NCLEX: Health Promotion and Maintenance

Health Promotion and Maintenance: DEVELOPMENTAL DISABILITIES

Focus topic: Health Promotion and Maintenance


Focus topic: Health Promotion and Maintenance

A. Introduction: Down syndrome (trisomy 21) is a chromosomal abnormality involving an extra chromosome #21 and resulting in 47 chromosomes instead of the normal 46 chromosomes. As a consequence, the child usually has varying degrees of mental retardation, characteristic facial and physical features, and other congenital anomalies. Down syndrome is the most common chromosomal disorder, occurring in approximately 1 of 800 to 1000 live births. Perinatal risk factors include advanced maternal age, especially with the first pregnancy (although average maternal age is now 25-28 years for an infant with Down’s); paternal age is thought to be a related factor. Multiple causality is suspected.

B. Assessment:

Focus topic: Health Promotion and Maintenance

1. Physical characteristics

a. Brachycephalic (small, round head) with oblique palpebral fissures (almond-shaped eyes) and Brushfield spots (speckling of iris)— depressed nasal bridge (“saddle nose”) and small, low-set ears.

b. Mouth

  • Small oral cavity with protruding tongue causes difficulty sucking and swallowing.
  • Delayed eruption/misalignment of teeth.

c. Hands

  • Clinodactyly—incurved little finger.
  • Simian crease—transverse palmar crease.

d. Muscles: hypotonic (“floppy baby”) with hyperextensible joints.

e. Skin: dry, cracked.

2. Genetic studies reveal an extra chromosome #21 (“trisomy 21”).

3. Intellectual characteristics

  • Mental retardation—varies from severely retarded to low-average intelligence.
  • Most fall within “trainable” range, or IQ of 36 to 51 (“moderate mental retardation”).

4. Congenital anomalies/diseases

  • 40% to 45% have congenital heart defects: mortality highest in clients with Down syndrome and cyanotic heart disease.
  • GI: tracheoesophageal fistula (TEF), Hirschsprung’s disease.
  • Thyroid dysfunction, especially hypothyroidism.
  • Visual defects: cataracts, strabismus.
  • Hearing loss.
  • Increased incidence of leukemia.

5. Growth and development

  • Slow growth, especially in height.
  • Delay in developmental milestones.

6. Sexual development

  • Delayed or incomplete.
  • Women—small number have had offspring (majority have had abnormality).
  • Men—infertile.

7. Aging

  • Premature aging, with shortened life expectancy.
  • Death—generally related to respiratory complications: repeated infections, pneumonia, lung disease.

 Health Promotion and Maintenance

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Risk for aspiration related to hypotonia.
  • Altered nutrition, less than body requirements, related to hypotonia or congenital anomalies.
  • Altered growth and development related to Down syndrome.
  • Self-care deficit related to Down syndrome.
  • Altered family processes related to birth of an infant with a congenital defect.
  • Knowledge deficit related to Down syndrome.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: prevent physical complications.

a. Respiratory

  • Use bulb syringe to clear nose, mouth.
  • Vaporizer.
  • Frequent position changes.
  • Avoid contact with people with upper respiratory infections.

b. Aspiration

  • Small, more frequent feedings.
  • Burp well during/after infant feedings.
  • Allow sufficient time to eat.
  • Position after meals: head of bed elevated, right side—or on stomach, with head to side.

c. Observe for signs and symptoms of: heart disease, constipation/GI obstruction, leukemia, thyroid dysfunction.

2. Goal: meet nutritional needs.

  • Suction (before meals) to clear airway.
  • Adapt feeding techniques to meet special needs of infant/child (e.g., use long, straight handled spoon).
  • Monitor height and weight.
  • As child grows, monitor caloric intake (tends toward obesity with advancing age).
  • Offer foods high in bulk to prevent constipation related to hypotonia.

3. Goal: promote optimal growth and development.

  • Encourage parents to enroll infant/toddler in early stimulation program and to follow through with suggested exercises at home.
  • Preschool/school-age: special education classes.
  • Screen frequently, using Denver II to monitor development.
  • Help parents focus on “normal” or positive aspects of infant/child.

4. Goal: health teaching.

  • Explain that tongue-thrust behavior is normal and that child should be re-fed.
  • Before adolescence—counsel parents and child about delay in sexual development, decreased libido, marriage and family relations.
  • In severe cases, assist parents to deal with issue of placement/institutionalization.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Physical complications are prevented.
  • Adequate nutrition is maintained.
  • Child attains optimal level of growth and development.


Focus topic: Health Promotion and Maintenance

A. Introduction: As defined by the American Psychiatric Association (APA), this diagnostic term includes a persistent pattern of inattention or hyperactivity-impulsivity. The exact cause and pathophysiology remain unknown. The major symptoms include a greatly shortened attention span and difficulty in integrating and synthesizing information. This disorder is three times more common in boys than girls, with onset before age 7; the diagnosis is based on the child’s history rather than on any specific diagnostic test.

B. Assessment:

Focus topic: Health Promotion and Maintenance

1. The behaviors exhibited by children with ADHD are not unusual behaviors seen in children. The behavior of children with ADHD differs from the behavior of non-ADHD children in both quality and appropriateness:

  • Motor activity is excessive.
  • Developmentally “younger” than chronological age.

2. Inattention

  • Does not pay attention to detail.
  • Does not listen when spoken to.
  • Does not do what he or she is told to do.

3. Hyperactivity

  • Fidgets and squirms excessively.
  • Cannot sit quietly.
  • Has difficulty playing quietly.
  • Seems to be constantly in motion, moving or talking; always “on.”

4. Impulsiveness

  • Blurts out answers before question is completed.
  • Has difficulty awaiting turn. Interrupts others.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Altered thought processes related to inattention and impulsiveness.
  • Impaired physical mobility related to hyperactivity.
  • Risk for injury related to impulsivity.
  • Self-esteem disturbance related to hyperactivity and impulsivity.
  • Knowledge deficit related to behavioral modification program, medications, and follow-up care.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: teach family and child about ADHD.

  • Provide complete explanation about disorder, probable course, treatment, and prognosis.
  • Answer questions directly, simply.
  • Encourage family to verbalize; offer support.

2. Goal: provide therapeutic environment using principles of behavior modification and/or psychotherapy.

  • Reduce extraneous or distracting stimuli.
  • Reduce stress by decreasing environmental expectations (home, school).
  • Provide firm, consistent limits.
  • Special education programs.
  • Special attention to safety needs.

3. Goal: reduce symptoms by means of prescribed medication.

a. Medications: Ritalin and Cylert—both are CNS stimulants but have a paradoxical calming effect on the child’s behavior. Tofranil and Norpramin—both are tricyclic
antidepressants that ↑ action of norepinephrine and serotonin in nerve cells, but also can have paradoxical calming effect on child’s behavior. Must monitor for development of tics and arrhythmias.

b. Health teaching (child and parents).

  • Need to take medication regularly, as ordered. Avoid taking medication late in the day because it may cause insomnia; monitor neurological and cardiac status. Assess for ↓ appetite → ↓ weight; avoid caffeine.
  • Need for long-term administration, with probable decreased need as child nears adolescence.

4. Goal: provide safe outlet for excess energy.

  • Alternate planned periods of outdoor play with schoolwork or quiet indoor play.
  • Channel energies toward safe, large-muscle activities: running track, swimming, bicycling, hiking.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Family and child verbalize understanding of “attention deficit disorders.”
  • Therapeutic environment enhances socially acceptable behavior.
  • Medication taken regularly, with behavioral improvements noted.
  • Excess energy directed appropriately.

Health Promotion and Maintenance: NEUROLOGICAL SYSTEM

Focus topic: Health Promotion and Maintenance


Focus topic: Health Promotion and Maintenance

A. Assessment:

Focus topic: Health Promotion and Maintenance

  • Abrupt onset: initial sign may be a seizure, following an episode of upper respiratory infection (URI)/acute otitis media.
  • Chills and fever.
  • Vomiting; may complain of headache, neck pain (older children).
  • Photophobia.
  • Alterations in level of consciousness: delirium, stupor, increased intracranial pressure.
  • Nuchal rigidity (older children).
  • Opisthotonos position: head is drawn backward into overextension; bulging fontanel (most significant finding in infants).
  • Hyperactive reflexes related to CNS irritability.

B. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Risk for infection related to communicability of meningitis.
  • Risk for injury related to CNS irritability and seizures.
  • Pain related to nuchal rigidity, opisthotonos position, increased muscle tension.
  • Sensory/perceptual alterations related to seizures and changes in level of consciousness.
  • Altered nutrition, less than body requirements, related to fever and poor oral intake.
  • Knowledge deficit regarding diagnostic procedures, condition, treatment, prognosis.

C. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: prevent spread of infection.

  • Institute standard precautions.
  • Enforce strict hand washing.
  • Institute and maintain respiratory isolation for minimum of 24 hours after starting IV antibiotics, at which time child is no longer considered to be communicable and can be removed from isolation.
  • Supervise all visitors in isolation techniques.
  • Identify family members and others at high risk: do cultures (Haemophilus influenzae, Escherichia coli, etc.); possibly begin prophylactic antibiotics (e.g., rifampin). Lumbar puncture (LP) is the definitive diagnostic test.
  • Treat with IV antibiotics (as ordered) as soon as possible after admission (after cultures are obtained); continue 10 to 14 days (until cerebrospinal fluid [CSF] culture is negative and child appears clinically improved).
  • Anticipate large-dose IV medications only—administer slowly in dilute form to prevent phlebitis.
  • Restrain as needed to maintain IV.

2. Goal: promote safety and prevent injury/seizures.

  • Maintain seizure precautions. Give anticonvulsants, as ordered (e.g., phenytoin).
  • Place child near nurses’ station for maximum observation; provide private room for isolation.
  • Minimize stimuli: quiet, calm environment.
  • Restrict visitors to immediate family.
  • Position: Head of bed (HOB) slightly elevated to decrease intracranial pressure. (If opisthotonos: side-lying, for comfort and safety.)

3. Goal: maintain adequate nutrition.

  • NPO or clear liquids initially; supplement with IVs, because child may be unable to coordinate sucking and swallowing.
  • Offer diet for age, as tolerated—child may experience anorexia (due to disease) or vomiting (due to increased intracranial pressure).
  • Monitor I&O, daily weights.

D. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • No spread of infection noted; immunize all children against H. influenzae type B
  • Safety maintained.
  • Adequate nutrition and fluid intake maintained.
  • Child recovers without permanent neurological damage (e.g., seizure disorders, hydrocephalus).


Focus topic: Health Promotion and Maintenance

A. Introduction: Reye syndrome, first described as a disease entity in the mid-1960s, is a multisystem disorder primarily affecting children between 6 and 12 years of age. Although not truly a “communicable disease,” studies have confirmed a relationship between aspirin administration during a viral illness (e.g., chickenpox, flu) and the onset
of Reye syndrome. The exact cause remains unknown. Reye syndrome is characterized by acute metabolic encephalopathy and fatty degeneration of the visceral organs, particularly the liver. Earlier diagnosis, more sophisticated monitoring equipment, and more aggressive treatment have greatly improved the survival rate of children with Reye syndrome. Recovery is generally rapid in those children who do survive, though they may suffer certain deficits.

B. Assessment:

Focus topic: Health Promotion and Maintenance

1. Onset typically follows a viral illness, just as child appears to be recovering.

2. Early signs and symptoms:

  • Rapidly progressing behavioral changes: irritability, agitation, combativeness, hostility, confusion, apathy, lethargy.
  • Vomiting, which becomes progressively worse.

3. Rapidly progressive neurological deterioration:

  • Cerebral edema and increased intracranial pressure.
  • Alteration in level of consciousness from lethargy through coma, decerebrate posturing, and respiratory arrest.

4. Liver biopsy reveals liver dysfunction, necrosis, and failure:

  • Elevated serum alanine aminotransferase (ALT) (serum glutamic-pyruvic transaminase [SGPT]), aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT]), lactate dehydrogenase (LDH), serum ammonia levels.
  • Severe hypoglycemia.
  • Increased prothrombin time, coagulation defects, and bleeding.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Altered cerebral tissue perfusion related to cerebral edema and increased intracranial pressure.
  • Altered hepatic tissue perfusion related to fatty degeneration of the liver.
  • Risk for injury related to coagulation defects and bleeding.
  • Knowledge deficit related to diagnosis, course of disease, treatment, and prognosis.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: reduce intracranial pressure.

  • Child is admitted to pediatric intensive care unit (PICU) for intensive nursing care, continuous observation, and monitoring.
  • Monitor neurological status and vital signs continuously.
  • Assist with/prepare for numerous invasive procedures, including endotracheal (ET) tube/mechanical ventilation and intracranial pressure (ICP) monitor.
  • Monitor closely for the development of seizures; institute seizure precautions.
  • Position: elevate HOB 30 to 45 degrees.
  • Administer medications as ordered:

(1)Osmotic diuretics (e.g., mannitol) to decrease ICP.

(2)Diuretics (e.g., Lasix) to decrease CSF production.

(3) Anticonvulsants (e.g., Dilantin, phenobarbital).

(4)Vitamin K, fresh frozen plasma, or platelet transfusions for overt or covert bleeding.

2. Goal: restore and maintain fluid and electrolyte balance, including perfusion of liver.

  • Administer IV fluids per physician’s order— usually 10% glucose (or higher).
  • Strict I&O.
  • Prepare for/assist with Foley catheter placement, central venous pressure (CVP) monitor, ICP monitor, nasogastric (NG) tube, etc.
  • Monitor serum electrolyte laboratory values.

3. Goal: prevent injury and possible bleeding.

  • Observe child for petechiae, unusual bruising, oozing from body orifices or tubes, frank hemorrhage.
  • Check all urine and stool for occult blood.
  • Monitor laboratory values, including prothrombin time (PT), partial thromboplastin time (PTT), platelets.
  • Administer blood products per physician’s order.

4. Goal: provide parents with thorough understanding of Reye syndrome.

  • Primary nurse assigned to provide care and follow through with teaching.
  • Encourage parents’ presence, even in PICU— explain all equipment and procedures in simple, direct terms.
  • Provide factual, honest, and complete information regarding disease, diagnosis, and prognosis.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Intracranial pressure is reduced and normal neurological functioning is restored.
  • Fluid and electrolyte balance is restored.
  • No clinical evidence of bleeding is found.
  • Parents express understanding of Reye syndrome.


Focus topic: Health Promotion and Maintenance

A. Introduction: Hydrocephalus, known to the layperson as “water on the brain,” is actually a syndrome resulting from disturbances in the dynamics of CSF. The accumulation of this fluid causes enlargement and dilation of the ventricles of the brain and increased ICP. If untreated, severe brain damage will result; treatment is a surgical shunting procedure that allows CSF to drain from the ventricles of the brain to another, less harmful area within the body: most commonly the peritoneal cavity, less often the jugular vein or right atrium of the heart. Hydrocephalus can develop as the result of a congenital malformation (e.g., Arnold-Chiari malformation); can be associated with other congenital defects (e.g., spina bifida); or can be acquired secondary to infection (e.g., meningitis), trauma, or neoplasm.

B. Assessment:

Focus topic: Health Promotion and Maintenance

1. Head: increased circumference—earliest sign of hydrocephalus in the infant (more than 1 inch/mo).

2. Fontanels: tense and bulging without head enlargement.

3. Veins: dilated scalp veins.

4. “Setting sun” sign: sclera visible above pupil; pupils are sluggish, with unequal response to light.

5. Cry: shrill, high pitched.

6. Developmental milestones: delayed.

7. Reflexes: persistence of neonatal reflexes; hyperactive reflexes.

8. Feeds poorly.

9. Signs of increased ICP:

  • Vomiting.
  • Irritability.
  • Seizures.
  • Decreased pulse.
  • Decreased respirations.
  • Increased blood pressure.
  • Widened pulse pressure.

10. History may reveal other CNS defects (e.g., spina bifida), infection (e.g., meningitis), trauma, or neoplasm.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Altered cerebral tissue perfusion related to increased intracranial pressure.
  • Impaired skin integrity related to enlarged head size and lack of motor coordination.
  • Altered nutrition, less than body requirements, related to anorexia and vomiting.
  • Anxiety related to diagnosis and uncertain outcome.
  • Knowledge deficit regarding care of the child with a shunt and follow-up care.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: monitor neurological status.

  • Measure head circumference daily, and note any abnormal increase.
  • Perform neurological checks at least every 4 hours to monitor for signs of increased ICP.
  • Report signs of increased ICP STAT to physician.
  • Assist with diagnostic procedures/treatments: ventricular tap, computed tomography (CT) scan, etc.

2. Goal: health teaching to reduce parental anxiety.

  • Do preoperative teaching regarding the shunt procedure: stress need to remove excessive CSF to relieve pressure on brain; done as soon as possible after diagnosis is
  • Stress early diagnosis and prompt shunting procedure to minimize the risk of long-term neurological complications.
  • Offer realistic information regarding prognosis:

(1) Surgically treated, with continued followup care: 80% survival rate.

(2)Of these survivors, 50% are completely normal and 50% have some degree of neurological disability (such as inattentiveness or hyperactivity).

3. Goal: provide postoperative shunt care.

a. Position:

  • Flat in bed for 24 hours to prevent subdural hematoma.
  • Gradually increase the angle of elevation of HOB, as ordered by surgeon.
  • On the nonoperative side, to prevent mechanical pressure and obstruction to shunt.

b. Monitor head circumference daily to note any abnormal increase that might indicate malfunctioning shunt.

c. Monitor vital signs; monitor for signs of increased ICP.

d. Monitor for possible complications:

  • Infection.
  • Malfunction of shunt: increased ICP.

4. Goal: provide discharge teaching to parents regarding home care of the child with a shunt.

  • Stress need for long-term follow-up care.
  • Discuss feeding techniques, care of skin (especially scalp), need for stimulation.
  • Prepare parents for shunt revisions to be done periodically as child grows.
  • Teach parents signs and symptoms of shunt malfunctioning (i.e., of increased ICP or infection) and to report these promptly to physician.
  • Encourage parents to enroll infant in “early infant stimulation” program to maximize developmental potential.
  • Stress need to monitor development at frequent intervals, make referrals prn.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Neurological functioning is maintained or improved.
  • Adequate nutrition is maintained.
  • No impairment of skin integrity occurs.
  • Parents’ anxiety is relieved; they verbalize understanding of how to care for child after discharge.


Focus topic: Health Promotion and Maintenance

A. Introduction: Febrile seizures are transient neurological disorders of childhood, affecting perhaps as many as 3% of all children. Although the exact cause of febrile seizures remains uncertain, they seem to be a relatively transient problem that occurs exclusively in the presence of high, spiked fevers. Children in the infant and toddler stages (6 months to 3 years) appear to be most susceptible to febrile seizures, and they are twice as common in boys as in girls. There also appears to be an increased susceptibility within families, suggesting a possible genetic predisposition.

B. Assessment:

Focus topic: Health Promotion and Maintenance

Focus topic: Health Promotion and Maintenance

  • History usually reveals presence of URI or gastroenteritis.
  • Occurs with a sudden rise in fever: often spiked and quite high (102°F or higher) vs. prolonged temperature elevation.

C. Analysis/nursing diagnosis:

Focus topic: Health Promotion and Maintenance

  • Risk for injury related to seizures.
  • Knowledge deficit related to prevention of future seizures, care of child having a seizure, and possible long-term effects.

D. Nursing care plan/implementation:

Focus topic: Health Promotion and Maintenance

1. Goal: reduce fever/prevent further elevation of fever.

  • Administer antipyretics, as ordered: acetaminophen only (not aspirin).
  • Use cool, loose, cotton clothes to decrease heat retention.
  • Avoid shivering, which increases metabolic rate and temperature.
  • Encourage child to drink cool fluids.
  • Monitor temperature hourly.
  • Minimize stimulation, frustration for child.

2. Goal: teach parents about care of child who experiences febrile seizure.

a. Discuss how to prevent seizures from recurring: best method is to prevent temperature from rising over 102°F.
b. Discuss how to handle seizures if they do recur: prevent injury, maintain airway, etc.
c. Answer questions simply and honestly:

  • 25% of children with one febrile seizure will experience a recurrence.
  • 75% of recurrences occur within 1 year.
  • Reassure parents of the benign nature of febrile seizures; 95% to 98% of children with febrile seizures do not develop epilepsy or neurological damage.

E. Evaluation/outcome criteria:

Focus topic: Health Promotion and Maintenance

  • Fever is kept below 102°F; additional seizures are prevented.
  • Parents verbalize their understanding of how to care for child at home.




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