Curbside consultation in pediatric dermatology.
Publisher: Slack, Inc
Skin conditions in infants, children, and adolescents are frequently seen in primary care offices. Diagnosing and managing pediatric skin conditions can be challenging. Both the expert and novice practitioners have difficulty differentiating between skin lesions and conditions and often rely on multiple resources to come to a diagnosis. Curbside Consultation in Pediatric Dermatology (Treat, 2012) is valuable clinical resource for practitioners. Dr. Treat, Assistant Professor of Pediatrics and Dermatology, Perelman School of Medicine, University of Pennsylvania, and Children's Hospital of Philadelphia, designed this book especially for physicians, nurse practitioners, and physician assistants who may occasionally or frequently manage pediatric patients.
Dr. Treat's vision to provide clinically relevant material supporting effective dermatology management is accomplished in this book. Presented in a conversational manner, this easy-to-read book highlights responses from expert pediatric physicians and dermatologists to common questions about pediatric skin conditions. Forty-nine clinical questions are posed in a total of eight sections. The sections are divided into topics, such as birthmarks/vascular and other skin lesions, rashes, atopic dermatitis, infections, and pigmentation to hair disorders to acne. The final section is reserved for unique questions, such as After Children Get Lacerations or Stitches, How Can I Help Prevent or Minimize Scarring? The book is augmented with multiple informative and easy-to-read tables and color-coded algorithms. Additionally, it is illustrated with color photographs to assist the practitioner in the diagnosis of a skin condition. A comprehensive index allows cross-referencing of conditions. Each question ends with suggested readings or references for the practitioner.
A wide variety of dermatology conditions are addressed in this informative resource, from scabies to Henoch Schonlein purpura, and from eczema to scarring. The physician authors of each of the 49 clinical questions share evidence-based management related to the clinical query. Each question is introduced with a history or definition of the topic in question. The depth of the response to each question depends on the complexity of the clinical issue. For instance, question 5 asks, "When Do I Worry About Midline Cutaneous Lumbosacral Lesions?" The comprehensive and detailed response includes definitions associated with spinal cord abnormalities and photographs of melanocyti nevus and hemagiomas, which help to clarify the clinical considerations, as well as evidence-based findings and recommendations. Screening tools, such as ultrasound and magnetic resonance imaging (MRI), and their risks are discussed. Wisely, the response ends with the suggestion to consult with pediatric neurosurgery when the pediatric patient is diagnosed with a spinal abnormality. Responses to other questions are not as comprehensive, due to simplicity of the diagnoses.
Although this book provides answers to questions about more complex pediatric dermatologic conditions, practitioners will not find discussions of a few more common pediatric skin conditions, such as Keratosis pilaris, and therefore, may need to use other pediatric dermatology resources. Responses to clinical questions include recommended diagnostic tests and pharmacological and nonpharmacological management. Depending on the clinical diagnosis, treatment may include necessary off-label recommendations that are not FDA-approved. When off-label treatment is recommended, it is noted that practitioners should evaluate and tailor the treatment in a thoughtful manner related to the individual needs of the patient.
Undoubtedly, this is an informative and comprehensive resource for practitioners in primary care. In addition to providing exemplar diagnosing and management strategies for pediatric dermatology, there is significant evidence of prevention and anticipatory guidance when applicable. However, there is missed opportunity to mention the Gardasil vaccine to help protect against vaginal and vulvar cancers in girls and condyloma in boys when Human Papilloma Viruse (HPV) was discussed. Importantly, responses to questions about sexually transmitted diseases alert the practitioner to screen for sexual abuse in the pediatric patient and the responsibility to report such to the legal authorities.
In conclusion, this book provides a foundation of expert pediatric dermatology advice from physicians around the country in one powerful resource. Certain responses to clinical questions presented in the textbook speak directly to physicians. A recommended addition to a future version of this book would include keeping the conversational tone directed to all health care providers in pediatric care. All practitioners in pediatrics will find this textbook to be a reference of significant value.
- Debra Connolly Shearer, EdD, MSN, FNP-BC,
Debra Connolly Shearer, EdD, MSN, FNP-BC, is the Director of theDoctor of Nursing Practice (DNP) Program and Clinical Assistant Professor, Villanova College of Nursing, Villanova, PA.
Beating the Odds at Autism: One Family's Winning Hand
Publisher: Infinity Publishing
Paperback; 108 Pages
Beating the Odds at Autism: One Family's Winning Hand is a 108-page book about a young man (Ross Burns) with autism and the journey he and his family have traveled to ensure that he learned to manage himself and his condition. The book does not claim to be a resource on methods to manage and treat the manifestations of autism. It is not a clinical treaties; it is a story of the journey of one family living with autism. It reads more like a blog, each chapter a thoughtful insight into the challenges, victories, and joys associated with living with a child with special needs. The primary voice is provided by Linda Burns, Ross's mother and primary advocate. Ross, at the time of the writings, is 16 to 19 years old. The chapters were written as he completed grades 11 and 12, and his first year of college. Most chapters have a section entitled "Let's hear how Ross feels about...;" thus, you are able to gain some of his perspective on a variety of topics. Again, Ross' comments are not intended as the scholarly musings of a seasoned writer; rather, these are the thoughts of a young man who has managed incredibly well in a world that labels and often ostracizes those who are different.
While I believe this book can be enlightening and helpful for families managing a child with autism, from my own experiences as a pediatric nurse, wife of a high school principal, mother of a child with attention deficit hyperactivity disorder (ADHD), and aunt to nephews with ADHD and autism, I could not relate to this family's experiences. The family engaged in 40 hours per week of Applied Behavioral Analysis (ABA) therapy from the time Ross was in preschool until he started kindergarten, and he kept up this schedule until well into middle school, "at which time his weekly hours would be reduced according to his mastery of the skills we were teaching." This commitment included providing workshops in their home to train therapist and family members, and having the therapist come to their home and/or accompany Ross to school (serving as a "shadow" to aid the teacher). At one point, Linda Burns describes how the family decided Ross needed more social skills training. Ross was in a special class, but after six months, the family believed that he was acting as the role model for everyone else, rather than learning new skills himself. Thus, the family decided to bring a social skills therapist to their home and invite friends and family to participate in classes with Ross.
I was tremendously impressed by the extensive behavioral treatments the family provided to Ross. However, I find this regimen unrealistic for most families who have a child with autism. The financial expense, the dedicated time, the constant presence of therapists in the home, and managing a schedule that is so child-focused seem out of the norm for most families with an autistic child to be able to achieve. My sister-in-law (mother to my autistic nephew) assured me that ABA therapy was the "gold-standard" for working with autistic children, and indeed, the 40-hour per week time commitment is normative practice for ABA therapy. She also shared that she personally knows of families who have gone bankrupt seeking such therapy for their child.
I applaud the efforts of Linda Burns and her family to be pioneers in this therapy, for sharing their success story, and for working to advocate that such therapy should be covered by health insurance policies and state aid to children with special needs. This book may be helpful for families pursuing ABA therapy as a viable option that is within their financial means, time commitment, and emotional/personal resources to pursue. For those families with much fewer personal and financial resources, I would help them pursue other treatment options. I think we should all be advocates to ensure this is a "hand" all families can pursue.
- Vicky R. Bowden, DNSc, RN,
Vicky R. Bowden, DNSc, RN, is a Professor, School of Nursing, Azusa Pacific University, Azusa, CA, and a member of the Pediatric Nursing editorial board.
Volunteering at Home and Abroad: The Essential Guide for Nurses
Jeanne Leffers, PhD, RN, and Julia Plotnick, MPH, RN, FAAN
Publisher: Honor Society of Nursing, Sigma Theta Tau International
Paperback; 308 Pages
Leffers and Plotnick's book is exactly what I was looking for 20 years ago. I could have benefitted from reading Volunteering at Home and Abroad: The Essential Guide for Nurses because like thousands of other nurses, I was determined to serve overseas and looked for good information on how to go about finding a volunteer position. I have been a nurse volunteer in 8 different organizations and 17 countries, and I have been asked by hundreds of people - how can I volunteer overseas? What organizations do I contact? Their usual answer is usually, "I am an ICU or OB or school nurse (or fill in any area of nursing). Is there a role for me? How do I prepare myself? And what do I take?"
Sometimes a friend/colleague/cousin will share a great experience, or just as often, a horrible experience, with volunteering overseas. In my opinion, this book lessens the likelihood of nurses having bad experiences because it prompts the reader to take an honest inventory and serious reflection. Readers are given steps to assess their motivation to volunteer and if they possess characteristics for volunteers, such as flexibility, openness, and humility, which are crucial when practicing in cross-cultural settings. This book answers the questions of what types of roles are available, how to prepare oneself, and what to pack.
The authors have a variety of volunteer experience, especially short-term positions, roles as faculty for student groups, and assignments to support ministries of health. Volunteering at Home and Abroad: The Essential Guide for Nurses provides the audience with a wide range of content that is essential (as the title asserts) in preparing nurses for a new, challenging, and generally unknown experience outside the community and their comfort zone.
Shortcomings in the book are worth a brief mention. The authors define long-term volunteer work as 2 to 6 months, whereas organizations (such as Doctors Without Borders) regard long-term as 12 months. Only 13 organizations were listed in the book, and readers will need to look beyond Volunteering at Home and Abroad: The Essential Guide for Nurses for agencies to research for opportunities. Specifically, readers need to be directed to major organizations that represent dozens of agencies offering positions (such as idealist.org and InterAction/Project Concern International).
I whole-heartedly recommend this book for nurses who are considering volunteering or - more importantly - for those in the process of committing to volunteering overseas. This book will help readers examine their personal motivation and readiness to volunteer and grasp an understanding of what qualities and skills are needed to be an effective volunteer, and ideally, have a positive experience of contributing to a greater good.
- Michelle D. Kelly, DNP, FNP-BC, PHN
Michelle D. Kelly, DNP, FNP-BC, PHN is an Associate Professor, Department of Nursing, Sonoma State University, Rohnert Park, CA. Dr. Kelly serves as a Medical Coordinator for Doctors Without Borders and has completed 17 humanitarian missions in impoverished and at-war countries. She is a Fulbright Scholar Specialist providing expertise to schools of nursing internationally. Dr. Kelly may be contacted via e-mail at Michelle.Kelly@sonoma.edu
Maternal Sensitivity: A Scientific Foundation for Practice
Publisher: Nova Science
For the first time this new book brings together the most noted interdisciplinary scientists in the field of maternal sensitivity and allows them to translate their findings for clinicians. The audience includes interdisciplinary professionals that focus on maternal-child health and development, individuals interested in public health and public policy, and early-career researchers and students in psychology, nursing, social work, and early childhood education. Pediatric nurses from many work settings will find this book to be a useful resource.
The book is edited and two chapters are co-authored by Drs. Deborah Winders Davis and M. Cynthia Logsdon, professors in the School of Medicine and the School of Nursing respectively at the University of Louisville and experts in maternal child interaction and parenting. The sections of the book include an introduction and definition of maternal sensitivity, gene environmental interaction, maternal sensitivity across the lifespan and in special populations, determinants of health, measurement, and interventions.
As the editors note in their introduction, maternal sensitivity is the best documented single predictor of child development. In the first chapter, Tamis-LeMonda and Baumwell define maternal sensitivity and the role of culture in the forms of responsiveness displayed by a mother. Massouda, Davis, and Logsdon describe boundaries and empirical indicators of maternal sensitivity in a concept analysis of maternal sensitivity. Landry and Smith compare and contrast theoretical frameworks that inform understanding of maternal sensitivity, and Beeghly, Fuertes, Liu, Delonis, & Tronick explain systems theory and the dyadic mutually regulated system of mother and child communication. Ciciolla, Crnic, Flamini, Morrison, and Logsdon describe the relationships between emotional availability and maternal sensitivity. Adding to our theoretical understanding of maternal sensitivity, Pluess and Belsky remind us that children may vary in their susceptibility to maternal sensitivity, and Mills Koonce and Propper outline the genetic variations that may be associated with different levels of maternal sensitivity.
The Maternal Sensitivity Across the Lifespan and in Special Populations section of the book includes information related to the state of the science of maternal sensitivity in infants, middle childhood, and in adolescent mothers, as well as in children in special populations. Crockenberg and Leerkes focus on maternal sensitivity in mothers with infants. Bradley and Pennar add to the science by describing the importance of maternal sensitivity in middle childhood to emotional openness, adaptive functioning, and school success in children. Tarabulsky, Moran, Pederson, Provost, and Larose critiqued four studies that provided an intervention to adolescent mothers in order to improve maternal sensitivity. Niccols and Smith provide an understanding of the link between maternal sensitivity and behavior problems in children with developmental delays. Day reminds us that economically challenged mothers face many challenges that impact their ability to be sensitive to the cues and needs of their children.
In the last section of the book, Health, Measurement, and Outcomes in Relation to Maternal Sensitivity, Zajicek-Farber describes the impact of environment and socioeconomic factors on maternal sensitivity. Moran, Pederson, and Tarabulsy provide an overview of measurement of maternal sensitivity. The final chapter of the book by Horowitz describes a successful intervention to improve maternal sensitivity in women with postpartum depression. The authors conclude with a list of questions about maternal sensitivity that are currently being explored by researchers and clinicians in the field, and they note that the science of maternal sensitivity will continue to expand as these questions are answered.
This book fills a gap in the literature and is a rare gift to support evidence based practice with mothers and children.
- Eileen Fowles, PhD, RN
Eileen Fowles, Phd, RN, is Assistant Professor, and Coordinator Graduate Maternity Program, University of Texas at Austin, School of Nursing, Austin, TX. She may be contacted via e-mail at email@example.com
Your Child Does Not Have Bipolar Disorder
Stuart L. Kaplan, MD
Published by Praeger
Hardcover, 176 Pages
The dramatic increase in the number of children diagnosed with bipolar disorder has been a hot topic for many, including parents and those in the child psychiatric community. In Your Child Does Not Have Bipolar Disorder, Dr. Kaplan, a Distinguished Life Fellow of the American Academy of Child and Adolescent Psychiatry, notes this sudden increase and the seeming trendiness of the diagnosis. He feels if the psychiatric diagnosis is not accurate, than the treatment that follows may be ineffective and possibly harmful. Many well-respected professionals have taken opposing views on the issue of pediatric bipolar disorder. With this book, Dr. Kaplan puts on the bookstore shelf a book for those who are skeptical of the "pediatric bipolar is under-diagnosed" books. He offers his well thought-out arguments on why this diagnosis may not be accurate for many already labeled, and provides talking points for parents who lean the other way - that bipolar disorder in children is over-diagnosed.
This book, by its title, clearly has a target audience in mind. Kaplan starts out with an eloquent description of how bipolar disorder presents in adults. The description of the moods - both during the depressed phase and the manic phase - and the cycling process provides the reader with an essential understanding of what bipolar disorder looks like in adults.
Kaplan then raises the question of how pediatric bipolar disorder has come to be known by that name. He points out that children diagnosed bipolar do not meet the strict diagnostic criteria in the DSM IV for symptom presentation or time criteria that are necessary for adult bipolar disorder. Whether this is a developmental subtype of bipolar disorder is a topic often discussed in the field of Child Psychiatry.
Most in the field, including Dr. Kaplan, feel the symptoms most important for clinicians to make a diagnosis of bipolar disorder in children include: mood lability, grandiosity, family history of bipolar disorder, aggression, and expansive/euphoric mood. For most clinicians, episodes of the symptoms and the fulfillment of DSM IV minimum time criteria are less relevant than the presence of these symptoms, which often are associated with functional impairment and distress.
Dr. Kaplan's experience with children who exhibit irritability and anger is that they are more accurately diagnosed as ADHD and Oppositional Defiant Disorder. Dr. Kaplan discusses the prevalence of ADHD in this age group, which is often co-morbid with other disorders.
The difference the diagnosis makes for Dr. Kaplan is that the children, when diagnosed with ADHD as the primary diagnosis, will be prescribed stimulant medications. In the author's experience, the treatment of the ADHD with stimulants will resolve irritability and anger symptoms, a treatment approach that will improve functioning at home and at school. He covers common concerns about stimulant medications being contraindicated with bipolar disorder.
The term "Severe Mood Dysregulation" is mentioned in his chapter on stimulant medication when he reports that in his experience stimulants, when prescribed in appropriate doses, address focus, concentration, and also aggression in these children.
For clinicians who routinely treat children with bipolar disorder, the most convincing argument for having the child diagnosed early, if one holds to the "kindling theory", is that lithium and anticonvulsants might prevent a worsening course of the "firing in the brain" associated with bipolar mood episodes. Kaplan does not think this theory has been adequately supported.
The conversation actively continues regarding the diagnostic categories for these children. The generally agreed-upon diagnosis may become "Severe Mood Dysregulation"; however, in the meantime, these children with their challenging behaviors need the interventions that promote their optimal functioning, at home and at school.
Throughout the book, Kaplan emphasizes the importance of a comprehensive diagnostic evaluation, including face-to-face interview with the child, evidence-based screening instruments, thorough history and interview with the parents, and consultation with the child's teacher. Such a comprehensive interview will allow the provider to establish an accurate treatment plan based on that individual child's target symptoms.
Kaplan ends the book with very informative chapters for parents. It explains a comprehensive plan of behavioral treatment for children with aggressive, oppositional misbehaviors. He also has a chapter of advice for Parents about medications for their child.
- Pamela Lusk, DNP, RN, FPMHNP-BC
Pamela Lusk, DNP, RN, FPMHNP-BC, is Director, Southwest Health Center for the Prevention & Treatment of Child/Adolescent Depression and Anxiety Disorders, College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ. The author can be contacted directly via email at firstname.lastname@example.org
Hope On The Hill: The First Century of Seattle Children's Hospital
Walt Crowley, David W. Wilma & the HistoryLink Staff
Published by History Ink/History Link in association with the University of Washington Press, 2010
Hardcover, 192 pages
This delightful book provides a historical accounting of events, personnel, and facts that have comprised the 100 year history of Seattle Children's Hospital. While one may presume this is a mere accounting of activities and growth of the institution, the writers have infused the text with insightful analysis of the manner in which events in the community, state, and world have impacted the development of Seattle Children's.
A fascinating aspect of the narrative is the voice of women in this historical accounting. The hospital was born from the vision of Anna Clise, wife of a prominant Seattle businessman, and mother of three children, one of whom died at a young age from inflammatory rheumatism. At that time there was no treatment, nor any physician or hospital west of Philadelphia that specialized in treating childhood ailments. How often we have seen the suffering and grief of women transform into an instrument of change that will eventually better the lives of others. Anna Clise founded the all-female Board of Trustees that would go on to establish the 8-bed Children's Orthopedic Hospital, which would grow to become the renowned Seattle Children's Hospital. These women recruited physicians to provide services, reviewed cases to determine which children might be allotted a bed in the facility, and raised funds to grow and operate the hospital. Today the Board of Trustees continues to consist primarily of women with a continuing dream to meet Anna Clise's goal of ensuring that every sick child in the community "receives the very best care that medical science and human compassion can provide (p. 161)."
Photographs and text boxes are liberally incorporated within the book to provide greater insight into the historical and social context of the times. A timeline in the back of book summarizes the primary events including the first open-heart operation, a visit to the hospital by Queen Elizabeth II, and the year of appointment of every chief nursing officer.
The book concludes with selected stories from the "Children's Story Project", a centennial anniversary project in which the hospital community shares personal experiences, memories, and reflections about the hospital. These stories are a clear reminder that though the walls of Seattle Children's have moved, grown, and expanded to now encompass 60 pediatric subspecialties, the heart of this outstanding institution stems from the compassion and dedication of those who have worked and volunteered over the past 100 years to advance the healthcare practices and improve the lives of children at Seattle Children's Hospital.
Though nursing history may not be your first reading choice, this book is a winner for all readers. This book is a gift; an intriguing story for your personal book list and a required text for every nursing school library.
-Vicky R. Bowden, DNSc, RN, Azusa CA
Vicky R. Bowden, DNSc, RN, is Director of the Honors Program and Professor, School of Nursing, Azusa Pacific University, Azusa, CA.
Josie's Story: A Mother's Inspiring Crusade to Make Medical Care Safe
Atlantic Monthly Press; 1st edition, 2009
Hardcover, 208 pages
Albert Einstein once said, "In the middle of every difficulty lies opportunity." In Josie's Story, Sorrel King takes us on her courageous journey from profound grief and anger to dedication and passion for safety in healthcare. The death of her 18-month-old daughter, Josie, led her to a cooperative working relationship with the very group that made the mistake responsible for Josie's death.
Josie King was admitted to Johns Hopkins Hospital in January 2001 for first and second-degree burns suffered as a result of a defective water heater. Josie's recovery was steady and unremarkable. However, as the King family was preparing for discharge and a much-anticipated homecoming, Sorrel noted a change in Josie's condition. She appeared dehydrated and more lethargic. Josie was not permitted oral fluids, and IV fluids had recently been discontinued, as her central line had become infected and required removal. Despite Sorrel's verbalization of concerns, the nursing staff reassured her that Josie's condition was stable and encouraged her to go home and rest. The following day, further symptoms of dehydration, coupled with a breakdown in hospital staff communication, led to the administration of a fatal dose of methadone, ultimately causing Josie's cardiac arrest.
Each year, between 44,000 and 98,000 deaths occur due to medical errors, as estimated by the Institute for Healthcare Improvement (n.d.). With this knowledge in hand, and her personal heartbreaking experience, Sorrel King set out on a crusade for beneficence and non-maleficence within our health care systems.
The King family eventually accepted a settlement offered by Johns Hopkins Hospital and began the Josie King Foundation (n.d.), whose mission is to "prevent others from dying or being harmed by medical errors." Their hope is to "create a culture of safety by uniting health care providers and consumers, and funding innovative safety programs." In conjunction with hospitals throughout our nation, the Foundation has implemented many programs to facilitate safety and improve communication within the health care setting. Condition Help is one such example of the Foundation's efforts. This program inspired the creation of Rapid Response Teams in hospitals nationwide. It allows the patient and family to activate a rapid response team in case of an emergency or if they feel they are not receiving necessary medical treatment/attention. Within minutes of activation, the call is answered by the nternal medicine house physician, a patient relations coordinator, the administrative nursing coordinator, and floor staff. Within the first year of its implementation, 100% of users believed their needs were met when they utilized this system. Additional programs that have been brought to fruition through the Josie King Foundation include the Maryland Disclosure Program and the Care for the Caregiver Program.
Josie's Story is an important read for all health care providers, but especially valuable to those in the nursing profession, because it candidly reminds us of our core role: protecting our patients. As an additional bonus, in the back of the book, Sorrel King has provided a helpful resource guide divided into two parts; the first part being for patients and their families, the second for health care providers with helpful reminders on providing safe and effective care. A DVD in which Sorrell King speaks about her experience is also available.
-Julie Hildebrand, BSN, MSN-student, Sacramento, CA
Julie Hildebrand, BSN, MSN-student, is a Registered Nurse, Northern California Children's Hematology/Oncology Medical Group, Sacramento, CA. She has seventeen years of clinical experience in the areas of Pediatrics, Pediatric Oncology, and the NICU, and is the mother of a child born with hypoplastic left heart syndrome, who died in the NICU.
Institute for Healthcare Improvement. (n.d.). A resource from the Institute of Healthcare Improvement. Retrieved from www.ihi.org
Josie King Foundation. (n.d.). Josie King Foundation. Retrieved from www.josieking.org
The Immortal Life Of Henrietta Lacks
Crown Publishing Group
Rebecca Skloot's new book, The Immortal Life Of Henrietta Lacks, is every ethicist's nightmare. As we turn the pages, we are exposed to racial cruelty, hospital malfeasance, researcher dishonesty, mental illness abuse, and American health care system maltreatment. This book recounts the true story of the Lacks family and the taking and using of their mother's cancer cells to create the famous and billion dollar-generating HeLa cell line. This book describes what happened when the Nazi trials at Nuremberg are ignored by American physicians at Johns Hopkins, who were apparently thinking that they had no need for oversight. National laws to protect research subjects were but a few months away. The use-for-profit of a person's cells and body parts, once collected, continues to be unregulated. Skloot describes her befriending of Lacks' family, who never received one cent from the profits generated by their mother's cell line. As they suffered, went uneducated, had no health care, and tussled with the law, 60,000 researchers worldwide wrote about scientific progress due to the use of the HeLa cells. In addition to a fascinating read, purchasing the book will generate funds for family members for the first time. Skloot has set up an educational foundation for the remaining Lacks family members. This is required reading for any nurse wishing to be involved in health care research and medical center ethics.
-Anita Catlin, DNSc, FNP, FAAN, Rohnert Park, CA
Anita Catlin, DNSc, FNP, FAAN, is a Professor of Nursing and Ethics Consultant, Sonoma State University, Rohnert Park, CA, and a Columnist, Ethics, Issues, & Commentary column, Pediatric Nursing.