Nursing > Exam > Nursing Assessment (Austin Peay State University) Exam Autumn 2019, answers _Exam 2 Blueprint. (All)
Nursing Assessment (Austin Peay State University) Exam Autumn 2019, answers _Exam 2 Blueprint_ Ch. 4 - Communication with parents and children: - Communication with Parents: • Introdu... ce self, ask how to address the parents (cultural awareness) • Ensure privacy and confidentiality • Ask broad, open-ended questions (encourages talking) - Communication with Children: • Get on child’s eye level • Approach child gently and quietly while involving the parent or care- giver • Always be truthful • Give the child choices as appropriate • Include play whenever possible • without parents present - Infancy: primarily use and understand nonverbal communication - and more on what they know when faced with new problems; want to know why something exists/how it works/why it is used; heightened concern with body integrity - Adolescents: build foundation, communicate effectively, encourage expres- sion of ideas/feelings, respect their views, respect privacy, importance of peers, plan for developmental regression during times of stress - Signs of Information Overload: • long periods of silence, wide eyes, fixed facial expressions, constant fidgeting, attempting to move away, nervous habits, sudden inter- rupting, looking around, yawning, eyes drooping, frequently looking at your watch or clock, attempting to change topic - Importance of Play: • can serve as therapeutic intervention, stress reliever, pain reliever/ - Sequence of physical examination; age specific approaches: posterior-2 mo.; anterior-12-18 mo. • Infants: apical • >2 years: Radial • Least invasive first: heart, lungs, bowel sounds Ch. 6 - Routine Immunizations; Immunization Reactions; Possible delayed - . • Birth: Hep B • 2 mo.: Hep B, RV, DTaP, Hib, PCV, IPV • 4 mo.: RV, DTaP, Hib, PCV, IPV • Separate syringes, different injection sites, live viruses given four weeks apart if not in same day - Contraindications (risks outweigh benefits): • **severe febrile illness • immunocompromised child/household member • recently acquired passive immunity (blood trans., immunoglobulins, maternal antibodies) (MMR & Varicella postponed for min. of 3 mo.) • known allergic response • religious beliefs - ->High Risk C & A: Two additional vaccines recommended: rotavirus vaccines RotaTeq (RV5) and Rotarix (RV1). Rotavirus is one of the leading causes of severe diarrhea in infants and young children. • For Infants 6-12 wks, with 2 additional doses at 4-10 wk intervals (2mL) but not after 32 wks old. - ->Human Papillomavirus (HPV) vaccines have been licensed for use in ado- lescents including 2vHPV, 4vHPV, and 9vHPV. These are given to female children and adolescents to prevent HPV-related cervical cancer. The • First dose at 11/12, second dose 2 mo. later, third dose 6 mo. later - Communicable diseases of childhood, Table 6-1, pg. 163-169, to include clinical presentation, peak period of communicability, need for isolation, therapeutic management, nursing care management, and greatest con- cern of disease for the following: 1. Chicken Pox (Varicella): (standard/airborne/contact) - Clinical Manifestations: - Therapeutic Management: • Acyclovir, Diphenhydramine, Antihistamines • Give bath and change clothes and linens daily; administer topical calamine lotions; keep child’s fingernails short and clean, apply mittens if child scratches, and keep child cool (can apply pres- sure if child is itchy) • AVOID aspirin- Reye syndrome • Maintain precautions until lesions have crusted 2. Erythema Infectiosum (Fifth Disease): - Rash appears in three stages: - After rash, no longer contagious - Antipyretics, analgesics, anti-inflammatory drugs; possible blood transfusion for transient aplastic anemia (isolation not needed un- less parvovirus suspected- then droplet) 3. Exanthum Subitum (Roseola Infantum): (standard) - Clinical Manifestations: • Persistent high fever (3-7 days) • bulging fontanel • rash- discrete rose-pink macules or maculopapules appearing first on trunk, then spreading to neck, face, and extremities; non- pruritic; blanches; lasts 1 to 2 days - Nonspecific Antipyretics - Monitor for seizures 4. Mumps: (droplet/contact/isolation) - Clinical Manifestations: • Fever, headache, malaise, anorexia 24 hours, followed by “ear- ache” that is aggravated by chewing - Maintain isolation during periods of communicability, institute droplet and contact precautions during hospitalization, encourage rest and decreased activity; analgesics for pain; apply hot or cold compresses 5. Measles (Rubeola): (isolation/airborne) - Manifestations: - stage - Antibiotics, maintain isolation until 5th day, encourage rest, an- tipyretics, dim lights, clean eyelids with warm water to remove se- cretions, cool-mist vaporizer, fluids, soft/bland foods 6. Pertussis (Whooping Cough): (isolation/standard/droplet) - Manifestations: • URTI (early/beginning), sneezing, lacrimation, cough (prolonged up to 10 wks), low grade fever, “whoop” during cough - Antimicrobial therapy, increased oxygen intake and humidity, flu- ids, isolation, nasopharyngeal culture, oral fluids, monitor for s/s of airway obstruction 7. Rubella (German Measles): (droplet) 8. Scarlet Fever: (standard/droplet) - Manifestations: • White to red strawberry tongue, abrupt high fever, pulse in- creased out of proportion to fever, rash- but not on face and worse in skin folds - Penicillin (full course), standard and droplet precautions for first 24 hours after initiation of treatment, encourage rest, fluids >>>Nursing Assessment in Identification of an Infection: • recent exposure to infectious agents • prodromal symptoms • immunization Hx • Hx of having disease >>>Nursing Care of Pt. with Communicable Disease: • isolation precautions • provide comfort • support family - Bacterial Skin Infections: impetigo contagiosa, cellulitis, management - Impetigo Contagiosa: (by staph) • Severity varies with skin integrity & immune and cellular de- fenses - Cellulitis: (by strep, staph, Haemophilus Influenzae) • Inflammation of skin and subcut tissues with intense redness, >>>Nursing Management: relief of pain, prevention of spread, and ensure hydration - Viral Skin Infections: verruca (warts), management - Verruca (warts) (HPV): • Manifestations: gray or brown, elevated, firm papule with rough- ened texture, single or multiple, asymptomatic - occur anywhere, but usually appear on exposed areas, such as fingers, hands, face, and soles • Management: Not uniformly successful; Local destructive ther- apy, individualized according to location, type, and number—sur- gical removal, electrocautery, curettage, cryotherapy (liquid ni- trogen), caustic solutions (lactic acid and salicylic acid in flexible collodion, retinoic acid, salicylic acid plasters), laser ablation • Common in children; Tend to disappear spontaneously; Course unpredictable; Most destructive techniques tend to leave scars; Autoinoculable; Repeated irritation will cause to enlarge>>get vaccinated early/before sexually active - Fungal Infections: tinea (capitus, corporis, pedis), candidiasis (moniliasis) - Dermatophytosis- fungal infections (ringworm) - >>Person-to-person or animal-to-person - >>Because of the infectious nature of the disease, affected chil- dren should not exchange grooming items, headgear, scarves, or other articles of clothing<< - Tinea Capitus: • lesions in scalp, scaly areas of alopecia, pruritic (scaly patches) • Tx: oral, shampoo used 2 x wk • Tx: Oral griseofulvin; Local application of antifungal preparation, such as tolnaftate, naftifine, miconazole, terbinafine, clotrimazole; applied 2.5 cm (1 inch) beyond periphery of lesion; application con- tinued 1 to 2 weeks after no sign of lesion - Tinea Pedis (athlete’s foot): • between toes or on plantar surface of feet • lesions vary: maceration and fissuring between toes, pinhead vesi- cles on plantar surface • common in adolescents and adults, rare in children; incidence with plastic shoes • Tx: topical, oral if severe; compresses or soaks with Burrow’s solu- tion, eliminate heat/perspiration by use of clean, light socks, venti- lated shoes - Candidiasis (moniliasis): • Tx: oral Nystatin; Fluconazole or Itraconazole antifungals - Pediculosis Capitis: management, preventing the spread of recurrence • Head lice, common in school-age children • Manifestations: itching, observation of white eggs attached to hair shafts confirms diagnosis • Management: - DO NOT share combs, hair ornaments, hats, caps, coats, and other items worn near the hair • PREVENT the Spread: do not share above items, machine wash all clothing/towels/linens, thoroughly vacuum carpets/car seats/stuffed animals/etc., seal non-washable items in plastic bags for 14 days, soak combs/brushes/etc. in lice-killing solution for one hour or boiling water for ten minutes, avoid physical contact with infected persons and belongings, inspect children in group settings on regular basis Ch. 9 - Infant Growth and Development, Table 9-1, pg. 302-306, gross and fine motor: see charts… • Growth occurs in spurts: - wt. gain 5-7 oz/wk - double birth wt by 6 mo - triple birth wt by 1 yr - height increases an inch/mo for 6 mo - double length by 1 yr - Gross Motor Development: • 2 mo- head lag • 4 mo- head control • 5-6 mo- parachute reflex • 7 mo- sit alone • 10 mo- move from prone to sitting • 11-12 mo- infant who does not pull to a standing position should be further evaluated for poss. hip dysplasia - Fine Motor Development: • 2-3 mo- grasping occurs as reflex and becomes gradually volun- tary • 6 mo- Palmar grasp using whole hand • 7 mo- transfer objects between hands • 10 mo- Pincer grasp using thumb and forefinger • 11 mo- remove objects from container • 12 mo- build tower of two blocks - Separation Anxiety: • develops between ages 4 and 8 months and is manifested through a predictable sequence of behaviors. Infants protest the physical separation from the mother through crying - Play Activities to include kinetic, tactile, visual, and auditory stimulation: - The activity of infants is primarily narcissistic and revolves around their own bodies. - Discriminate mother from other ind. & achieve object permanence. • 3 to 6 mo- infants show more discriminate interest in stimuli and begin to play alone with rattles or soft stuffed toys or with some- one else. More interaction during play. • 4 mo- infants laugh aloud, show preference for certain toys, and become excited when food or a favorite object is brought to them. They recognize images in a mirror, smile at them, and vo- calize to them. • 6 mo-1 yr- play involves sensorimotor skills. Games such as peek-a-boo and pat-a-cake are played. Verbal repetition and imi- tation of simple gestures occur in response to demonstration. Play is much more selective, not only in terms of specific toys, but also in terms of “playmates.” Although play is solitary or one sided, infants choose with whom they will interact. • 12 mo- they call their parents by name. - >>Play must provide interpersonal contact and recreational and educational stimulation. Infants need to be played with, not merely allowed to play . - Nutrition in first year and administration of iron supplements, vitamin D, and fluoride: • Breast milk is the most desirable food for the infant during the first 6 months. • Iron Supplements: - Iron-fortified rice cereal is recommended as the first solid food. • Vit. D: - recommended daily supplement of 400 iu, beginning in first few days of life to prevent Rickets and Vit. D defi- ciency - reports of accidental OD of liquid Vit. D in infants caused by packaging errors • Fluoride: - fluoride is an essential mineral for building caries-resistant - fluoride supplementation may be necessary if infant’s wa- ter supply does not contain adequate fluoride content • Whole milk is not recommended until after 12 months!! • No need for additional fluids in first 4-6 mo. • Honey should be avoided in the first 12 months because of the risk of infant botulism. Ch. 10 - Cow’s Milk Allergy, therapeutic and nursing care management: • a multifaceted disorder representing adverse systemic and local GI reactions to cow’s milk protein • allergy may be manifested within the first 4 months of life through a variety of signs and symptoms that may appear within 45 minutes of milk ingestion or after several days - GI manifestations: • Diarrhea, vomiting, colic, wheezing, gastroesophageal reflux, blood streaked mucous/loose stools - Respiratory manifestations: • Rhinitis, bronchitis, asthma, sneezing, coughing, chronic nasal discharge - Cutaneous: • Urticaria (hives), atopic dermatitis - Systemic: • Anaphylaxis - Diagnostic Eval: • Stool analysis for occult blood, Eosinophils, Leukocytes; serum IgE levels, skin-prick or scratch testing, challenge testing - Treatment of CMA: is elimination of cow's milk–based formula and all other dairy products. • this primarily involves changing the formula to a casein hy- drolysate milk formula (Pregestimil, Nutramigen, or Alimentum) in which the protein has been broken down into its amino acids through enzymatic hydrolysis. • approximately 50% of infants who are sensitive to cow's milk protein also demonstrate sensitivity to soy • . - Nursing Care Management: • principal nursing objectives are identification of potential CMA and appropriate counseling of parents regarding substitute for- mulas. • reassure parents that sub. formulas contain complete amounts of nutrients • educate parents about avoiding dairy products when introducing new foods- some foods labeled dairy free still contain cow’s milk protein - >>Food Sensitivity: IgE mediated immune response (cow’s milk al- lergy) - >>Food Intolerance: Non-IgE mediated immune response (lactose in- tolerance) - Failure to thrive, nursing care management: • FTT, or growth failure, is a sign of inadequate growth resulting - Nursing Management: • *primary management aimed at revering the cause of growth failure, therefore assess the family, child, and environment • provide sufficient calories to support “catch up” growth • behavior modification aimed at mealtime rituals, family social time • 24 kcal/oz formulas (infants) may be provided to increase caloric intake; 1-6 yrs 30kcal/oz - Atopic Dermatitis (eczema), therapeutic and nursing care management • Eczema or eczematous inflammation of the skin (pruritic) • usually begins during infancy and is associated with an allergic contact dermatitis with a hereditary tendency ( atopy ) • AD manifests in three forms based on the child's age and the dis- tribution of lesions: - Infantile (infantile eczema): Usually begins at 2 to 6 months of age; generally undergoes spontaneous remission by 3 years of age - Management: • Hydrate skin, relieve pruritus, prevent and minimize flareups or inflammation, and prevent and control secondary infections • Tepid bath with mild soap, Colloid bath (cornstarch in water), prevent drying after bathing • Oral Antihistamines, Antibiotics • * Fingernails and toenails are cut short and kept clean, filed fre- quently - Colic, therapeutic and nursing care management • abdominal pain or cramping that is manifested by loud crying and drawing the legs up to the abdomen, symptoms increase in late afternoon, younger than 3 mo. • Defined by the rule of 3’s: - crying or fussing for more than 3 hrs a day - occurring more than 3 days a week - for more than 3 weeks in a healthy infant - Management: • sedatives, antispasmodics, antihistamines, antiflatulents (some- times) • oral admin of Lactobacillus Reuteri: decrease crying • Simethicone may help decrease symptoms; dietary changes, cor- harm - SIDS, management • the sudden death of an infant younger than 1 year of age that re- mains unexplained after a complete postmortem examination, including an investigation of the death scene and a review of the case history • SIDS is the leading cause of postneonatal deaths (1 month to 12 months) - Risk Factors: • prone sleeping position, soft bedding, sleeping in a noninfant bed with an adult or older child, and maternal prenatal smoking. • LBW/preterm infants, low APGAR, recent viral illness, siblings of two or more SIDS victims, male gender, infants of American In- dian or African-American ethnicity • pacifier use at bedtime and naptime; updated childhood immu- nizations Ch. 11 - Egocentrism: • Inability to envision situations from perspectives other than one's own • 2-4 yrs; Piaget’s Preoperational stage - Example: If a person is positioned between the toddler and an- other child, the toddler (who is facing the person) will explain that both children can see the middle person's face. The young child is unable to realize that the other person views the middle person from a different perspective, the back. - Implication: Avoid moralizing about “why” something is wrong if it requires an understanding of someone else's feelings or opinion. Telling a child to stop hitting because hitting hurts the other person is often ineffective because, to the aggressor, it feels good to hit someone else. Instead, emphasize that hitting is not allowed. - Play for Toddlers: • The solitary play of infancy progresses to parallel play—the tod- dler plays alongside, not with, other children. (imitation allows them to engage in fantasy-pretending to be a firefighter); tactile play, educational toys and books - Toddler growth and development, Table 11-1, pg. 361-362, gross and fine motor: - Locomotion is the major gross motor skill acquired during toddler- hood, followed by increased eye-hand coordination. • walks by 12 mo • runs by 18 mo • climbs stairs by 2 yrs - 15 months: • Gross: walks without help (usually since 13 months old); creeps up stairs; kneels without support; cannot walk around corners or stop suddenly without losing balance without support; cannot throw ball without falling • Fine: constantly casting objects to floor; builds tower of two cubes; holds two cubes in one hand; releases a pellet into nar- row-necked bottle; scribbles spontaneously; uses cup well but of- ten rotates spoon before it reaches mouth - 18 months: • Gross: runs clumsily; falls often; walks up stairs with one hand held; pulls and pushes toys; jumps in place with both feet; seats self on chair; throws ball overhand without falling • Fine: builds tower of three or four cubes; release, prehension, and reach well developed; turns two or three pages in a book at a - 24 months: • Fine: builds tower of six or seven cubes; aligns two or more cubes like a train; turns pages of book one at a time; in drawing, imitates vertical and circular strokes; turns doorknobs; unscrews lids - 30 months: • Gross: jumps with both feet; jumps from chair or step; stands on one foot momentarily; takes a few steps on tiptoe • Fine: builds tower of eight cubes; adds chimney to train of cubes; good hand–finger coordination; holds crayon with fingers rather than fist; in drawing, imitates vertical and horizontal strokes; makes two or more strokes for cross; draws circles - Temper tantrums, negativism, and regression: - Temper Tantrums: • nearly universal during toddlerhood • abnormal tantrums: occur past 5 yrs old, last longer than 15 min., or occur more than 5 times per day - Negativism: • not an expression of being stubborn or insolent, but a necessary assertion of self-control. - Regression: • usually occurs in instances of discomfort or stress when one at- tempts to conserve psychic energy by reverting to patterns of behavior that were successful in earlier stages of development • * when regression does occur, best approach is to ignore it while praising existing patterns of appropriate behaviors Ch. 12 - Cognitive Development in preschoolers and concept of time, magical think- ing: • According to Erikson, acquiring a sense of initiative is the chief psychosocial task of the preschooler. Development of the superego occurs during this period, and conscience begins to emerge. • According to Kohlberg, these children are in the stage of naive instrumental orientation, in which they are concerned with satis- fying their own needs and, less frequently, the needs of others. • Preschoolers are generally unable to understand why something is acceptable or unacceptable. They are aware of appropriate be- havior primarily through punishment or reward and rely almost completely on parental principles for developing their own moral judgment. Verbal enforcement of limits is more effective in preschoolers than with toddlers. - Magical Thinking: because of their egocentrism and transductive rea- soning, preschoolers believe that thoughts are all powerful. Such think- ing places them in the vulnerable position of feeling guilty and respon- sible for bad thoughts that may coincide with the occurrence of a wished event. • time is best explained in relationship to an event, such as “Your mother will visit you after you finish your lunch.” • avoiding words such as yesterday, tomorrow, next week, or Tuesday to express when an event is expected to occur and in- stead associating time with expected daily events help children learn about temporal relationships while increasing their trust in others' predictions. - Fears, stress, and aggression in preschoolers: - Fears: • Animism: ascribing life-like qualities to inanimate objects • fear of the dark, being left alone (especially at bedtime), animals (particularly large dogs), ghosts, sexual matters (castration), and objects or persons associated with pain - Tx: Desensitization: type of conditioning that involves exposing children to feared object in a safe situation - Stress: • effective coping skills, ex- cessive stress is harmful • young children are especially vulnerable because of their limited capacity to cope (prepare child for upcoming changes to maxi- mize coping strategies) • expression of frustration, fear, or anxiety is hampered by inade- quate expressive language - Tx: **Prevention is the best approach to deal with stress. - Aggression: • refers to behavior that attempts to hurt a person or destroy prop- erty • aggression is influenced by a complex set of biological, sociocul- tural, and familial factors • preschool aggression may result from frustration, modeling be- havior, and reinforcement (gender increases risk) • Negative reinforcement: still draws attention to behavior Ch. 13 - Poison Ivy, therapeutic and nursing care management, prevention • three poisonous plants (ivy, oak, and sumac) • produces localized, streaked or spotty, inflamed, oozing, and painful impetiginous lesions that are often highly urticarial • the offending substance in these plants is an oil and urushiol that is extremely potent - Management: • application of calamine lotion, soothing Burrow solution com- presses, and/or Aveeno baths to relieve discomfort • Topical Corticosteroid gels - Burns, therapeutic and nursing care management • when categorized according to patient’s age and type of injury: - hot water scalds most common in toddlers - flame related burns more common in older children - children playing with lighters or matches account for 1/10 house fires - non-accidental burns indicate maltreatment - TBSA (total body surface area): measures the extent of a burn ex- pressed as a percentage - Superficial (first degree) burns: - Partial-thickness (second-degree) burns: • epidermis and varying degrees of the dermal layer, blistering occurs, possible edema, painful, moist, pink/red/ waxy white areas, heals in 14-21 days; sweat glands and hair follicles re- main intact • involve the entire epidermis and dermis and extend into sub- • *full thickness wounds are not capable of re-epithelialization, and require surgical excision and grafting to close the wound - Fourth-degree burns are full-thickness burns: • involve underlying structures, such as muscle, fascia, and bone, color variable, charring visible in deepest areas; auto- graphing (required for healing) or amputation (possibility) • the wound appears dull and dry, and ligaments, tendons, and bones may be exposed - **With all Full thickness burns/wounds: • causes increased capillary permiability, allowing plasma pro- teins, fluids, and electrolytes to be lost • edema, hypovolemia, kidney failure/AKI, hemoconcentration • GI Ulcers • increased CO -> stroke volume x heart rate • electrolyte imbalances: sodium and potassium>>too much potassium and too little sodium • hypoglycemia • anemia and decreased hemoglobin - Burn-related injuries include inhalation injury and wound sepsis. - Inhalation injury: • burns of the face and lips, singed nasal hairs, and laryngeal edema • upper airway obstruction is often associated with burn shock and fluid resuscitation - Pathophysiology: • Another systemic response is anemia, caused by direct heat destruction of RBCs, hemolysis of injured RBCs, and trapping of RBCs in the microvascular thrombi of damaged cells - Nursing Interventions: • include fluid replacement therapy, nutrition, medication, burn wound management, comfort measures, prevention of complica- tions, scar management, and prevention. • Psychosocial support of the burn victim focuses on fostering in- dependence and autonomy • ***Primary concerns for major burns: - Airway - Fluid: compensate for water and sodium lost to traumatized ar- eas and interstitial space; re-establish sodium balance; restore circulating volume; provide adequate perfusion; correct acido- - Nutrition: hypoglycemia can result, high protein and high calo- rie diet, may require supplementation with tube feedings in children - Infection - *Morphine Sulfate is drug of choice for severe burn injuries - Minor burns: - Major burns: • stop burning process, smother fire, place victim in horizontal position, remove burned clothing or jewelry, assess for ade- quate airway and breathing, if not breathing begin mouth-to- mouth, cover burn with clean cloth, keep victim warm, begin IV and O2 therapy as prescribed, transport to medical aid - Management during Acute Phase (first 24-48 hrs): • Primary concerns: Shock and Airway! • Monitor VS, output, fluid infusions, and respiratory parameters • IV infusion begun immediately and is regulated to maintain a uri- nary output of at least 1-2 mL/kg in children weighing less than 30 kg, and an output of 30-50 mL/hr in children weighing more than 30kg • evaluate burned extremity and check pulse every hour - Management and Rehabilitation Phase: • *Infection Prevention (close burn as quick as possible) • In pediatric burn patient, a decreased LOC, increased restless- ness, and lethargy are some of the first signs of overwhelming sepsis and may indicate inadequate hydration. - Ingestion of injurious agents to include gastric decontamination - The most frequently ingested poisons include cosmetics and personal care products, such as perfume, cologne, or aftershave; medications (acetaminophen, acetylsalicyclic acid, ibuprofen, opioids); - Emergency Treatment: • CALL Poison Control BEFORE initiating any treatment • Assess victim: initiate CPR if needed, assess mental status, take vitals, evaluate for concomitant trauma • Terminate exposure: empty mouth of pills or other material, flush any body surface exposed, remove contaminated clothing, bring inhalation victim into fresh air • Identify poison: question victim and witness, observe circum- stances surrounding poisoning, look for environmental clues, call poison control center • Prevent poison absorption: prevent aspiration by placing the child in side-lying, sitting, or kneeling position with the head be- low the chest • only for use after careful evaluation of the potential toxicity of the poison and the risks versus benefits • GID (e.g. ipecac, activated charcoal, and gastric lavage) • Activated charcoal: (common form of GID used) an odorless, tasteless, fine black powder that absorbs many compounds, cre- ating a stable complex • may be considered in the following situations: - Child may have ingested large amounts of carbamazepine, dapsone, phenobarbital, quinine, or theophylline. - Time to activated charcoal administration is within 1 hour after the poison ingestion. - Child has an intact or protected airway. • Gastric lavage may be performed to empty the stomach of the toxic agent; however, this procedure is associated with serious complications (gastrointestinal perforation, hypoxia, aspiration), and it is no longer recommended in all cases of ingestion. - Selected poisonings in children, Box 13-2, pg. 411-412, clinical manifesta- tions and treatment - Selected Poisonings in Children - Corrosives: (Strong Acids or Alkalis) Drain, toilet, and oven cleaners Electric dishwasher detergent (liquid because of higher pH, is more hazardous than granular) Mildew remover Batteries Clinitest tablets Denture cleaners Bleach tongue, and pharynx (respiratory obstruction) Coughing, hemoptysis Drooling and inability to clear secretions Signs of shock Anxiety and agitation • Comments: Household bleach is a frequently ingested corrosive but rarely causes serious damage. Liquid corrosives are easily ingested and cause more damage than granular/solid preparations. Liquids may also be aspirated, causing upper airway injury. Solid products tend to stick to and burn tissues, causing localized damage. • Treatment: Inducing emesis is contraindicated (vomiting re-damages the mucosa). Contact the PCC immediately. If the PCC or medical ad- vice and treatment not immediately available, it may be appropriate to dilute corrosive with water or milk (usually ≤120 ml [4 oz]). Do not - Hydrocarbons: Gasoline Kerosene Lamp oil Mineral seal oil (found in furniture polish) Lighter fluid Turpentine Paint thinner and remover (some types) • Clinical Manifestations: Gagging, choking, and coughing Burning throat and stomach Nausea Vomiting Alterations in sensorium, such as lethargy Weakness Respiratory symptoms of pulmonary involve- ment • Tachypnea • Cyanosis • Retractions • Grunting • Comments: Immediate danger is aspiration (even small amounts can cause bronchitis and chemical pneumonia). Gasoline, kerosene, lighter fluid, mineral seal oil, and turpentine cause severe pneumo- nia. • Treatment: Inducing emesis is generally contraindicated. Gastric de- contamination and emptying are questionable even when the hydro- carbon contains a heavy metal or pesticide; if gastric lavage must be - Acetaminophen • Clinical Manifestations: Occurs in four stages post ingestion: 1. 0 to 24 hours • Nausea • Vomiting • Sweating • Pallor 2. 24 to 72 hours • Patient improves • May have right upper quadrant abdominal pain 3. 72 to 96 hours • Pain in right upper quadrant • Jaundice • Vomiting • Confusion • Stupor • Coagulation abnormalities • Sometimes renal failure, pancreatitis 4. More than 5 days • Resolution of hepatoxicity or progress to multiple organ failure • May be fatal • Treatment: Antidote N-acetylcysteine (Mucomyst) is equally effective given intravenously or orally. When given orally may first be diluted in fruit juice or soda because of the antidote's offensive odor. An - Aspirin (Acetylsalicylic Acid) • Clinical Manifestations: Acute poisoning (early symptoms): • Nausea • Hyperventilation • Vomiting • Tinnitus Acute poisoning (later symp- toms): • Hyperactivity • Fever • Confusion • Seizures • Renal failure • Comments: May be caused by acute ingestion (severe toxicity occurs with 300 to 500 mg/kg). May be caused by chronic ingestion (i.e., >100 mg/kg/day for ≥2 days); can be more serious than acute inges- tion. Time to peak serum salicylate level can vary with enteric aspirin or the presence of concretions (bezoars). • Treatment: Hospitalization is necessary for severe toxicity. Activated charcoal is given as soon as possible (unless contraindicated by al- tered mental status). If bowel sounds are present, may be repeated every 4 hours until charcoal appears in the stool. Lavage will not re- Administer anticonvulsants if seizures present. Provide oxygen and ventilation for respiratory depression. Administer vitamin K for bleed- ing. In severe cases, hemodialysis (not peritoneal dialysis) is used. - Iron Mineral supplement or vitamin containing iron • Clinical Manifestations: Occurs in five stages (may have significant variation in symptoms and their progression): 1. Within 6 hours (if child does not develop gastrointestinal symptoms in 6 hours, toxicity is unlikely) • Vomiting • Hematemesis • Diarrhea • Hematochezia (bloody stools) • Abdominal pain • Severe toxicity may have tachyp- nea, tachycardia, hypotension, coma 2. Latency period—up to 24 hours of apparent improvement 3. 12 to 24 containers • Lack of parental awareness of iron toxicity • Resem- blance of iron tablets to candy (e.g., M&Ms) Toxic dose is based on the amount of elemental iron ingested. Common preparations in- • Treatment: Hospitalization is required when more than mild gas- troenteritis is present. Use whole bowel irrigation if radiopaque tablets are visible on abdominal x-ray; may need to be given via na- sogastric tube. Emesis empties the stomach more effectively than lavage. Activated charcoal does not absorb iron. Chelation therapy with deferoxamine should be used in severe intoxication (may turn urine red to orange). If IV deferoxamine is given too rapidly, hypoten- - Plants Poisonous plants listed in Box 13-1 • Clinical Manifestations: Depends on type of plant ingested. May cause local irritation of oropharynx and entire gastrointestinal tract. May cause respiratory, renal, and central nervous system symptoms. Topical contact with plants can cause dermatitis. • Comments: Plants are some of the most frequently ingested sub- stances. They rarely cause serious problems, although some plant in- gestions can be fatal. Plants can also cause choking and allergic re- actions. • Treatment: Wash from skin or eyes. Provide supportive care as needed. ASA, Acetylsalicylic acid; IV, intravenous; PCC, poison con- trol center. - Nursing care guidelines for poison prevention, pg. 414 • answered above - Lead poisoning to include risk factors, chelation therapy and nursing care management, and Community focus: Reducing blood lead levels, pg. 418 - The most important factor contributing to lead poisoning is its avail- ability in the child’s environment. - >>> Lead-based paint is the most toxic source of lead. A child does not need to eat loose paint chips to be exposed to the toxin; normal hand-to-mouth behavior, coupled with the presence of lead dust in the environment that has settled over the decades, is the usual method of poisoning. - Risk Factors: • living in homes before 1978 • poverty • urban areas • immigrant • unable to renovate home/update paint • lead paint • folk remedies for stomach aches • cosmetics/artistic paint • pottery/dishes containing lead - Chelation Therapy: • Chelation is the term used for removing lead from circulating • ), British antilewisite (BAL; dimercaprol, dimer- captopropanol), and Meso-2,3-dimercaptosuccinic acid (DMSA, Chemet, Succimer) • BAL (dimercaprol, dimercaptopropanol) is used in conjunction with EDTA with high lead levels or the presence of lead en- cephalopathy; contraindications for BAL are peanut allergies, he- patic insufficiency, in conjunction with iron. • Renal, hepatic, and hematologic parameters should be moni- tored. (hard on kidneys, monitor urinary output) - >> The neurologic system (CNS) is of most concern when young of cognitive and behavioral problems in young children, including aggression, hyperactivity, impulsivity, delin- quency, disinterest, and withdrawal. - >> Lead Encephalopathy: permanent brain damage can result in cognitive impairment, behavioral changes, possible paralysis, and seizures. - Nursing Management: • education about prevention: identifying sources of lead and de- tailed Hx from pt/family - Nursing care of the maltreated child, caregiver-child interaction, history and interview - physical abuse or neglect, emotional abuse or neglect, or sexual abuse - Child neglect is the most common form of maltreatment. Physical ne- glect involves the deprivation of necessities, such as food, clothing, shelter, supervision, medical care, and education. Emotional neglect generally refers to failure to meet the child’s needs for affection, atten- tion, and emotional nurturance. - The deliberate infliction of physical injury on a child, usually by • Parental characteristics: young parents, single parents, families with little social support, low socioeconomic status, undereduca- tion, low self-esteem, substance abuse, and lack of knowledge of parenting skills • Child characteristics: include preterm infants, disabled children, hyperactive, and children under the age of 3 years (NB-1 yr.) • Environmental characteristics: social isolation, poor support sys- tems, chronic stress, poverty, substitute care givers - The reported incidence of sexual abuse has increased in the past decade. Common forms are incest, molestation, rape, exhibitionism, child pornography, child prostitution, and pedophilia. Most sexual abuse is committed by men and by persons known to the child, with family members constituting up to two thirds of the perpetrators. - Nursing Management: • • >>>Once abuse is identified, it is important to **remove the child from the situation or environment to prevent further injury. • Provide a private place to talk, do not promise not to tell, do not express shock or criticize family, use their vocabulary to discuss body parts, reassure them that they have done the right thing by telling, reassure that the abuse is not their fault, determine im- mediate need for safety. Ch. 19 - Separation Anxiety, stages pertaining to separation anxiety, Box 19-1, pg. 555 • Manifestations of Separation Anxiety in Young Children - Stage of Protest • Behaviors observed during later infancy include: • Cries • Screams • Searches for parent with eyes • Clings to parent • Avoids and rejects contact with strangers • Additional behaviors observed during toddlerhood include: • Ver- bally attacks strangers (e.g., “Go away”) • Physically attacks strangers (e.g., kicks, bites, hits, pinches) • Attempts to escape to find parent • Attempts to physically force parent to stay • Behaviors may last from hours to days. Protest, such as crying, may be continuous, ceasing only with physical exhaustion. Ap- proach of stranger may precipitate increased protest. - Stage of Despair • Observed behaviors include: • Is inactive • Withdraws from oth- ers • Is depressed, sad • Lacks interest in environment • Is un- communicative • Regresses to earlier behavior (e.g., thumb sucking, bedwetting, use of pacifier, use of bottle) • Behaviors may last for variable length of time. Child's physical condition may deteriorate from refusal to eat, drink, or move. - Stage of Detachment • Observed behaviors include: • Shows increased interest in sur- roundings • Interacts with strangers or familiar caregivers • Forms new but superficial relationships • Appears happy • Detachment usually occurs after prolonged separation from par- ent; it is rarely seen in hospitalized children. Behaviors represent a superficial adjustment to loss. - >>Primary Nursing goal is to prevent separation!! - Minimizing loss of control • caused by unfamiliar environmental stimuli, physical restriction, al- tered routine, and dependency • lack of control increases perception of threat and can affect chil- dren’s coping skills - Isolation of hospitalized child - Admission to an isolation room increases all of the stressors typically associated with hospitalization. - further separation from familiar persons; additional loss of control; and added environmental changes, such as sensory deprivation and the strange appearance of visitors - Limited understanding of isolation: • Preschool children have difficulty understanding the rationale for isolation, because they cannot comprehend the cause-and-effect relationship between germs and illness. They are likely to view isolation as punishment. • Older children understand the causality better but still require in- formation to decrease fantasizing or misinterpretation. When a child is placed in isolation, preparation is essential for the child to feel in control. • With young children, the best approach is a simple explanation, such as “You need to be in this room to help you get better. This is a special place to make all the germs go away. The germs made you sick, and you could not help that.” - Preparation is Key: • show the mask, gloves, and gown and encourage to “dress up” in them>>playing with the strange apparel lessens the fear of seeing “ghostlike” people walk into the room. • all health care members in child’s care should introduce self and let the child see their faces before donning masks. • When the child's condition improves, appropriate play activities are provided to minimize boredom, stimulate the senses, provide a real or perceived sense of movement, orient the child to time and place, provide social interaction, and reduce depersonaliza- tion. - Opening window shades; providing musical, visual, or tac- tile toys; and increasing interpersonal contact can substi- tute mental mobility for the limitations of physical move- ment. - >>>A primary goal of nursing care for the child who is hospitalized is to minimize threats to the child’s development. Children who experi- ence prolonged or repeated hospitalization are at greater risk for de- velopmental delay or regression. The nurse who provides opportunities for the child to participate in developmentally appropriate activities further normalizes the child’s environment and helps reduce interfer- ence with the child’s ongoing development. [Show More]
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