63-27763-277

NURSING CARE OF NURSING CARE OF CHILDREN & YOUTHCHILDREN & YOUTH WITH EPISODIC AND WITH EPISODIC AND

LONG-TERM HEALTH NEEDSLONG-TERM HEALTH NEEDS

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Introduction to 63 277Introduction to 63 277

• Review of course outlineReview of course outline• Review of competency performance Review of competency performance

assessmentsassessments• PoliciesPolicies• Texts & Resources- DVDTexts & Resources- DVD• Clickers – class participationClickers – class participation• Clinical component 63 274Clinical component 63 274

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What Is Pediatrics ?What Is Pediatrics ?

• Who are the clients ?Who are the clients ?

• What is the setting ?What is the setting ?

• What is nursing’s role ?What is nursing’s role ?

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Pediatric Nursing is :Pediatric Nursing is :

• Practice of nursing involving the health Practice of nursing involving the health care of children from infancy to care of children from infancy to adulthoodadulthood

• Overall goal is to promote & assist the Overall goal is to promote & assist the child in maintaining optimal levels of child in maintaining optimal levels of health while recognizing the influence of health while recognizing the influence of the family on the child’s well beingthe family on the child’s well being

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PHILOSOPHY of PHILOSOPHY of Pediatric Nursing CarePediatric Nursing Care

• Focus on family- “family centered care”Focus on family- “family centered care”• AdvocacyAdvocacy• Atraumatic therapeutic careAtraumatic therapeutic care• Anticipatory guidanceAnticipatory guidance• Evidence-based practiceEvidence-based practice

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Philosophy & PrinciplesPhilosophy & Principles• Wellness the goalWellness the goal• Build on strengthsBuild on strengths• Everyday a new Everyday a new

opportunityopportunity• Nature + NurtureNature + Nurture• Child has rightsChild has rights• Diversity expectedDiversity expected

• Prevent injury/illnessPrevent injury/illness• Integrate Gr.& Dev.Integrate Gr.& Dev.• Evidence-based care Evidence-based care

adapts to needsadapts to needs• Family is constantFamily is constant• Family as partnersFamily as partners• Wholistic presenceWholistic presence

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Pediatric Nursing As SpecialtyPediatric Nursing As Specialty

• Complex – multiple ages & stagesComplex – multiple ages & stages

• Anatomy & physiology different from Anatomy & physiology different from adultadult

• Growth & developmental stages Growth & developmental stages

• Full of change Full of change

• Emphasis on anticipatory guidance, risk Emphasis on anticipatory guidance, risk reduction, injury prevention reduction, injury prevention

63-277 Winter 2006

Changing Pediatric SceneChanging Pediatric Scene• Partnership with familiesPartnership with families

• Changing demographics Changing demographics • Smaller familiesSmaller families• Ethnic diversityEthnic diversity

demands for adolescent caredemands for adolescent care

• Movement of care into home/communityMovement of care into home/community

• Health care cost containmentHealth care cost containment

63-277 Winter 2006

Changes in the Pediatric PopulationChanges in the Pediatric Population

technology & procedurestechnology & procedures• More serious and complex problemsMore serious and complex problems• Fragile newborns - Survivors of premature Fragile newborns - Survivors of premature

birthsbirths• Children with severe injuriesChildren with severe injuries• Children with disabilities who have survived Children with disabilities who have survived • More frequent and lengthy stays in hospitalMore frequent and lengthy stays in hospital

63-277 Winter 2006

Role of Pediatric NurseRole of Pediatric Nurse

• Therapeutic relationship• Family Advocacy• Caring• Disease Prevention• Health Promotion• Health Teaching

• Therapeutic relationship• Family Advocacy• Caring• Disease Prevention• Health Promotion• Health Teaching

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Role of Pediatric NurseRole of Pediatric Nurse• Support/counselingSupport/counseling• Restorative roleRestorative role• Coordination/collaborationCoordination/collaboration• Ethical Decision makingEthical Decision making• ResearchResearch• Health care planningHealth care planning

63-277 Winter 2006

Ethical-Legal IssuesEthical-Legal Issues

• Atraumatic careAtraumatic care• Bill of rightsBill of rights

• Consent for treatmentConsent for treatment• Age of assent (age 7)Age of assent (age 7)• Advanced directivesAdvanced directives• Maintaining nursing recordsMaintaining nursing records• ConfidentialityConfidentiality• Research with childrenResearch with children

63-277 Winter 2006

Nursing Care with Children & Nursing Care with Children &

FamiliesFamilies • Orient to “care by family” approach Orient to “care by family” approach • Increase family involvement Increase family involvement • Learn interpersonal skills Learn interpersonal skills

• Physical carePhysical care• Emotional careEmotional care

• Self-awareness Self-awareness • Critical thinking - purposeful, organized, goal-Critical thinking - purposeful, organized, goal-

directed directed

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FAMILY-CENTERED CAREFAMILY-CENTERED CAREAmerican Academy of Pediatrics 2003American Academy of Pediatrics 2003

• Respect for child & familyRespect for child & family• Recognition of effects of cultural, racial, Recognition of effects of cultural, racial,

ethnic & socioeconomic diversity on the ethnic & socioeconomic diversity on the family’s health care experiencefamily’s health care experience

• Identification of and expansion of the Identification of and expansion of the family’s strengthsfamily’s strengths

• Support of the family’s choices related Support of the family’s choices related to health careto health care

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Family-centered care cont’dFamily-centered care cont’d

• Maintenance of flexibility Maintenance of flexibility • Provision of honest, unbiased Provision of honest, unbiased

information in an affirming & useful information in an affirming & useful approachapproach

• Assistance with emotional & other Assistance with emotional & other support the child & family requiresupport the child & family require

• Collaboration with familiesCollaboration with families• Empowerment of familiesEmpowerment of families

Significance of Family Centered CareSignificance of Family Centered Care

• Family is constant in child’s lifeFamily is constant in child’s life• Family supported in care giving & decision makingFamily supported in care giving & decision making• Expertise in own family dynamics recognized Expertise in own family dynamics recognized • Family strengths built onFamily strengths built on• Needs of whole family consideredNeeds of whole family considered• Diversity among families honored & respectedDiversity among families honored & respected• Professionals enable & empower client familiesProfessionals enable & empower client families• Parent-professional partnershipParent-professional partnership

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AdvocacyAdvocacy

• Intervene to prevent developmental & health Intervene to prevent developmental & health problemsproblems

• Work with families to identify Work with families to identify needs, needs, strengths, goals, and plansstrengths, goals, and plans

• Educate about available servicesEducate about available services• Promote children’s well-being through Promote children’s well-being through

teaching, counseling, holistic care, teaching, counseling, holistic care, collaborationcollaboration

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Therapeutic RelationshipTherapeutic Relationship• Caring yet defined boundaries – not overinvolvedCaring yet defined boundaries – not overinvolved• Empower familiesEmpower families

• Promote family’s control over child’s health carePromote family’s control over child’s health care• Teach “how to” rather than “do for”Teach “how to” rather than “do for”• Decrease family dependence on health care Decrease family dependence on health care

providersproviders• Separate families’ needs from own needsSeparate families’ needs from own needs

• Open communicationOpen communication• Effective advocacyEffective advocacy

• See [p 15 – Guidelines…]See [p 15 – Guidelines…]

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UN Bill of Rights (1959) UN Bill of Rights (1959) & Convention of Rights (1989)& Convention of Rights (1989)

• Definition of a ChildDefinition of a Child

A child is recognized as a person under 18, unless A child is recognized as a person under 18, unless

national laws recognize the age of majority earliernational laws recognize the age of majority earlier

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• Children’s RightsChildren’s Rights• Freedom from discriminationFreedom from discrimination• Conditions of freedom & dignityConditions of freedom & dignity• Name & nationalityName & nationality• Adequate nutrition, Adequate nutrition, housing, recreation and housing, recreation and

medical servicesmedical services • Care of parents – moral, material securityCare of parents – moral, material security• Protection from neglect, exploitationProtection from neglect, exploitation• EducationEducation• First to receive protection and reliefFirst to receive protection and relief• Be brought up in a spirit of understanding, Be brought up in a spirit of understanding,

tolerance, friendship among peoples, peace & tolerance, friendship among peoples, peace & universal brotherhood universal brotherhood

63-277 Winter 2006

BILL OF RIGHTS for BILL OF RIGHTS for CHILDREN’S HEALTH CARECHILDREN’S HEALTH CARE

University Children’s Hospital - University of California-Irvine 2006University Children’s Hospital - University of California-Irvine 2006

• To be called by nameTo be called by name• To receive compassionate care in a careful, To receive compassionate care in a careful,

prompt& courteous mannerprompt& courteous manner• To know names of all providers caring for the To know names of all providers caring for the

childchild• To have basic needs met and usual To have basic needs met and usual

schedules or routines honouredschedules or routines honoured• To be kept without food or water when To be kept without food or water when

necessary for the shortest time possiblenecessary for the shortest time possible

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• To be unrestrained if ableTo be unrestrained if able• To have parents or other important persons To have parents or other important persons

with the childwith the child• To have an interpreter for the child & family To have an interpreter for the child & family

when neededwhen needed• To object noisily if desiredTo object noisily if desired• To be educated honestly about the child’s To be educated honestly about the child’s

health carehealth care• To be respected as a person (not being To be respected as a person (not being

talked about unless child knows what is talked about unless child knows what is happening)happening)

• To have confidentiality respected at all timesTo have confidentiality respected at all times

Atraumatic CareAtraumatic Care1.1. Prevent or minimize child’s separation from familyPrevent or minimize child’s separation from family2.2. Promote a sense of controlPromote a sense of control3.3. Prevent or minimize bodily injury and painPrevent or minimize bodily injury and pain

• Prepare child for procedure or treatmentPrepare child for procedure or treatment• Control painControl pain• Provide privacyProvide privacy• Encourage play for expression of fear or Encourage play for expression of fear or

aggressionaggression• Provide choicesProvide choices

4. Respect cultural differences4. Respect cultural differences

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63-277 Winter 2006

Preventing or Minimizing Preventing or Minimizing SeparationSeparation

☺Parents present at all times☺ Accommodations provided for comfort☺ Positive attitude of collaboration by staff☺ Family encouraged to participate according to comfort levels☺ Reminder to consider parent stress level, need for sleep, nutrition & relaxation☺ Nurses must augment & complement parent role

☺Parents present at all times☺ Accommodations provided for comfort☺ Positive attitude of collaboration by staff☺ Family encouraged to participate according to comfort levels☺ Reminder to consider parent stress level, need for sleep, nutrition & relaxation☺ Nurses must augment & complement parent role

63-277 Winter 2006

EPISODIC CAREEPISODIC CARE

• Occasional interaction of nurse Occasional interaction of nurse

with child and family..with child and family..• Education part of each interaction.Education part of each interaction.• Concerns may be developmental, growth, Concerns may be developmental, growth,

illness, care management or parenting needs.illness, care management or parenting needs.• Therapeutic relationship requiredTherapeutic relationship required• Best if consistent team in child-centred setting.Best if consistent team in child-centred setting.• Important to plan for ATRAUMATIC CARE.Important to plan for ATRAUMATIC CARE.

63-277 Winter 2006

Special Needs Children Special Needs Children Long Term Care PopulationsLong Term Care Populations

♦♦Cognitive ImpairmentCognitive Impairment♦ ♦ Sensory ImpairmentSensory Impairment♦ ♦ Communication ImpairmentCommunication Impairment♦ ♦ Chronic IllnessChronic Illness♦ ♦ Congenital disabilityCongenital disability♦ ♦ Developmental delayDevelopmental delay♦ ♦ DisabilityDisability♦ ♦ HandicapHandicap♦ ♦ ImpairmentImpairment♦ ♦ Technology-dependent childTechnology-dependent child

63-277 Winter 2006

Trends in Care for Child with Chronic Trends in Care for Child with Chronic Illness or DisabilityIllness or Disability

• Developmental FocusDevelopmental Focus• Family developmentFamily development• Family Centered CareFamily Centered Care• NormalizationNormalization• Home careHome care• MainstreamingMainstreaming• Early InterventionEarly Intervention• Managed careManaged care

63-277 Winter 2006

ANTICIPATORY GUIDANCEANTICIPATORY GUIDANCE

• Prevention - Deal with an issue before it Prevention - Deal with an issue before it becomes a problem becomes a problem

• Traditional Traditional • Information on normal growth & Information on normal growth &

developmentdevelopment• Nurturing childrearing practicesNurturing childrearing practices• Injury preventionInjury prevention

63-277 Winter 2006

Anticipatory GuidanceAnticipatory Guidance

• Role of NurseRole of Nurse• Base interventions on needs Base interventions on needs

identified by familyidentified by family• View family as having ability to be View family as having ability to be

competentcompetent• Provide opportunities for family to Provide opportunities for family to

achieve competenceachieve competence

63-277 Winter 2006

63-277 Winter 2006

Community Health ConceptsCommunity Health Concepts• Community Community

• group of individuals with shared characteristics or interests who group of individuals with shared characteristics or interests who interact with each otherinteract with each other

• Populations Populations • groups of people who live in a communitygroups of people who live in a community

• Target population Target population • more narrowly defined groups more narrowly defined groups

• DemographyDemography• study of population characteristicsstudy of population characteristics

• Demographic characteristics include age, gender, race ,ethnicity, Demographic characteristics include age, gender, race ,ethnicity, socioeconomic status & educationsocioeconomic status & education

• Risk Risk • probability of developing a disease, illness or injuryprobability of developing a disease, illness or injury

63-277 Winter 2006

Nursing Activities for the CommunityNursing Activities for the Community

• Needs assessment – community prioritiesNeeds assessment – community priorities

• Public HealthPublic Health • Health assessment, disease surveillance, Health assessment, disease surveillance,

policy developmentpolicy development

• Health promotionHealth promotion• Perinatal care, screening clinics, parenting Perinatal care, screening clinics, parenting

skills education, education on health/injury risksskills education, education on health/injury risks

• Injury PreventionInjury Prevention• Develop and implement prevention strategiesDevelop and implement prevention strategies

63-277 Winter 2006

Community AssessmentCommunity Assessment

• DemographicsDemographics• PopulationPopulation

• Culture, ethnicityCulture, ethnicity

• Social classSocial class

• Family size, typesFamily size, types

63-277 Winter 2006

• Community SystemsCommunity Systems• Health & social servicesHealth & social services• CommunicationCommunication• RecreationRecreation• Physical environmentPhysical environment• EducationEducation• Safety & transportationSafety & transportation• Politics & governmentPolitics & government• EconomicsEconomics

63-277 Winter 2006

Mortality and MorbidityMortality and Morbidity

• See selected statistical document for See selected statistical document for Essex/Chatham/-Kent/LambtonEssex/Chatham/-Kent/Lambton

63-277 Winter 2006

Vital StatisticsVital Statistics• Epidemiology –Epidemiology –science of population health science of population health

applied to detection of morbidity & mortality in applied to detection of morbidity & mortality in a a populationpopulation

• Mortality: Mortality: number of deaths in a specific number of deaths in a specific period (rate/100,000 population)period (rate/100,000 population)

• Infant Mortality Rate: Infant Mortality Rate: number of deaths number of deaths during 1during 1stst year of life (rate/1000 births) year of life (rate/1000 births)

• Morbidity: Morbidity: prevalence of a specific illness prevalence of a specific illness (rate/1000) (rate/1000)

• New Morbidity: New Morbidity: pediatric social illnesses e.g. pediatric social illnesses e.g. poverty, abuse, violence, school failure, poverty, abuse, violence, school failure,

divorcedivorce

63-277 Winter 2006

Leading Health Indicators for ChildrenLeading Health Indicators for Children

• Perinatal inheritancePerinatal inheritance• Optimal weightOptimal weight• NutritionNutrition• Injury/violenceInjury/violence• Environmental risks Environmental risks

(pollution)(pollution)• Access to health careAccess to health care• Substance use/abuseSubstance use/abuse

• Exposure to tobacco, Exposure to tobacco, alcoholalcohol

• Sexual behaviourSexual behaviour• Mental healthMental health• Gender Gender • Dominant ethnic groupDominant ethnic group• Family incomeFamily income• Home locationHome location• EducationEducation

63-277 Winter 2006

Leading Causes of Infant MortalityLeading Causes of Infant Mortality• Congenital anomaliesCongenital anomalies• PrematurityPrematurity• Low birth weightLow birth weight• Sudden infant death syndrome (SIDS)Sudden infant death syndrome (SIDS)• Maternal complications in pregnancyMaternal complications in pregnancy• Newborn birth complicationsNewborn birth complications• Respiratory distress syndrome (RDS)Respiratory distress syndrome (RDS)• Infections – bacterial sepsisInfections – bacterial sepsis• Birth asphyxiaBirth asphyxia• Intrauterine hypoxiaIntrauterine hypoxia

63-277 Winter 2006

Leading Causes of Childhood MortalityLeading Causes of Childhood Mortality

After 1 year of ageAfter 1 year of age• Injuries/accidents are leading cause of deathInjuries/accidents are leading cause of death• Adolescence: higher risk for – Adolescence: higher risk for –

• InjuryInjury• HomicideHomicide• SuicideSuicide• CancerCancer• Heart diseaseHeart disease

63-277 Winter 2006

Injuries – Risk FactorsInjuries – Risk Factors

• SexSex• TemperamentTemperament• StressStress• Alcohol/drug useAlcohol/drug use• History of previous injuryHistory of previous injury• Developmental characteristicsDevelopmental characteristics• Cognitive characteristicsCognitive characteristics• Anatomic characteristicsAnatomic characteristics

63-277 Winter 2006

Injury PreventionInjury Prevention

• Passive strategiesPassive strategies• Seat beltsSeat belts• HelmetsHelmets

• Active strategiesActive strategies• Anticipatory guidanceAnticipatory guidance• Self protection behavioursSelf protection behaviours

63-277 Winter 2006

Levels of PreventionLevels of Prevention• PrimaryPrimary

• Health promotion, disease & injury Health promotion, disease & injury preventionprevention

• SecondarySecondary• Screening & early diagnosisScreening & early diagnosis

• TertiaryTertiary• Disease management, optimizing Disease management, optimizing

rehabilitationrehabilitation

63-277 Winter 2006

Levels of PreventionLevels of Prevention

• Primary- focuses on health promotion & Primary- focuses on health promotion & prevention of disease or injuryprevention of disease or injury

• Well child clinicsWell child clinics• Immunization programsImmunization programs• Safety programs-prevention of injuriesSafety programs-prevention of injuries• Nutrition programsNutrition programs• Environmental effortsEnvironmental efforts• SanitationSanitation• Community parenting classesCommunity parenting classes

63-277 Winter 2006

63-277 Winter 2006

Levels of PreventionLevels of Prevention

• Secondary prevention- focuses on screening & Secondary prevention- focuses on screening & early diagnosisearly diagnosis

• TB screeningTB screening• Lead screeningLead screening• Mental health counseling for stressful Mental health counseling for stressful

events ie divorce, death, disastersevents ie divorce, death, disasters

Screening –purpose to detect & treat disease Screening –purpose to detect & treat disease early in the period of pathogenesis in order early in the period of pathogenesis in order to prevent the spread & progression of to prevent the spread & progression of diseasedisease

63-277 Winter 2006

Levels of PreventionLevels of Prevention

• Tertiary focuses on optimizing function Tertiary focuses on optimizing function for children with disability or chronic for children with disability or chronic diseases diseases

• RehabilitationRehabilitation• Disease management programs for Disease management programs for

asthma, cancer, etcasthma, cancer, etc• Special education programsSpecial education programs

63-277 Winter 2006

Best Practice Best Practice

• Evidence-based practice & researchEvidence-based practice & research• Optimize care & standardsOptimize care & standards• Share & disseminate findingsShare & disseminate findings

• FutureFuture• Collaborative management, ambulatory care, Collaborative management, ambulatory care,

home care, health promotionhome care, health promotion

• RNAO Best Practice GuidelinesRNAO Best Practice Guidelines

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EVIDENCE-BASED PRACTICEEVIDENCE-BASED PRACTICE

• EBP is the collection, interpretation & EBP is the collection, interpretation & integration of valid, important & integration of valid, important & applicable patient-reported, nurse-applicable patient-reported, nurse-observed & research derived observed & research derived informationinformation

• Combines knowledge with clinical Combines knowledge with clinical experience & intuitionexperience & intuition

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EBPEBP

• Begins with identification of the problemBegins with identification of the problem• Clinical questions are asked to allow for Clinical questions are asked to allow for

clear answersclear answers• Clinically relevant research is evaluatedClinically relevant research is evaluated• Findings from the history & physical are Findings from the history & physical are

analyzedanalyzed• Specific pathophysiology is reviewedSpecific pathophysiology is reviewed

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EPBEPB

• A care plan is developedA care plan is developed• Critical appraisal of what is known & Critical appraisal of what is known &

what is not known about the problemwhat is not known about the problem• Evidence is integrated with clinical Evidence is integrated with clinical

expertise and patient’s unique needsexpertise and patient’s unique needs• Interventions are initiated Interventions are initiated • Patient’s progress toward attainment Patient’s progress toward attainment

of outcomes is evaluatedof outcomes is evaluated

63-277 Winter 2006

RNAO BPG: RNAO BPG:

SUPPORTING & SUPPORTING &

STRENGTHENING STRENGTHENING

FAMILIESFAMILIES

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BEVIS’ NURSING SYSTEMBEVIS’ NURSING SYSTEM INPUT

NEEDS PROBLEMS

GOALSDESIRES

of IndividualsFamiliesGroups

THROUGHPUTCONCEPTS – LIFE

TASKSAdaptation

(Stresses & Strains)Maturation

TOOLSProblem-Solving/Decision-

MakingCommunication

Teaching/LearningManagement/Change

Caring

OUTPUTBEHAVIOURS

ProtectiveNurturative Generative

CLIENT SYSTEMS

IntrapersonalInterpersonalCommunity

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

63-277 Winter 2006

Use of Nursing ProcessUse of Nursing Process • AssessmentAssessment

• PhysiologicalPhysiological • History, examination, diagnosticsHistory, examination, diagnostics

• DevelopmentalDevelopmental • Developmental stages & tasksDevelopmental stages & tasks• Client & familyClient & family

• Psychosocial Psychosocial • Culture, language, religionCulture, language, religion• EconomicsEconomics• Family roles, health beliefsFamily roles, health beliefs• Communication Communication

63-277 Winter 2006

Nursing ProcessNursing Process (cont’d)(cont’d)

• Diagnosis & PlanningDiagnosis & Planning• NANDANANDA• Parenting & family diagnosesParenting & family diagnoses• Family-centred care goals/beliefs & identified Family-centred care goals/beliefs & identified

health goalshealth goals • Collaboration – mutual identification of goalsCollaboration – mutual identification of goals

63-277 Winter 2006

Nursing ProcessNursing Process (cont’d)(cont’d)

• InterventionsInterventions• creative nursing creative nursing • interdependent nursing actions, collaboration interdependent nursing actions, collaboration • identify supports/resources, referrals identify supports/resources, referrals • teaching/learning teaching/learning • ensure safety, security of child ensure safety, security of child • care appropriate to age & development care appropriate to age & development • caring, compassion, comfort caring, compassion, comfort