NUR331 Exam 4 Flashcards
1
Q
neurological differences in a child
A
- greatest amount of changes happen in the first year of life
- brain volume is reflected in head circumference
- cerebral blood flow and oxygen consumption is 2x
- progressive motor function
- fontanels allow brain to expand
- BBB is more permeable - more susceptible to infections
- small epidural space - fewer epidural hemorrhages
2
Q
neuro assessment - extra things to monitor in children
A
- febrile illness
- animal bite
- crying, irritable
- head circumference (<2)
- is LOC affecting ability to oxygenate?
- gag reflux
- incontinence baseline
- rash
- thermoregulation
- persistence of primitive reflexes
- posturing
3
Q
What do pinpoint pupils represent?
A
- poisoning
- brain stem dysfunction
4
Q
What do fixed and dilated pupils represent?
A
- brain damage if 5 mins+
5
Q
babinski reflex
A
- sole of foot stroked
- fans out toes and twists foot in
- disappears at 9mo-1yr
6
Q
blinking reflex
A
- flash of light or puff of air
- closes eyes
- permanent
7
Q
grasping reflex
A
- palms touched
- grasps lightly
- weakens at 3mo, disappears at 1yr
8
Q
moro reflex
A
- sudden move, loud noise
- startles, throws out arms and legs and then pulls them to the body
- disappears at 3-4mo
9
Q
rooting reflex
A
- cheek stroked or side of mouth touched
- turns towards source, opens mouth and sucks
- disappears at 3-4mo
10
Q
stepping reflex
A
- infant held upright with feet touching the ground
- moves feet as if they’re able to walk
- disappears at 3-4mo
11
Q
sucking reflex
A
- mouth touched by object
- sucks on object
- disappears at 3-4mo
12
Q
swimming reflex
A
- placed face down in water
- makes coordinated swimming movements
- disappears at 6-7mo
13
Q
tonic neck reflex
A
- placed on back
- makes fists and turns head to the right
- disappears at 2mo
14
Q
explain ICP change
A
- volume in brain should remain at an equilibrium
- small increase in one should equal a small decrease in another
- if not, increase in ICP
- causes - tumors/lesions, hemorrhage, edema of cerebral tissue (trauma, fall, shaken, infection), accumulation of CSF in ventricles
15
Q
CM of increased ICP in a child
A
- headache
- blurred vision
- diplopia
- pupils sluggish, repines to light
- seizure
- nausea, forceful vomiting
- lethargy
- increased sleeping
- declining school performance
- declining motor function
16
Q
CM of increased ICP in infants
A
- tense and bulging fontanel
- separated cranial sutures
- macewen sign (cracked pot)
- high pitched/cat like cry
- increased head circumference
- distended scalp veins
- feeding changes
- crying when held or rocked
- sun set eyes - see a lot of sclera above pupils
- taught and shiny skin over scalp
17
Q
late signs of increased ICP
A
- significant decrease in LOC
- decreased motor response to command
- decreased sensory response to pain
- fixed and dilated pupils
- decerebrate posturing - away from midline
- decorticate posturing - towards midline
- very late - high SBP, low HR/RR, high PP
18
Q
What should the nurse do when responding to an unconscious child?
A
- ABC
- stabilize spine when indicated
- treat shock
- reduce ICP when indicated
- frequent neuro assessment
- observe pupillary signs and LOC, VS
- pain management
- signs of pain are high HR and BP
- respiratory monitoring
- monitor ICP
- nutrition and hydration
- elimination
- thermoregulation
- positioning, hygiene, meds, stimulation, family support
19
Q
hydrocephalus
A
- an excessive collection of CSF in the ventricular system
- same S/S of increased ICP
- first sign - high head circumference
- can be congenital or acquired
- classified as communicating and noncommunicating or obstructive
- management - relief of pressure (shunt), treat the cause, treat complications, promote development
- NC - prevent breakdown of the scalp, monitor for increasing ICP, promote adequate nutrition, keep eyes moist (bulging eyes)
- post op - bedrest with HOB flat and supine, later the HOB may be elevated
- no contact sports, cannot go to the army
- shunt complication - infection
20
Q
When should an ICP monitor be inserted?
A
- GCS <7 or GCS>8 with respiratory problems
- deterioration of condition
- subjective judgement regarding clinical appearance and response
21
Q
EVD nursing considerations
A
- jugular compression can increase ICP so the patient turning side to side is contraindicated
- keep HOB 15-30 degrees
- ensure drainage system remains level with the patient’s tragus (ventricles)
- assess CSF output every hour
- sudden increase or decrease in output - call surgeon
- make sure all stopcocks are turned correct direction and cords are plugged in appropriatley
22
Q
TBI
A
- head injury by mechanical force that effects the meninges, skull, scalp, or brain
- young children are more at risk due to lack of head control and they are more at the mercy of someone else
- infants have decreased myelinization and immature motor function which causes them to fall when left unattended
- toddlers have heads larger than the body which makes them more likely to get injured
- school age kids are most likely to be hit as a pedestrian or while riding a bike
- adolescents engage in risk taking behaviors
- children respond differently because of larger head size, expandable skull, greater volume of blood in the brain, small subdural space, and thinner softer brain tissue
23
Q
types of TBI
A
- scalp laceration - superficial but will bleed a lot
- linear skull fx - single crack in school, likely have a bruise on head
- depressed skull fx - broken into several fragments and pushed inward, causes pressure on the brain
- basilar skull fx - break in the base of skull, usually results in a dura tear
24
Q
basilar skull fx
A
- may have raccoon eye or battle sign behind ear
- high risk of secondary infection
- avoid invasive procedures that could introduce a pathogen
- leakage of CSF is possible
- do not put anything in nose
- CSF has glucose and will have a halo around it
25
concussion
- alteration in mental status with or without loss of consciousness which occurs immediately after a traumatic blow to the head
- hallmark signs - confusion and amnesia
- CM - headache, dizziness/unsteady, confusion, disorientation, vision changes/sensitivity to light, nausea, drowsiness, amnesia, sensitivity to noise, tinnitus, irritability, loss of consciousness, hyperexcitability
- when to seek treatment - infant, lost consciousness, won't stop crying, complains of head and neck pain, vomits repeatedly, difficult to awaken, becomes difficult to console, isn't walking normally, unusual behavior, bleeding from mouth or nose, CSF leakage
26
TBI CM
- minor - may or may not lose consciousness, transient period of confusion, somnolence, listlessness, irritability, pallor, vomiting
- severe - signs of increased ICP, retinal hemorrhages, extraocular palsies, hemiparesis, elevated temp, unsteady gait
27
TBI management
- ABCs
- stabilize neck and spine
- frequent neuro assessment
- hypertonic solutions
- steroids to decrease inflammation
28
TBI complications
- hemorrhage - epidural and subdural
- infection - posttraumatic meningitis
- brain stem herniation
- hypothalamic dysfunction
- SIADH, DI - cerebral edema
- signs of progression - mental status changes, mounting agitation, development of focal lateral neuro signs, marked changes in VS, Cushing reflex, signs of brainstem involvement
29
meningitis
- inflammation of the meninges of the brain and spinal cord
- often preceded by ear infection, greater incidence in males
- newborn CM - poor sucking/feeding, apnea, weak cry, diarrhea, tense fontanel, jaundice
- infant CM - fever, poor feeding, n/v, increased irritability, high pitched cry, seizures
- children CM - fever, headache, nuchal rigidity, Kernig's sign, opisthotonos, seizures, altered sensorium, projectile vomiting, petechial or purpureal rash
- long term complications - blindness/deafness, intellectual disability, hydrocephalus, loss of extremities, cerebral palsy, seizures
- dx - LP results in high WBC, pressure, and protein, decreased glucose and positive culture
- meds - abx if bacterial, anticonvulsants, antipyretics, treat F/E imbalance
- high WBC, low glucose*
- communicability - isolation for first 24hrs, prevent complications, abx, seizure precautions and neuro checks, prevent increases in ICP, monitor for septic shock/circulatory collapse/dilutional hyponatremia/long term sequelae, adequate hydration and nutrition, parental support and reassrance
- prevent - vaccines*
30
nuchal rigidity, Brudzinski's sign
chin to chest movement hurts when knees are flexed (meningitis)
31
Kernig's sign
hamstring pain when knee and hip are flexed (meningitis)
32
opsthotonos
arching back (meningitis)
33
encephalitis
- inflammatory process of the CNS caused by variety of organisms, caused by HSV 1
- initial CM - nonspecific signs, fever, altered mental status, possible seizures
- other CM - can resemble meningitis, lasts few days and have complete recovery or has CNS involvement and doesn't completely recover or dies
- dx - clinical findings from organism, meningitis rule-out, CT may show hemorrhagic area, blood samples to determine organism
- management - observation and supportive care, low stimulation, high nutrition, same as meningitis
34
Reye syndrome
- rapidly progressive encephalopathy with hepatic dysfunction which begins several days after "apparent" recovery from viral illness associated with virus and aspirin
- causes fatty changes in the liver, ammonia, builds up in liver dysfunction, and edema occurs
- prodromal, rapid progression, then profuse vomiting with neuro impairment
- meds - muscle paralysis, anticonvulsants, diuretics
- management - ventilation, ICP monitoring, F/E balance, monitor lab studies
- prevent - don't give aspirin to kids
- NC - monitor BS Q2, seizure prec, monitor for bleeding and liver function, assess for increased ICP Q2, balance fluid intake to prevent dehydration/cerebral edema
35
epilepsy
- chronic condition with 2+ seizures that were not caused by reversible medical conditions
- classified by type and etiology
- location of electrical dysfunction determines what the seizure activity will look like
- VEEG
- management - antiepileptic drugs, keto diet (high fat low carb - encourages ketones to control seizure activity), give supplemental vitamins, can have a vagus nerve stimulator
- last route - surgery - focal resection, hemispherectomy, corpus callosotomy
- long-term care - educate caregiver on rescue meds, have rescue meds at all places that the child will be, avoid triggers, do not swim/bathe alone, wear helmet when biking, avoid open flames, avoid climbing tall heights, provide patient and family support, help child function to the best of their ability
- risk for injury and risk for aspiration*
36
febrile seizure
- temp 101+ without known cause of epilepsy, CNS infection, or metabolic abnormalities
- typically tonic clonic that is <15mins
- higher the temp, worse the symptoms
- home care - call EMS if it lasts longer than 5mins, usually not treated with antiepileptic drugs, prolonged can be treated with a benzo
37
nursing care during a seizure
- observe initially and determine duration
- protect from injury, do not put anything in their mouth
- do vitals and O2 if below 90%
- 5+mins requires rescue sedatives, IN midazolam, call HCP
38
integument developmental differences
- epidermis is loosely bound to the dermis - more prone to fluid loss
- skin is thin, blood vessels are closer to the surface - likely for abraisons
- more permeable
- more susceptible to superficial bacterial infections
- more apt to respond to a primary irritant
- less pigmentation
39
general integument interventions
- no powder or cornstarch - can breathe in, absorbs moisture
- light and loose non-irritative clothing
- keep skin clean and dry
- cut nails, apply mittens to infants at night
- wash hands, clean toys, keep open wounds covered, teach children not to share combs and hats
- avoid commercially prepared diaper wipes on irritated skin
40
dermatitis
- CM - erythema in convex surfaces of thighs, butt, perineum, waist, lower abdomen, creases spared
- NC - dry affected area and prevent contact with irritant, change wet diapers immediatley, occlusive ointments, wash off feces with water and mild soap, expose slightly irritated skin to air
41
candida albicans/thrush
- beefy red that extends into creases, satellite lesions
- precipitated by abx use, immunosuppression, or exposure to yeast
- treat with antifungals, nystatin cream
42
seborrheic dermatitis
- chronic recurrent inflammatory scaling disorder of the scalp and face
- etiology unknown
- most common in early infancy
- lesions are thick, adherent, yellowish, scaly, oily, patches, may or may not be itchy
- NC - may be prevented with adequate scalp hygiene, remove lesions by shampooing daily, anti-seborrheic shampoo to allow to remain on scalp until crusts are softened, rinse thoroughly, use soft brush to remove soften crusts
43
eczema
- pruritic inflammation of the skin associated with and allergy and a hereditary tendency
- more likely in winter
- mainly on knees, elbows, and back
- CM - erythematous vesicles and papules, weeping, oozing, crusting or scaling, distribution is mainly to cheeks, scalp trunk, and extensor surfaces
- management - relieve itching, colloid baths, benadryl, hydrate the skin, lubricate after bathing, air dry, use scent/dye free lotion, reduce inflammation, topical steroids, prevent or control secondary infection
- NC - avoid triggers, keep nails cut short, cover hands at night, long sleeves and pants, launder clothes and sheets in mild detergent, avoid soaps/bubble bath/oil/powder, room humidifier, observe for signs of infection, avoid exposure to latex, avoid hyperallergenic foods
44
contact dermatitis
- causes - nickel/metal, allergenic plants
- complications - secondary bacterial skin infection
- poison ivy - advances to streaked or spotty blisters, flush area immediately with cold water, scratching does not spread rash but can cause secondary infection
45
impetigo contagiosum
- highly contagious superficial infection of the skin due to group A strep or staph
- macular rash that progresses to a papular vesicular rash that forms a honey colored crust
- treatment - bacetracin, oral abx, no school for 24 hours, good hand washing, no sharing of towels and linens, cut nails short and cover hands at night, lover lesions to prevent spread
46
cellulitis
- deep locally diffuse infection fo the skin with systemic manifestations
- caused by strep or flu
- CM - fever, swelling, heat, tenderness of involved skin, malaise, regional lymphadenopathy
- management - abx, rest and immobilization, warm and moist compress, hospitalization if joint or facial involvment
47
HSV
- viral infection of skin and mucous membranes
- characterized by clusters or vesicles filled with clear fluid
- CM - burning, itching, vesicles on inflammatory base which dries forming a crust followed by exfoliation and spontaneous healing in 8-10 days
- treatment - topical warm compress, burrow solution, no salt
- kissing a baby with one can cause meningitis
48
verruca (warts)
- epidermal benign tumors caused by HPV
- clinical findings - solitary flesh colored papule with irregular scaly surface, may have pin point black spots
- treatment - cyrotherapy, salicylic acid paints
- education - most disappear without treatment, repeated irritation may cause enlargement
49
erythema infectiosum / fifth disease
- from parvovirus
- CM - rash, minor itching, tiredness, a sore throat, or a slight fever
- fetal death if mother infected during pregnancy
- aplastic crisis - kids with hemolytic disease or immunodeficiency
- rash - disappears in 1-4 days, maculopapular red spots on upper and lower extremities, lacey appearance on trunk, day 1 after facial rash for one week or more
50
varicella
- spread primarily by respiratory tract secretions and contact with skin lesions, communicable one day after rash appears until all lesions are crusted over
- CM - slight fever, malaise, anorexia, pruritic rash
- treatment - benadryl and cool bath to help with itching
- NC - strict isolation when hospitalized, encourage immunization (live), isolate at home until lesions are crusted, teach good skin care, no ASA
51
tinea / ringworm
- transmitted from humans or infected animals
- treated with topical antifungals (monitor liver enzymes)
- NC - encourage good health and hygiene, examine household pets, teach children not to share hats, scarves, helmets
52
pediculosis / lice
- infestation by pediculus humanus capitis
- found in hair usually behind ears and nape of neck
- intense itching
- treatment - permethrin 1% 10 mins or permethrin shampoo to dry hair for 10 mins (ovicidal)
- education - avoid shampoo contact with eyes, do not treat in bathtub or shower, apply shampoo to dry hair, apply only to infected area, wash bed clothes in hot water and hot dryer, comb out nits, soak brushes and combs, store unwashables in sealed plastic for 2 weeks
53
scabies
- impregnated female mite burrows into the stratum corneum of the epidermis and deposits eggs and feces
- CM - intense itching, maculopapular lesions on intertriginous areas
- management - scabicide permethrin 5% cream, and neurotoxic lindane for resistant cases, ivermectin is contraindicated in those younger than 5, treat all contacts
54
sunburns
- superficial or partial thickness
- prevention - PABA free sunscreen, avoid exposure between 10a-4p
- treatment - cool water, NSAIDs for pain, clean dressings, don't pop blisters or peel skin, stay hydrated
55
facial acne
- caused by an increased production of sebum in sebaceous glands, familial aspect
- open comedones (blackheads) or closed comedones (whiteheads), cystic lesions
- intervention - wash face, benzoyl peroxide
- classified as mild, moderate or severe
56
s/s of bites and stings
- bite or sting mark
- stinger, tentacle, or venom sac
- redness
- swelling
- pain or tenderness (treat with cold water)
- severe - anaphylaxis
57
care for insect stings
- examine, call 911 if known allergy
- remove stinger with credit card
- wash area with soap and water
- apply ice pack
- observe for signals of allergic reaction for at least 30 mins
- epipen can be used for anaphylaxis
58
tick bites
- can transmit rocky mountain spotted fever or lyme disease
- if not detected, it may remain for days
- medical treatment is not needed but monitor for s/s of lyme (rash, fever, chills, severe headache, joint and muscle aches)
- prevention - keep lawns mowed, brush cleaned up, and wood piles stacked, wear pants and long socks, wear light colored clothing, do not lay clothing on ground, walk in the middle of paths, comb through hair after being in an infested area, check body after exposure
59
first aid for tick bites
- remove tick by grasping close to the skin with tweezers, pull gently until it lets go
- wash area with soap and water
- put antiseptic on site and apply abx cream
- seek medical attention if rash appears or flu like symptoms
60
abuse
physical, sexual, emotional injury inflicted on a child by an adult
61
neglect
- failure of a caretaker to meet a child's environmental, nutritional, or medical needs
- act of omission
- contributing factors - lack of resources, poor parenting skills, failure to recognize emotional nurturing as essential need
- consequences - developmental delay, neuro consequences, poor socialization, parentification, death or serious injury when unsupervised, personality disorders
62
pediatric abusive head trauma
injury that occurs when a child receives deliberate blows to the head when dropped, thrown, or shaken
63
When should you consider neglect?
- child - frequently absent from school, begs or steals money for food, lacks medical or dental care, consistently dirty and has severe body odor, lacks sufficient clothing for winter, abuses alcohol or other drugs, states there is no one at home to provide care
- parent - appears to be indifferent to child, seems apathetic or depressed, behaves irrationally or in a bizzare manner, abusing alcohol or other drugs
64
family factors that are risks for abuse
- domestic violence
- isolation
- poverty and limited resources
- unemployment, single parent
- animal abuse
- increased exposure between parent and child
- major life changes
- substance abuse
- low self esteem
- poor impulse control
- abused as a child
- teenage parent
- negative view of the child
- depression
- unrealistic expectations of child's behavior
- corporal punishment
65
risk factors for abuse of the child
- conditions that alter parent and childhood bonding (NICU, cleft palate, myelomeningocele)
- hyperactivity or perceived defiance to parent, temperament
- resemblance to abusive person from last relationship
- prolonged or chronic illness
- colic
- multiple birth
- developmental delays
66
warning signs of abuse
- physical evidence of abuse or neglect
- no history to explain physical findings
- injury not consistent with history or developmental level
- delay in seeking medical attention
- history changes with repetition, conflicting stories
- parents blame child or sibling
- seek medical attention far from home
- reaction to injury is inappropriate
67
behavioral characteristics of abused children
- wary of adults
- vacant stare or always watchful
- overly compliant or passive, no movement with painful procedures
- does not turn to parents for support
- constantly tries to please parent and assess for parental reaction
- role reversal
- aggressiveness towards animals or smaller children
- shows sudden changes in behavior or school performance
- has learning problems
- comes to activities early and stays late
68
behavioral characteristics of abusive parents
- shows little concern for the child
- denies the existence of or blames the child for problems
- asks teachers or other caregivers to use harsh physical discipline if the child misbehaves
- sees the child as entirely bad
- demands a level of physical or academic performance that the child cannot achieve
- looks primarily to the child for care or attention
69
physical indicators of abuse
- bruises, welts, lacerations, abrasions, or broken bones
- various stages of healing
- clustered lesions, teeth marks, handprint
- shadow bruises
70
rule of ten - under 4
- torso
- ears
- neck
71
patterns of abuse in infancy
- more likely than any other age to experience fatal abuse, abusive head trauma, abusive fractures, munchausen's syndrome by proxy, global neglect with FTT
- predisposing - dependency, isolation, lack of language, size
- trigger is crying**
72
possible injuries from PAHT
- closed head injury
- open head injury with skill fx
- subdural hematoma
- death
- irreversible brain damage
- vision impairment
- spinal cord or CNS injury
- loss of speech and hearing
- problem with memory and attention, learning disabilities, cerebral palsy
73
s/s of PAHT
- seizures or posturing
- unequal pupils
- high pitched cry
- retinal hemorrhages
- pale, mottled, cold, clammy skin
- poor feeding
- bruising, vomiting
- change in LOC
- decrease in smiling or vocalizing
- behavior changes
- vision changes
- change in head control
- bradypnea or apnea
- bradycardia
- bulging fontanel
- associated - scalp bruises, traumatic alopecia, black eyes, fractures
74
PAHT perpetrator characteristics
- male less than 30
- education less than high school
- illiteracy
- depression
- social isolation
- substance abuse
- low self esteem
- poor impulse control
75
PAHT RF for child
- male
- colic
- premature
- low birth weight
- substance exposure
- special needs or medically fragile
- infants with NAS, cries frequently
- multiple birth
76
PAHT environmental RF
- domestic violence
- isolation
- poverty, limited resources
- single parent
- animal abuse
- increased exposure of parent and child
- major life changes
77
fractures of abuse
- most common sites - femur, humerous, tibia
- unexplained fractures in different stages of healing
- scapular fracture
- long bone fx
- chip fx of metaphyses
- spiral fx
- dislocations of shoulders and hips
78
toddler abuse RF
- toilet training difficulties
- temper tantrums
- perceived disobedience
- problems are exacerbated by caregivers unrealistic expectations
79
burns of abuse
- soles of feet, palms of hands
- pattern burns - iron, heater grates, cigarettes
- accidental immersion - irregularly shaped burn at point of major contact, splash marks, depth of burn decreases dramatically as distance, flow marks proceed from major burn region
- non accidental immersion - clear demyelinization between burned and unburned, sparing in flexion of creases or where pressure prevented fluid from contacting skin, absence of splash marks
80
abdominal injuries of burns
- ruptured liver or spleen, intestinal perf, pancreatic injury, AKI
- suspect if it doesn't look like seat belt or handle bars
81
period of purple crying
- peak of crying
- unexpected
- resists soothing
- pain like face
- long lasting
- evening
82
dr harvey 5 s's of soothing
shushing
side/stomach positioning
sucking
swaddling
swinging
83
strategies in instead of inflicting harm
- make sure basic needs are met
- check of signs of illness
- rock or walk with infant
- sing or talk
- offer pacifier or noisy toy
- stroller ride
- hold baby close against body and breathe calmly
- call for help
- take a 10 min break
- call doc
84
7 fatal nursing mistakes of abuse
- non specific s/s attributed to benign causes
- diagnose injury as accidental
- subtle physical exam clues mixed
- contaminate th history
- nice people gig
- give people the benefit of the doubt to adult instead of kid
85
recognition of PAHT
- common signs of PAHT - lethargy, irritability, decreased appetite, poor feeding, vomiting, seizures, odd bruises on child, not smiling or vocalization, posturing or being very rigid, difficulty breathing, eyes not tracking correctly, inability to lift head appearing very large
86
how to determine whether an accident or PAHT
- development of the child matching injury
- examine bruises carefully
- does the injury match age
- is history feasible
- injury witnessed
- social situation
- can described mechanism account for injury
87
how to document physical abuse
- date/time/place of occurrence
- sequence of events with times
- presence of witnesses
- verbal quotation from parent and child
- description of parent child interactions
- name/age/condition of other children in home
88
characteristics of sexual abusers
- male
- well known to child
- all social levels
- often in positions where they work closely with children
- abuse is repetitive
- coaxing and threats
89
characteristics of sexual abuse victims
- bruises, bleeding, irritation of external genitalia, torn/stained/bloody underclothing
- STD, pain with urination, swelling, itching, recurrent UTI, difficulty walking or sitting
- seldom ever make up
- possess sexual knowledge beyond age
- antisocial behaviors
- behavioral changes - anxiety, new/existing sexual curiosity, constant masturbation, seductive behavior, fear of strangers, new unwillingness to visit other homes
90
muchausen syndrome by proxy
- illness that one fabricates or induces in other person
- child characteristics - <6, uncooperative, anxious, fearful, negative
- perpetrator characteristics - usually mother, thrives in health environment, some health care knowledge, loving/cooperative/competent, suggest tests and procedures
- common presentations - apnea, seizures, bleeding, fevers, blood infections, vomiting, diarrhea
- when to suspect - unexplained prolonged illness, discrepancies between CM and hx, unresponsive to treatment, parent who refuses to leave child's room, parent's interaction with staff, family members with similar symptoms
