Care of Mother, Child, at Risk or with Problems
Nursing Care of a Family When a Child has an
Unintentional Injury
HEALTH PROMOTION AND RISK MANAGEMENT
▪ Poisoning is an important cause of serious injuries in
children younger than 6 years of age.
▪ Measures for a safe home environment include
actions such as installing child-resistant locks on low
cabinets where household products are stored,
moving plants to a higher surface or removing them
from the home until the child is older, keeping
matches in safe places, and teaching street safety.
HEAD TRAUMA
▪ Head injuries are always potentially serious not only
because they can cause an immediate threat to the
life of the child, but also because several
complications may follow.
▪ With a depressed skull fracture, for example,
recurrent seizures can occur.
▪ Many of these children show focal abnormalities on
an electroencephalogram (EEG) because of scar
tissue formation.
▪ Some children experience memory deficits or minor
personality changes after head injury.
▪ Symptoms such as headache, irritability, and postural
vertigo.
▪ Behavioral manifestations may include
aggressiveness or poor school performance.
Immediate Assessment
→ Neurologic assessment as soon as they are seen and
again at frequent intervals to detect signs and
symptoms of increased intracranial pressure (ICP) –
unreactive pupil.
→ Assess vital signs to detect these changes and
observe children’s pupils to be certain that they are
equal and react to light.
→ Assess children’s level of consciousness and motor
function.
→ Stabilize the neck with a brace until cervical trauma
has been ruled out.
Immediate Management
→ After a head injury, brain edema is likely because
fluid rushes into the inflamed and bruised area.
→ Both central venous and central arterial lines may be
inserted.
→ ICP monitoring may be initiated.
→ CT and MRI are ordered.
→ An attempt may be made to decrease brain edema
by intravenous (IV) administration of a hypertonic
solution, such as mannitol.
→ Steroids such as dexamethasone may be added to
decrease inflammation and edema.
→ Keeping the head elevated is also effective in
reducing ICP.
1 SKULL FRACTURE
→ Recognizing skull fractures in children is important,
because associated cerebral injury often occurs
under the fracture.
→ Many skull fractures are simple linear types, most
often involving the parietal bones. In some children,
the skull does not fracture, but the suture lines
separate (lamboid).
Assessment
▪ If the base of the skull is fractured, a child usually
exhibits orbital or postauricular ecchymosis.
▪ Rhinorrhea or otorrhea (clear fluid draining from the
nose or ear, respectively) may be present.
▪ Test the fluid discharge with a glucose reagent strip if
there is doubt about the source of the drainage (CSF
is positive).
▪ If a child is in shock, investigate for bleeding points
other than the head injury.
EVANGELISTA, E.M | BSN-2 | NCM 109 LEC (FINALS)| RN 2025
05
▪ If a skull fracture is linear with no underlying
pathology, no treatment except observation and
prescription of an analgesic is necessary.
▪ If a fracture is depressed (a bone fragment is pressing
inward) or compounded (bone is broken into pieces),
surgery will be necessary to remove or repair broken
fragments.
Therapeutic Management
▪ Keep the child in a semi-Fowler’s position so that fluid
drains out, not inward, to reduce the possibility of
introducing infection.
▪ Make certain that children do not attempt to hold
their nose or pack their nostrils with something to halt
the drainage.
▪ Because coughing and sneezing may allow air to
enter the meningeal space, coughing may be
suppressed by medication.
▪ If the drainage is excoriating to the upper lip, coat the
space with petrolatum.
▪ Children may be prescribed a prophylactic antibiotic
to reduce the risk for meningitis.
▪ If the drainage does not stop within a few days,
surgery will be necessary to repair the fracture and
reduce the danger of meningitis.
Potential Complications
▪ Leptomeningeal cyst
2 SUBDURAL HEMATOMA
→ Subdural hematoma is venous bleeding into the
space between the dura and the arachnoid
membrane.
→ The collection of blood is usually bilateral.
→ Infants usually have symptoms of increased ICP.
→ Seizures, vomiting, hyperirritability, and enlargement
of the head may occur.
→ Anemia caused by 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 by a subdural puncture through the lateral
aspect of a patent anterior fontanelle.
→ Infants receive conscious sedation or must be held
extremely still during the procedure so that they do
not move and cause the aspiration needle to be
inserted incorrectly.
→ Subdural punctures may need to be repeated daily
to empty the subdural space. Once the space is
empty, expanding brain tissue will naturally occlude
it.
→ In older children, surgery usually is necessary,
because the anterior fontanelle is closed and the
space cannot be reached by puncture.
3 EPIDURAL HEMATOMA
→ Epidural hematoma is bleeding into the space
between the dura and the skull.
→ This happens when head trauma is severe. Subdural
hemorrhage is usually venous bleeding, but epidural
hemorrhage is usually a result of rupture of the middle
meningeal artery and is, therefore, arterial bleeding.
→ It usually is intense and causes rapid brain
compression.
→ At the time of the injury, children become
momentarily unconscious.
→ Signs of cortical compression—vomiting, loss of
consciousness, headache, seizures, or hemiparesis
(paralysis on one side)—are observed.
→ Unequal dilation or constriction of the pupils.
→ The closer to the time of the injury that symptoms of
compression occur, the more extreme is the amount
of blood loss.
Care of Mother, Child, at Risk or with Problems
Nursing Care of a Family When a Child has an
Unintentional Injury
→ The treatment is surgical removal of the
accumulated blood and cauterization or ligation of
the torn artery.
4 CONCUSSION
→ Concussion is the temporary and immediate
impairment of neurologic function caused by a hard,
jarring shock.
→ It may occur on the side of the skull that was struck
(a coup injury) or on the opposite side of the brain (a
contrecoup injury.
→ Children have at least a transient loss of
consciousness at the time of the injury. They may
vomit and may show irritability after regaining
consciousness.
→ They typically have no memory (amnesia) of the
events leading up to the injury or of the injury itself.
→ Skull radiograph – to rule out skull fracture.
→ A child usually can be observed at home by the
parents, who are instructed to check the child’s level
of consciousness every 1 to 2 hours while the child is
awake.
→ Parents usually are instructed not to keep waking
children during the night, because multiple wakings
are disorienting and can be confused with
unconsciousness.
→ Parents should wake the child at least once during
the night, however, and assess that the pulse rate is
greater than 60 beats per minute.
→ To be certain that children are alert, parents can ask
them to name a familiar object, such as a favorite
toy, or to name the color of some object shown to
them.
→ There is an old belief that, if children fall asleep after
a head injury, they will die in their sleep; this belief
causes some parents to keep shaking children
awake or making them walk continually.
o Be certain they understand that it is all right for
children to sleep, but they must wake them at
least once to assess their status.
EVANGELISTA, E.M | BSN-2 | NCM 109 LEC (FINALS)| RN 2025
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5 CONTUSION
→ A brain contusion occurs when there is tearing or
laceration of brain tissue.
→ The symptoms are the same type as for concussion
but more severe.
→ There are specific symptoms related to the lacerated
brain area such as a focal seizure, eye deviation, or
loss of speech.
→ Surgery may be necessary to halt bleeding.
6 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
disorders.
Assessment
▪ Obtain a history to determine the circumstances
immediately before the time the child became
comatose.
▪ Undress the child completely so that all body parts
can be inspected.
▪ Count respirations and pulse and measure blood
pressure to establish baseline values, because
changes in these values often provide good clues
regarding the cause of coma.
▪ If bulbar (brainstem) compression is present, a child
cannot swallow effectively or safely. If this is
suspected, turn the child on the side to prevent
aspiration.
▪ Observe the eyes for signs of increased ICP.
▪ If both pupils are dilated, irreversible brainstem
damage is suggested, although such a finding may
also be present with poisoning from an atropine-like
drug.
▪ Pinpoint pupils suggest barbiturate or opiate
intoxication. One pupil dilated more than the other
suggests third cranial nerve compression.
▪ An eye may be deviated downward and laterally as
well. This also may be caused by a tentorial tear
(laceration of the membrane between the
cerebellum and cerebrum) and herniation of the
temporal lobe into the torn membrane.
▪ The retina of the eye should be examined for
papilledema.
▪ Lack of a doll’s eye reflex suggests that compression
of the oculomotor nerves (third, fourth, or sixth) or of
the brainstem is involved.
▪ Observe for posturing, such as decerebrate
posturing, which suggests cerebral compression and
dysfunction.
▪ Coma is usually graded according to a standard
scale so that changes in the level of consciousness
can be evaluated accurately (Glasgow Coma
Scale).
o A score of 3 to 8 on the scale suggests severe
trauma (a number less than 5 suggests a very
severe prognosis); a score of 9 to 12, moderate
trauma; and 13 to 15, slight trauma.
Therapeutic Management
▪ As a general rule, place a child who is comatose on
the side to reduce the risk of aspiration.
▪ Oral suctioning to remove mucus from the mouth and
pharynx may be necessary.
▪ If a child has acute signs of respiratory difficulty,
endotracheal intubation may be necessary to ensure
respiratory function.
▪ An IV route is established so that, when specific
measures such as blood replacement, electrolyte
replacement, or fluid replacement are needed, a
route for immediate administration will be available.
▪ Skull radiography, CT scan, or MRI may be done.
▪ Lumbar puncture is contraindicated if increased ICP
is present as release of fluid with the puncture can
cause brainstem compression into the cord.
Care of Mother, Child, at Risk or with Problems
Nursing Care of a Family When a Child has an
Unintentional Injury
▪ Obtain the child’s vital signs and assess neurologic
status, such as state of consciousness and the ability
of pupils to react to light, every 15 to 20 minutes or as
ordered.
7 CHOKING GAMES
→ Adolescents, seeking an inexpensive way to
experience a “rush” or euphoria, induce a partial or
complete loss of consciousness in themselves by
intentionally depriving their brain of oxygen for a
short period of time by strangulation or hanging or
reducing the oxygen able to reach their nose by
some technique such as pulling a plastic bag over
their head.
→ Extreme hyperventilation to induce hypocapnia is
yet another technique.
→ The practice is also known as erotic asphyxiation as it
also induces a sexual response. Unfortunately, the
game results in injury and death.
→ Injuries such as concussion, bone fractures, and
tongue biting may occur from falling. Teach parents
that the game exists and to be aware of signs that
their child might be interested or participating in the
game.
→ Common signs are discussion of the game,
bloodshot eyes, ligature marks on the neck, severe
headaches, disorientation, and the presence of
choke collars, ropes, scarves, or belts tied to
bedroom furniture.
ABDOMINAL TRAUMA
Assessment
▪ Assess vital signs frequently until they are stable.
▪ Hypotension (less than 80 mm Hg systolic pressure in
an older child; less than 60 mm Hg in an infant) usually
suggests hemorrhage, which may be hidden
abdominal bleeding.
▪ If abdominal trauma is suspected, an NG tube is
passed and stomach contents are aspirated to be
checked visually for blood and to test for occult
blood.
▪ An indwelling urinary (Foley) catheter is also inserted
to evaluate urine for blood and urine output.
▪ Evidence of blood in the urine or decreased output
may indicate accompanying kidney or bladder
trauma.
▪ Air under the diaphragm on the radiograph suggests
gastric or intestinal rupture with escape of air from
these organs into the peritoneal cavity.
▪ Free fluid in the abdomen, shown on the radiograph
when the child is turned on the side, suggests
leakage of bowel fluid or splenic rupture and pooling
of blood.
1 SPLENIC RUPTURE
→ In children, the spleen is the most frequently injured
organ in abdominal trauma, because it is usually
palpable under the lower left ribs.
→ It is frequently injured by inappropriately applied seat
belts in automobiles and by handlebar injuries in
bicycle accidents.
EVANGELISTA, E.M | BSN-2 | NCM 109 LEC (FINALS)| RN 2025
05
→ A with splenic injury have tenderness in the left upper
quadrant, especially on deep inspiration, when the
diaphragm moves down and touches the spleen.
→ They may hold their left shoulder elevated, so that
the diaphragm is raised on the left side, to keep this
from happening.
→ Occasionally, a child notices radiated left shoulder
pain while lying in a supine position (Kehr’s sign).
→ An IV line is begun immediately for fluid replacement,
and an IV pyelogram or MRI will be done to rule out
damage to the left kidney, which, because of its
location just behind the spleen, may also have
suffered trauma.
→ If bleeding is severe, immediate surgery, such as a
partial or total splenectomy, may be necessary to
halt bleeding and save the child’s life.
→ After a splenectomy, children are very susceptible to
infection, particularly pneumococcal infections
(pneumococcal vaccine is necessary).
2 LIVER RUPTURE
→ Livers are also more prone to rupture in children than
in adults, because the liver, like the spleen, is not
completely sheltered by the rib cage in children.
→ They show symptoms of blood loss, including
tachycardia, hypotension, anxiety, and pallor. The
hematocrit will be low or falling.
→ Such children need to be prepared for immediate
surgery, because the liver is a highly vascular organ,
and blood loss from it is acute and possibly life-
threatening.
→ The child may have colicky upper abdominal pain
that is relieved by emesis.
→ Liver studies, such as a liver arteriogram, are
necessary to reveal the extent of the problem.
→ After either liver or spleen surgery, children need
careful observation for return of bowel function,
assessment for the possibility that peritonitis may
develop, and careful reintroduction of oral nutrition.
DENTAL TRAUMA
Assessment
▪ If permanent teeth that have been knocked out
recently can be washed with saline in the
emergency department and replaced, there is a
good chance that they will reimplant successfully.
▪ If a tooth is knocked out, parents should rinse the
tooth in water, drop it in a salt solution or milk, and
bring it to the emergency department with them.
▪ Some dentists advocate immersing the tooth in an
antiseptic and then in an antibiotic solution before
replacing it.
▪ The child receives a course of oral antibiotics, such as
penicillin, to prevent infection.
▪ Only soft food must be eaten until the tooth has firmly
adhered (approximately 2 weeks).
▪ If a blow to a child’s teeth was extensive, a
radiograph may be taken to rule out a mandibular
or maxillary fracture.
Care of Mother, Child, at Risk or with Problems
Nursing Care of a Family When a Child has an
Unintentional Injury
▪ If a portion of a tooth cannot be located, the
possibility of aspiration must be considered and
confirmed or ruled out by a chest radiography.
▪ In young children, often a tooth is not knocked out
but is pushed back up into the gum. These teeth
gradually regrow, and, although they may darken in
color, they usually are healthy.
▪ If the affected tooth is a deciduous tooth, the
permanent tooth is rarely injured even though it is
already formed in the gum.
▪ At the appropriate time, the permanent tooth will
erupt normally.
NEAR DROWNING
→ Drowning is death caused by suffocation from
submersion in liquid. Inhaled water fills the lungs and
therefore blocks the exchange of oxygen in the
alveoli.
→ The second most common cause of death by
unintentional injury among children. The term near
drowning is used to describe the child with a
submersion injury who requires emergency treatment
and who survives the first 24 hours after injury.
→ Particularly at risk are male adolescents, because
they may take dares to swim farther than their ability
allows or may swim under the influence of alcohol,
which impairs their decision-making ability and their
physical coordination.
Pathophysiology of Drowning
▪ If they cannot get their head out of water at this
point, water will enter the larynx. This causes the
larynx to spasm, preventing any further water but
also air from entering the trachea, so asphyxia results.
▪ Salt water is hypertonic, causing fluid to osmose from
the bloodstream and enter the alveoli, increasing the
amount of fluid in the lung tissue and increasing
hypoxia. Tachycardia and decreased blood
pressure from hypovolemia result. Blood viscosity
increases as shown by an increased hematocrit level.
▪ Fresh water is hypotonic, so fluid in the lungs shifts into
the bloodstream because of osmotic pressure. This
can lead to hemolysis of red blood cells, a dilution of
plasma, and possibly hypervolemia with tachycardia
and increased blood pressure. If the release of
potassium from destroyed red blood cells is great
enough with fresh-water drowning, cardiac
arrhythmias may occur. In both instances, loss of
surfactant from lung alveoli, caused by introduction
of water (adult respiratory distress syndrome), can
lead to alveolar collapse on expiration.
▪ Parents should advocate for neighborhood pools to
be fenced and advise against hyperventilating
before swimming.
▪ Very young children display a mammalian diving
reflex when they plunge under cold water that helps
them survive drowning. Immediately after plunging
into cold water, a lifesaving bradycardia and
shunting of blood away from the periphery of the
body to the brain and heart occur. This reflex is
triggered when water is 70° F (21° C) or less and the
face is submerged first. This explains why very young
children can survive better than older children after
being submerged in water that is very cold.
Emergency Management
▪ When a child is pulled from the water after near
drowning, mouth-to-mouth resuscitation should be
started at once.
EVANGELISTA, E.M | BSN-2 | NCM 109 LEC (FINALS)| RN 2025
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▪ If cardiac arrest has occurred from hypoxia,
simultaneous measures to initiate cardiac action
must be taken.
▪ Typically, a child is intubated with a cuffed
intratracheal tube; mechanical ventilation with
positive end-expiratory pressure may be necessary to
force air into the alveoli.
▪ Because water has been swallowed, vomiting usually
occurs as the child is revived. The cuff of the
intratracheal tube prevents vomitus from being
aspirated. The child is given 100% oxygen so that as
much space as possible in the available lung alveoli
can be used.
▪ An NG tube is inserted to decompress the stomach,
prevent vomiting, and free up breathing space.
▪ Usually, albuterol is administered by aerosol to
prevent bronchospasm and, again, to allow the child
to make maximum use of the oxygen administered.
▪ If the child aspirated salt water, plasma may be
administered to replace protein being lost into the
lungs and prevent hypovolemia.
▪ If the child’s body temperature is very low, gradual
warming (not using a warming blanket) is advised so
that the metabolic requirement does not rise sharply
before alveolar space is ready to accommodate this
need.
▪ Extracorporeal membrane oxygenation may be
used.
▪ If the child is awake or only lethargic at the scene of
the accident and immediately afterward in the
hospital, the prognosis is greatly improved over that
of the child who is comatose.
POISONING
▪ Unlike other unintentional injuries, poisoning is entirely
preventable.
▪ Common agents include soaps, cosmetics,
detergents or cleaners, and plants.
▪ Be aware that when poisoning occurs in an older
child, it may not be poisoning but a suicide attempt.
Emergency Management of Poisoning at Home
If poisoning occurs, parents should telephone their local
poison control center to ask for advice. Information
parents need to provide includes:
▪ Child’s name, telephone number, address, weight,
and age and what the child swallowed.
▪ How long ago the poisoning occurred.
▪ The route of poisoning (oral, inhaled, sprayed on skin)
▪ How much of the poison the child took (the bottle
should say how many pills or liquid it originally held).
▪ If the poison was in pill form, whether there are pills
scattered under a chair or if they are all missing and
presumed swallowed.
▪ What was swallowed; if the name of a medicine is
not known, what it was prescribed for and a
description of it (color, size, shape of pills)
▪ The child’s present condition (sleepy? hyperactive?
comatose?)
If one child has swallowed a poison, parents should
investigate whether other children have also poisoned
themselves as a preschooler often shares “candy” with
a younger sibling.
Emergency Management of Poisoning at HC Facility
In the emergency department, the best method to
deactivate a swallowed poison is the administration of
activated charcoal, either orally or by way of an NG
tube.
Care of Mother, Child, at Risk or with Problems
Nursing Care of a Family When a Child has an
Unintentional Injury 05
▪ A sweet syrup may be added to the mixture to make Assessment
it more palatable. ▪ After a caustic ingestion, the child has immediate
▪ Caution parents that, as the charcoal is excreted pain in the mouth and throat and drools saliva
through the bowel over the next 3 days, stools will because of oral edema and an inability to swallow.
appear black. ▪ The mouth turns white immediately from the burn.
▪ Administer orally to conscious victims only. ▪ Later, the mouth turns brown as edema and
▪ Give the drug as soon as possible after poisoning. ulceration occur.
▪ Store the drug in a closed container, because it ▪ The child may immediately vomit blood, mucus, and
necrotic tissue.
absorbs gases from the air and is inactivated.
▪ The loss of blood from the denuded, burned surface
▪ Know that the solution feels gritty and tastes may lead to systemic signs of tachycardia,
disagreeable, so young children have difficulty tachypnea, pallor, and hypotension.
swallowing the drug. ▪ A chest radiograph may be ordered to determine
1 ACETAMINOPHEN POISONING whether pulmonary involvement has occurred from
→ Acetaminophen (Tylenol) is the any aspirated poison or whether an esophageal
drug most frequently involved in perforation has allowed poison to seep into the
mediastinum.
childhood poisoning today,
▪ An esophagoscopy under conscious sedation may
because parents use be done to assess the esophagus, although this test
acetaminophen to treat may be omitted because of the possibility that an
childhood fevers. esophagoscope might perforate the burned
→ Acetaminophen in large doses esophagus.
can cause extreme liver ▪ After 2 weeks, a barium swallow or esophagoscopy
destruction. may be performed to reveal the final extent of the
esophageal burns.
Therapeutic Management
→ Immediately after ingestion, the
▪ Parents will be advised to immediately take the child
child will experience anorexia,
to a health care facility for treatment.
nausea, and vomiting. Soon, ▪ Pharyngeal edema will be severe enough to obstruct
serum aspartate transaminase (AST [SGOT]) and the child’s airway by even 20 minutes after the burn.
serum alanine transaminase (ALT [SGPT]), liver ▪ To detect respiratory interference, assess vital signs
enzymes, become elevated. closely, especially the respiratory rate. In infants,
→ The liver may feel tender as liver toxicity occurs increasing restlessness is an important accompanying
(jaundice). sign of oxygen want.
→ In the emergency department, activated charcoal ▪ In the emergency department, intubation may be
necessary to provide a patent airway.
or acetylcysteine, the specific antidote for
▪ Assess the child also for the degree of pain involved.
acetaminophen poisoning, will be administered. A strong analgesic, such as morphine, may need to
be ordered and administered to achieve pain relief.
Acetylcysteine 3 HYDROCARBON INGESTION
▪ Administer it in a carbonated beverage to help the → Hydrocarbons are
child swallow it. substances contained in
▪ For small children, it is administered directly into an products such as kerosene
NG tube to avoid this difficulty. and furniture polish.
→ Because these substances
→ Before the child is discharged from a health care are volatile, fumes rise
facility, be certain the parents are comfortable with from them, and their major
any further assessment measures they will need to effect is respiratory, not
continue at home, such as temperature taking and gastric, irritation.
urging a high fluid intake.
→ Talk with the parents about the necessity for 4 IRON POISONING
childproofing their home. → Iron is frequently
2 CAUSTIC POISONING swallowed by small
→ Ingestion of a children because it is an
strong alkali, such ingredient in vitamin
as lye, which is preparations, particularly
often contained in pregnancy vitamins.
toilet bowl → When it is ingested, it is
cleaners or hair corrosive to the gastric mucosa and leads to signs
care products, and symptoms of gastric irritation.
may cause burns → The immediate effects include nausea and vomiting,
and tissue necrosis diarrhea, and abdominal pain.
in the mouth, → After 6 hours, these symptoms fade, and the child’s
esophagus, and condition appears to improve. By this time, however,
stomach. hemorrhagic necrosis of the lining of the GI tract has
→ It is important that occurred.
the parents do not → By 12 hours, melena (blood in stool) and
try to make a child hematemesis (blood in emesis) are present.
vomit after → Lethargy and coma, cyanosis, and vasomotor
ingestion of these collapse may occur.
substances, → Coagulation defects may occur, and hepatic injury
because they can also can result.
cause additional burning as they are vomited.

EVANGELISTA, E.M | BSN-2 | NCM 109 LEC (FINALS)| RN 2025

Care of Mother, Child, at Risk or with Problems
Nursing Care of a Family When a Child has an
Unintentional Injury
→ Shock resulting from an increase in peripheral
vascular resistance and decreased cardiac output.
→ Long-term effects can include gastric scarring.
Assessment
▪ The child’s serum iron level should be measured to
establish a baseline.
Therapeutic Management
▪ Stomach lavage will be done to remove any pills not
yet absorbed.
▪ A cathartic may be given to help the child pass
enteric-coated iron pills.
▪ Activated charcoal is NOT given, because it is not
effective at neutralizing iron.
▪ A soothing compound such as Maalox or Mylanta
(aluminum hydroxide and magnesium hydroxide)
may be given to help decrease gastric irritation and
pain.
▪ A child who has ingested a potentially toxic dose will
be given a chelating agent, such as IV or
intramuscular (IM) deferoxamine.
▪ Caution parents that deferoxamine causes urine to
turn orange as iron is excreted.
▪ An exchange transfusion is another way that excess
iron can be removed from the body.
▪ An upper GI x-ray series and liver studies may be
ordered.
▪ Parents may be asked to test any stool passed for the
next 3 days for occult blood, to assess for stomach
irritation and subsequent GI bleeding.
5 LEAD POISONING (PLUMBISM)
→ When lead enters the body, it interferes with red
blood cell function by blocking the incorporation of
iron into the protoporphyrin compound that makes
up the heme portion of hemoglobin in red blood
cells.
→ This leads to microcytic anemia.
→ Kidney destruction may occur.
→ The most serious effect, however, is lead encephalitis:
inflammation of brain cells because of the toxic lead
content.
Assessment
▪ Blood lead levels greater than 10 microg/dL.
▪ The usual sources of ingested lead are paint chips or
paint dust, home-glazed pottery, or fumes from
burning or swallowed batteries, windowsills.
▪ If a crib rail is painted with lead paint, a child will
ingest it as the child teethes on the rail.
▪ Restoring an older home saturates the air with lead
dust.
▪ In such homes, lead plumbing also may contaminate
the drinking water.
▪ As the child’s blood level of lead increases, severe
encephalopathy with seizures and permanent
neurologic damage will result.
▪ The most widely used method of screening for lead
levels is the blood lead determination (serum ferritin).
▪ The free erythrocyte protoporphyrin test (elevated) is
a simple screening procedure that involves only a
fingerstick.
▪ Basophilic stippling may be apparent on a blood
smear.
▪ A radiograph of the abd may reveal paint chips in the
intestinal tract.
▪ Damage to the kidney nephrons from the presence
of lead leads to proteinuria, ketonuria, and
glycosuria.
▪ The CSF may have an increased protein level.
Therapeutic Management
▪ A child with a blood lead level between 10 and 14
ug/dL needs to be rescreened to confirm the level.
15 ug/dL needs immediate intervention.
▪ Removal of the lead source.
▪ The walls must be covered by paneling or Masonite.
▪ Children with blood lead levels of greater than 45
ug/100 mL may be admitted to the hospital for
EVANGELISTA, E.M | BSN-2 | NCM 109 LEC (FINALS)| RN 2025
05
chelation therapy with agents such as dimercaprol
(BAL) or edetate calcium disodium (CaEDTA).
▪ Injections of EDTA, which must be given IM into a
large muscle mass, are painful and may be
combined with 0.5 mL of procaine.
▪ EDTA also removes calcium from the body; therefore,
serum calcium must be measured periodically to
determine whether it is at a safe level.
▪ Measure intake and output to ensure that kidney
function is adequate to handle the lead being
excreted.
▪ Edta may lead to kidney damage/nephrotoxicity.
▪ Weekly complete blood cell counts and renal and
liver function tests accompany the administration of
penicillamine.
▪ As a rule, children’s cribs should be placed about 3
feet away from walls in older homes to reduce the risk
of children’s picking at loose wallpaper when they
first wake in the morning or before they fall asleep at
night (plaster, which contains lead, clings to the
wallpaper).
6 PESTICIDE POISONING
→ Pesticide poisoning can occur by accidental
ingestion or through skin or respiratory tract contact
when children play in an area that has recently been
sprayed.
→ Many pesticides have an organophosphate base
that causes acetylcholine to accumulate at
neuromuscular junctions; this accumulation leads to
muscle paralysis.
→ Children develop nausea and vomiting, diarrhea,
excessive salivation, weakness of respiratory muscles,
confusion, depressed reflexes, and possibly seizures.
→ Activated charcoal may be administered if the
pesticide was swallowed.
→ If clothing is contaminated, remove it and wash the
child’s skin and hair.
→ To prevent coming in contact with the pesticide
yourself, wear gloves while bathing the child.
→ Intravenous atropine and a cholinesterase
reactivator, pralidoxime (Protopam Chloride) are
effective antidotes to reverse symptoms.
→ If parents apply a pesticide to children to help avoid
mosquito bites, diethyltoluamide (DEET)-based
pesticides appear to be safe if used sparingly, not
applied to a child’s face, and washed off when the
child returns indoors.
7 PLANT POISONING
→ Plant poisoning (ingestion of a growing plant) occurs
because parents commonly do not think of plants as
being poisonous.
8 POISONING BY DRUGS OF ABUSE
→ Typical drugs involved include codeine and
antidepressant drugs.
→ Children are often extremely disoriented after this
form of ingestion.
→ They may be having hallucinations.
Assessment
▪ Try to elicit a history.
▪ If friends accompany an ill child, point out that your
role is not that of a law enforcer.
▪ If a child is brought in by parents who have no idea
what drug could possibly have been taken, ask them
to have someone at home check the child’s
bedroom for drugs or what could be missing from the
medicine cabinet.
▪ Obtain blood specimens for electrolyte levels and a
toxicology screen.
▪ If the child is vomiting, save any vomitus for analysis.
Therapeutic Management
▪ Oxygen administration, electrolyte replacement and
IV fluid administration in an attempt to dilute the drug.
Care of Mother, Child, at Risk or with Problems
Nursing Care of a Family When a Child has an
Unintentional Injury
FOREIGN BODY OBSTRUCTION
1 FOREIGN BODIES IN THE EAR
→ If there is reason to think that the tympanic
membrane is intact, irrigating the object from the ear
canal with a syringe and normal saline may be
possible. This should not be done if the object is a
substance that will swell when wet, such as a peanut.
→ If it is possible that the tympanic membrane is
ruptured, the ear canal must not be irrigated or fluid
will be forced into the middle ear, possibly
introducing infection (otitis media).
→ Often, it is better to wait for an otolaryngologist to
care for the child, because trauma to the ear canal
during an attempt to remove a foreign body will
increase the edema and make removal even more
difficult.
2 FOREIGN BODIES IN THE NOSE
→ Foreign objects stuffed into the nose eventually
cause inflammation and purulent discharge from the
nares.
→ The odor accompanying such impaction is often the
first sign noticed by a parent.
→ Objects pushed into the nose usually can be
removed with forceps.
→ A local antibiotic might be necessary after removal if
ulceration resulted from the local irritation.
3 FOREIGN BODIES IN THE ESOPHAGUS/STOMACH
→ Children tend not to chew food well or to swallow
portions that are too big to pass safely through the
esophagus.
→ Pieces of candy, such as Lifesavers, are common
objects caught in the esophagus in young children;
coins may be swallowed by adolescents playing
drinking games.
→ Intense pain at the site where the object is lodged
will result.
→ If it is an object that will dissolve, such as a Lifesaver
or a piece of digestible meat, offer the child fluid to
drink to help flush the object into the stomach.
→ Even after the object dissolves or passes into the
stomach, the child will feel transient pain at the
original site of the obstruction.
→ 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.
→ Small coins, such as pennies and dimes, usually pass
by themselves without difficulty. Parents (or children
themselves if adolescents) should observe stools over
the next several days to determine that the coin does
pass through the GI tract (about 48 hours after
ingestion). Without frightening them, caution parents
to observe for signs of bowel perforation or
obstruction, such as vomiting or abdominal pain, until
the object has passed.
4 SUBCUTANEOUS OBJECTS
→ Children receive many wood splinters in the hands
and feet.
→ These usually are removed easily by a probing
needle and tweezers after cleaning with an
antiseptic solution.
→ If the penetrating object is metal, such as a sewing
needle or nail, its presence can be detected by
radiography.
→ If the object is one that would have been in contact
with soil, such as a rusty nail, the child will need
tetanus prophylaxis after extraction of the object if
tetanus immunization is not current.
EVANGELISTA, E.M | BSN-2 | NCM 109 LEC (FINALS)| RN 2025
05
FOREIGN BODY OBSTRUCTION
1 MAMMALIAN BITES
→ All of these bites can cause abra sions, puncture
wounds, lacerations, and crushing injuries re lated to
the size of the animal and the location of the bite.
→ The biggest concerns associated with animal bites
are the possibility of long-term scarring and
disfigurement and the possibility of infection,
especially rabies, from the presence of
microorganisms in the animal’s mouth.
2 SNAKE BITES
→ The effect of the bite of a rattlesnake, copperhead,
or cottonmouth moccasin (all pit vipers) is a failure of
the blood coagulation system.
→ The venom injected through the bite of these snakes
leads to neuromuscular paralysis.
Assessment
▪ A white wheal forms at the site, showing the puncture
marks, accompanied by excruciating pain at the site.
▪ Purplish erythema and edema begin to extend
rapidly from the site.
▪ Sanguineous fluid may be oozing from the bite.
▪ Systemic symptoms, such as dizziness, vomiting,
perspiration, and weakness, may be present.
▪ Because snake venom interferes with blood
coagulation, the child may have hematemesis or
bleeding from the nose, intestines, or bladder
because of subcutaneous or internal hemorrhage.
▪ The pupils may be dilated.
▪ If the envenomation is not treated, seizures, coma,
and death may result.
Emergency Management at the Scene
▪ Apply a cold compress to the bite.
▪ Urge the child to lie quietly, to slow circulation.
▪ Keep the bitten extremity dependent, again to slow
venous circulation.
▪ Commercial snakebite kits have rubber suction cups
in them for suctioning out venom.
▪ Excising the bite with a knife and sucking out venom
orally (no!).
Emergency Management at the HC Facility
▪ Ask the child or a person who was with the child to
describe the snake.
▪ Administer antiventin. Antivenin may contain a horse-
serum base. Therefore, before the serum is injected IM
or IV, a skin test may need to be performed to prevent
a possible anaphylactic reaction to the horse serum.
If the serum is given IM, do not inject it into an
edematous body part, because medication
absorption will be poor.
▪ Tetanus prophylaxis is instituted if the child’s
immunization status is unknown or if it has been more
than 10 years since a tetanus immunization was
given.
For avoiding snakebites:
▪ Look for snakes before stepping into underbrush.
▪ Do not lift up rocks without looking at what could be
under them.
▪ Listen for the telltale sound of a rattlesnake.
▪ Be aware that snakes sun on warm rocks.
▪ Know the markings of poisonous snakes.
THERMAL INJURIES
1 BURNS
→ With adults, the “rule of nines” is a quick method of
estimating the extent of a burn.
→ Depth of Burn. When estimating the depth of a burn,
use the appearance of the burn and the sensitivity of
the area to pain as criteria.
Care of Mother, Child, at Risk or with Problems
Nursing Care of a Family When a Child has an
Unintentional Injury
1st degree: superficial epidermis (erythematous, dry,
painful) – sunburn
2nd degree: epidermis and portion of dermis
(blistered, erythematous to white) – scalds
3rd degree: entire skin including nerves and blood
vessels – flame
Emergency Management of Burns
Minor Burns
▪ Immediately apply ice to cool the skin and prevent further
burning.
▪ Application of an analgesic–antibiotic ointment and a
gauze bandage to prevent infection is usually the only
additional treatment required.
▪ Caution parents to keep the dressing dry (no swimming or
getting the area wet while bathing for 1 week).
Moderate Burns
▪ Moderate or second-degree burns may have blisters. Do
not rupture them, because doing so invites infection.
▪ The burn will be covered with a topical antibiotic such as
silver sulfadiazine and a bulky dressing to prevent damage
to the denuded skin.
▪ The child usually is asked to return in 24 hours to assess that
pain control is adequate and there are no signs and
symptoms of infection.
▪ Broken blisters may be débrided (cut away) to remove
possible necrotic tissue as the burn heals.
Severe Burns
▪ The child with a severe burn is critically injured and needs
swift, sure care, including fluid therapy, systemic antibiotic
therapy, pain management, and physical therapy, to
EVANGELISTA, E.M | BSN-2 | NCM 109 LEC (FINALS)| RN 2025
05
survive the injury without a disability caused by scarring,
infection, or contracture.
Electrical Burns of the Mouth
▪ The immediate treatment for electrical burns of the mouth
is to unplug the electric cord and control bleeding.
▪ Pressure applied to the site with gauze is usually effective.
▪ Supply adequate
pain relief as long
as necessary.
▪ Clean the wound
about four times
a day with an
antiseptic
solution, such as
half-strength
hydrogen
peroxide, or as otherwise ordered to reduce the possibility
of infection (a real danger in this area, because bacteria
are always present in the mouth).
▪ The child may be able to drink fluids from a cup best. Bland
fluids, such as artificial fruit drinks or flat ginger ale, are best.
▪ Electrical burns of the mouth turn black as local tissue
necrosis begins. They heal with white, fibrous scar tissue,
possibly causing a deformity of the lip and cheeks with
healing. This can be minimized by the use of a mouth
appliance, which helps maintain lip contour.
▪ Obviously, you need to review with parents the importance
of not leaving “live” electrical cords where young children
can reach them.
Therapy for Burns
Topical Therapy
▪ Silver sulfadiazine (Silvadene) is the drug of choice for burn
therapy to limit infection at the burn site for children. It is
applied as a paste to the burn, and the area is then
covered with a few layers of mesh gauze.
▪ Antiseptic solutions, such as povidone-iodine (Betadine),
may also be used to inhibit bacterial and fungal growth.
Unfortunately, iodine stings as it is applied and stains skin
and clothing brown.
▪ Dressings must be kept continually wet to keep them from
clinging to and disrupting the healing tissue.
Débridement
▪ Débridement is the removal of necrotic tissue from a burned
area.
▪ Débridement reduces the possibility of infection, because it
reduces the amount of dead tissue.
▪ Children usually have 20 minutes of hydrotherapy before
débridement to soften and loosen eschar, which then can
be gently removed with forceps and scissors.
▪ Débridement is painful, and some bleeding occurs with it.
Premedicate the child with a prescribed analgesic, and
help the child use a distraction technique during the
procedure to reduce the level of pain.
▪ Children need to have a “helping” person with them, to
hold their hand, to stroke their head, and to offer some
verbal comfort during debridement.
Grafting
▪ Homografting (also called allografting) is the placement of
skin (sterilized and frozen) from cadavers or a donor on the
cleaned burn site. These grafts do not grow but provide a
protective covering for the area.
▪ In small children, heterografts (also called xenografts) from
other sources, such as porcine (pig) skin, may be used.
▪ Autografting is a process in which a layer of skin of both
epidermis and a part of the dermis is removed from a distal,
unburned portion of the child’s body and placed at the
prepared burn site, where it will grow and replace the
burned skin.
▪ The advantage of grafting is that it reduces fluid and
electrolyte loss, pain, and the chance of infection. After the
grafting procedure, the area is covered by a bulky dressing.
▪ The donor site on the child’s body (often the anterior thigh
or buttocks) is also covered by a gauze dressing.
Care of Mother, Child, at Risk or with Problems
Nursing Care of a Family When a Child has an
Unintentional Injury 05
▪ Both donor and graft dressings should be observed for fluid
drainage and odor.
▪ Observe the child to determine whether there is pain at
either site, which might indicate infection, as well as temp.

EVANGELISTA, E.M | BSN-2 | NCM 109 LEC (FINALS)| RN 2025