TERNOPIL STATE MEDICAL UNIVERSITY

TERNOPIL STATE MEDICAL UNIVERSITY

INSTITUTE OF NURSING

INTERNATIONAL NURSING SCHOOL

ASSOCIATE DEGREE NURSING PROGRAM

 

NURSING CARE OF CHILDREN Practicum

 

Methodical Instruction

for

PRACTICAL CLASS #1 (5 hours)

 

Theme: Course expectations and introduction to clinical areas. Introduction to pediatric assessment – orientation workshop.

 

Instructor: Dr. Nataliya Haliyash, MD, BSN

 

Room No.: Ternopil State Regional Pediatric Hospital.

 

STUDENT OBJECTIVES

Child and Family Communication

1.      The Communication Process

2.      Barriers to Communication

3.      Modes of Communication

4.      Verbal Communication

5.      Nonverbal Communication

6.      Nurse, Child, and Family Communication

7.      Cultural Impact on Communication

8.      Communicating with Children with Special Needs

Pediatric Assessment

1.      Physical Growth

2.      Health History

3.      Nutritional Assessment

4.      Developmental Assessment.

Care of Hospitalized Children

1.      The Nature of Illness in Childhood

2.      Reactions and Responses of Children to the Stressors of Illness and Hospitalization

3.      Alleviating the Anxieties of Children

4.      Preparation of Children and Families for Hospitalization

5.      Care of Children During Admission to a Hospital

6.      Preparation of Children for Surgery.

7.      Children with Chronic Illness

8.      Dimensions of Childhood Chronic Conditions

Pain Management

1.      Pain Physiology

2.      Gate Control Theory

3.      Pain Assessment

4.      Management of Acute Pain

5.      Chronic Pain.

 

STUDENTS ASSIGNMENTS

                                                                  TABLE 1

#	Topic Outline	Assignments
1.	The Communication Process –  Rapport and Trust –  Respect –  Empathy –  Listening –  Conflict Management –  Play –  Writing and Drawing –  Third-Party Communication –  Storytelling	Readings: 1)     Potts, N.L., Mandleco, B.L.; Chapter 13 pp. 353-370.
2.	Pediatric Assessment –  Health History –  Physical Examination –  Anthropometric Data –  Laboratory Evaluation –  Evaluation of Data	Readings: 2)     Potts, N.L., Mandleco, B.L.; Chapter 14 pp. 373-415 3)     Clinical Manual to Accompany Potts, N.L., Mandleco, B.L.; pp.
3.	Care of Hospitalized Children: Nursing diagnosis –  Anxiety/fear R/T separation from accustomed routine and support system; unfamiliar surrounding –  Anxiety/fear R/T distressing procedures –  Activity intolerance R/T generalized weakness, fatigue, imbalance between oxygen supply and demand –  Risk for injury/trauma R/T unfamiliar environment, therapies, hazardous equipment –  Bathing/hygiene self-care deficit R/T physical or cognitive disability, mechanical restrictions –  Dressing/grooming self-care deficit R/T physical or cognitive disability, mechanical restrictions	Readings: 1)     Potts, N.L., Mandleco, B.L.; Chapter 16-17, pp. 455-500. 2)     Clinical Manual to Accompany Potts, N.L., Mandleco, B.L.; pp.
4.	Pain Interview and History Pain Assessment Measures Management of Pain	Readings: 1)     Potts, N.L., Mandleco, B.L.; Chapter 18 pp. 517-534. 2)     Clinical Manual to Accompany Potts, N.L., Mandleco, B.L.; pp.

 

PRACTICUM OUTLINE (11:00 am till 13:00 pm)

 

1.      Group work: Introduction to clinical areas.

2.      Personal work: Master the next practical skills:

§        Pediatric Assessment:

·         Health History

·         Physical Examination

o       Measuring vital signs

·         Anthropometric Data

o       Measuring height, weight and head circumference

o       Measuring triceps skinfold thikness and midarm circumference

·         Laboratory Evaluation

·         Evaluation of Data.

§        Pediatric Communication Skills

§        Pain Assessment

 

§        Informed consent to treat child

§        Play activities for specific procedures

§        General hygiene and care

§        Collection of specimens

 

Students discussion (13:15 pm till 14:00 pm)

1.      Key Concepts

  The parameters of weight, length, or height, and head circumference (dependent on age) are essential for assessing physical growth. Using standardized growth charts, these measurements are used in determining normal and abnormal patterns.

  A pediatric health history includes biographical data, past health history, family health history, social history, and health maintenance activities.

  A nutritional assessment enables the nurse to provide anticipatory guidance, identify at-risk individuals, and collaborate with the health care team for early referral of the child as needed.

  A developmental assessment has several purposes: (1) validation that a child is developing normally or detects problems early, (2) identification of concerns of caregivers and child, and (3) provision of an opportunity for anticipatory guidance and teaching about ageappropriate expectations.

  In performing the physical assessment, techniques for approaching children vary from one age group to the next. However, a basic principle during any physical assessment is building a trusting relationship.

  Vital signs include temperature, respiration, pulse, and blood pressure, which are compared to normal ranges for the child’s age. These measurements provide information about the child’s basic physiological status.

  The skin is observed for color and lesions and palpated to determine temperature, texture, turgor, and edema.

  The head is inspected for shape, symmetry, and control, and the fontanels, suture lines, and surface characteristics are palpated.

  Examination of the eyes includes vision and strabismus screening, and assessment of the anterior and posterior segment structures.

  The thorax and lungs are examined using inspection, palpation, percussion, and auscultation.

  Assessment of the heart and peripheral vasculature consists of inspection (apical impulse, precordium), palpation (thrills, peripheral pulses), and auscultation of heart sounds.

  The order of abdominal assessment is inspection, auscultation, and palpation.

  The extent or degree of musculoskeletal assessment depends on the caregiver’s and child’s complaints of problems.

  A neurological examination includes assessment of infant reflexes (depends on age) and cranial nerves.

TABLE 2

Dosages of opioids used in children

 

2.     Review Questions

1.      Describe the components of a health history for a child. What information is gathered in the following areas: (a) past health history, (b) social history, and (c) health maintenance activities?

2.      List two environmental problems that put a child at risk for illness or death.

3.      What is the purpose of a nutritional assessment?

4.      What information is included in a nutritional assessment?

5.      Describe factors that could lead to invalid results from a developmental screening test.

6.      State an easy rule of thumb for determining normal systolic blood pressure in a child older than 1 year.

7.      How would the nurse obtain a height and weight for a 12-month-old child?

8.      Describe the sequence for assessing the abdomen.

9.      Describe the cranial nerve assessment of an infant and a toddler.

10. Describe a developmentally appropriate communication approach for each of the following age groups: infant (0–12 months), toddler (1–2 years), preschooler (3–5 years), school-age child (6–11 years), adolescent (12 years plus).

11. Describe two behaviors that negatively affect communication betweeurse and child, or nurse and caregiver, and discuss each.

12. Describe two behaviors that positively affect the relationship betweeurse and child, or nurse and caregiver, and discuss each.

13. Describe three nonverbal behaviors that, if engaged in, would contradict the nurse’s spoken words.

14. Describe how play can be used to develop rapport and trust, or give information to an infant, a five-year-old, and a ten-year-old.

15. Discuss the various factors affecting a child’s reaction to a hospital experience.

16. Describe how the relationships betweeurses and hospitalized children can be strengthened.

17. Describe how play can be used in helping hospitalized children cope with their experiences.

18. Discuss appropriate nursing interventions for hospitalized children of various developmental ages.

19. Discuss the behaviors caregivers might see in a child after the child is discharged from the hospital.

20. Describe common pediatric pain misconceptions. Delineate scientific information correcting the misperceptions.

21. How do infants experience pain? What indicates an infant is experiencing pain?

22. What unique pain behaviors do toddlers exhibit? Preschoolers? School-age children?

23. What differentiates an adolescent’s pain experiences from those of adults?

24. Describe the components of a complete pain assessment.

25. Choose three common pediatric pain assessment tools. Describe their implementation. For what age child is each appropriate?

26. How is patient-controlled analgesia used in children?

27. How are opioid side effects managed in children? (Specify side effect and management.)

28. Describe regional analgesia.

29. What are the characteristics of chronic pain in children? How is chronic pain treatment?

30. What would you include in a home treatment pain management plan? What treatments would you caution a family to use at home?

 

Reflective Thinking: Suspecting Child Abuse

     A young mother of five children brings her 2-year-old child, who is wheezing and having difficulty breathing, into the emergency department. The mother tells you she was up all night with the child. On auscultation of the posterior lung fields, you note three 4-millimeter rounded areas on the upper back that appear to be second-degree burns. There is erythema and tissue destruction surrounding the borders of each area.

§        What would be your first reaction?

§        How would you proceed with the assessment? What questions would you ask the mother?

§        Do you know your institution’s policy and your state’s laws on reporting suspected child abuse?

§        Are you, as a nurse, a mandated reporter?

Reflective Thinking: Jumping the Gun

     Active listening takes conscious effort, time, and practice. When you listen, you are able to convey in your own words what children and their caregivers have said and the feelings that were expressed. If you construct responses before children or caregivers finish speaking, or answer questions while they are being asked, listening isn’t occurring. Can you, in your own words, express the thoughts and feelings of the children and caregivers? If you cannot, you are not listening. Evaluate yourself. How well do you listen?

 

Critical Thinking: Communicating with Infants

     Ronnie, a 6-month-old infant diagnosed with meningitis, is fussy whenever you enter his room. How could you communicate with him when providing care?

Answer: Infants of this age often are fearful of strangers and will act fussy or prefer parents. While giving care, you can communicate with the infant by:

1. Playing low, soothing sounds from musical toys or mobile, singing a lullaby, or talking in a soothing tone.

2. Offering soft or silky material textures for the infant to touch or stroking the infant’s skin (avoid touching   head of Asian child).

3. Positioning in a gentle, unhurried manner, supporting infant’s head and neck.

4. Facilitating infant’s visual view to parents if they are present.

5. Picking up the infant firmly without excessive gestures and holding the infant upright rather than horizontal.

6. Minimizing bright lighting, sudden or loud movements or noise, or obscuring eye contact with parents when they are present.

7. Responding quickly to crying.

Critical Thinking: A Toddler Who Is Immobilized

         Charles, a healthy, active child of twenty months, has been admitted to the hospital and is placed in traction for treatment of a fractured femur. A hip spica cast will be applied within a few days, and a clinical pathway has been determined regarding care in traction, care after the cast is applied, and discharge instructions. He is the youngest of four children and is rarely cared for by adults other than his parents. His mother plans to stay with him throughout the hospital stay except for brief periods of a few hours each day.

         What kind of assessment data at the time of admission would assist you in understanding the effects of this child’s experience on the child and family? What strengths of a child of this age would facilitate coping? What strengths of the family would facilitate coping? What are ways of helping this child manage immobility, diminished control, and brief separations?

         Answer: Helpful assessment data at time of admission would include: child’s usual behavior on the occasions when parents are not present, or in the company of strangers; recent stresses of the child and/or family; child’s pattern of mobility and play (i.e., ability to play alone for short periods, preferred toys/games, and ways that other children in family play with him; ways that child is comforted when in distress).

         Strengths of children of this age in coping would include: the ability to receive the words and actions of comforting adults and other children, both to accept the help of others and to begin to learn how to comfort, for example, as seen in play; ability to express discomfort and distress in words and behavior; comforting toys/behaviors, for example, transitional objects, seeking contact comfort.

         Strengths of the family to facilitate coping would include quality of relationships of parents and children and their ability to identify stress in themselves and others within the family. Understanding their ways of managing problems and unexpected events helps iew stressful situations. Meaningful and accurate communication between and among members is important. In this family, it appears that parents have made a commitment to be with their children most of the time and mother is available to stay with him during hospitalization except for short periods.

         Considering Charles’s stage of development, assumptions about his behavior would include: his development of a sense of control over his body movements and functions as he begins to walk more steadily, begins to run and jump and revel in each new motor skill, and to engage in routines for bowel and bladder control; his ability to use verbal and nonverbal language to express needs and to become assertive in becoming autonomous, that is, beginning to develop a sense of self as separate from others and to exert his will. With restricted movement and change of environment, he most probably will respond with attempts to be as active as possible within the constraints of traction and a cast, and may resist or regress with changes of routines, for example, eating, sleeping, play, bowel and bladder. In a cast, he will want to be as active as possible, and keeping small objects and food from being put in the cast is often difficult.

         When his mother leaves during the day, he will most likely exhibit signs of protest and distress, even though he may have managed short separations at home well, particularly when siblings were there with him. His primary nurse’s presence during the actual leave-taking is helpful and provides initial comfort. His distress can be partially alleviated by mother’s leaving her scarf, sweater, watch, or similar item and planning bedside play, having familiar objects close by, going to the playroom during these times. Pictures of him with his family taped to the cribside or on his pajamas is also helpful. Discussing the leave-taking with his mother in advance and being as consistent as possible in the method and time away is helpful to establish a routine that can be tolerated. Explaining when she will return in terms of a familiar event, for example, TV program and/or arranging for a volunteer “grandmother” may also be helpful, particularly if this is a consistent person.

Critical Thinking: An Adolescent in Pain

         What would you say to Heather, a 16-year-old in obvious pain who refuses medications because she fears addiction? What if her family agreed and supported her decision?

         Answer: Remind Heather and her family she will feel much better and recuperate faster if she receives the narcotic. Tell her recent research does not demonstrate that addiction follows short-term use of narcotics for pain.

 

3.     POP-QUIZ (14:15 pm till 15:00 pm)

____      1.  Cephalocaudal development proceeds in which direction?

a.	head downward
b.	foot to midsection, followed by head to midsection
c.	toe to head
d.	extremities in toward the tailbone section of the body

ANS: A

____      2.  Infants start grasping with the whole hand, and as they develop they begin to use just the fingers. This development is an example of which of the following types of development?

a.	cephalocaudal	c.	anterior-posterior
b.	proximodistal	d.	internal-external

ANS: B

____      3.  When comparing the development of a number of children, you would expect which aspect of developmental change to be the same in all the children?

a.	basic sequence of changes	c.	length of each change
b.	onset of each change	d.	response

ANS: A

ANS: C

____      4.  When children learew developmental skills, the new skills:

a.	take longer to learn than earlier skills
b.	cause the child anxiety
c.	predominate over older skills
d.	are a minor focus compared to old skills

ANS:                  A

The oral stage occurs from birth to 1 year, with the infant being preoccupied with activities associated with the mouth, such as sucking. The oral stage of psychosexual development is not associated with the other defined age groups.

 

READINGS

 

WEB RESOURCES

American Academy of Pediatrics www.aap.org

National Maternal and Child Health Clearinghouse (NMCHC) www.nmchc.org

National Network for Child Care www.nncc.org

I Am Your Child www.iamyourchild.org 

 

Prepared by                                                                    Nataliya Haliyash

Sep. 10, 2007

 

Approved by Department of General Patient Care. Minute #2 from Oct.2, 2007

Revised by Department of General Patient Care. Minute #12 from June 17, 2008.

Revised by Department of General Patient Care. Minute #___ from ____, 200__.

Head of the Department                                    Associated Prof. Svitlana Yastremska, Ph.D., RN, BSN