Peds Lecture 3, Exam 1 January 21, 28, 2013
Physical assessment of children Vital Signs Know the norms per ae for P, !!, "P infants hiher hr, #p, rr$ %ant to count for a min$ &' (') )*KE +)*L- '.. )/E '()'! !! count 1 minute *uscultation +-$ +isual *pical pulse count 1 minute$ *#dominal #reathers til f cryin, chart that$ !adial pulse not accurate measure until after ae 2$ )emperature !ectal, 'ral, *xillary -ometimes rectal contraindicated 4less than 1 month, #leedin concerns, etc$5 !ectal is the clinical 6old -tandard when in dou#t )emperature rane 4eneral5 37$3$7 %e do a lot of axillary$ !ectal is old standard if in dou#t$ %e don9t routinely do it "P may use upper arm, lower le, upper le Hypertension in Children • • •
• •
HTN now affects up to 5% of all children. May be due to the increase in childhood obesity. Obese children are at a 3X higher risk of becoming hypertensive when compared to non obese children. In young children, HTN is more often secondary to an underlying pathological process. Make sure the BP cuff is the appropriate size
Screening for Hypertension • • • • • • •
All children 3 years of age and older should be screened at all health care encounters. 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 Transplant or malignancy Meds associated with HTN side effects.
Treating Children for Hypertension -tae 1 Lifestyle chanes • •
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. Whole family must adhere to lifestyle change.
-tae 2 *ntihypertensi:e 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.
Physical Assessment of Children (euroloical • • •
Fontanels Posterior-2/ Posterior-2/3 3 months, Anterior- 18 mos. Can indicate dehydration or ICP Level of consciousness How much effort does it take to stimulate the child Following commands
Peds Lecture 3, Exam 1 January 21, 28, 2013 • • •
Motor milestones- Head control by 3 mos Cognitive and Social development Response to environment
Infant reflexes…when do they disappear? oro, tonicnec;, rootin, rasp, #a#ins;i, corneal, etc$ 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 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 Sucking – Reflex persists through infancy. Weak or absent reflex indicates developmental delay or neurological abnormality Startle – Absence may indicate hearing impairment
Assessment of !C Assessment of Pain Assessment of "e#elopment • • • • •
On-going as child grows Assessed often with well child visits Need to know the norms or major milestones to assess development Use Erikson for comparison Psychosocial and cognitive level
Standardi$ed tests • •
Many to choose from. Denver is broad screening tool used often. Use specific ones for concerns (ie M-CHAT (Modified Checklist for Autism in Toddlers)
month old child who is in the hospital? *$ )emp, !!, %eiht, /!, "P "$ %eiht, !!, /!, )emp, "P @$ /!, !!, )emp, "P, %eiht &$ )emp, %eiht, "P, /!, !! Assessment of %rowth easurement of 6rowth is central to e:aluatin health status *ll plotted on rowth charts • • •
Height/length and weight On all visits Use centimeters and kilograms
/ead circumference *t the top of the eye#rows, the pinnia of the earAA )E-) ? • •
Up to 36 months The abdominal circumference, place a small mark at the same place. Check for ascites, abdominal distension, blockage, malabsorbtion
Peds Lecture 3, Exam 1 January 21, 28, 2013 &ody 'ass Index • • • • •
BMI is the best indicator of a healthy weight. Length for Height not as accurate BMI = kg/m-squared. Use decimals for fractions of pounds and inches Considered overweight if BMI is at or exceeds 85%
&'I ()estion *n 8 year old #oy weihs 27 ; and is 128 cm tall$ %hat is his "? *$ 0$20 "$ 18$0 @$ 0$7 &$ 1$> &'I example *This will +e on the exam, "o not need cm-.in * B year old #oy weihs 33 l#s B oC and is 3 D8 inches tall B di:ided #y 17 0$2 l# F33$2 l#s 33$2 di:ided #y 2$2 F 1$1 ; di:ided #y 8 0$72, F3$72 inches 3$72 G 2$B F >$7 cm " F 17$ /is " is at the H mar; I how would you explain this to his parents? %rowth Chart .or Practice Plot the followin on the rowth chart at the #ac; of your text#oo;$ "oy months old Lenth 7 cms %eiht 8$2 ; '.@ B cm %t for Lenth Approximate %rowth Rate )he first year has rapid rowth$ 6rowth slows the second year of life$ • • • •
Infants: Approximately 1 ½ lbs. per month for first 5 months. Birth Weight doubles at 5-6 months Infants: Approximately ¾ lb. per month during second half of infancy Birth weight triples by 12 months
Childhood !+esity '#esity has tripled in *merican children since 1>80$ >$H of infants and toddlers and a#out 1H of children and adolescents 'den, @$ L$ 420105$ /ih " remains steady in $ -$ children, adolescents$ JAMA, 303, pp$ 2B22B>$ @hildren at or a#o:e " >H are o#ese @hildren #etween 8>BH are o:erweiht )hose with " 8 th H should also #e screened for other comor#idities
Peds Lecture 3, Exam 1 January 21, 28, 2013
.ennoy, $ 420085$ @hildhood '#esity, Part %eiht E:aluation an d@omor#idity -creenin$ @onsultant for Pediatricians$ &ecem#er$ 0 11$ @hildren should #e manaed for weiht as early as ae 2
Childhood !+esity/ Comor+idities *sthma '#structi:e -leep *pnea /)( )ype 2 &ia#etes th .astin #lood suar for children 10 years or older if " 8 H with .amily history of )ype &ia#etes !ace or ethnicity associated with an increased ris; of dia#etes @linical features of insulin resistance /yperlipidemia .astin lipid profile Childhood !+esity/ *ssessment o o o o
Measure and determine BMI Skin fold thickness and waist circumference has not shown evidence of usefulness Obtain diet history and activity history Obtain family and past medical history
-chuman, *$ J$ 420085$ *n o#esity action plan$ @ontemporary Pediatrics 24B5, 31 Childhood !+esity/ Pre#ention @ounsel non o#ese patients to esta#lish weiht friendly and healthy lifestyle "reast feed first 7 months and continue for at least the first year$ .i:e or more fruits and :eies a day Limit suar sweetened #e:eraes Prepare more meals at home Eat at the ta#le as a family 7 times a wee; with )+ off$ /ealthy #rea;fast e:ery day n:ol:e the whole family in lifestyle chanes Parents should a:oid o:erly restricted feedin #eha:iors$ &iet rich in calcium Childhood !+esity/ )reatment • • •
Weight management programs that involve the family and include frequent visits to the PCP. Physical activity recommendations Dietary instruction.
edications (o weiht loss meds are appro:ed for use in children youner than 12 years$
Peds Lecture 3, Exam 1 January 21, 28, 2013 -urery nder in:estiation for use in se:erely o#ese adolescents$ 0ail)re to Thri#e
•
Inadequate growth No universal definition Weight less than 5% for age Persistent deviation from growth curve
•
Types
• • •
• • • •
Inadequate caloric intake Inadequate absorption (CF, hepatic disease, vit/mineral deficiencies) Increased metabolism (CHD, hyperthyroidism, immunodeficiency) Defective utilization (metabolic or genetic anomaly)
'anagement of 0TT •
• •
Diagnosis—exam, growth charts, diet history, rule out organic causes, family assessment, home assessment Management—reverse the malnutrition, catch up growth, treat coexisting problems Prognosis Related to the cause o Can we reverse the problem? o
1)rsing Care of 0TT )he nurse • •
Assessment of weight, growth. Documenting food intake, feeding behavior, interactions b/w care givers
Feeding • • •
Sufficient calories, feed on schedule, persistence, eye contact Quiet, non-stimulating feeding environment Positive, calm, structured feeding environment
)he Parent • •
Supporting a positive family-child relationship Parent education
)he @hild •
Developmental stimulation between feeds (NOT during feedings)
Inherited autosomal recessive Inability to metabolize phenylalanine Lacks enzyme to metabolize phenylalanine
Peds Lecture 3, Exam 1 January 21, 28, 2013 •
• •
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 Degeneration of grey and white matter
P56--'anifestations • •
Growth failure, vomiting, irritability, erratic behavior, spasticity, seizures, cognitive impairments Best outcomes if treatment started before 3 weeks of age.
"iagnosis8screening mandatory in 9: states &ianosis and treatment aimed at pre:ention of coniti:e disa#ilities )est close to new#orn dischare #ut #efore days old (eed sufficient exposure to Mmil;N to test 4at least 2B hours5 P568Treatment •
•
Treatment Low Phenylalanine Formula/Solution is only source of protein through o adolescence (Minimize Protein intake) Breast feeding MAY be OK if mother’s intake is low in phenylalanine o Diet allows for 20-30 mg/kg/day of phenylalanine, (stay away from diet coke et) o Maintain blood level of 2-8 mg/dl—cognitive deficits occur at levels of 10-15 Even with good control, could be some degree of intellectual impairment o Pregnant females must go back on the diet before the pregnancy to prevent fetal o brain damage Adults may experience mental decline if they do not continue the diet in o adulthood.
• •
Dramatic decline in infectious diseases due to widespread use of immunizations Single most important health measure Immunization status should be asked at each health care visit o
!ecommended 4.lu5 :s$ reuired :accines 4"TP; ''R etc227 -chedule
Contro#ersy with Vaccines • •
No association between vaccines and autism. Stems from a study that was funded by trial lawyers in 1998. Study retracted by the authors in 2004. o
Concern regarding Thimerosal )himerosal is a preser:ati:e o !ates may ha:e e:en increased since the remo:al of )himerosal$ o *t a reater ris; if not immuniCed for the illness$ • Pertussis, Measles and Mumps are a result of vaccine refusal! •
Peds Lecture 3, Exam 1 January 21, 28, 2013 Vaccine Ref)sal ost do not :accinate due parental concerns on :accine safety$ ost commonly cited concerns )himerisolF :ery few contain it (ot closely reulated Fmonitored #y .&* and @&@ &iseases Mnot a ris;NF international tra:el increases this ris; !ecei:e too many :accines at once F actually, the loads of antiens in a sinle :accine component ha:e decreased o:er time as technoloy impro:es Imm)ni$ation Sched)le @hanes often 4yearly or e:ery few years5 Recommended #s2 Re<)ired2 !euired is determined #y the state for school attendance !ecommended is the entire schedule$$$recommended #y the **P 4*merican *cademy of Pediatrics5$ Hepatitis & • • • • •
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 or SubQ
Rota#ir)s 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
"iptheria; Tetan)s; Pert)ssis 4"TaP7 • • •
Combination vaccine Given IM Common side effects to discuss: fever for 24-48 hours, localized pain at injection site, redness at injection site.
&iptheria #acterial infection can cause airway o#struction and se:ere seuelae )etanus painful, muscular riidity and often fatal Pertussis 4whoopin couh5 can cause se:ere respiratory distress *cellular form of :accine with less side effects Haemophil)s infl)en$ae type + 4Hi+7 • • • • • •
Given IM Protects against serious infections caused by Hib Bacterial meningitis Epiglottitis Pneumonia Sepsis
Inacti#ated Polio 4IPV7
Peds Lecture 3, Exam 1 January 21, 28, 2013 'P+ no loner a:aila#le in the -$ • • •
Polio can have neuromuscular, paralytic effects Given IM Used to be given orally, but now all doses given IM
'easles; ')mps; R)+ella 4''R7 • • •
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.
easles 4!u#eola5 :iral and can ha:e complications of larynotracheitis or encephalitis umps :iral and can ha:e complications such as encephalitis, deafness, sterility !u#ella 46erman easles5 :iralO#iest ris; is teratoenic effects on the fetus$ Varicella 4Chic3en pox7 • • •
• • •
•
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
Pne)mococcal and 4PCV7 Pre#nar • • • • • •
Given IM Very helpful for conditions of immunosuppression Sickle cell, asplenia, transplant, HIV For prevention of strep pneumo strains of bacteria Often cause ear infections, sinusitis, and pneumonia 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.
f o:er 2B months, can use the older pneumoccocal :accine$ -ome increasin resistance to this :accine is #ein noted$ Infl)en$a • • • • •
Given IM Don’t give if allergic to eggs Give in early fall Administered yearly as the predicted strain changes Recommended for children > 6 mos and especially those with underlying conditions.
Hepatitis A • • • • • •
Given IM in 2 doses Generally not required for school attendance Hepatitis A can cause serious liver complications Transmitted by fecal-oral route Required in some communities with a high rate of Hepatitis A Often required in food service
Peds Lecture 3, Exam 1 January 21, 28, 2013 'eningococcal 4'CV7 • • • •
Given IM Recommended for those in crowded living conditions For the prevention of meningoccal meningitis Adolescents targeted for this.
Vaccine Administration • • • •
Site/equipment 1 inch, 25 gauge needle for IM—nice place to start Vastus lateralis or Ventrogluteal for infant/young child Deltoid—preschool or older than 2 years of age
Safety • • • •
Good restraint Ok to give multiple injections, just use different sites Correct storage, reconstituation Do not combine unless it came as a combo vaccine
"e#elopmental Approach "oc)mentation • • • •
VIS, site, lot number, consent IM and SC injections IM Vastus lateralis, ventrogluteal, deltoid in older children
Imm)ni$ations and medications 4)s)ally anti+iotics7 -@ Arm for imm)ni$ations sed for insulin, hormone replacement, allery shots, some :accines$ 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 SY STEMIC steroids. Pregnancy—no live vaccines Recent blood, plasma, or IgG for live virus vaccines—wait a minimum of 3 months Seizure within several days of receiving a prior dose of vaccine. 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
!5 to gi#e a #accine when…22 • • • • •
Mild to moderate local reaction to past vaccine Mild, acute illness with or without low grade fever Current antibiotic therapy Prematurity Family history of seizure, SIDS, or adverse reaction to vaccine
Peds Lecture 3, Exam 1 January 21, 28, 2013 • • •
TB test Breast feeding or household contact with pregnant woman CAN receive if HIV + and asymptomatic
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• •
•
Use the correct dosing device Carefully measure it. o Don’t sneak medicine into food. Do not put in a bottle. o Administer into the cheek pocket. Mix in the smallest amount possible. May need to crush it and make it a liquid o Can flavor it. o Some meds you may repeat and others you may not. Do not always assume you repeat it if they spit it or vomit it.
0e#er 4neo nates ----hypothermia is common7 &efined as temperature 38 @ or 100$B . /armful fe:er is a#o:e B1$ @ or 10 . ost fe:ers are #rief with limited conseuences and are :iral in oriin (either the rise in temperature nor its response to anitpyretics indicates the se:erity of the infection$ n the hospital settin, howe:er, notify physician for temps if not expected or follow floor uidelines$ >#al)ation of 0e#er 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 Up to 90 days of age the “key” is if they appear “toxic” 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 concerns—should be evaluated in 24 hours. Tears stream only after 2 months.
Treatment of 0e#er • • • • • •
Aimed at relieving discomfort Medications– to lower the set point Acetaminophen 10-15 mg/kg per dose Ibuprofen 5-10 mg/kg per dose (after 6 mos. of age) NO aspirin for fever reduction %% Home treatments
Peds Lecture 3, Exam 1 January 21, 28, 2013 • •
Light clothing, air circulation, sponging (be careful!) Oral intake
Parental s)pport Education • When to follow up, correct medication dosing, correct home care Jan 28, 2013:
0e+rile Sei$)re 4not all 0S leads to >pilepsy or stat)s epileptica 4shol)ld last for 9 mins7 •
• • •
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) Tonic Clonic seizure occurs during the temperature rise
0ollow )p • •
Initial episode should be evaluated by pediatrician Complicated episodes may need further evaluation by neurology. Tell parents to turn the kids on the side o
Varicella @oster 4Chic3en Pox7 • • •
Transmitted: airborne and direct contact Incubation period: 14-21 days Communicable 5 days prior to rash onset and until last vesicle crusted over.
anifestations • • • • •
Fever Malaise Headache Itching Vesicular rash
Treatment of Varicella -upporti:e • • • • • • • • • •
Tylenol (No Aspirin) No benedryl till kids are 2 yrs old! Fluids Comfort for itching (baths) Immunization to prevent Treatment of secondary infections Cellulitis Meningitis Reye syndrome Illness more severe if on oral steroids Significant illness/death if immunocomprimised
(ursin mplications • • •
Monitor for complications Neurocomplications Infections
/ome care • • •
Treatment of rash Comfort Fluids
Peds Lecture 3, Exam 1 January 21, 28, 2013 •
OTC medications
solation if in /ospital •
Monitor visitors as well
>rythema Infectios)m 4th9s &isease5 •
Transmission: respiratory secretions and blood. Human Parvovirus B19
anifestations • • • •
Headache, malaise, body aches Maybe low grade fever 1 wk later, slapped cheek rash 1-2 wks: lacelike maculopapular rash on trunk and limbs that comes and goes for 1-3 wks.
(ursin mplications of th9s &isease •
Supportive Care
/ome care for itchy rash 4usually not itchy5 • • • • • •
Fluids Rest Keep out of sun with rash Avoid contact with pregnant women Contagious prior to symptoms Can cause aplastic crisis in children with hemolytic conditions
Young children often affected—hand to mouth/nose Often seen around the nose—can be anywhere though “Honey crusted” lesions
(ursin @are • • • •
Handwashing Antibiotics Razors discarded 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
Peds Lecture 3, Exam 1 January 21, 28, 2013 %hat can cause it? (-*&9s, analesics, :accines, and anti#ioticsF most common causes P@( alleryFB8G more li;ely to ha:e cephalosporin rxn .oodsF peanuts, tree nuts, shellfish, es, dairy, straw#erries most common Accident Pre#ention • • • • •
Injuries are number 1 in childhood mortality Take a developmental approach to prevention Poor planning, “top heavy”, awkward, impulsive, curious Situations that lead themselves to injury: Weather extremes, Saturdays, overcrowded areas, tension in the home, alcohol/drug use
0H of poisonins occur in the home &e:elopmental characteristics predispose children to poisonins$ •
Curiosity, oral experimentations, imitation
Pre#ention • • • • • •
Lock Poisons/Medications Up Keep out of sight Throw out old drugs, don’t let young children see adults take, keep meds in safe area Keep in original containers Don’t put in food containers, don’t refer to meds as candy Poison control number handy
Home Treatment of Ingestions *ssessment •
What did they take?
/ow much? %hen? 1. 2. 3.
Empty mouth Take child and container to the phone Call poison control
Treatments of Ingestions ay #e one in the E!Odepends on what was ta;en @harcoal • •
Absorbs compounds Poses risk for aspiration, intestinal obstruction, electrolyte imbalances
Peds Lecture 3, Exam 1 January 21, 28, 2013 •
Mix with diet soda as sweeteners reduce its absorption qualities—this may not be the case now.
@athartics • •
Stimulate evacuation of the bowel, decreasing intestinal absorption Use controversial
*ntidotes •
Mucomist for tylenol, Narcan, etc
ffects of ead /ematoloy • •
•
Anemia—lead competes with iron in making hemoglobin Renal Damage to renal tubules causes excretion of glucose, protein, amino acids and phosphate o —Fanconi Syndrome CNS Cerebral edema, encephalopathy, increased ICP, seizures, MR, blindness, paralysis, death o Developing brain is especially vulnerable o CNS effects are nonreversible o
&lood e#el Treatment Le:el R 10 !escreen in 1 year$ f exposure status chanes, do this sooner 101> Education and rescreenin$ (utritional inter:entions 20BB /ome and medical treatment B7> -tart chelation within B8 hrs, remo:e from en:ironment or 0
Peds Lecture 3, Exam 1 January 21, 28, 2013 mmediate medical inter:ention Treatment )reatment of home en:ironment @helation starts around le:els of BBB$ "'SA •
Oral agent used for lower levels
Calci)m >"TA and &A • •
Monitor for nephrotoxicity (UA daily), liver function tests and EKG Given in a monitored hospital setting
ong term effects of ead • • •
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
1)rsing Implications • • •
Education Assessment of development Case coordination
Child A+)se • • • • • •
Physical Abuse Physical Neglect Emotional Abuse Emotional Neglect Verbal Abuse Sexual Abuse
%hat is *#use? • • • • •
Deliberate maltreatment Deliberate withholding Shaming, ridiculing Emotional unavailability Exploitation
Ris3 factors of A+)se • • • • • • •
Drug and ETOH abuse Psychiatric disorders Environmental stressors Poor parenting experiences Marital/partner stressors Social isolation Inappropriate expectations of the child
Signs of Child A+)se • • • • • •
Unexplained burns, bruises, fractures. 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.
Peds Lecture 3, Exam 1 January 21, 28, 2013 1)rsing Implications ith Regard to Child A+)se • • •
Diagnosis History and physical Lab studies
(ursin implications •
Reassurance of the child
(ursin assessment • •
Does the history fit the evidence? Mandated reporter
Child 'altreatment - Physical • • • • • • • • • • • • • •
Non-Accidental Injury to a Child caused by a Caregiver Physical Indicators Red Flags Inconsistent Histories History and Exam Mismatch Withholding History No Knowledge of Circumstances Claims of Self-infliction Blaming of Siblings or Other Parent or Adult Delay in Seeking Care History of Other Injuries E.R. “Shopping” Inappropriate Rxn to Severity of injury Partial Confession
>arly 'otor 'ilestones A%> 'I>ST!1>S B months !aises /ead 7 months !olls ':er 8> months -its *lone 1012 months @rawls%al;s 1 months %al;s *lone 18 months @lim#s -tairs 222B months )hrows "all ':erhand 23 years )urns a /ot %ater Kno# 3 years *lternates .eet up the -tairs years @atches "all "ounced -uspicious /istories • • • •
!uns %ell Pedals )ricycle
No explanation for injury Inadequate explanation Contradictory or changing history Injury attributed to a 3 rd party (sibling, babysitter) – If sibling, is that child developmentally mature enough to have caused the injury
Peds Lecture 3, Exam 1 January 21, 28, 2013 &r)ise Color Scale Color !eddish "lueDPurple &ar; "lueDpurple 6reen ellow "rown !esolutionI@leared
Time 0rom InB)ry mmediate2B hrs 1 days days 10 days 101B days 2B wee;s
Parental &eha#ior Patterns Seen in A+)se • • • • • •
Lack of concern or detachment about the injury Lack of response to child in pain Overly concerned about trivial injuries Demonstrates unrealistic expectations of the child Parents themselves may have a H/O Drug or Alcohol Addiction or Psychosis Lack of trust in health professionals
Consider the Possi+ility of Physical 'altreatment when the Child/ • • • • •
Has unexplained burns, bite, bruises, broken bones, or black eyes Has fading bruises or other marks noticeable after an absence from school Seems frightened of the parents and protest or cries when it is time to go home Shrinks at the approach of a dults Reports injury by a parent or another adult caregiver
Consider the Possibility of Physical Abuse when the Parent or other Adult Caregiver: • Offers conflicting, unconvincing, or no explanation for the child’s injury Describes the child as ”evil” or in some other very negative way • • Uses harsh physical discipline with the child • Has a history of abuse as a child
S3in and Soft Tiss)e InB)ry • • • •
Bruises on face, lips, mouth, torso, back, buttocks and thighs Bruises in various stages of healing Degree of bruising is greater that expected for child’s activity level Dating bruises by color scale
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 e:idence I ust #e collected :ery, :ery carefully Types
Peds Lecture 3, Exam 1 January 21, 28, 2013 • • • •
Incest – Between family members – Not necessarily blood relatives Molestation – Indecent liberties – Touching, Fondling Exhibition – Indecent exposure Child Pornography
Consider the Possi+ility of Sex)al A+)se 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 Possi+ility of Sex)al A+)se when the Parent or !ther Ad)lt Caregi#er/ •
• •
Is unduly protective of the child or severely limits the child’s contact with other children, especially of the opposite sex Is secretive and isolated Is jealous or controlling with family members
Sex)al A+)se •
•
• • • •
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 child’s 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 * form of child sexual a#use is an a#normal interest in children that is #ased on the intention #y the perpetrator to #e sexually aroused #y children ')ncha)sen +y Proxy •
• •
A mental 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? o Do you remain concerned about minor problems that you have been told not to worry o about? Do you find yourself obsessing over possible medical problems that might affect your o children? Have you ever done an intentional act to make your child ill? o Do you have any motivation or will you derive any benefit if you make your child ill? o Parents that see this behavior in themselves should stop the medical attention-seeking o behavior immediately and seek psychiatric help as soon as possible.
(ursin !esponsi#ilities in @hild altreatment o
Identification
Peds Lecture 3, Exam 1 January 21, 28, 2013 o o o
Health professionals miss hundreds of cases of child maltreatment per year Nurses must perform excellent physical assessments and histories Somethings are not considered abuse o
o o o o o
o o
Coining (Cao Gio) – Involves rubbing a coin along area to cause “bad wind.” If a redpurple 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 S ocial Service will want to interview them. Testifying in Court
1)rsing "iagnoses Associated with Child 'altreatment o o o o o
Knowledge Deficit (of Staff) of Hospital Child Maltreatment Policy Ineffective Family coping: compromised R/T Factors that Contribute to Child Maltreatment Altered Growth and Development R/T Inadequate Caregiving High Risk for Violence (Abusive Family Member): Directed at others R/T maladaptive Behavior Altered Parenting R/T the Abusive parent’s inability to Attach or Bond with the Child
CAR> 0!R TH> CAR>%IV>RS @arin for a#used children is :ery, :ery emotionally drainin$ /ealth care pro:iders need to remem#er that if they do not ta;e care of themsel:es they cannot ta;e care of the children$ (o#ody has to do this alone so #e sure to ;now what your resources are and use them$
