PedsSpecialNeedsDying

Question 1

“Children who have or are at risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”

Answer 1

Special Needs. Mediaclly fragile children: prematurity, technology-dependency (ventilation), complex medical problems (like chronic things). Physical problems. Emotional, behavioral, developmental problems (on the outside they appear to be normal)

Question 2

Challenges of special needs children?

Answer 2

Increased medical care, prescription med needs and the cost. Educational services and accommodation. Multiple therapies, like occupational, physical, and speech. Care access and coordination, can be hard to keep track. Negative impact on mental health, needs screenings

Question 3

Special needs infants? Promoting growth and development?

Answer 3

Fail to develop a sense of trust, especially when parents have to work while they’re in the hospital. Multiple caregivers. Limited sensorimotor exploration, can’t use hand with an IV. Limited cognitive development.
P: consistent caregivers, build trust. Parental presence

Question 4

Special needs toddlers?

Promoting growth and development?

Answer 4

Difficulty developing autonomy, difficulty with exploring and making choices. Delayed motor and language development. Parents develop an over-arching feeling of doing for their child.
P: Parental presence. Limit-setting, role modeling is the best way. Independence, sitting them on the floor with toys from home so they can choose.

Question 5

Special needs preschoolers? Promoting growth and development?

Answer 5

Reduced development of initiative, lacks the ability to socialize. Hindered body image and guilt from magical thinking.
P: Self-help skills. Socialization, play room. Magical thinking, why are they in this station? Reassure them that it’s not their fault.

Question 6

Special needs school-age children? Promoting growth and development?

Answer 6

Fail to achieve a sense of industry. May be unable to express themselves. Limited peer relationships.
P: School work, education about condition, involvement in activities.

Question 7

Special needs adolescents? Promoting growth and development?

Answer 7

Difficult to achieve independence. Altered sense of identity. Delayed abstract thinking. Limited opportunity to make friendships.
P: Parental education, interpersonal skills. Involvement with their life, let them text, have friends who visit, give them privacy. Future plans.

Question 8

Effects of special needs children on the parents?

Answer 8

Grief. Chronic sorrow, loss of the “perfect child.” Stressors of daily living: jobs, housing, spouses, other children. Divorce rates are higher. “Vulnerable child syndrome.”

Question 9

Explain vulnerable child syndrome?

Answer 9

Starts in older infants and toddlers. Overprotective and overinvolved parent limit the child’s independence. Excessive unwarranted concerns, like small pains causing big reactions in the parent. Inconsistent or lax discipline. Child reinforces parent’s fears.

Question 10

Effects of special needs children on the siblings?

Answer 10

Relationship with parents depends on their perception of the special needs issue. Sibling adjustment: Knowledge, attitude, self-esteem, social support, parent’s awareness, time.

Question 11

Nursing management of children with special needs?

Answer 11

Help with optimal growth. Develop a therapeutic relationship. Perform screening and ongoing assessment: premature growth charts, vaccine schedule, down syndrome health care guidelines. Home care, care coordination, resources.

Question 12

Promoting home care for children with special needs? Care coordination?

Answer 12

Home: early discharge planning, caring for the technology-dependent child, like on a ventilator (home nurses, educating parents).
Coordination: Establish medical home, making sure the healthcare workers are communicating. Interdisciplinary referrals, parent support networks.

Question 13

Providing resources and case management for the child with special needs?

Answer 13

Government-funded educational opportunities. Early intervention program for <3yrs, which includes developmental testing, promotion, and resources. Individual Education Plan (IEP) >3yrs, which is education accommodations.
Financial resources. Respite care. Complementary therapies.

Question 14

When does one assist a child with special needs in times of transition?

Answer 14

Initial diagnosis or change in prognosis. Increased symptoms. Moving to a new setting. Developmental changes and stages, like finances once they reach adulthood. Med changes.

Question 15

Chromosomal deficit, looks very similar from one patient to the next. No standard treatment or cure. Multidisciplinary care. Risk factors and health history?

Answer 15

Trisomy 21, downs syndrome.
Risks are lack of prenatal care and AMA. History: CHD, hearing/vision impairment, thyroid disease, frequent infections, GI disorders (constipation). Atlanto-axial (neck) instability. Obesity (lower BMR). Cognitive deficits, feeding problems, seizures, leukemia, obstructive sleep apnea (OSA).

Question 16

Physical characteristics and g/d for downs syndrome?

Answer 16

Flat nasal bridge, additional eye creases, plantar creases across their hands. Growth and development is delayed, may not sit until 9-12 months.
Will go in the order as normal children but at a different rate.

Question 17

Tests that may be needed for a child with trisomy 21?

Answer 17

Echo for heart defects. Vision/hearing screening. Thyroid level. Cervical x-rays for neck instability. U/s of the abdomen.

Question 18

Promoting g/d and preventing complications for downs syndrome?

Answer 18

Speech therapy, occupational therapy, physical therapy. Special education, IEP and early intervention.
Handwashing because of the increased risk of infection. Regular medical care, screenings, dental care.

Question 19

Promoting nutrition for downs syndrome? Family support and education?

Answer 19

Obesity risk. Increase feeding time, prevent constipation, monitor BMI.
Involve the family. Meaningful education program.

Question 20

Pervasive developmental disorder (PDD). Impaired social interaction and communication.

Answer 20

Autism spectrum disorder. Synapses where communication is fade. Cause is unknown, probable genetic component, not MMR! Often diagnosed at 12-36 months, coincidentally around the time MMR vaccine is given.

Question 21

Health history and physical exam for autism?

Answer 21

Symptoms vary, everybody is different. Regression in skills.
Avoids eye contact during physical exam. Hypersensitivity to touch, so be careful as a provider when offering touch. Work up includes hearing and lead screens.

Question 22

Screening for autism spectrum disorder?

Answer 22

No babbling or pointing by 12 months, when it’s normally done around 6-12 months. No single words by 16 months, normally done at 9-12 months. No 2-word sentences by 24 months. Loss of language and social skills.

Question 23

Nursing management for autism?

Answer 23

Emotional and educational support: behavioral therapies, alternative therapies, diets, vitamins. ADHD meds: stimulants, antipsychotics. Treatment programs. Ensure services, structured environments/routines. Respite care.

Question 24

Best quality of life possible, while alleviating physical, psychological, emotional, and spiritual suffering. Includes chronic and life-threatening conditions.

Answer 24

Palliative care. Can co-exist with curative treatments. Multi-disciplinary. Family-centered care, they are the lead on this team.

Question 25

What are four concerning symptoms for the family when it comes to their dying child?

Answer 25

Pain and suffering, dyspnea, GI (constipation), LOC

Question 26

Can co-exist with curative treatments to increase the quality of life. Must be both terminally ill and have a prognosis of less than 6 months.

Answer 26

Hospice care. At home or at a hospice facility. Also includes ongoing bereavement care, once a child dies, there is a whole program for the family members to help with coping

Question 27

What questions and statements should be avoided when working with a family with a dying child?

Answer 27

How are you feeling? I understand how you feel. You have other people to live for. There is a reason for everything. They are in a better place.

Question 28

What are good statements to make when dealing with the family of a dying child?

Answer 28

What can I do for you? I can only imagine how you feel. Can I call anyone for you? Ask about their beliefs.

Question 29

Managing pain in the dying child?

Answer 29

Parents determine this is the most important. Meds include opioids, may require higher doses. No assessment needed, just give them pain meds. Nonpharmacologic methods, like positioning and a calm environment. Cluster nursing care so as not to disturb the child. Anxiolytics and benzos to calm anxiety.

Question 30

Providing nutrition in the dying child?

Answer 30

Expect a decreased appetite. Provide desired foods. Small and frequent meals, especially with n/v. Meds: ondansetron, diphenhydramine

Question 31

How to deal with dying infants/toddlers?

Answer 31

Be with the child in a “non-scary way.” Responds to family emotion, physical comfort. Frequent unstructured.

Question 32

How to deal with dying preschoolers?

Answer 32

Poor understanding of death, magical thinking. Don’t understand permanence and blame themselves. Drawing, maybe of heaven and their family.

Question 33

How to deal with dying school-age children?

Answer 33

Concrete understanding of death. Siblings. Scrapbooking.

Question 34

How to deal with dying adolescents?

Answer 34

Abstract thinking, fear, privacy. Journaling.

Question 35

Helping a family dealing with a dying child?

Answer 35

Anticipatory grief at the time of the diagnosis. Acute grief at the time of the death. Stages of grief, children go through them too. Provide privacy and a chance to say goodbye, Mourning.

Question 36

Kubler-Ross’ stages of grief?

Answer 36

Denial, anger, bargaining, depression, acceptance.

Question 37

Intentional infliction of physical and mental injury upon a child, that could be reasonably expected to result in physical or mental injury to a child.

Answer 37

Child abuse. Also includes: o Active encouragement of any person to commit an act that results or could result in physical or mental injury to a child. Engages in violent behavior that demonstrates a wanton disregard for the presence a child and could reasonably result in serious injury to the child

Question 38

What is included in child maltreatment? Risk factors for child abuse?

Answer 38

Neglect, physical abuse, sexual abuse, emotional abuse. Socioeconomic status, gender, age, depression or other mental health illness, drug/alcohol use in the home, domestic violence, parental history of abuse

Question 39

Act of omission, including failure to provide adequate clothing, nutrition, shelter, or supervision. Accounts for more child abuse deaths than any other type of abuse.

Answer 39

Neglect. Abandonment. Failure to ensure that child receives adequate health care, dental care, or education. May be chronic or acute. Recent studies estimate that 50-60% of deaths from abuse and neglect are not recorded.

Question 40

When should neglect be considered as a possibility?

Answer 40

Child is significantly below height and weight for age. Inappropriate clothing for climate. Lack of safe/sanitary shelter. Lack of medical/dental care. Untreated illness/injury. Poor hygiene

Question 41

Involvement of adults, older children or adolescents in sexual activities with children who cannot give the appropriate consent and who do not understand the significance of what is happening to them. Consider when?

Answer 41

Sexual abuse. Injury to the genital area. Sexually transmitted disease. Pregnancy in an adolescent. Child reports/engaged in inappropriate sexual behavior.

Question 42

A repeated pattern of damaging interactions between parent(s) and child that becomes typical of their relationship. Child repeatedly feels unloved, unwanted, worthless. Consider when?

Answer 42

Emotional abuse. Most commonly occurring type of abuse, but least likely to be reported. Lack of attachment. Lack of responsiveness to their environment. Failure to thrive

Question 43

Types of neglect?

Answer 43

Medical, drowning, motor vehicle crashes, children left unattended in vehicles, co-sleeping <2 years, unsafe sleeping, drug endangered children.

Question 44

Example of discrepancies between the history and the injury in abuse?

Answer 44

History given by parent does not explain the injury. Multiple injuries, various stages of healing. Delay in seeking medical attention. No history offered. History changes over time. Child developmentally not capable. Child would not reasonably be expected to have acted as described. Serious injury blamed on another child.

Question 45

Examples of inflicted injuries in abuse?

Answer 45

Skeletal injuries, bite marks, bruising, burns, shaken baby syndrome/abusive head trauma, battered child. Most common inflicted fractures are skull, humerus, femur, tibia, posterior ribs

Question 46

Bite marks in abuse?

Answer 46

Semi-circular or oval. Often viewed with UV light. <2.5cm vs 2.5-3.5cm seen in adult.

Question 47

Acts of commission towards the child by parent/caregiver. Results in harm or at least the intention to harm. Excessive corporal punishment. Consider a possibility when?

Answer 47

Physical abuse. History given by parent doesn’t match history, child gives unbelievable explanation, child reports injury by parent, child fearful to go home.

Question 48

Occurs after blunt trauma to skin which disrupts underlying blood vessels. Most common manifestation of abuse. Crying and not being potty trained are big triggers.

Answer 48

Bruises. Superficial injury caused by impact. Location can determine how soon it’s visible. Trauma to the blood vessels. Swelling secondary to information. Color changes.

Question 49

Bruise patterns to look for in abuse? Suspicious places?

Answer 49

Wire loops: elliptical shapes. Belt buckles, shoes, etc: look for pattern. Hand: parallel lines. Ligatures: circumferential marks.
Suspicious: infants, upper arms and thighs, face, ears, neck, genitalia, abdomen, buttocks

Question 50

Up to 3/4 of all physical abuse is caused by some type of burn, most common is got water. Types of burns?

Answer 50

Scald, flame, contact, electrical, chemical, radiation

Question 51

Explain scald and flame burns?

Answer 51

Scald: Typical accident, not abuse, is a splash or spill. Thick liquids maintain heat much longer, more extensive burn. Typical inflicted scald burn has well demarcated margins with no spill or splash.
Flame: Commonly inflicted on hands or feet. Punishment for playing with fire.

Question 52

Explain contact and electrical burns?

Answer 52

Contact: Made with heated objects. Look for pattern. Location is revealing.
Electrical: Severity dependent on strength of current, skin resistance, and contact time.

Question 53

Explain chemical and radiation burns?

Answer 53

Chemical: Important to know the causative agent. Amount of drainage is dependent on agent, strength, quantity, duration, and extent of penetration. Access MSDS.
Radiation: Direct or indirect. Often in context of neglect.

Question 54

Mimics of child abuse?

Answer 54

Mongolian spots, coining, cupping, moxibustion, impetigo, herpes zoster

Question 55

Explain shaken baby syndrome?

Answer 55

Head in the infect is 25% of body weight, with weak neck musculature, high water content in brain. Veins are stretched, exceed elasticity. Tear, causing bleeding. Brain strikes the skull. Immediate swelling.

Question 56

Shaken baby syndrome is not a result of?

Answer 56

Bouncing baby on the knee, baby falling off couch, walking/jogging with baby in backpack, throwing baby in the air, sudden stop in the car seat.

Question 57

Violent shaking, 2-4 cycles per second. A condition with s/s that is not mimicked by any other disease or medical condition.

Answer 57

Shaken baby syndrome resulting in head trauma. Crying is the number one trigger.

Question 58

Any person who knows, or has reasonable cause to suspect, that a child is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or other person responsible for the child’s welfare shall report such knowledge to the department

Answer 58

Mandatory reporting. Physician, osteopathic physician, medical examiner, etc… Health or mental health professional. Practitioner who relies solely of spiritual means for healing. School teacher or other personnel. Social worker. Law enforcement officer. Judge

Question 59

How to report child abuse?

Answer 59

Identify yourself; name, work address and phone number. Provide child’s information: name, age, race, sex, DOB. Clearly state your suspicion of what type of abuse is taking place. If possible, give names of siblings. Provide parent/caretaker information

Question 60

After the report of child abuse?

Answer 60

LE looks for element of crime; PI looks at child safety. Reports are given priority based on immediate risk to child (immediate vs. 24 hr. response). Cursory (1st)interview conducted by PI or LE with purpose of seeking indicators of abuse and the person responsible. LE or PI with request forensic interview, psychosocial assessment and/or forensic exam