Lecture# 3 01-21-14 Physical assessment Physical assessment of children o Vital Signs-KNOW!!

! Know the norms per age for P, RR, BP RR count 1 minute Auscultation VS. Visual o Watch chest fall and rise o Listen to HR on the axillary area Apical pulse count 1 minute Radial pulse not accurate measure until after age 2. Coratid cannot do both sides simoustanously Temperature: Rectal, Oral, Axillary-commonly done Sometimes rectal contraindicated (less than 1 month, bleeding concerns, etc.) Rectal is the clinical Gold Standard when in doubt o But not routinely done Temperature range (general) 36.5-37.6 BP: may use upper arm, lower leg, upper leg Order Heart rate Respiratory rate BP** NO BP on running IV side Hypertension Hypertension in Children o HTN now affects up to 5% of all children. May be due to the increase in childhood obesity. Usually seen in renal children o Obese children are at a 3X higher risk of becoming hypertensive when compared to nonobese children. o In young children, HTN is more often secondary to an underlying pathological process. o Make sure the BP cuff is the appropriate size Pump 10-15 mmhg above the base line In children-most worry about is diastolic pressure while adult worry about systolic pressure Screening for Hypertension o All children 3 years of age and older should be screened at all health care encounters. o Children younger than 3 years of age with comorbid conditions should also be screened. Prematurity or NICU stay CHD, Kidney disease, GU abnormality Family history of congenital kidney disease Transplant or malignancy Meds associated with HTN side effects. Treating Children for Hypertension o Stage 1: Lifestyle changes No evidence of organ damage, diabetes, and those who are asymptomatic After 6 months of lifestyle changes, need re evaluation and if still hypertensive then move to Stage 2. o Stage 2: Antihypertensive medications

Children who are symptomatic, HTN secondary to medications, diabetes, or evidence of organ damage Many medications for HTN have not been tested long term in children.

Assessment Physical Assessment of Children o Neurological Fontanels Anterior close at 2-years o Sunken = dehydration and o Bulging= increase cranial pressure Seen in N/V Seen in severe meningitis and.. Posterior close at 2 months Level of consciousness Following commands Motor milestones**know a few-signifant one Cognitive and Social development Response to environment Infant reflexeswhen do they disappear? Moro, tonic-neck, rooting, grasp o Gone by 4 months Babinski, corneal, etc. o a year to 18 months Corneal reflexes o Never goes a way, if it does = bad signs o Infant Reflexes Babinski Normal until approximately 2 years-of-age Moro Strongest during first 2 months. If present after 4 months, is indicative of brain damage Palmar Grasp Should disappear by 3-4 months o Rooting Disappears by 3-4 months may persist for up to 12 months when the child is sleeping Absence of reflex is indicative of severe neurological disorder o Sucking Reflex persists through infancy. Weak or absent reflex indicates developmental delay or neurological abnormality o Startle Absence may indicate hearing impairment If persistence = neuro issueinfantile spasms lead to death o Assessment of LOC How stimulation it take to wake up a child. Not resending = need furfure investigation o Assessment of Pain Assessment of Development o On-going as child grows Assessed often with well child visits o Need to know the norms or major milestones to assess development o Use Erikson for comparison Psychosocial and cognitive level o Standardized tests Many to choose from. Denver is broad screening tool used often. Not IQ test, it is social and emotional test

Use specific ones for concerns (ie M-CHAT (Modified Checklist for Autism in Toddlers)

Question. In what order should the following routine assessments be performed on a 9 months old child who is in the hospital? A. Temp, RR, Weight, HR, BP B. Weight, RR, HR, Temp, BP C. HR, RR, Temp, BP, Weight D. Temp, Weight, BP, HR, RR Assessment of Growth o Measurement of Growth is central to evaluating health status o All plotted on growth charts o Height/length and weight On all visits Use centimeters and kilograms o Head circumference Up to 36 months

Head circufrance-TEST o Top of the eye brown and wrap around occipital bone Abnominal cercumfrance o Suspect obstruciton, malabsorption Chest circumference Not rutienly done Body Mass Index-Know how to calculate!!!! o BMI is the best indicator of a healthy weight. Length for Height not as accurate Weight is very important in cardiac floor o BMI = kg/m-squared. o Use decimals for fractions of pounds and inches o Considered overweight if BMI is at or exceeds 85% o 80% BMI interpretation

 80% weight less while 20% weight more BMI Question An 8 year old boy weighs 26 kg and is 128 cm tall. What is his BMI? A. 0.20 B. 158.0 C. 0.6 D. 15.9 BMI example o A 4 year old boy weighs 33 lbs 4 oz and is 37 5/8 inches tall 4 divided by 16 = 0.25 lb 33.25 lbs 33.25 divided by 2.2 15.1 kg 5 divided by 8 = 0.625, 37.625 inches 37.625 X 2.54 95.6 cm BMI 16. 5 His BMI is at the 75% mark how would you explain this to his parents? Growth Chart For Practice: Plot the following on the growth chart at the back of your textbook. o Boy 7 months old Length 67 cms Weight 8.2 kg OFC 45 cm Wgt for Length Approximate Growth Rate o The first year has rapid growth. Growth slows the second year of life. o Infants: Approximately 1 lbs. per month for first 5 months. o Birth Weight doubles at 5-6 months o Birth weight triples by 12 months o Birth length double at 4 years of age o 50% of adult height at 2 years of age o Infants: Approximately lb. per month during second half of infancy Childhood Obesity Obesity has tripled in American children since 1980. o 9.5% of infants and toddlers and about 17% of children and adolescents o Ogden, C. L. (2010). High BMI remains steady in U. S. children, adolescents. Children at or above BMI 95% are obese Children between 85-94% are overweight Those with BMI >85th % should also be screened for other comorbidities Children should be managed for weight as early as age 2 o Managed by nutritionist, MD

Childhood Obesity: Comorbidities o Asthma o Obstructive Sleep Apnea o HTN o Type 2 Diabetes Fasting blood sugar for children 10 years or older if BMI >85th % with: Family history of Type II Diabetes

Race or ethnicity associated with an increased risk of diabetes Clinical features of insulin resistance Hyperlipidemia Fasting lipid profile

Childhood Obesity: Assessment o Measure and determine BMI o Skin fold thickness and waist circumference has not shown evidence of usefulness o Obtain diet history and activity history o Over 3 days periods o Obtain family and past medical history

Childhood Obesity: Prevention o Counsel non obese patients to establish weight friendly and healthy lifestyle o Breast feed first 6 months and continue for at least the first year. o Five or more fruits and veggies a day o Limit sugar sweetened beverages o Prepare more meals at home o Eat at the table as a family 5-6 times a week with TV off. o Healthy breakfast every day o Involve the whole family in lifestyle changes o Parents should avoid overly restricted feeding behaviors. o Diet rich in calcium Childhood Obesity: Treatment Weight management programs that involve the family and include frequent visits to the PCP. Physical activity recommendations Dietary instruction. Medications o No weight loss meds are approved for use in children younger than 12 years. Surgery o Under investigation for use in severely obese adolescents.

Failure to Thrive Inadequate growth o Can be physical or psychosocial or both No universal definition Weight less than 5% for age Persistent deviation from growth curve Types o Inadequate caloric intake o Inadequate absorption (CF, hepatic disease, vit/mineral deficiencies) o Increased metabolism (CHD, hyperthyroidism, immunodeficiency) o Defective utilization (metabolic or genetic anomaly)

** How do we know the baby is not getting enough breast milk? By number of wet diapers

Management of FTT o Diagnosisexam, growth charts, diet history, rule out organic causes, family assessment, home assessment o Managementreverse the malnutrition, catch up growth, treat coexisting problems o Prognosis Related to the cause Can we reverse the problem? -depends

Nursing Care of FTT o The nurse Assessment of weight, growth. Documenting food intake, feeding behavior, interactions o Feeding Sufficient calories, feed on schedule, persistence, eye contact o Persistence for 10-15 minutes Quiet, non-stimulating feeding environment Positive, calm, structured feeding environment o The Parent Supporting a positive family-child relationship Parent education o Evaluation= Have the parents report back to you o The Child Developmental stimulation between feeds o Question.. The nurse is caring for a 3 month old with FTT. Which of the following feeding techniques should be taught? A. Feed baby in a common room of the house. B. Let the baby demand feed C. Develop a structured feeding routine D. Double concentrate the formula to increase caloric intake. Phenylketonuria (PKU) Genetic disease o Inherited autosomal recessive Inability to metabolize phenylalanine o Lacks enzyme to metabolize phenylalanine o Phenylalanine is an essential amino acid found mainly in proteins but also in grains and fruits/vegetables High phenylalanine levels can cause severe cognitive impairments and erratic behavior o Degeneration of grey and white matter PKUManifestations o Growth failure, vomiting, irritability, erratic behavior, spasticity, seizures, cognitive impairments o Best outcomes if treatment started before 3 weeks of age. o Done in the hospital and by 7 days of age o Diagnosisscreening mandatory in 50 states Diagnosis and treatment aimed at prevention of cognitive disabilities Test close to newborn discharge but before 7 days old Need sufficient exposure to milk to test (at least 24 hours)

PKUTreatment -TEST!!! o Treatment Low Phenylalanine Formula/Solution is only source of protein through adolescence Breast feeding MAY be OK if mothers intake is low in phenylalanine Diet allows for 20-30 mg/kg/day of phenylalanine Kid will be on special formula o Maintain blood level of 2-8 mg/dlcognitive deficits occur at levels of 10-15 Even with good control, could be some degree of intellectual impairment Pregnant females must go back on the diet before the pregnancy to prevent fetal brain damage Stay away with soda and protein Adults may experience mental decline if they do not continue the diet in adulthood. Question TEST! Which teaching is most important for a child with PKU during a well-child visit? A. The child is able to eat a hamburger and milkshake daily. B. If the child wants a soda, a diet soda is preferred over milk or dairy. C. The child may have ice cream in any amount twice weekly. D. Low protein pasta and cereal are acceptable ImmunizationsDo not need to memorize when to get for the test, just know what they are for Immunizations Dramatic decline in infectious diseases due to widespread use of immunizations Single most important health measure o Immunization status should be asked at each health care visit Recommended vs. required vaccines o Recommended-Flue o Required-MMR Schedule Controversy with Vaccines o No association between vaccines and autism. There is no direct relationship between vaccines and autism to date o Stems from a study that was funded by trial lawyers in 1998. Study retracted by the authors in 2004. o Concern regarding Thimerosal Thimerosal is a preservative Rates may have even increased since the removal of Thimerosal. o At a greater risk if not immunized for the illness. Vaccine Refusal o Most do not vaccinate due parental concerns on vaccine safety. o Most commonly cited concerns: Thimerisol very few contain it Not closely regulated monitored by FDA and CDC Diseases not a risk international travel increases this risk Receive too many vaccines at once actually, the loads of antigens in a single vaccine component have decreased over time as technology improves

Immunization Schedule o Changes often (yearly or every few years) o Recommended vs. Required. Know for test!! Required is determined by the state for school attendance Recommended is the entire schedule...recommended by the AAP (American Academy of Pediatrics).

Hepatitis B Hepatitis B infections can lead to cirrhosis or liver cancer Can become a Hepatitis B carrier Rapid rise in Hepatitis B incidence during adolescents Transmitted by blood and body fluids Given IM Rotavirus Vaccine Newer Oral Start by 12 wks of age Currently being expanded to 14 wks + 6 days First dose recommended 6-12 wks Final dose by 32 wks. Currently being expanded to 8 months + 0 days

Live vaccine -SUB-Q chicken pox and MMR Live vaccine IM- flu nasal mist

Diptheria, Tetanus, Pertussis (DTaP) Combination vaccine Given IM Common side effects to discuss: fever for 24-48 hours, localized pain at injection site, redness at injection site. Diptheria: bacterial infection can cause airway obstruction and severe sequelae Tetanus: painful, muscular rigidity and often fatal Pertussis (whooping cough): can cause severe respiratory distress Acellular form of vaccine with less side effects Haemophilus influenzae type b (Hib) Given IM Protects against serious infections caused by Hib Bacterial meningitis Epiglottitis Pneumonia Sepsis Inactivated Polio (IPV) OPV no longer available in the US. Polio can have neuromuscular, paralytic effects Given IM Used to be given orally, but now all doses given IM Measles, Mumps, Rubella (MMR) Live, attenuated vaccine. Given Subcutaneously

Common Side effects to discuss include a rash (looks like measles) 7-10 days after the injection Do NOT give to pregnant women. Measles (Rubeola): viral and can have complications of laryngotracheitis or encephalitis Mumps: viral and can have complications such as encephalitis, deafness, sterility Rubella (German Measles): viralbiggest risk is teratogenic effects on the fetus.

Varicella (Chicken pox) Highly contagious viral illness Live attenuated vaccine, given subcutaneously. Common side effect to discuss: Rash (like chicken pox) at the injection site 7-10 days after the injection Store frozen Not recommended for pregnant women Given due to complications of chicken pox that can include encephalitis and serious secondary infections. May get mild case of chicken pox if exposed Pneumococcal and (PCV) Prevnar Given IM Very helpful for conditions of immunosuppression o Need to get vaccine even when they are not immunosuppression b/c diseases will kill them o Sickle cell, asplenia, transplant, HIV For prevention of strep pneumo strains of bacteria o Often cause ear infections, sinusitis, and pneumonia o PCV has decreased many cases of strep pneumo OM and a newer PCV vaccine that includes more serotypes of strep pneumo will decrease cases further. We will still be left with other causes of OM, however. If over 24 months, can use the older pneumoccocal vaccine. o Some increasing resistance to this vaccine is being noted. Influenza Given IM Dont give if allergic to eggs Give in early fall Administered yearly as the predicted strain changes Recommended for children > 6 mos and especially those with underlying conditions. Hepatitis A Given IM in 2 doses Generally not required for school attendance Hepatitis A can cause serious liver complications Transmitted by fecal-oral route Required in some communities with a high rate of Hepatitis A Often required in food service Meningococcal (MCV) Given IM Recommended for those in crowded living conditions For the prevention of meningoccal meningitis

Adolescents targeted for this.

Vaccine Administration Site/equipment o 1 inch, 25 gauge needle for IMnice place to start Vastus lateralis or Ventrogluteal for infant/young child Deltoidpreschool or older than 2 years of age Safety Good restraint Ok to give multiple injections, just use different sites Correct storage, reconstituation Do not combine unless it came as a combo vaccine Developmental Approach Documentation VIS, site, lot number, consent Parents should be educated in case of reaction IM and SC injections IM Vastus lateralis, ventrogluteal, deltoid in older children Immunizations and medications (usually antibiotics) SC Arm for immunizations Used for insulin, hormone replacement, allergy shots, some vaccines.

Contraindications for Vaccine Administration Severe febrile illness (It is NOT a fever unless >38) Past SERIOUS adverse reaction to the vaccine or vaccine component Long-term (>2 weeks) use of SYSTEMIC steroids. Pregnancyno live vaccines Recent blood, plasma, or IgG for live virus vaccineswait a minimum of 3 months Seizure within several days of receiving a prior dose of vaccine. Child does not have a seizure and never has one before Immunosuppression Transplantation: Generally no live virus vaccines if undergoing immunosuppression therapy HIV: Can receive live virus vaccines if asymptomatic AIDS: Is not considered an asymptomatic state. Chemotherapy: wait 3 months usually to restart vaccination schedule OK to give a vaccine when.. Mild to moderate local reaction to past vaccine Mild, acute illness with or without low grade fever Current antibiotic therapy o Not given w/i 24 hrs, given beyond day 6-7 and the symptoms have subsided Prematurity Family history of seizure, SIDS, or adverse reaction to vaccine TB test o Give they have positive TB test Breast feeding or household contact with pregnant woman CAN receive if HIV + and asymptomatic

Question Which is the nurses best response to a mother of a 2 month old infant who is getting an IPV and tells the nurse that the older brother is immunocompromised? A. Your baby should not be immunized today. B. Your baby will receive an OPV instead of IPV then today. C. You should keep you baby and your son separated for 2 weeks. D. Your baby can be immunized with IPV, he will not be contagious. o IPV is inactive form THINGS to KNOW about vaccine!! Which one are live and how to give it and contraindation to education the family Cannot mix immunization together unless it comes with it Giving oral medications to children Use the correct dosing device Carefully measure it. Dont sneak medicine into food. Do not put in a bottle. Administer into the cheek pocket. Mix in the smallest amount possible. May need to crush it and make it a liquid Can flavor it. Some meds you may repeat and others you may not. Do not always assume you repeat it if they spit it or vomit it. Fever Defined as temperature > 38 C or 100.4 F Harmful fever is above 41.7 C or 107 F-too high brain will fry Most fevers are brief with limited consequences and are viral in origin Neither the rise in temperature nor its response to anitpyretics indicates the severity of the infection. o Hypothermia is indication of infection in kiddos In the hospital setting, however, notify physician for temps if not expected or follow floor guidelines. Evaluation of Fever in Children Any infant less than 2-3 months old is evaluated immediately if febrile Less than 28 days usually receive a complete septic workup o Work up is lumbar puncture and blood count!!! Up to 90 days of age the key is if they appear toxic o They will look like difficult weight gain, poor color, sunken eye and futinales o Look at skin turgor at thigh and abdomen Any child with fever > 105 is evaluated immediately A child that looks or acts very sick is evaluated immediately Fever 104-105, younger than 2 years, fever > 3 days, fever gone for 24 hrs and then returns, or parental concernsshould be evaluated in 24 hours. Treatment of Fever Aimed at relieving discomfort-want to lower the set point Medications to lower the set point

o Acetaminophen 10-15 mg/kg per dose o Ibuprofen 5-10 mg/kg per dose (after 6 mos. of age) o NO aspirin for fever reduction Home treatments o Light clothing, air circulation, sponging (be careful!) Oral intake o Just enough to keep them peeing o Perfusion is very import About 5-6 wet diapers or 1ML/hr Indication of kidneys perfusion, good cardiac output and good hydration Parental support Education o When to follow up, correct medication dosing, correct home care

Febrile Seizure Affect about 3-5% of children and usually occur between the ages of 6 months and 3 years. Unusual after age 5 years. Cause is uncertain Temperature usually exceeds 38.8 C (101.8 F) o Tonic Clonic seizure occurs during the temperature rise o Last more than 10 minutes call 911 o Common before 6 months o Status epilepticus can last more than 30 minutes Follow up o Initial episode should be evaluated by pediatrician o Complicated episodes may need further evaluation by neurology

Varicella Zoster (Chicken Pox) Transmitted: airborne and direct contact Incubation period: 14-21 days Communicable 5 days prior to rash onset and until last vesicle crusted over.** Manifestations: o Fever o Malaise o Headache o Itching o Vesicular rash Treatment of Varicella Supportive Tylenol (No Aspirin) Fluids o More concern about fluids as oppose to nutrition Comfort for itching (baths) o Immunization to prevent o Treatment of secondary infections Cellulitis

Meningitis Reye syndrome Illness more severe if on oral steroids Significant illness/death if immunocomprimised

Nursing Implications Monitor for complications Neurocomplications Infections Home care Treatment of rash Comfort Fluids OTC medications Isolation if in Hospital Monitor visitors as well Erythema Infectiosum (5ths Disease)-Not covered in class Transmission: respiratory secretions and blood. Human Parvovirus B19 Manifestations: o Headache, malaise, body aches o Maybe low grade fever o 1 wk later, slapped cheek rash o 1-2 wks: lacelike maculopapular rash on trunk and limbs that comes and goes for 1-3 wks. Nursing Implications of 5ths Disease Supportive Care o Home care for itchy rash (usually not itchy) o Fluids o Rest o Keep out of sun with rash Avoid contact with pregnant women o Contagious prior to symptoms Can cause aplastic crisis in children with hemolytic conditions Impetigo

Bacterial infection of the skin. o Often spread by auto inoculation o Young children often affectedhand to mouth/nose o Spread pretty quick o Often seen around the nosecan be anywhere though o Honey crusted lesions o Need to be on abx for 24 hrs before able to go to school Nursing Care o Handwashing o Antibiotics o Razors discarded o Bleach kills it on surfaces

Allergic Reactions Can be: red, itchy, wheals, facial/tongue swelling, wheezing, difficulty breathing May be seen more in kids since they have first exposures to things There is a difference between food allergies and food sensitivities. Sensitivities may come and go in childhood o Can out growth the allergies, they need to carry epi-pen at all time What can cause it? o NSAIDs, analgesics, vaccines, and antibiotics most common causes o PCN allergy4-8X more likely to have cephalosporin rxn o Foods peanuts, tree nuts, shellfish, eggs, dairy, strawberries most common Accident Prevention Injuries are number 1 in childhood mortality Take a developmental approach to prevention o Poor planning, top heavy, awkward, impulsive, curious Situations that lead themselves to injury: o Weather extremes, Saturdays, overcrowded areas, tension in the home, alcohol/drug use Question.. An adolescent comes in for his yearly physical. Which would be the most appropriate injury prevention/safety teaching for him? A.Inquire which are his favorite sports and discuss his knowledge and application of appropriate safety principles. B. Tell him to be careful performing sports activities because every sport has the potential for injury. C. Tell him not to let his friends encourage him to drink or smoke or take any drugs. D. Ask his mother what sports he plays and if he wears a helmet with contact sports. Ingestions 90% of poisonings occur in the home Developmental characteristics predispose children to poisonings. o Curiosity, oral experimentations, imitation Prevention o Lock Poisons/Medications Up o Keep out of sight Throw out old drugs, dont let young children see adults take, keep meds in safe area o Keep in original containers Dont put in food containers, dont refer to meds as candy o Poison control number handy Home Treatment of Ingestions Assessment o What did they take? o How much? o When? Empty mouth Take child and container to the phone o Suspecting able to breath put the child on the side and open the mouth Call poison control

Treatments of Ingestions May be one in the ERdepends on what was taken Charcoal o Absorbs compounds o Poses risk for aspiration, intestinal obstruction, electrolyte imbalances o Mix with diet soda as sweeteners reduce its absorption qualitiesthis may not be the case now. Cathartics o Stimulate evacuation of the bowel, decreasing intestinal absorption o Use controversial Antidotes o Mucomist for tylenol, Narcan for opioid , etc Question. A child who has swallowed paint thinner is brought to the emergency department by her parent. The child is lethargic, gagging, and cyanotic (airway compromised). What is the best action for the nurse? A. Induce vomiting with ipecac. B. Insert gastric tube and give charcoal C. Prepare for intubation with cuffed ET tube-airway first D. Administer chelation therapy using DES Lead Poisoning Known health hazard o Absorbed by ingestion, inhalation, placental transfer o Most effected is Neuro Absorbed by the body and not fully eliminated Sometimes can be a part of cultural tradition Can get from paint, toys, water that come from contaminated house, old house that have old paint that contain lead in paint The child Young children absorb 50% of what they are exposed to while adults absorb 10% Ages 1-5 years, pica, high fat diet, iron deficiency, developmentally delayed, increased oral activity Parent may be distracted, unaware of pica Pathological Effects of Lead Hematology o Anemialead competes with iron in making hemoglobin Renal o Damage to renal tubules causes excretion of glucose, protein, amino acids and phosphateFanconi Syndrome CNS o Cerebral edema, encephalopathy, increased ICP, seizures, MR, blindness, paralysis, death o Developing brain is especially vulnerable o CNS effects are nonreversible Keleading agent needs to make sure they have plenty to fluid to flush it out Blood Level Treatment Level < 10 o Rescreen in 1 year. If exposure status changes, do this sooner 10-19

o Education and rescreening. Nutritional interventions 20-44 o Home and medical treatment 45-69 o Start chelation within 48 hrs, remove from environment > or = 70 o Immediate medical intervention Hydration is very important Treatment Treatment of home environment in treating lead poisoning Chelation starts around levels of 44-45. o DMSA Oral agent used for lower levels o Calcium EDTA and BAL Monitor for nephrotoxicity (UA daily), liver function tests and EKG Given in a monitored hospital setting Long-term effects of Lead Some pathophysiological effects are reversible Effects on CNS leave child with Cognitive Impairments, Behavior Changes, and Seizures Even low dose exposure may leave permanent effects of distractibility, impulsivity and learning disabilities Nursing Implications Education Assessment of development Case coordination

Abuse
Child Abuse Physical Abuse Physical Neglect Emotional Abuse Emotional Neglect Verbal Abuse Sexual Abuse What is Abuse? Deliberate maltreatment Deliberate withholding Shaming, ridiculing Emotional unavailability Exploitation Risk factors of Abuse Drug and ETOH abuse Psychiatric disorders Environmental stressors o Poor parenting experiences o Marital/partner stressors o Social isolation o Inappropriate expectations of the child Signs of Child Abuse Unexplained burns, bruises, fractures.

Severe child abuse is during potty training

The story must match the child injury if not = child abuse

Fading bruises or burns Bruises or welts in shapes or patterns Child shrinks in approach to adults Child is overly compliant Caretaker with conflicting story. Nursing Implications With Regard to Child Abuse Diagnosis o History and physical o Lab studies Nursing implications o Reassurance of the child o Nursing assessment Does the history fit the evidence? o Mandated reporter- if not report RN will lose the license Child Maltreatment Physical Non-Accidental Injury to a Child caused by a Caregiver Physical Indicators o Red Flags o Inconsistent Histories o History and Exam Mismatch o Withholding History o No Knowledge of Circumstances o Claims of Self-infliction o Blaming of Siblings or Other Parent or Adult o Delay in Seeking Care o History of Other Injuries o E.R. Shopping o Inappropriate Rxn to Severity of injury o Partial Confession Early Motor Milestones AGE 4 months 5-6 months 8-9 months 10-12 months 15 months 18 months 22-24 months 2-3 years 3 years 5 years

Hallmark Signs of abuse are torn frenulum which form pushing the bottle down /when child starts to abuse animal

MILESTONES Raises Head Rolls Over Sits Alone Crawls-Walks Walks Alone Climbs Stairs Throws Ball Overhand Runs Well Turns a Hot Water Knob Pedals Tricycle Alternates Feet up the Stairs Catches Ball Bounced

Suspicious Histories o No explanation for injury o Inadequate explanation o Contradictory or changing history o Injury attributed to a 3rd party (sibling, babysitter) If sibling, is that child developmentally mature enough to have caused the injury

Bruise Color Scale o Color o Reddish Blue/Purple o Dark Blue/purple o Green o Yellow o Brown o ResolutionCleared

Time From Injury Immediate-24 hrs 1-5 days 5-7 days 7-10 days 10-14 days 2-4 weeks

Parental Behavior Patterns Seen in Abuse o Lack of concern or detachment about the injury o Lack of response to child in pain o Overly concerned about trivial injuries o Demonstrates unrealistic expectations of the child o I told them not to do o Parents themselves may have a H/O Drug or Alcohol Addiction or Psychosis o Lack of trust in health professionals Consider the Possibility of Physical Maltreatment when the Child: o Has unexplained burns, bite, bruises, broken bones, or black eyes o Has fading bruises or other marks noticeable after an absence from school o Seems frightened of the parents and protest or cries when it is time to go home o Shrinks at the approach of adults o Reports injury by a parent or another adult caregiver Consider the Possibility of Physical Abuse when the Parent or other Adult Caregiver: o Offers conflicting, unconvincing, or no explanation for the childs injury o Describes the child as evil or in some other very negative way o Uses harsh physical discipline with the child o Has a history of abuse as a child Skin and Soft Tissue Injury o Bruises on face, lips, mouth, torso, back, buttocks and thighs Bruises in various stages of healing Degree of bruising is greater that expected for childs activity level Dating bruises by color scale

Question. A nurse is assessing the family of a child brought in for severe injuries. Which of the following behaviors by the parents indicates probable abuse? a. Delay in seeking treatment for the childs injuries. b. Detailed description of the events prior to the injuries. c. Anxious, concerned attitude d. Encouraging the child to explain the injuries. Child Abuse sexual Incidence is increasing Child needs to be referred to Sexual Abuse Management (SAM) Team Will be seen in E.R. if immediate physical problems evident Physical evidence Must be collected very, very carefully

Types Incest Between family members Not necessarily blood relatives Molestation Indecent liberties Touching, Fondling Exhibition Indecent exposure Child Pornography Consider the Possibility of Sexual Abuse when the Child: Has difficulty walking or sitting Suddenly refuses to change for gym or to participate in physical activities Reports nightmares or bed wetting Experiences a sudden change in appetite Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior Becomes pregnant or contracts a venereal disease, particularly if < 14 years old Runs away Reports sexual abuse by a parent or another adult caregiver Consider the Possibility of Sexual Abuse when the Parent or Other Adult Caregiver: Is unduly protective of the child or severely limits the childs contact with other children, especially of the opposite sex Is secretive and isolated Is jealous or controlling with family members

Sexual Abuse Besides the obvious acts of Child Sexual Abuse, other behavior must be evaluated to determine if the act is designed to create sexual gratification Activities can include: Any conventional sexual activity with a child. Also included are acts such as touching the childs genitals or fondling with the intention of arousing sexual feelings Prolonged kissing, cuddling, French kissing, and excessive touching Looking at children either with or without clothes Photographing, videotaping, or filming children with the intent to create sexual stimulation May include exposure of a child to erotic material Pedophilia - A form of child sexual abuse- is an abnormal interest in children that is based on the intention by the perpetrator to be sexually aroused by children Munchausen by Proxy An illness that one person (usually the mother, who has some health care experience) fabricates or induces in another person May cause a child to undergo needless painful testing Parents should ask themselves the following questions to determine if this condition might exist Are you overly concerned about the health of your child? Do you remain concerned about minor problems that you have been told not to worry about? Do you find yourself obsessing over possible medical problems that might affect your children? Have you ever done an intentional act to make your child ill? Do you have any motivation or will you derive any benefit if you make your child ill? Parents that see this behavior in themselves should stop the medical attention-seeking behavior immediately and seek psychiatric help as soon as possible.

Nursing Responsibilities in Child Maltreatment Identification Health professionals miss hundreds of cases of child maltreatment per year Nurses must perform excellent physical assessments and histories Something are not considered abuse Coining (Cao Gio) (NCLEX-Qs) Involves rubbing a coin along area to cause bad wind. If a red-purple discoloration appears, the treatment is considered successful. Performed by Vietnamese and other Asian-Pacific Groups Care of the Child Depends on the injury Protection of the child Prevention of abuse Reporting Mandatory If written report is done, report must be in common terms, not medical terms. If a medical term is used, there must be an explanation Parents are told that a report is being made and that Social Service will want to interview them. Testifying in Court Nursing Diagnoses Associated with Child Maltreatment o Knowledge Deficit (of Staff) of Hospital Child Maltreatment Policy o Ineffective Family coping: compromised R/T Factors that Contribute to Child Maltreatment o Altered Growth and Development R/T Inadequate Caregiving o High Risk for Violence (Abusive Family Member): Directed at others R/T maladaptive Behavior o Altered Parenting R/T the Abusive parents inability to Attach or Bond with the Child CARE FOR THE CAREGIVERS o Caring for abused children is very, very emotionally draining. Health care providers need to remember that if they do not take care of themselves they cannot take care of the children. o Nobody has to do this alone so be sure to know what your resources are and use them.