NUR320 - Exam 1 Study Guide

42) Why do infants cry when there is "nothing wrong?"

- Crying may sometimes be unknown - Look for reasons (gastric distress, hungry, wet or cold) and intervene

38) What is responsible for declining mortality and morbidity of children of all ages?

- advancements in prenatal screening and care - unintentional injury is the leading cause of death in children ages 1-19 yrs old. - mortality in newborns is related to low birth weight and congenital malformations

41) What are self-soothing behaviors of infants? What are self-regulating behaviors?

- provide pacifies - Provide mobiles, rattles, and music boxes to stimulate the senses - talk soothingly - play peek-a-boo with older infants.

26) Make sure you know how to promote growth and development of each age group and to provide anticipatory guidance of the parents

-Newborn: birth-1 month: Use reflexes as tools that help the newborn transition from the uterus to the external world. - Attachment is a key development in newborns - Newborns learn in the 1st month about safety, security, comfort, and food - Parents should use times when the baby is focused on their face to interact with them - To promote attachment: encourage frequent visits to the baby in the newborn care unit - Promote the parent holding the baby - Provide skin-skin contact of the baby and parent - point out the baby's responses to voice or touch - involve the parent in decisions about the baby - Infant (1 mo. to 1 yr.): Birth weight is doubled in the first 5 months & tripled by 1 year. - Height increases 1 foot. - Teeth rupture by 6 months - physical growth is associated with nutritional status - Neuro system is more mature: can sit, stand, and walk by 1 yr. - at 1 yr, they can recognize sounds and say a few words - engage in solitary play - cognitive development is seen by the use of manipulating toys - Infant play begins in a reflexive manner; moving extremities and grasping objects - infants communicating and engage in two-way interaction and express c comfort by soft sounds, cuddling, and eye contact. - Infants understand speech (receptive speech) more than they can speak (expressive speech). - Parents should learn to modify the child's environment to promote adaptation (ex. alternating babysitters) - Parents should talk to the infant using a high voice, sing, and teach words to their infant frequently. -Toddler (1-3yrs): displays independence, negativism, and pride in accomplishments - Body proportions: legs longer and head smaller to body size than during infancy - Usually has a potbelly; and masters potty training. - Child is in preoperational stage and object permanence is well developed - Have rudimentary problem solving, creative though, and understanding of cause and effect. - Toddlers play side by side with other children. (parallel play) - play is usually from things they see at home (ex. talking on the phone) - Temperament from infancy may change ( A pleasant baby may be slow to warm up to now). - they communicate frequently with other children - have temper tantrums to hand these, verbalize the feelings the toddler is showing; "You must be very upset that you cannot have that candy." - Communication for a toddler includes: - avoid telling them procedures too far in advance - Do not give choices, give short, clear instructions - Tell the child what is being done and the name of the object during an assessment. - Allow the child to cry during a frightening procedure - Parents are the best source of comfort during procedures. - Choose a reward (ex. sticker) after a procedure - perform painful procedures in a treatment room. - Preschool (3-6 yrs): language skills are well developed and child is able to understand and speak clearly. - has interest in the body and its functions - preschools play by interacting with each other (ex. 1 person cuts paper while the other person glues the paper). Associative play - enjoy large motor activities: ex. throwing a bally, riding a bike - engage in dramatic play - have imaginary thinking; ex: a dye injection will make them think they're going to die, or a "little stick" will be tree branches falling on them - Communication: use drawings to explain care - Use accurate names of body parts - allow the child to ask questions, and make choices. -School age (6-12 yrs old): entering the stage of industry - Parents should praise the child for their achievements to promote self- esteem. - Girls may start growth spurts by 9 or 10 yrs old -Boys growth spurt is usually a year later -Parents should closely monitor children for proper brushing and flossing. - Child has concrete operational thought; can solve problems and find alternative solutions - Rely on concrete experiences to form their thought content - Understands the concept of conservation. - Cooperative play cooperate with others and the ability to participate in order to a unified whole. Also involves rules and structure. - Play is extremely important method of learning and living at this time - Communication: Give the child awards for correct behavior - Include both parent and child in health care decisions. - Encourage parents to see their children as individuals who may not learn the same way. - provide them with information about the body so they can develop a healthy body image and understanding of the relationship between their bodies and sexuality - Adolescents (12-18 yrs old): the period of identity formation - Menstruation in girls is the last sign of puberty - apocrine and eccrine glands mature which increases sweating and odor - engage in formal operational thought can reason abstractly and understand the concepts of justice, truth, beauty, and power. - Peers are important in establishing identity and providing meaning - Inform parents of different personality types and help them support the teens uniqueness while providing structure - introduce the teens to kids with similar health problems - They should be allowed to choose if they want the parent present during an exam. - Give choices whenever possible; may need to negotiate to agree - provide info on safe sex, STDs, and alternatives if pregnant - parents should be encouraged to talk about sex with their teen

22) When is it appropriate for parents to do procedures, give medications, etc. while their child is hospitalized?

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47) Therapeutic vs. non-therapeutic relationships with children and families

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48) Atraumatic care

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45) Providing information to parents about their child's medical condition

1. Talk to the parents in person, in a private setting 2. Allow them to have a family member or friend for support. 3. present information in small amounts 4. use simple laungae and avoid medical terms. 5. share accurate up to date information 6. talk about the child's strengths and positive attributes, as well as their limitations and characteristics due to the illness or disability 7. Examine if the families needs were met and if additional resources are needed 8. Provide a follow up discussion 9. observe the patients facial expressions because most times they may stop listening after the medical condition has been told to them.

39) What age group is most concerned with body integrity? Body image?

Adolescents are most concerned with body image Body image: Specific facets of self-concept that forms about one's own body, body. - During and examination adolescents should be given the option of privacy - Nurses should offer education and explanations that focus on these issues to provide reassurance.

35) What are the types of play? Which age group engages in each type of play?

An 8-month-old infant is sitting on the floor, grasping blocks and banging them on the floor. Infants spend much oftheir time engaging in solitary play, or playing by themselves. However, when a parent walks by, the infant laughs and waves hands and feet wildly, showing that periodic interactions with others are pleasurable. Physical capabilities enable the infant to move toward and reach for objects ofinterest. Cognitive ability is reflected in manipulation ofthe blocks to create different sounds. Social interaction enhances play. The presence of a parent or other person increases interest in surroundings and teaches the infant different ways to play. The play of infants begins in a reflexive manner. When infants move extremities or grasp objects, they experience the foundations of play. They gain pleasure from the feel and sound of these activities, and gradually perform them purposefully. For example, when a parent places a rattle in the hand of a 6-week-old infant, the infant grasps it reflexively. As the hands move randomly, the rattle makes an enjoyable sound. The infant learns to move the rattle to create the sound and then finally to grasp the toy at will to play with it. The next phase of infant play focuses on manipulative behavior. The infant examines toys closely, looking at them, touching them, and placing them in the mouth. The infant learns a great deal about texture, qualities ofobjects, and all aspects ofthe surroundings. At the same time, interaction with others becomes an important part ofplay. The social nature of play is obvious as the infant plays with other children and adults. Toward the end of the first year, the infant's ability to move in space enlarges the sphere of play. Once infants crawl or walk, they can get to new places, find new toys, discover forgotten ...objects, or seek out other people for interaction. Play is a reflection of every aspect of development, fostering psychosocial skills and enhancing learning and maturation. (p. 150,153) Many changes in play patterns occur between infancy and toddlerhood. Developing motor skills enable toddlers to bang pegs into a pounding board with a hammer. The social nature of toddler play is also readily seen. Toddlers find the company of other children pleasurable, even though socially interactive play may not occur. Two toddlers tend to play with similar objects side by side, occasionally trading toys and words. This is called parallel play. This playtime with other children assists toddlers to develop social skills. Toddlers engage in play activities they have seen at home, such as talking on the phone. This imitative behavior teaches them new actions and skills . Physical skills are manifested in play as toddlers push and pull objects, climb in and out and up and down, run, ride a Big Wheel, turn the pages of books, and scribble with a pen. Both gross motor and fine motor abilities are enhanced during this age period. Cognitive understanding enables the toddler to manipulate objects and learn about their qualities. Stacking blocks and placing rings on a building tower teach spatial relationships and other lessons that provide a foundation for future learning. Various kinds of play objects should be provided for the toddler to meet play needs. These play needs can easily be met whether the child is hospitalized or at home (p. 155-156). The preschooler has begun to play in a new way. Toddlers simply play side by side with friends, each engaging in his or her own activities; but preschoolers interact with others during play. One child cuts out colored paper while her friend glues it on paper in a design. This new type of interaction is called associative play, and it is characterized by children interacting in groups and participating in similar activities. The child life therapist in hospital settings recognizes the therapeutic value of play in planning activities for children that enable them to work through feelings about procedures and separation, as well as facilitating the normal developmental need for interaction with other children. The role of the child life therapist is further discussed in Chapter 16. In addition to this social dimension of play, other aspects of play also differ. The preschooler enjoys large motor activities such as swinging, riding a tricycle, and throwing a ball. Increasing manual dexterity is demonstrated in greater complexity of drawings and manipulation of blocks and modeling. These changes necessitate planning ofplaytime to include appropriate activities. Preschool programs and child life departments in hospitals help meet this important need. Materials provided for play can be simple but should guide activities in which the child engages. Because fine motor activities are popular, paper, pens, scissors, glue, and a variety of other such objects should be available. The child can use them to create important images such as pictures of people, hospital beds, or friends. A collection of dolls, furniture, and clothing can be manipulated to represent parents and children, nurses and physicians, teachers, or other significant people. Because fantasy life is so powerful at this age, the preschooler readily uses props to engage in dramatic play, that is, living out the drama of human life. The nurse can use playtime to assess the preschooler's developmental level, knowledge about health care, and emotions related to healthcare experiences. Observations about objects chosen for play, content of dramatic play, and pictures drawn can provide important assessment data. The nurse can also use play periods to teach the child about healthcare procedures and offer an outlet for expression of emotions. See Chapter 16 for further information about use of play with hospitalized children, and Chapter 34 for a description of play therapy with children who have psychiatric and mental health needs. (p. 159-160). When a preschool teacher tries to organize a game of baseball, both the teacher and the children become frustrated. Not only are the children physically unable to hold a bat and hit a ball, but they also seem to have no understanding of the rules ofthe game and do not want to wait for their turn at bat. By 6 years of age, however, children have acquired the physical ability to hold the bat properlyand mayoccasionallyhit the ball. School-age children also understand that everyone has a role—the pitcher, the catcher, the batter, the outfielders. They cooperate with one another to form a team, are eager to learn the rules of the game, and want to ensure that these rules are followed exactly. The characteristics of play exhibited by the school-age child are cooperation with others and the ability to play a part in order to contribute to a unified whole. This type of play is called cooperative play. The concrete nature of cognitive thought leads to a reliance on rules to provide structure and security. Children have an increasing desire to spend much of playtime with friends, which demonstrates the social component of play. Play is an extremely important method oflearning and living for the school-age child. Active physical play has decreased in recent years as television viewing and playing ofcomputer games have increased, leading to poor nutritional status and other health risks in children. See Chapter 8 for further discussion of nutrition and physical activity in children. When a child is hospitalized, the separation from playmates can lead to feelings of sadness and purposelessness. School-age children often feel better when placed in multibed units with other children. Games can be devised even when children are using wheelchairs. Normal, rewarding parts of play should be integrated into care. Friends should be encouraged to visit or call a hospitalized child. Discharge planning for the child who has had a cast or brace applied should address the activities in which the child can participate and those the child must avoid. Reinforce the importance of playing games with friends. (p. 163-164).

9) Providing anticipatory guidance for each age group

Anticipatory Guidance is the prediction of the upcoming developmental tasks or needs of a child, and gearing teaching to those needs. Age-appropriate information should be included about healthy habits, but more importantly developmental stages need to be determined before providing anticipatory guidance!.

27) What is attachment? How can parents know if their child is attached to them?

Attachment is a strong emotional bond between people, and it can begin in the newborn period.When women hold their babies directly after birth, they tend to progress from touching them by fingertip, to full palm, and then enfolding them in hands and arms. Newborns are often alert after birth and follow the mother's face carefully with their eyes. This first interaction fosters attachment between the mother and baby. For many families, the process also involves attachment with the father, and sometimes siblings. The newborn learns quickly in the first month about safety and security, comfort, and food. If fed when hungry, held and comforted when in pain or distress, and played with several times daily, the baby learns that the parents and other caretakers can be trusted to meet its basic needs. Once the infant learns to trust that people will provide care, it is free to move on to explore the environment more actively. (p. 147) One of the first nurses to apply information about development, attachment, and infant/child behaviors was Dr. Kathryn Barnard. She sought to understand the impact of the first years oflife on later health and founded Nursing Child Assessment Satellite Training (NCAST), a program to teach nurses and other healthcare providers how to evaluate the parent-child interaction. Her work continues through an active program that provides training and tools for parent-child interaction, promoting early relationships, understanding babies' cues, promoting maternal mental health during pregnancy, assessing the child's environment, and assessing sleep (NCAST-AVENUW, 2007). Some parents may need ongoing help for a period of time to foster attachment with the child, such as parents who are very young or have imited experience with babies, parents with mental health problems, or the parents of a premature newborn. Challenges for parents of a high-risk infant include: - Guilt and grieving about the child's condition - Worry upon hospital discharge about whether skills are present to be competent in care of the baby - Concern about future development - Constant adaptation to changes as the child grows and develops Nursing interventions that can promote positive attachment with the high-risk infant include: - Encouraging frequent visits to the baby in the newborn care unit - Promoting holding of the baby - Providing for skin-to-skin contact ofthe baby and parent - Pointing out the baby's attributes and responses to voice or touch - Involving parents in care ofand decisions about the baby - Advocating for healthcare agency policies that are supportive of attachment between the infant and parents - Giving information and repeating as needed; letting parents have a telephone number they can call at any time to get information about the baby or talk with a supportive person - Arranging for ongoing developmental assessments on a regular basis once the infant is discharged from the hospital (p. 148).

43) When is it appropriate to tell children that they are dying?

Awareness of Dying by Developmental Age Infants and toddlers are not actually aware of death; they are aware of and react to changes in normal routines and parental nonverbal communication. Toddlers may know they "feel bad" but do not understand that their physical symptoms are associated with impending death. Preschool children can see their body deteriorate and feel the effects of medications used during disease progression and treatment. Changes in self-concept occur as they perceive these body changes. The preschool child often describes illness in terms of mutilation to the body. The child may realize that he or she is dying because ofthese physical changes, as well as the reactions ofparents and hospital staff. School-age children also have subtle fears about body integrity and anxieties related to the serious nature oftheir illness. This greater preoccupation with illness is considered by many professionals as the child's version of death anxiety, a feeling of apprehension or fear ofdeath. Children may express death anxiety as a concern with treatments that invade the body or interfere with normal body functions. Adolescents have a mature understanding of death, but the normal developmental milestones of adolescence add to their challenges in facing a terminal illness. They are struggling to establish their own identity and plans for the future. At a time when body image is extremely important, they may be faced with the possibility ofmutilation and disfigurement. Dying adolescents are often isolated from their peers during a period when peers are the most essential social group. Adolescents with terminal illnesses may be angry because they recognize their loss at a time when the whole world is opening up to them. Adolescents should not be expected to handle feelings in the same way as adults. They often avoid expressing anger, an expected stage ofgrieving, against the family by seeking to control and direct these feelings elsewhere. Adolescents often become angry at changes in treatment procedures, lack of explanations, and threats to their independence.As death nears, the adolescent may permit comforting and support and may accept care from warm and loving family members, as long as he or she is not treated condescendingly. Psychosocial Assessment of the Dying Child Children as young as 5 years of age can sense when they are seriously ill. They are undergoing treatments, not feeling well, and picking up cues from their parents that their condition is worsening. The dying child is usually aware of impending death even before being told. Kübler-Ross (1983) noted that children are more fearful of abandonment than death. The terminally ill child is reported to grieve loss offunction and the future, as well as leaving family members behind in sorrow (Hinds, Schum, Baker, et al., 2005). The child may feel a "conspiracy of silence" that leads the child to avoid the subject in an attempt to protect the parents from the truth. The child may believe that expressing an awareness of death and related fears will place added emotional burdens on family members. The result is that both parent and child miss the opportunity to share the comfort and love that could make the death more peaceful for the child and family survivors. The types of questions that children may ask include the following: - What will death be like? Will I have pain? - What will happen to me when I die? What happens after I die? - Will I be punished for the bad things I have done? - When will I be with [person(s) closest to child] again? - Will an angel come to take me away? What does heaven look like? - Will my parents be all right? - Can you come with me? - Will you remember me? (p. 724) Communicating with the Child of His or Her Impending Death Parents may prefer not to talk with the child about the seriousness of the illness and potential death out of a desire to protect the child from bad news. Parents may feel incapable of dealing directly with the child's questions about dying. They may feel that talking about the impending death takes away the child's hope. They may fear that they will be unable to cope with their own feelings during a frank discussion of the possibility of the child's imminent death. See Box 22-8 for reasons parents are more likely to talk with their children about their deaths. Identifying the appropriate time to assist the parent to have the conversation with the child often comes when the child knows something is very wrong, when the parent sees that the child could potentially die, or when a sibling is aware that a brother or sister may die (Wolfe, 2004). The child may ask ifhe or she is dying. Offer to set up a meeting with the parents and the healthcare team to discuss their fears and concerns about telling their child the truth. Explain that the child needs to trust his or her parents and healthcare providers. Even when the family is unwilling to talk with the child about death, some information should be provided to the child about the ongoing need for treatment and procedures. If treatments are performed without explanation, the child may experience increased anxiety. Be available to offer support and answer questions. When the family is ready, assist them in role-playing or possible words they can use to talk with their child about his or her death at a developmentally appropriate level (Box 22-9). Parents need to be receptive when the child initiates a conversation. Some children may be willing to talk through a stuffed animal or puppet, whereas others communicate through art. Emphasize to the parents that the child may actually need to hear the word dyingin order to understand. The child needs to know he or she will always be loved and remembered. Some parents may prefer that the child's questions be answered honestly by a member of the healthcare team. A professional who has special bereavement counseling training can assist children and families with the discussion. Some older children and adolescents may find it easier to talk about death with a friend or a nurse with whom there is a close relationship rather than their parents. (p. 728-729) BOX 22-9 Strategies for Communicating with the Dying Child - Make sure an agreement is reached early on with the parents and child about open communication. - Be receptive when children initiate a conversation. Recognize that behavior changes (disruptive behavior, withdrawal, anger, hyperalert state, sleeping more than usual) may indicate a struggle with emotions and an opportunity to engage the child in discussion. - Identify how much the child knows and wants to know. Identify any fantasies and concerns, and then provide correct information, matching the amount of information the child wants. - Allow the child to express his or her feelings and to be upset, even if this is a difficult discussion. - Reassure the child that you will be available to listen and give support. - Recognize that some children communicate best through nonverbal means, such as art and music. The child may be willing to talk through a puppet or a stuffed animal. - Acknowledge that the child's life can be complete, even if it is short. Let dying children know they will always be loved and remembered. - Empower children as much as possible in circumstances concerning their deaths. Reassure them of continued love and physical closeness. (p. 729)

21) Providing safety for children when parents are not present

BOX 1 6-3 Safety Measures for the Hospitalized Child (p. 498) NEWBORN AND INFANT - Use age-appropriate crib and bedding. - Secure equipment cords under the infant's gown or shirt. - Do not allow the infant to chew on cords. - Properly dispose of syringe caps and other small items that may present a choking hazard. - Establish with parents a list of persons who may visit the child. - Keep crib rails up when a parent is not at the bedside. TODDLER AND PRESCHOOLER - Maintain bed in low position. - Keep side rails up when a parent is not at the bedside. - Do not allow the child to chew on cords. - Keep room clutter-free. - Remove all unnecessary equipment from the child's room. - Properly dispose of syringe caps and other small items that may present a choking hazard. - Latex balloons should not be permitted due to the risk of suffocation. - If toddlers and preschoolers are curious about hospital equipment, provide them the opportunity to explore the equipment safely and with guidance (e.g., syringes without needles, blood pressure cuffs to satisfy curiosity). - Keep in mind that these children are naturally curious and explorative. - Instruct family members to inform staff when they are leaving the room to ensure that the toddler or preschooler is being observed. SCHOOL-AGE CHILD - Instruct the child to avoid manipulating hospital equipment such as intravenous fluid pumps, patient-controlled analgesia (PCA) pumps, and oxygen gauges. - Allow the child the opportunity to explore hospital surroundings and equipment with guidance. - Instruct family members to inform staff when they are leaving the room to ensure that the child is being observed. ADOLESCENT - Address issues such as smoking in the room and consuming alcohol since friends could possibly bring cigarettes or alcohol to the hospitalized adolescent.

8) How to establish rapport with children of all ages and their families.

Building Rapport? Establishing a trustful relationship w/your patient Erikson's First Theory Trust vs. Mistrust Data Collection • Introduction, Purpose of interview, Use of open- and closed-ended questions • Timing of questions • Nonverbal communication ****MOST important • Observations, Language • Honesty: NEVER lie to children, you don't want to violate their trust • Advocate for that patient • Get them to trust you • Treat their family as if it is the only family you have • To develop rapport demonstrate your interest in and concern for the child and family by actively listening to the info shared • Communicate as a nonjudgmental and non-controlling professional • Introduce yourself • Your name, title or position, and your role in caring for the child • To demonstrate respect ask all family members present what name they would prefer you ro use when talking to them • Explain the purpose of the interview and why the nursing history is different from the info collected from other health professionals "the nurses will use this info to help plan the best care suited to your child" • Provide privacy and remove as many distractions as possible • Direct the focus of the interview with open ended questions. Use close ended questions or directing statements to clarify info. • Ask one question at a time so that the parent or child understands what piece of info you want and so that you know which question is being answered • Use nonverbal behavior such as nodding, smiling, and eye contact at appropriate times to communicate that you are hearing the info shared • Be honest with the child when answering questions or when giving info about what will happen • Choose the language style that is best understood by the parent and the child. Use an interpreter to improve communication when you are not fluent in the language

10) When is it appropriate for someone less than 18 years to give consent for care?

Child Participation in Healthcare Decisions (p. 22) A child may be considered to have the capacity for competence, an ability to be involved in healthcare decisions requiring a certain degree of intellect, an ability to communicate, and an ability to remember. A child displays competence when he or she is able to use abstract reasoning, which generally occurs sometime during adolescence when abstract thinking skills have developed. The minor must demonstrate that he or she fully understands the treatment and the consequences (Smith, 2007). Children under 18 or 21 years of age (the age of majority), depending on state law, are considered minors, and consent from the parent or guardian is required to perform a medical or surgical procedure or treatment. Learn about the facility's policies and procedures on the rights of minors in the informed consent process. In some states minors can often legally give informed consent in the following circumstances: - When they are minor parents of the child patient - When they are emancipated minors (self-supporting adolescents under 18 years of age, not subject to parental control; e.g., married, serving in military, or granted emancipation by the court) - When they are between 16 and 18 years of age seeking birth control, prenatal care, mental health counseling, sexually transmitted disease treatment, or substance abuse treatment (Anderson, Schaechter, & Brosco, 2005) Mature minors (14- and 15-year-old adolescents who are able to understand treatment risks) are permitted in some states to give consent for treatment or to refuse treatment. In some cases the minor must convince a judge that he or she is mature enough to make an independent judgment about consent for treatment.

2) Cause of death among infants. Why are they the highest risk age group?

Children have different healthcare problems than adults, and the problems may depend on age and development. The leading causes of infant mortality (death occurring during the first year of life) vary according to the age and race ofthe infant. For example,the highest rates of infant mortality per 1,000 live births in the United States during 2004 occurred in Blacks (13.8), followed in decreas-ing order by American Indian and Alaskan Natives (8.9), Whites (5.7), Hispanics (5.7), and Asian or Pacific Islanders (3.6) (Heron, 2007; pp. 78-80). The leading causes of death in neonates (between birth and 28 days of age) are low birth weight, congenital malformations and chromosomal abnormalities, maternal complications of pregnancy, complications of placenta, and respiratory distress syndrome. Nearly two thirds ofalldeaths to infants during the first year of life occur in the first 28 days of life. Sudden infant death syndrome accounts for nearly 21.8% of deaths to infants in the postneonatal period (between 1 and 12 months of age). Congenital malformations, unintentional injuries, diseases ofthe circulatory system, and homicide are other leading causes of death. Figure 1-7 contrasts the leading causes ofdeath in the postneonatal period in 1993 and 2004.What could account for homicide as the fifth leading cause ofdeath in infants? See Chapter 18 for an answer. Despite the historical success in reducing the infant mortality rate, the United States does not compare well to the infant mortality rates found in other industrialized or develped countries with a population of at least 1 million. In 2005, the United States ranked 37th and Canada ranked 25th behind such nations as Singapore, Iceland, Sweden, Japan, France,and Germany (World Health Organization, 2007). Research and perinatal care programs for high-risk pregnant women and infants are directed at reducing the infant mortality rate. INSERT FIGURE 1.6 and 1.7 (p. 13).

49) Introduction of milk to the diet

Clinical Tip Cow milk (including evaporated milk) can lead to bleeding and anemia (see Chapter 28), can interfere with absorption of some nutrients, and has a high solute load (concentration) which immature kidneys can have difficulty excreting. Its use should be avoided during the first year of life. (p. 276).

28) How can you as a nurse make hospitalized infants feel secure?

Comforting the Distressed Infant Teen parents and those with little prior experience with babies need help to develop a repertoire of interventions to try when a baby is crying. Ask about how they comfort the baby. Suggest the following interventions if the parent does not state them: - Offer a breast or bottle feeding, especially if the last feeding was more than 2 hours ago. - If feeding was recent, hold the baby in a sitting position and rub or pat the back to help expel gastric gas. - Change the diaper if wet or dirty. - Place a hand on the abdomen and feel for movement. If movement or passing gas is present, hold the baby against the chest, walk slowly, and pat the back. - Swaddle the baby securely in a blanket and hold horizontally while rocking. - Hold the baby on your lap, secure the hands in yours, and talk softly. - Stroke the infant's skin; rock and sing to the baby. - Never shake or throw the baby, no matter how long the crying. Call your healthcare provider for suggestions if you feel like nothing works and you are very frustrated. (p. 378)

18) When is grief dysfunctional?

Complicated grief is an unhealthy grief that is not resolved, in which the griefis intensified to the level that the individual is so overwhelmed that it interferes with ability to function. Three characteristics of complicated grief include intrusion, denial, and dysfunctional adaptability. - Intrusion involves idealized memories ofthe deceased person for extended periods. - Denial is seen with the maintenance of a relationship with the deceased for an extended period, such as keeping the child's room exactly as it was before death for a very long time. - Dysfunctional adaptation involves an inability to make decisions, or to resume work, and having excessive fatigue and somatic symptoms. The individual may also have extreme expressions of guilt or delay in progress through griefstages (Dunne, 2004). Individuals with signs of complicated griefshould be referred for counseling. (p. 717-718)

24) What defense mechanisms do children use when confronting stressors such as hospitalization?

Development and behaviors then unfold as the ego balances the tension between the two opposing forces ofid and superego. The ego diverts impulses ofthe id and protects itselffrom excess anxiety created by the superego by use of defense mechanisms. These unconscious techniques distort reality to guide actions and prevent painful challenges to the personality. Defense mechanisms used by children can include regression to earlier stages of development, and repression of painful experiences such as child abuse. (p. 130). TABLE 5-2 Common Defense Mechanisms Used by Children (p. 131) Defense Mechanism: Regression Definition: Return to earlier behavior Example: A previously toilet trained child becomes incontinent when separated from parents during a hospitalization. Defense Mechanism: Repression Definition: Involuntary forgetting of uncomfortable situations Example: An abused child cannot consciously recall episodes of abuse. Defense Mechanism: Rationalization Definition: An attempt to make unacceptable feelings acceptable Example: A child explains hitting another because "he took my toy." Defense Mechanism: Fantasy Definition: A creation of the mind to help deal with unacceptable fear Example: A hospitalized child who is weak pretends to be Superman.

30) What is appropriate discipline for each age group? What is inappropriate discipline for each age group?

Discipline and Limit Setting Discipline is a method for teaching the rules that govern behavior or conduct. Punishment is the action taken to enforce the rules when the child misbehaves. Parenting styles play an important role in the type ofdiscipline used with children. When clear limits are set and consistently maintained, as with authoritative parenting, punishment may be needed less often. Limit setting and firm control of those limits are important for children to learn to what extent they can safely and independently operate within the environment. Firm limits also help children to feel secure because they are reassured by consistency and the sense of protection perceived by the limits. Punishment helps children learn that there are consequences for misbehavior and that other individuals may be affected by the behavior. This helps children develop a sense of responsibility for their behavior. Parents use various strategies for discipline and punishment. Factors that affect what type of discipline is used are related to sex ofthe child, education level and age ofthe parents, family income, and race. In addition, the type ofmisbehavior and the location in which it occurs affect the type of discipline used (Socolar, Savage, & Evans, 2007). Regalado, Sareen, Inkelas, et al., (2004) identified common strategies used with children between 19 and 35 months of age: - Reasoning—explaining why a behavior or action is inappropriate or describing how limit setting is important. By reasoning, parents can help the child to understand why certain behaviors are wrong. Similarly, parents can share personal stories and fables to help children understand social and moral values or to better understand acceptable behavior. - Behavior modification—giving positive rewards or reinforcement for good behavior or consistently ignoring inappropriate behavior to minimize the behavior. This encourages children to behave in specified ways. - Experiencing consequences—allowing the child to learn important lessons associated with misbehavior, such as taking away a toy, using a time-out, withdrawing privileges, or providing no dessert ifthe child misses dinner or does not eat nutritious foods. - Corporal punishment—spanking or inflicting pain with a paddle, whip, or other object. This is one of the most widely used techniques for punishing children (Slade & Wissow, 2004). It is not recommended as it teaches children that violence is acceptable. If parents are out of control or in a rage, the child may be seriously injured. - Scolding or yelling—using harsh language directed at the child. Clinical Tip Time-out is a punishment method of placing the child in a location away from toys and attention as a consequence of misbehavior. The general rule for the length of time-out is 1 minute per age. Nurses have an important educational role in helping parents to identify an appropriate discipline method and to take an authoritative role with their children. Encourage and educate parents about the need to be in charge, to set the rules, and to stand by them so that children learn how to behave. (p. 43) Partnering with Families: Positive Discipline [for Toddlers and Preschoolers] (p. 402). To provide structure that enhances the possibility of desirable behaviors: - Limit rules to those that are essential. It is easier to enforce a few important rules than many that are nonessential. - Provide an environment where the child is mainly free to explore safely in order to avoid constant cautions. For example, have adequate play space for toddlers with limited fragile glassware in the usual daily environment. It is easier for the toddler to learn not to touch a few objects when adequate objects are provided for play. - Spend time interacting with the child several times each day. Praise positive behaviors frequently. Preschoolers often like to have charts with stars to record picking up toys, helping a parent, and performing other positive behaviors. Once preschoolers obtain a certain number of stars they earn a reward such as stickers or an outing with the parent. When the child shows undesirable behaviors: - Use distraction as the first approach and praise the child for selecting the new activity suggested by the parent. - Tell the child one time that the behavior is unsatisfactory and what will happen if the behavior persists. - Separate the child from a setting in which behavior is undesirable. Place the child in "time-out," a separate place that is safe. Toddlers can be placed in a playpen or crib, while preschoolers are told to sit on a chair. One minute of time-out per year of age is a good length of time. Once time-out is over, provide a positive activity and move the child directly toward the activity. When undesirable behaviors include other people, such as biting or hitting: - Tell the child clearly that it is not appropriate to hurt another person. - Separate the child immediately from the situation and use time-out. - If there are repeated episodes, be sure the child is getting adequate sleep and food, has opportunities for active play that releases energy, and has positive attention from many people in the environment. Be sensitive to stresses such as a recent trauma or a new sibling. - Encourage children to "use words" instead of hitting or biting. Until able to do so on their own, parents can model this behavior. "You feel like saying 'I am really upset that you took my toy away.' Let's use words instead of hitting so your sister knows that." School-Age Child Parents often need guidance to help them in setting limits for their school-age children. The child is becoming more independent, but unacceptable behaviors must still be managed by successful discipline techniques. Some guidelines that can help families include: - Talking calmly—Express the behavior observed, why it is not acceptable, and its effects on others. If appropriate the child can help decide what should be done to change the behavior (i.e., removing a privilege or other solution). - Using natural or logical consequences—For example, if the child breaks an item he or she owns in anger, the item should not be replaced. - Withholding privileges—Be consistent in privileges withheld and be certain that they are privileges (such as attending a movie with friends) rather than essential (a meal). - Using time-out to separate the child from others — This technique can be helpful when the child needs time to redirect a temper or other such behavior. It is not helpful as a frequent technique for all undesirable behavior, especially when sent to the bedroom that may have a television, cell phone, and other technological devices. - Applying distraction—The child who is frustrated may learn to handle the stress ifthe parent suggests a brisk walk or other physical outlet. - Avoiding spanking and yelling—These techniques are not generally helpful and fail to teach the child positive substitutions for undesirable behavior. (p. 429). Adolescents Most adolescents require discipline or guidance from parents at certain times. However, constant battles over daily events are counterproductive. Instead, it is best if parents respect the teenager's need for a level ofautonomy and enact a few rules on important issues, so that parents have to enforce them only rarely. Guidelines that can help parents include the following: - Gradually increase the teen's independence. If there is success with growing responsibility, the teen may be ready for more. If the teen misuses independence (perhaps by staying out too late, having a party at home without parents present, lying about location on an evening out), there should be clear limits and loss of privileges. - Be willing to talk with and hear the teen's story. On the other hand, do not be talked out of consequences for the teen's bad decisions. - Recognize that driving a car, staying out late, and other activities are not a given. They are privileges for responsibility displayed. - Comment on a teen's behavior rather than making belittling comments about him or her as a person. - Realize that the teen is establishing independence and that the relationship will change. Be consistentand loving as your adolescent tries out and learns about limits and the self. - Provide discipline by talking about the unacceptable behavior, rather than belittling the teen. (p. 450-451).

3) Providing care for dying children—what are the major goals?

END-OF-LIFE CONSIDERATIONS AND DECISION MAKING (p. 719) When the family is faced with end-of-life decision making and care because of a child's chronic condition or multiple acute episodes, the familyrelies on the nurse and other members of the healthcare team to provide honest information about various treatment options and potential outcomes. Depending on cognitive abilities, developmental stage, physical and mental status, and prior experiences in health care, the child should also participate in the decision-making process (Beale, Baile, &Aaron, 2005). The family may need to consider issues such as palliative care, hospice care, Do Not Resuscitate requests, and continuation of education. BOX 22-2 Nursing Roles in Improving Pediatric Palliative and End-of-Life Care (p. 720) The nurse and other members of the healthcare team work collaboratively to improve end-of-life care for children and their families through the following actions: 1 . Plan nursing care for children with life-threatening medical conditions and their families that matches the child's physical, cognitive, emotional, and spiritual level of development. 2. Implement family-centered care, ensuring that families are part of the care team and that their beliefs, feelings, and desires are respected. 3. Plan and provide compassionate care for children with life-threatening conditions and for their families beginning at the time of diagnosis through death and bereavement. 4. Seek information, education, and mentoring to gain proficiency and skill in working effectively with children who are dying and their families. 5. Work within the healthcare facility to promote needed changes that will improve the palliative, end-of-life, and bereavement care for children and their families. 6. Participate in research designed to increase healthcare professionals' understanding of clinical, cultural, organizational, and other practices or perspectives that can improve palliative, end-of-life, and bereavement care for children and their families. BOX 22-3 Core Elements of Palliative Care (p. 720) ■ Children with chronic or life-threatening illnesses, conditions, or injury are served. ■ Services are family centered, with the goals and preferences of the patient and family integrated with the support and guidance in decision making by the healthcare team. ■ Palliative care ideally begins at the time of diagnosis of a life-threatening or debilitating condition and continues until the child is cured or dies, and into the bereavement period. ■ Regular assessments are performed to help patients and families understand changes in condition and how those changes impact care goals and future treatment. ■ An interdisciplinary care team provides palliative care, and includes physicians, nurses, psychologists, pharmacists, chaplains, social workers, child life therapists, and other needed health professionals. ■ A major focus of care is on the relief of pain and suffering associated with other condition symptoms. ■ Effective communication strategies are used to help the child and family develop care goals and make healthcare decisions. ■ The healthcare team needs to be skilled in the care of the dying child and bereaved family. ■ Palliative care should be provided in all healthcare delivery settings and be accessible to all children in need of services. ■ Evaluation of the care processes and outcomes should be performed to promote high-quality care. TABLE 22-5 Nursing Care for the Child at End of Life (p. 728) Airway clearance - Place the conscious child in Fowler's position to promote airway clearance. - Place the unconscious child in lateral position to promote airway clearance. - Suction oral and throat secretions as needed. Scopolamine drops or a patch may be used to help dry up secretions. - Maintain oxygen as indicated for hypoxia. Skin and hygiene care - Bathe diaphoretic child frequently and change bed linens as needed. - Provide frequent oral care for dry mouth. - Apply lotions and creams for dry or itching skin (encourage parents to participate). - Apply moisture barrier skin preparations for incontinence. Elimination - Encourage dietary fiber intake as tolerated to avoid constipation. - Administer stool softeners or laxatives as indicated, especially when opioids are prescribed because constipation is a side effect. - Provide a call light within reach for assistance onto bedpan or commode. - Ensure that bedpan, urinal, or commode chair are within easy access. - Place absorbent pads under the incontinent child; change linen as often as indicated. - Perform catheterization if necessary. - Maintain clean and odor-free room. Nutrition - Administer antiemetics for vomiting so that the child may still be able to eat. - Encourage liquid foods as tolerated. - Provide the child with preferred foods, including the child's favorite foods from home. - Encourage family participation at meal time. Fatigue/sleep - Prioritize activities of daily living to reduce unnecessary activities. - Plan rest periods and social interactions to maximize the child's energy for visitors. - Reduce sleep disruptions. Physical mobility - Reposition the bedridden child at frequent intervals (every 2 hours or as indicated) as the child may be too fatigued to move. - Support the child's position with pillows, blanket rolls, or towels as needed. - Use pressure-relieving surfaces as indicated. - If the child is able to sit in a chair, assist the child out of bed periodically. Sensory - Reduce the frequency of monitoring the child's blood pressure and heart rate. - Ask the alert child about his or her preference for room lighting. - Reduce the intrusion of hospital noise and unnecessary personnel in the patient's room. - Decrease excessive stimulation to reduce restlessness, agitation, or confusion.

23) Make sure you know Erickson's stages of development

Erikson's theory establishes psychosocial stages during eight periods of humanlife. For each stage, Erikson identifies acrisis, that is, a particular challenge that exists for healthy personality development to occur (Erikson, 1963, 1968). The word crisis in this contextrefers to normal maturational social needs rather than to a single critical event. Each developmental crisis has two possible outcomes: 1. When needs are met, the consequence is healthy and the individual moves on to future stages with particular strengths. 2. When needs are not met, an unhealthy outcome occurs that will influence future social relationships. Stages Trust Versus Mistrust (Birth to 1 Year). The task ofthe first year oflife is to establish trust in the people providing care. Trust is fostered by provision offood, clean clothing, touch, and comfort. If basic needs are not met, the infant will eventually learn to mistrust others. Developing a sense of trust leads the child, as he or she matures into an adult, to have confidence that the world is a good place and to approach life with a general sense of optimism. However, a balance between trust and mistrust is important. If a child is too trusting, child abuse or other poor outcomes may occur. The sense oftrust must predominate, but individuals need mistrust at times for healthy development. Autonomy Versus Shame and Doubt (1 to 3 Years). The toddler's sense of autonomy or independence is shown by controlling body excretions, saying no when asked to do something, and directing motor activity. Children who are consistently criticized for expressions of autonomy or for lack of control—for example, during toilet training—will develop a sense of shame about themselves and doubt in their abilities. Developing a healthy sense ofautonomy results in a person who can function with independence and self-direction. It is also important for the toddler to recognize feelings and needs ofothers, as excessive autonomy could lead to disregard and inability to work with others. Initiative Versus Guilt (3 to 6 Years). The young child is exposed to more people outside of the family and therefore initiates new activities and considers new ideas. This interest in exploring the world creates a child who is involved and busy. The child learns to assume new responsibilities and becomes aware of guiding principles for actions. Constant criticism for the child's activities, on the other hand, leads to feelings of guilt and a lack of purpose. Preschoolers' sense of initiative leads to the ability to start projects but they may not always see the value in completing them, a potentially frustrating situation for parents. Industry Versus Inferiority (6 to 1 2 Years). The middle years ofchildhood are characterized by development of new interests and by a focus on intellectual or cognitive pursuits. The child takes pride in accomplishments in sports, school, home, and community. Developing a sense of industry provides the child with purpose and confidence in his or her ability to be successful. If the child cannot accomplish what is expected, however, the result will be a sense ofinferiority. The child's sense of industry must be balanced by a realistic perspective gained over time, that there is always more to learn and that one cannot be the "best" at every activity. Identity Versus Role Confusion (1 2 to 1 8 Years). In adolescence, as the body matures and thought processes become more complex, a new sense ofidentity or selfis established. The adolescent tries out roles and examines what fits best for the self and family/society expectations. The self, family, peer group, and community are all examined and redefined. Identifying with values and roles provides guidance as the adolescent enters adulthood. The adolescent who is unable to establish a meaningful definition ofselfwill experience confusion in one or more roles of life. On the other hand, a certain amount of role confusion is desirable as it is the impetus for self-examination and provides the basis for establishment of identity. Nursing Application Erikson's theory is directly applicable to the nursing care of children. Health promotion and health maintenance visits in the community provide opportunities for helping caregivers to meet children's needs. The nurse asks for examples ofthe child's social interactions and self-concept. The child's behaviors can be explained within the perspective of developmental stages. Parents benefit from learning what the child's developmental tasks are at each stage and from discussing ideas about how to encourage healthy psychosocial delopment. Such discussions also may highlight parental concerns and provide a forum for reassurance about normal developmental characteristics, such as a preschooler who does not follow through on each activity, or an adolescent who tries different hairstyles each month. The child's usual support from family, peers, and others is interrupted by hospitalization. The challenge of hospitalization also adds a situational crisis to the normal developmental crisis a child is experiencing. Although the nurse may meet many of the hospitalized child's needs, continued parental involvement is necessary both during and after hospitalization to ensure progression through expected developmental stages. Asking parents about the child's developmental progression provides clues to activities and provides information about what the child needs in the hospital. (p. 133-134)

50) Imaginary friends

Imaginary friends are fictional characters created for improvisational role-playing. They often have elaborate personalities and behaviors. They may seem real to their creators, though they are ultimately unreal, as shown by studies.[1] The first studies focusing on imaginary friends are believed to have been conducted during the 1890s.[2] Imaginary friends are made often in childhood, sometimes in adolescence, and rarely in adulthood. They often function as tutelaries when played with by a child. They reveal, according to several theories of psychology, a child's anxieties, fears, goals and perceptions of the world through that child's conversations. They are, according to some children, physically indistinguishable from real people, while others say they see their imaginary friends only in their heads. There's even a third category of imaginary friend recognition: when the child doesn't see the imaginary friend at all, but can only feel his/her presence. Imaginary friends are more often seen as abnormal in adults, whereas quite common in children. Purposes It has been theorized that children with imaginary companions may develop language skills and retain knowledge faster than children without them, which may be because these children get more linguistic practice while carrying out "conversations" with their imaginary friends than their peers get.[3] Kutner (n.d.) holds that: Imaginary companions are an integral part of many children's lives. They provide comfort in times of stress, companionship when they're lonely, someone to boss around when they feel powerless, and someone to blame for the broken lamp in the living room. Most important, an imaginary companion is a tool young children use to help them make sense of the adult world.[4] Taylor, Carlson & Gerow (c2001: p. 190) hold that: ...despite some results suggesting that children with imaginary companions might be superior in intelligence, it is not true that all intelligent children create them.[5] A long-time popular misconception is that most children dismiss or forget the imaginary friend once they begin school and acquire real friends. According to one study, by the age of seven, sixty-five percent of children report that they have had an imaginary companion at some point in their lives.[6] Some psychologists[who?] have suggested that children simply retain but stop speaking about imaginary friends, due to adult expectations and peer pressure. Still, some children report creating or maintaining imaginary friends as pre-teens or teenagers. Few adults report having imaginary friends. Dr. Benjamin Spock believed that imaginary friends past age four indicated that something was "lacking" in the child or his environment. Some child development professionals still believe that the presence of imaginary friends past early childhood signals a serious psychiatric disorder.[7][8] Others disagree, saying that imaginary friends are common among school-age children and are part of normal social-cognitive development.[9] http://en.wikipedia.org/wiki/Imaginary_friend

33) Which developmental stages contain periods of rapid physical growth?

Infancy: birth weight is doubled by 5-6mo age, 3x by 1 year

TABLE 16-2 Stressors of Hospitalization for Children at Various Developmental Stages

Infant Developmental Stages and Stressors: - Separation anxiety - Stranger anxiety - Painful, invasive procedures - Immobilization - Sleep deprivation, sensory overload Responses: - Sleep-awake cycle disrupted - Feeding routines disrupted - Displays excessive irritability Nursing Management: - Encourage parental presence. - Adhere to the infant's home routine as much as possible. - Utilize topical anesthetics or preprocedural sedation as prescribed. - Promote a quiet environment and reduce excess stimuli. Toddler Developmental Stages and Stressors: - Separation anxiety - Loss of self-control - Immobilization - Painful, invasive procedures - Bodily injury or mutilation - Fear of the dark Responses: - Cries if parents leave the bedside -Is frightened if forced to lie supine - Wonders why parents don't come to the rescue - Associates pain with punishment Nursing Management: - Encourage parental presence. - Allow parents to hold the child in their lap for examinations and procedures when possible. - Allow choices when possible. - Utilize topical anesthetics or preprocedural sedation as prescribed. - Explain all procedures using simple developmentally appropriate language. - Provide a night-light. Preschooler Developmental Stages and Stressors: - Separation anxiety and fear of abandonment - Loss of self-control - Bodily injury or mutilation - Painful, invasive procedures - Fear of the dark and monsters Responses: - Displays difficulty separating reality from fantasy - Fears ghosts and monsters - Fears body parts will leak out when skin is not intact - Fears that tubes are permanent - Demonstrates withdrawal, projection, aggression, regression Nursing Management: - Encourage parental presence. - Allow choices when possible. - Utilize topical anesthetics or preprocedural sedation as prescribed. - Explain all procedures. - Provide a night-light or flashlight. School-Aged Child Developmental Stages and Stressors: - Loss of control - Loss of privacy and control over body functions - Bodily injury - Separation from family and friends - Painful, invasive procedures - Fear of death Responses: - Displays increased sensitivity to the environment - Demonstrates detailed recall of events to self and other patients Nursing Management: - Encourage parental participation. - Allow the child choices when possible. - Explain all procedures and offer reassurance. - Utilize topical anesthetics or preprocedural sedation as prescribed. - Encourage peer interaction via the Internet, phone calls, and other methods of communication. Adolescent Developmental Stages and Stressors: - Loss of control Fear of altered body image, disfigurement, disability, and death - Separation from peer group - Loss of privacy and identity Responses: Displays denial, regression, withdrawal, intellectualization, projection, displacement Nursing Management: - Include the adolescent in the plan of care. - Encourage discussion of fears and anxieties. - Explain all procedures. - Ask the adolescent his or her desire for parental involvement. - Encourage peer interaction. (p. 490)

11) Knowing how to order your physical assessment based on the age of the child

Infants Praise parental presence and responses/ Promote physical comfort and relaxation Distract infant with colorful toys/ Auscultate when quiet or sleeping 1. Do procedures that provoke crying at end of exam Auscultate 1st 2. Parents can help you during the examination 3. Keep them warm, if they get cold they drop their body tempt b/c they can't handle homeostasis. Newborns cant shiver Nursing Diagnosis: 1▫ risk for aspiration, developmental delays, malnourishment, family knowledge deficit, ineffective family coping Toddlers: on Parent's lap, Play, need Security object, Instruments, Control and choice 1. Application as a nurse apply SAFETY: toddlers are high risk b/c they are pushing for independence This exam is very difficult. 2. There are certain things a nurse can do to facilitate cooperation 3. Allow them to seat on the parent's lap. This is the person they trust the most. 4. They play to express how they feel and what they are thinking. Allow them to touch and play with instruments 5. like a blanket, allow them to maintain contact 6. Children lack control in environments they are not familiar with. Where do you want your injection, what color bandage do you want? Preschoolers: Sequence, Games & activities, let them touch instruments, Distraction 1. Notorious for temper tantrums 2. Keep ears for last 3. Distraction: you can tell them to look at your pen light when you are doing something Older children and adolescents Ensure modesty and privacy/Offer choices/Explain body parts and functions Decide on parental presence or absence/Consider need for nonparent chaperones Reassure adolescents of normalcy 1. They are extremely SHY 2. Give them as much privacy as possible 3. Always have a parent present while examining a child 4. Ask about sexual relations, safety, and household—ask parent to leave the room. Later interview parents alone w/o kids present 5. B/C puberty is stressful, tell them it's NORMAL Planning Assessment Newborn—plan assessments based on: - Presence or absence of reflexes - Attachment behaviors - States of alertness - High-risk status (premature, poverished) Infant—plan assessments based on: - Appropriate serial weight and height measurements - Presence of tooth eruptions - Ability to walk and talk • Toddler—plan assessments based on: - Increasing verbal ability and skill at walking - Ability to control elimination - Tooth eruption - Sense of cause and effect with understanding of object permanence (by 9months) Preschooler—plan assessments based on: - Presence of preoperational thought - Use of dramatic play - Increasing command of language and a corresponding increase in curiosity about the environment School-age—plan assessments based on: - Growing interest in peer group and extracurricular activities - Growth spurt occurring earlier in girls than boys - Ability to think about solutions and determine the best among several alternatives - Understanding of the concept of conservation Adolescence—plan assessments based on: - Child undergoes identity formation - Sexual maturity nearing completion - Formal operational thought processes possible - plan assessments based on: - Peer relationships important and different-gender relationships become serious - Knowledge that privacy, confidentiality, and honesty are means to gain trust in adolescent patients

37) Ethical perspectives of child health nursing

Legal and Ethical Issues in Pediatric Care Numerous legal and ethical dilemmas develop when caring for children. Examples include informed consent, the child's participation in healthcare decisions, the child's rights versus the parents' rights, confidentiality, withholding or withdrawing medical treatment, genetic testing, and organ transplantation issues. (p. 21). Ethical Concepts and Issues (p. 24-25). Ethics is the philosophic study of morality, and the analysis of moral problems and moral judgments. It is an inquiry into the justification of particular actions. Ethics has become a prominent discipline associated with the delivery of medical care and research due to many significant developments. The objective of ethical decision making is to promote the health and well-being and good dying ofthe patient, honoring the integrity of all participants in the decision-making process (Taylor, 2005). Major advances in medical technology, such as the ability to save the lives of severely impaired newborns, the ability to extend the lives of chronically ill and seriously injured children, genetic testing, and gene therapy, have resulted in challenges in making the best decision for the child and family. For example, dying used to be a natural process, but dying in the pediatric intensive care unit may be managed for severely ill children by withholding life support or choosing not to resuscitate (Gavrin, 2007). Healthcare professionals have a moral obligation to deliver care with compassion and respect for the inherent worth, dignity, and uniqueness of every individual (Taylor, 2005). Ethical guidelines are used to "define an issue, evaluate options, identify the best alternative, apply principles, and make a responsible and informed decision" (Weiss, 2006, p. 96). Ethical issues may arise from a moral dilemma, a conflict involving individual beliefs, social values, and ethical principles, with each possibly supporting different courses of action (e.g., performing or refraining from performing a therapy). Problems may develop because physicians, nurses, and parents have differing opinions about treatments for an infant or child with a serious or terminal condition. Approaches to ethical decision making should take into account social-political philosophy, philosophy of law, moral philosophy, and moral theology as well as the concrete realities that medicine and biology contribute. An ethical theory or framework for decision making is often used in healthcare institutions to guide individuals to determine an appropriate action. Theories focus on different outcomes, such as the consequences of the decision, the greatest happiness or avoidance ofsuffering, or utilitarianism (a merger of the consequences and greatest happiness for the greatest number). The four general ethical principles used in the development of a decision-making framework include: - Beneficence: an obligation to act or to make a decision to benefit the patient, promoting the child's well-being in addition to working with parents and other family members - Respect for patient's autonomy: right for self-determination or decision making, to protect the informed choices (consent and refusal) of patients capable of decision making - Nonmaleficence: to prevent harm, to prohibit inflicting harm - Justice: to treat all patients with fairness and respect, and to use scarce resources wisely to avoid waste in ineffective treatments All individuals must be treated with respect for culture, ethnicity, race, and religion (Gavrin, 2007). Professional integrity with regard to telling the truth and keeping promises is also important. Open communication and shared decision making between physicians, nurses, adolescents, and parents may help prevent many ethical dilemmas (Gavrin, 2007). Emotions play a significant role in the development ofethical dilemmas. Challenges arise when healthcare professionals have different values from patients, based on their culture and life experiences, or when value differences exist between members of the healthcare team caring for the child. Regardless, all health professionals want the care provided for a child to have a benefit. Parents also want to protect the child, and they have their vision of what is good for the child. Work with parents to form a therapeutic alliance and attempt to prevent conflicts when the family's values and the health professionals' values do not match. Make sure that families understand the uncertainty regarding their child's condition without giving a perception that a decision has been made, and find out what is important to them in the care of their child. They may be able to describe what they wish to avoid having happen to their child, and this may be a starting point for discussion and negotiation about their child's care. Healthcare institutions have ethics committees to resolve conflicts about treatment decisions. They function in one of the following ways: - Performing individual case consultations to resolve a conflict between health professionals and the child and family - Resolving a dispute between health professionals about the care to provide to a child - Serving as a forum to discuss policies about ethics within the healthcare facility - Educating health professionals and the community about ethical concepts

29) What is swaddling?

Many infants are assisted in soothing themselves when they are swaddled or tightly wrapped (see the Skills Manual). Start by placing the baby on a blanket on a flat surface. Securely take the bottom edge of the blanket and pull it tightly over the feet and up to the chest. Wrap the sides of the blanket around the baby so the arms are secured. Many babies will immediately quiet once swaddled, and will either sleep or become quietly alert. However, be aware that some babies find this position uncomfortable. If they fight the blanket and try to free themselves, this may not be an approach that works for quieting those particular babies. (p. 378)

7) Causes of death of children of all age groups

Neonates (b/w birth - 28 days): low birth weight, congenital malformations & chromosomal abnormalities, maternal complications of pregnancy/placenta/respiratory distress syndrome Postneonatal period (b/w 1-12mths of age):(Sudden infant death syndrome SIDS) congenital malformations, unintentional injuries, diseases of the circulatory system, homicide. Child mortality(1-19yrs of age): 1-4yrs: MOST COMMONunintentional injuries (MVA, drowning, fire burns, homicide, suffocation) o Congenital anomalies o Cancer o Homicide o Disease of the heart o HIV/AIDS 5-9yrs: MOST COMMONunintentional injuries (MVA, fire burns, drowning, homicide/firearm, suffocation) o Malignant neoplasms o Congenital Anomalies o Homicide o Disease of the heart o HIV/AIDS 10-14yrs: SAME injuries (MVA, suicide, suffocation, homicide, firearm, drowning, fire, burn) o Malignant Neoplasms o Suicide o Homicide o Congenital Anomalies 15-19yrs: Same injuries (MVA, homicide, firearm, suicide, firearm, suicide, suffocation, poisoning) o Homicide o Suicide o Malignant Neoplasms o Disease of the heart o Congenital Anomalies Research and perinetal care programs for high risk pregnant women and infants are directed at reducing the infant mortality rate. Injury prevention became a major focus of many national organizations and the federal maternal and child health programs in the United States beginning in 1980s Because Unintentional injury is the leading cause of death in all pediatric age groups except neoneates(0-28days)

36) Make sure you know injury prevention interventions for each age group.

New parents are sometimes unaware ofsources of potential injury for the newborn. Some aspects ofinjury prevention are pertinent to the newborn's immediate care. Other topics promote discussion and provide opportunities for anticipatory guidance. In the immediate newborn period, the nurse should assess the parents' knowledge ofinjury prevention strategies and promote healthy and safe habits. Injury prevention strategies include proper and consistent use ofan infant car seat, and strategies to prevent falls, burns, choking, drowning, and suffocation. Newborn safety awareness begins in the birth setting. Parents should be cautioned to lay the baby in a bassinet or crib rather than on the mother's bed. Teach the parents to use the bulb syringe in the event that the baby spits up a large amount of fluid, and to position the baby for sleep on the back rather than side-lying or prone. Parents should also be oriented to procedures in place to prevent newborn abduction and to their critical role in assuring newborn safety and security. Following hospital discharge, the nurse promotes safety by encouraging parents to think about the hazards that the child could encounter and how to eliminate them. In the newborn period, the parent or caregiver is uniquely responsible for ensuring that the newborn is not placed in a dangerous situation. The newborn cannot turn on a hot water faucet or run with a sharp object, but it is possible for the parent to inadvertently place the newborn in danger. The newborn is capable of twisting and rolling offany surface higher than the floor, falling out ofan infant carrier seat, or drowning while left unattended for a moment in a bathtub filled with only an inch or two of water. Parents might find it helpful to be aware that most pediatric injuries occur when the parents are under stress; for example, when a parent is hungry and tired (the hour before dinner), during pregnancy, during illness or death in the family, when there is tension between parents, and during changes in the environment, such as a change in the child's caregiver or the family's living environment (Shelov, 2004). At these times, the parent should be particularly vigilant and supervise children closely. Car safety seat - Choose an infant-only seat or a convertible seat suitable for an infant. - Infant rides rear-facing until at least 1 year of age and more than 20 lb. - The safest place for all children to ride is in the back seat. Never place a rear-facing car safety seat in the front seat with an active passenger air bag. - Use a car safety seat every time the infant is in the car. - Read and follow the manufacturer's instructions for the car safety seat and the vehicle owner's manual for installation information. - Dress the infant in clothes that allow the straps to go between the legs. Never place blankets under the baby or under the belts. Buckle the baby into the seat, and place blankets over the baby. - To make sure the car safety seat is installed correctly and the baby is positioned correctly, go to a car seat inspection station. A certified child passenger safety technician will assist you. Find a list of certified CPS technicians and safety seat inspection stations by state or zip code on the National Highway Traffic Safety Administration website or 1-866-SEAT-CHECK. (AAP, 2007c) Shaken baby syndrome: Never shake a baby. Recognize that sometimes you will not be able to console your baby. Shaking a baby, even for only a few seconds, can cause serious brain damage and death. One of four shaken babies dies. There are materials available for parents and professionals at http://www.dontshake.com Crib: Use a safety approved crib. Slats should be no more than 2 3/8 inches apart. Mattress should be firm and fit snugly into the crib. Keep crib rails raised. Co-sleeping: The American Academy of Pediatrics discourages co-sleeping due to the risk of SIDS (with overheating as a possible factor) and the danger of suffocation. Sleep with the baby nearby, but not in the parental bed. If the parent must sleep with the baby, ensure that the infant is supine, separated from any soft surfaces such as pillows; ensure that no blankets will cover the infant's head; beware of spaces between the mattress and the wall, headboard, or footboard; and do not sleep with the baby when under the influence of drugs or alcohol. The infant should never sleep in the same bed with siblings due to the high risk of suffocation (AAP, 2005a). Baby toys: Use age-appropriate baby toys. Check toys for sharp edges or loose parts. Keep older siblings' toys out of baby's reach. Do not use toys with loops or string cords. Drowning: Never leave a baby alone in the bathtub. If you must turn your back on the baby or leave the room, take the baby out of the tub. Suffocation: Keep plastic bags and wrappings away from baby (take the plastic bag off the crib mattress). Shake baby powder into your hand first, then apply it so the baby does not inhale it. Do not allow a baby or sibling to play with a latex balloon. Keep small objects (such as safety pins, coins, small toys) out of baby's reach. Do not attach pacifiers, medals, or other objects to the crib or to the baby's body with a string or cord. Do not put the crib near blinds, curtains, or anything with a hanging cord. Do not let the baby wear clothing with strings near the neck (such as a sweatshirt hood that ties with a cord) or a headband that could slip down and wrap around the baby's neck. Use a tight-fitting crib sheet that does not come loose when the corner is pulled. Burns: Set the hot water heater thermostat to 1 20°F (49°C). Do not smoke or drink hot liquids while holding the baby. Do not microwave bottles of formula or breast milk due to uneven heating. Do not expose baby to direct sunlight. Falls: Keep a hand on the baby while dressing or changing diaper on a surface other than the floor. Never leave the baby unsupervised on any high surface such as a bed, changing table, or sofa. Always keep one hand on the baby. Pet safety: Keep some distance between the newborn and the pet until the pet's initial reaction to the new baby is assessed. Never leave the baby unsupervised with the family dog or cat, or any animal capable of harming the newborn. Sibling supervision: Never leave the baby alone with a young sibling. When young children hold the baby, seat the child on a large soft surface, such as the couch, and supervise closely. Watch siblings for aggressive behavior toward the newborn, such as hitting or biting. Siblings may take on a caregiving role and imitate adults; watch for "feeding" of nonfood items or choking hazards. Fire safety: Install working smoke detectors on every floor of the house and in every sleeping area. Have a fire escape plan from the house and practice it. Poisoning: Post the universal phone number for the poison control center near your telephone: 1 -888-222-1222. Gun safety: Keep the household guns unloaded and locked up. Keep the ammunition locked up separately from the gun. Consider not keeping a gun in the household due to safety hazards for family members. In case of emergency - Know when and how to call the pediatric care provider. - Know when it is appropriate to go to the emergency department. - Take a first-aid class and learn CPR for children and adults. (p. 363-364). During the first year of life, injury becomes an increasingly common cause of mortality. Strategies must be included in each health supervision visit to lower the risk ofinjury. Nurses should never assume that parents understand how to insert an infant car seat correctly or what types of toys and foods can lead to choking. Know the most common hazards at each age and teach parents methods of avoiding them. Review at each visit the recommendation to place infants to sleep on their backs to lower the risk ofsudden infant death syndrome. Begin the conversation by asking parents what safety hazards they are aware of in the child's environment. Use this information as the starting point for discussion. Give positive feedback for their awareness of hazards and measures they have taken to prevent them. Consider using a home assessment survey that assists parents in identifying hazards that may be present in their homes. When infants visit friends, relatives, or neighbors, they may be exposed to other hazardous situations. Grandparents may not have a home that is "babyproofed" and the infant could have access to electrical cords, machinery, medicines, or other hazards. Help the parents to evaluate the childcare home or center. Are babies adequately supervised? Do older children have toys that could be harmful to the babies present? Do infants have access to cooking areas, hot water, or heaters? Can they crawl into bathrooms where there is access to toilets or other water sources? Focus on car safety, as this is a frequent cause ofinjury for infants. Provide brochures and other types of information about recommendations. Become a certified car seat examiner if possible and ask to view the infant's car seat. If this is not possible, locate examination centers in your community (frequently fire or police stations) and refer every family for a car seat examination. Provide resources for car seats if the family is not able to afford one. Discuss other possible safety hazards such as extensions on the parent bicycle and use of infant strollers in areas where cars are present. Injury prevention assessment and teaching strategies are examples of health maintenance activities. They are designed to minimize the exposure to hazardous environmental materials and practices. Consult materials from the SafeKids Campaign (national and worldwide) for specific helpful tips. Be certain that all care providers, including babysitters and family members, have emergency numbers readily available. TABLE 11-6 Injury Prevention in Infancy Falls: Mobility increases in first year of life, progressing from squirming movements to crawling, rolling, and standing. Do not leave infant unsecured in infant seat, even in newborn period. Do not place on high surfaces such as tables, hood of car, or beds unless holding child. Once mobile by crawling, keep doors to stairways closed or use gates. Standing walkers have led to many injuries and are not recommended. Burns: Infant is dependent on caretakers for environmental control. The second half of the first year is marked by crawling and increased mobility. Objects are explored by touching and placing in mouth. Check temperature of bath water and food/liquids for drinking. Do not hold the infant while drinking hot beverages. Cover electrical outlets. Supervise infant so that play with electrical cords cannot occur. Motor vehicle crashes: Infant is dependent on caretakers for placement in car. On impact with another motor vehicle, an infant held on a lap acts as a torpedo. Use only approved restraint systems (according to federal Motor Vehicle Safety Standards). The seat must be used for every trip, even if very short. The seat must be properly buckled to the car's lap belt system. Drowning: Infant cannot swim and is unable to lift head. Never leave infant alone in a bath of even 2.5 cm (1 in.) of water. Supervise when in water even when a life preserver is worn. Flotation devices such as arm inflatables are not certified life preservers. Poisoning: Infant is dependent on caretakers to keep harmful substances out of reach. Keep medicines out of reach. Teach proper dosage and administration of medicines to parents. Cleaning products and other harmful substances should not be stored where the infant can reach them. Remove plants from play areas. Have poison control center number by telephone. Choking: The second half of infancy is marked by exploratory reaching and mouthing objects. Infant explores objects by placing them in the mouth. Avoid foods that commonly cause choking. Keep small toys and all items with small parts away from infants, especially toys labeled "not intended for use by those under 3 years." Suffocation: Young infant has minimal head control and may be unable to move if vomiting or having difficulty breathing. Position infant on back for sleep. Do not place pillows, stuffed toys, or other objects near head. Do not use plastic in crib. Avoid latex balloons. Strangulation Infant is able to get head into railings or crib slats but cannot remove it. Curtain or blinds cords can strangulate the crawling or reaching infant. Be sure older cribs have slats spaced 6 cm (2 3/8 in.) or less apart. The mattress must fit tightly against the crib rails. TABLE 11 -7 Injury Prevention Topics by Age 1 month: Follow infant car safety guidelines. Put the baby to sleep on back. Avoid loose bedding and toys in crib; do not have bracelets, necklaces, string toys, or cords near the infant. Avoid tobacco use in the environment. Provide adult supervision of the baby at all times by trusted individuals. Test bath water temperature and never leave the baby alone in bath. Never place the baby on a high object such as a counter, table, or bed; always keep one hand on the baby during such activities as diaper changes to prevent falling. Wash hands correctly and often. Avoid contact with persons with communicable diseases. Have smoke alarms and avoid fire hazards. Learn infant CPR and airway obstruction removal. Never shake the baby. Have plans for emergency care. 2 months: Include topics above. Use only recommended playpens or cribs and keep sides up. Avoid moldy environments. Keep baby toys clean. Avoid direct sunlight for the baby. Keep sharp and small objects out of the baby's environment. Keep the hot water heater lower than 120°F. Review emergency plan with all care providers. 4 months: Include topics above. Get all poisonous substances out of the baby's view and reach; install locks to keep them inaccessible. Do not use latex balloons or plastic bags near the baby. Never use infant walkers. Be sure tap water is no hotter than 120°F. 6 months: Include topics above. If an infant-only car seat was used, switch to rear-facing convertible safety seat (intended for babies up to 40 lb) when the baby is 20-30 lb or 26 inches. Empty containers of water immediately after use; be sure pools or other bodies of water are locked and not accessible to the baby. Use sunscreen, hat, and long sleeves when the baby is in the sun. Keep heavy and sharp objects out of reach; check that all poisons are locked away, including in homes visited; keep pet food and cosmetics out of reach. Do not drink hot liquids or eat soup while holding the baby. Have the poison control number by phones and programmed into cell phones. Be alert for dangers of hot curling irons and other appliances. Have electrical cords out of reach and not hanging down. Have the home and environment checked for lead hazards. Lower infant crib mattress if still in upper position. Install gates and guards on stairs and windows. Never use an infant walker. 9 months: Include topics above. Crawl on the floor and look for hazards at the baby's eye level. Pad sharp corners on tables and other furniture. Watch for tables, chairs, and other devices the baby may use for climbing to unsafe places. Do not leave heavy or hot objects on tables with tablecloths as the infant may pull the cloth. Use barriers around woodstoves and other heating devices. Do not allow siblings or other children to have the responsibility to watch the infant in the yard, house, or bath. 12 months: Include topics above. May change to forward-facing car safety seat if baby is at least 20 lb and one year; install correctly and have installation checked; place in the backseat and never in the frontseat with a passenger air bag. Start showing the child how to wash hands frequently. Provide own personal items such as clothing and blankets to childcare providers; wash often. Change batteries in home smoke alarms and check the system. Turn handles to back of the stove; use back rather than front burners; watch for hot liquids. Check the care provider setting for safety hazards. Remember that responsible adults should always supervise your infant, not other children. Peruse the home once again for hazards now that the child is more active, climbing, and walking. Do not allow guns in the area where the young child plays or lives; guns must be unloaded, locked securely away, with ammunition locked in a separate location.(p. 383-386). Injuries remain a common healthcare problem for children during the toddler and preschooler years. The child's mobility,BOX 1 2-6 Research: The Children's Health Study The Children's Health Study is a large longitudinal study of children across the United States, designed to identify long-term effects of exposure to a va riety of environmental factors. The study began in 1992 with a focus on air pollution effects on California children. Reduced lung development in children exposed to high amounts of particulate contaminants was observed, although children improved if they moved to other communities. A wide range of natural and human-caused environmental conditions, social factors, genetics, and other issues will be considered in the coming years (Children's Health Study, 2005, 2006). Nurses should understand the environmental hazards in the areas where they work and tailor teaching in healthcare visits to minimize them. Are there days with unsafe air in your community? What is the rate of radon, lead, or other hazardous substances in homes physical skills, and lack of understanding about the presence of hazards put the child at particular risk. In addition, children are sometimes left to play alone for short periods, and toddlers and preschoolers can quickly get into dangerous situations. Every healthcare visit needs to include an assessment of risks and teaching to prevent injuries. Ask parents to name the most common hazards for the age of their child, and add other hazards to their awareness. Reinforce car safety, as the types of seats change when the child reaches 20 lb and then 40 lb (Biagioli, 2005). Be certain that parents provide children from 20 to 40 lb the following: - A convertible forward-facing seat that has been placed in the backseat - Harness straps at or above the shoulders Toddlers and preschoolers over 40 lb should be placed in a belt-positioning booster seat: - In the backseat - That uses both lap and shoulder belts - With the lap belt low and tight across the lap/upper thigh area and shoulder belt snug across the chest and shoulder Recommend that parents have their car seat checked by a childcare inspector. Give them the addresses ofthe closest inspection stations, which you can locate through the National Highway Traffic Safety Administration. Check your particular state laws regulating car safety seats for children. Other common and serious safety hazards are falls and drowning. In addition to providing general guidelines about safety, these most common injuries should be directly addressed. Children often fall down stairs, from counters where they have been placed or crawled, and from grocery carts. Drowning episodes occur when toddlers and preschoolers are not watched every moment while in the bathtub, near a pool or spa, or at a lake or ocean, or when they fall from boats without personal flotation devices on. Although all young children should begin to take swimming lessons, this does not guarantee their safety around water. (See Evidence-Based Practice: Drowning.) Children play with balls, and may follow them as they roll or are thrown into the street. Fenced yards and constant supervision are needed. Geographic areas should be considered. Urban dwelling may increase the chance ofexposure to air pollutants. Rural life may be accompanied by exposure to insecticides, or by activities with machinery that lead to accidents (Cherry, Huggins, & Gilmore, 2007). Ask about a typical day for the child to identify potential hazards in the environment. Nursing interventions concentrate on relaying to parents the severity of the risk of falls, environmental exposures, drowning, and other hazards for children. Teach parents to be aware ofthe dangers and to avoid them, both at home and in other settings. Refer them to classes on first aid and cardiopulmonary resuscitation. Clinical Tip: A number of young children die each year when they are left confined in parked vehicles. Occasionally children gain access to a vehicle and accidentally lock themselves inside. However, in most cases a parent leaves a child unattended, either forgetting the child is in the car, or remembering but underestimating the danger of heat effects (Guard & Gallagher, 2005). Nurses can be effective in instructing families to keep cars locked so young children cannot gain access, and to never leave a child in a parked car, either in or out of a car seat, even for a few moments. The child spends increasing time away from the parent. Childcare situations should provide the same supervision the child receives at home. Help parents to ask questions and feel confident in safety at other settings. For example, while parents may be cautious about gun safety at home, few ofthem inquire ifa home the child is visiting has guns and how they are stored. Preschoolers are generally interested in health and their bodies. This is a time when teaching can become directed at both the parents and the child. Preschoolers are receptive to practicing street crossing and tricycle/bicycle riding skills. It may be helpful to have a place in the clinic or office where they can be taught basic skills such as hand wash

31) Know how to assess parent-child interactions: which ones are appropriate and which ones are inappropriate?

Newborn: Responds to stroking, rocking, and skin to skin contact. They also should be swaddled to promote comfort and parents should be taught the infant massage Infant Respond to same stimuli as a newborn as well as singing, and toys that make noise - speak in a high pitched or soft tone - establish eye contact whenever possible - avoiding leaning over the infants face when talking forcefully - communicate through play such as peek-a-boo - use swaddling, rubbing, patting, and cuddling to quiet crying Toddler and Preschool - children at this age are egocentric - communicate with the child on their eye level - Use simple language and short sentences - Be honest with responses - Encourage the child to engage in imaginative play - Encourage the toddler to engage in parallel play - Encourage the preschooler to engage in dramatic play - Allow the child the opportunity to ask questions - Allow the child choices whenever possible School aged - Speak directly to the child - be honest in all responses - Encourage the child to express thoughts and feelings through drawing writing, or painting. Adolescent - Use a straightforward approach - Avoid comments or expressions that convey disapproval or surprise - Listen to what they are saying without interrupting - Offer them choices whenever possible to help with independence - Do not assume they have the same cognitive understanding as adults

1) Preparing infants, children and adolescents for hospitalization: providing teaching, etc. for each age group. How can we make hospitalization less stressful? When is it appropriate to let them play with equipment? Use a transitional object? Show them anatomical models vs. dolls, etc.?

Planned Hospitalization When hospitalization is planned, children and their parents have time to prepare for the experience. (See Partnering with Families: Parental Preparation ofChildren for Hospitalization.) Through preadmission preparation, children and their families are introduced to the acute care setting. Assess the family's knowledge and expectations and provide information about likely experiences. A variety of approaches can be used to provide information and allay fears: - Offer tours ofthe hospital unit or surgical area. This activity assists the child and family to become familiar with the environment they will encounter. During tours, preschoolers and school-age children can see and handle items with which they will come in contact. If a tour is not possible, photographs or a videotape can be used to demonstrate the medical setting and procedures. - Let the child play with the surgical team's attire. The child may overcome fear ofsurgical attire by trying it on and engaging in play while wearing it. - Teach the child about medical equipment—what it does and how it is used—perhaps through demonstration on a doll. - Use puppets and skits to help explain procedures to children. - Offer health fairs, as many hospitals do, to explain health procedures to children. During a tour, while hospitalized, or at home, the child can be exposed to books or films that explain in age-appropriate terms what to expect during various procedures. - Reinforce teaching through coloring books or other educational materials. (p. 496). Use developmentally appropriate techniques to assess the child's knowledge and feelings about an upcoming procedure. With a school-age child, for example, the nurse might explain the procedure using drawings, stories, body outline dolls, anatomically correct dolls, and conversation. When explaining procedures, use words that the child understands to describe the procedure and its purpose. Older children require explanations geared to their cognitive level and previous experiences. They will want to know what is happening, why,and what they can do to cope during the procedure. For adolescents, provide written information, videos, and other available media. Schedule time for questions and discussions. Adolescents can make many choices about their own health care. When possible, ask them to make those choices with questions such as "Do you want your hand numbed for the IV start?" Maintain a positive attitude when preparing adolescents and reassure them that it is normal to be frightened of unknown experiences. (p. 502). TABLE 16-7 Assisting Children Through Procedures (p. 504) DEVELOPMENTAL STAGE: Infant BEFORE PROCEDURE: None for infant. Explain to parents the procedure, the reason for it, and their role. Allow parents the option of being present for procedures. DURING PROCEDURE: Nursing staff should immobilize the infant securely and gently. Parents should not be asked to hold the child down. Perform the procedure quickly. Use touch, voice, pacifier, and bottle as distractions. Ask the parent to hold, rock, and sing to the infant after the procedure. DEVELOPMENTAL STAGE: Toddler BEFORE PROCEDURE: Give the explanation just before the procedure, since a toddler's concept of time is limited. Explain that the child did nothing wrong; the procedure is simply necessary. DURING PROCEDURE: Perform in treatment room. Nursing staff should immobilize the child securely. Give short explanations and directions in a positive manner. Avoid giving choices when none are available. For example, "We are going to do this now" is better than "Is it okay to do this now?" Allow the child to cry or scream. Comfort the child after the procedure. Give the child a choice of a favorite drink or special sticker. DEVELOPMENTAL STAGE: Preschool Child BEFORE PROCEDURE: Give simple explanations of the procedure. Basic drawings may be useful. While providing supervision, allow the child to touch and play with equipment to be used if possible. Since any entry into the body is viewed as a threat, state that the child's body will remain the same, and use adhesive bandages to reassure the child that the body is intact and parts will not "fall out." DURING PROCEDURE: Perform in treatment room. Nursing staff should immobilize the child securely. Give short explanations and directions in a positive manner. Encourage control by having the child count to 10 or spell name. Allow the child to cry. Give positive feedback for cooperation and getting through the procedure. Encourage the child to draw afterward to explore the experience. DEVELOPMENTAL STAGE: School-age Child BEFORE PROCEDURE: Clear, thorough explanations are helpful. Use drawings, pictures, books, and contact with equipment. Teach stress reduction techniques such as deep breathing and visualization. Offer a choice of reward after the procedure is completed. DURING PROCEDURE: Be ready to immobilize the child if needed. Allow the child to remain in position by self if he or she is able to be still. Explain throughout the procedure what is happening. Facilitate use of stress control techniques. Praise cooperative efforts. DEVELOPMENTAL STAGE: Adolescent BEFORE PROCEDURE: Give clear explanations orally and in writing. Teach stress reduction techniques. Explore fear of certain procedures, such as staple removal or venipuncture. DURING PROCEDURE: Assist the adolescent in self-control. Assist with use of stress control techniques. Explain expected outcomes and tell when results of the test will be completed.

5) The importance of family centered care: what is it? How can it be used?

Promoting Family Centered Care Partnering with families in the provision of health care is essential to promote the best outcome when caring for children. Families have important knowledge to share about their child, their child's health condition, and how their child responds to various actions and events. They also need access to information that will make it possible for them to fully participate in planning and decision making. Clinical Tip Some healthcare facilities are developing patient and family resource centers to provide information and support. In most cases, the resource center is a consumer-oriented health library with staffing, but peer support services may also be coordinated through the center (Institute for Family Centered Care, 2007). Families can be supported to access useful print or online information that helps them to become informed participants in decision making about their child's care. Resources can often be provided in the preferred language and appropriate reading level. Models and anatomically correct dolls may be available that provide hands-on learning for both parents and children. In addition, the family resource center may serve as a place for family members to read, rest, and reflect (Institute for Family Centered Care, 2007). While parents do expect healthcare providers to be technically competent, they also value the healthcare provider's communication skills, ability to interact with children effectively, and sense of care and compassion (MacKean, Thurston, & Scott, 2005). Research shows that parents want to collaborate with healthcare professionals in making decisions about their child's care. The child's opinions should also be integrated in the strategies for care. Strategies that the nurse and parents develop in partnership for care of the child must mesh with the family's cultural and ethnic illness-related behaviors, experiences, and beliefs (Sullivan-Bolyai, Sadler, Knafl, et al., 2004). See Developing Cultural Competence: Family-Centered Care. In almost all cases, the child leaves the healthcare setting and the family assumes responsibility for provision of needed care in the home. The family caregivers must not feel alienated from a healthcare system they need for continuing assistance. (See Partnering with Families: Guidelines for Effective Partnership.) At the same time, however, parents need to consider their own limitations. Before planning how to add more caregiving responsibilities to their routines, parents should assess their strengths in managing their ongoing family and caregiving responsibilities. Beyond the provision of nursing care itself, children and parents can participate in the development of policies and guidelines for family-centered care in all types of healthcare settings. Their experiences while receiving care in the healthcare setting may reveal valuable insights. Considering parents' perspectives can be critical for staff and hospital administrators to provide quality patient care and achieve successful patient satisfaction. Parents who exhibit leadership qualities can be empowered to serve on advisory boards or councils, representing the family and community perspective. Parental roles may include: - Assisting in the design and evaluation of programs and systems - Assessing a healthcare setting for its family-centered policies and care practices, as well as its cultural appropriateness - Participating in the renovation or construction of healthcare facilities - Recommending changes that will ultimately improve the quality of care - Educating health professionals about working effectively with families as partners in the child's care Parents can also serve a valuable role in family-to-family support networks by serving as mentors to families entering the healthcare system for a new chronic condition. Parents may also help raise awareness about specific healthcare issues, serve as advocates for public policy issues, and assist with fund-raising activities. Guidelines for working with families as advisors and tools for assessing the family-centered policies in various healthcare settings are available from the Institute of Family-Centered Care. Clinical Tip When providing care to children, recall that the family is central to all healthcare interventions. Parents and children are partners in care. Families need to sense that the nurse cares about them and respects them as an integral part of the child's life. It is important to consider how a healthcare setting's written policies, procedures, and literature for families refer to families and what attitudes these materials convey. Words like policies, allowed, and not permitted imply that hospital personnel have authority over families in matters concerning their children. Words like guidelines, working together, and welcome communicate an openness and appreciation for families in the care of their children. (p. 34-36).

4) Differentiating care provided by a nurse practitioner vs. RN. What is appropriate for the NP to do? What is appropriate for the RN to do?

RN: nursing diagnoses (ex. alteration in comfort, pain) ARNP: medical diagnoses and treatment (ex. otitis media, Rx. antibiotics) Pediatric nursing focuses on protecting children from illness and injury, assisting them to attain optimal levels of health, regardless of health problems, and rehabilitation. This focus fits with the American Nurses Association (2004, p. 7) definition of the scope of nursing practice: "the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation ofsuffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations." The predominant nursing roles in caring for children and their families include direct care, education, advocacy, and case management. Direct Care Provider The primary role ofpediatric nurses is to provide direct nursing care to children and their families in hospitals and various community settings such as health centers, schools, and the home. The nursing process provides the framework for delivery of direct pediatric nursing care. The nurse assesses the child and identifies the nursing diagnoses that describe the responses of the child and family to the health promotion and health maintenance plan and to any illness or injury experienced. The nurse then implements and evaluates nursing care. Pediatric nursing care is designed to meet the child's physical and emotional needs. It is offered in a manner sensitive to and compatible with the child's and family's cultural beliefs. It is tailored to the child's developmental stage, giving the child additional responsibility for self-care with increasing age, and ultimately assisting the adolescent with transition to adult health care.This care is also provided in partnership with the family,embracing the principles offamily-centered care. Nurses playan important role in minimizing the psychological and physical distress experienced by children and their families. Providing support to children and their families is one important aspect of direct nursing care. This often involves listening to the concerns of children and parents,being present during stressful or emotional experiences, and implementing strategies to help children and family members cope. Nurses can help families bysuggesting ways to support their children in the hospital, in out-of-hospital settings, and in the home. Nurses can also support families with informational resources, support groups, referrals for healthcare services, and in some cases respite care. As a member of the child's healthcare team, the nurse is responsible for collaborating with other health professionals and ensuring that the nursing care is coordinated with that of other professionals. In many cases, experienced pediatric nurses or those with graduate level education assume a leadership role in coordinating the collaboration of an interdisciplinary team of health professionals. In some cases the nurse recognizes that the child and family need care that is outside ofthe nurse's scope of practice or specific skill level, so a referral must be initiated. In other cases, an interdisciplinary team will meet to jointly develop a care plan for a child with a chronic condition. Nurses continually expand the range ofdirect care they provide. After developing experience and a comfort level in the care ofchildren typically seen in one setting,the pediatric nurse is often ready to move to a different setting or specialty area or to accept a leadership position. In some cases the experienced nurse may be given supervisory responsibility for nursing care provided by other members ofthe nursing care team. Other nursing professionals you will find in pediatric settings include: - Advanced practice nurses (e.g., clinical nurse specialists and pediatric nurse practitioners), who have a graduate level nursing education and are prepared to practice in a specialty area or at a higher level of responsibility. - Clinical nurse specialists, who serve as educators and role models, members ofthe clinical research team, consultants to the healthcare team, and change agents within the healthcare system. They often have a nursing practice with a specialty focus such as respiratory, cardiovascular, or oncology. - Pediatric nurse practitioners, who, in collaboration with physicians and other healthcare team members, perform assessment, diagnosis, and management of health conditions in office settings, schools, and hospitals. Nurse practitioners are now assuming a larger role within hospital settings in the management ofchildren with acute illnesses or the exacerbation ofchronic health problems. Experienced pediatric nurses and advanced practice nurses who enjoy teaching may choose to become nurse educators. Experienced pediatric nurses can serve as mentors to new nurses, serving as a role model, supporting their professional development, and promoting their clinical skills development. Advanced practice nurses may join a school of nursing faculty to teach pediatrics or support the nursing education programs provided within clinical health settings. Educator Education ofchildren and their families or caregivers improves treatment results. In pediatricn ursing, patient education ise specially challenging, because nurses must be prepared to work with children at various levels of understanding. More than providing simple facts, the goal of the education is to help the child and family make informed choices about health and healthy behavior. Depending on the needs ofthe child and family at any particular time, education can focus on health promotion, health maintenance, self-care, and management ofa health condition. Most hospitals encourage a parent to stay with the child and to provide much of the direct and supportive care. Nurses teach parents to watch for important signs and responses to therapies, to increase the child's comfort, and even to provide advanced care. Taking an active role prepares and empowers the parent to assume total responsibility for care after the child leaves the hospital. Education can be direct teaching to the child and family members about the medications needed to treat a specific health condition and other therapies that will be needed once the child is discharged. Patient education can also involve helping children adapt to the hospital setting and preparing them for procedures. Effective education requires planning and preparation by the nurse. An understanding ofthe child's developmental capabilities is important. The nurse needs to become fully informed about the condition and information to be taught, and then think about strategies and resources that will help the child and family learn to manage the health condition. An assessment of the child's and family's knowledge about the condition or health practices, their past experiences, and their attitudes and beliefs provides the starting point for education. Next, the nurse should establish rapport with the child and family to make it easier to provide education. Family members and the child will be more comfortable asking questions. Then, the nurse needs to determine strategies to reinforce the information taught. In some cases when the child or family has ambivalence or is nonadherent in recommended care, motivational interviewing (a brief counseling method to help families increase their motivation or readiness to change) is a potential strategy (Gance-Cleveland, 2007). Outcomes of education can be evaluated during future visits, particularly for children receiving ongoing health promotion and health maintenance care and for those with a chronic condition that requires home management. During educational sessions, the nurse can also provide support for the emotional needs of the child and family. Children and families should be encouraged to express their feelings and thoughts about the impact of the health condition, which may result in the exploration of potential strategies that could improve the psychological aspects ofliving with the condition. Advanced practice nurses and experienced pediatric nurses often have responsibility for providing education and counseling that is directed toward helping the child or family solve a problem or deal with an acute crisis. Advocate Advocacy—acting to safeguard and advance the interests of another—is directed at enabling the child and family to adjust to the changes in the child's health in their own way. To be an effective advocate, the nurse must be aware ofthe child's and the family's needs,the family's resources,and the healthcare services available in the hospital and the community. The nurse can then assist the family and the child to make informed choices about these services and to act in the child's best interests. For example,a nurse works to make sure the family member and child (to his or her level of understanding) have adequate information about treatment options to make an informed decision. The nurse must also protect the child and family by taking appropriate actions related to any potential or actual incidents of incompetent, unethical, or illegal practices by any member of the healthcare team. As advocates, nurses also ensure that the policies and resources of healthcare agencies meet the psychosocial needs of children and their families. This sometimes requires nurses to become active participants on committees that develop policies or guidelines for nursing and medical care or modernizing the healthcare facility design. In each case, the knowledge that the pediatric nurse contributes about the developmental and psychosocial needs of children is important in ensuring that the needs ofchildren are appropriately addressed in their healthcare facility. According to the United Nations Convention on the Rights of the Child, every child has a right to enjoy the highest attainable standard of health and access to healthcare facilities, and governments should take appropriate measures to help children achieve these rights (Kasper, 2004). Pediatric nurses should become active at the community level, advocating for legislative and regulatory changes that improve the health ofchildren. Nurses also advocate for improved health through community education about important health measures, such as universal health insurance for children or immunizations. Some pediatric nurses choose to obtain advanced education to specialize in ethics or public policy, or to become an attorney. In these roles, the nurse then takes a leadership position to promote and implement ethical practices and policy changes that benefit children and their families. Case Manager What happens when a child has significant health problems? When a child has a significant health problem or disabling condition, physicians, nurses, social workers, physical and occupational therapists,and other specialists come together to create an interdisciplinary plan to address the child's medical, nursing, developmental, educational, and psychosocial needs. Because nurses spend large amounts oftime providing nursing care for the child and family, they often know more than other healthcare professionals about the family's wishes and resources. As a member ofthe interdisciplinary care plan team, one important role for the nurse as the family's advocate is to ensure that the care plan considers the family's wishes and contains appropriate services. An experienced pediatric nurse or advanced practice nurse often becomes the child's case manager, coordinating the implementation of the interdisciplinary care plan. Sometimes the parent or a social worker becomes the case manager. Case managementis a process ofcoordinating the delivery of healthcare services in a manner that focuses on both quality and cost outcomes. This is often a collaborative practice with other healthcare providers that helps optimize the patient's self-care abilities, promotes continuity of care (an interdisciplinary process facilitating a patient's transition between and among settings based on changing needs and available resources), and encourages effective utilization ofresources. The case manager has expertise in interpreting and negotiating health care and pharmaceutical benefits (Norouzieh, 2005). The family is included in the planning and decision-making process, adhering to the family-centered care philosophy we describe in Chapter 2. This approach involves regular interaction between the case manager and the child and family to develop an individualized care plan in collaboration with the healthcare team. The case manager is also responsible for communication with all health team members for care coordination and advocating for the child and family. The nurse case manager has control over the use of healthcare resources that are considered appropriate for the patient's condition and links the child and family to these services. The goal is to help the child and family have the best healthcare outcome and decrease fragmentation ofcare, while controlling the cost of healthcare services.Controlling costs is essential for children with chronic conditions because those with health insurance often have a cap on total dollars allowable for the child. Case management may be used for care ofthe patient when hospitalized as well as for long-term care ofchronic conditions. Discharge planning is a form ofcase management. Good discharge planning promotes a smooth, rapid, and safe transition into the community and improves the results of treatment begun in the hospital. To be a discharge planner,the nurse needs to know about community medical resources, home care agencies qualified to care for children, healthcare services offered in the school setting, educational interventions, and services reimbursed by the child's health plan or other financial resources. (p. 3-7). BOX 1-1 Expected Competencies of the Pediatric Nurse (p. 3) The Society of Pediatric Nurses has described the competencies for pediatric prelicensure and early professional development for the generalist pediatric nurse. - An understanding of the unique anatomical, physiological, and developmental differences among neonates, infants, children, and adolescents, as well as the needs unique to the growth and development of children who have chronic conditions and their families; - The ability to care for children and promote their health in the context of their families; - The ability to communicate effectively with children, families, and other healthcare providers, demonstrating sensitivity to cultural issues, especially those related to how the family and healthcare providers tend to children's healthcare needs; - The provision of safety assurance and injury prevention to children and their families; - The ability to provide for the exceptional needs of children with episodic injuries or illnesses; - The ability to assess the unique growth and development needs of children who have chronic conditions and of their families; - An understanding of the economic, social, and political influences outside the family that have an impact on children's health and development and family functioning; and - An understanding of the ethical, moral, and legal dilemmas involving children, families, and healthcare professionals.

6) Differentiating high risk versus low risk children. If I give you children of various ages and ethnic groups, which one would you consider to be the highest risk for negative health outcomes?

Research indicates that racial and ethnic minorities in the United States receive lower quality health care than the White population, even when age and clinical factors such as severity of the condition are similiar (Gance-Cleveland, 2006). African Americans, Hispanics, and Asians are less likely to have a regular healthcare provider than Caucacians (Shi & Stevens, 2005). Individuals from minority groups are also much less likely to have health insurance than Caucasians (Gance-Cleveland, 2006). The morbidity and mortality for these populations is disproportionate as compared to Caucasians. One of the two major goals ofHealthy People 2010is to eliminate health disparities among segments of the population (U.S. Department of Health and Human Services, 2007). Health disparity populations are those groups with significant differences in disease incidence, prevalence, morbidity, mortality, or survival rates as compared to the general populations. Disparities in relation to gender, race, ethnic group, education, income, disability, geographic location, and sexual orientation are common. For example, while 16.7% ofall children were liv ing in poverty in 2002, the numbers were much higher in African American (40%) and Hispanic (30%) children (Gance-Cleveland, 2006). African Americans, Hispanics, Native Americans, Alaskan and Hawaiian Natives, Asians, and Pacific Islanders have high rates ofmorbidity and mortality associated with conditions such as birth defects, asthma, infant mortality, mental illness, cancer, diabetes, and cardiovascular disease (National Institutes of Health, 2002). These conditions have direct relevance to pediatric nurses. Infant mortality is directly related, while some other conditions such as heart disease and diabetes have their roots in youth due to a high rate of overweight among several minority youth groups. Clinical Tip Obesity and conditions related to it such as diabetes are prevalent among persons who are poor. Children who have Medicaid coverage are 6 times more likely to be obese than those children who are covered by a private insurance policy. Latino children ages 2 to 18 years are most at risk for being overweight, followed by Black children (National Institute for Health Care Management, 2007). Well-child visits with a focus on weight monitoring, evaluating community resources for availability of access to nutritious foods and physical activity, and education related to diet and activity are essential with these children to prevent complications such as diabetes and heart disease. Why do disparities exist? Let's examine some of the many reasons. Access and Barriers One reason disparities exist among cultural groups relates to access and barriers to care. Access ensures that children ofall races, ethnic groups, and income levels can obtain preventive care and treatment for illness or injury. Barriers delay or prevent healthcare for the child and may be related to the following factors (Gance-Cleveland, 2006; Kairys, 2006; Lassetter & Baldwin, 2004; Yearwood, 2007): - Lack ofhealth insurance among low-income families - Communication difficulties such as those experienced when families do not speak English - Lack of knowledge about cultural approaches to health care on the part ofcare providers - Transportation problems See Evidence-Based Practice: Investigating Culture and Healthcare Barriers. Lack of health coverage is a major barrier for children in many groups. Those in immigrant families are at particular risk, and the number of immigrants is increasing in both the United States and Canada. Approximately 18% of all children living in the United States have at least one parent who was born in another country (Johnson, Kominski, Smith, et al., 2005). Data from the U.S. Census Bureau (2004b) showed that in 2003 the percentage of children who were uninsured varied greatly depending on race. While 11.1% of non-Hispanic White children were uninsured, 19.5% ofBlack children and 32.7% of Hispanic children were without insurance. Additionally, 34.5% of the foreign-born population was uninsured compared to 13% of the native population. Recall the discussion in Chapter 1 that encouraged all families with children to seek a "home" that they can turn to for care and questions. Identification of that pediatric healthcare home makes it more likely that preventive care is received, that early diagnosis of healthcare problems can occur, and that prompt treatment or referral takes place. Families need access to healthcare services in their own communities and they must have means of transportation to the services. Working parents need services available at times that do not require them to miss work. Obtaining even basic or emergency services for children in rural areas may be difficult due to the lack ofproviders. Service hours must meet the needs of the population served. Language translators should be readily available. A welcoming atmosphere, pleasant surroundings, and reasonable wait time will all enhance use ofhealth care. Pediatric nurses are instrumental in surveying families and planning approaches that welcome them to healthcare settings. See Developing Cultural Competence: Use of Cultural Brokers in the Healthcare Setting. Lack of trust of healthcare providers can also be a barrier to care. Historically, groups such as Blacks and Native Americans were the recipients of inferior care and even unethical research studies. Members of these groups may continue to distrust healthcare providers. If inadequate care was received at some time or if care providers appear rude or noncaring, some families may prefer to treat children at home and seek care only in emergency situations. Trust can be enhanced when children and families of all races, ethnic groups, religious groups, and other populations are treated fairly and with respect. Collaborate with families to learn their healthcare goals and provide relationships with a stable group of health professionals when possible. (p. 69-70).

16) Decreasing stressors for hospitalized children

Strategies the nurse and family can implement to reduce the hospitalized child's stress include 1. Encouraging recreation and physical activity (if appropriate for child and not restricted due to condition) 2. Ensuring that the child obtains sufficient rest 3. Ensuring parental or other significant person's presence 4. Maintaining the child's usual routines RECREATION Newborn and Infant - Provide developmentally appropriate mobiles, rattles, and music boxes. - Hold and talk soothingly to the newborn or infant. - For the older infant, play "peek-a-boo" and similar games. Toddler and Preschooler - Provide developmentally appropriate toys. - Encourage coloring, singing, use of music, and games. - Take the toddler or preschooler to the playroom if possible. School-Age Child - Encourage participation in peer group activities if possible. - Provide favorite collection items or encourage a new hobby (collect-ing stamps or coins, building models, or playing board games for the child who has activity restriction). - Provide music, video games, or computer access. - Encourage the child to visit the playroom or recreation room and interact with other hospitalized school-age children. REST - Promote a calm, quiet environment to allow for rest periods. - Establish rituals to help the child prepare for sleep at night- for example, bathing, brushing teeth, reading a story, playing a quiet board game, or watching a favorite TV show (if necessary, record show to play at appropriate time). RELATIONSHIPS - Arrange for visits from family members, including siblings. - Encourage visits from friends. - If friends are unable to visit, encourage writing, calling, email, or live-computer chat to maintain communication. - Encourage school-age children and adolescents to attend peer support groups. ROUTINES - Ask families to inform nursing staff of the child's normal routines. - Provide transition objects from home, such as a blanket or favorite toy. - Talk with the older school-age child and adolescent to determine his or her wishes regarding routines (e.g., if the child prefers to perform hygiene in the mornings or evenings). - Inform the child or adolescent about anticipated changes to provide an opportunity to adapt. (p. 491)

15) What are the different stages of separation anxiety?

TABLE 16-3 Stages of Separation Anxiety PROTEST Screaming, crying; Clinging to parents; May resist attempts by other adults to comfort them DESPAIR Sadness: Quiet, appear to have "settled in;" withdrawal or compliant behavior; Crying when parents return DENIAL (DETATCHMENT) Lack of protest when parents leave; Appearance of being happy and content with everyone; Show interest in surroundings; Close relationships not established (p. 492).

17) What are the different types of loss? Different types of grief?

TABLE 22-4 Stages of Grieving and Nursing Management (p. 719) Stage: Denial Behavioral Responses: - Disbelief, it seems like a bad dream, unable to process the information about the death. - Questioning the reality of the death—did it really happen or was it a dream? - Unable to believe that the child will not come home again. - May make statements such as "This can't be happening" or "This can't be true." Nursing Management: - Be verbally supportive but refrain from reinforcing denial. Recognize that denial is one way parents face accepting the feelings of grief. - Don't argue—allow the child or parents to come to terms in their own time. Stage: Anger Behavioral Responses: - Child or family may direct anger at physicians or nurses at their inability to save the family member. - Anger may be associated with the bad things that have happened to a loved one or inability to control what happened. Nursing Management: - Recognize that anger is a normal response to feelings of loss and powerlessness. Painful feelings are now being acknowledged. - Avoid withdrawal or retaliation; do not take anger personally— remain with the child or parents even though they express anger. Stage: Bargaining Behavioral Responses: -Seeks to bargain to have life return to the way it was before the death. - It may serve as a temporary reprieve from anger and pain. -Guilt often accompanies bargaining, as parents focus on "what if" or "if only" scenarios. - Bargaining may also be associated with the future, such as seeing the loved one in heaven. Nursing Management: - Be supportive and listen to expressions of guilt. - Offer spiritual support if appropriate. Stage: Depression Behavioral Responses: - Sadness as acceptance of loss occurs. - Lethargic, and daily activities seem pointless. - Parent may withdraw from social and life activities temporarily. Nursing Management: - Depression is a normal response to the loss of a loved one. - Assist family and friends to understand the individual's decreased need to socialize. Stage: Acceptance Behavioral Responses: - Acceptance of the reality that the loved one is physically gone, and this is the permanent reality. - Final healing and adjustment occur while learning to live with the loss of the loved one. - While initial effort is to maintain life as it was, eventually changes in life are accepted and the person starts reaching out to others. Nursing Management: - Do not rush the family to progress through the stages more quickly than they are able to move. - Depending on the nature of the child's death, the acceptance stage may take months to years. - Encourage participation in activities that have meaning to the family member.

25) Make sure you know the major developmental milestones that we discussed in class: When should they lift head? Roll over? Walk independently? Etc.

TABLE 5-11 Physical Growth and Development Milestones During Infancy (p. 152-153) Birth to 1 month Physical Growth: - Gains 5-7 oz (1 40-200 g)/week - Grows 1.5 cm (1/2 in.) in first month - Head circumference increases 1.5 cm (1/2 in.)/month Fine Motor Ability: - Holds hand in fist - Draws arms and legs to body when crying Gross Motor Ability: - Inborn reflexes such as startle and rooting are predominant activity - May lift head briefly if prone - Alerts to high-pitched voices - Comforts with touch Sensory Ability: - Prefers to look at faces and black-and-white geometric designs - Follows objects in line of vision 2-4 Months Physical Growth: - Gains 5-7 oz (140-200 g)/week - Grows 1.5 cm (1/2 in.)/month - Head circumference increases 1.5 cm (1/2 in.)/month - Posterior fontanel closes - Ingests 120 mL/kg/24 hr (2 oz/lb/24 hr) Fine Motor Ability: - Holds rattle when placed in hand - Looks at and plays with own fingers - Brings hands to midline Gross Motor Ability: - Moro reflex fading in strength - Can turn from side to back and then return - Decrease in head lag when pulled to sitting; sits with head held in midline with some bobbing - When prone, holds head up and supports weight on forearms Sensory Ability: - Follows objects 180 degrees - Turns head to look for voices and sounds 6-8 Months Physical Growth: - Gains 3-5 oz (85-1 40 g)/week - Grows 1 cm (3/8 in.)/month - Growth rate slower than first 6 months Fine Motor Ability: - Bangs objects held in hands - Transfers objects from one hand to the other - Beginning pincer grasp at times Gross Motor Ability: - Most inborn reflexes extinguished - Sits alone steadily without support by 8 months - Likes to bounce on legs when held in standing position Sensory Ability: - Recognizes own name and responds by looking and smiling - Enjoys small and complex objects at play 8-10 months Physical Growth: - Gains 3-5 oz (85-140 g)/week - Grows 1 cm (3/8 in.)/month Fine Motor Ability: - Picks up small objects - Uses pincer grasp well Gross Motor Ability: - Crawls or pulls whole body along floor by arms - Creeps by using hands and knees to keep trunk off floor - Pulls self to standing and sitting by 10 months - Recovers balance when sitting Sensory Ability: - Understands words such as "no" and "cracker" - May say one word in addition to "mama" and "dada" - Recognizes sound without difficulty 10-12 Months Physical Growth: - Gains 3-5 oz (85-1 40 g)/week - Grows 1 cm (3/8 in.)/month - Head circumference equals chest circumference - Triples birth weight by 1 year Fine Motor Ability: - May hold crayon or pencil and make mark on paper - Places objects into containers through holes Gross Motor Ability: - Stands alone (1 6) - Walks holding onto furniture - Sits down from standing Sensory Ability: Plays peek-a-book and patty cake TABLE 5-13 Physical Growth and Development Milestones During Toddlerhood (p. 156) 1-2 Years Physical Growth: - Gains 8 oz (227 g) or more per month - Grows 3.5-5 in. (9-12 cm) during this year - Anterior fontanel closes Fine Motor Ability: - By end of second year, builds a tower of four blocks - Scribbles on paper - Can undress self - Throws a ball Gross Motor Ability: - Runs - Shows growing ability to walk, and finally walks with ease - Walks up and down stairs a few months after learning to walk with ease - Likes push-and-pull toys Sensory Ability: - Visual acuity 20/50 2-3 Years Physical Growth: - Gains 1.4-2.3 kg (3-5 lb)/year - Grows 5-6.5 cm (2-2.5 in.)/year Fine Motor Ability: - Draws a circle and other rudimentary forms - Learns to pour - Learning to dress self Gross Motor Ability: - Jumps - Kicks ball - Throws ball overhand Sensory Ability: TABLE 5-15 Physical Growth and Development Milestones During the Preschool Years (p. 159) 3-6 Years Physical Growth: - Gains 1.5-2.5 kg (3-5 lb)/year - Grows 4-6 cm (1.5-2.5 in.)/year Fine Motor Ability: - Uses scissors - Draws circle, square, cross - Draws at least a six-part person - Enjoys art projects such as pasting, stringing beads, using clay - Learns to tie shoes at end of preschool years - Buttons - Brushes teeth - Uses spoon, fork, knife Gross Motor Ability: - Throws a ball overhand - Climbs well - Rides tricycle Sensory Ability: - Visual acuity continues to improve - Can focus on and learn letters and numbers TABLE 5-17 Physical Growth and Development Milestones During the School-Age Years (p. 162-163) 6-12 Years Physical Growth: - Gains 1.4-2.2 kg (3-5 lb)/year - Grows 4-6 cm (1.5-2.5 in.)/year Fine Motor Ability: - Enjoys craft projects - Plays card and board games Gross Motor Ability: - Rides two-wheeler - Jumps rope - Roller skates or ice skates Sensory Ability: - Can read - Able to concentrate for longer periods on activities by filtering out surrounding sounds TABLE 5-19 Physical Growth and Development Milestones During Adolescence (p. 165) 12-18 Years Physical Growth: - Variation in age of growth spurt - During growth spurt, girls gain 7-25 kg (15-55 lb) and grow 2.5-20 cm (2-8 in.); boys gain approximately 7-29.5 kg (15-65 lb) and grow 1 1 -30 cm (4.5-12 in.) Fine Motor Ability: - Skills are well developed Gross Motor Ability: - New sports activities attempted and muscle development continues - Some lack of coordination common during growth spurt Sensory Ability: - Fully developed TABLE 5-12 Psychosocial Development During Infancy (p. 154) Birth-3 Months Play and Toys: - Prefers visual stimuli of mobiles, black-and-white patterns, mirrors - Auditory stimuli are music boxes, tape players, soft voices Responds to rocking and cuddling - Moves legs and arms while adult sings and talks - Likes varying stimuli—different rooms, sounds, visual images Communication: - Cooes - Babbles - Cries 3-6 Months Play and Toys: - Prefers noisemaking objects that are easily grasped like rattles - Enjoys stuffed animals and soft toys with contrasting colors Communication: - Vocalizes during play and with familiar people - Laughs - Cries less - Squeals and makes pleasure sounds - Babbles multisyllabically (mamamamama) 6-9 Months Play and Toys: - Likes teething toys - Increasingly desires social interaction with adults and other children - Soft toys that can be manipulated and mouthed are favorites Communication: - Increases vowel and consonant sounds - Links syllables together - Uses speechlike rhythm when vocalizing with others 9-12 Months Play and Toys: - Enjoys large blocks, toys that pop apart and go back together, nesting cups, and other objects - Laughs at surprise toys like jack-in-the-box - Plays interactive games like peek-a-boo - Uses push-and-pull toys Communication: - Understands "no" and other simple commands - Says "dada" and "mama" to identify parents - Learns one or two other words - Receptive speech surpasses expressive speech TABLE 5-14 Psychosocial Development During Toddlerhood (p. 157) 1-3 years Play and Toys: - Refines fine motor skills by use of cloth books, large pencil and paper, wooden puzzles - Facilitates imitative behavior by playing kitchen, grocery shopping, toy telephone - Learns gross motor activities by riding Big Wheel tricycle, playing with soft ball and bat, molding water and sand, tossing ball or beanbag - Develops cognitive skills through educational television shows, music, stories, and books Communication: - Increasingly enjoys talking - Exponential growth of vocabulary especially when spoken and read to regularly - Needs to release stress by pounding board, frequent gross motor activities, and occasional temper tantrums - Likes contact with other children and learns interpersonal skills TABLE 5-16 Psychosocial Development During Preschool Years (p. 160) 3-6 Years Play and Toys: - Associative play is facilitated by simple games, puzzles, nursery rhymes, and songs. - Dramatic play is fostered by dolls and doll clothes, play houses and hospitals, dress-up clothes, and puppets. - Stress is relieved by pens, paper, glue, and scissors. - Cognitive growth is fostered by educational television shows, music, stories, and books. Communication: - All parts of speech are developed and used, occasionally incorrectly. - The child communicates with a widening array of people. - Play with other children is a favorite activity. Health professionals can - Verbalize and explain procedures to children. - Use drawings and stories to explain care. - Use accurate names for body functions. - Allow the child to talk, ask questions, and make choices. TABLE 5-18 Psychosocial Development During the School-Age Years (p. 163) 6-12 Years Activities: - Gross motor development is fostered by ball sports, skating, dance lessons, water and snow skiing/boarding, and biking. - A sense of industry is fostered by playing a musical instrument, gathering collections, starting hobbies, and playing board and video games. - Cognitive growth is facilitated by reading, crafts, word puzzles, and schoolwork. Communication: - Mature use of language - Ability to converse and discuss topics for increasing lengths of time - Spends many hours at school and with friends in sports or other activities Health professionals can: - Assess child's knowledge before teaching - Allow the child to select rewards following procedures - Teach techniques such as counting or visualization to manage difficult situations - Include both parent and child in healthcare decisions TABLE 5-20 Psychosocial Development During Adolescence (p. 165) 12-18 Years Activities: - Sports—ball games, gymnastics, water and snow skiing/boarding, swimming, school sports - School activities—drama, yearbook, class office, club participation - Quiet activities—reading, schoolwork, television, computer, video games, music Communication: - Increasing communication and time with peer group—movies, dances, driving, eating out, attending sports events - Applying abstract thought and analysis in conversations at home and school

51) Providing care to children and families using Erikson's and Freud's theories

TABLE 5-3 Nursing Applications of Theories of Freud and Erikson Infant (birth to 1 year) Developmental Stage: Oral stage (Freud): The baby obtains pleasure and comfort through the mouth. Nursing Applications: When a baby is to be offered nothing by mouth (NPO), offer a pacifier if not contraindicated. After painful procedures, offer a baby a bottle or pacifier or have the mother breastfeed. Developmental Stage: Trust versus mistrust stage (Erikson): The baby establishes a sense of trust when basic needs are met. Nursing Applications: Hold the hospitalized baby often. Offer comfort after painful procedures. Meet the baby's needs for food and hygiene. Encourage parents to room in. Manage pain effectively with use of pain medications and other measures. Toddler (1 -3 years) Deveopmental Stage: Anal stage (Freud): The child derives gratification from control over body excretions. Nursing Applications: Ask about toilet training and the child's rituals and words for elimination during admission history. Continue the child's normal patterns of elimination in the hospital. Do not begin toilet training during illness or hospitalization. Accept regression in toileting during illness or hospitalization. Have potty chairs available in the hospital and childcare centers. Developmental Stage: Autonomy versus shame and doubt stage (Erikson): The child is increasingly independent in many spheres of life. Nursing Applications: Allow self-feeding opportunities. Encourage the child to remove and put on own clothes, brush teeth, or assist with hygiene. If restraint for a procedure is necessary, proceed quickly, providing explanations and comfort. Preschooler (3-6 years) Developmental Stage: Phallic stage (Freud): The child initially identifies with the parent of the opposite sex but by the end of this stage has identified with the same-sex parent. Nursing Applications: Be alert for children who appear more comfortable with male or female nurses, and attempt to accommodate them. Encourage parental involvement in care. Plan for playtime and offer a variety of materials from which to choose. Developmental Stage: Initiative versus guilt stage (Erikson): The child likes to initiate play activities. Nursing Applications: Offer medical equipment for play to lessen anxiety about strange objects. Assess children's concerns as expressed through their drawings. Accept the child's choices and expressions of feelings. School age (6-12 years) Developmental Stage: Latency stage (Freud): The child places importance on privacy and understanding the body. Nursing Applications: Provide gowns, covers, and underwear. Knock on door before entering. Explain treatments and procedures. Developmental Stage: Industry versus inferiority stage (Erikson): The child gains a sense of self-worth from involvement in activities. Nursing Applicatons: Encourage the child to continue schoolwork while hospitalized. Encourage the child to bring favorite pastimes to the hospital. Help the child adjust to limitations on favorite activities. Adolescent (12-18 years) Developmental Stage: Genital stage (Freud): The adolescent's focus is on genital function and relationships. Nursing Applications: Ensure access to gynecologic care for adolescent females and education for testicular examination for males. Provide information on sexuality. Ensure privacy during health care. Have brochures and videos available for teaching about sexuality. Developmental Stage: Identity versus role confusion stage (Erikson): The adolescent's search for self-identity leads to independence from parents and reliance on peers. Nursing Applications: Provide a separate recreation room for teens who are hospitalized. Take health history and perform examinations without parents present. Introduce the adolescent to other teens with the same health problem. (p. 132-133) Nursing Application of Freud's Theory Freud emphasized the importance ofmeeting the needs of each stage in order to move successfully into future developmental stages. His work has been criticized for several reasons: - He developed a theory of childhood by his work with adults, primarily women, who sought help in dealing with emotional issues. - He viewed males as dominant because of their possession ofa penis. - He ignored the effects of culture and other external experiences. However, some aspects ofhis theory appear to be supported by more current research and can be applied in nursing. Illness can interfere with normal developmental processes and add challenges for the nurse who is striving to meet an ill child's needs. For example, the importance ofsucking in infancy guides the nurse to provide a pacifier for the infant who cannot have oral fluids. Recall Sergio from the opening scenario. He did not have the ability or strength to suck after birth and was fed parenterally and by gavage. However, as soon as he was able, he was assisted to breastfeed in order to foster his oral musculature and his ability to gain comfort from sucking. The preschool child's concern about sexuality guides the nurse to provide privacy and clear explanations during any procedures involving the genital area. It may be necessary to teach parents that masturbation by the young child is normal and to help parents deal with it through distraction or refocusing. The adolescent's focus on relationships suggests that the nurse should include questions about significant friends during history taking. (p. 131).

44) What is magical thinking? How does this apply to children?

TABLE 5-4 Characteristics of Thought Identified by Piaget Characteristic: Magical thinking Definition: The belief that events occur because of one's thoughts or actions Develompent Stage: Preoperational thought Nursing Implications: Ask young children how they became ill, or what caused a parent's or sibling's illness. Correct misconceptions when the child blames self for causing problems by wishing someone ill or having bad behavior. (p. 135).

40) What is object permanence? How do you know when it has been developed?

TABLE 5-4 Characteristics of Thought Identified by Piaget (p. 135) Object permanence - Ability to understand that when something is out of sight it still exists Developmental Stage: Sensorimotor period, especially in coordination of secondary schemes substage from 8-12 months Nursing Implications: Before development of object permanence, babies will not look for toys or other objects out of sight; as the concept is developing they are concerned when a parent leaves since they are not certain the parent will return.

32) When should solid foods be introduced into the diet?

The American Academy of Pediatrics (2004) recommends introducing semisolid foods at 4 to 6 months. At this age the extrusion reflex (or tongue thrust) decreases and the infant can sit well with support. The infant is also developing the ability to appreciate texture and to swallow nonliquid foods, and can indicate desire for food or turn away when full. During months 6 through 12, the complementary foods are an addition to the intake of breast milk or formula, rather than replacing that essential intake (Hagan, Shaw, & Duncan, 2008). The first complementary food added to the infant's diet is usually rice cereal. The advantages of introducing cereal first are that it provides iron at an age when the infant's prenatal iron stores begin to decrease, it seldom causes allergy, and it is easy to digest. One to 2 tablespoons are fed to the infant once or twice daily just before formula or breastfeeding. The infant may appear to spit out food at first because of normal back-and-forth tongue movement. Parents should not interpret this early feeding behavior as indicating dislike for the food. With a little practice, the infant becomes adept at spoon feeding. Once the infant eats 1/4 cup of cereal twice daily, usually at 6 to 8 months of age, vegetables or fruits can be introduced (Table 8-8). It is wise to introduce only one new food at a time, waiting several days before the next, in order to clearly identify anyfood allergies or intolerances. By8 to 10 months, most fruits and vegetables have been introduced and strained meats or other protein (e.g., tofu, cheese, mashed cooked beans) can be added to the infant's diet. Finger foods are introduced during the second half of the first year as the infant's palmar and then finger grasps develop and as teeth begin to erupt. Infants enjoy toast, O-shaped cereal, finely sliced meats, cheese and tofu, and small pieces of cooked, softened vegetables. As food and juice intake increase, formula or breastfeedings decrease in amount and frequency (Table 8-9). Certain foods are more commonly associated with development of food allergy, and avoiding them in infancy may decrease allergy incidence. Recommendations for infants at risk due to family historyare to delay feeding of cow milk until 1 year, eggs until 2 years, and peanuts, nuts, fish, and shellfish until 3 years (AAP Committee on Nutrition, 2004). (p. 276-278) TABLE 8-8 Health Promotion—Introduction of Solid Foods in Infancy (p. 277) Introduce rice cereal at 4-6 months: Rice cereal is easy to digest, has low allergenic potential, and contains iron. Introduce fruits or vegetables at 6-8 months: Some healthcare providers recommend vegetable introduction before fruits. Fruits and vegetables provide needed vitamins. Vegetables are not as sweet as fruits; introducing them first may enhance acceptability to the infant. Introduce meats at 8-10 months: Meats are harder to digest, have high protein load, and should not be fed until close to 1 year of age. Use single-food prepared baby foods rather than combination meals. Combination meals usually contain more sugar, salt, and fillers. Introduce one new food at a time, waiting at least 3-4 days to introduce another. Delay feeding eggs, strawberries, wheat, corn, fish, and nut products until close to 2-3 years of age. If a food allergy or intolerance develops, it will be easy to identify. The foods listed are those most commonly associated with food allergy. Avoid carrots, beets, and spinach before 4 months of age. Have well water evaluated for nitrates. The recommended level is less than 10 mg/L. Nitrates in these foods and in water near agricultural runoff can be converted to nitrite by young infants, causing methemoglobinemia. Infants can be fed mashed portions of table foods such as carrots, rice, and potatoes. This is a less expensive alternative to jars of commercially prepared baby food; it allows parents of various cultural groups to feed ethnic foods to infants. Avoid adding sugar, salt, and spices when preparing own baby foods. Infants need not become accustomed to these flavors; they may get too much sodium from salt or develop gastric distress from some spices. Avoid honey until at least 1 year of age: Infants cannot detoxify Clostridium botulinum spores sometimes present in honey and can develop botulism. TABLE 8-9 Infant Nutritional Pattern (p. 278) Birth to 1 month - Eats every 2-3 hours, breast milk or formula - Consumes 2-3 oz (60-90 mL) per feeding - Has coordinated suck-swallow 2-4 months - Has coordinated suck-swallow - Eats every 3-4 hours - Consumes 3-4 oz (90-1 20 mL) per feeding 4-6 months - Begins baby food, usually rice cereal, 2-3 T, twice daily - Eats breast milk or formula four or more times daily - Consumes 4-5 oz (1 00-1 50 mL) per feeding 6-8 months - Eats baby food such as rice cereal, fruits, and vegetables, 2-5 T, three times daily - Eats breast milk or formula four times daily - Consumes 6-8 oz (1 60-225 mL) per feeding 8-10 months - Enjoys soft finger foods three times daily - Eats breast milk or formula four times daily - Consumes 6 oz (1 60 mL) per feeding - Uses cup with lid 10-12 months - Eats most soft table foods with family three times daily - Attempts to feed self with spoon though spills often - Eats breast milk or formula four times daily - Consumes 6-8 oz (1 60-225 mL) per feeding

14) Decreasing stressors for hospitalized school age children

The school-age child relies on parents and others for support and understanding during stressful events and procedures. Although school-age children attempt to maintain their composure during painful or invasive procedures, generally they still require a great deal of support. Major sources of stress for hospitalized school-age children include: - Loss ofcontrol related to body functions - Privacy issues - Fear ofbodily injury, pain, and concerns related to death - Separation from family and friends School-age children understand concepts,so parents who cannot remain at the bedside are encouraged to tell the child when they will return. Also encourage parents to be available for telephone calls to provide support and comfort to their child. Stressful procedures can lead to regression or other behavioral changes, although this is less likely than with younger patients. Inform the parents that this behavior is normal during stressful situations. Developmentally, school-age children exhibit a sense of industry, taking pride in their achievements at home, at school, and in sports. To foster that sense of industry, allow these children to participate in their care as much as possible. Encourage them to continue with schoolwork and to engage in creative outlets such as art or crafts. (p. 492-493).

13) Decreasing stressors for hospitalized toddlers

Toddlers are the group most at risk for a stressful experience as a result of illness and hospitalization. These children are old enough to understand that their routine has been disrupted but they lack the cognitive ability to understand why the disruption has occurred. Separation from parents is the major stressor, and they protest vigorously when their parents depart. When one or both parents cannot be present, they can leave mementos to comfort the child. These might include a piece of cloth scented with the mother's favorite perfume or father's cologne (unless the child has a respiratory condition or another contraindication for this intervention), an object belonging to a parent, or an audiotape or videotape with messages from the parents. Clinical Tip Dress code policies that allow or require pediatric nurses to wear colorful uniforms eliminate the anxiety related to "white uniforms" that has existed in the past. Uniforms with familiar characters may serve as a source of comfort and distraction for the child. Disruption of routine also causes stress for the toddler. The nurse encourages parents to remain present as much as possible for important rituals such as toileting, carrying out bedtime routines, and singing favorite nursery rhymes. Autonomy is a developmental characteristic of the toddler. Having their activities limited and being confined especially threaten children in this age group. When possible, maintain the toddler's normal home routines for bathing and other activities. Allow the toddler to have choices when possible, such as choosing the color of Jell-O or which gown/pajamas to wear. In addition to parental separation and schedule disruption, common stressors for the toddler include fear ofpain, fear of invasive procedures, fear of change, and fear of mutilation. The parents' presence plays a large role in diminishing these fears. In addition, therapeutic play with simple explanations can diminish these fears. Clinical Tip Toddlers may challenge a nurse by refusing to cooperate with treatments and procedures, including physical assessments. To diffuse such confrontations, encourage cooperation by offering the toddler some sense of control. For example, a nurse might comment, "Once I have listened to your heart, lungs, and stomach you can choose whether you want to ride in the wagon or be pushed in the big buggy to the playroom." (p. 491-492)

34) How can you make a physical assessment less stressor for a toddler?

Toddlers may be active, curious, shy, cautious, or slow to warm up. Because of stranger anxiety, toddlers do not like to be separated from their parents, so assessment on the parent's lap is usually preferred. Let the child hold a security object if it helps. Attempt to reduce the child's anxiety about the examination instruments by demonstrating their use on the parent or letting the parent hold the instrument first. Perform the cranial nerve assessment or developmental assessment as a method to gain cooperation for other procedures. Avoid asking the child if you can perform a part of the examination as the typical response will be "no." Tell the child what you will do at each step of the examination, using a confident voice that expects cooperation. When a choice is possible, let the child have some control by selecting which part of the examination to do next, such as touching the chest or the abdomen or letting the child choose to stand or sit for a certain part of the examination. Begin the examination by touching the feet and then moving gradually toward the body and head. Instruments to examine the ears, eyes, and mouth are usually viewed as the most fearful and should be used at the end ofthe examination. While much of the examination can be performed with the child sitting, it is possible to create a flat surface for the abdominal and genital examination by sitting close to the parent with knees together. For invasive procedures (ear, eye, and mouth exam) the parent can hold the child closely to the chest with legs between the parent's legs. (See Figure 7-22b.) Remember that much of the neurological and musculoskeletal assessment can be conducted by observing the child playand walkaround in the examining room. (p. 197)

46) What type of hospital bed is appropriate for each age group?

neonates and infants: incubators, bassinets with high sides and/or tops to prevent accidental crawling out and falls toddlers: toddler-sized beds with high sides and/or tops to prevent accidental climbing out and falls school-aged children: ultra-low pediatric specific beds adolescents: normal hospital beds OK

20) What is the main priority in providing care to children of all ages and their families?

safety

19) Dealing with denial among parents

• They usually want to prolong the treatment • Need to realize that length of life does not equal quality of life • You need to help them see the facts • Be verbally supportive but refrain from reinforcing denial. Recognize that denial is one way parents face accepting the feelings of grief. Stage: Denial (p. 719) Behavioral Responses: - Disbelief, it seems like a bad dream, unable to process the information about the death. - Questioning the reality of the death—did it really happen or was it a dream? - Unable to believe that the child will not come home again. - May make statements such as "This can't be happening" or "This can't be true." Nursing Management: - Be verbally supportive but refrain from reinforcing denial. Recognize that denial is one way parents face accepting the feelings of grief. - Don't argue—allow the child or parents to come to terms in their own time. BOX 22-11 Supporting a Healthy Family Grieving Process (p. 733) Nurses can assist families toward a healthy grieving process after a child's death in the following ways: - Provide information about the grieving process and explain that grief exerts tremendous stress on even the most loving relationships. Inform families that each person processes grief on his or her own timeline. - Encourage parents to show their emotions so young children and adolescents will learn that it is appropriate to share their feelings and to display appropriate grieving behavior. - Alert parents to the special needs of young children who may feel guilty that they caused the child's death due to their magical thinking. - Consider having the sibling participate in a bereavement group with other children of a similar age. The sibling may have an opportunity to honestly talk about his or her feelings and learn more about coping with personal struggles from other children (Davies, Collins, Steele, et al., 2007). - Advise parents to be watchful for their adolescents' responses to the death, and to seek help if any of the following behaviors are noticed: suicidal thoughts or actions, long-standing depression, isolation from friends and family, failing in school or overachieving, major changes in personality or attitude, serious eating problems, use of drugs or alcohol, fighting or criminal behavior, and inappropriate sexual activity (Kirwin & Hamrin, 2005). - Recommend open lines of communication between parents and bereaved siblings. - Explain that many family members and friends may distance themselves because they are uneasy with death and grief. - Inform families that major holidays, birthdays, and anniversary dates of the child's death may be especially difficult emotional times.

12) When is it appropriate for parents to stay for procedures like exams? IV insertion or other procedures? In the ICU?

• When the child is having a stressful procedure • The parents presence can help reduce the anxiety of the parent and child • Usually a good idea to have them there • ICUs are a stressful environment b/c of the noise and pumps and usually don't have 24 hours visiting hours so more stressful to child