Perspectives of Pediatric Nursing

1. Tobacco use

2. Behavior that results in injury and violence

3. Alcohol and substance use

4. Dietary and hygienic practices that cause disease

5. Sedentary lifestyle

6. Sexual behavior that causes unintended pregnancy and disease

Nutrition

Nutrition is an essential component for healthy growth and development. Human milk is the preferred form of nutrition for all infants. Breastfeeding provides the infant with micronutrients, immunologic properties, and several enzymes that enhance digestion and absorption of these nutrients. A recent resurgence in breastfeeding has occurred due to the education of mothers and fathers regarding its benefits and increased social support.

Children establish life-long eating habits during the first 3 years of life, and the nurse is instrumental in educating parents about the process of feeding and the importance of nutrition. Most eating preferences and attitudes related to food are established by family influences and culture. During adolescence, parental influence diminishes and the adolescent makes food choices related to peer acceptability and sociability. Occasionally these choices are detrimental to adolescents with chronic illnesses like diabetes, obesity, chronic lung disease, hypertension, cardiovascular risk factors, and renal disease.

Families that struggle with lower incomes, homelessness, and migrant status generally lack the resources to provide their children with adequate food intake, nutritious foods such as fresh fruits and vegetables, and appropriate protein intake. The result is nutritional deficiencies with subsequent growth and developmental delays, depression, and behavior problems.

Dental Care

Dental caries is the single most common chronic disease of childhood (Cheng, Han, and Gansky, 2008; Heuer, 2007). Nearly one in five children between the ages of 2 and 4 years has visible cavities (Kagihara, Niederhauser, and Stark, 2009). The most common form of early dental disease is early childhood caries, which may begin before the first birthday and progress to pain and infection within the first 2 years of life (Edelstein, 2005). Preschoolers of low-income families are twice as likely to develop tooth decay and only half as likely to visit the dentist as other children. Early childhood caries is a preventable disease, and nurses play an essential role in educating children and parents about practicing dental hygiene beginning with the first tooth eruption; drinking fluoridated water, including bottled water; and instituting early dental preventive care.

Immunizations

The two public health interventions that have had the greatest impact on world health are clean drinking water and childhood vaccination programs. Immunization rates differ depending on children’s race and ethnicity, family income, the state in which they live, types of vaccinations, and their age (whether adolescent or younger children) (Dougherty, Meikle, Owens, et al, 2005). The nurse should review individual immunization records at every clinic visit, avoid missing opportunities to vaccinate, and encourage parents to keep immunizations current (US Department of Health and Human Services, 2009). Nurses are responsible for keeping up with changes in immunization schedules, recommendations, and research related to childhood vaccines.

Obesity and Type 2 Diabetes

Childhood obesity is the most common nutritional problem among American children, is increasing in epidemic proportions, and is associated with type 2 diabetes (Matyka, 2008; Cali and Caprio, 2008). Obesity in children and adolescents is defined as a body mass index at or greater than the 95th percentile for youth of the same age and gender (Schwartz and Chadha, 2008). The National Health and Nutrition Examination Survey reported that the prevalence of overweight children doubled and the prevalence of overweight adolescents tripled between 1980 and 2000 (American Dietetic Association, 2008).

Advancements in entertainment and technology such as television, computers, and video games have contributed to the growing childhood obesity problem in the United States. Approximately 63% of 8- to 18-years-olds have a television in their bedrooms and watch it an average of 4 hours a day (Robinson and Sargent, 2005). Minority populations, especially African-American and Hispanic children from low-income families, watch more than 4 hours of television daily, exacerbating the effects of sedentary activity and intake of high-caloric, fatty foods (Fitzgibbon and Stolley, 2004). Lack of physical activity related to limited resources, unsafe environments, and inconvenient play and exercise facilities, combined with easy access to television and video games, increases the incidence of obesity among low-income, minority children. Overweight youth, especially children of Hispanic, African-American, and Native American descent, have increased risk for developing hypercholesterolemia, insulin resistance, diabetes, hypertension, and heart disease (Schwartz and Chadha, 2008; Matyka, 2008) (Fig. 1-1). The U.S. Department of Health and Human Services (2009) suggests that nurses focus on prevention strategies to reduce the incidence of overweight children from the current 20% in all ethnic groups, to less than 6%.

Childhood Injuries

Injuries are the most common cause of death and disability to children in the United States (Schnitzer, 2006) (Table 1-1). Motor vehicle accidents (MVAs) continue to be the most common cause of death in children older than 1 year of age. Other unintentional injuries (head injuries, drowning, burns, and firearm accidents) take the lives of children every day. Many childhood injuries and fatalities could be prevented by implementing programs of accident prevention and health promotion.

The type of injury and the circumstances surrounding it are closely related to normal growth and development (Box 1-2). As children develop, their innate curiosity compels them to investigate the environment and to mimic the behavior of others. This is essential to acquire competency as an adult, but can also predispose children to numerous hazards.

The child’s developmental stage partially determines the types of injuries that are most likely to occur at a specific age and helps provide clues to preventive measures. For example, small infants are helpless in any environment. When they begin to roll over or propel themselves, they can fall from unprotected surfaces. The crawling infant, who has a natural tendency to place objects in the mouth, is at risk for aspiration or poisoning. The mobile toddler, with the instinct to explore and investigate and the ability to run and climb, may experience falls, burns, and collisions with objects. As children grow older, their absorption with play makes them oblivious to environmental hazards such as street traffic or water. The need to conform and gain acceptance compels older children and adolescents to accept challenges and dares. Although the rate of injuries is high in children less than 9 years of age, most fatal injuries occur in later childhood and adolescence.

The pattern of deaths caused by unintentional injuries, especially from MVAs, drowning, and burns, is remarkably consistent in most Western societies. The leading causes of death from injuries and their trends are presented in Table 1-1. The majority of deaths from injuries occur in boys. It is important to note that accidents continue to account for more than three times as many teen deaths as any other cause (Annie E Casey Foundation, 2009). Fortunately, prevention strategies such as the use of car restraints, bicycle helmets, and smoke detectors have significantly decreased fatalities for children. Nevertheless, the overwhelming causes of death in children are MVAs, including occupant, pedestrian, bicycle, and motorcycle deaths; these account for more than half of all injury deaths (Centers for Disease Control and Prevention, 2006). Children under 1 year of age have the highest rate of death from MVAs, primarily from a failure to properly use car restraints (Fig. 1-2).

Pedestrian accidents involving children account for significant numbers of motor vehicle–related deaths. Most of these accidents occur at midblock, at intersections, in driveways, and in parking lots. Driveway injuries typically involve small children and large vehicles backing up.

Bicycle-associated injuries also cause a number childhood deaths. Children ages 5 to 9 years are at greatest risk of bicycling fatalities. The majority of bicycling deaths are from head injuries. Helmets reduce the risk of head injury by 85%, but few children wear helmets (National Safety Council, 2000). Community-wide bicycle helmet campaigns and mandatory-use laws have resulted in significant increases in helmet use. Still, issues such as stylishness, comfort, and social acceptability remain important factors in noncompliance. Nurses can educate children and families about pedestrian and bicycle safety. In particular, school nurses can promote helmet wearing and encourage peer leaders to act as role models.

Drowning and burns are among the top three leading causes of deaths for males and females throughout childhood (Fig. 1-3). In addition, improper use of firearms is a major cause of death among males (Fig. 1-4). During infancy, more boys die from aspiration or suffocation than do girls (Fig. 1-5). Approximately 70% of all unintentional poisonings are reported in children under 2 years of age (Bronstein, Spyker, Cantilena, et al, 2008; Franklin and Rodgers, 2008) (Fig. 1-6). By ages 4 to 5 years, unintentional poisonings are uncommon. Intentional poisoning, associated with drug and alcohol abuse and suicide attempt, is the second leading cause of death in adolescent females and third leading cause in adolescent males.

Violence

Each day, 10 children in the United States are murdered by gunfire, equivalent to approximately one child every hours (Groves, 2005). Strikingly higher homicide rates are found among minority populations, especially African-American children. The causes of violence against children and self-inflicted violence are not fully understood. Violence seems to permeate American households through television programs, commercials, video games, and movies, all of which tend to desensitize the child toward violence. Violence also permeates the schools with the availability of guns, illicit drugs, and gangs. The problem of child homicide is extremely complex and involves numerous social, economic, and other influences. Prevention lies in better understanding of the social and psychologic factors that lead to the high rates of homicide and suicide. Nurses need to be especially aware of young people who harm animals or start fires, are depressed, are repeatedly in trouble with the criminal justice system, or are associated with groups known to be violent. Prevention requires early identification and rapid therapeutic intervention by qualified professionals.

Pediatric nurses can assess children and adolescents for risk factors related to violence. Families that own firearms must be educated about their safe use and storage. The presence of a gun in a household increases the risk of suicide by about fivefold and the risk of homicide by about threefold. Technologic changes such as childproof safety devices and loading indicators could improve the safety of firearms (see Community Focus box).

Substance Abuse

Risk-taking behaviors, particularly in males, tend to begin in the first decade of life and continue into adolescence with drinking alcohol while driving, speeding, carrying a weapon, or using illicit drugs. Adolescent trends in cigarette smoking, alcohol use, and illicit drug abuse have declined since 2002. Approximately 9.8% of youth reported cigarette smoking, 15.9% reported alcohol use, and 9.5% reported illicit drug abuse within the past month (National Survey on Drug Use and Health, 2008). The slight decline in American youth’s illicit drug use is attributed to education regarding the adverse effects of illicit drugs, parental disapproval, decreased availability of drugs, and consistent participation in church and organized activities such as scouts and sports.

Mental Health Problems

Mental health problems affect one out of five school-age children in the United States. Children and adolescents with mental health problems are more likely to drop out of school than those with other disabilities (Kelleher, 2005). One of the most common mental health problems is attention deficit hyperactivity disorder (ADHD) (Kelleher, 2005). ADHD is characterized by inattentiveness, impulsivity, and at times hyperactivity, and it may occur in children as early as 3 years of age (Medd, 2003). ADHD affects every aspect of the child’s life, but is most obvious in the classroom. Medication, counseling, classroom interventions, behavior management strategies, and family education and counseling are all appropriate strategies to help children with mental health problems succeed.

Suicide is defined as a self-chosen death and is the third leading cause of death in children ages 10 to 19 (Doucette, 2005). The American Association of Suicidology (2009) estimates that there are 11.5 youth (15 to 24 years of age) suicides ever day. Suicide is preventable. Nurses should be alert to the symptoms of mental illness and potential suicidal ideation and be aware of potential resources for high-quality integrated mental health services (Coury, 2006).

Infant Mortality

The infant mortality rate is the number of deaths during the first year of life per 1000 live births. It may be further divided into neonatal mortality (<28 days of life) and postneonatal mortality (28 days to 11 months). In the United States infant mortality has decreased dramatically. At the beginning of the twentieth century the rate was approximately 200 infant deaths per 1000 live births. In 2006 the infant mortality rate was 6.69 deaths per 1000 live births (Heron, Hoyert, Murphy, et al, 2009).

From a worldwide perspective, however, the United States lags behind other nations in reducing infant mortality. In 2006 the United States ranked last among 29 nations that have a population of at least 2.5 million and had infant mortality rates equal to or lower than that of the United States. Hong Kong, Japan, Sweden, and Finland have the three lowest rates, with the United States ranked last behind Poland and Malaysia (Heron, Sutton, Xu, et al, 2010).

Birth weight is considered the major determinant of neonatal death in technologically developed countries. There is a relationship between LBW and infant morbidity and mortality (Heron, Sutton, Xu, et al, 2010). The lower the birth weight, the higher the mortality. The relatively high incidence of LBW (<2500 g [5.5 lb]) in the United States is considered a key factor in its higher neonatal mortality rate when compared with other countries. Access to and the use of high-quality prenatal care is a promising preventive strategy to decrease early delivery and infant mortality. Other factors that increase the risk of infant mortality include African-American race, male gender, short or long gestation, maternal age, and lower level of maternal education (Heron, Sutton, Xu, et al, 2010).

As Table 1-2 demonstrates, many of the leading causes of death during infancy continue to occur during the perinatal period. The first four causes—congenital anomalies, disorders relating to short gestation and unspecified LBW, sudden infant death syndrome, and newborn affected by maternal complications of pregnancy—accounted for about half of all deaths of infants under 1 year of age (Heron, Hoyert, Murphy, et al, 2009). LBW is a major indicator of infant health and a significant predictor of infant mortality (Heron, Sutton, Xu, et al, 2010). Many birth defects are associated with LBW, and reducing the incidence of LBW will help prevent congenital anomalies. Infant mortality resulting from HIV infection decreased significantly during the 1990s. In 2003 HIV/AIDS accounted for less than 0.2% of all infant deaths (Heron, Sutton, Xu, et al, 2010).

When infant death rates are categorized according to race, a disturbing difference is seen. Infant mortality for Caucasians is considerably lower than for all other races in the United States, with African-Americans having twice the rate of Caucasians. Although the infant mortality of all racial groups increased slightly between 2001 and 2002, the gap has remained constant, with the infant mortality rate expressed as a ratio of African-American to Caucasian deaths being relatively unchanged for the past decade (Heron, Sutton, Xu, et al, 2010). The LBW rate is also much higher for African-American infants than for any other group. One encouraging note is that the gap in mortality rates between Caucasian and non-Caucasian races other than African-Americans has narrowed in recent years. Infant mortality rates for Hispanics and Asian–Pacific Islanders have decreased dramatically during the past 2 decades (Heron, Sutton, Xu, et al, 2010).

Childhood Mortality

Death rates for children older than 1 year of age have always been lower than those for infants. Children ages 5 to 14 years have the lowest rate of death. However, a sharp rise occurs during later adolescence, primarily from injuries, homicide, and suicide (Table 1-3). In 2007 these causes were responsible for approximately 75% of deaths in teenagers and young adults 15 to 19 years old (Heron, Sutton, Xu, et al, 2010). The trend in racial differences that occurs in infant mortality is also apparent in childhood deaths for all ages and for both sexes. Caucasians have fewer deaths for all ages, and male deaths outnumber female deaths.

After 1 year of age, the cause of death changes dramatically, with unintentional injuries (accidents) being the leading cause from the youngest ages to the adolescent years. Violent deaths have been steadily increasing among young people ages 10 through 25 years, especially African-Americans and males. Homicide is the second leading cause of death in the 15- to 19-year age-group (see Table 1-3). Children 12 years of age and older tend to be killed by nonfamily members (acquaintances and gangs, typically of the same race) and most frequently by firearms. Suicide, a form of self-violence, is the third leading cause of death among children and adolescents 15 to 19 years of age.

Childhood Morbidity

Acute illness is defined as an illness with symptoms severe enough to limit activity or require medical attention. Respiratory illness accounts for approximately 50% of all acute conditions, 11% are caused by infections and parasitic disease, and 15% are caused by injuries. The chief illness of childhood is the common cold.

The types of diseases that children contract during childhood vary according to age. For example, upper respiratory tract infections and diarrhea decrease in frequency with age, whereas other disorders, such as acne and headaches, increase. Children who have had a particular type of problem are more likely to have that problem again. Morbidity is not distributed randomly in children. Children from poor families do not fare as well on health indicators compared with children from nonpoor families (Federal Interagency Forum on Child and Family Statistics, 2007). This finding suggests the need for heightened efforts to improve access to health care for low-income children.

Recent concern has focused on groups of children who have increased morbidity: homeless children, children living in poverty, LBW children, children with chronic illnesses, foreign-born adopted children, and children in daycare centers. A number of factors place these groups at risk for poor health. A major cause is barriers to health care, especially for the homeless, the poverty stricken, and those with chronic health problems. Other factors include improved survival of children with chronic health problems, particularly infants of VLBW.

Medicaid—In 1965 Medicaid was created under Title XIX of the SSA to reduce financial barriers to health care for the poor. It is the largest maternal-child health program. A major project under Medicaid is the Child Health Assessment Program (CHAP), which provides services for a large number of pregnant women and children. Not all poor children are eligible for Medicaid; financial eligibility varies considerably from state to state.

Women, Infants, and Children (WIC)—In 1974 the WIC Special Supplemental Food Program was started. This program provides nutritious food and nutrition education to low-income, pregnant, postpartum, and lactating women and to infants and children up to age 5 years. Other nutrition programs include Food Stamps, National School Lunch Program, School Breakfast Program, and Child Care Food Program. The Child Care Food Program provides financial assistance for nutritious meals to children in daycare centers, family and group daycare homes, and Head Start centers.

Education for All Handicapped Children Act (P.L. 94-142)—In 1975 P.L. 94-142 was passed to provide free, appropriate public education to all handicapped children from ages 3 to 21 years and to provide for supportive services (such as speech and counseling) that ensure the benefit of special education.

Education of the Handicapped Act Amendments of 1986 (P.L. 99-457)—In 1986 P.L. 99-457 was passed to allow for the provision of federal funding to states to develop and implement a statewide, comprehensive, coordinated, and multidisciplinary program of early intervention services for handicapped infants and toddlers and their families.

Omnibus Budget Reconciliation Act of 1990—Passage of this act required states to extend Medicaid coverage to all children ages 6 to 18 years with family incomes below 133% of the poverty level.

Family and Medical Leave Act (FMLA)—Signed into law in 1993, FMLA allows eligible employees to take up to 12 weeks of unpaid leave from their jobs every year to care for newborn or newly adopted children; to care for children, parents, or spouses who have serious health conditions; or to recover from their own serious health conditions. After the leave, the law entitles employees to return to their previous jobs or to equivalent jobs with the same pay, benefits, and other conditions.

Health Insurance Portability and Accountability Act (HIPAA)—The first federal privacy standards to protect patients’ medical records and other health information provided to health plans, doctors, hospitals, and other health care providers took effect on April 14, 2003. HIPAA, developed by the Department of Health and Human Services, sets new standards that provide patients with access to their medical records and more control over how their personal health information is used and disclosed. For further information, see the website www.hhs.gov/ocr/hipaa.

1. Attention to the full range of human experiences and responses to health and illness without restriction to a problem-focused orientation

2. Integration of objective data with knowledge gained from an understanding of the patient or group’s subjective experience

3. Application of scientific knowledge to the processes of diagnosis and treatment

4. Provision of a caring relationship that facilitates health and healing

Family-Centered Care

The philosophy of family-centered care recognizes the family as the constant in a child’s life. Service systems and personnel must support, respect, encourage, and enhance the family’s strength and competence by developing a partnership with parents (National Center for Cultural Competence, 2007). Nurses support families in their natural care-giving and decision-making roles by building on their unique strengths and acknowledging their expertise in caring for their child both within and outside the hospital setting (National Center for Cultural Competence, 2007). The nurse considers the needs of all family members in relation to the care of the child (Box 1-3). The philosophy acknowledges diversity among family structures and backgrounds; family goals, dreams, strategies, and actions; and family support, service, and information needs (Hooper, 2008).

Two basic concepts in family-centered care are enabling and empowerment. Professionals enable families by creating opportunities and means for all family members to display their current abilities and competencies and to acquire new ones to meet the needs of the child and family. Empowerment describes the interaction of professionals with families in such a way that families maintain or acquire a sense of control over their family lives and acknowledge positive changes that result from helping behaviors that foster their own strengths, abilities, and actions.

Although caring for the family is strongly emphasized throughout this text, it is highlighted in features such as Cultural Competence and Family-Centered Care boxes (see p. 16).

Atraumatic Care

Atraumatic care is the provision of therapeutic care in settings, by personnel, and through the use of interventions that eliminate or minimize the psychologic and physical distress experienced by children and their families in the health care system. Therapeutic care encompasses the prevention, diagnosis, treatment, or palliation of acute or chronic conditions. Setting refers to the place in which that care is given—the home, the hospital, or any other health care setting. Personnel includes anyone directly involved in providing therapeutic care. Interventions range from psychologic approaches, such as preparing children for procedures, to physical interventions, such as providing space for a parent to room in with a child. Psychologic distress may include anxiety, fear, anger, disappointment, sadness, shame, or guilt. Physical distress may range from sleeplessness and immobilization to disturbances from sensory stimuli such as pain, temperature extremes, loud noises, bright lights, or darkness. Thus atraumatic care is concerned with the where, who, why, and how of any procedure performed on a child for the purpose of preventing or minimizing psychologic and physical stress (Wong, 1989).

The overriding goal in providing atraumatic care is: first, do no harm. Three principles provide the framework for achieving this goal: (1) prevent or minimize the child’s separation from the family, (2) promote a sense of control, and (3) prevent or minimize bodily injury and pain. Examples of providing atraumatic care include fostering the parent-child relationship during hospitalization, preparing the child before any unfamiliar treatment or procedure, controlling pain, allowing the child privacy, providing play activities for expression of fear and aggression, providing choices to children, and respecting cultural differences.

Therapeutic Relationship

The establishment of a therapeutic relationship is the essential foundation for providing high-quality nursing care. Pediatric nurses need to have meaningful relationships with children and their families and yet remain separate enough to distinguish their own feelings and needs. In a therapeutic relationship, caring, well-defined boundaries separate the nurse from the child and family. These boundaries are positive and professional and promote the family’s control over the child’s health care. These boundaries are essential for effective family advocacy (Jacobson, 2002). Both the nurse and the family are empowered and maintain open communication. In a nontherapeutic relationship these boundaries are blurred, and many of the nurse’s actions may serve personal needs, such as a need to feel wanted and involved, rather than the family’s needs.

Exploring whether relationships with patients are therapeutic or nontherapeutic helps nurses identify problem areas early in their interactions with children and families (see Nursing Care Guidelines box). Although questions regarding the nurse’s involvement may label certain actions negative or positive, no one action makes a relationship therapeutic or nontherapeutic. For example, a nurse may spend additional time with the family but still recognize his or her own needs and maintain professional separateness. An important clue to nontherapeutic relationships is the staff’s concerns about their peer’s actions with the family.

Family Advocacy and Caring

Although nurses are responsible to themselves, the profession, and the institution of employment, their primary responsibility is to the consumer of nursing services: the child and family. The nurse must work with family members, identify their goals and needs, and plan interventions that best address the defined problems. As an advocate, the nurse assists the child and family in making informed choices and acting in the child’s best interest. Advocacy involves ensuring that families are aware of all available health services, adequately informed of treatments and procedures involved in the child’s care, and encouraged to change or support existing health care practices. The United Nations’ Declaration of the Rights of the Child (Box 1-4) provides guidelines for nursing practice to ensure that every child receives optimum care.

As nurses care for children and families, they must demonstrate caring, compassion, and empathy for others. Aspects of caring embody the concept of atraumatic care and the development of a therapeutic relationship with patients. Parents perceive caring as a sign of quality in nursing care, which is often focused on the nontechnical needs of the child and family. Parents describe “personable” care as actions by the nurse that include acknowledging the parent’s presence, listening, making the parent feel comfortable in the hospital environment, involving the parent and child in the nursing care, showing interest in and concern for their welfare, showing affection and sensitivity to the parent and child, communicating with them, and individualizing the nursing care. Parents perceive personable nursing care as being integral to establishing a positive relationship.

Disease Prevention and Health Promotion

Every nurse involved in caring for children must understand the importance of disease prevention and health promotion. A nursing care plan must include a thorough assessment of all aspects of child growth and development, including nutrition, immunizations, safety, dental care, socialization, discipline, and education. If problems are identified, the nurse intervenes directly or refers the family to other health care providers or agencies.

The best approach to prevention is education and anticipatory guidance. In this text each chapter on health promotion includes sections on anticipatory guidance. An appreciation of the hazards or conflicts of each developmental period enables the nurse to guide parents regarding childrearing practices aimed at preventing potential problems. One significant example is safety. Because each age-group is at risk for special types of injuries, preventive teaching can significantly reduce injuries, lowering permanent disability and mortality rates.

Prevention also involves less obvious aspects of caring for children. The nurse is responsible for providing care that promotes mental well-being (e.g., enlisting the help of a child life specialist during a painful procedure such as an immunization).

Health Teaching

Health teaching is inseparable from family advocacy and prevention. Health teaching may be the nurse’s direct goal, such as during parenting classes, or may be indirect, such as helping parents and children understand a diagnosis or medical treatment, encouraging children to ask questions about their bodies, referring families to health-related professional or lay groups, supplying patients with appropriate literature, and providing anticipatory guidance.

Health teaching is one area in which nurses often need preparation and practice with competent role models, since it involves transmitting information at the child’s and family’s level of understanding and desire for information. As an effective educator, the nurse focuses on providing the appropriate health teaching with generous feedback and evaluation to promote learning.

Support and Counseling

Attention to emotional needs requires support and, sometimes, counseling. The role of child advocate or health teacher is supportive by virtue of the individualized approach. The nurse can offer support by listening, touching, and being physically present. Touching and physical presence are most helpful with children because they facilitate nonverbal communication. Counseling involves a mutual exchange of ideas and opinions that provides the basis for mutual problem solving. It involves support, teaching, techniques to foster the expression of feelings or thoughts, and approaches to help the family cope with stress. Optimally, counseling not only helps resolve a crisis or problem but also enables the family to attain a higher level of functioning, greater self-esteem, and closer relationships. Although counseling is often the role of nurses in specialized areas, counseling techniques are discussed in various sections of this text to help students and nurses cope with immediate crises and refer families for additional professional assistance.

Coordination and Collaboration

The nurse, as a member of the health care team, collaborates and coordinates nursing care with the care activities of other professionals. A nurse working in isolation rarely serves the child’s best interests. The concept of holistic care can be realized through a unified, interdisciplinary approach by being aware of individual contributions and limitations and collaborating with other specialists to provide high-quality health services. Failure to recognize limitations can be nontherapeutic at best and destructive at worst. For example, the nurse who feels competent in counseling but who is really inadequate in this area may not only prevent the child from dealing with a crisis but also impede future success with a qualified professional.

Even nurses who practice in isolated geographic areas widely separated from other health professionals cannot be considered independent. Every nurse works interdependently with the child and family, collaborating on assessing needs and planning interventions so that the final care plan truly meets the child’s needs. Numerous disciplines often work together to formulate a comprehensive approach without consulting patients regarding their ideas or preferences. The nurse is in a vital position to include patients in their care, either directly or indirectly, by communicating their thoughts to the health care team.

Ethical Decision Making

Ethical dilemmas arise when competing moral considerations underlie various alternatives. Parents, nurses, physicians, and other health care team members may reach different but morally defensible decisions by assigning different weights to competing moral values. These competing moral values may include autonomy, the patient’s right to be self-governing; nonmaleficence, the obligation to minimize or prevent harm; beneficence, the obligation to promote the patient’s well-being; and justice, the concept of fairness. Nurses must determine the most beneficial or least harmful action within the framework of societal mores, professional practice standards, the law, institutional rules, the family’s value system and religious traditions, and the nurse’s personal values.

Nurses must prepare themselves systematically for collaborative ethical decision making. They can accomplish this through formal course work, continuing education, contemporary literature, and work to establish an environment conducive to ethical discourse. Moreover, nurses must be educated on the mechanisms for dispute resolution, case review by ethics committees, procedural safeguards, state statutes, and case law (Woods, 2005).

The nurse also uses the professional code of ethics for guidance and as a means for professional self-regulation. The Code of Ethics for Nurses by the American Nurses Association focuses on the nurse’s accountability and responsibility to the patient and emphasizes the nursing role as an independent professional, one that upholds its own legal liability.

Nurses may face ethical issues regarding patient care, such as the use of lifesaving measures for VLBW newborns or the terminally ill child’s right to refuse treatment. They may struggle with questions regarding truthfulness, balancing their rights and responsibilities in caring for children with AIDS, whistle-blowing, or allocating resources. Throughout the text such dilemmas are addressed in boxes titled Ethical Decision Making. Conflicting ethical arguments are presented to help nurses clarify their value judgments when confronted with sensitive issues.

Assessment

Assessment is a continuous process that operates at all phases of problem solving and is the foundation for decision making. Assessment involves multiple nursing skills and consists of the purposeful collection, classification, and analysis of data from a variety of sources. To provide an accurate and comprehensive assessment, the nurse must consider information about the patient’s biophysical, psychologic, sociocultural, and spiritual background.

Nursing Diagnosis

The second stage of the nursing process is problem identification and nursing diagnosis. At this point the nurse must interpret and make decisions about the data gathered. The nurse organizes or clusters these data into categories to identify significant areas and makes one of the following decisions:

The nursing diagnosis is the naming of the cue clusters that are obtained during the assessment phase. According to NANDA International (formerly the North American Nursing Diagnosis Association), the currently accepted definition of the term nursing diagnosis is that it is a clinical judgment about individual, family, or community responses to actual and potential health problems and life processes. Nursing diagnoses provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable (Johnson, Bulechek, Dochterman, et al, 2001). The Nursing Interventions Classification (NIC) consists of a standardized list of more than 400 examples of care provided by nurses in clinical practice. The Nursing Outcomes Classification (NOC) is a comprehensive, standardized system of patient outcomes that can be used to evaluate the results of specific nursing interventions. Examples of NIC and NOC concepts are listed in each Nursing Care Plan in this text to provide an understanding of the standardized language and how it relates to the individualized plan.

Not all children have actual health problems; some have a potential health problem, which is a risk state that requires nursing intervention to prevent the development of an actual problem. Potential health problems may be indicated by risk factors, or signs, that predispose a child and family to a dysfunctional health pattern and are limited to individuals at greater risk than the population as a whole. Nursing intervention are directed toward reducing risk factors. To differentiate actual from potential health problems, the word risk is included in the nursing diagnosis statement (e.g., Risk for Infection).

Signs and symptoms refer to a cluster of cues and defining characteristics that are derived from patient assessment and indicate actual health problems. When a defining characteristic is essential for the diagnosis to be made, it is considered critical. These critical defining characteristics help differentiate between diagnostic categories. For example, in deciding between the diagnostic categories related to family function and coping, the nurse uses defining characteristics to choose the most appropriate nursing diagnosis (see Family-Centered Care box).

Planning

After identifying the nursing diagnoses, the nurse develops a care plan and establishes outcomes or goals. The outcome is the projected or expected change in a patient’s health status, clinical condition, or behavior that occurs after nursing interventions have been instituted. The ultimate goal of nursing care is to convert the nursing diagnoses into a desired health state. The care plan must be established before specific nursing interventions are developed and implemented.

Implementation

The implementation phase begins when the nurse puts the selected intervention into action and accumulates feedback data regarding its effects (or the patient’s response to the intervention). The feedback returns in the form of observation and communication and provides a database on which to evaluate the outcome of the nursing intervention. It is imperative that continual assessment of the patient’s status occur throughout all phases of the nursing process, thus making the process a dynamic rather than static problem-solving method. Throughout the implementation stage, the main concerns are the patient’s physical safety and psychologic comfort in terms of atraumatic care.

Evaluation

Evaluation is the last step in the decision-making process. The nurse gathers, sorts, and analyzes data to determine whether (1) the established outcome has been met, (2) the nursing interventions were appropriate, (3) the plan requires modification, or (4) other alternatives should be considered. The evaluation phase either completes the nursing process (outcome is met) or serves as the basis for selecting alternative interventions to solve the specific problem.

With the current focus on patient outcomes in health care, the patient’s care is evaluated not only at discharge but thereafter as well to ensure that the outcomes are met and there is adequate care for resolving existing or potential health problems. One federal agency that has developed clinical guidelines is the Agency for Healthcare Research and Quality.*

Documentation

Although documentation is not one of the five steps of the nursing process, it is essential for evaluation. The nurse can assess, diagnose and identify problems, plan, and implement without documentation; however, evaluation is best performed with written evidence of progress toward outcomes. The patient’s medical record should include evidence of those elements listed in the Nursing Care Guidelines box.

• Although the infant mortality rate in the United States has declined over the past few decades, the United States lags significantly behind most other major countries, such as Canada.

• LBW, which is closely related to early gestational age, is considered the leading cause of neonatal death in the United States.

• Injuries are the leading cause of death in children over age 1 year, with the majority being MVA injuries.

• Childhood morbidity encompasses acute illness, chronic disease, and disability.

• Eighty percent of childhood illnesses are attributable to infections, with respiratory tract infections occurring two or three times more often than all other illnesses combined.

• The new morbidity refers to behavioral, social, and educational problems that can significantly alter a child’s health.

• Developmental stage and environment are important determinants of the prevalence of injuries at a given age and thus help to direct preventive measures.

• The philosophy of family-centered care recognizes that the family is the constant in a child’s life and that service systems and personnel must support, respect, and enhance the family’s strength and competence.

• Atraumatic care is the provision of therapeutic care in settings, by personnel, and through the use of interventions that eliminate or minimize the psychologic and physical distress experienced by children and their families in the health care system.

• The pediatric nurse’s roles include a therapeutic relationship, family advocacy, disease prevention and health promotion, health teaching, support and counseling, coordination and collaboration, ethical decision making, and research.

• EBP is the collection, interpretation, and integration of valid, important, and applicable patient-reported, nurse-observed, and research-derived information.

• The process of nursing children and families includes accurate and comprehensive assessment, analysis and synthesis of assessment data to arrive at a nursing diagnosis, planning of care, implementation of the plan, and evaluation of interventions.

• Since nurses are the principal caregivers within health care institutions, quality outcomes are used as a measure of the ability to provide excellence in patient care.