Prevention: Anticipation of cold conditions and knowledge of cold survival techniques are the basis of prevention. Children living in cold climates should have adequate protection when outdoors. Multiple layers of warm clothing are more effective than a single heavy layer for reducing the rate of heat loss, although they do not prevent it. Families living in cold climates should take precautions against unexpected prolonged exposure to cold (e.g., store extra blankets, food rations, and other equipment in their vehicles in the event of an unexpected mechanical breakdown).

Loss of central core heat can be reduced by 50% when an individual assumes the fetal position or when a person in water remains still. A person suspected of having hypothermia should be moved to a sheltered area, and wet clothing should be removed and replaced with dry, warm garments. Administration of warm, high-calorie liquids is important if the person is conscious.

Nursing Care Management

The most effective means of management is prevention. Parents always remember a severe response. A careful history taking will elicit evidence of a previous drug reaction. The history should include the name of the drug, nature of the reaction, drug dose, and how soon after administration the reaction occurred. (See History Taking, Chapter 6.)

Nurses who suspect that medication is the cause of the rash should withhold any further dose and report the eruption to the practitioner. Frequent offenders in drug reactions are penicillin and sulfonamides, and nurses must be alert to this possibility. However, even commonplace drugs such as aspirin and barbiturates, chemical agents in some foods, flavoring agents, and preservatives are capable of producing an undesired response. Persons who have severe reactions should wear a medical identification bracelet or necklace in case of emergency or inadvertent administration of the offending agent.

Nursing Care Management

Nursing care involves recognition of signs that indicate a possibility of the disease, referral for diagnosis, and family counseling and support. It is important that a diagnosis be made, even when the only manifestations are a few café-au-lait spots. The family needs to know the genetic implications and be alert for signs that indicate the child is developing more serious characteristics of the disease. Cancer occurs in patients with the disorder, although the rates vary widely. Other members of the family should be assessed for evidence of the disorder.

In addition, families need to know that children with NF1 have a significantly increased risk for learning, social, and emotional problems. Parents need to receive written materials about these problems that they can share with teachers and other adults who interact with the child. Children with NF1 should be screened using systematic standardized tests, and more aggressive and intensive treatment should be provided for speech, motor, and cognitive deficits that may contribute to social and emotional problems (Johnson, Saal, Lovell, et al, 1999).

The Children’s Tumor Foundation* is an organization dedicated to increasing public awareness of NF1, providing help and support to families affected by the disorder, and stimulating research.

Hymenoptera Stings

When a hymenopteran (a bee, in particular) stings, its barbed stinger penetrates into the skin. The stinger also contains a nerve ganglion, muscles, and a venom sac. As long as the stinger remains in the skin, the muscles push the stinger deeper, and venom is pumped into the wound. A study of different methods of extracting the stinger revealed that the method of removal did not influence the amount of venom injected into the wound. There was no difference in the amount of venom injected when the stinger was removed by external compression with forceps and when the stinger was flicked or scraped off the skin. The influencing factor was the amount of time from the bee sting to removal of the stinger; the longer the time interval, the greater the amount of venom injected (Visscher, Vetter, and Camazine, 1996). The best approach is to remove the bee stinger as quickly as possible and to get away from the vicinity of other bees to prevent further injury.

Children need to know how to avoid contact with bees and to recognize the insect (e.g., it is not part of the flower). For those who have become sensitized to hymenoptera stings and demonstrate a severe life-threatening systemic response, intramuscular administration of epinephrine provides immediate relief, and the drug must be available for emergency use. For hypersensitive children, a kit must be available that contains epinephrine, a hypodermic syringe, and perhaps ephedrine and an antihistamine preparation. Hypersensitive children should wear medical identification, such as a bracelet. Nurses should remind parents to frequently check the expiration date on the kit and replace an outdated one. Families should find out whether a nurse is available at the school; if not, someone at the school should be designated to inject the epinephrine in case of an emergency.

Children with a history of generalized reactivity to an insect sting should undergo skin testing with the radioallergosorbent test and possibly immunotherapy with venous extract (desensitization) to prevent serious or fatal reactions. In the United States venous extracts are available for the honeybee, yellow jacket, yellow hornet, and wasp.

Arachnid Bites

Most arachnids in the United States, including tarantulas, are relatively harmless. All spiders produce venom that is injected via fangs. Some are unable to pierce the skin; others produce a venom that is insufficiently toxic to be harmful. A local tissue reaction is relieved by cool compresses or the methods described for hymenoptera stings.

Only scorpions and two spiders—the brown recluse and the black widow—inject venom deadly enough to require immediate attention. Children bitten by these arachnids must receive medical attention as soon as possible.

Ticks are troublesome because they become partially imbedded in the skin as they feed. The recommended method for removal is to grasp the tick with curved forceps as close as possible to the point of attachment and pull straight up with a steady, even pressure. If a portion of the body (e.g., the head) remains, it can be removed with a sterile needle in the same manner as a sliver. The bite is cleansed with soap and a disinfectant after removal.

To avoid ticks, children should wear long pants tucked into the socks and a long-sleeved shirt when walking in infested areas, especially in the spring and summer. Ticks can also be picked up by dogs and other household pets. Parents are advised to check their children carefully for the organisms when their children have been in areas where ticks might be acquired.

Nonhuman

Nonhuman mammal bites are common injuries and are inflicted by both wild and domestic animals. Wild animal bites are discussed in relation to rabies in Chapter 37, and these wounds are treated in the same way as the bites of domestic animals such as dogs, cats, hamsters, and mice. The present discussion is directed primarily toward dog bites.

Approximately half the victims of dog bites are younger than 5 years of age; boys are bitten more frequently than girls (Bernardo, Gardner, O’Connor, et al, 2000). Stray dogs are seldom involved in attacks; most dogs involved are owned by the family of the victim or by a neighbor. Most dog attacks occur in or adjacent to the owners’ yards, and the attack is usually preceded by verbal or physical contact with the animal (Bernardo, Gardner, O’Connor, et al, 2000). This problem is increasing because of a growing trend of acquiring large, aggressive guard dogs. Most animal bites are caused by dogs. Cat bites are less frequent, although cat scratches are extremely common (see Cat Scratch Disease, p. 703). Most injuries caused by dogs and cats are to the upper extremities. Small children are more likely to receive bites or scratches to the head, face, and neck because they tend to put their heads near the animal’s head and flail their arms rather than protecting their heads.

Animal bites are potentially serious because of the likelihood of significant infection. Injuries vary in intensity from small puncture wounds to complete avulsion of tissue that is associated with significant crush injury. Dog bites are seen as lacerations or evulsions; cats exert less biting force, but their sharp teeth penetrate more deeply, inoculating organisms deep into tissues.

The location of a bite influences the incidence of infection. Injuries to the arm and hand tend to become infected more often than those on the legs, scalp, and face. Redness, swelling, and tenderness develop around the site of injury, often accompanied by purulent or serosanguineous drainage. It may be difficult to assess hand infection because most lymphatic drainage is contained in the dorsal subcutaneous space, and swelling occurs in this area when the injury may be elsewhere.

Human

Children often acquire lacerations from the teeth of other humans in rough play, during fights, or as victims of child abuse. Many preschool children bite others out of frustration or anger. Because human dental plaque and gingiva harbor pathogenic bacteria, all human bite wounds should receive attention. Delaying treatment increases the risk of infection.

If the laceration is less than 6 mm (0.25 inch) long, the wound can be treated at home. The wound is washed vigorously with soap and water, and a pressure dressing is applied to stop bleeding. Ice applications minimize discomfort and swelling. Increased pain or redness at the wound site is an indication that the child should receive medical attention for antibiotic therapy. Tetanus toxoid is needed if the child is insufficiently immunized. Wounds larger than 6 mm should receive medical attention.

Pathophysiology

Dental caries is a multifactorial disease. It involves a number of elements: (1) the host, (2) microorganisms, (3) substrate, and (4) time.

Diagnostic Evaluation

Because the permanent teeth erupt during middle childhood, children are more susceptible to the development of dental caries during this time than at any other age. Caries penetrates the vulnerable teeth rapidly at this age, whereas carious activity is slower and more irregular at later ages.

Caries on visible surfaces are easily detected by oral inspection. Large, extensive caries are apparent to the untrained eye, but small, beginning lesions are best identified by trained professionals. Caries between the teeth may not be located without x-ray examination. A common site of decay is the fissures of the molars.

Therapeutic Management

Well-informed health care professionals can provide dental information and make periodic dental assessments. However, dentists are prepared to provide both of these services and are the only ones qualified to treat most dental problems. Prophylaxis, including hygiene and fluoride treatment, is the major thrust of dental therapy. (See Chapter 14.) Plasticized sealant, applied to the deep fissures and grooves of healthy teeth, is effective in blocking cavity formation. Treatment of dental caries involves removal of all carious portions of the tooth as soon as decay is detected, preparation of a retentive cavity, and replacement of the lost portion of the tooth with a material that is durable in the mouth environment. This restoration of involved teeth not only prevents progression of established caries but also reduces the number of bacteria in the oral cavity to decrease the danger to uninvolved teeth.

Nursing Care Management

Oral inspection is an integral part of the nursing assessment of the child. If there is evidence of dental caries or another unhealthy state, the child is referred for dental services. Many families have a family dentist or a pedodontist who can provide needed care. However, an alarming number of children do not receive regular dental supervision, and a significant number reach adulthood without being examined or treated by a dentist. Nurses can be active members of preventive educational programs and serve as counselors to families regarding the importance of regular dental care, oral hygiene, and dietary management.

Nurses should encourage good oral hygiene and teach correct tooth cleaning to both children and their parents. The random brushing allowed during the early childhood years should be replaced by more careful and methodic cleaning techniques. Children should brush their teeth and use dental floss according to the method recommended by their dentists. (See Chapter 14.) Regular administration of fluoride is also important. (See Chapter 14.) Families should be aware of the fluoride content of their drinking water, including bottled water if it is used. School-age children can usually manage the chewable tablets, which have both a topical and a systemic effect.

Restriction of cariogenic foods is important to prevent dental caries, but this should be viewed as an activity in which all family members are involved and not simply a directive for the child to obey. It should not be communicated in such a way that the child interprets the withholding of sweets as a punishment.

Concern has been generated about the sugar content of children’s pharmaceutical products, especially because children with chronic conditions such as seizure disorders, asthma, and recurrent urinary tract or ear infections must take medications over a period of years. Children with chronic illness who regularly take medications containing sugar are cautioned to brush their teeth after taking the medication, just as they would after eating any carbohydrate substance. Children taking tricyclic antidepressants are also prone to develop dental caries.

The greatest task for nurses is counseling children and families to develop sound dental hygiene and nutritional practices. School nurses have an excellent opportunity to participate in community detection of dental needs, to educate children in dental hygiene, to make referrals, and to motivate children to comply with prophylaxis and treatment.

Children should be prepared for dental services in such a way that visits to the dentist are a positive experience. Keeping appointments and following through on recommended treatments and practices are habits that extend beyond childhood.

Nursing Care Management

Nursing care of the child with periodontal disease is primarily supportive; it includes education regarding dental hygiene and regular inspection of the gingival tissues for signs of early inflammation. Advise the child to see the dentist at any sign of inflammation or irritation.

Nurses caring for teenagers should observe for the use of chewing tobacco. The easily detectable clinical lesions appear as tooth erosion, periodontal destruction, and red or white mucosal alterations. The primary site of lesions is the anterior mandibular mucobuccal fold region.

Nursing Care Management

The nurse who detects malocclusion is obligated to recommend that the teeth be examined by a dentist. The sooner the child is evaluated, the sooner treatment can begin.

Although orofacial appearance is a subjective phenomenon, it can have an adverse effect on a child’s self-esteem and body image. Poorly aligned teeth can be a source of both psychologic and physical stress to affected children. Many children with severe malocclusion are teased by their peers or siblings.

If fixed appliances or braces are applied, the child is advised that there will be some discomfort for a few days. During the period of orthodontic treatments, which averages 18 to 30 months, proper oral hygiene is vital. Although the bands or brackets protect the teeth they cover, plaque can collect on the unprotected surfaces or under loose-fitting bands. The teeth should be brushed with a fluoride toothpaste after every meal and snack and at bedtime, using the method recommended by the dentist. Some orthodontists recommend using an oral irrigating device to remove food from between the teeth and around the braces. However, the device does not remove plaque and is not a substitute for thorough brushing. Some foods can damage the braces; others may be difficult to remove from the teeth during cleaning. Forbidden foods include chewing gum, ice, nuts, toffee and hard candy, corn on the cob, uncut apples, hard taco shells, nachos, and popcorn.

Occasionally, tooth movement or poking at the braces with a pencil or other object may cause an arch wire to break or protrude. If this happens, instruct the child to cover the broken portion with a special wax provided by the dentist and schedule an appointment as soon as possible. Regular visits are usually scheduled every 3 to 6 weeks. After the braces are taken off, a removable or permanent retainer must be used to maintain the desired position of the teeth. Placement of a permanent wire behind the front teeth requires no compliance from the youngster.

Sometimes children need considerable reinforcement for compliance with orthodontic treatment. It may be difficult for some to relate the present barriers of discomfort, inconvenience, and embarrassment to the future reinforcers of improved appearance and dental health. Teenagers with a heightened awareness of body image and physical attractiveness are especially at risk for noncompliance. (See Chapter 27 for a discussion of compliance.)

Nursing Care Management: Tooth Avulsion

A permanent tooth that is avulsed (evulsed, exarticulated, or “knocked out”) should be reimplanted by the child, parent, or nurse and stabilized as soon as possible so that the blood supply to the tooth can be reestablished and the tooth kept alive (American Academy of Pediatric Dentistry, 2009) (see Emergency Treatment box). If the tooth is replaced within 15 minutes, there is a better chance that it will become reattached and the roots will not resorb or the crown exfoliate. Avulsed primary teeth are usually not reimplanted.

Before reimplantation it is important to carefully rinse a dirty tooth in milk or saline solution or under running water to avoid disturbing the adhering periodontal membrane, which is essential to the success of the reimplantation. The tooth is held by the crown, not the root, while rinsing, with the drain plugged. The tooth is then fit back into its socket as atraumatically as possible (Troupe, 1995). If the tooth is reimplanted almost immediately, excessive pressure is not needed; however, it becomes extremely difficult after clot formation (in approximately 10 minutes). The tooth is held in place by the child during transportation to a dentist. If the child or parents are reluctant to reimplant the tooth, the next best alternative is to place the tooth in Viaspan, Hank’s Balanced Salt Solution, cold milk, saliva, contact lens solution, saline, or water for transport to the dentist (American Academy of Pediatric Dentistry, 2009). Cold milk has precisely the osmolality needed to maintain fluid balance within the tissues surrounding the tooth. Water is the least desirable storage medium because the hypotonic environment causes rapid cell lysis.

After reimplantation, the tooth usually becomes firmly attached, although endodontic therapy is often required. If reimplantation is not permanent, the tooth may be retained anywhere from 6 months to 12 years and facilitates normal development and occlusion, since loss of teeth during the period of permanent tooth eruption may adversely affect such development.

As with all mouth trauma, tooth avulsion causes a large amount of bleeding, which is frightening to children and their families. The nurse or anyone faced with dental trauma should be prepared to cope with the emotionality that accompanies tooth avulsion. Using a calm approach and providing gentle reassurance to the child are often successful in reducing anxiety.

Etiology and Pathophysiology

No clear cause for enuresis has been determined. However, predictive factors have been noted, including longer duration of sleep in infancy, a positive family history, and a slower rate of physical development in children up to 3 years of age. There is a high concordance rate of enuresis in monozygotic (identical) twins and an even higher one in dizygotic (nonidentical) twins, which suggests more than a pure genetic link in the disorder. Approximately 75% of all children with functional enuresis have a first-degree relative who has, or has had, the disorder.

Enuresis is primarily an alteration of neuromuscular bladder functioning and as such is benign and self-limiting. Emotional factors may influence the symptom. Some children exhibit temporary regressive behavior resulting in enuresis after the birth of a sibling or other trauma. Other children, such as those with attention deficit hyperactivity disorder (ADHD), may have occasional “accidents” when they become so involved in play that they are unaware of a full bladder or “forget” to empty the bladder. In other children enuresis may be related to problems with toilet training, such as the age at which training began; the emotional atmosphere surrounding the training situation; or an excessive amount of emotional dependence on the parent, usually the mother. Occasionally enuresis can be a behavioral manifestation of a personality disorder.

Although several theories have been proposed, no one theory thoroughly explains enuresis. The sleep theory stems from parental reports that these children sleep more soundly and are difficult to arouse from sleep.

Another theory relates to functional bladder capacity, the volume of urine voided after maximum delay of micturition. Although there is evidence that some children with enuresis have a smaller bladder capacity than unaffected children, other evidence suggests that this is not the cause. For example, children without enuresis but with a smaller bladder capacity awaken during the night to void, whereas children with enuresis do not awaken.

The nocturnal polyuria theory suggests that the kidneys of these children fail to concentrate urine during sleep because of insufficient secretion of antidiuretic hormone (ADH). The ADH circadian rhythm may thus be a significant biologic marker in enuresis, but additional research must be conducted to clarify its role.

The dysfunctional detrusor activity theory suggests that an unstable bladder detrusor muscle spontaneously contracts to produce bed-wetting, either because of abnormal innervation or as a result of other, unknown reasons. Studies to explore this theory have yielded contradictory and inconclusive results; more research is needed to clarify these contradictions and to determine whether there is a relationship between ADH production and detrusor activity.

Clinical Manifestations

The predominant symptom of enuresis is urgency that is immediate and accompanied by acute discomfort, restlessness, and sometimes urinary frequency. With nocturnal enuresis, the child may or may not feel urgency. If awareness of the urgency is present, the child often reports difficulty awakening to urinate. Spontaneous voiding during sleep occurs, which usually results in multiple nightly incidents. Spontaneous remission of nocturnal enuresis occurs in approximately 15% of cases. However, in some cases nocturnal enuresis continues into adolescence and adulthood.

Diagnostic Evaluation

During the initial phases of evaluation, a routine physical examination is performed to rule out physical causes, such as urinary tract infection, structural disorders, major neurologic deficits, nocturnal epilepsy, disorders that increase the normal output of urine (e.g., diabetes mellitus and diabetes insipidus), and disorders that impair the concentrating ability of the kidneys (e.g., chronic renal failure or sickle cell disease). The examination may include diagnostic evaluation of functional bladder capacity. Normal bladder capacity (in ounces) is the child’s age plus 2; therefore normal bladder capacity for 6-year-old is 8 oz (237 ml). Functional bladder capacity is determined by having the child hold off voiding until the strongest urgency is felt, at which time the child voids into a measurement container. A bladder volume of 300 to 350 ml (10 to 12 oz) is sufficient for retention of a night’s urine.

If psychologic difficulties are evident or a personality disorder is suspected, seek a routine psychiatric evaluation.

A history of wetting behavior is obtained, including information about the toilet-training process. Assess parental attitudes by listening and asking parents how they have attempted to cope with the wetting. An important feature of assessment is a baseline count of enuretic incidents and the time of day when each occurs. This is necessary not only to establish diagnostic reliability but also to confirm outcome success after treatment. The baseline information is gathered for 1 to 2 weeks by the child and family. It usually consists of a chart or calendar given to the family on which they indicate the date of the incident, the time of the incident, and the approximate volume of the urinary output.

Therapeutic Management

Enuresis not resulting from known organic causes has been treated in several ways. No single method has achieved universal endorsement. Frequently, more than one technique is employed. In some cases, a spontaneous decrease in bed-wetting occurs with age and irrespective of the treatments used (American Academy of Pediatrics, 2003). Successful treatment is defined as a specified period of dry nights, varying from 7 to 28 consecutive dry nights.

Conditioning therapy involves training the child to awaken to urinate after a stimulus is given, especially with a urine alarm. The device consists of a moisture-sensitive wire pad that is placed inside the underpants and is attached to a bell or buzzer. When the system detects moisture, the bell or buzzer sounds, which fully awakens the child. The child is thus conditioned to awaken at the initiation of micturition or to the stimulus of the bell or buzzer and eventually learns to continue voiding in the toilet. The urine alarm can be very effective, but children may relapse once they stop using it. Relapse is addressed by reinstituting the alarm during sleep. This method is inexpensive compared with drug therapy and has no side effects.

Retention control training was developed after the observation of reduced functional bladder capacity in children who were bed wetters. The child drinks fluids and delays urination as long as can be tolerated to stretch the bladder to accommodate increasingly larger volumes of urine. The use of Kegel, or pelvic muscle, exercises may be helpful in children with daytime enuresis.

In the waking schedule treatment, the child is awakened during the night at intervals to void. This method has been successful in reducing, but not eliminating, wetting incidents.

Drug therapy is increasingly being prescribed to treat enuresis. Three types of drugs are used: tricyclic antidepressants, antidiuretics, and antispasmodics. The selection depends on the interpretation of the cause. The drug used most frequently is the tricyclic antidepressant imipramine (Tofranil), which exerts an anticholinergic action in the bladder to inhibit urination. The dosage and time of administration are individualized, and the drug is given in amounts sufficient to lighten sleep but not to cause wakefulness. Some practitioners prescribe low doses, which reduces bed-wetting in two thirds of children. However, it is important to note that almost all children relapse when the medication is stopped. The suggested length of treatment is 6 to 8 weeks, followed by gradual withdrawal over 4 weeks. Because this drug is dangerous in overdosage, caution parents about safe use and the need to keep supplies of the drug from the reach of younger siblings.

Anticholinergic drugs, especially oxybutynin, reduce uninhibited bladder contractions and may be helpful for children with daytime urinary frequency. Success has also been achieved with desmopressin acetate (DDAVP) nasal spray, an analog of vasopressin, which reduces nighttime urinary output to a volume less than functional bladder capacity. Typically, the child receives two sprays before bedtime. The medication is generally well tolerated but may cause nasal irritation or, rarely, headache or nausea. A preparation of desmopressin acetate is also available in tablet form. This preparation is as effective and safe as the nasal spray but avoids the problem of nasal irritation.

One of the challenges of using the drug therapeutically is the difficulty in simulating the normal circadian rhythm of ADH secretion. Another concern is the expense of the treatment. Although DDAVP is effective in reducing the number of wet nights, only about 25% of children become completely dry, and the relapse rate is about 80% to 90% (Bosson and Lynn, 2001).

Other therapies and treatment options include stream interruption, paired associations, overlearning, reinforcement systems, and self-monitoring (motivation therapy). Frequently these therapies are coupled with other treatment modalities. In conclusion, alarms are the most effective treatment for enuresis, but desmopressin may provide temporary relief (Glazener, Evans, and Petro, 2004a, 2004b). Counseling may be beneficial in helping the child, and sometimes the family, adjust to the bed-wetting.

It is imperative that punishment not be used to correct enuresis. Supportive therapy such as teaching the child to change pajamas and bed linens, as well as restriction of fluids before bedtime, should be used in place of punishment. Behavior modification techniques, such as placing stars or stickers on a chart for each dry night and providing rewards for achieving a certain goal, are also helpful. Token or social reinforcement can also be used to enhance the rewards for success.

Nursing Care Management

No matter what techniques are used, the nurse can help both children and parents understand the problem of enuresis, the treatment plan, and the difficulties they may encounter in the process. Essential to the success of any method is the supportive management of parents and their children. Both need encouragement and patience. The problem is discussed with both the parent and the child, since any treatment involves and requires the child’s active participation. In some treatment interventions the child is in charge of the intervention; therefore parents must learn to support the child rather than intervene themselves. For example, children can strip their wet covers, limit fluids, and use the toilet before bedtime (American Academy of Pediatrics, 2006).

Parents should also be taught to observe for side effects of any medications used. All children with primary enuresis should be encouraged to void before bedtime. Diapering should be avoided. Positive reinforcement in the form of keeping diaries to record dry nights has been effective in fostering motivation in children.

The most important predictor for the outcome of treatment is family difficulties. Family disturbances influence the initial arrest of the enuresis, the relapse rate, and the long-term success rate.

Many parents believe that enuresis is caused by an emotional disturbance and fear that they have somehow produced the situation by improper childrearing practices. They need reassurance that the bed-wetting is not a manifestation of emotional disturbance and does not represent willful misbehavior. Parents need to understand that punishment such as scolding, shaming, and threatening is contraindicated because of their negative emotional impact and limited success in reducing the behavior. Encourage parents to be patient, to be understanding, and to communicate love and support to the child.

Communication with children is directed toward eliminating the emotional impact of the problem; relieving feelings of shame, guilt, and the burden of parental disapproval; building self-confidence; and motivating them toward independent control. More important, the nurse can provide consistent support and encouragement to help children through the inconsistent and unpredictable treatment process. Children need to believe that they are helping themselves and to maintain feelings of confidence and hope.

Etiology

One of the most common causes of encopresis is constipation, which may be precipitated by environmental change, such as having a new sibling, moving to a new house, changing schools, or even having to use new or unfamiliar toilet facilities. Chronic, severe constipation has a tendency to impair the usual movement and contractions of the colon, which can lead to fecal obstruction. Abnormalities in the digestive tract (e.g., Hirschsprung disease, anorectal lesions, malformations, and rectal prolapse) and medical conditions such as hypothyroidism, hypokalemia, hypercalcemia, lead intoxication, myelomeningocele, cerebral palsy, muscular dystrophy, and irritable bowel syndrome are also associated with constipation, which can lead to encopresis (Coughlin, 2003). Voluntary retention of stool may also follow an incident of painful defecation (e.g., in a child with anal fissures). Involuntary retention may be produced by emotional problems caused by the encopresis, which sets up a fear-pain cycle and results in learned abnormal defecation patterns. Psychogenic encopresis, in which the soiling is caused by emotional problems, is often related to a disturbed mother-child relationship.

Normally, children and adolescents have one or two soft-formed stools per day. Children with soiling problems tend to form large-bore stools, which are painful to excrete. Therefore they tend to avoid defecation and withhold stooling. Stool held in the rectum and sigmoid colon loses water and progressively hardens, which causes successively more painful bowel movements and a stretched rectal vault. Over time the child will lose the urge to defecate on his or her own (Montgomery, 2008). A pain-retention-pain cycle is established. Many children have diarrhea or loose leakage in their clothing and pass small amounts of hard stool, which suggests leakage around an impaction.

Children may experience exacerbations with transitions in the school setting. Some reasons for developing retentive tendencies at this time are fear of using school bathrooms, a busy schedule, and the interruption of an established time schedule for bowel evacuation. Children may also react to stress with bowel dysfunction.

Clinical Manifestations

The manifestation of simple constipation is painful expulsion of hard, pelletlike stools. Voluntary retention is usually temporary, with a history of a painful precipitating episode and blood-streaked stools. Involuntary retention is associated with a history of abdominal pain, distention, moodiness, poor appetite, and accumulation of stools with periodic passage of voluminous stools. Children display a characteristic posturing during suppression of colonic signals to defecate—stiffening, standing in a corner with straight legs and a bright red face, “doing a little dance,” “crawling,” or hiding behind furniture or behind a tree when playing outdoors. They typically hide soiled underwear. It is not unusual for soiling to take place after bathing because of reflex stimulation.

The child with encores often feels ashamed and may wish to avoid situations (e.g., camp or school) that might lead to embarrassment. School performance and attendance are affected as the child’s offensive odor becomes a target for scorn and derision by classmates. The child is not well liked by peers and may be severely rejected by the parents as a result of the symptom. Rejection by peers and parents causes further withdrawal and other behavioral manifestations.

Therapeutic Management

Direct treatment toward the cause of the soiling. To determine the cause, perform a complete physical examination, including a rectal examination. An abdominal x-ray film may be obtained to determine the severity of impaction. Diet, lubricants, and a toilet ritual that encourages the child to establish normal defecation are used. Fecal impaction is relieved by lubricants such as mineral oil; osmotic laxatives such as lactulose, sorbitol, or polyethylene glycol (PEG or MiraLax); and magnesium hydroxide. Customary dosages are usually insufficient. Mineral oil should be avoided in children who have dysphagia or vomiting to prevent risk of aspiration. Dietary changes may be helpful, including elimination of milk and dairy products and consumption of increased amounts of high-fiber foods, such as fruits, vegetables, and cereals, as well as increased fluids. Behavior therapy may be indicated to eliminate any fear that has developed as a result of painful defecation. Psychotherapeutic intervention with the child and the family may become necessary.

Nursing Care Management

A thorough history of the soiling is essential—when soiling began, how often it occurs and under what circumstances, and whether the child uses the toilet successfully at all. Because the parents and child are reluctant to volunteer information, direct questioning about the soiling is more successful.

Education regarding the physiology of normal defecation, toilet training as a developmental process, and the treatment outlined for the particular family is a prerequisite to a successful outcome. The regimen prescribed for stimulating elimination is explained to parents. Bowel retraining with mineral oil, a high-fiber diet, and a regular toileting routine is essential in treating encopresis or chronic constipation.

Encourage the child to sit on the toilet 10 to 15 minutes after meals for intervals of 10 minutes. Placing a footstool below the feet may relax the abdomen and make the child more comfortable. Enemas may be needed for impactions, but long-term use prevents the child from assuming responsibility for defecation. Initially lubricants are given liberally, but stimulant cathartics often cause abdominal cramps that can frighten the child. Positive reinforcement such as giving stickers, praising the child, and awarding special activities may encourage the child to participate in the bowel regimen.

Family counseling is directed toward reassurance that most problems resolve successfully, although the child may have relapses during periods of stress, such as vacations or illness (see Family-Centered Care box). If encopresis persists beyond occasional relapses, the condition needs to be reevaluated. Behavior modification techniques are explained, and the family is assisted with a plan suited to the particular situation.

Etiology

The exact cause of ADHD is unknown. A combination of organic, genetic, and environmental factors is probably involved. A variety of factors put a child at risk for symptoms of ADHD. ADHD is seen more often in children who have family members with ADHD, especially the father, a brother, or an uncle. There is also an increased incidence of substance abuse, conduct disorders, learning disabilities, depression, and antisocial personality disorder in families of children with ADHD. Chromosomal or genetic abnormalities such as fragile X syndrome have been implicated in ADHD. Girls with Turner syndrome have a high incidence of impaired spatial abilities and right-left directional sense, and a large number of boys with Klinefelter syndrome have learning, behavior, or peer problems. A sex-linked factor may be operating because the disorder is much more common in boys than in girls.

Other risk factors include exposure to toxins or medications, perinatal complications, chronic otitis media, head trauma, meningitis, neurologic infections, and mental disorders such as the affective disorders.

Another popular theory is the concept of a developmental lag. Distractibility, short attention span, and impulsiveness are normal characteristics of children at a much younger developmental level. However, research indicates that symptoms of ADHD do not diminish with age. Symptoms such as inattentiveness and impulsivity last into adolescence and young adulthood in many affected individuals (King, 2000). In addition, hyperactivity may be a normal variant of innate temperament in some children who represent the extreme end of the normal distribution curve for activity.

Support for a neurochemical etiology is suggested by the fact that many children with ADHD respond to medications that affect the central nervous system. Some children may have an absence or insufficiency of norepinephrine, dopamine, and serotonin. These neurotransmitters normally occur in high concentrations in the brain and affect activity level, mood, and awareness. It is hypothesized that children who lack these neurotransmitters experience learning difficulties in reading, math, and language and are prone to impulsivity. Many of these children respond to treatment with psychostimulants such as methylphenidate hydrochloride, which increases dopamine and norepinephrine levels (American Academy of Pediatrics, 2001). The fact that some children with ADHD manifest decreased symptoms in stressful situations (such as in the physician’s or principal’s office) provides additional support for this theory, since stress increases the level of norepinephrine.

Another neurochemical theory suggests that symptoms result from an excess of norepinephrine and/or an alteration in the reticular activating system of the midbrain, an area that controls consciousness and attention. This excess or abnormality interferes with the function of filtering out extraneous stimuli. Consequently, children are unable to focus on one stimulus and are compelled to respond to every stimulus in the environment. They demonstrate hyperactive behaviors that result from cognitive “flooding” and exaggerated arousal that overwhelms the attention filters and overrides inhibitory processes. Other theories maintain that symptoms of ADHD result from dysfunction in the brain circuits of the behavioral inhibition system; structural abnormalities in the prefrontal cortex, caudate, and thalamus; and a gene variant known to code for a receptor for dopamine.

Interest in diet as a factor in hyperactivity continues to generate controversy. Some believe that the observed behavior patterns are related to an innate sensitivity to food items such as sucrose or food additives such as aspartame (NutraSweet). This theory does not have widespread support and has not been validated by empirical studies. Nevertheless, some children do show improvement when certain foods are eliminated from the diet, particularly those that cause hyperallergic reactions, such as chocolate, cow’s milk, and eggs. A recent study by Konofal, Lecendreux, Arnulf, and colleagues (2004) suggests that low iron stores may contribute to ADHD because iron is a coenzyme of dopamine synthesis and that these children may benefit from iron supplementation.

Clinical Manifestations

The behaviors exhibited by the child with ADHD are not unusual aspects of child behavior. The difference lies in the quality of motor activity and the developmentally inappropriate inattention, impulsivity, and hyperactivity that the child displays. The manifestations may be numerous or few, mild or severe, and vary with the child’s developmental level. Any given child will not have every manifestation that is characteristic of the syndrome, and the degree of severity is highly variable. Mild manifestations of the symptoms may not be apparent in some educational and family environments, whereas severe symptomatology will be recognizable in most environments. Every child with ADHD is different from all other children with ADHD (Box 18-2).

Most behavioral manifestations are apparent at an early age, but the learning disabilities may not become evident until the child enters school. The disorder is unpredictable; it may remit spontaneously at any age, and the number of years that a child will require treatment is unknown.

A major clinical manifestation is distractibility. The stimuli may come from external sources or internal sources. Children frequently demonstrate immaturity relative to chronologic age. Selective attention is often seen, in which the child has difficulty attending to “nonpreferred” tasks, such as completing chores or finishing homework. The child may not consider the consequences of behavior, may take excessive physical risks (often beginning early in life), and may demonstrate inappropriate social skills.

Children with ADHD demonstrate one of three subtypes (American Psychiatric Association, 2000).

Diagnostic Evaluation

The basic characteristics outlined in Box 18-2 are used to establish a clinical diagnosis of ADHD. It is important to emphasize the need for a complete and thorough multidisciplinary evaluation of the child, incorporating the efforts of the pediatrician (often a developmental pediatrician or pediatric neurologist), psychologist, pediatric nurse, classroom teacher, reading and math specialist, special education teacher, possibly a speech therapist, and the child’s parents. The clinicians and professionals must first determine whether the child’s behavior is age appropriate or truly problematic.

A history, both medical and developmental, and a description of the child’s behavior should be obtained from as many observers of the child as possible, especially the parents and teachers, along with the health professionals involved. Descriptions of the child’s behavior in home and school situations should be included. In obtaining descriptive material, the interviewer must question the observers carefully, because some persons, especially parents, may be so concerned with gross behaviors that they overlook less distressing but equally important symptoms. For example, parents may report a “colicky” infant, a child who began to run soon after walking, a toddler who was compelled to touch everything in sight, and a child who resisted sleep until exhausted. A pregnancy and birth history may provide clues to a situation that might have produced an episode of hypoxia.

A physical examination, including vision and hearing screening and a detailed neurologic evaluation, will help rule out any severe neurologic disorders. Psychologic testing, especially projective tests, is valuable in identifying visual-perceptual difficulties, problems with spatial organization, and other phenomena that suggest cortical or diencephalic involvement, and it helps to identify the child’s intelligence and achievement levels.

Behavioral checklists and adaptive scales are also helpful in measuring social adaptive functioning in children with ADHD. Psychiatric disorders, medical problems, and traumatic experiences are ruled out, including lead poisoning, seizures, partial hearing loss, psychosis, and witnessing of sexual activity and/or violence.

Therapeutic Management

Management of the child with ADHD involves many approaches, including family education and counseling, medication, proper classroom placement, environmental manipulation, and behavior therapy and/or psychotherapy for the child (see Research Focus box).

Nursing Care Management

Nurses, especially school nurses, are active participants in all aspects of management of the child with ADHD. Nurses in the community setting work with families in the home on a long-term basis to help plan and implement therapeutic regimens and to evaluate the effectiveness of therapy. They coordinate services and serve as a liaison between health and education professionals directly involved in the child’s therapy program. School nurses understand the child’s special needs and work with teachers. Nurses in any setting (community, school, hospital, practitioner’s office) provide support and guidance to children and families during the difficult period of the child’s growing up with a disabling condition.

Management begins with an explanation to the parents and the child about the diagnosis, including the nature of the problem and the practitioner’s concept of the underlying central nervous system basis for the disorder. Most parents are confused and feel some measure of guilt. To some parents, a diagnosis of ADHD is confirmation of the fear that their child has some irreversible, serious disease; to others it is a relief. All need the opportunity to vent their feelings and suspicions. A common complaint of parents is that health professionals do not listen to what they have to say about their child. The health professional should focus on building self-esteem by encouraging the family to focus on developing their child’s strengths (e.g., sport, hobbies, and talents) rather than just weaknesses (Jellinek, 2008).

Parents need information about the prognosis and an understanding of the treatment plan. The greater their understanding of the disorder and its effects, the more likely they will be to carry out the recommended program of therapy. It is important that they understand that the therapy is not necessarily a panacea and that it will extend over a long period. This has particular significance for changes they need to make in environmental management. Reading material to help the child and family is available from a variety of sources.

Therapeutic Management

Special training activities in the schools can assist in areas of deficit such as visual and auditory perception and other areas involving integration and coordination. Programs for children with special learning disabilities assist them in successful achievement, personal adjustment, and eventual retention in the regular classroom (Lambros and Leslie, 2005). According to Public Law 94-142, the Education for All Handicapped Children Act, children with learning disorders must receive free public education in the least restrictive environment possible. (See Chapters 1 and 22.)

Nurses must understand which type of learning disability a child has to best provide direction for the child, parents, and teachers. Children with an auditory perceptual deficit appear unable to follow directions or to comprehend large amounts of verbal teaching. These children need to learn with diagrams, pictures, demonstration, and written lists. Children with a visual perceptual deficit may have difficulty reading, lining up numbers for mathematical operations, or judging distance. These children may have dyslexia and may do better with demonstration and a verbal approach. Children with an integrative deficit may have difficulty sequencing data or storing and retrieving sensory data. Multisensory techniques should be used, and comprehension should be checked frequently throughout instruction. Children with motor deficits may need to use computers or typewriters in the classroom because their handwriting will not improve. They may need to find alternatives to physical competition that requires coordination of movement (Selekman and Snyder, 2000). The Learning Disabilities Association of America* provides information and support to families who have a child with a learning disability. An online interactive website (www.ldonline.org) is also available for parents, teachers, and children with learning disabilities.

Children with learning disorders grow up to be adults with learning disorders. The goal is to help them identify their area of weakness and to compensate for it.

Therapeutic Management

Treatment of TS is primarily symptomatic and consists of child and family education and support. Children with more severe tics sometimes obtain symptomatic relief from medications. Various α-adrenergic agonists, neuroleptics, SSRIs, tricyclic antidepressants, and stimulants may be prescribed depending on the most significant symptoms to be alleviated. Psychostimulants and tricyclic antidepressants have been used to treat the coexisting symptoms of ADHD. Antidepressant medications such as clomipramine (Anafranil), fluoxetine (Prozac), and sertraline (Zoloft), which block the reuptake of serotonin in the brain, have also been used to treat obsessive-compulsive symptoms associated with TS. The goal is to use the lowest dose of medication that reduces symptoms to an acceptable level while enhancing the child’s development (Shapiro, 2002; Zinner 2004). Genetic counseling is also advised.

Nursing Care Management

Education of children, families, teachers, and others involved in children’s everyday life is a major aspect of therapy. Punishment for the behaviors is inappropriate because they are involuntary. Affected children are often quick to anger, have a low tolerance of frustration, and may engage in temper tantrums. These children need to be guided toward acceptable substitute behaviors to develop normally, both socially and emotionally. For example, suggesting that a child retire to a quiet area to gain control of emotions or providing a pillow, stuffed toy, or punching bag on which to vent feelings is often helpful.

Influential persons in the children’s lives must help foster feelings of self-esteem. Children with TS are in a constant, ongoing battle to control their impulses and need positive relationships with their parents to become well adjusted. A child’s self-concept can be damaged if parents react to the disability with controlling behaviors, guilt, anger, or hostility.

School nurses can help children with TS cope with teasing by their classmates, can advocate to ensure they are not barred from extracurricular activities, and can educate teachers and classmates about the effects of TS and which behaviors the child can and cannot control in the classroom. Many children with TS experience difficulty writing and benefit from using a tape recorder or computer in the classroom. They may also need extra time when taking standardized tests.

Nurses can assist families in long-term monitoring of symptoms, which includes establishing the waxing and waning pattern and determining whether symptoms interfere with development and adaptation or require more intensive therapy. Families of children taking medication need to be alert to possible side effects, including lethargy, personality change, increased appetite and overweight, depression, parkinsonian symptoms (tremor; muscle rigidity; shuffling gait; hypokinesia; and difficulty chewing, swallowing, and speaking), and anticholinergic symptoms (confusion, excitement, dilated pupils, blurred vision, dry mouth, and dysphagia).

The family may benefit from referral to health agencies such as the local health departments, social services, and parent groups. The Tourette Syndrome Association* is active in research and education and provides services to affected children and their families.

Nursing Care Management

Children need to deal with any traumatic event; much hinges on the intensity of the event and their reactions to it. Children’s reactions depend heavily on their social environment and the way in which their caretaking adults react to the event. Children usually react in the same manner as their caregivers (contagious pathology); therefore it is important to be aware of these reactions. In the second, or defense, phase of the PTSD the appropriateness of the defense mechanism must be assessed, and children must be assisted in the application of their defense. If children do not engage in some catharsis or if their defense phase is prolonged, they may need referral for special psychologic help.

Coping is a learned response, and children in the third phase can be helped to use their coping strategies to deal with their fears. Children usually are willing to accept reasoning. Those who are assisted in their catharsis and allowed expression will survive without serious lasting effects. Encourage them to play out the stress and/or discuss their feelings about the event. If they are unable to do this, they may become obsessed with the traumatic event and need professional help. Conversion reactions are common obsessive behaviors in children suffering from PTSD.

Children need professional help if any of the phases of PTSD are prolonged. Boys tend to have a prolonged defense phase more often than do girls. Occasionally the precipitating event will go unrecognized, and the affected child will engage in what is considered to be unusual behavior. Children exhibiting any sudden change in behavior need to be assessed for exposure to a traumatic event. When the change in behavior is determined to be caused by a traumatic event, treatment can be implemented.

Etiology

A number of factors can cause school phobia. Sometimes the complaints are related to a transient, specific cause, such as fear of a mismatched or overcritical teacher; fear of failing an examination or giving an oral recitation for a painfully shy child; or discrimination based on race, dress, or physical defect. Sometimes it may be related to a school bully or threatening gang. An insecure home situation in which children fear that they may be deserted by a parent may be the basis of anxiety, especially if the parent has previously threatened to leave.

A frequent source of fear is separation anxiety growing out of a strong, dependent relationship between the mother and child in which the child is reluctant to leave the mother and she is equally reluctant to have the child leave her (although this feeling may be unconscious on the mother’s part). The intense need for closeness between mother and child is normal in infancy, but the persistence of this type of relationship into childhood is inappropriate.

Characteristically, these children are not afraid to go to school; rather, they are afraid to leave home. They fear that something dreadful might happen while they are separated from their families. No event is required to trigger the associated behaviors. However, symptoms may be precipitated by a situation that intensifies the mutual dependency between the mother and the child, such as illness, arrival of a new baby, a move to a strange neighborhood or a new school, or parental discord.

In some instances children have an unrealistic, exaggerated view of their abilities and achievements. When they feel threatened by incidents that challenge their estimates of themselves, such as a minor episode that leads to embarrassment, return to school after an absence, transfer to another class, or even imagined social or academic failure, they become anxious and withdraw, frequently seeking proximity to the mother. Sometimes the step-up in expectations at school or change of important personnel at school (e.g., teacher or principal) is a contributing factor. Occasionally the child may be suffering from an undiagnosed learning disability.

Therapeutic Management

The treatment for school phobia depends on the cause. If the reason for the problem is an examination, a relationship with a bully, or a mismatch between teacher and child, it can be dealt with accordingly. When the child is helped to understand and cope with the fear, the symptoms usually disappear. In severe cases when returning to school is unsuccessful, professional psychiatric consultation is usually desirable to help identify possible distorted family relationships or a personality disturbance in the child and to help both the child and the family understand the sources of the problem.

Some children with a moderately severe separation anxiety disorder and school refusal may be treated with a tricyclic antidepressant. However, psychiatric evaluation is almost always required before anxiolytic agents are prescribed.

Nursing Care Management

Treatment of school phobia depends on the cause. The primary goal is to return the child to school. The longer the child is permitted to stay out of school, the more difficult it is to reenter. Parents must be convinced gently but firmly that immediate return is essential and that it is their responsibility to insist on school attendance.

A school reentry protocol may be necessary for a child with severe symptoms. In reentry programs, the child role-plays routines that are involved in getting ready for school and that occur at school. Relaxation techniques are also useful. The child usually goes to school for a half-day initially and then progresses to a full day. Children may be rewarded with points for each period during the day that they are able to remain in school. These points are then redeemed for rewards (e.g., playing with favorite toys or social rewards). Often the school nurse can provide both the teacher and the parents with support in carrying out this plan.

Etiology and Pathophysiology

Only a minority of youngsters with RAP have an organic basis for their pain. Organic causes include inflammatory bowel disease, peptic ulcer disease, lactose intolerance, pelvic inflammatory disease, urinary bladder infection, and pancreatitis. Psychogenic causes of abdominal pain, such as school phobia, depression, acute reactive anxiety, and conversion reaction, account for a small number of cases. Most children with RAP suffer from FAP.

In cases in which no organic disorder is identifiable, the abdominal pain of RAP has been attributed to dysfunction (Smith, 2001). Dysfunctional conditions causing RAP include constipation, chronic stool retention, overeating, irritable colon, and intestinal gas with heightened awareness of intestinal motility or dysmotility. Normally, intestinal contents arrive at the distal portion of the intestine with a relatively high fluid content, and fluid is extracted in the distal colon and rectum. If the normally relaxed distal intestine fails to relax and prevents the flow of its contents toward the rectum, the resulting excessive distention and spasms of the distal intestinal musculature produce pressure on nerve endings, causing pain.

The symptoms of RAP may result from multiple causes, and it is important to assess a number of factors that could place a child at risk for this condition. These include (1) somatic predisposition, dysfunction, or disorder; (2) lifestyle and habit, including routines, diet, and life tempo; (3) temperament and learned response patterns, such as the child’s behavior style, personality, and learned coping skills; and (4) milieu and critical events (i.e., the child’s intimate surroundings [familial, social, and cultural norms] and unexpected sources of stress or gratification).

Children at risk for RAP tend to be high achievers who have extensive personal goals or whose parents have unusually high expectations. They are described as being more mature and sensitive than others or as worriers. At risk are children who are overly concerned about what others think about them but have difficulty meeting the expectations of parents, teachers, and others. They are uncomfortable with expressions of anger or argument, especially directed at those persons who are significant in their lives. School attendance is adversely affected, and these children generally exhibit poor learning performance. It is not uncommon for symptoms to be aggravated during school days.

Clinical Manifestations

Children with RAP have real pain that is usually located in the periumbilical and/or epigastric area. On palpation the pain is more likely to be experienced in the epigastric area or in the lower right or left quadrant and is accompanied by vague tenderness without muscle guarding. The pain is irregular in time, duration, and intensity and is associated with either loose or pellet-formed stools. Other symptoms that may accompany the abdominal pain are headache, flushing, pallor, dizziness, and fatigue. Nausea, vomiting, diarrhea, and dysuria are sometimes part of the syndrome. The symptoms reflect the heightened intensity of response to stimulation of the autonomic bowel sites. Loose stools are a result of the exaggerated propulsive motility, and the pain is caused by the sharply increased mechanical tension in the gut.

Diagnostic Evaluation

Diagnosis is based on a complete family history, the child’s health history, physical examination, and laboratory tests. The family history may provide evidence of a hereditary disorder or mimicry of adult symptoms. The child is evaluated for evidence of an organic basis for symptoms, such as pain that radiates to the back, pain that awakens the child from sleep, persistent right upper or right lower quadrant pain, unexplained or recurrent fever, weight loss, gastrointestinal blood loss, significant vomiting, chronic severe diarrhea, or family history of inflammatory bowel disease (American Academy of Pediatrics, 2005). Pain is assessed for location, quality, frequency, duration, any associated symptoms, alleviating factors, and exacerbating factors (Smith, 2001).

Therapeutic Management

Treatment involves providing reassurance and reducing or eliminating symptoms. Hospitalization may be necessary, and the child frequently shows improvement in the hospital environment. Initial efforts are directed toward ruling out organic causes of the pain, relieving discomfort, and attempting to determine the situations that precipitate attacks.

Emphasize a high-fiber diet, psyllium bulk agents, lubricants such as mineral oil, and bowel training for pain associated with bowel patterns. Treatment may also include acid-reduction therapy for pain associated with dyspepsia; antispasmodic agents, smooth muscle relaxants, or low doses of psychotropic agents for pain. Dietary modifications may include removal of dairy products, fructose, and gluten for 2 to 3 weeks to rule out lactose intolerance, sensitivity to high sugar content, and celiac disease. Other treatments include cognitive-behavior therapy and biofeedback.

Nursing Care Management

The nurse can be instrumental in assessment and management of RAP in children. Many techniques used in a routine assessment elicit information that might help identify factors that contribute to the child’s symptoms. Evaluate the child’s social and psychologic adjustment, and obtain the details of the pain directly from the child. Questions that provide clues to parent-child relationships and the way the family deals with angry feelings provide information for diagnosis and management. Relationships with peers, school problems, and other concerns of the child need to be explored. Note any evidence of depression.

Once the diagnosis has been established, the parents and the child need an explanation of the pain, which can be compared to a skeletal muscle cramp, “charley horse,” or headache for easier comprehension. Reassurance that the symptoms are not unique to their child and that the pain is rarely associated with a severe disease can help relieve parental fears and anxieties.

Discuss a high-fiber diet with the child and family (see Chapter 33), and emphasize bowel training. The child is encouraged to establish a pattern of sitting on the toilet for 10 to 15 minutes immediately after breakfast to take advantage of the increased colonic activity following meals. If necessary, have the child use stimulatory suppositories to induce early morning defecation.

Once parents are reassured that there is no organic cause for the pain, they need guidance on what to do during a pain episode. Often they feel helpless and anxious, which tends to compound the child’s distress. The simple measure of having the child rest in a peaceful, quiet environment and providing comfort will often relieve the symptoms in a short time. Application of a heating pad may also ease the discomfort. (See Nonpharmacologic [Pain] Management, Chapter 7.) If pain is not relieved by these simple measures, teach parents how to administer antispasmodics, if prescribed. For example, if pain is precipitated by meals, having the child take the medication 20 to 30 minutes before mealtime may prevent an episode.

The most valuable assistance that the nurse can provide is support and reassurance to the family. When open communication is established and families are able to see a relationship between stress-provoking situations and the child’s symptoms, the chance for remedial action is enhanced. Follow-up care and continued support are essential because the symptoms tend to remit and exacerbate; therefore the availability of a supportive health professional can be a source of comfort to the child and family.

Therapeutic Management

Depressed children are managed by a health team specially trained in the care of children with mental disorders. Treatment is highly individualized and should be undertaken in the least constrictive environment, usually an outpatient setting. Suicidal children are admitted to the hospital for protection if the family is unable to provide constant monitoring. Hospitalization may also be advised for children with associated disruptive behavior, such as fighting with peers or family. Most therapeutic regimens focus on various combinations of counseling, psychotherapy, family therapy, cognitive therapy, education (teaching social and life skills that facilitate coping), environmental improvement, and pharmacotherapy.

Pharmacotherapy may involve tricyclic antidepressants or SSRIs such as fluoxetine, trazodone (Desyrel), sertraline, and paroxetine (Paxil), as well as bupropion (Wellbutrin) and venlafaxine (Effexor). There have been reports that antidepressant medications may cause increased suicidal thinking and behaviors in pediatric patients. This prompted the FDA to require black box drug labeling detailing potential suicide-related risks for pediatric patients.

Nursing Care Management

Nurses should be aware that depression is a problem that can easily be overlooked in the school-age child and one that can interrupt normal growth and development. Recognizing depression and making appropriate referrals is an important nursing function. Identification of the depressed child requires a careful history taking (health, growth and development, social, and family health); interviews with the child; and observations by the nurse, parents, and teachers. If antidepressants are prescribed, the child and family need to know that antidepressants must be at a therapeutic level for 2 to 4 weeks to achieve a beneficial effect. The child and family also need to monitor the child for side effects of the specific drug prescribed and any interactions with other drugs. (See Chapter 21 for a discussion of suicide, since suicidal ideation is common during depression.)

Nursing Care Management

Nursing of psychotic children is a highly specialized area, but because such problems are occurring with increasing frequency, nurses should recognize children who consistently demonstrate abnormal behavior and refer them for evaluation.

Nurses should also instruct family members of children taking antipsychotic drugs to observe for possible side effects. Common side effects of these drugs include dizziness, drowsiness, tachycardia, hypotension, and extrapyramidal effects such as abnormal movements and seizures. Agranulocytosis occurs in 1% of patients who take clozapine in the first few months of treatment. Therefore a mandatory monitoring program requires that patients taking clozapine have a white blood cell (WBC) count performed every week during the first 6 months of therapy and every other week for the second 6 months of therapy. Pharmacies and clinicians report the weekly WBC count and cannot dispense clozapine to the patient without evidence of a safe WBC count.

• Middle childhood is a relatively healthy period, and most problems encountered are not considered serious.

• The skin serves several important functions: protection, prevention of loss of body fluids, heat regulation, and sensation.

• It is important for nurses to be able to describe skin lesions accurately.

• The process of wound healing consists of inflammation, fibroplasia, scar contraction, and scar maturation.

• Wound healing occurs by primary, secondary, or tertiary intention.

• Bacterial, viral, and fungal infections are common in childhood.

• Prevention of infection or reinfection is the primary goal in management of pediculosis.

• Contact dermatitis may involve a reaction to a primary irritant or sensitization.

• Teaching prevention of thermal injury, especially sunburn, is an important nursing function.

• Adverse reactions to drugs occur more often in the skin than in any other organ.

• Dental care is essential in middle childhood; the most frequent problems that arise are dental caries and malocclusion.

• The behavior disorders of childhood are primarily ADHD and tic disorders.

• Other major behavior or mental disorders involving school-age children include school phobia, RAP, conversion reaction, depression, and schizophrenia.

Poison Ivy

Attention Deficit Hyperactivity Disorder