All topics

What fine motor skills are we expecting at 15 months of age?

build 2 block tower and use a cup well

What fine motor skills are we expecting at 18 months of age?

can manage a spoon for eating

What fine motor skills are we expecting at 2.5 years of age?

draws a circle

What fine motor skills are we expecting at 5 years of age?

uses scissors and can tie their shoes

Erickson Stage: Trust vs Mistrust

Age: Infant 0-1 year

Definition: the infant must meet goal of trusting the caregiver that their basic needs will be met.

Outcome of meeting goal: a person who has faith and optimism

Erickson Stage: Autonomy vs Shame and Doubt

Age: Toddler 1-3 years

Definition: the child must be provided an environment that permits self-care within reasonable limits, promoting sense of control about their bodies, themselves, and their environment

Outcome of meeting goal: a person who has self-control and willpower

Erickson Stage: Initiative vs Guilt

Age: Preschooler 3-6 years

Definition: The child must be provided opportunity to safely explore their environment using their imagination and all senses. Caregivers should guide them to tasks they are capable of while reinforcing limits without imposing guilt.

Outcome of meeting goal: a person who has direction and purpose

Erickson Stage: Industry vs Inferiority

Age: School Age 6-12 years

Definition: the child must be provided opportunity to achieve a sense of accomplishment thru developmentally achievable tasks, receive praise that promotes feelings of self - worth

Outcome of meeting goal: a person who has a sense of competence.

Erickson Stage: Identity vs Role Confusion

Age: Adolescent 12-19 years

Definition: The child is challenged to create a personal identity that is influenced strongly by the expectations of family, peers and larger social groups.

Outcome of meeting goal: devotion and fidelity to others the internalization of values and ideologies.

Fine motor skills:

the movement and control of small muscles of the body used to accomplish more difficult and delicate tasks.

- palmar hand grasp
- uses pincer grasp
- build 2 block tower and use a cup well
- can manage a spoon for eating
- draws a circle
- uses scissors and can tie their shoesWhat fine motor skills are we expecting at 5 months of age?

What fine motor skills are we expecting at 5 months of age?

Palmar hand grasp

What fine motor skills are we expecting at 8 months of age?

pincer grasp

Gross motor skills

ability to move and control large muscles in the body/groups of muscles.

- full head control
- rolls (from front to back)
- sit unsupported
- crawls
- pulls to standing position
- walk without help
- walks up and down stairs
- ride a tricycle
- throw ball overhead
- jump rope and walk backward

What are the four milestones of development?

1. Fine motor
2. gross motor
3. language
4 psychosocial

What gross motor skills are we expecting at 4 months of age?

full-head control

What gross motor skills are we expecting at 5 months of age?

rolls (from front to back)

What gross motor skills are we expecting at 8 months of age?

sit unsupported

What gross motor skills are we expecting at 15 months of age?

walk without help

What gross motor skills are we expecting at 9 months of age?

pulls to standing position

What gross motor skills are we expecting at 2 years of age?

walks up and down stairs

What gross motor skills are we expecting at 3 years of age?

ride a tricycle

What gross motor skills are we expecting at 4 years of age?

throw ball overhead

What gross motor skills are we expecting at 5 years of age?

jump rope and walk backward

Neonate

0-30 days old

total 24 hour fluid requirements: 150mL/kg/day

expected hourly urine output 3-4 mL/kg/hr

Infant

0-1 years old

Play: Solitary - play alone (uses rattle, looks at mirror, etc)

24 hour sleep requirements: 15 hours

SIDS reduction strategies:

1. sleeping supine on flat surface free of blankets or stuffed toys

2. suggest appropriate bedding

3. encourage breast feeding and tummy time

Total 24 hour fluid requirements: 100/50/20 mL/kg/day rule applies

Expected Hourly Urine Output: 1-2 mL/kg/hour

Discipline Strategies: N/A

Language skills: vocalizes with coos, starts with single syllable sounds such as "Daaa" or "Maa"

What are the basic infant needs?

feeding, comfort, stimulation

Toddler

1-3 years old

Play: parallel - child plays independently but next to other children (ex: child plays with blocks next to another child, but is not building the same structure or playing together)

24 hour sleep requirements: 12 hours

Total 24 hour fluid requirements: 100/50/20 mL/kg/day rule applies

Expected Hourly Urine Output: 1 mL/kg/hour

Discipline Strategies: redirection, time out

Language skills: speaks in 2-3 word phrases such as "hold me" "I do it"

Preschooler

3-6 years old

Play: associative - group of children participate in similar/identical activities without formal organization, group direction, group interaction, or a defined goal. (ex: preschooler's pretending to play house together. role mimicry)

24 hour sleep requirements: 12 hours

Common sleep disturbances: nightmare and night terrors

Nightmare interventions: sit with child, offer comfort

Night terror interventions: do not intervene, observe for safety

Total 24 hour fluid requirements: 100/50/20 rule applies

Expected Hourly Urine Output: 1 mL/kg/hour

Discipline Strategies: Redirect. time-out, reason, behavior modification

Language skills: speaks in sentences, can name colours, likes to talk incessantly.

School age

6 - 12 years old

Play: team/organized - play which is ordered by rules, has structure or hierarchy, and mutual collaboration to achieve formed goals (ex: playing sports on a school sports team. playing a board game)

24 hour sleep requirements: 11-9.25 hours

Total 24 hour fluid requirements: 100/50/20 rule applies

Expected Hourly Urine Output: 1 mL/kg/hour

Discipline Strategies: reasoning and behavior modification

Language skills: can define words, knows what words have different meaning; understands rules of grammar

Adolescent

12-19 years old

24 hour sleep requirements: 6-8 hours

Total 24 hour fluid requirements: 100/50/20 rule

Expected Hourly Urine Output: 0.5-1mL/kg/hour

Discipline Strategies: behavior modification and reasoning

Language skills: develops jargon used with peers, can adapt communication between social groups (parents/peers/teachers)

SIDS reduction strategies

1. sleeping supine on flat surface free of blankets or stuffed toys
2. suggest appropriate bedding
3. encourage breast feeding and tummy time

Colic

- typically only until 4 months of age

- frequent, prolonged, and intense crying in an otherwise healthy and well fed infant.

meeting criteria: crying for 3+ hours/day for 3+ days/week for 3 + weeks

Family centered nursing care strategies/education:

- massage baby's belly, change position frequently

- try smaller more frequent feedings and burp during and after each feeding

- colic typically peaks around 6 weeks of age and declines by 3-4 months

- parents need stress management/coping strategies

- encourage parents to seek respite care/support

- NEVER SHAKE BABY

Separation anxiety

- typically 4-8 months

- awareness of themselves as separate beings from their primary caregiver(s)

Family centered nursing care strategies/education:

- do diversional activities to distract infant

- postpone telling child you are leaving until you are close to leaving

- return soon after first departure to build sense of trust

Stranger fear

- typically 6-8 months

- infants ability to discriminate people that are unfamiliar

Family centered nursing care strategies/education:

- try to have usual caregivers perform/assist with procedures

- have close friends and family visit often

- approach child slowly and calmly

- have stranger smile at infant and connect with the parent

Object permanence

- typically 9 months

- understanding that an object exists even though it is no longer visible

Family centered nursing care strategies/education:

- play peek-a-boo with your child to encourage trust

- hide object under cup, then lift cup to show infant that object never disappeared.

Negativism

- typically toddler age

- direct opposition/resistance to verbal request/desired behavior, often characterized by using the "No" phrase as a way to assert independence

Family centered nursing care strategies/education:

- avoid asking questions that require "yes" or "no" response

- give toddler two options to choose from to prevent toddler from being able to say "no"

Toilet training

- typically toddler age

- ability to control bowel and bladder sphincters voluntarily

- fine and motor skills are necessary

Family centered nursing care strategies/education:

- toilet training can begin after your child begins to demonstrate behaviors that indicate they have the sensation of needing to urinate/defecate

- parents need to demonstrate patience and consistency

- use healthy rewards/stickers/praise

- nighttime control may develop last, use pull-ups

Picky Eating / "Food Jags"

- typically toddler 1-3 years

- insistence for one food item/food group repeatedly for each meal and may also demand specific preparation or presentation of the food without exception

Family centered nursing care strategies/education:

- this is a temporary issue and very normal

- begin with very small changes to their specific food jag

- give the toddler options on what they can eat

- do not dwell on the fact that they are not eating, this can become a power issue

Egocentrism

- typically preschool age

- they only see things from their point of view and lack empathy/sympathy for others

Family centered nursing care strategies/education:

- teach feelings by explaining how things can make other people feel. this can be done by reading stories

- be a good role model

Nocturnal Enuresis "night time bed wetting"

- typically school age 6-12 years

- involuntary passage of urine during sleep among children who are anatomically and developmentally capable of bladder control

Family centered nursing care strategies/education:

- limit fluids before bedtime and void immediately before going to bed

- parents should use positive reinforcement and communicate love and support to the child

- schedule predetermined times at night to wake up and use the bathroom

Screen time

- all ages

- exposure to media, incl TV, videos, digital books and mobile interactive technologies

Family centered nursing care strategies/education:

- for children younger than 18 months - discourage use of screen media other than video-chatting

- children 18-24 months should not use media by themselves

- children 2 years and older should be limited to 1 hour per day of media use

- no media use 1 hour before bedtime

- keep bedrooms, mealtimes and parent-child playtimes screen free

Mortality - Falls

Highest Risk ages: Infants and toddlers (0-3 years)

Family centered Nursing Care/Health Promotion Education:

Child motor control is unpredictable, especially when first learning to roll, crawl and walk.

Preventing falls is a big safety concern.

- remove loose rugs, have gates at top of stairs, raise crib railings to highest setting, and always using restraints in care seats, swings, high chairs, and bouncers are simple things we can do to prevent falls

- never leave infant unattended on any raised surface

- always keep side rails up when available.

Mortality - Drowning

Highest Risk ages: Toddler and Preschool (1-6 years)

Family centered Nursing Care/Health Promotion Education:

- never leave a child unattended near any body of water

- teach them to swim at an early age, and discuss proper water safety rules

- close toilet lids

- wear floatation devices

Mortality - Poisoning

Highest Risk ages: Preschool (3-6 years)

Family centered Nursing Care/Health Promotion Education:

Preschoolers are constantly putting things in their mouths as a result of their stage of development (initiative)

- lock up toxic substances and medications or place on a top shelf/out of reach

- supervise children

- know poison control phone number (1-800-222-1222)

Mortality - Burns

Highest Risk ages: ALL AGES

Family centered Nursing Care/Health Promotion Education:

- install and change batteries frequently on smoke detector

- check the temp of liquids before feedings and bathing

- never microwave formula/breast milk

- cocer electrical outlets

- wear appropriate outwear during cold weather

Mortality - Transportation related deaths

Highest Risk ages: >1 year

Family centered Nursing Care/Health Promotion Education:

Car Seat Safety across the ages:

- federally approved child safety seat: children under 4 years or less than 40 lbs

- booster seat: children under 8 years or under 4 feet - 9 inches

- safety seat belt or child safety seat: all children ages 8-15 years

- the recommended best place for a child passenger is the backseat

- helmet (sized appropriately and used when operating any mode of transportation)

- pedestrian safety skills (crossing the road at crosswalks, learning street signs/signals)

Mortality - Congenital Defects

Highest Risk ages: Infant 0-1 years

Family centered Nursing Care/Health Promotion Education:

This is the #1 cause of infant death

- encourage adolescents who are sexually active/intimate relationships the importance of maintaining a healthy self-monitoring (breast, testicle, and physical exams), STI prevention, and prenatal care if pregnancy is suspected.

- abstaining from drug/alcohol use, incl avoiding smoking/nicotine products

- taking necessary vitamins (folic acid)

What is the #1 cause of infant death?

Congenital Defects

Morbidity (Hospitalization) - Diseases of the Respiratory System

Highest Risk Ages: 1-10 years old

Family centered nursing care/Health Promotion Education:

A child's immune system is under developed until approx 9 months, increasing their risk of bacterial and viral upper respiratory infections

children have smaller and narrower respiratory structures, making inflammatory responses more likely to cause partial/complete airway obstruction.

Prevention to reduce communicable respiratory dieases:

1. wash hands

2. avoid people who are sick

3. obtaining all recommended CDC immunizations for ages.

Morbidity (Hospitalization) - Mental Illness

Highest Risk Ages: 10-15 years old

Family centered nursing care/Health Promotion Education:

The physical and emotional changes that occur during puberty can increase risk for ineffective coping

- educate parents about signs of depression, anxiety and being a victim of bullying

- teach coping measures to the patient and family

- ask pt "Do you feel safe?"

Morbidity (Hospitalization) - Pregnancy and Childbirth

Highest Risk Ages: 15-19 years old

Family centered nursing care/Health Promotion Education:

The #1 prevention for adolescent pregnancy is abstinence

- discuss how alcohol or drug use may impair judgment and increase risk for injury.

- educate children about reproduction and contraceptive use before puberty

- parents should discuss family values and beliefs related to intimate relationships with child.

Growth parameters and standardized evaluations

Norms / Age related variances:

Infants and Children 0-2 years: Use WHO Growth chart

Normal percentile range: Between the 2nd and 98th percentile

Children 2-20 years: Use CDC growth chart

Normal Percentile Rage: between 5th and 95th

What growth chart is used for infants and children 0-2 years?

WHO Growth Chart

What is the normal percentile range for infants and children 0-2 years?

Between the 2nd and 98th percentile

What growth chart is used for children 2-20 years?

CDC Growth Chart

What is the normal percentile range for children 2-20 years?

Between 5th and 95th percentile

Measuring Head Circumference

Place paper tape measure around the head, slightly above eyebrows and pinna of ears, and around occipital prominence of the skull.

measured up to age 36 months - unless ordered

measure to 0.5 cm increments

Norms:

- HC increases by 1.5 cm per month for 1st 6 months

- HC increases by 0.5 cm between 6 and 12 months

- Anterior fontanel closes by 12-18 months

- Posterior fontanel closes by 2-3 months

Obtaining weight

1. appropriate scale for age

2. place barrier on scale prior to use

3. zero scale

4. fully undress pt (take special note of dressing and equipment that cannot be removed)

5. record weight in KG. Provide family with weight in lbs when requested.

Anticipated weight gain norms:

Birth weight doubles by 6 months

Birth weight triples by 12 months

Weight increases by 2-3 kg/year until age 12 years

Pediatric overweight: BMI between 85th and 95th percentile for age and sex

Pediatric obesity: BMI over the 95th percentile for age and sex

Assessment of pediatric weight gain/loss over 24 hours:

- Infant + or -50 grams (0.05 kg) per day

- Child: + or - 200 grams (0.2 kg) per day

- Adolescent + or - 500 grams (0.5 kg) per day

Procedure for obtaining length for an infant

use measuring board/paper-covered surface.

- hold head midline, grasp knees together gently, push knees down until legs are fully extended and flat against the table.
- head is firmly at top of the board, and feet are at the bottom
- mark end points at top of head and bottom of heel if not using a board, then measure between 2 lines.

Procedure for obtaining height/stature for a standing child

- remove footwear; stand as tall as possible with head in midline and line of vision parallel to the floor.
- heels, buttocks and back of shoulders should touch the wall
- use a wall mounted unit, or paper tape measure and thick book at 90 degree angle on top of head

Anticipate growth in length/stature norms:

- infants grow approx 1 inch per month for 1st 6 months
- infants grow approx 0.5-2 inches per month for next 6 months
- toddlers grow approx 3 inches per year
- preschoolers grow approx 2.8-3.5 inches per year
- school age child grows approx 2 inches per year

Height increases

50% by age 1

Adolescence marks a time for

significant growth spurts, which vary among sex.

Social milestone at 2 months

social smile

PEWS

- Pediatric Early Warning Scoring

- valid and reliable research instrument designed to identify children at risk for clinical deterioration BEFORE arrest

- utilized at every vital sign assessment

- PEWS score 0-9 determines nursing action

Normal Vital Signs for Infant (7-12 months)

HR: 90-140
RR: 35-40

Normal Vital Signs for Toddler (13 months - 3 years)

HR: 70-130
RR: 25-30

Normal Vital Signs for Preschooler (4-6 years)

HR: 70-110
RR: 21-23

Normal Vital Signs for School age (7-12 years)

HR: 70-110
RR: 19-21

What does PEWS include?

Behavior:

0 - playing/appropriate

1 - sleeping appropriately

2 - any neuro concern

3- lethargic, confused, or difficult to arouse

Cardiovascular:

0 - pink/capillary refill 1-2 seconds

1 - tachycardia of 20 above normal rate

2 - pale/tachycardia of 30 above normal rate

3 - grey and mottled or capillary refill 4 seconds or above OR tachycardia of 40 above normal rate

Respiratory:

0 - Within normal parameters, no retractions

1 - >10 above normal parameters or retractions

2 - >20 above normal parameters with retractions

3 - >30 above or 5 below normal parameters with retractions and or grunting

How to use FLACC in patients who are awake

- observe for 1-5 minutes or longer
- observe legs and body uncovered
- reposition pt to observe activity
- assess body for tenseness and tone
- initiate consoling interventions if needed

FLACC

pain scale designated for children between ages 2 months to 7 years that provides pain assessment scale between 0 and 10

- Face

- Legs

- Activity

- Cry

- Consolability

How to use FLACC in patients who are asleep

- observe for 5 mins or longer.
- observe body and legs uncovered.
- if possible reposition pt
- touch and assess for tenseness and tone

CRIES

pain scale designed for children between ages of 32 weeks gestation and 6 months

- each of the 5 categories is scored from 0-2, which ersults in a total pain assessment score between 0 and 10.

Wong-Baker FACES scale

designed for children ages 3 years and above. Scale provides a pain assessment scale between 0-10.

Using FACES scale, read the words under each face to the child, beginning on the left. Ask the child to point to the face that matches the pain they feel.

Do not select the face for the child.. or base the score off of the face they are currently making.

Numeric pain scale

self-report tool designed for children who have normal cognitive ability and 8 years or age or older.

also referred to as visual analog scale (VAS), anchored with no pain on the 0 side and most pain on the 10 side.

Which stages of the nursing process should family be included in?

ALL stages

What are some examples of interventions that involve families?

- counseling
- teaching (stress management/coping, lifestyle modifications, anticipatory guidance), environmental modification, contracting

Family structure consists of:

individuals, each with a socially recognized status and position, who interact with one another on a regular, recurring basis in socially sanctioned ways.

Family structure types

- Traditional Nuclear
- Nuclear
- Blended
- Extended
- Single Parent

Authoritarian

- rigid control of child behavior and attitudes

- reward absolute obedience or forcefully punish

Democratic

- firm and consistent control based on reason and rules

- respectful of child's individuality

- realistic standards and reasonable expectations/discipline

Permissive

- little to no control over child actions

- inconsistent or absent discipline

Limit Setting

Establishing rules for acceptable behavior
- MUST BE REALISTIC FOR AGE AND DEVELOPMENT

Limits are effective at minimizing misbehavior when:

- consistently reinforced w/ an action taken to enforce the rule after non-compliance (consistency is key)

- terms of behavior and consequence for misbehavior are stated clearly

- teach desired behavior thru role play/mirroring

- discussed w/ child before stressful, special or unusual events

- call attention to unacceptable behavior AS SOON as it is noticed

- children receive praise when limits are observed (acceptable behavior is noticed)

Children need and benefit from limits:

- protects them from danger
- helps teach socially accepted behavior
- provides a sense of safety and security (children like routine, knowing what to expect)

Misbehavior Assessment

Assessment: Identify potential causes for misbehavior

- seeking attention, power, or control

- rules/limits haven't been stated clearly/consistently

- uncontrolled, frustration, anger, fear, pain, depression (limited or absent coping skills)

Misbehavior Diagnosis

Diagnosis: Identify potential or actual cause of misbehavior

Misbehavior Planning

Plan: Create Goals

1. Give praise whenever acceptable behavior is noticed. (no misbehavior noted)

2. Primary goal is to keep child SAFE, prevent illness and injury (misbehavior present)

3. Secondary goal is to address unacceptable behavior using a developmental appropriate discipline strategy (Misbehavior present)

Misbehavior Interventions

Interventions:

- Discipline: Actions used to teach rules of acceptable conduct, and also used to reinforce rules when there is non-compliance

Discipline is effective when:

- discussed before misbehavior, and carried out w/ consistency

- ALL family members are unified and committed to disciplinary action plan (includes expectations and what discipline will be if not met)

- timing of discipline (immediate is preferred)

- administered in privacy (discipline should not embarrass as a goal)

- Behavior orientation - disapproval of behavior, NOT the child

- termination of discipline allows child to have a "clean slate"

Developmentally appropriate discipline for infants:

limits and discipline can NOT be set/used

Developmentally appropriate discipline for toddlers:

time out

Developmentally appropriate discipline for preschoolers:

time out (primary)
behavior modification
reasoning

Developmentally appropriate discipline for school age:

time out (modified)
behavior modification (primary)
reasoning

Developmentally appropriate discipline for Adolescent:

behavior modification (primary)
reasoning
time out (modified)

Why is corporal punishment discouraged?

- teaches violence is acceptable
- may cause physical harm to the child
- acclimation to spanking increases subsequent severity over time

Time Out Guidelines for toddler thru adolescent

- set clear limits ahead of time

- ensure child understands limits

- explain process of time out to the child:

1. one warning

2. time out will occur in a safe, designated area, free from desired activity

3. length of time will be 1 minute per age

4. crying, screaming, disruptive behavior will postpone/prolong the time out. "Time out begins w/ quiet."

5. After designated time, child may leave area.

- modifications for school age and adolescent are blended with behavior modification

Behavior modification (preschooler - adolescent)

- preschoolers will still use Time Out as the PRIMARY strategy

- behavior that is rewarded will be repeated

- behavior that is not rewarded will be extinguished; always disapprove of the behavior, not the child.

- phrase requests for appropriate behavior positively (avoid threatening "if/then" statements)

Select age appropriate rewards:

- stickers, permission to keep desired items (cell phones, vehicle use, TV), permission to attend events (sleep overs, movies, etc)

- do not use food/sweets as a reward

- always follow up rewards with verbal praise

Cerebral palsy

a permanent neurological disorder that affects musculoskeletal development. (posture, motor function, muscle tone, and coordination)

The motor disorders of CP are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy and by secondary musculoskeletal problems.