Health is a complex phenomenon. It is a state of physical, mental & social well being and not merely the absence of disease

HISTORY OF THE CARE OF CHILDREN Influenced by their importance in society

“OFTEN VIEWED AS PROPERTY”Primitive timesAncient GreeceIndustrial Revolution 1700’s

Father of Pediatrics = Abraham Jacobimilkstations for pure milkpasteurization not required until much later

Late 1800’s first children’s hospital in Philadelphia

Prevention of Cruelty to Children Society based on the Society of Prevention of Cruelty to Animals1909 First Pediatric White House Conference – still meet q 10 yrs.

1912 The Children’s Bureau was established under thejurisdiction of the Dept. of Labor – then Dept. of Health, Education & Welfare NOW called Dept. of Health & HumanServices.

This federal dept. it to:1. Assist states in care of children2. Support child welfare3. Inform public of problems (unsafe toys, car seats, etc.

In 1920’s World Health Organization (WHO)major concern being women & children’s health

Now are many children’s advocate groups

1900’s isolate sick children1940’s studies by Spitz & Robertson on the detrimental effects

of isolation & maternal deprivationEven though knew the effect change was slow!

Still changing our attitudes about care of childrenImmunizations 1955 Salk polio vaccineNutritional advancesAntibiotics (improving with not only types but not abusing themControl of infectious diseasePatient/Parent education

20th century – focus shifts to prevention of illness health & social problems prevention of problems

Healthy People 2000 now 2010increase the span of healthy life for Americansreduce health disparities among Americansachieve access to preventive services for ALL Americans

HEALTH PROMOTION, HEALTH PROTECTION, PREVENTIVE SEVICES

TRENDS IN MATERNAL CHILD HEALTH

NURSE’S ROLE = MULTIFACETED

MORTALITY VS. MORBIDITY

Prevalence of illness & disease over a period of timeinfections = most common childhood illnesseswith respiratory infections as # 1

Morbidity denotes 3 things:1. Acute illness2. Chronic illness(a condition that persist for more than 30 days)

3. Disability (often measured in day off from school or days confined to bed. Can be result of acute or chronic illness.

children under 17 over 95% are not disabled, 2% have mild, 2% havemoderately and only 0.2% are severely (account for most $ spent)

Morbidity much more difficult to define & measure thanmortality

NEW MORBIDITY:

Problems besides disease or injury which affectchild’s health

Behavioral, social (family), educational problems

Cigarette Use:Lifetime use (ever tried)……………….70.4%Daily use ……………………………..25.3% White students……………….29.3%

Hispanic …………………….19.6% Black ………………………..11.2%

Current cigarette, cigar, or smokeless tobacco use……………………………………..32.8%

Births to: 1990 1998 teen moms 13% 13% ? single moms 28% 33% receiving late or no prenatal care 6% 4% moms who smoked in pregnancy 18% 13% low birth weight 7% 8% preterm birth 11% 12% mom less than 12th grade education 24% 22% teens already mother 24% 22%

source: “The Right Start” Report

Alcohol Lifetime Use………………….81.%Current Use of Alcohol………………..50%Episodic Heavy Use (>5drinks on >1day in last 30 days)……….32% Male…….34.9% Female…….28.1% White…………………..35.8% Hispanic………………32.1% Black………………….16%...

1999 Youth Risk Behavior Survey

9.9% students overweight (BMI > 95th percentile) Males 11.9% Females 7.9%30% students thought they were overweight Males 23.7% Females 36.4%42% students trying to lose weight(in last month) Males 26.1% Females 59.4% 7.6% had taken diet pills or liquids4.8% had vomited or taken laxatives

Males 2.2% Females 7.5%

Infant Mortality1900 ……………… 200 per 10001940 ……………… 47 .. ..1960 ……………… 26 .. ..1982 ……………… 11.2 .. .. (Black infants - 25.7 per 1000)1998 ……………… 7.2 .. ..1999 (Illinois)…….. 8.3 .. .. Blacks in IL….. 17.4 ..Whites in IL…. 6.2 Leading Causes Infant Mortality:#1 Congenital Anomalies #2 R/T Prematurity and LBW#3 SIDS

In 1998 7.2 %For whites 6.0%For blacks 13.8%For native Americans 9.3 %

Leading Causes Death Ages 1-4(per 100,000 live births) Injuries …………………. #1 Motor Vehicle Accident #2 Drowning #3 Fires and Burns #4 FirearmsCongenital anomaliesCancer Homicide

Leading Causes of Death Ages 10-24 per 100,000)Motor Vehicle Accidents……….31%Homicide………………………..18%Suicide…………………………..12%Leading Causes of Death Ages >24Cardiovascular disease ………….42%* Cancer……………………………24%**related to tobacco and drug use, unhealthy diet and physical inactivity, behaviors often established in adolescence

Mortality from injuries: per 100,000 live birthTYPES OF INJURIES under 1 1-4 5-14 15-24 MALES: % of deaths 2.4% 42% 52% 51% Motor vehicle 5.2 6.8 9.1 55.5Drowning 3.2 6.1 2.7 5.1Fire & burns 3.1 5.9 1.3 1.2Firearms 0.1 0.2 1.0 2.3Ingestion of food/object 5 2Mechanical suffocation 6.2 -- -- --Falls -- 0.6 0.3 ---Poisoning -- -- -- 1.6

Females % of deaths: 2.6% 35% 41% 45%Motor vehicle 5.6 6.1 4.8 19.7Drowning 2.3 3.5 0.7 0.6Fire & Burns 3.1 3.9 1.0 0.6

WHY DO WE CARE ABOUT STATISTICS????

Four different types of vaccines are currently available. •Attenuated (weakened) live virus is used in the measles, mumps, rubella(MMR) vaccine and the varicella (chicken pox) vaccine. These vaccines last longer than other vaccines, but can cause serious infections in people with compromised immune systems. •Killed (inactivated) viruses or bacteria used in some vaccines. For example, the pertussis vaccine uses killed virus. These vaccines are safe even in people with compromised immune systems. •Toxoid vaccines contain a toxin produced by the bacterium or virus. For example, the diphtheria and tetanus vaccines are actually toxoids. •Biosynthetic vaccines contain synthetic "man-made" substances. For example, the Hib (Haemophilus influenza type B) conjugate vaccine is a biosynthetic vaccine containing two antigens that are combined to form a "conjugate" molecule that triggers the immune system to produce antibodies that are effective against this disorder.

Immunization (vaccination) is a means of triggering acquired immunity. This is a specialized form of immunity that provides long-lasting protection against specific antigens, such as certain diseases. Small doses of an antigen (such as dead or weakened live viruses) are given to activate immune system "memory" (specialized white blood cells that are capable of "recognizing" the antigen and quickly responding to its presence).

A recommended immunization schedule for children includes:•Birth: HBV •2 months: Polio, DTaP, Hib, HBV, Pneumococcus •4 months: Polio, DTaP, Hib, Pneumococcus •6 months: Polio, DTaP, Hib, HBV, Pneumococcus •12 to 15 months: Hib, Pneumococcus, MMR, Varicella. The child may also be tested for TB. TEST at same time OR wait for 4-12 weeks before do skin test for TB because maybe chance for a false positive •15 to 18 months: DTaP •4 to 6 years: Polio, DPT, MMR (Note: MMR may be delayed to age 11 to 12) •14 to 16 years: Td (repeat as a booster every 10 years)

A recommended immunization schedule for adults includes:•Tetanus/diphtheria: A primary immunization series should be given once (if not received as a child), then routine booster doses of tetanus-diphtheria (Td) should be given every 10 years.

Know normal scheduleHow givenContraindicationWhat to teach

HepB = IM

DTaP, Td = IM

Hib = IM

MMR = sub Q IF PG?If need TB skin testWait 2 months after MMRIf allergic to gelatin,Neomycin can’t get

Varicella = sub Q IF PG?If allergic to gelatin,Neomycin can’t get

PCV = IM

IM

PO ?

IM now choice

Sub Q

Sub Q

Sub Q

IM

Sub Q

VACCINE INFORMATIONThe MMR vaccine is a "3-in-1" vaccine that protects against measles, mumps, and rubella. Although single antigen (individual) vaccines have been developed for each component of the MMR, they are not readily available and usually used only for very specific situations. An example of such a situation would be if an outbreak of either measles, mumps, or rubella was occurring in a specific community and public health officials deemed it necessary to immunize infants 6 to 12 months old. Single antigen vaccines might be used because they pose less risk to children younger than the recommended age of 12 months for the MMR. For children 12 months or older and adults, the risks of giving the single antigen vaccine are presumed to be the same as giving the MMR.

The first shot is recommended at 12-15 months. Because the first shot may not provide adequate lifetime immunity to some individuals, a second MMR is recommended prior to school entry at 4-6 years or prior to entry into junior high at 11-13 years. Some states require a second MMR at kindergarten

entry

Varicella vaccine is recommended between the ages of 12 and 18 months. (see immunization schedule) If a teenager is not known to have had Chicken pox, then blood can be drawn to see if he or she is susceptable to the disease, and if so the vaccine should be administered. Varicella vaccine has become a recommended childhood vaccine and now required in many states including Illinois.

NURSES'CAN FACILITATE ADJUSTMENT TO HOSPITALIZATION & POSTHOSPITALIZATION BY

Introducing self, explain role in appropriate terms & length to child/parents Allow child to adjust to you, don’t rush in and start procedures. Possibly include doll, bear, toy.Observe child Compliment child on something, utilize home items ie. blankets, pacifers, toys,ete. Get on their level physically (eye level) Give choices you can live with Be honest, explain & prepare child for what will happen, what is exppcted. Do NOT lie if something is going to hurt. State things positively, ie. I need you to Watch words, ie. "It will be just a little stick in the arm." Especially with toddlers &

preschoolers (even some young school age children). Remember toddlers have magical thinking and pre-schoolers have vivid imaginations. Let child see & handle equipment when possible, ie. BP cuffs, stethoscopes. Take BP on dous, stuffed animals,, etc.,, let them listen to their hearts, etc. or mo&s. Don’t forget privacy, Include Parent's, they are usually child's best advocate. Find out child!s vocab Rooming in for parents. Primary nursmg.

SOME SPECIFIC TECHNIQUES Sometimes when ________ some people feel ______. Do you ever feel that way? OR before procedure prepare child in open way. Sometimes this feels like a pinch and sometimes it doesn't bother people. You tell me what it feels like to you. Choice of shot (GUN) or injection on R or L hip, thigh, etc. "Medication given through the needle into the body to make you feel better. Drawing, crayons and paper very important Use power of suggestion, ie. if for pain, "this medicine will take the hurt away." "I need you to ........ "It is OK to cry but I need you to hold very still and not move."

Avoid giving NEGATIVE suggestion. PRAISE!!!! Use band aids, stickers, rewards, What if T_ , paper dolls to illustrate where something hurts, where procedure is going to take place, etc. Writings, Have child keep diary or daily log. Play: Provides diversion, relaxation, security. allows expression of feelings allows creative expression and often increases coping ability Stay with child during and after procedures! Praise! Comfort!Involve parent/significant person in procedure ?? At least in the comfort afterwards. KEEP PARENT INFORMED! INCLUDE PARENT!

UTILIZE PARENT THEY ARE THE EXPERT IN TIHEIR CHILD’S ACTIONS AND COPING ABILITY

NURSES'HAVE THE DUTY TO ALSO MAXIMIZE THE POTENTIAL BENEFITS OF HOSPITALIZATION.

NURSES'HAVE A WONDERFUL OPPORTUNITY TO FACILITATE POSITIVE CHANGE WITHIN THE CHILD AND AMONG THE FAMILY MEMBERS. THESE MAY INCLUDE: -Fostering or possibly improving parent-child relationship -Providing educational opportunities to learn more about their bodies, each

other and even what health professionals do, immunization schedules, proper nutrition, exercise, general health maintenance, preventing problems. -Promote self mastery ---- emphasize child's competence and avoid paying attention to the negative behavior. Although hospitalization is usually stressftd, point out how well child/parent are coping. -- PRAISE!-Provide increase socialization, self help groups when appropriate, ie. new diabetic, asthmatic, etc-Provide opportunity to master new procedures, ie. home meds, new procedures such as postural draining, inhalers, etc.

NURSES'HAVE THE DUTY TO ALSO MAXIMIZE THE POTENTIAL BENEFITS OF HOSPITALIZATION.

NURSES'HAVE A WONDERFUL OPPORTUNITY TO FACILITATE POSITIVE CHANGE WITHIN THE CHILD AND AMONG THE FAMILY MEMBERS. THESE MAY INCLUDE: -Fostering or possibly improving parent-child relationship -Providing educational opportunities to learn more about their bodies, each

other and even what health professionals do, immunization schedules, proper nutrition, exercise, general health maintenance, preventing problems. -Promote self mastery ---- emphasize child's competence and avoid paying attention to the negative behavior. Although hospitalization is usually stressftd, point out how well child/parent are coping. -- PRAISE!-Provide increase socialization, self help groups when appropriate, ie. new diabetic, asthmatic, etc-Provide opportunity to master new procedures, ie. home meds, new procedures such as postural draining, inhalers, etc.

SIBLINGS OF HOSPITALIZED OR ILL CHILD

FEAR (maybe me next!, or is my brother/sister going to die)GUILT ( why not me?, or I did or caused this to happen!) JEALOUSY (IR child is getting all the attention, new toys, is loved more) CONFUSION IMAGINATION (may make things worse in their own minds) ANGER - RESENTMENT THEIR BEHAVIOR MAY BE:

WUMRAWN ACTING OUT DEPRESSION REGRESSION TEARFUL, CLINGS TO PARENT

OR COMBINATION OF ANY OR ALL

PARENTS MAY ALSO EXPERIENCE: FEAR GUILT ANGER (MAY BE DISPLACED ONTO HOSPITAL STAFF

Separation anxiety

POST HOSPITAL BE14AVIOR MAY INCLUDE:

Aloofness from parents Dependant, clingy, demanding Sleep disturbances Hyperactivity Eating disturbances Regression Anger Jealous of siblings. Fighting with siblings. These are due to a nwnber of reasons, some include; separation from

significant people, familiar surroundings lack of opportunity to form new attachments or to keep existing ones strange

environment fear of having to return to the hospital/doctor Other influences are length and type of hospitalization Encourage parent to try to ignore negative/regressive behavior. Stress the

positive behavior.

THIS TOO SHALL PASS!!

Some hospitals use a form similar to this one. Most also add meaning to the child’s vocabulary Forms that I have cover: from newborn to 24 months, covering each months & what to expect or milestones.

ASSESSMENT ON ADMISSION IS VIP

Discover norm routine – bath, naps, playnorm comfort measures – pacifiers, blanket, favorite toysChild’s vocabulary – words for drink, bathroom, ect.

VaccinationsNew milestones – general growth & developmental. Is it nomal?

If possible pre-admission classes – benefit both parents & child

Utilize minimal contact initially – WHY ?

Observe – What? Why?

Incorporate parents WHY ?

Utilize common tools such as?

Color – posture – interaction with parents Developmentally – is he where he should be

Vital signs

Growth charts, Immunization charts, snellen E or picture chartsDenver Developmental

To test visual acuity in children who do not yet read and therefore cannot use the standard Snellen Eye Chart of alphabet letters, the eye care professional will use a chart in which the letter E is headed up, down, left and right. The child can then point in the same direction as the prongs of the E.

What is the Snellen Eye Chart?The Snellen Chart is made up of a series of letters, numbers or symbols of progressively smaller size, the largest at the top. "Normal" vision is 20/20. A person who can clearly read a one-inch letter at a distance of 20 feet is considered to have normal vision. All measurements obtained from use of the Snellen Chart are a comparison to that standard. Persons who have 20/40 vision, for example, can read at 20 feet what people with normal vision can read at 40 feet.

SnellenE or BlackbirdChartfor kidswho donot read or knowletters

Under the age of 2 years

Head circumferences – above eyebrows & pinna & around occipital prominenceEach visit until 2yrs, then yearly until school age, then PRN

After age 2 & plot on graph

Plot each visitregardless ifhospital ofdoctor’s visit

Look at plottedGrowth curve

Look at parents size

DENVER DEVELOPMENT SCREENING TOOL looks at:1. Personal – social2. Fine motor – adaptive3. Language4. Gross motor skills

Brazeleton = Neonatal Behavorial Assesment Scale (BNBSS) access the infant’s interactional behavior which can help parents focus on their infants individuality – ie. – some infants cannot comfort themselves & can be overstressed by too much stimulation; therefore, need intervention to decrease stimulation or to increase comfort action

Approximate timing of developmental changes in girls

Approximate timing of developmental changes in boys

BP often = number/P NB = 65/411 mo=95/58 2-5mos= 101/57

Size of cuff =VIPCuff width = approx 40% of the circumference of arm; bladder covers 80-100% 0f circumference of arm

Breast milk or formula for 1st yr

solids when extrusion reflex disappear 4-6 mos

Double birth wt at 6 mos.

Triple birth wt at 12 mos

Food introone at a time for5-7 days beforenext foodintroduced

Remember sequence for exam – for infants, toddlers, preschoolersAlways invasive part last – maybe ears, eyes, tempObserve motor skills & gait throughout history & examAuscultate while quietHeart rate, respiratory rate – count for full minutePerform traumatic parts of exam last

Changes in body portions from before birth to adulthood

GUIDELINES FOR REVIEW OF SYSTEMS

Written informed consent of the parent or legal guardian is required.One blanket consent is NOT sufficient. Separate informed permission mustbe obtained for each surgical or diagnostic procedure

In Wong book, p. 740, talks about informed consent involving children with amental age of 7 yrs or older.

Following vary from state to state: Mature minor = permits minor to give consent even though they are

not technically an adult as long as they understand consequences oftheir decisions. ie. Treatment for STD’s, contraceptive services,pregnancy, or drug/alcohol abuse

Emancipated minor = legally underage but recognized as having legal capacity of an adult. ie. Pregnancy, marriage, high school graduationliving independently, or in the military service

Treatment without parental consent: in emergency that include danger to life or permanent injury it is applied according to the lawConflicts with religious beliefs – most have procedures by which custody can be transferred to governmental or private agency

TEMPORARY CAREGIVERCONSENT FORM

SHOULD BEWITNESSES BY2 UNRELATED PEOPLE

Pain

4 basic means to assess pain 1. Objective physiological change ?

2. Behavioral change ?

3. Subjective data from child ?

4. Pain producing pathological findings from the chart ?

1. Increase pulse, respirations, BPpupils dilate, older children likeadults become diaphretic

2. Cry, kick, scream, increase activity,rub or pull at painful spots

3.-description, by 3 some even as young as 2, can verbalize or use doll or model to point or draw where it hurts-duration, type, location, severity-use pain scales, smiley faces, colors, etc.

4.What is wrong with child What was done to child

ALWAYS include parents – because they are child’s advocate, they know their child

DEVELOPMENTAL CHARACTERISTICS OF CHILDREN’S RESPONSES TO PAIN

Pain tolerance actually increases with age as coping skills improve

Even babies show pain

CHILDREN’S DEVELOPMENTAL CONCEPTS OF ILLNESS & PAIN

Medicate freely. If pain is continuous don’t use PRN meds BUT around clock or use PCA with parent’s involvement

Two principles to remember:1. Schedule med for pain prevention2. Dose for maximum comfort

It’s OK to cry, be aware of nonverbal pain

Some ER use a combination injection, DPT– Demerol, Phenegran & Thorazine Watch for med errors - immunization

ACRONYM FOR ASSESSMENT FOR PAINQ = question the childU = use pain rating scales – before & after TXE = evaluate actual behaviorS = secure parent’s & patient’s involvement – children may tell parent but some

times not nurseT = take action whether med or no pharmacological means such as distraction,

guided imagery, etc

Make sure you document what you did & the reaction to. If no relief find some other means or notify physician