Child Health Nursing Partnering with Children Families

Child Health Nursing Partnering with Children & Families Jane W. Ball Ruth C. Bindler Intro to Pediatrics Growth and Development Hospitalization, Pain, Death & Dying

• • Introduction to Pediatrics Class Objectives 20 minutes Describe the various roles of the pediatric nurse generalist and specialist. Discuss important historical events that contributed to current practice Describe the legislative, legal and ethical concepts which influence practicing pediatric care Describe environmental and technological trends that influence mortality in infancy and childhood. Discuss the various elements of family centerd care Describe the different types of family structure and family development Describe cultural influences on the family’s beliefs about health, illness, and treatment

Describe the various roles of the pediatric nurse

Nurses May Work in Many Different Areas of Pediatrics • Direct patient care • Education • Advocacy • Case management • Research

General Pediatrics Nurses Follow the Nursing Model • Assess • Use nursing diagnosis • Provide care based on nursing diagnosis WITH collaboration of healthcare team members

Nurses Provide Care for a Wide Range of Problems • Care of the healthy child • Care of the acutely ill • Care of the injured • Care of the chronically ill • Care of the client and family

Nurses Provide Care in a Wide Range of Settings • Hospitals • Healthcare provider offices and clinics • Home of the child • Rehabilitation centers • Schools, childcare centers • Community

Nurses May Specialize in Pediatrics • Standards of pediatric nursing developed • The Society of Pediatric Nurses – Scope and standards of pediatric nursing practice

Advanced Practice Nurse (APN) • • Graduate-level education in nursing Clinical nurse specialist Pediatric nurse practitioner More responsibility for care of client and client outcomes

Discuss important historical events and individuals that contributed to the evolution of current practice Historic Influences in Pediatric Nursing

Theodore Roosevelt • Started the FIRST White House Conference on Children • Children’s Bureau

Advances Contributing to Child Healthcare • Immunizations • Antibiotics • Technology

Describe the legislative, legal and ethical concepts which influence current pediatric care Legislative Legal ethical

First National Legislation • The 1920 Sheppard-Towner Act – Supported services to mothers and infants

Social Security Act • Aid to Families with Dependent Children (AFCD) in 1935 • Title V • Various legislative acts support child health

BOX 1– 2 Significant Federal Legislation Affecting Child Health

Healthy People 2010 • National objective to decrease mortality rates for high-risk categories • Education of injury prevention is active nursing role • Seeking funding from federal agencies for education of clients and community • http: //www. healthypeople. gov/

Massachusetts and SCHIP • Universal Access/Medicaid & SCHIP Expansion. In April of 2006, Massachusetts passed comprehensive health care reform called the "Act Providing Access to Affordable, Quality, Accountable Health Care. " The law does not specifically address children, but it does have components that will increase access for them. The law includes a Medicaid expansion from the previous level of 200 percent of federal poverty guidelines to 300 percent. The Commonwealth Insurance Plan will provide low-cost, state subsidized (for specified income levels) insurance that is portable from job to job; presumably, children will gain access to insurance through these programs. The individual mandate that all state residents have health insurance applies only to people over the age of 18. Enacted 4/12/06. More NCSL Information Text of legislation • www. kidscount. org has up to date information re census and health data by state and city.

Nurses Play Vital Role in Development of Child Healthcare • Current legislation • SCHIP

Legal/ethical issues related to Pediatric nursing care • Informed consent • Confidentiality • Ethical problem solving

Informed Consent • Healthcare provider must obtain • Must be obtained for invasive procedures and some medical treatments • May be delayed in emergency situations

Minor May Give Informed Consent in Certain Circumstances • Emancipated minor • Minor is parent of a child receiving treatment

Who can give informed consent • Custodial parent • “proxy” with written permission of parent or guardian • DSS in cases where parental rights have been removed

Who cannot give informed consent • Divorced non-custodial parent • Grandparent • Live-in boyfriend/girlfriend of custodial parent

When is informed consent not required? • Emergency treatment Often a physician will determine that a patient is in immediate need of medical treatment but is unable to give consent because of a physical or mental impairment. Medical treatment can be instituted under these circumstances once it is determined that: – a) a delay in treatment would be life threatening or cause the patient serious harm; – b) no close family member or surrogate is available to give consent on behalf of the patient; and – c) the physician has no evidence that would suggest that the patient would oppose the treatment. • The physician should document in the medical record the emergency circumstances under which the medical treatment without consent was rendered. This emergency exception should be narrowly construed.

Minor Defined by Individual State Laws • Until the person reaches age of adult based on state law, parent or guardian must provide informed consent • Parent or guardians have ultimate decision with some exceptions

Massachusetts Law re: emancipated minor • By Massachusetts law, for instance, someone under 18 is emancipated if he or she is married, widowed or divorced; is a member of the armed forces; has a child; or lives independently from parents and is managing his or her own financial affairs (even if, as some interpret it, this means living on the streets and panhandling. ) If you're an emancipated teenager, you can authorize your own care and therefore are entitled to more confidentiality. In some states, including Massachusetts, you can also be emancipated under particular conditions, such as pregnancy or having a disease, including a sexually transmitted disease, that poses a risk to public health. You can also be emancipated if you are 12 or older and are drug-dependent. The idea is to allow the teen to be assessed or treated without parents knowing, though doctors must tell parents if the condition poses a danger to life or limb.

Children Should Be Given Age-Appropriate Information • Assent and preference by child should be asked

Increase in Ethical Issues and Decisions • Nurses Use Four Ethical Principles – Beneficence – Nonmaleficence – Autonomy – Justice

Current Issues Causing Increasing Conflict for Nurses and Families • • End of life-sustaining treatment Genetic testing of children Organ transplant Research on children

Healthcare Institutions and Ethics Committies • Ethics committees resolve conflicts and make recommendations

Discuss the various elements of family centered care

Family Centered Care • Define family – Structure – Developmental stages

Family Structure Varies • Picture very different in American society • Types of family – – – – Nuclear Two-income nuclear Blended or reconstituted family Extended family Single-parent Binuclear family Heterosexual cohabitation Gay or lesbian family

FIGURE 2– 1 Families are diverse in their composition. In this case, the extended family has gathered for a picnic in the park. Jane W. Ball and Ruth C. Bindler Child Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

FIGURE 2– 5 Adolescents who become single parents often have challenges with balancing school, personal time, and care of the infant. Jane W. Ball and Ruth C. Bindler Child Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

FIGURE 2– 8 Family time is important, especially during those times when all members of the family need to work together toward a common goal. In this family, everyone is learning more about the condition of one child and what each can do to help. Jane W. Ball and Ruth C. Bindler Child Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Adoptive families Jane W. Ball and Ruth C. Bindler Child Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

FIGURE 2– 3 This child lives with his mother and grandparents following the divorce of his parents. The special attention provided by his grandfather is helping him to adapt to the change in his family, and it enables the mother to work feeling confident that her son is safely cared for before and after school. Jane W. Ball and Ruth C. Bindler Child Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

Genogram

Family Development • Changes over time • Family life cycle

FIGURE 2– 11 An ecomap illustrates the family’s relationships and interactions with groups and individuals in the immediate external environment.

Family Centered Care Standard of Care • Family role • Partnership between family and healthcare providers

Nursing Care Plan • Developed with family • Developed with child • Addresses issues concerning child, family, and healthcare provider

FIGURE 2– 2 Health facility policies that permit parents to be present during a procedure performed on their child are an example of a family-centered care policy. The parent plays an important role in providing security and comfort to this child who is having his port accessed for an IV infusion treatment. Jane W. Ball and Ruth C. Bindler Child Health Nursing: Partnering with Children & Families © 2006 by Pearson Education, Inc. Upper Saddle River, New Jersey 07458 All rights reserved.

FIGURE 1– 8 Ranking of infant mortality rates in 2001 among world nations. Note the ranking of the United States, far behind Canada, European nations, and many Asian nations. What could account for the poorer ranking? Note: From UNICEF. (2003). Official summary: The state of the world’s children 2003 (pp. 14– 18). New York: United Nations Publications.

Infant Mortality • Age 1 -28 days – Leading cause of death congenital anomaly • Age 29 days to one year – Leading cause of death SIDS

Neonatal Mortality 2001 data (deaths per 100, 000 live births) • Disorders related to short gestation and low birth weight (107. 4) • Congenital Anomalies (96. 3) • Maternal complications of pregnancy (37) • Complications of placenta, cord, and membranes (24. 8) • Respiratory distress syndrome (23. 4)

Infant (post neonatal period) Mortality 2001 data deaths per 100, 000 live births • • • SIDS (50. 8) Congenital anomalies (40. 7) Injuries (20. 6) Diseases of circulatory system (10. 1) Pneumonia and influenza (6. 9) Homicide (6. 9)

Children 1 -4 years death rate per 100, 000 children

Age-specific death rate per 100, 000 children in 1990 and 2001 for children 5 to 14 years of age.

Death rates per 100, 000 adolescents 15 to 19 yrs. in 1990 and 2000.

Child Mortality • Age 1 -4 – Leading cause of death unintentional injury • Age 5 -14 – Leading cause of death unintentional injury • Age 15 -19 – Leading cause of death unintentional injury • IN ALL AGE GROUPS – Leading unintentional injury was motor vehicle collisions for 2000

FIGURE 1– 10 Death rates from unintentional and intentional injuries per 100, 000 children ages 1 to 4 years in the United States in 1988 and 2001. Interventions such as car safety seats, enforcement of fences around swimming pools, and working smoke detectors in homes all contributed to reductions in unintentional injury deaths. Which types of injuries are unintentional (unplanned or accidental) and intentional (violence or homicide related)? Note: From Children’s Safety Network. (1991). A data book of child and adolescent injury. Washington, DC: National Center for Education in Maternal and Child Health; America’s Children 2004, http: //childstats. gov/ac 2004/tables/health 7 a. asp, accessed 2/9/2005.

FIGURE 1– 12 Death rates from unintentional and intentional injuries per 100, 000 children ages 5 to 14 years in the United States in 1988 and 2001. Intensive focus on infant and child passenger safety in motor vehicles has contributed to the reduction in motor vehicle–related deaths. What could be causing the increased rate of deaths due to firearms noted in 2001? See Chapter 7. Note: From Children’s Safety Network. (1991). A data book of child and adolescent injury. Washington, DC: National Center for Education in Maternal and Child Health; America’s Children 2004, http: //childstats. gov/ac 2004/tables/health 7 b. asp, accessed 2/9/2005.

FIGURE 1– 14 Death rates from all injuries per 100, 000 adolescents 15 to 19 years in the United States in 1988 and 2000. While the rate of motor vehicle–related deaths has decreased, a greater proportion of injury deaths is now due to firearms. How can you use these data with patients and families during patient teaching and when providing care? Note: From Children’s Safety Network. (1991). A data book of child and adolescent injury. Washington, DC: National Center for Education in Maternal and Child Health; Health Resources and Services Administration, Maternal and Child Health Bureau. (2002). Child Health USA 2002. Rockville, MD: U. S. Department of Health and Human Services.

Nursing Role in Injury Prevention • Education about causes of injury and death • Anticipatory guidance for parents and caregivers