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Metro Community College Nancy Pares, RN, MSN Healthcare provider must obtain Must be obtained for invasive procedures and some medical treatments May be delayed in emergency situations Discuss ethical, legal issues related to childhood period. Assess and document Review rights of minors Develop therapeutic relationship Verify prior consent Serve as witness Until the person reaches age of adult based on state law, parent or guardian must provide informed consent. Parent or guardians have ultimate decision, with some exceptions. Emancipated minor Minor is parent of a child receiving treatment Assent and preference by child should be obtained Ability to save lives of severely impaired infants Genetic testing Gene therapy Define Evaluate Identify Apply principles Make decisions Nurses use four ethical principles ◦ ◦ ◦ ◦ Beneficence Nonmaleficence Autonomy Justice Ethics committees resolve conflicts and make recommendations End of life-sustaining treatment Genetic testing of children Organ transplant Research on children Ongoing and cyclical Exchange of thoughts, feelings, information Importance of trust and rapport Components—sender, message, channel, receiver, response Discuss age appropriate assessment and therapeutic communication in the care of the child. Sender—generates the message Message—verbal, nonverbal, or abstract Channel—auditory, visual, kinesthetic Receiver—decodes the message Response—feedback to sender Verbal Nonverbal Abstract Verbal and written words, vocalizations ◦ Speaking to another ◦ Writing a letter ◦ Crying, laughing Influenced by development and cognitive level Influenced by culture How does the nurse use verbal communication in nursing care? Forms of Nonverbal Communication ◦ ◦ ◦ ◦ ◦ ◦ ◦ Paralanguage Gestures Touch Personal space Facial expression Body language Eye contact Forms of Nonverbal Communication ◦ Physical appearance ◦ Facial Expression ◦ Ambiguity Influence of development and cognitive level Influence of context—what is the situation? Influence of culture ◦ Congruence between verbal and nonverbal message How should nonverbal communication be applied to nursing care? Developmental level Skills Language development Cognitive development Emotional/personality development Primary mode of communication is nonverbal Express self through crying Respond to human voice and presence Touch has a positive effect Nursing strategies include: encourage parent to touch infant Communication is still primarily nonverbal Begin verbal communication with vocalizations Communicate through crying, facial expression Attentive to human voice and presence although no comprehension of words Respond to touch through patting, rocking, stroking Nursing strategies include: speak in highpitched voice, cuddle, pat, rub to calm Evolving verbal skills Use of language to express thoughts ◦ Greater receptive than expressive language ◦ Concrete and literal thinking,may misinterpret phrases ◦ Vocabulary depends on development and family’s use ◦ May ask many questions (preschooler) Short attention span Limited memory Cognitive development ◦ Egocentric ◦ Magical thinking ◦ Animism Nonverbal communication ◦ Express self through dramatic play and drawing Nursing strategies Cognitive development now able to use logic ◦ Begin to understand others’ viewpoints ◦ Begin to understand cause-effect ◦ Understanding of body functions Verbal communication ◦ Vocabulary is large ◦ Receptive and expressive language balanced ◦ Misinterpretations of phrases still common Nonverbal communication ◦ Can interpret nonverbal messages ◦ Expression of thoughts and feelings Abstract thinking without full adult comprehension Interpretation of medical terminology is limited Drive for independence Trust and understanding build rapport Need for privacy Nursing strategies include: straightforward approach, talk in private area If unable to communicate,may feel helplessness, fear, anxiety Family may become anxious Strategies ◦ Nonverbal—use gestures, picture boards, writing tablets ◦ Communication augmentation—system of head nods, eye blinks Approach to child—identify self as you enter room, announce departure Orient child to objects in room Speak before touching Explain any unfamiliar sounds Approach to child—face child when speaking, enter room slowly Assess degree of impairment—may need interpreter Cultural implications—need to develop plan of care in respect of culture Use of interpreters ◦ Family—could result in errors and inconsistency ◦ Use professional translators trained for patient encounters Other strategies include: communication with pictures, speaking in normal tone Development Language Physical skills Culture Barriers Play Culture Journaling Importance of rapport ◦ What is rapport? ◦ How do you establish rapport? With parents? With children? Introduction Purpose of interview Use of open- and closed-ended questions Timing of questions Nonverbal communication Observations Honesty Language Past health and illness history/ages of occurrence ◦ ◦ ◦ ◦ Birth history Communicable diseases and illnesses Hospitalizations and surgery Injuries Current health status ◦ Health maintenance pattern and last visit Family History Medications—prescribed and OTC ◦ ◦ ◦ ◦ ◦ ◦ Allergies Immunization status—up to date? Safety Activity and exercise Nutrition Sleep Review of systems Family composition Home environment, housing, neighborhood School or childcare Daily routines Changes in family or family life since last healthcare encounter ◦ Separation, divorce, or death of a parent ◦ Who lives in the household? Age-specific issues ◦ Newborns ◦ Adolescents Developmental status, history, and patterns ◦ ◦ ◦ ◦ Motor Cognitive Language Social Praise parental presence and responses Promote physical comfort and relaxation Distract infant with colorful toys Auscultate when quiet or sleeping Do procedures that provoke crying at end of exam Parent’s lap Play Security object Instruments Control and choice Sequence Games and activities Demonstrate and let them touch instruments Distraction Ensure modesty and privacy Offer choices Explain body parts and functions Decide on parental presence or absence Consider need for nonparent chaperones Reassure adolescents of normalcy Head Chest Abdomen Spine Skin imperfections Appearance Behavior Interaction with parents Interaction with examiner Length ◦ Birth to 24 months ◦ Measuring board Height ◦ After age 2 years ◦ Stadiometer Weight ◦ Infant scale Kilograms, grams, and pounds and ounces ◦ Standing scale ◦ Diapers and clothing Centimeters and inches ◦ ◦ ◦ ◦ Paper tape Measure twice Up to age 2 to 3 years Around supraorbital and occipital prominences Body mass index ◦ ◦ ◦ ◦ Less than 5th percentile Greater than 85th percentile Greater than 95th percentile Calculation: weight in kg/m2 of height Skin ◦ Color, temperature, moisture ◦ Rashes, lesions ◦ Skin turgor Hair ◦ Texture, amount, fullness ◦ Breaking off? ◦ Head lice Shape of head and face Symmetry Skull sutures Fontanels Inspection ◦ Hypertelorism ◦ Palpebral slant Inspection ◦ Extraocular movements (EOMs) Inspection ◦ Strabismus Light reflex Cover-uncover test Vision ◦ Infant tracking ◦ Age-appropriate tests of visual acuity Fundoscopy ◦ Red reflex ◦ Internal structures Inspection ◦ Symmetry Shape of tragus Position and alignment Ear canal Tympanic membrane Hearing assessment ◦ ◦ ◦ ◦ ◦ ◦ Newborn screening Audiometry Noise and whisper tests Tympanometry Bone and air conduction tests Indicators of hearing loss Inspection Palpation Percussion Patency Smell Lips Teeth Gums Mucosa Tongue Throat and tonsils Inspection ◦ Swelling ◦ Webbing Palpation ◦ Nodes ◦ Trachea ◦ Thyroid gland Range of motion ◦ Torticollis ◦ Meningismus Inspection ◦ Shape ◦ Chest deformities Inspection ◦ Movement, excursion ◦ Respiratory effort, retractions, respiratory rate ◦ Breasts Palpation ◦ Crepitus ◦ Tactile fremitus Auscultation ◦ Hyperresonance Percussion Inspection ◦ Precordial activity ◦ PMI Palpation ◦ Apical impulse ◦ Thrills Percussion Auscultation ◦ Rate and rhythm Auscultation ◦ Normal heart sounds S1 and S2 Splitting S3 Auscultation ◦ Abnormal heart sounds Murmurs Intensity, location, radiation, timing, quality Intensity grades Venous hum Pulse Related assessments Blood pressure Inspection ◦ ◦ ◦ ◦ ◦ Shape Umbilicus Rectus muscle Abdominal movements Inguinal area Auscultation Percussion Palpation Positioning Timing in examination Females Males Anus and rectum Puberty and sexual maturation ◦ Females ◦ Males Tanner Scale ◦ Sexual maturity rating (SMR) Inspection Palpation Range of motion Muscle strength Posture and spinal alignment Upper extremities ◦ Shoulders ◦ Arms and elbows ◦ Hands and wrist Lower extremities ◦ Hips Lower extremities ◦ Legs and knees ◦ Feet and ankles Cognitive functioning ◦ ◦ ◦ ◦ Behavior Communication skills Memory Level of consciousness Cerebellar function ◦ Balance ◦ Coordination ◦ Locomotion, gait Sensory functioning Primitive reflexes Superficial and deep tendon reflexes Onset of secondary sex characteristics vary Sexual maturity rating (SMR) ◦ Females: average of breast and pubic hair development ◦ Males: average of genital and pubic hair development Tanner stages: rating between 2–5, stage 1 is prepubertal Inspection and palpation to assign a tanner stage Identify normal findings Identify abnormal findings ◦ Sort normal from abnormal findings ◦ Group normal and abnormal findings together ◦ Recognize patterns from normal and abnormal findings ◦ Identify health concerns, problems, conditions Appropriate referral for treatment Determination of nursing diagnoses based on health assessment findings Collaboration with child, family, other healthcare providers to develop goals Identification and implementation of appropriate interventions Transition to extrauterine life ◦ Initiation of respirations ◦ Transition from fetal to adult circulation Physiologic condition and needs Resuscitation Apgar score ◦ Adaptation to extrauterine life ◦ 1 and 5 minute score ◦ Apgar criteria Ballard gestational age assessment tool ◦ Physical characteristics Skin Lanugo Plantar surfaces Ballard gestational age assessment tool ◦ Physical characteristics Breasts Ballard gestational age assessment tool ◦ Physical characteristics Ear cartilage and eyelid fusion Ballard gestational age assessment tool ◦ Physical characteristics Genitals Ballard gestational age assessment tool ◦ Neuromuscular characteristics Posture Ballard gestational age assessment tool ◦ Neuromuscular characteristics Square window Ballard gestational age assessment tool ◦ Neuromuscular characteristics Arm recoil Ballard gestational age assessment tool ◦ Neuromuscular characteristics Popliteal angle Ballard gestational age assessment tool ◦ Neuromuscular characteristics Scarf sign Ballard gestational age assessment tool ◦ Neuromuscular characteristics Heel-to-ear extension Small for gestational age Appropriate for gestational age Large for gestational age Growth curves Accuracy of anthropometric measures in newborns Head/body ratio Position Motor activity Cry Vital signs ◦ ◦ ◦ ◦ Thermoregulation Respirations Pulse Blood pressure Skin ◦ ◦ ◦ ◦ ◦ Peeling Lanugo Normal color variations Jaundice Common alterations Head ◦ Molding ◦ Caput succedaneum Head ◦ ◦ ◦ ◦ Cephalohematoma Sutures Fontanels Symmetry Eyes ◦ ◦ ◦ ◦ ◦ ◦ Chemical conjunctivitis Blink reflex Red reflex vs. opacities Sclerae Tracking Doll’s eye phenomenon Ears ◦ Position ◦ Skin lesions or tags ◦ Hearing Nose ◦ Appearance ◦ Patency of nares ◦ Flaring Mouth ◦ ◦ ◦ ◦ ◦ ◦ Palate Tongue, frenulum Buccal mucosa Gums Gag, suck, swallow Epstein’s pearls, neonatal teeth, inclusion cysts Neck ◦ ◦ ◦ ◦ ◦ Position Appearance Torticollis Webbing, skin folds Clavicles Chest Chest and Lungs ◦ Appearance—Barrel chest? ◦ Breasts—Engorgement? Nipple discharge? ◦ Respirations—Periodic breathing? Retractions? Grunting? ◦ Breath sounds Heart ◦ Location of apical impulse ◦ Murmurs ◦ Pulses Abdomen ◦ Appearance ◦ Bowel sounds ◦ Umbilicus and umbilical cord Genitalia and anus ◦ ◦ ◦ ◦ Appearance and relation to gestational age Females—vaginal discharge Males—penis, urethra, testes Patency of anus Stooling pattern Anal wink Extremities ◦ Deformities ◦ Injuries ◦ Developmental hip dysplasia Symmetry of creases Allis sign Barlow-Ortolani maneuver Spine ◦ Muscle strength and position ◦ Head control Neurological system ◦ ◦ ◦ ◦ Alertness Posture Protective reflexes Primitive reflexes Apply the nursing process to the care of the pediatric patient in various acute care settings ◦ ◦ ◦ ◦ Acute Isolation Emergency Intensive Care Unaware of illness and its effects Sense stress and anxiety in loved ones Awareness of self as separate from parents by 6 months Stranger anxiety Sees illness as punishment ◦ Has incorrect cause-and-effect perceptions ◦ Begins to understand concept of germs Knows outside body-part names ◦ Has vague knowledge of internal organs Knows cause and effect of illness Beginning understanding of body functions Older school age can understand explanations Understands complex nature of illness ◦ Multiple causes and effects ◦ Knows location and function of major organs Concerned with ◦ Effects of illness on appearance ◦ Body image Protest ◦ Screaming, crying, clinging ◦ Resists attempts to comfort Despair ◦ Sad, withdrawn, quiet ◦ Cries when parents return Denial ◦ Protest subsides, shows interest in setting ◦ Appears happy and content Separation ◦ All ages affected Fear of the unknown ◦ Injections, blood, being touched by strangers ◦ Pain, disfigurement, invasive procedures, death Loss of control ◦ Mobility, autonomy, privacy Separation ◦ Withdrawal, abandonment, regression Fear of the unknown ◦ Sleep disruption, anxiety reactions Loss of control Aggression, regression, displacement Disruption of daily routine Role change Anxiety and fear Need support, encouragement, honest information Coping strategies Cultural views Assess family ◦ Roles, knowledge, support systems Planned hospitalization ◦ Tours, videos, books to prepare Unplanned hospitalization ◦ Great stress on child and family ◦ Siblings may feel guilt, fear, or neglect Depend on ◦ ◦ ◦ ◦ ◦ Age Developmental level Perception and severity of illness Prior experience and coping Knowledge and understanding of illness Honesty Reassurance: they did nothing wrong to cause the illness Allow questions and discussion of feelings Encourage visits: prepare patient and siblings to minimize adverse reactions Recreation: toys, games, activities, physical activity Rest: calm, quiet; bedtime rituals Relationships: family members, siblings, peers, support groups Routines: follow normal routine, provide transition objects, provide consistent caregivers Rooming in ◦ 24/7 parental visitation/family time ◦ Parental involvement with care Communication ◦ Phones, beepers, location of family members ◦ Contact for change in condition, procedures ◦ Education Maximize control ◦ Give choices ◦ Encourage independence Therapeutic play ◦ Address fears, concerns Therapeutic recreation ◦ Interactive activities Minimize fears and anxieties Incorporate familiar routines into hospitalization Support family and loved ones Minimize loss of control; promote autonomy Assessment ◦ ◦ ◦ ◦ Knowledge and previous experiences Developmental age Coping abilities Feelings: fears, concerns Communication based on developmental level ◦ Clear ◦ Honest ◦ Age appropriate Assess: knowledge, perception, and feelings ◦ ◦ ◦ ◦ ◦ Purpose Past experience Will it be painful? Coping techniques Will parents be present? Communication ◦ Use understandable language ◦ Gear to cognitive level and past experience ◦ Share ways to cope during the procedure Physical preparation Depends on age and procedure NPO? Procedural checklist Pain management Focus on psychosocial needs Age-appropriate play Medical play/acting out procedures Therapeutic play Dramatic play Storytelling Drawings, body outlines Music, tape-recorded messages Puppetry Dramatic play Animal-assisted therapy General pediatric units Emergency department (ED) Neonatal intensive care unit (NICU), pediatric intensive care unit (PICU), or special care units Preoperative and postoperative units, postanesthesia care units (PACU) Short-stay, outpatient, or ambulatory surgical units Isolation Rehabilitation Provides feelings of control Prepares family for care required at home Reduces emotional stress and anxiety Promotes feelings of value, worth, and competence to care for their child Promotes parents feeling fully informed, trust of nursing staff Family ability to provide care ◦ Equipment, training Financial burdens Educational needs ◦ Parent teaching ◦ Return to schoolwork Plans for school, recovery, adaptation ◦ Individualized education plan (IEP) ◦ Individualized transition plan (ITP) Prepare the family ◦ Procedures, medications, emergencies Prepare parents to act as case managers Preoperative ◦ Teach purpose, sensations ◦ Allow transition objects: teddy bears, blankets ◦ Parental presence during anesthesia induction Postoperative ◦ Expectations during recovery ◦ Monitoring and assessment ◦ Nursing Care Plan:The Child Undergoing Surgery Informal or structured ◦ ◦ ◦ ◦ For child and parents Consider timing and level of understanding Consider special health needs Translators if needed Teaching plans: include all the domains ◦ Cognitive ◦ Psychomotor ◦ Affective Assess ◦ Knowledge, skills, feelings, expectations ◦ Cognitive level, ability, desire Set clear, measurable goal(s) Select method(s) ◦ Audio, video, text, demonstration, or combination Evaluate learning outcome ◦ How well was goal met? Effect on understanding of death Effect on behavioral response to death Effect on ability to communicate about death Describe the nursing interventions and stages of grief associated with the chronically ill or dying child Parent Grandparent Friend Pets or objects Loss of an aspect of self Loss of an object or pet Separation from an accustomed environment Losses not directly related to the child ◦ Crime ◦ Disasters ◦ Terror attacks Cultural traditions and practices Religion and spirituality Social support systems Promote open communication Struggle with emotions is common Identify what is known, how much child wants to know Listen and give support Decision is extremely difficult Parents or nurses may feel that aggressive therapies extend child’s suffering Parents and healthcare providers may disagree regarding interventions Refusal may be based on religious beliefs or desire to provide peaceful death Technical interventions may cause emotional stress to parents Court interventions may be used Consultation with hospital ethics committee Palliative care—an approach to improve QOL Hospice care—care focusing on ensuring comfort Do Not Resuscitate request Tissue and organ donation Autopsy Privacy Body language Social support Response to emotions Timing Illness- or injury-dependent changes Universal changes ◦ ◦ ◦ ◦ ◦ ◦ ◦ Cardiovascular system Respiratory system Neurological system Musculoskeletal system Renal system Altered nutrition Fluid and electrolyte imbalance Fears and concerns Coping skills Awareness ◦ Closed awareness ◦ Mutual pretense ◦ Open awareness Spiritual needs Fear Hopelessness Risk for caregiver role strain Interrupted family processes Anticipatory grieving Goal setting Competencies for high-quality end-of-life care Special concerns ◦ ◦ ◦ ◦ ◦ Pain management Trust Anger Education Desired religious or cultural practices Allow as much time as needed for farewells Provide privacy Save clothing and personal items Collect footprints, locks of hair, and so on Preserve the last clothes worn in a sealed bag to retain the child’s scent Identify and implement any religious or cultural practices desired by the family Clean and position the body Help parents predict when they may expect increased grief Remind parents to care for themselves mentally and physically Tell parents that people progress through grief at different rates Remind parents that grief puts a tremendous stress on relationships Encourage parents to provide for ongoing support of siblings Arrange for continued follow-up for families after the acute period of grief Helpless That they failed the dying child Sad Grief Special preparation is required for the nurse ◦ Mentorship with hospice nurse ◦ Debriefing sessions with mental health professional