Transcript Weeks 6 & 7 Winter 08 - University of Windsor

Weeks 6 & 7
Winter 08
Preschoolers
Preschoolers
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Resources for ppte:
Hockenberry et al( 2007), text
and supporting CD
Mosby’s electronic image
collection CD
Past pptes for 63-277 class
Partner pptes
Free Photos Community
image collections on-line
Children’s Photoshop CD
1998 BMJ Publishing Group
Ltd ( Haddon Matrix)
Personal study notes – Dr.
McMahon
Topics for study
 Preschool growth & developmental milestones- play,
sexual curiosity, preschool or daycare
 Common variations- senses, mobility, communication
 Autism
 Trauma (bites), Farm-related Injury
 Haddon Matrix
 Infections- skin, eye, ear, mouth, throat, giardia, helminth
encephalitis, meningitis, GABHS, Staph, Fifth’s disease
 ( G.U.) Urinary tract, G.I.
 Day surgery- “T & A” , Myringotomy , PE tubes
 Pain: assessment, prevention, & management
 Variations in elimination- Enuresis, Encopresis
 Hernias
 Nephrotic syndrome/ Nephrosis
Moving Into the World
Ages 3-5 Years
Biologic Development
 Avg wt gain 2.3 kg – 5 lbs /yr
 3 yrs - wt 14. 6 kg or 32 lbs
 4 yrs - wt 16.7 kg or 37 lbs
 5 yrs - wt 18.7 kg or 41 lbs
 Avg ht gain 6.75 to 7.5 cm (2.5 to 3 in/yr)
 3 yrs – 95 cm or 37 in
 4 yrs – 103 cm or 40.5 in
 5 yrs – 110 cm or 43.25 in
Anatomy & Physiology
3yrs
 Apical P 80-120
 R
20-30
 BP
92/55
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5 yrs *
70-110
20
96/57
 Slender, sturdy, graceful, agile, erect
* Variations for gender & body type
look at family genetic pattern and growth charts
Overview of preschool
developmental tasks
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PRESCHOOL – AGE 3-5 YEARS
PSYCHOSOCIAL STAGE [ERIKSON] Initiative vs. Guilt : Initiative is a sense of
confidence that allows child to plan, take action & test what kind of person he/she
can be. Reinforced by freedom, opportunity, encouragement. Outcome gives
purpose & direction or Guilt that occurs when made to feel bad about initiatives
made. Associated with non-mastery Outcomes of guilt, anxiety, fear, dependence.
DEVELOPMENTAL TASKS [HAVIGHURST] Learning to learn , sex differences &
sexual modesty relate oneself emotionally to parents, siblings & other people from
simple concepts of social & physical reality, learning to distinguish right & wrong,
developing a conscience
COGNITIVE DEVELOPMENT [PIAGET] Pre-conceptual [to 4 yr.] as above Preoperational or Intuitive [ 4-7 yr.]-transition to increased symbolic functioning -ability
to think in terms of classes, see relationships,
LANGUAGE DEVELOPMENT: deal with number concepts-defines objects in terms
of their use-still egocentric; unable to see another’s point of view
PSYCHOSEXUAL STAGE [FREUD] : Phallic interest focused around genital arearecognize differences between sexes-identification with parent of same sexOedipal or Electra complexes, penis envy, castration fears
Physical focus - LOCOMOTION and CO-ORDINATION
Psychosocial Development
 Initiative vs Guilt
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Energetic learning
Sense of accomplishment
Why? – What’s that ?- How come ?
Try things but do not understand consequences
Push limits, test rules, make own rules
Animistic thinking
Magical thinking
If it’s good for me then it’s a good thing
Rewards = good Punishment = bad
Oedipal stage Phallic stage (Electra complex)
 Strong attachment to same sex parent
Communication may involve learning new roles
as family composition and structure changes
 Preschooler needs assurance
of their role and place in the
family new members add stress.
 Ups and downs in sibling
relationships- older and
younger
 Child needs to have a special
place confirmed
 Regression may occur if
insecure or jealous.
Cognitive Development
 Preoperational phase
 Shift from egocentric to social awareness
 Preconceptual age 2-4
 Intuitive thought age 4-7
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Play – imagination, invent, imitate
Do not understand concepts of rt & lf, time & causality
Development of sexuality
Sociable & willing to please
Fear of mutilation & harm & loss of insides
Preschoolers’ Learning
Use language to explore & reframe world
Learn cause & effect
Meaning of symbols (melting snowman, Yucky face)
Develop memory & desire new information
Begin to learn self care
Able to tolerate separation from parents
Understand object permanence
By age 5 category differentiation ie animal, vegetable
Interest grows in one’s body- proper names- and how
might be different from others’- boys girls, a mommy,
a daddy
Prepare to enter society – day care, nursery school,
play groups, preschool
Preschool
 Provides opportunity for learning group cooperation,
adjusting to sociocultural differences
 Coping with frustration dissatisfaction & anger are hard
 For kids who lack peers or from impoverished homes,
may have many needs to be met before they can
advance
 Careful selection of experiences is important for future
learning & development- love school or not
 Present ideas as fun, exciting, & pleasurable
 Introduce child to teacher & facility- take time to show
around
 Help parent’s assess readiness for new activities
 Developmental assessments show change
School Readiness
Need for consistent limit setting
Explain discipline & lesson
Offer limited choices
Describe outcomes in positive simple terms
Short tempers & impatience balance out by age 5
Fear independence and time away will diminish love
Feelings of insecurity may lead to shyness or
bossiness
May go through periods of aggression & shyness
Teach stress management and how to voice worries
Rehearse plans for activities
Play
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Short attention spans
Associative play without rigid organization
Quiet games – blocks, painting, crafts
Cumulative play –pretending to be….
Imaginative play- dress up
Dramatic play- puppets
Imaginary friends
Mutual play with parents ie stories
Necessary for physical, social & mental dev’t
Universal – need safe place
Project - # of stages same as age of child
Observe the preschooler
at “work”
 Discuss the assessments that
you can make from this picture.
 Physical co-ordination,
posture, eye-hand coordination, colour
sense, organization,
dexterity, concentration,
figures, handedness
Toy Selection
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Right age
Right size
Right purpose
Right possibility
Right quality
Right learning
Right amount of
supervision
 Right storage &
maintenance
 Right link with
development
 Right cultural values
 Right ergonomics
 Nontoxic
 Nonflammable
 No small pieces
 No sharp parts
 No shock, burn
 No wrong way to play
 CSA or other approved
Language
 More sophisticated & complex
 Development explodes
 Early referral for assessment if unable to
understand, not using sentences, omission of
consonants, stuttering, omits plurals, monotone
 Able to learn another language
 Age 3 – 900 words 75% understood
 Age 5 -1500-2100 words 100% understood
Language
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Manipulation of tongue, lips, swallowing
Breathing coordination
Hearing acuity
Stimulation
3 yr – mother knows, 75% others, 900
words
 5 yr –1200-1500 words 100% others
Language Problems if:
 Speech largely unintelligible
 Failure to use sentences of 3 or more
words
 Frequent omission of initial consonants
 Monotone voice,
 omits verbs, plurals etc
Many preschool children prefer their
nonverbal language and behaviour to
show their emotions instead of words
 Parents and other care
providers should ask the
child what they are trying
to tell us. “Try to use
your words. What do you
want me to know?”
“Words can tell me more
than your actions. You
need to come, sit, and
talk. No hitting or
throwing.”
What would you do here?
Speech Disorders
 Causes: hearing loss, developmental
delay, brain trauma or lack of verbal
stimuli
 Under age 3 yr-Denver Articulation
Screening Exam, over age 3yr-Language
Milestone Scale
 Early intervention & therapy important
Clinical Manifestations of
Speech Disorder
 Dysfluency (stuttering)
 Articulation deficiency
 Voice disorders
See Page 1018, Box 24-11
Fragile X Syndrome
 most common cause of inherited mental
impairment.
 Impairment can range from learning disabilities
to more severe cognitive or intellectual
disabilities.
 FXS is the most common known cause of
autism or "autistic-like" behaviors
 Unusual in that either parent can carry the
gene
Treatment
 Early intervention in skills development:
cognitive, motor, language, ADL’s
 Often have aggression, anxiety,
hyperactivity and/or limited attention span
 Pharmacological interventions may be
needed for behavioural problems
Communication
Disorders
Communication
Impairment
 Developmental Language Disorder
 Expressive
 Receptive
 Speech
 Pragmatics
 Etiology
 Mental retardation
 Hearing impairment
 CNS dysfunction
 Autism
 Childhood schizophrenia
 Organic problems ie CP, cleft palate
 Genetic disorders ie Tourettes
Clinical Manifestations of
Language Disorders
 Assigning meaning to words
 Organizing words into sentences
 Altering word forms
*See pg. 1017 Box 24-10
Nursing Care of Children
with Communication
Impairment
 Prevention
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Early recognition
Timely intervention
Stuttering
Screening tests
Referral to speech language specialist
Education
Vision Screening
and variations
 Visual problems can be assessed as early as a few
days of age. Focusing on bright objects, designs, faces
and movement are all good signs of vision.
 Visual acuity changes with age and growth of the head
and eyes.
 Ongoing testing at well-child checkups is necessary to
prevent delays in cognitive and psychosocial
development
 Testing must be appropriate for age and abilities
 No light reflex at any age is considered abnormal –
with or without known trauma & must be investigated.
Normal Eye
review of structures
 Health and condition of
children can be revealed
through their eyes.
 Positioning, epicanthic
fold, position, reflection,
refraction, brightness,
colour of sclera, pupil
dilatation, reactivity,
equality of movement,
response to light, tears,
eyelash length,
movement
 Simply be looking
carefully at a child, one
can begin the
assessment of sight,
visual acuity, and links
to episodic variations or
chronic conditions /
genetic anomalies that
may have a holistic
impact on growth and
developmental
milestones
Allow the child to see that there is just light
coming from the ophthalmoscope before using.
 Difficult to get children
to keep eyes open .
May need gentle help
from parent to retract
eyelid. Take a photo!
 Angle at a distance to
look for red reflex
White reflex abnormal*
 Congenital cataracts
are abnormal
 Careful observation
required to assess
correct findings.
Should follow guidelines
in Jarvis and
Hockenberry et al. for
vision and hearing
appraisals. Part of a
school readiness
assessment protocol.
p.180-183
Testing for strabismus
 Strabismus describes the
unequal placement and
movement of the eye in its
socket: Due to weakened
muscles, birth trauma,
neurological conditions,
fatigue, unknown etiology.
May cause double vision,
unco-ordinated movements,
visual suppression,
headache, nausea, lack of
desire to read or play,
frowning, squinting, ‘crossed
eyes’, learning/cognitive
delays or changes
 Should be corrected ASAP.
Fun ways to assess sightedness-visual acuity.
Use in conjunction with the symbolic or nonverbal tumbling E Snellen or Denver, Allen, or LH
vision tests. Can play pirates, “ patch Rt first”
then over L eye then the other.
Assess for ear and eye alignment.
Abnormal placement has been linked to
kidney and cognitive anomalies+
Look for ear tags, creases, pinna and fold variations
Down Syndrome presents a cluster of findings that
confirm a genetic variation. The effects of the Trisomy 21
Down Syndrome: Trisomy 21
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1:700 births
Characteristics associated with Down’s
Small head [microcephaly]
Flattened forehead
Wide, short neck
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Epicanthal eye folds
White spots on eye iris [Brushfield spots, disappear after 1 yr]
Congenital cataracts
Flat nose
Small, low-set ears
Protruding tongue
Short broad hands
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Simian line on palm
Wide space between 1st and 2nd toes
Hearing loss
Increased incidence of diabetes, congenital heart
defect, and leukemia
Hypotonia
Language is delayed & requires speech therapy,
frequent ear infections
Vision problems
Teaching hygiene is an ongoing problem
Exercise program to promote muscle development
GOALS ARE
MAXIMIZATION of POTENTIAL,
NORMALIZATION, and INTEGRATION
 Special educational supports / program
 May go to a regular daycare or preschool
program but may be developmentally delayed
 Focus on building basic skills. preventing
illness, and increasing communication capacity
 May have numerous hospitalizations for
cardiac surgery & follow-up
Community activities are NB
 Special needs school programs,
community living group homes and
apartments
 Special summer camps, week-end relief
program at the Rotary Center,
 Speech & language therapists,
physiotherapists thru Rotary, preschool
program thru Rotary
Fetal Alcohol Syndrome
Ref. American Psychiatric Society
 Alcohol more dangerous than cocaine—readily
passes into fetal brain
 Binge drinking more serious than occasional
drinking depends on liver’s ability to detoxify
the alcohol
 No amount of alcohol is safe
 Effects unpredictable depends on amount of
alcohol, degree and stage of fetal development
 FAS is entirely preventable
 Need for education of the public
 True incidence unknown due to
complexity, lack of reporting and variation
of symptoms
 Numerous health/developmental
problems
Visual Impairment
 Legal blindness: 20/200
 Causes of impairments: perinatal
infections, injuries, postnatal infections
 Causative organisms can be from
transplacental or vaginal routes.
Common types- all STI’s, StrepB, Viral,
 Neonatal eye drops- Erythomycin routine
EYE INJURIES= emergency
 *See pg. 1011 for Emergency TX
Causes:
 Penetration by sharp object
 Non-penetrating foreign object – superficial
irritant
 Non-penetrating :Chemical flash burns,
Heat- thermal burns,Ultraviolet burns
 Blunt force trauma to orbit & eye causing
hyphema, hematoma ( black eye)
Eye injury Management
 Principles:
Prevent further trauma internal/external
Prevent infection
Prevent loss of vision, ocular damage
Prevent rubbing or pressure on eye
Promote rest, pain management
Support family members- expression of
emotions :worry, anger, remorse, blame
Inform of diagnostics, treatments, care
Assist in safety proofing situations and places
Emergency Treatment-penetrating injury
 Stabilize eye- do not move penetrating object, wrap externally to
stabilize, ice over forehead and nose
 Rush to ER, Call ahead- need Ophthamologist stat.
 Once there, sedate child (twilight sleep) to examine injured eye.
 Keep non-injured eye covered to reduce co-lateral movement
 Surgical / sterile removal of penetrating foreign object
 Follow up with microsurgical suturing,
 antibiotics, antihistamines, anti-inflammatory (steroids),
antianxiolytics, sedatives, analgesics, antihypertensives
 complete bed rest, Semi Fowler’s position 45- 30’
 both eyes may be patched,
 May need to have elbow restraints to prevent rubbing eyes.
 Comfort measures for parent and child.
 Diversional activities rely on alternate senses: hearing, touch, etc
 Await absorption of blood from aqueous chamber.
 Guarded prognosis
Emergency Eye treatments for
non-penetrating injuries
 Chemical burns- irrigate 20 minutes under clear
lukewarm running water, flushing gently under and
around all aspects inside and outside lids.
 Cover both eyes with clean cloth.
 Rush to ER -bring chemical container
 Keep in dark room, cover both eyes, rest
 Follow up with ophthamologist
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For Ultraviolet and flash burns, do all except irrigation -
Blunt force trauma to eye/face/head
 Use flashlight to inspect eyes- check pupil shape,
equality,& reactivity bilaterally
 look into anterior aqueous chamber for any signs of
blood (hyphema); Child may state not be able to see.
 Check tears to see if clear or blood tinged, or absent.
 Watch for vitreous leaks from sclera, or corners of eye,
or damaged tissue of eye, visual miniscus fluid across
iris: sterile dressing if leakage positive
 Check eye socket, orbit for fracture & iris for prolapse
 Rest with eyes closed, covered with cold cloth.
 Apply ice to reduce swelling if hyphema NOT present.
 Refer to ophthamologist STAT if hyphema present.
Visual Acuity
 Tests-Table 6-9 Pg. 182
 Types of Impairment Box 24-9 Pg. 1012
 School-Age common problems: myopia &
astigmatism, dyslexia
 Blind-need special education & devicesBraille, voice activated computers, Smart
boards, Magnification equipment,
personal readers.
Vision Testing
 Ocular alignment
 Visual acuity
 Peripheral vision
 Colour vision
Childhood Vision
Disorders
 Strabismus
 Abnormal deviation of alignment of eyes
 Can lead to amblyopia
 Strengthen weak eye muscles through
patching
 May require surgery
Vision Disorders
(cont’d)
 Amblyopia – “lazy eye”
 Stronger eye becomes dominant and retains
vision; weaker eye fails to develop normally
 Patching stronger eye
 May require glasses, surgery
Vision Disorders
(cont’d)
 Cataracts
 Congenital or acquired
 Requires early surgery to prevent blindness
 Retinoblastoma
 Intraocular malignancy
 “Cat’s eye reflex”
Color-Blindness
 X-linked, 10% males, 1% females
 Trouble with traffic lights, coordinating
clothing, career choices
Hearing Sense:
in constant need of assessment
Auditory capacity is vital to adaptation and
maturation . Helps make sense of the world.
Hearing Impairment
 Mild to profound
 May be caused by prenatal or postnatal
conditions ie. Malformations, toxins,
infections, maternal substance abuse
 **IPods are a concern
 Manifestations pg 1007
 Education of others
Nursing Care
 Hearing Aids – problem with acoustic
feedback – may be self-conscious
 Lip reading – need to incorporate sender’s
body language, facial expression – only
40% of spoken words are understood
 Sign Language
 Speech & Language Therapy
 Cued Speech – lip reading + hand signals
 Socialization
Health Promotion of
Preschoolers
 Toilet mastery may be continuing from
toddlerhood – child specific.
 Language development: girls outpacing boys
 Gross & fine motor refinement : boys outpacing
girls
 Walking, running, climbing, jumping, tricycle-bicycle,
tiptoes, skips, hops, skate, swim
 Drawing essential for development & reading –
scribbling to picture making progresses in stages –
placement, shape, design & pictorial (Kellogg,1969)
Health Promotion
Appetite larger –provide wider selection
•1800 cal/day (90 kcal)
•100 ml/kg
•Fiber, fruit, veggies - + 5/day
•Low fat or skim milk
•Fruit juice limit to 240 ml/day
Teach self care skills – how to get coat on etc
Teach dental care, tooth loss, regular check ups
Teach good hygiene
Introduce to safe people – family password
Need regular sleep patterns
Anticipatory guidance for parents –questions re sex,
bad words, telling tall tales, stealing, hurting
Parents worry when boys and girls become
fascinated with the body, its differences and
functions
 Guidelines to help parents understand and teach about modesty,
personal body space, rights and respect for other’s privacy.
 Linked with sexual role playing- Freud- Becoming aware of sexual
pleasure, excitement, One way to relieve stress . Must learn that
masturbation is a private activity, and must be done in a private
place
 Boys and girls may be fearful of the differences they see at
home, daycare, in innocent situations, - loss of penis, or envious
of other’s having one, or worried about why they are different(
don’t have one)
 Sexual predators are not always strangers. Must protect children
from personal violation.
 Newspaper article – obsessions of a preschool boy
 P.645-657
Injury Prevention
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Poisoning
Pedestrian motor vehicle injuries
Seat belts
Bicycle helmets
Emphasis on protection and education
for safety
 Less likely to fall d/t increased motor
co-ordination
Injury Prevention
 Know telehealth # 1-866-797-0000
 post near phone*
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Motor vehicles – correct seat belt, booster seat
Traffic safety rules- bicycle helmets
Water safety
Sunscreen
Safe playground equipment
Personal safety
Stranger safety
Farm safety –rural school programs
As Nurses…
 Ensure safety in homes, schools, day
care
 Support and advocate for safety of
families and individuals
 Implement healthy food choices in
lunches and snacks while promoting the
safety of children with allergies
 Education to parent, teachers, care
givers, and children
Haddon Phase-Factor Matrix
Useful for planning, strategy identification,
resource allocation
Host
(Human)
Phase
PreEvent
Event
PostEvent
Vector
(Vehicle)
Physical
Cultural
Environment Environment
Copyright ©1998 BMJ Publishing Group Ltd.
Haddon Phase-Factor Matrix
Application to Playground Safety
Host
(Human)
Vector
(Vehicle)
PreEvent
-before
the fall
Teaching re:
playground
rules
Construct safe Playground
equipment
design to
minimize risk.
Foster social
norms of orderly
play.
Event
- time of
fall/
impact
Teach how to
fall to
minimize
injury
Reduce sharp
protrusions to
reduce injury
in falls.
Use of resilient
surfacing.
Develop comm.unity systems to
monitor
playground
Benches placed
so parents can
supervise &
notice injury.
Ensure funding for
trained
emergency
personnel.
Phase
PostEvent
-after
injury
Teach children Playground
how to
accessible to
summon help rescue
personnel
Physical
Environment
Cultural
Environment
Farm Safety
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Majority of accidents – start-up’s
Falls from moving vehicles
Drownings
Electric shocks, poisonings
Animal attacks
Many farm kids grow up with
unsafe practices
 Working without supervision
 Riding on equipment- tractor or lawn
mower
 Know where child is at all times
Preventing Farm Injuries
1. Provide appropriate supervision
2. Encourage children to get help if
problem
3. Fence off dangerous areas
4. Safe play area
5. Identify and eliminate hazards
6. Practice no-riders policy
Preventing Farm Injuries
7.
8.
9.
10.
11.
12.
13.
(cont’d)
Do walk-around before starting machinery
List of emergency phone numbers
Tasks should be age-appropriate
No playing in grain trucks and bins
Leave livestock alone
Teach poison symbol & safety
Keep poisons/toxins out of reach
 Education & training essential
 Farm Safety 4 Just Kids
 Windsor Safety Village
 “Nothing raised on a farm is more
valuable than our children”
Animal Bites
 ½ victims of dog bites are under age 3 –
head, face & neck
 Cats may scratch – cat scratch fever
 Most owned by family or neighbour
 Socialization of puppies
 Need constant vigilance
 Prevention is key
Animal Safety
 Keep children away from
animal food
 Teach to respect animals
 Do not surprise or invade territory
 Do not interact with animal who
is sick
 Do not interact with animal with
new babies
Nutrition can be practiced!
Nutrition
 Nutritional requirement
approximately 90 kcal/kg
 Fluid requirement approximately 100
ml/kg daily
 Canada’s Food Guide application to
preschoolers- cultural variations
 Concerns about childhood obesity
Choosing Healthy Foods
Assist in Food
Preparation
Facts about Pain
in Infants and Children
 Infants, regardless of age, feel pain.
 The youngest premature infant has the
anatomic and physiologic components
to perceive pain or “nociception” and
demonstrates a severe stress response
to painful stimuli.
Operational Definition of
Pain
“Pain is whatever the experiencing person
says it is, existing whenever he says it
does.”
BELIEVE THE PATIENT!
Ref: McCaffery and Pasero: Pain: Clinical Manual,
1999).
 Threshold for responding to
cutaneous stimulation is
lowest in youngest neonates
 Inhibitory pathways do not
develop until after birth
Neonate
CRIES Pain Scale
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Crying
(0-2)
Requires increased O2 (0-2)
Increased V/S
(0-2)
Expression
(0-2)
Sleepless
(0-2)
0=no pain; 10=worst pain
Facial Expression of
Physical Distress
Possible Signs of Pain in the
Neonate: Behavioral
Variables
Vocalizations:
 Crying (often with apneic spells)
 Whimpering, groaning, moaning
State changes:
 Changes in sleep/wake cycles
 Changes in activity level
 Agitation or listlessness
Children Can Tell You
Where They Hurt
 Children beyond infancy can
accurately point to the body area or
mark the painful site on a drawing;
children as young as three years can
use pain scales.
Children Do Not Always
Tell The Truth About Pain
 Children may not admit having
pain to avoid an injection,
because of constant pain, or
because they believe others
know how they are feeling.
Question the Child
Verbal Indications of Pain
 Much less common than in adults
 May not understand term, such as “pain”
 May speak globally, such as “I don’t feel
good”
 May deny pain for fear of injection
 Cries, screams, groans, moans
QUESTT
 Question the patient
 Use pain rating scale
 Evaluate behavior and physiologic signs
 Secure family’s involvement
 Take cause of pain into account
 Take action and assess effectiveness
Behavioral Manifestations of
Pain May Not Reflect Pain
Intensity
 Children’s developmental level,
coping abilities, and
temperament, such as activity
level and intensity of reaction to
pain, influence pain behavior
Evaluate behaviors and
physiologic changes
Acute Pain vs Chronic Pain
 Acute pain activates body’s fight or flight
stress response.
 When pain persists, body begins to adapt
and there is a decrease in the sympathetic
responses.
 In chronic pain, stress response is absent
or diminished.
Bodily Movements:
 Limb withdrawal, swiping, or
thrashing
 Rigidity
 Flaccidity
 Clenching of fists
Observe for Specific
Behaviors that Indicate Local
Body Pain
 Pulling ears
 Rolling head from side to side
 Lying on side with legs flexed on
abdomen
 Limping
 Refusing to move a body part
Use Pain Rating Scale
 Select a scale that is suitable for the child’s
age, abilities, and preferences
 Teach child to use scale before pain is
expected, such as preoperatively
 Use same scale with child each time pain is
assessed
 Ask child about acceptable or functional
pain level
Wong-Baker FACES
Pain Rating Scale
Physiological Indications of
Acute Pain

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Dilated pupils
Increased perspiration
Increased rate/ force of heart rate
Increased rate/depth of respirations
Increased blood pressure
Decreased urine output
Decreased peristalsis of GI tract
Increased basal metabolic rate
Narcotics Are No More
Dangerous for Children Than
Adults
• Addiction from narcotics (opioids)
used to treat pain is extremely rare
in adults; no reports substantiate
this fear in children; reports of
respiratory depression in children
are rare.
Demerol




Offers sedation for 2.5-3.5 hours
Need high doses for adequate sedation
Toxic if renal impairment; cerebral irritant
Not recommended for the elderly or the young.
Prefer Codeine or Morphine if narcotic required
Concept of
“Total Pain Management”
Four aspects must be addressed:
1. Physical
2. Psychological
3. Social
4. Spiritual
Last 3 can be met only after pain and
related symptoms (e.g., N/V, anxiety) are
controlled
Take action and assess
effectiveness
The only reason to assess pain is TO TAKE
ACTION TO RELIEVE PAIN.
After intervention, assess child’s response to
pain relief measures.
 Determine timing of assessment based on
expected onset and peak effect of
intervention:
 IV analgesic: assess after 5 minutes and 15
minutes
Observe for Improvement in
Behavior Following an Analgesic
Communicable Diseases
 Has declined since immunizations
 Assessment (see p 652-660)
 Recent exposure
 Prodromal symptoms – fever or rash
 Immunization hx
 Previous history
 Goals
 Avoid spreading infection to others
 No complications
 Child will have minimal discomfort
 Child & family will receive adequate support
Bacterial Meningitis


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

Inflammation of meninges & CSF
90% cases from 1 mon to 5 yrs
Decreased incidence since HIB vaccine
Usually follows another bacterial infection
Also caused by streptococcus pneumoniae –
new vaccine available
 Neisseria menigitidis & others (p1677)
 Onset abrupt, fever, chills, h/a, vomiting,
decreased LOC, initial sign may be fever
 Irritable, agitated, photophobia,nuchal rigidity
Meningitis
 Complications - Septic shock, DIC- Waterhouse
Friderichsen syndrome
 High mortality – 90%
 Obstructionto flow of CSF, seizures,
hydrocephalus,compression to cranial nerves
 Dx by lumbar puncture – high WBC
 Tx – isolation, antimicrobials, hydration,
ventilation, reduced ICP, management of shock,
control of seizures, antipyretics, treatment of
complications, quite restful environment
Encephalitis
 Inflammatory process of CNS –bacteria,
spirochetes, fungi, protozoa, helminths & viruses
 May be direct invasion or postinfection
 Mild form lasts few days –full recovery
 50% of cases – cause unknown
 Associated with measles, mumps, varicella,
rubella, enteroviruses, herpes & West Nile
Encephalitis
 S&S – seizures, malaise, fever, h/a,
dizziness, apathy, stiffness of neck, N&V,
ataxia, tremors, speech difficulties
 Dx- LP, CT scan, blood cultures
 Rx -symptom relief, decrease ICP,
neurologic monitoring
Group A Beta Hemolytic Strep
 Sequelae
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
Strep throat
Otitis media
Scarlet fever (p 660)
Rheumatic heart disease- follows URI (p1511)
Acute glomerulonephritis (p1271)
Kawasaki disease (p1514)
Juvenile rheumatoid arthritis (p1820)
CNS – tics (p 792)
St Vitus dance (p1512)
Medications for Tx of GABHS
 Penicillin, Rifampin, Pen G, Biaxin,
Azithromycin, Clindamycin, Amoxicillin
Cephalosporin (see p 1149-1167)
 Emla cream for IV or IM (p 1066)




Check for allergies
Acetaminophen
Avoid ASA –Reye’s syndrome (p 1683)
Immune globulin for Kawasaki disease &
glomerulonephritis
Stomatitis
 Inflammation of the oral mucosa
 May be infectious or noninfectious
 Types normally seen in children
 1. Aphthous stomatitis
 Symptoms:
Stomatitis
 Types normally seen in children
 2. Herpetic stomatitis
 Symptoms:
Stomatitis
 Therapeutic Management (both types)
 Baby put all around mouth and let swallow
 Older switch and swallow
 Nursing Care
Nursing Care
 Distinguish oral lesions from coagulated milk
How?
 Treatment:

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
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

Nystatin is treatment of choice
Given before or after feedings?
Rinse mouth with plain water
Boiling items such as reusable nipples, bottles, pacifiers
Gentian violet sol’n plus the antifungal drugs in recurrent
What about breastfed babies?
Good hygiene!!!!!
Staphylococcal Infections
 Skin infections





Impetigo
Pyoderma
Folliculitis
Cellulitis
Staph scalded skin
 Toxic shock syndrome
Pharyngitis

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
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
Causes and risks
Clinical manifestations
Diagnostics
Therapeutic management
Nursing considerations
Tonsillitis and
Pharyngitis
Tonsillitis
 Pathophysiology and etiology
 Clinical manifestations
 Therapeutic management
 Medical
 Surgical
 Nursing considerations
Therapeutic management
 Medical – GABHS- antibiotic
 Surgical – tonsilectomy- controversial
 Warranted with chronic infection
 Age 3-4 yrs
 Complications
 Hemorrhage
 Earaches
 Pain
Tonsillitis
 Tonsils – mass of lymphoid tissue
 Waldeyer tonsilar ring (see p 1352)
 Filter & protect respiratory tract from pathogens
 Antibody formation
Tonsillitis begins with pharyngitis
– viral or bacterial
 Edema, difficulty swallowing & breathing
 Halitosis, cough
 Otitis media
Therapeutic management
 Medical – GABHS- antibiotic
 Surgical – tonsillectomy- controversial
 Warranted with chronic infection
 Age 3-4 yrs
 Complications
 Hemorrhage
 Earaches
 Pain
Postop care
 Know what tonsils were removed
 Assess for frequent swallowing, blg from nares,
clearing of throat, blood in mucus
 Pain management, ice chips, collar
 N&V management
 Frequent vital signs
 Watch for shock – tachy, pallor, hypotension,
restlessness, agitation, respiratory stridor, O2 sats,
cyanosis, difficulty swallowing
 Avoid gargles, high acid fluids, abrasive foods, red
& brown fluids
Tonsillectomy – Post Op
Care
 Observe for s/s of shock
 Watch for frequent swallowing – visually
inspect the throat
 Vital Signs
 Provide cool soft foods/liquids
 Discourage coughing/clearing throat
 Avoid red/brown coloured liquids
 Avoid milk products – coats throat
S&S of Shock
 If bleeding –Notify MD, bedrest, highFowlers, ice collar, calm environment
 Start V/S q15min, prepare for possible
return to OR
Upper Respiratory Tract
Infections
 Acute nasopharyngitis (cold)
 Rhinovirus, RSV, adenovirus, influenza virus,
parainfluenza virus
 Fever common in younger kids
 Also may have vomiting & diarrhea
 Runny nose, skin irritation
 Self limited –resolves in 4-10 days
 May also have otitis media
 Usually managed at home
 Rest, antipyretics, decongestants, cough
suppressants, push fluid intake
 Vaporization may provide relief
 Avoid contact with infected persons
 Handwashing
OTITIS MEDIA
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80% of children have had
50% three or more episodes by age 3
Lower incidence in breast fed babes
Reflux of milk into Eustachian tubes
Boys more often
2nd hand smoke
Strept pneumoniae, Hemophilus influenza, moraxella
catarrhalis
 Complications – hearing loss, ear-drum perforation,
labyrinthitis, mastoiditis, meningitis, cholesteatoma
Causes & Risk Factors
  risk with tobacco smoke
 Boys > girls
 Day care
Causes:
 Strep pneumoniae, Hemophilus influenza
 blocked Eustachian tubes –
 allergic rhinitis,
 bottle feeding d/t reflux of formula when fed
in the supine position
*decreased incidence with breast fed babies
Anatomic Position of ET
in Child and Adult
Otitis Media

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
Pain
Fever
Irritability
Loss of hearing
Redness, fluid or pus behind eardrum
What is a classic behaviour exhibited by
children when they have an ear infection?
S&S of OM
 Pain from fluid accumulating in middle ear
& pressure on surrounding structures
 High T, enlarged glands
 Rhinorrhea, vomiting & diarrhea
 Pharyngeal infection, anorexia
Diagnosis
 Otoscopy-dull gray membrane
Management of OM
 Antibiotics if warranted
 Symptom management
 Anlgesics, warm or cold, sleep on affected side
 Myringotomy & tube placement
 Pressure equalization (PE tubes), drainage, falls out
when healed. May need repeat
 Keep ears dry, ear plugs
 Mastoidectomy
 Tympanoplasty
Management
 Antibiotics
 Myringotomy, PE tubes
Nursing Care
 Fever & pain management
 Administer antibiotics – teaching re:
completing series
 Pre & post-op care – outpatient surgery
 Teaching about care for tubes – no water
in ears
Nursing Considerations
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Feed child sitting up
Increase risk with cleft palate
Teach to blow nose gently
Keep external ear dry & clean
Light coating of petroleum jelly
Ear wicks
Avoid air travel – chew gum
Watch for hearing deficit
Day Surgery
 Minimizes stress, risk of infection
and costs
 Pre-admission preparation is important
 What to expect and advance preparation
for home
 Explicit discharge instructions
Day Surgery
EMLA Cream
Local anesthetic (lidocaine & prilocaine
mixture)
Uses: IV insertion, blood draws
Can be left on for up to 3 hours on
children greater than 37 weeks gestation
How to Use:
 Apply to area **DO NOT rub into
the skin
 Cover with an occlusive dressing (Tegaderm)
– Cream needs to be in a thick layer
 Timing – needs to be left on at least 60
minutes
 Remove immediately before procedure and
wipe clean
 *Not for use around open wounds
Genitourinary
System
Common Illnesses
Genitourinary
Assessment
 History
 Family history, urinary patterns,
incontinence, bedwetting, pain, fever,
increase in weight
 Examination
 General appearance, examination of
genitalia
 Urine, I & O
 Pain, Vital signs
Diagnostic Tests
Urinalysis: What are the components of a
urinalysis (U/A)? What findings are
normal/abnormal?
24 Hour Urine Collection for: protein,
creatinine clearance *Nsg
Responsibilities
Blood tests: BUN, Creatinine, lead &
heavy metals, chemicals,
Ultrasound, xrays – KUB
Diagnostic Procedures
 Cystoscopy – visualization of bladder lining
with small scope
 Nsg care: sedation of child, monitoring of vitals,
explain may be pain upon urination for 24 hours,
small amount of blood in urine normal initially post
procedure
 Voiding Cystogram – bladder is filled with radio
isotope liquid via catheter – child stands to void
and x-rays taken – used to diagnose VUR
Diagnostic Procedures
 Intravenous Pyelogram – used to detect
malformations of ureters, renal pelvis, renal
calculi
 Most often used for diagnosis of vesicoureteral
reflux (VUR)
 Dye is injected via the vein and x-rays taken of
urinary system
 *Caution: Cross sensitivity
of dye with shellfish allergies
Intravenous Pyelogram
(IVP)
Enuresis
 “Bed wetting”
 More common in boys
 Usually ceases between 6 and 8 years of
age
 Diagnosis
 Developmental age of more than 5 years
 Two times per week or more for 3 months
 May have urgency, frequency
Enuresis (cont.)
 Organic causes
 Structural defects
 UTI, impaired kidney function, chronic renal
failure
 Neurologic deficits, endocrine disorders
(diabetes)
 Sickle cell disease
 Bladder volume of 300 to 350 ml is
sufficient to hold a night’s urine
Psychologic Factors
 “Sleep more soundly than other children”
 Emotional factors
 Familial tendency
Treatment for Enuresis
 Drugs
 Tofranil
 Oxybutynin
 DDAVP
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
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Bladder training
Fluid restriction in evenings
Interruption of sleep to void
Conditioned reflex response device
Urinary Tract Infections




Cystitis, pyelonephritis
Pathogen – E Coli most common
Tx with antibiotics – Bactrim
Causes: short urethra, urinary stasis, irritants,
sexual intercourse, transfer of pathogen from
anus
 Symptoms: may be vague




Dysuria, frequency, incontinence
Fever
Flank pain
 WBC, bacteria, blood in urine; urine +ve culture,
leukocyte esterase
Preventing UTIs

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Increase fluid intake
Empty bladder frequently
Avoid bubble baths & sprays
Wipe front to back after toileting
Wear cotton underwear
Perineal care
Notify dr. of signs of infection
Vesicoureteral Reflux
 May be unilateral or
bilateral
 Surgery to re-implant
ureters
 Loss of renal function
without correction
Why?
 DX: Voiding cystogram,
cystoscopy, IVP
Other Disorders
 Enuresis
 Urethral stenosis
 Ureteral dysplasias
 Hydronephrosis
 Wilms Tumor
Wilms Tumor
 “nephroblastoma” – most common renal
tumor of childhood
 Most common – 3 to 4 yrs of age
 S/S: nontender mass within the
abdomen, anemia, hypertension, weight
loss
 May metastasize – lungs, thoracic cavity
 Usually discovered by parents during
dressing/bathing
Therapeutic Mgt
 High survival rates if no mets
 Surgery to remove tumor &
chemotherapy
 Stage I and II – 90% cure rate with
multimodal therapy
 Transplant if both kidneys severely
affected
Nursing Care
 Surgery typically scheduled within 24-48
hrs
 Emotional care for child & parents
 Play therapy for younger children
 If left with 1 kidney – educate re: contact
sports
 Education re: prevention of UTI’s
Urinary Tract
Surgery
 Altered urinary elimination r/t malformation or
surgical procedure
 Risk for infection r/t indwelling catheter &
surgical site
 Pain r/t surgical incision &/or bladder spasm
 Body image disturbance r/t
malformation or surgical procedure
 Anxiety r/t invasive procedures
Bladder Exstrophy
Means that the bladder is essentially inside
out and exposed on the outside of the
abdomen.
(University of Virginia Health System)
Statistics
 Is noted in 1 of 30-50 000 live births. It is
more prevalent in boys than girls with a ratio
of 2:1.
 Other anomalies associated with this are:
 low set umbilicus
 the bones of the pelvis are widely separated
 boys have a short penis with an upward bend
 the clitoris in girls is bifid and although the vagina
is usually normal it may be short with a narrow opening.
Treatments
 Usually three surgeries need to occur
 The first one being within the first 48 hours of birth.
This is to internalize and close the bladder in
addition to closure of the abdominal wall defect.
 The second, for repairing of the epispadias and other
genital abnormalities, usually done between the
ages of 1 and 2.
 The final surgery involves the bladder neck
reconstruction typically preformed at age 5.
 My Research Question is how can nurses minimize
the impact an abnormality has on the family and
child immediately after birth and throughout their
life?
Nephrosis/Nephrotic
Syndrome
 glomerular permeability to plasma
proteinsproteinuria
 hypoalbuminuriaedema
 hyperlipidemia
 MCNS-minimal change nephrotic
syndrome in 80%
 Rx-rest, diet, corticosteroids
 Autoimmune disorder
 MCNS – 80%
Nephrotic Syndrome: S&S
 Urine – dark, foamy, frothy,  urine
output
 Edema – periorbital, dependent, ascites
 Weight gain; pale, stretched skin
 Fatigue, lethargy
 Susceptible to infection
 Diagnostic tests:
 Blood:  serum proteins,  cholesterol,
 ESR
 Urine:  protein, sp. gr., casts, RBC
 Renal biopsy
Care of Child with Nephrotic
Syndrome
 Fluid volume excess r/t accumulation in body
tissues
 Risk for infection r/t  body defenses
 Altered nutrition < body req. r/t anorexia
 Risk for impaired skin integrity r/t edema
 Activity intolerance r/t fatigue
 Body image disturbance r/t edema & steroid
effects
 Altered family processes r/t child’s serious
illness
Glomerulonephritis
 Autoimmune response to strep
 Inflammation of glomerulus -can lead to
sclerosis, permanent damage
 S&S:






Moderate edema
Cloudy, cola-coloured urine
 B/P
Fatigue, irritability, anorexia
Lab:  ASOT,  ESR
Urine:  protein,  sp.gr., blood+++
Nephrotic Syndrome
Glomerulonephritis
Fatigue
present
present
Anorexia
present
present
B/P
normal or decreased
elevated
Edema
severe
moderate
Urine
dark, foamy, frothy
 protein++,  sp. gr.
casts, few RBCs
 proteins
cholesterol,  ESR
ASOT normal
cloudy, cola-coloured
 blood ++,  sp. gr.
 protein (mild)
proteins normal
lipids, chol. normal
 ESR,  ASOT
Blood tests
Treatment
 Nephrotic Syndrome: bed rest, salt restriction
during periods of massive edema, no water
restriction
Meds: Corticosteroids (prednisone) until urine
is free of protein
 Glomerulonephritis: treatment is supportive –
antihypertensive & diuretic meds, iron
supplements, antibiotics for strep infection, no
added salt
Nursing Care
 Nephrotic





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
Strict I & O
Daily weight
Abdominal girth
Skin care
s/s of resp. infections
Promote food intake
Side effects of
prolonged steroid tx.
 Glomerulonephritis





Freq. BP monitoring
I&O
Daily weight
Neuro assessment
Allow frequent rest
periods
 Seizure precautions
Constipation
 3 or more days without
stool, passage of hard
stool
 Encopresis
 Functional or due to
disorder – e.g
Hirschprung
 Need dietary changes,
 fluid intake, regular
routine, stool softeners
Constipation
 An alteration in the frequency,
consistency, or ease of passage of stool
 May be secondary to other disorders
 Idiopathic (functional) constipation—no
known cause
 Chronic constipation—may be due to
environmental or psychosocial factors
Constipation in Childhood
 Often due to environmental changes or
control over body functions
 Encopresis: inappropriate passage of
feces, often with soiling
 May result from stress
 Management
Encopresis
 Primary encopresis = fecal incontinence
after age 4 years
 Secondary encopresis = fecal incontinence
in a child older than 4 years after period of
prior established fecal continence
Encopresis
 Associated with constipation & fecal
retention
 Watery contents bypass constipated stool
 May be confused with diarrhea
Encopresis (cont.)
 More common in males
 May follow psychological stress
 May be secondary to constipation or
impaction
 Therapeutic management
 Determine cause
 Dietary intervention, management of
constipation
 Psychotherapeutic interventions
Nursing Considerations
 History of bowel patterns, medications,
diet
 Educate parents and child
 Dietary modifications (age appropriate)
Hernias
 Protrusion of a structure through the
muscle wall
 Congenital defects or collagen synthesis,
trauma, or surgery
 Common: umbilical and inguinal; can
strangulate or incarcerate[confined]
 RX-surgery or mechanical reduction
Research
 There is much evidence to suggest a dramatic
increase in prevalence of allergies
 Furlong (2004) “prevalence of peanut allergy
doubled in children from 1997 to 2002
 Health Canada (2005) estimates 600,000
Canadians are affected by life threatening
allergies