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

Nurse’s 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 GROWTHA rapid pace from birth to 1 ½-2 yearsA slower pace from 2 years to puberty

Expected 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

DEVELOPMENT PSYCHOSOCIAL &

INTELLECTUAL

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

PLAY

PURPOSE OF PLAY

Sensorimotor developmentIntellectual developmentSocializationCreativitySelf-awarenessMoral valueTherapeutic value

TYPES OF PLAYSolitaryParallelAssociativeCooperativeOnlookerDramaticFamiliarization

COMMUNICATING WITH CHILDREN

INFANCYResponds 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 & 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: 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 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 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 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

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

NUTRITION

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 nutrients

GI 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 MONTHSNo 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)

INFANCY 6-12 MONTHSBy 8-9 months junior foods &

finger foods

By 1-year well-cooked table foods

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 YEARSFood 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

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 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

PEDIATRIC PAIN ASSESSMENT“Pain is whatever the child experiencing it says it is”.

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

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?

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

A mother of a toddler is frustrated and states “ I can’t get this child to eat!”. The nurse should help by reviewing the portion size for toddlers is _____ of an adult’s portion.

1.¼2. 2/33.½4.¾