6.4 Special Populations: Pediatric, Mental Health, Acute Care
Key Takeaways
- Family-centered care is the standard for pediatric patients — parents are partners in care, not visitors, and are included at the bedside whenever possible.
- De-escalation of an agitated resident uses a calm low voice, generous personal space (at least an arm's length), a clear exit for the CNA, and never argues with delusions.
- Never reinforce a hallucination by pretending to see or hear it; acknowledge the resident's feeling and redirect.
- Acute care CNAs see faster turnover, more invasive procedures, and shorter stays than long-term care, so handoff communication and accurate I&O become even more critical.
- Hospice and palliative care prioritize comfort, dignity, and family support; postmortem care is performed with the same respect given to a living resident.
Although the NC Nurse Aide I credential is geared toward long-term care, NC CNAs work across the continuum: pediatric home health, behavioral-health units, NC's acute-care hospitals, and hospice agencies regulated under 10A NCAC 13K. Each setting has its own safety pattern.
Pediatric Care
Children are not small adults. Growth and development drive both communication and safety.
| Age group | Approximate ages | Key developmental tasks | CNA implications |
|---|---|---|---|
| Infant | Birth-12 months | Trust vs. mistrust (Erikson); sensorimotor (Piaget) | Soothing voice, hold securely, keep parent in sight, never leave on a raised surface |
| Toddler | 1-3 years | Autonomy vs. shame | Offer simple choices ("red cup or blue cup?"), expect tantrums, never shame for toileting accidents |
| Preschool | 3-6 years | Initiative vs. guilt; magical thinking | Use simple, concrete words, allow medical play with a doll, do not say things like "the doctor is going to take a little of your blood" without context |
| School age | 6-12 years | Industry vs. inferiority | Explain procedures honestly, allow modesty, involve in self-care |
| Adolescent | 12-18 years | Identity vs. role confusion | Respect privacy intensely, ask permission to share information with parents when developmentally appropriate |
Family-centered care is the pediatric standard: parents are partners, not visitors. Include them in the plan, encourage rooming-in, and never separate parent and child for routine care unless clinically necessary.
Signs of child abuse — mandatory NC reporting
Under NC General Statute §7B-301, any person who suspects child abuse, neglect, or dependency must report to the county Department of Social Services. CNAs are mandatory reporters and cannot delegate this duty by simply telling a coworker.
Warning signs include:
- Bruises in patterns (belt-loop, hand-shaped), bruises in non-mobile infants, burns in glove/stocking distribution
- Injuries inconsistent with the reported mechanism or with the child's developmental stage
- Sexual knowledge or behavior outside the developmental norm; unexplained genital injury
- Severe untreated dental decay, failure to thrive, malnutrition
- Caregiver who is hostile to the child, blames the child for injuries, or delays seeking care
Mental-Health and Substance-Use Settings
In behavioral-health units (and in long-term care residents with psychiatric diagnoses), de-escalation is the core CNA skill.
De-escalation rules
- Stay calm. Your physiology drives the resident's. Take a breath before you speak.
- Use a low, slow voice. Volume escalates the room.
- Give space. At least one arm's length, often more. Do not corner the resident.
- Keep the exit clear for both you and the resident. Position yourself between the resident and the door only if it does not block their escape.
- One staff member talks. Multiple people giving directions creates chaos.
- Do not argue with delusions or reinforce hallucinations. If a resident says, "There are spiders crawling on the wall," do not say "I see them too" (reinforces) and do not say "That's crazy, there's nothing there" (argues). Say, "I don't see spiders, but I can tell this is upsetting you. Let's step out of this room."
- Offer choices that move toward calm. "Would you like to walk with me to the day room, or sit by the window?"
- Call for help early. Notify the nurse before the situation becomes a code.
Substance use
Residents may be in withdrawal (alcohol withdrawal can be life-threatening — tremor, sweating, hallucinations, seizures), on medication-assisted treatment (methadone, buprenorphine), or actively using. Report any signs of withdrawal, suspected substance use on the unit, or paraphernalia found in a room. Never confront — report.
Acute Care
NC's acute-care hospitals run on a faster clock than long-term care. Key differences for the CNA:
- Shorter stays — many patients are discharged in 1-3 days. Each shift carries more handoff.
- More invasive lines and tubes — IVs, central lines, telemetry, urinary catheters, NG tubes. Know what you may and may not touch.
- Strict I&O — fluid balance is monitored hourly in many units; record every cup, every ice chip.
- Faster vital-sign frequency — q4h or q2h is common; abnormal values escalate quickly.
- More fall risk — patients are sicker, drugged, and in an unfamiliar environment. Bed alarms, low beds, non-slip socks, and yellow gowns/wristbands are standard fall-risk indicators.
- Rapid response and code-blue teams are activated for any sudden deterioration; the CNA's role is to call for help, start chest compressions if trained and the patient is full code, and clear the area for the team.
Hospice and Palliative Care
Hospice is care for residents in the last six months of life when curative treatment has been stopped. The focus is comfort, dignity, and family support — not cure, not prolonging life.
Signs death is approaching
- Decreased appetite and thirst; difficulty swallowing
- Increased sleeping, decreased response to stimulation
- Mottled, cool, bluish skin on extremities; weak or irregular pulse
- Irregular breathing patterns: Cheyne-Stokes (cycles of deep then shallow then apnea), "death rattle" (gurgling from secretions in the throat)
- Incontinence, decreased urine output
- Restlessness or terminal agitation
- Periods of clarity ("surge") followed by withdrawal
CNA responsibilities at end of life
- Provide frequent mouth care (swabs, lip balm) — dry mouth is the most common reported discomfort.
- Reposition for comfort every 2 hours unless the care plan says otherwise; pad bony prominences.
- Keep the resident clean, warm, and dry.
- Speak to the resident as if they can hear you — hearing is the last sense to go.
- Welcome family at the bedside; offer chairs, water, tissues.
- Notify the nurse of any change in breathing, color, or responsiveness.
Postmortem care
After death, postmortem care is performed with the same respect as care for a living person. Wash the body, close the eyes and mouth gently, position the body in alignment, place dentures in the mouth or in a labeled container, remove tubes only if the nurse or policy allows (in coroner cases, leave everything in place). Allow the family time at the bedside. Follow the facility's identification and shrouding policy and any religious instructions documented in the care plan.
A resident in a NC behavioral-health unit is pacing, yelling, and clenching their fists. The CNA's BEST initial approach is to:
A hospice resident is unresponsive, with irregular breathing and mottled skin. The family is at the bedside, crying. The CNA should: