FAR EASTERN UNIVERSITY

Institute of Nursing

Care of the Mother and Child at Risk or with Problems

PEDIA

Module: HEALTH PROBLEMS COMMON IN SCHOOL AGE

Introduction:

The school-age period, between 6 and 12 years of age, usually is referenced in one of two ways: the age
of the “good kids” and/or the age of the “loose tooth.” Beginning at about 6 years of age, children begin to lose
their primary teeth and replace them with their permanent, adult teeth. During this time, children are in
elementary school, working hard to learn and to please both their teachers and their parents. When children are
unable to learn easily or to excel in any other area that they may endeavor to try they can become frustrated and
develop a feeling of inferiority. It is important for adults to listen to children’s desires and to provide positive
feedback whenever possible.

The many functions of the immune system—comprised of a number of organs and tissues, including,
but not limited to, the skin, bone marrow, spleen, and lymph system—are integral to the health and well-being
of the child. Infants and young children are at particular risk of infection because of the immaturity of their
immune systems. They are unable to mount either a rapid or an effective response to invading organisms
placing them at high risk for serious illnesses. In fact, children are unable to exhibit adult-level responses until
they have reached school age

Learning Outcomes

At the end of this module, the student will be able to

1. Describe the pathology for several illnesses of Common Health Problems in School Age.
2. Describe the assessment signs and symptoms seen in children with this health problems
3. Relate the assessment findings regarding difficulties specifically to the most common school age
illnesses
4. Discuss the treatment recommended for this disease
5. Provide safe and appropriate nursing interventions addressing health care needs of the at-risk/high
risk/sick clients during childbearing and childrearing
6. Demonstrate safe, appropriate and holistic care utilizing the nursing process.
7. Recognize cardinal signs and symptoms of the respiratory system that suggest life-threatening
emergencies.
8. Answers and submits activities provided using multi-disciplinary approach.

Topic Outline:

HEALTH PROBLEMS COMMON IN SCHOOL AGE

• Rheumatic Fever
• Diabetes Mellitus
• Rheumatoid Arthritis
• Scabies

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 • Pediculosis
• Impetigo

Summary of Content

RHEUMATIC FEVER
1. What Went Wrong?
o Rheumatic fever (RF) is an inflammatory disease that occurs after an infection with group Ab-
hemolytic streptococcal pharyngitis. The illness is self-limited and involves
§ Joints, skin, brain, serous surfaces, and heart.
§ Cardiac valve damage is the most significant complication.

2. Signs and Symptoms

o Lesions called Aschoff bodies
o Carditis involving the endocardium,
pericardium, and myocardium
o Apical systolic murmur
o Polyarthritis
o Erythema marginatum, a clear rash often over
trunk and proximal portion of extremities
o Subcutaneous nodules
o Chorea

3. Test Results
o There is no single definitive laboratory test to
diagnose RF.
o Clinical and laboratory findings are considered
along with evidence of a recent streptococcal
infection.

4. Treatment
o Ten-day course of antibiotic therapy
o Salicylates to control the inflammatory process

5. Nursing Interventions
o Promote compliance with the medication
regimen.
o Support child and family and return to
recovery.
o Prevent reoccurrence of the illness.

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 TEST YOURSELF (ACTIVITY#005)

1. What type of infection would likely be found in the history of a child who has rheumatic
fever?
_____________________________________________________________________
_____________________________________________________________________

2. Explain the terms carditis, polyarthritis, and chorea.

_____________________________________________________________________
_____________________________________________________________________

3. What are two important aspects in the prevention of rheumatic fever?

_____________________________________________________________________
_____________________________________________________________________

Note: Copy and paste activity then submit thru CANVAS or email. Do not forget to include your name and
section.

JUVENILE RHEUMATOID ARTHRITIS

1. What Went Wrong?
o Juvenile rheumatoid arthritis (JRA) is an autoimmune disease that causes chronic inflammation of
connective tissue and joints resulting in swelling, pain, and limited motion that occurs <16 years of
age. The synovial membrane becomes inflamed, called synovitis, resulting in increased fluid,
lymphocytes, and plasma in the joint, which causes the joint to swell and become joint effused. The
joint can erode and deform over time resulting in bone loss, osteoporosis, subluxation, and ankylosis.
There are two peak ages of onset—between 1 and 3 years and between 8 and 10 years of age.
• There are three types of JRA:
1. Oligoarticular: This affects fewer than five joints and might exhibit inflammation of
the iris without joint symptoms.
2. Polyarticular: This affects the small joints of the hands and weightbearing joints.
3. Systemic: This affects the entire body resulting in high fever that suddenly drops to
normal. A rash may appear and then suddenly disappear.

2. Signs and Symptoms

o Irritability
o Poor appetite
o Mild growth delay
o Tires easily Changes in gait
o Poor weight gain
o High fever
o Rash
o Flex position at rest

3. Test Results
o Increased erythrocyte sedimentation rate (ESR)
o Positive rheumatoid factor (RF) in serum

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 o Positive immunoglobulin (Ig)G and IgM present in serum
o Positive antinuclear antibodies (ANA) in serum
o Low hemoglobin

4. Treatments
o Administer non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen for
pain relief. It can take 3 weeks for anti-inflammatory response to occur.
o Administer slow-acting anti-rheumatic drugs (SAARDS) such as methotrexate, sulfasalazine,
and hydroxychloroquine to suppress the autoimmune response.
o Administer steroids if other treatments fail. Steroids reduce inflammation but have adverse side
effects with long-term use. Administer etanercept (Enbrel) if NSAIDs and SAARDS fail.
Etanercept blocks the binding of tumor necrosis factor with cell surface receptors, thus reducing
inflammation.
o Physical therapy to ensure safety ambulation.

Nursing alert!!
Monitor the patient for signs of infection because anti-inflammatory medication suppresses the immune system.

5. Nursing Interventions
o Perform range-of-motion exercise on the affected joint to maintain joint mobilization.
o Encourage nonweight bearing activities to strengthen muscles.
o Use splints and braces to reduce flexion and minimize pain. Monitor renal and hepatic labs to
detect adverse reaction to long use of NSAIDs.
o Apply warm compresses on joints when sleeping to prevent viscous that results in stiffness.
o Increase foods high in iron. Increase fluids if the patient has a fever to prevent dehydration.
o Encourage self-care and normal independent activities of daily life.
o No restrictions on daily activity.
o Teach the parent:
• To give the patient a warm bath when awaking to reduce stiffness
• To avoid the patient remaining in a fixed flexion position
• That the patient should sleep 8 to 10 hours at a time to avoid fatigue. Avoid naps because this
inactivity results in stiffness.
• That the patient should alternate between active and quiet activities to avoid fatigue.

Learning Activities

Activity#006
1. Read and choose 1 article below
2. Make a reaction paper following the prescribe format see link ( PEDIA ACTIVITY\Reaction Paper
Format.doc)
a. Juvenile Idiopathic Arthritis: Diagnosis and Treatment
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5127964/

b. Juvenile Idiopathic Arthritis – Changing Times, Changing Terms, Changing Treatments

https://pedsinreview.aappublications.org/content/38/5/221

c. The Hand and Wrist in Juvenile Rheumatoid Arthritis

https://www.jhandsurg.org/article/S0363-5023(15)00826-6/pdf

Note: Copy and paste activity then submit thru CANVAS or email. Do not forget to include your name and section

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DIABETES MELLITUS
1. What Went Wrong?
o Certain foods are converted into glucose, which is the primary energy supply. Insulin from beta
cells of the pancreas transports glucose into cells for cell metabolism.
o Diabetes mellitus occurs when beta cells either are unable to produce insulin (type 1 diabetes
mellitus) or produces an insufficient amount of insulin (type 2 diabetes mellitus). As a result,
glucose doesn’t enter cells and remains in the blood.
o Increased glucose levels in the blood signal the body to increase the intake of fluid to flush
glucose out of the body in urine, resulting in increased thirst and increased urination in the
patient. Cells become starved for energy because of the lack of glucose and signal the body to eat
causing the patient to experience an increase in hunger.
o There are three types of diabetes mellitus:
1. Type 1: Known as insulin dependent diabetes mellitus (IDDM). Beta cells are
destroyed by an autoimmune process. There is a genetic predisposition, although
coxsackie B, mumps, and congenital rubella viruses injure beta cells and can
result in type 1 diabetes.

2. Type 2: Known as noninsulin dependent diabetes mellitus (NIDDM). Beta

cells produce insufficient insulin.

3. Gestational diabetes mellitus: Insufficient insulin is produced by the mother

during pregnancy. Patients with gestational diabetes mellitus recover following
pregnancy; however, they are at risk for developing type 2 diabetes mellitus later
in life.

Nursing alert!!

Patients with type 1 and type 2 diabetes mellitus are at risk for vision loss (diabetic retinopathy), damaged
blood vessels and nerves (diabetic neuropathy), and kidney damage (nephropathy). However, complications
can be minimized by maintaining a normal blood glucose level through consistent monitoring, administering
insulin, and dieting.

2. Signs and Symptoms

o Type 1:
§ Fast onset because no insulin is being produced.
§ Increased appetite (polyphagia) because cells are starved for energy and are signaling a
need for more food.
§ Increased thirst (polydipsia) from the body attempting to rid itself of glucose.
§ Increased urination (polyuria) from the body attempting to rid itself of glucose.
§ Weight loss because glucose is unable to enter cells.
§ Frequent infections as bacteria feeds on the excess glucose.
§ Delayed healing because elevated glucose levels in the blood hinder healing process.

o Type 2:
§ Slow onset because some insulin is being produced.
§ Increased thirst (polydipsia) from the body attempting to rid itself of glucose.
§ Increased urination (polyuria) from the body attempting to rid itself of glucose.
§ Candidal infection as bacteria feeds on the excess glucose.
§ Delayed healing because elevated glucose levels in the blood hinder healing process.

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 3. Test Results
o Urine test: Increase glucose in urine (glucosuria).
o Fasting plasma blood glucose test: A plasma glucose level of ≥126 mg/dL (or 7.0 mmol/L) on
three different tests
o Oral glucose tolerance Test (OGTT): A plasma glucose of ≥200 mg/dL (or 11.1 mmol/L) 2 hours
after ingesting 75 g oral glucose.
o Random plasma glucose test: A plasma of ≥200 mg/dL or 11.1 mmol/L.
o Glycosylated hemoglobin A1C: ≥6.0%.

4. Treatment
o Type 1:
• Regular monitoring of blood glucose.
• Administer insulin to maintain normal blood glucose levels (see Table 9-1).
• Maintain a diabetic diet.
• Administer:
Rapid acting:
Aspart
Lispro
Glulisine
Short acting:
Regular insulin
Intermediate:
Human insulin
NPH
Human insulin
Zinc
Lente
Long acting:
Human insulin
Zinc
Ultralente
Glargine
Lantus
Inhaled insulin Exubera: A short-acting insulin for before-meal control

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 o Type 2:
• Maintain ideal body weight through diet and exercise.
• Regular monitoring of blood glucose.
• Administer oral sulfonylureas to stimulate secretion of insulin from the pancreas
(see Table 9-2).
• Administer oral Biguanides to reduce blood glucose production by the liver:
§ Metformin
• Administer thiazolidinediones to sensitize peripheral tissues to insulin:
§ Rosiglitazone
§ Pioglitazone
• Administer meglitinide analogs to stimulate section of insulin from the pancreas:
§ Repaglinide
• Administer D-phenylalanine derivative to stimulate insulin production:
§ Nateglinide
• Administer alpha-glucosidase inhibitors to delay absorption of carbohydrates in the intestine:
§ Acarbose Miglitol
• Administer DPP4 (dipeptidyl peptidase 4) inhibitors to slow the inactivation of incretin
hormones; GLP-I that assists insulin product in the pancreas:
§ Sitagliptin
• Administer incretin mimetics to assist insulin production in the pancreas and help regulate liver
production of glucose. It also decreases appetite and increases the time glucose remains
in the stomach before entering the small intestine for absorption.
• Administer amylin analog that causes glucose to enter the bloodstream slowly and can cause
weight loss:
§ Pramlintide

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 5. Nursing Intervention
o Educate the family and child about the disease and the importance of maintaining normal glucose
levels.
o Demonstrate blood glucose monitoring.
o Review diet and food choices, including portion sizes.
o Encourage exercise.
o Discuss coping skills to reduce stress.
o Teach self-injection of insulin (type 1).
o Teach importance of daily medications and self-care including insulin injection. Explain to the
family and patient the signs and symptoms and intervention for hypoglycemia, diabetic
ketoacidosis, and hyperglycemia.

Nursing alert!!
For hypoglycemia (sweating, lethargy, confusion, hunger, dizziness, weakness), administer 4 ounces of fruit
juice, several hard candies, glucose tablets, a small amount of carbohydrate or glucagon injection (causes the
liver to release glucose) to increase glucose levels. For hyperglycemia (fatigue, headache, blurry vision, dry
itchy skin), adjust the dose or type of medication; adjust meal planning. For diabetic ketoacidosis (DKA) (fruity
smell of acetone, constant urination, hyperventilation, agitation, sluggishness), administer insulin. Symptoms of
DKA are similar to alcohol intoxication.

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Learning Activities

Activity#007

Encircle the correct answer on the following questions

1. A 6-year-old child has just been diagnosed with type 1 diabetes. The nurse is providing
education to the parents regarding signs of hypoglycemia. Which of the following information
should the nurse include in her teaching session?
1. Child’s breath will smell like fruit.
2. Child will complain of excessive thirst.
3. Child will complain of sleepiness and will appear fatigued.
4. Child’s behavior will resemble a burst of anger or a temper tantrum

2. A nurse is providing education to 4 sets of parents whose children have been diagnosed with
type 1 diabetes. The nurse should provide follow-up education to the parents who state that
they will perform which of the following actions?
1. Parents of a 2-year-old: “We will have our daughter prick her finger for each glucose
testing.”
2. Parents of a 5-year-old: “We will give our daughter a code word that she will say
when she feels a hypoglycemic episode developing.”
3. Parents of a 9-year-old: “We will monitor our daughter as she draws up and
administers her insulin injections.”
4. Parents of a 17-year-old: “We will allow our daughter to take responsibility for all of
her own diabetic care.”

3. The nurse advises the parents of a 11½-year-old who is newly diagnosed with type 1 diabetes
that the child’s blood glucose level before dinner should be between 90 and 140 mg/dL. The
mother states, “But that is much higher than I read on an Internet Web site.” Which of the
following responses by the nurse is appropriate?
1. “I am sorry, I was thinking of the level for after dinner. The correct before dinner
level is 70 to 110 mg/dL.”
2. “The level is higher than what you will usually see because young children’s diets
are not as predictable as the diets of older children and adults.”
3. “The level before breakfast should be 70 to 100 mg/dL, but the before dinner level
should be a higher level.”
4. “You will find that your primary health-care provider will change the level at each
visit. The goal starts at a high level and drops as your child responds to the insulin.”

4. The school nurse is responsible for caring for a number of school children with type 1 diabetes.
Before which of the following activities should the nurse make sure a child consumes a snack?
The child who:
1. sculpts in art class.
2. plays in the band.
3. acts in the school play.
4. plays on the soccer team.

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 5. A child has recently been diagnosed with type 1 diabetes mellitus. Which of the following
factors in his medical and family histories would the nurse expect to see?
1. Child’s grandfather has been diabetic since childhood.
2. Child’s body mass index is 30.
3. Child rarely engages in aerobic activities.
4. Child has recently gained 15 pounds.

6. A teenage child has been diagnosed with type 2 diabetes. The nurse determines that the child
will likely be administered which of the following medications?
1. Metformin (Glucophage)
2. Aspart (Novolog)
3. Detemir (Levemir)
4. Glargine (Lantus)

7. Four sick children with type 1 diabetes have been admitted to the hospital. Which child is
most at risk of developing hypoglycemia? The child with:
1. bacterial sepsis.
2. intussusception.
3. jaundice.
4. chickenpox.

Provide your answer on the following questions

8. What do the terms polyuria, polydipsia, and polyphagia mean? 1 point each
_____________________________________________________________________
_____________________________________________________________________

9. What causes diabetic ketoacidosis to occur? 2 points

_____________________________________________________________________
_____________________________________________________________________

10. How is type 1 diabetes in the child treated? 3 points

_____________________________________________________________________
_____________________________________________________________________

11. Describe the symptoms of hypoglycemia and hyperglycemia 5 points

_____________________________________________________________________
_____________________________________________________________________

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SCABIES
1. What Went Wrong?
o Infestation by scabies mite occurs after exposure and
an impregnated female scabies mite deposits eggs in the
epidermis of the skin.

2. Signs and Symptoms

o Pruritus from the inflammatory response.
o Deep scratches from the itching.
o Maculopapular lesions in involved areas.
o Infants have eczema-like lesions as well as papules or
vesicles.
o Lesions may be located on hands and wrists (child 2
years of age).

Nursing alert!!

A child who is mentally challenged or has difficulty communicating may not be able to explain the discomfort;
thus examination of the skin and anticipatory treatment for itching may be needed.

3. Test Results
o Microscopic examination of a scraping from the lesion

4. Treatment
o Treatment with a scabicide (permethrin 5% cream [Elimite]).
o Ivermectin, an oral medication, may be given if topical medication is not effective (for children
>5 years of age).
o Antibiotics may be given for secondary infections.
o Members of the family who have been exposed may need to be treated.

5. Nursing Interventions
o Apply cream to all skin surfaces being careful to use gloves.
o Teach family and older child/adolescent the importance of following the prescribed regimen:
• Avoid applying cream after hot bath and avoid contact with eyes.
• Leave cream on skin for full 8 to 14 hours.
• Apply cream under nails.
• Explain that itching may persist after mites are killed because skin is still raw and needs
to heal.
• All clothes and bed linens must be washed in hot water and dried at high-heat settings.

PEDICULOSIS CAPITIS (HEAD LICE)

1. What Went Wrong?
o Infestation of the scalp by lice (Pediculus humanus capitis) is a common parasite invasion among
school-age children. The parasite lives by sucking blood from the host. The female lays nits
(eggs) at the base of the hair shaft, and the nits hatch in a week to 10 days increasing the parasitic
invasion.

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Nursing alert!!

Lice infestation is often a source of embarrassment for the family due to association with lack of hygiene.
Emphasize to the parents that anyone can be infected, and the usual cause is shared objects with an infected
child and not lack of cleanliness.

2. Signs and Symptoms

o Gray-tan colored lice visible at the base of the hair
o Translucent empty nit cases on the scalp
o White specks (nits) close to the scalp
o Itching caused by the insects’ movement and saliva on the scalp
o Scratch marks on scalp, particularly near ear, nape of neck, and back of head
o Inflammatory papules (elevated palpable lesion) due to infected lesions may be present.

3. Test Results
o Diagnosis is made with discovery of lice, nits, or nit cases on examination of scalp.

4. Treatment
o Shampoo with pediculicide preparation such as
• Permethrin 1% cream rinse (Nix)
• Pyrethrin with piperonyl butoxide (RID)
o Removal of nit cases
o Malathion 0.5% (children >2 years of age, 8- to 12-hour contact on scalp)
o Daily removal of nits with nit comb or other device to detect and remove lice

Nursing alert!!

If shampoo gets in the eye, flush well with water.

5. Nursing Interventions
o Prevention Provide client and family teaching regarding the spread of lice.
o Instruct parents, and provide education to community and schools, regarding the importance of
not sharing clothing or personal items such as combs among children.
o Maintain the personal items of children in separate containers.
o Explain that children who were infected may return to school before nits are totally absent;
remaining nits are often inactive or dead with no risk for further spread.
o Assist with treatment Clean infested clothing and place in dryer for at least 20 minutes.
o Dry clean items that cannot be washed (or seal in a bag for 2 weeks to allow death of any
parasites).
o Soak hair care items in lice-killing agent or boiling water.
o Systematically inspect the scalp of any child who scratches head, looking for lice, nits, or signs
of infestation.
o Family teaching and support Stress that cutting or shaving of hair is not needed to control spread
of lice in order to avoid unnecessary distress for the child.
o Assist family to obtain financial support, as needed, for expensive pediculicides or insecticides.
Support family by stressing that pediculosis is not a sign of poor sanitation.

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 CASE STUDY – Activity#008

An 8-year-old girl
Subjective Data
• Mother calls her 8-year-old child’s primary healthcare provider and states,
• “I just picked my daughter up from school because the school nurse says that my daughter
has lice. That can’t be. I wash my daughter’s hair every night.”

Objective Data
Nursing Assessment (performed via telephone)

Nurse states,
•“I am so sorry to hear that. It is possible for clean, healthy children to become infected with
lice.”
• “While I am on the phone, I want you to check your child’s hair. What do you see?”

Mother responds,
• “It looks like my daughter has dandruff.”

Nurse states,
• “Are you able to brush the dandruff off from your child’s hair?”

Mother responds,
• “No. It is really sticking to the hair! Oh, and my daughter says that her head itches really
bad. In fact, I see scratch marks all along her neck and behind her ears.”

Nurse states,
• “I am afraid that the school nurse is correct. Your child does have lice.”
• “I am sorry, I know that this is distressing. Please know, however, that it is not your or
your child’s fault. Lice are very small insects that can walk from one child to another very
easily. Or, your child may have borrowed a hat or hair brush from another child. This does
not, in any way, mean that your child is poorly cared for.”
• “The doctor has a standard care plan for children with lice and their families. Do you have
an e-mail address where I can send the instructions? If you have any questions, please
don’t hesitate to call me. And please also note, the doctor does recommend that you and
anyone else living in the home be treated at the same time. We also recommend that you
notify the parents of your child’s best friends so that they are informed.”

Mother responds with her e-mail address and thanks the nurse.

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 A. What subjective assessments indicate that this client is experiencing a health alteration?

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

B. What objective assessments indicate that this client is experiencing a health alteration?

1. _______________________________________________________________________

C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse
assign to this client?

1. _______________________________________________________________________

D. What interventions should the nurse plan and/or implement to meet this child’s and her family’s
needs?

1. _______________________________________________________________________

2. _______________________________________________________________________

3. _______________________________________________________________________

E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing
interventions?

1. _______________________________________________________________________

F. What physiological characteristics should the child exhibit after treatment?

1. _______________________________________________________________________

G. What subjective characteristics should the child exhibit after treatment?

1 _______________________________________________________________________
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IMPETIGO
1. What Went Wrong?
o Impetigo is a superficial skin infection caused most often by Staphylococcus aureus.
o Children who come in contact with infectious persons are at highest risk for spread of the
infection. Commonly found in toddlers or preschoolers.

2. Signs and Symptoms

o May begin with red macule that becomes
a vesicular lesion.
o Bullous lesions may be noted in neonatal
form.
o Lesions found on body surface, usually
trunk, extremities, face, perineum, or
buttocks.
o Lesions vary in size from millimeters to
several centimeters.
o Lesions often spread peripherally from
one skin area to another without
precautions.
o Lesions rupture easily and leave a red
moist eroded area.
o Minimal crusting in neonates. Honey-colored crusting may be noted in older infants and
children.
o May be noted in addition to eczema. Pruritus (itching) often noted.

3. Test Results
o Culture may be performed and commonly reveals S. aureus infection.

4. Treatment
o Isolation until treatment instituted
o Systemic antibiotics: Oral or intravenous if severe lesion
o Topical bactericidal ointment such as mupirocin (Bactroban)
o Burrow solution (1:20 solution) compress to skin to remove crusts, debris

5. Nursing Intervention
o Teach child and family the importance of handwashing and not touching lesions to minimize the
spread of infection to other areas of the body or to other persons.
o Explain that lesions often heal without scaring if no secondary infection occurs.
o Teach child and family to apply ointment and compress as ordered.

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Learning Resources:

Textbook: Hockenberry, M.; Wilson, D; Rodgers, C. Wong’s Nursing Care of Infants and Children (2019) 2nd
Philippine Edition: Elsevier Saunders

Video Links

https://www.youtube.com/watch?v=kqoEMvhXGiw

https://www.youtube.com/watch?v=eC80QsVuubQ

Articles

Juvenile Idiopathic Arthritis: Diagnosis and Treatment-

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5127964/

Juvenile Idiopathic Arthritis – Changing Times, Changing Terms, Changing Treatments

https://pedsinreview.aappublications.org/content/38/5/221

The Hand and Wrist in Juvenile Rheumatoid Arthritis

https://www.jhandsurg.org/article/S0363-5023(15)00826-6/pdf

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