student version introduction to child health nursing 2012-2013
TRANSCRIPT
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
PEDIATRIC NURSING A parent-nurse partnership
Nurse’s goals are to promote therapeutic relationship between
parent and child
continued 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 GROWTHA rapid pace from birth to 1 ½-2 years
A slower pace from 2 years to pubertyExpected 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
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
THEORISTS ASSOCIATED WITH DEVELOPMENT
Piaget Stages of cognitive development
Erikson 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
careAutonomy 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 toAnalytical thinkingProblem solvingPlanning for the future
FACTORS INFLUENCING GROWTH AND DEVELOPMENT
Genetics Environment Culture Nutrition Health status Family Parental attitudes Child-rearing philosophies
PURPOSE OF PLAY
Sensorimotor developmentIntellectual developmentSocializationCreativitySelf-awarenessMoral valueTherapeutic value
INFANCY
Responds to physical contactUse a gentle voiceSing-song qualityHigh pitchedNeed 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 worksWhy it is being done to themConcerned about body integrity
ADOLESCENTS
o Needs undivided attentiono Listen, be open-mindedo Avoid criticizingo Make expectations clear
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)
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 and Adolescents: head to toe, genitalia last, respect privacy
PEDIATRIC PHYSICAL EXAM
Growth measurementsHeight, 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 areasPersonal-socialFine-motorLanguageGross motor
Child’s 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 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
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
importantMay have an need for independenceOlder 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 behaviorsTeaching 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
unacceptablePhysical 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
INFANCY 0-6 MONTHS Breastmilk most desirable
Fe fortified formula alternative
No whole milk until 1 year oldAltered ability to be digestedIncreased risk of contaminationLack of components needed for
appropriate growth
INFANCY 6-12 MONTHS Breast milk or formula remains the
primary source of nutrition
May begin addition of solids b/c:GI tract is mature to handle complex
nutrientsGI tract is less sensitive to allergenic
foods Extrusion reflex has disappearedSwallowing is more coordinatedHead control is well developed,
voluntary grasping begins
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
Extrusion reflex still present (pushes food out of mouth)
TODDLERHOOD From 12-18 months rate of growth
slows
At 18 months decreased nutritional need, appetite declines, picky eaters
At 18 months may be able to adeptly use spoon, prefer fingers
Do not force food
TODDLERHOODMealtime should be pleasant
What is eaten is more important than how much is eaten
General serving size is ¼ to 1/3 of the adult portion
May have a hard time sitting through an entire meal
PRESCHOOLNeeds are similar to toddler
Average daily intake: 1800 calories
More agreeable to try new foods
Ready to socialize during meals
General serving size is ½ of an adult’s portion
SCHOOL AGE YEARS Food likes and dislikes are established
Important for parents to choose foods that promotes growth
Children eat away from home
Important to teach Food Pyramid Guide for nutrition instruction
Encourage the child to make good choices
ADOLESCENCECaloric and 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 popular
“ATRAUMATIC CARE”
Interventions that eliminate or minimize psychological and
physical distress experienced by children and their families in
the health care system
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 CONTROLChildren loose control over their
RoutineBodyBasic decisionsLoss of school, boredomAbility 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 separationMeans for release of tension & fearsMeans 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, restlessPreschoolers
Can locate pain, use face scaleFear bodily injury & mutilation
School-ageFear disability & deathPain is seen as punishment“Magical quality” of germsCan use faces scale
AdolescentsUse same pain scale as adults
CHILDREN ARE UNDER-MEDICATED BECAUSE OF THESE MYTHS:o infants don’t feel pain
o children tolerate pain better than adults
o children cannot tell you where it hurts
o children always tell the truth about pain
o children become accustomed to painful procedures
o parents do not want to be involved in child’s pain control
o narcotics are more dangerous for children
INTERVENTIONSNurses have an ethical obligation
to relieve a child’s suffering
Adequate pain relief leads toearlier mobilizationshortened hospital staysreduced costs
ASSESS THE CHILD USING QUESTT:Question the childUse pain rating scalesEvaluate behavior & physiologic
changesSecure the parents’ involvementTake into consideration: cause of
painTake 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.Child will be prepared2.Child will experience little or no separation
3.Child will maintain sense of control
4.Child will exhibit decreased fear of bodily injury
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?
2. Please let me finish this test before you start worrying, Maybe the baby will do better on the rest of the test
3. You really sound worried. Please keep in mind that no baby is expected to do all the things on this test
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 toddler’s room to check vital signs and begins to take the child’s BP first. The RN should:
1. Say nothing, this action is appropriate2. Suggest the student start with the
pulse3. Suggest the student start with the
temperature4. 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
2. Knocking on door before entering the child’s bedroom
3. Planning for playtime and offer a variety of materials from which to choose
4. Singing, rocking, and holding the child consistently
A toddler who is to be hospitalized brings a dirty, ragged Elmo stuffed animal with him. The nurse’s most appropriate action is:
1. Ask the toddler’s parents to find an identical new Elmo stuffed animal
2. Allow the toddler to keep the Elmo stuffed animal
3. Remove Elmo while the child is sleeping and tell the child when he wakes that Elmo is lost
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 child’s weight has increased “only” 4 pounds since the child’s 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
2. The poor weight gain may be a result of poor nutrition
3. The poor weight gain may indicate a more serious problem
4. The weight gain is not ideal but may be nothing to worry about
The nurse should suggest the best way for a toddler’s 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
2. Allow the toddler to “help” with chores
3. Assign the toddler simple tasks or errands
4. Teach the toddler car and street safety rules
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:1.Dramatic play
2.Familiarization
3.Cooperative play
4.Onlooker actions