pt centered care families exam 3 week 3

mandated reporters

why to report: failure to report is a misdemeanor

how to report: within 24 hours oral and 72 hours written, follow organizational guidelines, involve psychosocial team

what happens next? CPS (if investigation warranted and positive → civil court)

what happens after that? law enforcement (if investigation positive → criminal court)

BC OF SCREEN OUTS, ALWAYS USE THE WORD ABUSE AND EXPLAIN RATIONALE!

who to call?

CPS: immediate safety not a concern, but maltreatment is suspected

law enforcement: when immediate safety is an issue

child abuse specialist: advice on management, reporting, transfer of care

protective holds

can only be done by law enforcement

• LE can initiate for safety of the child/children

• parents retain decision making

• LE not the hospital, decide on terms of visitation

• health care workers would not be responsible for supervision

signs of abuse

• histories inconsistent with injuries

• delay in seeking medical care

• changing history

physical signs

• bruises on infants

• bruises on face, trunk, hands, ears, genitalia, or buttocks

• patterned bruises or burns

• fx of ribs, sternum, and scapula

• shaken baby syndrome

incidence of head trauma?

• abusive head injury is a leading cause of serious head injury in small children (shaken baby syndrome)

• 95% of serious head injury in <1 year

• higher in premature infants, twins, children with moms < 18 yrs, children in military families

• 2/3 perpetrators are male

• risk of fatal abuse increases 50x when an unrelated male is living in home/caring for baby

sexual abuse

under age 5 affects boys and girls equally

above age 5 boys rarely report

girls have higher rates of abuse as adolescence progresses

most exams “normal” (report is usually delayed, ano-genital area heals rapidly and often w/o scarring, the perpetrator may take care to not cause injury)

children must be over 3 yrs to be interviewed

STI’s IN CHILDREN OVER 3 LESS THAN 10 IS SUSPICIOUS!

physical forensic exam

pre pubertal

• test for STIs, do not treat empirically

• never do speculum exam

• evidence collection window up to 24 hours

post-pubertal

• consider testing for STIs, often treat empirically

• may require speculum exam

• evidence collection window up to 72 hours

neglect

failure of a caregiver to

• provide food, clothing, shelter, medical or mental health care, education, or appropriate supervision

• tough to prove, SDOH play a factor

(protect a child from conditions that endanger the child, and take steps to ensure that a child is educated as required by law!)

hydrocephalus

excess fluid in the ventricle in the brain

3 types

1. congenital

2. acquired (post injury or surgery)

3. infectious (usually time limited)

management: meds, external ventricular drain, shunts

nursing considerations: infection, monitor for signs of increased ICP, malfunction, education/when to call

signs of increased ICP (intracranial pressure) in infants?

• bulging fontanels

• increased head circumference

• high pitched cry

• distended scalp veins

• bradycardia

• respiratory changes

signs of increased ICP (intracranial pressure) in children?

• irritability

• headache

• vomiting

• diplopia

• seizures

• bradycardia

• respiratory changes

meningitis diagnosis

diagnosis is brudizinski’s sign and kernig’s sign (extension), LP (viral is clear, normal glucose and protein, bacterial is cloudy, elevated glucose, and gram stain…)

meningitis nursing considerations

• monitor for signs of increased ICP

• spinal headache (post LP)

• seizure precautions

• comfort measures

• calm, quiet, cool, dark room

• fluids and supportive cares

• meds for bacterial (antibiotics, steroids)

head injury

concerning if…

• loss of consciousness or confusion

• bleeding does not stop

• under 2 yrs

• vomiting

• seizures

• slurred speech or blurred vision

• inconsistent report

treatment: ice, rest, stitches…

concussion

common causes in children are

• sports (53%)

• school PE

• bike/recreation

• motor vehicle

• home accidents

• other

treatment: rest, low light, brain rest no screens, gradual return to school, no activities until symptom free

headaches

types: headache, migraine, cluster

acute onset: vision check, sleep, stress measures

reasons for concern: unusually severe, vomiting (without nausea), weakness/balance issues

seizure disorders

classified by type and etiology and location

• focal: one area of the brain

• generalized: entire brain

risk factors

• fever

• tumors

• infection

• toxins, drugs

• head injury

epilepsy

2 unprovoked seizures at least 24 hours apart

followed by 1 seizure within 10 years

clonic (grand mal) seizures

most prevalent, 3 phases

1. tonic: loss of consciousness, eye roll, arch (10-30 sec)

2. clonic: violent jerking (30-50 sec)

3. post ictal: sleepy, confused (30-60 minutes)

absence (petit mal) seizures

• onset between 4-12

• generally gone by adolescence

• brief LOC

• staring

• motionless

myoclonic seizures

• brief contractions of one or more muscle groups

• no LOC

• no postictal

atonic (drop attacks) seizures

• 2-5 years at onset

• lose muscle tone

• fall, then confusion

partial seizures

• focalized

• may just be tingling, eye aversion

infantile spasms (west syndrome)

• 4-8 months onset

• rarely after 2 years

• tx is ACTH

seizure disorder treatment

surgical procedures, vagal nerve stimulator, meds

meds

• immediate rescue: diazepam or lorazepam (often rectal)

• most rescue meds given rectally

side effects of meds are sleepiness, mental fog, and stevens johnson-lamotrigine

spina bifida

location of lesion determines impact

HIGHER LESION = GREATER IMPAIRMENT

T12: neurogenic bowel and bladder, impaired sensation and mobility of lower extremities (not able to walk)

L1-L3: hip flexion and feet issues

L2-L4: hip adduction

L3-S2: hip adduction and knee and hip flexion

S3: no motor impairment

spina bifida nursing considerations

• elimination issues (mitrofanoff and ace stoma!)

• risk for infection

• immobility

• nutrition

• risk for impaired skin integrity

• education

cerebral palsy

unknown causes

• in utero, during birth, neonatal period

• infection, insufficient oxygen, genetics

• more common in LBW babies

may include…

• seizures

• visual, hearing, or speech impairments

• cognitive impairments

• motor impairment

• spasticity, weakness

what are the 3 types of cerebral palsy?

spastic: high tone

dyskinetic: jerking or twisting movements

ataxic: wide gait, lack of coordination

(wide variation in presentation, not progresive)

risk for: immobility, pressure injuries, pain, respiratory issues, GI issues (nutrition and elim)

duchenne muscular dystrophy

neurodegenerative disease

• inherited genetic disorder

early symptoms: frequent falls, waddling gait, muscle weakness

progresses to: trouble swallowing, trouble breathing, heart problems, scoliosis

most may pass in their 20’s

• nursing considerations include early involvement w/palliative care and psychosocial support, respiratory support, mobility devices, advanced care planning…

musculoskeletal conditions

• soft tissue injury

• fracture

• infection

• congenital

fractures

• common injury in children

• methods of treatment differ for children and adults

• RARE IN INFANTS, WARRANTS INVESTIGATION!

• distal forearm is most common fx site

• school age most common

neurovasculature assessment (CMS)

used for musculoskeletal conditions involving tissue injury or immobilization (ex: fractures)

• skin color

• capillary refill time

• temp

• sensation

• movement of digits

• pulse distal to the site

assessment of fractures?

5 P’s

• pain

• pallor

• pulseless

• poikilothermia

• paresthesia

• paralysis

IF ALL 5 PRESENT AFTER IMMOBILIZATION, CONSIDER COMPARTMENT SYNDROME!

compartment syndrome

medical emergency, typically seen in first 24-48 hours

bleeding and swelling into the tissue

signs and symptoms

• 5 p’s! pain, pallor, poikilothermia (coolness)

• paresthesia (numbness, tingling)

• pulselessness (faint or diminished at early stages)

• paralysis (late finding)

cast needs to come off (often times just to check and be safe)

fasciotomy…

muscle; acute viral myositis

often a post viral syndrome

muscles become…

• inflamed, achey

• release myoglobin

• causes short term mobility issues

• can cause renal damage

nursing considerations

• admin fluids

• monitor renal status

• treat pain and inflammation

• encourage mobility

muscle rhabdomyolysis

rare in children BUT a medical emergancy

• typically after an injury, over use, or burns

• muscle breaks down and dies

• massive release of myoglobin and other toxins which damage the kidneys

• LIFE THREATENING

signs and symptoms

• muscle weakness

• swelling, tenderness

• dark urine, tea colored or red

nursing considerations

• monitor electrocytes and renal function

• fluids, rest

• may require dialysis or CRRT

osteomyelitis

• infectious process in the bone

• may be caused by exogenous or hematogenous sources

• staphylococcus aureus: the most common causative organism

osteomyelitis diagnosis

• signs and symptoms begin abruptly

• resemble symptoms of arthritis and leukemia (fatigue, achiness)

• marked leukocytosis

• bone cultures obtained from biopsy or aspirate

• radiographs (X rays: may appear normal at first)

• bone scans for diagnosis

osteomyelitis management

long term IV antibiotics (PICC line!)

• presentation may be subacute, with walled-off abscess rather than spreading infection

• prompt, vigorous intravenous antibiotics for extended period (3-4 weeks or even months)

• monitor hematologic, renal, hepatic responses to treatment

osteomyelitis nursing care

• promote bed rest and immobility of limb

• pain management

• long term IV access for antibiotics (PICC line)

• nutritional considerations

• long term hospitalization or therapy

• watch for DVT

• provide routine/activities

• psychosocial needs

• monitor labs

club feet

about 50% will have bilateral deformities

• may be corrected w/exercises or stretching, or splinting or serial casting

• may need surgery

• treatment starts at 1-2 weeks after birth

• GOAL IS FOR CORRECTION BEFORE CHILD STARTS TO WALK!

osteogensis imperfecta

less common, brittle bone disease

• genetic disorder

• results in frequent fractures and limb deformities

• severity varies by type and subtype

• most often wheel chair bound

• affects eyes, ears, and heart as well

achondroplasia

dwarfism

increased risk of: obesity, hydrocephalus, skeletal issues, bowed legs (varus)

multiple surgical corrections are often needed

• limited life expectancy but NOT terminal prognosis…