Nicole Tinny, MSN, CNS
Pediatrics
LSCC - Fall 2011
What is a family?
Every discipline has a definition
• Biological – perpetuation of the species
• Psychology – Responsibility for personality
development
• Economics – Productive unit providing for material
needs
• Sociology – Social unit that reacts with larger society
• A family is a group of people living together or in
close contact, who take care of one another and
provide guidance for the dependent members.
• Family is whatever/whoever the client considers it to
be.
• Family function: The interactions of family members
(caregiving, nurturing & training children)
• Family Structure –
organization/arrangement/composition
Types of families
• Nuclear: Husband, wife, children (natural or
adopted) living in common household
• Extended: Nuclear family plus relatives
• Single parent family: Usually headed by mother
• Binuclear: Joint custody in separate households
• Reconstituted: Stepparents, stepchildren
Alternative family structures:
• Polygamous – spouse has multiple mates
• Communal – share common ownership of property,
goods, children
• Same sex/homosexual parents
Family Centered Care
• The Family Plan of Care
– Remember you are caring for more than 1 person
(the entire family)
Professional Nursing Roles
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Provider of Care
Critical Thinker
Effective Communicator
Teacher
Collaborator
Advocate
Family Culture Characteristics
• Acculturation &
Assimilation
• Identity
• Connectedness
• Communication Pattern
• Socioeconomic Class
Subjective
• Health History
• Patterns of daily living
• ROS (review of systems)
ROS: Children
General
GI
Skin
GU
HEENT
Musculoskeletal
Neck
Neurological
Chest
Endocrine
CV
Objective
• Developmental Milestones
– Denver Development II Test
• Anthropometric Measurements
– Growth Charts
• Vital Signs
Objective
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Psychosocial development
Erickson’s Theory
Temperament
Age related variations in PA
Stages of Growth and
Development
• Newborn/Infant (birth to 12 months)
• Toddlerhood (1 to 3 years)
• Early Childhood (Preschool)
– (3 to 6 years)
• School-Age Child (6-12 years)
• Adolescence (12 to 19 years)
Developmental Assessment
• DDST –II identifies developmental age
– Evaluates 4 areas:
– 1. Personal-Social
– 2. Fine motor
– 3. Language
– 4. Gross motor
Anthropometric Measurements
– Length
– Weight
– BMI
– HC
– Skinfold thickness Measurements
Vital Signs
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Temperature
Pulse
Respirations
Blood Pressure
Psychosocial Development
(Erikson’s)
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Trust vs Mistrust
Autonomy vs Shame and Doubt
Initiative vs Guilt
Industry vs Inferiority
Identity vs Role Confusion
Temperament
• Birth: response to surroundings
• Baby: caretaker and environment
Age Related Variations (PA)
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Sensory
Physical
Cognitive
Language
Moral
Overall Assessment
• Establish a relationship with the family
• Ask Questions
• Comprehensive Health History
– Family Medical and Social History
– PMH
– Immunizations
– Developmental milestones
– ADL
– ROS
Physical Assessment
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Use all of your senses
Observation skills
Smell
Touch
Physical Assessment
General Impression
Ear Assessment
Cardiac Assessment
Skin Assessment
Nose/Sinus Assessment
Abdominal Assessment
Head Assessment
Throat/Mouth Assessment
GU/GI Assessment
Neck Assessment
Chest Assessment
Musculoskeletal Assessment
Eye Assessment
Lung Assessment
Neuro Assessment
General Principles
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Never lie to a child
Engage their help
Let them touch and feel
Treat assessments like games
If it’s going to hurt tell them
Health Promotion
• Infant and Child
– Nutrition
– Dental
– Sleep & Rest
– Immunizations
– Health Screenings
• Lead Poisoning
Health Promotion – Infant/Child
Nutrition
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Breast or bottle
Whole milk at 1 yr
Solids at least 4 months
Finger foods 8 to 12 months
Begin to use spoon – 1 yr to 18 months
Age 3 – Food Pyramid for Kids
Teething
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Drooling
Irritability
Chewing on objects
Crying episodes
Disrupted sleep and eating patterns
Sleep & Rest
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Newborns
Infants
Toddlers/Preschool
School-age
Health Promotion – Infant/Child
Social Aspects of Play
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Solitary Play
Onlooker Play
Parallel Play
Associative play
Cooperative play
Health Promotion
• Adolescent
– Nutrition
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Obesity
Dental Care
Sleep & Rest
Eating disorders
– Anorexia Nervosa
– Bulimia Nervosa
Parenting Styles
1. Dictatorial
2. Permissive or laissez faire
3. Democratic
Misbehavior
• Stretches the limits
• Minor consequences
• Major consequences
Types of Discipline
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Redirection
Reasoning
Time Out
Consequences
Behavior Modification
Corporal Punishment
Discipline – Newborn/Infant
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Discipline = teaching
Helps with overall function as an individual
Limit setting
Personal childrearing practice
Expectations for each developmental stage
Discipline - Toddler
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Teaches socialization & safety
Firm structure with safe limits
Be flexible with limits
Concrete vs realistic
Can do ≠ wants to do
PRAISE!!
Discipline – Early Childhood
(Preschool)
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Actions have consequences
Explain rules beforehand
Consequences = behavior being punished
Time-out
Charts, stickers, stars = encourage good
behavior (rewards)
• Helps regulate own behavior
Discipline – School-Age
• Internalize rules
• More independent = natural consequence for
behaviors
• Not “rescuing” from consequences
• Not all understand responsibility or ignore
consequences
• Timeout or grounding
Discipline - Adolescence
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Internalize responsibility
Needs parental support for rules
Monitor own actions through critical thinking
Positive behaviors should be the focus
Remove privileges
Verbal Communication
• Language and vocalizations
• May be used to distort reality
– Avoidance language
– Distancing language
Non-verbal
Communication
• Pitch, pause, rate, volume of speech
• Children understand tone and pitch
before meaning
• Children are sensitive to non-verbal
cues
Family-Centered
Communication
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Establishing rapport
Availability and openness to questions
Family education and empowerment
Feedback from children and families
Management of Conflict
Spirituality
Communication Development
and the Infant (0-1 yr)
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• Distinguish between
Cry, babble, coo
sounds
Single words, name
• Beginning of
an object
separation anxiety
Dependent on others • Interactions very
reflexive
Respond to
environmental stimuli • 1-2 min attention
span
Communication Development
and the Toddler (1-3yr)
• Two words
– “I do” “I want”
• Turn taking in
communication
• “No”; uses gestures
• Strong need for
security
• Separation anxiety
peaks
• Parallel play
• Needs routine
• Independence, but
dependent
• Explores
• Cause and Effect
• 3-5 min attention
span
Communication Development
and the Preschooler (3-6yr)
• Egocentric
• Concrete thinkers
still
• Speak in full
sentences
• “WHY”
• Stutters
• Attention seeking
behavior
• Cooperation
developing
• Set limits and
boundaries
• Developing concept
of time
• 5-10 attention span
Communication Development
and School age (6-12 yr)
• “WHY” changes to
“HOW”
• Recognizes
consequences for
actions
• Memory development
• Increase langauge
Still somewhat
concrete thinkers
• Logical thinking =
solve problems
• Metacognition
• Aware of own
thinking leads to
critical thinking
Communication Development for
Adolescents (12-19 yr)
• Adult concepts
• Make plans/sets
goals
• Competitive
• Group identity
• Close friends
• Questions authority
• Needs for privacy
• Logic to solve
problems
• Speak/write
correctly
• Communication skills
Communicating with
Children with Special Needs
In working with children with special
needs, the nurse must carefully assess
each child’s physical, mental, and
developmental abilities and determine the
most effective methods of communication.
Common Stressors During
Hospitalization
• Separation anxiety
• Loss of control
• Bodily injury & pain
Separation anxiety
• Toddlers – cling to parents, beg them to
stay, may be angry at mom if she leaves
and father stays
• Intervention – encourage parents to stay,
cot in room, bring objects from home (cup,
bottle, toy, blanket); if parent cannot stay
the nurse becomes caregiver…build trust
Separation anxiety
• Preschool- usually not quite as intense in
reactions; do not label a child as “spoiled
or a brat” – these are normal stress
responses
• Intervention – same as toddler
Separation anxiety
• Schoolage- usually handle separation well,
sometimes you have those who don’t cope
well –they may not ask for help, may not
express feelings
• Intervention - familiar objects from home
(pictures, radio, game-boy, pjs; look at
child as an individual; provide continuity of
care
Separation anxiety
• Adolescent: geared more towards
separation form peers and usual activities;
loneliness, boredom, depression, can act
against the nurse (sometimes a challenge
to care for)
• Intervention – provide association with
peers, use of phone, be a little more
relaxed with rules
Loss of control
• Toddlers – autonomy vs shame and doubt; can
temper tantrums – ask them to lie down
– IV lines are always a challenge they don’t like them
“in”
– Do not like change in routine
– Interventions- good admission assessment will help
find rituals & routine; bring favorite items from home
including food if diet allows
– Forced dependency b/c of hospital routine – let child
make decisions when possible (games, drinks)
Loss of control
• Preschooler – magical thinking! Fantasy,
superheroes, exaggerates what is to
happen or what is really happening
• -initiative vs guilt – view the hospital as
punishment “take me home, I’ll be good”
• Interventions- allow them to make
decisions; explain EVERYTHING do not
use threatening words
Loss of control
• School age- industry vs inferiority; very
vulnerable to loss of control they feel they
need to be productive
• Intervention – participate in care as much
as possible, allow them to make decisions,
explain things in advance, allow for
questions
Loss of control
• Adolescents – anything that threatens their
identity – identity vs role confusion
• Intervention – explain procedures, tiem to
prepare themselves, know what their
present needs are
The role of the Peds Nurse
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Care Provider
Teacher
Collaborator
Researcher
Advocate
Manager
Care Provider
• Empowers the family
Teacher
• To promote health of child; principles
of teaching and learning to change
family behavior when caring for child
Collaborator
• Coordinating and managing care
(interdisciplinary rounds)
Researcher
• Evidenced Based
Advocate
• Intercede on the child’s behalf because
they are a vulnerable group
Manager of Care
• Delegate tasks in order to work with
other personnel, plan, coordinate, and
collaborate
In General: The Peds Nurse
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Bathing
Feeding
Rest
Safety Measures
Infection Control
Fever-Reducing Measures
Emotional/Spiritual Support
Atraumatic Care
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FIRST DO NO HARM
Minimize separation
Promote sense of control
Prevent or minimize bodily injury or pain
Hospitalized child
and family
• Nursing assessment
– Parental needs
– Seek parental advice
– Open communication
– Concerns
– Trust
– Positive reinforcement
– Ongoing evaluation of POC
Preparing the child for
Procedures
• Know your patient and his needs
• Provide information in terms that can
understand
• Provide support
• Let the child know it’s ok to express his
feelings
• Praise the child
• Allow the child to “perform” the procedure
Pain Assessment and
Management
• Assessment of pain in infants
– Parent of care-giver participation is key
based on child’s “normal” behavior
patterns
– Requires frequent assessment
– Pain “clueing” – squirming, jerking,
Pain Assessment
and Management
• Toddlers –
– may react to non painful procedures as
violently as they do painful ones
– Explanations do not help
– Intense emotional upset & physical
resistance, overly active
– Can point to pain
Pain Assessment
and Management
• Preschooler –
– very vulnerable to threats of bodily injury
– Respond well to explanations
– More verbal “ I hate you”
– Can use face scale
Pain Assessment
and Management
• School age
– Less concerned with pain than disability or
death
– Ask questions
– Listen and attentive
– May try to postpone it
– Tolerate procedure well but it’s stressful
– Privacy
Pain Assessment
and Management
• Adolescent
– Body imagine is # 1 concern
– Do not want to be different from peers
– Privacy
– Need reassurance that everything is normal
– Self control about pain, more adult-like
Pain management
in the verbal child:
– Question the child
– Use a pain rating scale - >3 yo (faces) older
child 1-10 scale
– Look for behavioral and physical signs of pain
– preverbal behavior changes & VS changes
– Secure parent’s involvement
– Look at cause of pain – could anything else
be going on
– Take action and evaluate – both pharm and
non pharm
Pain Management
Techniques
• Non-pharmacologic: relaxation,
distraction, cutaneous stimulation
• Pharmacologic measures:
– Use pain medications preventively
– Avoid im injections if possible
– Prepare your patient
– Evaluate your interventions promptly
and reassess frequently
The chronically ill child
• Last longer than 3 months
– Physical
– Psychological
– Cognitive
• Adaptive devices
The chronically ill child
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Threat of unknown
Loss of control
Long-term effects not known
Frequent hospitalizations/clinic visits
Coping with unfamiliar people
The chronically ill child
• Therapeutic relationship
• General growth failure
– Patho of condition
• Severe hypoxia
• Chemo
– Developmental delay
• Parental , teacher, (positive or negative)
Caring for the Dying child
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Boundaries
Communication
Beliefs and Practices
Pain control
Hospice Care
Dying process and time of death
Nurses Response
Failure to Thrive
• Organic – physical ailments
• Nonorganic – maternal/child attahcment
• Idiopathic – unknown
SIDS
• Sudden death of infant younger than 1
year
• Peak age 2-4 month of life
• Pulmonary edema and intrathoracic
hemorrhage
• No sounds made at time of death
Autism
• Males vs females
• Abn EEG, cerebella hypoplasia,
permanent intellectual and behavioral
deficits
• Bizarre with interactions, communication,
and behavior
• “Rain Man” – idiot savant
Infant and Child Safety
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Medication storage
Crib safety
Smoke detectors
Car seats
Drowning
Falls
Poisoning
Choking
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Falls
Poisoning
Burns
Safety helmets
Environmental
Factors
Adolescent Safety
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Accidents and injuries •
Risk taking behaviors •
Driving
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Bicycle
Firearms
Water
Reproductive
Substance abuse
Violence
Tattooing/Body
piercing
Accident Prevention
Infant
• Motor vehicle safety - Rear facing car
seat until 20 lbs or 1 year
• Burns
• Falls
• Aspiration (leading cause of
choking…latex balloons)
• Child Proofing House
Accident Prevention
Toddler
• Injuries (MVA, drownings, poisoning, and
burns)
• Proper use of Car seats
– Forward facing after 1 year or 20 pounds
Accident Prevention
PreSchooler
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Child Abuse
Sexual Abuse
Fire/burn safety
Firearm safety
Personal safety – no to strangers
Issues Related to the
School-Age Child
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Adjustment to school
Self-care children (latchkey)
Obesity –meals on the run
Stress/Depression
Accident Prevention
– Safety education (car, fire/burn)
– Supervised sports (safety gear)
Issues Related to the
School-Age Child
• Behavioral problems
– ADHD – Attention Deficit/Hyperactivity Disorder
• Symptoms present before age 7 and present in at
least 2 settings
• Inappropriate inattention, impulsivity, and
hyperactivity
• Numerous, mild, severe
• Intelligence Quotient (IQ) - wide gap seen
between verbal and performance scores
• Ritalin & Dexedrine – most common drugs - watch
for nervousness, insomnia, increased BP,
decreased appetite, weight loss, growth
Issues Related to the
School-Age Child
– Enuresis – bedwetting
• 2 x week for 3 months
• Organic & psychogenic factors; cease b/tw 6-8 yrs;
boys
• Organic – structural problems (kidney), neurologic
deficits, diabetes
• Psychogenic – emotional factors, family hx
• Childhood depression
Issues Related to the
School-Age Child
School phobia – severe anxiety or fear of
school related experiences
• Anorexia, n/v, diarrhea, dizziness, HA, tired,
stomach aches
• s/s subside when child can stay home, holidays,
weekends
• Parents must be firm but gently that immediate
return to school is crucial
• Speak with teachers and counselors
Issues Related to the
School-Age Child
• Head Lice
• Bullying
• Food Allergies
Issues Related to the
Adolescent
• Body Image is biggest concern
• Eating disorders
– Obesity
– Anorexia Nervosa (AN) – etiology is unclear, but a
psychologic component is present
– Bulemia
Issues Related to the
Adolescent
• Smoking
• Substance abuse
– Changes in personality, behavior, physical
appearance
– Defense mechanism for anxiety, fear, anger
• Pregnancy
– Use of contraception
– Prenatal Care importance
– Reduction of Risky behaviors
Issues Related to the
Adolescent
• STD
• Suicide
– Warning signs
– Education to parents
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Car safety – seat belts
Violence toward others – control issues
Firearm safety
Lawn Mower accidents
Huffing
• Inhalant abuse
– Intervention clip youtube.com
Maltreatment of children
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Child physical abuse
Child sexual abuse
Child emotional abuse
Child neglect
Munchausen-by-proxy syndrome
– Deliberately making child sick
Depression: children and
adolescent (these are abbrev.)
• Period of 2 weeks with 5 key elements
present and persistent
– Sad or irritable mood
– Loss of interest
– Change in appetite or body weight
– Difficulty sleeping or oversleeping
– “being slowed down”
– Fatigue loss of energy
– Feelings of worthlessness or excessive guilt
– Decreased ability to think
Depression - infant
• Listlessness without physical cause
• Failure to respond to caregiver
Adolescent dating violence
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Learned behavior
Telling partner what to wear
Permission to go
Who he/she can be friends with
Making partner do something or not
unwillingly
• Destroy property
• Threatening after break up
• Repeated contact after breakup
Homicide
• 1/3 of all homicides occur in adolescents
• Stem from history of abuse in home
– Distant, passive, or absent fathers
– Dominant, overprotective, sexually inappro.
Mothers
– Violence b/tw family members
– Turmoil in home
– Feeling of distrust in home
Suicide
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3rd leading cause of death in adolescents
Overwhelmed/anxious
Peer pressure
Females engage (15%) – males carry out
(85%)
Lead Poisoning
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Lead based paint
Contaminated soil
Certain Vinyl mini-blinds
Folk remedies
Living near major highway
Contact with imported pottery, jewelry,
cosmetics