Chapter 17 A These disorders may be characterized by physical as well as psychologic signs and symptoms and must be distinguished from expected variances in growth and development B The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for diagnosis are behavioral manifestations that are not age appropriate, deviate from cultural norms, and create deficits or impairments in adaptive functioning. (In 2013, the DSM-V is expected to be published. Diagnostic categories will change through addition of new diagnoses and deletion or merging of others. This is particularly expected in the area of child and adolescent mental disorders.) C Psychiatric care of the child or adolescent is a subspecialty within psychiatric nursing. Although there is a wide range of deficits with these disorders, there are fundamental principles that apply D Care should be based on the child’s developmental level and directed toward helping the child grow emotionally. All children, especially these children, require 1. Protection from danger, including impulsive acts and self-destructive behavior 3. Basic physiologic needs to be met 4. Meaningful trusting relationships E There is increasing awareness of mental illnesses in children and adolescents that were formerly believed to occur only in adults. This includes bipolar disorder, schizophrenia, depression, and posttraumatic stress disorder (PTSD). Manifestations of these illnesses in the younger population may differ from those in adults. Treatments may be modified to meet the developmental level of the child and adolescent. 1. Attainment or delay of developmental milestones (e.g., motor, language, social, etc.) 2. Parental behavior and attitude (e.g., expectations, acceptance/rejection, encouragement/pressure) 3. Personal and family health history (e.g., vision, hearing, general health, perinatal history, familial disorders) 4. Onset, characteristics, and pattern of speech; ability to communicate with others 5. Level of anxiety, frustration, self-esteem 6. Behavioral manifestations (e.g., ability to perform activities of daily living (ADLs), hyperactivity, distractibility, attention span, impulsiveness, repetitive behaviors, tics, reports of somatic symptoms) 7. Social abilities (e.g., ability to connect with others/environment, aggressiveness, ability to follow directions/rules, respect for others and their belongings) 1. Develop a trusting relationship with the child and family b. Provide consistent caregivers c. Make explanations as clear as possible and at the appropriate cognitive level 2. Help the child to see self as worthwhile a. Encourage verbalization of feelings b. Accept child and focus on strengths to raise self-esteem c. Foster independence by emphasizing abilities and achievements rather than limitations d. Provide opportunities for the child to experience success and satisfaction e. Use positive reinforcement for child’s strengths and abilities f. Teach and role model more adaptive coping behaviors g. Increase sense of empathy through role modeling, role playing, group therapy h. Support and encourage the child’s movement toward independence but allow dependency when necessary 3. Establish an environment in which the child can gain or regain a favorable equilibrium a. Set realistic, attainable goals b. Maintain routines based on the child’s usual schedule; maintain safety c. Manage hyperactivity and aggressive behaviors: progress from avoiding situations that precipitate unacceptable behavior to monitoring behavior for increasing anxiety, signaling child to use self-control, and finally to placing child in “time out” when appropriate d. Set limits that are as realistic as possible but as firm as necessary, avoiding manipulation e. Provide for consistency, both in approach and in rules/regulations f. Use a firm system of rewards and punishments within set limits g. Point out reality, but accept the child’s views of it h. Recognize that the maladaptive behavior has meaning for the child or may be beyond the child’s control (e.g., tic disorder) i. Plan activities to provide a balance between energy expenditure and quiet time j. Introduce new situations gradually; permit child to have a familiar, comforting object k. Engage in parallel play to connect with a withdrawn child in a nonthreatening manner 4. Involve family in parenting education and management training (1) Gain an accurate understanding of their child’s strengths and weaknesses (2) Cope with feelings such as guilt, failure, or anger (3) Provide firm and consistent discipline and ignore temper tantrums b. Help parents and child to identify triggers to maladaptive behaviors c. Involve family in multifamily therapy to work through problems of daily life and to gain new information and more adaptive coping skills d. Provide parents with a list of available community resources e. Assist family with placement of child when home care can no longer be provided because of changes in child or ability of caregivers 5. Administer prescribed medications a. Pervasive developmental disorders: antipsychotics, stimulants b. Attention deficit hyperactivity disorder: methylphenidate (Ritalin, Concerta); give after breakfast to ensure dietary intake; a second dose should be administered before 6 PM to limit insomnia c. Tic disorders: sedatives, anticonvulsants (antiseizure); prescribed but usually have minimal effect d. Enuresis: desmopressin (DDAVP, Stimate); tricyclic antidepressants for children older than 5 years of age 6. Minimize long-term consequences a. Identify and ensure that deficits are treated early b. Support attendance at school, therapeutic nursery program, day treatment program, or special education program depending on age and degree of disability c. Provide ongoing assistance to promote social and academic success d. Provide activities appropriate for age and disorder (e.g., play, games, sports) e. Allow child time to verbalize, without completing words or sentences for child; use picture boards; use sign language; avoid nonverbal behavior that implies impatience f. Support child and parents receiving treatment
Nursing Care of Clients with Disorders Usually First Evident in Infancy, Childhood, or Adolescence
Overview
General Nursing Care Related to Disorders First Evident in Infancy, Childhood, or Adolescence
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