Physiopsychosocial Considerations

The physical, mental, and social considerations of children's health problems do

not lend themselves to specific conditions. These considerations include the
child's ability to deal with hospitalization, abuse, and death. They require
special empathy and sensitivity to the needs and feelings of children based on
age and related growth and development parameters.

Autism Spectrum Disorders

ASDs are complex neurodevelopmental disorders of unknown etiology. The
APA Diagnostic and Statistical Manual of Mental Disorders (DSM-5) revised
the definition for ASD based on two behavior domains that include difficulties
in social communication and social interaction, and unusually restricted,
repetitive behavior, interest or activities (American Psychiatric Association,
2013; Brentani, Paula, Bordini, et al, 2013; Lai, Lombardo, and Baron-Cohen,
2014).

ASD is now frequently diagnosed in toddlers because their atypical

development is being recognized early (Lai, Lombardo, and Baron-Cohen,
2014). It occurs in 1 in 68 children in the United States; is about four times
more common in boys than in girls; and is not related to socioeconomic level,
race, or parenting style (Centers for Disease Control and Prevention, 2014;
National Autism Association, 2015a).

Etiology
The cause of ASD is unknown. Researchers are investigating a number of
theories, including a link between hereditary, genetic, medical problems,
immune dysregulation/neuroinflammation, oxidative stress (damage to cellular
tissue), and environmental factors (Lai, Lombardo, and Baron- Cohen, 2014;
Rossignol and Frye, 2012). Individuals with ASD may have abnormal
electroencephalograms, epileptic seizures, delayed development of hand

1
dominance, persistence of primitive reflexes, metabolic abnormalities (elevated
blood serotonin), cerebellar vermis hypoplasia (part of the brain involved in
regulating motion and some aspects of memory), and infantile abnormal head
enlargement (Rutter, 2011).

The strong evidence for a genetic basis in twins is consistent with an

autosomal recessive pattern of inheritance. Twin studies demonstrate a high
concordance (60% to 96%) for monozygotic (identical) twins and less than 5%
concordance for dizygotic (nonidentical) twins. In addition, between 5% and
16% of boys with ASD are positive for the fragile X chromosome (Clifford,
Dissanayake, Bui, et al, 2007; Grafodatskaya, Chung, Szatmari, et al, 2010).

There is a relatively high risk of recurrence of ASD in families with one

affected child (Chawarska, Shic, Macari, et al, 2014; Rutter, 2011; Yoder,
Stone, and Walden, 2009). Several genes have been suggested as possible
causative factors in ASD (Kolevzon, Gross, and Reichenberg, 2007; Talkowski,
Minikel, and Gusella, 2014; Willsey and State, 2015).

The scientific evidence to date shows no link between measles, mumps, and
rubella (MMR) and thimerosal-containing vaccines and ASDs (Barile,
Kuperminc, Weintraub, et al, 2012; Price, Thompson, Goodson, et al, 2010;
Taylor, Swerdfeger, and Eslick, 2014; Uno, Uchiyama, Kurosawa, et al, 2015)
(see Translating Evidence into Practice box). ASD has been reported in
association with a number of conditions, such as FXS, tuberous sclerosis,
Prader-Willie syndrome, metabolic disorders, fetal rubella syndrome,
Haemophilus influenzae meningitis, and structural brain anomalies (National
Autism Association, 2015a; Peterson and Barbel, 2013). Recent reports have
retrospectively tied ASD to prenatal and perinatal events, such as maternal and
paternal ages over 40 years old (for fathers, 1 in 116 births; for mothers, 1 in
123 births), uterine bleeding during pregnancy, low Apgar score, fetal distress,
and neonatal hyperbilirubinemia (Amin, Smith, and Wang, 2011; Kolevzon,

2
Gross, and Reichenberg, 2007; National Autism Association, 2015b; Rutter,
2011). These same researchers, however, urge caution in interpreting these
findings.

Communication impairments are a common sign in children with ASD that

may range from absent to delayed speech. Any child who does not display
language skills such as babbling or gesturing by 12 months old, single words by
16 months old, and two-word phrases by 24 months old is recommended for
immediate hearing and language evaluation. Autism regression is when the
child seems to develop normally then regresses suddenly; this is a red-flag event
that has been frequently displayed in expressive language (Fernell, Eriksson,
and Gillberg, 2013; National Autism Association, 2015c).

Early recognition, referral, diagnosis, and intensive early intervention tend

to improve outcomes for children with ASD (Golnik and Maccabee-Ryaboy,
2010; Reichow, Barton, Boyd, et al, 2012; Peterson and Barbel, 2013;
Zwaigenbaum, 2010). Unfortunately, diagnosis is often not made until 2 to 3
years after symptoms are first recognized. However, in a recent retrospective
study, the majority of parents observed atypical development in their ASD
children before 24 months old (Lemcke, Juul, Parner, et al, 2013).

Prognosis
Even though ASD is usually a severely disabling condition. With early and
intensive interventions, the symptoms associated with autism can be greatly
improved and some cases reported symptoms were completely overcome
(National Autism Association, 2015a; Wodka, Mathy, and Kalb, 2013). Some
ultimately achieve independence, but most require lifelong adult supervision.
Aggravation of psychiatric symptoms occurs in about half of the children during
adolescence, with girls having a tendency for continued deterioration.

Early recognition of behaviors associated with ASD is critical to implement

appropriate interventions and family involvement. There is a growing body of

3
evidence that parent-delivered interventions are associated with some improved
outcomes, yet further research is needed in this area incorporating consistent
measures (Bearss, Burrell, Stewart, et al, 2015; Brentani, Paula, Bordini, et al,
2013; Oono, Honey, and McConachie, 2013). The prognosis is most favorable
for children with higher intelligence, functional speech, and less behavioral
impairment (Raviola, Gosselin, Walter, et al, 2011; Solomon, Buaminger, and
Rogers, 2011).

Nursing Care Management

Therapeutic intervention for children with ASD is a specialized area
involving professionals with advanced training. Although there is no cure for
ASD, numerous therapies have been used. The most promising results have
been through highly structured and intensive behavior modification programs.
In general, the objective in treatment is to promote positive reinforcement,
increase social awareness of others, teach verbal communication skills, and
decrease unacceptable behavior.

Providing a structured routine for the child to follow is a key in the

management of ASD.When these children are hospitalized, the parents are
essential to planning care and ideally should stay with the child as much as
possible. Nurses should recognize that not all children with ASD are the same
and that they require individual assessment and treatment. Decreasing
stimulation by using a private room, avoiding extraneous auditory and visual
distractions, and encouraging the parents to bring in possessions the child is
attached to may lessen the disruptiveness of hospitalization. Because physical
contact often upsets these children, minimal holding and eye contact may be
necessary to avoid behavioral outbursts. Take care when performing procedures
on, administering medicine to, and feeding these children because they may be
either fussy eaters who willfully starve themselves or gag to prevent eating, or
indiscriminate hoarders who swallow any available edible or inedible items,

4
such as a thermometer. Eating habits of ASD children may be particularly
problematic for families and may involve food refusal accompanied by mineral
deficiencies, mouthing objects, eating nonedibles, and smelling and throwing
food (Belschner, 2007; Herndon, DiGuiseppi, Johnson, et al, 2009).

Children with ASD need to be introduced slowly to new situations, with

visits with staff caregivers kept short whenever possible. Because these children
have difficulty organizing their behavior and redirecting their energy, they need
to be told directly what to do. Communication should be at the child's
developmental level, brief, and concrete.

Family Support

ASD, as with so many other chronic conditions, involves the entire family
and often becomes “a family disease.” Nurses can help alleviate the guilt and
shame often associated with this disorder by stressing what is known from a
biologic standpoint and by providing family support. It is imperative to help
parents understand that they are not the cause of the child's condition.

Parents need expert counseling early in the course of the disorder and
should be referred to the Autism Society website. The society provides
information about education, treatment programs and techniques, and facilities
such as camps and group homes. Other helpful resources for parents of children
with ASD are the local and state departments of mental health and
developmental disabilities; these organizations provide important programs and
in-school programs throughout the United States for children with ASD.

As much as possible, the family is encouraged to care for the child in the
home. With the help of family support programs in many states, families are
often able to provide home care and assist with the educational services the
child needs. As the child approaches adulthood and the parents become older,
the family may require assistance in locating a long-term placement facility.

5
 ABUSED CHILD
Child abuse (maltreatment) is defined as an intentional action toward a child
that includes the areas of physical abuse or neglect, emotional abuse or neglect,
and sexual abuse. The most common form of child abuse is neglect, which may
include deprivation of physical and/or emotional needs (food, clothing, shelter,
medical care, education, affection, love, nurturing) or aggressive emotional
abuse (isolation, terrorizing, rejection). Physical abuse may include burns,
bruises, fractures, lacerations, poisoning of the child; sexual abuse may be
indicated by bruising and bleeding of anus or genitals; discharge and pain in
genitals; sexually transmitted disease; urinary incontinence and infections or
odor, swelling, and itching of genitalia. Regardless of the type of abuse, the
nurse's responsibilities are to identify the maltreatment and to protect the child
from further abuse (Fig. 12.1).
Symptoms of Abused Child
• A child who's being abused may feel guilty, ashamed or confused
• He or she may be afraid to tell anyone about the abuse, especially if the
abuser is a parent, other relative or family friend. In fact, the child may
have an apparent fear of parents, adult caregivers or family friends.
That's why it is vital to watch for red flags, such as:
• Withdrawal from friends or usual activities
• Changes in behavior-such as aggression, anger, hostility or
hyperactivity- or changes in school performance
• Depression, anxiety or a sudden loss of self-confidence
• An apparent lack of supervision
• Frequent absences from school or reluctance to ride the school bus home
• Reluctance to leave school activities, as if he or she doesn't want to go
• Attempts at running away
• Rebellious or defiant behavior

6
• Attempts at suicide.
Specific signs and symptoms depend on the type of abuse.
Physical abuse signs and symptoms
• Unexplained injuries, such as bruises, fractures or burns
•Injuries that don't match the given explanation
• Untreated medical or dental problems
Sexual abuse signs and symptoms
• Sexual behavior or knowledge that, inappropriate for the child’s age
• Pregnancy or a sexually transmitted infection
• Blood in the child's underwear
• Statements that he or she was sexually abused
• Trouble walking or sitting
• Abuse of other children sexually.
Emotional abuse signs and symptoms
• Delayed or inappropriate emotional development
• Loss of self-confidence or self-esteem
• Social withdrawal
• Depression
• Headaches or stomachaches with no medical cause
• Avoidance of certain situations, such as refusing to go to school or ride
the bus
• Desperately seeks affection.
Neglect signs and symptoms
• Poor growth or weight gain
• Poor hygiene
• Lack of clothing or supplies to meet physical needs
• Taking food or money without permission

7
 • Eating a lot in one sitting or hiding food for later
• Poor record of school attendance
• Lack of appropriate attention for medical, dental or psychological
problems, even though the parents have been notified.
• Emotional swings that are inappropriate or out of context to the situation
• Indifference.
Parental behavior
Sometimes a parent's demeanor or behavior sends red flags about child
abuse. Warning signs include a parent who:
• Shows little concern for the child
• Appears unable to recognize physical or emotional distress in the child
• Denies that any problems exist at home or school, or blames the child for
the problems
• Consistently blames belittles or berates the child and describes the child
with negative terms, such as "worthless" or "evil"
• Expects the child to provide him or her with attention and care and
seems jealous of other family members getting attention from the child
• Uses harsh physical discipline or asks teachers to do so
• Demands an in appropriate level of physical or academic performance
• Severely limits the child's contact with others
• Offers conflicting or unconvincing explanations for a child's injuries or
no explanation at all.

Nursing management
A. Essential Nursing Diagnoses and Nursing Process Associated with these
Conditions
Nursing Diagnosis

8
Altered nutrition: Less than body requirements related to inability to ingest
food.
Assessment: Withholding of food by parent/caretaker, weight loss,
malnutrition, lack of
subcutaneous fat, failure to thrive.
Nursing Diagnosis
High risk for impaired skin integrity related to external factor of trauma.
Assessment: Disruption of skin surface (lacerations, burns, abrasion), various
skin trauma in different stages of healing, lack of bathing causing unclean skin,
teeth, hair.
Nursing Diagnosis
Altered growth and development related to inadequate caretaking,
indifference, environmental and stimulation deficiencies.
Assessment: Delay or difficulty in performing skills (motor, social, or
expressive) typical of age group, altered physical growth, inability to perform
self-care or self-control activities appropriate for age, flat affect, decreased
responses, withdrawal, antisocial behavior, fearfulness, poor relationships with
peers, regressive behavior, acting out behavior.
B. Specific Nursing Diagnoses and Nursing Process
Nursing Diagnosis
Anxiety of child related to threat to self-concept, change in health status,
change in interaction patterns, situational crisis (Table 12.1). feeling
Assessment: Increased apprehension and uncertainty, fearfulness,
powerlessness, fear of consequences, repeated episodes of maltreatment,
mistrust trembling, quivering voice, poor eye contact.

9
Table 12.1: Nursing interventions for anxiety of child
Interventions Rationales
Assess level of anxiety and fear in Provides information about the source
child and how is manifested; needs of and level of anxiety and what might
child that are the source of anxiety and relieve it any criteria to judge
reactions to staff and parent(s) improvement
Demonstrate affection and acceptance Promotes trust of staff and positive
of the child even if not returned or behavior of the child
ignored; avoid reinforcing any
negative behavior
Provide a play program with other Modifies negative behavior by
children; set aside time to be alone promoting interactions with others and
with child or quiet time for child as regarding desired behaviors; promotes
well; praise child or reward with a self-esteem
special treat when appropriate
Provide consistent staffing for child, Promotes familiarity and trusting
preferably late well to child relationship with staff
Allow expression of concerns and Provides opportunity to vent feelings,
fears of child about treatments, which reduces anxiety
environment; allow questions and
provide honest explanations and
communication at child's age level
Provide treatment of injuries; avoid Prevents increased anxiety and stress
treating child as a victim, asking too in child by discussion of abuse
many questions, or forcing any
discussion
Assess possible need for counseling Reduces anxiety and supports child in
services for the child dealing with abuse and negative

10
 behavior
Evaluation
• Reduces anxiety by establishing accepting, safe environment
• Participates in play with others
• Establishes relationships with staff member(s)
• Exhibits reduction in negative behavior, signs and symptoms of anxiety
and fear.
Nursing Diagnosis
Altered parenting related to unmet social and emotional maturation needs of
parental figures, ineffective role modeling, lack of knowledge, situational crisis
or incident (Table 12.2).
Assessment: lack of parental attachment behaviors, verbalization of resentment
toward child and of role inadequacy, inattention to needs of child,
noncompliance with health practices and medical care, inappropriate discipline
practices, frequent accidents and illness of child, growth and development lag in
child, history of child abuse abandonment, multiple caretakers without regard
for needs of child, evidence of physical and psychological trauma, actual
abandonment of child.

11
Table 12.2: Nursing intervention for altered parenting
Interventions Rationales
Assess parent(s) for achievement of Provides information about parent-
developmental tasks of self and child relationship and parenting styles
understanding of child's growth and that may lead to child abuse; identifies
development; how they are bonded parents at risk for violence or other
and attached to child; how they abusive behavior
interpret and respond to child; how
they accept and support child; how
they meet child's social, psychological
and physical needs
Provide a child nurturing role model Promotes development of parenting
for parent(s) to emulate, and suggest skills by imitation
what they might do to develop
parent(s) skills
Praise parent(s) for their participation Reinforces positive parenting
in child's care, tell them that they are behaviors and increases feeling of
giving good care to child adequacy
Include parent(s) in planning care and Promotes participation of parent(s) in
setting goals meeting child's needs
Provide an opportunity for parent(s) to Support parent(s) in meeting their own
express their feelings, personal needs, needs
and goals; avoid making judgmental
remarks or comparing them to other
parent(s)
Initiate referrals to social services, Provides options if parenting is
parenting classes, or counseling as unsatisfactory or inadequate
appropriate

12
 Evaluation
• Participate in child care with increased understanding of child's needs for
age and developmental level
• Reduce behaviors that are harmful to child and to relationship between
parent and child
• Demonstrate proper parenting behaviors
• Demonstrate improved and positive interaction with child
• Attend parenting classes and support group activities
• Meet own needs for health and optimal functioning
• Secure assistance to solve problems that lead to abusive behavior.
Nursing Diagnosis
High risk for other directed violence related to child abuse, maladaptive
behavior of parent(s) or other (Table 12.3).
Assessment: Sexual assault of child, evidence of physical abuse of child,
history of abuse of abuser, social isolation of family, low self-esteem of
caretaker, inadequate support systems, violence against other members of the
family.
Table 12.3: Nursing interventions for high risk for other directed violence
Interventions Rationales
Asses the abuser for violent behavior Provides information to determine
or other abusive patterns, use of warning signs of child abuse
alcohol or drugs, or other psychosocial
problems
Assess behavior of parent(s) toward Reveals characteristics that may
child, including response to the child's indicate risk for abuse
behavior, ability to comfort the child,

13
feelings and perceptions toward the
child, expectations for the child, over
protectiveness or concern for the child
Protect child and parental privacy by Protects the rights of the child and
notdiscussing events with others and parent(s)
preventing others from discussing
events with the abused child
Review laws governing child abuse Provides information about legal
aspects of child abuse and actions to
take on behalf of all concerned
Communicate information and needs Provides care plan for child based on
of child to those on the abuse team or court decision to caretakers working
to new caretakers if child being placed with the family
with a foster parent or someone other
than parents; provide written
instruction for care and child's needs
Accurately record facts, events, and Provides information that may be used
observations in an objective manner in legal action regarding abuse
Initiate referral to social worker, Provides support to child and family,
psychological counselor before and monitors behaviors following
discharge to home discharge

Evaluation
• Protects child from recurrence of or continuance of abuse
• Protects privacy of child and family

14
 • Complies with laws governing child abuse
• Records all events associated with suspected or actual child abuse
• Absence of trauma or injury to the child
• Identifies abusive behavior and acts to remove child from the abusive
environment
• Assists parent(s) in seeking support and self-help groups
• Referral to social worker, nurse, or counselor for economic, social,
psychological and physical needs of child and family.

THE PREGNANT ADOLESCENT

Adolescent pregnancy is not a new phenomenon. Historically, it was
common for women to marry as early as age 12 or 13 and have their first baby
at age 15. In today’s society, how- ever, marriage and childbearing are life
situations that are thought of as belonging to later years. Teenage pregnancies
still continue, however. Reasons for the high number of them include:
• Earlier age of menarche in girls (the average age is 12.4 years; many
girls begin menstruating at age 10 and so are ovulating and able to
conceive by age 11)
• Increase in the rate of sexual activity among teenagers
• Lack of knowledge about (or failure to use) contraceptives or abstinence
• Desire by young girls to have a child
Having an equally young sexual partner can contribute to pregnancy
incidence as in this situation, neither partner may be well versed in
contraceptive options (Buston, Williamson, & Hart, 2007). In addition, some
adolescents become pregnant as the result of rape or incest (Kandakai & Smith,
2007).
Failure of adolescents to obtain adequate knowledge of contraceptive
measures or abstinence is an issue that can be addressed by health care
providers. As protective measures are easy to use, the average adolescent should

15
not have difficulty following instructions. Adolescents are also capable of using
emergency contraceptive measures correctly and safely. Access to emergency
contraception is not associated with increased rates of unprotected intercourse
or with higher rates of pregnancy or sexually transmitted infections (Haynes,
2007). Unfortunately, providing this type of information does not always
resolve the problem because adolescents may lack money to purchase protection
such as birth control pills or a diaphragm. In addition, the egocentric
phenomenon of adolescence makes a sexually active teenager believe she will
not become pregnant: “It won’t happen to me.” On the other hand, some
adolescent girls actually plan pregnancy. They believe being pregnant will free
them from an intolerable school or home situation and give them someone to
love and someone to love them. This puts a tremendous responsibility on a
newborn to furnish love and change a girl’s life, and child abuse can occur
when the newborn can- not meet such expectations (Records, 2007).
At one time, pregnant unmarried girls were sent to a “secret” home or
shelter where they would stay throughout their pregnancy, give birth, place the
child for adoption, and re- turn home as if nothing had happened to them.
Today, pregnant teenagers remain at home, attend prenatal clinics, or come to
physicians’ offices just as older women. They give birth in birthing rooms at
hospitals, and as many as 90% keep their babies (NCHS, 2009). Few give birth
in alternative birth centers because the risk of cephalopelvic disproportion
makes adolescent pregnancies high risk. Home birth is not recommended for the
same reason. Offering increased guidance during pregnancy and for child care
during the fol- lowing years can be an important nursing role.
Developmental Tasks of Adolescence
Adolescence is a vulnerable time for pregnancy because the developmental
tasks of pregnancy are superimposed on those of adolescence. The
developmental tasks of the average adolescent are fourfold: to establish a sense

16
of self-worth or a value system, to emancipate from parents, to adjust to a new
body image, and to choose a vocation (Erikson, 1963). A girl in the process of
separating from her parents may be devastated by the reality of someone else
being dependent on her. She may need her parents’ financial help more than
ever to obtain pre- natal care and buy clothing for her new baby. If she must de-
pend on her parents’ health insurance, she may feel virtually trapped into
dependence. Helping adolescents to make their own health care decisions at
health care visits helps to foster a sense of independence in the middle of this
forced dependency. Consider, for example, the decision that the adolescent must
make about where to place a medication reminder chart: if it hangs in the
kitchen, her mother may monitor it; in her bedroom or in her school locker, she
alone will monitor it. An adolescent may not be able to choose when she comes
for care (her mother has the car to drive her only on Tuesday afternoons), but
during a visit she can do many things to feel in- dependent, such as weigh
herself, hold a mirror to view her pelvic examination, or be interviewed apart
from her parent.
Parents may have difficulty allowing a daughter to make her own health
care decisions this way. You may need to re- mind them that a pregnant
adolescent is regarded as an emancipated minor or a mature minor—a person
capable of making health care decisions—and so may sign permission for her
own care. Soon she will be caring for an infant, so she needs this practice in
independence and responsibility.
Pregnancy may interfere with the development of a healthy sexual
relationship and cause difficulty in establishing future intimate relationships if a
girl realizes that her current relationship has led to a situation detrimental to her.
To pre- vent this, it is useful to help her view the pregnancy as a growth-
producing experience. Most people can point to a day in their life when they
“grew up” (perhaps a day a parent became ill or the day they left home for

17
college). This pregnancy can be that “growing-up” revelation or a growth-
producing experience for her.
Establishing a value system or sense of identity can be difficult if health
care personnel treat a pregnant adolescent as though she is irresponsible.
Encouraging her to continue school is crucial to her self-esteem and to her
future, as well as to the future of her unborn child. Many schools have special
programs for pregnant adolescents that include aspects of prenatal care.
Prenatal Assessment
Adolescents are considered high-risk clients because they have a high
incidence of pregnancy-induced hypertension, iron-deficiency anemia, and
premature labor (Box 22.2). They also have a higher incidence of low-birth-
weight infants, a disproportion between fetal and pelvic size, and a high rate of
intimate partner abuse (Datner et al., 2007). Early and consistent prenatal care is
essential to their health and the health of their baby.
Unfortunately, many adolescents do not seek prenatal care until late in their
pregnancies as not seeking prenatal care is a way of protecting the pregnancy—
if she doesn’t tell anyone, no one can suggest she terminate the pregnancy.
After the sixth month, abortion is no longer a possibility, so she can feel free to
come for care without being subjected to this pressure.
Other factors contributing to the lack of prenatal care include:
• Denial she is pregnant
• Lack of knowledge of the importance of prenatal care
• Dependence on others for transportation
• Feeling awkward in a prenatal setting (an adult setting)
• Fear of a first pelvic examination
• Difficulty relating to authority figures

18
 A primary nursing or case management approach that minimizes the number
of health care providers a teenager is ex- posed to may be the most effective
method for providing care during the prenatal period. Some adolescents do well
in group prenatal care because it allows them to interact with a peer group. If a
community does not have a facility designed especially for adolescents, all
settings should accommodate adolescents’ needs, eliminating this reason for
poor prenatal care.
Health History
Take a detailed health history at the first prenatal visit of an adolescent to
establish individual risks. This is best done without the girl’s parents present.
The girl needs practice in being responsible for her own health, and having to
account for her health practices helps her do this. It also helps prevent her from
fabricating an answer to please a parent.
Some adolescents come to a facility with concerns such as “weight gain” or
“feeling tired all the time” rather than saying they are pregnant, hoping health
care providers will think of pregnancy as a possible reason for their symptoms.
This is part denial and part pregnancy protection. Always be alert to the
possibility of pregnancy when an adolescent describes symptoms that are vague
and hard to define. If the importance of what she is saying when she mentions
feeling “tired” or “nauseated” is missed, she may ask if someone will feel her
stomach. If told this is not necessary for any of the symptoms she has
mentioned, she may describe bigger symptoms, such as “terrible stomach pain.”
Think of possible pregnancy when you hear such a “growing” history.
Many adolescents want to keep their world totally separate from the adult
world and, to keep it separate, they do not voluntarily share information with
adults. When inter- viewing adolescents, be certain to press for the responses
needed to assess safely. Do not accept statements such as “I eat okay” as a

19
nutrition history or “I’m a very active person” as a history of rest and activity.
Ask for details.
If an adolescent delayed seeking health care, ask for the reason for this at
her first prenatal visit. Acknowledge that “protecting” the pregnancy is a
desirable motive, but that continuing with prenatal care is much more
beneficial.
If a parent does accompany a girl, ask the parent separately what, if any,
concerns he or she wishes to discuss. A young adolescent is still a daughter, and
a parent may be as concerned about her health during this pregnancy as the
parent was at health visits when the girl was being seen for a cold or a sports
injury.
A baby’s father may accompany a teenage girl into the clinic or office to
have the pregnancy diagnosis established. Because he is not married to her, he
does not have a legal right to participate in her decision concerning pregnancy,
abortion, or adoption, but he may not be devoid of feelings for the girl or the
baby. If he is an adolescent, he may feel sorrow that because of his age he
cannot provide adequately for the girl and baby. If a complication occurs, he
may feel genuine grief. Allowing him to offer support in the current pregnancy
helps him to learn more about himself and better define his role (Parra-Cardona,
Sharp, & Wampler, 2008). Be sure he receives compassionate education on
preventing further pregnancies until he is more mature.
Often, adolescent girls have not talked much to many pregnant women, so
they may need extra teaching to help them become aware of common pregnancy
symptoms such as urinary frequency, fatigue, and breast tenderness. Asking
what symptoms an adolescent is having, and reassuring her they are part of a
normal pregnancy, can help prevent her from attempting to treat them with
potentially teratogenic over-the-counter medications.

20
 As pregnancy progresses, listen for signs of “nest-building” behavior during
a pregnancy history. An adolescent girl may not have the financial resources to
buy clothing or a baby bed. She may reveal nest-building feelings by asking an
increasing number of questions about newborns. Offer suggestions, such as
making one article of clothing for the baby or saving her own money for one
article—activities that promote active
involvement in the pregnancy and provide a measure of nest- building
behavior (the girl who, week after week, spends her money on something else is
probably not as involved in the pregnancy as the girl who puts away even 1
dollar each week toward a pair of baby shoes).
Some adolescents have difficulty telling their parents about the pregnancy.
Role-playing or simulation may be an effective technique to help them prepare
to do this. Some girls report on a second visit that their parents were not nearly
as angry as they had anticipated. Instead, their parents reacted as if they had
been waiting to hear this news, having accepted it as inevitable months before.
Family Profile. Adolescents may leave home if their family disapproves of
their pregnancy, joining the ranks of homeless or adolescent runaways. Others
do not leave home but separate themselves emotionally from their family.
Trying to manage by themselves leaves adolescents with tremendous financial
strain and a devastating sense of loneliness. Be sure to ask a girl at prenatal
visits where she is living, what is the source of her income, and whom she
would call if she suddenly became ill.
Asking about home life may reveal a dysfunctional family or an incest
relationship as the cause of the pregnancy. If the girl is under legal age, incest is
considered child abuse. Know your local and state laws on this topic and make
the necessary report.
Because of family relationship problems, a girl may need help in making
arrangements for the next few months of her pregnancy and for child care

21
afterward. Will her parents allow her to live at home during the pregnancy? If
not, is there a relative she may go to? What kind of financial support does she
need? Family and social supports for pregnant adolescents have been shown to
be important influences on the maintenance of a healthy pregnancy lifestyle and
help pre- vent low birth weight in their children (Kaplan & Love- Osborne,
2008).
Be certain to ask if the girl is planning to continue with school. Pregnancy is
an egocentric time when outside inter- ests do not always seem important. Help
her to see that the months of pregnancy will go by faster if she is busy.
Remaining in school is a way of helping her stay busy. It also is important in
preparing for the future, because a high school education will be necessary to
obtain marketable skills to support herself and her baby. Once she has given
birth, re- turning to school may be difficult because she may have child care
problems and because she may feel she is more mature than the other girls (or
the other girls may make her feel this way). Any school that obtains federal
money cannot discriminate against students because they are physically
challenged. Many states interpret pregnancy as physically challenging, so in
those states a girl cannot be forced to leave school (or even asked to go to an
alternate school) because of pregnancy. You may need to advocate for a girl
with a school committee for a proper school placement.
Day History. Adolescents may be unwilling to provide a de- tailed day
history unless its purpose is well explained. Tell a pregnant teenager the
purpose of the history is to learn more about her as a whole person, not to
discover if she is doing things during the day she should not do. Adolescents are
private people; to allow you to walk through their adolescent
world for a day is a breach of adolescent philosophy. Ask in particular about
nutritional practices, sleep, daily activity, use of drugs, and whether she has
friends who can support her through this experience.

22
 Be certain to include questions about her medication history. Ask if she is
taking anything over the counter. Some adolescents take acne medication that is
potentially teratogenic, such as tetracycline or isotretinoin (Accutane) (Karch,
2009). Some take frequent doses of over-the- counter cold remedies or herbal
supplements. Impress upon adolescents the importance of not taking any
medication— even nonprescription—without prior approval from their
physicians or nurse-midwives during pregnancy. Pregnancy can become an
important growth experience if it provides the motivation some adolescents
need to withdraw from recreational drug use.
Physical Examination
Physical examination procedures with pertinent adolescent findings are
discussed in Chapter 34. Be certain to explain procedures as you do the
examination. A statement such as “Oh, you’re starting to have colostrum,” a
positive finding of pregnancy, may be frightening to an adolescent who does not
know what colostrum is. A better way to phrase such a finding might be, “Your
breasts are healthy. You’re already be- ginning to produce early breast milk.
Later on we’ll talk about the importance of breast milk for newborns.” This kind
of feedback makes a health examination a learning experience and relieves
anxiety for adolescents, who tend to be very concerned about body appearance.
It is an effective way to encourage healthy behavior patterns.
Adolescents are at an increased risk for pregnancy-induced hypertension,
probably because of immature blood vessels or an immune response to the
foreign protein of their fetus (Clark, Silver, & Branch, 2007). Few adolescents
are told the results of blood pressure determinations at health maintenance
visits, so they do not know what is their typical finding. Obtain a baseline blood
pressure at the first prenatal visit and make a point of informing the girl of her
blood pressure reading to encourage active health care participation in the
future. Adolescents are often active in a waiting room—walking to get a

23
magazine, returning it, or looking out the window; be certain that the girl has 15
minutes of rest before you take a blood pressure or the recording will be falsely
high.
Use a Doppler technique to obtain fetal heart tones, if possible, because
hearing the fetal heart helps an adolescent acknowledge the reality of her
pregnancy. For the same rea- son, make a point of assessing fundal height from
visit to visit to show the baby is growing.
Adolescents who use drugs may be reluctant to supply a urine specimen for
testing because they are afraid you are secretly looking for evidence of drug use.
In this instance, you may receive a cupful of water in place of a urine specimen.
If in doubt regarding the substance you are testing, check the specific gravity.
The specific gravity of water is 1.000, whereas urine specific gravity ranges
from 1.003 to 1.030.
Many adolescents like to weigh themselves at prenatal vis- its as weight
gain in early pregnancy is proof they are pregnant. It is good practice to make a
note of the clothing a girl is wearing the first time she is weighed (e.g., jeans, T-
shirt) so later weight determinations can be compared accurately. Be certain she
knows a healthy weight gain is important for fetal growth and that this weight
can be lost afterward.
Pregnancy Education
Adolescents need a great deal of health teaching during pregnancy because
they do not know many common measures of care that an older woman has
learned from experience. They are also often unwilling to follow health care
advice that makes them different in any way from their peers. On the other
hand, adolescents often do not have well-established health practices, so they
are adaptable.
Adolescent girls may respond to health teaching that is directed to their own
health more than to that of a fetus in- side them: “Eat a high-protein diet

24
because protein makes your hair shiny (or prevents split fingernails)” often
leads to better adherence than a statement such as “Protein is good for your
baby.” “Taking the iron supplement should make you feel less tired” is better
than “It will help build the baby’s blood supply,” for the same reason. These are
truthful statements and they appeal to an adolescent’s preoccupation with self.
In addition, this type of health teaching is the only form to which an adolescent
who is denying her pregnancy can respond.
Adolescents also need instructions about possible discomforts and changes
associated with pregnancy, and measures to relieve them. (See Chapter 12 for a
complete discussion.) Many adolescents develop hemorrhoids during pregnancy
because the disproportion of their body size to a fetus puts extra pressure on
pelvic vessels, causing blood to pool in rectal veins. Assure girls that this is a
pregnancy-related phenomenon that will resolve when the pregnancy is over.
Adolescents may also develop many striae across the sides of their
abdomens because so much stretching of the abdominal skin occurs. Assure
them again that, because of skin elasticity, these marks will probably fade after
pregnancy. Chloasma, excess pigment deposition on the face and neck, appears
at the same rate in adolescents as in older women. Adolescents, however, may
be more conscious of this pigment because overall they are more conscious and
concerned about their facial appearance. Suggesting a cover makeup and
offering reassurance the pigmentation will fade after pregnancy can help.

Nutrition
Good nutrition can be a major problem during an adolescent pregnancy
because many girls enter pregnancy with poor nutritional stores from years of
eating a less-than-optimal diet. Lack of good nutrition can result in preterm
birth and low- birth-weight newborns. The younger the girl is, the more likely
she is to have a low-birth-weight infant. To prevent these complications, a girl
should eat a sufficient diet to allow for the growth of a fetus and also provide

25
for the needs of her own growing body. Otherwise, protein, iron, folic acid, and
need to gain more weight than does the mature woman to supply adequate
nutrients. As more and more children are obese today than ever be- fore because
of overeating and lack of exercise, many adolescents enter pregnancy
overweight or obese. This can lead to macrosomia or overgrowth in a fetus, a
situation that leads to an increase in the number of cesarean births (Zhang et al.,
2008). Such adolescents should not actively restrict nutrients during pregnancy,
however, because although they are obese, their body may be deficient in
protein and vitamins.
Many adolescent girls eat poorly during pregnancy be- cause they simply do
not know what constitutes good nutrition. Some girls have little choice in what
foods are prepared at home. To change a dietary pattern, you may have to talk
to the person who does the cooking in the family.
Besides eating the right amount of food, a pregnant adolescent should be
sure to eat proper foods, possibly abandoning a food fad she has been following.
Some girls are so peer-oriented they balk at substituting a glass of orange juice
for a cola beverage because no one else they know drinks orange juice. The best
you may be able to accomplish is to secure her agreement to switch to
noncaffeinated soft drinks.
Many adolescents eat at least one meal a week at a fast- food restaurant.
Remember that if the girl is attending school, she eats at least one meal away
from home each day. If she travels by school bus, she may have to leave by 6:00
or 7:00 in the morning, so she needs suggestions on how to construct a quick
but healthy breakfast. If she leaves home this early, she will have a long wait
until lunchtime. Suggest midmorning snacks, such as fruit, that also supply
vitamins, not just empty calories. Be certain nutrition education includes how to
“brown-bag” or buy a nutritious cafeteria lunch (type A school lunches are
discussed in Chapter 32).

26
 Adolescents traditionally do not take medicine conscientiously, so they may
need frequent reminders that vitamin and iron supplements intended to
complement nutrition during pregnancy must not only be purchased but also
must be taken. Be sure a girl posts a medication reminder chart at home or in
her school locker to help increase adherence.
Activity and Rest
Adolescents vary greatly in their level of activity. Assess a girl’s
participation in sports and determine which ones (if any) may have to be
discontinued during pregnancy (e.g., diving, gymnastics, touch football). Many
girls practice sports not for the enjoyment of the sport but for the feeling of
“team” or companionship. You may need to suggest alter- native activities
(joining the drama or language club, inviting friends over once a week to watch
a movie) so they do not suffer from the loss of companionship.
Adolescent girls may not plan enough rest time during pregnancy, especially
if they are acting as if nothing is happening to them (Box 22.3). It may help to
explore a typical day and suggest ways to rest without compromising social
relationships (sitting, talking after school rather than walking through the park).
Physiologic Changes
A young girl may have distorted beliefs about her body. All adolescent girls
need substantial education on the physiologic changes that occur during
pregnancy. Despite all the health information given to children in school, it is
not uncommon to find an adolescent who thinks her baby is growing in her
stomach. Such a girl may be unwilling to eat large meals during pregnancy for
fear of suffocating or drowning her fetus. In addition, specific information about
labor and delivery is essential to counteract all the “scare stories” girls may be
hearing from their peers. Gaining this type of knowledge is another way that
pregnancy can be a growth experience. At the end of the pregnancy, this

27
adolescent will know a great deal more about her body and her ability to
monitor her health than her average classmate.
Childbirth Preparation
Adolescents have a strong need for peer companionship. When they become
pregnant, they often are cut off from fellow adolescents. This makes them
“ripe,” therefore, to join a class of adolescents in preparation for childbirth.
They are excellent students because being a student is age-appropriate for them.
They have enough childish magical belief operating that they are not skeptical
about whether prepared child- birth will work. In fact, believing that prepared
childbirth will work is an important component in a successful pre- pared
childbirth experience, so this becomes a self-fulfilling prophecy.
Birth Decisions
Pelvic measurements should be taken early and carefully in adolescent girls
as cephalopelvic disproportion is a real possibility because of the girl’s
incomplete pelvic growth (Shields et al., 2007). Most girls who are told their
baby will have to be born by cesarean birth respond well to the news, and many
are relieved, because surgery seems controlled and simple compared with the
agonies of labor they imagine. When a cesarean birth must be scheduled
because of cephalopelvic disproportion or poor fetal growth, the information
should be shared with the girl and her parents as soon as possible. Adolescents
want to know the truth. They tend to regard the withholding of information not
as protection but as an indication they are being treated as children.
Plans for the Baby
Adolescents may need additional time at prenatal visits to talk to a good
listener about how they feel about being preg- nant and becoming a mother.
Scared? Bewildered? Numb? Happy? Be certain they know all the options
available to them: keeping the baby, placing the baby in a temporary fos- ter
home or adoption. Adolescents, like all women, should be encouraged to

28
breastfeed (Britton et al., 2009). Breast tissue matures with pregnancy, so even
the very young adolescent is physically capable of breastfeeding.
Complications of Adolescent Pregnancy
As mentioned earlier, adolescent pregnancy carries the increased incidence
of pregnancy-induced hypertension, iron-deficiency anemia, preterm labor, and
cephalopelvic disproportion (see Box 22.2). Fortunately, with conscientious
prenatal care, these complications can be minimized.

HANDICAPPED CHILDREN
A handicapped condition makes the normal functions of the individual very
difficult and leads to dependency. These conditions are increasing day by day
due to changing lifestyle and complicated environment. It is a social problem.
Numbers are increasing but estimation of exact numbers is difficult.
Handicapped child is one who deviates from normal health status either
physically, mentally or socially and requires special care, treatment and
education.
Concept of Disability
According to WHO, the sequence of events leading to disability and
handicapped conditions are as follow:
Injury or disease: Considering accidents as an example, the above terms can
be explained. Accident as injury or disease causes loss of feet which is
considered as 'impairment. That leads to inability to walk which is 'disability'
and ultimate unemployment is considered as 'handicap
Impairment
It is defined as any loss or abnormality of psychological, physiological or
anatomical structure or function, e.g., loss of vision, loss of hearing, etc.
primary impairment may lead to secondary impairment, e.g. defective hearing
results in learning difficulties and poor school performance. Impairment can be

29
temporary or permanent, progressive or regressive, visible or invisible and
extrinsic or intrinsic. Impairment develops as consequence of disease or
disorders. eg accidents leading to loss of lower limbs (amputation), are
impairment. Impairment leads to disability.
Disability
It develops as the consequence of impairment, e.g. loss of limbs result in
inability to walk, i.e. an objectified event. Disability is the inability to carry out
certain activities which are considered as normal for the age and sex. Disability
has been defined as any restriction or lack of ability to perform an activity in the
manner or within the range considered as normal for a human being.
Handicap
It develops as a consequence of the disability. It is a socialized event
leading to disadvantages of individual's life and disturbances in the achievement
of full potential. It results in social isolation.
Handicap is defined as a disadvantage for a given individual resulting
from impairment or a disability that limits and prevents the fulfilment of a role
which is normal for that individual, depending on age, sex, social and cultural
factors
Handicapped children refer to those with presence of impairment or other
circumstances that are likely to interfere with normal growth and development
or with the capacity to learn. Primary handicap condition leads to secondary
handicap condition, e.g., blindness leads to economical handicapped situation,
Le. poverty. The child may have single or multiple handicap condition.
Classification
Handicapped children can be classified broadly into three groups
Physically Handicapped Children
These groups include the children with blindness, deaf and dumb,
congenital malformations like cleft lip, cleft palate, club foot, congenital heart

30
 disease, etc. post-polio residual paralysis, leprosy, accidents, burns injury, etc.
also lead to physical handicapped conditions. The most important causes of
physical handicaps are birth defect, malnutrition, infections and accidents.
These can be prevented by adequate support services
Physically handicapped children can be grouped according to the affected
part of the body. These include orthopedically handicapped, sensory
handicapped, neuro- logically handicapped and handicapped due to chronic
systemic diseases.

 Orthopedically handicapped children are those having congenital bony defect

(club foot), amputation due to accidental injury, bony defects following ricket,
fracture arthritis, leprosy, etc.
 Sensory handicapped children present with following problems
 Visual problems: Partial or complete blindness refractory errors, etc.
 Auditory problems: Partial hearing loss, dead and dumb
 Speech problems: Stammering, dysphonia
 Neurologically handicapped children include cerebral palsy, mental retardation,
convulsive disorders, hydrocephalus, spina bifida, postmeningitic or
postencephalitie sequelae, postpolio residual paralysis, degenerative diseases of
CNS, learning disabilities, etc.
 Handicapped condition due to chronic systemic disease e.g. heart disease,
bronchial asthma, diabetes mellitus muscular dystrophy, etc.
 Multiple physically handicapped children have combination of orthopedically,
sensory and neurological handicaps.
Mentally Handicapped Children
The term 'mental handicap' is now used for the condition mental retardation.
At least 2 to 3% of Indian population are mentally handicap in any one form.
Mental retardation is the significantly subaverage general intellectual
functioning existing concurrently with deficits in adaptive behavior manifested

31
during the developmental period. It includes low learning abilities, poor
maturation and social maladjustment in combination.
The malfunctioning of the brain is poorly understood in most cases, but
the physiological alteration may be identified in some children. The cognitive
and functional ability are affected with limitation in adaptive ability and
communication. Self-care, home-living, social interaction skill, community
relationship, self-directions, health behavior, safety measure, academic
achievement, leisure time utilization and working capacity are altered in
mentally handicapped children.
Mental handicaps are caused by multiple factors. In majority of the
cases (75%) causes are not precisely understood. The causative factors can be
genetic, social and physiological.
(Details of mental retardation are described in Chapter 21.)
Socially Handicapped Children
Socially handicapped children are those having disturbed opportunities for
healthy personality development due to social factors leading to
nonachievement of full potentialities. Social disturbances are found in the form
of broken family, parental inadequacy, loss of parents, poverty, lack of
educational opportunities, environmental deprivation and emotional
disturbances as lack of tender loving care.
These children include orphan child, abused child, addicted child, street
children, child labor, maternal deprivation, emotional deprivation, neglected or
destitute child, exploited or victimized and delinquent child. They are unable to
adjust with their living environment.
Causes
Major causes of handicapped conditions in children are con genital
anomalies, genetic disorders, poliomyelitis and other communicable diseases,
perinatal conditions, malnutrition, accidental injury and sociocultural factors.

32
 Prevention of Handicapped Conditions in Children
Handicapped conditions of children can be prevented by improvement of
maternal health and adequate care during periconceptional, prenatal and
intranatal period along with preventive measures during infancy, childhood and
adolescents.
The primary prevention can be achieved by the following measures:
 Genetic counseling-optimum maternal producing normal babies is between 20
and 30 years; this age for information should be explained to the couples along
with prevention and different aspects of genetic and chromosomal problems.
 Genetic screening of 'at-risk' people to prevent inherited diseases like
chromosomal or sex-linked congenital anomalies (e.g. Down's syndrome,
hemophilia, etc.) Reduction of consanguineous marriages by creating health
awareness.
 Universal immunization coverage especially for poliomyelitis and MMR
(mumps, measles, rubella).
 Improvement of nutritional status of mother and children especially for girl
child, the future mother.
 Prevention of iodine deficiency and folic-acid deficiency conditions in
periconceptional period.
 Essential care in antenatal, intranatal and neonatal periods. Prevention of
maternal and neonatal infections, birth injuries, asphyxia, hyperbilirubinemia,
important measures, etc.
 Avoidance of teratogenic agents in antenatal periods and special care of high-
risk mothers and children.
 Medical termination of pregnancy of malformed fetus.
 Improvement of health awareness about the preventive measures of
handicapped conditions in children by elimination of causes like malnutrition,
accidental injuries, etc.

33
 Management of Handicapped Children
Management of handicapped children requires multidisciplinary approach.
Early diagnosis and treatment of the particular cause of handicapping condition
along with disability limitation and rehabilitation should be promoted. The aim
of management is to safeguard against or halt the progression of the disease
process from impairment to disability and handicap. The approaches of
management should include the following aspects:
 Careful history, thorough physical examination and necessary investigations for
early detection of handicapped conditions are important.
 Regular medical supervision and developmental assessment help to identify the
abnormal condition early in initial stage by MCH or school health services.
 Treatment of particular handicapped condition by medical or surgical
management, eg. cataract, otitis media, leprosy, accidental injury, rickets,
congenital anomalies, etc.
 Correction of deformity, eg visual or hearing problems by spectacles or hearing
aids.
 Physiotherapy and exercise to improve physical conditions.
 Occupational therapy according to the child's ability and that should be
provided with music, painting, weaving wood-work, pottery, etc.
 Speech therapy to improve communication ability. Prosthetics, eg provision of
artificial limb in a child with amputed leg.
 Special care for mentally handicapped children with love, warmth, patience,
tolerance, discipline and avoidance of criticism.
 Counseling and guidance to the parents and family members for continuation of
care of the children with h emotional, educational and social support.
 Referral for welfare services (Govt, NGOs) for assistance of aids and
appliances, for special training and education, rehabilitation and support
services like pension, scholarship, special allowances, etc.

34
 Rehabilitation of Handicapped Children
Rehabilitation of handicapped children should be approached by
combined and coordinated use of medical, social, educational psychological and
vocational measures for training and retraining the children to the highest
possible level of functional ability. It includes all measures to reduce the impact
of disabled and handicapped conditions and to achieve social integration by
active participation of the individual in the community.
The process of rehabilitation should involve the following aspects;
 Medical rehabilitation includes restoration of functions by prosthesis, artificial
limbs, etc.
 Social rehabilitation includes restoration of family and social relationship by
replacement in the family.
 Educational rehabilitation includes specialized training and educational
facilities, eg braille for blind, sign language for deaf and dumb.
 Psychological rehabilitation includes restoration of personal dignity and
confidence during the period of growth and development and in adult life.
 Vocational rehabilitation includes restoration of the capacity to earn a
livelihood. This can be achieved by community participation and social
legislation for the handicapped individual. The community needs to offer
opportunities in shops, factories and other to the handicaps.
The handicapped child needs to be trained for an independent living with
special training and education. In India, there are more than 150 schools and
institution for the handicapped. These include day care centers, special school,
(for blind, deaf and dumb) vocational training centers, special hospitals for
crippled children, etc. These available welfare services of Government of India
provide support services to the handicapped individuals and enabling the
families to assume a large share of rehabilitation within the family cycle.
Nongovernment organizations (NGOs) are also working along with government
institutions for training, vocational guidance, counseling, manpower

35
development, research, assistance for supply of aids and appliances to the
handicapped and dissemination of information.
The Ministry of Welfare, Government of India has introduced a
comprehensive bill in the parliament known as 'persons with disabilities' (equal
opportunities, protection of right and full participation) Bill, 1995. It deals with
preventive and promotional aspects of rehabilitation.
The Children Act, 1960, provides for the care, protection, maintenance,
welfare, education and rehabilitation of socially handicapped children.
The following National Institutes are working for the specific disabilities
to provide care and welfare services in various aspects of the handicapped:
 National Institute for the Orthopedically Handicapped, Bonhooghly,
Kolkata.
 National Institute for the Mentally Handicapped, Secunderabad.
 National Institute for the Visually Handicapped, New Delhi and Dehradun.
 Ali Yavar Jung National Institute for the Hearing Handicapped, Mumbai.
 National Institute for Rehabilitation Training and Research, Cuttack.
Nursing Management of Handicapped Children
Nursing personnel play a vital role to assist the family members to cope with
the crisis situation for the handicapped condition Planning and providing care to
the handicapped children (especially physically and mentally handicapped) in
health care institutions and community are important nursing responsibilities
including parental involvement and community participation. Assisting the
family should be done strengthen effective relationship and bondage to prevent
children from becoming socially handicapped. Nurses are responsible for
creation of awareness in the society about the prevention of handicaps, the
abilities of the child with a handicap condition and the potentialities present in
him/he Nursing management should emphasize on three levels of prevention of
handicapped individual.

36
 Nursing care for the physically and mentally handicapped children in
hospital and home should emphasize on the following aspects other than the
specific problems present in them.
Nursing Assessment
Complete assessment of a handicapped child includes detailed history of
the condition, thorough physical and neurological examination, specific
investigations, review of developmental screening, assessment of parent-child
interaction and family coping, socioeconomic status, available support facilities,
etc.
Nursing Diagnoses
The important nursing diagnosis related to handicapped conditions may
include the following:
 Ineffective family coping and altered parenting related to handicapped
condition.
 Anxiety of the parents and family members. .
 Altered nutrition, less than body requirements.
 Potential for infection.
 Injury, risk for self-care deficit, bathing, feeding, dressing, toileting,
hygienic care, etc.
 Communication impaired.
 Physical mobility impaired.
 Elimination pattern.
 Altered activity intolerance.
 Altered sleep pattern.
 Sensory alteration, visual/auditory.
 Growth and development.
 Altered diversional activity deficit.
 Knowledge deficit related to continued care of handicapped children.

37
Nursing diagnosis should be made based on subjective data and objective data.
Nursing Interventions should be planned on the basis of priority problems
according to short-term and long-term goal. Handicapped children can be cared
in the general hospitals, special health care setting, and community health care
centers in primary level and at home. Daycare centers, special schools,
rehabilitation centers, occupational therapy and vocational training centers also
can provide various services to these children. Nurses are key person for home-
based or hospital- based care to guide and assist the parents and family
members to promote optimum health of the handicapped children Nurses are
also contributing in the special care settings for the handicapped children to
bring them as close to normality as possible, physically, mentally and socially.

DYING CHILD
Care of the dying child includes the physical and emotional interventions
necessary to support the totally dependent child and grieving family. Nursing
considerations involve the dissemination of information to the child, whose
perceptions of death and responses to death and dying are age-related. The
nurse should approach the parent(s) with sensitivity, caring, and honesty. The
nurse also helps the child move through the stages of awareness and acceptance,
and helps the parent(s) and family move through the stages of grieving.
Nursing management
A. Essential Nursing Diagnoses and Nursing Process Associated with this
Condition
Nursing Diagnosis
Sleep pattern disturbance related to internal factors of illness and stressors.
Assessment: Fatigue, lethargy, irritability, restlessness, pain, psychological
stress (anxiety, fear).
Nursing Diagnosis

38
Impaired physical mobility related to pain and discomfort.
Assessment: Weakness, inability to purposefully move fatigue, limited
strength, changes in consciousness.
Nursing Diagnosis
Altered nutrition: Less than body requirements related to inability to ingest
food.
Assessment: Weakness, anorexia, poor feeding, lack of interest in food.
Nursing Diagnosis
High risk for impaired skin integrity related to external factors of
immobilization.
Assessment: Redness, disruption of skin surface, prolonged pressure on skin
and bony prominences.
Nursing Diagnosis
Altered thought processes related to physiological changes.
Assessment: Disorientation, changes in consciousness.
Nursing Diagnosis
Ineffective airway clearance related to decreased energy and fatigue,
tracheobronchial secretions.
Assessment: Increasing secretions, changes in respiratory rate or depth (stridor,
irregularity), inability to cough and remove secretions. Note: see page no. 41
Nursing Diagnosis
Constipation related to less than adequate physical activity and intake.
Assessment: Frequency less than usual pattern, hard-formed stool, decreased
bowel sounds.
B. Specific Nursing Diagnoses and Nursing Process
Nursing Diagnosis

39
Pain related to biological, physical, psychological injuring agents (Table 12.4).
Assessment: Communication (verbal or coded) of pain descriptors, guarding,
protective behavior, facial mask of pain, crying, moaning, withdrawal, changes
in VS, irritability, restlessness.
Table 12.4: Nursing interventions for pain
Interventions Rationales
Assess severity of pain, fear of Provides information as a basis for
receiving pain medication, anxiety and analgesic administration
coping mechanisms associated with
pain, ability to rest and sleep
Administer analgesic intermittently or Provides 24 hours coverage of pain
continuously depending on pain medications to ensure freedom from
severity over 24 hours via PO, IV, any type of pain and discomfort
using narcotic and non-narcotic including administration of analgesic
medications; administer before any for prompt relief if given intermittently
painful procedure or care is performed
Provide position changes as tolerated, Reduces pain by nonpharmacologic
use pillows to support position, move measures
slowly with gentle handling, give
backrub
Provide companionship (family Reduces fear and supports comfort of
member or customary support person child
for child, familiar toys
Support coping mechanisms of child Promotes child's comfort, supports
and family and adjust analgesic coping abilities, and includes parent(s)
accordingly, with input from child, and child in decision making regarding
parent(s), and physician care
Dim lights, avoid noise, maintain Provides environment free of stimuli

40
clean, comfortable bed with loose that increases anxiety and pain
sheets and clothing, disturb for care
only when needed to promote comfort
Evaluation
• Controls pain and maintains comfort
• Reduces fear of pain and its consequences
• Administers correct analgesic by correct route based on continuous
assessment of pain control
• Administers nonpharmacologic measures to maintain comfort
• Reduces stimuli that trigger or increase pain.
Nursing Diagnosis
Anticipatory grieving related to perceived potential loss of significant other
(Table 12.5).
Assessment: Expression of distress at potential loss of child, denial of loss,
guilt, anger, sorrow, choked feelings, change in need fulfillment, crying, self-
blame.
Table 12.5: Nursing interventions for anticipatory grieving
Interventions Rationales
Assess stage of grief process, problems Provides information about need for
encountered, feelings regarding grieving, which varies with individuals
terminal nature of family illness and members of a when child's death is
potential loss of child expected
Provide emotional and spiritual Provides for emotional need of
comfort in an accepting environment, parent(s) and fam and helps them to
and avoid conversations that cause cope with dying child without adding
guilt or anger stressors that are difficult to resolve
Provide opportunities for family to Promotes progression through grieving

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express feelings and respond to child and ability to express desires for
commensurate with stage of grieving themselves and their child
Allow parent(s) and family members Promotes feelings that they are helping
to be with child as much as they feel a and supporting their child
need to, and help them understand the
child's behavior and needs
Assist family in identifying and use Promotes a helping relationship with
effective coping mechanisms and in the family
understanding situation over which
they have no control
Provide privacy when needed, while Promotes effective coping that is
being available to the family positive for the family
Arrange for clergy, social services, Provides for and assists with
hospice care, or return to home for alternative care and preferences for
dying as appropriate; support choices that care
made by the family
Evaluation
• Verbalizes understanding of grief process and responses
• Shares feelings with professionals and other members of the family
• Performs parental tasks/care to child
• Accepts and uses coping skills that support grieving
• Makes decisions regarding placement and care of dying child
• Contacts and utilizes support services of clergy, social services and
hospice as appropriate
• Maintains a presence of parent of family member and privacy to be with
child.
Nursing Diagnosis

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Anxiety of child and parent(s) related to threat of death (Table 12.6).
Assessment: Increased apprehension and fear of death, loss of control,
loneliness; increased feelings of helplessness and hopelessness; poor prognosis
of terminal illness.
Table 12.6: Nursing interventions for anxiety of parent(s) and child
Interventions Rationales
Assess anxiety level, fears and Reveals information needed for
concerns, ability to express needs, and interventions to relieve anxiety and
how anxiety is manifested increase comfort
Allow family member to stay with Promotes comfort of child and
child or remain with child during provides support during anxious and
stressful periods if family not able to fearful times
be there
Allow expressions of fears and Provides opportunity to vent feelings
concerns about terminal stage of and fears to reduce anxiety
illness, answer all questions honestly
based on what family has been told
about prognosis
Provide necessary procedures; avoid Promotes only palliative treatments,
procedures that increase pain or fear without interventions that increase
discomfort and anxiety
Provide calm reassurance and Promotes comfort and love of child to
kindness; be Promotes comfort and reduce anxiety
love of child to reduce available to
child at all times as needed for support
Involve child and parent(s) in as much Promotes interactions and attitude of
planning and care as possible without caring within family
forcing participation

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Evaluation
• Expresses and exhibits a reduction in anxiety, fear of loneliness
• States sources of anxiety and measures to reduce it
• Utilizes support systems and open visitation, remains with child whether
parent or family member
• Promotes accepting, nonjudgmental, calm environment
• Provides comfort measures for child and family to reduce anxiety and
concerns.

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