2 Who is the patient?6 year old female admitted to the hospital with a diagnosis of pneumoniaCurrently in 1st gradeLives at home with Mother, Father, and 2 year old siblingBoth parents work full time outside the homeGrandparents live in near by town and assist with child care
4 Pediatric Nursing is: A parent-nurse partnership Nurse’s goals are: to promote a therapeutic relationship between parent and childAccomplished by family-centered careTo promote continued growth and development
5 Definitions of Grwoth and Development GrowthIncrease in physical size of a whole or any of its parts, or an increase in number and size of cells: Growth can be measuredDevelopmentA continuous, orderly series of conditions that leads to activities, new motives for activities, and patterns of behavior
6 Stages of Growth and Development Neonate: first 28 days of life Infancy: birth to 1 year Toddler: 1 to 3 years Preschooler: 3 to 6 years School-ager: 6 to 10 years Prepubertal: 10 to 13 years Adolescent: 13 to 18 + years
7 Pace of Growth A rapid pace from birth to 1 ½-2 years A slower pace from 2 years to puberty4-6 lb/yearA rapid pace from puberty to approximately 15 yearsA sharp decline from 16 years to approximately 24 years when full adult size is reached
9 Theorists Associated with Development Piaget: Periods of cognitive developmentErikson: Stages of psychosocial developmentKohlberg: Stages of moral developmentFreud: Stages of psychosexual development
10 Promote Psychosocial Development (Erikson) Trust vs. Mistrust: (birth to 1 year)Establishes a sense of trust when basic needs areNurses should provide consistent, loving careAutonomy vs. Shame & Doubt: (1-3 yrs)Increasingly independent in manyspheres of lifeNurses should allow for self care & imitation
11 Initiative vs. Guilt: (3-6 yrs) Learns to initiate play activities. Nurses should encourage to explore environment with senses, promote imaginationIndustry vs. Inferiority: (6-12 yrs)Learns self worth as a workers & producersAllow children to compete and cooperate
12 Psychosocial Development (Erikson) Identity vs. Role Confusion: (12-18 yrs)Forms identity and establishment of autonomy from parentsPeers, society big influenceEncourage peer visitation, texting, phone calls
13 Intellectual Development (Piaget) Sensorimotor (birth to 2)learns from movement and sensory input.learns cause & effectPreoperational (2 to 7)Increasing curiosity and explorative behavior.Thinking is concreteEgocentrism
14 Intellectual Development (Piaget) Concrete Operational (7 to 11)Logical & coherent thoughtCan distinguish fact from fantasyFormal Operations (11 to 15 to adulthood)Acquisition of abstract reasoning leading toAnalytical thinkingProblem solvingPlanning for the future
15 Factors Influencing Growth and Development GeneticsEnvironmentCultureNutritionHealth statusFamilyParental attitudesChild-rearing philosophies
20 Infancy Respond to physical contact Gentle voice Sing-song quality High pitchedNeed to be held, cuddled
21 Early Childhood < 7 yrs egocentric, interpret words literallytell them what “they” can dolet them touch equipmentnonverbal messages should be clearmaintain eye leveluse quiet, calm voicebe specific, use simple words, short sentences, be honest
22 School Age want to know why an object exists how it works why it is being done to themconcerned about body integrity
23 Adolescents give undivided attention listen, be open-minded avoid criticizingmake expectations clear
25 Physical Exam Guidelines Non-threatening environmentPlace frightening equipment out of sightProvide privacyProvide time for play (stuffed animals, dolls)Observe for behaviors re: child’s readiness to cooperateBegin with the least intrusive examination (observation)
26 Age-specific approaches to exam Infant: auscultate heart, lungs first (head to toe NOT always appropriate)Toddler: inspect body area through play, introduce equipment slowlyPreschool: if cooperative: proceed head to toe, if not: same as toddlerSchool-age: head to toe, genitalia last, respect privacyAdolescent: same as school-age
28 Denver Developmental Screening Test (DDST-II) Evaluates development for children 0-6 in four areasPersonal-socialFine-motorLanguageGross motorChild’s mood must be typical for results to be valid (results may be altered if child is not feeling well, sedated)
29 Denver Developmental Screening Test (DDST-II) Provides a clinical impression on child’s overall developmentNot a predictor of future development, not an IQ testUsed for noting problems, monitoring, and to base a referral for additional developmental testing
30 Nursing Interventions based on Developmental Level Infants (0-12m) Use soft voice, sing-song, talk to and describe procedures as they are doneToddlers (1-2 yr) Separation anxiety peaks, seeing the nurse as a stranger increased anxiety: establish trust firstPreparation for a procedure should begin immediately before the eventPreschool (3-5 yr) Explain procedures according to senses (what child will feel, see, hear) Imagination is active...may see procedures as a consequence for misbehavior
31 Nursing Interventions based on Developmental Level School-age (6-11 yr) Use books, pictures to explain procedures, developmentally ready for detailed explanations. Organizing and collecting is an enjoyed activity, peers become more importantAdolescents (12 & up) Value privacy, group identification is important, may have an need for independence. Can understand adult concepts and can be prepared for a procedure up to a week in advance
32 Discipline (Limit Setting) Reinforcement of desired behaviors is most effectiveConsequences for negative behaviorsTeaching parents how to discipline avoids problems related to incorrect useAppropriate limit settingConsistencyConsequences should be told in advanceInclude truthful explanation of why behavior is unacceptablePhysical punishment is the least effective
33 Limit Setting and the Toddler Discipline must be consistent, immediate, realistic, age-appropriate, and related to the incidentClearly explain limits and give time for toddlers to respondAvoid arguments and extensive explanationsAvoid withdrawing love as punishmentSeparate toddler from behaviorPraise toddler for good behavior
35 Infancy 0-6 months Breastmilk most desirable Fe fortified formula alternative.No whole milk until 1 yr b/c:Altered ability to be digestedIncreased risk of contaminationLack of components needed for appropriate growth
36 No solids before 4-6 mos b/c: Not compatible with GI tractExposure to food antigens that may produce a food-protein allergyExtrusion reflex still present (pushes food out of mouth)
37 Infancy 6-12 monthsBreastmilk or formula remains the primary source of nutrition.Addition of solids b/c:GI tract is mature to handle complex nutrients & is less sensitive to allergenic foods.Extrusion reflex has disappeared.Swallowing is more coordinated.Head control is well developed, voluntary grasping begins.
38 Infancy 6-12 months4- 6 mos infant cereal mixed with formula or Breast milk (Rice, then oatmeal, barley)6 mos can introduce crackers as a teething food.6 mos fruit juice to sub for one milk feedingBaby food (pureed fruits and vegetables)*** introduce one at a time at 4-7 day intervalsNo Strawberries, eggs, peanuts
39 Infancy 6-12 months By 8-9 months junior foods & finger foods. By 1-year well-cooked table foods are served.
40 Toddlerhood From 12-18 mos rate of growth slows. At 18 mos decreased nutritional need, appetite declines, picky eatersAt 18 mos may be able to adeptly use spoon, prefer fingersDo not force food.
41 Toddlerhood Mealtime should be pleasant. What is eaten is more important than how much is eaten.General serving size: ¼ to 1/3 of the adult portion.May have a hard time sitting through an entire meal.
42 Preschool Needs are similar to toddler. Average daily intake: 1800 calories.By age 5 they are more agreeable to try new foods; are ready to socialize during meals.½ of an adult’s portion
43 School Age Years Likes & dislikes are established. Important for parents to choose foods that promotes growth.Eat away from home.Important to teach Food Pyramid Guide for nutrition instruction.Encourage the child to make good choices.
44 AdolescenceCaloric & protein requirements are higher than almost any time in life.Eating habits easily influenced by peers.Fad diets, high caloric foods low in nutritional value.
46 “Atraumatic Care”Use of interventions that eliminate or minimize psychological and physical distress that is experienced by children and their families in the health care system
47 Promotion of normal development Infants: oral-motor developmentToddlers: encourage mobility & exploration, language developmentPreschoolers: assistance with self-careSchool-aged: socialization, provision of games & tasks for masteryAdolescents: increased independence in managing own care
48 Stressors of Hospitalization Separation AnxietyLoss of ControlBodily Injury & Pain
49 1. Separation Anxiety (Universal fear of toddler) Protest: loud, demanding cries, rejects comfort measuresDespair: lies on abdomen, flat facial expression, weight loss, insomnia, loss of developmental skillsDenial or Detachment: silent expressionless child, deterioration of developmental milestones, may have trouble forming close relationships
50 Nursing DiagnosisAnxiety r/t separation from parents during hospitalization.Goal: child will exhibit minimal evidence of separation anxiety during hospitalization.Outcome criteria: observe child’s positive interactions with staff members & adherence to hospital routine, appropriate for age & stage of development.
51 Nursing Interventions Limit admissionsLimit hospital stayReduce painAdequately prepare child for proceduresOpen visiting (include siblings)Primary nursingUse of playHospital bed = “safe area”Increase control
52 2. Loss of Control Children loose control over their: Routine Body Basic decisionsLoss of school, boredomAbility to socialize
53 Interventions Infants: Provide consistent care Toddlers: maintain consistent routineToddlers often have security objects such as a stuffed animal that help them feel safe and securePreschoolers: need adequate preparation to unfamiliar experiences, fear bodily injurySchool-aged: provide schoolwork, socialAdolescents: same as schoolage, privacy
54 Interventions: Play! Provides diversion, brings about relaxation. Helps child feel more secure in strange environment.Helps lessen stress of separation.Means for release of tension & fears.Means for accomplishing therapeutic goals.Allows making choices & being in control.
55 3. Bodily Injury Procedures are uncomfortable Disease processes are painfulPostoperative pain can be very severe
56 Assess for Pain Infants: watch facial expression, FLACC Toddlers: grimace, clench teeth, restlessPreschoolers: can locate pain, use face scale, fear bodily injury & mutilation, literalSchool-aged: fear disability & death, pain is punishment, “magical quality” of germs, can use faces scaleAdolescents: use same pain scale as adults
57 Pediatric Pain Assessment Pain is whatever the child experiencing it says it is”.
58 Children are under-medicated because of these MYTHS: infants don’t feel painchildren tolerate pain better than adultschildren cannot tell you where it hurtschildren always tell the truth about painchildren become accustomed to painful proceduresparents do not want to be involved in child’s pain controlnarcotics are more dangerous for children
59 InterventionsNurses have an ethical obligation to relieve a child’s sufferingIn addition adequate pain relief leads toearlier mobilizationshortened hospital staysreduced costs.
60 Assess the child using QUESTT: Question the child.Use pain rating scales.Evaluate behavior & physiologic changes.Secure the parents’ involvementTake into consideration: cause of pain.Take action & evaluate results.
61 Interventions Medicate for Pain Non Pharmacological Therapy Cutaneous StimulationDistractionGuided ImageryHot or Cold applicationRelaxation
62 Hospitalization for all pediatric patients GOALS:Child will be prepared.Child will experience little or no separation.Child will maintain sense of control.Child will exhibit decreased fear of bodily injury.
64 While the nurse is administering the Denver Developmental Screening test to an infant, a mother expresses concern that her baby is not doing well. Which response is most appropriate for the nurse to make?Why are you so worried? Have you been having problems at home too?Please let me finish this test before you start worrying, Maybe the baby will do better on the rest of the testYou really sound worried. Please keep in mind that no baby is expected to do all the things on this testUnfortunately, your concerns seem to be valid. I will write up a consult with the child development specialist
65 The RN observes a nursing student entering a toddler’s room to check vital signs and begins to take the child’s temperature first. The RN should:Suggest the student start with the pulseSuggest the student start with the BPSuggest the student start with respirationsSay nothing, this action is appropriate
66 The nurse should teach parents of a preschooler that the best way for them to assist their child to complete the core developmental task of the preschooler is to:Encourage the child to remove and put on own clothesKnock on door before entering the child’s bedroomPlan for playtime and offer a variety of materials from which to choose.Sing to, rock, and hold the child consistently
67 A toddler who is to be hospitalized brings a dirty, ragged Barney stuffed animal with him. The nurse’s most appropriate action is:Ask the toddler’s parents to find an identical new Barney stuffed animalRemove Barney while the child is sleeping and tell the child when he wakes that Barney is lostAllow the toddler to keep the Barney stuffed animalDistract the toddler by taking him to the playroom and letting him select another stuffed animal
68 The mother of a preschooler expresses disappointment when her child’s weight has increased only 4 pounds since the child’s physical 1 year ago. The nurse should advise this mother that:A weight gain of 4-6 pounds/year is normal for a preschoolerThe poor weight gain may be a result of poor nutritionThe poor weight gain may indicate a more serious problemThe weight gain is not ideal but may be nothing to worry about
69 The nurse should suggest that the best way for a toddler’s parents to assist their child to complete the core developmental task of the toddler years is to:Allow the toddler to make simple decisionsAllow the toddler to “help” with choresAssign the toddler simple tasks or errandsTeach the toddler car and street safety rules
70 The nurse is preparing to change a toddler’s wound for the first time The nurse is preparing to change a toddler’s wound for the first time. Prior to the dressing change the nurse uses a gauze as a “blanket” for the child’s action figure. This is known as:Dramatic playFamiliarizationCooperative playOnlooker actions
71 A mother of a toddler is frustrated and states “ I can’t get this child to eat!”. The nurse should help by reviewing the portion size for toddlers is _____ of an adult’s portion.2/3