Pediatric Nursing Notes

Pediatric Nursing: Growth and Development (0-18 Years)

Introduction

• Focus on chapters 1, 2, 4, 5, 6, 13, 14, and 16.

Written Assignment

• Review the written assignment requirements and rubric.

LOTSOF Teaching

Common Issues

• Death, illness, and disease are significant concerns.
• Chronic conditions are also a key focus.

Injury by Age

• Unintentional injury is the leading cause of death for children aged 1-19 years.
• Specific causes vary by age:
  • <1 year: Suffocation, homicide
  • 1-4 years: Drowning, motor vehicle collisions (MVC)
  • 5-9 years: MVC, drowning
  • 10-14 years: MVC, suicide
  • 15-19 years: MVC, homicide (firearms), suicide

Comfort

• Considerations for pediatric patients: pain, position, and potty needs.

Legal/Ethical Considerations

• Parents generally provide consent for their child's treatment.
• Emancipated minors (self-supporting children <18 years) who are married, pregnant, have fathered a child, or are incarcerated may give informed consent for themselves and their child.
• Mature minors (non-self-supporting children 14-18 years) may consent for limited conditions such as testing/treatment for STIs, contraception, substance abuse treatment, and mental health treatment.
• Assent: Voluntary agreement to participate in research or treatment.

Privacy

• Adolescents may avoid seeking medical care/treatment due to fears of disclosure of confidential information.
• It's important to inform adolescents when confidentiality cannot be maintained.
• Disclosure is required for reportable diseases: HIV, TB, other STIs.
• Parental access to electronic health records and insurance billing statements may need to be considered.
• Non-disclosure is overridden when it puts the adolescent's life at risk or interferes with necessary medical treatment.

Family Centered Care

• The family is a constant in the child's life and a partner in healthcare.
• Providers seek input from families regarding mutual decision-making (negotiation).
• Trust is a fundamental element of the relationship between provider and family.
• The child is supported to learn about and participate in healthcare decision-making.
• Cultural values are integrated into planning and providing healthcare.

Promotion of Normal Development

• Child Life specialists focus on the psychosocial needs of hospitalized children.
• Therapeutic Play: Presents a direct opportunity to deal with fears or concerns.
• Dramatic Play: Medical situations are reenacted by the child.

Pain Rating Scale

• Mosby pain rating scale is used to assess pain levels, ranging from 0 (no hurt) to 10 (worst hurt).

Pain Management

• Distractions and Heating pads.
• Look for respiratory depression and constipation.
• Re-assess pain within an hour of intervention.

Medication Administration

• Consider when patients are able to tolerate oral medications.
• The deltoid muscle has not fully developed in young children.

Stages of Development

• Infancy: Birth to 12 months
• Toddlerhood: 1-3 years
• Preschool: 3-6 years
• School Age: 6-12 years
• Adolescence: 12-18 years

Growth Patterns

• Development progresses from head to toe.
• Gross motor skills develop before fine motor skills.

Expectations

• Goodness of Fit: Counsel parents on the wide diversity possible in children's behavior.
• Parental expectations should be realistic.
• Anticipatory guidance: Teach age-appropriate norms and what to expect.
• Health Supervision is essential.

Health Promotion and Maintenance

• Pediatric Health Care includes well-child visits (routine physicals).
• Health Supervision schedule: 2 weeks, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, then yearly.
• Components: Physical exam, developmental screening, nutrition, physical activity, oral health, and anticipatory guidance.

Weight Calculation

• To calculate BMI (Body Mass Index): $\text{Weight (kg)} / \text{Stature (m)}^2$
• Or, using US units: $\text{Weight (lb)} / \text{Stature (in)}^2 * 703$

Introduction to Infants

• Special considerations for infants with a fever less than 2 months old.

Infant Needs

• Infants need to meet certain milestones to advance properly.
• Use of pacifiers, breastfeeding, and bottle-feeding are important considerations.

Social and Emotional Development

• Social bonds and food/nutrition are crucial for development.
• Infants repeat reflexes; once something is removed, they understand it's gone.

Nursing Care

• Cluster care: Grouping care activities to minimize disturbance to the infant.

Assessment

• At 2 months, nurses can show hydration status by checking for bulging or sunken fontanelles to indicate dehydration levels.

Infant Communication

• Using a "baby voice" can aid in communication with infants.

Play in Infancy

• 3-6 months:
  • Enjoys soft toys with contrasting colors
  • Prefers noise-making objects (rattles)
  • Prefers easily grasped objects
• 6-9 months:
  • Safety is key to prevent choking
  • Prefers soft toys that can be manipulated or mouthed
  • Beginning to enjoy social interaction
  • Teething toys are important
• 9-12 months:
  • Plays interactive games like peek-a-boo
  • Uses push and pull toys
  • Enjoys surprise toys like jack-in-the-box
  • Nesting cups (stackable)
  • Toys that pop apart and go back together

Dehydration

• Infants are more prone to dehydration.

Nutrition

• Introduction of Solid Foods at 4-6 months of age
• Cereal at 4-6 months
• Fruits and vegetables at 6-8 months
• Meats at 8-10 months
• Introduce one new food at a time every 3-4 days to monitor for Allergies
• Avoid honey until 1 year of age
• No fruit juice until 1 year of age

Teething

• Teethers and Tylenol can help alleviate discomfort.

Physical Activity

• Provide opportunities for activity
• "Tummy time"
• Allow for freedom to move arms and legs
• Toys and other stimulating objects

Safety

• Prevent injury as they are trying to walk.
• Turn handles inward on pots on the stove to avoid burns.
• Use caution around pools and bathtubs; never leave unattended.
• Administer medications appropriately.
• Ensure appropriately sized food to prevent choking.
• Back sleeping is recommended; no blankets or co-sleeping.
• In cases of abuse: If crying can’t be soothed, put the baby in a safe space and take a minute to walk away.

Red Flags

• Less than 6-8 wet diapers a day
• Use electrolyte solutions.

Diagnostics

• X-rays are NOT common in children.
• Consider Shaken Baby Syndrome.

Question 1: Gross Motor Ability

• What is the normal gross motor ability of a 9-month-old infant?
  • Correct Answer: C. Crawls or pulls body along the floor.

Question 2: Vital Signs

• A 2-week-old is brought to the clinic for a first well-child visit. Which vital sign would require immediate attention?
  • Correct Answer: C. Temperature 96.8

Toddlers (1-3 years)

Growth and Development

• Growth slows considerably.
• Quadruple birth weight by age 2.
• By age 2, they have reached ½ of adult height.
• Chest circumference begins to exceed head circumference.
• Pot-bellied appearance with wide stance.
• Teeth eruption complete by 33 months.
• Brain growth is 75% complete by 2 years.

Vital Signs

• Temperature: 98-100°F
• Fever: 101-104°F
  • Seek immediate medical attention if >104.2°F with rash, inconsolable, lethargic, difficulty breathing, or otherwise symptomatic
• Heart Rate: 80-120
• Respiratory Rate: 20-30
• Blood Pressure: Systolic >88

Freud's Theory of Psychosexual Development: Toddler - Anal Stage

• Body control is the prime force in behavior.
• Characterized by increased motor ability and independent behavior.
• Nursing Implications:
  • Continue home rituals/elimination patterns and words for elimination
  • Regression is normal during illness or hospitalization.
  • Potty chairs in the hospital.

Erikson's Theory of Psychosocial Development: Toddlers - Autonomy Versus Shame and Doubt

• Increasing independence
• Nursing Implications:
  • Allow self-feeding opportunities
  • Encourage child to dress themselves
  • Encourage child to assist with hygiene

Piaget's Theory of Cognitive Development: Toddlers - Sensorimotor Stage (end)

• Increasing curiosity and exploration
• Improvement in language skills
• Nursing Implications:
  • Safe surroundings
  • Allow opportunities to manipulate objects
  • Name objects
  • Give simple explanations

Gross Motor Skills

• 12-13 months - walk alone using wide stance for balance
• 18 months – try to run but fall easily
• 2 years – walk up and down stairs
• 2½ years - jump using both feet, stand on one foot briefly, few steps on tiptoe, kicks ball
• 3 years – stand on one foot, walk on tiptoes, climb stairs with alternate footing, throws ball overhand

Parallel Play

• Toddlers engage in parallel play, not directly interacting with each other.

Temper Tantrums

• Temper tantrums are usually normal.

Physical Activity

• Important time to develop habits that carry into childhood
• "Free play"
• Minimum of 60 minutes of unstructured activity daily

Health Promotion & Injury Prevention

• Injuries cause more deaths in children age 1-4 than in any other childhood age-group except adolescence
• Traumatic injury is leading cause
• Unrestricted freedom achieved through locomotion combined with an unawareness of danger in the environment

Motor Vehicle Collisions

• Backseat is safest
• Should remain in a rear-facing car seat
• Approved safety seats only

Falls

• Gross motor skills improve – Able to climb
• Preventive Measures:
  • Supervise closely
  • Provide safe climbing toys
  • Teach acceptable places to climb

Drowning

• Toddler may walk on pool decks, stand on boats
• May fall into tubs, toilets, buckets and not be able to get the top of their body out
• Preventive Measures:
  • Supervise when near ANY water
  • Use approved life jackets
  • Child-resistant pool covers
  • Empty buckets when not in use

Poisoning

• Climb onto chairs and cabinets
• Medicines, cosmetics are easily reached
• Preventative measures:
  • Lock up medications/cleaning products/cosmetics
  • Child-resistant containers and cupboard locks
  • Know poison control number

Question 1: Motor Ability

• When assessing the motor ability of a 2-year-old toddler, which skills should the nurse expect the child to be able to do?
  • C. Walk up and down stairs.

Question 2: Milk Consumption

• According to the American Academy of Pediatrics, which of the following recommendations for milk consumption is accurate?
  • None of the options are 100% correct in all situations. Check current guidelines. AAP generally recommends whole milk until age 2, then lower fat options.

Preschoolers (3-6 years)

Growth and Development

• Physical growth slows and stabilizes
• Long bones of arms and legs with most growth
• Short, chubby to slender, long-legged
• Physical proportions are now sturdy, graceful, agile, and posturally erect.

Vital signs

• Temperature: 98-100°F
• Fever: 101-104°F
  • If > 104.2 with rash, inconsolable, lethargic, difficulty breathing or otherwise symptomatic seek immediate medical attention
• Heart Rate: 70-120
• Respiratory Rate: 20-30
• Blood Pressure: Systolic >90

Freud's Theory of Psychosexual Development: Preschooler - Phallic Stage

• Identifies with parent of opposite sex but by end, identifies more with same-sex parent
• Nursing Implications:
  • Pay attention to comfort level of child with male or female nurses and attempt to accommodate.
  • Encourage parental involvement
  • Plan for playtime
  • Offer a variety of materials/toys to choose from

Erikson's Theory of Psychosocial Development: Preschooler - Initiative versus Guilt

• The child likes to initiate play
• Nursing Implications
  • Planned playtimes with various toys
  • Offer medical equipment for play to lessen anxiety

Piaget's Theory of Cognitive Development: Preschoolers

• Nursing Implications
  • Assess concerns (expressed through drawings)
  • Accept child's choices and expression of feeling
  • Offer explanations for treatments
  • CLEARLY explain that a child is not responsible for illness

Fine Motor Ability

• Uses scissors
• Draws circle, square, cross, and at least a 6-part person
• Learns to tie shoes and button clothing
• Brushes own teeth
• Uses spoon, fork, and knife

Sensory and Gross Motor development

• Visual acuity improves, enabling focus and learning letters and numbers.
• Gross motor: Throw ball overhead, Clims wall/rock wall, Rides bicycle.

Nutrition

• Like toddler period
• Involve them in food preparation
• Food jags (eating only a few foods for several days/weeks)
• Fruit juice 4-6 ounces.
• "5 a day" fruits and vegetables
• "3 a day" dairy
• Limit intake of fast food and junk food

Health promotion: preschoolers

• Motor vehicle crashes
• Motor vehicle and pedestrian accidents
• Drowning
• Burns

Lead Poisoning

• Lead level higher than 10mcg/dl
• Children 7 and under are most vulnerable
• Sources
  • Lead-based paint
  • Battery casings
  • Industrial factories
  • Toys
  • Playground equipment

Lead Poisoning Screening

• All children enrolled in Medicaid and those considered high risk
• 12 months, 24 months, and between 3 and 6 years
• Levels
  • 10-19 – identify source
  • 20-69 - full medical evaluation
  • Over 44 - chelation therapy (administer agent that binds with lead)

Growth and Development School Age (6-12 years)

Growth and Development: School Age

• First growth spurt usually occurs.
• Body organs and immune system mature

Vital Signs

• Temperature: 98-100°F
• Fever: 101-104°F
  • If > 104.2 with rash, inconsolable, lethargic, difficulty breathing or otherwise symptomatic seek immediate medical attention
• Heart Rate: 70-110
• Respiratory Rate: 16-20
• Blood Pressure: Systolic >99

Freud's Theory of Psychosexual Development: School Age - Latency stage

• Importance on privacy and understanding the body
• Nursing Implications
  • Provide privacy (gowns, covers, underwear)
  • Explain treatments and procedures more in-depth

Erikson's Theory of Psychosocial Development: School Age - Industry versus Inferiority

• Development of new interests and activities
• Begins to take pride in accomplishments (self-worth)
• Nursing Implications
  • Continue schoolwork while hospitalized
  • Bring favorite activities to the hospital
  • Help child adjust to limitations while in the hospital

Piaget's Theory of Cognitive Development: School Age - Concrete Operational Stage

• Concept of conservation
• Better understanding of cause and effect
• Nursing Implications
  • Give clear instructions prior to procedures/treatments
  • Show medical equipment

Gross and Fine Motor Skills

• Develops coordination

Vision and Energy

• Conserve body mass by doing simple activities

Oral Health

• Typically lose first deciduous tooth at age 6
• Should visit a dentist every 6 months
• Teach frequent brushing and decrease in sugary snacks and drinks

Physical Activity

• Involvement in sport or activity is important to development
• Encourage family involvement in physical activities
• Limit the use of television, computers, and video games

Development of Self-Concept

• Body Image: Evaluate how their physical appearance, body configuration, and coordination compare with those of their peers
• Self-Esteem: Children's pictures of their individual worth; consists of both positive and negative qualities
• Depend almost entirely on external evidence of worth, such as school grades, teachers' comments and parental and peer approval

Nutrition

• Preparation of meals and snacks
• Good time to teach nutritious meals and snacks
• Sometimes resistant to new food items
• Nutritional needs increase with approaching growth spurt

Growth and Development: Adolescents (12-18 years)

Physical Changes

• Hair growth, breast development, and genital growth

Vital Signs

• Temperature: 98-100°F
• Fever: 101-104°F
  • If > 104.2 with rash, inconsolable, lethargic, difficulty breathing or otherwise symptomatic seek immediate medical attention
• Heart Rate: 60-100
• Respiratory Rate: 12-20
• Blood Pressure: Systolic >110

Freud's Theory of Psychosexual Development: Adolescents - Genital Stage

• Focus on genital function and relationships
• Nursing Implications
  • Provide information of sexuality
  • Privacy
  • Ensure access to gynecologic care for girls. Testicular exams for males
  • Brochures/videos about sexuality

Erikson's theory of Psychosocial Development: Adolescents - Identity versus Role Confusion

• Self-identity leads to independence from parents; begins relying on peers.
• Nursing Implications
  • Provide a separate rec room for teens
  • Take health history separate from parents
  • Introduce to other teens with the same condition

Piaget's Theory of Cognitive Development: Adolescents - Formal Operations Stage

• Capable of mature, abstract thought
• Nursing Implications
  • Give clear and complete information about health care
  • Offer written and verbal instructions
  • Continue to provide education about chronic illness.

Sexual Maturation

• Sexual maturation in girls:
  • Breast bud development occurs first (8-10 yrs); development before 6 yrs requires further evaluation
  • Menarche 10.5-15.5 years
• Sexual maturation in boys:
  • Testicular enlargement precedes all other changes (9-10 yrs)
• Mean age for completing sexual development in US is about 15 yrs.

Nutrition

• Need well over 2000 calories a day; if active in sports, require more
• Teach about good nutrition; be aware of fast food intake

Mental and Spiritual Health

• Self-regulation, self-esteem
• Body image
• Sexuality
• Nursing Implications
  • Sexual maturity rating and screening
  • Substance abuse screening
  • Depression and anxiety screening
  • Abuse and bullying

Health Promotion: Adolescents

• Injury is the leading cause of death
  • #1 Unintentional injury - motor vehicles
  • Homicide
  • Suicide

Injury Prevention: Adolescents

• Motor vehicles
  • Driver's education classes
  • Forbid texting while driving
  • Reinforce use of seatbelts
  • Discourage drug and alcohol use

Sexual behavior

• At risk for STIs and pregnancy
• Sexually active adolescents should be screened for STDs
• Need education and guidance regarding responsible sexual behaviors
• Sexuality questioning

Health Promotion: Adolescents

• Smoking
  • Beginning to smoke at a young age increases risk of heavy smoking and illness
• Alcohol
  • Drinking and driving is leading cause of death
• Marijuana