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Unformatted text preview: SAN JOSE STATE UNIVERSITY School of Nursing NURS 126--Nursing Theory IV--4 units COURSE DESCRIPTION Focus on direct health care of children and the childbearing family in various health care settings. Exploration of bio-psychosocial processes involved in health, life transitions, and illness with identification of related preventive and therapeutic nursing behaviors. PREREQUISITES Completion of Semester 5 COURSE OBJECTIVES Upon completion of this course, the student will: 1. 2. 3. Identify the normal and pathological characteristics of health related conditions in children and the childbearing family; Apply Family Systems Theory concepts to identify major nursing interventions in select health care situations for children and childbearing families; Identify development issues, communication patterns, teaching/learning needs, sexual development, substance abuse, and violence childbearing/childrearing families within the context of rapidly changing, multicultural health care environment; 4. 5. 6. Identify expected responses of the individual and family to health related conditions according to developmental needs and cultural characteristics; Identify primary, secondary, and tertiary levels of prevention associated with health related conditions of childbearing/childrearing individuals, families, and groups; Identify priorities in the assessment, planning, implementation, and evaluation of direct nursing care as a member of a multidisciplinary health care team with a variety of health related conditions for individuals, families, and groups involved with child bearing/child rearing; 7. 8. Identify standards of practice, legal and ethical issues related to childbearing and childrearing families; Identify care management activities and needs for patient advocacy for childbearing/childrearing individuals, families, and groups. COURSE REQUIREMENTS 1. 2. Completion of assigned study guides, readings, learning modules, and class activities. Completion of three exams with an overall average of at least 73%. Revised 01/03/09 IG 1 EVALUATION AND GRADING Evaluation is a continuous process and is the responsibility of both faculty and student. Academic Testing Institute (ATI)--A Tool for NCLEX-RN Exam Success: In preparation for taking the NCLEX-RN exam, and as part of the nursing program, students will be required to participate in the Academic Testing Institute's (ATI) Comprehensive Assessment & Review Program (CARP). ATI-CARP is progressive and sequential. At the beginning of each semester students are required to pay directly to ATI online and register for their resources and permits for exams. Each semester, different resources and content exams will be administered. Semester 6 has been selected to give the following ATI exam(s): Maternal-Newborn and Nursing Care of Children. The ATI exams for Semester 6 will be given during a Nursing 136 class period approximately 2 weeks before the final exams. ATI points earned will apply to Nursing 126 course points. The maximum a student can achieve in Nursing 126 course is 400 points. From three to five percent of the total points in this course will be awarded to students achieving the specific scores on the semester ATI exam.
SEM COURSE EXAM(s) Maternal-Newborn** (60 questions/60 min) Nursing Care of Children** (60 questions/60 min) % of course 5% 3% 5% 3% % 81.7% 75.0% 75.0% 70.0% Raw Score 49 45 45 42 6 Nursing 126 (4) 400 When, where, and how (computer or paper/pencil) the exam(s) will be given is dependent on faculty and university resources. Details will follow during the semester. For additional information please review the general information on the School of Nursing Website (http://www.sjsu.edu/nursing) under the heading: "IMPORTANT NEW REQUIREMENTS" and the ATI website: (http://www.atitesting.com/). Point distribution is as follows: Item Exam 1 Exam 2 Cumulative Final Case Studies/Activities ATI exam points Total Maximum Points 115 115 130 20 (10 each Mat/Peds) 20 (10 each exam) 400 For regular exams, please purchase SJSU Form T&E-200 answer sheet at the Spartan Bookstore. With the exception of documented true emergencies, students must contact the instructor PRIOR to an exam or quiz if he/she expects to miss the exam. If this is not done, the student will receive a zero on the exam. Faculty will decide if the student warrants a make-up exam and each situation will be dealt with individually. Students who receive LESS than a "C" grade should refer to the student progression policies for the School of Nursing. A copy is in the Student Handbook. Revised 01/03/09 IG 2 The following will be used for calculation the course grade, standardized in the School of Nursing 04/09; Grading Scale for 4 Unit Courses = 400 Points Total Point Spread 374 400 358 373 346 357 330 345 318 329 306 317 Percentages 94 100% 90 93% 87 89% 83 86% 80 82% 77 79% Grade Point Spread 290 305 278 289 266 277 250 265 Percentages 73 76% 70 72% 67 69% 63 66% Grade A AB+ B BC+ C CD+ D DF 238 249 60 62% 237 & 59% below Percentages calculated to the nearest .5% and rounded up (290/300 = 72.5%). REQUIRED TEXTS McKinney, E., James, S., Murray, S., and Ashwill, J. (2009). Maternal Child Nursing. (3rd ed.). St. Louis, MO: Elsevier. ATI (2007). Nursing Care of Children. RN Edition 7.0 Content Mastery Review Module. ATI (2007). Maternal-Newborn Nursing. RN Edition 7.1 Content Mastery Review Module Handbook of San Jose State University Nursing Students (Available in Print Shop) All readers designated for individual classes and sections (Available in Print Shop) TEACHING STRATEGIES Lecture-discussion, audiovisual aids, assigned readings, use of online resources. Class Notes, grades, and important communication will be available on the online classroom: BLACKBOARD-- http://sjsu6.blackboard.com/. Click on Spring 2010 classes. Also, a link to Semester 6 resources are available at my website: http://www.sjsu.edu/faculty_and_staff/faculty_detail.jsp?id=2760 POLICY STATEMENT on COURSE ACCOMODATIONS If you need course adaptations or accommodations because of a disability, or if you need special arrangements in case the building must be evacuated, please make an appointment with the instructor as soon as possible, or see the instructor during regularly scheduled office hours. Presidential directive 97-03 requires that students with disabilities requesting accommodations must register with DRC to establish a record of their disability. FACULTY Name: Office: Phone: Email: Website: Office Hours: Deepika Goyal PhD RN FNP HB 403 408-924-3149 [email protected] Irene Gonzales PhD RN CNP HB 412 408-924-3162 [email protected] Click on faculty on SON website: http://www.sjsu.edu/nursing/faculty.htm Thursdays around classes & by appt. Thursdays around classes & by appt. Revised 01/03/09 IG 3 POLICY STATEMENT on ACADEMIC INTEGRITY All SJSU Policies in the Catalog, Schedule of Classes and Academic Senate apply to this course (see http://info.sjsu.edu/static/catalog/policies.html ). Policies related to Academic Integrity, S02-4 and S03-7 can be found at. http://sa.sjsu.edu/download/judicial/Academic_Dishonesty_Policy.pdf With the increased use of the internet, frequently students unknowingly violate the Plagiarism policy. Before you complete assignments for this course please go to http://www2.sjsu.edu/leap/plagiar.htm and read more descriptions of plagiarism. If you have any questions regarding Academic Integrity, please ask the faculty for this course for clarification. DISRUPTIVE CLASS BEHAVIOR In the classroom environment, you must respect the rights of others seeking to learn, respect the professionalism of the instructor, and honor the differences of viewpoints. Student conduct which disrupts the learning process shall not be tolerated and may lead to disciplinary action and/or removal from class. COURSE WITHDRAWAL AND DROP/AD POLICY You are responsible for making sure you are registered for this class by the ADD date; in addition, you are responsible for dropping any class by the DROP date--found in the academic calendar for each semester. Please note: A student will not be able to add after the census date. SYLLABUS IS SUBJECT TO CHANGE The syllabus and schedule are subject to change in the event of extenuating circumstances. If you are absent from class, it is your responsibility to check on announcements made while you were absent. ADDITIONAL RESOURCES Additional Resources may be available on faculty Website. Preparation for class is defined as completing all assigned readings, pre-viewing assigned videos, and completing all learning activities prior to attending class. Faculty will attempt to clarify concepts and discuss variations seen in clinical settings throughout the life span. Students are strongly urged to review this information before class and exams. Online library research guides are available to you for this and any other class (http://www.library.sfsu.edu/instruction/guides/guides.html). The nursing guide has been updated recently, and the health sciences guide may be useful as well. Textbook resources for students from thePoint: http:thePoint.lww.com/Ricci-Kyle Clinical Simulation Model activities as recommended by Semester 6 faculty; contact Semester 6 chairperson for scheduling and details. Revised 01/03/09 IG 4 SCHEDULE OF CLASSES NURSING 126--Spring 2010 N126--Health of Women & Newborns Thursdays CL 222 1030am-1220pm
DATE GENERAL TOPICS READING McKinney, James, Murray, & Ashwill, 2009, 3rd Ed ATI Maternal Newborn Nursing 7.1. 1/28/10 Course Overview Newborn Assessment Newborn Feeding Common Newborn Issues Normal Postpartum Postpartum Complications McKinney Chap 22, 23 ATI: Chap 19, 20, 22 McKinney Chap 24 ATI: Chap 21, 24 McKinney Chap 21 ATI: Chap 15. 18 McKinney Chap 28 ATI: Chap 17 2/4/10 2/11/10 2/18/10 2/25/10 3/4/10 3/11/10 3/18/10 3/25/10 4/1/10 4/8/10 4/15/10 4/22/10 4/29/10 5/6/10 MIDTERM 1 Newborn Complications Guest Speaker : Arlene Spilker Prenatal-Normal Changes Prenatal-Diagnostic tests/procedures Prenatal-Complications of Pregnancy McKinney Chap 29, 3 ATI: Chap 23 McKinney Chap 13, 14, 15 ATI: Chap 3, 4, 6 McKinney Chap 16 ATI: Chap 7 McKinney Chap 26 ATI: Chap 8 SPRING BREAK MIDTERM 2 Labor and Childbirth Labor and Childbirth-Procedures Fetal Assessment Complications of Labor & Birth FURLOUGH DAY NO LECTURE Conception, Contraception, and Infertility Out of Class Assignment Women's Health Issues: TBA Final Review Final Cumulative Exam TBA McKinney Chap 17, 19 ATI: Chap 9, 10 McKinney Chap 18, 20 ATI: Chap 11, 13 McKinney Chap 27 ATI: Chap 14 McKinney Chap 10, 11, 12 ATI: Chap 1, 2 McKinney Chap 31 5/13/10 5/19 - 5/25 *Updated 11/09 this schedule is subject to change and may not be all-inclusive. SCHEDULE OF CLASSES NURSING 126--Spring 2010 N126--Health of Children and Their Families-- Thursdays CL 222 1:30pm-3:20pm
READINGS: DATE GENERAL TOPICS McKinney, James, etc, 2009; ATI -- Nursing Care of Children 7.0 1/28/10 Introduction and Basic Concepts Chapters 4, 32, 33, 35; Chapters 1, 2, 3, 11 Chapters 36, 37, 38, 39; Chapters 1, 2, 3, 12, 13 Chapters 5 & 6; Chapters 4 & 5 Chapters 7 & 8; Chapters 7 & 8 2/4/10 2/11/10 2/18/10 2/25/10 3/4/10 3/11/10 Basic Concepts continued Basic Concepts: Infant, Toddler, and Preschooler Basic Concepts: School Age and Adolescent MIDTERM 1 Respiratory System Cardiovascular and Blood Disorders Chapter 45; Chapters 15-19 Chapters 46, 47; Chapters 20-23 Chapters 49, 55; Chapters 29, 32-34 ; 49 Chapters 43, 51; Chapters 35-39 3/18/10 Integumentary Disorders in Children ENT Alterations Peds GI system Peds Endocrine & Metabolic SPRING BREAK MIDTERM 2 Peds Lymph/Immune/Infectious Diseases Musculo-Skeletal System Peds Neuro & Special Topics FURLOUGH DAY NO LECTURE Fluid & Electrolytes & Emergency Care Out of Class Assignment Genito-Urinary; Peds Heme-Onc Final Review Final Cumulative Exam TBA 3/25/10 4/1/10 4/8/10 4/15/10 4/22/10 4/29/10 5/6/10 Chapters 40, 41; Chapters 27-31 Chapter 50; Chapters 50-52 Chapter 52, 53, 54; Chapters 43-49 ; 54-56 Chapters 42, 34; Chapters 9, 53 Chapter 44, 48; Chapters 40, 41, 30 5/13/10 5/19 - 5/25 *Updated 11/09 this schedule is subject to change and may not be all-inclusive. The Normal Newborn
Deepika Goyal, PhD, RN, FNP Newborn Exam Apgar Score Ballard Exam for Gestational Age Initial Physical Exam Prophylactic Medications Establish Feeding Immediately After Birth
Priority Nursing Goals: Promote and maintain respirations (Bulb) Loss of Body Heat Collect pertinent data for initial assessment Institute prophylactic treatments against Gonorrhea Ophthalmia & Hemorrhagic Disorder Proper Identification Major Adjustments at Birth Institute and Sustain Respirations Clear Lung Fluid Stabilize Alveoli Redirect Blood Flow Close Down Fetal Shunts Activate All Organ Systems/Metabolic Processes Caring for Neonates Neonatal Period: First 28 Day of Life Early Neonatal Period: First Seven Days of Life Transitional Period: First 6 - 8 Hours of Life Physical Assessment of the Newborn Overview of the Newborn Assessment Size Macrocephaly or Microcephaly Changes in skin color Signs of birth trauma Malformations Evidence of respiratory distress Level of arousal Posture Tone Presence of spontaneous movement Symmetry of movements APGAR SCORES Caring for Neonates: Common Problems Soft Tissue Injury Skeletal Injury Hypothermia Hypoglycemia Hypocalcemia Polycythemia Physiologic Jaundice Variations in Gestational Age and Size Estimating Gestational Age
Term: 37 to 42 weeks gestation Preterm: Less than 37 weeks gestation Post Term: Greater than 42 weeks gestation Size related to Gestational Age
AGA: within 2 SD of the mean birth weight for a given gestational age SGA: more than 2 SD below the mean birth weight for a given gestational age (< 10th percentile) LGA: more than 2 SD above the mean birth weight for a given gestational age (> 90th percentile) Head & Face Head circumference and fontanelle size Check symmetry of face: when baby cries the sides of the face should move equally NEWBORN HEAD... Head... Check the head for molding, abrasions, or skin breakdowns Caput succedaneum Cephalhematoma Full range of motion--no masses motion--no Observe the eyes for discharge or irritation; check the pupils for reaction to light, equality of eye movements (normally there is some ocular inincoordination); check the sclerae for clarity, jaundice, or hemorrhage Newborn head... Caput Succedaneum (soft tissue swelling) Cephalohematoma (subperiostial bleeding) Head... Nose: patency of both nostrils; sneezing Mouth: check gums and hard and soft palates for any openings mucosa of the mouth normally clear (white patches that bleed on rubbing indicate thrush, a monilial infection) Head...Ears Head... Ears: auricles/canals open; vernix covers tympanic membrane, position? Upper earlobes normally curved (flatness may be indicative of kidney anomaly) Ear Positioning... Head - Eyes Assessment -- Chest Nipples mid-clavicular mid Chest auscultation: (noisy crackling sounds abnormal) Heart rate: regular 120 to 160 beats per minute (rubbing or unusual sounds abnormal) Respiratory Normal RR = 40-60 / min. 40 Lung Formation begins approx 4-8 wks 4 growth ends approx 4-5 yrs of age. 4- Assessment of fetal lung maturity Pulmonary surfactant PG L/S ratio - @ age 32 weeks, L/S ratio = 1, 2.0 by 35 weeks Airway dependent!--"Sniffing Position"--Use dependent!--" Position" --Use 100% O2 in Resuscitation Respiratory Surfactant synthesis and storage begins to occur 24-28 weeks gestation Surfactant surface active phospholipids lecithin and sphingomyelin critical for aveolar stability Newborn born before the lecithin/sphingomyelin (L/S) ratio is 2:1 will have varying degrees of respiratory distress May need synthetic surfactant if born with respiratory distress Respiratory Signs of Respiratory Distress: Grunting Flaring Retractions Duskiness Cyanosis (acrocyanosis vs. central cyanosis Loss of flexor tone Pallor CVS-Cardiovascular CVS Formation of Prenatal Heart approx. 3-7 wks gestation 3 3 Physiological Shunts--must Shunts--must close Ductus Venosus Foramen Ovale Ductus Arteriosus Fetal Circulation Cardiovascular System Normal rate 100-160--NSR 100- 160--NSR Blood Pressure 70/40-- MAP 40-50 70/40-40 Minimal Arrhythmias: Sinus Bradycardia/ Tachycardia--most common Tachycardia--most SVT-next most common SVTRare PVC's, or Blocks PVC' Central Nervous System
Neuro-developmental Milestones NeuroReflexes Tone (flexor) Need for Sedation ? Pain Management? Seizures--vs Clonus, jitteryness, Seizures--vs jitteryness, tremors, apnea from resp. etiology The dysmorphic infant... Maternal & Family History, Variations from Normal, Microsigns, Dermatoglyphics, ? Chromosome Analysis Microsigns, Dermatoglyphics, and Genetics Consult CNS--Neuro/Development Gross Development done by 26-28 wks 26gestation, myelinization continues until term. Neural Tube Defects Folic Acid!!! Spina bifida to Meningomyocele Encephalocele Anencephaly Hydrocephalus Folic Acid: 1994 NTDs by 70% --take prenatal--12 wks gestation prenatal--12 Most embryos with NTDs die in first trimester (inc NTDs @ 26days = 2.6% Incid NTDs @ term =.006% NTDs by correcting a deficiency or by overcoming a genetically induced metabolic block CNS--Neuro/Development--more... CNS--Neuro/Development--more... Thermoregulation Goal: Neutral Thermal Environment Cold Stress -- Sources Evaporation -- 23% total body heat loss (first) Conduction -- 3% total body heat loss Convection -- 12% total body heat loss Radiation -- 62% total body heat loss Signs and Symptoms of Cold Stress Lethargy Feeding intolerance Respiratory depression Acidosis Bright red color Thermoregulation-Consequences of Cold Stress... COOLING
Norepinephrine Pulmonary Vasoconstriction Pulmonary Artery Pressure Right to Left Shunting Pulmonary Vasoconstriction Increasing Acidosis Anaerobic Metabolism Hypoxia Extreme Cold Stress: When Thermoregulatory Mechanisms Fail Body Temperature Falls Precipitously and Results in: Metabolic Acidosis Hypoglycemia Decreased Arterial Blood Oxygen Levels Apnea Poor Growth and Repair Goal: Neutral Thermal Environment The temperature at which the newborn infant uses the least amount of calories to maintain normal body temperature for optimal health, growth, and repair. Neuro Assessment - Back: run a finger along the vertebral column; any dimples, separations, or swellings indicative of spina bifida Anus: patency confirmed with passage of meconium; inability to insert a rectal meconium; thermometer may be indicative of imperforate anus Breast feeding/Bottle feeding and Stooling Assessment -- Neuromuscular Development: Reflexes Rooting: (may persist for up to 12 months) Sucking: (persists throughout infancy) Gag: (persists throughout life) Grasp: lift the infant off a firm surface, baby will grasp; infant's head will lag as baby is raised (lessens by 8 months) More Reflexes... Babinski: toes will separate and flare out (< 1 year) Moro: (startle) sudden jar or change in equilibrium (< 3 to 4 months) Crawl: crawling movements will follow (< 6 weeks) Step or dance: (< 3 to 4 weeks) MORE systems... Skin Musculoskeletal Hematology Infectious Disease Assessment --Skin Body is normally pink (acrocyanosis normal), jaundice --abnormal < 24hrs --abnormal Milia (white,pinpoint spots over the nose caused (white,pinpoint by retained sebaceous secretions), birthmarks, nevi, forceps marks, ecchymosis, or papules are present Integumentary--Skin and Sweat glands, Hair, Nails More Mature and Intact with Increasing Gestational Age Newborns do not sweat--if they do they sweat--if are either very mad or have cardiac problems..... Skin Integrity essential for Immunological support--like adults--largest ORGAN! support--like adults--largest Assessment -- Extremities Hands and arms: thumbs clenched in fist Check for # and variation of fingers; wrist angle is zero Check clavicles and scapulae while putting arms through normal range of motion Palpate for fractures (green stick); crepitation Barlow's/Ortalani's...Hips Hip dislocation?... Feet and legs Check toes, pattern and number Adduct and abduct feet through range of motion; there should be no resistance or tightness Flex both legs onto the lower abdomen; there should be no resistance or tightness Assessment -- Genitalia--Males Palpate the scrotum for testes: descended or descending? Enlargement of scrotum: hydrocele vs hernia Observe tip of the penis for the urinary meatus & voiding Epispadias--meatus on upper surface of the Epispadias--meatus penis Hypospadias--meatus on lower surface Hypospadias--meatus Hypospadias--Meatus Undescended Testes Assessment -- Genitalia-Females Observe the genitalia for labia, urinary meatus, and vaginal opening Edema of labia and bloody mucoid discharge is normal Discharge from nipples normal Check for voiding Assessment --Abdomen + bowel sounds, round, non-distended, soft, no nonguarding Palpate liver on the right side: normally 1-2 cm 1below the R costal margin Observe umbilical cord for redness, odor, or discharge--# vessels present (normally one discharge--# vein and two arteries; 2 vessels ? Abdomen... Observe for umbilical hernia when newborn cries Palpate the femoral pulses --indicate intact circulation --indicate to extremities Brachial pulses > Femorals? Femorals? Newborn Meds during transition... AgNO3 or Ilotycin (Erythromycin eye ointment to both eyes--a ribbon eyes--a along the lower lid) Prophylaxis against gonorrhea and chlamydia State law--opthalmia neonatorum is a major law--opthalmia cause of blindness! Newborn Regional Metabolic Screening
Phenylketonuria (PKU) Hypothyroidism (congenital cretinism) Galactosemia Homocystinuria Maple Syrup Urine Disease (MSUD) Sickle Cell Anemia First Blood Specimen before Discharge (after first feeding) Second Specimen before 2 wks of age Metabolic/Endocrine IDM infant Mum's on MgSO4, Terbutaline Mum' Hypothyroid preemies Genetic Screening (State Law): PKU, MSUD, Homocystenuria, Sickle Cell Homocystenuria, Disease, Galactosemia, G6PD, Galactosemia, Tyrosinemia, hemoglobinopathies, Tyrosinemia, hemoglobinopathies, Congenital Hypothyroidism, Congenital adrenal hyperplasia, and biotinidase deficiency In Summary... Keep them warm Airway Dependent--Obligatory Nose Breathers Dependent--Obligatory Optimal Nutrition--Nonnutritive Suck!! Nutrition--Nonnutritive Minimize Environmental Stimuli during Healing phases! Minimize unnecessary caloric consumption Rigorous Pain Management--Newborns Feel Management--Newborns Pain and can't always tell you clearly! can' Monitor for anemia--(hct <40-45 in acute state) anemia--( <40- Planning/Implementation Monitor and Maintain a Patent Airway Suction (obligate nose breathers Position: side-lying position to facilitate sidedrainage of mucus (suction toward cheeks) Observe for signs of respiratory distress Grunting Flaring of nostrils Sternal Retractions Planning/Implementation... Provide warmth Clothing should be loose, soft Crib should be firm and provide protection Skin should be kept clean and dry to maintain integrity Planning/Implementation...
Administer Vitamin K Prevents hemorrhagic disease of the newborn Absence of bacteria in sterile gut of the newborn prevents formation of clotting factors Give 0.5-1.0 mg once during the first 6 hours 0.5of life IM into vastus lateralis muscle TB syringe, 25-gauge and 5/8" needle 255/8" Newborn Meds during transition... Planning/Implementation... Weigh daily Provide daily sponge bath--?? bath--?? Provide frequent diaper changes Care for cord..DRY! cord..DRY! Provide for feeding Teach care of infant(s) to parents infant(s) Planning/Implementation... Care of Circumcision-Gomco vs Plastibell Circumcision Observe for bleeding (Gomco) (Gomco) Observe for urination Diaper applied loosely Dressing changes Provide for human contact Body contact w/ another human--paramount for survival human--paramount Administer care w/ awareness of important early relationships Talking, rocking, & singing are an essential part of body contact with the newborn Evaluation/Outcomes No signs of respiratory distress present Temperature in normal range (36.5-37.5 C) (36.5Voiding commensurate with fluid intake (>6 wet diapers/day); Anus is patent; passing stool Initial weight loss within 10% range (<15%) No signs of severe jaundice, cephalic swelling, or neuromuscular impairment Normal growth (<10% in first few days, 1 ( oz/day) Supportive environment-- light, sound, tactile environment-stimulation, posture support, boundaries--watch boundaries--watch for Stress Signs! Signs! For Next Class Read: Breast versus Bottle; "suck/swallow/breathe" suck/swallow/breathe" Sleep/awake states Infant cues Position Postpartum nutrition plan Discharge Teaching: jaundice; circumcision; skin care; stools; ambient temperature & baby temp.; sleeping; positioning; safety; F/U Basic Concepts
How children are different! This class...
Family Centered Care Cultural Awareness Physical Assessment Vital Signs Pain Hospitalization & Illness Death & Dying Family Centered Care
Family 1 grp constant in a child's life child' FCC respect, collaboration, support Collaborate: home, community, hospital Cultural Diversity Knowledge of Growth & Devt. Child is priority; Family important too Family Composition + family parent-child warmth & respect parentFamily Assessment Tools Family Centered Care
Family Composition Nuclear Family Single-parent family SingleBlended family Extended family Same sex family Foster family Family Centered Care
Parenting Styles Dictatorial or authoritarian Permissive or laissez-faire laissezAuthoritative or democratic Family Centered Care
Promoting health behaviors Realistic limits and expectations based on developmental tasks Validate child's feelings child' Provide reinforcement for ++ behavior Focus on behavior not on child Explain expectations in a manner child can understand Family Centered Care
Family Assessment Genogram Structure Developmental tasks Family functions/roles Stressors Cultural Awareness
a collection of learned, adaptive, and transmitted social values and beliefs that form the context from which a group interprets the human experience Values and beliefs shared by members of ethnic, racial, social, or religious group Culture influences communication, dietary preferences, & dress Goal: transcultural nursing care--sensitive care-- and competent Cultural Awareness
a collection of learned, adaptive, and transmitted social values and beliefs that form the context from which a group interprets the human experience Know your own, value your own, be interested in knowing others: sensitive and with time...competent time... Watch Nonverbal behavior! When to use an interpreter (who, how?) Pediatric Exam
General Appearance--SYMMETRY! Appearance-- Skin, hair, and nails Lymph nodes Eyes: movements and appearance; Eyebrows, lids and lashes; Conjunctiva; lacrimal; sclera; corneas; pupils; iris; red reflex Ears: placement; patency; internal exam + hearing Symmetry Lymph nodes... Pediatric Exam
Nose: position; patent nares; septum midline; mucosa; smell Mouth/throat:
Lips Teeth Gums Palates/Uvula MM Tonsils Tongue Speech Pediatric Exam
Thorax and Lungs:
Chest shape Ribs/sternum Movement Breath sounds Breasts Circulatory System-- System--
Heart Sounds Pulses Capillary filling time Abdomen
Shape Bowel sounds Pediatric Exam
Shape Bowel sounds Liver Spleen Descending Colon Masses? Pediatric Exam
Length/Height, position, size-- size-- symmetry Joints Spine Gait Neuro... Neuro...
Reflexes--page 26--ATI Reflexes-- 26-- Cranial nerves--pages nerves-- 27--ATI 27-- DTRs Cerebellar fctn Language, cognition, fine motor movement Genetalia Male Female Vital Signs...General Info
"Normal" varies w/ age & condition? Normal" Infants--st HR & RR & st B/P Infants-- Tachycardia--common in acute Tachycardia-- illness or stress in infants & children Bradycardia--most seen w/ airway Bradycardia-- problems Hypotension--LATE sign of shock or Hypotension-- inadequate circulation in infants & children Important V/S in children...
Respiratory Rate--first... Rate-- first... Heart Rate & Body Temperature Blood Pressure Pain Level of Consciousness Accuracy of measurements...
Age Size Emotional State Physical Condition Equipment Movement Underlying disorders Resp. rate
First...no noise; don't touch...take First... don' touch... advantage of sleep/quiet--watch sleep/quiet-- abdominal wall raise & lower. Full minute! Assess for abnormalities... abnormalities...
Grunting, Flaring, Retractions Stridor, Wheezing, Tachypnea, Apnea, & Cyanosis Report any abnormalities, immediately. Assess work of breathing Heart Rate
all peripheral pulses; but measure APICAL pulse--for infants & small pulse-- children Count for 1 whole minute Document: Irregularities of R/R Tachycardia at rest--abnormal--?? rest-- abnormal-- Bradycardia CO Medical Emergency & CPR? Body Temperature
Why?--Hypo & Hyper is abnormal Why?-- Cold stress in infants dangerous... dangerous... Hyperthermia febrile seizures, etc. Report ANY abnormal findings; implement care to normalize temp... temp... Body Temperature
Know: F & C & how to use thermometer; avoid mercury Oral--over age 4 (developmentally)-- Oral-- (developmentally)-- not w/ oral surgery or seizures Axillary--In axilla for min. of 3 Axillary-- minutes...preferred in newborns minutes... (lowest) Body Temperature
Know: F & C & how to use thermometer; avoid mercury Rectal--avoid in newborns, children w/ Rectal-- cancer, bleeding disorders, anal surgery-- surgery-- Lubricate--comfortable position; safe Lubricate-- distance (highest)--CORE (highest)-- Tympanic--Convenience, ease & rapid Tympanic-- measurement--need proper seal & correct measurement-- placement--CORE placement--CORE Assessment Priority Rationale
4 yr old hospitalized w/ an acute asthmatic episode. V/S: HR 128-135; 128RR30-35; RR30B/P 93/48 Axillary temp of 98F 98 & Assessment Priority Rationale
7 yr old w/ cerebral palsy hospitalized for GERD. V/S:
HR 100-110, 100RR 20-30, 20B/P 96/54; Ax. Temp--99.5F Temp-- 99.5 & Assessment Priority Rationale & 8 mo. w/ pneumonia V/S: HR 160-170--dropping to 60s 160- 170--dropping occasionally during the previous shift RR 76, B/P 112/72; Ax. Temp--99.5F Temp-- 99.5 Assessment Priority Rationale
2 mo. old w/ fever & bilateral otitis media V/S:
HR 165-175 165RR 32-40, 32B/P 108/64; & Rectal Temp--102.5F (taken immediately Temp-- 102.5 prior to report, no intervention initiated) Assessment Priority Rationale
4 yr old hospitalized w/ an acute Asthmatic episode. & 8 mo. w/ Pneumonia 7 yr old w/ cerebral palsy hospitalized for GERD. 2 mo. old w/ fever & bilateral Otitis Media Nursing Management of the child w/ PAIN Assessment & Management of Pain in Children... Children...
Individualized based on:
physical assessment, V/S, developmental level, behavior, pain scale reporting coping style Growth & Development...
Identify the child's stage of development child' for readiness to use PAIN SCALES.
Assess the child's language skills (ability to child' use words in sequence, follow simple directions, & answer simple questions). Ask the child to count his or her fingers or up to 10 Determine whether the child can underst& concepts such as more or less & higher or lower Assessment Tools...
Age related pain scale ratings
Faces Numbers Emotional & Physical Signs Behavioral Cues How to Treat...
Evaluate type & duration...ethnicity & duration... family coping style...developmental stage. style... Non--Pharmacological--(start first) Non-- Pharmacological--
Age related Pharmacological--GOAL to provide Pharmacological-- comfort & rest--not eliminate all pain or rest-- discomfort! Document everything!!! Growth & Development
Methods of DISTRACTION for pain control vary according to the child's child' developmental stage & individual interests.
Infants: holding, cuddling, sucking a pacifier Preschoolers: engaging in therapeutic play, watching television or a video School-age children: talking about pleasant Schoolexperiences, listening to radio, watching television or a video Adolescent: having visitors, playing games, watching television, listening to radio or tape player. Age response...
Infants--grimace, tensing the body, Infants-- & crying Toddlers & Preschoolers--will Preschoolers-- protect their sore area & are usually able to point to area of pain School Age & Adolescent children-children-may be more stoic about pain due to peer pressure & fear of ridicule (esp. ) Culture...
Some ethnic groups, such as Asian, Native American, Anglo-Saxon-Germanic, Anglo- Saxon& Irish, do not openly express pain. People of Latin American, Italian, & Jewish descent are more likely to use both verbal & nonverbal methods to express pain freely. However, children have individualized responses, & younger children have had less time to acquire culturally learned behaviors. Cultural Considerations
The cultural experiences of health care professionals often contribute to their outdated attitudes about pain experiences by children. For example, health care workers may believe that being in pain for a little while is not so bad, that pain helps build character, or that using pain medication is a sign of a weak character. False Beliefs About Pain &
Pain Medication in Children
Children without obvious physical reasons for pain = no pain. Neonates do not feel pain. Children do not feel pain with the same intensity as adults because a child's nervous system is immature. Children tolerate discomfort well. They become accustomed to pain after having it for a while. Children tell you if they are in pain. They do not need medication unless they appear to be in pain. False Beliefs About Pain...
Children are not in pain if they can be distracted or they are sleeping. Children recover more quickly than adults from painful experiences such as surgery. Parents exaggerate or aggravate their child's pain. Children have no memory of pain. False Beliefs About Pain...
Narcotics are dangerous for children because they can cause respiratory depression & addiction. The best route for giving analgesics is intra-muscular. intraAfter surgery, children should not receive the next analgesic dose until they show obvious signs of pain. As-needed medication orders mean that Asmedication should be given as infrequently as possible. Physiologic Consequences of Unrelieved Pain in Children
Response to Pain
Respiratory Changes Rapid shallow breathing Inadequate lung expansion Inadequate cough Physiologic Consequences Alkalosis oxygen saturation Retention of secretions HR, sleep patterns; blood glucose, cortisol levels. fluid & electrolyte losses Neurological Changes sympathetic nervous system activity Metabolic Changes metabolic rate with perspiration Characteristics of Conscious Sedation & Deep Sedation
Assessment Factors Airway Conscious Sedation
Able to maintain airway independently & continuously Deep Sedation Unable to maintain airway independently or continuously Cough & gag reflexes Level of consciousness Reflexes intact Partial or complete loss of reflexes
Not easily aroused, may not respond purposefully to verbal or gentle physical stimulation Easily aroused with verbal or gentle physical stimulation Nursing Alert
Respiratory Depression (a respiratory rate less than 20 breaths/min in infants, 16 breaths/min in children, & 12 breaths/min in adolescents) may progress to respiratory arrest & is the major lifelifethreatening complication of opioid administration. Identify the time interval before drugdrugspecific peak respiratory depression occurs, & then carefully monitor the child's vital signs during that period. child' Nursing Alert
To prevent overdose, the PCA computerized pump has safety features that include the ability to set the maximum number of infusions per hour & the maximum amount of drug received in a given time period. Nursing Alert
monitor the child's vital signs child' advanced life support if the child should progress to deep sedation. In case complications occur, the following equipment should be immediately available:
suction apparatus, a bag-valve mask for assisted bagventilation with capability of 90%-100% oxygen 90%delivery, & oxygen supply (5L/min for more than 60 minutes), & antagonists to sedative medication. Legal & Ethical Considerations
Most children are unaware of their right to pain relief. Nurses & health care institutions have a duty to prevent & alleviate suffering. Pain management should be an institutional priority with a standard of care. Nurses have an ethical responsibility to monitor implementation of that standard. Legality & Ethics...
There is growing consensus that placebo use to assess & manage pain should be avoided, especially without consent. Studies suggest that placebos tend to be used for patients who are disliked, with whom staff have conflicts, or who have failed to respond to standard treatment. Placebo use involves deception. You must respect the patient's right to be patient' informed of treatment. Clinical Tips
The presence of physiologic symptoms such as nausea, fatigue, dyspnea, bladder & bowel distention, & fever may influence the intensity of pain felt by a child. The child's behavior or responses to child' pain stimuli may also be affected by fear, anxiety, separation from parents, anger, culture, age, or previous pain experience. Clinical Tips
When help in describing pain is needed, give the child over 6 years of age some words to select from, such as sharp, dull, aching, pounding, cold, hot, burning, throbbing, stinging, tingling, or cutting. Children do not exhibit distress in direct proportion to their pain intensity. Thus, behavioral measures may not match the child's self-report of pain intensity. child' self- Clinical Tips
Surgery & trauma = multiple sites of pain (incision or laceration, cut or bruised muscles, interrupted blood supply, nasogastric tubes placement, insertion sites of intravenous lines). When using pain scales in the assessment of a verbal child, attempt to identify ALL sites of pain. Then evaluate the intensity of pain at each site. Clinical Tips
Clinical signs that predict the development of respiratory depression include sleepiness, small pupils, & shallow breathing. Children at particular risk for respiratory depression induced by a narcotic are those with an altered level of consciousness, an unstable circulatory status, a history of apnea, or a know airway problem. Clinical Tips
Pain management kit--promote distraction, kit--promote imagery, & relaxation in children. Items that might be included are magic wands, pin-wheels, pinbubble liquid, a slinky spring toy, a foam ball, party noisemakers, & pop-up books. popIt may also be helpful to include items for therapeutic play such as syringes, adhesive bandages, alcohol swabs, & other supplies from a medical kit. The pain management kit may be especially helpful for children who are being prepared for surgery or for painful procedures & need to be distracted. Clinical Tips
Help children manage the pain from immunizations by "blowing away the shot pain". pain" As a form of distraction & imagery have the child repeatedly blow out air during the injection as if blowing bubbles EMLA--what is it? how to use? EMLA-- Felicia--5 yo, struck by a car. 6ago repair a liver Felicia--5 laceration. After spending 5 PACU, Peds Unit.; IV + Unit.; NG to suction. Abd. dressing--clean & dry. dressing--clean Felicia's mother rooming in. Because Felicia is thrashing in. around, her mother thinks she is in pain. She asks the nurse to give her some pain medication. When the nurse enters Felicia's room, she is napping & her facial expression indicates that she is not in pain. When the nurse attempts to straighten her position in bed, she moans. The nurse asks Felicia if she hurts, & she shakes her head no. According to Felicia's chart, she received pain medication just before her transfer from the post-anesthesia unit 3 hours ago. Her physician has postordered pain medication every 3-4 hours as needed.
How do you know whether Felicia is in pain ? Can you expect her to tell you if she feels pain? Is any additional assessment needed to justify giving Felicia more pain medication? What other pain relief measures could reduce or help to control her pain? Hospitalization & Illness Hospitalization & Illness
Definite Family Disruption & probable child's developmental child' regression Experience is long lasting... lasting... Address the child's individual needs ' child based on
Previous illness/hospitalization Knowledge base Developmental Level Honest age appropriate information... information... INFANT-- Implications of Hospitalization
Separation from the mother. Decrease in sensory stimuli. Breakdown in mother-infant relationship motherdue to:
Maternal guilt. Hostile, cold hospital environment. Mother's feelings of inadequacy in the mothering role. Subordination of the parents by the staff. Infant Resp. to Illness.
Indication of discomfort or pain.
Cries frequently. Displays excessive irritability. Appears lethargic or prostrate. Has high temperature. Has decreased appetite. Infant Response to Illness
Positive reaction behaviors. Cries loudly. Appears fussy & irritable. Rejects everyone except mother. Negative reaction behaviors. Withdraws from everyone. Cries monotonously. Appears completely passive. Hospitalization--Infants
Nursing actions detrimental effects of hospitalization. Hold a pre-hospitalization nursing preinterview w/ parents; give a tour of peds unit when possible.
Parents should meet staff, have procedures & regulations explained to them, & be told rationale behind rules. Family should be encouraged to visit frequently &/or to room in if possible. Hospitalization-- Infants
Counsel parents regarding infant's illness, get their understanding of disease & course of action. Correct any misconceptions Parents to participate in infant's care
Teach parents procedures they are capable of doing. Show respect for their superior knowledge of infant's likes, dislikes & habits. Most institutions now allow/encourage 24 hour visitation. Toddlers...-- Hospitalization.
Hospitalization -- threatening experience because of total number of new experiences involved. Because of the threat hospitalization may disrupt toddler's new sense of identity & independence. Toddlers...-- Hospitalization
Separation anxiety--child mourns anxiety-- absence of mother through protest, despair, & denial.
Cries loudly, throws tantrums. Child withdraws & shows no interest in eating, playing, etc. Behavior often mistaken for happy adjustment; ignores mother & may regress. Nursing behaviors: reassure the mother, build a relationship with the child, & provide warmth & support to the child during long hospitalization. Toddlers & Preschoolers
Fear loss of "body integrity" (prevalence of magical thought). Have no realistic perception of how body functions & may overreact to a simple procedure. Some toddlers believe that drawing blood will leave a hole & that the rest of their blood will leak out. Toddlers & Preschoolers
Resent disruption of normal rituals & routines. Toddlers are often very rigid about certain procedures, this allows them a sense of security & control over otherwise frightening circumstances. Loss of mobility is frustrating. Regression--Toddlers frequently abandon Regression-- most recently acquired behaviors & reverts to safer, less mature patterns. Toddlers & Preschoolers in response to illness. Indications of discomfort or pain.
Cry frequently. Display excessive irritability. Appear lethargic, withdrawn. Change eating pattern. Verbalize discomfort. Toddlers & Preschoolers in response to illness
Positive reaction behaviors.
Show aggressive behavior. Appear occasionally withdrawn. Fantasize about illness & procedures. Show regressive behavior. Negative reaction behaviors.
Appear completely passive or excessively aggressive. Display excessive regressive behavior. Withdraw from everyone. Toddlers & Preschoolers Implementation--Things you can do... Implementation--Things do...
Have mom leave an object of hers that child would recognize to "care for" until she can return-return-assures child that his or her mother will return. Encourage parents to be honest about when they are going & coming, i.e., do not tell child they will stay all night & then leave when child is asleep. Use puppet play to explain procedures & gain an understanding of child's perception of hospitalization. Use puppets to work out child's anxiety, anger & frustration. Toddlers & Preschoolers Implementation--Things you can do... Implementation--Things do...
During developmental history, elicit exact routines & rituals that the child uses; attempt to modify hospital routine to continue these rituals. Consistency among nursing staff in guidelines for behavior that is acceptable; set firm limits. Maintain a schedule that is consistent & as closely resembling the usual routine as possible. Toddlers & Preschoolers Problem Behaviors Depressed behavior.
Encourage child to express himself through play. Talk through a doll or stuffed animal for younger children. Don't avoid child; continue to interact & support. Consult with other professionals. Toddlers & Preschoolers Problem.... Problem... Aggressive behavior -Channel energy positively: older children may enjoy competitive activities; younger children can release tension through pounding boards, large motor activity, or clay projects. Set limits & praise for jobs well done. Help child gain a sense of mastery. Toddlers & Preschoolers Problem.... Problem...
Structure the child's day. Spend more time with the child & attempt to stimulate interest. Provide "win-win" choices. "win- Regressed behavior.
Regression is acceptable to a point because it allows child a brief return to a less mature & demanding time. Support independence, mastery of tasks, & self-care. self- SCHOOL-AGE CHILD-hospitalization.
The school-age child wants to understand schoolwhy things are happening. There is a heightened concern for privacy. The child is modest & fears disgrace. Hospitalization means an interruption in the child's busy school life, & the child fears that he or she will be replaced or forgotten by peer group. Absence from peer group means a disruption of close friendships. School-age Children in response to illness.
Indications of discomfort or pain.
Expresses that something is wrong. ("I feel sick.") Cries easily. Tells adult he or she is ill so adult can do something about it. Use pain assessment tool (e.g., Elands Color Tool). School-age Children in response to illness
Positive reaction behaviors.
Shows anger. Feels guilty. Fantasizes & is fearful. Displays increased activity in response to anxiety. Reacts to immobility by becoming depressed or angry or by crying. Cries or aggressively resists treatment. Needs parents & authority. School-age Children in response to illness
Negative reaction behaviors.
Is excessively guilty & angry & is unable to express feelings. Experiences night terrors. Displays excessive hyperactivity. Will not talk about experience. Is regressive & completely withdrawn. Shows excessive dependency. Has insomnia. To Administer Medication
Give child a choice of methods to take medication: whole, cut up, with water or apple juice, liquid vs. pill form Let older child give medication to himself Give rewards (stars, stickers) for taking medication Psychosocial Implementation
Teach the child about his or her illness; take the opportunity to explain the functioning of the body. Explain all procedures completely; allow the child to see special rooms (e.g., intensive care, cardiac cath. lab) prior to being sent there for treatments. Whenever possible, provide honest & direct explanations in age-appropriate language. age- Psychosocial Implementation
Provide opportunities for child to socialize with peer group.
Allow telephone privileges for calls to home & friends. Provide outlets for anger & frustration (perhaps Velcro or suction dart board). Give child opportunity to make choices & be independent, whenever possible. Protect child's privacy. Continue child's schooling by providing tutors. Provide child with the opportunity to master developmental tasks of age group. ADOLESCENT--Implications of illness. ADOLESCENT--Implications
Disruption of social system & peer group. Alteration of body image. Fear of loss of independence or actual loss. Alteration in plans for future. Interruption in development of relationships. Loss of privacy. The degree to which the young adult is affected is dependent on: Whether the illness is chronic or acute. Whether the prognosis necessitates a change in the client's future aspirations. How many changes must be accepted. Adolescents-Response to Illness. AdolescentsIndications of discomfort or pain.
Realizes something is wrong & seeks help. Shows high anxiety level. Verbalizes discomfort. Use pain assessment tool (e.g., Eland or 1-10 Likert Scale). Adolescents-Response to illness AdolescentsPositive reaction behaviors.
Shows resistance to accepting illness. Rebels against authority. Demands control & independence. Is fearful. Temporarily withdraws from social scene. Verbalizes how illness has affected him or her. Adolescents-Response to illness AdolescentsNegative reaction behaviors.
Holds in feelings about illness. Tries to manipulate staff. Becomes completely dependent. Denies illness. Adolescent--What you can do... Adolescent--What do...
In room with other adolescents. Telephone & visitation privileges, with limit setting. Encourage feeling of self-worth by allowing as much selfindependence as possible. Allow relationships to develop within reason. Provide for privacy. Assist client in identifying role models. Realistically discuss problems of illness.
Always provide information honestly. Encourage adolescent, to accept some responsibility on the hospital unit. DEATH & DYING Developmental age specific... specific... General Facts...
Loss of a child is one of the most difficult things a family will ever experience Each child & family will deal w/ death & dying in their own way, in their own time--can't be rushed; can't be time-- can' can' scheduled; can't be controlled or can' manipulated. General Facts...
If anticipated, family can plan the last days prior to death, the funeral, & degree of resuscitation efforts to be made. Nurse responsible for-- for--
Care Information to family All members of HC team must be notified-notified-clear PCP must write specific order re: exact nature of treatments to be withheld. If sudden, unexpected...no time for unexpected... "anticipatory grieving"--may delay or stall grieving" normal grieving General Facts...Child's concept Facts... Child'
Developmental age Nature of illness Degree of pain Level of consciousness Prior experience Fear is Normal--expressed in many ways! Normal-- Some children believe that will die at night in their sleep--fear higher at night sleep-- Nurse...explore child's & family's feelings Nurse... child' family' Infant--Toddler
No understanding of death Fear & anxiety over separation Preschool Child
Something that happens to others Not permanent Curious about death & people, animals & plants that have died Magical thinking; feel that "bad thought" might come true thought" Death is reversible Young School Age
Death is Final Believe they will die--but only in die-- distant future May understand that it is universal & suspects parents will die someday Fear pain associated w/ death Preadolescent/Adolescent
Able to understand death in logical manner Understand that death is universal & permanent Fear of disfigurement & isolation from peers Health adolescents often believe that death "will NOT happen to me!" me!" Invincibility beliefs are linked w/ high-risk highbehaviors (dangerous stunts, reckless driving, etc.) Elizabeth Kubler Ross
Stages of death & dying--grieving dying--
No correct way, no correct length of time Denial & Isolation Anger Bargaining Depression Acceptance Characteristics of Normal Grief Reactions
Feelings of tightness in throat Choking Empty feeling in abdomen Lack of muscular strength Subjective distress such as mental pain or distress Loss of usual behavior
Restlessness, inability to sit still, aimless movement Lack of capacity to initiate usual interests or activities Characteristics of Normal Grief Reactions
Preoccupation w/ image of the deceased
Feelings of tightness in throat Choking Empty feeling in abdomen Lack of muscular strength Subjective distress such as mental pain or distress Feelings of Guilt
Searches for ways death could have been prevented Accuses self or others of negligence or fault What you can do...
Focus care on pain relief & comfort measures for child Focus on priority needs for child & family Calm, quiet environment Sit quietly w/ child & family Avoid:
"I know how you feel"; "You can have another baby." feel" baby." Ask open-ended questions openSupply relevant & accurate information Involve family in all care Encourage family to use all sources of support Provide as normal environment as possible Talk to child; encourage any expression of feelings Identify stages in child & family Spend more time w/ child at night Allow child to do as much self-care as desired; assist family in selfdecisions & doing everyday care Review & know BLS Case...
The parents of a 12 yo boy have just been informed that their child's condition is child' terminal due to extensive metastasis. The family has been linked to a local support group for guidance.
What type of statements might you expect from the family or child? What interventions should be anticipated after a child's child' death? How is the management of a dying child different or same as care for a child w/ an acute or chronic illness? ...
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This note was uploaded on 09/08/2010 for the course NURS 126 at San Jose State University .