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WONG'S CLINICAL MANUAL OF PEDIATRIC NURSING, 6/e
LEARNING OBJECTIVES
On completion of this chapter the reader will be able to:
Define the terms mortality and morbidity.
Identify two ways that knowledge of mortality and morbidity can
improve child health.
List three major causes of death during infancy, early childhood,
later childhood, and adolescence.
List two major causes of illness during childhood.
Outline four events that were significant in the evolution of child
health care in the United States.
Describe five broad functions of the pediatric nurse in promoting
the health of children.
Define critical thinking.
Identify the five steps of the nursing process.
Define nursing diagnosis.
Differentiate among the three domains of nursing practice:
dependent, independent, and interdependent.
Differentiate a standard care plan from an individualized care
plan.
MORTALITY
Figures describing rates of occurrence for events such as death in
children are referred to as vital statistics. In the United States,
the National Center for Health Statistics (NCHS) is
responsible for the collection, analysis, and dissemination of
health data. Since 1991, several changes have occurred in the
reporting of health statistics. Figures for birth and death are based
on the person's state of residence, not the state in which the event
occurred. In addition, tabulation of race for live births has changed
from the race of the child to the race of the mother. As a result of
these changes, figures for births, deaths, and infant mortality
rates by race cannot be compared with statistics reported before
1991. Mortality statistics describe the incidence or number of
individuals who have died over a specific period. These statistics
are usually presented as rates per 100,000 and are calculated
from a sample of death certificates.
Infant Mortality
The infant mortality rate is the number of deaths during the
first year of life per 1000 live births. Infant mortality is divided
into neonatal mortality (<28 days of life) and postneonatal
mortality (28 days to 11 months). In the United States, there
has been a dramatic decrease in infant mortality. At the
beginning of the twentieth century the rate was approximately
200 infant deaths per 1000 live births. In 2002, infant mortality
rate was 6.9 per 1000 live births (MacDorman and others, 2002).
This decrease resulted primarily from improvements in perinatal
care, such as treatment of respiratory distress syndrome and
fewer deaths from sudden infant death syndrome (SIDS). The
mortality rate in 2002 for white infants was 5.7, and the rate for
African American infants was 14.1 (MacDorman and others,
2002). The challenge for this century is to reduce the gap
between infant mortality for white and African American infants.
From a global perspective, the United States lags behind other
developed countries. In 1999, the United States ranked last
among nations with the lowest infant death rates. Hong Kong had
the lowest infant death rate (MacDorman and others, 2002)
(Table 1-1). Although the exact reason for the low ranking of the
United States is unknown, one explanation may be that many
countries with lower infant death rates have national health
programs.
Childhood Mortality
Death rates for children older than 1 year of age have always
been less than the rate for infants (see Table 1-2). Children ages
5 to 14 years have the lowest rate of death (Table 1-4). However,
a sharp rise occurs during later adolescence, primarily from
injuries, homicide, and suicide. In 2000, these conditions were
responsible for approximately 72% of deaths in teenagers and
Injuries.
Injuries, the leading cause of death in children older than 1 year
of age, are responsible for more childhood deaths and
disabilities than all causes of disease combined. As children
grow older, the percentage of deaths from injuries increases
(Table 1-5). Injuries have not shown the dramatic declines seen
in other areas of childhood mortality because injuries have
traditionally been regarded as unavoidable accidents or
behavioral problems, rather than health problems. The term
accident suggests a chaotic, random event related to "luck" or
"chance." The term injury is now preferred because it indicates
a sense of responsibility and control.
TABLE 1-5
Mortality From Leading
Types of Unintentional Injuries, United
States, 1997 (Rates per 100,000
Population in Each Age-Group)
Modified from National Safety Council: Injury facts, Itaska, Il,
2000, National Safety Council.
Data from National Center for Health Statistics.
FIG. 1-1
FIG. 1-2
! NURSING ALERT
The history of the injury is essential in assessing
intentional injury from abuse or neglect. The following
questions are important:
WhenDid the parent or guardian seek immediate
medical attention or has there been a long delay?
WhereDoes the reported location of the accident
correlate with the nature of the injury?
Injury Prevention.
When comparing deaths from injuries with other causes of
childhood mortality, it is clear that preventing injuries is the
best strategy to improve survival. Nurses play a major role in
providing anticipatory guidance to parents and older children
regarding hazards during each age period.
Theoretically, all injuries are preventable. Injury prevention is
an ongoing part of health promotion for all age-groups.
Anticipatory guidance regarding developmental expectations
serves to alert parents to the types of injuries most common at
any given age. Early in the parent-child relationship, parents
need advice on how to provide a safe environment. It cannot be
assumed that parents of one or more children are familiar with
all areas of child safety. The addition of a new infant may cause
sibling rivalry, and the new infant may be at risk from a jealous
sibling. The American Academy of Pediatrics has developed an
injury prevention program named TIPP: The Injury
Prevention Program that provides useful information and
anticipatory guidance on safety issues for parents and health
care providers.* Another resource is the Consumer Product
Safety Commission (CPSC) of the US Government, which
provides publications that recommend areas of safety for
children.
* For more information contact the American Academy of
Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
IL 60007; (888) 227-1770; fax: (847) 228-1281;
http://www.aap.org.
MORBIDITY
The prevalence of specific illnesses in the population at a
particular time is known as morbidity statistics. These are
generally presented as rates per 1000 population because of their
greater frequency of occurrence. Unlike mortality, morbidity is
difficult to define and may denote acute illness, chronic disease, or
disability. Sources of data for morbidity statistics include reasons
for visits to physicians, diagnoses for hospital admission, and
household interviews. Unlike death rates, which are updated
Childhood Morbidity
Acute illness is defined as symptoms severe enough to limit
activity or require medical attention. Respiratory illness accounts
for about 50% of all acute conditions, infections and parasitic
disease cause 11%, and injuries cause 15%. 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 with age, but 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 tend to have more health problems. This
finding suggests a need for heightened efforts to improve access
to health care for low-income children.
Recent concern has focused on specific groups of children who
have increased morbidityhomeless children, children living in
poverty, children of LBW, children with chronic illnesses, foreignborn adopted children, and children in day care centers. Several
factors place these groups at risk for poor health. One factor is
barriers to health care, especially for the homeless, the poor, and
children with chronic health problems. Other factors include
improved survival of children with chronic health problems,
particularly infants of very LBW. Children living in or exposed to
at-risk environments such as the country of origin for adopted
children and day care centers may be more likely to have
medical problems such as infections (Lears, Guth, and
Lewandowski, 1998).
Injuries are an additional factor influencing morbidity. Each year
40,000 to 50,000 children are injured permanently and 1 million
children receive medical care because of unintentional injuries.
The most important aspect of morbidity is the degree of disability
it produces. Disability can be measured in days absent from
school or days confined to bed. On average, a child loses 5.3
days per year because of injury or illness. (The incidence of
chronic conditions is discussed in Chapter 18).
PEDIATRIC NURSING
PHILOSOPHY OF CARE
Nursing of infants and children is consistent with the revised
definition of nursing proposed by the Social Policy Task Force of
the American Nurses Association in 2003. This definition states
that "nursing is the prevention of illness, the alleviation of
suffering, and the protection, promotion, and restoration of health
in the care of individuals, families, groups, communities, and
populations" (American Nurses Association, 2001; American
Nurses Association, 2003). This definition incorporates the four
essential features of nursing practice:
1.
Attention to the full range of human experiences and
responses to health and illness without restriction to a problemfocused 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 (American Nurses Association, 2003)
Family-Centered Care*
The philosophy of family-centered care recognizes the family
as the one constant in a child's life. Three key components of
family-centered care are respect, collaboration, and support
(Galvin and others, 2000). Families are supported in their care
giving and decision-making when health care professionals build
on their unique strengths and acknowledge their expertise in
caring for their child both within and outside the hospital setting
(Newton, 2000). Patterns of living at home and in the community
are promoted, and the needs of all family members, not just the
child's are considered (Box 1-1). The philosophy of familycentered care acknowledges diversity among family structures
and backgrounds; family goals, dreams, strategies, and actions;
and family support, service, and information needs.
BOX 1-1
The Key Elements of FamilyCentered Care
Incorporating into policy and practice the recognition that the
family is the constant in a child's life while the service
systems and support personnel within those systems fluctuate
Facilitating family/professional collaboration at all levels
of hospital, home, and community care:
Care of an individual child
Program development, implementation, and evaluation
Policy formation
Exchanging complete and unbiased information
between family members and professionals in a supportive
manner at all times
Incorporating into policy and practice the recognition and
honoring of cultural diversity, strengths, and individuality
within and across all families, including ethnic, racial,
Atraumatic Care
Although tremendous advances have been made in pediatric
care, many changes that have cured illnesses and prolonged life
are traumatic, painful, upsetting, and frightening. Unfortunately,
minimizing the trauma of medical interventions has not kept
pace with technologic advances. Health professionals must be
aware of the stresses facing ill children and their families and
strive to provide interventions that are safe, effective, and
helpful. Health professionals must also attempt to provide
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 chronic or acute conditions. Setting
refers to whatever place that care is giventhe 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.
Case Management
Case management developed as an approach to coordinate care
and control costs. The benefits of case management include
improved patient/family satisfaction, decreased fragmentation of
care, and the ability to describe and measure outcomes for a
homogeneous group of patients.
Case managers are responsible and accountable for particular
groups of patients and often use timelines derived from
standards of care. Timelines have a variety of names: critical
paths, guidelines for care, case management plans, Caremaps,*
coordinated care plans, or other titles agreed on within a specific
agency. Regardless of their name, timelines are multidisciplinary
plans that include all the components of care for an episode or
multiple episodes of illness, as well as the expected outcomes or
result of care. Timelines can be confined to inpatient care or the
BOX 1-2
AHCPR Clinical Practice
Guidelines Relevant to Pediatric Practice
Acute pain management: operative or medical procedures and
trauma
Urinary incontinence
Pressure ulcers: prediction and intervention
Treatment of pressure ulcers
Diagnosis and treatment of depressed outpatients in primary
care settings
Diagnosis and treatment of sickle cell disease
Initial evaluation and early treatment of the HIV-infected
individual
Management of cancer-related pain
Diagnosis and treatment of heart failure
Otitis media with effusion
Modified from AHCRP (now known as AHRQ). To order
guidelines, contact AHCPR Publications Clearinghouse, PO Box
8547, Silver Spring, MD 20907, (800) 358-9295;
http://www.ahcpr.gov.
*
Caremap is a registered trademark of the Center for Case
Management, Inc., South Natick, MA 01760; (508) 651-2600.
Family Advocacy/Caring
Although nurses are responsible to themselves, the profession,
and the institution of employment, their primary responsibility is
to the consumer of nursing servicesthe child and the family.
The nurse must work with family members, identify their goals
and needs, and plan interventions that meet the defined
BOX 1-3
United Nations' Declaration of
the Rights of the Child
All children need:
To be free from discrimination
To develop physically and mentally in freedom and dignity
To have a name and nationality
To have adequate nutrition, housing, recreation, and medical
services
To receive special treatment if handicapped
To receive love, understanding, and material security
To receive an education and develop his or her abilities
To be the first to receive protection in disaster
To be protected from neglect, cruelty, and exploitation
To be brought up in a spirit of friendship among people
As nurses care for children and families, they must demonstrate
caring, compassion, and empathy for others. Aspects of caring
include atraumatic care and the development of a therapeutic
relationship. Parents perceive caring as a sign of quality nursing
care, which is often focused on the nontechnical needs of the
child and family. Parents describe "personable" care as nursing
actions that include acknowledging the parent's presence,
listening, making the parent feel comfortable, involving both the
parent and the child in care, showing interest and concern for
their welfare, communicating with them, and individualizing the
Health Teaching
Health teaching is inseparable from family advocacy and
prevention. Health teaching may be direct as during parenting
classes, or indirect as when nurses help parents and children to
understand a diagnosis or treatment, encourage children to ask
questions about their bodies, refer families to health-related
professional or lay groups, supply appropriate literature, and
provide anticipatory guidance. To be effective health teachers,
nurses need preparation and practice with competent role
models. Health education involves transmitting information at
the child and family's level of understanding. Effective educators
also focus on giving appropriate feedback and evaluation to
promote learning.
Support/Counseling
Attention to emotional needs requires support and sometimes
counseling. The role of child advocate or health teacher is
supportive because this role requires an individualized approach.
Support can be offered by listening, touching, and through
physical presence. Touching and physical presence are helpful
Restorative Role
The most basic of all nursing roles is the restoration of health
through care giving activities. Nurses are intimately involved with
meeting the physical and emotional needs of children, including
feeding, bathing, toileting, dressing, security, and socialization.
Although they are responsible for instituting physicians' orders,
they are also accountable for their own actions and judgments
regardless of written orders.
A significant aspect of restoration of health is continual
assessment and evaluation of physical status. The focus
throughout this text on physical assessment, pathophysiology,
and scientific rationale for therapy assists the nurse in decision
making regarding health status. The nurse must be aware of
normal findings to identify and document deviations. In addition,
the pediatric nurse should never lose sight of the child's
individual emotional and developmental needs because these
needs influence the course of the disease or illness.
Coordination/Collaboration
The nurse, as a member of the health team, collaborates and
coordinates nursing services with the activities of other
professionals. Working in isolation does not serve the child's best
interest. The concept of "holistic care" can only be realized
through a unified interdisciplinary approach. Being aware of
individual contributions and limitations to the child's care, the
nurse collaborates with other specialists to provide high-quality
health services. Failure to recognize limitations can be
BOX 1-4
Standard 5. Ethics
Research
Practicing nurses should contribute to research because they are
the individuals observing human responses to health and illness.
Unfortunately, few nurses systematically analyze their
observations. Pediatric nurses often devise innovative methods
to encourage children to comply with treatments. When nurses
evaluate these clinical interventions and share them with other
nurses in research publications, nursing practice becomes based
on empiric data or science, not tradition or trial and error.
The emphasis on measurable outcomes to determine the efficacy
of interventions (often in relation to the cost) demands that
nurses know whether clinical interventions result in positive
outcomes for their clients. The current trend toward evidencebased practice also necessitates that nurses question why an
intervention is effective and if there is a better approach. The
FUTURE TRENDS
The present shift from treatment of disease to promotion of health
has expanded nurses' roles in ambulatory care and highlighted the
prevention and health teaching aspects of nursing practice.
Prospective payment and the need for home care and community
health services require nurses to be more independent and to
acquire skills that are useful in settings beyond the hospital. These
trends are illustrated throughout the text, with increased emphasis
on prevention through anticipatory guidance, child health and
family assessment, and discharge planning and care in the home
and community. As changing social policy shapes the expanding
health care arena, the focus of nursing care is no longer on what
we do for families, but what we do in partnership with them.
The philosophy of family-centered care is no longer an option, but
a mandate.
Today, technologic advances and the demand for computer
knowledge in the work setting are obvious. The current shortage of
nurses will persist into the future, and the pressure to create
positions in the health care system that do not require a nursing
background will become more intense. As new categories of
! NURSING ALERT
When the registered nurse (RN) determines that someone
who is not licensed to practice nursing can safely provide
a selected nursing activity or task for a patient and
delegates that activity to the individual, the RN remains
responsible and legally accountable for the care
provided.
Changing demographics will also influence pediatric nursing.
Although the actual number of children younger than age 18 years
will increase to an estimated 78 million in 2020, their relative
importance in terms of the proportion of the total population will
decrease from 26% to 24%. In the future, the adult population will
grow faster than the pediatric population. The number of younger
children will decrease, but the number of older children will
increase. Racial composition of the population will also change.
The number of whites in the population will decrease, whereas the
number of individuals in minority groups will increase. The largest
increases will occur in the number of Hispanic and Asian births.
The impact of these changes will be an increase in the problems of
adolescents and minority groups. Because the elderly will make up
a larger percentage of the population, health care dollars will be
split between the youngest and oldest groups, with shrinking
resources to meet the needs of both. Nurses will need to be aware
of developments in adolescent medicine and to continually adapt
their care to the cultural milieu in which they practice. Finally, cost
containment will present an ever-present challenge to providing
quality care.
BOX 1-5
INTERPRETATION
What is the meaning or significance of the expressed data?
How are the evidence/data interpreted?
(includes data categorization or clustering, assigning
significance of data, and clarifying meaning of data within the
context)
ANALYSIS
What are the intended and actual inferential relationships
among the statements or concepts presented? What are some
underlying assumptions about the data presented? What
priorities of care are appropriate given the data presented?
NURSING PROCESS
The nursing process is a method of problem identification and
problem solving that describes what the nurse actually does. The
nursing process includes assessment, diagnosis, outcome
identification, planning, implementation, and evaluation. The
second step, nursing diagnosis, is the naming of the child's or
family's problem in common nursing language. The American
Nurses Association has established Standards of Practice and
Professional Performance (Box 1-6) that outline the components
included in each step of the nursing process.
BOX 1-6
American Nurses Association
Standards for Practice
Assessment
Assessment is a continuous process that operates at all phases
of problem solving and is the foundation for decision making. It
uses multiple nursing skills and consists of 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
BOX 1-7
Classification Systems for
Nursing Diagnoses
HUMAN RESPONSE PATTERNS*
ExchangingMutual giving and receiving
CommunicatingSending messages
RelatingEstablishing bonds
TAXONOMY II DOMAINS
Domain 1
Health Promotion
Domain 2
Nutrition
Domain 3
Elimination
Domain 4
Activity/Rest
Domain 5
Perception/Cognition
Domain 6
Self-Perception
Domain 7
Role Relationships
Domain 8
Sexuality
Domain 9
Coping/Stress Tolerance
Domain 10
Life Principles
Domain 11
Safety/Protection
Domain 12
Comfort
Domain 13
Growth/Development
*
Modified from the North American Nursing Diagnosis
Association: Nursing diagnoses: definitions and classifications,
19992000, Philadelphia, 1999, The Association.
Planning
After the nursing diagnosis has been identified, a care plan is
developed and outcomes or goals are established. The outcome
is the projected change in the patient's health status, clinical
condition, or behavior that occurs after nursing interventions.
The ultimate objective of nursing care is to convert the nursing
diagnosis into a desired health state. The plan must be
established before the interventions can be developed.
The end point of the planning phase is the development of the
nursing plan of care. The care plans in this text provide
guidelines for the care of children and families with a particular
problem and are standard as opposed to individualized care
plans (Table 1-6). Standard care plans are plans that are
sufficiently broad to account for situations that may develop in
patients with particular problems. For this reason, the care plans
often have numerous nursing diagnoses, both expected and
potential. These possible nursing diagnoses guide patient
observation and data collection in monitoring the development of
adverse reactions. Individualized care plans are plans that are
concerned with only those diagnoses that apply to a particular
patient situation. In actual practice, not all the problems
presented in the standard care plan may be relevant. When a
standard nursing care plan is used to develop an individualized
care plan, problems not pertinent to the situation should be
eliminated and the outcomes should be individualized to the
specific situation. To help the reader develop an individualized
care plan, the nursing diagnoses in the text are listed in order of
priority. In general, potential problems are discussed at the end
of the plan, except when nursing interventions are essential to
prevent a potential problem from becoming an actual problem.
Implementation
The implementation phase begins when the nurse puts the
selected intervention into action and accumulates feedback
regarding its effects. The feedback returns in observations and
communications that provide a database on which to evaluate
the outcome of the nursing intervention. Throughout the
implementation stage, the patient's safety and psychologic
comfort in terms of atraumatic care are the main concerns.
Evaluation
Evaluation is the last step in the decision making involved in the
nursing process. The nurse gathers, sorts, and analyzes data to
determine if (1) the goal has been met, (2) the plan requires
modification, or (3) another alternative should be considered. In
the text, observation guidelines are included in the standard care
plans to help the reader to identify methods to evaluate whether
the goals or outcomes are achieved. The evaluation stage either
completes the nursing process or serves as the basis for the
selection of other alternatives for intervention in solving the
specific problem.
Documentation
Although documentation is not one of the steps of the nursing
process, it is essential for evaluation. The nurse can assess and
identify problems, plan, and implement without documentation,
but evaluation requires written evidence of progress toward
outcomes. The documentation elements listed in the Guidelines
box should be included in the patient's medical record.
KEY POINTS
"Healthy People 2010" broadened the health care objectives of
the past and focuses on prevention as the method to accomplish
health goals.
Infant mortality rate in the United States is at an all-time low, but
the nation continues to lag behind other major countries.
Low birth weight (LBW), which is closely related to early
gestational age, is the leading cause of neonatal death in the
United States.
Injuries are the leading cause of death in children older than age
1 year, with the majority being motor vehicle injuries.
Childhood morbidity encompasses acute illness, chronic disease,
and disability.
Eighty percent of childhood illness is attributable to infections,
with respiratory tract infections occurring two to three times as
often as 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 factors in
the prevalence of injuries at every age and should guide injury
preventive measures.
During the early 1900s, public health initiatives such as
environmental strategies to control infection and the development
of antibiotics were the major advances leading to decreased
childhood deaths.
During the late 1900s, the advancement and application of
medical knowledge and technology, specifically in the care of highrisk and LBW newborns, lowered the number of deaths in children,
especially the neonatal mortality rate.
The work of Lillian Wald, a social reformer, had far-reaching
effects on child health and nursing. She started visiting nurse
References
Alfaro-Lefevre R: Critical thinking and clinical judgment, ed 3,
Philadelphia, 2004, WB Saunders.
Altemeirer WA: Prevention of pediatric injuries: so much to do, so
little time, Pediatr Ann 29 (6):324325, 2000.