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