Pediatric Module II Study Guide PDF

Pediatric Module II Study Guide Chapter 16: The Infant (14 questions) ❖ Developmental Theories o Erickson (trust vs mistrust): help parents learn how to work around wires and tubes while getting needs met o Freud (orality): discovery/exploration with their mouth...

Pediatric Module II Study Guide Chapter 16: The Infant (14 questions) ❖ Developmental Theories o Erickson (trust vs mistrust): help parents learn how to work around wires and tubes while getting needs met o Freud (orality): discovery/exploration with their mouth o Kohlberg (preconventional/premoral): can’t distinguish right from wrong o Sullivan (security): different levels of emotional response o Piaget (sensorimotor): birth to 2 years; when they become curious ❖ Normal vitals o Respiratory rate: 25-55 o Heart rate: 80-150 ❖ Oral stage o Hold infants during feeding times o Sucking brings comforts and tension relief o Pt on IV fluids, they must have a pacifier to make sure the sucking need is met ❖ Motor development o Grasp reflex disappears around 3 months o Prehension: occurs around 5-6 months; orderly sequence of development; grasp object between fingers and opposing thumbs o Object permanence: when infant can remember that object exists even when it is out of sight o Parachute reflex: 7-9 months as a protective mechanism; occurs when infant is lowered to the ground and their reaction is to extend their arms out o Pincer grasp: well-established by 1 year of age ❖ Primitive reflexes o Moro (startle reflex): disappears 1-3 months o Rooting (rubbing cheek): disappears 3-4 months o Extrusion (tongue thrusting to keep solid foods out): disappears 5-6 months o Babinski (rubbing sole of foot and toes spread): disappears 12-18 months ❖ Emotional development o Consistency is necessary to develop trust o Infants who are consistently picked up when they cry, they tend to have fewer crying episodes and less aggressive behavior later o Never force infants to reach milestones o Once infant shows readiness to learn a task, encouragement is key ❖ Characteristics (skin) o Milia: small white papules; usually along nose o Nevi: “stork bites”; little red spots usually on forehead o Mongolian spots: very common with darker skin tones; be sure to chart that infant was born with them as they commonly get mistaken with signs of abuse ❖ Need for constant care and guidance o Sensory play o Soothe crying children o Do not delay feedings to stick to routine; if infant appears hungry, feed them o Infants can recognize warmth and affection or realize when there is none ❖ Infant development (know these) o 1 month ▪ Present head lag ▪ Sleeps 20 hours/day ▪ Sleep on back ▪ Receives hormones from mom (can lead to swollen labia) ▪ Allow for tummy time (but watch at all times) ▪ Small streaks of blood (“baby period”) o 2 months ▪ Posterior fontanel closes ▪ Can hold head erect briefly ▪ Immunizations: Dtap, IPV, HIB, RV, HepB, and PCV ▪ Responsive smiling, learning to cry ▪ May have colic (episodes of crying and irritability) o 3 months ▪ Good head control ▪ Hands to mouth (exploration) ▪ Can hold rattles ▪ Enjoys interaction o 4 months ▪ Drooling and teething ▪ Can lift head and shoulders when on belly ▪ Reaches for objects ▪ Immunizations: Dtap, IPV, RV, PCV, and HIB o 5 months ▪ Can sit-up with support ▪ Interested in their toes  ▪ Reaches or tries to hold bottle ▪ 2-3 naps/day o 6 months ▪ Doubles birth weight ▪ Can turn over and pull up to sitting position ▪ Can drink from a cup ▪ Speaks in babble ▪ Introduce solid foods (rice cereal) ▪ Grabs things with whole hand ▪ Immunizations: Dtap, HIB, PCV, RV, HepB, and IPV o 7 months ▪ Beginning to crawl ▪ Can transfer objects (still use whole hand) ▪ Mood swings ▪ Teething pains (lower teeth will erupt first) ▪ Add fruits and finger foods (crackers) ▪ Can grasp with hand o 8 months ▪ Can sit alone ▪ Begin using pincer grasp ▪ Add vegetables ▪ 2 naps/day o 9 months ▪ Hand performance ▪ Imitates sounds they hear ▪ “cruising” (allow for exploration; they must hold onto surfaces) ▪ Add meats/beans to diet (can be chopped or mashed) o 10 months ▪ Stands with support ▪ Can recognize their own name ▪ Drinks juice or water from cup o 11 months ▪ Can understand simple directions ▪ Lots of gross motor activity o 12 months ▪ Triples birth weight ▪ 6 teeth ▪ Well-developed pincer grasp  ▪ May play at mealtime ▪ Immunizations: HIB, PCV, MMR, Varicella, HepA, Dtap ❖ Coping with irritable & lethargic infants o Shield their eyes from bright lights o Sit quietly with them (can talk in a soft voice) o Eliminate as much noise as possible o Swaddle snugly o Change their position slowly to avoid sudden movements o Provide nonnutritive sucking ❖ Developing positive sleep patterns o Newborns should sleep in 4-hr intervals o 4-6 months may sleep up to 8 hours o Synchronizing circadian rhythm of infant to family is a learned behavior o Position infants on their backs on a firm mattress o Infants rely on parents to soothe them to sleep ▪ Help them become self-soothers (swaddling, cradling, cuddling, pacifiers, thumb sucking) ❖ Illness prevention o Measure growth parameters (remember to notify HCP is the difference is 2 or more either way) o Assess developmental levels o Immunizations and draw labs Birth 2 4 months 6 months 12-15 4-6 years 11-12 years months months Hep B D Tap D Tap D Tap MMR D Tap Tdap Rotaviru Rotavirus Rotavirus Hep A MMR HPV s D Tap (15) IPV Meningococcal Hib Hib Hib Hib Varicella IPV IPV IPV PCV PCV PVC PCV Hep B Hep B Varicella ❖ Nutrition in infancy o Breast milk or formula during first year of life o No foods added into bottle o Restrain from whole cows milk until after 1 year of age o Low-fat milk should not be given under 2 yeas of age  o Never make bottles in advance (they’re only good for 24 hours) ▪ Throw away after 24 hr period; cannot warm them up ▪ Reheating bottles may cause uneven heat distribution and can cause severe burns in the infant o Introduce rice cereal at 5-6 months (after extrusion reflex disappears) o Give solid foods then formula o Dilutes juices can be given at 5-6 months (“sippy cup”) ❖ Play o Explore and imitate o Provide visual stimuli for newborns o Provide touch stimuli for infants o Provide manipulation toys for 1-year olds (push and pull toys) ❖ Safety issues/anticipatory guidance o Car seats always o Monitor closely for falls o Watch out for choking (they’ll put anything in their mouths) o Suffocation (be sure to properly place them in cribs) o Poisoning (lock all cabinets and keep meds out of reach) o Burns (sunscreen, protect wall outlets) ❖ Summary of Chapter 16 o Very rapid growth ▪ Doubled weight by 6 months ▪ Triple weight by 12 months ▪ Anterior fontanelle closes by 18 months ▪ Posterior fontanelle closes by 2 months Chapter 26: Care of a child with a cardiovascular disorder (10 questions) ❖ Fetal circulation: 3rd and 8th week gestation o Foramen ovale: diverts blood from right atrium directly to left atrium bypassing lungs o Ductus arteriosus: diverts most blood from pulmonary artery into the artery into aorta o Ductus venosus: diverts some blood away from the liver as it returns from the placenta ❖ S/S related to suspected cardiac pathology o FTT (failure to thrive) or poor weight gain o Cyanosis or pallor o Visual pulsations in neck veins  o Tachypnea or dyspnea o Irregular pulse rate o Finger clubbing o Fatigue during feeding or activity o Excessive perspirations especially over forehead ❖ Congenital heart disease causes (etiology) o Prenatal rubella in 1st trimester o Maternal alcoholism or ingestion of drugs during pregnancy o Maternal radiation o Maternal diabetes or malnutrition o Advanced maternal age ❖ Atrial Septal Defect (ASD)- increased pulmonary blood flow o Signs: murmur heard on routine physical exam ▪ Usually mild and may go undetected o Treatment: surgery to close opening with suture or patch; cardiology will follow for about a year afterwards o Prognosis: excellent o Where it occurs: opening in tissues separating hearts upper chambers ❖ Ventricular Septal Defect (VSD)-increased pulmonary blood flow o Signs: loud, harsh systolic murmur, FTT, poor feeder, fatigues easily ▪ Most common heart anomaly in children; mild to severe o Treatment: may close spontaneously ▪ Mild: observe, monitor, antibiotics with dental care ▪ Severe: surgery to patch hole o Prognosis: excellent (after surgery) o Where it occurs: opening between the ventricles ❖ Patent Ductus Arteriosus (PDA)- increased pulmonary blood flow o Signs: early- none; late- dyspnea; full and bounding pulse, wide pulse pressure, machinery-type murmur ▪ Occurs twice as often in girls o Patho: oxygenated blood recycles to lungs and causes pulmonary circulatory congestion o Treatment: preemies-Indocin; full term newborns- ligation surgery o Prognosis: excellent o Where it occurs: between pulmonary artery and aorta ❖ Coarctation of Aorta- obstruction o Signs: early- none; marked differences in BP and pulses of upper extremities and lower extremities, systolic murmur o Patho: narrowing of aortic arch OR descending aorta o Treatment: surgery to remove narrowed area and reconnect ends (ages 2-4), percutaneous balloon angioplasty for older children o Prognosis: good after surgery (if untreated, can lead to HTN or CHF) o Where it occurs: in aorta ❖ Tetralogy of Fallot- decreased pulmonary blood flow o 4 defects: stenosis of pulmonary artery, hypertrophy of right ventricle (thickness), overriding aorta, ventricular septal defect (VSD) o Signs: cyanosis, clubbing (due to chronic hypoxia), feeding problems, growth retardation, polycythemia, “tet spells” (increase return of venous blood back to the heart), chronic respiratory infections, “boot shaped” heart on x-ray ▪ Watch for child to go into “squatting position” ▪ Children may have bluish skin during crying episodes or feedings o Treatment: surgery to correct defects ▪ Prophylactic antibiotics before procedures o Prognosis: good after surgery o Where it occurs: pulmonary artery becomes narrowed; enlarged RV; blood mixes between RV and LV ❖ Hypoplastic Left Heart o Signs: gray/blue skin, dyspnea, weak pulses, murmur o Treatment: possible ventilator, prostaglandin E1 to keep DA open ▪ Heart transplant is NEEDED within 1 month of age  o Prognosis: fatal if untreated ▪ If baby doesn’t have PDA and patent foramen ovale, chances of survival are small o Where it occurs: left side of heart is underdeveloped; LA and RA blood flow mixes; PDA is an extra connection between aorta and PA; narrowing of aorta ❖ Parenting concerns o Help them adjust to normalcy as soon as possible o Never overindulge o Hold immunizations (if they’re having a heart transplant o Importance about dental care ❖ Acquired heart disease occurs after birth includes CHF, rheumatic fever, systemic hypertension, Kawasaki's disease o HF: decrease in cardiac output necessary to meet body’s metabolic needs ❖ Congestive Heart Failure (CHF): caused by respiratory infections, sepsis, HTN, and severe anemia o Signs: cyanosis, pallor, tachypnea, tachycardia, feeding difficulties, FTT, edema, respiratory infections, nasal flaring o Treatment: oxygen, Lanoxin, diuretics, small and frequent feedings o Nursing care: cluster care, strict I/Os, recognize digoxin toxicity s/s, dehydration, education of family members ▪ HOLD dig if pulse rate is below 100bpm and notify HCP ❖ Rheumatic Fever: reaction to group A beta hemolytic infection of throat; systemic collagen disease that affects joints, heart, CNS, skin, subcutaneous tissues o Risk factor: when there are a lot of people around the infant while growing up  o Signs: migratory polyarthritis, skin eruptions, Sydenham's chorea, rheumatic arthritis (mitral valve usually), abdominal pain, fever, pallor, fatigue o Diagnosis: jones criteria (2 major or 1 major and 2 minor), chest x-ray, throat culture o Treatment: penicillin or EESx10 days (then monthly for 5 years), aspirin, rest, small and frequent feedings o Prognosis: depends on diagnosis and treatment Jones criteria (JONES PEACE) Major Minor Joint (polyarthritis) PR interval Obvious carditis ESR elevation Nodules subcutaneous Arthralgia Erythema marginatum CRP elevation Sydenham’s chorea Elevated temp (fever) ❖ Systemic Hypertension (primary vs secondary) o Signs: usually none; headaches, vision problems, dizziness o Treatment: nutrition counseling, low sodium diet, weight loss, aerobic exercise, modify risk factors ❖ Hyperlipidemia o LDL= lazy and bad o HDL: healthy and good o Health promotion (pg 635) ▪ Fruits are nutritious ▪ Restrain from lots of juice ▪ Discourage large consumption of milk ▪ Be a good role model regarding daily exercise ▪ Be a nonsmoking parent  ❖ Kawasaki Disease: mucocutaneous lymph node syndrome o Signs: abrupt onset of high fever with NO response to antipyretics, strawberry tongue, enlarged non-tender lymph nodes, rash, swollen hands, peeling palms and soles of feet o Treatment: IV gamma globin given early in illness, aspirin, coumadin o Prognosis: good if treated and followed up o Nursing care: be supportive and provide education Chapter 30: The child with a skin condition (10 questions) ❖ Skin development and function o Main function is to PROTECT (first line of defense) o Prevents passage of harmful physical and chemical agents o Prevents loss of water and electrolytes o Can regenerate and repair itself ❖ Integumentary system o Infants have thinner epidermis o Absorption is much greater o Skin is drier and can chap easier o Less subcutaneous tissues= more sensitive to heat and cold o Perspiration occurs at age 3 (problem with thermoregulation until then) ❖ Skin disorders and variations o Possible sign of systemic disease or congenital problems o Skin color is important diagnostic criteria in certain diseases o Skin tests can help diagnose any allergies o Hair is inspected for color, texture, quality, distribution, and elasticity ▪ Can indicate nutritional status or sign of disease ▪ Medications can also cause changes in hair o Examples: milia, strawberry nevus, Mongolian spots, Portwine nevus Miliaria: “prickly heat” or rash caused by excess body heat and moisture; retaining of sweat that becomes blocked or inflamed due to rupture or leakage ❖ S/S: tiny pinhead-sized red papules, possible itchiness, diaper area rash or in skin folds ❖ Interventions: remove excess clothing, give baths, skin care, frequent diaper changes Intertrigo: “chafing”; dermatitis in skin folds ❖ S/S: red and moist patches in neck, inguinal, or gluteal folds o Can become aggravated by urine, feces, or moisture o More common with obese infants ❖ Interventions: prevention is key (keep affected area clean and dry) Seborrheic dermatitis: “cradle cap”; inflammation of skin with sebaceous glands ❖ S/S: thick, yellow, oily, adherent, crust-like scales on scald and forehead; like eczema; NO ITCHINESS o Common with newborns, infants, and puberty ❖ Interventions: shampoo hair consistently, baby oil at night, shampoo in morning, use a soft brush Diaper Dermatitis: irritated skin due to prolonged contact with urine, feces, laundry soaps, or friction; possibly due to solid foods, feedings, chemicals ❖ S/S: beefy red rash (Candida infection) ❖ Interventions: frequent diaper changes with meticulous skin care, cleanse peri area with warm water and dry gently after each change, for BM-cleanse with mild soap and water, keep area dry and allow to “air out”, zinc oxide (destin) Acne Vulgaris: inflammation of sebaceous glands and hair follicles (enlarge at puberty and secrete fatty substance-sebum), comedone is a plug for keratin, sebum, and bacteria ❖ S/S: open-blackhead; closed- whitehead ❖ Interventions: routine skin cleaning, avoid greasy hair products and makeup, topical or oral treatments, good hygiene, moderate exercise, balanced diet ❖ Educate to take meds as prescribed and for to avoid pregnancy Herpes Simplex Type 1: cold sore or fever blister; most communicable during early phase; recurrence is common ❖ Activated by stress, sun, menstrual cycle, fever ❖ S/S: tingling, itching, or burning lips; vesicles and crust formation (may take 10 days to heal) ❖ Interventions: antivirals (acyclovir) ❖ Educate to not pick at lesion and DON’T share lipstick Infantile Eczema: “atopic dermatitis”; inflammation of hypersensitive skin; seen in infants once they have things other than breastmilk; more like a symptom; comes with family history of allergies and asthma ❖ S/S: oversensitivity (worse in winter) ❖ Interventions: avoid overheating and exposure to irritants, improve hydration status, meds (antihistamines, topical steroids- NOT WITH VIRAL INFECTIONS) Staphylococcal Infection: primary infection that occurs from umbilicus or circumcision; can occur in or after discharge; can lead to septicemia if it enters bloodstream ❖ S/S: small pustules (REPORT IMMEDIATELY) ❖ Interventions: IV or ointment antibiotics o MRSA: contact isolation in hospital Impetigo: caused by staph or group A beta hemolytic strep; VERY CONTAGIOUS ❖ S/S: bullous form seen in infants, non-bullous seen in children and young adults o Newborns are susceptible (resistance to bacteria is LOW) ❖ Interventions: oral or parenteral antibiotics Fungal Infections: stratum corneum, hair and nails are invaded; larger than bacteria ❖ Tinea capitis: alopecia o Treatment: griseofulvin (avoid sun) ❖ Tinea corporis: oval scaly inflamed ring with a clear center  o Treatment: clotrimazole (pedis and cruris too) ❖ Tinea pedis: lesions between toes and on soles; itchy ❖ Tinea cruris: “jock itch” Pediculosis: 3 types (captitis, corporis, pubis); lice survival depends on blood extracted from infected person ❖ Treatment: nix, rid, pronto, comb dipped in 1:1 solution white vinegar and water; ovide for resistant bugs Scabies: parasitic; caused by female mice that burrow under skin and lay eggs that contain feces ❖ S/S: between fingers is common, intense itching at night, moist body folds ❖ Spreads through personal contact ❖ Treatment: permethrin; all famliy members must be treated too ❖ Burns o Thermal: due to fire or scaling vapor or liquid o Chemical: due to corrosive powder or liquids o Electrical: due to electrical currents that pass-through body o Radiation: due to x-rays or radioactive substances o 1st degree (superficial): epidermis only, red blanchable skin, painful ▪ Interventions: immerse in cool water and apply antimicrobials o 2 degree (partial thickness): epidermis and much of dermis, blistered skin nd that is moist red/pink and very painful ▪ Interventions: same as 1st degree if small; if larger, immerse in cool water, cover with sterile dressing and clean cloth, avoid breaking the blisters and seek medical attention immediately o Deep dermal (Deep partial thickness): extends into dermis; mottled skin that may be red tan or dull white; painful blisters ▪ Interventions: immerse in cool water, cover with sterile dressing or clean cloth, avoid breaking blisters ▪ Healing takes place in 30 days with extensive scarring o 3 degree (full thickness): subdermal; involves entire skin and its structures; rd tough leathery and dry skin; non-blanchable and no cap refill; dull brown tan black or pearly white color; painless  ▪ Interventions: immerse in cool water or rolling in blanket or a rug, clean sheet or sterile dressing, warm blanket and have pt lay down, avoid ointments; nearby ER immediately; skin graft will be needed o 4 degree (full thickness): all skin and nerve endings are destroyed including th muscle and bones; visible blood vessels and necrotic tissue ▪ Interventions: same as 3rd degree ❖ Secondary and tertiary complications from burns o Secondary infections o Disfigurements ❖ Emergency care of burns o STOP burning process o Assess condition ▪ Indications that flames have been inhaled: cyanosis, singed nasal hairs, charred lips, stridor ▪ Endotracheal tube (protect airway) ▪ Get IV ▪ Obtain blood and other fluids for testing ▪ NG tube (to empty stomach and prevent complications) o Cover the burn (wound care) ▪ Give pain meds before cleansing or debridement ▪ Increased risk of infection and fluid loss ▪ Nursing care: protective isolation, sterile equipment, avoid injury to granulation tissue ▪ Topical agents: silver sulfadiazine cream (NOT with sulfa allergy), mafenide acetate (NOT on face), bacitracin o Take to ER and provide reassurance to family members and friends ❖ Child’s response to burns o Thinner skin due to larger body surface area o Increased metabolism o Smaller muscle and fat content o More elastic skin o Immature immunity o Growth and developmental issues ❖ Skin grafts o Permanent ▪ Autograft: from themself ▪ Isograft: from identical twin or genotype o Temporary  ▪ Homograft: disease free cadavers ▪ Heterograft: tissues form different species ▪ Porcine xenograft: from pigskins o Tanner mesh graft: strip of split thickness skin is expanded to provide more coverage and maintains tension o Postage stamp graft: small pieces of donor skin placed on granulation tissue that is spaced out to allow for drainage and healing o Full cover (sheet) graft: sheets of skin places intact over wounds Chapter 33: Child with emotional or behavioral condition (11 questions) ❖ Manifestations: nail biting, finger sucking, stuttering, truancy, lying, stealing, aggressive behavior, disrespectful ❖ Organic behavioral disorders o Dyslexia: mixing up letters and numbers; language based ▪ Manifestations: difficulty with sounding out words, word recognition, reading comprehension, recognizing letters, learning rhymes, and confusing sound-alike words ▪ Multidisciplinary care is important o Autism spectrum disorder: diagnosed at 5 or older ▪ Manifestations: no babbling or pointing my 12 months, no spontaneous phrases by 24 months, loss of social skills, repetitive behaviors, little pretend play, rigid, prefers to play alone ▪ Prognosis: best if able to form communication skills by 5 years old ▪ Treatment: well-structured lifestyle, behavior mod, meds to help with behavior (in hopes to maximize child’s ability to live independently ▪ Nurse role: early identify abnormality, referral, monitor for SEs of medications, slow paced approach, minimize distractions, organize care and schedule time, ask before touching child, avoid sudden movement and loud noises o Obsessive compulsive disorder ▪ Manifestations: prolonged ritualistic behavior, social withdrawal, poor school performance, family conflicts ▪ Treatment: fluoxetine (Prozac), sertraline (Zoloft), cognitive behavior therapy o Attention deficit/ hyperactivity disorder (ADHD) ▪ Manifestations: inattention, increased distractibility, poor impulses, motor restlessness, underachiever, problems with social relationships, low self esteem  ▪Diagnosis: receptive language, expressive language, info processing, memory, motor coordination, orientation, behavior problems ▪ Treatment: multidisciplinary or individualized or cognitive behavioral therapy, fam support and emotional support, CAM Medications: ritalin, concerta, focalin, dexedrine, adderall ▪ Strategies in classroom: sit in front of pt, have pt focus on attention, repetition and give clear instructions, allow for breaks o Anorexia nervosa: starvation ▪ Manifestations: severe weight loss, dry skin, amenorrhea, lanugo, cold intolerance, low BP, abdominal pain, constipation ▪ Treatment: treat underlying cause, psychotherapy, behavior therapy (goal is to correct malnutrition) Medications: SSRIs (for depression) o Bulimia ▪ Binge-purge cycle: eat large amounts of food then induction of vomiting, use of laxatives, or diuretics ▪ Manifestations: dental caries (due to hcl acid expelled when vomiting), muscle weakness, depression, substance abuse, impulsiveness, throat irritation, esophageal tears ▪ Treatment: multidisciplinary approach ▪ Nurse role: educate, prevent, identify, and refer o Internet gaming disorder??????? ❖ Environmental or biochemical disorders o Depression: precursor to adolescent suicide ▪ Minor ▪ Major: mood disturbances and behavioral changes ▪ Manifestations: irritability, loss of appetite, sleep difficulties, lethargy, social withdrawal, sudden drop in grades, worthlessness feelings, lack of pleasure in activities ▪ Nurse role: recognize signs ▪ Treatment: meds and cognitive behavioral therapy o Suicide: 3rd leading cause of death in adolescents o Categories: ideations, gestures, attempts o Manifestations: flat affect, dropping grades, isolation, change in physical appearance, giving away possessions, talking about death  o Precipitating factors: family history, substance abuse, child abuse or neglect, family conflict, relationship problems, firearm availability o Substance abuse ▪ Experimentation: just trying it out ▪ Controlled use: only does it when they go out ▪ Abuse: daily use; begins affecting life ▪ Dependence: can be psychological or physical ▪ Psychological or physical ▪ Tolerance: when increased dose is needed to maintain same effect ▪ Early: alcohol, marijuana, gateway drugs (euphoria and CNS depression; possible cardiac arrest) ▪ Later: opiates, cocaine, meth, ecstasy, steroids ▪ Treatment: educate, prevent, outpatient or inpatient o Children of alcoholics ▪ Characteristics: unpredictable, increased risk of sexual or physical abuse, isolation, lack of structure ▪ Coping responses o Flight: flees feelings; spends less time at home o Fight: acts out and always gets in trouble o Perfect child: doesn’t want to make parents mad o Savior: will go out of way to help around the house; feels overly responsible ▪ Nurse role: recognition and intervention