Metro Community College Nancy Pares, RN, MSN

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

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

Objective 1 Discuss ethical, legal issues related to childhood period.

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

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.

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

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

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

Ethical Guidelines Define Evaluate Identify Apply principles
Make decisions

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

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

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

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

Objective 2 Discuss age appropriate assessment and therapeutic communication in the care of the child.

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

Communication Forms Verbal Nonverbal Abstract

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

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

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

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

Figure 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?

Figure 6-2 Facial expressions are a powerful means of communication
Figure 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?

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

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

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

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

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

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)

Short attention span Limited memory Cognitive development Egocentric Magical thinking Animism

Nonverbal communication Express self through dramatic play and drawing Nursing strategies

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

School-Age Children Verbal communication Nonverbal 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

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

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

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

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

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

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

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

Play Culture Journaling

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

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

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

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

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

Physiological Data Review of systems

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

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

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

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

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

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

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

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

Figure 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.

General Appraisal Appearance Behavior Interaction with parents
Interaction with examiner

Anthropometric Measurements
Length Birth to 24 months Measuring board

Figure 7-4 Measuring infant length
Figure 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.

Height After age 2 years Stadiometer

Weight Infant scale Kilograms, grams, and pounds and ounces Standing scale Diapers and clothing

Figure 7-6 Measuring head circumference
Figure 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.

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

Head and Face Shape of head and face Symmetry

Figure 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.

Head and Face Skull sutures Fontanels

Figure 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.

Eyes Inspection Hypertelorism Palpebral slant

Figure 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?

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

Eyes Inspection Extraocular movements (EOMs)

Figure 7-18 Inspection of the extraocular movements
Figure 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.

Eyes Inspection Strabismus Light reflex Cover-uncover test

Figure 7-19 Cover–uncover test
Figure 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.

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

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

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

Nose and Sinuses Inspection Palpation Percussion Patency Smell

Mouth and Throat Lips Teeth Gums Mucosa Tongue Throat and tonsils

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

Figure 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.

Neck and Lymph Nodes Range of motion Torticollis Meningismus

Chest Inspection Shape Chest deformities

Figure 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.

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

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

Chest Palpation Auscultation Percussion Crepitus Tactile fremitus
Hyperresonance Percussion

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

Heart Inspection Palpation Percussion Precordial activity PMI
Apical impulse Thrills Percussion

Heart Auscultation Rate and rhythm

Heart Auscultation Normal heart sounds S1 and S2 Splitting S3

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

Heart Pulse Related assessments Blood pressure

Abdomen Inspection Shape Umbilicus Rectus muscle Abdominal movements
Inguinal area

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

Abdomen Auscultation Percussion Palpation

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

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

Musculoskeletal System
Inspection Palpation Range of motion Muscle strength

Figure 7-54 Inspection of the spine for scoliosis
Figure 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.

Posture and spinal alignment

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

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

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

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

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.

Figure 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.

Upper extremities Shoulders Arms and elbows Hands and wrist

Figure 7-55 A, Normal palmar creases.

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.

Lower extremities Hips

Figure 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.

Figure 7-57 Ortolani-Barlow maneuver
Figure 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.

Figure 7-57 (continued) Ortolani-Barlow maneuver
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.

Lower extremities Legs and knees Feet and ankles

Figure 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.

Nervous System Cognitive functioning Behavior Communication skills
Memory Level of consciousness

Nervous System Cerebellar function Balance Coordination
Locomotion, gait

Nervous System Sensory functioning Primitive reflexes
Superficial and deep tendon reflexes

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

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

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

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

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

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

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

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

Figure 7-75 Ballard scoring system to assess gestational maturity
Figure 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.

Figure 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.

Figure 7-64 (continued) Sole creases
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.

Ballard gestational age assessment tool Physical characteristics Breasts

Figure 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.

Figure 7-65 (continued) Breast tissue
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.

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

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

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

Ballard gestational age assessment tool Neuromuscular characteristics Square window

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

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

Ballard gestational age assessment tool Neuromuscular characteristics Arm recoil

Figure 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.

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.

Ballard gestational age assessment tool Neuromuscular characteristics Popliteal angle

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

Ballard gestational age assessment tool Neuromuscular characteristics Scarf sign

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

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

Ballard gestational age assessment tool Neuromuscular characteristics Heel-to-ear extension

Figure 7-74 Heel-to-ear scoring
Figure 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.

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

Figure 7-76 Measuring the length of the newborn.

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

General Appearance and Behaviors
Vital signs Thermoregulation Respirations Pulse Blood pressure

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

Head Molding Caput succedaneum

Figure 7-78 Caput succedaneum
Figure 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.

Head Cephalohematoma Sutures Fontanels Symmetry

Figure 7-79 Cephalhematoma
Figure 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.

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

Objective 3 Apply the nursing process to the care of the pediatric patient in various acute care settings Acute Isolation Emergency Intensive Care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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)

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

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

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

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

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

Table 16-7 (continued) Assisting Children Through Procedures

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

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

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

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

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

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

Objective 4 Describe the nursing interventions and stages of grief associated with the chronically ill or dying child

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

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

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

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

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

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

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

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

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

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

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

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

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

Nursing Diagnosis for the Dying Child and Family
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

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

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

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

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

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

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

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

Metro Community College Nancy Pares, RN, MSN

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