NURS 2410 Unit 5 Metro Community College Nancy

NURS 2410 Unit 5 Metro Community College Nancy

NURS 2410 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 Nurses 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 Componentssender, message, channel, receiver, response

Components of Communication Cycle

Sendergenerates the message Messageverbal, nonverbal, or abstract Channelauditory, visual, kinesthetic Receiverdecodes the message Responsefeedback 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 contextwhat is the situation?

Influence of culture Congruence between verbal and nonverbal message 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?

Figure 6-2 Facial expressions are a powerful means of communication. What does this childs 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? Influence of Physical and Psychosocial Factors on Communication Process Physical factorslanguage, gender, environment Psychosocial factorsculture, health status,

emotions, space, and time Influence of Language Issues Language and linguistic differences and expectations Medical terminology and medical jargon Nursing strategies to minimize language

barriers Influence of Gender

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

Environmental factors Comfort

Privacy Nursing strategies to minimize environmental barriers Influence of Health Status

Physical condition Emotional responses Need for information Nursing strategies to minimize barriers

Application to Nursing Care Individualized approach Caring The nurses emotional investment in the child and family Evokes a feeling of security and comfort

Caring environment needed for communication Application to Nursing Care Empathy Ability to perceive another persons experience

Empathetic behaviors and expressions enhance communication 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 highpitched 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 familys use May ask many questions (preschooler) Toddlers and Preschoolers

Short attention span Limited memory Cognitive development Egocentric Magical thinking Animism

Toddlers and Preschoolers 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

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 Nonverbaluse gestures, picture boards, writing

tablets Communication augmentationsystem of head nods, eye blinks Communicating with Children Who Have Altered Vision Approach to childidentify 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 childface child when speaking, enter room slowly Assess degree of impairmentmay need interpreter Communicating with Non-EnglishSpeaking Children Cultural implicationsneed to develop plan of

care in respect of culture Use of interpreters Familycould 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 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.

Play Culture Journaling Planning and Implementation Promote therapeutic nursechildfamily

relationship Promote effective therapeutic communication Planning and Implementation Components Provide appropriate environment Establish trust

Maintain confidentiality Convey respect Use therapeutic communication skills Planning and Implementation Alternate techniques

Play Art Journaling Storytelling Bibliotherapy Appropriate use of humor

Evaluation of Outcomes Use of effective techniques Establishment of therapeutic relationship Recognize and respond to childs and familys themes 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 Figure 7-1 Observe the behavior of children and family members while you are collecting historical and physiologic

data. Components of Health History General information about the patient Demographic Emergency contact information Historical

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

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 Health maintenance pattern and last visit Family History

Physiological Data Medicationsprescribed and OTC Allergies Immunization statusup 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

Parents 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

Physiologic differences in children may produce normal variations in physical assessment

Head Chest Abdomen Spine Skin imperfections

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. 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. Have an assistant hold the infants 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. Anthropometric Measurements Height After age 2 years

Stadiometer Anthropometric Measurements Weight Infant scale Kilograms, grams, and pounds and ounces

Standing scale Diapers and clothing Anthropometric Measurements Head circumference 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. Anthropometric Measurements Centimeters and inches Paper tape Measure twice Up to age 2 to 3 years

Around supraorbital and occipital prominences Anthropometric Measurements 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 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 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.

Head and Face Skull sutures Fontanels 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. Eyes Inspection Hypertelorism Palpebral slant

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? 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. Have the child sit at your eye level. Hold a toy or penlight about 30 cm (12 in.) from the childs 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 Coveruncover 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

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

Ears Inspection 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 Swelling

Webbing Palpation Nodes Trachea Thyroid gland

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. Neck and Lymph Nodes Range of motion Torticollis Meningismus

Chest Inspection Shape Chest deformities 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. Figure 7-36 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 Crepitus

Tactile fremitus Auscultation Hyperresonance Percussion

Figure 7-37 One example of a sequence for auscultation of the chest. Heart Inspection Precordial activity PMI

Palpation 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. 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. Musculoskeletal System Posture and spinal alignment Figure 7-52 Normal development of posture and spinal curves. A, Infant 2 to 3 monthsHolds head erect when held upright; thoracic kyphosis when sitting.

Figure 7-52 (continued) Normal development of posture and spinal curves. B, 6 to 8 monthsSits 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, ToddlerProtuding abdomen; lumbar lordosis. Figure 7-52 (continued) Normal development of posture and spinal curves. E, School-age childHeight of shoulders and hips is level; balanced thoracic convex and lumbar concave curves. 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. Musculoskeletal System 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.

Musculoskeletal System Lower extremities Hips Figure 7-56 Flex the infants 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, Childrens National Medical Center, Washington, DC.

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 infants 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. 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. Musculoskeletal System Lower extremities Legs and knees Feet and ankles

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. 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 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 25, 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. 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), 417423. Used with permission from Elsevier. Copyright Elsevier, 1991. 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. 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.

Gestational Age Assessment Ballard gestational age assessment tool Physical characteristics Breasts 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. 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.

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

Physical characteristics Genitals Gestational Age Assessment Ballard gestational age assessment tool Neuromuscular characteristics Posture

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

Ballard gestational age assessment tool Neuromuscular characteristics Square window Figure 7-70 Square window sign. A, At approximately 28 to 32 weeks gestation, the angle is 90 degrees. Figure 7-70 (continued) Square window sign. B, At a gestational age of approximately 39 to 40 weeks, the angle is

commonly 30 degrees. Gestational Age Assessment Ballard gestational age assessment tool Neuromuscular characteristics Arm recoil

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. 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.

Gestational Age Assessment Ballard gestational age assessment tool Neuromuscular characteristics Popliteal angle Figure 7-72 To assess the popliteal angle, flex and hold the thigh to the abdomen while extending the leg at the knee.

Gestational Age Assessment Ballard gestational age assessment tool Neuromuscular characteristics Scarf sign Figure 7-73 Scarf sign. A, Until approximately 30 weeks gestation, the elbow moves past midline with no resistance.

Figure 7-73 (continued) Scarf sign. B, The elbow will not reach midline after 40 weeks gestation. Gestational Age Assessment Ballard gestational age assessment tool Neuromuscular characteristics Heel-to-ear extension

Figure 7-74 Heel-to-ear scoring. Move the infants 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 Physical Assessment of Newborn Head

Molding Caput succedaneum 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. Physical Assessment of Newborn

Head Cephalohematoma Sutures Fontanels Symmetry 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. Physical Assessment of Newborn Eyes Chemical conjunctivitis

Blink reflex Red reflex vs. opacities Sclerae Tracking Dolls eye phenomenon Physical Assessment of Newborn

Ears Position Skin lesions or tags Hearing Nose Appearance

Patency of nares Flaring Physical Assessment of Newborn Mouth Palate Tongue, frenulum

Buccal mucosa Gums Gag, suck, swallow Epsteins pearls, neonatal teeth, inclusion cysts Physical Assessment of Newborn Neck

Position Appearance Torticollis Webbing, skin folds Clavicles Chest

Physical Assessment of Newborn Chest and Lungs AppearanceBarrel chest? BreastsEngorgement? Nipple discharge? RespirationsPeriodic breathing? Retractions? Grunting?

Breath sounds Physical Assessment of Newborn Heart Location of apical impulse Murmurs Pulses

Abdomen Appearance Bowel sounds Umbilicus and umbilical cord Physical Assessment of Newborn

Genitalia and anus Appearance and relation to gestational age Femalesvaginal discharge Malespenis, urethra, testes Patency of anus Stooling pattern Anal wink

Physical Assessment of Newborn Extremities Deformities Injuries Developmental hip dysplasia Symmetry of creases

Allis sign Barlow-Ortolani maneuver Physical Assessment of Newborn Spine Muscle strength and position Head control

Neurological system Alertness Posture Protective reflexes Primitive reflexes

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 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, postanesthesia 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 Knowledge, skills, feelings, expectations Cognitive level, ability, desire

Set clear, measurable goal(s) Teaching Steps Select method(s) 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

Table 22-1 (continued) The Childs 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 Childs 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 childs 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 carean approach to improve QOL Hospice carecare focusing on ensuring comfort

Do Not Resuscitate request Tissue and organ donation Autopsy Informing Parents of a Childs 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 Planning and Implementation Goal setting Competencies for high-quality end-of-life care Planning and Implementation

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 childs 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

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