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Pediatric Primary Care

HEALTH MAINTENANCE Pediatric primary care includes health promotion and disease prevention interventions that will positively affect the well-being of children and their families. The goal of pediatric primary care is to achieve physical, emotional, and developmental health for all children. Primary prevention through immunizations, proper nutrition, and safety counseling are essential components of pediatric health care. IMMUNIZATIONS Disease prevention through immunizations has significantly reduced childhood morbidity and mortality from infectious diseases. However, despite effective immunizations, vaccine-preventable diseases are still present in the United tates and continue to pose significant public health problems. !urses are in a vital position to promote child health by assessing, recommending, and administering immunizations. " review of immunizations and administration of needed vaccines should be done at every health care visit. General Considerations Req irements o! National C"ild"ood #accine In$ ry Act %E!!ecti&e '())* %USA* This act mandated providers to notify all patients and parents about the ris#s and benefits associated with vaccines. The patient, parent, or legal guardian should be informed about the benefits and ris#s of immunizations. They must be provided with the current $accine %nformation tatement &$% ', developed by the (enters for Disease (ontrol and Prevention &(D(', before the administration of the vaccine. Health care providers must record the name of the vaccine $% publication &eg, polio', date of $% publication, and the date the $% was given to the patient or his family on the child)s medical record. *ederal law mandates that all health care providers must record the following information in the patient)s permanent medical record+ month, day, and year of administration, vaccine or other biologic administered, manufacturer, lot number, and e-piration date, and name, address, and title of the health care provider administering the vaccine. %n addition, the site and route of administration should be documented in the patient)s permanent record. Health care providers are re.uired to report selected events occurring after vaccination to the $accine "dverse /vents 0eporting ystem. Ro tine #accinations !or C"ildren in Nort" America (hildhood recommended vaccines include diphtheria, tetanus to-oid, acellular pertussis &DTaP', inactivated poliovirus vaccine &%P$', measles, mumps, rubella &110', Haemophilus influenzae type b &Hib' vaccine, hepatitis 2 vaccine &H2$', $aricella, and pneumococcal &P($3'. %n 4uly 5667, an influenza vaccine was added to the

recommended schedule for healthy children ages 8 to 57 months and is recommended for older children who are at high ris#. Imm ni+ation Sc"ed les 0outine immunizations are started in infancy, however, if a child is not immunized in infancy, immunizations may be started at any age. %f an immunization program is not begun in infancy, a slightly different schedule may be followed, depending on the child)s age and the prevalence of specific diseases at the time. "n interrupted primary series of immunizations does not need to be restarted, rather, the original series should be resumed regardless of the length of time that has elapsed. The immunoresponse is limited in a significant proportion of young infants, and the recommended booster doses are designed to ensure and maintain immunity. (urrent recommended immunization schedules can be found at http+99www.cdc.gov9nip. Contraindications and Preca tions %t is important to read the manufacturer)s insert for each vaccine before administration. Contraindications to all &accines, o "naphylactic reaction to a vaccine or a vaccine constituent. o 1oderate or severe illnesses with or without a fever. All li&e &ir s &accines %li&e oral -olio&ir s &accine .OP#/0 MMR0 #aricella* are contraindicated in, o Pregnancy. o %mmunosuppression or immunodeficiency. o Household or close contact with people who are immunosuppressed or immunodeficient. Diphtheria, tetanus, and pertussis &DTP'9DTaP:encephalopathy within 3 days of administration of previous dose of DTP9DTaP. %P$:anaphylactic reaction to neomycin, streptomycin, or polymy-in 2. 110 and $aricella:anaphylactic reactions to neomycin or gelatin. %nfluenza:anaphylactic reaction to eggs or egg protein. H2$:anaphylactic reaction to ba#er)s yeast. Misconce-tions Concernin1 #accine Contraindications Some "ealt" care -ro&iders ina--ro-riately consider certain conditions or circ mstances to 2e contraindications to &accination3 Conditions most commonly re1arded as s c" incl de, o 1ild acute illness with low-grade fever or mild diarrheal illness in an otherwise well child. o (urrent antimicrobial therapy or the convalescent phase of illness. o 0eaction to a previous DTaP dose that involved only soreness, redness, swelling in the immediate vicinity of the vaccination site, or temperature of less than ;6<= * &76.<= ('. o Prematurity.

Person using aerosolized steroids, short course of oral steroids &less than ;7 days', or topical steroids. o Pregnancy of mother or other household contact. o 0ecent e-posure to an infectious disease. o 2reast-feeding. o History of nonspecific allergies or relatives with allergies. o "llergies to penicillin or other antibiotic, e-cept anaphylactic reactions to neomycin or streptomycin. o "llergies to duc# meat or duc# feathers. o *amily history of seizures in people considered for pertussis or measles vaccination. o *amily history of sudden infant death syndrome in children considered for DTaP vaccination. o *amily history of an adverse event, unrelated to immunosuppression, after vaccination. o 1alnutrition. %n most cases, children with the above conditions can still be immunized.
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#accine Administration Considerations trict adherence to the manufacturer)s storage and handling recommendation is vital. *ailure to observe these precautions and recommendations may reduce the potency and effectiveness of vaccines. Health care personnel administering vaccines should be immunized against measles, mumps, rubella, hepatitis 2, influenza, tetanus, and diphtheria. >loves should be worn when administering vaccines. >ood handwashing techni.ue is mandatory before and after vaccine administration. terile, disposable needles and syringes should be discarded promptly in appropriate biohazard containers. Do not recap needles. Parenteral vaccines should be administered in the anterolateral aspect of the upper thigh in infants and in the deltoid area of the upper arm in older children and adolescents. 0ecommended routes of administration are included in the pac#age inserts of vaccines. 2efore administering a subse.uent dose of any vaccine, .uestion patients and parents about adverse effects and possible reactions from previous doses. 0outine vaccines can be safely and effectively administered simultaneously. S-eci!ic Imm ni+ations 4TaP DTaP is the preferred vaccine for all doses, however, whole cell DTP is an acceptable alternative in some parts of the world. *ewer adverse effects and local reactions will occur with the DTaP vaccine compared with the DTP. " time lapse of ? wee#s is recommended between the first three DTP9DTaP in@ections for desirable ma-imum effects. The combination of depot antigens is preferred because it is more immunogenic. "dministration of acetaminophen at the time of immunization and at 7 and ? hours after immunization decreases the incidence of febrile and local reactions.

2ecause of the increased ris# of possible reactions to either diphtheria or pertussis antigen, Td &adult-type tetanus and diphtheria to-ins' is recommended for children over age 3 years. *or contaminated wounds, a booster dose of tetanus should be given if more than < years have elapsed since the last dose. Protection of infants against pertussis should begin early. %n neonates, the best protection against pertussis is avoidance of household contacts by ade.uate immunization of older siblings. (hildren who have recovered from culture-proven pertussis do not need pertussis immunization. %f the fourth dose of pertussis vaccine is given after the fourth birthday, no further doses are needed.

T 2erc lin S5in Test %t is recommended that the tuberculin test be given before or at the time of the 110. The measles vaccine can temporarily suppress tuberculin reactivity if given 7 to 8 wee#s before a tuberculin test.

The fre.uency of repeated tuberculin testing depends on the following+ o 0is# of tuberculosis e-posure to the child. o Prevalence of tuberculosis in the population group. o Presence of underlying host factors in the child &immunosuppressive conditions or human immunodeficiency virus AH%$B infection'.

Measles #accine Usually given between ages ;5 and ;< months, but should be given at ;5 months in high-ris# areas. econd dose is recommended between ages 7 and 8 years. During an outbrea#, infants as young as age 8 months can be immunized. " second dose should be given between ages ;5 and ;< months and again at age ;; or ;5 years or at school entry. 1ild postimmunization symptoms include transient s#in rashes and fever up to 5 wee#s after vaccination. %mmunoglobulin preparations will interfere with the serologic response to measles vaccine, therefore, wait the specified time after administration for vaccination. M m-s #accine Usually administered in combination with measles and rubella vaccine between ages ;5 and ;< months. econd dose administered as 110 is important because a substantial number of cases have occurred in people with previous immunizations. %mportant to immunize susceptible children approaching puberty, adolescents, and adults. R 2ella #accine

Two doses of rubella vaccine are recommended to avoid conse.uences such as congenital rubella syndrome. %mportant to immunize postpubertal individuals, especially college students and military recruits. Comen should avoid pregnancy within D months of vaccine due to the theoretical ris# to the fetus.

Polio #accine Two types of trivalent vaccine are available:EP$, given orally, and %P$, given parenterally. 2oth are effective in preventing poliomyelitis. To reduce ris# of vaccine-induced polio with EP$, %P$ is recommended for infants and children in the U. . EP$ should not be given to infants and children living in households with an immunodeficient person. Five EP$ is e-creted in the stool for up to ; month after vaccination. $accine-induced polio is a ris# to both the vaccinated child and any immunosuppressed contact. H3 in!l en+ae Ty-e 6 #accine %ncidence of invasive disease caused by H. influenzae type 2 has declined dramatically since the introduction of the con@ugate vaccine. everal different types of Hib vaccines are available. Different vaccines have different schedules. 1inimal adverse reactions &pain, redness, or swelling at immunization site for less than 57 hours'. He-atitis 6 &accine There are two schedules for this vaccine. %nfants born to hepatitis 2 surface antigen &H2s"g'-negative mothers should receive the routine schedule. %nfants born to H2s"g-positive mothers should be on an accelerated vaccination schedule. 0ecommended for all infants born to H2s"g-negative mothers. Three-dose schedule is initiated in neonatal period or by age 5 months, the second dose is given ; to 5 months later, the third dose, 8 to ;? months later. "ll infants born to H2s"g-positive mothers, including premature neonates, should receive hepatitis 2 immunoglobulin and H2$ within ;5 hours after birth. The second dose is given between ages ; and 5 months, the third dose at age 8 months. Preterm neonates weighing less than 5,666 grams may have lower seroconversion rates. %nitiation of H2$ should be delayed until @ust before hospital discharge if the infant weighs 5,666 grams or more or until about age 5 months when other routine immunizations are given. "ll children and adolescents who have not had H2$ should be immunized. Pne mococcal #accines T"ere are t7o ty-es o! -ne mococcal &accines, o Pneumococcal con@ugate vaccine &P($39Prevnar'.

5D-valent pneumococcal polysaccharide &PP$9Pneumova-'. %n the U. . in 5666, P($3 was released and added to the recommended childhood vaccines for all children ages 5 to 5D months and certain children ages 5 to < years. /fficacy for the vaccine is G3H and the adverse effects are mild &fever and localized tenderness and redness at the in@ection site'. PP$ is recommended for children ages 5 to < years in certain high-ris# groups &sic#le cell disease, functional or anatomic asplenia, nephritic syndrome, chronic renal failure, immunosuppressive disorders, H%$ infections, cerebral spinal fluid lea#s'.
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In!l en+a #accine The influenza vaccine contains three virus strains and is changed yearly, based on predictions of predominate strains e-pected to circulate in the upcoming influenza season. This vaccine should be given to children ages 8 months or older with these conditions+ asthma or other chronic lung disease, cardiac disease, immunosuppressive disorders, H%$, hemoglobinopathies, including sic#le cell disease, diseases re.uiring long-term salicylate therapy, such as rheumatoid arthritis or Iawasa#i syndrome, chronic renal dysfunction, and chronic metabolic disease, including diabetes mellitus. %n 4uly 5667, influenza vaccine was added to the routine immunization schedule for healthy children ages 8 to 57 months. (hildren older than age 57 months may receive the vaccine to minimize the chance of getting influenza. This vaccine is given annually, before flu season, usually in Ectober, !ovember, or December. %n children ages ? years and younger, the first time influenza vaccine is administered, two doses should be given ; month apart. %n subse.uent years, only one dose is needed. Rota&ir s #accine %n ;GG?, rotavirus vaccine, which prevents the most common cause of diarrhea in childhood, was licensed for use in the United tates. "bout 3 months after licensure, rotavirus vaccine recommendations were suspended and later rescinded, and the vaccine was ta#en off the mar#et because of an increased incidence of intussusception in vaccinated infants. $accine trials are underway for the development of a new rotavirus vaccine. NUTRITION IN CHIL4REN The nutritional status of the child is an important aspect of health maintenance. " balanced diet influences child growth and psychosocial development. *eeding provides emotional and psychological benefits in addition to nutritional needs. %n !orth "merica, obesity in childhood has become a ma@or problem. >ood eating habits and proper foods introduced early in life could prevent morbidity from childhood obesity. The table below presents nutritional guidelines based on age and developmental maturation.

AGE AN4 4E#ELOPMENTAL IN8LUENCE ON NUTRITIONAL RE9UIREMENTS AN4 8EE4ING PATTERNS Neonate Birth-4 weeks !eonate)s rapid growth ma#es infant especially vulnerable to dietary inade.uacies, dehydration, and iron deficiency anemia. *eeding process is basis for infant)s first human relationship, formation of trust. *eeding reinforces mother)s sense of Jmotherliness.K 2ecause of limited nutritional stores, neonates re.uire vitamin and mineral supplements. !eonates re.uire more fluid relative to their size than adults.

N trition in C"ildren 8EE4ING PATTERN NURSING AN4 4IET CONSI4ERATIONS AN4 PARENTAL GUI4ANCE

2reast mil# or formula is generally given in 8 to ? feedings per day, spaced 5 to 7 hours apart.

Provide information to help parents ma#e decision concerning breast- or bottlefeeding. upport parents in their decision.

uc#ing ability is influenced by individual neuromuscular maturity.

*eeding schedules should be Breast-fed infant: individualized Help mother assume according to comfortable and infant)s needs. satisfying position for self and baby. Help mother to determine schedule, timing, and when infant is satisfied. Provide specific information about+ L*eeding techni.ue+ position, Jbubbling.K L(are of breasts. L1anual e-pression of mil# from breast. L1aternal diet. Bottle-fed infant: Provide specific information about+ LType of formula. LPreparation of formula+ measuring and sterilization. L/.uipment:types of bottles and nipples. L terilization of e.uipment. LTechni.ue of

feeding+ position, Jbubbling.K Help mother to determine when infant is satisfied, develop schedule for feeding. Provide information about normal characteristics of stools, signs of dehydration, constipation, colic, mil# allergy. Discuss need for vitamin supplements and how to administer. Discuss need for additional fluids during periods of hot weather, and with fever, diarrhea, and vomiting. Ebserve for evidence of common problems and intervene accordingly+ LEverfeeding. LUnderfeeding. LDifficulty digesting formula because of its composition. L%mproper feeding techni.ue, holes in nipples too large or too small, formula too hot or too cold, uncomfortable feeding position, failure to JbubbleK, improper sterilization, bottle propping. L2ottles should never be given to infants to ta#e to bed. The person feeding should be calm, gentle, rela-ed, and patient in

In!ant 3 months-1 year %ncreased neuromuscular

!umber of feedings per day decreases through

development allows infant to ma#e transition from a totally li.uid diet to a diet of mil# and solid foods as well as to more active participation in the feeding process. 3-6 months uc#ing refle- becomes voluntary and chewing action begins, infant can appro-imate lips to rim and cup and may begin drin#ing from cup at 8 months. 6-12 months Foses maternal iron stores at 8 months, first tooth erupts between ages 8 and G months, eyes and hands can wor# together, infant can sit without support and has developed grasp, can feed self a biscuit, bangs ob@ects on table, able to hold own bottle between ages G and ;5 months, can JpincerK grasp food, able to be weaned from bottle as child becomes developmentally able to ta#e sufficient fluids from the cup. *ood provides the infant with a variety of learning e-periences, motor control and coordination in selffeeding, recognition of shape, te-ture, color, stimulation of speech

the first year. 2y ages 7 to 8 months, generally ready to begin strained foods. The usual se.uence of foods is cereal followed by fruits and vegetables. 1eats may be started between ? and G months. e.uence may vary according to preferences of the family and health care provider. 1ashed table foods or @unior foods are generally started between ages 8 and ? months, when infant begins chewing action. %nfant begins to en@oy finger foods between ages ;6 and ;5 months. The transition from ironfortified formula or breast mil# to cow)s mil# is usually advised at about age ;5 months. 2y age ; year, most infants are satisfied with three meals and additional fluids throughout the

approach. Chen first offered purMed foods with a spoon, the child e-pects and wants to suc#. The protrusion of the tongue, which is needed in suc#ing, ma#es it appear as if the child is pushing the food out of mouth. This response should not be interpreted as disli#e for the food, it is a result of immature muscle coordination and surprise at the taste and feel of the new food. The baby foods selected should be high in nutrients without providing e-cessive calories. Personal and cultural preferences should be considered. %ron-fortified formulas and cereals are needed to prevent physiologic anemia. !ew foods should be offered one at a time and early in the feeding while the infant is still hungry. "llow D-< days between new foods. %nfants should be observed for allergic reactions when new foods are added. (ommon allergies are to citrus @uices, egg white, cow)s mil#, and peanut butter. These foods should be avoided until age ;5 months. "lso avoid honey until

movement through use of mouth muscles.

day.

1ealtime allows the infant to continue development of trust in a consistent, loving atmosphere. The infant is forming lifetime eating habits, it is therefore important to ma#e mealtime a positive e-perience.

age ;5 months due to the ris# of infantile botulism. *inger foods should be selected for their nutritional value. >ood choices include teething biscuits, coo#ed vegetables, bananas, cheese stic#s, and enriched cereals. "void nuts, raisins, and raw vegetables, which can cause cho#ing. Parents can be taught to prepare their own strained or @unior foods using a commercial baby food grinder or blender. Ceaning is a gradual process. L"ssist parents to recognize indications of readiness. LDo not e-pect the infant to completely drop old pattern of behavior while learning a new one, allow overlap of old and new techni.ues. L/vening feedings are usually the most difficult to eliminate because the infant is tired and in need of suc#ing comfort. LDuring illness or household disorganization, the infant may regress and return to suc#ing to relieve his discomfort and frustration.

NURSING ALERT O2tain a t"oro 1" n rsin1 "istory !or t"e "os-itali+ed in!ant t"at incl des !eedin1 -attern and sc"ed le: ty-es o! !oods t"at "a&e 2een introd ced: li5es and disli5es: 2reast or 2ottle !ed0 ty-e o! 2ottle: tem-erat re at 7"ic" in!ant -re!ers !oods and !l ids3 Toddler 1-3 years >rowth slows at the end of the first year. The slower growth rate is reflected in a decreased appetite. The toddler has a total of ;7 to ;8 teeth, ma#ing him more able to chew foods. %ncreased selfawareness causes the toddler to want to do more for self. 0efusals of food or of assistance in feedings are common ways in which the toddler asserts himself.

2ecause body tissues, especially muscles, continue to grow .uite rapidly, protein needs are high.

"ppetite is sporadic, specific foods may be favored e-clusively or refused from time to time. (hild may be ritualistic concerning food preferences, schedule, and manner of eating. Diet should include a full range of foods+ mil#, meat, fruits, vegetables, breads, and cereals. %ronfortified dry cereals &rice, barley' are an e-cellent source of iron during the second year of life. Elder toddler can be e-pected to consume about one-half the amount of food that an adult consumes.

Provide foods with a variety of color, te-ture, and flavor. Toddlers need to e-perience the feel of foods. Effer small portions. %t is fun for the child to as# for more. %t is more effective to give small helpings than to insist that he eat a specific amount. 1aintain a regular mealtime schedule. Provide appropriate mealtime e.uipment+ L ilverware scaled to size. LDishes:colorful, unbrea#able, shallow, round bowls are preferable to flat plates. LPlastic bibs, placemats, and floor coverings permit a rela-ed attitude toward child)s self-feeding attempts. L(omfortable seating at good height and distance from table. "dults who help toddlers at mealtime should be calm and

Chole mil# is recommended up to age 5 years.

rela-ed. "void bribes or force feeding because this reinforces negative behavior and may lead to a disli#e for mealtime. /ncourage independence, but provide assistance when necessary. Do not be concerned about table manners. "void the use of soda or JsweetsK as rewards or between-meal snac#s. %nstead, substitute fruit, @uice, or cereal. Toddlers who show little interest in eggs, meat, or vegetables should not be permitted to appease their appetite with carbohydrates or mil# because this may lead to iron deficiency anemia. 1il# should be limited to appro-imately ;8 ounces9day.

NURSING ALERT N rsin1 "istory !or t"e "os-itali+ed toddler s"o ld incl de !eedin1 -attern and sc"ed le: !ood li5es and disli5es: !ood aller1ies: s-ecial eatin1 eq i-ment and tensils: 7"et"er c"ild is 7eaned: 7"at c"ild is !ed 7"en ill3 Presc"ooler 3-5 years %ncreased manual de-terity enables child to have complete independence at

"ppetite tends to be sporadic. (hild re.uires the same basic four food groups as the

/mphasis should be placed on the .uality rather than the amount of food ingested. *oods should be

mealtime. Psychosocially, this is a period of increased imitation and seidentification. The preschooler identifies with parents at the table and will en@oy what parents en@oy. "dditional nutritional habits are developed that become part of the child)s lifetime practices. lower growth rate and increased interest in e-ploring his environment may decrease the preschooler)s interest in eating. /ating assumes increasing social significance. 1ealtime promotes socialization and provides the preschooler with opportunities to learn appropriate mealtime behavior, language s#ills, and understanding of family rituals.

adult, but in smaller .uantities. >enerally li#es to eat one food from plate at a time. Fi#es vegetables that are crisp, raw, and cut into finger-sized pieces. Eften disli#es strongtasting foods.

NURSING ALERT Consider c lt ral di!!erences3 Allo7 -arents to 2rin1 in !a&orite !oods or eatin1 tensils !rom "ome !or t"e "os-itali+ed -resc"ooler3 Enco ra1e !amily mem2ers to 2e -resent at mealtime3

attractively served, mildly flavored, plain, as well as being separated and distinctly identifiable in flavor and appearance. !utritional foods &eg, crac#ers and cheese, yogurt, fruit' should be offered as snac#s. Desserts should be nutritious and a natural part of the meal, not used as a reward for finishing the meal or omitted as punishment. Unless they persist, periods of overeating or not wanting to eat certain foods should not cause concern. The overall eating pattern from month to month is more pertinent to assess. *re.uent causes of insufficient eating+ LUnhappy atmosphere at mealtime. LEvereating between meals. LParental e-ample. L"ttention-see#ing. L/-cessive parental e-pectations. L%nade.uate variety or .uantity of foods. LTooth decay. LPhysical illness. L*atigue. L/motional disturbance. 1easures to increase food inta#e+ L"llow child to help

with preparations, planning menu, setting table, and other simple chores. L1aintain calm environment with no distractions. L"void between-meal snac#s. LProvide rest period before meal. L"void coa-ing, bribing, threatening. Sc"ool;a1e c"ild lowed growth rate during middle childhood results in gradual decline in food re.uirements per unit of body weight. The preadolescent growth spurt occurs about age ;6 in girls and about age ;5 in boys. "t this time, energy needs increase and approach those of the adult. %nta#e is particularly important because reserves are

Place children in small !utrition education should help the child to select foods wisely and to begin to plan and prepare meals. Parental attitudes continue to be important as the child copies parental behavior &eg, s#ipping brea#fast, not eating certain foods, consuming fast foods fre.uently'. 1ost children re.uire a nutritious brea#fast to avoid lassitude in late

2y this time, food practices are generally well established, a product of the eating e-periences of the toddler and preschool period. 1any children are too busy with other affairs to ta#e time out to eat. Play readily ta#es priority

laid down for the demands of adolescence. The child becomes dependent on peers for approval and ma#es food choices accordingly. The child e-periences increased socialization and independence through opportunities to eat away from home &eg, at school and homes of peers'.

unless a firm understanding is reached and mealtime is rela-ed and en@oyable.

morning. 1ealtime should continue to be rela-ed and en@oyable. Diversions, such as television, should be avoided. (alcium and vitamin D inta#e warrant special consideration. They must be ade.uate to support the rapid enlargement of bones. Parents and health care professionals should be alert to signs of developing obesity. %nta#e should be altered accordingly. Table manners should not be overemphasized. The young child typically stuffs mouth, spills foods, and chatters incessantly while eating. Time and e-perience will improve habits. Provide some companionship and conversation at the child)s level during meals. Peers should be invited occasionally for meals.

NURSING ALERT N rsin1 "istory o! t"e "os-itali+ed c"ild s"o ld incl de !ood -re!erences: mealtime -atterns and snac5s: !ood aller1ies: !ood -re!erences 7"en ill3 Pro&ide o--ort nities !or c"ildren to eat in small 1ro -s at ta2les3 Consider c lt ral di!!erences3

Allo7 -arents to 2rin1 in !a&orite !oods !rom "ome3 Allo7 c"ild to order "is o7n meal3 Adolescent 11-17 years Dietary re.uirements vary according to stage of se-ual maturation, rate of physical growth, and e-tent of athletic and social activity. Chen rapid growth of puberty appears, there is a corresponding increase in energy re.uirements and appetite.

Previously learned dietary patterns are difficult to change. *ood choices and eating habits may be .uite unusual and are related to the adolescent)s psychological and social milieu. >enerally, a significant percentage of the daily caloric inta#e of the adolescent comes from snac#ing.

1enstruating teen is particularly susceptible to iron-deficiency anemia.

(ontinue nutrition education, with emphasis on+ L electing nutritious foods high in iron. L!utritional needs related to growth. LPreparing favorite Jadolescent foods.K L*oods and physical fitness. %nformal sessions are generally more effective than lectures on nutrition. pecial problems re.uiring intervention+ LEbesity. L/-cessive dieting. L/-treme fads: eccentric and grossly restricted diets. L"nore-ia nervosa and bulimia. L"dolescent pregnancy. L%ron deficiency anemia. Provide nutritious foods relevant to the adolescent)s lifestyle. Discourage cigarette smo#ing, which may contribute to poor nutritional status by decreasing appetite and increasing the body)s metabolic rate.

NURSING ALERT Allo7 "os-itali+ed adolescent

to c"oose o7n !oods0 es-ecially i! on a s-ecial diet3 Pro&ide a re!ri1erator in t"e recreation room !or snac5s0 or tili+e a snac5 cart3 Ser&e !oods t"at a--eal to adolescents3 Use a n rsin1 "istory similar to t"at !or t"e sc"ool;a1e c"ild3 PATIENT E4UCATION GUI4ELINES 6reast;8eedin1 2reast-feeding is the best possible source of nutrition for your infant. %t provides an immunologic boost for the infant, protects against breast cancer, hastens postpartum healing, and serves as a wonderful bond between the infant and mother. Nou should begin breast-feeding in a .uiet, comfortable place that is free from interruption. Nou may need a pillow to help support the infant and a footstool to use to elevate your leg. 1a#e sure the infant is awa#e and dry before the feeding is started. %f awa#e and comfortable, the infant will settle down and feed better. The infant should also be hungry. Dress the infant appropriately so that the infant is not too warm or too cool during the feeding. %f too warm, the infant may fall asleep after the first few suc#s of mil#. " sleepy infant will not nurse well. %f too cool, the infant may be fussy and restless. Position infant at the breast by placing the infant in a semi-sitting position with face close to the breast and supported by one of your arms and hand. " pillow may be used under the infant for support. Nou may need to support your breast with your other hand. Proper positioning will provide the infant with comfort and security and ma#e it easier for the infant to suc# and swallow. This ma#es the nipple more easily accessible to the infant)s mouth and prevents obstruction of nasal breathing. Chen the feeding is to start, let the breast touch the infant)s chee#. Do not hold the chee#, but try to help the infant find the nipple. The rooting refle- will ta#e over and the infant will turn head toward breast with mouth open. %f you touch the chee#, the infant will become confused, perhaps turning toward your hand. The infant)s lips should be out over the areola and not @ust around the nipple before beginning to suc#. 2ecause the nipple is so small, suction cannot be achieved merely by grasping it. The areola must be in the infant)s mouth to establish suction and ma#e the suc# effective. Nou may notice the Jlet-downK refle- during the nursing period. 1il# flowing from the other breast during nursing is .uite normal. The length of feeding time may vary from < to D6 minutes. Fet the infant nurse until satisfied. Chen the infant is satisfied and has nursed well, the infant is rela-ed and usually falls asleep. The infant will stop suc#ing.

2urp the infant during and at the end of the feeding to prevent abdominal distention or regurgitation from air swallowed during the feeding. Ene or both breasts may be used at each feeding. %t ma#es no difference as long as the infant is satisfied at the end of the feeding and one breast is completely emptied at the feeding. %f both breasts were used, the second breast is not usually emptied and should be used first at the ne-t feeding. 0egular and complete emptying of the breast is the only stimulation for the production of mil#. Chen the infant has stopped suc#ing, the infant typically li#es to cling to the breast. To brea# this suction, insert a finger to the corner of the infant)s mouth and gently pull. Chen the infant has finished feeding, change the diaper if it is wet or soiled. Position the infant on the right side in bed. !ote whether the infant appears satisfied or still seems to be hungry. To continue successful breast-feeding, get ade.uate rest and nutrition. *or information and support, contact FaFeche Feague %nternational, ;766 !. 1eacham 0oad, chaumburg, %F 86;3D, ?73-<;G-33D6, http+99www.laleche.org, or read their publication The Comanly "rt of 2reast-feeding &8th ed.'

6reast;8eedin1 2reast-feeding is the natural and ideal nourishment that will supply an infant with ade.uate nutrition as well as immunologic and anti-infection properties. Cith breast mil# being at the proper temperature, it may prevent other >% disturbances as well. The development of allergies is reduced in breast-fed babies. 2reast-feeding provides psychological and emotional satisfaction for the infant and mother and can promote bonding. The physical closeness may also provide comfort after a frightening or painful procedure. 2reast-feeding can be continued through most illnesses and hospitalizations of the infant. %n times of stress, the infant may cope with breast-feeding better than bottle-feeding. 2ecause breast mil# is more easily and .uic#ly digested, shorter periods without food preoperatively and postoperatively may be necessary. "ttempts should be made to maintain the breast-feeding bond and routines of the child and mother. o upplemental artificial formula can be given to the infant if the mother is not available. o The mother can pump her breasts so that mil# can be given to the infant by way of bottle when she is not available. o 2reast mil# can be frozen for up to 8 months &chec# the facility)s specific policy'. o Thaw frozen breast mil# for use in tepid water. Do not use a microwave, which may destroy vitamins and nutritional properties. tress of new motherhood or illness in the infant or mother may decrease the mother)s mil# supply and inhibit her Jlet-downK refle-, as well as increase or decrease the infant)s desire to suc#le. Pumping may be initiated to help stimulate the mother)s mil# supply. "n electronic pump may be necessary if prolonged pumping is e-pected or if manual pumping is not successful.

/ducation and encouragement should be offered to all new mothers and those having difficulty or concerns about breast-feeding &see Patient /ducation >uidelines'.

6ottle;8eedin1 2ottle-feeding is a method of supplying nutrition to the infant by oral feedings, using a bottle and nipple set-up. 2ottle-feeding can supplement breast-feeding with formula or water, or can be the sole means of nutritional inta#e for the infant. 2ottle-feeding can also provide intermittent feedings of e-pressed breast mil# when the mother cannot be present at the time of the feeding. 2ottle-feeding can be a time of bonding between the mother and infant. The father or other capable members of the family should be taught bottle-feeding techni.ue as well. PROCE4URE GUI4ELINES 6ottle 8eedin1 E9UIPMENT terile nipple and bottle. terile formula or breast mil#. N rsin1 Action Pre-aratory -"ase ; %nfant should be awa#e and hungry. . (hange wet or soiled diaper. Rationale ; " sleepy infant will not feed well. " dry . diaper will provide comfort so that the infant will settle down and eat more easily. 5 To prevent error. .

5 Prepare formula according to . manufacturer)s instructions. (hec# formula for correct type and amount. D ome infants prefer warmed formula, D (hec# temperature of formula on inner wrist . not hot. . before feeding. 7 it in a comfortable chair. (radle the 7 Proper position will provide the infant with . infant with one hand and arm, while . comfort and security and will ma#e it easier supporting the infant against your body to suc# and swallow. Holding the infant will or lap. enhance trust-building and provide sensory stimulation. Per!ormance -"ase ; Fet the infant root for the nipple by ; Place the nipple on top of the tongue and far . touching the corner of the infant)s . enough into the mouth so suction can be mouth with the nipple. Chen the created when the infant suc#s. infant)s mouth opens, insert the nipple. 5 Hold the bottle at an angle to 5 This prevents the infant from suc#ing and . completely fill the nipple with fluid. . swallowing e-cessive amounts of air. D !ever prop the bottle or leave the D This is unsafe. hould vomiting occur, . infant unattended during feeding. . aspiration is more li#ely.

7 Handle the bottle carefully so as not to 7 (ontamination will increase the ris# of >% . contaminate the nipple or fluid. . disturbances. < %nfant)s feeding time will vary from ;6 < The length of time will depend on the infant)s . to 5< minutes. Position the infant so . age and how vigorously he suc#s. eye contact can be established during feeding. oothing tal# and fondling can provide additional comfort to the infant. 8 2urp the infant at least once during the 8 1ost infants swallow some air during . feeding and at the end of the feeding. . feeding. These positions aid in e-pelling air a. Place the baby in a sitting and thus prevent abdominal distention, position in your lap, tilt slightly discomfort, and regurgitation. $igorous forward, and gently rub or pat handling or patting may result in the infant the bac# or abdomen. spitting up or regurgitating feeding. b. Place the infant in a prone position on your shoulder and gently pat or rub the bac#. c. Place the infant in a prone position on your lap and gently rub or pat the bac#. 8ollo7; - -"ase ; "fter final burping, change the infant)s . wet or soiled diaper and place the infant in the crib on the right side. 5 (hec# the infant in a few minutes. %f . restless, pic# infant up and burp. !ote if any spitting-up has occurred.

; This position aids in emptying the stomach . and prevents regurgitation. 5 ome infants relieve themselves of air when . in the crib and bring up small amounts of formula at the same time.

NURSING ALERT <"en !eedin1 a -remat re in!ant0 t"e in!ant 7ill tire more easily and !all aslee-3 Allo7 !req ent rest -eriods0 and se a so!t ni--le so t"at less ener1y is needed to s c53 To stim late t"is in!ant to s c50 t"e n rse can 2r s" t"e in!ant=s c"ee5 7it" "er !in1er0 -lace "er t" m2 or !in1er nder t"e in!ant=s c"in0 or mo&e t"e ni--le slo7ly 2ac5 and !ort" in t"e in!ant=s mo t"3 8eedin1 time s"o ld not e>ceed ?@ min tes3 Aee- t"e in!ant 7arm d rin1 !eedin13 SA8ETB afety is an important aspect of child health and well-being. %n@uries are the leading cause of death for children in the United tates. "dditionally, in@ury is a significant cause of childhood morbidity. "lthough childhood deaths from other causes have decreased, deaths from in@uries remain constant. Role o! t"e N rse %dentify environmental hazards, and act to reduce or eliminate them. %dentify behavioral characteristics of individual children that may be related to accidental liability, and caution parents accordingly. Pay particular attention to children who show the following+

(haracteristics that increase e-posure to hazards, such as e-cessive curiosity, inability to delay gratification, hyperactivity, and daringness. o (haracteristics that reduce the child)s ability to cope with hazards, such as aggressiveness, stubbornness, poor concentration, low frustration threshold, and lac# of self-control. Provide anticipatory guidance about child development as it relates to accidents. Direct preventive teaching toward the intended audience, be it individuals or groups, children or adults. Participate in policy setting for accident prevention with great emphasis on effective public health measures.
o

Princi-les o! Sa!ety The type of accident li#ely to occur is influenced by the child)s age and developmental level. Parents who have #nowledge of their own child)s typical behavior patterns may foresee potential accident situations. (hildren are naturally curious, impulsive, and impatient. The young child needs to touch, feel, and investigate. (onsistent adult supervision will enable children to learn in a safe environment. (hildren copy the behavior of their parents and absorb parental attitudes. Parents and other adults should be a role model for using proper and safe methods. (hildren become less careful and less willing to listen to warnings and to observe routine safety precautions when they are tired or hungry. "n estimated G6H of all accidents are preventable. General Areas o! Ad lt Res-onsi2ility !or C"ild Sa!ety Motor #e"icle "utomobiles should be in good mechanical condition. Use properly fitted and installed car seats and seat belts. 2e aware of the guidelines for restraints based on the child)s age and weight. %nfants riding in a rear-facing car seat should never be placed in the front seat e.uipped with an air bag. The center rear seat is the safest seat for a child. The driver should loo# carefully in front and bac# of the car before getting into the car. Foc# all car doors. !ever leave young children in a car alone. Do not place heavy or sharp ob@ects on the same seat with a child. S-orts and Recreation Ieep e.uipment in good condition and proper wor#ing order. /ncourage the routine use of bi#e helmets.

Use o! 2i5e "elmets 2y all c"ildren !or sa!ety3 Cear appropriate clothing and safety e.uipment for the activity.

Use o! a--ro-riate -ads and "elmets !or sa!ety3 Do not attempt activities beyond one)s physical endurance. Ieep firearms and ammunition loc#ed up.

Electrical and Mec"anical Eq i-ment Enly underwriter-approved devices should be installed, they should be inspected periodically.

Dry hands before touching appliances. Ieep radios, transportable heaters, and hair dryers out of the bathroom. Disconnect appliances after each use and before attempting minor repairs. Ieep garden e.uipment and machinery in a restricted area. Teach proper use of the e.uipment as soon as the child is old enough. "void overloading electrical circuits. Discourage children from playing with or being in area where appliances or power tools &eg, washing machine, clothes dryer, saw, lawn mower' are in operation.

Pre&ention o! 8alls Ieep stairs well lighted and free from clutter. Provide sturdy railings. "nchor small rugs securely. Use rubber mats in the bathtub and shower. Use only sturdy ladders for climbing. Poisonin1s and In1estions Do not mi- bleaches with ammonia, vinegar, and other household cleaners. ee section on ingested poisons and pediatric poisoning &see page ;D87'. 2ecome familiar with the telephone number for poison control centers where available. Fabel poisonous household materials, and #eep them out of child)s reach. 8ire

1aintain an ade.uate fire escape plan, and routinely conduct home fire drills. Teach children escape routes as soon as they are old enough. Ieep a pressure-type, handheld fire e-tinguisher on each floor. %nstruct all family members who are old enough in its use. *it fireplaces with snug fireplace screens. tore gasoline and other flammable fluids in tightly covered containers that are clearly labeled and away from heat and spar#s. Dispose of paint- and oil-soa#ed cloths promptly. Use flame-retardant sleepwear. 1ar# children)s rooms so they are obvious to firefighters. Teach children about the danger of smo#e inhalation. Teach children to stop, drop, and roll if their clothing catches fire. 1aintain smo#e detectors in wor#ing order. Ieep lighters and matches out of the reach of children. Ieep children away from heated oven, stovetop, and outdoor grill.

S7immin1 Pools (ompletely enclose pool with a fence that complies with local regulations. The gate should be self-closing and have a loc#. %ndicate water depth with numbers on the edge of the pool. Place a safety float line where the bottom of the slope begins to deepen.

%nstall at least one ladder at each end of the pool. Fadders should have handrails on both sides, and the diameter of the rails should be small enough for a child to grasp. Use nonslip materials on ladders, dec#, and diving boards. %f the pool is used at night, install underwater lighting as well as outdoor lights. %nstall a ground fault circuit interrupter on the pool circuit to cut off electrical power and thus prevent electrocutions should electrical fault occur. %nstruct children about safety rules, such as not swimming alone, need for adult supervision, no running around the pool, and no pushing others. "void using radios or other electrical appliances around the pool. Ieep essential rescue devices and first-aid e.uipment close to the pool.

Emer1ency Preca tions 0ecord emergency telephone numbers in an obvious and easily accessible place. Ieep a well-stoc#ed first-aid #it immediately available for emergencies. Gi&e instr ction in -rinci-les o! !irst aid to all !amily mem2ers 7"o are old eno 1"3 o 0esponsible adults should enroll in first-aid courses offered by the "merican 0ed (ross and adult education programs. o 2e aware of first-aid procedure for+ 2urns. /lectrical shoc#. Poisoning. 2ites and stings. (uts, scrapes, and punctures. !ear drowning. *ractures. (ardiopulmonary arrest. o Teach children safety precautions concerning bicycles, answering the telephone or door, strangers outside the home, street safety. Inow the location of gas, water, and electrical switches and how to turn them off in an emergency. Teach children their addresses and telephone numbers and how to dial G;; in case of emergency. Miscellaneo s Ta#e advantage of preventive health care. o Ebtain recommended immunizations. o Have regular physical and dental e-aminations. ee# immediate treatment of all diseases and health problems. 2alance periods of wor#, rest, and e-ercise in daily living. PE4IATRIC CARE TECHNI9UE NURSING MANAGEMENT O8 THE CHIL4 <ITH 8E#ER

*ever is an abnormal elevation of body temperature. Prolonged elevation of temperature above ;67= * &76= (' may produce dehydration and harmful effects on the central nervous system &(! '. General Considerations Consider 2asic -rinci-les related to tem-erat re re1 lation in -ediatric -atients3 o Usually an infant)s temperature does not stabilize before age ; wee#. " neonate)s temperature varies with the temperature of the environment. o The degree of fever does not always reflect the severity of the disease. " child may have a serious illness with a normal or subnormal temperature. o *ebrile seizures may occur in some children when the temperature rises rapidly. o The range for normal temperature varies widely in children. " common e-planation for JfeverK is misinterpretation of a normal temperature reading. o " child)s temperature is influenced by activity and by the time of day, temperatures are highest in late afternoon. Temperature interpretation depends on accurate temperature measurement in a child. The mode should be appropriate for the child)s age and condition, and the thermometer should be left in place for the re.uired time period. Parents or caregivers should be taught the appropriate assessment of temperature as the child grows. Ca ses o! 8e&er in C"ildren %nfection. %nflammatory disease. Dehydration. Tumors. Disturbance of temperature-regulating center. /-travasation of blood into the tissues. Drugs or to-ins. N rsin1 Assessment Assess "istory o! -resent illness !or so rce o! !e&er3 o "ge of the child. o Pattern of the fever. o Fength of the illness. o (hange in normal patterns of eating, elimination, and recreation. o Ether symptoms:poor feeding, cough, earache, diarrhea, vomiting, and rash. o /-posure to any illness. o 0ecent immunizations or drugs. o Treatment of fever and effectiveness of treatment. o Previous e-periences with fever and its control. "ssess the general appearance of the child.

Per!orm a systematic -"ysical assessment3 o %nspection of the s#in for rashes, sores, flushed appearance. o %nspection of eyes, ears, nose, and throat for redness and drainage. o "uscultation of lungs for abnormal sounds. o !eurologic observation for changes in state of consciousness, pupillary reaction, strength of grip, abnormal muscle movement, or lac# of movement. o %nspection of e-ternal genitals for redness and drainage. o Presence of abdominal or flan# tenderness. "ssist with laboratory tests as indicated. %nitial tests typically include complete blood count, urinalysis, cultures of the throat, nasopharyn-, urine, blood, and spinal fluid, and chest O-ray. "ttempt to identify the pattern of the fever. Ta#e the child)s temperature by the same method every hour until stable, then every 5 hours until normal, then every 7 hours for 57 hours.

N rsin1 Meas res to Red ce 8e&er *ever does not necessarily re.uire treatment. The presence of fever should not be obscured by the indiscriminate use of antipyretic measures. However, if the child is uncomfortable or appears to-ic because of fever, an attempt should be made to reduce it by any of the following nursing measures or by a combination of these measures+ %ncrease the child)s fluid inta#e to prevent dehydration. /-pose the s#in to the air by leaving the child lightly dressed in absorbent material. "void warm, binding clothing and blan#ets. "dminister antipyretic drugs as prescribed. Use a tub bath or a hypothermia blan#et. A4MINISTERING ME4ICATIONS TO CHIL4REN "dministration of medication is usually traumatic for children. The proper approach to administration can facilitate the process and enhance the child)s understanding of the importance of ta#ing medications. Im-ortant Considerations The manner of approach should indicate that the nurse firmly e-pects the child to ta#e the medication. This manner usually convinces the child of the necessity of the procedure. /stablishing a positive relationship with the child will allow e-pression of feelings, concerns, and fantasies regarding medications. /-planation about medication should appeal to the child)s level of understanding &ie, through play or comparison to something familiar'. The nurse must mas# her own feelings regarding the medication. "lways be truthful when the child as#s, JDoes it taste badPK or JCill it hurtPK 0espond by saying, JThe medication does not taste good, but % will give you some @uice as soon as you swallow it,K or J%t will hurt for @ust a minute.K %t is typically necessary to mi- distasteful medications or crushed pills with a small amount of carbonated drin#, cherry syrup, ice cream, or applesauce.

!ever threaten a child with an in@ection when refusing oral medication. Do not mi- medications with large .uantities of food or with any food that is ta#en regularly &eg, mil#'. "void giving medications to a child at mealtime unless specifically prescribed. *or each medication administered, the nurse should #now the common use, safe dosage based on the child)s weight, contraindications, adverse effects, and to-ic effects. The child must be accurately identified before medication is given. Chen preparing %.1. in@ections, draw 6.5 cc of air into the syringe, in addition to the correct amount of medication. This clears the medication from the needle on in@ection and prevents bac#flow and the depositing of medication in subcutaneous fat when the needle is withdrawn.

Calc latin1 t"e Pediatric 4osa1e General Princi-les The nurse is responsible for #nowing the safe dosage range for the medication she administers. 8actors determinin1 t"e amo nt o! dr 1 -rescri2ed incl de, o "ction of the drug, absorption, deto-ification, and e-cretion are related to the maturity and metabolic rate of the child. o !eonates and premature neonates re.uire a reduced dosage because of+ Deficient or absent deto-ifying enzymes. Decreased effective renal function. "ltered blood-brain barrier and protein-binding capacity. o Dosage recommendations based on age-groups are not satisfactory because a child may be much smaller or larger than the average child in the age-group. o Dosages based on child)s weight are more accurate, however, these calculations have limitations. 2e alert to a prescription that would be inappropriate for a child. (onsult drug literature for recommended dosage and other information. Calc latin1 2y 6ody S r!ace Area The following formulas are used to estimate the pediatric dosage based on the child)s body surface area &2 "'. 2 " calculations are generally preferred because many physiologic processes in the child &eg, blood volume, glomerular filtration' are related to 2 ". urface area in s.uare meters Q Dose per s.uare meter R "ppro-imate child dose. urface area of child9surface area of adult Q Dose of adult R "ppro-imate child dose. urface area of child in s.uare meters9;.3< Q "dult dose R (hild dose. Calc latin1 2y Clar5=s R le (lar#)s rule may be used as an estimate of the pediatric dosage based on the child)s weight in respect to the adult dose of the drug+

(hild)s weight in pounds9;<6 Q "dult dose R "ppro-imate dose for child. NURSING ALERT Ens re -ro-er identi!ication o! all -atients &ia t"e identi!ication 2racelet 2e!ore administration o! medication3 Oral Medications In!ants Draw up medication in a plastic dropper or disposable syringe. /levate infant)s head and shoulders, depress chin with thumb to open mouth. Place dropper or syringe on the middle of the tongue and slowly drop the medication on the tongue. 0elease thumb, and allow the child to swallow. Chen the correct amount of medication has been measured, it can be placed in a nipple and the infant can suc# the medication through the nipple. %f the nurse feels comfortable managing the infant in her lap, it is acceptable to hold the infant for medication administration. Toddlers Draw up li.uid medications in a syringe or measure into medicine cup. 1edications may be placed in a medicine cup or spoon after being measured accurately in a syringe. /levate the child)s head and shoulders. .ueeze the cup and put it to the child)s lips, or place the syringe &without needle' in the child)s mouth, positioning the syringe tip in the space between the chee# mucosa and gum, and slowly e-pel the medicine. (hild may prefer using a familiar teaspoon. "llow the child time to swallow. "llow the child to hold the medicine cup if able and to drin# it at his own pace. &This may be a more agreeable method.' Effer a favorite drin# as a Jchaser,K if not contraindicated. The small, safe medicine cups can be given to the child for play. Sc"ool;A1e C"ildren Chen a child is old enough to ta#e medicine in pill or capsule form, teach the child to place the pill near the bac# of the tongue and immediately swallow fluid such as water or fruit @uice. %f swallowing of the fluid is emphasized, the child will no longer thin# about the pill. "lways praise a child after he ta#es medication. %f the child finds it particularly difficult to ta#e oral medications, e-press understanding and offer help. Intram sc lar Medications General Considerations !or Intram sc lar In$ections

"fter the medication is drawn from the vial, draw up an additional 6.5 to 6.D cc of air into the syringe, thus clearing the needle of medication and preventing medication seepage from the in@ection site. Chen in@ecting less than ; mF of medication, use a tuberculin syringe for accuracy. (lean site thoroughly, using friction with an antiseptic solution, let site dry. /stablish anatomic landmar#s. "lternate in@ection sites, and #eep record at bedside or on medication card.

Sites !or I3M3 in$ections in c"ildren, %A* rect s !emoris0 %6* deltoid0 %C* &entro1l teal3 "fter penetrating site, aspirate to chec# for blood vessel puncture. %f this occurs, withdraw the needle, and discard the medicine, and start again. "fter in@ection, massage site &unless contraindicated'. The complication of fibrosis and contracture of the muscle can be diminished by massage, warm soa#s, and range-of-motion e-ercises to disrupt and stretch immature scar tissue when multiple in@ections are being administered.

In!ants "cceptable sites include the rectus femoris &mid anterior thigh', vastus lateralis &middle third', or ventrogluteal. These are relatively free from ma@or nerves and blood vessels. The gluteus ma-imus and deltoid muscles are underdeveloped in the infant, and use of these sites can result in nerve damage. Rect s !emoris in$ection3 o Place the child in a secure position to prevent movement of the e-tremity. o Do not use a needle longer than ; inch. o Use upper .uadrant of the thigh. o %nsert needle at 7<-degree angle in a downward direction, toward the #nee. #ast s lateralis in$ection3 o Place the child in a prone or supine position.

"rea is a narrow strip of muscle e-tending along a line from the greater trochanter to lateral femoral condyle below. o %nsert needle perpendicular to s#in, S to ;T inches &5 to 7 cm' deep: needle parallel to floor. #entro1l teal in$ection3 o This site provides a dense muscle mass that is relatively free from the danger of in@uring the nervous and vascular systems. o The disadvantage is that the in@ection site is visible to the child. o "dministration. Place the child on his bac#. Place the inde- finger on the anterosuperior spine. Cith the middle finger moving dorsally, locate the iliac crest, drop finger below the crest. The triangle formed by the iliac crest, indefinger, and middle finger is the in@ection site. %n@ect needle perpendicular to the surface on which the child is lying. "fter administration of medication, hold and cuddle the infant.
o

Toddlers and Sc"ool;A1e C"ildren Postero1l teal in$ectionC --er o ter q adrant o >luteal muscles do not develop until a child begins to wal#, they should be used only when the child has been wal#ing for ; year or more. (omplications include sciatic nerve in@ury or subcutaneous in@ury &due to medication being in@ected' and poor absorption. o Upper outer .uadrant of the young child)s buttoc# is smaller in diameter than that of an adult, thus accuracy in determining the area comprising the upper outer .uadrant is essential. o "dministration Do not use a needle longer than ; inch. Position the child in a prone position. Place thumb on the trochanter. Place middle finger on the iliac crest. Fet inde- finger drop at a point midway between the thumb and middle finger to the upper outer .uadrant of the buttoc#. This is the in@ection site. %nsert needle perpendicular to the surface on which the child is lying, not to the s#in. #entro1l teal in$ection o 1ay be used for the older child who is difficult to restrain. o ee description and administration. 4eltoid in$ection o 1ay be used for older, larger children. o %naccurate site in@ection can result in damage to the radial nerve or brachial artery.

Determine in@ection site by palpating the acromion process of the shoulder and imagining an inverted triangle 5T to < fingerbreadths down from the acromion process. o %n@ect needle perpendicular to s#in S to ;;9? inches &5 to D cm' deep. Lateral and anterior as-ect o! t"e t"i1" o Do not use a needle longer than ; inch. o Use the upper outer .uadrant of the thigh. o %nsert needle at 7<-degree angle in a downward direction, toward the #nee. N rsin1 s --ort o! toddlers and older c"ildren o Prepare all e.uipment before approaching the child. o /-plain to the child where you are going to give the in@ection &site' and why you are giving it. o "llow the child to e-press his fears. o (arry out the procedure .uic#ly and gently. Have needle and syringe completely prepared and ready before contact with the child. o !umb the site of in@ection by rubbing the s#in firmly with cleaning swab or with ice &older children may assist with this'. 1inimize pain of an %.1. in@ection by in@ecting the needle into the muscle with a .uic#, darting motion. o "lways secure the assistance of a second nurse to help immobilize the child and divert his attention as well as to offer support and comfort. o Praise the child for behavior after the in@ection. "llowing the child to assist with applying a 2and-"id will give some feeling of comfort. o "lso encourage activity that will use the muscle site of the in@ection: promotes dispersal of medication and decreases soreness. This can also be done by firmly massaging the muscle after in@ection, unless contraindicated. o "ccurately record the in@ection site to ensure proper site rotation.
o

Intra&eno s Medications "dministration of %.$. medications may be done through a variety of techni.ues, including piggybac#, through a heparin loc#, through a volume control set, or through an implantable port. ee pages ?7 and ?< for information on these techni.ues. Prepare mi-tures aseptically &laminar-flow hood', and use sterile techni.ue when accessing the %.$. line. & epsis is a constant threat when a child is receiving %.$. medications.' 2e aware that an e-aggerated pharmacologic effect may e-ist with %.$. medications. "s with any medication, #now the use, adverse effects, and to-ic effects of the drug as well as the pharmacologic effect on the body. Dilute %.$. medications and in@ect slowly:never less than ; minute &this allows peripheral blood flow through the entire circulating system to dilute the medication and prevent high concentrations of the drug from reaching the brain and heart'. 2e #nowledgeable about compatibilities of drugs, electrolytes in %.$. solutions, and the fluid itself.

Ebserve the %.$. site fre.uently. 0estrain the child, as needed, to prevent infiltration. %nfiltration of fluids containing medications can cause rapid and severe tissue necrosis.

SPECIAL CONSI4ERATIONS IN PE4IATRIC PRIMARB CARE ACUTE POISONING /-posure to poisons can occur by ingestion, inhalation, or s#in or mucous membrane contact. This section focuses on the most common poisoning, to-ic ingestions. Poisoning by ingestion refers to the oral inta#e of a harmful substance that, even in a small amount, can damage tissues, disturb body functions and, possibly, cause death. The substances may include such medications as acetaminophen and iron, household products, and plants. (hildren are at ris# for acute poisoning. "ccording to the "merican "ssociation of Poison (ontrol (enters, in 5665, 8<.3H of the ;.< million reported poisoning cases occurred in children younger than age 56 years, over one-half &<5H' of these cases occurred in children younger than age 8 years. 1ore than G6H of poison e-posures occur in the home. The most common agents ingested by children younger than age 8 years are cosmetics and personal care products, cleaning products, analgesics, plants, and cough and cold medications. Pat"o-"ysiolo1y and Etiolo1y %mproper or dangerous storage of potentially to-ic substances. Poor lighting:causes errors in reading. H man !actors, o *ailure to read label properly. o *ailure to return poisons to their proper place. o *ailure to recognize the material as poisonous. o Fac# of supervision of the child. o Purposeful use of poison. To-in is ingested and may have limited local effects or continue to a stage of absorption and interference with metabolic processes and organ function. Typically occurs in children younger than age 8 years, with a pea# incidence between ;5 and 57 months. "cute poisoning may result in arrhythmias or permanent multiorgan damage due to initial loss of airway, breathing, circulation, and specific organ to-icity. Poisonin1 7it" Acetamino-"en "cetaminophen is a common drug-poisoning agent in children due to its replacement of salicylates. %ngestion by adolescents is fre.uently intentional. "cetaminophen is to-ic to the liver, resulting in cell necrosis and possibly cell death. Clinical Mani!estations P"ase I %!irst DE "o rs a!ter in1estion* 1ay be asymptomatic.

"nore-ia. !ausea and vomiting. Diaphoresis. 1alaise. Pallor.

P"ase II %DE to E) "o rs a!ter in1estion* ymptoms of phase % diminish or disappear. 0ight upper .uadrant pain due to liver damage. Fiver enlargement with elevated bilirubin and hepatic enzymes and prolonged prothrombin time. Eliguria. P"ase III %days ? to F a!ter in1estion* igns of hepatic failure, such as @aundice, hypoglycemia, coagulopathy, and encephalopathy. Pea# liver function abnormalities. "nore-ia, nausea, vomiting, and malaise may reappear. 0enal failure and cardiomyopathy may occur. P"ase I# "ssociated with recovery or progression to complete liver failure and death. 4ia1nostic E&al ation erum acetaminophen level 7 hours after ingestion. erial liver function tests. Urine and serum chemistry studies for renal function. Mana1ement "ctivated charcoal should be given if treatment is instituted within 8 to ? hours after ingestion, if treatment is begun after this time frame, activated charcoal is not used unless another to-ic substance was ingested. !-"cetylcysteine &1ucomyst' as an antidote given orally or %.$. This is the most e-tensively studied regimen for acetaminophen overdose. "s with all poisons, airway, breathing, circulation &"2(s', and treatment of shoc# are always the priority in management. Iron Poisonin1 %ron poisoning occurs fre.uently in childhood due to the prevalence of iron-containing preparations. The severity of iron poisoning is related to the amount of elemental iron absorbed. The range of potential to-icity is between <6 and 86 mg9#g. Clinical Mani!estations ?@ min tes to D "o rs a!ter in1estion, o Focal necrosis and hemorrhage of >% tract. o !ausea and vomiting, including hematemesis.

"bdominal pain. Diarrhea, usually bloody. evere hypotension. ymptoms subside after 8 to ;5 hours. G to DE "o rsC-eriod o! a--arent reco&ery3 DE to E@ "o rs, o ystemic to-icity with cardiovascular collapse, shoc#, hepatic and renal failure, seizures, coma and, possibly, death. o 1etabolic acidosis. D to E 7ee5s a!ter in1estion, o Pyloric and duodenal stenosis. o Hepatic cirrhosis.
o o o o

4ia1nostic E&al ation Meas rement o! ser m !ree iron3 o Total serum iron. o Total serum iron-binding capacity. o "bdominal O-ray to visualize iron tablets. Mana1ement >astric lavage. "dministration of defero-amine &Desferal' for severe cases:iron chelating agent that binds with iron and is e-creted in urine &urine will be bright red'. Primary Assessment in Ac te Poisonin1 Initial assessment s"o ld incl de A6Cs e&al ation0 le&el o! conscio sness0 &ital si1ns0 and ne rolo1ic assessment3 Assess !or sym-tomatic e!!ects o! -oisonin1 2y systems3 o >%:common in metallic acid, al#ali, and bacterial poisoning. These may include nausea and vomiting, diarrhea, abdominal pain or cramping, and anore-ia. o (! :may include seizures &especially with (! depressants, such as alcohol, chloral hydrate, barbiturates' and behavioral changes. Dilated or pinpoint pupils may be noted. o #in:rashes, burns to the mouth, esophagus and stomach, eye inflammation, s#in irritations, stains around the mouth, lesions of the mucous membranes. (yanosis may be visible, especially with cyanide and strychnine. o (ardiopulmonary:dyspnea &especially with aspiration of hydrocarbons' and cardiopulmonary depression or arrest. o Ether:odor around the mouth. Identi!y t"e -oison 7"en -ossi2le3 o Determine the nature of the ingested substance from the child)s history or by reading the label on the container. !ursing intervention may need to be implemented immediately after this assessment.

(all the nearest poison control center or to-icology section of the medical e-aminer)s office to identify the to-ic ingredient and obtain recommendations for emergency treatment. ave vomitus, stool, and urine for analysis when the child reaches the hospital.

NURSING ALERT It may 2e necessary to initiate emer1ency res-iratory and circ latory s --ort at t"is time3 I! needed0 o2tain &eno s access0 maintain sa!ety d rin1 sei+ re acti&ity0 and treat s"oc53 Ot"er7ise0 contin e 7it" assessment3 Primary Inter&entions Assistin1 t"e 8amily 2y Tele-"one Mana1ement Calmly o2tain and record t"e !ollo7in1 in!ormation, o !ame, address, and telephone number of caller. o /valuation of the severity of the ingestion. o "ge, weight, and signs and symptoms of the child, including neurologic status. o 0oute of e-posure. o !ame of the ingested product, appro-imate amount ingested, and time of ingestion. o 2rief past medical history. o (aller)s relationship to victim. %nstruct the caller about appropriate emergency actions. Direct the patient to the nearest emergency department. Dispatch an ambulance if necessary. %nstruct the caller to clear the child)s mouth of any unswallowed poison. %dentify what treatments have already been initiated. %nstruct the parents to save vomitus, unswallowed li.uid or pills, and the container and to bring them to the hospital as aids in identifying the poison. %dentify whether other children were involved in the poisoning to initiate treatment for them also. %f treatment is at home, follow-up phone calls should be made at D6 minutes, ; hour, and 7 hours after e-posure. Inter&ention Related to t"e Patient=s Condition S --ort A6Cs as needed3 Remo&in1 t"e Poison !rom t"e 6ody ;. %f the poison is non-pharmaceutical, have the child drin# ;66 to 566 mF of water. %f a medication was ingested, do not dilute with water, as this may speed absorption. 5. *or s#in or eye contact, remove contaminated clothing and flush with water for ;< to 56 minutes. D. *or inhalation poisons, remove from the e-posed site.

<. "dminister gastric lavage. &This is indicated when vomiting is undesirable or impossible because of the child)s condition or age, when induction of vomiting has been unsuccessful, or when the poison is one that is rapidly absorbed Aeg, cyanideB.' 8. *ollow lavage with a cathartic and activated charcoal to hasten removal of the poison from the >% tract. Use cautiously with young children. H3 6e a7are o! t"e dan1ers associated 7it" la&a1e3 o /sophageal perforation:may occur in corrosive poisoning. o >astric hemorrhage. o %mpaired pulmonary function resulting from aspiration. o (ardiac arrest. o eizures:may result from stimulation in strychnine ingestion.

4RUG ALERT 4o not administer "o se"old ne trali+in1 !oods or -rod cts % nless recommended 2y -oison control s-ecialist* 2eca se t"e "eat 1enerated 2y t"e c"emical reaction co ld res lt in a 2 rn %or e>acer2ation o! an e>istin1 2 rn*3 Red cin1 t"e E!!ect o! t"e Poison 2y Administerin1 an Antidote "n antidote may either react with the poison to prevent its absorption or counteract the effects of the poison after its absorption. !ot all poisons have specific antidotes. %nformation about appropriate antidotes for specific poisons is available through all poison control centers. "ntidotes for the most common poisons should be listed in the emergency department of the hospital. /ffectiveness of the antidote usually depends on the amount of time that elapses between ingestion of the poison and administration of the antidote. "ctivated charcoal absorbs all poisons e-cept cyanide, if given within ; hour of poisoning and after vomiting has occurred, in a dose of D6 to <6 g in a child and <6 to ;66 g in an adolescent in 8 to ? ounces &;33 to 5D8 mF' of water with sweetener. Eliminatin1 t"e A2sor2ed Poison 8orce di resis3 o "dminister large .uantities of fluid either orally or %.$. o (arefully monitor inta#e and output. "ssist with #idney dialysis, which may be necessary if the child)s #idneys are not functioning effectively. "ssist with e-change transfusion if this method is indicated for removing the poison. Pro&idin1 Emotional S --ort 0emain calm and efficient while wor#ing rapidly. 0eassure the child and his family that therapeutic measures are being ta#en immediately.

Discourage an-ious parents from holding, caressing, and overstimulating the child.

S 2seq ent N rsin1 Assessment and Inter&entions O2ser&in1 t"e C"ild !or Pro1ression o! Sym-toms CNS in&ol&ement o Ebserve for restlessness, confusion, delirium, seizures, lethargy, stupor, or coma. o "dminister sedation with caution:to avoid (! depression and mas#ing of symptoms. o "void e-cessive manipulation of the child. o ee nursing care of the child with seizures o ee nursing care of the unconscious patient Res-iratory in&ol&ement o Ebserve for respiratory depression, obstruction, pulmonary edema, pneumonia, or tachypnea. o Have artificial airway and tracheostomy set available. o 2e prepared to administer o-ygen and provide artificial respiration. o Ether nursing concerns+ !ursing care for mechanical ventilation. Procedures for administration of o-ygen Procedure for cardiopulmonary resuscitation Cardio&asc lar in&ol&ement o Ebserve for peripheral circulatory collapse, disturbances of heart rate and rhythm, or heart failure. o 1aintain %.$. therapy as directed to prevent shoc#. "ssess for complications of overhydration. o 2e prepared for cardiac arrest. GI in&ol&ement o Ebserve for nausea, pain, abdominal distention, and difficulty swallowing. o 1aintain %.$. therapy to replace water and electrolyte losses. o Effer a diet that is easily swallowed and digested. 2egin with clear li.uids. Progress to full li.uids, soft foods, and then a regular diet as the child)s condition improves. Aidney in&ol&ement o Ebserve the child for decreased urine output. 0ecord oral and %.$. inta#e and urine output e-actly. o Ebserve for hypertension. o %nsert indwelling catheter if necessary for urinary retention. o "dminister appropriate amounts of fluids and electrolytes. o ee nursing care of child with renal failure o (orrect and monitor acid-base balance. Pro&idin1 S --orti&e Care

1aintain ade.uate caloric, fluid, and vitamin inta#e. Eral fluids are preferable if they can be retained. "void hypothermia or hyperthermia. &(ontrol of body temperature is impaired in many types of poisoning.' 1onitor the child)s temperature fre.uently. O2ser&e closely !or in!lammation and tiss e irritation3 o This is especially important in ingestion of #erosene or other hydrocarbons, which cause chemical pneumonitis. o %solate the patient from other children, especially those with respiratory infections. o "dminister antibiotics as prescribed by the physician. Co nsel -arents 7"o ty-ically !eel 1 ilty a2o t t"e accident3 o /ncourage parents to tal# about the poisoning. o /mphasize how their .uic# action in getting treatment for the child has helped. o Discuss ways that they can be supportive to their child during the hospitalization. o Do not allow prolonged periods of self-incrimination to continue. 0efer parents to a psychologist for assistance in resolving these feelings if necessary. In&ol&e t"e yo n1 c"ild in t"era-e tic -lay to determine "o7 "e &ie7s t"e sit ation3 o The child commonly sees nursing measures as punishments for misdeed involving the poisoning. o /-plain treatment and correct misinterpretations in a manner appropriate for child)s age. %nitiate a community health nursing referral for any childhood poisoning incident. " home assessment should be made to identify problems and provide proper poisoning prevention interventions and education.

8amily Ed cation and Healt" Maintenance Stressin1 Pre&ention In!ormation concernin1 -oison -re&ention s"o ld 2e a&aila2le on e&ery "os-ital -ediatric nit and d rin1 e&ery c"ild "ealt" care &isit3 o 1any free boo#lets and home safety chec#lists are available from such sources as insurance companies and drug companies. o Teaching may be done with any parent regardless of the reason for the child)s hospitalization or office visit. Teac" t"e !ollo7in1 -reca tions, o Ieep medicines and poisons out of the reach of children. o Provide loc#ed storage for highly to-ic substances, select cabinet that is higher than child can reach or climb. o Do not store poisons in the same areas as foods. o 1a#e sure all containers are properly mar#ed and labeled. Ieep medicines, drugs, and household chemicals in their original containers.

Do not discard poisonous substances in receptacles where children can reach them, however, do discard used containers of poisonous substances. o Teach children not to taste or eat unfamiliar substances. o (lean out medicine cabinets periodically. o Ieep medications in childproof containers that are securely closed. o 0ead all labels carefully before each use. o Do not give medicines prescribed for one child to another. o !ever refer to drugs as candy or bribe children with such inducements. o !ever give or ta#e medications in the dar#. o /ncourage parents not to ta#e medication in front of young children because children role-play adult behavior. o uggest that mothers avoid #eeping medications in their purses or on the #itchen table. o Ieep baby creams and ointments away from young children. o !ever puncture or heat aerosol containers. o tore lawn and garden pesticides in a separate place under loc# and #ey outside of the house, do not store large .uantities of cleaning products or pesticides. "dvise parents to dispose of syrup of ipecac if they #eep it in the household. "ccording to the "merican "cademy of Pediatrics, there is no evidence supporting improved outcomes of poisonings with the use of ipecac. %n addition, there is potential for abuse of ipecac with bulimic or anore-ic teenagers, therefore, the recommendation for #eeping ipecac on hand to induce vomiting has been rescinded. Tell family to #eep a list of emergency telephone numbers including the poison control center, health care provider)s number, nearest hospital, and ambulance service. 0einforce the need for vigilance and consistent supervision of infants and young children due to their increased mobility, increased curiosity, and increased de-terity.
o

Teac"in1 Emer1ency Actions uspect poisoning with the occurrence of sudden, bizarre symptoms or peculiar behavior in toddlers and preschoolers. 0ead label on the ingested product, or call the health care provider, hospital, or poison control center for instructions about treatment for the poisoning. >ive all relevant information about the child, condition, and substance ingested. 1aintain an ade.uate airway in a child who is convulsing or who is not fully conscious. Dilute the poison with ;66 to 566 mF of water if advised. Trans-ort t"e c"ild -rom-tly to t"e nearest medical !acility3 o Crap the child in a blan#et to prevent chilling. o 2ring the container and any vomitus or urine to the hospital with the child. "void e-cessive manipulation of the child. "ct promptly but calmly.

Do not assume the child is safe simply because the emesis shows no trace of the poison or because the child appears well. The poison may have produced a delayed reaction or may have reached the small intestine where it is still being absorbed.

LEA4 POISONING There are appro-imately ; million children with elevated blood lead levels &U ;6 mg9dF' in the United tates. Fead poisoning, referred to as plumbism, results from some form of lead consumption. 2lood lead levels that e-ceed ;6 mg9dF can affect intellectual functioning in children. 1illions of children live in housing built before ;G<6, which contains the highest surface soil level and internal household dust contaminated with lead. !ormal hand-to-mouth activities of children may introduce leaded household dust, soil, and nonfood items into their >% tract. Pica &eating nonfood substances, particularly leaded paint chips' is generally associated with more severe degrees of poisoning. Pat"o-"ysiolo1y and Etiolo1y Etiolo1ic 8actors M lti-le e-isodes o! c"e7in1 on0 s c5in10 or in1estion o! non!ood s 2stances3 o Toys, furniture, windowsills, household fi-tures, and plaster painted with lead-containing paint. o (igarette butts and ashes. o "cidic @uices or foods served in lead-based earthenware pottery made with lead glazes. o (olored paints used in newspapers, magazines, children)s boo#s, matches, playing cards, and food wrappers. o Cater from lead pipes. o *ruit treated with insecticides. o Dirt containing lead fallout from automobile e-haust. o "nti.ue pewter, especially when used to serve acidic @uices or foods. o Fead weights &curtain weights, fishing sin#ers'. o (ontinuous pro-imity to lead-processing center. o Eccupations or hobbies that use lead. o %mported fol# remedies, cosmetics, food, or coo#ware that contain lead. In"alation o! ! mes containin1 lead %less common ca se in c"ildren*3 o Feaded gasoline. o 2urning storage batteries. o Dust containing lead salts. o Dust in the air at shooting galleries and in enclosed firing ranges with poor ventilation. o (igarette smo#e. Hi1"est incidence in c"ildren 2et7een a1es ' and G years0 es-ecially t"ose 2et7een a1es ' and ? years3 o High incidence in individuals living in old homes or deteriorated housing conditions. o !o significant difference in incidence by se-.

High incidence among siblings. ymptomatic lead poisoning occurs most fre.uently in summer months.
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NURSING ALERT Le1islation sti- lates t"at toys0 c"ildren=s ! rnit re0 and t"e interior o! "omes 2e -ainted 7it" lead;!ree -aint: "o7e&er0 t"e -ro2lem arises 7"en dee-er layers o! -aint and -laster on older -rod cts are contaminated 7it" lead3 One -aint c"icontains m c" more lead t"an is considered sa!e3 Systemic E!!ects Fead absorption from >% tract is affected by age, diet, and nutritional deficiency. Noung children absorb 76H to <6H and retain 56H to 5<H of dietary lead. %t ta#es the body twice as long to e-crete lead as it does to absorb lead. Lead is stored in t7o -laces in t"e 2ody, o 2one. o oft tissue. Principal to-ic effects occur in nervous system, bone marrow, and #idneys. Ner&o s system3 o 2rain:increased capillary permeability results in edema, increased intracranial pressure, and vascular damage, destruction of brain cells causes seizures, mental retardation, paralysis, blindness, and learning disabilities. o !eurologic damage cannot be reversed. o (! of young children and fetuses is most sensitive to lead. 6one marro73 o Fead attaches to red blood cells &02(s'. o %nhibition of a number of steps in the biosynthesis of heme, thus reducing the number of 02(s, increasing fragility, and reducing half-life. o The decreased production of hemoglobin results in anemia and respiratory distress. Iidneys:in@ury to the cells of the pro-imal tubules, causing increased e-cretion of amino acids, protein, glucose, and phosphate. 0ecurrence rate is high, especially if the lead is not removed from the home environment. Clinical Mani!estations ymptoms in young children may develop insidiously and may abate spontaneously. GI:anore-ia, sporadic vomiting, intermittent abdominal pain &colic', constipation. CNS:hyperirritability, decreased activity, personality changes, loss of recently ac.uired developmental s#ills, falling, clumsiness, loss of coordination &ata-ia', local paralysis, peripheral nerve palsies. Hematolo1ic:anemia, pallor. Cardio&asc lar:hypertension, bradycardia.

Diagnostic /valuation Detailed history with emphasis on the presence or absence of clinical symptoms, evidence of pica, family history of lead poisoning, possible source of e-posure to lead, recent change in behavior, developmental delay, or behavior problems, recent change of address, or recent renovations in the home. "ssess serum lead level and repeat confirmatory levels. Screenin1 !or Ele&ated 6lood Lead Le&els 6LOO4 CON8IRMATORB ACTION %I8 STILL <ITHIN REPEAT LEA4 6LL RANGE A8TER 6LL LE#EL CON8IRMATORB TEST* %6LL* I1JdL K '@ !one !o action re.uired. !one '@;'E Cithin ; month Provide education to decrease D months. e-posure. 'F;'( Cithin ; month Do environmental history, Cithin 5 educate on decreasing e-posure months. to and absorption of lead. D@;EE Cithin ; wee# "ll of the above for ;<-;G PFU !ot specified perform medical history and in guidelines. physical e-amination, detailed "t the environmental investigation with discretion of lead hazard reduction referrals the health care for social9community support. provider. EF;G( Cithin 5 days "ll of the above for 56-77 PFU !ot specified begin chelation therapy. in guidelines. "t the discretion of the health care provider. LH@ %mmediately "ll of the above for 7<-8G PFU !ot specified hospitalize. in guidelines. "t the discretion of the health care provider. "dapted from "merican "cademy of Pediatrics &;GG?'. creening for elevated blood levels. o 0epeat ;6 to ;G Vg9dF in D months, 56 to 77 Vg9dF in ; to 7 wee#s, 7< to <G Vg9dF in 7? hours, 86 to 8G Vg9dF in 57 hours, U 36 Vg9dF immediately. Hematologic evaluation for iron deficiency anemia. *lat plate of abdomen:may reveal radiopa.ue material if lead has been ingested during the preceding 57 to D8 hours. /rythrocyte protoporphyrin level:not sensitive enough for identifying lead levels below 5< mg9dF. (an be used to follow levels after medical and environmental

interventions for poisoned children have occurred. " progressive decline in erythrocyte protoporphyrin levels indicates that management is successful. 57-hour urine:more accurate than a single voided specimen in determining elevated urinary components that correspond with elevated blood lead levels. 0adiologic e-amination of long bones:unreliable for diagnosis of acute lead poisoning, may provide some indication of past lead poisoning or length of time poisoning has occurred. /detate calcium disodium provocation chelation test:used only in selected medical centers treating large numbers of lead-poisoned children, demonstrates increased lead levels in urine over an ?-hour period after in@ection of edetate disodium.

Mana1ement Remo&al o! Lead !rom t"e En&ironment 0emove leaded paint and paint chips or ob@ects containing lead from the child)s environment. 0emove child from environment during lead abatement process. N tritional Considerations (onsume ade.uate amounts of iron. %ron supplementation may be indicated to correct anemia. 0educed fat diet and small fre.uent meals will reduce the >% absorption of lead. /ncourage foods high in vitamin ( &such as fruits and @uices' and calcium &such as mil#, yogurt, and ice cream'. C"elation T"era-y (helation therapy is indicated in children with blood lead levels &2FF' between 7< and 36 Vg9dF. (hildren with 36 2FF or higher levels should be hospitalized immediately and started on the most aggressive chelation therapy available. /thylenediaminetetraacetic acid &/DT"', 2ritish anti-Fewisite &2"F', and succimer &(hemet' bind with lead in the blood to form nonto-ic compounds that are e-creted by the bowel and #idneys. /ffectiveness of therapy depends on degree and duration of lead poisoning. 6AL is 1i&en !irst to red ce t"e ris5 o! sei+ res3 o Used alone in patients with encephalopathy. o (ontraindicated in children with peanut allergies, those on iron therapy, and those with hepatic insufficiency. o "void in patients with glucose-8-phosphate dehydrogenase &>8PD' deficiency due to potential for hemolysis. o "dministered deep %.1.:results in pain and tissue necrosis at the in@ection site. o 1onitor for adverse effects including hypersensitivity reactions, hyperpyre-ia, tachycardia, hypertension, transient elevations of hepatic transaminases, nausea and vomiting, headache, con@unctivitis, lacrimation, rhinorrhea, salivation, and unpleasant urine and breath odor. E4TA

1ay be to-ic to the #idneys, therefore, monitor urinary output as well as renal and liver function studies. o "dminister %.$. C"emetCa--ro&ed !or se in '(('3 o !ot given to patients with encephalopathy, receiving iron therapy, and if there is ongoing e-posure to lead. o "dminister orally. o 1onitor hepatic transaminases, blood urea nitrogen, serum creatinine, (2( with differential, and occasional urinalysis. Dosage:depends on individual drug, the child)s weight, severity of poisoning, prior history, and whether other chelating agents are being used simultaneously. (helating drugs are usually given every 7 hours for < days. " second course of therapy may be needed if there is a rebound in the blood lead level. %ncreased oral and %.$. fluids are given to enhance e-cretion, e-cept if increased intracranial pressure is present. d-Penicillamine &(uprimine', another drug that chelates heavy metals, may be given for long-term chelation only if current e-posure to lead is definitely e-cluded. This is a third line agent and not usually used due to the high incidence of allergic reactions. %f this drug is used, it should be given on an empty stomach, 5 hours before brea#fast.
o

Additional Treatment upplemental calcium, phosphorus, and vitamin D to help lead move from the blood &where it is to-ic' to the bones &where it is nonto-ic'. *or the child with encephalopathy, corticosteroids are given and intensive care management is maintained until the acute stage is resolved. Com-lications evere and usually permanent mental, emotional, and physical impairment. !eurologic deficits. o Fearning disabilities. o 1ental retardation. o eizures. o /ncephalopathy. N rsin1 Assessment Parta5e in -rimary -re&ention t"ro 1" screenin1 !or lead -oisonin1Cs"o ld tar1et "i1";ris5 1ro -s3 T"is incl des c"ildren, o Cho live in homes built before ;G<6. o Cith iron deficiency anemia. o Cho are e-posed to contaminated dust or soil. o Cho have developmental delays. o Cho are victims of abuse or neglect. o Chose parents are e-posed to lead. o Cho live in low-income families.

"lso targeted screening of children who live in communities with more than 53H of houses built before ;G<6 or in populations where ;5H or more of the children have elevated lead levels. "ssess all children for signs of lead to-icity, including hyperactivity, developmental delay, constipation, anore-ia, colic#y abdominal pain, clumsiness, and pallor. %n.uire about presence of pica behavior in children younger than age 8 years. "ssess the child)s level of development. The Denver Developmental creening Test %% &DD T%%' may be useful for this purpose and will help detect delays possibly caused by lead poisoning.

N rsin1 4ia1noses 0is# for %n@ury related to seizures and encephalopathy "cute Pain related to chelation therapy in@ections Delayed >rowth and Development related to the effects of chronic lead e-posure (ompromised *amily (oping related to guilt and concern for child N rsin1 Inter&entions Protectin1 t"e C"ild 7it" Sei+ res and Ence-"alo-at"y Maintain sei+ re -reca tions3 o (rib or bed rails elevated and padded. o Tongue blade and suction e.uipment at bedside. 6e a7are t"at ence-"alo-at"y may occ r E to G 7ee5s a!ter !irst sym-toms, o udden onset of persistent vomiting. o evere ata-ia. o "ltered state of consciousness. o (oma. o eizures. o 1assive cerebral edema in younger children. O2ser&e !or si1ns o! increased intracranial -ress re %ICP* in t"e c"ild 7it" ence-"alo-at"y, o 0ising blood pressure. o Papilledema. o low pulse. o eizures. o Unconsciousness. Provide supportive care to maintain vital functions. Red cin1 Pain Associated 7it" C"elation T"era-y Plan appropriate play activities to prepare the child for the in@ections and as an outlet for the pain and anger the child feels. %mplement measures to decrease pain at in@ection site. o 0otate in@ection sites. o "pply warm pac#s to the site to decrease pain. o 1ove painful areas slowly. Provide diversion activities, fluids, and meals between in@ections.

1onitor inta#e and output and blood studies, such as electrolytes and liver and renal function tests, as directed.

Promotin1 Gro7t" and 4e&elo-ment Provide and encourage activities that will help the child to learn and progress from his present developmental state to meet the ne-t appropriate milestone. %nitiate appropriate referrals in cases of obvious developmental delays or learning difficulties. The referrals may be to such professionals as psychologists, psychiatrists, and specialists in early child education. hare the results of developmental testing with the parents, and discuss ways to provide stimulation for the child at home. Stren1t"enin1 8amily Co-in1 Use sensitivity in interviewing and teaching to avoid causing or increasing guilt feelings about the poisoning and to establish a positive, trusting relationship between the family and the health care facility. /-plain the treatment and its purpose because parents are commonly faced with putting an asymptomatic child through painful treatments. /ncourage fre.uent visits by parents and siblings, and facilitate family involvement. Comm nity and Home Care Considerations (arry out lead screening in the community. %t is recommended that all high-ris# children be screened for high lead levels between ages G and ;5 months and, if feasible, again at 57 months. creening policies, universal or targeted, are determined by local departments of health, based on the prevalence of ris# factors in the community. (oordinate community care efforts to return the child to a safe home. (ommunicate with community outreach wor#ers so that environmental case management is conducted. Fead abatement must be conducted by e-perts, not untrained parents, property owners, or contractors. uggest periodic, focused household cleaning to remove the lead dust, use a wet mop. /ncourage handwashing before meals and at bedtime to eliminate lead consumption from normal hand-to-mouth activity. O2ser&e t"e c"ild and ot"er c"ildren in t"e "ome !or -ica3 o Ebserve and record the child)s eating habits and food preferences. o 0eport any attempted eating of nonfood substances. o /ncourage the caregivers to provide regular meals and ma#e mealtime a pleasurable time for the child. o Teach the caregivers to discourage oral activity and to substitute activity that contributes to play, social s#ills, and ego development. o 0efer the family for additional social or psychiatric casewor# if indicated to reduce the economic and other factors that result in pica in the child. creen siblings and playmates of #nown cases immediately.

1a#e sure that the family is able to provide close supervision of the child or assist them to ma#e arrangements to ensure that the child is ade.uately supervised at home.

8amily Ed cation and Healt" Maintenance /nsuring Fong-Term *ollow-Up Teac" t"e -arents 7"y lon1;term !ollo7; - is im-ortant3 Tell t"em t"at resid al lead is li2erated 1rad ally a!ter treatment and, o 1ay result in the renewal of symptoms. o 1ay increase serum lead to a dangerous level. o 1ay cause additional damage to the (! , which may not become apparent for several months. tress that acute infections must be recognized and treated promptly because these may reactivate the disease. Teach that iron supplementation may be continued to treat anemia. "dvise the parents about medication administration and adverse effects and periodic complete blood count monitoring. Pre&entin1 Ree>-os re o! t"e C"ild to Lead "dvise the parents that the single most important factor in managing childhood lead poisoning is reducing the child)s ree-posure to lead. %nstruct the parents about the seriousness of repeated lead e-posure. %nitiate referrals to home health nursing and community agencies as indicated. NURSING ALERT C"ildren s"o ld not ret rn "ome ntil t"eir "ome en&ironment is lead !ree3 Pro&idin1 Comm nity Ed cation %nitiate and support educational campaigns through schools, day care centers, and news media to alert parents and children to hazards and symptoms of lead poisoning. Provide literature in clinics, waiting rooms, and other appropriate settings that stresses the hazards of lead, sources of lead, and signs of lead into-ication. upport legislation to study the nature and e-tent of the lead poisoning problem and to eliminate the causes of lead poisoning. %nclude the topic of pica and lead poisoning in nutritional teaching. *or additional information, contact the state or local health department or (D(, http+99www.cdc.gov. E&al ation, E>-ected O tcomes eizure precautions maintained, no signs of increased %(P Tolerates chelation therapy in@ections, e-presses anger through doll play Parents provide appropriate play and stimulation for development *amily involved in care, provides support to the child

Comm nica2le 4iseases Cith the dramatic success of immunizations, many childhood diseases have decreased in fre.uency. However, a number of communicable diseases still cause significant morbidity in children.

C"ild"ood 4iseases 4ISEASE0 INCU6ATION AN4 SBMPTOMS TREATMENT COMPLICA AGENT0 MO4E COMMUNICA6ILITB O8 PERIO4S TRANSMISSION0 AGE <HEN MOST COMMON C"ic5en-o> Varicella-zoster Incubation (I): ;;-5; >eneral ymptomatic+ horten (omp Highly days after e-posure. malaise, fingernails to prevent rare i communicablCommunicability (C): low-grade scratching. health e, ac.uired inEnset of fever &;-5 days fever, and Daily antiseptic econ before first lesion' until direct anore-ia for baths. infect last vesicle is dried &<-3 contact, 57 hours. Eral antihistamines Hemo days'. droplet 0ash: to decrease pruritus. varice spread, and macules to Treatment of itching+ encep airborne papules and throm 2a#ing soda &sodium transmission. vesicles to not co bicarbonate' or crusts can o oatmeal baths, 5-G years, within (alamine lotion to several 4anuary to 0eye lesions. hours. 1ay. %solation until all Diagnostic lesions have crusted. tests: Tzanc# Pruritus of "cyclovir &Wovira-' smear shows lesions may by mouth &P.E.' multinucleate be severe, within first 57 hours. d giant cells. and scratching "void salicylates. may cause scarring. Rash characterist ics: 0ash appears first on the head and mucous membranes, then becomes concentrated on body and

sparse on e-tremities, papulovesic ular eruption. Stre-tococcal P"aryn1itis X-Hemolytic I: 5-< days. stre tococc!s "ro! C: >reatest during initial # strain phase of illness. Direct or indirect contact with nasopharyng eal secretion of infected person or recently established carrier.

Enset is generally acute, high fever, headache, vomiting, chills. "fter ;5-57 hours: some sore throat of varying degrees of severity, dry throat, anterior cervical lymphadeno pathy, white tongue coating that becomes strawberryred tongue, e-udate on tonsils, scarlatina rash initially in a-illa, groin, and nec# area that becomes generalized. /nlarged lymph nodes in postauricula

%solation for ; day while starting prescription. "ntibiotic therapy+ LPenicillin >: %.1. LPenicillin $: P.E. /rythromycin &Pediazole':if allergic to penicillin. (ephalosporins P.E.

"cute glom ;-5 w stage 0heu wee# stage Perito cervic Pneum media sinus

0are under age D years, <-;8 years, incidence higher in winter and spring. Diagnostic tests: !asopharyng eal &throat' culture, rapid diagnostic test.

/ryth respo &scarl <-3 d subsi des.u on fac hands persis

R 2ella %German '?;day Measles* $!%ella &ir!s' $(# I: ;7-5; days after to"a &ir!s e-posure. Eral droplet C: $irus can be passed from 3 days before to < or

ymptomatic: isolation.

%n ado femal arthra

transplacenta days after rash appears. lly. chool age, young adults, spring, winter. Diagnostic tests: Tissue culture of throat, blood or urine, lateagglutination , enzyme immunoassa y, passive hemagglutina tion, fluorescent immunoassa y tests. Passive immunity: 2irth to age 8 months from maternal antibodies. Roseola In!ant m %E>ant"em s 2it m* H!man her es I: <-;< days. &ir!s-6 C: !ot #nown:believed Transmission not to be highly not #nown. contagious.

r, auricular, suboccipital, and cervical areas 57 hours before rash develops. /nanthem+ discrete rose spots on soft palate. /-anthem+ variable, begins on face, spreads .uic#ly over entire body, usually maculopapu lar, clears by third day.

/ncep

Throm

8-;? months, late fall to early spring.

*ever of ;6D=-;68= * &DG.7=-7;.;= (', either intermittent or sustained D-7 days with no clinical findings. *ever suddenly drops and macular or maculopapu

ymptomatic: antipyretic.

eizu fever

/ncep

lar rash develops on trun#, spreading to arms and nec#, mild involvement of face and legs, rash fades .uic#ly. R 2eola %Hard0 Red0 H;day Measles* )easles &ir!s* I: ;6-;5 days. $(#-containin" C: <th day of incubation aramy+o&ir!s to 7th day of rash. Direct contact with droplets from infected persons, respiratory route. Diagnostic tests: erologic procedures not routinely done. Passive immunity: 2irth to between ages 7 and 8 months if mother is immune before pregnancy.

*ever, lethargy, cough, coryza, and con@unctiviti s. 5-D days later, Iopli#)s spots on buccal pharyngeal mucosa &grayish white spots with reddish areolae', which disappear within ;5;? hours. 5 days later+ maculopapu lar rash appears at hairline and spreads to feet in ; day, rash begins to clear after D7 days.

ymptomatic+ L edatives. L"ntipyretic. L2ed rest in humid, comfortably warm room. LDar# room for photophobia. L"de.uate fluid.

Etitis Pneum laryn 1asto encep

"ppe

<-;6 years, adolescents, spring.

M m-s

)!m s &ir!s* aramy+o&ir!s Direct contact, airborne droplets, saliva and, possibly, urine.

I: ;7-5; days. C: 3 days before to G days after swelling appears, virus in saliva greatest @ust before and after parotitis onset.

chool age, all seasons but slightly more fre.uent in late winter and early spring. Diagnostic tests: (ell culture from saliva, urine, spinal fluid, or blood. Passive ubclinical immunity: infection 2irth to age may occur. 8 months if mother is immune before pregnancy. 4i-"t"eria ,oryne%acteri!m I: 5-7 days. (asal -i htheria di htheriae C: 5-7 wee#s untreated, (oryza with "c.uired ;-5 days with antibiotic increasing treatment. through viscosity, secretions of possibly carrier or epista-is, infected low-grade individual by fever. direct contact Chitish with gray contaminated membrane articles and may appear environment. over nasal

Headache, anore-ia, generalized malaise, fever ; day before glandular swelling, fever lasts ;-8 days. >landular swelling usually of parotid: one side or bilaterally. /nlargement and reddening of Charton)s duct and tensen)s duct.

%solation until swelling has subsided. ymptomatic+ L"nalgesics. LHydration. L"limentation. L"ntipyretics. L0est.

1eni Erchi epidid

"udit invol result deafn

Diphtheria antito-in %.$. "ntibiotic therapy &penicillin, erythromycin'. upportive treatment+ L0espiratory support. L%solation until three cultures are negative after antibiotic therapy is

1yoc !euri Paral To-ic hyalin of hea adren #idne >astr

!eph

%ncidence increased in autumn and winter. Diagnostic tests: (ultures of nose and throat.

septum. .haryn"eal and tonsillar di htheria >eneral malaise, low-grade fever, anore-ia. ;-5 days later, whitish gray membranou s patch on tonsils, soft palate, and uvula. Fymph node swelling, fever, rapid pulse, Jbull nec#.K /aryn"eal -i htheria Usually spread from pharyn- to laryn-. *ever, harsh voice, stridor, bar#ing cough, respiratory difficulty with inspiratory retraction. (onres iratory di htheria "ffects eye, ear, genitals or, rarely, s#in.

completed. L2ed rest for 5-D wee#s. LHydration. L%mmunization with diphtheria to-oid after recovery.

Pert ssis %<"oo-in1 Co 1"* Bordetella ert!ssis I: D-;5 days, mean of 3 Direct days. contact or C: 3 days after e-posure respiratory &greatest @ust before catarrhal stage' to D droplet wee#s after onset of spread. paro-ysms or until %nfants and cough has ceased. young children, females more than males. Diagnostic tests: (ulture of nasopharyng eal mucus.

0ta"e 1 2,atarrhal 0ta"e3 Fasts ;-5 wee#s. 0hinorrhea, con@unctival in@ection, lacrimation, mild cough, and lowgrade fever. 0ta"e 11 2.aro+ysmal 0ta"e3 Fasts 5-7 wee#s or longer. *re.uent severe, violent coughing attac#s occurring in clusters leading to vomiting, cyanosis, and e-haustion. 0ta"e 111 2,on&alescent 0ta"e3 Fasts 5 wee#s to several months. (oughing attac#s decrease, but may return with each respiratory

pecific+ L/rythromycin estolate. L"zithromycin. L(larithromycin. upportive+ L"ntipyretics. L2ed rest. LYuiet environment to reduce coughing. L>entle suctioning. L%ncrease fluid inta#e. LE-ygen.

0espi pneum atelec emph aspira pneum pneum

(! + encep coma

infection. Duration+ G months to 5 years. Sta-"ylococcal Scalded S5in Syndrome %Ritter=s 4isease* 4ro! 11 ha"eI: *ew days. 1alaise, ty e 0ta hylococc!s C: Enset of rash until fever, a!re!s after antibiotics initiated. irritability, Disseminated or from a asymptomat primary ic. infection site &usually nose 0ash or around develops in eyes'. three phases+ %nfants and L children /rythemato under ;6 us:macular years old. involving Diagnostic face, nec#, tests: a-illa, and (ultures of groin. s#in, L con@unctiva, /-foliative nasopharyn-, :upper stools, and layer of blood. epidermis 2iopsy of becomes e-foliated wrin#led epidermis. and can be removed by light stro#ing &!i#ols#y sign', crusting around eyes, mouth, and nose produce characteristi c Jsunburst,K radial

pecific+ LTherapy with penicillinase-resistant penicillin P.E., %.1., or %.$. ymptomatic+ L>entle cleaning of s#in with compresses.

/-ces electr pneum septic

pattern, irritable due to e-treme tenderness of s#in. L Des.uamati ve: epidermis peels away leaving moist areas that dry .uic#ly and heal in ;6;7 days. Poliomyelitis %Polio* Vir!s seroty es 1* 2* I: 3-;7 days, paralytic or (on aralytic .olio and 3 nonparalytic, D-< days Headache, %ncidence is for prodromal or minor lethargy, illness. higher in anore-ia, summer and C:%ncreases around onset vomiting, when virus is in throat fall. fever. and is e-creted in feces, $irus is 1uscle pain harbored in virus is present in throat and stiffness >% tract and ; wee# after onset, in of posterior is transmitted stool D-7 wee#s after. muscles, through nec#, and saliva, limbs. vomitus, and feces. .aralytic .olio ame as Noung nonparalytic children+ type, lasting pea#s in about ; "ugust, wee#. eptember, Then ;-5 and Ectober, days of in temperate central zones. nervous Diagnostic system tests: &(! ' %solation of symptoms+ poliovirus loss of deep from feces tendon and throat. refle-es,

!onparalytic+ upportive &ie, relief of pain'. L"nalgesics, heat. L/nteric isolation. L2ed rest. Paralytic+ Hospitalize. L*luid and electrolytes. L0est. L0elief of muscle pain and spasms. L0espiratory support. L1inimize s#eletal deformity.

0espi

Hype

positive Iernig)s and 2rudzins#i)s signs, lethargy. ;-5 days later, wea#ening of muscles and paralysis. Eryt"ema In!ectios m %8i!t" 4isease or Sla--ed C"ee5* .ar&o&ir!s B 15 I: 8-;7 days. 1ild fever, 0espiratory C:Until rash develops. chills, route. fatigue, or nonpruritic rash chool-age develops in children. three stages+ Diagnostic L udden tests: !ot appearance widely of bright available, erythema on %g1 chee#s. antibody test, L polymerase /rythemato chain us, reaction maculopapu detection lar rash on test. trun# and e-tremities. L0ash on body fades with central clearing giving a lacy or reticulated appearance. 0ash lasts 5DG days, fre.uently pruritic without des.uamatio

!o treatment is needed for healthy children. %mmunoglobulin for immunocompromise d patients.

(omp rare a health (hild abnor cells disea spher thalas devel aplas may r transf

%mmu patien sever anem

n.

Eccasional @oint arthropathy. *ever. $omiting. Profuse, watery, nonfoulsmelling diarrhea.

Rota&ir s $eo&iridae "ro! # I: ;-D days. 1ost C: Until 5-< days after diarrhea. common agent responsible for infantile diarrhea. *ecal-oral route.

Eral fluid and electrohydrate solution.

%soton with a

1aln may d malab dehyd

"ges 8 months to 5 years, most common in winter in temperate climates. Diagnostic tests: /nzymelin#ed immunosorb ent assay.

CHIL4 A6USE AN4 NEGLECT (hild abuse is any type of maltreatment of children or adolescents by their parents, guardians, or careta#ers. (hild abuse includes physical or emotional abuse, in@ury, trauma, neglect, or se-ual abuse of a child that is intentional and nonaccidental. A2 se incl des, 2attering:physical in@ury. Drug abuse:intentional administration of harmful drugs, especially during pregnancy. e-ual abuse. e-ual assault or molestation &non-family member'. %ncest &family offender'. /motional abuse:scapegoating, belittling, humiliating, lac# of mothering.

Ne1lect is t"e omission o! certain a--ro-riate 2e"a&iors0 7it" s c" omission "a&in1 detrimental -"ysical or -syc"olo1ical e!!ects on de&elo-ment3 Ne1lect incl des, (hild abandonment. Fac# of provision of the basic needs of survival, including shelter, clothing, stimulation, medical care, food, love, supervision, education, attention, emotional nurturing, and safety. Etiolo1y and Incidence The cause of child abuse and maltreatment is multidimensional. The abuse may be related to the combined presence of three factors+ special #ind of child, special #ind of parent or careta#er, special circumstances of crisis. "buse occurs in all ethnic, geographic, religious, educational, occupational, and socioeconomic groups. %n 566;, an estimated G66,666 children were victims of child abuse and neglect in the United tates. *urthermore, ;,D5; child maltreatment fatalities were reported in 566;. The most common type of abuse is neglect &86H of cases', followed by physical abuse &5DH', se-ual abuse &GH', emotional maltreatment &7H', and other forms of abuse &7H'. Contri2 tin1 8actors %ncidents of child abuse may develop as a result of disciplinary action ta#en by the abuser who responds in uncontrolled anger to real or perceived misconduct of the child. The parents may confuse punishment with discipline. J>ood parentingK may be e.uated with physical contact to eradicate child behavior. The abuser may be a stern, authoritarian disciplinarian. %ncidents of child abuse may develop out of a .uarrel between careta#ers. The child may come to the aid of one parent and may find himself in the midst of the .uarrel, marital discord is common. The abuser may be under a great deal of stress because of life circumstances &debt, poverty, illness' and may thus resort to child abuse. (risis and stress may be ongoing. The abuser may have a low frustration tolerance level and may not have a well-developed means of coping with stress in general. The abuser may be into-icated with alcohol or drugs at the time of the abuse, only ;6H of abusers have a history of mental illness. (hild abuse may occur by surrogate caregiver, ie, a babysitter or boyfriend. Fac# of effective parenting, inappropriate parent-child bonding, and punitive treatment as a child may contribute to the parent becoming an abuser. S-eci!ic c"aracteristics e&ident in many a2 sin1 -arents incl de, o Fow self-esteem:a sense of incompetence in role, unworthiness, unimportance, have difficulty controlling aggressive impulses, commonly live in social isolation. o Unrealistic attitudes and e-pectations of the child, little regard for the child)s own needs and age-appropriate abilities, lac# of #nowledge related to parenting s#ills.

*ear of re@ection:a deep need to feel wanted and loved, but a feeling of re@ection when love is not obvious, a crying infant may elicit a feeling of re@ection. o %nability to accept help:isolation from the community, loneliness. o Unhappiness due to unsatisfactory relationships, may loo# to child for satisfaction of own emotional needs. o (hild abusers are commonly the children of abuse or victims of spousal abuse. %ncidents of child abuse may develop from a general attitude or resentment or re@ection on the part of the abuser toward the child. "typical child behavior &eg, hyperactivity or a technology-dependent child who needs additional care' may unintentionally provo#e the abuser. The degree of the family crisis is not usually in proportion to the degree of abuse.
o

Clinical Mani!estations C"aracteristics o! t"e C"ild t"at S"o ld Raise S s-icion The child is usually younger than age D years. chool-age children and adolescents are also sub@ect to abuse. The average age of a se-ually abused child is G years. >eneral health of the child indicates neglect &diaper rash, poor hygiene, malnutrition, unattended physical problem'. (haracteristic distribution of fractures &scattered over many parts of body'. Disproportionate amount of soft tissue in@ury. /vidence that in@uries occurred at different times &healed and new fractures, resolving and fresh bruises'. (ause of recent trauma in .uestion. History of similar episodes in the past. !o new lesions during the child)s stay in the hospital. 1ay show a wide range of reactions:may be either very withdrawn or overactive. The child may be an-ious, tense, or nervous, or show regressive behavior. The child may show unusual affection for strangers or may be overly fearful of adults and avoid any physical contact with them. *or se-ual abuse+ the child may fear no one will believe him, may e-perience self-blame, most #now their abusers. (hildren may not JtellK about abuse from parents, fearing a loss of security, Ja bad parent is better than no parent at all.K 2ehavior problems, depression, acting-out behaviors, and aggression toward younger children may result. *or abuse that occurs in school or day care, the child may e-hibit fear of the teacher, have nightmares, decrease school attendance, or develop psychosomatic illnesses. In$ ries or Ty-es o! A2 se t"at May Occ r 2ruises, welts &linear or loopli#e'. "brasions, contusions, lacerations &most common'.

Counds, cuts, punctures. 2urns &cigarette, radiator', scalding:stoc#ing or glove distribution. 2one fractures. prains, dislocations. ubdural hemorrhage or hematoma, Jsha#en baby syndrome.K 2rain damage. %nternal in@uries. Drug into-ication. 1alnutrition &deliberately inflicted'. *reezing, e-posure. Chiplash-type in@ury. /ye in@uries, periorbital in@uries, ear bruises. Dirty, infected wounds or rashes. Une-plained coma in infant. *ailure to thrive:developmental delay, malnutrition with decreased muscle mass, decreased interaction with environment and with others, dental caries, listlessness, behavior problems. e-ually transmitted diseases:genital trauma, recurrent urinary tract infection, pregnancy.

Mana1ement The goal of treatment is to ensure the physical and emotional safety of the child. Therefore, treatment is inclusive of other family members and careta#ers and is often focused on the parents. " team approach is employed to determine the most effective use of community resources to protect the child and help the parents. %t is estimated that ?6H to G6H of abusing parents can be rehabilitated. The ideal approach is to return the child to the biological parents after treatment concludes. Co nselin1 is o!!ered to "el- -arents do t"e !ollo7in1, o Understand and redirect their anger. o Develop an ade.uate parent-child relationship. o ee their child as an individual with his own needs and differences. o Understand child development and normal behaviors of developing children. o Fearn about effective discipline techni.ues. o /n@oy the child. o Develop realistic e-pectations of their child. o Decrease their use of criticism. o %ncrease parents) sense of self-esteem and confidence. o /stablish supportive relationships with others. o %mprove their economic situation &if appropriate'. o how progress toward the physical, emotional, and intellectual development of their child. N rsin1 Assessment Identi!y !amily or c"ild at ris53 o "lcohol or drug abuser.

"dolescent parent. Fow-income, single-parent family. 1ultiple births. Unwanted child. ic#ly and more demanding child. Premature child with long separation from mother at birth. Ins-ect !or e&idence o! -ossi2le a2 se3 o Describe completely on the medical record all bruises, lacerations, and similar lesions as to location and state of healing. Foo# carefully at areas generally covered with clothing &ie, buttoc#s, underarms, behind #nees, bottom of feet'. o "s# how in@uries occurred and record descriptions of the in@ury, including the date, time, and place of the event. (ollect necessary specimens for identification of organisms, sperm, or semen. Ta#e color photographs as indicated. "ssess developmental level of the child. O2ser&e !or 2e"a&iors common in a2 sin1 or ne1lectin1 -arents3 6e a7are t"at not all a2 sin1 -arents e>"i2it t"ese 2e"a&iors 2 t 2e alert !or t"e -arent 7"o, o "n-iously volunteers information or withholds information related to an in@ury. o >ives e-planation of the in@ury that does not fit the condition or gets story confused concerning the in@ury. o hows inappropriate reaction or concern to severity of in@ury. o 2ecomes irritable about .uestions being as#ed. o eldom touches or spea#s to the child, does not respond to child. 1ay be critical or indicate unreal e-pectations of child &or may be oversolicitous to the child'. o Delays see#ing medical help, refuses to sign permit for diagnostic studies, fre.uently changes hospitals or health care providers. o hows no involvement in the care of the hospitalized child, does not in.uire about the child. o Ebtains little or no prenatal care and shows inappropriate response to the neonate, acts disinterested or unhappy with the child. "ssess the parent-child relationship in the areas of appropriate involvement in care, show of affection, reaction to arrival and leaving, e-pectations, role portrayal. Assess !or si1ns o! se> al a2 se3 Se> al a2 se s"o ld 2e s s-ected 7"en t"e yo n10 -re- 2ertal c"ild -resents 7it", o >enital trauma not readily e-plained. o >onorrhea, syphilis, or other se-ually transmitted organisms. o 2lood in urine or stool. o Painful urination or defecation. o Penile or vaginal infection or itch. o Penile or vaginal discharge. o 0eport of increased, e-cessive masturbation.
o o o o o o

0eport of increased, unusual fears. Trauma to genitalia, inner thigh, breast. Esta2lis" a relations"i- 7it" t"e c"ild 2ased on m t al res-ect0 em-at"y0 and sensiti&ity to !acilitate ! rt"er in&esti1ation3 o (onsideration of the child)s emotions in con@unction with a good relationship may encourage the child to e-press feelings either verbally or through drawings or play. o Prepare the child physically and psychologically for the necessary physical and pelvic e-amination. o Tal# with the child without the presence of the parents, especially when incest is possible. 0eport suspicion of child abuse based on your assessment. "ll provinces have mandatory reporting laws. "ll states provide statutory immunity for those who report real or suspected child abuse. There is no immunity from civil or criminal liability for failure to report such. !otify the appropriate officials.
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NURSING ALERT I! t"e alle1ed se> al a2 se occ rred 7it"in HD "o rs o! t"e "ealt" care &isit0 or i! tra ma or 2leedin1 is -resent0 an immediate -"ysical e>amination s"o ld 2e done3 I! more t"an HD "o rs "a&e -assed since t"e alle1ed se> al a2 se0 t"e -"ysical e>amination mi1"t 2e delayed3 A!ter c"ild a2 se "as 2een re-orted0 additional c"ildren in t"e !amily may 2e e>amined as 7ell3 NURSING ALERT E&ery n rse is morally and le1ally res-onsi2le to re-ort and -ro&ide -rotecti&e ser&ices !or t"e a2 sed c"ild3 6ecome !amiliar 7it" la7s0 -roced res0 and -rotecti&e ser&ices in yo r comm nity and state3 N rsin1 4ia1noses *ear related to e-periences with abuse %mpaired Parenting related to abusive treatment of a child N rsin1 Inter&entions Relie&in1 8ear and 8osterin1 Tr st 2e aware that some of these children have never learned how to trust an adult, they are fearful of giving affection for fear of re@ection. "ssign one nurse to care for the child over a period of time. 1a#e no threatening moves toward the child. The child will indicate readiness and awareness of the environment by verbal or facial e-pressions. Touch the child gently. Provide nonthreatening physical contact &hold and fre.uently cuddle the child'. Pic# up and carry child around, encourage any e-ploration of your face and hair. Provide appropriate opportunities for play. et limits for the child.

Provide therapeutic play to allow the child to e-press fears and anger in a nonverbal manner, be non@udgmental and supportive with e-pression of feelings, correct misconceptions. Pro&ide additional "el- in t"ese areas, o Having ambivalent feelings toward the parents or any adult careta#er. o Evercoming low self-image and the fear that something is wrong with him. o *earing future abuse on his return home or for misbehavior in the hospital.

Pro&idin1 S --ort in Parentin1 "ssume a non@udgmental attitude that is neither punitive nor threatening. (onvey a desire to help the parents through the healing process. 0efrain from .uestioning them about the incident of abuse. The health care provider, social wor#er, and investigative authority will interview the suspected abuser. %nclude the parents in the hospital e-perience &ie, orient them to the unit and to any procedure to be done to the child'. erve as a role model in the management of the child)s behavior as well as their own. Try to give the parents as much information as possible about the care of their child. Fisten to what they are saying. 0efrain from challenging all the information they may give. /-press appropriate concern and #indness. 0emain ob@ective yet empathic. This will help foster the parents) self-respect and improve their self-image and dignity. Discuss the reporting to the authorities with them because of the widespread nature of the problem and the need for education and assistance. upport the parents who may have feelings of guilt, anger, and helplessness. /-plain to them the e-tent of trauma, and educate them. "llow them to e-press their feelings. upport their parental role in handling the child &eg, allow the child to tal# about or play out the incident, but do not force it'. 2uild a relationship by wor#ing with the parents) strengths rather than their wea#nesses. Use compliments as positive reinforcement. Assist t"e -arents to learn sa!e and a--ro-riate -arentin1 s5ills3 o 0emember that many of these parents were abused as children and have no role models or personal e-perience with nurturing behaviors. o *oster attachment between child and parents, not between child and nurse, when the parents are present, the latter would increase their feelings of incompetence in the parenting role. o (orrect erroneous e-pectations as to what is appropriate behavior for a particular age-group. o /ncourage the parents to ta#e time out from caring for their children to meet their own needs, assist them in identifying safe and appropriate resources for their child)s care. Provide the parents with psychological support and reinforcement for appropriate parenting behaviors. Cor# with the parents in planning for the child)s future care.

Determine in what areas the parents need help. Does the infant cry oftenP How does this ma#e the parents feelP How do the parents comfort the childP %s there someone the parents can call for helpP

NURSING ALERT A critical -art o! 7or5in1 in t"is area is learnin1 to reco1ni+e0 e>amine0 and 7or5 7it" yo r o7n !eelin1s o! an1er0 dis1 st0 and contem-t !or t"e -arents3 It may "elto do t"e !ollo7in1, 0ealize that most abusing parents do love their children and want the best for them despite their ambivalent feelings for the children. Understand the dynamics of child abuse and neglect. This crisis is due to the stress with which the parents are unable to cope and to the deprivations they have themselves suffered in the past. Comm nity and Home Care Considerations !urses typically provide home care visits as part of a multidisciplinary team engaging in e-tensive community follow-up. /ducation and continued assessment are the focus. Teac" t"e -arents a2o t normal 1ro7t" and de&elo-ment3 o >ive specific information about and e-amples of the types of behavior to e-pect at the various stages of development. Point out in a nonthreatening way normal behavior e-hibited by their child. o Provide specific strategies for dealing with whatever behavior the child e-hibits. o erve as a role model and teacher, minimize intensity when the parents become threatened. Teac" t"e -arents "o7 to se disci-line 7it"o t resortin1 to -"ysical !orce3 o Discipline must be consistent. Effer suggestions for alternative ways of handling undesirable behavior &eg, time-out'. o uggest using a reward system for acceptable behavior &eg, a trip to the zoo, staying up later than usual for a special television show, a special treat'. o %nstruct the parents to withhold rewards for unacceptable behavior. Teac" c"ildren "o7 to a&oid 2ein1 t"e &ictims o! a2 se3 o Teach them about Jgood touchK and Jbad touch.K o /mphasize that they can say no to anyone who wants to touch their body. o Provide names or places where they can go if they feel they are being abused. o "ssist them in dealing with their fears that their parents will be sent to @ail or that they will be removed from the home. 6e alert !or si1ns o! a2 se in t"e sc"ool3 I! a teac"er is s s-ected o! 2ein1 t"e a2 ser0 t"e c"ild may, o Display increased fear of the teacher. o Decrease school attendance. o Develop psychosomatic symptoms during school days. o Develop nightmares.

Corry e-cessively over school performance.

8amily Ed cation and Healt" Maintenance Teach the parents and child &if age is appropriate' any specific instructions relative to in@ury and follow-up care. /nsure that the family #nows where and when to follow up. 0eview schedule for well-child visits and immunizations so the family can #eep up with routine care. 1a#e #nown to the parents your continued concern and your availability as a source of help. Help them to use resources in the community including the home health nurse, social wor#er, and therapists. 0efer those interested in learning more about abuse to the following agencies+ Prevent (hild "buse "merica, ;-?66-<<!(P(", !ational (learinghouse on (hild "buse and !eglect %nformation, ;-?66-*N%-DD88, http+99www.calib.com9nccanch E&al ation, E>-ected O tcomes /-hibits appropriate developmental behavior 2oth parents participate in feeding and playing with child