Mental Nursing

nur20 · Oct 29, 2001

http://mentalhelp.net/ http://www.harcourthealth.com/MERLIN/Fortinash/ http://www.mhsource.com/

a-rose · Oct 30, 2001

Thanks for your help!

And how do you proceed to mental nursing for the patients?

a-rose · Nov 3, 2001

How do you make the mental nursing to 3-7-years child?

nur20 · Nov 5, 2001

http://www.ispn-psych.org/html/acapn.html

MollyJ · Nov 7, 2001

Hi a-rose

You are asking broad questions but I would guess you have a specific concern.

Mental health care of children is often built around their development, typical issues and concerns of the age, and concerns specific to the child. You also have to look at the family system that the child comes from and how that might impact things.

Developmentally, 3 year olds are known as pre-schoolers. If you are a nursing student, look in your books for the characteristics of the pre-schooler. They have typically mastered walking, are talking fairly fluently and constantly, may have trouble managing their emotions (tantrums) but aren't as volatile as 2 year olds. they are curious about alot of things about them and like to be physically active. They may besiege parents with why questions because they are trying to learn about the world about them. They can truly play with other children (as opposed to the parallel or side-by-side play of the toddler). I am looking at my Whaley and Wong ped's textbook and it has a very nice synopsis of toddler development.

Typical issues for the pre-schooler include starting to master some school oriented knowledge like colors, they may be identified as having speech problems at this age (should have a 900 word vocabulary in the 3 y/o and their speech should be understood by most people in their lives), they are learning to get along with their peers, they have fears, have to be physically active.

Concerns about a child's mental health may evolve related to failure to acheive developmental markers. A child who is speech or developmentally delayed may act out his frustration by striking out at adults or other children and concerns may focus on his acting out. However, for these kids, assessing and intervening on their developmental or speech delays may be key to helping abate their frustration, though they may need education or support to express their frustration appropriately.

Remember that Erickson says the tasks of this age are initiative vs guilt. through mastery of play and physical tasks, the child grows to see himself as capable and able. When a pre-schooler says something like, "Mommy, I do it myself!" they are trying to exert initiative. Too many don'ts, negatives, rules applied randomly and the child can feel guilty and ineffective. Also, children who are raised in difficult or chaotic homes may have residual issues with Erickson's previous stages, basic trust and autonomy vs shame and doubt. See also information about attachment theory (Bowlby and Ainsworth). Children who are poorly attached may be anxious when separated (which can be seen in "normal" kids, but poorly attached children may cope poorly with separation). I think attachment difficulties are sometimes manifested (and I am not an expert in attachment theory) in kids who have been with parents so sporadically when young that they have learned that adults, whether you like them or not, will come and go in your life, so their is little point in expending emotional energy to become attached. They will, eventually, leave you behind. So these kids may be hungry for contact but may hold themselve back because they are tired of "investing" in the relationship to only to see the adult leave again. I HYPOTHESIZE that that is what is happening with many troubled kids that I see in my middle school and high school setting. These kids may be invisible or they may create trouble to at least get some attention from adults or they may be bottomless pits of emotional need.

When you work with a pre-schooler, the first thing is to just simply give them the gift of your loving acceptance. Loving acceptance does not mean you accept abuse or acting out (though neither do you take it personally). It means you are willing to hold them accountable for what they do wrong and give them appropriate consequences AND that you are willing to NOTICE when they do it right. Through play, you may come to see what developmental concerns the child has. How does the child play, talk, move compared to his peers? The child may let you see some of his anxieties and concerns in play. Remember it is normal for kids to have fears and anxieties. One of the strongest things any of us can do is ground ourselves solidly in interactions with a wide range of kids so we recognize the wide range of "normal" behavior for a given age and can spot deviations from the norm. It is an art and not quickly accomplished.

If you are working with a child that you have emotional concerns about, the most important thing to do is become grounded in what is normal for children of that age. Normal kids can say outrageous things, throw nuclear proportion tantrums, be frustrating. If you are not a nurse, their are excellent developmental books available and you should get one of those.

Perhaps reading this will help you to articulate your concerns more specifically. Feel free to re-post.

a-rose · Nov 10, 2001

Thank you very much!

And how do nurse 3-7-years child who fears injection?

Home Health Columnist / Guide · Nov 10, 2001

Play therapy: Let the children handle toy syringes, pretend injecting a stuffed animal or doll, picking out the type of bandaid to cover injection site. Use distraction by the nursing staff while actual injection given " Look at your feet and curl down your toes"--child busy doing that as you swiftly SQ inject med in arm.

All these practiced at my pediatricians office for my child who feared needles.

MollyJ · Nov 10, 2001

I worked in a vaccination clinic (public health) where we all too often did not have time for the niceties of vaccination and injections. Still we wanted to make it as non-intrusive as possible. Also, I think it makes a great deal of difference if you are talking about a child with cancer or other chronic illness who will need repeated needle sticks versus a child getting routine vaccination. Due to vaccine schedule, we saw kids last about age 18 months (if they were on schedule) and then again at age 5 for pre-school vaccines.

My guiding principles were this.

Children especially at age 5 often know they are getting vaccines. If they have older sibs, they will make sure they know. If they don't know, they need to know what the plan is but not with lots of time to agonize about it.

I usually said something to the 5 year old like, "I'm going to give you some medicine under your skin, one in your leg, one in your arm. You will feel a little stick, but it won't last long."

They might ask if it will hurt and I usually say that it does but it doesn't last long. I believe in being truthful with kids.

I tried to be as organized (have the vaccines ready to go) and deft as possible.

We often did vaccine clinics where many children either knew what was going on or sometimes could see it ie a mom bring several sibs in for shots on the same day. Are your hairs standing on end Nrs Karen? In sibling situations, I favored doing the most anxious child (and usually the eldest and most aware) first, but if the mom persuaded me she had a rationale for doing it another way, we'd do it that way.

For 5 year old vaccines, we did oral polio first (it's been a while), then DPT and then MMR. MMR was the stingiest, so we did it last.

I'd probably do IPV first now, since it is fairly non irritating.

We also did least restraint possible: babies on mom's laps, 2 to 5 year olds on mom's lap, though the nurse in my pediatricians office did my son at age 5 sitting on an exam table and they both did beautifully. She expected him to be controlled and he was.

After the first year, after giving oral polio, we would sit the child on mom's lap facing forward. Mom would put her forearms over her child's forearms and then either mom or I would trap the child's leg between my or her legs. I usually like to do this myself, that is trap their knee or lower femur between my knees. I would say something like, "mom's going to give you a bear hug," I would do DPT in the leg (vastus lateralis) and then MMR in the upper arm. I would try to slow down injection of both because I came to believe that slow injection of vaccine reduced local discomfort at the time of the shot. Many kids would be amazed to find that injection didn't hurt, but they'd notice the vaccines.

Every once in a while, we would have a really out of control child and we would lay them down and "do the deed". I'd say this happened very rarely, about 1 or 2 older kids per year.

Some children come in with a lot of anxiety and they are hard to calm, but the fact is that vaccination is an uncomfortable procedure that must be accomplished so you do it as deftly as possible and you commend the child for their cooperation. I usually told children it was okay to cry, because it stings and commended them for holding still (to the extent they were able to do).

Like nurse Karen, I have told kids to blow out, wiggle their toes whatever while we do the injection. Some kids do well with this, others don't. It gives them something else to think about. It takes minimal practice beforehand. You can do this with pre-schoolers. Try it with toddlers but I'd be a little surprised if they could hang in there with you to do it.

Small children Toddlers and pre-schoolers are afraid of blood leaking out of their body, even small amounts, so bandaids are important. We did alot of drawing on the bandaids (bear faces, etc).

Children need comforting after vaccine. I remember a newborn that the mother DID NOT COMFORT. Watched her infant cry and said, "She might as well get used to it; that's the way the world is." I picked her up and crooned. Babies need crooning after traumatic procedures.

In the ED, I gave occasional IM injections to kids, also. Children need a support person they trust, so I would not give an injection without that person in the room. Kids fear shots in the buttocks, so I use vastus lateralis almost exclusively. I don't know if local anesthetic creams are "in" for pre-vaccine care or not.

Toddlers and pre-schoolers feel out of control during vaccination, so you give them what control they can have: a favorite blanket, a toy, closeness of mom. I had one child that came to clinic clutching a piece of mom's lingerie (silky underwear). Mom was embarassed, but I thought it was a good plan. Some kids are calmed by the feeling of silky things.

a-rose · Jan 17, 2002

Thank you very much!

But it¡-s difficult to do venipuncture for child who fears injection. They cry, fiddle with their limbs¡¡.. How do you deal with it?