Chapter 21: Caring for the Child in the Hospital, the Community, and Across Care Settings Flashcards
Growth and Development
- children primarily learn through stimulation and play
- play helps children develop fine and gross motor skills, hand-eye coordination, communication skills, social skills, problem-solving skills, and memory development
- nursing care should focus on providing toys and stimulation that are appropriate based on developmental age of the child and the situation
- nurse can encourage the family members to bring the child’s favorite things from home to minimize stress and create a sense of safety for the child as he or she receives care in different settings
- when hospitalization is required, healthy restoration is priority, but consideration of growth and development must be included in the nurse’s plan of care
Gathering Health History: Establishing a Relationship with the Patient and Family
-children vary in language skills, clarity of speech, cognitive abilities, and social skills
-some children can verbalize where they hurt, other may react by crying
>each child must be approached with these differences in mind; any differences that fall out of the realm of what is considered normal growth and development should be noted by the nurse and other members of the health care team
-for the infant or nonverbal child, the nurse begins the health history with an interview of the parents, grandparents, foster parents, or any adult guardian accompanying the child to the health-care setting
-After introductions are made, important to clarify the identity of the person who has brought the child in for care
-Young children need to feel secure before engaging in conversation with the nurse; the nurse should establish a rapport with the parent first; once the child feels comfortable with the nurse present, the child may be more apt to contribute to the interview process
-The older-school aged child may elect to be interviewed without the parent in the room; this allows the child to speak freely of his concerns and to ask questions regarding his health; nurse should peak with the parent separately to determine if the parent has specific concerns or issues that may need to be addressed during the visit
-With the adolescent, the nurse may ask the parent to leave the room during the discussion of issues r/t social and sexual content; adolescent needs to know that a discussion can take place without the parents knowledge to allow for the provision of appropriate medical and nursing care that will ensure safety of the child
>exceptions to maintaining confidentiality involve instances concerning abuse or a life-threatening situation
Family Dynamics
family dynamics are assessed by observing the behaviors between the child and his parents
>Questions to consider:
-during a health-care visit, does the parent or caregiver seem appropriately concerned about the problem?
-does the parent or caregiver have the information that a responsible parent would know regarding the child’s illness, past medical history, and immunizations? Is the Parent or caregiver a reliable historian?
-is the parent or caregiver providing comfort to the child if the child is frightened?
-does the parent or caregiver appear angry about being in the office?
-is the parent or caregiver aware of the needs of the child?
-does the child look well cared for?
Asking Questions
- interview conducted in a comfortable room with available seating for the parent and with eye-level interaction with both parent and child
- unhurried environment; encourages the parent to ask questions appropriate to the health of the child
- nurse projects a genuine interest in and a desire to help the child and family; lays foundation for a positive therapeutic relationship
- open-ended questions allows for concerns to be explored, as the nurse invites the child or parent to tell his story by asking, “how can I help you today?” or, for a problem-oriented visit, “what made you come in today?”
- a focused or problem-oriented health history is then obtained
- When clarifying the child’s history, nurse may use the mnemonic OLD CAT to ask appropriate questions
- after chief complaint is determined, the child’s past medical history is reviewed: past acute illness and history of chronic illnesses, immunization history, hospitalizations, emergency room visits, serious injuries, operations, and current medication usage
- inquiries are made as to the use of any OTC medications, herbal preparations, or folk remedies and any history of allergic reactions to food, medications, and environmental allergens
Mnemonic “OLD CAT”
used to ask the appropriate questions or a child
ex:
-Onset: “when did the pain start?”
-Location: “where is the pain?”
-Duration: “how long does the pain last?”
-Character: “can you tell me on a scale 1 to 10 how bad it is?”, Or, for a younger child, ask the parent, “how much pain do you think the child is experiencing?” or use a pain scale that is appropriate for the child’s level of development
-Aggravating/Alleviating: “what has made the pain better or worse?”
-Timing: “when does the pain start/stop?”
Mnemonic “SODA”
the impact of the current illness is evaluated by inquiring about the child’s daily activities
- Sleep: “how has your child been sleeping?”
- Output: “how many times per day do you____?” (use the expression the family has adopted to convey urine/stool output) or, for the younger child ask, “how many wet diapers has he had today?”
- Diet: “how much fluid has your child taken in today?”
- Activity: “has the child’s activity level changed since he has been ill?”
Comprehensive Health History
- Family Medical and Social History
- Past Medical History
- Immunizations
- Developmental Milestones
- Patterns of Daily Activities (Sleep, Nutrition)
- Macronutrients (Protein, Carbohydrates, Fat, Play, Activities, and School)
- Review of Systems
Comprehensive Health History: Family Medical and Social History
documenting the current household makeup and the age and health of each family member
- ages and cause of death of any deceased parents, grandparents, and siblings
- chronic illnesses experienced by family members
- inherited diseases
- parent’s professions, religious affiliations or spiritual beliefs, and family activities
- for the older child, interviewed without the presence of the parent, the social history must also include information regarding grade level, friendships, drug or alcohol use, smoking, sexual activity, and safe sex practices
Comprehensive Health History: Past Medical History
- history of the pregnancy, labor and delivery, and the health of the baby at birth; birth weight and APGAR scores; any difficulties in feeding, breathing, jaundice, or other medical problems in the early neonatal period
- Past medical hx in child includes: all acute illnesses, chronic illnesses and the medications prescribed, herbal products, and home remedies
Comprehensive Health History: Immunizations
- common childhood diseases the child may have had are documented
- any immunizations received; if any are current; maintaining current immunizations protects the child and family against preventable communicable diseases
Comprehensive Health History: Developmental MIlestones
- solid foundation in growth and development is a necessity for the nurse working in a pediatric setting
- developmental assessment is essential to determine if a child’s development is within normal range, delayed, or the child is at risk
- milestones can be assessed using the Denver II Screening test in children from birth to 6 years
Denver II Screening Test
can be used to assess developmental milestones in children from birth to 6 years of age
-assesses personal-social, fine-motor adaptive, gross motor, and language skills
-nurse documents the child’s behavior during administration of the test, including compliance, interest in surroundings, fearfulness, and a subjective measure of the child’s attention span
-after the test has been administered, the parents may be asked if the child’s performance was characteristic of his normal behaviors
>Referral is needed when the child has “failed” the test with 2 or more delays, if there is no improvement in areas of concern 3 months after the initial screen, or if the child is determined to be “un-testable” at two consecutive screenings
Comprehensive Health History: Patterns of Daily Activities: Sleep
- nurse must determine both the number of hours and the quality of sleep the child receives each night
- sleep requirements change as the child grows, and each child’s sleep requirements are different
- newborns= sleep 16 or 17 hours a day, in stretches of 2 to 3 hours at a time; babies able to sleep through the night by 6 months
- children: some can sleep anywhere under any conditions while other suffer sleepless nights if there is even the slightest change in their normal routine; naps may be part of a child’s life up to the preschool years; may experience nightmares or night terrors that can disrupt sleep, nightmares may reflect the struggles children experience during the day or the fears a child has regarding separation, impulses, or conflicts; night terrors occur during first few hours of sleep; nightmares and night terrors can be frightening experiences; a child can recount her nightmares; the child has no recollection of night terrors
Comprehensive Health History: Patterns of Daily Activities: Nutrition
- questions based on child’s age
- if the infant is breastfed, information on how often and for how long the child is fed at each feeding and how many wet diapers are changed in the course of one day; sufficient breast milk intake= six or more wet diapers and gain weight
- if the infant is receiving formula, information on type of formula, the amount taken at each feeding, and the number of feedings per day; note if and when juices or solid foods have been started and whether supplements or vitamins have been prescribed
- children and adolescence, a 24-hour recall elicits the food items eaten in a typical day and reflects sociocultural trends
- document food allergies for all children
- foods ad caloric intake should be appropriate for age and developmental level
Comprehensive Health History: Macronutrients
> Protein:
-10 to 35% of daily caloric intake must come from protein sources such as dairy products, eggs, lean meat, seafood, poultry, beans, and peas (e.g. pinto, lentils, lima, split pea, and white beans), soy products (e.g. soy bean, tofu, and veggie burgers), and nuts and seeds (e.g. almonds, peanuts, and sesame seeds); protein each week should include 8 oz of seafood because this is a good source of lean protein and omega-3 fatty acids; after age 2, whole milk should be switched to low-fat or skim milk
Carbohydrates:
-account for 45 to 65% of daily caloric intake; grains, fruits, and vegetables; half of all grain servings per day should be whole grains like quinoa, oatmeal, and brown rice or pasta
Fat:
-20 to 35% should be from fat; saturated fat (those solid at room temp) are implicated in the development of heart disease; animal fat (meat and milk products) is the main source of saturated fat; important to recommend skinless poultry, lean meat, and fat-free milk when preparing meals for children; unsaturated fat (liquid at room temp) known as oils (olive oil, canola oil, and soy bean oil) provide healthy alternatives to saturated fats
