Test2 Ch 8

COMPONENTS OF LEARNING NEEDS ASSESSMENT (educational process is targeted at both the child, when developmentally appropriate, and the adult members of the family)

Assess • Learner characteristics: Find out more about the child's and family's life and how the child's illness has affected it. Learn more about the child's and family's social, cultural, and spiritual values. • Learner needs and readiness: This includes what the child and family want and need to know and what they know already; their readiness and willingness to learn; their motivation to learn and emotional concerns; and their capacity to learn, such as physical or cognitive abilities including the ability to read and developmental level. • Learning style: Determine how the child and family learn best, as well as preferred learning methods. • Learning barriers: Identify cultural or language barriers, cognitive or physical disabilities, presence of pain, and lack of support network.

Positive Outcomes of Family-Centered

Care for Children • Anxiety is decreased. • Children are calmer and pain management is enhanced. • Recovery times are shortened. • Families' confidence and problem-solving skills are improved. • Communication between the health care team and the family is also improved. • A decrease in health care costs is seen. • Health care resources are used more effectively

Components of a Complete Physical

Examination • Assessment - General appearance, vital signs, body measurements, and pain assessment • Examination - Head, neck, eyes, ears, nose, mouth and throat, skin, thorax and lungs, breasts, heart and peripheral perfusion, abdomen, genitalia and rectum, musculoskeletal system, and neurologic system.

Grading Heart Murmurs in Children

GRADE 1 Barely audible; sometimes heard, sometimes not. Usually heard only with intense concentration GRADE 2 Quiet, soft; heard each time the chest is auscultated GRADE 3 Audible, intermediate intensity GRADE 4 Audible, with a palpable thrill GRADE 5 Loud, audible with edge of the stethoscope lifted off the chest GRADE 6 Very loud, audible with the stethoscope placed near but not touching the chest

Questions for the REVIEW OF SYSTEMS

Growth and development Weight loss or gain, appropriate energy and activity levels, fatigue, behavioral changes such as irritability, nervousness, anger, or increased crying Skin Easy bruising or bleeding, rash, lesion, skin disease, pruritus, birthmarks, or change in mole, pigment, hair, or nails Head and neck Head injury, headache, dizziness, syncope Eyes and vision Pain, redness, discharge, diplopia, strabismus, cataracts, vision changes, reading difficulties, need to sit close to the board at school or close to the TV at home Ears and hearing Earache, recurrent ear infection, tubes in eardrums, discharge, difficulty hearing, ringing, excess cerumen Mouth, teeth, and throat Swollen gums, pain with teething, caries, tooth loss, toothache, sores, difficulty with chewing or swallowing, hoarseness, sore throat, mouth breathing, change in voice Respiratory system and breasts Nasal congestion or discharge, cough, wheeze, noisy breathing, snoring, shortness of breath or other difficulty breathing, problems with or changes in breasts Cardiovascular system Murmur, color change (cyanosis), exertional dyspnea, activity intolerance, palpitations, extremity coldness, high blood pressure, high cholesterol Gastrointestinal system Nausea, vomiting, abdominal pain, cramping, diarrhea, constipation, stool holding, anal pain or itching Genitourinary system Dysuria; polyuria; oliguria; narrow urine stream; dark, cloudy, or discolored urine; difficulty with toilet training; bedwetting Boys: undescended testicles, pain in penis or scrotum, sores or lesions, discharge, scrotal swelling when crying, changes in scrotum or penis size, addition of pubic hair Girls: vaginal discharge, itching rash, problems with menstruation or menstrual cycle, development of pubic hair Musculoskeletal system Joint or bone pain, stiffness, swelling, injury (e.g., broken bones or sprains), movement limitation, decreased strength, altered gait, changes in coordination, back pain, posture changes or spinal curvature Neurologic system Numbness, tingling, difficulty learning, altered mood or ability to stay alert, tremors, tics, seizures Endocrine system Increased thirst, excessive appetite, delayed or early pubertal changes, problems with growth Hematologic system Swelling of lymph nodes, pale color, excessive bruising

VARIATIONS IN SKIN COLOR AND THEIR CAUSES

Pallor (defined as decreased pinkness in light-skinned patients, ashy-gray in dark-skinned) is caused by anemia, shock, fever, or syncope. Peripheral cyanosis (blue discoloration) occurs in nails, soles, and palms and may be caused by anxiety or cold; also associated with central cyanosis. Central cyanosis (blueness of the lips, tongue, oral mucosa, trunk) is caused by hypoxia or circulatory collapse. Overall yellow color (jaundice) may be physiologic in the newborn or related to liver or hematopoietic disease in any age child. Yellowing of nose, palms, and soles may result from excess intake of yellow vegetables. Redness of the skin results from blushing, exposure to cold, hyperthermia, inflammation (localized), or alcohol ingestion. Lack of color in skin, hair, and eyes is related to albinism.

Questions Appropriate to Ask When

Performing a Cultural Assessment • Who is the person caring for the child at home? • Who is the authority figure in the family? • What is the social support structure? • Are there any special dietary needs and concerns? • Are any traditional health practices used? • Are any special clothes or other items used to help maintain health? • What religious beliefs, ceremonies, and spiritual practices are important?

Role of the Nurse When Performing a

Physical Assessment of a Child • Establish rapport and trust • Demonstrate respect for the child and parent/caregiver • Communicate effectively by listening actively, demonstrating empathy, and providing feedback • Observe systematically • Obtain accurate data • Validate and interpret data accurately

Distraction Methods

the child point toes inward and wiggle them. • Ask the child to squeeze your hand. • Encourage the child to count aloud. • Sing a song and have the child sing along. • Point out the pictures on the ceiling. • Have the child blow bubbles. • Play music appealing to the child.

Intravenous Maintenance Fluid Calculations by Body Weight

• <10 kg in weight 100 mL per kg of weight = # mL for 24 hours Example: A child weighs 7.4 kg. 7.4 × 100 = 740 mL (daily requirement) 740/24 = 30.8 or 31 mL/hour • 11-20 kg in weight 100 mL per kg of weight for the first 10 kg + 50 mL/kg for the next 10 kg = # mL for 24 hours Example: A child weighs 16 kg. (10 × 100 = 1,000) plus (6 × 50 = 300) Total = 1,300 mL (daily requirement) 1,300/24 = 54 mL/hour • >20 kg in weight 100 mL/kg for the first 10 kg + 50 mL/kg for the next 10 kg + 20 mL/kg for each kg > 20 kg = # mL for 24 hours Example: A child weighs 30 kg. (10 × 100 = 1,000) plus (10 × 50 = 500) plus (10 × 20 = 200) Total = 1,700 mL (daily requirement) 1,700/24 = 70.8 or 71 mL/hr

Therapeutic Communication Techniques

• Active listening • Using open-ended questions • Eliminating barriers to communication • Establishing a medical home

Medication

• Adjusted to height, weight, and concerned with the low range of dose and the High range dose. • The pediatric dosage should not exceed the minimum recommended adult dosage. Generally, once a child or adolescent weighs 50 kg or greater, the adult dose is frequently prescribed

Role of the Nurse in Outpatient and Ambulatory Care Settings

• Admission and assessment • Preoperative teaching and preparation • Child assessment and support • Postoperative monitoring • Case management • Discharge planning • Teaching

Specific Learning Principles Related to Parents

• Adults are self-directed. -Adults value independence and want to learn on their own terms. -Teaching strategies that include such concepts as role playing, demonstration, and self-evaluation are most helpful. -Using this model, nurses can partner with families to ensure that education is interactive and adopt the role of facilitator rather than lecturer. • Adults are problem focused and task oriented. -Adults learn best when they perceive there is a gap in their knowledge base and want information and skills to fill the gap. -Providing a reason to learn can often motivate families that appear slow to comply with their child's care and education. • Adults want an immediate need satisfied. -Adults learn best at a time when learning meets an immediate need. - Presenting information in an organized, sequential, and timely fashion can often help families understand the importance of learning a particular piece of information or task. • Adults value past experiences and beliefs. -Adults bring an accumulated wealth of experiences to each health care encounter; this provides a rich base for new learning. -Education should take into account a wide range of backgrounds. -Appreciating and using individual differences during teaching encounters can help improve compliance and reduce resistance to educational goals.

Psychological Effects of Hospitalization on Children

• Anxiety and fear related to the overall process • Potential for bodily injury, physical harm, and pain • Separation from home, family, friends, etc. - Anger and guilt - Separation anxiety - Regression - Other types of defense mechanisms

CALCULATION OF BODY MASS INDEX (BMI) English Formula: Metric Formula:

• BMI for age plots at less than the 5th percentile is considered to be underweight. • BMI between the 85th and 95th percentiles indicates risk for overweight. • BMI greater than the 95th percentile indicates the child is overweight.

Methods to Promote Coping in Children

• Breathing techniques • Distraction techniques • Imagery • Music • Child teaching before events

The Adolescent Health Transition Project (AHTP) recommends the following schedule:

• By age 14, ensure that a transition plan is initiated and that the IEP reflects post-high school plans. • By age 17, explore health care financing for young adults. If needed, notify the local division of vocational rehabilitation by the autumn before the teen is to graduate from high school of the impending transition. Initiate guardianship procedures if appropriate. • Notify the teen that all rights transfer to him or her at the age of majority. • Check the teen's eligibility for SSI the month the child turns 18. • Determine if the child is eligible for SSI work incentives. • If the youth is attending college, contact the college's campus student disability service program. • By age 21, ensure that the young adult has registered with the Division of Developmental Disabilities for adult services if applicable (AHTP, 2011).

Disadvantages of Home Health Care

• Can be an intrusion to family privacy • Care can be overwhelming. • Financial issues can be a burden. - Care can be more costly. - Having a caregiver at home can contribute to financial strain.

Reasons for Majority of Hospitalizations of Children

• Children younger than 5 years - Respiratory diseases • Older children - Respiratory diseases, mental health problems, injuries, and gastrointestinal disorders • Adolescents - Problems related to pregnancy, childbearing, mental health, and injury

Methods for Transporting Infants or Children

• Cradle method for carrying infants up to 3 months of age.One hand grasps the infant's thighs; the other arm supports the infant's head and back. • The "over-the-shoulder" method for carrying infants up to 7 months of age. Support the head if the infant does not have head control. • Football method for carrying infants up to 2 months of age. The forearm and hand support the body and head of the infant. • A wagon with rails and padding is used to transport small children.

Components of the Health History

• Demographics • Chief complaint and history of present illness • Past health history • Review of systems • Family health history • Developmental history • Functional history • Family composition, resources, and home environment

NURSING INTERVENTIONS FOR FAMILIES OF CHILDREN WITH SPECIAL HEALTH CARE NEEDS

• Develop written health plans. • Provide care coordination and collaboration with specialists in other disciplines, early intervention, schools, and public agencies. • Address needs for prior authorization for treatments, medications, or specialist referrals; retain copies in the child's chart of authorization forms and approvals. • Modify office routines to promote family and child comfort. • Assist parents with child care decisions. Know community resources available to children with special health care needs. • When the child is hospitalized, encourage high levels of parental participation. • Provide care coordination across multiple health settings. • Educate child care providers on child health needs. • Help parents get involved with parent support networks.

Red Flags Indicating Poor Literacy Skills

• Difficulty filling out forms • Frequently missed appointments • Noncompliance and lack of follow-up with treatment regimens • History of medication errors • Responses such as "I forgot my glasses" or "I'll read this when I get home" • Inability to answer questions about treatment or medicines • Avoiding asking questions for fear of looking stupid

Exploring Family Dynamics During the Health History

• Does the parent make eye contact with the infant? • Does the parent anticipate and respond to the infant's needs? • Are the parents ineffective when dealing with a toddler's temper tantrum? • Do the parents' comments increase the school-age child's sense of self-worth? • Behavioral observations are crucial to proper assessment of the family's needs.

Role of the Community-Based Nurse

• Education and communication • Discharge planning and case management • Advocacy and resource management • Physical care

Role of the Nurse in Family-Centered Care

• Empower children and their families through education • Assess the learning needs and provide education that is appropriate to the educational and developmental levels of the child and family • Encourage the family to participate in the child's care

Steps of the Admission Process

• Establish a trusting, caring relationship. • Introduce self and smile. • Let the child and family know what will happen and what is expected of them. • Communicate at age-appropriate levels. • Orient child and family to hospital unit. • Perform nursing interview.

FTT

• Failure to thrive (FTT) is a term used to describe inadequate growth in infants and children. The child fails to demonstrate appropriate weight gain over a prolonged period of time. Length or height velocity and head circumference growth may also be affected. • Developmental disability (mental or physical or combination impairment resulting in lifelong disability) may contribute to FTT, as the child's ability to consume adequate nutrition is impaired because of sensory or motor delays, such as with cerebral palsy.

Discharge Instruction Information

• Follow-up appointment information • Guidelines for when to contact physician or nurse practitioner • Diet • Activity level allowed • Medications • Additional treatments the child requires at home • Specific dates for the child to return to school or day care • Referral information

Principle Suggestions for Nursing Care Preventing or minimizing physical stressors Suggestions for Atraumatic Care

• For painful injections, blood draws, or IV insertion, use numbing techniques (see Chapter 14). • During painful or invasive procedures, avoid traditional restraint or "holding down" of the child. • Use alternative positioning such as "therapeutic hugging." • If the above-mentioned positions are not an option, have the parent stand near the child's head to provide comfort. • Insert a saline lock if the child will require multiple doses of parenteral medications. • Advocate for minimal laboratory blood draws. • Minimize intramuscular or subcutaneous injections. • Provide appropriate pain management (refer to Chapter 14).

Types of Admissions

• General inpatient unit (acute conditions, shorter stays, admission and treatment occur simultaneously. Lack child-oriented services) • Emergency and urgent care department (Injury from accidents, increased anxiety, procedure test performed, provide comfort such as holding ,touching etc.) • Pediatric intensive care unit (unfamiliar high tech equip. large staff, child will experience pain , increase stimulation, and uncomfortable procedure. Welcome families and encourage to stay with child) • Outpatient or special procedures unit • Rehabilitation unit or hospital

Home Health Care

• Goal - Promoting, restoring, and maintaining the health of the child • Role of nurses in the home care setting - Direct providers of care, child and family educators, child and family advocates, and case managers

Components of the Health Assessment

• Health interview and history • Observation of the parent-child interaction • Assessment of the child's emotional, physiologic, cognitive, and social development • Physical assessment

Working With an Interpreter

• Help the interpreter prepare and understand what needs to be done ahead of time. - The interpreter is the communication bridge, not the content expert; the interpreter's timing may not match that of others involved. • Speak slowly and clearly; avoid jargon. • Pause every few sentences so the interpreter can translate your information. • Talk directly to the family, not the interpreter. • Give the family and the interpreter a break. • Express the information in two or three different ways if needed. • Use an interpreter to help ensure the family can read and understand translated written materials. • Avoid side conversations during sessions. • Remember that just because someone speaks another language, it doesn't mean he or she will be a good interpreter. • Do not use children as interpreters.

Risk Factors for Heart Alterations in Children

• History of prematurity, very low birthweight, or other neonatal intensive care complication • Congenital heart disease • Recurrent urinary tract infections, hematuria, proteinuria, known renal disease or urologic malformations, family history of congenital renal disease • Malignancy, bone marrow transplant or solid organ transplant • Treatment with medications that raise BP • Systemic illnesses associated with hypertension such as neurofibromatosis and tuberous sclerosis • Increased intracranial pressure

Goals of Child and Family Education

• Improve the child and family's health literacy • Encourage communication with physicians or nurse practitioners • Improve health outcomes and promote healthy lifestyles • Encourage involvement of child and family in care and decision making about care • Improve compliance with care and treatment plan • Promote a sense of autonomy and control

Organic Causes of Failure to Thrive

• Inability to suck and/or swallow correctly • Malabsorption • Diarrhea • Vomiting • Alterations in metabolism and caloric/nutrient needs associated with a variety of chronic illnesses

BASICS FOR COMMUNICATING WITH CHILDREN

• Introduce yourself and explain your role. Position yourself at the child's level. • Allow the child to remain near the parent if needed, so the child can remain comfortable and relaxed. • Smile and make eye contact with the child if culturally appropriate. • Direct your questions and explanations to the child. • Listen attentively and pause to allow time for the child to formulate his or her thoughts. • Use the child's or family's terms for body parts and medical care when possible. • Speak in a calm, quiet, confident, and unhurried voice. • Use positive rather than negative statements and directions. • Encourage the child to express his or her feelings and ask questions. • Observe for nonverbal cues. • Ask for permission if you need to approach the child to avoid appearing threatening.

Four Phases of Nursing Care for Hospitalized Children

• Introduction -involves the initial contact with children and their families and it establishes the foundation for a trusting relationship. Use favorite toys and common television shows to establish rapport. Allow the child to participate in the conversation without the pressure of having to comply with requests or undergo any procedures. • Building a trusting relationship -using appropriate language, games, and play such as singing a song during a procedure, preparing the child adequately for procedures, and providing explanations and encouragement. Get down to the child's level and play on his or her terms. • Decision-making phase -nurse gives some control over to the child by allowing him or her to participate in making certain decisions. This phase is critical to maintaining the trust the child has developed. For example, it is imperative to decide how much control the child will have during treatment, how much information to share with the child about upcoming events, and whether parents should participate. Reinforce the child's use of coping strategies that lead to healthy outcomes by providing options whenever it is safe to do so. • Providing comfort and reassurance -uses techniques such as praising the child and providing opportunities to cuddle with a favorite toy.

Promoting a sense of control Suggestions for Atraumatic Care

• Maintain the child's home routine related to activities of daily living. • In the hospital, use primary nursing. • Encourage the child to have a security item present if desired. • Involve the child and family in planning care from the moment of the first encounter. • Empower the family and child by providing knowledge. • Allow the child and family choices when they are available. • Make the environment more inviting and less intimidating.

Medically fragile child

• Medically fragile children for many years these children lived in hospitals their entire lives. Due to concerns about the high cost of long-term hospitalization and the diminished quality of life for these children, alternative care settings in the community, such as medically fragile day care centers, are being developed. • Medically fragile day care centers are specifically designed to meet the needs of these children. Most centers accept children who have complicated medical needs or are dependent on technology. • health professionals are present at these centers to provide for the children's medical, emotional, and developmental needs. Nurses trained in pediatric and neonatal care, physical therapists, occupational therapists, speech therapists, child life specialists, and social workers staff the centers; some centers have respiratory therapists on site. Children are able to receive all of their prescribed therapies while at the center • Most centers are located in the community to help ease transportation issues. Some centers provide transportation to and from home or school.

Services provided by a CLS include:

• Non-medical preparation for tests, surgeries, and other medical procedures • Support during medical procedures • Therapeutic play • Activities to support normal growth and development • Sibling support • Advocacy for the child and family • Grief and bereavement support • Emergency room interventions for children and families • Hospital pre-admission tours and information programs -Outpatient consultation with families

Steps of the Physical Examination

• Observation - Checking color, warmth, characteristics, and texture visually and smelling for any odor • Palpation - Validating observations • Percussion - Determining the location, size, and density of organs or masses • Auscultation - Listening to heart, lungs, and abdomen with stethoscope

NURSING INTERVENTIONS DURING THE CHILD'S HOSPITALIZATION FOR FAILURE TO THRIVE

• Observe parent-child interactions, especially during feedings. • Develop an appropriate feeding schedule. • Provide feedings as prescribed (usually 120 kcal/kg/day is needed to demonstrate proper weight gain). • Weigh the child daily and maintain strict records of intake and output. • Educate parents about proper feeding techniques and volumes. • Provide extensive support to alleviate parental anxiety related to the child's inability to gain weight.

Determining Characteristics of Chief Complaints

• Onset, duration, characteristics, and course (location, signs, symptoms, exposures, and so on) • Previous episodes in the child or family • Previous testing or therapies, what makes it better or worse • What the concern means to the child and family • Inquiry about any exposure to infectious agents

Eye Assessment (PERRLA)

• PERRLA: Pupils are equal, round, reactive to light and accommodation. • The eyes demonstrate accommodation, or focusing at different distances, if the pupil constricts as the object moves closer. • Absence of pupillary reflexive action after age 3 weeks may indicate blindness.

Factors Influencing Family Reaction to Illness/Hospitalization

• Parenting style • Family-child relationship • Family members' coping skills • Cultural, ethnic, and religious variations • Values and practices related to illness • General response to stress • Attitudes about the care of a sick child

Techniques to Reduce Stress in Children During Procedures

• Perform nursing care on stuffed animals or dolls. • Avoid the use of medical terms. • Allow the child to handle some equipment. • Teach the child the steps of the procedure. • Show the child the room where he or she will be staying. • Introduce the child to the health care personnel. • Explain the sounds the child may hear. • Let the child sample the food that will be served.

Aspects of the Past Health History

• Prenatal or perinatal history, past illnesses, other developmental problems • Prior history of illnesses, accidents, or injuries in past • Any operations or hospitalizations child has had • Child's diet and allergies • Child's immunization status • Any medications child is taking • Menstrual history in adolescent females

PRINCIPLES OF ATRAUMATIC CARE

• Prevent or minimize physical stressors, including pain, discomfort, immobility, sleep deprivation, inability to eat or drink, and changes in elimination. • Avoid or reduce intrusive and painful procedures, such as injections, multiple punctures, and urethral catheterization. • Avoid or reduce other kinds of physical distress, such as noise, smells, shivering, nausea and vomiting, sleeplessness, restraints, and skin trauma. • Control pain via frequent assessments and use of pharmacologic and nonpharmacologic interventions. • Prevent or minimize parent-child separation. • Promote family-centered care, treating the family as the patient. • Use core primary nursing. • Consider research findings related to preferences of parents and children and whether or not to be together. • Promote a sense of control. • Elicit the family's knowledge about the child and his or her health condition, promoting partnerships, empowerment, and enabling. • Reduce fear of the unknown through education, familiar articles, and decreasing the threat of the environment. • Provide opportunities for control, such as participating in care, attempting to normalize daily schedule, and providing direct suggestions.

Preventing or minimizing child and family separation Suggestions for Atraumatic Care

• Promote family-centered care. • In the hospital, provide comfortable accommodations for the parent. • Allow the family the choice about whether to stay for an invasive procedure, and support them in their decision.

Three Stages of Separation Anxiety

• Protest - Displays crying, agitation, rejection of others, anger, inconsolable grief • Despair - Is withdrawn and quiet without crying; displays apathy, depression, lack of interest, overall feelings of sadness • Detachment - Uses coping mechanisms, displays resignation but not contentment, may have developmental delays

General guidelines for preparation include the following:

• Provide a description of and the reason for the procedure using age-appropriate language ("the doctor will look at your blood to see why you are sick"). • Describe where the procedure will occur ("the x-ray department has big machines that won't hurt you; it's a little cold there too"). • Introduce strange equipment the child may see ("you will lie on a special bed that moves in the big machine, but you can still see out"). • Describe how long the procedure will last ("you will be in the x-ray department until lunchtime"). • Identify unusual sensations that may occur during the procedure ("you may smell something different" [e.g., alcohol smell]; "the MRI machine makes loud noises"). p. 218 p. 219 Inform the child if any pain is involved. • Tell the child it is okay to cry or yell. Identify any special care required after the procedure ("you will need to lie quietly for 15 minutes afterward"). • Discuss ways that may help the child stay calm, such as using distraction methods or relaxation techniques ("during the procedure you may want to count from 1 to 100 or sing your favorite song")

Providing a Sense of Control for the Hospitalized Child

• Provide effective communication and teaching. - Find a balance between neutral and affective communication. - Use verbal communication and nonverbal communication. - Use developmental techniques for communicating with children. • Assist family to obtain necessary information and resources.

Restraint Policy

• Reason for the restraint • Child assessment parameters identifying the need for the restraint • Use of at least one alternative method for restriction before using a restraint • Use of the least restrictive type of restraint for the purpose • Need for a written order by a licensed independent practitioner (LIP) within 1 hour of application of the restraint • Need for face-to-face evaluation by LIP within 1 hour of application of the restraint

Nonverbal Communication

• Relax; maintain an open posture, with the arms uncrossed. • Sit opposite the family and lean forward slightly. • Maintain eye contact. • Nod your head to demonstrate interest. • Note the child's or parent's posture, eye contact, and facial expressions.

Focus of Family-Centered Care

• Respect for the child and family • Recognition of the effects of cultural, racial, ethnic, and socioeconomic diversity on the family's health care experience • Identification of and expansion of the family's strengths • Support of the family's choices related to the child's health care • Maintenance of flexibility • Provision of honest, unbiased information in an affirming and useful approach • Assistance with the emotional and other support the child and family require • Collaboration with families • Empowerment of families

EIGHT RIGHTS OF PEDIATRIC MEDICATION ADMINISTRATION

• Right Medication Check order and expiration dates. Know action of medication and potential side effects (use pharmacy, drug formulary). Ensure that the medication provided is the medication that is ordered. • • Right Patient Confirm child identity since children may deny their identity in attempt to avoid an unpleasant situation, play in another child's bed, or remove ID bracelet. Confirm identity each time medication is given. Verify child's name with caregiver to provide additional verification. • • Right Time Give within 20 to 30 minutes of the ordered time. For a medication given on an as-needed (PRN) basis, know when it was last given and how much was given during the past 24 hours. • • Right Route of Administration • • Check ordered route and ensure this is the most effective and safest route for this child; clarify any order that is confusing or unclear. Give the medication by the route ordered. If there is a need to change route, always check with prescriber (e.g., if a child is vomiting and has an order for an oral medication, the medication may need to be given via the IV or rectal route). • • Right Dose Calculate the recommended dose according to child's weight and double-check your calculations. Always question the pharmacist and/or prescriber if the ordered dose falls outside the recommended dose range. Unusually large or small volumes or dosages should always be verified. • • Right Documentation Record administration of the medication on the appropriate paper or computerized form according to agency policy. Ensure that all medications administered and refused are documented. • • Right to Be Educated Provide simple explanations to the child based on his or her level of understanding. Explain to the parents or caregiver about the medication to be given and what to expect from it. Use a positive, firm approach with the child. • • Right to Refuse Provide explanations to the child and parents to clarify any misconceptions or relieve fears. Reinforce the rationale for medication use. Respect the child's or parents' option to refuse.

Techniques to Improve Learning

• Slow down and repeat information often. --Since most of the education in a health care setting is done verbally, repeat important information at least four or five times. • Speak in conversational style using plain language. --When writing directions, write only several words, bullet points, or phrases. Use common, "living-room-type" language containing one or two syllables whenever possible. • "Chunk" information and teach in small bites. --This is especially important when there are large amounts of complex information for the family to learn. Teach for 10 to 15 minutes, give the learner a break, and return later to "chunk" again. • Prioritize information and teach "survival skills" first. --Due to time constraints and multiple demands on the part of staff, coupled with the rapid turnaround times of health care encounters for children, there never seems to be enough time to teach. Nurses must provide the child and family with the necessary information to meet their immediate needs. This may include information about: The child's medical condition Treatment information Why the information is important Possible problems, adverse effects, or concerns What to do if problems arise Who to contact for further help, information, or supplies • Use visuals. --Use visual resources to enhance and reinforce learning when available. Drawing simple pictures and charts or using alternative methods such as color-coding often allows learning to occur for families who are having difficulty grasping information or concepts. • Teach using an interactive, "hands on" approach. --When the learner uses hands-on practice or participates in care, learning occurs more quickly and easily. Learning first on a doll or model can ease anxiety and bolster self-confidence before care or procedures on the child are actually performed.

TYPES OF RESTRAINTS

• Soft limb restraint PURPOSE: Wrist or ankle restraint to prevent range of motion of extremities SAFETY CONCERN: Check wrist or ankle for any sign of circulatory, integumentary, or neurologic compromise. • Elbow restraint PURPOSEPrevents child from flexing and reaching face, head, IV and other tubes SAFETY CONCERN:Position the restraint so it does not rub against axilla. Check pulse, temperature, and capillary refill of the extremity. • Mummy restraint PURPOSE: Body restraint using a sheet folded in a square appropriate to size of infant or young child to secure the whole body of the child or every extremity except for one SAFETY CONCERN: Ensure that all extremities are secured within the sheet. • Jacket (vest) restraint PURPOSE: Jacket worn by child with ties attached to the child's back and to side of bed. Used to keep children flat in bed, such as after surgery, or safe in chair SAFETY CONCERN: Ensure the child can turn head to side and that the head of the bed is elevated, if possible. Place ties in back so child cannot manipulate them. • Crib top bubble restraint PURPOSE: Clear plastic cover over the bed to prevent older infant or young child from climbing out of bed and falling SAFETY CONCERN: Ensure that there are no tears or loose plastic.

Reasons for Shift of Care From Hospitals to Communities

• Strained health care funding • Shorter hospital stays • Cost containment • Acute care not good environment for children

Evaluating Learning

• The child or family demonstrates a skill. • The child or family repeats back or teaches back the information in own words. • The child or family answers open-ended questions. • The child or family responds to a pretend scenario in their home.

Documentation of Child and Family Teaching

• The learning needs assessment • Information on the child's medical condition and plan of care • Goals of child education; date goal is met • Teaching method used and how received by child and family • Medications, including drug-drug and drug-food interactions • Modified diets and nutritional needs • Safe use of medical equipment • Follow-up care and community resources discussed

Techniques for Providing Atraumatic Care

• Therapeutic communication - Goal directed - Focused and purposeful • Therapeutic play - Provides emotional outlet or coping devices • Child education - Helps child understand the reason for the hospitalization/procedures

Verbal Communication

• Use open-ended questions that do not restrict the child's or parent's answers. • Redirect the conversation to maintain focus. • Use reflection to clarify the parent's feelings. • Paraphrase the child's or parent's feelings to demonstrate empathy. • Acknowledge emotions. • Demonstrate active listening by using the child's or family's own words.

Preventing/Minimizing Physical Stressors

• Utilize a child life specialist. - Specially trained individual who provides programs to prepare children for hospitalization and painful procedures • Minimize physical distress during procedures. - Use positions that are comfortable to the child. • Therapeutic hugging - Use distraction methods.

Child life specialist (CLS)

• a specially trained individual who provides programs that prepare children for hospitalization, surgery, and other procedures that could be painful • The goal of the CLS is to decrease the child's anxiety and fear while improving and encouraging the child's understanding and cooperation. • The CLS considers the needs of siblings or other children who may be affected by the child's illness or trauma. • The CLS provides engaging and uplifting events by coordinating special entertainment and activities. • The CLS is an excellent resource and provides education to health care providers and families.

Factors Affecting a Child's Response to Illness and Hospitalization

•Amount of separation from parent/caregiver •Age •Developmental level •Cognitive level •Previous experience with illness and hospitalization •Recent life stresses and changes •Type and amount of preparation •Temperament •Innate and acquired coping skills •Seriousness of the diagnosis/onset of illness or injury (e.g., acute or chronic) •Support systems available, including the family and health care professionals • Cultural background •Parents' reaction to illness and hospitalization