Pediatric Nursing: Growth, Development, and Clinical Care

Introduction to Pediatric Nursing and Growth Frameworks

• Overview of Pediatric Nursing: Facilitated by Julie Vandergrifft, MSN, RN at Gurnick Academy of Medical Arts. The focus is on the specialized care of children based on developmental needs rather than just chronological age.
• Core Care Philosophy: Developmental needs significantly impact a child’s response to illness. Nurses must understand what is normal to identify deviations and plan care accordingly.
• Anatomical Differences: Children differ from adults in anatomy and physiology, leading to varying responses to illness and treatment.
• Key Terms in Child Development:
  • Development: A progressive increase in the function of the body.
  • Growth: An increase in physical size, measured in feet or meters ($m$) and pounds ($lbs$) or kilograms ($kg$).
  • Maturation: The total way in which a person grows and develops, dictated by inheritance.
  • Cephalocaudal development: Proceeds from head to toe. For example, an infant raises the head before sitting and gains trunk control before walking.
  • Proximodistal development: Proceeds from midline to periphery. For example, an infant grasps with the whole hand before pinching with fingers.

Developmental Stages and Classification

• Age-Based Terminology:
  • Neonate: Birth to $4\,weeks$.
  • Infant: $4\,weeks$ to $1\,year$.
  • Toddler: $1\,year$ to $3\,years$.
  • Preschool: $3$ to $6\,years$.
  • School-age: $6$ to $12\,years$.
  • Adolescent: $12$ to $18\,years$.

Physical Growth Patterns and Physiological Variations

• Height and Length:
  • Height: A standing measurement.
  • Length: Measurement of an infant in the recumbent (lying down) position.
  • Linear growth: Caused by the skeletal system and fluctuates until puberty.
• Weight Trends:
  • Infants lose $3-4\%$ of their birth weight by day $5$ of life.
  • Birth weight doubles by $5-6\,months$ and triples by $1\,year$.
  • After $1\,year$, gain should be approximately $4-6\,lbs/year$.
• Body Proportions:
  • Fetus: Head is the fastest-growing part.
  • Infancy: Trunk grows most rapidly.
  • Childhood: Legs grow most quickly.
• Metabolic Rate: Energy use and oxygen consumption are higher in children than adults.
• Respiratory System:
  • Small airways can easily be blocked with mucus.
  • Short, straight eustachian tubes predispose children to middle ear infections.
  • Thin chest walls and immature muscles mean minimal pressure interference with respirations.
• Cardiovascular and Fluid Balance:
  • Newborns have high oxygen consumption and require high cardiac output in the first few months.
  • Kidney function is not mature until the end of the $2nd\,year$ of life, predisposing infants to dehydration and poor drug elimination.
• Immunity:
  • Passive immunity from the mother provides protection for the first $3\,months$ of life.
  • Full immunity (mature immunoglobulin levels) is not reached until puberty.
• Bone Growth:
  • Fetal bones start as connective tissue, then cartilage, then bone.
  • Children require Vitamin A, Vitamin D, and Calcium for growth.
  • Growth occurs along the epiphyseal plates; bone is constantly synthesized and re-absorbed.

Pediatric Vital Signs and Data Collection

• Respiratory Rates:
  • Newborn to $1\,year$: $30$ to $35/min$.
  • $1$ to $2\,years$: $25$ to $30/min$.
  • $2$ to $6\,years$: $21$ to $25/min$.
  • $6$ to $12\,years$: $19$ to $21/min$.
  • $12\,years$ and older: $16$ to $19/min$.
• Pulse Rates:
  • Newborn: $110$ to $160/min$ (activity dependent).
  • $1\,week$ to $3\,months$: $107$ to $180/min$.
  • $3\,months$ to $2\,years$: $70$ to $150/min$.
  • $2$ to $10\,years$: $60$ to $110/min$.
  • $10\,years$ and older: $50$ to $90/min$.
• Temperature Standards (Recommended Routes):
  • $3-6\,months$: $37.5^{\circ}C$ ($99.5^{\circ}F$); Axillary or Rectal.
  • $1\,year$: $37.7^{\circ}C$ ($99.0^{\circ}F$); Axillary or Rectal.
  • $3\,years$: $37.2^{\circ}C$ ($99.0^{\circ}F$); Axillary, Tympanic, Oral (if cooperative), Rectal.
  • $5\,years$: $37.0^{\circ}C$ ($98.6^{\circ}F$).
  • $7\,years$: $36.8^{\circ}C$ ($98.2^{\circ}F$).
  • $9-11\,years$: $36.7^{\circ}C$ ($98.1^{\circ}F$).
  • $13\,years$: $36.6^{\circ}C$ ($97.9^{\circ}F$).
• Blood Pressure:
  • Compare to standard measurements (National High Blood Pressure Education Program).
  • Influenced by age, height, and sex.
  • Cuff sizes: $0-1\,year$ ($1.5"$), $2-8\,years$ ($3"$), $8-12\,years$ ($4.5"$).
• Assessment Sequence: Least invasive first (visual assessment), then auscultation, with reflexes and BP last. History survey includes medications, immunizations, and family values.

Growth Charts and Analysis

• Standard Tools: WHO growth standards for ages $0-2$; CDC growth charts for ages $2$ and older.
• Interpretation:
  • Solid black line designates the median.
  • Separate charts exist for boys and girls.
  • Children should consistently follow their established curves.
  • A difference in more than $2\%$ levels can indicate underweight or overweight conditions.

Influencing Factors and Family Dynamics

• Factors Affecting Development:
  1. Heredity: Role of DNA.
  2. Nationality and Race: Includes cultural practices.
  3. Ordinal Position: Language and motor development vary by birth order.
  4. Gender: Rates of physical, cognitive, and emotional development differ between males and females.
  5. Environment: Prenatal influences, home environment, and family support.
• Family Structures: Nuclear, Single-parent, Extended, Foster parent, Alternative, Blended, Homosexual, Dual career, Polygamous, and Cohabitation.

Developmental and Moral Theories

• Erikson’s Stages of Development: Tasks must be mastered at each stage to achieve maturity; each builds on the success of the previous stage.
• Piaget’s Theory of Cognitive Development:
  • Sensorimotor: Birth to reflexes; concern with sensations/actions affecting self.
  • Preoperational: Egocentric; thinks everyone sees the world as they do.
  • Concrete operations: Logical reasoning limited to own experience; understands cause and effect.
  • Formal operations: Ability to develop abstract concepts; problem-solving orientation.
• Kohlberg’s Theory of Moral Development: Three levels (Preconventional, Conventional, Postconventional), each with two stages; emphasis on the individual conscience within society.

Nutrition and Digestive Function

• Newborn Digestion: Immature for first $3\,months$. Minimal saliva. $HCl$ and rennin in the stomach and trypsin in the intestines help digest milk.
• Feeding Guidelines:
  • Infants: Breast milk or formula for the first year. Introduce solid foods (usually rice cereal) at $5-6\,months$.
  • Juice Limits: Ages $1-6$ (max $4\,oz/day$); Ages $7-18$ (max $8\,oz/day$).
  • Preschoolers: Common for protein and calorie deficiencies; prone to dawdling and regression.
  • Adolescents: Nutrition is critical during rapid growth; monitor for eating disorders and obesity.
• Childhood Obesity: BMI Percentile formula: $\frac{\text{Weight in lbs}}{\text{Height in inches}^2} \times 703$. Increased from $7\%$ in 1980 to $18\%$ in 2010 for ages $6-11$.
• Feeding the Ill Child: Appetite often decreases. Use a tablespoonful of food for each year of age as a guide. Provide pacifiers for NPO infants to meet sucking needs.

Specialized Clinical Procedures and Safety

• Specimen Collection:
  • Lumbar Puncture (Spinal Tap): Child lies on side, back parallel to table edge, knees flexed, head brought down to knees. Nurse holds firmly. Rest flat post-procedure to avoid headache.
• Medication Administration:
  • Six Rights: Patient, Drug, Dose, Time, Route, Documentation.
  • Variables: Absorption, Metabolism, and Excretion are age-dependent.
  • Oral Admin: Preferred route. Mix with small amounts of nonessential food (applesauce) if needed. Use an oral syringe for small doses.
• IV Therapy (TLC - Touch Look Compare):
  • Phlebitis: Vein inflammation (redness, warmth, pain).
  • Hematoma: Blood pooling outside the vessel (bruising).
  • Infiltration: Fluid leaks into tissue (swelling, cool skin, blanching).
  • Hypervolemia: Fluid overload (elevated BP, crackles, shortness of breath).
• Oxygen and Suctioning:
  • Pulse Oximetry: Expected SaO2 is $95-100\%$. Levels $< 91\%$ require intervention; $< 86\%$ is a life-threatening emergency.
  • Suctioning: Limit to $< 5\,seconds for infants and $< 10\,seconds for children. Allow $30-60\,seconds$ rest between aspirations.

Oral Health and Pediatric Play

• Teeth:
  • Deciduous (Baby) Teeth: Vital for jaw development; premature loss leads to poor alignment of permanent teeth.
  • Hygiene: Starts with first tooth eruption. Replace toothbrush every $3\,months$ or after viral illness.
  • Nursing Bottle Caries: Occurs when sugars (milk/juice) pool in the mouth during sleep; seen in ages $18\,months$ to $3\,years$.
• Play: Defined as the "work" of children.
  • Therapeutic Play: Used for assessment and creative expression.
  • Hospital Play: Encouraged in designated playrooms for non-communicable patients.
  • Toys: Select based on developmental level; avoid stuffed animals for children with certain conditions (e.g., allergies/asthma).