Perspectives of Pediatric Nursing

1. Perspectives of Pediatric Nursing Nursing of the Childrearing Family

2. 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.

3. Early Reformers • Study of Pediatrics began in mid-1800s Abraham Jacobi, Father of Pediatrics • Isabel Hampton Robb (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

4. 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 health • Healthy People 2020—where do we go from here?

5. 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 (current statistics) • Diverse family systems • Cultural diversity – must be culturally sensitive • Current AAP position on School Nurses

6. 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

7. Mortality & Morbidity Data Why do we care about this stuff? • Provides rationale for planning and delivering care • Tells us the causes of death and illness • High-risk age groups for disorders or hazards • Driving force for funding → Advances in treatment and prevention • Guides us in providing specific areas of health counseling • www.cdc.gov • Infant mortality statistics—leading causes of death • Birth defects, preterm births, maternal complications, SIDS, injuries

8. Infant Mortality • US ranks 29thamong 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 mostimportant, early identification of risk factors, and early intervention • Other risk factors: male, black race, maternal age, maternal education, short or long gestation

9. Childhood Mortality • Leading cause of death >1yr through adolescence – Unintentional Injuries • Leading cause of death from unintentional injuries – >4 yrs: 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

10. 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—2014 • Causes of death from violence by age from CDC--2014

11. Atraumatic Care • Providing therapeuticcare that eliminates or minimizes the psychologic and physical distress experienced by children & families in the health care system • Goal: First, do no harm • Prevent or minimize child’s separation from their family • Promote a sense of control • Prevent or minimize bodily injury and pain

12. Family –CenteredCare • Recognizes family as the constant in child’s life • Needs of all family members are addressed • Acknowledges diversity among family structures and backgrounds • Empowerment – 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(9th ed.), p. 8 (10th ed.)

13. Safety • Clinical decision-making re: child safety is critical in the hospital, but also in pediatrician’s offices, WIC clinics, school settings. • Assess the child’s symptoms for communicability. • Protect other children in the environment by initiating isolation procedures. • Observe the child’s environment and remove any harmful objects or elements that could cause injury.

14. 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 • A nurse’s goal is to: • Promote a therapeutic relationship between parent and child, • Integrate family-centered care in planning • Strive to maintain appropriate growth and development of the child.

15. Cultural Influences • Culture: 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

16. New perspective on culture

17. 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

18. Other Factors • Heredity – innate susceptibility acquired through generations of evolutionary changes within a certain population • Cystic Fibrosis: almost nonexistent in Asians & African-Americans • Lactase deficiency: African-Americans, Asians, Arabs, Native Americans • Tay-Sachs disease: Jews • Sickle cell disease: Blacks

19. Physical Characteristics • Different skin tones require modification of assessment techniques to √ for cyanosis or jaundice – Hockenberry, p. 152 (9th ed.), p. 124 (10th ed.) • Mongolian spots on babies • Stature and body build

20. 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

21. 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

22. FamiliesChapter 2 • 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

23. 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

24. 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. Resiliency to stress through adjustment and adaptation emphasizes that stress doesn’t have to be pathological • Developmental Theory: addresses family change over time, using family life-cycle stages • Duvall Stages of the Family (Box 2-1)

25. 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.

26. Socioeconomic Influences • Poverty: not a social class but a condition • Visible: lack of money or material resources • Invisible: social & cultural deprivation; inferior employment & education opportunities; lack or inferior medical services • Most overwhelming influence on health

27. Children & Poverty • In US, nearly twice as likely to be poor as citizens >65 yrs old • 1 in 5 children live in poverty (current statistics) • Much higher rate in US than in other comparable countries • 60% live in suburbs or rural areas • ↑ in chronically poor vs episodically poor

28. 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

29. 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

30. 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.

31. 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.

32. 3 Things Needed for Informed Consent(Hockenberry, pp. 999-1000, 9th ed. Pp. 883-885 10th ed.)) • 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.

33. 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.

34. 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.

35. WHO can give INFORMED CONSENT for CHILDREN? (cont’d) • Mature & Emancipated Minor • Mature Minor’s doctrine: permits minors to give consent who are >14 years of age, who can understand all elements of informed consent, 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

36. 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

37. 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.

38. 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

39. 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.

40. 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.

41. 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

42. Calculation • 8# 8oz = 8.5lbs x 1kg/2.2 lbs = 3.86kg • 3.86kg x 75mg/kg/day = 290mg/day • Dose ordered: 100mg x 3 (q 8hr)=300mg/day • What do you think? Remember that there is a maximum dose for meningitis that is still safe.

43. 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

44. United Nations’ Declaration of the Rights of the Child • All Children Need: • To be free from discrimination • To develop physically & mentally in freedom and dignity • To have a name and nationality • To have adequate nutrition, housing, recreation, and medical services • To receive special treatment if handicapped • To receive love, understanding, & maternal security • To receive an education and develop their abilities • To be the first to receive protection in disaster • To be protected from neglect, cruelty, & exploitation • To be brought up in a spirit of friendship among people

45. You’ve got the basics! • Enjoy the wonderful world of Pediatric Nursing! It’s one of the most rewarding things you will ever do!!