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Leading Causes of Death in
Children Older than 1 Year in the
United States
Perspectives of Pediatric Nursing
Infant Mortality Rates
Compared to other countries with a population of at least 25 million, the United States is ranked last among 27 countries in infant mortality.
The leading cause of death in infants younger than 1 year in the United States is congenital anomalies, accounting for 20.1% of deaths.
Causes of Death in Children
The major cause of death for children older than 1 year in the United States is unintentional injuries (accidents).
The leading causes of death in adolescents ages 15 to 19 years are suicide and homicide.
Unintentional Injuries
The majority of deaths from unintentional injuries occur in males. The pattern of death varies greatly among different ethnic groups, and the causes of unintentional deaths vary with age and gender.
Mortality and Morbidity Statistics
Mortality statistics refer to the number of individuals who have died over a specific period, while morbidity statistics show the prevalence of specific illness in the population at a particular time.
Suicide Ideation
Suicide is the third leading cause of death in children ages 10 to 19 years, so the nurse should assess this age group for suicide ideation.
Family-Centered Care
Family-centered care recognizes that the family is the constant in a child's life and encourages the family to be part of the decision-making process.
Clinical Reasoning
Clinical reasoning is a purposeful and goal-directed process based on rational and deliberate thought.
Evidence-Based Practice
Evidence-based practice (EBP) involves decision making based on the latest available data, combining knowledge with clinical experience and intuition.
Nursing Diagnosis
Signs and symptoms are the cues and clusters of defining characteristics derived from a patient assessment that indicate actual health problems.
Childhood Health Problems
Childhood obesity is the most common nutritional problem among children, and it is associated with type 2 diabetes.
Atraumatic Care
Allowing the child a choice of juice to drink when taking oral medications provides the child with a sense of control, which is an important aspect of atraumatic care.
Therapeutic and Nontherapeutic Nursing Actions
Criticizing parents for not visiting their child is a nontherapeutic action, while reading a fairy tale, discussing feelings with a fellow nurse, and working with parents to decrease dependence on health care providers are therapeutic actions.
Childhood Injury Risk
Preschool children are at risk for childhood injury due to the cognitive characteristic of magical and egocentric thinking.
The child with the most risk factors related to childhood injury is a male with a high activity level and a stressful home life.
Stressors, both positive and negative, are cumulative and affect the family. Adaptation requires a change in family structure or interaction.
Interactional Theory
Interactional theory is not a family theory. Interactions are the basis of general systems theory.
Erikson's Theory
Erikson's theory applies to individual growth and development, not families.
Developmental Systems Theory
Developmental systems theory is an outgrowth of Duvall's theory. The family is described as a small group, a semi-closed system of personalities that interact with the larger cultural system. Changes do not occur in one part of the family without changes in others.
Family Types
Extended Family
An extended family contains at least one parent, one or more children, and one or more members (related or unrelated) other than a parent or sibling.
Blended Family
A blended family contains at least one stepparent, stepsibling, or half- sibling.
Nuclear Family
A nuclear family consists of two parents and their children. No other relatives or nonrelatives are present in the household.
Binuclear Family
In binuclear families, parents continue the parenting role while terminating the spousal unit. For example, when joint custody is assigned by the court, each parent has equal rights and responsibilities for the minor child or children.
Homosexual (Gay-Lesbian) Families
Although gay or lesbian families may be different from heterosexual families, the environment can be as healthy as any other. Lacking a nurturing environment and stability is reflective on the parents and family,
not the type of family. There is little evidence to support that children become homosexual like their parents.
Qualities of Strong Families
A clear set of family rules, values, and beliefs that establish expectations about acceptable and desired behavior is one of the qualities of strong families that help them function effectively. Strong families have a sense of congruence among family members regarding the value and importance of assigning time and energy to meet needs. Varied coping strategies are used by strong families. The sense of commitment is toward the growth and well- being of individual family members, as well as the family unit.
Parenting Styles
Permissive Parenting
Permissive parents avoid imposing their own standards of conduct and allow their children to regulate their own activity as much as possible. The parents exert little or no control over their children's actions.
Dictatorial or Authoritarian Parenting
Dictatorial or authoritarian parents attempt to control their children's behavior and attitudes through unquestioned mandates. They establish rules and regulations or standards of conduct that they expect to be followed rigidly and unquestioningly.
Democratic Parenting
Democratic parents combine permissive and dictatorial styles. They direct their children's behavior and attitudes by emphasizing the reasons for rules and negatively reinforcing deviations.
Discipline
For effective discipline, parents must be consistent and must follow through with agreed-on actions. Withdrawal of love and approval is never appropriate or effective. The 4-year-old child will test limits and may misbehave. Children of this age do not respond to verbal reasoning. Realistic goals should be set for this age group. Discipline strategies should be appropriate to the child's age and temperament and the severity of the misbehavior.
Physical Punishment of Children
Through the use of physical punishment, children learn what they should not do. When parents are not around, it is more likely that children will misbehave because they have not learned to behave well for their own sake
Monosomy : An abnormal number of chromosomes whereby the chromosome is represented by a single copy in a somatic cell. Nondisjunction : The failure of homologous chromosomes or chromatids to separate during mitosis or meiosis.
Sporadic Conditions
Sporadic describes a birth defect previously unidentified in a family.
Down Syndrome
Children with Down syndrome have low-set ears. Infants with Down syndrome have hypotonia, not hypertonia. Children with Down syndrome have short hands with broad fingers.
Sex Chromosome Defects
Turner syndrome is a common sex chromosome defect.
Hemophilia
Hemophilia is a disorder of blood coagulation inherited in an X-linked recessive pattern.
X-Linked Recessive Inheritance
In X-linked recessive disorders, the affected individuals are usually male. With recessive traits, usually two copies of the gene are needed to produce the effect. Because the male only has one X chromosome, the effect is visible with only one copy of the gene. Females are usually only carriers of X-linked recessive disorders. The X chromosome that does not have the recessive gene will produce the normal protein, so the woman will not show evidence of the disorder. The transmission is from mother to son. Usually the mother and father are unaffected.
Characteristics of X-Linked Recessive Inheritance
Affected individuals are principally males. Affected individuals have unaffected parents. Affected parents will have a 50% chance of having an affected son and a 50% chance of having an unaffected daughter. Unaffected daughters of affected fathers will be carriers.
Hemophilia A
Hemophilia A is the most common type of hemophilia and is inherited as an X-linked recessive trait. It is a disorder of blood coagulation caused by a deficiency of factor VIII, a protein essential for blood clotting.
Symptoms and Complications of Hemophilia
Excessive bleeding and difficulty in stopping bleeding, even from minor cuts or injuries Spontaneous bleeding into joints, muscles, and other soft tissues Potentially life-threatening bleeding, such as intracranial hemorrhage
Diagnosis and Management of Hemophilia
Diagnosis is made through blood tests to measure the levels of clotting factors. Treatment involves replacement of the missing clotting factor, either through infusion of factor concentrates or administration of desmopressin (DDAVP) to stimulate the release of factor VIII. Prophylactic treatment with factor concentrates is often used to prevent bleeding episodes. Supportive care, such as physical therapy and pain management, is also important.
Genetic Counseling and Family Planning
Genetic counseling is recommended for individuals and families affected by hemophilia. Prenatal testing, such as chorionic villus sampling or amniocentesis, can be used to detect the presence of the hemophilia gene in the fetus. Carrier testing and preimplantation genetic testing may also be options for family planning.
Heparin Sodium (Heparin)
Heparin is the anticoagulant used during pregnancy and is not a teratogen. Teratogens are agents that cause birth defects when present in the prenatal environment, and they account for the majority of adverse intrauterine effects not attributable to genetic factors. Types of teratogens include drugs such as phenytoin (Dilantin), warfarin (Coumadin), and isotretinoin.
Communication and Physical Assessment of
the Child and Family
Nurse-Patient Interaction
The first thing the nurse should do when seeing an adolescent and their parents for the first time is to introduce themselves. This helps establish rapport and makes the family feel comfortable. Effective communication can be blocked by using stereotyped comments or clichés. Silence, on the other hand, can be an effective interviewing tool, as it allows the interviewee to sort out their thoughts and feelings.
Nursing Assessment of Children
Asking about Sexual Activity
When assessing an adolescent girl, it is important to ask both the girl and her parent if she is sexually active. Asking the adolescent girl directly if she is having sex with anyone is a well-understood question. The phrase "sexually active" is broadly defined and may not provide specific information for the nurse to provide necessary care. Using gender-neutral terms like "anyone" is preferred over gender- specific terms like "boyfriend" or "girlfriend". This conveys acceptance and inclusivity to the adolescent. Questioning about sexual activity should occur when the adolescent is alone, without the parent present.
Nutritional Assessment of Hispanic Families
When conducting a nutritional assessment on a Hispanic family, the nurse may find that their diet consists mainly of vegetables, legumes, and starches. This diet is not lacking in protein, but rather is providing sufficient essential amino acids. Many vegetarian diets, including this combination of foods, can be sufficient for growth and development. A dietary assessment should still be conducted, but the nurse should recognize that this type of diet is common in some cultures and can meet nutritional needs.
Measuring Muscle Mass
Of the parameters listed, upper arm circumference correlates best with measurements of total muscle mass. Muscle serves as the body's major protein reserve and is considered an index of the body's protein stores. Height is reflective of past nutritional status, while weight is indicative of current nutritional status. Skinfold thickness is not the best indicator of total muscle mass.
Privacy During Physical Assessments
When performing a physical assessment on a 10-year-old girl, it is appropriate to give her the option of having her mother stay in the room or leave. Respecting the child's need for privacy during the examination is important, even though the child is a minor. The mother's presence or absence should be determined by the child's preference, as the child is old enough to help make this decision.
Identifying Overweight Children
According to the National Center for Health Statistics criteria, children with a BMI-for-age at or above the 85th percentile and less than the 95th percentile are considered at risk for being overweight. Children with a BMI-for-age at or above the 95th percentile are considered overweight. Children with a BMI-for-age between the 10th and 75th percentiles are within the normal range.
Indications for Rectal Temperatures
Rectal temperatures are recommended when definitive measurements are necessary, such as in infants older than 1 month of age. Rectal temperatures are not done in the newborn period to avoid trauma to the rectal mucosa. Rectal temperature is an intrusive procedure that should be avoided whenever possible.
Assessing Radial Pulses in Children
Satisfactory radial pulses can be taken in children older than 2 years of age. In infants and young children, the apical pulse is more reliable than the radial pulse.
Selecting Blood Pressure Cuff Size
If the appropriate size blood pressure cuff is not available, the next larger size should be used. Using a cuff that is too small may result in a falsely high blood pressure reading.
Assessing Petechiae in Dark-Skinned Individuals
In dark-skinned individuals, petechiae (small distinct pinpoint hemorrhages) are best observed in the oral mucosa and conjunctiva. These areas provide the best contrast to visualize petechiae in darker skin tones.
Evaluating Head Lag in Infants
Significant head lag after 6 months of age strongly indicates cerebral injury and requires further evaluation. Head control is a normal developmental milestone, so persistent head lag should be promptly referred for further assessment.
Hearing Screening in Young Children
Pure tone audiometry is an appropriate screening test for hearing that the nurse can administer to a 5-year-old child. This test uses an audiometer to produce sounds at different volumes and pitches in the child's ears, and the child is asked to respond when the tone is heard.
Pain Management in Children
The FACES Scale
The FACES scale is a validated tool for assessing pain in children as young as 3 years old. Children are asked to color the face that best describes their level of pain. The child's own estimate of their pain should be used, as physiologic measures may not accurately reflect long-term pain. The FACES scale is not appropriate for use with adolescents. The FACES scale is useful in pain assessment but is not as accurate as physiologic responses.
Nonpharmacologic Pain Management Techniques
Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. The nonpharmacologic strategy should be matched with the child's pain severity and be taught to the child before the onset of the painful experience. Tricking children into believing they do not have pain may mitigate the child's experience with mild pain, but the child will still know the discomfort was present.
Neonatal Procedural Pain Management
Nonnutritive sucking and oral sucrose have been demonstrated to have calming and pain-relieving effects for neonates. Tactile stimulation has a variable effect on response to procedural pain. Commercial warm packs and disturbing the infant's sleep cycle are not effective pain control measures.
Patient-Controlled Analgesia (PCA) for Children
The PCA prescription can be set for a basal rate for a continuous infusion of pain medication, with additional doses administered by the patient, parent, or nurse as necessary. The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl.
Effective analgesia can be obtained with the parents and nurse giving boluses as necessary, as the child may not understand the concept of pushing a button.
Pain Management in Preterm Infants
Preterm and newborn infants perceive and react to pain in the same manner as children and adults. Painful stimuli cause a global stress response, including cardiorespiratory changes, palmar sweating, increased intracranial pressure, and hormonal and metabolic changes. Adequate analgesia and anesthesia are necessary to decrease the stress response in preterm infants.
Procedural Pain Management
For a bone marrow aspiration and biopsy, the combination of fentanyl and midazolam should be used to provide conscious sedation. EMLA (eutectic mixture of local anesthetics) is an effective topical analgesic agent when applied to the skin 60 minutes before a procedure.
Opioid Side Effects and Management
Constipation is one of the most common side effects of opioid administration. If a child receiving a continuous IV low-dose infusion of morphine develops respiratory depression, IV naloxone should be administered.
Levels of Sedation
During moderate sedation, the patient responds to verbal commands but may not respond to light tactile stimulation, cognitive function is impaired, and respiratory function is adequate. In minimal sedation, the patient responds to verbal commands and may have impaired cognitive function, but the respiratory and cardiovascular systems are unaffected. In deep sedation, the patient cannot be easily aroused except by painful stimuli, and the airway and spontaneous ventilation may be impaired, but cardiovascular function is maintained.
Timing of Nonopioid Analgesic Administration
Nonsteroidal anti-inflammatory drugs (NSAIDs) take about 1 hour for maximum effect, so timing is crucial.
Advantages of Intravenous Bolus Pain Medication
Administration
Faster onset of action compared to oral administration.
Medication Management for Anxiety in Burn
Patients
Prescription for Anxiety Control
Benzodiazepines, such as lorazepam (Ativan), are prescribed as antianxiety agents. Opioid analgesics, such as oxycodone (OxyContin), fentanyl (Sublimaze), and morphine sulfate (Morphine), are not used for anxiety control.
Medication Management for Neuropathic
Cancer Pain
Prescription for Neuropathic Pain Control
Anticonvulsants, such as gabapentin (Neurontin), have demonstrated effectiveness in neuropathic cancer pain. Ativan is an antianxiety agent, and Dilaudid and MS Contin are opioid analgesics.
Pertussis Vaccination
Vaccination Schedule
The acellular pertussis vaccine is recommended by the American Academy of Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of pertussis, and the vaccine is not given after age 7 years.
Minimizing Discomfort during Infant
Immunizations
Pain Management Strategies
Topical anesthetic agents, such as EMLA (eutectic mixture of local anesthetic) and vapor coolant sprays, can be used to minimize the discomfort associated with intramuscular injections. Infants have neural pathways that indicate pain, and they perceive and react to pain in the same manner as children and adults.
Immunizations for Infants with
Immunocompromised Siblings
Vaccination Considerations
DTaP (diphtheria, tetanus, acellular pertussis) and IPV (inactivated poliovirus vaccine) can be safely given to the infant, as they are not live vaccines and do not pose a risk to the immunocompromised sibling.
Serious Reactions to Vaccine Administration
Potential Reactions
The primary serious reaction to be alert for is an allergic reaction. Mild febrile reactions and local skin irritation at the injection site are also common but not serious.
Appropriate Injection Sites for Infant and
Child Immunizations
Recommended Sites
The deltoid muscle is recommended for children 12 months and older. The ventrogluteal and anterolateral thigh sites can safely be used for the administration of vaccines to infants. The dorsogluteal site is avoided in children due to the location of nerves and veins.
Skin Lesion Identification
Vesicle
An elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid.
Papule
An elevated, palpable, firm, circumscribed lesion smaller than 1 cm in diameter, with a brown, red, pink, tan, or bluish red color.
Pustule
An elevated, superficial lesion similar to a vesicle but filled with purulent fluid.
Scabies Management
Treat all family members if symptoms develop, as scabies is highly contagious. Symptoms may last 2 to 3 weeks, even with proper treatment. Carefully treat all areas of the body, not just where the rash is present.
Health Promotion of the Newborn and Family
Brown Adipose Tissue (BAT) in Newborns
Brown adipose tissue (BAT) in newborns generates heat for distribution to other parts of the body. BAT has a larger content of mitochondrial cytochromes and a greater capacity for heat production through intensified metabolic activity than ordinary adipose tissue. Heat generated in brown fat is distributed to other parts of the body by the blood. BAT is located in superficial areas such as between the scapulae, around the neck, in the axillae, and behind the sternum.
Gastrointestinal Tract of Full-Term Newborns
Newborns have a very limited stomach capacity, requiring frequent small feedings. The colon has a relatively small volume, resulting in increased bowel movements. Peristaltic waves are rapid in newborns. Pancreatic lipase is deficient, limiting the absorption of fats.
Newborn's First Stool (Meconium)
Meconium is the newborn's first stool, composed of amniotic fluid, intestinal secretions, shed mucosal cells, and possibly blood. The first meconium stool should occur within the first 24 hours after birth, although it may be delayed up to 7 days in very low-birth-weight newborns.
Infant Kidney Function
Infants have a functional deficiency in the kidneys' ability to concentrate urine and cope with fluid and electrolyte stress. Infants' urine is colorless and odorless. The first voiding usually occurs within 24 hours of delivery, with newborns voiding when the bladder is stretched to 15 ml, resulting in about 20 voidings per day.
Apgar Score
The Apgar score reflects an infant's status in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 8 to 10 indicates an absence of difficulty adjusting to extrauterine life.
Periods of Reactivity in Newborns
The first period of reactivity is an excellent time for parents to acquaint themselves with the newborn, as the infant is alert, cries vigorously, and appears interested in the environment. The second period of reactivity begins when the infant awakes from a deep sleep and ends when the amounts of respiratory mucus have decreased.
Sleep and Wakefulness Patterns in Newborns
The quiet alert stage is the best stage for newborn stimulation, as the newborn's eyes are wide open and bright, and the newborn responds to the environment. Muscle twitches and irregular breathing are common during light sleep.
Assessing Newborn Physical Maturity
The degree of flexion in the arms and legs can be used to determine gestational age when the newborn is quiet and in a supine position. Length and chest circumference reflect the newborn's size and weight, which vary according to race and gender. Birth weight alone is a poor indicator of gestational age and fetal maturity.
Newborn Skin Characteristics
The vernix caseosa is the grayish white, cheeselike substance that covers a newborn's skin. Mongolian spots are irregular areas of deep blue pigmentation, which are common variations found in newborns of African, Asian, Native American, or Hispanic descent.
Newborn Vital Signs
The apical heart rate of a stabilized newborn is typically between 120 and 140 beats per minute.
Abnormal Findings in Newborns
Abnormal findings in newborns may include respiratory distress, cyanosis, jaundice, and congenital anomalies.
