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2 diseases of the newborn


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2 diseases of the newborn

  1. 1. Di s e a s e s o f t h e Ne wb o r n Pr e p a r e d b y : Ha n s Ch r i s t i a n f . Vi t u g RN, MA N c F a c u l t y /C l i n i c a l I n s t r u c t o r /R e v i e w e r
  2. 2. "Necrotizing"means the deathof tissue, "entero"refers to thesmall intestine,"colo" to the largeintestine, and"itis" meansinflammation.
  3. 3. An acuteinflammatorydisease of the bowelwith increasedincidence inpreterm and highrisk infants
  4. 4. Theories to Support that Explains NEC1.Little supply of oxygenation -> plus feeding -> stress to the intestinal wall -> allowing bacteria to invade intestinal wall and bloodstream -> necrosis/perforation of the intestinal wall -> decrease absorption of the vitamins and minerals and Leak of bacteria into abdomen causing peritonitis.2.Difficult deliveries -> deprived oxygenation -> vital organs receives more oxygen3.Increased RBC counts – thickens the blood and impaired circulation -> hinder the transport of oxgenation
  5. 5. How does it happen?• Prematurity remains the most prominent risk factor• Great damage to mucosal lining  diminished blood supply  stop secreting protective lubricating mucus  unprotected bowel attacked by proteolytic enzymes  unable to synthesize IgM  Gas-forming bacteria invades damaged area  produce intestinal pneumatosis (presence of air in the submucosal or subserosal surfaces of the bowel)
  6. 6. Signs and Symptoms• Infant may “not look well”• Poor feeding• Apnea• Vomiting (often bile stained)• Decreased U/O• Hypothermia• Distended abdomen• Gastric residuals• Blood in the stools
  7. 7. Diagnostic EvaluationRadiographySausage-shapeddilation of theintestines“Soap suds” orbubbly appearance of thickened bowelwall
  8. 8. Diagnostic EvaluationLaboratoryexaminations – Anemia – Leukopenia – Leukocytosis – Metabolic acidosis – Electrolyte imbalance
  9. 9. Therapeutic Management• Oral feedings withheld for at least 24 to 48 hours• Breast feeding is preferred• Antibiotics• Probiotics – Lactobacillus acidophilus – Bifidobacterium infantis
  10. 10. Nursing Management• Observation and assessment• Infants left undiapered• Position infant supine or on the side• Vital signs including blood pressure –Avoid rectal temperature
  12. 12. Some newborns breathing duringthe first hours of life is more rapidand labored than normal becauseof a lung condition called transienttachypnea of the newborn (TTN).
  13. 13. Definition• A respiratory problem seen in the newborn shortly after delivery• It is likely due to retained lung fluid• Common in 35+ week gestation babies who are delivered by caesarian section without labor• Resolves over 24-48 hours• Causative Factors – Pulmonary immaturity – Mild surfactant deficiency
  14. 14. Causes of TTNTTN, also called "wet lungs" or type IIrespiratory distress syndrome, usuallycan be diagnosed in the hours afterbirth.TTN can occur in both preemies(because their lungs are not yet fullydeveloped) and full-term babies.
  15. 15. New borns at higher risk for TTNinclude those who are:delivered by cesarean section(C-section)born to mothers with diabetesborn to mothers with asthmasmall for gestational age (smallat birth)
  16. 16. Pathophysiology• Lower levels of circulating catecholamines after a caesarean section which are necessary to alter the function of channels that absorb excess fluid from the lungs• Delayed absorption of fetal lung fluid from the pulmonary lymphatic system increased fluid in the lungs  increased airway resistance and reduced lung compliance
  17. 17. Clinical Manifestations• Period of rapid breathing• Tachypnea• Intracostal and subcostal retractions• Grunting• Nasal flaring• Possible cyanosis
  18. 18. Diagnostic Evaluation and Therapeutic Management• Diagnostic evaluation – Chest X-ray – Levels of PG were found to be negative in certain newborns• Management – Supplemental oxygen – Antibiotics
  19. 19. ERYTHROBLASTOSIS FETALIS/HEMOLYTIC DISEASE OF THE NEWBORNAbnormal, rapiddestruction of RBCHyperbilirubinemiain the first 24hours of life ismost often theresult
  20. 20. Hemolytic disease of the newborn (HDN)Major causes of RBC destruction – Rh Incompatibility (Isoimmunization) • Mother is Rh negative, and infant is Rh positive • May not occur in first pregnancy • Increased risk of fetal blood being transferred to maternal circulation  subsequent pregnancy with Rh (+) fetus maternal antibodies formed will attach and destroy fetal erythrocytes • Progressive hemolysis in utero  fetus compensates, accelerates rate of erythropoesis  immature RBCs appear  erythroblastosis fetalis (hydrops fetalis)
  21. 21. Hemolytic disease of the newborn (HDN)Major causes of RBC destruction – ABO Incompatibility • Between a mother with type O and an infant with A or B blood groups. • Anti-A and Anti-B already present in the maternal circulation cross the placenta and attach to fetal RBCs  hemolysis • Less severe hemolytic reaction the Rh incompatibility • May occur in first pregnancy
  22. 22. Signs and SymptomsJaundice –Most not jaundice at birthAnemiaHypovolemicshock may developHypoglycemia
  23. 23. Diagnostic Evaluation• Maternal antibody titer (Indirect Coomb’s test)• Amniocentesis• Ultrasound
  24. 24. Therapeutic ManagementPrevention of Rh Isoimmunization –Administration of RhIg –RhIg (RhoGAM) – must be administered to unsensitized mothers within 72 hours after the first delivery –Admin of RhIg at 26 to 28 weeks of gestation further reduces risk of isoimmunization
  25. 25. Therapeutic Management• Exchange Transfusion –Infants blood is removed in small amounts (5 to 10 ml at a time) and replaced with compatible blood –For severe hydrops• ABO incompatibility –Early detection and phototherapy
  26. 26. Nursing Management• Recognizing jaundice – initial nursing responsibility• Prepares family incase of transfusion and assist practitioner – Infant remains NPO during procedures – Maintain documentation of blood volume exchange, time, cumulative record of the total blood exchanged – Vital signs – Signs of transfusion reactions
  28. 28. Down Syndrome• The genetic disorder most frequently seen as causing moderate to severe mental retardation• Etiology is unknown – Genetic predisposition – Exposure to radiation before conception – Immunologic problems – Infection
  29. 29. Clinical Manifestations• Bradycephaly• Back of the head is flat• Epicanthal folds• Palpebral fissure slanting laterally upward• Tongue may protrude• Narrow palate• Low-set ears• Short broad hands• Transpalmar crease (simian line)• Short stature• Rag-doll appearance• IQ of 50-70
  30. 30. Diagnostic Evaluation• Evident at birth• Prenatal testing• Chromosomal analysis
  31. 31. Therapeutic Management• Surgery to correct cardiac abnormalities, GI malformations and craniofacial deviations• Neck radiography before the child participates in any sports
  32. 32. Nursing Management• Options for fluid and calorie intake – Breastfeeding may not be possible, immature sucking reflex – Special bottles and utensils• Routine – Changes causes frustration and decreased coping abilities• Encourage self-care• Advise X-rays before participating in sports
  34. 34. Cold Stress• Infants lack shivering response• Norepinephrine (SNS) stimulates fat metabolism to produce internal heat  blood  surface tissues• Increased in metabolism  increased oxygen consumption• Norepinephrine  vasoconstriction  decrease oxygen decreased glucose metabolism• Results: Hypoxia, Metabolic acidosis, Hypoglycemia
  35. 35. Three primary methods for maintaining a neutral thermal environment• Incubator• Radiant warming panel• Open bassinet with cotton blankets
  36. 36. Temperature control• Warm items first• Plastic wrap• Careful drying• Kangaroo care
  37. 37. Incubator Care• Double walled incubators –improve infants ability to maintain a desirable temp reduces energy expenditure r/t heat regulation• Pre-warm incubator first• Head covering when outside of the incubator
  38. 38. Essential public strategy that enablesthe early detection and management ofseveral congenital metabolic disorders,which if left untreated , may lead tomental retardation and even deathFor early detection and management ofcongenital metabolic disordersTHE NEWBORN SCREENING PROGRAM
  39. 39. Newborn Screening Program (NBS)• Mandated through RA 9288 (The Newborn Screening Act of 2004)• Done between 24-72 hours after birth
  40. 40. Collection of NBS Samples• Through heel prick method: 4 drops of blood is drawn from heel puncture blotted onto a filter paper• Air dry 4-6 hours• Sent to laboratory within 24 hours• BEST - 48th to 72nd hours of life• ACCEPTABLE - anytime after 24 hours from birth until 2 weeks of age
  41. 41. Sample collection donebefore the ideal time mayresult in: Falsely elevated thyroid stimulating hormone (TSH) = false (+) screen for CH Falsely elevated 17 hydroxyprogesterone (17-OH-P) = false (+) screeen for CH Falsely low galactose and phenylalalnine = false (-) screen for GAL and PKU
  42. 42. Disorders tested for newborn screening• Congenital Hypothyroidism (CH)• Congenital Adrenal Hyperplasia (CAH)• Galactosemia (GAL)• Phenylketonuria (PKU)• Glucose-6-Phospate-Dehydrogenase Deficiency (G6PD)
  43. 43. Congenital Hypothyroidism (CH)
  44. 44. Congenital Hypothyroidism (CH)• aka Cretinism• Lack or absence of thyroid hormone
  45. 45. (H-U-Mi-D)Hereditary conditionsUnderdevelopment of the fetalthyroid glandsMaternal Intake of anti thyroid drugsduring pregancyDeficiency, Maternal Iodine
  46. 46. *ManifestationsPoor suck and feedingJaundiceHypotoniaCool pale dry skinSwelling around the eyesLarge swollen tongueLarge fontanels with late closurePoor weight gain and growthHoare sounding cryDelayed milestone (sitting, crawling, walkingand talking)
  47. 47. *TreatmentLifetime oral doses of thyroid hormone. L-ThyroxineNursing Considerations:Instruct parents to avoid Soy-basedformulas and iron supplements.Avoid adjusting medications withoutMD’s order to prevent undermedication or over medication.
  48. 48. Excessive medication cancause : D-I-T-SDiarrheaInability to sleepTachycardiaShakiness in the child
  49. 49. *TreatmentRegularmonitoring ofthe child’sweight, overallhealth andthyroidhormones level
  50. 50. Congenital Adrenal Hyperplasia (CAH)
  51. 51. Congenital Adrenal Hyperplasia (CAH)• Excessive or deficient production of sex steroids• Severe salt loss, dehydration and abnormally high levels of male sex hormones in both boys and girls• If not detected and treated early, infants may die within 7-14 days
  52. 52. Congenital Adrenal Hyperplasia (CAH)CAH is caused by adeficiency of adrenalgland hormones.21 hydroxylaseis missing or notworking correctly.
  53. 53. Congenital Adrenal Hyperplasia (CAH)21-OH is responsible for the productionof hormones :CORTISOL is involved in glucosemetabolism and in normal inflammationand immune response.ALDOSTERONE is responsible for bloodpressure and sodium retention.
  54. 54. Congenital Adrenal Hyperplasia (CAH)*Manifestations• Poor feeding• Listlessness and drowsiness• Vomiting• Diarrhea• Weight loss• Hypotension• Hyponatremia• Metabolic acidosis
  55. 55. Muscle growth at an early ageEnlargement of penis during childhood
  56. 56. Early deepening of thevoiceEarly beard
  57. 57. Pubic hair and underarm hair duringchildhood Severe acne
  58. 58. M-E-E-E-P-S-SMuscle growth at an early ageEnlargement of penis during childhoodEarly deepening of the voiceEarly beardPubic hair and underarm hair duringchildhoodSmaller than normal testicles
  59. 59. Severe acneMale pattern baldness
  60. 60. Early puberty changes such as hair inairmpits and pubic areaLack of menstrual periods or scanty orirregular periods
  61. 61. Excess hair on the face and bodyDeep, husky voice
  62. 62. (S-M-E-L-E-D)Severe acneMale pattern baldnessEarly puberty changes such as hairin airmpits and pubic areaLack of menstrual periods or scantyor irregular periodsExcess hair on the face and bodyDeep, husky voice
  63. 63. *TreatmentLifetime administration of thedeficient or missing hormonesHYDROCORTISONESlessens the amount ofandrogens (prevents earlypuberty and allows for moretypical growth and
  64. 64. Over medication can results toCushing’s syndrome (Stretchmarks, rounded face, weightgain, hypertension and boneloss).Under medication can occurduring periods of stress andillness when higher doses of the
  65. 65. Correctivesurgery forenlarged clitoris(can be done asearly as one tothree years ofage. To separatelabia and to
  66. 66. Galactosemia (GAL)
  67. 67. Galactosemia (GAL)This hereditary disorder ischaracterized by the lack of theenzyme Galactose-1-Phosphateuridyl Transferase (GALT) thatconverts galactose to glucose, theform of sugar that can be used bybody cells.
  68. 68. Galactosemia (GAL)Initial symptoms also include: (F-L-I-P)Failure to gain weightLethargyIrritabilityPoor feeding and poor suck
  69. 69. Galactosemia (GAL)Treatment: Giving the child a speciallactose free formula and exclusion oflactose and galactose foods such asmilk (including breast milk) and otherdairy products from the diet throughout life.
  70. 70. Galactosemia (GAL)Foods that should be avoided:Milk and all dairy productsProcessed and pre packaged foodsTomato saucesCertain medicationsAny foods or drugs which contain the ingredientsLactulose, Casein, Caseinate, Lactalbumin, Curds,Whey or Whey solids
  71. 71. Galactosemia (GAL)Calcium and Vitamin Ddeficiency is likely to developin a child on a lactose free.Therefor, the child is givensupplements to preventdeficiencies
  72. 72. Phenylketonuria (PKU)
  73. 73. Phenylketonuria (PKU)A metabolic disorder characterized bylack of enzyme Phenylalaninehydroxylase (PAH) needed to processthe amino acid phenylalanineThe resultant build up of the saidprotein in the body leads to mentalretardation
  74. 74. Phenylketonuria (PKU)• Excessive accumulation of phenylalanine = brain damage• Dx – Guthrie test• Mx - Low protein diet; breastmilk
  75. 75. Glucose-6-Phospate-Dehydrogenase Deficiency (G6PD)
  76. 76. G6PD is one ofmany enzymesthat help thebody processcarbohydratesand turn theminto energy.
  77. 77. Glucose-6-Phospate-Dehydrogenase Deficiency (G6PD)• A condition where the body lacks the enzyme called G6PD a metabolic enzyme especially important in RBC metabolism• Hemolytic anemia resulting from exposure to certain drug, food and chemical
  78. 78. Child during Hospitalization
  79. 79. STRESSORS AND THE CHILD’S REACTIONIllness and Hospitalization:
  80. 80. Children are particularly vulnerableto the crises of illness andhospitalization because:1.Stress represents a change from the usual state of health and environmental routine1.Children have limited number of coping mechanisms to resolve stressors
  81. 81. SEPARATION ANXIETY• Also known as Anaclitic depression• Major stress especially for children ages 16 to 30 months• Three Phases: –Phase of Protest –Phase of Despair –Phase of Detachment
  82. 82. SEPARATION ANXIETY Three Phases:Phase of Protest • React aggressively to separation from parent • Behavior is from a few hours to several days
  83. 83. SEPARATION ANXIETY Three Phases:Phase ofDespair •Child is less active •Withdraws from others
  84. 84. SEPARATION ANXIETY Three Phases:Phase ofDetachment • Also called denial • Appears detached and uninterested in parents’ visits • Appears to finally adjust to the surroundings
  85. 85. Loss of Control INFANTS – Trust – Inconsistent care and deviations from daily routine• TODDLERS – Autonomy – Egocentric pleasures – Rely on the consistency and familiarity of daily rituals – Altered routine and rituals – Regression• PRESCHOOLERS – Egocentrism and magical thinking – Physical restriction, altered routines and enforced dependency
  86. 86. Bodily Injury and Pain• INFANTS – Infants younger than 6 months • no obvious memory of previous pain – Facial expression of discomfort – React with physical resistance – Distraction and anticipatory preparation does little to lessen immediate reaction to pain• TODDLERS – Intrusive experience produce anxiety – React with intense emotional upset and physical resistance – Communicate about their pain
  87. 87. Bodily Injury and Pain• PRESCHOOLERS – Cause of illness is seen as concrete action the child does or the child fails to do  self-blame – Contagion – proximity of two object or persons causes the illness – Injection - fear that the puncture will not close• SCHOOL-AGE CHILDREN – May be less concerned with pain than disability – Major concern is their fear of being told that something is wrong with them – Aware of the significance of different illnesses
  88. 88. Bodily Injury and Pain• SCHOOL-AGE CHILDREN – Passive acceptance of pain – Nondirective request for support – When someone identifies unspoken messages and offers support, they readily accept it• ADOLESCENTS – The nature of bodily injury may be more important based on the adolescents’ perception rather than the actual degree of severity of the illness – Changes in body image is their concern – Privacy – Reluctance to disclose pain
  90. 90. Communication• Speak in quiet pleasant tones• Bend down• Do not use clichés.• Explain all procedures• Be honest• Be careful in making promises• Observe nonverbal communication for clues to level of understanding• Do not threaten• Allow child to show feelings• Provide time to talk
  91. 91. Communication• Teach parents to anticipate next stage of development• If teaching is interrupted, start over from the beginning• Provide independence• Do not compare child’s progress to that of anyone else• Provide praise• Instead of asking what something is, ask child to give it a name or tell you about it• Allow choices where possible• Involve parents in child’s care
  92. 92. Communication• Keep routines• If parents cannot stay with child, encourage them to bring in a favorite toy, pictures of family members or to make tape to played for the child
  93. 93. Play
  94. 94. • Toddler – Enjoys repetition – Solitary play – Parallel play• Preschooler – Role play, make believe, associative play• School-age – Group, organized activities – Group goals with interaction
  95. 95. Play• Play is a very important part of development for your growing child.• Not only is play time entertaining for your child, but it also provides stimulation, increases skills and coordination, provides an outlet for your childs energy, and helps to encourage exploration by your child.
  96. 96. Play is also important for the following reasons (Lippincott Williams & Wilkins, 2005)Play is an excellentstress reducer andtension reliever. Itallows the childfreedom ofexpression to act outhis fears, concernsand anxieties
  97. 97. Play is also important for the following reasons (Lippincott Williams & Wilkins, 2005)Play provides asource ofdiversionalactivity,alleviatingseparationanxiety
  98. 98. Play is also important for the following reasons (Lippincott Williams & Wilkins, 2005)Play provides thechild with a sense ofsafety and securitybecause while he isengaging in play, heknows that nopainful procedureswill occur.
  99. 99. Play is also important for the following reasons (Lippincott Williams & Wilkins, 2005)Developmentallyappropriate play fostersthe child’s normalgrowth anddevelopment, especiallyfor children who arerepeatedly hospitalizedfor chronic conditions
  100. 100. Play is also important for the following reasons (Lippincott Williams & Wilkins, 2005)• Play puts the child in the driver’s seat, allowing him to make choices and giving him a sense of control
  101. 101. Play – Way to solve problems – Express creativity – Decrease stress – Prepare for procedures – Enhance fine and motor skills• Make play appropriate for mental age and physical/disease state• Multisensory stimulation• Safe toys for mental age• Offer play specific to age group
  103. 103. Concept of PainPreoperational Thought (2-7 yrs)Relates to pain primarily as physical concrete experienceMagical disappearance of painPain as punishmentHold someone accountable for own painConcrete Operational Thought (7-10 yrs)Relates to pain physicallyPerceive psychologic painFears bodily harm & annihilationPain as punishmentFormal Operational Thought (13 yrs and older)Give reason for painPerceives several types of psychologic painFears losing control during painful experience
  104. 104. Q-U-E-S-T (PAIN ASSESSMENT)QUESTION the child’s parents and childtoo, if he is old enough to respondUSE appropriate pain assessmentEVALUATE the child’s behaviourSECURE the parent’s active participationin treatmentTAKE the cause of the pain intoconsideration
  105. 105. ASSESSMENT• Wong-Baker FACES Pain Rating Scale
  106. 106. ASSESSMENT• FLACC (Face, Legs, Activity, Cry and Consolability) – for infants and very young children• Behavior is observed to assess painMeasures each of the five identifiedcategories on a 0 to 2 scale• The higher the total score, the more pain
  107. 107. CRIES Neonatal Postoperative Pain Measurement ScaleCryingRequires oxygen to maintain saturationabout 95%Increased heart rate and bloodpressureExpressionSleeplessness
  108. 108. Neonatal Infant Pain ScaleFacial ExpressionCryingBreathingpatternsState of arousalMovement ofarms and legs
  109. 109. Premature Infant pain ProfileGestational ageHeart rateOxygen saturationBehavioral stateBrow bulgeEye squeezeNasolabial furrow
  110. 110. INFANT Mouth stretched open Eyes tightly shutFacial expression Brows and forehead knitted Cheeks raised high enough
  111. 111. Younger Children Narrowing of the eyes Grimace or fearful appearance Frequent and longer lasting bouts of crying with a tone that is higher and louder than normal Less receptiveness to comforting by parents or other caregivers Holding or protecting the painful areas
  112. 112. P-A-I-N ManagementPharmacologic interventionsAnticipate and prevent or minimize painrelated to hospitalization, procedure andtreatmentIdentify and relieve existing painNon pharmacologic interventions to reducestress, increase comfort and enhance
  113. 113. Pharmacologic Intervention – mainstay of painmanagement and it depends on the specificneeds of the patientOpioid analgesics-Highly effective pain relievers andconstitute the core of most pharmacologicinterventions to manage acute pain ininfants and children-Oral, sublingual, rectal, nasal,subcutaneous, transdermal, IV andintraspinal*Morphine (MS contin)*Fetanyl (Duragesic)
  114. 114. Non Opioid Analgesics-are prescribed to managemild to moderate pain.-infants and childrenmetabolize non opioidanalgesics in the same mannerand at the same rate as adult.
  115. 115. NSAIDS-relieve for mild to moderate pain andanti inflammatory effects-Ibuprofen (advil); Naproxen(Naprosyn); Tolmetin (Tolectin);Indomethacin (Indocin) & Ketorolac(Toradol) are approved for use inchildren-S.E: Inhibition of platelet aggregationand GI irritation
  116. 116. Acetaminophen-Is the DOC for treating mild pain.Available in suppository, liquid and tableform.-it has the added benefit of helpingreduce fever and is very safe, even forneonates.-long term can cause risk of liverdamage
  117. 117. EMLA Cream (lidocaine 2.5% and prilocaine 2.5%),applied to intact skinunder occlusivedressing, providesdermal analgesia bythe release oflidocaine andprilocaine from thecream into theepidermal and dermallayers of the skin
  118. 118. • Complementary and alternative medicine (CAM) – Complementary Pain Medicine • Music Therapy • Hypnosis • TENS (transcutaneous electric nerve stimulation) unit • Acupuncture – Non-Pharmacologic Care • Comfort, positioning and non-nutritive sucking • Distraction • Relaxation • Guided Imagery • Biofeedback • Behavioral Contracting
  119. 119. Pediatric Surgery
  120. 120. Pediatric Surgery• Preoperative classes – Younger – simple and as close to the time of the procedure as possible• Allow to play with equipment• Teach and provide time to practice• Show pictures• Describe sensations• Detect misconceptions or fantasies• Parents can often be helpful in preparing
  121. 121. PEDIATRIC SURGERY• Preoperative class• Listen to child for clarifying misunderstandings• Give simple information about the system that will be affected• Use of anatomically correct dolls• Preschool boys: allow to look at penis after surgery• Post surgery: helping child master a threatening situation and minimizing physical and psychological complications
  123. 123. Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)InfancyConcept of death – NONENursing considerations:Be aware that the older infantwill experience separationanxietyHelp the family cope with deathso they can be available to theinfant
  124. 124. Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)Early childhoodKnows the words “DEAD” and“DEATH”. Reactions are influencedby the attitude of the parents.Nursing considerations:Help the family members includingsiblings cope with their feelingsAllow the child to express his ownfeelings in an open and honestmanner.
  125. 125. Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)Middle childhood.Understands universality andirreversibility of death. May havea fear of parents dying.Nursing considerationsUse play to facilitate the child’sunderstanding of deathAllow siblings to express theirfeelings.
  126. 126. Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)Late childhoodBeings to incorporate family and cultural beliefsabout death. Explores views of an afterlife andfaces the reality of own mortalityNursing considerationsProvide opportunities for the child to verbalize hisfearsHelp the child discuss his concerns with the family
  127. 127. Concept of Death in Childhood (Lippincotts William and Wilkins, 2005)AdolescenceAdult perception of death, but still focused on theHERE and NOWNursing considerationsUse opportunities to open discussion about deathAllow expression of feelings of guilt, confusion andanxietySupport and maintain self esteem
  128. 128. Helping Families to Cope• Accept and support participants• Be available and express your availability• Encourage parents to assist in the care of their child• Encourage involvement of siblings• Religious associations as source of strength and support
  129. 129. Helping parents to talk with their child about dyingif he is ready to do soEncouraging all family members to express theirfeelings, even though they might be difficult tohearAllowing families to spend as much time aspossible with the dying childAllowing and encouraging parents to continue totake an active role in their child’s careReminding parents that they don’t always have tobe strong and ask for help
  130. 130. Thank you for Listening!