Transcript Child Health Nursing Partnering with Children & Families

Child Health
Nursing
Partnering with
Children & Families
Jane W. Ball
Ruth C. Bindler
Chapter 31
Alterations in
Genitourinary Function
Child Health Nursing: Partnering with Children & Families
By Jane W. Ball and Ruth C. Bindler
© 2006 Pearson Education, Inc.
Pearson Prentice Hall
Upper Saddle River, NJ 07458
Urinary System
• Maintains balance
• Removal of waste products
• Functionally immature until puberty
Urinary System
• Functions:
– Excrete wastes
– Maintain acid-base and fluid and
electrolyte balance
– Regulation of Blood pressure
– Stimulation of production of
erythropoietin
– Regulation of calcium metabolism
• By activation of vitamin D
Review of Urinary A&P
• The key structures of the urinary sx are
the Kidneys and the Urinary Tract
• To produce urine, the various parts of the
kidney perform 3 basic functions
– Glomerular filtration (the process of filtering
blood as it flows through the kidneys)
– Tubular resorption (necessary fluids,
electrolytes, proteins + blood cells are
retained)
– Tubular secretion (waste products+ fluids
filtered out)
FIGURE 31–1
The urinary system is comprised of the kidneys,
ureters, bladder, and urethra. The kidneys are located between the
twelfth thoracic (T12) and third lumbar (L3) vertebrae.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Urinary System
• Ureters
– Carry waste fluid from kidneys to bladder
• Bladder
– Stores urine
– Bladder capacity in ounces estimated by
adding 2 to child’s age
– Bladder can hold 1-1 ½ ounces for every year
of age
– Muscular organ
Urinary System
• Kidneys:
– Nephrons
• Perform filtration, reabsorption and
secretion
– Filtration occurs at the glomerulus,
Bowman’s capsule and the basement
membrane
– Most renal growth occurs during the
first 5 years of life. This increase in size
is d/t the enlargement of the nephrons.
The nephrons are the structural and functional unit of the kidneys.
They filter water and wastes across the glomerular capillaries to maintain the body
fluid level, electrolyte composition, and pH. A nephron holds six glomeruli,
Bowman’s capsule, proximal tubule, loop of Henle, distal tubule, and the collecting
duct.
FIGURE 31–2
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Kidneys
• Kidneys are immature at birth. As
child grows, concentration of urine
becomes more efficient
– Refer to Box 31-3
– First 2 years of life: less efficient at
regulating f/e and acid/base balance
– Urine output per kg body weight is
greater in infancy than childhood/
adolescents.
• Kidney less able to concentrate urine
Urinary System
• For the kidneys to function
effectively, the following conditions
need to be present
– Unimpaired renal blood flow
– Adequate glomerular ultrafiltration
– Normal tubular function
– Unobstructed urine flow
Urinary System
• Diagnostic tests for Urinary System
Conditions:
– Refer to Table 31-2 p1178 in text
• Normal Urinalysis Results:
– Refer to Table 31-3 p 1179 in text
Structural Defects of the Urinary
System
• Bladder Exstrophy
• Hypospadias and Epispadias
• Obstructive Uropathy
• Congenital Hydronephrosis
• Vesicoureteral Reflux
Bladder Exstrophy
• Rare congenital defect (1 in 40,000
newborns)
• Etiology: failure of abdominal wall to
close during fetal development
– Leads to eversion of the bladder
• Treatment:
– Surgical reconstruction in several stages
• Nursing care:
– Cover w/ wet sterile gauze postdelivery, prepare for surgery
FIGURE 31–3
This child has exstrophy of the bladder. Note the extrusion of
the posterior bladder wall through the lower abdominal wall and deformity of the
penis.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Hypospadias and Epispadias
• Congenital anomalies involving and
abnormal location of the urethral meatus
• Result from failure of the urethra folds to
fuse completely over the urethral groove
• Familial tendency but exact mechanism
unknown
• Hypospadias often occurs in conjunction
with congenital inguinal hernias,
undescended testes, chordee
• Epispadias often occurs with bladder
exstrophy
FIGURE 31–4
Hypospadias and epispadias. A, In hypospadias, the
urethral canal is open on the ventral surface of the penis. B, In epispadias
the urethral canal is open on the dorsal surface.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Hypospadias vs epispadias
• The urethral
meatus may be
located anywhere
along the course of
the ventral surface
of the penile shaft
• The meatal
opening islocated
on the dorsal
surface of the
penile shaft, and
may be at the level
of the bladder
neck.
Hyposapdias/ Epispadias
Treatment
• For mild cases of hypospadias, no
intervention is necessary
• Surgical correction is the tx of choice
– Corrected during the first year of life
• DO NOT CIRCUMCISE as foreskin tissue
may be used in reconstruction
• Goals of Surgery:
– Placement of the urethral meatus at the end of
the glans penis allowing for good urine stream
– Release of chordee to straighten penis
– Cosmetic appearance
Hypospadias/ Epispadias
Nursing Responsibilities
• Assist in the identification of defects
in complete newborn exam
• Prevent potential complications
• Promote parental understanding and
attachment
• Promote normal voiding pattern
Obstructive Uropathy
• Structural or functional abnormalities
of the urinary system that interferes
with urine flow and results in urine
backflow into the kidneys.
• The condition can occur anywhere
along the urinary tract.
• Pressure caused by urine backup
often leads to hydronephrosis
Obstruction may occur in either the upper or lower urinary tract. Common
sites of obstruction occur at the ureteropelvic valve, the ureterovesicular junction, or the
posterior urethral valve. Why would damage from posterior urethral valves potentially be worse
than other obstructions? Renal failure is most likely to occur when both kidneys are affected by
hydronephrosis.
FIGURE 31–6
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Hydronephrosis
• An accumulation of urine in the renal pelvis as a
result of obstructed outflow, and compromises
kidney function.
• Most children with hydronephrosis are born with
the condition although it can develop during
childhood. It is the most common urinary tract
anomaly (abnormality) and ranges in severity. In
mild hydronephrosis, the pelvic (the part of the
kidney that collects the urine) dilation is barely
noticeable, whereas in severe hydronephrosis the
swelling occupies much of the abdomen.
Hydronephrosis
Pathophysiology of
Hydronephrosis
• When pressure in the kidney pelvis= the filtration
pressure in the glomerular capillary, glomerular
filtration stops. In response, Blood pressure
increases as the body attempts to increase the
glomerular filtration pressure, however increasing
pressure usually leads to cell death.
• Metabolic acidosis results when the distal
nephrons are impaired in their ability to secrete
H+ ions.
• Impaired ability to concentrate urine results in
polydypsia and polyuria.
• Obstruction results in urinary stasis, promoting
bacterial growth
• Chronic renal failure eventually results when
hydronephrosis damages the renal parenchyma
causing obstructive nephropathy
Hydronephrosis
• Facts about hydronephrosis
• It is four to five times more common
in males than females.
• It can occur in one or both kidneys.
• Most mild cases and even some
moderate cases may resolve on their
own.
• More severe cases may require
surgery.
Hydronephrosis
• What are the symptoms of
hydronephrosis?
– In mild cases and even some moderate cases
of hydronephrosis, children will have no
symptoms and the condition may disappear on
its own within the first year of life.
– In more severe cases, when kidney function is
affected, the infant or child can experience
pain, bleeding and infections. These symptoms
may not develop until months or years after
hydronephrosis is first detected.
– Tx= surgery to correct blockage
Vesicoureteral Reflux
• VUR results in backflow of urine from
the bladder into the kidneys
• Prevents complete emptying of the
bladder and creates a reservoir for
bacterial growth
• The defect results from incomplete
development of the ureterovesical
junction, or from a structural
anomaly.
VUR Grades (I-VI)
VUR
• 70% of children with symptomatic UTI’s
have VUR
• Diagnosis:
– Renal US
– VCUG
• a voiding cystourethrogram (VCUG) is an x-ray
examination of a child's bladder and lower urinary
tract that uses fluoroscopy and a contrast material.
• Complications
– Reflux of infected urine can cause pylonephritis
Disorders Affecting Urinary
Elimination
• Urinary Tract Infections (UTI’s)
• Enuresis
UTI
• A microbial invasion of the kidneys,
ureters, bladder, or urethra
• In the neonatal period, UTI’s occur
most commonly in males, possibly
b/c of the higher incidence of
congenital abnormalities
• By age 4 months, UTIs are more
common in females b/c of the
placement and size of the urethra
UTI
• Causes:
–
–
–
–
–
Incomplete bladder emptying
Irritation by bubble baths
Poor hygiene
VUR
Urinary tract obstruction
• Pathophysiology:
– Bacteria enter the urethra and ascend the
urinary tract
– E.coli (Gram -) causes approximately 75-90%
of all UTIs in females
UTI
• What is the difference b/t these 3
conditions?
– Cystitis (bladder)
– Urethritis (urethra)
– Pyelonephritis (ureters, renal pelvis and
renal parenchyma)
– Most common disorder of GU tract in
children
UTI
• Complications:
– Risk of renal failure:
• UTI under age 1
• Delay in diagnosis
• Anatomic or neurologic obstruction
• Recurrent episodes of upper UTI
UTI
• Complications:
– VUR
– Glomerulonephritis
– Bacteremia
– Sepsis
– Septic Shock
• Tests:
– Clean catch Urine Analysis and urine Cxresults yield large amounts of bacteria
– Increased urine pH
UTI
• Clinical Findings:
– Abdominal pain
– Enuresis
– Frequency and Urgency
– Pain/ burning w/ urination (dysuria)
– Hematuria
– Lethargy or irritability
– Poor feeding patterns
– Cloudy, foul-smelling urine
UTI
• What is the most common clinical
presentation of UTI in the child under 2?
– Fever with associated s/sx including:
•
•
•
•
•
•
V/D
Irritability
Poor PO intake
Malodorous urine
Oliguria
Constipation
– Please Refer to Table on page 1187 for other
clinical manifestations of UTIs
Normal Urinalysis Results
• Normal values used in many laboratories are given below:
• Glucose: negative (quantitative less than 130 mg/day or 30
mg/dL).
• Bilirubin: negative (quantitative less than 0.02 mg/dL).
• Ketones: negative (quantitative 0.5–3.0 mg/dL).
• pH: 5.0–8.0.
• Protein: negative (quantitative 15–150 mg/day, less than 10
mg/dL).
• Blood: negative.
• Nitrite: negative.
• Specific gravity: 1.015–1.025.
• Urobilinogen: 0–2 Ehrlich units (quantitative 0.3–1.0 Ehrlich
units).
• Leukocyte esterase: negative.
• Red blood cells: 0–2 per high power field.
• White blood cells: 0–5 per high power field (0–10 per high power
field for some standardized systems).
• Also note color and odor of urine
Urine Culture
• A urine culture is a diagnostic
laboratory test performed to detect
the presence of bacteria in the urine
(bacteriuria).
• Usually takes 24-48 hours for results
• If symptomatic, treat empirically
Nursing care of UTI’s
• Administer abx as Rx’d; instruct parents
to complete entire course of abx
• Encourage fluids to help to flush infection
from the urinary tract
• Teach proper toileting hygeine
• Encourage child to use toilet every 2 hours
• Discourage bubble baths
• Teach parents about s/sx of UTIs
Enuresis
• Repeated involuntary voiding by a
child who has reached an age which
bladder control is expected (5-6 y.o)
– Enuresis at night= nocturnal enuresis
• 50% of cases
• More common in boys
– Enuresis during day= diurnal enuresis
• More common in girls
– Further categorized as primary,
intermittent and secondary
Enuresis
• Primary:
– Child has never had a dry night; attributed to
maturational delay and small functional
bladder
• Intermittent:
– Child has occasional nights or periods of
dryness
• Secondary:
– Child begins bedwetting who has been reliably
dry for 6-12 months; associated with stress,
infections and sleep disorders
Enuresis
• Clinical manifestations for diurnal
enuresis:
– Frequency
– Urgency
– Constant dribbling
– Involuntary loss of control after voiding
• Clinical manifestations for nocturnal
enuresis:
– bedwetting
Enuresis
• A thorough hx is obtained. See Box 31-3
• Clinical therapy:
– Spontaneous cure rate in 15% of cases/year
– Multitreatment approach most efficient
• 1/3 of nocturnal enuresis tx’d w/ meds
• See page 1191 for meds used to tx enuresis
• Behavioral interventions
– Fluid intake programs, bladder alarms, and bladder
training
Enuresis
• Nursing management:
– Thorough hx
– Evaluate if parents and child are equally
motivated to resolve problem
– Teaching
Kidney Disorders
• Nephrotic Syndrome
• Renal Failure
• Glomerulonephritis
• Hemolytic Uremic Syndrome
• Polycystic Kidney Disease
Nephrotic Syndrome
• Condition in which the kidneys lose a
significant amount of protein in the urine,
resulting in low blood levels of protein.
• Nephrotic syndrome refers not to a
specific disease but to a clinical state
characterized by:
–
–
–
–
Proteinuria
Hypoalbuminemai
Hyperlipidemia
edema
Nephrotic Syndrome
• If nephron’s allow increased protein
to escape from the blood what does
this lead to?
Nephrotic Syndrome
Note the contrast between the normal glomerular anatomy and the
changes that exist in nephrotic syndrome permitting protein to be excreted in the
urine. The lower albumin blood level stimulates the liver to generate lipids and
excessive clotting factors. Edema results from decreased oncotic plasma pressure,
renin-angiotensin-aldosterone activation, and antidiuretic hormone secretion.
FIGURE 31–7
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
The initial kidney injury is usually associated with an acute condition such as
sepsis, trauma, and hypotension, or the result of treatment for an acute condition with a
nephrotoxic medication. Injury to the kidney can occur because of glomerular injury,
vasoconstriction of capillaries, or tubular injury. All consequences of injury lead to decreased
glomerular filtration and oliguria.
FIGURE 31–9
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nephrotic Syndrome
• Primary nephrotic syndrome occurs
predominantly in preschool children
• Incidence peaks b/t ages 2-3 years
• Syndrome rare after age 8
• More common in boys
• Some forms may progress to ESRD
Nephrotic Syndrome
• How does this happen?
– Injury to glomerular filtraiton membrane
allows the loss of plasma proteins (especially
albumin and immunoglobulin)
– This results in decreased levels of serum
albumin (hypoalbuminemia)
– Hypoalbuminemia results in decreased colloidal
osmotic pressure and fluid accumulation in the
interstitial spaces.
– Edema results from Na and H2O retention
Nephrotic Syndrome
• Clinical Manifestations by body
system:
– Renal
• Oliguria, and dark, frothy urine
– CV
• HTN (later stages), tachycardia
– Vascular
• Thrombosis
– Gastrointestinal
• Anorexia, abd pains, n/v/d
– Skin
• Pallor, shiny w/ prominent veins, brittle hair, edema,
skin breakdown
– Pulmonary
• Respiratory distress and pulmonary congestion
FIGURE 31–8
syndrome.
This boy has generalized edema, a characteristic finding in nephrotic
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Nephrotic Syndrome
• Diagnostic Tests:
– Ua= severe proteinuria (primary
indicator), hematuria and casts; also
an elevated spec grav b/c of the
proteinuria
– Renal biopsy= identifies the type of
nephrotic syndrome the child has, and
can be used to monitor response to
medical management
– Blood studies show: serum creatinine,
BUN, choles
Minimal Change Nephrotic
Syndrome
• Glomeruli appear normal or show only
minimal changes on microscopic eval.
• Most common form of Nephrotic
Syndrome
– MCNS affects 85% children w/ nephrotic
syndrome
– Usually affects children b/t 2-7 years
– Poorer prognosis, progresses more rapidly to
renal failure
MCNS
• Etiology and Pathophysiology:
– Cause unknown; immune-mediated
• (often preceded by URI)
– The glomeruli appear normal or only have a
minimal change in appearance, but their
permeability is greatly affected
– Characteristic symptoms include
•
•
•
•
Edema…weight gain
Excessive clotting factors
Hyperlipidemia
Low serum sodium
Nursing Care of the Child
with Nephrotic Syndrome
• Physiologic/ Psychosocial assessment
• Administer medications
• Prevent infections
• Prevent skin breakdown
• Nutrition/ fluid needs
• Promote rest
• Provide emotional support
• Teaching/ DC planning
Nephrotic Syndrome
• Medications: refer to pgs 1196-1197
• Corticosteroid therapy
• Alylating/ Cytotoxic Agents
• Cylosporine Therapy
(immunosuppressants)
• Diuretics
• ACE Inhibitors
• Antithrombolitic therapy
• NSAIDS
Nephrotic Syndrome
• Medications:
– Prednisone or prednisolone
• Stimulates remission by reducing the
excretion of protein in the urine
• Children who respond to this therapy will
continue to take Rx X 6 weeks, and then
taper
Nephrotic Syndrome
• Discharge Planning:
– Parents need to monitor protein in urine
daily using dipsticks
– Understand that relapses do occur
– No added salt diet
– Monitor weight
Acute and Chronic Renal
Failure
• Occurs when the kidney is unable to
excrete wastes and concentrate urine
• Acute- occurs suddenly and may be
reversible
• Chronic-occurs gradually and permanently
• Azotemia: accumulation of nitrogenous
wastes in blood
• Oliguria: urine output 0.5-1ml/kg/hour
• Anuria: absent urine output
This child is undergoing hemodialysis. A, Note the
surgically implanted vascular graft. One needle is placed in the arterial end of the
graft (red tubing), and one needle is placed in the venous end (blue tubing) for
blood return. B, The child is able to draw or perform other quiet activities during
dialysis treatment. Note that the child’s blood pressure is carefully monitored
throughout the treatment.
FIGURE 31–11 (continued)
B
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
Renal Failure
• Acute Renal Failure:
– Refer to Table on pg 1200 for Clinical
Manifestations
• Nursing Management:
–
–
–
–
–
–
Monitor side effects of medications
Prevent infection
Meet nutritional needs (Table 31-8 p 1207)
Maintain fluid restrictions
Provide emotional support
D/C planning: anticipatory teaching
Acute Postinfectious
Glomerulonephritis
• Glomerulonephritis: an inflammation
of the glomeruli of the kidneys
– Acute or chronic
– In children, most often a response to
GABHS infection of skin or pharynx (aka
Post-Strep Glomerulonephritis)
– Other organisms: Staph, Pneumococcus
and coxsackievirus
– Abx are not a tx for APIGN. Abx are
Rx’d to tx the original infection
APIGN
• Highest in children ages 2-12
• More common during winter and spring
months
• The child typically has a h/o a recent
respiratory infection (w/in 1-2 weeks) or
impetigo.
• The child recovers from infection, then
develops APIGN after 8-14 days
• Glomerular damage occurs as a result of
an immune complex reaction that localizes
on the glomerular capillary wall
APIGN
• Clinical Manifestations:
–
–
–
–
–
% of children are asymptomatic
Abrupt onset of abdominal pain
Irritability
Microscopic hematuria (most all cases)
Acute HTN
• Nonspecific symptoms
– These can include general malaise,
weakness, and anorexia and are present
in 50% of patients.
– Approximately 15% of patients complain
of nausea and vomiting.
APIGN
• Clinical Manifestations:
• Dark urine (brown-, tea-, or cola-colored)
– This is often the first clinical symptom.
– Dark urine is caused by hemolysis of red blood
cells that have penetrated the glomerular
basement membrane and have passed into the
tubular system.
• Periorbital edema and dependent edema
– The onset of puffiness of the face or eyelids is
sudden. It is usually prominent upon
awakening and, if the patient is active, tends
to subside at the end of the day.
– In some cases, generalized edema and other
features of circulatory congestion, such as
dyspnea, may be present.
– Edema is a result of a defect in renal excretion
of salt and water, and can result in HTN
FIGURE 31–13
Infection from group A beta-hemolytic Streptococcus causes an immune response that
causes inflammation and damage to the glomeruli. Protein and red blood cells are allowed to pass through the
glomeruli. Blood flow to the glomeruli is reduced due to obstruction with damaged cells and renal insufficiency
results, leading to the retention of sodium, water, and waste.
Jane W. Ball and Ruth C. Bindler
Child Health Nursing: Partnering with Children & Families
© 2006 by Pearson Education, Inc.
Upper Saddle River, New Jersey 07458
All rights reserved.
APIGN
• Lab Findings:
–
–
–
–
–
–
–
–
Hematuria
Proteinuria
Leukocytes
Decreased serum protein
Anemia
ESR increased
Serum IgG antibodies against Strep +
Circulatory overload causing EKG changes
APIGN Nursing Care
• Assessment:
–
–
–
–
–
–
–
VS, especially BP
F&E’s with strict I’s & O’s, specific gravity
Daily weights
Urine dipstick for + hematuria, +proteinuria
Assess edema (periorbital, dependent)
Measure abdominal girth
Auscultate heart and lung sounds, not
respiratory effort
– Monitor neurologic signs secondary to HTN
(LOC, HA, sz activity, vomitting)
Hemolytic Uremic Syndrome
• Hemolytic uremic syndrome (HUS) is a disease
primarily of infancy and early childhood.
• It is characterized by the triad of hemolytic
anemia, thrombocytopenia, and acute renal
failure.
• Diarrhea and upper respiratory infection are the
most common precipitating factors.
• HUS is the most common cause of acute renal
failure in children.
• It occurs mostly in infants and children from 6
months to 4 years.
HUS
• Verotoxin causes damage to the lining of the glomerular
arterioles resulting in swelling of the endothelial cells.
• The lining of the glomerular arterioles becomes inflamed,
swollen, and occluded w/ particles of platelets and fibrin.
• RBC and PLTs are damaged as they flow through the
partially occluded vessels.
• As the damaged cells reach the spleen, they are destroyed
and removed from circulation. This leads to hemolytic
anemia.
• 90% of children w/ this syndrome, have recently
experienced E.coli GI infection.
– Over ½ cases by contaminated beef
HUS
• The bacterial infection causes endothelial
cell injury in the lining of the small
glomerular arterioles.
• This cell damage triggers clotting
mechanisms that occlude the arterioles
and capillaries.
• This plt aggregation results in
thrombocytopenia (b/c plts are damaged
by irregular blood cells), and the kidneys
become swollen
• Although damage occurs mainly in the
endothesial lining of the glomerular
arterioles, other organs can be involved
(heart, pancreas)
HUS Clinical Manifestations
• Prodromal stage:
– URI
• 1-7 days:
– fever, Irritability, weakness, lethargy,
lymphadenopathy, skin rash, abdominal
pain w/ N/V/D
• Acute Stage:
– Hemolytic anemia, HTN, Pallor and
purpura, neurologic involvement, and
renal failure
Management of HUS
• Supportive tx to maintain kidney
function
• Daily plasma exchange until
remission is achieved
• Maintenance of fluid and electrolyte
balance and correction of acidosis to
prevent szs
• Corticosteroids
• Early dialysis if ARF develops
• Management of HTN
HUS
• Nursing Management:
–
–
–
–
Same as with acute kidney failure
Dialysis
Diet of small, high-calorie, high-carbohydrate
Diet of low Na++, potassium and phosphorus
• Education and Prevention:
– Reduce risk of consumption of cantaminated
beef
– Cook ground beef to 155 degrees
– Wash hands when handling raw meat
– Use meat thermometer
Toilet Training
• Physical Readiness
• Social and cultural aspects of toilet
training in children (p 446 in text)