38.3: Application to Care

Learning Objectives

By the end of this section, you will be able to:

• Demonstrate appropriate application of multiple theories of development
• Discuss aspects of well care specific to different populations across the life span
• Discuss aspects of vaccination administration and post-assessment

To care for patients across the life span, nurses must have a baseline understanding of growth and development at each stage of life. Newborns through older adults, and each stage in between, all have a subset of needs and concerns. For example, communication and the spectrum of growth and development pose challenges unique to the pediatric population, while chronic diseases and comorbidities that come with an extended life span create another subset of complications in older adult patients.

Well Care across the Life Span

Well-visits and preventive care are crucial to the overall well-being of people on an individual and community level. Well-visits are more frequent in the younger years when developmental milestones are identified and reviewed. As will be discussed later in this section, a significant part of this preventive care is the process of immunization.

Well-Visit Schedule

While many patients find themselves visiting a healthcare provider only when they have an acute illness or problem, it is important for individuals to maintain regular well-visits with a focus on preventive care. Different from an appointment for a new issue, well-visits provide an opportunity for preventive care and screening to occur before issues arise. Well-visits allow communication between patient and provider and help the provider make a plan for the overall well-being of each patient.

Life-Stage Context

Preventive Care

Due to the importance of preventive care, part of the Healthy People 2030 initiative from The U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion is a strong focus on preventive health (Office of Disease Prevention and Health Promotion, 2023). Their preventive care objectives for the general public include the following:

• increase the proportion of children who receive a developmental screening
• increase use of the oral healthcare system

Further objectives are identified by the following categories:

• adolescents
• cancer
• community
• diabetes
• health care access and quality
• health policy
• heart disease and stroke
• mental health and mental disorders
• oral conditions
• osteoporosis
• pregnancy and childbirth
• sensory or communication disorders
• sexually transmitted infections (Office of Disease Prevention and Health Promotion, 2023)

After 3 years of age, it is recommended for patients to have an annual well-visit. During these well-visits, multiple components should be reviewed, including vital signs and baseline laboratory tests; any medications the patient is taking should also be reviewed, and adjustments should be made as needed. Additionally, age- or health-related screenings such as mammograms, pap smears, colonoscopies, and vision screenings may either be ordered or referred out to a specialist for completion. Prior to age 3, there is a more frequent well-visit schedule for children:

• 1 week
• 1 month
• 2 months
• 4 months
• 6 months
• 9 months
• 12 months
• 15 months
• 18 months
• 24 months
• 30 months
• 3 years

This increased frequency for younger children is warranted due to the many physical, mental, and emotional changes during this time frame. After 3 years of age, a yearly well-visit is recommended pending any additional healthcare conditions.

Link to Learning

The American Academy of Pediatrics provides a schedule of well-visits that includes details for what should happen at each visit.

Early childhood is a crucial span of time to ensure proper growth and development. Well-visits are an optimal time for nurses and providers to deliver anticipatory guidance for caregivers. The anticipatory guidance involves proactively counseling caregivers regarding significant physical, psychological, emotional, and developmental changes their child will encounter in the future. This guidance is specifically tailored to the current age and stage of the patient as well as the stage they will encounter next. The nurse must also consider any communication barriers. Variations in language, cultural nuances, or varying levels of health literacy can act as barriers that may impact the comprehension of crucial information. Therefore, the nurse needs to approach anticipatory guidance with sensitivity, employing clear and simple language, utilizing visual aids when necessary, and ensuring caregivers fully grasp the information relevant to the child's physical, psychological, emotional, and developmental well-being.

Cultural Context

Communication Barriers

During their career, nurses are likely to encounter patients of all ages, stages, health levels, backgrounds, health literacy levels, and cultures. Though there are many factors to consider when interacting with and educating patients, one of the most foundational is language and communication. If there is a language or communication barrier between healthcare provider and patient or caregiver, everyone is likely to walk away from the care event confused and frustrated. Official translators must be used when there are any noted language barriers involving speaking, reading, or writing. Most healthcare systems have multiple forms of translators to ensure proper care of patients. This may be a physical person who is able to translate between languages, a phone call to a translator who can speak between languages, or a video call that allows the translator to view all participants while also translating. Depending on the size of the healthcare system and the urgency of a patient’s needs, there is a time and place for each method, but one must be used if there is a discrepancy between languages. Nurses should not allow family members to translate even if able to understand and speak both languages, as it is impossible to ensure proper translation of all crucial information.

Atraumatic Care

No matter the population with which the nurse is working, atraumatic care should be practiced. The atraumatic care is care that strives to eliminate as much trauma as possible from the experience for the patient. This is important to help minimize the psychological impact that can arise from healthcare interventions.

Life-Stage Context

Providing Comfort and Demonstrating Atraumatic Care

Based on their developmental age and stage, patients may find different experiences traumatic, and nurses may need to take different actions accordingly. For example, while performing an adult physical assessment, the nurse can verbally direct individuals as necessary to complete the exam. Adult patients typically understand why they must assume certain positions and remain still while the nurse uses a variety of instruments to check vital signs. Completing a similar task on a child—especially a young child who cannot understand what is happening—often proves a more challenging task. Because infants are soothed when held during times of distress, nurses can allow caregivers to hold a child during most of the physical exam; in addition to providing the least traumatic experience possible for the patient, the nurse is more likely to gather accurate information from a calm, cooperative child. If no caregiver is available, the nurse can simulate this experience by holding or soothing the child before, during, or after completion of a care task.

Atraumatic care may look different for older children. For example, pediatric settings often have a playroom or other dedicated space in which no medical care is completed. This provides a safe place for patients to play, learn, and relax. Similarly, difficult or painful procedures may take place in a separate room from those in which routine examinations are conducted. This helps patients to relax during examinations, as they perceive the space as a safer, more healing environment. If steadying a patient or part of the patient is needed to complete a procedure safely, a trained medical professional should be the one to complete this safety hold. This leaves caregivers or loved ones available afterward to help provide comfort. Additionally, when support staff who are trained to properly stabilize and assist in a procedure, it limits the risk to providers and patients. Utilizing interdisciplinary team members, such as a child life specialist, can also be of benefit when providing care.

Vaccination and Immunization

Though often used together, vaccination and immunization are not interchangeable terms. Vaccination is the act of presenting a vaccine to the body to elicit protection from a specific disease. Immunization is the method by which a person develops protection against a disease through vaccination. There are two main types of immunity, active and passive. Active immunity refers to immunity obtained from an individual’s exposure to an antigen to which their own body then elicits an immune response to create antibodies. Vaccinations are an example of active immunity. On the other hand, passive immunity refers to immunity that is obtained from antibodies created outside of the person and then introduced to the body. Breastfeeding is an example of passive immunity. Immunizations play a crucial role in creating herd immunity, which occurs when a significant portion of the population (the “herd”) becomes immune to a disease. When this happens, the disease can no longer spread within the population and may vanish completely.

Link to Learning

The website for the CDC provides specific definitions for vaccine, vaccination, immunity, and immunization to help provide clarity among these related terms.

The main function of the body’s immune system is to distinguish “self” from “non-self.” A toxin or foreign object the body determines to be a threat is called an antigen. Once the immune system identifies an antigen, it will elicit an immune response and work to eradicate it from the body, in the process creating antibodies. An antibody is a protective protein produced by the immune system to help fight invaders. By creating antibodies for a specific antigen, the immune system learns to recognize that antigen (or similar ones) moving forward and attack more efficiently. In essence, the immune system creates a blueprint for fighting off illness or disease more effectively if exposed in the future. This is how the process of immunization provides protection against specific diseases through vaccinations. A vaccination contains a weakened or inert form of a particular antigen—not enough to cause the disease itself, but sufficient to trigger the immune system to create antibodies, thus providing immunity for that disease.

There are multiple categories of vaccinations, with some more common than others. Categories of vaccinations currently used include inactivated, live-attenuated, messenger RNA (mRNA), toxoid viral vector, subunit, recombinant, polysaccharide, and conjugate vaccines (U.S. Department of Health and Human Services, 2022). Though obtaining vaccinations does require significant effort and time on the forefront, a fully immunized patient is protected from the physical, emotional, and financial risks of many dangerous infectious diseases.

Link to Learning

The CDC provides a schedule for childhood and adolescence vaccinations, including a “catch-up” schedule for individuals who missed the recommended doses.

Pre-Vaccination Care

For patients to obtain the best results from a vaccination, healthcare providers must understand appropriate pre- and post-care guidelines and be able to educate patients and caregivers regarding these topics. First and foremost, consent must be obtained prior to any vaccination administration. Patients who are considered adults or emancipated may sign this consent themselves. Those who are considered minors (not emancipated) or who have designated another person to make their healthcare decisions must have a guardian or caregiver sign consent.

Link to Learning

The CDC provides a recommended adult immunization schedule for those aged 19 years and older.

The provider must give patients and caregivers a vaccination information sheet (VIS) containing all pertinent information regarding the vaccine’s purpose as well as known side effects or adverse reactions the patient may have. The provider should also discuss allergies and contraindications with patients and caregivers and review the outlined vaccination schedule. Many children working their way through vaccinations may need a “catch-up” plan if they veer off schedule or need to adjust for other reasons. Patients who are acutely ill may not be in a stable condition to receive a vaccination, but those with a minor illness may still be able to obtain the vaccination. This should be discussed with the healthcare provider prior to administration.

Link to Learning

The CDC maintains current vaccination information sheets for all vaccines.

Barriers to Vaccination

There are many reasons patients may choose not to receive vaccinations and why caregivers may choose not to have their children receive vaccinations. It is the nurse’s role to provide factual information regarding this topic and help eliminate barriers when possible. Some possible barriers that nurses can help patients overcome include the following:

• challenges with access or proximity to facility
• anticipated side effects of vaccine
• misunderstanding of normal immune response and adverse reaction or contraindication
• belief that vaccination is unnecessary because they or their child is not at risk
• belief that natural immunity, acquired by contracting the disease, is better
• scheduling challenges
• cost
• personal preferences
• religious beliefs
• distrust of the healthcare system

The first step in helping patients and caregivers is understanding their specific concerns or barriers. Nurses should provide information, resources, and support no matter what choice the patient ultimately makes. Though healthcare providers may have different opinions from those of their patients and families, it is not appropriate to place judgement or decrease care levels because of these differences.

One large effort to eliminate the cost limitation for families is the Vaccines for Children (VFC) program, a federally funded program implemented in 1994 in response to the measles epidemic of 1989–1991. VCF vaccines are provided free to people with low incomes or no insurance through private physicians who have registered with the program. Additionally, the Affordable Care Act of 2010 classifies immunizations approved by the Advisory Committee on Immunization Practices (ACIP) as preventive services and mandates new health plans to cover them without charging a co-payment, deductible, or coinsurance (Centers for Disease Control and Prevention (CDC), 2022). Individual states also have a variety of resources to help provide free or discounted vaccinations. In an effort to combat the barrier of multiple trips to a medical facility for separate injections, the use of FDA-approved, manufacturer-produced combination vaccines is encouraged when appropriate.

Vaccination Administration

Vaccinations are injected via intramuscular (IM), subcutaneous (SQ), or oral (PO) routes. Appropriate needle size and injection location are dictated by the type of vaccine and age and size of the patient (Immunize Action Coalition, 2020). For IM injections, the needle should be inserted at a 90-degree angle to the skin. Each muscle injected must have the capacity to hold the volume of the medication, an important factor in minimizing local reaction. The vastus lateralis (a thigh muscle) is the optimal location for children 12 months and younger due to its development and capacity. If the deltoid muscle is selected for children under 10 years of age, the needle size may need to be adjusted (Figure 38.7 Table 38.3) lists other appropriate sites for IM injections.

Figure 38.7 (a) The vastus lateralis is the preferred IM injection site for infants and toddlers aged 0 to 3 years. (b) The deltoid is the preferred IM injection site for those aged 3 and older. (attribution a and b: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Age	Injection Site	Needle Size
Newborn (0–28 days)	Anterolateral thigh muscle	5/8 inches (22–25 gauge)
Infant (1–12 months)	Anterolateral thigh muscle	1 inch (22–25 gauge)
Toddler (1–2 years)	Anterolateral thigh muscle Alternate: Deltoid muscle (upper arm) if muscle mass is adequate	1–1 ¼ inches (22–25 gauge) 5/8–1 inch (22–25 gauge)
Children (3–10 years)	Deltoid muscle (upper arm) Alternate: Anterolateral thigh muscle	5/8–1 inch (22–25 gauge) 1–1 ¼ inches (22–25 gauge)
Children and adults (11 years and older)	Deltoid muscle (upper arm) Alternate: Anterolateral thigh muscle	5/8–1 inch (22–25 gauge) 1–1 ½ inches (22–25 gauge)

Table 38.3 Intramuscular (IM) Needle Injection Administration

Table 38.4 lists appropriate sites for SQ injections. For example, the most suitable SQ site in infants from birth to 12 months is the fatty tissue of the anterolateral thigh. The most suitable location for a SQ injection in those 12 months and older is the fatty tissue overlying the triceps. Needle insertion for SQ injections should be completed at a 45-degree angle.

Age	Injection Site	Needle Size
Birth to 12 months	Fatty tissue overlying the anterolateral thigh muscle	5/8 inches (23–25 gauge)
12 months and older	Fatty tissue overlying the triceps	5/8 inches (23–25 gauge)

Table 38.4 Subcutaneous (SQ) Needle Injection Administration Subcutaneous injection sites and needle size vary by age. Selecting the correct needle size and injection site can help ensure accurate administration and patients’ comfort.

Post-Vaccination Care

Following administration of a vaccine, providers should educate patients or caregivers about how to manage expected symptoms and side effects as well as when to seek additional care. When they return home, patients or caregivers should monitor for adverse reactions. It is normal for patients to have a low-grade fever, chills, body aches, pain or redness at the injection site, or fatigue following administration—these are all expected responses of the body to the triggered immune system as it creates antibodies to the introduced antigen. However, if patients have a high-grade fever, difficulty breathing, systemic rash, swelling or redness that proceeds down the extremity, or additional signs of allergy or severe reaction, they should reach out to a healthcare provider immediately for guidance.

Documentation

Following administration of a vaccine, the provider will need to document several pieces of information:

• date of administration
• name of vaccine given
• manufacturer
• lot number
• expiration date
• site and route of administration
• name and title of who administered the vaccine
• notification of VIS given

Link to Learning

The CDC maintains a web page with facts about the Vaccination Information Sheets that must be given to patients prior to administration of a vaccine.

Documentation is important to help mitigate safety concerns for patients and expedite follow-up care as needed. Information about the site and route of administration is important when assessing for local site reaction. Information about the manufacturer, lot number, expiration date, and name of vaccination allow providers to follow up if there is a concern with a batch of vaccination or an identified adverse reaction. Additionally, it is important for patients and caregivers to maintain the recommended intervals for vaccinations, as detailed in the age-appropriate schedule. Having this information documented allows for tracking of vaccinations and helps healthcare providers develop an individualized plan for each patient.

The Vaccine Adverse Event Reporting Systems (VAERS) is the national vaccine safety surveillance program. National Institutes of Health. This program compiles reported information in order to create educational documents such as the VIS.

Link to Learning

The CDC provides guidelines for documentation of vaccinations as well as insight into the importance of documentation.