Ch. 71 Fundamentals of Pediatric Nursing and communication PDF

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how to take care of pediatrics, safely, effectively, how to communicate with peds and parents of sick children. very helpful...

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71 Fundamentals of Pediatric Nursing TERMS       

circumoral cyanosis health maintenance health supervision immunization pediatrician pediatrics well-child visit

ACRONYMS          

APRN DDST HELP IPPB NPO OFC PICC TPN URI VIS

 Pediatrics is the area of care that deals with children and adolescents.  Nursing care of children is called pediatric nursing. o The healthcare provider in this field is a pediatrician, although family practitioners, nurse practitioners (NP) or advanced practice nurses (APRN), and physician assistants (PA) also provide pediatric care.  The primary emphasis in current pediatric healthcare is on prevention of diseases and accidents, maintenance of good health, safety awareness, and positive lifestyle promotion. o The healthcare role of the advanced practice nurse has increased in conjunction with the preventative care needs of the younger population.  Possible settings for healthcare delivery include the home, school, community healthcare facility, day-surgery center, healthcare provider’s office, summer camp, residential setting, or hospital.

HEALTH MAINTENANCE

 The goal of pediatric nursing: Prevention of disease, disorders, and disability  The most effective method of promoting the growth and development of healthy children: o Well-baby and well-child visits for health maintenance or health supervision  Preventive healthcare monitors growth rates and achievement of developmental milestones, and provides opportunities for early detection of health problems.  Well-child visits allow for immunization appointments, school and athletic physicals, and screening for eye and ear problems.  Health facilities offer excellent spaces to display educational brochures, pamphlets, or booklets that are often free from Websites such as the American Pediatric Academy, the CDC, and many other reliable healthcare sources.  The nurse has an opportunity to observe family interactions and can notify the healthcare provider of behaviors that suggest family dysfunction. o Counseling of family caregivers can be provided before crises develop (see In Practice: Educating the Client 71-1). o Remember that some children are cared for in families headed by persons other than their biologic parents. Gather data that includes information about the relationships within a child’s immediate family when you initiate care. o Also consider the child’s cultural and religious background.

 During each visit, the nurse should obtain specific information related to the child’s age.  Well-child visit information includes vital signs, height and weight, occipital–frontal circumference (OFC) of the head (to 3 years of age), abdominal girth, and limb measurements. o Plot the child’s height and weight on a growth chart that allows comparison with other children of the same age. o At each visit, the child’s growth should be compared with what is considered “normal limits.” Early detection of abnormal trends can lead to preventive treatments.  The Denver-II Developmental Screening Test (DDST) is a tool used to identify developmental delays in infants, toddlers, and preschoolers.  The Hawaii Early Learning Profile (HELP) charts are designed to help determine a child’s developmental level. o The charts are available in sets that cover six primary domains:   

Cognitive Language gross motor

  

fine motor social-emotional self-help

-If a delay is identified or suspected, a more detailed evaluation of the child may be performed.

Physical Examination  The primary caregiver will complete a physical examination that will become a reference point for evaluating future illnesses.  Many examiners use a head-to-toe checklist.  Some protocols use a body system approach (e.g., cardiovascular, neurologic, pulmonary). o In this way, patterns are established, and nothing is overlooked.  When an exception to the established normal trend is noted, it is described in detail on the child’s chart.

Immunization

 Immunization provides people with temporary or permanent protection against certain diseases.  The immunization program begins shortly after the child’s birth and should be continued on a regular schedule.  Family caregivers must present records of immunizations to the child’s school; failure to do so may result in the child’s exclusion from the school.  Most immunizations can be given even when the child has a mild illness. o Immunizations are very important healthcare actions designed to help, not only the individual child, but also society in general. o Very important that individuals receiving immunizations have the most current and verified information available regarding both the productive expected effects and the nonbeneficial effects of each immunization, as well as the effects related to combinations of immunizations given throughout an individual’s lifetime.  The CDC provides Vaccine Information Statements (VIS) that explain both the benefits and possible risks of a vaccine to parents or vaccine recipients.  Yearly recommended immunizations are easily viewed on printable summary tables available on the CDC immunization web pages.  Some individuals have objections to vaccination protocols. o Most objections are based on pseudo-science or exaggerated, inaccurate information.  Extensive research is available to the public regarding these concerns (Box 71-1).  The CDC and numerous professional healthcare agencies strongly support immunization.

Specific Care for Age Groups Infant Care  Infant health supervision includes documentation of milestones of development and growth, as well as documentation of immunizations and family teaching.  General observations: • How family caregivers hold the infant • If the infant “cuddles” with family caregivers • General cleanliness of the infant • The infant’s response to painful procedures • The infant’s appearance of health or illness; weight compared with length

 Specific observations:

• Equal, active movement of all extremities

• Tone and pitch of the infant’s cry

• General activity level

• General respiratory status

• Alertness

• Fontanels, reflexes

• Skin color, warmth, and texture

• Achievement of developmental milestones

Toddler Care  As a toddler’s growth progresses, independence and autonomy become important.  Documentation for a well-child checkup will include : • Age of weaning from breast or bottle to cup (usually achieved by age 12 months) • Ages at which toilet training was started and completed • Language development • Play patterns and activities • Sleep patterns

 Discuss with family caregivers their child’s behavior patterns and the type of discipline they use at home.  Encourage caregivers to begin dental checkups for toddlers as early as 12 months of age.  Teaching requires a strong focus on safety. o Toddlers are very mobile, but lack the judgment to protect themselves. o Observe caregiver–toddler interaction.

Preschooler Care

 The physical examination for preschool children focuses on readiness for school.  Use a systems checklist to evaluate each child’s physical condition. o Focus also on: o sleep patterns o safety o relationships with peers, siblings, and family caregivers  Evaluation of speech, hearing, and vision is critical in the preschool years. o Each must be within normal limits to facilitate learning. o Determine if a child’s developmental age is commensurate with his or her chronologic age. o An adequate attention span is essential, follow directions, and focus on a task.  Evaluate gross and fine motor control. o These characteristics are evaluated earlier, but they become a special focus in the preschool examination.

School-Age Child Care  Continue to plot the school-age child’s height and weight on the growth grid to establish a comparison with other children of the same age.  Emphasize successful completion of schoolwork and relationships with peers, siblings, and family caregivers.  Evaluate nutrition, elimination, and sleep patterns.  Immunization status needs to be reviewed o using the most current immunization recommendations

Adolescent Care  Health supervision issues for adolescents focus on puberty and a smooth transition to young adulthood.  Adolescents require an update of the diphtheria-tetanus immunization.

 Adolescents are capable of expressing individual concerns o you will benefit from talking separately with caregivers and with adolescents.  The adolescent may present with such problems as acne vulgaris, menstrual dysfunction, inadequate nutrition, sexually transmitted diseases, suicidal ideation, or chemical abuse.

o

Many adolescents benefit from professional counseling.

 Adolescents need certain accommodations to preserve their self-respect and identity. o They do not belong either with young children or only with adults. o Adolescents feel more comfortable and are able to relate better with healthcare personnel in a setting customized for them.  If a specialized setting is unavailable, the adolescent should be placed with others close to his or her age.  In any situation, clear rules should be posted so that all adolescents know the setting’s guidelines.  Illness or injury can seriously threaten self-image. o Many young people worry about damage to their bodies or about death, whether the threat is real or not.  They are often acutely aware of their emerging sexuality o their modesty should be respected o Include adolescents in planning and performing care as much as possible to encourage their emerging independence.  Adolescents need nonbiased and accurate information regarding their rapidly changing bodies and the issues they may encounter during this transition to young adulthood.  Health education should include: o information concerning sexually transmitted diseases and prevention, including HIV/AIDS, sexual identity, pregnancy, and birth control.  Teenagers also need clear and nonjudgmental information about substance use and abuse, depression, and suicide.

THE HOSPITAL EXPERIENCE  Short- or long-term hospitalization can be traumatic and disturbing for children and families. o Small children usually do not understand what is happening or why they are being taken away from home.  Illness threatens body image at any age.  You will see nurses in the pediatric department dressed in colorful scrubs.  The units are decorated with pictures of animals or cartoon characters to make the children feel more comfortable.

Age-Related Concerns

Infants, Toddlers, and Preschoolers  Even before children are 1 year of age, they become frightened of strangers and are aware of their family’s absence.  From ages 1 to 5 years, children often exhibit severe anxiety when separated from home and family.  Very young children have concrete thought processes and often misinterpret what they hear.  The following statements are examples of what to avoid saying when caring for children. (The statements in parentheses give an example of what the child might be thinking.) • “I am going to take your blood pressure.” (Where are you taking it?) Instead you might say: “I am going to find out how strong your heart is beating right now.” • “I am going to give you a shot.” (Are you going to shoot me with a gun?) Instead, you might say: “I am going to give you some medicine.” • “This will only feel like a little bee sting.” (Oh, no, I’m afraid of bees!) Instead you might say: “This may hurt a little. Hold your teddy bear tightly to help you.”

 Keep sentences short, and phrase statements so the child knows what to do, not what to avoid o (e.g., instead of saying, “Don’t cross the street alone,” say to the child, “Always cross the street with an adult”).  Tell children who are to remain in the hospital overnight that nurses work at night also, in case they are worried that they will be alone (see In Practice: Nursing Care Guidelines 71-1).

School-Age Children and Adolescents  Older children are able to understand the need for hospitalization, although they often hide many fears.  Younger school-aged children may experience fear of separation when they are ill. o Peer relationships are important to children, especially adolescents.  Most healthcare facilities allow friends to visit, but activities should be regulated to prevent sick teens from becoming overtired. o A telephone should be available for the child client; however, rules for its use should be clearly established.

Family-Centered Care  Most healthcare facilities make every effort to meet a child’s need to be part of a family unit.  Family-centered care may include rooming-in (Fig. 71-1). o Healthcare personnel encourage family caregivers to remain with children during their hospital experience. o Participation in care by family members promotes a less-stressed child and parent.  If family members are unable to remain with their children, caregivers should assure the children that they will return. o State the time of their return in terms that children will understand (e.g., “before lunch,” “after your nap”). o They can also give children a possession to hold until their return.  Nurturing measures, such as providing a doll, a toy, or a teddy bear, can help to relieve anxiety; the object becomes a physical reminder that the family caregiver will return.  Family caregivers react in various ways to hospitalization. o Reactions often depend on the following factors: • The seriousness of the child’s illness

• The family’s former experiences with illness and hospitalization

• The immediate threat to the child’s life

• The family’s style of coping with stress

• Family situation

• The caregivers’ beliefs and values

• Ego resources of the family caregivers

Preparation  Hospitalization often causes apprehension and fear in families.  Helping children successfully adjust is an important nursing goal.  One way to ease this adjustment is to prepare children for the experience at their own level of comprehension. o Tell children what to expect and help them avoid feeling abandoned or punished. o If possible, a tour of the healthcare facility before admission provides a foundation for preparing the child. o Encourage family caregivers to include the child in packing for the trip to the facility. o Remind them to be sure to bring along special items.

Separation Anxiety and Loss of Control  Separation anxiety is a developmental milestone for children under normal circumstances. o Going from a familiar person and environment (e.g., parent and home) and the initiation of an unfamiliar, and therefore stressful, new lifestyle (e.g., hospital caregivers and facility environments). o a fear associated with the separation and changes in routine o They feel threatened and unsafe.  Separation anxiety is a panic reaction, with behaviors that include crying, resisting attention or treatment, and screaming. o Loss of control often accompanies separation anxiety, and affects most children in a hospital setting.  Loss of control refers to the child’s inability to maintain newly learned concepts associated with autonomy, such as walking, being potty trained, or feeding oneself.  There are three phases of separation anxiety: protest, despair, and denial. o Each phase extends into the next.  The phases of separation anxiety manifest themselves as behavioral changes (Box 71-2). o Protest takes the form of crying and rejection of new caregivers. o Despair appears sad or apathetic. o Denial has the appearance of resolved stranger anxiety because the child may seem to identify and accept the new environment and staff while seeming to deny and avoid parental attention.  Infants and preschool-age children have only minimal abilities to comprehend abstract concepts such as time, consequences, or illness.  Older children have a better understanding of these concepts; therefore, for the older child, separation is not perceived as a threat.

 Prior to a hospitalization, children benefit from preexposure to a new environment. o Many hospitals offer hospital tours designed for the pediatric client and the family.  Occasionally, a mild sedative is necessary to help reduce pediatric trauma, especially if the child is in severe distress and pain. o Some medical professionals encourage a parent to be with the child at all times, for example, during treatment in an emergency room.  Because of the concerns related to separation anxiety and loss of control, nursing considerations must include an understanding of age-appropriate growth and developmental milestones. o For example, at the toddler stage, it is important to help the child maintain as much independence as possible, by encouraging self-feeding and dressing, and age-appropriate communication between child and caretaker

Transcultural Considerations  Children and families from a culture that differs from most of the clients or nurses in a healthcare facility may be confused and frightened.  Children who do not understand the language may be especially frightened and have a difficult time.  Family caregivers should translate for their children, if possible.  It is helpful for the staff to communicate with children, and make them feel comfortable and relaxed. o Allowing them to be with other children as much as possible is also beneficial.  Keeping pictures of common items available can help children to communicate their needs, thereby making them feel less isolated.

BASIC PEDIATRIC CARE AND PROCEDURES Admitting Children to the Healthcare Facility  A special effort should be made to be alert to the needs of both the family caregivers and the child.  Make family members as comfortable and secure as possible; it is important to earn their confidence and cooperation. o If children see that their family caregivers accept and trust you, they become more willing to accept you as well.  Ask family caregivers about their child’s special needs, likes and dislikes, allergies, and special vocabulary, especially for items such as the “potty.” o You can include children in gathering this information by directing the questions to them.  You should also introduce them to roommates.  The playroom is a nonthreatening environment in which the family and nursing staff can get to know each other, thereby helping to put children at ease.

Assisting With the Physical Examination  The equipment for the physical examination of a child is the same as that for an adult, except that some pieces are smaller.  The child’s cooperation is of utmost importance and a little extra time in helping the child be comfortable works wonders.  Show the child the equipment and let him or her handle it to promote a sense of control.

 If the child is too young, ill, or frightened to understand how to cooperate, you may need to restrain him or her for parts of the examination. o Use restraint only as a last resort because it makes children feel more threatened and frightened.

Data Collection on Admission  Observe the child carefully for any signs of rash, abrasion, discharge, or alteration in consciousness level.  Note complaints of pain or other symptoms, as you would for an adult.  Carefully document all observations.  If you have reason to think a child has been battered or abused in any way, report your beliefs to your supervisor—this is a legal responsibility

Vital Signs  Obtain and document vital signs on admission (Table 71-1).

Respiration  Take respirations before taking other vital signs, because you will be unable to obtain an accurate respiratory rate if a child is crying.  Count the respiratory rate for 1 full minute.  If you cannot obtain a respiratory rate because of crying, observe for signs of respiratory distress by checking skin color, pallor, and the presence of breath sounds. ...