/dl with total bilirubin less than 5 mg/dl

Early diagnosis is key (surgery within first 60 days)

Management Hepatic portoenterostomy: segment of intestine is anastomosed

Progressive cirrhosis still occurs in many children

Support is important

Supplication of fat soluble vitamins

Aggressive nutritional support

- Cleft Lip and Cleft Palate

Occur during embryonic development and most common congenital deformities

CL: failure of maxillary and median nasal processes to fuse

Can be unilateral or bilateral

CP: midline fissure of palate that results from failure of the two palatal processes to fuse

CL/P and CP are distinct from isolated CP

Multifactorial inheritance, exposure to tetragons, foliate deficiency and show up between

4th and 10th week of embryonic development

Impact on the feeding is biggest complication

Surgical correction

Cleft Lip


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Usually 2-3 months

Rule is 10 weeks old, 10 pound, and have hemoglobin of 10

Tennison-Randall triangular flap and Millard rotational advancement technique

Cleft Palate

6-12 months

Management Speech impairment

Pressure-equalization tubes placed

Extensive orthodontics

Feeding

Growth failure in infants

CL typically have no difficulty breast feeding

CP and CL/P often unable to feed using conventional methods

Position an infant with CP in an upright position with head supported

Help with suctioning (Pigeon bottle)

Burping is important due to swallowing of excessive air

-Hypertrophic Pyloric Stenosis Circumferential muscles of the pyloric sphincter becomes

thickenedelongation and narrowing of pyloric channel

First 2-5 weeks of life, causing projectile nonbilious vomiting, dehydration, metabolic

alkalosis, and growth failure

More common in full term infants

Diagnosis

Olive like mass palpable when stomach is empty

Vomiting usually occurs 30-60 minutes after feeding and becomes projectile

Become dehydrated and appear malnourished

Ultrasonography

Hungry, avid feeder, distended upper abdomen Management

Surgical relief

Preop: infant needs rehydrated and metabolic alkalosis corrected with parenteral

fluid and electrolyte administration, decompress stomach with NG tube

Feeding usually 4-6 hours postoperatively, start small and frequent of an

electrolyte solution or sterile water

-Intussusception

Most common obstruction in children between 3 months-3years

Segment of bowel telescopes into another segment, pulling mesentery with it

Children initially seen with screaming, irritability, lethargy, vomit, diarrhea, fever,

dehydration, and shock

Management

Radiologist guided pneumonia with or without water soluble contrast

IV fluids, NG decompression, and antibiotic drug

Nurse monitors all stools before surgery

Passage of normal brown stools normally indicates intussusception has reduced itself


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- Malabsorption syndromes Chronic diarrhea and malabsorption of nutrients

Complication: growth failure

Celiac disease:

The Four Signs: steatorrhea, general malnutrition, abdominal distention, secondary

vitamin deficiencies

Normally between the ages of 6 months and 2 years Hypotonic, poor appetite

In ages 5-7: abdominal pain, nausea, vomiting, bloating, constipation, dental

enamel defects, anemia, short stature, pubertal delay

Intolerance to dietary wheat and related proteins

Wheat, barley, rye, and oat grains

Damages mucosa of small intestine and leads to villous atrophy

Genetically predisposed

Celiac Crisis: acute, severe episodes or profuse watery diarrhea and vomiting

Infections, prolonged fluid and electrolyte depletion, and emotional disturbance

are causes

Diagnosis

Biopsy of small intestine

Institute new diet: good response in 1-2 days (weight gain improved appetite)

and no diarrhea within a few weeks

Serologic tests: antigliadin antibodies

Associated with type 1 diabetes, thyroiditis, arthritis, primary biliary cirrhosis,

Down, Turner, Williams

Management

Primarily dietary: gluten free

Avoid wheat, rye, barley and oats

Chronic disease : Lymphoma is most serious complication Nursing Care

Explaining disease to family and helping with diet changes

Gluten is often added to foods with hydrolyzed vegetable protein: read labels!

Some need lactose free diet as well and avoid high fiber foods like nuts, raisins,

ray vegetables and fruits

Consult with registered dietician

Digestive defects: enzymes necessary for digestion are diminished or absent

Cystic fibrosis (pancreatic)

Biliary or liver (bile flow)

Lactase deficiency (lactose intolerance)

Absorptive defects: intestinal mucosal transport system is impaired

Anatomic Defects: extensive resection of bowel or short-bowel syndrome

-Short-bowel syndrome Malabsorptive disorder that occurs as a result of decreased

mucosal surface area, usually because of extensive resection of the small intestine

Causes: necrotizing enterocolitis, volvulus, jejunal atresia, and gastroschisis


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Definition: Decreased intestinal surface area for absorption of fluid, electrolytes, and

nutrients

A need for PN (feeding)

Management

Preserve as much length of bowel as possible during surgery

Maintain optimum nutritional status, growth, and development while intestinaladaptation occurs

Stimulate intestinal adaptation with enteral feeding

Minimize complications related to disease process and therapy

Nutritional support is long term focus

Initial phase: PN as primary source

Secondary phase: introduction of enteral feeding (after surgery)

Decrease PN solution in terms of calories, amount, and total hours infused per

day

Final phase: sustained exclusively by enteral feedings

Risk for nutritional deficiency secondary to malabsorption of fat soluble vitamins

(A, D, E, K) and trace minerals

Use of H2 blockers, PPIs

Bacterial overgrowth is often a problem: altering cycles of broad spectrum antibiotics

Also watch for metabolic acidosis and gastric hyper secretion

Surgical interventions: intestinal valves, tapering enteroplasty, intestinal lengthening

Nursing Care

Most important: monitoring and administration of nutritional therapy

Avoid infection, occlusions, dislodgement or accidental removal of lines

Routine ostomy care

5. Abdominal trauma- Gastroschisis Protrusion of intra abdominal contents through defect in abdominal wall

lateral to umbilical ring; there is no peritoneal sac covering the exposed bowel

Symptoms: defect obvious at delivery if not detected prenatally by ultrasonography

Nursing Management

Surgical repair of defect

Use of Siloh pouch

Preoperative

Keep sac covered with bowel bag

BG decompression

Maintain thermoregulation

Monitor electrolyte status

IV fluids

Antibiotics

Observe exposed bowel for necrosis

Postoperative

Monitor vitals, especially BP

Bowel decompression with NG tube


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IV fluids

Pain management

Monitor surgical closure site

Monitor lower extremities for pulses

Monitor for return of bowel function

- Omphalocele Protrusion of intraadbominal viscera into base of umbilical cord; sac covered

with peritoneum without skin

Symptoms: obvious on inspection

However might look like hematoma in umbilical cord

Nursing Management

Surgical repair

Preoperative

Protect defect from trauma

Keep sac or viscera moist with saline soaked dressings

Maintain thermoregulation

Carry out routine IV fluid infusion

Prophylactic antibiotics

Keep patient NPO

Assess for associated birth defects (CL or CP)

Postoperative

Monitor vital signs and BP

Pain management

Bowel decompression with NG tube

Iv fluids

Monitor return of bowel function

- Hernias Protrusion of an organ or organs through an abnormal opening

Danger when circulation is impaired

Congenital Diaphragmatic

Abdominal organs through opening in the diaphragm, commonly left side

Severe respiratory compromise and inability to adequately expand lungs

Seen within a few hours after birth, tachy, cyanosis, dyspnea, impaired cardiac

output

Management

Avoid bag and mask ventilation because fill stomach with air

Provide supportive treatment

Administration of inhaled nitric oxide

Preoperative

Monitor respiratory status, provide oxygen supplementation

Monitor cardiovascular status, reduce stimulation

Maintain NG suction, oxygen, and IV fluids

Medication: sedation, muscular paralysis, inotropes

Postoperative


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Carry out routine care

Relieve pain, support family

Hiatal

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