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Community/Public Health Nursing Practice E Book: Health for Families and Populations (Maurer, Community/ Public Health Nursing Practice) 5th Edition, (Ebook PDF)
Kay J. Cowen received her BSN from East Carolina University in Greenville, North Carolina, and began her career as a staff nurse on the pediatric unit of North Carolina Baptist Hospital in Winston-Salem. She developed a special interest in the psychosocial needs of hospitalized children and preparing them for hospitalization. This led to the focus of her master’s thesis at the University of North Carolina at Greensboro (UNCG) where she received a master of science in nursing education degree with a focus in maternal child nursing.
Mrs. Cowen began her teaching career in 1984 at UNCG where she continues today as clinical professor in the Parent Child Department. Her primary responsibilities include coordinating the pediatric nursing course, teaching classroom content, and supervising a clinical group of students. Mrs. Cowen shared her passion for the psychosocial care of children and the needs of their families through her first experience as an author in the chapter “Hospital Care for Children” in Jackson & Saunders’ Child Health Nursing: A
Comprehensive Approach to the Care of Children and Their Families published in 1993.
In the classroom, Mrs. Cowen realized that students learn through a variety of teaching strategies and became especially interested in the strategy of gaming. She led a research study to evaluate the effectiveness of gaming in the classroom and subsequently continues to incorporate gaming in her teaching. In the clinical setting, Mrs. Cowen teaches her students the skills needed to care for patients and the importance of family-centered care, focusing on not only the physical needs of the child but also the psychosocial needs of the child and family.
During her teaching career, Mrs. Cowen has continued to work part time as a staff nurse: first on the pediatric unit of Moses Cone Hospital in Greensboro and then at Brenner Children’s Hospital in Winston-Salem. In 2006 she became the part-time pediatric nurse educator in Brenner’s Family Resource Center. Through this role she is able to extend her love of teaching to children and families.
Through her role as an author, Mrs. Cowen is able to extend her dedication to pediatric nursing and nursing education. She is married and the mother of twin sons.
We dedicate this book to our partners: ~our families for their unwavering support ~colleagues who have grown and learned with us, and continue to help expand our thinking ~families and children with whom we work, for teaching us the essentials of child health nursing ~students who are our collaborators now and in their future careers as nurses
Thank You
We would like to express our deep gratitude to our colleagues from schools and hospitals across the country for their time over the past 3 years. These individuals assisted us in the revision of this book by contributing and reviewing manuscript chapters and contributing to the supplements that accompany this title. Child Health Nursing: Partnering with Children & Families has benefited immeasurably from your efforts, insights, and willingness to share your expertise as teachers and nurses.
CONtriButOr
Chapter 4: genetics and genomics influence
Linda D. Ward, MN, ARNP
Clinical Assistant Professor Washington State University College of Nursing Spokane, Washington
suPPleMeNtal CONtriButOrs
Jane Brown, MSN, RN Associate Professor Walters State Community College Morristown, Tennessee
Laura L. Brown, RN, MSN, CPN Nursing Instructor Asheville Buncombe Technical Community College Asheville, North Carolina
Pamela P. DiNapoli, PhD, RN Associate Professor University of New Hampshire Durham, New Hampshire
Donna Eberly, RN, MSN Instructor Western Iowa Tech Community College Sioux City, Iowa
reviewers
Mike Aldridge, Concordia University Texas
Kim Amer, DePaul University
Janice Bidwell, San Diego State University
Sharon Koval Falkenstern, PhD, CRNP, PNP-C, CNE
Assistant Professor, Coordinator of NP Option
The Pennsylvania State University University Park, Pennsylvania
Leslie Holmes, RN, BSN, MSN Instructor, Family and Community Nursing Nell Hodgson Woodruff SON Emory University Atlanta, Georgia
Mary Jo Konkloski, RN, MSN, ANP Coordinator, RN Program
Finger Lakes Health College of Nursing Geneva, New York
Patricia Kuster, PhD, RN, CPNP
Assistant Professor
Samuel Merritt College School of Nursing Sacramento, California
Brenda Lykins, RNC-NIC, BSN
Neonatal Outreach Coordinator MultiCare Regional Perinatal Outreach Program Tacoma, Washington
Adelaide R. McCulloch
Patricia Bobbitt, Wake Forest University School of Medicine
Sally Brooks, The University of Louisiana at Monroe
Michael Brown, The University of Texas Health Science Center at Houston
Karyn Casey, The University of Tennessee
Teresa Chase, University of Kentucky
Jennifer Compere, Brenner Children’s Hospital
Joseph De Santis, University of Miami
Linda Esposito, Wake Forest Baptist Medical Center
Melissa Ethington, The University of Texas Health Science Center at Houston
Niki Fogg, Texas Woman’s University
Betty Freund, Kent State University
Julie Garcia, The University of Texas Health Science Center at San Antonio
Carol Hall Grantham, Georgia State University
Debbie Hancock, The University of North Carolina at Greensboro
Kristen Harrison, Wake Forest Baptist Medical Center
Amy Zlomek Hedden, California State University, Bakersfield
Michelle Howell, Wake Forest Baptist Medical Center
Kim Hutchinson, Wake Forest Baptist Medical Center
Arlene Johnson, Clemson University
Eleanor Kehoe, College of Staten Island
Mary Kishman, College of Mount St. Joseph
Julie Kordsmeier, The University of North Carolina at Greensboro
Heidi Krowchuk, The University of North Carolina at Greensboro
Laura Kubin, Texas Woman’s University
Brenda Millet, MSN, RN-BC Staff Development Specialist Children’s National Medical Center Washington, DC
Cheryl Shaffer, RN, MS, PNP, ANP, PhD(c) Associate Professor Suffolk County Community College Selden, New York
Lisa D. South, RN, DSN Assistant Professor
The University of Alabama at Birmingham Birmingham, Alabama
Jane K. Walker, BBA, RN, CLNC, PhD(c)
Associate Professor of Nursing
Walters State Community College Morristown, Tennessee
Jeannie Weston, MS, CNS, BSN
Assistant Clinical Instructor Emory University Atlanta, Georgia
Sarah Kulinski, Lenoir-Rhyne University
Patricia Kuster, Samuel Merritt University
Lin Lin, The University of Texas Health Science Center at Houston
Antoinette McCray, Norfolk State University
Cheryl Mele, Drexel University
Mary Ellen Mitchell-Rosen, Nova Southeastern University
Heidi Monroe, Seattle Pacific University
Brenda Pavill, University of North Carolina Wilmington
Sue Perkins, Washington State University
Kathleen Peterson, The College at Brockport
Janice Pitman, Brenner Children’s Hospital
Kari Crawford Plant, Levine Children’s Hospital
Deborah Roberts, Sonoma State University
T. Kim Rodehorst-Weber, University of Nebraska Medical Center
Carol Rossman, Calvin College
Michele Shaw, Washington State University
Anita Smith, Wake Forest University School of Medicine
Daphnee Stewart, Mercer University
Phyllis Thatcher, Wake Forest Baptist Medical Center
Debra Thomson, Wake Forest Baptist Medical Center
Maureen Tippen, University of Michigan-Flint
Theresa Turick-Gibson, Hartwick College
Diane Van Os, Westminster College
Darla Vogelpohl, University of Toledo
Beverly Bockstruck West, University of Memphis
Melissa Williams, Augusta State University
Cecilia Wilson, Texas Woman’s University
Preface
The world children grow up in today is vastly different from the world we experienced in our early years. Our evolving social environment has resulted in diverse family structures and roles. Multiple racial and ethnic groups now commonly share communities, work environments, and recreation. A variety of technology applications are part of children’s daily routines. Nutritional patterns have changed due to the complexity of daily lives and food marketing, and the environment is identified as an increasing influence on child and adolescent health. The geospatial design elements of communities, including schools, modes of transportation, and safety in neighborhoods, have altered daily behaviors. Life in complex societies offers new challenges to mental health, and homes provide diverse risk and protective factors in managing the health and illness of child family members. New ways of treating diseases, from applications of genomics to a current generation of medications, influence youth health. Healthcare reform, electronic health records, new approaches to chronic and acute condition management, and a focus on prevention have contributed to changes in the information that nurses and other healthcare providers need. We draw heavily upon Healthy People 2020 in this text to guide our suggested interventions and evaluation of goals for health conditions. In addition to an evolution of influences on child health, there have been incredible achievements in nursing education. The American Association of Colleges of Nursing (AACN) published the Essentials of Baccalaureate Education for Professional Nursing Practice in 2008. While we know that many Associate Degree Nursing programs use our books, we also are aware that a number of those programs also use “the Baccalaureate Essentials” in establishing their curricula. We have therefore applied the Essentials throughout the book and cite them in a new feature (see a description later in this preface). In 2009, the “Carnegie Report” on Educating Nurses: A Call for Radical Transformation was published. This long-awaited study emphasized the importance of connecting classroom and clinical learning, focusing on clinical reasoning when working with students, and fostering career ladders and lifelong learning. These recommendations inform our clinical judgment and clinical reasoning features. Finally, in 2010, the Institute of Medicine (IOM) released The Future of Nursing: Leading Change, Advancing Health. The IOM recommended that nurses function to the full extent of their education and training, achieve higher levels of education, be full partners with physicians and other healthcare professionals in the redesign of health care, and work to plan policies that ensure data collection and information infrastructure.
Child Health Nursing: Partnering with Children & Families is a contemporary pediatric nursing textbook. Excellence in pediatric nursing care, whether it is in the acute care setting or in the community, is a challenge and the major objective guiding today’s pediatric nurse. You, as a student, will be challenged to synthesize previous information with new knowledge, apply evidence-based findings, collaborate with other healthcare professionals and families, and integrate current knowledge to use clinical reasoning skills in planning pediatric nursing care. You will be challenged to lead, examining ways in which you can positively influence the health care of children and their families in the challenging times of healthcare reform.
The third edition of Child Health Nursing builds upon the strong foundation and planning of the first two editions and addresses the
need for fresh approaches to child and adolescent health care and nursing education in several ways. Themes in this book include:
■ Partnering with Children and Their Families
■ The Roles and Essential Functions of the Nurse
■ Health Promotion and Health Maintenance
■ Collaboration with Families and Healthcare Providers
■ Evidence-Based Practice
■ Clinical Reasoning
The subtitle, Partnering with Children & Families, reflects the core value of our textbook—emphasizing family-centered care, recognition of the family as the central influence in each child’s life, and respect for families from all cultures. Families are viewed as case managers, as partners with healthcare providers, and as integral participants in care in all pediatric nursing settings. Partnership and interprofessional collaboration are other key concepts of our textbook. In the past, we introduced the BindlerBall Child Healthcare Model as a paradigm with which to view health care of children. This model illustrates an important core value—that all children need health promotion and maintenance interventions, no matter where they seek care or what health conditions they may be experiencing. Families may visit offices or other community settings, specifically to obtain health supervision care; or nurses may integrate health promotion and maintenance into the care for children with acute and chronic illness in a variety of inpatient and outpatient settings. The Bindler-Ball Healthcare Model places health promotion and maintenance at the foundation of a pyramid to demonstrate the need to apply these concepts with all children. See Chapter 1 for an introduction to this model.
what’s New iN this editiON
■ Baccalaureate Essentials Boxes highlight the nine essentials of nursing education identified by the American Association of Colleges of Nursing.
■ NANDA-I 2012-2014 nursing diagnoses for multiple conditions.
■ Updated Healthy People 2020 goals for the pediatric population.
■ More Evidence-Based Practice features emphasize nursing research and offer a critical thinking element.
■ Clinical Judgment speed bumps to encourage critical thinking.
■ Clinical Reasoning section at the end of chapter to help with application of concepts and synthesis.
■ New statistics, and integration of current health care implications and environmental considerations.
OrgaNizatiON
The six units in this textbook have a unifying theme. The first unit, Nurses, Children, and Families, lays the foundation for a thorough understanding of pediatric nursing in today’s world. It discusses the nurse’s roles in caring for children in the hospital, community, and home, as well as the concepts of family-centered care and cultural considerations.
The second unit focuses on Child Concepts and Application, melding theory with application so that concepts can be applied to pediatric nursing care in a variety of settings. Genetics and genomics are current concepts that will be increasingly employed in future health care. We describe concepts of growth and development and child/family
communication in separate chapters, and examine applications to pediatric nursing. The pediatric assessment chapter provides basic and detailed information that will be applied in all pediatric healthcare settings.
The third unit focuses on Health Promotion and Maintenance Through Childhood. The first chapter introduces basic concepts, and each of the remaining five chapters applies health promotion and maintenance concepts with specific approaches for children at each developmental stage from newborn through adolescence. Nurses assess children thoroughly, establish goals in partnership with the family, intervene to promote and maintain health and foster development, and evaluate the outcomes of care. This unique approach minimizes repetition throughout the book, and underscores the need for all children to receive routine health promotion and health maintenance to achieve optimal health.
The fourth unit, Child Healthcare Settings and Considerations, explores the various settings in which care occurs. In addition to the hospital, nurses and nursing students are likely to provide care in community settings, such as health centers, schools, and homes, where health promotion and maintenance activities predominate. Special considerations for the care of children during disasters are also discussed. Shorter hospitalizations have become the norm, thereby increasing the need for more comprehensive care in community settings, such as specialty outpatient centers where nurses coordinate care for children with various health conditions. Children need special attention when they have chronic health conditions, when they have lifethreatening illnesses or injuries, or when they need end-of-life care.
The fifth unit discusses Nursing Care for Common Health Conditions. The unit begins with a chapter on infant, child, and adolescent nutrition, which discusses both nutritional requirements for health and some common nutritional disruptions. A chapter on social and environmental influences addresses topics pertinent to children and
Visuals That Teach
The art program of this book continues to use a thoroughly integrated approach, beginning with the cover and carried through the interior of the textbook. The cover of Child Health Nursing features hand-painted tiles from Rydal Elementary School in Abington, Pennsylvania. Art is both a method of expression and a healing modality, and the feelings, design, and colors of the tiles integrated throughout this book will help you identify with children and their families, and understand their experiences.
their families in today’s world, such as violence and substance use. A chapter on pediatric pain assessment and management provides general nursing care concepts that are woven through the remainder of the book. Another chapter focuses on the prevention and treatment of infectious and communicable diseases, a significant role in pediatric nursing care.
The sixth unit consists of 14 chapters that address Nursing Care of Specific Health Conditions. Information about health conditions, including both illnesses and injuries, is grouped by body systems, eliminating the need for duplication at various places in the text. This streamlined approach builds on previous concepts rather than repeating them, integrating a developmental approach with pertinent conditions affecting all age groups from newborn to adolescent.
The chapters fully describe diseases and injuries beginning with an anatomic and physiologic overview, pediatric differences, and system-specific assessment guidelines. This is followed by a discussion of the etiology, pathophysiology, clinical manifestations, and collaborative care, including diagnostics and clinical therapy sections for each of the major conditions. Nursing management of major conditions contains detailed sections on assessment and diagnosis, planning and intervention, and evaluation of care. The book is readable and understandable, taking the student from present knowledge level to mastery of new material. The many features further enhance the readability of the material for students coming from various backgrounds and nursing programs and curricula.
Sample nursing care plans will assist you in applying developmental, psychosocial, and physiologic concepts to the care of children with specific conditions. North American Nursing Diagnosis Association (NANDA International) diagnoses are used, as well as the current Nursing Intervention Classifications (NIC) and Nursing Outcomes Classifications (NOC).
Gorges has very broad responsibilities for maintaining the health of all the children
A Day in the Life of a Nurse helps identify the roles and focus of nursing care in each of three settings: the hospital, the healthcare center, and the school setting.
PHOTO STORY. . .
MANAGING MYELODYSPLASIA
Daily exercise using crutches is
Tests for Short Stature PURPOSE RELATED TO SHORT STATURE
Screens for growth hormone deficiency
Detects pituitary malformation or tumor
testing
Tests for growth hormone deficiency
Identifies other potential causes of delayed growth
Screens for inflammatory bowel disease with anemia
Screens for celiac disease
Felner, E. I. (2011). Hypopituitarism. In R. M. Kliegman, B. F. Schor, & R. E. Behrman, Nelson textbook of pediatrics (19th ed., Saunders Elsevier; Cooke, D. W., Divall, S. A., & Radovick, S. In S. Melmed, K. S. Polonsky, P. R. Larsen, & H. M. Kronenberg, (12th ed., pp. 935–1053). Philadelphia, PA: Saunders Elsevier.
clonidine, glucagon, insulin, L-dopa) are adrelease of growth hormone, may be used to hormone deficiency. Confirmation of the disorder demonstrate a growth hormone response (with 10 ng/mL) after presentastimuli as previously menendocrinologists believe than other tests, such as low hormone deficiency may ocmore other pituitary hormay be total deficiency (no produced) or partial deficiency produced, but not enough growth).
■ Growth hormone deficiency
■ Renal failure
■ Turner syndrome
■ Noonan syndrome
■ Short stature from Prader-Willi syndrome (PWS)
■ Children with a history of intrauterine growth retardation
■ Idiopathic short stature
Source: Data from Cooke, D. W., Divall, S. A., & Radovick, S. (2011). Normal and aberrant growth. In S. Melmed, K. S. Polonsky, P. R. Larsen, & H. M. Kronenberg, Williams textbook of endocrinology (12th ed., pp. 935–1053). Philadelphia, PA: Saunders Elsevier; Ferguson, L. A. (2011). Growth hormone use in children: Necessary or designer therapy? Journal of Pediatric Health Care, 25(1), 24–30; Sperling, M. A. (2010). Treatment of short children with GH plus IGF-1: Are two hormones better than one? Infectious Diseases in Children, 23(1), 46–48.
The photographs and drawings throughout the textbook do more than illustrate concepts and examples. You will find critical thinking opportunities among the figure captions. These unique highlights, also appearing in the text itself, encourage you to apply information and analyze the nursing implications needed to provide care for children and their families, thus adding true learning value to the visuals.
Photo Stories help bring information and concepts “alive” to develop a deeper understanding about the effect of a specific condition on the child and family. These stories include photographs of a child or situation to demonstrate the challenges a child and family may face in managing the condition.
treatment are important maximum adult height estimation of skeletal maevaluate the child with a growth used to predict final height. the hand or wrist bone is stage of bone ossification and child. Using standardized ossification, radiologists can dechronologic and bone ages delayed (less than the child’s (greater than the child’s age) indicative of a systemic chronic abnormality requiring inves-
deficiency, replacement theradministered to promote growth Growth hormone replacement
requires subcutaneous injections 6 to 7 times per week and generally continues for several years until growth is complete. The pediatric endocrinologist adjusts the dosage based on response to treatment (Ferguson, 2011). See Box 32–2 The child usually experiences increased growth velocity for the first year of treatment, followed by a gradual decrease in growth for subsequent months or years. Growth should progress at least at the normal growth rate for age while the child is continued on growth hormone treatment. If growth is slower than anticipated, compliance to therapy must be considered before the dosage is increased. Replacement therapy is continued until either the child achieves an acceptable height or growth velocity drops to less than 2 cm (1 in.)
As They Grow Bone Age
FIGURE 32–4 ■ The radiograph of the hand and wrist of a 3-year-old and 13-year-old girl reveal significant differences in skeletal maturation that are closely tied to physiologic maturation. The 3-year-old has many bones in the hand and wrist that have not fully developed. The secretion of estrogen during puberty has resulted in the development and calcification of secondary ossification centers of most of the bones in the hand and wrist of the 13-year-old.
Source: Courtesy of Dorothy Bulas, M.D., Children’s National Medical Center.
As They Grow illustrations help you visualize the important anatomic and physiologic differences between a child and an adult. These features illustrate the important ways that a child’s development influences healthcare needs and how the child progresses through developmental stages.
The text explains in-depth pathophysiology of pediatric conditions, and accompanying Pathophysiology Illustrated figures allow you to see into the body to visualize the causes and effects of conditions on children. These elaborate drawings illustrate conditions on a cellular or organ level, and may also portray the step-by-step process of a disease. Drawings or photos with artistic overlays relate disease to its anatomic location and action.
Pathophysiolog y Illustrated Asthmatic Episode
BOX 32–2
FDA-Approved Uses of Growth Hormone in Children
arterial exists, the oxygen
impulses, continues to increase until approximately 4 years of age. Brain growth results in the increasing head circumference in infants and toddlers. Brain growth continues until the child is 12 to 15 years of age.
TABLE 32–9 Laboratory Findings in the Child with Diabetic Ketoacidosis
Respirator y Distress and Respirator y Failure 747
come damaged in a very short time Because the nervous system helps to control and coordinate many body functions, alterations in neurologic function can have widespre ad effects on the body’s metabolism.
NEUROLOGIC ASSESSMENT
Nursing Assessment and Diagnosis
Features That Help You Use This Book Successfully
LABORATORY STUDY RESULTS
Serum glucose Greater than 200 mg/dL
cricoid cartilage, is often performed if long-term airway management is needed.
Serum ketones Positive
Myelination, the progressive covering of axons with layers of myelin or a lipid protein sheath, is also incomplete at birth. Lack of myelination is associated with the presence of primitive reflexes. As the myelination progresses, the primitive reflexes disappear. See Table 7–19 8 for the expected appearance and disappearance of primitive reflexes during early infancy This process continues throughout childhood, proceeding in a cephalocaudal direction. The myelination process accounts for the progressive acquisition of fine and gross motor skills and coordination during early childhood, and it is ultimately responsible for the speed and accuracy of nerve impulses.
Arterial blood gas pH Acidotic—pH less than 7.3 and bicarbonate less than 15 mEq/L
Urine Positive for ketones (ketonuria)
Assisted ventilation must be provided until the child breathes spontaneously or until mechani cal ventilation is initiated Children are often sedated to optimize ventilation. Continuous positive airway pressure (CPAP) is one form of PEEP used to improve oxygenation and lung compliance When respirator y failure cannot be managed, it results in cardiopulmonar y arrest.
Serum potassium Elevated, decreased, or normal
In infants and young children the vertebral bodies are wedge shaped, the ligaments permit more movement, and the articulating facets at C1 and C2 permit more sliding in cases of injury. The child’s spinal cord attains adult characteristics after 10 ye ars of age when the vertebral body loses its wedge shape and the facets become more vertically aligned (Mathison, Kadom, & Krug, 2008).
Serum chloride Elevated
Serum sodium Decreased
Continuously monitor the child’s vital signs, respiratory status, perfusion, and mental status. Assess for changes in neurologic status, respiratory pattern, blood pressure, and heart rate. Monitor for cardiac arrhythmias associated with hypokalemia. Assess for signs of dehydration, including dry skin and mucous membranes, and depressed fontanels in infants.
Performing a nursing assessment of the child with a potential or actual neurologic condition involves a careful review of the signs and symptoms in many body systems and analysis of their relationship to neurologic functioning. Use the guidelines in Table 33–3 to perform a comprehensive assessment of a child with a neurologic condition. Numerous diagnostic procedures and laboratory tests are used for the diagnosis of neurologic conditions (Table 33–4). Additional information about these diagnostic procedures and laboratory tests can be found in Appendixes D and E 8
Nursing students face challenges in their education—managing demands on their time, applying research findings, evaluating components of evidence-based practice, and developing their critical thinking skills. Thus instructors and students alike value the in-text learning aids that we include in our textbooks to meet the challenges of pediatric nursing in today’s world. We developed a textbook that is easy to learn from and easy to use as a professional reference. The following guide will help you use the features and resources from Child Health Nursing to succeed in the classroom, in the clinical setting, on the NCLEX-RN® examination, and in nursing practice.
Nursing diagnoses that apply to the child with diabetic ketoacidosis may include:
ALTERED STATES OF CONSCIOUSNESS
■ Injury, Risk for related to altered cerebral function
The brain depends on a continuous blood flow to meet its high demands for oxygen. Through an autoregulatory process, the cerebral blood vessels dilate to maintain the cerebral blood flow in response
Serum phosphate Decreased
Serum osmolality Elevated
When acute respirator y failure becomes life threatening, extracorporeal membrane oxygenation (ECMO) may be initiated (Ayad, Dietrich, & Mihalov, 2008). ECMO is a cardiopulmonar y bypass system with external oxygenation and a pump mechanism that provides respirator y and hemodynamic support. It allows the lungs to rest and heal However, several significant complications may result from its use, such as bleeding, stroke, renal insufficiency, hypertension, seizures, electrolyte abnormalities, pneumothorax, cardiac dysfunction, and infection (Ayad et al., 2008). This is a complex and expensive treatment available in special centers, so the child may have to be transferred to anot her hospital to re ceive this therapy.
■ Fluid Volume: Deficient related to osmotic diuresis
Level of consciousness (LOC) is perhaps the most important indicator of neurologic dysfunction. Consciousness, the responsiveness or awareness of the mind to sensory stimuli, has two components: (1) Alertness, or arousal, the ability to react to stimuli, is controlled
■ Nutrition, Imbalanced: Less than Body Requirements related to catabolism of protein and fat for fuel
TABLE 33–3 Assessment Guidelines for the Child with a Neurologic Condition
■ Knowledge, Deficient related to recognition, treatment, and prevention of diabetic ketoacidosis
Source: Data from Cooke, D. W., & Plotnick, L. (2008b). Management of diabetic ketoacidosis in children and adolescents. Pediatrics in Review, 29, 431–436; Jerreat, L. (2010). Managing diabetic ketoacidosis. Nursing Standard, 24(34), 49–55; McFarlane, K. (2011). An overview of diabetic ketoacidosis in children. Paediatric Nursing, 23(1), 14–19.
Assessment Guidelines for the Child tables in each of the systems chapters provide an overview of the key aspects of an integrated assessment for conditions within the body system.
Collaborative Care
Nursing Management
Level of consciousness
■ Is the infant or child difficult to arouse?
Planning and Implementation
■ Is the infant or child irritable or difficult to calm or console?
■ Is the child oriented? Can the child tell the examiner his or her name and age?
■ What is the child’s ability to concentrate? Can the young child name pictures of animals? Can the older child answer simple math questions or spell words?
■ The Glasgow Coma Scale provides a numeric score for future comparison. See Table 33–5
Cranial nerves
Fontanels and sutures
Cognitive function
Pupils
TABLE 33–6 Assessment of Cranial Ner ves in the Unconscious Child
■ Assess the cranial nerves. See Table 7–18 8 8 See Table 33–6 for methods to indirectly assess cranial nerves in the unconscious child.
■ Palpate fontanels and suture lines on the infant’s scalp.
The immediate goal of collaborative care is to normalize the pH level, restore blood glucose to target level, and correct fluid and electrolyte imbalance. The long-term goal of management includes preventive education to reduce the risk of further diabetic ketoacidosis episodes.
Vital signs
■ Are the child’s verbal skills developmentally appropriate for age?
■ Does the child follow directions and respond appropriately?
■ Check the pupils for size and reaction to light and accommodation. See Figure 33–4 on page 1154
Nursing care is focused on the recognition of progression from respiratory distress to respirator y failure and supportive care to the child and family
■ Assess heart rate, respiratory rate, and blood pressure.
Intravenous fluids are given in boluses of 10 to 20 mL/kg rapidly over 5 minutes if the child is in hypovolemic shock. Adequate fluids are given to reverse the fluid deficit. The insulin infusion must be carefully titrated to control the gradual reduction in hyperglycemia. Monitor blood glucose levels hourly or as indicated. Frequently monitor the electrolytes and acid–base status, as well as urine glucose and ketone levels as indicated. Intake and output are monitored hourly. Assess for signs of hypoglycemia which may occur during insulin infusion.
CRANIAL NERVES AND REFLEX
Diagnostic Tests
REFLEX ASSESSMENT PROCEDURE AND NORMAL FINDINGS
Posture and movement
Nursing Assessment and Diagnosis
II, III
Pupillar y Shine a light source in the eye.
II, IV, VI
Clinical Therapy
Oculocephalic
red simularbia in the emia unrefailure. spirator y mechani cal increase the pedionsiveness decreases. endotracheal protected monitorthat the hea. See eation of neck at the
See Table 32–9 for laboratory findings in diabetic ketoacidosis. CT scan of the brain and possible intubation and implementation of intracranial pressure (ICP) lowering strategies will be required.
Practice Alert
■ Inspect the infant’s posture and movement by using the primitive reflexes. See Table 7–19 8
■ Observe the child’s play or other spontaneous activity to assess strength as well as symmetry and smoothness of movements.
Monitor the child for changes in vital signs, respirator y status, and level of responsiveness. Perform the respirator y assessment using guidelines in Table 25–1 Signs and symptoms of respirator y compromise may progress rapidly. Detection of earlier subtle signs is important so interventions can be initiated to prevent progression to respirator y failure. Attach a cardiorespirator y monitor and pulse oximeter. S erial blood gases may be needed to monitor the child.
Practice Alert
III, VIII
Oculovestibular
Rapid, concentrically constricting pupils indicate intact cranial ner ves II, III.
Neck stiffness
Pain
Family history
with a demonstrates interpreting the and the pH 90 mmHg or less. than indicate oxygen to left, and the tisand the Altered States of Consciousness 1155
■ Monitor for an increased systolic blood pressure, a widened pulse pressure, bradycardia, and irregular respirations (late signs of increased intracranial pressure).
Only regular insulin is administered intravenously for treatment of hyperglycemia or diabetic ketoacidosis. Do not use other insulin types as they may lower the blood glucose too rapidly or too slowly.
■ Evaluate muscle strength and tone, comparing side to side. Is any weakness present?
■ Test the child’s coordination for smoothness and symmetry of response.
Perform with eyes held open (doll’s eyes) and head moved horizontally or vertically
■ Are the child’s motor skills developmentally appropriate for age? Were motor skills acquired at the appropriate age? Has the child lost a previously acquired skill?
The child with ketoacidosis is hospitalized. Medical management includes isotonic intravenous fluids and electrolytes for dehydration and acidosis. Short-acting insulin (0.1 unit/kg per hour) is administered by continuous intravenous infusion pump to decrease the serum glucose level at a rate not to exceed 100 mg/dL/hr. Faster reduction of hyperglycemia and serum osmolality increases the risk for cerebral edema. When glucose is lowered too rapidly, water is freed and attracted to the glucose, which has accumulated in large quantities in the brain. Bicarbonate is not routinely used for treatment of DKA as it places the child at increased risk for hypokalemia, acidosis, and cerebral edema (Cooke & Plotnick, 2008b). As insulin is administered, potassium shifts to the cells, resulting in hypokalemia. Potassium supplementation is given only after confirmation of renal function.
■ Assess deep tendon reflexes for smoothness and symmetry of response. See Table 7–20 8
intubation is performed. A tracheostomy may be performed for longterm airway management. Frequent suctioning may be required Keep suction apparatus with catheters at the bedside along with oxygen, resuscitation bag and mask, and extra endotracheal or tracheostomy tubes (if applicable). Pulse oximetry or arterial blood gas analysis is performed at regular intervals to ensure that gas exchange is adequate Assisted ventilation may be required (refer to the Skills Manual ). Anticipate that seizures may occur. Pad the side rails to protect the child from injury
■ Assess for neck stiffness (nuchal rigidity).
When head is turned suddenly to the right, the eyes of an infant or comatose patient look to the left, and similarly look to the right when the head is turned to the left. Absence of this reflex suggests brainstem dysfunction in comatose patients.
■ Assess level of pain when present.
Perform Routine Nursing Care
■ Is there a family history of headaches, seizures, neurofibromatosis, or other neurologic condition?
Precaution: Cer vical spine injur y must be ruled out before this assessment is performed.
Place the head in a midline and slightly elevated position. Inject ice water into the ear canal.
When the child has a chronic respiratory or neuromuscular condition, development of respiratory failure may be gradual as muscles associated with breathing may be weakened. Signs will be subtle. Be particularly alert to behavior changes in addition to respiratory signs. Pulse oximetr y and serial blood gases may be needed to monitor the child.
Eyes deviating toward the irrigated ear indicate intact cranial ner ves III, VIII.
Precaution: Ensure that the tympanic membrane is intact to keep fluid from entering the middle ear
Note: A physician usually performs this assessment.
V, VII Corneal Gently touch the cornea with a sterile cotton swab.
If the corneal reflex is absent, place artificial tears in the eyes and cover with gauze, taping over so they remain closed Perform routine mouth care by brushing the teeth and using swabs with water. Gently clean the oral mucosa in newborns and keep secretions from accumulating
The child is tapered off intravenous insulin and transitioned to subcutaneous insulin when clinically stable. Oral feedings are reintroduced when the child is alert enough and the glucose level is stabilized. This plan varies according to the primary healthcare provider or endocrinologist.
Clinical Tip
Provide adequate nutrition. Initially, nutrients may be supplied intravenously. A nasogastric or transpyloric tube may be inserted if the infant or child remains unconscious or is not alert enough to take food by mouth. A gastrostomy tube may be inserted if it is anticipated that enteral feeds will be needed for longer than 3 months. (S ee the Skills Manual .)
Insulin binds to IV tubing. Run 50 to 100 mL of insulin through the new IV tubing to saturate all the binding sites. This ensures that the full dose of insulin reaches the child from the outset.
If the child has an endotrache al tube or tracheostomy tube, assess for secretions that may further obstruct the airway Examples of nursing diagnoses associated with respirator y failure include:
Practice Alerts warn you of safety precautions and other nursing alerts to consider in providing safe care.
Cerebral edema is the most common cause of DKA-related deaths. Mannitol is kept on standby for treatment of neurologic symptoms secondary to cerebral edema (Cooke & Plotnik, 2008b).
A blink indicates intact cranial ner ves V, VII.
IX, X Gag Irritate the phar ynx with a tongue depressor or cotton swab.
See Chapter 33 8 for information about cerebral edema.
■ Breathing Pattern, Ineffective associ ated with prolonged tachypnea and muscle fatigue
A gagging response indicates intact cranial ner ves IX, X.
Nursing Management
■ Airway Clearance, Ineffective related to sedation and loss of protective cough reflex
Clinical Judgment
■ Communication: Verbal, Impaired related to artificial ai rway
Prevent complications associated with immobility (muscle atrophy, contractures, and skin breakdown) as described in Box 33–2 Nurses support physical therapy efforts with extra passive range of motion exercises.
Provide Sensory Stimulation
Electrolytes are replaced as needed. Potassium is not administered until the child has voided to confirm renal function. Monitor for signs and symptoms of hypokalemia, including hypotension, weak pulse, shallow respirations, and muscle weakness. Continuous cardiac monitoring is performed to detect cardiac conduction changes related to hypokalemia. Weigh the child daily. Provide emotional care and support to the child and family.
Clinical Tips are “pearls” from clinical nursing experts embedded throughout the textbook.
Care in the Community
Some signs of the intact neurologic status of an infant (newborn to 2 months of age) are a cr y with a loud and energetic quality, a strong suck, and suck-swallowing coordination. What is one additional sign?
■ Family Processes, Interrupted related to child’s life-threatening illness
Nursing care focuses on administering insulin, fluids, and electrolytes, and monitoring the child for signs and symptoms of associated complications. Once the child is stabilized, the focus of care shifts to educating the child and family on methods to prevent further episodes of diabetic ketoacidosis.
Planning and Implementation
Following are nursing diagnoses that may be appropriate for the child with an altered level of consciousness:
Position the child with respirator y distress in an upright position (by elevating the head of the bed) with the head in midline to help maintain the airway Administer oxygen as ordered (Figure 25–9 ■).
■ Breathing Pattern, Ineffective related to neuromuscular dysfunction associated with increased intracranial pressure
■ Aspiration, Risk for related to poor control of secretions with decreased level of consciousness
■ Skin Integrity, Risk for Impaired related to agitation and skin rubbing against bedding
■ Communication: Verbal, Impaired related to physiologic con-
Because the child with a severely altered level of consciousness may still be able to he ar, talking to him or her may be beneficial. Listening to music or tapes of family members talking or reading can soothe a child when family members cannot be present. Explain all procedures and actions to the parents and child. Encourage the parents to stroke and touch the child in a soothing manner
When the child becomes more alert, gradually and repeatedly orient the child to time, place, and person, depending on his or her age and level of understanding. Encourage parents to bring objects or toys from home to make the environment more familiar and promote a feeling of security
The prevention of future episodes of diabetic ketoacidosis is important. Partner with the child and family to ensure they learn strategies to keep hyperglycemic episodes from progressing to diabetic ketoacidosis. (See Partnering with Families: Preventing DKA.) Parents should have specific instructions on how often to check the blood glucose and when to check the urine for ketones when the child is
NEW! Clinical Judgment speed bumps appear when an opportunity for critical thinking arises.
Provide Emotional Support
Explain the child’s condition to the family in simple terms. Encourage parents to take part in the child’s care and therapy as much as possible
related to
term and emotional health of diagnosed provide home hool nursher facilities grows; this family, and ew on page ies to mainneeded (see re). ons are peror respirags may be of infancy with fluids, and ensure erform range of y. Physical ractures. It is keeping the Splints may provide parents
Arrange a the child’s determine educaestablished. mputers if ention proas possible not ask the g books to fer the child contributes needs. Surger y, of the child ily care are providing a members, and creates a family to respite ther a famcoordinate ce and supAsk what and family
Case Scenarios and photos at the beginning of the chapter engage you with a child’s real-life experience with a specific health challenge. Additional information about the child and family appears throughout the chapter to illustrate application of nursing care. Use the questions embedded in each scenario to apply pathophysiologic, psychosocial, family, culture, developmental, or nursing process considerations. At the end of the chapter, a detailed Clinical Reasoning in Action exercise picks up the opening scenario and asks you to apply what you have read.
Legal and Ethical Considerations Muscular Dystrophy Care
6. Integrate
ASSESSMENT FOCUS ASSESSMENT GUIDELINE
7. Summarize strategies for preparing children and families for discharge from the hospital setting.
Growth
8. Evaluate the effectiveness of teaching strategies used with the hospitalized child and his or her family
■ Carefully measure weight, length, or height and plot on a growth curve.
■ Compare measurements at different ages to assess the growth pattern over time and to assess the growth velocity.
Blood pressure/pulse
“Why
do
they need to take my tonsils out? They’re fine where they are!”
—Tiona, age 5
Anterior pituitary
Growth
The child with muscular dystrophy has a shortened life span. Parents provide comprehensive care and require support both physically and emotionally as the child’s condition progresses. The child continues to develop in many ways, especially cognitively, as the years pass. Therefore, the needs for explanation and ability to understand the diagnosis change for the child over time. Parents may have difficulty initiating discussions with the growing child about desire for end-of-life care (Penner, Cantor, & Siegel, 2010). An ethical approach to care demands that such a complex chronic disease be managed by an interdisciplinar y team that collaborates on a regular basis. The child, family, and a variety of health, social, and educational professionals should all be part of the team. The plan of care will include physical, emotional, cognitive, and palliative care; it will evolve and change as the child grows older Nurses are essential members of the team and may work with families as team managers.
Facial characteristics
Neck
Muscles
Genitalia and secondary sexual characteristics
■ Assess blood pressure and compare to expected norms for age. See Appendix B 8
■ Inspect the face for unusual features such as a protuberant tongue, protuberant eyes, or moon face.
Five-year-old Tiona Lewallen has a histor y of frequent tonsillitis and is scheduled for a tonsillectomy and adenoidectomy in the morning. Her mother has brought her in today for preoperative evaluation and instruction. Tiona has no other health problems. Her experience with health care is limited to well-child checkups and immunizations as well as several visits to the otolar yngologist in the past year She has no prior hospitalizations. Tiona will return at 6:30 a.m. for surger y. She will be admitted to the pediatric day short-stay unit for a few hours following surger y and will then be discharged home as long as she is able to drink fluids and take oral pain medication. How should the nurse assess what Tiona knows about her surger y? What techniques should be used to teach Tiona about the surger y? What instructions should Tiona’s mother receive from the nurse in the preoperative clinic related to care prior to surgery?
Clinical Re asoning in Action
INTRODUCTION
Body odor
Skin
Recall Tiona, the child described in the beginning of the chapter She is a 5-yearold girl who was admitted to the hospital for a tonsillectomy and adenoidectomy (T&A).
DESCRIPTION
Parents may exhibit feelings of guilt and hopelessness. The mother who learns she has carried the gene that affects her son can be devastated. Encourage parents to express their feelings. Genetic counseling is recommended for the entire family, and it is especially important to identify women who are carriers of one of the X-linked disorders. Siblings may feel neglected because their brother or sister is receiving so much attention. They may be concerned that they will develop the disease. Sometimes multiple children in a family are affected with the condition and as one child worsens, the effect on siblin gs is profound On the other hand, siblings without the disease may feel guilty for their good health. Encourage the parents to involve siblings in the affected child’s care to reassure them of their importance (See Chapter 16 8 for ideas about involvement of siblings in care.)
■ Palpate the neck for an enlarged thyroid or goiter.
■ Assess strength and muscle tone.
■ Assess external genitalia for signs of ambiguous genitalia, or inappropriate size for age.
■ Determine the child’s stage of development for each characteristic (breast and pubic hair for girls, genital and pubic hair for boys) by comparing to the images in Figures 7–43, 7–44, and 7–45 8 8
■ Assess the sexual maturity rating with information in Figure 7–46 8 Compare the stage of development to the age of the boy or girl to determine early or delayed onset of puberty.
■ Assess body odor for unusual smell (e.g., sweet, musty, cheesy, sweaty feet).
2. As Tiona and her mother are preparing to leave the hospital, Tiona says, “I am going to be good so I do not have to come to the hospital anymore!” How should the nurse respond?
■ Assess skin color, noting areas of unusual pigmentation.
Mental status ■ Note affect. Assess for anxiety, irritability, or lethargy.
Following Tiona’s operation, she refused to drink liquids because it hurt when she swallowed. After receiving intravenous pain medication, Tiona realized that she could swallow without too much pain and began to eat Popsicles and drink liquids. She was then switched to oral pain medication. Later in the day, Tiona was drinking liquids well enough to be discharged home.
DISCUSSION
3. Tiona’s mother states that she is worried that her daughter will not drink enough at home. What can the nurse suggest to Tiona’s mother to encourage her to drink fluids? What are the symptoms of dehydration that Tiona’s mother should watch for over the next few days?
Family history ■ Assess for family history of metabolic or endocrine disorders.
4. Children Tiona’s age have many fears and stressors related to hospitalization and surgery. How can her mother assist Tiona to express her feelings about the hospital experience once she is home?
Note: *Refer to Chapter 7 8 for the actual techniques of assessment mentioned in this table.
1. What information should the nurse include in the discharge teaching plan for Tiona’s mother?
NCLEX-RN® Review
FIGURE 32–2 ■ Feedback mechanism in hormonal stimulation of the gonads during puberty.
The anterior pituitary gland is considered to be the “master gland” of the body. The major function of the anterior pituitary gland is the production and release of thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), luteinizing hormone (LH), follicle-stimulating hormone (FSH), growth hormone (GH), and
1. The nurse is caring for a female child who is recovering from a motor vehicle accident. The child’s parents ask if it is okay to bring the child’s siblings to visit. What is the most appropriate response by the nurse?
1. “No, it would not be good for your child to see her siblings as it may make her worse.”
3. Which behavior by a child’s parents is the best indicator that they understand how to administer medication to the child at home following surgery?
1. The parents sign the written discharge instruction verifying understanding of the instructions.
As the child’s condition weakens, the family again needs additional support. They experience grieving, each person in their own way. They have lived with chronic sorrow and now need to prepare for the child’s death. The child is usually old enough to recognize the deteriorating condition. See Chapter 18 8 for further discussion of bereavement and end-of-life care
2. “No, it would be very upsetting for your child’s siblings to see her this way.”
Tables of Diagnostic Procedures and Laboratory Tests pertinent to the specific systems assist you in clinical when you need the information.
Inborn errors of metabolism (inherited biochemical abnormalities of the urea cycle and amino acid and organic acid metabolism) often have a significant impact on the endocrine system’s ability to support growth and development. Some chromosomal abnormalities also result in disturbances in growth and sexual development. These disorders are discussed on page 1141
TABLE 32–3 Diagnostic Procedures and Laboratory Tests for the Endocrine System*
3. “Yes, it is okay to bring your child’s siblings to see her as long as you bring someone to watch them.”
2. The parents give the medication to the child using the appropriate technique in the nurse’s presence.
DIAGNOSTIC PROCEDURES LABORATORY TESTS
4. “Yes, it is okay to bring your child’s siblings for a visit as long as we educate them on what to expect when they visit.
ACTH stimulation test
2. How can the nurse best limit the amount of separation anxiety that the hospitalized toddler will experience?
3. The parents state they understand how to administer the medication and deny questions.
Fasting plasma glucose
4. The parents state they can give the medication to the child using appropriate technique.
Adrenal (ACTH) suppression test
Bone age
1. Reduce the amount of time spent with the child when the parents are not present.
Computed tomography (CT)
2. Discourage the amount of time the parents hold their child while hospitalized.
Hemoglobin A1c
Hormone levels
4. The nurse is caring for a 5-year-old male child who will be having a tonsillectomy performed. What teaching method is most appropriate for this child prior to the surgical procedure?
1. Provide the child’s mother with brochure about the procedure.
Insulin-like growth factor (IGF-1) and Insulin-like growth factor-binding protein
Evaluation
3. Encourage the parents to leave the child’s room when care is being provided.
DISORDERS OF PITUITARY FUNCTION
Expected outcomes of nursing care for the child with muscular dystrophy include maintenance of optimal mobility and development, positive self-image for the affected child, and positive management of the emotional challe nges by all family memb ers.
Fluid deprivation test
Karyotype
4. Encourage parental involvement in the child’s care and suggest rooming in if possible.
The pituitary gland consists of two lobes, an anterior lobe and a posterior lobe. The functions of the posterior pituitary gland include regulation of fluid balance through release of antidiuretic hormone (ADH), which is stored in the hypothalamus; and production of oxytocin, which is also stored in the hypothalamus.
Refe rences
Bind ler, R. C., Ball J. W., Lade wig, P. W., & London M. L. (2011). Clinical skills manual for maternal & child nursing care (3rd ed p. 110). Upp er Saddle
River, NJ: Pe arson.
Complementar y Therapy Muscular Dystrophy
Brain Injury Association of America. (2011). A guide to selecting and monitoring brain injury rehabilitation services Retrieved from http://www.biausa.org/Default aspx?SiteSearchID 1192&ID /search-results.htm
Chahal, N., Manlhiot, C., Colapinto, K., Alphen, J. V., McCrindle, B. W & Rush, J. (2009). Association between parental anxiety and compliance with preoperative requirements for pediatric outpatient surgery. Journal of Pediatric Health Care, 25(6), 372–377.
Many families who have a child with muscular dystrophy use different types of complementar y care. The nurse always assesses for such approaches, provides information as needed by the family, makes recommendations for complementary therapies that may be helpful, and cautions against those that could be harmful due to interactions with medications or other problems. Common complementar y care used in muscular dystrophy includes dietar y enhancement. This enhancement includes vitamins A, C, E, D, and B-complex; minerals such as calcium, magnesium, zinc, and selenium; probiotic supplement; omega-3 fatty acids; herbal remedies such as green and rhodiola rosea teas; muscular and immunologic enzymes such as coenzyme Q10, N-acetyl cysteine, acetyl-L-carnitine, creatine, and L-theanine; melatonin to promote sleep; and massage to assist with reduction of muscle spasms (University of Mar yland Medical Center, 2011).
2. Sit with the child while he watches a video about the procedure.
3 IGFBP-3
3. Use dolls to teach the child about the procedure.
Magnetic resonance imaging (MRI)
See Appendix I 8 8 for answers.
Thyroid radioactive iodine uptake (RAIU) scan
Newborn metabolic screening
4. Allow the child to talk to other children who have had the procedure.
Provocative growth hormone testing
Thyroid antibodies
Note: *See Appendixes D and E 8 for information about these diagnostic procedures and for expected laboratory tests values.
Crenshaw J. T., & Winslow, E. H. (2008). Preoperative fasting and medication instruction: Are we improving? AORN Journal, 88(6), 963–976.
Disch, J Dreher M., Davidson, P Sinioris, M., & Wainio, J. A. (2011). The role of the chief nurse officer in ensuring patient safety and quality. Journal of Nursing Administration, 41(4), 179–185.
Fisher M. J & Broome, M. E. (2011). Parent-provider communication during hospitalization. Journal of Pediatric Nursing, 26(1), 58–69.
Forsner, M., Jansson, L., & Söderberg, A. (2009). Afraid of medical care: School-aged children’s narratives about medical fear Journal of Pediatric Nursing, 24(6), 519–528. Frisch, A. M., Johnson, A., Timmons, S., & Weatherford, C. (2010). Nurse practitioner role in preparing families for pediatric outpatient surgery. Pediatric Nursing, 36(1), 41–47.
Drahota, A., & Malcarne, V. L. (2008). Concepts of illness in children: A comparison between children with and without intellectual disability Intellectual and Developmental Disabilities, 46(1), 44–53. Emergency Nurses Association. (2009). Emergency nursing resource: Family presence during invasive procedures and resuscitation in the emergency department Retrieved from http://www.ena.org/IENR/ENR/Documents/ FamilyPresenceENR.pdf
Complementary Therapy boxes present approaches other than traditional medical prescriptions that may be used by children and families to maintain health or treat diseases. These boxes discuss research when it is present to support or refute the efficacy of these modalities. At other times, they alert you about information to gather from the family and to consider when planning care.
are in similar over time or if body prophysician, nurse channel to anin the 25th percentile performed clues to nudietary insuggest specific
a description of activities in the last day. Then start with the most recent event and move backwards, integrating food intake into the daily schedule. For example, you might begin by saying, “You mentioned you got up early to come to the clinic today. What did Sam eat at home before you left? Did he have a snack as you traveled here or
■ Promotes a healthy school environment by ensuring immunization compliance, monitoring playground equipment safety, promoting infection control, and implementing programs for bullying and violence prevention
■ Educates students about healthy lifestyles, good nutrition, exercise, oral health, smoking cessation, sexually transmitted infections, and pregnancy prevention
■ Manages students with chronic conditions, administers medications, and participates in the development of individualized health plans (IHPs) and individualized education plans (IEPs) for those with disabilities
Developing Cultural Competence Growth Grids
■ Refers students’ families to healthcare providers and insurance programs and connects students with needed services (e.g., for substance abuse treatment, behavioral and mental health, and reproductive health)
■ Serves as a leader in the preparation of policies for school-wide emergencies, school health programs, mental health intervention, and student and faculty health emergencies
The growth grids now in use were standardized using a cross section of the U.S. population and are generally reflective of most children. However, children from some other countries or cultures may fall outside these curves. For example, new immigrants or adoptees may be in lower percentiles, and catch up over several months or years. Children of immigrants from developing countries tend to be larger than their parents. Even when small, children should follow normal growth patterns. For example, a child may remain at the 10th or 25th percentile for height, but continue to slowly grow and not fall to a lower percentile.
■ Identifies and reports clusters of symptoms that may indicate an epidemic
Source: Data from American Academy of Pediatrics Council on School Health. (2008). Role of the school nurse in providing school health services. Pediatrics, 121(5), 1052–1056; Robert Wood Johnson Foundation. (2010). Unlocking the potential of school nursing: Keeping children healthy, in school, and ready to learn. Retrieved from http://www.rwjf.org/files/research/cnf14.pdf
Developing Cultural Competence boxes challenge you to explore differences among racial, ethnic, and social groups, and to plan nursing care that addresses the issues of health disparity.
date grades for screening and selected children who must be screened for conditions such as visual or hearing problems, and scoliosis screening in public schools. B, The school nurse treats this child with a nebulizer to determine if the asthma episode can be controlled before calling the parent to come and pick up the child and seek care from the primary care provider. The parent should be informed of nebulizer treatment provided in case the child’s asthma episode continues and additional treatment is needed.
Legal and Ethical Considerations Child Nutrition Reauthorization Act
The Child Nutrition Reauthorization Act of 2010, titled the Healthy, Hunger-Free Kids Act of 2010, continues the federal school meal programs (breakfast, lunch, after-school snack, and summer food service) for low-income children and increases access to nutritional foods. The program also has goals for nutrition education and physical activity in an effort to address childhood obesity. School nurses may work with food service personnel in the nutrition programs for healthy eating and in creating a nutrition education program for students (Sherry, 2008). See Chapter 19 8 8
Legal and Ethical Considerations boxes identify laws and ethical issues pertinent to pediatric nursing topics.
Medications Used to Treat boxes list the actions, indications, and important nursing implications for medications.
778 Unit VI | Chapter 25 | Alterations in Respiratory Function
Medications Used to Treat Asthma
QUICK-RELIEF MEDICATION ACTION/INDICATION
Short-Acting Beta2-Agonists (SABA)
Albuterol
Levalbuterol
Pirbuterol:
Metered dose inhaler (MDI) or nebulizer
Corticosteroids
Methylprednisolone
Prednisone
Prednisolone: Oral
Anticholinergic
Ipratropium: Metered dose inhaler (MDI) or nebulizer
Relaxes smooth muscle in airway leading to rapid bronchodilation (within 5–10 minutes) and mucus clearing
Drug of choice for acute therapy and for prevention of exercise-induced bronchospasm
NURSING MANAGEMENT
■ Use this rescue medication before inhaled steroid, wait 1–2 minutes between puffs, wait 15 minutes to give inhaled steroid. Child should hold breath 10 seconds after inspiring. Then rinse mouth and avoid swallowing medication. Use a spacer
■ Differences in potency exist, but all products are comparable on a per puff basis.
■ Some dose-related side effects include tachycardia, nervousness, nausea and vomiting, and headaches.
■ Regular use more than 2 days a week for symptom control indicates a loss of control and need for additional therapy
Diminishes airway inflammation, secretions, and obstruction, enhances bronchodilating effect of beta2-agonists
Used for acute asthma episodes that are not completely responsive to beta2-agonists; helps reduce rate of hospitalization
Inhibits bronchoconstriction and decreases mucus production with an onset of action in 30–90 minutes
DAILY CONTROL MEDICATIONS ACTION/INDICATION
Long-Acting Beta2-Agonists (LABA)
Salmeterol
Formoterol:
Dry powder inhaler (DPI)
Inhaled Corticosteroids (ICS)
Beclomethasone
Evidence-Based Practice boxes further enhance the approach to research. We describe a particular nursing problem and investigate the evidence from several studies that explore solutions to the problem. We emphasize nursing research, provide an interpretation explaining the implications of the studies, and then invite you to apply critical thinking skills to further identify nursing care approaches.
Budesonide
Flunisolide
Fluticasone
Mometasone
Triamcinolone:
Metered dose inhaler (MDI) or nebulizer
Methylxanthines
Theophylline: Oral
Mast-Cell Inhibitors
Cromolyn sodium Nedocromil:
Metered dose inhaler (MDI) or nebulizer
Relaxes smooth muscles in airway, used for nocturnal symptoms and prevention of exercise-induced bronchospasm.
These medications should not be used as single therapy for asthma in children, but prescribed in combination with corticosteroids (U.S. Food and Drug Administration, 2010).
■ Short-term therapy should continue until child achieves 80% peak expiratory flow rate personal best or symptoms resolve.
■ Give with food to reduce gastric irritation.
■ Give oral dose in early morning to mimic normal peak corticosteroid blood level.
■ Assess for potential adverse effects of long-term therapy: decreased growth, unstable blood sugar, and immunosuppression.
■ Do not use for primary emergency treatment because of delayed onset.
■ Rinse mouth afterward to get rid of bitter taste.
■ Side effects include increased wheezing, cough, nervousness, dry mouth, tachycardia, dizziness, headache, and palpitations.
■ Prevent medication contact with eyes.
NURSING MANAGEMENT
■ Do not use for acute asthma episode.
■ Take pre-exercise dose 30–60 minutes before activity Do not use additional dose before exercise if already using twice-daily doses which should be 12 hours apart.
■ Caution against overdosage as side effects such as tachycardia, tremor, irritability, and insomnia will last 8–12 hours.
Practice Care Coordination for Children with Special Healthcare Needs
Anti-inflammatory, controls seasonal, allergic, and exercise-induced asthma
Effectively reduces mucosal edema in airways
■ Report failure to respond to usual dose as this may indicate a need for stepped-up therapy
■ Administer with spacer or holding chamber
PROBLEM Children with special healthcare needs require assistance from a variety of programs and services to maximize their potential. Fragmentation of care may result in the child’s needs being unmet.
EVIDENCE
■ Separate parts and clean inhaler daily
■ Rinse mouth and gargle following treatment to remove drug from oropharynx to reduce chance of cough, thrush, and dysphonia.
coordination by nurses as an integral aspect of each visit decreased the number of visits to the primary care provider and to the emergency department Antonelli, Stille, & Antonelli, 2008).
A longitudinal study compared the use of pediatric practice-based
■ Monitor growth; however recommended doses do not have long-term or irreversible effects on vertical growth (Fong & Levin, 2007).
Relaxes muscle bundles that constrict airways; dilates airway; provides continuous airway relaxation; sustained release for prevention of nocturnal symptoms
Data were analyzed from the 2005–2006 National Survey of Children with Special Healthcare Needs to determine the association between receiving adequate care coordination, family–provider relations, and outcomes in the child and family Data indicated that 68.2% of the families reported receiving some type of assistance with care coordination. Of these, 59.2% indicated they received adequate help, and 40.8% indicated the assistance was inadequate. Adequate care coordination was associated with family-centered care, satisfaction with care received, and a partnership with healthcare professionals. Families who reported receiving adequate care coordination were less likely to have problems with specialty referrals, family financial burden, and reduction in work hours. These families also had less out-of-pocket expenses, fewer visits to the emergency department per month, and fewer missed days of school for the CSHCN than families who reported receiving inadequate assistance with care coordination Turchi, Berhane, Bethell, et al., 2009).
■ Prevent eye exposure through proper MDI, nebulizer, or DPI administration.
■ Monitor for headache, gastrointestinal upset, dizziness, and infection.
■ Use exactly as prescribed.
■ Tablet should not be crushed or chewed.
■ Use for long-term control. Works best when a therapeutic serum level (10–20 mcg/L) is maintained; give same time each day
■ Requires serum level monitoring and dose adjustment.
■ Limit caffeine intake.
Anti-inflammatory, inhibits early and late phase asthma response to allergens and exercise-induced bronchospasm; may be used for unavoidable allergen exposure.
A descriptive study of six pediatric primary care practices was conducted to evaluate the effectiveness of a care coordination measurement tool. Other purposes of the study were to describe care coordination activities that occurred in a pediatric primary care setting, to assess the relationship of care coordination activities in this setting to outcomes related to the use of resources, and to measure personnel costs related to care coordination activities. The study found that care coordination activities were used by patients at all levels of acuity, including children and youth with special healthcare needs; the care coordination tool was used effectively in the pediatric primary care setting; care coordination provided by nurses instead of physicians in this setting decreased costs; and care
May be used as a substitute for inhaled corticoste-
■ Side effects include tachycardia, dysrhythmias, restlessness, tremors, seizures, insomnia, hypotension, severe headaches, vomiting, and diarrhea.
■ Do not use at time of symptom development or acute exacerbation.
■ The patient must use up to 4 times a day to be effective.
■ Therapeutic response is seen in 2 weeks; maximum benefit may not be seen for 4–6 weeks.
for hospitalfor hospito answer
emotional risk for follow fibrosis or lessness. hospital admisvironment, responses, anticipated s care. Give ncerns. Refer to t is needed
■ General pediatric unit
■ Short-stay unit, outpatient unit, or ambulatory surgical unit
■ Emergenc y department
■ Neonatal intensive care unit (NICU) or pediatric intensive care unit (PICU)
A randomized controlled trial measured how monitoring and discussing healthrelated quality of life (HRQoL) improved psychosocial well-being in adolescents with type 1 diabetes. Ninety-one adolescents between the ages of 13 and 17 with type 1 diabetes participated in the study and were randomly assigned to the HRQoL intervention group or the control group. During a 12-month period, all participants had 3 scheduled visits for routine diabetes care at 3-month intervals. The intervention group completed the Pediatric Quality of Life Inventory on a computer at each visit prior to being seen by the healthcare provider. The results were discussed with the adolescent during the visit. Over the 12-month period, mean scores for psychosocial health, behavior, mental health, and family activities improved in the intervention group except for those adolescents with the highest hemoglobin A1c values. Adolescents in the intervention group demonstrated higher self-esteem at follow-up visits and were more satisfied with care than those in the control group (de Wit, Delemarre-van de Waal, Bokma, et al., 2008).
Baccalaureate Essential II Basic Organizational and Systems Leadership for Quality Care and Patient Safety
A cross-sectional design was utilized to determine the impact of family support and environment on quality of life, adherence to treatment, and metabolic control in 157 adolescents ages 10 to 18 with type 1 diabetes. Four instruments were used in the study: a self-report questionnaire on adherence, Diabetes Family Behavior Scale, Family Environment Scale, and Diabetes Quality of Life. Results of the study indicated that increased family support predicted a better quality of life in both males and females, and higher family conflict predicted a lower quality of life. Increased family support also predicted an increase in adherence in females. Additionally, the study found that the longer the teen had been diagnosed with diabetes, the less likely he or she was to be adherent to a management plan and to have good metabolic control. Results
Quality improvement and safety is a priority for healthcare organizations. Nurses at the bedside have a major influence on the quality of care provided and the safety of the patient; however, it is the responsibility of the organization’s leadership to provide the staffing and resources so that safe and quality care can be provided (Disch, Dreher, Davidson, et al., 2011). Healthcare providers must advocate for best practices that focus on risks unique to children. Children in the healthcare setting are at risk for harm related to misidentification, adverse effects from high-alert medications, and healthcare-acquired or associated infection (Steering Committee on Quality Improvement and Management & Committee on Hospital Care, 2011). Young children are especially vulnerable to injur y because of their developmental immaturity, including the inability to recognize safety risks. It is essential that the hospital environment be free of hazards that pose risks for children.
RESEARCH boxes focus on relevant research studies to give students additional information and background information.
Partnering with Families boxes help you to apply the concepts of family-centered nursing care by providing approaches and teaching in a format directly applicable when you work with families.
necessary for home management, including insulin administration, blood glucose testing, meal planning, and the recognition and treatment of both hypoglycemia and hyperglycemia. Partner with the child and family to identify barriers to management.
Explain the goals of insulin therapy. Teach the parents and child (if age appropriate) how to draw up and administer insulin or how to use an insulin pen. Insulin pens might be accepted more readily than the traditional syringe and vial method; they are easier to transport, they provide more accurate dosing, and they decrease
BOX 32–6
can Americans scored significantly higher than Caucasians on both measures. Participants who lived in single-parent homes had poorer diabetic control, as indicated by a higher hemoglobin A1c, but had higher scores in resilience (Winsett, Stender, Gower, et al., 2010).
IMPLICATIONS
Developmental tasks of adolescents focus on development of self-concept and self-esteem. Adolescents with type 1 diabetes must also cope with the increasing responsibility for complex self-management, including insulin administration, blood glucose testing, exercise, and nutrition. Self-esteem and self-concept often become linked with the disease as peers react to the differences noted. Life satisfaction, perceived control, and worries associated with having diabetes are important considerations when counseling the teenager and family about the management of diabetes. Additionally, it is important to know that adolescents value parental involvement and care rather than perceiving it as a reason for conflict. Parental involvement and supervision is important in helping adolescents transition successfully to self-management of their disease. Peers are also very important to adolescents with diabetes. Continued involvement in school activities and summer camps provide excellent avenues for friendship and promote a positive quality of life.
NEW! Baccalaureate Essentials boxes focus on the nine essentials of nursing education identified by the American Association of Colleges of Nursing.
CRITICAL THINKING APPLICATION
What questions can be used to explore an adolescent’s perceptions of family involvement, care, and control? How can you address quality of life issues in adolescents with diabetes? What questions can be asked to determine the adolescent’s self-efficacy and resilience?
anxiety associated with needles and insulin administration in public (Hanas, de Beaufort, Hoey, et al., 2011). Rotating the injection sites is important to decrease the chances of lipoatrophy, loss of subcutaneous tissue, or hypertrophy, in which collagen is replaced by fat cells (Figure 32–10 ■). The absorption rate of insulin varies by the site used. Insulin is usually absorbed most rapidly from the abdomen; however, insulin absorption is increased in the extremities with exercise. An understanding of the different types of insulin and their actions is essential.
Research: Communication Between Adolescents with Type 1 Diabetes and Their Parents
Transcripts of interactions between adolescents ages 11 to 15 years with type 1 diabetes and their parents were analyzed. Participation in the study required that the adolescent had been diagnosed with type 1 diabetes for at least a year and have no other chronic illness, psychologic problems, or learning disability Transcripts were based on a 10-minute interaction between the adolescent and his or her parents in which a diabetes management task, identified by the teen as a source of disagreement, was discussed.
Five themes were identified from the transcripts: fear, frustration, discounting, normalizing, and trusting. Parents demonstrated frustration, fear and difficulty in trusting the child with the daily management of diabetes. Parents were also fearful of long-term complications. Adolescents demonstrated frustration because they did
not feel their parents recognized their successes in their diabetes management. Discounting was noted in statements by parents that showed a lack of respect for the adolescents’ opinions and failure to include the adolescents in decisions related to their care. These statements further added to the child’s frustration. The theme of normalizing was noted in only a few families and included statements indicating that the family was attempting to view diabetes as a normal aspect of the adolescent’s life. The other themes of fear, frustration, trust, and discounting were cited as barriers to achieving the goal of normalcy
The study concluded that effective communication between parents and adolescents with type 1 diabetes is essential and that nurses should work with families to facilitate communication related to diabetes management (Ivey, Wright, & Dashiff, 2009). EVIDENCE
Partnering with Families
Helping the Infant Sleep
Video
Helping the Infant Sleep
Helping an infant to self-regulate and be able to sleep for longer periods is often a stressful challenge for families. Parents need to have substantial sleep periods themselves to be refreshed and able to deal with daily life. When up several times during the night with a baby, parents may become irritable and fatigued. Question the family about the baby’s sleep routine. The infant passes into light sleep several times at night and may awaken; self-regulation will assist in helping the infant get back to sleep. Suggestions helpful for the family are as follows:
■ Place the baby to sleep in a quiet and darkened room, a “sleep friendly” environment.
■ Establish a consistent sleep routine and time; the routine may involve some cuddling and rocking time but should not be vigorous, stimulating play
and psychologic health are closely related to these factors. For many parents, membership in a faith-based congregation provides spiritual sustenance and an important sense of belonging. This group may also provide food, clothing, and care for the new infant. Sometimes parents who have not attended institutionalized services will choose to do so to offer a significan t spiritual home for their new child. Services such as christening and blessing an infant welcome the child formally into the family and provide meaning to parents and extended family members. Having a baby often helps parents to feel that they have an important meaning and purpose in life, regardless of a faith-based membership An atmosphere where the infant is valued and offers
■ Provide a consistent transitional object, such as a favorite blanket each night.
■ Put the baby to bed while still awake but drowsy rather than after falling asleep, so the infant learns self-soothing skills.
■ Do not tr y to awaken the baby in non-rapid eye movement (NREM or quiet) sleep.
■ For the baby who has trouble going to sleep, remain in the room for a few minutes but do not establish eye contact; place a hand on the abdomen or chest or gently hold flailing arms and legs.
Source: Data from National Sleep Foundation. (2011). Sleep, infants, and parents. Retrieved from http://www.sleepfoundation.org/articles/ask-the-expert/sleep-infants-and-parents
cues related to hunger or discomfort, the nurse plans interventions to help prevent further problems. Teaching, demonstrations, and acknowledging parent success are all health maintenance actions. An expected outcome for these activities is the reestablishment of expected growth and development, and age-appropriate interactions of the infant with others.
The infant’s social interactions, both within and outside the family,
284 Unit III | Chapter 10 | Health Promotion and Maintenance of the Infant
of otitis media. The major risk factor for frequent otitis media is low socioeconomic status, regardless of ethnicity ( Smith & Boss, 2010). Be alert for risk factors, plan prevention programs, and ensure prompt care and teaching about treatments for families of children affected. What prevention measures would you emphasize for families? See the nursing management section on otitis media for suggestions of preventive approaches.
of ear pain (F
24–9 ■ ). Diarrhe a, vomiting, and fever are typical of otitis media. Irritability and “acting out” may be signs of a related hearing impairment. The child with otitis media often has night awakenings with cr ying due to increased pressure when prone or supine. See the Clinical Manifestations table for further detail.
Clinical Manifestations Acute Otitis Media and Otitis Media with Effusion
ETIOLOGY
Acute otitis media—bacterial infection in the middle ear from pathogens transferred from the nasophar ynx; most common infectious agents are S. pneumoniae, H. influenzae, M. catarrhalis
Otitis media with effusion collection of fluid in the middle ear behind the tympanic membrane which is not infected with bacteria.
Examination—bulging tympanic membrane, air or fluid bubbles present behind tympanic membrane; immobile or poorly mobile tympanic membrane, red (or other color change such as white, gray, or yellow as long as bulging is present) tympanic membrane, reduced visibility of tympanic membrane landmarks with displaced light reflex.
Behavioral—difficulty hearing or responding as expected to sounds.
Examination—signs of acute inflammation are NOT present; tympanic membrane is retracted or neutral; immobile or partly mobile tympanic membrane; yellow or gray tympanic membrane; opaque or thickened tympanic membrane with visibility of landmarks reduced.
Nursing Care Plans are present in every chapter dealing with health conditions. They illustrate the conceptual approach that nurses need in caring for children, including assessment, NANDA nursing diagnoses, goals, plans, interventions (with NIC), and evaluation (with NOC).
CLINICAL THERAPY
Treat ear pain with anesthetic eardrops, herbal pain products instilled into the auditor y canal, or systemic acetaminophen or ibuprofen.
Verify that the tympanic membrane is intact before inserting eardrops. Obser ve the child’s condition for 48–72 hours and if not improved, treat with course of antibiotics.
Provide symptomatic treatment of pain. Carefully assess hearing acuity over several months. Assess speech if loss of hearing acuity occurs. Assess development.
Clinical Manifestations boxes link etiology, clinical manifestations, and clinical therapy for specific conditions.
about age-appropriate foods. Since appetite may be impaired during periods of treatment, the child may be lacking fruits, vegetables, or other foods, as well as the nutrients they include. Encourage parents to be sure the child has a well-balanced diet during periods of remission.
■ Perform developmental screening of young children. Provide suggestions for parents about the stimulation that is appropriate for the child’s age. Include quiet activities that can be used when the child is fatigued or receiving therapy These might include reading books, listening to music, and working on a computer Have the parent plan for these activities on days that the child goes for chemotherapy or other treatment.
■ Ask about the school-age child’s progress in school. Performance may be altered due to neurologic effects of treatment as well as missing school. Plan for the family to partner with the school personnel for provision of tutors, computer programs, or other needed assistance.
■ Encourage continued social contact with peers when blood counts are adequate to prevent infection.
PHYSICAL ASSESSMENT AND SCREENING
■ Careful physical assessments are performed to identify any abnormalities that may result from cancer or its treatment. Be alert for signs of anemia, neutropenia, and thrombocytopenia; refer for treatment and suggest preventive measures such as infection control for neutropenia.
Cardiopulmonary and neuromuscular assessments are particularly important. Vision and hearing should be assessed prior to treatment and periodically throughout. Include measurements of fine and gross motor activity
ELIMINATION
■ Toddlers may have an interruption in toilet training during periods when they do not feel well. Help parents to understand this regression, and encourage them to start again when the child is feeling better
■ Some medications cause diarrhea or constipation, so evaluate bowel patterns and provide guidance as needed. Skin care instruction may be needed if the child has diarrhea and is relatively immobile. Increasing fluids and fiber foods may be needed for constipation.
■ Evaluate urinary output since many medications have effects on kidney function. Encourage adequate fluids
Health Promotion & Maintenance Overviews summarize the needs of children with specific chronic conditions, such as asthma or diabetes. These overviews teach you to look at the child who has a chronic illness like any other child, with health maintenance needs for prevention, education, and basic care.
End-of-Chapter Review
Chapter Highlights summarize key points of the chapter.
Clinical Reasoning in Action refers back to the chapter-opening scenario and asks critical thinking questions to help students apply knowledge to real patient care.
NCLEX-RN® Review prepares students for course exams on chapter content and gives exposure to all formats of NCLEX®-style questions.
Detailed References provide the basis for evidence-based nursing care and support the currency and accuracy of the textbook.
saline. Contemporary Pediatrics, 28(2), 30–38. American Academy of Allergy Asthma, and Immunology (AAAAI). (2013). What is a peak flow meter? Retrieved from http://www.aaaai.org/ American Academy of Pediatrics (AAP). (2012). Red book: 2012 Report of the Committee on Infectious Diseases (29th ed.). Elk Grove Village, IL: Author American Academy of Pediatrics (AAP) Committee on Infectious Disease. (2009). Policy statement—Modified recommendations for use of palivizumab for prevention of respiratory syncytial virus infections. Amirav I. (2010). To inhale or not to inhale: Is that the question? A simple method of DPI instruction. Journal of Pediatrics, 156(2), 339–339e1. Antoon, A. Y & Donovan, M. K. (2007). Burn in uries. In R. M. Kliegman, R. E. Behrman, H. B. Jenson, & B. F. Stanton, Nelson textbook of pediatrics (18th ed pp. 450–458). Philadelphia, PA: Elsevier Saunders. Askin, D. F & Diehl-Jones, W. (2009). Pathogenesis and prevention of chronic lung disease in the neonate. Critical Care Nursing Clinics of North America, 21 11–25. Asthma Initiative of Michigan for Healthy Lungs. (2011).
Emergency Medical Clinics of North America, 26 953–959. Baker, L. K., & Denyes, M. J. (2008). Predictors of self-care in adolescents with cystic fibrosis: A test of Orem’s theories
Bonkowsky, J. L., & Tieder J. S. (2009). A pragmatic approach to ALTEs. Contemporary Pediatrics, 26(11), 54–63. Brashers, V. L. (2010a). Alterations in pulmonary function. In K. L. McCance, S. E. Huether, V. L. Brashers, & N. S. Rote, Pathophysiology: The biologic basis for disease in adults and children (6th ed pp 1266–1309). St. Louis, MO: Mosby Elsevier Brashers, V. L. (2010b). Structure and function of the pulmonary system. In K. L. McCance, S. E. Huether, V. L. Brashers, & N. R. Rote, Pathophysiology: The biologic basis for disease in adults and children (6th ed pp 1242–1265). St. Louis, MO: Mosby Elsevier Busse, W. W Morgan, W. J Gergen, P. Mitchell, H. E., Gern, J. E., Liu, A. H., Sorkness, C. A. (2011). Randomized trial of omalizumab (Anti-IgE) for asthma in inner-city children. New England Journal of Medicine, 364(11), 1005–1015. Callahan, K. A., Panter T. M., Hall T. M., & Slemmons, M. (2010). Peak flow monitoring in pediatric asthma management: A clinical practice column submission. Journal of Pediatric Nursing 25 12–17. Camargo, C. A., Rachelefsky, G., & Schatz, M. (2009). Managing asthma exacerbations in the emergency department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the management of asthma exacerbations. Journal of Allergy and Clinical Immunology 124 S5–S14. Carbajal R Biran, V Lenclen, R Epaud, R Cimerman, P Thibau t, P Fauroux, B. (2008). EMLA cream and nitrous oxide to alleviate pain induced by palivizumab (Synagis) intramuscular injections in infants and young children. Pediatrics, 121(6), e1591–e1598. Carrier C. T. (2009). Back to sleep: A culture change to improve practice Newborn & Infant Nursing Reviews, 9(3), 163–168.
Centers for Disease Contro and Prevention (CDC). (2008). Initiating change: Creating an asthmafriendly school Retrieved from http://www.cdc.gov/ HealthyYouth/asthma/creatingafs/index.htm
Centers for Disease Contro and Prevention (CDC). (2011a). Trends in tuberculosis—United States, 2010. Morbidity and Mortality Weekly Report 60(11), 333–337. Centers for Disease Contro and Prevention (CDC). (2011b). Vital signs: Asthma prevalence disease characeristics, and self-managemen education—United States, 2001–2009. Morbidity and Mortality Weekly Report 60(17), 547–552. Chipps, B Zeiger R. S., Murphy K., Mellon, M., Schatz, M., Kosinski M., Ramachandran, S. (2011). Longitudinal validation of the Test for Respiratory Asthma Contro in Kids in pediatric practices. Pediatrics, 127(3), e737–e747.
Clark, A. P., Giuliano K., & Chen, H. (2006). Pulse oximetry revisited: “But his O2 was normal!” Clinical Nurse Specialist, 20(6), 268–272. Coffman, S. (2009). Late preterm infants and risk for RSV Maternal and Child Nursing, 34(6), 378–384.
bandage is prepared. This action prevents more air from entering the chest. For a closed pneumothorax, a needle or tube thoracostomy is performed rapidly to relieve the pressure in the chest. This is usually performed before a chest radiograph that often reveals air in the chest. A chest tube is inserted and a closed drain-
Chapter Highlights
■ Respiratory conditions are the most common cause of hospitalization in children between 1 and 9 years of age and a leading cause in children between 10 and 19 years of age.
■ The child’s airway is shorter and narrower than an adult’s. These differences create a greater potential for obstruction. The lungs have no muscles of their own, so respiration is powered by the diaphragm and intercostal muscles.
■ Children under 2 years have an increased risk of developing tuberculosis, and if untreated have a greater chance of progressing to active TB and spreading beyond the lungs (e.g., meningitis and disseminated TB).
■ Foreign body aspiration is most often caused by small objects that make their way into the child’s mouth, such as foods, small toy parts, or household objects like beads, safety pins, coins, or buttons. The increasing mobility and tendency to put small objects in the mouth makes this a major health problem for infants and toddlers.
■ Asthma is one of the most common chronic respiratory disorders in childhood. The respiratory difficulties of an acute asthma episode result from inflammation that causes the normal protective mechanisms of the lungs (mucous formation, mucosal swelling, and airway muscle contraction) to overreact in response to a stimulus and cause airway obstruction.
■ Signs of impending respiratory failure in infants and children include worsening respiratory distress, irritability lethargy mottled color or cyanosis, diaphoresis, and increased respiratory effort such as dyspnea (difficulty breathing), tachypnea (increased respiratory rate), nasal flaring, grunting, and retractions.
■ Bronchopulmonary dysplasia (BPD) usually develops in neonates with a birth weight of 1000 g or less and a gestational age at birth of less than 28 weeks who are treated with oxygen and positive-pressure ventilation for respiratory failure or respiratory distress syndrome. Treatment leads to inflammation and damage to the bronchioles, resulting in fibrosis, edema of the bronchioles, and smooth muscle hypertrophy
■ Sudden infant death syndrome (SIDS) is a leading cause of death in infants. Onset of the fatal episode occurs during sleep and remains unexplained after a thorough investigation, including an autopsy, a review of the circumstances of death, and the clinical history.
Signs of smoke inhalation injury in children include burns of the face and neck, singed nasal hairs, soot around the mouth or nose, and hoarseness with stridor or voice change.
■ Apnea is cessation of respiration lasting longer than 20 seconds, or any pause in respiration associated with cyanosis, marked pallor, hypotonia, or bradycardia.
■ Pulmonary contusion occurs in association with blunt chest trauma. The energy from the injury often bruises the lung tissue in the absence of rib fractures. Although the child may appear initially asymptomatic, respiratory distress often develops within a few hours.
■ Three types of apnea are noted in neonates: central apnea, in which there is complete cessation of breathing; obstructive apnea, in which there is an absence of nasal airflow when respiratory efforts are present; and mixed apnea, in which a central respiratory pause either precedes or follows airway obstruction.
■ A pneumothorax may become life threatening if internal pressure from a closed pneumothorax is not vented. Air leaking into the chest cavity during inspiration cannot escape during expiration, increasing compression. Venous blood return to the heart is impaired as the mediastinum shifts toward the unaffected lung.
Clinical Re asoning in Action
■ Obstructive sleep apnea syndrome is a disorder of breathing during sleep that in children is commonly caused by enlarged tonsils and adenoids. Children have symptoms of sleep deprivation such as daytime sleepiness, poor attention, increased activity aggression or acting-out behavior and poor school performance.
DISCUSSION
INTRODUCTION
Return to the scenario at the beginning of the chapter Hannah and her mother are learning more about asthma management during a health center visit with the nurse practitioner She has no asthma symptoms during today’s visit, and has taken all medications prescribed since her recent hospitalization.
DESCRIPTION Prior to the acute asthma episode that occurred at school, Hannah had used only short-acting beta2-agonists for symptoms, about once a week. During her hospitalization she needed systemic corticosteroids and was sent home with oral corticosteroids that were tapered and discontinued 3 days ago. Because of the severity of her asthma episode, Hannah’s daily treatment will be changed from step 1 for intermittent asthma to step 2 for mild persistent asthma.
Coleman-Phox, K., Odouli R., & De-Jun, L. (2008). Use of a fan during sleep and risk of sudden infant death syndrome. Archives of Pediatrics and Adolescent Medicine, 162(10), 963–968. Cruz, A. T & Starke, J. R. (2010). Pediatric tuberculosis. Pediatrics in Review 31(1), 13–25. Cuff S., & Loud, K. (2008). Exercise-induced bronchospasm. Contemporary Pediatrics, 25(9), 88–95. Cystic Fibrosis Foundation. (2011a). About cystic fibrosis: What you need to know Retrieved from http://www.cff.org/AboutCF/ Cystic Fibrosis Foundation. (2011b). About cystic fibrosis: Frequently asked questions Retrieved from http:// www.cff. org/AboutCF/Faqs/ Cystic Fibrosis Foundation. (2011c). Screening for cystic fibrosis Retrieved from http://www.cff.org/ AboutCF/Testing/NewbornScreening/ScreeningforCF/ Cystic Fibrosis Foundation. (2011d). Airway clearance techniques Retrieved fromhttp://www.cff.org/ treatments/Therapies/Respiratory/AirwayClearance/ D’Agustino J. (2010). Pediatric airway nightmares. Emergency Medical Clinics of North America, 28 119–126. Davis, P. G., Schmidt, B Roberts, R. S., Doyle, L. W Asztalos, E., Haslam, R Tin, W. (2010). Caffeine for apnea of prematurity trial: Benefits may vary in subgroups. Journal of Pediatrics, 156(3), 382–387. Dukhovny D Lorch, S. A., Schmidt, B Doyle, L. W Kok, J. H., Roberts, R. S., Zupancic, J. A. F. (2011). Economic evaluation of caffeine for apnea of prematurity Pediatrics, 127(1), e146–e155. Duncan, J. R Paterson, D. S., Hoffman, J. M., Mokler D. J Borenstein, N. S., Belliveau, R. A., Kinney H. C. (2010). Brainstem serotonergic deficiency in sudden infant death syndrome.Journal of the American Medical Association, 303(5), 430–437. Durbin, W. ., & Stille, C. (2008). Pneumonia. Pediatrics in Review, 29(5), 147–158. Everard, M. L. (2006). Aerosol delivery to children. Pediatric Annals, 35(9), 630–636. Fakhoury K. F Sellers, C., Smith, E. O Rama, J. A., & Fan, L. L. (2010). Serial measurements of lung function in a cohort of young children with bronchopulmonary dysplasia. Pediatrics, 125(6), e1441–e1447.
Flume, P. A., O’Sullivan, B. P Robinson, K. A., Goss, C. H., Mogayzel P. J Willey-Courand, D. B Cystic Fibrosis Foundation, Pulmonary Therapies Committee (2007). Cystic fibrosis pulmonary guidelines: Chronic medications for maintenance of lung health. American Journal of Respiratory and Critical Care Medicine, 176 957–969. Fong E. W & Levin, R. H. (2007). Inhaled corticosteroids for asthma. Pediatrics in Review, 28(6), e30–e35. Fu L. Y Colson, E. R Corwin, M. J & Moon, R. Y. (2008). Infant sleep location: Associated maternal and infant characteristics with sudden infant death syndrome prevention recommendations. Journal of Pediatrics, 153(4), 503–508. Geary, C., Caskey M., Fonseca, R & Malloy M. (2008). Decreased incidence of bronchopulmonary dysplasia after early management changes, including surfactant and nasa continuous positive airway pressure treatment at delivery lowered oxygen saturation goals, and early
Review
1. Describe the signs and symptoms that would indicate that Hannah’s asthma is progressing in severity Develop an asthma action plan that provides guidance for daily management as well as managing asthma symptoms to
2. Identify information about the family’s lifestyle and home environment that could be potential triggers for Hannah’s asthma.
3. Develop an asthma education plan that corresponds to Hannah’s stage of development, and identify appropriate self-care responsibilities to begin teaching her
4. Describe the essential elements of an individualized health plan for Hannah and the actions that must be taken to have one developed in collaboration with the school nurse.
3. An 8-year-old
is diagnosed with viral pneumonia and sent home from the clinic without an antibiotic prescription. The symptoms worsen, and the child returns to the clinic a week later with signs of a higher fever listlessness, and a harsh, productive cough. The child’s mother states, “I knew a prescription for antibiotics was needed.” Which indicates the nurse’s most appropriate response?
1. “It is better to wait to make sure so we don’t use antibiotics unnecessarily This approach also saves healthcare dollars.”
2. “Sometimes we just do not know. I’m glad you came back in.”
Acknowledgments
It is both challenging and a significant responsibility to write a pediatric textbook. Pediatric nursing is constantly changing due to new knowledge and technologies. It is inspiring to observe this evolution of pediatric nursing practice and to have the opportunity to share with nursing students much of our enthusiasm for working with children and their families. We appreciate the opportunity to contribute to the education of a new generation of nurses.
This edition of the textbook used the strong foundation of the first edition and integrated some new features. The production of a textbook requires a team that is fully committed to the vision from the beginning of the revision through the final production process. We were fortunate to have a close collaborative relationship with our publishing company, Pearson. Kim Norbuta, our nursing editor, infused new ideas and approaches into the textbook and accompanying learning aids. We are excited about the coming application of simulations as methods of expanding understanding of pediatric nursing for the student. Julie Alexander, vice president and publisher, has once again enthusiastically supported this venture on behalf of Pearson.
Our developmental editor, Kim Wyatt, has worked with us for several books; she is a cheerleader and a friend, and she has an exquisite eye for detail. She worked side by side with a new editor, Mary Cook, to ensure the quality and timeliness of the present edition. Mary was essential in cultivating our relationship with reviewers— her pleasant and competent manner was outstanding. We thank Maria Reyes, production editor; Patrick Walsh, production managing editor; and editorial assistant Erin Rafferty, for their expertise and valuable contributions. Our thanks also go to Mary Siener for
the textbook design. At S4Carlisle Publishing Services, we thank Lynn Steines for coordinating production, and Joan Lyon for her copyediting skills.
George Dodson took many of the photos in this book. We sincerely thank the children, families, and nurses who allowed us to illustrate development, pediatric healthcare conditions, and nursing care of children in hospital, home, and community settings.
One chapter in the book was written by an expert in a specialized field. We particularly thank Linda Ward for her contributions on genetics and genomics. She is a participant in the National Institutes of Health Summer Genetics Institute and a researcher in education of nurses on these important topics, and we could have no better contributor. We would also like to acknowledge the academic- and clinical-based pediatric nurses who served as reviewers and consultants. Their valuable feedback enabled us to more appropriately focus our chapters for today’s student nurses and the practice of pediatric nursing.
This book emphasizes partnering with families to provide comprehensive care for children. Our own families are also critically important to our lives. Without them we could not reach our own personal and professional goals, and we depend on them every day for support, love, and caring. We thank them for their enduring partnerships and contributions that made this book a reality.
Jane W. Ball
Ruth C. Bindler
Kay J. Cowen
UNIT I
Nurses, Children, and Families 1
Chapter 1
Child Health Nursing: Concepts, Roles, and Issues 2
Overview of Pediatric Health Care 3
Role of the Nurse in the Care of Children 3
Direct Care Provider 3
Patient Educator 5
Patient Advocacy 6
Case Manager 6
Research 6
History of Child Health Care 7
The Beginnings of Child Health Nursing 7
Historic Legislation 8
Other Advances in Child Health Care 8
Nursing Process in Pediatric Care 9
Clinical Reasoning 9
Evidence-Based Practice 9
Assessing Quality of Health Care 10
Contemporary Climate for Pediatric Nursing Care 11
Partnering with Families:
Family-Centered Care 11
Culturally Competent Care 11
Pediatric Health Statistics 12
Infant Mortality 12, Child Mortality 13
Healthy People 2020 14
Morbidity and Hospitalization 14
Healthcare Financing 14
Health Benefits 15
Healthcare Technology 16
Legal and Ethical Concepts and Responsibilities 16
Informed Consent 19, Child Participation in Healthcare Decisions 20, Child’s Rights Versus Parents’ Rights 20, Confidentiality 21, Patient
Self-Determination Act 21
Ethical Concepts and Issues 22
Withholding or Withdrawing Medical Treatment 22, Genetic Testing of Children 23, Organ Transplantation Issues 23
Partnering with Children and Their Families 24
Chapter 2
Family-Centered Care: Theory and Application 28
Family Roles 29
Family-Centered Care 29
History of Family-Centered Care 29
Promoting Family-Centered Care 30
Family Composition 32
Nuclear Family 32
Blended or Reconstituted Family 32
Extended Family 33
Single-Parent Family 33
Binuclear Family 33
Heterosexual Cohabiting Family 34
Gay and Lesbian Family 34
Family Functioning 34
Transition to Parenthood 34
Parental Influences on the Child 35
Family Size 35
Sibling Relationships 35
Parenting 35
Authoritarian Parents 36
Authoritative Parents 36
Permissive Parents 36
Indifferent Parents 36
Parent Adaptability 36
Assessing Parenting Styles 37
Discipline and Limit Setting 38
Special Family Considerations 39
Divorce and Its Effects on Children 39
Stepparenting 39
Foster Care 40
Foster Parenting 41
Health Status of Foster Children 41
Transition to Permanent Placement 41
Adoption 42
Legal Aspects of Adoption 42
Preparation for Adoption 42
International Adoptions 43
Family Theories 43
Family Development Theory 44
Family Systems Theory 44
Family Stress Theory 45
Family Assessment 45
Family Stressors 45
Family Strengths 45
Collecting Data for Family Assessment 46
Family Assessment Tools 46
Genogram 47, Family Ecomap 47, Family APGAR 47, Home Observation for Measurement of the Environment 47, Friedman Family Assessment Model 48, Calgary Family Assessment Model 48
Family Support Services 50
Nursing Management 50
Chapter 3
Cultural Influences 55
Culture—Definitions and Basic Concepts 56
Culture and Nurse Theorists 56
Application of Cultural Theories 58
Definitions Related to Culture 58
Demographics and Cultural Diversity in the United States 59
Cultural Competence in Nursing 59
Health Care and Culture 60
Disparities in Health and Barriers to Health Care 60
Access and Barriers 60, Biological Differences 62, Environmental Differences 63
Cultural Practices That Influence Health Care 63
Family Roles and Organization 63, Communication 64, Time Orientation 65, Nutrition 66
Health Beliefs, Approaches, and Practices 66
Health Beliefs 66, Health Approaches and Practices 67
Nursing Management 71
UNIT II
Child Concepts and Application 77
Chapter 4
Genetic and Genomic Influences 78
Partnering with Families: Meeting the Standard of Genetic Nursing Care Delivery 79
Impact of Genetic Advances on Health Promotion and Health Maintenance 80
Genetic Basics 82
Cell Division 82
Chromosomal Alterations 83
Alterations in Chromosome Number 84, Structural Chromosomal Alterations 84
Genes 85
Distribution and Function of Genes 86, Mitochondrial Genes 86, Gene Alterations and Disease 86, Gene Alterations That Decrease Risk of Disease 87, Genetic Variation: Single Nucleotide Polymorphisms and Copy Number Variants 88
Principles of Inheritance 88
Mendelian Pattern of Inheritance 88
Dominant Versus Recessive Disorders 88, Autosomal Dominant 88, Autosomal Recessive 89, X-Linked 89, X Inactivation 91, Y-Linked Disorders 91
Variability in Classic Mendelian Patterns of Inheritance 91
Theoretic Framework 117, Levels or Systems 117, Nursing Application 119
Temperament Theory 119
Theoretic Framework 119, Nursing
Application 120
Resiliency Theory 120
Theoretic Framework 120, Nursing Application 121
Influences on Development 121
Growth and Development by Age Group 122
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The Historical Element in Geographical Science.
While so many a spot in the great continental land-mass was once the home of a high culture, and from being a cradle of arts and sciences has become a deserted waste, the civil and political condition of many people in the remote districts on the oceanic side of the globe has advanced with unprecedented rapidity. The course of development has been very different from what it was formerly. Distances, natural influences, natural productions even, yield always to the victorious march of man, and disappear before his tread; or, in other words, the human race is more and more freed from the forces of nature; man is more and more disenthralled from the dominion of the earth which he inhabits. The history of specific districts and of entire continents confirms this.
The first inhabitant of the sandy valley of the Nile was a dweller in a waste, as the nomadic Arab is to-day. But the later and more cultivated Egyptians transformed that waste, through the agency of irrigation and canals, into the most fruitful garden of the world. They not only rose themselves, but raised their own country, hitherto so sterile, into a place of the first importance, and did it by the simplest of means,—the bringing the water and the land into more intimate relations. Through neglect and the tyranny of successive kings, the fruitful valley sank again into its waste condition. The district around Thebes became a desert, the fruitful Mareotis a swamp; similar phenomena occurred in many parts of Europe and Asia.
Another example of man’s subjugation of nature is found in great mountain chains. During the first centuries after Christ, the cultivated south of Europe was separated from the uncultivated Celtic and Teutonic north by a great natural barrier, the unbroken, untraversed Alpine chain, which passed through all central Europe from west to east. At the south lay the rich states of the old world, beyond the Alps was the cold and barren north. But this old formidable barrier has vanished, as the thronged cantons of
Switzerland and the crowded villages of the Tyrol yearly bear witness; and they draw thousands of tourists instead of repelling them. What a mighty change! From Provence to Styria run the stately forms of the Alpine chain; but the deep recesses and the lofty highlands are thickly peopled, the forests are thinned, the obstructing rocks removed. No longer a barrier between the north and the south, as it was in the time of Julius and Augustus Cæsar, Switzerland has become a country of stupendous highways. The peaks which were once unapproachable, and around which merely eagles idly flew, are now the passes of Mount Cenis, the Simplon, Saint Gothard, the Splügen, and Saint Bernard; while the snowy heights of Ortler, in eastern Alps, now give place to a public road. Over the Semmering Alp a railway even passes. Just as the wild horse of Toorkistan has given up his freedom and has become the tame and useful servant of civilization, so this Alpine segment of the globe has changed all its relations to the adjacent countries. The influence of the most stupendous natural objects is weakened every year. The physical dimensions may and do remain unchanged, but their influence on life and on history is undermined by those new conditions which operate so powerfully in freeing man from the dominion of nature. The power of man makes him master of the earth, and gives even the key to the subjection of the grandest mountain chains into his hands.
In further illustration of this, take the Ural chain, which was and still is the eastern division line of one continent, and the western barrier of another, but which has become, since the days of Peter the Great, a grand center of labor and commerce, a great avenue of civilization in its return passage from Europe to Asia. And so everywhere, from the wild Caucasus and the Himalayas to the grand Cordilleras of America, the same progress is seen; man becomes more and more the conqueror over nature. And not in mountains alone, but in the great forest regions of central Europe, in the primitive wilderness of North America, and in the marshes of the Netherlands, does man vanquish the forces which once fettered him. The once fearful wastes of Sahara have become the track of
caravans; the sterile plains of Australia and California have drawn great colonies to their gold mines; the ice seas at the north have become, through the efforts of Parry, Franklin, and others, the scene of heroic exploits and of grand struggles of man with nature; indeed, the greatest victories of modern civilization have been there, and the playgrounds of polar bears and walruses have witnessed the noblest humanities, and the loftiest courage, and the most disinterested heroism of the age.
The continents and oceans have witnessed still greater transformations. The seas were once the impassable barriers of nations. The birds of the air only traversed the great distances which separated shore from shore. The metallic stores of the earth, the vegetable and animal kingdoms were not transferred to any extent from place to place; the sea brought nothing from lands remotely foreign but drift-sand, cocoa-nuts, floating wood, ice masses, and seaweed, swept by the great currents from shore to shore. But now the seas are no barriers; they do not separate the continents but bind them together, and unite the destinies of nations in the closest manner. The great improvements in ocean navigation have entirely changed the relations of the entire globe. The isolated island of St. Helena, which was for centuries at the very confines of the known world, became, within the second decade of the present century, a prison-house for the great European robber, and lay guarded under the eye of Europe. The Cape of Good Hope, which was for centuries the limit of Portuguese navigation, has become a mere halting-place for sailing ships and steamers. The voyage from England to China has been narrowed, within one hundred years, from an eight months’ to a four months’ sail. These great changes have been mainly effected by the agency of steam. Steam has transformed the smaller seas into mere bridges, and England and France are securely joined, Marseilles and Algiers; while Prussian Stettin is brought into proximity with Swedish Stockholm and Russian Petersburg. The voyage to America, that remote land, which before the days of Columbus was as inaccessible as the moon, was made by him in seventy days, but is now accomplished in ten. Even Australia cannot
be said to be distant; a steamer needs but seventy-five days to reach it, and ten of those are consumed on the Isthmus of Suez. No island now lies beyond the world of commerce. The most active traffic exists between places the most remote. The wool and the wheat of Australia control the price of those commodities in London, and the value of cotton in America fixes that of woven goods and even of bread in Europe.
The great rivers too have been curtailed of their relative importance, and have been shortened by steam sixfold. They can be stemmed too, which is an immense gain, for in the primitive stages of navigation they could only be sailed upon downward, from source to mouth. In 1854, four hundred steamers traversed the Mississippi and its branches, and came into contact with a region one-third as large as Europe. The Indus, Ganges, Irrawaddy, Nile, La Plata, and even the Amazon, the monarch of rivers, which drains a country half as large as Europe, are now more or less open to steam navigation. The great river systems of central Europe too are thoroughly navigated; and Southern Germany, Trebizond, Mayence, Cologne, and London may be grouped as neighbors. The land-locked seas are reduced to insignificance, and their shores are now covered with villages and cities, from the Platten-See of Hungary up to the Caspian and the great lakes of North America.
To sum all up in one word, the mighty influence of Time on the geographical development of the earth is displayed in the clearest manner. But this influence is not the same for all localities on the globe. While there are some people and some places which are left behind, there are others which have made wonderful progress, and have taken and now hold a foremost place. And such a position is that of Europe at the present moment. Europe, the most central of all continents, in relation to the great land-mass of the earth, and also the one most equally removed from the middle point of the great water-mass, touches the whole remaining world at the greatest number of points, and this, in conjunction with her remarkably broken coast-line, so favorable to the purposes of
navigation, have given her her place of command, and have assigned to England her evident role of mistress of the seas.
And looking from the present to the past, we see that as some great tribes of men have given the whole fruits of their natural existence to the world for its future use, so some places, and those of no insignificant size sometimes, have conferred upon the world, the trust which they once held, and now recede, as it were, from view. They were great in the past, and the results of their greatness are now incorporated in the world’s life. The earth is one; and through the agency of what we may call either time or history, all its parts are in ceaseless action and reaction on each other. Though some great districts seem now to have no part to play, the element of time draws them into the great cosmos; they once had a great share in the world’s affairs, and the fruits which they brought to completion are merely in other hands. The earth is, therefore, as was stated in the introduction, a unit, an organism of itself: it has its own law of development, its own cosmical life; it can be studied in no one of its parts and at no special epoch of its history. The past and the future, the near and the remote, are all blended in a system of mutual interdependence, and must be looked at together.
This is shown clearly in the past of Asia, and the present of Europe and some parts of the new world, while the history of all central Africa seems to lie wholly in the future. Heretofore it has enjoyed no progress excepting along its northern rim. The middle portion of the old world has outlived its primitive ethnographical impulse, and sunk back into a state of slumberous inaction. Asia, to call this region by its recognized name, has projected its own life from the center to the circumference; by this I mean, that while it seems to be exhausted of its old vigor, other countries inherited its power. The population of Asia is much less than it was in the time of Alexander the Great, much less than during the Mohammedan and Mongolian conquests, when all the habitable parts of that immense continent were bound together by highways of commerce and travel. On the other hand, the coasts are now of much more value and significance than they were in ancient times, and navigation has
dotted her sea outline with splendid and populous cities. These seem, by reason of the facilities which steam affords, to be brought near to Europe; while the natives who inhabit central Asia are not only widely separated from the civilized world, but are divided up and set against each other by religious and political enmities of the most bitter kind. This is displayed in its fullest force by the comparative inapproachability of the great mountain chains, the Ural, the Taurus, and the Caucasus, and yet more by the unchanged barbarism of the central tribes, the hostile political relations, lacking all of the amenities and mutual dependencies of European policy, and the deadly antagonism of Mohammedanism and Christianity. This last is the curse which the natives of the earth have brought upon themselves. It is the clashing of religious faiths which has put the extinguisher on Asiatic progress, annihilated her enterprise, and set her in her present isolation. Still this barrier is not absolutely settled and for all time, but already it shows that it is capable of some modification. The politico-religious system of the Chinese is rending under our eyes; the old bonds which Mohammedanism once laid on Asia are now sensibly relaxed. The great highways of travel through the country of the Euphrates and Tigris and the extended archæological investigations of modern times have operated mediatorially between Europe and Asia; while steam navigation on the Danube has brought Turkey, a hitherto undissolved Asiatic element in European life, into closer relations with the great powers of the West. The great missionary enterprise, too, of modern times, has been laboring to remould the ideas of the Asiatic nations, while navigation has operated on the material and more appreciable interests of commerce and industry.
There are no possible limits to be assigned to the perfectibility of the globe as the abode of man; no possible bounds to his enterprise. The construction of a canal through the Isthmus of Panama would bring the eastern coast of Asia seven thousand miles nearer than it is now to the Atlantic shores of America and Europe. By saving the mere doubling of Cape Horn, one-third of the periphery of the globe would be annihilated, so far as the labor and expense of navigation
are concerned. North America would nearly double its resources when its Atlantic and Pacific coasts stand in close connection and interdependence. The projected canal at Suez would exercise an unbounded influence over Asia in binding it anew to Europe. The building of highways through the passes of the Ural, the Caucasus, and Himalayas is yet to be accomplished; and only now are great roads constructing over the Rocky Mountains, welding North America together. The construction of railways on the high plateaus of central Africa will transform that vast undeveloped district, so rich in resources for the future. The changes which art is yet to effect on our globe are beyond all possible computation, and it might be said, beyond any possible exaggeration.
We turn away from these glances into the future to look upon the past, the long ages when men lived in rudeness and ignorance, having no art, and knowing nothing beyond the little tract where they were born, and to which they remained chained. There was no binding of shore to shore, and of continent to continent, through the mediatorial agency of seas and oceans. And this gave to the continents a far greater individuality than they have now, and a much higher degree of apparent influence than now when we cannot view them excepting as parts of the great complex which forms the world. The wanderings of the old nomadic races, the enlarging of the domains of culture, the transfer of the natural productions of all climes, as well as the traditional ideas of all lands, proceeded from the central portions of the ancient world toward the extremities. The manner of this progress, following as it does the order of history, displays more clearly than almost anything else the close dependence of all national development upon geographical conditions, and their indissoluble connection. Without this connection the order of historical events would have been completely changed. In no instance has there been self-evolved progress in the North, East, South, or West; it uniformly began at the geographical center, at the point of conflict between the Orient, the Occident, and the tropical South.
Western Asia, northern Africa, and southeastern Europe were the homes of the earliest culture, and it is to them that all other parts of the world owe the light which they enjoy, though they may have received it at second or third hand. The territory of which I speak extended from the highlands of India to Italy, and from the Nile to the Don, including the valleys of the Euphrates and the Gihon. This broad and fertile reach of territory has been the fruitful mother of the world’s present thought and culture. Nor must we overlook the fact that, despite what was said above, regarding the oceans as the greatest barriers to the spread of civilization, that smaller seas aided it, for the very country of which I speak was intersected by five important seas, and to them it is under immeasurable obligations for its development. This Asiatic-Africo-European belt has exercised the greatest influence on all the course of human affairs, on all colonization, on the differing of races and languages, and the arts of war and of peace, over the habitable world. This territory lies as the background of all the events of history, and has given to every one its distinctive character and its appropriate place. Nor can we in the future dispense with the element involved in this, of historical occurrences yet to come dependent on past geographical conditions, although this will be far less marked than it has been in the past. It demands and will demand a far larger measure of investigation and thought than it has yet received. Whatever independent progress the New World and Australia may seem to be making, and whatever interest they may awaken in the minds of students, not even they can be looked at without regard to their relations to the ancient historical lands, the source of all the inherited culture which they are enjoying in their vigorous youth. India, Egypt, Palestine, Greece, and other countries still stand out as the formative lands of all modern history, and we cannot study the present without studying them. They are to the student what Plutarch’s Lives are to the biographer, the imperishable and unequaled models which gain new luster as time rolls on. It is therefore not without reason that ancient geography ought to be subjected to a more systematic treatment than the geography of the Middle Ages. The latter, though not unworthy of a large place, had no relations of special importance to
the whole world, to the study of the physical conditions of the most imposing objects of nature, to the connection as cause and effect of events past, present, and to come.
From these foundation principles, we advance to a more full study of the configuration of the surface of the globe, for which we are now in a measure prepared.
PART II.
A more extended Investigation regarding the Earth’s Surface.
It is the province of Hydrography to deal with the oceanic world; Geography proper concerns itself simply with solid forms. The Hydrography of the globe we must pass over, however. Aside from the fact that it would lead us into studies of the most protracted nature, it forms strictly one department of nautical science. Besides, there is the less occasion to speak of it here at length, that works of great excellence have been published, relating to that branch. We turn therefore to the land, and shall study the world of waters only so far as it exerts influence on the land.
By land we mean the islands as well as the continents, for, as remarked before, the difference between them is merely relative. To the land division of the globe, however, belong all rivers and the internal fresh water lakes, however large. The basis of difference does not lie in the fact that one part of the globe is water, the other part land, but in the fact that one is a tract of uniform evenness, the other of constantly varying surface, the internal rivers and lakes only being frills, so to speak, to the elevated region, and not sharing the sea level of the great oceanic mass. Uniformity of surface is then the chief characteristic of the sea; a lack of it, of the land. A mathematical level is a thing unknown on extended districts, and an approximation to it is very rare. Even the basins of former seas do not display a perfectly level bed. The plains of North Germany are characterized by this billowy rolling. The flats along the Danube, in Hungary, and along the Po, in North Italy, have really important deviations from a true level, though the eye is not able to discern them. Milan is four hundred feet above the Adriatic; but the eye
does not discern that it is not at the center of a plain as perfect as the surface of the sea itself, and yet that plain does shelve gradually away till the Adriatic checks and defines it. Pesth is two hundred and fifteen feet above the ocean level, yet the gradual decline to the Black Sea is undiscernible to the eye. The immense plains along the Amazon, even the celebrated llanos on the Orinoco, which Alexander von Humboldt likens to inland seas of verdure, have a not insignificant slope from west to east. The middle point of these llanos near the City of Calabozo, about 100 geographical miles from the sea, he found to be 180 feet above the sea level; far lower indeed than Milan or Pesth, relatively, yet at a perceptible elevation. All of these plains were once the bottom of the sea; the Adriatic laved the base of the Apennines and the Cottian Alps, and the Atlantic swept westward over the llanos of the Orinoco and the Essequibo, having the Sierra de Venezuela on the north and the Sierra Parima on the south, till it was checked by the Cordilleras of Merida and Pamplona.
Depression and elevation, then, are the characteristics of the land. They are both measured from the level of the sea; their absolute altitude is reckoned from the imaginary sea level, extended over the whole globe. Their mutual relations to each other are determined from their relative heights. The absolute elevation above the level of the ocean can be determined in a number of ways. If the heights to be measured are in the immediate vicinity of the sea, a simple system of triangulation will effect it. If they are removed from the sea, the difficulties are greater, and increase according to the distance from the sea. The heights of great inland mountains are determined by complicated operations with the spirit-level, protracted trigonometrical calculations, the unwearied and skillful use of the barometer, and constant appeal to the boiling point of water. The description of these methods falls within the province of Physics.
As the determination of the heights of the loftiest mountains could not be made before the appointments of scientific explorers have attained to a certain degree of accuracy and delicacy, the knowledge
of them in former times was almost wholly relative. The inquiries of La Condamine, Saussure, and de Luc, in the Andes and the Swiss Alps, are almost the only ones to be trusted among those of the older observers. All unscientific travelers without accurate instruments confounded absolute heights with relative heights, and innumerable errors crept therefore into the earlier text-books. It is only within the most recent times that Hypsometry has attained to the dignity of a science.
To meet and counteract the errors alluded to above, and current in the loose language of popular speech, we shall use a new and indeed arbitrary terminology,—arbitrary because the data which mensuration will sometimes furnish are now, in part, wanting. We will divide the earth not relatively, but absolutely, into highlands and lowlands. The great districts often met, whose elevations are very moderate, we call lowlands. They are, for the most part, immense plains, varied but little above the level of the sea. The great districts which inclose mountain ranges we call highlands, and sometimes plateaus. True highlands can often embrace very extended and elevated plains, and these plains again may include hills and mountains. This does not affect their character as highlands, which lies in the fact of elevation rather than in more or less modified variation of surface. There may be vast variety in the physical manifestations of a great plateau district, entirely independent of the relative effects produced by the distribution of its surface into plains, rolling land, hills, and mountains.
In the lowlands there may exist hills to some extent, and these may even be combined in ranges, provided only that they do not violate the uniform characteristics of the district in which they are found.
The highlands are generally met with in the interior of the continents; the lowlands at the coasts. Yet there are exceptions to this.
In the transitions from lowlands to highlands there is great diversity. We can speak of three distinct bases of discrimination: a
sudden and abrupt ascent; a rise in elevation so gradual as scarcely to be perceived; and a terrace formation. Yet in these there is a blending of one variety with another; there is no place sharply marked, where we can say that one form ends and another begins. There are constantly found modifications of these three transitional phases. The plains along the Indus and the Ganges rise sharply to the plateaus of Thibet The flat Pacific coast of South America is exchanged with equal abruptness for the highlands of Peru. The transition is a gradual one from the lowlands of North Germany, along the Baltic and the North Sea, through Saxony and Bohemia to the Bavarian highlands, north of the Alps. The Spanish highlands form a series of terraces, increasing in height from south to north. The immense plateaus of central Asia are also terrace formations, of diminishing elevation, as they advance to Siberia; so, too, are the eastern plateaus of Peru, falling off in altitude toward the plains of the Amazon.
Just as varied are the heights taken from the sea level of the leading plateaus. Yet they never rise to a point of elevation comparable with those of isolated mountain peaks or ranges. These attain, in no insignificant numbers, the height of 24,000 feet, while some ascend thousands of feet beyond that. In Mount Everest, of the Himalaya chain, the loftiest summit yet measured (29,000 feet) is found; although it may be that future investigations more to the south will disclose yet greater heights.
Highlands.
Continuous highlands or plateaus seldom attain an elevation greater than a half or a third of the loftiest mountains; the most elevated range in altitude, from 8000 to 12,000 feet above the sea level. On an average, they lie about 4000 to 5000 feet above the sea. We take the last height as a convenient point of demarkation between the two classes of highlands—those of the first and those of the second magnitude. It is an arbitrary point, of course, and the division there must remain, without a natural base to rest upon, till
more results in Hypsometry shall have determined the real point of average between the combined lowlands and the combined highlands of the earth’s surface. Meantime this division will be of great service to us in enabling us to bring into a definite and appreciable classification many facts which would otherwise not be so well understood in their relations.
Highlands or Plateaus ofthe FirstClass.
By plateaus of the first class, we mean those high, continuous plains which lie at the elevation of more than from 4000 to 5000 feet above the sea level. The extreme height to which such plateaus rise is a fact yet to be ascertained. At an elevation of from 4000 to 5000 feet the highlands of the first class merge into those of the second. The point of transition is, of course, very difficult to fix with precision.
The high plateaus of Asia rise more than 14,000 feet. They inclose the head-waters of the Ganges and the Indus. All central Asia is a vast congeries of highlands; but, as a body, they by no means belong to the most elevated of the globe. They are colossal in their length and breadth, but not in their uniform altitude. In the latter respect, they are far more varied than is generally supposed.
The plateau of Thibet attains, in its whole great extent of 1800 miles in length and 500 miles in breadth, an average elevation of 10,800 feet above the sea level. In some cases it rises, of course, much higher, as, near the holy lake Manasarowar, for instance, where it is 14,000 feet above the sea. Others sink, as at Ladakh, in Little Thibet, to an altitude of about 9000 feet; so, too, Gertope, in the region remarkable for its goats and the rich shawls manufactured there, and Shiffke, are about 9804 feet above the sea. The plateau of Great Thibet, east of Lassa, the capital, and north of the Upper Brahmapootra or Yam-Dzangbotscha, is 9000 feet in elevation. There are also districts filled with mountain groups of great heights, but where the depressions sink to the level of the
valleys of the Indus, Sutlej, Brahmapootra, as low indeed as 5460 feet, as at Cashmere, so that there is no lack of diversity in the great plateau of Thibet.
The plateau of Mongolia, or more exactly the desert of Gobi, can be ranked only on its lower edges, where it touches the Chinese frontier, as of the first class, although in extent it is twice as large as the great plateau of Thibet. Only near the north bend of the HoangHo and near Peking does it reach an altitude of 8000 feet, and gradually sinks away as it advances toward the northern frontier of the Chinese territory, to 5100 feet, and farther north to 4000 feet; in the middle portions of the great table-land it is depressed to a height of 2400 to 3600 feet; it rises again at the head-waters of the Orkhon and the Toola to an elevation of 4620 feet, and falls off in terraces toward Kiakhta, near the northern boundary, where it is 1330 feet high, Selenghinsk, on the Selenga, where it is 1632 feet high, and Berch-Udaisk, where it is 1458 feet high, till it reaches Lake Baikal, 1332 feet above the sea level according to Humboldt, though Erman makes it greater.
Western Mongolia, (west of the meridian of Lassa, and west of the point where the Tarine flows into Lake Lop,) upper Bokhara, and upper Toorkistan were formerly considered to be a highland district; this is now subject to doubt. We shall discuss this further on.
Africa, too, has highlands of the first class, which, however, do not rise to the extreme height of the plateau of Thibet. As in Asia, so in central Africa, the old supposition of the existence of a plateau of colossal extent has been very much done away with by the more exact and critical modern investigations. The strip of territory lying between 4° and 10° north latitude has been demonstrated by Barth and Vogel to be destitute of highlands. The range of mountains announced as discovered by Mungo Park, and called the Kong Mountains, is proved to have no real existence, and of course his statement fails of verification that that range is the northern limit of an elevated central plateau. The peaks which really do rise in the Kong territory form no continuous ridge; they are mere isolated
groups of moderate height. Between these groups the lowlands continue toward the south, in an unbroken level, for an immense distance. How far south of the equator the central African plateau begins, is yet unascertained, for the snow-tipped peaks of Kilimandjaro and Kenia, discovered by Rebmann and Krapf, in the parallel of Mombas, 1° to 3° south latitude, are of immense height, it is true, but they do not demonstrate the existence of a plateau of the first class there. They rise out of table-land about 2000 feet above the sea level, which Krapf explored in the year 1849.
The Abyssinian plateau, on the contrary, takes rank among the most elevated on the globe. At 10° north latitude, south of the sources of the Blue Nile, lies Upper Abyssinia, or the kingdom of Shoa, with its capitals, Ankobar and Angolalla, 10,000 feet above the sea. Still farther to the north, in the ancient kingdom of Gondar, the German naturalist Rüppel ascertained the level of Lake Tzana to be 7000 feet above the ocean; to the southward of that the land rises to a still greater height, and northward of Gondar the plateau ascends to an elevation of 8000 feet, and mountains are met with 14,000 feet high. The terrace of Axaw on the east is 6650 feet above the Red Sea, which lies along its border.
To the south of Shoa lie the highlands of Kaffa and Enarea. All travelers agree in the statement that the inhabitants of that region are light-complexioned; and Johnson draws from this the conclusion that the central plateau must rise to a height of over 10,000 feet to harbor people of a whiter hue than the dwellers of the less elevated localities. He saw a number of men of light complexion who came as far as from the fifth degree south latitude, not from mountain homes, but from high table-lands.
The plateau of South Africa rises at Lattakoo, in the country of the Bechuanas, north of the Orange River, to the height of 6000 feet. To the east, near the Snow Mountains, where the river has its source, it ascends to an altitude of over 10,000 feet. To the north, discovery had made great progress since 1849. There, on a broad plateau, Oswell and Livingstone brought to the knowledge of the world the
existence of Lake Ngami, whose surface is 2825 feet above the level of the sea. The plateau which includes this lake at its place of deepest depression cannot be less than 3000 feet high, and at some localities yet higher. Still more to the north, at latitude 14° south, on the water-shed between the Zaire or Congo on the west and the Zambeze in the east, the plateau reaches an elevation of 5000 feet, according to Livingstone. Yet farther to the west, it rises still higher and takes undisputed rank among plateaus of the first class. There, at 18° south latitude, Galtne, on his journey of discovery in 1850, ascended the table-land of Ovompâ, a region of great natural productivity. On the way thither, going from south to north, at 21° south latitude, and therefore in the parallel of Lake Ngami, but about 500 miles westward, he ascended north of the Swakop River, the table-land of Demara, which he found to be 6000 feet high. From that plateau mountains, Koniati and Ometako, for instance, rise to a height of 8800 feet. From the Swakop River to Lake Ngami there is a continuous plateau.
The high table-land of southern central Africa does not then extend, as was once supposed, as far north as 9° north latitude, nor even to the later limit of 4½° north latitude; but at about 4° 10′ the distinction between lowland and highland seems to be sharply drawn, as the cataracts which terminate the navigation of the White Nile indicate. Here Father Knoblecher turned back in 1849, but he ascended the first of the mountains which there began to rise; his eye reached onward to mountains very near or on the equator. He says that those high mountains stand upon an elevated table-land. Thus, here at the source of the White Nile we have a plateau seemingly of the first rank. From such a plateau it is probable that the snow-capped mountains, seen by Rebmann and Krapf in the neighborhood of the equator, rose, which they thought, approaching from the eastern coast, held the source of the Nile.
At the northwest of Africa, too, at 10° north latitude, the territory which feeds the springs of the Senegal and the Niger is supposed to be a plateau of great elevation and of great extent. But at present
our lack of knowledge prevents our attaining certainty regarding it. No thorough system of measurement has been yet applied there.
America possesses a number of plateaus of the first class. To the most prominent of these belong the ones which were first thoroughly studied by Alexander von Humboldt. It is to him that we owe our first accurate impressions of table-lands which, before his day, had been indiscriminately confounded with mountains, and had had no place assigned to them in the department of Geography. Doubtless, too, great prominence was given to plateaus at the outset; they were pushed into unseemly proportion to other matters as well worthy of investigation, but they have come into their true place, and now only wait the development of new facts regarding the size and height of some, to be properly understood and appreciated.
The measurements made in North, Central, and South America give the following results; much more complete, it may be remarked, than the results yet gained in Asia and Africa.
To the plateaus of the first class belong in America, at latitude 0°, the plain of Quito, almost 9000 feet above the sea, (Los Pastos in the north being near 11,000 feet,) and to the south, at 17° south latitude, the plateau of Upper Peru. Here the great Lake Yiticaca is found, 12,000 feet above the sea; eastward of the lake, the tableland rises yet higher, and at Alto de Toleda it is 14,000 feet in elevation, as high as the highest part of Thibet. At 20° south latitude, south of Lake Yiticaca, is the City of Potosi, whose streets are 12,822 feet above the Pacific.
In Central America is found, at 20° north latitude, the extended table-land of Mexico, 500 miles wide, rising to a height of 7000 feet, and farther to the north, in New Mexico, the plateau of Santa Fé, 35° north latitude east of the Rocky Mountains, and 7100 feet above the sea. The table-land on the west side of the mountains, and toward the Great Salt Lake, is undoubtedly just as elevated.
Europe and Australia are wanting in plateaus of the first rank, and in general the whole immense flat northern districts of the globe, though we are not yet quite familiar enough with the extreme north of America to speak with entire confidence regarding it.
Plateaus ofthe SecondClass.
Elevated plains which are at once continuous and bounded by a definite line of demarkation, and which do not attain an altitude of more than 4000 or 5000 feet, are considered plateaus of the second class. They are far more general over the whole earth than plateaus of the first class; in every one of the great divisions of the globe they appear in the utmost possible diversities of elevation, sometimes so gradually ascending that the lowest limit is hardly to be perceived. This makes it not only expedient but necessary to assign to plateaus a fixed though arbitrary system of classification, for without it we could attain to no thorough view of all their relations. This general system must afterward be confirmed and justified by protracted special investigations.
That not all the vast plains of Central Asia, from Thibet to the Altai Mountains, and from the Belur range to the Chinese Gobi, belong to the first class of plateaus, has been demonstrated by the Russian measurements, made by Fuss and Bunge in 1832, between Lake Baikal, Kiakhta, and Peking, and rendered highly probable by the investigations of Klaproth, Humboldt, and Zimmermann. Toward the northwest the plateaus generally sink from the moderate elevation of the Middle Gobi, 4000 feet, to Lake Baikal, 1332 feet above the sea, Lake Zaison, not 1000 feet above the sea, and the border of the plateau at Choimailocha, the Chinese frontier post on the Siberian line, 1000 feet above the sea, then to the lower border of the plateau of Bookhtarminsk (936 feet) and Semipalatinsk on the Irtish, (708 feet,) where the great Siberian plain begins. In the valley of the Tarim and of Lake Lop, pomegranates and grapes thrive, and cotton, which has been raised of an excellent quality in Eelee, is found at a height of from 1200 to 2000 feet. And in contrast with the great
arctic plain of Northern Asia, not 500 feet above the level of the sea, this central plateau will take its place as distinctively of the second rank.
The plateau of Persia lies on the border of both classes; for while the central portion touches 4000 feet, some parts rise much higher and some sink much deeper than the normal point. These balance each other, and the average is about the maximum elevation of plateaus of the second degree.
East of the Persian plateau lies the plateau of Cabool, 6000 feet above the sea. On the northern edge of Afghanistan is the plateau of Bamain, 7500 feet in elevation. More to the south is the high plain of Candahar, being 3500 feet, and the City of Candahar, 3264 feet above the sea. The plateau of Kweltah west of the Bolan Pass is 5220 feet. Still farther to the south is the great plain of Beloochistan, 7000 feet, with the City of Kelat, 5418 feet above the sea.
In the central part of the eastern Persian plateau in ancient Gedrosia, Drangiana, and Parthia, and Lake Zareh, the depression is the lowest. At Lake Zareh the elevation is 2100 feet; at Herat, more to the north, 2628 feet. In West Persia, on the meridian of the Caspian Sea, it rises higher; on the northern edge at Teheran it is 3672 feet; at Schabred, southeast of Astrabad, it is 4000 feet; at Kasbin, west of Teheran, it is 4000 feet; and at Samegon, 5700 feet. The lowest depression at Com and Kashan is not 2000 feet above the sea. Toward the northwest Persia thrusts up a short arm into the adjoining territory of Armenia. This is the highland of Ayerbaijan, Zoroaster’s “Land of Fire.” This connecting plateau of 7000 feet elevation belongs to the first class. To the west of this the plateau of Armenia extends in varying range of elevation, from that of Lake Van, 5124 feet, to the plain of the Aras, (the ancient Araxes,) on which the double cone of Ararat rises to a height of 14,656 feet. But the table-land at the northern base of Ararat, the site of Erdschmiazin, is only 2860 feet high, Erivan a little higher, and Erdzeroune, on the plateau of the Taurus, the plain of the Upper Euphrates, 5730 feet.
The plateaus of Asia Minor embrace wide plains extending through the whole of the country, at an elevation toward the east, in ancient Lycaonia and Cappadocia, of 3000 feet, and sinking toward the west to 2000 feet.
To the plateaus of Armenia and Lycaonia, Strabo, whose home was there, and who carefully studied them, gave the expressive name of ὀροπέδια, i.e. mountain plains, a term which corresponds remarkably with our word plateau, but which, as Humboldt has remarked, was not of much use among the ancients. Strabo, however, directed attention also to the Oropedia of Sicily and India.
In India, Deccan displays similar formations, which rise gradually from south to north in Mysore, in Poonah of the Mahrattas, and in the table-land of Vindhya and Malwah, to 2000, 3000, and even 4000 feet. Deccan enjoys an admirable climate and the richest abundance of all natural productions. China too must have plateaus, for the Chinese word youen indicates very clearly a large elevated plain.
In Arabia the plateaus of the second class are largely found, and their height ascends from north to south, instead of from south to north as in Deccan. The Syrian Hauran is 2000 feet high, the plateau of Damascus 2200 feet, the plateau of Taif, above Mecca, 3000 feet, the plateau of Sapaa, in Southern Arabia, 4000 feet.
In North Africa that portion of the great Sahara which has heretofore been considered a low plain, lying between Tripoli and Lake Tchad, has been ascertained by the German explorers, Overweg and Vogel, to be a table-land of the second class, ranging in elevation from 1000 to 2000 feet. It begins at the Chorean plateau (2000 feet) in the south of Tripoli, and sinks to an elevation of 800 feet in the neighborhood of Lake Tchad. The average altitude is about 1500 feet. This moderate elevation of Sahara corresponds with the equally high plateau of Cyrenaica, 2000 feet.
The Atlas plateau, in the northwest of Africa, rises to a greater height—2000 to 3000 feet; the upper course of the Draa, near the
Sahara, being 3000 feet; the high, broad table-land on which Timbuctoo lies, according to Renon’s measurement, is 1500 to 1800 feet above the sea.
In south Africa the low, or rather the moderate plateau, which borders the district of the Bechuanas on the north, rises, as it advances toward the lower rim of Africa, at Cape Colony, to an altitude of 3000 feet.
America has many plateaus of the second range of elevation, but her highlands of the first class are so imposing in extent, as well as in elevation, that they have been more carefully observed than the table-lands of the second class.
Along the eastern slope of the Andes, on the same parallel with the great plains of the Orinoco, the Amazon, and the La Plata, these plateaus extend, touching the base of the mountains, and appearing rather as terraces, or vast plains of transition, from the highlands to the lowlands, than as independent forms. Where Alexander von Humboldt measured them, west of the low plains of the Amazon, he found their height, measured from the sea, to range from 1050 to 1200 feet; he describes them as having the appearance of vast plains, and as differing from the lowlands of the Amazon only in their greater elevation; their slope toward the narrowing of the Pongo de Mauseriche being too slight to be appreciable.
Between the threefold forks of the Northern Andes, Humboldt ascertained the heights of ten plateaus, extending as far as the plains of Orinoco, and called by the various names, according to their elevation Tierras templadas, or temperate districts, Tierras calientas, or warm districts, and Tierras frias, or cold districts— varying in height from 1800 to 6600 feet, the highest belonging clearly to the first class of plateaus.
The mountains of Brazil are interspersed among plateaus of the second class. The Brazilian mountains are not true ranges, but lie in groups, their height varying from 2700 to 5700 feet, and between
them are the vast elevated plains, called Campas, which are true plateaus of the second class.
The southern point of South America, south of the Rio Negro, as far as the Straits of Magellan, known as the plateau of Patagonia, is a true table-land of from 1200 to 1400 feet in height. It is composed of ragged strata of porphyry or of vast lava-masses, and has been explored by Captain Fitz Roy, in 1837, from the mouth of the Santa Cruz River to the snow-capped Andes in the west. The plateau diminishes gradually in elevation from west to east, till it touches the sea line.
In North America the broad plateau extending through Northern Texas and the Indian Territory, and lying on both sides of the Arkansas River, increases in elevation gradually from St. Louis, on the Mississippi, less than 500 feet above the sea, to Santa Fé, on the upper course of the Rio Bravo, 7000 feet above the sea. It ascends so slightly that the rise is imperceptible to the eye, the broad plains there taking the name of prairies. St. Louis is 420 feet in absolute elevation; the eastern Arkansas plateau 1500 to 3000 feet; the high western Arkansas table-land from 3000 to 7000 feet, where, at the point of greatest altitude, lies the City of Santa Fé, in the Territory of New Mexico, 7047 feet above the sea. This broad, sloping tract reaches out to a great extent at the north, crossing the Missouri, and embracing the colossal North American lakes. Lake Huron and Lake Michigan, about 578 feet deep, and Lake Superior, 627 feet deep, lie in vast hollows in that great continuous plateau, which extends into the British Possessions, rises again to 800 or 1000 feet in elevation, and is rocky and craggy, yet not enough so as to take the name of a mountain chain, but simply to form a clearly-marked water-shed, which Fremont and Nicollet have measured.
In Australia and Europe plateaus of the second grade of elevation are not wanting. In Australia, however, they are limited to the triangular district in the southeast, which has become the place of settlement for the chief English colonies, and which, bearing the
name of King’s Table-land, rises to a height of 2500 feet, and occupies the largest area of all the Australian table-lands.
In Europe this physical feature is displayed most distinctly in the Spanish plateaus, which occupy by far the largest proportion of the entire peninsula. Madrid lies on one of these plateaus, at a height of 2100 feet, five times as high as Paris, on the Seine, and as high as Innspruck, in the very heart of the Tyrol; Toledo, in the valley of the Tagus, is 1734 feet above the sea. The average elevation of New Castile, the central part of Spain, is 2000 feet. Old Castile, which borders it on the north, separated from it by the Guadarrama ridge, is about a thousand feet higher. Burgos, in the center, is 2700 feet above the sea; Segovia, to the south, 3100 feet. The average elevation of Old Castile is 3000 feet.
Then comes in natural order the Bavarian plateau, in southern Germany, ranging from 1500 to 1600 feet high, a broad table-land, on which lie Munich and Augsburg. It extends along the course of the Danube from west to east, from Lower Switzerland to Ratisbon.
According to the mean measurements of Humboldt, the lower plateau of Auvergne, in southern France, is 1040 feet in elevation; still less in altitude (840 feet) is the plateau of Burgundy and Lothringia, between the Vosges and the Ardennes. Limousin, Aveyron, la Forez, Monts, and Côte d’Or are plateaus.
The plateau of Lothringia, whose mean elevation is 648 feet, lies between the Rhine and the Moselle. The plateau of Luxemburg extends northward to the Eifel, where Prum lies, and to the Ardennes, where Malmedy, Eupen, Namur, Liege, and Aix-la-Chapelle lie.
In Middle Germany, a series of plateaus of the second grade begins in Upper Hesse, and extends eastward, crossed by mountains and valleys, traversing Upper Silesia and Galicia, and running along the northern side of the Carpathian Mountains to Podolia, on the Dnieper, thus embracing a strip extending through the larger part of central Europe.
A line of plateaus begins still farther to the north, at the low hills of Jutland, crossing Holstein, Mecklenberg, the whole southern edge of Pomerania, and extending to Lithuania and the Valdai Hills. It is characterized by a band of inland lakes, whose basins it incloses, and is crossed by the valleys of the Oder, Vistula, Niemen, and Duna. It has been called the Pomerania lake country. In the hollows where the lakes lie, (whose surfaces are, at the highest, not more than 300 feet above the sea,) and yet more in the depressions, where rivers break through, the level descends to as low a point as that of the great plain of Central Europe; but at other places it rises to an elevation as high as 500 feet, and so touches upon the limits of plateaus of the second range. Many parts of this broad upland may possibly be formed of shifting sand dunes which have been gradually piled up along the sea line. The plateau reaches its highest point at the eastern end, in the Valdai Hills, where it averages 1000 feet in elevation. The highest point is 1100 feet. East of the Volga, which rises at the eastern side of these hills, the plateau falls off by imperceptible steps, till it is lost in the great Russian plain.
In the peninsulas of Southern Europe, as in the Morea, (2000 feet,) and in the Crimea, (800 to 1200 feet,) the plateau again appears in not insignificant proportions.
The lower range of plateaus, it will be seen, is far more frequently met with through all parts of the earth than the higher, yet both combined occupy a larger share of the surface of the globe. We can designate them as sharply defined and broadly massive elevations, in contradistinction to the long, narrow, and broken masses which have received the name of mountain chains. The latter have too often been confounded with the former and have received from geographers a treatment disproportionately full in relation to their claims. The plateau has been until recently an almost forgotten geographical element. Humboldt restored it to its rightful place; by many hundreds of measurements he has accurately settled its form, its effect on climate, on isothermal lines, on agriculture, on the physical and moral life of nations, and even on the course of human history.
In closing this attempt at a general consideration of plateaus, I must confirm the reproach which Humboldt has cast upon most geographers of this day for their abuse of the word plateau. And I must at the same time admit that it is justly due to some parts of my own “Erdkunde,” where I have considered the plateau systems of Central Asia and Africa. When I wrote the pages of that work, thirty and more years ago, there were no scientific measurements then made of those regions, and the general ignorance led to a premature generalization, in which I used the ascertained features of the New World as probably in analogy with the unexplored center of the Old World. This use of really untrue analogies was carried by others to great lengths, and choratographers went so far as to depict the country according to the hypothesis of those who had written at first hand, and after using all the lights then existing, but who had never supposed that what they had indicated in general terms, would be afterward made so definite and real to the public eye. Those untrue statements of my own, I must leave however just as they are, and rejoice that the great advance of science has led to the accurate knowledge of the great plateaus of which the civilized world then knew but little. One word more: I set the lower limit of plateaus of the second grade at 500 feet, lower therefore than the great master in Physical Geography set his.
“Elevations of the soil,” says Humboldt, “which do not display a marked difference in climate and vegetation from the country around them, are not rightly called plateaus.” His meaning is, that the name does not relate to absolute height measured from the sea, but harmonious climatic relations existing between contiguous districts, one of which is more elevated than the other. Highland and lowland are therefore to him words of unfixed meaning, if they do not stand in the contrast of height, climate, relief, and rates of temperature. Humboldt therefore did not consider the depression of Central Asia, at the Taringol, as a plateau; and table-lands from 200 to 1200 feet in absolute elevation, i.e.from the sea level, are passed over by him as not worthy of the same name which he applied to the plains 6000 to 10,000 feet above the sea.
Dealing as I do with the elementary features and the physical contrasts of countries which for the most part are now thoroughly explored, I prefer, for the purpose of elucidating the subject of Physical Geography, to consider the plateau as beginning at 500 feet above the level of the sea. By comparing the plateaus of both hemispheres it is not difficult to deal with a variety of features, and to make a number of discriminations which, without an absolute standard, it would be impossible to make.
We pass to the consideration of the much more varied and more imposing characteristics of mountains.
Mountains and Mountain Lands.
Mountain lands cannot, in the strict use of language, be compared with plateaus, except in way of contrast, because they are not uniform, broad, and sharply defined tracts, but extend in a linear direction, having as their chief feature the longitudinal axis of the mountain chain. Groups of mountain ridges may be separated from each other, or may be united in any coherent way which does not make them continuous, and yet, despite the want of continuity, form a perfect whole.
Mountains, with their fissures, chasms, abysses, valleys, ravines, clefts, precipices,—in a word, their varied diversities of feature, broken through in every direction, the whole chain rent into fragments by these transverse breaks, are in direct contrast with plateaus. They have quite often a common range of elevation, which, measured from the sea level, is not unfrequently much greater than the districts lying at their base. Yet this relation is only incidental, it is not essential. There is no necessary connection between the height of the outlying plateau and the height of the mountain range. In Switzerland the mountains rise to the altitude of 13,000 or 14,000 feet; the country at the foot of the Alps is but 1000 to 2000 feet above the sea. Here the distance between the summit and the plateau at the base suggests no relation between them.
The distinctive characteristic of a mountain land is the height of isolated groups. Great differences of elevation within small distances characterize mountain regions; small differences within great distances characterize plateaus. The plateau depends upon uniform evenness of surface, or an approximation to it, over a large extent of territory. The mountain range is the exact opposite, the development of all kinds of extremes within a limited space, and the consequent individualization of the locality where it stands. Mountain lands cannot therefore be identified with the type of the highland and the plateau. The mountain chain has a character of its own, whether existing in unbroken unity, or subdivided into subordinate ranges, ridges, and spurs, and whether the summits are conical or sharply pointed,—whether also of moderate, medium, or loftiest elevation.
And high as mountains rise, their height is equivalenced by the depth of the depressions which form their valleys; the higher the mountain, the deeper the abyss which cleaves to the base. The immensely elevated peaks of the loftiest chains find their correspondence in the narrow ravines and the mountain lakes at the foot; the precipitous summits of the great American chain have their barrancos in the Andes and their cañons in the Rocky Mountains. The valleys are in natural contrast with the summits. They have just as little of the uniformity of lowland plains as the mountain tops have of the uniformity of elevated table-lands. They are infinite in variety, highly individualized, and always adapt themselves to the characteristics of the chain which conditions them. The mountain, too, has no uniformity in its character; it embraces within the smallest compass the production of all climes, and unites the characteristics of both highland and lowland. Mountain regions have therefore had a great influence in history and in the development of humanity, even greater than the more monotonous plateaus, which in general harbor nomadic races and give little encouragement to permanently settled people. For this reason the geographer cannot, like the geologist, classify high table-lands and mountains together; he cannot draw the same inferences from the plateau as from the mountain range; to the geographer the plateau is not a lower type
of mountain, but the two, in their relations to man and to history, suggest entirely different results and condition entirely different processes.
And yet it must be confessed that mountains do stand in intimate connection with plateaus of both classes, and that the transitions from the one form to the other are well worthy of study. Yet the present lack of correct measurements has made this little understood.
It is not the element of height alone which gives mountains their significance. There are many other features, which are little studied, yet of real import. It is, however, not a matter of indifference whether a chain thrusts up its peaks 1000, 5000, 10,000, or 20,000 feet, and the height has been made and will continue to be made a subject of careful investigation. In reference to height, we distinguish what, in a general sense, we call mountains,[3] into hills, mounts, and mountains of various degrees of magnitude. Yet the height of the highest range, in comparison with the diameter of the earth, is insignificant, only about ¹⁄₁₇₀₀, and the combined mass of mountains are of no more account in comparing them with the entire mass of the globe, than the roughnesses on the rind of an apple, or perhaps more exactly still, than those on the shell of an egg. The combined mountain systems in the world would not suffice, if transferred to the North and South Pole, to fill out the earth to such an extent that the polar and equatorial diameters would be equal.
In following out his profound scientific investigations, Alexander von Humboldt, in order to ascertain the center of the earth’s gravity, taking into account the existing elevations above the ocean level, was led to the conclusion that too great importance was formerly assigned to mountains in their relations not to the course of history, but to the earth as subject to mathematical laws. Very careful observations revealed the fact to him that all the mountains of France, if reduced to a level and spread out, would raise the grade of the whole country to a height not more than 816 feet above the
sea line. All the mountains of Europe, distributed in like manner, would raise the level to only about 630 feet. In Asia the same process would make the vast plain only 1080 feet high, in North America 702 feet, in South America only 1062 feet; while the mountains of the entire globe would raise the level to only 947 feet above the level of the sea. So insignificant are the combined mountain systems of the earth in respect to size, in comparison with the immense body on which they stand, though their importance is great when we regard their influence on the localities where they are found. Yet in this last regard, mountains deserve careful study, for they not only exercise and have exercised a great influence over nature and man, but they serve as our best key to open to our view the internal structure of the earth.
Some mountains, though of great height and broad base, like Etna, Vesuvius, Teneriffe, and many volcanoes, belong to no true mountain system; and even when they lie near together, and yet have no inner principle of unity, they are not spoken of as a chain or a range: they make merely a mountainous district. It is the repetition of the common type and the existence of a continuous valley which gives a right to use the names chain and range.
The linear extent and height of mountain ranges vary very much; no definite limits to these can be assigned. Yet there are few chains which are less than 25 miles long and 1500 feet high. Other features are necessary in order to determine the strict application of the word chain or range; one is a ridge-like or comb-like aspect; (that it should be a water-shed is not essential, although very common;) another feature is that the rock composing it should be of the same geological formation. Sand dunes, although occurring in regular and ridge-like uniformity, like those in Holland, and looking from a distance like a mountain chain, are not to be reckoned as mountain chains, though like the tells on the Syrian steppes and dunes in the Netherlands and along the Baltic coast, they sometimes rise to the height of a thousand feet. In South Germany and in the neighborhood of lofty mountains, such elevations are called mere hills; at the north foot of the Alps, yet greater heights are almost
