A Message from Mark Baiada

BAYADA Home Health Care has a special purpose—to help people have a safe home life with comfort, independence, and dignity.

BAYADA will only succeed with your involvement and commitment as a member of our home health care team. I recognize your importance to the organization and appreciate your compassion, excellence, and reliability.

I value the skills, expertise, and experience that you bring with you. And, as an organization, BAYADA is committed to providing you with opportunities to help broaden your expertise and experience. Acquiring new skills will allow you to participate in the care of a wider variety of clients. That makes you an increasingly valuable member of our home health care team. Most importantly, our clients benefit when you successfully master new skills that contribute to their safety and well-being.

BAYADA University and the School of Nursing courses are designed to help you perfect your knowledge and skill to achieve clinical excellence in the care of clients. I applaud your willingness to continue the journey of life-long learning and wish you continued success in your professional development as an important member of the BAYADA team.

Sincerely,

Mark Baiada President

Table of Contents

Welcome ...... iv

Introduction to home care ...... 1

Psychosocial ...... 13

Growth and development ...... 28

Assessment...... 69

Pathophysiology ...... 131

Nutrition and hydration ...... 182

Medication administration ...... 203

Safety ...... 220

Rehabilitation ...... 255

Equipment ...... 282

Pain, palliative care, and hospice ...... 200

Documentation ...... 318

Return demonstration checklists ...... 328

Welcome

Welcome to BAYADA University. The goal of the BAYADA Home Health Care School of Nursing is the Achievement of Clinical Excellence (ACE).

At BAYADA, we are committed to providing our clients and families with the best care possible. To accomplish this, we rely on our exceptional nurses who follow our core values of compassion, excellence, and reliability.

For the pediatric client who has a life altering condition or illness, it is important to them and their families that they receive care from nurses who are compassionate, competent, and confident.

It is also important to us that we provide a supportive learning environment for all of our team members. This means helping nurses gain knowledge and master the skills that will enable them to best meet the care requirements of our clients.

Strategies for achieving our goals To ensure that you can meet our high standards of nursing care and that you have opportunities to grow in your professional practice, all nurses at BAYADA receive:

• General orientation upon hire • Specific orientation for new case assignments • Continuing education and in-service opportunities

The ACE Clinical Learning System is part of our ongoing commitment to professional staff development.

The ACE Clinical Learning System is self-directed, which means that you, the learner, will take responsibility for your own learning. We believe that you can best determine when and where you want to learn. Self-directed learning also allows you to learn at your own pace. You can take the time you need to master both the learning and performance objectives before you are formally tested on them.

Depending on your experience level, you could master the learning objectives by reading this self-directed learning course in three to four hours. It may take more time and it may take less.

Also depending on your experience level, you may practice the performance objectives on a mannequin for one to two hours and feel competent to demonstrate your mastery. You may be very familiar with basic nursing procedures and require very little practice time. You may need more practice time. That’s the beauty of self- directed learning. You can control when, where, and how to pace your learning.

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Who must complete this clinical course? New nurses with no experience in the care of pediatric clients in the home are required to complete the appropriate self-directed learning course.

New nurses with experience in pediatric home care are encouraged to complete the self- directed learning book and video but may forego the practice component.

All nurses who will be caring for pediatric clients in the home must perform a return demonstration and pass the relevant exam with mastery to certify that they are competent to be oriented to a client, begin a preceptor program, or be permanently coded.

Components of the system The ACE Clinical Learning System contains the following elements:

• Self-directed learning package • Laboratory practice and guided practice • Return demonstration • Certification exam • Preceptorship and orientation

Self-directed learning course The self-directed learning book and video present the information and procedures you will need to know in order to deliver safe care to a pediatric client in the home care setting. Your service office staff will give you the appropriate self-directed learning course relative to the type of clients for whom you will care.

Each section of this book begins with a series of learning objectives. They identify the subjects you must be able to list or discuss before moving to the next section.

Quizzes at the end of each section will test your mastery of the learning objectives. Do not continue to the next section until you have mastered the current section’s learning objectives by passing the section quizzes with 100 percent score. You will see the quiz symbol in the margin when there is a quiz to be completed.

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Welcome

This icon refers to BAYADA Home Health Care policy.

Laboratory practice and guided practice Once you have read the book and completed every quiz with 100 percent mastery you may practice the newly learned skills and procedures on mannequins in a laboratory setting. Practice means performing the new skills and tasks until you have mastered them.

You may choose to practice on your own and then schedule time with the nurse educator or coach for additional guided practice. Or, you may want to schedule guided practice first, ask questions, and then practice on your own. Or you may not wish to practice at all. The choice is yours. Guided practice will give you the benefit of feedback from the nurse educator or coach. You will see a stethoscope symbol in the text margins to indicate when practice is needed.

Return demonstration Once you feel completely confident in your abilities to successfully demonstrate the performance objectives of the pediatric home care course, you must schedule a return demonstration with the clinical instructor or clinical manager. At the end of this self- directed learning course is a sample Return Demonstration Checklist which lists all of the skills you will be expected to fully demonstrate.

Certification exam Passing the certification exam signifies that you have successfully mastered the cognitive objectives of this course. The certification exam may be completed before, at the same time, or after you perform the return demonstration.

The person who gave you this self-directed learning package will tell you how to schedule time to take the certification exam.

Upon successful completion of the self-directed learning package, the return demonstration, and the certification exam, you will be ready to be oriented to a client or begin a preceptor program.

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Preceptorship and orientation After you have successfully completed the certification exam and the return demonstration, you will begin your precepting period in the home setting. You will work side by side with a preceptor to demonstrate your skills you performed in the lab setting. Initially, you will have a minimum of 16 to 24 hours or orientation for each age range; infant, 0 to 18 months and pediatric, 19 months to 18 years, depending of the client’s skill level and your experience. The orientation period will continue until you have successfully demonstrated all the required skills for that client. At that point, you will be able to work independently on that client. Ongoing, you will receive a minimum of two hours of orientation to new clients.

Learning objectives

Chapter one: Introduction to home care 1. Discuss the psychosocial impact of a medically fragile child 2. Discuss professional boundaries in dealing with clients and their families 3. Discuss how to create and maintain a positive and collaborative environment when providing home health care services 4. Discuss guidelines for encouraging client compliance 5. Discuss guidelines for effective client teaching

Chapter two: Psychosocial 1. Discuss the psychosocial impact of a chronically ill child on the caregivers 2. List commonalities of parents with children with special needs 3. Discuss the practical insights for caregivers

Chapter three: Growth and development 1. List the stages of childhood 2. List the developmental milestones for each group 3. List the recommended immunizations 4. Discuss prematurity and how to determine adjusted age

Chapter four: Assessment 1. Demonstrate how to obtain vital signs and measurements 2. State normal, age-related vital signs 3. Describe and perform a pediatric assessment 4. Describe normal and abnormal assessment findings per system: a. Skin

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b. Head, eyes, ears, nose, and throat c. Pulmonary d. Cardiovascular e. Gastrointestinal f. Genitourinary and reproductive g. Musculoskeletal h. Neurological and developmental 5. Identify signs and symptoms of abuse 6. List the elements of a psychosocial assessment

Chapter five: Pathophysiology 1. List common chronic childhood disorders a. Prematurity b. Asthma c. Apnea d. Bronchopulmonary dysplasia e. Reflux f. Seizures g. Cerebral palsy h. Neuromuscular diseases such as dystrophy and spinal muscular atrophy 2. Discuss pathophysiology as it relates to chronic childhood diseases 3. List appropriate interventions related to each discussed disease process 4. List signs and symptoms of the disease process

Chapter six: Nutrition and hydration 1. Discuss fluid and caloric intake for each age group 2. List causes of feeding intolerances 3. Discuss alternative feeding methods 4. Demonstrate placement, care, and maintenance of feeding tubes 5. Discuss developmental issues related to fluid imbalance 6. List components of a physical assessment for assessing hydration status 7. List signs, symptoms, and degrees of hydration

Chapter seven: Medication administration 1. Demonstrate metric conversions 2. Demonstrate calculations 3. List the five rights of medication administration

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4. List methods of administration 5. List the steps for appropriate documentation 6. Identify special considerations in medication administration 7. Identify methods to safely administer medications and prevent errors

Chapter eight: Safety 1. List age and developmental risk factors 2. List environmental related risk factors 3. Discuss emergency responses to various risk factors 4. Discuss infection control and standard precautions

Chapter nine: Rehabilitation 1. Discuss the significance of educational intervention plans 2. Identify members of the multidisciplinary team and their function 3. List adaptive equipment and discuss safe use of each

Chapter 10: Equipment 1. List the use and function of each of the following pieces of equipment a. Oxygen b. Pulse oximeter c. Apnea monitor d. Nebulizer e. CPAP/BiPAP f. Therapy vest and percusser g. Feeding pumps h. Coughalator i. Hand ventilator j. Compressor and humidifier 2. Discuss safety and maintenance of the equipment

Chapter 11: Pain, palliative care, and hospice 1. Discuss types and assessment of pain 2. Identify medications and comfort measures 3. Identify responses to interventions 4. List integrative comfort measures 5. Define palliative care 6. Discuss the requirements related to a DNR

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7. Identify the signs of approaching death 8. Discuss documentation of the dying process and pronouncement

Chapter 12: Documentation 1. List steps of the nursing process 2. Discuss basic documentation rules 3. List who to notify when changes in client status occurs 4. Demonstrate documentation related to assessments, interventions, outcomes, and emergencies

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Our special thanks to the following individuals who have contributed to this program

Elizabeth Brady, RN, BSN, Pediatric Clinical Support Specialist

Barbara A. Colin, RN, MSN, Chief Nursing Officer

Susan Engel, RN, BSN, Infection Control Coordinator

Georgette Gibbs, RN, Pediatric Clinical Support Specialist

Jackie Kirchhoff, RN, MSN, Clinical Support Specialist

Kim Lynn, RN, BSN, CRRN, Pediatric Clinical Support Specialist

Margit Moran, RN, BSN, Pediatric Clinical Support Specialist

Kathleen Pfeiffer, RN, BSN, Director of Pediatric Clinical Operations

Elizabeth Wenger, RN, BS, Pediatric Clinical Manager

Other contributors

Albert M. Freedman, Ph.D., Licensed Psychologist Molly Watson, parent; Parent Speak

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Introduction

Once you complete this section, you should be able to: 1. Discuss the psychosocial impact of a medically fragile child 2. Discuss professional boundaries in dealing with clients and their families 3. Discuss how to create and maintain a positive and collaborative environment when providing home health care services 4. Discuss guidelines for encouraging client compliance 5. Discuss guidelines for effective client teaching

Contents

Psychosocial impact of a medically fragile child ...... 3 Fear ...... 3 Anger, depression, and guilt ...... 4 Caregiver strain ...... 4 Maintaining professional boundaries ...... 4 Guidelines for establishing professional boundaries ...... 5 The benefits of maintaining professional boundaries ...... 5 Risks when professional boundaries are not maintained ...... 6 Staying on track as a professional ...... 6 Professional boundaries: questions to guide your actions ...... 6 Creating a collaborative working environment ...... 6 Guidelines for collaboration ...... 7 Encouraging client compliance ...... 8 Guidelines for compliance ...... 8 Effective client teaching ...... 9 Guidelines for teaching ...... 9

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Psychosocial impact of a medically fragile child Clients and their families are well aware of the critical importance that home health care plays in the life and well-being of a child. Families know that home health care provides the ability for the family to maintain the family unit and keep their loved one at home.

Clients and their families also understandably have many concerns and anxieties related to the disease process. The need for home health care often intensifies the already stressful aspects of living with a child with a disability or serious medical condition.

The home health care nurse needs to be aware of common psychosocial challenges experienced by clients and family members. A thoughtful and reasoned approach to responding to the emotional needs of clients and family members strengthens the relationship between nurses and clients, thereby increasing the effectiveness of the services provided in the home.

Among the many issues that nurses may encounter in family caregivers and other family members are fear, anger, depression, guilt, and caregiver strain.

Fear Family members experience fear as a Parents often have many fears related to their child’s disabilities such as the result of the disability child’s general health and uncertainty about the future. Many of our clients or disease process of have had at least one hospitalization and family caregivers are keenly aware their loved one. of the importance of clinical excellence in preventing problems and Family members fear emergency situations. The need for assistance is often the primary reason the possibility of a more serious illness that nursing has been requested for the client in the home. Clients rely on or the loss of their you, the nurse, to provide safe, thoughtful, and responsible care. loved one. Additionally, the caretaking needs of the client can have significant impact on quality of life, independence, and employment of family members.

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Anger, depression, and guilt Emotional reactions to the underlying injury or disease such as anger, depression, and guilt are often reactions to the loss of control that has occurred.

Parents may experience unresolved anger related to the many changes that have occurred in their lives. These feelings of anger and resentment may be the result of:

• Increased dependence on others for providing basic health care needs for their child • Feelings of powerlessness due to frequent changes in the child’s needs • A sense of responsibility for the impact of a medically fragile child on the family including other children in the home

Parallel feelings of anger and guilt related to the impact of providing ongoing care for a child may also be experienced by all family members.

Caregiver strain The impact of caring for a loved one on the family caregiver can often be overlooked. In home health care cases, the role of the client’s family caregiver is critical. Without them, the client would often be unable to remain at home.

The burden of this responsibility often takes an emotional toll on family caregivers. They too, experience a loss of control, loss of freedom, and a sense of loss in their own lives. Family caregivers may experience anger, anxiety, and despair, which may parallel the emotional state of the client. Complicating these feelings is the guilt that often accompanies them. Physical strain, loss of sleep, and the stress inherent in caring for a medically fragile child may leave family caregivers more susceptible to feelings of anger and guilt.

Maintaining professional boundaries Understanding the dynamics of the family can help you, the nurse, to identify supportive strategies to assist not only the client but also the client’s family. Working together with the family will help ensure that the client is safely and successfully maintained in the home. While attending to the physical and emotional needs of the client and family, however, the nurse must always be aware of appropriate professional boundaries.

The power of the nurse comes from the professional position, access to confidential medical information, and the ability to meet the physical needs 4

Introduction

of clients who are unable to care for themselves. Establishing appropriate boundaries will support your efforts to balance the difference in power between you and the client while continuing to meet the client’s needs. The nurse’s power must be used to assist the client rather than misused in any way. Clients and their families expect the nurse to act in their best interests and to show respect for the client at all times. Maintaining consistent professional boundaries supports the goal of respecting the dignity of the client.

Guidelines for establishing professional boundaries • Arrive on time • Dress appropriately • Avoid discussing personal issues • Treat client and family respectfully • Communicate clearly with the client and family regarding the treatment plan • Be self-aware: know yourself and your own needs • Recognize when you experience stress and seek supervision • Promote the independence of the client and family • Remain client-focused

The benefits of maintaining professional boundaries

To the family and To the client To the nurse caregiver

• Promotes the self- • Provides clarity • Supports a confidence, self-worth, regarding expectations professional and and dignity of the of staff in the home positive approach to client • Promotes providing services • Fosters independence understanding of • Assists the nurse in and sense of agency procedures communicating clearly responsibility for the and protocols regarding expectations client’s own care • Fosters child of clients and families • Allows for client/family advocacy role, which • Reduces the risk of involvement in reduces the burden on over- or under- decision-making about caregivers involvement in the treatment approaches case

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Risks when professional boundaries are not maintained

When providing health care in the home, establishing and maintaining Repeatedly crossing appropriate professional boundaries can be difficult, but the blurring or boundaries can lead to the loss of absence of professional boundaries could place both the client and the professional nurse at risk. When professional boundaries are not maintained, confusion objectivity, can emerge between the needs of the nurse and the needs of the client or promotion of family. This type of confusion can lead to boundary violations. inappropriate dependency, and over-involvement in the personal affairs Staying on track as a professional of the client and family. Every nurse who enters the home of a vulnerable client or family has the potential to cross professional boundaries. It is common for nurses to inadvertently cross boundaries in subtle ways, but the truly professional and aware nurse quickly recognizes these brief boundary-crossing “excursions” and makes an effort to regain the professional balance as soon as possible. While returning to the established boundaries, the nurse should also carefully examine any resulting consequences to the client or the professional relationship caused by the boundary crossing.

Ask your clinical manager for help and be open to suggestions. Always remember that your office and clinical manager are available to support you.

Professional boundaries: questions to guide your actions  Do all of your actions support the best interests of the client?

If you have questions  Are you able to use both the words “yes” and “no” comfortably with a about your client and parents? professional role or become concerned  Are you able to adapt to the routines and lifestyle of the client and about your level of involvement in a family when working in the home? case, seek support and direction from  Do you feel confident that the client and family are clear about your role? your clinical Do you have a clear sense of the client’s and family’s expectations of you? manager.  Do you consult with your clinical manager when you are unclear about your professional role or you feel you may be losing your objectivity with a client or family?  Is the dignity of the client and family being respected at all times?

Creating a collaborative working environment Our nurses work closely with and under the supervision of physicians. Nurses provide medical care based on specific medical orders. The nurse, however, can only follow the physician’s orders with the cooperation of the client and family. It is vitally important to create and maintain a positive and collaborative environment when providing home health care services.

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For over 30 years, clients and their families have provided feedback to BAYADA Home Health Care nurses about the qualities and characteristics of nurses who create a positive environment in the home. Clients and families value professional nurses who:

• Demonstrate a caring attitude • Listen respectfully • See the child as a whole person—not their disability • Carry themselves with confidence • Demonstrate clinical competence • Recognize and enhance their power and knowledge • Convey and support a sense of hope within the home

Guidelines for collaboration Researchers have also identified key ingredients to successful collaboration between home health care professionals and families. Research has shown that professional collaboration with the family is most successful when it: 1. Promotes a relationship in which family members and professionals work together to ensure the best services for the client and the family. 2. Recognizes and respects the knowledge, skills, and experience that both families and professionals bring to the relationship. 3. Acknowledges that the development of trust is an integral part of a collaborative relationship. 4. Facilitates open communication—families and professionals feel free to express themselves. 5. Creates an atmosphere in which the cultural traditions, values, and diversity of families are acknowledged and honored. 6. Recognizes that negotiation is essential in a collaborative relationship. 7. Brings to the relationship the mutual commitment of families, professionals, and communities to meet the needs of clients and their families.1

1 Bishop KK, Woll J, Arango P. Family/professional collaboration for children with special health care needs and their families. University of Vermont: Family/Professional Collaboration Project, Department of Social Work; 1993.

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Encouraging client compliance Establishing a positive working relationship with the client and family usually leads to a pattern of consistent client compliance with medical protocols and orders. A client’s or caregiver’s noncompliance may prevent you, the nurse, from performing your job effectively. Noncompliance may also cause the client harm.

Guidelines for compliance The following guidelines for the nurse are provided to assist you in maintaining a collaborative relationship with clients and family members while keeping client compliance a high priority in your work in the home: • Gain client and family’s respect and confidence by remaining professional—the client needs to be able to count on you • Be consistent in your behavior and in your delivery of care • Involve the client and family in the care and make them partners who collaborate with you in the delivery of care • Develop a routine together • Provide choices to the client whenever possible • Respect family members • Ask the family to tell you about their normal household routines and preferences and show the family that you are willing to incorporate their personal preferences into your care as much as possible • Explain the specific types of medical care and procedures you are providing and the reasons for them • Do not assume the client or family has received information about the client’s care from other professionals • Maintain your objectivity and honesty when interacting with the client and family • Remain nonjudgmental at all times when in the home

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Effective client teaching A significant responsibility for every one of our home health care professionals is to teach the client and family. Helping clients and families learn about the client’s care empowers everyone involved to make informed decisions and function more independently and effectively. Good client teaching helps clients and families properly differentiate between their abilities and their limitations.

Guidelines for teaching To promote effective teaching and learning in the home, consider the following guidelines: 1. Teach to the learning level of your client and family—don’t use medical or technical terms or abbreviations which may be unfamiliar. 2. Allow uninterrupted quiet time for teaching. When possible, schedule a time when you know you will be able to avoid interruptions or distractions. Allow sufficient time so the client or caregiver does not feel rushed or overwhelmed. 3. Allow time for the client and family to practice the procedures you have demonstrated. 4. Build on past learning. Begin with simple tasks and slowly build to more complicated procedures. Avoid overwhelming the learner. Each step of the way, check with the client and family member to ensure they are able to keep up with you. 5. Allow plenty of time for questions and create an accepting environment in which the client and family caregiver do not feel uncomfortable asking questions. 6. Provide opportunities for the client and caregiver to perform procedures they have been taught. Do not do everything for them. Ultimately, the goal is to have the client and family caregiver understand and capably provide the care independently. 7. Ask questions to assess learning. If the client and caregiver are not learning effectively, seek assistance and guidance from your manager. The client’s safety is always the highest priority and must be maintained.

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Before continuing on to the next section, answer the following questions by circling the appropriate letter. Check your responses with the answers below.

1. Which psychosocial issue might family caregivers experience while caring for a child with special needs? (A) Fear and anger.

(B) Depression and guilt. (C) Caregiver strain. (D) All of the above.

2. Which of the following would NOT be helpful in establishing professional boundaries? (A) Arriving on time. (B) Avoiding discussion of personal issues. (C) Dressing provocatively. (D) Treating the client and family respectfully.

3. Clients and families value professional nurses who do all of the following EXCEPT: (A) Demonstrate a caring attitude. (B) Share their professional and personal concerns with the family. (C) Carry themselves with confidence and demonstrate clinical competence. (D) Listen respectfully.

4. Research has shown that professional collaboration with the family is most successful when it: (A) Recognizes and respects the knowledge, skills, and experience that families and professionals bring to the relationship. (B) Acknowledges that the development of trust is an integral part of a collaborative relationship. (C) Creates an atmosphere in which the cultural traditions, values, and diversity of families are acknowledged and honored. (D) All of the above.

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5. Which guideline would NOT assist you in maintaining a collaborative relationship with your client and family members while keeping client compliance a high priority?

(A) Develop a routine together. (B) Provide choices to the client when possible. (C) Be inconsistent in your behavior and in your delivery of care. (D) Incorporate the family’s personal preferences into your care as much as possible.

6. To promote effective teaching and learning in the home, you would consider all of the following EXCEPT: (A) Teach using the latest medical terminology. (B) Allow uninterrupted quiet time for teaching. (C) Allow time for the family to practice the procedures you have demonstrated. (D) Keep in mind the goal is to have the caregiver understand and capably provide the care independently.

Answers: 1. D, 2. C, 3. B, 4. D, 5. C, 6. A

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Psychosocial

Once you complete this section, you should be able to: 1. Discuss the psychosocial impact of a chronically ill child on the caregivers 2. Indentify methods of conflict resolution 3. Discuss the impact of diversity 4. Indentify family support systems

Contents

Overview ...... 15 The good news, the bad news ...... 16 Parents are the gateway to your clients ...... 16 Statistical support ...... 17 The theory of chronic sorrow ...... 17 The fatigue of chronicity ...... 19 The balsa wood bridge theory ...... 20 Practical insights for caregivers ...... 21 Setting boundaries ...... 24 Our special children...... 24 Positive outcomes...... 24 A universal apology ...... 25

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“That my child, therefore, may have some small share in creating this new light, I tell her story. She cannot know what she does, but I who am her mother will do it for her and in her name, that others like her may have the benefits of a fuller knowledge, a better understanding.” Pearl S. Buck – The Child Who Never Grew

Who better to teach nurses about the psychosocial needs of family caregivers than the parents of our clients? The following chapter was developed by Molly Watson, the mother of Maggie, who has mitochondrial disease, and has been a BAYADA client since 2000. Molly is the founder of Parentspeak, an organization dedicated to enhancing partnerships between health care providers and parents to advance the care of children with severe disabilities.

Overview Welcome to the world of pediatric home health care. As a parent, I commend you for your commitment to our children. You are valued as an integral component of our children’s medical and emotional well-being. You will quickly find out that, in order to best meet the needs of our children, you must be able to have a productive and mutually respectful relationship with their parents. In many ways, you have a double challenge—you must care for our children while navigating the complex environment of home health care and the family. You may even feel like you have a second client in the parent, since they are often the children’s main mode of communication.

With this in mind, the following section has been designed to:

• Provide insight into the emotional and practical mindsets of the parents • Improve communication between parents and home health care professionals • Enhance the care of medically fragile children and children with disabilities by establishing the framework of a lasting relationship

Parents and caregivers work toward the singular goal of providing the best possible care for the child. With this in mind, we hope you will be well- equipped to form a productive partnership with the parents in order to maximize the care of the child.

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The good news, the bad news The good news is that our child qualifies for in-home nursing care. We have waited and fought and debated, and now finally, we have been given the news that help is on the way. But this is also the bad news. Our child “qualifies” for home health care. Hooray. Our child has enough wrong with them for experts to say they need professional nursing at home. They might have a severe seizure disorder or profound developmental disabilities; they might require oxygen or need around-the-clock respiratory treatments; they could have a tracheostomy, a ventilator, a feeding tube…the list goes on and on. And the reality of those issues, combined with our grief over the loss of the child we once had or dreamed of having, wreak havoc on our emotions as parents. So it’s easy to see why it is both good news and bad news.

Parents are the gateway to your clients In pediatric home health care, it is vital to understand the home environment you are stepping into. While each client’s needs are different, there are several commonalities among the parents of children with disabilities. Developing a basic understanding of these will help you in your ability to form a productive and mutually respectful partnership with the parents.

The parent of a child with severe disabilities struggles every day with a variety of emotional and practical issues. This chapter will try to shed some light on those mindsets, so that nurses may have a deeper understanding of what motivates parents and what keeps them up night after night, long after their child is asleep, or the night nurse has taken over. The following areas will be covered:

• Statistical support • The theory of chronic sorrow • The fatigue of chronicity • The balsa wood bridge theory • Practical insights for caregivers • Positive outcomes • A “universal apology”

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Statistical support A formal research study fielded by Dr. L. Andrew Koman of Wake Forest University in 1997 looked at the impact on parents of raising a child with cerebral palsy. The study found that:

• 90 percent of primary caregivers were the child’s mother • 65 percent of parents reported living on a “rollercoaster” • 40 percent reported having no time left to care for the rest of the family • 40 percent reported family sacrifice and parent fatigue as common problems • 45 percent considered having no more children • 43 percent of the parents had difficulty finding appropriate babysitters and caretakers, often relying on relatives for regular and emergency childcare assistance • 13 percent of parents had to reduce the number of hours they were employed in order to care for their child • 34 percent had to quit their jobs, in addition to the 13% who had reduced work hours These are just a few of the complex emotional and practical issues that parents of children with severe disabilities face every day. These statistics set the stage for much of the material covered in this chapter.

The theory of chronic sorrow In the 1960s, Dr. Simon Olshansky, a researcher in the field of rehabilitation, observed parents of children with developmental disabilities and found that these parents suffered from a “pervasive, persistent, psychological and emotional response.” He termed this condition “chronic sorrow.” Chronic sorrow is the recurring grief and sadness of a parent that occurs throughout the lifetime of their child with disabilities. Dr. Olshansky identified it as a natural response to an ongoing tragic event. The cornerstone of chronic sorrow is profound grief.

In order to gain a better understanding of chronic sorrow, it is important to look a bit deeper at grief. Elisabeth Kübler-Ross, MD, studied grief extensively and wrote the landmark book On Death and Dying (New York: Scribner; 1969). In it, she identifies the five stages of grief, as listed here.

1. Denial: The “This can’t be real” stage. “I must be dreaming. When I wake up everything will be fine.”

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2. Anger: The “Why me?” stage. “How could this happen to me? What did I do to deserve this?”

3. Bargaining: The “If I do this, you’ll do that” stage. “Just let this test come back fine and I will never ask for another favor.”

4. Depression: The “Defeated” stage. “I can’t bear to face going through this, putting my family through this.”

5. Acceptance: The “This is going to happen” stage. “I’m ready. I don’t want to struggle anymore. I know I can find happiness again in spite of this.”

Chronic sorrow has a way of retreating and reappearing in the parents throughout the life of the child. It may fade over time, only to rear its ugly head on a birthday, a holiday, or simply an extra-hard day for the parent. It can wash over the parent like a tsunami and send them back to any one of the stages of grief, or even several. It’s like a freshly scabbed wound that gets ripped off over and over again.

Psychotherapist Susan Roos, PhD, used Dr. Simon Olshanky’s research as a basis for her theory of “living loss.” She found that parents of children with disabilities suffer from a “living” loss because the person they are grieving for is not physically dead. Still, the child they had dreamed about prior to birth has died, in a very real sense. The death of a loved one has a somewhat finite period of mourning, while the loss associated with your child is visible, ever-present, and ongoing. Roos validates living loss as an appropriate reaction to an irresolvable condition. There is extreme internal conflict that arises as parents struggle with grief and mourning while caring for their disabled child.

Parents are also challenged to learn to love in a new way. Without the typical parent-child exchanges that help define the relationship, parents must rely on instinct and subtlety. Many of our children can never make eye contact with us, reach for our noses, coo in response to a tickle, or call us “mama” or “daddy.” So we find new ways of bonding with them and developing a relationship that allows us to feel as if they know and love us in return.

While Kübler-Ross defined the fifth stage of grief as acceptance, reaching a nirvana of total and complete acceptance in this situation is rare. Instead, parents work toward defining a new sense of “normal” for themselves and their families. I’ve often heard a parent say, “Yes, life is good now. It’s not what I ever thought it would be and it still hurts, but we’ve figured out our new life and it’s okay.” Yet, even after years and years of adjusting to the

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situation and passionately loving and advocating for their child, the chronic sorrow remains. Author and mother of a daughter with Rett syndrome, Susan Zimmerman, put it eloquently when she wrote:

“We must go to those places of pain that sit at our core like molten lava. There, we are burned to ash. All that came before has changed. The pain and fire have become a part of us. The ash becomes fertilizer for new growth.”

The fatigue of chronicity Parents experiencing this kind of fatigue might be thinking,“But I am afraid to look at my feelings now, afraid that I will discover that the emotions that have propelled me in the past will be gone and something worse will have taken their place: weariness. Can I last as long as it will take?”

The “fatigue of chronicity” is not a scientific term. A support group for parents of children with severe neurological impairments coined the term one night when discussing the rigors of the daily (and nightly) care of their children. Quite simply, it is mentally and physically exhausting to care for our children day in and day out. Over time, the routine of care can be profoundly draining, particularly for the mother, who is often the primary caregiver. The addition of nursing care greatly helps this fatigue, allowing a much-wanted and often necessary break for the parents—a time to recharge emotionally and physically.

In addition to the daily medical, nutritional, hygienic, and therapeutic needs of these children, there are many other ongoing needs parents must manage, including but not limited to:

• Physician’s appointments and follow-up visits - On average, 6 specialist appointments at least twice a year (that is 12 visits a year if there are no major illnesses) • Hospitalizations - From something as “simple” as respiratory syncytial virus (RSV) to as complex as spinal rod replacement surgery with subsequent complications and sepsis • Therapy appointments • School meetings • In-home nursing management • County meetings • Supply management

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• Prescription management • Constant need for durable medical equipment (DME) • Battles with insurance

All of this adds up to more sheer work and administrative care than most people believe is humanly possible. Parents are driven by primal love, dedication, and desire to protect their children. This powers them through to meet the demands of an extreme situation.

The care of the child with disabilities also significantly impacts other critical areas of the parents’ lives, namely:

• Interference with work schedule • Interference with marriage - There is reportedly a higher divorce rate among parents of children with disabilities • Inability to meet the needs of the other children within the household - This results in profound guilt about not meeting their needs • Inability for the primary caregiver (usually the mother) to take proper care of themselves - Whether it’s getting enough sleep, eating properly, or simply taking five minutes to read the paper

Due to the lack of true respite care options and limited funding, parents often feel as if they are living life on a treadmill and fear the worst: their eventual own inability to meet the demands of their child’s care.

Finally, as parents, we often feel as if we can never do enough for our children. We carry an unrealistic sense of blame for our children’s situations and guilt that if only we could do more, the situation might change. We also feel as if there is always something new to learn:

• As the child ages • As the condition progresses • As the inherent changes in the “system” occur

The balsa wood bridge theory Many a child has been given the elementary school science project of building a bridge out of flimsy balsa wood. Often, this is a team exercise and requires a great deal of planning, skill, and even a bit of luck. Once the bridge has been built, a series of weights are placed on it to test its

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structural strength. If the bridge has not been built properly, the weights will destroy the bridge.

Building a support network for a child with severe disabilities and their family is a bit like building a balsa wood bridge. Once the bridge has finally, carefully, and sometimes painfully been built, it can fall apart if one of the supporting structures is removed or if too much pressure is applied. The rebuilding process must begin again.

The bridge can snap for a variety of reasons:

Repeated health setbacks A child may be admitted to the hospital for weeks at a time. The nurses that were in place in the home before the hospitalization have been reassigned to other clients to fill their hours. New nurses must be identified and oriented.

Loss of any member of the team Frequent turnover is common. A physician moves, a therapist has a baby, a nurse retires, or the child changes schools. This requires parents to reeducate the new member(s). Telling their child’s story and explaining the care routine again often feels endless and is inherently exhausting and frustrating.

Turnover can be an emotional upheaval We get attached to those who help us, help our children. More importantly, our children become attached to them—it is the natural byproduct of a good partnership. There is an added sense of emotional loss when a team member leaves.

Keep in mind that any one of the above occurrences will also likely trigger one of the stages of grief.

Practical insights for caregivers You are about to work with a new client and enter a new home. Here are a few practical tips aimed at making the transition go more smoothly. These tips assume that you have been through the required orientation for the new client and therefore do not address any of the child’s medical needs.

Of utmost importance is to listen to parental experiences, comments, and instincts. There is rarely a time when a parent’s instincts are incorrect. Remember, they have made it their life’s study to understand this child. So listen to them, but don’t be afraid to give your input. Over time, you too, will become an expert on this child. Often, nurses who take care of a

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child bring something new to the parent’s attention that has positively impacted their child’s care.

Once you have a clear understanding of all of the required needs of the child, take the time to delve beyond medications, treatments, and therapies to really get to know the child. Our kids are about subtlety.

Some things to explore may be: 1. Do they have a favorite toy, book, stuffed animal, blanket, or song? 2. Do they like a sponge bath or a tub bath? 3. Do they like warm or cooler water? 4. Do they like outside walks? 5. Do they need to be held to soothe them or do they need space? 6. What is considered a “treat” for them? 7. What activities do they like or dislike? 8. Do they nap on a regular basis or just doze occasionally? 9. Are they sensitive to too much stimulus? 10. What do they like to do with their siblings? Their parents? 11. Do they like outings? 12. Are they ticklish? 13. Do they need more or less pressure with hugs or massages?

The list can be endless, but as with any child, there are things that rise to the top that are important to them. Knowing these will help you build a relationship with the child. A parent will be grateful if you simply ask, “Tell me about the little special things your child likes and doesn’t like.”

Keep in mind that what is considered “normal” behavior for the child is of vital importance in order to determine any deviation in the pattern— become familiar with each and every nuance of body language so as to discern a look of pleasure from one of discomfort.

Closely observe how other caregivers relate to the individual. Watch how a mother soothes her child when fussy, persuades her child to smile, and challenges and encourages both physical and mental development.

It is also important to consider how your activities may or may not interfere with the family routine:

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1. When is the best time to give a bath so as not to interfere with a sibling’s bath time? 2. When is the best time to draw up the client’s medications in the kitchen without interfering with the family’s mealtime? 3. If you are a night shift nurse, what are the situations in which a parent would want to be awakened? 4. How do the other children relate to their sibling’s handicap, and can you encourage their participation in joint activities? 5. When is it good to introduce new changes to the routine of care? For example, suggesting that time in the stander might best be planned to do during a feed instead of just after? 6. Establish preferred communication at the beginning. In addition to the Nurse’s Note, does the parent want a quick informal note in a communication book with just the highlights from the shift? Does the parent prefer a complete verbal rundown from you at the end of the shift? (If so, you and the parent would need to block out a 15 minute window before the end of your shift so that you can still leave on time) 7. Would the parent like you to handle supply management (if it does not interfere with your ability to meet the child’s needs)? For example, night nurses can often spare a few moments to call in refill prescriptions over the phone and take inventory of the supplies. Day shift nurses can be a huge help if they manage the medical supply refills.

As professional home health care providers, nurses have the ability to encourage parents to take a break from the routine of care necessary for a child with special needs. It is tough for a parent to relinquish the care of their child, even though they may trust a professional. With the complex array of emotions parents battle each day, including fear, guilt, and the desire to protect their child, it is hard to step back and let the nurse do their job. As the parent’s degree of comfort with you increases, so too will their ability to let go while you are there.

Simple ways to encourage this could be suggesting that they:

• Take a nap • Take a shower • Run to the supermarket or do other errands • Take a walk around the block or go to the gym • Call a friend

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• Spend some uninterrupted quality time with their other children • Grab a cup of coffee with their spouse

Even these seemingly small things can make a huge difference in the day of a parent who has a child with special needs. It is a chance to recharge a much-depleted battery. All parties will benefit, including the child.

Setting boundaries According to the dictionary, a boundary is “something that indicates or fixes a limit or extent.” It can be daunting to know when to give and when to pull away in home health care. A nurse must be a constant presence in the realm of the client, yet strive to be an invisible guest in the client’s home. Sometimes you will be welcomed into the family, but at other times, it may be important to isolate yourself so the family’s life can resume a normalcy within itself, as if the need for a nurse did not exist.

Parents strive to avoid pulling nurses into their personal affairs. Nurses also have to strive to avoid bringing personal issues to work with them. That is difficult for both parties when parents and nurses, work so closely together in such intimate situations as they care for the child. We have to set boundaries that are often outside our realm of comfort as caring individuals. As we develop a relationship with “our” nurse, it is natural to want to extend that to a deeper friendship. But most of the time, we cannot assume any greater participation in their lives as parents already have a plate that is overflowing with our own challenges.

Our special children As a client of a home health care provider, we assume that all of our child’s practical and functional needs will be met while under the watchful eye of a home health care nurse. Medications will be administered accurately and on time, self-care tasks will be attended to regularly and in a thorough manner, therapy routines will be adhered to, and any other key tasks that have been identified in the Plan of Care will be carried out.

Many nurses can meet these functional requirements in an outstanding manner, but the nurses who stand out and make a lasting difference are those who develop a relationship with our children. They remember that our children are so much more than the condition with which they are labeled. They recognize the strong and vital spirit that lies within.

Our special children can speak volumes if you just listen closely. There are great life lessons held in their silence.

Positive outcomes While this chapter has spent a great deal of time looking at the somewhat negative impacts of raising a child who has special needs, there are also 24

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many positive outcomes. They are often hard to articulate because they are specific to each individual. Interestingly, the magazine Mental Retardation published a study that examined some of the positive outcomes and found that family members reported:

• “They are better because of the experience” • Positive transformations for the entire family • Renewed abilities to adapt to a changing world • This situation is not necessarily easy, but it leads to a richer and fuller life • All prior definitions of “richer and fuller life” are redefined in this new scenario

Again, Susan Zimmerman captured it well when she wrote:

“Those losses that cause the most pain, those challenges that leave our hearts tied in knots and our mouths dry, those things we most dread can be our greatest opportunities. They take us places we never expected to go. They open unimaginable vistas. They allow us to find our own path.”

A universal apology After reading this chapter from a parent’s point of view, I hope you have a better understanding of the environment in which you work and what motivates parents. There will be days when you may feel underappreciated, over-scrutinized, or just plain worn out. We may not say it, but we know this can happen. I’d like to take a moment to apologize for all of us parents. We are often not proud of our behavior, yet can’t keep ourselves from doing it. Many times the stressors of our everyday life caring for a child with special needs are too much for us to bear, and we often misdirect anger, aggression, frustration, and emotion onto our health care team. Most times it’s a case of the wrong place, at the wrong time. Perhaps your shift is beginning just after a doctor’s visit where there was some bad news delivered. Or perhaps the parent was up all night with the child and is sleep- deprived. Maybe there is an issue with a sibling or within the marriage. We ask you not to take these events personally and to try to appreciate where they come from. Home health care nurses are on the frontline each day with parents. We could not care for our children in the same way without you. Please know that what you do each day and night is invaluable and greatly appreciated.

Thank you for helping us help our children, and for helping us.

Molly Watson

Molly Watson is the mother of Maggie. Maggie was born with mitochondrial disease, and began receiving care from BAYADA in 2000. Molly is the founder of 25

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Parentspeak, an organization dedicated to enhancing partnerships between health care providers and parents to advance the care of children with severe disabilities.

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References Koman L.A. Impact of cerebral palsy. Wake Forest University: UCP Research and Educational Foundation; 1997.

Olshansky S. Chronic sorrow. Social Casework. 1962;43:190–193.

Kübler-Ross E. On Death and Dying. New York: Scribner; 1997.

Roos S. Chronic Sorrow, A Living Loss. New York: Brunner-Routledge; 2002.

Zimmerman S. Keeping Katherine, A Mother’s Journey to Acceptance. New York: Three Rivers Press; 1996.

Gill B. Changed by a Child. Sauk Center, MN: Main Street Books; 1998.

Dykens E. Happiness, well-being and character strengths: outcomes for families and siblings of persons with mental retardation. Mental Retardation. 2005;43(5):360–364.

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Growth and Development

Once you complete this section, you should be able to: 1. List the stages of childhood 2. List the developmental milestones for each age group 3. List the recommended immunizations 4. Discuss prematurity and how to determine adjusted age

Contents

Introduction ...... 30 Stages of childhood ...... 31 Adjusted or corrected age ...... 32 Sleep ...... 32 Newborn reflexes ...... 35 Growth and developmental changes: 1 month to 9 years ...... 38 Growth and developmental changes during adolescence ...... 59 Immunizations...... 61

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Introduction In order to deliver appropriate and safe care, pediatric nurses must be knowledgeable about child development.

Information that is gathered during the developmental assessment will enable the nurse to approach the child based on their real developmental age, rather than their chronological age. It is possible and indeed probable that a child will be at different functional levels in the various areas of development.

A child who is 15 years old chronologically and has muscular dystrophy (MD), for example, may be at only a 1-month level in gross motor development but functioning at a normal chronological age in cognitive and physical development. In order to provide safe and appropriate care for this client, we adjust safety considerations to take into account developmental findings. Measures will be put in place to prevent this client from falling or being injured based on the one-month age level of gross motor function, but our general approach to this client should be appropriate to a cognitively functioning 15-year-old child. With a diagnosis such as MD, the gross motor development will not improve. Our goal will be to maintain an optimal level of function as long as possible while continuing to foster maximum potential in the other areas of development.

Regardless of a child’s disability, we work toward helping each child function at their maximum potential. Knowledge of behaviors that can be expected at various stages of development is essential. Developmental characteristics from age 1 month to 21 years have been outlined to assist you with this information.

The developmental characteristics that will be assessed are:

• Physical growth • Gross motor development • Fine motor development • Sensory development • Vocalization • Socialization and cognition

Assessment of the newborn will include evaluation of infant reflexes. Typically, developmental assessment refers to the age level at which the child is functioning. For example, gross motor function for an 18-month- old child is, in addition to other skills, the ability to walk and run clumsily. With this in mind for a normal child, you would implement appropriate 30

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safety measures such as making sure gates in place at stairs and that sharp corners of tables are padded.

Information related to the child’s developmental age can be obtained from the parents, therapists, teachers, and during your assessment with use of the tools included in this chapter. For each new case you are assigned you will be expected to determine the child’s developmental level at that time and periodically thereafter, especially following any change in condition or hospitalization. You will be coordinating the child’s home health care with the other members of the care team such as physical therapy, occupational therapy, speech therapy, and teachers. All of these disciplines are focused on the child’s current level of development and have specific goals and interventions in place to bring the child to their maximum potential. It is important that you are aware of these goals and interventions, since you will be spending prolonged amounts of time with the child and will have many opportunities to make use of your knowledge of these aspects of the child’s care.

It will be necessary to refer to the information in this chapter on an ongoing basis.

Stages of childhood The developmental age period for pediatrics is divided into four groups:

Infancy: From birth to 12 months. During the first 28 days, the child is called a “neonate,” and this period is known as the neonatal period. During this time, the baby is making major physical adjustments from intrauterine life. The period of infancy when the child develops to 12 months is one of rapid growth and development in motor, cognitive, and social abilities.

Early childhood: This period is divided into two subgroups. Age 1 to 3 years – toddler Ages 3 to 6 years– preschooler This age group from 1 to 6 years old is categorized as the period of time that begins when the child stands upright to walk until they enter elementary school. This is a period of dynamic activity and growth. It is the time for accelerated physical and personality growth, the development of an acquired language, and mastery of tasks.

Middle childhood: Ages 6 to 10. This age group is commonly referred to as “school age.” During middle childhood, the child spends more time with peers, away from the parents. There continues to be a steady rate of growth physically, mentally, and socially. This is an important time of the development of self-concept.

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Later childhood: Like early childhood, this period is also divided into two subgroups.

Age 10 to 13 years – prepubescent Age 13 to approximately 18 years – adolescence

Later childhood begins with the onset of puberty and continues until the entry into the adult world, usually marked at the graduation of high school. The physical and emotional maturation is marked by biological changes and emotional anarchy.

It is important to remember that the population we care for may not fall into these exact stages of childhood.

Adjusted or corrected age A full-term pregnancy gives an infant 40 weeks of gestation. If the full gestation period is not reached, the infant is born prematurely. For approximately the first 2 years of life, premature infants cannot be compared to the same level of development as a full-term infant. In order to accurately judge the premature (“preemie”) child’s development, the premature birth period must be taken into consideration and the age adjusted accordingly, which provides an appropriate level against which the infant can accurately be compared.

Adjusted age formula Subtract the number of months that the child was born prematurely from the current age of the child now, and that will equal the adjusted age. Age in months calculation: (current age in months) – (# of months premature) = adjusted age

Example: The 12-month-old infant you are caring for was born prematurely at 28 weeks gestation. With a full-term being 40 weeks, you subtract 28 weeks from 40, to determine that your client was born 12 weeks (or 3 months) premature. Subtracting 3 months from the infant’s current age of 12 months gives you the adjusted age of 9 months.

Sleep Sleep is a natural requirement and is necessary for physical and physiologic health. Appropriate sleep and rest allow the body to repair tissue and promote growth and healing. The length of time spent in sleep and sleep requirements decrease throughout childhood. Active sleep is referred to as REM (rapid eye movement) sleep. During this period of sleep there is irregular heart rhythm and respiration. There are many body movements and short REM. The body requirement for oxygen, 32

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blood flow to the brain, and body temperature increases. During this time, it would be expected for O2 saturations to drop slightly. It is also during REM sleep that dreams occur. During quiet sleep, the heartbeat and respiration are even and there is an absence of body and eye movements.

There are four stages of quiet sleep. Stage 1 starts with drowsiness Best practice: and decreasing awareness of surroundings. Stage 2 ranges from the end • Limit the number of period of drowsiness to the period of time when a sleeping child can be times you disturb awakened easily. Stage 3 is when the breathing and heart rate stabilize the client during a and muscles are relaxed. In stage 4 sleep, it is difficult to be roused night shift. except with strong stimuli. During this stage 4 sleep, the restorative • Cluster activities functions of sleep occur. REM sleep makes up 50 percent of an infant’s whenever possible. sleep time, whereas older children have only about 20 percent REM sleep. Partial waking is a normal part of the sleep pattern. After about an hour of stage 4 sleep, the child will awaken for a few seconds or minutes and then return to sleep. The partial waking should not be mistaken for sleeplessness.

Disturbances in sleep Parasomnias are sleep disturbances characterized by partial arousals during sleep or the transitions between wakefulness and sleep and they are more common in children than in adults. Some parasomnias include sleepwalking, sleep talking, teeth grinding, bedwetting, nightmares, and night terrors. There is a significant difference between night terrors and nightmares.

Nightmares occur most commonly in young children. Typically, a child with a nightmare wakes up completely, is very anxious, and usually remembers the dream. Nightmares require no treatment, except for reassuring and comforting the child. When nightmares become more frequent or occur regularly, it may be a sign of stress in the child's life or environment. The content of the nightmare may be a clue to what is stressing the child.

Night terrors occur less commonly than nightmares, in fact, they occur in less than 5 percent of children ages 4 to 12. Children with night terrors are awake but out of control. The child may appear to be awake and frightened, staring with eyes wide open. They may also be sweating, breathing heavily, and verbalizing seeing objects that are not really there. This period of terror may last for up to several minutes and then the child usually goes back to sleep. What distinguishes night terrors from nightmares is that the child does not recall the dream or event leading to the night terror, and in many cases, does not recall that anything at all happened during the night. Do not attempt to awaken a child who is having a night terror. Maintain the child’s safety, comfort them with gentle touch and a soft reassuring voice. Remain calm. Avoid restraining the child. Avoid activity that may cause additional terror, such as loud noise 33

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or shaking in an attempt to wake them. Night terrors occur more frequently in children who are not getting adequate rest.

Typical sleep requirements in infancy and childhood Nighttime Daytime Total Age sleep (hrs) sleep (hrs) sleep (hrs) 1 month 8.5 (many naps) 7.5 (many naps) 16 3 months 6–10 5–9 15 6 months 10–12 3–4.5 14.5 9 months 11 3 (2 naps) 14 12 months 11 2.5 (2 naps) 13.5 18 months 11 2.5 (1–2 naps) 13.5 2 years 11 2 (1 nap) 13 3 years 10.5 1.5 (1 nap) 12 4 years 11.5 11.5 5 years 11 11 6 years 10.5–11 10.5–11 7 years 10.5 10.5 8 years 10– 0.5 10–10.5 9 years 10 10 n/a 10 years 9.5–10 9.5–10 11 years 9.5 9.5 12–13 years 9–9.5 9–9.5 14 years 9 9 15 years 8.5–9 8.5–9 16 years 8.5 8.5

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Newborn reflexes

Reflex Characteristics When present Consequences

Corneal reflex The infant blinks at At birth and If not present, (blinking) sudden appearance throughout life may indicate of a bright object or neurological or at the approach of eye damage an object toward the cornea

Pupillary reflex Constriction of At birth and If not present by the pupil when a throughout life age 3 weeks may bright light is indicate presented blindness. If the pupil is fixed, dilated, or constricted, may indicate anoxia or brain damage

Doll’s Eyes When the infant’s Disappears as If it persists it head is moved fixation develops indicates slowly to left or neurological right, the eyes lag damage behind and do not immediately adjust to the new position

Sucking reflex The infant begins Present the first 3 Failure or (Works in strong sucking months then persistence may conjunction with movements when becomes indicate brain the rooting reflex) there is voluntary. The dysfunction. circumoral sucking reflex Verbal dyspraxia, stimulation, will and rooting reflex articulation also occur work together problems, and without dribbling may be stimulation signs of retention of this reflex

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Rooting reflex When the infant Disappears at 3– Failure or is being touched 4 months, but it is persistence may or stroked on the not unusual to be a sign of side of the mouth persist up to 12 dysfunction with or cheek, turns months the same head to the side problems noted being touched above in sucking reflex

Extrusion reflex When the infant’s Disappears at Presence after 4 tongue is about 4 months months may touched or indicate cerebral depressed the palsy infant forces the tongue outward

Grasp reflex When the infant’s Palmer grasp Retention of the (plantar and palm of hands or lessens after 3 palmer reflex palmer) soles of the feet months, replaced may affect (at the base near by a voluntarily pencil grip, so the digits) are movement. child has large, untidy touched, the Planter grasp handwriting; infant responds lessens after 8 hand tires by flexion of the months quickly because fingers or toes of the pressure used to write. May have trouble expressing creatively. May experience speech problems and stuttering. Retention of the planter reflex may result in problems with running, walking, tripping, or clumsiness

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Babinski When stroking Should disappear Presence after 1 the sole of the after age 1 year, year indicates foot upward from 2 years at the damage to the heel across the latest nerve pathways ball of the foot, from the spine to the infant has the brain dorsiflexion of the great toe and fanning of the other toes

Startle reflex A sudden loud Usually appears Absence of or (Some noise causes the when Moro reflex failure of the professionals use infant to respond disappears. startle reflex to the startle reflex with abduction of Present emerge is and the Moro the arms and throughout life indication of reflex flexion of the neurological interchangeably) elbows, and the dysfunction hands remain clenched

Asymmetric tonic When the infant’s Present at birth. Persistence can neck head is turned to Disappears by 3– hinder sitting, one side, the arm 4 months and is standing, and and leg extend replaced by walking on that side and symmetric the opposite arm positioning of and leg flex both sides of the body

Galant reflex When the infant’s Disappears by Can affect ability (trunk back is stroked age 4 months to sit still, incurvation) alongside the attention deficit, spine, the hips bladder control move upward (bedwetting) toward the stimulated side

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Crawl reflex When positioned Disappears at Absence of or prone, the infant about age 6 failure of crawl makes crawling weeks reflex to emerge movements with is indication of the arms and neurologic legs dysfunction

Growth and developmental changes: 1 month to 9 years

1 month 2 months

Physical . Weight gain of 150– . Posterior fontanel 210 g (5–7 oz) closed weekly . Height gain of 2.5 cm (1 in) monthly . Newborn reflexes present and strong

. Crawling reflex disappears

Gross motor . Assumes flexed . Assumes less flexed position with pelvis position when prone: high but knees not hips flat, legs less under abdomen extended, arms when prone (at birth flexed, head side to knees are flexed side under abdomen) . Less head lag when . Can turn head from pulled to sitting side and can lift head position momentarily when . Can maintain head prone on same plane as . Has marked head rest of body when lag, especially when held in ventral pulled from lying to suspension sitting position . When prone, can lift . Holds head head almost 45 momentarily parallel degrees and in midline when . When held in sitting suspended in prone position, head is held position up but bobs forward . Assumes asymmetric . Assumes asymmetric

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tonic neck reflex tonic neck reflex position when supine position intermittently . When held in standing position, body is limp at knees and hips

. In sitting position, back is uniformly rounded, absence of head control

Fine motor . Hands predominantly . Hands frequently closed open . Grasp reflex strong . Grasp reflex fading . Hands clench on contact with rattle

Sensory . Able to fixate on . Beginning of moving object in binocular fixation range of 45 degrees and convergence to when held at a near objects distance of 20–25 cm . When supine, follows (8–10 in) dangling toy from . Visual acuity side to point beyond approaches 20/100 midline . Follows light to . Visually searches to midline locate sounds . Quiets when hears a . Turns head to side voice when sound is made at level of ear

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Vocalization . Cries to express . Vocalizes, distinct displeasure from crying . Makes small, throaty . Crying becomes sounds distinctive and with . Makes comfort purpose sounds during feeding

Socialization and . Is in sensory motor . Demonstrates social cognition stage 1 use of smile in response to reflexes and stage various stimuli 2 primary reactions to immediate environment (1–4 months) . Watches parent’s face intently as they talk to infant

3 months 4 months

Physical . Newborn reflexes are . Drooling begins fading . Moro, tonic neck, and rooting reflexes have disappeared

Gross motor . Able to hold head . Has almost no head more erect when lag when pulled to sitting, but head still sitting position bobs forward . Balances head well . Has only slight head in sitting position lag when pulled to . Back is less rounded, sitting position curved only in the . Assumes symmetric lumber region body position . Able to sit erect if . Able to raise head propped up and shoulders from . Able to raise head prone position to and chest off surface a 45–90 degree to 90–degree angle angle, bears weight . Assumes on forearms predominant . When held in symmetric position standing position, . Rolls from back to able to bear slight side fraction of weight on legs

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. Regards own hands

Fine motor . Actively holds . Inspects and plays rattle but will not with hands, pulls reach for it clothing or blanket over face in play . Tries to reach objects with hand but overshoots . Grasps objects with both hands . Plays with rattle placed in hand, shakes it but cannot pick it up if dropped . Can carry objects to mouth

Sensory . Follows object to . Able to accommodate periphery (180 to near objects degrees) . Binocular vision (both . Locates sound by eyes working turning head side to together) fairly well side and looking in established same direction . Can focus on a 1.25 . Begins to have ability cm (1/2 in) block to coordinate stimuli . Beginning eye-hand from various senses coordination

Vocalization . Squeals to show . Makes constant pleasure sounds . Coos, babbles, (n, k, g, p, b) chuckles . Laughs aloud . Vocalizes when . Vocalization changes smiling according to mood . “Talks” a great deal when spoken to . Less crying during periods of wakefulness

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Socialization and . Displays . Demands attention cognition considerable interest by fussing, becomes in surroundings bored if left alone . Ceases crying when . Enjoys social parent enters room interaction with . Can recognize people familiar faces and . Anticipates feeding objects, such as a when sees bottles or bottle mother (if . Shows awareness of breastfeeding) strange situations . Shows excitement with whole body, squeals, breaths heavily . Begins to show memory

5 months 6 months

Physical . Teething begins . Growth rate may . Birth weight doubles begin to decline . Weight gain of 90–150 g (3–5 oz) weekly for the next 6 months . Height gain to 1.25 cm (1/2 in) monthly for the next 6 months . Teething may begin with eruption of the 2 lower central incisors . Chewing and biting occurs

Gross motor . No head lag when . When positioned pulls to sitting prone, infant can lift position chest and upper . When sitting, able to abdomen off table, hold head erect and bearing weight on steady hands . Able to sit for longer . When about to be periods when back is pulled to a sitting well-supported position, infant will lift . Back is straight head . When prone, . Sits in a high chair assumes symmetric with back straight

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positioning with arms . Will roll from back to extended abdomen . Can turn over from . When held in a abdomen to back standing position, will . Will put feet to mouth bear almost all of when supine own weight . Hand regard is absent

Fine motor . Able to grasp objects . Will pick up a voluntarily dropped object . Uses palmer grasp, . Will drop one object bidextrous approach when given another . Plays with toes . Will grasp and . Takes objects directly manipulate small to mouth objects . Holds one object . Will hold bottle while regarding a . Will grasp feet and second one pull to mouth

Sensory . Visually pursues a . Will adjust posture to dropped objects see an object . Is able to sustain . Prefers more inspection of an complex visual object stimuli . Can localize sound . Can localize sounds made below the ear above ear . Will turn head to side, then look up and down

Vocalization . Squeals . Begins to imitate . Makes vowel cooing sounds sounds interspersed . Babbling resembles with consonant one-syllable sounds (ah-goo) utterances (ma, mu, da, di, hi) . Vocalizes to toys and image in the mirror . Takes pleasure in hearing own voice

Socialization and . Smiles at mirror . Recognizes parents, cognition image begins to fear . Pats bottle or breast strangers

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with both hands . Hold arms out to be . More enthusiastically picked up playful, but may have . Has definite likes rapid mood swings and dislikes . Is able to discriminate . Begins to imitate strangers from family (cough, sticking . Vocalizes displeasure tongue out) when object is taken . Excites when hearing away footsteps . Discovers parts of . Laughs when body head is hidden in a towel . Briefly searches for a dropped object . Frequent mood swings (from crying to laughing with little or no provocation)

7 months 8 months

Physical . Eruption of lower . Begins to show central incisors regular pattern in bladder and bowel elimination . Parachute reflex appears

Gross motor . When positioned . Will stand steadily supine, unsupported spontaneously lifts . Readily bears weight head off the table on legs when . Sits erect supported, may stand momentarily holding onto furniture . Sits leaning forward . Adjusts posture to on both hands reach for object . When positioned prone, bears weight on one hand . Bears full weight on

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feet . When held in a standing position, bounces actively

Fine motor . Transfers object from . Has beginning pincer one hand to the other grasp using index, . Has unidextrous fourth, and fifth approach and grasp fingers against lower . Holds two objects part of thumb more than . Releases an object at momentarily will . Bangs object on table . Rings bell purposely . Rakes at a small . Retains two objects object while regarding third object . Secures an object by pulling on a string . Reaches persistently for toys out of reach

Sensory . Can fixate on small objects . Responds to own name . Localizes sound by turning head in an arc . Beginning awareness of depth and space . Has taste preferences

Vocalization . Produces vowel . Makes consonant sounds and chained sounds: t, d, and w syllables . Listens selectively to (baba, dada, kaka) familiar words . Vocalizes 4 distinct . Utterances portray vowel sounds emphasis and . “Talks” when others emotion are talking . Combines syllables such as dada, but does not ascribe meaning to them

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Socialization/ . Increasing fear of . Increasing anxiety cognition strangers, shows over loss of parent, signs of fretfulness particularly mother , when parent and fear of strangers disappears . Responds to “no” . Imitates simple acts . Dislikes dressing and and noises diaper changes . Tries to attract attention by coughing or snorting . Plays “peek-a-boo” . Demonstrates dislike of food by keeping lips closed . Exhibits oral aggressiveness in biting and mouthing . Demonstrates expectation in response to repetition of stimuli

9 months 10 months

Physical . Eruption of upper . Labyrinth-righting central incisors may reflex is strongest begin (when infant is in prone or supine position, is able to raise head

Gross motor . Creeps on hands and . Can change from knees prone to sitting . Sits steadily on floor position for prolonged time . Stands while holding (10 minutes) onto furniture, sits by . Recovers balance falling down when leaning forward . Recovers balance but cannot do so easily while sitting when leaning . While standing, lifts sideways one foot to take a . Pulls self to standing step position and stands holding onto furniture

Fine motor . Uses thumb and . Crude release of an index finger in crude object beginning

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Growth and Development

pincer grasp . Grasps bell by handle . Preference for use of dominant hand now evident . Grasps third object . Compares two objects by bringing them together

Sensory . Localizes sounds by turning head diagonally toward sound . Depth perception increasing

Vocalization . Responds to simple . Says “dada, mama” verbal commands with meaning . Comprehends . Comprehends “no-no” “bye-bye” . May say one word (hi, bye, no)

Socialization and . Parent (usually . Inhibits behavior to cognition mother) is verbal command of increasingly “no-no” or to own important for own name sake . Imitates facial . Shows increasing expression, waves interest in pleasing bye-bye parent . Extends toy to . Begins to show fears another person but of going to bed and will not release it being left alone . Develops object . Puts arms in front of permanence face to avoid having . Repeats actions that it washed attract attention and cause laugher . Pulls another person’s clothing to attract attention . Plays interactive games such as pat-a- cake . Reacts to adult anger, cries when scolded

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. Demonstrates independence in dressing, feeding, locomotive skills, and testing parents . Looks at and follows pictures in a book

11 months 12 months

Physical . Eruption of lower . Birth weight tripled lateral incisors may . Birth length increased begin by 50% . Head and chest circumference equal – head circumference 46.5 cm (18 ½ in) . Has total of 6–8 teeth . Anterior fontanel almost closed

Gross motor . When sitting, pivots . Walks with one hand to reach toward back held to pick up an object . Cruises well . Cruises or walks . May attempt to stand holding onto furniture alone momentarily, or with both hands may attempt first step held alone . Can sit down from standing position without help

Fine motor . Explores objects . Releases object in more thoroughly cup (clapper inside bell) . Attempts to build two- . Has neat pincer block tower but fails grasp . Tries to insert a small . Drops objects object into a narrow- deliberately for them necked bottle but to be picked up fails . Puts one object after . Can turn pages in a another into a book, many at a time container (sequential play) . Able to manipulate an object to remove it from tight-fitting

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enclosure

Sensory . Discriminates simple geometric forms (circle) . Amblyopia (lazy eye) may develop with lack of binocularity . Can follow rapidly moving object . Controls and adjusts response to sound, listens for sound to recur

Vocalization . Imitates definite . Says 3–5 words speech patterns besides “dada, mama” . Comprehends meaning of several words (comprehension always precedes verbalization) . Recognizes objects by name . Imitates animal sounds . Understands simple verbal commands (give it to me, show me your eyes)

Socialization and . Experiences joy and . Shows emotion such cognition satisfaction when a as jealousy, affection task is mastered (may give hug or kiss . Reacts to restrictions on request), anger, with frustration and fear . Rolls ball to another . Enjoys familiar on request surroundings and . Anticipates body explores away from gestures when a parent familiar nursery . Is fearful in strange rhyme or story is situation, clings to being told (holds toes parent and feet in response . May develop habit of to “this little piggy “security blanket” or

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went to market”) favorite toy . Plays games such as . Has increasing “up-down”,” so big” determination to and “peek-a-boo” practice skills . Shakes head for “no”

15 months 18 months

Physical . Steady growth in . Physiologic anorexia height and weight from decreased . Head circumference growth needs 48 cm (19 in) . Physiologically able . Weight 11 kg (24 lb) to control sphincters . Height 78.7 cm (31 . Anterior fontanel in) closed

Gross motor . Walks without help . Runs clumsily, falls (usually since 13 often months) . Walks up stairs with . Creeps up stairs one hand held . Cannot walk around . Pulls and pushes corners or stop toys suddenly without . Jumps in place with losing balance both feet . Assumes standing . Seats self on chair position without . Throws ball overhand support without falling . Cannot throw ball without falling

Fine motor . Constantly casting . Builds tower of 3 or 4 objects to floor blocks . Builds tower of two . Release and reach blocks are well-developed . Holds two cubes in . Turns pages in a one hand book 2 or 3 at a time . Releases a small . In drawing, makes object into narrow- strokes imitatively necked bottle . Manages spoon

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Growth and Development

. Scribbles without rotation spontaneously . Uses cup with lid well but rotates spoon

Sensory . Able to identify geometric forms, places round object into appropriate hole . Binocular vision well- developed . Displays an intense and prolonged interest in pictures

Vocalization . Uses expressive . Says 10 or more jargon words . Says 4–6 words . Points to a common including names object such as a . “Asks” for objects by shoe or ball and to 2 pointing or 3 body parts . Understands simple commands . May use head- shaking gesture to denote “no” . Uses “no” even while agreeing to the request

Socialization and . Tolerates some . Greater imitator cognition separation from (“domestic mimicry”) parent . Takes off gloves, . Less likely to fear socks, and shoes strangers and unzips . Beginning to imitate . Temper tantrums parents, such as may be more evident cleaning house . Beginning awareness (sweeping, dusting, of ownership (“my folding clothes, toy”) mowing lawn) . May develop . May give up the dependency on bottle independently transitional objects . Kisses and hugs such as a security parents, may kiss blanket pictures in a book . Expressive of

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emotions, has temper tantrums

24 months 30 months

Physical . Head circumference . Birth weight 49–50 cm (19.5–20 quadrupled in) . Primary dentition (20 . Chest circumference teeth) completed exceeds head circumference . Lateral diameter of chest exceeds anteroposterior diameter (decrease in barrel shape of chest) . Usual gain in height of 10–12.5 cm (4–5 . May have daytime in) bowel and bladder . Usual weight gain of control 1.8–2.7 kg (4–6 lb) . Adult height approximately double height at 2 years . May have achieved readiness for beginning daytime control of bowel and bladder . Primary dentition of 16 teeth

Gross motor . Goes up and down . Jumps with both feet stairs alone with two . Jumps from chair or feet on each step step; stands on one . Runs fairly well, with foot momentarily wide stance . Takes a few steps on . Picks up object tiptoe without falling . Kicks ball forward without overbalancing

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Fine motor . Builds tower of 6 or 7 . Builds tower of 8 blocks blocks . Aligns two or more . Adds height to train blocks like a train of objects . Turns pages of a . Good hand-finger book one at a time coordination, holds . In drawing, imitates crayon with fingers vertical and circular rather that fist strokes . Moves fingers . Turns doorknobs, independently unscrew lids . In drawing, imitates vertical and horizontal strokes, makes two or more strokes

Vocalization . Has vocabulary of . Gives first and last approximately 300 name words . Refers to self by . Uses 2–3 word appropriate pronoun phrases . Uses plurals . Uses pronouns (I, . Names one color me, you) . Understands directional commands . Gives first name, refers to self by name . Verbalizes need for toileting, food, or drink . Talks incessantly

Socialization and . Stage of parallel play . Separates more cognition . Has sustained easily from mother attention span . In play, helps put . Temper tantrums things away; can decreasing carry breakable . Pulls people to show objects; pushes with them something good steering . Increased . Begins to notice sex independence from differences, knows mother own sex . Dresses self in . May attend to toilet simple clothing needs without help except for wiping

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36 months 4 years

Physical . Weight gain 1.8–2.7 . Pulse, respiratory kg (4–6 lb) rate decrease . Average weight 14.6 . Growth rate same as kg (32 lb) 3 years . Height gain 7.5 cm . Average weight 16.7 (3 in) kg (36.75 lb) . Average height 95 . Length at birth will be cm (37.25 in) doubled . May have nocturnal . Potential for bladder and bowel development of “lazy control eye” (amblyopia)

Gross motor . Walking, running, . Can skip, hop on one climbing, jumping are foot well established . Throws balls . Rides a tricycle overhand . Walks on tip toes . Walks down stairs . Jumps off bottom alternating feet step . Goes upstairs alternating feet but comes down using both feet on one step . Balances on one foot for a few seconds . Will try to dance but balance still not adequate

Fine motor . Can copy a circle, . Can trace a cross imitate a cross, and a diamond vertical and . Will copy a square horizontal lines, . Can add 3 parts to cannot draw stick stick figures figure . Successfully uses . Crayons and pencils scissors to cut picture held with fingers not following the lines fist . Can lace shoes, but . Will scribble, but can not tie a bow names what has been drawn . Can make circle with facial features . Builds a tower of 9 or 10 blocks

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. Places small objects in narrow-necked containers

Vocalization . Approximately 900 . Vocabulary of >1500 words in vocabulary words . Uses sentences of 3– . Talks in sentences of 4 words 4–5 words . Talks endlessly . Exaggerated whether anyone is storytelling listening . Knows simple songs . Asks many questions . Questioning at peak . Sing songs . Can name one or more colors . Understands prepositional phases such as “in front of” . Comprehends analogies (ex: if fire is hot, ice is ____)

Socialization and . Dresses self with . Independent, selfish, cognition help for buttons and impatient shoes . Verbally and . Attention span physically aggressive increased . Has mood swings . Completely feeds self and many fears . Can prepare simple . Tells family story with meals like cereal and no regard to privacy milk . Enjoys entertaining . Can help with others household chores . Associative play like setting table and . Has imaginary friends drying dishes . Sexual curiosity and . May exhibit fears, exploration such as fear of dark . Understands time or going to bed and has sense of . Knows own sex and daily schedule sex of others . More social . Associative and awareness parallel play . Considers everything . Beginning to play in one dimension, simple games but such as weight, makes own rules height . Preconceptual phase . Can count correctly . Egocentric thoughts but has poor

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and behaviors understanding of . Beginning concept of math time . Understands set . Beginning to have limits and obeys ability to see . Follows rules, but not another’s perspective because of understanding right and wrong

5 years 6 years

Physical . Pulse and . Growth slowing respirations decrease . Weight 17–23.6 kg slightly (35.5–58 lb) . Average weight 18.7 . Height 106–1,123.5 kg (41.25 lb) cm (42–48 in) . Average height 110 . Loss of first tooth cm (43.25 in) . Constant activity . Permanent dentition . Vision reaches level eruption begins of maturity . Establishment of handedness

Gross motor . Skips and hops . Frequently returns to alternating feet finger feeding . Throws and catches . More aware of hand ball well as a tool . Able to jump rope . Increase in dexterity . Can skate with good balance . Can walk backwards with heel to toe . Can jump from 12 inches height and land on toes . Can balance on foot with eyes closed

Fine motor . Ties shoelaces . Likes to draw, print, . Can use pencil, and color scissors, and other . Will use knife to tools spread butter on . Copies a diamond bread and triangle . Adds several parts to stick figure . Prints a few letters,

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numbers, and may print first name

Vocalization . Approximately 2,100 . Defines objects by words in vocabulary their use or function . Speaks in sentences instead of by name of 6–8 words using all parts of speech . Can name coins . Can name 4 or more colors . Knows names of time related words (days of the week, month) . Can follow 3 commands in concession

Socialization and . Less difficult and . Attends first grade cognition aggressive . Will count 13 items . Independent and . Knows whether it is shows responsibility morning or afternoon . Decrease in fears . Will follow 3 . Eager to please consecutive . Manners have commands improved . Know which hand is . Improved self care, right and which is left may need assistance . Increased with dressing and cooperation and person hygiene sharing . Close work difficult . Enjoys children own because of age farsightedness and . Becoming social unrefined hand-eye . Engages in rough coordination play . Associative play . Frequently jealous of . Will follow the rules younger siblings but cheats to avoid . Occasional temper losing tantrums . May understand the . More independent concept of numbers by counting items . Use of time associated words with understanding

7 years 8–9 years

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Physical . Growth accelerates . Growth continues at to at least 5 cm (2 in) 5 cm (2 in) a year a year . Weight: 19.6-39.6 kg . Weight averages 17– (43-87 pounds) 30 kg (39–66 lb) . Height: 117-141.8 cm . Height averages (46-56 inches) 111–129.7 cm (44– . Lateral incisors 51 in) (maxillary) and . Eruption of maxillary mandibular cuspids central incisors and erupt lateral mandibular . Very active. incisor . Bones grow at fast . Jaw expands to pace accommodate eruption of permanent teeth

Gross motor . Repeats tasks to . Movement now master them graceful and poised . Develops caution . More limber when attempting new task

Fine motor . Will use knife for . Uses cursive writing cutting . Smoothness and . Appropriate use of speed of fine motor comb and brush control . Dresses self completely

Vocialization/language . When reading, often . Participates in music skips words and does and sports not stop at periods . Can count backward from 20 to 1 . Can describe items in detail and not by function . Understands fractions . More adept at reading

Socialization and . Less resistant . Easy to get along cognition . May steal with at home . Enjoys making choices . Likes the reward . Notices if there are system parts missing from a . More sociable picture . Interested in boy-girl . Can repeat 3 numbers relationships but not

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backwards willing to admit it . Can tell time and use . Enjoys competition clock for practical use . Plays mostly in group . Takes part in group of own sex, but is play beginning to mix . Does not need a lot of . Modesty develops company, entertains self . Prefers playing with members of own sex

Growth and developmental changes during adolescence Early Middle Late adolescence adolescence adolescence (10–14 years) (14–17 years) (17–21 years)

Growth . Rapid . Growth . Physically accelerating decelerating in mature growth girls . Structure and . Secondary sex . Stature 95% of reproductive characteristics adult height growth almost appear . Secondary sex complete characteristics advanced

Cognition . Explores . Developing . Abstract newfound ability capacity for thinking for limited abstract . Can perceive abstract thought thinking and act on . Explores new . Enjoys long-range values and intellectual operations energies powers, often . Able to view . Compares idealistic terms problems “normality” with . Concern with comprehensively peers of same philosophic, . Intellectual and sex political, and functional social problems identity established

Identity . Preoccupied . Modifies body . Body image with rapid body image and gender changes . Very self- role definition . Trying out centered; nearly secured various roles increased . Mature sexual

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. Measurement narcissism identity of . Tendency . Phase of attractiveness toward inner consolidation of by acceptance experience and identity or rejection of self-discovery . Stability of self- peers . Has a rich esteem . Conformity to fantasy life . Social roles group norms . Idealistic defined and . Able to perceive articulated future implications of current behavior and decisions

Relationship with . Defining . Major conflicts . Emotional and parents independence over physical and independence separation dependence and control from parents boundaries . Low point in complete . Strong desire to parent-child . Independence remain relationship from family dependent on . Greatest push with less parents while for emancipation conflict trying to detach . Final, irreversible . Emancipation . No major emotional nearly secured conflicts over detachment from parental control parents; mourning

Relationship with . Seeks peer . Strong need for . Peer group peers affiliations to identity to affirm recedes in counter self-image importance in instability . Behavioral favor of individual generated by standards set friendship rapid change by peers . Testing of . Increase of . Acceptance by relationships close, idealized peers extremely against friendships with important; fears possibility of members of the rejections permanent opposite sex . Exploration of alliance . Struggle for sexual . Relationships mastery takes attraction characterized by place within giving and peer group sharing

Sexuality . Self exploration . Multiple plural . Forms stable and evaluation relationships relationship and

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. Limited dating, . Decisive turn attachment to usually in toward sexual another groups orientation . Growing . Limited intimacy . Exploration of capacity for “self-appeal” mutuality and . Feeling of reciprocity “being in love” . Dating as a . Tentative couple establishment . Intimacy of relationship involves commitment rather than exploration and romanticism

Psychological . Wide mood . Tendency . More health swings toward inner consistency of . Intense experiences; emotion daydreaming more . Anger more . Anger introspective apt to be outwardly . Tendency to concealed expressed with withdraw when moodiness, upset or temper, feelings are hurt outbursts, . Feelings of verbal insults, inadequacy and name common; calling difficulty in asking for help

Immunizations Babies are immune to many diseases due to antibodies obtained in utero and postnatally from breast milk. The duration of this immunity may last from one month to one year.

Before vaccines, morbidity and mortality rates were high from diseases that vaccines now prevent, such as whooping cough, measles, and polio. Those same diseases exist today, but since most children are now protected by vaccines, we do not see these diseases as often.

Immunizing individual children also helps protect the health of the community, especially those who are not immunized. People who are not immunized include those who are too young to be vaccinated, those who cannot be vaccinated for medical reasons, those who have not developed immunity, and those whose parents refuse to allow them to be vaccinated

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for religious reasons or concerns over their safety. People who received a vaccine but who have not developed immunity are also protected.

Disease prevention is the key to public health. Vaccines help prevent infectious diseases and save lives. Vaccines are responsible for the control of many infectious diseases that were once common in this country, including polio, measles, diphtheria, pertussis (whooping cough), rubella (German measles), mumps, tetanus, Haemophilus influenzae (hepatitis) type b (Hib), human papillomavirus (HPV), and chicken pox (varicella).

Although no vaccine is 100 percent effective, most routine childhood immunizations are effective for 85 to 95 percent of the children who receive them. The US has near-record low incidence of vaccine- preventable diseases, but the bacteria and viruses that cause them still exist. The diseases that have been eliminated from the US can still be contracted in other countries if travelers are not immunized.

The Advisory Committee on Immunization Practices (ACIP) consists of 15 members that are experts in the fields associated with immunization that provides advice and guidelines to the Centers for Disease Control and Prevention (CDC) on the most effective means to avert vaccine- preventable diseases.

The ACIP is the only committee in the federal government responsible for the development of written recommendations for the routine administration of vaccines including appropriate timing, dosage, and contraindications of immunizations. As advances in the research of immunizations continue, the recommendations may change.

Because the Recommended Childhood and Adolescent Immunization schedule for the United States changes yearly, you can refer to these websites for the most recent recommendations. • Advisory Committee on Immunization Practices www.cdc.gov/nip/acip • American Academy of Pediatrics www.aap.org • American Academy of Family Physicians www.aafp.org

Adverse reactions to immunizations should be reported to The Vaccine Adverse Event Reporting System (VAERS) at www.vaers.hhs.gov. The most common reactions to vaccines are minor and include: • Redness and swelling at the injection site • Fever • Rash

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Pain and fever after immunizations may be treated with acetaminophen or ibuprofen. If there is no physician’s order in the home, you will have to call the physician to obtain an order. Reportable events include but are not limited to: • Anaphylaxis or anaphylactic shock • Encephalopathy • Any sequelae (including death) from anaphylaxis or anaphylactic shock • Events described in the manufacturer’s package insert regarding contraindications to additional doses • Brachial neuritis (tetanus in any combination) • Chronic arthritis (rubella in any combination) • Thrombocytopenia (measles in any combination) • Paralytic polio (oral polio) or vaccine-strain polio viral infection • In a nonimmunodeficient recipient • In an immunodeficient recipient • In a vaccine-associated community case

Each state has laws governing its own immunization schedule and exemptions. Requirements vary from state to state and exemptions may be granted for medical, moral, or religious reasons. All states now require proof of immunization or other evidence of immunity against some of these diseases for admission to public school.

Parents have the right to refuse immunizations for their child.

Parents should be made aware that opting out of immunizations leaves their child vulnerable to vaccine-preventable diseases in the event of an outbreak. To protect the children who have not been immunized, the children should remain home during outbreaks of the diseases against which they have not been immunized. Unvaccinated children should be kept at home if there is an outbreak of a vaccine-preventable disease within the family. These illnesses should be reported to the pediatrician or family physician.

Immunization vocabulary Anaphylaxis and anaphylactic shock - Severe, acute, and potentially lethal systemic allergic reactions.

Immunization – The process of providing (administering) active or passive immunity artificially by giving an immunobiologic agent.

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Immunity – Inherited or acquired state in which an individual is resistant to the occurrence of a specific disease.

Natural immunity – Resistance to infection possessed at birth.

Passive immunity – Temporary immunity by transfusion of immune globulins or antitoxins, either artificially (from another human or animal that has been activity immunized against an antigen) or naturally (from mother to fetus via the placenta).

Toxoid – A modified bacterial toxin that has been rendered nontoxic, but retains the ability to stimulate formation of antitoxins.

Vaccination – The physical act of administering any vaccine or toxoid.

Vaccine – A suspension of live or inactivated microorganisms or fractions of microorganism administered to induce immunity.

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Before continuing on to the next section, answer the following questions by circling the appropriate letter. Check your responses with the answers below.

1. The period between when a child begins to walk upright and when they enter school is categorized as: (A) School age.

(B) Early childhood. (C) Middle childhood. (D) Infancy.

2. The stage of childhood during which growth is usually most rapid is: (A) School age. (B) Early childhood. (C) Middle childhood. (D) Infancy.

3. At what age should a baby start to turn from abdomen to back? (A) 5 months. (B) 2 months. (C) 7 months. (D) 12 months.

4. What is the condition indicated if there is persistence in the extrusion reflex? (A) Dyspraxia. (B) Brain damage. (C) Cerebral palsy. (D) Blindness.

5. Birth weight should have tripled by what age? (A) 18 months. (B) 12 months. 65

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(C) 24 months. (D) 6 months.

6. Resistance to an infection as result of an exposure to an invading agent, either bacterial, viral or a toxin, is a(an) (A) Active immunity. (B) Natural immunity. (C) Passive immunity. (D) Acquired immunity.

7. Adjusted age is: (A) The age at which a child is functioning developmentally. (B) How old the child would be if born full-term. (C) The number of weeks early the child was born. (D) The number of weeks gestation the child completed.

8. If an infant is born at 28 weeks gestation, and is now 17 weeks old, what is the infant’s adjusted age? (A) 17 weeks. (B) 12 weeks. (C) 5 weeks. (D) 45 weeks.

9. The adjusted age is used to determine developmental level during what time period? (A) Through the first year of life. (B) For approximately the first two years of life. (C) Until the child meets all developmental milestones. (D) When the child enters first grade.

Answers: 1. B, 2. D, 3. A, 4. C, 5. B, 6. D, 7. B, 8. C, 9. B

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References http://www.kidshealth.org/parent/growth/index.html http://www.lpch.org/diseaseHealthInfo/HealthLibrary/growth/index.html http://www.nlm.nih.gov/medlineplus/infantandtoddlerdevelopment.html http://www.hec.ohio- state.edu/famlife/yc/growth.htm#general%20http://www.ronengold.com/re ferring-doctors.htmldevelopment www.cdc.gov/nip/acip www.aap.org www.aafp.org http://www.msu.edu/course/asc/823f/casby/reflexslides.html http://www.stjohns.com/greystone/pediatric/newborn/behrefx.aspx http://ke016.k12.sd.us/CD%20reflexes.htm www.momodevelopment.com/01lezen/leestafel/documents/031106Zooming... http://www.childbirths.com/euniversity/newborn.htm http://health.enotes.com/childrens-health-encyclopedia/neonatal-reflexes http://health.allrefer.com/health/infantile-reflexes-infantile-reflexes.html http://vaers.hhs.gov/pdf/ReportableEventsTable.pdf

Wong DL, Hockenberry MJ, Wilson D, Winkelstein ML, Ahmann E, DiVito TP. Whaley & Wong’s Nursing Care of Infants and Children. 6th ed. St. Louis: Mosby; 1999.

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68

Assessment

Once you complete this section, you should be able to: 1. Demonstrate how to obtain vital signs and measurements 2. State normal age-related vital signs 3. Describe and perform a pediatric system assessment 4. Describe normal and abnormal assessment findings per system a) Integumentary (skin) b) Head, eyes, ears, nose, and mouth c) Pulmonary d) Cardiovascular e) Genitourinary (abdomen) f) Reproductive g) Musculoskeletal h) Nervous 5. Identify signs and symptoms of abuse 6. List elements of a psychosocial assessment

Contents

Introduction ...... 71 Growth measurement ...... 72 Vital signs measurement ...... 73 Assessment of the skin (integumentary system) ...... 79 Assessment of the nails and hair ...... 84 Assessment of the head, ears, eyes, nose, and mouth ...... 84 Assessment of the respiratory system ...... 88 Assessment of the cardiovascular system ...... 98 Assessment of the abdominal systems ...... 101 Assessment of the reproductive system ...... 105 Assessment of the musculoskeletal system ...... 107 Assessment of the nervous system ...... 109 Assessment of abuse ...... 115 Assessment of psychosocial needs ...... 122

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Assessment

70

Assessment

Introduction The following physical assessment material is directed toward the child receiving skilled nursing care in the home versus the “well child.” The pediatric home health care client is often affected by congenital or chronic conditions that create unique challenges in performing a skilled assessment.

Preparing for the physical assessment

1. A stethoscope should be part of each nurse’s personal equipment. Blood pressure equipment will be provided as needed. Thermometers are provided in the home.

2. Know the child’s baseline status. This will assist in performing an accurate assessment. Baseline for some clients may not fall within normal range but will be considered normal for that client

This is critical in making decisions regarding nursing interventions or reporting findings to the physician. For example, a 14-year-old child with hypoplastic lung disease has a resting respiratory rate of 32, which is baseline for this child, so nursing intervention or reporting to the physician is not appropriate. In determining the child’s baseline, there should be validation of abnormal findings with the parents or clinical manager.

3. For the younger child, attempt to incorporate the assessment into fun activities. Play facilitates the developmental growth of the child and may make the assessment easier. Remember, this is home health care. We are not recreating a hospital environment.

4. Certain assessments may not be required. For example, blood pressure tests may not be required for a child who has no clinical indication for them to be obtained. Unless ordered otherwise, obtaining the child’s temperature regularly may be necessary only when there are signs and symptoms of illness.

5. The physical exam of children must be flexible; a systematic approach may not be possible.

6. Regardless of the child’s communication skills, always communicate with the child using a kind, firm, and direct approach and language that is developmentally appropriate.

7. Respect the privacy of the child and expose only the area being examined.

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8. Allow choices whenever possible.

9. Make positive statements.

10. Do not make assumptions based on isolated findings. Look at the whole picture.

Observational assessment Assessment begins at the moment of initial contact with the child. Observation comprises at least 80 percent of the assessment. Initial observations may reveal how well a child is feeling based solely on their activity level and demeanor. How a child is acting is often the best indicator of how sick a child is. Activity level and demeanor will help determine the child’s baseline behaviors.

An almost complete respiratory assessment can be made via observation. Respiratory rate, color, work of breathing, presence or absence of cough, and presence of audible wheezing all can be observed within moments.

Other areas that are observed may include general appearance, posture, hygiene, mental status, hearing and visual acuity, movement and tone of extremities, nutrition and hydration, and pain level.

Growth measurement Weight An accurate weight is important in determining fluid and caloric needs as well as in medication management of the pediatric client.

Children younger than 1 year should be weighed at least once a month. Clients older than 1 year should be weighed when ordered by the physician or to derive a nutritional assessment. A child’s weight may be difficult to obtain in the home if a child is non-weight bearing or is too large to be safely held to be weighed.

Methods for obtaining weight

1. Weigh infants and young children nude on a platform-type scale. Protect an infant by placing your hand above the child’s body to prevent falling off the scale.

2. Weigh older children in underwear on a standing-type scale if the child is weight-bearing. Older children weighing 50 pounds or less may be

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held by an adult and weighed on a normal scale. Subtract the adult’s weight from the total weight to determine the child’s weight.

3. Check that the scale is balanced before weighing, if appropriate.

Report weight loss or lack of consistent gain prior to adolescence. If weight is plotted on a growth chart, the child’s weight should remain within the same percentile over time.

Length or height The length or height of children should be obtained at least once a month. The pediatric home health care client’s length or height will be obtained during visits to the primary physician or by the clinical manager during the monthly visit.

Head circumference Head circumference is measured in children 2 years and younger or if the child’s head warrants a concern (for example, in children with shunts or children born prematurely). Measuring head circumference will be ordered by the physician if it is required in the home health care setting.

Method for obtaining head circumference Measure with a paper tape measure at the greatest circumference, from the top of the eyebrows and pinna of the ear to the occipital prominence of the skull.

Vital signs measurement Body temperature It is important to know the factors influencing body temperature and the sites for temperature measurement.

Factors influencing body temperature

1. The temperature-regulating mechanisms in infants and young children are not well developed and dramatic fluctuations can occur. A young child’s temperature may vary as much as 1.6 °C in a single day.

Fluctuations are less apparent as temperature-regulating mechanisms mature. The control of body heat loss increases with age. The ability of muscles to shiver increases with maturity and the child accumulates ever-greater amounts of adipose tissue necessary for 73

Assessment

insulation against heat loss.

The infant produces relatively more heat per unit of body weight than the adult does, as reflected by the infant’s higher average body temperature.

2. Environmental factors and relatively minor infections can produce a much higher temperature in infants and young children than would be expected in older children and adults. External environment and even excessive clothing or swaddling may raise temperature.

3. Active exercise, stress, or crying may temporarily raise temperature.

4. Diurnal variation may affect temperature. Body temperature is lowest between 1:00 am and 4:00 am, and highest between 4:00 pm and 6:00 pm.

5. Temperature is regulated by the hypothalamus. Some children with neurological issues or brain damage may not have normal temperature regulation. Temperature can be unstable, either low or high, with no other known cause in children who have: • Severe spina bifida • Brain damage due to trauma • Congenital conditions such as agenesis of corpus collosum • Degenerative conditions such as cerebral palsy • Brain tumor affecting the temperature control center of the brain • Post-meningitis • Seizure disorder • Spinal cord injury

6. Recognize that some children have unique temperature patterns. Know their baseline.

7. Fever may induce seizure activity. For this reason, high or rapidly increasing temperatures need to be addressed quickly.

8. Temperature may be the most critical diagnostic indicator of illness because fever may be the only symptom the child exhibits.

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Normal rectal temperature in children Age Fahrenheit, degrees Centigrade, degrees 3 months 99.4 37.5

6 months 99.5 37.5

1 year 99.7 37.7

3 years 99.0 37.2

5 years 98.6 37.0

7 years 98.3 36.8

9 years 98.1 36.7

11 years 98.0 36.7

13 years 97.8 36.6

Site of temperature measurement The temperature measurement site is often selected based on the child’s age, physician orders, and what is least traumatic.

1. Axilla – Used in all age groups but may be contraindicated when accuracy is critical. Accuracy may be affected by poor peripheral perfusion and tends to underestimate core body temperature.

Place the thermometer under the arm with the tip in the center of the bare axilla and hold the child’s arm firmly against his or her side.

2. Oral – Must be a cooperative child at least 5 years or older who can follow directions and has adequate muscle control. Contraindicated when a child is comatose, is seizure-prone, breathes by mouth, or is on oxygen (oxygen through mask lowers oral temperature).

Place the thermometer under the tongue or in the left or right sublingual pocket.

3. Rectal – Generally taken only as a last resort. May be used for all children older than 3 months. Not recommended if the child has diarrhea or rectal irritation, an anal or rectal congenital condition, or has recently had anal or rectal surgery. Contraindicated in a child with a diagnosis related to hematology, oncology, or children prone to

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vasovagal response. Accuracy is affected by stool in the rectum.

Place the thermometer 2.5 cm (1 in) into the rectum and hold securely. Child may be side lying, supine, or prone.

Clinical alert: 4. Tympanic – Accuracy in children under 3 years is questionable. May be contraindicated when a child has acute otitis media or sinusitis. • Aspirin is never given to children because of its Ear canal must be straightened for accuracy. For children older than 3 association with years, pull pinna of ear up and back. For children younger than 3 Reye’s syndrome years, pull pinna of ear down and back.

• The administration of antipyretics is 5. Always record site of temperature. not proven to prevent the recurrence of Pulse rate febrile seizures The factors influencing increased pulse rate are: • Medications such as Ventolin • Activity • Crying and feeding in an infant • Fever: an increase of 10 to 15 beats per centigrade of increase in temperature • Anxiety • Pain • Hemorrhage

The factors influencing decreased pulse rate are: • Medications such as Digoxin • Increased intracranial pressure

Normal range of pulse rates (bpm) With exercise Age Resting awake Resting asleep or fever Birth 100–180 80–160 Up to 220 1 week to 100–220 80–180 Up to 220 3 months 3 months to 80–150 70–120 Up to 200 2 years 2 years to 70–110 60–100 Up to 180 10 years 10 years to adult 55–90 50–90 Up to 180 76

Assessment

Methods for measuring pulse rate Clinical alert: • Measure the pulse when the child is quiet and document the child’s • Increased pulse activity or anxiety level when the pulse is recorded rate occurs early in respiratory • Apical pulse is measured in children younger than 2 years or whenever distress, while a radial pulse is difficult to locate decreased pulse rate occurs late in • The pulse rate should be assessed for 1 full minute respiratory distress • Sinus arrhythmia is a normal variation in children • Decreased pulse rate during • Increased rate during inspiration and decreased rate during expiration respiratory distress are normal (could be misinterpreted as irregular rhythm) is an ominous finding and warrants calling 911 Respiratory rate

• Tachycardia may The factors influencing increased respiratory rate are: be the strongest • and possibly only Anatomy and physiology— indication that the Infants and young children inhale a relatively small amount of air and client is in distress; exhale a relatively large amount of oxygen. They have fewer alveoli and decreased pulse thus, less surface through which gas exchange can occur. Together rate is more with a higher metabolic rate, these factors cause an increased ominous than tachycardia in a respiratory rate. young child • Age – rate is higher in younger children • Fever • Increased activity • Anxiety • Pain

The factors influencing decreased respiratory rate are: Clinical alert: • Age – rate is slower in older children • When in distress, respiratory rate • Position – slumping impedes ventilatory movements; infants and increases children in car seats may desaturate dramatically in infants and young • Pain – abdominal pain or fractured ribs may cause decreased children respirations • The rhythm is irregular in young Methods for measuring respiratory rate infants, who experience sharp • For infants and younger children, place fingers or a hand just below the increases in rate and apneic spells child’s xiphoid process so the inspiratory rises can be felt • Respirations may also be assessed by listening to breath sounds • Apnea lasting longer than 15-20 through a stethoscope seconds is considered 77 pathologic and should be reported to a physician Assessment

• Assess respirations before beginning intrusive procedures • If the child is crying, wait until calm • Count respirations for 1 full minute

Normal respiratory rates in children Age Respiratory rate (RRpm) Premature infant 40–90 Neonate 30–80 1 year 20–40 2–3 years 20–30 5 years 20–25 10 years 17–22 15 years to adult 15–20

Blood pressure Blood pressure is not routinely measured in a child receiving home health care unless there is a clinical indication or physician’s order.

The factors influencing increased blood pressure are: • Renal disease • Increased intracranial pressure • Coarctation of the aorta • Phenochromocytoma • Acute pain • Diurnal variation – BP is usually higher during the morning and afternoon • Increased activity

The factors influencing decreased blood pressure are: • Narcotic analgesics • Diuretics • Diurnal variation – BP is usually lower during the evening and night • Hemorrhage • Septic shock

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Methods for measuring blood pressure • Blood pressure readings should be performed before other anxiety-producing procedures • Select appropriate site – do not use an extremity with damage, altered blood flow, or venous access device • Select the appropriate cuff size – cuff should cover at least 75 percent of the upper arm or thigh in children and adolescents (an overly large cuff may produce low readings and a cuff that is too narrow may produce high readings)

Normal blood pressure values Age Girls Boys SBP/DBP, mm Hg SBP/DBP, mm Hg 1 month 84/52 86/52 6 months 91/53 90/53 1 year 91/54 90/56 2 years 90/56 91/56 4 years 92/56 93/56 6 years 96/57 96/57 8 years 99/59 99/60 10 years 102/62 102/62 12 years 107/66 107/64 14 years 110/67 112/64

Assessment of the skin (integumentary system) The integumentary system reveals much information about the health of the child regarding physical health (or abuse), nutritional, circulatory, and hydration status. When you are assessing the child’s skin, the room should have a good source of light and it should be warm.

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Assessment Comments

Observe the skin for odor. Odor may indicate poor hygiene or infection.

Observe the color of the skin. Most • Skin color is genetically reliably assessed in the sclera, determined conjunctiva, nail beds, around the • Light skinned (from milky white mouth, on palms, and soles of feet. to rose colored) Observe for abnormalities such as • Dark skinned (various shades pallor, cyanosis, erythema, of brown, red, yellow, and ecchymosis, petechiae, and jaundice. olive) • Cyanosis in a child with darker skin may appear ashen gray • Mongolian spots are irregular areas of deep blue pigmentation, usually in sacral, lumbar, and gluteal regions; seen predominately in newborns of African, Native American, Asian, or Hispanic descent

Observe for moisture. Skin should be dry. Mucous membranes should be moist.

Palpate the skin for temperature. Generalized hyperthermia may Compare one side of the body with indicate fever or brain disorder. the other, and the upper with the Children with neurological disorders lower extremities. may not be able to regulate their body temperature.

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Assess for turgor by grasping a fold A skinfold that returns slowly into on the upper arm or abdomen place may indicate dehydration. between the fingers and quickly release. Note the ease with which the skin moves and returns into place.

Palpate and observe for edema. Edema is dependent. Children who do not walk or are bedridden will display edema in the sacral area. Children who are wheelchair-bound often exhibit edema in the lower extremities. Edema may also be present on the dependent side of the face.

Inspect and palpate for lesions. Observe for signs of pruritis.

Common childhood disorders associated with lesions

Allergic disorders 1. Eczema Acute: erythema, vesicles, exudates, and crusts. Chronic: pruritic, dry, scaly and thickened rash. Infantile form found on cheeks, forehead, scalp, and extensor surfaces. Childhood form found on wrists, ankles, and flexor surfaces. 2. Allergic reactions Almost any type of lesion possible. Common manifestations are urticaria (hives) and contact dermatitis. Lesions may be intensely pruritic.

Contagious Diseases 1. Measles Erythematous maculopapular eruption starts on face and gradually spreads downward. It appears 3 to 4 days after onset of fever, malaise, cough, and conjunctivitis. The rash is more severe in earlier sites becoming less intense as it spreads. After 3 to 4 days, the rash assumes a brownish appearance. 2. Rubella Pinkish-red maculopapular exanthema starting on the face, rapidly spreading downward to legs by the end of the first day. The rash is usually gone by the third day. Children rarely have any symptoms prior to the rash.

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3. Roseola After 4 to 5 days of high fever in a child who appears only mildly ill, rose-pink macules or maculopapules first appear on trunk. 4. Chickenpox Following mild fever with symptoms of upper respiratory illness, itching rash progresses from macule to papule to vesicle to crust. Rash begins on trunk and spreads primarily to face and proximal extremities. Most children are now being vaccinated for chickenpox; however, they may still become infected with a mild case of chickenpox or shingles (herpes zoster).

Bacterial infection 1. Impetigo Itching rash begins with reddish macule, and then vesicle appears. Vesicle ruptures, producing a moist erosion. Exudate dries, producing a honey-colored crust. Pruritic. This rash must be treated with antibiotic ointment or oral antibiotics if infection is extensive.

Viral infections 1. Herpes simplex (cold sore) Grouped vesicles on an erythematous base, found near lips, nose, genitalia, and buttocks. Vesicles dry, leaving a crust. 2. Herpes zoster (shingles) Rash follows dermatome of affected nerve and appears in crops of vesicles. Pain and itching are common.

Fungi 1. Candidiasis Eruptions have sharp borders and include red papules, pustules, and satellite lesions. This rash commonly occurs in the diaper area, around G- tube sites, and in skin creases. Will not respond to diaper creams or antibiotic ointments. 2. Tinea corporis (ringworm) Pruritic red, round, or oval scaly areas. Central area is clear.

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Infestations 1. Scabies The female mite infests the skin by producing linear, brownish-gray burrows. In infants, lesions are commonly found on face, palms, and soles. In children, lesions are commonly found on apposed surfaces of skin and interdigital areas, and on the extensor surfaces of joints and wrists, lower back, abdomen, genitalia, and buttocks. 2. Pediculosis corporis (body lice) Lesions appear as red macules, wheals, and excoriated papules on the back and on areas that have close contact with clothing. Pruritic. Hair should be inspected for eggs that look like white dandruff, which is not easily removed from the shaft of the hair.

Vascular Lesions 1. Vascular stains Permanent lesions that are present at birth and are initially flat and erythematous. Any vascular structure, capillary, vein, artery, or lymphatic may be involved. The two most common vascular stains are the port-wine stain and the nevus flameus. The port-wine lesions are pink, red, or (rarely) purple stains of the skin that thicken, darken, and proportionately enlarge as the child grows. The nevus flameus (stork bite) is usually located on the eyelids or the nape of the neck. 2. Hemangiomas “Strawberry hemangiomas” are benign cutaneous tumors that involve only capillaries. These are often not apparent at birth but may appear within a few weeks, enlarge considerably during the first year of life, and tend to resolve spontaneously by age 2 to 3 years. The hemangiomas are bright red, rubbery nodules with a rough surface and a well-defined margin.

Miscellaneous 1. Acne Lesions appear on face, neck, shoulders, upper chest, and back in about 85 percent of adolescents. Lesions may be noninflamed (comedomes) or inflamed. 83

Assessment

Assessment of the nails and hair Assessment Comments

Inspect nails for color, shape, Nails should be pink, convex, smooth, condition, and infection. and flexible, not brittle. Note color changes, such as a blue or yellow tint. Children with chronic respiratory or cardiac conditions may develop clubbing (base of the nail becomes swollen and feels springy when palpated).

Inspect hair for color, texture, amount, Signs of poor nutrition include stringy, distribution, elasticity, and hygiene. dull, dry, depigmented hair. Observe for signs of head lice. Loss of hair may indicate lack of stimulation (such as lying in the same positions for prolonged periods) or hair pulling. Certain medications may cause hair loss or growth.

Assessment of head, eyes, nose, and mouth Head

Assessment Comments

Observe shape and symmetry. Minor asymmetry is common in infants younger than 4 months and is related to molding. Flattened areas may be a result of persistent positioning of the child. Uneven molding may indicate premature closing of sutures, an abnormal finding.

Observe and palpate anterior fontanel Anterior fontanel is diamond-shaped while child is sitting. and closes between months 9 and 18. Should be soft, flat, and pulsatile. A depressed fontanel may indicate dehydration. A bulging fontanel may indicate increased intracranial pressure.

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Note head control (especially in Head lag after 6 months may indicate infants) and head posture. a neuromuscular disorder such as cerebral palsy.

Percuss frontal sinuses. Evidence of pain, wincing, or grimacing, may indicate sinus infection.

Ears

Assessment Comments

Inspect the external ear canal for Ear pulling, irritability, fever, or general hygiene, discharge, and drainage from one or both ears may excoriation. Palpate the mastoid for indicate ear infection. Pain and tenderness. tenderness may indicate mastoiditis.

Clues for detecting hearing impairment • Lack of startle or blink reflex in response to a loud sound • Failure to be awakened by loud environmental noise during infancy

• Failure to localize a source of sound by age 6 months Clinical alert: • Lessened experimental sound play and squealing Children who have had tubes placed in • Failure to develop intelligible speech by age 24 months their ears due to receiving otitis media • Less interest and involvement in vocal nursery games will have drainage from their ears during • Use of gestures rather than verbalization to express desires, especially an infection, and after age 15 months require antibiotic drops as prophylaxis for water exposure Note: Children who are developmentally delayed may exhibit some of the above issues without hearing impairment.

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Eyes

Assessment Comments

Inspect eyelids for color, swelling, Puffiness may be related to thyroid or discharge, and lesions. renal disorders. If the area around the eyelids appears sunken, the child may be dehydrated. Shadow under the eyes may indicate fatigue or allergy. When the eyes are closed, the lids should completely cover the cornea and sclera. Incomplete closure can result in chronic eye irritation and infection.

Inflammations of the eyelid: • Hordeolum or stye – Inflammation of sebaceous glands near lashes, usually on lower eyelid, with painful, red, swollen areas • Internal stye – Acute inflammation of sebaceous glands of upper lid; when upper lid is everted, stye appears as a yellow line across the edge of the eyelid • Blepharitis – Inflammation of edge of lid with red, scaly, crusted lid edges • Dacryocystitis – Inflammation and blockage of lacrimal sac or duct with swelling, redness, and pain, below and to nasal side of inner canthus, with purulent drainage

Inspect the conjunctivae by gently Should be pink and glossy. Redness, pulling down the lower lid. dryness or swelling is abnormal. Pallor may accompany anemia.

Inspect the sclerae for color. Sclerae should be white and clear. Tiny black marks in children with dark skin is normal. Yellow may indicate jaundice.

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Inspect pupils for shape, size, Pupils are normally round and equal equality, and response to light. in size, although inequality is not uncommon and may be nonpathologic if other findings are normal. Pupils should respond quickly to light. Report unequal pupils that may be associated with other abnormal neurological findings.

Observe extraocular movements. Children with neurological dysfunction Have a child follow object through six may track an object inconsistently. fields of gaze.

Note: Visual acuity may be impossible to assess in the majority of home health care clients. An infant or child should respond by blinking in response to light.

Nose

Assessment Comments

Observe the external nares for flaring, Flaring nares indicate respiratory discharge, excoriation, and odor. distress. Yellow or green discharge may indicate infection. Odor may indicate a foreign body.

Mouth

Assessment Comments

Inspect the lips for color, moisture, Lips should be intact, pink. and firm. swelling, sores, and fissures. Blueness of the lips is a reliable sign of cyanosis in light-skinned children. Cracked lips are usually the result of harsh or dry climate, mouth breathing, or fever. Fissures at the corners of the mouth may indicate deficiency of riboflavin or niacin.

Inspect the oral mucosa, gums, and The oral membranes are normally tongue for color, moisture, intactness, pink, firm, smooth, and moist. Gums and bleeding. may appear bluish in children with 87

Assessment

dark skin. Red, swollen, and bleeding gums may indicate infection or poor oral hygiene. Some anticonvulsant medications may cause hyperplastic gum tissue. A red tongue may be related to vitamin deficiency. White curdy patches on the gum margins or palate usually indicates thrush. Dry, sticky mucous membranes suggest dehydration.

Thrush

Inspect teeth for condition. In children Alert parents to obvious caries and 5 years or older, check if any teeth any loose teeth. Loose teeth may be are loose. removed to prevent their aspiration.

Observe for presence of odor. Odor can indicate poor oral hygiene, constipation, sinusitis, dehydration, or systemic illness.

Assessment of the respiratory system Rationale for a pulmonary assessment • Respiratory disorders are common in infancy and childhood and can be acute, life-threatening, or chronic • For children, unlike adults, respiratory dysfunction is the most frequent cause of cardiac arrest • Knowledgeable assessment will provide timely and appropriate intervention and prevent deterioration in the child’s condition and potential respiratory failure • Many of the clients cared for in home health care are at higher risk for respiratory dysfunction and rely on the nurse’s ability to assess and provide interventions

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Pediatric differences in anatomy and physiology The airway of a child continues to grow and develop until about age 12. The neck of a young child is much smaller than that of an adult, resulting in airway structures that are much closer together. Let’s look at some of the differences between an adult and a child’s respiratory system and evaluate how these differences may impact care.

Upper airway In the infant and small child, the length and, more importantly, the diameter of the trachea is much smaller than the adult’s—only one-fourth the size. A relatively small amount of swelling or secretions can cause occlusion of the airway. Infants also have relatively little cartilage in the trachea and bronchi, allowing these structures to collapse more readily.

(Prentice-Hall)

The diameter of an infant’s airway is approximately 4 mm, in contrast to an adult’s airway diameter of 20 mm. An inflammatory process in the airway causes swelling that narrows the airway and airway resistance increases. As depicted in the above illustration, swelling of 1 mm reduces the infant’s airway diameter to 2 mm (that is, by 50 percent), while the adult’s airway is narrowed to 18 mm (that is, by only 5 percent). Air must move more quickly in the infant’s narrowed airway to get the same volume of air to the lungs. The motion of the quickly moving air against the side of the airway increases airway resistance.

During the first five years of life, the trachea grows in length more than width. The child’s little finger is a good estimate of the size of his upper airway. The narrower airway in a child results in increased airway resistance.

Tracheal position is another difference. Below we see the comparison between that of adults versus that of children.

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In children, the trachea is shorter and the angle of the right main bronchus at the bifurcation is more acute that in the adult. As a result of tracheal placement, the larynx and glottis are also placed higher in the oropharynx, making the child more prone to aspiration.

The following chart demonstrates other comparative differences between the adult upper airway and the upper airway of a child.

(Prentice-Hall)

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Assessment

Lower airway The child’s lower respiratory tract continues to grow and mature until puberty. This is good news for our clients with bronchopulmonary dysplasia. This growth of new, healthy lung tissue affords them the opportunity to vastly improve their respiratory function and may limit the need for ventilatory support. At birth, the lungs contain only 25 million alveoli and are not fully developed. The number of alveoli continues to increase to 200 million by age eight. These alveoli then cease to increase in number but instead grow in size and complexity until puberty. This growth results in increased area for gas exchange. Lung growth is closely correlated with linear growth. This is why pulmonologists tend to be focused on consistent weight gain—the taller the child, the greater the lung surface area.

Children have less compensatory reserve than adults. They tire easily. The younger the child, the more susceptible he or she is to respiratory distress and failure due to all of the factors discussed above. Grunting is a compensatory mechanism that infants and young children use to maintain positive airway pressure when they are in respiratory distress. The respiratory rate would be doubled if the child could not grunt. Infants and young children also have a greater metabolic demand for oxygen, requiring 6 to 8 ml/kg/min, in contrast to an adult who only requires 3 to 4 ml/kg/min. This is why in respiratory distress, a child requires faster oxygen replenishment than an adult.

Ventilation is defined as the movement of air in and out of the airways and alveoli. This is accomplished through the workings of the diaphragm and intercostal muscles. Children under the age of six rely primarily on the diaphragm for respiratory effort due to immaturity of the intercostal muscles. In children, the ribs are primarily cartilage and are very flexible. When in respiratory distress, the negative pressure caused by diaphragmatic movement may result in the chest wall being drawn inward, resulting in retractions. The picture below labels common sites of chest-wall retractions.

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Assessment

(Prentice-Hall)

Retractions occur in infants and children under the age of 6. The depth and location of retraction is often indicative of the degree of distress. Intercostal retraction generally indicates mild distress. Subcostal, suprasternal, and supraclavicular retractions indicate moderate distress. These retractions, accompanied by involvement of accessory muscles, indicate severe distress.

The factors that increase the risk of respiratory distress are: 1. Ineffective airway clearance • Neurological dysfunction, such as cerebral palsy • Neuromuscular diseases, such as spinal muscular atrophy • Seizure activity 2. Impaired gas exchange • Chronic lung issues secondary to atelectasis from repeated aspiration (GERD) • Lung disease secondary to prematurity • Ineffective breathing patterns related to neuromuscular diseases, scoliosis, apnea, immobility • Narrowing or constriction of airways secondary to reactive airway disease 3. Delayed growth and development related to chronic lack of oxygen

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Assessment

Pediatric differences in respiratory assessment Respiratory assessment consists of four basic techniques: observation, palpation, percussion, and auscultation.

Observation Observation will comprise approximately 90 percent of your pulmonary assessment and begins the moment the child is encountered. Be aware of the child’s baseline pulmonary status since the child’s baseline may not always fall within normal range.

Observe the following with every assessment: • Activity level and demeanor (level of consciousness) • Simultaneous chest expansion and abdominal rise. Asymmetric chest rise is associated with a pneumothorax or significant atelectasis. • Color • Respiratory rate – count the respiratory rate when the child is quiet because the rate rises to increase oxygen in response to excitement, fear, respiratory distress, fever, and other conditions. • Coordination of rib cage and abdominal movements: • Children younger than age 7 are diaphragmatic breathers, so the abdomen rises with inspiration. During respiratory distress, rib and abdominal movements become paradoxical, creating ineffective breathing patterns and poor air exchange • In children older than age 7, breathing becomes thoracic and the abdomen and chest should move together. Abdominal breathing in an older child may indicate respiratory distress or a fractured rib • Listen for audible chest sounds: • Stridor – high pitched crowing sounds indicate obstruction of the large airways. Stridor and barking cough accompany croup. Inspiratory stridor accompanies epiglottitis • Grunting • Hoarseness – accompanies croup • Snoring – expiratory snoring accompanies epiglottitis • Wheezing – indicates reactive airway disease, bronchiolitis or foreign body aspiration • When there is a cough, note the following: • Onset • Duration • Type – dry, hacking, moist, barking • Progress – better, worse, unchanged, persistent • Pattern – daytime, nighttime, both; different intensity with time and activity • Associated symptoms – sore throat, dyspnea, elevated temperature 93

Assessment

• Secretions

Normal respiratory rates in children

Age Respiratory rate (RRpm)

Premature infant 40–90

Neonate 30–80

1 year 20–40

2–3 years 20–30

5 years 20–25

10 years 17–22

15 years to adult 15–20

A sustained respiratory rate greater than 60 breaths per minute is an important sign of respiratory distress. At that rate, children develop hypoxemia quickly if interventions are not started. The child’s airway is very narrow, resulting in higher airway resistance than occurs in adults. When the respiratory rate exceeds 60 breaths per minute, inspired oxygen does not reach the alveoli for gas exchange because air moves no farther than the upper airway. (Eichelberger, Ball, Pratsch et al. 1998.).

Palpation Feel for the following physical signs: 1. Skin temperature 2. Presence or absence of moisture; cool, clammy skin 3. Use of respiratory muscles 4. Point of tenderness 5. Presence and quality of vibrations (tactile fremitus)

Tactile fremitus are the vibrations produced by talking and crying. These vibrations can be heard by palpation on the chest wall. Place the palms of your hands on each side of the chest to evaluate the quality and distribution of the vibrations. As the child speaks or cries, move your hands systematically over the anterior and posterior chest, comparing the quality of your findings from side to side. The vibrations are normally palpated over the entire chest. Decreased fremitus indicates that air is trapped in the lungs, as occurs with bronchospasm. Increased fremitus indicates lung consolidation, as occurs with atelectasis. 94

Assessment

Percussion This is the process of listening to sound produced by tapping on the anterior and posterior chest wall. It is not a useful tool in infants and small children.

Auscultation of the chest for breath sounds Select a routine sequence for auscultating the entire chest so assessment of all lobes of the lungs will be consistently performed. The following picture shows one suggested chest auscultation sequence.

Auscultation is the best tool in pediatric respiratory assessment, Clinical alert: not especially with smaller children and infants, for the following reasons: • DO listen on a bare Sounds are easily transferred from one area to another, making accurate chest assessment difficult The child often cannot be directed to cough or take a deep breath • DO listen in a quiet environment Congestion in upper airway causes sounds that will transmit to other areas • Listen to entire lung field Note: Although auscultation is not the most reliable tool for respiratory systematically assessment in infants, it is a mandatory part of assessment. Use an • Clear the airway of infant or pediatric stethoscope to help localize any unexpected breath secretions before sounds. Use the stethoscope diaphragm because it transmits high- auscultation pitched breath sounds better.

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Assessment

Normal breath sounds 1. Vesicular Gentle rustling sound during inspiration in a healthy person. Inspiratory phase is longer and louder than expiratory phase. In infants, expiration may be difficult to hear. Vesicular sounds are normally heard throughout the lung fields. 2. Bronchial Louder than vesicular with short inspiratory and long expiratory phase. Heard over the trachea and main stem bronchi. Note: If heard elsewhere in the lungs, bronchial breath sounds indicate consolidation or fibrous disease.

Abnormal breath sounds 1. Rales Defined in three ways: fine, medium or coarse crackles. Rales are generally not cleared by coughing. • Fine rales occur at the end of inspiration. • Medium rales are heard in mid-stage of inspiration. • Coarse rales are heard throughout inspiration. 2. Rhonchi Coarse sounds with inspiration and expiration that are usually cleared with coughing. 3. Wheezes Squeaky musical noises associated with a prolonged expiratory phase. 4. Pleural friction rubs Dry grating sounds heard with inspiration and expiration.

Respiratory distress Measurement of oxygen saturation in the blood via pulse oximetry will assist in evaluation of respiratory distress. Do not depend on the pulse oximeter as a reliable measure of respiratory distress without a full assessment of the client.

Always be alert for these important signs and symptoms of respiratory distress: 1. Tachypnea 2. Restlessness or agitation 3. Difficulty feeding 4. Demeanor changes – irritability, lethargy, fatigue, or confusion 96

Assessment

5. Orthopnea 6. Anxiety 7. Color change 8. Peripheral cyanosis may be due to cold environment, anxiety, or poor perfusion but does not indicate hypoxemia in absence of other signs of respiratory distress 9. Central cyanosis is due to a marked drop in the oxygen-carrying capacity of the blood and is identified in the lips, tongue, and oral mucosa 10. Mottling and cyanosis of the trunk indicate severe hypoxemia; not detected in children with dark skin who will appear ashen or gray 11. Grunting respirations caused by early closure of the glottis during expiration. Grunting is a physiological attempt to maintain positive end-expiratory pressure (PEEP), helping keep small airways open to increase oxygenation. 12. Nasal flaring – dilation of the nares on inspiration may indicate

Clinical alert: increased work of breathing.

• If GERD is a known 13. Retractions – during retractions, the chest appears to sink in just diagnosis and the below the neck or under the breastbone with each breath to bring air child is into the lungs. experiencing respiratory 14. Diaphoresis – skin may feel cool or clammy or the child may be distress, in sweaty. addition to responding to the 15. Wheezing. respiratory issues, remember to deal with the issues Response to respiratory distress contributing to The goal for our response to respiratory distress is to provide optimal GERD respiratory function. Based on assessment of the child’s respiratory status, the cause or causes of distress must be determined and we must • For example, stop appropriately respond to eliminate the cause and provide optimal the feeding, if appropriate, vent aeration. the G-tube and place the child in a position with the Cause of respiratory distress Interventions per physician orders head elevated Inability to clear secretions secondary Position change. Suction. CPT. to ineffective cough. Nebulizer treatment, NSS for thick secretions. Coughalator. Oxygen for desaturations.

Ineffective air exchange due to Bronchodilators via nebulizer or MDI. narrowing or constriction of airways Oxygen for desaturation. Inhaled secondary to asthma. steroids.

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Ineffective air exchange due to CPT. Inhaled medications via atelectasis secondary to repeated nebulizer. Oxygen for desaturation. pneumonias or lung disease of prematurity.

Ineffective breathing patterns Position to facilitate optimal secondary to neuromuscular ventilation. Oxygen for desaturation. disorders, scoliosis, or immobility. Noninvasive assist with ventilation via BiPAP.

Assessment of the cardiovascular system Assessment of the cardiovascular system in the pediatric home health care client does not require knowledge specific to diagnose heart murmurs or other cardiac anomalies. This discussion of cardiovascular assessment will be limited to providing you with the ability to determine that the client’s cardiac function is normal and perfusion is adequate. In the event that you are providing care for a client with a diagnosed cardiac condition, it is expected that you will familiarize yourself with any symptoms and potential interventions that would be common to that condition.

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Assessment Comments

Inspect the chest with the child seated The chest should be symmetrical– in a semi-Fowler’s position. Look at asymmetric chest expansion may the anterior chest wall from an angle, signal congestive failure. A comparing both sides of the rib cage pulsation may be visible in thin with each other. children, during fever, or with anxiety.

Auscultate heart sounds when the child is quiet. Evaluate for the following:

Quality Sounds should be clear and distinct, not muffled, diffuse or distant. If a murmur is detected that was never heard before, report it to a physician.

Intensity Should not be weak or pounding.

Rate Should be the same as the radial pulse.

Rhythm Should be regular and even. An arrhythmia that occurs normally in many children is sinus arrhythmia, in which the heart rate increases and decreases with expiration. Differentiate this rhythm from a truly abnormal arrhythmia by having the child hold their breath, if possible. If the arrhythmia is caused by sinus arrhythmia, the cessation of breathing will cause the heart rate to remain steady.

Palpate the peripheral arteries for Normally pulses are palpable, equal in equality, rhythm, and pulse rate. intensity and in rhythm. Palpate the radial pulse. The radial pulse is best felt in children older than age 2. Palpate brachial pulse if radial pulse is difficult to locate. Radial pulse may be difficult to palpate in children with spasticity. Palpate the dorsalis pedis pulse along the upper medial aspect of the foot.

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Assess capillary refill time, an Capillary refill should be “brisk,” that important test of peripheral circulation. is, less than 2 seconds. Prolonged Blanch the nail bed with sustained refill may indicate poor systemic pressure for a few seconds and then perfusion. release the pressure. The time it takes for the nail to return to its original color is the capillary refill time.

Assess extremities for signs of poor Cyanosis or mottling may indicate peripheral perfusion. Poor peripheral poor perfusion. Skin will be pale perfusion will also cause changes in (pallor). Extremities may be cool and the child’s level of consciousness due clammy. to lack of adequate amounts of oxygen to the brain.

Clinical manifestations of heart failure

Clinical alert: The three ways that heart failure (HF) can be evident and their signs and Call 911 and begin symptoms are listed below. chest compressions in a child whose 1. Impaired myocardial function heart rate is less than 60 beats per minute • Tachycardia and who has signs of poor perfusion • Sweating (inappropriate) • Decreased urinary output • Fatigue • Weakness • Restlessness • Anorexia • Pale, cool extremities • Weak peripheral pulses • Decreased blood pressure • Gallop rhythm

2. Pulmonary congestion • Tachypnea • Dyspnea • Retractions (infants) • Flaring nares

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• Exercise intolerance • Orthopnea • Cough • Cyanosis • Wheezing • Grunting

3. Systemic venous congestion • Weight gain • Peripheral edema, especially periorbital • Ascites • Neck vein distention

Assessment of the abdominal systems The abdominal cavity contains the organs and structures of the genitourinary, gastrointestinal, and hematopoietic systems, so this becomes a multisystem assessment. Many factors affect the function of these systems such as diet, immobility, medications, stress, and other problems that may have an indirect effect on gastrointestinal (GI) function. Most pediatric home health care clients have a variety of GI issues that affect them on an ongoing basis.

Comparative anatomy and physiology of the pediatric versus adult gastrointestinal system The primary functions of the GI tract are the digestion and absorption of nutrients and water, elimination of waste products, and secretion of various substances required for digestion. The liver, located in the right upper quadrant of the abdomen has several important functions, including biosynthesis of protein; production of blood clotting factors; metabolism of fat, protein, and carbohydrates; production of bile; metabolism of bilirubin; and detoxification.

At birth, the GI tract is immature and it does not fully mature until the child is age 2. Many differences exist between the digestive tract of the infant or child and that of the adult. For example, the muscle tone of the lower esophageal sphincter does not assume adult levels until the infant is 1 year old. This lax sphincter muscle tone explains why young infants frequently regurgitate after feedings. Intestinal peristalsis in children is rapid, with emptying time being 2½ to 3 hours in the newborn infant and 3 to 6 hours in older infants and children.

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Stomach capacity is 10 to 20 ml in the neonate compared with 10 to 200 ml in the 2-month-old infant, 1500 ml in the 16-year-old and 2000 to 3000 ml in the adult. The stomach is round and lies somewhat horizontally until 2 years of age. The parietal cells of the stomach do not produce adult levels of hydrochloric acid until age 6 months. The gastrocolic reflex, or movement of the contents toward the colon, is rapid in young infants, as evidenced by the frequency of stools.

The intestine, which underwent rapid growth in utero, undergoes further growth spurts when the child is 1 to 3 years old and again at 15 to 16 years. After birth, the musculature of the anus develops as the infant becomes more upright. The child then becomes able to voluntarily control defecation.

Assessment Comments

Assess for anorexia, or difficulties with Intolerance may present as oral feeding. If alternative feeding restlessness, irritability, elevated heart methods are being used, inquire rate, gastric distention, or other signs about tolerance of feeds. and symptoms of GERD.

Assess for emesis. Determine • Frequency • Volume • Force (ie; projectile) • Color • Hematemesis • Relationships to food intake

Assess for pain. If possible, assess pain for • Site • Frequency • Duration • Character (crampy, sharp, stabbing) • Radiation • Onset (sudden or gradual) • Progression • Aggravating and relieving factors • Associated symptoms

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Assess bowel habits. Assess for: • Frequency, quantity, color, and consistency of stool • Presence of blood • Pain before, during, or after defecation

Types of stools and related findings

Type of stool Related findings

Soft or liquid, light yellow Common in breast-fed babies

Soft or pasty, green Common in formula-fed babies

Watery, pale Associated with celiac disease

Liquid or watery, green Diarrhea. Indicative of infectious disorde inflammatory bowel disease, chemothera Hirschsprung’s disease, or laxative use

Grossly bloody diarrhea May be indicative of ulcerative colitis or infectious dysentery

Black May indicate that the child is receiving iro or has gastric or duodenal bleeding

Gray or clay-colored Biliary atresia

Undigested food in stool Common in infants who are unable to completely digest foods such as corn

Currant jelly stool (blood or mucous) Indicative of intussusception, Meckel’s diverticulum

Frothy, greasy, foul smelling Indicative of cystic fibrosis

Ribbon-like Indicative of Hirschsprung’s disease

Firm, hard Associated with diet, inadequate fluid or fiber intake, obstructive disorders, irritabl bowel syndrome, medications, overly rig toilet training.

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Note: Many pediatric home health care clients are nonverbal and will be unable to describe the presence of or nature of their pain. You may have to rely on the use of a “nonverbal” pain assessment tool.

Assessment of the gastrointestinal system should consist of four basic techniques:

Inspection 1. Size, shape, and contour – Note any distension or asymmetry (in infancy, abdomen is typically protuberant; in early childhood the abdomen is still protuberant but flattens when the child is lying down). Size and tone of the abdomen give some indication of general nutritional status and muscular development. A large, prominent, flabby abdomen is often seen in obese children, whereas a concave abdomen suggests undernutrition. Carefully note a protruding abdomen, which may indicate abdominal distention, ascites, tumors, or organomegaly. A protuberant abdomen with spindly extremities and flat, wasted buttocks is seen in malnutrition that may occur from inadequate protein intake or from diseases such as cystic fibrosis. 2. Presence of scars, ecchymotic areas, excessive hair distribution, or distended veins. Superficial veins may be visible in thin, light-skinned children, but distended veins are an abnormal finding and suggest vascular or abdominal obstruction or abdominal distention.

Clinical alert: 3. Peristaltic waves. Inspect the abdomen for movement by standing at eye level to the abdomen. Visible peristaltic waves nearly always • Before deciding indicate intestinal obstruction, and in the infant younger than 2 that bowel sounds are absent, you months, indicate pyloric stenosis. must listen for a 4. Inspect the umbilicus for color, discharge, odor, inflammation, and minimum of 5 minutes in each herniation. area where sounds are not heard Auscultation

• Bowel sounds can 1. Auscultation should be done before palpation. The stethoscope must be stimulated, if be pressed firmly against the abdominal surface. present, by stroking the 2. The most important sound to listen for is peristalsis, or bowel sounds, abdomen with a which sound like short metallic clicks and gurgles. Loud grumbling fingernail noises are familiar “stomach growls” and usually denote hunger. Depending on when the child last ate, a sound may be heard every 10 to 30 seconds.

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3. High-pitched tinkling sounds indicate diarrhea, gastroenteritis, or obstruction. 4. Always report an absence of bowel sounds because this usually denotes an abdominal disorder such as paralytic ileus.

Percussion 1. Percussion is a tool that can assist you in determining the presence of excess gas in the abdomen of a child who is irritable or the presence of a full bladder in a child who has not voided. 2. Percussion will not necessarily be performed on a daily basis.

Palpation 1. If a child complains of pain in any abdominal area, palpate that area last. 2. Use light palpation to assess tenderness, guarding, and superficial masses. Watch the child’s facial expression because a withdrawal or tense facial expression may indicate apprehension, pain, or nausea. 3. A distended bladder may be palpable above the symphysis pubis.

Clinical alert: Assessment of the reproductive system Assessment of the reproductive system will include ongoing evaluation to • Breast determine onset of reproductive maturation, assessment of breast tissue development before age 8 may for any abnormalities, and assessment of the external genitalia to detect be normal but infections that may require further evaluation. requires careful assessment Assessment of Breasts Comment • Certain medications and Inspect the breasts. Note size, Contour and size of the breasts and some neurological contour, and symmetry. changes in the areola indicate sexual disorders may cause precocious maturity in girls. One breast may puberty: the develop before the other. Dimpling development of and alterations in the contour of the secondary sexual breast may indicate cancer. Redness characteristics before the age of 8 may signal infection. years

• In males, development of breast tissue (gynecomastia) 105 may be caused by hormonal or systemic disorders Assessment

Inspect the nipple and areola. Note Edema of the nipple or areola may color, size, shape, presence of indicate the presence of cancer. discharge, and color of discharge. Discharge is abnormal and may be due to hormonal causes. Presence of any discharge should be reported to the physician.

Systematically palpate the entire Note location, size, consistency, and breast. shape of any mass. Any palpated mass should be reported to the physician.

Assessment of female genitalia Comment

Inspect the urethral and vaginal Redness and swelling of labia may openings for edema, redness, and indicate infection, masturbation, or discharge. sexual abuse.

Redness and foul-smelling discharge from the vagina may indicate infection, a foreign body, or sexual abuse.

A white, cheesy discharge from the vagina indicates a candidal infection.

Assessment of male genitalia Comment

Inspect the urinary meatus for shape, The urinary meatus is normally placement, discharge, and ulceration. slightly ventral at the tip of the penis Note whether the child is circumcised. and slit-like. A urinary meatus that is If uncircumcised and older than 3 ventral is called hypospadias. A years of age, attempt to retract the meatus that is dorsal is called foreskin. Do not forcibly attempt to epispadias. A round meatus may retract the foreskin. indicate stenosis of the meatus related to repeated infections. Any discharge from the urethra is abnormal and should be reported to the physician.

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A testis should be present in each Inspect the scrotum for color, size, sac, freely movable, smooth, equal in symmetry, edema, masses, and size to the other. The left testis is lesions. Palpate the testes. Cold, lower than the right. Undescended touch, exercise, and stimulation may testes before age 3 may descend cause the testes to ascend into the without intervention. There are a pelvic cavity. number of syndromes and genetic disorders that may include the absence of a testis or a testis that is undescended.

Assessment of the musculoskeletal system The majority of pediatric home health care clients have muscular dysfunction and alteration in mobility related to their diagnosis. These issues lead to frequently seen complications such as scoliosis, osteoporosis, spasticity, and contractures.

Scoliosis This condition involves complex lateral and rotational curvature and deformity of the spine. It often occurs as a secondary symptom of other conditions such as cerebral palsy or spinal muscular atrophy. Severe scoliosis may cause respiratory and GI function to be impeded due to compression of internal organs. Comfortable positioning becomes a challenge for the nonambulatory client. Skin integrity may be compromised by the use of orthotic devices.

Osteoporosis Osteoporosis in children is a skeletal disorder characterized by compromised bone strength that increases the risk of pathological fractures. This occurs due to the absence of motion and weight bearing activity, which leads to bone demineralization.

Spasticity This occurs when certain nerve signals do not reach muscles because of injury or disease that affects parts of the brain or spinal cord. Common conditions associated with spasticity include cerebral palsy, spinal cord injury, and brain injury. Spasticity is characterized by tight, stiff muscles that make movement, especially moving arms or legs, difficult or uncontrollable. Spasticity may be painful, especially if it pulls joints into abnormal positions or prevents normal movement. When spasticity is generalized, daily care becomes challenging and interferes with dressing, walking, positioning, sitting, transferring, or standing. Spasticity may be triggered by a stimulus such as pain, reflux, or constipation.

Contractures 107

Assessment

The risk of contractures is high in a child who has altered mobility. In the absence of normal stretching, collagen fibers generated within the joint become fibrotic and further limit movement. This tissue fibrosis creates a shortening of the muscles and a contracture of the joint. This process is further exaggerated because flexor muscles are stronger than the extensor muscles. Unless range of motion intervention is provided, contractures will develop within 3 to 7 days of continuous immobility. Contractures of the large joints such as hips and knees can severely affect mobility and positioning.

Assessment Comment

Observe the curvature of the spine. This assessment may be difficult in the nonambulatory child. (See description of scoliosis above.)

Inspect the spine for dimples or tufts May indicate spina bifida occulta. of hair. Observe mobility of cervical Movement of the head in all directions spine. should be effortless. Hyperextension of the neck and spine (opisthotonos), which is accompanied by pain when the head is flexed, should be referred for immediate evaluation.

Inspect the extremities for The temperature in each extremity temperature, color, tenderness, and should be equal, although the feet masses. may normally be colder than the hands. Coolness denotes decreased circulation, such as from occlusion of a blood vessel, whereas heat indicates increased blood flow from infection or inflammation. Enlargement of bone or swelling with redness, heat, and tenderness needs further evaluation. It may signify trauma, infection, or an underlying disease process. Palpation over a possible fractured bone may elicit crepitation, a grating sound produced by movement of broken ends of the bone.

Evaluate the joints for range of Spasticity may cause evaluation of

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motion. ROM to be difficult or impossible. Spasticity and contractures will cause decreased ROM. Low muscle tone may cause hyperflexibility.

Note symmetry and quality of muscle Extremes in muscle tone will be development, tone, and strength. observed in the pediatric home health Estimate tone by grasping the muscle care client – from low tone in spinal and feeling its firmness when it is muscular atrophy to high tone and relaxed and contracted. If possible, spasticity in cerebral palsy. estimate strength by having the child use an extremity to push or pull against resistance.

Assessment of the nervous system Assessment of the nervous system is the broadest and most diverse type of assessment, because every human function—physical and emotional—is controlled by neurologic impulses. In this discussion, we will address issues relating to behavior, cognitive and perceptual development, sensory and cerebellar function, deep tendon reflexes, and cranial nerve function.

Behavior Evaluation of behavior is one of the most subjective and variable assessments. It is an overall impression of the child’s personality, affect, activity level, social ability, and attention span. Day-to-day changes are to be expected. It is essential to know the child’s baseline level of consciousness (LOC) for comparison. Evaluation of the state of consciousness is one element of a complete behavioral assessment. It is as critical in pediatric as in adult assessment. It can be a challenge to determine the LOC of a nonverbal infant or child. The quality of the awake child (smiling, looking around, and interacting with parents) should be described as well as sleep patterns and ease in arousing from the sleeping state.

Descriptive terms relating to level of consciousness

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Full consciousness – client is alert, attentive, and follows commands. If asleep, responds promptly to external stimulation and once awake, remains attentive.

Lethargy – client is drowsy but awakens, although not really fully, with stimulation. Will answer questions and follow commands, but will do so slowly and inattentively.1

Obtundation – client is difficult to arouse and needs constant stimulation in order to follow a simple command. May respond verbally with one or two words, but will drift back to sleep between stimuli.

Stupor – client arouses only to vigorous and continuous stimulation; typically, a painful stimulus is required.1 May moan briefly but does not follow commands. Only response may be an attempt to withdraw from or remove the painful stimulus.

Coma – client does not respond to continuous or painful stimulation. Does not move except, possibly, reflexively, and does not make any verbal sounds.

Cognitive-perceptual Evaluate the child’s current level of function utilizing a growth and development screening tool as provided in the chapter on growth and development. It is important to identify the child’s method of communication and its effectiveness.

Motor function in infants Assessing motor function in the infant includes testing and checking for tone, strength, and deep tendon reflexes (DTRs). Observation of the infant’s resting posture is a critical part of this examination because the infant is developmentally unable to participate in the more traditional approach to the motor examination. At rest, infants normally have a slightly flexed posture at the hips, knees, and arms. They should be able to move their extremities to a full stretch.

Abnormal tone is present when this normal stretch is absent, with persistence of increase in tone or the absence of flexion in a flaccid posture. Frequently, flaccidity or decreased tone is evidenced by an outward rotation at the hips with the legs externally rotated in a frog-leg position. Individual muscle testing is not possible.

However, several muscle groups may be assessed for tone:

Neck tone — assessed by the traction maneuver. With the infant lying supine on a flat surface, the infant is pulled to a sitting position. At 4 to 5 110

Assessment

months of age, the infant should be able to maintain the head in a neutral position. Abnormal tone is indicated by the head falling backward or requiring support.

Shoulder tone — assessed by holding the infant in vertical suspension with the examiner’s hands under the arms at the armpits. The infant should hold in that position with the arms remaining flexed and no rise in the shoulders. Inability to maintain that position is know as “slipping through,” and is a response that indicates abnormal shoulder tone.

Leg tone — assessed by placing the infant in the vertical position with the feet placed on the examining surface. The 4-month-old infant should be at least momentarily able to support his or her weight. Inability to support any weight implies decreased tone. Increased tone is manifested by an extensor posture to the legs with preference for placement on the toes and crossing or scissoring of the legs. Strength in the infant is tested by the infant’s ability to move the muscles against gravity. DTRs are obtained at the biceps, triceps, Achilles, and patellar tendons. The Achilles reflex is present but difficult to elicit in young infants. Plantar (Babinski) responses are obtained by stroking the dorsum (outside edge) of the foot. In infants, a plantar grasp response can be elicited if the stimulus is applied to the center of the foot.

There is some controversy about when the specific age of an infant with an extensor response (movement of the great toe upward with fanning of other toes) indicates abnormality, but most authors continue to suggest that the extensor response may be normal up to the age of 1 year. Muscle bulk and consistency are evaluated by palpation of the arm and leg muscles. In a 4-month-old infant, the muscles have a degree of firmness. Determination of muscle bulk is a subjective estimate of the volume of muscle.

Motor function in older children Assessing motor function in older children includes the following four areas:

Muscular tone — basic constant ongoing contraction or muscular activity in the muscles. It can be understood as a baseline or background level. Tone may be normal, too low, or too high. Hypotonic children appear floppy. Young children who may be hypotonic have difficulty maintaining posture against gravity and prefer to sit in a leaning position against something or lie on the floor. Preschool-age children may sit in a fashion that appears lazy. Rather than sitting upright, they mostly sit in a slouching manner, leaning on the chair or table with their head on top of the table or they may lie down during activities as much as possible. Of course, this positioning can also be observed in older children and is

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often erroneously interpreted as a sign of lack of interest or even disrespect.

By contrast, when muscular tone is too high (hypertonic), children appear somewhat stiff and do not move in a smooth and natural way. Youngsters may move somewhat like a puppet or robot, and they lack the ordinarily smooth nature of movement on small motor acts. Basic muscle tone that is too high or too low is one of the components of impaired motor skills. Children must fight low muscular tone to carry out movements, expending energy to maintain postures and activities. Hypertonic children may make mistakes because of the over-activation of the muscular units.

Gross motor skills — the ability of children to carry out activities that require large muscles or groups of muscles. Muscles or groups of muscles should act in a coordinated fashion to accomplish a movement or a series of movements. Examples of gross motor tasks are walking, running, throwing something, jumping, standing on one leg, playing hopscotch, and swimming. Posture is an important element to consider in the assessment of gross motor skills. Adequate posture may make all the difference between being able or not able to execute a movement.

Fine motor skills — movements of small muscles that act in an organized and subtle fashion, for instance, the hands and feet working together, or the muscles of the head (as in the tongue, lips, and facial muscles), to accomplish more difficult and delicate tasks. Fine motor skills are the basis of coordination, which begins with transferring from hand to hand and crossing the midline when aged 6 months. Examples of fine motor activities are writing, sewing, drawing, putting a puzzle together, imitating subtle facial gestures, pronouncing words (which involves coordination of the soft palate, tongue, and lips), blowing bubbles, and whistling. Many children who have difficulties in their fine motor skills also have difficulties in articulating sounds or words.

Muscular strength — the intensity of the muscle contraction exerted voluntarily that may be required to carry out an activity. Some children who struggle with motor clumsiness appear weak and slender and may have an inadequate strength in their movements. A child with diminished muscular strength appears floppy or scrawny, with thin arms, forearms, and legs. These children may execute movements that other children take for granted. Asking the child to shake hands and squeeze the hand are techniques clinicians use to assess the child’s strength. These hypotonic children cannot apply much pressure so the handshake feels weak and the squeeze may be unremarkable. They fatigue easily and claim to be unable to carry out simple tasks. For example, they may write with only thin lines in barely visible traces and the pencil may slip out of their hand easily.

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On the other end of the continuum, some children may appear very strong and muscular. For instance, children with hypertonicity in the leg muscles may walk on their tiptoes and develop a higher muscular mass in the leg muscles to maintain this position. Children who are too strong often appear brusque in their movements. Instead of softly caressing someone on the face, they may involuntarily slap the person when they are attempting to show affection. The same occurs while giving a hug, which to others may feel more like a hard squeeze or even being physically crushed in the child’s unintentional hypertonic grip.

Sensory functioning Sensory functioning is assessed mainly in terms of the sensory cranial nerves (vision and hearing) and peripheral sensation. Cranial nerve function can be tested in the infant; however, the method of obtaining a response varies by the age and developmental level of the infant. Many of the techniques are similar to adult assessment.

Elements of cranial nerve testing are as follows:

Cranial Nerve I – ability to smell is not evaluated in the infant. Older children can be asked to identify strong odors such as coffee or lemon with their eyes closed.

Cranial Nerve II, III and IV – observe for perception of light, visual acuity, and color vision. Have the child track an object or light visually. Some infants may prefer to fix on the face normally, so that fixation on the examiner’s face may easily be used. Check for proper placement of the eyelid.

Cranial Nerve V – strength of masseter muscles in an infant can be determined by noting the strength of the infant’s suck on a pacifier or bottle. Have an older child bite down hard and observe for symmetry. See if the child can detect light touch on the cheeks and jaw with eyes closed.

Cranial Nerve VII – in the infant, facial symmetry is observed when the infant spontaneously smiles or cries. Have the older child make a funny face or show you their teeth. Older children can also be asked to identify sweet or salty tastes. Strength of eyelid closure can be noted during the instillation of eye drops or by asking the child to close his eyes and then open them as you resist their efforts.

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Cranial Nerve VIII – noting an alerting response to voice or bell tests hearing is acceptable in an infant. Observe for loss of balance or vertigo in older children as well as hearing.

Cranial Nerve IX – the gag reflex is tested as in adults. Always check time of the last feeding with the parents. Infants may vomit when gag reflex is tested if it is immediately after a feeding. Testing of this reflex will give an indirect evaluation of the infant’s ability to swallow.

Cranial Nerve X, XI, XII – observe for hoarseness of the voice, swallowing, and placement of the uvula. Observe for strength and symmetry of shoulder shrug and head turning in children. Indirect evidence for cranial nerve XI can be obtained by noting symmetry of head position when placed in the sitting position. Have children stick out their tongue and move it in all directions. In infants, observations for worm-like movements of the tongue (fasciculation) are critical, particularly when the presenting symptom is weakness. This is best observed at the edges of the tongue. You must observe the tongue at rest, not on forced protrusion from the mouth.

Cerebellar functioning The cerebellum mainly controls balance and coordination. The assessment of cerebellar function mainly includes observations of the child’s posture, body movement, and gait.

Common tests of cerebellar function

Finger-to-nose test – With the child’s arm extended, ask them to touch the nose with the index finger, both with the eyes open, then both eyes shut.

Heel-to-shin test – While child is standing, have him or her run the heel of one foot down the shin of the other leg, both with the eyes open, then eyes shut.

Romberg test – With the eyes closed, have the child stand with the heels together. Falling or leaning to one side is abnormal and is called Romberg sign.

Reflexes Testing of reflexes is an important part of the neurologic exam. Persistence of primitive reflexes, loss of reflexes, or hyperactivity of deep tendon reflexes is usually the result of brain injury. Deep tendon reflexes include the triceps, biceps, brachioradialis, patellar, and the Achilles

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tendon. Refer to chapter 3, Growth and development, for the assessment of reflexes. Soft signs One of the difficulties in assessing the nervous system is differentiating clearly between normal and abnormal findings. There is a gray area sometimes referred to as “soft signs,” findings that are normal in a young child but disappear in the normal course of development. Soft signs represent the persistence of a more primitive form of behavior or response and failure to perform the age-specific activity. There is some controversy regarding the significance of these soft signs.

Some neurologic soft signs include: • Short attention span • Unusual body movements such as “mirroring” • Poor coordination and sense of position • Excessive, sustained, and purposeless movement (hyperactivity) • Hypoactivity • Impulsiveness • Labile emotions • Distractibility • No established handedness • Language and articulation problems • Perceptual deficits such as space, form, movement, and time • Problems with learning, especially reading, writing, and arithmetic

Assessment of abuse Child abuse is doing something or failing to do something that results in harm to a child or puts a child at risk of harm. The abuse can be physical, sexual, or emotional. Neglect, or not providing for a child’s needs, is also a form of abuse. The presence of a single sign does not prove child abuse is occurring, however, when these signs appear repeatedly or in combination you should take a closer look at the situation and consider the possibility of child abuse.

Physical abuse Any injury resulting from physical aggression is defined as physical abuse—even if the injury was not intended.

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Signs of physical abuse: • Unexplained burns, bites, bruises, broken bones, or black eyes • Fading bruises or other marks noticeable after an absence from school • Frightened of the parents and protests or cries when it is time to go home • Shrinks at the approach of adults • Reported injury by a parent or another adult caregiver • Parent or caregiver offers conflicting, unconvincing, or no explanation for the child’s injury • Parent or caregiver describes the child as “evil” or in another very negative way • Parent or caregiver uses harsh physical discipline with the child • Parent or caregiver has a history of abuse as a child

Sexual abuse Any sexual interaction between an adult and child is defined as sexual abuse. The definition encompasses performance of sexual acts, fondling, violations of bodily privacy, exposure to adult sexuality (viewing pornography or dirty-joke telling), and commercial exploitation through child pornography or prostitution. Regardless of the child’s behavior or reactions, it is the responsibility of the adult not to engage in sexual acts with children.

Signs of sexual abuse: • Difficulty walking or sitting • May have bruising in the genital areas • Reports of nightmares or sudden bedwetting • Sudden change in appetite • Demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior • Becomes pregnant or contracts a venereal disease, particularly if under age 14 • Runs away from home • Is secretive and isolated • Child reports sexual abuse by a parent or another adult caregiver

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• Parent or caregiver is unduly protective of the child or severely limits the child’s contact with other children, especially children of the opposite sex • Parent or caregiver is jealous or controlling with family members

Emotional abuse Any attitude, behavior, or failure to act that interferes with the child’s mental health or social development is emotional abuse. It includes intimidation, shaming, blaming, rejecting, withholding affection, extreme punishment, exposure to violence, child exploitation, or abduction. Emotional abuse is always present when another form of abuse is found.

Signs of emotional abuse: • Shows extremes in behavior, such as overly compliant or demanding behavior, extreme passivity, or aggression • Is either inappropriately adult or inappropriately infantile • Is delayed in physical or emotional development • Has attempted suicide • Reports lack of attachment to the parent • Parent or caregiver constantly blames, belittles, or berates the child • Parent or caregiver is unconcerned about the child and refuses to consider offers of help for the child’s problems • Parent or caregiver overtly rejects the child

Neglect A pattern of failing to provide for a child’s basic needs is defined as neglect. A single act of neglect might not be considered child abuse, but repeated neglect is. Neglect is divided into three basic types: physical, educational, and emotional.

Signs of neglect: • Frequently absent from school • Begs or steals food or money • Lacks needed medical or dental care, immunizations, or glasses • Is consistently dirty or has severe body odor • Lacks sufficient clothing for the weather • States that there is no one at home to provide care

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• Parent or caregiver appears to be indifferent to the child • Parent or caregiver seems apathetic or depressed • Parent or caregiver behaves irrationally or in a bizarre manner • Parent or caregiver is a known abuser of alcohol or other drugs • Parent or caregiver is not following the ordered plan of care • Parent or caregiver not providing appropriate follow-up to medical issues or concerns • Parent or caregiver not providing required supplies or medications

These types of abuse (physical, sexual, emotional, neglect) are more typically found in combination than alone. A physically abused child, for example, is often emotionally abused as well, and a sexually abused child also may be neglected. However, children with diagnosed behavioral problems may show these signs in the absence of abuse. Therefore it is important to know and understand the child’s baseline behavior.

Munchausen by proxy This syndrome is a form of abuse where the perpetrator, usually the child’s mother, deliberately makes the child sick or convinces others that the child is sick. The parent or caregiver misleads others into thinking that the child has medical problems by lying and reporting fictitious episodes. The parent may exaggerate, fabricate, or induce symptoms. As a result, physicians order tests, try different types of medications, and may even hospitalize the child or perform surgery to determine the cause.

Typically, the perpetrator feels satisfied when attention and sympathy is received from the physicians, nurses, and others who come into contact with him or her and the child. It is believed that it is just the attention that’s gained from the “illness” of the child that drives the behavior.

Diagnosis of Munchausen by proxy is very difficult. Since the perpetrator appears to be so caring and attentive, often no one suspects any wrongdoing. It’s not unusual for medical personnel to overlook the possibility of Munchausen by proxy because it goes against the belief that the parent or caregiver would ever deliberately hurt their child.

Some findings that may lead to a suspicion of Munchausen by proxy: • A child has multiple medical problems that don’t respond to treatment or that follow a persistent and puzzling course • Physical or laboratory findings that are highly unusual, do not correspond with the child’s medical history, or are physically or clinically impossible

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• Child has short-term symptoms that tend to stop when the perpetrator is not present • Parent or caregiver isn’t reassured by good news when test results find no medical problems and continues to insist that the child is ill • Parent or caregiver appears to be medically knowledgeable or fascinated with medical details or seems to enjoy the hospital environment • Parent or caregiver is unusually calm in the face of serious difficulties with the child’s health • Parent or caregiver is highly supportive and encouraging of the physician, or conversely, is angry and demands further intervention, more procedures, second opinions, or transfers to more sophisticated facilities

The parent or perpetrator may insist that the child be seen by a large number of various physicians, may frequently change the child’s physician, and even seek services in varying hospitals for the child, for the same issue.

Abuse and children with disabilities Children with disabilities are often easy targets for abusers. Parents who become violent towards their child may not be reacting to the child’s condition alone, but to social isolation and stigma. It is not uncommon for family and friends to distance themselves, many times leaving no social support. It can be difficult to find a school willing to take the child. There may be limited services to help parents with their child’s specific needs. These issues can compound an already stressful situation to produce a potentially violent one.

While many parents are violent towards children without a disability, when a child with a disability lives in a violent setting, their disability often serves to compound and intensify the nature and extent of the abuse, for example: • A mobility-impaired child may be less able to flee when physically or sexually assaulted • If the child is hearing impaired, they may be unable to communicate about the abuse he or she is experiencing with anyone outside of the household, unless an outsider uses sign language or understands the specific signs the child uses (when the abuser is the interpreter to others outside the household, this further limits the child’s ability to report)

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• A child who is intellectually impaired may not be able to anticipate a parent’s growing anger or know when or how to leave the room to avoid being struck

The nature of a child’s disabilities may be interpreted negatively by the parent, or cause tension. The increased tension can begin long before the child is diagnosed as having a disability. For example: • A child with a hearing impairment may be regarded as disobedient • A child with vision problems may not make eye contact and appear to be unresponsive • A child with a neurological disorder may be difficult to comfort or feed

Many people do not acknowledge the existence of the risk for abuse to result from a child’s disability. This is supported by some of the following myths: • Children with disabilities are asexual and therefore do not need sex education (results in denying them information that may help them prevent abuse) • Children with disabilities are unable to manage their own behavior (results in family caregivers exerting unnecessary control) • Children with disabilities do not feel pain (results in adverse “therapies” being used) • All family caregivers are special and good (results in a lack of awareness and attention to signs of abuse or neglect)

It is important to remember that not all households with disabled children are the same, not even when in similar communities, cultures, or with related diagnoses. Stress can impact the dynamics in the home differently, specifically including the interactions with the child. Even families that have been noted as coping and providing daily care for their child with disabilities can reach a breaking point. Primary caregiver burnout can occur when the child’s needs have suddenly become too demanding or excessive. You may notice a change in the primary caregiver’s behavior or interactions within the home. It is our responsibility, as a constant presence in the home, to note these changes, express our concerns, and attempt to find resources to assist the family. Always report any of these observations to your clinical manager.

Typical signs of suspected abuse in the home health care setting include: • Failure of the family to provide equipment or medications • Failure to administer treatments or medications in nursing absence

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• Failure to provide basic personal hygiene such as diaper changes • Failure to use a pulse oximeter or apnea monitor during hours of sleep or when child is unattended • Noncompliance with feedings • Noncompliance with safety measures (eg, safety harness, side rails) • Failure to make or keep medical appointments • Not being accessible for staff to report to or receive report from • Being detached from the child and all parental care responsibilities • Caregiver sleeping rather than attending to child’s needs • Child lacks appropriate stimulation or cognitive experience • Child lacks necessary supervision • Parent claims child is behaving badly

Mandatory reporting The legal standard for reporting entails reasonable suspicion of abuse (Foreman and Bernet, 2000; Kalichman 1999). In most states, failure to report suspected child abuse carries both criminal and civil sanctions and could elicit charges that may jeopardize professional licensure or certification. It is important for you to know your state’s reporting requirements on abuse and neglect. Any time you have a concern about activities in the home, whether or not you have the ability to prove anything, it is your responsibility to discuss your concerns with your clinical manager. If it is decided that the child is potentially at risk, reporting is required. Remember that professionals are not required to prove abuse, nor should they blur their professional boundaries by attempting to substantiate the probability of abuse.

Despite the creation of mandatory reporting laws, professionals who come in contact with children are often reluctant to report suspected child abuse. There are many unfortunate reasons for this reluctance, including misunderstanding of the reporting laws, fear of making an inaccurate report, poor impressions of child protective services, fear that reporting will exacerbate the situation, fear of legal retribution, belief that proof is needed before a report should be made, and lack of understanding of what constitutes maltreatment or abuse. The adverse impact that continued abuse and neglect has on the child affects psychological, behavioral, cognitive, and academic development. Failure to report suspected abuse is illegal and violates many professional ethical codes. Always inform your clinical manager of any disturbing situations you encounter in the home.

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Assessment of psychosocial needs The term “psychosocial assessment” is used to describe a formal evaluation of an individual or family that is intended to clarify their non- biomedical needs and priorities. A structured approach discovers issues, problems, and concerns that may not be obvious or volunteered. It enables members of the nursing team to document important psychosocial issues to be given to the multidisciplinary team, which can then link clients to important local services and resources.

As the field nurse, you will observe many psychosocial aspects of a client’s care. Some may be related to the family dynamics that directly impact client care. Again, any observations that concern you should be reported to your clinical manager.

The general factors in a psychosocial assessment and observation include personal, social, and economic elements. In pediatrics, these issues pertain to the entire family unit and are influenced by the family’s cultural and religious beliefs as well as by psychological and emotional issues.

Psychosocial assessment grid

Element Issues that may impact care

Primary caregiver • Who is the primary caregiver? • Are other caregivers available, in or out of the home? • Living arrangements • Other dependents in the home • Home safety or health hazard status • Ability to meet client’s ADL needs • Citizenship status • Condition or background with: - Psychiatric history - History of (or currently known) suicidal or homicidal ideation or gestures - Substance abuse or treatment history - Abuse history - Legal history

Social • History of family of origin • Nuclear family history • Current support systems • Community resources • Spiritual, religious, and cultural resources • Client’s medical management needs (primary 122

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physician or specialty consults, multidisciplinary team) • Problem identification and solving ability • Coping ability and compliance with care

Economic • Employment status • Wage earner • Financial resources • Physical survival and security status • Insurance resources

It is necessary to observe both client and family interactions during the shift. An accurate psychosocial observation includes an in-depth understanding of the primary caregiver’s role as he or she sees it. The primary caregiver needs to demonstrate an understanding of the client’s developmental, behavioral, and medical history.

Knowing the primary caregiver’s knowledge base, perception of disease status and risk, and expected outcome, the nurse can assess the family’s willingness or ability to adhere to the plan or treatment. This information will assist in assessing the need for further parent or primary caregiver training and reinforce education and the proper resources, referrals, and assistance for them.

Parents and caregivers of a child with special needs must learn new ways to cope with the following: • Gaining mastery over medical information • Disciplining and setting limits • Fostering separation and independence • Advocating for community resources and schools • Managing stress • Meeting diverse needs of all family members

Remembering the need to effectively communicate empathy, the nurse must also recognize his or her own experience, culture, and values as well as their personal issues and what impact this has on the therapeutic relationship.

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Before continuing on to the next section, answer the following questions by circling the appropriate letter. Check your responses with the answers below.

1. Which of the following is NOT an accurate statement related to growth measurement in the pediatric client? (A) Children younger than 1 year should have weight, length, and head circumference measured on a regular basis. (B) Loss of weight or lack of consistent weight gain should be reported to the physician. (C) It is not a concern if a child’s weight that is plotted on a growth chart does not remain within the same percentile over time. (D) An accurate weight is important in fluid, caloric, and medication management of the pediatric client.

2. It is important to consider which of the following when evaluating a child’s heart rate? (A) Normal resting (awake) heart rate for an infant age 1 week to 3 months is 100–220 bpm. (B) Measurement of the pulse should be done when the child is quiet, so the child’s activity or anxiety level when the pulse is recorded should also be documented. (C) A decreased pulse rate during respiratory distress is an ominous finding and warrants calling 911. (D) All of the above.

3. Which of the following factors would NOT cause increased respiratory rate in a typical 18-month-old? (A) Increased activity. (B) Fever. (C) Feeding. (D) Anxiety.

4. In preparing for the physical assessment of a child, you must consider all of the following EXCEPT: (A) The child’s baseline status must be known when evaluating whether a finding is abnormal and the child’s parent is the best source to validate what the child’s baseline is. (B) Assumptions should never be based on isolated findings; you must look at the whole picture. (C) A blood pressure is always necessary with every assessment.

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(D) How a child is acting is often the best indicator of how sick a child is.

5. You receive report on Juan, a 3-month-old infant with failure to thrive. The report is significant for good progress with oral feedings and no deviations from baseline in his normal vital signs. In your assessment, you note that Juan is dressed in a

blanket sleeper with two blankets. His heart and respiratory rates are mildly elevated and his temperature is elevated to 100ºF axillary. He is active, pleasant, and alert. Initially you would: (A) Notify Mom and the physician that Juan is febrile. (B) Administer Tylenol PRN. (C) Remove the extra blankets and recheck the temperature in 1 hour. (D) Administer Tylenol and notify the physician.

6. On initial assessment of a new client who is Hispanic, you note a darkened, bluish discoloration in the gluteal region, roughly 4 by 5 cm with irregular rounded borders. You should: (A) Notify the physician and clinical manager that you feel the client is being abused. (B) Recognize and document the Mongolian spot in your Nurse’s Note. (C) Call Child Protective Services immediately. (D) Attempt to wash it off.

7. All of the following are true about the anterior fontanel EXCEPT that it: (A) Closes between 9 and 18 months (B) Is diamond-shaped (C) Is soft, flat, and pulsatile (D) Is slightly depressed.

8. The anatomies of the pediatric and adult airway are different. Which of the following statements is FALSE concerning the pediatric airway? (A) The nasopharynx is smaller and easily occluded during infections. (B) A small oral cavity and a large tongue increase the risk of obstruction. (C) Grunting in infants and young children is a normal mechanism to maintain positive airway pressure. (D) The larynx and glottis are high in the neck, increasing the risk of aspiration.

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9. You receive a report from Mom about Angela, a 6-month-old infant with a chromosomal abnormality. Mom reports she slept well but ate little of her morning feeding. On assessment, Angela’s heart rate is 190 at rest, her respiratory rate is 70, and

you hear a soft grunting sound after each breath. She does not wake during your assessment and you note that the area just below the rib cage is depressed with each breath. You would: (A) Allow Angela to go back to sleep because she is obviously tired. (B) Attempt to reposition Angela to a prone position to optimize her oxygenation. (C) Administer blow by oxygen per physician orders, notify the physician and clinical manager of the change in status, and follow their directions. (D) Check Angela’s temperature, and if normal, see if you can get her to eat.

10. Your client is 4 years old. He is apneic, mottled, and dusky and has a heart rate of 51. You would: (A) Perform back blows and chest thrusts until his airway clears. (B) Begin rescue breathing. (C) Give positive pressure ventilation with supplemental oxygen. (D) Begin CPR.

11. Signs of heart failure in an infant or small child may include: (A) Tachypnea, plethora, increased appetite. (B) Bradycardia, fatigue, excitability. (C) Tachypnea, tachycardia, peripheral and/or periorbital edema, and anorexia. (D) Weight loss, wheezing, and increased urinary output.

12. A complete GI assessment includes: (A) Assessment for feeding tolerance. (B) Assessment for emesis and bowel pattern. (C) Assessment for pain. (D) All of the above.

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13. Spasticity is characterized by all of the following EXCEPT: (A) Tight, stiff muscles that make movement of arms and legs difficult or uncontrollable. (B) Pain.

(C) Collagen fibers in the joint that become fibrotic and limit movement. (D) Triggered by a stimulus such as pain, reflux, or constipation.

14. Persistence of primitive reflexes, loss of reflexes, or hyperactivity of deep tendon reflexes is: (A) Usually normal, because all children develop differently. (B) Usually a result of brain injury. (C) Not common in preterm infants. (D) Associated with Down’s syndrome.

15. Which of the following statements is TRUE? (A) Abuse is only reportable if there is more than one type of abuse occurring. (B) Abuse is not a concern when dealing with a developmentally disabled child. (C) Munchausen’s by proxy is easily diagnosed. (D) Reporting abuse is mandated in most states.

16. What should you do if you suspect a child is being abused? (A) Report it to the hotline number immediately. (B) Observe for continued signs of abuse. (C) Ignore it. (D) Discuss your findings with your clinical manager prior to filing a report.

17. Which of the following is not considered abuse? (A) Disciplining the child. (B) Failing to make or keep medical appointments for the child. (C) Not providing appropriate stimulation for growth and development. (D) Overly rejecting a child.

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18. The key elements of a psychosocial evaluation are: (A) Social, religious, financial. (B) Cultural, economic, psychological. (C) Personal, economic, social.

(D) Cultural, religious, medical.

19. The psychosocial assessment involves: (A) The client. (B) The primary caregiver. (C) The entire family (D) All of the above.

Answers: 1. C, 2. D, 3. C, 4. C, 5. C, 6. B, 7. D, 8. C, 9. C, 10. D, 11. C, 12. D, 13. C, 14. B,15. D, 16. D, 17. A, 18. C, 19. D

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References Assessment Wong DL, Hockenberry MJ. Nursing Care of Infants and Children. St Louis: Mosby; 2003.

Engel J. Pocket Guide to Pediatric Assessment. St Louis: Mosby; 2002.

Hazinski M. Manual of Pediatric Care. St. Louis: Mosby; 1999.

London M, Ladewing P, Ball J, Binder R. Maternal and Child Nursing Care. 2nd ed. Upper Saddle River, NJ: Prentice Hall; 2007.

Seidel H, Ball J, Dains J, Benedict G. Mosby’s Guide to Physical Examination. 5th ed. St. Louis: Mosby; 2003.

Webster H, Huether S. Alteration in pulmonary function in children. In: Huenther S. McCance K, ed. Pathophysiology: The Biologic Basis for Disease in Adults and Children. 3rd ed. St. Louis: Mosby; 1998.

Kessler Rehabilitation CRRN Review Handbook. NCN Conference Manual; 2005.

Abuse http://findarticles.com/p/articles/mi_qa4013/is_200301/ai_n9216048 http://www.childwelfare.gov/pubs/prevenres/focus/ http://www.nlm.nih.gov/medlineplus/childabuse.html http://kidshealth.org/parent/general/sick/munchausen.html http://www.childwelfare.gov/pubs/factsheets/signs.cfm http://www.childwelfare.gov/responding/mandated.cfm

Psychosocial http://www.uth.tmc.edu/uth_orgs/hcpc/procedures/volume2/chapter3/treat ment_services-04.htm http://www.contemporarypediatrics.com/contpeds/article/articleDetail.jsp?i d=108019 http://www.mtctplus.org/intranet/clinical-manuals.html http://www.psychiatrictimes.com/p040940.html http://www.tcikids.com/psychosocialservices.htm http://www.gemdatabase.org/GEMDatabase/WA-CE/mrdd98.htm http://www.therenalnetwork.org/AboutUs/pedSOC.html http://www.co-pediatrics.com

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