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Chapter 1
Child Health Evolution
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
Key Terms
• Anticipatory guidance
• Critical thinking
• Emancipated minor Evidence-based
practice
• Healthy People 2000: National Health Promotion
and Disease Prevention Objectives
• HIPAA
Holistic
• Infant mortality rate Informed consent
• Mature minor doctrine Morbidity
• Pediatric
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Learning Objectives
• Define or identify vocabulary terms listed
• List government programs that have affected the
care of children
• Contrast present-day causes of morbidity and
mortality with those of the past
• Discuss current health care trends in pediatrics
and the effect they have on nursing care
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Pediatrics
• The branch of medicine that deals specifically
with children, their development, childhood
diseases, and the treatment of such diseases
• The study of pediatrics began under Abraham
Jacobi (1830-1919), a Prussian-born physician
– Known today as the father of pediatrics
– Paved the way for the promotion of children’s
health through the establishment of “milk stations”
• Mothers could bring sick children for treatment and
learn the importance of pure milk and its proper
preparation
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Pediatrics
Recent Evolution of Nursing Care
• Over the past 100 years, the nursing care of
children has evolved into a holistic approach
– Children have a physical, intellectual, emotional,
and spiritual nature with needs that differ
according to their developmental level
• Modern medicine has reduced death and
disability over the past 100 years
– Allows pediatric nurses to focus on improving the
scope and quality of their care for each child
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Government Programs
• White House Conference on Children and
Youth
– First one in 1909
– Issued 15 recommendations
• E.g.: Children’s Bureau for Child Welfare, est. 1912
• Social Security
– Began matching state/federal funds for
maternal/child care and child disability in 1935
– Supports preventive health programs; i.e.,
immunization, screenings
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Government Programs
• The Fair Labor Standards Act
– Passed in 1938
– Regulates work conditions for children under 18
• Medicaid and the Children and Youth Project
– Formed in 1965
– Provides care for children in low-income and inaccessible
areas
• The Special Supplemental Food Program for Women,
Infants, and Children (WIC)
– Started in 1966
– Safeguards the health of low-income
women and children up to age 5
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Government Programs
• The Child Nutrition Act
– Enacted in 1966
– Provides free or reduced-rate meals for lowincome children
• The Missing Children’s Act
– Passed in 1982
– Established a clearinghouse for efforts and
services related to missing children
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Government Programs
Safeguarding Uninsured and Underinsured Children
• The Children’s Defense Fund
– Advocates children’s health care reform
• The Balanced Budget Act of 1997
– Established the State Children’s Health Insurance
Program (SCHIP) as Title XXI of the Social Security Act
• Expands insurance coverage to many uninsured children
ineligible for Medicaid
• The Patient Protection & Affordable Care Act
• The Health Care & Education Reconciliation Act of 2010
– Both address the issue of inadequate health care
coverage for children
Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.
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Government Programs
Health Promotion
• Healthy People 2000: National Health Promotion
and Disease Prevention Objectives
– 1990 – document released by the U.S. Department of
Health and Human Services
– Presents an opportunity for Americans to take
responsibility for their own health
– Equal access to health care for all, particularly the most
vulnerable (i.e., infants and children)
• Healthy People 2010 is a follow-up to Healthy People
2000
• Healthy People 2020 continues to strive for a healthier
nation
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Changes in Mortality and Morbidity
• Infant Mortality Rate
– The number of infant deaths per 1000 live
births
– Has declined from approximately 200 in 1900
to 20 deaths in 1970 to 6.77 in 2007.
– Infant mortality among infants of non-Hispanic
black mothers is much higher than nonHispanic whites and Hispanic mothers
(Heron, Sutton, Xu, et al., 2010).
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# of infant deaths per 1000 live births
U.S. decline in infant mortality rate over the past 100
years
250
200
150
20%
100
50
2%
.68%
0
1900
1970
2007
Year
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Changes in Mortality and Morbidity
• Childhood morbidity (illness, chronic disease,
disability) is affected by
–
–
–
–
general health
socioeconomic status
access to health care
psychosocial factors
• At-risk children who often have more frequent
illnesses:
–
–
–
–
homeless
live in poverty
attend daycare regularly
decreased access to the health care system
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Current Practice
Education Requirements
• Because of the rapid changes taking place in
health care today, it is the nurse’s
responsibility to update his or her knowledge
continually
• Nurses have a responsibility to the
community and to their profession
– Involvement in community and professional
organizations is not simply encouraged; it is
absolutely essential for continued growth in an
ever-changing society
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Current Practice
Research and Roles
• Evidence-based practice
– Through examination of research literature,
nurses can analyze important evidence and
improve the quality of care for their patients
• Anticipatory guidance
– Caring for children in today’s society
necessitates careful assessment and early
identification of children and families at risk
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Current Practice
Critical Thinking and the Nursing Process
• Critical Thinking
– Emphasizes process, inquiry, reasoning, creativity,
and ingenuity, so that the nurse can draw the best
conclusion regarding a situation
– One’s ability to think and find solutions that provide
the most effective nursing care
• The Nursing Process incorporates five phases
–
–
–
–
–
Assessment
Diagnosis
Planning
Implementation (intervention)
Evaluation
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Current Practice
Critical Thinking and the Nursing Process
• Assessment phase
– Also known as the data-gathering phase
– The nurse obtains information about the child’s
physical, social, and emotional health, as well as
the family’s adaptation to health alterations
• Diagnostic phase
– Lists problems that emerge from the assessment
– Diagnoses approved by the North American
Nursing Diagnosis Association (NANDA) are
listed on the inside back cover of your textbook.
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Current Practice
Critical Thinking and the Nursing Process
• Planning phase
– Nurse uses goal-setting and outcome criteria to
construct a plan of care to treat diagnoses
• Implementation (intervention) phase
– Nurse executes plan of care constructed in the
planning phase
• Evaluation phase
– Nurse appraises the changes experienced by the
child or family in relation to achieving goals or
outcomes
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Documentation
• The nurse must document assessment
findings throughout the child’s stay,
regardless of setting
• Ensures completeness of care
• Important legally
– Always document time
– Each patient’s chart is a legal document
– In lawsuits, if something was not charted, it
was not done!
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Confidentiality and Informed Consent
• Health Insurance Portability & Accountability Act
(HIPAA)
– Enacted in 1996
– Requires strict observance of confidentiality
within the hospital setting
• This includes spoken confidentiality and patient records
– When working with older children and teens,
nurses should explain confidentiality and its limits
• Plan to harm oneself or others
• Any abuse that may have occurred
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Confidentiality and Informed Consent
• Informed consent
– Obtained from the parent or legal guardian when written approval is
needed to perform a procedure for an underage, not emancipated
minor
– Nurses are responsible for witnessing the signing of informed
consent
• Emancipated minor
– Adolescent younger than 18 years old, but no longer under parental
authority
• Mature minor doctrine
– Laws designed to afford young people medical care without parental
consent
– Varies from state to state (NJ has no provision for minor or
emancipated minors to consent to routine medical treatment)
•
[NAEHCY; Faegre & Benson LLP; January 15, 2009; SUBJECT: Unaccompanied Youth and Access to Medical
Care]
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Health Care Delivery Settings
Clinics and Offices
• Outpatient facilities and/or community clinics
– Run by larger hospital with collaborating group of
physicians, or a private physician’s office
• Both general and specialty clinics exist
– Cardiac, orthopedic, respiratory, etc
• Elective surgery in outpatient clinics
• Parents/caretakers are taught all of a child’s recovery
needs at home for a same-day discharge procedure
• Triage
– In most offices/clinics, nurses triage (prioritize) and
respond to telephone inquiries
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Health Care Delivery Settings
Office and Home Care
•
•
•
•
Pediatric Nurse Practitioner (PNP)
– Provide in-clinic patient care, and routine physical exams in collaboration with the
physician
– Often the primary contact person for children in the health care system
Increasingly home care is popular due to technical improvements
– Ongoing IV therapy home care
– Phototherapy home care for jaundice
– Lower cost
– Increased patient satisfaction
Case Manager
– Plays a vital role in home care arrangements by managing complete medical
care for the patient
– Facilitates linking home care families into a wide variety of network services
Hospice
– A team of hospice nurses and caregivers assist the families in providing home
care for terminally ill children
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Health Care Delivery Settings
Other Settings
• Support groups
– Geared toward family support and learning
– Group therapy aids in the prevention of mental health
problems for children who have undergone stressful situations
• Camps
– Many exist in the U.S. for children with chronic illnesses
– Camp nurses ensure children receive proper care
• Parish nurses
– Promote health within the context of a faith community
• Long-term care facilities
– May be necessary for children with severe mental retardation,
multiple disabilities or medical fragility
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The Hospital Setting
• Pediatric units differ from adult units
– A more cheerful, casual atmosphere in keeping with the
child’s emotional and physical needs
• Most pediatric departments include a playroom with
toys for various age groups run by a child life
specialist
– Nurses provide age-appropriate toys to children who
can’t leave their rooms
• A flexible routine is typically maintained in regards to
eating, play, and rest
• Most hospitals provide beds and encourage parents
to stay with their children
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The Child’s Reaction to Hospitalization
• Factors
–
–
–
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Age
Previous illness-related experiences
Support of family and health professionals
Emotional status
MOMMY?!!
• Stressors
–
–
–
–
Separation anxiety
Loss of control
Bodily injury
Pain
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The Child’s Reaction to Hospitalization
Infants and Toddlers
• Separation anxiety
– The major stressor of hospitalization for toddlers
– Occurs in the following stages
• Grief
– Protesting loudly and crying for
their mothers until falling asleep from exhaustion
• Despair
– Depression, lethargy, refusal to eat
• Denial
– Deny the need for mother by appearing detached and
uninterested in her visits
– A disguise to prevent further emotional pain
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The Child’s Reaction to Hospitalization
Infants and Toddlers
• Loss of control
• Regression
– Toddlers will abandon recently acquired skills and
demand assistance with tasks previously
mastered
– Nurses should remind parents that this is normal
behavior when toddlers are hospitalized
• Fear of injury
– Minimizing fear of injury stressors
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The Child’s Reaction to Hospitalization
Infants and Toddlers
• Dealing with the stressors of hospitalization
– Toddlers achieve control through choices
– Forewarn children about any unpleasant or new
experience immediately beforehand
– Be honest about procedures, etc., that may hurt
– Explain procedures step-by-step as they occur
– Encourage play with safe equipment; i.e.,
stethoscopes under supervision
– Administer treatments in a room other than the
child’s room
– Allow toddlers out of the crib whenever possible
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The Child’s Reaction to Hospitalization
Preschoolers
• Separation anxiety
• Uncooperative; frequently ask for parent
• Loss of control
– Many preschoolers perceive hospitalization as
punishment
• Regression
– E.g.: bedwetting
• Fantasy
•
–
–
–
Pre-logical thinking; fantasy
Fear of hospital machinery
Nightmares
Fear of bodily harm during procedures
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The Child’s Reaction to Hospitalization
Preschoolers
• Communication between nurse and patient
– Use understandable language when describing
procedures
– Communicate time as a series of events, not
hours and minutes
– Be aware of verbal and nonverbal cues
– Participate in fantasies in a positive way, giving
the child control over imagined situations
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The Child’s Reaction to Hospitalization
School-Age Children
• Separation anxiety
• Miss parents but miss friends more
• Loss of control
– Children in this age group are learning to control
their feelings and actions
– Independence is limited
– They may have changes in vital signs due to
stress when hospitalized, even if making efforts to
seem calm
• Fear of pain, bodily harm, permanent
disability, body disfigurement or death
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The Child’s Reaction to Hospitalization
School-Age Children
• Dealing with the stressors of hospitalization
– Bring items from home for familiarity and control
– Drawing
– Board games with involved adults
– Maintain the child’s privacy
– Continue education; connect to the outside world
– Encourage classmate correspondence; Oh, the
cell phones!!!
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The Child’s Reaction to Hospitalization
Adolescents
• May be hesitant to have visitors
– May be embarrassed by appearance
– Fear that illness or procedures will change them
• Compliance may be a problem with a chronic disease
– Probably afraid and stressed, even if they seem calm
• Dealing with the stressors of hospitalization
– Fear of the unknown; explain everything in an
age-appropriate manner
– Offer choices to maintain control and
independence
– Clear limits and expectations so adolescents feel
less confused
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The Hospitalized Child
The Family’s Reaction to Hospitalization
• Parents may initially feel guilty, helpless, and
anxious
• Developing a trusting relationship with
parents is often the key to helping the child
• Hospitalization may cause financial problems
for the family
• The nurse assesses the family’s needs and
develops interventions to meet these needs
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The Hospitalized Child
The Family’s Reaction to Hospitalization
• Nursing Interventions
– Assist parents in obtaining written and verbal
information concerning the condition of the child and
the treatment plan
– Orient the family to hospital and explain all
procedures
– Refer the parents as needed to social services
– Listen to parents’ concerns and clarify information
– Involve parents in the care of the child
– Provide for rooming-in
– Reinforce positive parenting
– Provide educational resources as necessary
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The Nurse’s Role
Admission Process
• Provide a tour for the parents and child before admission, if
possible to decrease fear of the unknown
• Focus on pleasant and positive aspects—but not to the
point where hospitalization seems to involve no discomforts
• Security objects from home reduce anxiety in an unfamiliar
setting
• Explain certain procedures, listen to patients and encourage
questions
• Document admission information; perform a systems review
and physical examination of the child
• All medications are reconciled upon admission, transfer,
and discharge
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The Nurse’s Role
Health History
• Statistical information (name, address, phone
number)
• Patient profile (eating and sleeping habits,
educational level, developmental level, etc.)
• Health history (birth history, illnesses,
immunizations, previous hospitalizations, allergies,
etc.)
• Family history (information concerning the health
status of the immediate family)
• Lifestyle and life patterns (social, psychological,
physical, and cultural environment)
• Review of systems
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The Nurse’s Role
Systems Review
• When examining the child, generally proceed
in a head-to-toe manner while collecting vital
signs
• Note the facial expression and the general
appearance of the child
• Always talk to the parents about how they
think their child is doing, because they know
their child best
• Be sure to document and report any unusual
or abnormal findings
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The Nurse’s Role
Systems Review
• Pulse
– The pulse rate varies considerably in different children of
the same age and size
– Apical pulse is preferred for infants and small children
• The apical rate /respiratory rates of the newborn infant are
high and gradually decrease with age until adult values are
reached
• Respirations
– Observe the movement of the abdominal wall as
respirations are mostly abdominal at this time
– After about age 7 years, measure respirations the same
way as the adult’s
– Lungs should be clear to auscultation with no
adventitious or abnormal breath sounds
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Blood Pressure
• Ensure the blood
pressure cuff’s bladder
length is 80-100%
circumference of the
arm and the width is
40% of the
circumference of the
arm
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imprint of Elsevier, Inc.
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The Nurse’s Role
Cultural and Religious Preferences
• Cultural beliefs affect how a family perceives
health and illness
• Some practices raise concerns of abuse
– E.g.: Coining; cupping
• Educate families that strict disciplinary
practices may place them in jeopardy with
child protective services
• Respect any rites, dietary restrictions, etc.,
associated with a family’s religion, as long as
it does not interfere with the child’s well-being
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The Nurse’s Role
Discharge Planning
• Preparation for discharge begins on admission
• Directions for home treatment should be given to
parents gradually throughout their child’s
hospitalization
• Documentation includes time of departure,
person with whom the child departs, patient’s
behavior, instructions/medications given to the
patient or parents, and weight/vital signs upon
discharge
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The Nurse’s Role
Discharge Planning
• Prepare parents for potential post-hospitalization behavior
problems
– Clinging, regression in bowel and bladder control, aggression, fears,
nightmares, negativism
– Return former family responsibilities within the limits of the child’s
present abilities as soon as possible
– Avoid making the child a center of attention because of illness. Praise
accomplishments unrelated to illness
– Be kind, firm, and consistent if the child misbehaves
– Be truthful to maintain trust
– Provide suitable play materials: Clay, paints, doctor/nurse kits. Allow free
play
– Listen to the child, clear up misconceptions about the illness
– Don’t leave child alone for a long period or overnight until a sense of
security is regained
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Safety
Transporting, Positioning, and Restraining the Child
• Means of transportation varies with a child’s age
• Ensure that a patient’s identification band is secure
before leaving the unit
• Holding a baby
– Head and back support is necessary for young infants
– Random movements of small children necessitate secure
holding
• Restraints should rarely be used
– Detailed documentation is required
– Restraints must be removed at least every 2 hours to
avoid impairing circulation and assess skin status
• Therapeutic holding
– Holding a child in a secure, comfortable manner
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Safety
Transporting, Positioning, and Restraining the Child
Do
• Lock wheelchairs and stretchers before placing patients in them
• Use safety straps with children when sitting
• Apply restraints correctly to prevent constriction of a part. Check
institutional policy on frequency of releasing restraints and providing range of motion
• Handle infants and small children carefully. Use elevators rather
than stairs. Walk at the child’s pace
• Place a hand on the infant or child’s back or abdomen when you
turn your back to the child
• Always look for small objects which can become choking hazards
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Safety
Transporting, Positioning, and Restraining the Child
Do
• Protect children from entering the treatment room, elevator,
utility rooms, and stairwells
• Keep crib sides up at all times when unattended in bed. Use
enclosed (bubble top) cribs for older infants and toddlers to
keep them from falling or climbing out of the crib
• Turn an infant perpendicular to the side of the bed when rails
are down. Ensure that the infant will not roll off when rails are
down
• Place cribs so that children cannot reach electrical outlets and
appliances
• Check hospital policy for children who are alone (for instance,
policy may recommend that the door be kept open)
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Safety
Transporting, Positioning, and Restraining the Child
Don’t
• Don’t force-feed children. There is a danger of choking, which
may cause lung disease or sudden death
• Don’t allow patients to use wheelchairs or stretchers as toys
• Don’t leave a child unattended in a highchair, infant seat (if it
is placed on any area above the floor), swing or stroller or in a
bath tub
• Don’t leave a child unattended on an examination table
– Always keep your hand on the child
• Don’t leave small children unattended out of their cribs in their
rooms
• Do not tie balloons to the crib rails
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Safety
Medical Asepsis
• Contaminated
– A person/object that has come into contact with an infected patient
• Disinfected
– Killing microorganisms physically or chemically
Do
• Wash your hands before and after caring for each patient
• Properly disinfect any item brought out of an isolation room
• Do wear a gown if holding a patient; change between patients
Don’t
– Don’t cause cross-infection
• Diapers, toys, and materials that belong in one patient’s storage unit
should not be borrowed for another patient’s use
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Safety
General Safety Guidelines
Do
• Inspect toys for sharp edges and removable parts
• Identify the patient properly before giving medications
• Keep medications, solutions lotions, tissues, disposable pads
and diapers, and safety pins out of infant’s reach
• Keep the medication room locked when not in use
• Locate fire exits and extinguishers on the unit and learn how to
use them properly. Become familiar with the facility's fire manual
• Supervise playroom activity
• Take proper precautions when oxygen is in use
• Use electrical outlet safety plugs on the unit
• Continually assess the patient setting for safety issues
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Safety
General Safety Guidelines
Don’t
• Don’t leave medications at the bedside
• Don’t leave any medication administration materials in
the child’s bed or infant’s crib
• Be aware of wear you place the caps from the pediatric
oral syringes. Do not leave in the bed!
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Implications of Pediatric Surgery
Patient Preparation
• The nurse should give simple information about the
system that will be affected
– Stress that this is the only area of the body that will be
involved
• Children need to know what to expect on the day of
surgery; use a doll to demonstrate
• Children are particularly fearful of surgery and need
both physical and psychological preparation
• The child should be able to easily understand
explanations and information given in simple terms
• It is important to always be truthful; this establishes
trust
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The Child in Pain
Definition and Challenges
• Children of all ages experience pain and
are entitled to appropriate pain
management
• Pain is an individual, subjective
experience, and health care providers
need to identify and treat pain adequately
• Always ask the child and/or the parents
about past pain experiences and known
coping mechanisms
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The Child in Pain
Evaluation
• When evaluating the child, include
precipitating factors, location, onset, duration,
quality, intensity, and characteristics of the
pain
• Pain scales
– 1 to 10 Pain Rating Scale
– FLACC
• Infants and young children
– Oucher Scale
• 2- to 7-year-olds
– Wong-Baker FACES Pain Rating Scale
• Preschool and young school-age
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FLACC pain scale
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The Child in Pain
Intervention
• Oral administration is generally used for mild to moderate pain
• When the child needs immediate pain relief for more intense pain,
intravenous administration is indicated
• For moderate to severe pain that is expected to persist, continuous
dosing or around-the-clock dosing at fixed intervals is recommended
• Pain medication may also be administered rectally, by intramuscular
(IM) injection, transdermally, or topically (EMLA, LMX)
• Nonopioid analgesics are most effective for mild to moderate pain
and have antipyretic effects as well
• Opioids are used to manage most forms of moderate to severe
acute and chronic pain
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The Child in Pain
Intervention
• Nonpharmacologic interventions
– Used in conjunction with pharmacologic
interventions or by themselves
– Complementary or alternative medicine
(CAM)
• Hypnosis
•
•
•
•
– Altered state of consciousness. Suggestions
can lead to changes in behavior or physical
sensations
TENS unit
Acupuncture
Chiropractors
Massage therapy
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