INTRODUCTION TO PEDIATRICS KORINA BANKS, DNP, MSN, RN 2 Principles of Pediatric Nursing Family Centered Care • enabling – families are given opportunity to display their caring abilities and gain new ones • empowerment – families are given the ability to maintain or acquire sense of control and make positive changes. Principles of atraumatic care Prevent separation Promote sense of control Minimize bodily injury Role of Pediatric Nurse Therapeutic relationship Family advocacy Health promotion and teaching Injury prevention Family support Influences on Child Health Social roles: •Primary vs Secondary groups Self-esteem & culture: •some cultures promote more pride and independence than others Communities: •The more external and internal assets, the less risky behavior 3 Peer Groups •Risk taking behaviors Cultural & Religious Health Beliefs & Practices: •Some practices may be considered abusive in the dominant culture and are reportable, while others are tolerated 4 Growth & Development 5 GROWTH/DEVELOPMENT/ SEQUENTIAL TRENDS GROWTH Increase in number and size of cells as they divide and synthesize new proteins Physiological size (height, weight, bone length, etc.) DEVELOPMENT Advancement from lower to more advanced stage of complexity; increased capacity through growth, maturation, and learning Acquisition of skills and functioning SEQUENTIAL TRENDS Based on the concept that each child will normally pass through each stage of growth and development in a predictable sequence Universal and basic to all human beings, but each person accomplishes these individually DIRECTIONAL GROWTH Cephalocaudal Head to toe direction Proximo distal Near to far Midline to peripheral concept 6 BIOLOGIC GROWTH & PHYSICAL DEVELOPMENT Growth occurs both internally and externally Dramatic growth from birth to 4 yrs old and again at age 12 during puberty Neurologic maturation: most occurs before birth Periods of rapid neurological growth between 15-29 weeks gestation Rapid growth from birth to 1 year; continues through early childhood More gradual rate through childhood into adolescence Severe illness or malnutrition will affect the rate of both growth and development 7 ERIKSON (Psychosocial) Trust vs. mistrust (birth to 1 year)-basic needs must be met by a loving person. Outcome is faith and optimism. Autonomy vs. shame and doubt (1 to 3 years)-centered on toddler’s ability to control their body, themselves and their environment. Favorable outcome is self-control and willpower Initiative vs. guilt (3 to 6 years)-characterized by vigorous, intrusive behavior; enterprise; and a strong imagination. Develop a conscience with an inner voice that warns and threatens. If activities are in direct conflict with parents, can be made to feel guilty. Outcomes: direction and purpose. Industry vs. inferiority (6 to 12 years)-children are ready to be workers and producers, engaging in tasks they can carry through to completion. They learn to compete, and cooperate-they learn rules. Outcome is competence. Identity vs. role confusion (12 to 18 years)-period of rapid body changes. Adolescents struggle to fit the roles they have played and ones they hope to play. Peers are important. Need to integrate concepts and values with those of society and to come to a decision about an occupation. Outcome is devotion and fidelity to others and to values and ideologies. Core conflict is role confusion. 8 PIAGET (Cognitive) Sensorimotor (birth-2yrs) Simple learning; behavior imitation Problem solving through trial and error Preoperational (2-7 years) Egocentric Able to make simple associations; thought is concrete and tangible Transductive reasoning: women with big bellies are pregnant Concrete operations (7-11 years) Thoughts becoming logical and coherent; able to classify and sort Problem solving is concrete and systematic Less self-centered Formal operations (11-15 years) Adaptable and flexible Able to think in abstract terms, form hypotheses 9 10 Role of Play in Development FUNCTIONS OF PLAY 1. 2. 3. 4. 5. 6. Sensorimotor development Intellectual development Creativity Self-awareness Therapeutic value Moral value 11 COMMON TYPES OF PLAY 12 Unoccupied play (infant) -child is not mobile and has random movements with no purpose. Solitary play (infant/toddler)-play alone with their interest centered on their own activity Onlooker play (infant/toddler) -watch what other children are doing but do not make any attempt to enter the play activity Parallel play (toddler)-children play independently but with other children Associative play (preschooler)-children play together with no group goal Cooperative play (school-age)-play is organized and children play in a group with other children working to complete a goal 13 Communication with the Pediatric Patient Communicating with Children Infants: respond to non-verbal cues - cannot understand verbal ones yet. Cooing and crying are their main forms of communication Early Childhood: egocentric, respond best when you discuss how THEY will be effected. Experience of others has no interest to them. School-Age: want explanations and reasons for everything. Need to know why. Adolescence: confidentiality is important *Nurses will have to be more creative when communicating with kids. 14 15 Physical assessment Physical Assessment Sequence-head to toe Growth Charts-pattern over time most important World Health Organization (WHO) 0-2yrs CDC charts for 2yrs and older Components of assessment 1. Length-usually until 24-36mo; then use height 2. Weight-naked preferred if using infant scale 3. Head Circumference 4. Temperature 5. Pulse-trends down with age 6. Respirations-trends down with age 7. B/P-trends up with age 16 Physical Assessment Other components of the assessment: 1. General Appearance 2. Skin-variations in racial groups (color, temp, turgor, texture) 3. Accessory Structures (Hair & scalp, secondary hair, nails) 4. Lymph Nodes 5. Head & Neck (shape, symmetry, ROM) 6. Eyes (PERRLA) 7. Ears- infants pull pinna down & back, and children older than 3, pull pinna up and back 8. Nose 9. Mouth & Throat 10. Chest 22 Physical Assessment Other components of the assessment: 1. Lungs- rate, rhythm, depth, quality 2. Heart-sounds, cap refill, perfusion 3. Abdomen-skin, bowels, umbilicus, hernias 4. Genitalia 5. Anus 6. Back 7. Extremities 8. Joints 9. Muscles 10. Neurologic-cerebellum function, reflexes, cranial nerves 23 24 Pain assessment & management Pain Scales NIPS (facial expression, cry, breathing pattern, arms, legs, state of arousal)- neonates <2mo FLACC (Face, legs, activity, cry, consolability)- infants >2mo Wong-Baker Faces -3-4yo Numeric Scale (0-10)- 8 years and older. May be used as early as 5 (as long as they can count and understand values of the numbers) 25 Non-Pharm Management Containment Positioning Ex: Swaddling Sucking Ex: Blanket rolls to provide a “nest” Ex: Providing pacifier Kangaroo care Ex: Skin to skin contact with a parent Distraction Relaxation Music/pet/art therapy 26 Pharm Management For mild to moderate: Acetaminophen NSAIDS (Ex: Ibuprofen) For moderate to severe: Opioids (morphine, dilaudid, fentanyl) Adjuvant: Antianxiety: Diazepam (valium) & midazolam (versed) Tricyclic antidepressants (amitriptyline) Antiepileptics (gabapentin, clonazepam) Stool softeners/Laxatives Antiemetics Diphenhydramine Steroids 27 Developmental milestones INFANT Age Physical Motor Sensory & Cognition 1 mo. • Wt. gain of 5-7 oz weekly for 1st 6 mos. • Height gain of 1 in monthly for 1st 6 mos. • Primitive reflexes present • Obligatory nose breather • Flexed position • Can turn head side to side when prone • Marked head lag when pulled from lying position • No head control when in sitting position • Grasp reflex strong • Visual acuity 20/100 • Quiets when hears a voice • Cries to express displeasure • Makes comfort sounds during feeding 2 mos. • Posterior fontanel closed • Less head lag • Can lift head 45 degrees off table • Head held up but bends in sitting position • Hands open; grasp reflex fading • Visually searches to locate sounds • Vocalizes distinct from crying • Social smile • Coos 3 mos. • Primitive reflexes fading • Able to hold head but still bobs • Slight head lag • Grasp reflex absent • Holds objects but will not reach for them • Follows objects into periphery • Turns head to follow sounds • Coos, squeals to show pleasure Age Physical Motor Sensory & Cognition 4 mos. • Moro, tonic neck, rooting reflex gone • • • • • Almost no head lag Able to sit propped Rolls from back to side Puts objects in mouth Plays with hands • Begins hand-eye coordination • Laughs aloud • Fusses when bored or left alone • Shows excitement 5 mos. • Birth weight doubles • May have tooth eruption • No head lag • Rolls from abdomen to back • Grasps objects voluntarily • Visually pursues dropped object • Squeals and coos • Discovers body parts • Rapid mood swings 6 mos. • Growth rate may begin • Sits in highchair with back to decline straight • Teething: two lower • Rolls from back to central incisors abdomen • Begins chewing and • Holds bottle biting • • • • Beginning stranger danger Imitates sounds, actions Babbles one syllable Briefly searches for dropped object Age Physical Motor Sensory & Cognition 7 mos. • Eruption of upper central incisors • Sits, leaning forward on hands • Bounces when held in standing position • Transfers objects from one hand to another • Bangs cube on table • • • • • Responds to own name Has taste preferences Increasing stranger danger Plays peekaboo Oral aggressiveness (biting) 8 mos. • Regular bowel/bladder patterns • Sits steadily unsupported • Bears weight on legs when supported • Pincer grasp beginning • Reaches for toys • • • • Makes consonant sounds Combines syllables Responds to “no” Dislikes dressing/diapering 9 mos. • Eruption of upper lateral incisors • Creeps on hands and knees • Pulls self to standing position, creeps along furniture • Crude pincer grasp • Responds to simple verbal commands • Shows fears of going to bed and being left alone Age Physical 10 mos. Motor Sensory & Cognition • Can change from prone to • Says mama, dada with sitting meaning • Creeps along furniture, sits • Comprehends bye-bye by falling • Waves • Develops object permanence • Cries when scolded 11 mos. • Eruption of lower lateral incisor • Cruises or walks with both hands held • Imitates definite speech sounds • Shows joy with task completion • Rolls ball on request • Shakes head no 12 mos. • Birth weight tripled • Birth length increased by 50% • Anterior fontanel nearly closed • Walks with one handheld • Attempts to build 2-block tower • Says 3-5 words besides mama, dada • Has favorite toy or blanket Developmental milestones TODDLER Age Physical Motor Language/socialization 15 mos. • Steady growth • Creeps up stairs • Says 4-6 words • Tolerates separation from parents • Temper tantrums 18 mos. • Anterior fontanel closed • Physiologically able to control sphincters • Runs clumsily • Throws ball overhand without falling • Manages spoon • Says 10 or more words • Awareness of ownership (my toys) 24 mos. • Weight gain of 4-6 lbs./yr.; height 4-5 in • Runs fairly well • Talks incessantly- 300 words • Parallel play 30 mos. • Birth weight quadrupled • Jumps with both feet • Knows first and last name • May be potty trained Developmental milestones PRESCHOOLER Age Physical Motor Language/socialization 3 years • May have achieved nighttime bowel/bladder control • Rides tricycle • Walks up stairs with alternating feet • Can copy some shapes • Dresses self • Vocab 900 words; 3–4-word sentences • Play is parallel and associative • Is egocentric in thought • Attempts to please parents 4 years • Growth rate similar to previous year • Birth length doubled • Hops on one foot • Uses scissors • Vocab 1500 words; 4–5-word sentences • Very independent • Play is associative • Rebels if parent expectations are high 5 years • Handedness is • Throws/catches ball established • Walks backward • Eruption of permanent • Balances on alternate teeth may begin feet • Vocab 2100 words; 6–8-word sentences • Play is associative; may cheat • Gets along with parents • Able to tolerate other points of view Developmental milestones SCHOOL AGE SCHOOL AGE School age ranges from 6-12 years Growth continues at a slower, steady rate Height increase of 2 inches per year; weight increase of 2-6 lbs per year Self concept and body image begins in school age children Active age- plays with friends Lots of maturity occurs at 8-9 years of age Puberty may begin at 10-12 years Developmental milestones ADOLESCENT Early adolescence (1114) Middle adolescence (15- Late adolescence (1817) 20) • Rapid growth= body image issues • Secondary sex characteristics appear • Conforms to group norms • Decline in self esteem • Increase in ‘best friend’ relationships • Wide mood swings, moodiness, temper outbursts • Growth decelerating in females • Develops abstract thinking • Modifies body image • Self-centered • Able to understand future implications of current behavior • Major conflicts over independence/contro l • Behavioral standards set by peer group • Withdraws when upset/feelings are hurt • Physically mature • Established abstract thought • Able to view problems comprehensively • Increase in self esteem • Emotional/physical separation from parents complete • Peer group recedes in favor of individual relationships • Anger more apt to be concealed 45 Reactions to illness & Hospitalization Reactions to Hospitalization- Loss of Control Infant Reliant on parent Assign primary nurse, stick to routine Toddlers Hospitalization disrupts autonomy; may cause regression Follow daily routine Preschoolers Egocentric; may view hospitalization as punishment. Fear body mutilation Need reassurance School age Strive for independence, fear abandonment, injury and death Need reassurance Adolescence Struggle for independence; hospitalization may cause anger Benefit from contact with peers 46 47 Nutrition Obesity Increase in body weight resulting from an excessive accumulation of body fat relative to lean body mass. Overweight=BMI between 85th-95th percentile Obesity= BMI greater than or equal to 95th percentile Consequences/Complications: include elevated blood cholesterol, high blood pressure, respiratory disorders, orthopedic conditions, cholelithiasis, fatty later disease, cancer, Type II diabetes, poor body image, low self-esteem, social isolation, depression, and rejection. 48 Childhood Obesity South Carolina •Childhood obesity is a global epidemic and affects over one-third of adults (39.8%) and 19.7% of children in the United States (Rust et al., 2020). South Carolina children have a rate of obesity of 20.1% (State of Childhood Obesity, 2020). •Childhood obesity is higher among Hispanic children (26.2 %) and non- Hispanic Black children (24.8%) (Centers for Disease Control and Prevention [CDC], 2022). •Myrtle Beach, South Carolina ranks 13th in the nation for being the most obesity city (McCann, 2022). Obesity Influencing factors: 1. Environmental Conditions 2. Community Factors 3. School lunches, vending machines, allowing students to leave for lunch Physical Inactivity 5. Unsafe neighborhoods, increased availability of fast-food restaurants, overzealous food advertising Institutional factors 4. Abundance of food, limited access to low-fat foods, reduced or minimal activity, snacking, family/cultural views, socioeconomic status Video games, TV Psychologic factors Positive reinforcement and comfort 50 Failure to Thrive Weight (and sometimes height) below the 5th percentile for age Risk Factors & Causes: Organic: Preemie, IUGR, CHD Nonorganic: Poverty, neglect, knowledge deficit Clinical manifestations Growth/developmental delays Withdrawn, apathetic Minimal smiling, avoidance of eye contact Treatment: reverse the cause 51 Immunizations Most up-to-date vaccine schedules can be found on the CDC website https://www.cdc.gov/vac cines/schedules/index.html Review types of immunity: https://www.cdc.gov/vaccines/vac-gen/immunity-types.htm Start at birth, continue through adolescence and beyond Preterm infants- at appropriate chronological age Series- if missed, pick up were left off Contraindications for vaccines Severe febrile illness Known allergy to vaccine ** minor illness such as a cold is not a contraindication** Severely immunocompromised children should not receive live viruses Children receiving immunoglobulin therapy should not get MMR and varicella vaccines for minimum of 3 months Recommended Child and Adolescent Immunization Schedule (cdc.gov) Immunizations Administration Must have consent signed VIS provided to parent Immunization reactions Immunizations among the safest and most reliable drugs available Serious reactions rare; mild side effects more common Side effects usually occur within a few hours or days Local tenderness, erythema, swelling at injection site Low-grade fever Drowsiness, eating less, prolonged crying Treatment of side effects- cold compress to area, comfort measures https://ww w.immunize .org/
