Care of children and Families during Health and Illness

Family centered care

Recognizes the family as the constant in the childs life Family is the childs primary source of strength and support Childs and familys perspectives and information are important in clinical decision making

Pediatric Nurse

Provides support based on respect, encouragement, enhancement of strengths and encouragement of competence Gives developmentally appropriate care/communication

Roles of Pediatric Nurse

Health promotion through education, screening, and prevention measures Disease prevention through rapid assessment and early interventions Health restoration via acute, critical and outpatient care Community health nursing focusing on communities and client groups Complex care coordination for children with multiple morbidities or complex chronic diseases requiring a multidisciplinary approach Death and dying care, symptom management at the end of life

Settings of Care

Primary

Primary care provider offices, Public health departments

Secondary

Acute care hospital units, Critical care hospital units Home care, Specialty clinics for children with special needs

Tertiary

Subjective Assessment

Collecting data from care giver to identify and clarify pertinent information the individualizes needs

Individual and family coping

Experiences with health care Health maintenance Factors relating to access to care

Socioeconomic status

Subjective Assessment contd

Cultural influences

Factors influencing Growth and Development

Spiritual and alternative practices

Genetics: Inherited factors Gender: Specific differences Intelligence: IQ Temperament

Easy: adapts well, positive mood (40-50%) Difficult: withdraws from new situations, negative mood (10%)

Easy to care for Irregular habits Fairly inactive

Slow to warm up to: adapts slowly, negative mood (15%)

Subjective Assessment contd

Environment

Nature vs Nurture

Nutrition

Breast feeding/Bottle feeding Food pyramid

Daily servings from each group

Breads, vegetables, fruit, milk, fats

Objective Assessments

Health maintenance

Physical Growth

Growth chart tool

Measured in percentile

Developmental Milestones

Major markers of normal development

Denver developmental tool

Anticipatory Guidance

Predictable teaching stages (e.g. safety and prevention)

Growth and development

Growth-denotes an increase in physical size (quantitative change) Growth charts are tool

Height- measured in inches or cm Weight- measured in lbs or kg Head circumference

Body system review Infant

Physiologic anemia @ 2-3 mos (fetal RBCs distroyed) Respiratory- rate decreases by end of 1st yr from 30/60 to 20/30 per min

Mucous production and small lumen increase risk for URI

GI-amylase deficient necessary for carbohydrate digestion till 3rd month

Body system review contd

Lipase-necessary for fat digestion decreased in the first year

Liver: immature- inadequate conjugation of drugs Extrusion Reflex- present till 3-4 mos

Drinking from cup poss @ 4 mos (independent @ 8-10 months)

Body system contd

Immune system: function @ 2 months

Not plentiful till school age Protect from infection Can shiver to provide warmth Adipose tissue

Adjust to cold-mature @ 6 mos

Body system review contd

Kidneys: not as efficient as adult Endocrine: immature in response to pituitary stimulation

Adrenocorticotropic hormone Insulin

Fluid: Extracellular 35%/Intracellular 40% (adult 20/40)

Increased suseptability to dehydration with fluid loss d/t illness

Body system contd

Teeth: Eruption

6 mos central incisor- new one each month 20 deciduous teeth-replaced @ age 6-7

G & D contd

Development- denotes an increase in skill or ability to function ( a qualitative change)

Denver developmental test- tool

Recording caregivers report Observing performance skills

G& D contd

Principles of Growth and Development

Proceeds in sequence

Weigt triples/hight increases 50% Sit-crawl-stand-walk Walk 9mos-14mos (normal) Neuro peaks 1st year---genital tissue grows little till puberty Head to tail

Proceeds in orderly sequence

Children pass through stages at different rates

Body systems do not develop at the same rate

Development is cephalocaudal

G & D cont.

Proceeds from proximal to distal

Arms/hands-coordination
Control distal parts ( lg crayons @ 3yrs old/ Fine pen @ 12 yrs old Cannot learn tasks until nervous system is mature enough/missing target times longer Replaced by purposeful movements Practice but capable of catching up

Proceeds from gross to refined skills

Optimal time for experiences or learning

Neonatal reflexes must be lost before proceeding

Great deal of skill is learned by practice

Development contd

Basic divisions of Childhood

Neonate Infant Toddler Preschooler School-age-child Adolescent

first 28 days of life 1mo-1yr 1-3yrs 3-5yrs 6-12yrs 13-20yrs

Development contd

Psychosexual

Freudian Theory

Nursing implications: oral stimulation (infant), bowel and bladder control (toddler), accept sexual interest (preschool), positive experiences affecting self esteem growth (school age), opportunities to relate to opposite sex (adolescent)

Oral stage (Infant) Anal stage (Toddler) Phallic stage (Preschooler) Latent stage (School age) Genital stage (Adolescent)

Development contd

Psychosocial

Eriksons stages

Trust versus mistrust (infant) Autonomy versus shame (toddler) Initiative versus guilt (preschool) Industry versus inferiority (school age) Identity versus role confusion (adolescent)

Nursing implications: Provide primary caregiver (infant), Provide opportunities for decision making (toddler), Provide opportunities for exploring (preschooler), Provide opportunities for child to feel rewarded for accomplishment (school age), Provide opportunities for discussion about feelings (adolescent)

Development contd

Cognitive

Piagets Stages

Nursing Implications: Infant Learns permanence (eight month anxiety) Toddler Prelogical reasoning (may lead to false conclusions and faulty judgement) Preschooler Centering (see only one characteristic of an object) lack of conservation (ability to discern changes in physical properties) reversibility( retrace steps) -thinking is influenced by fantasy-assimilation (taking information and changing it to fit their existing ideas)-Egocentrism School-Age Recognize cause-and-effect relationships Adolescent Abstract Thought

Sensorimotor Preoperational Thought /Intuitive Thought Concrete Operational Thought Formal Operational Thought

Nutrition

Fiber-whole grains, raw fruits and vegetables

Preschool cereals

Fat intake-not restricted for 1st 2 yrs- needed for mylination of nerve fibers Sugars-dental caries and obesity Salt/sodium-acquired taste Protein-bones, skin, hair,muscles Carbohydrate- supply energy Vitamins- for cell activity Minerals- bone development

Development Milestones

Age 1 months-smiles Age 3 months-vocalizes, hand control Age 4 months-head control; grasps Age 6 months- sits briefly, rolls backabdomen Age 9 months-pulls up, crawls Age 11 months-stands alone, walks with support Age 12 months-walks alone

Emotional development

1 month- differentiates faces-best with caregiver 6 mos-social smile 8 mos-fear of strangers @ height

9 mos-aware of changes in tone cries when scolded 12 mos- alert and responsive when approached

Normal sign of healthy attachment (object permanence)

Toddler

Cognitive and Psychosocial Development

Autonomy vs shame or guilt

Taking pride in accomplishments now allows them to grow to be confident children

Parallel play Safety

Accidental ingestion of poisons most common in toddlers Car seat until 40 lbs Lead screening

Toddler contd

Dress-socks, underpants, undershirt Sleep-2 naps/8 hrs. @ night-1 nap/12 hrs. @ night Teeth-dental visit @ 2 Toilet training- individualized 2-3 yrs Negativism

Important to achieve independence later

Temper tantrums

Preschool

Physical appearance

Body type becomes apparent

Slim- ectomorph Large- endomorph

Handedness appears More language-asks questions Egocentric

Developmental

Preschool contd

Imagination keen

Cannot differentiate between fantasy and reality

Imaginary friends Difficulty sharing Encourage creative play Bubbles, painting, modeling clay

Initiative vs guilt

Development of can do attitude

Gender role needs exposure to opposite gender adult

Preschool contd

Nutrition: food pyramid-meat minimal Safety: head injuries major

Dress: dress themselves-like bright colors-difficulty with buttons Fears- fear of the dark

Helmets

Fear of mutilation Fear of separation or abandonment Minor illnesses # 1 Sibling rivalry-jealousy Stuttering and swearing

Need night light

School age

Physical

Growth slow and steady Eruption of permanent teeth Brain growth complete Innocent heart murmur may become apparent

L ventricle enlarges to be strong enough to pump blood to growing body

School-age contd

Sex education

Development of secondary sex characteristics Obesity

50% of school age children are obese Influential factors

Genetics and Environment Reduce calories and fat Exercise program Counseling

Weight loss goals

School age contd

Industry vs inferiority

Mastery of useful skills and tools of the culture, learning how to play & work with peers; characterized by competence

Attitudes of peers important

Enjoy reading books

School age continued

Safety

Bicycle Stranger Social pressure

Stealing, bullying, drugs etc

Media influence Physical threats

Violence and terrorism

Adolescent

Puberty

Boys Girls

Sexual maturation

Changes and milestones

Secondary sex characteristics

Tanners staging

Peer importance Body image Risky behavior

Adolescent contd

Identity vs role confusion

Begins to develop a sense of I; this process is lifelong; peers become of paramount importance; child gains independence from parents, characterized by faith in self

Main areas of achievement

Body image acceptance Establish a value system Make a career decision Become emamcipated from adults

Adolescents contd

Communicating with adolescents

Assure confidentiality Make no assumptions Remain non-judgemental Pose open-ended questions

Young adult

Intimacy vs Isolation

The ability to relate well with other people, not only with members of the opposite sex but also with ones own sex to form long-lasting friendships Characterized by the ability to think abstractly, conceptualize verbally, and express ones feelings and thoughts about various aspects of life

Young adulthood

Implementation of therapeutic nursing interventions

Promotion of positive hospital stay

Minimize hospital stay Provide continuity Decrease separation anxiety

Safety promotion and poison prevention Use of immobilization

Restraints Obtaining specimens

Relieving pain

Interventions contd

Promoting adequate sleep Promoting appropriate play Communication with families Diet

Fluid and caloric needs Formula and other preparations

Surgery Preparation for home care

Medication administration

What differentiates pediatric from adult? Ophthalmic administration Otic administration IM and Subcutaneous Medication administration

5 rights Oral, IV, IM, SC

Medication Administration

Absorption

Transfer of drug from its point of entry into the bloodstream

Movement through the bloodstream Conversion into active form Elimination of raw drug

Distribution

Metabolism

Excretion

Medications contd

Intranasal

On back
Inner to outer canthus

Ophthalmic

Otic

Younger than 3 yrs (pinna down and back) Older than 3 yrs (pinna up and back)
Sphincter muscle Likely to remove

Rectal

Transdermal

Medications contd

Intramuscular/Subcutaneus

Infants- vastus lateralis Older children deltoid or ventrogluteal

Honesty about pain involved

Emla cream can be used

Aspirate when indicated Message when indicated Quickness

Good technique

Childrens response to illness

Fear of unknown Separation anxiety

Stages

Fear of pain and mutilation Loss of control Anger/ Guilt Regression

Protest Despair Denial

Parents response

Financial Siblings Work schedules Past experiences

Childs response to Hospitalization

Age and cognitive development Parental responses to illness or hospitalization

Preparation of the child and family Coping skills of the child and family

Psychological benefits of hospitalization

Nursing diagnosis

Health seeking behaviors Knowledge deficit Fear Altered family process Risk for altered nutrition Pain Safety

Anxiety/fear

Anxiety/fear related to separation from routine Goal: patient will experience minimized separation Intervention: what would you include

Risk for injury

Risk for injury from medication related to sensitivity, excessive dose, decreased GI motility Goal: patient will not develop constipation and will receive treatments for other opioid-related side effects Interventions: What would you include?

Risk for injury/trauma

Risk for injury/trauma related to unfamiliar environment, therapies, hazardous equipment Goal: patient will experience no injury Interventions: What would you include?

Family: anxiety/fear

Anxiety/fear related to situational crisis, threat to role functioning, changes in environment Goal: family will be prepared for special procedures (e.g. radiology, diagnostic tests, surgery) Intervention: What would you include?