1. Major Hematologic Disorders

• Iron Deficiency Anemia: The most common anemia in children, often caused by excessive milk intake (>24 oz/day) displacing iron-rich foods.

◦ Management: Administer iron supplements (give with Vitamin C/juice, avoid milk) and limit milk intake. Stools may turn tarry green.

• Sickle Cell Disease (SCD): Genetic disorder where HgbS replaces normal HgbA, causing RBCs to sickle, obstructing blood flow.

◦ Crisis Management: Prioritize hydration (1.5–2x maintenance), oxygenation, and pain control (opioids, NSAIDs). Medical emergency: Acute chest syndrome or splenic sequestration.

• Hemophilia: X-linked recessive clotting deficiency (A=Factor VIII, B=Factor IX).

◦ Safety: Prevent bleeding (no contact sports, soft toothbrush). Treat bleeds with RICE (Rest, Ice, Compression, Elevation) and factor replacement.

2. Pediatric Oncology

Unlike adult cancers (epithelial/environmental), childhood cancers are largely embryonal (tissue-based), grow rapidly, and are highly responsive to treatment.

• Leukemia (ALL/AML): The malignancy of bone marrow/blood. ALL is the most common. Diagnosis via bone marrow biopsy; lumbar puncture checks CNS involvement.

• Solid Tumors:

◦ Wilms Tumor: Renal tumor. Never palpate the abdomen pre-op to prevent rupture/metastasis.

◦ Neuroblastoma: Neural crest tumor, often presents as an abdominal mass crossing the midline.

◦ Retinoblastoma: Signaled by "cat's eye reflex" (whitish glow in pupil).

3. Critical Pharmacology & Safety

Chemotherapy requires specialized handling due to toxicity.

• Vincristine: A mitotic inhibitor.

◦ FATAL WARNING: For IV use only. Fatal if given intrathecally.

◦ Side Effects: Peripheral neuropathy (foot drop), constipation, vesicant (extravasation risk).

• Methotrexate: Folate antimetabolite.

◦ Risks: Myelosuppression, hepatotoxicity, mucositis, renal failure (requires hydration/alkalinized urine).

◦ Rescue Agent: Leucovorin is used to neutralize toxic effects.

• Daunorubicin/Doxorubicin: Anthracyclines.

◦ Risks: Severe cardiotoxicity (lifetime cumulative dose limits apply) and red/orange urine.

• Etoposide: Topoisomerase inhibitor.

◦ Admin: Watch for hypotension during rapid infusion (infuse over 30–60 mins).

• Prednisone: Corticosteroid used for induction/palliation.

◦ Side Effects: Hyperglycemia, mood changes, immunosuppression, Cushing’s syndrome. Must taper to avoid adrenal insufficiency.

• Mesna: A cytoprotectant agent.

◦ Use: Must be given with Ifosfamide or Cyclophosphamide to prevent hemorrhagic cystitis (bladder bleeding).

4. Nursing Priorities

• Neutropenia: Infection is the leading cause of death. Calculate ANC; implement protective isolation if ANC <500. No fresh flowers/fruit; monitor temp closely.

• Infants & Toddlers:

◦ Positioning: Perform the exam on the caregiver’s lap to reduce anxiety,.

◦ Sequence: Use a "least invasive to most invasive" approach. Auscultate the heart and lungs while the child is quiet; perform traumatic procedures (ears, throat, hips) last,,,.

◦ Technique: Use distractions (toys, bubbles) and simple terms. For toddlers, avoid asking "yes/no" questions if there is no choice; instead, use short phrases to direct them,.

• Preschoolers (3–5 years):

◦ Fears: They often fear bodily mutilation. Allow them to inspect equipment (like the stethoscope) before use to reduce anxiety,.

◦ Cooperation: Use games (e.g., "blow out the light" for lung sounds) and offer choices when possible,.

• School-Age (6–12 years):

◦ Agency: They value control and understanding. Explain how things work and answer questions truthfully. They can generally tolerate a head-to-toe sequence,.

◦ Privacy: Respect their modesty and need for privacy,.

◦ Respect: Communicate directly with the adolescent, not just the parent,.

The Health History (The Foundation)

The health history provides the context for the physical exam and includes the Chief Complaint, Review of Systems, and Family History (often visualized with a genogram),.

• Observation is Key: Much of the assessment occurs before touching the child. Observe the parent-child interaction for eye contact, comfort measures, and behavioral cues to assess family dynamics and potential attachment issues,,,.

• Functional History: Beyond medical issues, assess "daily life" factors:

◦ Safety: Car seats, smoke detectors, bicycle helmets,.

◦ Nutrition: 24-hour dietary recall and "junk food" consumption,.

◦ Sleep & Activity: Screen time habits and sleep patterns,.

Key Physical Exam Techniques & Findings

Pediatric anatomy requires specific examination adjustments and interpretation of "normal" variations.

1. Vital Signs & General Appearance

• Sequence: Measure vital signs (HR, RR) while the child is calm. Blood pressure can be frightening and is often done last or with age-appropriate explanation,.

• Red Flags: Watch for lethargy, listlessness, or lack of response to the environment, which may indicate serious illness,.

2. Head, Eyes, Ears, Nose, Throat (HEENT)

• Fontanels: The posterior fontanel closes by 2 months; the anterior fontanel closes between 9 and 18 months. A sunken fontanel suggests dehydration; a bulging one may indicate increased intracranial pressure,.

• Ear Exam:

◦ Under 3 years: Pull the pinna down and back to straighten the canal,.

◦ Over 3 years: Pull the pinna up and back,.

• Eyes: Check for the "red reflex"; absence may indicate cataracts or retinoblastoma,. Strabismus (crossing eyes) is intermittent/normal up to 4 months but requires referral if persistent,.

• Nose: Infants <1 month are obligate nose breathers; nasal obstruction can cause respiratory dis.

Health supervision is the proactive provision of care focused on optimizing a child's growth, development, and wellness through a partnership between the family and the healthcare team.

This 80/20 summary isolates the critical frameworks, screening milestones, and preventative strategies that constitute the core of pediatric health supervision.

1. The Core Framework: The Medical Home

The most effective health supervision occurs within a medical home, defined not as a building, but as an approach to care that is accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective.

• Goal: Promote optimal health by preventing injury and illness rather than just treating acute sickness.

• Partnership: Success relies on a trusting relationship where the family serves as the constant in the child's life, while the nurse facilitates care and education.

• Cultural Competence: Nurses must integrate the family's cultural values into the health plan; if a care plan conflicts with a family's health beliefs, it is unlikely to succeed.

2. The Three Components of Health Supervision

Every pediatric visit is organized around three central activities:

1. Developmental Surveillance and Screening: Continuous observation of growth and development combined with standardized testing at specific ages.

2. Injury and Disease Prevention: Interventions such as immunizations and safety education.

3. Health Promotion: Teaching parents and children about healthy living (nutrition, hygiene, oral health) to maintain wellness.

3. Critical Screening Milestones

Nurses must perform specific screenings at designated ages to detect issues early.

Screening Type

Key Timing & Guidelines

Developmental

Surveillance occurs at every visit.Standardized Screening is recommended at 9, 18, and 30 months.Autism Screening is specifically performed at 18 and 24 months.

Vision

Newborns: Assessed for structural abnormalities and fixation; high-contrast objects (black and white) are best for infants <6 months.Universal Screening: Starts at age 3 using charts like the "Tumbling E" or LEA symbols.

Hearing

Universal Newborn Screening: Should be done before discharge (or by 1 month).Follow-up: Diagnosis by 3 months; intervention by 6 months to prevent developmental delays.

Metabolic

Newborn Screening: Mandatory state tests for over 35 conditions (e.g., PKU, sickle cell) performed via heel stick after 48 hours of age.

Lead & Anemia

Lead: Risk assessment at 6, 9, 12, 18, 24 months; levels >3.5 mcg/dL are dangerous.Anemia: Screen at 4, 15, 18, 24, and 30 months, checking hemoglobin/hematocrit.

Hypertension

Universal Screening: Begins at age 3 years.

Critical Red Flag: Any child who "loses" a developmental milestone (e.g., could sit but now cannot) requires an immediate full neurological evaluation.

Effective nursing care for a child in pain requires individualized assessment using age-appropriate tools and a multimodal management approach that combines medication with behavioral strategies.

1. Assessment: The QUESTT Principle

Accurate assessment is the foundation of pain management. The text highlights the QUESTT framework as a key guide:

• Question the child.

• Use a reliable, valid pain scale.

• Evaluate behavior and physiologic changes.

• Secure parental involvement.

• Take the cause of pain into account.

• Take action.

Choosing the Right Tool:

• Infants & Non-verbal: Rely on behavioral and physiologic indicators (facial expressions, crying, heart rate, oxygen saturation) and scales like NIPS or FLACC.

• Toddlers to Teens: Move toward self-report tools. Use FACES (ages 3+) or Numeric scales (ages 5+).

• Crucial Myth-Busting: Nurses must recognize that newborns do feel pain, and a child who is playing or sleeping may still be in significant pain.

2. Management: A Multimodal Approach

Treatment should be tailored to the child's developmental level and the intensity of the pain.

• Non-Pharmacologic: These are essential for reducing anxiety and pain perception.

◦ Cognitive/Behavioral: Distraction, relaxation, guided imagery, and positive self-talk.

◦ Biophysical: Heat/cold application, massage, and nonnutritive sucking with sucrose for infants.

• Pharmacologic: Involves the use of analgesics (opioids/non-opioids), adjuvants, and anesthetics.

3. The Nurse’s Role

Beyond administration, the nurse acts as a safety monitor and advocate.

• Procedural Pain: Minimize trauma by using topical anesthetics, therapeutic hugging, and preparing the child ahead of time.

• Monitoring: Continually assess vital signs (specifically for respiratory depression) and watch for common opioid side effects like constipation and pruritus (itching)

Based on the provided sources, the following is a summary focusing on the adolescent age group (11 to 20 years), covering their developmental milestones, vital signs, and immunization schedule.

Adolescent Growth and Development

Adolescence is defined as the transition from childhood to adulthood, spanning ages 11 to 20. This period is characterized by rapid physical, cognitive, and psychosocial changes.

• Physiologic Changes: Puberty is driven by the hypothalamus releasing GnRH, stimulating the pituitary to release FSH and LH, which triggers gonadal response (estrogen in females, testosterone in males). Females generally enter puberty (ages 9–10) and reach physical maturity before males. A distinct growth spurt occurs, with females gaining 15–55 lbs and males gaining 15–65 lbs during this period. Organ systems mature, resulting in increased respiratory volume and blood volume, while the basal metabolic rate reaches adult levels.

• Cognitive Development (Piaget): Adolescents enter the Formal Operations stage. Early adolescence involves limited abstract thought, while middle and late adolescence (14–20 years) see the development of abstract thinking, deductive reasoning, future planning, and the ability to think outside the present.

• Psychosocial Development (Erikson): The primary task is Identity vs. Role Confusion. Adolescents strive to develop a sense of self and autonomy separate from parents. Peer groups become the essential source of support and identity validation, often leading to conflict with parents and a focus on conformity to peer norms.

Vital Signs (Adolescents 13–18 Years)

The expected physiological ranges for this age group approach adult values:

• Temperature: Approximately 36.6° C (97.9° F) via oral, axillary, or tympanic routes.

• Pulse Rate: 50 to 100 beats/minute.

• Respirations: 16 to 20 breaths/minute.

• Blood Pressure: Systolic less than 120 mmHg; Diastolic less than 80 mmHg.

• Pain Assessment: The Numeric Scale (0–10) is the standard tool for self-reporting pain in children 5 years and older. The FACES scale (0–5 or 0–10) may also be used.

Immunization Schedule (7–18 Years)

The CDC recommends the following vaccines specifically for adolescents, assuming the childhood primary series was completed.

Routine Vaccinations at 11–12 Years:

• Tdap (Tetanus, diphtheria, and acellular pertussis): 1 dose is routinely administered at 11–12 years.

• HPV (Human papillomavirus): Routinely recommended at 11–12 years (can start at age 9). If started before age 15, it is a 2-dose series (0, 6–12 months). If started at age 15 or older, it is a 3-dose series (0, 1–2, 6 months).

• Meningococcal ACWY (MenACWY): 1st dose at 11–12 years, with a booster dose recommended at 16 years.

Routine Annual Vaccination:

• Influenza: 1 dose annually for all adolescents.

Catch-up and Risk-Based Vaccinations:

• Meningococcal Serogroup B (MenB): Recommended based on shared clinical decision-making for adolescents ages 16–23 (preferred 16–18 years), or for those at increased risk (e.g., asplenia).

• Dengue: Recommended for ages 9–16 years living in endemic areas with laboratory confirmation of previous dengue infection.

• Catch-up: Adolescents with incomplete histories should receive catch-up doses for Hepatitis B, Hepatitis A, Poliovirus (IPV), MMR, and Varicella.

• COVID-19: Recommended per current schedule details

Growth and Development

Physical Maturation School-age children experience slow, progressive growth, gaining an average of 2 to 3 kg (4–7 lb) and growing 5 to 7 cm (2–2.5 in) per year. The immune system reaches adult levels of immunoglobulins around age 10, respiratory rates decrease as breathing becomes diaphragmatic, and blood pressure increases while the pulse rate decreases.

Developmental Stages

• Psychosocial (Erikson): The primary task is Industry vs. Inferiority. Children develop a sense of self-worth by acquiring skills and succeeding in tasks at school and home. If expectations are too high or support is lacking, feelings of inferiority may develop,.

• Cognitive (Piaget): Children enter the Concrete Operational stage (ages 7–11). They master the concept of conservation (understanding matter does not change when its form changes), learn to tell time, and engage in serial ordering, though they still lack abstract thinking,.

• Moral (Kohlberg): This is the Conventional level. Younger school-age children (7–10) view behavior as "good" or "bad" based on consequences and pleasing others, while older children (10–12) respect "law and order" and the Golden Rule,.

Social and Safety Concerns Peer relationships become vital, with a shift toward same-sex friend groups. Common concerns include bullying, screen time management, and obesity,. Safety education is critical, specifically regarding bicycle helmets, water safety, and car safety (using booster seats until the child is 4 feet 9 inches tall),.

Vital Signs (School-Age: 6 to 12 Years)

General guidelines for expected vital signs in this age group are:

• Temperature: 36.7°C to 36.8°C (98.1°F to 98.2°F).

• Pulse Rate: 60 to 110 beats/min.

• Respirations: 20 to 25 breaths/min.

• Blood Pressure (Average 50th Percentile):

◦ Males: 96/55 to 106/62 mm Hg.

◦ Females: 94/56 to 105/62 mm Hg.

• Pain Assessment: For children 3 years and older, the FACES scale or Oucher photographic scale is appropriate. The Numeric scale (0–10) can be used for children 5 years and older who can verbally report pain levels.

Vaccination Schedule

The CDC recommends the following routine immunizations for this age group,,:

• Ages 4–6 Years (School Entry):

◦ DTaP (Diphtheria, tetanus, and acellular pertussis): 5th dose.

◦ IPV (Inactivated poliovirus): 4th dose.

◦ MMR (Measles, mumps, rubella): 2nd dose.

◦ Varicella (Chickenpox): 2nd dose.

• Ages 11–12 Years:

◦ Tdap (Tetanus, diphtheria, acellular pertussis): 1 adolescent booster dose,.

◦ MenACWY (Meningococcal serogroups A, C, W, Y): 1st dose,.

◦ HPV (Human papillomavirus): Routine vaccination recommended (2-dose series if started before age 15),.

• Annual/Other:

◦ Influenza: 1 dose annually (or 2 doses if previously unvaccinated and under age 9),.

◦ COVID-19: Recommended per current CDC guidelines.

◦ Dengue: Recommended for ages 9–16 living in endemic areas with laboratory-confirmed previous infection

Physical Growth and Vital Signs Preschoolers generally gain 4.5 to 6.5 lb (2 to 3 kg) and grow 2.5 to 3.5 inches (6.5 to 9 cm) per year. As they lose baby fat and gain muscle, they assume a more mature, sturdy posture. Neurologic myelination is typically complete by age 3, facilitating bowel and bladder control.

For children ages 3 to 5, normal vital signs are:

• Pulse: 70 to 120 beats per minute.

• Respirations: 20 to 25 breaths per minute.

• Temperature: Averages 37.2°C (99.0°F) at age 3, decreasing to 37.0°C (98.6°F) by age 5.

• Blood Pressure: Systolic ranges from 89–98 mm Hg and diastolic from 46–53 mm Hg, depending on sex.

• Pain Assessment: The FLACC scale is appropriate for ages 2 months to 7 years; however, children aged 3 and older can use self-report tools like the FACES scale or the Oucher photographic scale.

Developmental Stages

• Psychosocial (Erikson): This period is defined by "Initiative vs. Guilt," where children learn to plan activities, please parents, and develop a conscience. They may feel remorse when behaving badly.

• Cognitive (Piaget): Preschoolers are in the preoperational stage, characterized by magical thinking (thoughts cause events), animism (lifelike qualities to inanimate objects), and egocentrism.

• Motor Skills:

◦ Age 3: Rides a tricycle, goes up stairs with alternating feet, builds towers of 9-10 blocks, and undresses self.

◦ Age 4: Throws ball overhand, hops on one foot, uses scissors, and copies capital letters.

◦ Age 5: Skips, somersaults, prints some letters, ties shoelaces, and dresses independently.

• Language: Vocabulary expands from 1,500 words at age 4 to 2,100 words by age 5. Children ask "why" and "when" questions and speak in sentences of 4 to 5 words by age 5.

Health Promotion and Safety Preschoolers require 10 to 13 hours of sleep daily. Nightmares (remembered, child wakes up) differ from night terrors (child remains asleep, no memory of event). Nutritional needs include 700 to 1,000 mg of calcium and 7 to 10 mg of iron daily. Milk intake should be limited to 16 to 24 oz per day to prevent iron deficiency and obesity. Safety measures include using forward-facing car seats with a harness until outgrown, then a belt-positioning booster seat until a height of 145 cm is reached.

Vaccination Schedule (Ages 4–6 Years) Routine immunizations for this age group focus on booster doses before entering school. The schedule includes:

• DTaP (Diphtheria, tetanus, acellular pertussis): 5th dose recommended at ages 4–6 years.

• IPV (Inactivated Poliovirus): 4th dose recommended at ages 4–6 years.

• MMR (Measles, mumps, rubella): 2nd dose recommended at ages 4–6 years.

• Varicella (Chickenpox): 2nd dose recommended at ages 4–6 years.

• Influenza: 1 or 2 doses annually, depending on vaccination history.

• COVID-19: Recommended based on current formulations and guidelines.

For children who are behind schedule, catch-up guidance indicates that the 5th DTaP dose is not necessary if the 4th dose was administered at age 4 or older. Similarly, a 4th IPV dose is indicated if all previous doses were given before age 4

Physical Growth and Vital Signs

Infancy involves rapid physical maturation. Newborns may lose up to 10% of their birth weight but regain it by 10 to 14 days. Weight doubles by 4 to 6 months and triples by 1 year,. The posterior fontanel closes by 2 months, while the anterior closes by 12 to 18 months.

Vital Signs by Age:

• Heart Rate: Newborn (110–160/min); Infant (90–160/min).

• Respirations: Newborn (30–60/min); Infant (25–60/min).

• Blood Pressure (Average): Newborn (64/41 mm Hg); Infant (85/50 mm Hg).

• Temperature: Ranges from 37.5°C (99.5°F) at 3 months to 37.7°C (99.9°F) at 1 year (axillary/rectal routes preferred).

Pain Assessment: Nurses should use age-appropriate tools like the CRIES scale for neonates (assessing crying, oxygen requirement, vital signs, expression, and sleeplessness). For infants 2 months to 7 years, the FLACC scale (Face, Legs, Activity, Cry, Consolability) is used.

Developmental Stages and Theories

Development proceeds in a cephalocaudal (head-to-toe) and proximodistal (center-to-outward) pattern. For premature infants, developmental milestones and growth are assessed using their adjusted age (chronological age minus weeks premature),.

• Psychosocial (Erikson): Trust vs. Mistrust. Caregivers must meet needs promptly to foster trust; delayed gratification is learned over time,.

• Cognitive (Piaget): Sensorimotor Stage. Infants progress from reflexes to purposeful acts. Key achievements include Object Permanence (realizing objects exist when unseen, around 9 months) and mental representation,.

Key Motor Milestones:

• 2 Months: Holds head up when prone; social smile,.

• 4 Months: Rolls from back to side; holds head steady; places objects in mouth,.

• 6 Months: Rolls from back to front; sits with support (tripod); holds bottle,.

• 9 Months: Sits unsupported; pulls to stand; uses crude pincer grasp,.

• 12 Months: Walks with one hand held or cruises; sits from standing; uses fine pincer grasp,.

Nutrition: Breast milk is the preferred complete nutrition for the first 6 months,. Vitamin D supplements are recommended immediately, and iron supplements may be needed after 4 months for exclusively breastfed infants.

• Solids: Introduce at 6 months (starting with iron-fortified cereal). Introduce new foods every 3–5 days to identify allergies,.

• Prohibited: No cow's milk or honey before 1 year.

Sleep and Dental: Infants should sleep on a firm mattress in the supine (back) position to prevent SIDS,. Teething typically begins between 6 to 10 months; clean teeth with a cool, wet washcloth.

Safety:

• Car Seats: Rear-facing in the back seat at a 45-degree angle,.

• Home: Cover outlets, use safety gates, set water heater <49°C, and avoid small choking hazards (grapes, coins, candy),.

Immunization Schedule (0 to 12 Months)

• Birth: Hepatitis B (Hep B).

• 2 Months: DTaP, Rotavirus (RV), IPV (Polio), Hib, PCV (Pneumococcal), Hep B.

• 4 Months: DTaP, RV, IPV, Hib, PCV.

• 6 Months: DTaP, IPV, PCV, Hep B, RV, Hib.

• 6 to 12 Months: Seasonal Influenza vaccination (yearly).

Toddlers typically gain 3 to 5 pounds and grow 3 inches in height per year. By age 2, they attain approximately half of their adult height, and the anterior fontanel closes by 18 months.

Vital Signs (Ages 1–3 Years):

• Temperature: Ranges from 37.7°C (99.9°F) at 1 year to 37.2°C (99.0°F) at 3 years.

• Pulse: 80 to 140 beats/min.

• Respirations: 25 to 30 breaths/min.

• Blood Pressure (1–2 years):

◦ Male: Systolic 85–91, Diastolic 37–46.

◦ Female: Systolic 86–89, Diastolic 40–49.

• Pain Assessment: The FLACC scale (Face, Legs, Activity, Cry, Consolability) is used for children aged 2 months to 7 years.

Developmental Stages

Psychosocial (Erikson): The toddler enters the stage of Autonomy vs. Shame and Doubt. This period is marked by the child's desire to exert control, often leading to negativism (the consistent use of "no") and temper tantrums as they struggle between dependence and independence.

Cognitive (Piaget):

• Sensorimotor (12–24 months): Toddlers engage in tertiary circular reactions, experimenting with behaviors and developing object permanence.

• Preoperational (2–7 years): Characteristics include animism (attributing lifelike qualities to objects), domestic mimicry (imitating household tasks), and symbolic thought.

Motor and Language Milestones:

• Gross Motor: Toddlers walk independently by 15–18 months. By 24 months, they can kick a ball and walk up stairs; by 30 months, they jump with both feet.

• Fine Motor: Skills progress from using a spoon at 15 months to turning doorknobs at 30 months and copying a circle by 36 months.

• Language: Receptive language (understanding) develops faster than expressive language. Speech evolves from single words ("mama/dada") at 15 months to telegraphic speech (2-3 word sentences like "want cookie") by 24 months.

Social and Safety: Play is primarily parallel play, where toddlers play alongside but not with other children. Safety is a priority due to increasing mobility; hazards include poisoning, drowning, and burns. Car seats should remain rear-facing until at least age 2 or until the child meets the manufacturer's height/weight requirements.

Vaccination Schedule (12 Months – 3 Years)

The CDC recommends the following immunization schedule for this age group:

• 12 to 15 Months:

◦ Hib (Haemophilus influenzae type b): Booster dose.

◦ PCV (Pneumococcal conjugate): Dose 4.

◦ MMR (Measles, mumps, rubella): Dose 1.

◦ VAR (Varicella): Dose 1.

◦ HepA (Hepatitis A): Dose 1 (routine vaccination is a 2-dose series between 12–23 months, separated by at least 6 months).

• 15 to 18 Months:

◦ DTaP (Diphtheria, tetanus, acellular pertussis): Dose 4.

• 6 to 18 Months (Range):

◦ HepB (Hepatitis B): Dose 3 (must be at least 24 weeks of age).

◦ IPV (Inactivated poliovirus): Dose 3.

• Annual:

◦ Influenza: 1 or 2 doses annually depending on vaccination history

Core Definition and The Three Principles

Atraumatic care is defined as therapeutic care that minimizes or eliminates the psychological and physical distress experienced by children and their families within the health care system. Rooted in the premise of "do no harm," this approach relies on three fundamental principles:

1. Preventing or minimizing physical stressors: This includes avoiding pain, sleeplessness, and bodily injury. Nurses should utilize pharmacological interventions and comfort positions, such as "therapeutic hugging" (holding the child securely to prevent movement without forceful restraint), rather than "holding down" a child.

2. Preventing or minimizing child-family separation: Recognizing the family as the patient, nurses must support family-centered care and allow parents to stay with their children during procedures whenever possible.

3. Promoting a sense of control: Hospitalization often induces helplessness; nurses can counter this by respecting home routines, allowing choices (e.g., which juice to drink), and fostering a partnership where the child and family actively participate in care.

Therapeutic Communication and Psychological Safety

Effective interaction is vital for reducing anxiety and is dictated by the child's developmental stage.

• Developmental Approaches: Infants rely on touch and tone, while toddlers and preschoolers require simple, concrete language and play. School-age children benefit from explanations and being allowed to ask questions, whereas adolescents require privacy, confidentiality, and respect for their independence.

• Language Selection: Nurses must avoid medical jargon that can be misinterpreted (e.g., using "special kind of sleep" instead of "put to sleep" to avoid fear of death, or "tube" instead of "catheter").

• The Child Life Specialist (CLS): These professionals are essential for "high-value" care; they provide nonmedical preparation for surgeries, facilitate therapeutic play (an emotional outlet for stress), and act as advocates to foster the child’s well-being. Utilizing a CLS is considered an indicator of excellence in pediatric care.

Family-Centered Care and Cultural Competence

Family-centered care acknowledges that the family is the constant in a child's life and the primary source of strength. It requires a partnership based on respect, information sharing, and collaboration.

• Cultural Humility: Nurses must identify who the decision-makers are and respect cultural practices.

• Language Access: When a family does not speak English, trained interpreters are essential; family members should not be used as interpreters to prevent medical errors and maintain confidentiality.

• Assessment: Before teaching, nurses must assess learning styles, literacy levels, and barriers such as language or pain.

• Developmental Teaching: Toddlers should be told about procedures immediately beforehand to prevent anxiety, while school-age children can be prepared days in advance.

Procedural Preparation and Support

Preparation is key to minimizing trauma.

• Before: Explain what will happen using sensory details (what the child will hear, see, or feel) to lower anxiety.

• During: Use distraction (blowing bubbles, singing) and parental support rather than restraint.

• After: Encourage medical play (using puppets or dolls) to allow the child to express feelings, and offer praise for their cooperation