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Perspectives of Pediatric Nursing


advocate Upon completion of the chapter, the learner will be able to:
atraumatic care
case management 1. Describe the major components, concepts, and influences involved in the nursing
evidence-based practice of children and their families.
practice 2. Identify the key milestones in the evolution of pediatric nursing and child health.
family-centered care 3. Compare the past definitions of health and illness to the current definitions as well as
morbidity the measurement of health and illness in children.
mortality 4. Explain the components of the nursing process as they relate to nursing practice for
nursing process children and their families.
standard of care 5. Identify the major roles and functions of pediatric nursing, including the scope of
practice and the professional standards for pediatric nurses.

To love children means to see them, respect them, share life with them, but also let them go.
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Isabelle Romano is a 6-year-old girl with cerebral palsy. She was born at 28 weeks gestation and is cur-
rently admitted to the hospital due to difficulty breathing secondary to pneumonia. Her parents are very
active in her care. Isabelle lives at home with her parents and two brothers, Sergio and Tito. Consider how
your role as a nurse can affect this family.

C hildren are the future of

our society and special gifts to the world. Their overall
Family-Centered Care
Parents or guardians play a critical role in the health and
health has improved, and rates of death and illness in well-being of children. Providing care through a family-
some areas have decreased, but we still must focus on centered approach leads not only to better outcomes
childrens health both in the United States and globally. but also to better consumer satisfaction. The family is
Habits and practices established in childhood have pro- the childs primary source of support and strength. The
found effects on health and illness throughout life. As a knowledge that the family has about a childs health or
society, creating a population that cares about children illness is vital. Family-centered care involves families
and promotes solid health care and lifestyle choices is and caregivers working in a collaborative partnership to
crucial. Pediatric nurses play a major role in this task. determine goals and plans for health care (Woodside et al.,
They are often in the trenches advocating on various 2001). It works well in all arenas of health care, from
issues, drawing attention to the importance of health care preventive care of the healthy child to long-term care of
for children, and dealing with lack of resources, lack of the chronically or terminally ill child. Family-centered
access to health care, and the focus on acute care rather care enhances parents and caregivers confidence in
than education and prevention. their own skills and also prepares children and young
This chapter provides an overview of pediatric nurs- adults for assuming responsibility for their own health
ing, including important philosophical beliefs, the health care needs. Key elements of family-centered care include
status of children, and contemporary issues and trends demonstrating interpersonal sensitivity, providing gen-
in childrens health care. The chapter concludes with a eral health information, communicating specific health
description of how pediatric nurses use the nursing process information, and treating people with respect (Woodside
to care for children and their families. et al., 2001).
According to the American Academy of Pediatrics
Introduction to (2003), family-centered care focuses on several core
Pediatric Nursing
Respect for the child and family
Pediatric nursing is the practice of nursing involved in the
Recognition of the effects of cultural, racial, ethnic, and
health care of children from infancy through adolescence.
socioeconomic diversity on the familys health care
In the United States the number of children under age
18 years is approximately 73.5 million, accounting for
Identification of and expansion of the familys strengths
25% of the population (Child Trends, 2006a). The defin-
Support of the familys choices related to the childs
ition of nursing, the diagnosis and treatment of human
health care
responses to actual or potential health problems, also
applies to the practice of pediatric nursing (American Maintenance of flexibility
Nurses Association, 2004). However, the overall goal of Provision of honest, unbiased information in an affirm-
pediatric nursing practice is to promote and assist the child ing and useful approach
in maintaining optimal levels of health while recognizing Assistance with the emotional and other support the
the influence of the family on the childs well-being. This child and family require
goal involves the practice of health promotion and disease Collaboration with families
prevention as well as assisting with care during disease or Empowerment of families
illness. When childrens health care is provided through a
family-centered approach, many positive outcomes are
Philosophy of Pediatric Nursing Care possible. Anxiety is decreased. Children are calmer and
Children need accessible, continuous, comprehensive, pain management is enhanced. Recovery times are short-
coordinated, family-centered and compassionate care that ened. Families confidence and problem-solving skills are
focuses on their changing physical and emotional needs improved. Communication between the health care team
(Deal et al., 1998). Pediatric nurses provide this care by and the family is also improved, leading to greater satis-
focusing on the family, providing atraumatic therapeutic faction for both health care providers and health care con-
care, and using evidence-based practice. These three con- sumers (families). Ways to increase collaboration between
cepts represent an overarching philosophy of pediatric the family and the health care team may include a family
nursing care and are integrated throughout the chapters advisory board, newsletter, or parent resource notebooks.
of this text. Methods for increasing communication between the health
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care team and the family may include the use of mailboxes therapeutic care through interventions that minimize
or dry-erase boards for updating the daily plan of care, physical and psychological distress for children and their
including the parents participation in rounds, or through families. Pediatric nurses must be vigilant for any situa-
a daily assessment of health status by the child or family. tion that may cause distress and must be able to identify
Vigilant parents are committed to their childs care. potential stressors. They take steps to minimize separation
They demonstrate resilience in their ability to make it of the child from the family, and the nursing care they
through the emotional upheaval associated with an illness. provide decreases the childs exposure to stressful situa-
They may experience changes in their other relationships tions and prevents or minimizes pain and bodily injury.
as well as in the relationships they have with health care Chapter 3 provides additional information related to
providers (Dudley & Carr, 2004). Research has shown atraumatic care.
that families desire and appreciate nurses sensitivity to the
inconveniences that their childs illness may impose upon Evidence-Based, Case Management Care
the family (Miceli & Clark, 2005). Families want to have Modern pediatric health care focuses on an interdiscipli-
their emotional and spiritual needs addressed, their con- nary plan of care designed to meet the childs physical,
cerns attended to, and their accommodations improved developmental, educational, spiritual, and psychosocial
(when the child is hospitalized) (Fig. 1.1). They want to be needs. Nurses coordinate the implementation of this
included and valued in the health care decision-making interdisciplinary plan in a collaborative manner to ensure
process (Miceli & Clark, 2005) and to establish rapport continuity of care that is cost-effective, quality-oriented,
with the nurses caring for their child (Espezel & Canam, and outcome-focused. This type of care is termed case
2003). Practicing true family-centered care may empower management. Box 1.1 highlights the components of
the family, strengthen family resources, and help the child case management. When the nurse functions as a case
feel more secure throughout the process. manager, patient and family satisfaction is increased, frag-
mentation of care is decreased, and outcome measure-
ment for a homogeneous group of patients is possible.
How could family-centered care help the Romano Case management uses a system of plans, often
family described at the beginning of the chapter? referred to as critical paths, that are derived from stan-
dards of care with a multidisciplinary approach that
produces clinical practice guidelines. Implementing this
Atraumatic Care philosophy leads to outcomes that are expected as a result
Children may undergo a wide range of interventions, of delivery of that care and may lead to future payment
many of which can be traumatic, stressful, and painful. tied to the practice guidelines. The Agency for Health
The various settings in which the child receives care can Care Policy and Research and the National Guidelines
be scary and overwhelming to the child and family, and Clearinghouse maintain current clinical practice guide-
interacting with various health care personnel in various lines. Clinical practice guidelines are rooted in evidence-
settings can cause anxiety. Thus, another major com- based practice.
ponent of the pediatric nursing philosophy is providing Evidence-based practice involves the use of
atraumatic care. This is a philosophy of providing research findings in establishing a plan of care and imple-
menting that care. Evidence-based practice is a problem-
solving approach to making nursing clinical decisions
(Newhouse, 2006). This concept of nursing practice
includes the use of the best current evidence in making

BOX 1.1

Collaborative process involving assessment, planning,

implementation, coordination, monitoring, and
Advocacy, communication, and resource management
Patient-focused comprehensive care across a
Coordinated care with an interdisciplinary approach
Figure 1.1 Providing a comfortable area for the parent
to rest is an important component of family-centered care. Commission for Case Management Certification. (n.d.).
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decisions about the care of children and their families. their sick infants and also stressed the importance of
Evidence-based practice may lead to a decrease in varia- pasteurization. This one intervention led to a decrease
tions in care while at the same time increasing quality. in infant deaths.
An example of evidence-based practice is the current In the early 1900s, Lillian Wald established the Henry
pediatric blood pressure measurement recommenda- Street Settlement House in New York City; this was
tions. Due to the difficulty with obtaining consistent and the start of public health nursing. This facility provided
appropriate blood pressure measurements in children, medical and other services to poor families. These ser-
as well as the increase in blood pressure in children over vices included home nurse visits to teach mothers about
the past several years, the National High Blood Pressure health care.
Education Program Working Group published recom- Health care personnel were trained to take care of
mendations for routine blood pressure measurement in children in hospitals, but parents of hospitalized chil-
children. The guidelines address factors affecting the dren were discouraged from visiting to prevent the spread
childs blood pressure, use of auscultatory or oscillomet- of infection. Restricting parents from being involved in
ric measurement devices, appropriate blood pressure their childs care was also thought to minimize emo-
cuff size and application, and site of blood pressure tional stress.
measurement. The goal is to permit early screening and Nursing in public schools began in 1902 with the
identification of children at risk for hypertension (Schell, appointment of Lina Rogers as a full-time public school
2006). Recent studies provide evidence that nurse-led nurse in New York. A professional course in pediatric
interventions improve overall health and management of nursing was started in the early 1900s at Teachers College
chronic illness. of Columbia University.
The turn of the 20th century brought new knowledge
The Evolution of Pediatric Nursing about nutrition, sanitation, bacteriology, pharmacology,
in Relationship to Child Health medication, and psychology. Penicillin, corticosteroids,
The historical perspective of pediatric nursing includes and vaccines, which were developed during this time,
the devastating epidemics that affected children in the assisted with the fight against communicable diseases. By
past, societal trends in our country, changes in the health the end of the 20th century, technological advances had
care system, and federal and state regulations. This dis- significantly affected all aspects of health care. These trends
cussion will provide a brief overview of the evolution of have led to increased survival rates in children. However,
pediatric nursing. By reviewing these historical events, many children who survive illnesses that were previously
pediatric nurses can gain a better understanding of the considered fatal are left with chronic disabilities. For
current and future status of pediatric nursing. example, before the 1960s, extremely premature infants
In past centuries in the United States, the health of did not survive because of the immaturity of their lungs.
the country was poorer than it is today; mortality rates Mechanical ventilation and the use of medications to fos-
were high and life expectancy was short. When a flood of ter lung development have increased survival rates in pre-
immigrants from Europe settled in the eastern American mature infants, but survivors are often faced with a
cities, infectious diseases were rampant because of the myriad of chronic illnesses such as bronchopulmonary
crowded living conditions, inadequate and unsanitary dysplasia, retinopathy of prematurity, cerebral palsy, or
food (e.g., contaminated milk), and harsh working con- developmental delay. This increased survival has resulted
ditions (including child labor). Devastating epidemics of in a significant increase in chronic illness relative to acute
smallpox, diphtheria, scarlet fever, and measles hit chil- illness as a cause of hospitalization and mortality.
dren the hardest. During this period, the prevalent view In the 1960s, changes in the health care delivery sys-
was that children were a commodity; their role was to tem and shifts in the populations health status led to the
increase the population and share in the work to be done. development of the nurse practitioner role. The 1970s
This view changed over the years, as public schools were brought cost-control systems from the federal govern-
established and the court system began viewing children ment because of rapid escalation of health care expendi-
as minors. tures. In addition, the considerable changes in the U.S.
Over time, changes occurred that focused attention health care system in the 1980s have affected pediatric
on the health of children. In 1870, the first pediatric nursing and child health care. The emphasis of care is on
professorship for a physician was awarded in the United quality outcomes and cost containment. Some of these
States to Abraham Jacobi, who is known as the father of changes brought more advanced practice nurses into the
pediatrics. For the first time, the medical community field of pediatrics.
realized there was a need to provide specialized training Finally, in the 1980s, the Division of Maternal-Child
and education about children to health care providers. Health Nursing Practice of the American Nurses Asso-
In 1889 Jacobi established milk distribution centers, ciation developed maternal-child health standards to
which provided mothers with uncontaminated milk for provide important guidelines for delivering nursing care.
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The Pediatric Nursing Role baccalaureate-prepared nurse, is responsible for integrat-

and Health Care Settings ing care from before admission to after discharge.
The advanced practice role is an expanded nursing role
The professional pediatric registered nurse provides three that requires additional education and skills in the assess-
levels of health care services: primary, secondary, and ment and management of children and their families. The
tertiary. The primary level of service focuses on health pediatric nurse practitioner (PNP) has a masters degree
promotion and illness prevention and typically occurs in and national certification in the specialty area. The PNP is
the community. The pediatric nurse may provide this an independent and autonomous practitioner, managing
level of service in a variety of settings, including health children in primary, acute, or intensive care or providing
clinics or offices, schools, homes, daycare centers, and long-term management of the child with a chronic illness.
summer camps. The secondary level of service is gener- The clinical nurse specialist has a masters degree and pro-
ally provided in acute treatment centers that focus on vides expertise as an educator, clinician, or researcher,
the diagnosis and treatment of illness. The pediatric meeting the needs of staff, children, and families.
nurse functions at the secondary level when working in Various changes in the health care system continue
settings such as general pediatric hospital units, pediatric to encourage the development of the advanced practice
intensive care units, emergency departments, ambula- role for pediatric nursing. Table 1.1 describes the func-
tory clinics, surgical centers, and psychiatric centers. tions of the family nurse practitioner, the neonatal nurse
The tertiary level of service involves restorative, rehabil- practitioner, and the pediatric nurse practitioner as well
itative, or quality-of-life care and takes place in rehabil- as the pediatric clinical specialist and case manager.
itation centers or hospice programs or through service
with a home health agency. The American Academy of Colleges of
Although nurses in each setting might have specific Nursing (2005) has recommended that
roles and responsibilities, they all share universal roles nurse practitioner education be moved
that can be identified as primary and secondary roles, the from the masters to the doctoral level
differentiated practice role, and the advanced practice by the year 2015.
role. Within all of these roles, the nurse ensures that com-
munication with the child and family is based on the Standards of Care and Performance
childs age and developmental level.
The primary role of the pediatric nurse is to provide
in Todays Environment
direct nursing care to children and their families, being In any role, the professional pediatric nurse is held
an advocate, educator, and manager. As a child and accountable for nursing actions that adhere to the stan-
family advocate, the nurse safeguards and advances the dards of care. A standard of care is a minimally
interests of children and their families by knowing their accepted action expected of an individual of a certain
needs and resources, informing them of their rights and skill or knowledge level and reflects what a reasonable
options, and assisting them to make informed decisions. and prudent person would do in a similar situation.
In the primary role of educator, the nurse instructs and Professional standards from regulatory agencies, state
counsels children and their families about all aspects of or federal laws, nurse practice acts, and other specialty
health and illness. The pediatric nurse uses and integrates groups regulate nursing practice in general. The American
research findings to establish evidence-based practice, Nurses Association (ANA) and the Society of Pediatric
managing the delivery of care in a cost-effective manner Nurses (SPN) have formulated specific standards of care
to promote continuity of care and an optimal outcome for and professional performance for pediatric clinical nursing
the child and family. practice (Table 1.2). These standards are tools that deter-
In the secondary role, the pediatric nurse serves mine if care constitutes adequate, effective, and acceptable
as a collaborator, care coordinator, and consultant. nursing practice. They also serve as guides and legal mea-
Collaborating with the interdisciplinary health care sures for this special area of practice. These standards pro-
team, the pediatric nurse integrates the childs and fam- mote consistency in practice, provide important guidelines
ilys needs into a coordinated plan of care. In the role of for care planning, assist with the development of outcome
consultant, the pediatric nurse ensures that the childs criteria, and ensure quality nursing care. The ANA-SPN
and familys needs are met through such activities as standards specify what is adequate and effective for gen-
support group facilitation or working with the school eral pediatric nursing and promote consistency in practice.
nurse to plan the childs care.
In the differentiated practice role, the nurses experi-
ence, competence, and educational level determine the
Childrens Health Status
nurses role. For example, a clinical coordinator typically Since children are a gift to this world, it is societys
holds a baccalaureate degree and fills a leadership role responsibility to nurture and care for them. Health used
in a variety of settings. The case manager, also usually a to be defined simply as the absence of disease; health was
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Table 1.1 Advanced Practice Roles for Pediatric Nurses

Role Function

Pediatric nurse practitioner (PNP) Provides health maintenance care for children (well-child examinations,
developmental screening, immunizations, anticipatory guidance, and
school physicals)
Diagnoses and treats common childhood illnesses
Provides care to acutely, chronically, or critically ill children (performs
in-depth physical assessments and health histories, interprets laboratory
and diagnostic tests, prescribes medications, and performs therapeutic
treatments) (National Association of Pediatric Nurse Practitioners, 2006)
Family nurse practitioner (FNP) Provides health care to individuals throughout the life span
Performs health assessments, orders and interprets diagnostic and
laboratory tests, prescribes pharmacologic and nonpharmacologic
treatments (American Academy of Nurse Practitioners, 2002)
Neonatal nurse practitioner (NNP) Differentiates the nurse practitioner role to the care of the newborn
Functions in similar manner to the PNP or FNP, but within the newborn
nursery or neonatal intensive care unit (National Association of
Neonatal Nurses, 2002)
Clinical nurse specialist Serves as a consultant in a particular area of expertise
specialist in specific pediatric Researches, educates, and serves as a role model for expert nursing care
areas, such as pediatric in specialty field (National Association of Clinical Nurse Specialists, n.d.)
oncology clinical nurse specialist
Case managerspecialist in Supervises a group of patients from the time they enter a health care
pediatric hospitals and other setting until they are discharged from the setting
pediatric health care settings Monitors effectiveness, cost, and patient satisfaction

measured by monitoring the mortality and morbidity of a efforts. For example, one objective under physical activ-
group. Over the past century, though, the focus of health ity is to increase the proportion of adolescents who engage
has shifted to disease prevention, health promotion, and in vigorous physical activity three or more days per week
wellness. The World Health Organization (2006) defines for 20 or more minutes per occasion (U.S. Department
health as a state of complete physical, mental, and social of Health and Human Services, 2000). Healthy People
well-being, and not merely the absence of disease or infir- 2010 1.1 highlights the major health concerns of the 21st
mity. Thus, the definition of health is complex; it is not century that need to be addressed.
merely the absence of disease or a review of mortality and
morbidity statistics. Measurement of Childrens
In 1979, the U.S. Surgeon Generals Report, Healthy
Health Status
People, presented an agenda for the nation that identified
the most significant preventable threats to health. With Measuring a childs health status is not always a simple
the series of updates that followed, including the present process. For example, some children with chronic ill-
one, Healthy People 2010: National Health Promotion and nesses do not see themselves as ill if they can manage
Disease Prevention Objectives, the country has a compre- their disease. A traditional method of measuring health
hensive health promotion and disease prevention agenda is to examine mortality and morbidity data. This infor-
that emphasizes childrens health (U.S. Department of mation is collected and analyzed to provide an objective
Health and Human Services, 2000). Major goals are to description of the nations health.
increase the quality and years of healthy life and to elim-
inate health disparities between ethnic groups by target- Mortality
ing the lifestyle choices and environmental conditions Mortality is the number of individuals who have died
that cause 70% of premature deaths in the United States. over a specific period. This statistic is presented as rates
There are 10 specific health indicators, including chil- per 100,000 and is calculated from a sample of death cer-
drens health indicators, that serve as a way to evaluate the tificates. The National Center for Health Statistics, under
progress made in public health; they also serve as focal the Department of Health and Human Services, collects,
points to coordinate the national health improvement analyzes, and disseminates these data.
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Table 1.2 American Nurses Association/Society of Pediatric Nurses Scope and Standards
of Pediatric Nursing Practice

Standard Description

Standard of care 1. Assessment: The pediatric nurse collects health data.

2. Diagnosis: The pediatric nurse analyzes the assessment data in
determining diagnosis.
3. Outcome identification: The pediatric nurse identifies expected
outcomes individualized to the client.
4. Planning: The pediatric nurse develops a plan of care that
prescribes interventions to obtain expected outcomes.
5. Implementation: The pediatric nurse implements the interventions
identified in the plan of care.
6. Evaluation: The pediatric nurse evaluates the childs and familys
progress toward attainment of outcomes.
Standards of professional 1. Quality of care: The pediatric nurse systematically evaluates the
performance quality and effectiveness of pediatric nursing practice.
2. Performance appraisal: The pediatric nurse evaluates his or her
own nursing practice in relation to professional practice standards
and relevant statutes and regulations.
3. Education: The pediatric nurse acquires and maintains current
knowledge in pediatric nursing practice.
4. Collegiality: The pediatric nurse contributes to the professional
development of peers, colleagues, and others.
5. Ethics: The pediatric nurses decisions and actions on behalf of
children and their families are determined in an ethical manner.
6. Collaboration: The pediatric nurse collaborates with the child,
family, and health care provider in providing client care.
7. Research: The pediatric nurse uses research findings in practice.
8. Resource utilization: The pediatric nurse considers factors related
to safety, effectiveness, and cost in planning and delivering care.

Neonatal and Infant Mortality as the number of deaths in relation to 1,000 live births.
Neonatal mortality is the number of infant deaths occur- The infant mortality rate is used as an index of the gen-
ring in the first 28 days of life per 1,000 live births. The eral health of a country. Generally, this statistic is one
infant mortality rate refers to the number of deaths occur- of the most significant measures of childrens health. In
ring in the first 12 months of life. It also is documented 2003, the infant mortality rate in the United States was
6.85 per 1,000 live births (Hoyert et al., 2006; Fig. 1.2).
The infant mortality rate varies greatly from state to
HEALTHY PEOPLE 2010 state as well as between ethnic groups. The United States
Major health concerns of the 21st century
Physical activity
Deaths per 1,000 live births

Overweight and obesity 40

Tobacco use
Substance abuse
Responsible sexual behavior 20
Mental health 10
Injury and violence
Environmental quality
1940 1950 1960 1970 1980 1990 2000
Immunizations 2003
Access to health care Figure 1.2 Infant and neonatal mortality from 1940 to
2003. (Adapted from Hoyert et al., 2006.)
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has one of the highest gross national products in the Nations Childrens Fund, 2001). One study showed that
world and is known for its technological capabilities, but preschool children who had been injured previously dis-
it ranked 27th in infant mortality rates among industri- played significantly higher numbers of injury behaviors
alized nations in 2000 (U.S. Department of Health and (Bruce et al., 2004). This suggests that screening for injury
Human Services, 2006). The main causes of early infant behaviors can be a useful tool when nurses are providing
death in this country include problems occurring at birth injury prevention counseling.
or shortly thereafter, such as prematurity, low birthweight,
congenital anomalies, sudden infant death syndrome, and Morbidity
respiratory distress syndrome. Morbidity is the measure of prevalence of a specific ill-
ness in a population at a particular time. It is presented
in rates per 1,000 population. Morbidity is often diffi-
African-Americans and American Indian/Alaskan
cult to define and record because the definitions used
Native infants have consistently had higher
infant mortality rates than other ethnic groups vary widelyfor example, visits to the physician or diag-
(Federal Interagency Forum on Child and Family nosis for hospital admission. Also, data may be difficult
Statistics, 2006). to obtain, such as that gathered by household interviews
from research studies. Morbidity statistics are revised less
frequently because of the difficulty in defining or obtain-
Congenital anomalies remain the leading cause of ing the information.
infant mortality in the United States. Low birthweight In general, however, 56% of children enjoyed excel-
and prematurity are major indicators of infant health and lent health and 28% had very good health as reported
significant predictors of infant mortality (Hoyert et al., in a summary of health statistics for children in 2002
2006). The lower the birthweight, the higher the risk of (Dey et al., 2004). Factors that may increase morbidity
infant mortality; thus, the high incidence of low birth- include homelessness, poverty, low birthweight, chronic
weight (<2,500 g) in the United States plays a factor in health disorders, foreign-born adoption, attendance at
the higher infant mortality rate when compared to other daycare centers, and barriers to health care. For exam-
countries (Guyer et al., 2000). ple, 16% of children live in poverty and have a higher
incidence of disease, limited coordination of health ser-
Childhood Mortality vices, and limited access to health care, except for visits
Childhood mortality is defined as the number of deaths to the emergency department (Federal Interagency Forum
per 100,000 population in children 1 to 14 years of age. on Child and Family Statistics, 2006). Although the
The childhood mortality rate in the United States has poverty rate declined from 22% in 1993 to 17% in 2004,
decreased by about 50% since 1980. In 2003, the mortal- 47% of African-American children live in poverty; these
ity rate for children ages 1 to 4 years was 31 per 100,000 children are particularly at increased risk for illness
and the rate for children ages 5 to 14 years was 17 per (Federal Interagency Forum on Child and Family
100,000 (Child Trends, 2006b). The leading cause of Statistics, 2006).
death in children is motor vehicle accidents. These deaths The most important aspect of morbidity is the degree
can often be prevented through education about the value of disability it produces, which is identified in children as
of using car seats and seat belts, the dangers of driving the number of days missed from school or confined to bed.
under the influence of alcohol and other substances, and In 2002, only 25% of children did not miss any school due
the importance of pedestrian safety. Other causes of child- to illness or injury; however, 6% missed more than 10 days
hood mortality include suicide, homicide, and human of school because of injury or illness (National Center for
immunodeficiency virus infection. Health Statistics, 2004). In the United States during 2002,
The United Nations Childrens Fund survey (2001) 3.4 million children (ages 1 to 21 years) were hospitalized
revealed that in 26 of the richest nations, 40% of all deaths (National Center for Health Statistics, 2006). Figure 1.3
in children age 1 to 14 years result from intentional and shows the major causes of hospitalization by age in the
unintentional injuries. Even as research continues into the United States.
preventable nature of childhood injuries, unintentional Common health problems in children include respi-
injury remains a leading cause of mortality and morbidity ratory disorders, such as asthma; gastrointestinal distur-
in children. These injuries have far-reaching consequences bances, which lead to malnutrition and dehydration; and
for children, families, and society in general. Factors asso- injuries. Twelve percent of children in the United States
ciated with childhood injuries include single parenthood, have asthma, and another 12% of children have respi-
low maternal education level, young maternal age at child- ratory allergies (National Center for Health Statistics,
birth, poor housing, large family size, parental drug or 2004). Diseases of the respiratory system were the major
alcohol abuse, or low support within the family (United cause of hospitalization for children 1 to 9 years of age
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Major Causes of Hospitalization, 2002

Number of hospital discharges, in thousands







14 59 1014 1519

Respiratory disorders Endocrine/nutrition/metabolic/immune disorders

Infectious/parasitic disorders Digestive disorders
Injury Skin/subcutaneous disorders
Mental disorders Pregnancy/childbirth
Genitourinary disorders

Figure 1.3 2002: causes of hospitalization in children.

(National Center for Health Statistics, 2004). As more Environmental and psychosocial factors are now
immunizations become available, common childhood an identified area of concern in children. They
communicable diseases affect fewer children. The track- include academic difficulties, complex psychi-
ing of the leading indicators from Healthy People 2010 atric disorders, self-harm and harm to others, use
provides some positive information related to improving of firearms, hostility at school, substance abuse, HIV/AIDS, and
adverse effects of the media.
childrens health.
One trend in the United States is the increasing num-
ber of children with mental health disorders and related
emotional, social, or behavioral problems. The American
Role of the Pediatric Nurse
The nurses role in relation to morbidity and mortality in
Academy of Pediatrics (2001) estimates that 13 million
children involves educating the family and community
children in the United States have mental healthrelated
regarding the usual causes of deaths, the types of child-
problems. These problems may limit the childs educa-
hood illnesses, and the symptoms that require health
tional success. They also increase the childs risk for sig-
care. The goal is to raise awareness and provide guidance
nificant mental health problems later in life or emotional
and counseling to prevent unnecessary deaths and ill-
problems and possible use of firearms, reckless driving,
nesses in children. The health of children is basic to their
promiscuous sexual activity, and substance abuse during
well-being and development, and the attention given to
adolescence. Overall, these behavioral, social, and edu-
childrens health in this country has slowly increased over
cational problems can interfere with childrens social and
the years. The pediatric nurse is in an excellent position
academic development.
to improve the future health of children.
The incidence of mental health disorders and related
emotional, social, or behavioral problems can range from
Federal Legislation Affecting
5% to 30%, depending on how one defines the problems.
Some experts include poverty, violence, aggression, non- Child Health
compliance, school failure, or adjustment issues related Numerous federal programs have had a major impact on
to divorce and blended families as part of this group of child health. President Theodore Roosevelt began the
problems and identify them as a new group of diseases crusade to assist children and their families, especially the
of children (Altemeier, 2000). Many times insurance poor. The establishment of the Childrens Bureau in
does not reimburse for these problems, leading to addi- 1912 began a period of studying economic and social fac-
tional concerns such as lack of treatment. tors related to infant mortality, infant care in rural areas,
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and other factors related to childrens health. The goal tative units, community care settings, long-term facilities,
of these legislative efforts was to better the standards of homes, and schools. For example, after an acute hospital
care. These actions demonstrate the value that society has stay, a child may be able to complete therapy at home,
placed on the welfare of children. Table 1.3 lists several school, or another community setting and can re-enter
significant pieces of federal legislation and describes their the hospital for short periods for specific treatments or
impact on childrens health. illness. This continuum of care works well for children,
since current statistics indicate that 80% of children
usually receive their medical care in doctors offices, 18%
Contemporary Issues and in clinics, and only 1% in hospitals (National Center for
Trends in Child Health Care Health Statistics, 2006).
Over the past century, the health care system has changed
to recognize the unique qualities and needs of children. Quality-of-Life Issues
This new health care system believes that children have Quality of life is being emphasized in addition to physical
a special value, are vulnerable, and require protection. health. For example, Public Law 108-446 provides for
Health care practices continue to evolve, presenting unique children with disabling conditions to attend regular school
challenges for the new century. Specific changes include: and allows for an extended role of the pediatric nurse to
Health care cost containment serve as school nurse. In addition, technological advances
Preventive care present issues at the end of life. Therefore, pediatric nurses
Continuum of care must expand the scope of health care they provide to
Quality-of-life issues include assessment of psychosocial factors in areas of self-
Worldwide threats to children esteem and independence, making home visits, and using
Differences and uniqueness of children and their families excellent interviewing skills to obtain information that
Significant improvements in the diagnosis and treat- may assist in the care related to these areas.
ment of diseases and disorders
Empowerment of health care consumers Concerns Over World Threats
Reduction in barriers to health care and Safety
Protection of childrens rights
Disasters such as the terrorist attacks of Sept. 11, 2001,
Each of these changes will continue to affect children the killings at Columbine High School, or devastating
and pediatric nursing practice. Societal needs as well as weather events such as Hurricane Katrina can have a
global needs drive these transformations. significant impact on the well-being of children. The
increase in stressors such as war, terrorism, school vio-
Health Care Cost Containment lence, and natural disasters may reduce childrens coping
abilities (Ryan-Wenger et al., 2005) and may lead to alter-
A goal of managed care has been to reduce health care
ations in growth and development (Crane & Clements,
costs, and these efforts have shortened hospital stays for
2005). Children who have experienced these events are
children and increased nurses awareness of the costs of
at risk for posttraumatic stress disorder, behavioral prob-
supplies and services. The overall challenge is to main-
lems, and depression (Wexler et al., 2006). These disas-
tain the quality of care while reducing its cost.
ters may be most difficult for children who have previously
gone through a major loss or already suffer from anxiety or
Preventive Care depression (Davidhizar & Shearer, 2002). Pediatric nurses
Efforts to reduce costs have also led to an increased must be aware of the effects of world threats on children
emphasis on preventive care. Anticipatory guidance is so that they can assess for alterations and intervene to
vital during each health contact with children and their promote security and stability.
families. Education of the family includes everything from
keeping the home safe to preventing illness. These are Diverse Patient Populations
major points of emphasis for pediatric nurses as they
The United States is no longer a melting pot of various
deliver care to children and their families.
cultures and ethnicities but a society in which each dis-
tinct individual brings a diversity and richness that as a
Continuum of Care whole enriches the country. Today, children do not fit
In an effort to become more cost-effective and to provide into a set category or group. Children and families vary
care more efficiently, the nursing care of children now in terms of culture, family structure, socioeconomic sta-
encompasses a continuum of care that extends from acute tus, background, and circumstances, so each child enters
care settings such as hospitals to outpatient settings such the health care system as a unique individual. Pediatric
as ambulatory care clinics, primary care offices, rehabili- nurses must have greater sensitivity to the background of
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Table 1.3 Milestones in Federal Programs in Support of Childrens Health

Date Action Impact

1909 First White House Conference on Care of Addressed the poor working and living conditions
Dependent Children (convened by of many children in the United States
President Theodore Roosevelt)
1912 U.S. Childrens Bureau Established the first governmental agency to
oversee childrens health and environmental
1921 Maternity & Infancy (Sheppard-Towner) Act Provided grants to states to establish maternal
and child health divisions in state health
1930 White House Conference on Child Welfare Produced the Childrens Charter, documenting
Standards and American Academy of the childs need for health, education,
Pediatrics welfare, and protection
1935 Title V of the Social Security Act Established federalstate partnership and
provided Aid to Dependent Families and
Children (ADFC), maternal-child health
services, and child welfare services
1959 14th General Assembly of United Nations Approved the Declaration of the Rights of the
1965 Medicaid Program under Title XIX of Social Provided state block grants to reduce financial
Security Act; special programs such as Child barriers to health care for the poor and special
Health Assessment Program services to pregnant women and young
1966/1974 Women, Infants, Children (WIC) program Provided nutritional supplementation and
education to low-income families; pregnant,
postpartum, and lactating women; and
infants and children up to age 5
1969 U.S. Childrens Bureau moves to Office of Established greater presence for the programs
Health, Education & Welfare (HEW).
1975 Education for All Handicapped Children Act Established federally mandated special
(Public Law 94-142) education in public schools.
Title XX Social Services Provided block grants to daycare, emergency
shelters, counseling, family planning, and other
services for children.
1981 Alcohol, Drug Abuse & Mental Health block Began funding services for children and
grants adolescents with mental health issues
1986 Education of Handicapped Act Amendments Established federal funding for states to create
(Public Law 99-457) statewide, comprehensive, coordinated, and
multidisciplinary early-intervention services for
handicapped infants and toddlers
1990 Omnibus Budget Reconciliation Act Extended Medicaid coverage to all children (6 to
18 years) with family income below 133% of
poverty level
1993 Family & Medical Leave Act (FMLA) Allowed eligible employees to take up to
12 weeks of unpaid leave from their jobs every
year to care for newborns or newly adopted
children or children, parents, or spouses who
have a serious health condition; employee
can return to previous job or a comparable
job with the same conditions
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each child and must be able to provide care that addresses Financial Barriers
the childs uniqueness. Although the poverty rate is declining in this country,
in 2001, 36% of Americas households with children
Improvements in Diagnosis had inadequate physical housing, crowded housing,
and Treatment or housing that cost more than 30% of the household
income (Federal Interagency Forum on Child and Family
Tremendous improvements in technology and biomed-
Statistics, 2006). In addition, the percentage of children
icine have created a trend toward earlier diagnosis and
covered by health insurance was 88%, leaving 12% of chil-
treatment of disorders and diseases. Throughout the 1990s
dren uninsured. However, the majority of insurance cov-
remarkable progress was made linking genetics and patho-
erage since 1999 is not from private health insurance but
physiologic processes. For example, female fetuses with
from government-supported plans (Federal Interagency
congenital adrenal hyperplasia, a genetic disorder result-
Forum on Child and Family Statistics, 2006). Many
ing in a steroid enzyme deficiency that can lead to dis-
children and families do not have insurance, do not have
figuring anatomic abnormalities, are beginning to receive
enough insurance to cover services obtained, or cannot
treatment before birth. In addition, many genetic defects
pay for services.
are being identified so that counseling and treatment may
occur early.
Sociocultural and Ethnic Barriers
As a result of this improved diagnosis and treatment,
Sociocultural and ethnic factors also pose barriers. For
the pediatric nurse now cares for children who have sur-
example, white, non-Hispanic children overall are more
vived once-fatal situations, are living well beyond the usual
likely than African-American and Hispanic children to
life expectancy for a specific illness, or are functioning
be in very good or excellent health. The proportion of
and attending school with chronic disabilities. While pos-
children ages 6 to 18 who are overweight is increasing,
itive and exciting, these advances and trends pose new
but the largest increase is occurring in African-Americans
challenges for the health care community. For example,
and Mexican-Americans (Federal Interagency Forum on
as care for premature newborns improves and survival
Child and Family Statistics, 2006). This is just one exam-
rates have increased, so too has the incidence of long-
ple of the problems that different ethnic groups face in
term chronic conditions such as respiratory airway dys-
relation to health.
function or developmental delays. As a result, pediatric
Lack of transportation, the need for both parents
nurses care for children at all stages along the health
to work, and genetic factors also pose barriers to seek-
illness continuum, from well children, to those who are
ing health care. Knowledge barriers (e.g., lack of under-
occasionally ill, to those with chronic, sometimes dis-
standing of the importance of prenatal care or preventive
abling conditions.
health care), language barriers (e.g., speaking a different
language than the health care providers), or spiritual bar-
Empowerment of Consumers riers (e.g., religious beliefs discouraging some forms of
Due to the influence of managed care, the focus on pre- treatment) also exist.
vention, better education, and technological advances,
people have taken increased responsibility for their own Health Care Delivery System Barriers
health. Parents now want information about their childs The health care delivery system itself can create barriers,
illness, they want to participate in making decisions about such as the cost containment movement. Eighty-five per-
treatment, and they want to accompany their children to cent of employed families with insurance are covered by
all health care situations. As child advocates who value some type of managed health care plan or health mainte-
family-centered care, pediatric nurses can provide such nance organization (HMO). This prospective payment
empowerment and can address specific issues for children system based on diagnosis-related groups (DRGs) limits
and families. Pediatric nurses must respect the familys the amounts of health care the family may receive. This
views and concerns, address those issues and concerns, also includes Medicaid reimbursement. As a result, the
regard the parents as important participants in their trend is to discharge patients as soon as possible and
childs health, and always include the child and family in deliver care in the home or through community-based
the decision-making process. services. The overall plan may improve access to preven-
tive services but may limit the access to specialty care,
Barriers to Health Care which has a major impact on children with chronic or
long-term illnesses.
Even with the federal and state programs available to
assist children and families, barriers to appropriate, cost-
Protection of Childrens Rights
effective, coordinated, and timely health care remain.
Barriers can be financial, sociocultural, or ethnic, or part A number of national and international organizations
of the health care system itself. have been formed in recent years to protect childrens
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rights both in the United States and worldwide. These information (Flores & Dodier, 2005). Nurses can ensure
organizations focus on such issues as violence and abuse, that privacy is maintained when using computerized doc-
child labor and soldiering, juvenile justice, child immi- umentation and an EMR by doing the following:
grants and orphaned children, and abandoned or home-
Always maintain the security of your personal log-in
less childrenall of which can have a negative impact on
information; never share it with other health care
childrens health. A child whose rights are restored and
providers or other persons.
upheld has an improved opportunity for growth, devel-
Always log off when leaving the computer.
opment, education, and health. As advocates for children,
Do not leave patient information visible on a monitor
nurses support policies that protect childrens rights and
screen when the computer/monitor is unattended.
improve childrens health care. Do not use e-mail to communicate confidential patient
Parents and guardians generally make choices about information.
their childs health and services. As the legal custodians
of minor children, they decide what is best for their
child. Chapter 3 provides further information pertain- Referring back to Isabelle Romano and her family
ing to childrens rights in relation to health care deci- from the beginning of the chapter, what trends in child
sion making. health care may have affected them?

Confidentiality Issues in Caring

for Children Use of the Nursing Process
With the establishment of the Health Insurance Portability in Caring for Children
and Accountability Act of 1996 (HIPAA), confidentiality and Their Families
of health care information is now required. The primary
Pediatric nursing involves all the essential components of
intent of the law was to maintain health insurance cover-
contemporary nursing practice. The American Nurses
age for workers and their families when they change or lose
Associations (2004) definition of nursing, the diagno-
jobs. Another aspect of the law requires the Department of
sis and treatment of human responses to actual or poten-
Health and Human Services to establish national stan-
tial health problems, also applies to the practice of
dards for electronic transactions for health information
pediatric nursing. The pediatric nurse makes use of the-
on individuals. The plan also addresses security and pri-
ories and research pertaining specifically to children as
vacy issues involving health information about individu-
well as general nursing concepts and research.
als. For example, no information that clearly identifies a
Nurses must know about current trends in health so
patient can be on public display, including information that they can provide appropriate anticipatory guidance,
on a patients chart. In the pediatric area, information is counseling, and teaching for children and families and
shared only with the legal parents or guardians or individ- can identify high-risk groups so that interventions can be
uals as established in writing by the parents. This law pro- initiated early, before illness or death occurs. The nurse
motes the security and privacy of childrens health can use the information introduced in the above review
information. of trends to develop and deliver a plan of care that is real-
istic and relevant to the childs health and welfare. The
Computer Privacy nurse performs this task using a framework called the
Electronic medical records (EMRs) improve efficiency nursing process.
and accuracy in a variety of clinical settings and may also The nursing process is used to care for the child and
improve the quality of patient care by simplifying the family during health promotion, maintenance, restora-
recording of complete data (Roukema et al., 2006). The tion, and rehabilitation. It is a problem-solving method
EMR allows all health care disciplines to share informa- based on the scientific method that allows nursing care to
tion about a patient (Adams et al., 2003). The computer be planned and implemented in a thorough, organized
can be a powerful tool for improving efficiency and com- manner to ensure quality and consistency of care. The
municating health information in the pediatric arena. In nursing process is applicable to all health care settings
addition to illness data, growth data with appropriate age- and consists of five steps: assessment, nursing diagnosis,
based ranges, medication dosages related to weight, and outcome identification and planning, implementation,
records of immunizations may be communicated across and outcome evaluation.
various settings via computer (Hinman et al., 2004). Pa- 1. Assessment involves collecting data about the child
tient confidentiality and privacy must be maintained as and family and performing physical assessment during
it is with paper documentation. At each point of elec- community-based health services, at admission to an
tronic transmission, patient data must remain secure, acute care setting, at periodic times during the childs
and the HIPAA privacy rule applies to electronic patient hospitalization or care, and during home care visits.
3735-01_UT1-CH01.qxd 6/29/07 3:31 PM Page 18


2. The nurse analyzes the data to make judgments about

the childs health and developmental status. The nurs- scope%2bof%2bpractice%2bv2.pdf.
ing diagnoses that result from this judgment process American Academy of Pediatrics: Committee on Psychosocial
describe health promotion and health patterns that Aspects of Child and Family Health. (2001). The new morbidity
pediatric nurses can manage. revisited: A renewed commitment to psychosocial aspects of pedi-
atric care. Pediatrics, 108, 12271230.
3. The next step in the process involves developing nurs- American Academy of Pediatrics, Committee on Hospital Care, Institute
ing care plans that incorporate goals or expected out- for Family-Centered Care. (2003). Policy statement: family-centered
comes that improve the childs dysfunctional health care and the pediatricians role. Pediatrics, 112(3), 691696.
American Association of Colleges of Nursing. (2005). Commission
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vide for optimal developmental outcomes. The care only practice doctorates with the DNP degree title. Retrieved August
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4. These interventions are implemented, adapted to the practice. Silver Spring, MD: American Nurses Association.
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5. The process is continually evaluated and updated dur- at risk of injury. Journal of Pediatric Nursing, 19(2), 121127.
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Law and more. Retrieved August 27, 2006, from http://www.
Standardized care plans for specific nursing diagnoses
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the data collected during the assessment of the child and Crane, P. A., & Clements, P. T. (2005). Psychological response to
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MULTIPLE CHOICE QUESTIONS 5. The school nurse is planning a screening program.
What items should be included to address issues
1. What is the number-one cause for mortality among related to the new morbidity?
a. Academic difficulties, violence, and other mental
a. Human immunodeficiency virus health issues
b. Congenital anomalies b. The number of children with chronic illness at the
c. Motor vehicle accidents school
d. Low birthweight c. Statistics related to health insurance coverage of
the children
2. The nurse is assessing the vital signs of a child who
is being evaluated in an urgent care center. The d. HIV infection, asthma and respiratory allergy
child is to be seen by the pediatric nurse practitioner testing
(PNP). The mother asks, Why is my child seeing
the PNP and not the doctor? What is the best CRITICAL THINKING EXERCISES
response by the nurse? 1. Detail how the nursing process fits into the frame-
a. The PNP functions similar to the physicians work of pediatric nursing.
assistant, so you should be perfectly at ease.
2. Discuss how the role of the pediatric nurse differs
b. The child may be seen by the physician instead if from the role of the advanced practice pediatric
youd like. nurse.
c. Seeing the PNP is just one more step in having
your child evaluated in this setting. STUDY ACTIVITIES
d. The PNP is an experienced RN with advanced edu- 1. Describe how you will incorporate family-centered
cation in the diagnosis and treatment of children. care into your nursing care in the pediatric clinical
3. When caring for children, how does the nurse best
incorporate the concept of family-centered care? 2. Research a current policy, bill, or issue being debated
a. Encourages the family to allow the physician to on the community, state, or national level pertaining
make health care decisions for the child to child health or welfare. Summarize the major facts
and supporting or opposing issues and present them
b. Uses the concepts of respect, family strengths, in a class presentation or paper.
diversity, and collaboration with family
3. Obtain a standardized care plan from the hospital
c. Advises the family to choose a pediatric provider
unit. Evaluate whether it is based on evidence-based
who is on the childs health care plan
practice. Develop an individualized care plan for a
d. Recognizes that families undergoing stress related child you are caring for. Compare and contrast the
to the childs illness cannot make good decisions two types of care plans.
4. In an effort to control health care costs, what is the 4. The following events were milestones in the support
best recommendation by the nurse? of childrens health. Place them in the correct
a. Shop around to find the most inexpensive health sequence, from oldest to most recent:
insurance plan. _____ a. Declaration of the Rights of the Child
b. Find a job that provides family health insurance approved
at a minimal cost. _____ b. WIC program established
_____ c. U.S. Childrens Bureau established
c. Stress primary prevention, using the health care _____ d. Sheppard-Towner Act passed
system for check-ups. _____ e. Family and Medical Leave Act passed
d. Avoid seeing a health care provider until your _____ f. Education for all Handicapped Children
child becomes ill. Act passed.