exam 2 Flashcards
Specific diets for different conditions: GI
Appendicitis: NPO for surgery
Celiac Disease: Foods Allowed:
Potato, soy, rice or bean flour
Cornmeal, flax, quinoa
Plain, fresh, or frozen fruits and vegetables
Meat, fish, beans, peanut butter, nuts
Milk and milk products (unless made with gluten additives)
Butter, margarine, salad dressings, sugar, honey, jelly, marshmallows ground coffee, tea
Foods to Avoid
Wheat products: rye, barley, oats, durum flower, farina
Creamed or breaded vegetables, canned backed beans, some French fries
Malted milk, flavored or frozen yogurt
Meats or poultry prepared with gluten or fillers, some egg substitues
Commercial salad dressings, prepared soups, condiments, sauces, nondairy cream substitutes, licorice
Biliary Atresia: Give A, D, E, K
GERD: smaller more frequent feedings
childhood obesity risk factors and treatments
..
appropriate nursing interventions for GERD
Smaller, more frequent feedings
Keeping child upright for 30 min after feeds
Administer proton-pump inhibitors
Educate parents on both pharm and non-pharm interventions
care of the patient with appendicitis
Observe for pain be suddenly relieved without intervention
Monitor temperature
Keep NPO for surgery
Administer IV pain meds
Post-op care may include IV antibiotics (if perforated)
classic s/s of various GI disorders
Appendicitis: Abdominal pain- RLQ N/V Fever small frequent soft stools when pain goes away- they have perforated
Meckel's Diverticulum: Bleeding Anemia Abdominal pain (when obstruction occurs) Abdominal distention Hypoactive bowel sounds
Biliary Atresia: Jaundice Clay colored stool Failure to thrive Enlarged liver/spleen Elevated bilirubin, aks phos, liver enzymes
Pyloric Stenosis Projectile vomit- fresh milk Weight loss Progressive dehydration Lethargy
Celiac Disease Diarrhea Steatorrhea (fatty stools) Constipation FTT Abdominal distension or bloating Irritability Dental disorders Anemia Delayed onset of puberty
Intussusception Sudden onset of intermittent abdominal pain Knees drawn up Vomiting and diarrhea Currant-jelly stools Lethargy Sausage-shaped mass in upper abdomen
Gastroesophageal Reflux (GER) Vomiting or regurgitation FTT Irritability Respiratory symptoms Dysphagia or refusing to eat Abnormal neck posturing Abdominal pain
Caring for child with Meckel’s Diverticulum
Diagnostic Tests Abdominal x-rays Meckel scan Stool tests (for color, consistency, and blood) CBC
IVF for NPO status
PRBCs if anemia is present
Prepare child and family for surgery if indicated
Pain control
Cleft palate/cleft lip pre-op and post op
Protect the suture line!!! Use elbow restraints Position child in supine or side-lying Avoid spoons, straws, pacifiers, or PO syringes May breastfeed, may need special nipple for bottle feeding Pain medication and keeping child calm Lip: Lay on Back Palate: Lay on Stomach
Increased ICP manifestations/treatment
Intervene quickly to prevent long-term damage or death!
Symptoms
Headaches
Morning emesis with immediate relief
Complaining of blurry or double vision
Progress to seizure activity
herniated brain is the worst case from intracranial pressure
infant: Head enlargement Anterior fontanel—tense, bulging, non-pulsatile Scalp veins dilated Cranial sutures separated “Bossing” of frontal bone “Setting-sun” eyes Changes in LOC/irritable/lethargic Opisthotonos Poor feeding Shrill, high pitched cry Developmental delay Seizures Periodic/Irregular breathing is an ominous sign, precedes apnea
Older Child: Headache, Nausea/Vomiting Ataxia Strabismus/Diplopia Pupil response to light—sluggish or unequal Papilledema Changes in LOC Potential Intellectual Impairment Seizures
Manifestations/treatment/teaching: seizures, spina bifida, cerebral palsy, meningitis
seizures
Types
Focal/Partial- 60% of seizures, impairment of consciousness, localization, and progression of the seizure, one hemisphere of the brain
General- absence and tonic/clonic seizures, affects the whole brain
Unknown- epileptic spasms where it is unclear whether the mod of onset is general or focal
Primary treatment- anticonvulsants
Secondary treatment- surgery, Nurse will do preop/postop care and discharge teaching
Education- help families cope, explain the importance of medication adherence, oral care (Dilantin)
Observe and report seizure activity
Time, oxygenation status, safety, take in everything, do not restrain, ease to the ground if standing
Danger- seizure lasting 30 minutes or so many seizures that the child cannot recover
Febrile seizures:
Treatment- identify cause of high temperature and treat
Spina Bifida
Defect without protrusion of the spinal cord or meninges.
These children don’t typically need immediate medical intervention
Benign and asymptomatic
Will note a dimple, patch of hair, or discoloration of skin
Education of presence and monitoring of symptoms of tethered cord
Cerebral Palsy
Mobility- critical to development in the child with CP. Treatment could include physiotherapy, pharmacological management, or surgery. PT/OT are very involved and include the parents on the process.
Nutrition- May have difficulty eating and swallowing r/t poor mouth, tongue, and throat control. They need more time and support. Special diets such as soft or pureed. Manual support of the jaw and proper positioning to help with chewing and swallowing and to prevent choking and aspiration. All efforts will be exhausted, barring the child isn’t suffering, before going to a feeding tube.
Support and Education- Lifelong disorder that based on severity could include daily intensive therapy from caregivers, encourage respite care, understand that when a child is admitted that it is a chance for the family to take a break. Try to not judge when they are gone. Education requires help from social work, parents, teachers, and support staff.
Meningitis
Can lead to brain damage, nerve damage, deafness, stroke, death
Must act fast!
Deterioration over 24 hours
Diagnosis with an LP and administer antibiotics after sample has been collected
Examination
Opsithotonic position (infant) or c/o neck pain
Positive Kernig and Brudzinski
Rash- petechial, vesicular, or macular
Interventions- aimed at reducing ICP and maintain perfusion, treating volume deficits, controlling seizures, and prevent injury from altered LOC
Isolation- Droplet isolation for first 24 hours after initiation of antibiotics, then standard precautions
Otitis media: cause, treatment, education
Inflammation of the middle ear with presence of fluid
Follows upper respiratory infection- strep and influenza infections most common
Complications- hearing loss, expressive speech delay, perforation, meningitis (EXTREME!)
Antibiotics vs observing, analgesics
Trisomy 21: characteristics, G&D, education
The structures of the face are very distinct. You also will note that the nasal passages are smaller. In infants the depressed bridge of the nose leaves them a small nasal passage. With the protruding tongue and mouth open most of the time, keeping secretions clear is important. Dry mucous membranes will make eating and babbling/talking a challenge.
single palmer crease, short 5th finger that curves here separated 1st & 2nd toes
widel
Promotion of nutrition
Diffuclty with suck and feeding due to lack of muscle tone, small mouth, large tongue, underdeveloped nasal bone, and chronically stuff nose
Bulb syringe, humidification, and changing position will help with feeding, breast feeding is usually possible and the antibodies help with fighting infection
No need for special diets unless they have an underlying GI disease like celiac
What dietary restrictions or additions are there for the following disorders? Galactosemia, PKU, Diabetes, Salt wasting CAH.
Galactosemia: No milk products, no breast milk, soy based formula
PKU: Special formula
Breast feed if mom is following PKU diet
DM1: carb control
DM2: Less trans-fats, more fruit/veggies, balanced, incorporate fav foods, portion size, exercise
Limit bad sugars
Salt wasting CAH: salt
What does the nurse need to emphasize with medication teaching for the following endocrine disorders? Congenital hypothyroidism, Diabetes, CAH, Growth hormone deficiency, precocious puberty
Congenital Hypothyroidism: Education: s/s hyper/hypo, lifelong supplements, medications, not changing meds
DM1:
Teaching skills (glucose checks & admin. Insulin & nutrition
Administer insulin based on 1. Glucose levels, 2. For meals
Have parent check sugars in night after sports
DM2: Education on lifestyle modifications
CAH: Ambiguous genitalia: provide comfort to parents, encourage parent bonding, explain in simple terms
Non-salt: receives life-long supplements
Medications for Salt-Wasters
Need aldosterone replaced also
Florinef Acetate oral once a day
Also need an injectable form of cortisone ie Solu-cortef on hand to administer if child is vomiting and cannot keep medication down or when experiencing severe stress
Increased dietary salt encouraged
Medic Alert Bracelet
GH Deficiency: GH injections: sites, give at night (body naturally secretes at night)
Educate how to give it, very expensive
Precocious puberty: Dress according to dev stage, peers of same age
LHRH analogs or synthetic hormones that block the body’s production of the sex hormones.
Given IM once every 4 weeks. Usually see no side effects.
Girls: decrease in breast size or at least no more development
Boys: the penis and testicles may shrink back to normal size.
Height will also slow down to the expected rate before puberty
Discontinue when puberty is expected
How would the nurse’s approach to teaching a newly diagnosed diabetic four year old differ from a ten year old and a 17 year old?
Toddler: cake icing (not the best option) carb followed by protein or carb & protein (protein sandwich, nuggets, chocolate milk)
Fear of needles, strangers, picky eaters
Teen: scars, not fitting in, appearance
School age: rewards, games, sports
Teen: thinking of appearance, they think they are invincible- starting experimenting with drugs & alcohol, consider their mindset
What advice would you give to a Type 1 Diabetic who wanted to join a soccer team?
What advice would you give to a Type 2 Diabetic who wanted to join a soccer team?
DM1: Have parent check sugars in night after sports (bottom out), Cells utilize blood glucose more effectively
Exercise lowers blood sugar
Helps insulin to enter the cell more readily
Insulin requirement is reduced
Always carry a carbohydrate source to treat hypoglycemia or take before exercise to prevent
DM2: hell yeah
What careful considerations does the nurse need to make when talking with parents of a child diagnosed with precocious puberty?
Provide support and anticipatory guidance
Dress and activities should be appropriate for chronological age
Sexual interest usually match’s child’s age
After puberty, child is no longer different from peers
Child is fertile if untreated. No form of contraception is recommended unless the child is sexually active
Teach parents and child injection procedure if needed
How would you teach the mother of a newly diagnosed baby with congenital hypothyroidism about how to recognize s/s of hyperthyroidism and hypothyroidism?
HYPO prior to 6 weeks: Poor feeding Lethargy Prolonged neonatal jaundice Respiratory difficulty & bradycardia Constipation Hoarse cry Large fontanels
after 6 weeks: Depressed nasal bridge Short forehead Puffy eyelids Large tongue Course dry lusterless hair Large fontanels and wide cranial sutures Umbilical Hernia Abdominal distension Hypothermia
What would you suggest to a mother who wants to breast feed her newborn recently diagnosed with PKU? What about a mother with a baby who has galactosemia?
PKU:
Special formula
Breast feed if mom is following PKU diet- NO phenylanine herself
Galactosemia:
No milk products, no breast milk, soy based formula
Why is it important for parents to get to know their pharmacist?
Hidden galactose in meds
So pharmacists are away of their galactosemia
How would you know if growth hormone therapy was effective? How would the nurse know when it may be time to stop the therapy?
Growth 4-4.8 inches the first year and 2.7-3.5 following year
Usually a prompt increase in growth rate after treatment starts (usually noticeable within three or four months.) then the rate slowly declines over time but continues to be greater than would be without treatment.
The decision as to when to stop meds is made jointly by parents, child, and doctor. Consider stopping treatment when growth slows to less than 1-2 inches per year. But usually epiphysis closure is definitive criteria to stop. Average length of treatment 6.5 years. Minimal side effects of medication. Arthralgia, myalgia, injection site reaction, edema. May see worsening of scoliosis and slipped cap epiphysis.
How would you manage a sick day for a patient with DM I?
How would you manage a sick day for a patient with CAH who receives hydrocortisone pills each morning?
DM1:
Monitor blood glucose every 2-4 hours
Do NOT stop taking insulin
Monitor urine for ketones (Strip) every 2-4 hours
Maintain hydration
If able to tolerate food take soft bland foods and 8 oz of fluid per hour
Notify health care practitioner if vomiting and BS above 240
CAH: Lifelong replacement is needed with increased doses during periods of stress, surgery, infection, or injury.
salt wasters: Also need an injectable form of cortisone ie Solu-cortef on hand to administer if child is vomiting and cannot keep medication down or when experiencing severe stress
HUS triad
- Hemolytic anemia
- Thrombocytopenia
- acute renal failure
Watery diarrhea- hemorrhagic colitis- triad of hus
Pre-op care of Epispadias/Bladder Extrophy
Meticulous hygiene
Sterile, nonadherent moist dressing placed over exposed bladder
Moist barrier ointment for surrounding skin
Fluid management
Following primary surgery, nursing care is aimed at: decreasing pain and agitation, No crying, preserving pelvic immobility, maintaining ureteric catheter patency, maintaining operative site intact.
Parent teaching: Appearance of defect, Realistic outcomes, Teach signs/symptoms of infection, Sponge baths, don’t immerse in wate
Teaching and s/s UTI in different ages
More common in girls – shorter urethra
CM: stomach ache
Infant: fussy, low grade fever
Wearing a diaper is susceptible
Potty training- UTI, bad perineal care
Tx: antibiotic
Prevention: frequent diaper changes, no bubble bath, avoid hot tubs and pools, drinking water, cranberry juice
AGN and Nephrotic syndrome: teaching/clinical manifestations/nursing care
AGN CM: Edema -- periorbital Anorexia Cola-colored urine Decreased urine output Pale, irritable, lethargic HA, abdominal discomfort, dysuria Increased BP hematuria
management:
No specific treatment
Recovery often spontaneous
Supportive measures
Hospitalization for substantial edema, hypertension, or significant oliguria
Rest as needed
Thorough assessments
Assess urine volume, color, character
Assess child’s appearance
Assess behavior
Advise family against bringing in salty foods, not to consume salty foods in front of child
Divide amount of fluid allowed evenly and provide throughout the day
Provide it in small cups to give the illusion of increased quantity
Activity planning: need for frequent rest periods
Infection prevention
Frequent health supervision once/if at home (weekly to monthly)
Assess BP every 4-6 hours
Assess body weight daily
Strict I/O
Consider sodium and water restriction
Dialysis for severe cases
Medication Therapy: Loop diuretics i.e. furosemide, Calcium channel blockers, beta blockers, ACE inhibitors, Antibiotics, anti-convulsants if seizures are present
Nutrition: Sodium restriction, Restrict foods with potassium if oliguria is present, Protein restriction for severe azotemia
Nephrotic Weight gain Edema Diarrhea, loss of appetite, malabsorption Decreased UO Urine is dark and frothy Pallor Skin breakdown Irritable Fatigue, lethargic Weight loss is often obscured by edema Nails are white Normal or decreased BP Susceptible to infection Goals: Reduce the excretion of urinary protein Maintain protein-free urine Prevent / treat acute infection Control edema Good nutrition (including protein, restrict salt) Corticosteroid therapy Prednisone daily for six weeks, then tapered for six weeks Expect improvement 7-21 days after initiating steroids Immunosuppressant therapy Indicated with frequent relapsing or steroid-resistant nephrotic syndrome Oral alkylating agent such as cyclophosphamide Loop Diuretics: Furosemide Plasma expander like human albumin Prognosis With early detection and prompt treatment, damage to membrane is minimal and full renal function is often restored Relapse
Daily weight I/O Urine for albumin Abdominal girth Edema Skin condition Shock and infection Skin care Infection prevention Nutrition Diversion Family Anticipatory Guidance and Support
VUR care/medications/teaching
Prevent pyelonephritis!!!
Conservative, non-operative therapy is effective in most cases
High incidence of spontaneous resolution over time
Low-dose antibacterial therapy with frequent urine cultures
Surgery may be indicated with recurrent UTI’s, intolerance to antibiotics, noncompliance with therapy, or VUR after puberty in females
Follow up ultrasounds post-operatively to evaluate renal growth
Enuresis management
Conditioning therapy Retention control training Waking schedule treatment Medication therapy (anticholinergic effect) Punishment is not treatment! Supportive therapy Child’s role Fluid restriction Behavior modification Patient education for the child and the parents ANTICIPATORY GUIDANCE Encouragement, patience and support Child’s active participation Side effects of medications Avoid diapering Positive reinforcement
Legg Calve Perthes vs Slipped Capital Epiphysis- presentation and treatment
SKFE
Femoral head dislocates from the neck and shaft of the femur at the level of the epiphyseal plate
Cause- mostly unknown!
Teen growth spurt
Hormonal alterations
Management
Quick intervention is needed!!
Screw inserted percutaneously into the femoral head
Osteoarthritis may be a long term complication
Legg-Calve-Perthes
Avascular necrosis of the femoral head
Most often children 4-8 years old, males more than females
Patho
Interruption of the blood supply to femoral head
Swelling of soft tissue around the hip
New blood vessels develop to provide the area with circulation allowing bone resorption and deposition
18-24 months for revascularization, more likely to fracture in this process.
Over time the femoral head is reformed
Treatment
Anti-inflammatory meds
Activity limitation
Bracing, casting, or traction recommended
Nursing implications
Pain medications
Education!!
know how to properly place the brace and care for skin under the brace. Exercise of unaffected extremity is recommended. Treatment is based on severity of the disease. Sometimes no treatment except for avoiding contact sports. Often swimming and bicycling is recommending to help with range of motion without further damage.
Fractures in children and casting- process and complications
Clinical manifestations
Swelling, bruising or redness, pain or tenderness
Diminished functional use of affected part
Muscular rigidity
Crepitus
Vascular injury
Complications
Circulatory impairment, nerve compression syndromes
Physeal damage
Nonunion, Malunion
Infection, Pulmonary emboli
- Observe nerve/circulation status closely
- Reposition every 2 hours
- Support wet cast with pillow & palm hand
- Elevate extremity
- Petal rough cast edges
- No objects under cast
- R.O.M. to extremity distal to cast
- Restrict strenuous activity
- Report foul odor, observe drainage
- Clean soiled areas
- Prepare for cast removal
- Provide positive diversion and therapeutic play
JIA- medication adherence, treatment/cares
Pain
Medications for inflammation
Maintain joint range of motion without tension on the joints
Splits or orthotics can be used, monitor skin for breakdown
Psychosocial needs
School
Adequate sleep to minimize fussiness and non-compliance
Support groups
maintain weight
Hip Dysplasia- dx and treatment
assessment
Trendelenburg Gait
Trunk shifts over affected joint
Ortolani Maneuver
Abduct hips , listen and feel for a clunk
Barlow Maneuver
Adduct hips and feel for the femoral head slipping out
treatment Early detection is important! Pavlik Harness Keeps knees flexed and hips abducted to allow hips to grow normally Cares Do not adjust straps, only remove as directed Sleep on back Long socks and shirt under harness Call doctor with complications
Club Foot casting
Starts as soon after birth as possible
Bracing, casting, or surgical release of soft tissue
Once casted, skin assessment is important. Show parents how to assess temperature and cap refill of extremities when home as this will be an outpatient procedure if the child has no other problems. There will be pressure on the skin to move the foot into placement!
Bones should be set before they start walking
Sickle Cell crisis: cause, manifestation, treatment, Hgb F
cause
Diagnosed 3-4 months of age
Individuals of African, Mediterranean, Middle Easter, and Indian decent
Recessive genes for sickle cell are passed on from both parents who have the gene or trait
Stress on the body can cause sickling: trauma, infection, fever, acidosis, dehydration, physical exertion, excessive cold exposure, or hypoxia. Blood gets viscous and starts to clump in small capillaries preventing normal blood flow.
manifestation Pain and clumping most often occurs in the joints, but can be anywhere in the body. Clumping in the lung capillaries leads to acute chest. This is a medical emergency. This leads to decreased gas exchange, producing hypoxia, which leads to further sickling. retinopathy/blindness avascular necoris splenomegaly hematuria ab pain dactylics osteomyelitis priapism anemia CHF
treatment
aggressive hydration. They will get 2x maintenance fluids IV for the first few days. Once they start to have a decrease in pain we can change them to IV+PO.
Narcotics- ED protocol and then PCA+basal rate
IV fluids
Antibiotics if febrile
Hgb F
decreased hgb- shorter cell life
Anemia
RBCs and Hgb are lower than normal
Causes Decreased production or RBCs Lack of dietary intake of nutrients needed to produce the cells Alterations in the cell structure Malfunctioning tissues (bone marrow) Toxin exposure (lead poisoning) Blood loss Genetic and cellulation development disorders
iron deficiency anemia Lack of iron to produce hemoglobin Peak prevalence in children 6-24 months and puberty Causes Cow’s milk consumption 50% of iron in maternal milk is absorbed 10% of iron in cow’s milk is absorbed Assessment Health history Milk consumption Lack of supplementation Diet Chronic or acute blood loss Exam Fatigue, lethargy, pallor Safety Risk for changes in neuro function Unsteady gait related to dizziness Dietary interventions Infants fed only iron fortified formula Breast fed infants to start on supplementation at 4-5 months Limit milk to 24oz per day Education on iron rich foods Picky eaters Supplementation Proper iron fortified diet Oral or IV supplement Blood transfusions Oral care Stool softeners
Hemophilia injury management/treatment
TREAT THE BLEED
Treat with RICE
REST—immobilize for comfort and to prevent further bleeding
ICE—apply cold to promote vasoconstriction
COMPRESSION—pressure to encourage clot formation
ELEVATION—elevate joint
Gentle active ROM
Only after bleeding stopped—within 24 to 48 hours
Allow client to control own pain tolerance
DO NOT do passive exercise
Could stretch joint capsule
Could cause bleeding with acute episode
Management Prevention Factor replacement NEVER THROW FACTOR AWAY! HIV Education
Diagnostic procedures for oncologic processes: nurses role
treat side effects of chemo
labs: Labs drawn and focused on will be determined by the suspected dx, same with radiology. A common practice when cancer is suspected is a chest xray to look for mediastinal mass. If this child with a mass is sedated and they are unable to maintain their airway, we have a serious emergency!!
radiology
procedures: bone marrow aspirate or biopsy as well as lumbar puncture.
Biopsy of the tumor: would dictate and pre-op and post-op cares for the nurse.
education
Scared!!
Lots of teaching and hands on practice with central lines
When to be alarmed
Temp of 101 or greater (or climbing)
Cough or rapid breathing
Oozing gums, nose bleed lasting longer than 10 minutes
Lethargic, fatigue
Ear, head, neck ache (nuchal rigidity)
Problems with central line: broken, red/sore
Abdominal pain, problems eating
Symptoms at diagnosis: leukemia, retinoblastoma, neuroblastoma, wilm’s
leukemia: bone pain
metastasis to blood, bone, CNS, spleen, liver or more
retinoblastoma: Cat Eye reflex Strabismus Red, painful eye, often with glaucoma Blindness (late sign)
neuroblastoma:
Swollen/asymmetric abdomen
Bowel and bladder dysfunction
Bruising of the eyes
Wilm’s:
Swelling, mass in abdomen
R/T compression: HTN, hematuria, wt loss, fever, mets to lungs
Neutropenia
risk for infection
low WBC, neutrophil count
ANC calculation
ANC= Bands+Segs (or Neutrophils) x WBC(10)
< 500 neutropenic
Parental characteristics, common characteristics of abused children
social isolation
poor support system
parental low self-esteem & less adequate maternal functioning
Alcohol abuse (caregiver)—The compulsive use of alcohol that is not of a temporary nature.
Drug abuse (caregiver)—The compulsive use of drugs that is not of a temporary nature.
Financial problem (caregiver)–A risk factor related to the family’s inability to provide sufficient financial resources to meet minimum needs.
Inadequate housing (caregiver)–A risk factor related to substandard, overcrowded, or unsafe housing conditions, including homelessness.
compatibility between child & parents temperament and parents ability to deal with behavioral style
abuse prevention
Child Abuse Prevention and Treatment Act (CAPTA)
provides funds to states to improve CPS systems
assist states with screening and investigating child abuse and neglect report
child protective services (MO)
department of children & families (KS)
reporting child abuse
When in doubt, report. Worst case scenario, it was nothing and a social worker visit the house. Best case scenario, you save lives!!!! And break cycles!!!
mandatory reporter
abuse in different cultures
Cupping, coining, Eastern medicine practices used that could appear to be abuse
goal: Better circulation, helps lymphatic system
Understanding of concept of death
Infant
Unconditional love and trust
Ensure family is available to the child
Toddler (1-3 yo.)
Familiarity and routine
Maximize time with parents, bring in items from home
Child (3-5 yo.)
Death is punishment for wrong doing, correct this misunderstanding
Use precise language
Help family express that they will miss the child and will continue to function when they are gone
School age (5-10 yo.)
Concrete understanding of death
Need specific honest details
Encourage to help with decisions
Young adolescent (10-14 yo.)
Benefits from reinforcement of self-esteem
Respect privacy and need for peers
Support the need for independence and decision making
Older teen (14-18 yo.)
Adult-like understanding
Needs support through honest, detailed explanations and need to be heard!
Family centered care
Honesty with parents and child (as developmentally appropriate)
Clarify and answer questions
No judgment
Sensitive to ethnic, spiritual, or cultural preferences
assure change in focus to pain control & comfort
