NCLEX-RN: Pediatric Nursing

Pediatric Nursing: SPECIAL TOPICS IN PEDIATRIC NURSING

Focus topic: Pediatric Nursing

Special topics in pediatric nursing include a broad category of subjects relevant to pediatrics, but which do not fit in the system format. This section encompasses venereal diseases, the mentally retarded child, accidents, the battered child syndrome, and, finally, death and children.

Pediatric Nursing: Behavioral and Mental Health Problems

Focus topic: Pediatric Nursing

Pediatric Nursing: Failure to Thrive

Focus topic: Pediatric Nursing

Definition: A syndrome characterized by an infant’s failure to grow and develop. Etiology is nonspecific. May be organic or non-organic.

Assessment
A. Assess history of infant: feeding problems, vomiting, sleep disturbance, irritability, sucking ability, aversion to formula, and irregularity in daily activities.
B. Assess general physical–physiological status to assist in ruling out organic (physiological) cause of disorder.
C. Assess usual nutritional intake to help determine if cause is related to deficient intake, malabsorption, or poor assimilation.

  •  Assess number of calories, quality of calories, and feeding patterns.
  •  Check weight daily and observe reaction to nutritional program.

D. Assess nature of mother–child relationship.

  • Relationship patterns.
  •  Ability of mother to perceive infant’s needs.

Implementation
A. Priorityprovide sufficient nutrients so that infant will grow.

  •  Develop a structured feeding routine.
  •  Weigh daily to assess weight gain.
  •  Foster parent–infant attachment.
  • Consult with dietician, occupational therapist, and physical therapist.

B. Provide nurturing to infant.

  •  Ensure a warm, loving environment through holding, cuddling, and physical contact.
  •  Limit number of persons interacting with infant; primary nursing preferred.
  •  Spend time talking to infant and building a trusting relationship.
  •  Maintain as much eye-to-eye contact as possible.

C. Provide a positive, quiet, non-stimulating environment to promote psychosocial growth.
D. Assist parents to develop a positive relationship with infant.

  •  Do not be judgmental in evaluating parent– infant relationship.
  •  Support parent as she/he attempts to cope with situation.
  • Encourage parent to express feelings.
  •  Include parent in plan of care.
  •  Evaluate continuing parent–infant relationship.

E. Document feeding behaviors and evaluate infant progress.
F. Coordinate referral services for family when infant discharged.

Pediatric Nursing: Child Abuse

Focus topic: Pediatric Nursing

Definition: Child maltreatment is any non-accidental physical abuse resulting from an absence of reasonable standards of care by the parents or the child’s caretaker.

Epidemiology
A. Incidence.

  •  In 2010, approximately 695,000 children were identified as victims of substantiated physical,sexual, or emotional abuse or neglect. The national rate of victimization is 12.4 per 1000 children.
  •  In 2010, 78% suffered neglect, 18% were physically abused, and 9% experienced sexual abuse. Approximately 1560 children died from maltreatment in 2010. Eighty percent of children killed were younger than 4 years of age.
  •  In the hospital emergency room it is estimated that 10% of the injuries seen in children under 5 are actually caused by parents or are the result of negligence.

B. Victims.

  •  Premature infants have a three times greater risk of becoming battered children than fullterm infants.
  •  Stepchildren have an increased risk.
  •  Often are physically or developmentally delayed.
  •  Have behavior that makes the child seem demanding or “difficult.”

C. Environment.

  •  Abuse usually occurs on the same day as a crisis or stressful event.
  • Abuse may occur during periods of economic hardship.
  •  Abuse usually occurs in anger after the parent (or perpetrator) is provoked.

Clinical Indications of Abuse
A. History of the problem.

  •  The cause given for the condition is implausible, e.g., punishment is inappropriate for the age of the child.
  •  There are discrepancies in the history from neighbors or various members of the family.
  •  There is a delay in seeking medical help for the child.

B. Physical examination and indications for diagnosis.

  •  Bruises, welts, and scars in multiple stages of healing, in unusual locations.
  •  Fingermark pattern of bruises.
  •  Bite, rope, or choke marks.
  •  Cigarette and/or hot water burns.
  •  Eye damage, subdural hematoma, failure to thrive, and/or intraabdominal injuries.
  •  Radiographic findings of multiple bone injuries at different stages of healing.
  •  Passive, non-communicative, and/or withdrawn child.
  •  Shaken baby syndrome, now called abusive head trauma, has been documented in children up to 5 years of age.

Characteristics of Perpetrators
A. Majority of perpetrators of physical abuse are direct relatives (81% were parents with mothers more likely than fathers); approximately only 2% are caregivers.
B. Parents were usually abused as children.
C. Abusers are unable to utilize outside help (neighbors, friends, or professionals) when angry at their child; isolated from community and social groups.
D. Spouse of abuser frequently does not know how to prevent the occurrence or recurrence of the abuse.
E. Abusive parents frequently have unreasonable expectations of their children they expect a baby to meet their needs, cannot cope with demands of infant (or protracted crying).
F. Characteristics of the abusive family.

  •  Intense competition for emotional resources within the family for affection, attention, nurturing.
  • Unpredictable and unstable family environment.
  • Conflict resolution generally achieved through aggression or power struggle between family members.
  •  Communication characterized by mixed or double messages, threats, or a focus on nonverbal communication rather than direct verbalization.
  •  Frequent domination by a single family member who maintains control through manipulation, intimidation, deceit, and aggression.

Legal Responsibility
A. Both nurse and doctor are legally responsible to report a suspected battered child to the proper authorities.
B. The designated community authorities are responsible for determining placement of the abused child.
C. Support prevention educational programs.

Pediatric Nursing: Attention Deficit–Hyperactivity Disorder

Focus topic: Pediatric Nursing

Definition: A developmental disorder that involves a group of behavioral symptoms with difficulty in attention and concentration, impulse control, and hyperactivity.

Characteristics
A. The prevalence of attention deficit–hyperactivity disorder (ADHD) in children ages 4–17 in the United States was approximately 9.5% (in 2010). The male to female ratio was 2:1.
B. Symptoms may become apparent as early as age 3 or 4 years, but medication is not started until the child is in a structured school setting.

C. ADHD is more common in first-degree biologic relatives, which suggests a genetic predisposition for the disorder.
D. There are several theories about the cause of ADHD including central nervous system abnormalities, prenatal substance abuse, complications related to labor and delivery, chaotic and abusive home environments.

Assessment
A. Identify child with this disorder by assessing presence of diagnostic criteria. Behavior must be inconsistent with developmental level, persist for at least 6 months, and demonstrate at least six of the following behaviors for diagnosis of ADHD.

  •  Inattention.
    a. Does not complete things, often loses things, is forgetful in daily activities.
    b. Fails to give close attention to details or makes careless mistakes.
    c. Demonstrates difficulty in concentrating.
    d. Easily distractible by external stimuli, has difficulty organizing tasks.
    e. Cannot stick to a play activity.
  •  Impulsivity.
    a. Often acts before thinking.
    b. Moves rapidly from one activity to another.
    c. Cannot organize work effectively.
    d. Requires close supervision.
    e. Interrupts in class.
    f. Cannot wait to take turns; has difficulty in group activities.
  •  Hyperactivity.
    a. Runs around, jumps, and climbs constantly, excessively.
    b. Cannot sit still or stay seated for very long, interrupts, blurts out answers in school, has difficulty waiting turn and staying in seat.
    c. Moves around during sleep.
    d. Seems to be always active, fidgets or squirms.
  • Onset before 7 years of age.
  •  Cause is not identified as schizophrenia, affective disorder, mental retardation, or other disorder.
  •  Must be present in two or more locations (home, school, or other social situation— church, recreation).

B. Observe for additional traits.

  •  Negativistic.
  •  Emotional lability.
  • Easily frustrated.
  •  Non-localizing neurological signs, learning disabilities, and abnormal electroencephalogram (EEG) may or may not be present.

Implementation
A. Coordinate treatment plan with physician, family, and educational counselor.

  •  Behavioral therapy with medications is preferred.
  •  Behavior therapy alone has lesser results.

B. Provide safe environment with minimal stimulation.

  •  Decrease number of stimuli; reduce extraneous stimuli.
  •  Set limits on behavior.
  •  Structure activities.
  •  Provide for energy outlets: Allow large muscle movements.
  •  Provide for quiet area and time.

C. Establish primary relationship, if possible, with short contact times.
D. May establish behavior modification program; encourage positive behavior. Assist to build selfesteem, which is usually low.
E. Assist client to establish own controls and behavior.
F. The consensus is that it is NOT necessary to limit sugar, additives, and artificial colors. It may be helpful to add sugar, additives and, or artificial coloring and determine if the child’s behavior changes.
G. Stimulant medications cause the child to have a poor appetite. Plan ways to be sure that the child has adequate intake of healthy foods throughout the day.
H. Administer medication

  •  Ritalin (methylphenidate) and its newer timed-release forms (Concerta, Ritalin LA, Metadate ER).
  •  Dexedrine (dextroamphetamine) or Adderall (amphetamine/dextroamphetamine) and long acting form (Adderall XR).
  •  Strattera (atomoxetine), a non-stimulant medication.

I. Obtain observations of the child from several settings using standardized questionnaires such as the Conners’ Teacher Rating Scale in order to titrate medication dosage for best effects.

Pediatric Nursing: Learning Disorders

Focus topic: Pediatric Nursing

Definition: Described as the inability to acquire, retain, or broadly use specific skills or information, which affects how a person understands, remembers and responds to new information.

Characteristics
A. Result from deficiencies in attention, memory, or reasoning and can cause difficulty in listening or paying attention, speaking, reading or writing, and in math performance.
B. Include disorders such as dyslexia, dysgraphia, dyscalculia, dyspraxia, and information-processing disorders.

Assessment (Warning Signs)
A. Delays in language development: Children are unable to put sentences together by age 2½.
B. Speech difficulty: Parents and others cannot understand what children say more than half of the time at age 3 years.
C. Coordination difficulty: Children are unable to tie shoes, button, hop, and cut by around age 5.
D. Short attention span: Between 3 and 5 years old, children are unable to sit still while being read a short story. (Attention span should increase with age during this period.)
E. Eye, ear, speech, and psychological evaluations are helpful; early diagnosis is critical.

Implementation
A. No evidence that special diets, vitamins, or visual programs provide quick fixes.
B. Children need individualized approach, specific to identified learning disability, and help in developing lifelong strategies to accommodate the disorder.

Pediatric Nursing: Autism

Focus topic: Pediatric Nursing

Definition: A disorder where a young child cannot develop normal social relationships, has language delays or uses abnormal language, may fail to develop normal intelligence, and engages in ritualistic or compulsive behavior. Also referred to as pervasive developmental disorder syndrome (PDDS).

Characteristics
A. Signs usually appear before age 3 years.
B. Previously occurred in about 5 out of 10,000 children.
C. As of 2014, Centers for Disease Control and Prevention (CDC) estimates that 1 in 68 children (or 14.7 per 1000 eight-year-olds) in multiple communities in the United States has been identified with autism spectrum disorder (ASD). Retrieved November 23, 2014, from: http://www .cdc.gov/media/releases/2014/p0327-autismspectrum- disorder.html

Assessment
A. Abnormal development seen in language (about 50% may never speak). Echolalia or reverse pronouns, unusual pitch and rhythm are common, and children rarely are able to carry an interactive dialogue.
B. Social relationships abnormal.

  •  Infants avoid eye contact, do not cuddle, lack of attachment to parents, prefer to play alone rather than with other children; older children are unable to interpret expressions or moods of others.
  •  Behavior involves repetitive movements (such as hand flapping, rocking, or selfinjury), excessive attachment to particular inanimate objects.

C. Majority have intellectual delays.

  •  Unpredictable performance on IQ tests.
  •  Some have ability to perform complex mental or musical skills, but are unable to use the skills in a socially productive or interactive manner.

D. Diagnosis: made by close observation and standardized tests. Metabolic, chromosomal, or genetic abnormalities must be ruled out before diagnosis is made.

Implementation
A. Prognosis influenced by language skills at age 7, and those with severe intelligence deficits may require institutional care.
B. Behavioral modification and special education including physical, occupational, and speech therapy may be helpful.
C. Drug therapy ineffective for underlying disorder, but may help reduce ritualistic behaviors. Anti-psychotics may alleviate self-injurious behavior.
D. Special diets, immunologic therapies, and GI therapies are still unproven.

Pediatric Nursing

Pediatric Nursing: Asperger’s Syndrome (Pervasive Developmental Disorder-Not Otherwise Specified)

Focus topic: Pediatric Nursing

Definition: Children have impaired social interactions and repetitive behaviors similar to children with autism. Language skills and IQ are normal or above average.

Characteristics
A. Children tend to function at higher levels than children with autism, and may be able to function independently.
B. Psychotherapy may also be helpful.

Pediatric Nursing: Depression

Focus topic: Pediatric Nursing

Definition: Intense sadness, often following a recent loss or sad event, but persists and becomes out of proportion to the event.

Characteristics
A. May affect a small percentage of children and around 14% of adolescents; familial tendencies are noted.
B. Physiological causes must be investigated.
C. Other behavioral/psychiatric problems, such as schizophrenia, must also be ruled out.
D. History from parents and teachers, and structured questionnaires aid in diagnosis.
E. Risk factors.

  •  Stressful life events (death, divorce).
  •  Head injury.
  •  Substance abuse.
  •  Child abuse, neglect.
  •  Family history of depression.
  • Unstable relationships with friends, unstable care giving.
  • Chronic illness.

Assessment
A. Signs include irritability, angry outbursts, loss of enjoyment in usual activities, faltering school performance, relationship problems with friends and family, sleep disturbances (excessive sleeping or difficulty), concentration or memory problems, decreased energy, change in eating habits, preoccupation with death or suicidal ideation/threats.
B. Any talk of suicide should be taken seriously.

Implementation
A. Rule out physical causes (e.g., thyroid disorder), bipolar disorder, schizophrenia, or other psychiatric disorders.
B. Combination psychotherapy and antidepressant therapy is needed.
C. Selective serotonin re-uptake inhibitor (SSRI) medications can cause some “activation” of suicidal thoughts. Current research indicates that SSRIs are NOT prohibited in children and adolescents. However, the decision whether to use a particular SSRI should be based on its potential for a therapeutic effect.
D. Cognitive-behavioral therapy to increase coping skills and social skills to provide skills to manage stress.

Pediatric Nursing: Sexual Abuse

Focus topic: Pediatric Nursing

Characteristics
A. The perpetrator is more likely to be a family friend or neighbor (75.9%) compared with a parent (2.7%).
B. Perpetrators are most often males who have mental issues, rationalizing behaviors, social skills/empathy deficits, and decreased coping skills.
C. Many perpetrators were abused as children themselves.

Assessment (Behaviors, Parent Clues, Outcomes)
A. The child may exhibit

  •  Difficulty walking or sitting.
  •  Pain on urination or in the genital area.
  •  Previously toilet-trained child may have urinary accidents.
  •  Bruising or laceration of perineal tissue (vaginal or rectal).
  • Nightmares or other sleep disturbances.
  •  Decreased appetite.
  •  Sudden refusal to participate in gym or other physical activities.
  •  Overt aggression.
  • Sexual language and innuendo that is not appropriate for age.
  •  Adolescents might be sexually promiscuous.

B. The parent may be:

  • Overly protective.
  • Isolating the child from others.
  • Overly controlling.

C. The child may or may not report the sexual abuse even with direct questioning; some report years later; may keep secrets, accept blame for the situation, may disassociate during the abuse to avoid the pain and feelings.

Pediatric Nursing

Pediatric Nursing: Death and Children

Focus topic: Pediatric Nursing

Assessment
A. Assess child’s understanding of death.

  •  Young child’s concerns.
    a. Views death as temporary separation from parents, sometimes viewed synonymously with sleep.
    b. May express fear of pain and wish to avoid it.
    c. Child’s awareness is lessened by physical symptoms if death comes suddenly.
    d. Gradual terminal illness may simulate the adult process: depression, withdrawal, fearfulness, and anxiety.
  •  Older children’s concerns.
    a. May identify death as a “person” to be avoided.
    b. May ask directly if they are going to die.
    c. Concerns center around fear of pain, fear of being left alone, and leaving parents and friends.
  • Adolescent concerns.
    a. Recognize death as irreversible and inevitable.
    b. Often avoids talking about impending death and staff may enter into this “conspiracy of silence.”
    c. Adolescents have more understanding of death than adults tend to realize.

B. Assess impact of death on child.
C. Assess parent’s ability to cope with death of child.

Implementation
A. Always elicit child’s understanding of death before discussing it with him or her.
B. Before discussing death with child, discuss it with child’s parents.
C. Parental reactions include the continuum of grief process and stages of dying.

  • Reactions depend on previous loss experience.
  •  Reactions also depend on relationship with the child and circumstances of illness or injury.
  •  Reactions depend on degree of parental guilt.
  • D. Assist parents in expressing their fears, concerns, and grief so that they may be more supportive of the child.

E. Assist parents in understanding siblings’ possible reactions to a terminally ill child.

  • Guilt: belief that they caused the problem or illness.
  •  Jealousy: desire for equal attention from parents.
  • Anger: feelings of being left behind.

F. Enlist multidisciplinary support.

Pediatric Nursing: Sudden Infant Death Syndrome

Topic: Pediatric Nursing

Definition: The sudden, unexplainable death of an infant during sleep, with the exact cause unknown despite a thorough investigation that includes a complete autopsy, examination of the death scene, and review of the clinical history.

Characteristics
A. SIDS was the second leading cause of death in infants from 1–12 months of age in 2009.
B. Peak incidence from 2–4 months of age. Uncommon after age 6 months.
C. Higher incidence in winter, June and July, and low income groups.
D. On autopsy results vary; inflammation of upper respiratory tract and pulmonary edema have been found.
E. Maternal factors: lower socioeconomic status.
F. Infant factors: SIDS more common in premature and small for gestational-age infants; male gender, prenatal exposure to cigarette smoke or alcohol, under age 6 months.
G. Sleep: Most deaths are unobserved; death during sleep is common.
H. Extrinsic modifiable risk factors: prone sleeping position, bed sharing, use of soft bedclothes or soft mattresses, putting the infant to sleep on upholstered furniture or adult mattresses, and exposure to cigarette smoke.
I. Familial recurrence: genetic predisposition among American Indian and African American ethnic groups.
J. Etiology unknown. Current research accepts that SIDS is the result of an interaction among nonmodifiable (intrinsic) and modifiable (extrinsic) risk factors.

Assessment
A. Assess age of infant and remaining epidemiologic findings.
B. Assess for prematurity/low-birth-weight infant.
C. Check for respiratory pauses, sleep apnea.
D. Check for gastroesophageal reflux/apnea associated with regurgitation after feeding, or tiring during feeding
E. Assess for past history of oxygen administration. (C, D, E specific to an apparent life-threatening event [ALTE].)

Implementation
A. Recent research has shown that there is a correlation between SIDS and infants sleeping on abdomen. Incidence of SIDS in the United States has decreased more than 70% since the original “Back-to-Sleep” program in 1994. Teach mothers to place infant on back for sleep, to place the infant on a firm surface in a bassinet or crib in the parents’ room for sleeping.
B. Apneic episode discovered: infant responds when stimulated (referred to as ALTE). Instruct parents in care.

  • Shake/stimulate infant. If no response, immediately begin rescue breathing and CPR.
  •  Take infant to physician or nearest emergency room.
    a. Record accurate history from parents: time of discovery of infant, color of infant, skin temperature, spontaneous respirations after stimulation.
    b. Ask relevant questions: Was CPR begun? How long after? How long was it continued? Did infant respond? Did there appear to be regurgitation of formula when infant was discovered? When did infant last eat?
  •  Assist physician in a complete neurological, developmental, and physical exam of infant, including lab work.
  •  Teach parents CPR.
  •  Instruct parents about care of a child on a home monitor (controversial).
  •  Give parents phone numbers for respite care and support groups.

C. Infant dies; upon autopsy, SIDS is diagnosed.

  •  Support parents through loss and grieving process. Reassure parents that they did everything right for the child. Emphasize blamelessness of parents and siblings.
  •  Inform parents of result of autopsy as soon as possible so grieving process may begin.
  •  Refer parents to National Foundation for SIDS, other local support groups.

Pediatric Nursing: Dental Development

Focus topic: Pediatric Nursing

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Pediatric Nursing: Recommended Immunization Schedules For Persons Aged 0 Through 18 Years–United States, 2014

Focus topic: Pediatric Nursing

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Pediatric Nursing: Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind United States, 2014

Focus topic: Pediatric Nursing

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Pediatric Nursing: Drug Administration For Children

Focus topic: Pediatric Nursing

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Pediatric Nursing: Fluid Requirements In Children

Focus topic: Pediatric Nursing

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Pediatric Nursing: Pediatric Infectious and Communicable Diseases

Focus topic: Pediatric Nursing

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Pediatric Nursing: Nutritional Guidelines for Infants and Children

Focus topic: Pediatric Nursing

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