What does the nurse anticipate that a preschooler will perceive death as?

11

CARING FOR CRITICALLY ILL CHILDREN AND THEIR FAMILIES

Jodi E. Mullen and Mary Frances D. Pate

AJ was almost 2 years old and had never been in the hospital. In the weeks before admission, his parents noticed that he was holding his head to one side and resisting efforts to straighten it. AJ was also becoming ataxic. A few days before admission, he experienced emesis and became lethargic. His parents were frightened when they were told that AJ had a malignant brain tumor. He was admitted to the pediatric intensive care unit (PICU) after craniotomy for removal of the tumor, was medically stable, and required routine postoperative care. The morning after surgery, AJ was awake and looked around but avoided eye contact. He refused to smile or to pay attention to books or toys. He held his special blanket close to his face. His eyes were huge under the gigantic turban of gauze and tape. With pain medication, he relaxed somewhat but still refused to interact with his nurse.

AJ initially brightened when his mother arrived but showed little interest in her efforts to beguile him. Because AJ was preverbal, it was impossible for him to tell us why he was so unhappy. As his mother talked, she stated that AJ was one of four boys. His oldest brother was almost 5 years old, the next boy was 3 years old, and AJ had a twin brother, NJ. The boys’ father was at home with them until grandparents arrived from another state to help with their care.

AJ’s mother was assured that the children were welcome to visit and that the certified child-life specialist would help them understand what to expect before coming into the unit. When the rest of the family arrived, AJ was observed closely. The sight of his father and older brothers elicited a response similar to that of his mother’s arrival, but when AJ saw his twin brother, a metamorphosis occurred. When twin NJ saw AJ, he broke loose from his father’s hand and ran to the bed. It was suggested that his mother pick up NJ and place him on the bed next to AJ, at which time AJ became a “new man.” He sat up straight, looked around the room, and smiled with his nurse and his entire family. AJ’s twin had brought Mylar balloons, and within minutes both AJ and NJ were hitting the balloons and laughing out loud. AJ’s mother later expressed her feelings about the encounter. When she and AJ’s father had seen the change in their son, they were able to remain hopeful about their ability to face the future. Their need, at that time, was for their family to be together. AJ’s special need was to be with his twin brother.

Regardless of the anticipated outcome, admission of a child to the PICU is a highly stressful event for families. Effective pediatric critical care nurses see the child and family as an integral unit that is central to the healthcare system and are perceptive to the needs of the entire family as they move through the crisis. Nurses who view patients and families as partners in care acknowledge both the psychosocial and physical needs of the developing child and family. When guided by the American Association of Critical-Care Nurses (AACN) Synergy Model for Patient Care, nursing practice places the patient’s and the family’s needs as its central or driving force. When nursing competencies are based on these needs, optimal patient outcomes result (Curley, 2001). By practicing within the Synergy Model for Patient Care, the pediatric critical care nurse can articulate how he or she contributed to the patient’s outcomes.

THE SYNERGY MODEL FOR PATIENT CARE

The AACN Synergy Model for Patient Care was initially developed by the AACN Certification Corporation to serve as the foundation for certifying critical care nursing practice (AACN Certification Corporation, 2015; Hardin & Kaplow, 2017).

A.    Core Concepts

The following are core concepts of the Synergy Model for Patient Care:

2B.    Patient and Family Characteristics

Every patient and his or her family bring a unique set of characteristics to the care situation. Each characteristic exists along a continuum, and the patient can fluctuate along that continuum as his or her needs evolve over time.

C.    Nurse Competencies

Nurse competencies are driven by the needs of the patient and family. These competencies reflect the integration of nursing knowledge, skills, and experiences that are required to meet the patient’s and family’s needs and to optimize their outcomes. Each competency has different levels of experience ranging along a continuum from novice to competent to expert practitioner. Although the competencies, as a whole, reflect the entirety of nursing practice, each competency becomes more or less important depending on the patient’s needs at the time.

D.    Outcomes

Optimal outcomes result when the patient characteristics and nursing competencies are matched. Because the Synergy Model for Patient Care views the patient and family as active participants in the model, the outcomes measured should be patient and family driven. The following are examples of potential outcomes to be measured (Curley, 2001).

The following case study illustrates the use of the Synergy Model for Patient Care in practice:

DK, a 9-year-old male, was diagnosed with asthma at the age of 4. He presented at the emergency department with a 24-hour history of increasing difficulty breathing, wheezing, and coughing. DK has been hospitalized once or twice a year since diagnosis and has been in the PICU on three occasions. He was placed on continuous oxygen and nebulized aerosol therapy and was admitted to the PICU for further observation and care. DK was admitted within the past hour and a physical assessment had been completed. In addition, he was 3evaluated from a nursing perspective using the Synergy Model for Patient Care. According to the patient characteristics of the model, he could be described as follows.

Stability

DK was moderately stable. He was currently able to maintain a steady state but had the potential of deteriorating. He was receiving oxygen, aerosol treatments, and intravenous (IV) fluids. He was tachypneic and tachycardic and had moderate work of breathing.

Complexity

DK’s case was mildly complex. Currently, only one body system was affected. His family system was relatively uncomplicated; his mother was a single parent and DK had two younger siblings, aged 7 and 4 years.

Predictability

DK’s condition was moderately predictable. He was moving along the expected course of his illness. Although he has been in the PICU on three previous occasions, he had not required mechanical ventilation and had always improved as expected once therapies were initiated.

Resiliency

DK was highly resilient. He had no other underlying conditions that would complicate his situation and had demonstrated previously that he could return to his usual level of functioning.

Vulnerability

DK had a low level of vulnerability. He was only mildly susceptible to stressors that might affect his outcome. This susceptibility was influenced by his history of asthma, previous medication regimen, and young and relatively healthy physique.

Participation in Decision Making

DK and his mother both had a high level of participation. He was alert and asking questions and had a fairly good understanding of his condition and what would help him get better. His mother was present and asking appropriate questions.

Participation in Care

DK and his mother both had a high level of participation in care. His mother had made care arrangements for her other children so as to allow her to remain at the hospital with DK. She was informed about our unit’s family-centered care philosophy and invited to participate as a partner with staff in DK’s care.

Resource Availability

DK and his mother had moderate resource availability. His mother expressed some financial concerns related to recently changing jobs and not yet having health insurance for her family. In addition, the family car had broken down and they were relying on public transportation. She did have an extended family that was supportive of her situation and her son’s medical needs.

By having a holistic picture of DK and his family’s characteristics, nurses were able to think about what nursing competencies would be an important match for improved patient outcomes. Although all the competencies are important, some would be more valuable in this situation. Nurses would need to rely on strong clinical judgment skills to monitor DK for improvement or worsening of his condition. Nurses would use caring practices to create a therapeutic environment for this family, and nurses would be vigilant to prevent complications from DK’s therapies and the hospitalization itself. Nurses would use collaboration skills when working with him and his mother and also in determining whom to consult to help with the family’s financial and transportation needs. Finally, nurses would be a facilitator of learning by ensuring that DK and his mother received additional asthma education.

Outcome goals were discussed with DK and his mother, and we agreed that satisfaction with care, absence of complications, and progressive improvement with discharge from the PICU and, eventually the hospital, were important.

CHILDHOOD DEVELOPMENT: PSYCHOSOCIAL, EMOTIONAL, AND COGNITIVE FACTORS

Knowledge of normal growth and development and the ability to assess the child’s developmental level are crucial to working effectively with children and parents in any healthcare setting. Historically, children used to be viewed as small adults. Pediatric nurses now understand that using a developmental perspective is the ideal norm. Those who experience children as individuals at a particular level of development find caring for children a rich and rewarding adventure.

The following section describes general childhood developmental concepts. Individual differences exist, and these stages serve as a general guide for the nurse. Erikson’s stages of psychosocial development, 4Freud’s theory of personality development, and Piaget’s stages of cognitive development are summarized.

A.    Developmental Stages in Infancy (0–12 Months)

B.    Developmental Stages of Toddlers (1–3 Years)

C.    Developmental Stages of Preschoolers (3–5 Years)

D.    Developmental Stages of School-Age Children (6–12 Years)

E.    Developmental Stages of Adolescents (12–18 Years)

DEVELOPMENTALLY APPROPRIATE ASSESSMENT OF CHILDREN

Children usually respond well to honesty, gentleness, and respect. Most children want to please their parents and other adults as well.

A.    General Principles for Working With Children

B.    Principles for Working With Infants

C.    Principles for Working With Toddlers

D.    Principles for Working With Preschoolers

E.    Principles for Working With School-Age Children

F.    Principles for Working With Adolescents

G.    Principles for Working With Adolescents as Parents

STRESS RESPONSES AND COPING BEHAVIORS

Critical illness and hospitalization in the PICU are stressful experiences for all children. This stress arises not only from the underlying medical condition, but also from the PICU environment and experience itself.

A.    Physiologic Response to Stress

When a human body is faced with a stressful stimulus, the autonomic nervous system is activated, releasing hormones that control physiologic defense mechanisms. The following are signs of this nervous system activation:

7B.    Response to Psychological Stress and Hospitalization

An important part of the human stress response is what the child thinks or feels about what is happening. As children mature, their perception of stress becomes more important to their overall stress response.

ISSUES RELATED TO HOSPITALIZATION

A.    Fear and Anxiety

Most children experience some fear and anxiety when hospitalized. Fears may be reality based, related to previous procedures or hospitalizations, or the result of magical thinking. Information given to a child by friends or relatives may be incorrect, and the child may inadvertently hear frightening comments made by others. Children in the hospital may witness fear in others and may see or hear things from other bed spaces that cause fear and anxiety.

B.    Pain

Children in pain frequently receive too little medication or they may receive no analgesia at all. Despite an increase in the emphasis on pain management in children over the past several years, some misconceptions about children and pain persist (Table 1.1). AACN’s Essentials of Pediatric Critical Care Orientation (EPCCO) provides a broad overview of this topic, and can be used to orient nurses caring for critically ill children, and as a review to reinforce concepts.

TABLE 1.1    Misconceptions About Pain in Children

C.    Separation From Family and Friends

Support from family and friends is important to children, and the need for support and closeness increases during times of illness. If children are separated from loved ones, long-term effects, such as impaired trust, diminished intellectual and motor functioning, and disturbed behavior, are possible. Preventing separation of the child from his or her family is the standard of care in pediatric acute and critical care units. Family-centered care practices ensure the closeness of loved ones as familiar trusted sources of security.

D.    Limited Understanding

Misconceptions about illness, treatment, and caregiver motives may result from a child’s limited understanding. Magical thinking may lead children to conclude that an illness is punishment for misbehavior. Words such as “cut” or “take” can be misconstrued by children and increase levels of fear. The vivid imagination of childhood supplies answers to any unanswered questions or unexplained situations.

E.    Loss of Control

Hospitalized children are rarely given choices related to their treatment regimen, which results in little sense of control. Physical restraint can increase the anxiety related to hospitalization and, when at all possible, should be reserved as a measure of last resort. Frequently restraints can be avoided with proper preparation of the child, and therapeutic holding may be used for temporary immobilization. Therapeutic holding with the child on the caregiver’s lap or in a hug position allows close physical contact with a caregiver or family member during procedures and helps to decrease patient anxiety. Allowing choices, when choices are truly present, can assist the child in dealing with feelings that result from the perceived loss of control.

ISSUES RELATED TO CRITICAL CARE UNITS

FB was 5 years old and had been admitted to the PICU after she fell from a second-story window while jumping on the bed. She had experienced a traumatic brain injury from the fall and was intubated. She lay unresponsive, sedated, and in a darkened room to decrease stimuli as the rhythmic swoosh of the ventilator breaths continued. On occasion, an alarm or a conversation would break the silence. Another healthcare provider entered the room to examine her and without a word started turning her side to side as FB winced in pain. The nurse gasped, went to the bedside, and stopped any further “assessment.” As the nurse whispered a soft-spoken apology to FB, a tear ran down her face.

A.    Sensory Overload

Sensory overload can occur for the child in the PICU because of the around-the-clock activity.

B.    Sensory Deprivation

Although there is an excess of stimulation in most PICUs, there is a lack of the normal types of stimulation beneficial for children. Mealtimes and clothing will most likely change. Important bedtime rituals are changed, especially with unfamiliar blankets, beds, toys, and pajamas. Adults other than parents are directing the child’s activities and schedule. Restricted activity leads to feelings of isolation and boredom and interferes with the child’s ability to cope with the stress of hospitalization. Physical activity is a method frequently used by children to cope with stress. Sensory deprivation may lead to depression and regression and can interfere with normal development. Children who are intubated also have difficulty communicating and may fear that they might never be able to speak again.

C.    Sleep Deprivation

Children in the PICU may experience sleep deprivation because of repeated caregiver interactions and environmental stimuli, and each child has a unique sleep experience (Kudchadkar, Aljohani, & Punjabi, 2014; Table 1.2). Sleep assessment is difficult as each child is an individual and differs by age, illness, medication, and type of interventions (Kudchadkar et al., 2014). Day–night orientation can be lost because children in the PICU sleep less than normal, and often any sleep that is achieved will be interrupted. The physical effects of sleep deprivation may result in immune-system vulnerability, inefficient temperature regulation, and impaired healing of cells and tissues. Anxiety, irritability, confusion, and hallucinations are just a few of the psychological symptoms that may be seen in children experiencing sleep deprivation (Gregory & Sadeh, 2012). Nonpharmacologic interventions that can improve sleep include subdued lighting, unit quiet times, earplugs, and formalized noise-reduction protocols (Kudchadkar et al., 2014).

TABLE 1.2    Causes of Sleep Deprivation in the PICU

NREM, nonrapid eye movement (sleep); REM, rapid eye movement (sleep).

Source: Reproduced with permission from Slota, M. C. (1988). Implications of sleep deprivation in the pediatric critical care unit. Focus on Critical Care, 15(3), 35–43.

D.    Lack of Privacy

Some PICUs are large, open units where patients and families experience “living in public.” Open areas allow “strangers” (other visitors and hospital employees) to see the children and their parents. Children may also be aware of procedures and crises that occur at beds close to their own, and the need for close observation sometimes leads to physical exposure of the child.

E.    Technology Dependence

The number of technology-dependent patients has increased since the development of mechanical ventilation (Rennick & Childerhose, 2015). Critically ill, unstable children are the highest priority in the PICU. Chronically ill but stable children who are technology dependent may receive less developmental and psychosocial support when the PICU is busy or understaffed. Technology may interfere with parental attachment or lead to the parents’ emotional withdrawal from their child. Technology-dependent children may experience long periods of separation from home, school, and friends. Children are aware that alarms are related to them and exhibit fear when any alarm is triggered. Chronic sleep disruption can affect learning, growth, healing, and developmental progress.

11F.    PICU Design Considerations

Issues associated with hospitalization may be decreased through the intentional design of critical care units. AACN partners with the Society of Critical Care Medicine and the American Institute of Architects Academy of Architecture for Health to recognize such units. These care areas integrate the needed functionality of a high-acuity setting with the humanitarian needs of patients and families.

DEVELOPMENTALLY APPROPRIATE INTERVENTIONS

A.    Pain Management

TABLE 1.3    Guidelines for Age-Appropriate Assessment of Pain

CRIES, Crying Requires increased oxygen administration, Increased vital signs, Expression, Sleeplessness; FLACC, Faces, Legs, Activity, Cry, and Consolability; r-FLACC, Faces, Legs, Activity, Cry, and Consolability-Revised; INRS, Individualized Numeric Rating Scale; N-PASS, Neonatal Pain Agitation Sedation Scale; NCCPC, Non-Communicating Children’s Pain Checklist; NFCS, Neonatal Facial Coding System; NIPS, Neonatal Infant Pain Scale; PIPP-R, Premature Infant Pain Profile-Revised.

TABLE 1.4    Age-Appropriate Nonpharmacologic Pain Management Strategies

Note: To be combined with appropriate analgesia, as indicated.

16

17B.    Iatrogenic Withdrawal Syndrome

Children who receive prolonged administration of opioids and/or benzodiazepines (>5 days) are at risk for iatrogenic withdrawal syndrome, which can occur with the abrupt discontinuation or too-rapid weaning of these medications. Symptoms may include agitation, increased motor tone, dilated pupils, sweating, nasal congestion, fever, mottling, seizures, poor sleep, hallucinations, grimacing, yawning, poor feeding, vomiting, and diarrhea (Mondardini et al., 2014). An assessment tool, such as the Withdrawal Assessment Tool-1 (Franck, Scoppettuolo, Wypij, & Curley, 2012) or the Sophia Observation withdrawal Symptoms-scale (Ista, de Hoog, Tibboel, Duivenvoorden, & van Dijk, 2013), should be used to identify and monitor withdrawal symptoms. Switching to medications with a longer half-life, using the enteral route when possible, and gradually tapering medications are appropriate interventions for iatrogenic withdrawal (Mondardini et al., 2014). The family or the older child may fear medication addiction. Help them understand that tolerance and dependency are physiologic phenomenon and that the child is not psychologically addicted to the medication. This fact is often not well understood by families and may be a source of anxiety.

C.    Communication

The nurse’s words, tone of voice, body language, facial expressions, actions, and emotions all convey messages to patients and families. It is important to communicate in a developmentally appropriate manner. Acute and critical care nurses can use communication in a positive way to help children and families as they struggle to cope with the stress of hospitalization.

D.    Delirium

Delirium is a common yet underrecognized problem for acutely ill hospitalized children. The delirious child experiences an onset of cerebral dysfunction with a change or fluctuation in baseline mental status, which includes inattention and either disorganized thinking or an altered level of consciousness (AACN, 2016a).

E.    Interventions for Sleep Deprivation, Sensory Deprivation, and Sensory Overload

F.    Facilitation of Play

Having an opportunity to play while in the hospital normalizes and humanizes the environment while allowing the child to release tension and express feelings. Play can also provide diversion while giving children the opportunity to exercise control over their hospital experience. The child who is acutely or critically ill presents a different challenge to caregivers interested in providing play opportunities for their patients.

TABLE 1.6    Sample Schedule to Enhance Circadian Rhythms During Hospitalization

Note: Schedule adapted as possible during hospitalization and recovery.

G.    Provision of Psychosocial and Emotional Support for the Child

SM and EM were 3-year-old and 7-year-old siblings who were unrestrained during a motor-vehicle crash. Both their parents suffered extensive injuries and were being treated in the adult intensive care unit. The sisters had serious injuries but were being admitted to the PICU in stable condition. Both were awake and experiencing fear and pain.

SM cried when the nurse placed her in the bed and attached electrodes and monitoring equipment to her body. She continually tried to remove her IV catheter. Her nurse spoke in soothing tones as pain medication was administered, and she was given a toy to distract her attention away from the IV. Soon SM’s grandparents arrived, and she was observed to visibly relax when she made reassuring eye contact with a familiar face.

In the next room, EM was very quiet. Because of her injuries, her eyelids were swollen shut. She would not speak but would nod “yes” or “no” when asked a question. EM was oriented to the room around her and was told her why she was in the hospital, reminding her that nothing was her fault. She nodded “yes” when asked if she wanted to listen to cartoons on the television. Her nurse arranged for a volunteer to sit with EM when her grandparents could not be with her.

PSYCHOSOCIAL NEEDS OF FAMILIES

A.    Family Assessment

B.    Interventions With Families

Multiple studies have been done to identify family needs when a child is critically ill. Families want reassurance, access to the ill child, and information. Nurses caring for the child and family unit ensure that interventions take into account concepts of family-centered care, which allow for family involvement (as much as desired by the family) in the planning and implementation of care. Family-centered care has been shown to be beneficial to the child and family unit—and healthcare providers—through intentional planning, implementation of family-centered care policies, education, and ongoing family-centered competency building by the entire healthcare team (Coats et al., 2018 ; see Chapter 10 for more information on family-centered care).

TABLE 1.7    Nursing Mutual Participation Model of Care

Source: Reproduced with permission from Curley, M. A. Q., & Meyer, E. C. (2001). Caring practices: The impact of the critical care experience on the family. In M. A. Q. Curley & P. A. Moloney-Harmon (Eds.), Critical care nursing of infants and children (2nd ed.). Philadelphia, PA: W. B. Saunders.

INTERVENTIONS FOR DYING CHILDREN

NK, a previously healthy 9-month-old, had been admitted to the PICU overnight and diagnosed with bacterial meningitis. His condition had quickly deteriorated, and he required intubation and placement on a mechanical ventilator. Medications were being used to improve his blood pressure, and an arterial catheter and a central venous catheter had been placed. NK was not responsive and did not seem to be aware of anything taking place around him.

As the shift began, the nurse quickly surveyed the situation in NK’s room. It would be challenging to keep up with the multiple care priorities this patient needed, including ongoing assessments, administration of blood products, antibiotics, and placement of a device to monitor pressure in the brain. In addition, two devastated parents clung to each other in the corner of the room, unable to fathom what unspeakable things were happening to their precious child. His nurse established communication with NK’s parents by introductions. Using simple words, his nurse explained what the nurses were doing for NK and answered what questions his parents could bring themselves to ask. Although not aware of it at that moment, his nurse was soon to become the catalyst that would help this family start transitioning from being the “parents of a healthy boy” to the “parents grieving for a lost child.”

The extremely high pressure in NK’s brain then confirmed the worst: A child who had been eating Cheerios and playing with his 2-year-old brother just yesterday was now neurologically devastated to the point that he would not survive. The critical care team’s outcome goals for NK changed from curing his illness to orchestrating his peaceful and dignified death experience.

The nurse facilitated communication between the pediatric intensivist and the parents and talked about how the parents would say good-bye to their son. The PICU has a strong bereavement philosophy, and the program has many interventions that we offer families during this 26devastating time. NK’s parents were assisted in deciding what options would be right for themselves and their son. Supported by the research-based policy of family-centered care, loving grandparents, aunts and uncles, a godfather, and the family priest encircled the parents when, for the last time, the child was placed in his mother’s arms. At the parents’ request, the intensivist and the nurse joined this intimate circle. All eyes were overflowing with tears when the child’s godfather said a prayer for the parents and then prayed blessings on the critical care team.

A.    Pain Management in the Terminally Ill

B.    Forgoing Life-Sustaining Medical Treatment

C.    Caring for the Potential Organ and Tissue Donor

D.    Caring for the Conscious, Dying Child

The conscious, dying child may benefit from the opportunity to communicate about his or her own personal dying process. The use of an age-appropriate, advance-planning guide can provide a framework for guiding this dialogue (Mullen, Reynolds, & Larson, 2015). Occasionally, families insist that children not be told about their impending death. Whether and how impending death is disclosed to a child can be influenced by the family’s religious and cultural heritage, previous experience with death, and other influences. It is important to help the parents realize that the child probably already knows or suspects and may not talk about it simply because he or she senses the parents’ avoidance.

E.    Caring for Bereaved Families

Grief is the cognitive, emotional, physical, psychological, and spiritual response to an overwhelming loss. Grief is frequently described in terms of stages, phases, or symptoms. Although these references are helpful in understanding grief, grief is not a linear process. The bereaved person moves in and out of the phases at various times in the grief process. Symptoms of one phase may overlap with another, and time limits should not be imposed on the individual for completion of this painful process. When a child dies, parental grief is the subjective, individualized response to a hideous loss. The impact is long lasting and life altering.

Pediatric critical care nurses play a special role and have myriad opportunities to help children and their families cope with hospitalization, the intensive care unit environment, and the stressors that accompany this disruption to their daily lives. Children should be approached in a manner consistent with their developmental level and interventions tailored to their unique needs. Hospitalized children require assistance to help them cope with fear, anxiety, and pain. Nursing interventions will focus on facilitating communication, sleep, play, and providing for the emotional needs of the child and family. Finally, when children and their families must face the end of life, pediatric nurses will rely on important strategies to support bereavement needs.

31REFERENCES

American Academy of Pediatrics Committee on Bioethics. (1994). Guidelines on forgoing life-sustaining medical treatment [Reaffirmed 2008]. Pediatrics, 93(3), 532–536. Retrieved from pediatrics.aappublications.org/content/pediatrics/93/3/532.full.pdf

American Academy of Pediatrics Committee on Child Abuse and Neglect and Committee on Bioethics.(2000). Forgoing life-sustaining medical treatment in abused children [Reaffirmed 2007]. Pediatrics, 106, 1151–1153. doi:10.1542/peds.106.5.1151

American Academy of Pediatrics Section on Hospice and Palliative Medicine and Committee on Hospital Care. (2013). Pediatric palliative care and hospice care commitments, guidelines, and recommendations. Pediatrics, 132(5), 966–972. doi: 10.1542/peds.2013-2731

American Association of Critical-Care Nurses. (2015). The AACN synergy model for patient care. Retrieved from www.aacn.org/nursing-excellence/aacn-standards/synergy-model

American Association of Critical-Care Nurses. (2016a). AACN practice alert: Assessment and management of delirium across the life span. Retrieved from www.aacn.org/clinical-resources/practice-alerts/delirium-assessment-and-management

American Association of Critical-Care Nurses. (2016b). AACN practice alert: Family presence during resuscitation and invasive procedures. Retrieved from www.aacn.org/clinical-resources/practice-alerts/family-presence-during-resuscitation-and-invasive-procedures

Bell, L. E. (Ed.). (2015). AACN scope and standard for acute and critical care nursing practice. Aliso Viejo, CA: American Association of Critical-Care Nurses.

Berube, K. M., Fothergill-Bourbonnais, F., Thomas, M., & Moreau, D. (2014). Parents’ experience of the transition with their child from a pediatric intensive care unit (PICU) to the hospital ward: Searching for comfort across transitions. Journal of Pediatric Nursing, 29(6), 586–595. doi:10.1016/j.pedn.2014.06.001

Beyer, J. E., Turner, S. B., Jones, L., Young, L., Onikul, R., & Bohaty, B. (2005). The alternate forms reliability of the Oucher pain scale. Pain Management Nursing, 6(1), 10–17. doi:10.1016/j.pmn.2004.11.001

Board, R., & Ryan-Wenger, N. (2003). Stressors and stress symptoms of mothers with children in the PICU. Journal of Pediatric Nursing, 18(3), 195–202. doi:10.1053/jpdn.2003.38

Boerlage, A., Ista, E., Duivenvoorden, H., Wildt, S., Tibboel, D., & van Dijk, M. (2015). The COMFORT behaviour scale detects clinically meaningful effects of analgesic and sedative treatment. European Journal of Pain, 19(4), 473–479. doi:10.1002/ejp.569

Breau, L. M., McGrath, P. J., Camfield, C. S., & Finley, G. A. (2002). Psychometric properties of the non-communicating children’s pain checklist-revised. Pain, 99(1), 349–357. doi:10.1016/S0304-3959(02)00179-3

Brooten, D., Youngblut, J. M., Seagrave, L., Caicedo, C., Hawthorne, D., Hidalgo, I., & Roche, R. (2013). Parent’s perceptions of health care providers actions around child ICU death: What helped, what did not. American Journal of Hospice & Palliative Care, 30(1), 40–49. doi:10.1177/1049909112444301

Coats, H., Bourget, E., Starks, H., Lindhorst, T., Saiki-Craighill, S., Curtis, J. R., . . . Doorenbos, A. (2018). Nurses’ reflections on benefits and challenges of implementing family-centered care in pediatric intensive care units. American Journal of Critical Care, 27(1), 52–58. doi:10.4037/ajcc2018353

Curley, M. A. Q. (2001). The essence of pediatric critical care nursing. In M. A. Q. Curley & P. A. Moloney-Harmon (Eds.), Critical care nursing of infants and children (2nd ed., pp. 3–16). Philadelphia, PA: W. B. Saunders.

Curley, M. A. Q., Harris, S. K., Fraser, K. A., Johnson, R. A., & Arnold, J. H. (2006). State behavioral scale: A sedation assessment instrument for infants and young children supported on mechanical ventilation. Pediatric Critical Care Medicine: 7(2), 107–114. doi:10.1097/01.PCC.0000200955.40962.38

Curley, M. A. Q., & Meyer, E. C. (2001). Caring practices: The impact of the critical care experience on the family. In M. A. Q. Curley & P. A. Moloney-Harmon (Eds.), Critical care nursing of infants and children (2nd ed., pp. 47–67). Philadelphia, PA: W. B. Saunders.

Delaney, J. W., & Downar, J. (2016). How is life support withdrawn in intensive care units: A narrative review. Journal of Critical Care, 35, 12–18. doi:10.1016/j.jcrc.2016.04.006

de Vos, M. A., Bos, A. P., Plotz, F. B., van Heerde, M., de Graaff, B. M., Tates, K., … Willems, D. L. (2015). Talking with parents about end-of-life decisions for their children. Pediatrics, 135(2), e465–e476. doi:10.1542/peds.2014-1903

Dubois, A., Capdevila, X., Bringuier, S., & Pry, R. (2010). Pain expression in children with an intellectual disability. European Journal of Pain, 14(6), 654–660. doi:10.1016/j.ejpain.2009.10.013

Eggly, S., Meert, K. L., Berger, J., Zimmerman, J., Anand, K. J., Newth, C. J., … Nicholson, C. (2011). A framework for conducting follow-up meetings with parents after a child’s death in the pediatric intensive care unit. Pediatric Critical Care Medicine, 12(2), 147–152. doi:10.1097/PCC.0b013e3181e8b40c

Franck, L. S., Scoppettuolo, L. A., Wypij, D., & Curley, M. A. (2012). Validity and generalizability of the withdrawal assessment tool-1 (WAT-1) for monitoring iatrogenic withdrawal syndrome in pediatric patients. Pain, 153(1), 142–148. doi:10.1016/j.pain.2011.10.003

Gregory, A. M., & Sadeh, A. (2012). Sleep, emotional and behavioral difficulties in children and adolescents. Sleep Medicine Reviews, 16(2), 129–136. doi:10.1016/j.smrv.2011.03.007

Guzzetta, C. (2016). Family presence during resuscitation and invasive procedures. Critical Care Nurse, 36, e11–e14. doi:10.4037/ccn2016980

Hardin, S. R., & Kaplow, R. (Eds.). (2017). Synergy for clinical excellence: The AACN synergy model for patient care (2nd ed.). Burlington, MA: Jones & Bartlett.

Hicks, C. L., von Baeyer, C. L., Spafford, P. A., van Korlaar, I., & Goodenough, B. (2001). The Faces Pain Scale–Revised: Toward a common metric in pediatric pain measurement. Pain, 93(2), 173–183. doi:10.1016/S0304-3959(01)00314-1

Hockenberry, M., & Wilson, D. (Eds.). (2013). Wong’s essentials of pediatric nursing (9th ed.). St. Louis, MO: Mosby.

Hoover, S. M., Bratton, S. L., Roach, E., & Olson, L. M. (2014). Parental experiences and recommendations in donation after circulatory determination of death. Pediatric Critical Care Medicine, 15(2), 105–111. doi:10.1097/PCC.0000000000000035

Hsu, T., Ryherd, E., Waye, K. P., & Ackerman, J. (2012). Noise pollution in hospitals: Impact on patients. Journal of Clinical Outcomes Management, 19(7), 301–309. Retrieved from pdfs.semanticscholar.org/27db/5536c0a580983f3efd1b30374f64cacacd65.pdf

Hummel, P., Puchalski, M., Creech, S., & Weiss, M. (2008). Clinical reliability and validity of the N-PASS: Neonatal pain, agitation and sedation scale with prolonged pain. Journal of Perinatology, 28(1), 55–60. doi:10.1038/sj.jp.7211861

Hunt, A., Goldman, A., Seers, K., Crichton, N., Mastroyannopoulou, K., Moffat, V., … Brady, M. (2004). Clinical validation of the paediatric pain profile. Developmental Medicine & Child Neurology, 46(1), 9–18. Retrieved from onlinelibrary.wiley.com/doi/pdf/10.1111/j.1469-8749.2004.tb00428.x

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