Peds - Ch. 30: Atraumatic Care of Children and Families

A parent wants to wait outside the room while a procedure is completed on his young child, saying, "I don't think I can stand to see you do this!" The nurse's best response is:

"Certainly. I will stay with your child during the procedure." Excusing the parent from the procedure is the best response. The parent's needs and abilities need to be respected and supported. Children usually receive the most support from parents. However, others can provide effective support, including nurses and child life personnel. Consider, also, that an anxious parent usually means an anxious child. Assist the parent to comfort the child after the procedure.

Nursing students are learning about the importance of therapeutic communication in their pediatric course. The nursing instructor identifies a need for further teaching when a student makes which statement?

"It is best to stand when listening to a child to demonstrate knowledge." Good listening is not passive but active. Posture reveals greatly whether one is listening. Sitting, not standing, means the nurse is actively listening and interested in what the child has to say. Leaning forward, not backward, displays interest in the child and conveys an openness. The nurse can convey good listening habits by pulling up a chair to the bedside or to a table when the child is sitting and engaging with the child at the same level.

The parents of a 2-month-old infant have learned that their infant has hemophilia. The parents are visibly upset and ask how this could have happened to them. What is the nurse's best response?

"News like this is difficult to hear. Let's talk about what this means for your child." The nurse's best response is to therapeutically acknowledge the parents' concerns and the fact that it is upsetting to them. Next, the nurse should give the parents information about what the diagnosis means for them and their child. While the diagnosis is not the parents' fault, saying that "things like this happen" sometimes is nontherapeutic. Telling the parents that there is no need to worry or that the nurse understands how they feel is untrue and nontherapeutic.

What should be the first step in developing a teaching plan for a 9-year-old child who needs education about a gluten-free diet for the treatment of celiac disease?

Assessing the child's current level of understanding Client education occurs when nurses share information, knowledge, and skills with children and their families. For this to be effective, the nurse would first have to assess the child's and family's current level of understanding, the child's cognitive level, the child's physical ability and any psychosocial concerns. The child learns best when the child's input is valued and the child is actively involved in the learning process. Giving the child a video to watch or a pamphlet to read does not allow interaction for learning or the ability to ask questions or voice concerns. If the child is to be on a gluten-free diet, the parents responsible for purchasing the food should also be included in the teaching. Collecting facts about the child's likes and dislikes would be important to know, because gluten-free substitutions may be available. These, however, are not the primary actions. The assessment comes first.

The nurse is caring for a hospitalized pediatric client. Which intervention will the nurse include to encourage family-centered care?

Have a team meeting with the client, family, and involved health care providers. Family-centered care involves a partnership between the child, family, and health care provider in planning, providing, and evaluating care. It works well with children of any age and in all arenas of health care, from preventive care of the healthy child to long-term care of the chronically ill child. All providers should be involved in the child's plan of care, not just the health care provider or nurses. Encouraging rooming-in and sibling visitation is important for stability and to limit the client's anxiety, not for family-centered care. The child would only need to be assessed by the psychologist if the child were demonstrating emotional difficulties associated with the disease.

A 7-year-old child with sickle cell anemia who comes to the hospital frequently appears withdrawn and depressed. The client refuses to talk to anyone or even admit to feeling sad. What would be the best thing for the nurse to do that might help the child deal with his or her feelings?

Get the client to draw a picture. A useful nonverbal technique to assess how children feel about a frightening experience is to ask them to draw a picture. Children cannot always verbally express what they are feeling. Being able to convey feelings on paper can open the door for the nurse or child life specialist to help the child deal with the problem. Humor will not fill the void. It is not effective with depression because it is not interpreted as humor. Usually children are looking for a firm support person to be with them, not an amusing one. Using music can be helpful, but the child should pick the type of music that will then convey the mood. The nurse should not leave the child alone. Doing so will only add to further isolation.

The nurse is preparing to reduce a young parent's anxiety about a child needing hospitalization. Which action should the nurse prioritize?

Include the parent in the medical decision-making. The family-centered care approach is a researched-based philosophy that promotes family coping with a child needing medical attention. The nurse should collaborate with the family to address the family's needs, as well as the medical care of the child. Including the parent in the process of medical decision-making would be the priority. The other choices (letting the parents know about the tests to be performed; relaying messages; addressing concerns promptly instead of setting aside to discuss all the concerns simultaneously) would be additional ways to include the parents in the process and relay necessary information to be able to make informed decisions.

A nursing instructor is teaching a class about the basic functions of families. The instructor determines the class is successful when the students correctly choose which statement as a basic function of the family?

Reproduction remains an important function of many families. The family serves two functions in relation to society: to reproduce and to socialize offspring. Couples today are less, not more, concerned about unplanned pregnancies. This is because of the development of the various family planning methods. It is the responsibility of the older members to teach the younger ones how to function as adults; however, the younger members also teach the older members about the changing world. There are some families where some adults are not wage earners but may stay at home for a variety of reasons (by choice, disability, etc.), which can result in limited resources available for the family.

A nurse is assigned to care for a 6-month-old infant hospitalized with diarrhea and dehydration. Because the infant does not have developed speech, what can the nurse do to communicate with the infant?

Sing to the infant. Infants primarily communicate through touch, sight, and hearing. Communication can occur through cuddling, holding, rocking, and singing to the infant. The child cannot read, so writing on the whiteboard would be beneficial only for the parents. A 6-month-old infant uses toys as developmental tools, not communication tools. The infant may want to snuggle with the stuffed animal while the nurse tells the story or sings.

The nurse is caring for a hospitalized preschool child and needs to hang IV fluids by the infusion pump. The nurse introduces the infusion pump to the child based on what developmental principle?

The child may think the equipment causes the pain. Preschool-age children tend to be frightened of intrusive procedures. Teaching about intrusive procedures or medical equipment or explaining to children why it is necessary calls for clear explanations and praise for learning. Preschool-age children are interested in learning because developing a sense of initiative is the main developmental task. The nurse should keep explanations short and words simple. A preschooler's attention span rarely exceeds 5 minutes. Because preschool children notice only one characteristic of an object, the nurse may need to repeat the instructions or explanations later. Children need to have explanations for the needed aspects of care they are to receive.

When caring for hospitalized teens, nurses should choose their words and actions carefully since adolescents typically are concerned about:

appearing out of control of the situation and/or themselves. Adolescents are concerned about how others view them. They wish not to do or say "dumb" things or appear babyish. This concern may cause them to worry about postanesthesia behavior or about how they might react to a procedure. Independence is desired yet a concern. Mobility restrictions, mutilation, and separation are more common fears/anxieties in preschool-age children and school-age children.

The nurse is educating the family of a 2-year-old boy with bronchiolitis about the disorder and its treatment. The family parents speak only Chinese. Which action, involving an interpreter, can jeopardize the family's trust?

asking the interpreter questions not meant for the family Asking questions or having private conversations with the interpreter may make the family uncomfortable and destroy the child/nurse relationship. Translation takes longer than a same-language appointment and must be considered so that the family is not rushed. Using a nonprofessional runs the risk that he or she won't be able to adequately translate medical terminology. Using an older sibling can upset the family relationships or cause legal problems.

A nurse is preparing to teach an 8-year-old child recently diagnosed with diabetes how to give an insulin injection. Which is the best technique for the nurse to use?

demonstration The purpose of demonstration is to show how the procedure actually is done. Having to imagine steps is little different than reading about them. School-aged children, because of their stage of cognitive development (concrete operations), learn best by demonstration. Watching a video is a good teaching strategy to show the process but it does not have the "real" syringe and vial the child can see and touch. Once the demonstration is complete the child should be allowed to return the demonstration and/or have time to practice with the nurse's assistance.

A nurse is teaching an 11-year-old child about the use of incentive spirometry prior to abdominal surgery. The child yells, "I am not going to use this stupid thing, and I wish you would just leave me alone!" What is the priority therapeutic response by the nurse?

"I understand that you are angry and nervous about your surgery, but please don't yell." The typical response at hearing an angry outburst is to imitate it. This is not therapeutic, however. The nurse should make a point of not allowing oneself to be drawn into the child's anger, while at the same time acknowledging it is all right to be angry ("I understand that you're angry but please don't shout"). Help the child to focus the anger if at all possible in order to better understand it and begin to deal with it. Telling the child shouting is disrespectful is not understanding the root of the problem. Bringing the parents into the situation places the blame on them for the anger instead of addressing the primary problem.

The nurse is caring for a 7-year-old child scheduled for a tonsillectomy the next day. The client states, "I really wish I was not having surgery tomorrow. I am not excited about this. Maybe I will be better by tomorrow." Which response by the nurse is most appropriate?

"You sound worried. Let's talk about tomorrow." Therapeutic communication is an interaction between two people that is planned (deliberately intending to determine the true way a child feels), has structure (use specific wording techniques that will encourage the response you expect to elicit), and is helpful and constructive (at the end of the exchange the nurse will know more about the child than at the beginning, and the child, ideally, also knows more about a particular problem or concern). The child seems worried; therefore, the nurse would discuss the child's feelings with the child to determine the best course of action. It is not appropriate for the nurse to state "hope you are better" or "everything was fine" as these are not therapeutic. If possible, it would be appropriate for the child to tour the operating room prior to surgery, after discussion the child's feelings. Seeing the location may help alleviate some fears.

A parent brings a toddler to the clinic for treatment of a possible ear infection. How will the nurse communicate effectively with this child?

Approach the toddler while the toddler is being held by the parent. Toddlers are often fearful at their developmental level. Nurses should approach toddlers at a slow pace and while the toddler is being held by the parent to allay this fear. Nurses should use the toddlers' preferred words for objects or actions so these children can better understand, rather than using correct medical terminology the children will not understand. Privacy is most important to the adolescent age group. Toddlers are too young to make independent health care choices.

A 6-year-old reports pain in the stomach upon eating. The nurse replies, "Let me see if I have this right. Every time you eat anything, you get a pain in your tummy?" The nurse is using which technique of therapeutic communication?

Clarifying Clarifying consists of repeating statements others have made so both people can be certain that the message is understood. This is an example of clarifying. Reflecting is restating the last word or phrase. Open-ended questions invite a variety of responses and allow the client to give all the pertinent information needed to answer the question. Perception checking documents a feeling or emotion that is reported. It is a way of understanding others accurately instead of jumping to conclusions.

A preschool child fell off a tricycle and broke an arm that will require surgical repair. The nurse wants to prepare the child for surgery. Which is the best technique the nurse could use to teach the child about what to expect?

Dolls Teaching preschool children about what to expect from a hospital experience is often taught using a series of puppets or dolls to represent different hospital personnel such as the surgeon, a nurse, and a nurse's assistant. Preschool children are particularly receptive to puppets and dolls because, with their imagination at its peak, they believe the puppet or doll is actually talking to them. Children can practice giving the doll "shots" or submitting it to procedures they will experience. Coloring, games, and demonstration can be helpful in many situations, but dolls allow the child to have a hands-on learning experience.

A nurse is providing care for a child diagnosed with beta-thalassemia who is receiving a blood transfusion. The child reports being bored and asks to go to the playroom. What is the best action for the nurse to take?

Have a child-life specialist find an appropriate activity to occupy the child during the transfusion. The best action the nurse can take is to have the child-life specialist work with child to find something interesting the child can do while in the room. There is a safety issue involved if the nurse tries to administer the transfusion in the playroom. The nurse can deny the request or explain the need for rest but if the child is feeling well it will likely not be enough to satisfy the child. Finding an appropriate activity for the child to engage in is the best option.

A 10-year-old child with sickle-cell anemia is frequently in the pediatric center of a hospital. What intervention can the nurse provide that will allow the child the sense of control that meets the goals promotes atraumatic care?

Maintain the child's home routine related to activities of daily living. To promote a sense of control that meets the goals of atraumatic care, the nurse would attempt to maintain the child's home routine related to activities of daily living. In the hospital, the nurse would use primary nursing. The nurse would encourage the child to have a security item present if desired. Other measures include involving the child and family in planning care from the moment of the first encounter, empowering them by providing knowledge, allowing them choices when available, and making the environment more inviting and less intimidating. The nurse could advocate for minimum blood draws, but with the child's disease this will likely not happen. The nurse can help the child with reassurance and topical pain medication for laboratory draws to prevent the discomfort of multiple needlesticks. These actions, however, do not offer the child a sense of control.

The nurse is teaching the parents of a newborn with a metabolic problem about the disorder and its treatment. What is the least effective teaching technique?

Provide literature for the parents to read and then have them ask questions. The parents may not understand the literature based on their reading level or ability, their understanding of terms, or their own overall literacy. They may not ask questions for all of the former reasons or to avoid appearing "dumb." The other techniques should provide support by using "lay" words, exchanging ideas (discussion) regarding managing an emergency, and using a common visual symbol (USDAs "MyPlate") to teach about nutrition.

The nurse has worked diligently with an adolescent to meet his teaching-learning needs and make adaptations for managing his illness to suit his preferences and lifestyle. Even so, there is evidence of noncompliance. The nurse's interpretation is:

Some noncompliance should be expected due to the teen's desire for independence, expression of his personal values, and peer acceptance. Acceptance of some noncompliance by this teen is necessary. Finding compromise to limit noncompliance is important. Developmentally, the adolescent is capable of formal thought. Connecting present and future should not be an issue. There may be some measure of inattentiveness to teaching and some need for more home support, but these do not represent the main reason for noncompliance.

A 15-year-old client with type 1 diabetes has been noncompliant with the dietary regimen. When educating the adolescent, what is the most important thing the nurse can do to allow the adolescent to be in control and involved in the decision-making process?

Speak directly to the adolescent and consider the client's input in the decisions about care and education. A teaching tip for adolescents that will allow them control and involvement in the decision-making process is to speak directly to them and consider their input in all decisions about their care and education. Adolescents are particularly sensitive about maintaining body image and the feelings of control and autonomy. Reasons as to why things are important should be conveyed to them. The nurse should collaborate with the teen to develop an acceptable solution to being compliant. The nurse should also expect some noncompliance from adolescents. Even with noncompliance in some areas, there some things the adolescent does well—and the adolescent should be praised for these accomplishments. Choices can be offered whenever possible but for a client with diabetes these choices are often limited.

A school-aged child learns how to do range-of-motion exercises but has been unable to perform them correctly from day to day. Which approach is best for the nurse to take to encourage compliance by the child?

State "Good job" to the child when performing the range-of-motion exercises correctly. Children maintain behaviors better when given praise. This makes learning a positive experience and facilitates the client's industry stage of psychosocial development. Visitation hours are not a priority for the school-age child; this would be more rewarding for the adolescent client. The nurse should encourage the child, not only the parents. Preventing disfigurement is not a concept easily attainable for the school-age child and would be more appropriate for the adolescent.

An 8-year-old child is scheduled to have a tonsillectomy and adenoidectomy in 2 weeks. What intervention can the nurse provide to help the child and family adjust to the hospitalization?

Take the child on a tour of the facility and surgical suite and explain what to expect preoperatively and postoperatively. Nurses can help children cope with the experience by using age-appropriate and child-specific interventions. Preparation can help children and their families to adjust to illness and hospitalization. Preparing the child reduces stress and fear. As much as possible, the nurse or child life specialist can show the child the areas where the child will have surgery, play with age-appropriate dolls to learn such things as IV insertion, and answer all the child's questions. Telling the child the parents will not be able to see him or her increases fear and anxiety. Being able to have a popsicle after surgery is the truth, but it is not the entire truth nor does it prepare the child for unknown places. The purpose of prehospital preparation is not to interview the child but to prepare the child.

The nurse is educating an 8-year-old client newly diagnosed with diabetes mellitus on how to administer insulin. Which finding best indicates the nurse's education was successful?

The child demonstrates good technique in self-injection of insulin. As a final step of communication or teaching, what was communicated or learned must be evaluated. A new plan may need to be developed and teaching continued if communication or learning was less than optimal. An example of an outcome criterion is the child demonstrates good technique in self-injection of insulin, which will include gaving the child draw up the correct amount of insulin, but tht alone does not indicate the client is able to self-administer insulin. The purpose of the education is to have the child, not the parents, develop skills to provide self-care. Learning about foods for hypoglycemia is a separate topic than self-administration of insulin.

The nurse is assessing the learning needs for a 12-year-old boy with a chronic health condition, as well as his parents. Which aspect would be least pertinent to a learning needs assessment?

The family belongs to a mainline traditional faith community. Membership in this traditional faith community impacts learning needs the least. There are no particular values or traditions that would require modification of the care plan for a child with his health problem. Parents experiencing a highly charged emotional state creates a learning barrier for them. A very healthcare-literate person would require less repetition and simplification of the explanations given. A deaf mother may require an interpreter if the nurse does not know American Sign Language.

Following a principle of learning, the nurse can anticipate that school-age children will best learn a skill such as bandaging if they:

are allowed to practice it. School-age children are in a concrete cognitive stage. They learn best if they can actually practice procedures and demonstrate them on their own. Nurses should explain procedures and the reasons for them in a simple logical way. This age group is not yet where they can think abstractly. They learn best with role playing, games, and show and tell. They need activities that create enthusiasm. Watching someone else do the procedure or seeing it in a book does not allow the child to learn the material and master the procedure. Children should not be criticized for not learning well. The technique of teaching should be changed to meet the child's learning needs.

A nurse is caring for a small child with leukemia who will be hospitalized frequently for chemotherapy. What type of referral can the nurse make that will help the child and family through this time?

child life specialist A child life specialist (CLS) is a specially trained individual who provides programs that prepare children for hospitalization, surgery, and other procedures that could be painful. The CLS is a member of the multidisciplinary team and works in conjunction with health care providers and parents to foster an atmosphere that promotes the child's well being. The CLS provides therapeutic play, nonmedical preparation for surgeries and procedures, support for siblings, advocacy for the child and family, and grief/bereavement support. An occupational therapist would be needed if there were injuries to the upper extremities or hands. A child psychologist would only be warranted if the child was exhibiting psychological distress.

A 9-year-old child is newly diagnosed with asthma. The nurse plans to teach the child about triggers related to the diagnosis. What would be the best approach for this child?

play an allergy trivia game with the child Learning through play is a valuable tool at this age. School-age children like to participate in their learning. Watching a video is more passive rather than active. It does not give the child the chance to ask questions or get explanations about things in the video that were not understood. Giving the child a list of what he or she cannot have is a negative approach. Using a negative approach generally causes rejection, so the child will not follow through. Educating clients and their families is a large role of nursing.

A 4-year-old adopted child has begun to ask questions about when she was born. Which suggestions by the clinic nurse would be considered the most appropriate answer for this child related to her birth? Select all that apply.

-Explain to the child that she grew inside another woman, but after the birth she was given to her adoptive mom and dad to raise. -Avoid criticizing the biological parents but reinforce how much the adoptive mom and dad love them. At least by 4 years, children are old enough to fully understand the story of their adoption: they grew inside the body of another woman who, because she could not care for them after they were born, gave them to the adopting parents to raise and love. It is important for parents not to criticize a birth mother as part of the explanation because children need to know, for their own self-esteem, that their birth parents were good people and they were capable of being loved by them, but things just did not work out that way. At age 4, children do not understand HIV status, not being able to provide for the needs of an infant, or prison terms.

During the change of shift report, the nurse reports concerns about the parents of a hospitalized child understanding the written literature provided concerning the child's plan of treatment. Which observations would provide support to this concern? Select all that apply.

-The child's mother provides little responses to information provided. -The child's medical record contains information indicating the family frequently misses appointments. -The child's mother asks the nurse to complete paperwork for her. Understanding health-related information can be challenging. It is a role of the nurse to ensure an understanding of information and materials provided. Signs that information is not being understood may include asking few questions about the plan of treatment. Missed appointments may also signal a lack of understanding. Asking the nursing staff to complete paper work may signal a lack of understanding or possibly an inability of the family to do it themselves.

The nurse is caring for a parent of a 10-month-old infant. The parent is upset and states, "I have so many questions, but the doctor seems too busy to answer my questions." What is the best action by the nurse?

Assist the parent in preparing a list of questions for the health care provider's next visit. Empowering parents so that they can be active partners in their child's care is part of family-centered care. Helping the parent state and write questions will provide information to which the nurse can respond plus help the parent interact more effectively with the health care provider and other health team members. Relaying the parent's questions may be helpful on limited occasions but places the nurse between the parent and the health care provider, relaying information in a "third party" manner. Keeping the parent at the bedside watching and waiting causes unnecessary watchfulness and stress. Supporting the busy schedule of the health care provider burdens the parent further.

The nurse is preparing to teach a 9-year-old child how to do active range-of-motion exercises. Which technique would be most appropriate to use?

Demonstrate the technique by performing it the same way each time. For a 9-year-old child, consistent instruction using hands-on techniques is best. All the attention should be focused on the nurse as the nurse is teaching. Achievement and accomplishment are very important to the school-age child. Gaining control over the situation by learning what the nurse is teaching is important to the child's self-esteem. Teaching different ways to perform a technique would be confusing to the child; he or she would likely not learn the skill correctly. The child is not able to dictate how to perform the skills.

During an office visit to monitor a father's blood pressure, he shares with the nurse that his family is very stressed and experiencing a lot of tension since one or both parents may lose their jobs, their oldest child is applying for colleges (which costs a lot of money), and they recently lost their pet. Which advice should the nurse provide that may prevent an unintentional (accidental) injury?

The parents should try to avoid unintentional injuries like leaving pills out on the counters where younger children can accidentally poison themselves. The nurse can offer several strategies to reduce family stress. The nurse should encourage parents to reach out for support and explain that under stress, it is easy to become so involved in a problem that one does not realize that other people are around who want to help. Remind family members that unintentional (accidental) injuries increase when people are under stress. Children are more apt to poison themselves when the family is under stress because parents are more apt to leave pills on counters during this time. The nurse should also counsel parents not to rush decisions or make final adaptive outcomes to a stressful situation. As a rule, major decisions should be delayed at least 6 weeks after a stressful event; 6 months is even better. Finally, counsel parents to anticipate life events and plan for them to the extent possible.

A recently licensed nurse asked the charge nurse what it means to provide atraumatic care to hospitalized children. Which response by the charge nurse would be accurate?

The underlying premise refers to the concept of "do no harm." Atraumatic care can also be called therapeutic care; it minimizes the child's and family's physical and psychological distress when cared for within the health care system. It is based on the underlying premise of "do no harm." Assigning one nurse to one child is ideal, but may not be practical from a resource and acuity standpoint. Health care-acquired infections are prevented as much as possible, but would be only one aspect of atraumatic care, not the entire concept. Nurses provide atraumatic care to all hospitalized children, regardless of injury or illness.

The nurse is teaching a 15-year-old boy with type 2 diabetes and his parents how to monitor glucose levels. Which communication technique is least effective?

ignoring the adolescent's tirade about his therapy The least effective technique is ignoring the adolescent's tirade about his therapy. He is expressing frustration over his lack of control, and his emotions should be acknowledged. Paraphrasing the parents' comments recognizes their feelings. Using the teen's words during the conversation indicates active listening and interest. Reflection clarifies the parents' understanding and point of view.