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Copy of Exam 3- peds
Basic Biology (BIOL 111)
Campbell University
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ACES and Maltreatment- Effects on long term health
● What are ACES = Adverse Childhood Experiences ○ Caused by Toxic Stress ■ Constant production of cortisol because you are in a constant state of stress ■ Causes the mind and body stays on alert and can no longer regulate their emotions ○ Affects long term health into adulthood ■ Persons who had experienced ACES had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; ■ A 2- to 4-fold increase in smoking, poor self-rated health, ≥50 sexual intercourse partners, and higher risk of sexually transmitted disease ■ A 1- to 1-fold increase in physical inactivity and severe obesity. ■ The higher the exposure the greater their chances for ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. ● ACES Study: ○ The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study is one of the largest investigations of childhood abuse and neglect and household challenges and later-life health and well-being. ○ The original ACE Study was conducted at Kaiser Permanente from 1995 to 1997 with two waves of data collection. Over 17,000 Health Maintenance Organization members from Southern California receiving physical exams completed confidential surveys regarding their childhood experiences and current health status and behaviors. ● Categories of ACES ○ 1. Abuse ■ Emotional– verbal abuse of the child (“you’re stupid”) ■ Physical– spanking, hitting, burning ■ Sexual– inappropriate touching to full sexual penetration ○ 2. Neglect→ know the difference ■ Emotional– not fulfilling emotional needs (not being there when the kid needs you) ■ Physical– not meeting physical needs (not getting fed, bathed) ○ 3. Household Challenges ■ Mother treated violently ■ Household substance abuse ■ Household mental illness ■ Parental separation or divorce ■ Incarcerated household member ○ Other ACES ■ Peer victimization– bullying ■ Teen dating violence– could be sexual assault, control, stalking, physical ■ Loss of parent
■ Community violence ■ Historical trauma– something that happened in the past that is still traumatic to the family ■ War ■ Poverty
How bad is the problem? ● ACEs are common. ● Preventing ACEs could potentially reduce a large number of health conditions. ● Some children are at greater risk than others. ● ACEs are costly. ● What are the consequences? ○ Lasting negative effects on health, well being, opportunity ○ Increase risk of injury, sexually transmitted diseases; maternal and childhealth problems, teen pregnancy
Risk Facto rs for ACE’s ● Family/Individual ○ Low income ○ Low education ○ High parenting or economic stress– multiple children, children with special needs/chronic illness, single parenting, parenting in a divorced family ○ Inconsistent discipline– not the same rules at both houses ○ Use of negative communication styles ○ Acceptance of violence– violence becomes normal ● Community ○ High rates of violence ○ High unemployment ○ High poverty ○ Low community involvement ○ Food insecurity ○ Unstable housing
Protective Factors ● Family and Individual ○ Families who create safe, stable nurturing relationships ○ Children who do well in school and form positive peer relationships ○ Children who have positive adult role models outside of the family ○ Families able to meet basic needs of food, shelter and health ○ Families that engage in fun activities together ● Community ○ Access to safe, stable housing ○ Access to safe nurturing childcare and high-quality preschools. ○ Engaging after school programs
● Other injuries ● Delay in seeking care**- old fractures ● Inappropriate responses– “he’s always so clumsy”
Findings of Maltreatment- Physical ● Physical Neglect ○ FTT, Lack of hygiene, Frequent injuries, Delay in seeking healthcare, Dull affect, School absences, Self stimulating activities ● Physical Abuse ○ Bruises in various stages of healing, Bruising in a non-mobile child, Multiple fractures in different stages of healing, Burns, laceration, Fear of parents, Lack of emotional response
Findings of Maltreatment- Emotional ● Emotional Neglect and Abuse ○ FTT, Eating disorder, Enuresis (peeing themselves at night), Sleep disturbances, Self stimulating behaviors, Withdrawal, Developmental delay, Suicide attempts ○ Caregivers behavior with emotional neglect/abuse ■ Rejection of child, terrorizing child, ignoring child, verbally assaulting child, pressuring child excessively
Findings of Maltreatment- Sexual ● Bruises, lacerations, Bleeding of genitalia, anus or mouth, STD, Difficulty walking or standing, UTI, Regressive behavior, Withdrawal, Use of sexually explicit language inappropriate for age or development, Unusual body odor, Bloody or torn underwear ● Sexual Abuse – the employment, use, persuasion, or inducement of a child to engage in any sexually explicit conduct. Includes pedophilia, prostitution, incest, molestation, or pornography
Shaken Baby Syndrome– Infant abuse ● Usually, child is forcibly shaken from excessive crying ● Can be from a blow to the head from a fist or object ● May not be seen until severe symptoms emerge ● Findings ○ Early Normal exam, vomiting, poor feeding, Respiratory distress, Retinal Hemorrhages (first thing you assess), Seizures, posturing, Alterations in LOC, Apnea/Bradycardia, Blindness, Unresponsiveness ● Nursing Care ○ Full assessment for other injuries– anytime you suspect abuse! ○ NOTIFY authorities ○ Remove the child from the care of the alleged abuser ○ Make clear and objective notes about physical findings– “dad yelled at mom” not “its seems like the dad is yelling at the mom” ○ Be honest, direct, and professional
○ Provide support to both child and parent
Posttraumatic Stress Disorder (PTSD) ● Children with ACE’s and Maltreatment are at high risk for this ● Caused by traumatic incident, repeated trauma (ACE’s), psychiatric disorder, natural disaster, sexual abuse, or witnessing a homicide, suicide or other violent event ● PTSD initial response ○ Lasts a few minutes to 2 hours ○ Increase in stress hormones (fight or flight) ○ Psychosis ● PTSD Second phase ○ Last approximately 2 weeks ○ Period of calm (numbness, denial) ○ Defense mechanisms decrease ● PTSD Third phase ○ Extends 2-3 months ○ Clients gets worse instead of better ○ Depression, phobias, anxiety, conversion reactions, repetitive movements, flashbacks, or obsessions ● Nursing Care ○ Referral to appropriate services ○ Monitor for behavioral changes ○ Assist family with coping ○ Allow expression of feelings– they want to express their story over, and over, and over again ○ Prevent long term effects ○ Caused by traumatic incident, repeated trauma, psychiatric disorder, natural disaster, sexualsexual abuse, or witnessing a homicide, suicide or other violent event
How do we stop ACE’s and Maltreatment?
○ Stage I– Marriage and an independent home ■ Reestablish couple identity, realign relationships with extended family, Make decisions regarding parenthood ○ Stage II– Families with infants ■ infants- Integrate infants into the family unit, accommodate to new parenting and grandparenting roles, Maintain marital bond ○ Stage III– Families with preschoolers ■ Socialize Children, parents and children adjust to separation ○ Stage IV– Families with school aged children ■ Children develop peer relationships, parents adjust to their children’s peers and school influences ○ Stage V– Families with teenagers ■ Adolescents develop increasing autonomy, parent refocus on midlife marital and career issues, parents begin to shift to concern for the older generation ○ Stage VI– Families as launching careers ■ Parent and young adults establish independent identities, parent renegotiate marital relationship ○ Stage VII– Middle aged families ■ Reinvest in couple identity with concurrent development of independent interests, realign relationships to include in-laws and grandchildren, Deal with disabilities and death of older generation ○ Stage VIII– Aging families ■ Shift from work to leisure and semi-retirement or full retirement, maintain couple and individual functioning while adapting to the aging process, prepare for own death, and deal with the loss of spouse, siblings and/or peers ○ Strengths ■ Provides a dynamic view of family ■ Addresses changes within the family as well as the family as a social system ■ Anticipates stressors that occur with transitions. ○ Limitations ■ Traditional model more easily applied to two parent families with children ■ Use of age of oldest child and marital duration as a marker of stage transition sometimes problematic. ○ Applications ■ Anticipatory guidance, educational strategies, and developing or strengthening family resources for management of transitions in life. Family Structure ● Traditional – Married couple with only biological children ● Nuclear – 2 parents (not necessarily married) and their children, biological, step, adoptive, foster
● Blended – At least one step-parent, step sibling or half sibling. Step siblings do not share a common biological parent. ● Extended – At least one parent, one or more children, and one or more members (related or not) other than a parent or sibling. ● Single parent families- ● Binuclear – parents continuing parenting role while ending spousal role. ● Polygamous – more commonly multiple wives, but occasionally multiple husbands ● Communal – emerged from disenchantment with most contemporary life choices. Shred responsibility for everything including child rearing ● LBGTQ – Same sex parents
Parenting ● Parenting styles: ○ Authoritarian – try to control child behavior with unquestioned mandates ○ Permissive – exerts little or no control over child’s actions, rarely punish and discuss reasons and elicit opinions with child ○ Democratic/authoritative – Combination of the above styles, They discuss the reasons for rules and negatively enforce deviations. Relies on guilt or shame, not fear of punishment if caught. Gives the child some choices ○ Passive – parents are uninvolved with discipline at all. Child has all the control. ● Special situations ○ The adopted child, divorce, single parenting, parenting in dual earning families, foster parenting ● Discipline means to teach. Limits must be set because the more limits are set the more children understand what is expected of them and less you will need to discipline them.
The Adopted Child ● Parent Child bonding – The more caregivers the child has prior to adoption the more they will have issues with attachment. ● Issues of Origin – the task of telling the child how and why they were adopted. ● Adolescence – May use adoption as justification for acting out, may have feelings of abandonment from biological parents, may worsen issues with identity formation while they fantasize or try to know about their biological parents ● Cross-racial, and international adoption – need to work to preserve racial heritage, may experience bigotry or racism if appearance is significantly different from adoptive parents, may only have limited health information prior to adoption.
Divorce Process ● Acute- Decision to separate, first legal steps of dissolution, departure of one spouse from home, usually dad, lasts from several months to more than a year and is accompanied by family stress and a chaotic atmosphere. ● Transitional – Adults and children assume unfamiliar roles and relationships within a new family structure. Accompanied by change in residence, reduced standard of living, altered lifestyle, larger share of economic burden, and altered parent-child relationships
● Commitment – need to be on the same page and consistent ● Unity ● Flexibility– don’t want to scream at a teenager in front of their friends, don’t want to put a kid in timeout in the mall ● Planning– what are we going to do if our child behaves a certain way ● Behavior orientation– they have to know what behavior they are doing is wrong ● Privacy ● Termination
Social Influences on Families ● Surrounding environment ○ School/learning environment ■ School is important site of health promotion- Physical education, nutrition, counseling, psychological and social services, as social and emotional climate, family and community engagement occurs at school ■ School connectedness is important – they and their learning matter to the adults and peers at their school. School is the center of cultural diffusion. ○ Peer cultures ■ Very important as children proceed through school. Peer groups with similar values as the adults in the child’s life produce mild conflict. Can develop into a complex social system where the need for acceptance outweighs family and school values ○ Social roles in the community ■ Poverty, uneducated families, lesser level of education available, violence in community and accepted by community
Cultural influences on Families ● Social determinants ○ Diversity– the practice or quality of including or involving people from a range of different social and ethnic backgrounds and of different genders, sexual orientations, etc. ○ Equity– the ability to have the equal chance at pursuing something ○ Inclusivity– including everyone no matter the race religion pronoun ○ Race – people grouped together by outward physical appearance; Ethnicity – Classification aimed at grouping individuals who consider themselves or are considered by other to share common characteristics that differentiate them from the other collectivities in a society and from which they develop the distinction ○ Social Class – relates to the family’s economic and educational levels and their ability to access resources needed to thrive in daily life. ○ Religious and traditional influences – Religion is a specific set of beliefs whereas spirituality is a unique awareness, belief, practice and experience starting in childhood. Cultural influences can play a large role in health care and health disparities. If the culture they are raised in does not believe in western medicine, or uses herbal remedies, refuses blood transfusions (can harm health)
○ Mass media influences – Violence- increase violence and aggression, Sex – influences choices and introduces alternate lifestyles and choices , Substance use and abuse – alcohol and tobacco heavily marketed, obesity- increases with increased screen time, body image- poor role models ○ Land of Origin and Immigration Status- Nearly half of all the world’s displaced people are children, they experience mental and sometimes physical trauma, may have had challenges in their relocation, may be afraid or unable to seek health care, many do not speak the language
Cultural Traditions to Maintain, Protect, and Restore Health ● Physical aspects of caring for the body– respect these traditions as long as they are not harmful to the child’s health ○ Special clothes ○ Foods ○ Medicines ● Feelings, attitudes, rituals, actions related to health ● Spiritual aspects of health ○ Identity (who I am) ○ Customs/prayers/healing
Health beliefs and practices ● Natural forces ● Supernatural forces ● Imbalance of forces ● Health protection ○ Folk healers ○ Practices and remedies ○ Faith healing and religious rituals
QUESTIONS:
Which of the following (after the family) is most likely to have the greatest influence on providing continuity between generations? A. Schools B. Race C. Social class D. Government
Children may feel that they are responsible for their parents’ divorce and interpret the separation as punishment. At what age is this most likely to occur? A. 1 year B. 4 years C. 8 years D. 13 years
wrong b/c they love to walk around ● School age children – Monkey bars, trampolines Adolescents – Sports, risk taking, MVA ● Clavicle most fractured bone in all age groups ● Clinical Manifestations of Fracture ○ Edema ○ Pain with point tenderness ○ Deformity ○ Ecchymosis ○ Decreased use* especially toddlers ○ Warmth, erythema ○ Crepitus ● Types of Fractures Won’t have to identify
● Comminuted– many pieces ● Plastic deformity– bone bends but doesn’t crack
Bone Healing and Remodeling ● Rapid healing in children ● Neonatal period— 2 to 3 weeks ● Toddlers – 3 to 5 weeks ● School Age – 4 to 6 weeks ● Adolescence— 6 to 12 weeks
Types of Casts
Nursing Care of a Child with a Fracture ● GOAL: Promote healing, prevent injury or complications ● Pulses, Capillary refill, skin color, and temperature** 6 P’s ● Palpation of cast for hot spots ● Alleviate pressure on nerves, treat pain ○ Compartment syndrome ● Assess pain frequently ● Monitor neurovascular status regularly ● Maintain alignment ● Promote ROM of fingers and toes and unaffected extremities ● Instruct about activity restrictions ● Reassure patient and caregiver ● Discuss calcium intake as well as Vitamin D** ○ b/c they are deficient in these ● Promote nutrition and hydration ● Support growth and development ● Support family system
Nursing Considerations for Casts ● Cast care initial ● Monitor for edema ● Neurovascular checks ● Elevation* key to preventing compartment syndrome ○ ABOVE the heart!! → ● Ice ● Support cast while positioning ● Monitor for drainage or “hot” spots ● Assess skin around cast edges ● Crutch training as needed– weight on the hands, NOT the under arms (can damage the nerves), height of the nipple line ● Cast care at home ○ Keep cast dry – no tub baths
■ If nerve tissue is damaged by pressure ■ If circulation to nerve tissue is interrupted ■ Effects of improper positioning ■ Range of motion ○ Sensory and perceptual deprivation ● Psychologic ○ Diminished environmental stimuli ○ Altered perception of self and environment ○ Increased feelings of frustration, helplessness, anxiety Depression, anger, aggressive behavior ○ Developmental regression
Nursing Care Management ● Physical assessment ● Prevent injury and complications ● Encourage activity and use of devices ○ Orthotics and prosthetics ○ Crutches, canes, and wheelchairs ● Pressure reduction mattresses and position changes and ROM exercises ○ Branden Q scale (don’t need to know) ● Child-life specialists, visitors, school activities ● Child participates in self-care ● Support of family
Assessment of Compartment Syndrome ● 5 P’s (for Story, it’s 5) ● Pain-worsening ● Paresthesia (numbness) ● Pulselessness or capillary refill >5 seconds – always write the exact amount of seconds! ● Paralysis (movement distal to the fx.) ● Pallor
The Child in Traction ● Traction: extended pulling force may be used to: ○ Provide rest for an extremity ○ Help prevent or improve contracture deformity ○ Correct a deformity ○ Treat a dislocation ○ Allow position and alignment ○ Provide immobilization ○ Reduce muscle spasms (rare in children)
Traction: Essential Components ● Traction: forward force produced by attaching weight to distal bone fragment
○ Adjust by adding or subtracting weights – a nurse should never do this unless ordered by a physician (not ordered often) – “Don’t touch the traction!” ● Countertraction: backward force provided by body weight ○ Increase by elevating foot of bed ● Frictional force: provided by patient’s contact with the bed
Types of Traction ● Manual traction: applied to the body part by the hand placed distally to the fracture/dislocation site ● Skin traction: pulling mechanisms are attached to the skin with adhesive material or elastic bandage (1st pic) ● Skeletal traction: applied directly to skeletal structure by pin, wire, or tongs inserted into or through the diameter of the bone distal to the fracture (2nd pic) ● Cervical traction: screws inserted to the skull and attached to a halo (screws into the skull) that is either attached to weight or a vest. (3rd pic)
Nursing
Considerations of Child in Traction ● Assessing the patient in traction ○ Comfort - pain control ○ Traction alignment ○ Weights hang freely ● Skin care issues ○ Pin care (per individual institutional protocol, no universal protocols) ○ Skin without abrasions ○ Decubitus– pressure ulcers
Nursing Considerations of Child in Traction ● Monitor Neurovascular status regularly. ● Provide ROM and encourage mobility as possible. ● Encourage deep breathing and IS ● Change positions frequently ● NEVER release traction unless for an emergency or under direct supervision of the provider. ● Support and educate patient and family
Distraction ● Process of separating opposing bones to encourage regeneration of new bone in the created space ● Device used is called external fixator and/or a frame ● Can be used when limbs are unequal in length and new bone is needed to elongate the
● Radiographic exam
Treatments ● Pavlik Harness– 6 months or younger ● Bracing/Spica cast– 6 months or older ● Hip surgery
Nursing Care of DDH ● Maintain harness in place – don’t want knees above the hip b/c you can cause necrosis from pressure ● Check straps for adjustment and skin integrity ● Promote normal growth and development ● Educate parents on skin care ● If spica cast is needed, follow the guide on spica cast care.
Tales Equinovarus– ClubFoot ● 1 to 2 per 1000 ● Males more affected ● Involves soft tissue deformities ● Four deformities ○ Inward twist at ankle ○ Inward twist of foot ○ Contracture of the Achilles tendon ○ Atrophied gastrocnemius ● Treatments ○ Manipulation with serial casting for 4-12 weeks ○ Tenotomy – tendon release ○ Bracing after casting and tenotomy ■ Bracing for 2-4 years after casting and tenotomy. ○ Surgical correction is rare. It can be performed if full correction is not achieved with casting and tenotomy. ● Nursing Considerations for Club Foot Casting ○ Inspect areas around cast for breakdown. ○ Perform NV checks daily once home. ○ Alert provider if cast gets wet or slips off– should always see the toes sticking out of the casts, if you can’t then it is moving ○ Educate parents on treatment and long- term expectations ● DDH and club foot go hand in hand, if you have someone with clubfoot, check for DDH
Osteogenesis Imperfecta ● Genetic disorder ● Caused by a genetic defect that affects the body’s production of collagen ● Collagen is the major protein of the body’s connective tissue ● Less than normal or poor collagen leads to weak bones that fracture easy
● Often called “brittle bone disease” ● Characteristics ○ Demineralization, cortical thinning ○ Multiple fractures with pseudoarthrosis (false joint- there's a joint where there shouldn’t be) ○ Exuberant callus formation ○ Blue sclera ○ Wide sutures ○ Pre-senile deafness (in second or third decade of life) (pre-senile= before old age) ■ When they become an adult (20-30), they should begin hearing testing ■ A warning that in their 20-30s they may have trouble with hearing ● Classification of OI know which you can live with and which you can’t, and which are more severe so basically know the different types ○ Type I: mild bone fragility, blue sclera, normal teeth, pre-senile deafness, poor dentition, most common form ○ Type II: Lethal– don’t survive the trauma of birth and sometimes in utero ○ Type III: Severe bone fragility, progressive deformities, marked growth failure. ○ Type IV: Mild to moderate bone fragility, normal sclera, short stature, possible abnormal dentition. ● Nursing Considerations of OI ○ Type I and IV most common ○ Type II Lethal ○ Primarily supportive care ○ Drug– Pamidronate (increases bone density) ○ EXTREME caution with handling to prevent fractures (Type III) *** ○ Genetic counseling ○ Family education ■ Nutrition ■ Handling and transferring ■ Sports participation – swimming!, no weight bearing
Legg-Calve-Perthes Disease ● Self-limited, idiopathic, occurs in children ages 3 to 12, more common in males ages 4 to 8 ● Avascular necrosis of femoral head (left hip in pic) ○ Dying of the bone from the lack of blood flow ● 10% to 15% of cases have bilateral hip involvement ● Most have delayed bone age ● May present with a complaint of knee pain and/or intermittent painless limp. ● Treatment ○ Rest and non-weight bearing (crutches) when painful; allowed to use their leg normally when not in pain ○ No high impact or running sports (soccer, football, basketball)
Copy of Exam 3- peds
Course: Basic Biology (BIOL 111)
University: Campbell University
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