PEDIATRIC NURSING

ADDITIONAL FACTS

PREPARED BY: LIZA CLAIRE S. TORRNEO, BSN. RN.

Stages of Development
Infancy is the period from birth until age 1. The toddler stage is the period from ages 1 to 3. The preschool stage lasts from 3 to 6. School-age refers to children ages 6 to 12. Adolescence is the period from age 12 to 19.

Psychosocial Development
A developmental framework for the entire life span was first proposed by Erik Erikson in 1959. Eriksons psychosocial theory has been further refined but essentially remains the same today. Erikson believed that the psychosocial development of the individual is a function of the ego as well as social and biologic processes. In order for the person to grow, he must resolve these crises and master the task at hand.

Stages of Psychosocial Theory

Trust Vs. Mistrust (birth - age 1). Autonomy Vs. Shame & Doubt (ages 1-3) 1Initiative Vs. Guilt (ages 3-6) 3Industry Vs. Inferiority (ages 6-12) 6Identity Vs. Role Confusion (ages 12-19) 12IN ORDER FOR THE PERSON TO GROW, HE MUST RESOLVE THE CRISIS AND MASTER THE TASK AT HAND.

Cognitive Development
According to Jean Piaget cognitive or Piaget, intellectual acts occur when the individual is adapting to and organizing the perceived environment around him. Piaget thought the child moves through four stages of cognitive development.
MOVING FROM RELATIVELY SIMPLE TO VERY COMPLEX OPERATIONS.

Cognitive Development
Sensorimotor stage (birth age 2)
Object permanence Casuality Spatial relationship

Preoperational stage (age 2 7)

Representational language and symbols Transductive reasoning

Concrete Operational stage (ages 7-11) Formal Operational Thought stage (ages 11-15)
IT IS THROUGH EXPERIENCE WITH THE ENVIRONMENT THAT DEVELOPMENT IS PUSHED AHEAD.

Psychosexual Development!
Development of human sexuality is influenced by physical, emotional, and cultural aspects in the society in which we live. This sexuality is part of the total person, which develops overtime. Its expressed through many avenues, including a persons attitudes, feelings, beliefs, and self-image.
SIGMUND FREUD THEORIZED THAT SEXUAL FEELINGS ARE PRESENT IN SOME FORM FROM THE NEWBORN PERIOD THROUGH ADULTHOOD. HE FELT THAT HUMAN NATURE HAS TWO SIDES: RATIONAL INTELLECT AND IRRATIONAL DESIRES.

Psychosexual Development
Oral Stage ( birth age 1 ) Anal Stage ( ages 1 3 ) Phallic Stage ( ages 3 6 ) Latency Period ( ages 6 12 ) Genitalia Stage ( ages 12 and older )
SATISFACTION MUST BE ACHIEVED BEFORE

A PERSON CAN MOVE ON TO THE NEXT STAGE. IF HE ISNT FULLY SATISFIED, ITS POSSIBLE HE MAY NEVER FULLY COMPLETE THE STAGE.

Moral Development
LAWRENCE KOHLBERGS ideas of moral reasoning (the basis of ethical behavior) are based on the work of Piaget and the American philosopher John Dewey. As the childs intelligence and ability to interact with others mature, his patterns of moral behavior mature as well.
MORAL DEVELOPMENT OCCURS THROUGH

SOCIAL INTERACTION AND COULD BE PROMOTED THROUGH FORMAL EDUCATION.

Moral Development
Preconventional level of morality (ages 2 to 7) Conventional level of morality (ages 7 to 12 ) Postconventional autonomous level of morality (ages 12 and older)
KOHLBERG PROPOSED THREE LEVELS OF MORAL DEVELOPMENT THROUGH WHICH THE PERSON MUST PASS. AS THE CHILD COMPREHENDS AND UNDERSTANDS A STAGE, HE CAN THEN PROGRESS TO THE NEXT STAGE.

Caring for the Hospitalized Child

Hospitalization is a major stressor for any individual, but especially for a child. Separation of the child from his parents, siblings, and usual support systems further adds to the emotional stress. Added to these stressors are fear, pain, and discomfort associated with the childs illness or injury, as well as the diagnostic and therapeutic interventions.
PARENTS SHOULD BE ALLOWED TO SPEND AS MUCH TIME AS POSSIBLE WITH THE HOSPITALIZED CHILD.

The Importance of Play

Play is an excellent stress reducer and tension reliever. It allows the child freedom of expression to act out his fears, concerns, and anxieties. Play provides a source of diversional activity, alleviating separation anxiety. Play provides the child with a sense of safety and security, because while playing, he knows that no painful procedures will occur. Developmentally appropriate play foster the childs normal growth and development. Play allows the child to make choices and gives him a sense of control.
PLAY IS THE MOST IMPORTANT ASPECT

OF THE CHILD. IT BECOME EVEN MORE IMPORTANT TO A HOSPITALIZED CHILD.

Assessing PAIN!
To help you stay focused when assessing pain the young patient, remember, QUEST.  Q question the childs parents and the child too, if hes old enough to respond.  U - use appropriate pain assessment tools.  E evaluate the childs behavior.  S secure the parents active participation in treatment.  T take the cause of the pain into consideration.
THE CHILDS VITAL SIGNS CAN BE PAIN INDICATORS. ELEVATED PULSE, BLOOD PRESSURE, OR RESPIRATIONS CAN BE SIGNS OF PAIN AND STRESS.

PAINFUL MEASURES
CRIES Neonatal Postoperative Pain Measurement Scale CRIES Inventory is one of the easier tools to use. Five separate factors are scored on a scale of 0 to 2. Infants with a score of zero would be pain-free. A total score of 10 would indicate extreme pain. Premature Infant C crying Neonatal Infant Pain Profile Pain Scale R requires Oxygen  Gestational Age saturation Facial Expression  Heart rate I increase Heart Crying rate and Blood pressure E Expression S - Sleeplessness Breathing patterns State of arousal Movements of arms and legs  Oxygen saturation  Behavioral state  Brow bulge  Eye squeeze  Nasolabial furrow

Pain measures .for a child capable of speaking!

FACES pain-measuring scale
For the child ages 3 and older can use faces scale to rate his pain.

Visual analog scale

Is simply a straight line with phrase No pain and at one end The most pain possible

Chip pain-measuring tool

Uses four identical chips to signify levels of pain and can be used for a child who understands the concept of adding
1. This chip is just a little bit of hurt. 2. This next chip is a little more hurt. 3. This next chip is a lot of hurt. 4. This last chip is the most hurt you can have.

MANAGING PAIN
Pharmacologic Intervention Morphine (MS Contin) and 1. Opioid analgesics fentanyl (Duragesic), PCAs! 2. Non-opioid analgesics NSAIDs, acetaminophens 3. Adjuvant therapies Antianxiety meds, anticonvulsants, Corticosteroids, etc. Non-pharmacologic Intervention Positioning, 1. Cognitive-behavioral therapies distraction, touching, gentle massage 2. Physical Therapy Thermotherapy 3. Complementary Therapy Music and Aroma therapy
PAIN MANAGEMENT IS MOST EFFECTIVE WHEN IT PREVENTS, LIMITS, OR AVOIDS NOXIOUS STIMULI AND INVOLVES ADMINISTERING ANALGESICS.

Sequence of Tooth Eruption

Teeth Central Incisor Lateral Incisor Cuspid First molar Second molar Lower/Mandibular Upper/Maxillary 6-10 months 10-16 months 17-23 months 14-18 months 23-31 months 8-12 months 9-13 months 16-22 months 13-19 months 25-33 months Purpose Shear, cut Shear, cut Tear Grind, chew Grind, chew

MOST NEONATES DONT HAVE TEETH. OCCASIONALLY, A NATAL TOOTH WILL BE PRESENT AT BIRTH. THIS TOOTH REQUIRES NO INTERVENTION UNLESS ITS LOOSE AND POSES A RISK OF ASPIRATION.
THE AVERAGE AGE AT FIRST TOOTH ERUPTION IS 8 MONTHS.

Common Manifestations in an infant who is teething:

Note:
 DROOLING

 EAR PULLING  COUGHING DUE TO EXCESSIVE SALIVA  CHIN OR FACILA RASHES  WAKEFULNESS  CHEEK RUBBING  LOSS OF APPETITE  DIFFICULTY BREAST FEEDING

Although some infants exhibit vomiting, diarrhea, and fever while teething, nurses must not ascribe these symptoms right away to teething. Further assessment must be performed to make sure that these signs and symptoms are not cause by more serious conditions such as infection.

Sleep Requirements in Infancy

AGE 1 week 1 month 3 months 6 months 9 months 12 months Hours of Sleep / Day 16 15 15 14 14 13

THIS CHART SHOWS THE AMOUNT OF SLEEP PER 24 HOURS ( including nighttime and naps ) NEEDED BY INFANTS AGES 1 WEEK TO 12 MONTHS

CHOKING HAZARDS
These foods can easily cause choking and should be avoided during infancy: hotdogs hard candy nuts ice cubes popcorn

grapes uncooked vegetable chunks lumps of peanut butter

APGAR SCORING
Criteria
Appearance Pulse Grimace Activity Respirations

Indicator
Color Heart Rate Reflex Irritability Muscle Tone Respiratory Effort

0
Pale or Blue Absent No Response Limp Absent

1
Acrocyanosis Less than 100 Grimace Some Flexion Slow and Regular

2
Totally Pink More than 100 Vigorous cry Active Movement Good Cry

EACH ITEM IS GIVEN A SCORE OF 0, 1, 2. Total scores of 0 -3 represent severe distress; Scores of 4 6 signify moderate difficulty; and scores of 7 10 indicate absence of difficulty in adjusting to extrauterine life.

Denver Developmental Screening Test

The most widely used developmental screening test for young children that have been developed by Dr. William Frankenburg and his colleagues in Denver, Colorado. Interpretation of scores scores:
Advanced, OK, Caution, Delay

Interpretation of test: test

Normal, Suspect, Untestable

Newborn Reflexes - Eyes

Blinking or Corneal Reflex
Infant blinks at sudden appearance of a bright light or at approach of an object toward cornea; persists throughout life.

Pupillary reflex
Pupil constricts when a bright light shines toward it; persists throughout life.

Dolls eye reflex

As head is moved slowly to right or left, eyes lag behind and do not immediately adjust to new position of head; disappears as fixation develops; if persists, indicate neurologic damage.

Newborn Reflexes - Nose

Sneeze
Spontaneous response of nasal passages to irritation or obstruction; persist throughout life.

Glabellar
Tapping briskly on glabella (bridge of the nose) causes eyes to close tightly.

Newborn Reflexes Mouth & Throat

Sucking
Infant begins strong sucking movements of circumoral area in response to stimulation; persists throughout infancy; even without stimulation, such as during sleep.

Gag
Stimulation of posterior pharynx by food, suction, or passage of a tube causes infant to gag; persist throughout life.

Rooting
Touching or stroking the cheek along side of mouth causes infant to turn head toward that side and begin to suck; should disappear at about 3-4 months, but may persist up to 12 months.

Newborn Reflexes Mouth & Throat

Extrusion
When tongue is touched or depressed, infant responds by forcing it outward; disappears by age 4 months.

Yawn
Spontaneous response to decreased oxygen by increasing amount of inspired air; persists throughout life.

Cough
Irritation of mucous membranes of larynx or tracheobronchial tree cause coughing; persist throughout life; usually present after first day of birth.

Newborn reflexes - Extremities

Grasp
Touching palms of hands or soles of feet near base of digits causes flexion of hands and toes. Palmar grasp lessens after age 3 months; to be replaced by voluntary movement; plantar grasp lessens by 8 months of age.

Babinski
Stroking outer sole of foot upward from heel and across ball of foot causes toes to hyperextend and hallux to dorsiflex; disappears after age 1 year.

Ankle clonus
Briskly dorsiflexing foot while supporting knee in partially flexed position results in one to two oscillating movements; eventually no beats should be felt.

Newborn Reflexes - Mass

Moro
Sudden jarring or change in equilibrium cause sudden extension and abduction of extremities and fanning of fingers, with index finger and thumb forming a C shape, followed by flexion and adduction of extremities; legs may weakly flex; infant may cry; disappears after age 3-4 months; usually strongest during first 2 months.

Crawl
When placed on abdomen, infant makes crawling movements with arms and legs; disappears at about age 6 weeks.

Trunk incurvation (Galant) reflex

Stroking the infants back alongside spine causes hips to move toward stimulated side; disappears by age 4 weeks.

Newborn Reflexes - Mass

Startle
A sudden loud noise causes abduction of the arms with flexion of elbows; hands remain clenched; disappears by age 4 months.

Asymmetric tonic neck

When infants head is turned to side, arm and leg extend to that side, and opposite arm and leg flex; disappears by age 3-4 months, to be replaced by symmetric positioning of both sides of body.

Placing
When infant is held upright under arms and dorsal side of foot is briskly placed against hard object, such as table, leg lifts as if foot is stepping on table; age of disappearance varies.

Newborn Reflexes - Mass

Perez
While infant is prone on a firm surface, thumb is pressed along spine from sacrum to neck; infant responds by crying, flexing extremities, and elevating pelvis and head; lordosis of the spine, as well as defecation and urination, may occur; disappears by age 4-6 months.

Dance or Step
If infant is held so that sole of foot touches a hard surface, there is a reciprocal flexion and extension of the leg, stimulating walking; disappears after age 3-4 weeks, to be replaced by deliberate movement.

 I ron supplement (4 to 6 months), immunization N o choking hazard F ear of stranger peaks at 8 months A llow to use a pacifier if NPO N ote the weight changes T rust V.S. mistrust S olitary play

 T alk to the child at simple terms O ffer choices to the child to provide some control D ont leave alone near the bathtub or swimming pool D oubt and Shame Vs. Autonomy L earns about death @ age 3 E limination pattern R rituals and routines

 P ush-pull toys ush(mobile), parallel play (forget sharing) R rituals and routines (eyes & consistency), regression A utnomy VS shame and doubt, accidents (death) I nvolve parents S eparation anxiety E limination and explore

 P lay is associative/cooperative R gression is common E xplain procedures S ame age group for room assignment C - urious H ighly imaginative O bserve for Initiative Vs. Guilt O ff limits to the kitchen (risk for poisoning and burn) L oss of body part is a common fear

S ame sex stage C ompetitive play H eroworship O bserve for Industry Vs. Inferiority O ff limits to vehicles L oss of control is a common fear E xplain procedures R egression is common

 D eath (bogeyman), honesty funerals and burials I ndustry VS inferiority (collections) M odesty (privacy) P eers (own sex) L oss of control hospitalization, encourage decision making E - xplanation of procedures

 P eer group activities, peer pressure A ltered body image dont want to be seen different I dentity image college or career R ole diffusion S eparation from peers