NUR320 - Exam 1 Study Guide - Part II

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textbook supplementals from textbook and mynursingkit.com

Chapter 1: Nurse's Role in Care of the Child: Hospital, Community Settings, and Home

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■ Roles of nurses in caring for children include providing direct care (health promotion, health maintenance, and nursing care for health conditions), patient education, patient advocacy, and case management, and minimizing the psychological and physical distress experienced by children and their families.

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■ Nurses care for children in many different settings: various units within the hospital and outpatient clinics, schools, childcare centers, physician offices, community health centers, rehabilitation centers, and the home.

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■ Family-centered care is a method designed to meet the emotional, social, and developmental needs of children and families needing health care.

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■ Nurses must identify culturally relevant facts about their patients to provide appropriate and competent care to an increasingly diverse population.

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■ Unintentional injury is the leading cause of death for children between 1 and 1 9 years of age.

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■ Efforts to increase the number of children with access to health care include the State Children's Health Insurance Program (SCHIP) currently being implemented nationwide.

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■ Documentation of nursing care is essential for risk management and quality improvement. Documentation must include the patient assessment, the nursing care plan, the child's responses to medical therapies and nursing care, and the regular evaluation of the child's progress toward nursing goals.

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■ Informed consent is the formal preauthorization for an invasive procedure or participation in research. Parents typically give informed consent for children under 18 years of age unless the child is an emancipated minor, a self-supporting adolescent not subject to parental control.

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■ Children need to become more actively involved in decisions about their care as their decision-making abilities develop. Even though they cannot provide informed consent, federal guidelines mandate that children as young as 7 years of age receive information about treatment procedures and research project participation and give their assent.

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■ Because adolescents fear disclosure of confidential information, they may avoid seeking health care. When adolescents have a reportable disease, it is important to inform them that confidentiality cannot be maintained, as a report must be made to a public health agency.

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■ Adolescents at a higher risk of death due to a serious acute or chronic condition should be encouraged to talk with their parents and jointly prepare advance directives.

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■ Federal regulations require a formalized ethical decision making process to assist healthcare providers and families in making important decisions about witholding, withdrawing, or limiting a child's therapy.

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CRITICAL THINKING IN ACTION:
Drew Santo is a 3-year-old boy who has a seizure disorder that until a week ago was fairly well controlled by medication. He and his family receive health care at the center serviced by their health plan. A pediatric nurse and pediatrician collaborate in providing Drew's health care and monitoring his developmental progress. Drew had a seizure in the last week. His phenytoin blood level, taken the day of the seizure, was slightly lower than the therapeutic range. This likely indicates that his parents have given Drew his medication fairly regularly, but perhaps he needs a higher dosage or a different medication. Because of the recent seizure, an electroencephalogram (EEG) is ordered to identify any change in the electrical pattern in the brain. Other laboratory tests are also ordered, following the guidelines of the health center's clinical pathway for children with seizure disorders. Over the past 2 years, Drew's family and the pediatric nurse have worked in partnership to ensure that Drew is treated as a healthy child with a chronic condition. The nurse has helped his parents to obtain information about his condition, to understand the action of his medication, and to take appropriate measures when he has a seizure. Drew's parents are upset that he has again had a seizure, especially when they have done everything they could to keep the seizures under control. They have been able to think of him as a normal boy because he had not had a seizure for a long time. Now they wonder if they will be able to keep treating him that way. In how many different settings could you find nurses providing care to children with this condition? Does the type of nursing care provided to children differ among these settings?

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INTRODUCTION:
Return to the scenario about Drew at the beginning of the chapter. Despite his seizure disorder Drew has been developing normally, meeting expected developmental milestones as evaluated by the Denver II (see Chapter 11).

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DESCRIPTION:
The pediatric nurse has worked closely with the family to ensure that all of Drew's healthcare needs are addressed during health promotion and health maintenance visits. Prior to the seizure, the nurse had been helping the parents to ensure that all healthcare requirements were met for Drew to attend a new childcare center. The pediatric nurse will now modify the nursing care plan to integrate the needed diagnostic procedures and treatment for Drew's seizure disorder, and to help the parents manage their increased concerns about his seizure disorder.

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DISCUSSION
1 . Identify all the roles of Drew's nurse in working with this child and his family. What other roles could nurses have within this healthcare center and in other settings to support the nursing care provided to Drew and his family? Consider the roles of a nurse manager in the healthcare setting, a nurse consultant to the childcare center, and a nurse in the emergency department.

The roles for the nurse are direct care provider, advocate, educator and case manager. The nurse is a liaison to other personnel in the preschool and any other activity in which the child participates. The nurse consultant would partner with the health care provider and family to assess, plan, implement and evaluate emergency care plans in the preschool. This plan may also include safe delegation of health care in the community setting. The emergency room nurse participates in evidence based practice for emergency treatment of seizures. Any nurse will be participating in research activities that may direct the care of children with seizures.

2. Informed consent is often needed before diagnostic procedures are performed and prior to releasing healthcare information. What is the process for obtaining informed consent in your healthcare setting? What is the nurse's role in the process? What needs to happen before health information is released to the childcare center? How does this healthcare facility ensure compliance with HIPAA?

The first step in obtaining informed consent is to determine who has legal responsibility for the child. This may be done in partnership with social services. Prior to the procedure, the person performing the procedure will obtain the consent. The nurse is often the witness. The nurse will also be the person who is available for additional explanation if the parents/guardians need it. The nurse is responsible to assure that the proper consent is in place before the procedure is performed. A release of information signed by the parent/guardian is required before releasing information to the child care center. The child care center OR the health care provider may initiate the release of information. HIPAA regulations are posted and families sign a statement that they understand their rights. Physical privacy barriers are in place.

3. The healthcare setting where Drew receives care has an evidence-based clinical pathway for the management of children with seizures. Identify a clinical pathway that has been developed for a pediatric healthcare condition in your healthcare setting. How is the clinical pathway used and how does this process differ from implementation of a nursing care plan?

An example of a clinical pathway would be for children with asthma in the hospital setting. The pathway is utilized by all care providers from the emergency department and the inpatient units. It dictates all aspects of care from an interdisciplinary standpoint. The plan includes medical interventions, diagnostic tests, comfort measures, family centered care, goals and outcomes, and discharge parameters. It differs form a nursing care plan because it is developed and implemented by ALL health care team members. The nursing care plan is specifically individualized for the child and family, whereas the clinical pathway is a general population guideline.

4. Describe the nursing interventions for the modified nursing care plan for diagnostic procedures, treatment, and family concerns.

Nursing interventions for the modified care plan include:
Preparation for the child for the indicated tests, educating family and child with developmental appropriate methods, offering support for family concerns and linking family with available resources as needed.

accommodation

The process of changing an individual's cognitive structures to include data from recent experiences.

adherence

The extent to which a patient or parent acts consistently with regard to recommended care.

advance directives

A patient's living will or appointed durable power of attorney for healthcare decisions.

Advocacy

Acting to safeguard and advance the interests of another.

Assent

Voluntary agreement to participate in a research project or to accept treatment.

autonomy

Right for self-determination in decision making or to protect the informed choices of patients who are capable of decision making.

Beneficence

An obligation to act or make a decision to benefit the patient.

Case management

A process of coordinating the delivery of healthcare services in a manner that focuses on both quality and cost outcomes.

Clinical pathways (critical pathways)

Structured care plans for a specific patient problem that outline patient goals and essential steps in the management of a child by multiple healthcare professionals within a healthcare facility.

Clinical practice guidelines

Specific medical and nursing assessments and interventions that occur during specific time intervals for a specific condition; often adopted by an institution for all healthcare providers to follow so that quality of care is increased and costs of care are minimized.

competence

An ability to be involved in healthcare decisions requiring a certain degree of intellect, an ability to communicate, and an ability to remember.

Confidentiality

An agreement between a patient and a provider that information discussed during the healthcare encounter will not be shared without the permission of the patient.

continuity of care

An interdisciplinary process of facilitating a patient's transition between and among settings based on changing needs and available resources.

Critical thinking

An individualized, creative thinking or reasoning process that the nurse uses to solve problems.

emancipated minors

Self-supporting adolescents under 18 years of age not subject to parental control.

Ethics

The philosophic study of morality, and the analysis of moral problems and moral judgments.

Evidence-based practice

Integration of the best research evidence with an individual's clinical expertise and the patient's values or preferences.

Family-centered care

A partnership between families, the nurse, and other health professionals in which the priorities and needs of the family are addressed when the family seeks health care; a dynamic, deliberate approach to building collaborative relationships between health professionals and families that are respectful of diversity and beliefs about the nature of the child's condition and ways to manage it.

Health literacy

The degree to which individuals have the capacity to obtain and understand basic health information needed to make appropriate health decisions.

healthcare home

A continuous, comprehensive, family-centered, and compassionate source of health care. Also known as a medical home.

Informed consent

A formal preauthorization for an invasive procedure or participation in research.

Justice

Fairness in the use of resources.

Managed care

A health delivery system that combines financing and delivery of specified healthcare services with the following elements in place: clinicians are contracted to provide services for a preset fee, clinicians are selected according to specific standards, formal programs of quality assurance and utilization review are in place, and members of the health program have incentives to use selected clinicians.

Mature minors

Adolescents of 14 and 15 years of age who are able to understand treatment risks and who, in some states, can consent to or refuse treatment.

Medical futility

The treatment of an irreversibly dying patient that provides no physiologic benefit to the patient.

medical home

A continuous, comprehensive, family-centered, and compassionate source of health care. Also known as a healthcare home.

moral dilemma

A conflict of social values and ethical principles that support different courses of action.

morbidity

An illness or injury that limits activity, requites medical attention or hospitalization, or results in a chronic condition.

Nonmaleficence

To prevent harm.

partnership

A relationship in which participants join together to ensure healthcare delivery in a way that recognizes the critical role and contribution of each partner in promoting health, preventing illness, and managing healthcare conditions.

privacy

Ability of an individual to relate information in a protected manner.

Quality improvement

The continuous study and improvement of the processes and outcomes of providing healthcare services to meet the needs of patients by examining the system and processes of care and service delivery.

Risk management

A process established by a healthcare institution to identify, evaluate, and reduce the risk of injury to patients, staff, and visitors, and thereby reduce the institution's liability.

1 . Which is an important difference between general and advanced practice roles in child health nursing?

1 . Only the general practice nurse can act as a patient advocate.
2. Only the general practice nurse can educate patients and families.
3. Only the advanced practice nurse can act as a case manager.
4. Only the advanced practice nurse can manage medications.

4. Only the advanced practice nurse can manage medications.

Rationale: Both the advanced and general practice nurse are responsible for functioning as a client advocate, can act as a case manager, and can educate clients and families. However, only an advanced practice nurse can manage client medications. Cognitive Level: Application; Client Need: Safe, Effective Care Environment; Nursing Process: Implementation; Learning Outcome: Describe and differentiate between the general and advanced practice nurse roles in child health nursing.

2. In which situations are children at risk of injury? Choose all that apply.

1 . An infant is crawling on the floor while older children are playing nearby.
2. An adolescent is learning how to become a safe babysitter.
3. A toddler is playing on the playground while at preschool.
4. A school-age child likes to imitate her older sibling's movements while on her bike.
5. An adolescent is attending a gathering of school friends after a dance.

1 . An infant is crawling on the floor while older children are playing nearby.
3. A toddler is playing on the playground while at preschool.
4. A school-age child likes to imitate her older sibling's movements while on her bike.
5. An adolescent is attending a gathering of school friends after a dance.

Rationale: In all but one ofthese situations, there is the possibility of the child getting hurt. The infant may put small parts ofthe toys in his/her mouth; the toddler may fall while on the playground; the school-age child may not physically be capable ofsafely doing the same movements as her older sibling; and adolescents are more likely to do activities as a result ofpeer pressure, when other adolescents are around. The safe babysitter class poses no immediate threat to the adolescent's safety. Cognitive Level: Comprehension; Client Need: Physiologic Integrity; Nursing Process: Assessment; Learning Outcome: Analyze the current causes of child morbidity and mortality and identify opportunities for nurses to intervene.

3. In planning an educational session for parents of toddlers concentrating on primary prevention, which indicates the most appropriate topic on which the nurse should concentrate?

1 . Unintentional injury prevention
2. Seizure management
3. Child abuse prevention
4. Sudden infant death prevention

1. Unintentional injury prevention

Rationale: Toddlers ages 1 to 4 are most likely to be hospitalized or killed from unintentional injury. Therefore, the nurse should concentrate on this topic for these parents. Seizure management is not primary prevention, and although child abuse can occur in this age group, injuries occur more frequently. SIDS does not occur in this age group. Cognitive Level: Analysis; Client Need: Physiological Integrity; Nursing Process: Planning; Learning Outcome: Analyze the current causes ofchild morbidity and mortality and identify opportunities for nurses to intervene.

4. A child and his grandfather arrive in the emergency department after a car collision. The grandfather does not have custody of the child. What should be the nurse's next action?

1 . Obtain the custodial parent's telephone number for permission.
2. Provide emergency care to both under implied consent.
3. Register and provide care to the grandfather but transfer the child.
4. Ensure permission to treat is obtained prior to registering them.

1. Obtain the custodial parent's telephone number for permission.

Rationale: No indication is given regarding the nature of the injuries for either the grandfather or the child. Therefore, permission to treat should be obtained from the custodial parent. Implied consent only applies in life or death situations and there is no indication ofthis in the stem. Registration can occur while permission to treat is obtained, and transferring cannot occur until the child has a medical screening exam. Cognitive Level: Application; Client Need: Physiological Integrity; Nursing Process: Implementation; Learning Outcome: Contrast the policies for obtaining informed consent of minors with policies for adults.

1. Which role would the nurse be serving when helping parents understand and respond to the needs of an ill child's siblings?

1. Advocate
2. Researcher
3. Educator
4. Case manager

1. Advocate

Rationale: The nurse acts to safeguard the child's interests by educating and supporting his parents; therefore, advocate is correct. A team effort is not being coordinated as it relates to the child's needs, so case manager is incorrect. The nurse is, in fact, educating the child's parents. The education is focused specifically on advocacy in relation to the child's needs, so educator also is incorrect. Though the nurse would certainly want to provide evidence-based care to the family, the role in this instance is that of an advocate for the child, not a researcher.

2. In planning care for a student with a seizure disorder, the school nurse considers that this child's educational rights are protected by which most recent federal legislation?

1. Title V
2. Healthy Start
3. The Individual with Disabilities Education Act
4. Sheppard-Towner Act

3. The Individual with Disabilities Education Act

Rationale: The Individual with Disabilities Education Act was designed to ensure that all children have access to appropriate education in the least restrictive environment. The other choices are not the most recent. Review IDEA 1997.

3. Prior to identifying a nursing diagnosis for a 3-year-old child with seizure disorder, it is important that the nurse:

1. Define nursing intervention classifications (NICs) relevant to his care.
2. Carry out interventions specified in the nursing care plan for him.
3. Synthesize data to make a judgment about the child's problems.
4. Use both objective and subjective measures to assess progress in meeting goals for the child.

3. Synthesize data to make a judgment about the child's problems.

Rationale: It is important to assess prior to making decisions; therefore, synthesizing data to make a judgment about the child's problems is the best answer. Carrying out interventions specified in the nursing care plan for him would be premature; remember that the nurse should assess before any intervention. Defining nursing intervention classifications (NICs) relevant to his care would not be done yet; after assessing, the nurse would examine the NIC database. Using both objective and subjective measures to assess progress in meeting goals for the child also is incorrect. First the nurse would have to define those goals, following a comprehensive assessment.

4. The nurse assigned to care for a 3-year-old child with seizure disorder is unsure of protocols for nursing management of children with seizure disorders. To identify the best evidence to use to provide care, the nurse should consult:

1. Internet search engines.
2. Critical pathways for 3-year-old children.
3. Clinical practice guidelines.
4. Research studies.

3. Clinical practice guidelines.

Rationale: Clinical practice guidelines are most valuable in promoting uniformity and excellence in care. The wealth of both credible and incorrect information on the Internet precludes the use of Internet search engines for best care. A synthesis of the best research is provided in clinical practice guidelines. Individual articles are not sufficient as guides to practice. Because the child is 3 years old, the nurse would need to consult only critical pathways that have as their focus protocols for managing seizures in children. These are found in clinical practice guidelines.

5. The nurse is planning educational interventions to reduce the incidence of the number one cause of mortality in children ages 1 to 4. Recognizing the developmental needs of this age group, the nurse would focus the session on which topic?

1. Child abuse prevention
2. Seizure disorder management
3. Unintentional injury awareness
4. Sudden infant death syndrome (SIDS) recognition

3. Unintentional injury awareness

Rationale: Unintentional injury awareness includes motor vehicle accidents, so teaching should include prevention factors. Although all the other choices are a significant cause of mortality, they are not the number one problem for children ages 1 to 4.

6. The nurse recognizes the need to update knowledge related to the most common cause of hospitalization in children. On which body system should continuing education focus?

1. Cardiac
2. Musculoskeletal
3. Gastrointestinal
4. Respiratory

4. Respiratory

Rationale: Respiratory diseases are the most common admission to hospitals in children from 1 to 14 years old. They account for 33% of hospital discharges in the 1- to 14-year-old age group.

7. The nurse is caring for a pediatric patient not covered by insurance. Which statement to the child's parents regarding the State Child Health Insurance Program is accurate?

1. Eligibility for coverage is determined based on household income and the number of children.
2. Eligibility for the program is determined based on the child's medical diagnosis.
3. Early application is recommended due to the large number of applications received annually.
4. Families are only eligible if the parents are unemployed.

1. Eligibility for coverage is determined based on household income and the number of children.

Rationale: The State Child Health Insurance Program is designed to provide the patient with health insurance comparable to federal/state employee benefit programs. This program is undersubscribed, with lack of knowledge of its eligibility requirements being one of the barriers to subscription.

8. A 15-year-old is hospitalized following her second relapse of acute myelogenous leukemia and is scheduled for a bone marrow transplant. She tells the nurse that she doesn't want to go through with it and that she would rather die. The nurse should:

1. Ensure that her parents sign the informed consent form.
2. Inform the physician and nursing supervisor.
3. Cancel the procedure.
4. Inform the patient's teacher.

2. Inform the physician and nursing supervisor.

Rationale: The child is of an age where issues of consent need to be considered seriously; therefore, informing the physician and nursing supervisor is the best answer. Telling her teacher of her decision violates patient confidentiality. Canceling the procedure is not under the nursing scope of practice. Ensuring that her parents sign the informed consent form does not address the moral conflict in this situation.

Rationale: The child is of an age where issues of consent need to be considered seriously; therefore, informing the physician and nursing supervisor is the best answer. Telling her teacher of her decision violates patient confidentiality. Canceling the procedure is not under the nursing scope of practice. Ensuring that her parents sign the informed consent form does not address the moral conflict in this situation.

9. An adolescent client states that he would rather die than undergo a prescribed treatment. Which of the following ethical principles should direct the nurse in planning care for this client? (Select all that apply.)

1. Nonmaleficence
2. Compassion
3. Justice
4. Beneficence
5. Autonomy

1. Nonmaleficence
4. Beneficence
5. Autonomy

Rationale: Autonomy, the right to self-determination, and involvement in decision making should be respected in all individuals to the extent of their capacities. Adolescents are able to think abstractly and should have this right respected. Often it is compromised. Beneficence - an obligation to act or to make a decision to benefit the client, promoting the child's well-being in addition to working with parents and other family members - and nonmaleficence, preventing harm, also are appropriate. Justice, or fairness in the use of scarce resources, is another ethical principle important to consider in decision making but is not central to this situation. Compassion is considered a virtue, not an ethical principle.

10.In order to administer a medication safely to a pediatric client, what drug information must the nurse be aware of that is not always essential when administering a medication to an adult client?

1. Recommended dose per kilogram of body weight
2. Indicators of drug toxicity
3. Incompatibilities with other medications
4. Commonly expected side effects

1. Recommended dose per kilogram of body weight

Rationale: Children require medication doses based on weight or body surface area. Consequently, nurses must determine the appropriateness of the ordered dose and be able to calculate its preparation. Drug calculations are very complex and consequently pose a greater risk for error.

Rationale: Children require medication doses based on weight or body surface area. Consequently, nurses must determine the appropriateness of the ordered dose and be able to calculate its preparation. Drug calculations are very complex and consequently pose a greater risk for error.

How would you design the content of a smoking prevention patient education brochure for an immigrant population of parents written at the fifth- to sixth-grade level designed to help them counsel their school-aged children? Ensure that the brochure is both linguistically and culturally appropriate.

The brochure should be written in short words of no more than two syllables when possible with words familiar to the target audience (e.g., urinate might be better referred to as pass water). Medical terms should be expressed with simple language (e.g., pulmonary function might be changed to ease of breathing). The brochure should use short sentences as well with active rather than passive verbs. The words used should be well understood by the audience. Including graphics is a great idea. Make sure that they are correct and clearly labeled.

Now design the content of a smoking prevention patient education brochure for a population of 12-year-old students written at the fifth- to sixth-grade level. The brochure should be written in a way that attends to what is important to the children. Ensure that the writing is both developmentally and culturally appropriate.

The brochure should be written in short words of no more than two syllables when possible with words familiar to the target audience (e.g., urinate might be better referred to as pee with a school-aged population). Medical terms should be expressed with simple language (e.g., pulmonary function might be changed to the way you breathe). The brochure should use short sentences as well with active rather than passive verbs. The words used should be well understood by the audience (e.g., until adolescence, children have difficulty understanding abstract concepts). Including graphics is a great idea. Make sure that they are correct, attractive, and clearly labeled.

A 10-year-old client sustained a deep laceration on her leg from falling on a rusty can. She had lost a significant amount of blood by the time she arrived at the hospital with her parents. Neither the child nor her parents agree to an emergency blood transfusion ordered by the physician.

Think about all the reasons why the parents and child might want to select a different treatment than that proposed by the physician (e.g., cultural, religious, protection of child, etc.), and suggest a course of action that respects the family's autonomy while protecting the child from hypovolemia.

Your answer might include their fear of the transmission of disease through blood products; their past experiences with such treatment; their religious orientation, which might forbid transfusions, believing them to be morally and spiritually sinful; and cultural prohibitions from using blood.
Ethical issues arise from a moral dilemma, a conflict of social values and ethical principles that support different courses of action that could be correct, depending on the individual's values and beliefs. Whereas adults are permitted to refuse blood products (even when death can occur), most healthcare institutions have policies that address the care of children in need of blood products.

A 10-year-old client sustained a deep laceration on her leg from falling on a rusty can. She had lost a significant amount of blood by the time she arrived at the hospital with her parents. Neither the child nor her parents agree to an emergency blood transfusion ordered by the physician.

Now consider the point of view of health professionals, and suggest strategies to respect both the physician's and family's points of view.

Physicians educated in North America tend to practice from a biomedical (scientific) rather than a holistic perspective. Ordering a treatment for a child reflects the ethical principles of beneficence, an obligation to make decisions to benefit the patient, and nonmaleficence, the intent to prevent harm. Given the emergency nature of many situations involving moral conflicts around blood products, many practitioners use plasma expanders whenever possible to prevent the need to transfuse blood. However, judicial decisions to use blood products for children sometimes are sought, and the blood is transfused against the judgment of the parents.

A 10-year-old client sustained a deep laceration on her leg from falling on a rusty can. She had lost a significant amount of blood by the time she arrived at the hospital with her parents. Neither the child nor her parents agree to an emergency blood transfusion ordered by the physician.

Think about your response as the nurse providing care to the child and family. How would you participate in the decision-making process?

The answer should include such steps in ethical problem solving as collecting as much information as possible; identifying if surrogate decision makers exist; seeking consultation on all possible courses of action; identifying strengths and benefits of all courses of action; ensuring that the family is an active participant in any decision made; and collaborating with the physician and associated health professionals working with the family.

What factors or evidence led to changes in public health practice that reduced the infant mortality rates in the early 1900s?

By 1915, the infant mortality rate had decreased from 200 per 1,000 (the rate from 1850 to 1880) to 100 per 1,000 live births. Causes of death included communicable disease, poor nutrition, and epidemics of "summer diarrhea." Improvements in infant health stemmed from a national legislative focus on prenatal care and infant health services. Funding allowed the development of initiatives to promote the health of neonates. Regulations were enacted to improve the sanitation of milk, and artificial infant formulas were developed. All of these developments had an impact on mortality rates.

What evidence led to the initiation of school health nursing?

Many children in the early 20th century were absent or sent home from school because of illness. In the Northeast corridor of the United States, physicians inspected schools and examined students to identify infectious disease.

What were the roles of nurses in these historical beginnings of child healthcare services?

In the 1890s, Lillian Wald, RN, recognized the need for health promotion and disease prevention among New York's immigrant population, and in her center, The Henry Street Settlement, nurses actively sought improvements in social conditions affecting health.

In 1902, Wald assigned a nurse to a school as a pilot project that was successful in reducing absenteeism. This school nursing model soon spread to other cities in the United States and Canada. The nurses monitored for illness, educated about personal hygiene and disease prevention, and were successful in their goal to improve the health of children.

Chapter 5: Concepts of Growth and Development

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■ Development unfolds in a predictable pattern, but at different rates dependent on the particular characteristics and experiences of each child.

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■ Major theories of development encompass the psychosexual (Freud), psychosocial (Erikson), cognitive (Piaget), moral (Kohlberg), social learning (Bandura), and behavioral (Skinner and Watson) components of individuals.

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■ The ecologic theory of Bronfenbrenner and the temperament theory of Chess and Thomas emphasize the interactions of the individual within the environment.

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■ Resiliency theory examines risk and protective factors that hinder or help children and families when dealing with developmental and life crises.

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■ Influences on the developmental process include one's genetic potential and a series of environmental influences unique to each family and individual.

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■ The newborn period begins at birth and ends at about 1 month, and is characterized by adaptation to extrauterine life, establishing periods of varying alertness, and specific physical findings.

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■ Infancy spans the time from 1 month to 1 year, and is marked by rapid physical growth, mastery of basic fine and gross motor skills, and beginning cognitive and language skills.

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■ Toddlers range in age from 1 to 3 years, and become increasingly mobile and communicative. They master control over excretion and are known for exerting their own opinions and wishes to parents. Injury prevention and toilet training are specific parental teaching needs.

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■ Preschool years range from 3 to 6 and are marked by increasing social skills. Most preschool children attend childcare programs and learn to play with other children. Continued mastery of physical coordination and language occurs.

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■ School age spans the years from 6 to 1 2, when children mature in many areas. They show slow, steady growth until reaching puberty between 9 and 12 years, when a growth spurt marks increased height and weight, as well as sexual maturation.

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School-age children play cooperatively with other children and participate in various school and community activities.

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■ Adolescence occurs from about 1 2 years of age through the teen years. Adolescents establish their own identities distinct from parents and other adults. They are mature physically and cognitively. The peer group exerts the major influence at this age.

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■ The nurse is involved in assessing development at each stage, and in providing anticipatory guidance to families to foster optimal development.

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INTRODUCTION
Consider Sergio, who was introduced in the chapter-opening scenario. He is now 6 months of age and growing well. His mother has altered her work schedule to stay with him each day; she works for a few hours in the evening when her husband is home. One pair of grandparents live about 30 miles
away and visit frequently. The family has medical insurance but has had to budget carefully to pay household bills since Yolanda is working less and they have expenses connected with Sergio's care.

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DESCRIPTION
Since they have no other children and have limited experience with children, Pepe and Yolanda, Sergio's parents, have all the needs of new parents. Due to prematurity, Sergio has additional needs for developmental surveillance and parental education. Sergio is 24.5 inches (62 cm) long and weighs 1 5 lb (6.8 kg). Some developmental milestones that the nurse observes include:

■ Personal social—smiles, watches his own hand
■ Fine motor—hands meet at midline, regards and watches small objects, and has begun to grasp a rattle
■ Language—turns to sounds and voices, squeals and makes a variety of other sounds
■ Gross motor—holds head steady when in sitting position; holds head and chest up using arms when prone

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DISCUSSION
1 . Sergio and his parents have many challenges and yet possess many strengths. Using the theory of resilience, list the infant's and family's risks and protective factors.

Protective factors:
Baby is well loved and cared for.
Mother's work is flexible so she can care for him during the day.
Father is able to care for infant when mother is at work.
Grandparents are close and visit often.
Family has medical insurance and they access health care.
Care at the clinic is continuous with caring provider
Family is able to maintain housing, food, etc.
Risk factors
Prematurity predisposes infant to respiratory infections and possible developmental delays
Parents are new parents with limited experience.
Income is limited and expenses for family have increased.

2. Calculate Sergio's height and weight percentiles. Consult the growth grids in Appendix Aand the Skills Manual for correct analysis. Since he is steadily growing, what summary can you provide for Sergio's parents? What nutritional advice should you provide for them?

Sergio is just below the 3rd percentile for length and at the 10th percentile for weight. It can be expected that Sergio will be small for his age, but since his growth remains steady, he is fine. The nurse should encourage Sergio's mother to continue to breast feed him, although he should be on supplemental iron. If they haven't already, the parents should begin solid foods, offering one food at a time. Traditionally babies start on rice cereals and progress to vegetables and fruits.

3. Analyze Sergio's developmental milestones. Consult the list of expected milestones in this chapter and on the Denver II Developmental Test in Chapter 9. What skills will Sergio learn next? What specific suggestions do you have for his parents as they seek to encourage his development?

Personal-Social: Sergio will work for a toy and begin to be interested in feeding himself
Fine Motor: Sergio will begin reaching for objects and will develop object permanence
Language: Sergio will continue to develop speech sounds, babble, and say "mama and dada"
nonspecifically. He will enjoy imitating parents' speech sounds

4. Assume that you are the nurse in the clinic where Sergio receives health care. Briefly outline the physical measurements, developmental observations, and family assessments that you will complete at each visit.

Physical measurements: length, weight, occipital frontal circumference, all charted on a percentile chart and monitored according to child's individual trend
Development: Summary of personal social, fine motor, language, and gross motor development relative to established norms and calibrated according to prematurity
Family Assessments: Evaluation of risk and protective factors, family strengths and areas for growth; family resources and coping strategies; parental knowledge regarding child care.

animism

The process of attributing lifelike qualities to nonliving things; common in thoughts of young children.

assimilation

Adopting and incorporating characteristics of a new culture within one's practices.

associative play

A type of play that emerges in preschool years when children interact with one another, engaging in similar activities and participating in groups.

Attachment

A strong emotional bond between people.

centration

Focus on only one particular aspect of a situation; common in thoughts of preschoolers.

cephalocaudal development

The process by which development proceeds from the head downward through the body and toward the feet.

collective monologue

Speaking in separate conversations even though each person waits for the other to speak; common in speech of preschoolers.

conservation

The knowledge that matter is not changed when its form is altered.

cooperative play

A type of play that emerges in school years when children join into groups to achieve a goal or play a game.

defense mechanisms

Technique used by the ego to unconsciously change reality, thereby protecting the individual from excessive anxiety.

Development

An increase in capability or function.

dramatic play

A type of play in which a child acts out the drama of daily life.

Ecologic theory

A theory of development that emphasizes the importance of interactions between the developing child and the settings in which the child lives.

ego

The realistic part of the person, which develops during infancy and searches for acceptable methods of meeting impulses.

egocentrism

The inability to consider the perspective of another; seeing things only from one's own point of view.

expressive jargon

Use of unintelligible words with normal speech intonations as if truly communicating in words; common in toddlerhood.

expressive speech

Words a young child can speak; usually less than the child is able to understand (receptive speech).

Growth

An increase in physical size.

id

The basic sexual energy that is present at birth and drives the individual to seek pleasure.

magical thinking

The belief of young children that events occur because of their thoughts or wishes.

mutagenesis

Permanent changes in the fetus' genetic material.

Nature

The genetic or hereditary capability of an individual.

Nurture

The effects of environment on an individual's performance.

Object permanence

The knowledge that an object or person continues to exist when not seen, heard, or felt.

parallel play

A type of play that emerges in toddlerhood when children play side by side but demonstrate little or no social interaction.

protective factors

Characteristics of a child and family that provide strength and assistance in dealing with a crisis.

proximodistal development

The process by which development proceeds from the center of the body outward to the extremities.

puberty

Period of life when the ability to reproduce sexually begins, characterized by maturation of the genital organs, development of the secondary sex characteristics, and the onset of menstruation in females.

receptive speech

The ability to understand words.

Resilience

The ability to function with healthy responses, even during significant stress and adversity.

risk factors

Characteristics of a child or family that promote or contribute to health system challenges.

Self-efficacy

A person's belief that he or she can change behavior to produce a desired outcome.

solitary play

Playing alone, with one's self.

superego

A moral and ethical system that develops in childhood and contains a set of values and conscience.

teratogenesis

Abnormal development of the fetus.

transductive reasoning

Connecting two events in a cause-effect relationship simply because they occur together in time; common in thoughts of preschoolers.

1 . The nurse notes that a 6-month-old infant boy who weighed 7 pounds at birth now weighs 15 pounds. Based on the evaluation of the infant's current weight, what is the nurse's next action?

1 . Ask the parent why the child does not eat enough.
2. Immediately inform the physician.
3. Chart the assessment.
4. Teach how not to overfeed the baby.

3. Chart the assessment.

Rationale: The baby's weight should be just about double the birth weight by 6 months. The other options treat the weight as if it is either too high or too low. Cognitive Level: Analysis; Client Need: Health Promotion and Maintenance; Nursing Process: Evaluation; Learning Outcome: Synthesize information from several theoretical approaches to plan assessments of the child's growth and developmental milestones.

2. When planning nursing care for a hospitalized 9-year-old child, which intervention is most developmentally appropriate?

1 . Encourage the child to continue schoolwork.
2. Provide a separate recreation room for activities.
3. Encourage the child to brush teeth twice a day.
4. Offer medical equipment for play.

1.; Encourage the child to continue schoolwork.

Rationale: The developmental task ofa 9-year-old is industry according to Erikson; thus, the nurse should encourage the continuation of schoolwork. The separate recreation room is appropriate for adolescents, toddlers need reminders to brush, and playing with medical toys is appropriate for preschool-age children. Cognitive Level: Analysis; Client Need: Health Promotion and Maintenance; Nursing Process: Planning; Learning Outcome: Plan nursing interventions for children that are appropriate for the child's developmental state and that apply developmental theories and frameworks.

3. A mother is watching her school-age child learn self-care techniques after being recently diagnosed with type 1 diabetes. Which is a correct statement?

1 . "Bandura's theory states children learn new behaviors best when imitating others."
2. "Erikson's stages describe school-age children learning by attaining goals."
3. "Piaget believes learning will take place more quickly when abstract thinking develops."
4. "Freud's description of personality development affects learning ability."

1. "Bandura's theory states children learn new behaviors best when imitating others."

Rationale: Goal attainment, developing abstract thinking, and personality development are not as closely related to learning self-care as is Bandura's social learning theory, which is described in option 1. Cognitive Level: Application; Client Need: Health Promotion and Maintenance; Nursing Process: Evaluation; Learning Outcome: Plan nursing interventions for children that are appropriate for the child's developmental state and that apply developmental theories and frameworks.

4. During a developmental assessment, a parent complains that she has a "difficult" toddler. What advice would the nurse offer to the parent?

1 . "Toddlers are flexible. Accepting new rules will occur quickly."
2. "Do not expect the child to adapt quickly to new situations."
3. "Encourage associative play and this will get better."
4. "Spanking your child will make the difficult behavior improve."

2. "Do not expect the child to adapt quickly to new situations."

Rationale: Toddlers are not flexible and do not adapt to anything quickly. Associative play does not occur until preschool age, and spanking should not be encouraged. Cognitive Level: Analysis; Client Need: Health Promotion and Maintenance; Nursing Process: Planning; Learning Outcome: Use data collected during developmental assessments to plan appropriate nursing interventions that promote development ofchildren and adolescents.

1. A 4-year-old who has been toilet-trained becomes incontinent when hospitalized for surgery. The most appropriate nursing diagnosis based on this assessment finding is:

1. Growth and Development Altered related to incontinence.
2. Ineffective Individual Coping related to hospitalization.
3. Urinary Elimination, Altered related to incontinence.
4. Coping, Defensive related to stress of hospitalization.

4. Coping, Defensive related to stress of hospitalization.

Rationale: A toilet-trained 4-year-old who becomes incontinent during hospitalization is coping with the stress of this experience through the defense mechanism of regression. This is an effective means of coping for a child this age.

2. A 14-year-old has been diagnosed with insulin-dependent diabetes. Which technique is most appropriate in order to facilitate coping with this diagnosis?

1. Give the adolescent specific instructions.
2. Introduce the adolescent to another teenager who is successfully managing his diabetes.
3. Warn the teen of the consequences of noncompliance.
4. Encourage increased dependence on parents for several weeks.

2. Introduce the adolescent to another teenager who is successfully managing his diabetes.


Rationale: The adolescent benefits from meeting teens who are successfully managing a similar diagnosis. The adolescent might not respond well to being instructed what to do. Although the teen needs information related to consequences of noncompliance, this should never be in the form of a warning. In addition, this information would not facilitate coping with the diagnosis. The teen needs to remain as independent as possible. Although parents must learn the information as well, the teen still is encouraged to be very involved in his care and to be as independent as possible.

3. Which toy is most age appropriate for a 2-year-old?

1. Playhouse
2. Nesting cups
3. Mobile
4. Toy vacuum cleaner

4. Toy vacuum cleaner

Rationale: A 2-year-old benefits from having push-pull toys that encourage movement and autonomy. Nesting cups are appropriate for older infants. Mobiles are appropriate for young infants. Playhouses are appropriate for preschool-age children.

4. Which intervention is most appropriate in order to facilitate the development of trust in an infant who is hospitalized?

1. Place pictures of the child's family at the bedside.
2. Encourage the parents to room in and participate in care.
3. Offer the infant a pacifier.
4. Play tapes of the mother's voice.

2. Encourage the parents to room in and participate in care.

Rationale: Encouraging parents to stay at the bedside and participate in care promotes a sense of trust in the infant. Placing pictures at the bedside and playing tapes of the mother's voice are more appropriate to decrease the feeling of separation in an older infant and toddler; however, they do not promote the development of trust. A pacifier satisfies the oral needs that an infant has, not the development of trust.

5. Which observation is most representative of the type of play usually seen in toddlers?

1. Two children putting a puzzle together
2. A child who sits on the floor by himself playing with blocks
3. The child who dresses up like a fireman
4. Two children sitting side by side, each playing with a toy truck

4. Two children sitting side by side, each playing with a toy truck

Rationale: Two children sitting side by side playing with similar toys is an example of parallel play, which dominates in toddlers. The child who sits on the floor by himself playing with blocks is demonstrating solitary play, seen in infants. The child who dresses up like a fireman is demonstrating dramatic play, seen in preschool-age children. Two children putting a puzzle together are demonstrating associative play, also characteristic of preschool-age children.

6. The nurse notes that a 5-month-old has significant head lag when she attempts to pull the infant to a sitting position. Based on this assessment, the nurse recognizes that the infant:

1. Has some degree of mental retardation.
2. Is developing normally.
3. Needs further assessment and evaluation.
4. Has been neglected by the parents.

3. Needs further assessment and evaluation.

Rationale: Head lag should not be present in a 5-month-old. The nurse cannot conclude that the child has been neglected or has some degree of mental retardation based on head lag alone. The child needs further assessment and evaluation.

7. The nurse is preparing a 4-year-old for surgery. Which technique is most appropriate?

1. Allow the child to handle safe medical equipment.
2. Limit the teaching to one 1-hour session.
3. Use an anatomically correct doll to explain the procedure.
4. Explain to the child that she will be put to sleep for the procedure.

1. Allow the child to handle safe medical equipment.

Rationale: The preschool-age child learns well by participating in therapeutic play, such as handling safe medical equipment. Terms such as "put to sleep" might be misinterpreted by the child. Anatomically correct dolls are not appropriate for preschool-age children. The preschool-age child benefits from several short teaching sessions.

8. Which nursing intervention is most developmentally appropriate for a hospitalized 10-year-old?

1. Allow the child to assist with dressing changes.
2. Encourage the child to play with safe medical equipment.
3. Encourage dependency on parents while the child is hospitalized.
4. Obtain a complete health history from the child.

1. Allow the child to assist with dressing changes.

Rationale: Allowing the child to participate in care and assist with procedures such as dressing changes promotes the development of industry, characteristic of school-age children. Playing with safe medical equipment is more appropriate with preschool- and young school-age children. Encouraging dependency does not promote the development of industry and could lead to a sense of inferiority. The 10-year-old probably will not be able to give a complete health history.

9. The nurse notes that a 6-month-old infant who weighed 7 pounds at birth now weighs 15 pounds. What is the nurse's evaluation of the infant's current weight?

1. The infant should be hospitalized for failure to thrive.
2. The infant's weight is appropriate for his age.
3. The infant needs weekly follow-up to assess weight.
4. The infant has been consuming more calories than needed.

2. The infant's weight is appropriate for his age.

Rationale: The infant should double his birth weight by 5 to 6 months; therefore, the weight of 15 pounds is appropriate. There is no need for weekly weights in an infant who is thriving. There is no indication of failure to thrive, nor is there any indication that the child has been consuming too many calories.

10. A child who weighed 8 pounds at birth should weigh __________ pounds at 12 months of age.

24

A child should double his birth weight by 5-6 months and triple it by one year.

What are some of the values that adolescents might develop?

These values might relate to respect for others, responsibility for actions, or establishing goals.

What questions can you ask teens that might help you to learn some of their values?

Examples of some questions are: "Have you started to think about what you will do after graduation?" "What sports do you enjoy?" "Do you ever drive after drinking?" "What happens when you do something your parents do not approve of?"

Why would it be important for a nurse to examine adolescent identity information in caring for teens in the hospital or community?

The nurse needs to realize that adolescence is a time when the teen has a need to leave the past and be different—to establish self-identity. Rules might be broken in the quest to establish self-awareness. If the teen is diagnosed with a chronic illness during this time, difficulties may arise. The teen might rebel because the illness is interfering with the need for independence and control. Introducing the adolescent to a teen who has managed the same problem is generally very successful.

When preparing a preschooler for a procedure, do you think it would help to have someone who has had the procedure before come and talk with the child? Will the child be interested in hearing the perspective of another?

Probably not. A more effective approach is to teach the child what it will feel like to her. Show her pictures, take her on tours, and let her touch and use stethoscopes and other materials to increase her understanding.

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