1 Perspectives of Pediatric Nursing

7/23/2019 1 Perspectives of Pediatric Nursing

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1 Perspectives of Pediatric Nursing

MARILYN L. WINKELSTEIN

http://evolve.elsevier.com/Wong/essentials/

Ree!er to c"ec# out $our copanion %&'R(M

RELATE& T(PI%S and A&&ITI(NALRES()R%ES

IN TE*T

Admission Assessment, Ch. 21

Classifcation o High-Risk Ne!orns, Ch. 9

Comm"nit#-$ased N"rsing Care o the Child and %amil#, Ch. 2

C"lt"ral/Religio"s &n'"ences on Health Care, Ch. 4

Histor# (aking, Ch. 6

&n)"r# *revention: &nant, Ch. 10+ (oddler, Ch. 12+ *reschooler, Ch.13+ chool-Age Child, Ch. 15+ Adolescent, Ch. 16

*h#sical and evelopmental Assessment o the Child, Ch. 7

cope o the *ro!lem Chronic &llness, isa!ilit#, Ch. 18

pina $ifda 0#elomeningocele, Ch. 32

"icide, i

%& %(MPANI(N

1"idelines2oc"mentation o N"rsing Care


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LEARNIN, (+-E%TIES

(n cop/etion of t"is c"apter t"e reader 0i// !e a!/e to

efne the terms mortalityand morbidity.

&denti# to a#s that knoledge o mortalit# and mor!idit# canimprove child health.

3ist three ma)or ca"ses o death d"ring inanc#, earl# childhood,later childhood, and adolescence.

3ist to ma)or ca"ses o illness d"ring childhood.

5"tline o"r events that ere signifcant in the evol"tion o childhealth care in the 7nited tates.

escri!e fve !road "nctions o the pediatric n"rse in promotingthe health o children.

efne critical thinking.

&denti# the fve steps o the n"rsing process.

efne n"rsing diagnosis.

i;erentiate among the three domains o n"rsing practice:dependent, independent, and interdependent.

i;erentiate a standard care plan rom an individ"ali4ed careplan.

2EALT2 &)RIN, %2IL&2((&

(he World Health Organization (WHO)has defned health as


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and morbidityillness among gro"ps o individ"als over specifcperiods. (he !alance !eteen ph#sical, mental, and social ell!eing and the presence o disease is inerred rom anal#sis o datarelating to mortalit# and mor!idit#.

0ortalit# and mor!idit# data also provide inormation a!o"t = theca"ses o death and illness, > high-risk age-gro"ps or certaindisorders or ha4ards, ? advances in treatment and prevention, and@ specifc areas o health co"nseling. "ch inormation is val"a!leto n"rses !eca"se it g"ides the planning and deliver# o n"rsingcare.

32EALT2Y PE(PLE 4555 AN& 45153

Altho"gh the health o children in the 7nited tates improveddramaticall# d"ring the tentieth cent"r#, several areas o

concern remain. erio"s domestic pro!lems s"ch as ac"iredimm"nodefcienc# s#ndrome A&, dr"g a!"se, violence, and"nanted pregnancies have direct e;ects on the health ochildren. ol"tions to these pro!lems lie in theirprevention.

&n the last to decades, doc"ments s"ch as Healthy People2000and Healthy People 2010esta!lished national healtho!)ectives and served as the !asis or the development o stateand comm"nit# plans. Healthy People 2010, released in >BBB,contains to overriding goals: = to increase the "alit# andlength o health# lie and > to eliminate health disparities. (he

doc"ment also contains =B leading health indicators relating toiss"es s"ch as s"!stance a!"se, in)"r# and violence, and otherpriorit# areas or the nation6s health. (he health indicators serveas oc"s areas or health improvement e;orts. 0an# states haveorked ith comm"nit# coalitions to develop their on versions oHealthy People 2010. (he Healthy People Toolkit*o"nd on the&nternet provides eamples o state and national eperiences"sing the o!)ectives o Healthy People 2010.

D http://.health.gov/health#people/state/toolkit.

M(RTALITY

%ig"res descri!ing rates o occ"rrence or events s"ch as death inchildren are reerred to as vital statistics. &n the 7nited tates,the Nationa/ %enter for 2ea/t" Statistics 6N%2S7isresponsi!le or the collection, anal#sis, and dissemination ohealth data. ince =EE=, several changes have occ"rred in thereporting o health statistics. %ig"res or !irth and death are !ased


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on the person6s state o residence, not the state in hich the eventocc"rred. &n addition, ta!"lation o race or live !irths has changedrom the race o the child to the race o the mother. As a res"lt othese changes, fg"res or !irths, deaths, and inant mortalit#rates !# race cannot !e compared ith statistics reported !eore

=EE=. Mortality statisticsdescri!e the incidence or n"m!er oindivid"als ho have died over a specifc period. (hese statisticsare "s"all# presented as rates per =BB,BBB and are calc"latedrom a sample o death certifcates.

Infant Morta/it$

(he infant mortality rateis the n"m!er o deaths d"ring thefrst #ear o lie per =BBB live !irths. &nant mortalit# is dividedinto neonatal mortalityF>G da#s o lie andpostneonatalmortality>G da#s to == months. &n the 7nited tates, there

has !een a dramatic decrease in inant mortalit#. At the!eginning o the tentieth cent"r# the rate as approimatel#>BB inant deaths per =BBB live !irths. &n >BB>, inant mortalit#rate as 9.E per =BBB live !irths 0acorman and others, >BB>.(his decrease res"lted primaril# rom improvements in perinatalcare, s"ch as treatment o respirator# distress s#ndrome andeer deaths rom s"dden inant death s#ndrome &. (hemortalit# rate in >BB> or hite inants as .I, and the rate orArican American inants as =@.= 0acorman and others,>BB>. (he challenge or this cent"r# is to red"ce the gap!eteen inant mortalit# or hite and Arican American inants.

%rom a glo!al perspective, the 7nited tates lags !ehind otherdeveloped co"ntries. &n =EEE, the 7nited tates ranked lastamong nations ith the loest inant death rates. Hong Jong hadthe loest inant death rate 0acorman and others, >BB>(a!le =-=. Altho"gh the eact reason or the lo ranking o the7nited tates is "nknon, one eplanation ma# !e that man#co"ntries ith loer inant death rates have national healthprograms.

TA+LE 1'1 Infant Morta/it$ Rate 6IMR7 for1888 for %ountries of 49:559555Popu/ation and Wit" E;ua/ to or Less T"ant"e )nited States Rate for 1888 6Rate per1559555 Live +irt"s7


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%rom 0acorman 0% and others: Ann"al s"mmar# o vitalstatistics >BB=, Pediatri!==B9:=B?IK=B>, >BB>.

ata rom "nited #ation!$ 1998 %e&o'raphi (ear)ookPop+lation and ,ital -tati!ti! eport, tatistical *apers, series

A, vol 3==, no. =, Lan"ar# >BBB+ Pop+lation and ,ital -tati!ti!eport, tatistical *apers, series A, vol 3===, no. =, Lan"ar#>BB=+ Pop+lation and ,ital -tati!ti! eport, tatistical *apers,series A, vol 3&M, no =, Lan"ar# >BB>.


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irth !eightis considered the ma)or determinant o neonataldeath in technologicall# developed co"ntries. (here is a defniterelationship !eteen !irth eight and mortalit# 1"#er and


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others, >BBB. (he high incidence o lo! birth !eight ("W)F>BB g in the 7nited tates is a ke# actor in its higherneonatal mortalit# rates hen compared ith other co"ntries.Access to and "se o high-"alit# prenatal care is the single mostimportant preventive strateg# to decrease earl# deliver# and

inant mortalit#. 5ther actors that increase the risk o inantmortalit# incl"de Arican American race, male gender, short orlong gestation, maternal age, and a lo level o maternaled"cation 1"#er and others, >BBB.

Altho"gh there has !een a stead# and signifcant decline ininant mortalit#, the n"m!er o deaths in the frst #ear o lie isstill proportionatel# high hen compared ith death rates atother ages (a!le =->. erio"s health conditions in preterm 3$Winants occ"r most oten d"ring the frst 9 months ater hospitaldischarge. &n the 7nited tates, the death rate or inants

#o"nger than = #ear o age is greater than the rate orindivid"als ages = thro"gh @ #ears. &t is not "ntil age andolder that the death rate !egins to eceed the rate or inants.

TA+LE 1'4 &eat" Rates !$ Age and SeBBB, #ational ,ital -tati!ti! eport!, vol @E, no =>,

H#attsville, 0, >BB=, National Center or Mital tatistics.


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&n the =E9Bs, attention as oc"sed on perinatal health care inan e;ort to decrease the n"m!er o neonatal deaths. Neonatalmortalit# declined rom >B. per =BBB live !irths in =EB to @.9per =BBB live !irths in >BBB Ho#ert and others, >BB=. (hisdecline res"lted rom advances in neonatal intensive care and!etter treatment o perinatal illnesses. Hoever, man# o theleading ca"ses o death d"ring inanc# contin"e to occ"r d"ringthe perinatal period (a!le =-?. (he frst o"r ca"ses2congenital

anomalies, disorders related to short gestation and "nspecifed3$W, &, and ne!orn a;ected !# maternal complications opregnanc#2acco"nt or almost hal o all deaths o inants#o"nger than = #ear o age 0inino and mith, >BB=.

TA+LE 1'= Morta/it$ Rates for 15 Leading%auses of Infant &eat" in 45559Pre/iinar$ &ata 6Rate per 1555 Live+irt"s7

0odifed rom 0inino A0, mith $3: eaths: preliminar# dataor >BBB, #ational ,ital -tati!ti! eport!, vol @E, no =>,H#attsville, 0, >BB=, National Center or Mital tatistics.


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Altho"gh a n"m!er o perinatal pro!lems have !enefted romimproved treatment, congenital anomalies contin"e to !e aleading ca"se o inant mortalit#. (he incidence o the ma)orit# o!irth deects has remained s"!stantiall# the same. Heart deectshave !een rising, !"t the increase is the res"lt o improved

methods o detection, not increased !irths o a;ected inants.Anencephal# and spina !ifda are epected to decrease ith therecommendation o olic acid s"pplementation or all omen ochild!earing age see pina $ifda 0#elomeningoceleO, Chapter?> Red"cing 3$W ill also prevent congenital anomalies. &nantmortalit# res"lting rom h"man imm"nodefcienc# vir"s H&Minection has decreased signifcantl#+ in =EEG, H&M/A&acco"nted or less than B.?P o all deaths in childhood 0"rph#,>BBB.

When inant death rates are categori4ed according to race, inant

mortalit# or hites is loer than or all other races in the 7nitedtates, and the inant mortalit# rate or Arican Americans istice the rate or hites. (he gap !eteen these to racialgro"ps has remained airl# constant. (he 3$W rate is also higheror Arican American inants than or an# other gro"p. Reasonsor these high rates are "nknon. 5ne enco"raging note is thatthe gap in mortalit# rates !eteen hite and nonhite racesother than Arican Americans is narroing. &nant mortalit# ratesor Hispanics and Asian *acifc &slanders decreased dramaticall#d"ring the last >B #ears 1"#er and others, >BBB.

%"i/d"ood Morta/it$

eath rates or children older than = #ear o age have ala#s!een less than the rate or inants see(a!le =->. Children ages to =@ #ears have the loest rate o death (a!le =-@. Hoever,a sharp rise occ"rs d"ring later adolescence, primaril# romin)"ries, homicide, and s"icide. &n >BBB, these conditions ereresponsi!le or approimatel# I>P o deaths in teenagers and


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#o"ng ad"lts = to =E #ears old 0inino and mith, >BB=. (hetrend in racial di;erences that occ"rs in inant mortalit# is alsoseen in childhood deaths or all ages and or !oth sees. Whiteshave eer deaths or all ages, and male deaths o"tn"m!eremale deaths.

TA+LE 1'> ?ive Leading %auses of &eat"in %"i/dren in t"e )nited States Se/ectedAge Interva/s9 4555 Pre/iinar$ &ata6Rates per 15595557

0odifed rom 0inino A0, mith $3: eaths: preliminar# dataor >BBB, #ational ,ital -tati!ti! eport!, vol @E, no =>,H#attsville, 0, >BB=, National Center or Mital tatistics.

Ater = #ear o age, there is a dramatic change in the ca"se odeath. 7nintentional in)"ries accidents are the leading ca"se odeath rom the #o"ngest ages to the adolescent #ears. &naddition, violent deathsare increasing among #o"ng peopleages =B thro"gh > #ears, especiall# among Arican Americanmales. Homicide is the second leading ca"se o death in the =-to =E-#ear age-gro"p see(a!le =-@. Children => #ears o ageand older are more likel# to !e killed !# non-amil# mem!ersac"aintances and gangs, t#picall# o the same race and mostre"entl# !# frearms. %irearm homicide is the leading ca"se odeath among Arican American males ages = to =E #ears.#$icideis the third leading ca"se o death among adolescentsand #o"ng ad"lts = to >@ #ears old see(a!le =-@.

(he ca"ses o increased violence against children and sel-in'icted violence are not "ll# "nderstood. &n #o"ng children, theincrease in homicide ma# represent more acc"rate identifcationo child a!"se. (he pro!lem o child homicides is comple andinvolves ps#chological, social, and economic actors. N"rsesneed to !e aare o #o"ng people ho are depressed, repeatedl#in tro"!le ith the criminal )"stice s#stem, or associated ithgro"ps knon to !e violent. *revention re"ires identifcation othese individ"als and therape"tic intervention !# "alifed


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proessionals. *ediatric n"rses can also assess children andadolescents or risk actors related to violence s"ch as thepresence o a g"n in a ho"sehold and ed"cate amilies,teachers, and comm"nit# leaders a!o"t the importance omaintaining sae, nonviolent homes, schools, and neigh!orhoods.

(he ma)or declines in death rates d"ring childhood haveocc"rred in deaths ca"sed !# gastrointestinal diseases,inectio"s diseases, perinatal conditions, neoplasms, and in)"ries.(he a!sence o inectio"s diseases as a leading ca"se o death isrelated to the "se o anti!acterial agents and imm"ni4ations.eaths ca"sed !# inectio"s diseases have decreasedconsidera!l# in recent #ears. &n partic"lar, deaths rom H&Minection have decreased, and H&M is no longer one o the =leading ca"ses o death 1"#er and others, >BBB. 5therdisorders s"ch as neoplasms have !ecome more prominent

ca"ses o death, altho"gh childhood deaths rom cancer arec"rrentl# less re"ent than ever !eore see 3e"kemias, Chapter>9.

%n&$ries'

&n)"ries, the leading ca"se o death in children older than = #earo age, are responsi!le or more childhood deaths anddisa!ilities than all ca"ses o disease com!ined. As childrengro older, the percentage o deaths rom in)"ries increases(a!le =-. &n)"ries have not shon the dramatic declines seen

in other areas o childhood mortalit# !eca"se in)"ries havetraditionall# !een regarded as "navoida!le accidents or!ehavioral pro!lems, rather than health pro!lems. (he termaccidents"ggests a chaotic, random event related to


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(he pattern o deaths ca"sed !# "nintentional in)"ries,especiall# rom motor vehicles, droning, and !"rns, isconsistent in Western societies. Hoever, the 7nited tateseceeds other co"ntries in the n"m!er o violent deaths. (he

leading ca"ses o deaths rom in)"ries or each age-gro"paccording to se are presented in(a!le =-. (he ma)orit# odeaths rom in)"ries occ"r in males. &t is important to note thataccidents acco"nt or more teen deaths than an# other so"rceAnnie 8. Case#, >BB=. %ort"natel#, prevention strategies s"chas the "se o car restraints, !ic#cle helmets, and smokedetectors have res"lted in a signifcant decrease in atalities or#o"nger children. All states have legislation re"iring #o"ngchildren to !e properl# restrained in motor vehicles. espitesaet# e;orts, hoever, the overhelming ca"se o death inchildren older than = #ear o age is motor vehicle 0M-related

atalities, incl"ding occ"pant, pedestrian, !ic#cle, andmotorc#cle deaths %ig. =-=. 8ven tho"gh theperenta'eoinants d#ing rom 0M in)"ries is small compared ith the totaln"m!er o deaths in inanc#, children #o"nger than = #ear oage contin"e to have a high death rate rom 0M occ"pantdeaths !eca"se the# are not properl# restrained.

?I,. 1'1


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0otor vehicle in)"ries are the leading ca"se o death inchildren older than = #ear o age. (he ma)orit# o theatalities involve occ"pants ho are "nrestrained.

When deaths rom in)"ries are compared according to se andage, the ca"ses o death di;er. (he developmental stage o thechild determines the t#pe o in)"r# that is most likel# to occ"r ata specifc age. %or eample, a child !eteen the ages o = and

@ #ears is e"all# likel# to die as an occ"pant or as a pedestrianin 0M in)"ries. Hoever, children ages to E #ears are morelikel# to die rom pedestrian crashes, and adolescents are morelikel# to die rom occ"pant crashes. Children ages to =@ are atgreatest risk o !ic#cling atalities. (he ma)orit# o !ic#clingdeaths are rom head in)"ries. Helmets red"ce the risk o headin)"r# !# GP, !"t e children ear helmets National aet#Co"ncil, >BBB.

roning and !"rns are the second and third leading ca"ses odeath in males ages = to =@, !"t the order is reversed in

emales %ig. =->. roning is a signifcant ca"se o death inolder teenagers. &n addition, improper "se o frearms is a ma)orca"se o death in males %ig. =-?. "ring inanc#, more malesdie rom aspiration or s";ocation than do emales %ig. [email protected] than hal o all poisonings occ"r in children #o"nger than> #ears o age %ig. =-. $# ages @ to #ears, "nintentionalpoisonings are "ncommon. Another increase occ"rs in the =-to >@-#ear age-gro"p, in hich poisoning is the third leading


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ca"se o death in males and second in emales. *oisoning inthis age-gro"p is oten intentional and represents death roms"icide especiall# emales or dr"g a!"se.

&t is important to remem!er that not all in)"ries are

"nintentional+ some ma# !e intentional and represent a!"se ors"icide. When in)"ries occ"r, n"rses ma# need to helpdetermine i the# ere intentional.

?I,. 1'4

A, roning is the second leading ca"se o death rom in)"r#in !o#s and the third in girls ages to =@ #ears. +, $"rns arethe second leading ca"se o death rom in)"r# in girls andthe third in !o#s ages = to =@ #ears.

?I,. 1'= &mproper "se o frearms is theo"rth leading ca"se o death rom in)"r# in!o#s to >@ #ears and girls ages to =@ #ears


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?I,. 1'> 0echanical s";ocation is oten theleading ca"se o death rom in)"r# in inants.


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?I,. 1': *oisoning ca"ses a considera!len"m!er o in)"ries in children "nder @ #ears oage, !"t it is the third leading ca"se o deathrom in)"r# in males and second in emales"s"all# rom s"icide ages = to >@ #ears.


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B N)RSIN, ALERT

T"e "istor$ of t"e in@ur$ is essentia/ in assessingintentiona/ in@ur$ fro a!use or neg/ect. T"e fo//o0ing

;uestions are iportant

W"enC&id t"e parent or guardian see# iediateedica/ attention or "as t"ere !een a /ong de/a$D

W"ereC&oes t"e reported /ocation of t"e accidentcorre/ate 0it" t"e nature of t"e in@ur$D


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2o0CAre t"e circustances surrounding t"e in@ur$/ogica/D

%n&$ry Prevention'

When comparing deaths rom in)"ries ith other ca"ses ochildhood mortalit#, it is clear that preventing in)"ries is the!est strateg# to improve s"rvival. N"rses pla# a ma)or role inproviding anticipator# g"idance to parents and older childrenregarding ha4ards d"ring each age period.

(heoreticall#, all in)"ries are preventa!le. &n)"r# prevention isan ongoing part o health promotion or all age-gro"ps.Anticipator# g"idance regarding developmental epectationsserves to alert parents to the t#pes o in)"ries most common atan# given age. 8arl# in the parent-child relationship, parents

need advice on ho to provide a sae environment. &t cannot !eass"med that parents o one or more children are amiliar ithall areas o child saet#. (he addition o a ne inant ma# ca"sesi!ling rivalr#, and the ne inant ma# !e at risk rom a )ealo"ssi!ling. (he American Academ# o *ediatrics has developed anin)"r# prevention program named %PP he %n&$ryPrevention Programthat provides "se"l inormation andanticipator# g"idance on saet# iss"es or parents and healthcare providers.DAnother reso"rce is the %onsuer ProductSafet$ %oission 6%PS%7o the 7 1overnment, hichprovides p"!lications that recommend areas o saet# or

children.QD %or more inormation contact the Aerican Acade$ ofPediatrics, =@= Northest *oint $o"levard, 8lk 1rove Millage,&3 9BBBI+ GGG >>I-=IIB+ a: G@I >>G-=>G=+http://.aap.org.Q %or more inormation call GBB 9?G-C*C or GBB 9?G->>I>.

M(R+I&ITY

(he prevalence o specifc illnesses in the pop"lation at apartic"lar time is knon as morbidity statistics. (hese aregenerall# presented as rates per =BBB pop"lation !eca"se o theirgreater re"enc# o occ"rrence. 7nlike mortalit#, mor!idit# isdic"lt to defne and ma# denote ac"te illness, chronic disease, ordisa!ilit#. o"rces o data or mor!idit# statistics incl"de reasonsor visits to ph#sicians, diagnoses or hospital admission, andho"sehold intervies. 7nlike death rates, hich are "pdated


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ann"all#, mor!idit# statistics are revised less re"entl# and ma#not represent the general pop"lation.

%"i/d"ood Mor!idit$

*c$te illnessis defned as s#mptoms severe eno"gh to limitactivit# or re"ire medical attention. Respirator# illness acco"ntsor a!o"t BP o all ac"te conditions, inections and parasiticdisease ca"se ==P, and in)"ries ca"se =P. (he chie illness ochildhood is the common cold.

(he t#pes o diseases that children contract d"ring childhoodvar# according to age. %or eample, "pper respirator# tractinections and diarrhea decrease ith age, !"t other disorderss"ch as acne and headaches increase. Children ho have had apartic"lar t#pe o pro!lem are more likel# to have that pro!lem

again. 0or!idit# is not distri!"ted randoml# in children. Childrenrom poor amilies tend to have more health pro!lems. (hisfnding s"ggests a need or heightened e;orts to improve accessto health care or lo-income children.

Recent concern has oc"sed on specifc gro"ps o children hohave increased mor!idit#2homeless children, children living inpovert#, children o 3$W, children ith chronic illnesses, oreign-!orn adopted children, and children in da# care centers. everalactors place these gro"ps at risk or poor health. 5ne actor is!arriers to health care, especiall# or the homeless, the poor, and

children ith chronic health pro!lems. 5ther actors incl"deimproved s"rvival o children ith chronic health pro!lems,partic"larl# inants o ver# 3$W. Children living in or eposed toat-risk environments s"ch as the co"ntr# o origin or adoptedchildren and da# care centers ma# !e more likel# to havemedical pro!lems s"ch as inections 3ears, 1"th, and3eandoski, =EEG.

&n)"ries are an additional actor in'"encing mor!idit#. 8ach #ear@B,BBB to B,BBB children are in)"red permanentl# and = millionchildren receive medical care !eca"se o "nintentional in)"ries.

(he most important aspect o mor!idit# is the degree o disa!ilit#it prod"ces. +isabilitycan !e meas"red in da#s a!sent romschool or da#s confned to !ed. 5n average, a child loses .?da#s per #ear !eca"se o in)"r# or illness. (he incidence ochronic conditions is disc"ssed in Chapter =G.


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%or man# children childhood is a time o relative health, !"t it isthe rare child ho never !ecomes ill. 8d"cation o parentsregarding the "s"al t#pes o childhood illnesses and recognitiono s#mptoms that re"ire treatment is an important part on"rsing care. Health promotion and health ed"cation are

important roles or pediatric n"rses.

T"e Ne0 Mor!idit$

&n addition to disease and in)"r#, children ace !ehavioral, social,amil#, and ed"cational pro!lems that are reerred to as the ne!morbidityorpediatric social illness. (hese pro!lems e.g.,povert#, violence, school ail"re interere ith children6s socialand academic development. 8stimates o the incidence o thesepro!lems var# rom P to ?BP.

Altho"gh no concl"sive characteristics have !een identifed orchildren ith ne mor!idit# pro!lems, several fndings appear todefne at-risk gro"ps. (hese incl"de = children rom losocioeconomic stat"s, > o the male gender, and ? ith asi!ling ho has had a previo"s in)"r# Altemeier, >BBB.

E(L)TI(N (? %2IL& 2EALT2 %ARE IN T2E)NITE& STATES

Children in colonial America ere !orn into a orld ith man#

ha4ards to their health and s"rvival. 8pidemics ere common.*h#sicians ere e, and onl# a small n"m!er had ormal training.0idives ere "ntrained and !ased their practice on pasteperiences. $ooks providing inormation on childcare and eedingere scarce and, hen availa!le, ere help"l onl# to literateparents.

0edical care !# ph#sicians as limited to ealth# amilies holived in or co"ld travel to more developed cities. Children holived on arms ere cared or !# another amil# mem!er or !# acompetent neigh!or. (raveling medicine men and vario"s orms o

"acker# ere common. Children ho ere !o"ght as slaves or!orn to slaves had onl# as m"ch care as their oner as a!le orilling to provide. Native American children ere treatedaccording to the tradition o their tri!e, hich as oten a mit"reo medicine, magic, and religion. With the coloni4ation o America,Native Americans ere eposed to ne, oten atal, diseases.


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Relia!le statistics on childhood mortalit# d"ring the colonial periodare "navaila!le. 8pidemic diseases incl"ded smallpo, measles,m"mps, chickenpo, in'"en4a, diphtheria, #ello ever, cholera,and hooping co"gh. #senter# as the most common ca"se ochildhood death. 5ther diseases that contri!"ted to childhood

illness ere the


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other illnesses identifed in the school. An o"tgroth o thisn"rsing involvement in school health as the development opediatric co"rses and clinical eperience in schools o n"rsing.

As ca"ses o disease ere identifed, emphasis on isolation and

asepsis occ"rred. &n the earl# =EBBs, children ith contagio"sdiseases ere isolated rom ad"lt patients. *arents ereprohi!ited rom visiting !eca"se the# might transmit disease toand rom the home. 8ven to#s and personal articles o clothingere kept rom the child. &n the =E@Bs, the investigations o pit4and Ro!ertson highlighted the e;ects o isolation and maternaldeprivation on instit"tionali4ed children. (heir research stim"latedinterest in the ps#chologic health o children and res"lted inchanges or hospitali4ed children, s"ch as rooming-in, si!lingvisitations, child lie programs, prehospitali4ation preparation,parent ed"cation, and hospital schooling.

&n'"enced !# social reormers s"ch as 3illian Wald, nationalleaders took action to improve children6s living conditions. &n =EBE,*resident (heodore Roosevelt convened the frst White Ho$se/onference on /hildren, hich oc"sed on the care odependent children and addressed the deplora!le orkingconditions o #o"ngsters. As a res"lt o this conerence, the '#'/hildrens $rea$as esta!lished in =E=>. (his marked the!eginning o a period o st"dies o economic and social actorsrelated to inant mortalit#, maternal deaths, and maternal andinant care in r"ral settings. (hese st"dies stim"lated the creation

o !etter standards o care or mothers and children and led to thefrst Maternity and %nfancy *ct. (his act provided grants tostates to develop a ivision o 0aternal and Child Health 0CH asa "nit o the health department and in'"enced the creation o the*merican *cademy of Pediatrics.

&n =E?, itle of the #ocial #ec$rity *ct (##*)as passedand a ederal-state partnership as esta!lished "nder theadministration o the Children6s $"rea". (itle M incl"ded ederalgrants-in-aid to states matched !# state "nds, or three t#pes oork: maternal and child health (M/H), /rippled /hildrens

#ervices (//#), and child !elfare services. (he frst programsprovided !# (itle M ere prenatal, postnatal, and child healthclinics. Another oc"s o the CC as orthopedic care. With therecognition that a child6s a!ilit# to "nction co"ld !e limited !# achronic illness, state CC programs !ecame involved ith childrenith developmental, !ehavioral, and ed"cational pro!lems andmore recentl# ith home care o children ith comple medicalconditions. (his !roadened concept as re'ected in the =EG


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passage o legislation that changed the name o the CC to theProgram for /hildren !ith #pecial Health 3eeds (/#H3).

5ther ederal programs that have had a ma)or impact on maternaland child health incl"de the olloing:

Medicaid.0edicaid as created in =E9 "nder (itle T&T o theocial ec"rit# Act to red"ce fnancial !arriers to health care orthe poor. &t is the largest maternal-child health program. A ma)orpro)ect "nder 0edicaid is the Child Health Assessment *rogramCHA*, hich provides services or pregnant omen andchildren. %inancial eligi!ilit# varies rom state to state.

Aid to ?ai/ies 0it" &ependent %"i/dren 6A?&%7.(he Ao =E? esta!lished A%C as a cash grant program to ena!lestates to aid need# children itho"t athers.

M%2 Services +/oc# ,rant.0CH ervices $lock 1rant provideshealth services to mothers and children, partic"larl# those ithlo income or limited access to health services. &ts primar#p"rposes are to red"ce inant mortalit# and the incidence opreventa!le disease and handicapping conditions among childrenand to increase the availa!ilit# o prenatal, deliver#, andpostpart"m care to eligi!le mothers.

A/co"o/9 &rug A!use9 and Menta/ 2ea/t" +/oc# ,rant.8sta!lished !# the 5mni!"s $"dget Reconciliation Act o =EG=,this !lock grant provides "nds to states or = pro)ects to

s"pport prevention, treatment, and reha!ilitation related tos"!stance a!"se and > grants to comm"nit# mental healthcenters or the identifcation, assessment, and treatment oseverel# mentall# dist"r!ed children and adolescents.

Socia/ Services +/oc# ,rant.8sta!lished "nder (itle TT o theA, this grant provides states ith "nds or child da# care,protective and emergenc# services, co"nseling, amil# planning,home-!ased services, inormation and reerral, and adoption andoster care services.

Woen9 Infants9 and %"i/dren 6WI%7.(he W&C pecial"pplemental %ood *rogram as started in =EI@. &t providesn"tritio"s ood and n"trition ed"cation to lo-income, pregnant,postpart"m, and lactating omen and to inants and children "pto age #ears. 5ther n"trition programs incl"de %ood tamps,National chool 3"nch *rogram, chool $reakast *rogram, andthe Child Care %ood *rogram, hich provides fnancial assistance


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or n"tritio"s meals to children in da# care centers, amil# andgro"p da# care homes, and Head tart centers.

Education for A// 2andicapped %"i/dren Act 6P.L. 8>'1>47.*.3. E@-=@> as passed in =EI to provide ree p"!lic ed"cation

to all handicapped children ages ? to >= #ears and to provides"pportive services s"ch as speech and co"nseling that ens"rethe !eneft o special ed"cation.

Education of t"e 2andicapped Act Aendents of 18F6P.L. 88'>:7.&n =EG9, *.3. EE-@I as passed to allo ederal"nding to states to develop and implement a stateide,comprehensive, coordinated, and m"ltidisciplinar# program oearl# intervention services or handicapped inants and toddlersand their amilies.

(ni!us +udge Reconci/iation Act of 1885.(his actre"ired states to etend 0edicaid coverage to all children ages9 to =G #ears ith amil# incomes !elo =??P o the povert#level.

?ai/$ and Medica/ Leave Act 6?MLA7.%03A as signed intola in =EE?. (his Act allos eligi!le emplo#ees to take "p to =>eeks o "npaid leave rom their )o!s ever# #ear to care orne!orn or nel# adopted children+ to care or children, parents,or spo"ses ho have serio"s health conditions+ or to recoverrom their on serio"s health conditions. Ater the leave, the laentitles emplo#ees to ret"rn to their previo"s )o!s or e"ivalent)o!s ith the same pa#, !enefts, and other conditions.

2ea/t" Insurance Porta!i/it$ and Accounta!i/it$ Act62IPAA7.(he frst-ever ederal privac# standards to protectpatients6 medical records and other health inormation providedto health plans, doctors, hospitals and other health careproviders took e;ect on April =@, >BB?. H&**A, developed !# theepartment o Health and H"man ervices HH, are nestandards that provide patients ith access to their medicalrecords and more control over ho their personal healthinormation is "sed and disclosed. %or "rther inormation see the

e!site: http://.hhs.gov/ocr/hipaa .

espite ederal and state programs availa!le to assist children andamilies, serio"s !arriers to health care remain. (hese incl"de =4nancial barriers, s"ch as not having ins"rance, havingins"rance that does not cover certain services, or !eing "na!le topa# or services+ > system barriers, s"ch as having to travelgreat distances or health care or state-to-state variations in


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0edicaid !enefts+ and ? 5no!ledge barriers, s"ch as a lack o"nderstanding o the need or prenatal or child health s"pervisionor an "naareness o the services availa!le. (he c"rrent thr"st inhealth care is to improve access to health care or all children andtheir amilies.

Another ma)or change in health care deliver# has !een theesta!lishment o aprospective payment system!ased ondiagnosis6related gro$ps (+.7s). (he R1 categories defnepretreatment (prospective) billingor 7.. hospitalsreim!"rsed !# 0edicare. When hospitals are held fnanciall#responsi!le i 0edicare patients eceed the allotted admissionsta#, patients are discharged earl#. 8arl# discharges have createda need or home care and comm"nit#-!ased services. Health carecost containment remains a national priorit#, and c"rrentl#, man#children are enrolled in managed care companies and health

maintenance organizations (HMOs).D&n some instances, thesecompanies and organi4ations have improved access to preventivehealth care or children, !"t in other cases, the# have red"cedaccess to specialt# care or children ith chronic conditions4ilag#, =EEG.

D %or inormation on managed care reerences andreso"rces, contact http://.n"rsingorld.org.

PE&IATRI% N)RSIN,

P2IL(S(P2Y (? %AREN"rsing o inants and children is consistent ith the revisedde4nition of n$rsingproposed !# the ocial *olic# (ask %orce othe American N"rses Association in >BB?. (his defnition statesthat BB?. (his defnition incorporates the o"ressential eat"res o n"rsing practice:

1. Attention to the "ll range o h"man eperiences andresponses to health and illness itho"t restriction to a pro!lem-oc"sed orientation

4. &ntegration o o!)ective data ith knoledge gained roman "nderstanding o the patient or gro"p6s s"!)ective eperience


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=. Application o scientifc knoledge to the processes odiagnosis and treatment

>. *rovision o a caring relationship that acilitates health andhealing American N"rses Association, >BB?

?ai/$'%entered %areG

(he philosoph# o family6centered carerecogni4es the amil#as the one constant in a child6s lie. (hree ke# components oamil#-centered care are respect, colla!oration, and s"pport1alvin and others, >BBB. %amilies are s"pported in their caregiving and decision-making hen health care proessionals !"ildon their "ni"e strengths and acknoledge their epertise incaring or their child !oth ithin and o"tside the hospital settingNeton, >BBB. *atterns o living at home and in the comm"nit#

are promoted, and the needs o all amil# mem!ers, not )"st thechild6s are considered $o =-=. (he philosoph# o amil#-centered care acknoledges diversit# among amil# str"ct"resand !ackgro"nds+ amil# goals, dreams, strategies, and actions+and amil# s"pport, service, and inormation needs.

+(* 1'1 T"e Ke$ E/eents of ?ai/$'%entered %are

&ncorporating into polic# and practice the recognition that the

family is the constantin a child6s lie hile the services#stems and s"pport personnel ithin those s#stems '"ct"ate

%acilitating family8professional collaborationat all levelso hospital, home, and comm"nit# care:

Care o an individ"al child

*rogram development, implementation, and eval"ation

*olic# ormation

9:changing complete and $nbiased information!eteen amil# mem!ers and proessionals in a s"pportivemanner at all times

&ncorporating into polic# and practice the recognition andhonoring of c$lt$ral diversity, strengths, and individ"alit#ithin and across all amilies, incl"ding ethnic, racial,


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spirit$al, social, economic, ed$cational, and geographicdiversity

Recogni4ing and respecting di;erent methods of copingand implementing comprehensive policies and programs that

provide developmental, ed$cational, emotional,environmental, and 4nancial s$pportto meet the diverseneeds o amilies

8nco"raging and acilitating family6to6family s$pportandnetorking

8ns"ring that home, hospital, and comm$nity serviceands$pport systemsor children needing speciali4ed health anddevelopmental care and their amilies are


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*artnerships impl# the !elie that partners are capa!leindivid"als ho !ecome more competent !# sharing knoledge,skills, and reso"rces in a manner that !enefts all participants.Colla!oration is vieed as a contin""m. %amilies have the optiono !eing an#here along the contin""m, depending on their

strengths and needs and their relationships ith proessionals.(he n"rse can help everyamil#, incl"ding those ith a previo"shistor# o serio"s personal or amil# pro!lems, to identi# theirstrengths, !"ild on them, and ass"me a comorta!le level oparticipation. Altho"gh caring or the amil# is strongl#emphasi4ed thro"gho"t the tet, it is highlighted in eat"res s"chas C"lt"ral Aareness, %amil# %oc"s, and %amil# Home Care!oes.

D %or additional inormation, please vie BB, Washington, C >BB?9, >B> 9?G-==@@.

Atrauatic %are

Altho"gh tremendo"s advances have !een made in pediatriccare, man# changes that have c"red illnesses and prolonged lieare tra"matic, pain"l, "psetting, and rightening. 7nort"natel#,

minimi4ing the tra"ma o medical interventions has not keptpace ith technologic advances. Health proessionals m"st !eaare o the stresses acing ill children and their amilies andstrive to provide interventions that are sae, e;ective, andhelp"l. Health proessionals m"st also attempt to provideatra"matic care.

*tra$matic careis the provision o therape"tic care in settings,!# personnel, and thro"gh the "se o interventions that eliminateor minimi4e the ps#chologic and ph#sical distress eperienced !#children and their amilies in the health care s#stem.

herape$tic careencompasses the prevention, diagnosis,treatment, or palliation o chronic or ac"te conditions. #ettingreers to hatever place that care is given2the home, thehospital, or an# other health care setting. Personnelincl"desan#one directl# involved in providing therape"tic care.%nterventionsrange rom ps#chologic approaches, s"ch aspreparing children or proced"res, to ph#sical interventions, s"chas providing space or a parent to room in ith a child.


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Psychologic distressma# incl"de aniet#, ear, anger,disappointment, sadness, shame, or g"ilt. Physical distressma# range rom sleeplessness and immo!ili4ation to theeperience o dist"r!ing sensor# stim"li s"ch as pain,temperat"re etremes, lo"d noises, !right lights, or darkness.

Atra"matic care is concerned ith the ho, hat, hen, here,h#, and ho o an# proced"re perormed on a child or thep"rpose o preventing or minimi4ing ps#chologic and ph#sicalstress Wong, =EGE.

(he overriding goal in providing atra"matic care is 4rst, do noharm. (hree principles provide the rameork or achieving thisgoal: = prevent or minimi4e the child6s separation rom theamil#+ > promote a sense o control+ and ? prevent orminimi4e !odil# in)"r# and pain. 8amples o atra"matic careincl"de ostering the parent-child relationship d"ring

hospitali4ation, preparing the child !eore an# "namiliartreatment or proced"re, controlling pain, alloing the childprivac#, providing pla# activities or epression o ear andaggression, providing choices to children, and respecting c"lt"raldi;erences.

Atra"matic care is an integral part o n"rsing care disc"ssions inthe tet. Atra"matic Care !oes highlight selected eamples andseveral !oes oc"sing on c"lt"re, amil# teaching, research, andcritical thinking incorporate atra"matic care. Chapter >=, %amil#-Centered Care o the Child "ring &llness and Hospitali4ation is

organi4ed according to principles o atra"matic care.

%ase Manageent

Case management developed as an approach to coordinate careand control costs. (he !enefts o case management incl"deimproved patient/amil# satisaction, decreased ragmentation ocare, and the a!ilit# to descri!e and meas"re o"tcomes or ahomogeneo"s gro"p o patients.

Case managers are responsi!le and acco"nta!le or partic"lar

gro"ps o patients and oten "se timelines derived romstandards o care. (imelines have a variet# o names: criticalpaths, g"idelines or care, case management plans, Caremaps,Dcoordinated care plans, or other titles agreed on ithin a specifcagenc#. Regardless o their name, timelines are m"ltidisciplinar#plans that incl"de all the components o care or an episode orm"ltiple episodes o illness, as ell as the epected o"tcomes orres"lt o care. (imelines can !e confned to inpatient care or the


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entire contin""m o care, incl"ding home care see also Chapter>B.

&n addition to providing care in a s#stematic manner, proessionaland government organi4ations oten ollo clinical practice

g$idelinesor the care o an illness, disease, or pro!lem. Caretimelines are developed ithin an instit"tion and re'ect localpractice patterns, !"r clinical practice g"idelines are developedon a national level and re'ect research related to a specifcdisease or illness. (he*gency for Healthcare .esearch and=$ality (*H.=)is a ederal agenc# that has developed severalclinical practice g"idelines relevant to pediatrics i.e., ac"te painmanagement, the management o otitis media ith e;"sion, andthe diagnosis and treatment o sickle-cell disease $o =->.

+(* 1'4 A2%PR %/inica/ Practice

,uide/ines Re/evant to Pediatric Practice

Ac"te pain management: operative or medical proced"res andtra"ma

7rinar# incontinence

*ress"re "lcers: prediction and intervention

(reatment o press"re "lcers

iagnosis and treatment o depressed o"tpatients in primar#care settings

iagnosis and treatment o sickle cell disease

&nitial eval"ation and earl# treatment o the H&M-inectedindivid"al

0anagement o cancer-related pain

iagnosis and treatment o heart ail"re

5titis media ith e;"sion

0odifed rom AHCR* no knon as AHRU. (o orderg"idelines, contact AHC*R *"!lications Clearingho"se, *5 $oG@I, ilver pring, 0 >BEBI, GBB ?G-E>E+http://.ahcpr.gov.D Caremap is a registered trademark o the %enter for %aseManageent9 Inc., o"th Natick, 0A B=I9B+ BG 9=->9BB.


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R(LE (? T2E PE&IATRI% N)RSE

T"erapeutic Re/ations"ip

A therape"tic relationship is the essential o"ndation or "alit#n"rsing care. *ediatric n"rses m"st relate to children and theiramilies in a meaning"l a#, and #et remain separate eno"gh todisting"ish their on eelings and needs. &n a therape$ticrelationship, caring, ell-defned !o"ndaries separate then"rse rom the child and amil# *eternel)-(a#lor, >BB>. (hese!o"ndaries are positive and proessional and promote theamil#6s control over the child6s health care R"shton, 0c8nhill,and Armstrong, =EE9. Within a therape"tic relationship, !oth then"rse and the amil# are empoered, and open comm"nicationis maintained. &n a nontherape$tic relationship, !o"ndariesare !l"rred, and man# o the n"rse6s actions ma# serve personalneeds, s"ch as a need to eel anted and involved, rather thanthe amil#6s needs. ome settings make the esta!lishment o!o"ndaries more dic"lt than others. %or eample, in the homecare setting several actors challenge the defnition o!o"ndaries. (he inormal home environment, the cas"al socialconversations among amil# mem!ers, the participation !#amil# mem!ers in the care o the child, and the attempt !#some amilies to incorporate the home care n"rse into the amil#all present ma)or challenges to esta!lishing and maintainingclear !o"ndaries.

8ploring hether relationships ith patients are therape"tic ornontherape"tic helps n"rses identi# pro!lem areas earl# in theirinteractions ith children and amilies. Altho"gh "estions oreploring t#pes o involvement can !e la!eled negative orpositive, no one action makes a relationship therape"tic ornontherape"tic. %or eample, n"rses ma# spend additional timeith the amil# !"t still recogni4e their on needs and maintainproessional separateness. An important cl"e to nontherape"ticrelationships is the sta;6s concerns a!o"t their peer6s actionsith the amil#.

?ai/$ Advocac$H%aring

Altho"gh n"rses are responsi!le to themselves, the proession,and the instit"tion o emplo#ment, their primar# responsi!ilit# isto the cons"mer o n"rsing services2the child and the amil#.(he n"rse m"st ork ith amil# mem!ers, identi# theirgoalsand needs, and plan interventions that meet the defned


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pro!lems. As an advocate, the n"rse assists children and theiramilies in making inormed choices and acting in the child6s !estinterest. Advocac# involves ens"ring that amilies are aare oall availa!le health services, inormed o treatments andproced"res, involved in the child6s care, and enco"raged to

change or s"pport eisting health care practices. (he 7nitedNations eclaration o the Rights o the Child $o =-? providesg"idelines or n"rsing practice to ens"re that ever# child receivesoptim"m care. (he n"rse "ses this knoledge to adapt care orthe child and the amil#.

+(* 1'= )nited Nations &ec/aration oft"e Rig"ts of t"e %"i/d

All children need:

(o !e ree rom discrimination

(o develop ph#sicall# and mentall# in reedom and dignit#

(o have a name and nationalit#

(o have ade"ate n"trition, ho"sing, recreation, and medicalservices

(o receive special treatment i handicapped

(o receive love, "nderstanding, and material sec"rit#

(o receive an ed"cation and develop his or her a!ilities

(o !e the frst to receive protection in disaster

(o !e protected rom neglect, cr"elt#, and eploitation

(o !e !ro"ght "p in a spirit o riendship among people

As n"rses care or children and amilies, the# m"st demonstratecaring, compassion, and empath# or others. Aspects o caring

incl"de atra"matic care and the development o a therape"ticrelationship. *arents perceive caring as a sign o "alit# n"rsingcare, hich is oten oc"sed on the nontechnical needs o thechild and amil#. *arents descri!e


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n"rsing care. *arents perceive


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oncolog#, and ne"rolog#. As ith the *N* role, the ed"cationalpreparation or the CN incl"des a grad"ate degree in n"rsing.ome grad"ate programs com!ine the *N* and CN roles. $oth*N*s and CNs are commonl# called advanced n$rsepractitioners*3Psor*.3Ps.

8ver# n"rse ho is involved ith caring or children m"stpractice preventive health. (he !est approach to prevention ised"cation and anticipator# g"idance. &n this tet, each chapteron health promotion also incl"des sections on anticipator#g"idance. An appreciation o the ha4ards o each developmentalperiod ena!les the n"rse to g"ide parents regarding childrearingpractices that are aimed at preventing potential pro!lems. 5nesignifcant eample is saet#. $eca"se children o ever# age areat risk or in)"r#, ed"cation o the parents is essential todecrease disa!ilit# and prevent mortalit#.

*revention also involves less o!vio"s aspects o care s"ch aspromoting mental health. %or eample, it is not s"cient toadminister imm"ni4ations itho"t regard or the ps#chologictra"ma associated ith administering imm"ni4ations.

2ea/t" Teac"ing

Health teaching is insepara!le rom amil# advocac# andprevention. Health teaching ma# !e direct as d"ring parentingclasses, or indirect as hen n"rses help parents and children to

"nderstand a diagnosis or treatment, enco"rage children to ask"estions a!o"t their !odies, reer amilies to health-relatedproessional or la# gro"ps, s"ppl# appropriate literat"re, andprovide anticipator# g"idance. (o !e e;ective health teachers,n"rses need preparation and practice ith competent rolemodels. Health ed"cation involves transmitting inormation atthe child and amil#6s level o "nderstanding. 8;ective ed"catorsalso oc"s on giving appropriate eed!ack and eval"ation topromote learning.

SupportH%ounse/ing

Attention to emotional needs re"ires s"pport and sometimesco"nseling. (he role o child advocate or health teacher iss"pportive !eca"se this role re"ires an individ"ali4ed approach."pport can !e o;ered !# listening, to"ching, and thro"ghph#sical presence. (o"ching and ph#sical presence are help"l


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ith children !eca"se these interventions acilitate nonver!alcomm"nication.

Co"nseling involves a m"t"al echange o ideas and opinionsthat provides the !asis or m"t"al pro!lem solving. &t involves

s"pport, teaching, ostering epression o eelings or tho"ghts,and helping amilies to cope ith stress. 5ptimall#, co"nselingnot onl# helps to resolve a crisis or pro!lem !"t also ena!les theamil# to attain a higher level o "nctioning, greater sel-esteem,and closer relationships. Altho"gh advanced practice n"rsesre"entl# do most o the ormal co"nseling o parents andchildren, co"nseling techni"es are disc"ssed in this tet to helpst"dents and n"rses cope ith immediate crises and reeramilies or additional proessional assistance.

Restorative Ro/e

(he most !asic o all n"rsing roles is the restoration o healththro"gh care giving activities. N"rses are intimatel# involved ithmeeting the ph#sical and emotional needs o children, incl"dingeeding, !athing, toileting, dressing, sec"rit#, and sociali4ation.Altho"gh the# are responsi!le or instit"ting ph#sicians6 orders,the# are also acco"nta!le or their on actions and )"dgmentsregardless o ritten orders.

A signifcant aspect o restoration o health is contin"alassessment and eval"ation o ph#sical stat"s. (he oc"s

thro"gho"t this tet on ph#sical assessment, pathoph#siolog#,and scientifc rationale or therap# assists the n"rse in decisionmaking regarding health stat"s. (he n"rse m"st !e aare onormal fndings to identi# and doc"ment deviations. &n addition,the pediatric n"rse sho"ld never lose sight o the child6sindivid"al emotional and developmental needs !eca"se theseneeds in'"ence the co"rse o the disease or illness.

%oordinationH%o//a!oration

(he n"rse, as a mem!er o the health team, colla!orates andcoordinates n"rsing services ith the activities o otherproessionals. Working in isolation does not serve the child6s !estinterest. (he concept o


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nontherape"tic and perhaps destr"ctive. %or eample, the n"rseho eels competent in co"nseling !"t ho is reall# inade"atein this area ma# not onl# prevent the child rom dealing ith acrisis !"t also impede "t"re s"ccess ith a "alifedproessional.

8ven n"rses ho practice in isolated geographic areas separatedrom other health proessionals are not totall# independent.8ver# n"rse orks interdependentl# ith the child and amil#,colla!orating on needs and interventions so the fnal care plan isone that tr"l# meets the child6s needs. 7nort"natel#,colla!oration and coordination ith the child and the amil# issometimes lacking in health care planning. N"mero"s disciplinesoten ork together to orm"late a comprehensive approachitho"t cons"lting the child and the amil#. (he n"rse is in a vitalposition to incl"de the child and amil# mem!ers in their care,

either directl# or indirectl#, !# comm"nicating their tho"ghts tothe health team.

Et"ica/ &ecision Ma#ing

8thical dilemmas arise hen competing moral considerations"nderlie vario"s alternatives. *arents, n"rses, ph#sicians, andother health care team mem!ers ma# reach di;erent !"t morall#deensi!le decisions !# assigning di;erent eight to thecompeting moral val"es. (hese competing moral val"es ma#incl"de a$tonomy, the patient6s right to !e sel-governing+

nonmale4cence, the o!ligation to minimi4e or prevent harm+bene4cence, the o!ligation to promote the patient6s ell-!eing+and&$stice, the concept o airness Cornelison, =EEG+ alvatoreand $ater, =EEG. N"rses m"st determine the most !enefcial orleast harm"l action ithin the rameork o societal mores,proessional practice standards, the la, instit"tional r"les,religio"s traditions, the amil#6s val"e s#stem, and the n"rse6spersonal val"es.

When ethical con'icts occ"r, n"rses ma# eperience con'ictinglo#alties to their proession, colleag"es, patients and amilies,

instit"tions, and societ#. (he n"rse6s role in ethical decisionmaking can !e am!ig"o"s. A n"rse ma# !e o!liged to carr# o"tproced"res that are !ased on ph#sician orders or hospital polic#!"t inconsistent ith the patient6s !est interest. 5ten, mem!erso the health care team do not seek the n"rse6s inp"t, leaving then"rse ith incomplete inormation or itho"t a voice in clinicaldecision making.


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(he role o n"rses as mem!ers o the health care team )"stifestheir participation in colla!orative ethical decision making.N"rses ro"tinel# "se a s#stematic pro!lem-solving method, then$rsing process, to resolve clinical pro!lems. 7sing the n"rsingprocess, the n"rse collects pertinent ph#siologic and

ps#chosocial data, assesses relevant val"es held !# the patientand amil#, and incorporates data into a plan o care. 8ach othese activities is a cr"cial component o ethical decisionmaking.

N"rses spend most o their time in direct patient care, and are ina "ni"e position to provide insight a!o"t the child6s conditionand response to therap#. (he# also assist amilies !# interpretinginormation a!o"t the child6s condition, prognosis, and treatmentoptions, and !# acilitating inormed decisions. $eca"se o theirrelationship to amilies, n"rses represent children and parents6

val"es, !elies, and preerences. N"rses also serve as the liaison!eteen the amil# and other health team mem!ers.

&n their practice, n"rses "se a proessional code o ethics org"idance and proessional sel-reg"lation. (he Code o 8thics orN"rses ith &nterpretive tatements American N"rsesAssociation, >BB= oc"ses on the n"rse6s acco"nta!ilit# andresponsi!ilit# to the client and emphasi4es the n"rse6s role as anindependent proessional one ith legal lia!ilit# $o =-@.

N"rses m"st prepare themselves or colla!orative ethicaldecision making. (his is accomplished thro"gh ormalco"rseork, contin"ing ed"cation, contemporar# literat"re, and!# orking in environments that are cond"cive to ethicaldisco"rse. N"rses m"st !e aare o mechanisms or con'ictresol"tion, case revie !# ethics committees, proced"ralsaeg"ards, state stat"tes, and case la.

+(* 1'> Standard :. Et"ics

T2E N)RSE INTE,RATES ET2I%AL PR(ISI(NS IN ALLAREAS (? PRA%TI%E

Measureent %riteria

(he n"rse:

1. elivers care in a manner that preserves/protects patienta"tonom#, dignit#, and rights


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4. 0aintains patient confdentialit# ithin legal and reg"lator#parameters

=. erves as a patient advocate assisting patients indeveloping skills so the# can advocate or themselves

>. 0aintains a therape"tic and proessional patient-n"rserelationship ith appropriate proessional role !o"ndaries

:. Contri!"tes to resolving ethical iss"es o patients,colleag"es, or s#stems

F. Reports illegal, incompetent or impaired practices.

%rom: #+r!in'$ -ope and !tandard! o pratiep"!liccomment drat, Lan"ar# >BB?, Washington, C, >BB?,American N"rses Association.

N"rses re"entl# ace ethical iss"es regarding patient care, s"chas the "se o liesaving meas"res or ver# 3$W ne!orns or theright o a terminall# ill child to re"se treatment. (he# ma#str"ggle ith "estions regarding tr"th"lness, their rights andresponsi!ilities in caring or children ith A&, histle-!loing,or reso"rce allocation. (hro"gho"t the tet, ethical dilemmas areaddressed in


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concept o evidence-!ased practice involves anal#4ing andtranslating p"!lished clinical research into ever#da# n"rsingpractice. When n"rses !ase their practice on science andresearch and doc"ment clinical o"tcomes, the# validate theircontri!"tions to health not onl# or clients, third-part# pa#ers,

and instit"tions, !"t also or the n"rsing proession %reda, =EEG.8val"ation is essential to the n"rsing process, and research isone o the !est a#s to accomplish it.

2ea/t" %are P/anning

(oda#, the n"rse6s role has epanded !e#ond the n"cle"s o theamil# to incl"de the comm"nit#-!ased health driven s#stem.(raditionall#, n"rses ere involved in p"!lic health either on acontin"o"s or an episodic !asis. N"rses ere involved in healthcare planning on a political or legislative level less re"entl#.

%"t"re n"rses ill need to incorporate a political component intotheir proessional identit# and attempt to in'"ence the decision-making !od# o government.D

As the largest health care proession, n"rsing has a val"a!levoice, especiall# as amil#/cons"mer advocate. N"rses m"st!ecome aare o comm"nit# needs, interested in the orm"lationo !ills, and s"pportive o politicians to ens"re passage orre)ection o signifcant legislation. N"rses also need to !ecomeactivel# involved ith gro"ps that are dedicated to the elare ochildren e.g., proessional n"rsing societies, parent-teacher

organi4ations, parent s"pport gro"ps, and vol"nteerorgani4ations.

Health care planning involves not onl# providing ne services tochildren and their amilies !"t also promoting the highest "alit#in eisting services. &n addition to olloing the Code o 8thics orN"rses, n"rses ens"re ecellence in their proession !# olloingstandards o practice. A standard of practiceis the level operormance that is epected o a proessional. &n the past,pediatric n"rsing has not had national or international standardso care or ed"cation. 0ost pediatric n"rses oten merged ith

other specialties ithin n"rsing and olloed the tandards o0aternal-Child Health N"rsing or the standards o several o thepediatric specialties, s"ch as pediatric oncolog# n"rsing or schooln"rsing.DHoever, as the theoretical, practice, and research!ases or pediatric n"rsing mat"re, the need or standards opractice or all !asic pediatric n"rses and or advanced practiceregistered n"rses has !ecome more evident. &n >BB?, the ociet#o *ediatric N"rses and the American N"rses Association


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p"!lished the -ope and -tandard! o Pediatri #+r!in'. (hisdoc"ment identifes standards o practice that are congr"entith c"rrent proessional polic# or !oth the n"rse generalist andthe advanced pediatric n"rsing care.D

(hro"gho"t the tet, the highest standards o n"rsing practiceare re'ected in the emphasis on thoro"gh assessment, the oc"son scientifc rationale as the !asis or care, the s"mmar# on"rsing care goals and responsi!ilities, and the comprehensivedisc"ssion o groth and development.

D (he olloing are so"rces o inormation on governmentiss"es: White Ho"se Comment 3ine, >B> @9-====, E A0K *08(+ White Ho"se a: >B> @9->@9=+ White Ho"se e-mail:presidentVhiteho"se.gov.D Availa!le rom the Association of Pediatric (nco/og$Nurses, @IBB W. 3ake Ave, 1lenvie, &3. 9BB>-=@G, G@I

?I-@I>@, a: GII I?@-GI, and the Nationa/ Associationof Sc"oo/ Nurses, 3amplighter 3ane, *5 $o =?BB,car!oro"gh, 08 B@BI@, >BI GG?->==I+ http://.nasn.org.D %or more inormation on the cope and tandards o*ediatric N"rsing, contact the ociet# o *ediatric N"rses, IIE@1ro rive, *ensacola, %3 ?>=@-I=I>+ = GBB I>?->EB>+ %a:GB @G@-GI9>+ e!site: http://.pedsn"rses.org

?)T)RE TREN&S

(he present shit rom treatment o disease to promotion o health

has epanded n"rses6 roles in am!"lator# care and highlighted theprevention and health teaching aspects o n"rsing practice.*rospective pa#ment and the need or home care and comm"nit#health services re"ire n"rses to !e more independent and toac"ire skills that are "se"l in settings !e#ond the hospital. (hesetrends are ill"strated thro"gho"t the tet, ith increased emphasison prevention thro"gh anticipator# g"idance, child health andamil# assessment, and discharge planning and care in the homeand comm"nit#. As changing social polic# shapes the epandinghealth care arena, the oc"s o n"rsing care is no longer on hate do foramilies, !"t hat e do in partnership !iththem.

(he philosoph# o amil#-centered care is no longer an option, !"ta mandate.

(oda#, technologic advances and the demand or comp"terknoledge in the ork setting are o!vio"s. (he c"rrent shortage on"rses ill persist into the "t"re, and the press"re to createpositions in the health care s#stem that do not re"ire a n"rsing!ackgro"nd ill !ecome more intense. As ne categories o


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orkers enter the health care feld, n"rses m"st contin"e to"pdate their knoledge o technolog# and prove their "ni"econtri!"tion to health care. N"rses m"st "se technolog# and learnto ork colla!orativel# ith "nlicensed assistive personnel.nlicensed assistive personnel (*P)


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A s#stematic tho"ght process is essential to a proession !eca"seit helps the proessional to meet the needs o the client. /riticalthin5ingis p"rpose"l, goal-directed thinking that assistsindivid"als to make )"dgments !ased on evidence rather thang"essork Alaro-3e%evre, >BB@+ "llivan and ecker, >BB=. As

ith the n"rsing process, critical thinking is !ased on the scientifcmethod o in"ir#.

Critical thinking is a comple developmental process !ased onrational and deli!erate tho"ght. $ecoming a critical thinker allosthe proessional n"rse to ac"ire and appl# knoledge thateemplifes disciplined and sel-directed thinking. (he cognitiveskills "sed in high-"alit# thinking re"ire intellect"al discipline,sel-eval"ation, co"nterthinking, opposition, challenge, ands"pport. Critical thinking transorms the a#s in hich individ"alsvie themselves, "nderstand the orld, and make decisions.

When thinking is clear, precise, acc"rate, relevant, consistent, andair, a logical connection develops !eteen the elements otho"ght and the pro!lem at hand. el-eval"ation "estions thatenhance the development o critical thinking are listed in $o =-.

$eca"se critical thinking is s"ch an important skill, Critical(hinking 8ercises are incl"ded thro"gho"t this tet. (heseeercises present n"rsing practice sit"ations that re"ire criticalthinking skills. el-eval"ation "estions re"ire the st"dent toprovide rational and deli!erate ansers !ased on sel-directedthinking. (he aim o these eercises is to enhance so"nd clinical

)"dgment.

+(* 1': %ritica/ T"in#ing Process

INTERPRETATI(N

What is the meaning or signifcance o the epressed dataHo are the evidence/data interpreted

incl"des data categori4ation or cl"stering, assigningsignifcance o data, and clari#ing meaning o data ithin the

contet

ANALYSIS

What are the intended and act"al inerential relationshipsamong the statements or concepts presented What are some"nderl#ing ass"mptions a!o"t the data presented Whatpriorities o care are appropriate given the data presented


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incl"des identi#ing "nstated ass"mptions, constr"cting a mainconcl"sion and reasons to s"pport the concl"sion

EAL)ATI(N

oes the evidence presented s"pport the concl"sions !eingdran Ho are the arg"ments eval"ated

incl"des assessing credi!ilit# o data or statements epressed,assessing the logical strengths o the act"al or intendedinerential relationships among statements or descriptions

IN?EREN%E

What alternatives concl"sions or options might !e dran romthe epressed data What alternative perspectives might !epresented as options to one6s on concl"sions &denti#ing an

"nderl#ing ca"se o an illness/health pro!lem.

incl"des process o "estioning availa!le evidence,con)ect"ring alternatives, and draing concl"sions

E*PLANATI(N

L"sti# one6s reasoning !ehind concl"sions dran andarg"ments h#potheses prod"ced !ased on the evidence ordata. oes the contet"al evidence s"pport concl"sions

incl"des stating res"lts, )"sti#ing proced"res, and presentingarg"ments

SEL?'RE,)LATI(N

(o eamine one6s on reasoning and validate res"lts. Are!iases present hich a;ect one6s thinking/concl"sions a!o"tthe data

incl"des sel-eamination and sel-correction

0odifed rom %acione *: Critial thinkin'$ hat it i! and hy it

o+nt!, =EE>, =EEG, 0ill!rae, Cali, Caliornia Academic *ress,retrieved on @/?B/B? romhttp://.insightassessment.com/articles.html+ "llivan 8L,ecker *L: *ro!lem solving and decision making. &n "llivan 8L,ecker *L: :etive leader!hip and &ana'e&ent in n+r!in', ed ,7pper addle River, NL, >BB=, *rentice Hall+ Alaro-3eevre R:Critial thinkin' and linial +d'&ent, ed ?, *hiladelphia, >BB@,W$ a"nders.


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N)RSIN, PR(%ESS

(he n"rsing process is a method o pro!lem identifcation andpro!lem solving that descri!es hat the n"rse act"all# does. (hen"rsing process incl"des assessment, diagnosis, o"tcome

identifcation, planning, implementation, and eval"ation. (hesecond step, n"rsing diagnosis, is the naming o the child6s oramil#6s pro!lem in common n"rsing lang"age. (he AmericanN"rses Association has esta!lished tandards o *ractice and*roessional *erormance $o =-9 that o"tline the componentsincl"ded in each step o the n"rsing process.

+(* 1'F Aerican Nurses AssociationStandards for Practice

%rom #+r!in'$ -ope and !tandard! o pratiep"!lic commentdrat, Lan"ar# >BB?, Washington, C, >BB?, American N"rsesAssociation.

;!!e!!&ent

Assessment is a contin"o"s process that operates at all phaseso pro!lem solving and is the o"ndation or decision making. &t"ses m"ltiple n"rsing skills and consists o p"rpose"l collection,classifcation, and anal#sis o data rom a variet# o so"rces. (oprovide an acc"rate and comprehensive assessment, the n"rsem"st consider inormation a!o"t the patient6s !ioph#sical,ps#chologic, socioc"lt"ral, and spirit"al !ackgro"nd.

#+r!in' %ia'no!i!


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(he second stage o the n"rsing process is pro!lem identifcationand n"rsing diagnosis. At this point, the n"rse m"st interpret andmake decisions a!o"t the data gathered. (he n"rse organi4es orcl"sters data into categories to identi# signifcant areas andmakes one o the olloing decisions:

X No d$sfunctiona/ "ea/t" pro!/esare evident+ nointerventions are indicated.

X Ris# for d$sfunctiona/ "ea/t" pro!/eseists+interventions are needed to acilitate health promotion.

X Actua/ d$sfunctiona/ "ea/t" pro!/esare evident+interventions are needed to acilitate health promotion.

(he n"rsing diagnosis phase involves the naming o c"e cl"stersthat are o!tained d"ring the assessment phase. (he North

American N"rsing iagnosis Association6s NANA6s accepteddefnition o n$rsing diagnosisis


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a/uing2(he assigning o relative orth

%"oosing2(he selection o alternatives

Moving2Activit#

Perceiving2(he reception o inormation

Kno0ing2(he meaning associated ith inormation

?ee/ing2(he s"!)ective aareness o sensation or a;ect

?)N%TI(NAL 2EALT2 PATTERNS

2ea/t" perception'"ea/t" anageent pattern2*erceptions related to general health management andpreventive practices

Nutritiona/'eta!o/ic pattern2&ntake o ood and '"idsrelated to meta!olic re"irements

E/iination pattern2Reg"larit# and control o ecretor#"nctions, !oel, !ladder, skin, and astes

Activit$'e


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TA*(N(MY II &(MAINS

&oain 1 C2ea/t" Prootion

&oain 4 CNutrition

&oain = CE/iination

&oain > CActivit$HRest

&oain : CPerceptionH%ognition

&oain F CSe/f'Perception

&oain CRo/e Re/ations"ips

&oain CSe


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(he second component o n"rsing diagnosis, the etiology,descri!es the ph#siologic, sit"ational, and mat"rational actorsthat ca"se the pro!lem or in'"ence its development. (heetiolog# is ritten "sing NANA diagnostic categories e.g., denial o illness, ?lo economic reso"rces, or @ c"lt"ral con'ict. &nterventions ora knoledge defcit are ver# di;erent rom interventions or loeconomic reso"rces.

(he third component, signs and symptoms, reers to a cl"stero c"es or defning characteristics that are derived rom patientassessment and indicate act"al health pro!lems. When a

defning characteristic is essential or the n"rsing diagnosis to !emade, it is considered critical. (hese critical defningcharacteristics help di;erentiate !eteen diagnostic categories.%or eample, in deciding !eteen the diagnostic categoriesrelated to amil# process and parenting, the defningcharacteristics are important in choosing the most appropriaten"rsing diagnosis see %amil# %oc"s !o.

?AMILY ?(%)S )sing &eJning%"aracteristics to Se/ect an Appropriate

Nursing &iagnosisAn =G-month-old onl# child is admitted ith respirator# distressand a pres"mptive diagnosis o epiglottitis. &nitial n"rsingactions oc"s on the ph#siologic stat"s o the child. As thecondition sta!ili4es, amil# assessment data are gathered. (hechild6s imm"ni4ations are c"rrent, he is clean and ellno"rished, and his developmental age is appropriate. (he


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parents are !oth present at admission. (he mother is distra"ghta!o"t the s"dden onset o respirator# distress. he states thatearlier her child had onl# a


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*arent ver!ali4es or demonstrates eelings o g"ilt, anger,ear, aniet#, or r"strations a!o"t e;ect o child6s illness onamil# process

?ai/$ Processes9 Interrupted2a change in amil#

relationships or "nctioning.

#elected de4ning characteristics

8pressions o con'ict ithin the amil#

Changes in comm"nication patterns among amil# mem!ers

Among these three diagnoses, the most relevant one isCon


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D 0odifed rom the North American N"rsing iagnosisAssociation: #+r!in' dia'no!e!$ de=nition! and la!!i=ation!,1999>2000, *hiladelphia, =EEE, (he Association.Q 0odifed rom 1ordon 0: ?an+al o n+r!in' dia'no!i!, ed E,t 3o"is, >BBB, 0os!#.Y

North American N"rsing iagnosis Association: #+r!in'dia'no!i!$ de=nition! and la!!i=ation, >BB?K>BB@,*hiladelphia, >BB?, (he Association.

Plannin'

Ater the n"rsing diagnosis has !een identifed, a care plan isdeveloped and o+to&e!or goals are esta!lished. (he o+to&eis the pro)ected change in the patient6s health stat"s, clinicalcondition, or !ehavior that occ"rs ater n"rsing interventions.(he "ltimate o!)ective o n"rsing care is to convert the n"rsing

diagnosis into a desired health state. (he plan m"st !eesta!lished !eore the interventions can !e developed.

(he end point o the planning phase is the development o then"rsing plan o care. (he care plans in this tet provideg"idelines or the care o children and amilies ith a partic"larpro!lem and are standard as opposed to individ"ali4ed careplans (a!le =-9. #tandard care plansare plans that ares"cientl# !road to acco"nt or sit"ations that ma# develop inpatients ith partic"lar pro!lems. %or this reason, the care plansoten have n"mero"s n"rsing diagnoses, !oth epected and

potential. (hese possi!le n"rsing diagnoses g"ide patiento!servation and data collection in monitoring the development oadverse reactions. %ndivid$alized care plansare plans that areconcerned ith onl# those diagnoses that appl# to a partic"larpatient sit"ation. &n act"al practice, not all the pro!lemspresented in the standard care plan ma# !e relevant. When astandard n"rsing care plan is "sed to develop an individ"ali4edcare plan, pro!lems not pertinent to the sit"ation sho"ld !eeliminated and the o"tcomes sho"ld !e individ"ali4ed to thespecifc sit"ation. (o help the reader develop an individ"ali4edcare plan, the n"rsing diagnoses in the tet are listed in order o

priorit#. &n general, potential pro!lems are disc"ssed at the endo the plan, ecept hen n"rsing interventions are essential toprevent a potential pro!lem rom !ecoming an act"al pro!lem.

TA+LE 1'F %"aracteristics of Standard andIndividua/ied Nursing %are P/ans


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/&ple&entation

(he implementation phase !egins hen the n"rse p"ts theselected intervention into action and acc"m"lates eed!ackregarding its e;ects. (he eed!ack ret"rns in o!servations andcomm"nications that provide a data!ase on hich to eval"ate

the o"tcome o the n"rsing intervention. (hro"gho"t theimplementation stage, the patient6s saet# and ps#chologiccomort in terms o atra"matic care are the main concerns.

val+ation

8val"ation is the last step in the decision making involved in then"rsing process. (he n"rse gathers, sorts, and anal#4es data todetermine i = the goal has !een met, > the plan re"iresmodifcation, or ? another alternative sho"ld !e considered. &nthe tet, o!servation g"idelines are incl"ded in the standard careplans to help the reader to identi# methods to eval"ate hetherthe goals or o"tcomes are achieved. (he eval"ation stage eithercompletes the n"rsing process or serves as the !asis or theselection o other alternatives or intervention in solving thespecifc pro!lem.

%o+&entation

Altho"gh doc"mentation is not one o the steps o the n"rsingprocess, it is essential or eval"ation. (he n"rse can assess and

identi# pro!lems, plan, and implement itho"t doc"mentation,!"t eval"ation re"ires ritten evidence o progress toardo"tcomes. (he doc"mentation elements listed in the 1"idelines!o sho"ld !e incl"ded in the patient6s medical record.

,)I&ELINES &ocuentation of Nursing%are


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&nitial assessments and reassessments

N"rsing diagnoses and/or patient care needs

&nterventions identifed to meet the patient6s n"rsing careneeds

N"rsing care provided

*atient6s response to, and the o"tcomes o, the care provided

A!ilities o patient and/or, as appropriate, signifcant othersto manage contin"ing care needs ater discharge

(he n"rsing process has !ecome an integral part o proessionalpractice. (he-oint %oission on Accreditation of2ea/t"care (rganiations 6-%A2(7incorporated the n"rsing

process into the accreditation process. (he frst LCAH5 standardon hich n"rsing service is eval"ated states that individ"ali4ed,goal-directed n"rsing care is provided to patients thro"gh the "seo the n"rsing process. (he LCAH5 accredits man# health careproviders s"ch as hospitals, n"rsing homes, am!"lator# services,and home care agencies+ organi4ations that re"se or ailaccreditation are "na!le to receive ederal "nds, s"ch as0edicare or 0edicaid.

Another oc"s area or LCAH5 accreditation is the "se ocontin$o$s >$ality improvement (/=%). (his process is an

ongoing revie o s#stems, pro!lem identifcation, and resol"tionthat allos instit"tions to esta!lish and maintain "alit# care"llivan and ecker, >BB=. LCAH5 standards change over time.%or eample, in >BBB, ne standards ere added to address theiss"es o pain assessment and management. &n >BB?, nationalpatient saet# goals ere added to address the pro!lem opatient saet# in health care organi4ations.D

C"rrentl#, the attention in health care is oc"sed on patiento"tcomes. Criteria have !een esta!lished or changes thatsho"ld occ"r in the patient as a res"lt o the interaction ith the

health care team. At discharge, the care is eval"ated to ens"rethat these o"tcomes ere met.

D (he-oint %oission on Accreditation of 2ea/t"care(rganiations 6-%A2(7has esta!lished a toll-ree hot lineGBBO EE@-99=B to enco"rage patients, their amilies,caregivers, and others to share concerns regarding "alit# ocare iss"es at accredited health care organi4ations. Complaintsma# !e anon#mo"s ma# !e sent to the 5ce o U"alit#


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0onitoring, Loint Commission, 5ne Renaissance $lvd, 5ak!rook(errace, &3, 9B=G=+ a: 9?B IE>-9?9+ e-mail:complaintV)caho.org+ http://.)caho.org.

KEY P(INTS

B=B< !roadened the health care o!)ectives othe past and oc"ses on prevention as the method to accomplishhealth goals.

&nant mortalit# rate in the 7nited tates is at an all-time lo, !"tthe nation contin"es to lag !ehind other ma)or co"ntries.

3o !irth eight 3$W, hich is closel# related to earl#gestational age, is the leading ca"se o neonatal death in the7nited tates.

&n)"ries are the leading ca"se o death in children older than age= #ear, ith the ma)orit# !eing motor vehicle in)"ries.

Childhood mor!idit# encompasses ac"te illness, chronic disease,and disa!ilit#.

8ight# percent o childhood illness is attri!"ta!le to inections,ith respirator# tract inections occ"rring to to three times asoten as all other illnesses com!ined.

(he


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services in Ne Sork Cit# and as instr"mental in esta!lishing therole o the frst "ll-time school n"rse.

(he philosoph# o amil#-centered care recogni4es the amil# asthe constant in a child6s lie and that service s#stems and

personnel m"st s"pport, respect, enco"rage, and enhance thestrength and competence o the amil#.

Atra"matic care is the provision o therape"tic care in settings,!# personnel, and thro"gh the "se o interventions that eliminateor minimi4e the ps#chologic and ph#sical distress eperienced !#children and their amilies in the health care s#stem.

0anaged care is a health care deliver# s#stem that attempts to!alance cost and "alit# thro"gh a netork o health careproviders and predetermined prospective pa#ment or services.

Roles o the pediatric n"rse incl"de esta!lishing a therape"ticrelationship, amil# advocac#, disease prevention/healthpromotion, health teaching, s"pport-co"nseling,coordination/colla!oration o care, ethical decision making,research, and health care planning.

With the shit in oc"s rom treatment o disease to promotion ohealth, n"rses6 roles are epanding !e#ond traditional health careacilities into am!"lator# care centers, schools, the amil#6s homeand the comm"nit#.

Changing demographics in the 7nited tates ill res"lt in greatersignifcance o adolescents6 and minorit# gro"ps6 pro!lems anddecreasing reso"rces or health care.

Critical thinking is p"rpose"l, goal-directed thinking !ased onrational and deli!erate tho"ght.

(he process o n"rsing children and amilies incl"des acc"rateand complete assessent, anal#sis o assessment data to arriveat a nursing diagnosis, p/anningo care, ip/eentationothe plan, and eva/uationo interventions.

ReferencesAlaro-3eevre R: Critial thinkin' and linial +d'&ent, ed ?,*hiladelphia, >BB@, W$ a"nders.Altemeirer WA: *revention o pediatric in)"ries: so m"ch to do, solittle time, Pediatr ;nn>E 9:?>@K?>, >BBB.


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Annie 8. Case# %o"ndation: @id! o+nt data )ook$ !tate pro=le!o hild ell)ein', Washington, C, >BB=, Center or the t"d#o ocial *olic#.American N"rses Association: e'i!tered proe!!ional n+r!e! and+nlien!ed a!!i!tive per!onnel, Washington, C, =EE@, American

N"rses *"!lishing.American N"rses Association: Code o ethi! or n+r!e! ithinterpretive !tate&ent!, Washington, C, >BB=, American N"rses*"!lishing.American N"rses Association, N"rsing6s ocial *olic# tatementRevision (ask %orce: #+r!in'! !oial poliy !tate&ent, 2003,Washington, C, >BB?, American N"rses *"!lishing.Cornelison AH: A profle o ethical principles,A Pediatr #+r!=?9:?G?K?G9, =EEG.%reda 0C: (oard evidence-!ased practice, ?aternal Child #+r!>?:=II, =EEG.

1alvin 8 and others: Challenging the precepts o amil#-centeredcare: (esting a philosoph#, Pediatr #+r!>99:9>K9?>, >BBB.1ordon 0: ?an+al o n+r!in' dia'no!i!, ed E, t 3o"is, >BBB,0os!#.1"#er $ and others: Ann"al s"mmar# o vital statistics: trends inthe health o Americans d"ring the >Bth cent"r#, Pediatri!=B99:=?BIK=?=I, >BBB.Ho#ert 3 and others: Ann"al s"mmar# o vital statistics: >BBB,Pediatri!=BG9:=>@=K=>, >BB=.3ears 0J, 1"th JL, 3eandoski 3: &nternational adoption: aprimer or pediatric n"rses, Pediatr #+r!>@:IGKG9, =EEG.

0acorman 0% and others: Ann"al s"mmar# o vital statistics2>BB=, Pediatri!==B9:=B?IK=B>, >BB>.0inino A0, mith $3: eaths: preliminar# data or >BBB, #ational,ital -tati!ti! eport!, vol @E, no =>, H#attsville, 0, >BB=,National Center or Mital tatistics.0"rph# 3: eaths: fnal data or =EEG, #ational ,ital -tati!ti!eport!, vol @G, no ==, H#attsville, 0, >BBB, National Center orHealth tatisticsNational aet# Co"ncil: /n+ry at!, >BBB edition, &taska, &l,National aet# Co"ncil.Neton 0: %amil#-centered care: c"rrent realities in parent

participation, Pediatr #+r!>9>:=9@K=9G, >BBB.North American N"rsing iagnosis Association, #+r!in'dia'no!i!$ de=nition! and la!!i=ation 2003>2004, *hiladelphia,>BB?, (he Association.*eternel)-(a#lor C: *roessional !o"ndaries. A matter otherape"tic integrit#,A P!yho!o #+r! ?ent Health -er@B@:>>K>E, >BB>.


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R"shton CH, 0c8nhill 0, Armstrong 3: 8sta!lishing therape"tic!o"ndaries as patient advocates, Pediatr #+r!>>?:=GK=GE,=EE9.alvatore (, $ater (:;d&ini!trative ethi!$ a '+ide or ho&eare provider!, pringfeld, *a, =EEG, HC0A 3td.

"llivan 8L, ecker *L: :etive leader!hip and &ana'e&ent inn+r!in', ed , 7pper addle River, NL, >BB=, *rentice Hall.4ilag# *: 0anaged care or children: e;ect on access to careand "tili4ation o health, +t+re Child, G> s"mmer:?EK9B, =EEG.Wong : *rinciples o atra"matic care. &n %eeg M, editor: Pediatrin+r!in'$ or+& on the +t+re$ lookin' toard the 21!t ent+ry,*itman, NL, =EGE, Anthon# L Lannetti.

Hocken!err#, 0aril#n L. Hocken!err#. on'! !!ential! o Pediatri#+r!in' 7th dition. 8lsevier, >BB. =.Fv!k:B-?>?-B>E?-Zo"tline=[

Documents

1 Perspectives of Pediatric Nursing