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Introduction to Pediatric Nursing. Who is the patient?. 6 year old female admitted to the hospital with a diagnosis of pneumonia Currently in 1 st grade Lives at home with Mother, Father, and 2 year old sibling Both parents work full time outside the home

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Introduction to Pediatric Nursing

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Introduction to pediatric nursing l.jpg

Introduction to Pediatric Nursing


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Who is the patient?

  • 6 year old female admitted to the hospital with a 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


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Answer:


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Pediatric Nursing is:

  • A parent-nurse partnership

  • Nurse’s goals are:

    • to promote a therapeutic relationship between parent and child

    • Accomplished by family-centered care

    • To promote continued growth and development


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Definitions of Grwoth and Development

  • Growth

    • Increase in physical size of a whole or any of its parts, or an increase in number and size of cells: Growth can be measured

  • Development

    • A continuous, orderly series of conditions that leads to activities, new motives for activities, and patterns of behavior


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Stages of Growth and Development

Neonate: first 28 days of life

Infancy: birth to 1 year

Toddler: 1 to 3 years

Preschooler: 3 to 6 years

School-ager: 6 to 10 years

Prepubertal: 10 to 13 years

Adolescent: 13 to 18 + years


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Pace of Growth

  • A rapid pace from birth to 1 ½-2 years

  • A slower pace from 2 years to puberty

    • 4-6 lb/year

  • A rapid pace from puberty to approximately 15 years

  • A sharp decline from 16 years to approximately 24 years when full adult size is reached


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Psychosocial & Intellectual Development


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Theorists Associated with Development

  • Piaget:Periods of cognitive development

  • Erikson:Stages of psychosocial development

  • Kohlberg: Stages of moral development

  • Freud:Stages of psychosexual development


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Promote Psychosocial Development (Erikson)

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 self care & imitation


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Initiative vs. Guilt: (3-6 yrs)

  • Learns to initiate play activities.

  • Nurses should encourage to explore environment with senses, promote imagination

  • Industry vs. Inferiority: (6-12 yrs)

  • Learns self worth as a workers & producers

  • Allow children to compete and cooperate


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Psychosocial Development (Erikson)

Identity vs. Role Confusion: (12-18 yrs)

  • Forms identity and establishment of autonomy from parents

  • Peers, society big influence

  • Encourage peer visitation, texting, phone calls


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Intellectual Development (Piaget)

Sensorimotor (birth to 2)

  • learns from movement and sensory input.

  • learns cause & effect

    Preoperational (2 to 7)

  • Increasing curiosity and explorative behavior.

  • Thinking is concrete

  • Egocentrism


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Intellectual Development (Piaget)

Concrete Operational (7 to 11)

  • Logical & coherent thought

  • Can distinguish fact from fantasy

    Formal Operations (11 to 15 to adulthood)

    Acquisition of abstract reasoning leading to

    Analytical thinking

    Problem solving

    Planning for the future


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Factors Influencing Growth and Development

  • Genetics

  • Environment

  • Culture

  • Nutrition

  • Health status

  • Family

  • Parental attitudes

  • Child-rearing philosophies


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Play


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Purpose of Play

  • Sensorimotor development

  • Intellectual development

  • Socialization

  • Creativity

  • Self-awareness

  • Therapeutic value

  • Moral value


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Types of Play

  • Solitary

  • Parallel

  • Associative

  • Cooperative

  • Onlooker

  • Dramatic

  • Familiarization


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Communicating with Children


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Infancy

  • Respond to physical contact

  • Gentle voice

  • Sing-song quality

  • High pitched

  • Need to be held, cuddled


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Early Childhood < 7 yrs

egocentric, interpret words literally

  • tell them what “they” 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


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want to know why an object exists

how it works

why it is being done to them

concerned about body integrity

School Age


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Adolescents

  • give undivided attention

  • listen, be open-minded

  • avoid criticizing

  • make expectations clear


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Physical & Developmental Assessment


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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: child’s readiness to cooperate

  • Begin with the least intrusive examination (observation)


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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: head to toe, genitalia last, respect privacy

  • Adolescent: same as school-age


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Pediatric Physical Exam: Key Points

  • Growth measurements

    • Height, weight, Head circumference (<2 yrs)

  • Physiologic measurements

  • General appearance (hygiene, posture, behavior)

  • Lungs/ Heart

  • Skin (color, texture, moisture, turgor)

  • Lymph nodes (tender, large, warm may indicate infection)

  • Eyes, ears, nose, throat

  • Abdomen/Genitalia


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Denver Developmental Screening Test (DDST-II)

  • Evaluates development for children 0-6 in four areas

    • Personal-social

    • Fine-motor

    • Language

    • Gross motor

  • Child’s mood must be typical for results to be valid (results may be altered if child is not feeling well, sedated)


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Denver Developmental Screening Test (DDST-II)

  • Provides a clinical impression on child’s 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


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Nursing Interventions based on Developmental Level

  • Infants (0-12m) Use soft voice, sing-song, talk to and describe procedures as they are done

  • Toddlers (1-2 yr) Separation anxiety peaks, seeing the nurse as a stranger increased anxiety: establish trust first

    Preparation for a procedure should begin immediately before the event

  • Preschool (3-5 yr) Explain procedures according to senses (what child will feel, see, hear) Imagination is active...may see procedures as a consequence for misbehavior


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Nursing Interventions based on Developmental Level

  • School-age (6-11 yr) Use books, pictures to explain procedures, developmentally ready for detailed explanations. Organizing and collecting is an enjoyed activity, peers become more important

  • Adolescents (12 & up) Value privacy, group identification is important, may have an need for independence. Can understand adult concepts and can be prepared for a procedure up to a week in advance


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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


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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


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Nutrition


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Infancy 0-6 months

  • Breastmilk most desirable

  • Fe fortified formula alternative.

    No whole milk until 1 yr b/c:

  • Altered ability to be digested

  • Increased risk of contamination

  • Lack of components needed for appropriate growth


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No solids before 4-6 mos b/c:

  • 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)


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Infancy 6-12 months

  • Breastmilk or formula remains the primary source of nutrition.

    Addition of solids b/c:

  • GI tract is mature to handle complex nutrients & is less sensitive to allergenic foods.

  • Extrusion reflex has disappeared.

  • Swallowing is more coordinated.

  • Head control is well developed, voluntary grasping begins.


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Infancy 6-12 months

  • 4- 6 mos infant cereal mixed with formula or Breast milk (Rice, then oatmeal, barley)

  • 6 mos can introduce crackers as a teething food.

  • 6 mos fruit juice to sub for one milk feeding

  • Baby food (pureed fruits and vegetables)

  • *** introduce one at a time at 4-7 day intervals

  • No Strawberries, eggs, peanuts


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Infancy 6-12 months

  • By 8-9 months junior foods & finger foods.

  • By 1-year well-cooked table foods are served.


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Toddlerhood

  • From 12-18 mos rate of growth slows.

  • At 18 mos decreased nutritional need, appetite declines, picky eaters

  • At 18 mos may be able to adeptly use spoon, prefer fingers

  • Do not force food.


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Toddlerhood

  • Mealtime should be pleasant.

  • What is eaten is more important than how much is eaten.

  • General serving size: ¼ to 1/3 of the adult portion.

  • May have a hard time sitting through an entire meal.


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Preschool

  • Needs are similar to toddler.

  • Average daily intake: 1800 calories.

  • By age 5 they are more agreeable to try new foods; are ready to socialize during meals.

  • ½ of an adult’s portion


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School Age Years

  • Likes & dislikes are established.

  • Important for parents to choose foods that promotes growth.

  • Eat away from home.

  • Important to teach Food Pyramid Guide for nutrition instruction.

  • Encourage the child to make good choices.


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Adolescence

  • Caloric & 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.


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Care of the Hospitalized Child


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“Atraumatic Care”

Use of interventions that eliminate or minimize psychological and physical distress that is experienced by children and their families in the health care system


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Promotion of normal development

  • Infants: oral-motor development

  • Toddlers: encourage mobility & exploration, language development

  • Preschoolers: assistance with self-care

  • School-aged: socialization, provision of games & tasks for mastery

  • Adolescents: increased independence in managing own care


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Stressors of Hospitalization

  • Separation Anxiety

  • Loss of Control

  • Bodily Injury & Pain


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1. 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


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Nursing Diagnosis

Anxiety r/t separation from parents during hospitalization.

Goal: child will exhibit minimal evidence of separation anxiety during hospitalization.

Outcome criteria: observe child’s positive interactions with staff members & adherence to hospital routine, appropriate for age & stage of development.


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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


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2. Loss of Control

  • Children loose control over their:

    • Routine

    • Body

    • Basic decisions

    • Loss of school, boredom

    • Ability to socialize


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Interventions

  • Infants: Provide consistent care

  • Toddlers: maintain consistent routine

  • Toddlers often have security objects such as a stuffed animal that help them feel safe and secure

  • Preschoolers: need adequate preparation to unfamiliar experiences, fear bodily injury

  • School-aged: provide schoolwork, social

  • Adolescents: same as schoolage, privacy


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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.


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3. Bodily Injury

  • Procedures are uncomfortable

  • Disease processes are painful

  • Postoperative pain can be very severe


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Assess for Pain

Infants: watch facial expression, FLACC

Toddlers: grimace, clench teeth, restless

Preschoolers: can locate pain, use face scale, fear bodily injury & mutilation, literal

School-aged: fear disability & death, pain is punishment, “magical quality” of germs, can use faces scale

Adolescents: use same pain scale as adults


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Pediatric Pain Assessment

Pain is whatever the child experiencing it says it is”.


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Children are under-medicated because of these MYTHS:

  • infants don’t feel pain

  • 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 child’s pain control

  • narcotics are more dangerous for children


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Interventions

  • Nurses have an ethical obligation to relieve a child’s suffering

  • In addition adequate pain relief leads to

    • earlier mobilization

    • shortened hospital stays

    • reduced costs.


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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.


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Interventions

  • Medicate for Pain

  • Non Pharmacological Therapy

    • Cutaneous Stimulation

    • Distraction

    • Guided Imagery

    • Hot or Cold application

    • Relaxation


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Hospitalization for all pediatric patients

GOALS:

  • Child will be prepared.

  • Child will experience little or no separation.

  • Child will maintain sense of control.

  • Child will exhibit decreased fear of bodily injury.


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Practice Questions!


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While the nurse is administering the Denver Developmental Screening test to an infant, a mother expresses concern that her baby is not doing well. Which response is most appropriate for the nurse to make?

  • Why are you so worried? Have you been having problems at home too?

  • Please let me finish this test before you start worrying, Maybe the baby will do better on the rest of the test

  • You really sound worried. Please keep in mind that no baby is expected to do all the things on this test

  • Unfortunately, your concerns seem to be valid. I will write up a consult with the child development specialist


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The RN observes a nursing student entering a toddler’s room to check vital signs and begins to take the child’s temperature first. The RN should:

  • Suggest the student start with the pulse

  • Suggest the student start with the BP

  • Suggest the student start with respirations

  • Say nothing, this action is appropriate


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The nurse should teach parents of a preschooler that the best way for them to assist their child to complete the core developmental task of the preschooler is to:

  • Encourage the child to remove and put on own clothes

  • Knock on door before entering the child’s bedroom

  • Plan for playtime and offer a variety of materials from which to choose.

  • Sing to, rock, and hold the child consistently


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A toddler who is to be hospitalized brings a dirty, ragged Barney stuffed animal with him. The nurse’s most appropriate action is:

  • Ask the toddler’s parents to find an identical new Barney stuffed animal

  • Remove Barney while the child is sleeping and tell the child when he wakes that Barney is lost

  • Allow the toddler to keep the Barney stuffed animal

  • Distract the toddler by taking him to the playroom and letting him select another stuffed animal


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The mother of a preschooler expresses disappointment when her child’s weight has increased only 4 pounds since the child’s physical 1 year ago. The nurse should advise this mother that:

  • 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


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The nurse should suggest that the best way for a toddler’s parents to assist their child to complete the core developmental task of the toddler years is to:

  • Allow the toddler to make simple decisions

  • Allow the toddler to “help” with chores

  • Assign the toddler simple tasks or errands

  • Teach the toddler car and street safety rules


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  • The nurse is preparing to change a toddler’s wound for the first time. Prior to the dressing change the nurse uses a gauze as a “blanket” for the child’s action figure. This is known as:

  • Dramatic play

  • Familiarization

  • Cooperative play

  • Onlooker actions


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  • A mother of a toddler is frustrated and states “ I can’t get this child to eat!”. The nurse should help by reviewing the portion size for toddlers is _____ of an adult’s portion.

  • ¼

  • 2/3

  • ½

  • ¾


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