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iv  About the Authors

Kay J. Cowen
Kay J. Cowen received her BSN from Comprehensive Approach to the Care of Children and Their Families
East Carolina University in Green- published in 1993.
ville, North Carolina, and began her In the classroom, Mrs. Cowen realized that students learn
career as a staff nurse on the pediat- through a variety of teaching strategies and became especially inter-
ric unit of North Carolina Baptist ested in the strategy of gaming. She led a research study to evaluate
Hospital in Winston-Salem. She the effectiveness of gaming in the classroom and subsequently con-
developed a special interest in the tinues to incorporate gaming in her teaching. In the clinical setting,
psychosocial needs of hospitalized Mrs. Cowen teaches her students the skills needed to care for patients
children and preparing them for hospitalization. This led to the focus and the importance of family-centered care, focusing on not only the
of her master’s thesis at the University of North Carolina at Greens- physical needs of the child but also the psychosocial needs of the
boro (UNCG) where she received a master of science in nursing edu- child and family.
cation degree with a focus in maternal child nursing. During her teaching career, Mrs. Cowen has continued to work
Mrs. Cowen began her teaching career in 1984 at UNCG where part time as a staff nurse: first on the pediatric unit of Moses Cone
she continues today as clinical professor in the Parent Child De- Hospital in Greensboro and then at Brenner Children’s Hospital in
partment. Her primary responsibilities include coordinating the Winston-Salem. In 2006 she became the part-time pediatric nurse
pediatric nursing course, teaching classroom content, and super- educator in Brenner’s Family Resource Center. Through this role she
vising a clinical group of students. Mrs. Cowen shared her passion is able to extend her love of teaching to children and families.
for the psychosocial care of children and the needs of their families Through her role as an author, Mrs. Cowen is able to extend her
through her first experience as an author in the chapter “Hospital dedication to pediatric nursing and nursing education. She is mar-
Care for Children” in Jackson & Saunders’ Child Health Nursing: A ried and the mother of twin sons.

We dedicate this book to our partners:

~our families for their unwavering support
~colleagues who have grown and learned with us, and continue to help expand our thinking
~families and children with whom we work, for teaching us the essentials of child health nursing
~students who are our collaborators now and in their future careers as nurses

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 Thank You
We would like to express our deep gratitude to our colleagues from schools and hospitals across the country for their time over the past 3 years.
These individuals assisted us in the revision of this book by contributing and reviewing manuscript chapters and contributing to the supple-
ments that accompany this title. Child Health Nursing: Partnering with Children & Families has benefited immeasurably from your efforts,
insights, and willingness to share your expertise as teachers and nurses.

Contributor
Chapter 4: Genetics and Genomics Sharon Koval Falkenstern, PhD, CRNP, Brenda Millet, MSN, RN-BC
PNP-C, CNE Staff Development Specialist
Influence Assistant Professor, Coordinator of NP Option Children’s National Medical Center
Linda D. Ward, MN, ARNP The Pennsylvania State University Washington, DC
Clinical Assistant Professor University Park, Pennsylvania Cheryl Shaffer, RN, MS, PNP, ANP, PhD(c)
Washington State University College of Nursing Leslie Holmes, RN, BSN, MSN Associate Professor
Spokane, Washington Instructor, Family and Community Nursing Suffolk County Community College
Nell Hodgson Woodruff SON Emory University Selden, New York
SUPPLEMENTAL CONTRIBUTORS Atlanta, Georgia Lisa D. South, RN, DSN
Jane Brown, MSN, RN Mary Jo Konkloski, RN, MSN, ANP Assistant Professor
Associate Professor Coordinator, RN Program The University of Alabama at Birmingham
Walters State Community College Finger Lakes Health College of Nursing Birmingham, Alabama
Morristown, Tennessee Geneva, New York Jane K. Walker, BBA, RN, CLNC, PhD(c)
Laura L. Brown, RN, MSN, CPN Patricia Kuster, PhD, RN, CPNP Associate Professor of Nursing
Nursing Instructor Assistant Professor Walters State Community College
Asheville Buncombe Technical Community College Samuel Merritt College School of Nursing Morristown, Tennessee
Asheville, North Carolina Sacramento, California Jeannie Weston, MS, CNS, BSN
Pamela P. DiNapoli, PhD, RN Brenda Lykins, RNC-NIC, BSN Assistant Clinical Instructor
Associate Professor Neonatal Outreach Coordinator Emory University
University of New Hampshire MultiCare Regional Perinatal Outreach Program Atlanta, Georgia
Durham, New Hampshire Tacoma, Washington
Donna Eberly, RN, MSN Adelaide R. McCulloch
Instructor
Western Iowa Tech Community College
Sioux City, Iowa

Reviewers
Mike Aldridge, Concordia University Texas Sarah Kulinski, Lenoir-Rhyne University
Kim Amer, DePaul University Patricia Kuster, Samuel Merritt University
Janice Bidwell, San Diego State University Lin Lin, The University of Texas Health Science Center at Houston
Patricia Bobbitt, Wake Forest University School of Medicine Antoinette McCray, Norfolk State University
Sally Brooks, The University of Louisiana at Monroe Cheryl Mele, Drexel University
Michael Brown, The University of Texas Health Science Center at Houston Mary Ellen Mitchell-Rosen, Nova Southeastern University
Karyn Casey, The University of Tennessee Heidi Monroe, Seattle Pacific University
Teresa Chase, University of Kentucky Brenda Pavill, University of North Carolina Wilmington
Jennifer Compere, Brenner Children’s Hospital Sue Perkins, Washington State University
Joseph De Santis, University of Miami Kathleen Peterson, The College at Brockport
Linda Esposito, Wake Forest Baptist Medical Center Janice Pitman, Brenner Children’s Hospital
Melissa Ethington, The University of Texas Health Science Center at Houston Kari Crawford Plant, Levine Children’s Hospital
Niki Fogg, Texas Woman’s University Deborah Roberts, Sonoma State University
Betty Freund, Kent State University T. Kim Rodehorst-Weber, University of Nebraska Medical Center
Julie Garcia, The University of Texas Health Science Center at San Antonio Carol Rossman, Calvin College
Carol Hall Grantham, Georgia State University Michele Shaw, Washington State University
Debbie Hancock, The University of North Carolina at Greensboro Anita Smith, Wake Forest University School of Medicine
Kristen Harrison, Wake Forest Baptist Medical Center Daphnee Stewart, Mercer University
Amy Zlomek Hedden, California State University, Bakersfield Phyllis Thatcher, Wake Forest Baptist Medical Center
Michelle Howell, Wake Forest Baptist Medical Center Debra Thomson, Wake Forest Baptist Medical Center
Kim Hutchinson, Wake Forest Baptist Medical Center Maureen Tippen, University of Michigan-Flint
Arlene Johnson, Clemson University Theresa Turick-Gibson, Hartwick College
Eleanor Kehoe, College of Staten Island Diane Van Os, Westminster College
Mary Kishman, College of Mount St. Joseph Darla Vogelpohl, University of Toledo
Julie Kordsmeier, The University of North Carolina at Greensboro Beverly Bockstruck West, University of Memphis
Heidi Krowchuk, The University of North Carolina at Greensboro Melissa Williams, Augusta State University
Laura Kubin, Texas Woman’s University Cecilia Wilson, Texas Woman’s University

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 Preface
The world children grow up in today is vastly different from the world need for fresh approaches to child and adolescent health care and
we experienced in our early years. Our evolving social environment nursing education in several ways. Themes in this book include:
has resulted in diverse family structures and roles. Multiple racial and ■ Partnering with Children and Their Families

ethnic groups now commonly share communities, work environ- ■ The Roles and Essential Functions of the Nurse

ments, and recreation. A variety of technology applications are part ■ Health Promotion and Health Maintenance

of children’s daily routines. Nutritional patterns have changed due ■ Collaboration with Families and Healthcare Providers

to the complexity of daily lives and food marketing, and the environ- ■ Evidence-Based Practice

ment is identified as an increasing influence on child and adolescent ■ Clinical Reasoning

health. The geospatial design elements of communities, including

The subtitle, Partnering with Children & Families, reflects the core
schools, modes of transportation, and safety in neighborhoods, have
value of our textbook—emphasizing family-centered care, recognition of
altered daily behaviors. Life in complex societies offers new challenges
the family as the central influence in each child’s life, and respect for fami-
to mental health, and homes provide diverse risk and protective factors
lies from all cultures. Families are viewed as case managers, as partners
in managing the health and illness of child family members. New ways
with healthcare providers, and as integral participants in care in all pedi-
of treating diseases, from applications of genomics to a current genera-
atric nursing settings. Partnership and interprofessional collaboration are
tion of medications, influence youth health. Healthcare reform, elec-
other key concepts of our textbook. In the past, we introduced the Bindler-
tronic health records, new approaches to chronic and acute condition
Ball Child Healthcare Model as a paradigm with which to view health care
management, and a focus on prevention have contributed to changes
of children. This model illustrates an important core value—that all chil-
in the information that nurses and other healthcare providers need.
dren need health promotion and maintenance interventions, no matter
We draw heavily upon Healthy People 2020 in this text to guide our
where they seek care or what health conditions they may be experiencing.
suggested interventions and evaluation of goals for health conditions.
Families may visit offices or other community settings, specifically to ob-
In addition to an evolution of influences on child health, there have
tain health supervision care; or nurses may integrate health promotion
been incredible achievements in nursing education. The American As-
and maintenance into the care for children with acute and chronic illness
sociation of Colleges of Nursing (AACN) published the E ­ ssentials of Bac-
in a variety of inpatient and outpatient settings. The Bindler-Ball Health-
calaureate Education for Professional Nursing Practice in 2008. While we
care Model places health promotion and maintenance at the foundation
know that many Associate Degree Nursing programs use our books, we
of a pyramid to demonstrate the need to apply these concepts with all
also are aware that a number of those programs also use “the Baccalaure-
children. See Chapter 1 for an introduction to this model.
ate Essentials” in establishing their curricula. We have therefore applied
the Essentials throughout the book and cite them in a new feature (see
a description later in this preface). In 2009, the “Carnegie Report” on
WHAT’S NEW IN THIS EDITION
Educating Nurses: A Call for Radical Transformation was published. This ■ Baccalaureate Essentials Boxes highlight the nine essentials of
long-awaited study emphasized the importance of connecting classroom nursing education identified by the American Association of
and clinical learning, focusing on clinical reasoning when working with Colleges of Nursing.
students, and fostering career ladders and lifelong learning. These recom- ■ NANDA-I 2012-2014 nursing diagnoses for multiple conditions.
mendations inform our clinical judgment and clinical reasoning features. ■ Updated Healthy People 2020 goals for the pediatric population.
Finally, in 2010, the Institute of Medicine (IOM) released The Future of ■ More Evidence-Based Practice features emphasize nursing re-
Nursing: Leading Change, Advancing Health. The IOM recommended search and offer a critical thinking element.
that nurses function to the full extent of their education and training, ■ Clinical Judgment speed bumps to encourage critical thinking.
achieve higher levels of education, be full partners with physicians and ■ Clinical Reasoning section at the end of chapter to help with
other healthcare professionals in the redesign of health care, and work to application of concepts and synthesis.
plan policies that ensure data collection and information infrastructure. ■ New statistics, and integration of current health care implica-
Child Health Nursing: Partnering with Children & Families is a tions and environmental considerations.
contemporary pediatric nursing textbook. Excellence in pediatric
nursing care, whether it is in the acute care setting or in the commu- Organization
nity, is a challenge and the major objective guiding today’s pediatric The six units in this textbook have a unifying theme. The first unit,
nurse. You, as a student, will be challenged to synthesize previous Nurses, Children, and Families, lays the foundation for a thorough un-
information with new knowledge, apply evidence-based findings, derstanding of pediatric nursing in today’s world. It discusses the nurse’s
collaborate with other healthcare professionals and families, and in- roles in caring for children in the hospital, community, and home, as
tegrate current knowledge to use clinical reasoning skills in planning well as the concepts of family-centered care and cultural considerations.
pediatric nursing care. You will be challenged to lead, examining The second unit focuses on Child Concepts and Application, meld-
ways in which you can positively influence the health care of chil- ing theory with application so that concepts can be applied to pediatric
dren and their families in the challenging times of healthcare reform. nursing care in a variety of settings. Genetics and genomics are cur-
The third edition of Child Health Nursing builds upon the strong rent concepts that will be increasingly employed in future health care.
foundation and planning of the first two editions and addresses the We describe concepts of growth and development and child/family

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 Visuals That Teach  vii

communication in separate chapters, and examine applications to pe- their families in today’s world, such as violence and substance use. A
diatric nursing. The pediatric assessment chapter provides basic and de- chapter on pediatric pain assessment and management provides gen-
tailed information that will be applied in all pediatric healthcare settings. eral nursing care concepts that are woven through the remainder of
The third unit focuses on Health Promotion and Maintenance the book. Another chapter focuses on the prevention and treatment
Through Childhood. The first chapter introduces basic concepts, and of infectious and communicable diseases, a significant role in pediatric
each of the remaining five chapters applies health promotion and nursing care.
maintenance concepts with specific approaches for children at each The sixth unit consists of 14 chapters that address Nursing Care
developmental stage from newborn through adolescence. Nurses of Specific Health Conditions. Information about health conditions,
assess children thoroughly, establish goals in partnership with the including both illnesses and injuries, is grouped by body systems,
family, intervene to promote and maintain health and foster devel- eliminating the need for duplication at various places in the text.
opment, and evaluate the outcomes of care. This unique approach This streamlined approach builds on previous concepts rather than
minimizes repetition throughout the book, and underscores the repeating them, integrating a developmental approach with perti-
need for all children to receive routine health promotion and health nent conditions affecting all age groups from newborn to adolescent.
maintenance to achieve optimal health. The chapters fully describe diseases and injuries beginning with
The fourth unit, Child Healthcare Settings and Considerations, an anatomic and physiologic overview, pediatric differences, and
explores the various settings in which care occurs. In addition to the system-specific assessment guidelines. This is followed by a dis-
hospital, nurses and nursing students are likely to provide care in com- cussion of the etiology, pathophysiology, clinical manifestations,
munity settings, such as health centers, schools, and homes, where and collaborative care, including diagnostics and clinical therapy
health promotion and maintenance activities predominate. Special sections for each of the major conditions. Nursing management
considerations for the care of children during disasters are also dis- of major conditions contains detailed sections on assessment and
cussed. Shorter hospitalizations have become the norm, thereby diagnosis, planning and intervention, and evaluation of care. The
increasing the need for more comprehensive care in community set- book is readable and understandable, taking the student from pres-
tings, such as specialty outpatient centers where nurses coordinate care ent knowledge level to mastery of new material. The many features
for children with various health conditions. Children need special at- further enhance the readability of the material for students coming
tention when they have chronic health conditions, when they have life- from various backgrounds and nursing programs and curricula.
threatening illnesses or injuries, or when they need end-of-life care. Sample nursing care plans will assist you in applying develop-
The fifth unit discusses Nursing Care for Common Health Condi- mental, psychosocial, and physiologic concepts to the care of chil-
tions. The unit begins with a chapter on infant, child, and adolescent dren with specific conditions. North American Nursing Diagnosis
nutrition, which discusses both nutritional requirements for health Association (NANDA International) diagnoses are used, as well as
and some common nutritional disruptions. A chapter on social and the current Nursing Intervention Classifications (NIC) and Nursing
environmental influences addresses topics pertinent to children and Outcomes Classifications (NOC).

Visuals That Teach

366 Unit IV | Chapter 14 | Nursing Care of the Child in the Community

A DAY IN THE LIFE

of a School Nurse

The art program of this book continues to use a thoroughly inte-

grated approach, beginning with the cover and carried through the
interior of the textbook. The cover of Child Health Nursing features Left. Johnny’s teacher sent him to the school nurse because he complained about a sore throat. Ellen performs an assessment to determine if his
parents should be called to take him home or to his healthcare provider. Right. Kevin gets medication each day at lunchtime for attention deficit
hyperactivity disorder. The timing of the medication is important to improve his concentration and learning during the afternoon.

hand-painted tiles from Rydal Elementary School in Abington,

Pennsylvania. Art is both a method of expression and a healing
T he school nurse is the only health professional in the school environ-
ment. Thus Ellen Gorges has very broad responsibilities for main- Ellen Gorges has very
taining the health of all the children attending the school (and in some
cases multiple schools). Because all children are entitled to an education broad responsibilities for
modality, and the feelings, design, and colors of the tiles integrated by federal law, Ellen may provide care to children who are healthy and to
those who have health conditions. Many children with special healthcare maintaining the health of
needs and chronic conditions attend school regularly, as well as children
all the children attending
throughout this book will help you identify with children and their who are recovering from acute illness and injury episodes.
Activities that Ellen often performs include the following:
the school.
families, and understand their experiences.
■ Assessing student health complaints
■ Providing emergency care and first aid to students and faculty Ellen also gives attention to the health of the school faculty, by assess-
■ Administering medications ing and counseling them about their health needs.
■ Ensuring immunization compliance Because the scope of school nursing is so
■ Screening students for health conditions broad, it has become a specialty within pediatric
■ Educating faculty and health aides to rec- nursing, often requiring additional education and
ognize illnesses or health problems among certification as a school nurse or school nurse
students in the classroom and to provide practitioner.
needed health care as appropriate for a child
with special healthcare needs

A Day in the Life of a Nurse helps identify the roles and focus of ■ Documenting health care provided to
students
Participating in development of student in-

nursing care in each of three settings: the hospital, the healthcare

■

dividualized health plans and health-related

accommodations needed for learning

center, and the school setting.

■ Ensuring a safe environment for students
and faculty The school nurse performs scoliosis screen-
■ Serving as a student advocate ing of all students in the fifth grade to enable
early identification of the condition and refer-
ral as necessary to a student’s healthcare
provider.

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 these reasons
of the behavior of someone else. Individuals make decisions about health
behaviors based on thought about the consequences and outcomes of those 3. Transtheoretical Stages of Change Model. This model suggests that
behaviors. The person’s characteristics, such as self-efficacy and outcome individuals engage in stages prior to taking any actions that lead to change
expectancy, interact with the external environment and the behavioral choices in health behaviors. The five stages are precontemplation, contemplation,
available. All of these components interact to determine health behaviors, and preparation, action, and maintenance (Erol & Erdogan, 2008). Those in early
all can be influenced to promote health. If you were seeking to promote physi- stages are unlikely to begin behavioral change before about 6 months, while
cal activity behaviors in youth, some essential components would be: the action phase includes immediate readiness to change. Understanding
■ Encourage youth to believe they could perform the activity (self-efficacy).
the adolescent’s stage of change can guide the nurse to approach teaching
and motivation activities in a more realistic manner. If you were planning an
■ Point out the positive aspects of the behavior (outcome expectancy).
intervention with adolescents who smoke, some strategies could include the
■ Show youth how to do the activity (modeling). following:
■ Provide a physical setting and opportunity for performing the behavior ■ Ask if the teen is ready to take steps now to stop smoking, or would like
(environment). to do it in the future.
■ Allow trial and error, and choice in time and extent of activity (behavioral ■ Assist the adolescent to move from precontemplation and contemplation

viii  Visuals That Teach choices).

2. Health Belief Model. This theory attempts to explain why some individu-
phases to the action phase by providing information and resources about
smoking dangers and cessation programs.
als take actions to prevent disease or promote health while others do not. ■ Assist the adolescent in the action phase with strategies to remain
Factors that influence the likelihood of taking on preventive behaviors include smoke-free.
the perceived susceptibility to disease, seriousness of the disease, perceived ■ If the individual has recently quit smoking, ask about times when tempted
Structural Defects 1183 benefits of preventive action, and barriers to preventive action. Modifying to smoke and strategize to increase the potential for maintenance.

PHOTO STORY. . .
MANAGING MYELODYSPLASIA
Initial observations will guide some of the interactions with the
teen. For example, if a teen is overweight, provide a quiet and private
location while taking the weight, and do not announce the weight
aloud. Being alert, quiet, and sensitive are all important qualities of
the nurse working with adolescents.
In the discussion of health promotion and health maintenance of
the school-age child (see Chapter 12 ), it was noted that the health-
Daily exercise using crutches is

8
care partnership grew from one with parents to one encompassing
important for Sam to maintain the the child as a partner as well. By adolescence, children should be as-
strength to continue bearing weight suming more of a partnership role in their own health care. As the
visit begins, greet adolescents warmly, ask about their concerns and
and walking independently. questions, and ask for their opinions and reactions throughout the
visit. This will demonstrate that their thoughts are valued and that
S am is a 7-year-old child with myelodysplasia. Sam and his parents are seen every few months in
the multidisciplinary spina bifida clinic located in the university medical center about 100 miles
from his home. The health professionals in this clinic help the family coordinate care for Sam with his Sam has been placed on the exam-
they play an important role in guiding the healthcare visit. When
adolescents are visiting the same office or clinic that they came to
ining table so his lower extremities
local pediatrician and physical therapy center. An important part of the health visit is to measure his can be evaluated. Next his socks during childhood, they usually know and feel comfortable with the
height and weight and to determine that growth is occurring as expected. In particular, it is important to will be removed so his feet can be
monitor for signs of excessive weight gain as this would potentially reduce his mobility. inspected.
care providers. If the setting is new to them, explain procedures and
introduce personnel so they feel more at ease.

GROWTH AND DEVELOPMENTAL

SURVEILLANCE
Adolescence spans several years, and growth and developmental is-
FIGURE 13–2 ■ Parents often accompany teens with a healthcare problem in for the
sues vary throughout the period. For young adolescents, those from
examination. Provide an opportunity to see both the teen and parent privately, and in- about 12 to 13 years of age, growth measurement remains important.
Unit VI | Chapter 32 | Alterations in Endocrine and Metabolic Function tegrate general health promotion and health maintenance into the visit. What questions Many youth are still growing, and use of percentile grids continues
can you ask this teen? What teaching might be needed? to be an important part of care. Growth should remain in the same

32–4 Diagnostic Tests for Short Stature BOX 32–2 FDA-Approved Uses of Growth Hormone in Children
PURPOSE RELATED TO SHORT STATURE
Growth hormone deficiency
■
d IGFBP-3 Screens for growth hormone deficiency A scale with a chair■attached Renalis failure
often used to mea- Assessing height is also important to
sure the weight of children with an inability to stand contrast with weight and to calculate a
e pituitary gland Detects pituitary malformation or tumor without support. ■ Turner syndrome body mass index. In this case Sam is us-
ing crutches to stand erect.
■ Noonan syndrome
ve growth hormone testing Tests for growth hormone deficiency
Identifies other potential causes
■so Short
Sam’s lesion is at the L4 to L5 level, stature
he can flex from
his hips and Prader-Willi
extend his his skin.syndrome (PWS) his socks will be removed to check for
As this visit is completed, The photographs and drawings throughout the textbook do more
knees,ofbutdelayed
he has weak ankle extension, toe flexion, and hip extension. He has signs of redness or lesions on his feet and lower extremities, especially
growth minimal sensation in his lower legs and feet.Children
■
are also affected. Sam and his parents■have
with
His bladder and
Idiopathic
worked hard short
a history
bowel sphincters of intrauterine
stature
to establish bowel
where braces maygrowth
rub. retardation
The health professionals at the spina bifida clinic are encouraging Sam
than illustrate concepts and examples. You will find critical thinking
e (girls) Detects Turner syndrome (seecontrol
page with1139)
opportunities among the figure captions. These unique highlights,
a high-fiber diet and to establish a specific time of day for bowel to be as mobile as possible. Daily exercise using crutches is important
Source:
evacuation. Sam has learned to perform Dataself-catheterization
intermittent from Cooke, D.forW., Divall,
for himS.to A., & Radovick,
maintain S. to(2011).
the strength continueNormal
bearing and
weightaberrant
and walking
unction studies Detects hypothyroidism (see page 1108)to reduce the risk for kidney
bladder control growth. In S. Melmed, K. S. Polonsky,
damage. P. R. Larsen,
independently. & H. M.
This enables SamKronenberg,
to interact with Williams textbook
his environment of
and other

d cortisol levels Detects other pituitary hormonal

deficiencies
During the health visit, Sam’s general health is reviewed, along with
changes in muscle tone, joint range of motion, and any signs of damage to
children in school. As the visit is finishing, Sam’s mobility is evaluated by
endocrinology (12th ed., pp. 935–1053). Philadelphia, PA: Saunders Elsevier; Ferguson, L. A.
watching him walk down the hall with his crutches.
(2011). Growth hormone use in children: Necessary or designer therapy? Journal of Pediatric
also appearing in the text itself, encourage you to apply information
atinine, pH, specific gravity, Detects chronic renal failure
Health Care, 25(1), 24–30; Sperling, M. A. (2010). Treatment of short children with GH plus
IGF-1: Are two hormones better than one? Infectious Diseases in Children, 23(1), 46–48. and analyze the nursing implications needed to provide care for chil-
ogen, electrolytes (see Chapter 31 )
dren and their families, thus adding true learning value to the visuals.
8

e blood count and Screens for inflammatory bowel disease

te sedimentation rate with anemia
requires subcutaneous injections 6 to 7 times per week and generally
n antibodies Screens for celiac disease
continues for several years until growth is complete. The pediatric
Photo Stories helpendocrinologist
bring information
adjusts the dosage and
ata from Parks, J. S., & Felner, E. I. (2011). Hypopituitarism. In R. M. Kliegman, B. F. based on concepts “alive” to de-
response to treatment The text explains in-depth pathophysiology of pediatric conditions,
velop a deeper understanding about
(Ferguson, 2011). See Box 32–2
W. St. Geme III, N. F. Schor, & R. E. Behrman, Nelson textbook of pediatrics (19th ed.,
1881). Philadelphia, PA: Saunders Elsevier; Cooke, D. W., Divall, S. A., & Radovick, S.
the
. effect of a specific condition
The child usually experiences increased growth velocity for the and accompanying Pathophysiology Illustrated figures allow you
on the child and family. first yearThese stories
followedinclude
mal and aberrant growth. In S. Melmed, K. S. Polonsky, P. R. Larsen, & H. M. Kronenberg,
of treatment,
xtbook of endocrinology (12th ed., pp. 935–1053). Philadelphia, PA: Saunders Elsevier.
by a gradualphotographs of a child
decrease in growth for to see into the body to visualize the causes and effects of conditions
subsequent months or years. Growth should progress at least at the
or situation to demonstratenormal growth ratetheforchallenges
age while the childa ischild
continuedand family may
on growth on children. These elaborate drawings illustrate conditions on a cel-
face
tions (arginine, clonidine, glucagon, inL-dopa)
insulin, managing
are ad- the
red to stimulate release of growth hormone, may be used to
condition.
hormone treatment. If growth is slower than anticipated, compli-
ance to therapy must be considered before the dosage is increased. lular or organ level, and may also portray the step-by-step process of
m growth hormone deficiency. Confirmation of the disorder
d on failure to demonstrate a growth hormone response (with
Replacement therapy is continued until either the child achieves an
acceptable height or growth velocity drops to less than 2 cm (1 in.)
a disease. Drawings or photos with artistic overlays relate disease to
evel greater than 10 ng/mL) after presenta- its anatomic location and action.
two provocative stimuli as previously men-
However, some endocrinologists believe
t is less reliable than other tests, such as low As They Grow Bone Age
evels. Growth hormone deficiency may oc- Chronic Lung Diseases 771
ne or with one or more other pituitary hor-
deficiencies. It may be total deficiency (no According to the hygiene hypothesis, these protective
hormone produced) or partial deficiency
growth hormone produced, but not enough
Pathophysiology Illustrated Asthmatic Episode factors increase exposure to infections in early life that
enable the child’s immune system to develop along a
nonallergic pathway (National Asthma Education and
ort normal growth). Prevention Program, 2007, p. 23).
Mucous
y diagnosis and treatment are important gland Inflammation causes the normal protective mecha-
Capillaries
ure attainment of maximum adult height Normal bronchiole nisms of the lungs (mucous formation, mucosal swell-
al. Bone age (an estimation of skeletal ma- and alveoli ing, and airway muscle contraction) to overreact in
is used to evaluate the child with a growth response to a stimulus and cause an acute asthma epi-
sode (sudden onset of breathing difficulty with cough,
m and can be used to predict final height. wheeze, or breathlessness) and airway obstruction. The
raphic imaging of the hand or wrist bone is trigger, a stimulus initiating an acute asthma episode,
evaluate the stage of bone ossification and Normal can be inflammatory or noninflammatory. Triggers
bronchiole
e bone age of the child. Using standardized increase the frequency and severity of smooth muscle
for bone ossification, radiologists can de- contraction (bronchospasm), and airway responsive-
Mucus ness is enhanced through inflammatory mechanisms.
e if the child’s chronologic and bone ages Normal production
Inflammatory
Asthma triggers include exercise, viral or bacterial
alveoli reaction such as
Significantly delayed (less than the child’s Mucous membranes
increases.
increased capillary agents, allergens (mold, dust, pollen, furry pets, birds),
permeability and
advanced (greater than the child’s age) become inflamed histamine release fragrances, food additives, pollutants, weather changes
and edematous.
ge may be indicative of a systemic chronic (humidity and temperature), and emotions or stress.
or hormone abnormality requiring inves- The asthma triggers may vary for individual children.
With exposure to a trigger, IgE and sensitized mast
n (Figure 32–4 ■). FIGURE 32–4 ■ The radiograph of the hand and wrist of a 3-year-old and 13-year-old girl reveal significant dif-
cells may be activated, leading to the release of many
ferences in skeletal maturation that are closely tied to physiologic maturation. The 3-year-old has many bones
Therapy inflammatory mediators (e.g., histamines, prostaglan-
in the hand and wrist that have not fully developed. The secretion of estrogen during puberty has resulted in the
dins, and leukotrienes). The inflammatory mediators
wth hormone deficiency, replacement ther- development and calcification of secondary ossification centers of most of the bones in the hand and wrist of the release pro-inflammatory cytokines, causing chronic
h GH is administered to promote growth 13-year-old. airway inflammation that may be associated with air-
velopment. Growth hormone replacement Source: Courtesy of Dorothy Bulas, M.D., Children’s National Medical Center. way remodeling (permanent airway damage that
involves thickening of the subbasement membrane,
Thickened Mucous glands subepithelial fibrosis, airway smooth muscle hyper-
basement hypersecrete trophy and hyperplasia, blood vessel proliferation and
Airway membrane and proliferate.
narrows, dilation, and mucous gland hyperplasia and hyperse-
restricting cretion) (Brashers, 2010a). This results in decreased
As They Grow illustrations help you visualize the important ana- airflow.
Smooth muscles Restricted airflow
airway elasticity and decreased lung function. These
permanent alterations are not prevented by or fully
tomic and physiologic differences between a child and an adult.
constrict. prevents proper
filling of alveoli and responsive to currently available treatments (Brashers,
Hyperinflated gas exchange. 2010a; National Asthma Education and Prevention
These features illustrate the important ways that a child’s develop- alveoli
Collapsed
Program, 2007, pp. 16–19). The reactive airway re-
sponses to stimuli are present before the trigger initi-
ment influences healthcare needs and how the child progresses alveoli
ates the physiologic sequence that results in an asthma
episode.
through developmental stages. FIGURE 25–12 ■ What can cause an asthmatic episode? Some asthma triggers are exercise, infection, and
Airway narrowing results from bronchial con-
striction, airway swelling, and production of copious
allergies. This illustration shows how asthma obstructs airflow through bronchoconstriction and inflammatory amounts of mucus. Mucus clogs small airways, trapping
changes, narrowing the airway and thus increasing production of mucus. air below the plugs (Figure 25–12 ■). Decreased perfu-
sion of the alveolar capillaries results from hypoxic
vasoconstriction and increased pressure due to hyperinflation of the al-
Etiology and Pathophysiology veoli. Hypoxemia leads to an increased respiratory rate with a reduced
Asthma is a chronic inflammatory disease of the lungs in children minute volume (air breathed per minute) because of airway resistance.
who are genetically susceptible. More than 100 genes are associated
with the susceptibility and pathogenesis of asthma (Brashers, 2010a). Clinical Manifestations
Some of these genes regulate the inflammatory process. It is caused by The sudden appearance of breathing difficulty (cough, wheeze,
the interplay of multiple factors, including indoor air contaminants or breathlessness) is often referred to as an acute asthma episode,
(e.g., tobacco smoke, pet dander, and cockroach feces), outdoor air asthma flare, or asthma attack. The infant or child who has had fre-
DESIGN SERVICES
disease OF
# 108438   Cust: Pearson   Au: Ball  Pg. No. viii C/M/Y/K
S4carlisle
pollutants, recurrent respiratory viral infections, and allergic quent episodes of coughing or frequent respiratory infections should
(e.g., atopic eczema, hay fever, and food allergies). Protective factors also be evaluated for asthma. Frequent coughing, especially at night,
Title: Child Health Nursing   Server: Short / Normal
that reduce the risk for asthma include a large family size, later Services
Publishing birth is the warning signal that the child’s airway is very sensitive to stimuli;
order, childcare attendance, dog in the family, and living on a farm. it may be the only sign in “silent” asthma.
 The full-term newborn has a complete but immature nervous sys- to physiologic changes such as fluctuating cerebral perfusion pres-
tem at birth. The infant is born with all of the nerve cells that will exist sure from decreased cardiac output, increased intracranial pressure,
throughout life, but maturation of these nerve cells continues after birth. or constriction of the neck’s blood vessels due to positioning. When
The number of glial cells and dendrites, which enable receipt of nerve blood flow and oxygenation are not maintained, the brain cells be-
impulses, continues to increase until approximately 4 years of age. Brain come damaged in a very short time. Because the nervous system helps
growth results in the increasing head circumference in infants and tod- to control and coordinate many body functions, alterations in neuro-
dlers. Brain growth continues until the child is 12 to 15 years of age. logic function can have widespread effects on the body’s metabolism.
Myelination, the progressive covering of axons with layers of Disorders of Pancreatic Function 1133
myelin or a lipid protein sheath, is also incomplete at birth. Lack of
myelination is associated with the presence of primitive reflexes. NEUROLOGIC FeaturesASSESSMENT
That Help You Use This Book Successfully ix   
TABLE 32–9 Laboratory FindingsAsinthe themyelination
Child progresses, the primitive reflexes Nursing
disappear. Assessment
Performing a and
nursing Diagnosis
assessment of the child with a potential or ac-
See Table 7–19 for the expected appearance and Continuously
disappearance tual neurologic
monitor the condition involves
child’s vital a careful
signs, review of the
respiratory signs and
status, per-
Features That Help You Use This Book Successfully
with Diabetic Ketoacidosis

8
of primitive reflexes during early infancy. This process continues symptoms in many body systems and analysis of their relationship to
Respiratory Distress and Respiratory Failure 747 fusion, and mental status. Assess for changes in neurologic status, re-
LABORATORY STUDY throughout
RESULTS childhood, proceeding in a cephalocaudal direction. The neurologic functioning. Use the guidelines in Table 33–3 to perform
myelination process accounts for the progressive acquisition spiratory pattern,
of fine blood pressure,
a comprehensive andofheart
assessment a childrate.
with Monitor
a neurologicfor cardiac
condition.
ciation Curve cricoidSerum glucose
cartilage, andGreater
is often performed if long-term than
gross motor 200 mg/dL
skills
airway and coordination during early childhood,
management arrhythmias and it associated
Numerous diagnostic procedures andAssess
with hypokalemia. laboratory
fortests
signsare of
used for
dehy-
Nursing students
is needed.
Serum face
ketones challenges in their education—managing
is ultimately
Positive
responsible for the speed and de-accuracyof pediatric
of nerve impulses.nursing
dration, in today’s
the diagnosis
including dry about world.
of neurologic
skin these We
conditions
and diagnostic
mucousprocedures developed
(Table 33–4).aAdditional
membranes, textbook
and depressed
in- that
In infants and young children the vertebral bodies are wedge formation and laboratory tests can
mands on
Assistedtheir
Arterial time,
ventilation
blood gas pHapplying
must beresearch
provided
shaped,findings,
until
Acidotic—pH evaluating
theless
the ligaments child
permit
than andcom-
breathes
7.3more movement,
bicar- is the
and easy to learn
fontanels
articulating from
in infants.
be foundand easy to use
in Appendixes D andasE a professional
. reference. The

8
PaO2 SpO2 ponents of evidence-based
spontaneously practice,
or until mechanical and
facets
ventilation atdeveloping
bonate C1less
isandinitiated.
C2 permit
than their
15 mEq/L critical
more sliding
Children in cases offollowing
injury. The guide
child’
Nursing will help
s diagnoses thatyouapplyusetothethe features
child withand resources
diabetic ketoaci- from
spinal cord attains adult characteristics after 10 years of age when the
(mm Hg) (%) thinking
are oftenskills.
sedated
Urine Thus instructors
to optimize and students
ventilation. Continuous
Positive alike
for value
positive
ketones the in-text
airway
(ketonuria) Child
dosis
vertebral body loses its wedge shape and the facets become more ver-
Health
may Nursing
include:
ALTERED to succeed
STATES in
OF the classroom,
CONSCIOUSNESS in the clinical set-
100 98 learning
pressureaids
Serum that
(CPAP) we
potassium include
is one formin
ofour
PEEP textbooks
used
tically todecreased,
to improve
aligned
Elevated, (meet
Mathison, the challenges
oxygenation
orKadom,
normal& Krug, 2008). ting, on the NCLEX-RN®
■ Injury, Level
Risk examination,
forofrelated
consciousness and
(LOC)cerebral
to altered in function
is perhaps nursing practice.
the most important indi-
90 97 and lung compliance. When respiratory failure The braincannotdependsbe on managed,
a continuous blood flow to meet its high cator of neurologic dysfunction. Consciousness, the responsiveness
■ Fluid Volume: Deficient related to osmotic diuresis
Serum chloride Elevated
demands for oxygen. Through an autoregulatory process, the cerebral or awareness of the mind to sensory stimuli, has two components:
80 95 it results in cardiopulmonary arrest. blood vessels dilate to maintain the cerebral blood flow in■response Nutrition,(1)Imbalanced: Lessthe
Alertness, or arousal, than Body
ability Requirements
to react related
to stimuli, is controlled
6 70 93 Serum sodium Decreased
When acute respiratory failure becomes life threatening, extra- to catabolism of protein and fat for fuel
4 60 90 Serum phosphate oxygenation (ECMO) Decreased
50 84
corporeal membrane may be initiated (Ayad, ■ Knowledge, Deficient related to recognition, treatment, and
2 Dietrich, Serum& Mihalov,
osmolality 2008). ECMO is a cardiopulmonary Elevated bypass sys-
40 75 TABLE 33–3 Assessment Guidelines for the Child with a Neurologic prevention
Condition of diabetic ketoacidosis
30 60 tem with external oxygenation and a pump mechanism
ASSESSMENT FOCUS
that provides
ASSESSMENT GUIDELINES NANDA-I © 2012
Source: Data from Cooke, D. W., & Plotnick, L. (2008b). Management of diabetic ketoacidosis in
20 35 respiratory
Assessment and hemodynamic support.Level It allows the lungs to ■ Isrest andor child difficult to arouse?
children and Guidelines
adolescents. Pediatrics in Review, 29, 431–436; of consciousness
Jerreat, L. (2010). the infant
Managing diabetic
10 14 heal. However, several significant complications may result ■ Isfrom itsor child
theofinfant Planning
irritable or difficult and Implementation
to calm or console?
for the Child tables in
ketoacidosis. Nursing Standard, 24 (34), 49–55; McFarlane, K. (2011). An overview diabetic keto-
use, such as inbleeding,
acidosis stroke,
children. Paediatric renal
Nursing, insufficiency,
23(1), 14–19. hypertension, sei-
■ Is the child oriented? Can the Intravenous fluids
child tell the examiner his or herare
namegiven
and age?in boluses of 10 to 20 mL/kg rapidly over
each
zures,ofelectrolyte
the systems chap- pneumothorax, cardiac dysfunction,
abnormalities, ■ What is the child’s ability to concentrate? Can the young child name pictures of animals? Can the older child answer simple math
5 minutes if the child is in hypovolemic shock. Adequate fluids are
80 90 100 110 120 ters
and provide
infection an (Ayadoverview
et al., 2008). This is a complex and ■expensive
questions or spell words?
given to reverse the fluid deficit. The
The Glasgow Coma Scale provides a numeric score for future comparison. See Table 33–5insulin
. infusion must be carefully
Hg) (PaO2) of the keyavailable
treatment aspectsinofspecial an centers, Cranial so the child may have to be
Collaborative Care nerves ■ Assess the cranial nerves. See titrated
Table 7–18 to. control
See Table 33–6the
for gradual
methods to reduction
indirectly assess in
cranial hyperglycemia.
nerves in the unconsciousMonitorchild.

8
essure of oxygen in arterial integrated
transferred assessment
to another hospital for to receive this and
Fontanels therapy.
sutures ■ Palpate fontanels and suture lines blood glucose
on the infant’s scalp. levels hourly or as indicated. Frequently monitor the
The immediate Altered States of Consciousness 1155
ear. When hypoxia exists, the conditions within goal theof collaborative care is to normalize
Cognitive function
the pH level,
electrolytes and acid–base status, as well as urine glucose and ketone
■ Are the child’s verbal skills developmentally appropriate for age?

hypoxia does not exist, oxygen Nursing restore blood

Management glucose to target level, and correct fluid and
■ Does theelectrolyte
child follow directions and respond appropriately?
body system. levels as indicated. Intake and output are monitored hourly. Assess for
ry reading is associated with a TABLEimbalance.
33–6 The long-term
Assessment of Cranial goal of management includes
Pupils
Nerves
■ Check thepreventive intubation
pupils for size and reaction toislightperformed.
and accommodation. A tracheostomy
See Figure 33–4 on may be. performed for long-
page 1154
Nursing care is focused on the recognition of progression from respi- signs of hypoglycemia which may occur during insulin infusion.
ssociation curve demonstrates education to reduce the risk of further
Vital signsdiabetic ketoacidosis ■ Assess heartepisodes. term
rate, respiratory airway
rate, and bloodmanagement.
pressure. Frequent suctioning may be required. Keep
ortant in correctly interpreting the ratory distressintothe Unconscious
respiratory failure Childand supportive care to■ the Monitorchild
for an increasedsuction apparatus
systolic blood with pulse
pressure, a widened catheters at the bedside
pressure, bradycardia, and irregularalong with
respirations oxygen,
(late signs of increased
and
CRANIAL Diagnostic
family.
NERVES REFLEX Tests ASSESSMENT PROCEDURE intracranial pressure). Practice Alert
resuscitation
■ Inspect the infant’s posture and Only
bag
regular
and
insulin
mask, and extraintravenously
is administered
endotracheal or tracheostomy
for treatment of hyperglycemia
AND REFLEX See Table 32–9 for laboratory
AND NORMAL FINDINGSfindings Posture and in diabetic ketoacidosis.
movement CT movement by using the primitive reflexes. See Table 7–19 .

8
entration is adequate, and the pH
Nursing Assessment and Diagnosis tubes (if applicable). Pulse oximetry or arterial blood gas analysis
lower is
of in- developmentally appropriate for age? Were motor skills acquired at the appropriatethey
or diabetic ketoacidosis. Do not use other insulin types as may the blood
■ Observe the child’s play or other spontaneous activity to assess strength as well as symmetry and smoothness of movements.
ated with a PaO2 of 90 mmHg or II, III scan of the Shine braina and light possible
source in the intubation
eye. and implementation
performed
■ Are the child’s motor skills glucose at too
regular
rapidly intervals to ensure that gas exchange
or too slowly. age?isHas
adequate.
the child lost a
Pupillarytracranial
Monitor the child pressure
for changes
Rapid,
(ICP) in
concentrically
lowering
vital strategies
signs,
constricting respiratory
pupils
will bestatus,
required.
indicate intact
previouslyand acquired skill?
Assisted ventilation may be required (refer to the Skills Manual ).
aO2 of 60 mmHg or less. level of responsiveness. cranial Perform
nerves II, III. the respiratory assessment using
■ Evaluate muscle strength and tone, comparing side to side. Is any weakness present?

with a PaO2 of less than Clinical Therapy ■ Test the child’s coordinationAnticipate
for smoothness and thatsymmetry
seizures may occur. Pad the side rails to protect the
of response.
guidelines in Table 25–1with . Signs and symptoms of respiratory com- The child is tapered off intravenous insulin and transitioned to
II, IV, VI The child with Performketoacidosis eyes heldisopen hospitalized.
(doll’s eyes) and Medical
head■ moved management
Assess childforfrom
deep tendon reflexes injury.
smoothness and symmetry of response. See Table 7–20 .
promise may progress rapidly. Detection of earlier subtle signs is subcutaneous insulin when clinically stable. Oral feedings are rein-

8
reater than 95% can indicate Oculocephalic
includes isotonic horizontally or vertically. fluids
intravenous and electrolytes
Neck stiffness forfordehydra-
■ Assess neck stiffness (nuchal rigidity).
important so interventions can be initiated to prevent progression to Perform Routine
troduced Nursing
when Careis alert enough and the glucose level is stabi-
the child
tion and acidosis.When head is turned suddenly
Short-acting Pain to the
insulin (0.1right, the eyesper
unit/kg ■ of an
Assess in- of is
hour)
level painad-
when present.
respiratory failure.fant Attach a cardiorespiratory themonitor and■pulse If the
ox- history of headaches, corneal
lized.seizures,reflex plan variesorplace
is absent,
Thisneurofibromatosis, accordingartificial
other neurologicto
tears
the in the eyes
primary and cover
healthcare provider
as easily release the oxygen to ministered by orcontinuous comatose patient look
Family
intravenous tohistory left, and similarly
infusion pump looktoatofamily
Is there
decrease with gauze, taping over so they remain
condition?
closed. Perform routine mouth
on curve shifts to the left, and imeter. Serial blood gases may be needed to monitor the child.
the right when the head is turned to the left. Absence of this or endocrinologist.
the serum glucose reflex suggestslevel brainstem
at a rate dysfunction
not to exceed 100 mg/dL/hr.
in comatose patients. Faster care by brushing the teeth and using swabs with water. Gently clean
Hg.
reduction of hyperglycemia and serum osmolality increases the risk the oralClinicalmucosaTip in newborns and keep secretions from accumulating.
dily releases oxygen to the tis- Practice Alert Precaution: Cervical spine injury must be ruled out before
ve shifts to the right, and the for cerebralchronic
When the child has a this
edema.
assessment When
respiratory
glucose is lowered too rapidly, water is Provide
is performed.
or neuromuscular condition, development Insulin adequate
binds to IV tubing.nutrition. Run 50 Initially,
to 100 mL nutrients may bethesupplied
of insulin through new IV tubing to
n 70 mmHg. of freed failure
and attracted to the glucose, which haswith accumulated in large saturate allAthe
intravenously. binding sites.
nasogastric orThis ensures thattube
transpyloric the fullmay dose beofinserted
insulin reachesif the
III, respiratory
VIII may be
Place thegradual
head in as muscles
a midline andassociated
slightly elevatedbreathing
position. may
be quantities
weakened.
Oculovestibular Signs in willthe
beice
Inject brain.
subtle.
waterBeintoBicarbonate
particularly
the ear canal. is not
alert routinely
to behavior changesusedin for ad- treat- child from the outset.
the infant or child remains unconscious or is not alert enough to take
dition toment of DKA
respiratory signs.asPulse
it places oximetry the child
and serialat increased
blood gases riskmay forbehypokalemia,
needed
to monitor the child.
Eyes deviating toward the irrigated ear indicate intact cranial food by mouth. A gastrostomy tube may be inserted if it is anticipated
must be considered simul- acidosis, and cerebral
nerves III, VIII. edema (Cooke & Plotnick, 2008b). As insulin that enteral feeds will are
Electrolytes be needed
replaced foraslonger
needed. than 3 months.is(See
Potassium not the adminis-
status. Hypercarbia in the is administered, potassium shifts to the cells, resulting in hypokale-
Precaution: Ensure that the tympanic membrane is intact Skills Manualtered until the.)child has voided to confirm renal function. Monitor
failure. Hypoxemia unre- mia.
If the Potassium
child hastoankeep supplementation
fluid from entering
endotracheal tubethe is given
or middle only
ear. aftertube,
tracheostomy confirmation
assess of Prevent complications associated with immobility (muscle atro-
gn of respiratory failure. Clinical
for signs Tips andare “pearls” of
symptoms from clinical nursing
hypokalemia, including experts embedded
hypotension,
renal function.
for secretions thatNote:
mayAfurther
physicianobstruct the airway.
usually performs this assessment. phy,throughout
contractures, and skin respirations,
breakdown) and as described in Box 33–2 .
weak pulse, the shallow
textbook. muscle weakness. Continu-
Practice
V, VIIExamples
Corneal
Cerebral
Alerts ofwarn edema
Gentlyyou
nursing isthesafety
of
diagnoses
touch
thecornea
most
associated common
precautions
with a sterile with cause
and
respiratory
cotton swab.
of DKA-related
other nursing Nursesous
failure support physical therapy efforts withtoextra passive range of
cardiac monitoring is performed detect cardiac conduction
g the cause of respiratory include:
alerts to deaths.
considerMannitolinA blink
providing is kept oncare.
indicatessafe
standby for treatment of neurologic
intact cranial nerves V, VII. motionchanges exercises. related to hypokalemia. Weigh the child daily. Provide emo-
with oxygen, mechanical symptoms secondary to cerebral
■ Breathing Pattern, Ineffective associated with prolonged tachy-
edema (Cooke & Plotnik, 2008b).
IX, X Gag
See ChapterIrritate 33 thefor pharynx with a tongue depressor or cotton swab.
information about cerebral edema. Provide Sensory and
tional care support to the child and family.
Stimulation
essure (PEEP) to increase pnea and muscle fatigue
8

A gagging response indicates intact cranial nerves IX, X. Because Care theinchild with a severely altered level of consciousness may
the Community
n are admitted to the pedi- ■ Airway Clearance, Ineffective related to sedation and loss of
Nursing Management still beThe ableprevention
to hear, talking to him
of future or her may
episodes be beneficial.
of diabetic ketoacidosis Listening is impor-
protective cough reflex to music or tapes of family members talking or reading can soothe
he level of responsiveness Nursing care focuses on administering insulin, fluids, and electro- tant. Partner with the child and family to ensure they learn strategies
Clinical Judgment Verbal, Impaired related to artificial airway
■ Communication:
a childtowhen
e airway patent decreases. Some lytes,ofand
■ signs
Family the monitoring
intact
Processes, neurologic
Interruptedthestatus
childrelated
offor ansigns
infant and symptoms
(newborn
to child’ to 2 months
s life-threatening of associated
of keepfamily membersepisodes
hyperglycemic cannot be frompresent. Explaintoalldiabetic
progressing proce- keto-
age) are complications.
a cry with a loud and Once the child
energetic quality,is astabilized,
strong suck,the andfocus of care shifts to
suck-swallowing
dures and
acidosis. (See Partnering with Families: Preventing DKA.)toParents
actions to the parents and child. Encourage the parents
ertion of an endotracheal illness stroke should and touch thespecific
child ininstructions
a soothing manner.
e tube must be protected educating
coordination.
NANDA-I © 2012
What isthe onechild
additional and family
sign? on methods to prevent further epi- NEW!
When
have
Clinical
the and childwhen
Judgment speedon
becomes morethealert,
how often
bumps
gradually
appear to when
and when
check an
repeatedly
theopportu-
blood
End-tidal CO2 monitor- sodes of diabetic ketoacidosis. glucose
nity for critical thinking arises. to check urine for ketones the child is
Planning and Implementation orient the child to time, place, and person, depending on his or her
iration to ensure that the Following are nursing diagnoses that may be appropriate for the age and level of understanding. Encourage parents to bring objects
oned in the trachea. See Position
child withthe an child
alteredwith levelrespiratory
of consciousness: distress in an upright position or toys from home to make the environment more familiar and pro-
eostomy, the creation of (by elevating the head of the bed) with the head in midline to help mote a feeling of security.
■ Breathing Pattern, Ineffective related to neuromuscular dys-
h the anterior neck at the maintain the airway. Administer oxygen as ordered (Figure 25–9 ■).
function associated with increased intracranial pressure Provide Emotional Support
■ Aspiration, Risk for related to poor control of secretions with
Explain the child’s condition to the family in simple terms. Encourage
decreased level of consciousness parents to take part in the child’s care and therapy as much as possible.
■ Skin Integrity, Risk for Impaired related to agitation and skin

rubbing against bedding

■ Communication: Verbal, Impaired related to physiologic con-

dition of decreased level of consciousness BOX 33–2 Care of the Child Who Is Immobile
■ Family Processes, Interrupted related to care of a child with an DESIGN SERVICES OF
# 108438   Cust: Pearson   Au: Ball  Pg. No. ix ■ Help keep the body in proper C/M/Y/K alignment with splints orS4carlisle rolls made of towels
acquired disability Title: Child Health Nursing   Server: Short / Normal
or blankets. Publishing Services
 therapeutic play 407 3. Describe the child’s and family’s adaptation to hospitalization.
1100 therapeutic
Unit VI recreation 409
| Chapter 32 | Alterations in Endocrine4.and Metabolic
Apply Function
family-centered care principles to the hospital setting.
treatment room 399
5. Identify nursing strategies to minimize the stressors related to hospitalization.
GHRF = Growth Hormone 6. Integrate the concept of family presence
TABLE 32–2 during procedures
Assessment and nursing
Guidelines strategies
for the Child to pre-
Releasing Factor Sleep pare the family.
Hypothalamus with an Endocrine Condition*
rhythms
7. Summarize strategies for preparing children
ASSESSMENT and families
FOCUS for discharge
ASSESSMENT from the hospital
GUIDELINE
Stress
Glucagon setting.
α-adrenergic
Growth ■ Carefully measure weight, length, or height and plot
x  Features That Help You Use This Book Vasopressin
Successfully neurons
8. Evaluate the effectiveness of teaching strategies used with
on athe hospitalized
growth curve. child and his or
Hypoglycemia
her family. ■ Compare measurements at different ages to assess
GHRF the growth pattern over time and to assess the
letal Function Somatostatin growth velocity.
+ –
Bloodmy
“Why do they need to take pressure/pulse
tonsils out? ■ Assess blood pressure and compare to expected
equirements related to They’re fine where they are!” norms for age. See Appendix B .

8
Case Legal
Scenarios andand Ethical
photosConsiderations
at the be- Facial characteristics Inspect the face for unusual features such as a pro-
■
—Tiona, age 5
tuberant tongue, protuberant eyes, or moon face.
inal illness ginning Muscular Dystrophy
of the chapter engage Careyou with Anterior
– pituitary Neck ■ Palpate the neck for an enlarged thyroid or goiter.
– Five-year-old Tiona Lewallen has a history of frequent tonsillitis and
a child’s real-life
The child experience
with muscular with
dystrophy has aa spe-
shortened life span. Parents is scheduled
providefor a tonsillectomy and Muscles adenoidectomy in the morn-■ Assess strength and muscle tone.
cific comprehensive
health challenge. Additional
care and require support both in-physically and emotionally
Negative ing.Growth
Herasmother
the has brought her in today for preoperative evaluation■
Genitalia and secondary Assess external genitalia for signs of ambiguous
feedback andhormone
instruction. Tiona has no other health problems. Her experience
usually long term and child’s condition
formation aboutprogresses.
the child The child
and continues
family to develop in many with ways, espe- sexual characteristics genitalia, or inappropriate size for age.
health care is limited to well-child checkups and immunizations
d emotional health of cially cognitively, as the years pass. Therefore, the needs for explanation and+ ability Target ■ Determine the child’s stage of development for
appears throughout the chapter to illus-
to understand the diagnosis change for the child over time. Parents
as well as several visits to the otolaryngologist in the past year. She has no
the child is diagnosed priormay have organs
hospitalizations. Tiona will return at 6:30 a.m. for surgery. She will eachbe characteristic
admit- (breast and pubic hair for girls,
tratedifficulty
application
initiatingof nursingwith
discussions care.
theUse thechild about desire fortedend-of-life
growing genital
to the pediatric day short-stay unit for a few hours following surgery and will andthen
pubicbehair for boys)home
discharged by comparing
as long to the
s often provide home images in Figures
care (Penner,
questions Cantor, & Siegel,
embedded 2010).scenario
in each An ethical approach to care demands thatto drink fluids and take oral pain medication. How should
as she is able the nurse assess7–43what, 7–44
Tiona ,knows
and 7–45about .

8
them in school nurs- such a complex chronic disease be managed by an interdisciplinary herteam thatWhat techniques should be used to teach Tiona about■ the
surgery? Assess the sexual
surgery? maturity rating
What instructions shouldwith information
Tiona’s
ics and other facilities to apply pathophysiologic,
collaborates on a regular basis. Thepsychoso-
child, family, and a variety of health,mother social,
receive from the nurse in the preoperative clinic related to care in Figure
prior to7–46
References 415
surgery?. Compare the stage of develop-

8
as the child grows; this cial, and
family, culture,
educational developmental,
professionals should all be partorof the team. The plan of care will ment to the age of the boy or girl to determine early

the care;Clinical Reasoning in Action

includeprocess
physical, emotional, cognitive, and or delayed onset of puberty.
r the child, family, and nursing considerations. Atpalliative it will evolve and change
as the child grows older. Nurses are essential members of theHeart team and may work Body odor ■ Assess body odor for unusual smell (e.g., sweet,
nce Overview on page end with
of the chapter,
families a detailed Clinical
as team managers. INTRODUCTION 2. As Tiona andmusty, cheesy,
her mother sweaty
are preparing feet).the hospital, Tiona says, “I
to leave
her therapies to main- ­Reasoning in Action exercise picks up Skin
Recall Tiona, the child described in the beginning of the chapter. She is a 5-year- am going■to Assess
be good so I docolor,
skin not have to come
noting areasto theofhospital
unusual anymore!”
How should the nurse respond?
family as needed (see the opening scenario and asks youLiver to ap-
old girl who was admitted to the hospital for a tonsillectomy and adenoidectomy
(T&A).
pigmentation.
3. Tiona’s mother states that she is worried that her daughter will not drink
ystrophy Care). ply whatParents
you may
haveexhibit
read. feelings of guilt and hopelessness.
DESCRIPTION
The mother Mental status ■ Note affect. Assess for anxiety, irritability, or
enough at home. What can the nurse suggest to Tiona’s mother to encour-
lethargy.
age her to drink fluids? What are the symptoms of dehydration that Tiona’s
who learns she has carried the gene that affects Followingher son can
Tiona’s be devas-
operation, she refused to drink liquids because it hurt when
mother should watch for over the next few days?
she swallowed. After receiving intravenous pain medication, TionaFamily realizedhistory
that ■ Assess for family history of metabolic or endocrine
evaluations are per- tated. Encourage parents to express their feelings. she
Genetic
could swallow
counseling
without too much pain and began to eat Popsicles and drink 4. Children Tiona’s age have many fears and stressors related to hospitaliza-
disorders.
Pancreas
ter oxygen or respira- is recommended for the entire family, and it isliquids. especially was thenimportant
SheKidney switched to oral pain medication. Later in the day, Tiona tion and surgery. How can her mother assist Tiona to express her feelings
was drinking liquids well enough to be discharged home. about the hospital experience once she is home?
tube feedings may be to identify women who are carriers of one of the X-linked disorders. Note: *Refer to Chapter 7 for the actual techniques of assessment mentioned in this table.

8
DISCUSSION
dystrophy of infancy Siblings may feel neglected because their brother or sister is receiving
1. What information should the nurse include in the discharge teaching plan
function with fluids, so much attention. They may be concerned that they willmother?
for Tiona’s develop the The anterior pituitary gland is considered to be the “master gland”
Monitor and ensure disease. Sometimes multiple children in a family are affected with the of the body. The major function of the anterior pituitary gland is the
tion. Perform range of condition and as one child worsens, the effect on siblings is profound.
On the other hand, siblings without the disease may feel guilty for their
NCLEX-RN® Review production and release of thyroid-stimulating hormone (TSH), ad-
renocorticotropic hormone (ACTH), luteinizing hormone (LH),
vel of ability. Physical
oint contractures. It is good health. Encourage the parents to involve siblings
1. The nursein isthecaring for a female child who is recovering follicle-stimulating
affected from a motor 3. Which hormone
behavior by a(FSH), growth
child’s parents hormone
is the best indicator that(GH),
they un- and
FIGURE 32–2 ■ Feedback mechanism in hormonal stimulation of the gonads during
vehicle accident. The child’s parents ask if it is okay to bring the child’s derstand how to administer medication to the child at home following
posture by keeping the child’s care to reassure them of their importance. (See
puberty. Chapter
siblings to visit. What 16 is the most appropriate response by the nurse? surgery?
8

wheelchair. Splints may for ideas about involvement of siblings in care.) 1. “No, it would not be good for your child to see her siblings asTABLE it may make 1. The parents sign the written discharge instruction verifying understanding of
32–3 Diagnostic Procedures and Laboratory Tests
her worse.” the instructions.
r position. As the child’s condition weakens, the family again needs
2. “No, it would be very addi-
upsetting for your child’s siblings to see her this way.” for 2.theTheEndocrine
parents give the System
medication to* the child using the appropriate technique in

tional support. They experience

Inborn grieving,
errors of each person
metabolism
Tables of Diagnostic Procedures and Laboratory Tests perti- someone
in
(inherited
to
their
watch
own
3. “Yes, it is okay to bring your child’s siblings to see her as long as you bring
them.”biochemical ab- DIAGNOSTIC PROCEDURES
3.
the nurse’s presence.
The parents state they LABORATORY
understand TESTS
how to administer the medication and deny

and provide parents way. They have lived with chronic

normalities of the sorrow
urea and
cycle now
and amino need
4. “Yes,
acid toand
it is okay toprepare
organic acid me-
bring your child’s siblings for a visit as long as we educate questions.
nent to the specific systems assist you in clinical when them on what you need
to expect the
when they visit. ACTH stimulation test Fasting plasma glucose
4. The parents state they can give the medication to the child using appropriate
velopment. Arrange a for the child’s death.tabolism)
The child is usually
often old enough
have a significant impact to recognize
on the endocrine the system’s technique.
information.
deteriorating condition.
ability See Chapter
to support 18 andfor
growth
2. How can the nurse best limit the amount of separation anxiety
further
development. discussion
hospitalized Some
toddler of
willchromosomal
experience? ab-
Adrenal that (ACTH)
the suppression test Hemoglobin A1c
4. The nurse is caring for a 5-year-old male child who will be having a ton-
to evaluate the child’s Bone age Hormone levels
8

normalities care.
bereavement and end-of-life also result in disturbances in growth and sexual develop-
1. Reduce the amount of time spent with the child when the parents are not sillectomy performed. What teaching method is most appropriate for this
d to determine educa- present.
ment. These disorders are discussed2.on pagethe 1141
Computed tomography
. of time the parents hold their child while hospitalized.
(CT)
child Insulin-like growth factor (IGF-1) and
prior to the surgical procedure?
Discourage amount 1. Provide the child’s motherInsulin-like growth
with brochure about factor-binding
the procedure. protein
should be established. Evaluation Fluidprovided.
3. Encourage the parents to leave the child’s room when care is being deprivation test 2. Sit with the child while he watches a video about the procedure.
3 IGFBP-3
r home computers if Expected outcomesDISORDERS
of nursing care OFforPITUITARY
the child with FUNCTION
muscular dys-
4. Encourage parental involvement in the child’s care and suggest
possible.
rooming in if
Karyotype 3. Use dolls to teach the child about the procedure.
Newborn
4. Allow the child to talk to other metabolic
children who screening
have had the procedure.
arly intervention pro- trophy include maintenance of optimal mobility and development,
The pituitary gland consists of two lobes, an anterior lobe and a pos-
Magnetic resonance imaging (MRI)
See Appendix I for answers.Provocative growth hormone testing
8

Thyroid radioactive iodine uptake (RAIU)

positive self-imageterior
for thelobe. The functions
affected child, andofpositive
the posterior pituitary of
management gland include scan Thyroid antibodies
r as long as possible. regulation of fluid balance through release of antidiuretic hormone
h, and do not ask the
the emotional challenges by all family members. References
(ADH), which is stored in the hypothalamus; and production of oxy- Note: *See Appendixes D and E for information about these diagnostic procedures and for
8

ing. Reading books to tocin, which is also stored in the hypothalamus. expected laboratory tests values.
Bindler, R. C., Ball, J. W., Ladewig, P. W., & London, Crenshaw, J. T., & Winslow, E. H. (2008). Preoperative and resuscitation in the emergency department. Retrieved
evision offer the child M. L. (2011). Clinical skills manual for maternal &
child nursing care (3rd ed., p. 110). Upper Saddle
fasting and medication instruction: Are we improving?
AORN Journal, 88(6), 963–976.
from http://www.ena.org/IENR/ENR/Documents/
FamilyPresenceENR.pdf
tolerated contributes River, NJ: Pearson. Disch, J., Dreher, M., Davidson, P., Sinioris, M., & Fisher, M. J., & Broome, M. E. (2011). Parent-provider

Complementary Therapy
Brain Injury Association of America. (2011). A guide to Wainio, J. A. (2011). The role of the chief nurse officer communication during hospitalization. Journal of Pedi-
being. selecting and monitoring brain injury rehabilitation ser- in ensuring patient safety and quality. Journal of Nursing atric Nursing, 26(1), 58–69.
child needs. Surgery, Muscular Dystrophy
vices. Retrieved from http://www.biausa.org/Default.
aspx?SiteSearchID=1192&ID=/search-results.htm
Administration, 41(4), 179–185.
Drahota, A., & Malcarne, V. L. (2008). Concepts of ill-
Forsner, M., Jansson, L., & Söderberg, A. (2009). Afraid
of medical care: School-aged children’s narratives about
portation of the child Chahal, N., Manlhiot, C., Colapinto, K., Alphen, J. V., ness in children: A comparison between children with
and without intellectual disability. Intellectual and Devel-
medical fear. Journal of Pediatric Nursing, 24(6), 519–528.
McCrindle, B. W., & Rush, J. (2009). Association be- Frisch, A. M., Johnson, A., Timmons, S., & Weatherford,
constant daily care are Many families who have a child with muscular dystrophy use different types of
tween parental anxiety and compliance with preop-
Complementary Therapy boxes
opmental Disabilities, 46(1), 44–53.
present
C. (2010). approaches
Nurse practitioner role in preparing other
families than tra-
erative requirements for pediatric outpatient surgery. Emergency Nurses Association. (2009). Emergency nurs- for pediatric outpatient surgery. Pediatric Nursing, 36(1),
this care, providing a complementary care. The nurse always assesses for such
Journalapproaches, provides
of Pediatric Health Care, 25(6), 372–377.
ditional medical
ing resource: Family prescriptions
presence during invasive procedures that
41–47. may be used by children and fam-
family members, and information as needed by the family, makes recommendations for complementary
therapies that may be helpful, and cautions against those that could be harmful ilies to maintain health or treat diseases. These boxes discuss research
many years creates a
er the family to respite
due to interactions with medications or other problems. Common complementary when it is present to support or refute the efficacy of these modalities.
care used in muscular dystrophy includes dietary enhancement. This enhance- At other times, they alert you about information to gather from the
rtain that either a fam- ment includes vitamins A, C, E, D, and B-complex; minerals such as calcium, mag-
manager to coordinate nesium, zinc, and selenium; probiotic supplement; omega-3 fatty acids; herbal family and to consider when planning care.
s to resource and sup- remedies such as green and rhodiola rosea teas; muscular and immunologic en-
Association. Ask what zymes such as coenzyme Q10, N-acetyl cysteine, acetyl-L-carnitine, creatine, and
L-theanine; melatonin to promote sleep; and massage to assist with reduction of
o the child and family muscle spasms (University of Maryland Medical Center, 2011).
ophy).

DESIGN SERVICES OF
# 108438   Cust: Pearson   Au: Ball  Pg. No. x C/M/Y/K
Title: Child Health Nursing   Server: Short / Normal
S4carlisle Publishing Services
 It is easy to gather the data and analyze results, and only a few min-
first aid and handling life-threatening allergy and asthma events FIGURE 14–4 ■ A, The school is often the setting for screening tests of large groups
utes are needed. Ask the parent or child to list all foods eaten during
of students at risk for a problem. Screening tests are often organized so all children in a
the past 24Screens
hoursstudents
(Figurefor19–11
conditions that impair learning, such as poor vision and
■
■ ). It is usually helpful to ask for
n either very low or very high hearing, and refers them for further evaluation particular grade are assessed, as in this test to detect vision problems. State laws man-
a description of activities in the last day. Then start with the most
■ Promotes a healthy school environment by ensuring immunization compli- date grades for screening and selected children who must be screened for conditions
recent eventance, monitoring playground equipment safety,food
and move backwards, integrating intake
promoting into the
infection control, such as visual or hearing problems, and scoliosis screening in public schools. B, The
d circumference are in similar daily schedule. For example,
and implementing you might
programs begin
for bullying andby saying,
violence “You men-
prevention school nurse treats this child with a nebulizer to determine if the asthma episode can be
tioned you got up early
■ Educates to about
students comehealthy
to thelifestyles,
clinic today. What exercise,
good nutrition, did Samoraleathealth, controlled before calling the parent to come and pick up the child and seek care from the
small. at home before
smoking you left? Did
cessation, he have
sexually a snack
transmitted as youand
infections, traveled here
pregnancy or
prevention Features
primary care provider. The parent shouldThat Help Youof Use
be informed This Book
nebulizer Successfully
treatment provided in   xi
case the child’s asthma episode continues and additional treatment is needed.
have continued over time or if ■ Manages students with chronic conditions, administers medications, and
participates in the development of individualized health plans (IHPs) and
if there is a lack of body pro- individualized education plans (IEPs) for those with disabilities
■ Refers students’ families to healthcare providers and insurance programs
the child to a physician, nurse
anges from one channel to an-
Developing Cultural Competence
and connects students with needed services (e.g., for substance abuse
Legal and Ethical Considerations
d has usually been in the 25th Growthtreatment,
Grids behavioral and mental health, and reproductive health) Child Nutrition Reauthorization Act
ddenly is in the 90th percentile ■ Serves as a leader in the preparation of policies for school-wide emergencies,
The Child Nutrition Reauthorization Act of 2010, titled the Healthy, Hunger-Free
assessment must be performed The growth school
grids now in use
health were standardized
programs, mental healthusing a cross section
intervention, of theand
and student U.S.
faculty Kids Act of 2010, continues the federal school meal programs (breakfast, lunch,
population and areemergencies
health generally reflective of most children. However, children from
after-school snack, and summer food service) for low-income children and in-
some other countriesand
■ Identifies or cultures
reports may fall outside
clusters these that
of symptoms curves.
mayFor example,
indicate new
an epidemic creases access to nutritional foods. The program also has goals for nutrition edu-
immigrants or adoptees may be in lower percentiles, and catch up over several
Source: DataChildren
from American Academy of Pediatrics Council on countries
School Health. (2008). Role of the cation and physical activity in an effort to address childhood obesity. School nurses
months or years. of immigrants from developing tend to be
school nurse in providing may work with food service personnel in the nutrition programs for healthy eating
ent provide clues to nu- larger than their parents. Evenschool
when health services.
small, Pediatrics,
children should 121follow
(5), 1052–1056; Robert Wood
normal growth
and in creating a nutrition education program for students (Sherry, 2008). See
patterns.Johnson Foundation. (2010). Unlocking the potential of school nursing: Keeping children healthy,
For example, a child may remain at the 10th or 25th percentile for
be affected by dietary in- in school, and ready to learn. Retrieved from http://www.rwjf.org/files/research/cnf14.pdf Chapter 19 .
height, but continue to slowly grow and not fall to a lower percentile.

8
oms may suggest specific

Developing Cultural Competence boxes challenge you to explore Legal and Ethical Considerations boxes identify laws and ethical
differences among racial, ethnic, and social groups, and to plan nurs- issues pertinent to pediatric nursing topics.
ing care that addresses the issues of health disparity.

778 Unit VI | Chapter 25 | Alterations in Respiratory Function

Medications Used to Treat Asthma

QUICK-RELIEF MEDICATION ACTION/INDICATION NURSING MANAGEMENT
Short-Acting Beta2-Agonists Relaxes smooth muscle in airway leading to rapid ■ Use this rescue medication before inhaled steroid, wait 1–2 minutes between
(SABA) bronchodilation (within 5–10 minutes) and mucus puffs, wait 15 minutes to give inhaled steroid. Child should hold breath
Albuterol clearing 10 seconds after inspiring. Then rinse mouth and avoid swallowing
Drug of choice for acute therapy and for prevention medication. Use a spacer.
Levalbuterol
of exercise-induced bronchospasm ■ Differences in potency exist, but all products are comparable on a per puff
Pirbuterol: basis.
Metered dose inhaler (MDI) or
Medications Used to Treat nebulizer ■ Some dose-related side effects include tachycardia, nervousness, nausea and
vomiting, and headaches.
boxes list the actions, indica- ■ Regular use more than 2 days a week for symptom control indicates a loss of
tions, and important nursing control and need for additional therapy.
Corticosteroids Diminishes airway inflammation, secretions, and
implications for medications. obstruction, enhances bronchodilating effect of
■ Short-term therapy should continue until child achieves 80% peak expiratory
flow rate personal best or symptoms resolve.
Methylprednisolone
beta2-agonists ■ Give with food to reduce gastric irritation.
Prednisone
Used for acute asthma episodes that are not com- ■ Give oral dose in early morning to mimic normal peak corticosteroid blood level.
Prednisolone: pletely responsive to beta2-agonists; helps reduce
Oral rate of hospitalization
■ Assess for potential adverse effects of long-term therapy: decreased growth,
unstable blood sugar, and immunosuppression.
Anticholinergic Inhibits bronchoconstriction and decreases mucus ■ Do not use for primary emergency treatment because of delayed onset.
Ipratropium: production with an onset of action in 30–90 minutes ■ Rinse mouth afterward to get rid of bitter taste.
Metered dose inhaler (MDI) ■ Side effects include increased wheezing, cough, nervousness, dry mouth,
or nebulizer tachycardia, dizziness, headache, and palpitations.
■ Prevent medication contact with eyes.
DAILY CONTROL MEDICATIONS ACTION/INDICATION NURSING MANAGEMENT
Long-Acting Beta2-Agonists Relaxes smooth muscles in airway, used for noctur- ■ Do not use for acute asthma episode.
(LABA) nal symptoms and prevention of exercise-induced ■ Take pre-exercise dose 30–60 minutes before activity. Do not use additional
Salmeterol bronchospasm. dose before exercise if already using twice-daily doses which should be
Formoterol: These medications should not be used as single 12 hours apart.
Dry powder inhaler (DPI) therapy for asthma in children, but prescribed in ■ Caution against overdosage as side effects such as tachycardia, tremor,
434 Unit IV |with
combination Chapter 16 | Nursing Care
corticosteroids of theFood
(U.S. Child with
andaDrug
Chronic Condition
irritability, and insomnia will last 8–12 hours.
Administration, 2010).
■ Report failure to respond to usual dose as this may indicate a need for

Inhaled Corticosteroids (ICS)

Evidence-Based Practice
Anti-inflammatory, controls seasonal, allergic, and ■
stepped-up therapy. for Children with Special Healthcare Needs
Care Coordination
Administer with spacer or holding chamber.
Beclomethasone exercise-induced asthma Separate partscoordination
and cleanbyinhaler daily.
Evidence-Based Practice boxes further enhance PROBLEM
Children with
Effectively special healthcare
reduces mucosal needs require
edema
■
assistance from a variety of pro-
in airways
nurses as an integral aspect of each visit decreased the number
of visits to the primary care provider and to the emergency department (Antonelli,
Budesonide ■ Rinse mouth and gargle following treatment to remove drug from oropharynx
grams and services to maximize their potential. Fragmentation of care may result Stille, & Antonelli, 2008).
the approach to research. We describe a particu-
Flunisolide in the child’s needs being unmet. to reduce chanceAoflongitudinal
cough, thrush, and dysphonia.
study compared the use of pediatric practice-based care coor-
dination to an agency-based model of care coordination. Six pediatric practices
lar nursing problem and investigate Fluticasone
the evidence EVIDENCE ■ Monitor growth; however, recommended doses do not have long-term or
participated in the study. Three of the practices continued agency-based care co-
Data were analyzed from the 2005–2006 National Survey of Children with irreversible
Special effects on vertical
ordination (comparisongrowth
group)(Fong & Levin,
while three 2007
practices had).a nurse care coordinator
from several studies that explore solutions
Mometasoneto the Healthcare Needs to determine the association between receiving adequate care
coordination, family–provider relations, and outcomes in the child and Prevent
■ family. placed onsite,
Dataeye exposure
who received
through propertraining
MDI, and quality improvement
nebulizer, (intervention group).
or DPI administration.
Triamcinolone: Children and youth with special healthcare needs were identified. At baseline, 262
problem. We emphasize nursing research, pro-(MDI)
Metered dose inhaler
indicated that 68.2% of the families reported receiving some type■of Monitor assistancefor headache,
with care coordination. Of these, 59.2% indicated they received adequate help, and
gastrointestinal
of these families/children wereupset, dizziness,
interviewed. and infection.
At 18 months, 76 families/children in
the intervention group and 68 in the comparison group were interviewed. Results
vide an interpretation explaining the orimplications
nebulizer 40.8% indicated the assistance was inadequate. Adequate care coordination■ Use exactly
associated with family-centered care, satisfaction with care received, and a partner-
was asofprescribed.
the study indicated that families who received practice-based care coordination
reported a higher level of satisfaction with care coordination, were more likely to
of the studies, and then invite you toMethylxanthines
apply criti- Relaxes
ship withmuscle
healthcarebundles that Families
constrictwhoairways; Tabletcareshould not be crushed or chewed.
professionals. ■
reported receiving adequate report that their experience with care coordination had improved, reported fewer
Theophylline: dilates airway;
coordination wereprovides continuous
less likely to airway
have problems relax- referrals,
with specialty family finan-
■ Use for long-term barrierscontrol. Worksservices,
to healthcare best when a therapeutic
and were treated betterserum
by the level
staff in the office
cal thinking skills to further identify Oral
nursing care cial burden,
ation; and reduction
sustained release in work hours. These families
for prevention also had less out-of-pocket
of nocturnal
expenses, fewer visits to the emergency department per month, and fewer
symptoms
(10–20 (Wood et al., 2009).
missedmcg/L) is maintained; give same time each day.

approaches. days of school for the CSHCN than families who reported receiving ■
sistance with care coordination (Turchi, Berhane, Bethell, et al., 2009).
inadequate
Requires IMPLICATIONS
as- serum level monitoring and dose adjustment.
Practice-based care coordination in which the nurse works with families to fa-
A descriptive study of six pediatric primary care practices was■conductedLimit caffeine
to intake.coordination of services is effective and leads to greater satisfaction with
cilitate
evaluate the effectiveness of a care coordination measurement tool. ■ SideOther pur- care, reduced costs, and fewer barriers to healthcare services. The nurse assists
effects include tachycardia, dysrhythmias, restlessness, tremors, sei-
poses of the study were to describe care coordination activities that occurred families to identify needed programs and services and is in an excellent position
in a pediatric primary care setting, to assess the relationship of carezures, insomnia,
coordina- hypotension,
to serve as a liaison severe
between headaches,
these programsvomiting, andtodiarrhea.
and the family decrease the risk
tion activities in this setting to outcomes related to the use of resources, and to for fragmentation of care.
Mast-Cell Inhibitors Anti-inflammatory, inhibits early and late phase ■ Do not use at time of symptom development or acute exacerbation.
measure personnel costs related to care coordination activities. The study found
Cromolyn sodium asthma
that careresponse
coordination toactivities
allergens wereand exercise-induced
used by patients at all levels■ ofThe patient
acuity, in- mustCRITICAL THINKING APPLICATION
use up to 4 times a day to be effective.
bronchospasm;
cluding children and may be with
youth usedspecial
for unavoidable al- the care coordination
healthcare needs; Why is care coordination a vital aspect of care of CSHCN? What is an
Nedocromil: lergen
tool wasexposure.
■ Therapeutic response
used effectively in the pediatric primary care setting; care coordination example ofis seen in 2 weeks;
coordination maximum
of services benefitHow
for CSHCN? maydonot be seen
nurses play a
Metered dose inhaler (MDI) provided by nurses instead of physicians in this setting decreased costs; forand
4–6careweeks.vital role in care coordination for CSHCN?
or nebulizer May be used as a substitute for inhaled corticoste-
■ Adverse reactions include wheezing, bronchospasm, throat irritation,
roids in mild persistent asthma, but evidence of their
effectiveness for pediatric asthma is weak nasal congestion, and anaphylaxis. Immediately report these symptoms to
# 108438   Cust: Pearson   Au: from
Ball  Pg. a pediatric
No. healthcare provider
xi Asperen, 2009). to an adult healthcare provider
physician. in their decision to lead the careDESIGN SERVICES
coordination processOF
by helping the
C/M/Y/K
Title: Child Health Nursing   Server:
(Robinson & Van
(White & Hackett, 2009). (See Evidence-Based Practice: Care Coor-
dination for Children with Special Healthcare Needs.)
parents to become knowledgeable about the child’s condition and
Short /treatment
Normal regimen. Encourage thePublishing Services
parents to take
S4carlisle
an active role in the
 ease including insulin administration, exercise, nutrition, and self-esteem issues A descriptive comparative pilot study explored the concepts of self-efficacy
Children admitted to a hospital may be
associated withcared
a chronicfor in one
illness. orself-efficacy
How can more of and quality of life be maxi- and resilience in 81 adolescents ages 10 to 16 years who attended a diabetes
the following units: mized in adolescents with type 1 diabetes? camp. The Self-Efficacy for Diabetes Scale was used. Results showed that both
self-efficacy and resilience scores were moderately high in this population. Afri-
ng about the hospital. ■ General pediatric unit EVIDENCE can Americans scored significantly higher than Caucasians on both measures.
A randomized controlled trial measured how monitoring and discussing health-
■ Short-stay unit, outpatient unit, or ambulatory surgical unit Participants who lived in single-parent homes had poorer diabetic control, as in-
related quality of life (HRQoL) improved psychosocial well-being in adolescents dicated by a higher hemoglobin A1c, but had higher scores in resilience (Winsett,
■ Emergency department with type 1 diabetes. Ninety-one adolescents between the ages of 13 and 17
Stender, Gower, et al., 2010).
f any age for hospital- ■ Neonatal intensive care unit with type 1 diabetes participated in the study and were randomly assigned to
(NICU) or pediatric intensive care
ring a child for hospi- xii  Features
unit That
the HRQoL
Help You Use This Book
(PICU)
intervention group or the control group. During a 12-month period,
Successfully IMPLICATIONS
all participants had 3 scheduled visits for routine diabetes care at 3-month inter- Developmental tasks of adolescents focus on development of self-concept and
ng available to answer vals. The intervention group completed the Pediatric Quality of Life Inventory on a self-esteem. Adolescents with type 1 diabetes must also cope with the increas-
computer at each visit prior to being seen by the healthcare provider. The results ing responsibility for complex self-management, including insulin administration,
were discussed with the adolescent during the visit. Over the 12-month period, blood glucose testing, exercise, and nutrition. Self-esteem and self-concept
mean scores for psychosocial health, behavior, mental health, and family activities often become linked with the disease as peers react to the differences noted.
improved in the intervention group except for those adolescents with the high- Life satisfaction, perceived control, and worries associated with having diabetes
at emotional risk for Baccalaureate Essential II est hemoglobin A1c values. Adolescents in the intervention group demonstrated are important considerations when counseling the teenager and family about the
higher self-esteem at follow-up visits and were more satisfied with care than
Basic Organizational and Systems Leadership
those in the control group (de Wit, Delemarre-van de Waal, Bokma, et al., 2008).
management of diabetes. Additionally, it is important to know that adolescents
value parental involvement and care rather than perceiving it as a reason for
for Quality Care and Patient Safety A cross-sectional design was utilized to determine the impact of family sup-
port and environment on quality of life, adherence to treatment, and metabolic
conflict. Parental involvement and supervision is important in helping adolescents
ts that follow control in 157 adolescents ages 10 to 18 with type 1 diabetes. Four instru- NEW!
Baccalaureate Essentials
transition successfully boxesoffocus
to self-management on the
their disease. Peersnine essen-
are also
important to adolescents with diabetes. Continued involvement in school activi-
very
Quality improvement and safety is amentspriority for healthcare organizations. Nurses tials ofDia-nursing
were used in the study: a self-report questionnaire on adherence, education
ties and summer camps identified by avenues
provide excellent the American
for friendship Association
and promote a
at the bedside have a major influence beteson the Behavior
Family quality ofScale,
careFamily
provided and theScale, and Diabetes Quality
Environment positive quality of life.
of Life. Results of the study indicated that
safety of the patient; however, it is the responsibility of the organization’s lead- increased family of
support Colleges
predicted of Nursing.
ch as cystic fibrosis or ership to provide the staffing and aresources
better quality of lifesafe
so that in both
and males
qualityandcare
females,
can and higher family conflict CRITICAL THINKING APPLICATION
predicted a lower quality of life. Increased family support also predicted an What questions can be used to explore an adolescent’s perceptions of family
r hopelessness. be provided (Disch, Dreher, Davidson, et al., 2011 ). Healthcare providers must
increase in adherence in females. Additionally, the study found that the longer involvement, care, and control? How can you address quality of life issues in
advocate for best practices that focus on risks unique to children. Children in the
red for hospital admis- the teen had been diagnosed with diabetes, the less likely he or she was to be adolescents with diabetes? What questions can be asked to determine the ado-
healthcare setting are at risk for harm relatedtotoa misidentification,
adherent management plan and adverse effects
to have good metabolic control. Results lescent’s self-efficacy and resilience?
m to the environment, from high-alert medications, and healthcare-acquired or associated infection
ng truthful responses, (Steering Committee on Quality Improvement and Management & Committee on
Discuss the anticipated Hospital Care, 2011). Young children are especially vulnerable to injury because
in the child’s care. Give of their developmental immaturity,necessary
includingfor
thehome
inabilitymanagement, including
to recognize safety risks.insulin administration, anxiety associated with needles and insulin administration in public
blood glucose
It is essential that the hospital environment testing,
be free meal planning,
of hazards and the
that pose risks for recognition and treat- (Hanas, de Beaufort, Hoey, et al., 2011). Rotating the injection sites
and concerns. Refer to ment of both hypoglycemia and hyperglycemia. Partner with the is important to decrease the chances of lipoatrophy, loss of sub-
children.
onal support is needed. child and family to identify barriers to management. cutaneous tissue, or hypertrophy, in which collagen is replaced by
Explain the goals of insulin therapy. Teach the parents and child fat cells (Figure 32–10 ■). The absorption rate of insulin varies by
(if age appropriate) how to draw up and administer insulin or how the site used. Insulin is usually absorbed most rapidly from the ab-
to use an insulin pen. Insulin pens might be accepted more read- domen; however, insulin absorption is increased in the extremities
ily than the traditional syringe and vial method; they are easier to with exercise. An understanding of the different types of insulin and
transport, they provide more accurate dosing, and they decrease their actions is essential.

BOX 32–6 Research: Communication Between Adolescents with Type 1 Diabetes and Their Parents

Transcripts of interactions between adolescents ages 11 to 15 years with type 1 not feel their parents recognized their successes in their diabetes management.
RESEARCH boxes diabetes and their parents were analyzed. Participation in the study required that
the adolescent had been diagnosed with type 1 diabetes for at least a year and
Discounting was noted in statements by parents that showed a lack of respect
for the adolescents’ opinions and failure to include the adolescents in decisions
focus on relevant have no other chronic illness, psychologic problems, or learning disability. Tran- related to their care. These statements further added to the child’s frustration. The
scripts were based on a 10-minute interaction between the adolescent and his theme of normalizing was noted in only a few families and included statements
research studies to or her parents in which a diabetes management task, identified by the teen as a indicating that the family was attempting to view diabetes as a normal aspect of the
give students addi- source of disagreement, was discussed. adolescent’s life. The other themes of fear, frustration, trust, and discounting were
Five themes were identified from the transcripts: fear, frustration, discounting, cited as barriers to achieving the goal of normalcy.
tional information normalizing, and trusting. Parents demonstrated frustration, fear, and difficulty in The study concluded that effective communication between parents and adoles-
and background trusting the child with the daily management of diabetes. Parents were also fearful cents with type 1 diabetes is essential and that nurses should work with families to fa-
of long-term complications. Adolescents demonstrated frustration because they did cilitate communication related to diabetes management (Ivey, Wright, & Dashiff, 2009).
information.

284 Unit III | Chapter 10 | Health Promotion and Maintenance of the Infant

Partnering with Families

Helping the Infant Sleep

Helping the Infant Sleep

Helping an infant to self-regulate and be able to sleep for longer periods is ■ Provide a consistent transitional object, such as a favorite blanket each
often a stressful challenge for families. Parents need to have substantial sleep night.
Partnering with Families periods themselves to be refreshed and able to deal with daily life. When up ■ Put the baby to bed while still awake but drowsy rather than after falling
several times during the night with a baby, parents may become irritable asleep, so the infant learns self-soothing skills.
boxes help you to apply the and fatigued. Question the family about the baby’s sleep routine. The infant ■ Do not try to awaken the baby in non-rapid eye movement (NREM or quiet)
concepts of family-centered passes into light sleep several times at night and may awaken; self-regulation sleep.
Video

will assist in helping the infant get back to sleep. Suggestions helpful for the For the baby who has trouble going to sleep, remain in the room for a few
nursing care by providing
■

family are as follows: minutes but do not establish eye contact; place a hand on the abdomen or
approaches and teaching ■ Place the baby to sleep in a quiet and darkened room, a “sleep friendly” chest or gently hold flailing arms and legs.
environment.
in a format directly appli- ■ Establish a consistent sleep routine and time; the routine may involve some Source: Data from National Sleep Foundation. (2011). Sleep, infants, and parents. Retrieved from
cable when you work with cuddling and rocking time but should not be vigorous, stimulating play. http://www.sleepfoundation.org/articles/ask-the-expert/sleep-infants-and-parents

families.

and psychologic health are closely related to these factors. For many cues related to hunger or discomfort, the nurse plans interventions
parents, membership in a faith-based congregation provides spiritual to help prevent further problems. Teaching, demonstrations, and ac-
sustenance and an important sense of belonging. This group may also knowledging parent success are all health maintenance actions. An
provide food, clothing, and care for the new infant. Sometimes par- expected outcome for these activities is the reestablishment of ex-
ents who have not attended institutionalized services will choose to pected growth and development, and age-appropriate interactions of
do so to offer a significant spiritual home for their new child. Services the infant with others.
such as christening and blessing an infant welcome the child formally
into the family and provide meaning to parents and extended family
members. Having a baby often helps parents to feel that they have an RELATIONSHIPS
important meaning and purpose in life, regardless of a faith-based Family
membership. An atmosphere where the infant is valued and offers The infant’s social interactions, both within and outside the family,
meaning to the lives of the adults present is a positive atmosphere for display enormous growth in the first year. The family is the primary
emotional growth. Assess the family’s meaningful activities, practices, unit where the infant learns DESIGN
to interact with other
SERVICES OF people. Therefore,
# 108438   Cust: Pearson
and   Au: Ball  Pg. No. xiirituals. Ask about needs or desires for C/M/Y/K
Title: Child Health Nursing
engagement
  Server:
referrals
in faith-based
in the community such as to an organized religious group orShort
nurses should examine family dynamics during health supervision
/ Normal
visits. Strengths and needs of the family are
Publishing identified during psycho-
Services
S4carlisle
 American Indian and Alaska Native children have a very high rate of otitis media, the Clinical Manifestations table below.
perhaps due to culturally related bony structure of the ear, nose, and mouth. Black Infants and young children have characteristic behaviors that
children have a higher incidence of the condition than White children. However,
indicate otitis media may be present. Pulling at the ear is a sign
White children are more likely to have tympanostomy tube insertion for treatment
of otitis media. The major risk factor for frequent otitis media is low socioeconomic of ear pain (Figure 24–9 ■ ). Diarrhea, vomiting, and fever are
status, regardless of ethnicity ( Smith & Boss, 2010). Be alert for risk factors, plan typical of otitis media. Irritability and “acting out” may be signs
prevention programs, and ensure prompt care and teaching about treatments for of a related hearing impairment. The child with otitis media of-
families of children affected. What prevention measures would you emphasize for ten has night awakenings with crying due to increased pressure
families? See the nursing management section on otitis media for suggestions of
when prone or supine. See the Clinical Manifestations forUse This Book Successfully  xiii
tableYou
Features That Help
preventive approaches.
further detail.

Clinical Manifestations Acute Otitis Media and Otitis Media with Effusion
ETIOLOGY CLINICAL MANIFESTATIONS CLINICAL THERAPY
Acute otitis media—bacterial infec- Behavioral—ear pain, pulling at ear, rapid onset, irritability, mal- Treat ear pain with anesthetic eardrops, herbal pain
tion in the middle ear from pathogens aise, poor feeding. products instilled into the auditory canal, or systemic
transferred from the nasopharynx; most Examination—bulging tympanic membrane, air or fluid bubbles acetaminophen or ibuprofen. Clinical Manifes-
common infectious agents are S. pneu- present behind tympanic membrane; immobile or poorly mobile Verify that the tympanic membrane is intact before
moniae, H. influenzae, M. catarrhalis. tympanic membrane, red (or other color change such as white, inserting eardrops. tations boxes link
gray, or yellow as long as bulging is present) tympanic membrane, Observe the child’s condition for 48–72 hours and if etiology, clinical
reduced visibility of tympanic membrane landmarks with displaced not improved, treat with course of antibiotics.
light reflex. manifestations,
Otitis media with effusion— Behavioral—difficulty hearing or responding as expected to Provide symptomatic treatment of pain. and clinical ther-
collection of fluid in the middle ear behind sounds. Carefully assess hearing acuity over several months. apy for specific
the tympanic membrane which is not Examination—signs of acute inflammation are NOT present; tym- Assess speech if loss of hearing acuity occurs.
infected with bacteria. panic membrane is retracted or neutral; immobile or partly mobile Assess development. conditions.
tympanic membrane; yellow or gray tympanic membrane; opaque
or thickened tympanic membrane with visibility of landmarks
reduced.

Solid Tumors 967

Nursing Care Plans are present in every chapter dealing with health
conditions. They illustrate the conceptual approach that nurses need Health Promotion & Maintenance Overview The Child Receiving Cancer Treatment

in caring for children, including assessment, NANDA nursing diag- Cancer treatment often extends for several years, so the child the child to treatments, and having disturbed sleep at night.
needs to continue health promotion and health mainte- Assess both the child’s sleep patterns and the family’s
noses, goals, plans, interventions (with NIC), and evaluation (with nance visits. experiences. Encourage plans for respite care to en-
able rest periods. Provide cots, rocking chairs, and
GROWTH AND DEVELOPMENT SURVEILLANCE
NOC). ■ The child is assessed for height, weight, and
body mass index. This provides information
other comfortable settings for the child and fam-
ily members during treatments.
■ Both the child and parents may not expect or
about growth patterns which may be altered
understand the profound fatigue that occurs dur-
by cancer treatment. If indicated, 24-hour diet
ing cancer treatment. They can be helped to plan
recalls and other nutritional assessments are
for providing quiet times, eliminating electronic media
performed.
at sleep time, and replenishing energy through naps, mas-
■ Teaching is provided about age-appropriate foods. Since ap-
sage, relaxing baths, and spending time with family.
petite may be impaired during periods of treatment, the child may be lack-
432 Unit IV | Chapter 16 | Nursing Care of the Child with a Chronic Condition ing fruits, vegetables, or other foods, as well as the nutrients they include. PHYSICAL ACTIVITY
Encourage parents to be sure the child has a well-balanced diet during ■ Since the child has periods of fatigue, patterns of physical activity may
periods of remission. decrease. Emphasize the importance of integrating physical activity

Nursing Care Plan The Child with a Chronic Condition ■ Perform developmental screening of young children. Provide suggestions
for parents about the stimulation that is appropriate for the child’s age.
when the child feels well, since it is needed for learning gross motor
skills, facilitating blood flow, improving mental status, and setting pat-
Include quiet activities that can be used when the child is fatigued or terns for the future.
INTERVENTION RATIONALE EXPECTED OUTCOME receiving therapy. These might include reading books, listening to music,
DISEASE AND INJURY PREVENTION STRATEGIES
1. Nursing Diagnosis: Knowledge, Deficient (Child) related to learning self-care skills
and working on a computer. Have the parent plan for these activities on ■ The child with cancer has the same safety hazards as other children of
days that the child goes for chemotherapy or other treatment.
NIC Priority Intervention—Individual NOC Suggested Outcome—Knowledge: Extent of understanding the same age, and such topics as car safety seats, fire prevention, water
■ Ask about the school-age child’s progress in school. Performance may be
Teaching: Planning, implementing, and conveyed about treatment regimen safety, and violence prevention should be addressed.
altered due to neurologic effects of treatment as well as missing school.
evaluating a teaching program designed to ■ An important hazard for children with cancer is infection due to decreased
Plan for the family to partner with the school personnel for provision of
address a patient’s particular need immune response and neutropenic episodes. Keep records of immuniza-
tutors, computer programs, or other needed assistance.
GOAL: The child will acquire self-care skills for lifetime management.
tion status. Follow the recommendations of the CDC and AAP for other
■ Encourage continued social contact with peers when blood counts are
immunizations. Teach the hazards of exposure to large groups and those
Assess the child’s developmental level Learning goals for the child must match The child demonstrates the proper technique in the self-care adequate to prevent infection.
■ ■ ■ with infections when the child’s immune system is compromised and neu-
and select an educational approach and knowledge and skill expectations appropriate skill and is able to assume responsibility for that skill with su- PHYSICAL ASSESSMENT AND SCREENING tropenia is present. Teach care of central lines and other potential sources
self-care activities to match. for the developmental stage. pervision by the parent. Responsibility for self-care increases as
new skills are learned.
■ Careful physical assessments are performed to identify any abnormali- of infection. Have families report signs of infection and exposure to known
■ Review with the child all steps involved ■ The child may have watched the routine used by ties that may result from cancer or its treatment. Be alert for signs of illnesses promptly.
in the self-care skill and how to perform parents many times, and asking the child to list
anemia, neutropenia, and thrombocytopenia; refer for treatment and
the skill. each step helps the nurse identify extra training MENTAL AND SPIRITUAL HEALTH
needed. suggest preventive measures such as infection control for neutropenia.
■ Use demonstration/return demonstration ■ Evaluate the child and family for signs of anxiety and depression. Ask
Cardiopulmonary and neuromuscular assessments are particularly im-
until the child is comfortable with ■ Evaluation permits positive reinforcement and how they are managing the cancer treatment and what poses the great-
procedures. guidance for modification of techniques. portant. Vision and hearing should be assessed prior to treatment and
est challenges. Refer to other families with similar circumstances for
periodically throughout. Include measurements of fine and gross motor
■ Help parents develop a planned sequence ■ Parents need guidance to identify appropriate support.
of self-care skills to teach the child. self-care skills that the child is developmentally activity. ■ Ensure that the child has contact with friends through childcare or school,
■ Discuss a plan for increased responsibility ready to learn. ELIMINATION or via phone, letters, and computer.
for self-care with the child and parents. ■ Parents often need encouragement to transition ■ Toddlers may have an interruption in toilet training during periods when ■ Find out the impact of the child’s cancer on the parents’ jobs. Ask how the
responsibility to the child, becoming a supervisor they do not feel well. Help parents to understand this regression, and en- siblings have been coping, what changes there are in school performance,
rather than the person controlling care.
courage them to start again when the child is feeling better. and whether teachers and others are aware of the stress the sibling may
2. Nursing Diagnosis: Family Processes, Interrupted related to management of a chronic disease ■ Some medications cause diarrhea or constipation, so evaluate bowel be experiencing.
NIC Priority Intervention—Normalization NOC Suggested Outcome—Family Health Status: Overall health
patterns and provide guidance as needed. Skin care instruction may be
TRANSITIONAL CARE
Promotion: Assisting parents and other fam- status and social competence of family unit needed if the child has diarrhea and is relatively immobile. Increasing flu- ■ As the child’s treatment ends, instruct them about needed periodic
ily members of children with chronic illnesses ids and fiber foods may be needed for constipation.
follow-up with the oncologist. Continue to perform neurologic examina-
or disabilities in providing normal life experi- ■ Evaluate urinary output since many medications have effects on kidney
ences for their children and families
tions and ascertain school performance. Be alert for signs of secondary
function. Encourage adequate fluids for age to ensure elimination of
tumors.
GOAL: The child and family will manage the required treatments, monitoring, and medication regimen for the child’s condition while maintaining family routines medications. ■ Ask about worries regarding the future. As teens grow older, have them
and functioning. SLEEP AND FATIGUE take over more responsibility for informing care providers of their cancer
■ Assess the child’s and family’s lifestyle and ■ Fitting the child’s care to the child’s and family’s ■ The child and family maintain important family routines and ■ Children undergoing treatment often have disturbed sleep patterns. Par- history and assist them to transition to adult healthcare providers.
attempt to fit the child’s care needs into lifestyle promotes adherence to the regimen and successfully manage the child’s condition. ents of young children may become exhausted working all day, getting
those schedules. healthier family processes.
■ Discuss the family’s routines for special ■ It is important for the child to participate in special
occasions and vacations and any activities events with the family and peers to promote
important to the child. Identify ways to psychologic development.
modify the child’s management for these
occasions and activities.
3. Nursing Diagnosis: Coping, Readiness for Enhanced related to self-care management of a chronic condition
NIC Priority Intervention—Resiliency NOC Suggested Outcome—Health-Seeking Behavior:
Promotion: Assisting individuals, families, and Personal actions to manage stressors that tax an individual’s
communities in development, use, and strength- resources.
ening of protective factors to be used in coping
with environmental and societal stressors Health Promotion & Maintenance Overviews summarize the
needs of children with specific chronic conditions, such as asthma
GOAL: The child will develop a support system network.
■ Talk with the child about how to tell ■ These important persons can assist the child in an ■ The child identifies the friends, teachers, and other important
friends, teachers, and other important emergency if they have enough information to persons informed about the chronic condition who can provide

■
persons about the chronic condition.
Discuss ways to explain the condition to ■
assess the problem.
Having an opportunity to plan and role-play the
support when needed. or diabetes. These overviews teach you to look at the child who has
important persons and how to answer
questions.
conversation will reduce the child’s anxiety about
condition disclosure. a chronic illness like any other child, with health maintenance needs
Role-play ways to talk about the condition Sharing information about the condition helps oth-
for prevention, education, and basic care.
■ ■
with friends and teachers. ers understand changes in lifestyle needed by the
■ Encourage the child to attend peer support child.
groups or camps specific to the child’s ■ Learning and support networks developed at camp
condition. can promote development of problem-solving skills
that increase coping abilities.

DESIGN SERVICES OF
# 108438   Cust: Pearson   Au: Ball  Pg. No. xiii C/M/Y/K
Title: Child Health Nursing   Server: Short / Normal
S4carlisle Publishing Services
 sema (air leakage in the tissue). The child with a closed pneumo- drainage system.
thorax may have breath sounds decreased or absent on the injured
side, and the child may be in respiratory distress. A tension pneu- Nursing Management
mothorax with a mediastinal shift may be seen as the lung col- Nursing care focuses on airway management and maintaining
lapses. Signs of tension pneumothorax include increasing tracheal lung inflation. The child usually arrives on the nursing unit with
deviation, respiratory distress, decreased or absent breath sounds a chest tube and drainage system in place. Continued close obser-
on one side, decreased chest wall movement, and paradoxical vation for respiratory distress is essential. Carefully monitor vital
breathing. signs and respiratory function. When the chest tube is removed,
the site is covered with an occlusive dressing and the child’s re-
Collaborative Care spiratory status is carefully monitored for signs of respiratory
Immediate treatment for an open pneumothorax is covering the distress.

xiv  End-of-Chapter Review
wound with an airtight seal; however, a gloved hand can be used Complications of chest tube placement include hemothorax (if
until a bandage is prepared. This action prevents more air from en- the thoracostomy and chest tube are improperly placed), lung tissue
tering the chest. For a closed pneumothorax, a needle or tube tho- injury, and scarring from poor tube placement (especially if the tube
racostomy is performed rapidly to relieve the pressure in the chest. is placed too near the breast in girls). If a hemothorax occurs, monitor
This is usually performed before a chest radiograph that often re- blood draining into the chest tube system and the child’s physiologic

End-of-Chapter Review veals air in the chest. A chest tube is inserted and a closed drain- status for hypovolemic shock. See Chapter 26 for the management

8
age system is attached to help remove the air and reinflate the lung of a child in hypovolemic shock.

Chapter Highlights summarize key points of

the chapter.
Chapter Highlights
Clinical Reasoning in Action refers back to
the chapter-opening scenario and asks criti- Respiratory conditions are the most common cause of hospitalization in chil-
■

dren between 1 and 9 years of age and a leading cause in children between
■ Sudden infant death syndrome (SIDS) is a leading cause of death in infants.

Onset of the fatal episode occurs during sleep and remains unexplained after

cal thinking questions to help students apply 10 and 19 years of age.

■ The child’s airway is shorter and narrower than an adult’s. These differences
a thorough investigation, including an autopsy, a review of the circumstances
of death, and the clinical history.

knowledge to real patient care. create a greater potential for obstruction. The lungs have no muscles of their
own, so respiration is powered by the diaphragm and intercostal muscles.
■ Laryngotracheobronchitis (LTB) is a viral croup syndrome with signs of an

upper respiratory illness, ®

hoarseness,
NCLEX-RN 799 inspiratory stridor, and a
Reviewtachypnea,
■ Foreign body aspiration is most often caused by small objects that make their seal-like barking cough. Fever may or may not be present.
■ way into the child’s mouth, such as
Children under 2 years have an increased risk of developing tuberculosis, and foods, small toy parts,
■ or household objects Epiglottitis is caused by bacterial
In cystic fibrosis, defective chloride-ion transport across the exocrine and epi-
■ invasion of the soft tissue of the larynx,
NCLEX-RN® Review prepares students for like beads,
if untreated have a greater chance safety pins,tocoins,
of progressing activeorTBbuttons. The increasing mobility
and spreading andwalls
thelial cell tendencyresults in ancausing
abnormal inflammation
accumulation andof edema
viscous,ofdehydrated
the epiglottis and surrounding tissues
to put small objects
beyond the lungs (e.g., meningitis and disseminated TB). in the mouth makes this a major health problem for infants that can result in life-threatening
mucus that affects the respiratory, gastrointestinal, and reproductive systems. airway obstruction. Classic signs of epi-
course exams on chapter content and gives ex- ■ Asthma is one of the most commonand toddlers.chronic respiratory disorders in child- ■ Signs of smoke inhalation injury glottitis include
in children dysphonia,
include burns ofdysphagia,
the face and drooling,
neck, and distressed respiratory
Signs of impending respiratory
hood. The respiratory difficulties of an acute asthma episode result from
■ failure in infants and children include worsen- effort.
singed nasal hairs, soot around the mouth or nose, and hoarseness with stridor
posure to all formats of NCLEX®-style questions. inflammation that causes theingnormalrespiratory distress,
protective irritability, lethargy,
mechanisms mottled color or
of the lungs or voice
cyanosis, diapho-
change. ■ Neonatal respiratory distress syndrome is the most common cause of respi-

(mucous formation, mucosalresis, and increased

swelling, and airway respiratory
muscle effort such astodyspnea
contraction) ■ (difficulty
Pulmonarybreathing),
contusion occursratory distress in with
in association pretermbluntinfants,
chest and the incidence
trauma. The increases to 60% of all
tachypnea
overreact in response to a stimulus and (increased
cause airway respiratory rate), nasal flaring, grunting,
obstruction. energy andfrom
retractions.
the injury oftenpreterm
bruises infants
the lung withtissue
a gestational age of less
in the absence than 28 weeks.
of rib

Detailed References provide the basis for ■ Apnea is cessation of respiration

Bronchopulmonary dysplasia (BPD) usually develops in neonates with a birth
■

weight of 1000 g or less and respiration

a gestationalassociated
lasting
withofcyanosis,
age at birth
longer
less thanmarked
28 weeks
than 20 seconds, or any pause in A higher risk for meconium
fractures. Although the child may appear initially asymptomatic, respiratory
pallor, hypotonia,
distressor bradycardia.
■

often develops withinvanced

aspiration syndrome occurs
gestational age, greater than 40 weeks. The meconium causes a
a few hours.
in neonates of ad-

­evidence-based nursing care and support the Three types of apnea are noted in
who are treated with oxygen and positive-pressure ventilation for respiratory
■

failure or respiratory distress complete

syndrome.cessation
Treatmentof leads
breathing;
neonates:
obstructiveand
to inflammation
central apnea,
■ in which there is chemical inflammation of the
A pneumothorax may become life threatening if internal pressure from a closed
apnea, in which there is an
pneumothorax is not airway
ab- vented. Air obstruction,
leaking and persistent
into the chest
airway
cavity during
that
pulmonary
can lead to pulmonary
hypertension.
inspiration
edema, small

currency and accuracy of the textbook. sence of nasal airflow when respiratory
damage to the bronchioles, resulting in fibrosis, edema of the bronchioles,
and smooth muscle hypertrophy.
efforts are
which a central respiratory pause either precedes or follows
present; and mixed apnea, in Respiratory syncytial virus (RSV)
cannot escape during expiration, increasing compression. Venous blood return
to airway
the heartobstruction.
■

is impaired as theamediastinum
lower respiratoryshiftstract
towardillness
is the most
that occurslung.
the unaffected
common cause of bronchiolitis,
when an infecting agent (virus or
■ Obstructive sleep apnea syndrome is a disorder of breathing during sleep that bacterium) causes inflammation and obstruction of the bronchioles.
in children is commonly caused by enlarged tonsils and adenoids. Children ■ Symptoms of pneumonia in infants and children include elevated tempera-

Clinical Reasoning in Action have symptoms of sleep deprivation such as daytime sleepiness, poor atten-
tion, increased activity, aggression or acting-out behavior, and poor school
ture, crackles, wheezes, cough, dyspnea, tachypnea, restlessness, and de-
creased breath sounds if consolidation occurs.
performance.
INTRODUCTION DISCUSSION
Return to the scenario at the beginning of the chapter. Hannah and her mother 1. Describe the signs and symptoms that would indicate that Hannah’s asthma
are learning more about asthma management during a health center visit with is progressing in severity. Develop an asthma action plan that provides guid-
the nurse practitioner. She has no asthma symptoms during today’s visit, and ance for daily management as well as managing asthma symptoms to avoid
has taken all medications prescribed since her recent hospitalization. an emergency department visit.
DESCRIPTION 2. Identify information about the family’s lifestyle and home environment that
Prior to the acute asthma episode that occurred at school, Hannah had used could be potential triggers for Hannah’s asthma.
only short-acting beta2-agonists for symptoms, about once a week. During her 3. Develop an asthma education plan that corresponds to Hannah’s stage
hospitalization she needed systemic corticosteroids and was sent home with oral of development, and identify appropriate self-care responsibilities to begin
corticosteroids that were tapered and discontinued 3 days ago. Because of the teaching her.
severity of her asthma episode, Hannah’s daily treatment will be changed from 4. Describe the essential elements of an individualized health plan for Hannah
step 1 for intermittent asthma to step 2 for mild persistent asthma. and the actions that must be taken to have one developed in collaboration
with the school nurse.

NCLEX-RN® Review
800 Unit VI | Chapter 25 | Alterations in Respiratory Function
1. The nurse is caring for an infant who was admitted to the hospital for the 3. An 8-year-old child is diagnosed with viral pneumonia and sent home from the
treatment of RSV bronchiolitis. What assessment item would the nurse clinic without an antibiotic prescription. The symptoms worsen, and the child
References report immediately to the healthcare provider?
1. Increased temperature
returns to the clinic a week later with signs of a higher fever, listlessness, and a
harsh, productive cough. The child’s mother states, “I knew a prescription for an-
2. Increased heart rate tibiotics was needed.” Which indicates the nurse’s most appropriate response?
Adams, S. M., Good, M. W., & Defranco, G. M. (2009). Behm, I., Kabir, Z., Connolly, G. N., & Alpert, H. R. Coleman-Phox, K., Odouli, R., & De-Jun, L. (2008). Use
Sudden infant death syndrome. American Family (2012). Increasing prevalence of smoke-free homes and of a fan during sleep and risk of3.sudden
Decreased pulsesyn-
infant death oximeter saturations 1. “It is better to wait to make sure so we don’t use antibiotics unnecessarily. This
Physician, 79(10), 870–874. decreasing rates of sudden infant death syndrome in the drome. Archives of Pediatrics 4. and
Decreased bowel
Adolescent sounds
Medi- approach also saves healthcare dollars.”
Ajao, T. I., Oden, R. P., Joyner, B. L., & Moon, R. Y. (2011). United States: An ecological association study. Tobacco cine, 162(10), 963–968.
Control, 21, 6–11. 2. The neonatal nurse is giving discharge instructions to parents of an infant 2. “Sometimes we just do not know. I’m glad you came back in.”
Decisions of black parents about infant bedding and Cruz, A. T., & Starke, J. R. (2010). Pediatric tuberculosis.
sleep surfaces: A qualitative study. Pediatrics, 128(3), Bonkowsky, J. L., & Tieder, J. S. (2009). A pragmatic ap- diagnosed with bronchopulmonary dysplasia (BPD). Teaching was ineffec-
Pediatrics in Review, 31(1), 13–25.
3. “You do not want to expose your child to medication unnecessarily. Now it is
proach to ALTEs. Contemporary Pediatrics, 26(11), tive if which statement necessary, because it is bacterial pneumonia.”
494–502. Cuff, S., & Loud, K. (2008). Exercise-induced broncho- is made by one of the parents?
54–63. spasm. Contemporary Pediatrics, 4. “Antibiotics are not effective for viral pneumonia. Bacteria can grow later in the
Akinbami, L. J., Moorman, J. E., & Liu, X. (2011, January 1. “I25can
(9),expect
88–95.my baby to require diuretic therapy.”
12). Asthma prevalence, health care use, and mortality: Brashers, V. L. (2010a). Alterations in pulmonary func- Cystic Fibrosis Foundation.2.(2011a). About my
“I can expect cystic
baby to be on oxygen therapy for the rest of his life.” duration of the illness, making antibiotics necessary later.”
United States, 2005–2009. National Health Statistics tion. In K. L. McCance, S. E. Huether, V. L. Brashers, & fibrosis: What you need to3. know . Retrieved
Reports, 32, 1–16. N. S. Rote, Pathophysiology: The biologic basis for dis- “I can expect myfrom
baby to receive respiratory treatments at least once daily.” 4. The nurse is caring for a pediatric patient who may be experiencing ob-
http://www.cff.org/AboutCF/
Allergy and Asthma Network. (2010). Medications at ease in adults and children (6th ed., pp. 1266–1309). 4. “I can expect to come to the office monthly during winter months for at least structive sleep apnea syndrome. What questions are appropriate to include
St. Louis, MO: Mosby Elsevier. Cystic Fibrosis Foundation. (2011b). About cystic fibro-
school. Retrieved from http://aanma.org/advocacy/meds- 1 year.” from http://
sis: Frequently asked questions. Retrieved in the history assessment for this child? (Select all that apply)
at-school/ Brashers, V. L. (2010b). Structure and function of the www.cff. org/AboutCF/Faqs/
pulmonary system. In K. L. McCance, S. E. Huether, 1. “Does your child sleep on his/her back?”
Al-Saif, S., Alvard, R., Manfreda, J., Kwatkowsky, K., Cystic Fibrosis Foundation. (2011c). Screening for
Cates, D., Qurashi, M., & Rigato, H. (2008). A ran- V. L. Brashers, & N. R. Rote, Pathophysiology: The bio- 2. “Does your child complain of evening headaches?”
logic basis for disease in adults and children (6th ed., cystic fibrosis. Retrieved from http://www.cff.org/
domized controlled trial of theophylline versus CO2 AboutCF/Testing/NewbornScreening/ScreeningforCF/
3. “Does your child have any signs of hyperactivity?”
inhalation for treating apnea of prematurity. Journal of pp. 1242–1265). St. Louis, MO: Mosby Elsevier.
4. “Does your child have difficulty with schoolwork?”
Pediatrics, 153(4), 513–518. Busse, W. W., Morgan, W. J., Gergen, P. J., Mitchell, H. E., Cystic Fibrosis Foundation. (2011d). Airway clear-
ance techniques. Retrieved fromhttp://www.cff.org/ 5. “Does your child wet the bed?”
Alverson, B., & Ralston, S. L. (2011). Management of Gern, J. E., Liu, A. H., . . . Sorkness, C. A. (2011). Ran-
treatments/Therapies/Respiratory/AirwayClearance/
bronchiolitis: Focus on hypertonic saline. Contemporary domized trial of omalizumab (Anti-IgE) for asthma in See Appendix I for answers.
8

Pediatrics, 28(2), 30–38. inner-city children. New England Journal of Medicine, D’Agustino, J. (2010). Pediatric airway nightmares.
364(11), 1005–1015. Emergency Medical Clinics of North America, 28,
American Academy of Allergy, Asthma, and Immunol- 119–126.
ogy (AAAAI). (2013). What is a peak flow meter? Re- Callahan, K. A., Panter, T. M., Hall, T. M., & Slemmons,
trieved from http://www.aaaai.org/ M. (2010). Peak flow monitoring in pediatric asthma Davis, P. G., Schmidt, B., Roberts, R. S., Doyle, L. W., Asz-
management: A clinical practice column submission. talos, E., Haslam, R., . . . Tin, W. (2010). Caffeine for ap-
American Academy of Pediatrics (AAP). (2012). Red Journal of Pediatric Nursing, 25, 12–17. nea of prematurity trial: Benefits may vary in subgroups.
book: 2012 Report of the Committee on Infectious Journal of Pediatrics, 156(3), 382–387.
Diseases (29th ed.). Elk Grove Village, IL: Author. Camargo, C. A., Rachelefsky, G., & Schatz, M. (2009).
Managing asthma exacerbations in the emergency de- Dukhovny, D., Lorch, S. A., Schmidt, B., Doyle, L. W.,
American Academy of Pediatrics (AAP) Committee on partment: Summary of the National Asthma Education Kok, J. H., Roberts, R. S., . . . Zupancic, J. A. F. (2011).
Infectious Disease. (2009). Policy statement—Modified and Prevention Program Expert Panel Report 3: Guide- Economic evaluation of caffeine for apnea of prematu-
recommendations for use of palivizumab for prevention lines for the management of asthma exacerbations. Jour- rity. Pediatrics, 127(1), e146–e155.
of respiratory syncytial virus infections. nal of Allergy and Clinical Immunology, 124, S5–S14. Duncan, J. R., Paterson, D. S., Hoffman, J. M., Mokler,
Amirav, I. (2010). To inhale or not to inhale: Is that the Carbajal, R., Biran, V., Lenclen, R., Epaud, R., Cimerman, D. J., Borenstein, N. S., Belliveau, R. A., . . . Kinney, H. C.
question? A simple method of DPI instruction. Journal P., Thibault, P., . . . Fauroux, B. (2008). EMLA cream and (2010). Brainstem serotonergic deficiency in sudden in-
of Pediatrics, 156(2), 339–339e1. nitrous oxide to alleviate pain induced by palivizumab fant death syndrome.Journal of the American Medical
Antoon, A. Y., & Donovan, M. K. (2007). Burn injuries. (Synagis) intramuscular injections in infants and young Association, 303(5), 430–437.
In R. M. Kliegman, R. E. Behrman, H. B. Jenson, & children. Pediatrics, 121(6), e1591–e1598. Durbin, W. J., & Stille, C. (2008). Pneumonia. Pediatrics
B. F. Stanton, Nelson textbook of pediatrics (18th ed., Carrier, C. T. (2009). Back to sleep: A culture change to in Review, 29(5), 147–158.
pp. 450–458). Philadelphia, PA: Elsevier Saunders. improve practice. Newborn & Infant Nursing Reviews, Everard, M. L. (2006). Aerosol delivery to children. Pedi-
Askin, D. F., & Diehl-Jones, W. (2009). Pathogenesis 9(3), 163–168. atric Annals, 35(9), 630–636.
and prevention of chronic lung disease in the neonate. Centers for Disease Control and Prevention (CDC).
Critical Care Nursing Clinics of North America, 21, Fakhoury, K. F., Sellers, C., Smith, E. O., Rama, J. A., &
(2008). Initiating change: Creating an asthma- Fan, L. L. (2010). Serial measurements of lung function
11–25. friendly school. Retrieved from http://www.cdc.gov/ in a cohort of young children with bronchopulmonary
Asthma Initiative of Michigan for Healthy Lungs. HealthyYouth/asthma/creatingafs/index.htm dysplasia. Pediatrics, 125(6), e1441–e1447.
(2011). How to use a metered-dose inhaler the right Centers for Disease Control and Prevention (CDC).
way. Retrieved from http://www.getasthmahelp.org/ Flume, P. A., O’Sullivan, B. P., Robinson, K. A., Goss,
(2011a). Trends in tuberculosis—United States, 2010. C. H., Mogayzel, P. J., Willey-Courand, D. B., . . . Cystic
inhalers_main.asp Morbidity and Mortality Weekly Report, 60(11), Fibrosis Foundation, Pulmonary Therapies Committee
Ayad, O., Dietrich, A., & Mihalov, L. (2008). Extracorpo- 333–337. (2007). Cystic fibrosis pulmonary guidelines: Chronic
real membrane oxygenation. Emergency Medical Clin- Centers for Disease Control and Prevention (CDC). medications for maintenance of lung health. American
ics of North America, 26, 953–959. (2011b). Vital signs: Asthma prevalence, disease charac- Journal of Respiratory and Critical Care Medicine,
Baker, L. K., & Denyes, M. J. (2008). Predictors of self-care teristics, and self-management education—United States, 176, 957–969.
in adolescents with cystic fibrosis: A test of Orem’s theo- 2001–2009. Morbidity and Mortality Weekly Report, Fong, E. W., & Levin, R. H. (2007). Inhaled corticoste-
ries of self-care and self-care deficit. Journal of Pediatric 60(17), 547–552. roids for asthma. Pediatrics in Review, 28(6), e30–e35.
Nursing, 23(1), 37–48. Chipps, B., Zeiger, R. S., Murphy, K., Mellon, M., Schatz, Fu, L. Y., Colson, E. R., Corwin, M. J., & Moon, R. Y.
Banasiak, N. C. (2007). Childhood asthma: Part two: M., Kosinski, M., . . . Ramachandran, S. (2011). Longi- (2008). Infant sleep location: Associated maternal and
Management update. Journal of Pediatric Health Care, tudinal validation of the Test for Respiratory Asthma infant characteristics with sudden infant death syn-
21(3), 184–191. Control in Kids in pediatric practices. Pediatrics, 127(3), drome prevention recommendations. Journal of Pedi-
Baraldi, E., & Filippone, M. (2007). Chronic lung disease e737–e747. atrics, 153(4), 503–508.
after premature birth. New England Journal of Medicine, Clark, A. P., Giuliano, K., & Chen, H. (2006). Pulse oxim- Geary, C., Caskey, M., Fonseca, R., & Malloy, M. (2008).
357(19), 1946–1955. etry revisited: “But his O2 was normal!” Clinical Nurse Decreased incidence of bronchopulmonary dysplasia
Baum, C. R. (2008). What’s new in pediatric carbon Specialist, 20(6), 268–272. after early management changes, including surfactant
monoxide poisoning? Clinical Pediatric Emergency Coffman, S. (2009). Late preterm infants and risk for and nasal continuous positive airway pressure treatment
Medicine, 9, 43–46. RSV. Maternal and Child Nursing, 34(6), 378–384. at delivery, lowered oxygen saturation goals, and early

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Acknowledgments
It is both challenging and a significant responsibility to write a pedi- the textbook design. At S4Carlisle Publishing Services, we thank
atric textbook. Pediatric nursing is constantly changing due to new Lynn Steines for coordinating production, and Joan Lyon for her
knowledge and technologies. It is inspiring to observe this evolution copyediting skills.
of pediatric nursing practice and to have the opportunity to share George Dodson took many of the photos in this book. We sin-
with nursing students much of our enthusiasm for working with cerely thank the children, families, and nurses who allowed us to il-
children and their families. We appreciate the opportunity to con- lustrate development, pediatric healthcare conditions, and nursing
tribute to the education of a new generation of nurses. care of children in hospital, home, and community settings.
This edition of the textbook used the strong foundation of the One chapter in the book was written by an expert in a specialized
first edition and integrated some new features. The production of a field. We particularly thank Linda Ward for her contributions on ge-
textbook requires a team that is fully committed to the vision from netics and genomics. She is a participant in the National Institutes
the beginning of the revision through the final production process. of Health Summer Genetics Institute and a researcher in education
We were fortunate to have a close collaborative relationship with of nurses on these important topics, and we could have no better
our publishing company, Pearson. Kim Norbuta, our nursing edi- contributor. We would also like to acknowledge the academic- and
tor, infused new ideas and approaches into the textbook and accom- clinical-based pediatric nurses who served as reviewers and con-
panying learning aids. We are excited about the coming application sultants. Their valuable feedback enabled us to more appropriately
of simulations as methods of expanding understanding of pediatric focus our chapters for today’s student nurses and the practice of pe-
nursing for the student. Julie Alexander, vice president and pub- diatric nursing.
lisher, has once again enthusiastically supported this venture on be- This book emphasizes partnering with families to provide com-
half of Pearson. prehensive care for children. Our own families are also critically
Our developmental editor, Kim Wyatt, has worked with us for important to our lives. Without them we could not reach our own
several books; she is a cheerleader and a friend, and she has an exqui- personal and professional goals, and we depend on them every day
site eye for detail. She worked side by side with a new editor, Mary for support, love, and caring. We thank them for their enduring part-
Cook, to ensure the quality and timeliness of the present edition. nerships and contributions that made this book a reality.
Mary was essential in cultivating our relationship with reviewers—
her pleasant and competent manner was outstanding. We thank
Jane W. Ball
­Maria Reyes, production editor; Patrick Walsh, production manag-
Ruth C. Bindler
ing editor; and editorial assistant Erin Rafferty, for their expertise
Kay J. Cowen
and valuable contributions. Our thanks also go to Mary Siener for

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Contents
Chapter 2
UNIT I Family-Centered Care:
Nurses, Children, and Families 1 Theory and Application 28
Family Roles 29
Chapter 1 Family-Centered Care 29
Child Health Nursing: History of Family-Centered Care 29
Concepts, Roles, and Issues 2 Promoting Family-Centered Care 30
Overview of Pediatric Health Care 3 Family Composition 32
Nuclear Family 32
Role of the Nurse in the Care of Children 3 Blended or Reconstituted Family 32
Direct Care Provider 3 Extended Family 33
Patient Educator 5 Single-Parent Family 33
Patient Advocacy 6 Binuclear Family 33
Case Manager 6 Heterosexual Cohabiting Family 34
Research 6 Gay and Lesbian Family 34
History of Child Health Care 7 Family Functioning 34
The Beginnings of Child Health Nursing 7 Transition to Parenthood 34
Historic Legislation 8 Parental Influences on the Child 35
Other Advances in Child Health Care 8 Family Size 35
Nursing Process in Pediatric Care 9 Sibling Relationships 35
Clinical Reasoning 9 Parenting 35
Evidence-Based Practice 9 Authoritarian Parents 36
Assessing Quality of Health Care 10 Authoritative Parents 36
Contemporary Climate for Pediatric Permissive Parents 36
Nursing Care 11 Indifferent Parents 36
Partnering with Families: Parent Adaptability 36
Family-Centered Care 11 Assessing Parenting Styles 37
Culturally Competent Care 11 Discipline and Limit Setting 38
Pediatric Health Statistics 12 Special Family Considerations 39
Infant Mortality 12, Child Mortality 13 Divorce and Its Effects
Healthy People 2020 14 on Children 39
Morbidity and Hospitalization 14 Stepparenting 39
Healthcare Financing 14
Health Benefits 15 Foster Care 40
Healthcare Technology 16 Foster Parenting 41
Health Status of Foster Children 41
Legal and Ethical Concepts and
Transition to Permanent Placement 41
Responsibilities 16
Regulation of Nursing Practice 16 Adoption 42
Accountability and Risk Management 16 Legal Aspects of Adoption 42
Accountability 16, Patient Safety 16, Preparation for Adoption 42
Risk Management 18 International Adoptions 43
Legal and Ethical Issues in Pediatric Care 19 Family Theories 43
Informed Consent 19, Child Participation in Family Development Theory 44
Healthcare Decisions 20, Child’s Rights Versus Family Systems Theory 44
Parents’ Rights 20, Confidentiality 21, Patient Family Stress Theory 45
Self-Determination Act 21
Ethical Concepts and Issues 22 Family Assessment 45
Withholding or Withdrawing Medical Treatment 22, Family Stressors 45
Genetic Testing of Children 23, Organ Family Strengths 45
Transplantation Issues 23 Collecting Data for Family
Partnering with Children and Their Families 24 Assessment 46

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Family Assessment Tools 46 Principles of Inheritance 88

Genogram 47, Family Ecomap 47, Family Mendelian Pattern of Inheritance 88
APGAR 47, Home Observation for Measurement Dominant Versus Recessive Disorders 88,
of the Environment 47, Friedman Family Autosomal Dominant 88, Autosomal Recessive 89,
Assessment Model 48, Calgary Family X-Linked 89, X Inactivation 91, Y-Linked
Assessment Model 48 Disorders 91
Family Support Services 50 Variability in Classic Mendelian Patterns
Nursing Management 50 of Inheritance 91
Penetrance 92, New Mutation 92, Anticipation 92,
Variable Expressivity 92, Sex-Limited Traits 92,
Chapter 3 Sex-Influenced Traits 92
Cultural Influences 55 Other Variations in Monogenic Inheritance 92
Culture—Definitions and Basic Concepts 56 Imprinting 92
Culture and Nurse Theorists 56 Uniparental Disomy 93
Application of Cultural Theories 58 Polygenic and Multifactorial Inheritance 93
Definitions Related to Culture 58 Neural Tube Defects 93
Demographics and Cultural Diversity Congenital Heart Defects 93
Cleft Lip and Palate 93
in the United States 59
Autism Spectrum Disorder 93
Cultural Competence in Nursing 59 Collaborative Care 93
Health Care and Culture 60 Diagnostic Procedures 93
Disparities in Health and Barriers to Nursing Management 96
Health Care 60 The Role of the Nurse in Genetic Testing 98
Access and Barriers 60, Biological Differences 62, Visions for the Future 104
Environmental Differences 63
Cultural Practices That Influence Health Care 63 Chapter 5
Family Roles and Organization 63, Concepts of Growth and Development 107
Communication 64, Time Orientation 65,
Nutrition 66 Principles of Growth and Development 108
Health Beliefs, Approaches, and Practices 66 Major Theories of Development 108
Health Beliefs 66, Health Approaches Freud’s Theory of Psychosexual
and Practices 67
Development 109
Nursing Management 71 Theoretic Framework 109, Stages 109, Nursing
Application 109
Erikson’s Theory of Psychosocial
Development 109
UNIT II Theoretic Framework 109, Stages 110, Nursing
Application 113
Child Concepts and Application 77 Piaget’s Theory of Cognitive Development 113
Theoretic Framework 113, Stages 113, Nursing
Chapter 4 Application 115
Genetic and Genomic Influences 78 Kohlberg’s Theory of Moral Development 115
Theoretic Framework 115, Stages 116, Nursing
Partnering with Families: Meeting the Standard Application 116
of Genetic Nursing Care Delivery 79 Social Learning Theory 116
Impact of Genetic Advances on Health Promotion Theoretic Framework 116, Nursing Application 116
and Health Maintenance 80 Behaviorism 116
Theoretic Framework 116, Nursing Application 117
Genetic Basics 82 Ecologic Theory 117
Cell Division 82 Theoretic Framework 117, Levels or Systems 117,
Chromosomal Alterations 83 Nursing Application 119
Alterations in Chromosome Number 84, Structural Temperament Theory 119
Chromosomal Alterations 84 Theoretic Framework 119, Nursing
Genes 85 Application 120
Distribution and Function of Genes 86, Mitochondrial Resiliency Theory 120
Genes 86, Gene Alterations and Disease 86, Gene Theoretic Framework 120, Nursing Application 121
Alterations That Decrease Risk of Disease 87,
Genetic Variation: Single Nucleotide Polymorphisms Influences on Development 121
and Copy Number Variants 88 Growth and Development by Age Group 122

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Newborn (Up to 1 Month) 122 Newborn 152

Physical Growth and Development and Prenatal Infant 152
Influences 122 Toddler and Preschooler 153
Cognitive Development 124 School-Age Child 154
Psychosocial Development 124 Adolescent 154
Infant (1 Month to 1 Year) 126 The Child with Special Needs 154
Video Understanding Growth and Communicating with the Child with an Alteration
in Visual Perception 154, Communicating with the
Development 126
Child with an Alteration in Hearing Perception 155,
Cognitive Development 126 Communicating with the Child Who Does Not Speak
Psychosocial Development 130 English 155
Video Stages of Play 130, Personality and
Nursing Management 155
Temperament 130, Communication 130
Toddler (1 to 3 Years) 131
Physical Growth and Development 131 Chapter 7
Cognitive Development 131 Pediatric and Newborn Assessment 163
Psychosocial Development 132
Play 132, Personality and Temperament 133, Obtaining the Child’s History 164
Communication 133 Communication Strategies 164
Preschool Child (3 to 6 Years) 134 Strategies to Build Rapport with the Family
Physical Growth and Development 134 and Child 164
Cognitive Development 135 Data to Be Collected 165
Psychosocial Development 135 Patient Information 165, Physiologic Data 165,
Play 135, Personality and Temperament 135, Psychosocial Data 167, Developmental Data 168
Communication 137 Developmental Approach to the Examination 168
School-Age Child (6 to 12 Years) 137 Newborns and Infants Under 6 Months
Physical Growth and Development 138 of Age 169
Cognitive Development 139 Infants over 6 Months of Age 169
Psychosocial Development 139 Toddlers 169
Play 139, Personality and Temperament 140, Preschoolers 169
Communication 140, Sexuality 140 School-Age Children 169
Adolescent (12 to 18 Years) 140 Adolescents 169
Physical Growth and Development 140 Anatomic and Physiologic Characteristics
Cognitive Development 140 of Infants and Children 169
Psychosocial Development 141 General Appraisal 171
Activities 141, Personality and Temperament 142, Anthropometric Measurements 171
Communication 142, Sexuality 142 Infants and Toddlers 171, Preschoolers and
School-Age Children 172, Older Children and
Chapter 6 Adolescents 173
Child and Family Communication 146 Assessing Skin and Hair 173
Inspection of the Skin 173
Communication and the Nurse–Child–Family
Skin Color 173
Relationship 147 Palpation of the Skin 174
Forms of Communication 147 Temperature 174, Texture 174, Moistness 174,
Verbal Communication 147 Resilience (Turgor) 174
Nonverbal Communication 147 Capillary Refill Time 174
Facial Expressions 149, Body Language 149, Skin Lesions 175
Eye Contact 149, Touch 150, Physical Inspection of the Hair 175
Appearance 150 Palpation of the Hair 175
Factors Influencing Communication with Children Assessing the Head and Face 175
and Their Families 150 Inspection of the Head and Face 175
Medical Jargon 150 Palpation of the Skull 176
Gender 151 Sutures 176, Fontanels 176
Child’s Health Status 151
Assessing Eyes and Vision 177
Nursing Attitudes 151
Inspection of the External Eye Structures 177
Developmental and Cognitive Considerations for Eye Size and Spacing 177, Eyelids and
Communication with Children 152 Eyelashes 178, Eye Color 178, Pupils 178

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Inspection of the Eye Muscles 178 Third Heart Sound 196, Murmurs 196, Venous
Extraocular Movements 179, Corneal Light Hum 196
Reflex 179, Cover–Uncover Test 179 Completing the Heart Examination 196
Inspection of the Internal Eye Structures 179 Palpation of the Pulses 196, Blood Pressure 196,
Red Reflex 180 Other Signs 197
Vision Assessment 180 Assessing the Abdomen 197
Infants and Toddlers 180, Visual Fields 180, Topographic Landmarks of the
Standardized Vision Charts 180
Abdomen 197
Assessing the Ears and Hearing 181 Inspection of the Abdomen 198
Inspection of the External Ear Structures 181 Shape 198, Umbilicus 198, Rectus Muscle 198,
Inspection of the Tympanic Membrane 181 Abdominal Movement 198
Hearing Assessment 182 Auscultation of the Abdomen 198
Infants and Toddlers 183, Preschool and Older Percussion of the Abdomen 198
Children 183, Bone and Air Conduction of Palpation of the Abdomen 198
Sound 183 Light Palpation 198, Deep Palpation 199,
Assessing the Nose and Sinuses 184 Other Masses 199
Inspection of the External Nose 184 Assessment of the Inguinal Area 199
Palpation of the External Nose 184 Inspection 199, Palpation 199
Nasal Patency 184 Assessing the Genitalia and Perineum 199
Assessment of Smell 184 Preparation of Children for the
Inspection of the Internal Nose 184 Examination 199
Mucous Membranes 184, Nasal Septum 184, Females 199
Discharge 185 Inspection of the External Genitalia 199,
Inspection of the Sinuses 185 Palpation 200
Assessing the Mouth and Throat 185 Males 200
Inspection of the Mouth 185 Inspection of the External Genitalia 200,
Lips 185, Teeth 185, Mouth Odors 186, Gums Palpation 201
and Buccal Mucosa 186, Tongue 187, Palate 187 Inspection of the Anus and Rectum 201
Palpation of the Mouth Structures 187 Palpation of the Anus and Rectum 201
Inspection of the Throat 187 Assessment of Pubertal Development
Assessing the Neck 187 and Sexual Maturation 201
Inspection of the Neck 187 Females 201
Palpation of the Neck 188 Males 202
Lymph Nodes 188, Trachea 188, Thyroid 188 Sexual Maturity Rating 202
Range of Motion Assessment 188 Assessing the Musculoskeletal
Assessing the Chest 188 System 202
Topographic Landmarks of the Chest 188 Inspection of the Bones, Muscles,
Inspection of the Chest 190 and Joints 204
Shape of the Chest 190, Chest Palpation of the Bones, Muscles,
Circumference 190, Chest Movement and and Joints 204
Respiratory Effort 190, Respiratory Rate 191 Range of Motion and Muscle Strength 204
Palpation of the Chest 191 Active Range of Motion 204,
Chest Wall 191, Tactile Fremitus 191 Passive Range of Motion 204,
Auscultation of the Chest 191 Muscle Strength 204
Breath Sounds 192, Vocal Resonance 192, Posture and Spinal Alignment 204
Abnormal Breath Sounds 193, Abnormal Voice Inspection of the Upper Extremities 204
Sounds 193
Inspection of the Lower Extremities 205
Percussion of the Chest 193 Hips 205, Legs 206
Assessing the Breasts 193 Assessing the Nervous System 206
Inspection 193 Cognitive Function 206
Palpation 193 Behavior 206, Communication Skills 207,
Assessing the Heart 193 Memory 207, Level of Consciousness 207
Inspection of the Precordium 193 Cerebellar Function 207
Palpation of the Precordium 194 Balance 207, Coordination 207, Gait 208
Apical Impulse 194, Abnormal Sensations 194 Sensory Function 208
Percussion of the Heart Borders 194 Superficial Tactile Sensation 208, Superficial Pain
Auscultation of the Heart 194 Sensation 208
Heart Rate and Rhythm 194, Differentiation of Heart Cranial Nerve Function 208
Sounds 195, Splitting of the Heart Sounds 195, Infant Primitive Reflexes 210

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Superficial and Deep Tendon Reflexes 210 At Birth 254

Superficial Reflexes 212, Deep Tendon Assessment of Risk and Protective
Reflexes 212 Factors 255
Analyzing Data from the Physical Newborn Visit Following Hospital
Examination 213 Discharge 257
Routine Health Supervision
Newborn Assessment 214 Visits 257
Newborn Transition 214
Assessment at Birth 214 General Observations 257
Assessment of the Newborn 214 Growth and Developmental
Gestational Age Assessment 215, Size for Surveillance 258
Gestational Age 219, General Appearance 220, At Birth 258
Vital Signs 220, Skin 220, Head 221, Assessing Growth and Development
Eyes 222, Ears 223, Nose 223, Mouth 223, in the Outpatient Setting 259
Neck 223, Chest and Lungs 223, Heart 223,
Abdomen 224, Genitalia and Anus 224, Nutrition 260
Extremities 224, Neurologic System 225 Breastfeeding 260
Formula Feeding 262
Physical Activity 263
UNIT III Oral Health 263
Mental and Spiritual Health 263
Health Promotion and Maintenance Promoting Maternal Mental Health 264
Through Childhood 228 Promoting Newborn Mental Health 264
Relationships 267
Chapter 8 Disease Prevention Strategies 269
Concepts of Health Promotion Injury Prevention Strategies 270
and Maintenance 229 Nursing Management 270
Definitions of Health Promotion
Chapter 10
and Maintenance 230
Health Promotion and Maintenance
Application of Resilience and Ecologic
of the Infant 275
Theories 231
Health Supervision in the Pediatric Early Contacts with the Family 276
Healthcare Home 234 General Observations 276
Components of Health Promotion Growth and Developmental
and Maintenance Visits 236 Surveillance 277
Contacts with the Family 237 Nutrition 279
General Observations 237 Physical Activity 280
Growth and Developmental
Surveillance 237 Oral Health 281
Nutrition 239 Mental and Spiritual Health 282
Physical Activity 240 Relationships 284
Oral Health 241 Family 284
Mental and Spiritual Health 241 Social Interactions 286
Relationships 244 Disease Prevention Strategies 286
Disease Prevention Strategies 244
Injury Prevention (Safety) Strategies 246 Injury Prevention Strategies 288
Additional Topics 247 Nursing Management 288
Nursing Management 247
Chapter 11
Chapter 9 Health Promotion and Maintenance
Health Promotion and Maintenance of the Toddler and Preschooler 295
of the Newborn 252
General Observations 296
Early Contacts with the Family 253 Growth and Developmental
Prenatal 253
Surveillance 297
Prenatal Assessment of Risk and Protective
Factors 253 Nutrition 299

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Physical Activity 301

Oral Health 302
UNIT IV
Mental and Spiritual Health 304 Child Healthcare Settings
Relationships 307 and Considerations 358
Disease Prevention Strategies 309
Injury Prevention Strategies 311 Chapter 14
Nursing Management 314 Nursing Care of the Child in the Community 359
Chapter 12 Community-Based Health Care 360
Characteristics of Community-Based Health
Health Promotion and Maintenance
Care 360
of the School-Age Child 319
Roles of Nurses in Community Settings 361
General Observations 320 Role of the Pediatric Nurse in an Office or Health
Growth and Developmental Center Setting 361
Surveillance 321 Identifying Severely Ill and Injured Children 361,
Telephone Advice 362, Educating the Child and
Nutrition 322 Family 362, Identifying Community Resources 363,
Physical Activity 324 Ensuring a Safe Environment for Children 363
Oral Health 326 Role of the Pediatric Nurse in a Hospital
Outpatient Setting 363
Mental and Spiritual Health 326 Specialty Care Ambulatory Clinics 363, Urgent Care
Self-Concept 326 or Emergency Department Settings 364
Sexuality 328 Role of the Nurse in a School Setting 364
Sleep 328 Community Health Focus 367, School-Based Health
School 328 Centers 367, Preparation for Emergencies 367,
Mental Health Disorders 329 Children with Special Healthcare Needs 368,
Spiritual Health 329 Facilitating the Child’s Return to School 369
Nursing Role 329 Nursing in Childcare Settings 369
Reducing Disease Transmission 370, Health
Relationships 329
Promotion 370, Environmental Safety 370,
Disease Prevention Strategies 330 Care for Children with Illnesses 370, Emergency
Injury Prevention Strategies 332 Care Planning 370
Nursing Management 334 Other Community Settings 371
Role of the Nurse in Camp Settings 371
Chapter 13 Home Healthcare Nursing 371
Characteristics of Children in Home Care
Health Promotion and Maintenance Services 372, Role of the Pediatric Nurse in Home
of the Adolescent 340 Care 372
General Observations 341 Nursing Management 372
Community Health Nursing 374
Growth and Developmental
Emergency Care Planning 377
Surveillance 342
Emergency Medical Services for Children 377
Nutrition 343 Important Pediatric Physiologic Differences 377
Physical Activity 346 Disaster Preparedness 378
Oral Health 347 Clinical Manifestations 379, Clinical Therapy 379
Nursing Management 380
Mental and Spiritual Health 347
Self-Concept 347
Sexuality 348 Chapter 15
Sleep 348 Nursing Care of the Hospitalized Child 385
School 349
Mental Health Disorders 349 Effects of Hospitalization on Children and Their
Spiritual Health 349 Families 386
Nursing Role 349 Children’s Understanding of Health and
Relationships 349 Illness 386
Newborn 386, Infant 387, Toddler 389,
Disease Prevention Strategies 351 Preschooler 390, School-Age Child 390,
Injury Prevention Strategies 352 Adolescent 390
Nursing Management 354 Family Responses to Hospitalization 391

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Siblings’ Experience 391 Parental Reaction 421

Family Assessment 392 Siblings’ Reactions 421
Nurse’s Role in the Child’s Adaptation to Stressors on the Family 421
Hospitalization 393 Caregiver Burden 422
Planned Hospitalization 393 Maltreatment of the Child with a Chronic
Unexpected Hospitalization 394 Condition 422
Nursing Care of the Hospitalized Child 394 Family Financial Issues 422
Special Units and Types of Care 394 Promoting Healthy Family
General Pediatric Care Unit 395, Short-Stay, Coping 423
Outpatient, and Ambulatory Surgical Units 395, The Child with a Chronic Condition 424
Emergency Care 395, Intensive Care Unit 396, Developmental Considerations 424
Isolation 396, Rehabilitation 396 Newborn and Infant 424, Toddler 424,
Parental Involvement and Parental Presence 397 Preschooler 425, School-Age Child 425,
Preparation for Procedures 397 Adolescent 425
Psychologic Preparation 397, Physical Education and Schooling 426
Preparation 397 Educational System Planning 426, The Child’s
Performing the Procedure 399 Response to Entering School 427, Education
Preparation for Surgery 400 for Children Who Are Medically Fragile 427,
Preoperative Care 404 Homeschooling 428
Psychosocial Preparation 404, Parental Presence Transition to Adulthood 428
During Anesthesia Induction 404, Physical Collaborative Care 429
Preparation 404 Hospitalization 429, Ethical Issues 429,
Postoperative Care 405 Transition Between Hospital and
Postoperative Home Care Instructions 406 Home 429, Health Promotion and Health
Maintenance of Children with Chronic
Strategies to Promote Coping and Normal Conditions 430
Development of the Hospitalized Child 406 Nursing Management 430
Rooming In 406
Nurse’s Reactions to Care of Children
Child Life Programs 406
Therapeutic Play 407 with a Chronic Condition 436
Newborn and Infant 408, Toddler 408,
Preschooler 408, School-Age Child 409, Chapter 17
Adolescent 409 Nursing Care of the Child with a Life-
Strategies to Meet Educational Threatening Illness or Injury 440
Needs 410
Child and Family Teaching 411, Teaching Life-Threatening Illness or Injury 441
Plans 411, Teaching for Children with Special Settings Encountered by Children
Healthcare Needs 412
with a Life-Threatening Condition 441
Preparation for Home Care 412 Emergency Department 441
Assessing the Child and Family in Preparation Pediatric Intensive Care Unit 442
for Discharge 412 Neonatal Intensive Care Unit 442
Preparing the Child and Family for Discharge 413
Child’s Experience of a Life-Threatening Illness
Preparing the Child and Family for Home Health
or Injury 443
Care 413
Coping Mechanisms 443
Preparing the Child and Family for Long-Term
Nursing Management 444
Care or Rehabilitation 413
Parents’ Experience of a Child’s
Life-Threatening Illness or
Chapter 16
Injury 446
Nursing Care of the Child with a Chronic The Family in Crisis 446
Condition 417 Parental Reactions to Life-Threatening Illness
or Injury 447
General Concepts in the Care of a Child
Shock and Disbelief 447, Anger and
with a Chronic Condition 418 Guilt 448, Deprivation and Loss 448,
Overview of Chronic Conditions 418 Anticipatory Waiting 448, Readjustment or
The Family of a Child with a Chronic Mourning 448
Condition 419 Nursing Management 448
Informing the Parents 419 The Siblings’ Experience 453
Informing the Child 421 Nursing Management 453

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Chapter 18 Nutrition Facts Labels 485

End-of-Life Care and Bereavement 457 Recommendations for Dietary Intake 486
Nutritional Needs 487
Death in Children 458 Preterm Infant 487
Concepts of Loss and Death 458 Infancy—Birth to 6 Months 489
Loss 458 Breast and Formula Feeding 490
Death 458 Infancy—6 to 12 Months 492
Introduction of Complementary Foods 492,
The Child’s Experience with Death and Loss 458
Dental Care 494
Death of a Parent 459
Toddlerhood 494
Death of a Grandparent 459
Preschool 496
Death of a Friend 459
School Age 496
Other Potentially Significant Losses 459
Adolescence 497
Factors Influencing Family Responses to Death
Nutritional Challenges 497
and Loss 461
Culture 461 Nutritional Assessment 498
Faith-Based Beliefs and Spirituality 462 Physical and Behavioral Measurement 498
Growth Measurement 498, Additional Physical
Grief and Bereavement 462 Measurement 501
Stages of Grieving 462 Dietary Intake 501
Social Support System 463 24-Hour Recall of Food Intake 501, Food Frequency
End-of-Life Considerations and Decision Questionnaire 502, Dietary Screening
Making 464 History 502
Food Diary 502
Palliative Care 464
Advance Care Planning 466 Common Nutritional Concerns 505
Hospice Care 466 Childhood Hunger 505
Ethical Issues Surrounding a Child’s Death 466 Overweight and Obesity 505
Withdrawing or Withholding Treatment 467, Collaborative Care 506
Conflicts Regarding Parental Refusal of Nursing Management 507
Treatment 467, Do-Not-Resuscitate Orders 467, Food Safety 507
Euthanasia 468 Common Dietary Deficiencies 510
End-of-Life Nursing Care for the Child Who Iron 510, Calcium 510, Vitamin D 511
Is Dying 468 Folic Acid 511, Protein-Energy
Malnutrition 512
Awareness of Dying by Developmental Age 468
Celiac Disease 512
Nursing Management 468
Etiology and Pathophysiology 512, Clinical
Family Care After the Death of a Child 475 Manifestations 512
Communicating with Parents When a Child Dies Collaborative Care 512
Unexpectedly 475 Diagnostic Tests 512, Clinical Therapy 512
Parents’ Reactions to a Child’s Death 476 Nursing Management 512
The Death of a Newborn or Young Infant 476 Food Reactions 513
Nursing Management 476 Nursing Management 514
Siblings’ Reactions to a Child’s Death 476 Feeding and Eating Disorders 514
Nursing Management 476 Colic 515, Pica 515, Rumination 516, Feeding
Nurses’ Reactions to Caring for the Children Disorder of Infancy and Early Childhood (Failure
to Thrive) 516
Who Die 477
Collaborative Care 516
Nursing Management 517
Anorexia Nervosa 517
UNIT V Collaborative Care 518
Diagnostic Tests 518, Clinical Therapy 518
Nursing Care for Common Nursing Management 518
Health Conditions 481 Bulimia Nervosa 519
Collaborative Care 522
Diagnostic Tests 522, Clinical Therapy 522
Chapter 19 Nursing Management 522
Infant, Child, and Adolescent Nutrition 482 Nutritional Support 523
Sports Nutrition and Ergogenic Agents 523,
Nutrition Concepts 483 Health-Related Conditions 523, Vegetarianism 524,
Major Dietary Components 483 Enteral Therapy 524, Total Parenteral Nutrition 524

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Chapter 20 Poisoning 564

Social and Environmental Influences Etiology and Pathophysiology 565, Clinical
Manifestations 565
on Child and Adolescent Health 529 Collaborative Care 565
Diagnostic Tests 565, Clinical Therapy 565
Theoretical Frameworks 530
Nursing Management 567
Social Influences on Child Health 531 Ingestion of Foreign Objects 567
Poverty 531 Nursing Management 568
Homelessness 531
Stress 532 Chapter 21
Families 533 Pain Assessment and Management 573
School and Childcare 534
Community 535 Pain 574
Culture 535 Pathophysiology of Pain 574
Lifestyle Activities and Their Influences Neonatal Pathophysiology 575
Misconceptions About Pain in Children 575
on Child Health 535
Developmental Aspects of Pain Perception,
Substance Use 536
Tobacco Use 536 Memory, and Response 575
Collaborative Care 537 Cultural Influences on Pain 576
Clinical Therapy 537 Physiologic Consequences of Pain 577
Nursing Management 537 Effects on Newborns 577
Alcohol Use 538, Drug Use 539 Pain Assessment 577
Collaborative Care 540 Pain History 577
Diagnostic Procedures 540, Clinical Therapy 540 Pain Assessment Scales 578
Nursing Management 540 Behavioral Pain Scales for Newborns 578,
Physical Inactivity and Sedentary Behavioral Pain Scales for Infants and Young
Behavior 543 Children 579, Assessing Children with Cognitive
Injury and Protective Equipment 544 Impairment 579, Self-Report Pain Rating Tools
Body Art 546 for Children 579
Sexual Orientation 547 Pain Location 582
Effects of Violence 548 Acute Pain 582
Schools and Communities 548 Clinical Manifestations 582
Physiologic Indicators 582, Behavioral
War and Terrorism 549
Indicators 582
Bullying 549
Collaborative Care 583
Incarceration 550 Diagnostic Procedures 583, Clinical
Abandoned Babies 550 Therapy 583, Nonpharmacologic Methods of Pain
Hazing 550 Management 587
Domestic Violence 550 Nursing Management 588
Dating Violence 550
Chronic Pain 594
Nursing Management 550
Etiology and Pathophysiology 594
Child Abuse 554
Clinical Manifestations 594
Physical Abuse 555, Physical Neglect 555,
Emotional Abuse 555, Emotional Neglect 556, Selected Chronic Pain Conditions 594
Sexual Abuse 556 Sickle Cell Disease 594, Cancer Pain 595, Complex
Regional Pain Syndrome 595
Collaborative Care 557
Diagnostic Tests 557, Clinical Therapy 558 Collaborative Care 595
Diagnostic Testing 595, Clinical Therapy 595
Nursing Management 558
Nursing Management 595
Munchausen Syndrome by Proxy 560
Nursing Management 560 Sedation and Pain Management for Medical
Environmental Influences on Child Health 561 Procedures 596
Environmental Contaminants 561 Nursing Management 598
Nursing Management 562
Lead Poisoning 563 Chapter 22
Etiology and Pathophysiology 563, Clinical Immunizations and Communicable Diseases 602
Manifestations 563
Collaborative Care 563 Communicable Disease as a Health Problem 603
Diagnostic Tests 563, Clinical Therapy 563 Special Vulnerability of Newborns and Infants
Nursing Management 564 to Infection 603

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Vulnerabilities of Children to Infection 603 Collaborative Care 671

Public Health and Communicable Diseases 604 Nursing Management 671
Infection Control 604 Hyponatremia 672
Immunization 605 Collaborative Care 673
Diagnostic Tests 673, Clinical
Etiology and Pathophysiology 605
Therapy 673
Clinical Manifestations 606
Nursing Management 673
Collaborative Care 606
Immunization Schedule 606, Vaccine Safety 615
Potassium Imbalances 673
Hyperkalemia 674
Nursing Management 616
Collaborative Care 674
Communicable Diseases in Infants and Diagnostic Tests 674, Clinical Therapy 674
Children 623 Nursing Management 674
Etiology and Pathophysiology 623 Hypokalemia 676
Bacteria 624, Viruses 625, Fever 625 Collaborative Care 676
Clinical Manifestations 625 Diagnostic Tests 676, Clinical Therapy 676
Collaborative Care 639 Nursing Management 676
Diagnostic Procedures 639, Clinical Therapy 639 Calcium Imbalances 678
Nursing Management 640 Hypercalcemia 678
Sepsis 641 Collaborative Care 679
Etiology and Pathophysiology 642 Diagnostic Tests 679
Clinical Manifestations 642 Nursing Management 679
Hypocalcemia 680
Collaborative Care 643
Diagnostic Procedures 643, Clinical Therapy 643 Collaborative Care 680
Nursing Management 643 Nursing Management 680
Magnesium Imbalances 682
Emerging Infection Control Threats 643 Hypermagnesemia 682
Collaborative Care 644 Nursing Management 682
Nursing Management 644 Hypomagnesemia 682
Nursing Management 683
Phosphorus Imbalances 683
UNIT VI Clinical Evaluation of Fluid and Electrolyte
Imbalance 684
Nursing Care of Specific Health
Acid–Base Imbalances 684
Conditions 649 Respiratory Acidosis 684
Etiology and Pathophysiology 685, Clinical
Chapter 23 Manifestations 686
Alterations in Fluid, Electrolyte, Collaborative Care 687
Nursing Management 687
and Acid–Base Balance 650 Respiratory Alkalosis 688
Anatomy and Physiology 651 Nursing Management 688
Physiology of Fluid and Electrolyte Balance 651 Metabolic Acidosis 689
Etiology and Pathophysiology 689, Clinical
Physiology of Acid–Base Balance 651
Manifestations 690
Buffers 652, Role of the Lungs 652, Role of the
Kidneys 652, Role of the Liver 653 Collaborative Care 690
Nursing Management 690
Pediatric Differences 653
Metabolic Alkalosis 690
Fluid Volume Imbalances 655 Nursing Management 691
Extracellular Fluid Volume Imbalances 655 Mixed Acid–Base Imbalances 691
Extracellular Fluid Volume Deficit
(Dehydration) 655 Chapter 24
Collaborative Care 657
Diagnostic Tests 658, Clinical Therapy 659
Alterations in Eye, Ear, Nose,
Nursing Management 659 and Throat Function 694
Extracellular Fluid Volume Excess 665
Nursing Management 666 Anatomy and Physiology 695
Interstitial Fluid Volume Excess (Edema) 666 Eye 695
Nursing Management 668 Ear 695
Nose, Throat, and Mouth 695
Electrolyte Imbalances 669
Sodium Imbalances 670 Pediatric Differences 695
Hypernatremia 671 Eye 695

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Ear 696 Disorders of the Mouth 732

Nose, Throat, and Mouth 697 Mouth Ulcers 733
Disorders of the Eye 697 Collaborative Care 733
Infectious Conjunctivitis 697 Diagnostic Tests 733, Clinical Therapy 733
Ophthalmia Neonatorum 697, Additional Neonate Nursing Management 734
Eye Conditions 697, Bacterial Conjunctivitis 698, Mouth and Dental Emergencies 734
Viral Conjunctivitis 699, Allergic Conjunctivitis 699
Collaborative Care 699 Chapter 25
Nursing Management 699 Alterations in Respiratory Function 738
Periorbital Cellulitis 700
Visual Disorders 700 Anatomy and Physiology 739
Etiology and Pathophysiology 701, Clinical Pediatric Differences 739
Manifestations 702 Upper Airway Differences 739
Collaborative Care 703 Lower Airway Differences 740
Diagnostic Tests 703, Clinical Therapy 704 Respiratory Assessment 741
Nursing Management 704
Respiratory Distress and Respiratory Failure 741
Color Blindness 704
Foreign Body Aspiration 741
Retinopathy of Prematurity 704
Etiology and Pathophysiology 742, Clinical
Etiology and Pathophysiology 704, Clinical
Manifestations 743
Manifestations 705
Collaborative Care 743
Collaborative Care 705
Diagnostic Tests 743, Clinical Therapy 743
Diagnostic Tests 705, Clinical Therapy 706
Nursing Management 744
Nursing Management 706
Respiratory Failure and Acute Respiratory
Visual Impairment 708
Distress Syndrome 745
Collaborative Care 708
Etiology and Pathophysiology 745, Clinical
Nursing Management 708 Manifestations 745
Injuries of the Eye 711 Collaborative Care 746
Nursing Management 711 Diagnostic Tests 746, Clinical Therapy 747
Disorders of the Ear 712 Nursing Management 747
Otitis Media 712 Apnea 748
Etiology and Pathophysiology 712, Clinical
Apnea of Prematurity 749
Manifestations 712
Nursing Management 749
Collaborative Care 714
Apparent Life-Threatening Event 749
Diagnostic Tests 714, Clinical
Etiology and Pathophysiology 749, Clinical
Therapy 714
Manifestations 749
Nursing Management 715
Collaborative Care 749
Otitis Externa 718 Diagnostic Tests 749, Clinical Therapy 749
Hearing Impairment 718 Nursing Management 750
Etiology and Pathophysiology 718, Clinical
Manifestations 719
Obstructive Sleep Apnea 750
Etiology and Pathophysiology 751, Clinical
Collaborative Care 719 Manifestations 751
Diagnostic Tests 720, Clinical Therapy 721
Collaborative Care 751
Nursing Management 721 Diagnostic Tests 751, Clinical Therapy 752
Injuries of the Ear 726 Nursing Management 752
Disorders of the Nose and Throat 727 Sudden Infant Death Syndrome 753
Epistaxis 727 Etiology and Pathophysiology 753, Clinical
Nursing Management 727 Manifestations 753
Nasopharyngitis 727 Collaborative Care 753
Nursing Management 728 Nursing Management 753
Sinusitis 729 Croup Syndromes 754
Pharyngitis 730 Laryngotracheobronchitis 755
Collaborative Care 730 Etiology and Pathophysiology 755, Clinical
Nursing Management 731 Manifestations 755
Tonsillitis and Adenoiditis 731 Collaborative Care 755
Etiology and Pathophysiology 731, Clinical Diagnostic Procedures 755, Clinical Therapy 755
Manifestations 731 Nursing Management 756
Collaborative Care 731 Epiglottitis (Supraglottitis) 757
Diagnostic Tests 731, Clinical Therapy 731 Etiology and Pathophysiology 757, Clinical
Nursing Management 731 Manifestations 757

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Collaborative Care 758 Collaborative Care 788

Diagnostic Procedures 758, Clinical Therapy 758 Diagnostic Procedures 788, Clinical Therapy 789
Nursing Management 758 Nursing Management 792
Bacterial Tracheitis 759 Injuries of the Respiratory System 795
Nursing Management 759 Smoke Inhalation Injury 795
Lower Airway Disorders 759 Etiology and Pathophysiology 796, Clinical
Neonatal Respiratory Distress Syndrome 759 Manifestations 796
Etiology and Pathophysiology 759, Clinical Collaborative Care 796
Manifestations 759 Nursing Management 796
Collaborative Care 759 Blunt Chest Trauma 796
Diagnostic Procedures 759, Clinical Therapy 760 Pulmonary Contusion 796
Nursing Management 760 Nursing Management 797
Meconium Aspiration Syndrome 760 Pneumothorax 797
Etiology and Pathophysiology 760, Clinical Etiology and Pathophysiology 797, Clinical
Manifestations 760 Manifestations 798
Collaborative Care 760 Collaborative Care 798
Diagnostic Procedures 760, Clinical Therapy 760 Nursing Management 798
Nursing Management 760
Transient Tachypnea of the Newborn 761 Chapter 26
Nursing Management 761 Alterations in Cardiovascular Function 803
Bronchitis 761
Nursing Management 761 Anatomy and Physiology 804
Bronchiolitis and Respiratory Pediatric Differences 805
Syncytial Virus 761 Fetal Circulation 805
Etiology and Pathophysiology 761, Clinical
Transition from Fetal to Pulmonary Circulation 805
Manifestations 762
Heart Hemodynamics 805,
Collaborative Care 762
Cardiovascular Changes as the Child Grows 805
Diagnostic Procedures 762, Clinical Therapy 762,
Oxygenation 807, Cardiac Functioning 807
Prevention of RSV 762
Cardiac Assessment 808
Nursing Management 762
Pneumonia 765 Congenital Heart Disease 808
Etiology and Pathophysiology 765, Clinical Etiology and Pathophysiology 809
Manifestations 766 Clinical Manifestations 810
Collaborative Care 766 Collaborative Care 810
Diagnostic Procedures 766, Clinical Therapy 766 Diagnostic Procedures 810, Clinical Therapy 810
Nursing Management 767 Nursing Management of the Child Undergoing
Tuberculosis 767 a Cardiac Catheterization 812
Etiology and Pathophysiology 767, Clinical Congenital Heart Defects That Increase Pulmonary
Manifestations 767
Blood Flow 813
Collaborative Care 768
Etiology and Pathophysiology 813
Diagnostic Procedures 768, Clinical Therapy 768
Clinical Manifestations 813
Nursing Management 769
Collaborative Care 813
Chronic Lung Diseases 770 Diagnostic Procedures 813, Clinical Therapy 813
Asthma 770 Nursing Management Prior to Surgery 816
Etiology and Pathophysiology 771, Clinical Nursing Management at the Time of Surgery 817
Manifestations 771, Life-Threatening Asthma
Exacerbation 772 Defects Causing Decreased Pulmonary Blood Flow
Collaborative Care 772 and Mixed Defects 820
Diagnostic Procedures 772, Clinical Therapy 772 Etiology and Pathophysiology 820
Nursing Management 774 Defects Causing Decreased Pulmonary
Bronchopulmonary Dysplasia (Chronic Lung Blood Flow 820
Mixed Defects 820
Disease) 783
Etiology and Pathophysiology 783, Clinical Clinical Manifestations 820
Manifestations 785 Defects Causing Decreased Pulmonary Blood
Flow 820, Mixed Defects 822
Collaborative Care 785
Diagnostic Procedures 785, Clinical Therapy 785 Collaborative Care 822
Diagnostic Procedures 822, Clinical Therapy 822
Nursing Management 785
Nursing Management 826
Cystic Fibrosis 788
Etiology and Pathophysiology 788, Clinical Defects Obstructing Systemic Blood Flow 828
Manifestations 788 Etiology and Pathophysiology 828

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Clinical Manifestations 828 Nursing Management 853

Collaborative Care 828 Injuries of the Cardiovascular System 855
Nursing Management 828 Hypovolemic Shock 855
Congestive Heart Failure 829 Etiology and Pathophysiology 855, Clinical
Etiology and Pathophysiology 832 Manifestations 855
Clinical Manifestations 832 Collaborative Care 856
Collaborative Care 832 Diagnostic Procedures 856, Clinical Therapy 856
Diagnostic Procedures 832, Clinical Therapy 832 Nursing Management 857
Nursing Management 834 Distributive Shock 858
Cardiomyopathy 839 Nursing Management 859
Dilated Cardiomyopathy 839 Obstructive Shock 859
Hypertrophic Cardiomyopathy 839 Nursing Management 859
Nursing Management 840 Cardiogenic Shock 859
Nursing Management 859
Heart Transplantation 840 Myocardial Contusion 859
Nursing Management 840 Commotio Cordis 859
Pulmonary Artery Hypertension 840
Etiology and Pathophysiology 840 Chapter 27
Clinical Manifestations 841
Collaborative Care 841
Alterations in Immune Function 864
Nursing Management 841 Anatomy and Physiology 865
Acquired Heart Diseases 841 Pediatric Differences 867
Infective Endocarditis 841
Etiology and Pathophysiology 841, Clinical
Immunodeficiency Disorders 867
Manifestations 841 B-Cell and T-Cell Disorders 868
DiGeorge Syndrome 869, Immunodeficiency with
Collaborative Care 842
Hyper-IgM 869
Diagnostic Procedures 842, Clinical Therapy 842
Nursing Management 842 Severe Combined Immunodeficiency
Rheumatic Fever 843 Disease 869
Etiology and Pathophysiology 869, Clinical
Epidemiology 843, Clinical Manifestations 843
Manifestations 869
Collaborative Care 843
Diagnostic Procedures 843, Clinical Therapy 844
Collaborative Care 869
Diagnostic Tests 869, Clinical Therapy 869
Nursing Management 844
Nursing Management 870
Kawasaki Disease 844
Etiology and Pathophysiology 844, Clinical
Wiskott-Aldrich Syndrome 871
Manifestations 844 Nursing Management 872
Collaborative Care 845 Human Immunodeficiency Virus and Acquired
Diagnostic Procedures 845, Clinical Therapy 845 Immune Deficiency Syndrome 872
Nursing Management 845 Etiology and Pathophysiology 872, Clinical
Manifestations 873
Cardiac Arrhythmias 846 Collaborative Care 873
Etiology and Pathophysiology 846 Diagnostic Tests 873, Clinical Therapy 876,
Clinical Manifestations 847 Medication Therapy 876
Bradycardias 847, Tachycardias 847, Long QT Nursing Management 877
Syndrome 847
Collaborative Care 847 Autoimmune Disorders 883
Diagnostic Procedures 847, Clinical Therapy 847 Systemic Lupus Erythematosus 883
Etiology and Pathophysiology 884, Clinical
Nursing Management 850
Manifestations 884
Dyslipidemia 850 Collaborative Care 885
Epidemiology and Pathophysiology 850 Diagnostic Tests 885, Clinical Therapy 885
Clinical Manifestations 851 Nursing Management 885
Collaborative Care 851 Juvenile Idiopathic Arthritis 888
Diagnostic Tests 851, Clinical Therapy 851 Etiology and Pathophysiology 888, Clinical
Nursing Management 851 Manifestations 889
Hypertension 852 Collaborative Care 889
Etiology and Pathophysiology 852 Diagnostic Tests 889, Clinical Therapy 889
Clinical Manifestations 853 Nursing Management 889
Collaborative Care 853 Allergic Reactions 891
Diagnostic Procedures 853, Clinical Therapy 853 Collaborative Care 893

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Nursing Management 893 Nursing Management 926

Anaphylaxis 894 Von Willebrand Disease 928
Etiology and Pathophysiology 895, Clinical Collaborative Care 928
Manifestations 895 Nursing Management 928
Collaborative Care 895 Disseminated Intravascular Coagulation 928
Nursing Management 895 Etiology and Pathophysiology 929, Clinical
Latex Allergy 896 Manifestations 929
Collaborative Care 897 Collaborative Care 929
Nursing Management 897 Diagnostic Tests 929, Clinical Therapy 929
Graft-Versus-Host Disease 897 Nursing Management 929
Etiology and Pathophysiology 897 Immune Thrombocytopenic Purpura 930
Clinical Manifestations 897 Collaborative Care 930
Collaborative Care 897 Nursing Management 930
Diagnostic Tests 897, Clinical Therapy 898 Henoch-Schönlein Purpura 931
Nursing Management 898 Collaborative Care 931
Nursing Management 931
Chapter 28 Meningococcemia 931
Etiology and Pathophysiology 931, Clinical
Alterations in Hematologic Function 902 Manifestations 932
Anatomy and Physiology 903 Collaborative Care 932
Red Blood Cells 903 Diagnostic Tests 932, Clinical Therapy 932
White Blood Cells 904 Nursing Management 932
Platelets 904 Hematopoietic Stem Cell Transplantation
Pediatric Differences 904 (HSCT) 932
Anemia 904 Collaborative Care 933
Clinical Therapy 933
Iron Deficiency Anemia 905
Etiology and Pathophysiology 906, Clinical Nursing Management 933
Manifestations 906
Collaborative Care 906 Chapter 29
Diagnostic Tests 906, Clinical Therapy 907 The Child with Cancer 939
Nursing Management 907
Normocytic Anemia 908 Anatomy and Physiology 940
Collaborative Care 908 Pediatric Differences 940
Nursing Management 908 Childhood Cancer 940
Sickle Cell Disease 908 Etiology and Pathophysiology 941
Etiology and Pathophysiology 909, Clinical External Stimuli 941, Immune System and
Manifestations 911 Gene Abnormalities 942, Chromosomal
Collaborative Care 914 Abnormalities 943
Diagnostic Tests 914, Clinical Therapy 914 Clinical Manifestations 944
Nursing Management 916 Collaborative Care 944
Thalassemias 921 Diagnostic Tests 944, Clinical Therapy 945, Special
Etiology and Pathophysiology 921, Clinical Issues in Childhood Cancer 951
Manifestations 922 Nursing Management 953
Collaborative Care 923 Solid Tumors 966
Diagnostic Tests 923, Clinical Therapy 923
Brain Tumors 966
Nursing Management 923 Etiology and Pathophysiology 966, Clinical
Hereditary Spherocytosis 924 Manifestations 968
Aplastic Anemia 924 Collaborative Care 968
Etiology and Pathophysiology 924, Clinical Diagnostic Tests 969, Clinical Therapy 969
Manifestations 924
Nursing Management 970
Collaborative Care 924 Neuroblastoma 971
Diagnostic Tests 924, Clinical Therapy 924
Etiology and Pathophysiology 971, Clinical
Nursing Management 924 Manifestations 972
Bleeding Disorders 925 Collaborative Care 972
Hemophilia 925 Diagnostic Tests 972, Clinical Therapy 972
Etiology and Pathophysiology 925, Clinical Nursing Management 972
Manifestations 925 Wilms Tumor (Nephroblastoma) 973
Collaborative Care 925 Etiology and Pathophysiology 973, Clinical
Diagnostic Tests 925, Clinical Therapy 926 Manifestations 973

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xxx  Contents

Collaborative Care 974 Etiology and Pathophysiology 999, Clinical

Diagnostic Tests 974, Clinical Therapy 974 Manifestations 999
Nursing Management 974 Collaborative Care 1000
Bone Tumors 975 Diagnostic Tests 1000, Clinical Therapy 1000
Osteosarcoma (or Osteogenic Nursing Management 1000
Sarcoma) 975 Pyloric Stenosis 1001
Collaborative Care 975 Etiology and Pathophysiology 1002, Clinical
Diagnostic Tests 975, Clinical Therapy 975 Manifestations 1002
Ewing Sarcoma 975 Collaborative Care 1003
Nursing Management 976 Diagnostic Tests 1003, Clinical Therapy 1003
Leukemia 977 Nursing Management 1003
Etiology and Pathophysiology 977 Gastroesophageal Reflux and Gastroesophageal
Clinical Manifestations 978 Reflux Disease 1004
Collaborative Care 978 Etiology and Pathophysiology 1004, Clinical
Diagnostic Tests 978, Clinical Therapy 978 Manifestations 1004
Nursing Management 979 Collaborative Care 1004
Diagnostic Tests 1005, Clinical Therapy 1005
Soft Tissue Tumors 980 Nursing Management 1005
Hodgkin Disease 980 Abdominal Wall Defects 1006
Etiology and Pathophysiology 980, Clinical Omphalocele 1006, Gastroschisis 1007
Manifestations 980
Collaborative Care 1007
Collaborative Care 981 Diagnostic Tests 1007, Clinical Therapy 1007
Diagnostic Tests 981, Clinical Therapy 981
Nursing Management 1007
Non-Hodgkin Lymphoma 981 Intussusception 1008
Etiology and Pathophysiology 981, Clinical
Etiology and Pathophysiology 1008, Clinical
Manifestations 982
Manifestations 1008
Collaborative Care 982 Collaborative Care 1008
Diagnostic Tests 982, Clinical Therapy 982
Diagnostic Tests 1008, Clinical Therapy 1008
Rhabdomyosarcoma 982 Nursing Management 1009
Etiology and Pathophysiology 982, Clinical
Volvulus 1009
Manifestations 982
Nursing Management 1009
Collaborative Care 982
Diagnostic Tests 982, Clinical Therapy 983 Hirschsprung Disease 1009
Etiology and Pathophysiology 1009, Clinical
Retinoblastoma 983
Manifestations 1009
Etiology and Pathophysiology 983, Clinical
Manifestations 983 Collaborative Care 1010
Diagnostic Tests 1010, Clinical Therapy 1010
Collaborative Care 983
Diagnostic Tests 983, Clinical Therapy 983 Nursing Management 1010
Nursing Management 984 Anorectal Malformations 1011
Collaborative Care 1011
Diagnostic Tests 1011, Clinical Therapy 1011
Chapter 30 Nursing Management 1011
Alterations in Gastrointestinal Function 989 Hernias 1013
Congenital Diaphragmatic Hernia 1013
Anatomy and Physiology 990 Etiology and Pathophysiology 1013, Clinical
Esophagus and Stomach 990 Manifestations 1013
Pancreas 990 Collaborative Care 1013
Liver and Gallbladder 990 Diagnostic Tests 1013, Clinical Therapy 1013
Spleen 990 Nursing Management 1013
Small and Large Intestine 991 Umbilical Hernia 1014
Pediatric Differences 991 Ostomies 1014
Structural Defects 991 Nursing Management 1015
Cleft Lip and Cleft Palate 992 Inflammatory Disorders 1015
Etiology and Pathophysiology 992, Clinical Appendicitis 1015
Manifestations 992 Etiology and Pathophysiology 1015, Clinical
Collaborative Care 993 Manifestations 1016
Diagnostic Tests 993, Clinical Therapy 993 Collaborative Care 1016
Nursing Management 994 Diagnostic Tests 1016, Clinical Therapy 1016
Esophageal Atresia and Tracheoesophageal Nursing Management 1017
Fistula 999 Necrotizing Enterocolitis 1018

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 Contents  xxxi

Etiology and Pathophysiology 1018, Clinical Collaborative Care 1037

Manifestations 1018 Diagnostic Tests 1037, Clinical Therapy 1037
Collaborative Care 1019 Nursing Management 1038
Diagnostic Tests 1019, Clinical Therapy 1019 Cirrhosis 1039
Nursing Management 1019 Nursing Management 1039
Meckel’s Diverticulum 1020 Injuries to the Gastrointestinal System 1039
Collaborative Care 1020 Abdominal Trauma 1039
Nursing Management 1020 Etiology and Pathophysiology 1039, Clinical
Recurrent Abdominal Pain 1020 Manifestations 1039
Nursing Management 1020 Collaborative Care 1040
Inflammatory Bowel Disease 1020 Diagnostic Tests 1040, Clinical Therapy 1040
Etiology and Pathophysiology 1020, Clinical Nursing Management 1040
Manifestations 1021
Collaborative Care 1021 Chapter 31
Diagnostic Tests 1021, Clinical Therapy 1021
Nursing Management 1021
Alterations in Genitourinary Function 1046
Peptic Ulcer 1023 Anatomy and Physiology 1047
Etiology and Pathophysiology 1023, Clinical
Manifestations 1023 Pediatric Differences 1048
Collaborative Care 1024 Urinary System 1048
Diagnostic Tests 1024, Clinical Therapy 1024 Reproductive System 1048
Nursing Management 1024 Urinary Tract Infection 1049
Disorders of Motility 1024 Etiology and Pathophysiology 1049
Gastroenteritis (Acute Diarrhea) 1024 Clinical Manifestations 1050
Etiology and Pathophysiology 1024, Clinical Collaborative Care 1050
Manifestations 1024 Diagnostic Tests 1050, Clinical Therapy 1051
Collaborative Care 1024 Nursing Management 1051
Diagnostic Tests 1025, Clinical Therapy 1025 Structural Defects of the Urinary System 1052
Nursing Management 1025 Bladder Exstrophy 1052
Constipation 1028 Etiology and Pathophysiology 1052, Clinical
Etiology and Pathophysiology 1028, Clinical Manifestations 1052
Manifestations 1028 Collaborative Care 1052
Collaborative Care 1029 Diagnostic Tests 1053, Clinical Therapy 1053
Diagnostic Tests 1029, Clinical Therapy 1029 Nursing Management 1053
Nursing Management 1029 Hypospadias and Epispadias 1054
Encopresis 1030 Etiology and Pathophysiology 1054, Clinical
Nursing Management 1030 Manifestations 1055
Intestinal Parasitic Disorders 1030 Collaborative Care 1055
Nursing Management 1030 Diagnostic Tests 1055, Clinical Therapy 1055
Nursing Management 1055
Disorders of Malabsorption 1032
Obstructive Uropathy 1056
Short Bowel Syndrome 1032 Etiology and Pathophysiology 1056, Clinical
Nursing Management 1033 Manifestations 1057
Hepatic Disorders 1033 Collaborative Care 1057
Hyperbilirubinemia of the Newborn 1033 Diagnostic Tests 1057, Clinical Therapy 1057
Etiology and Pathophysiology 1033, Clinical Nursing Management 1058
Manifestations 1033 Vesicoureteral Reflux 1058
Collaborative Care 1033 Nursing Management 1059
Diagnostic Tests 1033, Clinical Therapy 1033 Prune-Belly Syndrome 1059
Nursing Management 1033 Nursing Management 1059
Biliary Atresia 1034
Enuresis 1059
Etiology and Pathophysiology 1035, Clinical
Manifestations 1035
Etiology and Pathophysiology 1060
Collaborative Care 1035 Clinical Manifestations 1060
Diagnostic Tests 1035, Clinical Therapy 1035 Collaborative Care 1060
Diagnostic Tests 1060, Clinical Therapy 1060
Nursing Management 1035
Viral Hepatitis 1036 Nursing Management 1061
Etiology and Pathophysiology 1036, Clinical Renal Disorders 1061
Manifestations 1037 Nephrotic Syndrome 1061

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 Some sausage and coarse bread was brought to me on an
earthenware platter, and my arms were unbound that I might eat, the
sentries sitting down close to me with loaded pistols in their hands.
As the reader may suppose, I ate ravenously and without stopping to
consider what the sausage was made of; but I was very disappointed
to see that Ned Burton was not disposing of his supper also. I quickly
guessed the reason of this, however. It was evident that we were not
all to be allowed to take our meals at the same time for fear of our
making some desperate attempt at escape whilst our arms were
free. Perhaps on the whole this was a wise precaution.
When my hunger was satisfied I took another pull at the water
pannikin, and began to feel more myself again. Inferior as the food
was, it instilled new life into my veins and raised my spirits
wonderfully. My head still ached painfully, and the muscles of my
arms were terribly stiff and sore; but I felt convinced that no serious
harm had accrued from the blow I had received on the head, and
that was something to be very thankful for.
I should have liked to prolong my meal as much as possible so as
to allow of the muscles and sinews of my arms regaining some of
their ordinary elasticity; but I was afraid that my doing so would still
further postpone my coxswain’s supper hour, so I finished off as
quickly as possible, and submitted quietly to the indignity of having
my arms bound again.
I had the great satisfaction a minute or two later of seeing Ned peg
into his prison allowance as if he had not had anything to eat for a
month. It was really a great relief to me, for I could not help feeling
anxious as to the effect of the severe flogging he had so lately
received at the hands of the mule-driver, for severe no doubt it had
been. I could not see Ned’s face at all distinctly, as he was so much
in the deep shadow, but I augured favourably from his apparently
prodigious appetite.
My brief conversation with Mr. Triggs recurred to my memory as I
lay ruminating upon the floor of the cave. The gunner had pooh-
poohed the idea that the chief had effected our capture with the
notion of making away with us, founding his belief on the length of
time that had elapsed since we had been taken prisoners. It
appeared to me doubtful whether much importance could be
attached to that. I knew that the gunner was considered a man of
sound judgment; but it also occurred to me that he had already made
one fatal mistake in endeavouring to make a reconnaissance in a
hostile country with an inadequate force, and he might even now be
making mistake number two, and deceiving himself egregiously.
Yet it seemed the most plausible explanation of our capture, that a
demand for a heavy ransom would be made to the Spanish or the
British Government—that is, supposing that the chief and his
followers were simple bandits and nothing more; and for all I knew to
the contrary, they might be. But then it occurred to me that even if a
ransom were paid and we were released, the subsequent
extermination of the whole band by the Spanish troops and an
English naval brigade would be a comparatively easy matter. Would
bandits allow themselves to run this terrible risk? Had their
stronghold been situated in the midst of inaccessible mountains far
from the haunts of man, the case would have been different; but this
cave—
My ruminations were suddenly cut short at this point by the loud
baying of the Cuban bloodhound, which had arisen from its
crouching position and was alternately sniffing the air and glancing at
its master. The next moment a messenger arrived in a breathless
condition and handed a note to the chief.
The latter took the missive without uttering a word, tore it open,
and quickly mastered the contents. Then he gave one or two short
sharp words of command, in response to which all his followers leapt
to their feet and busied themselves in preparations for an immediate
departure.
I was thunderstruck at this sudden resolve on the part of the chief,
and wondered what it portended. I calculated that it must now be
somewhere about midnight, though I could not tell for certain.
My thoughts were suddenly turned into a still more disagreeable
channel; for the chief stalked up to me, in company with his ferocious
four-footed satellite, and made the latter deliberately smell me all
over. This repellent couple then crossed over and went through the
same performance with Ned Burton. Then they disappeared around
a corner of the cavern, doubtless in search of Mr. Triggs. I am
ashamed to say that I felt in mortal terror when that fierce-looking
dog came and poked his great jowl and snout against me, as if in
search of a nice tender place in which to bury his fangs. There could
be no doubt as to the reason of this strange procedure. The dog was
to be familiarized with our scent, so that in the event of his being put
upon our trail he would follow it up with more bloodthirsty zest.
It gave one a “creepy” feeling to think of it!
The chief now came hurriedly striding back into the main part of
the cavern again, and pointing first at me and then at Ned Burton,
issued some order in his usual domineering manner.
Immediately we were seized, lifted upon our feet, and blindfolded.
It was evident that we were going to set off on a journey
somewhere, and my heart sank within me at the thought; for not only
was my poor head still racked with pain, but I felt terribly fatigued as
well, and almost overcome with a strong desire to sleep.
In rasping tones the chief marshalled his men and enjoined silence
upon them. Every voice was hushed, but I could clearly distinguish
the heavy breathing of my bête noire, the Cuban bloodhound, as it
followed its master about.
One hope animated me at this moment, and that was that the chief
was about to beat a retreat in consequence of the advance of the
naval brigade, and therefore that there was a chance of our being
succoured ere long.
“Jim Beddoes must have given the alarm before this,” I muttered
to myself, “and we shall soon be free again.”
We moved off almost at once, and I quite expected, from what Mr.
Triggs had said, that we should immediately emerge into the open
air; but to my surprise this was not so. No fresh air of heaven fanned
my heated brows, and I did not stumble over stones and inequalities
in the ground. I was impelled forward at a rapid pace, but it was quite
evident that we were still underground. It was equally evident to me
that we were following some narrow, dark, and tortuous passage.
The flickering light of torches penetrated, to a certain extent, the
bandage over my eyes, and I was gifted with a keen sense of smell,
which revealed to me the fact that I was breathing the noxious
atmosphere of an ill-ventilated subterranean tunnel charged with
mephitic vapours. The footfalls of the men, as they trooped along,
sounded hollow and unreal, as also did the occasional ring or clang
of their weapons. Now and again the sound of water dripping over
rocks smote upon my ears, and I heard the rush and gurgle of a
stream—no doubt the one that had fed the cavern cascade—as it
forced its way through some underground aqueduct of nature’s own
making.
It was terribly tantalizing to be blindfolded.
The way seemed to me interminable. Once or twice I began to feel
my head swim round; but I managed to pull myself together with a
great effort, hoping every moment that we should emerge from the
subterranean passage and be enabled to breathe pure air.
The idea occurred to me that it might be difficult, indeed, to
discover the main entrance to the cavern if it was by such an
approach as this, and one could hardly blame Jim Beddoes for not
having discovered our prison. I felt sure that the gunner had been
mistaken in thinking that he saw the mouth of the cave from where
he lay, and I concluded that he had probably been deceived by the
descent of the flood of light from some orifice overhead.
At length I began to breathe more freely. The mephitic vapours
were gradually giving place to a purer atmosphere. It was like new
life to me, and the feeling of faintness passed away. Still we seemed
to wind along the tortuous tunnel. Still the measured tramp, and the
reverberating echoes upon the rocky vault.
A low word of command issued by the chief; a halt; a whispered
conference which appeared to last some time; a few hurried footfalls,
and then a sound of some heavy obstruction being rolled back. I felt
a sudden rush of cold night air. With what ecstatic delight did I draw
it into my lungs, and feel it playing over my face and hair. My nerves
were instantly braced up, and my head ached with less intensity.
 Another order came from the chief, still in a low tone, as if he were
fearful of being overheard.
Once more we moved forward, and then a strange thing
happened. I was bent almost double by the men who were
conducting me, and pushed through what seemed to be a small
square orifice in the rocks.
 CHAPTER XV.
A MARCH TO THE COAST.

I WAS in the open air. Of course I knew that at once.

There was very little delay. Another whispered conference, and
we moved on again. The ground was now broken and rough, and
from the woodland scents which were wafted to my nostrils I came to
the conclusion that we were in the depths of one of the Cuban
forests. Occasionally, too, I stumbled, in spite of my guards’
precautions, over rocks and tree-roots.
No one spoke. The route was one evidently well known to the
chief and his myrmidons, for they seemed to me to glide on
unerringly. At times we climbed the sides of low hills, but as a rule
we followed a downward gradient. I felt sure that there was no path,
and that we were simply striking a bee-line across country. As there
was no moon, some of the men carried torches. Judging from the
smell, I should say they were made of some resinous wood.
It occurred to me that our captors were running a great risk in thus
marching across country by the light of torches; but I concluded that
they knew their own business best.
One thing was certain—the affair was a very urgent one.
There was a mystery about the whole business which puzzled me
much. To unravel it seemed impossible.
I cannot tell how far we travelled on this dreary journey, but I think
a couple of hours or so must have elapsed when I was astonished to
hear the distant sound of waves breaking upon a rocky shore.
We were approaching the sea.
My mind immediately became filled with gloomy forebodings, for I
conjectured that our captors were about to embark in some vessel
and take us away from the island of Cuba altogether.
 This was a terrible thought, and one that in my most dejected hour
had never occurred to me. All trace of us might be lost if once we
were forcibly removed from Spanish soil. And whither were these
villains going to take us?
Whilst I was oppressed with these sombre thoughts, a little
incident occurred which cheered me somewhat. The bandage which
was around my eyes had slipped a little, and I was enabled to see to
a certain extent what was going on around me. It was very dark, but
the flare of the torches enabled me to see objects close at hand. As
far as I could tell, we had just emerged from the forest, and were
now following a stony track leading down to the sea-coast. The latter
was not visible in the intense gloom that prevailed; but every
moment the roar of the waves became more distinctly audible, and
the briny breath of the ocean came sweeping up on the wings of the
night breeze.
At the head of the party, I could just discern the chief, who was
evidently acting as guide; and I could also see the gunner and Ned
Burton, who were only a few paces in front of me. My coxswain, I
thought, seemed to walk with some difficulty, and I attributed this to
the effects of the flogging he had received.
In about ten minutes’ time we were near enough to the sea to
enable me to make out the white surf of the breakers as they dashed
on some outlying rocks that seemed to act as a natural breakwater
to the little bay we were approaching. The booming noise of the
waves breaking upon the beach was mild compared to the roar
caused by this buffeting of the great boulders. The storm clouds we
had observed in the sky during the afternoon had all vanished, and
the celestial star-gems, flashing and twinkling, shone down brilliantly
from their setting of dark lapis lazuli. Not a vapour obscured the clear
radiance of heaven’s vaulted dome, with its ghostly light from a
myriad distant worlds.
Was that a dark-hulled, rakish-looking vessel I saw riding upon the
sombre waters of the bay?
It looked uncommonly like it, but the faint starlight was so
deceptive, and the glare of the torches so distracting, that I really
could not tell for certain. That it was a genuine little bay we were fast
descending into seemed beyond all question, for I could now make
out the dark irregular line of the coast as it reared itself against the
starlit sky.
My thoughts were now concentrated upon the vessel I thought I
had seen anchored in the bay. Had she been a genuine trader, she
would surely have had a light burning as a signal to other vessels to
give her a wide berth.
Ah, there she was! Yes, I saw her indistinctly, it is true; but still that
hasty glance was enough to satisfy a sailor’s keen eye.
What was this mysterious craft?
There was no time to ruminate further on this head, for we had
now arrived upon the beach, which was composed of patches of firm
sand and shingle, interspersed here and there with a few slab rocks,
and terminated at either end by low but precipitous dark cliffs.
I peered about me intently, fully expecting to see boats drawn up
on the beach, and attendant crews waiting close at hand. Nothing of
the kind, however, was visible.
“The chief will send up a rocket,” I muttered to myself, “and then
boats will be dispatched from the vessel in the bay.”
How earnestly I hoped that the bandage over my eyes would not
be examined by any of my meddlesome jailers! I considered it of
great importance that I should continue to see, even to a limited
extent, what was going on.
My conjecture as to the firing of a rocket was falsified. No such
fiery messenger clove through the darkness, nor did we halt for a
moment. Without uttering a word, the chief led the way along the
beach in the direction of the cliffs at the northern extremity of the bay.
I glanced again and again at the dusky outline of the vessel, fully
expecting to see the flashing of lights, or to detect the sound of
voices. All, however, remained still, silent, and dark, as if every one
on board was buried in slumber. Once, indeed, I thought a signal
rocket had soared up into the air from her upper deck, but it turned
out to be a bright and beautiful meteor which shot across the sky just
above her masts.
As we neared the cliffs, I saw that there were many lofty detached
rocks on the sands close to them, and others jutting out into the sea
in every direction. On these latter the waves were breaking in
showers of foaming spray. It was not at all rough, but the tide was
evidently flowing.
Suddenly my eye fell upon a natural archway amid some of the
loftiest rocks, and as I gazed the chief disappeared through it,
followed closely by the leading files. The next moment I had passed
through the aperture myself; and so surprised was I at the scene that
burst upon my view that I almost gave vent to a cry of astonishment.
Fortunately I restrained myself just in time, or the consequences
might have been fatal to my seeing anything more.
We were advancing along the shores of a miniature almost land-
locked cove, the beach of which was composed of extraordinarily
fine white sand, quite free from pebbles and rocks. Drawn up on the
strand were two black boats, the crews of which were lounging about
close at hand. The instant, however, that we appeared upon the
scene, these men were on the alert, and began making preparations
for launching the boats. A slight tall man, however, who was
enveloped in a Spanish cloak, detached himself from the crowd, and
advanced to meet us with hasty strides. I was alarmed to see that he
had in close attendance on him a Cuban bloodhound, of much the
same aspect and dimensions as the one with which I had already
made acquaintance. As this individual approached, we were ordered
by the chief to halt, and the latter took the stranger aside and held a
private conference with him. The two dogs took the opportunity to
greet each other, and judging by their whimpers of delight seemed to
be very old friends.
The cove was very sheltered, and its waters lay in almost a stark
calm, reflecting as in a gigantic mirror the gorgeous stars which
strewed the firmament. Now and again a fish rose to the surface
amid a burst of phosphorescent light which disturbed its tranquillity.
The beach was somewhat steep and the sand firm. A better landing-
place for boats could not have been found in the island of Cuba, I am
certain.
As far as I could tell in the dim light—the torches had now been
extinguished—the boats were of a good size, but certainly not
capable of embarking us all.
The conference the chief had been holding with his mysterious
friend had now terminated, and the latter issued some order to the
boats’ crews, the effect of which was that the two craft were run
down the steep beach with great speed into the water. Three or four
men jumped into each and seized their oars. Then the chief gave his
satellites the word of command, and before I knew where I was I
found myself forcibly seized by four men, carried down to the water’s
edge, and then unceremoniously bundled into the stern-sheets of
one of the boats. Anxiously I peered out to see what would become
of my fellow-prisoners, and was relieved to see that they had both
been placed in the other boat.
It made me despondent indeed to find that my fears were realized,
and that we were to be forcibly removed from Cuba; but had I—
through some nefarious scheme of the chief—been separated from
my shipmates altogether, the blow would naturally have been far
more severe.
The chief got into the boat in which I had been placed, and my
bête noire came and threw himself down close to me, his fangs
being within an inch or so of my face. Feeling his hot breath quite
distinctly, I tried to shift my position, but I found that I was effectually
wedged in by my jailers. The remaining dog got into the other boat.
To my surprise, a number of the men who had accompanied us
from the cavern remained on shore, evidently having received orders
of some kind from their chieftain. I thought it possible that the boats
might be going to return for them after we had been safely disposed
of on board the vessel.
In an instant, and in dead silence, the two craft were pushed off
into deep water, and their noses were turned in the direction of the
open sea. The oars were muffled, and gave out little or no sound; but
the blades appeared to be plunging in and out of liquid fire, so full of
phosphorescent light were the star-begemmed waters of the little
cove.
I had little doubt that we were being taken on board the vessel I
had seen in the larger bay, and this conjecture proved quite correct.
In spite of the tide being against us, we spun along at a very rapid
pace; for the men pulled with tremendous energy, although with
quick, jerky strokes. In a minute or two we had passed through the
narrow, rock-guarded entrance of the little cove, and were in the
rougher water outside.
From my position in the boat I could only partially see the vessel
we were steering for, and the light was very deceptive; but I took her
to be a small brig of foreign build and rig.
Our boat outstripped the other, and we got alongside first.
Two minutes later I was securely manacled in irons on the
starboard side of the lower deck, just amidships, my bandage and
lashings having been removed.
It was degradation indeed, but I determined to try to face my fate
manfully. “Never say die!” should be my motto; and somehow the
saying of the heroic Sir Humphrey Gilbert came into my mind,
“Heaven is as near to us on the sea as on the land.”
 CHAPTER XVI.
IN IRONS.

F IVE minutes after I had been put in irons, Mr. Triggs and Ned
Burton, under a strong guard, were brought down a hatchway
ladder just over my head. I was overjoyed to find that they were
going to be manacled close to me, for I had not in the least expected
such good fortune. As soon as my shipmates’ legs had been
secured, and their arms and eyes set free, our guards hung a lantern
to the beams, went away, and left us alone.
It was evident that the vessel was going to get under way at once,
for there was a great hubbub on deck, and I thought I could
distinguish the noise of a windlass and of a cable coming in at the
hawse-hole. I knew, too, that the land wind was blowing, and felt
sure that the chief would wish to take advantage of it to get clear of
the coast before dawn.
Mr. Triggs and Ned were as delighted to see me as I was to see
them.
“They didn’t mean to put us together, I suspect,” said the gunner;
“but it so happens they’ve got irons only in this part of the ship, and
can’t well help themselves.”
“This is an armed vessel,” said I, watching my shipmates’ faces
keenly, “and must be a privateer, or perhaps a piratical craft of some
kind.”
The gunner started.
“How did you gain that information, youngster?” he asked.
“Weren’t you blindfolded?”
Ned was watching me curiously. I was grieved to see by the light
of the flickering lantern that his face looked haggard and drawn.
 I told them how my bandage had slipped down, and had enabled
me to spy to a certain extent upon the doings of our captors.
“That was a slice of luck, and no mistake,” said the gunner,
rubbing his hands; “and if ever we succeed in circumventing these
villains, your knowledge may prove to be most important.”
“What do you think they’re going to do with us, Mr. Triggs?” I
asked.
“I’m just as much puzzled as ever,” answered the gunner. “They
want to get a ransom for us, I s’pose, but ’tis the most mysterious
business I was ever mixed up in.”
“The owdacious swabs!” put in Ned angrily. “I only hope that our
skipper will make a clean sweep of ’em when he hears tell of their
little game.”
I condoled with my coxswain as to the vile treatment he had
received at the instigation of the mule-driver.
Ned thanked me warmly for my sympathy.
“Of course, I knew you’d feel for me, sir,” he said; “but don’t you
trouble your head any more about the matter, but try to forget it. I’d
do the same myself, but my back is that stiff and sore I’m blowed if I
can.”
“Now just a word or two of advice, if you’ll excuse it,” observed the
gunner, “and then we must try to get forty winks, for it’s no good
blinking the matter we’re all as tired out and exhausted as we can
be. The advice is this: We had better not be seen talking by any one.
If any member of the crew comes down on this deck, mum’s the
word! Take no notice of any insults or bad treatment. Try to look as if
you liked it. Keep your weather eyes lifting, and your ears open, but
look as stupid as owls. Now, good-night, and God bless you both!”
Ten minutes later the gunner and Ned Burton were actually fast
asleep. Sailors who have seen as many years of service as they had
seem to be able to fall into the arms of Morpheus at a moment’s
notice, even under extraordinary conditions.
How I envied my companions in misfortune!
 For a long while—or so it seemed to me—sleep would not seal my
eyes. The hurried rushing to and fro of men on deck, the creaking
and clanking of spars and cables, the subdued shouts of those in
command, and the answering hails from the crew—all combined to
keep my senses on the alert and to banish slumber. Besides all this,
my brain was in a whirl. All the strange adventures of the last twelve
hours recurred again and again to my memory, and my anxious
thoughts kept dwelling also upon the deadly perils of our present
situation, and of the utterly unknown future looming like a gloomy
cloud upon the horizon of our lives. I was especially oppressed with
the dark foreboding that our shipmates would be unable to discover
that we had been torn away from the shores of Cuba. I pictured them
anxiously and energetically searching every nook and cranny of the
valleys and hills in a vain search for us, and utterly ignorant of our
real whereabouts.
It was weak and foolish of me to take this pessimistic view of
matters, but the reader must kindly remember that I was in a very
exhausted and overwrought state.
The waves were dashing against the vessel’s sides; she heeled
over slightly under the influence of the land breeze; the noises on
deck had ceased. We were under way.
The gentle, almost imperceptible motion of the little craft seemed
to lull me to rest, and in a few minutes, in spite of the hard deck, my
heavy iron manacles, and still heavier forebodings, I fell into a
feverish, restless sleep—rocked in the cradle of the deep.
I was awoke some hours later by feeling a heavy hand upon my
chest, and hearing a loud, fierce voice in my ear.
 CHAPTER XVII.
ON BOARD THE PIRATE BRIG.

I STARTED up. It was broad daylight. The ill-favoured countenance

of the mule-driver was the first thing that met my gaze. The fellow
was kneeling on the deck beside me, and there was a sardonic grin
upon his swarthy visage as he stared at me.
“No can possible wake them mans,” he said, indicating my still
slumbering shipmates with a jerk of one of his skinny fingers; “dare
say you can do him.”
I started violently.
This rascal, then, spoke English, or a rude smattering of it, at any
rate!
The mule-driver noted my surprise, and gave a guffaw. Then he
pointed to three basins of some kind of porridge which stood upon
the deck close beside him. In each reposed a wooden spoon of very
ample dimensions.
“Brokefast!” he ejaculated. “Englishmans get plenty fat on him,”
and before I had recovered from my astonishment he had glided
away and disappeared swiftly and silently up the hatchway.
“An evil spirit!” I muttered to myself with an involuntary shudder,
and then I aroused my shipmates by calling them by their names. At
first they seemed greatly startled, but they quickly realized their
position, and asked me how I had slept.
I told them of the mule-driver’s appearance, and of his knowledge
of English; and then I pointed to the three basins of porridge, which
were just within my reach.
“Understands our lingo, does he?” remarked Mr. Triggs
thoughtfully. “Then he’s a smart fellow in his way, you may depend,
and knows a doosid sight more about us than he ought to.”
 “He wouldn’t have been of much use to his mates as a spy if he
hadn’t ferreted out summat or another,” said Ned. “Will you be so
kind, Mr. Darcy, as to give me up one of them basins of skilly, for I’m
mortal empty and mortal dry?”
I glanced at my coxswain, and was pleased to see that he was
looking better and cheerier.
In a moment we each had a basin of porridge in our hands, and
were assiduously stirring the not very appetizing compound
contained therein.
The gunner sniffed scornfully at his.
“Hominy stirabout, as I’m a living sinner!” he ejaculated; “and
flavoured with rancid butter.”
“A villanous compound, but not bad at the price,” I said, trying to
put a good face upon the matter.
Ned made no observations, but was already half-way through his
portion.
When he had completely emptied his basin, he placed it carefully
on the deck beside him, wiped his mouth on the sleeve of his jumper,
and remarked sententiously,—
“Must keep body and soul together somehow. Don’t you sniff at
yer wittles, Mr. Triggs, or maybe the swabs’ll put you on half-rations!”
I managed to swallow a few mouthfuls; but it really was a villanous
compound, and I could get no further.
“I suppose there ain’t no chance of getting soap and water out of
these thunderin’ thieves,” said Ned, glancing at his grimy hands;
“’tain’t in their line, as you may say.”
“I’m afraid not,” said I; “but we can ask the mule-driver next time
we see him.”
At this very moment the subject of our conversation came down
the ladder, and approached us with the object of removing our
porridge-basins. I noticed that he glanced in a furtive, underhand
manner at Ned Burton.
 “No,” he growled out in answer to my request that we might have
some soap and water; “we no wash ourself, why you do him?” Then
he slouched off whistling.
“No soap and no baccy!” said Ned plaintively, as soon as the
fellow was out of hearing. “’Tis hard upon a chap, and no mistake.”
At Mr. Triggs’s suggestion, we exercised our arms gently, so as to
get the stiffness out of them; and the good effect it had was
wonderful. I am afraid my coxswain found it rather a painful
operation, but he made no complaint.
“I’d like to practise fisticuffs on some of these rascals’ heads,”
observed Ned after we had finished. “A lesson or two in boxing
’twould be, and nothing to pay for the larnin’.”
The deck on which we were confined was rather dark even in
broad daylight, being illuminated only by the rays of light which came
down the small adjacent hatchway, and by three or four remarkably
dirty scuttles in the ship’s side. Amidships, I noticed that there were a
good many casks and cases securely fastened to stanchions by
stout rope; but what they contained I had no means of ascertaining.
Close to my left hand was a row of bulkheads, and these stretched
athwartships right across the deck, and had a door in the middle,
which I fancied opened into the crew’s sleeping-quarters.
The little craft was evidently going through the water at a slashing
pace. She was almost on an even keel, but we could plainly hear the
water rushing and gurgling past under her counter. The gunner gave
it as his opinion that she was running before the wind at eight or nine
knots an hour. Silence seemed to prevail fore and aft, and we could
not even hear the flapping of canvas, the cheeping of spars, or the
rattle of a rope through a block.
Once I heard the melancholy bay of a bloodhound, and could not
help thinking that it was a sound of evil omen.
The morning wore on, and we saw nothing of the chief. Every half-
hour or so the mule-driver crept down the hatchway ladder to see
that we were safe. He had pistols stuck ostentatiously into his belt
upon these occasions, but always resolutely and sullenly refused to
answer any questions we addressed to him, so at last we gave it up
as a hopeless job.
It was really a great relief to us that the chief did not put in an
appearance, for we felt strongly that no appeal for mercy, or demand
for release, would have the slightest effect upon him; nor was he
likely to proffer any explanation as to his reasons for kidnapping us.
Again, we none of us wished to renew our acquaintance with his
ferocious-looking bloodhound, nor to be introduced to the latter’s
compatriot, which doubtless was also on board.
The morning passed away wearily. It was a great boon to be able
to converse with one another, but we were a melancholy trio, as the
reader may suppose, for at present we saw no chance of being able
to free ourselves from a terribly irksome and even cruel captivity.
No bells were struck on board the brig—for such I believed the
little craft to be—and we had no means of telling the time. I think,
however, it must have been about noon that the mule-driver, whose
name I had discovered was Miguel, brought us a mess of dried fish
and rice for our mid-day meal. From the ancient smell which seemed
to hover about the former article of food, we did not anticipate much
enjoyment from eating it; but, to our surprise, it did not prove at all
unpalatable, and we finished every morsel of it with great gusto, Ned
declaring that he had not had such a “tuck-in” for months, and that
fighting-cocks weren’t in the running with us at all.
In the afternoon we slept long and heavily, but we awoke—all
confessed to it—feeling feverish and irritable. If Miguel had
inadvertently put his ugly visage at this moment within reach of Ned
Burton’s prodigious fist, I fancy he would quickly have retired from
whence he came, a wiser and an uglier man, and have made tracks
for the galley to try to coax the ship’s cook out of a raw beefsteak.
Happily for us no such fearful contretemps occurred; and, as the
effects of our afternoon snooze wore off, we began to feel more
amicably inclined towards our fellow-creatures.
“Ned,” said Mr. Triggs abruptly, “where’s your knife?”
 “My knife!” ejaculated the seaman. “Well, that’s a good un anyhow.
Why, it’s where your ticker and t’other gimcrack vallables is—up the
spout!”
“My ticker up the spout!” said the gunner with a sudden
assumption of dignity; “I don’t quite follow your meaning.”
“Well, I was speaking in a sort of parrydox or conundrum, I take it,
Mr. Triggs,” answered Ned, floundering, as was sometimes his wont,
into expressions of which he did not know the meaning. “What I just
meant to say was that these blooming highwaymen, or pirates, or
whatever scum they are, have pouched the whole bag of tricks. My
knife and lanyard, my baccy-box, and a ring my great-aunt give me
just afore we sailed from England, have gone the same way as your
watch, and trinkets, and such like.”
“I’m sorry for it,” said Mr. Triggs; “a knife would have been worth its
weight in gold to us.”
“Likely enough,” assented Ned, looking at his superior a little
curiously. “I reckon you’d have liked it handy to eat bread and
cheese with if the pirates give you a chance.”
“No, I like whittling to amuse myself,” said the gunner with a sly
wink; “though it’s very useful too sometimes to cut one’s stick.”
“That’s as true as gospel,” answered the seaman with a grin; “but I
tell you what, you might sit there and whittle and whittle till the crack
o’ doom, but you wouldn’t cut no sticks while them young cables is
riveted to your blessed feet. That’s a conundrum if ever there was
one.”
“Ah, I keep a brighter look-out ahead than you do, Ned. I should
like to have a knife handy for operations ashore a little later on.”
My coxswain stared.
“How do you know they’re going to put us ashore?” he asked.
“They may keep at sea for a long time to come.”
“Has it ever occurred to you, Mr. Triggs, that we might be
marooned?” I put in anxiously.
 “Pooh!” answered the gunner, “maroon your grandmother. What
possible benefit would it be to them to put us ashore on a desert
island, I should like to know?”
“Some spite against our government, or naval authorities,” I
answered.
“Ah, there’s something more than mere spite at the bottom of this
business, my lad, don’t you make any mistake. Now, shall I tell you
what I think these kidnapping fellows are?”
“Fire away!” I said laconically.
“Well, I think they’re out-and-out pirates—that’s what I think they
are,” said the gunner emphatically; “and I’m under the impression
that their headquarters are on some almost unknown island a
considerable distance from Cuba, and that they prey upon the
shipping that passes to and fro in these seas. I also think that they
are mixed up in the smuggling business, and that, owing to the laxity
of the Spanish navy, they have managed to form a depôt in those
caves which we—”
“Ha, ha! I see zat you know all that am posshible to tell about him!”
exclaimed a high-pitched voice from the hatchway, and the next
moment, to our great dismay, the crafty sallow visage of Miguel
appeared, glaring at us through the steps of the ladder.
“What a mean spy-cat!” exclaimed Ned indignantly.
The gunner felt very much nonplussed.
“’Tain’t much use my giving you fellows good advice,” he said sotto
voce, “when I let my own tongue wag and run away with me like that.
The chief will have a down upon me now, that you may depend
upon.”
I watched Miguel curiously to see what he would do next, fully
expecting that he would come and insult us in some way, for I knew
quite well what a mean and petty nature the man had. To my
surprise, however, he only gave one of his sardonic grins, and then
disappeared in his stealthy fashion up the companion ladder.