PERSPECTIVES OF
PEDIATRIC NURSING
Nursing of the Childrearing Family
OBJECTIVES
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Identify ways mortality and morbidity data can
be used to improve child health care.
Identify factors that may contribute to our country’s high infant
mortality rate.
State the major cause of death for (a) infants and (b) children 1 to
18.
Identify factors that make a child susceptible to health problems.
Discuss the relevance of Healthy People 2020 to nursing practice
and list at least six health indicators.
Discuss the relevance of cultural sensitivity to the implementation
of comprehensive pediatric nursing care.
Discuss the impact that socioeconomic influence can have on health
and child development.
Discuss the importance of family centered care.
Give an example of atraumatic care
Describe the roles of the pediatric nurse in today’s health care
system.
EARLY REFORMERS
 Study
of Pediatrics began in mid-1800s
Abraham Jacobi, Father of Pediatrics
 Isabel Hampton (1893) wrote about the
challenges of pediatric nursing:
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“the habit of observation on the part of the nurse is of
the highest degree of importance…we have to depend
on signs to tell us where the trouble is located, and we
may be able to gather facts of much importance from
what are apparently quite trivial symptoms.”
 Lillian
Wald (1893) established Henry
Street → home nursing visits, school
nursing, ‘founder of public health nsg’
 Lina Rogers – 1st full time school nurse
OUTCOMES
↑
knowledge base of parents re: prevention
 ↑ in sanitation and hygiene → ↓ illness
 Nutritional improvements → ↓malnutrition
 Early intervention & tx → ↓in communicable
disease
 Improved living conditions
 US Children’s Bureau (1912)
 1st Maternity and Infancy Act → MCH Bureau
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http://mchb.hrsa.gov/
 Numerous
federal programs with focus on
maternal and child health
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Healthy People 2020—where do we go from here?
CHALLENGES OF PEDIATRIC NURSING
 Communication
– must be creative
 Developmental, cognitive, physical
differences
 Health problems specific to pediatrics
 Among the most vulnerable and
disadvantaged in society; 1 in 5 live in
poverty (2009)
 Diverse family systems
 Cultural diversity – must be culturally
sensitive
HEALTHY PEOPLE 2020 LEADING
HEALTH INDICATORS
 Physical
Activity
 Overweight and obesity
 Substance and Tobacco Abuse
 Responsible Sexual Behavior
 Mental Health
 Injury and Violence
 Environmental Quality
 Immunization
 Access to Health Care
 Adolescent Health
 Diabetes
 Early interventions for children with
disabilities
MORTALITY & MORBIDITY DATA
WHY DO WE CARE ABOUT THIS
STUFF?
 Provides
care
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rationale for planning and delivering
Tells us the causes of death and illness
High-risk age groups for disorders or hazards
Driving force for funding → Advances in treatment
and prevention
Guides us in providing specific areas of health
counseling
 www.cdc.gov
 Office
of Minority Health—infant mortality
statistics
INFANT MORTALITY
 US
behind 29 other developed nations - major
diff is lack of national health program
 Death rate for infants < 1yr greater than any
other age up to age 54
 #1 cause of death <1 yr: congenital anomalies
 LBW major determinant of neonatal death &
major indicator of infant health and mortality
 Prenatal care most important, early identification
of risk factors, and early intervention
 Other risk factors: male, black race, maternal age,
maternal education, short or long gestation
CHILDHOOD MORTALITY
 Leading
cause of death >1yr through
adolescence – Unintentional Injuries
 Leading cause of death from unintentional
injuries – Motor Vehicles (♂ >♀ teens)
 Firearm Homicide 1st among black males
15-19
 Developmental stage & environment
determine prevalence & type of injury
 Critical to assess safety needs in
hospitalized setting and home
environment
 Newer CDC link. 10 leading causes of
death and injury
CHILDHOOD MORBIDITY
 Acute
& chronic illness or disability
 Respiratory illness: 50% of all acute
illness
 Morbidity not distributed randomly –
access to health care major contributor
 Risk factors: poverty, homelessness,
children of LBW, chronic illness, foreign
born adopted children, children in day
care
 The “new morbidity”: social, behavioral,
educational problems that effect health
 Causes of unintentional death by age from
CDC
ATRAUMATIC CARE
 Providing
therapeutic care that eliminates
or minimizes the psychologic and physical
distress experienced by children &
families in the health care system
 Goal: First, do no harm
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Prevent or minimize child’s separation from
their family
Promote a sense of control
Prevent or minimize bodily injury and pain
FAMILY –CENTERED CARE
 Recognizes
family as the constant in
child’s life
 Needs of all family members are
addressed
 Acknowledges diversity among family
structures and backgrounds
 Empowerment – helping families
maintain or acquire a sense of control and
competence by fostering their strengths
and abilities, and by treating them with
respect and acknowledging their expertise
in caring for their child.
 See Box 1-3, p 11(9th ed.), p. 8 (10th ed.)
PARENT-PROFESSIONAL PARTNERSHIP
Implies the belief that partners are capable
individuals who become more capable by sharing
knowledge, skills and resources
 Nurse can help families identify their strengths,
build on them, and assume a comfortable level of
participation
 Our role is to strengthen their ability to nurture
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CULTURAL INFLUENCES
 Culture:
pattern of assumptions, beliefs,
& practices that unconsciously frames or
guides the outlook & decisions of a group
 Race: traits that are transmissible by
descent &are sufficient to characterize
those as a distinct human type
 Ethnicity: people sharing a unique
cultural, social, and linguistic heritage
 Ethnocentrism: attitude that one’s own
ethnic group is superior to others
NEW PERSPECTIVE ON CULTURE
CULTURAL INFLUENCES ON
HEALTH CARE (CHAPTER 2)
 May
view illness in a child differently
 Gender of child may be a factor
 Time orientation differs among cultures
 Authority figure in family
 Interactions: verbal & nonverbal
 Food customs
 Health beliefs & Practices
OTHER FACTORS
 Heredity
– innate susceptibility acquired
through generations of evolutionary
changes within a certain population
 Cystic
Fibrosis: almost
nonexistent in Asians & AfricanAmericans
 Lactase deficiency: AfricanAmericans, Asians, Arabs, Native
Americans
 Tay-Sachs disease: Jews
 Sickle cell disease: Blacks
PHYSICAL CHARACTERISTICS
Different skin tones require modification of
assessment techniques to √ for cyanosis or
jaundice – Hockenberry, p. 152 (9th ed.), p. 124 (10th ed.)
 Mongolian spots on babies
 Stature and body build
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RELIGIOUS INFLUENCES
Religion influences lifestyles of many cultures
 Meeting family’s spiritual needs can give them
strength, esp. during stressful times
 Certain rites/beliefs surrounding birth and death
 Diet and food practices
 Medical practices
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CONCLUSION
Goal is to adapt ethnic practices to the family’s
health needs rather than try to change their
beliefs
 Practices that do no harm should be respected
 Remember: No cultural group is homogeneous;
there is always great diversity within groups
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FAMILIES
CHAPTER 2
 Relationships
between dependent children
and one or more protective adults
 Basically it is what an individual
considers it to be
 Must understand family’s strengths &
stressors & how they function
 Assess how this impacts the child &
his/her health
FAMILY SYSTEMS THEORY
Derives from general systems theory
 The family is a system that continually interacts
with its members and the environment
 Emphasis on “interaction”
 Problems do not lie in any one member but in the
type of interactions used by the family
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FAMILY STRESS THEORY
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Families encounter stressors, both predictable
and unpredictable. When family experiences too
many stressors for it to cope adequately, a crisis
ensues. Adaptation requires a change in family
structure and/or interaction. Resiliency to stress
through adjustment and adaptation emphasizes
that stress doesn’t have to be pathological
Developmental Theory: addresses family change
over time, using family life-cycle stages
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Duvall Stages of the Family (Box 2-1)
FAMILIES–
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Various types of family structures:
2 parents, 1 parent, grandparent(s),
relative, non-relative, stepparent,
foster parents, adoptive, blended families,
divorced, extended, gay-lesbian,
polygamous, communal, etc.
SOCIOECONOMIC INFLUENCES
 Poverty:
 Visible:
not a social class but a condition
lack of money or material
resources
 Invisible: social & cultural
deprivation; inferior employment &
education opportunities; lack or
inferior medical services
 Most overwhelming influence on
health
CHILDREN & POVERTY
 In
US, nearly twice as likely to be
poor as citizens >65 yrs old
 1 in 5 children live in poverty (2009)
 Much higher rate in US than in
other comparable countries
 60% live in suburbs or rural areas
 ↑ in chronically poor vs episodically
poor
EFFECTS OF POVERTY
 High
correlation between poverty and
prevalence of illness
 Uninsured or underinsured so limited
access to health services
 High infant mortality
 Substandard housing; crowded living
 Unbalanced meals and/or insufficient food
 Miss more school due to illness
HOMELESSNESS
 Fastest
growing homeless: families
 Most common – single moms w/2-3 kids
 Children = more than 1/3 of homeless
 Some are “runaway” adolescents
 Many have been victims of or witnessed
forms of abuse
 Physical and mental disorders are greater
in this population
IMPORTANCE OF SAFETY IN PEDIATRICS &
ANTICIPATORY GUIDANCE
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It is critical for the nurse to assess the
safety needs of all children in the hospitalized
setting:
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side rails up, dangerous objects out of reach, belts on high
chairs and infant seats, no plastic bags nearby
It is also as imperative for the nurse to assess the
home environment for safe practices
Consistent use of car seats
 Locked cabinets for all dangerous chemicals, drugs, etc.
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Anticipatory Guidance focuses on preventative
teaching for caregivers based on the
developmental needs of the child.
INFORMED CONSENT
 Definition:
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Refers to the Legal and Ethical requirements
that patients must completely understand
proposed treatment, including the RISKS &
BENEFITS as well as alternative procedures.
Should be done by the primary physician, but
the nurse is often involved in confirming that
the patient understands the information and
has the patient sign the consent for treatment
forms.
This is a big issue in Pediatrics.
3 THINGS NEEDED FOR INFORMED
CONSENT (HOCKENBERRY, PP. 999-1000,
9TH ED. PP. 883-885 10TH ED.))
 Person
must be “capable” of giving
consent ( have adequate mental
capacities), & be over the age of 18 years.
 Person must receive enough information
necessary to make an intelligent decision.
 Person must act voluntarily when
exercising freedom of choice without
fraud, force, deceit, duress, or other forms
of constraint or coercion.
ASSENT
An ethical requirement that a child be informed
about a proposed treatment or plan of care and
agree or concur with the decisions made by the
person(s) giving Informed Consent.
 Age where “assent” begins is ~7 years.
 Demonstrates respect for child’s right to know at
this level of intellectual development.
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WHO CAN GIVE INFORMED CONSENT
FOR CHILDREN?
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Parent or Legal Guardian—
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need to be careful when dealing with divorced
families as to who has legal guardianship.
Evidence of Consent/ Oral Consent
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e.g. via telephone with 2 persons listening and
witnessing.
WHO CAN GIVE INFORMED CONSENT
FOR CHILDREN? (CONT’D)
 Mature
& Emancipated Minor
Mature Minor’s doctrine: permits minors to
give consent who are >14 years of age, who can
understand all elements of informed consent,
as long as they understand consequences
 Emancipated Minor: Person under 18 yrs who
is recognized as having legal capacity of an
adult under these circumstances:
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Pregnancy
 Marriage
 High school graduation
 Living independently
 Military service
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WHO CAN GIVE INFORMED CONSENT
FOR CHILDREN? (CONT’D)
In IL, if < 18 yrs, can give consent if: PG,
married, or is a parent
 Mature minor doctrine
 In IL, do not NEED consent for:
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Contraceptives (includes EC) or
Pregnancy testing
STI tx, includes HIV testing & tx (>12 yrs)
Abortion (this changes)
Sexual Assault tx
Emergency care – consent implied by law
Substance abuse care (> 12)
Mental health services if >12 – 5 session limit
WHO CAN GIVE INFORMED CONSENT
FOR CHILDREN? (CONT’D)
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Treatment without parental consent—
Times of emergency which include a “danger/threat
to life or possibility of permanent injury”
 In this instance, no consent is needed.
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WHO CAN GIVE INFORMED CONSENT
FOR CHILDREN? (CONT’D)
 Parental
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Negligence—
In cases of neglect or abuse by parent/legal
guardian, most states have statutory procedures by
which custody of the child is transferred to a
governmental or private agency (like DCFS) and
consent for treatment can then be obtained.
The State does interfere with a parent’s rights in
the interest of protection of the child
Blood Transfusion for a child of Jehovah’s Witness parents
 Medical tx for children of Christian Scientists
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WHO CAN GIVE INFORMED CONSENT
FOR CHILDREN?
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Summary:
As an RN, work within the law.
 Respect the patient and family wishes
as appropriate.
 Give full, informed consent after the
primary caregiver has reviewed it
with the appropriate parties, being
sure that the benefits AND the risks of
the procedure(s) have been discussed in
terms the consumer/family can
understand.
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VARIATIONS IN NURSING TECHNIQUES WITH
CHILDREN
Pediatric medication administration is well covered on the
3 videos on reserve in the library.
 Physical Assessment of the child is covered in Hockenberry,
et al, 2011 ch. 6. A video is available in the library as well:
#VHS 0007 Saunders OR # VC99 3023 (old but thorough).
 Communication Techniques is in Chapter 6 of Hockenberry
et al, 2011. Also integrated in ppt. on Phys. Assess.
 Pediatric Variations of Nursing Interventions is in Chapter
27 of Hockenberry et al, 2011.(lots of tables and photos, and
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charts. You don’t have to know it all right away. Use it as a reference.)
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Note the COMMON LABORATORY TESTS in Appendix C
of Hockenberry et al, 2011.
DRUG DOSAGE CALCULATION
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Assess the safety of the following drug dosage for a
4-day-old baby weighing
8# 8oz:
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Methicillin 100mg IV q 8hrs.
Recommended dosage: (from drug book)
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IM/IV for children <7 days and > 2000g=
75mg/kg/day in divided dosages q 8 hr.
Up to 150mg/kg/day for meningitis
CALCULATION
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8# 8oz = 8.5lbs x 1kg/2.2 lbs = 3.86kg
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3.86kg x 75mg/kg/day = 290mg/day
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Dose ordered: 100mg x 3 (q 8hr)=300mg/day
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What do you think?
ROLE OF THE PEDIATRIC NURSE
 Therapeutic
relationships
 Family Advocacy/Caring
 Health Promotion/Disease Prevention

Anticipatory Guidance
 Support/Counseling
 Restorative
Role
 Coordination/Collaboration
 Ethical Decision Making
 Research – evidence based practice
 Health Care Planning – family & consumer
advocates
UNITED NATIONS’ DECLARATION
RIGHTS OF THE CHILD
 All
OF THE
Children Need:
To be free from discrimination
 To develop physically & mentally in freedom and
dignity
 To have a name and nationality
 To have adequate nutrition, housing, recreation, and
medical services
 To receive special treatment if handicapped
 To receive love, understanding, & maternal security
 To receive an education and develop their abilities
 To be the first to receive protection in disaster
 To be protected from neglect, cruelty, & exploitation
 To be brought up in a spirit of friendship among people
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YOU’VE GOT THE BASICS!
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Enjoy the wonderful world of Pediatric Nursing!
It’s one of the most rewarding things you will
ever do!!