Week 1: Nursing Care of Sick Children and Growth, Development, and Health Promotion of Children

Children Come with Parents

-Always begin with the assumption parents want what’s best for the child

-Are part of a family

-Family language to describe child’s world

Children are Dynamic Individuals

-Actively growing

-Evolving development

Important Points

-Children have concrete view of world

-Play is the work of children

-Differences in anatomy and physiology

Are children little adults?

NO

Why is hospitalization very scary to a child?

Lack the cognitive skills to understand what’s happening

Why is hospitalization stressful to the parents of a sick child?

They can’t take the hurt away

Why does the unfamiliar environment of the hospital affect a child?

-Disruption of usual routine

-Subjected to painful procedures

Can you always follow a systemic approach when working with children?

No, a flexible approach

What order should things go when doing stuff with children?

Non-threatening to most invasive

Working with Parents

-Always introduce yourself and role (be clear)

-Interact with child and parents (involve child)

-Monitor parents’ responses and interactions with the child

What should you avoid asking the child when working with them?

If you can do any part of the exam

Interacting with the Child

-Tell them what you are doing each step

-Allow child choices when possible

-Let child handle equipment

-Use games when appropriate

What should be observed in pediatrics?

-General appearance

-Nutritional state

-Behavior

-Skin

-Odors

-Position

-Sight and hearing

-Character of cry

-Character of respirations

-Muscular movements

Should you completely undress the child?

No, try to avoid and be aware of modesty needs of school-age and adolescent children

Unwilling Child

-Put the child at ease (course of action)

-Relieve fears

-Allow to become accustom to situation (hold security object)

-Have child sit in parent’s lap

Where is separation anxiety typically seen?

Infants and toddlers

-6 to 30 months of age

Three Phases of Separation Anxiety

-Protest

-Despair

-Detachment

Separation Anxiety in Infants

-Crying, screaming

-Clings to parents

Separation Anxiety in Toddlers

-More goal directed

-Verbal attacks

-Physical attacks

-Attempt to physically force parents to stay

Separation Anxiety in Preschoolers

-Can tolerate short periods

-Refusing to eat

-Difficulty in sleeping

-Uncooperative with self-care activities

Separation Anxiety in School-age/Adolescents

-Try to appear strong

-Miss peers

How can separation anxiety and its effects be minimized?

Parent participation

-Accommodations

-Monitor parent's needs

-Use resources

Assign consistent nurses

Be aware of behaviors

-Educate parents that this is normal

-Allow these behaviors

Infants Loss of Control

-Developing sense of trust

-Cues missed or misinterpreted

-Hospital routines/schedules

-Inconsistent caregivers

Toddlers Loss of Control

Striving for autonomy

-Play, motor skills, daily rituals

Altered routines and rituasl

-Eating, sleeping, bathing, toileting and play

React with negativism and regression

Preschoolers Loss of Control

Feel omnipotent and all-powerful

-Egocentric and magical thinking

-View everything from this perspective

View illness/hospital as punishment for something real or imagined

-Feelings of shame, guilt, and fear

School-Age Loss of Control

Striving for independence and productivity

-Altered family roles, fears of death or disability, loss of peer acceptance, inability to cope with stress

Hospital procedures usurp independence

Boredom

Adolescence Loss of Control

-Quest of personal identity

-Patient role fosters dependency and depersonalization

-Separated from peers

What are 4 ways to minimize loss of control?

1. Promote freedom of movement(creativity to increase mobility)

2. Maintaining the child’s routine (allow input)

3. Encouraging independence (allow to participate in decisions)

4. Promote understanding

Family-Centered Care

-Recognizing that the family is the constant in the child’s life

-Partnering with parents

-Support their caregiving and decision-making roles

-Recognize and honor the influence of cultural diversity of the family

Parental Stressors

-Roller coaster of emotions

-Lack of knowledge

-Altered parenteral roles

-Care of the other children

-Financial

Role of Pediatric Nurse

-Therapeutic relationship

-Patient and family advocacy

-Disease prevention and health promotion

-Heath teaching

-Coordination and collaboration

Atraumatic Care

First, Do No Harm

-Provision of therapeutic care in settings by personnel through the use of interventions that eliminate or minimize the psychological/physical distress experienced by children and their families

How can you prevent of minimize physical stressors?

1. Avoid/reduce intrusive/painful procedures

2. Avoid/reduce other types of physical stress

3. Pain control

School Nurse

-Health screenings and development of education and prevention programs

-Handing acute injury and illness

-Tracking and preventing communicable diseases

-Managing chronic conditions

Outpatient Pediatric Nurses

-Primary care

-Ambulatory care

-Outpatient Clinic

-Outpatient Surgery

Who do we see at a pediatric ED?

-Pediatric patients up until their 21st birthday

-Small population of patients over 21 years of age still followed by pediatric specialist (cardiac, pulmonary, neurology/neurosurgery)

What do we do at a pediatric ED?

-Check in → Vitals → Assessment and triage (prioritization) → Room assignment → disposal (Discharge, admit, transfer)

-Pediatrics=family centered care

-Include family/caregivers in every aspect of patient’s care

-Advocate: what is the best for your patient?

Acuity

Expected Resources based on chief complaint and patient history

What is wait time based on in the ED?

Patient acuity, NOT check in time

Acuity Category 5

-Ear pain

-Rash

-Fever

-Diarrhea/vomiting

Acuity Category 4

-Ankle pain

-Cough

-Urinary pain

Acuity Category 3

-Arm injury

-Abdominal pain

Acuity Category 2

-Respiratory distress

-Sickle cell pain/fever

-Fever with central line

Acuity Category 1

-Sepsis

-Intubation

-Trauma

-Arrest

N-PASS

Neonatal Pain, Agitation, And Sedation Scale

FLACC Score

-Face

-Legs

-Activity

-Cry

-Consolability

FACES Pain Rating Scale

Appropriate for Ages 4 and up

Preparing a Child for a Procedure

-Varies based on age

-Honesty is crucial

-Adjust language

-Let them feel their feelings

Chronic Illness Defined

A condition that is long term, persisting for more than 3 months

-Does not spontaneously resolve

-Is without a complete cure

-Has residual characteristics

-Limits activities of daily living

Chronic Illness Goals for the Child

-Achieve and maintain normalization

-Obtain the highest level of health and function possible

Chronic Illness Goals for the Family

-Remain intact

-Achieve and maintain normalization

-Maximize function throughout the illness

Goals for Chronic Care

-Empowerment

-Promote normal development

-Establish realistic goals

How can a stressful environment be decreased in a chronic illness child?

-Teaching the child and parents

-Include child in developing a routine

-Familiar objects: Dehospital

Maintaining Normalcy in Pediatrics

-Likely to be frequently hospitalized so a room is often provided for school lessons

-Flexibility can help chronically ill and stay on track

-IEP can help with goals

-Partner with school nurse

Noncompliance and Teens

-Start to make their own decisions about their illness and management

-May try decreasing their medicine or not taking it without discussing this with their healthcare provider

-Often feel angry, self-conscious, or unable to cope with their illness

-Need is to non-judgmental as they get back on track

-Help them take ownership of their illness

Family Dynamics

-A situational crisis for the family

-Illness trajectory

-Normalization

-Family resiliency

-Maintaining social integration

-Equitable allocation of resources

Parent-to-parent Support

-Helps to see how illness affects another family

-Can help navigate unknowns

-Understanding

Supporting Siblings

-Concerns and needs of the sibling can be more difficult to address

-Vary according to age and development level

-Siblings often have feelings of guilt

-Provide education regarding treatment of child

-Siblings may regress developmentally

-Relationships with other family members may be altered

Child’s Sibling Reaction to Illness

-Jealousy

-Insecurity

-Resentment

-Confusion

-Anxiety

Causes of Siblings Reaction to Illness

-Misunderstanding

-Lack of attention

-Being worried

-Magical thinking

-

Sibling Support

-Can allow parents to be with ill child without feeling like they have abandoned other children

-Different emotions may be felt

-Express feelings in different ways

-Safe and supportive environment

-Staff can keep children busy

-Medical play

Newborn

Birth to 1 month

Infancy

1 month to 1 year

Toddlerhood

1 to 3 years

Preschool Age

3 to 6 years

School Age

6 to 11/12 years

What kind of pace is seen from birth to 2 years?

Rapid

Pace from 2 years to puberty?

Slower

Pace from puberty to 15 years?

Rapid

Pace from 16 years to 24?

Sharp decline

Patterns of Growth

-Cephalocaudal Growth

-Proximodistal Growth

-General to specific Growth

-Simple to complex growth

Factors Influencing Growth and Development

-Family

-Culture

-Nutriton

-Genetics

-Environment

Head Circumference

Measured on all children from birth to 24 months of age

-Plotted on a standardized growth chart on all visits

Underweight

Less than the 5th percentile

Normal/Healthy Weight

5th percentile to 84th percentile

Overweight

85th percentile to 94th percentile

Obese

Greater than 95th percentile

What is crucial for early identification of concerns and intervention of development in pediatrics?

Continuous screening and assessment

When is the most dramatic time of development?

Infancy

Assessment of Development

-A combination of developmental surveillance and screening

-Observation is often the most valuable method

-General screening: Ages and stages questionnaire, infant development inventory, and parents evaluation and developmental status

Classification of Play

Patterns of children’s play can be organized according to content and social character

Content of Play

-Social-affective play

-Sense-pleasure play

-Skill play

-Unoccupied behavior

-Dramatic or pretend play

-Games

Development Assessment

-Interview of parents

-Assess child’s ability to think through situations

-Assess child’s verbal ability

-Carefully observe the child

Promoting Development

-Encouraging play

-Providing opportunities to use skills and learn

-Educating families

Birth to 11 Months of Age Nutrition

-Bottle feeding, breastfeeding, and iron supplements

-Intro to solid foods

-Weaning

Birth to 11 Months of Age Dental Health

Brushing/cleaning

Birth to 11 Months of Age Immunizations

Vaccine schedules

Birth to 11 Months of Age Safety/Injury Prevention

-Car safety

-Home safety

-Safe sleep

Promoting Optimal Health in the Infant (Birth to 11 months)

-Nutriton

-Sleep and activity

-Dental health

-Immunizations

-Safety/injury prevention

6 Steps to Safe Sleep

1. Alone

2. On Back

3. In a Crib

4. Nothing in babies crib

5. Do not overdress

6. Do not smoke

Promoting Optimal Health in the Toddler (12-36 months)

-Nutrition

-Sleep and activity

-Dental health

-Safety/injury prevention

Toddler (12-36 months) Nutrition

-Picky eaters

-Emphasizing healthy eating habits

Toddler (12-36 months) Sleep and Activity

-Decrease in total sleep

-Sleep resistance

-High activity

-Safe play

Toddler (12-36 months) Dental Health

Initial dental visit

Toddler (12-36 months) Safety/injury Prevention

Car seats

Preschooler (3 to 5 years) Sleep and Activity

-Sleep patterns vary widely

-Learning new skills

Preschooler (3 to 5 years) Safety/injury Prevention

-Helmets

-Outdoor safety

-Crossing the street

-Communicable diseases

Promoting Optimal Health in the School Aged Child

-Sleep and Rest

-Exercise and activity

-Screen time

-Dental health

-Sex education

-Safety and injury prevention

School Aged Child (6 to 12 years of age) Sleep and Rest

Establish a bedtime routine

School Aged Child (6 to 12 Years of Age) Dental Health

Adult teeth