INTRODUCTION

TO
CHILD HEALTH NURSING

WHO IS YOUR
PATIENT?
6 year old female admitted to the hospital

with a medical diagnosis of pneumonia

Currently in 1st grade
Lives at home with Mother, Father, and 2
year old sibling
Both parents work full time outside the
home
Grandparents live in near by town and
assist with child care

ANSWER:

PEDIATRIC
NURSING
A parent-nurse partnership

Nurses

goals are to promote

therapeutic relationship between
parent and child
continued

growth and development

GROWTH
AND
DEVELOPMENT

DEFINITIONS OF GROWTH AND

DEVELOPMENT

Growth

Increase

in physical size of a whole or any of its parts

Increase in number and size of cells
Growth can be measured

Development
A

continuous, orderly series of conditions

leads to activities and patterns of behavior

PACE OF GROWTH
A

rapid pace from birth to 1 -2 years

slower pace from 2 years to puberty

Expected 4-6 lb/year

rapid pace from puberty to

approximately 15 years

sharp decline from 16 years to

approximately 24 years when full adult
size is reached

STAGES OF GROWTH AND

DEVELOPMENT

Neonate first 28 days of life

Infancy birth to 12 months

Toddler 1 to 3 years

Preschooler 4 to 5 years

School-ager 6 to 10 years

Prepubertal 11 to 12 years

Adolescent 13 to 18 + years

DEVELOPMENT
PSYCHOSOCIAL &
INTELLECTUAL

THEORISTS ASSOCIATED
WITH DEVELOPMENT

Piaget

Erikson Stages of psychosocial development

Kohlberg Stages of moral development

Freud

Stages of cognitive development

Stages of psychosexual development

PSYCHOSOCIAL DEVELOPMENT
Trust vs. Mistrust (birth to 1 year)
Establishes a sense of trust when basic
needs are
Nurses should provide consistent, loving
care
Autonomy vs. Shame & Doubt: (1-3 yrs)
Increasingly independent in many spheres
of life
Nurses should allow for choices and self
care

PSYCHOSOCIAL DEVELOPMENT
Initiative vs. Guilt (3-6 yrs)
Learns to initiate play activities, imitate adult
behavior
Nurses should encourage to explore environment
with senses, promote imagination

Industry vs. Inferiority (6-12 yrs)

Learns self worth as workers & producers
Nurses should promote children to compete and
cooperate

PSYCHOSOCIAL
DEVELOPMENT
Identity vs. Role Confusion (12-18 yrs)
Forms identity and establishment
of autonomy from parents
Peers and society big influence
Nurses should encourage peer visitation,
texting, phone calls

INTELLECTUAL
DEVELOPMENT
Sensorimotor (birth to 2)
Learns from movement and sensory input
Learns cause & effect

Preoperational (2 to 7 years)
Increasing curiosity and explorative behavior
Thinking is concrete
Egocentrism is dominant

INTELLECTUAL DEVELOPMENT
Concrete Operational (7 to 11 years)

Logical & coherent thought

Can now distinguish fact from fantasy

Formal Operations (11 to adulthood)

Acquisition of abstract reasoning leading to
Analytical thinking
Problem solving
Planning for the future

FACTORS INFLUENCING GROWTH

AND DEVELOPMENT
Genetics

Environment
Culture

Nutrition
Health

Family

status

Parental

attitudes
Child-rearing philosophies

PLAY

PURPOSE OF PLAY
Sensorimotor

development
Intellectual development
Socialization
Creativity
Self-awareness
Moral value
Therapeutic value

TYPES OF PLAY
Solitary
Parallel

Associative

Cooperative
Onlooker

Dramatic

Familiarization

COMMUNICATING WITH
CHILDREN

INFANCY
Responds

to physical contact
Use a gentle voice
Sing-song quality
High pitched
Need to be held, cuddled

EARLY CHILDHOOD < 7 YRS

Remember

they are egocentric and

interpret words literally

Tell

them what children can do

Let them touch equipment
Nonverbal messages should be clear
Maintain eye level
Use quiet, calm voice
Be specific, use simple words, short
sentences, be honest

SCHOOL AGE
Wants

to know why an object exists

How it works
Why it is being done to them
Concerned about body integrity

ADOLESCENTS

Needs undivided attention

o Listen, be open-minded
o Avoid criticizing
o Make expectations clear
o

PHYSICAL & DEVELOPMENTAL

ASSESSMENT

PHYSICAL EXAM GUIDELINES

Non-threatening environment
Place frightening equipment out of sight
Provide privacy
Provide time for play (stuffed animals, dolls)
Observe for behaviors re: childs readiness to
cooperate
Begin with the least intrusive examination
(observation)

AGE-SPECIFIC APPROACHES TO EXAM

Infant:

auscultate heart, lungs first

(head to toe NOT always appropriate)

Toddler:

inspect body area through play,

introduce equipment slowly

Preschool:

if cooperative: proceed head to

toe, if not: same as toddler

School-age

and Adolescents: head to

toe, genitalia last, respect privacy

PEDIATRIC PHYSICAL EXAM

Growth measurements
Height, weight, head circumference (<3 yrs)

Physiologic measurements (VS)

General appearance (hygiene, posture, behavior)

Body Systems (heart, lungs, abdomen are key

areas)

DENVER DEVELOPMENTAL
SCREENING TEST (DDST-II)

Evaluates development for children 0-6 in four

areas
Personal-social
Fine-motor
Language
Gross motor

Childs

mood must be typical for results to

be valid
Results may be altered if child is not
feeling well, sedated

DENVER DEVELOPMENTAL
SCREENING TEST (DDST-II)

Provides a clinical impression on childs overall

development
Not a predictor of future development, not an IQ
test
Used for noting problems, monitoring, and to
base a referral for additional developmental
testing

NURSING INTERVENTIONS BASED ON

DEVELOPMENTAL AGE
(NOT CHRONOLOGICAL AGE)

Infants (0-12m)
Use

soft voice, sing-song,

Talk to and describe procedures as they are done

Toddlers (1-3 yr)

Separation

anxiety peaks (nurse is a stranger)

Preparation for a procedure should begin immediately
before the event

NURSING INTERVENTIONS BASED

ON DEVELOPMENTAL AGE
(NOT CHRONOLOGICAL AGE)

Preschool (4-5 yr)

Explain

procedures according to senses (what child

will feel, see, hear)
Imagination is active...may see procedures as a
consequence for misbehavior

School-age (6-10 yr)

Use

books, pictures to explain procedures

Developmentally ready for detailed explanations
Organizing and collecting is an enjoyed activity
Peers become more important, parents still main
influence

NURSING INTERVENTIONS
BASED ON DEVELOPMENTAL AGE
(NOT CHRONOLOGICAL AGE)
Pre-Adolescents/Adolescents

Value

(11 & up)

privacy, group identification is

important
May have an need for independence
Older adolescent can understand adult
concepts
Can be prepared for a procedure up to a
week in advance

DISCIPLINE (LIMIT SETTING)

Reinforcement

of desired behaviors is

most effective
Consequences for negative behaviors
Teaching

parents how to discipline avoids

problems related to incorrect use
Appropriate limit setting
Consistency
Consequences should be told in advance
Include truthful explanation of why behavior is
unacceptable

Physical

punishment is the least effective

LIMIT SETTING AND THE TODDLER

Discipline

must be consistent, immediate,

realistic, age-appropriate, and related to
the incident
Clearly explain limits and give time for
toddlers to respond
Avoid arguments and extensive
explanations
Avoid withdrawing love as punishment
Separate toddler from behavior
Praise toddler for good behavior

NUTRITION

INFANCY 0-6 MONTHS

Breastmilk

most desirable

Fe

fortified formula alternative

No

whole milk until 1 year old

Altered

ability to be digested
Increased risk of contamination
Lack of components needed for appropriate
growth

INFANCY 6-12 MONTHS

Breast

milk or formula remains the

primary source of nutrition

May

begin addition of solids b/c:

GI tract is mature to handle complex
nutrients
GI tract is less sensitive to allergenic
foods
Extrusion reflex has disappeared
Swallowing is more coordinated
Head control is well developed,
voluntary grasping begins

INFANCY 6-12 MONTHS

4-

6 months infant cereal mixed with formula

or Breast milk (Rice, then oatmeal, barley)
6 months can introduce crackers as a
teething food.
6 months fruit juice to substitute for one
milk feeding
Baby food (pureed fruits and vegetables)
Introduce one food at a time at 4-7 day
intervals
No strawberries, eggs, peanuts until after 12
months of age

INFANCY 0-6 MONTHS

No solids before 4-6 months of age b/c:
Solids are not compatible with GI tract
Exposure

to food antigens that may

produce a food-protein allergy

Extrusion

reflex still present (pushes food

out of mouth)

INFANCY 6-12
MONTHS
By

8-9 months junior foods & finger

foods

By

1-year well-cooked table foods

TODDLERHOOD
From

12-18 months rate of growth slows

At

18 months decreased nutritional need,

appetite declines, picky eaters

At

18 months may be able to adeptly use

spoon, prefer fingers

Do

not force food

TODDLERHOOD
Mealtime

should be pleasant

What

is eaten is more important than

how much is eaten

General

serving size is to 1/3 of the

adult portion

May

have a hard time sitting through

an entire meal

PRESCHOOL
Needs

are similar to toddler

Average
More

daily intake: 1800 calories

agreeable to try new foods

Ready

to socialize during meals

General

portion

serving size is of an adults

SCHOOL AGE YEARS

Food

likes and dislikes are established

Important

for parents to choose foods that

promotes growth

Children

eat away from home

Important

to teach Food Pyramid Guide for

nutrition instruction

Encourage

the child to make good choices

ADOLESCENCE
Caloric

and protein requirements

are higher than almost any time
in life

Eating

habits easily influenced

by peers

Fad

diets, high caloric foods low

in nutritional value popular

CARE OF THE
HOSPITALIZED
CHILD

ATRAUMATIC CARE
Interventions that eliminate or
minimize psychological and
physical distress experienced by
children and their families in the
health care system

STRESSORS OF
HOSPITALIZATION

Separation Anxiety

Loss of Control

Bodily Injury & Pain

STAGES OF SEPARATION ANXIETY

(Universal fear of toddler)
Protest

loud, demanding cries, rejects comfort measures

Despair

lies on abdomen, flat facial expression, weight loss,

insomnia, loss of developmental skills

Denial

or Detachment

silent expressionless child, deterioration of

developmental milestones, may have trouble forming
close relationships

NURSING
INTERVENTIONS
Limit

admissions
Limit hospital stay
Reduce pain
Adequately prepare child for procedures
Open visiting (include siblings)
Primary nursing
Use of play
Hospital bed = safe area
Increase control

LOSS OF CONTROL
Children

loose control over their

Routine
Body
Basic decisions
Loss of school, boredom
Ability to socialize

INTERVENTIONS

Infants

Provide

consistent care

Toddlers

Maintain

consistent routine
Encourage brining security objects (stuffed anima)l
that help them feel safe and secure

Preschoolers
Need

adequate preparation to unfamiliar experiences

Fear bodily injury

School-age, pre-adolescent and adolescents

Provide

schoolwork, social time, privacy

INTERVENTIONS: PLAY!
Provides diversion, brings about
relaxation
Helps child feel more secure in strange
environment
Helps lessen stress of separation
Means for release of tension & fears
Means for accomplishing therapeutic
goals
Allows making choices & being in
control

BODILY INJURY

Procedures are uncomfortable

Disease processes are painful

Postoperative pain can be very severe

ASSESS FOR PAIN

Infants

and Toddlers
Grimace, clench teeth, restless
Preschoolers
Can locate pain, use face scale
Fear bodily injury & mutilation
School-age
Fear disability & death
Pain is seen as punishment
Magical quality of germs
Can use faces scale
Adolescents
Use same pain scale as adults

PEDIATRIC PAIN ASSESSMENT

Pain is whatever the child experiencing it says it is.

CHILDREN ARE UNDERMEDICATED BECAUSE OF

THESE
MYTHS:
o infants dont
feel pain
o

children tolerate pain better than adults

children cannot tell you where it hurts

children always tell the truth about pain

children become accustomed to painful procedures

parents do not want to be involved in childs pain

control

narcotics are more dangerous for children

INTERVENTIONS
Nurses

have an ethical obligation to

relieve a childs suffering

Adequate

pain relief leads to

earlier mobilization
shortened hospital stays
reduced costs

ASSESS THE CHILD USING

QUESTT:
Question

the child
Use pain rating scales
Evaluate behavior & physiologic
changes
Secure the parents involvement
Take into consideration: cause of pain
Take action & evaluate results

INTERVENTIONS

Medicate for Pain

Non Pharmacological Therapy

Cutaneous

Distraction
Guided

Stimulation

Imagery
Hot or Cold application
Relaxation

HOSPITALIZATION FOR ALL

PEDIATRIC PATIENTS

Child will be prepared

2.Child will experience little or no
separation
3.Child will maintain sense of control
4.Child will exhibit decreased fear of
bodily injury
1.

PRACTICE QUESTIONS!

The nurse is administering the Denver Developmental

Screening test to an infant. The mother expresses
concern that her baby is not doing well. Which
response is most appropriate for the nurse to make?
1.

Why are you so worried? Have you been having

problems at home too?

2.

Please let me finish this test before you start

worrying, Maybe the baby will do better on the rest
of the test

3.

You really sound worried. Please keep in mind that

no baby is expected to do all the things on this test

4.

Unfortunately, your concerns seem to be valid. I will

write up a consult with the child development
specialist

The RN observes a nursing student

entering a toddlers room to check vital
signs and begins to take the childs BP
first. The RN should:
1.
2.
3.
4.

Say nothing, this action is appropriate

Suggest the student start with the pulse
Suggest the student start with the
temperature
Suggest the student start with
respirations

The nurse teaches parents of a 4-year-old about

the best way to assist their child in completing
the core developmental task of the preschooler by:
1.

2.

3.

4.

Encouraging the child to remove and put on own

clothes
Knocking on door before entering the childs
bedroom
Planning for playtime and offer a variety of
materials from which to choose
Singing, rocking, and holding the child
consistently

A toddler who is to be hospitalized brings a dirty,

ragged Elmo stuffed animal with him. The nurses
most appropriate action is:
1.

Ask the toddlers parents to find an identical new

Elmo stuffed animal

2.

Allow the toddler to keep the Elmo stuffed animal

3.

Remove Elmo while the child is sleeping and tell the

child when he wakes that Elmo is lost

4.

Distract the toddler by taking him to the playroom

and letting him select another stuffed animal

The mother of a preschooler expresses

disappointment when her childs weight has
increased only 4 pounds since the childs physical 1
year ago. The nurse should advise this mother that:
1.

2.

3.

4.

A weight gain of 4-6 pounds/year is normal for a

preschooler
The poor weight gain may be a result of poor
nutrition
The poor weight gain may indicate a more serious
problem
The weight gain is not ideal but may be nothing to
worry about

The nurse should suggest the best way for

a toddlers parents to assist their child to
complete the core developmental task of
the toddler years is to:
1.

Allow the toddler to make simple decisions

2.

Allow the toddler to help with chores

3.

Assign the toddler simple tasks or errands

4.

Teach the toddler car and street safety

rules

The nurse is preparing to change a toddlers wound

for the first time. Prior to the dressing change the
nurse uses a gauze as a blanket for the childs
action figure. This is known as:
1.Dramatic play
2.Familiarization
3.Cooperative
4.Onlooker

play

actions

A mother of a toddler is frustrated and states I

cant get this child to eat!. The nurse should help
by reviewing the portion size for toddlers is _____
of an adults portion.

1.
2.

2/3

3.
4.