Atraumatic Care & Pediatric Health Assessment

refusal of parents: what is done?

If the parents refuse treatment but the health care team feels the treatment is reasonable and warranted, the case should be referred to the institution's ethics committee. If the issue remains unresolved, then the judicial system becomes involved

Procedure if parents are in the room during procedure/ CPR

If we do that we need to have a plan for that because we don't want them to get in the way Let the staff know the parents are there to make sure nobody says anything inappropriate Have someone explain to them what is going and on what to do

Specific or invasive procedures consent

If we ever have to do more spesific or invasive procedures typically requires an additional consent - is a specific consent ex. blood, start PIIC line, surgical procedures, photography Need the person able to sign for child to do that

Purpose swaddeling

security/comfort, saftey, warmth secure the whole body of the child or every extremity except for one

How do you know if your getting a true o2 stat

if on the machine it shows your HR and your O2 stat Have consistent pleth or wave form

INTRO TO PEDS *informed consent/assent/refusal of medical tx* (slides 1-6)

*CH 1 pp. 48-53*

INTRO TO PEDS atraumatic care (slides 7-13)

*CH 30*

*I N T R O T O P E D S* *health assessment* (slides 14-22)

*CH 32 pp. 1158-1176*

*I N T R O T O P E D S* *Hospitalization, Safety, Hygiene, Play, & Teaching* (slide 23)

*CH 33 - pp. 1208-1220*

Important treatment aspect of pediatrics

Always thinking about psycho social issues of kids of all ages

Communication with toddlers

* have to be careful and approach them slowly * can work yourself in by talking to a parent first *Use very simple language and images so they can understand - use toddlers words for objects so they better understand *Prepare toddlers for procedures just before they are about to occur. *Use storytelling, dolls, and books.

Communication with famlies

* make sure if they speak a different language than they get the right information * technology for interpreters *make sure that all goal of the child are met before educating on a different topic- -keep the focus on what the family goals are * every opportunity with the child is an opportunity to try to educate family -ex. if they see you do a dressing change they can watch you and then do it next time -explain everything to a patient but also a parent

Communication with preschoolers

- Be honest - Use simple concrete terms - allow them to have choices - prepare about an hour before procedure - use medical play

Dissent (child-oriented)

- Disagreeing with the treatment plan - We have to stop and see if we can fix that * we want the kids on board - Age 13-17years- binding in some states

Communication with infants

- Infants: * make sure needs are met * respond to crying in timely fashion * allow time for the infant to warm up to you * talk to baby directly * Talk to them in a soothing/ calm tone * use play and playful persuasion

Assent (child-oriented)

- a younger child Agreeing to the treatment plan - not in a formal way or legally signing anything but you just want the kid to be educated and informed on everything and know what is going to happen - Child's participation in the decision-making process - Age > or = 7 years

Communication: Adolescents

-Always respect privacy. • Ensure confidentiality. • Use appropriate medical terminology, defining words as necessary. • Prepare the teen up to 1 week before a procedure.

Elbow restraint

-Rigid, padded, fabric splint -Minimizes movement of elbow joint -Helps with patients who pick on IV lines in antecubital or NG tube Prevents child from flexing and reaching face, head, IV and other tubes

Newborn Weight Calculations

1 1b = 454 grams 1 ounce = 28 grams 1 lb = 16 ounces

Age of toddler

1-3 years

Replacement Fluids formula

20 mL/kg of normal saline (N/S) or Ringer's lactate. -Never dextrose Infuse rapidly as an IV bolus.

Age of pre-schooler

3-6 years

Normal precential for height, head circumfrance, weight

3-97%

age of infant

4 weeks to 1 year

school age

6-12 years

Effective communication with children

A big part of pediatrics is learning out to speak to them ex. - Position at child level -Ask for permission if you need to approach the child to avoid appearing threatening -Use positive rather than negative statements -Allow the child to remain near the parent if needed -• Introduce yourself and explain your role. -Listen and allow time for the child to formulate his or her thoughts. -Direct your questions and explanations to the child. - Let them play, touch and feel equipment on a doll to dork out stress (medical play) -Encourage the child to express his or her feelings and ask questions.

Special circumstances with consent

A child not living with biological parents - foster care - relative - adopted - baby sitter Parental consent after divorce -Ability to give consent for health care rests with parent who has legal custody by divorce degree

Family presence during procedure

If a family can't be there for procedures or choose not to that is fine we can always get other staff to help during the procedure - often parents do want to be there - dependent on hospital policies or provider-driven Important to know if parents are allowed to be there from a hospital standpoint

If the cuff is too large

If the cuff is too large, the BP reading will be lower

restraints for children: reason

A lot of times the restraints used are medical restraints - ex. they are in the ICU and kids rip they're (lines out, NG tube, central line) for their safety we might have to restrain them Emphasize that the rationale is to maintain the child's safety; the restraint is not punishment.

Mature minor exceptions

A mature minor is usually an adolescent over 14 years of age and is considered sufficiently mature and intelligent to make the decision for treatment -In some states, a minor may give consent to certain medical treatments. - not legally emanicpated Can be difficult in the hospital if a teenage is refusing treatment because they do have a say but technically legally it is the parent that has consent

Growth Assessment

Accurate assessment of growth is a critical skill for the pediatric nurse: -Height/length -Weight -BMI - >3 years of age -Head circumference <2 years of age -Growth charts * need to b growing in a steady way

What is important to do with guardian that comes in with child

Always ask what their relationship is with the child at the bedside - never assume

Cribs and safe

Always need to make sure we have side rails on and that it is developmentally appropriate for the child Infants might not have the top plastic cover over the cribs -Clear plastic cover over the bed to prevent older infant (8-10 months) or young child from falling and climbing out of bed

Gather necessary equipment and toys

Always think about the things that you are going to need prior ex. stethoscope, distractions (infant for pacifier, toddler- let them play with a stethoscope so bring extra ) Don't have unlimited time - attention span is limited washable toys in the examination area to use as dis- tractions during the assessment. take out one piece of equipment at a time Provide appropriate covers to ensure the child's comfort, or have the child remain dressed until the time of the examination.

Differences in Pediatric Assessment

Approach to patient Communication with child and parent Order of assessment - prioritize your assessment according to why they are there - if they are there for resp you gotta know your RR and lung sounds Fontanel in children < 2 years Heart rate and Respiratory rate for a full minute Work of breathing - -retractions - diphramatic breathers - irregular pattern - key in any resp rate illness

Legal Issues

Assent (child-oriented) Dissent (child-oriented)

Temperature for children: techniques

Axillary or temporal temperatures < 4 - 5 years Oral temp > 4 - 5 years more common with temporal which can be used on any age group

When is BMI done

BMI (Body Mass Index) is done on all children over the age of 2 years.

Blood Pressure rate

BP increases with age Norms based on age, gender, height one of the last things you try to do because they hate it - preschool and down do it later

What determines assessment

Based on all the information obtained during the health history developmental stage of child - developmentally are they appropriate for age or not What is their age What is their temparment Health status - what is the most important thing that I need to get on this kid depending on their health problem - how sick are they? - ex. A very ill child will not waste energy protesting the examination, so the nurse can move quickly in that situation. - ex. A healthy child, however, will express his or her normal developmental stage and will show varying degrees of resistance to the examination. Prioritize your assessment and what your going to get done depending on all these things

Confidential care

Before the age of 18, minors do have the right to confidential care in certain matters - depends on the state

If the cuff is too small

If the cuff is too small, the BP reading will be higher

Therapeutic play

CLS organizes these Therapeutic play is non-directed and focuses on helping the child cope with feelings and fears - can be used to teach children about their health status or to allow them to work through issues in their lives. In emotional outlet play or traumatic play, the child acts out or dramatizes real-life stressors. -For example, using a wooden hammer and pegs can allow the child to express anger Drawing: expresses his or her thoughts/ feeling . Medical play: allow the kids to give fake shots to the doll and nurses

Informed consent

Certain procedures, however, require a specific process of informed consent Needed for: -Needed for: major and minor surgery; invasive procedures -Treatments placing the client at higher risk, such as chemotherapy or radiation therapy

How to Minimize physical stress in hospital

Child Life Specialist Therapeutic hugging -should be used for procedures and treatments, such as IV insertion, where the child needs to remain still -Is used instead hold a child down -family member can hug the child to help keep them still Distraction Minimize invasive procedures -Keep the IV in if there is no infection/ infiltration -Bundle the lab draws *try to push labs together -Use saline lock if pt. requires multiple medications Provide adequate pain management -Always need to be thinking about child's pain because that communication can sometimes be difficult -Using topical numbing with invasive procedures

% of children population

Children = 25% of population (73.5 million)' - good job security

Minimum Urine Output

Children >1mL/kg/hour

What do we tell teenager about confidentiality

Confidential if they are not a threat to themselves or others

Legal Issues with peds

Consent (parent-oriented) -Initial consent form -Informed consent -Special circumstances Minors - less than 18 years of age - mainly dealing with minors Exceptions to Parental Consent - emancipated minor - confidential care Parental refusal of treatment

Assessment with adolesence

Cooperative but can be stubborn they like their privacy - inform them that their privacy will be respected May need to ask parents to leave when asking more personal questions - "is it okay if I have your mom step out for a few mins" - get more open honest communication Show respect in your approach to them - non-judgmental attitude If you ask questions of teenagers you will usually get an answer - keep a good poker face - show no judgment -Typically honest

Respirations assessment:

Count for 1 minute, especially in infants Infants are diaphragmatic breathers May have an irregular pattern - that's why we have to get it for a min - can be fast and then slow down

Blood Pressure cuff size

Cuff size should fit child: 40% of upper arm length 80-100% of arm circumference

Fontanel assessment

Depressed fontanels -dehydration Bulging- -increased cranial pressure/hydrocephelous -if baby is crying they will be bulging Normal: -Should be soft and level with skull Elevate head a little bit to check them closes at 9-18 months

Child developmental history

Determine the age when landmarks in gross motor control were achieved, such as sitting, standing, walking, pedaling, and so on When they started to walk/ crawl When they sat up Are they holding their head up Important to see where they are out

Assessment techniques on toddlers

Distractions: -Bubbles -Stickers -Medical play with your devices -Might do an assessment on their teddy bear first Position: -Keep them with their parent: in lap or stand between sitting caregivers lap -Always stay down at their level- eye to eye makes you less intimidating Approch: -Talk to a parent first and mom thinks your okay, make a good connection with parents * they get a lot of non-verbal -Introduce your equipment -Only expose one area of the body at a time with the stethoscope * on top first and then underneath after *when one item of clothes is removed put back on another Who to talk to: -Talk with the child and with the parent together -If developmentally able to talk to you it might take them a little to be able to talk to you - have more patience for their response

When do the most errors happen

Poor communication - be mindful how to give report and what things are important Bed-side report is now done - sometimes there is extra communication that is done outside the room also

younger children and consent

Even with minors that are not able to consent for themselves we still do want them to know what is going on

Circumstances where we are unable to get a consent

Ex. if a child comes in and emergent situation we do not wait for consent for treatment - we treat and then work out the legal issues as we go - try to make contact with parents over the phone

Growth issues in kids

Failure to thrive can be a first indication that there might be some problem Always need to keep up with the growth and make sure it is happening correctly Look at nutrition

Temperature for children: fever

Fever considered > 38˚C (100.4˚ F) Recheck temp < 36˚C (96.8 ˚ F) and q 2 hrs if elevated

What increases pulse

Fever, anxiety, pain and activity increase pulse

Religious or cultural beliefs issues

Find alternatives for treatment ex. JW will get cardiac surgery but they can't get blood so we developed a whole way of treating them so they mostly would not need blood after surgery

Preparing for the Physical Exam

Focus on the chief complaint or any system that prompts the nurse's critical thinking The process reflects the developmental stage, age, temperament, and health status of a child -all determine how you are going to do your assessment Gather necessary equipment and toys

What is done if parents and minor don't agree on treatment

Further education Alternative treatments that can be done Just give time if possible - the medical team might come to a decision but it takes the parents a little longer to come along Involve bioethics committee of the hospital Go to the courts in emergency - always a judge on call 24/7 so that if parents don't want to give consent and we think it's needed then we can go to the judge - If we don't do that and then treat the child without consent it can be battery on that child

Reaserch on family presence during procedures

Generally, positive experience even in situations of codes when they are doing CPR - may want to know that everything was done or talk to them at that moment

Health status

Gives a sense of urgency if their situation is critical - some you may have more time than others

Normal pulse in peds

Have to listen for 1 full min: Neonate (110-160) Infant (100-160)

What is Pediatric Nursing?

Health care of children from infancy through adolescence In general, Up to 18 years of age

Oxygen Saturation normal%

Healthy infants and children: 97-99% -Continuous stat or intermittent There are many Potential sources of error in reading -only some kids will have this on

RR in peds

Infant (30-60) one full min

Approaching the child

Infants Toddlers Preschoolers School age children Adolescents Table 32.2, pg 1164

Functional history ex.

Is important to know about that kid's routine - what can they do developmentally - what is their routine (2 naps a day or 1?) - bath at night or the morning? - potty trained or not? - safty measures (seat belts) - feed themselves or not? Important to know so we know how much care to provide when the family is not there

Safest place for ID band

Is on the patient not on the bedside

Biggest thing you have in your relationship with children

Is trust

Is swaddeling a restrint?

It can be thought of as a restraint but we don't need special orders for that

Environment in pediatrics

It is a different ball game in pediatrics- the vibe is different - Family-centered care - Make it colorful, bright, fun, friendly - Decrease stress by creating a happy environment ex. clowns, playrooms, pet therapy, personalities of peds nurses

What is important to be aware of in a pediatric setting

It is important to be mindful of who the parental role of the person for the child - it may not be the biological parents and as a result, might get tricky if it's not. -ex. foster parents, grandma Always important to make sure who the adult is with the patient that comes in -always clarify

Role of parent

It is important to keep the role of the parent as a comforter and not a bad guy with us ex. if we do have to hold the child it is good to have staff to do that and then have the mom give the hug after

Ways to maintain childs routine

Just keep to normal ALDs ex. know what time the child naps, baths, how they eat, what they eat, what they can and can't do, any disabilities Make sure they have a routine

Potential sources of error in reading o2 monitor

KIDS DON'T STOP MOVING -Might have to hold kid still and then take the highest number you get Foot is cold

Emancipated minor exceptions

Legally in some states that acknowledge an emancipated minor for certain things - ex. married at a young age (can consent for yourself ) - ex. teenage mother (can consent for yourself) - Financial independence and separate living arrange- ment from parents - Court-determined emancipation * go in front of court and show that they are intellectually and developmentally able to make their own decisions

Exceptions to Parental Consent

Mature minor/Emancipated minor - mature minor is considered 14 Confidential care to minors

Initial consent form

Most care rendered in a health care setting is covered by the initial consent for treatment is signed at admission

Health Assessment in Children

Multiple components: -Observe parent-child interaction -Pre/perinatal history *Ask about the prenatal history (any problems with pregnancy), perinatal history (any problems with labor and delivery) * was it a full-term baby, a premature baby *Document the child's prior history of illnesses -Immunizations * Very important to find out where they are out in their immunizations Allergies -Developmental history -Functional history *The functional history should contain information about the child's daily routine -Growth - diet -Chief complaint * Do history of illness (PPQQRSTU) * is done after all of that stuff *Record the chief complaint in the child's or parent's own words. -Performing physical exam *After the history comes the physical examination. *It should focus on the chief complaint or any of the systems that engaged the nurse's critical thinking while taking the history. * depends on the finding above

Maintain Safety: nurses role

Name band - the band is much more important with kids - clarify with the family that is there or ask the kid for their first name - Look at the chart -Ensure the child has an identifi- cation band in place at all times. Use of restraints Transport of the child -Anytime you move a child around they always have to be buckled in - bouncy seats, high chairs, -When carrying an infant, good support of the back and head is vita Medication administration Safety during procedures Superior Communication

Policy for restraints

Need orders for certain restraints - orders updated every 24 hours Tie to non-movable part of bed Check restraints 15 minutes following initial place- ment and then every hour for proper placement. Assess the temperature of the affected extremities, pulses, and capillary refill, initially after 15 minutes and then every hour after placement. Remove the restraint every 2 hours to allow for range of motion and repositioning

Normal temperature in peds

Neonate (97.7°F to 99.5°F) All others (97°F to 100.3°F)

Newborn weight loss in new borns

Newborns may lose up to 10% of their weight after birth. Most will gain it back by 10-14 days. To calculate % of weight loss, subtract current weight from birth weight. Divide this amount (the amount of loss) by the birth weight and multiply by 100.

Bioethics committe

Not medical people - people of the committee that come together with an ethicist as the chair and they hear all sides of the issue and come up with the best plan to help

How to Promoting a sense of control

Offer reasonable choices when able Flexibility and creativity with care -You have to be flexible and creative with your care they don't do everything on your timeline - depends on what is going on, their age, ect. you may have to modify their assessment Maintain child's home routine and security items Effective communication

Location of BP

Older kids you can get BP by brachial artery on the arm Sometimes on younger kids we will do the lower extremity below the calf - tell them to wiggle their toes

Parental refusal

Parents may refuse treatment if they perceive that their child's quality of life will be significantly impaired by the medical care that is offered. We can sometimes override that if we believe the child needs it (advocate for child) - start with education and find out issues - Waiting for the family for coming on board - ethics committee - Legal route

What is done if client can't give consent or if the parent is not avalible

Person in charge of child (relative, babysitter, or teacher) may give consent for emergency treatment if he or she has a signed form from the parent or legal guardian allowing him or her to do so. During an emergency situation, a verbal consent, via the telephone, may be obtained. Health care providers can provide emergency treatment to a child without con- sent if they have made reasonable attempts to contact the child's parent or legal guardian

How can kids work out their stress

Playing -Supervised play with medical equip- ment in the hospital environment can help children work thorough their feelings about what has happened to them Drawing

Assessment with school-age

Position: - on exam table with caregiver in eyesite Who to talk to: -child and parent -don't use medical works with kids -Have to learn how to go back and forth between child and parents Approche: -Can usually do a head to toe *Are usually cooperative -Might like to help: *take the thermometer from you or flush their IV, put a cuff on - enjoy participating and mastering things -A lot of explanation with them

Assessment with Preschoolers

Position: - some may sit on exam table with mothers hand on lap Approch: -Typically pretty cooperative *reward them for good behavior -Offer them simple explanations *they are very literal -Be careful with the words you use when explaining things with them -preschooler may be willing to undress completely, leaving just the underpants on. - have to be quick during an assessment - the more you go in and the more comfortable they get with you Distractions: -Medical play with equipment - Allow them to "help you" by holding pen light Who to talk to: - explain steps to caregiver and child With toddlers and pre-schoolers you might not be able to do a head-to-toe, might just have to do what they will allow you to do at that moment

Communication with school-age kids

Prepare the child a few days in advance for a procedure. Allow the child to express feelings honestly. allow the child to ask questions related to care and treatment, and allow adequate time for all of the questions to be answered. Use diagrams, illustrations, books, and videos.

Atraumatic Care: the nurses role

Preventing or minimizing physical stressors Preventing or minimizing child and family separation - the expectation is for parents to be able to be at the bedside because it makes it less stressful for kids and families and has better outcomes \ - family separation is not well based off of facts bc it causes trauma Promoting a sense of control

How to Preventing or minimizing child and family separation

Provide Family-centered care Presence/assistance during procedures Parents should be Comforter - Not a bad guy

Play in pediatrics!!!

Provide Play Activities -Unstructured play -Play as part of nursing care -Therapeutic play Supply different toys in their bed, have families bring toys/movies from home - play as much as they can

Child life speciliest: what do they do

Provide activities for children - theraputic play - activities to support normal growth and development Provide family, sibling and grief support Non-medical preperation for interventions Send volunteers to play with kids Child experts Education of the patient, and siblings, - siblings and families help with decreasing stress from procedures ex. I have 4 pt. and one child crying you can ask for them to help hold the kid

Oxygen Saturation technique

Pulse rate on pulse-oximeter should coincide with apical pulse to achieve accurate reading

Pulse assessment

Pulse rates decrease with age Apical pulse for 1 minute

RR techniques `

Put stethoscope on and listen to RR Put hand on chest for older Put hand on belly for little ones Visually

Respirations assessment increase and decreases with?

Respiratory rates decrease with age Fever, anxiety, pain and activity increase rate

Blanket consent form

Seeks to cover all aspects of client care is not specific. - is done when the patient comes in to the hospital that is just a consent for treatment - allows us to start treatment on them

Types of restraints

Soft limb Elbow restraint Mummy Crib top bubble restraint

Safety during procedures for children

Spinal taps - the most important thing is to keep them in a certain position - we can't expect the child to stay in that position so we have to hold them in that position Injection - know that they will likely change their mind about the injection try to stabilize in some way

Emancipated minor

The emancipated minor is considered to have the legal capacity of an adult and may make health care decisions

Family-centered care

The family is not guest or visitors but they are partners in care! - family is a constant We can't do things for the kid without consent from the parent Family members support one another well beyond the health care provider's brief time with them The parent is the one who takes care of them at home - we have to educate them how to take good care of the kid especially with chronic illness ex. asthma

Key to pediatric assessment

The physical way you go through it is not much different: What is different is how you approach the kid, how much time you have, focus of assessment and how you communicate with them

Atraumatic Care defintion

Therapeutic care that minimized or eliminates the psychological and physical stress experienced by children and families in the healthcare setting - we know for a fact in and of itself that being in the hospital is one of the most stressful experiences even if the outcome is fine - kids experience a high degree of stress so we want to provide atraumatic care as best as we can

What is the philosophy of pediatrics

family centered care

Who do you get concent from in peds

Typically dealing with minors, so when we get consent we are getting it from the parents Legally, 18 or under they can not consent for themselves.... however there are some exceptions to that

What do you do if the person that brings a kid in is not the biological parent?

Typically it is figured out during admission, however we can always get help with sorting out the legal issues via. social work

Pediatric nursing exceptions

Typically up to 18 years of age, however, there are some congenital problems we do treat kids that are older than that (ex. 21) Depends on what problem they have that they are born with (ex. cardiac can be a congenital issue or cystic fibrosis that they don't find out about until later ) Some chronic issues can be a bit of a challenge to have kids move onto adult care

Unstructred play

Unstructured play allows children to control events, ideas, and relationships

The Nurse's Role in Caring for the Hospitalized Child

Use effective communication techniques Provide child and family education •Language barriers •Literacy issues •Focus on family's goals Prepare for discharge -* prepare for discharge from the start Maintain Safety

Play as part of nursing

Use play as appropriate while providing routine nursing care to the child. When using play as part of nursing care, it is impor- tant to evaluate the outcome of play. Ex. Using our imagination talk to them about this princesses Make things a game so the cooperate with you -ROM throw bean bag Bubbles to take deep breaths

Examples of confidental care in florida

We are able to provide confidential care to the age of minor from the age of 12-17 ex: -pregnancy counseling -prenatal care -contraception -testing and treatment of STIs -substance abuse - mental illness. Not mandated to contact the parents - however, we try to come from the approach of getting the whole family involved but not everyone's home families are always safe.

Pt. teaching with crib side rails

We have to let the parents know how to do the side rains Make sure they have them at the correct level When you are not in the room the parents have to know they can't leave them up or down

Where are stressful procedures done for kids

We try to avoid doing any painful procedures in pt. room We try to bring them to a treatment room so that their room and the play room is a safe place

Goal with teenagers

We want teenagers to be on board with what the plan of care is - be honest - we want their consent -however, if there is a disagreement between the parent and the child it can get hard

Allow for a sense of control examples

We want to be able to offer choices when able ex. if you take this medication, what do you want to drink after it What type of sticker do you want after your IV

What is done before we even get to that Health assessment of child

We want to look and observe about how the parent and child are acting How is their relationship

BMI (body mass index)

Weight Category BMI Underweight < 5th percentile Normal weight 5th to <85th percentile Overweight 85th to <95th percentile Obese >95th percentile

Functional history: what is it

What a child does in their course of the day and what we need to do to provide to them

Assessment on infant techniques

Who to talk to: - keep a running dilaoge with caregiver Position: -Stay in the parents arms with older infants - can be in crib for good assessment for younger infants Approach: - If the infant is asleep, auscultate the heart, lungs, and abdomen first while the baby is quiet. -Count the heart rate and respiratory rate before undressing the baby. Completely undress newborns and infants down to their diaper -Perform the assessment in a head-to-toe manner, leaving the most traumatic procedures, such as examination of the ears, nose, mouth, and throat, until last Distractions: - Distractions: pacifier, toys, soothing voices, our face can be the dstractions, smile, bright colors - younger infants love faces that are 10-12 inches from their face

Play in pediatrics

You know a kid is not feeling well when they don't want to play - if a kid is one day not laying there doing anything and then the next day want to go to play room that is a good sign

Age of a Neonate

birth to 4 weeks

What is Child life speciliest:

child life specialist (CLS) is a specially trained in- dividual who provides programs that prepare children for hospitalization, surgery, and other procedures that could be painful Help with psychological standpoint and behavior stand point