NUR 320 PEDS - Study Guide For Exam 1: Fall 2013

1. Preparing infants, children and adolescents for hospitalization: providing teaching,

etc. for each age group. How can we make hospitalization less stressful?
Give simple explanations before the procedure based on the childs developmental level:
Infants (age 0 to 1)
- No TEACHING needed for the infant.
- Explain to the parents the procedure, the reason for it, and their role.
- Allow parents the option of being present for procedures. Always encourage parental
presence.
- Adhere to the infants home routine as much as possible. Promote a quiet environment and
reduce excess stimuli.

Toddler (ages 1 to 3) they love saying NO(egocentric)

- Give the explanation just before the procedure, since a toddler's concept of time is limited.
- Explain that the child did nothing wrong; the procedure is simply necessary.
- Encourage parental presence; they experience major separation anxiety.
- Allow the parents to hold the child in their lap for examinations and procedures
when possible.
- Allow choices when possible.
- Explain all procedures using simple developmentally appropriate language.
- Provide a night-light.

Preschoolers (ages 3 to 6)
- Give simple explanations of the procedure. Basic drawings may be useful.
- While providing supervision, allow the child to touch and play with equipment to
be used if possible. Since any entry into the body is viewed as a threat, state that
the child's body will remain the same (fear of bodily mutilation), and use adhesive
bandages to reassure the child that the body is intact and parts will not "fall out."
- Encourage parental presence. Allow for choices when possible. Explain all procedures.
Provide a night-light or flashlight.
- Band Aids and ice are our best friends when dealing with this age group.

School Age (ages 6 to 12). During hospitalization, try to have them placed with
another school age patient.
- Clear, thorough explanations are helpful. Use drawings, pictures, books, and contact
with equipment.
- Teach stress reduction techniques such as deep breathing and visualization.
- Offer a choice of reward after the procedure is completed.
- They are very concerned with body integrity, privacy, and modesty (note: modesty is
important for all ages). They fear loss of control over their bodies.
- They need more support from their parents than they are able to admit.
Encourage parental participation. - Allow the child to make choices if possible. Give them the
power to choice between foods or times when the vital signs or procedure will be done.
- Explain all procedures and offer reassurance.
- Encourage peer interaction via the internet, phone calls, and other
communication methods.
- Peers are becoming more important
Allow child to make choices if possible: If you have to put an IV in child, but their septic.
Dont negotiate, put IV in and start treatment. BUT if you have to give them pills ask if
they want to have it before or after breakfast. NOT IF THEIR SUPER SICK- dont negotiate to
put an IV in with the child.

Adolescents (ages 12 to 18)

- Give clear explanations orally and in writing.
 - Teach stress reduction techniques. Explore fear of certain procedures, such as staple
removal or venipuncture.
- Include the adolescent in the plan of care.
- Encourage discussion of fears and anxieties. Explain all procedures.
- Ask the adolescent his or her desire for parental involvement. Encourage peer interaction.
- Major concern is about a change in body image. Teaching should always focus on
the here and now.
- They are not future thinkers yet.
- Encourage them to share a room with another teen(same sex) when hospitalized
if possible (in order to connect and to not feel alone).
- Someone w/ Lupus is on high dose steroids. -will have body image probs cuz S/E:
weight gain, hair growth, depression
-Cushing disease==cuz moon face abdomen distended, striae on belly

2. When is it appropriate to let them play with equipment? Use a transitional object?
Show them anatomical models vs. dolls, etc.?
When hospitalization is planned, children and their parents have time to prepare for the
experience. Through preadmission preparation, children and their families are introduced to
the acute care setting. Assess the family's knowledge and expectations and provide
information about likely experiences. Let the child play with the surgical team's attire. The
child may overcome fear of surgical attire by trying it on and engaging in play while wearing
it. Teach the child about medical equipment -what it does and how it is used- perhaps
through demonstration on a doll. Use puppets and skits to help explain procedures to
children.. WHEN DO I LET CHILD PLAY WIT DOLL? NCLEX QUES .. TODDLERS????
Infant (birth to 1 year): Infants are in the Oral Stage according to Freud. The baby obtains
pleasure and comfort through the mouth. Nursing Implications: When a baby is to be offered
nothing by mouth (NPO), offer a pacifier (transitional/comfort object) if it is not
contraindicated. After painful procedures, offer the baby a bottle or pacifier or have the
mother breastfeed.
Preschooler (ages 3 to 6): Preschoolers are in the Initiative versus guilt stage according to
Erikson. The child likes to initiate play activities. Nursing implications: Offer medical
equipment to play to lessen anxiety about strange objects .
School age (ages 6 to 12): Concrete Operational stage according to Paiget. The child is
capable of mature thought when allowed to manipulate and see objects. Nursing
Implications: Give clear instructions about details of treatment. Show the child equipment
that will be used in treatment.
Adolescents (ages 12 to 18): Formal operational thought(thinking logical) according to
Piaget. The adolescent is capable of mature, abstract thought. Nursing implications: Give
clear and complete information about health care and treatments. Offer both written and
verbal instructions.

3. Cause of death among infants. Why are they the highest risk age group?
SIDS-Sudden Infant Death Syndrome
- SIDS is the leading cause of death among infants (age 28 days to 1 yearthe postnatal
period)
- SIDS is the unexpected death of a child under the age of 1 in which an autopsy does not
show an explainable cause of death.
- Most SIDS deaths occur between 2 and 4 months of age (very critical period; most
vulnerable). However, the babies need to be monitored until the age of 1.
- Babies should be placed on their backs (supine position) when they sleep.
Remember the phrase, Back to Sleep. The change in recommended sleep position for
newborns and infants from the stomach to the back has been credited with much of this
decreased rate of SIDS.

4. Providing care for dying childrenwhat are the major goals?

 When the family is faced with end-of-life decision-making and care because of a child's
chronic condition or multiple acute episodes, the family relies on the nurse and other
members of the healthcare team to provide honest information about various treatment
options and potential outcomes. The child should also participate in the decision-making
process. The family may need to consider issues such as palliative care, hospice care, Do Not
Resuscitate requests, and continuation of education. The nurse and other members of the
healthcare team work collaboratively to improve end-of-life care for children and their families
through the following actions:

1. Plan nursing care for children with life-threatening medical conditions and their families
that match the child's physical, cognitive, emotional, and spiritual level of development.
2. Implement family-centered care, ensuring that families are part of the care team and
that their beliefs, feelings, and desires are respected.
3. Plan and provide compassionate care for children with life-threatening conditions and
for their families beginning at the time of diagnosis through death and bereavement.
4. Seek information, education, and mentoring to gain proficiency and skill in working
effectively with children who are dying and their families.
5. Work within the healthcare facility to promote needed changes that will improve the
palliative, end-of-life, and bereavement care for children and their families.
6. Participate in research designed to increase healthcare professionals' understanding of
clinical, cultural, organizational, and other practices or perspectives that can improve
palliative, end-of-life, and bereavement care for children and their families.

Nursing care for the Child at End of Life include: airway clearance; skin and hygiene
care; bowel and urine elimination; providing good nutrition; promoting sleep; encouraging
physical mobility; and promoting a sensory-sensitive environment.

5. Differentiating care provided by a nurse practitioner vs. RN. What is appropriate

for the NP to do? What is appropriate for the RN to do?
RN: provides nursing diagnoses (ex. alteration in comfort, pain)
ARNP: provides medical diagnoses and treatment (ex. otitis media, Rx. antibiotics)

Pediatric nursing focuses on protecting children from illness and injury, assisting
them to attain optimal levels of health, regardless of health problems, and
rehabilitation. This focus fits with the American Nurses Association definition of the scope of
nursing practice: "the protection, promotion, and optimization of health and abilities,
prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of
human response, and advocacy in the care of individuals, families, communities, and
populations." The predominant nursing roles in caring for children and their families include
direct care, education, patient advocacy, and case management. Pediatric nursing care is
designed to meet the child's physical and emotional needs. It is offered in a manner sensitive
to and compatible with the child and family's cultural beliefs. It is tailored to the child's
developmental stage, giving the child additional responsibility for self-care with increasing
age, and ultimately assisting the adolescent with transition to adult health care. This care is
also provided in partnership with the family, embracing the principles of family-centered care.

A nurse practitioner (NP) is an advanced practice registered nurse (APRN) who has
completed advanced didactic and clinical education beyond that required of the
registered nurse (RN) role. They have a graduate level nursing education and are
prepared to practice in a specialty area or at a higher level of responsibility. Nurse
practitioners manage acute and chronic medical conditions (both physical and mental)
through comprehensive history taking, physical exam, and the ordering of diagnostic tests
and treatments. NPs (within their scope of practice) are qualified to diagnose medical
problems, order treatments, prescribe medications, and make referrals for a wide range of
acute and chronic medical conditions.
6. The importance of family centered care: what is it? How can it be used?
Promoting Family Centered Care - Partnering with families in the provision of health care
is essential to promote the best outcome when caring for children. Families have important
knowledge to share about their child, their child's health condition, and how their
child responds to various actions and events. They also need access to information that
will make it possible for them to fully participate in planning and decision-making. Research
shows that parents want to collaborate with healthcare professionals in making decisions
about their child's care. The child's opinions should also be integrated in the strategies for
care. Strategies that the nurse and parents develop in partnership for care of the child must
mesh with the family's cultural and ethnic illness-related behaviors, experiences, and beliefs.

Remember, parents are a constant: 24/7. You are caring for the child and the
entire family. Reports should be done at the patients bedside with the family around. We
inform the family of the plan for the day. Families need to sense that the nurse cares
about them and respects them as an integral part of the child's life. It is important to consider
how a healthcare setting's written policies, procedures, and literature for families refer to
families and what attitudes these materials convey. Words like policies, allowed, and not
permitted imply that hospital personnel have authority over families in matters concerning
their children. Words like guidelines, working together, and welcome communicate an
openness and appreciation for families in the care of their children.

7. Differentiating high risk versus low risk children. If I give you children of various
ages and ethnic groups, which one would, you consider to be the highest risk for
negative health outcomes?
High-risk children: African Americans, Hispanics, and Asians are less likely to have a regular
healthcare provider than Whites. Morbidity(disease) and mortality for these populations is
higher. Children living in poverty. Lack of health insurance among low-income families.
Immigrants. Socioeconomic status. 72% of hospitalizations were for infants under the age of
1.
Low-risk children: High income. Whites. Educated parents.

8. Causes of death of children of all age groups

Infant (Age 1 day to 27 days): Prematurity; Other causes: Low birth weight, congenital
malformations.
Infant (Age 28 days to 1 year): SIDS
Toddler (Age 1 to 4 years): Leading cause of death: Unintentional injury; DROWNING, THEN
HOMICIDE
School-age (Age 5 to 9 years): Unintentional injury, MOTOR VEHICLES, THEN DROWNING
School-age/Adolescence (Age 10 to 14 years): Unintentional injury, MOTOR VECHICLES,
THEN SUICIDE
15 to 19: Motor vehicles, then homicide

Other leading causes between 10-19: cancer, homicide, suicide, congenital anomalies, heart
diseases.

9. How to establish rapport(close friendship) with children of all ages and their
families.
Talk at Eye level.
Treat their family as if it the only family you have.
To develop rapport demonstrate your interest in and concern for the child and family by
actively listening to the info shared
Communicate as a nonjudgmental and non-controlling professional
Advocate for that patient
 Get them to trust you
Introduce yourself: your name, title or position, and your role in caring for the child
To demonstrate respect ask all family members present what name they would prefer you
to use when talking to them
Explain the purpose of the interview and why the nursing history is different from the info
collected from other health professionals "the nurses will use this info to help plan the best
care suited to your child"
Provide privacy and remove as many distractions as possible
Direct the focus of the interview with open-ended questions. Use close-ended questions or
directing statements to clarify info.
Ask one question at a time so that the parent or child understands what piece of info you
want and so that you know which question is being answered
Use nonverbal behavior such as nodding, smiling, and eye contact at appropriate times to
communicate that you are hearing the info shared
Be honest with the child when answering questions or when giving info about what will
happen
Choose the language style that is best understood by the parent and the child. Use an
interpreter to improve communication when you are not fluent in the language

10. Providing anticipatory guidance for each age group

Anticipatory Guidance is the prediction of the upcoming developmental tasks or needs of a
child, and gearing teaching to those needs. Age-appropriate information should be included
about healthy habits, but more importantly developmental stages need to be
determined before providing anticipatory guidance. (Look at developmental milestones
and theories: Question 21, 23, 48)

11. When is it appropriate for someone less than 18 years to give consent for care?
Minor Defined by Individual State Laws: Until the person reaches age of adult based on
state law, parent or guardian must provide informed consent. Parent or guardians have ultimate
decision, with some exceptions.

In some states minors can often legally give informed consent in the following
circumstances:
1) When they are minor parents of the child patient
2) When they are emancipated minors (self-supporting adolescents under 18 years of age,
not subject to parental control; e.g., married, serving in military, or granted emancipation
by the court)
3) 16-18 years of age seeking birth control, prenatal care, mental health
counseling, sexually transmitted disease treatment, or substance abuse
treatment.
4) Mature minors (14- and 15-year-old adolescents who are able to understand treatment
risks) are permitted in some states to give consent for treatment or to refuse treatment. In
some cases the minor must convince a judge that he or she is mature enough to make an
independent judgment about consent for treatment.

12. Knowing how to order your physical assessment based on the age of the child
.
Newborns and infants under 6 months of Age:
a. Keep parent present to provide comfort and security.
b. Provide physical comfort by feeding, using a pacifier, cuddling or change the
diaper to keep the infant calm and quiet.
c. Distractions (rocking or clicking noises)
d. Observe infant for general level of activity, overall mood, and responsiveness to
handling.
 e. Make sure hands and stethoscope are warm. Keep motions gentle.
f. Take advantage of times the infant is quiet or asleep to auscultate the lungs, heart, and
abdomen.
g. If the infant continues to be quiet or can be quieted with a pacifier, palpate tha
abdomen while the muscles are relaxed.
h. Palpate femoral pulses.
i. The remainder of the examination can proceed in a head to toe sequence.
j. Portions of the examination that will disturb the infant should be performed at the end.

Infants over 6 months of Age:

a. Keep older infant with parent.
b. Can be examined on the parents lap or against the parents chest.

Toddlers:
a. Keep toddlers with parents.
b. Can be examine on the parents lap.
c. Let the child hold security object.
d. Perform cranial nerve assessment or developmental assessment as a method to gain
cooperation for other procedures.
e. Tell the child what you will do at each step of the exam; avoid asking the
child if you can perform a part of the exam. Cause they will usually tell u no
f. Begin exam by touching the feet and then moving gradually toward the body and head.
g. Instruments to examine the ears, eyes, and mouth are usually viewed as the
most fearful and should be used at the end of the exam.
h. Neurologic and musculoskeletal assessment can be conducted by observing the child
play and walk.
i. Dont cooperate with anything-do give them CHOICES [not OPTION whether or not]
j. Let them keep their security objects (transitional)

Preschoolers:
a. Some children prefer to have head, eyes, ears, and mouth examined firs; others prefer
to postpone them to end of examination.
b. All the child to touch and play equipment. Let them play wit ur equipment.
c. Use games to reduce anxiety.
d. Give simple explanations about assessment.
e. Use distraction to gain cooperation.
f. Fantasy starts at this age so they think when you touch them you are
ripping their body apart

School-age children:
a. Can have child sit on the examining table.
b. Provide guidance about what they can do at each step to help.
c. Anticipate modesty and offer a patient gown to cover the underwear.
d. Let the older school-age child determine if the exam will be conducted in
privacy or with parent/sibling present.
e. Head-to-toe sequence.
f. Demonstrated instruments.
g. Offer as many choices as possible to help child feel empowered.

Adolescents:
a. Provide a private place to undress.
b. Head-to-toe sequence.
c. Perform in private without parents/siblings unless requested.
 d. Provide reassurance about the normal progression of secondary sexual
characteristic development and what further changes to expect. .. ensure
them they are normal!!

13. When is it appropriate for parents to stay for procedures like exams? IV
insertion or other procedures? In the ICU?
At all times
When the child is having a stressful procedure
The parents presence can help reduce the anxiety of the parent and child
Usually a good idea to have them there

ICU stressful environment b/c of the noise and pumps

o Dont have 24 hours visiting hours so more stressful to child
o During Procedures: Try to involve parents in care as much as possible, except for
during painful procedures. By having parents separated during these, the parent can
come in and comfort the child after the procedure without being seen as a cause of the
pain (Exception: developmentally delayed).
o ICU: Occasionally parents may be asked to leave during bedside rounds, report, and
emergency situations. Parents can become upset during these times.
Frequent family visits should be encouraged, especially for children who require
isolation, as they may experience lack of stimulation.

Physical Preparation
- Procedures generally occur in preoperative area (meds, IV start, etc)
- Depends on age and procedure
- Procedural/preoperative checklist
Parental Involvement and Presence
- Provides feelings of control
- Prepares family for care requires at home
- Reduces emotional stress and anxiety
- Promotes feelings of values, worth, and competence care for their child
- Promotes parents feeling fully informed, trust of nursing staff

14. Decreasing stressors for hospitalized toddlers. Decreasing stressors for

hospitalized school age children Toddler (Band aids)
- Developmental stressors Separation anxiety(MAIN ONE!!!), loss of self control,
immobilization, painful invasive procedures, bodily injury or mutilation, fear of the
dark
- Nursing Management- Encourage parental presence, allow parents to hold
the child in their lap for examinations and procedures when possible (go to
least invasive first- belly and ears save to last), allow choices when possible,
utilize topical anesthetics or procedural sedation as prescribed, explain all
procedures using simple developmentally appropriate language, provide a night-
light

Preschooler (allow choices, they see illness and hospitalization as punishment)

- Developmental stressors Separation anxiety and fear of abandonment, loss of self-
control, bodily injury or mutilation, painful invasive procedures, fear of the dark and
monsters
- Nursing Management Encourage parental presence, allow choices when possible,
utilize topical anesthetics or procedural sedation as prescribed, explain all
procedures, provide a night-light or flashlight
 School-age child (privacy issues; age of reasoning; by 9yr understands death same as a
adult)
- Developmental stressors Loss of control, loss of privacy and control over
body functions, bodily injury, separation from family and friends, painful
invasive procedures, fear of death
- Nursing Management Encourage parental participation, allow the child choices
when possible, explain all procedures and offer reassurance, utilize topical
anesthetics or preprocedural sedation as prescribed, encourage peer interaction via
the internet, phone call, and other methods of communication

15. What are the different stages of separation anxiety? . KNOW!!!!!

Protest
- Screaming, crying, clinging
- Resists attempts to comfort

Despair
- Sad, withdrawn, quiet
- Crying when parents return

Denial (Detachment)
- Protest subsides, shows interest in setting
- Appears happy and content

16. Decreasing stressors for hospitalized children KNOW!!

Stress Reduction: The 4Rs
- Recreation: toys, games, activities, physical activity
- Rest: calm, quiet, bedtime rituals
- Relationships: family members, siblings, peers, support groups
- Routines: follow normal routine, provide transition objects, provide consistent
caregivers

Minimizing stressors
- Maximize control
o Give choices
o Encourage independence
- Therapeutic play
o Address fears, concerns
- Therapeutic Recreation
o Interactive activities

17. Dealing with denial among parents

Stage: Denial (p. 719)CHECK
Denial: maintenance of relationship w deceased for an extended period (keeping
childs room exactly same after death for long time)
They usually want to prolong the treatment
Need to realize that length of life does not equal quality of life
You need to help them see the facts

Behavioral Responses:
- Disbelief, it seems like a bad dream, unable to process the information about the death.
 - Questioning the reality of the deathdid it really happen or was it a dream?
- Unable to believe that the child will not come home again.
- May make statements such as "This can't be happening" or "This can't be true."
Nursing Management:
- Be verbally supportive but refrain from reinforcing denial. Recognize that denial is one
way parents face accepting the feelings of grief.
- Don't argueallow the child or parents to come to terms in their own time.

BOX 22-11 Supporting a Healthy Family Grieving Process (p. 733)

Nurses can assist families toward a healthy grieving process after a child's death in the
following ways:
- Provide information about the grieving process and explain that grief exerts tremendous
stress on even the most loving relationships. Inform families that each person processes grief
on his or her own timeline.
- Encourage parents to show their emotions so young children and adolescents will learn that
it is appropriate to share their feelings and to display appropriate grieving behavior.
- Alert parents to the special needs of young children who may feel guilty that they caused
the child's death due to their magical thinking.
- Consider having the sibling participate in a bereavement group with other children of a
similar age. The sibling may have an opportunity to honestly talk about his or her feelings and
learn more about coping with personal struggles from other children (Davies, Collins, Steele,
et al., 2007).
- Advise parents to be watchful for their adolescents' responses to the death, and to seek help
if any of the following behaviors are noticed: suicidal thoughts or actions, long-standing
depression, isolation from friends and family, failing in school or overachieving, major
changes in personality or attitude, serious eating problems, use of drugs or alcohol,
fighting or criminal behavior, and inappropriate sexual activity (Kirwin & Hamrin, 2005).
- Recommend open lines of communication between parents and bereaved siblings.
- Explain that many family members and friends may distance themselves because they are
uneasy with death and grief.
- Inform families that major holidays, birthdays, and anniversary dates of the child's death
may be especially difficult emotional times.

18. What is the main priority in providing care to children of all ages and their
families? Safety Measures
INFANT== secure cords under the infants gown,
Toddler== bed low, rails up wen parents not at bedside, instruct familt members to
inform staff when they are leaving room to ensure that the toddler or preschooler
is being observed.
School age child== dont let use hospital euqiment like PCA, Intravenous fluid
pumps, oxygen gauges
Adolescents==address smoking & alcohol in room cause friends could bring some..
& only take meds given by nurse
 Nursing Care focus
- Minimize fears and anxiety
- Incorporate familiar routines into hospitalization
- Support family and loved ones
- Minimize loss of control; promote autonomy

19. Providing safety for children when parents are not present .kids less than 3
need to put side rails
Infants- crib and bedding, secure cords, dispose of syringe caps, have a list of ppl who are
allowed to visit the child.
Toddlers and Preschoolers- keep bed in low position, keep side rails up when parent is not
present, secure cords, keep room clutter free, dispose of syringe caps, no latex balloons.
School aged- instruct child to avoid handling hospital equipment (IV pumps, PCA machines,
oxygen gauges) by themselves, allow to explore equipment with guidance.
Adolescents- address alcohol and smoking issues, instruct ingestion of meds given by nurse
only.

Put them in a high top crib so they cant fall out or climb out of the bed????????????????
20. When is it appropriate for parents to do procedures, give medications, etc.
while their child is hospitalized?

When the mother is the main caregiver (ex. Chronic illness child)
The parents need to know how to do the procedures for their child so it is good for them to
do it
Provide info on how the parent can keep the child comfortable by (singing, massaging,
warm blanket, praying, or reading)

21. Make sure you know Ericksons stages of development

 Trust when basic needs are met. (feeding and holding, & responding to cues)
Autonomy by showing control over toys and activities.. Egocentric, so give them
some control
o Accept regression in toileting during illness or hospitalization
o Do not begin toilet training during illness or hospitalization
o Have potty chairs available in the hospital and childcare centers.
o Encourage the child to remove and put on own clothes, brush teeth, or assist with
hygine.
o If restrain for a procedure is necessary, proceed quickly, providing explanations
and comfort.
o Ensure safe surroundings to allow opportunities to manipulate objects
o Name objects and give simple explanations.
Initiative by planning and carrying out activities
o like helping, they love to draw
o plan playtime,
o assess drawing cause kids express themselves that way
o Medical equipment for play to less anxiety.
Industry by achieving in sports activities
o .give them tasks to do
o love collect things
o school is their job
o privacy(gowns), knock on door b4 entering
o Encourage doing school work while hospilized
o Show the child equipment that will be used in treatment.
o If youre shy and not figuring out where you fit in, you may be in inferior
route
Identity by having independence from parents and reliance on peers.. privacy,
incorporate their peers
o Ensure access to gynecologic care for adolescent females and education for
testicular examination for males.
o Provide information on sexuality
o Provide a separate recreation room for teens who are hospitalized.
o Take a health history and perform examinations w/out parents present
 oOffer both written & verbal instructions
oContinue to provide education about the disease to the adolescent with a chronic
illness, as mature thought now leads to greater understanding.
22. What defense mechanisms do children use when confronting stressors such as
hospitalization?
Regression- return to earlier behavior Ex. Toddlers regressing in potty training
Repression- involuntary forgetting Ex. Abused child cannot remember episode
Rationalization- unacceptable becomes acceptable Ex. Hitting someone
Fantasy- mind creation to protect self Ex. A hospitalized child who is weak pretends to be
superman. (pg. 110)

Aggression
o Displacementtaking out anger on someone else
o Separation withdrawal and abandonment
o Fear of the unknown sleep disruption, anxiety

Stress reduction
o Recreation-toys, games, activities
o Rest-calm, quiet, bedtime rituals
o Relationships-family members, friends, siblings
o Routines-follow normal routine

23. Make sure you know the major developmental milestones that we discussed in
class: When should they lift head? Roll over? Walk independently? Etc. pgs. 152-
160
Ch. 5- slides 65+
Birth to 1 month= holds hand in fist; inborn reflexes predominate
Lift head= 2-4 months
Roll over= 4-6 months
Walk independently= 1 year old
Sitting up= 8 months
Pincer grasp, crawls, can say dada or mama= 8-10 months
Potty trained= 2-3 years old
6-12 (school aged)= ride a 2-wheeler and other sports activities

For details check the quizlet below:

http://quizlet.com/12493415/nur320-exam-1-study-guide-flash-cards/
24. Make sure you know how to promote growth and development of each age
group and to provide anticipatory guidance of the parents **Cephalocaudal growth
Newborn: birth-1 month:
- Use reflexes as tools that help the newborn transition from the uterus to the external world.
- Attachment is a key development in newborns
- Newborns learn in the 1st month about safety, security, comfort, and food
- Parents should use times when the baby is focused on their face to interact with them

- To promote attachment: encourage frequent visits to the baby in the newborn care unit
- Promote the parent holding the baby
- Provide skin-skin contact of the baby and parent
- point out the baby's responses to voice or touch
- involve the parent in decisions about the baby

Infant (1 mo. to 1 yr.):

- Birth weight is doubled in the first 5/6 months & tripled by 1 year.
- Height increases 1 foot.
- Teeth rupture by 6 months
- physical growth is associated with nutritional status
- Neuro system is more mature: can sit, stand, and walk by 1 yr.
- at 1 yr, they can recognize sounds and say a few words
- engage in solitary play
- cognitive development is seen by the use of manipulating toys
- Infant play begins in a reflexive manner; moving extremities and grasping objects
- infants communicating and engage in two-way interaction and express c comfort by soft
sounds, cuddling, and eye contact.
- Infants understand speech (receptive speech) more than they can speak
(expressive speech).
- Parents should learn to modify the child's environment to promote adaptation (ex.
alternating babysitters)
- Parents should talk to the infant using a high voice , sing, and teach words to their infant
frequently.

Toddler (1-3yrs):
- displays independence, negativism, and pride in accomplishments
- Body proportions: legs longer and head smaller to body size than during infancy
- Usually has a potbelly; and masters potty training.
- Child is in preoperational stage and object permanence (understanding that objects
continue to exist even when they cannot be observed) is well developed
- Have rudimentary problem solving, creative though, and understanding of cause and effect.
- Toddlers play side by side with other children. (parallel play)
- play is usually from things they see at home (ex. talking on the phone)
- Temperament from infancy may change ( A pleasant baby may be slow to warm up to now).
- they communicate frequently with other children
- have temper tantrums to hand these, verbalize the feelings the toddler is showing;
"You must be very upset that you cannot have that candy."
- Communication for a toddler includes:
- avoid telling them procedures too far in advance
- Do not give choices, give short, clear instructions!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
- Tell the child what is being done and the name of the object during an assessment.
- Allow the child to cry during a frightening procedure
- Parents are the best source of comfort during procedures.
- Choose a reward (ex. sticker) after a procedure
- perform painful procedures in a treatment room.

Preschool (3-6 yrs):

- language skills are well developed and child is able to understand and speak clearly.
- has interest in the body and its functions
- preschools play by interacting with each other (ex. 1 person cuts paper while the other
person glues the paper). Associative play
- enjoy large motor activities: ex. throwing a bally, riding a bike
- engage in dramatic play (includes role-playing, puppetry, and fantasy play. It does not
require interaction with another).
- have imaginary thinking; ex: a dye injection will make them think they're going to die, or
a "little stick" will be tree branches falling on them
- Communication: use drawings to explain care
- Use accurate names of body parts
- allow the child to ask questions, and make choices.

School age (6-12 yrs old):

- entering the stage of industry(likes to play sports, achieve things, collect,
pirvacy)
- Parents should praise the child for their achievements to promote self- esteem.
 - Girls may start growth spurts by 9 or 10 yrs old
-Boys growth spurt is usually a year later (11-12)
-Parents should closely monitor children for proper brushing and flossing.
- Child has concrete operational thought; can solve problems and find alternative solutions
- Rely on concrete experiences to form their thought content
- Understands the concept of conservation( knowledge that matter is not change when its
formed is altered)concrete operational thought, they understand by age 7 ITS PIAGET
THEORY

- Cooperative play cooperate with others and the ability to participate in order to a
unified whole. Also involves rules and structure.
- Play is extremely important method of learning and living at this time
- Communication: Give the child awards for correct behavior
- Include both parent and child in health care decisions.
- Encourage parents to see their children as individuals who may not learn the same way.
- provide them with information about the body so they can develop a healthy body image
and understanding of the relationship between their bodies and sexuality

Adolescents (12-18 yrs old):

- the period of identity formation
- Menstruation in girls is the last sign of puberty
- apocrine and eccrine glands mature which increases sweating and odor
- engage in formal operational thought can reason abstractly and understand the concepts
of justice, truth, beauty, and power.
- Peers are important in establishing identity and providing meaning
- Inform parents of different personality types and help them support the teens uniqueness
while providing structure
- introduce the teens to kids with similar health problems
- They should be allowed to choose if they want the parent present during an exam.
- Give choices whenever possible; may need to negotiate to agree
- provide info on safe sex, STDs, and alternatives if pregnant
- parents should be encouraged to talk about sex with their teen

25. What is attachment? How can parents know if their child is attached to them?
- Attachment is a strong emotional bond between people, and it can begin in the newborn period.
- Newborns are often alert after birth and follow the mother's face carefully with their eyes.
- The newborn learns quickly in the first month about safety and security, comfort, and food. If
fed when hungry, held and comforted when in pain or distress, and played with several times
daily, the baby learns that the parents and other caretakers can be trusted to meet its basic
needs.
- Once the infant learns to trust that people will provide care, it is free to move on to explore the
environment more actively. (p. 147)

Nursing interventions that can promote positive attachment with the high-risk infant
include:
- Encouraging frequent visits to the baby in the newborn care unit
- Promoting holding of the baby
- Providing for skin-to-skin contact of the baby and parent
- Pointing out the baby's attributes and responses to voice or touch
- Involving parents in care of and decisions about the baby
- Advocating for healthcare agency policies that are supportive of attachment between the infant
and parents
- Giving information and repeating as needed; letting parents have a telephone number they can
call at any time to get information about the baby or talk with a supportive person
- Arranging for ongoing developmental assessments on a regular basis once the infant is
discharged from the hospital (p. 148).

26. How can you as a nurse make hospitalized infants feel secure?
Comforting the Distressed Infant
Teen parents and those with little prior experience with babies need help to develop a repertoire
of interventions to try when a baby is crying. Ask about how they comfort the baby. Suggest
the following interventions if the parent does not state them:
- Offer a breast or bottle feeding, especially if the last feeding was more than 2 hours ago.
- If feeding was recent, hold the baby in a sitting position and rub or pat the back to help expel
gastric gas.
- Change the diaper if wet or dirty.
- Place a hand on the abdomen and feel for movement. If movement or passing gas is present,
hold the baby against the chest, walk slowly, and pat the back.
- Swaddle the baby securely in a blanket and hold horizontally while rocking.
- Hold the baby on your lap, secure the hands in yours, and talk softly.
- Stroke the infant's skin; rock and sing to the baby.
- Never shake or throw the baby, no matter how long the crying. Call your healthcare provider for
suggestions if you feel like nothing works and you are very frustrated. (p. 378)

27. What is swaddling?

Swaddling is wrapping infants in blankets so that movement of the limbs is tightly restricted.
- Many infants are assisted in soothing themselves when they are swaddled or tightly wrapped
(see the Skills Manual).
- Many babies will immediately quiet once swaddled, and will either sleep or become quietly
alert. However, be aware that some babies find this position uncomfortable. If they fight
the blanket and try to free themselves, this may not be an approach that works for quieting
those particular babies. (p. 378)

28. What is appropriate discipline for each age group? What is inappropriate
discipline for each age group?
Discipline is a method for teaching the rules that govern behavior or conduct. Punishment is
the action taken to enforce the rules when the child misbehaves.
Firm limits also help children to feel secure because they are reassured by consistency and
the sense of protection perceived by the limits. Punishment helps children learn that there are
consequences for misbehavior and that other individuals may be affected by the behavior.
This helps children develop a sense of responsibility for their behavior.

Common strategies used with children between 19 and 35 months of age:

Reasoningexplaining why a behavior or action is inappropriate or describing how limit
setting is important. By reasoning, parents can help the child to understand why certain
behaviors are wrong.
Behavior modificationgiving positive rewards or reinforcement for good behavior or
consistently ignoring inappropriate behavior to minimize the behavior. This encourages
children to behave in specified ways.
Experiencing consequencesallowing the child to learn important lessons associated with
misbehavior, such as taking away a toy, using a time-out, withdrawing privileges
Corporal punishmentspanking or inflicting pain with a paddle, whip, or other object. This
is one of the most widely used techniques for punishing children (Slade & Wissow, 2004). It is
not recommended as it teaches children that violence is acceptable.
Scolding or yellingusing harsh language directed at the child.

Partnering with Families: Positive Discipline [for Toddlers and Preschoolers] (p.
402).
To provide structure that enhances the possibility of desirable behaviors:
- Limit rules to those that are essential. It is easier to enforce a few important rules than many
that are nonessential.
- Provide an environment where the child is mainly free to explore safely in order to avoid
constant cautions. For example, have adequate play space for toddlers with limited fragile
glassware in the usual daily environment. It is easier for the toddler to learn not to
touch a few objects when adequate objects are provided for play.
- Spend time interacting with the child several times each day. Praise positive behaviors
frequently. Preschoolers often like to have charts with stars to record picking up toys, helping
a parent, and performing other positive behaviors. Once preschoolers obtain a certain number
of stars they earn a reward such as stickers or an outing with the parent.

School-Age Child. 6-11/12

The child is becoming more independent, but unacceptable behaviors must still be managed
by successful discipline techniques.
- Talking calmlyExpress the behavior observed, why it is not acceptable, and its effects on
others. If appropriate the child can help decide what should be done to change the behavior
(i.e., removing a privilege or other solution).
- Using natural or logical consequencesFor example, if the child breaks an item he or she
owns in anger, the item should not be replaced.
- Withholding privilegesBe consistent in privileges withheld and be certain that they are
privileges (such as attending a movie with friends) rather than essential (a meal).
- Using time-out to separate the child from others This technique can be helpful when the
child needs time to redirect a temper or other such behavior. It is not helpful as a frequent
technique for all undesirable behavior, especially when sent to the bedroom that may have a
television, cell phone, and other technological devices.
- Applying distractionThe child who is frustrated may learn to handle the stress ifthe parent
suggests a brisk walk or other physical outlet.
- Avoiding spanking and yellingThese techniques are not generally helpful and fail to teach
the child positive substitutions for undesirable behavior. (p. 429).

Adolescents
 Most adolescents require discipline or guidance from parents at certain times. However,
constant battles over daily events are counterproductive. Instead, it is best if parents respect
the teenager's need for a level of autonomy and enact a few rules on important issues, so
that parents have to enforce them only rarely. Guidelines that can help parents include the
following:
- Gradually increase the teen's independence. If there is success with growing responsibility,
the teen may be ready for more. If the teen misuses independence (perhaps by staying out
too late, having a party at home without parents present, lying about location on an evening
out), there should be clear limits and loss of privileges
- Comment on a teen's behavior rather than making belittling comments about him or her as
a person.
- Realize that the teen is establishing independence and that the relationship will change.
- Provide discipline by talking about the unacceptable behavior, rather than
belittling the teen. (p. 450-451).

29. Know how to assess parent-child interactions: which ones are appropriate and
which ones are inappropriate?
Newborn
Responds to stroking, rocking, and skin to skin contact. They also should be swaddled to
promote comfort and parents should be taught the infant massage

Infant---Respond to same stimuli as a newborn as well as singing, and toys that make noise
- speak in a high pitched or soft tone
- establish eye contact whenever possible
- avoiding leaning over the infants face when talking forcefully
- communicate through play such as peek-a-boo. Object permanence(happens 8-
12mths)
- use swaddling, rubbing, patting, and cuddling to quiet crying

Toddler and Preschool

- children at this age are egocentric
- communicate with the child on their eye level
- Use simple language and short sentences
- Be honest with responses
- Encourage the child to engage in imaginative play
- Encourage the toddler to engage in parallel play
- Encourage the preschooler to engage in dramatic play
- Allow the child the opportunity to ask questions
- Allow the child choices whenever possible

School aged
- Speak directly to the child
 - be honest in all responses
- Encourage the child to express thoughts and feelings through drawing writing, or
painting. (LOVE TO DRAW)

Adolescent
- Use a straightforward approach
- Avoid comments or expressions that convey disapproval or surprise
- Listen to what they are saying without interrupting
- Offer them choices whenever possible to help with independence
- Do not assume they have the same cognitive understanding as adults

30. When should solid foods be introduced into the diet? .STARTS 4-6MTHS!!!
The American Academy of pediatrics recommends: Introduce rice cereal at 4-6
months, introduce first cuz low allergenic potential
Introduce fruits and vegetable at 6-8 months (introduce dark green leafy vegetables
before fruits)
Introduce meats at 8-10 months
Introduce one new food at a time to asses for allergies, waiting at least 3-4days
to introduce another

31. Which developmental stages contain periods of rapid physical growth?

Infancy (pg. 146) birth weight is doubled by 5-6mo age, 3x by 1 year and adolescence
(pg. 140)

32. How can you make a physical assessment less stressor for a toddler?
o Encourage parental presence
o Allow parents to hold child in their lap for examinations and procedures when possible
Provide a night-light Have the child sit on their parents lap during the assessment
Demonstrate the use of equipment on the parent or let the parent hold the
instrument first. So they can see that the parent trust u!!!!!
Do NOT ask the child what to do, tell them what your going to do next
Give them choices on what part of the exam to do next.
Hold security objects
Demonstrate on parent
START w/ FEET and then ASCEND toward the body & heart.
Instruments for EYE, EARS, and MOUTH should be used at the END b/c they are the most
fearful for kids.
Children at this age usually have stranger anxiety, and can be shy
Observe child play and walk around in the examination room--- This is Neurological &
muscular assessment!!!!!

33. What are the types of play? Which age group engages in each type of play?
a. Infant
i. Solitary play
ii. Physical capabilities enable the infant to move to-ward and reach for objects of
interest.
iii. Cognitive ability is reflected in manipulation of the blocks to create different
sounds. Social interaction enhances play.
 iv. Begins to play in a reflexive manner(moves limbs & touch objects)
v. Manipulative behavior as the infant examines toys closely, looking at them,
touching them, and placing them in the mouth.
b. Toddler
i. Refines fine motor skills by use of cloth books, large pencil and paper, wooden
puzzles
ii. Facilitates imitative behavior by playing kitchen, grocery shopping, toy telephone
iii. Learns gross motor activities by riding tricycle with big wheels, playing with soft
ball and bat, molding water and sand, tossing ball or beanbag
iv. Develops cognitive skills through educational television shows, music, stories,
and books
c. Preschool
i. Simple games, puzzles, nursery rhymes, and songs facilitate associative play.
ii. Dramatic play is fostered by dolls and doll clothes, play houses and hospitals,
dress-up clothes, and puppets.
iii. Pens, paper, glue, and scissors relieve stress.
iv. Educational television shows, music, stories, and books foster cognitive growth.
v. imaginary thinking;
d. School-Aged
i. Gross motor development is fostered by ball sports, skating, dance lessons,
water and snow skiing/boarding, and biking.
ii. Playing a musical instrument, gathering collections, starting hobbies, and
playing board and video games foster a sense of industry.
iii. Cognitive growth is facilitated by reading, crafts, word puzzles, and schoolwork.
iv. Co operative play == organized play
e. Adolescent
i. Sportsball games, gymnastics, water and snow skiing/boarding, swimming,
school sports
ii. School activitiesdrama, yearbook, class office, club participation
iii. Quiet activitiesreading, schoolwork, television, computer, video games, music

34. Make sure you know injury prevention interventions for each age group.
a. Infancy
i. Do not leave infant unsecured in infant seat, even in newborn period, on high
places (tables, etc.) or beds.USE ONLY REAR FACING CAR
SEATS!!!!
ii. Once mobile, keep stairs and doors closed/gated
iii. Check temperature of bath water and food/liquids
iv. Cover electrical outlets
v. Use only approved restraint
vi. Never leave infant alone in as little as 1in of water
vii. Keep medications out of reach; teach proper dosage/administration
viii. Have poison control number; keep plants out of reach
ix. Avoid foods/toys that commonly cause choking
x. Position infant on back for sleep; do not place pillows, stuffed toys, or objects
near head; no plastic in crib; avoid latex balloons
b. Toddlerhood
i. Supervise toddler closely. Provide safe climbing toys. Begin to teach
acceptable places for climbing.
ii. Keep medications & poisonous material locked away; keep poison control
number; use child-restraint containers & cupboard closures
iii. Keep pot handles turned inward on stove. Do not burn fires without
close supervision. Use a fire screen.
iv. Supervise any child near water. Swimming classes do not protect a toddler
from drowning
 v. Use child-resistant pool and spa covers. Use approved child life jackets
near water and on boats. Empty buckets when not in use.
vi. Use approved safety seat only. Keep the child in a rear-facing seat
until 2 years of age or until achieving the highest weight or height
recommended for the seat by the manufacturer.
c. Preschool
i. Appropriate car seat or booster chair in back seat & make sure child is belted
properly
ii. Teach child to keep away from the road when playing
iii. No swimming without supervision
iv. Instruct the child in the dangers of matches, lighters, and similar items. Teach
the child to stop, drop, and roll if clothes are on fire.
v. Practice escapes from home are useful.
vi. Keep needles out of reach
vii. Avoid use of electrical cords/cover outlets
d. School-Aged
i. Teach child safe outside play, especially near streets.
ii. Reinforce use of bike helmet.
iii. Teach biking safety rules and provide safe places for riding.
iv. Teach safe street-crossing behaviors.
v. Teach child never to touch guns without parent present.
vi. Guns should be kept unloaded and locked away. Guns and
ammunition should be stored in different locations.
vii. Be sure guns have trigger locks.
viii. Teach child what to do in case of fire or if toxic substances touch skin or eyes.
ix. Reinforce teaching about 911
x. Provide telephone numbers of people to contact in case of an
emergency or if child feels lonely.
xi. Leave child alone for brief periods initially, and evaluate childs success in
managing time.
xii. Teach child not to accept rides from or talk to or open doors to strangers.
xiii. Teach child how to answer the phone.
33. - Do not place children in the front seat of the car
34. - Use a booster seat until the child can sit with knees bent over the edge of
the seat

a. Adolescent
i. Insist on drivers education classes & graduated license law adherence
ii. Enforce rules about safe driving
iii. Use seat belts for every trip
iv. Take license away from youth who drink & drive, even once
v. Encourage use of protective sporting gear
vi. Teach safe boating practices
vii. Teach hazards of drug/alcohol use & with motorized equipment
viii. Encourage swimming only w/friends
ix. Reinforce rules and teach about risk of diving

35. Ethical perspectives of child health nursing, review terms discussed in class.
a. Beneficence - make decisions that benefit the patient
b. Non-maleficence - reduce the risk of harm - use interventions that promote most
benefits.
c. Autonomy - right for self determination
d. Justice - Treat all with fairness and respect
e. Current issues: End of life-sustaining treatment; Genetic testing of children; Organ
transplant; Research on children
36. What is responsible for declining mortality and morbidity of children of all ages?
Injury prevention and safety is crucial.
- advancements in prenatal screening and care
- unintentional injury is the leading cause of death in children ages 1-19 yrs old, NO
NEONATES!!!
- mortality in newborns is related to low birth weight and congenital malformations

37. What age group is most concerned with body integrity? Body image?
Adolescents are most concerned with body image
Body image: Specific facets of self-concept that forms about one's own body, body.
- During and examination adolescents should be given the option of privacy
- Nurses should offer education and explanations that focus on these issues to provide
reassurance.
a. Body integrity: Pre-schoolers..fear body mutilation
b. Body image: Adolescent

38. What is object permanence? How do you know when it has been developed?
PIAGET Characteristics of Thought Identity
Coordination of secondary schemes8 to 12 months
- Object permanence ability to understand that when something is out of sight it still
exist
Ex: when the infant remembers when a hidden object is likely to be found, or
playing peekaboo

Nursing implications:
- Before development of object permanence, babies will not look for toys or other objects
out of sight.. Play pee-a-boo to remind them that their parents will return
- before development of object permanence, babies will not look for toys or other objects
out of sight , As the concept develops they are concerned when a parent leaves since
they are not certain the parent will return

39. What are self-soothing behaviors of infants? What are self-regulating

behaviors?
a. Self-soothing behavior: refers to an infants ability to settle to sleep at the beginning of
the night and to put herself back to sleep upon awakening during the night; pacifier,
swaddling
b. Self-regulating behavior: the ability to maintain state and self-console

40. Why do infants cry when there is nothing wrong?

There may be no reason for the child crying but you should always assess the child.
- Crying may sometimes be unknown
- Look for reasons (gastric distress, hungry, wet or cold) and intervene

41. When is it appropriate to tell children that they are dying?

Awareness of Dying by Developmental Age
An understanding of the dying childs experiences during each developmental stage can
assist the nurse and the family in delivering individualized care to the child.
Children as young as 5 years of age can sense when they are seriously ill . A
childs awareness of death develops more rapidly when he or she is experiencing the
progression of the disease and related medical treatment.
** How you approach a child is always based on their developmental level. Considerations:
- Effect on understanding of death
- Effect on behavioral response to death
- Effect on ability to communicate about death
 - By 6 years of age, children recognize death as permanent
- By ages 9-10, children understanding of death is the same as an adult
- School aged children should know that they are dying.

Make sure and encourage the parents to be honest to their child about their condition.
Promote strong sense of security to infant, calm voice, support to parents.
Maintain routine.

School aged children should know that they are dying.

Acknowledge that the childs life can be complete even if it is short
Tell the parents that the child may need to hear the word dying
Let the child know that he/she will always be remembered
identify the appropriate time to assist the parent in telling their child

42. What is magical thinking? How does this apply to children?

TABLE 5-4 Characteristics of Thought Identified by Piaget
Characteristic: Magical thinking -- happens wit preschoolers!!!!!!!!!!!!!!!!!!!
Definition: The belief that events occur because of one's thoughts or actions
Development Stage: Preoperational thought. Preoperational - In the INITIATIVE
STAGE (4 to 7 years), the child relies on transductive reasoning (drawing conclusions
from one general fact to another.

Nursing Implications:. Ask young children how they became ill, or what caused
a parent's or sibling's illness. Correct misconceptions when the child blames self for
causing problems by wishing someone ill or having bad behavior. (p. 135).
For example, when a child disobeys a parent and then falls and breaks an arm that day,
the child may ascribe the broken arm to bad behavior.
Cause-and-effect relationships are often unrealistic or a result of magical thinking.

43. Providing information to parents about their childs medical condition

talk to the parents in person, in a private setting
allow them to have a family member or friend for support.
present information in small amounts
use simple language and avoid medical terms.
share accurate up to date information
talk about the child's strengths and positive attributes, as well as their
limitations and characteristics due to the illness or disability
examine if the families needs were met and if additional resources are needed
provide a follow up discussion
observe the patients facial expressions because most times they may stop
listening after the medical condition has been told to them.

44. What type of hospital bed is appropriate for each age group?
Cribs children less than 3 years old

Neonates and infants: incubators, bassinets with high sides and/or tops to prevent
accidental crawling out and falls
Toddlers: toddler-sized beds with high sides and/or tops to prevent accidental
climbing out and falls
School-aged children: ultra-low pediatric specific beds
Adolescents: regular hospital beds
 *Parent MUST sign a liability document if they want to have a normal size bed for their
child of 3 years of age or younger.

45. Therapeutic vs. non-therapeutic relationships with children and families

Nursing care of the dying child and family focuses on providing family-centered support for
the physical and psychological needs of the child and the family members.
**If a parent expresses a lot of anger when their child diagnosed as a healthcare
provider be mindful of their situation.

Be verbally supportive, be honest, and truthful

Show compassion and a sense of connection with the child and family members
Acknowledge the familys emotions and be prepared for tears
Do not reinforce denial
Recognize that anger is a normal response to feelings of loss
Remain with the child or parents even though they express anger
Actively listen, using eye contact and stillness
Offer spiritual support if appropriate
Encourage the family to create memories

46. Temper tantrums ----most common toddlers!!!!

Temper tantrums are common in toddlers and are manifested as episodes of screaming,
crying, ponding objects, kicking and otherwise showing anger. Toddlers may be expressing
frustration with something that has occurred. They have learned that they are independent
individuals and have an effect by showing their dismay. Temper tantrums should gradually
decrease in number as the child grows into the preschool years. Some specific suggestions
for dealing with tantrums.
Do not respond to minor anger that includes crying and screaming.
Separate the child from others with a time-out equivalent to 1 minute/year of a childs
age.
Be sure the child is safe
Talk calmly to the child verbalizing his or her feeling and what the child needs to calm
down.
Leave public places to return home or to a quit setting.

47. Review how to promote therapeutic communication with the children and
families.
Building Rapport! Establishing a trustful relationship w/your patient
Erikson's First Theory Trust vs. Mistrust
Data Collection
Introduction, Purpose of interview, Use of open- and closed-ended questions
Timing of questions
Nonverbal communication ****MOST important
Observations, Language
Honesty: NEVER lie to children, you don't want to violate their trust

Advocate for that patient

Get them to trust you
Treat their family as if it is the only family you have
To develop rapport demonstrate your interest in and concern for the child and family by
actively listening to the info shared
Communicate as a nonjudgmental and non-controlling professional
Introduce yourself
Your name, title or position, and your role in caring for the child
 To demonstrate respect ask all family members present what name they would prefer
you to use when talking to them
Explain the purpose of the interview and why the nursing history is different from the
info collected from other health professionals "the nurses will use this info to help plan
the best care suited to your child"
Provide privacy and remove as many distractions as possible
Direct the focus of the interview with open ended questions. Use close ended questions
or directing statements to clarify info.
Ask one question at a time so that the parent or child understands what piece of info
you want and so that you know which question is being answered
Use nonverbal behavior such as nodding, smiling, and eye contact at appropriate times
to communicate that you are hearing the info shared
Be honest with the child when answering questions or when giving info about what will
happen
Choose the language style that is best understood by the parent and the child. Use an
interpreter to improve communication when you are not fluent in the language

48. Providing care to children and families using Eriksons and Freuds theories
Infant (birth to 1 year)
FREUD - Oral stage:
The baby obtains pleasure and comfort through the mouth.
Nursing Applications:
When a baby is to be offered nothing by mouth (NPO), offer a pacifier if not contraindicated.
After painful procedures, offer a baby a bottle or pacifier or have the mother breastfeed.

ERIKSON - Trust versus mistrust stage:

The baby establishes a sense of trust when basic needs are met.
Nursing Applications:
Hold the hospitalized baby often. Offer comfort after painful procedures. Meet the baby's
needs for food and hygiene. Encourage parents to room in. Manage pain effectively with use
of pain medications and other measures.

Toddler (1 -3 years)
FREUD - Anal stage:
The child derives gratification from control over body excretions.
Nursing Applications:
Ask about toilet training and the child's rituals and words for elimination during admission
history. Continue the child's normal patterns of elimination in the hospital. Do not begin toilet
training during illness or hospitalization. Accept regression in toileting during illness or
hospitalization. Have potty chairs available in the hospital and childcare centers.

ERIKSON - Autonomy versus shame and doubt stage:

The child is increasingly independent in many spheres of life.
Nursing Applications:
Allow self-feeding opportunities. Encourage the child to remove and put on own clothes, brush
teeth, or assist with hygiene. If restraint for a procedure is necessary, proceed quickly,
providing explanations and comfort.

Preschooler (3-6 years)..think cause illness(magical thinking)

FREUD - Phallic stage:
The child initially identifies with the parent of the opposite sex but by the end of this stage
has identified with the same-sex parent.
Nursing Applications:
Be alert for children who appear more comfortable with male or female nurses, and attempt
to accommodate them. Encourage parental involvement in care. Plan for playtime and
offer a variety of materials from which to choose.

ERIKSON - Initiative versus guilt stage:

The child likes to initiate play activities.
Nursing Applications:
Offer medical equipment for play to lessen anxiety about strange objects. Assess
children's concerns as expressed through their drawings. Accept the child's choices and
expressions of feelings.

School age (6-12 years). AGE OF REASONING!!!

FREUD - Latency stage:
The child places importance on privacy and understanding the body.
Nursing Applications:
Provide gowns, covers, and underwear. Knock on door before entering. Explain
treatments and procedures.

ERIKSON - Industry versus inferiority stage:

The child gains a sense of self-worth from involvement in activities.
Nursing Applicatons:
Encourage the child to continue schoolwork while hospitalized. Encourage the child to
bring favorite pastimes to the hospital. Help the child adjust to limitations on favorite
activities.. If youre shy and not figuring out where you fit in, you may be in
inferior route

Adolescent (12-18 years)

FREUD - Genital stage:
- The adolescent's focus is on genital function and relationships.
Nursing Applications:
Ensure access to gynecologic care for adolescent females and education for testicular
examination for males. Provide information on sexuality. Ensure privacy during health care.
Have brochures and videos available for teaching about sexuality.

ERIKSON - Identity versus role confusion stage:

The adolescent's search for self-identity leads to independence from parents and reliance
on peers.
Nursing Applications:
Provide a separate recreation room for teens who are hospitalized. Take health
history and perform examinations without parents
present. Introduce the adolescent to other teens with the same health problem. (p. 132-133)

Nursing Application of Freud's Theory

Freud emphasized the importance of meeting the needs of each stage in order to move
successfully into future developmental
stages. His work has been criticized for several reasons:
- He developed a theory of childhood by his work with adults, primarily women, who sought
help in dealing with emotional issues.
- He viewed males as dominant because of their possession ofa penis.
- He ignored the effects of culture and other external experiences.
However, some aspects ofhis theory appear to be supported by more current research and
can be applied in nursing.

Illness can interfere with normal developmental processes and add challenges for the nurse
who is striving to meet an ill child's needs. For example, the importance ofsucking in infancy
guides the nurse to provide a pacifier for the infant who cannot have oral fluids. Recall Sergio
from the opening scenario. He did not have the ability or strength to suck after birth and was
fed parenterally and by gavage. However, as soon as he was able, he was assisted to
 breastfeed in order to foster his oral musculature
and his ability to gain comfort from sucking. The preschool child's concern about
sexuality guides the nurse to provide privacy and clear explanations during any
procedures involving the genital area. It may be necessary to teach parents that
masturbation by the young child is normal and to help parents deal with it through distraction
or refocusing. The adolescent's focus on relationships suggests that the nurse should include
questions about significant friends during history taking. (p. 131).

Band aid for which age group???

Recommendations/Nursing Interventions:

Infants: Encourage family to be active through touch, sight and sound. Meet oral needs/ provide
stimulation such as pacifiers, age appropriate teething toys. Rock and touch with light stroking to
provide tactile stimulation, minimize excess noise and stimuli, allow periods of rest.

Toddlers/Preschoolers: Separation is major stressor they may protest vigorously when parents
depart. Give piece of clothing w smell of mom/dad unless contraindicated (ie resp. distress).
Provide similar routine as home of bathing, sleeping, toileting. For independence give choices
(color of jello or choice of pajamas to wear, which color pill to take 1st). Other common stressors;
fear of pain, invasive procedures, change or mutilation, help by providing consistence presence
of parents, role pay exercise. Nurses can wear colorful or uniforms with familiar characters
(fear of white uniform). Parents should not disappear when child is sleeping (develop lack of trust
from child), if parents need to leave need to tell the child when they will return (ie before dinner)
and call child throughout the day.

School-Aged: Major stressors include; loss of control related to body functions, privacy, fear of
bodily injury, pain, and concerns related to death, separation from friends and family. Explain to
parents regression is normal during stressful situations. To foster sense of industry (child takes
pride in achievements), have child participate in their care as much as possible, encourage
school work, arts and crafts.

Adolescents: Reoccupation with appearance and body image are paramount in this age group!
Provide education about these issues. Hospitalization my lead to dependence of parents resulting
in frustration and anger, encourage privacy and independence, allow them to discuss
thoughts and feelings to build rapport. Major stressors include; loss of independence, control &
privacy, fear of bodily injury, or change in body image. Fear of disability, pain and death.
Separation from peers, home and school. To foster independence & establishing self
identity, provide as much privacy (knocking on door, asking before assessments), encourage
participation in decisions and plan of care. Nurses can help with social and coping skills through
role play and relaxation training, allow choice of clothing, hair, music (self-image importance).
Allow flexible visiting hours from peers, or provide internet for social networking. Encourage
participation within hospital for teen recreation.

Find out age rolling over???

Children are at a greater risk for medical and medication errors: precision is really required, kids
cant tell you anything, 80% of the drugs arent approved by the FDA for children but we still use
them. If decimal points in wrong place- you could kill somebody. Drugs are based on weight.
Look at how many mg per kg for children
Theres a pharmacist on the teams to talk to to check dose too

Growth: refers to physical size and quantitative change.

Development: Refers to an increase in capabilities or functions.
Cephalocaudal: head to feet
Proximodistal: center to extremities

Toddlers ==dont have a concept of time

Freud: psychosexual energy is centered in specific parts of the body at certain ages.
-There are 3 components of personality
1. ID: I want it now.hidden
Present at birth, seeks pleasure, - sexual energy
The id can not tolerate frustration, lacks the ability to problem solve. Not logical!

2. Ego: I need to do a bit of planning to get it..smallest portionvisible

same
Realistic part -develops to met the Id impulses in an acceptable manner.
Develops defense mechanisms to assist in decreasing anxiety.

3. Superego: No, you cant have it right now, its not right.biggestvisible
same
Last portion of personality to develop.
Represents moral and ethical component (conscience).
-Freuds Iceberg metaphor
Id is completely below the waters surface.
The superego is partially below and partially above the surface.
In comparison to the superego, the ego is more fully above the surface in the realm
of conscious awareness (ego =iceberg)
- Most thinking takes place unconsciously

Infancy is the most rapid period of growth. Adolescence is next

-Minimally breast feed for 3 months.

- If mom cant breast feed, you need to use formula for 1 whole year- formula has iron
which helps w/ RBC production- so dont start whole milk until 1 year.
- WICC program: helps women get formula for free.
- Treat breast milk like a biohazard product- make sure to give right baby the right
breast milk

By 3 years of age, our personality is established already. Weight is 4x what it was at birth.
Separation from parents is very stressful for toddlers. Routine structure makes them feel safe.

Cooperative play is when children play in groups to achieve a goal or play a game. -School
ager(age of reasoning)

Average girl starts getting menses at 12 due to the hormones in food, better nutrition, better
lifestyles.
Once she gets her period, her physical growth pretty much stops- she probably wont get much
taller.

Make sure infants brain is growing- measure head circumference and chest circumference.