Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Pediatric Nursing Care Ellise Adams and Mary Ann Towle Chapter 1 Pediatric Nursing in the Community

Pediatric Nursing Care of the child from birth through the teenage years Come in contact with children in a variety of settings Role of the LPN/LVN ranges from assisting the healthcare team to providing first aid Be prepared to teach, provide direct care, and refer as needed

Changes in Nursing Four features of nursing practice (ANA)  Attend to full range of human responses to health and illness – holistic care  Integrate objective and subjective data  Apply scientific knowledge  Provide caring relationship

History of Pediatric Nursing Developments in Pediatric Nursing  The term “client” refers to the entire family  Nurses observe parenting skills and provide teaching to positively affect the child

Nursing Process Systematic approach to planning and implementing nursing care  Assessing  Nursing Diagnosing  Planning  Implementing  Evaluating

Nursing Process

Community-Based Practice Levels of care  Primary care  Health prevention to maintain health and prevent illness  Secondary care  Treatment of illness to return client to health  Tertiary care  Management of chronic, terminal, complicated, long-term health care problems

Roles of the LPN/LVN Collaborating with the interdisciplinary team Participating in the nursing process Using problem-solving skills  Inductive and deductive reasoning  Using critical thinking and critical thinking care maps Teaching health promotion

Prioritizing and Implementing Most critical aspects of care must be initiated first  Airway, breathing, circulation Next priority is client safety and comfort Plan and implement care for several clients at a time

Delegation Transfer authority or right to perform nursing task to competent individual in a selected situation Retain accountability for tasks delegated Base delegation on:  Client assessment  Individual situation  Skill of individual unlicensed person

Five Rules of Delegation Right task Right circumstances Right person Right direction/communication Right supervision

Direction for Delegation What is to be done Expected outcome of task Possible complications What unlicensed person should do if complications happen

Delegation Unlicensed person accepting delegated task may not redelegate task to someone else Unlicensed person is not qualified to delegate nursing care Licensed nurse is accountable for outcome of task delegated Supervision is giving direction for and inspecting task performed

Legal and Ethical Issues Affecting Children Vary from state to state Need to understand general principles Obtain legal advice for complex issues

Parents’ Rights Authority to make decisions for minor children Right to give informed consent for procedures Right to have nursing care provided in an unbiased manner

Exceptions to Parents’ Rights Parents are incapacitated and unable to make decision Actual or suspected child abuse or neglect Parents’ choice does not permit life-saving procedures for child

Child’s Rights Mature Minor Act Emancipated minors Patient’s Bill of Rights

Expectations of Parents and Children in Health Care Provide accurate and complete information about health issues Increase knowledge about diagnosis and treatment Be responsible for their own actions Report changes in client condition Keep appointments Meet financial obligations for health care

Privacy and Confidentiality Privacy  Screening from view Confidentiality  Keep secret any privileged information Parents may have right to access their dependent child’s medical record

Legally Reportable Situations Reportable diseases  Sexually transmitted infections  Food-borne infections  Some viral or airborne infections Child abuse or neglect Threats to injure oneself Suspicion of abuse

LPN/LVN’s Role in Legal and Ethical Issues Follow scope and standards of practice Provide testimony Do no harm Participate in ethics committees Refer client to support groups Participate in staff support groups Participate in clinical research by assisting with the administration of complementary therapy and collecting data

Priorities in Nursing Care Therapeutic listening  Reflecting, open-ended questions, silence Critical thinking Awareness of the law

Practice within limits of state nurse practice act Know laws of state practicing in Never advise client based on your values Uphold client confidentiality Nursing Interventions in Legal or Ethical Situations

Collaborate with other health care members Practice culturally sensitive nursing care Provide quality nursing care Report incidents promptly and accurately

Family Two or more people related by blood or marriage who reside together Two or more individuals who come together for the purpose of nurturing

Back to Directory Family

Types of Family Units Nuclear family Extended family Single-parent family

Other Frameworks for Family Binuclear Family Step Family Blended Family Cohabiting Family Communal Family

Culture Style of behavior patterns Beliefs Products of human works Within a given community or population

Religion/Ethnicity Religion  Belief in a superhuman power Ethnicity  Identity based on common ancestry, race, religion, culture  Race is biological deviations

Culture Theory Cultural factors considered when working with families  Communication  Space  Time  Role

Cultural Competence Back to Directory

Functions of the Family Functions of the family are:  Provide economic support for other family members  Satisfy emotional needs for love and security  Provide a sense of place and position in society

Family Assessment Techniques and Tools Ongoing process of examining relationships and functioning of members Assessment of Relationships  Stages of growth and development of members  Genogram – diagram of relationships among family members  Ecomap – diagram of family member interactions

Assessment of Environment Assessing the home  Condition of housing, inside and out  Availability of water, garbage, sanitation  Cooking and refrigeration facilities  Sleeping arrangement  Safety hazards Assessing the neighborhood or community

Role of LPN/LVN in Family Assessment and Care Data collection Report findings Implement written plan of care Identify healthy functioning patterns as well as characteristics of stress Document findings Report observations

Nursing Process When Caring for the Family Collect data on family Identify appropriate nursing diagnoses Plan and implement interventions for nursing care Evaluate nursing care

Characteristics of Family Under Stress Become defensive Blame others for their problems Use ineffective communication and problem- solving Cause individuals to feel unwanted, unloved, worthless Block communication leading to additional stress

Growth Process of increasing physical size Progresses from simple to complex

Development Process of maturation Refinement of body systems, thought processes, judgment Progresses from simple to complex Cephalocaudal Proximodistal

Development

Factors Influencing Growth and Development Heredity Nationality, race, culture Order of birth Gender Family structure Physical and emotional environment

Theories of Development Theories provide a framework for studying the world around us Different theoretical approaches to growth and development  Systems approach  Physical growth  Cognitive ability  Moral development  Socialization patterns

Piaget’s Stages of Cognitive Development Sensorimotor  Birth to 2 years  Interacts with environment by reflex response Preoperational  Ages 2 to 7  Interacts with environment through use of symbols

Piaget’s Stages of Cognitive Development Concrete operational  Ages 7 to 11  “Black or white”, “right or wrong” Formal operations  Ages 11 to 16  Abstract comprehension

Erikson’s Levels of Psychosocial Development Infancy  Newborn to 1 year  Trust versus mistrust Early Childhood  Ages 1 to 3 years  Autonomy versus Shame and Doubt

Erikson’s Levels of Psychosocial Development Late Childhood  Ages 3 to 6 years  Initiative versus guilt School Age  Ages 6 to 12 years  Industry versus inferiority

Erikson’s Levels of Psychosocial Development Adolescence  Ages 12 to 20 years  Identity versus role confusion Young Adult  Ages 20 to 40 years  Intimacy versus Isolation

Freud’s Stages of Psychosexual Development Five stages Behavior is motivated and often unconscious Defense mechanisms protect the ego

Stages of Physical Growth and Development Infant (Birth - 1 Year)  Doubles birth weight by 5 months  Triples birth weight by 12 months  Height grows by 12 inches  Head growth slows, torso and limbs grow  Body systems mature  Teeth erupt at about 6 months

Stages of Cognitive Development Infant  Reflexes to interacting with environment  Speech develops from noises to words  Sleeps 20 to 22 hours per day  Increases wakefulness to 2 to 3 hours at a time

Milestones and Deviations Infancy  Roll over  Grasp  Sit alone, crawl, stand

Stages of Physical Growth and Development Toddler (1-3 years)  Walk to run, climb, stand on one foot  Ride bicycle  Growth slows, pot-bellied abdomen  Cuts up to 20 teeth, feeds self

Stages of Cognitive Development Toddler  Vocabulary increases to 1000 words  Parallel play  Separation anxiety  Temper tantrums

Milestones and Deviations Toddler  Runs, jumps  Dress and undress self  Communication advances  Toilet training begins

Stages of Physical Growth and Development Preschool (3 – 6 years)  Learns to obey rules  Uses imagination  Height increases by 2 to 21/2 inches  Weight increases 4 to 5 pounds a year  Gains muscle strength and coordination

Stages of Cognitive Development Preschool  Knows name and age  Develops understanding of relationships  Identifies with gender  Vocabulary increases to 2000 words  Follows three simple commands

Milestones and Deviations Preschool  Toilet trained  Ride bicycle  Begins to write  Tie shoes

Stages of Physical Growth and Development School-Age Child (6-12 years)  Height increases 2 inches a year  Weight increases 2 pounds a year  Body proportions change  Loses teeth and gains 26 permanent teeth

Stages of Cognitive Development School-Age Child  Learns to compromise, cooperate with others  Learns to reason  Learns to understand cause-and-effect  Vocabulary increases to 2500 words  Questions family rules and traditions  Joins clubs and teams

Milestones and Deviations School-Age  Reads  Plays sports  Loses and erupts teeth

Stages of Physical Development Adolescent ( years)  Height increases earlier in females  Weight increases earlier in females  Increase in sex hormones cause physical changes  Tanner’s stages of sexual maturity

Stages of Cognitive Development Adolescent  Concrete to abstract comprehension  Self-centered, strong identity  Hormonal changes, sexuality development  Peers have positive or negative influence  Feelings of immortality

Milestones and Deviations Adolescence  Well-developed skills  Puberty changes

Milestones and Deviations

Age-Appropriate Teaching Guidelines Establish therapeutic relationship Communicate appropriately Be sensitive to developmental issues Refer to appropriate resources Refer to support groups

Priorities in Nursing Care Establish a therapeutic relationship Communicate appropriately for the client’s age level Determine stage of development and cognitive level Validate teaching through age appropriate means to ensure client understanding

Assessment Role of the LPN/LVN is to assist in the assessment of the pediatric client Preprinted tools guide data collection Measure height, weight, and head circumference and record on growth chart Observe activity, gross and fine motor control, language development

Diagnosing Possible diagnoses  Impaired parenting related to developmental delay  Delayed growth and development related to inadequate bonding  Situational Low Self-esteem related to rapid physical growth associated with adolescence

Outcomes Parent provides for child’s physical, emotional, cognitive, and social needs The child will accomplish milestones of physical, cognitive, and psychosocial tasks expected for age group The adolescence will verbalize acceptance of new physical characteristics

Planning and Implementation Encourage parents to consider the client’s age and stage of development Be sensitive to developmental issues Teach normal findings to expect Encourage age-appropriate communication Refer family to parent support groups and parenting classes

Planning and Implementation Help family develop realistic expectations Offer age-appropriate toys Explore the child’s feelings regarding physical changes Set limits about negative self-comments

Evaluating Careful assessment needed to evaluate the child with developmental delays Parenting skills need to be evaluated as the child ages Careful attention needs to be given to the adolescent’s self esteem

Illness Prevention Categories Primary prevention  Prevent health problems from developing Secondary prevention  Early detection and treatment Tertiary prevention  Treating existing disease  Preventing complications  Well-child visits  Hygiene  Immunizations

Illness Prevention Activities

Health Promotion Activities Environmental safety  Injuries Psychosocial health  Promoting self-esteem  Providing discipline  Promoting play  Promoting good nutrition

Health Promotion Activities Infant  Falls  Choking  Car safety  Promoting self-esteem  Promoting play  Appropriate toys  Good nutrition  Oral health - teething

Nutrition Infant  Breastfeeding  Bottlefeeding  Solid foods  Food allergies  Oral health

Bottle Mouth

Health Promotion Activities

Toddler  Environmental safety to avoid injuries  Toilet training  Discipline  Play  Appropriate toys  Nutrition  Oral health – care of the teeth

Nutrition Toddler  One tablespoon of food per age  Cow’s milk  Feeds self  Oral health

Health Promotion Activities Preschooler  Injuries, car seats, increased independence  Strangers  Health education  Organized learning  Discipline  Play and appropriate toys  Nutrition  Oral health

Nutrition Preschooler  Three meals and two snacks per day  Nutritious foods  Begin to assist with meals  Oral health, dental care

Health Promotion Activities School-Age  Pedestrian and bicycle safety  Latch-key children  Promote self-esteem  Play, school sports  Discipline  Nutrition  Oral Health

Nutrition School-Age  Eat one meal per day away from home  Nutritious snacks and meals  Proper etiquette  Increased appetite  Oral health

Health Promotion Activities Adolescent  Risk-taking behaviors  Health education  Sexual contact, substance abuse  Self-esteem  Play, peers  Discipline  Nutrition  Oral Health

Nutrition Adolescent  2000 to 3000 calories per day  Increase need for iron, calcium, zinc, vitamins  Three nutritious meals and snacks  Prepare own foods  Oral health, dental care  Piercings

Nutrition Obesity  Malnutrition in US  High fat, carbohydrate, sodium diets  Low fruit, vegetables, fiber, and water diets

Nutrition Nurse should monitor:  Weight, height  Nutritional status  Nutritional intake  Environmental factors

Nutrition Nurse should teach:  Adequate nutrition  Risks of inadequate nutrition

Therapeutic Play Allows the individual to deal with fears Fears associated with health care experiences

Hospitalized Child Causes stress and anxiety for client and family Young children cannot fully comprehend or participate in care Parents may have feelings of fear, anger, or guilt Two parents may not agree on plan of care Siblings curious and may feel responsible

Special Accommodations for Pediatric Clients Hospitals may have special units for care of pediatric clients Overnight facilities may be provides so the family may stay close to the hospitalized child Nurses in small hospitals may care for pediatric clients infrequently

Age Appropriate Preparation for Hospitalization Reason for hospitalization determines guidelines for preparing families  Elective procedures allow for written and verbal teaching coupled with a facility tour  Chronic illness may mean exploring prior experiences with hospitalization and instructions on new experiences  In an emergency there may be little time for preparation  Age of child also determines what type of preparation is needed

Preparing for the Hospitalization of an Infant Infant  Parents and sibling need instruction  Provide reassurance  May need to separate parents and siblings during painful procedures  Comfort infant after procedure  Family or hospital personnel in attendance

Preparing Child for Hospitalization Infant  Separation anxiety  Stages of separation  Parental involvement to promote security  Honest communication to develop trust  Requires supervision unless sleeping

Separation Anxiety Apprehension due to parents not present Three stages:  Protest  Despair  Detachment

Preparing Toddlers for Hospitalization Toddler  Identifies body parts for pain  Uses magical thinking  Give brief instruction prior to procedure  Tell child if procedure is painful  Separation anxiety present  Requires supervision unless sleeping

Preparing the Preschooler for Hospitalization Follow rituals and routine practices Need reassurance illness is not their fault Frightened by new people and experiences Encourage parents to participate in care Parents reinforce instructions provided by nurse Have familiar objects for security

Preparing the School-Aged Child for Hospitalization School-Age  Can participate in care and treatment  Understand written and verbal instructions  Need parent support  Brings favorite item from home for comfort  Participate in variety of activities  Can be left alone for brief periods

Preparing the Adolescent for Hospitalization Adolescent  Active participant in care  Embarrassed, modest or uncomfortable with body changes  Provide for privacy  Understands instructions  Encourage questions  Encourage visits from friends

Parental Preparation for Child’s Hospitalization Establish a positive relationship Answer questions Provide emotional support Orient to hospital environment

Preparation for Procedures

Priorities of Care Make the child feel safe and secure Observe for signs of anxiety or fear Diagnosis for every child to include Fear related to hospitalization Outcomes:  Express less fear  Interact appropriately with nurse  Rest quietly in bed

Nursing Interventions to Reduce Fear Approach with a smile and introduce self Allow child to:  Keep parent or guardian close  Keep favorite toy or blanket Provide a tour Allow child to touch and see equipment Developmentally appropriate activities Assign the same nurse when possible Encourage parents to comfort often

Diagnosing and Outcomes Possible nursing diagnosis  Self care deficit  Delayed growth and development  Interrupted family processes  Risk for caregiver role strain Expected outcomes  Provide as much self-care as possible  Maintain or show progress in growth and development  Verbalize appropriate methods of managing stress

Nursing Interventions Help parents provide a safe environment Encourage self-care Teach care givers to provide care Encourage verbalization of feelings Plan to minimize stress Referrals