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Child Health Nursing Child Health Nursing Partnering With Children Families 3Rd Edition PDF Full Chapter PDF
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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.
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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
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s
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).
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-
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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
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.
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
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?
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
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
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
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
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.
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
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.
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.
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
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
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
■
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).
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(2008). Initiating change: Creating an asthma- Fan, L. L. (2010). Serial measurements of lung function
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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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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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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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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.
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.