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 GROWTH
A
rapid pace from birth to 1 ½-2 years
A
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
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
status
 Family
 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: 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
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
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
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
most desirable
 Fe
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
 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 disappeared
Swallowing is more coordinated
Head 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)
INFANCY 6-12 MONTHS
 By
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
TODDLERHOOD
 Mealtime
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
PRESCHOOL
 Needs
are similar to toddler
 Average
 More
daily intake: 1800 calories
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
ADOLESCENCE
Caloric
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


Despair


loud, demanding cries, rejects comfort measures
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
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
INTERVENTIONS
 Nurses
have an ethical obligation to
relieve a child’s suffering
 Adequate
pain relief leads to
 earlier mobilization
 shortened hospital stays
 reduced costs
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?
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.
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
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
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
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.
¼
2.
2/3
3.
4.
½
¾