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Type 1 diabetes mellitus has increased in children by 23% from 2001 to 2009. Rural communities additionally have increased disparities related to access barriers and a large minority population with poorer overall health. Research evidence supports telemedicine as an effective alternative to bring preventive diabetes care to remote areas. This article presents an overview of the leadership role of advanced practice registered nurses (APRNs) with the implementation and evaluation of a pediatric diabetes telemedicine program at a rural pediatric outpatient specialty clinic in partnership with a tertiary center telemedicine network. The telemedicine program quality improvement (QI) project explored caregiver satisfaction with a convenience sample of caregivers (N = 14) using a nine-item Telemedicine Diabetes Caregiver Satisfaction Survey (TDCSS), with responses ranging from 1 = strongly disagree to 5 = strongly agree. Findings indicate caregivers were highly satisfied with communication/ privacy (M = 4.8), access to care (M = 4.1), and quality of services (M = 5.0). The multidisciplinary collaborative teamwork, continuous QI, and dependable technology were integral to the quality of the telemedicine clinical initiative. APRNs provided technology expertise, interdisciplinary collaboration leadership, care coordination, and advocacy for policy changes. Results demonstrate that telemedicine and APRN leadership can help implement innovative programs into rural communities to improve access to care, healthcare cost, and outcomes.

Patient and family education is a critical element of diabetes management. Manychildren with new onset type 1 diabetes present with symptoms of diabeticketoacidosis (DKA) and are hospitalized at diagnosis. These children and theirfamilies receive their initial education in the hospital setting. As soon as bloodglucose levels are stabilized and the acidosis is corrected, the patient is dischargedhome, usually within three days (Nettles, 2005). There is little time toprovide the skills and education, as well as emotional support, for a smooth transitionto home. It is a challenge to achieve these goals if the only resource personfor diabetes education is the clinical nurse specialist (CNS). The CNS for a 14-bed pediatric unit sought to expand the role of the bedside nurse to being the primaryeducator of patients with diabetes through education and support. All nursesattended an eight-hour workshop on diabetes. A DKA protocol was developedthrough multidisciplinary collaboration, and nurses were educated on this protocol.Additionally, the CNS organized a diabetes resource cart that contains thetools for diabetes education. The protocol and education materials wereuploaded in the Pediatric SharePoint site to make them accessible to nurses. Most importantly, the CNS developed a structured patient education plan that isoutcome-oriented, and based on review of current literature and practices in theunit. This initiative resulted in an increase in nursing confidence and expertiserelated to diabetes care as demonstrated by competencies met by nurses andanecdotal evidence from nurses and patients’ caregivers.

Patient education in a pediatric setting is unique. There are different patient ages, degrees of learning, and diagnoses to take into account when educating children and their families. A new and innovative trend in practice called Interactive Patient Care (IPC) integrates technology into care processes to advance pediatric nursing education and patient and family satisfaction. Children's Specialized Hospital is the first pediatric rehabilitation hospital to develop and implement this type of program using an IPC platform from the GetWellNetwork. With the implementation of the GetWellNetwork, Children's Specialized Hospital has achieved positive results in patient satisfaction, health care utilization, quality, and safety measures.

Pediatric health care practitioners have the ability to impact a child's HRQoL. Children's HRQoL is well documented in the literature as an important matter for children receiving health care, with research to support its significance in their lives. Children and adolescents have much to teach practitioners, and listening to their perspectives of health care experiences has a direct effect on the clinician's ability to improve their HRQoL. Pediatric practitioners focused on providing high-quality patient care must incorporate the goal to positively influence children's HRQoL.

Fall prevention programs that include reliable, valid, and clinically tested screening tools have demonstrated more positive effects for adult and geriatric populations than those not including such assessment. In contrast, because falling is a natural part of growth and development for pediatric patients, progression toward effective prevention programs for this population has proven to be a challenge; a significant impediment is the lack of definition regarding what constitutes a reportable fall. This project explored pediatric health care providers' perceptions of patient falls in order to define a reportable pediatric fall and inform development of a prevention program. A concept analysis of defining attributes, antecedents, and consequences of pediatric falls from literature formed the basis for a set of questions; a convenience sample of 28 pediatric health care providers in an acute care hospital in New England participated in six moderated focus groups. Constant comparison method was used to code the qualitative data and develop themes. Participants unanimously agreed on several points; as expected, their years of experience in pediatric practice provided valuable insight. Three major themes emerged: patient characteristics, caregiver characteristics, and environmental characteristics. Based on factors identified by staff, a screening tool was adopted and integrated into the electronic medical record. Staff were actively engaged in developing definitions, selecting tools, and identifying next steps toward a comprehensive fall reduction program for their patients. As a result, they have embraced changes and advocated successfully for endorsement by the organization.

Problem: Pediatric nurses often use an inappropriate tool to assess pain in children younger than 36 months of age., Objective: This intervention intended to improve the nursing practice of assessing pain in preverbal (less than 36 months of age) children., Methods: Pain assessment frequency and use of a pain assessment pediatric tool use was evaluated pre- and post-intervention via a retrospective chart review and a survey of pediatric nurses. Parametric and non-parametric statistical tests were used to determine significant differences between pre- and post-intervention data for both approaches., Results: The chart review data showed a significant increase in the number of times pain was assessed and documented post-educational intervention. Similarly, the survey data analysis showed a significant post-intervention increase in the use of a pain assessment tool and that most nurses used the FLACC pain assessment tool when assessing pain in preverbal children., Conclusion: Educating staff nurses about the use of an appropriate pain assessment scale altered practice and improved the frequency of pain assessment of preverbal children.

In the United States, one in every 68 children has autism spectrum disorder (ASD) (Centers for Disease Control and Prevention, 2014). ASD is a developmental disorder of the brain that is characterized by impairments in social interaction, communication, and repetitive patterns of behavior (American Psychiatric Association [APA], 2013). Nurses have a duty to provide high quality care to children with ASD. Effective communication is essential to providing quality care. Three main theories attempt to explain how the ASD brain functions and the implications on communication: lack of theory of mind, weak central coherence, and lack of executive function. Children with ASD have difficulties in vocalic, kinesthetic, and proxemic aspects of communication (Notbhom, 2006). Simple adaptations to environment and style can make the communication between nurses and children with ASD easier and more effective (Aylott, 2000; Green et al., 2010).

The treatment of Pediculosis capitis, or head lice, is fraught with misinformation, myths, and mismanagement. Common myths include the need to exclude children from school, the need to remove all visible nits ("no-nit" policies), the need for massive environmental cleaning, that head lice live for long periods of time, and that schools are a common location for lice transmission. Head lice are a common childhood nuisance, causing embarrassment and emotional trauma in both children and families. This article explores and challenges the commonly held beliefs about the identification, management, and treatment of Pediculosis by presenting current recommended evidence-based practice. It also challenges pediatric nurses, and school nurses in particular, in alignment with the National Association of School Nurses (NASN) Position Statement on Pediculosis Management in the School Setting, to act as change agents for reasonable and effective school policies and practices.

Autism spectrum disorders (ASDs) are a group of developmental disabilities that can cause significant social, communication, and behavioral challenges for children and families. An estimated one in 88 children in the United States are affected by an ASD. Early identification and intervention have been shown to improve outcomes for these children, and the routine well-child visit is a critical opportunity for pediatric health care providers to obtain developmental information relating to ASD identification. Although current recommendations suggest ASD screening at 18 and 24 months of age, research suggests that ASD-specific behaviors and delays emerge earlier in infancy. The purpose of this article is to identify key developmental tasks that can be assessed by pediatric primary care providers to determine increased risk for ASD in infants at nine, 12, and 15 months prior to formal screening for ASD at 18 and 24 months.

This integrative literature review focuses on the health risks associated with late-preterm infants (34 to 36 and 6/7 weeks gestation) and the implications for newborn primary care providers and pediatric nurses. Common morbidities in the late-term population included hyperbilirubinemia, respiratory compromise, hyperglycemia and poor feeding, temperature instability, and infection. Primary care providers should be aware of these morbidities to be sure risk-focused evaluation is performed during and after the birth hospitalization, and treatment is administered when necessary.

This study attempted to answer the question, "Do nurses perceive coping kits to be effective at meeting the needs of hospitalized children with developmental disabilities who are at increased risk for challenging behaviors?" A cross-sectional post-test survey study design was used, with a convenience sample of 24 registered nurses at a Midwestern free-standing children's hospital. A coping kit with simple communication cards, social script book, and distraction items (toys) was developed to enhance communication and distract children with developmental disabilities (including autism spectrum disorder) undergoing procedures in the hospital. A modified version of Hudson's (2006) intervention effectiveness survey was used to measure the nurse's perception of the effectiveness of the coping kit. Nurses perceived the coping kits to be effective for decreasing their patient's anxiety, calming the child's behavior, and increasing cooperation during procedures. The nurse can develop a plan of care that includes a coping kit to help gain cooperation with the hospitalized child with challenging behaviors.

Pediatric acute care nurses questioned the practice of weighing disposable infant diapers immediately after voiding. This study asked the research question, "Does volume of saline, diaper configuration, and/or size of diaper statistically effect changes in diaper weights over time?" The method was an experimental, laboratory model. Pre-set volumes of saline were added to disposable diapers that were then left folded or unfolded. Each diaper was weighed immediately post-wetting and re-weighed at hourly intervals for seven hours. Data were analyzed using a repeated measures analysis of variance (RMANOVA) with balanced data (F-test). Diaper weight changes over time were statistically significant for all time points and for all volumes regardless of diaper size; however, the changes in weight were small and without clinical significance. It is appropriate to weigh diapers at the end of eight hours without risk of altering subsequent fluid management of patients in open-air, non-humidified environments. This practice has led to more efficient use of nurses' time with fewer interruptions for patients and families.

Adherence of participants in a long-term clinical trial is necessary to assure validity of findings. This article examines adherence differences between single-parent and two-parent families in the Childhood Asthma Management Program (CAMP). Adherence was defined as the percentage of completed daily diary cards and scheduled study visits during the course of the trial. Logistic regression and ordinal logistic regression analyses were used. Children from single-parent families had a lower percentage of completed diary cards (72% vs. 84%) than two-parent families. Single-parent families were also more likely to reschedule visits (62% vs. 45%) and miss more clinic visits (23% vs. 17%) than two-parent families. Suggestions are given for study coordinators to assist participants in completing a long-term clinical trial. Many suggestions may be adapted for nurses in inpatient or outpatient settings for assisting parents of patients with chronic diseases.

Palliative care is an emerging nursing specialty and is developing a dedicated spot in the field of pediatrics. As a specialty, palliative care focuses on quality of life and symptom management for patients who are living with chronic and life-threatening diseases. In pediatrics, advances in health care mean that many children are living longer with these conditions and could benefit from services that focus on quality of life and superior symptom management. Palliative care can be provided concurrently with curative therapies and is philosophically similar yet distinct from hospice services.

In Part I of this three-part article, the psychological and medical care of the child wishing to change gender was described. In Part II, preparation for surgery for young adults who were genetically female and undergo surgery to transition to male identity was presented. This third part presents the surgical treatments for gender reassignment procedures for a genetic male wishing to reassign as female. Discussion is included about how parents are responding to these wishes from their prepubescent and teenage children.

Seizures are a common neurologic disorder of childhood, and many pediatric nurses will care for children with epilepsy during their careers. The term "seizure precautions" is used frequently in nursing practice; however, its definition varies among institutions. Childhood epilepsy has many phenotypes, and while some children require airway clearance and ventilatory support in the event of a seizure, many will not. The bedside equipment for a child with seizures should reflect the patient's symptoms. To that end, an algorithm based on seizure classification and current practice in seizure precautions is presented to aid bedside nurses in safely caring for children with seizures. The algorithm may also be used to assist in educating parents about the safest way to care for their child at home, without sending contradictory messages about different needs for equipment in the hospital and in the home.

Children are born with "spiritual competence," an inner quality or power for faith development. Traditions from early nursing practice address the care of those who are in distress, suffering, questioning the reason for illness or pain, or seeking meaning and purpose in their lives. Increased demands on time and rapidly changing complex medical cases allow less time and energy directed toward spiritual issues for the nurse, while at the same time increasing the possibility of spiritual needs of the child and family. The following discussion is a synthesis of faith development theory, effects of spirituality in children, spiritual assessment techniques, and intervention strategies for children.

Topic: A review of psychopharmacology and the genetic considerations with pharmokinetics is followed through a case study to demonstrate the optimal clinical treatment of the child with pediatric behavioral issues., Purpose: The knowledge of the pharmacokinetic and pharmacodynamic consequences of medications in clinical practice is of the utmost importance for all pediatric nurse practitioners. Drug interactions occur when the efficacy or toxicity of a medication is changed with the addition of another medication or dosage change., Sources: An integrative literature review from nursing, medicine, psychology, and child psychiatry., Conclusions: The current climate of a child psychiatric specialist shortage leaves the charge of this vulnerable population in the hands of the primary care provider. Pediatric primary care now requires a clear understanding of the psychostimulant and non-stimulant medications, thorough screening of each child, appropriate dosage regulation, and close monitoring of all outcomes. It is imperative that pediatric nurse practitioners understand the pharmacological interactions and safety in the treatment of children with behavioral issues.

Although evidence-based practice exists to apply the principles of safe patient handling and movement (SPHM) to prevent nursing musculoskeletal injuries in the workplace, nurses and nursing staff continue to use "body mechanics" when moving, lifting, and transferring patients. In this day of a nursing shortage, one that will continue to worsen, valued professionals must remain on the job and free from preventable, work-related injuries. As states enact laws requiring health care facilities to develop and institute SPHM programs, hospitals will be held to task to produce SPHM policies, procedures, plans, and protocols in their institutions.

Central venous catheters are integral to the care of acutely ill children, providing reliable vascular access for infusions, hemodynamic monitoring, and blood sampling. However, there are risks associated with their use, the most common of which is central line-associated blood stream infections. These infections result in increased lengths of stay, increased costs, and high mortality rates. A thorough review of research evidence has been completed to fully appreciate the state of the evidence regarding the effects of bundling together the care for central venous catheters, and practice recommendations have been provided. Published studies have been appraised and evaluated for clinical and statistical significance. This appraisal has resulted in clear and specific recommendations for evidence-based practice applications, and potential policy implications are outlined in this article.

Chronic sorrow is defined as a normal grief response associated with an ongoing living loss that is permanent, progressive, recurring, and cyclic in nature. If a parent experiencing chronic sorrow has a support system that is inadequate or does not receive appropriate intervention for ineffective coping, it is possible that chronic sorrow can become a pathological grief state similar to depression. Nurses must recognize that chronic sorrow is a normal grief response associated with a living loss, learn to appropriately assess chronic sorrow in parents of chronically ill children, and develop ways to support parents experiencing chronic sorrow by applying evidence-based strategies to facilitate effective coping.

This integrative literature review examines the long-term sensorineural hearing loss associated with cisplatin chemotherapy treatment in children with cancer. CINAHL, PsychInfo, Medline, Google Scholar, and Google databases were searched for research related to cisplatin-induced ototoxicity. The characteristics, prevalence, and underlying mechanisms of cisplatin ototoxicity are discussed. Primary care implications, including how and when to monitor the hearing of childhood cancer survivors, ways to provide family support, and education about the significance of hearing losses, and an overview of the management for hearing impairments are presented.

Understanding the adoption experience can help health care providers develop sensitivity to the special tasks of adopted children and their families. Children who are adopted at older ages may face particular challenges. Age at adoptive placement, the burden of loss, pre-adoptive experiences, and the challenge of attachment are all significant issues in older-child adoption. Pediatric nurses demonstrate sensitivity and support to adopted children and their families by using appropriate language about adoption; understanding the significance of missing health information; providing appropriate referrals as needed; and displaying an open, caring attitude.

This article examines the evidence-based guidelines for diagnosis and treatment of acute cough in children. Cough is a common symptom in children and a frequent reason for consultation in primary care. Generally, an acute cough is a self-limiting condition resulting from expected childhood viral illnesses. However, a child should be thoroughly evaluated to rule out a serious underlying condition or disease responsible for the cough. Parents are often concerned and anxious about their child's cough. The use of over-the-counter cough and cold medications is widespread and parents commonly request primary care providers to provide prescriptions to alleviate cough symptoms. The American College of Chest Physicians has recommended clinical practice guidelines based on the conclusion of systematic reviews. These reviews indicate that cough medications offer no symptomatic relief for acute cough in children, and the use of cough and cold medications is inappropriate in young children and also places young children at risk for potential side effects and adverse reactions. The management of acute cough in children is based on a "wait, watch, review" approach. Clinicians should educate parents on expected illness duration, the risks of using over-the-counter medications, and discuss safe, supportive care measures to alleviate the child's discomfort.

Pediatric nurse practitioners (PNPs) have a primary role in providing parent-inclusive well-child physical and developmental examinations. Although routine physical examinations are well defined, developmental assessments, including communication and cognition, are not. Currently a number of developmental screening tests exist; however, none have become established as the "gold standard" for the primary health care professional as none are convenient or time-efficient to employ. In particular, there is a need for a screening tool that PNPs can use to evaluate early development in their youngest patients. This article offers a screening instrument capable of being easily completed through parent interview in a routine integrated well-child exam. The screening includes questions that probe communication and cognition in infants and toddlers, and identifies atypical behaviors that are considered by developmental specialists to be "red flags" and precursors to later communication and cognitive disorders. A brief description of the nature of communication and cognitive disorders in young children is included.

Rashes are common in the pediatric population yet can be quite problematic for nurse practitioners to diagnose. A thorough history and physical examination, along with some simple procedures, will aid in identifying these skin conditions. Four cases are presented, which may initially prove challenging to diagnose, and symptoms are categorically examined to arrive at the accurate diagnoses. Treatment guidelines, options, and the role of parental education and involvement also are discussed.

This article reviews the literature related to functional abdominal pain (FAP) in childhood, including the definition, etiology, contributing factors, clinical diagnosis, therapy and management, and associated long-term health effects. FAP is determined when no specific structural, infectious, inflammatory, or biochemical cause can be found in a child with chronic pain. The presence of abdominal pain as an isolated symptom is more suggestive of FAP, whereas multiple symptoms are more likely to be due to an organic or biochemical condition. While the exact cause of FAP is not completely understood, most researchers and clinicians agree that it is of multi-factorial etiology coupled with an altered brain-gut interaction. Children are highly susceptible to influences around them and can experience pain in response to normal childhood feelings and experiences. Psychological disorders such as anxiety and depression are common in both children with FAP and their parents. Children with FAP tend to have low levels of self-directedness, internalize their feelings and worries, and ruminate over issues they cannot control. The biopsychosocial model has proved to be a worthwhile framework for children with FAP, as it recognizes the interaction between social and environmental influences, psychological processes, and the state of the body. Interventions that focus on the child's cognitive processes associated with abdominal pain and the family's response to the pain have increased efficacy over standard education and reassurance. Providing children and families with techniques to use when experiencing pain decreases alterations in normal daily activities and improves long-term health outcomes.

A commonly stated reason for dissatisfaction among nurses is that their input regarding patient care and suggestions for improvement in the workplace environment are not solicited or recognized. Nurses can have an active voice in their practice by using the five steps for implementing EBP and being involved in the process of EBP within the work setting. Pediatric nurses have the unique opportunity to become empowered and make a significant difference in their patients' and family's lives by continually asking questions about treatments and care, searching for and evaluating the evidence to support or refute traditional practices, implementing best practice, and evaluating the effectiveness of the evidence as it applies to nursing practice.

Because of advances in medical technology, many critically burned children now survive horrendous injures that they would not have survived less than 10 years ago. Pediatric burn intensive care unit (BICU) nurses provide around the clock care, giving them greater contact with the children than any other health care professional. Often the children are alone in the hospital because their parents or care providers were injured or killed in the accident, live in another country, or are at home caring for other family members. Thematic analysis of data obtained during 112 hours of interviews and 134 hours of observation with 16 BICU nurses resulted in the identification of four categories of nurses' practices that helped the holistic healing of children who were alone on the BICU of a hospital in the southwestern United States: (a) being a parent-minded nurse; (b) sustaining human connections; (c) receiving the patient as a child; and (d) renewing the spirit of the child.

This article reviews the physiology of cerebrospinal fluid formation and flow, the causes of hydrocephalus in the pediatric patient, symptoms of increased intracranial pressure, recent advances in shunt technology, the medical and surgical management of hydrocephalus, and potential complications of ventricular shunting devices. Nursing care in the post-operative period and for the child with shunt malfunction is discussed, as well as the long-term management needs and anticipatory guidance issues as related to a child with a ventricular shunting device. A case study of an infant with hydrocephalus illustrates key concepts.

This observation study examined the behaviors of 20 sedated, mechanically ventilated children, ages 1 month to 14 years. Observations were made using the Comfort Scale at the beginning and end of the two-hour observation period and of body and facial movements, behavior state, and environmental activity occurring during the 2-hour period. Mean Comfort scores at both measurement points were 16, below the target sedation level. In addition, while most children were in sleep states, they exhibited many body movements, particularly of the upper extremities. Body movements were related to behavior state but not to Comfort scores. Environmental activity was not significantly related to child activity, behavior state, or Comfort scores. Sedation scales in children may be best used in conjunction with behavior observations although further research is needed to determine the predictive capabilities of either scales or behavior on actual ventilation outcomes.

Emergency contraception (EC) is a contraceptive method used safely and successfully by women for more than 30 years to prevent pregnancy. Nurses at all levels are often the first point of contact for a woman who is requesting EC, thus it is particularly important for them to stay abreast of both the facts regarding the use of this product and the current political controversies. It is particularly important for Nurse Practitioners (NPs) working in primary care with adolescents to remain cognizant of the significant barriers that remain for many women of all ages trying to access this important contraceptive tool.

Explaining failure to thrive (FTT) in dichotomous terms--organic versus non-organic --no longer applies in the context of modern pediatric nursing. FTT has turned out to be much more multifaceted. One infant's story illustrates the complexities and long-term ramifications of a pediatric feeding disorder and the challenges faced by health care professionals and families in their care. The story illustrates how physiologic, sensorimotor, and behavioral issues can all impact a child's inability to gain weight as expected. With greater understanding, pediatric nurses can appreciate their role as members of a multidisciplinary pediatric feeding disorder team.

A pediatric nurse reflects on her practice by recounting her experience while caring for a child with Guillian Barre 20 years ago. Principles and lessons relevant to guide pediatric nursing practice in today's health care environment are identified.

This literature review focuses on the Human Figure Drawing (HFD) methods put forth by Elizabeth Koppitz as a screening instrument. Children's drawings have potential as a mental health screening aide for health care practitioners in the primary care setting. This paper focuses on self-portrait drawings as a screening technique for emotional well-being, anxiety, and depression in school-aged children (6-12 years old). Using Koppitz's emotional indicators checklist for mental health, practitioners can use the child's HFD as a quick screening tool. Although the HFD is not diagnostic and can not be used as the sole indicator for anxiety or depression, two or more emotional indicators may signal to the clinician that further psychiatric assessment and referral is needed.

This study investigated the relationships among health-promoting self-care behaviors, self-care self-efficacy, and self-care agency in an adolescent population. The purpose of this study was to identify the relationships among these concepts as well as the specific influence of spiritual growth, a component of health-promoting self-care behaviors, on self-care agency. The instruments used in this study included the Health-Promoting Lifestyle Profile II (HPLPII) scale, the Self-Rated Abilities for Health Practices (SRAHP) scale, and the Exercise of Self-Care Agency (ESCA) scale. A canonical correlation identified a significant variate having a correlation of .95 (p < .000) accounting for 90% of the variance explained. The loading variables included the HPLPII subscale of spiritual growth and the ESCA subscale of initiative and responsibility. The study results indicate that spiritual growth is significantly related to an adolescent's initiative and responsibility for self-care.