Study Guide Pediatrics Exam #1

STAGES:Infant: Birth to 12 monthsToddler: 1 to 3 yearsPre-School: 3 to 5 yearsSchool Age: 5 to 12 yearsAdolescence: 13 to 19 years

General Pediatric Concepts Use of Caring: Knowing, Alternating Rhythms(when to

interact full-force and when to back off), Patience, Honesty, Trust, Humility, Hope and Courage

Atraumatic Care – Concept of “Do No Harm” prevent psychological and physical distress

Demonstrated by:o Prevent Separation from parento Promote Control (in children as young as 3)o Minimize or prevent hurt or paino Preparation o Privacyo Allow playtime for expression of fear and aggressiono Respect Cultural differences

General Pediatric Concepts: 4-5 questions Use of caring; Atraumatic care: What is it and how is it demonstrated by nurses in practice;

Family-centered care: Promotion of it; Informed consent in pediatrics; Importance of CulturalCare in pediatrics

Atraumatic care: Most of what is done to children to cure illness and prolong life is traumatic,

painful, upsetting, and frightening. Health professionals must direct their attention to providing atraumatic care 3 principles provide the framework for atraumatic care:

(1) Prevent or minimize the child’s separation from the family(2) Promote a sense of control(3) Prevent or minimize bodily injury and pain

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Atraumatic care: physical and psychological comfort? Atraumatic care is concerned with any procedure performed on a child for the

purpose of eliminating psychologic and physical stressors Psychological distress includes: anxiety, fear, anger, disappointment, sadness,

shame, or guilt Physical distress ranges from sleeplessness and immobilization to disturbing

sensory stimuli such as pain, temperature extremes, loud noises, bright lights, or darkness

Ways a nurse can provide atraumatic care: Fostering the parent- child relationship during hospitalization Preparing the child before any unfamiliar treatment or procedure Controlling pain Allowing privacy Providing play activities for expression of fear and aggressions Providing choices if available Respecting cultures

Care of Child in hospital: Preparing child for invasive procedures:

o What is best re: atraumatic care? Trying to do no harm; prevent and minimize seperation from parent; promote a sense of control for the child as young as 3 years old; prevent and minimize physical or psychological pain; allow child and parent to be together as much as possible; allow child to make decision and choices; prepare child before any unknown treatment or procedure; allow child privacy; allow child to play

What is the safest way to administer different types of medications to children depending on age and developemental level)?

o when administering liquids especially to infants, administer in a way to prevent aspiration (slowly, allowing the child to swallow)-do not add the medication to the formula;

o when administering an IM shot, make sure that the needle is the approprite length for the childs size and weight, know the medication that’s being given, the childs ability to assume the required position safely, the amount and character of the drug.

o when administering eye meds-have child lay supine or sitting, head extended, and looking up; pull down lower lid and place eye drop in conjunctiva

o when administering ear drops-for children 3 years and younger pull the pinna down and back; in children older than 3 pull the pinna up and back.

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Meeting the needs of children in pain: pharmacological vs. nonpharmacological approaches:

o Nonpharmacologic- prepare child for procedures; educate patient to procedure; build trust with child and parent, distraction techniques, relaxation, guided imagery, positive self talk, thought stopping. *Nonpharmacological measures can supplement but not prevent pharmacologic measures.

o Pharmacologic- administer analgesics;

Family-centered care- incorporating into policy that the family is the constant in the child’s life while the service system and support systems within those systems fluctuate. Enabling and Empowerment

Key elements:o Facilitate family-professional collaboration at all levels of hospital,

home and community care (individual child, program development and policy formation)

o Exchange complete and unbiased informationo Honor cultural diversity (ethnic, racial, spiritual, social, economic,

educational, environmental and financial)o Recognize and respect different methods of copingo Encourage and facilitate family to family networking and supporto Ensure that home, hospital and community service support systems

are flexible, accessible and comprehensive for diverse family needs

o Appreciate families as families and children as children beyond the needs of the health services

Family-centered care: Two basic concepts in family-centered care are enabling and empowerment Enable by creating opportunities for all family members to display abilities

and to acquire new ones to meet the needs of the child Empowerment is the interaction between professionals and families so

families maintain a sense of control. Make the family feel confident in the care of their child Partnerships imply the belief that partners are capable individuals who

become more capable by sharing knowledge, skills, and resources in a manner that benefits all participants. Collaboration is viewed as a continuum.

The nurse can help every family by identifying their strengths, building on them, and assuming a comfortable level of participation

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Professionals ENABLE by creating opportunities for all family members to display abilities and to acquire new ones to help best meet the needs of the child

EMPOWERMENT is the interaction b/w professionals and families so that families maintain a sense of control over their own lives

The nurse can help families to identify their strengths and build upon them Health care must be based within the family system so that health beliefs and

behaviors can focus on health promotion and illness prevention

Informed Consent in Pediatrics: The process by which patients or their surrogates receive the information Information should include: expected care or treatment, potential risks,

benefits, and alternatives, and what might happen if the patient chooses not to consent

Patient has the right to accept or refuse any health care. As long as children are minors (<18 yrs.), their parent or legal guardian are

required to give informed consent before any treatment or procedures The state may intervene if the parents refuse to give consent If a female minor is pregnant, she is emancipated and can give her own

consent If parent/guardian is not present in an emergency. Consent of 2 licensed

professionals can be used, but informed consent of the family must be acquired asap

Informed Consent in Pediatricso Parents have full legal control and responsibility of minors.

Informed consent must be given by parents before any medical treatment or procedure.

o Married Parents – only permission of one parent is requiredo Divorced Parents – permission must be obtained from custodial

parento Physician’s responsibility to explain procedure, risks, benefits and

alternativeso The nurse witnesses the parents signature and may reinforce what

the patient has been toldo Exceptions are when the parents are not available and the child

needs urgent medical attentiono The state may intervene if the parents refuse to give consento Verbal consent by phone may be obtained but must have 2

witnesseso Children 7 and older should be part of decision makingo Emancipated (married, pregnant, high school graduate, or military)

may sign own consent

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o Children 14-18 have some rights? o In Tennessee, foster children 14 and older can make own medical

decisionso In Tennessee, children 16 and up have the right to confidentiality

and psychiatric careo Confidential treatment can be obtained for STD’s, alcohol and

drugs treatment, and contraceptive advice in all stateso In life threatening cases, treatment may be given without parental

consent if parents cannot be reached. Document efforts to reach parents.

o State can override parental rights in cases of life and death or risk to health.

o Some states give parents unrestricted rights to copy of their minor child’s medical records

Importance of Cultural Care in PediatricsA child’s self-concept evolves from ideas about his or her social roleA child’s self-esteem is influenced by his or her own cultureNurses have responsibility to understand the influence of culture, race and ethnicity on the development of social and emotional relationships, childrearing practices and attitudes toward health.A child’s physical characteristics and susceptibility to health problems are related to ethnic and cultural variations of heredity and socioeconomic forces. Culture plays a critical role in the socialization of children Culture is the context of the child’s experience of health and illness, wellness and sicknessA holistic view of any child requires that the nurse understand the ways that culture contributes to the development of social and emotional relationships and influences practices towards healthCulture fosters and reinforces those behaviors deemed desirable and appropriateSome cultures encourage aggressive behaviors in children

-Guidelines for culturally sensitive interactions:o Allow family members to choose where they sit or stand

(boundaries)o Observe interactions to determine acceptable body gestureso Avoid appearing rushedo Be an active listenero Observe for cues regarding eye contacto Learn appropriate use of pauses and interruptionso Ask for clarification if nonverbal meaning is unclearo Learn if smiling is friendliness or taboo

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o Learn appropriate terms of addresso Use positive tone of voiceo Speak slowly and clearly not loudlyo Encourage questionso Learn basic words and sentences in family’s language if possibleo Avoid professional termso When asking questions, explain how the information will be used

and to what benefito Repeat important information more than onceo Arrange for interpreter when necessaryo Use information written in the family’s languageo Address intergenerational needso Be honest and open

Child Health Assessment Communication Techniques

o Allow children time to feel comfortable – stranger anxiety- talk to Mom first. Don’t rush into touching them

o Avoid sudden, rapid advances, broad smiles, extended eye contact, or other gestures that may be seen as threatening ( pointing, loud or boisterous) Talk to parent if child is initially shy – win over parent then

win over childo Communicate through transition objects such as dolls, puppets, or

stuffed animals before questioning a young child directlyo Give older children time to talk without their parent presento Assume a position that is eye level with the childo Speak in a quiet, unhurried, confident voice.o Speak clearly, be specific, use simple words and short

sentences(Don’t give large amounts of instructions)o State directions and suggestions positively (will help you feel

better)o Offer choices only when they existo Be HONEST!o Allow them to express their concerns and fearso Use a variety of communication techniques: drawing, three wishes,

play, storytelling, dreamso Infants and nonverbal children use nonverbal behaviors (and

verbalizations in infants) to express their feelingso Creative verbal techniques: I messages (avoid use of you), 3rd

person technique, facilitative responding, storytelling, mutual storytelling, bibliotherapy, dreams, what if questions, 3 wishes,

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rating game, word association game, sentence completion, pros and cons.

o Creative nonverbal techniques: writing, drawing, magic, and play

o Infant Primarily use non verbal communication

Smile and coo when content Cry when distressed Crying is provoked by unpleasant stimuli from inside or

outside Loud, harsh sounds are frightening Hold infants so they can see their parents Respond to adult’s nonverbal behavior; become quiet when

cuddled or patted Until age of stranger anxiety, respond to any firm, gentle

handling and quiet, calm speech Older infants perceive everything as threat until proven

otherwise. Pick them up firmly, without gestures. More comfortable upright and so they can see parent.

o Toddler and preschooler (early childhood) Remember that they take everything literally Do not smile while doing something painful Keep unfamiliar items out of view until needed Children 5 yrs or younger are egocentric Focus the communication on THEM. Children 5 yrs or

younger are egocentric Allow them to touch and examine objects that will come in

contact with them Everything is direct and concrete to small children so watch out

for statements that they make take literally ( ex., “a little stick in the arm”, “coughing your head off”)

Use short simple directions/sentences and words that are familiar

Keep unfamiliar equipment out of view until it is needed

o School age years Want explanations and reasons for everything

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Want to know functional aspect of all procedures, objects and activities and how it applies to them—need to know what & why

Have a heightened concern of body integrity/body image Rely more on what they know than what they see They need to know what and why something is going to be

done to them If you make them feel more comfortable, they will interject

more personal ideas, feelings, and interpretations of events

o Adolescents No single approach works all the time Don’t attempt to impose values on them Give support, be attentive, try not to interrupt, and avoid

comment or expressions that convey disapproval or surprise. Avoid prying or asking embarrassing questions and resist any

impulse to give advice Build a foundation by spending time with them Encourage expression of ideas and feelings Respect their views Tolerate differences Praise good points Respect their privacy Set a good example Be courteous and open minded Avoid criticizing or judgment Avoid the “ third degree” More concerned about body image than pain.

More communication techniqueso “I” messageso Facilitative response

Listen carefully and reflect back to the patients feelingso Story tellingo Mutual story telling

Have the child tell a story about something and then tell another story similar to the child’s but with differences to help them with problem areas

o Bibliotherapy Use books in a supportive process

o Dreams Ask a child to talk about a dream or a nightmare

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o Word associationo Sentence Completion

Present a partial statement and have the child complete it (ex., the thing I like best about myself is _____)

o Writingo Drawingo Magic Trickso Play

PLAY DURING HOSPITALIZATION: Functions of Play in the Hospital:a. Facilitates mastery over an unfamiliar situationb. Provides opportunity for decision making and controlc. Helps to lessen stress of separationd. Provides opportunity to learn about parts of body, their functions, and own disease/disabilitye. Corrects misconceptions about the use and purpose of medical equipment and proceduresf. Provides diversion and brings about relaxationg. Helps the child feel more secure in a strange environmenth. Provides a means to release tension and express feelingsi. Encourages interaction and development of positive attitudes toward othersj. Provides an expressive outlet for creative ideas and interestsk. Provides a means for accomplishing therapeutic goals

Play Activities for Specific Procedures:Fluid Intake:a. Make freezer pops using child's favorite juice.b. Cut gelatin into fun shapes.c. Make game of taking sip when turning page of book or during games such as "Simon says."d. Use small medicine cups; decorate the cups.e. Color water with food coloring or powdered drink mix.f. Have a tea party; pour at small table.g. Let child fill a syringe and squirt it into mouth or use it to fill small, decorated cups.h. Cut straws in half, and place in small container (much easier for child to suck liquid).i. Decorate straw; cut out small design with two holes, and pass straw through; place small sticker on straw.j. Use a "crazy" straw.k. Make a progress poster; give rewards for drinking a predetermined quantity.

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Deep Breathing:a. Blow bubbles with bubble blower.b. Blow bubbles with straw (no soap).c. Blow on pinwheel, feathers, whistle, harmonica, balloons, toy horns, or party noise makers.d. Practice on band instruments.e. Have blowing contest using balloons, boats, cotton balls, feathers, marbles, Ping-Pong balls, pieces of paper; blow such objects over a table top goal line, over water, through an obstacle course, up in the air, against an opponent, or up and down a string.f. Move paper or cloth from one container to another using suction from a straw.g. Use blow bottles with colored water to transfer water from one side to the other.h. Dramatize scenes, such as "I'll huff and puff and blow your house down" from the "Three Little Pigs."i. Do straw-blowing painting.j. Take a deep breath and "blow out the candles" on a birthday cake.k. Use a little paint brush to paint nails with water, then blow nails dry.

Range of Motion and Use of Extremities:a. Throw beanbags at fixed or movable target; toss wadded paper into a wastebasket.b. Touch or kick Mylar balloons held or hung in different positions (if child is in traction, hang balloon from trapeze).c. Play tickle toes; have child wiggle them on request.d. Play games such as Twister or "Simon says."e. Play pretend and guess games (e.g., imitate a bird, butterfly, horse).f. Have tricycle or wheelchair races in safe area.g. Play kick or throw ball with soft foam ball in safe area.h. Position bed so that child must turn to view television or doorway.i. Have child climb wall with fingers like a spider.j. Pretend to teach aerobic dancing or exercise; encourage parents to participate.k. Encourage swimming if feasible.l. Play video games or pinball (fine motor movement).m.Play hide and seek game; hide toy somewhere in bed (or room, if ambulatory), and have child find it using specified hand or foot.n. Provide clay to mold with fingers.o. Have child paint or draw on large sheets of paper placed on floor or wall.p. Encourage combing own hair; play beauty shop with "customer" in different positions.

Soaks:a. Play with small toys or objects (cups, syringes, soap dishes) in water.b. Wash dolls or toys.c. Bubbles may be added to bath water if permissible; more bubbles to create shapes or "monsters."d. Pick up marbles or pennies* from bottom of bath container.e. Make designs with coins on bottom of container.f. Pretend a boat is a submarine by keeping it immersed.g. During soaks, read to child, sing with child, or play game such as cards, checkers, or

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other board game (if both hands are immersed, move the board pieces for the child).

Sitz bath: a. Give child something to listen to (music, stories) or look at (Viewmaster, book).b. Punch holes in bottom of plastic cup, fill with water, and let it rain on child.c. Small objects such as marbles or coins, as well as gloves or balloons, are unsafe for young children because of possible aspiration. Latex products also present the risk of an allergic reaction.

Injections:a. Let child handle syringe (without needle), vial, and alcohol swab and pretend to give an injection to doll or stuffed animal.b. Use syringes to decorate cookies with frosting, squirt paint, or target shoot into a container.

c. Draw a "magic circle" on area before injection; draw smiling face in circle after injection, but avoid drawing on puncture site.d. Allow child to have a collection of syringes (without needles); make wild creative objects with syringes.e. If child is receiving multiple injections or venipunctures, make a progress poster; give rewards for predetermined number of injections.f. Have child count to 10 or 15 during injection or "blow the hurt away."

Ambulation:a. Give child something to push: b. Toddler, push-pull toyc. School-age child, wagon or decorated intravenous (IV) standd. Adolescent, a doll in a stroller or wheelchaire. Have a parade; make hats, drum, and so on.f. Extending Environment (Patients in Traction, etc.):g. Make bed into a pirate ship or airplane with decorations.h. Put up mirrors so patient can see around room.i. Move patient's bed frequently, especially to playroom, hallway, or outside.

How should nurses implement communication techniques appropriately for different age children? Infancy: 1. Because they are unable to use words, infants primarily use and understand nonverbal

communication. Infants communicate their needs and feelings through nonverbal behaviors and vocalizations that can be interpreted by someone who is around them for a sufficient time. Infants smile and coo when content and cry when distressed. Crying is provoked by unpleasant stimuli from inside or outside, such as hunger, pain, body restraint, or loneliness. Adults interpret this to mean that an infant needs something and consequently try to alleviate the discomfort and reduce tension. Crying (or the desire to cry) persists as a part of everyone's communication repertoire.

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2. Infants respond to adults' nonverbal behaviors. They become quiet when they are cuddled, are patted, or receive other forms of gentle physical contact. They derive comfort from the sound of a voice, even though they do not understand the words that are spoken. Until infants reach the age at which they experience stranger anxiety, they readily respond to any firm, gentle handling and quiet, calm speech. Loud, harsh sounds and sudden movements are frightening.

3. Older infants' attention is centered on themselves and their parents; therefore any stranger is a potential threat until proved otherwise. Holding out the hands and asking the child to “come” is seldom successful, especially if the infant is with the parent. If infants must be handled, simply pick them up firmly without gestures. Observe the position in which the parent holds the infant. Most infants learn to prefer a particular position and manner of handling. In general, infants are more at ease upright than horizontal. Also, hold infants so they can see their parents. Until they develop the understanding that an object (in this case the parent) removed from sight can still be present, they have no way of knowing the object is still there.

Early Childhood.1. Children younger than 5 years of age are egocentric. They see things only in relation

to themselves and from their point of view. Therefore, focus communication on them. Tell them what they can do or how they will feel. Experiences of others are of no interest to them. It is futile to use another child's experience in an attempt to gain the cooperation of small children. Allow them to touch and examine articles that will come in contact with them. A stethoscope bell will feel cold; palpating a neck might tickle. Although they have not yet acquired sufficient language skills to express their feelings and wants, toddlers are able to communicate effectively with their hands to transmit ideas without words. They push an unwanted object away, pull another person to show them something, point, and cover the mouth that is saying something they do not wish to hear.

2. Everything is direct and concrete to small children. They are unable to work with abstractions and interpret words literally. Analogies escape them because they are unable to separate fact from fantasy. For example, they attach literal meaning to such common phrases as “two-faced,” “sticky fingers,” or “coughing your head off.” Children who are told they will get “a little stick in the arm” may not be able to envision an injection (Fig. 6-3). Therefore, avoid using a phrase that might be misinterpreted by a small child (see Family Home Care box under Preparation for Procedures, Chapter 27).

3. Use language that is consistent with the child's developmental level. For example, in talking with a toddler, use simple, short sentences; repeat words that are familiar to the child; and limit descriptions to concrete explanations. Be certain that nonverbal messages are consistent with words and actions. For example, do not smile while doing something painful; children may think you enjoy hurting them.

4. Young children assign human attributes to inanimate objects. Consequently they fear that objects may jump, bite, cut, or pinch all by themselves. Children do not know that these devices are unable to perform without human direction. To minimize their fear, keep unfamiliar equipment out of view until it is needed.

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School-Age Years.1. Younger school-age children rely less on what they see and more on what they know

when faced with new problems. They want explanations and reasons for everything but require no verification beyond that. They are interested in the functional aspect of all procedures, objects, and activities. They want to know why an object exists, why it is used, how it works, and the intent and purpose of its user. They need to know what is going to take place and why it is being done to them specifically. For example, to explain a procedure such as taking a blood pressure, show the child how squeezing the bulb pushes air into the cuff and makes the “silver” in the tube go up. Let the child operate the bulb. An explanation for the reason might be as simple as, “I want to see how far the silver goes up when the cuff squeezes your arm.” Consequently, the child becomes an enthusiastic participant.

2. School-age children have a heightened concern about body integrity. Because of the special importance and value they place on their body, they are sensitive to anything that constitutes a threat or suggestion of injury to it. This concern extends to their possessions, so that they may appear to overreact to loss or threatened loss of treasured objects. Helping children voice their concerns enables the nurse to provide reassurance and to implement activities that reduce their anxiety. For example, if a shy child dislikes being the center of attention, ignore that particular child by talking and relating to other children in the family or group. When children feel more comfortable, they will usually interject personal ideas, feelings, and interpretations of events.

3. Older children have an adequate and satisfactory use of language. They still require relatively simple explanations, but their ability to think concretely can facilitate communication and explanation. Commonly, they have sufficient experience with health and health care workers to understand what is transpiring and what is generally expected of them.

Adolescence.1. As children move into adolescence, they fluctuate between child and adult thinking

and behavior. They are riding a current that is moving them rapidly toward a maturity that may be beyond their coping ability. Therefore, when tensions rise, they may seek the security of the more familiar and comfortable expectations of childhood. Anticipating these shifts in identity allows the nurse to adjust the course of interaction to meet the needs of the moment. No single approach can be relied on consistently, and encountering cooperation, hostility, anger, bravado, and a variety of other behaviors and attitudes can be expected. It is as much a mistake to regard the adolescent as an adult with an adult's wisdom and control as it is to assume that the teenager has the concerns and expectations of a child.

2. Frequently adolescents are more willing to discuss their concerns with an adult outside the family, and they often welcome the opportunity to interact with a nurse outside the presence of their parents. They are accepting of anyone who displays a genuine interest in them. However, adolescents are quick to reject persons who

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attempt to impose their values on them, whose interest is feigned, or who appear to have little respect for who they are and what they think or say.

3. As with all children, adolescents need to express their feelings. Generally, they talk freely when given an opportunity. However, what adolescents say cannot always be taken at face value. When emotional factors are involved, the feelings that are interjected into words are as significant as the words themselves. To give support, be attentive, try not to interrupt, and avoid comments or expressions that convey disapproval or surprise. Avoid prying and asking embarrassing questions, and resist any impulse to give advice. Frequently, adolescents reveal their feelings or a source of concern or ask a question when they are involved in routine matters such as a physical assessment.

4. Teenagers characteristically have a language and culture all their own that further sets them apart. To avoid misinterpretation, clarify terms frequently. Occasionally, adolescents refuse to answer or answer only in monosyllables. Usually this happens when they are opposed to the contact or do not yet feel safe enough to reveal themselves. In this instance confine discussions to neutral topics to reduce the element of threat until they feel more secure. Be alert for signals indicating they are ready to talk. The major sources of concern for adolescents are attitudes and feelings toward sex, substance abuse, relationships with parents, peer-group acceptance, and development of a sense of identity.

5. Interviewing the adolescent presents some special issues. The first may be whether to talk with the adolescent alone or with the adolescent and parents together. Of course, if the parent is not there, the only question is whether to suggest to the teenager that the parents be interviewed at another time. If the parents and teenager are together, talking with the adolescent first has the advantage of immediately identifying with the young person, thus fostering the interpersonal relationship. However, talking with the parents initially may provide insight into the family relationship. In either case, give both parties an opportunity to be included in the interview. If time constraints are important, such as during history taking, clarify these at the onset to avoid appearing to “take sides” by talking more with one person than with the other.

6. Confidentiality is of great importance when interviewing adolescents. Explain to parents and teenagers the limits of confidentiality, specifically that young persons' disclosures will not be shared unless they indicate a need for intervention, as in the case of suicidal behavior.

7. Another dilemma in interviewing adolescents is that two views of a problem frequently exist—the teenager's and the parents'. Clarification of the problem is a major task. However, providing both parties an opportunity to discuss their perceptions in an open and unbiased atmosphere can, by itself, be therapeutic. Demonstrating positive communication skills can help families communicate more effectively.

Exam approach techniques o Approach slowly and do as much as possible in parent’s lapo Provide infant with security itemso Use distraction and facial expression

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o Do non invasive things first

o Infants Child lying flat or in parent’s arms Use distraction with older infant Assess heart, pulse, lungs, respirations while quiet, then head

to toe Eyes, ears and mouth near end Check reflexes as body parts are examined Moro reflex last

o Toddler Sitting or standing by parent; prone or supine in parent’s lap Minimal contact initially Allow to inspect equipment Assess heart, lungs while quiet, then head to toe Eyes, ears and mouth last

o Preschooler Prefer standing or sitting Allow to handle equipment Head to toe if cooperative Same as toddler if uncooperative

o School age Prefer sitting Younger prefer parent closeness; older may desire privacy Respect privacy Explain procedures Head to toe Genitalia last

o Adolescent Explain findings Proceed as for a school age child

Atraumatic Care: Reducing Distress from Otoscopy in Young Children:Make examining the ear a game by explaining that you are looking for a “big elephant” in the ear. This kind of make-believe is an absorbing distraction and usually elicits cooperation. After examining the ear, clarify that “looking for elephants” was only pretend and thank the child for letting you look in his or her ear. Another great distraction technique is asking the child to put a finger on the opposite ear to keep the light from getting out.

ATRAUMATIC CARE: Encouraging Opening the Mouth for Examination1. Perform the examination in front of a mirror.2. Let child first examine someone else's mouth, such as the parent, the nurse, or a

puppet; then examine child's mouth.

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3. Instruct child to tilt the head back slightly, breathe deeply through the mouth, and hold the breath; this action lowers the tongue to the floor of the mouth without using a tongue blade.

Vital Signs Always listen/feel/look for 1 minute to get your baseline:

It is best to measure vital signs while the child is quiet. Make sure to document child behavior during vital signs. Example: “Child was crying during vital signs”.

AGE 10-18: Normal Vital signs are very close to that of the adult Pulse, respirations, and temperature: decreases with age

If child is <2-3 years old, listen for one full minute with the bell for the apical pulse.

o Vital Signs Pulse- must count 1 full minute

Infant 120- 160 Toddler 80-120 Age 10 70-110 Over 17 60-100 For every one degree of temperature elevation add 10 bpm

Respirations Newborn 30-60 (INFANTS: abdominal breathers) One year 20-40 Six years 16-20 (SCHOOL AGE: chest breathers) Over 17 12-20

Blood pressure- start checking at age 2 unless hospitalized (B/P increases with age)

Temperature Normal 98.6 (normal temp for an infant is 99 degrees) Febrile (Temperature) >100.4 Height – checked upon admission / it helps to push the infants

knees down Weight – daily (use baby scales up to 35 lbs.)

You can weigh the Mom and child together and subtract the Mom’s weight.

Nurse has to balance scale before you weigh the child. This is very important because of the fact that Medications are prescribed based on Mg/Kg/Dose.

Head Circumference – check up until 36 months of age Measure around the widest part of the head. Put the

measuring tape above the eyebrows and around the occipital part of the head.

o Examination

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General Appearance Skin

Color Texture Temp Moisture Turgor Birthmarks Bruises, lesions

Head and Neck Fontanels

o Posterior closed by 2 monthso Anterior closes between 9-18 months

Head size (hydrocephalus/microcephaly) Face Eyes

o Red reflexo Papillary light reactiono Earso Noseo Throat o Moutho Teeth

Check for tooth decay Heart

o Murmurso PMI <8 4th ICS, >8 5th ICS

Lungs Abdomen

Color Sounds Tenderness

Genitalia Back and Extremities

o Spine o Legs

Hip clicks Gluteal folds

o Pulses tiny baby- femoral and brachial older- pedal and radial

o ROMo Strengtho Neurological

Orientation

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PERRLA Babinski reflex

Pediatric Health History: how to obtaino Identifying Information

Who the person is Their willingness to communicate Use of interpreters, etc. Name, address, telephone, birthday, race, sex, religion, date,

informanto Chief Complaint

Specific reason for the child’s visit to the clinic, office, or hospital Elicit it by asking open ended questions

o Present Illness 4 major components

1. Details on onset 2. Complete interval history 3. The present status 4. Reason for seeking help now

Assess for pain… type, location, severity, duration, influencing factors

o History Birth history

The mothers health Labor and delivery Infants condition immediately after birth Prenatal attitudes Crises during pregnancy

Previous Illnesses, Injuries, Operations Ask specifically about colds, earaches, childhood diseases

(measles, mumps, rubella, chicken pox, scarlet fever, whooping cough, etc.)

Ask about injuries that required medical attention and operations including the dates

Allergies Ask about food and drug reactions or latex allergies

Current Meds List all meds including… name, dose, schedule, duration,

and reason for administration Immunizations

Know all immunizations the child has received Growth and Development

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Weights at 6 months, 1 yr., 2 yrs., and 5 yrs. Length at 1 and 4 Number of teeth Ages of holding head up, sitting alone, walking alone, first

word Present school grade Grades Interaction with other children

Habits Ask about any habits that may be of concern to the parents A common one is sleep habits

Sexual History A component of adolescents health assessment Discuss advantages of delaying sexual activity Discuss contraceptive options and limiting partners

Family medical History Helps discover potential existence of hereditary or familial

diseases in the parents and children Confined to first degree relatives ( parents, grandparents,

aunts and uncles) Geographic location

o Explore birthplace, and travel to different areas outside the country

Family Structure Assessment of the family is important b/c the quality of the

family relationship is a factor in physical and emotional health

Collect the data about the composition of the family and the relationships among the members

Psychosocial history Concentrates on children’s personal status such as school

adjustment and any unusual habits Obtain an idea of how children handle themselves in terms

of dealing with others

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o Exam Approach and techniques/ Comfort positioning

Position Sequence PreparationINFANTSits in parents lap, or with parent in sight

If quiet, auscultate their heart, lungs, and abdomenRecord HR and RRPalpate and percuss same areas; Proceed in usual head-to-toe direction; Perform traumatic procedures last; Elicit reflexes as body part examines; Elicit moro reflex last

Completely undress if room temp permits; leave diaper on male; Gain cooperation with distraction ( rattles, talking); Have older infants hold an object in their hand; smile and use soft voices; Pacify with bottle of sugar water;

TODDLERSitting or standing on/by parent;Prone or supine in parents lap

Inspect body area through play ( count fingers and tickle toes); use minimal physical contact initially; introduce equipment slowly; auscultate, percuss, palpate whenever quiet; Perform traumatic procedure last

Have parent remove outer clothing; remove under ware as that body part is examined; Allow them to inspect equipment; If uncooperative, perform procedures quickly; Praise for cooperative behavior

PRESCHOOL CHILDPrefer standing or sitting; Usually cooperative prone/ supine; prefer parents

If cooperative, proceed in head to toe direction; if uncooperative, proceed as with toddler

Require self undressing; allow to wear underpants if shy; offer equipment for inspection; briefly

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closeness demonstrate use; Give choices when possible

SCHOOL-AGE CHILDPrefer sittingCooperate in most positionsYounger may prefer parents presence; Older child may prefer privacy

Proceed in head-to-toe direction; May examine genitalia last in older child; Respect need for privacy

Require self- undressing; allow to wear underpants; give gown to wear; explain purpose of equipment and significance of procedure; Teach about body functions and care

Comfort positioningo See table in notes above!

Child Health Historyo Obtain by direct interview if feasible. o Communication techniques:

Encourage parent to talk Direct focus Cultural awareness Silence empathy anticipatory guidance avoid blocks interpreter

o Unique aspects of a child’s health history Use open ended, fact-finding questions Birth history

Mother’s health during pregnancy Labor and delivery Infant’s condition immediately after birth Emotional Factors

Detailed Feeding History Immunizations Growth and development

Use of the pediatric assessment triangleo A quick and easy way to see if intervention is needed immediately

or you can take a breath and do a more thorough assessment

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o Work of Breathing Rate too slow or too fast or absent Use of accessory muscles, retractions, nasal flaring Regular? Quality of breath sounds: wheezes, stridor, diminished

o Appearance A= alert, interacts with environment and parents V= responds to voice P=responds only to painful stimulation (knuckle to sternum) U= Unresponsive

o Skin Color Pink with brisk (<2 second) capillary refill (big toe or nose) Pale Mottled (assess ambient temperature) Cyanotic or blue

Care of Children and Families facing Hospitalization Stressors children face during hospitalization

o Separation- especially in toddlers (6-36 months)Stages:1. Protest -crying and loud tantrums (positive and normal,

indicates healthy relationship)2. Despair -less active and begin to withdraw. May regress. (May

be normal but you must intervene)3. Detachment - suddenly TOTALLY cooperative (example- no

crying during painful procedure). Needs serious help. May be sign of abused child.

o Loss of Control (especially in adolescents) Caused by health and illness, loss or alteration in normal routine or ritual. Questions to ask upon admission to prevent: What is normal routine? What are previous experiences?

o Bodily Injury- (especially preschooler or school age) Helped by offering explanations, preparation and demonstrations

o Pain- Fear and stress of Pain. Perception dependent on age, growth and development. Assess-vital signs, expressions and mannerisms Demerol should not be given to children Morphine is the drug of choice Sucking helps infants EMLA cream

Stressors Children Experience by Age

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o Infant-Separation & Paino Toddler- Separation, Loss of Control, Bodily Injury and Pain

(physical constriction, loss of routine and rituals, dependency)o Preschool-Separation, Loss of Control (sense of own power),

Bodily injury and Pain (intrusive procedures, mutilation)o School-age Separation (parents and peers), Loss of Control

(enforce dependency, altered family roles), Bodily Injury and Death(fear of illness itself, disability, death, intrusive procedures in genital area)

o Adolescents – Separation (esp. from peers) , Loss of Control (loss of identity, enforced dependency), Bodily injury and Pain (mutilation, sexual changes)

Manifestations of Separation Anxiety (Stressor) in Young Children

PHASE OF PROTEST

Observed Behaviors During Later Infancy

•Cries•Screams•Searches for parent with eyes•Clings to parent•Avoids and rejects contact with strangers

Additional Behaviors Observed During Toddlerhood

Verbally attacks strangers (e.g., “Go away”)•Physically attacks strangers (e.g., kicks, bites, hits, pinches)•Attempts to escape to find parent•Attempts to physically force parent to stay•Behaviors possibly lasting from hours to days•Protests, such as crying, often continuous, ceasing only with physical exhaustion•Increased protests precipitated by approach of stranger

PHASE OF DESPAIR

•Inactive•Withdrawn from others•Depressed, sad•Uninterested in environment•Uncommunicative

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•Regresses to earlier behavior (e.g., thumb sucking, bed-wetting, use of pacifier, use of bottle)•Behaviors lasting for variable length of time•Child's physical condition deteriorating from refusal to eat, drink, or move

PHASE OF DETACHMENT

•Shows increased interest in surroundings•Interacts with strangers or familiar caregivers•Forms new but superficial relationships•Appears happy•Detachment occurring usually after prolonged separation from parent; rarely seen in hospitalized children•Behaviors representative of a superficial adjustment to loss

Methods for Managing Stressorso Separation Anxiety

Assign primary nurse and try to maintain facets of normal routine – (when parent absent)

Be physically close to child, use quiet tone, soothing words, eye contact and touch.

Tell child why the parent must leave and an idea about how long

Leave favorite articles from home Employ comfort measures

o Loss of Control and Autonomy Promote freedom of movement Maintain the child’s routine

o Encourage independence Promote understanding Allow child to express feelings of protest Accept regressive behaviors without comment Provide privacy Encourage peer contacts

o Prevent or Minimize Bodily Injury Perform procedures as quickly as possible and maintain parent

contact Use of bandages – important to toddlers and preschoolers Explain and evaluate understanding of procedure

o Provide Developmentally appropriate activities Appropriate educational services

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Use play and expressive techniques Nondirective play that allows for freedom of

expression- drawing, tricycles and wagons, beanbags, clay and play doh.

Dramatic play-puppets, replicas or hospital equipmento Meet Physical Needs Promptlyo Employ comfort measures and pain reduction techniques

Pain assessment in childreno Why is this important?

Consequences of fear of bodily injury can last a lifetime

Importance of pain assessment in child care (pgs. 206- 213)o Behavioral Assessment of pain

Assessment of facial expressions and body movement in infants helps to evaluate their pain

Useful in measuring pain of those who lack communication skills Provides important information that can’t be obtained from self

report Provides a more complete picture of the pain experience FLACC pain scale is a commonly used one with behavioral

assessmento Physiological measures

HR, RR, BP, sweating, etc., are not localized responses to pain, but are responses to stress

Provide indirect measure of paino Self- Report Measures

FACES pain scale

Pain assessment at different ages

Age Pain AssessmentYoung Infants Generalized body response of thrashing

Loud cryingFacial expressions of pain; brows lowered and drawn, eyes closed tightly, mouth open and squarish

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Demonstrates no association b/w approaching stimulus and subsequent painOlder Infants Localized body response with deliberate withdrawal of stimulated area; loud

cryingFacial expressions of pain or angerPushing the stimulus away after it is applied

Young Children

Loud screaming and cryingVerbal expressions of Ow, Ouch, that hurtsBrashing of arms and legsPushes away BEFORE the stimulus is appliedRequests termination of procedureClings to parentsMay become irritable and restlessSchool age childrenStalling behavior such as, “ wait!”, or “ I am not ready!”Muscular rigidity, clenched fists, white knuckles, contracted limbs, body stiffness, closed eyes, wrinkles forehead

Adolescents Less vocal protestMore motor activityMore verbal expression such as “It hurts” or “you’re hurting me.”Increased muscle tension and body control

Useful tools to use for pain assessmento FLACC

Face…legs…activity…cry…consolabilityo FACES pain scale

6 cartoon faces that a child can point to so that they can describe their pain

o OUCHER 6 photos of children’s faces Each face has a range… anywhere from 0 -100 Can be changed to fit the child’s race

o COLOR TOOl Have them color on a drawing of a child where their pain is

o DOLLS Have a younger child point to where the doll is hurting which may

be where they are hurting also

o Questions to Ask to Assess Child Pain- Tell me what pain is Tell me about the hurt you have had before Do you tell others when you hurt? If so , Who? What do you do for yourself when you are hurting? What do you want others to do for you when you hurt? What don’t you want others to do for you when you hurt?

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What helps the most to take your hurt away?

o QUESTT Q=question the child –

child’s verbal statement of pain is most important factor in assessment (around 3 can answer themselves) Can point on themselves or drawing

be aware of reasons child may deny or not tell about pain

U=use pain rating scale Because it provides a subjective, quantitative

measurement of pain Choose scale appropriate for child Use same scale to avoid confusion Use scale for pain only Rate pain after intervention Teach use of scale before pain

E=evaluate behavior Common indicators of pain in children Physiologic changes Observe for change in behaviors after analgesia

S=secure parent’s involvement Because they know their child best Question to discover past reactions to pain in order to

determine early signs T=take cause of pain into account T=take action

Non pharmalogical and pharmalogical pain relief methodsPharmalogical Nonpharmalogical

General StrategiesForm a trusting relationshipPrepare the childAvoid evaluative statements such as “This will really hurt a lot.”Give the child a doll which becomes “the patient” and allow the child to do everything to the doll that is going to be done to themDistractionInvolve the child in play: record player, have the child sing alongHave the child take deep breaths and blow out until told to stopRead stories or tell jokesBlow bubbles

Relaxation

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With infants, rock them in a wide, rhythmic motionAsk the child to take in deep breaths and go limpHave them assume a comfortable position

ImageryHave the child describe details of a highly pleasurable eventCombine with relaxation

Positive Self talkTeach child positive statements to say when in pain

Thought stoppingIdentify positive facts about the painful event ( “ it doesn’t last long)Identify reassuring informationCondense positive and reassuring thoughts into a set of brief statementsHave the child repeat positive statements

Cutaneous StimulationRhythmic rubbingUse of pressureBehavioral ContractingUse stars are rewards

Pharmacological and Non pharmacological Pain Control Pharmacological Routes

o Morphine is drug of choice; Demerol should not be given to children

o Oral Preferred route Requires higher dose Peak effect in 1.5-2 hours (disadvantage when pain is severe)

o Sublingual- More rapid than oral Avoids first pass effect Few drugs available in this form

o IV – bolus Preferred for rapid control (onset in 5 minutes) advantage for

acute pain, procedural and break through pain Initial bolus dose is controversial Needs to be repeated hourly for continuous coverage

o IV-continuous Preferred over bolus and IM for maintaining control Steady blood levels Easy to titrate doses Divide IM dose by drug’s expected duration Full peak is delayed, best combined with bolus dose

o Subcutaneous

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When oral and IV routes not available Same blood levels as IV

o Patient Controlled anesthesia –any routeo IM

Painful admin – hated by children Some drugs cause tissue damage Wide fluctuation in absorption (faster deltoid than gluteal) Shorter duration and more expensive)

o Intranasal Versed – may be traumatic Should not be used in patients receiving morphine like drugs

o Intradermal Primarily for skin anesthetics Local anesthetics cause stinging, burning (buffer with sodium

bicarbonate)o Topical

EMLA cream-Must be placed 1-2 hours before procedure TAC-ready in 15 minutes

Used for suturing Not on mucous membranes or denuded skin or end

arterioles

o Transdermal – pain patch Not safe for children under 12 Not to treat initial pain (takes 12-24 hours)

o Rectal Disliked by children – preferred over IM Variable absorption rate

o Regional Nerve Blocko Inhalationo Epidural

o Non-pharmacological techniques General: Trusting relationship(express concern, take an active

role in pain control), help child prepare for procedure (use non-pain descriptors), avoid evaluative statements, stay with child during painful procedure, (encourage parent to stay- stand at head of the bed and talk softly), involve parents in learning and using non-pharm. methods, educate about the pain to lessen anxiety, give child a doll to demonstrate procedures.

Distraction – play, blowing, blowing bubbles, yelling or saying ouch, kaleidoscope, humor, reading, playing games, visit with friends

Guided imagery Relaxation-

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Infant or child- o hold vertically against chest or shouldero rock in wide, rhythmic arc – no bouncing

slightly older childo take deep breath and go limpo comfortable positiono progressive relaxationo keep eyes open

Positive self-Talk Thought Stopping

Identify positive facts about the event Identify reassuring information Condense positive and reassuring facts into a set of

brief statements and have child memorize them Have child repeat memorized statements whenever

thinking about or experiencing the painful event Cutaneous Stimulation

Massage, pressure, rhythmic rubbing or application of heat or cold

TENS - electrical stimulation

Behavioral Contracting Informal-as young as 4 or 5 give stars or tokens as

rewards Formal- use a written contract, rewards and

consequences

How are parents involved in pain managemento Ask the parents about the child’s pain experience historyo What words does your child use for paino How do you know your child is in paino What has worked best for controlling your child’s paino Use parent as an asset for controlling pain

Role of the parent in their hospitalized childo Family is an essential part of the child’s care and illness

experience. Family to be partners in the care of the child. Establish a priority of their values Provide information

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Growth and Development

Growth and Development: 15-16 questions Know the tasks of each age group and basic milestone

development-infancy through 4 years. Focus is on the blocked areas on the charts in your book and major points on power point slides..

Erickson Fine/Gross Motor Biological growth Cognitive

Infant (0-1)

Trust vs. Mistrust

1mo.

2mo.

3mo.

4mo.

5mo.

6mo.

7mo.

recliner

Grasp when something is handed to themRecliner with raising head, chestHands openLift head, chest, weight bear on their armsVoluntarily grasp objectsAbility to roll overSitter, head control

Transfer objects from

Birth weight (rapid weight gain 1st 6 mo.)

2x birth weight

Rooting, sucking, crying

Object permanence

Onset of separation anxietyStranger anxiety lasting until 8mo.

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8mo.9mo.10mo.

11mo.

12mo.

hand to handParachute reflex‘crude pincher grasp’crawler to cruiserstand, hold on to furnitureoffer object to someone elsemove from prone to sitting‘neat pincher grasp’walk while holding onto furniturebuild tower of 2 blockswalk with one hand held

3x birth weight length increases 50%

Recognize that the mother is leaving

Tasks of each age group and basic milestoneso Infant – (birth -1 year)

Weight @6 months =2 X birth weight, weight at 1 year = 3 x birth weight (gain 5-7 ounces weekly for first 6 months)

Length – at 1 year increase by 50% (grows 1 inch/month for first 6 months)

Head circumference – 13-14 inches (greater than chest circumference), increases by 1.5 cm/month for first 6 months

Posterior Fontanel closes @ 2-3 months; anterior @ 12-18 months

Heart rate gradually slows, blood pressure increases Respirations- primarily abdominal, rate slows down Trust vs. mistrust

Trust develops when needs consistently met Tolerates little frustration, no delay in gratification Separation anxiety >6months

Motor Quotient Motor Age / Chronological Age X 100 =MQ >85 is normal <75 is abnormal

Milestones: 1-3 months recliner 3-6 months recliner while raising head, chest 6-9 months sitter

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9-12 months crawler 1 month

Turns head side to side, assumes flexed position w/out knees under abdomen when prone,

Able to focus on moving object 8-10 inches away 2 months

Less flexed when prone-hips flat , legs extended, arms flexed, head to side less head lag,

Vocalizes, distinct from crying Demonstrates social smile in response to stimuli

3 months Actively holds rattle but will not reach for it Follows objects to periphery Locates sound by turning head to side and looking in

same direction Squeals aloud to show pleasure

4 months Moro tonic neck and rooting reflexes disappear Has almost no head lag when pulled to sitting Balances head well in sitting position Rolls from back to side Inspects and plays with hands; pulls blanket or clothing

over face in play Laughs aloud

5 months Can turn from abdomen to back Able to grasp objects voluntarily

6 Months May begin teething ; may chew and bite Begins to imitate sounds Babbling resembles 1 syllable utterances Briefly searches for dropped object (object

permanence) Rolls back to abdomen

7 Months Sits, leaning forward on both hands Transfers objects from one hand to the other Can fixate on very small objects Produces vowel sounds and chained syllables Increasing fear of strangers, fretfulness when parents

disappear

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8 months Sits steadily unsupported

9 months Pulls self to standing position and stands holding

furniture Uses thumb and forefinger in crude pincer grasp

10 months Says da-da and mama with meaning Develops object permanence Crawls (may be backward)

11 months Cruises or walks holding onto furniture or with both

hands 12 months

Birth weight tripled Birth length 50%increase Walks with 1 hand held May attempt to stand alone or try 1st step Says 3-5 words besides mama and dada Searches for object (only where last seen)

Infants Fine Motor

Grasping begins 2-3 months as a reflex when something is handed to them

Hands are open at 3 months Infants can voluntarily grasp objects by 5 months 7 months transfer objects from hand to hand 8-9 months ‘crude pincher grasp’ 10 months offer object to someone else 11 months ‘neat pincher grasp’ 1 year- try to build a tower of 2 blocks

Gross Motor Full term infant can momentarily hold their head up 4 months lift head and front of the chest 90 degrees above

the table, and weight bear on their arms 4-6 months head control is established 5 months have the ability to roll over Parachute reflex at 7 months which is a protective response

to falling Convex lumbar curve appears when the child begins to sit

at 4 months 7 months, infants can sit alone By 10 months they can maneuver from a prone to a sitting

position

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Crawling by 9 months and can stand and hold onto furniture

By 11 months they walk by holding onto furniture By 1 year they may walk with one hand held

Biological growth Rapid during the first 6 months Infants gain 1.5 lbs per month until 5 months Weight at 6 months is 2x birth weight Weight at 1 year is triple the birth weight By 1 year length increase by 50%

Respiratory Respiration continues to be abdominal The close proximity of the trachea to the bronchi and its

branching structures can cause an infectious agent to be rapidly transmitted

The short eustacian tube ( ears) causes infection to ascend

Neurological development The head size at 1 year should have increased by 33% Brain weight at 1 year is 2 ½ times what it was at birth Posterior fontanel closes: 6-8 weeks Anterior fontanel closes: 12-18 months

Cardiac Growth Infants heart is 55% of chest cavity HR slows and BP increases

Nutrition and Digestions Fetal iron stores are depleted by 4-6 months Human milk is the most desirable, complete diet for the

infant All infants should receive a daily vitamin D supplement

starting at 2 months to help prevent rickets The extusion reflex causes food to be pushed out of the

mouth but is gone by 3-4 months Infants have an immature digestive system Solid food remains undigested before 4- 6 months Stomach enlarges, peristalsis slows

Psychosocial behavior Erikson’s Trust vs. Mistrust

o Trust acquired during infancy provides foundation for all succeeding phases

o Trust develops when needs are constantly met

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o Distrust develops when care is inconsistent or inadequate

o During the first 3-4 months, food intake is most important social activity

o Newborns can tolerate little frustration or delay of gratification

o Total concern for one’s health is at heighto Infants may use more controlled behaviors to

interact with others such as instead of crying, they may hold out their hands to signal they want to be held

o Tactile stimulation is important when establishing trust

o The total quality of the interpersonal relationship influences the infants formulation of trust

o Pleasure principle: tolerates little frustration with no delay in gratification

Separation anxietyo Begins at 4- 8 monthso By 1 year they are able to anticipate her departure

by watching her behaviors and may protest before she leaves

Cognitive Development Piaget

o 1st stage (birth to 1 month): identified by use of reflexes- sucking, rooting, crying

o 2nd stage (1-4 months): marks the replacement of reflexes with VOLUNTARY acts- the reflexes become deliberate acts that elicit certain responses;

o 3rd stage (4-8 months): reactions are repeated and prolonged for the response that results, ex-> grasping and holding become shaking, banging, and pulling

Imitation is also in this 3rd stage. Object permanence is critical in this stage

and plays a role in separation anxietyo 4th stage( 9-12 months): New motor skills and

explore their environment; discover that hiding an object doesn’t make it disappear, and this is the beginning of intellectual reasoning

Social Development

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Bonding should begin before birth Attachment

o During formation of attachment from child to the parent, the infant has 4 stages

1st few weeks: respond to anyone 8- 12 wks: respond more to the mother than

anyone else, but still respond to others 6 months: show a distinct preference to the

mother 7-8 months: begin attaching to other

members of the family; mostly the father Separation Anxiety

o 4-8 monthso Object permanence is starting to develop, and the

infant is aware that the parent may be absento By 11- 12 months, infants may be able to recognize

its time for their mother to leave by watching her behaviors

o To help with this, a parent can let the child hear their voice as they leave the room, or use transitional objects such as a blanket or toy

Stanger Anxietyo Most prominent b/w 6-8 monthso When infants become attached to one person, they

are less friendly to others Language

1st verbal communication= crying By 2months, single vowel sounds develop; ah, eh, uh By 3 months the consonant n.k.g.p.b are added By 6 months they can imitate sounds and add t,d, and ,w

and combine syllables (“dada”) 10- 11 months, they know the meaning of ‘dada’ 9- 10 months they know the meaning of “no” 1 year they can say 3-5 words and may understand up to

100 words Temperament

The infants behavioral style influences the interaction b/w the parent and child

Nurses responsibility to help the family understand the infants temperament as it related to family dynamics and eventual well being of the child and family unit

Easy child: even tempered, regular habits, positive approach

Slow to warm up child: adapts slowly, moody, inactive

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o Toddler (1-3 years) Praise

P= push/ pull toysR= rituals and routine aggressionA= autonomy/ shame and doubt; accidentsI= Involve ParentsS= separation anxietyE= elimination and explore

“me”- explores environment- seeks parental reassurances- control of themselves and environment

physiological anorexia = picky eater (causes slow growth)

mutilation: cut finger and think that they will bleed to death

Biological development: Weight growth slows considerably - @ 2.5 yrs: 4x birth

weight Weight gain 4-6 lbs./yr Height: gain 3 in/yr At 2 yr: head circumference = chest circumference Brain growth: 75%

Locomotion and manual dexterity: 15 mo. à walks 18 mo. à runs but falls easily 2yr. à runs up and down stairs

egocentrismmood swings: says ‘no’

Moral and Body Knowledge Knows punishment means bad and rewarding

means good Do not over stimulate toddlers by giving them

lots of choices; only give them 2 choices Autonomy vs. shame and doubt

Explores environment, seeks parental reassurances, control of self and environment

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Mood swings- negativism, temper tantrums, pleasure principle

Super egoism and conscience begins Ritualism- need to maintain sameness and reliability Deliberate trials, lack of memory transfer Tolerate longer separation but protest when parents

leave Animism-blame stairs for falling Negativism- says NO No concern of wrongdoing 20 teeth by 2.5-3 years

Milestones 15 months-

o Walkso Drops pellet in bottle, throws objects, makes

tower of two blocks 18 months- runs but falls easily 2 years-runs up and down stairs 24 months-makes circular stroke, draws vertical line

Piaget’s cognitive sensory- motor stage continues until 2 yrs of age

During this time, the cognitive process rapidly develops The main achievement is acquisition of language The child uses active experimentation Newly acquired physical skills are important The ability to venture away from the parent and tolerate

prolonged separation increases Become aware of object permanence Refers to self by name

o Biological Development Weight at 2.5 years: 4x birth weight Weight gain 4-6 pounds/ year Height gain 3 inches a year At 2 years head circumference= chest circumference Brain growth: 75% complete Pot- belled appearance Physiological system mature by 2 years Can control elimination (potty trained) Better temp. regulation Slow growth -> physiological anorexia

o Locomotion and manual dexterity 15 mos: walks 18 mos: runs but falls easily 2 years: runs up and down stairs

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15 mos: drops pellet in bottle, throws objects, makes tower of 2 blocks

24 mos: makes circular stroke draws vertical lineo Psychological development

Erikson’s autonomy verses shame and doubto Conflicted on exerting autonomy and

relinquishing the enjoyed dependence on otherso Exerting their will has negative consequences

and being dependant can cause them to be rewarded

o On the other hand, continued dependency can create doubt and it is accompanied by shame

o Without limits, they have no guidelines for establishing their control

o They hold on and let goo One minute they may be engrossed in an

activity and the next minute, they may be angry because they were unable to manipulate a toy

o This stage is the development of the ego Mood swings, says NO Pleasure Principle and temper tantrums Super egoism and conscience begins

o Cognitive development Deliberate trials, lack of memory transfer, prone to

accidents Simple causal relations; push button… light on Tolerate longer separation but protest when parents leave Thinking and reasoning begins but still primitive Aware of height and space and shapes Stands on box to reach object EGOCENTRISM: cant see from another’s perspective ANIMISM: blames stairs for falling Preoccupied with sameness IRREVERSIBILITY: can’t undo if told to stop

o Moral and Body Knowledge Knows punishment means bad and rewarding means good Do not over stimulate toddlers by giving them lots of

choices; only give them 2 choices

o Preschool (3-5) Weight- 5lbs/year Height: 2-3 inches/year Energetic: walks, runs, jumps, plays Magic:

M= Mutilation

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A=associative play and abandonment G=guilt I=initiative and imaginary playmate, imagination C=curious Initiative vs. Guilt

o Develops conscienceo Imaginationo Egocentric

Biological development Gain 5 lbs a year

Psychosocial Development Erickson: Initiative vs. guilt

Cognitive Development Develop conscience- inner voice Egocentric Curious- constantly asking WHY?

Social Development Tolerate separation, but not long Can cope with changes More social- communicates better Can care for self: eat, dress Obeys; knows role in the family

o School-age (6-12 years) DIMPLE

D=death I= Industry vs Inferiority M=Modesty P=Peers L=Loss of Control E= Explanation

Growth spurts and latency periods (4-6 lbs/year; 2 inches/year) 1st loss tooth (ugly duckling stage) Puberty begins Learns to Follow rules Acquires reading, writing, math and social skills Develops confidence and learns about new things Cooperates- needs peer approval Develops conscience- determines right from wrong

Industry Vs Inferiority

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Stealing, lying, cheating may be normal behavior for this age group

Biological Development Growth spurts, 1st tooth lost, ugly duckling stage Puberty begins

Psychosocial Erickson Industry vs. Inferiority Self esteem and self concept Cooperates but needs approval

Cognitive Development Piagets concrete operation See from others perspective, memory storage, has

judgment Can serialize and group objects Can read and problem solve

Moral and body knowledge Aware of bodies and disabilities Compares self to peers Makes judgments about moral things Learns right from wrong Memorizes prayers and understands simple stories Can differ boy from girl

Social Development Interpersonal relationships: same sex friends

o Adolescent (12 – 18 years) PAIRS

P=Peers A=alteration in image I= identity R=Role (Who) S= Separation from Peers

Puberty –wide range but earlier for girls Quest for individual identity and Independence Establish a value system Make a career decision Emancipation from parents Intensely need peers, unpredictable, insecure, mood swings,

risk-takers need and want limits Future thinking, abstract thinking, egocentric Body image is important

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Erikson’s Identity verses role confusion Alteration in Image- very concerned with body image Puberty: wide range, girls earlier than boys

Biological Development Hormones activate Sexual Maturation: Follows orderly sequence Girls mature 2 years earlier than boy’s mature Tanner’s Assessment (p. 814- 817)

Psychosocial Development Have a quest for Individual Identity and Independence 1. Accept changed body image Establish a value system Make a career decision Emancipation from parents

When a minor is pregnant, they are emancipated from their parents

Social Development Unpredictable Mood Swings Risk Takers

Cognitive Development Abstract thinking Ego centric BODY IMAGE AND PEER ACCEPTANCE IS

IMPORTANT!!

Miscellaneous Information/More Milestones in Children 6 mo. Weight: double the birth weight 6 months weight

Avg. 16 lbs 1 year. Weight: triple the birth weight 1 year weight

Avg. 21.5 lbs average weight gain per year: around 5 lbs/year toddlers and up sits with and without help when: with help @ 4 mo. w/out help @ 7 mo. when to expect crawling, pulling up, and walking

Crawling 9 months Pulling up 9 months Walking 1 year

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fontanel’s close when Posterior fontanel closes 6- 8 weeks Anterior fontanel closes 12- 18 months (avg. 14 months)

separation anxiety at what age 4-8 months

stranger fear at what age 6-8 months

the importance of consistency of care and routines

Growth and Development:May be duplicate information

What would be anticipatory guidance for the infant, toddler (push-pull toys), preschooler, school-age or adolescent child re: norms in growth and development?

o Infant (pg 561) Teach parents about car safety-> facing rearward, in the

middle, not close to an air bag Teach about postpartum emotional needs Teach care of infants and help them understands their

individual needs and temperament Reassure that too much attention will not spoil the child Teach about safety and immunizations

o Toddler (pg 560) Prepare them about stranger anxiety Guide them concerning discipline Encourage showing most attention when the child is behaving

well Discuss readiness for weaning Explore parents feelings regarding the child’s sleep patterns

o Preschooler ( pg 660) 3 years old

Prepare parents for child’s widening personal relationships Encourage enrollment in preschools Stress limit setting Encourage choices

4 years old Prepare parents to handle discipline constructively and to

look for resistance to parental authority Prepare them for a highly imaginative child that indulges in

tall tales Prepare them for increase in nightmares Provide reassurance that a period of calm begins at age 5

5 years old

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Help prepare them for child’s entrance into school Make certain that immunizations are up to date Suggest swimming lessons Encourage parents to limit TV and to screen shows for

appropriate content

o School age (pg 748) Age 6

Parents should expect strong food choices and refusal of certain foods

Anticipate susceptibility to certain illnesses Teach about bike safety Encourage child to have a private bedroom

Age 7- 10 Prepare about improvement in health but warn that allergies

may increase Expect an increase in minor injuries More demands at 8 years for mothers Fathers should expect increasing admiration at age 10 Prepare for prepubescent changes in girls

o Adolescent (pg 748) Prepare child for prepubescent changes Growth spurt in girls Sex education should be adequate Parents should expect an increase in masturbation Educate children about experimentation with harmful activities

SPACES S- smoking; self- worth P- pot, peer pressure, planning A- alcohol C- chaperons, curfew, chastity E- exercise S- safe choices

Preschool: Normal Fears-afraid of the dark, being left alone, large animals, snakes, ghost, sexual matters, and objects and persons associated with pain.

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-fear of loss of body parts(ie afraid that the drain is going to swallow them up; afraid their going to fall down the toilet.-Animisn- giving things that have no life, life (ie blaming the stairs for making them fall).

Toddlers: Anticipatory guidance re: development and safetyDevelopment:-they weigh 4 times their birth weight-they gain 4-6 lbs per year-they gain 3 inches per year-head circumference= chest circumference-voluntary control on elimination-walks @ 15 months; runs @ 18 months but falls easily; runs up and down stairs @ 2 years; @ 15 months is able to throw objects and make tower of 2 blocks; @ 24 months makes circular strokes and draws vertical lines.-Egocentrism-they cant see from others perspective-Animism- blames stairs for falling-Autonomy vs Shame & Doubt-very social-less stranger anxiety- object permanence- knows that an object or person still exists even though its not seen, heard, or felt

Safety: - continue to use care seat properly; children 1 year or older should be in a

forward facing position in the back seat.- Supervise indoor and outdoor activities- Childproof home environment: stairways, cupboards, medicine cabinets,

outlets- Prevent from suffocation (plastic bags, toys, pacifiers)- Prevent from burns (ovens, heaters, sunburns, check water and food temp)- Prevent from falls (stairs, windows, walkers)- Prevent aspiration; poisonings, medications (big issue)

Adolescent: Appropriate anticipatory guidance with understanding of their developmental and safety needs:

- Identity vs Role of Confusion- Anticipatory guidance: Smoking and self worth; Pot, peer pressure, planning;

Alcohol; Chaperon, curfew, chastity; Exercise; Safe choices. (SPACES).- Accidents are leading cause of death(motor vehicle, sports, firearms, and

suicide).

Anticipatory Guidance- the process of understanding upcoming developmental needs & teaching caregivers to meet

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those needs. Include: health habits, prevention of illness and injury, prevention of poisoning, nutrition, dental care, sexuality)

o Infant: Proper weight and height development. Developmental

milestones. Immunizations. Safety: proper car seat; side rails of crib up; never unattended

on table, bed or bathtub; temperature of bathwater, no bottles at bedtime, injury prevention (aspiration of small objects, suffocation with plastic bags or cords, falls, poisonings and burns)

Susceptible to dehydration Needs met consistently to develop trust Separation anxiety 4-8 months

o Toddler Proper growth and developmental milestones, immunizations Need for ritualism and sameness Teach proper dental hygiene Mood swings and temper tantrums- “no” phase

Proper car seat, supervise indoor and outdoor play, syrup of ipecac, childproof home, suffocation (bags, pacifiers, toys, refrigerator), burns (water and food temp), falls (windows, stairs, balconies, walkers), aspirations/poisonings

o Preschooler Growth & developmental landmarks, immunizations prior to

school Car seat to 40 lbs or 40 inches or 4 years (then booster seat to

age 9), teach safety habits (traffic safety, strangers, fire prevention/safety, water safety), supervision of television

Sibling rivalry Constantly asking why? Wants to care for self (dress and eating) Booster seat until 8 years old or 80 pounds (4foot9inches) Teach safety habits and injury prevention Traffic safety/bicycle safety Strangers Fire prevention/safety Water safety

o School age Growth and developmental milestones, immunizations

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Puberty begins Bone growth faster than muscle and ligament development=

prone to greenstick fractures Greater stamina and energy May develop myopia by 8 years Risk of obesity All permanent teeth except molars by age 12 Safety: accidents less likely, proper use of sports equipment,

discourage risk taking(smoking, alcohol, drugs, sex), sex education, injury prevention (firearms, bicycle safety, smoking, hobbies)monitor video and computer time

Intolerant to opposite sex Need to be honest with children and answer their questions

Table 17-2 àInjury Prevention During School-Age YearsDEVELOPMENTAL ABILITIES RELATED TO RISK OF INJURYINJURY PREVENTIONMotor vehicle accidents1. Is increasingly involved in activities away from home2. Is excited by speed and motion3. Is easily distracted by environment4. Can be reasoned with5. Educate child regarding proper use of seat belts while a passenger in a vehicle6. Maintain discipline while the child is a passenger in a vehicle (e.g., ensure that child

keeps arms inside, does not lean against doors or interfere with driver)7. Remind parents and children that no one should ride in the bed of a pickup truck8. Emphasize safe pedestrian behavior9. Insist that child wear safety apparel (e.g., helmet) when applicable, such as riding

bicycle (see Family Home Care box, p. 746), motorcycle, moped, or all-terrain vehicle (see Family Home Care box, p. 745)

Drowning1. Is apt to overdo2. May work hard to perfect a skill3. Has cautious, but not fearful, gross motor actions4. Likes swimming5. Teach child to swim6. Teach basic rules of water safety7. Select safe and supervised places to swim

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8. Check sufficient water depth for diving9. Caution child to swim with a companion10. Ensure that child uses an approved flotation device in water or boat11. Advocate for legislation requiring fencing around pools12. Learn cardiopulmonary resuscitationBurns1. Has increasing independence2. Is adventuresome3. Enjoys trying new things4. Make sure smoke detectors are in homes5. Set water heaters to 48.9°C (120°F) to avoid scald burns6. Instruct child regarding behavior in areas involving contact with potential burn

hazards (e.g., gasoline, matches, bonfires or barbecues, lighter fluid, firecrackers, cigarette lighters, cooking utensils, chemistry sets); instruct child to avoid climbing or flying kite around high-tension wires

7. Instruct child in proper behavior in the event of fire (e.g., fire drills at home and school)

8. Teach child safe cooking (use low heat; avoid any frying; be careful of steam burns, scalds, or exploding foods, especially from microwaving)

Poisoning1. Adheres to group rules2. May be easily influenced by peers3. Has strong allegiance to friends4. Educate child regarding hazards of taking nonprescription drugs and chemicals,

including aspirin and alcohol5. Teach child to say no if offered illegal or dangerous drugs or alcohol6. Keep potentially dangerous products in properly labeled receptacles, preferably out of

reachBodily damage1. Has increased physical skills2. Needs strenuous physical activity3. Is interested in acquiring new skills and perfecting attained skills4. Is daring and adventurous, especially with peers5. Frequently plays in hazardous places6. Confidence often exceeds physical capacity7. Desires group loyalty and has strong need for friends' approval8. Attempts hazardous feats9. Accompanies friends to potentially hazardous facilities10. Delights in physical activity11. Is likely to overdo12. Growth in height exceeds muscular growth and coordination13. Help provide facilities for supervised activities14. Encourage playing in safe places

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15. Keep firearms safely locked up except during adult supervision16. Teach proper care of, use of, and respect for potentially dangerous devices (e.g.,

power tools, firecrackers)17. Teach children not to tease or surprise dogs, invade their territory, take dogs' toys, or

interfere with dogs' feeding18. Stress use of eye, ear, or mouth protection when using potentially hazardous objects

or devices or when engaged in potentially hazardous sports19. Do not permit use of trampolines except as part of supervised training20. Teach safety regarding use of corrective devices (glasses); if child wears contact

lenses, monitor duration of wear to prevent corneal damage21. Stress careful selection, use, and maintenance of sports and recreation equipment,

such as skateboards and in-line skates (see Family Home Care box, p. 747)22. Emphasize proper conditioning, safe practices, and use of safety equipment for sports

or recreational activities23. Caution against engaging in hazardous sports, such as those involving trampolines24. Use safety glass and decals on large glassed areas, such as sliding glass doors25. Use window guards to prevent falls26. Teach name, address, and phone number and emphasize that child should ask for help

from appropriate people (e.g., cashier, security guard, police) if lost; have identification on child (e.g., sewn in clothes, inside shoe)

Teach stranger safety:1. Avoid personalized clothing in public places2. Caution child to never go with a stranger3. Have child tell parents if anyone makes child feel uncomfortable in any way4. Always listen to child's concerns regarding others' behavior5. Teach child to say no when confronted with uncomfortable situations.

o Adolescent Puberty- body odor, acne, secondary sex characteristics

(breasts, menarche, hair, growth of genitalia, nocturnal emissions, voice change)

Accidents leading cause of death – motor vehicle, sports and firearms

BIG FOCUS àDrug and alcohol education, sex education, discourage risk-taking

“Risky behaviors”àWHY? Because they think that they are invincible…normal

Lack of impulse control Body image and peer acceptance is important Proper use of sports equip., diving drowning, driver’s ed., seat

belts, violence prevention, crisis intervention (stress, depression, eating disorders), risk of body piercing

Want and need limits!

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VERY IMPORTANT à Health promotion (self-exams à SBE & TSE à leading cause of death in males age 16-26???)

Injury prevention (automobiles, sports, traffic rules) SPACES

S=smoking, self worth P=pot, peer pressure, planning A=alcohol C=chaperons, curfew, chastity E=exercise S= safe choices

Common Developmental issueso Toddler-Temper tantrums, negativism, toilet training, sibling

rivalry and stresso Preschool – Fears and stress, aggression, speech problemso School age- limit setting –(dishonesty), coping with school

experience, Fears: death, Violence, School

Important to remember about milestones:o Each child displays definite predictable patterns of growth and

development. These patterns are universal to all human beings. However, variations exist in the age at which milestones are reached.

o Trends are : head to tail, near to far, simple to complexo Positive and negative stimuli enhance or defer achievement of skill

or functiono Factors influencing development: genetics, nutrition, prenatal and

environmental factors, family and community, cultural.

OTHER STUDY GUIDE INFOGrowth and Development:Preschool: Normal Fears

afraid of the dark, being left alone, large animals, snakes, ghost, sexual matters, and objects and persons associated with pain.

fear of loss of body parts(ie afraid that the drain is going to swallow them up; afraid their going to fall down the toilet.

Animisn- giving things that have no life, life (ie blaming the stairs for making them fall).

Toddlers: Anticipatory guidance re: development and safetyDevelopment:

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they weigh 4 times their birth weight they gain 4-6 lbs per year they gain 3 inches per year head circumference= chest circumference voluntary control on elimination walks @ 15 months; runs @ 18 months but falls easily; runs up and down

stairs @ 2 years; @ 15 months is able to throw objects and make tower of 2 blocks; @ 24 months makes circular strokes and draws verticle lines.

Egocentrism-they cant see from others perspective Animism- blames stairs for falling Autonomy vs Shame & Doubt very social less stranger anxiety object permanence- knows that an object or person still exsist even though

its not seen, heard, or felt

Safety: continue to use care seat properly; children 1 year or older should be in a

forward facing position in the back seat. Supervise indoor and outdoor activities Childproof home environment: stairways, cupboards, medicine cabinets,

outlets Prevent from suffocation (plastic bags, toys, pacifiers Prevent from burns (ovens, heaters, sunburns, check water and food temp Prevent from falls (stairs, windows, walkers Prevent aspiration/poisoning

Adolescent: Appropriate anticipatory guidance with understanding of their developmental and safety needs:

Identity vs Role of Confusion Anticipatory guidance: Smoking and self worth; Pot, peer pressure,

planning; Alcohol; Chaperon, curfew, chastity; Exercise; Safe choices. (SPACES).

Accidents are leading cause of death(motor vehicle, sports, firearms, and suicide).

STAGES:Infant: Birth to 12 monthsToddler: 1 to 3 yearsPre-School: 3 to 5 yearsSchool Age: 5 to 12 yearsAdolescence: 13 to 19 years

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Erikson Phase I (Infant = birth–1 yr): Developing a Sense of Trust: Trust vs. Mistrust

Trust acquired during infancy provides foundation for all succeeding phases Trust develops when needs are consistently met Distrust develops when care is inconsistent or inadequate Food intake (first social activity), grasping, tactile stimulation, biting (leads to

first conflict: biting mother’s nipple) Pleasure principle: tolerates little frustration with no delay in gratification

Phase II ( Toddler ): Developing a Sense of Autonomy while overcoming a sense of doubt and shame Autonomy vs. Doubt and Shame

Institute limit setting and consistent discipline, holding on and letting go of objects, taste preferences become stronger, development of ego

Negativism and ritualism (w/out: dependency and regression occur) Awareness of potential failure creates doubt and shame Opportunities for self-mastery: play activities, toilet training, crisis of sibling

rivalry, and successful interactions with significant others Phase III (Preschooler): Developing a Sense of Initiative: Initiative vs. Guilt

Feelings of guilt, anxiety, and fear may result from thoughts/actions that differ from expected behavior

Development of the superego, or conscience Learning right from wrong and good from bad (beginning of morality),

acceptable and unacceptable behavior through punishment and reward Rely almost completely on parental principles for developing their own moral

judgment More aware of danger, can be relied on to listen and obey. If allowed to disagree and question, they will develop socially acceptable

behavior and independence in thought and action

Phase IV (School Age 6-13): Developing a Sense of industry Industry vs. inferiority or stage of accomplishment

Goal: to achieve a sense of personal and interpersonal competence through the acquisition of technology and social skills

Growing independence, building skills, interests expand, want to engage in tasks that can be carried through to completion

When children can accomplish tasks that need to be done and perform well despite individual differences in capacities and emotional development, and when they are suitably rewarded, children develop a sense of industry and accomplishment that prepares them for establishing a stable identity later in life

A sense of accomplishment is achieved around 6 yrs of age. Failure to develop a sense of accomplishment may result in inferiority

Phase V (Adolescent): Development of Autonomy (independence) Identity vs. Role Confusion

Social forces play a large role in shaping an adolescents sense of self The key to identity lies in an adolescents interactions with others

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The people they interact with serve as a mirror that reflect back to the adolescent to what he or she should be

Society plays a role in identity formation “Who am I?” come to terms with self-identity Self expression through clothing, music, their friends Rebellion

Erikson(Seth’s Notes) Trust vs. Mistrust (Infant)

o Trust acquired during infancy provides foundation for all succeeding phases

o Trust develops when needs are constantly meto Distrust develops when care is inconsistent or inadequateo During the first 3-4 months, food intake is most important social activityo Newborns can tolerate little frustration or delay of gratificationo Total concern for one’s health is at heighto Infants may use more controlled behaviors to interact with others such as

instead of crying, they may hold out their hands to signal they want to be held

o Tactile stimulation is important when establishing trusto The total quality of the interpersonal relationship influences the infants

formulation of trusto Pleasure principle: tolerates little frustration with no delay in gratification

Autonomy vs. Doubt and shame (Toddler)o Conflicted on exerting autonomy and relinquishing the enjoyed

dependence on otherso Exerting their will has negative consequences and being dependant can

cause them to be rewardedo On the other hand, continued dependency can create doubt and it is

accompanied by shameo Without limits, they have no guidelines for establishing their controlo They hold on and let goo One minute they may be engrossed in an activity and the next minute,

they may be angry because they were unable to manipulate a toyo This stage is the development of the ego

Initiative vs. guilt (Preschool)o Conflict arises when children overstep their limits and experience guilt

for not behaving appropriatelyo They may have thoughts of wishing a parent were dead, especially if

they have a sense of rivalry or competition with that parento They are learning right from wrongo Are generally unable to understand why something is or is not

acceptable

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o Verbal limits are much more effective with this groupIndustry vs. Inferiority ( school age)

o A sense of accomplishment is achieved around 6 yrs of ageo They achieve a sense of personal and interpersonal competence through

the acquisition of technologic and social skillso Failure to develop a sense of accomplishment may result in inferiority

Identity vs. role confusion (Adolescents)o Social forces play a large role in shaping an adolescents sense of selfo The key to identity lies in an adolescents interactions with otherso The people they interact with serve as a mirror that reflect back to the

adolescent to what he or she should be o Society plays a role in identity formation

GROWTH MEASUREMENTS:

1. Plot results on growth charts; length/height to age, weight to age, length to weight2. Overall pattern of growth is more important than any single measurement3. Use the 5th and the 95th percentiles for determining which children are outside

normal limitsLength/height:

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a. Recumbent length (birth to 36months/3years) with child supine and legs extendedb. Use crown to heel measurementc. Children older than 2 years may stand shoeless as straight as possible

Weight : a. Use appropriately sized beam scaleb. Weigh naked infant lying or sittingc. Weigh older children on upright scale dressed only in underpants or light gownd. Calculate body mass index (BMI) for children over age 3

BMI calculations & interpretation:Calculate body mass index (BMI) for children over age 3

Body Mass Index Formula: English Formula

BMI = [(Weight in pounds ÷ Height in inches) ÷ Height in inches] × 703BMI OF < 25 is ideal.

Fractions and ounces must be entered as decimal values.*Example: A 33-pound, 4-ounce child is 37⅝ inches tall.33.25 pounds divided by 37.625 inches, divided by 37.625 inches × 703 = 16.5

Nurse needs to focus on education if patient falls into the following categories:1. >95% for age and gender are overweight 2. 85-94% are at risk for becoming overweight3. Anorexiaà25%4. If BMI has increased 2 or more points in 12 months??5. Ask about Family history of HTN or Hyperlipidemia6. Nurse needs to be concerned about anorexia or bulimia

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EXAMPLES OF CASE STUDIES

CASE: INFANT GROWTH & DEVELOPMENT:

ELIZABETH IS A 6-MONTH-OLD GIRL DELIVERED AT 40 WEEKS OF GESTATION WEIGHING 3.4 KG (7 POUNDS, 8 OUNCES). SHE NOW WEIGHS 6.8 KG (15 POUNDS). THE NURSE IS DISCUSSING INFANT GROWTH AND DEVELOPMENT WITH ELIZABETH’S MOTHER.

1.ELIZABETH’S MOTHER IS CONCERNED THAT HER BABY ISN’T GAINING ENOUGH WEIGHT. THE NURSE CAN ASSURE THE PARENT AND PROVIDE ANTICIPATORY GUIDANCE. WHICH OF THE FOLLOWING STATEMENTS SHOULD BE MADE TO ELIZABETH’S MOTHER?

A. ELIZABETH IS GAINING WEIGHT WELL. AT 6 MONTHS AN INFANT IS EXPECTED TO HAVE DOUBLED HIS OR HER BIRTH WEIGHT. AT 1 YEAR THE WEIGHT SHOULD TRIPLE.

B. ELIZABETH IS GAINING WEIGHT WELL. AT 6 MONTHS AN INFANT IS EXPECTED TO HAVE TRIPLED HIS OR HER BIRTH WEIGHT. AT 1 YEAR WEIGHT SHOULD TRIPLE.

C. ELIZABETH IS GAINING WEIGHT WELL. AT 6 MONTHS AN INFANT IS EXPECTED TO HAVE DOUBLED HIS OR HER BIRTH WEIGHT. AT 1 YEAR WEIGHT SHOULD QUADRUPLE.

D. ELIZABETH IS NOT GAINING WEIGHT AS EXPECTED. AT 6 MONTHS AN INFANT IS EXPECTED TO HAVE TRIPLED HIS OR HER BIRTH WEIGHT. AT 1 YEAR THE WEIGHT SHOULD QUADRUPLE.

2. ELIZABETH’S MOTHER SAYS HER INFANT REACHES FOR HER FOOD. SHE ASKS IF IT IS ALL RIGHT TO LET THE BABY FEED HERSELF. WHAT IS THE MOST APPROPRIATE RESPONSE?

A. GRASPING OCCURS DURING THE FIRST MONTH AS A REFLEX AND GRADUALLY BECOMES VOLUNTARY. BY 4 MONTHS INFANTS CAN

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HOLD THEIR BOTTLE, GRASP THEIR FEET AND PULL THEM TO THEIR MOUTH, AND FEED THEMSELVES A CRACKER.

B. GRASPING OCCURS DURING THE FIRST 2-3 MONTHS AS A REFLEX AND GRADUALLY BECOMES VOLUNTARY. BY 6 MONTHS, INFANTS CAN HOLD THEIR BOTTLE, GRASP THEIR FEET AND PULL THEM TO THEIR MOUTH, AND FEED THEMSELVES A CRACKER.

C. GRASPING OCCURS DURING THE FIRST 4-5 MONTHS AS A REFLEX AND GRADUALLY BECOMES VOLUNTARY. BY 7 MONTHS, INFANTS CAN HOLD THEIR BOTTLE, GRASP THEIR FEET AND PULL THEM TO THEIR MOUTH, AND FEET THEMSELVES A CRACKER.

D. GRASPING OCCURS DURING THE FIRS 6-8 MONTHS AS A REFLEX AND GRADUALY BECOMES VOLUNTARY. BY 9 MONTHS, INFANTS CAN HOLD THEIR BOTTLE, GRASP THEIR FEET AND PULL THEM TO THEIR MOUTH, AND FEED THEMSELVES A CRACKER.

3. ELIZABETH’S MOTHER IS AWARE OF THE IMPORTANCE OF PLAY FOR CHILDREN. WHAT GAMES AND INTERACTIONS SHOULD THE NURSE RECOMMEND?

A. ENCOURAGE THE INFANT TO PLAY PUSH-PULL TOYS.B. HANG MOBILES WITH BLACK AND WHITE DESIGNS ABOVE THE

CRIB.C. PLACE AN UNBREAKABLE MIRROR WHERE THE INFANT CAN SEE

HERSELF.D. POINT TO BODY PARTS AND NAME EACH ONE.

CHAPTER 13: HEALTH PROMOTION DURING INFANCY:CASE STUDY: BREASTFEEDING:LAUREN IS A BREAST-FED, 2-WEEK-OLD INFANT WHO WEIGHED 2.9 KG (6 POUNDS, 5 OUNCES) AT BIRTH. SHE NOW WEIGHS 3.2 KG (7 POUNDS, 3 OUNCES) AND APPEARS HEALTH. THE NURSE IS DISCUSSING BREAST-FEEDING WITH LAUREN’S MOTHER.

1.WHICH OF THE FOLLOWING SHOULD THE NURSE RECOMMEND FOR SORE NIPPLES?

A. WASH THE NIPPLES WITH AN ANTIMICROBIAL SOAP TO PREVENT INFECTION.

B. POSITION THE INFANT SO THAT ENTIRE AREOLA IS NOT GRASPED.C. EXPRESS MILK MANUALLY AND BOTTLE-FEED INFANT UNTIL

NIPPLES HEAL.D. VARY INFANT’S POSITION AT BREAST; FOR EXAMPLE, USE THE

“FOOTBALL HOLD” AT TIMESRATIONALE:

A. SOAPS AND SELF-PRESCRIBED TREATMENTS FOR SORE NIPPLES SHOULD BE AVOIDED.

B. WHEN POSITIONING THE INFANT, THER MOTHER SHOULD ENSURE THE INFANT GRASPS THE ENTIRE AREOLA AND SHOULD USE DIFFERENT POSITIONS.

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C. SOME MOTHERS EXPERIENCE LATCH-ON DISCOMFORT FOR THE FIRST FEW DAYS WHEN A BABY STARTS NURSING. NIPPLE DISCOMFORT AFTER THIS PERIOD IS USUALLY DUE TO INCORRECT POSITIONING OF THE BABY, WHICH CAN BE EASILY REMEDIED. BOTTLE-FEEDING IS NOT NECESSARY AND SHOULD BE AVOIDED UNTIL BREAST-FEEDING IS WELL ESTABLISHED TO PREVENT NIPPLE PREFERENCE.

D. DIFFERENT POSITONS, SUCH AS THE FOOTBALL HOLD, SHOULD BE USED TO ENCOURAGE PROPER POSITIONING OF THE INFANT IN WHICH THE ENTIRE AREOLA IS GRASPED.

2. LAUREN’S MOTHER SAYS THAT THE BABY HAS BEEN “HUNGRIER THAN USUAL” THE PAST SEVERAL DAYS AND WANTS TO NURSE MORE OFTEN. THE NURSE SHOULD RECOMMEND WHICH OF THE FOLLOWING?

A. INCREASE THE FREQUENCY OF FEEDINGS TO ENSURE ADEQUATE MILK SUPPLY.

B. OFFER LAUREN A BOTTLE OF FORMULA AFTER BREAST-FEEDING.C. BEGIN FEEDIN LAUREN A SMALL AMOUNT OF RICE CEREAL

SEVERAL TIMES A DAY.D. BREAST FEED EVERY 4 HOURS, USING A PACIFIER BETWEEN

FEEDING TO KEEP LAUREN CONTENT.RATIONALE :

A. MILK PRODUCTION DEPENDS ON THE PRINCIPLE OF SUPPLY AND DEMAND. INCREASING THE FREQUENCY OF FEEDING WILL INCREASE THE DEMAND FOR MILK PRODUCITON.

B. SUPPLEMENTAL BOTTLE-FEEDINGS SHOULD BE AVOIDED UNTIL BREAST-FEEDING IS WELL ESTABLISHED TO PREVENT NIPPLE PREFERENCE.

C. SOLID FOOD IS NOT COMPATIBLE WITH THE ABILITY OF THE GI TRACT AND NUTRITIONAL NEEDS OF THE NEWBORN AND SHOULD NOT BE INTRODUCED BEFORE 4 TO 6 MONTHS.

D. DECREASING THE FREQUENCY OF BREAST-FEEDING WILL DECREASE THE DEMAND FOR MILK PRODUCTION, THUS DECREASING THE MILK SUPPLY FOR THE INFANT.

3.LAUREN’S MOTHER SAYS SOMETIMES IT IS DIFFICULT TO STIMULATE THE LET-DOWN REFLEX. WHICH OF THE FOLLOWING IS THE MOST APPROPRIATE RECOMMENDATION?

A. APPLY WARM COMPRESSES BEFORE FEEDING.B. AVOID TOUCHING BREASTS OR NIPPLES BEFORE FEEDING.C. WEAR A WELL-FITTING NURSING BRA 24 HOURS A DAY.

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D. FEED LAUREN IN A QUIET PLACE, USING THE SAME FEEDING POSITION EVERY TIME.

RATIONALE : A. THE APPLICATION OF WARM, MOIST COMPRESSES TO THE BREASTS

A FEW MINUTES BEFORE BREAST FEEDING CAN STIMULATE THE LET-DOWN REFLEX.

B. GENTLE STROKING FROM THE TOP OF THE BREAST TO THE NIPPLE WILL STIMULATE THE SET-DOWN REFLEX.

C. ALTHOUGH A WELL-FITTING NURSING BRA IS NEEDED FOR EXTRA SUPPORT DURING NURSING, THIS WILL NOT STIMULATE THE LET-DOWN REFLEX.

D. THE LET-DOWN REFLEX IS A PSYCHOSOMATIC RESPONSE THAT BEST OCCURS WHEN THE MOTHER IS RELAXED. THE FEEDING POSITION, HOWEVER, SHOULD BE VARIED AND DOES NOT INFLUENCE THE LET-DOWN REFLEX.

CASE STUDY: HEALTH PROBLEMS OF INFANTS (CH. 13)

SARA IS A FORMULA-FED, 1-MONTH-OLD INFANT WHO WEIGHED 3.2.KG (7 POUNDS, 2 OUNCES) AT BIRTH. SHE IS GAINING WEIGHT WELL AND APPEARS HELATHY. SARA’S MOTHER LOOKS EXHAUSTED AND STATES SHE IS CONCERNED AND FRUSTRATED AND FEELS LIKE SHE IS NOT A GOOD MOTHER.1. SARA’S MOTHER STATES THAT THE BABY BEGINS TO CRY EARLY IN

THE EVENING AND CONTINUES TO CRY FOR HOURS. THE CRYING STARTED ABOUT A WEEK AGO. SARA’S MOTHER IS WORRIED THERE IS SOMETHING WRONG WITH THE BABY; NOTHING SHEDOES SEEMS TO HELP. THE NURSE RECOGNIZES THIS DESCRIPTION OF PAROXYSMAL ABDOMINAL PAIN. WHICH OF THE FOLLOWING IS THE MOST APPROPRIATE RESPONSE TO THE MOTHER’S CONCERNS?

A. TELL HER TO IGNORE THE CRYING FOR AS LONG AS POSSIBLE BEFORE PICKING THE BABY UP.

B. PROVIDE SUPPORT TO THE PARENTS. STRESS THAT DESPITE THE CRYING AND OBVIOUS PAIN, THE INFANT IS DOING WELL.

C. ENCOURAGE THE MOTHER TO BE MORE RESPONSIVE TO THE CHILD TO PREVENT THE CRYING EPISODES.

D. CHANGE THE CHILD’S FORMULA TO A SOY-BASED PRODUCT.

SARA’S MOTHER HAS HEARD ABOUT A CONDITION CALLED SUDDEN INFANT DEATH SYNDROME (SIDS) AND ASKS THE NURSE HOW SHE CAN PROTECT HER BABY. THE NURSE SHOULD RECOMMEND THE FOLLOWING:

A. PLACE SARA TO SLEEP ON HER BACK.B. PLACE SARA TO SLEEP ON HER STOMACH.C. USE A HOME MONITOR TO ASSESS FOR APNEIC EPISODES.

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D. PLACE SARA TO SLEEP ON HER SIDE WITH SOFT PILLOWS FOR SUPPORT.

CHAPTER 14: HEALTH PROMOTION OF THE TODDLER AND FAMILY:CASE STUDY: TOILET TRAINING/TODDLER DEVELOPMENT:

MATT IS A HEALTHY 2 AND A HALF YEAR OLD WHOSE MOTHER ASKS THE NURSE FOR ADVICE ABOUT TOILET TRAINING. MATT’S MOTHER IS EXPECTING HER SECOND CHILD IN 4 MONTHS AND HAS NO PREVIOUS EXPERIENCE WITH TOILET TRAINING.1.THE NURSE SHOULD DO WHICH OF THE FOLLOWING FIRST?

A. ASK MATT IF HE WANTS TO LEARN TO USE THE TOILET.B. DISCUSS SIGNS THAT INDICATE MATT IS READY TO BEGIN

TOILET TRAINING.C. ENCOURAGE THE MOTHER TO INITIATE TOILET TRAINING AFTER

THE BIRTH OF THE NEW BABY.D. ASSESS THE MOTHER TO DETERMINE WHY SHE HAS WAITED SO

LONG TO BEGIN TOILET TRAINING.RATIONALE:

A. “NEGATIVISM,” THE PERSISTENT NEGATIVE RESPONSE TO REQUESTS, IS A CHARACTERISTIC OF TODDLERS IN THEIR QUEST FOR AUTONOMY. ASKING A TODDLER A “YES” OR “NO” QUESTION WILL OFTEN RESULT IN A “NO” RESPONSE. THEREFORE ASKING MATT IF HE WANTS TO LEARN TO USE THE TOILET IS NOT THE MOST ACCURATE WAY TO ASSESS HIS READINESS.

B. PHYSICAL ABILITY AND COMPLEX PSYCHOPHYSIOLOGIC FACTORS ARE REQUIRED FOR TOILET-TRAINING READINESS. ONE OF THE MOST IMPORTANT RESPONSIBILITIES OF NURSES IS TO HELP PARENTS IDENTIFY SIGNS OF READINESS IN THEIR CHILD.

C. THE ADDITION OF A NEW BABY TO THE FAMILY OFTEN INVOLVES CHANGES TO THE FAMILY THAT ARE RESENTED BY THE TODDLER. THER FIRST FEW WEEKS AT HOME WITH A NEWBORN AND TODDLER

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CAN BE CHALLENGING FOR THE PARENTS AND SHOULD NOT BE COMPLICATED BY THE CHALLENGE OF TOILET TRAINING.

D. THE AVERAGE AGE FOR TOILET TRAINING IN THE UNITED STATES IS 2.56 YEARS FOR BOYS. THE MOTHER IS REQUESTING ADVICE ON TOILET TRAINING AT AN APPROPRIATE AGE FOR HER TODDLER.

2. MATT’S MOTHER TELLS THE NURSE THAT SHE CAN’T AFFORD TO BUY A POTTY CHAIR. SHE EXPLAINS THAT THEY ARE SAVING MONEY BECAUSE THEY WILL SOON HAVE THE ADDED EXPENSE OF ANOTHER CHILD. THE MOST APPROPRIATE ACTION BY THE NURSE IS:

A. SUGGEST WAYS TO TOILET TRAIN MATT WITHOUT A POTTY CHAIR.

B. REFER FAMILY TO SOCIAL SERVICES FOR FINANCIAL ASSISTANCE.

C. RECOMMEND POSTPONING TOILET TRAINING UNTIL THEY CAN AFFORD A POTTY CHAIR.

D. HAVE MATT SIT ON A REGULAR TOILET TO ASSESS WHETHER HIS FEET WILL TOUCH THE FLOOR.

RATIONALE:A. If a potty chair is not available, many other techniques are available to assist the

child in toilet training. Having the child sit facing the toilet tank or placing a small bench under the child’s feet can provide added support.

B. A number of techniques can be helpful when initiating toilet training; a potty chair is not necessary for successful toilet training.

C. A number of techniques can be helpful when initiating toilet training; a potty chair is not necessary for successful toilet training.

D. Having the child sit facing the toilet tank or placing a small bench under the child’s feet can provide the support necessary when his feet do not touch the floor.

3. Matt is brought to the clinic 4 and a half months later because he has an ear infection. The nurse asks about toilet training. His mother says, “He has done real well except, since the baby came, he has wanted to wear diapers instead of

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underpants. I have been letting him wear diapers. He takes them on and off to use the toilet. I hope that is OK.” The most appropriate action by the nurse is:

A. Assess why the mother decided to let Matt wear diapers.B. Recommend that mother put Matt back into underpants immediately.C. Reassures mother that regression such as this is common in toddlers after the

birth of a sibling.D. Explain to mother that negativism such as this is common in toddlers who are

toilet trained before they are ready.RATIONALE :

A. Sibling rivalry may cause a toddler to revert to more infantile forms of behavior. The mother is demonstrating an understanding of this response in her toddler and allowing him to express his feelings. The nurse should support the mother’s actions rather than assessing further.

B. The toddler’s regression is a common sign of his feelings and will pass as he learns to accept the changes in his lifestyle. This expression should not be suppressed by making the child wear his underpants.

C. Parents are reassured that the period of regression will pass when the toddler learns to accept the changes in his lifestyle.

D. The regression demonstrated by the toddler is a common form of communicating angry feelings followed the addition of a newborn to the family. This should not be interpreted as a lack of toilet-training readiness.

CHAPTER 17:CASE STUDY: INJURY PREVENTION:Patrick is an active 7 year old who lives with his parents and two younger siblings in a house in the suburbs of a small city. He enjoys being outside and riding his bike.1.What is the most common cause of severe injury and death in the school-age child?

A. BurnsB. DrowningC. Motor vehicle accidentsD. Cancer

2.What is the most effective means to support accident prevention?A. Purchase new equipment.B. Supervise all activities.C. Educate the child and family.D. Hang posters in the school.

3.Patrick always asks his mother why he cannot ride in the front seat of the car beside her. At what age can a child be allowed to ride in the front passenger seat of cars with airbags?

A. 11 yearsB. 12 yearsC. 5 yearsD. 16 years

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CHAPTER 21:CASE STUDY: TEEN SMOKING:Danielle is a 17 year old high school senior. She and her friends started smoking 2 years ago, at age 15. Danielle is aware of the risks associated with smoking, but she and her friends think it is cool to smoke, and “besides, everyone is doing it.”1.Which of the following is the most appropriate nursing intervention to discourage teen smoking?

A. Ignore the issue, since teens never listen to adults.B. Lecture on the effects of smoking on growth and development.C. Promote programs that include peers, parents, mass media, and community

organizations.D. Provide models of smoke-filled lungs to the schools.

2.Identify the most common reason that teenagers start smoking.A. Peer pressureB. RelaxationC. CuriosityD. Family history

CASE STUDY: BURNSTYLER, A 3-YEAR-OLD BOY, WAS BURNED OVER 30% OF HIS BODY BY PULLING A HOT POT OF COFFEE OFF THE COUNTER ONTO HIMSELF. HIS UPPER TORSO, RIGHT ARM, AND HAND ARE BURNED. HE IS ADMITTED TO THE BURN UNIT EMERGENCY CENTER.1. It is determined that the injury includes both full and partial thickness burns. How would this burn be classified?

A. MildB. ModerateC. MajorD. Severe

RATIONALE:A. Burns classified as mild involve only partial thickness burns over 10% of the total

body surface area.B. Burns classified as moderate involve only partial thickness burns, involving 10%

to 20% of the total body surface area.C. Major burns include partial thickness burns involving greater than 20% of the

total body surface area and full thickness burns.D. Severe is not a term used by the severity grading system adopted by the American

Burn Association.

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2.Tyler weighs 15kg (33 pounds). Fluid replacement therapy is considered minimally adequate when hourly urinary output is:

A. 5 mlB. 15 mlC. 25 mlD. 50 ml

RATIONALE:A-Dà Fluid replacement is maintained at a rate that will provide an hourly urinary output of 1 to 2 ml/kg for children weighing less than 30kg (66 pounds). This would be a minimum urinary output of 15ml for a child weighing 15kg (33 pounds).

3. The analgesic of choice for Tyler’s pain is:A. AcetaminophenB. CodeineC. DemerolD. Morphine

RATIONALE:A. Acetaminophen is used in combination with an opioid such as codeine only in children with less severe injuries.B. Codeine is used in combination with a nonopioid such as acetaminophen only in children with less severe injuries. C. Demerol is not recommended for chronic use (or for more than 48 hours at a time) because of the accumulation of its metabolite, normeperidine. Normeperidine is a central nervous system stimulant that can produce anxiety, tremors, myoclonus, and generalized seizures.D. Morphine sulfate is the drug of choice because of its extensive distribution.

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