Psychosocial,+Abuse,+Chronic+Conditions,+Loss


 * Psychosocial_Abuse and Neglect_Chronic Illnesses and Loss **

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 * Attention deficit hyperactivity disorder (ADHD, ADD) **

Diagnostic criteria for ADD and ADHD include symptoms of inattention, impulsivity, and hyperactivity.

Most prevalent, common neuro-behavioral disorder of childhood Deficiency in self regulation 5 - 10 %, more common in boys

Causes: Unknown theories focus on: Genetic as 10-35% have a first degree relative with symptoms Physiological - Deficiency in dopamine Environmental - head injury, lead poisoning, prenatal cigarette and alcohol exposure

Symptoms generally present before age 7 Clear evidence of social, academic or occupational impairment Impairment from the symptoms are present in two or more settings The symptoms do not occur just during a mental disorders presentation Nursing Care involves tracking growth and development

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">Medications <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> ADHD’s principal characteristics are inattention, hyperactivity, and impulsivity.

<span style="color: #d93fb7; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Symptoms of Hyperactivity-Impulsive Type: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Restlessness, often fidgeting with hands or feet, or squirming while seated <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Running, climbing, or leaving a seat in situations where sitting or quiet behavior is expected <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Blurting out answers before hearing the whole question <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Difficulty waiting in line or taking turns

<span style="color: #d624c4; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Symptoms of Inattention Type: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Ignores details; makes careless mistakes <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Has trouble sustaining attention in work or play <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Does not seem to listen when directly addressed <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Does not follow through on instructions; fails to finish

<span style="color: #db37de; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Symptoms of Combined Type (most children and adolescents with ADHD have this type): <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Demonstrates symptoms of both inattention and hyperactivity-impulsivity (six or more symptoms of both) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Has symptoms that have persisted for at least six months

<span style="color: #e02fcf; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Manifestations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Inattention, poor planning, organization, and time management <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Results: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Trouble with schools, teachers, friends

<span style="color: #e038da; font-family: 'Times New Roman',Times,serif; font-size: 130%;">How It Is Diagnosed <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">ADHD can be difficult to diagnose. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">A diagnosis of ADHD is based on the number, persistence, and history of symptomatic behaviors <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Parents or teachers may be the first to notice possible signs of ADHD. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diagnosis of adult ADHD is based on symptoms, impairments, and history. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diagnosis should be made by a professional with training in ADHD or mental disorders.

<span style="color: #d336d6; font-family: 'Times New Roman',Times,serif; font-size: 130%;">CDC's Checklist/Survey: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Simply fill out the child's name, age and today's date and then check off the signs or symptoms the child has shown. Take the completed checklist to your child's health care provider.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">**Six or more** of the following symptoms of inattention have been **present for at least 6 months** to a point that is inappropriate for developmental level <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often does not give close attention to details or makes careless mistakes in schoolwork, work, or other activities.
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Inattention **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often has trouble keeping attention on tasks or play activities.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often does not seem to listen when spoken to directly.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often does not follow through on instructions and fails to finish schoolwork, chores, or duties (loses focus, gets sidetracked).

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often has trouble organizing activities.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often avoids, dislikes, or doesn't want to do things that take a lot of mental effort for a long period of time (schoolwork)

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often loses things needed for tasks and activities (e.g. toys, school assignments, pencils, books, or tools).

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Is often easily distracted.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Is often forgetful in daily activities.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Six or more of the following symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for developmental level
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Hyperactivity / Impulsivity **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often fidgets with hands or feet or squirms in seat when sitting still is expected.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often gets up from seat when remaining in seat is expected.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often excessively runs about or climbs when and where it is not appropriate (adolescents or adults may feel very restless).

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often has trouble playing or doing leisure activities quietly.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Is often "on the go" or often acts as if "driven by a motor".

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often talks excessively.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often blurts out answers before questions have been finished.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often has trouble waiting one's turn.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often interrupts or intrudes on others (e.g., butts into conversations or games).


 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">What do you see? **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Ask a relative, friend, coach, teacher or child care provider to tell you what your child does.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Print a blank checklist and forward them.

<span style="color: #d633d0; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Treatment:
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Pharmacotherapy: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Stimulant medication: Ritalin, Dexedrine, Adderall (increase availability of dopamine increasing concentration and attention) Side effects - anorexia, weight loss, abdominal pain, headache, insomnia, tachycardia, hypertension

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Antihypertensive medications Clonidine or Tenex (decrease impulsivity)

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Antidepressants (Strattera) selective norepinephrine reuptake inhibitor (not controlled substance,not habit forming, not for drug abuse) Observe for liver damage

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Behavior management: help to follow rules, complete tasks, positive reinforcement <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Educational interventions: developmental disability free public education, least restrictive environment <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Family education: Caregivers not at fault, support groups

<span style="color: #cc35bd; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Possible Nursing diagnoses: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Impaired social interaction <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Risk for injury <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Chronic low self esteem <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Compromised family coping

<span style="color: #d62fd0; font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Outcomes: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Acceptable social skills, improved ability to interact with peers <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Free of injury, free from unnecessary risk <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Increased feelings of self worth <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Identify family coping strategies for disruptive behaviors <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Appropriate limit setting and environmental structure

<span style="color: #db37d5; font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Care: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Pharmacotherapy <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Teaching about medication regimen and side effects <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Height, weight BP monitored <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Drug holidays <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Home care (time routines for waking, homework, chores; Clear written rules; Simple instructions with demonstration, ask to repeat back; 1 or 2 instructions at a time; special quiet spot, choices within time limits,; Self expression, activities that feed sense of success, sleep schedule) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Evaluate care

<span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">School avoidance, school refusal <span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">Notable that symptoms subside after misses school and on weekends <span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">Reentry programs combine readying for school with relaxation techniques
 * <span style="color: #ea1fea; font-family: 'Times New Roman',Times,serif; font-size: 23px;">School phobia **


 * <span style="color: #ea1fea; font-family: 'Times New Roman',Times,serif; font-size: 23px;">Recurrent abdominal pain **

<span style="color: #9e18cd; font-family: 'Times New Roman',Times,serif; font-size: 18px;">Clinical Manifestations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">Three episodes of abdominal pain in 3 months that interferes with functioning and has spastic bowel symptoms <span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">Pain irregular in time, duration, and intensity

<span style="color: #9e18cd; font-family: 'Times New Roman',Times,serif; font-size: 18px;">Causes: <span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">Often occurs in sensitive over achievers who are not comfortable with expressions of anger from caregivers

<span style="color: #9e18cd; font-family: 'Times New Roman',Times,serif; font-size: 18px;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">Acid reduction agents and antispasmodics <span style="font-family: 'Times New Roman',Times,serif; font-size: 18px;">Rest, comfort, quiet, heating pad

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Separation anxiety <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">School Phobia <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Social Phobia <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Generalized anxiety disorder (GAD - 10-20%) excessive worry about future events, worriers, perfectionists <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Separation anxiety disorder (SAD) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Obsessive-compulsive disorder recurrent, intrusive, thoughts, fears (cleanliness, aggressive thoughts, worry, symmetry); obsessive, compulsive rituals or behaviors (washing, repeating, checking, counting, ordering, touching) Behaviors aimed at reducing stress or preventing a dreaded event
 * <span style="color: #d840db; font-family: 'Times New Roman',Times,serif; font-size: 22.1px;">Anxiety: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Post traumatic stress disorder <span style="color: #d941d3; font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">* Social anxiety can lead to depression - deficit social skills lead to ineffective interactions with environment and peers leading to lowered self esteem.

<span style="color: #d134c1; font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Clinical Manifestations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Stomachaches, headaches, nausea, vomiting <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Vertigo, palpitations, faintness <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Restlessness, fatigue, difficulty concentrating <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Irritability, sleep disturbances, muscle tension

<span style="color: #db37d5; font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Assessment developmental, social history, and coping styles <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Anxiety that interferes with ability to function, perform

<span style="color: #d536d9; font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Reduce symptoms, relieve distress <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Minimize disability <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Enhance developmental potential <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Education <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Consultation with schools <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Cognitive behavioral therapies <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Pharmacological therapy adjunct (antidepressants, maybe benzodiazepines short term)

<span style="color: #db40cc; font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Nursing Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Fear related to separation <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Impaired social interaction <span style="color: #0a090a; font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Ineffective individual coping

<span style="color: #d62fbb; font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Outcome: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Normal development with minimal anxiety <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Child will attend school, social functions with minimal anxiety <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Child will initiate social interactions <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Child will cope with anxiety <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Child will use relaxation, deep breathing, self talk to control anxiety

<span style="color: #db40d5; font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Care: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Include child in care <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">School nurses to note changes <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Child to identify outlets for anxiety <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Evaluation can child attend school

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">2 types: Major depressive disorders (MDD); Dysthymic disorders (DD) less intense but more chaotic
 * <span style="color: #cf44c1; font-family: 'Times New Roman',Times,serif; font-size: 170%; line-height: 1.5;">Mood disorders/Depression: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Signs and Symptoms: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Depressed mood <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Frequent sadness, tearfulness, or crying <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Feelings of hopelessness <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Loss of interest in favorite activities <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Lack of enthusiasm, energy or motivation <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Changes in eating or sleeping habits, or fatigue <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Relationship difficulty and/or social withdrawal <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Increased irritability, anger or hostility <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Frequent physical complaints <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Poor concentration, forgetfulness, indecision <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Feelings of worthlessness or excessive guilt <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Extreme sensitivity to rejection or failure <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Talk of running away or actually running away <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Poor school performance or excessive absences <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Talk or thoughts of suicide, or self-destructive behavior

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">**Distinction between sadness and depression = duration * Depression exists most of the day, almost everyday for at least 2 weeks.**

<span style="color: #cc43b6; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Children's depression inventory <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Children's depression rating <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Physical assessment to rule out Mono, seizure disorder, hypo/hyperthyroidism, drug abuse/withdrawal

<span style="color: #db3ade; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Psychotherapy: individual, family, play and group therapy and cognitive behavioral therapy (CBT - behavior modification to change negative cognitions)

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Psychotropic medications (not tricyclic antidepressants (Tofranil, Elavil) but selective serotonin reuptake inhibitors (SSRI - best due to low side effects, low lethality, easy administration once a day -Prozac, Zoloft, Paxil)

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Hospitalization for safe controlled environment (firearms used in 67%), inadequate supervision, agitated behavior, mania, intoxication, substance abuse, psychotic, male, prior attempt, familial history for completed suicide)

<span style="color: #db3dd5; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Management: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Assessment <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Teach coping, parenting skills, to identify risk factors, <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Care for, debriefing, support groups for care givers/family

<span style="color: #d636c6; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Warning signs of suicide: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Suicide: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">3rd leading cause of death during the teen years <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%; line-height: 1.5;">Plan that includes a method, place, time, clear intent, and no rescue plan <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Major life changes <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Conflict with care givers <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Suicidal clues/hints giving away possessions <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Decreased performance in school <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Accident proneness <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Mood swings <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Withdrawal from family and friends <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Increase in drug or alcohol use <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Change in appetite <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Loss of interest in personal appearance

<span style="color: #d932c8; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Nursing management: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Assess: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Mood - using variety of words - sad, depressed, blue, down, unhappy <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Somatic complaints <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Sleep patterns <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Family life <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Recent stressful events <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Have you ever so sad that you thought about killing yourself or wished you were dead? <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">If yes, ask about the plan - method, time, place, availability of means, lethality, support system, resources <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Have you ever done anything on purpose to hurt or kill yourself?

<span style="color: #e03ada; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Nursing Diagnoses: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Low self esteem <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Impaired social interaction <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Disturbed sleep <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Risk for injury, self directed <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Risk for use of drugs, self medication

<span style="color: #ce41d1; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Outcomes: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Express positive feelings <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Interact appropriately <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Demonstrate less withdrawal <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Safe from harm, free from self injurious behavior, or high risk activity engagement

<span style="color: #d529d9; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Plan: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Education of child and family <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Education on S&S of depression/suicide <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Education that SSRI can take a few weeks for full effect <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Sleep: BR just for sleep, no naps, routine, physical exercise, limit caffeine


 * <span style="color: #d624a4; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Substance Abuse **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Substance abuse maladaptive use of substances leading to impairment and distress, "self-medicating" <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Substance dependence withdrawal - adverse physical symptoms, tolerance and loss of control over use <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Substances used: alcohol, tobacco, marijuana, opiates, cocaine, amphetamines, barbiturates, hallucinogens, inhalants

<span style="color: #d943d3; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Cause: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Genetics <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Family factors <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Peer influence <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Individual factors <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Neighborhood factors <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Media

<span style="color: #d536d9; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Manifestations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Vary depending on the substance, the age and weight of the child <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">CNS Depressants - Alcohol, barbiturates. Calmness, drowsiness. Toxicity decreased coordination, judgment, accidents, respiratory depression, coma, death <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Opiates - euphoria, analgesia Toxicity respiratory depression, cerebral edema, death <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">CNS Stimulants - Amphetamines - well-being, euphoria. Toxicity hypertension, hyperthermia, convulsions, CV shock <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Hallucinogens - alter perceptions, feelings Side effects - convulsions, cardiovascular collapse

<span style="color: #d633d0; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Physical Signs and Symptoms: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Bloodshot eyes <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Weight loss <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Nasal irritation <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Slurred speech <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Abnormal pupil dilatation or constriction <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Increase in accidents/injuries <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Gather information from a variety of sources

<span style="color: #d638d9; font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Nursing management:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Assess <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Irrational behavior <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Preoccupation with occult <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Absences from school <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Decline in school/work performance <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Lethargy, hyperactivity, agitation <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Changes in personality, friends, activities, appearance <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Rebelliousness <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Mental or physiological deterioration <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Loss of money, paraphernalia

<span style="color: #d938c9; font-family: 'Times New Roman',Times,serif; font-size: 130%; line-height: 1.5;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Varies depending on substance <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Inpatient, residential, day treatment depends on other disorders, hx treatment failure, risk for withdrawal <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Pharmacotherapy - treatment of withdrawal <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Self help, peer support - Alcoholics Anonymous (AA), Narcotics Anonymous (NA) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Changes in lifestyle, coping

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Primarily females, 10-19
 * <span style="color: #d624a4; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Eating Disorders **
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Anorexia Nervosa (AN) **

media type="youtube" key="3jjahuKnuFw" width="560" height="315"

<span style="color: #e038d0; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Theoretical Causes: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Disturbance in levels of neurotransmitters <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Individual or Familial conflicts, issues with control

<span style="color: #d033de; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Manifestations:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Extreme weight loss <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Refusal to eat <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Irrational fear of being overweight <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Pronounced disturbance in body image <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Physical manifestations - amenorrhea, hypothermia, muscle wasting, cardiac dysrhythmias, hypotension, brittle nails

<span style="color: #d336d6; font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">< 85% of expected weight <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Altered body perceptions <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Denial

<span style="color: #d534d9; font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Initially improvement in weight, normalization of eating patterns, restoration of health <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Correction of F&E imbalances <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Hospitalization brief to restore health, weight cannot be gained too quickly or it can lead to cardiac overload <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Target goal weight gain to within 10% of ideal body weight <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Individual therapy - to correct distortions, patient may experience significant fear/anxiety as begin to gain weight <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Family therapy - to correct disturbed patterns of interaction <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Pharmacologic interventions, SSRIs <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 1.5;">Nursing management - kind, nurturing but firm, interventions to ^ self esteem beyond thin body

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Binge eating followed by guilt and purging with vomiting and laxative use <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Usually female ages 15 -30, peak 18-19 <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Risk includes involvement in sports which require low body weight, abuse, familial history of depression or eating disorders <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Binge/purge activities may occur several times a day <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Bulimics lose the ability to response to normal hunger and satiety <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Complications - dehydration, esophagitis, tooth erosion <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Diagnosed by binge eating, sense of lack of control over eating, vomiting, misuse of laxatives to avoid weight gain
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Bulimia Nervosa (BN) **

<span style="color: #d336d6; font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Individual, family and group therapy <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Pharmacologic interventions, SSRIs <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Behavior modification, CBT

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Organic FFT caused by a physical problem (< common, usually gastroesophageal reflux, celiac, pyloric stenosis, heart disease, CNS or endocrine disturbances) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Non-organic FFT (more common, poverty, lack of social support, family stress, errors in formula prep, caregiver knowledge deficit, inadequate breast milk, attachment difficulties)
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Failure to Thrive (FFT) **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Growth failure <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Failure to maintain weight gain <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Loss of SQ fat <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Reduced muscle mass <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Developmental delays <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Apathy
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Manifestations: **

<span style="color: #cc32d9; font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">History/physical <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Observation of dietary interventions

<span style="color: #ca38d6; font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px; line-height: 25.35px;">Catch up growth - 150% o <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">f recommended calorie intake <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Multidisciplinary team with dietician, etc <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.9px;">Nursing management - observation of caregiver child, feeding schedule, education, monitors weight gain, intake, output, role model appropriate interactions, non-blame, encourage family members

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Self-injury is most common in youth having trouble coping with anxiety. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Focus on skill building and identifying environmental stressors that trigger self-injury.
 * <span style="color: #d624a4; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Self-Injury from a Youth Development Perspective **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Self-injury is most often a silent, hidden practice aimed at either squelching negative feelings or overcoming emotional numbness.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Being willing to listen to the self-injurer while reserving shock or judgment encourages them to use their voice rather than their body as a means of self-expression...drawing

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Self-injury serves a function. An important part of treatment is helping youth to find other, more positive ways to accomplish the same psychological and emotional outcome, i.e. explicitly teach coping skills.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">• Assessment and treatment should seek to understand why youth self-injure and then build on the strengths youth already possess.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Cutting/Eating disorders: media type="youtube" key="7GAWGYbAjTQ" width="560" height="315"

<span style="color: #c9061d; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Abuse and Neglect, Chronic Illness and Loss http://childabuse.stanford.edu/

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Abuse and Neglect media type="youtube" key="PFsyC5mzyl8" width="560" height="315"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Child Neglect – harmful, malicious withholding of physical, nutritional, health care, emotional or educational necessities <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Physical abuse <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Psychological abuse <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Sexual abuse
 * <span style="color: #db0922; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Child maltreatment – intentional injury of a child includes: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Inadequate care (inadequate food, clothing, hygiene, healthcare, supervision, drugs) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Inadequate physical care (lack of heat, water, plumbing, beds, garbage, structural chemical, hazards. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Inadequate parenting (school absences, inappropriate discipline, locked out, no limits)
 * <span style="color: #d90f27; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Child Neglect: **

media type="youtube" key="bF3j5UVCSCA" width="560" height="315"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">*Primary cause of death with abuse most often neurological damage -Head – hematomas, lacerations, bruises, brain injuries, shaken baby <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">*Second most common cause of death from abuse is abdominal damage to internal organs – chest, abdomen, liver, pancreas, spleen, kidney, bladder <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">* Also, skin, bruises, burns, bites, lacerations and skeletal damage
 * <span style="color: #bf0a1f; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Physical abuse **<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> most common:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Lack of attention <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Lack of affection <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Lack of supervision <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Children birth to 1 highest rate
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Psychological damage: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Stress without social supports <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Intolerance of normal development, inappropriate expectations <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Intensity of involvement criticism <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Coercive actions deficient parenting skills <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Right to influence authoritarian, punitive, neglectful <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Characteristics 20’s, no diploma, little coping, poverty level <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Patterns of abuse intergenerational <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Privacy of the home secluded <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Difficult transitions births, deaths, separation, loss, unemployment, alcohol
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Risk factors for abuse: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Old and new bruises <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Bruises on skull, face, buttocks, breast, abdomen <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Burns, welts, whip marks <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Injury inconsistent with history <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Spiral fractures <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Burns – scald, immersion, stocking, flexion, splash <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Behavioral indications <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Frightened <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hyper alert, increased startle, <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Over eager to please <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Anxiety hearing children cry <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Lack of attachment <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Extremes - Aggressive, detached, withdrawn <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Day dreaming, staring
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Signs of physical abuse: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Lethargy <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Extreme irritability <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Vomiting //with// //no fever or other signs of illness// <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Seizure, bulging fontanelles <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Redness in eye
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">S&S Shaken Baby **

Shaken Baby Syndrome – profound neurological impairment, retinal hemorrhages, subarachnoid, subdural hemorrhages, unconsciousness, scarring, paralysis…

http://dontshake.org/

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Shaken Baby

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">media type="youtube" key="kgHRWH4USmw" height="377" width="504"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Caregivers fabricate signs and symptoms of disease or cause illness in their children <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Expose their child to harmful, painful medical procedures. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Treatment is ineffective <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Previous child death or illness in family <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Attention seeking
 * <span style="color: #cc0a21; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Munchausen syndrome by proxy: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Location, color, size, shape, of any injuries <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Characteristics of bruises <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Pain, tenderness associated with injury <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Level of hygiene <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Date, time, place of event <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Chronological account of injury <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Witnesses <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Exact quotations <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Does the account make sense, is it consistent with injury
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Assessment for abuse: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Caregiver’s willingness to share <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Cooperative nature <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Empathy toward child <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Nonverbal (eye contact) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Child-caregiver relationship
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Note: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Private, assure confidentiality <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Reassure, not in trouble <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Use child’s own words in documentation <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Allow time to express self and talk <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Encourage child to show injuries <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Use therapeutic play <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Reassure child it is ok to share with caregiver (nurse)
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">When interviewing the child: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Ignoring, degrading child <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Rejecting child <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Isolating child <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Terrorizing, threatening child <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Verbally assaulting child <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Exploiting child <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Pressuring child into older responsibilities <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Exposing child to violence
 * <span style="color: #d40839; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Psychological Abuse: **

media type="youtube" key="ly2NJkb2gVQ" width="560" height="315" <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">S&S <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Recognizing <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Reporting

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Assault, statutory, date, rape, incest <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Exploitation <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Exhibitionism <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Pedophilia <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Child molestation
 * <span style="color: #cc0226; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Sexual abuse <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> can include: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Difficulty walking or sitting <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Unusual or precocious sexual knowledge or activity <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Reports of regression - bed wetting, nightmares <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Suddenly refuses to change for gym <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Sudden change in appetite <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Jealous, controlling family members who isolates child from others
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Signs and symptoms may include: **

media type="youtube" key="KUTLxDzglrY" width="560" height="315"

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Children who are at risk to develop a chronic physical, developmental, emotional or behavioral problem, which necessitates intervention beyond what is generally required.
 * <span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Chronic Illness/Loss and Bereavement **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Affects the child – lost school days, delays, emotional stresses, scheduling, time consuming treatments <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Affects the parents or guardian – lost work days, stress, and fear, finances, time management <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Affects the siblings – embarrassed, guilt, anger, fear

<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Focus is on the developmental level not chronological age or illness

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Disability versus handicap?

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">*A child’s future depends on how well the family functions

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Communication <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Engaged, open, honest, private conversations and teaching <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Time for understanding, questions and clarification <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Anticipatory guidance…what’s around the corner <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Therapeutic relationship <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Acknowledge and respect parents expertise <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Medical team

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Cultural impact <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Affects values on life, perceptions, productivity, time, spirituality <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Communication, decision making with head of household

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Normalization <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Integration into society at large <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">School, work, hobbies <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Assist with support groups <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Community resources, early intervention, Baby Net <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Maximize potential <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Laws - Mainstreaming, individualized educational programs (IEP)

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Family adjustment and anticipated stress points: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Initial shock and denial – diagnosis, helplessness, isolation, fear, depression <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Resurfaces at times of exacerbation or developmental milestones ~ Chronic Sorrow <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Start of school <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Reaching ultimate attainment <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Adolescence <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Future placement <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Death

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Adaptation includes: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Acceptance <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Management <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Meeting developmental needs of the child <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Meeting developmental needs of the family <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Educate others <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Establishment of a support system

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Mothers <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Peaks and valleys, isolation, <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Cope - primary care giver

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Fathers: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Feel ineffective as protector <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Anger <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Escape to work to dull pain <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Knowledge seeking <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Option exploration <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Praying <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Weighing choices

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">media type="youtube" key="uqhCfHeNcxY" width="672" height="501"
 * <span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Chronic Sorrow: **

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Special assistance necessary for single parent families

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Siblings: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Changes in recent years as public image of disabled has changed <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">May feel stigma <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Increased responsibility <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Decreased family finances, resources, time <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Knowledge deficit and increased fear <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Support groups can help verbalize feelings

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Nurses Assessment of: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Parental Coping <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Child adjustment <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Family support <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Anticipatory guidance <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Stressors <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Resources <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Knowledge level

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Approach behaviors move toward acceptance: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Information seeking <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Shares burden <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Freely expresses sorrow <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Acceptance, realistic expectations <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Seeks help and resources <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Attributes meaning to the disability <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Acknowledges personal individual growth

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Avoidance behaviors move away from acceptance and adjustment <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Fails to acknowledge seriousness of situation <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Withdrawal, anger <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Resorts to props, alcohol, drugs, self medication <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Punishes self, guilt <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Magical thinking, defers responsibility of situation <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Refuses treatment or conversely looks for cures <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Not accepting of disease or reality for future

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Expressions of shock and denial: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Physician shopping <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Denial of illness, symptoms <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Refusal to believe tests <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Delaying consent <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Withdrawal, asking no questions

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Examples of adjustment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Guilt and self-accusation <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Bitterness and anger <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Overprotection - sacrifice; restricts growth, play; goals too high or low, no discipline <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Rejection - detachment <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Denial – deny disorder or overcompensate <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Gradual acceptance – promote physical, social, self care activities

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Adjustment can be affected by: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Support system – marriage, extended, alternative, communication <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Perception – perception cause, knowledge, effects on family <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Coping – rx crisis, rx child, childrearing, religion, culture, attitudes <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Resources <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Concurrent stressors

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">The child’s coping: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Competence and optimism <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Withdrawal <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Irritable, moody, acts out <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Compliant <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Seeks support <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">*Hope

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<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Communication and encouraging expression: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Describe the behavior – “You seem angry today…” <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Give evidence of understanding – “Being angry is natural…” <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Give evidence of caring – “ It must be difficult to endure all this…” <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Help focus on feelings – “Maybe you wonder why this has happened…” <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Clarification – repeat words of pt./family for clarity, “So you are saying you feel sad” <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Silence – is OK, listen, you do not always have to respond <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Caring touch <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">It is alright not to know the answer, “I don’t know but I will find out for you” <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Community resources <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Parent to parent – locally Family Connections <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Respite care

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">To assist the child: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Prepare them for the reality of the disorder or disability <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Allow for participation and self-care, ownership <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Sharing <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Control <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Expectations

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Chronic Illness:

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<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Loss and Bereavement:

While we typically think of loss as related to death, it can be related to many different situations. Relocation Loss of possession Pet loss Separation/divorce

Child’s concept of death is dependent on age, development and cognitive ability: Young children: Death is temporary, reversible, fear separation Physically may experience decreased activity, appetite, regression Emotionally may experience fear, anxiety, irritability

School age: Understand death is not reversible, not inevitable, fear mutilation May experience depression, fear of rejection, fantasies of reuniting with loved one Older children (9/10) death irreversible, inevitable, universal but deny own death, experience guilt *Surviving siblings - physically may exhibit concern over own health, abdominal pain, headache, body aches, nausea, joint and muscle pain

Teens: Understand death is permanent May experience betrayal, anger, withdrawal Physically may note a decreased or increased activity, appetite Increase in risky behavior

**Denial** – It’s not true **Anger** – I hate you **Bargaining** – I’ll behave if you stay…let her stay **Depression** – Sorrow, don’t leave me… **Acceptance** – My friend is in Heaven
 * Expected stages of grief: **
 * Kubler-Ross stages (1969) **


 * Worden suggests that children need to be assisted with acceptance **

**Task 1:** **Accept** the loss, not believe that the person will return to life **Task 2:** **Experience** the pain or emotional aspects of the loss **Task 3:** **Adjust** to an environment in which the deceased is missing
 * // *Task 4: Relocate the dead person’s memory within one’s life and find ways to memorialize the person //**

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Physical presence Repetition may be needed Utilize books Acknowledge feelings Assist with sorting through emotions, acceptance…anger, etc. Avoid rationalizations Focus on feelings, good memories Referrals
 * Nursing Measures to help care for the grieving child/family **

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<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Loss of sensation and movement in lower body moving upward <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Sensation of heat although body feels cool <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Tactile senses decrease <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Sensitivity to light <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">*Hearing is the last sense to fail <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Confusion <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Loss of consciousness, slurred speech <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Muscle weakness <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Loss of bowel and bladder control <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Decreased appetite and thirst <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Difficulty swallowing <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Change in respiratory pattern <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Cheyne-Stokes <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">“Death rattle”
 * <span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Physical signs of approaching death: **

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">Options: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Ethics <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Physician health care team <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Parental decision making <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Treatment options <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Hospital <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Hospice or home <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Organ donation, autopsy <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Fears of pain and suffering, dying alone, death

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">At death: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Provide for child’s comfort <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Do what the parents desire as far as life saving <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Allow child and families to relive memories <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Express feelings of loss and sorrow too <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Provide family with needed information <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Allow for respite <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Allow time to rock, hold child <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Arrange for or offer spiritual support

<span style="color: #ce1c1c; font-family: 'Times New Roman',Times,serif; font-size: 140%;">After: <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Attend funeral or visitation <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Initiate or maintain contact <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Compassionate friends, memorials, and involvement in organizations <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Refer to the dead child by name, share memories <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Encourage communication and discourage self-medicating to dull pain <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Emphasize grief is a process <span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Different for everyone

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<span style="color: #df3a3a; font-family: 'Times New Roman',Times,serif; font-size: 14pt;">References:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Hockenberry, M. J., & Wilson, D. (2009). Wong's essentials of pediatric nursing (8th ed.). St. Louis, MO: Mosby Elsevier.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Potts, N. L., & Mandleco, B. L. (2012). Pediatric nursing: Caring for children and their families (3rd ed.). New York, NY: Delmar Cengage Learning.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">ADHD <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">http://youtu.be/u82nzTzL7To

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Obesity <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">http://youtu.be/6nM6NDe3hQM

Anorexia https://youtu.be/3jjahuKnuFw

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Cutting/Eating Disorders https://youtu.be/7GAWGYbAjTQ

Abuse and Neglect: [|**https://youtu.be/PFsyC5mzyl8**]

[|**https://youtu.be/ly2NJkb2gVQ**]

https://youtu.be/bF3j5UVCSCA

https://youtu.be/KUTLxDzglrY?list=PLDh3KDPe5XEM20934YBR-Sn47ySBh01O9

Chronic Sorrow: https://youtu.be/uqhCfHeNcxY

chronic illness in children http://youtu.be/PwQ60WqyXM4

Chronic illness: https://youtu.be/uOl1YvHA6YE

Children and grief hospice http://youtu.be/m7rYSIpGuQk

Loss http://youtu.be/J_XmJKVN1oM

Helping children cope with loss http://youtu.be/wRqp2qgPHXc

<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">Loss video http://youtu.be/dRK6uaBFzUQ

Infant mortality http://youtu.be/7gfV1rOtSN8

Sibling loss http://youtu.be/Mbod9tJ_ujM <span style="rgb(189, 8, 28) url("data: image/svg+xml; border-radius: 2px; border: medium none; color: #ffffff; cursor: pointer; display: none; font: bold 11px/20px "Helvetica Neue",Helvetica,sans-serif; opacity: 1; padding: 0px 4px 0px 0px; position: absolute; text-align: center; text-indent: 20px; width: auto; z-index: 8675309;">Save