Comprehensive Final Review

Alterations in Health (Diagnosis)

• Nurses care for pediatric clients with psychosocial as well as physical problems; psychosocial issues such as depression may result from physical illness, exist independently, or cause physical symptoms. Covers depression and suicide, posttraumatic stress disorder, attention-deficit/hyperactivity disorder, autism spectrum disorder, intellectual disability, failure to thrive, bullying, and child maltreatment. Depression is easily missed in school-age children because they cannot articulate feelings well, and findings must persist 2 weeks to diagnose major depressive disorder. ADHD inattentiveness, hyperactivity, and impulsiveness usually appear before age 7. Autism spectrum disorder is a group of complex neurodevelopmental disorders affecting communication and social interaction. Maltreatment occurs across all economic and educational backgrounds and includes physical, sexual, and emotional abuse and neglect.

Health Promotion & Disease Prevention

Assessment — Risk Factors

• Depression: family history and traumatic events
• PTSD: possible genetic predisposition, a traumatic or repeated trauma, existing mental health disorder, natural disaster, sexual assault, witnessing homicide, suicide, or other violence
• ADHD: familial tendency, exposure to toxins or medications, chronic otitis media, meningitis, or head trauma
• Autism spectrum disorder: possible genetic component with cause unknown
• Intellectual disability: familial, social, environmental, organic, or unknown causes; congenital rubella or syphilis, fetal alcohol syndrome, chronic lead ingestion, brain trauma, gestational disorders
• Intellectual disability from preexisting disease: cerebral palsy, Down syndrome, hydrocephaly, microcephaly, metabolic disorders, and mental health disorders
• Failure to thrive: prematurity with low birth weight or intrauterine growth restriction, poverty, family stress, resistance to feeding, weak maternal-child attachment, and caregiver neglect, inexperience, or health and childrearing beliefs
• Failure to thrive, organic causes: prematurity, congenital heart disease, cerebral palsy, Down syndrome, cystic fibrosis, celiac disease, hyperthyroidism, hepatic disease, chronic kidney failure, and gastresophageal reflux

Assessment — Expected Findings

• Depression: sad expression, staying alone, withdrawal from family, friends, and activities, fatigue, tearfulness, feeling ill, worthlessness, weight loss or gain, sleep changes, lost interest and falling performance in school, statements of low self-esteem, hopelessness, suicidal ideation
• Suicide assessment: ask directly about suicidal thinking, which does not plant the idea; clues may be overt ('There is no reason to go on') or covert ('Things look pretty grim')
• Suicide plan assessment: whether a plan exists, its lethality, whether the child can describe it exactly, and whether they can access the method; a sudden shift from sadness to calm happiness can signal intent
• PTSD: flashbacks, hypervigilance, anger outbursts following a traumatic event
• ADHD inattention: careless mistakes, difficulty sustaining attention, not seeming to listen, not following through, disorganization, avoiding tasks requiring mental effort, losing things, distractibility, forgetfulness
• ADHD hyperactivity: fidgeting, not staying seated, running inappropriately, difficulty with quiet play, constant busyness, excessive talking
• ADHD impulsivity: blurting answers, difficulty waiting turns, frequent interrupting, striking out, biting, shouting
• Autism spectrum: delays in social interaction, social communication, or imaginative play before age 3, distress at routine changes, unusual attachment to objects, inability to start or sustain conversation, gestures instead of words, delayed or absent language, grunting or humming

Laboratory Tests

• CBC, urinalysis, and tests for sexually transmitted infections or bleeding

Diagnostic Procedures

• Guided by findings and injuries — radiographs and CT or MRI

Nursing Care

• Individualize the plan of care and obtain health, growth, and developmental history
• Assess for substance use and for actual or potential risk to self, including plan, lethality, and access to means
• Assist with coping strategies, encourage peer group discussion, mentoring, and counseling, and interview the child directly
• Monitor for adverse effects and suicidal ideation on SSRIs or SNRIs and refer to psychotherapy
• PTSD: monitor for behavior changes, help child and family with coping, allow expression of feelings, and work to prevent or reduce long-term effects
• ADHD: obtain medical, developmental, and behavioral history and use behavioral checklists with adaptive scales
• ADHD approach: calm, firm, and respectful, model acceptable behavior, get the child's attention before giving short clear directions, set consistent limits on unacceptable behavior, and plan physical activity that channels energy into success
• Autism: assist with screening tools such as the Modified Checklist for Autism in Toddlers, and refer to early intervention, physical, occupational, and speech-language therapy
• Autism behavior program: positive reinforcement, increasing social awareness, teaching verbal communication, reducing unacceptable behaviors, realistic goals, structured opportunities for small successes, and clear rules

Medications

• Fluoxetine is first-line for acute depressive disorders in children and adolescents; if it fails, try a second SSRI such as sertraline, escitalopram, or citalopram
• Selective norepinephrine reuptake inhibitors may be used case by case
• Methylphenidate and dextroamphetamine: titrate the dose gradually to effect, give the last dose at least 6 hr before bedtime to prevent insomnia, and monitor height and weight because of growth suppression
• Stimulant adverse effects: insomnia, anorexia, nervousness, hypertension or hypotension, tachycardia, anemia; avoid caffeine and store the drug securely because of misuse potential
• Atomoxetine, a selective norepinephrine reuptake inhibitor, titrated gradually with monitoring for suicidal ideation

Therapeutic Procedures

Client Education

• Watch for adverse effects, expect up to 2 weeks for therapeutic effect, and never stop the medication abruptly
• Failure to thrive: recognize and respond to the infant's hunger cues and mix formula exactly per written step-by-step instructions
• Bullying: observe for signs, ask questions, obtain family support, refer to counseling and bully-prevention programs, follow investigation and reporting procedures, and refer for mental health evaluation since bullying can signal an emerging mental health disorder

Interprofessional Care

• Initiate social services referrals
• Bullying types: verbal (teasing, name calling, inappropriate sexual comments, taunting, threatening), social (deliberate exclusion, spreading rumors, public embarrassment), and physical (hitting, kicking, pinching, spitting, tripping, pushing, rude gestures)
• Bullying occurs during or after school on the bus, playground, en route to school, or in the neighborhood; cyberbullying happens on phones, computers, and tablets during gaming, social media, or texting

Complications

• Extreme malnourishment — prepare child and parents for tube feedings or IV therapy
• Maltreatment types: physical (shaken baby syndrome, fractures, factitious disorder imposed on another), sexual (sexual contact without consent, any sexual behavior toward a minor, adolescent dating violence), emotional (humiliating, threatening, or intimidating a child and undermining self-worth), and neglect (failure to provide for the child's needs)