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Introduction to Pediatric Nursing

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1 Introduction to Pediatric Nursing

2 Who is the patient? 6 year old female admitted to the hospital with a diagnosis of pneumonia Currently in 1st grade Lives at home with Mother, Father, and 2 year old sibling Both parents work full time outside the home Grandparents live in near by town and assist with child care

3 Answer:

4 Pediatric Nursing is: A parent-nurse partnership Nurse’s goals are:
to promote a therapeutic relationship between parent and child Accomplished by family-centered care To promote continued growth and development

5 Definitions of Grwoth and Development
Growth Increase in physical size of a whole or any of its parts, or an increase in number and size of cells: Growth can be measured Development A 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 puberty 4-6 lb/year A rapid pace from puberty to approximately 15 years A sharp decline from 16 years to approximately 24 years when full adult size is reached

8 Psychosocial & Intellectual Development

9 Theorists Associated with Development
Piaget: Periods of cognitive development Erikson: Stages of psychosocial development Kohlberg: Stages of moral development Freud: Stages of psychosexual development

10 Promote Psychosocial Development (Erikson)
Trust vs. Mistrust: (birth to 1 year) Establishes a sense of trust when basic needs are Nurses should provide consistent, loving care Autonomy vs. Shame & Doubt: (1-3 yrs) Increasingly independent in many spheres of life Nurses 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 imagination Industry vs. Inferiority: (6-12 yrs) Learns self worth as a workers & producers Allow children to compete and cooperate

12 Psychosocial Development (Erikson)
Identity vs. Role Confusion: (12-18 yrs) Forms identity and establishment of autonomy from parents Peers, society big influence Encourage peer visitation, texting, phone calls

13 Intellectual Development (Piaget)
Sensorimotor (birth to 2) learns from movement and sensory input. learns cause & effect Preoperational (2 to 7) Increasing curiosity and explorative behavior. Thinking is concrete Egocentrism

14 Intellectual Development (Piaget)
Concrete Operational (7 to 11) Logical & coherent thought Can distinguish fact from fantasy Formal Operations (11 to 15 to adulthood) Acquisition of abstract reasoning leading to Analytical thinking Problem solving Planning for the future

15 Factors Influencing Growth and Development
Genetics Environment Culture Nutrition Health status Family Parental attitudes Child-rearing philosophies

16 Play

17 Purpose of Play Sensorimotor development Intellectual development
Socialization Creativity Self-awareness Therapeutic value Moral value

18 Types of Play Solitary Parallel Associative Cooperative Onlooker
Dramatic Familiarization

19 Communicating with Children

20 Infancy Respond to physical contact Gentle voice Sing-song quality
High pitched Need to be held, cuddled

21 Early Childhood < 7 yrs
egocentric, interpret words literally tell them what “they” can do let them touch equipment nonverbal messages should be clear maintain eye level use quiet, calm voice be 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 them concerned about body integrity

23 Adolescents give undivided attention listen, be open-minded
avoid criticizing make expectations clear

24 Physical & Developmental Assessment

25 Physical Exam Guidelines
Non-threatening environment Place frightening equipment out of sight Provide privacy Provide time for play (stuffed animals, dolls) Observe for behaviors re: child’s readiness to cooperate Begin 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 slowly Preschool: if cooperative: proceed head to toe, if not: same as toddler School-age: head to toe, genitalia last, respect privacy Adolescent: same as school-age

27 Pediatric Physical Exam: Key Points
Growth measurements Height, weight, Head circumference (<2 yrs) Physiologic measurements General appearance (hygiene, posture, behavior) Lungs/ Heart Skin (color, texture, moisture, turgor) Lymph nodes (tender, large, warm may indicate infection) Eyes, ears, nose, throat Abdomen/Genitalia

28 Denver Developmental Screening Test (DDST-II)
Evaluates development for children 0-6 in four areas Personal-social Fine-motor Language Gross motor Child’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 development Not a predictor of future development, not an IQ test Used 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 done Toddlers (1-2 yr) Separation anxiety peaks, seeing the nurse as a stranger increased anxiety: establish trust first Preparation for a procedure should begin immediately before the event Preschool (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 important Adolescents (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 effective Consequences for negative behaviors Teaching parents how to discipline avoids problems related to incorrect use Appropriate limit setting Consistency Consequences should be told in advance Include truthful explanation of why behavior is unacceptable Physical punishment is the least effective

33 Limit Setting and the Toddler
Discipline must be consistent, immediate, realistic, age-appropriate, and related to the incident Clearly explain limits and give time for toddlers to respond Avoid arguments and extensive explanations Avoid withdrawing love as punishment Separate toddler from behavior Praise toddler for good behavior

34 Nutrition

35 Infancy 0-6 months Breastmilk most desirable
Fe fortified formula alternative. No whole milk until 1 yr b/c: Altered ability to be digested Increased risk of contamination Lack of components needed for appropriate growth

36 No solids before 4-6 mos b/c:
Not compatible with GI tract Exposure to food antigens that may produce a food-protein allergy Extrusion reflex still present (pushes food out of mouth)

37 Infancy 6-12 months Breastmilk 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 months 4- 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 feeding Baby food (pureed fruits and vegetables) *** introduce one at a time at 4-7 day intervals No 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 eaters At 18 mos may be able to adeptly use spoon, prefer fingers Do 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 Adolescence Caloric & 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.

45 Care of the Hospitalized Child

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 development Toddlers: encourage mobility & exploration, language development Preschoolers: assistance with self-care School-aged: socialization, provision of games & tasks for mastery Adolescents: increased independence in managing own care

48 Stressors of Hospitalization
Separation Anxiety Loss of Control Bodily Injury & Pain

49 1. Separation Anxiety (Universal fear of toddler)
Protest: loud, demanding cries, rejects comfort measures Despair: lies on abdomen, flat facial expression, weight loss, insomnia, loss of developmental skills Denial or Detachment: silent expressionless child, deterioration of developmental milestones, may have trouble forming close relationships

50 Nursing Diagnosis Anxiety 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 admissions Limit hospital stay Reduce pain Adequately prepare child for procedures Open visiting (include siblings) Primary nursing Use of play Hospital bed = “safe area” Increase control

52 2. Loss of Control Children loose control over their: Routine Body
Basic decisions Loss of school, boredom Ability to socialize

53 Interventions Infants: Provide consistent care
Toddlers: maintain consistent routine Toddlers often have security objects such as a stuffed animal that help them feel safe and secure Preschoolers: need adequate preparation to unfamiliar experiences, fear bodily injury School-aged: provide schoolwork, social Adolescents: 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 painful Postoperative pain can be very severe

56 Assess for Pain Infants: watch facial expression, FLACC
Toddlers: grimace, clench teeth, restless Preschoolers: can locate pain, use face scale, fear bodily injury & mutilation, literal School-aged: fear disability & death, pain is punishment, “magical quality” of germs, can use faces scale Adolescents: 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 pain children tolerate pain better than adults children cannot tell you where it hurts children always tell the truth about pain children become accustomed to painful procedures parents do not want to be involved in child’s pain control narcotics are more dangerous for children

59 Interventions Nurses have an ethical obligation to relieve a child’s suffering In addition adequate pain relief leads to earlier mobilization shortened hospital stays reduced costs.

60 Assess the child using QUESTT:
Question the child. Use pain rating scales. Evaluate behavior & physiologic changes. Secure the parents’ involvement Take into consideration: cause of pain. Take action & evaluate results.

61 Interventions Medicate for Pain Non Pharmacological Therapy
Cutaneous Stimulation Distraction Guided Imagery Hot or Cold application Relaxation

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.

63 Practice Questions!

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 test You really sound worried. Please keep in mind that no baby is expected to do all the things on this test Unfortunately, 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 pulse Suggest the student start with the BP Suggest the student start with respirations Say 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 clothes Knock on door before entering the child’s bedroom Plan 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 animal Remove Barney while the child is sleeping and tell the child when he wakes that Barney is lost Allow the toddler to keep the Barney stuffed animal Distract 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 preschooler The poor weight gain may be a result of poor nutrition The poor weight gain may indicate a more serious problem The 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 decisions Allow the toddler to “help” with chores Assign the toddler simple tasks or errands Teach 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 play Familiarization Cooperative play Onlooker 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

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