NCLEX: Health Promotion and Maintenance

Health Promotion and Maintenance: MUSCULOSKELETAL AND NEUROMUSCULAR SYSTEMS

Focus topic: Health Promotion and Maintenance

Orthopedic conditions in infants and children are many and varied, but treatment is based on basic principles of nursing care. Common Pediatric Orthopedic Conditions and Signs of developmental dysplasia of the hip and The four major curve patterns in idiopathic scoliosis offer a quick review of the major pediatric orthopedic conditions.

Health Promotion and Maintenance
Health Promotion and Maintenance

I. CEREBRAL PALSY

Focus topic: Health Promotion and Maintenance

A. Introduction: Cerebral palsy (CP) is the most common permanent physical disability of childhood. It is a neuromuscular disorder of the pyramidal motor system resulting in debilitating impaired voluntary muscle control. The damage appears to be fixed and nonprogressive, and the cause is unknown. However, although a variety of factors have been implicated in the etiology of CP, it is now known that CP results more commonly from prenatal brain abnormalities.

Health Promotion and Maintenance

B. Assessment:

Focus topic: Health Promotion and Maintenance

1. Most common type of cerebral palsy—spastic.

a. Delayed developmental milestones.
b. Tongue thrust with difficulty swallowing and sucking. Poor weight gain. Aspiration may occur.
c. Increased muscle tone: “scissoring” (legs crossed, toes pointed).
d. Persistent neonatal reflexes.
e. Associated problems:

  • Mental retardation in 30% of children with cerebral palsy (70% are normal).
  • Sensory impairment: vision, hearing.
  • Orthopedic conditions: congenital dysplasia of hip, clubfoot.
  • Dental problems: malocclusion.
  • Seizures.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Ineffective airway clearance related to hyperactive gag reflex and possible aspiration.
  • Altered nutrition, less than body requirements, related to difficulty sucking and swallowing.
  • Fluid volume deficit related to difficulty sucking and swallowing.
  • Impaired verbal communication related to difficulty with speech.
  • Sensory/perceptual alterations related to potential vision and hearing defects.
  • Risk for injury related to difficulty controlling voluntary muscles.
  • Self-esteem disturbance related to disability.
  • Note: Because the level of disabilities with CP can vary, the nurse must select those diagnoses that apply, and clearly specify the individual child’s limitations in any diagnostic statements.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: maintain patent airway.

  • Have suction and oxygen readily available.
  • Use feeding and positioning techniques to maintain patent airway.
  • Institute prompt, aggressive therapy for URIs, to prevent the possible development of pneumonia.

2. Goal: promote adequate nutrition.

  • Diet: high in calories (to meet extra energy demands).
  • Ensure balanced diet of basic foods that can be easily chewed. Refer to dentist for early dental care.
  • Provide feeding utensils that promote independence.  Feed in upright position.
  • Relaxed mealtimes, decreased emphasis on manners, cleanliness.
  • Monitor I&O, weight gain.
Health Promotion and Maintenance

3. Goal: facilitate verbal communication.

  • Refer to speech therapist.
  • Speak slowly, clearly to child.
  • Use pictures or actual objects to reinforce speech.

4. Goal: prevent injury. Refer to information on safety throughout growth and development sections, pp. 256–257, 258, 260, 261.

  • Use individually designed chairs with restraints for positioning and safety.
  • Provide protective helmet to prevent head trauma.
  • Implement seizure precautions.

5. Goal: provide early detection of and correction for vision and hearing defects.

  • Arrange for screening tests.
  • Assist family with obtaining corrective devices: eyeglasses, hearing aids.

6. Goal: promote locomotion.

  • Encourage “infant stimulation” program to assist infant in reaching developmental milestones.
  • Refer to physical therapy for exercise program.
  • Incorporate play into exercise routine.
  • Use devices that promote locomotion: parallel bars, crutches, and braces.
  • Surgical approach may be needed to relieve contractures.
  • Medications: focus on ↓ excessive motion and tension; antianxiety agents, skeletal muscle relaxants, Botox injections, baclofen pump (IT).

7. Goal: encourage independence in ADLs.

  • Adapt clothing, feeding utensils, etc., to facilitate self-help.
  • ncourage child to perform ADLs as much as possible; offer positive reinforcement.
  • Assist parents to have realistic expectations for their child; avoid excessively high expectations that might increase frustration.

8. Goal: promote self-esteem.

  • Praise child for each accomplishment or for sincere effort.
  • Help child dress and groom self daily in an attractive “normal” manner for developmental level and age.
  • Encourage child to form friendships with children with similar problems.
  • Enroll child in special education classes to meet the child’s educational needs.
  • Encourage parents to expose child to wide variety of experiences.

E. Evaluation/outcome criteria:

  • Patent airway and adequate oxygenation maintained.
  •  Adequate nutrition maintained, and child begins to grow and gain weight.
  •  Child has an acceptable means of verbal communication.
  • Safety is maintained.
  • Vision and hearing within normal limits using corrective devices prn.
  • Child is as mobile as possible, given disabilities.
  • Child is performing ADLs, within capabilities.
  • Child has positive self-image/self-esteem.

II. SPINA BIFIDA (MYELODYSPLASIA)

Focus topic: Health Promotion and Maintenance

A. Introduction: Three different types of spina bifida:

  • Spina bifida occulta—a “hidden” bony defect without herniation of the meninges or cord; not visible externally, no symptoms are present, and no treatment is needed.
  • Spina bifida cystica—visible defect of the spine with external saclike protrusion.
    a. Meningocele (Comparison of Two Major Types of Spina Bifida).
    b. Myelomeningocele—see Comparison of Two Major Types of Spina Bifida . Most serious type of spina bifida cystica and also most common. The remainder of this section deals with myelomeningocele exclusively.

B. Assessment:

Focus topic: Health Promotion and Maintenance

  • Congenital defect.
  • Readily detected by visual inspection in delivery room: round, bulging sac filled with fluid, usually in lumbosacral area.
  • Sensation and movement: complete lack below the level of the lesion.
  • Urinary: retention, with overflow incontinence.
  • Fecal: constipation, fecal impaction, oozing of liquid stool around impaction.
  • 80% to 85% develop signs and symptoms of hydrocephalus.
  • May have associated orthopedic anomalies: clubfoot, developmental hip dysplasia.
Health Promotion and Maintenance

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Risk for injury/infection related to rupture of the sac.
  • Altered urinary elimination related to urinary retention and overflow incontinence.
  • Impaired skin integrity related to immobility.
  • Constipation related to fecal incontinence and impaired innervation.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: prevent rupture of the sac and possible infection (preoperative).

  • Position: no pressure on sac; prone, to prevent contamination with urine or stool.
  • No clothing or diapers, to avoid pressure on sac.
  • Place in heated isolette to maintain body temperature. Avoid radiant heat, which can dry and crack the sac.
  • Keep sac covered with sterile, moist, nonadherent dressing (sterile normal saline) to prevent drying, cracking, and leakage of CSF; change every 2 to 4 hours; document appearance of sac with each dressing change to note signs and symptoms of infection, leaks, abrasions, or irritation.
  • Enforce strict aseptic technique to prevent infection (leading cause of morbidity/ mortality in neonatal period).
  • Avoid repeated latex exposure (e.g., gloves, catheters) to decrease risk of latex allergy.

2. Goal: prevent infection in postoperative period.

  • Position: prone, side-lying, or partial side-lying.
  • Use myelomeningocele apron (specific type of dressing) to prevent urine or stool from contaminating suture line.
  • Administer antibiotics as ordered.
  • Use strict aseptic techniques in dressing changes; standard precautions to prevent infection.

3. Goal: prevent urinary retention and UTI.

  • Monitor I&O, offer extra fluids to flush kidneys.
  • Keep urethral meatus clean of stool to prevent ascending bacterial infection.
  • Monitor urinary output for retention.
  • Administer antibiotics/urinary tract antiseptics as ordered.

4. Goal: prevent complications of prolonged immobility or associated orthopedic anomalies.

  • Position: hips abducted.
  • Use positional devices, rotating pressure mattress/flotation mattress.
  • Refer to physical therapy for ROM exercises.
  • Make necessary referrals for care of possible clubfoot/developmental hip dysplasia.

5. Goal: monitor for possible development of hydrocephalus. Occurs in 90% to 95% of infants born with myelomeningocele.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Integrity of sac is maintained until surgery is done.
  • No infection occurs.
  • Adequate patterns of urinary and bowel elimination are achieved with necessary support.
  • Complications of immobility, orthopedic anomalies are prevented or treated promptly.

Health Promotion and Maintenance: ACCIDENTS: INGESTIONS AND POISONINGS

Focus topic: Health Promotion and Maintenance

I. GENERAL PRINCIPLES OF TREATMENT FOR INGESTIONS AND POISONINGS

Focus topic: Health Promotion and Maintenance

A. Prevention: refer to section on toddler safety, p. 258.

B. How to induce vomiting:

1. Drug of choice—syrup of ipecac (available over the counter; does not require a physician’s order). If families with young children keep this medication on hand it should be administered only if directed by Poison Control Center. Note: Safety of ipecac has been questioned due to esophageal tears (when misused) and anorexia nervosa/bulimia (when abused).

2. Dose:

  • 30 mL for adolescents over 12 years; repeat dosage once if vomiting has not occurred within 20 minutes.
  • 15 mL for children 1 to 12 years; repeat dosage once if vomiting has not occurred within 20 minutes. Note: Do not administer to infants less than 1 year of age without physician’s order.
  • 10 mL for infants 6 to 12 months; do not repeat dosage.

3. Follow dose of ipecac with 4 to 8 oz of tap water or as much water as child will drink. In young children, give water first because child may refuse to drink anything else after tasting the ipecac.

4. The child must vomit the syrup of ipecac to avoid its being absorbed and causing potentially fatal cardiotoxicity (cardiac arrhythmias, atrial fibrillation, severe heart block).
If child does not vomit within 20 minutes of second dose, summon paramedics; gastric lavage may be indicated upon arrival in emergency department. Do not manually stimulate gagging because gagging may ↑ vagal response → significant bradycardia.

C. When not to induce vomiting:

  • Child is stuporous or comatose.
  • Poison ingested is a corrosive substance or petroleum distillate.
  • Child is having seizures.
  • Child is in severe shock.
  • Child has lost the gag reflex.

II. SALICYLATE POISONING

Focus topic: Health Promotion and Maintenance

A. Assessment:

1. Determine how much aspirin was ingested, when, which type.
2. Evaluate salicylate levels: normal, 0; therapeutic range = 15 to 30 mg/dL; toxic, >30 mg/dL.
3. Early identification of mild toxicity:

  • Tinnitus (ringing in the ears).
  • Changes in vision, dizziness.
  • Sweating.
  • Nausea, vomiting, abdominal pain.

4. Immediate recognition of salicylate poisoning:

  • Hyperventilation (earliest sign).
  • Fever—may be extremely high (105° to 106°F).
  • Respiratory alkalosis or metabolic acidosis.
  • Late signs: bleeding tendencies, severe electrolyte disturbances, liver or kidney failure.

B. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Ineffective breathing patterns related to hyperventilation/respiratory alkalosis.
  • Fluid volume deficit (dehydration) related to increased insensible loss of fluids through hyperventilation, increased loss of fluids through vomiting, and increased need for
    fluids due to hyperpyrexia (fever).
  • Risk for injury related to bleeding.
  • Anxiety related to parental/child feelings of guilt, uncertainty as to outcome, invasive nature of treatments.
  • Knowledge deficit regarding accident prevention.

C. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: promote excretion of salicylates.

  • If possible, induce vomiting using syrup of ipecac (save, bring to emergency department).
  • Assist with gastric lavage, if appropriate.
  • Administer activated charcoal as early as possible.
  • Administer IV fluids, as ordered.
  • Assist with hemodialysis, as ordered, to promote excretion of salicylates and fluids.

2. Goal: restore fluid and electrolyte balance.

  • Monitor I&O, urinalysis, specific gravity.
  • Prepare sodium bicarbonate, administer as ordered to correct metabolic acidosis.
  • Monitor IV fluids and electrolytes.
  • NPO initially (NG tube).

3. Goal: reduce temperature.

  • No aspirin or acetaminophen, which might further complicate bleeding tendencies or lead to liver or kidney damage.
  • Supportive measures: cool soaks, ice packs to armpits/groin, hypothermia blanket.

4. Goal: prevent bleeding and possible hemorrhage.

  • Monitor urine and stools for occult blood.
  • Insert NG tube to detect gastric bleeding.
  • Observe for petechiae, bruising; monitor laboratory values for Hct and Hgb.
  • Administer vitamin K as ordered to correct bleeding tendencies.

5. Goal: health education to prevent another accidental poisoning.

  • Teach principles of poison prevention.
  • Stress need to avoid accidental overdose with over-the-counter medications or dosage mix-ups.
  • Allow child/parents to verbalize guilt, but avoid blaming or scapegoating.

D. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Aspirin is successfully removed from child’s body without permanent damage.
  • Fluid and electrolyte balance is restored and maintained.
  • Child is afebrile.
  • Bleeding is controlled, no hemorrhage occurs.
  • No further episodes of poisoning occur.

III. ACETAMINOPHEN POISONING

Focus topic: Health Promotion and Maintenance

A. Assessment:

Focus topic: Health Promotion and Maintenance

  • Determine how much acetaminophen was ingested, when, and which type.
  • Evaluate acetaminophen levels: normal = 0; therapeutic range = 15 to 30 mcg/mL; toxic = 150 mcg/mL 4 hours after ingestion.
  • Initial period (2–4 hours after ingestion): malaise, nausea, vomiting, anorexia, diaphoresis, pallor.
  • Latent period (1–3 days after ingestion): clinical improvement with asymptomatic rise in liver enzymes.
  • Hepatic involvement (may last 7 days or may be permanent): pain in RUQ, jaundice, confusion, hepatic encephalopathy, clotting abnormalities.
  • Gradual recuperation.

B. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Altered tissue perfusion (liver) related to hepatic necrosis.
  • Fluid volume deficit related to increased loss of fluids secondary to vomiting and diaphoresis.
  • Risk for injury related to bleeding and clotting disorders.
  • Anxiety related to parental/child feelings of guilt, uncertainty as to outcome, and invasive nature of treatments.
  • Knowledge deficit regarding accident prevention.

C. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: promote excretion of acetaminophen.

  • If possible, induce vomiting; save, bring to emergency department.
  • Assist with gastric lavage, if appropriate.
  • Administer activated charcoal.
  • Assist with obtaining acetaminophen level 4 hours after ingestion.

2. Goal: prevent permanent liver damage.

  • Treatment must begin as soon as possible; therapy begun later than 10 hours after ingestion has no value.
  • Administer the antidote (acetylcysteine [Mucomyst]) per physician’s order. Usually administered in cola or through NG tube because of offensive odor. Given as one loading dose and 17 maintenance doses.
  • Monitor hepatic functioning—assist with obtaining specimens and check results frequently; be aware that liver enzymes will rise and peak within 3 days and then should
    rapidly return to normal.

3. Goal: restore fluid and electrolyte balance.

  • Monitor vital signs and perform neurological checks every 2 to 4 hours and prn.
  • Monitor I&O; urine analysis, including specific gravity; and weight.
  • Monitor IV fluids as ordered.

4. Goal: prevent bleeding.

  • Assist in monitoring child’s PT; notify physician of significant changes.
  • Monitor urine and stool for occult blood.
  • Observe for and report any petechiae or unusual bruising.

5. Goal: health education to prevent another accidental poisoning. (See Goal 5, Nursing care plan/implementation, Salicylate poisoning.)

D. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Acetaminophen is successfully removed from child’s body.
  • Normal liver function is reestablished.
  • Fluid and electrolyte balance is restored and maintained.
  • No further episodes of poisoning occur.

IV. LEAD POISONING (PLUMBISM)

Focus topic: Health Promotion and Maintenance

A. Introduction: Lead poisoning is a heavy-metal poisoning that occurs from ingestion or inhalation of lead. In children, this is most common in the toddler age group (1–3 years) and is usually a chronic type of poisoning that occurs as the result of repeated ingestions of lead. Older plumbing is one source of lead. Children who engage in the practice of pica, the ingestion of non-nutritive substances, often ingest lead in flecks of lead-based paint from plumbing, walls, furniture, or toys. In addition, research demonstrates that the parent-child relationship is a significant variable in lead poisoning; typically, there is a lack of adequate parental supervision that enables the child to engage in pica repeatedly over a fairly long time, until symptoms of lead poisoning become evident. (Pathophysiological effects of lead poisoning shows the pathophysiological effects of lead poisoning.)

B. Assessment:

Focus topic: Health Promotion and Maintenance

  • Investigate history of pica.
  • Evaluate parent-child relationship.
  • Chronic lead poisoning: vague, crampy abdominal pain; constipation; anorexia and vomiting; listlessness.
  • Neurological, renal, hematological effects: Pathophysiological effects of lead poisoning. “Blood lead line”—bluish-black line seen in gums.
  • X-rays: lead lines in long bones and flecks of lead in GI tract.
  • Elevated serum blood lead levels: ≥ 20 mcg/dL requires clinical management; ≥ 45 mcg/dL requires parenteral chelating therapy.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Altered thought processes related to neurotoxicity.
  • Activity intolerance (and risk for infection) related to anemia.
  • Altered urinary elimination related to excretion of lead by kidneys.
  • Pain related to lead poisoning and its treatment.
  • Knowledge deficit related to etiology of lead poisoning.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: promote excretion of lead.

  • Administer chelating agents (EDTA [IM or IV], BAL [IM only]) as ordered. Chelation therapy typically continues over several days, with multiple treatments daily.
  • Monitor kidney function carefully: the treatment itself is potentially nephrotoxic. Maintain adequate oral intake of fluids.
  • Institute seizure precautions.

2. Goal: prevent reingestion of lead.

  • Determine primary source of poisoning.
  • Eliminate source from child’s environment before discharge.
  •  Follow up with home care referral.
    (1) Screen other siblings prn.
    (2)Monitor blood lead level of all children in the home.
Health Promotion and Maintenance

3. Goal: assist child to cope with multiple painful injections when treated with IM chelation therapy.

  • Prepare child for treatment regimen.
  • Stress that this is not a punishment.
  • Rotate sites as much as possible.
  • May use a local anesthetic (e.g., procaine, injected simultaneously with chelating agent to decrease pain of injections).
  • Apply warm soaks to injection sites: may help lessen pain.
  • Encourage child to self-limit gross muscle activity (which increases pain).
  • Offer child safe outlets for anger, fear, frustration—punching bag, pounding board, clay.
  • Offer opportunity for medical play with empty syringes, etc.

4. Goal: health teaching.

  • Stress (to child and parents) that removing the lead is the only way to prevent permanent, irreversible neurological damage (irreversible damage may have already occurred).
  • Teach that the chelating agent binds with the lead and promotes its excretion through the kidneys.

E. Evaluation/outcome criteria:

  • Lead is successfully removed from child’s body without permanent damage.
  • No further episodes of lead poisoning.
  • Child copes successfully with the disease and its treatment.

Health Promotion and Maintenance: PEDIATRIC SURGERIES: NURSING CONSIDERATIONS

Focus topic: Health Promotion and Maintenance

I. In general, basic care principles for children are the same as for adults having surgery.

II. EXCEPTIONS:

Focus topic: Health Promotion and Maintenance

  • Children should be prepared according to their developmental level and learning ability.
  • Children cannot sign own surgical consent form; to be done by parent or legal guardian.
  • Parents should be actively involved in the child’s care.

III. Pediatric Surgeries: Nursing Considerations, which reviews specific nursing care for the most common pediatric surgical procedures.

Health Promotion and Maintenance
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