NOTES:

Pos reinforcement- focus on the child’s appropriate behaviors rather than emphasizing the
inappropriate ones. Immediate, consistent, and frequent feedback is crucial. This feedback can
be in the form of smiles, praise, special attention, or rewards such as extra privileges or a
special token or activity. Providing the feedback immediately is important so that the child
learns to associate the feedback with the appropriate behavior, thereby reinforcing the
behavior.

Care of Dying Child-

assess family dynamics to determine plan of care)- Does the parent make eye contact with the
infant? Does the parent anticipate and respond to the infant’s needs? Are the parents
ineffective when dealing with a toddler’s temper tantrum? The plan of care may need to be
adjusted to teach appropriate responses to the infant’s needs or toddler’s behavior. Do the
parents’ comments increase the school-age child’s sense of self-worth? Behavioral observations
are crucial to proper assessment of the family’s needs Does the child look at the
parent/caregiver before answering? Does the child seem relaxed and happy with the
parent/caregiver, or is the child tense? The infant will appear calm and relaxed if his or her
needs are generally met. Crying may occur when the baby is ill or frightened, but may also
indicate discomfort with the parent or caregiver. Use a calm and comforting voice with the
infant. Infants respond well to higher-pitched and soothing voices. When observing the
relationship between the adolescent and the parent/caregiver, does the parent/caregiver allow
the adolescent to speak, or does he or she frequently interrupt? Does the parent/caregiver
contradict what is being said? Observe the body language of the adolescent: does the teen
seem relaxed or tense? Since adolescents are between childhood and adulthood, they have
unique needs. They are experiencing a time of multiple physical and emotional changes, many
of which they cannot control. They need to know that the nurse is interested in what they have
to say (Sass & Kaplan, 2014). The use of open-ended questions allows the adolescent to talk.
“Tell me about your. …” or “What have you noticed about … ?” are comfortable phrases to use
to elicit the information needed. Be aware of your own reactions to the adolescent’s questions
or behaviors, such as nonverbal and facial expressions. Talk with the adolescent using accurate
language that is developmentally and age appropriate.

Atraumatic Care:
Abuse: Elicit the health history, noting the chief complaint and timing of onset. Assess for
appropriateness of the parent–child attachment (often altered in the case of neglect). Pay
particular attention to statements made by the child’s parent or caretaker. Is the history given
consistent with the child’s injury? Identify abuse and violence by screening all children and
families using these questions: • Questions for children: • Are you afraid of anyone at home? •
Who could you tell if someone hurt you or touched you in a way that made you uncomfortable?
• Has anyone hurt you or touched you in that way? • Questions for parents: • Are you afraid of
anyone at home? • Do you ever feel like you may hit or hurt your child when frustrated? Assess
for risk factors in children and parents or caretakers. Risk factors for abuse in children include
poverty, prematurity, cerebral palsy, chronic illness, or intellectual disability. Risk factors for
being abusers in parents or caretakers include a history of being abused themselves, alcohol or
substance abuse, or extreme stress. Determine if the child has a history of hurting self or others
(e.g., cutting), running away, attempting suicide (taking one’s own life), or being involved in
high-risk behaviors. Note inappropriate sexual behavior for developmental age, such as
seductiveness, as this may indicate sexual abuse. Note history of chronic sore throat or
difficulty swallowing, which may occur with forced oral sex or sexually transmitted infections.
Document history of genital burning or itching (associated with sexual abuse). Note nonspecific
symptoms of emotional abuse such as low self-confidence, sleep disturbance, hypervigilance,
headaches, or stomachaches. Take Note! A delay in seeking medical treatment, a history that
changes over time, or a history of trauma that is inconsistent with the observed injury all
suggest child abuse. Observe the parent–child interaction, noting fear or an excessive desire to
please. Note the infant’s level of consciousness. Vigorous shaking in the infant leads to
intracranial hemorrhage and shaken baby syndrome. Inspect the skin for bruises, burns, cuts,
abrasions, contusions, scars, and any other unusual or suspicious marks. Current or healed
scratches or cuts may be found on parts of the body ordinarily covered by clothing in the child
who self-mutilates. Burns that occur in a stocking or glove pattern, or only to the soles or
palms, are highly suspicious for inflicted burns. Injuries in various stages of healing are also
indicative of abuse. Bruises on the chest, head, neck, or abdomen are suspicious for abuse.
Nonambulatory children infrequently experience bruises or fractures. Figure 28.1 shows injury
sites usually indicative of abuse; Figure 28.2 is a photograph of a child who was beaten with an
electric cord. Observe for inflammation of the oropharynx (may occur with forced oral sex).
Inspect the anus and penis or vaginal area for bleeding or discharge (which may indicate sexual
abuse).

Refer suspected cases of neglect or abuse to the local child protection agency. When abusive
activity is identified in the hospital, notify the social services and risk management
departments. In addition to physical or palliative care needed for the injuries, abused children
need to redevelop a sense of trust in adults. Provide consistent care to the abused child by
assigning a core group of nurses. Child abuse requires a multidisciplinary approach that may
include psychological therapy for the child and family. Role model appropriate caretaking
activities to the parent or caregiver. Call attention to normal growth and development activities
noted in the infant or child, as sometimes parents have expectations of child behavior that may
be unrealistic based on the child’s age, leading to the abuse. Praise parents and caretakers for
taking appropriate steps toward getting help and for providing appropriate care to the child.
Refer parents to Parents Anonymous, an organization dedicated to the prevention of child
abuse through strengthening of the family (see for a link to this website). When it is determined
by the child protective team that the child would be in danger to continue living in the current
situation, the child may be removed from the home. If the child is removed from the family
temporarily or permanently, provide the foster or adoptive family with education necessary to
assume the child’s care.

Coping:
The child’s ability to work through a situation will also affect his or her responses to illness and
hospitalization. This ability depends on the age of the child, his or her perceptions of the event,
previous encounters with health care personnel, and support from significant others.

If ignoring or negating the problem- teaching breathing techniques like blowing bubbles,
pinwheels, or party noise makers
If stoicism, passive acceptance- distract with books or games
If acting out- yelling, kicking, screaming, crying- use imagery with tapes of scenarios
If have anger, withdrawal, rejection- give child music
If intellectualizing- teach before events or procedures