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MCN, The American Journal of Maternal/Child Nursing
Issue: Volume 21(2), March/April 1996, pp 67-71
Copyright: © Lippincott-Raven Publishers.
Publication Type: [Professionally Speaking]
ISSN: 0361-929X
Accession: 00005721-199603000-00008
[Professionally Speaking] < Previous Article Table of Contents Next Article >
Nursing Standards For Child Development

JOST, KATHLEEN E.

Author Information
Kathleen E. Jost, RN, MS, a clinical nurse specialist at Children's Hospital of Oklahoma,
Oklahoma City, is a clinical assistant professor at the University of Oklahoma, Oklahoma
City.
Abstract
As the nature of child development is all-encompassing, it is essential to isolate age-
appropriate stressors and goals.

Knowledge of growth and development is fundamental to pediatric nursing and incorporated

into every aspect of nursing care. However, the use of the knowledge of development is
rarely reflected in documentation and standards of care.
In our children's hospital, the Nurse Practice Committee identified the need to incorporate
developmental outcomes into every child's plan of care or critical path and to document
developmental status in the nurse's notes. As clinical nurse specialist on the committee, I
agreed to develop the standards to assist nurses in meeting these two hospital goals.
Our early discussions underscored the difficulty inherent in writing these standards. One
nurse pointed out that everything we do involves development, from how we talk to a child,
to giving medicine, to taking a temperature. According to this nurse, it would be impossible
to include everything in our documentation. Another nurse argued that by charting in the
activity column, we were already charting development. "Up to playroom," for example,
communicates that the child is doing age-appropriate activities. Others debated the
differences in the wide variety of children and the medical diagnoses seen at the hospital,
questioning whether developmental outcomes could be the same for a child with a chronic
illness and a child admitted for routine surgery.
Some nurses wanted our developmental goal to be "Maintain normal growth and
development." Although this was appropriate, it was considered too broad. Indeed, we
questioned whether it was necessary to address every child's motor, language, psychosocial,
and cognitive development.
Our discussion led to certain common concerns: separation from parents for infants; inability
to make choices for toddlers; the fear of needles for preschoolers; and altered body image
for teenagers. It became apparent that our primary concern consisted of those aspects of
hospitalization that could potentially have an adverse effect on a child's development. I was
now able to develop a common nursing diagnosis on which to base the standard of care:
alteration in development related to the stressors of hospitalization.
The results are five age-specific standards - infant, toddler, pre-school, school-aged, and
adolescent - all based on this diagnosis. Each standard lists the unique age-specific stressors
for its age group, such as loss of autonomy for the toddler and separation from peer group
for adolescents; patient outcomes; and recommended nursing actions. Since procedures are a
stressor for all children, age-specific outcomes and actions for preparing children for
procedures are included in all standards. Each standard contains several stressors and patient
outcomes, which are not applicable to all children in the designated age group. Based on the
assessment, the nurse must choose the most appropriate outcome for the child, thus allowing
individualization of the plan of care.
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Each standard also includes a reference list of three textbooks, in case the nurse needs more
information in working with a specific child. The three books selected are readily available,
either on the unit or in the hospital library (1-3). Whaley and Wong's Essentials of Pediatric
Nursing is updated regularly and is particularly recommended for its extensive bibliography
on growth and development, which includes relevant research articles. Nursing Care of the
Critically Ill Child, besides being a good resource, lends credibility to the importance of
developmental goals for children who are seriously ill. Emotional Care of Hospitalized
Children is useful for its basic guidelines on preparing children for procedures.
Using the Standards in Charting
After the standards were written, each nursing unit developed its own specific teaching
module. Nurses selected two case studies that represented patients typically seen in the unit.
They then wrote sample care plans and entries on the nursing progress notes.
The biggest challenge for the nurses was writing the progress notes. The exercise pointed to
two recommendations for charting.
1) Keep the charting focused on the outcome identified on admission in the care plan or
critical path. Our hospital uses focus charting, which means that a focus is identified in the
progress notes. Using only the word development as the focus can lead to a common
mistake. For example, suppose that the admission nurse admits a baby, does a
developmental assessment, identifies separation from parent as a stressor and parent-infant
attachment as the desired outcome, but fails to include the wordattachment when recording
the goal.
The next day, the nurse assigned to the baby writes under "Focus: Development" a detailed
developmental assessment, such as "baby lifts head 45° off mattress when prone, visually
tracks 180°." This time-consuming entry is totally unnecessary, since the concern was
attachment, not physical development.
Appropriate charting would address parent-infant attachment; for example, "Mother present
in room but afraid to touch baby. `I don't want to hurt him'." Using a key word from the
outcome in the focus statement, such as"Focus: Development/Attachment," will help avoid
the original mistake.
2) Keep the chart notes concise. This sounds
like an obvious suggestion in today's health care
environment, where nursing time is at a
premium, especially as nurses anticipated that
developmental charting would require too much No
time. Surprisingly, however, nurses needed No No Caption
assistance in writing concise notes, identifying Caption Caption Available...
key phrases, and making to-the-point entries. Available... Available...
The problem was not a lack of time, but, rather,
knowing how to chart effectively. Tables
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Consider, for example, a chart entry for "Focus: Development/Procedures." In the data
column, the nurse wrote a lengthy description of a child's behavior when the phrase "child
uncooperative during procedure" would have sufficed.
Related Materials
Implementation of the nursing standards led to the development of other aids that ultimately
strengthened nursing care. For example, one nursing action indicated on the Infant Standard
is to provide parents with information related to developmental sequelae of hospitalization,
such as regression and heightened stranger anxiety. Focus on this aspect of infant care led to
home care instruction that has been helpful to parents. (See Home Care Instructions:
Common Baby Behaviors, a one-page handout included with the standards.)
One nursing aid revised as a result of the standard was the developmental assessment tool.
As the developmental standard is based on using the admission assessment to individualize
patient outcomes, we reviewed the assessment data we were obtaining and adapted the form
for our present needs.
Developmental assessment forms are divided into five age groups, identical to the standards.
Data are collected on developmental milestones, as well as other information that will
identify potential stressors of hospitalization. Pertinent information includes parents' visiting
plans, reaction to separation from parents, routines at home, independence in activities of
daily living, usual comfort measures, school performance, participation in social activities,
and peer relationships.
During the development of critical pathways, it became necessary to integrate
developmental support given to children and families as a critical component of care.
However, as critical pathways for specific medical diagnoses usually apply to several age
groups, predetermined developmental outcomes and interventions could not be included. We
thus designed pathways with "Development" as a major category, along with "Medications"
and"Nutrition/Hydration." The nurse individualizes the pathway by writing in the
appropriate stressors, outcomes, and interventions. Although this step requires additional
time, using the nursing standards facilities the process.
Back to Top
Evaluation of the hospital's goals for the broad area of child development- including
documentation in the care plans, critical pathways, and progress notes - is ongoing. The
Quality Assessment/Improvement Committee monitors indicators on development and has
noted that many nursing units are meeting their goals. Because of the work done to create
the Nursing Standard: Child Development, nurses are able to meet documentation
requirements and communicate the developmental care at the heart of nursing for children.
NURSING STANDARD: TODDLER DEVELOPMENT
Problem: Altered development related to the stressors of hospitalization.
Toddler Stressors:
Separation from parents
Loss of autonomy
Procedures
Decreased sensory stimulation to promote development
Parental knowledge deficit related to hospitalization
Outcomes:
1. Toddler tolerates separation from parents as evidenced by no symptoms of despair of
detachment (separation anxiety).
2. Toddler demonstrates autonomy as evidenced by making choices and maintaining rituals.
3. Toddler tolerates procedures with no adverse developmental consequences.
4. Toddler engages in age-appropriate play activities for stimulation and diversion.
5. Parents verbalize understanding of developmental support for hospitalized toddler.
Nursing Actions:
1.1 Facilitate parental visiting.
1.1.1 Inform parents of facilities available for parents, such as parent bed, lounge, showers,
and cafeteria.
1.1.2 Assist parents in solving problems of potential barriers to visiting, such as
transportation, siblings, work.
1.1.3 If parent is unable to visit, assist to identify alternative caregiver for infant;
grandparent, relative, or friend.
1.2 Make recommendations to parents on how to depart from child.
1.2.1 Be honest with child when it's time to leave.
1.2.2 Inform child about the time of their return in terms that child will understand. For
example, at breakfast time or when Barney is on television.
1.2.3 Advise parents to leave immediately after announcing their departure.
1.3 Recommend that parents bring familiar objects to remind child of home and family,
especially if parents are unable to visit. Suggestions include comfort objects (blanket or toy),
family photographs, favorite toy, drawings by siblings, or cassette/video recording of family.
1.4 Inform parents about separation anxiety.
1.4.1 Importance of parental visiting.
1.4.2 Stress that protest when parent leaves, although difficult for parents, is expected
behavior and indicative of normal development.
1.4.3 Explain that protest may include verbal cries, physical aggression, or clinging to
parents.
1.5 Encourage child to talk about parents and/or other significant family members.
2.1 Give child opportunity to make choices: Do you want apple juice or orange juice? Do
you want your bath now or after breakfast?
2.2 Try to maintain or incorporate aspects of home routines for feeding, bedtime, bathing,
toileting, naps, and play.
2.3 Document developmental regression that occurs.
2.3.1 Do not attempt to change regressive behavior.
2.3.2 Instruct parents that regression is a normal reaction to the stress of hospitalization and
the child's loss of control.
2.3.3 Provide comfort measures.
2.3.4 Continue to offer child the opportunity to develop autonomy through exercising
control and maintaining rituals.
2.4 Set limits, as necessary. Assist parents in identifying behaviors that can be tolerated and
when to set limits. For example, cannot pull IV out, has to take medicine, can verbally
protest but should not hit.
3.1 Prepare equipment and supplies prior to involving child.
3.2 Perform painful procedures in treatment room rather than the child's bed.
3.3 Prepare child just before carrying out procedure.
3.4 Teaching sessions should be limited to 5 to 10 minutes.
3.5 Explanations should be in terms of what child will see, hear, feel, or smell.
3.6 Do not use body outlines or give information about the inside of body, as toddlers do not
understand this.
3.7 Avoid talking about toddler within his hearing - prepare parents separately.
3.8 Choose words carefully. Toddlers' interpretations are literal (i.e., dye-die, IV-ivy, stick).
3.9 Use a firm, direct approach.
3.10 Give only one direction at a time. For example, "Sit down" and then,"Squeeze my
hand."
3.11 Use distraction techniques, as appropriate, during procedure.
3.12 Allow parent to be present during the procedure.
3.13 Postprocedure, allow child to play with safe equipment used in his treatment, such as
stethoscope, syringe.
3.14 Provide comfort measures after procedure is completed and involve parent in
comforting child.
4.1 Provide age-appropriate toys for visual, auditory, and tactile stimulation. Recommended
toys for this age are musical toys, simple picture books, nesting toys, dolls, stuffed animals,
cars, or any toy that is sturdy, easily washed, and has no small parts.
4.2 Provide, as appropriate, activities to stimulate gross and fine motor skills. Toys to
provide motor stimulation are nesting toys, any toy that involves putting objects into a
container, books, or dolls that provide practice on self-help skills (buttoning, zippers), shape
sorters, and push-pull toys.
4.3 Provide toys that will provide an outlet for feelings of anger or frustration, if indicated.
For example, toys that involve the opportunity to pound, hammer, throw, or punch.
4.4 Consult child life or physical therapy/occupational therapy as necessary or refer to
Volunteer Service.
5.1 Give parents information on how to support child during hospitalization.
5.2 Prepare parents for possible behavioral reactions to hospitalization, such as regression,
excessive clinging, vigorous protest to separation, or aggression.
5.3 Assist parents in understanding these behaviors as a normal reaction to the stress of
hospitalization.
5.4 Instruct parents to provide support and secure environment and not to use increased
discipline in an attempt to "correct" this behavior (although limit setting may be necessary).
5.5 Advise parents that these behaviors will resolve on their own as child feels secure and
regains a sense of autonomy.
Back to Top
Copyright © by Children's Hospital of Oklahoma, Oklahoma City, OK, 1995.
HOME CARE INSTRUCTIONS: COMMON BABY BEHAVIOURS
INTRODUCTION
For babies, being ill and being in the hospital can be very stressful. Some of the things in the
hospital that can be especially stressful to babies are as follows: 1) contact with many
strangers; 2) painful or uncomfortable procedures that are done; 3) separation from parents
or other family members. Fortunately, babies have a great ability to deal with these stressors,
especially with the help of their mothers and fathers.
INSTRUCTIONS
A. Baby reactions after hospitalization:
Some of the baby behaviors that can be expected after hospitalization are listed below.
These behaviors are a normal reaction to hospitalization. Not all babies will do these things,
but being prepared for their possible occurrence is helpful.
1. Clinging to parent. May want parent in sight all the time.
2. Increased fear of strangers.
3. Vigorous protest to being separated from mother.
4. Demanding parents' attention.
5. Changes in sleep and eating patterns.
6. Shorter sleeping times.
7. Increased nighttime wakenings.
8. Baby may want to do things he did at a younger age, for example, a child who was
drinking mostly from a cup may now want a bottle again.
B. What to do:
1. Your baby is not spoiled and is not misbehaving. Although this reaction to hospitalization
can be upsetting to a busy parent, your baby's behavior will return to normal in a few weeks.
2. Help your baby feel secure by giving the attention baby wants and respect baby's fears of
strangers.
3. Spending extra time holding, rocking, and cuddling your baby will help make the first
days at home easier.
4. Trying to change or stop these behaviors is not necessary.
5. DO NOT use discipline to try and force your baby to give up these behaviors.
C. At home:
Behaviors that are expected after a baby is discharged from the hospital have been
described. These behaviors will go away by themselves in about three (3) weeks or less, as
your baby feels secure and comfortable at home.
PHONE NUMBERS
If you are concerned about your baby's behavior after hospitalization, discuss your concerns
with your physician or nurse practitioner.
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Copyright © Children's Hospital of Oklahoma, Oklahoma City, Oklahoma, 1995.
REFERENCES
1. Hazinski, M.F. Nursing Care of the Critically Ill Child, 2nd ed. St. Louis, Mosby-Year
Book, 1992. [Context Link]
2. Petrillo, M., and Sanger, S. Emotional Care of Hospitalized Children: An Environmental
Approach, 2nd ed. Philadelphia, Lippencott, 1980. [Context Link]
3. Wong, D.L. Whaley and Wong's Essentials of Pediatric Nursing, 4th ed. St. Louis,
Mosby-Year Book, 1993. [Context Link]

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< Previous Article Table of Contents Next Article > Charting
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