PEDIATRIC NURSING

1. PEDIATRIC NURSING Care of the Child and Family

2. Developmental Theorists • Maslow’s Hierarchy of Needs (1954) • Erik Erikson - Psychosocial Theory • Jean Piaget - Cognitive Theory

3. Maslow’s Hierarchy of Needs • Principles: • An individual’s needs are depicted in ascending levels on the hierarchy • Needs at one level must be met before one can focus on a higher • level need • Levels of Maslow’s Hierarchy of Needs: • Physiologic/Survival Needs • Safety and Security Needs • Affection or Belonging Needs • Self-esteem/Respect Needs • Self-actualization Needs

4. TRUST VS. MISTRUST • Birth - 1 year • World/Self is good • Basic needs met • Met = happy baby • Unmet = crying, tense, clinging • Stranger Anxiety • Separation Anxiety Photo Source: Del Mar Image Library; Used with permission

5. AUTONOMY VS. SHAME & DOUBT 1 – 3 years • Sense of control • Exerts self/will • Pride in self-accomplishment • Negativism • Ritualism/Routines • Parallel play Photo Source: Del Mar Image Library; Used with permission

6. INITIATIVE VS. GUILT 3 – 6 years • “Can-do” attitude • Behavior is goal-directed and imaginative • Play is work • Be careful with criticism Photo Source: Del Mar Image Library; Used with permission

7. INDUSTRY VS. INFERIORITY 6 – 12 years • Mastery of skills • Peers in both play and work • Rules important • Competition • Predictability Photo Source: Del Mar Image Library; Used with permission

8. IDENTITY VS. ROLE CONFUSION 12 -18 years • Sense of “I” • Peers are very important • Independence from parents • Self-image Photo Source: Del Mar Image Library; Used with permission

9. Piaget’s Cognitive Theory Development of Thought Processes: 30 – 2 years: Sensorimotor 32 – 7 years: Preoperational 37 – 11 years: Concrete Operations 311 years + : Formal Operations

10. SENSORIMOTOR Birth - 2 years • Reflexive behavior leads to intentional behavior • Egocentric view of world • Cognitive parallels motor development • Object Permanence

11. PREOPERATIONAL THOUGHT 2 - 7 years • Egocentric thinking • Magical thinking • Dominated by self-perception • Animism • No irreversibility • Thoughts cause actions Photo Source: Del Mar Image Library; Used with permission

12. CONCRETE OPERATIONS 7 - 11 years • Systematic/logical • Fact from fantasy • Sense of time • Problem solve • Reversibility • Cause & effect • Humor Photo Source: Del Mar Image Library; Used with permission

13. FORMAL OPERATIONS 11 years - Adult • Abstract thinking • Analyze situations • New ideas created • Factors altering this: • Poor comprehension • Lack of education • Substance abuse Photo Source: Del Mar Image Library; Used with permission

14. Infant Physical Tasks • Physical Tasks: 0 - 6 months: • Fastest growth period • Gains 5-7 oz (142-198 g) weekly for 6 months • Grows 1 inch (2.5 cm) monthly for 6 months • Head circumference is equal to or larger than chest circumference • Posterior fontanel closes at 2-3 months* • Obligate nose breathers* • Vital signs: HR and RR faster and irregular* • Motor: behavior is reflex controlled • sits with or without support at 6 mo* • rolls from abdomen to back • Sensory: able to differentiate between light and dark • hearing and touch well developed • TOYS = Mirror, Music, Mobile

15. Infant Physical Tasks • Physical Tasks 6 - 12 months: • Gains 3-5 oz (84-140g) weekly for next 6 months • * triples weight by 12 months • Gains 1/2 in (1.25 cm) monthly for next 6 months • Teeth begin to come in • Motor: Intentional rolling over from back to abdomen* • Starts crawling and pulling to a stand* • Develops pincer grasp* • Sits without support by 9 months* • Sensory: Can fixate on and follow objects • Localizes sounds

16. Infant Psychosocial Tasks Vocalizations: • Distinction in cry at 1 month • Coos at 3 months • Begins to imitate sound at 6 months – babbles • Verbalizes all vowels at 9 months • Can say 4–5 words at 12 months Socialization: • Social smile at 2 months • Demands attention & social interaction at 4 months • Stranger anxiety & comfort habits begin at 6 months* • Separation anxiety develops at 9 months* Photo Source: Del Mar Image Library; Used with permission

17. Infant Cognitive Tasks Neonates Reflexes only 1-4 months Recognizes faces Smiles and shows pleasure Discovers own body and surroundings 5-6 months Begins to imitate 7-9 months Searches for dropped objects *Object Permanence begins Responds to simple commands Responds to adult anger 10-12 months Recognizes objects by name Looks at and follows pictures in books

18. Toddler Physical Tasks: • Slow growth period • Gains 11 lbs (5 kg) • Grows 8 inches (20.3 cm) • Anterior fontanel closes at • 12 - 18 months* • Primary dentition (20 teeth) complete by 2½ years • Develops sphincter control – toilet training possible* Motor Tasks: • Walks alone by 12 - 18 months* • Climbs and runs fairly well by 2 years • Rides tricycle well by 3 years Photo Source: Del Mar Image Library; Used with permission

19. Toddler Cognitive Tasks • Follows simple directions by 2 years • Uses short sentences by 18 months • *favorite words “no” and “mine” = Autonomy • Knows own name by 12 months, refers to self • Achieves object permanence • Uses “magical” thinking • Uses ritualistic behavior • Repeats skills to master them and decrease anxiety • Egocentric thinking - thoughts cause actions

20. Toddler Psychosocial Tasks • Increases independence • Able to help with dressing self • Temper tantrums (autonomy) • Beginning awareness of ownership (me and mine) • Shares possessions by 3 years • Vocabulary increases to over 900 words • Toilet training • Fears: separation anxiety, loss of control TOYS = Push-pull toys, large blocks

21. Preschooler Physical Tasks: • Slow growth rate continues • Weight increases 4-6 lbs (1.8–2.7 kg) a year • Height increases 2½ inches (5-6.25 cm) a year • Permanent teeth appear Motor Tasks: • Walks up & down stairs • Skips and hops on alternate feet • Throws and catches ball, jumps rope • Hand dominance appears • Ties shoes and handles scissors well • Builds tower of blocks Photo Source: Del Mar Image Library; Used with permission

22. Preschooler Cognitive Tasks • Can only focus on one idea at a time • Begins awareness of racial and sexual differences • Develops an understanding of time • Learns sequence of daily events • Able to understand some time-oriented words • Begins to understand the concept of causality • Has 2,000 word vocabulary • Is very inquisitive and curious

23. Preschooler Psychosocial Tasks • Becomes independent • Gender-specific behavior is evident by 5 years • Egocentricity changes to awareness of others • Understands sharing • Aggressiveness and impatience peak at 4 years • Eager to please and shows more manners by 5 years • Behavior is goal-directed and imaginative • Play is work* TOYS = Dolls, Dress-up, Imagination

24. Preschooler Psychosocial Tasks Fears: about body integrity (Fear & Injury) are common Magical and animistic thinking allows illogical fears to develop* Observing injuries or pain of others can precipitate fear Able to imagine an event without experiencing it Guilt and shame are common*

25. School-age Physical Tasks: • Slow growth continues • Weight doubles over this period • Gains 2 inches (5 cm) per year • At age 9, both sexes are the same size • At age 12, girls are bigger than boys • Very limber but susceptible to bone fractures • Develops smoothness & speed in fine motor skills • Energetic, developing large muscle coordination, stamina & strength • Has all permanent teeth by age 12 Photo Source: Del Mar Image Library; Used with permission

26. School-Age Cognitive Tasks • Period of Industry: • Likes to accomplish or produce • Interested in exploration & adventure • Develops confidence • Rules become important* • Concepts of time and space develop: • Understands causality, permanence of mass & volume • Masters the concepts of conservation, reversibility, • arithmetic and reading • Develops classification skills • Begins to understand cause and effect*

27. School-Age Psychosocial Tasks • School occupies half of waking hours; has cognitive and • social impact on child • Morality develops • Peer relationships start to be developed • Enjoys family activities • Has increased self-direction - tasks are important • Has some ability to evaluate own strengths & weaknesses • Enjoys organizational activities (sports, scouts, etc.)* • Modesty develops as child becomes aware of own body* TOYS = Board games, computer games, learning activities

28. Adolescent Physical tasks: • Period of rapid growth • Puberty starts • Girls: height increases 3 inches/year • Boys: growth spurt around 13-yrs-old height increases 4 inches/year weight doubles between 12-18 yrs • Body shape changes: Girls have fat deposits in thighs, hips & breast, pelvis broadens Boys become leaner with a broader chest Photo Source: Del Mar Image Library; Used with permission

29. Adolescent Sexual Development GirlsBoys Breasts develop Facial Hair growth Menses begins Voice changes First 1 –2 years infertile Enlargement of testes at 13 yrs Nocturnal emission during sleep Reaches reproductive maturity with viable sperm at 17 yrs

30. Adolescent Cognitive Tasks • Develops abstract thinking abilities • Often unrealistic • Sense of invincibility = risk taking behavior* • Capable of scientific reasoning and formal logic • Enjoys intellectual abilities • Able to view problems comprehensively ACTIVITIES = Music, video games, communication with peers

31. Adolescent Psychosocial Tasks Early Adolescent: Prone to mood swings Needs limits and consistent discipline Changes in body alter self-concept Fantasy life, daydreams, crushes are normal Middle Adolescent: Separate from parents Identify own values and define self* Partakes/conforms to peer group/values* Increased sexual interest May form a “love” relationship Formal sex education begins

32. Adolescent Psychosocial Tasks Late Adolescent: Achieves greater independence* Chooses a vocation Finds an identity* Finds a mate Develops own morality Completes physical and emotional maturity Fears: Threats to body image – acne, obesity Rejection Injury or death, but have sense of “invincibility” The unknown

33. Let’s Review A 10 month-old baby was admitted to the pediatric unit. Each time the nurse enters the room the baby begins to cry. The most appropriate action by the nurse would be to: A. Complete all procedures quickly in order to decrease the amount of time the baby will cry. B. Ask another nurse to assist you with the baby’s care. C. Distract the baby. D. Encourage the parent to stay by the bedside and assist with the care.

34. Let’s Review A 6 month-old is admitted to the pediatric unit for a 3 week course of treatment. The infant’s parents cannot visit except on weekends. Which action by the nurse indicates an understanding of the emotional needs of an infant? A. Telling the parents that frequent visits are unnecessary. B. Placing the infant in a room away from other children. C. Assigning the infant to different nurses for varied contacts. D. Assigning the infant to the same nurse as much as possible.

35. Let’s Review Which child is most likely to be frightened by hospitalization? A. 4 month-old admitted with a diagnosis of bronchiolitis. B. 2 year-old admitted with a diagnosis of cystic fibrosis. C. 9 year-old admitted with a diagnosis of abdominal pain. D. 15 year-old admitted with a diagnosis of a fractured femur.

36. Infant Nutrition Birth – 6 months: • Breast milk is most complete diet • Iron-fortified formulas are acceptable • No solid foods before 4 months* 6 - 12 months: • Breast milk or formula continues* • Diluted juices can be introduced • Introduction of solid foods*(4-6 mo): cereal, vegetables, fruits, meats • Finger foods at 9-10 months • Chopped table foods at 12 months • Gradual weaning from bottle/breast • No honey (risk for botulism)

37. Toddler Nutrition • Able to feed self – autonomy & messy! • Appetite decreases- physiologic anorexia • Negativism may interfere with eating • Needs 16 – 20 oz. milk/day • Increased need for calcium, iron, and phosphorus – risk for iron deficiency anemia • Caloric requirements is 100 calories/kg/day • No peanuts under 3 years of age (allergies)* • Do not restrict fats less than 2 years of age* • Choking is a hazard (no nuts, hot dogs, popcorn, grapes)* Photo Source: Del Mar Image Library; Used with permission

38. Preschooler Nutrition • Caloric requirements is 90 calories/kg/day • May demonstrate strong taste preferences • 4 years old – picky eaters • 5 years old – influenced by food habits of others • Able to start social side of eating • More likely to try new foods if they assist in food preparation • Establish good eating habits - obesity

39. School-Age Nutrition • Caloric needs diminish, only need 85 kcal/kg • Foundation laid for increased growth needs • Likes and dislikes are well established • “Junk” food becomes a problem • Busy schedules – breakfast is important • Obesity continues to be a risk • Nutrition education should be integrated into the school program

40. Adolescent Nutrition Nutritional requirements peak during years of maximum growth: Age 10 – 12 in girls Age 14 – 16 in boys Food intake needs to be balanced with energy expenditures Increased needs for: Calcium for skeletal growth Iron for increased muscle mass and blood cell development Zinc for development of skeletal, muscle tissue and sexual maturation Photo Source: Del Mar Image Library; Used with permission

41. Adolescent Nutrition (continued) Eating and attitudes towards food are primarily family/peer centered Skipping breakfast, increased junk food, decreased fruits, veggies, milk Boys eat foods high in calories. Girls under-eat or have inadequate nutrient intake.

42. Let’s Review The nurse recommends to parents that popcorn and peanuts are not good snacks for toddlers. The nurse’s rationale for this action is: A. They are low in nutritive value. B. They cannot be entirely digested. C. They can be easily aspirated. D. They are high in sodium.

43. Let’s Review Nutrition is an important aspect of health promotion for the infant. Priority information to give the parents concerning infant nutrition would include (check all that apply): A. Restrict the fat intake of the infant to help reduce the chances of an obese child. B. Breast or infant formula must be continued for the first year. C. Encourage the use of a pacifier for non-nutritive sucking needs. D. Introduction of solid foods should begin at 4-6 months.

44. Play is the work of Children • Enhances Motor Skills • Enhances Social Skills • Enhances Verbal Skills • Expresses Creativity • Decreases Stress • Helps Solve Problems

45. Appropriate Play Activities Infants - Solitary Play, stimulation of senses (music, mirror) Toddler - Parallel Play, make believe, locomotion (push-pull toys), gross & fine motor, outlet for aggression & autonomy Preschooler - Associative Play, Imaginary Playmate, dramatic & imitative, gross & fine motor School Age - Cooperative Play, rules dominate play, team games/sports, quiet games/activities, joke books Adolescent - Group activities predominate, activities involving the opposite sex in later years

46. Preparation for Procedures • Allow child to play with equipment • Demonstrate procedure on doll for young child • Use age-appropriate teaching activities • Describe expected sensations • Use simple explanations • Clarify any misconceptions • Involve parents in comforting child • Praise/reward child when finished Photo Source: Del Mar Image Library; Used with permission

47. Communicating with Children • Provide a trusting environment • Get down to child’s eye level • Use words appropriate for age • Always explain what you are doing • Always be honest • Allow choices when possible • Allow child to show feelings/talk

48. Let’s Review The single most important factor for the nurse to recognize when communicating with a child is: A. The child’s chronological age. B. Presence or absence of the child’s parents. C. Developmental level of the child. D. Nonverbal behaviors of the child.

49. Health Promotion Childhood Immunizations Well child check-ups Nutrition Screenings throughout childhood (APGARS, newborn screenings, lead poisoning, vision/hearing, scoliosis) Health Teaching

50. Immunizations • Primary prevention of many communicable diseases • Vaccines safety • MMR vaccine and autism (no correlation) • Reactions (pre-medicate with Tylenol) • Live attenuated vaccines (MMR, Varicella) • Weakened form of disease • Body produces immune response • Contraindicated in immunosupressed individuals • Inactivated (killed virus/bacteria or synthetic) • 1st dose only “primes” system- immunity develops after 3rd