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NURS 2410 Unit 5 Metro Community College Nancy Pares, RN, MSN.

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1 NURS 2410 Unit 5 Metro Community College Nancy Pares, RN, MSN

2 Informed Consent Healthcare provider must obtain Must be obtained for invasive procedures and some medical treatments May be delayed in emergency situations

3 Nurse’s role in obtaining informed consent Assess and document Review rights of minors Develop therapeutic relationship Verify prior consent Serve as witness

4 Minor Defined by Individual State Laws 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.

5 Minors May Give Informed Consent in Certain Circumstances Emancipated minor Minor is parent of a child receiving treatment

6 Children Should Be Given Age-Appropriate Information Assent and preference by child should be obtained

7 Advances in Medical Treatment Ability to save lives of severely impaired infants Genetic testing Gene therapy

8 Ethical Guidelines Define Evaluate Identify Apply principles Make decisions

9 Increase in Ethical Issues and Decisions Nurses use four ethical principles – Beneficence – Nonmaleficence – Autonomy – Justice

10 Healthcare Institutions and Ethics Committees Ethics committees resolve conflicts and make recommendations

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12 Current Issues Causing Increasing Conflict for Nurses and Families End of life-sustaining treatment Genetic testing of children Organ transplant Research on children

13 Communication Ongoing and cyclical Exchange of thoughts, feelings, information Importance of trust and rapport Components—sender, message, channel, receiver, response

14 Components of Communication Cycle Sender—generates the message Message—verbal, nonverbal, or abstract Channel—auditory, visual, kinesthetic Receiver—decodes the message Response—feedback to sender

15 Communication Forms Verbal Nonverbal Abstract

16 Verbal Communication Verbal and written words, vocalizations – Speaking to another – Writing a letter – Crying, laughing Influenced by development and cognitive level

17 Verbal Communication Influenced by culture How does the nurse use verbal communication in nursing care?

18 Nonverbal Communication Forms of Nonverbal Communication – Paralanguage – Gestures – Touch – Personal space – Facial expression – Body language – Eye contact

19 Nonverbal Communication 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

20 Figure 6-1 The nurse is sending a message to the older child, the receiver. Notice the nonverbal communication expressed by the young girl. What message is she communicating? How should the nurse respond?

21 Figure 6-2 Facial expressions are a powerful means of communication. What does this child’s facial expression convey? What actions can the nurse take to reduce her distress?

22 Forms of Nonverbal Communication How should nonverbal communication be applied to nursing care?

23 Influence of Physical and Psychosocial Factors on Communication Process Physical factors—language, gender, environment Psychosocial factors—culture, health status, emotions, space, and time

24 Influence of Language Issues Language and linguistic differences and expectations Medical terminology and medical jargon Nursing strategies to minimize language barriers

25 Influence of Gender Prior experiences Expectations of women and men Cultural influences Nursing strategies to minimize gender barriers

26 Influence of Environment Environmental factors Comfort Privacy Nursing strategies to minimize environmental barriers

27 Influence of Health Status Physical condition Emotional responses Need for information Nursing strategies to minimize barriers

28 Application to Nursing Care Individualized approach Caring – The nurse’s emotional investment in the child and family – Evokes a feeling of security and comfort Caring environment needed for communication

29 Application to Nursing Care Empathy – Ability to perceive another person’s experience – Empathetic behaviors and expressions enhance communication

30 Considerations for Communication with Children Developmental level Skills Language development Cognitive development Emotional/personality development

31 Newborns 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

32 Infants 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

33 Infants Respond to touch through patting, rocking, stroking Nursing strategies include: speak in high- pitched voice, cuddle, pat, rub to calm

34 Toddlers and Preschoolers 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)

35 Toddlers and Preschoolers Short attention span Limited memory Cognitive development – Egocentric – Magical thinking – Animism

36 Toddlers and Preschoolers Nonverbal communication – Express self through dramatic play and drawing Nursing strategies

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38 School-Age Children Cognitive development now able to use logic – Begin to understand others’ viewpoints – Begin to understand cause-effect – Understanding of body functions

39 School-Age Children 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

40 Adolescents Abstract thinking without full adult comprehension Interpretation of medical terminology is limited Drive for independence

41 Adolescents Trust and understanding build rapport Need for privacy Nursing strategies include: straightforward approach, talk in private area

42 Communicating with Children Who Have Physical and Developmental Disabilities 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

43 Communicating with Children Who Have Altered Vision Approach to child—identify self as you enter room, announce departure Orient child to objects in room Speak before touching Explain any unfamiliar sounds

44 Communicating with Children Who Have Altered Hearing Approach to child—face child when speaking, enter room slowly Assess degree of impairment—may need interpreter

45 Communicating with Non-English- Speaking Children 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

46 Communication Assessment for Child and Family Development Language Physical skills Culture Barriers

47 Figure 6-4 Most hospitals have designated interpreters that you should use. If not available, find a professional interpreter whom you have identified beforehand and who knows medical terms and the cultural norms of the family. The interpreter should be positioned to improve communication. Maintain eye contact with the parent or patient, not the interpreter. To ensure confidentiality of information for parents, avoid using a family member for history taking.

48 Play Culture Journaling

49 Planning and Implementation Promote therapeutic nurse–child–family relationship Promote effective therapeutic communication

50 Planning and Implementation Components – Provide appropriate environment – Establish trust – Maintain confidentiality – Convey respect Use therapeutic communication skills

51 Planning and Implementation Alternate techniques – Play – Art – Journaling – Storytelling – Bibliotherapy – Appropriate use of humor

52 Evaluation of Outcomes Use of effective techniques Establishment of therapeutic relationship Recognize and respond to child’s and family’s themes

53 Communication as a Cornerstone of History Taking Importance of rapport – What is rapport? – How do you establish rapport? With parents? With children?

54 Strategies to Facilitate Rapport and Data Collection Introduction Purpose of interview Use of open- and closed-ended questions Timing of questions Nonverbal communication Observations Honesty Language

55 Figure 7-1 Observe the behavior of children and family members while you are collecting historical and physiologic data.

56 Components of Health History General information about the patient – Demographic – Emergency contact information – Historical Physiological data Psychosocial data

57 Physiological Data Chief complaint (CC) History of present illness (HPI)

58

59 Physiological Data Past health and illness history/ages of occurrence – Birth history – Communicable diseases and illnesses – Hospitalizations and surgery – Injuries

60

61 Physiological Data Current health status – Health maintenance pattern and last visit Family History

62 Physiological Data Medications—prescribed and OTC – Allergies – Immunization status—up to date? – Safety – Activity and exercise – Nutrition – Sleep

63

64 Physiological Data Review of systems

65

66 Psychosocial Data Family composition Home environment, housing, neighborhood School or childcare Daily routines

67 Psychosocial Data 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

68 Psychosocial Data Developmental status, history, and patterns – Motor – Cognitive – Language – Social

69 Facilitating Examination of Infants 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

70 Facilitating Examination of Toddlers Parent’s lap Play Security object Instruments Control and choice

71 Facilitating Examination of Preschoolers Sequence Games and activities Demonstrate and let them touch instruments Distraction

72 Facilitating Examination of Older Children and Adolescents 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

73 Physiologic differences in children may produce normal variations in physical assessment Head Chest Abdomen Spine Skin imperfections

74 Figure 7-8 Mongolian spots are large patches of bluish skin often seen on the buttocks. They are a normal occurrence in a large majority of Native American, Asian, Black, and Hispanic infants, but are sometimes mistaken for bruises.

75 General Appraisal Appearance Behavior Interaction with parents Interaction with examiner

76 Anthropometric Measurements Length – Birth to 24 months – Measuring board

77 Figure 7-4 Measuring infant length. Have an assistant hold the infant’s head in the midline while you gently push down on the knees until the legs are straight. Position the heels of the feet on the footboard, and record the length to the nearest 0.5 cm or 1/4 inch.

78 Anthropometric Measurements Height – After age 2 years – Stadiometer

79 Anthropometric Measurements Weight – Infant scale Kilograms, grams, and pounds and ounces – Standing scale – Diapers and clothing

80 Anthropometric Measurements Head circumference

81 Figure 7-6 Measuring head circumference. Wrap the tape around the head at the supraorbital prominence, above the ears, and around the occipital prominence, the point of largest circumference of the head.

82 Anthropometric Measurements Centimeters and inches – Paper tape – Measure twice – Up to age 2 to 3 years – Around supraorbital and occipital prominences

83 Anthropometric Measurements Body mass index – Less than 5th percentile – Greater than 85th percentile – Greater than 95th percentile – Calculation: weight in kg/m 2 of height

84 Skin and Hair Skin – Color, temperature, moisture – Rashes, lesions – Skin turgor Hair – Texture, amount, fullness – Breaking off? – Head lice

85 Head and Face Shape of head and face Symmetry

86 Figure 7-14 Draw an imaginary line down the middle of the face over the nose and compare the features on each side. Significant asymmetry may be caused by paralysis of cranial nerve V or VII, in utero positioning, or swelling from infection, allergy, or trauma.

87 Head and Face Skull sutures Fontanels

88 Figure 7-13 The sutures are fibrous connections between the bones of the skull that have not yet ossified. The fontanels are formed at the intersection of these sutures where bone has not yet formed. Fontanels are covered by tough membranous tissue that protects the brain. The posterior fontanel closes between 2 and 3 months after birth. The anterior fontanel and sutures are palpable up to the age of 18 months. The suture lines of the skull are seldom palpated after 2 years of age. After that time, the sutures rarely separate.

89 Eyes Inspection – Hypertelorism – Palpebral slant

90 Figure 7-16 Draw an imaginary line across the medial canthi and extend it to each side of the face to identify the slant of the palpebral fissures. When the line crosses the lateral canthi, the palpebral fissures are horizontal and no slant is present. When the lateral canthi fall above the imaginary line, the eyes have an upward slant. A downward slant is present when the lateral canthi fall below the imaginary line. Epicanthal folds are present when an extra fold of skin partially or completely covers the caruncles in the medial canthi. What type of slant does this child have? Are epicanthal folds present?

91 Figure 7-17 The eyes of this boy with Down syndrome show an upward slant.

92 Eyes Inspection – Extraocular movements (EOMs)

93 Figure 7-18 Inspection of the extraocular movements. Have the child sit at your eye level. Hold a toy or penlight about 30 cm (12 in.) from the child’s eyes and move it in all six directions indicated. Both eyes should move together, tracking the object.

94 Eyes Inspection – Strabismus Light reflex Cover-uncover test

95 Figure 7-19 Cover–uncover test. With the child at your eye level, ask the child to look at a picture on the wall. A, As you cover one eye with an index card or paper cup, observe for any movement of the uncovered eye. If it jumps to fixate on the picture, the uncovered eye has a muscle weakness. B, As you remove the cover from the eye, observe the covered eye for any movement to fixate on the picture. If an eye has a muscle weakness, it will drift to a relaxed position when covered.

96 Eyes Vision – Infant tracking – Age-appropriate tests of visual acuity Fundoscopy – Red reflex – Internal structures

97

98 Ears Inspection – Symmetry Shape of tragus Position and alignment Ear canal Tympanic membrane

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100 Ears Hearing assessment – Newborn screening – Audiometry – Noise and whisper tests – Tympanometry – Bone and air conduction tests – Indicators of hearing loss

101 Nose and Sinuses Inspection Palpation Percussion Patency Smell

102 Mouth and Throat Lips Teeth Gums Mucosa Tongue Throat and tonsils

103 Neck and Lymph Nodes Inspection – Swelling – Webbing Palpation – Nodes – Trachea – Thyroid gland

104 Figure 7-32 The neck is palpated for enlarged lymph nodes around the ears, under the jaw, in the occipital area, and in the cervical chains of the neck.

105 Neck and Lymph Nodes Range of motion – Torticollis – Meningismus

106 Chest Inspection – Shape – Chest deformities

107 Figure 7-35 Measure the chest with a tape measure placed just under the axilla and at the nipple line. Record the circumference to the nearest 0.5 cm or 1/4 inch.

108 Figure 7-36 Two types of abnormal chest shape. A, Pectus excavatum (funnel chest). B, Pectus carinatum (pigeon chest).

109 Chest Inspection – Movement, excursion – Respiratory effort, retractions, respiratory rate – Breasts

110

111 Chest Palpation – Crepitus – Tactile fremitus Auscultation – Hyperresonance Percussion

112 Figure 7-37 One example of a sequence for auscultation of the chest.

113 Heart Inspection – Precordial activity – PMI Palpation – Apical impulse – Thrills Percussion

114 Heart Auscultation – Rate and rhythm

115

116 Heart Auscultation – Normal heart sounds S 1 and S 2 Splitting S 3

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118 Heart Auscultation – Abnormal heart sounds Murmurs Intensity, location, radiation, timing, quality Intensity grades Venous hum

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120 Heart Pulse Related assessments Blood pressure

121 Abdomen Inspection – Shape – Umbilicus – Rectus muscle – Abdominal movements – Inguinal area

122 Figure 7-45 Sequence for indirect percussion of the abdomen.

123 Abdomen Auscultation Percussion Palpation

124 Genitalia and Perineal Areas Positioning Timing in examination Females Males Anus and rectum

125 Genitalia and Perineal Areas Puberty and sexual maturation – Females – Males Tanner Scale – Sexual maturity rating (SMR)

126 Musculoskeletal System Inspection Palpation Range of motion Muscle strength

127 Figure 7-54 Inspection of the spine for scoliosis. Ask the child to slowly bend forward at the waist, with arms extended toward the floor. Run your forefinger down the spinal processes, palpating each vertebra for a change in alignment. A lateral curve to the spine or a one-sided rib hump is an indication of scoliosis.

128 Musculoskeletal System Posture and spinal alignment

129 Figure 7-52 Normal development of posture and spinal curves. A, Infant 2 to 3 months—Holds head erect when held upright; thoracic kyphosis when sitting.

130 Figure 7-52 (continued) Normal development of posture and spinal curves. B, 6 to 8 months—Sits without support; spine is straight.

131 Figure 7-52 (continued) Normal development of posture and spinal curves. C, 10 to 15 months— Walks independently; straight spine.

132 Figure 7-52 (continued) Normal development of posture and spinal curves. D, Toddler—Protuding abdomen; lumbar lordosis.

133 Figure 7-52 (continued) Normal development of posture and spinal curves. E, School-age child—Height of shoulders and hips is level; balanced thoracic convex and lumbar concave curves.

134 Figure 7-53 Does this child have legs of different lengths or scoliosis? Look at the level of the iliac crests and shoulders to see if they are level. See the more prominent crease at the waist on the right side? This child could have scoliosis.

135 Musculoskeletal System Upper extremities – Shoulders – Arms and elbows – Hands and wrist

136 Figure 7-55 A, Normal palmar creases.

137 Figure 7-55 (continued) B, Transverse crease associated with Down syndrome. Source: Photo B from Zitelli, B. J., & Davis, H. W. (Eds.). (2002). Atlas of pediatric physical diagnosis (4th ed.). St. Louis, MO: Mosby-Year Book.

138 Musculoskeletal System Lower extremities – Hips

139 Figure 7-56 Flex the infant’s hips and knees so the heels are as close to the buttocks as possible. Place the feet flat on the examining table. The knees are usually the same height. A difference in knee height (Allis sign) is an indicator of hip dislocation (see also Chapter 35). Source: Courtesy of Dee Corbett, RN, Children’s National Medical Center, Washington, DC.

140 Figure 7-57 Ortolani-Barlow maneuver. A, Place the infant on his or her back and flex the hips and knees at a 90-degree angle. Place a hand over each knee with the thumb over the inner thigh, and the first two fingers over the upper margin of the femur. Move the infant’s knees together until they touch, and then put downward pressure on one femur at a time to see if the hips easily slip out of their joints or dislocate.

141 Figure 7-57 (continued) Ortolani-Barlow maneuver. B, Slowly abduct the hips, moving each knee toward the examining table. Keep pressure on the hip joints with the fingers in a lever-type motion. Equal hip abduction, with the knees nearly touching the examining table, is normal. Any resistance to abduction or a clunk felt on palpation can be an indication of a congenital hip dislocation.

142 Musculoskeletal System Lower extremities – Legs and knees – Feet and ankles

143 Figure 7-58 To evaluate the child with knock-knees, have the child stand on a firm surface. Measure the distance between the ankles when the child stands with the knees together. The normal distance is not more than 5 cm (2 in.) between the ankles.

144 Nervous System Cognitive functioning – Behavior – Communication skills – Memory – Level of consciousness

145 Nervous System Cerebellar function – Balance – Coordination – Locomotion, gait

146

147 Nervous System Sensory functioning Primitive reflexes Superficial and deep tendon reflexes

148

149 Table 7-20 (continued) Techniques for Assessing Selected Primitive Reflexes, with Normal Findings and Their Expected Age of Occurrence

150

151

152 Secondary Sex Characteristics 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

153 Secondary Sex Characteristics Tanner stages: rating between 2–5, stage 1 is prepubertal Inspection and palpation to assign a tanner stage

154 Analyzing Health Assessment Findings 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

155 Planning and Implementation 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

156 Assessment of the Newly Born Transition to extrauterine life – Initiation of respirations – Transition from fetal to adult circulation

157 Immediate Assessment After Birth Physiologic condition and needs Resuscitation Apgar score – Adaptation to extrauterine life – 1 and 5 minute score – Apgar criteria

158

159 Gestational Age Assessment Ballard gestational age assessment tool – Physical characteristics Skin Lanugo Plantar surfaces

160 Figure 7-75 Ballard scoring system to assess gestational maturity. Source: Reprinted from Ballard, J. L., Khoury, J. C., Wang, L., Eilers-Walsmann, B. L., & Lipp, R. (1991). New Ballard score, expanded to include extremely premature infants. Journal of Pediatrics, 119 (3), 417–423. Used with permission from Elsevier. Copyright Elsevier, 1991.

161 Figure 7-64 Sole creases. A, At a gestational age of approximately 35 weeks, the newborn has few sole creases only on the anterior portion of the foot.

162 Figure 7-64 (continued) Sole creases. B, At term, the newborn has deep creases down to and including the heel as the skin loses fluid and dries after birth.

163 Gestational Age Assessment Ballard gestational age assessment tool – Physical characteristics Breasts

164 Figure 7-65 Breast tissue. To assess breast tissue, gently compress the tissue between the middle and index fingers and measure the tissue in millimeters. A, At a gestational age of 38 weeks, the newborn has a visible raised area that is 4 mm in diameter on palpation.

165 Figure 7-65 (continued) Breast tissue. To assess breast tissue, gently compress the tissue between the middle and index fingers and measure the tissue in millimeters. B, At a gestational age of 40 to 44 weeks, the newborn has 10 mm breast tissue.

166 Gestational Age Assessment Ballard gestational age assessment tool – Physical characteristics Ear cartilage and eyelid fusion

167 Gestational Age Assessment Ballard gestational age assessment tool – Physical characteristics Genitals

168 Gestational Age Assessment Ballard gestational age assessment tool – Neuromuscular characteristics Posture

169 Figure 7-69 Resting posture. A, At a gestational age of approximately 31 weeks, there is extension of the upper extremities and beginning flexion of the thighs.

170 Figure 7-69 (continued) Resting posture. B, At term, the newborn exhibits hypertonic flexion of all extremities.

171 Gestational Age Assessment Ballard gestational age assessment tool – Neuromuscular characteristics Square window

172 Figure 7-70 Square window sign. A, At approximately 28 to 32 weeks’ gestation, the angle is 90 degrees.

173 Figure 7-70 (continued) Square window sign. B, At a gestational age of approximately 39 to 40 weeks, the angle is commonly 30 degrees.

174 Gestational Age Assessment Ballard gestational age assessment tool – Neuromuscular characteristics Arm recoil

175 Figure 7-71 Elicit the arm recoil by flexing the arms at the elbows to the chest for 5 seconds. A, Then extend the arms at the elbows.

176 Figure 7-71 (continued) Elicit the arm recoil by flexing the arms at the elbows to the chest for 5 seconds. B, Release the arms to see the amount of recoil. In healthy newborns, the angle of flexion is usually less than 90 degrees followed by rapid recoil to the flexed position.

177 Gestational Age Assessment Ballard gestational age assessment tool – Neuromuscular characteristics Popliteal angle

178 Figure 7-72 To assess the popliteal angle, flex and hold the thigh to the abdomen while extending the leg at the knee.

179 Gestational Age Assessment Ballard gestational age assessment tool – Neuromuscular characteristics Scarf sign

180 Figure 7-73 Scarf sign. A, Until approximately 30 weeks’ gestation, the elbow moves past midline with no resistance.

181 Figure 7-73 (continued) Scarf sign. B, The elbow will not reach midline after 40 weeks’ gestation.

182 Gestational Age Assessment Ballard gestational age assessment tool – Neuromuscular characteristics Heel-to-ear extension

183 Figure 7-74 Heel-to-ear scoring. Move the infant’s foot as near to the head or ear as possible and determine the distance between the heel and head.

184 Size for Age Small for gestational age Appropriate for gestational age Large for gestational age Growth curves Accuracy of anthropometric measures in newborns

185 Figure 7-76 Measuring the length of the newborn.

186 General Appearance and Behaviors Head/body ratio Position Motor activity Cry

187 General Appearance and Behaviors Vital signs – Thermoregulation – Respirations – Pulse – Blood pressure

188 Physical Assessment of Newborn Skin – Peeling – Lanugo – Normal color variations – Jaundice – Common alterations

189

190 Physical Assessment of Newborn Head – Molding – Caput succedaneum

191 Figure 7-78 Caput succedaneum. Following vaginal birth, some newborns develop swelling and a collection of serous fluid in the scalp due to birth trauma. The swelling often crosses the suture lines.

192 Physical Assessment of Newborn Head – Cephalohematoma – Sutures – Fontanels – Symmetry

193 Figure 7-79 Cephalhematoma. Following vaginal birth, some newborns develop a collection of blood between the surface of the cranial bone and the periosteal membrane due to birth trauma. The swelling is usually confined to one cranial bone and does not cross the suture lines. Source: Photo from Zitelli, B. J. & Davis, H. W. (Eds.). (2007). Atlas of pediatric physical diagnosis (5th ed., p. 42, Fig. 2-30). From: Anonymous (2006). Cephalhematoma, Consultant for pediatricians, 5(7), 444. Reprinted with permission. Copyright Elsevier, 2007.

194 Physical Assessment of Newborn Eyes – Chemical conjunctivitis – Blink reflex – Red reflex vs. opacities – Sclerae – Tracking – Doll’s eye phenomenon

195 Physical Assessment of Newborn Ears – Position – Skin lesions or tags – Hearing Nose – Appearance – Patency of nares – Flaring

196 Physical Assessment of Newborn Mouth – Palate – Tongue, frenulum – Buccal mucosa – Gums – Gag, suck, swallow – Epstein’s pearls, neonatal teeth, inclusion cysts

197 Physical Assessment of Newborn Neck – Position – Appearance – Torticollis – Webbing, skin folds – Clavicles Chest

198 Physical Assessment of Newborn Chest and Lungs – Appearance—Barrel chest? – Breasts—Engorgement? Nipple discharge? – Respirations—Periodic breathing? Retractions? Grunting? – Breath sounds

199 Physical Assessment of Newborn Heart – Location of apical impulse – Murmurs – Pulses Abdomen – Appearance – Bowel sounds – Umbilicus and umbilical cord

200 Physical Assessment of Newborn Genitalia and anus – Appearance and relation to gestational age – Females—vaginal discharge – Males—penis, urethra, testes – Patency of anus Stooling pattern Anal wink

201 Physical Assessment of Newborn Extremities – Deformities – Injuries – Developmental hip dysplasia Symmetry of creases Allis sign Barlow-Ortolani maneuver

202 Physical Assessment of Newborn Spine – Muscle strength and position – Head control Neurological system – Alertness – Posture – Protective reflexes – Primitive reflexes

203

204 Health/Illness Understanding: Infant 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

205

206 Health/Illness Understanding: Toddler/Preschooler 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

207 Health/Illness Understanding: School-age Knows cause and effect of illness Beginning understanding of body functions Older school age can understand explanations

208 Health/Illness Understanding: Adolescents 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

209 Stages of Separation Anxiety Protest – Screaming, crying, clinging – Resists attempts to comfort Despair – Sad, withdrawn, quiet – Cries when parents return

210 Stages of Separation Anxiety Denial – Protest subsides, shows interest in setting – Appears happy and content

211

212 Illness/Hospitalization Effects 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

213

214 Table 16-2 (continued) Stressors of Hospitalization for Children at Various Developmental Stages

215 Illness/Hospitalization Responses Separation – Withdrawal, abandonment, regression Fear of the unknown – Sleep disruption, anxiety reactions Loss of control Aggression, regression, displacement

216 Family Responses to Hospitalization Disruption of daily routine Role change Anxiety and fear Need support, encouragement, honest information Coping strategies Cultural views

217

218 Adaptation to Hospitalization 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

219

220 Sibling Reactions Depend on – Age – Developmental level – Perception and severity of illness – Prior experience and coping – Knowledge and understanding of illness

221 Strategies for siblings 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

222 Stress Reduction: The 4 Rs 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

223 Enhancing Hospitalization 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

224 Minimizing Stressors Maximize control – Give choices – Encourage independence Therapeutic play – Address fears, concerns Therapeutic recreation – Interactive activities

225 Nursing Care Focus Minimize fears and anxieties Incorporate familiar routines into hospitalization Support family and loved ones Minimize loss of control; promote autonomy

226 Preparation for Procedures Assessment – Knowledge and previous experiences – Developmental age – Coping abilities – Feelings: fears, concerns

227 Preparation for Procedures Communication based on developmental level – Clear – Honest – Age appropriate

228 Psychological Preparation Assess: knowledge, perception, and feelings – Purpose – Past experience – Will it be painful? – Coping techniques – Will parents be present?

229 Psychological Preparation Communication – Use understandable language – Gear to cognitive level and past experience – Share ways to cope during the procedure

230 Parental Presence Physical preparation Depends on age and procedure NPO? Procedural checklist Pain management

231 Child Life Programs Focus on psychosocial needs Age-appropriate play Medical play/acting out procedures Therapeutic play Dramatic play

232 Techniques for Therapeutic Play Storytelling Drawings, body outlines Music, tape-recorded messages Puppetry Dramatic play Animal-assisted therapy

233

234 Special Units and Types of Care General pediatric units Emergency department (ED) Neonatal intensive care unit (NICU), pediatric intensive care unit (PICU), or special care units Preoperative and postoperative units, post- anesthesia care units (PACU)

235 Special Units and Types of Care Short-stay, outpatient, or ambulatory surgical units Isolation Rehabilitation

236 Parental Involvement and Presence 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

237

238 Discharge Considerations Family ability to provide care – Equipment, training Financial burdens Educational needs – Parent teaching – Return to schoolwork

239 Preparation for Home Care 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

240 Preparation for Surgery Preoperative – Teach purpose, sensations – Allow transition objects: teddy bears, blankets – Parental presence during anesthesia induction

241

242

243 Table 16-7 (continued) Assisting Children Through Procedures

244 Preparation for Surgery Postoperative – Expectations during recovery – Monitoring and assessment – Nursing Care Plan:The Child Undergoing Surgery

245 Child and Family Teaching Informal or structured – For child and parents – Consider timing and level of understanding – Consider special health needs – Translators if needed

246 Child and Family Teaching Teaching plans: include all the domains – Cognitive – Psychomotor – Affective

247 Teaching Steps Assess – Knowledge, skills, feelings, expectations – Cognitive level, ability, desire Set clear, measurable goal(s)

248 Teaching Steps Select method(s) – Audio, video, text, demonstration, or combination Evaluate learning outcome – How well was goal met?

249 Developmental Stage Effect on understanding of death Effect on behavioral response to death Effect on ability to communicate about death

250

251 Table 22-1 (continued) The Child’s Developmental Understanding of Death, Potential Behaviors, and Nursing Considerations

252 Sources of Loss for Children Parent Grandparent Friend Pets or objects Loss of an aspect of self Loss of an object or pet Separation from an accustomed environment

253 Sources of Loss for Children Losses not directly related to the child – Crime – Disasters – Terror attacks

254 Factors Affecting a Child’s Response to Loss Cultural traditions and practices Religion and spirituality Social support systems

255 Communicating with the Dying Child Promote open communication Struggle with emotions is common Identify what is known, how much child wants to know Listen and give support

256 Withdrawing or Withholding Treatment Decision is extremely difficult Parents or nurses may feel that aggressive therapies extend child’s suffering

257 Parental Refusal of Treatment 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

258 Parental Refusal of Treatment Court interventions may be used Consultation with hospital ethics committee

259 End-of-Life Decisions Palliative care—an approach to improve QOL Hospice care—care focusing on ensuring comfort Do Not Resuscitate request Tissue and organ donation Autopsy

260 Informing Parents of a Child’s Prognosis or Death Privacy Body language Social support Response to emotions Timing

261 Physiological Changes in the Dying Child Illness- or injury-dependent changes

262 Physiological Changes in the Dying Child Universal changes – Cardiovascular system – Respiratory system – Neurological system – Musculoskeletal system – Renal system – Altered nutrition – Fluid and electrolyte imbalance

263 Assessment of the Dying Child and Family Fears and concerns Coping skills Awareness – Closed awareness – Mutual pretense – Open awareness Spiritual needs

264 Nursing Diagnosis for the Dying Child and Family Fear Hopelessness Risk for caregiver role strain Interrupted family processes Anticipatory grieving

265 Planning and Implementation Goal setting Competencies for high-quality end-of-life care

266

267

268 Planning and Implementation Special concerns – Pain management – Trust – Anger – Education – Desired religious or cultural practices

269 Arrange for Parents and Others to Say Good-bye Allow as much time as needed for farewells Provide privacy

270 Provide Mementos 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

271 Postmortem Care Identify and implement any religious or cultural practices desired by the family Clean and position the body

272 Psychosocial Support 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

273 Psychosocial Support 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

274 Nurses Who Work with Dying Children May Feel: Helpless That they failed the dying child Sad Grief

275 Stress Management Special preparation is required for the nurse – Mentorship with hospice nurse – Debriefing sessions with mental health professional


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