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Chapter 1: Perspectives of Pediatric Nursing Health Care for Children Healthy People 2020 o Framework for identifying essential components for child health promotion programs o Designed to prevent future health problems in children o Goal to increase quality and length of healthy life and eliminate health disparities Substance abuse Dental caries---single most common chronic disease of childhood o Begins practicing dental hygiene beginning w/ the first tooth eruption; drinking fluoridated water, including bottled water; and instituting early dental preventive care Violence Mental health disorders Child Health Promotion Provides opportunities to reduce differences in current health status among members of different groups and ensure equal opportunities and resources to enable all children to achieve their fullest health potential “Bright Futures” ---book on kind of what to expect in the upcoming months or years –also provides family support, physical activity, healthy weight, dental carries o Really hits hard on safety! Case Study A group of nursing students have been asked to participate in a pediatric health fair. They will talk to participants about health care for children. The nursing students know that the health fair will include both parents and children of all ages. Leading Health Indicators (Healthy People 2020)
- Physical inactivity
- Overweight and obesity (#1 nutritional problem in children) o Greater than the 95th^ percentile---child is considered obese
- Tobacco use
- Substance abuse
- Responsible sexual behavior
- Mental health
- Injury and violence
- Environmental quality
- Immunization
- Access to health care Development Developmental processes are unique to each stage of development: o Infant o Toddler o Early Childhood o Adolescence Continuous screening and assessment are essential for early intervention when problems are found. Nutrition in Infancy Breast-feeding is BEST o Human milk is the preferred form of nutrition for all infants o Provides Micronutrients Immunologic properties Enzymes that enhance digestion and absorption Nutrition in Childhood Lifelong eating habits established by age 3 Parent teaching Eating preferences and attitudes related to food are established by: o Family influences o Culture Homelessness and low income associated with lack of resources to provide children with adequate, nutritious meals. Case Study (Cont.)
When talking to parents about childhood obesity and type 2 diabetes, which topics should the nursing students discuss with the parents? Select all that apply. a) Obesity in children and adolescents is defined as a body mass index at or greater than the 95th percentile for youth of the same age and gender. b) Easy access to television and video games has increased the incidence of obesity. c) Lack of physical exercise contributes to obesity. d) The importance of allowing children to choose their favorite foods every day, including sweets such as dessert. e) The importance of maintaining a normal body weight. f) Overweight youth have increased risk for not only type 2 diabetes, but also high blood pressure and dyslipidemia. Dental Care Dental caries are preventable o Dental hygiene beginning with first tooth eruption o Role of fluoridated water o Early dental preventive care o Parent and child teaching Case Study (Cont.) The single most common chronic disease of childhood is? a) Arthritis Cancer b) Dental caries c) Diabetes Immunizations: Role of Nurse Review individual immunization records at every clinic visit Avoid missing opportunities to vaccinate Encourage parents to keep immunizations current (U.S. Department of Health and Human Services, 2009) Keep up with changes in immunization schedules, recommendations, and research related to childhood vaccines www.cdc.gov/vaccines HPV--- usually given at 11 yrs of age o Girls pass out from HPV vaccine—less likely to happen if given at a younger age (9yrs) Childhood Health Problems Obesity and Type 2 Diabetes, p. 3 Childhood Injuries, p. 3 Violence, p. 6 Mental Health Problems, p. 6 Case Study (Cont.) When talking to parents about pedestrian accidents, the nursing students know that the top reasons involving children are related to motor vehicle–related deaths. Most of these accidents will occur in which areas? Select all that apply. a) Driveways b) Freeways c) Intersections d) Midblock e) Parking lots Mortality statistics refer to the number of individuals who have died over a specific period Infant Mortality o Death in first year of life per 1000 live births* o 6 lives per 1000 live births (in 2011)** neonatal mortality (<28 days of life) low birth weight (less than 2500g---5lbsish) postneonatal mortality (28 days to 11 months) o the lower the birth weight, the higher the mortality o First 4 causes ( accounted for about half of all deaths of infants under 1 year of age) 1) Congenital anomalies 2) Disorders r/t short gestation and unspecified LBW 3) SIDS
b) Empowerment c) Atraumatic care eliminate or minimize distress (psychological/ physical) d) Enabling Atraumatic Care Eliminate or minimize distress o Psychologic Anxiety, fear, anger, disappointment, sadness, shame, or guilt o Physical Sleeplessness and immobilization to disturbances from sensory stimuli such as pain, temperature extremes, loud noises, bright lights, or darkness Goals of Atraumatic Care Prevent or minimize separation from the family Promote sense of control Prevent or minimize bodily injury and pain Examples o Foster the parent-child relationship o Prepare child before any treatment or procedure o Control pain o Allow privacy o Provide play activities for expression of fear and aggression o Providing choices to children o Respecting cultural differences Role of the Pediatric Nurse Therapeutic Relationship Family Advocacy and Caring Disease Prevention and Health Promotion Health Teaching Injury Prevention injuries kill or disable more children over 1 year old than all childhood diseases combined Support and Counseling Coordination and Collaboration Ethical Decision Making Ethical Decision Making Ethical dilemmas = competing moral considerations Competing moral values may include o Autonomy patients right to be self-governing o Nonmaleficence minimize or prevent harm (do no harm) o Beneficence promote the patients well-being (do good) o Justice concept of fairness Determine the most beneficial or least harmful action within the framework of o Societal mores o Professional practice standards o The law o Institutional rules o Family’s value system and religious traditions o Nurse’s personal values Evidence-Based Practice Based on valid, important, and applicable patient-reported, nurse-observed, and research-derived information
Combines knowledge with clinical experience and intuition Provides a rational approach to decision making that facilitates best practice GRADE Criteria for EBP Evaluates the quality of research articles used to develop practice guidelines Rates the quality of the evidence Establishes a strong versus weak recommendation for practice change The GRADE Criteria to Evaluate the Quality of the Evidence CLINICAL REASONING AND THE PROCESS OF PROVIDING NURSING CARE TO CHILDREN AND FAMILIES Clinical Reasoning Cognitive process that uses formal and informal thinking to gather and analyze patient data, evaluate the significance of the information, and consider alternative actions. Nursing Process Assessment Nursing diagnosis they provide the basis for the selection of nursing interventions o Clinical judgment about the clients response to actual or potential health problems. The outcome statement guides the necessary interventions. Planning Implementation Evaluation Documentation: Written Evidence of Progress toward Outcomes Initial assessments/reassessments Nursing diagnoses and/or patient care needs Interventions identified to meet patient’s nursing care needs Nursing care provided Patient’s response to, and outcomes of, care provided Abilities of patient and/or, as appropriate, significant other(s) to manage continuing care needs after discharge Quality Outcome Measures U.S. Department of Health and Human Services National Strategy for Quality Improvement in Health Care has three quality aims: o Better care o Healthy People/Healthy Communities o Affordable Care o Full report at www.qualityforum.org Chapter 2: Social, Cultural, Religious, and Family Influences on Child Health Promotion Family Theories Consanguineous blood relationships
o Ignoring o Time-out place them in an environment that doesn’t has a lot of stimulation o Corporal (Physical punishment) spanking, etc. Special Parenting Situations Parenting the adopted child Parenting and divorce Single parenting Parenting in Dual-earning families Foster parenting Sociocultural Influences on Families Surrounding Environment o School/learning environment o Peer cultures o Social roles Local Community Influences Social Determinants o Race and ethnicity influence o Social class (wealth vs. poverty) o Religious and traditional influences o Mass media influences Understanding Culture Cultural Definitions Components of Cultural Humility o Assess Family health beliefs and practices Cultural Traditions to Maintain, Protect, and Restore Health Physical aspects of caring for the body o Special clothes o Foods o Medicines Feelings, attitudes, rituals, actions related to health Spiritual aspects of health o Identity (who I am) o Customs/prayers/healing Health Beliefs and Practices Natural forces Supernatural forces Imbalance of forces Health protection o Folk healers o Practices and remedies o Faith healing and religious rituals Chapter 4: Communication, Physical, and Developmental Assessment Communication and Interviewing Establishing the setting o Introduction o Ensure privacy and confidentiality o Appropriate computer and phone communication Case Study
A nurse is assessing children in a pediatric health clinic. As part of the physical assessment, the nurse knows that communication is key to a successful interview with the parents and the child. Using an organized approached and including patient teaching will be most effective throughout the process. Communication Parents/ Caregivers o Directing the focus o Encouragement during interviewing o Cultural awareness o Listening/ using silence o Empathy o Providing anticipatory guidance process of understanding upcoming developmental needs and then teaching caregivers to meet those needs o Avoiding blocks and information overload o Using an interpreter Case Study (Cont.) When interviewing a child and parent(s) at the beginning of a visit, it will be important for the nurse to follow which of the guiding principles? Select all that apply. a) Address parents however you think would be appropriate b) Include children in the interaction by asking them their name, age, and other information c) Provide as much privacy as possible d) Inform the family of the limits of confidentiality e) Young children should be given play provision to keep them occupied during the parent-nurse interview Communication Techniques Play Developmentally appropriate creative techniques Verbal o I messages o Third person Nonverbal o Writing o Drawing Case Study When a 10-year-old child asks if a procedure is going to hurt, as the nurse, you know it will hurt for a little bit. The best response is: a) Be honest and answer, “Yes, for a little bit.” b) Change the subject and say, “It’s beautiful day outside, isn’t it?” c) Say, “NO, because you’re a big boy. It won’t hurt a bit.” d) Smile broadly and ask, “What do you think?” Chapter 5: pain assessment and management in children Pain Assessment: Influencing Factors Age Developmental level Cause and nature of the pain Ability to express the pain Six Core Domains Intensity Satisfaction with treatment Symptoms and adverse events Physical recovery Emotional response Economic factors Types of Pain Acute Chronic or recurrent Chronic and Recurrent Pain Assessment Chronic
For 8 years and older 0 to 10 scale widely used Easy to use Little research for reliability and validity Visual Analog Scale (VAS) “No hurt” to “biggest hurt” are more appropriate than “least pain sensation to worst intense pain imaginable.” Requires a higher degree of abstraction than the Numeric Rating Scale (NRS). Recommended because of the lack of supportive evidence through psychometric studies with the NRS in children and adolescents. Adverse Events Signs, symptoms, laboratory findings, or diseases that occur after medications for pain are initiated Constipation Most common o Need to screen Multidimensional Assessments Adolescent Pediatric Pain Tool (APPT) o Assesses pain location, intensity, and quality Anterior and posterior body outline on one side 100-mm word-graphing rating scale with a pain descriptor o Facilitates assessments of pain quality + location Pediatric Pain Questionnaire (PPQ) Assesses patient and parental perceptions of pain Cognitive and developmental considerations Eight areas of inquiry: pain history, pain language, the colors children associate with pain, emotions children experience, the worst pain experiences, the ways children cope with pain, the positive aspects of pain, and the location of the child’s current pain Three components of the PPQ o VASs o Color-coded rating scales o Verbal descriptors The child, parent, and physician each complete the form separately Chapter 23: Pediatric Nursing Interventions and Skills General Concepts Related to Pediatric Procedures Informed consent o Age of majority/competence----age 18! o Should include the expected care or treatment; potential risks, benefits, and alternatives; and what might happen if the patient chooses not to consent Requirements for obtaining informed consent o “Assent” for older children and adolescents o Assent means the child or adolescent has been informed about the proposed treatment, procedure, or research and is willing to permit a health care provider to perform it. Eligibility for giving informed consent o Treatment without parental consent o Emancipated minor o Mature minor Assent Not necessarily a legal binding form.. but more of an ethical thing that can be done o More involved in their care Meaning—Child has been informed and is willing Developmentally appropriate awareness of the nature of his or her condition Telling the patient what to expect Assessing understanding Soliciting an expression of child’s willingness to accept the proposed procedure Emancipated Minor
Legally under the age of majority but is recognized as having the legal capacity of an adult under circumstances prescribed by state law, such as pregnancy, marriage, high school graduation, independent living, or military service Treatment Not Requiring Parental Permission or Knowledge AKA “medically emancipated” conditions All 50 states have legislation, but it varies o Sexually transmitted infections o Mental health services o Alcohol and drug dependency o Pregnancy o Contraceptive advice Preparation for Procedures Psychologic preparation o Age-specific guidelines for preparation o Based on developmental characteristics Establish trust and provide support Parental presence and support Explanation to the child Performing Procedures Benefits of using special treatment room for procedures Expect success Involve the child Provide distraction Postprocedural Support Encourage expression of feelings Positive reinforcement Use of play in procedures Using Play to Ease Children’s Fears Infection control Patient with HIV would be under “standard precautions”--- which involves the use of barrier protection, such as gloves, goggles, gown, or mask to prevent contamination from blood, all body fluids, secretions, and excretions except sweat, regardless of whether they contain visible blood; nonintact skin; and mucous membranes Growth and Development Principles of Growth & Development Growth and development Increase in number and size of cell Growth increase in physical size of a whole or any of its parts Stages of Development: o Infancy (birth to 12 months)---most rapid period of growth Neonatal—birth to 28 days Infancy—1-12 months o Early Childhood (1-6 years) Toddler (1-2) Preschool (3-4) Kindergarten/ Early grade school (5-6) o Middle Childhood (6-11 years) Pre-teen “tween stage” (11-12) o Later Childhood (adolescent) (11-12/13) Patterns o Directional trends ---we will typically grow and develop in a specific regular related direction 1 st-- head to toe (ex: babies have bigger heads) Cephalocauda l: head to toe--- development proceeds from head downward through body towards feed 2 nd— proximaldistal or near too far. Trunks to tips Midline, core organs first, then arms and legs
Become overly preoccupied of the way they look to others o Preoccupation w/ physical appearance o Examines and redefines self, family, peer group, and community o Peer group is very important o Rejects the identity presented by his parents and attempts to create his own identity o Identity often based on peers o Seek emancipation from parents o Value system (struggles to keep rules that they have made) o Vocation o Provide for adolescent to discuss feelings Principles of Growth & Development Piaget’s Cognitive Development---KNOW!! Sensorimotor (birth-2 years) o Progress from reflex activity to repetitive behaviors, to imitative behaviors---natural reflex of their body o Develop sense of cause and effect o Infant learns about world through senses and motor activity o Trial and error problem solving o Language enables child to better understand world o Develop object permanence---Ex: take rattle and remove it behind your back…. That child still knows the object exists ---actively searched for a hidden object Preoperational Thinking (2-7 years) o Move from egocentric (unable to put oneself in the place of another) thought to social awareness o Increasing language skills o Use of imaginative play o Play becomes more socialized o Forms symbolic thought Concrete Operational Thinking (7-10 years) o Thought becomes increasingly logical and coherent
o Conservation of matter —being able to recognize that 4oz of water is the same amt no matter if it’s in a small wide glass, or a tall skinny glass. o Able to shift attention from one perceptual attribute to another (decentration) o Consider points of view other than their own o Able to classify and sort facts, do problem solving o Acquires conversational skills Formal Operational Thinking (12+ years) o Think in abstract terms o Draw logical conclusions o Make hypothesis and test them o Able to logically manipulate abstract and unobservable concepts o Adaptable and flexible o Able to deal w/ contraindications o Uses scientific approach to problem solve Neonatal Period: Birth – 28 days Normal Findings: o Pulse 110-160 bpm o Respirations : 32-60 breaths/min o Blood Pressure : 82/46 mmHg o Head circumference = Chest circumference o Head length is ¼th total body length Behavior is under reflexive control have no purposeful actions or movements (EVERYTHING IS REFLEXIVE) Neonatal Reflexes Rooting/Sucking touch cheek they will turn face towards—how they get food o Disappears at 4 months , becomes purposeful Palmar /Plantar Grasp place finger in palm and curl downward o Palmar— disappears at 3-4 mo. o Plantar— disappears at 8 mo. Tonic Neck : turn head to left, arm and leg on left extend (or right) o infant needs to be asleep— disappears @ 3-4 months Moro/Startle: hold child in semi sitting, allow head and trunk to fall back, flails arms out and then in o disappears around 4 months Babinski : upside down/ backwards J on foot, toes fan OUT, signs on neuro damage in older individual o Usually disappears by 12 months of age o This is abnormal if this continues throughout life…. Could indicate a neurological damage Labyrinth righting —Infant in prone or supine position is able to raise head; appears at 2 months, strongest at 10 months Neck righting —While infant is supine, head is turned to one side; shoulder, trunk, and finally pelvis will turn toward that side; appears at 3 months, until 24 to 36 months Body righting —A modification of the neck-righting reflex in which turning hips and shoulders to one side causes all other body parts to follow; appears at 6 months, until 24 to 36 months Otolith righting —When body of an erect infant is tilted, head is returned to upright, erect position; appears at 7 to 12 months, persists indefinitely Landau —When infant is suspended in a horizontal prone position, the head is raised and legs and spine are extended; appears at 6 to 8 months, lasts until 12 to 24 months Parachute —When infant is suspended in a horizontal prone position and suddenly thrust downward, hands and fingers extend forward as if to protect against falling (see Fig. 10-1); appears at 7 to 9 months, persists indefinitely
Complete head lag at 1 month Partial head lag at 2 months Almost no head lag at 4 months (should be no head lag at 5 months) Infant momentarily lifts head at 1 month. Infant lifts head and chest 90 degrees and bears weight on forearms at 4 months. Infant lifts head, chest, and upper abdomen and can bear weight on hands at 6 months. Infant: Sensory Development know the order of occurrence, but not exact time/months 1 month: Visual acuity 20/100; Follows light to midline 2 months: Binocular fixation and convergence to near objects beginning 3 months: Follows object to periphery 5 months: Visually pursues dropped object 7 months: Responds to own name; Has taste preference 12 months: Begins to discriminate simple geometric forms Infant: Vocal Development 1 month: Cries to express displeasure; Makes small throaty sounds; comfort sounds with feeding 2 months: Coos; vocalizes to familiar voice 3 months: Babble/Chuckle; Less crying while awake 4 months: Laughs aloud; Starts making consonant sounds (n, k, g, p, b) 6 months: Begins to imitate sounds 8 months: Combines syllables such as dada 12 months: dada, mama with meaning; May say 3-5 words Infant: Social Development 1 month: Sensorimotor phase, Stage 1, Use reflexes 2 months: Social smile responding to stimuli 4 months: Enjoys social interaction 6 months : Begins to recognize parents and fear strangers ; Holds out arms to be picked up 8 months: Increase anxiety over parent leaving; Responds to the word NO 10 months: Develops object permanence; Waves Bye-Bye 11-12 months: Plays “so big” and “Peek-a-boo”; Show emotions (jealousy, hug, kiss, anger, fear) Infant Nutrition Human milk or formula for first 4 to 6 months exclusively Nutritional supplements for exclusively breast fed babies: o Vitamin D—possibly within the first couple months o Iron Breast milk: o Increases intelligence level, sense of independent o Decreases incident of childhood allergies, asthma, cancer
o Maternal aspects if a mother breastfeeds for 2 years of her life---her own personal risk of breast cancer will decrease as much as 50% Better bonding Better weight loss after baby o Infants who are breastfed of bottle fed do not need additional water during the first 4 months of life Number and volume of feedings will vary over time o 30-32 oz./day is normal max o Bottle fed 3-4 hours, older 4-6 hours o Nurse about 8 times a day, initially When and how to add food??? o Cereal/ “rice cereal”: 4 months o Fruits and vegetables: after 6 months Can do either 1 first: introduce 1 at a time and take 5-6 days before introducing next food Trying to prevent any allergic reaction—better to pinpoint the causing factor if less food is being given at the time o Mashed table food 6-7 months o 7-8 months: table foods, no more bottle can affect teeth development o Get rid of bottle about 8 months or so….move over and start using the cup. o 9-12 months old--- can almost be eating all types of table foods o Don’t give children honey until the age of 2 d/t fear of botulism o Don’t give peanut butter to a child—typically until they’re 2-3!---definitely no peanut butter the 1st^ year of life Family allergies, hold off o Breast milk or formula for first year of life o Whole milk at 1 year old (for the next year of life)---babies need the fat for their body Infant Play Birth to 1 month o Look at infant at close range o Hang mobiles with black and white designs 2-3 months o Provide bright objects o Take infant to various rooms while doing chores 4-6 months
-tiredness -pain in muscle, joints and stomach -diarrhea and vomiting -jaundice -liver damage -liver cancer -death -- If mom is positive for Hep. B they might get immunoglobin Hep B to stop the transfer Rotavirus --- given orally well tolerated- protect child against diarrhea contact isolation recommended doses: o 1 st: 2 months of age o 2 nd: 4 months of age o 3 rd: 6 months of age (if needed) Child much get the first dose of this vaccine before 15 weeks of age, and the last by age 8 months. May safely be given at the same time as other vaccines Tell doctor if your baby has severe allergies that you know of, including a sever allergy to latex If the baby has had a type of bowel blockage called “intussusception”.. they should not get vaccine DTaP --- diphtheria and pertussis are spread from person to person (enters through cuts or wounds)
- Diphtheria causes think covering in the back of the throat: can lead to breathing problems, paralysis, heart failure, and even death
- Tetanus (lockjaw ) causes painful tightening of the muscles, usually all over the body: can lead to “locking” of the jaw so the victim cannot open his mouth or swallow. Tetanus leads to death in up to 2 out of 10 cases -Pertussis (whooping cough) causes coughing spells so bad that it is hard for infants to eat, drink or breathe. Can last for weeks: can lead to pneumonia, seizures (jerking and staring spells), brain damage, and death. Fever 24 – 48 hours after injection, low grade Soreness, redness and swelling at site Fussiness and general malaise Contraindication o Underlying Neurological symptoms o Previous reaction Adverse Reactions Fever >105, Seizures (DTaP) , Shock like-state o Seizure precaution Give Tylenol (any age) Ibuprofen (> 6 months age) o Can cause kidney failure – kidney production decrease CDC info: Children should get 5 doses of DTap vaccine o 2 months o 4 months o 6 months o 15-18 months o 4-6 years Children who are moderately or severely ill should usually wait until they recover before getting DTap Never get another dose of DTap if you’ve experienced a life-threatening allergic reaction, or suffered a brain or nervous system disease within 7 days after a dose was given DTap is not licensed for adolescents, adults, or children 7yrs or older
o A vaccine called Tdap is similar to DTaP. A single dose of Tdap is recommended for people 11 through 64 years of age. Another vaccine, called Td, protects against tetanus and diphtheria, but not pertussis. It is recommended every 10 years. o Tdap pregnant women should get a dose of Tdap during every pregnancy, to protect the newborn from pertussis. Infants are most at risk for severe, life threatening complication from pertussis. Tdap Can protect adolescents and adults from tetanus, diphtheria, and pertussis. One dose of Tdap is routinely given at age 11 or 12 Td —another vaccine which protects from tetanus and diphtheria o Should be given every 10 years IPV —polio prevention Well tolerated, few side effects Contraindications o Previous reaction to neomycin, streptomycin, or polymyxin B CDC info: -children get 4 doses of IPV (subq) -2 months -4 months -6-18 months -Booster dose at 4-6 years MMR --- spread from person to person through the air (LIVE VACCINE) ** Measles airborne precaution Low grade fever, anorexia, and malaise 7-10 days after injection Contraindications o Allergic reaction to antibiotic neomycin and eggs--- do not get vaccine o Immunodeficiency----do not give to immunocompromised patients Ex: HIV/ AIDs –low cd4 count ---then do not give vaccine o Pregnancy —should not receive during pregnancy. Wait until after birth to receive the vaccine. Women should avoid getting pregnant for 4 weeks after vaccination with MMR vaccine. Adverse reactions o Persistent fever with other signs of illness Get within 12-15 months CDC info: -should get 2 doses of MMR -1st^ dose: 12-15 months of age -2nd^ dose: 4-6 years of age (may be given earlier, if at least 28 days after the 1st^ dose) MMR may be given at the same time as other vaccines Can see this mixed with varicella (chickenpox)—(MMRV) LIVE VACCINES Won’t have onset of s/s until 5-10 days Tell your doctor if the person getting the vaccine: -HIV/AIDS -using steroids -Has cancer--- or using radiation or drugs for treatment -low platelet count -has gotten another vaccine within the past 4 weeks -recent transfusion or received other blood products HIB this disease is serious that is caused by bacteria. Usually affects children under 5 years old. *germs spread from person to person
- HIB disease was the leading cause of bacterial meningitis among children under 5 years old in the U.S.
