Introduction to Pediatric

Nursing
Who is the patient?
6 year old female admitted to the hospital
with a diagnosis of pneumonia
Currently in 1
st
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 is:
A parent-nurse partnership

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

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

Pace of Growth
A rapid pace from birth to 1 -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

Psychosocial & Intellectual
Development
Theorists Associated
with Development
Piaget: Periods of cognitive
development
Erikson: Stages of psychosocial
development
Kohlberg: Stages of moral
development
Freud: Stages of psychosexual
development
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


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

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

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

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

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
Therapeutic value
Moral value

Types of Play
Solitary
Parallel
Associative
Cooperative
Onlooker
Dramatic
Familiarization


Communicating with
Children

Infancy
o Respond to physical contact
o Gentle voice
o Sing-song quality
o High pitched
o Need to be held, cuddled

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

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


Adolescents
give undivided attention
listen, be open-minded
avoid criticizing
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: childs
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: head to toe, genitalia last,
respect privacy
Adolescent: same as school-age
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

Denver Developmental
Screening Test (DDST-II)
Evaluates development for children 0-6 in four
areas
Personal-social
Fine-motor
Language
Gross motor

Childs 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 childs
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 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

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

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 yr b/c:
Altered ability to be digested
Increased risk of contamination
Lack of components needed for
appropriate growth

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)


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.


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

Infancy 6-12 months
By 8-9 months junior foods &
finger foods.

By 1-year well-cooked table
foods are served.


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.

Toddlerhood
Mealtime should be pleasant.
What is eaten is more important
than how much is eaten.
General serving size: to 1/3 of
the adult portion.
May have a hard time sitting
through an entire meal.

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.
of an adults portion

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.

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.

Care of the Hospitalized
Child

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


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


Stressors of Hospitalization
1. Separation Anxiety
2. Loss of Control
3. Bodily Injury & Pain


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

Nursing Diagnosis
Anxiety r/t separation from parents during
hospitalization.

Goal: child will exhibit minimal evidence of
separation anxiety during hospitalization.

Outcome criteria: observe childs positive
interactions with staff members &
adherence to hospital routine, appropriate
for age & stage of development.


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

2. 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
Toddlers often have security objects such as a
stuffed animal that help them feel safe and secure
Preschoolers: need adequate preparation to
unfamiliar experiences, fear bodily injury
School-aged: provide schoolwork, social
Adolescents: same as schoolage, 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.


3. Bodily Injury
Procedures are uncomfortable

Disease processes are painful

Postoperative pain can be very severe

Assess for Pain
Infants: watch facial expression, FLACC
Toddlers: grimace, clench teeth, restless
Preschoolers: can locate pain, use face
scale, fear bodily injury & mutilation,
literal
School-aged: fear disability & death, pain
is 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:
infants dont feel pain
children tolerate pain better than adults
children cannot tell you where it hurts
children always tell the truth about pain
children become accustomed to painful
procedures
parents do not want to be involved in
childs pain control
narcotics are more dangerous for
children


Interventions
Nurses have an ethical obligation to
relieve a childs suffering
In addition 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
GOALS:
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!
While the nurse is administering the Denver
Developmental Screening test to an infant,
a 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 toddlers room to check vital
signs and begins to take the childs
temperature first. The RN should:
1. Suggest the student start with the pulse
2. Suggest the student start with the BP
3. Suggest the student start with respirations
4. Say nothing, this action is appropriate

The nurse should teach parents of a preschooler
that the best way for them to assist their child to
complete the core developmental task of the
preschooler is to:

1. Encourage the child to remove and put on own
clothes
2. Knock on door before entering the childs
bedroom
3. Plan for playtime and offer a variety of materials
from which to choose.
4. Sing to, rock, and hold the child consistently
A toddler who is to be hospitalized brings a dirty,
ragged Barney stuffed animal with him. The
nurses most appropriate action is:

1. Ask the toddlers parents to find an identical new
Barney stuffed animal
2. Remove Barney while the child is sleeping and tell
the child when he wakes that Barney is lost
3. Allow the toddler to keep the Barney stuffed
animal
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 childs weight
has increased only 4 pounds since the
childs 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 that the best
way for a toddlers 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
toddlers wound for the first time. Prior
to the dressing change the nurse uses
a gauze as a blanket for the childs
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 cant get this child to eat!.
The nurse should help by reviewing
the portion size for toddlers is _____
of an adults portion.
1.
2. 2/3
3.
4.