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1
chapter
Perspectives of Pediatric Nursing

Key TERMS Learning OBJECTIVES

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
health has improved, and rates of death and illness in
some areas have decreased, but we still must focus on
childrens health both in the United States and globally.
Habits and practices established in childhood have pro-
found effects on health and illness throughout life. As a
society, creating a population that cares about children
and promotes solid health care and 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, and dealing with lack of resources, lack of
access to health care, and the focus on acute care rather
than education and prevention.
This chapter provides an overview of pediatric nurs-
ing, including important philosophical beliefs, the health
status of children, and contemporary issues and trends
in childrens health care. The chapter concludes with a
description of how pediatric nurses use the nursing process
to care for children and their families.
Introduction to
Pediatric Nursing
Pediatric nursing is the practice of nursing involved in the
health care of children from infancy through adolescence.
In the United States the number of children under age
18 years is approximately 73.5 million, accounting for
25% of the population (Child Trends, 2006a). The defin-
ition of nursing, the diagnosis and treatment of human
responses to actual or potential health problems, also
applies to the practice of pediatric nursing (American
Nurses Association, 2004). However, the overall goal of
pediatric nursing practice is to promote and assist the child
in maintaining optimal levels of health while recognizing
the influence of the family on the childs well-being. This
goal involves the practice of health promotion and disease
prevention as well as assisting with care during disease or
illness.
Philosophy of Pediatric Nursing Care
Children need accessible, continuous, comprehensive,
coordinated, family-centered and compassionate care that
focuses on their changing physical and emotional needs
(Deal et al., 1998). Pediatric nurses provide this care by
focusing on the family, providing atraumatic therapeutic
care, and using evidence-based practice. These three con-
cepts represent an overarching philosophy of pediatric
nursing care and are integrated throughout the chapters
of this text.
6
Family-Centered Care
Parents or guardians play a critical role in the health and
well-being of children. Providing care through a family-
centered approach leads not only to better outcomes
but also to better consumer satisfaction. The family is
the childs primary source of support and strength. The
knowledge that the family has about a childs health or
illness is vital. Family-centered care involves families
and caregivers working in a collaborative partnership to
determine goals and plans for health care (Woodside et al.,
2001). It works well in all arenas of health care, from
preventive care of the healthy child to long-term care of
the chronically or terminally ill child. Family-centered
care enhances parents and caregivers confidence in
their own skills and also prepares children and young
adults for assuming responsibility for their own health
care needs. Key elements of family-centered care include
demonstrating interpersonal sensitivity, providing gen-
eral health information, communicating specific health
information, and treating people with respect (Woodside
et al., 2001).
According to the American Academy of Pediatrics
(2003), family-centered care focuses on several core
principles:
Respect for the child and family
Recognition of the effects of cultural, racial, ethnic, and
socioeconomic diversity on the familys health care
experience
Identification of and expansion of the familys strengths
Support of the familys choices related to the childs
health care
Maintenance of flexibility
Provision of honest, unbiased information in an affirm-
ing and useful approach
Assistance with the emotional and other support the
child and family require
Collaboration with families
Empowerment of families
When childrens health care is provided through a
family-centered approach, many positive outcomes are
possible. Anxiety is decreased. Children are calmer and
pain management is enhanced. Recovery times are short-
ened. Families confidence and problem-solving skills are
improved. Communication between the health care team
and the family is also improved, leading to greater satis-
faction for both health care providers and health care con-
sumers (families). Ways to increase collaboration between
the family and the health care team may include a family
advisory board, newsletter, or parent resource notebooks.
Methods for increasing communication between the health
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care team and the family may include the use of mailboxes
or dry-erase boards for updating the daily plan of care,
including the parents participation in rounds, or through
a daily assessment of health status by the child or family.
Vigilant parents are committed to their childs care.
They demonstrate resilience in their ability to make it
through the emotional upheaval associated with an illness.
They may experience changes in their other relationships
as well as in the relationships they have with health care
providers (Dudley & Carr, 2004). Research has shown
that families desire and appreciate nurses sensitivity to the
inconveniences that their childs illness may impose upon
the family (Miceli & Clark, 2005). Families want to have
their emotional and spiritual needs addressed, their con-
cerns attended to, and their accommodations improved
(when the child is hospitalized) (Fig. 1.1). They want to be
included and valued in the health care decision-making
process (Miceli & Clark, 2005) and to establish rapport
with the nurses caring for their child (Espezel & Canam,
2003). Practicing true family-centered care may empower
the family, strengthen family resources, and help the child
feel more secure throughout the process.
How could family-centered care help the Romano
family described at the beginning of the chapter?
Atraumatic Care
Children may undergo a wide range of interventions,
many of which can be traumatic, stressful, and painful.
The various settings in which the child receives care can
be scary and overwhelming to the child and family, and
interacting with various health care personnel in various
settings can cause anxiety. Thus, another major com-
ponent of the pediatric nursing philosophy is providing
atraumatic care. This is a philosophy of providing
Figure 1.1 Providing a comfortable area for the parent
to rest is an important component of family-centered care.
Chapter 1 PERSPECTIVES OF PEDIATRIC NURSING 7
therapeutic care through interventions that minimize
physical and psychological distress for children and their
families. Pediatric nurses must be vigilant for any situa-
tion that may cause distress and must be able to identify
potential stressors. They take steps to minimize separation
of the child from the family, and the nursing care they
provide decreases the childs exposure to stressful situa-
tions and prevents or minimizes pain and bodily injury.
Chapter 3 provides additional information related to
atraumatic care.
Evidence-Based, Case Management Care
Modern pediatric health care focuses on an interdiscipli-
nary plan of care designed to meet the childs physical,
developmental, educational, spiritual, and psychosocial
needs. Nurses coordinate the implementation of this
interdisciplinary plan in a collaborative manner to ensure
continuity of care that is cost-effective, quality-oriented,
and outcome-focused. This type of care is termed case
management. Box 1.1 highlights the components of
case management. When the nurse functions as a case
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.
Case management uses a system of plans, often
referred to as critical paths, that are derived from stan-
dards of care with a multidisciplinary approach that
produces clinical practice guidelines. Implementing this
philosophy leads to outcomes that are expected as a result
of delivery of that care and may lead to future payment
tied to the practice guidelines. The Agency for Health
Care Policy and Research and the National Guidelines
Clearinghouse maintain current clinical practice guide-
lines. Clinical practice guidelines are rooted in evidence-
based practice.
Evidence-based practice involves the use of
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
COMPONENTS OF CASE MANAGEMENT
Collaborative process involving assessment, planning,
implementation, coordination, monitoring, and
evaluation
Advocacy, communication, and resource management
Patient-focused comprehensive care across a
continuum
Coordinated care with an interdisciplinary approach
Commission for Case Management Certification. (n.d.).
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8 Unit 1 INTRODUCTION TO PEDIATRIC NURSING
decisions about the care of children and their families.
Evidence-based practice may lead to a decrease in varia-
tions in care while at the same time increasing quality.
An example of evidence-based practice is the current
pediatric blood pressure measurement recommenda-
tions. Due to the difficulty with obtaining consistent and
appropriate blood pressure measurements in children,
as well as the increase in blood pressure in children over
the past several years, the National High Blood Pressure
Education Program Working Group published recom-
mendations for routine blood pressure measurement in
children. The guidelines address factors affecting the
childs blood pressure, use of auscultatory or oscillomet-
ric measurement devices, appropriate blood pressure
cuff size and application, and site of blood pressure
measurement. The goal is to permit early screening and
identification of children at risk for hypertension (Schell,
2006). Recent studies provide evidence that nurse-led
interventions improve overall health and management of
chronic illness.
The Evolution of Pediatric Nursing
in Relationship to Child Health
The historical perspective of pediatric nursing includes
the devastating epidemics that affected children in the
past, societal trends in our country, changes in the health
care system, and federal and state regulations. This dis-
cussion will provide a brief overview of the evolution of
pediatric nursing. By reviewing these historical events,
pediatric nurses can gain a better understanding of the
current and future status of pediatric nursing.
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 because of the
crowded living conditions, inadequate and unsanitary
food (e.g., contaminated milk), and harsh working con-
ditions (including child labor). Devastating epidemics of
smallpox, diphtheria, scarlet fever, and measles hit chil-
dren 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, as public schools were
established and the court system began viewing children
as minors.
Over time, changes occurred that focused attention
on the health of children. In 1870, the first pediatric
professorship for a physician was awarded in the United
States to Abraham Jacobi, who is known as the father of
pediatrics. For the first time, the medical community
realized there was a need to provide specialized training
and education about children to health care providers.
In 1889 Jacobi established milk distribution centers,
which provided mothers with uncontaminated milk for
their sick infants and also stressed the importance of
pasteurization. This one intervention led to a decrease
in infant deaths.
In the early 1900s, Lillian Wald established the Henry
Street Settlement House in New York City; this was
the start of public health nursing. This facility provided
medical and other services to poor families. These ser-
vices included home nurse visits to teach mothers about
health care.
Health care personnel were trained to take care of
children in hospitals, but parents of hospitalized chil-
dren were discouraged from visiting to prevent the spread
of infection. Restricting parents from being involved in
their childs care was also thought to minimize emo-
tional stress.
Nursing in public schools began in 1902 with the
appointment of Lina Rogers as a full-time public school
nurse in New York. A professional course in pediatric
nursing was started in the early 1900s at Teachers College
of Columbia University.
The turn of the 20th century brought new knowledge
about nutrition, sanitation, bacteriology, pharmacology,
medication, and psychology. Penicillin, corticosteroids,
and vaccines, which were developed during this time,
assisted with the fight against communicable diseases. 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 fos-
ter lung development have increased survival rates in pre-
mature infants, but survivors are often faced with a
myriad of chronic illnesses such as bronchopulmonary
dysplasia, retinopathy of prematurity, cerebral palsy, or
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 the 1960s, changes in the health care delivery sys-
tem and shifts in the populations health status led to the
development of the nurse practitioner role. The 1970s
brought cost-control systems from the federal govern-
ment because of rapid escalation of health care expendi-
tures. In addition, the considerable changes in the U.S.
health care system in the 1980s have affected pediatric
nursing and child health care. The emphasis of care is on
quality outcomes and cost containment. Some of these
changes brought more advanced practice nurses into the
field of pediatrics.
Finally, in the 1980s, the Division of Maternal-Child
Health Nursing Practice of the American Nurses Asso-
ciation developed maternal-child health standards to
provide important guidelines for delivering nursing care.
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The Pediatric Nursing Role
and Health Care Settings
The professional pediatric registered nurse provides three
levels of health care services: primary, secondary, and
tertiary. The primary level of service focuses on health
promotion and illness prevention and typically occurs in
the community. The pediatric nurse may provide this
level of service in a variety of settings, including health
clinics or offices, schools, homes, daycare centers, and
summer camps. The secondary level of service is gener-
ally provided in acute treatment centers that focus on
the diagnosis and treatment of illness. The pediatric
nurse functions at the secondary level when working in
settings such as general pediatric hospital units, pediatric
intensive care units, emergency departments, ambula-
tory clinics, surgical centers, and psychiatric centers.
The tertiary level of service involves restorative, rehabil-
itative, or quality-of-life care and takes place in rehabil-
itation centers or hospice programs or through service
with a home health agency.
Although nurses in each setting might have specific
roles and responsibilities, they all share universal roles
that can be identified as primary and secondary roles, the
differentiated practice role, and the advanced practice
role. Within all of these roles, the nurse ensures that com-
munication with the child and family is based on the
childs age and developmental level.
The primary role of the pediatric nurse is to provide
direct nursing care to children and their families, being
an advocate, educator, and manager. As a child and
family advocate, the nurse safeguards and advances the
interests of children and their families by knowing their
needs and resources, informing them of their rights and
options, and assisting them to make informed decisions.
In the primary role of educator, the nurse instructs and
counsels children and their families about all aspects of
health and illness. The pediatric nurse uses and integrates
research findings to establish evidence-based practice,
managing the delivery of care in a cost-effective manner
to promote continuity of care and an optimal outcome for
the child and family.
In the secondary role, the pediatric nurse serves
as a collaborator, care coordinator, and consultant.
Collaborating with the interdisciplinary health care
team, the pediatric nurse integrates the childs and fam-
ilys needs into a coordinated plan of care. In the role of
consultant, the pediatric nurse ensures that the childs
and familys needs are met through such activities as
support group facilitation or working with the school
nurse to plan the childs care.
In the differentiated practice role, the nurses experi-
ence, competence, and educational level determine the
nurses role. For example, a clinical coordinator typically
holds a baccalaureate degree and fills a leadership role
in a variety of settings. The case manager, also usually a
Chapter 1 PERSPECTIVES OF PEDIATRIC NURSING 9
baccalaureate-prepared nurse, is responsible for integrat-
ing care from before admission to after discharge.
The advanced practice role is an expanded nursing role
that requires additional education and skills in the assess-
ment and management of children and their families. The
pediatric nurse practitioner (PNP) has a masters degree
and national certification in the specialty area. The PNP is
an independent and autonomous practitioner, managing
children in primary, acute, or intensive care or providing
long-term management of the child with a chronic illness.
The clinical nurse specialist has a masters degree and pro-
vides expertise as an educator, clinician, or researcher,
meeting the needs of staff, children, and families.
Various changes in the health care system continue
to encourage the development of the advanced practice
role for pediatric nursing. Table 1.1 describes the func-
tions of the family nurse practitioner, the neonatal nurse
practitioner, and the pediatric nurse practitioner as well
as the pediatric clinical specialist and case manager.
The American Academy of Colleges of
Nursing (2005) has recommended that
nurse practitioner education be moved
from the masters to the doctoral level
by the year 2015.
Standards of Care and Performance
in Todays Environment
In any role, the professional pediatric nurse is held
accountable for nursing actions that adhere to the stan-
dards of care. A standard of care is a minimally
accepted action expected of an individual of a certain
skill or knowledge level and reflects what a reasonable
and prudent person would do in a similar situation.
Professional standards from regulatory agencies, state
or federal laws, nurse practice acts, and other specialty
groups regulate nursing practice in general. The American
Nurses Association (ANA) and the Society of Pediatric
Nurses (SPN) have formulated specific standards of care
and professional performance for pediatric clinical nursing
practice (Table 1.2). These standards are tools that deter-
mine if care constitutes adequate, effective, and acceptable
nursing practice. They also serve as guides and legal mea-
sures for this special area of practice. These standards pro-
mote consistency in practice, provide important guidelines
for care planning, assist with the development of outcome
criteria, and ensure quality nursing care. The ANA-SPN
standards specify what is adequate and effective for gen-
eral pediatric nursing and promote consistency in practice.
Childrens Health Status
Since children are a gift to this world, it is societys
responsibility to nurture and care for them. Health used
to be defined simply as the absence of disease; health was
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10 Unit 1 INTRODUCTION TO PEDIATRIC NURSING

Table 1.1 Advanced Practice Roles for Pediatric Nurses

Role Function

Pediatric nurse practitioner (PNP)
Family nurse practitioner (FNP)
Neonatal nurse practitioner (NNP)
Clinical nurse specialist
specialist in specific pediatric
areas, such as pediatric
oncology clinical nurse specialist
Case managerspecialist in
pediatric hospitals and other
pediatric health care settings
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)
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)
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)
Serves as a consultant in a particular area of expertise
Researches, educates, and serves as a role model for expert nursing care
in specialty field (National Association of Clinical Nurse Specialists, n.d.)
Supervises a group of patients from the time they enter a health care
setting until they are discharged from the setting
Monitors effectiveness, cost, and patient satisfaction

measured by monitoring the mortality and morbidity of a
group. Over the past century, though, the focus of health
has shifted to disease prevention, health promotion, and
wellness. The World Health Organization (2006) defines
health as a state of complete physical, mental, and social
well-being, and not merely the absence of disease or infir-
mity. Thus, the definition of health is complex; it is not
merely the absence of disease or a review of mortality and
morbidity statistics.
In 1979, the U.S. Surgeon Generals 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 2010: National Health Promotion and
Disease Prevention Objectives, the country has a compre-
hensive health promotion and disease prevention agenda
that emphasizes childrens health (U.S. Department of
Health and Human Services, 2000). Major goals are to
increase the quality and years of healthy life and to elim-
inate health disparities between ethnic groups by target-
ing the lifestyle choices and environmental conditions
that cause 70% of premature deaths in the United States.
There are 10 specific health indicators, including chil-
drens health indicators, that serve as a way to evaluate the
progress made in public health; they also serve as focal
points to coordinate the national health improvement
efforts. For example, one objective under physical activ-
ity is to increase the proportion of adolescents who engage
in vigorous physical activity three or more days per week
for 20 or more minutes per occasion (U.S. Department
of Health and Human Services, 2000). Healthy People
2010 1.1 highlights the major health concerns of the 21st
century that need to be addressed.
Measurement of Childrens
Health Status
Measuring a childs health status is not always a simple
process. For example, some children with chronic ill-
nesses do not see themselves as ill if they can manage
their disease. A traditional method of measuring health
is to examine mortality and morbidity data. This infor-
mation is collected and analyzed to provide an objective
description of the nations health.
Mortality
Mortality is the number of individuals who have died
over a specific period. This statistic is presented as rates
per 100,000 and is calculated from a sample of death cer-
tificates. The National Center for Health Statistics, under
the Department of Health and Human Services, collects,
analyzes, and disseminates these data.
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Chapter 1 PERSPECTIVES OF PEDIATRIC NURSING 11

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
Neonatal mortality is the number of infant deaths occur-
ring in the first 28 days of life per 1,000 live births. The
infant mortality rate refers to the number of deaths occur-
ring in the first 12 months of life. It also is documented
HEALTHY PEOPLE 2010
Major health concerns of the 21st century
Physical activity
as the number of deaths in relation to 1,000 live births.
The infant mortality rate is used as an index of the gen-
eral health of a country. Generally, this statistic is one
of the most significant measures of childrens health. In
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
state as well as between ethnic groups. The United States
50
Deaths per 1,000 live births

Overweight and obesity 40

Infant
Tobacco use
30
Substance abuse
Responsible sexual behavior 20
Neonatal
Mental health 10
Injury and violence
0
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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12 Unit 1 INTRODUCTION TO PEDIATRIC NURSING
has one of the highest gross national products in the
world and is known for its technological capabilities, but
it ranked 27th in infant mortality rates among industri-
alized nations in 2000 (U.S. Department of Health and
Human Services, 2006). The main causes of early infant
death in this country include problems occurring at birth
or shortly thereafter, such as prematurity, low birthweight,
congenital anomalies, sudden infant death syndrome, and
respiratory distress syndrome.
African-Americans and American Indian/Alaskan
Native infants have consistently had higher
infant mortality rates than other ethnic groups
(Federal Interagency Forum on Child and Family
Statistics, 2006).
Congenital anomalies remain the leading cause of
infant mortality in the United States. Low birthweight
and prematurity are major indicators of infant health and
significant predictors of infant mortality (Hoyert et al.,
2006). The lower the birthweight, the higher the risk of
infant mortality; thus, the high incidence of low birth-
weight (<2,500 g) in the United States plays a factor in
the higher infant mortality rate when compared to other
countries (Guyer et al., 2000).
Childhood Mortality
Childhood mortality is defined as the number of deaths
per 100,000 population in children 1 to 14 years of age.
The childhood mortality rate in the United States has
decreased by about 50% since 1980. In 2003, the mortal-
ity rate for children ages 1 to 4 years was 31 per 100,000
and the rate for children ages 5 to 14 years was 17 per
100,000 (Child Trends, 2006b). The leading cause of
death in children is motor vehicle accidents. 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 safety. Other causes of child-
hood mortality include suicide, homicide, and human
immunodeficiency virus infection.
The United Nations Childrens Fund survey (2001)
revealed that in 26 of the richest nations, 40% of all deaths
in children age 1 to 14 years result from intentional and
unintentional injuries. Even as research continues into the
preventable nature of childhood injuries, unintentional
injury remains a leading cause of mortality and morbidity
in children. These injuries have far-reaching consequences
for children, families, and society in general. Factors asso-
ciated with childhood injuries include single parenthood,
low maternal education level, young maternal age at child-
birth, poor housing, large family size, parental drug or
alcohol abuse, or low support within the family (United
Nations Childrens Fund, 2001). One study showed that
preschool children who had been injured previously dis-
played significantly higher numbers of injury behaviors
(Bruce et al., 2004). This suggests that screening for injury
behaviors can be a useful tool when nurses are providing
injury prevention counseling.
Morbidity
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-
cult to define and record because the definitions used
vary widelyfor example, visits to the physician or diag-
nosis for hospital admission. Also, data may be difficult
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-
ing the information.
In general, however, 56% of children enjoyed excel-
lent health and 28% had very good health as reported
in a summary of health statistics for children in 2002
(Dey et al., 2004). Factors that may increase morbidity
include homelessness, poverty, low birthweight, chronic
health disorders, foreign-born adoption, attendance at
daycare centers, and barriers to health care. For exam-
ple, 16% of children live in poverty and have a higher
incidence of disease, limited coordination of health ser-
vices, and limited access to health care, except for visits
to the emergency department (Federal Interagency Forum
on Child and Family Statistics, 2006). Although the
poverty rate declined from 22% in 1993 to 17% in 2004,
47% of African-American children live in poverty; these
children are particularly at increased risk for illness
(Federal Interagency Forum on Child and Family
Statistics, 2006).
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 2002, only 25% of children did not miss any school due
to illness or injury; however, 6% missed more than 10 days
of school because of injury or illness (National Center for
Health Statistics, 2004). In the United States during 2002,
3.4 million children (ages 1 to 21 years) were hospitalized
(National Center for Health Statistics, 2006). Figure 1.3
shows the major causes of hospitalization by age in the
United States.
Common health problems in children include respi-
ratory disorders, such as asthma; gastrointestinal distur-
bances, which lead to malnutrition and dehydration; and
injuries. Twelve percent of children in the United States
have asthma, and another 12% of children have respi-
ratory allergies (National Center for Health Statistics,
2004). Diseases of the respiratory system were the major
cause of hospitalization for children 1 to 9 years of age
3735-01_UT1-CH01.qxd 6/29/07 3:31 PM Page 13

Chapter 1 PERSPECTIVES OF PEDIATRIC NURSING 13

Major Causes of Hospitalization, 2002

Number of hospital discharges, in thousands

600

500

400

300

200

100

0
14 59 1014 1519
Age

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,
3735-01_UT1-CH01.qxd 6/29/07 3:31 PM Page 14
14 Unit 1 INTRODUCTION TO PEDIATRIC NURSING
and other factors related to childrens health. The goal
of these legislative efforts was to better the standards of
care. These actions demonstrate the value that society has
placed on the welfare of children. Table 1.3 lists several
significant pieces of federal legislation and describes their
impact on childrens health.
Contemporary Issues and
Trends in Child Health Care
Over the past century, the health care system has changed
to recognize the unique qualities and needs of children.
This new health care system believes that children have
a special value, are vulnerable, and require protection.
Health care practices continue to evolve, presenting unique
challenges for the new century. Specific changes include:
Health care cost containment
Preventive care
Continuum of care
Quality-of-life issues
Worldwide threats to children
Differences and uniqueness of children and their families
Significant improvements in the diagnosis and treat-
ment of diseases and disorders
Empowerment of health care consumers
Reduction in barriers to health care
Protection of childrens rights
Each of these changes will continue to affect children
and pediatric nursing practice. Societal needs as well as
global needs drive these transformations.
Health Care Cost Containment
A goal of managed care has been to reduce health care
costs, and these efforts have shortened hospital stays for
children and increased nurses awareness of the costs of
supplies and services. The overall challenge is to main-
tain the quality of care while reducing its cost.
Preventive Care
Efforts to reduce costs have also led to an increased
emphasis on preventive care. Anticipatory guidance is
vital during each health contact with children and their
families. Education of the family includes everything from
keeping the home safe to preventing illness. These are
major points of emphasis for pediatric nurses as they
deliver care to children and their families.
Continuum of Care
In an effort to become more cost-effective and to provide
care more efficiently, the nursing care of children now
encompasses a continuum of care that extends from acute
care settings such as hospitals to outpatient settings such
as ambulatory care clinics, primary care offices, rehabili-
tative units, community care settings, long-term facilities,
homes, and schools. For example, after an acute hospital
stay, a child may be able to complete therapy at home,
school, or another community setting and can re-enter
the hospital for short periods for specific treatments or
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%
in clinics, and only 1% in hospitals (National Center for
Health Statistics, 2006).
Quality-of-Life Issues
Quality of life is being emphasized in addition to physical
health. For example, Public Law 108-446 provides for
children with disabling conditions to attend regular school
and allows for an extended role of the pediatric nurse to
serve as school nurse. In addition, technological advances
present issues at the end of life. Therefore, pediatric nurses
must expand the scope of health care they provide to
include assessment of psychosocial factors in areas of self-
esteem and independence, making home visits, and using
excellent interviewing skills to obtain information that
may assist in the care related to these areas.
Concerns Over World Threats
and Safety
Disasters such as the terrorist attacks of Sept. 11, 2001,
the killings at Columbine High School, or devastating
weather events such as Hurricane Katrina can have a
significant impact on the well-being of children. The
increase in stressors such as war, terrorism, school vio-
lence, and natural disasters may reduce childrens coping
abilities (Ryan-Wenger et al., 2005) and may lead to alter-
ations in growth and development (Crane & Clements,
2005). Children who have experienced these events are
at risk for posttraumatic stress disorder, behavioral prob-
lems, and depression (Wexler et al., 2006). These disas-
ters may be most difficult for children who have previously
gone through a major loss or already suffer from anxiety or
depression (Davidhizar & Shearer, 2002). Pediatric nurses
must be aware of the effects of world threats on children
so that they can assess for alterations and intervene to
promote security and stability.
Diverse Patient Populations
The United States is no longer a melting pot of various
cultures and ethnicities but a society in which each dis-
tinct individual brings a diversity and richness that as a
whole enriches the country. Today, children do not fit
into a set category or group. Children and families vary
in terms of culture, family structure, socioeconomic sta-
tus, background, and circumstances, so each child enters
the health care system as a unique individual. Pediatric
nurses must have greater sensitivity to the background of
3735-01_UT1-CH01.qxd 6/29/07 3:31 PM Page 15

Chapter 1 PERSPECTIVES OF PEDIATRIC NURSING 15

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
conditions
1921 Maternity & Infancy (Sheppard-Towner) Act Provided grants to states to establish maternal
and child health divisions in state health
departments
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
Child
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
children
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
3735-01_UT1-CH01.qxd 6/29/07 3:31 PM Page 16
16 Unit 1 INTRODUCTION TO PEDIATRIC NURSING
each child and must be able to provide care that addresses
the childs uniqueness.
Improvements in Diagnosis
and Treatment
Tremendous improvements in technology and biomed-
icine have created a trend toward earlier diagnosis and
treatment of disorders and diseases. Throughout the 1990s
remarkable progress was made linking genetics and patho-
physiologic processes. For example, female fetuses with
congenital adrenal hyperplasia, a genetic disorder result-
ing in a steroid enzyme deficiency that can lead to dis-
figuring anatomic abnormalities, are beginning to receive
treatment before birth. In addition, many genetic defects
are being identified so that counseling and treatment may
occur early.
As a result of this improved diagnosis and treatment,
the pediatric nurse now cares for children who have sur-
vived once-fatal situations, are living well beyond the usual
life expectancy for a specific illness, or are functioning
and attending school with chronic disabilities. While pos-
itive and exciting, these advances and trends pose new
challenges for the health care community. For example,
as care for premature newborns improves and survival
rates have increased, so too has the incidence of long-
term chronic conditions such as respiratory airway dys-
function or developmental delays. As a result, pediatric
nurses care for children at all stages along the health
illness continuum, from well children, to those who are
occasionally ill, to those with chronic, sometimes dis-
abling conditions.
Empowerment of Consumers
Due to the influence of managed care, the focus on pre-
vention, better education, and technological advances,
people have taken increased responsibility for their own
health. Parents now want information about their childs
illness, they want to participate in making decisions about
treatment, and they want to accompany their children to
all health care situations. As child advocates who value
family-centered care, pediatric nurses can provide such
empowerment and can address specific issues for children
and families. Pediatric nurses must respect the familys
views and concerns, address those issues and concerns,
regard the parents as important participants in their
childs health, and always include the child and family in
the decision-making process.
Barriers to Health Care
Even with the federal and state programs available to
assist children and families, barriers to appropriate, cost-
effective, coordinated, and timely health care remain.
Barriers can be financial, sociocultural, or ethnic, or part
of the health care system itself.
Financial Barriers
Although the poverty rate is declining in this country,
in 2001, 36% of Americas households with children
had inadequate physical housing, crowded housing,
or housing that cost more than 30% of the household
income (Federal Interagency Forum on Child and Family
Statistics, 2006). In addition, the percentage of children
covered by health insurance was 88%, leaving 12% of chil-
dren uninsured. However, the majority of insurance cov-
erage since 1999 is not from private health insurance but
from government-supported plans (Federal Interagency
Forum on Child and Family Statistics, 2006). Many
children and families do not have insurance, do not have
enough insurance to cover services obtained, or cannot
pay for services.
Sociocultural and Ethnic Barriers
Sociocultural and ethnic factors also pose barriers. For
example, white, non-Hispanic children overall are more
likely than African-American and Hispanic children to
be in very good or excellent health. The proportion of
children ages 6 to 18 who are overweight is increasing,
but the largest increase is occurring in African-Americans
and Mexican-Americans (Federal Interagency Forum on
Child and Family Statistics, 2006). This is just one exam-
ple of the problems that different ethnic groups face in
relation to health.
Lack of transportation, the need for both parents
to work, and genetic factors also pose barriers to seek-
ing health care. Knowledge barriers (e.g., lack of under-
standing of the importance of prenatal care or preventive
health care), language barriers (e.g., speaking a different
language than the health care providers), or spiritual bar-
riers (e.g., religious beliefs discouraging some forms of
treatment) also exist.
Health Care Delivery System Barriers
The health care delivery system itself can create barriers,
such as the cost containment movement. Eighty-five per-
cent of employed families with insurance are covered by
some type of managed health care plan or health mainte-
nance organization (HMO). This prospective payment
system based on diagnosis-related groups (DRGs) limits
the amounts of health care the family may receive. This
also includes Medicaid reimbursement. As a result, the
trend is to discharge patients as soon as possible and
deliver care in the home or through community-based
services. The overall plan may improve access to preven-
tive services but may limit the access to specialty care,
which has a major impact on children with chronic or
long-term illnesses.
Protection of Childrens Rights
A number of national and international organizations
have been formed in recent years to protect childrens
3735-01_UT1-CH01.qxd 6/29/07 3:31 PM Page 17
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 immi-
grants and orphaned children, and abandoned or home-
less childrenall of which can have a negative impact on
childrens health. A child whose rights are restored and
upheld has an improved opportunity for growth, devel-
opment, education, and health. As advocates for children,
nurses support policies that protect childrens rights and
improve childrens health care.
Parents and guardians generally make choices about
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-
ing to childrens rights in relation to health care deci-
sion making.
Confidentiality Issues in Caring
for Children
With the establishment of the Health Insurance Portability
and Accountability Act of 1996 (HIPAA), confidentiality
of health care information is now required. The primary
intent of the law was to maintain health insurance cover-
age for workers and their families when they change or lose
jobs. Another aspect of the law requires the Department of
Health and Human Services to establish national stan-
dards for electronic transactions for health information
on individuals. The plan also addresses security and pri-
vacy issues involving health information about individu-
als. For example, no information that clearly identifies a
patient can be on public display, including information
on a patients chart. In the pediatric area, information is
shared only with the legal parents or guardians or individ-
uals as established in writing by the parents. This law pro-
motes the security and privacy of childrens health
information.
Computer Privacy
Electronic medical records (EMRs) improve efficiency
and accuracy in a variety of clinical settings and may also
improve the quality of patient care by simplifying the
recording of complete data (Roukema et al., 2006). The
EMR allows all health care disciplines to share informa-
tion about a patient (Adams et al., 2003). The computer
can be a powerful tool for improving efficiency and com-
municating health information in the pediatric arena. In
addition to illness data, growth data with appropriate age-
based ranges, medication dosages related to weight, and
records of immunizations may be communicated across
various settings via computer (Hinman et al., 2004). Pa-
tient confidentiality and privacy must be maintained as
it is with paper documentation. At each point of elec-
tronic transmission, patient data must remain secure,
and the HIPAA privacy rule applies to electronic patient
Chapter 1 PERSPECTIVES OF PEDIATRIC NURSING 17
information (Flores & Dodier, 2005). Nurses can ensure
that privacy is maintained when using computerized doc-
umentation and an EMR by doing the following:
Always maintain the security of your personal log-in
information; never share it with other health care
providers or other persons.
Always log off when leaving the computer.
Do not leave patient information visible on a monitor
screen when the computer/monitor is unattended.
Do not use e-mail to communicate confidential patient
information.
Referring back to Isabelle Romano and her family
from the beginning of the chapter, what trends in child
health care may have affected them?
Use of the Nursing Process
in Caring for Children
and Their Families
Pediatric nursing involves all the essential components of
contemporary nursing practice. The American Nurses
Associations (2004) definition of nursing, the diagno-
sis and treatment of human responses to actual or poten-
tial health problems, also applies to the practice of
pediatric nursing. The pediatric nurse makes use of the-
ories and research pertaining specifically to children as
well as general nursing concepts and research.
Nurses must know about current trends in health so
that they can provide appropriate anticipatory guidance,
counseling, and teaching for children and families and
can identify high-risk groups so that interventions can be
initiated early, before illness or death occurs. The nurse
can use the information introduced in the above review
of trends to develop and deliver a plan of care that is real-
istic and relevant to the childs health and welfare. The
nurse performs this task using a framework called the
nursing process.
The nursing process is used to care for the child and
family during health promotion, maintenance, restora-
tion, and rehabilitation. It is a problem-solving method
based on the scientific method that allows nursing care to
be planned and implemented in a thorough, organized
manner to ensure quality and consistency of care. The
nursing process is applicable to all health care settings
and consists of five steps: assessment, nursing diagnosis,
outcome identification and planning, implementation,
and outcome evaluation.
1. Assessment involves collecting data about the child
and family and performing physical assessment during
community-based health services, at admission to an
acute care setting, at periodic times during the childs
hospitalization or care, and during home care visits.
3735-01_UT1-CH01.qxd 6/29/07 3:31 PM Page 18
18 Unit 1 INTRODUCTION TO PEDIATRIC NURSING
2. The nurse analyzes the data to make judgments about
the childs health and developmental status. The nurs-
ing diagnoses that result from this judgment process
describe health promotion and health patterns that
pediatric nurses can manage.
3. The next step in the process involves developing nurs-
ing care plans that incorporate goals or expected out-
comes that improve the childs dysfunctional health
patterns, promote appropriate health patterns, or pro-
vide for optimal developmental outcomes. The care
plan includes the specific nursing actions that assist in
obtaining the outcomes.
4. These interventions are implemented, adapted to the
childs developmental level and family status, and mod-
ified if the childs response indicates the need. The care
plan incorporates the family in addition to the child.
5. The process is continually evaluated and updated dur-
ing the partnership with the child and family.
Standardized care plans for specific nursing diagnoses
and critical pathways for case management are often used
in various pediatric settings. In general, care plans and crit-
ical pathways are becoming more evidence-based, using
a combination of research, group consensus, and past
health care decisions to identify the most effective inter-
ventions for the child and family. The nurse is responsible
for individualizing these standardized care plans based on
the data collected during the assessment of the child and
family and for evaluating the childs and familys response
to the nursing interventions.
The dimensions of pediatric health care are chang-
ing. We live in a global community in which distances
have been minimized, enabling all of us to learn, share,
and exchange information. The pediatric nurse needs to
be alert to the wide-ranging developmental and mental
health needs of children as well as to the traits and behav-
iors that may lead to serious health problems. The scope
of pediatric health care practice is much broader today,
and pediatric nurses must include quality evidence-based
interventions when developing the plan of care. In addi-
tion, pediatric nurses must incorporate new information
about genetics and neurobiology and must continue to
keep up with the technology explosion.
In the beginning of the chapter you were introduced
to the Romano family. How can you empower this family
to help them provide the best care to Isabelle?
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20 Unit 1 INTRODUCTION TO PEDIATRIC NURSING
Chapter
ChapterWORKSHEET
MULTIPLE CHOICE QUESTIONS
1. What is the number-one cause for mortality among
children?
a. Human immunodeficiency virus
b. Congenital anomalies
c. Motor vehicle accidents
d. Low birthweight
2. The nurse is assessing the vital signs of a child who
is being evaluated in an urgent care center. The
child is to be seen by the pediatric nurse practitioner
(PNP). The mother asks, Why is my child seeing
the PNP and not the doctor? What is the best
response by the nurse?
a. The PNP functions similar to the physicians
assistant, so you should be perfectly at ease.
b. The child may be seen by the physician instead if
youd like.
c. Seeing the PNP is just one more step in having
your child evaluated in this setting.
d. The PNP is an experienced RN with advanced edu-
cation in the diagnosis and treatment of children.
3. When caring for children, how does the nurse best
incorporate the concept of family-centered care?
a. Encourages the family to allow the physician to
make health care decisions for the child
b. Uses the concepts of respect, family strengths,
diversity, and collaboration with family
c. Advises the family to choose a pediatric provider
who is on the childs health care plan
d. Recognizes that families undergoing stress related
to the childs illness cannot make good decisions
4. In an effort to control health care costs, what is the
best recommendation by the nurse?
a. Shop around to find the most inexpensive health
insurance plan.
b. Find a job that provides family health insurance
at a minimal cost.
c. Stress primary prevention, using the health care
system for check-ups.
d. Avoid seeing a health care provider until your
child becomes ill.
5. The school nurse is planning a screening program.
What items should be included to address issues
related to the new morbidity?
a. Academic difficulties, violence, and other mental
health issues
b. The number of children with chronic illness at the
school
c. Statistics related to health insurance coverage of
the children
d. HIV infection, asthma and respiratory allergy
testing
CRITICAL THINKING EXERCISES
1. Detail how the nursing process fits into the frame-
work of pediatric nursing.
2. Discuss how the role of the pediatric nurse differs
from the role of the advanced practice pediatric
nurse.
STUDY ACTIVITIES
1. Describe how you will incorporate family-centered
care into your nursing care in the pediatric clinical
setting.
2. Research a current policy, bill, or issue being debated
on the community, state, or national level pertaining
to child health or welfare. Summarize the major facts
and supporting or opposing issues and present them
in a class presentation or paper.
3. Obtain a standardized care plan from the hospital
unit. Evaluate whether it is based on evidence-based
practice. Develop an individualized care plan for a
child you are caring for. Compare and contrast the
two types of care plans.
4. The following events were milestones in the support
of childrens health. Place them in the correct
sequence, from oldest to most recent:
_____ a. Declaration of the Rights of the Child
approved
_____ b. WIC program established
_____ c. U.S. Childrens Bureau established
_____ d. Sheppard-Towner Act passed
_____ e. Family and Medical Leave Act passed
_____ f. Education for all Handicapped Children
Act passed.