chapter 1 child health evolution copyright © 2012 by saunders, an imprint of elsevier, inc

Chapter 1

Child Health Evolution

Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.

Key Terms

• Anticipatory guidance• Critical thinking• Emancipated minor Evidence-based

practice• Healthy People 2000: National Health Promotion

and Disease Prevention Objectives• HIPAA Holistic• Infant mortality rate Informed consent• Mature minor doctrine Morbidity• Pediatric

1-2Copyright © 2012 by Saunders, an imprint of Elsevier, Inc.

Learning Objectives

• Define or identify vocabulary terms listed• List government programs that have affected the

care of children• Contrast present-day causes of morbidity and

mortality with those of the past• Discuss current health care trends in pediatrics

and the effect they have on nursing care


Pediatrics

• The branch of medicine that deals specifically with children, their development, childhood diseases, and the treatment of such diseases

• The study of pediatrics began under Abraham Jacobi (1830-1919), a Prussian-born physician – Known today as the father of pediatrics– Paved the way for the promotion of children’s

health through the establishment of “milk stations” • Mothers could bring sick children for treatment and

learn the importance of pure milk and its proper preparation


PediatricsRecent Evolution of Nursing Care

• Over the past 100 years, the nursing care of children has evolved into a holistic approach– Children have a physical, intellectual, emotional,

and spiritual nature with needs that differ according to their developmental level

• Modern medicine has reduced death and disability over the past 100 years – Allows pediatric nurses to focus on improving the

scope and quality of their care for each child


Government Programs

• White House Conference on Children and Youth– First one in 1909– Issued 15 recommendations

• E.g.: Children’s Bureau for Child Welfare, est. 1912

• Social Security– Began matching state/federal funds for

maternal/child care and child disability in 1935– Supports preventive health programs; i.e.,

immunization, screenings


Government Programs

• The Fair Labor Standards Act– Passed in 1938– Regulates work conditions for children under 18

• Medicaid and the Children and Youth Project– Formed in 1965– Provides care for children in low-income and inaccessible

areas• The Special Supplemental Food Program for Women,

Infants, and Children (WIC) – Started in 1966– Safeguards the health of low-income women and children up to age 5


Government Programs

• The Child Nutrition Act– Enacted in 1966– Provides free or reduced-rate meals for low-

income children

• The Missing Children’s Act– Passed in 1982– Established a clearinghouse for efforts and

services related to missing children


Government ProgramsSafeguarding Uninsured and Underinsured Children

• The Children’s Defense Fund – Advocates children’s health care reform

• The Balanced Budget Act of 1997 – Established the State Children’s Health Insurance

Program (SCHIP) as Title XXI of the Social Security Act• Expands insurance coverage to many uninsured children

ineligible for Medicaid

• The Patient Protection & Affordable Care Act• The Health Care & Education Reconciliation Act of 2010

– Both address the issue of inadequate health care coverage for children


Government ProgramsHealth Promotion

• Healthy People 2000: National Health Promotion and Disease Prevention Objectives– 1990 – document released by the U.S. Department of

Health and Human Services – Presents an opportunity for Americans to take

responsibility for their own health– Equal access to health care for all, particularly the most

vulnerable (i.e., infants and children)• Healthy People 2010 is a follow-up to Healthy People

2000• Healthy People 2020 continues to strive for a

healthier nation


Changes in Mortality and Morbidity

• Infant Mortality Rate – The number of infant deaths per 1000 live

births– Has declined from approximately 200 in 1900

to 20 deaths in 1970 to 6.77 in 2007.– Infant mortality among infants of non-Hispanic

black mothers is much higher than non-Hispanic whites and Hispanic mothers (Heron, Sutton, Xu, et al., 2010).


Changes in Mortality and Morbidity

• Childhood morbidity (illness, chronic disease, disability) is affected by – general health– socioeconomic status – access to health care– psychosocial factors

• At-risk children who often have more frequent illnesses:– homeless– live in poverty– attend daycare regularly– decreased access to the health care system


Current PracticeEducation Requirements

• Because of the rapid changes taking place in health care today, it is the nurse’s responsibility to update his or her knowledge continually

• Nurses have a responsibility to the community and to their profession– Involvement in community and professional

organizations is not simply encouraged; it is absolutely essential for continued growth in an ever-changing society


Current PracticeResearch and Roles

• Evidence-based practice– Through examination of research literature,

nurses can analyze important evidence and improve the quality of care for their patients

• Anticipatory guidance– Caring for children in today’s society

necessitates careful assessment and early identification of children and families at risk


Current PracticeCritical Thinking and the Nursing Process

• Critical Thinking– Emphasizes process, inquiry, reasoning, creativity,

and ingenuity, so that the nurse can draw the best conclusion regarding a situation

– One’s ability to think and find solutions that provide the most effective nursing care

• The Nursing Process incorporates five phases– Assessment– Diagnosis– Planning– Implementation (intervention)– Evaluation



• Assessment phase– Also known as the data-gathering phase– The nurse obtains information about the child’s

physical, social, and emotional health, as well as the family’s adaptation to health alterations

• Diagnostic phase– Lists problems that emerge from the assessment– Diagnoses approved by the North American

Nursing Diagnosis Association (NANDA) are listed on the inside back cover of your textbook.



• Planning phase– Nurse uses goal-setting and outcome criteria to

construct a plan of care to treat diagnoses

• Implementation (intervention) phase– Nurse executes plan of care constructed in the

planning phase

• Evaluation phase– Nurse appraises the changes experienced by the

child or family in relation to achieving goals or outcomes


Documentation

• The nurse must document assessment findings throughout the child’s stay, regardless of setting

• Ensures completeness of care• Important legally

– Always document time– Each patient’s chart is a legal document– In lawsuits, if something was not charted, it

was not done!


Confidentiality and Informed Consent

• Health Insurance Portability & Accountability Act (HIPAA)

– Enacted in 1996

– Requires strict observance of confidentiality within the hospital setting

• This includes spoken confidentiality and patient records

– When working with older children and teens, nurses should explain confidentiality and its limits

• Plan to harm oneself or others

• Any abuse that may have occurred


Confidentiality and Informed Consent

• Informed consent– Obtained from the parent or legal guardian when written approval is

needed to perform a procedure for an underage, not emancipated minor

– Nurses are responsible for witnessing the signing of informed consent

• Emancipated minor– Adolescent younger than 18 years old, but no longer under parental

authority• Mature minor doctrine

– Laws designed to afford young people medical care without parental consent

– Varies from state to state (NJ has no provision for minor or emancipated minors to consent to routine medical treatment)

• [NAEHCY; Faegre & Benson LLP; January 15, 2009; SUBJECT: Unaccompanied Youth and Access to Medical Care]


Health Care Delivery SettingsClinics and Offices

• Outpatient facilities and/or community clinics– Run by larger hospital with collaborating group of

physicians, or a private physician’s office

• Both general and specialty clinics exist– Cardiac, orthopedic, respiratory, etc

• Elective surgery in outpatient clinics• Parents/caretakers are taught all of a child’s recovery

needs at home for a same-day discharge procedure

• Triage– In most offices/clinics, nurses triage (prioritize) and

respond to telephone inquiries


Health Care Delivery SettingsOffice and Home Care

• Pediatric Nurse Practitioner (PNP)– Provide in-clinic patient care, and routine physical exams in collaboration with the

physician– Often the primary contact person for children in the health care system

• Increasingly home care is popular due to technical improvements– Ongoing IV therapy home care– Phototherapy home care for jaundice– Lower cost– Increased patient satisfaction

• Case Manager– Plays a vital role in home care arrangements by managing complete medical

care for the patient– Facilitates linking home care families into a wide variety of network services

• Hospice– A team of hospice nurses and caregivers assist the families in providing home

care for terminally ill children


Health Care Delivery SettingsOther Settings

• Support groups– Geared toward family support and learning– Group therapy aids in the prevention of mental health

problems for children who have undergone stressful situations• Camps

– Many exist in the U.S. for children with chronic illnesses– Camp nurses ensure children receive proper care

• Parish nurses– Promote health within the context of a faith community

• Long-term care facilities– May be necessary for children with severe mental retardation,

multiple disabilities or medical fragility


The Hospital Setting

• Pediatric units differ from adult units– A more cheerful, casual atmosphere in keeping with the

child’s emotional and physical needs• Most pediatric departments include a playroom with

toys for various age groups run by a child life specialist– Nurses provide age-appropriate toys to children who

can’t leave their rooms• A flexible routine is typically maintained in regards to

eating, play, and rest• Most hospitals provide beds and encourage parents

to stay with their children


The Child’s Reaction to Hospitalization

• Factors– Age– Previous illness-related experiences– Support of family and health professionals– Emotional status

• Stressors– Separation anxiety– Loss of control– Bodily injury– Pain


MOMMY?!!MOMMY?!!

The Child’s Reaction to HospitalizationInfants and Toddlers

• Separation anxiety– The major stressor of hospitalization for toddlers– Occurs in the following stages

• Grief– Protesting loudly and crying for their mothers until falling asleep from exhaustion

• Despair– Depression, lethargy, refusal to eat

• Denial– Deny the need for mother by appearing detached and

uninterested in her visits– A disguise to prevent further emotional pain



• Loss of control

• Regression– Toddlers will abandon recently acquired skills and

demand assistance with tasks previously mastered

– Nurses should remind parents that this is normal behavior when toddlers are hospitalized

• Fear of injury– Minimizing fear of injury stressors



• Dealing with the stressors of hospitalization – Toddlers achieve control through choices– Forewarn children about any unpleasant or new

experience immediately beforehand– Be honest about procedures, etc., that may hurt– Explain procedures step-by-step as they occur– Encourage play with safe equipment; i.e.,

stethoscopes under supervision– Administer treatments in a room other than the

child’s room– Allow toddlers out of the crib whenever possible


The Child’s Reaction to HospitalizationPreschoolers

• Separation anxiety • Uncooperative; frequently ask for parent

• Loss of control– Many preschoolers perceive hospitalization as

punishment• Regression

– E.g.: bedwetting• Fantasy

• Pre-logical thinking; fantasy– Fear of hospital machinery– Nightmares– Fear of bodily harm during procedures


The Child’s Reaction to HospitalizationPreschoolers

• Communication between nurse and patient– Use understandable language when describing

procedures– Communicate time as a series of events, not

hours and minutes– Be aware of verbal and nonverbal cues– Participate in fantasies in a positive way, giving

the child control over imagined situations


The Child’s Reaction to HospitalizationSchool-Age Children

• Separation anxiety• Miss parents but miss friends more

• Loss of control– Children in this age group are learning to control

their feelings and actions– Independence is limited– They may have changes in vital signs due to

stress when hospitalized, even if making efforts to seem calm

• Fear of pain, bodily harm, permanent disability, body disfigurement or death


The Child’s Reaction to HospitalizationSchool-Age Children

• Dealing with the stressors of hospitalization– Bring items from home for familiarity and control– Drawing– Board games with involved adults– Maintain the child’s privacy– Continue education; connect to the outside world– Encourage classmate correspondence; Oh, the

cell phones!!!


The Child’s Reaction to HospitalizationAdolescents

• May be hesitant to have visitors– May be embarrassed by appearance– Fear that illness or procedures will change them

• Compliance may be a problem with a chronic disease– Probably afraid and stressed, even if they seem calm

• Dealing with the stressors of hospitalization– Fear of the unknown; explain everything in an

age-appropriate manner– Offer choices to maintain control and

independence– Clear limits and expectations so adolescents feel

less confused


The Hospitalized ChildThe Family’s Reaction to Hospitalization

• Parents may initially feel guilty, helpless, and anxious

• Developing a trusting relationship with parents is often the key to helping the child

• Hospitalization may cause financial problems for the family

• The nurse assesses the family’s needs and develops interventions to meet these needs


The Hospitalized ChildThe Family’s Reaction to Hospitalization

• Nursing Interventions– Assist parents in obtaining written and verbal

information concerning the condition of the child and the treatment plan

– Orient the family to hospital and explain all procedures

– Refer the parents as needed to social services– Listen to parents’ concerns and clarify information– Involve parents in the care of the child– Provide for rooming-in– Reinforce positive parenting– Provide educational resources as necessary


The Nurse’s RoleAdmission Process

• Provide a tour for the parents and child before admission, if possible to decrease fear of the unknown

• Focus on pleasant and positive aspects—but not to the point where hospitalization seems to involve no discomforts

• Security objects from home reduce anxiety in an unfamiliar setting

• Explain certain procedures, listen to patients and encourage questions

• Document admission information; perform a systems review and physical examination of the child

• All medications are reconciled upon admission, transfer, and discharge


The Nurse’s Role Health History

• Statistical information (name, address, phone number)

• Patient profile (eating and sleeping habits, educational level, developmental level, etc.)

• Health history (birth history, illnesses, immunizations, previous hospitalizations, allergies, etc.)

• Family history (information concerning the health status of the immediate family)

• Lifestyle and life patterns (social, psychological, physical, and cultural environment)

• Review of systems


The Nurse’s RoleSystems Review

• When examining the child, generally proceed in a head-to-toe manner while collecting vital signs

• Note the facial expression and the general appearance of the child

• Always talk to the parents about how they think their child is doing, because they know their child best

• Be sure to document and report any unusual or abnormal findings


The Nurse’s RoleSystems Review

• Pulse– The pulse rate varies considerably in different children of

the same age and size– Apical pulse is preferred for infants and small children• The apical rate /respiratory rates of the newborn infant are

high and gradually decrease with age until adult values are reached

• Respirations– Observe the movement of the abdominal wall as

respirations are mostly abdominal at this time– After about age 7 years, measure respirations the same

way as the adult’s– Lungs should be clear to auscultation with no

adventitious or abnormal breath sounds


Blood Pressure

• Ensure the blood pressure cuff’s bladder length is 80-100% circumference of the arm and the width is 40% of the circumference of the arm

Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-43

The Nurse’s RoleCultural and Religious Preferences

• Cultural beliefs affect how a family perceives health and illness

• Some practices raise concerns of abuse– E.g.: Coining; cupping

• Educate families that strict disciplinary practices may place them in jeopardy with child protective services

• Respect any rites, dietary restrictions, etc., associated with a family’s religion, as long as it does not interfere with the child’s well-being


The Nurse’s RoleDischarge Planning

• Preparation for discharge begins on admission• Directions for home treatment should be given to

parents gradually throughout their child’s hospitalization

• Documentation includes time of departure, person with whom the child departs, patient’s behavior, instructions/medications given to the patient or parents, and weight/vital signs upon discharge


The Nurse’s RoleDischarge Planning

• Prepare parents for potential post-hospitalization behavior problems– Clinging, regression in bowel and bladder control, aggression, fears,

nightmares, negativism– Return former family responsibilities within the limits of the child’s

present abilities as soon as possible– Avoid making the child a center of attention because of illness. Praise

accomplishments unrelated to illness– Be kind, firm, and consistent if the child misbehaves– Be truthful to maintain trust– Provide suitable play materials: Clay, paints, doctor/nurse kits. Allow free

play– Listen to the child, clear up misconceptions about the illness– Don’t leave child alone for a long period or overnight until a sense of

security is regained


SafetyTransporting, Positioning, and Restraining the Child

• Means of transportation varies with a child’s age• Ensure that a patient’s identification band is secure

before leaving the unit• Holding a baby

– Head and back support is necessary for young infants– Random movements of small children necessitate secure

holding• Restraints should rarely be used

– Detailed documentation is required– Restraints must be removed at least every 2 hours to

avoid impairing circulation and assess skin status• Therapeutic holding

– Holding a child in a secure, comfortable manner



Do• Lock wheelchairs and stretchers before placing patients in them

• Use safety straps with children when sitting• Apply restraints correctly to prevent constriction of a part. Check

institutional policy on frequency of releasing restraints and providing range of motion

• Handle infants and small children carefully. Use elevators rather than stairs. Walk at the child’s pace

• Place a hand on the infant or child’s back or abdomen when you turn your back to the child

• Always look for small objects which can become choking hazards



Do• Protect children from entering the treatment room, elevator,

utility rooms, and stairwells• Keep crib sides up at all times when unattended in bed. Use

enclosed (bubble top) cribs for older infants and toddlers to keep them from falling or climbing out of the crib

• Turn an infant perpendicular to the side of the bed when rails are down. Ensure that the infant will not roll off when rails are down

• Place cribs so that children cannot reach electrical outlets and appliances

• Check hospital policy for children who are alone (for instance, policy may recommend that the door be kept open)



Don’t• Don’t force-feed children. There is a danger of choking, which

may cause lung disease or sudden death• Don’t allow patients to use wheelchairs or stretchers as toys• Don’t leave a child unattended in a highchair, infant seat (if it

is placed on any area above the floor), swing or stroller or in a bath tub

• Don’t leave a child unattended on an examination table– Always keep your hand on the child

• Don’t leave small children unattended out of their cribs in their rooms

• Do not tie balloons to the crib rails


SafetyMedical Asepsis

• Contaminated– A person/object that has come into contact with an infected patient

• Disinfected– Killing microorganisms physically or chemically

Do• Wash your hands before and after caring for each patient• Properly disinfect any item brought out of an isolation room• Do wear a gown if holding a patient; change between patients

Don’t– Don’t cause cross-infection• Diapers, toys, and materials that belong in one patient’s storage unit

should not be borrowed for another patient’s use


SafetyGeneral Safety Guidelines

Do• Inspect toys for sharp edges and removable parts• Identify the patient properly before giving medications• Keep medications, solutions lotions, tissues, disposable pads

and diapers, and safety pins out of infant’s reach • Keep the medication room locked when not in use• Locate fire exits and extinguishers on the unit and learn how to

use them properly. Become familiar with the facility's fire manual• Supervise playroom activity• Take proper precautions when oxygen is in use• Use electrical outlet safety plugs on the unit• Continually assess the patient setting for safety issues


SafetyGeneral Safety Guidelines

Don’t• Don’t leave medications at the bedside• Don’t leave any medication administration materials in

the child’s bed or infant’s crib• Be aware of wear you place the caps from the pediatric

oral syringes. Do not leave in the bed!


Implications of Pediatric SurgeryPatient Preparation

• The nurse should give simple information about the system that will be affected– Stress that this is the only area of the body that will be

involved• Children need to know what to expect on the day of

surgery; use a doll to demonstrate• Children are particularly fearful of surgery and need

both physical and psychological preparation• The child should be able to easily understand

explanations and information given in simple terms• It is important to always be truthful; this establishes

trust


The Child in PainDefinition and Challenges

• Children of all ages experience pain and are entitled to appropriate pain management

• Pain is an individual, subjective experience, and health care providers need to identify and treat pain adequately

• Always ask the child and/or the parents about past pain experiences and known coping mechanisms


The Child in PainEvaluation

• When evaluating the child, include precipitating factors, location, onset, duration, quality, intensity, and characteristics of the pain

• Pain scales– 1 to 10 Pain Rating Scale– FLACC

• Infants and young children– Oucher Scale

• 2- to 7-year-olds– Wong-Baker FACES Pain Rating Scale

• Preschool and young school-age


FLACC pain scale


The Child in PainIntervention

• Oral administration is generally used for mild to moderate pain • When the child needs immediate pain relief for more intense pain,

intravenous administration is indicated• For moderate to severe pain that is expected to persist, continuous

dosing or around-the-clock dosing at fixed intervals is

recommended• Pain medication may also be administered rectally, by intramuscular

(IM) injection, transdermally, or topically (EMLA, LMX)• Nonopioid analgesics are most effective for mild to moderate pain

and have antipyretic effects as well• Opioids are used to manage most forms of moderate to severe

acute and chronic pain


The Child in PainIntervention

• Nonpharmacologic interventions– Used in conjunction with pharmacologic

interventions or by themselves– Complementary or alternative medicine

(CAM)• Hypnosis

– Altered state of consciousness. Suggestions can lead to changes in behavior or physical sensations

• TENS unit • Acupuncture• Chiropractors• Massage therapy


chapter 1 child health evolution copyright © 2012 by saunders, an imprint of elsevier, inc

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