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MCN Week 16 17 Book
MCN Week 16 17 Book
Chapter
Nursing Care of a Family When a
52 Child Has an Unintentional Injury
K E Y T E R M S Jason, a 5-year-old
1543
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1544 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1545
Because the emergency department nurse is often the Evaluating children in an emergency department is dif-
first person who sees a child after an injury, be ready to ficult, because they may be too young to communicate or
make a preliminary assessment of the extent of a child’s unconscious or they are so frightened that they cannot
injuries before a physician arrives. Remember that chil- stop crying to report which body parts are painful or to
dren may be seriously hurt but not crying because they indicate which parts should be assessed first. Spend a few
are in shock. They may be hemorrhaging, but, if they are minutes attempting to calm children and get them past
bleeding internally, the blood may not be visibly evident. this initial fright, unless symptoms of major body system
Accidents become fatal when lung, heart, or brain func- disturbances require that you direct your immediate ef-
tion becomes inadequate. These three body systems, forts elsewhere. Parents need frequent explanations of care
therefore, must be evaluated first (Airway, Breathing, given or planned, because as long as they are worried and
Circulation and Disability, or an ABCD evaluation). tense, children cannot be calmed easily.
Table 52.2 lists signs and symptoms to assess when de- A proportion of unintentional injuries in children re-
termining the respiratory, cardiovascular, and neurologic sult from child abuse. Conflicting histories or a parent
status of an injured child. and child recounting different stories is a hallmark of
While conducting a preliminary assessment of a child’s this. Always ask yourself if this could be a possibility (see
major body systems, take a brief history of the accident. Chapter 55).
What happened? How long ago did it happen? Was the
child using protective equipment such as a helmet or a se- Nursing Diagnosis
cured seatbelt? What have the parents done? If the child The nursing diagnosis used most frequently with injured
fell, how far was the fall? On what body part did the child children is Pain. Depending on the particular injury, several
land? (A head injury is more likely to be serious than an other nursing diagnoses are relevant, as are those that relate
ankle injury, although a child may be in more pain and to the suffering that parents experience when their child is
may have more obvious symptoms with the lesser injury.) injured. Examples of possible nursing diagnoses are:
Ask the parents what they think are their child’s major in- • Pain related to fractured tibia from sports injury
juries. Children may report one body part hurts at first, • Ineffective airway clearance related to burned
but then a small cut elsewhere begins to bleed, and they esophageal tissue
focus on the minor bleeding as their major injury. If par- • Impaired physical mobility related to severe burn
ents say, “At first, he acted as if his stomach hurt,” this injury
may be the first suggestion that he has a serious abdomi- • Disturbed body image related to change in physical
nal injury such as splenic rupture. appearance from thermal injury
• Parental fear related to outcome after head injury
in child
• Interrupted family processes related to child’s uninten-
tional injury
TABLE 52.2 ✽ Important Assessments on Initial • Anxiety related to apprehension and lack of knowl-
Examination of an Injured Child edge regarding medical treatment of child
1546 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
injury happened and plan ways to make their immedi- Examples of expected outcomes suggesting achieve-
ate or community environment safe for children. An ment of goals are:
organization that might be appropriate for referral is
the American Association of Poison Control Centers • Child swallows fluids without distress after esophageal
(http://www.aapcc.org). burns.
• Child states pain is at tolerable level within 30
minutes.
Implementation
• Child demonstrates full range of motion in hand after
The extent of a child’s injury depends on the injuring
thermal injury.
agent, the part of the body that was injured, and often the
• Child states he understands that wearing a seat belt is
immediate care, including both physical and psychologi-
an important safety measure.
cal management, that a child receives.
• Child states she will wear helmet when riding bicycle
The diameter of the airway in children is smaller than
in adults, so an injury to this body area almost always re-
in the future. ❧
sults in a greater danger of airway closure than in adults.
This could happen from the child’s inhaling a substance,
such as water, that directly obstructs the airway or from HEALTH PROMOTION AND
inhaling toxic fumes that cause inflammation along the RISK MANAGEMENT
lining of the airway, resulting in obstruction. A blow to
the neck can result in edema of surrounding tissues, caus- In every care setting, nurses have the unique opportunity
ing the airway to close. among health care professionals to provide child and family
Injuries may involve some blood loss. Fortunately, a teaching concerning the prevention of accidents. Even in the
child’s circulatory system is capable of rapid compensa- acute care setting when an accident has already occurred,
tion for blood loss by vasoconstriction. Because the total nurses can provide valuable instruction to families about
volume of blood in a child is reduced, however, blood loss safeguarding their children against future accidents. In a
in children is always potentially serious. Because of this, community setting, nurses have a great opportunity for as-
many health care agencies have standing orders that allow sessment of the unique threats that are present in particular
emergency care nurses to begin intravenous normal saline environments such as lead-based paint or kerosene heaters in
boluses on children with obvious blood loss. older homes, risk of drowning in a home with an unfenced
Often, in the emergency department, large portions swimming pool, or the danger for children riding in the back
of the child’s body must be exposed to view so that care of pickup trucks. To teach effective accident prevention,
can be given easily. This means that rapid cooling can nurses need to be knowledgeable about common measures
occur. Because of the large body surface area of children that prevent injury.
in relation to weight, always be conscious of body tem- Poisoning is an important cause of serious injuries in chil-
perature and take active measures to decrease cooling by dren younger than 6 years of age; more than 1 million
keeping a child covered as much as possible during ex- episodes occur every year (Dart & Rumack, 2008). Common
amination times. household agents are often the cause. Since passage of the
Standard infection precautions must be maintained in Poison Prevention Packaging Act of 1970, potentially haz-
emergency situations, the same as at any other time. ardous products must be sold in child-resistant containers.
Parental consent must be obtained for treatment proce- Passage of this act initiated a decrease in the incidence of
dures even in an emergency, except for life-saving actions, childhood poisonings from common medicines.
such as cardiopulmonary resuscitation. In these instances, The home environment may still contain products that
action can and should be taken to save a child’s life with can be hazardous and poisonous to children if handled im-
or without parental permission (it is assumed that parents properly. Plants, cosmetics, and cleaning products can be
would consent to life-saving procedures). Delaying emer- dangerous to children if ingested or absorbed through the
gency procedures until parents can be located may result skin. Teach parents to be aware of these dangers and of
in permanent disability or death. strategies for maintaining a safe home environment, includ-
ing learning basic first aid procedures.
Outcome Evaluation Measures for a safe home environment include actions
After an injury, children need follow-up care to be certain such as installing child-resistant locks on low cabinets where
that the immediate interventions were adequate and that household products are stored, moving plants to a higher sur-
healing is taking place. Evaluation visits are also the time face or removing them from the home until the child is older,
to determine whether the child’s environment has been keeping matches in safe places, and teaching street safety. In
changed and is safer now than at the time of the accident addition, parents should anticipate that, even in the safest en-
(if applicable). At the time of the accident, parents may vironment, a child can be injured. Along with knowledge of
have been too anxious to hear health supervision informa- basic first aid, the telephone number of the local poison con-
tion. Now, with the accident behind them, they are ready trol center should be posted by the telephone.
for such information and prepared to make changes.
If an injury could not have been anticipated, parents
appreciate hearing one more time that such an accident HEAD TRAUMA
could not have been avoided and that they are good par- Children receive head injuries when they are involved in mul-
ents. This helps them maintain adequate self-esteem to tiple-trauma accidents, such as automobile crashes. Falls from
continue to function well as parents. swing sets, porches, and bunk beds also cause many head in-
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1547
juries. Other children are injured by being struck on the head urine is between 1.003 and 1.030; pulse remains be-
by an object, such as a baseball, rock, or hockey puck, or by tween 60 to 100 beats per minute; blood pressure
falling from a bicycle (Faries & Battan, 2008). remains consistent for age group; lungs are clear to
Head injuries are always potentially serious not only be- auscultation.
cause they can cause an immediate threat to the life of the When hypertonic solutions are being infused intra-
child, but also because several complications may follow. With venously into children, assess vital signs frequently to
a depressed skull fracture, for example, recurrent seizures can be certain that the fluid load being pulled into the in-
occur. Many of these children show focal abnormalities on an travascular system does not overtax it. This fluid must
electroencephalogram (EEG) because of scar tissue formation. be excreted by the kidneys to keep the vascular sys-
Some children with seizure involvement have normal EEGs, tem from becoming overloaded. Keep accurate intake
however, so, by itself, the EEG is of limited value in predict- and output records to ensure that the kidneys are
ing whether posttraumatic seizures will occur. functioning, and test the specific gravity of urine to
Some children experience memory deficits or minor per- detect the development of pituitary compression and
sonality changes after head injury (Fazio et al., 2007). resultant overproduction or underproduction of antidi-
Symptoms such as headache, irritability, and postural ver- uretic hormone from the posterior pituitary.
tigo (sensation of feeling faint or the inability to maintain
normal balance—also known as posttrauma syndrome) also Nursing Diagnosis: Risk for delayed growth and devel-
may occur. Behavioral manifestations may include aggres- opment related to late sequelae of head injury
siveness or poor school performance. It often is difficult to Outcome Evaluation: Child shows no evidence of any
determine whether these symptoms are organic or the result alteration in thought processes, seizure activity, or
of being treated differently than usual by anxious parents. memory at follow-up visits. Cognitive and physical de-
velopment are appropriate for age.
Immediate Assessment Helping care for a child with a head injury can be dif-
All children with head trauma require a neurologic assess- ficult for parents because they are so worried. Offer
ment as soon as they are seen and again at frequent intervals information on the child’s progress as it becomes
to detect signs and symptoms of increased intracranial pres- available to you. Urge parents to help care for the
sure (ICP). Increasing pressure puts stress on the respiratory, child to increase their sense of control.
cardiac, and temperature centers, causing dysfunction in During the acute phase of illness, ensure that
these areas. With increased pressure, the pupils become slow parents are informed about the dangers of increased
or unable to react immediately. Level of consciousness and ICP. If they ask about the possibility that personality
motor ability decrease, pulse and respiratory rates decrease, changes or seizures will develop later in life, their
and temperature and pulse pressure increase. questions should be answered truthfully. At the same
Assess vital signs to detect these changes and observe chil- time, do not give unnecessary warnings about
dren’s pupils to be certain that they are equal and react to observing the child carefully in the months to come.
light. Assess children’s level of consciousness and motor Head injuries by themselves are worrisome enough
function. Stabilize the neck with a brace until cervical trauma to parents and children without adding to their
has been ruled out. burden.
1548 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
Frontal suture tissue, bone cannot heal and actually erodes, so that the frac-
Anterior fontanel ture site becomes progressively larger, not smaller. This be-
comes evident on a follow-up radiograph. It may be sus-
pected if a child develops focal seizures or symptoms of
Frontal bone increased ICP. The defect may be palpated on the skull as an
Coronal suture underlying indentation. Surgical resection is necessary to re-
move the cyst.
Sagittal suture
Subdural Hematoma
Subdural hematoma is venous bleeding into the space be-
Parietal bone tween the dura and the arachnoid membrane (Fig. 52.2A). It
occurs when head trauma lacerates minute veins in this area
(Amirjamshidi et al., 2007). The collection of blood is usu-
ally bilateral.
Subdural hematomas tend to occur in infants more often
Lambdoid suture than in older children. Symptoms may occur within 3 days
Posterior fontanel
or as late as 20 days after trauma. Infants usually have symp-
Occipital toms of increased ICP. Seizures, vomiting, hyperirritability,
bone
and enlargement of the head may occur. Anemia caused by
FIGURE 52.1 Location of suture lines of the skull. the substantial blood loss is a prominent sign. Angiography
or ultrasound reveals the extent of the hematoma.
In infants, accumulated subdural blood may be removed
Take a careful history of the accident, so that the strength by a subdural puncture through the lateral aspect of a patent
of the blow to the head can be judged. Shock with hypoten- anterior fontanelle. The procedure is similar to a lumbar
sion rarely occurs with an isolated head injury. If a child is in puncture. Infants receive conscious sedation or must be held
shock, investigate for bleeding points other than the head in- extremely still during the procedure so that they do not move
jury. Skull fractures are confirmed by skull radiography. and cause the aspiration needle to be inserted incorrectly.
If a skull fracture is linear with no underlying pathology, Without conscious sedation, half of the success of subdural
no treatment except observation and prescription of an anal- puncture depends on the ability to hold the child still.
gesic is necessary. In about 3 weeks, a repeat radiograph will Subdural punctures may need to be repeated daily to
be needed to confirm that healing has taken place. Parents empty the subdural space. Once the space is empty, expand-
can be reassured that a second radiograph this soon is not ing brain tissue will naturally occlude it. If the space has not
harmful but necessary. been occluded after 2 weeks of daily punctures, active bleed-
If a fracture is depressed (a bone fragment is pressing in- ing is still present, and surgery usually is necessary to reduce
ward) or compounded (bone is broken into pieces), surgery the space and halt bleeding.
will be necessary to remove or repair broken fragments. In older children, surgery usually is necessary, because the
Cranial surgery of this type is discussed in Chapter 49. anterior fontanelle is closed and the space cannot be reached
by puncture.
Therapeutic Management
If CSF is draining from the nose, a child will be admitted to Epidural Hematoma
the hospital for observation. Keep the child in a semi-
Fowler’s position so that fluid drains out, not inward, to re- Epidural hematoma is bleeding into the space between the
duce the possibility of introducing infection. Make certain dura and the skull (Fig. 52.2B). This happens when head
that children do not attempt to hold their nose or pack their trauma is severe. Subdural hemorrhage is usually venous bleed-
nostrils with something to halt the drainage. Because cough- ing, but epidural hemorrhage is usually a result of rupture of
ing and sneezing may allow air to enter the meningeal space, the middle meningeal artery and is, therefore, arterial bleeding.
coughing may be suppressed by medication. If the drainage It usually is intense and causes rapid brain compression.
is excoriating to the upper lip, coat the space with petrola- At the time of the injury, children become momentarily
tum. Children may be prescribed a prophylactic antibiotic to unconscious. They then regain consciousness and, to the un-
reduce the risk for meningitis. If the drainage does not stop trained eye, appear to be well for minutes or hours. Then
within a few days, surgery will be necessary to repair the frac- signs of cortical compression—vomiting, loss of conscious-
ture and reduce the danger of meningitis. Air that enters in- ness, headache, seizures, or hemiparesis (paralysis on one
tracranial spaces usually is absorbed rapidly. If radiographs at side)—are observed. On physical examination, unequal dila-
72 hours still show air in the cerebral spaces, it implies that a tion or constriction of the pupils may be present. Decorticate
skull defect remains, and surgery may be indicated to close posturing (see Chapter 49) may be seen, indicating extreme
the defect. pressure on upper cortical centers. If the pressure is allowed
to continue unchecked, cortical compression may be so great
Potential Complications that brainstem, respiratory, or cardiovascular function be-
comes impaired.
A long-term complication of even a linear fracture may be a As a rule, the closer to the time of the injury that symp-
leptomeningeal cyst. This results from projection of the arach- toms of compression occur, the more extreme is the
noid membrane into the fracture site. With the interfering amount of blood loss. The treatment is surgical removal of
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1549
Subdural hematoma
Dura mater
Pia
arachnoid
Dura mater
Epidural
hematoma
A B
FIGURE 52.2 (A) Subdural hematoma. The red area in the upper left area of the drawing is the hematoma. Note
the shift of structures. (B) Epidural hematoma. The red area in the lower left area of the drawing is the hematoma.
Note the broken blood vessel and the shift of midline structures.
the accumulated blood and cauterization or ligation of & Matthews, 2008). It may occur on the side of the skull
the torn artery. The earlier the process is recognized and that was struck (a coup injury) or on the opposite side of the
treated, the less the chance of residual damage from extreme brain (a contrecoup injury; Fig. 52.3). As the brain recoils
pressure or anoxia to the involved portion of the brain. from the force of the blow and strikes the posterior surface of
the skull, this second injury occurs. Children have at least a
Concussion transient loss of consciousness at the time of the injury. They
may vomit and may show irritability after regaining con-
Concussion is the temporary and immediate impairment of sciousness. They typically have no memory (amnesia) of the
neurologic function caused by a hard, jarring shock (Wilson events leading up to the injury or of the injury itself. For
Head
strikes
object
A B
1550 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
some children, this makes being asked questions about the Undress the child completely so that all body parts can be
accident extremely upsetting because they do not remember inspected. Although head injury is most likely to be the un-
anything that happened and feel a frightening loss of control. derlying cause of coma or seizure, metabolic disturbances
The child requires a skull radiograph to rule out skull frac- such as diabetes mellitus, dehydration, severe hemorrhage, or
ture and observation for 24 hours to rule out severe brain drug ingestion, also must be considered as possible causes.
trauma, edema, or laceration. A child usually can be observed Count respirations and pulse and measure blood pressure to
at home by the parents, who are instructed to check the establish baseline values, because changes in these values
child’s level of consciousness every 1 to 2 hours while the often provide good clues regarding the cause of coma. A child
child is awake. Parents usually are instructed not to keep with increased ICP, for example, will show decreased pulse
waking children during the night, because multiple wakings and respiratory rates and increased blood pressure. Diabetes,
are disorienting and can be confused with unconsciousness. in contrast, leads to increased respirations. Hemorrhage leads
Parents should wake the child at least once during the night, to an increased pulse rate and decreased blood pressure. Drug
however, and assess that the pulse rate is greater than 60 beats ingestion may lead to either increased or decreased measure-
per minute. ments, depending on the drug ingested.
To be certain that children are alert, parents can ask them If bulbar (brainstem) compression is present, a child can-
to name a familiar object, such as a favorite toy, or to name not swallow effectively or safely. If this is suspected, turn the
the color of some object shown to them. Telling parents their child on the side to prevent aspiration. Observe the eyes for
name or where they live is equally revealing. signs of increased ICP. If both pupils are dilated, irreversible
Give parents the telephone number to call if they have brainstem damage is suggested, although such a finding may
any questions about their child’s care. Advise them to call if also be present with poisoning from an atropine-like drug.
their child’s behavior changes in any way that seems worri- Pinpoint pupils suggest barbiturate or opiate intoxication.
some. Many parents need to set an alarm clock to wake One pupil dilated more than the other suggests third cranial
themselves during the night to assess their child’s status. nerve compression. An eye may be deviated downward and
There is an old belief that, if children fall asleep after a head laterally as well. This also may be caused by a tentorial tear
injury, they will die in their sleep; this belief causes some (laceration of the membrane between the cerebellum and
parents to keep shaking children awake or making them cerebrum) and herniation of the temporal lobe into the torn
walk continually. Be certain they understand that it is all membrane. This situation requires immediate surgery to cor-
right for children to sleep, but they must wake them at least rect temporal compression.
once to assess their status (see Focus on Nursing Care The retina of the eye should be examined for papilledema,
Planning Box 52.2). which will be present if increased pressure is long-standing
(more than 24 to 48 hours). Lack of a doll’s eye reflex sug-
Contusion gests that compression of the oculomotor nerves (third,
fourth, or sixth) or of the brainstem is involved. Observe for
A brain contusion occurs when there is tearing or laceration posturing, such as decerebrate posturing, which suggests
of brain tissue (Fig. 52.4). The symptoms are the same type cerebral compression and dysfunction.
as for concussion but more severe. In addition, there are spe- Many laboratory studies are helpful in determining the
cific symptoms related to the lacerated brain area such as a cause of coma. Blood glucose, blood electrolytes, blood urea
focal seizure, eye deviation, or loss of speech. Surgery may be
necessary to halt bleeding. The child’s prognosis depends on
the extent of the injury and effectiveness of therapy. Intracerebral
hemorrhage
Coma
Coma (unconsciousness from which a child cannot be
roused) or stupor (grogginess from which a child can be
roused) may be present in children after severe head trauma.
Coma and stupor are both symptoms of underlying disor-
ders; a history of the injury must be obtained so that treat-
ment can be directed specifically toward the cause.
Assessment
Obtain a history to determine the circumstances immediately
before the time the child became comatose. Assess children
in coma carefully and completely, so that the cause of the de- FIGURE 52.4 Intracerebral hemorrhage. The central large
creased consciousness can quickly be determined. dark area represents the hemorrhage. Note the midline shift.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1551
Jason, a 5-year-old boy, is seen in the emergency de- edematous area on the middle of his forehead. His twin
partment after an automobile accident. His family is sister, in a car seat beside him, was not injured. His
here on vacation. Child is crying and upset, although mother tells you, “I’m sure he’s not injured badly. He
the only visible signs of trauma are a reddened and was wearing his seat belt.”
Family Assessment ✽ Child is staying with twin sister him. Pupils equal, round, reactive to light and accommo-
and two parents in motel room while on 10-day vacation. dation bilaterally. 1.5-cm raised area noted on forehead.
Father normally works as a salesman. Mother clerks in Skin intact without evidence of bleeding. Child cries
department store. Father describes finances as “good.” when area is touched. Negative otorrhea or rhinorrhea.
Father concerned because rented car was totally de- Small 2-cm abrasion noted on right knee; 3-cm abrasion
stroyed in accident and his insurance may not cover this. noted on right hand. No other injuries noted. Able to
move all extremities through range of motion.
Client Assessment ✽ A 5-year-old boy visibly upset
A diagnosis of mild contrecoup concussion is made,
and crying. Height and weight at 75th percentile for age.
and child is to be discharged to motel in parents’ care.
Child unable to report or recall anything about the inci-
dent. Mother reports he was restrained by a seat belt Nursing Diagnosis ✽ Risk for injury related to effects of
but not a car seat. Head hit side window when a car concussion
struck their vehicle.
Vital signs: temperature, 99.4° F (37.5° C); respira- Outcome Criteria ✽ Child remains alert and oriented;
tions, 18 breaths/minute; pulse, 62 bpm; and blood pres- easily arousable. Pupils equal, round, react to light and
sure, 110/62 mm Hg. Left pupil is more dilated than his accommodation; vital signs within age-acceptable para-
right; it reacts sluggishly to light. Glasgow Coma score is meters; exhibits no signs or symptoms of neurologic
10. Alert enough to name toy racing car brought in with dysfunction.
Team Member
Responsible Assessment Intervention Rationale Expected Outcome
Nurse Take history of acci- Assess child’s vital Changes in vital signs, Parent describes acci-
dent, speed car was signs, level of con- level of conscious- dent and reactions of
traveling, and posi- sciousness, and ness, or neurologic child since accident.
tion of child in neurologic function function indicate a
vehicle. initially, and then worsening of the
every 30 min until child’s condition and
discharge. possibly increasing
intracranial pressure.
Consultations
Procedures/Medications
Physician/nurse Assess whether child’s Institute measures to Crying increases Parents are able to
demeanor (crying) is calm the child. intracranial pressure. calm child to allow
from fright or pain. Encourage the par- Involving the parents for better evaluation
ents to hold and provides them with a of condition.
reassure him. concrete activity,
helping to provide
some sense of
control over the
situation.
Physician/nurse Assess whether child Schedule a skull radi- Skull radiograph rules out Child cooperates with
has had experi- ograph or other a possible skull frac- diagnostic proce-
ence with x-ray diagnostic tests as ture secondary to the dures; results are
examination. ordered, such as CT trauma. CT scan or available for physi-
scan or MRI. MRI helps determine cian review.
any areas of bleeding
or edema if present.
(continued)
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1552 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
Nutrition
Nurse Assess whether If not NPO, feed small Vomiting is a symptom of Child eats some food
child has vom- amount of a favorite increased intracranial without vomiting.
ited since head food to be certain pressure.
injury. child does not have
vomiting.
Patient/Family Education
Nurse Assess what par- Teach parents how A contrecoup injury Parents state they un-
ents understand contrecoup injuries causes injury or edema derstand why their
about concus- occur and symp- to the posterior brain. child has posterior
sion in children. toms they cause. (eye control) cranial
symptoms, such as
unequal pupils.
Psychosocial/Spiritual/Emotional Needs
Nurse Assess whether Orient the child to his Children often have no Parents and child state
child or parents surroundings. Offer memory of events with they understand
have any ques- explanations about concussion. Parents procedures being
tions about care. any treatments or are in strange commu- carried out. Voice
procedures that are nity. Orientation and confidence in new
to come. explanation help to situation.
minimize a child’s fear
of the unknown and of
his situation.
Nurse Attempt to identify Encourage parents to Identification of the mean- Parents state they were
the meaning and express their feel- ing and effect of the not responsible for
effect of the ings about them- child’s accident assists accident, or at least
child’s accident selves as parents in determining the did everything possi-
for the parents and their role in the degree to which the ble to avoid their
(e.g., father child’s accident. situation is affecting child’s injury.
upset over rent- the parents.
a-car liability).
Discharge Planning
Nurse/physician Assess whether Instruct parents to rouse Frequent waking can be Parents state they will
parents will be the child approximately disorienting to a child remain in motel for
staying in city or every 2 hours during and can be confused 24 hours, rather
traveling back daytime hours and at with altered levels of than fly home imme-
home during least once during the consciousness, but diately, so they can
next 24 hours. night, asking the child occasional waking is a observe child.
to name a familiar good way to assess
object or color. whether complications
are occurring.
Nurse Assess whether par- Schedule a return ap- A follow-up visit is neces- Parents state they un-
ents will be able pointment to clinic sary to be certain child derstand importance
to keep a follow- for 24-hour follow- can travel safely. of follow-up visit and
up appointment up visit. Supply will keep appoint-
for additional clinic telephone ment with child.
care. number if needed
before then.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1553
nitrogen (BUN), liver function tests, blood gas studies, lum- Lumbar puncture has little value at first in predicting the
bar puncture, and toxicology tests may be ordered to rule out severity of a head injury, because any degree of cerebral con-
possible causes such as bacterial meningitis or hemorrhage. tusion usually leads to increased CSF pressure. Lumbar
Computed tomography (CT) or MRI will be done if a head puncture is contraindicated if increased ICP is present as re-
injury is the most likely cause (Claret-Teruel et al., 2007). lease of fluid with the puncture can cause brainstem com-
Coma is usually graded according to a standard scale so pression into the cord. Obtain the child’s vital signs and as-
that changes in the level of consciousness can be evaluated ac- sess neurologic status, such as state of consciousness and the
curately. Figure 52.5 shows the Glasgow Coma Scale, a com- ability of pupils to react to light, every 15 to 20 minutes or
monly used evaluation system (Morris, 2008). Because this as ordered. Accurately and carefully record this information
system was devised as an adult assessment scale, it must be so that a picture of gradual change will become apparent.
modified for use with children or infants. Such a modifica- A child’s prognosis after coma depends on the initial cause
tion is shown in Box 52.3. of the coma. If the increased ICP can be relieved before any
A score of 3 to 8 on the scale suggests severe trauma (a permanent brain damage results, the effects of the coma will
number less than 5 suggests a very severe prognosis); a score be transient. Prognosis is always guarded, however, because
of 9 to 12, moderate trauma; and 13 to 15, slight trauma. coma reflects a potential health problem for a child.
Therapeutic Management
If children are unconscious for longer than a transient period,
Nursing Diagnoses and Related
they usually are admitted to an observation unit for further Interventions
assessment. As a general rule, place a child who is comatose ✽
on the side to reduce the risk of aspiration. Oral suctioning Care of the child in coma is directed toward maintain-
to remove mucus from the mouth and pharynx may be nec- ing body function in an optimal state until the child
essary. If a child has acute signs of respiratory difficulty, en- reawakens.
dotracheal intubation may be necessary to ensure respiratory Nursing Diagnosis: Risk for ineffective airway clear-
function. ance related to brainstem pressure
An IV route is established so that, when specific measures
such as blood replacement, electrolyte replacement, or fluid Outcome Evaluation: Child’s respiratory rate remains
replacement are needed, a route for immediate administra- between 16 and 20 breaths/minute; there are no re-
tion will be available. Blood will be drawn for a complete tractions or signs of obstruction.
blood count, electrolyte determination, toxicology tests, and Some children who are comatose require endotra-
cross-matching. If the cause of the coma is unknown, a lum- cheal intubation or tracheostomy to ensure an open
bar puncture and EEG may be done. Skull radiography, CT airway. Some are placed on mechanical ventilation.
scan, or MRI may be done. Oxygen may be prescribed if arterial blood gases
To pain 2 X X X
No response 1
Localizes pain 5 X X
Flexion withdrawal 4 X X
Flexion 3 X
Extension 2
No response 1
Conversation confused 4 X X
Inappropriate speech 3 X
Incomprehensible sounds 2 X X
No response 1
FIGURE 52.5 Glasgow Coma Scale scoring for a child. A score of 3 to 8 denotes severe
trauma; 9 to 12, moderate trauma; 13 to 15, slight trauma. Notice the gradual improvement
from coma in this example.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1557
a good chance that they will reimplant successfully. If a tooth hypertonic, causing fluid to osmose from the bloodstream
is knocked out, parents should rinse the tooth in water, drop and enter the alveoli, increasing the amount of fluid in the
it in a salt solution or milk, and bring it to the emergency de- lung tissue and increasing hypoxia. Tachycardia and de-
partment with them (Andersson, 2007). creased blood pressure from hypovolemia result. Blood vis-
Some dentists advocate immersing the tooth in an antisep- cosity increases as shown by an increased hematocrit level.
tic and then in an antibiotic solution before replacing it. If a Fresh water is hypotonic, so fluid in the lungs shifts into
tooth is replaced, it usually is wired into place to hold it in good the bloodstream because of osmotic pressure. This can lead
alignment. The child receives a course of oral antibiotics, such to hemolysis of red blood cells, a dilution of plasma, and pos-
as penicillin, to prevent infection. Only soft food must be eaten sibly hypervolemia with tachycardia and increased blood
until the tooth has firmly adhered (approximately 2 weeks). pressure. If the release of potassium from destroyed red blood
If a blow to a child’s teeth was extensive, a radiograph may cells is great enough with fresh-water drowning, cardiac ar-
be taken to rule out a mandibular or maxillary fracture. If a rhythmias may occur. In both instances, loss of surfactant
portion of a tooth cannot be located, the possibility of aspi- from lung alveoli, caused by introduction of water (adult res-
ration must be considered and confirmed or ruled out by a piratory distress syndrome), can lead to alveolar collapse on
chest radiography. In young children, often a tooth is not expiration (Bowers & Anderson, 2008).
knocked out but is pushed back up into the gum. These teeth Parents should advocate for neighborhood pools to be
gradually regrow, and, although they may darken in color, fenced and advise against hyperventilating before swimming.
they usually are healthy. If the affected tooth is a deciduous When children blow off carbon dioxide with hyperventilation
tooth, the permanent tooth is rarely injured even though it is this way, and then swim underwater for an extended period of
already formed in the gum. At the appropriate time, the per- time, carbon dioxide levels will rise, but not adequately
manent tooth will erupt normally. enough to cause them to experience distress. Oxygen levels
decrease causing drowsiness and listlessness (children drown
without struggling or realizing their danger).
NEAR DROWNING Very young children display a mammalian diving reflex
when they plunge under cold water that helps them survive
Drowning is death caused by suffocation from submersion drowning. Immediately after plunging into cold water, a life-
in liquid. Inhaled water fills the lungs and therefore blocks saving bradycardia and shunting of blood away from the pe-
the exchange of oxygen in the alveoli. More than 3500 chil- riphery of the body to the brain and heart occur. This reflex
dren die from drowning annually, making it the second most is triggered when water is 70° F (21° C) or less and the face
common cause of death by unintentional injury among chil- is submerged first. This explains why very young children can
dren. The term near drowning is used to describe the child survive better than older children after being submerged in
with a submersion injury who requires emergency treatment water that is very cold.
and who survives the first 24 hours after injury (Lee, Mao, &
Thompson, 2007). Emergency Management
Most infant drownings occur in bathtubs; 1- to 4-year-old
children most frequently drown in artificial pools; older chil- When a child is pulled from the water after near drowning,
dren most frequently drown in bodies of fresh water. The mouth-to-mouth resuscitation should be started at once. If
majority of drowning accidents that take place outside the cardiac arrest has occurred from hypoxia, simultaneous mea-
home occur in the summer months, when more children are sures to initiate cardiac action must be taken. The technique
swimming and boating. Particularly at risk are male adoles- of cardiopulmonary resuscitation for infants and children is
cents, because they may take dares to swim farther than their discussed in Chapter 41.
ability allows or may swim under the influence of alcohol, Assuming that cardiopulmonary resuscitation is effective,
which impairs their decision-making ability and their physi- the child needs follow-up care at a health care facility, be-
cal coordination. cause the child is certain to be acidotic from accumulated
carbon dioxide and hypoxia (resulting from lack of oxygen
Pathophysiology of Drowning because of the water in the alveoli) and is at risk for respira-
tory infection from contaminants in the water.
When children’s heads are submerged and they first inhale Follow-up care aims to increase the child’s oxygen and car-
water, they cough violently from the irritation of the water in bon dioxide exchange capacity, using the lung areas that are
their nose and throat. If they cannot get their head out of not filled with water. Typically, a child is intubated with a
water at this point, water will enter the larynx. This causes the cuffed intratracheal tube; mechanical ventilation with positive
larynx to spasm, preventing any further water but also air end-expiratory pressure may be necessary to force air into the
from entering the trachea, so asphyxia results. If a child is ven- alveoli. Because water has been swallowed, vomiting usually
tilated at this point, treatment usually is very effective because occurs as the child is revived. The cuff of the intratracheal
there is little water in the lungs. The condition more closely tube prevents vomitus from being aspirated. The child is
simulates asphyxia that occurs with croup or when a foreign given 100% oxygen so that as much space as possible in the
body, such as a nut, lodges in the trachea and stops air flow. available lung alveoli can be used. An NG tube is inserted to
If treatment is not given at this point, the larynx relaxes decompress the stomach, prevent vomiting, and free up
from the asphyxia and water enters the lungs. Oxygen can no breathing space. Usually, albuterol is administered by aerosol
longer be exchanged, because the alveoli fill with water. to prevent bronchospasm and, again, to allow the child to
Hypoxia deepens, and cardiac arrest occurs. make maximum use of the oxygen administered. If the child
Additional changes that occur when water enters the lungs aspirated salt water, plasma may be administered to replace
depend on whether the water is fresh or salt. Salt water is protein being lost into the lungs and prevent hypovolemia.
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If the child’s body temperature is very low, gradual warm- when poisoning occurs in an older child, it may not be poi-
ing (not using a warming blanket) is advised so that the soning but a suicide attempt.
metabolic requirement does not rise sharply before alveolar
space is ready to accommodate this need. Extracorporeal
membrane oxygenation may be used. Nursing Diagnoses and Related
Unfortunately, neurologic damage occurs in as many as
21% of near-drowning incidents. If the child is awake or Interventions
only lethargic at the scene of the accident and immediately ✽
afterward in the hospital, the prognosis is greatly improved Nursing Diagnosis: Risk for injury related to matura-
over that of the child who is comatose. tional age of child and presence of poisons
Outcome Evaluation: Parents identify poisonous and
toxic items in the home and describe how they are
Nursing Diagnoses and Related stored safely; parents state local poison control cen-
Interventions ter number; parents describe measures to seek help
immediately if poisoning occurs.
✽
Nursing Diagnosis: Risk for infection related to foreign
substance in respiratory tract
Emergency Management of Poisoning at Home
Outcome Evaluation: Child’s temperature remains within
normal parameters orally; rales are absent on lung If poisoning occurs, parents should telephone their local poi-
auscultation; respiratory rate is within age-acceptable son control center to ask for advice. Information parents need
parameters. to provide includes:
Following near drowning, a child may be prescribed • Child’s name, telephone number, address, weight, and
prophylactic antibiotic therapy to prevent pneumonia age and what the child swallowed
and additional airway interference. Assess vital signs • How long ago the poisoning occurred
and auscultate lung sounds for adventitious sounds, • The route of poisoning (oral, inhaled, sprayed on skin)
such as rales or fine rhonchi. Turning the child every • How much of the poison the child took (the bottle should
2 hours if on bedrest and encouraging deep breath- say how many pills or liquid it originally held).
ing and incentive spirometry every hour help to aerate • If the poison was in pill form, whether there are pills scat-
the lungs fully and prevent the accumulation of fluid, tered under a chair or if they are all missing and presumed
which promotes infection. swallowed
Nursing Diagnosis: Fear related to near-drowning • What was swallowed; if the name of a medicine is not
experience known, what it was prescribed for and a description of it
(color, size, shape of pills)
Outcome Evaluation: Child discusses fears; child • The child’s present condition (sleepy? hyperactive? comatose?)
states that she understands that, although frightening,
the experience is over, and she is now safe. If one child has swallowed a poison, parents should inves-
tigate whether other children have also poisoned themselves
Children may be admitted to an observation unit for as a preschooler often shares “candy” with a younger sibling.
monitoring of blood gases until water from the alveoli
is absorbed and they once again can ventilate effec-
tively on their own. Such children may wake at night
Emergency Management of Poisoning at the
from a nightmare that they are drowning. They need Health Care Facility
their parents to reassure them that they are now safe In the emergency department, the best method to deactivate
and definitely out of the water. Near drowning is a a swallowed poison is the administration of activated char-
thoroughly frightening experience. Encourage chil- coal, either orally or by way of an NG tube.
dren to verbalize this fright. They may need support Activated charcoal is supplied as a fine black powder that
from parents before they try swimming again after is mixed with water for administration. A sweet syrup may be
such a frightening experience. added to the mixture to make it more palatable. Caution par-
ents that, as the charcoal is excreted through the bowel over
the next 3 days, stools will appear black (Box 52.6).
POISONING Always follow emergency measures to neutralize a poison
with an education program for the family to prevent poison-
Poisoning occurs most commonly in children between the ing from happening again. Specific measures for each age
ages of 2 and 3 years. It occurs in all socioeconomic groups. group are discussed in previous chapters, along with prob-
Common agents include soaps, cosmetics, detergents or lems and concerns of that age group.
cleaners, and plants. Poisoning can occur from over-the-
counter drugs, such as vitamins, iron compounds, aspirin, or Acetaminophen Poisoning
acetaminophen, or from prescription drugs, such as antide-
pressants. Unlike other unintentional injuries, poisoning is Acetaminophen (Tylenol) is the drug most frequently involved
entirely preventable. Parents need education about the high in childhood poisoning today, because parents use
risk for poisoning and strategies for maintaining a home en- acetaminophen to treat childhood fevers. Told that aceta-
vironment that is safe for children of all ages. Be aware that minophen is safer than aspirin, parents may not be as careful
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1559
• Administer orally to conscious victims only. a. Advise the parents that their child must never receive ac-
• Give the drug as soon as possible after poisoning. etaminophen again.
• Store the drug in a closed container, because it ab- b. Counsel the parents about not taking medications in front of
sorbs gases from the air and is inactivated. children.
• Know that the solution feels gritty and tastes disagree- c. Question an order to give activated charcoal to neutralize
able, so young children have difficulty swallowing the the drug.
drug. May have to be administered by NG tube. d. Sympathize with parents, but reassure them this poisoning
• Caution child or parent that stools will be black for is not serious.
several days after administration.
Caustic Poisoning
about putting this drug away as they were with aspirin. If their Ingestion of a strong alkali, such as lye, which is often con-
child swallows acetaminophen, they may delay bringing the tained in toilet bowl cleaners or hair care products, may cause
child for help, thinking it is a harmless drug. Acetaminophen burns and tissue necrosis in the mouth, esophagus, and stom-
in large doses, however, is not an innocent drug; it can cause ach. It is important that the parents do not try to make a child
extreme liver destruction (Morgan & Borys, 2008). vomit after ingestion of these substances, because they can
Immediately after ingestion, the child will experience cause additional burning as they are vomited (ATSDR, 2008).
anorexia, nausea, and vomiting. Soon, serum aspartate
transaminase (AST [SGOT]) and serum alanine transami- Assessment
nase (ALT [SGPT]), liver enzymes, become elevated. The After a caustic ingestion, the child has immediate pain in the
liver may feel tender as liver toxicity occurs. mouth and throat and drools saliva because of oral edema and
Parents should call their local poison control center. In an inability to swallow. The mouth turns white immediately
the emergency department, activated charcoal or acetylcys- from the burn. Later, the mouth turns brown as edema and ul-
teine, the specific antidote for acetaminophen poisoning, will ceration occur. There may be such marked edema of the lips
be administered. Acetylcysteine prevents hepatotoxicity by and mouth that it is difficult to examine them. The child may
binding with the breakdown product of acetaminophen so immediately vomit blood, mucus, and necrotic tissue. The loss
that it will not bind to liver cells. Unfortunately, acetylcys- of blood from the denuded, burned surface may lead to sys-
teine has an offensive odor and taste. Administer it in a temic signs of tachycardia, tachypnea, pallor, and hypotension.
carbonated beverage to help the child swallow it. For small A chest radiograph may be ordered to determine whether
children, it is administered directly into an NG tube to avoid pulmonary involvement has occurred from any aspirated poi-
this difficulty. If the child is admitted to an observation unit, son or whether an esophageal perforation has allowed poison
continue to observe for jaundice and tenderness over the to seep into the mediastinum. An esophagoscopy under con-
liver; assess ALT and AST levels as ordered. scious sedation may be done to assess the esophagus, although
this test may be omitted because of the possibility that an
esophagoscope might perforate the burned esophagus. After
Nursing Diagnoses and Related 2 weeks, a barium swallow or esophagoscopy may be per-
Interventions formed to reveal the final extent of the esophageal burns.
✽
Nursing Diagnosis: Situational low self-esteem related Therapeutic Management
to child’s poisoning When parents whose child has ingested a caustic substance
Outcome Evaluation: Parents state guidelines for con- call a poison control center to ask for advice on how to pro-
tinued assessment of child at home; parents state ceed, they will be advised to immediately take the child to a
ways they can improve “childproofing.” health care facility for treatment. There is a high possibility
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that pharyngeal edema will be severe enough to obstruct the Iron Poisoning
child’s airway by even 20 minutes after the burn.
To detect respiratory interference, assess vital signs closely, Iron is frequently swallowed by small children because it is an
especially the respiratory rate. In infants, increasing restlessness ingredient in vitamin preparations, particularly pregnancy vi-
is an important accompanying sign of oxygen want. In the tamins. When it is ingested, it is corrosive to the gastric mu-
emergency department, intubation may be necessary to pro- cosa and leads to signs and symptoms of gastric irritation
vide a patent airway. Assess the child also for the degree of pain (Aldridge, 2007). The immediate effects include nausea and
involved. A strong analgesic, such as morphine, may need to vomiting, diarrhea, and abdominal pain. After 6 hours, these
be ordered and administered to achieve pain relief. symptoms fade, and the child’s condition appears to im-
prove. By this time, however, hemorrhagic necrosis of the
lining of the GI tract has occurred. By 12 hours, melena
(blood in stool) and hematemesis (blood in emesis) are pres-
Nursing Diagnoses and Related ent. Lethargy and coma, cyanosis, and vasomotor collapse
Interventions may occur. Coagulation defects may occur, and hepatic in-
✽ jury also can result. Shock resulting from an increase in pe-
Nursing Diagnosis: Risk for ineffective airway clear- ripheral vascular resistance and decreased cardiac output can
ance related to burns of esophagus and mouth occur. Long-term effects can include gastric scarring from fi-
brotic tissue formation.
Outcome Evaluation: Child’s respiration rate remains
within 16 to 20 breaths/minute.
Assessment
Starting therapy immediately after a caustic burn with a
steroid such as dexamethasone (Decadron) and con- It is difficult to estimate the amount of iron a child has swal-
tinuing it for about 4 weeks helps to reduce the chance lowed, because parents can only guess at the number of pills
of permanent esophageal scarring. In addition, chil- in the bottle. In addition, the amount of elemental iron in
dren may be prescribed a prophylactic antibiotic to compounds varies. The child’s serum iron level should be
reduce the possibility of infection and additional inflam- measured to establish a baseline.
mation in the denuded mouth and esophageal area.
Children who respond well to steroid therapy usu- Therapeutic Management
ally recover with no important sequelae. Children who Parents should contact their poison control center immediately
do not receive steroid therapy for some reason may after the ingestion. In the emergency department, stomach
be left with scarring of the esophagus, resulting in lavage will be done to remove any pills not yet absorbed. A
complete obstruction. To correct complete obstruc- cathartic may be given to help the child pass enteric-coated iron
tion, a gastrostomy for feeding and repeated surgical pills. Activated charcoal is not given, because it is not effective
procedures are necessary. Sometimes transplanta- at neutralizing iron. A soothing compound such as Maalox or
tion of intestinal tissue or a synthetic graft is required Mylanta (aluminum hydroxide and magnesium hydroxide)
to replace stenosed esophageal tissue. may be given to help decrease gastric irritation and pain.
Nursing Diagnosis: Risk for imbalanced nutrition, less A child who has ingested a potentially toxic dose will be
than body requirements, related to esophageal stric- given a chelating agent, such as IV or intramuscular (IM) de-
ture from burn scarring feroxamine. Chelating agents combine with metals and allow
them to be excreted from the body. Caution parents that de-
Outcome Evaluation: Child’s diet meets recommended
feroxamine causes urine to turn orange as iron is excreted.
daily allowance requirements for age.
An exchange transfusion is another way that excess iron
Oral intake commonly will be a problem for the first can be removed from the body. An upper GI x-ray series and
week following a caustic injury because of soreness in liver studies may be ordered 1 week after the ingestion to
the child’s mouth. Liquid food is introduced first. screen for long-term effects. The hope is that the iron load
Liquid passing through the burned and scarring was removed from the stomach in time so that not all of it
esophagus tends to maintain esophageal patency, so was absorbed.
it is therapeutic for the burn as well as nutritious for the Assist with emergency measures, such as gastric lavage, and
child. Observe children carefully the first time they at- administer chelating agents as ordered. Parents may be asked to
tempt to drink something for coughing, choking, or test any stool passed for the next 3 days for occult blood, to as-
cyanosis, signs that are indicative of esophageal sess for stomach irritation and subsequent GI bleeding. Be cer-
stenosis or perforation. IV fluid may be needed as a tain that parents understand how to do this accurately.
supplement for such children. If a child is totally un-
able to swallow, gastrostomy feedings or total par-
enteral nutrition will be necessary.
Nursing Diagnoses and Related
Interventions
Hydrocarbon Ingestion ✽
Hydrocarbons are substances contained in products such Nursing Diagnosis: Deficient parental knowledge re-
as kerosene and furniture polish. Because these substances lated to the danger of iron as a poison
are volatile, fumes rise from them, and their major effect is Outcome Evaluation: Parents state ways they have
respiratory, not gastric, irritation (see Chapter 40). safeguarded their child from future iron exposure.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1561
Iron poisoning occurs frequently because parents do Many children with fairly high blood lead levels are
not think of iron pills or vitamins containing iron as asymptomatic. Others show insidious symptoms of anorexia
real medicine. Additionally, because many children’s and abdominal pain caused by the presence of lead in the
vitamins are manufactured in the shapes of familiar stomach. Children with encephalopathy usually have begin-
television or cartoon characters, children often think ning symptoms of lethargy, impulsiveness, and learning
of vitamins as candy. difficulties. As the child’s blood level of lead increases, severe
When you instruct parents to use an iron supple- encephalopathy with seizures and permanent neurologic
ment for themselves or their children, stress that over- damage will result.
doses can be fatal to small children. Teach them to The most widely used method of screening for lead
think of iron as they would any other medicine and levels is the blood lead determination (serum ferritin).
keep it out of the reach of small children. Unfortunately, this test requires the use of atomic absorp-
tion spectrophotometry, which is a costly procedure. The
free erythrocyte protoporphyrin test is a simple screening
Lead Poisoning procedure that involves only a fingerstick. Because proto-
porphyrin is blocked from entering heme by the lead, it will
When lead enters the body, it interferes with red blood cell be elevated in a child with lead poisoning.
function by blocking the incorporation of iron into the pro- Basophilic stippling (an odd striation of basophils) may
toporphyrin compound that makes up the heme portion of be apparent on a blood smear. A radiograph of the abdomen
hemoglobin in red blood cells (Morgan & Borys, 2008). This may reveal paint chips in the intestinal tract (Fig. 52.6A).
leads to a hypochromic, microcytic anemia. Kidney destruc- “Lead lines” (areas of increased density) may be present near
tion may occur in addition, causing excess excretion of the epiphyseal line of long bones (see Fig. 52.6B). The thick-
amino acids, glucose, and phosphates in the urine. The most ness of the line shows the length of time lead ingestion has
serious effect, however, is lead encephalitis: inflammation of been occurring (Kosnett, 2007).
brain cells because of the toxic lead content. Lead poisoning Damage to the kidney nephrons from the presence of lead
(plumbism), like all forms of poisoning in children, tends to leads to proteinuria, ketonuria, and glycosuria. Urine analy-
occur most often in the toddler or preschool child. (See sis reveals this. The CSF may have an increased protein level.
Chapter 30 for measures to prevent lead poisoning.)
Centers for Disease Control and Prevention. (2008). Preventing lead poisoning in young children. Washington, DC: U.S.
Department of Health and Human Services, Public Health Service.
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an accident, the child will need counseling to avoid drug use forced into the middle ear, possibly introducing infection
or about which drugs do not mix. If the incident was an at- (otitis media).
tempted suicide, the child will need observation and counsel- Often, it is better to wait for an otolaryngologist to care
ing toward more effective coping mechanisms in self-care. for the child, because trauma to the ear canal during an at-
tempt to remove a foreign body will increase the edema and
Therapeutic Management make removal even more difficult.
Children need supportive measures for their specific symp- Foreign Bodies in the Nose
toms, including oxygen administration, electrolyte replace-
ment (particularly if there is accompanying nausea and vom- Foreign objects stuffed into the nose eventually cause in-
iting), and perhaps IV fluid administration in an attempt to flammation and purulent discharge from the nares. The odor
dilute the drug. accompanying such impaction is often the first sign noticed
Children who have swallowed a drug of abuse need im- by a parent. Objects pushed into the nose usually can be re-
mediate treatment followed by investigation into the events moved with forceps. A local antibiotic might be necessary
leading to the poisoning. This potentially lethal ingestion after removal if ulceration resulted from the local irritation.
may act as a turning point in the child’s life, possibly alerting
the child and family to a drug problem and the need for help. Foreign Bodies in the Esophagus or Stomach
Factors such as reduction of fear and anxiety, increased cop-
ing mechanisms, knowledge of the effects of drug use, and Children tend not to chew food well or to swallow portions
availability of referral sources for a drug problem are impor- that are too big to pass safely through the esophagus. Pieces
tant areas to address. (See Chapter 33 for more information of candy, such as Lifesavers, are common objects caught in
related to adolescents and drug use.) the esophagus in young children; coins may be swallowed by
adolescents playing drinking games. Orthodontic appliances
may become dislodged and swallowed. Intense pain at the
✔Checkpoint Question 52.2 site where the object is lodged will result. If it is an object
Suppose Jason’s older brother had lead poisoning. What is that will dissolve, such as a Lifesaver or a piece of digestible
the most common source of lead poisoning in young children? meat, offer the child fluid to drink to help flush the object
a. Smelling lead fumes from cooking utensils. into the stomach. Even after the object dissolves or passes
b. Chewing on batteries that fall out of toys. into the stomach, the child will feel transient pain at the orig-
c. Drinking lead-contaminated drinking water. inal site of the obstruction.
d. Chewing on chips of lead-based outdoor paint. Magnets, particularly those in watches or hearing aids, are
also frequently swallowed by young children. These need to
be removed by endoscopy as soon as possible as they can lead
to bowel perforation or volvulus (Schierling et al., (2008).
Objects, such as a part of a toy or a chicken bone, that will
FOREIGN BODY OBSTRUCTION not dissolve and should not be passed, are also removed by
endoscopy (Weissberg & Refaely, 2007).
Foreign bodies can become lodged in children’s esophagus,
Small coins, such as pennies and dimes, usually pass by
ear canals, or noses, causing stasis of secretions and infection.
themselves without difficulty. Parents (or children them-
Direct obstruction or laceration of the mucous membrane
selves if adolescents) should observe stools over the next sev-
may also result, leading to serious consequences.
eral days to determine that the coin does pass through the GI
Whether a foreign substance is inhaled or embedded else-
tract (about 48 hours after ingestion). Without frightening
where, nursing interventions should focus first on comfort-
them, caution parents to observe for signs of bowel perfora-
ing the child and aiding in removal of the substance, and
tion or obstruction, such as vomiting or abdominal pain,
then on teaching the child and parents ways to avoid such oc-
until the object has passed. If there is any doubt, a radiograph
currences in the future.
taken 3 to 7 days after ingestion will establish whether the
object has been evacuated from the body.
Foreign Bodies in the Ear
Any child with a history of draining exudate from the ear Subcutaneous Objects
canal needs an otoscopic examination to establish the reason Children receive many wood splinters in the hands and feet.
for the drainage. In toddlers and preschoolers, the drainage These usually are removed easily by a probing needle and
often is the result of a foreign body in the ear canal. The ob- tweezers after cleaning with an antiseptic solution. If the pen-
ject might be a small piece of a toy, a piece of paper, a small etrating object is metal, such as a sewing needle or nail, its
battery, or food, such as a peanut (Singh et al., 2007). presence can be detected by radiography. If the object is one
Removal of a foreign body from the ear is difficult because that would have been in contact with soil, such as a rusty
children are afraid that the instrument used will hurt them, nail, the child will need tetanus prophylaxis after extraction
so they have difficulty lying still for the procedure. If there is of the object if tetanus immunization is not current.
reason to think that the tympanic membrane is intact, irri-
gating the object from the ear canal with a syringe and nor- What if... You received a call from your neighbor stating
mal saline may be possible. This should not be done if the that her 2-year-old son has swallowed a penny? What in-
object is a substance that will swell when wet, such as a
terventions would you expect to be necessary? What
peanut. If it is possible that the tympanic membrane is rup-
signs and symptoms would suggest GI obstruction?
tured, the ear canal must not be irrigated or fluid will be
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1565
BITES available, they should be used at the site where the bite oc-
curred. Excising the bite with a knife and sucking out the
Children receive bites from snakes and animals such as dogs venom orally (often shown in old western movies) is of ques-
or raccoons; they occasionally receive bites from other chil- tionable value and contradicts rules of standard infection pre-
dren. The source of a bite needs to be documented as human cautions. If the person administering the treatment has open
bites can also result from sexual abuse. mouth lesions, such as carious teeth, the procedure could be
dangerous to that person (venom is not dangerous when
Mammalian Bites swallowed, only when absorbed through open lesions).
Excising the bite also may lead to secondary infection and, if
Dog bites account for approximately 90% of all bites in- done too vigorously, may injure tendon or muscle. No time
flicted on humans, and children and adolescents are involved should be wasted before the child is transported to a health
in one third to one half of reported incidents. The dog is usu- care facility for treatment.
ally one owned by the child’s family. Cat bites, wild animal
bites, and human bites also constitute a threat, although they Emergency Management at the Health Facility
are less common in children. All of these bites can cause abra-
sions, puncture wounds, lacerations, and crushing injuries re- In the emergency facility, ask the child or a person who was
lated to the size of the animal and the location of the bite with the child to describe the snake. In areas where snakebites
(Jacobs, Guglielmo, & Chin-Hong, 2009). The biggest con- are frequent, keep available photographs of the venomous
cerns associated with animal bites are the possibility of long- snakes commonly found. Even a preschooler may be able to
term scarring and disfigurement and the possibility of infec- identify the snake by pointing to a photograph. Specific an-
tion, especially rabies, from the presence of microorganisms tivenin is then administered. Because rattlesnakes, copper-
in the animal’s mouth. This latter subject is discussed in heads, and cottonmouth moccasins are all one type of snake
Chapter 43. (pit vipers), one form of antivenin acts against all of these
bites. Specific antivenin is prepared for coral snake or cobra
Snakebite bites and is kept at most zoos. If the child receives antivenin
promptly after a bite, the prognosis for full recovery is good.
In the United States, snakebites tend to occur during the Tetanus prophylaxis is instituted if the child’s immunization
warm months of the year, from April to October. Most fatal status is unknown or if it has been more than 10 years since a
snakebites (envenomations) in the United States are copper- tetanus immunization was given.
head or rattlesnake bites. Copperheads are found in eastern Antivenin may contain a horse-serum base. Therefore,
and southern states, and rattlesnakes in almost every state. A before the serum is injected IM or IV, a skin test may need
few bites occur from cottonmouth moccasins or coral snakes to be performed to prevent a possible anaphylactic reaction
(both found in southeastern states). The effect of the bite of to the horse serum. If the serum is given IM, do not inject
a rattlesnake, copperhead, or cottonmouth moccasin (all pit it into an edematous body part, because medication ab-
vipers) is a failure of the blood coagulation system (Clark, sorption will be poor. Giving antivenin in the limb oppo-
2007). Coral snakes are known for the small coral, yellow, site the bitten limb is just as effective as administering it
and black rings encircling their body. Fortunately, they are into the bitten limb.
shy and seldom bite. However, the venom injected through
the bite of these snakes leads to neuromuscular paralysis.
1566 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
Assessment Burns
The affected body part appears white or erythematous; Burns are injuries to body tissue caused by excessive heat (heat
edema is present and it feels numb. Degrees of frostbite are greater than 104° F [40° C]). Such injuries commonly occur
summarized in Table 52.4. Explore the cause of frostbite by in children of all ages after infancy. They are the second great-
careful history taking. It occurs most frequently in children est cause of unintentional injury in children 1 to 4 years of age
who have been skiing, snowmobiling, or snowboarding for and the third greatest cause in children age 5 to 14 years.
long periods. If parents failed to provide adequate clothing Toddlers are often burned by pulling pans of scalding water or
because they underestimated the degree of cold outside, the grease off the stove and onto themselves or from bath water
possibility of neglect or child abuse must be ruled out as a that is too hot (Leahy et al., 2007). They can bite into electri-
cause. Frostbite also can occur from sucking on popsicles and cal cords. Older children are more apt to suffer burns from
from inhalant abuse. flames when they move too close to a campfire, heater, or fire-
place; touch a hot curling iron; or play with matches or lighted
Therapeutic Management candles. Eye burns can occur from splashed chemicals in sci-
ence classes (Pavan-Langston & Hamrah, 2008). Some burns
Always warm frostbitten areas gradually. Sudden warming in- (particularly scalding) can be caused by child abuse (Hicks &
creases the metabolic rate of cells; without adequate blood flow Stolfi, 2007). Burn injuries tend to be more serious in children
to the area because of still-present vasoconstriction, additional than in adults, because the same size burn covers a larger sur-
damage can occur. Administration of a vasodilator and use of face of a child’s body. As many as 50% of burns could be pre-
hyperbaric oxygen may help reduce the effect on body cells. vented with improved parent and child education.
Assessment
Nursing Diagnoses and Related When children are brought to a health care facility with a
Interventions burn injury, the first questions must be, “Where is the burn
✽ and what is its extent and depth?” Burns are classified ac-
Nursing Diagnosis: Pain related to frostbite damage cording to the criteria of the American Burn Association as
to cells major, moderate, or minor (Huether & McCance, 2007).
These classifications are shown in Table 52.5. Along with the
Outcome Evaluation: Child states that pain is con-
trolled at a tolerable level.
As soon as warming begins, the frostbitten area be-
comes extremely painful because the cells that are TABLE 52.5 ✽ Classification of Burns
Classification Description
Minor First-degree burn or second-
TABLE 52.4 ✽ Degrees of Frostbite degree burn ⬍10% of body
surface or third-degree burn
Degree Description ⬍2% of body surface; no area
of the face, feet, hands, or
First Mild freezing of epidermis; appears genitalia burned
erythematous with edema Moderate Second-degree burn between
Second Partial- or full-thickness injury; appears 10% to 20% or on the face,
erythematous with blisters and pain hands, feet, or genitalia or
occurring after rewarming third-degree burn ⬍10% of
Third Full-thickness injury (epidermis, dermis, body surface or if smoke
and subcutaneous tissue); appears inhalation has occurred
white Severe Second-degree burn ⬎20% of
Fourth Complete necrosis with gangrene and body surface or third-degree
possible ultimate loss of body part burn ⬎10% of body surface
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1567
size and depth, be certain to assess and document the loca- and is misleading in the very young child. Data for deter-
tion of the burn. Face and throat burns are particularly haz- mining the extent of burns in children are shown in Figure
ardous because there may be accompanying but unseen 52.7. Computer analysis is now available to rapidly assess the
burns in the respiratory tract. Resulting edema could lead to extent of burns.
respiratory tract obstruction. Hand burns are also hazardous
because, if the fingers and thumb are not positioned properly Depth of Burn. When estimating the depth of a burn, use
during healing, adhesions will inhibit full range of motion in the appearance of the burn and the sensitivity of the area to
the future. Burns of the feet and genitalia carry a high risk for pain as criteria. Descriptions of tissue at various burn depths
secondary infection. Genital burns are also hazardous be- are shown in Table 52.6 and are illustrated in Figure 52.8.
cause edema of the urinary meatus may prevent a child from Partial-thickness burns include first- and second-degree
voiding. burns. A first-degree burn involves only the superficial epi-
With adults, the “rule of nines” is a quick method of esti- dermis. The area appears erythematous. It is painful to touch
mating the extent of a burn. For example, each upper ex- and blanches on pressure (Fig. 52.9A). Scalds and sunburn
tremity represents 9% of the total body surface; each lower are examples of first-degree burns. Such burns heal by simple
extremity represents two 9s, or 18%, and the head and neck regeneration and take only 1 to 10 days to heal.
represent 9%. Because the body proportions of children are A second-degree burn involves the entire epidermis. Sweat
different from those of adults, this rule does not always apply glands and hair follicles are left intact. The area appears very
Infant
Anterior A A Posterior
1 1.25
1.25 1
1.5 1.5
2 2 2
2 1.5
13 1.25 13
1.5
1.25
B B
1 2.5 2.5
B
C B
C
C C
1.75 1.75
1.75 1.75
A 5-9 year-old A
1 1
2 13 2
2 13 2
1.5 1.5
1.5 1.5
1 2.5 2.5 1.25
1.25 1.25 1.25
B B
B B
C C C C
1568 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
Epidermis
Superficial
(1st degree)
Split
Partial thickness
thickness
(2nd degree)
Full
thickness
Full
thickness
(3rd degree)
Dermis
Subcutaneous
tissue
A B
FIGURE 52.9 Partial-thickness burns. (A) An infant with a first-degree burn on the arm and chest caused by scalding with hot
water. (B) A toddler with a second-degree burn caused by scalding. The area appears severely reddened and moist with some
blistering. (A, © Dr. P. Marazzi/SPL/Science Source/Photo Researchers. B, © NMSB/Custom Medical Stock Photograph.)
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1569
1570 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
lip contour. Obviously, you need to review with parents the tissue (Fig. 52.11). If the anterior throat is burned, for
importance of not leaving “live” electrical cords where young example, the head will be hyperextended to keep scar
children can reach them. tissue that forms on the anterior neck from pulling the
chin down against the chest in a contracture. It is diffi-
cult for children to watch television in this position or
Nursing Diagnoses and Related even to view activities on the unit so they need to be
encouraged to maintain this position. If they have
Interventions burns at extremity joints, they may have splints applied
✽ over burn dressings to maintain the joints in extension.
Nursing Diagnosis: Pain related to trauma to body cells Again, this makes activities very difficult and adds to
Outcome Evaluation: Child states that pain is at a tol- their stress if they do not have adequate pain relief.
erable level. Children who experience smoke inhalation may be
unconscious from brain anoxia immediately after a
Morphine sulfate is commonly the agent of choice. It
burn. Most children, however, are awake and very
can be administered IM, but, because circulation is
aware of the pain and treatments involved. Therefore,
impaired in children with shock, IV or epidural admin-
a priority need is immediate pain relief. After the first
istration is most effective. Use of patient-controlled
week following a major burn, some children develop
analgesia before performing any burn care such as
symptoms of delirium, seizures, and coma that result
débridement (the removal of necrotic tissue from a
from toxic breakdown of damaged cells, sensory de-
burned area) is also effective. Be sure to assess after
privation, isolation, and lack of sleep. Nursing care
administration that pain relief was adequate.
aimed at reducing unnecessary stimuli and providing
In addition to the pain from the burn, children may
adequate pain relief helps to prevent these late symp-
be required to remain in awkward positions to keep
toms from occurring.
joints overextended for most of every day. Doing so
helps to prevent formation of contractures from scar Nursing Diagnosis: Deficient fluid volume related to
fluid shifts from severe burn
Outcome Evaluation: Skin turgor remains good; hourly
urine output is greater than 1 mL/kg, with specific
gravity between 1.003 and 1.030; vital signs are within
acceptable parameters.
Immediately after a severe burn, the child’s circulatory
system becomes hypovolemic, because of a loss of
plasma, which oozes from blood vessels into the burn
site and then sequesters in edematous tissue sur-
rounding the site. This outpouring of plasma is caused
by an increased permeability of capillaries (or dam-
age to capillaries). It is most marked during the first
6 hours after a burn. It continues to some extent for the
first 24 hours.
A primary response of the myocardium to the shock
A of burn injury and hypovolemia can lead to a marked
reduction in cardiac output and decreased blood pres-
sure. Therefore, even with relatively minor burns, moni-
tor vital signs closely to allow early detection of this
event. A child may be severely anemic because of in-
jury to red blood cells caused by heat and loss of blood
at the wound site. The large amount of sodium lost with
the edematous burn fluid and the release of potassium
from damaged cells can lead to an immediate hypona-
tremia and hyperkalemia (Table 52.7).
Lactated Ringer’s solution is the commercially
available solution most compatible with extracellular
fluid. Usually, it is one of the first fluids begun for fluid
replacement, although normal saline may be used. A
FIGURE 52.11 (A) An adoles- child may also need plasma replacement and addi-
cent’s hand scarred from third- tional fluid, such as 5% dextrose in water. Do not
degree burns. Note the proper
administer potassium immediately after a burn until
extension and alignment of the
hand and fingers, which were kidney function is evaluated, to be certain that extra
maintained by the use of splints potassium can be eliminated. IV fluid is usually ad-
(B) during healing. (A, © Dr. P. ministered by the most convenient venous access, so
Marazzi/SPL/Science that morphine sulfate can be administered to relieve
B Source/Photo Researchers.) pain. A more stable fluid line may then be inserted.
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1571
1572 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
Symptoms of smoke inhalation may not occur im- tic therapy to prevent aspiration of vomitus. The tube
mediately but only 8 to 24 hours after the burn. A chest must remain in place until bowel sounds are detected.
radiograph taken at this time will reveal collecting ede- This usually occurs within 24 hours but may take as
matous fluid and decreased aeration. Continue to as- long as 72 hours in severely burned children. Fluid suc-
sess the child’s temperature every 4 hours for the first tioned from an NG tube may be blood-tinged (coffee-
week after the injury, to assess that lung infection is not ground fluid) because of bleeding caused by stomach
developing. Bronchodilators and antibiotics may be vessel congestion. Closely observe this drainage for a
prescribed. High-frequency ventilation may be helpful change to fresh bleeding, which can be caused by a
to keep alveoli functioning. Some children need extra- stress ulcer (Curling’s ulcer). This type of ulcer can be
corporeal membrane oxygenation (ECMO) support prevented by administering a histamine-2 receptor an-
because smoke inhalation has compromised their lung tagonist, such as cimetidine (Tagamet) or a proton
function to such a great extent. pump inhibitor such as omeprazole (Prilosec) in an at-
Nursing Diagnosis: Risk for impaired urinary elimina- tempt to reduce gastric acidity and ulcer formation.
tion related to burn injury If a bleeding ulcer occurs, gastric lavage with iced
saline may be necessary. Blood for transfusion should
Outcome Evaluation: Child’s urine output is greater be readily available, because the blood loss from a GI
than 1 mL/kg of body weight per hour. ulcer can be rapid and severe.
Because the child’s blood volume decreases immedi- If a child has burns over more than 30% of the body
ately after a burn, renal function is threatened by kidney surface, paralytic ileus may occur. Symptoms of in-
ischemia just when it is needed to rid the body of break- testinal obstruction, such as vomiting, abdominal dis-
down products from burned cells. If the child is burned tention, and colicky pain, will appear within hours of
over more than 10% of body surface, urinary output the burn.
may decrease immediately. Blood volume must be Children with severe burns usually are allowed
maintained by IV fluid administration to establish good nothing by mouth for 24 hours because of the danger
urinary output once more. Urine output should be of vomiting or paralytic ileus. After this, most children
1 mL/kg of body weight per hour. The specific gravity are able to eat, so oral feedings are begun as soon as
of urine also should be monitored to determine whether possible. To supply adequate calories for increased
the kidneys can concentrate urine to conserve body metabolic needs and spare protein for repair of cells,
fluid (failing kidneys lose this ability rapidly). In the days the diet is high in calories and protein (25 kcal/kg
after the burn, because products of necrotic tissue and body weight plus 40 kcal for each percent of burn sur-
toxic substances must be evacuated by the kidneys face per 24 hours). Children may also need supple-
and antidiuretic hormone and aldosterone levels are in- mental vitamins (particularly B and C) and iron sup-
creased in response to low blood pressure, kidney plements (Moelleken, 2009). High-protein drinks may
function may fail again. If free hemoglobin from de- be necessary between meals to ensure an adequate
stroyed red blood cells plugs kidney tubules (acute protein intake (Faries & Battan, 2008).
tubular necrosis), urine color will be red to black be- Because adequate nutrition is important, it may be
cause of the hemoglobin present. necessary to supplement the child’s diet with IV or
An indwelling urinary (Foley) catheter should be in- parenteral nutrition solutions or NG tube feeding. As
serted in the emergency department, and an immedi- additional methods of stimulating interest in eating,
ate urine specimen should be obtained for analysis. A encourage school-age children to help add intake
diuretic, such as mannitol, may be administered to and output columns, help the dietitian add a calorie-
flush hemoglobin from the kidneys. If this is effective, count list, or keep track of their own daily weight
the urine returns to its usual straw color. Throughout (taken at the same time each day in the same cloth-
the child’s hospital stay, observing urinary output is a ing). It may be helpful to make contracts with older
major nursing responsibility. children for a good nutritional intake.
Nursing Diagnosis: Risk for imbalanced nutrition, less Nursing Diagnosis: Risk for injury related to effects of
than body requirements, related to burn injury burn, denuded skin surfaces, and lowered resistance
Outcome Evaluation: Child’s weight remains within to infection with burn injury
normal age-appropriate growth percentiles; skin tur- Outcome Evaluation: Child’s temperature remains at
gor remains normal; urine specific gravity remains be- 98.6° F (37° C); skin areas surrounding burned areas
tween 1.003 and 1.030. show no signs of erythema or warmth.
After burns, the metabolic rate increases in children There appears to be some defect in the ability of neu-
as the body begins to pool its resources to adjust to trophils to phagocytize bacteria after burn injury. The
the insult. If children do not receive enough calories in formation of immunoglobulin G antibodies also ap-
IV fluid, their body will begin to break down protein. parently fails. For these reasons, a child has reduced
This is particularly dangerous because a child needs protection against infection. Staphylococcus aureus
protein for burn healing. Additionally, breakdown of and group A -hemolytic streptococci are the gram-
protein can lead to acidosis. positive organisms, and Pseudomonas aeruginosa is
After a severe burn, some children are nauseated the gram-negative organism, that commonly invade
from the systemic shock. An NG tube may be inserted burn tissue. Children are usually prescribed par-
and attached to low, intermittent suction as prophylac- enteral penicillin to prevent group A -hemolytic
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CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1573
streptococcal infection and tetanus toxoid to prevent Netting is useful to hold dressings in place, because it expands
tetanus. In addition to bacteria, fungi also may invade easily and needs no additional tape.
burns. Candida species are the most frequently seen
(Madoff, 2008). Topical Therapy. Silver sulfadiazine (Silvadene) is the drug
Nose, throat, and wound cultures may be done im- of choice for burn therapy to limit infection at the burn site
mediately and then daily to detect offending organ- for children. It is applied as a paste to the burn, and the area
isms. Bacteria and fungi can penetrate the burn es- is then covered with a few layers of mesh gauze. Silver sulfa-
char readily, so this tissue offers little protection from diazine is an effective agent against both gram-negative and
infection. Fortunately, granulation tissue, which forms gram-positive organisms and even against secondary infec-
under the eschar 3 to 4 weeks after the burn, is resis- tious agents, such as Candida. It is soothing when applied
tant to microbial invasion. and tends to keep the burn eschar soft, making débridement
Systemic antibiotics are not very effective in con- easier. It does not penetrate the eschar well, which is its one
trolling burn-wound infection, probably because the drawback.
burned and constricted capillaries around the burn Antiseptic solutions, such as povidone-iodine (Betadine),
site cannot carry the antibiotic to the area. For this rea- may also be used to inhibit bacterial and fungal growth.
son, any equipment used with the child must be ster- Unfortunately, iodine stings as it is applied and stains skin and
ile, to avoid introducing infection. Children are placed clothing brown. Dressings must be kept continually wet to
on a sterile sheet on the examining table. Personnel keep them from clinging to and disrupting the healing tissue.
caring for the severely burned child should wear caps, If Pseudomonas is detected in cultures, nitrofurazone
masks, gowns, and gloves, even for emergency care. (Furacin) cream may be applied. If a topical cream is not ef-
Although their burns may be covered by gauze fective against invading organisms in the deeper tissue under
dressings, children usually are cared for in private the eschar, daily injections of specific antibiotics into the
rooms to help reduce the possibility of infection. deeper layers of the burned area may be necessary.
Helping children maintain their self-esteem and keep- If a burned area, such as the female genitalia, cannot be
ing them from withdrawing from social contacts can be readily dressed, the area can be left exposed. The danger of
difficult when infection control precautions are required. this method is the potential invasion of pathogens.
Escharotomy. An eschar is the tough, leathery scab that
Therapy for Burns forms over moderately or severely burned areas. Fluid accu-
mulates rapidly under eschars, putting pressure on underly-
Second- and third-degree burns may receive open treatment, ing blood vessels and nerves. If an extremity or the trunk has
leaving the burned area exposed to the air, or a closed treat- been burned so that both anterior and posterior surfaces have
ment, in which the burned area is covered with an antibacter- eschar formation, a tight band may form around the extrem-
ial cream and many layers of gauze. These two methods are ity or trunk, cutting off circulation to distal body portions.
compared in Table 52.8. A synthetic skin covering (Biobrane), Distal parts feel cool to the touch and appear pale. The child
artificial skin (Integra), or amniotic membrane from placentas notices tingling or numbness. Pulses are difficult to palpate,
can be used to help decrease infection and protect granulation and capillary refill is slow (longer than 5 seconds). To allevi-
tissue. As a rule, burn dressings are applied loosely for the first ate this problem, an escharotomy (cut into the eschar) is per-
24 hours to prevent interference with circulation as edema formed (Moelleken, 2009). Some bleeding will occur after
forms. Be certain not to allow two burned body surfaces, such escharotomy. Packing the wound and applying pressure usu-
as the sides of fingers or the back of the ears and the scalp, to ally relieves this.
touch, because, as healing takes place, a webbing will form
between these surfaces. Do not use adhesive tape to anchor Débridement. Débridement is the removal of necrotic tissue
dressings to the skin; it is painful to remove and can leave ex- from a burned area. Débridement reduces the possibility
coriated areas, which provide additional entry for infection. of infection, because it reduces the amount of dead tissue
1574 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1575
Outcome Evaluation: Child states that he understands home and possessions to fire. They may need help in
the reason for infection control precautions; child ac- establishing priorities. It may be important that they
cepts it as a necessary part of therapy. wait at home one morning for an insurance inspector to
Infection control measures involved in the care of chil- make an estimate on damage to their house or furni-
dren with major burns consist of more than just plac- ture caused by the fire. Other tasks, such as shopping
ing the child in a private room. Aseptic technique and or house cleaning, could possibly be done by relatives
appropriate barriers are necessary to reduce the risk or neighbors, leaving them time to visit their child.
of exposing the child to infection. In some agencies, Nursing Diagnosis: Deficient diversional activity re-
all the people who come into the room must wear lated to restricted mobility after severe burn
gowns, masks, caps, and sterile gloves. The child is
Outcome Evaluation: Child expresses interest in obtain-
doubly isolated—by distance and by never being
ing school homework; child communicates with friends
touched directly.
and relatives by way of telephone, letters, or e-mail.
It is easy for children with burns (who were told
measures such as not to play with matches or go too Remember that, even if a child’s chest, abdomen, and
close to the fireplace) to interpret confinement in a hands are burned, he does not stop thinking so chil-
room as punishment. Make every effort to make the dren who are burned need stimulation in their envi-
child’s environment as warm and comforting as possi- ronment. A television set is good for passing time but
ble, despite infection control procedures. Place chil- should not be the child’s main communication with the
dren’s beds so they can see as much unit activity as outside world. Listening to favorite tapes, having sto-
possible. Decorate walls in front of them with cards ries read to them, talking about what is going on at
they receive or with a changing gallery of pictures home or what they normally do at school, and doing
drawn by staff members of things in which the child schoolwork are also important.
appears interested. It is important to make toys and play materials
Provide time for children to discuss their feelings available. Make certain to visit the child just to talk to
about being kept in a room by themselves. A question him or come to play a game at times other than pro-
such as, “It’s hard to understand a lot of things about cedure or treatment times. The child may be hospital-
a hospital; do you understand why your bed is in this ized for a long time. He needs to view the nursing staff
special room?” gives children a chance to express as friends and caregivers. Frequent visits convey that
their feelings. he is not alone and that others are aware of important
Show parents how to put on gowns, gloves, and needs.
masks (depending on agency policy), so they can Nursing Diagnosis: Disturbed body image related to
participate in the child’s care as much as possible. changes in physical appearance with burn injury
Parents often do not ask to do these things sponta-
neously when their children are severely burned. They Outcome Evaluation: Child expresses fears about
are in a state of grief, so they do not react in a normal physical appearance; demonstrates desire to resume
manner. They may believe the bulky dressings will age-appropriate activities.
make it impossible for them to hold the child. Actually, Children with burns are often forced to become ex-
the closed bulky dressings on the burned area make tremely dependent on the nursing staff because of the
it possible for the child to be held. If it is not possible position in which they must lie and because the bulky
for the child to be held, help the parents to see that dressings that cover their arms or hands prevent them
stroking their child’s face or touching a hand (even from feeding themselves. They respond to this forced
with gloves in place) gives the child a feeling of still dependence at first with gratitude. They are hurt, and
being loved. someone is taking care of them. After a period, how-
Nursing Diagnosis: Interrupted family processes re- ever, their response may become less healthy. The
lated to the effects of severe burns in family member young school-age child or preschooler may revert to
bedwetting or baby talk. Older children respond by
Outcome Evaluation: Family members state that they becoming openly aggressive to counteract their feel-
are able to cope effectively with the degree of stress ings of helplessness. They attempt to re-establish in-
to which they are subjected; family demonstrates pos- dependence in the ways that they can, often by refus-
itive coping mechanisms. ing to eat or to lie in a position that is best for them.
Children with severe burns always have a difficult hos- Make certain to allow independent decision-making
pitalization because of the pain, restrictions, and (at whenever possible. Children must take their 10 o’clock
some point) awareness of the disfigurement that ac- medicine, for example, but they can choose the fluid
companies major burns. they want to swallow after it. They must be fed meals
Some parents grieve so deeply over the child’s con- because of the bulky dressings over their hands, but
dition or are so concerned with other upsetting factors they can decide which food they will eat first. They
in their lives (many burns happen because of situa- must have their dressings changed, but they can
tional crises in the family) that their interaction with the choose the story you will read them afterward.
child seems to falter or proves very difficult for them. Be careful not to give choices when there really are
They may avoid visiting because the sound of the none to give. Inappropriate questions include, “Can I
child’s crying when they leave is more than they can change your dressing now?” “Do you want dinner
endure. At the same time, they may have lost their now?” “Will you swallow this pill?”
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1576 UNIT 7 The Nursing Role in Restoring and Maintaining the Health of Children and Families With Physiologic Disorders
Immediately after a severe burn, children (if they parents’ biggest concern. A father who dreamed that
are old enough to understand), parents, and proba- his son would be a great track star may be most con-
bly the hospital staff are most concerned with cerned about a leg scar; the child may be most con-
whether the child will live. After body systems have cerned about a facial burn.
stabilized and it seems appropriate to reassure the Children watch you as you care for them to see if
parents that their child will live, thoughts turn to the you find them unattractive. As dressings are removed,
child’s cosmetic appearance. At first, it is easy for children may expose parts of their body seemingly in-
children and parents to ignore this problem, be- appropriately, to see if you are shocked or revolted by
cause the burned areas are covered by dressings. them. It is easy to think that you will not react this way,
Even when the dressings are removed for débride- but, for everyone, the first sight of a severe burn is
ment or whirlpool therapy, it is easy for children to a shock and it is difficult not to react accordingly.
assume that the appearance of the burned area is Imagining how children feel, realizing that this muti-
only temporary and that the area will eventually heal lated skin is their skin, helps health care providers
and have a good appearance. They have probably maintain a professional attitude.
never seen anyone with a scar from a second- or Returning to school can be difficult for children
third-degree burn and have no reason to worry who have been hospitalized or have been receiving
about it (Fig. 52.14). home care for a long time. Their old friends have
When children see others on the unit with burn new friends, so they may feel cut out of school ac-
scars, they begin to realize what healing will look like. tivities. They look different if they have burn scars.
Depending on the extent and the site of the burn, par- The appearance of scar formation can be improved
ents and children have varying degrees of difficulty by the application of pressure dressings that the
accepting this reality. It can cause them to lose confi- child wears 24 hours a day. If the child has facial
dence in health care personnel. burns, facing friends with a compression bandage
Parents and children need time to talk about their in place or returning for laser therapy to reduce burn
feelings. A girl may be extremely concerned if her scarring may be difficult. They need a great deal of
chest is burned because she is worried that breast tis- support from health care personnel to be able to en-
sue will not develop, a very real concern, depending dure this. Some children need referral for formal
on the extent of the burn (Foley et al., 2008). Her par- counseling. Some parents need formal counseling
ents may be most concerned because they can see also, to help them accept their child’s changed
that, although a blouse can cover her chest, her right appearance.
hand will not have full function. Do not assume that
your biggest concern is the same as the child’s or the
✔Checkpoint Question 52.3
If Jason spilled scalding hot water on his hand, which of the
following would be the best emergency action?
a. Apply an ice compress to his hand.
b. Pour vegetable oil over his hand.
c. Cover his hand with a gauze dressing.
d. Apply hand lotion to keep the area moist.
CHAPTER 52 Nursing Care of a Family When a Child Has an Unintentional Injury 1577
Chart Booklet
March 2014
WHO Library Cataloguing-in-Publication Data:
15 booklets
Contents: - Introduction, self-study modules – Module 1: general danger signs for
the sick child – Module 2: The sick young infant – Module 3: Cough or difficult
breathing – Module 4: Diarrhoea – Module 5: Fever – Module 6: Malnutrition and
anaemia – Module 7: Ear problems – Module 8: HIV/AIDS – Module 9: Care of
the well child – Facilitator guide – Pediatric HIV: supplementary facilitator guide –
Implementation: introduction and roll out – Logbook – Chart book
1.Child Health Services. 2.Child Care. 3.Child Mortality – prevention and control.
4.Delivery of Health Care, Integrated. 5.Disease Management. 6.Education,
Distance. 7.Teaching Material. I.World Health Organization.
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Printed in Switzerland
Integrated Management of Childhood Illness
SICK CHILD AGE 2 MONTHS UP TO 5 YEARS
Determine if this is an initial or follow-up visit for this USE ALL BOXES THAT MATCH THE
problem. CHILD'S SYMPTOMS AND PROBLEMS
if follow-up visit, use the follow-up instructions TO CLASSIFY THE ILLNESS
on TREAT THE CHILD chart.
if initial visit, assess the child as follows:
Ask: Look: Any general danger sign Pink: Give diazepam if convulsing now
Is the child able to drink or See if the child is lethargic VERY SEVERE Quickly complete the assessment
breastfeed? or unconscious. DISEASE Give any pre-referal treatment immediately
Does the child vomit Is the child convulsing URGENT attention
Treat to prevent low blood sugar
everything? now? Keep the child warm
Has the child had Refer URGENTLY.
convulsions?
A child with any general danger sign needs URGENT attention; complete the assessment and any pre-referral treatment immediately so referral is not delayed.
THEN ASK ABOUT MAIN SYMPTOMS:
Does the child have cough or difficult breathing?
If yes, ask: Look, listen, feel*: Any general danger sign Pink: Give first dose of an appropriate antibiotic
For how long? Count the or SEVERE Refer URGENTLY to hospital**
Classify
breaths in COUGH or Stridor in calm child. PNEUMONIA OR
one minute. DIFFICULT VERY SEVERE
Look for BREATHING DISEASE
chest
CHILD Chest indrawing or Yellow: Give oral Amoxicillin for 5 days***
indrawing.
MUST BE Fast breathing. PNEUMONIA If wheezing (or disappeared after rapidly
Look and
CALM acting bronchodilator) give an inhaled
listen for
bronchodilator for 5 days****
stridor.
If chest indrawing in HIV exposed/infected child,
Look and
give first dose of amoxicillin and refer.
listen for
Soothe the throat and relieve the cough with a
wheezing.
safe remedy
If wheezing with either If coughing for more than 14 days or recurrent
fast breathing or chest wheeze, refer for possible TB or asthma
indrawing: assessment
Give a trial of rapid acting Advise mother when to return immediately
inhaled bronchodilator for up Follow-up in 3 days
to three times 15-20 minutes
No signs of pneumonia or Green: If wheezing (or disappeared after rapidly acting
apart. Count the breaths and
very severe disease. COUGH OR COLD bronchodilator) give an inhaled bronchodilator for
look for chest indrawing
5 days****
again, and then classify.
Soothe the throat and relieve the cough with a
If the child is: Fast breathing is: safe remedy
2 months up to 12 months 50 breaths per minute or more If coughing for more than 14 days or recurrent
wheezing, refer for possible TB or asthma
12 Months up to 5 years 40 breaths per minute or more assessment
Advise mother when to return immediately
Follow-up in 5 days if not improving
*If pulse oximeter is available, determine oxygen saturation and refer if < 90%.
** If referral is not possible, manage the child as described in the pneumonia section of the national referral guidelines or as in WHO Pocket Book for hospital care for children.
***Oral Amoxicillin for 3 days could be used in patients with fast breathing but no chest indrawing in low HIV settings.
**** In settings where inhaled bronchodilator is not available, oral salbutamol may be tried but not recommended for treatement of severe acute wheeze.
Does the child have diarrhoea?
Two of the following signs: Pink: If child has no other severe classification:
If yes, ask: Look and feel:
Lethargic or unconscious SEVERE Give fluid for severe dehydration (Plan C)
For how long? Look at the child's general
for DEHYDRATION Sunken eyes DEHYDRATION OR
Is there blood in the stool? condition. Is the child:
Not able to drink or drinking If child also has another severe
Lethargic or
poorly classification:
unconscious? Classify DIARRHOEA
Skin pinch goes back very Refer URGENTLY to hospital with mother
Restless and irritable? giving frequent sips of ORS on the way
slowly.
Look for sunken eyes. Advise the mother to continue
Offer the child fluid. Is the breastfeeding
child: If child is 2 years or older and there is
Not able to drink or cholera in your area, give antibiotic for
drinking poorly? cholera
Drinking eagerly,
Two of the following signs: Yellow: Give fluid, zinc supplements, and food for some
thirsty?
Restless, irritable SOME dehydration (Plan B)
Pinch the skin of the
Sunken eyes DEHYDRATION If child also has a severe classification:
abdomen. Does it go back:
Drinks eagerly, thirsty Refer URGENTLY to hospital with mother
Very slowly (longer
Skin pinch goes back giving frequent sips of ORS on the way
than 2 seconds)?
slowly. Advise the mother to continue
Slowly? breastfeeding
Advise mother when to return immediately
Follow-up in 5 days if not improving
Not enough signs to classify Green: Give fluid, zinc supplements, and food to treat
as some or severe NO DEHYDRATION diarrhoea at home (Plan A)
dehydration. Advise mother when to return immediately
Follow-up in 5 days if not improving
Dehydration present. Pink: Treat dehydration before referral unless the child
and if diarrhoea 14 SEVERE has another severe classification
days or more PERSISTENT Refer to hospital
DIARRHOEA
No dehydration. Yellow: Advise the mother on feeding a child who has
PERSISTENT PERSISTENT DIARRHOEA
DIARRHOEA Give multivitamins and
minerals (including zinc) for 14 days
Follow-up in 5 days
If yes: Any general danger sign or Pink: Give first dose of artesunate or quinine for severe malaria
Decide Malaria Risk: high or low Stiff neck. VERY SEVERE FEBRILE Give first dose of an appropriate antibiotic
High or Low Malaria DISEASE Treat the child to prevent low blood sugar
Then ask: Look and feel:
Risk
For how long? Look or feel for stiff neck.
or above)
If more than 7 days, has fever been Look for runny nose.
Classify FEVER Refer URGENTLY to hospital
present every day? Look for any bacterial cause of
Has the child had measles within the fever**. Malaria test POSITIVE. Yellow: Give recommended first line oral antimalarial
last 3 months? Look for signs of MEASLES. MALARIA
Generalized rash and or above)
One of these: cough, runny nose, Give appropriate antibiotic treatment for an identified bacterial cause
or red eyes. of fever
Advise mother when to return immediately
Do a malaria test***: If NO severe classification
Follow-up in 3 days if fever persists
In all fever cases if High malaria risk.
If fever is present every day for more than 7 days, refer for
In Low malaria risk if no obvious cause of fever present. assessment
Malaria test NEGATIVE Green:
Other cause of fever PRESENT. FEVER: or above)
NO MALARIA Give appropriate antibiotic treatment for an identified bacterial
cause of fever
Advise mother when to return immediately
Follow-up in 3 days if fever persists
If fever is present every day for more than 7 days, refer for
assessment
Any general danger sign Pink: Give first dose of an appropriate antibiotic.
No Malaria Risk and No
Stiff neck. VERY SEVERE FEBRILE Treat the child to prevent low blood sugar.
Travel to Malaria Risk
DISEASE
Area
or above).
Refer URGENTLY to hospital.
No general danger signs Green:
No stiff neck. FEVER or above)
Give appropriate antibiotic treatment for any identified bacterial
cause of fever
Advise mother when to return immediately
Follow-up in 2 days if fever persists
If fever is present every day for more than 7 days, refer for
assessment
**Look for local tenderness; oral sores; refusal to use a limb; hot tender swelling; red tender skin or boils; lower abdominal pain or pain on passing urine in older children.
*** If no malaria test available: High malaria risk - classify as MALARIA; Low malaria risk AND NO obvious cause of fever - classify as MALARIA.
**** Other important complications of measles - pneumonia, stridor, diarrhoea, ear infection, and acute malnutrition - are classified in other tables.
Does the child have an ear problem?
If yes, ask: Look and feel: Tender swelling behind the Pink: Give first dose of an appropriate antibiotic
Is there ear pain? Look for pus draining from ear. MASTOIDITIS Give first dose of paracetamol for pain
Is there ear discharge? the ear. Classify EAR PROBLEM Refer URGENTLY to hospital
If yes, for how long? Feel for tender swelling
Pus is seen draining from Yellow: Give an antibiotic for 5 days
behind the ear.
the ear and discharge is ACUTE EAR Give paracetamol for pain
reported for less than 14 INFECTION Dry the ear by wicking
days, or Follow-up in 5 days
Ear pain.
Pus is seen draining from Yellow: Dry the ear by wicking
the ear and discharge is CHRONIC EAR Treat with topical quinolone eardrops for 14 days
reported for 14 days or INFECTION Follow-up in 5 days
more.
No ear pain and Green: No treatment
No pus seen draining from NO EAR INFECTION
the ear.
THEN CHECK FOR ACUTE MALNUTRITION
CHECK FOR ACUTE MALNUTRITION Oedema of both feet Pink: Give first dose appropriate antibiotic
LOOK AND FEEL: Classify OR COMPLICATED Treat the child to prevent low blood
Look for signs of acute malnutrition NUTRITIONAL WFH/L less than -3 z- SEVERE ACUTE sugar
STATUS scores OR MUAC less MALNUTRITION Keep the child warm
Look for oedema of both feet.
Determine WFH/L* ___ z-score. than 115 mm AND any Refer URGENTLY to hospital
Measure MUAC**____ mm in a child 6 months or older. one of the following:
Medical
If WFH/L less than -3 z-scores or MUAC less than 115 complication present
mm, then: or
Check for any medical complication present: Not able to finish RUTF
Any general danger signs or
Any severe classification Breastfeeding
Pneumonia with chest indrawing problem.
If no medical complications present: WFH/L less than -3 z- Yellow: Give oral antibiotics for 5 days
Child is 6 months or older, offer RUTF*** to scores UNCOMPLICATED Give ready-to-use therapeutic food for a child
eat. Is the child: OR SEVERE ACUTE aged 6 months or more
MUAC less than 115 mm MALNUTRITION Counsel the mother on how to feed the child.
Not able to finish RUTF portion? Assess for possible TB infection
AND
Able to finish RUTF portion? Advise mother when to return immediately
Able to finish RUTF.
Follow up in 7 days
Child is less than 6 months, assess
breastfeeding: WFH/L between -3 and - Yellow: Assess the child's feeding and counsel the
2 z-scores MODERATE ACUTE mother on the feeding recommendations
Does the child have a breastfeeding OR MALNUTRITION If feeding problem, follow up in 7 days
problem? Assess for possible TB infection.
MUAC 115 up to 125 mm.
Advise mother when to return immediately
Follow-up in 30 days
WFH/L - 2 z-scores or Green: If child is less than 2 years old, assess the
more NO ACUTE child's feeding and counsel the mother on
OR MALNUTRITION feeding according to the feeding
recommendations
MUAC 125 mm or more.
If feeding problem, follow-up in 7 days
*WFH/L is Weight-for-Height or Weight-for-Length determined by using the WHO growth standards charts.
** MUAC is Mid-Upper Arm Circumference measured using MUAC tape in all children 6 months or older.
***RUTF is Ready-to-Use Therapeutic Food for conducting the appetite test and feeding children with severe acute malanutrition.
THEN CHECK FOR ANAEMIA
Check for anaemia Severe palmar pallor Pink: Refer URGENTLY to hopsital
Look for palmar pallor. Is it: SEVERE ANAEMIA
Severe palmar pallor*? Classify
Some pallor Yellow: Give iron**
Some palmar pallor? ANAEMIA Classification
arrow ANAEMIA Give mebendazole if child is 1 year or older and
has not had a dose in the previous 6 months
Advise mother when to return immediately
Follow-up in 14 days
No palmar pallor Green: If child is less than 2 years old, assess the
NO ANAEMIA child's feeding and counsel the mother according
to the feeding recommendations
If feeding problem, follow-up in 5 days
Positive virological test in Yellow: Initiate ART treatment and HIV care
ASK child CONFIRMED HIV Give cotrimoxazole prophylaxis*
Classify OR INFECTION
Has the mother or child had an HIV test? HIV counselling to the mother
status Positive serological test in a
IF YES: child 18 months or older Advise the mother on home care
Decide HIV status: Asess or refer for TB assessment and INH
Mother: POSITIVE or NEGATIVE preventive therapy
Child: Follow-up regularly as per national guidelines
Virological test POSITIVE or NEGATIVE Mother HIV-positive AND Yellow: Give cotrimoxazole prophylaxis
Serological test POSITIVE or NEGATIVE negative virological test in HIV EXPOSED Start or continue ARV prophylaxis as
a breastfeeding child or only recommended
If mother is HIV positive and child is negative or stopped less than 6 weeks Do virological test to confirm HIV status**
unknown, ASK: ago
Was the child breastfeeding at the time or 6 weeks before OR counselling to the mother
the test? Mother HIV-positive, child Advise the mother on home care
Is the child breastfeeding now? not yet tested Follow-up regularly as per national guidelines
If breastfeeding ASK: Is the mother and child on ARV OR
prophylaxis?
Positive serological test in a
IF NO, THEN TEST: child less than 18 months
Mother and child status unknown: TEST mother. old
Mother HIV positive and child status unknown: TEST child.
Negative HIV test in mother Green: Treat, counsel and follow-up existing infections
or child HIV INFECTION
UNLIKELY
* Give cotrimoxazole prophylaxis to all HIV infected and HIV-exposed children utill confirmed negative after cessation of breastfeeding.
** If virological test is negative, repeat test 6 weeks after the breatfeeding has stopped; if serological test is positive, do a virological test as soon as possible.
THEN CHECK THE CHILD'S IMMUNIZATION, VITAMIN A AND DEWORMING STATUS
MAKE SURE CHILD WITH ANY GENERAL DANGER SIGN IS REFERRED after first dose of an appropriate antibiotic and other urgent treatments. Treat all children with a general danger sign to prevent low
blood sugar.
HIV TESTING AND INTERPRENTING RESULTS
HIV testing is RECOMMENDED for:
Interpreting the HIV Antibody Test Results in a Child less than 18 Months of Age
Breastfeeding status POSITIVE (+) test NEGATIVE (-) test
NOT BREASTFEEDING, and has not in HIV EXPOSED and/or HIV infected - Manage as if they could be infected. HIV negative Child is not HIV infected
last 6 weeks Repeat test at 18 months.
BREASTFEEDING HIV EXPOSED and/or HIV infected - Manage as if they Child can still be infected by breastfeeding. Repeat test once breastfeeding has been
could be infected. Repeat test at 18 months or once discontinued for more than 6 weeks.
breastfeeding has been discontinued for more than 6 weeks.
WHO PAEDIATRIC STAGING FOR HIV INFECTION
Symptoms/Signs No symptoms, or only: Enlarged liver and/or spleen Oral thrush (outside neonatal Oesophageal thrush
Persistent generalized Enlarged parotid period). More than one month of herpes simplex ulcerations.
lymphadenopathy (PGL) Skin conditions (prurigo, seborraic dermatitis, extensive Oral hairy leukoplakia. Severe multiple or recurrent bacteria infections > 2
molluscum contagiosum or warts, fungal nail infection Unexplained and unresponsive episodes in a year (not including pneumonia) pneumocystis
herpes zoster) to standard pneumonia (PCP)*
Mouth conditions recurrent mouth ulcerations, linea therapy: Kaposi's sarcoma.
gingival Erythema) Diarhoea for over 14 days Extrapulmonary tuberculosis.
Recurrent or chronic upper respiratory tract infections Fever for over 1 month Toxoplasma brain abscess*
(sinusitis, ear infection, tonsilitis, Thrombocytopenia*(under Cryptococcal meningitis*
ortorrhea) 50,000/mm3 for 1month Acquired HIVassociated rectal
Neutropenia* (under fistula
500/mm3 for 1 month) HIV encephalopathy*
Anaemia for over 1 month
(haemoglobin under 8 gm)*
Recurrent severe bacterial
pneumonia
Pulmonary TB
Lymp node TB
Symptomatic lymphoid
interstitial pneumonitis (LIP)*
Acute necrotising ulcerative
gingivitis/periodontitis
Chronic HIV associated lung
diseses including
bronchiectasis*
*Conditions requiring diagnosis by a doctor or medical officer - should be referred for appropriate diagnosis and treatment.
TREAT THE CHILD
CARRY OUT THE TREATMENT STEPS IDENTIFIED ON THE ASSESS AND CLASSIFY CHART
Spacers can be made in the following way: Artemether-Lumefantrine Artesunate plus Amodiaquine tablets
Use a 500ml drink bottle or similar. tablets Give Once a day for 3 days
Cut a hole in the bottle base in the same shape as the mouthpiece of the inhaler. (20 mg artemether and 120
This can be done using a sharp knife. mg lumefantrine)
WEIGHT (age) (25 mg AS/67.5 (50 mg AS/135 mg
Cut the bottle between the upper quarter and the lower 3/4 and disregard the upper quarter of the Give two times daily for 3 mg AQ) AQ)
bottle. days
Cut a small V in the border of the large open part of the bottle to fit to the child's nose and be used as Day Day
a mask. Day 1 Day 2 day 3 Day 2 Day 3 Day 2 Day 3
1 1
Flame the edge of the cut bottle with a candle or a lighter to soften it.
In a small baby, a mask can be made by making a similar hole in a plastic (not polystyrene) cup. 5 - <10 kg (2 months up
1 1 1 1 1 1 - - -
to 12 months)
Alternatively commercial spacers can be used if available.
10 - <14 kg (12 months
1 1 1 - - - 1 1 1
To use an inhaler with a spacer: up to 3 years)
Remove the inhaler cap. Shake the inhaler well. 14 - <19 kg (3 years up to
2 2 2 - - - 1 1 1
Insert mouthpiece of the inhaler through the hole in the bottle or plastic cup. 5 years)
The child should put the opening of the bottle into his mouth and breath in and out through the mouth.
A carer then presses down the inhaler and sprays into the bottle while the child continues to breath
normally.
Wait for three to four breaths and repeat.
For younger children place the cup over the child's mouth and use as a spacer in the same way.
Give paracetamol every 6 hours until high fever or ear pain is gone.
* If a spacer is being used for the first time, it should be primed by 4-5 extra puffs from the inhaler.
PARACETAMOL
AGE or WEIGHT
TABLET (100 mg) TABLET (500 mg)
2 months up to 3 years (4 - <14 kg) 1 1/4
3 years up to 5 years (14 - <19 kg) 1 1/2 1/2
TEACH THE MOTHER TO GIVE ORAL DRUGS AT HOME
Follow the instructions below for every oral drug to be given at home.
Also follow the instructions listed with each drug's dosage table.
Give Iron*
Give one dose daily for 14 days.
IRON/FOLATE
IRON SYRUP
TABLET
Soothe the Throat, Relieve the Cough with a Safe Remedy Treat Thrush with Nystatin
Safe remedies to recommend: Treat thrush four times daily for 7 days
Breast milk for a breastfed infant. Wash hands
_____________________________________________________________________________
Instill nystatin 1ml four times a day
_____________________________________________________________________________ Avoid feeding for 20 minutes after medication
Harmful remedies to discourage:
_____________________________________________________________________________ Advise mother to wash breasts after feeds. If bottle fed advise change to cup and spoon
_____________________________________________________________________________ Give paracetamol if needed for pain
_____________________________________________________________________________
Give Mebendazole
Give 500 mg mebendazole as a single dose in clinic if:
hookworm/whipworm are a problem in children in your area, and
the child is 1 years of age or older, and
the child has not had a dose in the previous 6 months.
GIVE THESE TREATMENTS IN THE CLINIC ONLY
Give Artesunate Suppositories or Intramuscular Artesunate or
Explain to the mother why the drug is given.
Determine the dose appropriate for the child's weight (or age). Quinine for Severe Malaria
Use a sterile needle and sterile syringe when giving an injection. FOR CHILDREN BEING REFERRED WITH VERY SEVERE FEBRILE DISEASE:
Measure the dose accurately. Check which pre-referral treatment is available in your clinic (rectal artesunate suppositories,
Give the drug as an intramuscular injection. artesunate injection or quinine).
If child cannot be referred, follow the instructions provided. Artesunate suppository: Insert first dose of the suppository and refer child urgently
Intramuscular artesunate or quinine: Give first dose and refer child urgently to hospital.
IF REFERRAL IS NOT POSSIBLE:
Give Intramuscular Antibiotics For artesunate injection:
Give first dose of artesunate intramuscular injection
GIVE TO CHILDREN BEING REFERRED URGENTLY Repeat dose after 12 hrs and daily until the child can take orally
Give Ampicillin (50 mg/kg) and Gentamicin (7.5 mg/kg). Give full dose of oral antimlarial as soon as the child is able to take orally.
For artesunate suppository:
AMPICILLIN Give first dose of suppository
Repeat the same dose of suppository every 24 hours until the child can take oral antimalarial.
Dilute 500mg vial with 2.1ml of sterile water (500mg/2.5ml).
Give full dose of oral antimalarial as soon as the child is able to take orally
IF REFERRAL IS NOT POSSIBLE OR DELAYED, repeat the ampicillin injection every 6 hours.
For quinine:
Where there is a strong suspicion of meningitis, the dose of ampicillin can be increased 4
times. Give first dose of intramuscular quinine.
The child should remain lying down for one hour.
Repeat the quinine injection at 4 and 8 hours later, and then every 12 hours until the child is able
GENTAMICIN
to take an oral antimalarial. Do not continue quinine injections for more than 1 week.
7.5 mg/kg/day once daily
If low risk of malaria, do not give quinine to a child less than 4 months of age.
AMPICILLIN GENTAMICIN
AGE or WEIGHT
500 mg vial 2ml/40 mg/ml vial
RECTAL ARTESUNATE INTRAMUSCULAR INTRAMUSCULAR
2 up to 4 months (4 - <6 kg) 1m 0.5-1.0 ml SUPPOSITORY ARTESUNATE QUININE
4 up to 12 months (6 - <10 kg) 2 ml 1.1-1.8 ml AGE or WEIGHT 50 mg 200 mg
suppositories suppositories 60 mg 150 mg/ml* 300 mg/ml*
12 months up to 3 years (10 - <14 kg) 3 ml 1.9-2.7 ml vial (20mg/ml) 2.4 (in 2 ml (in 2 ml
Dosage 10 Dosage 10 mg/kg ampoules) ampoules)
3 years up to 5 years (14 - 19 kg) 5m 2.8-3.5 ml mg/kg mg/kg
2 months up to 4
1 1/2 ml 0.4 ml 0.2 ml
months (4 - <6 kg)
4 months up to 12
Give Diazepam to Stop Convulsions months (6 - <10 kg)
2 1 ml 0.6 ml 0.3 ml
Turn the child to his/her side and clear the airway. Avoid putting things in the mouth. 12 months up to 2
2 - 1.5 ml 0.8 ml 0.4 ml
Give 0.5mg/kg diazepam injection solution per rectum using a small syringe without a needle (like a years (10 - <12 kg)
tuberculin syringe) or using a catheter.
2 years up to 3
Check for low blood sugar, then treat or prevent. 3 1 1.5 ml 1.0 ml 0.5 ml
years (12 - <14 kg)
Give oxygen and REFER
If convulsions have not stopped after 10 minutes repeat diazepam dose 3 years up to 5
3 1 2 ml 1.2 ml 0.6 ml
years (14 - 19 kg)
DIAZEPAM
AGE or WEIGHT
10mg/2mls * quinine salt
2 months up to 6 months (5 - 7 kg) 0.5 ml
6 months up to 12months (7 - <10 kg) 1.0 ml
12 months up to 3 years (10 - <14 kg) 1.5 ml
3 years up to 5 years (14-19 kg) 2.0 ml
GIVE THESE TREATMENTS IN THE CLINIC ONLY
Are you trained to use Start rehydration by tube (or mouth) with ORS solution:
a naso-gastric (NG) give 20 ml/kg/hour for 6 hours (total of 120 ml/kg).
tube for rehydration? Reassess the child every 1-2 hours while waiting for
NO transfer:
If there is repeated vomiting or increasing abdominal
distension, give the fluid more slowly.
Can the child drink?
If hydration status is not improving after 3 hours, send the
NO child for IV therapy.
After 6 hours, reassess the child. Classify dehydration. Then
choose the appropriate plan (A, B or C) to continue treatment.
If still breastfeeding, continue by offering breast milk first before every RUTF feed.
Give only the RUTF for at least two weeks, if breastfeeding continue to breast and gradually introduce foods recommended for the age (See Feeding recommendations in COUNSEL THE MOTHER
chart).
When introducing recommended foods, ensure that the child completes his daily ration of RUTF before giving other foods.
Offer plenty of clean water, to drink from a cup, when the child is eating the ready-to-use therapeutic food.
STEP 2: DECIDE IF CAREGIVER IS ABLE TO GIVE ART STEP 4: RECORD BASELINE INFORMATION ON THE CHILD'S HIV TREATMENT CARD
Check that the caregiver is willing and able to give ART. The Record the following information:
Weight and height
to another adult who can assist with providing ART, or be part Pallor if present
of a support group. Feeding problem if present
Caregiver able to give ART: GO TO STEP 3 Laboratory results (if available): Hb, viral load, CD4 count and percentage. Send for any laboratory tests
Caregiver not able: classify as CONFIRMED HIV INFECTION that are required. Do not wait for results. GO TO STEP 5
but NOT ON ART. Counsel and support the
caregiver. Follow-up regularly. Move to the step 3 once the
caregiver is willing and able to give ART.
Birth up to 3 YEARS ABC or AZT + 3TC + LPV/r ABC or AZT + 3TC + NVP ABC or AZT + 3TC + NVP
AZT + 3TC + ABC
3 years and older ABC + 3TC + EFV ABC or AZT + 3TC + EFV or NVP ABC or AZT + 3TC + EFV
AZT + 3TC + ABC
AB AC AVIR (AB C )
Z IDO VUDINE (AZ T or Z DV)
L AMIVUDINE (3T C )
WEIGHT (KG) T arget dos e: 8mg/K g/dos e twice daily
20 mg/ml liquid 60 mg dispersible tablet 300 mg tablet 10 mg/ml liquid 60 mg tablet 300 mg tablet 10 mg/ml liquid 30 mg tablet 150 mg tablet
Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily Twice daily
3 - 5.9 3 ml 1 - 6 ml 1 - 3 ml 1 -
6 - 9.9 4 ml 1.5 - 9 ml 1.5 - 4 ml 1.5 -
10 - 13.9 6 ml 2 - 12 ml 2 - 6 ml 2 -
14 - 19.9 - 2.5 - - 2.5 - - 2.5 -
20 - 24.9 - 3 - - 3 - - 3 -
25 - 34.9 - - 1 - - 1 - - 1
TREAT THE HIV INFECTED CHILD
PERSISTENT DIARRHOEA
After 5 days: MALARIA
Ask:
Has the diarrhoea stopped? If fever persists after 3 days:
How many loose stools is the child having per day? Do a full reassessment of the child. > See ASSESS & CLASSIFY chart.
DO NOT REPEAT the Rapid Diagnostic Test if it was positive on the initial visit.
Treatment:
If the diarrhoea has not stopped (child is still having 3 or more loose stools per day), do a full Treatment:
reassessment of the child. Treat for dehydration if present. Then refer to hospital.
If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE.
If the diarrhoea has stopped (child having less than 3 loose stools per day), tell the mother to follow
If the child has any othercause of fever other than malaria, provide appropriate treatment.
the usual feeding recommendations for the child's age.
If there is no other apparent cause of fever:
If fever has been present for 7 days, refer for assessment.
Do microscopy to look for malaria parasites. If parasites are present and the child has finished a
full course of the first line antimalarial, give the second-line antimalarial, if available, or refer the
child to a hospital.
If there is no other apparent cause of fever and you do not have a microscopy to check for
parasites, refer the child to a hospital.
GIVE FOLLOW-UP CARE FOR ACUTE CONDITIONS
EAR INFECTION
After 5 days:
FEVER: NO MALARIA Reassess for ear problem. > See ASSESS & CLASSIFY chart.
Measure the child's temperature.
If fever persists after 3 days:
Do a full reassessment of the child. > See ASSESS & CLASSIFY chart. Treatment:
Repeat the malaria test. If there is , refer URGENTLY to
hospital.
Treatment: Acute ear infection:
If the child has any general danger sign or stiff neck, treat as VERY SEVERE FEBRILE DISEASE. If ear pain or discharge persists, treat with 5 more days of the same antibiotic. Continue wicking
to dry the ear. Follow-up in 5 days.
If a child has a positive malaria test, give first-line oral antimalarial. Advise the mother to return in 3
If no ear pain or discharge, praise the mother for her careful treatment. If she has not yet
days if the fever persists.
finished the 5 days of antibiotic, tell her to use all of it before stopping.
If the child has any other cause of fever other than malaria, provide treatment. Chronic ear infection:
If there is no other apparent cause of fever: Check that the mother is wicking the ear correctly and giving quinolone drops tree times a day.
If the fever has been present for 7 days, refer for assessment. Encourage her to continue.
Treatment:
If the child has COMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores or
MUAC is less than 115 mm or oedema of both feet AND has developed a medical complication
or oedema, or fails the appetite test), refer URGENTLY to hospital.
If the child has UNCOMPLICATED SEVERE ACUTE MALNUTRITION (WFH/L less than -3 z-scores
or MUAC is less than 115 mm or oedema of both feet but NO medical complication and passes
appetite test), counsel the mother and encourage her to continue with appropriate RUTF feeding. Ask
mother to return again in 14 days.
If the child has MODERATE ACUTE MALNUTRITION (WFH/L between -3 and -2 z-scores or MUAC
between 115 and 125 mm), advise the mother to continue RUTF. Counsel her to start other foods
according to the age appropriate feeding recommendations (see COUNSEL THE MOTHER chart). Tell
Home care:
Plan for the next follow-up visit
Counsel the mother about any new or continuing problems
HIV testing:
If appropriate, put the family in touch with organizations or people who could provide support
If new HIV test result became available since the last visit, reclassify the child for HIV according to the Advise the mother about hygiene in the home, in particular when preparing food
test result. Plan for the next follow-up visit
FEEDING COUNSELLING
Feeding Recommendations
Feeding recommendations FOR ALL CHILDREN during sickness and health, and including HIV EXPOSED children on ARV prophylaxis
Newborn, birth up to 1 week 1 week up to 6 6 up to 9 months 9 up to 12 months 12 months up to 2 years 2 years and older
months
Immediately after birth, put your baby in Breastfeed as often Breastfeed as Breastfeed as often Breastfeed as often Give a variety of
skin to skin contact with you. as your child wants. often as your child as your child wants. as your child wants. family foods to
Allow your baby to take the breast within Look for signs of wants. Also give a variety of Also give a variety of your child,
the first hour. Give your baby colostrum, hunger, such as Also give thick mashed or finely mashed or finely including animal-
the first yellowish, thick milk. It protects beginning to fuss, porridge or well- chopped family food, chopped family food, source foods and
the baby from many Illnesses. sucking fingers, or mashed foods, including animal- including animal- vitamin A-rich
Breastfeed day and night, as often as your moving lips. including animal- source foods and source foods and fruits and
baby wants, at least 8 times In 24 hours. Breastfeed day and source foods and vitamin A-rich fruits vitamin A-rich fruits vegetables.
Frequent feeding produces more milk. night whenever vitamin A-rich and vegetables. and vegetables. Give at least 1 full
If your baby is small (low birth weight), your baby wants, at fruits and Give 1/2 cup at each Give 3/4 cup at each cup (250 ml) at
feed at least every 2 to 3 hours. Wake the least 8 times in 24 vegetables. meal(1 cup = 250 ml). meal (1 cup = 250 each meal.
baby for feeding after 3 hours, if baby hours. Frequent Start by giving 2 to Give 3 to 4 meals ml). Give 3 to 4 meals
does not wake self. feeding produces 3 tablespoons of each day. Give 3 to 4 meals each day.
DO NOT give other foods or fluids. Breast more milk. food. Gradually Offer 1 or 2 snacks each day. Offer 1 or 2
milk is all your baby needs. This is Do not give other increase to 1/2 between meals. The Offer 1 to 2 snacks snacks between
especially important for infants of HIV- foods or fluids. cups (1 cup = 250 child will eat if between meals. meals.
positive mothers. Mixed feeding Breast milk is all ml). hungry. Continue to feed If your child
increases the risk of HIV mother-to-child your baby needs. Give 2 to 3 meals For snacks, give your child slowly, refuses a new
transmission when compared to each day. small chewable patiently. Encourage food, offer
exclusive breastfeeding. Offer 1 or 2 items that the child "tastes" several
snacks each day can hold. Let your your child to eat. times. Show that
between meals child try to eat the you like the food.
when the child snack, but provide Be patient.
seems hungry. help if needed. Talk with your
child during a
meal, and keep
eye contact.
A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.
FEEDING COUNSELLING
Infant formula
Always use a marked cup or glass and
spoon to measure water and the
scoop to measure the formula
powder.
Wash your hands before preparing a
feed.
Bring the water to boil and then let it
cool. Keep it covered while it cools.
FORMULA FEED exclusively. Do not give Give 1-2 cups (250 - 500 ml) of infant Give 1-2 cups (250 - 500 ml) of boiled,
Measure the formula powder into a
any breast milk. Other foods or fluids formula or boiled, then cooled, full then cooled, full cream milk or infant
marked cup or glass. Make the scoops
are not necessary. cream milk. Give milk with a cup, not a formula.
level. Put in one scoop for every 25 ml
Prepare correct strength and amount bottle. Give milk with a cup, not a bottle.
of water.
just before use. Use milk within two Give: Give: Add a small amount of the cooled
boiled water and stir. Fill the cup or
can store formula for 24 hours.
glass to the mark with the water. Stir
Cup feeding is safer than bottle
well.
feeding. Clean the cup and utensils * * Feed the infant using a cup.
with hot soapy water.
Start by giving 2-3 tablespoons of food 2 or family foods 3 or 4 times per day. Give Wash the utensils.
Give the following amounts of formula 8 - 3 times a day. Gradually increase to 1/2 3/4 cup (1 cup = 250 ml) at each meal.
to 6 times per day: cup (1 cup = 250 ml) at each meal and to
Offer 1-2 snacks between meals.
Age in months Approx. amount and times giving meals 3-4 times a day.
Continue to feed your child slowly, Cow' s or other animal milks are not
per day Offer 1-2 snacks each day when the
patiently. suitable for infants below 6 months of
0 up to 1 60 ml x 8 child seems hungry.
Encourage - but do not force - your child age (even modified).
1 up to 2 90 ml x 7 For snacks give small chewable items
to eat. For a child between 6 and 12 month of
2 up to 4 120 ml x 6 that the child can hold. Let your child try to
4 up to 6 150 ml x 6 age: boil the milk and let it cool (even if
eat the snack, but provide help if needed.
pasteurized).
Feed the baby using a cup.
* A good daily diet should be adequate in quantity and include an energy-rich food (for example, thick cereal with added oil); meat, fish, eggs, or pulses; and fruits and vegetables.
FEEDING COUNSELLING
Stopping Breastfeeding
STOPPING BREASTFEEDING means changing from all breast milk to no breast milk.
This should happen gradually over one month. Plan in advance for a safe transition.
1. HELP MOTHER PREPARE:
Mother should discuss and plan in advance with her family, if possible
Express milk and give by cup
NEXT WELL-CHILD VISIT: Advise the mother to return for next immunization according to
immunization schedule.
SICK YOUNG INFANT AGE UP TO 2 MONTHS
ASK: LOOK, LISTEN, FEEL: Any one of the following Pink: Give first dose of intramuscular antibiotics
Is the infant having Count the signs VERY SEVERE Treat to prevent low blood sugar
Classify ALL YOUNG
difficulty in feeding? breaths in one DISEASE Refer URGENTLY to hospital **
YOUNG INFANTS Not feeding well or
Has the infant had minute. Repeat Advise mother how to keep the infant warm
INFANT Convulsions or
convulsions (fits)? the count if more on the way to the hospital
MUST Fast breathing (60 breaths
than 60 breaths
BE per minute or more) or
per minute.
CALM Severe chest indrawing or
Look for severe
or
chest indrawing.
Low body temperature (less
Measure axillary or
temperature. Movement only when
Look at the umbilicus. Is it stimulated or no movement
red or draining pus? at all.
Look for skin pustules.
Umbilicus red or draining pus Yellow: Give an appropriate oral antibiotic
Look at the young infant's
Skin pustules LOCAL Teach the mother to treat local infections at home
movements.
If infant is sleeping, ask
BACTERIAL Advise mother to give home care for the young
the mother to wake
INFECTION infant
him/her. Follow up in 2 days
Does the infant move None of the signs of very Green: Advise mother to give home care.
on his/her own? severe disease or local SEVERE DISEASE
If the young infant is not bacterial infection OR LOCAL
moving, gently stimulate INFECTION
him/her. UNLIKELY
Does the infant not
move at all?
** If referral is not possible, management the sick young infant as described in the national referral care guidelines or WHO Pocket Book for hospital care for children.
CHECK FOR JAUNDICE
If jaundice present, ASK: LOOK AND FEEL: Any jaundice if age less Pink: Treat to prevent low blood sugar
When did the jaundice Look for jaundice (yellow than 24 hours or SEVERE JAUNDICE Refer URGENTLY to hospital
appear first? eyes or skin) CLASSIFY Yellow palms and soles at Advise mother how to keep the infant warm
Look at the young infant's JAUNDICE any age on the way to the hospital
palms and soles. Are they
Jaundice appearing after 24 Yellow: Advise the mother to give home care for the
yellow?
hours of age and JAUNDICE young infant
Palms and soles not yellow Advise mother to return immediately if palms and
soles appear yellow.
If the young infant is older than 14 days, refer to a
hospital for assessment
Follow-up in 1 day
No jaundice Green: Advise the mother to give home care for the
NO JAUNDICE young infant
IF YES, LOOK AND FEEL: Two of the following signs: Pink: If infant has no other severe classification:
Look at the young infant's general condition: Movement only when SEVERE Give fluid for severe dehydration (Plan C)
Infant's movements Classify stimulated or no movement DEHYDRATION OR
Does the infant move on his/her own? DIARRHOEA for at all If infant also has another severe
Does the infant not move even when stimulated but DEHYDRATION Sunken eyes classification:
then stops? Skin pinch goes back very Refer URGENTLY to hospital with
Does the infant not move at all? slowly. mother giving frequent sips of ORS on
Is the infant restless and irritable? the way
Advise the mother to continue
Look for sunken eyes.
breastfeeding
Pinch the skin of the abdomen. Does it go back:
Very slowly (longer than 2 seconds)? Two of the following signs: Yellow: Give fluid and breast milk for some dehydration
or slowly? Restless and irritable SOME (Plan B)
Sunken eyes DEHYDRATION If infant has any severe classification:
Skin pinch goes back Refer URGENTLY to hospital with
slowly. mother giving frequent sips of ORS on
the way
Advise the mother to continue
breastfeeding
Advise mother when to return immediately
Follow-up in 2 days if not improving
Not enough signs to classify Green: Give fluids to treat diarrhoea at home and
as some or severe NO DEHYDRATION continue breastfeeding (Plan A)
dehydration. Advise mother when to return immediately
Follow-up in 2 days if not improving
Positive virological test in Yellow: Give cotrimoxazole prophylaxis from age 4-6
ASK young infant CONFIRMED HIV weeks
Classify INFECTION Give HIV ART and care
Has the mother and/or young infant had an HIV test? HIV Advise the mother on home care
status
Follow-up regularly as per national guidelines
IF YES: Mother HIV positive AND Yellow: Give cotrimoxazole prophylaxis from age 4-6
What is the mother's HIV status?: negative virological test HIV EXPOSED weeks
Serological test POSITIVE or NEGATIVE in young Start or continue PMTCT ARV prophylaxis as per
What is the young infant's HIV status?: infant breastfeeding or if national recommendations**
Virological test POSITIVE or NEGATIVE only stopped less than 6 Do virological test at age 4-6 weeks or repeat 6
Serological test POSITIVE or NEGATIVE weeks ago. weeks after the child stops breastfeeding
OR Advise the mother on home care
If mother is HIV positive and NO positive virological test Mother HIV positive, young Follow-up regularly as per national guidelines
in child ASK: infant not yet tested
Is the young infant breastfeeding now? OR
Was the young infant breastfeeding at the time of test Positive serological test in
or before it? young infant
Is the mother and young infant on PMTCT ARV
Negative HIV test in mother Green: Treat, counsel and follow-up existing infections
prophylaxis?*
or young infant HIV INFECTION
UNLIKELY
Ask: LOOK, LISTEN, FEEL: Not well attached to breast Yellow: If not well attached or not suckling effectively,
Is the infant breastfed? If Determine weight for age. or FEEDING PROBLEM teach correct positioning and attachment
yes, how many times in 24 Look for ulcers or white Classify FEEDING Not suckling effectively or OR If not able to attach well immediately, teach the
hours? patches in the mouth Less than 8 breastfeeds in LOW WEIGHT mother to express breast milk and feed by a cup
Does the infant usually (thrush). 24 hours or If breastfeeding less than 8 times in 24 hours,
receive any other foods or Receives other foods or advise to increase frequency of feeding. Advise
drinks? If yes, how often? drinks or the mother to breastfeed as often and as long as
If yes, what do you use to Low weight for age or the infant wants, day and night
feed the infant? Thrush (ulcers or white If receiving other foods or drinks, counsel the
patches in mouth). mother about breastfeeding more, reducing other
foods or drinks, and using a cup
If not breastfeeding at all*:
Refer for breastfeeding counselling and
possible relactation*
Advise about correctly preparing breast-milk
substitutes and using a cup
Advise the mother how to feed and keep the low
weight infant warm at home
If thrush, teach the mother to treat thrush at home
Advise mother to give home care for the young
infant
Follow-up any feeding problem or thrush in 2 days
Follow-up low weight for age in 14 days
Not low weight for age and Green: Advise mother to give home care for the young
no other signs of inadequate NO FEEDING infant
feeding. PROBLEM Praise the mother for feeding the infant well
ASSESS BREASTFEEDING:
Has the infant breastfed in the previous hour?
If the infant has not fed in the previous hour, ask the
mother to put her infant to the breast. Observe the
breastfeed for 4 minutes.
(If the infant was fed during the last hour, ask the mother if
she can wait and tell you when the infant is willing to feed
again.)
Is the infant well attached?
not well attached good attachment
TO CHECK ATTACHMENT, LOOK FOR:
Chin touching breast
Mouth wide open
Lower lip turned outwards
More areola visible above than below the mouth
(All of these signs should be present if the attachment is
good.)
Is the infant suckling effectively (that is, slow deep sucks,
sometimes pausing)?
not suckling effectively suckling effectively
Clear a blocked nose if it interferes with breastfeeding.
Ask: LOOK, LISTEN, FEEL: Milk incorrectly or Yellow: Counsel about feeding
What milk are you giving? Determine weight for age. unhygienically prepared or FEEDING PROBLEM Explain the guidelines for safe replacement feeding
How many times during the Look for ulcers or white Classify FEEDING
Giving inappropriate OR Identify concerns of mother and family about
day and night? patches in the mouth replacement feeds or LOW WEIGHT feeding.
How much is given at each (thrush). If mother is using a bottle, teach cup feeding
Giving insufficient
feed? Advise the mother how to feed and keep the low
replacement feeds or
How are you preparing the weight infant warm at home
milk? An HIV positive mother
If thrush, teach the mother to treat thrush at home
mixing breast and other
Let mother demonstrate or Advise mother to give home care for the young
feeds before 6 months or
explain how a feed is infant
prepared, and how it is Using a feeding bottle or
Follow-up any feeding problem or thrush in 2 days
given to the infant. Low weight for age or Follow-up low weight for age in 14 days
Are you giving any breast Thrush (ulcers or white
milk at all? patches in mouth).
What foods and fluids in Not low weight for age and Green: Advise mother to give home care for the young
addition to replacement no other signs of inadequate NO FEEDING infant
feeds is given? feeding. PROBLEM Praise the mother for feeding the infant well
How is the milk being
given?
Cup or bottle?
How are you cleaning the
feeding utensils?
THEN CHECK THE YOUNG INFANT'S IMMUNIZATION AND VITAMIN A STATUS:
TEACH THE MOTHER HOW TO KEEP THE YOUNG INFANT WARM ON THE WAY TO THE HOSPITAL
Provide skin to skin contact
OR
Keep the young infant clothed or covered as much as possible all the time. Dress the young infant with extra clothing including hat, gloves, socks and wrap the infant in a soft dry cloth and cover with
a blanket.
To Treat Skin Pustules or Umbilical Infection To Treat Thrush (ulcers or white patches in mouth)
The mother should do the treatment twice daily for 5 days: The mother should do the treatment four times daily for 7 days:
Wash hands Wash hands
Gently wash off pus and crusts with soap and water Paint the mouth with half-strength gentian violet (0.25%) using a soft cloth wrapped around the finger
Dry the area Wash hands
Paint the skin or umbilicus/cord with full strength gentian violet (0.5%)
Wash hands
ASSESS EVERY YOUNG INFANT FOR "VERY SEVERE DISEASE" DURING FOLLOW-UP VISIT
Treatment:
If umbilical pus or redness remains same or is worse, refer to hospital. If pus and redness are improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local
infection at home.
If skin pustules are same or worse, refer to hospital. If improved, tell the mother to continue giving the 5 days of antibiotic and continue treating the local infection at home.
DIARRHOEA
After 2 days:
Ask: Has the diarrhoea stopped?
Treatment
If the diarrhoea has not stopped, assess and treat the young infant for diarrhoea. >SEE "Does the Young Infant Have Diarrhoea?"
If the diarrhoea has stopped, tell the mother to continue exclusive breastfeeding.
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT
JAUNDICE
After 1 day:
Look for jaundice. Are palms and soles yellow?
Treatment:
If palms and soles are yellow, refer to hospital.
If palms and soles are not yellow, but jaundice has not decreased, advise the mother home care and ask her to return for follow up in 1 day.
If jaundice has started decreasing, reassure the mother and ask her to continue home care. Ask her to return for follow up at 2 weeks of age. If jaundice continues beyond two weeks of age, refer
the young infant to a hospital for further assessment.
FEEDING PROBLEM
After 2 days:
Reassess feeding. > See "Then Check for Feeding Problem or Low Weight".
Ask about any feeding problems found on the initial visit.
Counsel the mother about any new or continuing feeding problems. If you counsel the mother to make significant
changes in feeding, ask her to bring the young infant back again.
If the young infant is low weight for age, ask the mother to return 14 days of this follow up visit. Continue follow-up until the infant is gaining weight well.
Exception:
If you do not think that feeding will improve, or if the young infant has lost weight, refer the child.
Exception:
If you do not think that feeding will improve, or if the young infant has lost weight, refer to hospital.
GIVE FOLLOW-UP CARE FOR THE YOUNG INFANT
THRUSH
After 2 days:
Look for ulcers or white patches in the mouth (thrush).
Reassess feeding. > See "Then Check for Feeding Problem or Low Weight".
If thrush is worse check that treatment is being given correctly.
If the infant has problems with attachment or suckling, refer to hospital.
If thrush is the same or better, and if the infant is feeding well, continue half-stregth gentian violet for a total of 7 days.
Skin Problems
IF SKIN IS ITCHING
SIGNS CLASSIFY TREATMENT UNIQUE FEATURES IN HIV
AS:
Itching rash with small papules PAPULAR Treat itching: Is a clinical stage 2 defining case
and scratch marks. Dark spots ITCHING Calamine lotion
with pale centres RASH Antihistamine oral
(PRURIGO) If not improves 1% hydrocortisone
Can be early sign of HIV and needs assessment
for HIV
An itchy circular lesion with a RING Whitfield ointment or other antifungal cream if few Extensive: There is a high incidence of co
raised edge and fine scaly area WORM patches existing nail infection which has to be treated
in the centre with loss of hair. (TINEA) adequately to prevent recurrence of tinea
If extensive refer, if not give:
May also be found on body or infections of skin.
web on feet Ketoconazole
Fungal nail infection is a clinical stage 2
for 2 up to 12 months(6-10 kg) 40mg per day
defining disease
for 12 months up to 5 years give 60 mg per day
or give griseofulvin 10mg/kg/day
if in hair shave hair treat itching as above
Rash and excoriations on torso; SCABIES Treat itching as above manage with anti scabies: In HIV positive individuals scabies may
burrows in web space and 25% topical Benzyl Benzoate at night, repeat for 3 manifest as crust scabies.
wrists. face spared days after washing and or 1% lindane cream or
Crusted scabies presents as extensive areas
lotion once wash off after 12 hours
of crusting mainly on the scalp, face back and
feet. Patients may not complain of itching. The
scales will teeming with mites
IDENTIFY SKIN PROBLEM
Vesicles in one area HERPES Keep lesions clean and dry. Use local antiseptic Duration of disease longer
on one side of ZOSTER If eye involved give acyclovir 20 mg /kg 4 times daily for 5 days Haemorrhagic vesicles,
body with intense pain Give pain relief necrotic
or scars Follow-up in 7 days ulceration
plus shooting pain. Rarely recurrent, disseminated
Herpes zoster is or multi-dermatomal
uncommon in
children except where
Is a Clinical stage 2 defining
they are
disease
immuno-compromised,
for example
if infected with HIV
NON-ITCHY
SIGNS CLASSIFY AS: TREATMENT UNIQUE FEATURES IN
HIV
Skin coloured pearly white papules with MOLLUSCUM Can be treated by various Incidence is higher
a central umblication. It is most CONTAGIOSUM modalities: Giant molluscum (>1cm in
commonly seen on the face and trunk in Leave them alone unless size), or coalescent
children. superinfected Pouble or triple lesions
Use of phenol: Pricking each lesion may be seen
with a needle or sharpened More than 100 lesions
orange stick and dabbing the lesion may be seen.
with phenol Lesions often chronic and
Electrodesiccation difficult to eradicate
Liquid nitrogen application (using Extensive molluscum
orange stick) contagiosum is a Clinical
stage 2 defining disease
Curettage
The common wart appears as papules WARTS Treatment: Lesions more numerous
or nodules with a rough (verrucous) Topical salicylic acid preparations ( and recalcitrant to
surface eg. Duofilm) therapy
Liquid nitrogen cryotherapy. Extensive viral warts is a
Electrocautery Clinical stage 2 defining
disease
Greasy scales and redness on central SEBBHORREA Ketoconazole shampoo Seborrheic dermatitis may
face, body folds If severe, refer or provide tropical be severe in HIV
steroids infection.
For seborrheic dermatitis: 1%
Secondary infection may
hydrocortisone cream X 2 daily
be common
If severe, refer
CLINICAL REACTION TO DRUGS
Wet, oozing sores or excoriated, thick patches ECZEMA Soak sores with clean water
to remove crusts(no soap)
Dry skin gently
Short time use of topical
steroid cream not on face.
Treat itching
Severe reaction due to cotrimoxazole or NVP involving the skin STEVEN Stop medication refer The most lethal reaction to
as well as the eyes and the mouth. Might cause difficulty in JOHNSON urgently NVP, Cotrimoxazole or even
breathing SYNDROME Efavirens
MANAGEMENT OF THE SICK CHILD AGED 2 MONTHS UP TO 5 YEARS
Name: Age: Weight (kg): Height/Length (cm):
Ask: What are the child's problems? Initial Visit? Follow-up Visit?
Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.
ART INITIATION RECORDING FORM
FOLLOW THESE STEPS TO INITIATE ART IF CHILD DOES NOT NEED URGENT REFERRAL
Name: Age: Weight (kg): Date:
ASSESS (Circle all findings) TREAT
STEP 1: CONFIRM HIV INFECTION YES ____ NO
Child under 18 months: Virological test positive Send tests that are required ____
Check that child has not breastfed for at least 6 weeks Send confirmation test
Child 18 months and over: Serological test positive If HIV infection confirmed, and child is in stable condition, GO TO STEP 2
Second serological test
positive
Check that child has not breastfed for at least 6 weeks
STEP 2: CAREGIVER ABLE TO GIVE ART YES ____ NO
Caregiver available and willing to give medication If yes: GO TO STEP 3. ____
Caregiver has disclosed to another adult, or is part If no: COUNSEL AND SUPPORT THE CAREGIVER.
of a support group
STEP 3: DECIDE IF ART CAN BE INITIATED AT FIRST LEVEL YES ____ NO
Weight under 3 kg If any present: REFER ____
Child has TB If none present: GO TO STEP 4
STEP 4: RECORD BASELINE INFORMATION
Weight: _____ kg Send tests that are required and GO TO STEP 5
Height/length _____ cm
Feeding problem
WHO clinical stage today: _____
CD4 count: _____ cells/mm3 CD4%: _____
VL (if available): _____
Hb: _____ g/dl
STEP 5: START ART AND COTRIMOXAZOLE PROPHYLAXIS
Less than 3 years: initiate ABC +3TC+LPV/r, or RECORD ARVS & DOSAGES HERE:
other recommended first-line regimen
1. ____________________________________________________________
3 years and older: initiate ABC+3TC+ EFV, or other
2. ____________________________________________________________
recommended first-line
3. ____________________________________________________________
PROVIDE FOLLOW-UP CARE Follow-up according to national guidelines NEXT
FOLLOW-UP
DATE:
_______
RECORD ACTIONS AND TREATMENTS HERE:
ALWAYS REMEMBER TO COUNSEL THE MOTHER AND PROVIDE ROUTINE CARE
FOLLOW-UP CARE FOR CONFIRMED HIV INFECTION ON ART: SIX STEPS
Name: Age: Weight (kg): Height/legth (cm): Date:
Circle all findings
STEP 1: ASSESS AND CLASSIFY RECORD
ASK: does the child have any problems? If yes, record here: ___________________________________________________ ACTIONS
ASK: has the child received care at another health YES ____ NO ____ TAKEN:
facility since the last visit?
Check for general danger signs:
NOT ABLE TO DRINK OR BREASTFEED
VOMITS EVERYTHING If general danger signs or ART severe side effects, provide pre-referral treatment
CONVULSIONS and REFER URGENTLY
LETHARGIC OR UNCONSCIOUS
CONVULSING NOW
Check for ART severe side effects:
Severe skin rash
Yellow eyes
Assess, classify, treat, and follow-up main symptoms according to IMCI guidelines.
Difficulty breathing and severe abdominal pain Refer if necessary.
Fever, vomiting, rash (only if on Abacavir)
Check for main symptoms:
Cough or difficulty breathing
Diarrhoea
Fever
Ear problem
Other problems
STEP 2: MONITOR ARV TREATMENT RECORD
Assess adherence: 1. REFER NON-URGENTLY IF ANY OF THE FOLLOWING ARE PRESENT: ACTIONS
TAKEN:
Takes all doses - Frequently misses doses - Not gaining weight for 3 months
Occasionally misses a dose - Loss of milestones
Not taking medication Poor adherence despite adherence counselling
Assess side-effects Significant side-effects despite appropriate management
Higher clinical stage than before
Nausea - Tingling, numb, or painful hands, feet, or
CD4 count significantly lower than before
legs - Sleep disturbances -
LDL higher than 3.5 mmol/L
Diarrhoea - Dizziness - Abnormal distribution of Triglycerides (TGs) higher than 5.6 mmol/L
fat - Rash - Other
2. MANAGE MILD SIDE-EFFECTS
Assess clinical condition:
3. SEND TESTS THAT ARE DUE
Progressed to higher stage
CD4 count
Stage when ART initiated: 1 - 2 - 3 - 4 - Unknown
Viral load, if available
Monitor blood results: Tests should be sent after LDL cholesterol and triglycerides
6 months on ARVs, then yearly. Record latest
OTHERWISE, GO TO STEP 3
results here:
DATE: _____ CD4 COUNT:________cells/mm3
CD4%: __________
Viral load: _________
If on LPV/r: LDL Cholesterol: _________ TGs:
____________
STEP 3: PROVIDE ART AND OTHER MEDICATION
ABC+3TC+LPV/r RECORD ART DOSAGES:
ABC+3TC+EFV 1. ____________________________________________________________
Cotrimaoxazole 2. ____________________________________________________________
Vitamin A 3. ____________________________________________________________
Other Medication COTRIMOXAZOLE DOSAGE:_______________________________________
VITAMIN A DOSAGE: _____________________________________________
OTHER MEDICATION DOSAGE:
1. __________________________________________________________
2. __________________________________________________________
3. ___________________________________________________________
STEP 4: COUNSEL DATE OF
Use every visit to educate the caregiver and provide RECORD ISSUES DISCUSSED: NEXT VISIT:
support, key issues include:
How is child progressing - Adherence - Support to
caregiver - Disclosure (to others & child) - Side-
effects and correct management
RECORD ACTIONS TAKEN:
MANAGEMENT OF THE SICK YOUNG INFANT AGED UP TO 2 MONTHS
Name: Age: Weight (kg):
Ask: What are the infant's problems?: Initial Visit? Follow-up Visit?
ASSESS (Circle all signs present) CLASSIFY
CHECK FOR SEVERE DISEASE AND LOCAL BACTERIAL INFECTION
Is the infant having difficulty in feeding? Count the breaths in one minute. ___ breaths per minute
Has the infant had convulsions? Repeat if elevated: ___ Fast breathing?
Look for severe chest indrawing.
Look and listen for grunting.
Look at the umbiculus. Is it red or draining pus?
Return for follow-up in ... days. Advise mother when to return immediately. Give any immunization and feeding advice needed today.
Weight-for-age GIRLS
Birth to 6 month s (z-sco res)
._-
FOA ANY SICK Ctll.O .
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€) The n in addition , all sick children are routinely at An essential component of IMCI is the
checked for: counselling of caregivers regarding h o me care:
• Nutritional and immunization status, • Appropr iate feeding and fluids ,
• HIV statu s in high HIV settings, and • When to retu rn to the clinic immediat ely, a nd
• When to retu rn for follow -up
• Other pote ntial pl'Oblems.