PERSPECTIVES OF PEDIATRIC NURSING

Nursing of the Childrearing Family

OBJECTIVES

Identify ways mortality and morbidity data canbe used to improve child health care.

Identify factors that may contribute to our country’s high infant mortality rate.

State the major cause of death for (a) infants and (b) children 1 to 18.

Identify factors that make a child susceptible to health problems.

Discuss the relevance of Healthy People 2020 to nursing practice and list at least six health indicators.

Discuss the relevance of cultural sensitivity to the implementation of comprehensive pediatric nursing care.

Discuss the impact that socioeconomic influence can have on health and child development.

Discuss the importance of family centered care. Give an example of atraumatic care Describe the roles of the pediatric nurse in today’s health care

system.

EARLY REFORMERS

Study of Pediatrics began in mid-1800s Abraham Jacobi, Father of Pediatrics

Isabel Hampton (1893) wrote about the challenges of pediatric nursing:

“the habit of observation on the part of the nurse is of the highest degree of importance…we have to depend on signs to tell us where the trouble is located, and we may be able to gather facts of much importance from what are apparently quite trivial symptoms.”

Lillian Wald (1893) established Henry Street → home nursing visits, school nursing, ‘founder of public health nsg’

Lina Rogers – 1st full time school nurse

OUTCOMES

↑ knowledge base of parents re: prevention ↑ in sanitation and hygiene → ↓ illness Nutritional improvements → ↓malnutrition Early intervention & tx → ↓in communicable

disease Improved living conditions US Children’s Bureau (1912) 1st Maternity and Infancy Act → MCH Bureau

http://mchb.hrsa.gov/ Numerous federal programs with focus on

maternal and child healthHealthy People 2020—where do we go from here?

CHALLENGES OF PEDIATRIC NURSING

Communication – must be creative Developmental, cognitive, physical

differences Health problems specific to pediatrics Among the most vulnerable and

disadvantaged in society; 1 in 5 live in poverty (2001)

Diverse family systems Cultural diversity – must be culturally

sensitive

HEALTHY PEOPLE 2020 LEADING HEALTH INDICATORS Physical Activity Overweight and obesity Substance and Tobacco Abuse Responsible Sexual Behavior Mental Health Injury and Violence Environmental Quality Immunization Access to Health Care Adolescent Health Diabetes Early interventions for children with

disabilities

MORTALITY & MORBIDITY DATA WHY DO WE CARE ABOUT THIS STUFF? Provides rationale for planning and

delivering care Tells us the causes of death and illnessHigh-risk age groups for disorders or hazardsDriving force for funding → Advances in treatment

and preventionGuides us in providing specific areas of health

counseling www.cdc.gov http://www.hhs.gov/news/factsheet/

infant.html Office of Minority Health—infant mortality

statistics

INFANT MORTALITY

US behind 29 other developed nations - major diff is lack of national health program

Death rate for infants < 1yr greater than any other age up to age 54

#1 cause of death <1 yr: congenital anomalies LBW major determinant of neonatal death &

major indicator of infant health and mortality Prenatal care most important, early

identification of risk factors, and early intervention

Other risk factors: male, black race, maternal age, maternal education, short or long gestation

CHILDHOOD MORTALITY Leading cause of death >1yr through

adolescence – Unintentional Injuries Leading cause of death from

unintentional injuries – Motor Vehicles (♂ >♀ teens)

Firearm Homicide 1st among black males 15-19

Developmental stage & environment determine prevalence & type of injury

Critical to assess safety needs in hospitalized setting and home environment

Newer CDC link. 10 leading causes of death and injury

CHILDHOOD MORBIDITY Acute & chronic illness or disability Respiratory illness: 50% of all acute

illness Morbidity not distributed randomly –

access to health care major contributor Risk factors: poverty, homelessness,

children of LBW, chronic illness, foreign born adopted children, children in day care

The “new morbidity”: social, behavioral, educational problems that effect health

Causes of unintentional death by age from CDC

ATRAUMATIC CARE

Providing therapeutic care that eliminates or minimizes the psychologic and physical distress experienced by children & families in the health care system

Goal: First, do no harmPrevent or minimize child’s separation

from their familyPromote a sense of controlPrevent or minimize bodily injury and pain

FAMILY –CENTERED CARE Recognizes family as the constant in

child’s life Needs of all family members are

addressed Acknowledges diversity among family

structures and backgroundsEmpowerment – helping families

maintain or acquire a sense of control and competence by fostering their strengths and abilities, and by treating them with respect and acknowledging their expertise in caring for their child.

See Box 1-3, p 11

PARENT-PROFESSIONAL PARTNERSHIP Implies the belief that partners are capable

individuals who become more capable by sharing knowledge, skills and resources

Nurse can help families identify their strengths, build on them, and assume a comfortable level of participation

Our role is to strengthen their ability to nurture

CULTURAL INFLUENCESCulture: pattern of assumptions,

beliefs, & practices that unconsciously frames or guides the outlook & decisions of a group

Race: traits that are transmissible by descent &are sufficient to characterize those as a distinct human type

Ethnicity: people sharing a unique cultural, social, and linguistic heritage

Ethnocentrism: attitude that one’s own ethnic group is superior to others

CULTURAL INFLUENCES ON HEALTH CARE (CHAPTER 2) May view illness in a child differently Gender of child may be a factor Time orientation differs among

cultures Authority figure in family Interactions: verbal & nonverbal Food customs Health beliefs & Practices

OTHER FACTORSHeredity – innate susceptibility

acquired through generations of evolutionary changes within a certain populationCystic Fibrosis: almost

nonexistent in Asians & African-Americans

Lactase deficiency: African-Americans, Asians, Arabs, Native Americans

Tay-Sachs disease: JewsSickle cell disease: Blacks

PHYSICAL CHARACTERISTICS

Different skin tones require modification of assessment techniques to √ for cyanosis or jaundice – Hockenberry, p. 152

Mongolian spots on babies Stature and body build

RELIGIOUS INFLUENCES

Religion influences lifestyles of many cultures Meeting family’s spiritual needs can give

them strength, esp. during stressful times Certain rites/beliefs surrounding birth and

death Diet and food practices Medical practices

CONCLUSION

Goal is to adapt ethnic practices to the family’s health needs rather than try to change their beliefs

Practices that do no harm should be respected

Remember: No cultural group is homogeneous; there is always great diversity within groups

FAMILIESCHAPTER 3

Relationships between dependent children and one or more protective adults

Basically it is what an individual considers it to be

Must understand family’s strengths & stressors & how they function

Assess how this impacts the child & his/her health

FAMILY SYSTEMS THEORY

Derives from general systems theory The family is a system that continually

interacts with its members and the environment

Emphasis on “interaction” Problems do not lie in any one member but in

the type of interactions used by the family

FAMILY STRESS THEORY Families encounter stressors, both

predictable and unpredictable. When family experiences too many stressors for it to cope adequately, a crisis ensues. Adaptation requires a change in family structure and/or interaction.

Developmental Theory: addresses family change over time, using family life-cycle stages

FAMILIES–

Various types of family structures: 2 parents, 1 parent, grandparent(s),relative, non-relative, stepparent,foster parents, adoptive, blended families,divorced, extended, gay-lesbian,polygamous, communal, etc.

SOCIOECONOMIC INFLUENCES

Poverty: not a social class but a conditionVisible: lack of money or material

resources Invisible: social & cultural

deprivation; inferior employment & education opportunities; lack or inferior medical services

Most overwhelming influence on health

CHILDREN & POVERTY

In US, nearly twice as likely to be poor as citizens >65 yrs old

1 in 5 children live in poverty (2001)

Much higher rate in US than in other comparable countries

60% live in suburbs or rural areas↑ in chronically poor vs

episodically poor

EFFECTS OF POVERTY

High correlation between poverty and prevalence of illness

Uninsured or underinsured so limited access to health services

High infant mortality Substandard housing; crowded living Unbalanced meals and/or insufficient

food Miss more school due to illness

HOMELESSNESS

Fastest growing homeless: families Most common – single moms w/2-3

kids Children = more than 1/3 of homeless Some are “runaway” adolescents Many have been victims of or

witnessed forms of abuse Physical and mental disorders are

greater in this population

IMPORTANCE OF SAFETY IN PEDIATRICS & ANTICIPATORY GUIDANCE

It is critical for the nurse to assess the safety needs of all children in the hospitalized setting: side rails up, dangerous objects out of reach, belts on

high chairs and infant seats, no plastic bags nearby It is also as imperative for the nurse to

assess the home environment for safe practices Consistent use of car seats Locked cabinets for all dangerous chemicals, drugs, etc.

Anticipatory Guidance focuses on preventative teaching for caregivers based on the developmental needs of the child.

INFORMED CONSENT

Definition: Refers to the Legal and Ethical

requirements that patients must completely understand proposed treatment, including the RISKS & BENEFITS as well as alternative procedures.

Should be done by the primary physician, but the nurse is often involved in confirming that the patient understands the information and has the patient sign the consent for treatment forms.

This is a big issue in Pediatrics.

3 THINGS NEEDED FOR INFORMED CONSENT (HOCKENBERRY, PP. 999-1000)

Person must be “capable” of giving consent ( have adequate mental capacities), & be over the age of 18 years.

Person must receive enough information necessary to make an intelligent decision.

Person must act voluntarily when exercising freedom of choice without fraud, force, deceit, duress, or other forms of constraint or coercion.

ASSENT An ethical requirement that a child be

informed about a proposed treatment or plan of care and agree or concur with the decisions made by the person(s) giving Informed Consent.

Age where “assent” begins is ~7 years. Demonstrates respect for child’s right to

know at this level of intellectual development.

WHO CAN GIVE INFORMED CONSENT FOR CHILDREN?

Parent or Legal Guardian— need to be careful when dealing with

divorced families as to who has legal guardianship.

Evidence of Consent/ Oral Consent e.g. via telephone with 2 persons listening

and witnessing.

WHO CAN GIVE INFORMED CONSENT FOR CHILDREN? (CONT’D)

Mature & Emancipated MinorMature Minor’s doctrine: permits minors to

give consent even though they are not technically adults, as long as they understand consequences

Emancipated Minor: Person under 18 yrs who is recognized as having legal capacity of an adult under these circumstances: Pregnancy Marriage High school graduation Living independently Military service

WHO CAN GIVE INFORMED CONSENT FOR CHILDREN? (CONT’D)

In IL, if < 18 yrs, can give consent if: PG, married, or is a parent

Mature minor doctrine In IL, do not NEED consent for:

• Contraceptives (includes EC) or Pregnancy testing

• STI tx, includes HIV testing & tx (>12 yrs)• Abortion (this changes)• Sexual Assault tx • Emergency care – consent implied by law• Substance abuse care (> 12)• Mental health services if >12 – 5 session limit

WHO CAN GIVE INFORMED CONSENT FOR CHILDREN? (CONT’D)

Treatment without parental consent— Times of emergency which include a

“danger/threat to life or possibility of permanent injury”

In this instance, no consent is needed.

WHO CAN GIVE INFORMED CONSENT FOR CHILDREN? (CONT’D)

Parental Negligence— In cases of neglect or abuse by parent/legal

guardian, most states have statutory procedures by which custody of the child is transferred to a governmental or private agency (like DCFS) and consent for treatment can then be obtained.

The State does interfere with a parent’s rights in the interest of protection of the child Blood Transfusion for a child of Jehovah’s Witness

parents Medical tx for children of Christian Scientists

WHO CAN GIVE INFORMED CONSENT FOR CHILDREN?

Summary:As an RN, work within the law. Respect the patient and family

wishes as appropriate. Give full, informed consent after

the primary caregiver has reviewed it with the appropriate parties, being sure that the benefits AND the risks of the procedure(s) have been discussed in terms the consumer/family can understand.

VARIATIONS IN NURSING TECHNIQUES WITH CHILDREN

Pediatric medication administration is well covered on the 3 videos on reserve in the library.

Physical Assessment of the child is covered in Hockenberry, et al, 2011 ch. 6. A video is available in the library as well: #VHS 0007 Saunders OR # VC99 3023 (old but thorough).

Communication Techniques is in Chapter 6 of Hockenberry et al, 2011. Also integrated in ppt. on Phys. Assess.

Pediatric Variations of Nursing Interventions is in Chapter 27 of Hockenberry et al, 2011.(lots of tables and photos, and charts. You don’t have to know it all right away. Use it as a reference.)

Note the COMMON LABORATORY TESTS in Appendix Cof Hockenberry et al, 2011.

DRUG DOSAGE CALCULATION

Assess the safety of the following drug dosage for a 4-day-old baby weighing 8# 8oz: Methicillin 100mg IV q 8hrs.

Recommended dosage: (from drug book) IM/IV for children <7 days and > 2000g=

75mg/kg/day in divided dosages q 8 hr.Up to 150mg/kg/day for meningitis

CALCULATION

8# 8oz = 8.5lbs 2.2 lbs/kg = 3.86kg

3.86kg x 75mg/kg = 290mg/day

Dose ordered: 100mg x 3 (q 8hr)=300mg/day

What do you think?

ROLE OF THE PEDIATRIC NURSE

Therapeutic relationships Family Advocacy/Caring Health Promotion/Disease Prevention

Anticipatory Guidance Support/Counseling Restorative Role Coordination/Collaboration Ethical Decision Making Research – evidence based practice Health Care Planning – family & consumer

advocates

UNITED NATIONS’ DECLARATION OF THE RIGHTS OF THE CHILD

All Children Need:To be free from discriminationTo develop physically & mentally in freedom and dignityTo have a name and nationalityTo have adequate nutrition, housing, recreation, and

medical servicesTo receive special treatment if handicappedTo receive love, understanding, & maternal securityTo receive an education and develop their abilitiesTo be the first to receive protection in disasterTo be protected from neglect, cruelty, & exploitationTo be brought up in a spirit of friendship among people

YOU’VE GOT THE BASICS!

Enjoy the wonderful world of Pediatric Nursing! It’s one of the most rewarding things you will ever do!!