pediatric primary care

8/13/2019 Pediatric Primary Care

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Pediatric Primary Care

HEALTH MAINTENANCE

Pediatric primary care includes health promotion and disease prevention interventions

that will positively affect the well-being of children and their families. The goal of

pediatric primary care is to achieve physical, emotional, and developmental health for allchildren. Primary prevention through immunizations, proper nutrition, and safety

counseling are essential components of pediatric health care.

IMMUNIZATIONS

Disease prevention through immunizations has significantly reduced childhood morbidity

and mortality from infectious diseases. However, despite effective immunizations,vaccine-preventable diseases are still present in the United tates and continue to pose

significant public health problems. !urses are in a vital position to promote child health

by assessing, recommending, and administering immunizations. " review of

immunizations and administration of needed vaccines should be done at every health care

visit.

General Considerations

Reqirements o! National C"ild"ood #accine In$ry Act %E!!ecti&e '())* %USA*

This act mandated providers to notify all patients and parents about the ris#s and

benefits associated with vaccines.

The patient, parent, or legal guardian should be informed about the benefits and

ris#s of immunizations. They must be provided with the current $accine

%nformation tatement &$%', developed by the (enters for Disease (ontrol andPrevention &(D(', before the administration of the vaccine. Health care providers

must record the name of the vaccine $% publication &eg, polio', date of $%publication, and the date the $% was given to the patient or his family on thechild)s medical record.

*ederal law mandates that all health care providers must record the following

information in the patient)s permanent medical record+ month, day, and year of

administration vaccine or other biologic administered manufacturer, lot number,and epiration date and name, address, and title of the health care provider

administering the vaccine.

%n addition, the site and route of administration should be documented in the

patient)s permanent record. Health care providers are reuired to report selected events occurring after

vaccination to the $accine "dverse /vents 0eporting ystem.

Rotine #accinations !or C"ildren in Nort" America

(hildhood recommended vaccines include diphtheria, tetanus tooid, acellular pertussis

&DTaP' inactivated poliovirus vaccine &%P$' measles, mumps, rubella &110'

Haemophilus influenzae type b &Hib' vaccine hepatitis 2 vaccine &H2$' $aricella andpneumococcal &P($3'. %n 4uly 5667, an influenza vaccine was added to the


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recommended schedule for healthy children ages 8 to 57 months and is recommended for

older children who are at high ris#.

Immni+ation Sc"edles

0outine immunizations are started in infancy however, if a child is not

immunized in infancy, immunizations may be started at any age. %f animmunization program is not begun in infancy, a slightly different schedule may

be followed, depending on the child)s age and the prevalence of specific diseases

at the time.

"n interrupted primary series of immunizations does not need to be restarted

rather, the original series should be resumed regardless of the length of time that

has elapsed.

The immunoresponse is limited in a significant proportion of young infants, and

the recommended booster doses are designed to ensure and maintain immunity.

(urrent recommended immunization schedules can be found at

http+99www.cdc.gov9nip.

Contraindications and Precations

%t is important to read the manufacturer)s insert for each vaccine before administration. Contraindications to all &accines,

o "naphylactic reaction to a vaccine or a vaccine constituent.

o 1oderate or severe illnesses with or without a fever.

All li&e &irs &accines %li&e oral -olio&irs &accine .OP#/0 MMR0 #aricella*

are contraindicated in,

o Pregnancy.

o %mmunosuppression or immunodeficiency.

o Household or close contact with people who are immunosuppressed or

immunodeficient. Diphtheria, tetanus, and pertussis &DTP'9DTaP:encephalopathy within 3 days of

administration of previous dose of DTP9DTaP.

%P$:anaphylactic reaction to neomycin, streptomycin, or polymyin 2.

110 and $aricella:anaphylactic reactions to neomycin or gelatin.

%nfluenza:anaphylactic reaction to eggs or egg protein.

H2$:anaphylactic reaction to ba#er)s yeast.

Misconce-tions Concernin1 #accine Contraindications

Some "ealt" care -ro&iders ina--ro-riately consider certain conditions or

circmstances to 2e contraindications to &accination3 Conditions most

commonly re1arded as sc" inclde,o 1ild acute illness with low-grade fever or mild diarrheal illness in an

otherwise well child.

o (urrent antimicrobial therapy or the convalescent phase of illness.

o 0eaction to a previous DTaP dose that involved only soreness, redness,

swelling in the immediate vicinity of the vaccination site, or temperatureof less than ;6


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o Person using aerosolized steroids, short course of oral steroids &less than

;7 days', or topical steroids.

o Pregnancy of mother or other household contact.

o 0ecent eposure to an infectious disease.

o 2reast-feeding.

o History of nonspecific allergies or relatives with allergies.o "llergies to penicillin or other antibiotic, ecept anaphylactic reactions to

neomycin or streptomycin.

o "llergies to duc# meat or duc# feathers.

o *amily history of seizures in people considered for pertussis or measles

vaccination.

o *amily history of sudden infant death syndrome in children considered for

DTaP vaccination.

o *amily history of an adverse event, unrelated to immunosuppression, after

vaccination.

o 1alnutrition.

%n most cases, children with the above conditions can still be immunized.

#accine Administration Considerations

trict adherence to the manufacturer)s storage and handling recommendation is

vital. *ailure to observe these precautions and recommendations may reduce the

potency and effectiveness of vaccines.

Health care personnel administering vaccines should be immunized against

measles, mumps, rubella, hepatitis 2, influenza, tetanus, and diphtheria. >loves

should be worn when administering vaccines. >ood handwashing techniue is

mandatory before and after vaccine administration.

terile, disposable needles and syringes should be discarded promptly in

appropriate biohazard containers. Do not recap needles. Parenteral vaccines should be administered in the anterolateral aspect of the upper

thigh in infants and in the deltoid area of the upper arm in older children andadolescents. 0ecommended routes of administration are included in the pac#age

inserts of vaccines.

2efore administering a subseuent dose of any vaccine, uestion patients and

parents about adverse effects and possible reactions from previous doses. 0outine vaccines can be safely and effectively administered simultaneously.

S-eci!ic Immni+ations

4TaP

DTaP is the preferred vaccine for all doses however, whole cell DTP is anacceptable alternative in some parts of the world. *ewer adverse effects and local

reactions will occur with the DTaP vaccine compared with the DTP.

" time lapse of ? wee#s is recommended between the first three DTP9DTaP

in@ections for desirable maimum effects.

The combination of depot antigens is preferred because it is more immunogenic.

"dministration of acetaminophen at the time of immunization and at 7 and ?

hours after immunization decreases the incidence of febrile and local reactions.


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2ecause of the increased ris# of possible reactions to either diphtheria or pertussis

antigen, Td &adult-type tetanus and diphtheria toins' is recommended for

children over age 3 years. *or contaminated wounds, a booster dose of tetanus should be given if more than

< years have elapsed since the last dose.

Protection of infants against pertussis should begin early. %n neonates, the best protection against pertussis is avoidance of household

contacts by adeuate immunization of older siblings.

(hildren who have recovered from culture-proven pertussis do not need pertussis

immunization.

%f the fourth dose of pertussis vaccine is given after the fourth birthday, no further

doses are needed.

T2erclin S5in Test

%t is recommended that the tuberculin test be given before or at the time of the

110. The measles vaccine can temporarily suppress tuberculin reactivity if

given 7 to 8 wee#s before a tuberculin test.

The freuency of repeated tuberculin testing depends on the following+

o 0is# of tuberculosis eposure to the child.

o Prevalence of tuberculosis in the population group.

o Presence of underlying host factors in the child &immunosuppressive

conditions or human immunodeficiency virus AH%$B infection'.

Measles #accine

Usually given between ages ;5 and ;< months, but should be given at ;5 months

in high-ris# areas.

econd dose is recommended between ages 7 and 8 years. During an outbrea#, infants as young as age 8 months can be immunized. "

second dose should be given between ages ;5 and ;< months and again at age ;;

or ;5 years or at school entry.

1ild postimmunization symptoms include transient s#in rashes and fever up to 5

wee#s after vaccination.

%mmunoglobulin preparations will interfere with the serologic response to measles

vaccine therefore, wait the specified time after administration for vaccination.

Mm-s #accine

Usually administered in combination with measles and rubella vaccine between

ages ;5 and ;< months. econd dose administered as 110 is important because a substantial number of

cases have occurred in people with previous immunizations.

%mportant to immunize susceptible children approaching puberty, adolescents, and

adults.

R2ella #accine


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Two doses of rubella vaccine are recommended to avoid conseuences such as

congenital rubella syndrome.

%mportant to immunize postpubertal individuals, especially college students and

military recruits.

Comen should avoid pregnancy within months of vaccine due to the theoretical

ris# to the fetus.

Polio #accine

Two types of trivalent vaccine are available:EP$, given orally, and %P$, given

parenterally. 2oth are effective in preventing poliomyelitis.

To reduce ris# of vaccine-induced polio with EP$, %P$ is recommended for

infants and children in the U..

EP$ should not be given to infants and children living in households with an

immunodeficient person. Five EP$ is ecreted in the stool for up to ; month after

vaccination. $accine-induced polio is a ris# to both the vaccinated child and any

immunosuppressed contact.

H3 in!len+ae Ty-e 6 #accine

%ncidence of invasive disease caused by H. influenzae type 2 has declined

dramatically since the introduction of the con@ugate vaccine.

everal different types of Hib vaccines are available. Different vaccines have

different schedules.

1inimal adverse reactions &pain, redness, or swelling at immunization site for less

than 57 hours'.

He-atitis 6 &accine

There are two schedules for this vaccine. %nfants born to hepatitis 2 surface

antigen &H2s"g'-negative mothers should receive the routine schedule. %nfantsborn to H2s"g-positive mothers should be on an accelerated vaccination

schedule.

0ecommended for all infants born to H2s"g-negative mothers. Three-dose

schedule is initiated in neonatal period or by age 5 months the second dose is

given ; to 5 months later the third dose, 8 to ;? months later.

"ll infants born to H2s"g-positive mothers, including premature neonates,

should receive hepatitis 2 immunoglobulin and H2$ within ;5 hours after birth.

The second dose is given between ages ; and 5 months the third dose at age 8

months.

Preterm neonates weighing less than 5,666 grams may have lower seroconversion

rates. %nitiation of H2$ should be delayed until @ust before hospital discharge ifthe infant weighs 5,666 grams or more or until about age 5 months when otherroutine immunizations are given.

"ll children and adolescents who have not had H2$ should be immunized.

Pnemococcal #accines

T"ere are t7o ty-es o! -nemococcal &accines,

o Pneumococcal con@ugate vaccine &P($39Prevnar'.


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o 5-valent pneumococcal polysaccharide &PP$9Pneumova'.

%n the U.. in 5666, P($3 was released and added to the recommended childhood

vaccines for all children ages 5 to 5 months and certain children ages 5 to oodchoices include teething

biscuits, coo#ed

vegetables, bananas,cheese stic#s, and

enriched cereals. "void

nuts, raisins, and rawvegetables, which can

cause cho#ing.

Parents can be taught to

prepare their own

strained or @unior foodsusing a commercial

baby food grinder or

blender.

Ceaning is a gradual

process.

L"ssist parents torecognize indications of

readiness.

LDo not epect theinfant to completely

drop old pattern ofbehavior while learninga new one allow

overlap of old and new

techniues.

L/vening feedings areusually the most

difficult to eliminate

because the infant istired and in need of

suc#ing comfort.

LDuring illness orhousehold

disorganization, the

infant may regress and

return to suc#ing torelieve his discomfort

and frustration.


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Chole mil# is

recommended up

to age 5 years.

relaed. "void bribes or

force feeding because

this reinforces negativebehavior and may lead

to a disli#e for

mealtime. /ncourageindependence, but

provide assistance when

necessary. Do not beconcerned about table

manners.

"void the use of soda

or JsweetsK as rewards

or between-meal

snac#s. %nstead,

substitute fruit, @uice, or

cereal. Toddlers who show

little interest in eggs,

meat, or vegetablesshould not be permitted

to appease their appetite

with carbohydrates ormil# because this may

lead to iron deficiency

anemia. 1il# should belimited to

approimately ;8ounces9day.

NURSING ALERT

Nrsin1 "istory !or t"e

"os-itali+ed toddler s"old

inclde !eedin1 -attern and

sc"edle: !ood li5es and

disli5es: !ood aller1ies:

s-ecial eatin1 eqi-ment and

tensils: 7"et"er c"ild is

7eaned: 7"at c"ild is !ed

7"en ill3

Presc"ooler

3-5 years

%ncreased manual

deterity enables child

to have completeindependence at

"ppetite tends to

be sporadic.

(hild reuires the

same basic fourfood groups as the

/mphasis should be

placed on the uality

rather than the amount

of food ingested. *oods should be


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mealtime.

Psychosocially, this is a

period of increasedimitation and se

identification. The

preschooler identifieswith parents at the table

and will en@oy what

parents en@oy.

"dditional nutritional

habits are developed

that become part of the

child)s lifetimepractices.

lower growth rate and

increased interest in

eploring hisenvironment may

decrease the

preschooler)s interest ineating.

/ating assumes

increasing social

significance. 1ealtimepromotes socialization

and provides the

preschooler withopportunities to learn

appropriate mealtime

behavior, language

s#ills, andunderstanding of family

rituals.

adult, but in

smaller uantities.

>enerally li#es to

eat one food from

plate at a time.

Fi#es vegetables

that are crisp,raw, and cut into

finger-sized

pieces. Eftendisli#es strong-

tasting foods.

attractively served,

mildly flavored, plain,

as well as beingseparated and distinctly

identifiable in flavor

and appearance. !utritional foods &eg,

crac#ers and cheese,

yogurt, fruit' should beoffered as snac#s.

Desserts should be

nutritious and a natural

part of the meal, notused as a reward for

finishing the meal or

omitted as punishment.

Unless they persist,periods of overeating or

not wanting to eat

certain foods should notcause concern. The

overall eating pattern

from month to month ismore pertinent to

assess.

*reuent causes of

insufficient eating+

LUnhappyatmosphere at

mealtime. LEvereating between

meals.

LParental eample. L"ttention-see#ing.

L/cessive parental

epectations.

L%nadeuate variety oruantity of foods.

LTooth decay. LPhysical illness. L*atigue.

L/motional

disturbance.

1easures to increase

food inta#e+

L"llow child to help

NURSING ALERT Consider cltral di!!erences3

Allo7 -arents to 2rin1 in !a&orite !oods or eatin1

tensils !rom "ome !or t"e "os-itali+ed -resc"ooler3

Encora1e !amily mem2ers to 2e -resent at mealtime3


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with preparations,

planning menu, setting

table, and other simplechores.

L1aintain calmenvironment with no

distractions.

L"void between-meal

snac#s. LProvide rest period

before meal.

L"void coaing,bribing, threatening.

Place children in smallSc"ool;a1e c"ild

lowed growth rate

during middle

childhood results in

gradual decline in foodreuirements per unit of

body weight.

The preadolescent

growth spurt occurs

about age ;6 in girlsand about age ;5 in

boys. "t this time,energy needs increase

and approach those of

the adult. %nta#e isparticularly important

because reserves are

2y this time, food

practices are

generally well

established, aproduct of the

eating

eperiences of the

toddler andpreschool period.

1any children are

too busy withother affairs to

ta#e time out to

eat. Play readily

ta#es priority

!utrition education

should help the child to

select foods wisely and

to begin to plan andprepare meals.

Parental attitudes

continue to be

important as the child

copies parental behavior&eg, s#ipping brea#fast,

not eating certain foods,consuming fast foods

freuently'.

1ost children reuire a

nutritious brea#fast toavoid lassitude in late


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laid down for the

demands of

adolescence.

The child becomes

dependent on peers for

approval and ma#esfood choices

accordingly.

The child eperiences

increased socializationand independence

through opportunities to

eat away from home

&eg, at school andhomes of peers'.

unless a firm

understanding is

reached andmealtime is

relaed and

en@oyable.

morning.

1ealtime should

continue to be relaedand en@oyable.

Diversions, such as

television, should beavoided.

(alcium and vitamin D

inta#e warrant special

consideration. Theymust be adeuate to

support the rapid

enlargement of bones.

Parents and health care

professionals should be

alert to signs of

developing obesity.%nta#e should be altered

accordingly.

Table manners should

not be overemphasized.

The young child

typically stuffs mouth,

spills foods, andchatters incessantly

while eating. Time and

eperience will improve

habits. Provide some

companionship andconversation at the

child)s level during

meals. Peers should beinvited occasionally for

meals.

NURSING ALERT

Nrsin1 "istory o! t"e

"os-itali+ed c"ild s"old

inclde !ood -re!erences:

mealtime -atterns and

snac5s: !ood aller1ies: !ood

-re!erences 7"en ill3 Pro&ide

o--ortnities !or c"ildren to

eat in small 1ro-s at ta2les3

Consider cltral di!!erences3


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Allo7 -arents to 2rin1 in

!a&orite !oods !rom "ome3

Allo7 c"ild to order "is o7n

meal3

Adolescent

11-17 years Dietary reuirements

vary according to stage

of seual maturation,rate of physical growth,

and etent of athletic

and social activity.

Chen rapid growth of

puberty appears, there is

a corresponding

increase in energy

reuirements andappetite.

1enstruating teen is

particularly susceptibleto iron-deficiency

anemia.

Previouslylearned dietary

patterns are

difficult tochange.

*ood choices and

eating habits may

be uite unusualand are related to

the adolescent)s

psychological and

social milieu.

>enerally, a

significant

percentage of thedaily caloric

inta#e of the

adolescent comesfrom snac#ing.

(ontinue nutritioneducation, with

emphasis on+

Lelecting nutritiousfoods high in iron.

L!utritional needs

related to growth. LPreparing favorite

Jadolescent foods.K

L*oods and physical

fitness.

%nformal sessions aregenerally more effective

than lectures on

nutrition.

pecial problems

reuiring intervention+

LEbesity. L/cessive dieting.

L/treme fads:

eccentric and grosslyrestricted diets.

L"noreia nervosaand bulimia. L"dolescent

pregnancy.

L%ron deficiency

anemia.

Provide nutritious foods

relevant to the

adolescent)s lifestyle.

Discourage cigarette

smo#ing, which may

contribute to poornutritional status bydecreasing appetite and

increasing the body)s

metabolic rate.

NURSING ALERT

Allo7 "os-itali+ed adolescent


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to c"oose o7n !oods0

es-ecially i! on a s-ecial diet3

Pro&ide a re!ri1erator in t"e

recreation room !or snac5s0

or tili+e a snac5 cart3 Ser&e

!oods t"at a--eal toadolescents3 Use a nrsin1

"istory similar to t"at !or t"e

sc"ool;a1e c"ild3

PATIENT E4UCATION GUI4ELINES

6reast;8eedin1

2reast-feeding is the best possible source of nutrition for your infant. %t provides an

immunologic boost for the infant, protects against breast cancer, hastens postpartumhealing, and serves as a wonderful bond between the infant and mother.

Nou should begin breast-feeding in a uiet, comfortable place that is free frominterruption. Nou may need a pillow to help support the infant and a footstool to

use to elevate your leg.

1a#e sure the infant is awa#e and dry before the feeding is started. %f awa#e and

comfortable, the infant will settle down and feed better. The infant should also be

hungry.

Dress the infant appropriately so that the infant is not too warm or too cool during

the feeding. %f too warm, the infant may fall asleep after the first few suc#s of

mil#. " sleepy infant will not nurse well. %f too cool, the infant may be fussy and

restless.

Position infant at the breast by placing the infant in a semi-sitting position with

face close to the breast and supported by one of your arms and hand. " pillowmay be used under the infant for support. Nou may need to support your breastwith your other hand. Proper positioning will provide the infant with comfort and

security and ma#e it easier for the infant to suc# and swallow. This ma#es the

nipple more easily accessible to the infant)s mouth and prevents obstruction of

nasal breathing. Chen the feeding is to start, let the breast touch the infant)s chee#. Do not hold

the chee#, but try to help the infant find the nipple. The rooting refle will ta#e

over and the infant will turn head toward breast with mouth open. %f you touch the

chee#, the infant will become confused, perhaps turning toward your hand. The infant)s lips should be out over the areola and not @ust around the nipple

before beginning to suc#. 2ecause the nipple is so small, suction cannot beachieved merely by grasping it. The areola must be in the infant)s mouth toestablish suction and ma#e the suc# effective.

Nou may notice the Jlet-downK refle during the nursing period. 1il# flowing

from the other breast during nursing is uite normal.

The length of feeding time may vary from < to 6 minutes. Fet the infant nurse

until satisfied. Chen the infant is satisfied and has nursed well, the infant is

relaed and usually falls asleep. The infant will stop suc#ing.


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/ducation and encouragement should be offered to all new mothers and those

having difficulty or concerns about breast-feeding &see Patient /ducation

>uidelines'.

6ottle;8eedin1

2ottle-feeding is a method of supplying nutrition to the infant by oral feedings,using a bottle and nipple set-up.

2ottle-feeding can supplement breast-feeding with formula or water, or can be the

sole means of nutritional inta#e for the infant.

2ottle-feeding can also provide intermittent feedings of epressed breast mil#

when the mother cannot be present at the time of the feeding.

2ottle-feeding can be a time of bonding between the mother and infant. The father

or other capable members of the family should be taught bottle-feeding techniue

as well.

PROCE4URE GUI4ELINES

6ottle 8eedin1E9UIPMENT

terile nipple and bottle.

terile formula or breast mil#.

Nrsin1 Action Rationale

Pre-aratory -"ase

;.

%nfant should be awa#e and hungry.(hange wet or soiled diaper.

;.

" sleepy infant will not feed well. " drydiaper will provide comfort so that the infant

will settle down and eat more easily.

5.

Prepare formula according tomanufacturer)s instructions. (hec#formula for correct type and amount.

5.

To prevent error.

.

ome infants prefer warmed formula,

nothot.

.

(hec# temperature of formula on inner wrist

before feeding.7

.

it in a comfortable chair. (radle the

infant with one hand and arm, while

supporting the infant against your bodyor lap.

7

.

Proper position will provide the infant with

comfort and security and will ma#e it easier

to suc# and swallow. Holding the infant willenhance trust-building and provide sensory

stimulation.

Per!ormance -"ase

;. Fet the infant root for the nipple bytouching the corner of the infant)s

mouth with the nipple. Chen the

infant)s mouth opens, insert the nipple.

;. Place the nipple on top of the tongue and farenough into the mouth so suction can be

created when the infant suc#s.

5

.

Hold the bottle at an angle to

completely fill the nipple with fluid.

5

.

This prevents the infant from suc#ing and

swallowing ecessive amounts of air.

.

!ever prop the bottle or leave theinfant unattended during feeding.

.

This is unsafe. hould vomiting occur,aspiration is more li#ely.


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7

.

Handle the bottle carefully so as not to

contaminate the nipple or fluid.

7

.

(ontamination will increase the ris# of >%

disturbances.

astric lavage.

"dministration of deferoamine &Desferal' for severe cases:iron chelating agent

that binds with iron and is ecreted in urine &urine will be bright red'.

Primary Assessment in Acte Poisonin1

Initial assessment s"old inclde A6Cs e&alation0 le&el o! consciosness0

&ital si1ns0 and nerolo1ic assessment3

Assess !or sym-tomatic e!!ects o! -oisonin1 2y systems3o >%:common in metallic acid, al#ali, and bacterial poisoning. These may

include nausea and vomiting, diarrhea, abdominal pain or cramping, andanoreia.

o (!:may include seizures &especially with (! depressants, such as

alcohol, chloral hydrate, barbiturates' and behavioral changes. Dilated or

pinpoint pupils may be noted.o #in:rashes, burns to the mouth, esophagus and stomach, eye

inflammation, s#in irritations, stains around the mouth, lesions of the

mucous membranes. (yanosis may be visible, especially with cyanide andstrychnine.

o (ardiopulmonary:dyspnea &especially with aspiration of hydrocarbons'and cardiopulmonary depression or arrest.

o Ether:odor around the mouth.

Identi!y t"e -oison 7"en -ossi2le3

o Determine the nature of the ingested substance from the child)s history or

by reading the label on the container. !ursing intervention may need to be

implemented immediately after this assessment.


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o (all the nearest poison control center or toicology section of the medical

eaminer)s office to identify the toic ingredient and obtain

recommendations for emergency treatment.o ave vomitus, stool, and urine for analysis when the child reaches the

hospital.

NURSING ALERT

It may 2e necessary to initiate emer1ency res-iratory and circlatory s--ort at t"is

time3 I! needed0 o2tain &enos access0 maintain sa!ety drin1 sei+re acti&ity0 and

treat s"oc53 Ot"er7ise0 contine 7it" assessment3

Primary Inter&entions

Assistin1 t"e 8amily 2y Tele-"one Mana1ement

Calmly o2tain and record t"e !ollo7in1 in!ormation,

o !ame, address, and telephone number of caller.

o /valuation of the severity of the ingestion.

o "ge, weight, and signs and symptoms of the child, including neurologic

status.

o 0oute of eposure.

o !ame of the ingested product, approimate amount ingested, and time of

ingestion.

o 2rief past medical history.

o (aller)s relationship to victim.

%nstruct the caller about appropriate emergency actions.

Direct the patient to the nearest emergency department. Dispatch an ambulance if

necessary. %nstruct the caller to clear the child)s mouth of any unswallowed poison.

%dentify what treatments have already been initiated.

%nstruct the parents to save vomitus, unswallowed liuid or pills, and the container

and to bring them to the hospital as aids in identifying the poison.

%dentify whether other children were involved in the poisoning to initiate

treatment for them also.

%f treatment is at home, follow-up phone calls should be made at 6 minutes, ;

hour, and 7 hours after eposure.

Inter&ention Related to t"e Patient=s Condition

S--ort A6Cs as needed3Remo&in1 t"e Poison !rom t"e 6ody

;. %f the poison is non-pharmaceutical, have the child drin# ;66 to 566 mF of

water. %f a medication was ingested, do not dilute with water, as this may speed

absorption.

5. *or s#in or eye contact, remove contaminated clothing and flush with water for

;< to 56 minutes.

. *or inhalation poisons, remove from the eposed site.


36/66


37/66

Discourage anious parents from holding, caressing, and overstimulating the

child.

S2seqent Nrsin1 Assessment and Inter&entions

O2ser&in1 t"e C"ild !or Pro1ression o! Sym-toms

CNS in&ol&emento Ebserve for restlessness, confusion, delirium, seizures, lethargy, stupor, or

coma.

o "dminister sedation with caution:to avoid (! depression and mas#ing

of symptoms.

o "void ecessive manipulation of the child.

o ee nursing care of the child with seizures

o ee nursing care of the unconscious patient

Res-iratory in&ol&ement

o Ebserve for respiratory depression, obstruction, pulmonary edema,

pneumonia, or tachypnea.

o Have artificial airway and tracheostomy set available.o 2e prepared to administer oygen and provide artificial respiration.

o Ether nursing concerns+

!ursing care for mechanical ventilation. Procedures for administration of oygen

Procedure for cardiopulmonary resuscitation

Cardio&asclar in&ol&ement

o Ebserve for peripheral circulatory collapse, disturbances of heart rate and

rhythm, or heart failure.

o 1aintain %.$. therapy as directed to prevent shoc#. "ssess for

complications of overhydration.

o 2e prepared for cardiac arrest. GI in&ol&ement

o Ebserve for nausea, pain, abdominal distention, and difficulty swallowing.

o 1aintain %.$. therapy to replace water and electrolyte losses.

o Effer a diet that is easily swallowed and digested.

2egin with clear liuids.

Progress to full liuids, soft foods, and then a regular diet as the

child)s condition improves.

idney in&ol&ement

o Ebserve the child for decreased urine output. 0ecord oral and %.$. inta#e

and urine output eactly.

o Ebserve for hypertension.o %nsert indwelling catheter if necessary for urinary retention.

o "dminister appropriate amounts of fluids and electrolytes.

o ee nursing care of child with renal failure

o (orrect and monitor acid-base balance.

Pro&idin1 S--orti&e Care


38/66


39/66

o Do not discard poisonous substances in receptacles where children can

reach them however, do discard used containers of poisonous substances.

o Teach children not to taste or eat unfamiliar substances.

o (lean out medicine cabinets periodically.

o Ieep medications in childproof containers that are securely closed.

o 0ead all labels carefully before each use.o Do not give medicines prescribed for one child to another.

o !ever refer to drugs as candy or bribe children with such inducements.

o !ever give or ta#e medications in the dar#.

o /ncourage parents not to ta#e medication in front of young children

because children role-play adult behavior.

o uggest that mothers avoid #eeping medications in their purses or on the

#itchen table.

o Ieep baby creams and ointments away from young children.

o !ever puncture or heat aerosol containers.

o tore lawn and garden pesticides in a separate place under loc# and #ey

outside of the house do not store large uantities of cleaning products orpesticides.

"dvise parents to dispose of syrup of ipecac if they #eep it in the household.

"ccording to the "merican "cademy of Pediatrics, there is no evidencesupporting improved outcomes of poisonings with the use of ipecac. %n addition,

there is potential for abuse of ipecac with bulimic or anoreic teenagers

therefore, the recommendation for #eeping ipecac on hand to induce vomiting hasbeen rescinded.

Tell family to #eep a list of emergency telephone numbers including the poison

control center, health care provider)s number, nearest hospital, and ambulance

service.

0einforce the need for vigilance and consistent supervision of infants and youngchildren due to their increased mobility, increased curiosity, and increased

deterity.

Teac"in1 Emer1ency Actions

uspect poisoning with the occurrence of sudden, bizarre symptoms or peculiar

behavior in toddlers and preschoolers.

0ead label on the ingested product, or call the health care provider, hospital, or

poison control center for instructions about treatment for the poisoning. >ive allrelevant information about the child, condition, and substance ingested.

1aintain an adeuate airway in a child who is convulsing or who is not fully

conscious. Dilute the poison with ;66 to 566 mF of water if advised.

Trans-ort t"e c"ild -rom-tly to t"e nearest medical !acility3

o Crap the child in a blan#et to prevent chilling.

o 2ring the container and any vomitus or urine to the hospital with the child.

"void ecessive manipulation of the child.

"ct promptly but calmly.


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Do not assume the child is safe simply because the emesis shows no trace of the

poison or because the child appears well. The poison may have produced a

delayed reaction or may have reached the small intestine where it is still beingabsorbed.

LEA4 POISONINGThere are approimately ; million children with elevated blood lead levels & ;6 mg9dF'in the United tates. Fead poisoning, referred to as plumbism, results from some form of

lead consumption. 2lood lead levels that eceed ;6 mg9dF can affect intellectual

functioning in children.

1illions of children live in housing built before ;G% tract. Pica &eating nonfood substances, particularly leaded paint chips' isgenerally associated with more severe degrees of poisoning.

Pat"o-"ysiolo1y and Etiolo1yEtiolo1ic 8actors

Mlti-le e-isodes o! c"e7in1 on0 sc5in10 or in1estion o! non!ood s2stances3

o Toys, furniture, windowsills, household fitures, and plaster painted with

lead-containing paint.

o (igarette butts and ashes.

o "cidic @uices or foods served in lead-based earthenware pottery made with

lead glazes.

o (olored paints used in newspapers, magazines, children)s boo#s, matches,

playing cards, and food wrappers.

o Cater from lead pipes.

o *ruit treated with insecticides.o Dirt containing lead fallout from automobile ehaust.

o "ntiue pewter, especially when used to serve acidic @uices or foods.

o Fead weights &curtain weights, fishing sin#ers'.

o (ontinuous proimity to lead-processing center.

o Eccupations or hobbies that use lead.

o %mported fol# remedies, cosmetics, food, or coo#ware that contain lead.

In"alation o! !mes containin1 lead %less common case in c"ildren*3

o Feaded gasoline.

o 2urning storage batteries.

o Dust containing lead salts.

o Dust in the air at shooting galleries and in enclosed firing ranges with poorventilation.

o (igarette smo#e.

Hi1"est incidence in c"ildren 2et7een a1es ' and years0 es-ecially t"ose

2et7een a1es ' and ? years3

o High incidence in individuals living in old homes or deteriorated housing

conditions.

o !o significant difference in incidence by se.


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o High incidence among siblings.

ymptomatic lead poisoning occurs most freuently in summer months.

NURSING ALERT

Le1islation sti-lates t"at toys0 c"ildren=s !rnitre0 and t"e interior o! "omes 2e

-ainted 7it" lead;!ree -aint: "o7e&er0 t"e -ro2lem arises 7"en dee-er layers o!

-aint and -laster on older -rodcts are contaminated 7it" lead3 One -aint c"i-

contains mc" more lead t"an is considered sa!e3

Systemic E!!ects

Fead absorption from >% tract is affected by age, diet, and nutritional deficiency.

Noung children absorb 76 to


42/66

Diagnostic /valuation

Detailed history with emphasis on the presence or absence of clinical symptoms,

evidence of pica, family history of lead poisoning, possible source of eposure tolead, recent change in behavior, developmental delay, or behavior problems,

recent change of address, or recent renovations in the home.

"ssess serum lead level and repeat confirmatory levels.Screenin1 !or Ele&ated 6lood Lead Le&els

6LOO4

LEA4

LE#EL

%6LL*

1JdL

CON8IRMATORB

6LL

ACTION %I8 STILL


43/66

interventions for poisoned children have occurred. " progressive decline in

erythrocyte protoporphyrin levels indicates that management is successful.

57-hour urine:more accurate than a single voided specimen in determining

elevated urinary components that correspond with elevated blood lead levels.

0adiologic eamination of long bones:unreliable for diagnosis of acute lead

poisoning may provide some indication of past lead poisoning or length of timepoisoning has occurred.

/detate calcium disodium provocation chelation test:used only in selected

medical centers treating large numbers of lead-poisoned children demonstrates

increased lead levels in urine over an ?-hour period after in@ection of edetatedisodium.

Mana1ement

Remo&al o! Lead !rom t"e En&ironment

0emove leaded paint and paint chips or ob@ects containing lead from the child)s

environment.

0emove child from environment during lead abatement process.

Ntritional Considerations

(onsume adeuate amounts of iron. %ron supplementation may be indicated to

correct anemia. 0educed fat diet and small freuent meals will reduce the >% absorption of lead.

/ncourage foods high in vitamin ( &such as fruits and @uices' and calcium &such

as mil#, yogurt, and ice cream'.

C"elation T"era-y

(helation therapy is indicated in children with blood lead levels &2FF' between

7< and 36 Vg9dF. (hildren with 36 2FF or higher levels should be hospitalizedimmediately and started on the most aggressive chelation therapy available.

/thylenediaminetetraacetic acid &/DT"', 2ritish anti-Fewisite &2"F', and

succimer &(hemet' bind with lead in the blood to form nontoic compounds that

are ecreted by the bowel and #idneys.

/ffectiveness of therapy depends on degree and duration of lead poisoning.

6AL is 1i&en !irst to redce t"e ris5 o! sei+res3

o Used alone in patients with encephalopathy.

o (ontraindicated in children with peanut allergies, those on iron therapy,

and those with hepatic insufficiency.o "void in patients with glucose-8-phosphate dehydrogenase &>8PD'

deficiency due to potential for hemolysis.o "dministered deep %.1.:results in pain and tissue necrosis at the

in@ection site.

o 1onitor for adverse effects including hypersensitivity reactions,

hyperpyreia, tachycardia, hypertension, transient elevations of hepatictransaminases, nausea and vomiting, headache, con@unctivitis, lacrimation,

rhinorrhea, salivation, and unpleasant urine and breath odor.

E4TA


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o 1ay be toic to the #idneys therefore, monitor urinary output as well as

renal and liver function studies.

o "dminister %.$.

C"emeta--ro&ed !or se in '(('3

o !ot given to patients with encephalopathy, receiving iron therapy, and if

there is ongoing eposure to lead.o "dminister orally.

o 1onitor hepatic transaminases, blood urea nitrogen, serum creatinine,

(2( with differential, and occasional urinalysis.

Dosage:depends on individual drug, the child)s weight, severity of poisoning,

prior history, and whether other chelating agents are being used simultaneously.

(helating drugs are usually given every 7 hours for < days. " second course of

therapy may be needed if there is a rebound in the blood lead level.

%ncreased oral and %.$. fluids are given to enhance ecretion, ecept if increased

intracranial pressure is present.

d-Penicillamine &(uprimine', another drug that chelates heavy metals, may be

given for long-term chelation only if current eposure to lead is definitelyecluded. This is a third line agent and not usually used due to the high incidence

of allergic reactions. %f this drug is used, it should be given on an empty stomach,5 hours before brea#fast.

Additional Treatment

upplemental calcium, phosphorus, and vitamin D to help lead move from the

blood &where it is toic' to the bones &where it is nontoic'.

*or the child with encephalopathy, corticosteroids are given and intensive care

management is maintained until the acute stage is resolved.

Com-lications evere and usually permanent mental, emotional, and physical impairment.

!eurologic deficits.

o Fearning disabilities.

o 1ental retardation.

o eizures.

o /ncephalopathy.

Nrsin1 Assessment

Parta5e in -rimary -re&ention t"ro1" screenin1 !or lead -oisonin1s"old

tar1et "i1";ris5 1ro-s3 T"is incldes c"ildren,

o Cho live in homes built before ;G


45/66

"lso targeted screening of children who live in communities with more than 53

of houses built before ;G


46/66

1onitor inta#e and output and blood studies, such as electrolytes and liver and

renal function tests, as directed.

Promotin1 Gro7t" and 4e&elo-ment

Provide and encourage activities that will help the child to learn and progress

from his present developmental state to meet the net appropriate milestone. %nitiate appropriate referrals in cases of obvious developmental delays or learning

difficulties. The referrals may be to such professionals as psychologists,psychiatrists, and specialists in early child education.

hare the results of developmental testing with the parents, and discuss ways to

provide stimulation for the child at home.

Stren1t"enin1 8amily Co-in1

Use sensitivity in interviewing and teaching to avoid causing or increasing guilt

feelings about the poisoning and to establish a positive, trusting relationship

between the family and the health care facility.

/plain the treatment and its purpose because parents are commonly faced withputting an asymptomatic child through painful treatments.

/ncourage freuent visits by parents and siblings, and facilitate family

involvement.

Commnity and Home Care Considerations

(arry out lead screening in the community. %t is recommended that all high-ris#

children be screened for high lead levels between ages G and ;5 months and, if

feasible, again at 57 months. creening policies, universal or targeted, are

determined by local departments of health, based on the prevalence of ris# factorsin the community.

(oordinate community care efforts to return the child to a safe home.(ommunicate with community outreach wor#ers so that environmental casemanagement is conducted.

Fead abatement must be conducted by eperts, not untrained parents, property

owners, or contractors.

uggest periodic, focused household cleaning to remove the lead dust use a wet

mop.

/ncourage handwashing before meals and at bedtime to eliminate lead

consumption from normal hand-to-mouth activity.

O2ser&e t"e c"ild and ot"er c"ildren in t"e "ome !or -ica3

o Ebserve and record the child)s eating habits and food preferences.

o 0eport any attempted eating of nonfood substances.o /ncourage the caregivers to provide regular meals and ma#e mealtime a

pleasurable time for the child.

o Teach the caregivers to discourage oral activity and to substitute activity

that contributes to play, social s#ills, and ego development.o 0efer the family for additional social or psychiatric casewor# if indicated

to reduce the economic and other factors that result in pica in the child.

creen siblings and playmates of #nown cases immediately.


47/66

1a#e sure that the family is able to provide close supervision of the child or assist

them to ma#e arrangements to ensure that the child is adeuately supervised at

home.

8amily Edcation and Healt" Maintenance

/nsuring Fong-Term *ollow-Up Teac" t"e -arents 7"y lon1;term !ollo7;- is im-ortant3 Tell t"em t"at

residal lead is li2erated 1radally a!ter treatment and,

o 1ay result in the renewal of symptoms.

o 1ay increase serum lead to a dangerous level.

o 1ay cause additional damage to the (!, which may not become

apparent for several months.

tress that acute infections must be recognized and treated promptly because

these may reactivate the disease.

Teach that iron supplementation may be continued to treat anemia. "dvise the

parents about medication administration and adverse effects and periodic

complete blood count monitoring.

Pre&entin1 Ree>-osre o! t"e C"ild to Lead

"dvise the parents that the single most important factor in managing childhood

lead poisoning is reducing the child)s reeposure to lead.

%nstruct the parents about the seriousness of repeated lead eposure.

%nitiate referrals to home health nursing and community agencies as indicated.

NURSING ALERT

C"ildren s"old not retrn "ome ntil t"eir "ome en&ironment is lead !ree3

Pro&idin1 Commnity Edcation

%nitiate and support educational campaigns through schools, day care centers, and

news media to alert parents and children to hazards and symptoms of lead

poisoning.

Provide literature in clinics, waiting rooms, and other appropriate settings that

stresses the hazards of lead, sources of lead, and signs of lead intoication.

upport legislation to study the nature and etent of the lead poisoning problem

and to eliminate the causes of lead poisoning.

%nclude the topic of pica and lead poisoning in nutritional teaching.

*or additional information, contact the state or local health department or (D(,

http+99www.cdc.gov.

E&alation, E>-ected Otcomes

eizure precautions maintained no signs of increased %(P

Tolerates chelation therapy in@ections epresses anger through doll play

Parents provide appropriate play and stimulation for development

*amily involved in care provides support to the child
https://remote.smh.ca/,DanaInfo=www.cdc.gov+https://remote.smh.ca/,DanaInfo=www.cdc.gov+https://remote.smh.ca/,DanaInfo=www.cdc.gov+


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Commnica2le 4iseases

Cith the dramatic success of immunizations, many childhood diseases have decreased in

freuency. However, a number of communicable diseases still cause significantmorbidity in children.

C"ild"ood 4iseases4ISEASE0

AGENT0 MO4E

O8

TRANSMISSION0

AGE


49/66

sparse on

etremities,

papulovesicular

eruption.

Stre-tococcal P"aryn1itisX-Hemolyticstretococc!s "ro!

# strain

Direct or

indirect

contact withnasopharyng

eal secretion

of infected

person or

recentlyestablished

carrier.

0are under

age years


50/66


51/66

lar rash

develops on

trun#,spreading to

arms and

nec# mildinvolvement

of face and

legs rashfades

uic#ly.

R2eola %Hard0 Red0 ;day Measles*

)easles &ir!s*

$(#-containin"

aramy+o&ir!s

Direct

contact withdroplets from

infectedpersons,

respiratory

route.Diagnostic

tests:

erologic

proceduresnot routinely

done.Passiveimmunity:

2irth to

between ages7 and 8

months if

mother isimmune

before

pregnancy.


52/66

)!ms &ir!s*

aramy+o&ir!s

Direct

contact,

airborne

droplets,saliva and,

possibly,

urine.

chool age

all seasons

but slightly

more

freuent inlate winter

and earlyspring.Diagnostic

tests:(ell

culture fromsaliva, urine,

spinal fluid,

or blood.

Passiveimmunity:

2irth to age

8 months ifmother is

immune

beforepregnancy.

I:;7-5; days.

C:3 days before to G

days after swellingappears virus in saliva

greatest @ust before and

after parotitis onset.

Headache,

anoreia,

generalizedmalaise

fever ; day

beforeglandular

swelling

fever lasts;-8 days.

>landular

swelling

usually ofparotid:

one side or

bilaterally.

/nlargementand

reddening of

Charton)sduct and

tensen)s

duct.

ubclinical

infection

may occur.

%solation until

swelling has

subsided.

ymptomatic+

L"nalgesics. LHydration.

L"limentation. L"ntipyretics.

L0est.

4i-"t"eria

,oryne%acteri!m

dihtheriae

"cuired

through

secretions of

carrier orinfected

individual bydirect contact

with

contaminatedarticles and

environment.

I:5-7 days.

C:5-7 wee#s untreated

;-5 days with antibiotic

treatment.

(asal ihtheria

(oryza with

increasing

viscosity,

possibly

epistais,low-grade

fever.

Chitish

gray

membrane

may appearover nasal

Diphtheria antitoin

%.$.

"ntibiotic therapy

&penicillin,

erythromycin'.

upportive treatment+

L0espiratory

support.

L%solation untilthree cultures are

negative after

antibiotic therapy is


53/66

%ncidence

increased in

autumn andwinter.

Diagnostic

tests:(ultures of

nose and

throat.

septum.

.haryn"eal and

tonsillar dihtheria

>eneral

malaise,low-gradefever,

anoreia.

;-5 days

later,whitish gray

membranou

s patch on

tonsils, softpalate, and

uvula. Fymph node

swelling,

fever, rapid

pulse, Jbullnec#.K

/aryn"eal

ihtheria

Usually

spread from

pharyn tolaryn.

*ever, harsh

voice,

stridor,

bar#ingcough

respiratory

difficultywith

inspiratory

retraction.

(onresiratory

dihtheria

"ffects eye,

ear, genitals

or, rarely,s#in.

completed.

L2ed rest for 5-

wee#s. LHydration.

L%mmunization

with diphtheriatooid after recovery.


54/66

Pertssis %


55/66

infection.

Duration+ G

months to 5years.

Sta-"ylococcal Scalded S5in Syndrome %Ritter=s 4isease*ro! ha"e-

tye 0tahylococc!s

a!re!s

Disseminated

from aprimary

infection site

&usually nose

or aroundeyes'.

%nfants and

childrenunder ;6

years old.

Diagnostic

tests:(ultures of

s#in,

con@unctiva,nasopharyn,

stools, andblood.2iopsy of

efoliated

epidermis.

I:*ew days.

C:Enset of rash until

after antibiotics initiated.

1alaise,

fever,irritability,

or

asymptomatic.

0ash

develops in

three

phases+ L

/rythematous:macular

involving

face, nec#,

ailla, andgroin.

L

/foliative:upper

layer ofepidermisbecomes

wrin#led

and can be

removed bylight

stro#ing

&!i#ols#ysign'

crusting

around eyes,mouth, and

nose

producecharacteristi

c

Jsunburst,K

radial

pecific+

LTherapy withpenicillinase-resistant

penicillin P.E., %.1.,

or %.$.

ymptomatic+

L>entle cleaning of

s#in with

compresses.


56/66

pattern

irritable due

to etremetenderness

of s#in.

LDesuamati

ve:

epidermispeels away

leaving

moist areas

that dryuic#ly and

heal in ;6-

;7 days.

Poliomyelitis %Polio*Vir!s serotyes 1* 2*

and 3

%ncidence is

higher in

summer andfall.

$irus is

harbored in

>% tract andis transmitted

throughsaliva,

vomitus, andfeces.

Noung

children+pea#s in

"ugust,

eptember,

and Ectober,

in temperatezones.

Diagnostictests:

%solation of

poliovirusfrom feces

and throat.

I:3-;7 days, paralytic or

nonparalytic -< daysfor prodromal or minor

illness.

C:%ncreases around onsetwhen virus is in throat

and is ecreted in feces

virus is present in throat

; wee# after onset, instool -7 wee#s after.

(onaralytic .olio

Headache,

lethargy,

anoreia,

vomiting,fever.

1uscle pain

and stiffness

of posteriormuscles,

nec#, andlimbs.

.aralytic .olio

ame as

nonparalytic

type, lastingabout ;

wee#.

Then ;-5

days of

centralnervous

system

&(!'symptoms+

loss of deep

tendonreflees,

!onparalytic+

upportive &ie, reliefof pain'.

L"nalgesics, heat.

L/nteric isolation. L2ed rest.

Paralytic+

Hospitalize.

L*luid and

electrolytes. L0est.

L0elief of muscle

pain and spasms. L0espiratory

support.

L1inimize s#eletaldeformity.


57/66

positive

Iernig)s and

2rudzins#i)ssigns,

lethargy.

;-5 days

later,

wea#ening

of muscles

andparalysis.

Eryt"ema In!ectiosm %8i!t" 4isease or Sla--ed C"ee5*

.ar&o&ir!s B 1

0espiratory

route.

chool-age

children.

Diagnostictests:!ot

widely

available%g1

antibody test,

polymerasechain

reactiondetectiontest.

I:8-;7 days.C:Until rash develops.

1ild fever,

chills,fatigue, or

nonpruriticrashdevelops in

three stages+

Luddenappearance

of bright

erythema on

chee#s. L

/rythemato

us,maculopapu

lar rash on

trun# andetremities.

L0ash on

body fadeswith central

clearing

giving a

lacy orreticulated

appearance.

0ash lasts 5-

G days

freuently

pruriticwithout

desuamatio

!o treatment is

needed for healthychildren.

%mmunoglobulin for

immunocompromised patients.


58/66

n.

Eccasional

@ointarthropathy.

Rota&irs$eo&iridae "ro! #

1ost

common

agent

responsiblefor infantile

diarrhea.

*ecal-oral

route.

"ges 8months to 5

years most

common inwinter in

temperate

climates.Diagnostic

tests:

/nzyme-

lin#ed

immunosorbent assay.

I:;- days.

C:Until 5-< days after

diarrhea.

*ever.

$omiting.

Profuse,

watery, non-

foul-

smellingdiarrhea.

Eral fluid and

electrohydratesolution.

CHIL4 A6USE AN4 NEGLECT

(hild abuse is any type of maltreatment of children or adolescents by their parents,

guardians, or careta#ers. (hild abuse includes physical or emotional abuse, in@ury,

trauma, neglect, or seual abuse of a child that is intentional and nonaccidental.

A2se incldes,

2attering:physical in@ury.

Drug abuse:intentional administration of harmful drugs, especially duringpregnancy.

eual abuse.

eual assault or molestation &non-family member'.

%ncest &family offender'.

/motional abuse:scapegoating, belittling, humiliating, lac# of mothering.


59/66

Ne1lect is t"e omission o! certain a--ro-riate 2e"a&iors0 7it" sc" omission "a&in1

detrimental -"ysical or -syc"olo1ical e!!ects on de&elo-ment3 Ne1lect incldes,

(hild abandonment.

Fac# of provision of the basic needs of survival, including shelter, clothing,

stimulation, medical care, food, love, supervision, education, attention, emotional

nurturing, and safety.

Etiolo1y and Incidence

The cause of child abuse and maltreatment is multidimensional. The abuse may be related

to the combined presence of three factors+ special #ind of child, special #ind of parent or

careta#er, special circumstances of crisis. "buse occurs in all ethnic, geographic,religious, educational, occupational, and socioeconomic groups.

%n 566;, an estimated G66,666 children were victims of child abuse and neglect in

the United tates. *urthermore, ;,5; child maltreatment fatalities were reported

in 566;. The most common type of abuse is neglect &86 of cases', followed by physical

abuse &5', seual abuse &G', emotional maltreatment &7', and other formsof abuse &7'.

Contri2tin1 8actors

%ncidents of child abuse may develop as a result of disciplinary action ta#en by

the abuser who responds in uncontrolled anger to real or perceived misconduct of

the child. The parents may confuse punishment with discipline. J>ood parentingKmay be euated with physical contact to eradicate child behavior. The abuser may

be a stern, authoritarian disciplinarian.

%ncidents of child abuse may develop out of a uarrel between careta#ers. The

child may come to the aid of one parent and may find himself in the midst of the

uarrel marital discord is common. The abuser may be under a great deal of stress because of life circumstances

&debt, poverty, illness' and may thus resort to child abuse. (risis and stress maybe ongoing. The abuser may have a low frustration tolerance level and may not

have a well-developed means of coping with stress in general.

The abuser may be intoicated with alcohol or drugs at the time of the abuse only

;6 of abusers have a history of mental illness.

(hild abuse may occur by surrogate caregiver, ie, a babysitter or boyfriend.

Fac# of effective parenting, inappropriate parent-child bonding, and punitive

treatment as a child may contribute to the parent becoming an abuser.

S-eci!ic c"aracteristics e&ident in many a2sin1 -arents inclde,

o Fow self-esteem:a sense of incompetence in role, unworthiness,unimportance, have difficulty controlling aggressive impulses commonly

live in social isolation.

o Unrealistic attitudes and epectations of the child, little regard for the

child)s own needs and age-appropriate abilities, lac# of #nowledge related

to parenting s#ills.


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Counds, cuts, punctures.

2urns &cigarette, radiator', scalding:stoc#ing or glove distribution.

2one fractures.

prains, dislocations.

ubdural hemorrhage or hematoma Jsha#en baby syndrome.K

2rain damage. %nternal in@uries.

Drug intoication.

1alnutrition &deliberately inflicted'.

*reezing, eposure.

Chiplash-type in@ury.

/ye in@uries, periorbital in@uries, ear bruises.

Dirty, infected wounds or rashes.

Uneplained coma in infant.

*ailure to thrive:developmental delay malnutrition with decreased muscle

mass decreased interaction with environment and with others dental caries

listlessness behavior problems. eually transmitted diseases:genital trauma, recurrent urinary tract infection,

pregnancy.

Mana1ement

The goal of treatment is to ensure the physical and emotional safety of the child.

Therefore, treatment is inclusive of other family members and careta#ers and is

often focused on the parents. " team approach is employed to determine the most

effective use of community resources to protect the child and help the parents.

%t is estimated that ?6 to G6 of abusing parents can be rehabilitated. The ideal

approach is to return the child to the biological parents after treatment concludes.

Conselin1 is o!!ered to "el- -arents do t"e !ollo7in1,o Understand and redirect their anger.

o Develop an adeuate parent-child relationship.

o ee their child as an individual with his own needs and differences.

o Understand child development and normal behaviors of developing

children.

o Fearn about effective discipline techniues.

o /n@oy the child.

o Develop realistic epectations of their child.

o Decrease their use of criticism.

o %ncrease parents) sense of self-esteem and confidence.

o /stablish supportive relationships with others.o %mprove their economic situation &if appropriate'.

o how progress toward the physical, emotional, and intellectual

development of their child.

Nrsin1 Assessment

Identi!y !amily or c"ild at ris53

o "lcohol or drug abuser.


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o "dolescent parent.

o Fow-income, single-parent family.

o 1ultiple births.

o Unwanted child.

o ic#ly and more demanding child.

o Premature child with long separation from mother at birth. Ins-ect !or e&idence o! -ossi2le a2se3

o Describe completely on the medical record all bruises, lacerations, and

similar lesions as to location and state of healing. Foo# carefully at areas

generally covered with clothing &ie, buttoc#s, underarms, behind #nees,

bottom of feet'.

o "s# how in@uries occurred and record descriptions of the in@ury, including

the date, time, and place of the event.

(ollect necessary specimens for identification of organisms, sperm, or semen.

Ta#e color photographs as indicated.

"ssess developmental level of the child.

O2ser&e !or 2e"a&iors common in a2sin1 or ne1lectin1 -arents3 6e a7aret"at not all a2sin1 -arents e>"i2it t"ese 2e"a&iors 2t 2e alert !or t"e

-arent 7"o,

o "niously volunteers information or withholds information related to an

in@ury.

o >ives eplanation of the in@ury that does not fit the condition or gets story

confused concerning the in@ury.

o hows inappropriate reaction or concern to severity of in@ury.

o 2ecomes irritable about uestions being as#ed.

o eldom touches or spea#s to the child does not respond to child. 1ay be

critical or indicate unreal epectations of child &or may be oversolicitous

to the child'.o Delays see#ing medical help refuses to sign permit for diagnostic studies

freuently changes hospitals or health care providers.

o hows no involvement in the care of the hospitalized child does not

inuire about the child.

o Ebtains little or no prenatal care and shows inappropriate response to the

neonate acts disinterested or unhappy with the child.

"ssess the parent-child relationship in the areas of appropriate involvement in

care, show of affection, reaction to arrival and leaving, epectations, role

portrayal.

Assess !or si1ns o! se>al a2se3 Se>al a2se s"old 2e ss-ected 7"en t"e

yon10 -re-2ertal c"ild -resents 7it",o >enital trauma not readily eplained.

o >onorrhea, syphilis, or other seually transmitted organisms.

o 2lood in urine or stool.

o Painful urination or defecation.

o Penile or vaginal infection or itch.

o Penile or vaginal discharge.

o 0eport of increased, ecessive masturbation.


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o 0eport of increased, unusual fears.

o Trauma to genitalia, inner thigh, breast.

Esta2lis" a relations"i- 7it" t"e c"ild 2ased on mtal res-ect0 em-at"y0

and sensiti&ity to !acilitate !rt"er in&esti1ation3

o (onsideration of the child)s emotions in con@unction with a good

relationship may encourage the child to epress feelings either verbally orthrough drawings or play.

o Prepare the child physically and psychologically for the necessary

physical and pelvic eamination.

o Tal# with the child without the presence of the parents, especially when

incest is possible.

0eport suspicion of child abuse based on your assessment. "ll provinces have

mandatory reporting laws. "ll states provide statutory immunity for those who

report real or suspected child abuse. There is no immunity from civil or criminal

liability for failure to report such. !otify the appropriate officials.

NURSING ALERT

I! t"e alle1ed se>al a2se occrred 7it"in D "ors o! t"e "ealt" care &isit0 or i!

trama or 2leedin1 is -resent0 an immediate -"ysical e>amination s"old 2e done3

I! more t"an D "ors "a&e -assed since t"e alle1ed se>al a2se0 t"e -"ysical

e>amination mi1"t 2e delayed3 A!ter c"ild a2se "as 2een re-orted0 additional

c"ildren in t"e !amily may 2e e>amined as 7ell3

NURSING ALERT

E&ery nrse is morally and le1ally res-onsi2le to re-ort and -ro&ide -rotecti&e

ser&ices !or t"e a2sed c"ild3 6ecome !amiliar 7it" la7s0 -rocedres0 and -rotecti&e

ser&ices in yor commnity and state3

Nrsin1 4ia1noses

*ear related to eperiences with abuse

%mpaired Parenting related to abusive treatment of a child

Nrsin1 Inter&entions

Relie&in1 8ear and 8osterin1 Trst

2e aware that some of these children have never learned how to trust an adult

they are fearful of giving affection for fear of re@ection.

"ssign one nurse to care for the child over a period of time.

1a#e no threatening moves toward the child. The child will indicate readiness

and awareness of the environment by verbal or facial epressions.

Touch the child gently.

Provide nonthreatening physical contact &hold and freuently cuddle the child'.

Pic# up and carry child around encourage any eploration of your face and hair.

Provide appropriate opportunities for play.

et limits for the child.


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Provide therapeutic play to allow the child to epress fears and anger in a

nonverbal manner be non@udgmental and supportive with epression of feelings

correct misconceptions. Pro&ide additional "el- in t"ese areas,

o Having ambivalent feelings toward the parents or any adult careta#er.

o Evercoming low self-image and the fear that something is wrong withhim.

o *earing future abuse on his return home or for misbehavior in the hospital.

Pro&idin1 S--ort in Parentin1

"ssume a non@udgmental attitude that is neither punitive nor threatening. (onvey

a desire to help the parents through the healing process.

0efrain from uestioning them about the incident of abuse. The health care

provider, social wor#er, and investigative authority will interview the suspected

abuser.

%nclude the parents in the hospital eperience &ie, orient them to the unit and to

any procedure to be done to the child'. erve as a role model in the managementof the child)s behavior as well as their own. Try to give the parents as muchinformation as possible about the care of their child. Fisten to what they are

saying.

0efrain from challenging all the information they may give.

/press appropriate concern and #indness. 0emain ob@ective yet empathic. This

will help foster the parents) self-respect and improve their self-image and dignity.

Discuss the reporting to the authorities with them because of the widespread

nature of the problem and the need for education and assistance.

upport the parents who may have feelings of guilt, anger, and helplessness.

/plain to them the etent of trauma, and educate them. "llow them to epress

their feelings. upport their parental role in handling the child &eg, allow the childto tal# about or play out the incident, but do not force it'.

2uild a relationship by wor#ing with the parents) strengths rather than their

wea#nesses. Use compliments as positive reinforcement.

Assist t"e -arents to learn sa!e and a--ro-riate -arentin1 s5ills3

o 0emember that many of these parents were abused as children and have

no role models or personal eperience with nurturing behaviors.

o *oster attachment between child and parents, not between child and nurse,

when the parents are present the latter would increase their feelings of

incompetence in the parenting role.

o (orrect erroneous epectations as to what is appropriate behavior for a

particular age-group.o /ncourage the parents to ta#e time out from caring for their children to

meet their own needs assist them in identifying safe and appropriate

resources for their child)s care.

Provide the parents with psychological support and reinforcement for appropriate

parenting behaviors.

Cor# with the parents in planning for the child)s future care.


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Determine in what areas the parents need help. Does the infant cry often How

does this ma#e the parents feel How do the parents comfort the child %s there

someone the parents can call for help

NURSING ALERT

A critical -art o! 7or5in1 in t"is area is learnin1 to reco1ni+e0 e>amine0 and 7or5

7it" yor o7n !eelin1s o! an1er0 dis1st0 and contem-t !or t"e -arents3 It may "el-

to do t"e !ollo7in1,

0ealize that most abusing parents do love their children and want the best for

them despite their ambivalent feelings for the children.

Understand the dynamics of child abuse and neglect. This crisis is due to the

stress with which the parents are unable to cope and to the deprivations they havethemselves suffered in the past.

Commnity and Home Care Considerations

!urses typically provide home care visits as part of a multidisciplinary team engaging inetensive community follow-up. /ducation and continued assessment are the focus.

Teac" t"e -arents a2ot normal 1ro7t" and de&elo-ment3

o >ive specific information about and eamples of the types of behavior to

epect at the various stages of development. Point out in a nonthreateningway normal behavior ehibited by their child.

o Provide specific strategies for dealing with whatever behavior the child

ehibits.

o erve as a role model and teacher minimize intensity when the parents

become threatened.

Teac" t"e -arents "o7 to se disci-line 7it"ot resortin1 to -"ysical !orce3

o

Discipline must be consistent. Effer suggestions for alternative ways ofhandling undesirable behavior &eg, time-out'.

o uggest using a reward system for acceptable behavior &eg, a trip to the

zoo, staying up later than usual for a special television show, a special

treat'.

o %nstruct the parents to withhold rewards for unacceptable behavior.

Teac" c"ildren "o7 to a&oid 2ein1 t"e &ictims o! a2se3

o Teach them about Jgood touchK and Jbad touch.K

o /mphasize that they can say no to anyone who wants to touch their body.

o Provide names or places where they can go if they feel they are being

abused.

o

"ssist them in dealing with their fears that their parents will be sent to @ailor that they will be removed from the home.

6e alert !or si1ns o! a2se in t"e sc"ool3 I! a teac"er is ss-ected o! 2ein1 t"e

a2ser0 t"e c"ild may,

o Display increased fear of the teacher.

o Decrease school attendance.

o Develop psychosomatic symptoms during school days.

o Develop nightmares.


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o Corry ecessively over school performance.

8amily Edcation and Healt" Maintenance

Teach the parents and child &if age is appropriate' any specific instructions

relative to in@ury and follow-up care.

/nsure that the family #nows where and when to follow up. 0eview schedule for well-child visits and immunizations so the family can #eep

up with routine care.

1a#e #nown to the parents your continued concern and your availability as a

source of help. Help them to use resources in the community including the home

health nurse, social wor#er, and therapists.

0efer those interested in learning more about abuse to the following agencies+

Prevent (hild "buse "merica, ;-?66-

http+99www.calib.com9nccanch

E&alation, E>-ected Otcomes /hibits appropriate developmental behavior

2oth parents participate in feeding and playing with child
https://remote.smh.ca/,DanaInfo=www.calib.com+nccanchhttps://remote.smh.ca/,DanaInfo=www.calib.com+nccanch

pediatric primary care

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