Introduction to Pediatric Nursing

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 goals are: • to promote a therapeutic relationship between parent and child • Accomplished by family-centered care • To promote continued growth and development

5. Definitions of Grwoth and Development • Growth • 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. Pace of Growth • A rapid pace from birth to 1 ½-2 years • A slower pace from 2 years to puberty • 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

8. Psychosocial & Intellectual Development

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

10. Promote Psychosocial Development (Erikson) 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 self care & imitation

11. Initiative vs. Guilt: (3-6 yrs) • Learns to initiate play activities. • Nurses should encourage to explore environment with senses, promote imagination • Industry vs. Inferiority: (6-12 yrs) • Learns self worth as a workers & producers • Allow children to compete and cooperate

12. Psychosocial Development (Erikson) Identity vs. Role Confusion: (12-18 yrs) • Forms identity and establishment of autonomy from parents • Peers, society big influence • Encourage peer visitation, texting, phone calls

13. Intellectual Development (Piaget) Sensorimotor (birth to 2) • learns from movement and sensory input. • learns cause & effect Preoperational (2 to 7) • Increasing curiosity and explorative behavior. • Thinking is concrete • Egocentrism

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

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

16. Play

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 < 7 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. want to know why an object exists how it works why it is being done to them concerned about body integrity School Age

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 • Begin with the least intrusive examination (observation)

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 • Height, weight, Head circumference (<2 yrs) • 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. 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

34. Nutrition

35. Infancy 0-6 months • Breastmilk most desirable • Fe fortified formula alternative. No whole milk until 1 yr 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 (Rice, then oatmeal, barley) • 6 mos can introduce crackers as a teething food. • 6 mos fruit juice to sub for one milk feeding • Baby food (pureed fruits and vegetables) • *** introduce one at a time at 4-7 day intervals • No Strawberries, eggs, peanuts

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 • 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. Care of the Hospitalized Child

46. “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

47. 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

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

49. 1. 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

50. 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.