Words of Wisdom To Love children means to see them, respect them, and listen to them.
KEY TERMS assent
“do not resuscitate” (DNR) order emancipated
minor
informed consent mature minor minor
morbidity mortality nursing process standard of care
Learning Objectives
Upon completion of the chapter, you will be able to:
1. Compare the past definitions of health and illness to the current definitions.
2. Identify the key milestones in the history of child health.
3. Discuss different methods of measuring child health.
4. Discuss the philosophy of pediatric nursing care.
5. Identify the major roles and functions of pediatric nursing, including the scope of practice and the professional standards for pediatric nurses.
6. Explain the components of the nursing process as they relate to nursing practice for children and their families.
7. Identify ethical concepts related to providing nursing care to children and their families.
8. Describe legal issues related to caring for children and their families.
Isabelle Romano is a 6-year-old girl with cerebral palsy. She was born at 28 weeks’ gestation and is currently
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.
Children are the future of our society. Their overall health has improved, and rates of death and illness in some areas have decreased, but we still must focus on children’s health both in the United States and globally. Habits and practices established in childhood have profound effects on health and illness throughout life. As a society, creating a population that cares about children and promotes preventative and quality health care and positive lifestyle choices is crucial. Pediatric nurses play a major role in this task. They are often “in the trenches” advocating on various issues, drawing attention to the importance of health care for children, encouraging a focus on education and prevention, and assisting families who lack resources or access to health care. This chapter provides an overview of child health, an introduction to pediatric nursing, and a discussion of ethical and legal issues related to caring for children.
CHILD HEALTH
Children are a gift to this world, and, as such, it is society’s responsibility to nurture and care for them. In the past, health was defined simply as the absence of disease; health was measured by monitoring the mortality and morbidity of a group. Over the past century, however, the focus of health has shifted to disease prevention, health promotion, and wellness. The World Health Organization (2011) defines health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.”
The History of Child Health and Child Health Care
In past centuries in the United States, the health of the country was poorer than it is today; mortality rates were high and life expectancy was short. When a flood of immigrants from Europe settled in the eastern American cities, infectious diseases were rampant due to crowded living conditions, inadequate and unsanitary food (e.g., contaminated milk), lack of any childhood immunizations, and harsh working conditions (including child labor). Devastating epidemics of smallpox, diphtheria, scarlet fever, and measles hit children the hardest. During this period, the prevalent view was that children were a commodity; their role was to increase the population and share in the work to be done. This view changed over the years. Public schools were established and the court system began viewing children as minors. The health of children began to receive more and more attention.
As the end of the 19th century neared, doctors and scientists gained a much better understanding of the root causes of illness. This knowledge helped fuel public health efforts such as the campaign for safe milk supply, which lead to pasteurizing milk and to dispensing free milk in some cities (Richter, 2004). Compulsory vaccination programs began during this time. In the late 1800s some states mandated smallpox vaccination as a condition of school attendance. These public health efforts led to a decrease in infant and child deaths (Richter, 2004).
In the late 19th and early 20th centuries, cities became healthier places to live due to urban public health improvements, such as sanitation services and treated municipal water (Richter, 2004). The threat of childhood diseases such as diphtheria, cholera, polio, and yellow fever began to take less of a toll on children (Richter, 2004). The turn of the 20th century brought new knowledge about nutrition, sanitation, bacteriology, pharmacology, medication, and psychology. Penicillin, corticosteroids, and increased numbers of vaccines, which were developed during this time, assisted with the fight against communicable diseases. Thus, by the end of the 20th century, unintentional injuries surpassed disease as the leading cause of death for children older than 1 year (Richter, 2004).
By the end of the 20th century, technological advances had significantly affected all aspects of health care. These trends have led to increased survival rates in children. However, many children who survive illnesses that were previously considered fatal are left with chronic disabilities. For example, before the 1960s, extremely premature infants did not survive because of the immaturity of their lungs. Mechanical ventilation and the use of medications to foster lung development have increased survival rates in premature infants, but survivors are often faced with myriad chronic illnesses such as chronic lung disease (bronchopulmonary dysplasia), retinopathy of prematurity, cerebral palsy, and developmental delay. This increased survival has resulted in a significant increase in chronic illness relative to acute illness as a cause of hospitalization and mortality.
In recent years there have been tremendous improvements in technology and biomedicine. This has created a trend toward earlier diagnosis and treatment of disorders and diseases. Throughout the 1990s remarkable progress was made linking genetics and pathophysiologic processes. For example, female fetuses diagnosed with congenital adrenal hyperplasia, a genetic disorder resulting in a steroid enzyme deficiency that can lead to disfiguring anatomic abnormalities of sexual characteristics, are able to receive treatment before birth. This can lead to fewer anatomic abnormalities and may even allow for normal female genitalia to develop (Mayo Foundation for Medical Education and Research, 2009). In addition, many genetic defects are being identified so that counseling and treatment may occur early.
In addition to improvement in technology and biomedicine, a number of national and international organizations have been formed in recent years to protect children’s rights both in the United States and worldwide. These organizations focus on such issues as violence and abuse, child labor and soldiering, juvenile justice, child immigrants and orphaned children, and abandoned or homeless children—all of which have a negative impact on children’s health. A child whose rights are restored and upheld has an improved opportunity for growth, development, education, and health.
The gains in child health have been huge, but, unfortunately, these gains are not shared equally among all children. Certain health concerns, such as poor nutrition, obesity, infections, lead poisoning, and asthma, affect poor children at higher rates and with greater severity than affluent and middle-class children (National Institute for Health Care Management, 2007). Unintentional injuries continue to be the leading cause of death in children older than 1 year, but children’s health remains threatened by illnesses and other health- related conditions in the 21st century (Centers for Disease Control and Prevention [CDC]/National Center for Health Statistics, 2010). Obesity, environmental toxins, allergies, drug abuse, child abuse and neglect, and mental health problems are among some of the key issues that endanger children’s health today.
Federal Legislation Affecting Child Health
Numerous federal programs have had a major impact on child health. President Theodore Roosevelt began the crusade to assist children and their families, especially the poor. The establishment of the Children’s Bureau in 1912 began a period of studying economic and social factors related to infant mortality, infant care in rural areas, and other factors related to children’s health. The goal of these legislative efforts was to improve the standards of health care. These actions demonstrate the value that society has placed on the welfare of children. Table 1.1 lists several significant pieces of federal legislation and describes their impact on children’s health.
Measurement of Children’s Health Status
In 1979, the U.S. Surgeon General’s Report Healthy People presented an agenda for the nation that identified the most significant preventable threats to health. With the series of updates that followed, including the present one, Healthy People 2020: The Road Ahead, the United States has a comprehensive health promotion and disease prevention agenda that is working toward improving the quantity and quality of life for all Americans (U.S. Department of Health and Human Services, 2010a). Overarching goals are to eliminate preventable disease, disability, injury, and premature death; achieve health equity, eliminate disparities, and improve the health of all groups; create physical and social environments that promote good health; and promote healthy development and behaviors across every stage of life (U.S. Department of Health and Human Services, 2010a). The principle behind this report is that setting national objectives and monitoring their progress can motivate action and change. The report incorporates input from public health and prevention experts; federal, state, and local governments; over 2,000 organizations; and the public in developing health objectives.
There are specific health topic areas, including children’s health topics, which serve as a method for evaluation of progress made in public health. These topic areas also serve as focal points to coordinate national health improvement efforts. For example, one objective under the physical activity topic is to increase the proportion of adolescents who meet current federal physical activity guidelines for aerobic physical activity and for muscle-strengthening activity (U.S. Department of Health and Human Services, 2010a).
Healthy People 2020 monitors four foundation health measures to assess the progress toward promoting health, preventing disease and disability, eliminating disparities, and improving quality of life (see the Healthy People 2020 feature for additional information on these health measures) (U.S. Department of Health and Human Services, 2010a).
HEALTHY PEOPLE 2020 Four Foundation Health Measures 1. General health status
• M easures include:
• Life expectancy
• Healthy life expectancy
• Years of potential life lost
• Physically and mentally unhealthy days
• Self-assessed health status
• Limitation of activity
• Chronic disease prevalence
2. Health-related quality of life and well-being
• M easures include:
• Physical, mental, and social health-related quality of life
• Well-being/satisfaction
• Participation in common activities
3. Determinants of health (a range of personal, social, economic, and environmental factors that influence health status)
• Include:
• Biology
• Genetics
• Individual behavior
• Access to health services
• The environment in which people are born, live, learn, play, work, and age 4. Disparities
• M easures include differences in health status based on:
• Race/ethnicity
• Gender
• Physical and mental ability
• Geography
Healthy People Objectives based on data from http://www.healthypeople.gov. From U.S. Department of Health and Human Services. (2010). HealthyPeople.gov.
Retrieved December 11, 2010, from http://www.healthypeople.gov/2020/about/default.aspx
Measuring a child’s health status is not always a simple process. For example, some children with chronic illnesses do not see themselves as “ill” if their disease is under control. A traditional method of measuring health is to examine mortality and morbidity data.
This information is collected and analyzed to provide an objective description of the nation’s health.
Mortality Data
Mortality is the number of individuals who have died over a specific period. This statistic is generally presented as rates per 100,000 population and is calculated from a sample of death certificates. The National Center for Health Statistics, under the Department of Health and Human Services, collects, analyzes, and disseminates these data.
NEONATAL AND INFANT MORTALITY RATE
Neonatal mortality is the number of infant deaths occurring in the first 28 days of life per 1,000 live births. The infant mortality rate refers to the number of deaths occurring in the first 12 months of life. It also is documented as the number of deaths in relation to 1,000 live births. The infant mortality rate is used as an index of the general health of a country. Generally, this statistic is one of the most significant measures of children’s health. In 2007, the infant mortality rate in the United States was 6.8 per 1,000 live births (U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 2010). See Figure 1.1.
The infant mortality rate varies greatly from state to state as well as between ethnic groups. The United States has one of the highest gross national products in the world and is known for its technological capabilities, but its infant mortality rate is much higher, in some cases double, compared to most other developed nations (MacDorman & Mathews, 2008; U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 2010). The main causes of early infant death in the United States include problems occurring at birth or shortly thereafter, such as prematurity, low birthweight, congenital anomalies, sudden infant death syndrome, respiratory distress syndrome, unintentional injuries, and bacterial sepsis (Stanton
& Behrman, 2007; Xu, Kochanek, Murphy, & Tejada-Vera, 2010).
FIGURE 1.1 Infant and neonatal mortality from 1940 to 2007. (Adapted from Xu, J. Q., Kochanek, K. D., Murphy, S . L., & Tejada-Vera, B. [2010]. Deaths:
Final data 2007. National Vital Statistics Reports, 58(19). Hyattsville, MD: National Center for Health S tatistics. Retrieved February 16, 2011, from http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf
Take Note!
Non-Hispanic African American infants have consistently had higher infant mortality rates compared to other ethnic groups (Xu et al., 2010).
Preterm births and low birthweight are key risk factors for infant death; the lower the birthweight, the higher the risk of infant mortality. The percentage of infants born preterm in the United States is increasing; thus, the impact of preterm-related causes of infant death has increased. This increase may play a role in the plateau in infant mortality rates seen from 2000 to 2007 and in the higher infant mortality rates in the United States compared with other developed countries (U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 2010; Xu et al., 2010).
CHILDHOOD MORTALITY RATE
Childhood mortality is defined as the number of deaths per 100,000 population in children between 1 and 14 years of age. The childhood mortality rate in the United States has decreased by about 50% since 1980 (Child Trends, 2010). In 2007, the mortality rate for children between ages 1 and 4 years was 28.6 per 100,000, with the leading cause of death being unintentional injuries
followed by congenital malformations (CDC/National Center for Health Statistics, 2010). The mortality rate for children ages 5 to 14 years was 15.3 per 100,000, with the leading cause being unintentional injuries followed by cancer (CDC/National Center for Health Statistics, 2010). Other causes of childhood mortality include suicide, homicide, diseases of the heart, influenza, and pneumonia.
Even as research continues into the preventable nature of childhood injuries, unintentional injury, such as motor vehicle accidents, fires, drowning, bicycle or pedestrian accidents, poisoning, and falls, remains a leading cause of mortality and morbidity in children.
These injuries have far-reaching consequences for children, families, and society in general. Risk factors associated with childhood injuries include young age, male gender, low socioeconomic status, parents who are unmarried or single, low maternal education level, poor housing, parental drug or alcohol abuse, or low support within the family. These deaths can often be prevented through education about the value of using car seats and seat belts, the dangers of driving under the influence of alcohol and other substances, and the importance of pedestrian and bicycle safety, fire safety, water safety, and home safety.
Take Note!
In the United States, Native American children, followed by African American children, have the highest unintentional injury death rate (Bishai et al., 2008).
Morbidity Data
Morbidity is the measure of prevalence of a specific illness in a population at a particular time. It is presented in rates per 1,000 population. Morbidity is often difficult to define and record because the definitions used vary widely. For example, morbidity may be defined as visits to the physician or diagnosis for hospital admission. Also, data may be difficult to obtain. Morbidity statistics are revised less frequently because of the difficulty in defining or obtaining the information.
In general, however, 57% of children in the United States enjoyed excellent health and 27% had very good health as reported in a summary of health statistics for children in 2009 (U.S. Department of Health and Human Services, 2010b). Factors that may increase morbidity include homelessness, poverty, low birthweight, chronic health disorders, foreign-born adoption, attendance at day care centers, and barriers to health care. For example, 20.7% of children live in poverty and have a higher incidence of disease, limited coordination of health services, and limited access to health care, except for visits to the emergency department (U.S. Census Bureau, 2010). The overall poverty rate is 14.3%, which is the highest poverty rate since 1994 (U.S. Census Bureau, 2010). However, the poverty rate among African Americans and Hispanics is 25.8% and 25.3%, respectively; these children are particularly at increased risk for illness (U.S. Census Bureau, 2010).
The most important aspect of morbidity is the degree of disability it produces, which is identified in children as the number of days missed from school or confined to bed. In 2009 about one quarter of school children, ages 5 to 17, did not miss any school due to illness or injury; however, approximately 5% missed 11 or more days of school because of injury or illness (U.S. Department of Health and Human Services, 2010b).
Common health problems in children include respiratory disorders, such as asthma; gastrointestinal disturbances, which lead to malnutrition and dehydration; and injuries. Asthma is the leading chronic disease in children, affecting 10% of children in the United States (U.S. Department of Health and Human Services, 2010b). Another 11% of children have respiratory allergies, 10% suffer from hay fever, 5% from food allergies, and 12% from other allergies (U.S. Department of Health and Human Services, 2010b). In 2005 to 2006 diseases of the respiratory system were the major cause of hospitalization for children 1 to 9 years of age, while mental health disorders were the leading cause for children 10 to 14 years of age (U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 2010). In the United States during 2006, there were 4 hospital discharges for every 100 children (age 1 to 21 years) (U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, 2010). The age distribution for inpatient care has changed dramatically over the past 40 years. The percent of inpatients younger than 15 years of age declined from 13% to 7% in 2006 (DeFrances, Lucas, Buie, & Golosinskiy, 2008). Figure 1.2 shows the major causes of hospitalization by age in the United States.
FIGURE 1.2 Causes of hospitalization in children, 2005–2006. (From U.S. Department of Health and Human Services, Health Resources and Services Administration, M aternal and Child Health Bureau. (2010). Child health USA 2010. Rockville, M D: U.S. Department of Health and Human Services. Retrieved M arch 15, 2010, from http://www.mchb.hrsa.gov/chusa10/index.html)
As more immunizations become available, common childhood communicable diseases affect fewer children. The tracking of the leading topics from Healthy People 2020 provides some positive information related to improving children’s health. Improvements have occurred in child health, but morbidity and disability from some conditions, such as asthma, diabetes, attention deficit disorders, and obesity, have increased in recent decades. Also, disparities in health status among US children according to race and socioeconomic status demonstrate widening social inequalities.
One trend in the United States is the increasing number of children with mental health disorders and related emotional, social, or behavioral problems. The American Academy of Pediatrics estimates that 14 million, or 1 in 5, children in the United States have mental health–related problems (American Academy of Pediatrics, n.d.). These problems may limit the child’s educational success.
They also increase the child’s risk for significant mental health problems later in life or emotional problems and possible use of firearms, reckless driving, promiscuous sexual activity, and substance abuse during adolescence. Overall, these behavioral, social, and educational problems can interfere with children’s social and academic development. Often, insurance does not reimburse for these problems, leading to additional concerns such as lack of treatment.
Environmental and psychosocial factors are now an area of concern in children. They include academic difficulties, complex psychiatric disorders, self-harm and harm to others, use of firearms, hostility at school, substance abuse, HIV/AIDS, and adverse effects of the media.
Referring back to Isabelle Romano and her family from the beginning of the chapter, what changes in child health may have affected them?