Pediatric Considerations

Encompasses problems related to childhood through adolescence.

CARE SETTING

Any setting in which nursing contact with children occurs/care is provided.

ASSESSMENT FACTORS (in addition to routine assessments)

Age and gender

Developmental level

Patterns of communication with SOs

Perception of body and its functions: in health and illness

Behavior when anxious, afraid, withdrawn, angry

SIGNIFICANT OTHERS

Nuclear family, extended family

Family developmental cycle

Child’s role in family tasks and functions

Peer group, friends

Socioeconomic

Social class, value system

Social acceptability of current situation

CULTURAL

Ethnic background, heritage, and residence

DISEASE (ILLNESS)

Condition requiring treatment and response of patient/family to situation

Nature of condition—acute, chronic, recurrent

Emotional response to current treatments

Past experience with illness, hospitalization, and healthcare providers

If illness is terminal, what do patient and family expect?

Availability/use of resources

NURSING PRIORITIES

1. Enhance level of comfort/minimize pain.

2. Reduce anxiety/fear.

3. Provide growth-promoting environment for child and parent(s).

4. Prevent/minimize complications.

DISCHARGE GOALS

1. Reports/indicates pain relieved.

2. Child/family dealing appropriately with current situation.

3. Safe environment maintained.

4. Plan in place to meet needs after discharge.

NURSING DIAGNOSIS: Pain, acute May be related to Injuring agents (biological, chemical, physical, psychological) Possibly evidenced by Verbal cues Changes in appetite and eating, sleep pattern Guarded/protective behavior; restlessness, moaning, crying, irritability Autonomic responses DESIRED OUTCOMES/EVALUATION CRITERIA—CHILD WILL: Pain Level (NOC) Report pain is relieved/controlled. Manifest decreased restlessness/irritability. Demonstrate age-appropriate blood pressure, pulse and respiratory rates.

ACTIONS/INTERVENTIONS Pain Management (NIC) Independent Perform routine comprehensive pain assessment, including location, characteristics, onset/duration, frequency, quality, severity (using 0–10 scale, facial expressions, or color scale). Accept child’s description of pain. Investigate changes in frequency or description of pain. Observe for guarding, rigidity, and restlessness. Monitor heart rate, blood pressure (BP) (using correctly sized cuff), and respiratory rate, noting age-appropriate normals/variations. Note location/type of surgical incisions, injuries/trauma. Provide comfort measures, e.g., repositioning, back rub, use of heat/cold. Encourage diversional activities, e.g., TV, music, reading, playing quiet games. Review procedures/expectations and tell patient when it will hurt.

RATIONALE Assessment of children involves observational skills and may require enlisting the aid of parent/caregiver to clarify cues and verbalizations. Pain is subjective and cannot be experienced by others. May signal worsening of condition or development of complications. Nonverbal expressions may signal pain or changes in pain severity. Changes in autonomic responses may indicate increased pain before child verbalizes. Note: Autonomic responses change with acute pain not chronic pain. Influences degree/severity of pain manifestations. Nonpharmacological pain management promotes relaxation, may reduce level of pain and enhance coping. Helps distract patient’s attention from pain and reduces tension. Reduces concern of the unknown and helps patient deal with the reality of the anticipated pain.

ACTIONS/INTERVENTIONS Pain Management (NIC) Collaborative Encourage rest periods. Administer medications as indicated.

RATIONALE Helps reduce fatigue and enhances coping ability. A regular schedule may be required to manage pain effectively. As condition resolves, advancing to a prn schedule may be sufficient.

NURSING DIAGNOSIS; Anxiety/Fear; Coping, ineffective May be related to Situational/maturational crisis; interpersonal transmission/contagion Threat to/change in health/role status Natural/innate origin (e.g., pain, loss of physical support) Separation from support system in potentially stressful situation (e.g., hospitalization, hospital procedures) Learned response (e.g., conditioning, modeling from or identification with others) Possibly evidenced by Excessive psychomotor activity, restlessness, crying, lack of eye contact, withdrawal, sleep disturbances/nightmares Avoidance or attack behaviors; reports of being scared, expressed concerns about changes Social inhibition; shy, withdrawn demeanor DESIRED OUTCOMES/EVALUATION CRITERIA—CHILD WILL: Anxiety Control (NOC) Appear relaxed and report/demonstrate relief from somatic manifestations of anxiety. Engage in age-appropriate activities in absence of parent/primary caregiver without fear or distress noted. Demonstrate a decrease in somatic complaints and physical symptoms when faced with stressful situations (e.g., impending separation from SO).

ACTIONS/INTERVENTIONS Anxiety Reduction (NIC) Independent Establish an atmosphere of calmness, trust, and genuine positive regard. Provide explanations in language appropriate for age. Use terms familiar to child (e.g., care activities—”walk” instead of “ambulate”; procedures—”take a picture” instead of “fluoroscope”).

RATIONALE Trust and unconditional acceptance are necessary for satisfactory nurse/child/family relationship. Calmness is important because anxiety is easily transmitted from one person to another and children are often adept at sensing changes in the moods of adults around them. Accurate communication promotes trust and creates an atmosphere where child feels free to ask questions. Promotes understanding/accurate expectations. Note: Children may become frightened of things they cannot articulate.

ACTIONS/INTERVENTIONS Anxiety Reduction (NIC) Independent Ensure child of his or her safety and security (e.g., listen to child, identify needs, be available for support). Be honest with child and parents, e.g., say “Yes, this will hurt and I will help you manage it.” Refrain from conversations unrelated to child in his or her presence, or failing to include child in conversations regarding him or her. Maintain home routines whenever possible. Encourage child/parents to bring transitional object from home (e.g., familiar toys, special pillow/blanket, pictures/posters, music) if hospitalized. Provide consistency of caregivers. Promote family interaction, i.e., child and family contact. Encourage parents to participate in care planning and care provision. Emphasize importance of staff/family giving verbal prompts in anticipation of absences. Provide honest information about leaving and returning. Help family support child emotionally by being available, Active-Listening, etc. Provide child with choices when possible. Schedule ample time for play and age-appropriate diversions. Use play materials (e.g., puppets, doll house, doctor/nurse kits, fairy tale stories, clay, sand tray). Engage in exercise program as appropriate to situation.

RATIONALE Strange surroundings, changes in routine, and loss of control in situation create anxiety and can be very frightening. Children may believe that situation is punishment for some wrongdoing (imagined or real) on their part. Providing information, being available can be reassuring. Promotes trust and enhances relationship with nurse/caregiver. Ignoring the child/talking about (not to) them or allowing child to overhear partial or unrelated conversations may be very stressful and result in child imagining things that are incorrect. Use of age-appropriate object enhances sense of security when child or adolescent is hospitalized or in treatment setting. Becoming acquainted with caregiver enhances sense of security, facilitates communication, and lessens anxiety. Family involvement in activities promotes continuity of family unit, provides opportunity to learn/practice new skills, and enhances coping skills. Avoidance of these issues increases the likelihood of anxiety responses when separation occurs. Conveys acceptance of child and confidence in ability to cope with situation. Promotes sense of control, demonstrates regard for individual. Promotes normalcy and helps divert attention from situation. Play therapy enables child to explore conflicts, express fears, and release tension. Provides physical outlet for energy, releasing tension. May stimulate release of endorphins, decreasing anxiety and enhancing child’s ability to deal with illness/situation.

ACTIONS/INTERVENTIONS Anxiety Reduction (NIC) Collaborative Administer medications as indicated.

RATIONALE Mild sedation can be effective in ameliorating symptoms of anxiety and enhancing child’s receptiveness to therapeutic regimen.

NURSING DIAGNOSIS: Activity intolerance [specify level] May be related to Generalized weakness; bedrest or immobility Imbalance between oxygen supply and demand Pain, extreme stress Possibly evidenced by Report of fatigue or weakness; exertional discomfort or dyspnea; abnormal heart rate or blood pressure response to activity DESIRED OUTCOMES/EVALUATION CRITERIA—CHILD WILL: Endurance (NOC) Participate in customary activities at desired level. Report absence of fatigue.

ACTIONS/INTERVENTIONS Activity Therapy (NIC) Independent Ascertain child’s usual level of activity, taking into account age and developmental level. Note how present situation is affecting level of activity: immobilization, use of restraints, casts or traction, presence of heart or respiratory impairment, cancer, and treatments. Determine usual sleep/rest routine and bedtime rituals/security objects. Plan care with adequate rest periods. Adjust activities, reduce intensity level or discontinue activities as needed. Assist with activities of daily living(ADLs) and promote exercise as indicated. Promote participation in individually appropriate recreational and diversional activities.

RATIONALE Establishes baseline, in order to determine needed interventions and to assess progress of recovery. Presence of certain disease processes/trauma, treatment modalities have potential for interfering with patient’s usual/desired level of activity. Attempting to maintain usual sleep routines promotes rest and maximizes energy and endurance. Protects patient from injury and enhances ability to participate in activity to improve strength. Enhances sense of well-being.

ACTIONS/INTERVENTIONS Activity Therapy (NIC) Independent Monitor response to activity including BP, pulse, respiratory rate, skin color, and behavior. Collaborative Provide/monitor response to oxygen therapy and medications. Refer to physical/occupational therapists to develop activity and exercise programs.

RATIONALE Helps identify/monitor degree of fatigue and potential for complications. May be needed to improve tolerance to activity, treat underlying cause for fatigue. Helpful in creating a plan to meet individual needs.

NURSING DIAGNOSIS: Growth and Development, risk for delayed Risk factors may include Separation from parents and family, peer group Environmental and stimulation deficiencies; effects of physical disability/confinement Inadequate care, multiple caretakers, prolonged, painful treatments Possibly evidenced by [Not applicable, presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—CHILD WILL: Child Development: (specify age)] (NOC) Perform motor, social, and/or expressive skills typical of age group within scope of present capabilities. Demonstrate weight/growth-stabilization or progress toward age-appropriate size.

ACTIONS/INTERVENTIONS Development Enhancement: Child/Adolescent (NIC) Independent Determine existing factors/condition(s) that could contribute to growth deviation, including familial history of pituitary tumors, Marfan’s syndrome, genetic anomalies, and so forth. Determine child’s birth weight and length and compare present growth. Measure developmental level using age-appropriate tests such as the Denver Developmental Screening Test. Note reported losses/alterations in functional level.

RATIONALE Plan of care will be based on individual factors present, immediacy of threat, and potential long-term complications. Identifies the child’s status compared with other children of the same age. Provides comparative baseline and basis for choosing developmentally appropriate interventions.

ACTIONS/INTERVENTIONS Development Enhancement: Child/Adolescent (NIC) Independent Note chronological age, familial factors (body build/stature). Review expectations for current height/weight percentiles and degree of deviation. Note severity/pervasiveness of situation (e.g., individual showing effects of long-term physical/emotional abuse/neglect versus individual experiencing recent onset situational disruption or inadequate resources during period of crisis or transition). Determine child’s cognitive/perceptual level, e.g., grade level in school, infant ability to roll over or sit unsupported. Note behavioral (e.g., withdrawal/aggression) reaction to environment and stimuli. Determine occurrence/frequency of significant stressful events, losses, separation, and environmental changes (e.g., abandonment, divorce, death of parent/sibling, aging, relocation). Provide information regarding normal growth/ development as appropriate, including pertinent reference materials. Identify realistic goals with child/parents. Discuss actions to take to avoid/minimize preventable complications. Identify nature and effectiveness of parenting/caregiving activities (e.g., inadequate, inconsistent, unrealistic/ insufficient expectations; lack of stimulation, limit setting, responsiveness). Encourage self-care activities as appropriate, e.g., feeding, grooming, play. Collaborative Assist with therapy to treat/correct underlying conditions (e.g., Crohn’s disease, cardiac problems, or renal disease); endocrine problems (e.g., hypothyroidism, type 1 diabetes mellitus, growth hormone abnormalities); genetic/intrauterine growth retardation; infant feeding problems, nutritional deficits. (Refer to ND, Nutrition, imbalanced [specify].)

RATIONALE Aids in determining growth expectations. Problems existing over a long period may have more severe effects and require longer course of treatment to reverse. Illness/injury can lead to a temporary increase in level of dependency/decline in functional level. Although this may not be of major concern for the short term, chronic/recurrent conditions may delay acquisition of important developmental milestones. Lack of resolution or repetition of stressor can have a cumulative effect over time and result in regression in, or deterioration of, functional level. Helps parents understand potential changes in relation to current illness/problem. Provides anticipatory guidance. Increases probability of reaching goals, managing situation more effectively. Assessment of parenting and potential for conflict and negative interaction between parent/caregiver and child identifies interventions needed to maximize care. Promotes independence and maintenance of self-esteem. Illness, hospitalization, treatments, and separation from parents/family have a negative effect on physical/psychological growth and development.

ACTIONS/INTERVENTIONS Development Enhancement: Child/Adolescent (NIC) Collaborative Include nutritionist and other specialists (e.g., physical/ occupational therapist) in developing plan of care. Refer to available community resources as appropriate (e.g., public health programs, such as WIC, medical equipment supplies, nutritionists, substance abuse programs, specialists in endocrine problems/genetics).

RATIONALE Use of multidisciplinary team increases likelihood of developing a well-rounded plan of care that meets child’s special and varied needs. Although acute situations may be readily resolved with limited support and few ill effects, chronic/recurrent conditions require many resources to maximize growth potential of patient and family.

NURSING DIAGNOSIS: Nutrition: imbalanced, risk for less than body requirements Risk factors may include Inability to ingest or digest food or absorb nutrients because of biological, psychological, or economic factors Increased metabolic demands Possibly evidenced by [Not applicable, presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—CHILD WILL: Nutritional Status (NOC) Ingest nutritionally adequate diet for age, activity level, and metabolic demands. Demonstrate stable weight/progressive weight gain toward goal.

ACTIONS/INTERVENTIONS Nutrition Management (NIC) Independent Identify children at risk for malnutrition (e.g., intestinal surgery, hypermetabolic states, restricted intake, prior nutritional deficiencies). Determine ability to chew, swallow, taste; presence of mechanical barriers; or conditions such as lactose intolerance, cystic fibrosis, diabetes, inflammatory bowel diseases. Determine child’s current nutritional status using age-appropriate measurements, including weight and body build, strength, activity level, sleep/rest cycles.

RATIONALE Provides opportunity for early intervention. These factors can affect ingestion and/or digestion of nutrients, and specific dietary choices. Identifies individual nutritional needs and provides comparative baseline.

ACTIONS/INTERVENTIONS Nutrition Management (NIC) Independent Elicit information from child/parent of younger child regarding typical daily food intake, determining foods and beverages normally consumed. Note types of snacks. Discuss eating habits and food preferences (likes and dislikes). Determine psychological factors, cultural or religious desires/influences on dietary choices. Determine whether infant is breastfed or formula-fed and typical pattern of feedings during a 24-hr period. Note type and amounts of solid foods an infant/young toddler eats. Auscultate bowel sounds. Note characteristics of stool (color, amount, frequency, and so on). Discuss with parent what types of candy, other sweets, snacks, and sodas child eats/drinks. Emphasize importance of well-balanced, nutritious intake. Provide information regarding individual nutritional needs and ways to meet these needs within financial constraints. Avoid arguing over food intake. Provide food without comment. Review drug regimen, side effects, and potential interactions with other medications/over-the-counter drugs. Clarify family/caregiver access to/use of resources such as food stamps, budget counseling, WIC, community food bank, and/or other appropriate assistance programs. Collaborative Establish a nutritional plan that meets individual needs incorporating specific food restrictions, special dietary needs. Consult dietitian/nutritional team as indicated. Review indicated laboratory data (e.g., serum albumin/prealbumin, transferring, amino acid profile, iron, blood urea nitrogen [BUN], nitrogen balance studies, glucose, liver function, electrolytes, total lymphocyte count, indirect calorimetry).

RATIONALE Baseline information to determine adequacy of intake. Knowledge of child’s specific likes/dislikes may be helpful in meeting child’s nutritional needs during a time when appetite is suppressed or child has no interest in food. Dietary beliefs, such as vegetarianism, can affect nutritional intake. Ethnic food choices can improve a child’s intake when appetite is poor. Providing usual and typical feedings is important to infant well-being and early growth. Provides information about digestion/bowel function and may affect choice/timing of feeding. Identifies what child eats in a typical day. Provides opportunity for identifying and providing healthy snacks. Although nutritious intake is important, arguing over food is counterproductive. Providing age-appropriate guidelines to children as well as to parents/care provider may help them in making healthy choices. Timing of medication doses, interaction with certain foods can alter effect of medication or digestion/absorption of nutrients. May be necessary to improve child’s intake and/or availability of food to meet nutritional needs. Corrects/controls underlying causative factors (e.g., diabetes, cancer, malabsorption syndrome, and anorexia). Useful in determining individual nutritional needs and therapeutic diet. Indicators of nutritional health and effects of nutrients in organ function.

ACTIONS/INTERVENTIONS Nutrition Management (NIC) Collaborative Refer for dental hygiene/professional care, counseling/psychiatric care, and family therapy as indicated. Refer to home care resources and so on when indicated by specific condition/illness.

RATIONALE May be needed to provide assistance, support, and direction for meeting nutritional needs not only in the present but for achieving long-term goals as well. To assist with initiation/supervision of home nutrition therapy when used.

NURSING DIAGNOSIS: Injury, risk for (specify: trauma, suffocation, poisoning) Risk factors may include Developmental age, cognitive or emotional difficulties Disease or injury process, use of restraining device Use of pharmaceutical agents, narrow therapeutic margin of safety of some drugs, exposure to substances (e.g., tobacco, alcohol, street drugs) Lack of safety or drug education/precautions Immune/autoimmune dysfunction, malnutrition, exposure to nosocomial agents Possibly evidenced by [Not applicable, presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—CHILD WILL: Risk Control (NOC) Be free of injury. CAREGIVER/PARENT—WILL: Verbalize understanding of individual risk factors that contribute to possibility of injury. Take steps to correct identified risks and protect patient from hazards.

ACTIONS/INTERVENTIONS Risk Surveillance (NIC) Independent Identify individual risk factors, e.g., airway patency, therapeutic use of potentially toxic medications, invasive lines/procedures, exposure to latex products, impaired neurological status, seizure activity, exposure to safety hazards, immobility/use of restraints, presence of fractures, malnutrition, fluid deficit/excess. Handle infant/child gently. Release restraints periodically per protocol. Provide appropriate level of supervision.

RATIONALE Provides opportunity to modify environment/eliminate factors that place child at risk. Skin/tissues are more fragile and at greater risk for damage. Permits monitoring of patient’s well-being, allows for timely intervention.

ACTIONS/INTERVENTIONS Risk Surveillance (NIC) Independent Initiate safety precautions as individually appropriate, e.g., bed in low position, padded side rails, infection precautions, medications in childproof containers, etc. Have age-appropriate equipment available, e.g., properly sized BP cuffs, IV catheters, airway adjuncts, and oxygen mask/hood; suction equipment, ventilator bag, low-flow IV pump, warming devices. Monitor medication administration closely, especially dosage measurements and conversions. Use pediatric concentrations of medications when available. Ascertain recurrent exposure to latex gloves, catheters/tubing, etc. Note history of allergies, eczema. Review home situation for safety hazards. Ascertain parent/caregiver knowledge of safety needs, injury prevention in home setting. Provide bibliotherapy/written resources for parent/caregiver and child, including information about smoking, substance use, and safer sex practices. Encourage parent/caregiver to learn cardiopulmonary resuscitation (CPR) and individually appropriate procedures or emergency interventions/responses, such as carrying an EpiPen. Collaborative Refer to community education programs and resources as indicated.

RATIONALE Preventing injuries and complications is a prime responsibility of parents and caregivers. Prevents treatment-related injuries and ensures availability of life-saving equipment. Provides for effective therapeutic management, prevents overdose, and reduces risk for toxic reactions. Repeat exposure increases risk of developing sensitivity/adverse reaction to latex products. Promotes a safe environment. Provides information for later review and self-paced learning. Being prepared for emergencies promotes confidence for adults and children in their own ability to deal with their situation. Can provide additional opportunities for improving parenting skills, obtaining necessary equipment.

NURSING DIAGNOSIS: Fluid volume, risk for imbalance Risk factors may include Lack of adequate intake, increase in fluid needs, e.g. fever Rapid/sustained loss, e.g., hemorrhage, burns, vomiting, diarrhea, fistulas Rapid/excessive fluid replacement Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—CHILD WILL: Hydration (NOC) Demonstrate adequate fluid balance as evidenced by stable vital signs, palpable pulses/good quality, normal skin turgor, moist mucous membranes; individual appropriate urinary output; lack of excessive weight fluctuation (loss/gain), and absence of edema. PARENT/CAREGIVER WILL: Verbalize understanding of child’s fluid needs. Promote adequate age-appropriate fluid intake.

ACTIONS/INTERVENTIONS Fluid Management (NIC) Independent Note potential sources of fluid loss/intake, presence of conditions such as diabetes, burns, use of total parenteral nutrition (TPN), etc. Note child’s age, size, weight, and cognitive abilities. Monitor vital signs, mucous membranes, weight, skin turgor, breath sounds, urinary and gastric output, amount of blood draws, hemodynamic measurements. Review child’s intake of fluids. Determine child’s normal pattern of elimination, and whether child is toilet trained. Determine whether child has problems with urination, such as urine retention, bed-wetting, burning, holding. Note uses of drainage devices such as nasogastric tube, wound drain; use of laxatives, enemas, and suppositories.

RATIONALE Causative/contributing factors for fluid imbalances. Affects ability to tolerate fluctuations in fluid level and ability to respond to fluid needs. Indicators of hydration status. Note: Hypotension indicative of developing shock may not be readily observed in pediatric patients until very late in the clinical course. Children often do not take in enough oral fluids to meet hydration needs. Provides information for baseline and comparison. If child is in diapers, output may be determined by weighing diapers. Evaluation of these issues is important for determining cause and treatment of underlying problem. May increase fluid and electrolyte losses.

ACTIONS/INTERVENTIONS Fluid Management (NIC) Collaborative Administer IV fluids via control device/pump. Replace electrolytes as indicated by oral route whenever possible. Monitor laboratory results, e.g., hemoglobin/hematocrit (Hb/Hct), BUN, urine osmolality/specific gravity. Arrange with laboratory to combine common tests and draw smallest amount of blood that is necessary to perform required tests.

RATIONALE Because smaller volumes are administered, close monitoring and regulation is required to prevent fluid overload while correcting fluid balance. Oral replacement solutions formulated for children are often safer and better tolerated when given orally if time/condition allows. Indicators of adequacy of hydration/therapeutic interventions. Excessive/repetitive blood draws may markedly reduce Hb/Hct levels in pediatric patients.

NURSING DIAGNOSIS: Family Processes, interrupted/Parenting, impaired May be related to Situational transition and/or crises (illness, trauma, disabling/expensive treatments); shift in health status of a family member Developmental transition; modification in family finances, family social status Lack of/ineffective role model; lack of support between or from significant other(s) Interruption in bonding process; lack of appropriate response of child to parent/parent to child Lack of knowledge; unrealistic expectation for self, child, partner Possibly evidenced by Changes in communication patterns; participation in decision making, expressions of conflict within family Frequent verbalization of disappointment in child, resentment toward child; inability to care for/discipline child Lack of parental attachment behaviors Growth and/or developmental lag in child DESIRED OUTCOMES/EVALUATION CRITERIA—PARENT/CAREGIVER WILL: Family Functioning (NOC) Verbalize positive feelings about parenting abilities. Be involved in problem-solving solutions for current situation. Develop skills to deal with present situation. Strengthen parenting skills.

ACTIONS/INTERVENTIONS Family Support (NIC) Independent Determine existing situation and parental perception of the problems, noting presence of specific factors such as psychiatric/physical illness, disabilities of child or parent. Identify developmental stage of the family (e.g., first child/new infant, school-age/adolescent children, stepfamily.) Determine cultural/religious influences on parenting expectations of self/child, sense of success/failure. Assess parenting skill level, considering intellectual, emotional, and physical strengths and limitations. Note attachment behaviors between parent and child(ren), recognizing cultural background. Encourage parent(s) to hold and spend time with child, particularly newborn/infant. Observe interactions between parent(s) and child(ren). Note presence/effectiveness of extended family/support systems. Stress the positive aspects of the situation, maintaining a positive attitude toward parent’s capabilities and potential for improving. Involve all members of the family in learning activities. Encourage parent(s) to identify positive outlets for meeting own needs (e.g., going to a movie or out to dinner). (Refer to Self-Esteem, situational/chronic low). Discuss issues of step-parenting and ways to achieve positive relationships in a blended family.

RATIONALE Identification of the individual factors will aid in focusing interventions and establishing a realistic plan of care. These factors affect how family members view current problems and choices of solutions. This information is crucial to helping the family identify and develop a treatment plan that meets its specific needs, enhancing likelihood of success. Identifies areas of need for further education, skill training, and factors that might interfere with ability to assimilate new information. Lack of eye contact and touching may indicate bonding problems. Failure to bond effectively is thought to affect subsequent parent-child interaction. Identifies relationships, communication skills, and feelings about one another. Provides role models for parent(s) to help them develop own style of parenting. Note: Role models may be negative and/or controlling. Helping parent(s) to feel accepting about self and individual capabilities will promote growth. Learning new skills is enhanced when everyone is participating and interacting. Parent often believes it is “selfish” to do things for own self, that children are primary. However, parents are important, children are important, and the family is important. As a rule, when parents take care of themselves, their coping abilities are enhanced and they are better parents. Blending two families can be a very demanding task, and preconceived ideas can be counterproductive.

ACTIONS/INTERVENTIONS Family Support (NIC) Collaborative Refer to resources such as books, classes, support groups.

RATIONALE Providing information/role models can help people learn to negotiate and develop skills for parenting and living together.

NURSING DIAGNOSIS: Body Temperature, risk for imbalanced Risk factors may include Extremes of age/weight, dehydration, exposure to cold/hot environments, illness/trauma affecting temperature regulation Possibly evidenced by [Not applicable; presence of signs/symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—CHILD WILL: Thermoregulation (NOC) Regain/maintain appropriate body temperature for age/size. PAENT/CAREGIVER WILL: Risk Control (NOC) Provide proper environmental controls and safeguards.

ACTIONS/INTERVENTIONS Temperature Regulation (NIC) Independent Note conditions promoting fevers. Measure/monitor child’s temperature, using properly functioning thermometer. Discuss variables in temperature measurements for age of child and where temperature is measured.

RATIONALE Infection, inflammation, hot environment, dehydration. All children experience fever at some time. Inaccurate measurement can result in inappropriate treatment. Knowledge of normal ranges for age of child (e.g., newborn through adolescent) is critical to knowing when a fever requires treatment. Temperature may be measured orally, rectally, and at the axillary space, with rectal measurement being on average approximately one degree higher than oral, and axillary being one degree lower than oral.

ACTIONS/INTERVENTIONS Temperature Regulation (NIC) Independent Be aware of heat loss related to age/body mass. Observe for seizure activity. Provide safety precautions as indicated. Adjust bedclothes and linens, environment. Apply cool cloth to head, bathe in lukewarm bath. Collaborative Administer antipyretics as indicated.

RATIONALE Newborn is more vulnerable to heat loss than older child because of body surface area, higher metabolic rate, and sensitivity to environmental conditions. Higher fevers may trigger febrile seizures in susceptible children. Limiting linens, use of room fan, etc. can help lower body temperature. Some degree of fever may be useful for fighting infection; however, excessive levels may have adverse effects and require intervention.

NURSING DIAGNOSIS: Health Maintenance, risk for ineffective Risk factors may include Unachieved developmental tasks Perceptual or cognitive impairment Ineffective individual/family coping Lack of material resources, psychosocial supports Possibly evidenced by [Not applicable; presence of signs/symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—PARENT/CAREGIVER WILL: Health Seeking Behavior (NOC) Identify necessary health maintenance activities. Verbalize understanding of factors contributing to current situation. Develop plan to meet specific needs.

ACTIONS/INTERVENTIONS Health System Guidance (NIC) Independent Explore with parents how child’s health status is maintained, e.g. nutrition, exercise, sleep/rest, immunization status, environmental issues such as childcare setting, homelessness.

RATIONALE Identifies strengths, may reveal problems requiring immediate intervention.

ACTIONS/INTERVENTIONS Health System Guidance (NIC) Independent Discuss mother’s health status when pregnant with child, e.g., exposure to toxic agents, substance use, and complications of pregnancy/birth. Ascertain frequency of routine health exams, including eye and dental care, monitoring by primary care provider, and immunizations. Note desire/level of ability to meet health maintenance needs, as well as self-care ADLs. Develop plan with parent/caregiver for child’s care. Provide time to listen to concerns of parent/caregiver. Provide anticipatory guidance for periods of wellness, and identify ways parent can adapt when progressive illness/ long-term health problems occur. Provide for communication and coordination between the healthcare facility team and community healthcare providers. Monitor adherence to prescribed medical regimen. Provide information about individual healthcare needs. Identify signs and symptoms requiring further evaluation and follow-up. Collaborative Make referral as needed for community support services (e.g., homemaker/home attendant, skilled nursing care, well-baby clinic). Refer to social services as indicated. Arrange for hospice services if needed.

RATIONALE Helps identify issues that may arise in child’s future health status. Identifies areas of child’s healthcare that may be lacking, and provides parents with information about areas that need to be monitored/care provided for optimum health. Care providers and children who can provide much of their own care may have areas of need, either because of illness or other stressors. Allows for incorporating existing strengths or limitations, assistance in adapting and organizing care as necessary. Long-term care for chronically ill child or acute care to a child can be very challenging to parent’s physical, emotional, and financial resources. Information and support is vital for maintaining and managing effective health practices. Promotes continuation of care. Plan of care can be altered as needed. Provides for prevention of complications and early intervention in times of illness. Provides for childcare and parental support. May need assistance with financial, housing, or legal concerns. May be indicated when illness is terminal.