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: The Child with INTELLECTUAL / Cognitive Impairment

Focus topic: Pediatric Nursing

Pediatric Nursing: General Concepts

Focus topic: Pediatric Nursing

A. Intellectual impairment is used to describe a significant limitation in both intellectual and functional capacity. Intellectual impairment has replaced the term mental retardation to describe people with below-average intellectual functioning. This means that the condition manifests in measured intelligence (IQ) and also in adaptive behavior assessed as language skills, cognition, academic ability, self-help skills, social behaviors, and motor performance).
B. Intellectual impairment may result from

  •  Genetic conditions: inborn errors of metabolism, chromosomal abnormalities (Down syndrome).
  •  Fetal or birth-related factors: fetal alcohol syndrome, maternal infections, asphyxia, prematurity, hyperbilirubinemia.
  •  Familial factors: low parental intelligence or environmental deprivation.
  •  Acquired conditions: CNS infections, lead poisoning, hydrocephalus (untreated), tumors or posttraumatic injury.

Pediatric Nursing: Caring for Children with Intellectual/ Cognitive Impairment

Focus topic: Pediatric Nursing

A. Treat the child according to developmental age rather than chronological age.

Pediatric Nursing: Classification Of INTELLECTUAL/Cognitive Impairment

Focus topic: Pediatric Nursing

Pediatric Nursing

B. Give the child as much stimulation and love as a child with normal cognitive abilities.
C. Behavioral modification therapy works well with children.
D. Support parents’ reaction to the birth of a child with intellectual impairment.

  • Birth presents a threat to the parents’ marital relationship and family dynamics.
  •  Stages of reactions.
    a. Denial: initial reaction of defense, which protects the parents from admitting that this child, this extension of themselves, is not normal.
    b. Self-awareness: recognition of difference between their child and other children.
    c. Recognition of problem: active search for information on their child’s problem and for professional advice.

E. Assess developmental delay—may be first indication of impairment (almost 75% have no physical abnormality).
F. Diagnosis is difficult and should be done by skilled team to ensure no child is mislabeled.

Pediatric Nursing: Down Syndrome

Focus topic: Pediatric Nursing

Etiology
A. Caused by the presence of an extra chromosome, number 21.
B. Usually the result of nondisjunction in division of gametes. Incidence increases dramatically with increasing maternal age. The incidence of Down syndrome is 1 in 400 births if the mother is 35 years old and 1 in 100 births if the mother is 40 years old.

Assessment
A. Assess facial characteristics: almond-shaped eyes, round face, protruding tongue, flattened posterior and anterior surfaces of the skull, epicanthal folds, and flat nose.
B. Assess musculoskeletal system: Muscles are flaccid and joints are loose.

C. Assess extremities: broad hands, abnormal palmar crease, in-curved fifth finger, first and second toe widely spaced.
D. Assess mental capacity: ranges from moderate to severe intellectual impairment.
E. The condition is apparent at birth with observable features. Down syndrome can be identified prenatally by amniocentesis, chorionic villi sampling, and with maternal blood tests at 20–22 weeks’ gestation.

Implementation
A. Refer parents for genetic counseling.
B. Following discharge from hospital, provide follow-up for the family for counseling and child guidance.
C. Refer to the community health agency for follow-up.
D. Alert the parents to the child’s increased susceptibility to infections and the need for extra precautions to prevent illness.
E. Assist the parents in developing a program for the child by identifying for them signs of neurological development in the child that indicates readiness for developmental tasks such as sitting, self feeding, and crawling.

Pediatric Nursing: Immunizations

Focus topic: Pediatric Nursing

A. Refer to schedule (Appendix 13-2).
B. The schedule format shows

  • One schedule for persons aged 0–18 years for routine recommendations.
  •  A different schedule for catch-up for persons 0–18 years.
  •  Special populations are represented with bars.

C. The rotavirus vaccine (Rota) is recommended in a three-dose schedule at ages 2, 4, and 6 months. If the Rotarix product is used, then administer it at 2 and 4 months only.

  •  The first dose should be administered at ages 6 weeks through 12 weeks with subsequent doses administered at 4- to 10-week intervals.
  • Rotavirus vaccination should not be initiated for infants aged > 12 weeks and should not be administered after age 32 weeks.

D. The influenza vaccine is recommended for all children beginning at age 6 months using the inactivated product as an intramuscular injection. The live virus influenza may be given to persons 2–49 years in good health.
E. The human papillomavirus vaccine (HPV) is recommended in a three-dose schedule, with the second and third doses administered at 2 and 6 months after the first dose.

  •  Routine vaccination with HPV is recommended for girls and boys aged 11–12 years. HPV4 may be given to boys and girls. HPV2 may only be given to girls.
  • Vaccination series can be started as young as age 9 years.
  • Catch-up vaccination is recommended for boys and girls aged 13–18 who have not been vaccinated previously or who have not completed the full vaccine series.

F. Educating parents.

  •  Need for immunizations.
  •  Minimizing pain and psychological trauma  most well-child visits at 12 scheduled dates will still include at least three injections (or as many as five, if no combination vaccines are used).
  •  Although many studies have found no link between vaccines and autism, recent developments from CDC in 2014 have disclosed there is a link between MMR vaccine and autism with African American boys being the most affected. (but to this day, it remains a controversial issue).
  •  Thimerosal (ethylmercury) has been essentially eliminated from pediatric vaccines. Studies have not demonstrated any cognitive and behavioral problems in babies who might have received these thimerosal containing vaccines in the past.
  •  If doses of vaccines are switched to combination vaccines, there are no additive adverse effects and immunity is equal to receiving the doses separately.
  •  Educate parents about possible side effects (fever, fussiness, local reaction) to immunizations  and management (Tylenol/Advil to manage fever and pain, massage and warm compresses to local reactions).

Pediatric Nursing: Poisoning

Focus topic: Pediatric Nursing

Definition: Ingestion of toxic substances, which may result in death or severe illness.

Characteristics
A. The most common age group affected is 2-year-old because of their exploration of the environment through tasting.
B. The major cause of poisoning is improper storage of toxic agents.

  •  Legislation has mandated childproof tops on prescription drugs, but many children can still remove the tops.
  •  Some new forms of drugs, such as transdermal patches or lozenges, are packaged so that they present a danger.

C. Interventions for poisoning.

  •  Identify the toxic substance and retrieve the poison and its container.
  • Consult local poison control telephone number and inform them of the toxic substance.
  •  Reverse the effect of the poison.
  •  Vomiting is contraindicated with some substances.

D. Poison control center should always be consulted before treatment is initiated.
E. As of 2008, syrup of ipecac is no longer recommended or available.

Pediatric Nursing: Types of Poisoning

Focus topic: Pediatric Nursing

A. Tylenol (acetaminophen) poisoning (a substance commonly ingested by children).

  •  Toxic dose uncertain, seriousness of ingestion determined by amount ingested and length of time before intervention, and if toxicity is acute or cumulative. Start treatment if single dose is > 150 mg/kg or 7.5 g by history.
  •  Symptoms: diaphoresis; nausea and vomiting; lethargy; weakness, pallor, decreased urine output, liver failure.
  •  Intervention: Call poison control center and follow directions; lavage with activated charcoal; antidote Mucomyst (acetylcysteine) binds with acetaminophen.

B. Aspirin (salicylate) poisoning.

  •  Moderate toxicity is 300–500 mg/kg; severe toxicity is > 500 mg/kg.
  •  Symptoms: hyperventilation (from severe acidosis); nausea and vomiting; delirium; dizziness; confusion; bleeding, diaphoresis, fever (hyperexia), tinnitus (chronic toxicity).
  •  Intervention: Induce vomiting; lavage with activated charcoal; IV fluids; dialysis in severe cases; vitamin K if  bleeding present.

C. Chemical poisoning.

  •  Toxic dose: Any corrosive chemical is toxic.
  •  Symptoms: respiratory problems, burns.
  •  Interventions: Avoid emesis, which could cause further damage; dilute with water if ordered; maintain patent airway; give steroids if ordered.

Pediatric Nursing: Lead Poisoning

Focus topic: Pediatric Nursing

Definition: An environmental disease caused by the ingestion of lead-based materials, such as paint.

Characteristics
The effects of lead exposure to young children and pregnant women are as follows.
A. By inhalation or ingestion.

  • Fatigue, poor attention span, irritability, hyperactivity.
  •  Decreased IQ scores, poor school performance, behavior problems, perceptual-motor difficulties.
  •  Anemia.
  •  GI: poor appetite, nausea and vomiting (N&V), constipation, lead line in gums.
  •  Renal: glycosuria, proteinuria, renal failure.

B. Lead crosses the placenta.

  •  Increased risk of miscarriage.
  •  Fetal malformations.
  •  Low birth weight.
  • Pregnancy-induced hypertension (PIH).

Assessment
A. Standard blood levels indicating toxicity have been lowered from < 25 mg/dL to < 5 mg/dL. This level aids in early detection and treatment, before severe symptoms appear. CDC has recommended that public health actions be initiated for children ages 1-5 with blood lead levels above 5 micrograms per deciliter (μg/dL) (retrieved from CDC on November 23, 2014: http://www.cdc.gov/nceh/lead/)

  •  Children with serum lead levels > 20–25 mg/ dL should be removed from the lead source.
  •  Children with lead levels between 5 and 15 mg/dL should be monitored frequently.
  •  Children with lead levels > 35 mg/dL should begin chelation treatment (see Implementation).

B. Obtain serum lead levels for children ages 12–36 months annually if enrolled in child health screening in government programs and if lead questionnaire indicates possible exposure. Children typically do not have observable symptoms indicative of elevated lead levels.
C. Assess gastrointestinal symptoms.

  • Unexplained, repeated vomiting; loss of weight.
  •  Vague chronic abdominal pain.
  •  Pallor, listlessness, fatigue due to anemia caused by interference with the biosynthesis of heme.

D. Assess central nervous system symptoms.

  •  Irritability.
  •  Drowsiness.
  •  Ataxia.
  •  Convulsive seizures.

Implementation
A. Institute preventive measures.

  •  Inspect structures built before 1978 (especially before 1955) in which lead-based paint was used.
  •  Change old lead pipes that have corroded.
  • Cover areas painted with lead paint with plywood or linoleum or hire specially trained persons to remove lead-based paint.
  •  Educate parents to have children wash hands before eating, and to provide a diet high in iron, calcium, and vitamin C, which will prevent the absorption of lead if ingested.
  •  Educate parents to avoid the use of lead containing ceramic dishes as storage containers for food. Avoid lead in candy. Do not buy toys or jewelry that contain lead. Avoid home remedies that contain lead.
  •  Remove clothing and wash after hobbies or activities that involve lead (for example, mining, stained glass, ceramics, auto repair).

B. Treat condition.

  •  Medications that aid in removal of lead are Endrate or EDTA (calcium disodium edetate) and BAL (dimercaprol)—given IM only.
  • Method: IV preferable because IM injections are very painful.
    a. With EDTA observe for signs of hypocalcemia: tetany and convulsions.
    b. Provide for seizure precautions.
    c. Record accurate intake and output to evaluate kidney response to chelating agents.

Pediatric Nursing: Treatment of Poisoning at Home

Focus topic: Pediatric Nursing

A. Keep poison control telephone number immediately available.
B. Instructions to the family.

  • When poisoning occurs, telephone the control number. Be sure to know the brand name of the poison and the approximate amount ingested.
  • Institute the program suggested by poison control.
  •  If no telephone number is available, call a physician and take the child to the emergency room; bring the bottle of poison and have a neighbor or a friend drive.

C. Diagnostic information the physician will need.

  •  What child ingested.
  • The amount ingested.
  •  Odor on breath.
  •  Pupil changes.
  • Presence of abdominal pain, nausea, or vomiting.
  • Convulsions.

Pediatric Nursing: Accidental Injury

Focus topic: Pediatric Nursing

Definition: Unexpected events that lead to recognizable injury or metabolic changes.

Pediatric Nursing: General Categories of Injuries

Focus topic: Pediatric Nursing

A. Incidence: Unintentional injuries are the leading cause of death from 1 to 19 years of age.
B. Each year, 20–25% of all children sustain an injury severe enough to require medical attention and missed school.

  •  For every childhood death from injury, there are 34 hospitalizations and 1000 ER visits.
  •  Lower socioeconomic status and male sex have higher incidence of accidental death.

C. The top three causes of death by age group (CDC 2012 statistics).

  •  0–1 years.
    a. Developmental and genetic conditions that were present at birth (neonatal cause of death).
    b. Unintended injuries suffocation, motor vehicle accident (MVA), drowning, and burns. From 1 month to 12 months of age LEADING cause of death.
    c. Sudden infant death syndrome (SIDS).
    d. All conditions associated with prematurity and low birth weight.
  •  1–4 years.
    a. Unintended injuries MVA, drowning, fire/burns, suffocation, pedestrian, falls.
    b. Cancer.
    c. Heart disease.
    d. Homicide.
  •  5–9 years.
    a. Unintended injuries MVA, fires/ burns, drowning, suffocation, other land transport (bicycles, skateboards, etc.), pedestrian, firearms.
    b. Cancer.
    c. Influenza and pneumonia.
    d. Homicide.
  • 10–19 years.
    a. Unintended injuries MVA, drownings, fires/burns, other land transport, suffocation, poisoning, firearms.
    b. Suicide.
    c. Cancer.
    d. Homicide.

D. There are almost twice as many deaths in the first year of life as there are in the next 13 years total (due to congenital defects and SIDS).

  •  The death rate rises rapidly following puberty due to the large number of deadly accidents (MVAs), homicides, and suicides in the 15- to 24-year age group.
  •  The top three causes of death in teens should all be preventable.
  •  Other top causes of accidental death are drowning, fire, falls, and poisoning.

Pediatric Nursing: Accident Prevention

Focus topic: Pediatric Nursing

A. Control of agent when possible.

  •  Education of parents as to what substances are hazardous and how to “safety-proof ” a home.
  •  Use of car seats and seat belts, use of bicycle helmets.
  •  Smoke detectors in home.
  •  Decrease temperature on hot water heater to 120°F or 48.89°C.
  • Safe storage of poisons and prescriptions (with safety caps).
  •  Pools should have 5-foot-tall circumferential fence, vigilant observation of children around water.
  •  Firearms kept unloaded and with trigger locks and locked up where child cannot obtain access.

B. Recognition of risk.

  •  Provide accident prevention education appropriate to the age of the child.
  •  For children with a history of accidents, take special care to make the environment safe.
  •  Encourage parents and siblings to take CPR course.

C. Control of the environment; during crisis periods in families, suggest help for child care and supervision.
D. Encourage families to make “disaster plans.”

Pediatric Nursing: Car Restraints

Focus topic: Pediatric Nursing

A. Educate parents about car seats.

  • After even a minor accident, replace car seat.
  • Car seat faces rear until child is 2 years old.
  • At 40 pounds, use a booster seat and be sure seat belt is positioned correctly.

B. Do not place child in front of air bag because child could be thrown into air bag after braking.
C. All children under 12 are safest in back seat because of air bags.
D. Children should be in protected car or booster seats until adult belt fits them properly.

FURTHER READING/STUDY:

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