INTRODUCTION

TO CHILD HEALTH

NURSING

WHO IS YOUR PATIENT?

6

year old female admitted to the hospital with a medical 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

ANSWER:

PEDIATRIC NURSING
A

parent-nurse partnership

Nurses

goals are to promote therapeutic relationship between parent and child

continued growth and development

GROWTH
AND

DEVELOPMENT

DEFINITIONS OF GROWTH AND DEVELOPMENT

Growth

Increase in physical size of a whole or any of its parts Increase in number and size of cells Growth can be measured

Development
A continuous, orderly series of conditions leads to activities and patterns of behavior

PACE OF GROWTH
A A

rapid pace from birth to 1 -2 years

slower pace from 2 years to puberty Expected 4-6 lb/year

rapid pace from puberty to approximately 15 years sharp decline from 16 years to approximately 24 years when full adult size is reached

STAGES OF GROWTH AND DEVELOPMENT

Neonate first 28 days of life Infancy birth to 12 months Toddler 1 to 3 years Preschooler 4 to 5 years School-ager 6 to 10 years Prepubertal 11 to 12 years Adolescent 13 to 18 + years

DEVELOPMENT PSYCHOSOCIAL & INTELLECTUAL

THEORISTS ASSOCIATED WITH DEVELOPMENT

Piaget Erikson

Stages of cognitive development Stages of psychosocial development

Kohlberg Stages of moral development Freud Stages of psychosexual development

PSYCHOSOCIAL DEVELOPMENT
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 choices and self care

PSYCHOSOCIAL DEVELOPMENT
Initiative vs. Guilt (3-6 yrs) Learns to initiate play activities, imitate adult behavior Nurses should encourage to explore environment with senses, promote imagination

Industry vs. Inferiority (6-12 yrs) Learns self worth as workers & producers Nurses should promote children to compete and cooperate

PSYCHOSOCIAL DEVELOPMENT
Identity vs. Role Confusion (12-18 yrs) Forms identity and establishment of autonomy from parents Peers and society big influence Nurses should encourage peer visitation, texting, phone calls

INTELLECTUAL DEVELOPMENT
Sensorimotor (birth to 2)
Learns from movement and sensory input Learns cause & effect

Preoperational (2 to 7 years)
Increasing curiosity and explorative behavior Thinking is concrete Egocentrism is dominant

INTELLECTUAL DEVELOPMENT
Concrete Operational (7 to 11 years)

Logical & coherent thought

Can now distinguish fact from fantasy

Formal Operations (11 to adulthood) Acquisition of abstract reasoning leading to Analytical thinking Problem solving Planning for the future

FACTORS INFLUENCING GROWTH AND DEVELOPMENT

Genetics

Environment
Culture Nutrition

Health
Family

status

Parental

attitudes Child-rearing philosophies

PLAY

PURPOSE OF PLAY
Sensorimotor

development Intellectual development Socialization Creativity Self-awareness Moral value Therapeutic value

TYPES OF PLAY
Solitary Parallel Associative

Cooperative
Onlooker Dramatic Familiarization

COMMUNICATING WITH CHILDREN

INFANCY
Responds

to physical contact Use a gentle voice Sing-song quality High pitched Need to be held, cuddled

EARLY CHILDHOOD < 7 YRS

Remember

they are egocentric and interpret words literally

Tell

them what children 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

SCHOOL AGE
Wants

to know why an object exists How it works Why it is being done to them Concerned about body integrity

ADOLESCENTS

Needs undivided attention o Listen, be open-minded o Avoid criticizing o Make expectations clear
o

PHYSICAL & DEVELOPMENTAL ASSESSMENT

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: childs readiness to cooperate Begin with the least intrusive examination (observation)

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 if cooperative: proceed head to toe, if not: same as toddler and Adolescents: head to toe, genitalia last, respect privacy

Preschool:

School-age

PEDIATRIC PHYSICAL EXAM

Growth measurements Height, weight, head circumference (<3 yrs)

Physiologic measurements (VS) General appearance (hygiene, posture, behavior) Body Systems (heart, lungs, abdomen are key areas)

DENVER DEVELOPMENTAL SCREENING TEST (DDST-II)

Evaluates development for children 0-6 in four areas Personal-social Fine-motor Language Gross motor

Childs

mood must be typical for results to be valid Results may be altered if child is not feeling well, sedated

DENVER DEVELOPMENTAL SCREENING TEST (DDST-II)

Provides a clinical impression on childs 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

NURSING INTERVENTIONS BASED ON DEVELOPMENTAL AGE (NOT CHRONOLOGICAL AGE)

Infants (0-12m)

Use soft voice, sing-song, Talk to and describe procedures as they are done

Toddlers (1-3 yr)

Separation anxiety peaks (nurse is a stranger) Preparation for a procedure should begin immediately before the event

NURSING INTERVENTIONS BASED ON DEVELOPMENTAL AGE (NOT CHRONOLOGICAL AGE)

Preschool (4-5 yr)

Explain procedures according to senses (what child will feel, see, hear) Imagination is active...may see procedures as a consequence for misbehavior

School-age (6-10 yr)

Use books, pictures to explain procedures Developmentally ready for detailed explanations Organizing and collecting is an enjoyed activity Peers become more important, parents still main influence

NURSING INTERVENTIONS BASED ON DEVELOPMENTAL AGE (NOT CHRONOLOGICAL AGE)

Pre-Adolescents/Adolescents

(11 & up)

Value privacy, group identification is important May have an need for independence Older adolescent can understand adult concepts Can be prepared for a procedure up to a week in advance

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

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

NUTRITION

INFANCY 0-6 MONTHS

Breastmilk Fe

most desirable

fortified formula alternative

No

whole milk until 1 year old

Altered ability to be digested Increased risk of contamination Lack of components needed for appropriate growth

INFANCY 6-12 MONTHS

Breast

milk or formula remains the primary source of nutrition begin addition of solids b/c: GI tract is mature to handle complex nutrients GI tract is less sensitive to allergenic foods Extrusion reflex has disappeared Swallowing is more coordinated Head control is well developed, voluntary grasping begins

May

INFANCY 6-12 MONTHS

4-

6 months infant cereal mixed with formula or Breast milk (Rice, then oatmeal, barley) 6 months can introduce crackers as a teething food. 6 months fruit juice to substitute for one milk feeding Baby food (pureed fruits and vegetables) Introduce one food at a time at 4-7 day intervals No strawberries, eggs, peanuts until after 12 months of age

INFANCY 0-6 MONTHS

No solids before 4-6 months of age b/c: Solids are not compatible with GI tract
Exposure

to food antigens that may produce a food-protein allergy reflex still present (pushes food out of mouth)

Extrusion

INFANCY 6-12 MONTHS

By

8-9 months junior foods & finger foods 1-year well-cooked table foods

By

TODDLERHOOD
From At

12-18 months rate of growth slows

18 months decreased nutritional need, appetite declines, picky eaters 18 months may be able to adeptly use spoon, prefer fingers not force food

At

Do

TODDLERHOOD
Mealtime What

should be pleasant

is eaten is more important than how much is eaten serving size is to 1/3 of the adult portion have a hard time sitting through an entire meal

General

May

PRESCHOOL
Needs

are similar to toddler daily intake: 1800 calories

Average More

agreeable to try new foods to socialize during meals serving size is of an adults

Ready

General

portion

SCHOOL AGE YEARS

Food

likes and dislikes are established

Important

for parents to choose foods that promotes growth eat away from home

Children

Important

to teach Food Pyramid Guide for nutrition instruction the child to make good choices

Encourage

ADOLESCENCE
Caloric

and protein requirements are higher than almost any time in life habits easily influenced by

Eating

peers
Fad

diets, high caloric foods low in nutritional value popular

CARE OF THE HOSPITALIZED CHILD

ATRAUMATIC CARE
Interventions that eliminate or minimize psychological and physical distress experienced by children and their families in the health care system

STRESSORS OF HOSPITALIZATION

Separation Anxiety

Loss of Control Bodily Injury & Pain

STAGES OF 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

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

LOSS OF CONTROL
Children

loose control over their Routine Body Basic decisions Loss of school, boredom Ability to socialize

INTERVENTIONS

Infants

Provide consistent care

Toddlers
Maintain consistent routine Encourage brining security objects (stuffed anima)l that help them feel safe and secure

Preschoolers
Need adequate preparation to unfamiliar experiences Fear bodily injury

School-age, pre-adolescent and adolescents

Provide schoolwork, social time, privacy

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

BODILY INJURY

Procedures are uncomfortable Disease processes are painful Postoperative pain can be very severe

ASSESS FOR PAIN

Infants

and Toddlers Grimace, clench teeth, restless Preschoolers Can locate pain, use face scale Fear bodily injury & mutilation School-age Fear disability & death Pain is seen as punishment Magical quality of germs Can use faces scale Adolescents Use same pain scale as adults

PEDIATRIC PAIN ASSESSMENT

Pain is whatever the child experiencing it says it is.

CHILDREN ARE UNDER-MEDICATED BECAUSE OF THESE MYTHS:

o o o o o o

infants dont 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 childs pain control

narcotics are more dangerous for children

INTERVENTIONS
Nurses

have an ethical obligation to relieve a childs suffering pain relief leads to earlier mobilization shortened hospital stays reduced costs

Adequate

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

INTERVENTIONS

Medicate for Pain Non Pharmacological Therapy

Cutaneous Stimulation Distraction Guided Imagery Hot or Cold application Relaxation

HOSPITALIZATION FOR ALL PEDIATRIC

PATIENTS

1.
2.

3. 4.

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

PRACTICE QUESTIONS!

The nurse is administering the Denver Developmental Screening test to an infant. The mother expresses concern that her baby is not doing well. Which response is most appropriate for the nurse to make?
1.

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

2.

3.

4.

Unfortunately, your concerns seem to be valid. I will write up a consult with the child development specialist

The RN observes a nursing student entering a toddlers room to check vital signs and begins to take the childs BP first. The RN should:
1. 2. 3.

4.

Say nothing, this action is appropriate Suggest the student start with the pulse Suggest the student start with the temperature Suggest the student start with respirations

The nurse teaches parents of a 4-year-old about the best way to assist their child in completing the core developmental task of the preschooler by:
1.

Encouraging the child to remove and put on own clothes Knocking on door before entering the childs bedroom

2.

3.

Planning for playtime and offer a variety of materials from which to choose
Singing, rocking, and holding the child consistently

4.

A toddler who is to be hospitalized brings a dirty, ragged Elmo stuffed animal with him. The nurses most appropriate action is:
1.

Ask the toddlers parents to find an identical new Elmo stuffed animal Allow the toddler to keep the Elmo stuffed animal Remove Elmo while the child is sleeping and tell the child when he wakes that Elmo is lost

2.

3.

4.

Distract the toddler by taking him to the playroom and letting him select another stuffed animal

The mother of a preschooler expresses disappointment when her childs weight has increased only 4 pounds since the childs physical 1 year ago. The nurse should advise this mother that:
1.

A weight gain of 4-6 pounds/year is normal for a preschooler The poor weight gain may be a result of poor nutrition

2.

3.

The poor weight gain may indicate a more serious problem

The weight gain is not ideal but may be nothing to worry about

4.

The nurse should suggest the best way for a toddlers parents to assist their child to complete the core developmental task of the toddler years is to:
1.

Allow the toddler to make simple decisions Allow the toddler to help with chores

2.

3.

Assign the toddler simple tasks or errands

Teach the toddler car and street safety rules

4.

The nurse is preparing to change a toddlers wound for the first time. Prior to the dressing change the nurse uses a gauze as a blanket for the childs action figure. This is known as: 1. Dramatic play
2.

Familiarization Cooperative play Onlooker actions

3.

4.

A mother of a toddler is frustrated and states I cant get this child to eat!. The nurse should help by reviewing the portion size for toddlers is _____ of an adults portion.

1.
2.

2/3

3. 4.