TODDLER

 Result of their curiosity at this stage of life – explore using their senses + common problem

BURNS
 Skin damage that results from thermal, chemical, electrical, and radioactive agents
 Injuries to body tissue caused by excessive heat (<40’C)
 2nd greatest cause of unintentional injury in children 1-4 years of age
 Incidence:
o Thermal burns are the most common type of burns
o 50% of cases occur in children 5 years and younger

Classification – depends on the degree of skin involvement

Minor  1st and 2nd degree burn <10% of body surface

 3rd degree burn <2% of body surface
 No area of the feet, hands or genitalia burned

Moderate  2nd degree burn between 10% - 20% or on the face, hands, feet or genitalia
 3rd degree burn <10% body surface
 Smoke inhalation has occurred

Severe  2nd degree burn >20% of body surface

 3rd degree burn >10# of body surface

o Classification and Depth of Burns

Severity Depth of Tissue Appearance Example
Involved

Minor Epidermis Erythematous, dry, Sunburn

(partial thickness) painful

Moderate (partial Epidermis Blistered, Scalds

thickness) Portion of erythematous to
dermis white
Severe (full Entire skin, Leathery; black Flame
thickness) including nerves or white; not
and blood sensitive to pain
vessels in skin (nerve
endings
destroyed)
 o
 Determination of Extent of burns in Children (TBSA)


 Emergency Management of Burns
 Minor Burns
 Pain and death of skin cells – must be treated seriously
 Immediately apply ice to cook skin and prevent further burning (public health – toothpaste – temporarily relief)
 Analgesic-antibiotic ointment, gauze bandage – to prevent infection (if blistered has not ruptured, gauze bandage is
not necessary) (avoid pricking of the blister
– skin covers the burn serves a protection from infection)
 Ff-up in 2 days – inspect are for secondary infection and dressing change
 Keep dressing dry – no swimming or getting the are wet for 1 week
o 1st degree burns usually heal by this time
 Moderate Burns
 Do not rupture blisters - invites infection
 Cover w/ topical antibiotic - silver sulfadiazine, bulky dressing to prevent damage to denuded skin
 Ff-up in 24 hours to assess that pain control is adequate and no s/sx of infection
 Broken blisters - debrided (cut away) to remove possible necrotic tissue
 Severe Burns
 Fluid therapy, systemic antibiotic therapy, pain management and physical therapy
o To survive w/o disability caused by scarring, infection, or contracture
 Electrical Burns of the mouth
 Child puts the prongs of a plugged-in electrical cord in the mouth or chews on an electric cord = severe burn  ulcer
 Blood vessels burn  active bleeding
 Immediate Tx:
o Unplug electric cord and control bleeding
o Apply pressure to the site
o Admit to hospital for at least 24 hrs
– edema in the mouth  airway obstruction
 Adequate pain relief
 Clean wound OlD w/ antiseptic sol.
o To reduce possibility of infection
 Eating a problem
o Mouth is sore
o May be able to drink fluids from cup
o Bland fluids - fruit drinks, ginger ale
 Mouth turns black = local tissue necrosis
o May cause deformity of lip and cheeks
– Lip appliance – helps maintain mouth contour
 Nursing Diagnoses
 Pain r/t trauma to body cells
o Outcome Evaluation: Child states pain is at tolerable level
o Morphine sulfate: IM, IV or epidural administration
 Deficient fluid volume r/t fluid shifts from severe burn
o Outcome evaluation: skin turgor remains good; hourly urine output > 1 mL/kg/hr w/ specific gravity bet.
1.003-1.030; VS are w/in acceptable parameters
 Risk for ineffective breathing pattern r/t respiratory edema from burn injury
o RR remains w/in 16-20 breaths/min; lung auscultation reveals no rales
o Fluid shifts after burn injury – 1st 24 hours
 Remobilization of fluid after 48 hours

–
 Risk for imbalanced nutrition, less than body requirements r/t burn injury
o Outcome evaluation: weight remains w/n normal age-appropriate growth percentiles; skin turgor remains
normal; urine specific gravity: 1.003 - 1.030
o Diet high in calories (IV)- MR es as body begins to pool its resources to adjust
– If not enough - begin to break down CHON - dangerous coz CHON needed for burn healing; can lead
to acidosis
o NG tube - nauseated from systemic shock; adequate nutrition
 Risk for injury r/t effects of burn, denuded skin surfaces, and lowered resistance to infection w/ burn injury
o Neutrophils cannot phagocytize bacteria after burn injury
o Formation of immunoglobulin G (IgG) antibodies also apparently fails
– Child has reduced protection against infection
– Staphylococcus aureus, group A B-hemolytic streptococci (gram +) organisms; Pseudomonas
deruginosa (gram -)  commonly invede burn tissue

 Therapy for Burns

METHOD Description Advantages Disadvantages

Burn  Allows  Requires
exposed to frequent strict
air; used for inspection isolation
superficial  follow to prevent
burns/ body healing infection;
parts prone process  Area may
to infection (crust and scrape and
OPEN (neck, face, eschar bleed easily
trunk, forms and impede
perineum) protective healing
barrier)
 Eliminates
need for
dressing
changes =
painful
 Covered  Provides
w/ non- better  Painfu
adherent protection l
fine mesh from injury dressi
gauze and  Easier to ng
fluffed turn and chang
CLOSED
gauze position es
 Used for child  Possibility
moderate  Allows of infection
and severe more increased –
burns freedom to dark,
play moist
environmen
 – Topical Applications
o O o C
P L
E O
N S
E
D
 Sulfamylon  Furacin
(mefenide (nitrofurazone)
acetate)  may cause allergic
 penetrates wounds contact dermatitis,
rapidly superinfection
 painful, may
cause o B
metabolic acidosis et
 Effective a
di
against n
pseudomonas e
 •  painful
 Sylvadene  may cause
(silver toughening of eschar
sulfadiazide) = difficult
 penetrates wounds debridement
slowly  effective against a
 Soothing variety of infectious
 keeps eschar soft, dses
making
 debridement easier  Silver nitrate
 inexpensive; easily
applied
 stains and stings
may cause
electrolyte
imbalance

 Escharotomy
 Eschar -- tough, leathery scab formed over moderately or severely burned areas
oFluid accumulates rapidly under eschar= pressure on underlying blood vessels and nerves
–  cutting off circulation
o distal parts -- feel cool to touch, appears pale, tingling, numbness; pulses difficult to
opalpate, capillary refill slow (>5 secs)
 "cut into the eschar"
 Some bleeding after  pack wound and apply pressure


 Debridement
o Removal of necrotic tissue from burned area
o Reduces possibility of infection -- reduces amt. of dead tissue present on w/c microorganism could thrive
o 30 mins of hydrotherapy -- to soften and loosen eschar
o Then w/c then can be gently removed with forceps and scissors -- allows granulation tissue to form
o Prepa for skin grafting
o GRAFTING
– Homografting (allografting)
 Placement of skin (sterilized and frozen) from cadavers or donor on cleaned burn site
 These do not grow but provide protective covering for the area
– Heterografts (xenografts)
 From other sources - e.g. porcine (pig)
 Used in small children
 – Autografting
 Process in w/c a layer of skin of both epidermis and part of dermis (called a split-
thickness graft) is removed from a distal unburned portion of child's body and placed at
the prepared burn site where it will grow and replace burned skin
 Cultured epithelium
o Can be grown into coherent sheet and supply unlimited source for autografts
 Nursing Care
 Provide priority admission care: ensure patent airway
o Hospitalization for burns 5% - 12% of body surface or more
o Prepare for intubation -- for laryngeal edema
o O2 as ordered
o NGT - to prevent vomiting, aspiration, and abdominal distension
 Maintain adequate oxygenation
o Monitor carefully intubate child; humidified air as ordered
o Monitor respiratory fxn q hourly or PRN
o Observe/monitor:
– Signs of respiratory distress: rales, wheezes, flaring, stridor, tachypnea, dyspnea, and air hunger
– ABGS
o Prevent hypostatic pneumonia thru turning, coughing, deep breathing
o Check neck and chest for eschars - may constrict
 Relieve shock, maintain fluid and electrolyte balance
o Assess and estimate accurately percentage of body surface burned -- Lund-Browder Classification
o Administer prescribed volume of fluids accurately
o Solutions used:
– Crystalloid solutions (NSS, LRS) - 1st 24 hrs to promote dieresis
– Colloid solutions (albumin, plasma) ff. dieresis
o For the computation of F&E, body weight (kg) and percent (%) of body surface area are used
– Parkland/Baxter Formula
 Meticulous wound care
 Strict I&O
o Indwelling catheter
o Daily weight
o Diaper count and weighing
o Check hematocrit
– Lund-Browder Classification

–


 Calculation of fluid replacement in burns

 Parkland/Baxter formula
 24 hr fluid reqt. = 4 mL LRS x %body surface area burned x body weight in kg
o 50% = fluids to be administered in the 1st 8 hrs post- burn
o Remaining 50% to be given over the next 16hrs
– 25% = fluids to be administered in the next 8 hrs
– 25% = fluids to be administered in the next 8 hrs
 Nursing Care
 Maintain isolation
o Reverse isolation
– Psychological support – child may feel separation anxiety, guilt, punishment
o Strict handwashing techniques and use of protective clothes
o Observe and report signs of infection:
– Wound infection: fever, redness @ wound site; offensive/foul odor, green- gray drainage
– Systemic infection: fever and chills, tachycardia, hyperemia
 Provide and maintain adequate nutrition
o Provide diet high in CHON, Cal, vitamins and minerals
o Improve appetite – anorexia due to isolation, discomfort, emotional depression
 Limit or alleviate pain
o Assess extent of pain: verbal, non-verbal
o Distinguish wound pain from Fear (dark, isolation, strange environment)
o Use comfort measures
o Age-related diversional activities
o Analgesics prior to procedures: often narcotics may be required
 Provide emotional support
o Pleasurable touch to unaffected areas (lotion application)
o Utilize play therapy
o Prepare child for tx
– Doll play: re-enact tx on the doll to work through feelings
– Answer questions clearly and truthfully
o Spend time listening to child's fears and concerns
 Prevent contractures
o Maintain correct body alignment
o Turn a 2hrs
o Perform ROM exercises
o Use traction and splints to maintain position as required
o Promote fxnal use and position of burned areas
o Protect graft site; observe for signs of infection
o Encourage participation in ADL
o Ambulate early when appropriate
 Observe for complications:
o Shock - most common in the 1st 24hrs
 o Infection - most common after 1st 24hrs
– May be local wound infections, respiratory, or systemic
o Curling's ulcers (stress ulcers) by the 3rd - 4th week after, w/ signs of:
– Coffee-ground emesis
– Abdominal distention
– Melena
– Anemia
o Constriction due to eschars (chest wall)
– Prepare for escharotomy

 POISONING
 A state of ill-health due to swallowing of common non- nutritive materials
 Etiology
 Developmental curiosity - developmental age (2 – 3 y.o)
 Faulty storage of poisonous substances
 Incidence: Peak during toddler period

– Acetaminophen poisoning
 In large doses can cause liver destruction
 Immediately after ingestion: nausea and vomiting
 Soon after:
o Serum aspartate transaminase (AST, GOT) and serum alanine transaminase (ALT, SGPT) – liver enzymes -
become elevated
o Liver feel tender = liver toxicity
 Antidote: acetylcysteine
o Prevents hepatoxicity by binding w/ the breakdown, product of acetaminophen so it will not bind to liver
cells
o Has offensive odor
– Administer via carbonated drinks
– For small children - into an NG tube
o Continue to observe for jaundice and tenderness over liver
o Assess ALT and AST levels as ordered

 Caustic poisoning
 Ingestion of a strong alkali, such as LYE (toilet bowl cleaners, hair care products)
 May cause burns and tissue necrosis in the mouth, esophagus and stomach
 Do not try to make child vomit – cause additional burning
 Assessment
 Immediate pain in mouth and throat and drools saliva = oral edema and inability to swallow
 Mouth turns white  brown (edema and ulceration)
 Vomiting of blood, mucus, and necrotic tissue
 Loss of blood (from denuded surface)  systemic signs of tachycardia, tachypnea, pallor and hypotension
 Chest radiograph
Esophagoscopy
 Therapeutic Management
 Immediately take child to health care facility
 Assess VS closely esp. RR*
 Watch out for increasing restlessness (infants) -- oxygen want
 Intubation may be necessary -- ensure patent airway
 Assess degree of pain involved -- Morphine may be ordered
  Iron poisoning
 When ingested  corrosive to the gastric mucosa  s/sx of gastric irritation
 Immediate effects: nausea, vomiting, diarrhea, and abdominal pain
 By 6 hrs:
o s/sx fade, child's condition appears to improve
o By this time, hemorrhagic necrosis of the lining of the Gl tract has occurred
 By 12 hrs:
o Melena and hematemesis present
o Lethargy and coma, cyanosis, and vasomotor collapse may occur
o Coagulation defects, hepatic injury
o Shock from  in peripheral vascular resistance and
o ed cardiac output
 Long-term effects
o Gastric scarring from fibrotic tissue formation
 Therapeutic Management
 Stomach lavage -- to remove any pills not yet absorbed
 Soothing compound Maalox (aluminum hydroxide) or Mylanta (magnesium hydroxide) -- to help  gastric irritation
and pain
 Antidote: deferoxamine
o IV or IM
o Chelating agent that combine w/ metals and allows its excretion
o Caution parents: urine turns orange as iron is excreted
 Exchange transfusion – to remove excess iron
 Upper Gl series and liver studies may be ordered week after ingestion
o To screen for long-term effects
 Assist w/ emergency measures: lavage, meds
 Stool exam for next 3 days for occult blood
o To assess for stomach irritation and Gl bleeding

 LEAD Poisoning
 Poisoning due to Ned levels of lead resulting from ingestion and absorption of lead-containing substances
 Also referred to as plumbism
 Etiology
 Most common cause: lead-based paint (used in houses before 1950s, US)
 Lead value of more than 15 mcg (ug)/dL - health hazard
 Incidence
 Most common in toddlers and preschoolers
o Prevalent in children 1 - 6 yrs of age who live in old deteriorated houses
 Pica - tendency to eat non-edible substance
 Pathophysiology
 Lead enters the body interferes w/ RBC fn by blocking the incorporation of iron into the proporphyrin compound that
makes up the heme portion of hemoglobin in RBC
 
 Leads to hypochromic, microcytic anemia
 
 Kidney destruction may occur  excess excretion of amino acids, glucose, and phosphates in urine
 Most serious effect: LEAD encephalitis
o Inflammation of brain cells because of toxic lead content
 Assessment
 (+) lead poisoning: 2 successive blood lead levels >10 ug/dL
 Usual sources of ingested lead:
o Paint chips or paint dust, home-glazed pottery, or fumes from burning or swallowed batteries
o Crib, windowsills - child teething
o Lead plumbing - may contaminate drinking water
 Signs and Symptoms
 May be asymptomatic; symptoms appear when lead blood level is 70 mcg/dL
 Fatigue, pallor, listlessness
 Gl complaints: anorexia, vomiting, weight loss
 Irritability, clumsiness
 Ataxia, loss of coordination, seizures
 Acute lead colic and encephalopathy: most severe forms
o Early sx: lethargy, impulsiveness, learning difficulties
o As lead blood level es: seizures and permanent neurologic damage
 Diagnostic Tests
 Serum ferritin - blood lead determination
  erythrocyte protoporphyrin (EP) levels
o Fingerstick
o Protoporphyrin is blocked from entering heme by the lead = elevated
 Basophylic stippling (odd striation of basophils) apparent on blood smear
 Radiograph:
o Abdomen: reveals paint chips in the intestinal tract
o Long bones: "lead lines" (areas of fed density) near epiphyseal line
– Thickness of line = length of time ingestion has been occurring
 Treatment
 Widespread screening programs
 Prevention: reduction of lead from environment (responsibility of health agency)
o Reduce lead from air (by eliminating lead additives from automotive fuels), drinking water (enforcing
standard for lead content), and reduce lead content of foods (canned foods)
 Prompt separation of child from sources of lead: cornerstone of tx
 Chelation therapy - remove lead from soft tissue and bone (tho' more from RBC), allowing it to be eliminated into
the urine
o > 45ug/dL: BAL (dimercaprol) or edetate calcium disodium (CaEDTA)
– Given as multiple IM injections (large muscle mass)
– Painful - may be combined w/ procaine 0.5 mL
– EDTA removes calcium from body = calcium measured periodically
o Chelation therapy before onset of symptom lessens risk of encephalopathy
 Fluid and electrolyte; 10% D5W and mannitol - to decrease ICP as necessary
 For seizures:
o Initially Diazepam
o Repeated doses of paraldehyde, and
o Long-term anticonvulsant therapy w/ phenobarbital
 Nursing Care
 Prevention is the best nursing care. Provide teaching:
o  iron and calcium in the diet - low dietary calcium and iron enhances toxic effects
o Observe care in toy selection for infants and young children -- shd not be lead-painted
 Provide care to child and parents for drug administration
 Administer BAL and CaEDTA as recommended
o BAL and CaEDTA injected simultaneously t separate IM sites in 6 ÷ doses/day for 5 days
o Pain relief at injection sites using warm soaks and site rotation
 Maintain hydration;  fluids and measure
 I&O because chelating therapy is renal toxic & Monitor VS, I&0, and signs of ICP

 CHILD ABUSE
 Physical and sexual abuse and emotional neglect of children
Etiology: Exact cause
 unknown Predisposing factors
 Child factors
 Product of unexpected, unwanted, difficult pregnancy, labor, and delivery
 Physically ill or defective, the "different child"
 Child may not fulfill the need of the caretaker
 Parental factors
o Abused when they were kids; lacking in basic sense of trust; yearning for love
o Young age, dependent, but w/ little or no support system
o Loners (no social affiliation)
o Immature emotional responses and coping patterns
o Lack of knowledge of normal G&D of the child
 Environmental factors
o Chronic financial stress
o Divorce, parental separation
o Chronic social and emotional stress
Incidence: younger children under 4 years old
 Diagnostic tests/ procedures
 Careful history-taking and physical examination
 Complications
o Further abuse
o Psychological problems or disorders
o Death
 Signs of physical abuse
 Burns, bruises, scars, cigarette marks on the skin
 Fractures, dislocations (unreported)
 Poor hygiene, w/ head lice or skin disease
 Malnutrition, retarded physical growth and devt.
 Delayed language devt.
 Absence of immunization
 Inappropriate reactions: withdrawal from people, passivity, or restlessness
 Absence of protest on admission of toddler

– Emotional abuse/neglect
 A pattern of behavior that attacks a child's emotional development and sense of self-worth
 Includes excessive, aggressive or unreasonable demands that place expectations on a child beyond his or her capacity
 Constant criticizing, belittling, insulting, rejecting and teasing are some of the forms these verbal attacks can take
 Also includes failure to provide the psychological nurturing necessary for a child's psychological growth and
development -- providing no love, support or guidance
o FTT
o Sleep disturbances
o Withdrawal and fearfulness
o Sucking fingers, biting nails
o Delayed language development
o Delinquency or runaway behavior
o Shows provocative behavior that generates anger from others
o Does not seek out parents for comfort and affection
o Reactions indicate tendency to avoid

 Sexual abuse
 Being overly affectionate or knowledgeable in a sexual way inappropriate to the child's age
 Medical problems such as chronic itching, pain in the genitals, STIs
 Other extreme reactions, such as depression, self- mutilation, suicide attempts, running away, overdoses, anorexia
 Personality changes such as becoming insecure or clinging
 Regressing to younger behavior patterns such as thumb sucking or bringing out discarded cuddly toys
 Sudden loss of appetite or compulsive eating
o Being isolated or withdrawn
o Inability to concentrate
o Lack of trust or fear of someone they know well, such as not wanting to be alone with a babysitter or child
minder
o Starting to wet again, day or night/nightmares
o Become worried about clothing being removed
o Suddenly drawing sexually explicit pictures
o Trying to be 'ultra-good' or perfect; overreacting to criticism

 CEREBRAL PALSY
 Neuromuscular disorder characterized by lack of control of the voluntary muscles, spastic and involuntary
movements, abnormal muscle tone and incoordination
 Etiology
 Anoxia to the brain: most significant factor
 Infection
 Predisposing factors
 Prenatal: heredity, X-ray, and any factor that results in
 ed blood flow/oxygenation to fetal brain
 Intranatal: difficult labor/delivery; birth trauma/injury; all causes of fetal anoxia, including analgesia/anesthesia
 Postnatal: devtal brain anomalies, and CNS, trauma and infections like meningitis and encephalitis
 Signs and symptoms
 An infant who was subjected to prenatal or intranatal factors may manifest early signs of CP:
o Abnormal posturing
o Difficult feeding
o Tremors, seizures
 o Persistence of primitive reflexes: Moro,
tonic neck and fisting
 Later, signs of delayed motor development
 Treatment
 Exercises: passive and active
 Medications:muscle relaxants,
anticonvulsants, tranquilizers
 Braces, ambulation devices: crutches, walkers
o Prevention of contractures – major goal in the tx
o Braces are used to reduce possibility of contractures
 Nursing care
 Promote adequate nutritional intake
o calories to meet addt'l demands of
constant muscle movement
o Feed slowly; Calm, peaceful environment
o Adequate fluid intake: maintain 1&0
o Use special silverware and dishes, as
needed (padded spoon, nonskid dishes)
o Modify feeding technique to compensate
or deal w/ tongue thrusting or extrusion
reflex
 Promote maximum mobility and development
of self- help skills
o Teach use of braces, splints, support
chair or wheelchair as needed
o Teach self-help skill -- one skill at a time
o Avoid movements, incidents, and
situations that trigger abnormal
movements; calmness and tranquility are
favorable
o Encourage participation
o Value of proper alignment, ROM exercises
and stretching 3 x a day
 Ensure safety when ambulating
o Use safety prec and equipment when ambulating
o Observe seizure prec
o Provide safe toys: nothing that can cause
falls, skidding, slipping
 Administer drugs, as ordered, noting positive
effects, toxic effects, and other untoward effects