Peds chapter 1

History of child's health part 1

In past centuries in the United States, the health of the country was poorer than it is today; mortality rates were high and life expectancy was short. When a flood of immigrants from Europe settled in the eastern American cities, infectious diseases were rampant due to crowded living conditions, inadequate and unsanitary food (e.g., contaminated milk), lack of any childhood immunizations, and harsh working conditions (including child labor). Devastating epidemics of smallpox, diphtheria, scarlet fever, and measles hit children the hardest. During this period, the prevalent view was that children were a commodity; their role was to increase the population and share in the work to be done. This view changed over the years. Public schools were established and the court system began viewing children as minors. The health of children began to receive more and more attention. As the end of the 19th century neared, doctors and scientists gained a much better understanding of the root causes of illness. This knowledge helped fuel public health efforts such as the campaign for safe milk supply, which led to pasteurizing milk and to dispensing free milk in some cities (Maternal and Child Health Bureau [MCHB], Health Resources and Services Administration [HRSA], U.S. Department of Health and Human Services, [n.d.]). Compulsory vaccination programs began during this time. In the late 1800s, some states mandated smallpox vaccination as a condition of school attendance. These public health efforts led to a decrease in infant and child deaths (MCHB, HRSA, U.S. Department of Health and Human Services, [n.d.]). In the late 19th and early 20th centuries, cities became healthier places to live due to urban public health improvements, such as sanitation services, treated municipal water, and improvements in hygiene (MCHB, HRSA, U.S. Department of Health and Human Services, [n.d.]). The threat of childhood diseases such as diphtheria, cholera, polio, and yellow fever began to take less of a toll on children (MCHB, HRSA, U.S. Department of Health and Human Services, [n.d.]). The turn of the 20th century brought new knowledge about nutrition, sanitation, bacteriology, pharmacology, medication, and psychology. Penicillin, corticosteroids, and increased numbers of vaccines, which were developed during this time, assisted with the fight against communicable diseases. Thus, by the end of the 20th century, unintentional injuries surpassed disease as the leading cause of death for children older than 1 year (Guyer, Freedman, Strobino, & Sondik, 2000; Richter, 2004). By the end of the 20th century, technologic advances had significantly affected all aspects of health care. These trends have led to increased survival rates in children. However, many children who survive illnesses that were previously considered fatal are left with chronic disabilities. For example, before the 1960s, extremely premature infants did not survive because of the immaturity of their lungs. Mechanical ventilation and the use of medications to foster lung development have increased survival rates in premature infants, but survivors are often faced with myriad chronic illnesses such as chronic lung disease (bronchopulmonary dysplasia), retinopathy of prematurity, cerebral palsy, and developmental delay. This increased survival has resulted in a significant increase in chronic illness relative to acute illness as a cause of hospitalization and mortality. (Kyle 6) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Legal issues when working with a child

Minors (children younger than 18 years of age) generally require adult guardians to act on their behalf. Parents ultimately are the decision makers for their children. Biologic or adoptive parents are usually considered to be the child's legal guardian. When divorce occurs, one or both parents may be granted custody of the child. In certain cases (such as child abuse or neglect, or during foster care), a guardian ad litem may be appointed by the courts. This person generally serves to protect the child's best interests. States generally require parental or guardian consent for minors to receive medical treatment, but some exceptions exist (refer to the section on consent below). Confidentiality of patient information should always be maintained within the context of the state law and the institution's policies. (Kyle 18) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Morbidity data

Morbidity is the measure of prevalence of a specific illness in a population at a particular time. It is presented in rates per 1,000 population. Morbidity is often difficult to define and record because the definitions used vary widely. For example, morbidity may be defined as visits to the physician or diagnosis for hospital admission. Also, data may be difficult to obtain. Morbidity statistics are revised less frequently because of the difficulty in defining or obtaining the information. In general, however, 56% of children in the United States enjoyed excellent health and 27% had very good health as reported in a summary of health statistics for children in 2011 (Bloom, Cohen, & Freeman, 2012). Factors that may increase morbidity include homelessness, poverty, low birth weight, chronic health disorders, foreign-born adoption, attendance at day care centers, and barriers to health care. For example, 21.8% of children live in poverty and have a higher incidence of disease, limited coordination of health services, and limited access to health care, except for visits to the emergency department (DeNavas-Walt, Proctor, & Smith, 2013). The overall poverty rate is 15%, which is the highest poverty rate since 1994 (DeNavas-Walt et al., 2013). However, the poverty rate among African Americans and Hispanics is 27.2% and 25.6%, respectively; these children are particularly at increased risk for illness (DeNavas-Walt et al., 2013). The most important aspect of morbidity is the degree of disability it produces, which is identified in children as the number of days missed from school or confined to bed. In 2011 more than one quarter of school children, aged 5 to 17, did not miss any school due to illness or injury; however, approximately 5% missed 11 or more days of school because of injury or illness (Bloom et al., 2012). Common health problems in children include respiratory disorders, such as asthma; gastrointestinal disturbances, which lead to malnutrition and dehydration; and injuries. Asthma is the leading chronic disease in children, affecting 14% of children in the United States (Bloom et al., 2012). Another 11% of children have respiratory allergies, 9% suffer from hay fever, 6% from food allergies, and 13% from skin allergies (Bloom et al., 2012). In 2010 diseases of the respiratory system, such as asthma and pneumonia, were the major cause of hospitalization for children 1 to 9 years of age, while mental health disorders were the leading cause for children 10 to 14 years of age (U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 2013). In the United States during 2010, there were 3.5 hospital discharges for every 100 children (age 1 to 21 years) (U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 2013). Figure 1.2 shows the major causes of hospitalization by age in the United States. FIGURE 1.2 Causes of hospitalization in children, 2010. (From U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. (2013). Child health USA 2012. Rockville, MD: U.S. Department of Health and Human Services. Retrieved November 9, 2013, from http://mchb.hrsa.gov/chusa12/hs/hsc/downloads/img/hHa.gif) As more immunizations become available, common childhood communicable diseases affect fewer children. The tracking of the leading topics from Healthy People 2020 provides some positive information related to improving children's health. Improvements have occurred in child health, but morbidity and disability from some conditions, such as asthma, diabetes, attention deficit disorders, and obesity, have increased in recent decades. Also, disparities in health status among U.S. children according to race and socioeconomic status demonstrate widening social inequalities. p. 12 p. 13 One trend in the United States is the increasing number of children with mental health disorders and related emotional, social, or behavioral problems. The American Academy of Pediatrics estimates one in five children in the United States have mental health-related problems (American Academy of Pediatrics, n.d.; Office of Adolescent Health, 2013). These problems may limit the child's educational success. They also increase the child's risk for significant mental health problems later in life or emotional problems and possible use of firearms, reckless driving, promiscuous sexual activity, and substance abuse during adolescence. Overall, these behavioral, social, and educational problems can interfere with children's social and academic development. Often, insurance does not reimburse for these problems, leading to additional concerns such as lack of treatment. Environmental and psychosocial factors are now an area of concern in children. They include academic difficulties, complex psychiatric disorders, self-harm and harm to others, use of firearms, hostility at school, substance abuse, HIV/AIDS, and adverse effects of the media. (Kyle 11-13) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Parental refusal of medical treatment

Parental autonomy (the right to decide for or against medical treatment) is a fundamental, constitutionally protected right but not an absolute one. The general assumption is that parents act in the best interest of their children. Ideally, medical care without informed consent should be given only when the child's life is in danger. In some cases parents may refuse medical treatment for their child. This refusal may arise when treatment conflicts with their religious or cultural beliefs, and the nurse should be aware of some of these common beliefs. Some religions, such as Christian Science, Pentecostal, Church of the First Born, and Followers of Christ, prefer prayer or faith healing to allopathic medicine (Hall, 2012). Jehovah's Witnesses refuse blood product administration based on their religious beliefs (Kitney, Kanani, & De Souza, 2012). Persons from an Islamic background may refuse the use of any potentially addictive substances such as narcotics or medicines containing alcohol (Perry, Sorajjakool, Yelland, & McMillan, 2011). Sometimes, common ground may be reached between the family's religious or cultural beliefs and the health care team's recommendations; communication and education are the keys in this situation. Take Note! Do not assume what a family's beliefs are based on religious affiliation. Assess the views of each family and child on an individual basis. In other cases, parents may refuse treatment if they perceive that their child's quality of life may be significantly impaired by the medical care that is offered. The health care team must appropriately educate the family and communicate with them on a level that they can understand. The child and family should be informed of what to expect with certain tests or treatments. The health care team should make a clinical assessment of the child's and family's understanding of the situation and their reasons for refusing treatment. Active listening may allow the physician to address the concerns, fears, or reservations the family may have regarding their child's care. Refusal of medical care may be considered a form of child neglect. If providing medical treatment may prevent substantial harm or suffering or save a child's life, physicians and the judicial system strive to advocate for the child. The state has an overriding interest in the health and welfare of the child and can order that medical treatment proceed without signed informed consent; this is referred to as parens patriae (the state has a right and a duty to protect children). If the parents refuse treatment and 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 or in complex cases, the judicial system may become involved (American Academy of Pediatrics, 2011a). (Kyle 20-21) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Continuing role of the pediatric nurse

Providing Culturally Focused Care The United States is no longer a "melting pot" of various cultures and ethnicities, but a society in which each distinct individual brings a diversity and richness that as a whole enriches the country. Today, children do not fit into a set category or group. Children and families vary in terms of culture, family structure, socioeconomic status, background, and circumstances, so each child enters the health care system as a unique individual. Pediatric nurses must have greater sensitivity to the background of each child and must be able to provide care that addresses the child's uniqueness. Providing Care Across the Health-Illness Continuum As a result of improved diagnosis and treatment, the pediatric nurse now cares for children who have survived once-fatal situations, are living well beyond the usual life expectancy for a specific illness, or are functioning and attending school with chronic disabilities. While positive and exciting, these advances and trends pose new challenges for the health care community. For example, as care for premature newborns improves and survival rates have increased, so too has the incidence of long-term chronic conditions such as respiratory airway dysfunction or developmental delays. As a result, pediatric nurses care for children at all stages along the health-illness continuum, from well children to those who are occasionally ill to those with chronic, sometimes disabling, conditions. p. 14 p. 15 Providing Family-Centered Care Due to the influence of managed care, the focus on prevention, better education, and technologic advances, people have taken increased responsibility for their own health. Parents now want information about their child's illness, they want to participate in making decisions about treatment, and they want to accompany their children to all health care situations. As child advocates who value family-centered care, pediatric nurses can provide such empowerment and can address specific issues for children and families. Pediatric nurses must respect the family's views and concerns, address those issues and concerns, regard the parents as important participants in their child's health, and always include the child and family in the decision-making process (see Chapter 8 for more information). Providing Preventative Care Efforts to reduce costs have also led to an increased emphasis on preventive care. Anticipatory guidance is vital during each health contact with children and their families. Education of the family includes everything from keeping the home safe to preventing illness. These are major points of emphasis for pediatric nurses as they deliver care to children and their families. Providing Continuum of Care In an effort to become more cost effective and to provide care more efficiently, the nursing care of children now encompasses a continuum of care that extends from acute care settings such as hospitals to outpatient settings such as ambulatory care clinics, primary care offices, rehabilitative units, community care settings, long-term facilities, homes, and schools. For example, after an acute hospital stay, a child may be able to complete therapy at home, school, or another community setting and can re-enter the hospital for short periods for specific treatments or illness. This continuum of care works well for children, since current statistics indicate that among children who have a regular place for care, 74% usually receive their medical care in doctors' offices, 24% in clinics, 1% in hospital-based clinics, and 1% in hospital emergency rooms (Bloom et al., 2012). Providing Child and Family Teaching The nurse's role in relation to morbidity and mortality in children involves educating the family and community regarding the usual causes of deaths, the types of childhood illnesses, and the symptoms that require health care. The goal is to raise awareness and provide guidance and counseling to prevent unnecessary deaths and illnesses in children. The health of children is basic to their well-being and development, and the attention given to children's health in this country has slowly increased over the years. The pediatric nurse is in an excellent position to improve the future health of children. Participating in Research Pediatric nursing involves all the essential components of contemporary nursing practice. The pediatric nurse makes use of theories and research pertaining specifically to children as well as general nursing concepts and research. Nurses must know about current trends in child health so that they can provide appropriate anticipatory guidance, counseling, and teaching for children and families and can identify high-risk groups so that interventions can be initiated early, before illness or death occurs. Implementing the Nursing Process The pediatric nurse performs all of these tasks using the framework of the nursing process. The nursing process is used to care for the child and family during health promotion, maintenance, restoration, and rehabilitation. It is a problem-solving method based on the scientific method that allows nursing care to be planned and implemented in a thorough, organized manner to ensure quality and consistency of care. The nursing process is applicable to all health care settings and consists of five steps: assessment, nursing diagnosis, outcome identification and planning, implementation, and outcome evaluation. Assessment. Assessment involves collecting data about the child and family and performing physical assessment during community-based health services, at admission to an acute care setting, at periodic times during the child's hospitalization or care, and during home care visits. Nursing diagnosis. The nurse analyzes the data to make judgments about the child's health and developmental status. The nursing diagnoses that result from this judgment process describe health promotion and health patterns that pediatric nurses can manage. Planning and expected outcomes. The next step in the process involves developing nursing care plans that incorporate goals or expected outcomes that improve the child's dysfunctional health patterns, promote appropriate health patterns, or provide for optimal developmental outcomes. The care plan includes the specific nursing actions that assist in obtaining the outcomes. Implementation. These interventions are implemented, adapted to the child's developmental level and family status, and modified if the child's response indicates the need. The care plan incorporates the family in addition to the child. Evaluation. The process is continually evaluated and updated during the partnership with the child and family. Concept Mastery Alert Assessment. When prioritizing care for children who witnessed a traumatic incident, the nurse must remember that assessment is the first step in the nursing process. p. 15 p. 16 Standardized care plans for specific nursing diagnoses and critical pathways for case management are often used in various pediatric settings. In general, care plans and critical pathways are becoming more evidence based, using a combination of research, group consensus, and past health care decisions to identify the most effective interventions for the child and family. The nurse is responsible for individualizing these standardized care plans based on the data collected during the assessment of the child and family and for evaluating the child's and family's response to the nursing interventions. (Kyle 14-16) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Advanced directives

The Patient Self-Determination Act of 1990 established the concept of advance directives. Advance directives determine the child's and family's wishes should life-sustaining care become necessary. Parents are generally the surrogate decision makers for children; however, the American Academy of Pediatrics encourages health care providers to take into consideration the views of the child when possible (American Academy of Pediatrics and Committee on Bioethics, 2008). If the child's interests are not served by prolonged survival, then the physician or advanced practitioner should educate the parents about the extent of the child's illness, diagnostic and therapeutic options, and potential for ongoing quality of life (American Academy of Pediatrics & Committee on Bioethics, 2008). After discussion with other family members, friends, and spiritual advisors, the parents may make the decision to forego life-sustaining medical treatment, either withdrawing treatment or deciding to withhold certain further treatment or opt not to resuscitate in the event of cardiopulmonary arrest (American Academy of Pediatrics & Committee on Bioethics, 2008). Life-sustaining care may include antibiotics, chemotherapy, dialysis, ventilation, cardiopulmonary resuscitation, and artificial nutrition and hydration. Some families may choose to withdraw these treatments if they are already in place or not begin them should the need arise. "Do not attempt resuscitation (DNAR)" orders are in place for some children, particularly the terminally ill. Some institutions have started using the term AND ("Allow Natural Death"). No matter what term is used, these orders should include specific instructions regarding the child's and family's wishes (e.g., some families may desire oxygen but not chest compressions or code medications). When the child is hospitalized, the DNAR order must be documented in the physician orders and updated according to the facility's policy. DNAR orders may also be in place in the home, but only a few states allow emergency medical services to honor a child's DNAR order in the home. Children with DNAR orders may also still be attending school. In that case, the health care professionals involved should meet with the school officials (the board of education and its legal counsel) to discuss how the DNAR request can be upheld in the school setting. The health care provider should help educate the school about the child's condition, potential complications, and health care goals (American Academy of Pediatrics & Committee on School Health and Committee on Bioethics, 2013). They should work with the school and family on developing an individualized health care plan that will include what to do instead of CPR, such as comfort measures (American Academy of Pediatrics & Committee on School Health and Committee on Bioethics, 2013). The Baby Doe regulations, which are an amendment to the U.S. Child Abuse Protection and Treatment Act, provide specific guidelines on how to treat extremely ill, premature, terminally ill, and/or disabled infants regardless of the parents' wishes (White, 2011). These cases encompass complex ethical issues and continue to be surrounded by legal uncertainty. Therefore, physicians must continue to work with parents of extremely sick or premature infants to ensure that they are accurately informed about the condition of their child and the risks and benefits to treatment. Physicians must also be aware of federal, state, and hospital policies regarding care of very ill, premature, and/or disabled newborns. The nurse must be knowledgeable about the laws related to health care of children in the state where he or she practices as well as the policies of the health care institution. The nurse must be sensitive to the various ethical situations that he or she may become involved in and should apply knowledge of laws as well as concepts of ethics to provide appropriate care. (Kyle 21-22) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Assent

Assent means agreeing to something. In pediatric health care, the term assent refers to the child's participation in the decision-making process about health care (American Academy of Pediatrics, 2011a). The age of assent depends on the child's developmental level, maturity, and psychological state. The American Academy of Pediatrics recommends that children and adolescents be involved in the discussions about their health care and kept informed in an age-appropriate manner (American Academy of Pediatrics & Committee on Bioethics, 2011a). As a child gets older assent or dissent should be given more serious consideration. The pediatric patient needs to be empowered by physicians to the extent of their capabilities, and as children mature and develop over time they should become the primary decision maker regarding their health care (American Academy of Pediatrics & Committee on Bioethics, 2011a). The American Academy of Pediatrics recommends that if a physician asks the child's opinion about the direction of treatment or participation in research, then the child's view and desires should be seriously considered (American Academy of Pediatrics & Committee on Bioethics, 2011a). When obtaining assent, first help the child to understand his or her health condition, depending on the child's developmental level. Next, inform the child of the treatment planned and discuss what he or she should expect. Then determine what the child understands about the situation and make sure he or she is not being unduly influenced to make a decision one way or another. Lastly, ascertain the child's willingness to participate in the treatment or research (American Academy of Pediatrics & Committee on Bioethics, 2011a). Assent is a process and should continue throughout the course of treatment or research protocol. The converse of assent, which is dissent (disagreeing with the treatment plan), may be ethically binding (American Academy of Pediatrics & Committee on Bioethics, 2011a). If the physician is not going to honor the child's dissent, the argument can be made that he or she should not ask for the child's assent. In some cases, such as cases of significant morbidity or mortality, dissent may need to be overridden. These cases need to be looked at on an individual basis. If the decision is made to move forward with treatment despite the child's dissent, then this decision must be explained to the child in developmentally appropriate terms. There has been an increased emphasis on including children in research studies. Children are not little adults, but 70% of medicines given to children have only been tested on adults (National Institutes of Health, 2012). In research studies investigators and investigation review boards (IRBs) are responsible for ensuring that measures are taken to protect the children in the studies. The nurse caring for these children also has the responsibility to ensure protection at all stages of the research process. Nurses can become members of the IRB as well as become familiar with studies that have been approved in their work setting to help ensure that their pediatric patients are protected. (Kyle 21) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Child health

Children are a gift to this world, and, as such, it is society's responsibility to nurture and care for them. In the past, health was defined simply as the absence of disease; health was measured by monitoring the mortality and morbidity of a group. Over the past century, however, the focus of health has shifted to disease prevention, health promotion, and wellness. The World Health Organization (WHO) (2013) defines health as "a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity." (Kyle 6) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Philosophy of Pediatric Nursing

Children need access to care that is continuous, comprehensive, coordinated, family centered, and compassionate. This care needs to focus on their changing physical, developmental, and emotional needs. Pediatric nurses provide this care by focusing on the family, providing atraumatic therapeutic care, and using evidence-based practice. These three concepts represent an overarching philosophy of pediatric nursing care and are integrated throughout the chapters of this text. Parents or guardians play a critical role in the health and well-being of children. Providing care through a family-centered approach leads not only to better outcomes but also to better consumer satisfaction. The family is the child's primary source of support and strength. The knowledge that the family has about a child's health or illness is vital. Family-centered care involves a mutually beneficial partnership between the child, the family, and health care professionals (American Academy of Pediatrics, Committee on Hospital Care, Institute for Patient and Family-Centered Care, 2012). It applies to the planning, delivery, and evaluation of health care for children of all ages in any setting (see Chapter 8). Children may undergo a wide range of interventions, many of which can be traumatic, stressful, and painful. The various settings in which the child receives care can be scary and overwhelming to the child and the family, and interacting with health care personnel in various settings can cause anxiety. Thus, another major component of the pediatric nursing philosophy is providing atraumatic care. This is a philosophy of providing therapeutic care through interventions that minimize physical and psychological distress for children and their families (see Chapter 8). Evidence-based practice involves the use of research findings in establishing a plan of care and implementing that care. It is a clinical decision-making approach involving the integration of the best scientific evidence, patient values and preferences, clinical circumstances, and clinical expertise to promote best outcomes (Melnyk & Fineout-Overholt, 2010). It is important that nurses develop the skills and knowledge necessary to ask pertinent clinical questions, search for current best evidence, analyze the evidence, integrate the evidence into practice when appropriate, and evaluate the outcomes. Evidence-based practice may lead to a decrease in variations in care while at the same time increasing quality and improving health care. (Kyle 13-14) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Consent

Generally, only persons over the age of majority (18 years of age) can legally provide consent for health care. Since children are minors, the process of consent involves obtaining written permission from a parent or legal guardian. In cases requiring a signature for consent, usually the parent gives consent for care for children younger than 18 years of age except in certain situations (see below). (Kyle 18) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Evolution of pediatric nursing

In 1870, the first pediatric professorship for a physician was awarded in the United States to Abraham Jacobi, who is known as the father of pediatrics. For the first time, the medical community realized there was a need to provide specialized training and education about children to physicians. In the early 1900s, Lillian Wald established the Henry Street Settlement House in New York City; this was the start of public health nursing. This facility provided medical and other services to poor families. These services included home nurse visits to teach mothers about health care. During this time, health care personnel were trained to take care of children in hospitals, but parents of hospitalized children were discouraged from visiting to prevent the spread of infection. Restricting parents from being involved in their child's care was also thought to minimize emotional stress. Nursing in public schools began in 1902 with the appointment of Lina Rogers as a full-time public school nurse in New York. A professional course in pediatric nursing was started in the early 1900s at the Teachers' College of Columbia University. In the 1960s, changes in the health care delivery system and shifts in the population's health status led to the development of the nurse practitioner role. Loretta Ford was the founder of the first nurse practitioner program. The 1970s brought cost-control systems from the federal government because of rapid escalation of health care expenditures. In addition, the considerable changes in the United States health care system in the 1980s affected pediatric nursing and child health care. The emphasis of care was on quality outcomes and cost containment. Some of these changes brought more advanced-practice nurses into the field of pediatrics. In the 1980s, the Division of Maternal and Child Health Nursing Practice of the American Nurses Association developed maternal and child health standards to provide important guidelines for delivering nursing care. In the 1990s, the Institute of Medicine published reports pointing out the need to improve quality and safety of the American health care system. This led to an increased focus on improving health care outcomes. As the health care environment continued to increase in complexity and patients hospitalized got sicker, programs were created for nurses to obtain a level of expertise and to validate mastery of their skills and knowledge by passing a national standardized examination. Registered nurses and nurse practitioners can be certified in their specialty, such as pediatrics. These certifications show a commitment to lifelong learning and the ability to stay up to date in the rapidly changing health care environment. In recent years, pediatric nursing certifications have become increasingly specialized, for example, a certified pediatric hematology/oncology nurse or a certified pediatric emergency nurse. (Kyle 13) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Measurements of a child's mortality

In 1979, the U.S. Surgeon General's Report Healthy People presented an agenda for the nation that identified the most significant preventable threats to health. With the series of updates that followed, including the present one, Healthy People 2020: The Road Ahead, the United States has a comprehensive health promotion and disease prevention agenda that is working toward improving the quantity and quality of life for all Americans (U.S. Department of Health and Human Services, 2012). Overarching goals are to eliminate preventable disease, disability, injury, and premature death; achieve health equity, eliminate disparities, and improve the health of all groups; create physical and social environments that promote good health; and promote healthy development and behaviors across every stage of life (U.S. Department of Health and Human Services, 2012). The principle behind this report is that setting national objectives and monitoring their progress can motivate action and change. The report incorporates input from public health and prevention experts; federal, state, and local governments; over 2,000 organizations; and the public in developing health objectives. There are specific health topic areas, including children's health topics, which serve as a method for evaluation of progress made in public health. These topic areas also serve as focal points to coordinate national health improvement efforts. For example, one objective under the physical activity topic is to increase the proportion of adolescents who meet current federal physical activity guidelines for aerobic physical activity and for muscle-strengthening activity (U.S. Department of Health and Human Services, 2012). Healthy People 2020 monitors four foundation health measures to assess the progress toward promoting health, preventing disease and disability, eliminating disparities, and improving quality of life (see the Healthy People 2020 feature on page 11, for additional information on these health measures) (U.S. Department of Health and Human Services, 2012). Measuring a child's health status is not always a simple process. For example, some children with chronic illnesses do not see themselves as "ill" if their disease is under control. A traditional method of measuring health is to examine mortality and morbidity data. This information is collected and analyzed to provide an objective description of the nation's health. (Kyle 7) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Standards of Care (Practice)

In any role, the professional pediatric nurse is held accountable for nursing actions that adhere to the standards of care. A standard of care is a minimally accepted action expected of an individual of a certain skill or knowledge level and reflects what a reasonable and prudent person would do in a similar situation. Professional standards from regulatory agencies, state or federal laws, nurse practice acts, and other specialty groups regulate nursing practice in general. The National Association of Pediatric Nurse Practitioners (NAPNAP), the Society of Pediatric Nurses (SPN), and the American Nurses Association (ANA) (2008) have formulated specific standards of care and professional performance for pediatric clinical nursing practice (Table 1.2). These standards are tools that determine if care constitutes adequate, effective, and acceptable nursing practice. They also serve as guides and legal measures for this special area of practice. These standards promote consistency in practice, provide important guidelines for care planning, assist with the development of outcome criteria, and ensure quality nursing care. The ANA-SPN standards specify what is adequate and effective for general pediatric nursing and promote consistency in practice. Based on the Institute of Medicines competencies for nursing, Quality and Safety Education for Nurses (QSEN) initiatives were developed to be integrated into nursing education. These quality and safety initiatives or competencies help nurses improve the quality and safety of our health care system. Go to thePoint to find QSEN standards mapped to this textbook. National Patient Safety Goals (NPSG) have also been developed by the Joint Commission to address specific areas of concern regarding patient safety and to help accredited organizations improve patient safety (Joint Commission, 2015). The goals focus on problems that have been identified in health care safety and ways to solve them. Throughout the text, look for the NPSG icon to learn about pertinent safety goals. Nurses need to understand these competencies and goals and utilize them to improve the quality and safety of their nursing practice. (Kyle 16) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

History of child's health part 2

In recent years there have been tremendous improvements in technology and biomedicine. This has created a trend toward earlier diagnosis and treatment of disorders and diseases. Throughout the 1990s remarkable progress was made linking genetics and pathophysiologic processes. For example, female fetuses diagnosed with congenital adrenal hyperplasia, a genetic disorder resulting in a steroid enzyme deficiency that can lead to disfiguring anatomic abnormalities of sexual characteristics, are able to receive treatment before birth. This can lead to fewer anatomic abnormalities and may even allow for normal female genitalia to develop (Mayo Foundation for Medical Education and Research, 2011). In addition, many genetic defects are being identified so that counseling and treatment may occur early. p. 6 p. 7 In addition to improvement in technology and biomedicine, a number of national and international organizations have been formed in recent years to protect children's rights both in the United States and worldwide. These organizations focus on such issues as violence and abuse, child labor and soldiering, juvenile justice, child immigrants and orphaned children, and abandoned or homeless children—all of which have a negative impact on children's health. A child whose rights are restored and upheld has an improved opportunity for growth, development, education, and health. The gains in child health have been huge, but, unfortunately, these gains are not shared equally among all children. Certain health concerns, such as poor nutrition, obesity, infections, lead poisoning, and asthma, affect poor children at higher rates and with greater severity than affluent and middle class children (Seith & Isakson, 2011). Unintentional injuries continue to be the leading cause of death in children older than 1 year, but children's health remains threatened by illnesses and other health-related conditions in the 21st century (Centers for Disease Control and Prevention [CDC]/National Center for Health Statistics, 2013). Obesity, environmental toxins, allergies, drug abuse, child abuse and neglect, and mental health problems are among some of the key issues that endanger children's health today. (Kyle 6-7) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Exceptions to informed consent

In some states, a mature minor may give consent to certain medical treatment. The physician must determine that the adolescent (usually older than 14 years of age) is sufficiently mature and intelligent to make the decision for treatment. The provider also considers the complexity of the treatment, its risks and benefits, and whether the treatment is necessary or elective before obtaining consent from a mature minor (American Academy of Pediatrics, et al., 2011b). State laws vary in relation to the definition of an emancipated minor and the types of treatment that may be obtained by an emancipated minor (without parental consent). The nurse must be familiar with the particular state's law. Emancipation may be considered in any of the following situations, depending on the state's laws. Membership in a branch of the armed services Marriage Court-determined emancipation Financial independence and living apart from parents Pregnancy Mother younger than 18 years of age The emancipated minor is considered to have the legal capacity of an adult and may make his or her own health care decisions (American Academy of Pediatrics, et al., 2011b). Many states do not require the consent or notification of parents or legal guardians when providing specific care to minors. Depending on the state law, health care may be provided to minors for certain conditions, in a confidential manner, without including the parents. These types of care may include pregnancy counseling, prenatal care, contraception, testing for and treatment of sexually transmitted infections and communicable diseases (including HIV), substance abuse and mental illness counseling and treatment (American Academy of Pediatrics, et al., 2011b). These exceptions allow children to seek help in a confidential manner; they might otherwise avoid care if they were required to inform their parents or legal guardian. Again, laws vary by state, so the nurse must be knowledgeable about the laws in the state where he or she is licensed to practice. (Kyle 19) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Mortality data

Mortality is the number of individuals who have died over a specific period. This statistic is generally presented as rates per 100,000 population and is calculated from a sample of death certificates. The National Center for Health Statistics, under the U.S. Department of Health and Human Services, collects, analyzes, and disseminates these data. NEONATAL AND INFANT MORTALITY RATE Neonatal mortality is the number of infant deaths occurring in the first 28 days of life per 1,000 live births. The infant mortality rate refers to the number of deaths occurring in the first 12 months of life. It also is documented as the number of deaths in relation to 1,000 live births. The infant mortality rate is used as an index of the general health of a country. Generally, this statistic is one of the most significant measures of children's health. In 2013, the infant mortality rate in the United States was 5.9 per 1,000 live births (Central Intelligence Agency, 2013). See Figure 1.1. (Kyle 7) The infant mortality rate varies greatly from state to state as well as between ethnic groups. The United States has one of the highest gross national products in the world and is known for its technologic capabilities, but its infant mortality rate is much higher, in some cases double, compared to most other developed nations (Central Intelligence Agency, 2013; U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 2013). The main causes of early infant death in the United States include short gestation, low birth weight, congenital anomalies, maternal complications during pregnancy, sudden infant death syndrome, respiratory distress syndrome, unintentional injuries, and bacterial sepsis (Murphy, Xu, & Kochanek, 2012). Preterm births and low birth weight are key risk factors for infant death; lower the birth weight, higher the risk of infant mortality. The percentage of infants born preterm in the United States hit a peak in 2006; thus, the impact of preterm-related causes of infant death was increased during this time. This increase may play a role in the plateau in infant mortality rates seen from 2000 to 2007 and in the higher infant mortality rates in the United States compared with other developed countries (U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 2013). Since 2006, preterm birth rates have declined each year (Hamilton, Martin, & Ventura, 2013). By 2012, the preterm birthrate was 11.54% which was down 10% from 2006 (Hamilton et al., 2013). CHILDHOOD MORTALITY RATE Childhood mortality is defined as the number of deaths per 100,000 population in children between 1 and 14 years of age. The childhood mortality rate in the United States has decreased significantly since 1980, but disparities by gender, age, race, and ethnicity persist (Child Trends DataBank, 2013). In 2010, the mortality rate for children between ages 1 and 4 years was 26.5 per 100,000, with the leading cause of death being unintentional injuries followed by congenital malformations (CDC/National Center for Health Statistics, 2013). The mortality rate for children aged 5 to 14 years was 12.9 per 100,000, with the leading cause being unintentional injuries followed by cancer (CDC/National Center for Health Statistics, 2013). Other causes of childhood mortality include suicide, homicide, diseases of the heart, influenza, and pneumonia. (Kyle 10 Even as research continues into the preventable nature of childhood injuries, unintentional injury, such as motor vehicle accidents, fires, drowning, bicycle or pedestrian accidents, poisoning, and falls, remains a leading cause of mortality and morbidity in children. These injuries have far-reaching consequences for children, families, and society in general. Risk factors associated with childhood injuries include young age, male gender, low socioeconomic status, parents who are unmarried or single, low maternal education level, poor housing, parental drug or alcohol abuse, or low support within the family. These deaths can often be prevented through education about the value of using car seats and seat belts, the dangers of driving under the influence of alcohol and other substances, and the importance of pedestrian and bicycle safety, fire safety, water safety, and home safety. (Kyle 11) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Informed consent

Most care given in a health care setting is covered by the initial consent for treatment signed when the child becomes a patient at that office or clinic or by the consent to treatment signed upon admission to the hospital or other inpatient facility. Certain procedures, however, require a specific process of informed consent. Procedures that require informed consent include major and minor surgery; invasive procedures such as lumbar puncture or bone marrow aspiration; treatments placing the child at higher risk, such as chemotherapy or radiation therapy; procedures or treatments involving research; application of restraints; and photography involving children. p. 18 p. 19 The informed consent process, which must be done before the procedure or specific care, addresses the legal and ethical requirement of informing the child and parent about the procedure. It originates from the right of the child and family to direct their care and the ethical responsibility of physicians to involve the child and family in health care decisions. Nurses should involve children and adolescents in the decision-making process to the extent possible, though the parent is still ultimately responsible for giving consent. The physician or advanced practitioner providing or performing the treatment and/or procedure is responsible for informing the child and family about the procedure and obtaining consent by providing a detailed description of the procedure or treatment, the potential risks and benefits, and alternative methods available. The nurse's responsibility related to informed consent includes the following: Determining that the parents or legal guardians understand what they are signing by asking them pertinent questions Ensuring that the consent form is completed with signatures from the parents or legal guardians Serving as a witness to the signature process Box 1.1 describes the key elements of informed consent, although laws vary from state to state. Nurses must become familiar with state laws as well as the policies and procedures of the health care agency. Treating children without obtaining proper informed consent is a violation of their rights and the physician and/or facility may be held liable for any damages (Murray, 2012). (Kyle 18-19) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Federal legislation affecting health care

Numerous federal programs have had a major impact on child health. President Theodore Roosevelt began the crusade to assist children and their families, especially the poor. The establishment of the Children's Bureau in 1912 began a period of studying economic and social factors related to infant mortality, infant care in rural areas, and other factors related to children's health. The goal of these legislative efforts was to improve the standards of health care. These actions demonstrate the value that society has placed on the welfare of children. Table 1.1 lists several significant pieces of federal legislation and describes their impact on children's health. (Kyle 7) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

True

Parents and guardians generally make choices about their child's health and services. As the legal custodians of minor children, they decide what is best for their child. Nurses caring for children and their families make (Kyle 17) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Pediatric nursing

Pediatric nursing is the practice of nursing involved in the health care of children from infancy through adolescence. In the United States the number of children younger than age 18 years is approximately 73.7 million, accounting for almost 24% of the population (Federal Interagency Forum on Child and Family Statistics, 2013). The definition of nursing, "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations," also applies to the practice of pediatric nursing (American Nurses Association, 2013). However, the overall goal of pediatric nursing practice is to promote and assist the child in maintaining optimal levels of health while recognizing the influence of the family on the child's well-being. This goal involves the practice of health promotion and disease prevention as w (Kyle 13) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Role of the Pediatric Nurse

The primary role of the pediatric nurse is to provide direct nursing care to children and their families, being an advocate, educator, and manager. As a child and family advocate, the nurse safeguards and advances the interests of children and their families by knowing their needs and resources, informing them of their rights and options, and assisting them to make informed decisions. In the role of educator, the nurse instructs and counsels children and their families about all aspects of health and illness. The pediatric nurse ensures that communication with the child and family is based on the child's age and developmental level. The pediatric nurse uses and integrates research findings to establish evidence-based practice, managing the delivery of care in a cost-effective manner to promote continuity of care and an optimal outcome for the child and family. The pediatric nurse also serves as a collaborator, care coordinator, and consultant. Collaborating with the interdisciplinary health care team, the pediatric nurse integrates the child's and family's needs into a coordinated plan of care. In the role of consultant, the pediatric nurse ensures that the child's and family's needs are met through such activities as support group facilitation or working with the school nurse to plan the child's care. The dimensions of pediatric health care are changing. We live in a global community in which distances have been minimized, enabling all of us to learn, share, and exchange information. The pediatric nurse needs to be alert to the wide-ranging developmental and mental health needs of children as well as to the traits and behaviors that may lead to serious health problems. The scope of pediatric health care practice is much broader today, and pediatric nurses must include quality evidence-based interventions when developing the plan of care. In addition, pediatric nurses must incorporate new information about genetics and neurobiology and must continue to keep up with the technology explosion. (Kyle 14) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Nursing practice roles in various health care settings

The professional pediatric registered nurse provides care for children in a variety of settings. Acute care focuses on the diagnosis and treatment of illness and occurs in such settings as general pediatric hospital units, pediatric intensive care units, emergency departments, ambulatory clinics, surgical centers, and psychiatric centers. In the community the focus is usually on health promotion and illness prevention. Various community settings include health clinics or offices, schools, homes, day care centers, and summer camps. Care involving restorative, rehabilitative, or quality-of-life care generally takes place in rehabilitation centers or hospice programs or through service with a home health agency. There are various practice roles where the nurse's experience, competence, and educational level determine the nurse's position. For example, a clinical coordinator typically holds a baccalaureate degree and fills a leadership role in a variety of settings. The case manager, also usually a baccalaureate-prepared nurse, is responsible for integrating care from before admission to after discharge. The case manager coordinates the implementation of the interdisciplinary team in a collaborative manner to ensure continuity of care that is cost effective, quality oriented, and outcome focused. Various changes in the health care system continue to encourage the development of the advanced practice role for pediatric nursing. The advanced practice role is an expanded nursing role that requires additional education and skills in the assessment and management of children and their families. The pediatric nurse practitioner (PNP) has a master's degree and national certification in the specialty area. The PNP is an independent and autonomous practitioner. The PNP provides health maintenance care for children (such as well-child examinations and developmental screenings) and diagnoses and treats common childhood illnesses. He or she manages children's health in primary, acute, or intensive care settings or provides long-term management of the child with a chronic illness. The family nurse practitioner (FNP) and neonatal nurse practitioner (NNP) function in a similar manner to the PNP but provide care to individuals throughout the lifespan and to newborns, respectively. The clinical nurse specialist has a master's degree and provides expertise as an educator, clinician, or researcher, meeting the needs of staff, children, and families. (Kyle 16) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Special situations to informed consent

There are special situations related to informed consent. If the parent is not available, then the person in charge (relative, babysitter, or teacher) may give consent for emergency treatment if that person 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 telephone may be obtained. Two witnesses must be listening simultaneously and will sign the consent form, indicating that consent was received via telephone. Physicians can provide emergency treatment to a child without consent if they have made reasonable attempts to contact the child's parent or legal guardian (American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, & Committee on Bioethics, 2011b). In urgent or emergent situations, appropriate medical care should never be delayed or withheld due to an inability to obtain consent (American Academy of Pediatrics, et al, 2011b). Certain federal laws, such as the Emergency Medical Treatment and Labor Act (EMTALA), require that every child who presents at an emergency department is given a medical examination regardless of informed consent or reimbursement ability (American Academy of Pediatrics, et al., 2011b). Table 1.3 gives further information about other special situations. (Kyle 19) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.

Confidentiality issues

With the establishment of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, confidentiality of health care information is now required. The primary intent of the law is to maintain health insurance coverage for workers and their families when they change or lose jobs. Another aspect of the law requires the U.S. Department of Health and Human Services to establish national standards for electronic transactions for health information on individuals. Due to the increased use of electronic medical records (EMRs) and electronic billing, there is an increased possibility that personal health information might be inappropriately distributed. Patient confidentiality and privacy must be maintained as it is with paper documentation. Nurses can ensure that privacy is maintained when using computerized documentation and an EMR by doing the following: Always maintain the security of your personal log-in information; never share it with other nurses or other persons. Always log off when leaving the computer. Do not leave patient information visible on a monitor screen when the computer/monitor is unattended. Use safeguards, such as encryption, when using alternative means of communication, such as e-mail. HIPAA also addresses security and privacy issues involving health information about individuals. The HIPAA Security Rule establishes national standards to protect electronic personal health information. The HIPAA Privacy Rule ensures proper protection of personal health information while allowing for the flow of health information needed to provide and promote high-quality care (U.S. Department of Health and Human Services, n.d.). As long as reasonable precautions have been taken to protect the child's privacy, the privacy rule allows certain disclosures that assist in patient care. State privacy laws and professional practice standards also exist to protect personal health information, and care providers must follow whichever guidelines are more stringent. In the pediatric area, information is shared only with the legal parents or guardians or individuals as established in writing by the parents. This law, along with professional obligation, promotes the security and privacy of children's health information. Exceptions to Confidential Treatment in Children There are exceptions to confidential treatment in children. For example, all states require reporting of suspicion of physical or sexual child abuse and injuries caused by a weapon or criminal act. Abuse cases are reported to the child welfare authorities, criminal acts to the police. If the minor is a threat to himself or herself, information may need to be disclosed to protect the child. The physician must also follow public health laws that require reporting certain infectious diseases to the local health department (e.g., tuberculosis, hepatitis, HIV, and other sexually transmitted infections). Finally, there is a duty to warn third parties when a specific threat is made to an identifiable person. Physicians must strike a balance between confidentiality and required disclosure. Even if disclosure is required, it is recommended that the physician discuss the issue with the child and when possible inform the minor of the limits to confidentiality and consent prior to the initiation of care (Snyder L, for the American College of Physicians Ethics, Professionalism, and Human Rights Committee, 2012). (Kyle 22) Kyle, Terri. Lippincott CoursePoint for Kyle: Essentials of Pediatric Nursing. CoursePoint, 4/30/16. VitalBook file.