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 goal is to promote a therapeutic relationship between parent and child
Accomplished by family-centered care

5. Definitions of Growth and Development
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. Biologic Determinants of Growth in Infancy
Height: stable measurement of growth (double birth height at 2 years)
Weight: birth weight triples by end of 1st year

8. Pace of Growth A rapid pace from birth to 1 ½-2 years
A slower pace from 2 years to puberty
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

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

10. Psychosocial, Intellectual, and Moral Development

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

12. Psychosocial Development (Erikson)
Trust vs. Mistrust: (birth to 1 year)
Provide consistent, loving care
Autonomy vs. Shame & Doubt: (1-3 yrs)
Allow for self care, imitation
Initiative vs. Guilt: (3-6 yrs)
Encourage to explore environment with senses, promote imagination

13. Psychosocial Development (Erikson)
Industry vs. Inferiority: (6-12 yrs)
Want to be workers & producers, like to compete and cooperate
Identity vs. Role Confusion: (12-18 yrs)
Peers, society big influence
Forms identity and establishment of autonomy

14. Intellectual Development (Piaget)
Sensorimotor (birth to 2)
learn cause & effect
Preoperational (2 to 7)
Thinking is concrete
“egocentrism”

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

16. Important Tasks of Toddlerhood
Recognition of self as a separate person, with own will
Control of impulses and acquisition of socially acceptable ways to communicate wants and needs
Control of elimination
Toleration of separation from the parent

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 < 5 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

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
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. Guidelines for Discipline 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 yoa 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
6 mos can introduce crackers as a teething food.
6 mos fruit juice to sub for one milk feeding
Baby food (fruits first then vegs)
*** introduce one at a time at 4-7 day intervals

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 Years 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. Dietary Guidelines for Children older than 2 Years
Aim for fitness
̶ Healthy weight
̶ Daily physical activity
Build a healthy base
̶ Use pyramid to guide food choices
̶ Eat a variety of grains, fruits, and vegetables
̶ Keep food safe to eat
Choose sensibly
̶ Foods low in fat, cholesterol, sugar, and salt

46. Care of the Hospitalized Child

47. “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

48. 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

49. Stressors of Hospitalization
Separation Anxiety
Loss of Control
Bodily Injury & Pain

50. 1. Separation Anxiety (Universal fear of toddler)
Protest: loud, demanding cries, rejects comfort measures
Despair: wailing cry, rejects parents, 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

51. 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.

52. Nursing Interventions
Limit admissions
Limit hospital stay
Reduce pain
Adequately prepare child
Open visiting (include siblings)
Primary nursing
Use of play
Hospital bed = “safe area”
Increase control

53. 2. Loss of Control Infants: need consistent care
Toddlers: maintain consistent routine
Preschoolers: need adequate preparation to unfamiliar experiences, fear bodily injury
School-aged: fear loss of control, boredom
Adolescents: separation from peers

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 and Pain Infants: facial expression
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
Adolescents: use same pain scale as adults

56. Pediatric Pain Assessment
“Pain is whatever the child experiencing it says it is”.

57. 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

58. 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.

59. 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.

60. 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

61. 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

62. The nurse should counsel 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:
Have the preschooler watch the parents do chores
Answer their preschooler’s questions simply but truthfully
Minimize the preschooler’s fear of the dark and monsters
Insist on clear fluent speech

63. 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

64. Answer: # 3 Allow the toddler to keep the Barney stuffed animal
Rationale: Toddlers often have security objects such as a stuffed animal that help them feel safe and secure.
There is no harm to the child as he has been living with the toy in this condition for some time.
Removing the toy would cause psychological stress, nor should the parents attempt to replace it

65. 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

66. Answer: # 1 A weight gain of 4-6 pounds/year is normal for a preschooler
Rationale: A preschooler normally gains 4-6 pounds a year. The nurse should reassure the mother that the weight gain is within normal limits

67. 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”
Assign the toddler simple tasks or errands
Teach the toddler car and street safety rules

68. The nurse should be aware that which description is uncharacteristic of the play practices of children in the school-age years?
Boys and girls seek each other to play
Both sexes like to collect things
School age children like to play with same sex children
School age children like competitive games