Transcript NURS 2410 Unit 5x

Metro Community College
Nancy Pares, RN, MSN
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Healthcare provider must obtain
Must be obtained for invasive procedures and
some medical treatments
May be delayed in emergency situations
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Discuss ethical, legal issues related to
childhood period.
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Assess and document
Review rights of minors
Develop therapeutic relationship
Verify prior consent
Serve as witness
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Until the person reaches age of adult based
on state law, parent or guardian must provide
informed consent.
Parent or guardians have ultimate decision,
with some exceptions.
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Emancipated minor
Minor is parent of a child receiving treatment
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Assent and preference by child should be
obtained
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Ability to save lives of severely impaired
infants
Genetic testing
Gene therapy
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Define
Evaluate
Identify
Apply principles
Make decisions
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Nurses use four ethical principles
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Beneficence
Nonmaleficence
Autonomy
Justice
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Ethics committees resolve conflicts and make
recommendations
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End of life-sustaining treatment
Genetic testing of children
Organ transplant
Research on children
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Ongoing and cyclical
Exchange of thoughts, feelings, information
Importance of trust and rapport
Components—sender, message, channel,
receiver, response
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Discuss age appropriate assessment and
therapeutic communication in the care of the
child.
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Sender—generates the message
Message—verbal, nonverbal, or abstract
Channel—auditory, visual, kinesthetic
Receiver—decodes the message
Response—feedback to sender
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Verbal
Nonverbal
Abstract
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Verbal and written words, vocalizations
◦ Speaking to another
◦ Writing a letter
◦ Crying, laughing
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Influenced by development and cognitive
level
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Influenced by culture
How does the nurse use verbal
communication in nursing care?
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Forms of Nonverbal Communication
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Paralanguage
Gestures
Touch
Personal space
Facial expression
Body language
Eye contact
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Forms of Nonverbal Communication
◦ Physical appearance
◦ Facial Expression
◦ Ambiguity
 Influence of development and cognitive level
 Influence of context—what is the situation?
 Influence of culture
◦ Congruence between verbal and nonverbal message
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How should nonverbal communication be
applied to nursing care?
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Developmental level
Skills
Language development
Cognitive development
Emotional/personality development
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Primary mode of communication is nonverbal
Express self through crying
Respond to human voice and presence
Touch has a positive effect
Nursing strategies include: encourage parent
to touch infant
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Communication is still primarily nonverbal
Begin verbal communication with
vocalizations
Communicate through crying, facial
expression
Attentive to human voice and presence
although no comprehension of words
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Respond to touch through patting, rocking,
stroking
Nursing strategies include: speak in highpitched voice, cuddle, pat, rub to calm
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Evolving verbal skills
Use of language to express thoughts
◦ Greater receptive than expressive language
◦ Concrete and literal thinking,may misinterpret
phrases
◦ Vocabulary depends on development and family’s
use
◦ May ask many questions (preschooler)
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Short attention span
Limited memory
Cognitive development
◦ Egocentric
◦ Magical thinking
◦ Animism
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Nonverbal communication
◦ Express self through dramatic play and drawing
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Nursing strategies
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Cognitive development now able to use logic
◦ Begin to understand others’ viewpoints
◦ Begin to understand cause-effect
◦ Understanding of body functions
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Verbal communication
◦ Vocabulary is large
◦ Receptive and expressive language balanced
◦ Misinterpretations of phrases still common
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Nonverbal communication
◦ Can interpret nonverbal messages
◦ Expression of thoughts and feelings
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Abstract thinking without full adult
comprehension
Interpretation of medical terminology is
limited
Drive for independence
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Trust and understanding build rapport
Need for privacy
Nursing strategies include: straightforward
approach, talk in private area
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If unable to communicate,may feel
helplessness, fear, anxiety
Family may become anxious
Strategies
◦ Nonverbal—use gestures, picture boards, writing
tablets
◦ Communication augmentation—system of head
nods, eye blinks
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Approach to child—identify self as you enter
room, announce departure
Orient child to objects in room
Speak before touching
Explain any unfamiliar sounds
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Approach to child—face child when speaking,
enter room slowly
Assess degree of impairment—may need
interpreter
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Cultural implications—need to develop plan
of care in respect of culture
Use of interpreters
◦ Family—could result in errors and inconsistency
◦ Use professional translators trained for patient
encounters
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Other strategies include: communication with
pictures, speaking in normal tone
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Development
Language
Physical skills
Culture
Barriers
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Play
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Culture
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Journaling
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Importance of rapport
◦ What is rapport?
◦ How do you establish rapport?
 With parents?
 With children?
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Introduction
Purpose of interview
Use of open- and closed-ended questions
Timing of questions
Nonverbal communication
Observations
Honesty
Language
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Past health and illness history/ages of
occurrence
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Birth history
Communicable diseases and illnesses
Hospitalizations and surgery
Injuries
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Current health status
◦ Health maintenance pattern and last visit
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Family History
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Medications—prescribed and OTC
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Allergies
Immunization status—up to date?
Safety
Activity and exercise
Nutrition
Sleep
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Review of systems
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Family composition
Home environment, housing, neighborhood
School or childcare
Daily routines
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Changes in family or family life since last
healthcare encounter
◦ Separation, divorce, or death of a parent
◦ Who lives in the household?
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Age-specific issues
◦ Newborns
◦ Adolescents
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Developmental status, history, and patterns
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Motor
Cognitive
Language
Social
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Praise parental presence and responses
Promote physical comfort and relaxation
Distract infant with colorful toys
Auscultate when quiet or sleeping
Do procedures that provoke crying at end of
exam
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Parent’s lap
Play
Security object
Instruments
Control and choice
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Sequence
Games and activities
Demonstrate and let them touch instruments
Distraction
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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
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Head
Chest
Abdomen
Spine
Skin imperfections
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Appearance
Behavior
Interaction with parents
Interaction with examiner
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Length
◦ Birth to 24 months
◦ Measuring board
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Height
◦ After age 2 years
◦ Stadiometer
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Weight
◦ Infant scale
 Kilograms, grams, and pounds and ounces
◦ Standing scale
◦ Diapers and clothing
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Centimeters and inches
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Paper tape
Measure twice
Up to age 2 to 3 years
Around supraorbital and occipital prominences
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Body mass index
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Less than 5th percentile
Greater than 85th percentile
Greater than 95th percentile
Calculation: weight in kg/m2 of height
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Skin
◦ Color, temperature, moisture
◦ Rashes, lesions
◦ Skin turgor
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Hair
◦ Texture, amount, fullness
◦ Breaking off?
◦ Head lice
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Shape of head and face
Symmetry
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Skull sutures
Fontanels
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Inspection
◦ Hypertelorism
◦ Palpebral slant
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Inspection
◦ Extraocular movements (EOMs)
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Inspection
◦ Strabismus
 Light reflex
 Cover-uncover test
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Vision
◦ Infant tracking
◦ Age-appropriate tests of visual acuity
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Fundoscopy
◦ Red reflex
◦ Internal structures
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Inspection
◦ Symmetry
 Shape of tragus
 Position and alignment
 Ear canal
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Tympanic membrane
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Hearing assessment
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Newborn screening
Audiometry
Noise and whisper tests
Tympanometry
Bone and air conduction tests
Indicators of hearing loss
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Inspection
Palpation
Percussion
Patency
Smell
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Lips
Teeth
Gums
Mucosa
Tongue
Throat and tonsils
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Inspection
◦ Swelling
◦ Webbing
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Palpation
◦ Nodes
◦ Trachea
◦ Thyroid gland
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Range of motion
◦ Torticollis
◦ Meningismus
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Inspection
◦ Shape
◦ Chest deformities
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Inspection
◦ Movement, excursion
◦ Respiratory effort, retractions, respiratory rate
◦ Breasts
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Palpation
◦ Crepitus
◦ Tactile fremitus
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Auscultation
◦ Hyperresonance
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Percussion
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Inspection
◦ Precordial activity
◦ PMI
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Palpation
◦ Apical impulse
◦ Thrills
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Percussion
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Auscultation
◦ Rate and rhythm
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Auscultation
◦ Normal heart sounds
 S1 and S2
 Splitting
 S3
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Auscultation
◦ Abnormal heart sounds
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Murmurs
Intensity, location, radiation, timing, quality
Intensity grades
Venous hum
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Pulse
Related assessments
Blood pressure
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Inspection
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Shape
Umbilicus
Rectus muscle
Abdominal movements
Inguinal area
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Auscultation
Percussion
Palpation
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Positioning
Timing in examination
Females
Males
Anus and rectum
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Puberty and sexual maturation
◦ Females
◦ Males
 Tanner Scale
◦ Sexual maturity rating (SMR)
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Inspection
Palpation
Range of motion
Muscle strength
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Posture and spinal alignment
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Upper extremities
◦ Shoulders
◦ Arms and elbows
◦ Hands and wrist
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Lower extremities
◦ Hips
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Lower extremities
◦ Legs and knees
◦ Feet and ankles
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Cognitive functioning
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Behavior
Communication skills
Memory
Level of consciousness
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Cerebellar function
◦ Balance
◦ Coordination
◦ Locomotion, gait
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Sensory functioning
Primitive reflexes
Superficial and deep tendon reflexes
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Onset of secondary sex characteristics vary
Sexual maturity rating (SMR)
◦ Females: average of breast and pubic hair
development
◦ Males: average of genital and pubic hair
development
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Tanner stages: rating between 2–5, stage 1 is
prepubertal
Inspection and palpation to assign a tanner
stage
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Identify normal findings
Identify abnormal findings
◦ Sort normal from abnormal findings
◦ Group normal and abnormal findings together
◦ Recognize patterns from normal and abnormal
findings
◦ Identify health concerns, problems, conditions
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Appropriate referral for treatment
Determination of nursing diagnoses based on
health assessment findings
Collaboration with child, family, other
healthcare providers to develop goals
Identification and implementation of
appropriate interventions
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Transition to extrauterine life
◦ Initiation of respirations
◦ Transition from fetal to adult circulation
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Physiologic condition and needs
Resuscitation
Apgar score
◦ Adaptation to extrauterine life
◦ 1 and 5 minute score
◦ Apgar criteria
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Ballard gestational age assessment tool
◦ Physical characteristics
 Skin
 Lanugo
 Plantar surfaces
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Ballard gestational age assessment tool
◦ Physical characteristics
 Breasts
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Ballard gestational age assessment tool
◦ Physical characteristics
 Ear cartilage and eyelid fusion
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Ballard gestational age assessment tool
◦ Physical characteristics
 Genitals
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Ballard gestational age assessment tool
◦ Neuromuscular characteristics
 Posture
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Ballard gestational age assessment tool
◦ Neuromuscular characteristics
 Square window
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Ballard gestational age assessment tool
◦ Neuromuscular characteristics
 Arm recoil
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Ballard gestational age assessment tool
◦ Neuromuscular characteristics
 Popliteal angle
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Ballard gestational age assessment tool
◦ Neuromuscular characteristics
 Scarf sign
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Ballard gestational age assessment tool
◦ Neuromuscular characteristics
 Heel-to-ear extension
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Small for gestational age
Appropriate for gestational age
Large for gestational age
Growth curves
Accuracy of anthropometric measures in
newborns
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Head/body ratio
Position
Motor activity
Cry
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Vital signs
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Thermoregulation
Respirations
Pulse
Blood pressure
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Skin
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Peeling
Lanugo
Normal color variations
Jaundice
Common alterations
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Head
◦ Molding
◦ Caput succedaneum
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Head
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Cephalohematoma
Sutures
Fontanels
Symmetry
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Eyes
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Chemical conjunctivitis
Blink reflex
Red reflex vs. opacities
Sclerae
Tracking
Doll’s eye phenomenon
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Ears
◦ Position
◦ Skin lesions or tags
◦ Hearing
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Nose
◦ Appearance
◦ Patency of nares
◦ Flaring
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Mouth
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Palate
Tongue, frenulum
Buccal mucosa
Gums
Gag, suck, swallow
Epstein’s pearls, neonatal teeth, inclusion cysts
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Neck
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Position
Appearance
Torticollis
Webbing, skin folds
Clavicles
Chest
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Chest and Lungs
◦ Appearance—Barrel chest?
◦ Breasts—Engorgement? Nipple discharge?
◦ Respirations—Periodic breathing? Retractions?
Grunting?
◦ Breath sounds
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Heart
◦ Location of apical impulse
◦ Murmurs
◦ Pulses
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Abdomen
◦ Appearance
◦ Bowel sounds
◦ Umbilicus and umbilical cord
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Genitalia and anus
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Appearance and relation to gestational age
Females—vaginal discharge
Males—penis, urethra, testes
Patency of anus
 Stooling pattern
 Anal wink
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Extremities
◦ Deformities
◦ Injuries
◦ Developmental hip dysplasia
 Symmetry of creases
 Allis sign
 Barlow-Ortolani maneuver
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Spine
◦ Muscle strength and position
◦ Head control
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Neurological system
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Alertness
Posture
Protective reflexes
Primitive reflexes
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Apply the nursing process to the care of the
pediatric patient in various acute care
settings
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Acute
Isolation
Emergency
Intensive Care
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Unaware of illness and its effects
Sense stress and anxiety in loved ones
Awareness of self as separate from parents by
6 months
Stranger anxiety
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Sees illness as punishment
◦ Has incorrect cause-and-effect perceptions
◦ Begins to understand concept of germs
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Knows outside body-part names
◦ Has vague knowledge of internal organs
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Knows cause and effect of illness
Beginning understanding of body functions
Older school age can understand
explanations
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Understands complex nature of illness
◦ Multiple causes and effects
◦ Knows location and function of major organs
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Concerned with
◦ Effects of illness on appearance
◦ Body image
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Protest
◦ Screaming, crying, clinging
◦ Resists attempts to comfort
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Despair
◦ Sad, withdrawn, quiet
◦ Cries when parents return
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Denial
◦ Protest subsides, shows interest in setting
◦ Appears happy and content
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Separation
◦ All ages affected
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Fear of the unknown
◦ Injections, blood, being touched by strangers
◦ Pain, disfigurement, invasive procedures, death
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Loss of control
◦ Mobility, autonomy, privacy
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Separation
◦ Withdrawal, abandonment, regression
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Fear of the unknown
◦ Sleep disruption, anxiety reactions
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Loss of control
Aggression, regression, displacement
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Disruption of daily routine
Role change
Anxiety and fear
Need support, encouragement, honest
information
Coping strategies
Cultural views
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Assess family
◦ Roles, knowledge, support systems
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Planned hospitalization
◦ Tours, videos, books to prepare
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Unplanned hospitalization
◦ Great stress on child and family
◦ Siblings may feel guilt, fear, or neglect
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Depend on
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Age
Developmental level
Perception and severity of illness
Prior experience and coping
Knowledge and understanding of illness
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Honesty
Reassurance: they did nothing wrong to cause
the illness
Allow questions and discussion of feelings
Encourage visits: prepare patient and siblings
to minimize adverse reactions
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Recreation: toys, games, activities, physical
activity
Rest: calm, quiet; bedtime rituals
Relationships: family members, siblings,
peers, support groups
Routines: follow normal routine, provide
transition objects, provide consistent
caregivers
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Rooming in
◦ 24/7 parental visitation/family time
◦ Parental involvement with care
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Communication
◦ Phones, beepers, location of family members
◦ Contact for change in condition, procedures
◦ Education
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Maximize control
◦ Give choices
◦ Encourage independence
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Therapeutic play
◦ Address fears, concerns
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Therapeutic recreation
◦ Interactive activities
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Minimize fears and anxieties
Incorporate familiar routines into
hospitalization
Support family and loved ones
Minimize loss of control; promote autonomy
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Assessment
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Knowledge and previous experiences
Developmental age
Coping abilities
Feelings: fears, concerns
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Communication based on developmental level
◦ Clear
◦ Honest
◦ Age appropriate
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Assess: knowledge, perception, and feelings
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Purpose
Past experience
Will it be painful?
Coping techniques
Will parents be present?
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Communication
◦ Use understandable language
◦ Gear to cognitive level and past experience
◦ Share ways to cope during the procedure
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Physical preparation
Depends on age and procedure
NPO?
Procedural checklist
Pain management
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Focus on psychosocial needs
Age-appropriate play
Medical play/acting out procedures
Therapeutic play
Dramatic play
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Storytelling
Drawings, body outlines
Music, tape-recorded messages
Puppetry
Dramatic play
Animal-assisted therapy
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General pediatric units
Emergency department (ED)
Neonatal intensive care unit (NICU), pediatric
intensive care unit (PICU), or special care
units
Preoperative and postoperative units, postanesthesia care units (PACU)
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Short-stay, outpatient, or ambulatory surgical
units
Isolation
Rehabilitation
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Provides feelings of control
Prepares family for care required at home
Reduces emotional stress and anxiety
Promotes feelings of value, worth, and
competence to care for their child
Promotes parents feeling fully informed, trust
of nursing staff
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Family ability to provide care
◦ Equipment, training
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Financial burdens
Educational needs
◦ Parent teaching
◦ Return to schoolwork
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Plans for school, recovery, adaptation
◦ Individualized education plan (IEP)
◦ Individualized transition plan (ITP)
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Prepare the family
◦ Procedures, medications, emergencies
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Prepare parents to act as case managers
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Preoperative
◦ Teach purpose, sensations
◦ Allow transition objects: teddy bears, blankets
◦ Parental presence during anesthesia induction
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Postoperative
◦ Expectations during recovery
◦ Monitoring and assessment
◦ Nursing Care Plan:The Child Undergoing Surgery
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Informal or structured
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For child and parents
Consider timing and level of understanding
Consider special health needs
Translators if needed
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Teaching plans: include all the domains
◦ Cognitive
◦ Psychomotor
◦ Affective
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Assess
◦ Knowledge, skills, feelings, expectations
◦ Cognitive level, ability, desire
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Set clear, measurable goal(s)
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Select method(s)
◦ Audio, video, text, demonstration, or combination
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Evaluate learning outcome
◦ How well was goal met?
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Effect on understanding of death
Effect on behavioral response to death
Effect on ability to communicate about death
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Describe the nursing interventions and stages
of grief associated with the chronically ill or
dying child
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Parent
Grandparent
Friend
Pets or objects
Loss of an aspect of self
Loss of an object or pet
Separation from an accustomed environment
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Losses not directly related to the child
◦ Crime
◦ Disasters
◦ Terror attacks
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Cultural traditions and practices
Religion and spirituality
Social support systems
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Promote open communication
Struggle with emotions is common
Identify what is known, how much child wants
to know
Listen and give support
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Decision is extremely difficult
Parents or nurses may feel that aggressive
therapies extend child’s suffering
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Parents and healthcare providers may
disagree regarding interventions
Refusal may be based on religious beliefs or
desire to provide peaceful death
Technical interventions may cause emotional
stress to parents
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Court interventions may be used
Consultation with hospital ethics committee
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Palliative care—an approach to improve QOL
Hospice care—care focusing on ensuring
comfort
Do Not Resuscitate request
Tissue and organ donation
Autopsy
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Privacy
Body language
Social support
Response to emotions
Timing
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Illness- or injury-dependent changes
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Universal changes
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Cardiovascular system
Respiratory system
Neurological system
Musculoskeletal system
Renal system
Altered nutrition
Fluid and electrolyte imbalance
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Fears and concerns
Coping skills
Awareness
◦ Closed awareness
◦ Mutual pretense
◦ Open awareness
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Spiritual needs
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Fear
Hopelessness
Risk for caregiver role strain
Interrupted family processes
Anticipatory grieving
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Goal setting
Competencies for high-quality end-of-life
care
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Special concerns
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Pain management
Trust
Anger
Education
Desired religious or cultural practices
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Allow as much time as needed for farewells
Provide privacy
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Save clothing and personal items
Collect footprints, locks of hair, and so on
Preserve the last clothes worn in a sealed bag
to retain the child’s scent
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Identify and implement any religious or
cultural practices desired by the family
Clean and position the body
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Help parents predict when they may expect
increased grief
Remind parents to care for themselves
mentally and physically
Tell parents that people progress through
grief at different rates
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Remind parents that grief puts a tremendous
stress on relationships
Encourage parents to provide for ongoing
support of siblings
Arrange for continued follow-up for families
after the acute period of grief
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Helpless
That they failed the dying child
Sad
Grief
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Special preparation is required for the nurse
◦ Mentorship with hospice nurse
◦ Debriefing sessions with mental health professional