CHILD AND ILLNESS – Nursing Diagnosis and Intervention

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Physiologic differences between children and adult

1. Skin (Integumentary System)

• Apocrine sweat glands in axillae, perineal and genital areas are small and nonfunctional from birth. Begin to function between 8-10 years old. At puberty, functions increase.

• Body odor is as a result of bacterial decomposing apocrine sweat.

• Adipose tissue accumulates during infancy, then declines in early childhood. Beginning of school age. again starts to accumulate.

• Sebaceous glands increase secretion in puberty resulting in acne, especially on the face.

2. Respiratory system

• Respiratory rate:
Fast in infancy because of more dead air space. As the lungs develops, respiratory rate decreases.

 

Respiratory system Differences

Infection is common because:

• Tissues of the respiratory tract are delicate and do not produce mucus as they will do during childhood.

• The dermal layers of the mucous membranes and epithelium do not provide protection

• There is less humidification & warming of air by other structures

• Infection travels faster to other parts because of the closeness of the parts

• Small size airways causes easy obstruction

• Large tonsils & adenoids make tonsillitis easy.

 

3. Heart & circulatory system

• Newborn pulse rate: 140 beat per minute and slows down over the years.

• When infant is sleeping respirations are slow, heart rate can be irregular -Systolic pressure in newborn is low because of: weakness of left ventricle.

• As left ventricle gains strength. systolic pressure increases.

• Capillaries are able to respond to heat and cold in the environment in later infancy, by contracting to conserve body heat and by dilating to lose body heat .

 

4. Hematologic System

• RBCs macrocytic (large): Life span in neonate is 80 days while in adult is 120 days.

• Physiologic anemia appears in 4- 12 weeks because of cessation of eryrthropoiesis when respiration starts.

• Drop from high fetal levels of fetal RBC .

• Lack of stimulation by erythropoietin resulting from inactivity of the bone marrow.

 

5. Fluids and Electrolytes

• Total body water in infant: 750 ml/kg of body weight.

• Total body water in adult: 550 ml/kg of body weight.

• Newborn 75 -80 % of body weight is water

• Adult 60 % of body weight is water

 

Children, particularly infants develop ketosis and dehydration much faster because:

• Infants retain less water within cells and have more extra cellular fluid which is easily lost.

• The rate of turn over of body water per unit of body weight is more rapid in infant because of their higher metabolic rate & increased urinary output

• Larger body surfaces area in proportion to weight, therefore greater water loss, because of insensible water loss.

• Immature kidneys -impaired ability to conserve fluids and electrolyte.

 

6. Urinary system

• Young infant cannot concentrate urine

• Acute renal failure does not follow chronic renal failure as in adult because young kidneys grow and increase the number of functioning cells.

 

7. Endocrine system

• Endocrine system is important in regulation of growth during childhood.

• Anti-diuretic hormone (ADH) produced by the posterior lobe of the pituitary glands is limited in first year of age. Therefore, diluted urine is expected by infant.

• After birth and early childhood, because of immaturity of body’s metabolism of sugar, blood glucose fluctuates

 

8. Gastrointestinal System

• Cardiac sphincters of stomach is more relaxed in infant, so vomiting is more frequent.

• Peristaltic waves may go in reverse resulting in spitting up and vomiting

• Stools of infant are more loose because feeds are mainly liquid and they pass rapidly through the digestive system.

• Stool becomes formed as solids are introduced and normal flora develops.

• Gastrointestinal tract not able to secret adequate enzyme and fluids and cannot protect them from infection

• Liver is immature during the first year and contain less glycogen ,so more prone to hypoglycemia.

• Control of defecation and urination develops during 2- 3 years.

 

9. Reproductive system

Females:

• Ovaries-increase in size and increase production of estrogen

• By 12 years, appearance of ovary like adult.

• By 13 years, ovulation begins and corpora lutea are seen

Males:

• Testes size increases slowly till school age.

• Greater increases between 6-12 years.

• Genitalia in boys, begins to enlarge between 9½ and 13 ½ years.

• Development is complete between 13 to 17 years

 

10. Musculoskeletal System

• Changes in body proportion is:

• Newborn head is ¼ of the total body length.

• At 6 years it is 1/6 of total body length.

• Adult head is 1/8 of total body length .

• These changes occur because head size increases slowly but the trunk and lower extremities grow rapidly.

• Easy to injure head of infant because the size and weight of head.

• Sutures of the skull not united in new born. In increased intracranial pressure, head enlarges.

• Shape of the head and chest can be changed by constant pressure

 

11. Neurologic System

• Brain grows fast in the first year- 2/3 of adult weight .

• Brain weight continues to increase and physiologic functioning of brain increases greatly with stimulation.

• Most neonatal reflexes disappear between 2-4 months. Examples are: sucking, rooting, palmer grasp, planter grasp, moro reflex.

• Babinski reflex disappears by one year.

• Myelination completed by age 2 when child’s movements are better coordinated.

• Electroencephalography (EEG), changes as electrical activity of the brain changes with growth

 

Sensory function

• Eyes: Lachrymal glands begin to function by 2-3 m .

• Visual acuity: is 20/20 by 6 years. At birth, eye is less spherical and has hyperopic acuity (farsightedness)

• At 8 years, reaches adult size. Puberty myopia (shortsightedness) is common at this age.

• Hearing: Newborn can hear loud noises and respond with generalized movements.

• By 2 months, can hear softer sound and can turn head to that direction.

 

12. Lymphoid and Immune system

• Lymphoid tissues are well developed at birth

• Tonsils and lymph nodes grow bigger due to antigen stimulation (infection)

• During adolescence, adult level of immunoglobulin are achieved.

• Immunoglobulins:

• IgG: Pass through placenta and enter into fetus, after birth IgG level decreases and infant starts to produce own.

• IgM and IgA are produced by the infant.

• Breast-fed babies get antibodies (especially IgA) from milk and colostrum provides local gastrointestinal immunity.

 

Variations in vital signs

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Types of diseases of children

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Definitions

1. Esophageal Artesia: Failure of the esophagus to develop into a continuous passage from the throat to the stomach resulting in obstruction of the normal infant swallowing route.

2. Imperforate Anus : Malformation in which there is no anal opening.

3. Polycystic Kidneys: Kidney enlarged and filled with cysts

 

Tracheoesophageal fistula and atresia – Types

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Imperforate anus

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4. Erethroblastosis Fetalis: A hemolytic disease of the newborn, fetalis characterized by anemia, jaundice, enlarged liver & spleen, generalized edema. Caused by blood incompatibility, Rh negative mother, Rh positive father, and fetus is Rh positive.

5. Rickets: Vitamin D deficiency, affecting bone  development, failure in mineralization in rapid growing bones resulting in skeletal deformities. 

6. Scurvy: Vitamin C deficiency leads tendency to bleed and  degeneration of muscles.

7. Leukemia : An abnormal proliferation and maturation of bone marrow which interfere with normal production of RBCs, WBCs and platelets. It is the most common cancer in children.

8. Wilms Tumor (Nephroblastoma): Rapidly developing tumor of the kidneys that usually occurs in children.

 

9 Beliefs Guiding Pediatric Nursing Practice

1. The family is the basic unit of society.

2. Each child within a family needs love and security to develop feeling of love and self-esteem

3. Each child is a unique individual who has needs based on his or her family background, level of growth and development and degree of illness.

4. The pediatric nurse seeks to promote, maintain and restore health in both children and their parents.

5. Each ill child should be under the accountable care of one professional nurse.

6. The family and the child should be included with the health and nursing team in planning for therapeutic and nursing intervention.

7. Within a safe environment, the child who has an acute or chronic illness needs expert physical care, emotional support and play to express feelings.

8. Parents who have trusting relationship with the nurse feels welcomed whenever they visit and participate in the care of their ill child.

9. The family members and the child are under stress when a child is terminally ill or dying. They should be emotionally supported so that the child can die with dignity.

 

Meaning of Illness to Children

 

• Illnesses that includes hospitalization are experiences outside the usual occurrences of childhood.

• Most children have little knowledge about hospitalization.

• Child’s response to illness depends on
– Stage of cognitive development

– Past experiences

– Level of knowledge

• Concept of the cause of illness
– Preschool – Magical

– School-age – Illness result from breaking rules

– Preadolescent – Caused by germs

– Adolescent – Multiple causes including germs

 

Differences in response of children and adults

• Inability to communicate

• Inability to monitor own care

• Differences in nutritional needs

• Differences in fluid and electrolyte balance

• Systemic response to illness

• Age specific diseases

• Separation anxiety

• Inability to communicate

• Inability to monitor own care

• Differences in nutritional needs

• Differences in fluid and electrolyte balance

• Systemic response to illness

• Age specific diseases

• Separation anxiety

 

Stages of separation anxiety

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Children with special health care needs – Definitions

• Chronic illness: A condition that interferes with daily functioning for more than 3 months in a year or causes hospitalization of more than one month.

• Congenital disability: A disability that has existed since birth but is not necessarily hereditary.

• Developmental delay: A maturational lag – an abnormal slower rate of development in which a child demonstrates a functioning level below that is observed in normal children of the same age.

• Disability: A long term reduction in the child’s ability to engage in day-to-day activities.

• Handicap: A condition or barrier imposed by society, the environment or one’s own self.

 

Impact of illness to children and families

• A child’s reaction to chronic illness or disability depends on his or her developmental level.

• In a child with a chronic illness normal development should be fostered in areas of temperament, intelligence, motor skills, and relationship with family and friends.

• Factors influencing a child’s coping to illness are age, developmental stage, gender, type and duration of illness and family relationships.

 

Impact of chronic illness on an infant

Develop-mental tasks

Effects of chronic illness

Supportive interventions

Develop trust

Multiple care givers and frequent separations.
Deprived of consistent nurturing
Encourage consistent care givers and care by parents in hospital or other care settings.
Encourage parents to visit frequently (rooming in)

attach to parents

Delayed because of separation, parental grief or inability to accept child’s condition

Emphasize healthy, perfect qualities of the infant.
Help parents learn special care needs of the infant.

Develop-

mental tasks

Effects of chronic illness

Supportive interventions

learn through sensory motor experiences

Increased exposure to painful experiences over pleasurable ones.
Limited contact with environment from restricted movement or confinement.
Expose infant through pleasurable experiences through all senses (touch, hearing, sight, taste and movement)
Encourage age appropriate developmental skills – holding bottle.

begin to develop a sense of separateness from parents

Increased dependency on parent for care.
Parental over involvement in care.
Encourage all family members to participate in care.
Encourage periodic respite from caring.

Impact of chronic illness on a toddler

Develop-

mental tasks

Effects of chronic illness

Supportive interventions

Develop autonomy

Master locomotor & language skills

Increased dependency on parent
Limited opportunity to test own abilities & limits.
Encourage independence in feeding, toileting and dressing.
Allow simple choices.
Provide toys that facilitate gross motor skills.

learn through sensory motor experiences, beginning preopera-tional thought

Increased exposure to painful experiences

Institute age appropriate discipline and limit setting.
Accept negative & ritualistic behaviors as normal.
Provide sensory experiences.

 

Impact of chronic illness on preschool child

Develop-

mental tasks

Effects of chronic illness

Supportive interventions

Develop initiative and purpose, Master self care skills

Limited opportunity for success in accomplishing simple tasks or mastering self care skills.

Encourage mastery of self-help skills.

Begin to develop peer relationship

Limited opportunities for socialization with peers.
Protection within family may cause child to fear criticism & withdraw.
Encourage socialization such as inviting friends to play, day care experience or trip to park.
Provide age appropriate play (associative play).
Help child deal with criticism.

Develop-mental tasks

Effects of chronic illness

Supportive interventions

Develops sense of body image and sexual identification

Awareness of body may center on pain, anxiety and failure.
Sex role identification focused primarily on mothering skills.
Encourage interaction with same sex and opposite sex peers and adults.

Learns through preoperational thought

Guilt feelings.
Thinks he or she caused the illness.
Reassure that illness is not a punishment for his or her mistakes.

 

Impact of chronic illness on school child

Develop-mental tasks

Effects of chronic illness

Supportive interventions

Develop a sense of accomplish-ment

Limited opportunities to achieve and compete (many school absences and inability to participate in sports).
Encourage school attendance.
Schedule medical visits at times other than school.
Encourage to make up missed work.
Encourage physical activity.
Inform teachers and class mates about child’s disease

Form peer relationships

Limited opportunities for socialization.

Encourage socialization.

Learn through concrete operations

Incomplete understanding of the imposed physical limitations and treatment

Provide child with information about his / her condition.
Encourage creative activities.

 

Impact of chronic illness on adolescent

Develop-

mental tasks

Effects of chronic illness

Supportive interventions

Develop personal and sexual identity

Increased sense of feeling different from peers and less able to compete with peers in appearance, abilities and special skills.
Accept the difficulties experienced with adolescent as part of normal development (rebelliousness, risk taking, lack of cooperation, hostility to authority).
Provide instruction on  interpersonal and coping skills.
Encourage socialization with peers both with and without special needs.

Achieve independence from family

Increased dependency on family.
Limited job / career opportunities.
Encourage increased responsibility to care for self or management of disease.

Developmental tasks

Effects of chronic illness

Supportive interventions

Form personal relationships

Limited opportunity for heterosexual friendships.
Less chance to discuss sexual concerns with peers.
Increased concerns such as why did he / she get the disease? Or Can he / she marry?
Encourage activities appropriate for age (attending parties, sports).
Be alert to cues that signal readiness for information on sexuality.
Emphasize good appearance.

Learn through abstract thinking

Decreased opportunity for earlier stages of cognition may impede achieving level of abstract thinking.

Discuss planning for future and how condition can affect choices.

 

Children’s understanding to dying

A child’s understanding and experience of death is related to the child’s developmental stage.

• Infants and toddler
Have no concept of death. Immobilization, regression to less independent level of behavior, separation, intrusive or painful procedures and alterations in ritualistic routine are great threats to seriously ill toddlers. They are upset by parental behaviors of sadness, anxiety, depression or anger.

• Preschool children
Children between 3-5 years have heard the word “death” and have some idea. They see death as departure or as a type of sleep. They consider disease as punishment for their actions. If parents do not stay with the child during hospitalization or procedures they think parents do it for their previous misdeeds. Their greatest fear is concerning separation from parents

• School age children
Still children associate disease to misdeeds and experience guilt. Yet, they accept logical explanations. Children of 6-7 years relate death to supernatural powers such as God, ghost or a bogey man. By 9-10 years most children have the adult concept of death. School children fear the expectation of death more than its realization. Therefore anticipatory preparation is needed for them. The sick child may exhibit fear of death through verbal uncooperativeness. Encourage the child to talk about the concerns.

• Adolescent
They have mature understanding of death. They may consider deviations from acceptable behavior as cause of illness. Even though they understand death, it is more difficult for them to accept it.

 

Nursing diagnoses for a child with chronic illness

1. Delayed growth and development R/T chronic illness, parental reactions and repeated hospitalizations.

2. Risk for interrupted family process R/T situational crisis.

3. Anxiety and fear R/T tests, procedures and hospitalization.

4. Risk for injury / complications R/T the developmental stage or nature of disease.

5. Lack of stimulation / play R/T hospitalization.

6. Impaired social interaction R/T hospitalization.

7. Self care deficit R/T specific impairment (specify).

8. Disturbed body image R/T perception of disability.

 

Needs of children

• Physiological needs for children

1. Respiration

• Assess the breathing pattern.

• Clear the airways by positioning and suction.

• Administer Oxygen.

• Monitoring Oxygen saturation and blood gas.

2. Nutrition

• Assess the nutritional status.

– Assist the child in feeding.

– Monitor intake and output.

3. Maintenance of body temperature

• Check the body temperature.

• Maintain room temperature.

• Proper clothing according to the climate.

•Physiological needs for children

4. Rest and sleep

• Provide a comfortable bed.

•Provide calm and quiet environment.

• Avoid painful procedures at sleep timings.

5. Elimination

• Assess elimination pattern

• retention of urine, incontinence, constipation, diarrhoea.

Safety and security needs

• Protect the child from physical injuries.

• Use restraints whenever necessary. – Do not leave medicines at bedside.

• Involve parents in caring.

• Encourage bringing security objects. .

• Love and belonging

• Involve parents in caring.

• Encourage bringing security objects.

• Maintain friendly relationship with the child.

• Recognition and esteem

• Call the child by pet name.

• Encourage self-care.

• Praise the child for each positive response made.

• Creativity and self actualization

• Provide toys appropriate for age.

• Encourage plays permitted by the child’s health status.

• Provide books and pictures.

 

Psychological reactions of parents upon hospitalization of their child

Psychological reactions

1. Separation from child

2. Fear other people may take their place

3 . Feelings of in adequacy

4. Not competent for what they are doing

5. Anxiety

6. Guilt

 

Nursing Interventions for parents upon hospitalization of their child

• Explain the need for hospitalization

• Allow the parents to visit the child

• Involve the parents in giving care

• Encourage them to ventilate feelings

• Teach the special care needed the child.

– Encourage parents to ask questions and clarify doubts

– Praise the parents for what caring for the child.

– Identify the cause of anxiety

– Reassure parents

– Inform the parents the of progress in the child’s condition

– Encourage express their feelings of guilt

– Explain that child’s illness is not a punishment for parent’s sins .

– Reinforce spiritual faith

 

Expected outcomes from parents upon hospitalization of their child

• Parents verbalize feelings of attachment to the child.

• Parents demonstrate competence in caring for the child.

• Parents verbalize reduction in the level of anxiety and guilt.

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