NURS 2410 Unit 5 Metro Community College Nancy Pares, RN, MSN.

NURS 2410 Unit 5

Metro Community CollegeNancy 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

Nurse’s 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• Components—sender, message, channel,

receiver, response

Components of Communication Cycle

• Sender—generates the message• Message—verbal, nonverbal, or abstract• Channel—auditory, visual, kinesthetic• Receiver—decodes the message• Response—feedback 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 context—what 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 child’s 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 factors—language, gender, environment

• Psychosocial factors—culture, 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 nurse’s 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 person’s 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 high-pitched 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 family’s

use– May ask many questions (preschooler)


• Short attention span• Limited memory• Cognitive development

– Egocentric– Magical thinking– Animism


• 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

– Nonverbal—use gestures, picture boards, writing tablets

– Communication augmentation—system of head nods, eye blinks

Communicating with Children Who Have Altered Vision

• Approach to child—identify 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 child—face child when speaking, enter room slowly

• Assess degree of impairment—may need interpreter

Communicating with Non-English-Speaking Children

• Cultural implications—need to develop plan of care in respect of culture

• Use of interpreters– Family—could 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 nurse–child–family relationship

• Promote effective therapeutic communication


• Components– Provide appropriate environment– Establish trust– Maintain confidentiality– Convey respect

• Use therapeutic communication skills


• 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 child’s and family’s

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

• Medications—prescribed and OTC– Allergies– Immunization status—up 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

• Parent’s 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 infant’s 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.


• Height– After age 2 years– Stadiometer


• Weight– Infant scale

• Kilograms, grams, and pounds and ounces

– Standing scale– Diapers and clothing


• 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.


• Centimeters and inches– Paper tape– Measure twice– Up to age 2 to 3 years– Around supraorbital and occipital prominences


• 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 child’s 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 Cover–uncover 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.


• Posture and spinal alignment

Figure 7-52 Normal development of posture and spinal curves. A, Infant 2 to 3 months—Holds head erect when held upright; thoracic kyphosis when sitting.

Figure 7-52 (continued) Normal development of posture and spinal curves. B, 6 to 8 months—Sits 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, Toddler—Protuding abdomen; lumbar lordosis.

Figure 7-52 (continued) Normal development of posture and spinal curves. E, School-age child—Height 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.


• 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.


• Lower extremities– Hips

Figure 7-56 Flex the infant’s 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, Children’s 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 infant’s 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.


• 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 Findingsand 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 2–5, 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


• 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), 417–423. 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.



• 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.



• Ear cartilage and eyelid fusion



• Genitals


• 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.



• 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.



• 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.



• 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.



• 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.



• Heel-to-ear extension

Figure 7-74 Heel-to-ear scoring. Move the infant’s 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


• 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.


• 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.


• Eyes– Chemical conjunctivitis– Blink reflex– Red reflex vs. opacities– Sclerae– Tracking– Doll’s eye phenomenon


• Ears– Position– Skin lesions or tags– Hearing

• Nose– Appearance– Patency of nares– Flaring


• Mouth– Palate– Tongue, frenulum– Buccal mucosa– Gums– Gag, suck, swallow– Epstein’s pearls, neonatal teeth, inclusion cysts


• Neck– Position– Appearance– Torticollis– Webbing, skin folds– Clavicles

• Chest


• Chest and Lungs– Appearance—Barrel chest?– Breasts—Engorgement? Nipple discharge?– Respirations—Periodic breathing? Retractions?

Grunting?– Breath sounds


• Heart– Location of apical impulse– Murmurs– Pulses

• Abdomen– Appearance– Bowel sounds– Umbilicus and umbilical cord


• Genitalia and anus– Appearance and relation to gestational age– Females—vaginal discharge– Males—penis, urethra, testes– Patency of anus

• Stooling pattern• Anal wink


• Extremities– Deformities– Injuries– Developmental hip dysplasia

• Symmetry of creases• Allis sign• Barlow-Ortolani maneuver


• 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, post-

anesthesia 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 Child’s 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 Child’s 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 child’s 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 care—an approach to improve QOL• Hospice care—care focusing on ensuring

comfort• Do Not Resuscitate request• Tissue and organ donation• Autopsy

Informing Parents of a Child’s 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


• Goal setting• Competencies for high-quality end-of-life care


• 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 child’s 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

NURS 2410 Unit 5 Metro Community College Nancy Pares, RN, MSN.

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