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Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved. Pediatric Nursing Care Ellise Adams and Mary Ann Towle Chapter 1 Pediatric Nursing in the Community
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Pediatric Nursing Care of the child from birth through the teenage years Come in contact with children in a variety of settings Role of the LPN/LVN ranges from assisting the healthcare team to providing first aid Be prepared to teach, provide direct care, and refer as needed
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Changes in Nursing Four features of nursing practice (ANA) Attend to full range of human responses to health and illness – holistic care Integrate objective and subjective data Apply scientific knowledge Provide caring relationship
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History of Pediatric Nursing Developments in Pediatric Nursing The term “client” refers to the entire family Nurses observe parenting skills and provide teaching to positively affect the child
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Nursing Process Systematic approach to planning and implementing nursing care Assessing Nursing Diagnosing Planning Implementing Evaluating
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Nursing Process
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Community-Based Practice Levels of care Primary care Health prevention to maintain health and prevent illness Secondary care Treatment of illness to return client to health Tertiary care Management of chronic, terminal, complicated, long-term health care problems
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Roles of the LPN/LVN Collaborating with the interdisciplinary team Participating in the nursing process Using problem-solving skills Inductive and deductive reasoning Using critical thinking and critical thinking care maps Teaching health promotion
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Prioritizing and Implementing Most critical aspects of care must be initiated first Airway, breathing, circulation Next priority is client safety and comfort Plan and implement care for several clients at a time
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Delegation Transfer authority or right to perform nursing task to competent individual in a selected situation Retain accountability for tasks delegated Base delegation on: Client assessment Individual situation Skill of individual unlicensed person
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Five Rules of Delegation Right task Right circumstances Right person Right direction/communication Right supervision
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Direction for Delegation What is to be done Expected outcome of task Possible complications What unlicensed person should do if complications happen
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Delegation Unlicensed person accepting delegated task may not redelegate task to someone else Unlicensed person is not qualified to delegate nursing care Licensed nurse is accountable for outcome of task delegated Supervision is giving direction for and inspecting task performed
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Legal and Ethical Issues Affecting Children Vary from state to state Need to understand general principles Obtain legal advice for complex issues
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Parents’ Rights Authority to make decisions for minor children Right to give informed consent for procedures Right to have nursing care provided in an unbiased manner
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Exceptions to Parents’ Rights Parents are incapacitated and unable to make decision Actual or suspected child abuse or neglect Parents’ choice does not permit life-saving procedures for child
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Child’s Rights Mature Minor Act Emancipated minors Patient’s Bill of Rights
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Expectations of Parents and Children in Health Care Provide accurate and complete information about health issues Increase knowledge about diagnosis and treatment Be responsible for their own actions Report changes in client condition Keep appointments Meet financial obligations for health care
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Privacy and Confidentiality Privacy Screening from view Confidentiality Keep secret any privileged information Parents may have right to access their dependent child’s medical record
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Legally Reportable Situations Reportable diseases Sexually transmitted infections Food-borne infections Some viral or airborne infections Child abuse or neglect Threats to injure oneself Suspicion of abuse
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LPN/LVN’s Role in Legal and Ethical Issues Follow scope and standards of practice Provide testimony Do no harm Participate in ethics committees Refer client to support groups Participate in staff support groups Participate in clinical research by assisting with the administration of complementary therapy and collecting data
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Priorities in Nursing Care Therapeutic listening Reflecting, open-ended questions, silence Critical thinking Awareness of the law
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Practice within limits of state nurse practice act Know laws of state practicing in Never advise client based on your values Uphold client confidentiality Nursing Interventions in Legal or Ethical Situations
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Collaborate with other health care members Practice culturally sensitive nursing care Provide quality nursing care Report incidents promptly and accurately
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Family Two or more people related by blood or marriage who reside together Two or more individuals who come together for the purpose of nurturing
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Back to Directory Family
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Types of Family Units Nuclear family Extended family Single-parent family
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Other Frameworks for Family Binuclear Family Step Family Blended Family Cohabiting Family Communal Family
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Culture Style of behavior patterns Beliefs Products of human works Within a given community or population
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Religion/Ethnicity Religion Belief in a superhuman power Ethnicity Identity based on common ancestry, race, religion, culture Race is biological deviations
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Culture Theory Cultural factors considered when working with families Communication Space Time Role
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Cultural Competence Back to Directory
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Functions of the Family Functions of the family are: Provide economic support for other family members Satisfy emotional needs for love and security Provide a sense of place and position in society
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Family Assessment Techniques and Tools Ongoing process of examining relationships and functioning of members Assessment of Relationships Stages of growth and development of members Genogram – diagram of relationships among family members Ecomap – diagram of family member interactions
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Assessment of Environment Assessing the home Condition of housing, inside and out Availability of water, garbage, sanitation Cooking and refrigeration facilities Sleeping arrangement Safety hazards Assessing the neighborhood or community
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Role of LPN/LVN in Family Assessment and Care Data collection Report findings Implement written plan of care Identify healthy functioning patterns as well as characteristics of stress Document findings Report observations
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Nursing Process When Caring for the Family Collect data on family Identify appropriate nursing diagnoses Plan and implement interventions for nursing care Evaluate nursing care
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Characteristics of Family Under Stress Become defensive Blame others for their problems Use ineffective communication and problem- solving Cause individuals to feel unwanted, unloved, worthless Block communication leading to additional stress
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Growth Process of increasing physical size Progresses from simple to complex
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Development Process of maturation Refinement of body systems, thought processes, judgment Progresses from simple to complex Cephalocaudal Proximodistal
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Development
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Factors Influencing Growth and Development Heredity Nationality, race, culture Order of birth Gender Family structure Physical and emotional environment
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Theories of Development Theories provide a framework for studying the world around us Different theoretical approaches to growth and development Systems approach Physical growth Cognitive ability Moral development Socialization patterns
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Piaget’s Stages of Cognitive Development Sensorimotor Birth to 2 years Interacts with environment by reflex response Preoperational Ages 2 to 7 Interacts with environment through use of symbols
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Piaget’s Stages of Cognitive Development Concrete operational Ages 7 to 11 “Black or white”, “right or wrong” Formal operations Ages 11 to 16 Abstract comprehension
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Erikson’s Levels of Psychosocial Development Infancy Newborn to 1 year Trust versus mistrust Early Childhood Ages 1 to 3 years Autonomy versus Shame and Doubt
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Erikson’s Levels of Psychosocial Development Late Childhood Ages 3 to 6 years Initiative versus guilt School Age Ages 6 to 12 years Industry versus inferiority
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Erikson’s Levels of Psychosocial Development Adolescence Ages 12 to 20 years Identity versus role confusion Young Adult Ages 20 to 40 years Intimacy versus Isolation
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Freud’s Stages of Psychosexual Development Five stages Behavior is motivated and often unconscious Defense mechanisms protect the ego
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Stages of Physical Growth and Development Infant (Birth - 1 Year) Doubles birth weight by 5 months Triples birth weight by 12 months Height grows by 12 inches Head growth slows, torso and limbs grow Body systems mature Teeth erupt at about 6 months
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Stages of Cognitive Development Infant Reflexes to interacting with environment Speech develops from noises to words Sleeps 20 to 22 hours per day Increases wakefulness to 2 to 3 hours at a time
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Milestones and Deviations Infancy Roll over Grasp Sit alone, crawl, stand
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Stages of Physical Growth and Development Toddler (1-3 years) Walk to run, climb, stand on one foot Ride bicycle Growth slows, pot-bellied abdomen Cuts up to 20 teeth, feeds self
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Stages of Cognitive Development Toddler Vocabulary increases to 1000 words Parallel play Separation anxiety Temper tantrums
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Milestones and Deviations Toddler Runs, jumps Dress and undress self Communication advances Toilet training begins
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Stages of Physical Growth and Development Preschool (3 – 6 years) Learns to obey rules Uses imagination Height increases by 2 to 21/2 inches Weight increases 4 to 5 pounds a year Gains muscle strength and coordination
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Stages of Cognitive Development Preschool Knows name and age Develops understanding of relationships Identifies with gender Vocabulary increases to 2000 words Follows three simple commands
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Milestones and Deviations Preschool Toilet trained Ride bicycle Begins to write Tie shoes
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Stages of Physical Growth and Development School-Age Child (6-12 years) Height increases 2 inches a year Weight increases 2 pounds a year Body proportions change Loses teeth and gains 26 permanent teeth
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Stages of Cognitive Development School-Age Child Learns to compromise, cooperate with others Learns to reason Learns to understand cause-and-effect Vocabulary increases to 2500 words Questions family rules and traditions Joins clubs and teams
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Milestones and Deviations School-Age Reads Plays sports Loses and erupts teeth
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Stages of Physical Development Adolescent (12 - 20 years) Height increases earlier in females Weight increases earlier in females Increase in sex hormones cause physical changes Tanner’s stages of sexual maturity
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Stages of Cognitive Development Adolescent Concrete to abstract comprehension Self-centered, strong identity Hormonal changes, sexuality development Peers have positive or negative influence Feelings of immortality
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Milestones and Deviations Adolescence Well-developed skills Puberty changes
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Milestones and Deviations
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Age-Appropriate Teaching Guidelines Establish therapeutic relationship Communicate appropriately Be sensitive to developmental issues Refer to appropriate resources Refer to support groups
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Priorities in Nursing Care Establish a therapeutic relationship Communicate appropriately for the client’s age level Determine stage of development and cognitive level Validate teaching through age appropriate means to ensure client understanding
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Assessment Role of the LPN/LVN is to assist in the assessment of the pediatric client Preprinted tools guide data collection Measure height, weight, and head circumference and record on growth chart Observe activity, gross and fine motor control, language development
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Diagnosing Possible diagnoses Impaired parenting related to developmental delay Delayed growth and development related to inadequate bonding Situational Low Self-esteem related to rapid physical growth associated with adolescence
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Outcomes Parent provides for child’s physical, emotional, cognitive, and social needs The child will accomplish milestones of physical, cognitive, and psychosocial tasks expected for age group The adolescence will verbalize acceptance of new physical characteristics
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Planning and Implementation Encourage parents to consider the client’s age and stage of development Be sensitive to developmental issues Teach normal findings to expect Encourage age-appropriate communication Refer family to parent support groups and parenting classes
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Planning and Implementation Help family develop realistic expectations Offer age-appropriate toys Explore the child’s feelings regarding physical changes Set limits about negative self-comments
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Evaluating Careful assessment needed to evaluate the child with developmental delays Parenting skills need to be evaluated as the child ages Careful attention needs to be given to the adolescent’s self esteem
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Illness Prevention Categories Primary prevention Prevent health problems from developing Secondary prevention Early detection and treatment Tertiary prevention Treating existing disease Preventing complications Well-child visits Hygiene Immunizations
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Illness Prevention Activities
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Health Promotion Activities Environmental safety Injuries Psychosocial health Promoting self-esteem Providing discipline Promoting play Promoting good nutrition
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Health Promotion Activities Infant Falls Choking Car safety Promoting self-esteem Promoting play Appropriate toys Good nutrition Oral health - teething
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Nutrition Infant Breastfeeding Bottlefeeding Solid foods Food allergies Oral health
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Bottle Mouth
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Health Promotion Activities
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Toddler Environmental safety to avoid injuries Toilet training Discipline Play Appropriate toys Nutrition Oral health – care of the teeth
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Nutrition Toddler One tablespoon of food per age Cow’s milk Feeds self Oral health
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Health Promotion Activities Preschooler Injuries, car seats, increased independence Strangers Health education Organized learning Discipline Play and appropriate toys Nutrition Oral health
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Nutrition Preschooler Three meals and two snacks per day Nutritious foods Begin to assist with meals Oral health, dental care
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Health Promotion Activities School-Age Pedestrian and bicycle safety Latch-key children Promote self-esteem Play, school sports Discipline Nutrition Oral Health
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Nutrition School-Age Eat one meal per day away from home Nutritious snacks and meals Proper etiquette Increased appetite Oral health
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Health Promotion Activities Adolescent Risk-taking behaviors Health education Sexual contact, substance abuse Self-esteem Play, peers Discipline Nutrition Oral Health
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Nutrition Adolescent 2000 to 3000 calories per day Increase need for iron, calcium, zinc, vitamins Three nutritious meals and snacks Prepare own foods Oral health, dental care Piercings
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Nutrition Obesity Malnutrition in US High fat, carbohydrate, sodium diets Low fruit, vegetables, fiber, and water diets
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Nutrition Nurse should monitor: Weight, height Nutritional status Nutritional intake Environmental factors
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Nutrition Nurse should teach: Adequate nutrition Risks of inadequate nutrition
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Therapeutic Play Allows the individual to deal with fears Fears associated with health care experiences
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Hospitalized Child Causes stress and anxiety for client and family Young children cannot fully comprehend or participate in care Parents may have feelings of fear, anger, or guilt Two parents may not agree on plan of care Siblings curious and may feel responsible
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Special Accommodations for Pediatric Clients Hospitals may have special units for care of pediatric clients Overnight facilities may be provides so the family may stay close to the hospitalized child Nurses in small hospitals may care for pediatric clients infrequently
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Age Appropriate Preparation for Hospitalization Reason for hospitalization determines guidelines for preparing families Elective procedures allow for written and verbal teaching coupled with a facility tour Chronic illness may mean exploring prior experiences with hospitalization and instructions on new experiences In an emergency there may be little time for preparation Age of child also determines what type of preparation is needed
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Preparing for the Hospitalization of an Infant Infant Parents and sibling need instruction Provide reassurance May need to separate parents and siblings during painful procedures Comfort infant after procedure Family or hospital personnel in attendance
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Preparing Child for Hospitalization Infant Separation anxiety Stages of separation Parental involvement to promote security Honest communication to develop trust Requires supervision unless sleeping
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Separation Anxiety Apprehension due to parents not present Three stages: Protest Despair Detachment
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Preparing Toddlers for Hospitalization Toddler Identifies body parts for pain Uses magical thinking Give brief instruction prior to procedure Tell child if procedure is painful Separation anxiety present Requires supervision unless sleeping
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Preparing the Preschooler for Hospitalization Follow rituals and routine practices Need reassurance illness is not their fault Frightened by new people and experiences Encourage parents to participate in care Parents reinforce instructions provided by nurse Have familiar objects for security
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Preparing the School-Aged Child for Hospitalization School-Age Can participate in care and treatment Understand written and verbal instructions Need parent support Brings favorite item from home for comfort Participate in variety of activities Can be left alone for brief periods
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Preparing the Adolescent for Hospitalization Adolescent Active participant in care Embarrassed, modest or uncomfortable with body changes Provide for privacy Understands instructions Encourage questions Encourage visits from friends
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Parental Preparation for Child’s Hospitalization Establish a positive relationship Answer questions Provide emotional support Orient to hospital environment
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Preparation for Procedures
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Priorities of Care Make the child feel safe and secure Observe for signs of anxiety or fear Diagnosis for every child to include Fear related to hospitalization Outcomes: Express less fear Interact appropriately with nurse Rest quietly in bed
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Nursing Interventions to Reduce Fear Approach with a smile and introduce self Allow child to: Keep parent or guardian close Keep favorite toy or blanket Provide a tour Allow child to touch and see equipment Developmentally appropriate activities Assign the same nurse when possible Encourage parents to comfort often
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Diagnosing and Outcomes Possible nursing diagnosis Self care deficit Delayed growth and development Interrupted family processes Risk for caregiver role strain Expected outcomes Provide as much self-care as possible Maintain or show progress in growth and development Verbalize appropriate methods of managing stress
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Nursing Interventions Help parents provide a safe environment Encourage self-care Teach care givers to provide care Encourage verbalization of feelings Plan to minimize stress Referrals
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