Evidence-based Practice
Integrate best current evidence with
clinical expertise and patient/family
preferences and values for delivery of
optimal health care
www.qsen.org
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Who is Betty Neuman’s “Client”?
 An individual, a family, a group or a
community.
 Continuous exchanges between the
client system and the environment
 The model is Wholistic—looks at all
aspects of the client’s five key variables
and how each impacts and is impacted
by the other.
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The Client System According to Neuman
Physiological
Developmental
Stressor
Spiritual
Resource
Psychological
Socio-cultural
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How can we apply NSM to family?
 Family as core
 What are family strengths? (FLD)
 Individual systems as
 Stressors
 Resources
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What makes a family healthy?
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What are risk factors to a
family’s health?
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Potential ND for families
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Decisional conflict
Compromised family coping
Disabled family coping
Ineffective family Therapeutic regimen
management
 Interrupted Family processes
 Readiness for enhanced Family Coping
7
Stressors of Hospitalization
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Fear
Separation – family & peers
Feelings of loss of control
Regression common
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Infant & Toddlers
Separation anxiety (6-30 months)
 3 phases
 Protest:
 Despair:
 Detachment:
F
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Toddlers
 React to any intrusive procedure the
same
 Developing autonomy
 Rituals and routines
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Preschool
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Less obvious separation anxiety
Fears mutilation
Literal interpretation of words
Like familiar routines & rituals
Magical thinking
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School-Age
 Some separation anxiety
 Fears:
 Body disability & death
 Dependence /loss of control
 Ask relevant questions
 Understand cause and effect
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Adolescent
 Separation
 Body & body image
 Control important
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Playroom
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A safe area
NO Intrusive procedures
Not for administering medications.
Therapeutic Play
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Risk for Falls
 Who’s at risk?
 “Humpty Dumpty” ®assessment tool
 Individualized plan of care
 4 siderails up not a restraint, it’s safety.
 Communicate
 Educate
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Risk for Impaired Skin Integrity
 Who’s at risk? (i.e. “risk factors”)
 Braden Q Scale
 Mobility
 Activity
 Sensory Perception
 Moisture
 Friction-Shear
 Nutrition
 Tissue perfusion and oxygenation
16
Pain
 Subjective and personal
 “an unpleasant sensory and emotional
experience…
 Associated with actual or potential tissue
damage”
 QSEN competencies on patient-centered
care: “Demonstrate comprehensive
understanding of the concepts of pain and
suffering, including physiologic models of
pain & comfort.” (www.qsen.org)
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Myths about Pain
 Neonates do not experience pain.*
 Children have no memory of pain.*
 Correct amount of pain for a specific injury or

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procedure*
Parent’s exaggerate.
Children tell you about pain.
Children become addicted to narcotics
easier.*
Narcotics cause respiratory depression easier
in children.*
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Influences on Pain Assessment
 Previous experience with pain
 Developmental level
 Ex: language ability
 Young infants: generalized response – not
able to localize.
 Type of pain – acute or chronic
 Parental response to child's pain
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Behavioral Indicators
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Restless, agitated
Difficult to distract
Irritability
Facial grimacing
Posturing
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Drawing up knees
Anorexia
Lethargy
Sleep disturbances
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Spirituality
Spiritus
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Meaning
Value
Transcendence
Connecting
 Becoming
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Spiritual Assessment
 Religion: system of practices
 Culture – strong influence on
spirituality
 Professional responsibility
 Collaborative
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Spiritual Assessment of Children
 Infant: sense of trust
 Toddler: rituals & routines
 Pre-school: concept of God concrete
 family’s beliefs & customs important
 School-age: good vs evil; help receiving
love, hope, forgiveness
 Adolescents: need for meaning &
purpose in life.
 Listen
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Nursing Dx
 Spiritual Distress
 Risk for Spiritual Distress
 Readiness for enhanced Spiritual
well-being
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Chronic Illness
 McKinney : a chronic illness or
condition is one that is:
 long term
 Does not resolve spontaneously
 Usually without complete cure
 frequently has residual characteristics that
limit ADL &/or require adaptation or
special assistance.
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Needs of Family /Caregiver
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Illness a family experience
Reduce physical & emotional burdens
Provide knowledge & skill
Resources for support
Promote healthy coping
 Help prepare for impending death
26
Caregiver role strain
 Stages of caregiving
 http://www.alsa.org
 Caregiver and care recipient at risk when
caregiver overloaded.
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Perception of Death: Infants &
Toddlers
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Lack understanding of concept
Greatest fear is separation
No sense of time
Reaction to loss of caregiver
28
Perception of Death: preschoolers
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Death temporary & reversible
Magical thinking
Behaviors:
Questions
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Perception of Death:
School-age
 Death irreversible
 By age 10, universality
 Behaviors:
30
Perception of Death: Adolescent
 Death irreversible, universal,
inevitable
 Personal, but distant
 Better understanding illness & death
 Behaviors:
31
Nursing Care
 Be available
 Personal beliefs & expectations
 Time & attention to the dying child.
 Recognize need to talk
 Pain control, oral care, privacy
 Information
 Allow family members time
32
Children with Special Needs
 Visual
 Neurologic
Impairment
 Hearing
Impairment
 Language
 Aphonic
impairment
 Chronic illness
 Congenital disability
 Developmental delay
or disability
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Etiology
 Hereditary- 5%
 Early embryonic alterations
 Early Intrauterine /neonatal
conditions
 Acquired childhood
 Environmental problems
 Unknown
34
35
Congenital Hypothyroidism
 A deficiency of thyroid hormone present
at birth.
 Screening: 2-6 days after birth
 Untreated: severe mental retardation.
 Primary prevention (of negative
outcome): lifelong thyroid supplements
F
36
Down Syndrome
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Small square head
Upward slant to eyes
Flat nasal bridge
Protruding tongue
Hyperflexibility, muscle weakness
Wide space between big & 2nd toes
37
Down Syndrome-higher incidence of:
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Congenital heart malformations
Frequent respiratory tract infections
Thyroid disorders
 incidence of leukemia
Atlantoaxial instability
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Nursing Care
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Early detection
Developmental level
Strengths vs. disabilities
Support parents
Encourage socialization
Appropriate therapy
39
Nursing Care
 Promote optimal growth &
development
 Behavior modification program
 Anticipatory guidance
40
Safety Concerns
 Poor short-term memory
 Learn at a slower rate
 Physical problems w/mobility
41
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The Hospitalized Child