CHAPTER: 14

“HEALTH PROBLEMS OF EARLY

CHILDHOOD”
HANIFAH, DIMACALING
HANNA, CADANG
JAMAICA, ANGOT
REXIL, MIRA
ROGELYN, VALDERAM
SLEEP PROBLEMS
• Such sleep disturbances are
• The preschool years are a prime
typically related
time for sleep disturbances.
Children may have trouble going to  increasing autonomy
sleep, wake during the night, have  negative sleep associations
difficulty resuming sleep after
 nighttime fears
waking during the night, have
nightmares or sleep terrors, or  inconsistent bedtime routines
prolong the inevitable bedtime  lack of limit setting
through elaborate rituals.
 • Consequences of inadequate sleep
• sleep problems associated with
 daytime tiredness
media use
 behavior changes
 delayed sleep onset
 Hyperactivity
 Nightmares
 difficulty concentrating
 night wakings
 impaired learning ability
 daytime tiredness
 poor control of emotions and impulses
 difficulty waking in the morning
 strain on family relationships
CHARACTERISTIC NIGHTMARES SLEEP TERRORS

Description A scary dream; takes place during rapid- A partial arousal from very deep (state
eyemovement (REM) sleep and is IV, non-REM) sleep
followed by full waking

Time of distress After dream is over, child wakes and During terror itself, as child screams and
cries or calls; not during nightmare itself thrashes; afterward is calm

Time of occurrence In second half of night, when dreams Usually 1-4 hr after falling asleep, when
are most intense non-REM sleep is deepest

Child’s behavior Crying in younger children, fright in all;
behaviors persistent even though child
is awake
Initially may sit up, thrash, or run in
bizarre manner, with eyes bulging, heart
racing, and profuse perspiring; may cry,
scream, talk, or moan; shows apparent
fright, anger, or obvious confusion,
which disappears when child is fully
awake
CHARACTERISTIC NIGHTMARES SLEEP TERRORS

Responsiveness to others Is aware of and reassured by another’s is not very aware of another’s presence, is not
presence comforted, and may push person away and
scream and thrash more if held or restrained

Return to sleep May be considerably delayed because of Usually rapid; often difficult to keep child
persistent fear awake

Description of dream Interventions Accept dream as real fear. Observe child for a few minutes, without
interfering, until child becomes calm or wakes
fully.
COSLEEPING
- In which parents allow the children to sleep with them , is an accepted
cultural practice among many African-American, Hispanic, and Asian families.
- Others who have adopted cosleeping include parents who believe that
cosleeping promotes parent-child bonding, parents who think that cosleeping
diminishes their child’s night-time fears or other sleep disturbances, and
mothers who are breastfeeding.
• INGESTION OF INJURIOUS
AGENTS
-the passage of the Poison
Prevention Packaging Act of
1970, which requires that certain
potentially hazardous drugs and
household products be sold in
child-resistant containers, the
incidence of poisonings in
children has decreased
dramatically.
• The most frequently ingested poisons include
 Cosmetics and personal care products
(deodorants, makeup, perfume, cologne,
mouthwash)
 Analgesics (acetaminophen, acetylsalicylic
acid, ibuprofen, opioids)
 Household cleaning products (bleaches,
dishwashing detergents, disinfectants)
 Foreign bodies, toys, and miscellaneous
substances (desiccants, coins, glow products,
bubble-blowing solutions)
 Topical preparations (camphor, diaper care and
rash products, topical steroids, hydrogen
peroxide 3%)
POISONOUS AND NONPOISONOUS PLANTS
Poisonous Plants (Toxic Parts) Nonpoisonous Plants
 Apple (leaves, seeds)  African violet
 Apricot (leaves, stem, seed pits)  Aluminum plant
 Azalea (all parts)  Asparagus fern
 Buttercup (all parts)  Begonia
 Castor oil plant (bean or seeds—extremely toxic)  Boston fern
 Cherry (wild or cultivated) (twigs, seeds, foliage)  Christmas Cactus
 Daffodil (bulbs)  Coleus
 Gardenia
 Dumbcane (dieffenbachia) (all parts)
 Grape ivy
 Elephant ear (all parts)  Jade plant
 Foxglove (leaves, seeds, flowers)  Piggyback plant
 Hemlock (all parts)  Poinsettia†
 Holly (berries) Hyacinth (bulbs)  Prayer plant
 Ivy (berries, leaves)  Rose
 Lily (all parts)  Rubber tree
 Mistletoe* (berries, leaves)  Snake plant
 Oak tree† (acorn, foliage)  Spider plant
 Peach (pit and leaves)  Swedish ivy
 Philodendron (all parts)  Wax plant
 Plum (pit) Poison ivy, poison oak (leaves, stems, sap,  Weeping fig
fruit, smoke from burning plants)  Zebra plant
 Pokeweed, pokeberry (roots, berries, leaves [when
eaten raw])
EMERGENCY TREATMENT
• Poisoning
1. . Assess the victim:
• Initiate cardiorespiratory support if needed (airway, breathing, circulation).
• Assess mental status; reevaluate routinely.
• Take vital signs; reevaluate routinely.
• Evaluate for possibility of concomitant trauma or illness; treat prior to initiation of gastric
decontamination.
2. Terminate exposure:
• Empty mouth of pills, plant parts, or other material.
• Flush any body surface (including the eyes) exposed to a toxin with large amounts of
moderately warm water or saline.
• Remove contaminated clothing, including socks and shoes, and jewelry. Ensure protection of
rescuers and health care workers from exposure.
• Bring victim of an inhalation poisoning into fresh air.
3. . Identify the poison:
• Question the victim and witnesses.
• Observe the circumstances surrounding the poisoning (e.g., location, activity just before
ingestion).
• Look for environmental clues (e.g., empty container, nearby spill, odor on breath) and save all
evidence of poison (e.g., container, vomitus, urine).
• Be alert to signs and symptoms of potential poisoning in the absence of other evidence,
including symptoms of ocular or dermal exposure.
• Call the poison control center or other competent emergency facility for immediate advice
regarding treatment.
4. . Prevent poison absorption:
• Place the child in a side-lying, sitting, or kneeling position with the head below the chest to
prevent aspiration.
• Gastric Decontamination
-Although pediatric poison ingestions are
common, they rarely result in significant morbidity
or mortality
-Consider using gastrointestinal
decontamination (GID) only after careful evaluation
of the potential toxicity of the poison and the risks
versus benefits
-If the child is admitted to an emergency
facility, gastric lavage may be performed to empty
the stomach of the toxic agent; however, this
procedure can be associated with serious
complications (e.g., gastrointestinal perforation,
hypoxia, aspiration).
-In a minority of poisonings, specific antidotes
are available to counteract the poison.
• Activated charcoal (AC)
-Another method of gastrointestinal
decontamination
-an odorless, tasteless, fine black powder that
absorbs many compounds, creating a stable complex.
-is mixed with water or other liquid to form a
slurry.
• Prevention of Recurrence
-The ultimate objective is to prevent poisonings
from occurring or recurring. Home safety education
improves poison prevention practices
-the effectiveness of parent education on
preventing unintentional injuries.
-One effective counseling method is first to
discuss the difficulties of constantly watching and
safeguarding young children
POISONING-NURSING CARE MANAGEMENT
• A poisoning is more than a physical emergency for the child,it is
usually represents an emotional crisis for the parents,particularly in
terms of guilt,self-approach, and insecurity in the parenting role.

• Passive measures ( do not require active

participation) have been most successful in
preventing poisoning and include using child-
resistant closures and limiting number of tablets in
one container.

HEAVY METAL POISONING

• Mercury toxicity

☑️SOURCES:
• King mackerel
• shark
• swordfish
• tilefish
NURSING CARE GUIDELINES
POISON PREVENTION
• ASSESS POSSIBLE CONTRIBUTING FACTORS IN OCCURENCE OF INJURY, SUCH AS DISCIPLINE,PARENT-CHILD
RELATIONSHIP,DEVELOPMENTAL ABILITY,ENVIRONMENTAL FACTORS,AND BEHAVIOR PROBLEMS.

• INSTITUTE ANTICIPITARORY GUIDANCE FOR POSSIBLE FUTURE INJURIES BASED ON CHILD'S AGE AND
DEVELOPMENTAL LEVEL.

• INITIATE REFERRAL TO APPROPRIATE AGENCY TO EVALUATE HOME ENVIRONMENT AND NEED FOR INJURY-
PROOFING MEASURES.

• PROVIDE ASSISTANCE WITH ENVIRONMENTAL MANIPULATION,SUCH AS LEAD REMOVAL WHEN

NECESSARY.
• EDUCATE PARENTS REGARDING SAFE STORAGE OF TOXIC SUBSTANCES

• ADVISE PARENTS TO TAKE DRUGS OUT OF SIGHT OF CHILDREN

• TEACH CHILDREN THE HAZARDS OF INGESTING NONFOOD ITEMS.

• DISCUSS PROBLEMS OF DISCIPLINE AND CHILDREN'S NONCOMPLIANCE AND OFFER STRATEGIES FOR
EFFECTIVE DISCIPLINE

• ADVISE PARENTS TO CONTACT PCC

CAUSES OF LEAD POISONING
SOURCES OF LEAD
• LEAD-BASED PAINT IN DETERIORATING CONDITION
• LEAD SOLDIER
• LEAD CRYSTAL
• BATTERY CASINGS
• LEAD FISHING SINKERS
• LEAD CURTAIN WEIGHTS
• LEAD BULLETS
☑️SOME OF THESE MAY CONTAIN LEAD:
• CEREMIC WARE
• WATER
• POTTERY
• PEWTER
• DYES
• UNDUSTRIAL FACTORIES
• VINYL MINIBLINDS
• ARTIST BLINDS
☑️OCCUPATIONS AND HOBBIES AND INVOLVING LEAD:

• BATTERY AND AIRCRAFT MANUFACTURING

• LEAD SMELTING
• BRASS FOUNDRY WORK
• RADIATOR REPAIR
• MINING
• JEWELRY MAKING
PATHOPHYSIOLOGY AND CLINICAL MANIFESTATION

☑️LEAD CAN AFFECT ANY PART OF THE BODY,INCLUDING

THE RENAL,HEMATOLOGIC,AND NEUROLOGIC SYSTEMS.

☑️CHILDREN WHO ARE IRON DEFICIENT ABSORB LEAD

MORE READILY THAN THOSE WITH SUFFICIENT IRON
STORES.

☑️LEAD TOXICITY TO THE ERYTHROCYTES LEADS TO THE

RELEASE OF THE ENZYME ERYTHROCYTE PROTPORPHYRIN
(EP).

☑️LEAD POISONING CAN CAUSE A NUMBER OF COGNITIVE

AND BEHAVIORAL PROBLEMS IN YOUNG CHILDREN,
INCLUDING
AGGRESSION,HYPERACTIVITY,IMPULSIVITY,DELIQUENCY,DI
SINTEREST AND WITHDRAWAL.
DIAGNOSTIC EVALUATION
☑️CHILDREN WITH LEAD POISONING RARELY HAVE SYMPTOMS
EVEN AT LEVELS REQUIRING CHELATION THERAPY.A
DIAGNOSIS OF LEAD POISONING IS BASED ONLY ON THE LEAD
TESTING OF A VENOUS BLOOD SPECIMEN FROM A
VENIPUNCTURE.THE COLLECTION PROCESS IS IMPORTANT.THE
ACCEPTABLE BLL HAS DROPPED FROM 40mcg/dl in 1970 to
10mcg/dl TODAY.

ANTICIPATORY GUIDANCE
☑️THE MOST EFFECTIVE PREVENTION OF KEAD EXPOSURE IS
ENSURING THE ENVIRONMENTAL EXPOSURES ARE REDUCED
BEFORE CHILDREN ARE EXPOSED.
THE FOLLOWING INFORMATION SHOULD BE MADE AVAILABLE TO FAMILIES
BEGINNING DURING PRENATAL AND POSTNATAL CARE (CENTERS FOR DISEASE
CONTROL AND PREVENTION ADVISORY COMMITTEE ON CHILDHOOD LEAD
POISONING PREVENTION,2012):

• HAZARDS OF LEAD-BASED PAINT IN OLDER HOUSING

• WAYS TO CONTROL LEAD HAZARDS SAFETY
• HOW TO CHOOSE SAFE TOYS
• HAZARDS ACCOMPANYING REPAINTING AND RENOVATION OF HOMES BUILT BEFORE 1978
• OTHER EXPOSURE SOURCES,SUCH AS TRADITIONAL REMEDIES,THAT MIGHT BE RELEVANT
FOR FAMILY.

SCREENING FOR LEAD POISONING

• WHEN PRIMARY PREVENTION FALLS,SECONDARY PREVENTION SCREENING

EFFORTS FOR ELEVATED BLLs CAN IDENTIFY CHILDREN MUCH EARLIER THAN IN THE
PAST.
PERSONAL RISK QUESTIONS:

• DOES YOUR CHILD LIVE IN OR

REGULARLY VISIT A HOUSE THAT WAS
BUILT BEFORE 1950?
• DOES YOUR CHILD LIVE IN OR REGULARY
VISIT A HOUSE BUILT BEFORE 1978 WITH
RECENT OR ONGOING RENOVATIONS
WITHIN THE PAST 6 MONTHS?
• DOES YOUR CHILD HAVE A SIBLING OR
PLAYMATE WHO HAS OR HAD LEAD
POISONING?
THERAPEUTIC MANAGEMENT
☑️THE DEGREE OF CONCERN,URGENCY, AND NEED FOR MEDICAL
INTERVENTION CHANGE AS THE LEAD LEVEL INCREASES.

🔘AREAS THAT THE NURSE NEEDS TO DISCUSS WITH THE FAMILY

OF EVERY CHILD:
• NEEDS FOR THE FOLLOW-UP TESTING TO MONITOR THE CHILD'S BLL
• RESULTS OF AN ENVIRONMENTAL INVESTIGATION IF APPLICABLE
• IMPORTANCE OF GOOD NUTRITION IN REDUCING THE ABSORPTION AND EFFECTS
OF LEAD;FOR PERSONS WITH POOR NUTRITION AL PATTERNS,ADEQUATE INTAKE
IF IRON AND CALCIUM AND IMPORTANCE OF REGULAR MEALS
CHELATION THERAPY
☑️USED FOR REMOVING FROM CIRCULATING BLOOD AND
THEORITICALLY,SOME LEAD FROM ORGANS AND
TISSUES.

PROGNOSIS
☑️IN CHILDREN WITH LEAD ENCEPHALOPATHY,PERMANENT
BRAIN DAMAGE CAN RESULT IN COGNITIVE
IMPAIRMENT,BEHAVIOR CHANGES,POSSIBLE PARALYSIS AND
SEIZURES.

NURSING CARE MANAGEMENT

☑️THE PRIMARY NUSRING GOAL IS TO PREVENT THE CHILD
INITIAL OR FURTHER EXPOSURE TO LEAD
Prepared by: Hanna B. Cadang
CHILD MALTREATMENT

The broad term child maltreatment includes

intentional physical abuse or neglect, emotional
abuse or neglect, and sexual abuse of children,
usually by adults.
CHILD NEGLECT
● is generally defined as the failure of a parent or the
other person legally responsible for the child welfare
to provide for the child’s basic needs and an adequate
level of care.
● Factors for child neglect are lack of knowledge of
child’s needs,lack of resources and caregiver
substance abuse.
TYPES OF NEGLECT
❏ PHYSICAL NEGLECT - FOOD , CLOTHING ,
SHELTER , SUPERVISION , MEDICAL CARE AND
EDUCATION.
❏ EMOTIONAL NEGLECT - AFFECTION , ATTENTION ,
AND EMOTIONAL NURTURANCE.
PHYSICAL ABUSE
● The deliberate infliction of physical injury on a child ,
usually by the child’s caregiver , is termed physical abuse.
● Can include anything from bruises and fractures to brain
damage.
● Minor physical injury is responsible for more reported
cases of maltreatment than major physical abuse causes
more deaths.
ABUSIVE HEAD TRAUMA ( AHT )
● is a serious form of physical abuse caused by violent shaking of
infants and young children. Other commonly used terms include
shaken baby syndrome , inflicted head injury and neuroinflicted
brain injury.
● Infants have a large head -to- body ratio , weak muscles and a
large amount of water in brain. violent shaking causes the brain to
rotate within the skull, resulting in shearing forces that tear blood
vessels and neurons.
The characteristics injuries occur
are intracranial bleeding (subdural
and subarachnoid hematomas ) .
injuries may also include fractures
of the ribs and long bones. Most
often there are no signs of external
injury, making diagnosis difficult .
Traumatic brain injury is often not an
isolated event, with a large number of
children showing evidence of a previous
injury. The long-term outcomes of AHT
include seizures disorders ; visual
impairments, including blindness;
developmental delays; hearing loss
;cerebral palsy; and mild to profound
mental , cognitive or motor impairments.
MUNCHAUSEN SYNDROME BY PROXY
Also known as medical child abuse or factitious disorder
by proxy, is a rare but serious form of child abuse in which
caregivers deliberately exaggerate or fabricate histories and
symptoms or induce symptoms. It is a form of child
maltreatment that may include physical , emotional , and
psychologic abuse for the gratification of the caregiver.
FACTORS PREDISPOSING TO PHYSICAL ABUSE
THREE RISK FACTORS ARE COMMONLY
IDENTIFIED IN CHILD ABUSE :
1. PARENTAL CHARACTERISTICS
2. CHARACTERISTICS OF THE CHILD
3. ENVIRONMENTAL CHARACTERISTICS
SEXUAL ABUSE
● is one of the most devastating types of
child maltreatment, and estimates
indicate that it has increased
significantly during the past decade.
EXHIBITIONISM : indecent exposure, usually exposure of
the genitalia by an adult man to children or women.
CHILD PORNOGRAPHY : arranging and photographing, in
any media, sexual acts involving children, alone or with
adults or animals, regardless of consent by the childs legal
guardian; also may denote distribution of such material in
any form with or without profit.
CHILD PROSTITUTION : involving children in sex acts for
profit and usually with changing partners.

PEDOPHILIA : Literally mean “ love of child “ and does not

denote a type of sexual activity but rather the preference of
an adult for prepubertal children as the means of achieving
sexual excitement.
laban future
frontlinurse!!
Chapter 14: Health Problems
of Early Childhood
Characteristics of Abusers and Victims
• Anyone, including siblings and mothers, can be sexual abusers, but a
typical abuser is a man whom the victim knows. Offenders come from
all levels of society; however, a higher risk of child abuse has been
noted among families with incomes below the poverty level.
• Incestuous relationships between father or stepfather and daughter
are generally prolonged, and the victims are usually reluctant to
report the situation because of fear of retaliation and fear that they
will not be believed. Typically, incestuous relationships begin later
than other forms of child abuse. The eldest daughter is usually
abused, but in her absence, another sister may be substituted. Sibling
incest may also occur. Sexual abuse by relatives with a strong
emotional bond with the victim, such as a parent, is often the most
devastating to the child.
• Boys are also victims of both intrafamilial and extrafamilial abuse.
Compared with female victims, male victims are much less likely to
report abuse, and they may suffer much greater emotional harm from
incestuous relationships. Boys are likely to be subjected to anal
penetration and oral–genital contact. They often have subtle physical
findings and are abused by a father, stepfather, or mother's boyfriend.
• Significant risk factors for child sexual abuse include parental
unavailability, lack of emotional closeness and flexibility, social
isolation, emotional deprivation, and communication difficulties.
Most sexual abuse is committed by men and by persons known to the
child, such as family members.
• Around 20% to 25% of child sexual abuse cases involve penetration
or oral–genital contact.
Initiation and Perpetuation of Sexual Abuse
• The cycle of sexual abuse often starts insidiously unless it involves an
isolated attack, such as rape. Often offenders spend time with the
victims to gain their trust before initiating any sexual contact. Most
victims are then pressured into being an accessory to the sexual activity
through various means and may be unaware that sexual activity is part
of the offer.
• Children may not reveal the truth for fear that their parents would not
believe them if they told, especially if the offender is a trusted member
of the family. Some fear that they will be blamed for the situation, and
many young children with limited vocabulary have difficulty describing
the activity when they do have the courage or opportunity to reveal the
abuse
• Methods Used to Pressure Children into Sexual Activity • The child is
offered gifts or privileges or has privileges withheld.
• The adult misrepresents moral standards by telling the child that it is
“okay to do.”
• Isolated and emotionally and socially impoverished children are
enticed by adults who meet their needs for warmth and human
contact.
• The successful sex offender pressures the victim into secrecy by
describing it as a “secret between us” that other people would take
away if they found out.
• The offender plays on the child's fears, including fear of punishment
by the offender, fear of repercussions if the child tells, and fear of
abandonment or rejection by the family.
• Incest most frequently occurs between siblings, but it may also be
between fathers or stepfathers and daughters, or grandfather and
granddaughter. Sibling incest has been found to have adverse
outcomes during childhood that extend into adulthood and are just as
damaging as father– daughter abuse.
• Victims may take years to disclose this abuse. However, not all
incestuous relationships follow this pattern of silence. Reports of
father–daughter incest during child custody conflicts have become
more common and have raised serious concerns regarding the
possibility of false accusation. Rather than tolerating or denying the
child's sexual abuse, the other parent (usually the mother) is typically
the chief accuser.
Nursing Care of the Maltreated Child
• A critical responsibility of health professionals is identifying abusive
situations as early as possible. Nurses who increase their knowledge
of the different types of abuse and neglect and underlying causes will
enhance their ability to identify, intervene, and prevent children from
maltreatment and neglect.
• The characteristics that may predispose members of some families to
commit abuse can serve as a framework for assessing vulnerability
but are never predictive of actual abuse. A careful, detailed history
and interview combined with a thorough physical examination are the
diagnostic tools needed to identify abuse. Nurses have a special role
because they may be the first person to see the child and parent and
are the consistent caregivers if the child is hospitalized
Nursing Care Guidelines
Talking with Children Who Reveal Abuse
• Provide a private time and place to talk.
• Do not promise not to tell; tell them that you are required by law to
report the abuse.
• Do not express shock or criticize their family.
• Use their vocabulary to discuss body parts.
• Avoid using any leading statements that can distort their report.
• Reassure them that they have done the right thing by telling.
• Tell them that the abuse is not their fault and that they are not bad or
to blame.
• Determine their immediate need for safety.
• Let the child know what will happen when you report.
• In interviewing the child and family, the nurse must be careful to
avoid biasing the child's retelling of the events. Some experts suggest
that health professionals limit the interview to the child's physical and
mental health concerns and leave topics of the family's social, legal,
or other problems to the police or the Child Protective Services.
• If this is not possible, make an effort to coordinate the interview
process so that all pertinent health care professionals can be present
for the interview.
• Recognition of abuse or neglect necessitates a familiarity with both
physical and behavioral signs that suggest maltreatment.
• No one indicator can be used to diagnose maltreatment. It is a pattern or
combination of indicators that should arouse suspicion and lead to
further investigation. It is important to note that some situations (such as
bleeding disorders, osteogenesis imperfecta, or sudden infant death
syndrome) may be misinterpreted as abuse.
• Unintentional injuries, such as burns from metal buckles on car seats,
bruising from seat belts, or spiral fractures from a twist and fall injury,
may also be wrongly diagnosed as abuse. Normal variants, such as
mongolian spots and congenital anomalies of genitalia, can be mistaken
for abuse.
Warning Signs of Abuse
• Child has physical evidence of abuse or neglect, including previous
injuries.
• History is incompatible with the pattern or degree of injury, such as
bilateral skull fractures after being dropped.
• Explanation of how injury occurred is vague or the parent or guardian
is reluctant to provide information.
• The patient is brought in with a minor, unrelated complaint, and
significant trauma is found.
• Histories are contradictory among caregivers.
• Explanation of how injury occurred is vague or the parent or guardian
is reluctant to provide information.
• The patient is brought in with a minor, unrelated complaint, and
significant trauma is found.
• Histories are contradictory among caregivers.
• The mechanism of injury provided is not possible given age or
developmental level of the patient, such as 6-month-old turning on hot
water.
• Bruising or other injury is present in a non-mobile patient.
• The patient's affect is inappropriate in relation to the extent of injury.
• Evidence of abusive or neglectful parent–child interaction is present.
• The parent, guardian, or custodian disappears after bringing in the
patient for trauma or a patient with suspicious injury is brought in by an
unrelated adult.
• The patient has multiple fractures of differing ages.
• There was a delay in seeking care.
• The parent or caregiver discloses that abuse has or may have
occurred.
• The patient makes an outcry of abuse or neglect.
 Caregiver–Child Interaction
• The nurse can use the initial contact with the family to assess the
interaction between the caregiver and the child. Observations of the
caregivers should include emotional support for the child,
attentiveness to the child's needs, and concern for the child's injury.
Although caregivers and children may vary in responses to a stressful
event, note an unusual caregiver–child relationship and factor this
into the overall evaluation of the child.
• Certain behavioral responses of the parents to their child and to the
interviewer should alert the nurse to the possibility of maltreatment.
Abusive parents may have difficulty showing concern toward their
child.
• They may be unable or unwilling to comfort the child. Abusers may
blame the child for the injuries or belittle him or her for being clumsy
or stupid.
• When interacting with health care workers, the parent may become
hostile or uncooperative. During the child's hospitalization, they may
not participate in the child's care and may show little concern for his
or her progress, eventual discharge, or need for follow-up care.
History and Interview
Child Physical Abuse
• It is often difficult to distinguish child maltreatment from accidental
injuries.
• A purposeful, skilled history and appropriate interview questions help
the nurse ensure the right course of action.
• Knowledge of mechanism of injury and child development is essential.
Cases of abuse are often detected when the child or caregiver history
of events does not match with physical findings. Children who are
verbal can often give a history of the injury.
• Separating the child from the caregiver may provide a more reliable
history. It is important to ask non-leading, open-ended questions. The
history should include a narrative of the injury from both caregiver
and child (if verbal). Date, time, and location where the injury took
place along with who was present at the time of the injury are
essential questions.
Neglect and Emotional Abuse
• Each child may manifest different responses to neglect, depending on
the situation and developmental age of the child. The goal of the
interview is to determine whether the child is in a safe environment
and whether the caregiver has the skills and resources to care for the
child. It is often difficult to determine whether the circumstances
constitute poor parenting skills or true neglect.
Clinical Manifestations of Potential Child
Maltreatment
Physical Neglect
Suggestive Physical Findings
• Growth failure Signs of malnutrition, such as thin extremities,
abdominal distention, lack of subcutaneous fat
• Poor personal hygiene
• Unclean or inappropriate dress
• Evidence of poor health care, such as delayed immunization,
untreated infections, frequent colds
• Frequent injuries from lack of supervision
Suggestive Behaviors
• Dull and inactive affect; excessively passive or sleepy
• Self-stimulatory behaviors, such as finger sucking or rocking
• Begging or stealing food
• Absenteeism from school
• Substance abuse
• Vandalism or shoplifting
Emotional Abuse and Neglect
Suggestive Physical Findings
• Growth failure (failure to thrive)
• Eating or feeding disorder
• Enuresis
• Sleep disorder
Suggestive Behaviors
• Self-stimulatory behaviors, such as biting, rocking, or sucking
• During infancy, lack of social smile and stranger anxiety
• Withdrawal from environment and people
• Unusual fearfulness
• Antisocial behavior, such as destructiveness, stealing, cruelty to
animals or people
• Extremes of behavior, such as over-compliant and passive or
aggressive and demanding
• Lags in emotional and intellectual development, especially language
• Suicide attempts
Physical Abuse
Suggestive Physical Findings
Bruises and welts (may be in various stages of healing)
• On face, lips, mouth, back, buttocks, thighs, or areas of torso
• Regular patterns descriptive of object used, such as belt buckle,
hand, wire hanger, chain, wooden spoon, squeeze or pinch marks
• May be present in various stages of healing
Burns
• On soles, palms, back, or buttocks
• Patterns descriptive of object used, such as round cigar or cigarette
burns; sharply demarcated areas from immersion in scalding water;
rope burns on wrists or ankles from being bound; burns in the shape of
an iron, radiator, or electric stove burner
• Absence of “splash” marks and presence of symmetric burns
• Stun gun injury: Lesions circular, fairly uniform (≤0.5 cm), and paired
about 5 cm apart
Fractures and dislocations
• Skull, nose, or facial structures
• Injury denoting type of abuse, such as spiral fracture or dislocation
from twisting of an extremity or whiplash from shaking the child
• Multiple new or old fractures in various stages of healing Lacerations
and abrasions
• On backs of arms, legs, torso, face, or external genitalia
• Unusual symptoms, such as abdominal swelling, pain, and vomiting
from punching
• Descriptive marks, such as from human bites or pulling out of hair
Chemical
• Unexplained repeated poisoning, especially drug overdose
• Unexplained repeated poisoning, especially drug overdose
Suggestive Behaviors
• Wary of physical contact with adults
• Apparent fear of parents or going home
• Lying very still while surveying environment
• Inappropriate reaction to injury, such as failure to cry from pain
• Lack of reaction to frightening events
• Apprehensive when hearing other children cry
• Indiscriminate friendliness and displays of affection
• Superficial relationships
• Acting-out behavior, such as aggression, to seek attention
• Withdrawal behavior
Sexual Abuse
Suggestive Physical Findings
• Bruises, bleeding, lacerations, or irritation of external genitalia, anus,
mouth, or throat
• Torn, stained, or bloody underclothing
• Pain on urination or pain, swelling, and itching of genital area
• Penile discharge
• Sexually transmitted disease, nonspecific vaginitis
• Difficulty in walking or sitting
• Unusual odor in the genital area
• Recurrent urinary tract infections
• Presence of sperm
• Pregnancy in young adolescent
 PHYSICAL ASSESSMENT CHILD PHYSICAL ABUSE

-The goal of the physical assessment for child physical abuse id identification of all injuries. A
systematic head-to-toe examination follows.
-Record the location and a detailed description of all injuries.
-Not all forms of physical abuse have obvious signs. Intaabdominal organ injury from blunt trauma to
the abdomen can occur without signs of external abdominal bruising.

NEGLECT AND EMOTIONAL ABUSE

-Assessment of the child’s height, weight, nutrition status, hygiene, and age appropriate interaction is
important for the overall picture of potential neglect.
-Any persistent and unexplained change in the child’s behavor is an important due to possible emotional
abuse.
 SEXUAL ABUSE
The goal of the physical is to document genital findings. In most cases, the genital examination finding are normal,
which does not mean that sexual abuse did not occur.
-The female genital examination should include a description of the vulva, hymen, and surrounding tissue.
-For male victims, swelling, abrasions, or bruising of the genital tissue raises concerns for abuse.
-Therefore unless the child is seen within a few days of injury, the genital tissue may appear normal.

NURSING CARE MANAGEMENT PROTECT THE CHILD FROM FURTHER ABUSE

The nurse may come in contact with abused children in an emergency department, practitioner’s
office, home, daycare center, or school.
 SUPPORT THE CHILD
-Children suspected of being abused are often hospitalized for medical management of their injuries and to allow further
assessment of their safety needs.
-The child should be treated as a child with usual physical needs, developmental task, and play interest not as a victim of abuse.
-The goal of the nurse child relationship is to provide a role model for the parents in helping them relate positively and
constructively to their child and to foster a therapeutics environment for the child in his or her reprieve from the abusing
situation.

SUPPORT THE FAMILY

When parental ignorance of childbearing practices has played a part in the abuse, the nurse can educate the
parent regarding children’s physical and emotional needs.
-They may also need help in dealing with their frustation so that they do not vent anger on the child.
-Advice family members to encourage the child to resume normal activities and observed the child for signs of
distress.
 PLAN FOR DISCHARGE
-Discharge planning should begin as soon as the legal disposition for placement has been decided, which may be
temporary foster home placement, return to the parents, or permanent termination of parental right.
-Whenever possible, foster parents are encouraged to visit in the hospital, and the nurse should take an active role in
helping the new parents understand the child, as well as the child’s health care needs.

PREVENT ABUSE
-The nurses provided information on normal child growth and development and routine health care needs, served
as informal support persons, and referred families to appropriate services when a need for assistance was identified.
-Nurses in neonatal intensive care units can minimize the effects of separation by encouraging parents to visit and
can help parents become comfortable caring for their child.
-Nurses must be sensitive to parental needs for attention, reassurance, and reinforcement and should refer parents
to community services and self help groups.
-It is equally important to teach children safety in terms of potential risk situations.