Review – Child Abuse & Poisoning

HESI-Comprehensive-Review-for-the-NCLEX-RN
Child Abuse & Poisoning

Child Abuse

1. Description: Physical and mental injury, sexual abuse, and emotional and physical neglect; a national problem from which 3000 to 5000 children die each year (see Abuse in Chapter 7, Psychiatric Nursing).

Poisonings

Description: Ingesting, inhaling, or absorbing a toxic substance

1. Poisoning, particularly by ingestion, is a common cause of childhood injury and illness.
2. Most poisonings occur in children younger than 6 years, with a peak at age 2 years.
3. The exploratory behavior, curiosity, and oral motor activity of early childhood place the child at risk for poisonings.
4. About 90% of poisonings occur in the home.

Nursing Assessment

1. Child found near source of poison
2. Gastrointestinal (GI) disturbance: nausea, abdominal pain, diarrhea, vomiting
3. Burns of mouth, pharynx
4. Respiratory distress
5. Seizures, changes in level of consciousness
6. Cyanosis
7. Shock

Analysis (Nursing Diagnoses)

1. Risk for poisoning related to . . .
2. Deficient knowledge (home safety) related to . . .

Nursing Plans and Interventions

1. Identify the poisonous agent quickly!
2. Assess the child’s respiratory, cardiac, and neurologic status.
3. Instruct parent to bring any emesis, stool, etc., to the emergency department.
4. Determine the child’s age and weight.
5. Poison removal and care may require gastric lavage, activated charcoal, or naloxone HCl (Narcan).
6. Teach home safety.
   1. Poison-proof and child-proof the home.
   2. Identify location of poisons: under the sink (cleaning supplies, drain cleaners, bug poisons); medicine cabinets; storage rooms (paints, varnishes); garages (antifreeze, gasoline); poisonous plants (philodendron, dieffenbachia).
   3. Put locks on cabinets.
   4. Use safety containers: do not place poisonous materials in other non-safe containers.
   5. Discard unused medications.
   6. Make sure child is always under adult supervision.
   7. Post telephone number for local poison control center next to telephone.
   8. Examine the environment from the child’s viewpoint (the height to which a 2 to 5-year-old can reach).
7. Contact community health nurse or child welfare agency if necessary.

Lead Poisoning

1. Description: It is estimated that 2.2% of children younger than 6 years of age living in the United States have blood levels greater than 10 mcg/dL.
2. Children 6 years of age and younger are most vulnerable to the effects of lead.
3. Although numerous sources of lead can result in exposure in young children, the major cause of lead poisoning is deteriorating lead-based paint.
4. Lead enters the body through ingestion, inhalation, or, in the case of an unborn child, placental transfer when the mother is exposed. The most common route is ingestion either from hand-to-mouth behavior via contaminated hands, fingers, toys, or pacifiers or, less often, from eating sweet-tasting loose paint chips found in a home built before 1950s or in a play area.
5. Lead can affect any part of the body, but the renal, neurologic, and hematologic systems are the most seriously affected.
6. The blood lead level (BLL) test is currently used for screening and diagnosis.
7. Erythrocyte protoporphyrin (EP) test (a good indicator of early toxic effects of lead) remains useful as a clinical tool, along with the BLL test, to help estimate the potential body burden of lead in a child.

Nursing Assessment

1. Screen for lead poisoning using Centers for Disease Control and Prevention  (CDC)  guidelines  of  blood lead surveillance and other risk factor data collected over time to establish the status and risk of children throughout the state.
2. In areas without available data, universal screening is recommended.
   1. All children should have a BLL test at the ages of 1 and 2 years.
   2. Collect blood in a capillary tube, and send to the laboratory.
   3. During collection, avoid contamination of blood specimen and lead on the skin.
   4. Any child between 3 and 6 years of age who has not been screened should also be tested.
3. Obtain a history of possible sources of lead in the child’s environment.
4. Physical  assessment

1. General signs
   1. Anemia
   2. Acute crampy abdominal pain
   3. Vomiting
   4. Constipation
   5. Anorexia
   6. Headache
   7. Lethargy
   8. Impaired growth
2. Central nervous system (CNS) signs (early)
   1. Hyperactivity
   2. Aggression
   3. Impulsiveness
   4. Decreased interest in play
   5. Irritability
   6. Short attention span
3. CNS signs (late)
   1. Mental retardation
   2. Paralysis
   3. Blindness
   4. Convulsions
   5. Coma
   6. Death

Analysis (Nursing Diagnoses)

1. Risk for poisoning related to …
2. Interrupted family processes related to …
3. Risk for injury related to …

Nursing Plans and Interventions

1. Identify sources of lead in the environment.
2. Administer prescribed chelating agents to reduce high BLLs.
   1. Ask family if child is allergic to peanuts; if so, cli  ent should not be given chelating agents such as dimercaprol (also called BAL [British antiLewisite]), d-penicillamine, or calcium disodium EDTA.
   2. Rotate injection sites if chelating agent is given intramuscularly.
      1. Reassure child that injections are a treatment, not a punishment.
      2. Administer   the   local   anesthetic   procaine with IM injection of CaNa₂ EDTA to reduce discomfort.
      3. Apply EMLA cream over puncture site 2½ hours before the injection to reduce discomfort.
   3. Avoid giving iron during chelation because of possible interactive effects.
   4. If home oral chelation therapy is used, teach family proper administration of medication.
3. Administer prescribed cleansing enemas or cathartic for acute lead ingestion.
4. Assist family to obtain sources of help for removing lead from the environment.
   1. Do not vacuum hard-surfaced floors or windowsills or window wells in homes built before 1960 because this spreads dust.
   2. Wash and dry child’s hands and face frequently, especially before the child eats.
   3. Wash toys and pacifiers frequently.
   4. Make sure that home exposure is not occurring from parental occupations or hobbies.

Review of Child Health Promotion List two contraindications to live virus immunization. List three classic signs and symptoms of measles. List the signs and symptoms of iron deficiency. Identify food sources of vitamin A. What disease occurs with vitamin C deficiency? What measurements reflect present nutritional status? List the signs and symptoms of dehydration in an infant. List the laboratory findings that can be expected in a dehydrated child. How should burns in children be assessed? How can the nurse best evaluate the adequacy of fluid replacement in children? How should a parent be instructed to child-proof a house? What interventions should the nurse perform first in caring for a child who has ingested a poison? What early signs should the nurse assess for if lead poisoning is suspected?

Answers to Review Immunocompromised child or a child in a household with an immunocompromised individual Photophobia, confluent rash that begins on the face and spreads downward, and Koplik spots on the buccal mucosa Anemia; pale conjunctiva; pale skin color; atrophy of papillae on tongue; brittle, ridged, or spoon-shaped nails; and thyroid edema Liver, sweet potatoes, carrots, spinach, peaches, and apricots Scurvy Weight, skin-fold thickness, and arm circumference Poor skin turgor, absence of tears, dry mucous membranes, weight loss, depressed fontanel, and decreased urinary output Loss of bicarbonate/decreased serum pH, loss of sodium (hyponatremia), loss of potassium (hypokalemia), elevated Hct, and elevated BUN By using the Lund-Browder chart, which takes into account the changing proportions of the child’s body By monitoring urine output By being taught to lock all cabinets, to safely store all toxic household items in locked cabinets, and to examine the house from the child’s point of view Assessment of the child’s respiratory, cardiac, and neurologic status Anemia, acute cramping, abdominal pain, vomiting, constipation, anorexia, headache, lethargy, hyperactivity, aggression, impulsiveness, decreased interest in play, irritability, short attention span