Pediatric Nursing

GENERAL PRINCIPLES
Definition of Terms
Growth: increase in size of a structure. Development: increased complexity in thought, skill, & function. Maturation: physiologically determined pattern for growth & development. Cephalocaudal: head-to-toe progression of growth. Proximodistal: trunk-to-periphery progression of growth

Rates of Development
Infancy & Adolescence: fast growth periods Toddler, preschool, school-age: slow growth periods Fetal period & Infancy: head & neurologic tissue grow the fastest Toddler & Preschool periods: trunk grows more rapidly than other tissues School-age: limbs grow most Adolescence: trunk grows faster

Child Development Theorists

Sigmund Freud (Psychosexual Theory)

Erik Erikson (Psychosocial Theory)

Lawrence Kohlberg
(Moral Development Theory)

Jean Piaget (Cognitive Theory)

Unit I Health Promotion of the Newborn and Family

(birth-1 year)

1. PROMOTING OPTIMAL GROWTH & DEVELOPMENT IN INFANCY

1.1Biologic Development
A. Proportional Changes B. Sensory Changes C.Maturation of Systems D.Neurological Reflexes that Appear during Infancy

A. Proportional Changes
Weight (gain 1.5 lbs/month until 6
months; triples at 1 year)

Height (cephalocaudalproximodistal) Head Circumference (inc. by 2

cm/month from birth to 3 months)

Heart (55% of the chest width)

B. Sensory Changes
Eyes
(birth)

Presence of Dolls eye reflex Tear glands are not yet able to fxn. (4 wks) Can watch intently when parent speaks to infant Tear glands begin to function

(6-12 wks) Binocularity (fixation of 2 ocular images into 1 cerebral picture) Disappearance of Dolls eye reflex (20-28 wks) Develops color preference for yellow & red Prefers more complex visual stimuli

(28-44 wks)
Depth perception develops Lack of binocular vision indicates strabismus (lack of ocular muscle development) (44-52 wks) Visual loss is developing if strabismus is present

(birth) Responds to loud noise by startle or Moro reflex Responds to human voices more rapidly than to any other sounds Quieting effect from low-pitched sounds such as lullaby, metronome, or heartbeat

Ears

(24-32 wks) Responds to own name

(40-50 wks)

Knows several words such as no and names of family members Knows to control & adjust response to sound such as listening for the sound to occur again

C. Maturation of Systems
Respiratory system Ears Immune system Cardiovascular system Blood (presence of HgbF until 5th month)

 GIT - Liver - Reflexes such as: Sucking (nutritive & nonnutritive) Swallowing ( Santmyer swallow)

 Metabolism ( ACTH): mineralocorticoids and glucocorticiods) less tolerance for stress Kidneys immaturity predisposes infants to dehydration Skin 40% ECF in baby to 20% in adults

Predisposes infants to dehydration

D. Neurologic Reflexes that appear during infancy

Newborn Reflexes
reflex actions originating in the central nervous system that are exhibited by normal infants but not in neurologically intact adults natural physical responses a baby has that helps him or her to survive outside of the womb

 generally subside within a few months as the baby grows and matures reflexes help pediatricians identify if a baby is growing and maturing as he or she should be.

Reflex Stimulation Respons e Startles; Sudden throws move; out arms, loud noise legs then pulls them toward body

Duration

M O R O

Disappears at three to four months

Reflex Stimulation Response Duration

R O O T I N G

Cheek stroked or side of mouth touched

Turns toward source, opens mouth and sucks

Disappears at three to four months

Rooting Reflex

Reflex Stimulation Respons Duration e

S U C K I N G

Mouth Sucks touched on by object object Disappears

at three to four months

Sucking Reflex

Reflex Stimulation Respons Duration e

Toni Placed on back c neck

Makes fists and turns Disappears head to at two the right months

Reflex Stimulation

Respon Duration se

G R A S P

Palms touched

Grasps Weakens tightly at three months; disappears at 1 year

Reflex
S T E P P I N G

Stimulation Respons Duration e

Infant held upright with feet touching ground

Moves feet as if to Disappears walk at three to four months

Reflex

Stimulatio Respons Duration n e

Babin- Sole of ski foot stroked

Fans out toes and twists foot in

Disappears at nine months to 1 year

Babinski Reflex

Reflex Stimulation Response Duration

Para- Thrust chute forward in vertical position

Extends hands and fingers forward

Appears at seven to nine months

Why should nurses be familiar with the different infantile reflexes?

Reflexes help identify if a baby is growing and maturing normally.

Exercise Identify the following Infant reflexes

The Sucking Reflex

The Tonic Neck Reflex

The Babinski Reflex

The Parachute Reflex

The Palmar Grasp Reflex

The Stepping Reflex

The Parachute Reflex

Additional Reflex

Labyrinth Righting
- infant raises head - appears at 2 months; strongest at 10 months

Fine Motor Development - includes the use of hands & fingers a. Crude Pincer Grasp (810 months) b. Pincer Grasp (11 months)

Gross Motor Development

-Developmental maturation in posture, head balance, sitting, crawling, standing, and walking

A.Head Control
- head

lag at 1 month - partial head lag at 2 months - no head lag at 4 months

B. Rolling Over
- Ability to willfully turn over from abdomen to back (5 months) - turn over from back to abdomen (6 months)

C. Sitting -sit alone with hands for

support (7 months) - sit while unsupported (8 months) - prone to sitting position (10 months)

D. Crawling
-

Most infants start crawling at 9 months

E. Standing
- With support ;both hands held (11 months) - With one hand held (12 months)

Absence indicates possible developmental hip dysplasia.

How to calculate the Motor Quotient:

Motor Age MQ = Chronological Age X 100

>85=Normal; <70=Not Normal; 70-85=Borderline

1.2 Psychosocial Development

Developing a sense of trust (Erikson); trust of self, of others, & of the world
Overcoming ORAL stage (Freud)

Erikson's psychoso cial crisis stages

Freudian life stage / psychorelationships / sexual issues stages/ age range

basic virtue (potential positive outcomes from each crisis)

maladaptati on / malignancy (negative outcomes from unhelpful experience)

1. Trust v Oral Mistrust (0-1 yrs. Old)

infant/ mother / Hope and feeding and Drive being comforted, teething, sleeping

Sensory Distortion / Withdrawal

Infants needs:
a. Feeding/Food b. Comfort c. Stimulation d. Care

These needs must be met in order to instill trust in the infant which allows a feeling of physical comfort & security.

Trust assists infants in experiencing unfamiliar situations with minimum fear.

The infant & parent must jointly satisfy their needs for mutual regulation of frustration.

What is the possible outcome if both parent and infant fail to achieve a satisfying relationship?

Mistrust is the eventual outcome.

How can nurses help parents to instill trust to their babies?

By feeding the baby on demand, not too late or too early, & providing the baby comfort & stimulation.

What if the parents are not available to the baby?

Someone should substitute as a caregiver who is warm, loving, responsible, & interactive.

The fathers emotional attachment to the infant is important in the mothers well-being

2 oral-social stages:
Stage 1
- (3-4 mos.) crying as primary means for attention - (>4 mos.) grasping & reaching to parents

Tactile stimulation is important in acquiring total quality of interpersonal relationship.

Stage 2
- (6 mos.) biting occurs - During breastfeeding, biting upsets the mother but also relieves teething discomfort

How can you help the mother solve the conflict?

By weaning the baby Begin bottle-feeding or use of pacifiers

1.3 Cognitive Development

-Sensorimotor Phase (Piaget) - Explains how we are able to know

Stage
Sensorimotor (Birth-2 yrs)

Characterized by Differentiates self from objects Recognizes self as agent of action and begins to act intentionally Achieves object permanence

Sensorimotor Stage/ Age CharacteristicBehavior Stage 1 Reflexive Simple reflex Stage activity such as (0-1 grasping, month)

sucking.

Stage 2 Primary Circular Reactions (1-4 months)

Reflexive behaviors occur in stereotyped repetition such as opening and closing fingers repetitively.

Stage 3 Repetition of Secondary actions to produce Circular interesting Reactions consequences such (4-8 months) as pulling a string to set it into motion or shaking a rattle to make a noise.

Stage 4 Responses become Coordin coordinated into ation of complex sequences. Second Actions are ary "intentional" ex. Reactio infant reachesbehind ns a screen to obtain a (8-12 months) hidden object.

 Learn about their body through kinesthetic and tactile experiences Learn that body parts are useful by bringing objects to mouth

1.4 Development of Body Image

Mouth is the primary area of pleasure Hands are the secondary area of pleasure

1.5 Social Development

socializing agents:

1. Attachment 2. Language Development 3. Play

1.Attachment
Physical contact with humans; Critical to optimum child development Attachment of parent and child begins before birth

At 6 months, infants show a distinct preference to the mother.

What are the effects of prolonged parental separation?

 Physical & mental retardation Inability to form trusting relationships Language impairment Deficiency in abstract thinking AND

Reactive Attachment Disorder

Not cuddly with parents Fails to make eye contact with parents Destructive to self & others

 Maltreated and orphaned children are the usual victims Signs of the disorder can be seen as before the age of 5 Without interventions, the child will fail to develop a conscience & suffer from antisocial personality disorder leading to criminal acts

What should be done when parental separation occurs?

Help should be given to provide a suitable substitute parent to minimize physiologic and behavioral effects.

Separation Anxiety

Separation Anxiety
Begins at 4-8 months as child develops awareness of self & mother as separate beings. By 11 months, they can anticipate her departure by watching her behavior & begin to protest before she leaves.

Stranger Anxiety Begins at 6-8 months

when child develops fear of strangers.

 Crying is the first means of communication; means for social contact Crying as a means to be feed, changed or held

2. Language Development

 (5-6 weeks) beginning of vocalization (10-11 months) begins to ascribe meaning to words Can vocalize up to 4 words during infancy

3.

PLAY

Important for psychosocial growth Play in infants is narcissistic & revolves around their body (solitary play). The quality of interpersonal interaction is more important than any toy. Enjoys peek-a-boo at 10-12 months

Solitary Play

TEMPERAMENT

1.6 TEMPERAMENT
Behavioral style of an infant Influences the type of interaction between the infant & parents. Parents should accept & deal with the behavior to avoid creating conflict.

The DIFFICULT Infant

 Responds to

scheduled
feeding & structured care giving Sleeps less With high activity level; needs constant watching Have higher IQ if born in rich families
Responds to scheduled feding & structured care giving Have higher IQ if born in rich families

The Slow to Warm Up/Shy Infant

 Demonstrates more stranger fear Requires gradual & frequent preparation for new situations and people

The EASY Infant

 Sociable, happy, playful, & attention seeking Gentle, tender, affectionate, & sensitive

Parents need to be reminded to feed the child who sleeps longer & cries rarely.

Provide the parents with background information regarding their childs temperament to help them cope with their childs behavior & give them ideas on how to rear the child.

GROWTH & DEVELOPMENT TABLE DURING INFANCY (pp. 516-521)

1.7 Coping with Concerns Related to Normal Growth & Development in Infancy

A.Separation Anxiety & Stranger Fear - normal developmental behavior - child should not be perceived as antisocial

What are effective ways to reduce stranger fear in infants?

B. Spoiled Child Syndrome

- the ff. are NOT signs of spoiling: crying in infancy, negativism & tantrums, persistent exploration in toddlers, ADHD, etc. -indulging children, combined with clear limits & expectations, does not cause spoiling

C. Limit Setting & Discipline

Babies cry because they have a need to be met, not to irritate the parents (irritable babies usually are victims of Shaken Baby Syndrome). Giving attention to a crying baby is not spoiling A crying baby whose needs are immediately met are better adjustable & does not cry too often later on.

D. Alternative Child Care Arrangement E. Thumb Sucking & Use of Pacifiers

- Helps infant in coping with stress - Normal & healthy unless when it extends to preschool years (4-6 yrs.). - Malocclusion occurs when sucking extends 46 yrs. or when teeth erupts. - Benefits of nonnutritive sucking: increase wt. gain, decrease hospital stay, improve pain mgt

Louis Vuitton Pacifier

F.Teething
- Occurs at 6 months

# of teeth= age in months-6 Ex. 12 months 6 = 6 teeth

Teething causes stress & pain to the child.

What health teaching can you give to the family?

- Give ice cubes, frozen pacifier or washcloth to the child to numb the pain - When teething interferes with feeding, give acetaminophen or ibuprofen for no more than 3 days

G. Infant Shoes
- Buy flexible shoes to prevent impeding the development of supportive muscles.

2. PROMOTING OPTIMAL HEALTH DURING INFANCY

2.1 Nutrition
(0-6 months)
Breastmilk Whole milk is best given after 1 year. No honey due to risk of botulism No nuts or egg whites until 12 mos. No solid food; can cause allergy, vomiting, or diarrhea

(6 months onwards)

- Weaning - Give food rich in Iron, vit. A, Calcium, & other vitamins & minerals.

- Give sugary drinks in cups, not bottles.

 Introduce the infant to different kinds of food but DONT OVERFEED the child.

2.2 Sleep & Activity

Total daily sleep is approximately 15 hours Family teaching to PREVENT sleep problems: - Place infants awake on their crib while lulling them to sleep. - Use the crib for sleeping only, not as playpen; avoid hanging toys over the bed. Most infants are normally active

2.3 Dental Health

Avoid giving milk bottle in bed. Avoid giving fruit juices in bottle. Once tooth erupts, cleaning should begin. Wipe tooth/teeth with clean damp cloth.

2.4 Immunizations
AGE Birth Birth 6 wks 6 wks 9 mos. VACCINE BCG Hepatitis B DPT OPV Measles DOSE 1 3 3 3 1 DURATION --1 month 1 month 1 month ---

CONTRAINDICATIONS FOR IMMUNIZATION

Minor illnesses (cough, fever, diarrhea) are NOT contraindicated to immunization. Severe allergic reaction Anaphylactic reaction Immunosuppression

Is immunization important? Why?

2.5 Preventing Injuries

Injury is the leading cause of death in children ages 6-12 months.

 Aspiration of Foreign Objects (pacifiers, toys, powder, liquids, candy, nuts) Suffocation & Drowning (blankets, plastic bags, cords, bucket of water, pools) Falls (beds, stairs, buildings, furniture) Poisoning (cleaning chemicals, drugs, small batteries, paints, insecticides) Burns (hot water, sunburns, electrical wires) Motor Vehicles (improper restraint within the vehicle, riding on the lap) Bodily Damage (sharp objects, forks, toothpick, diaper pins)

Causes of Injury

A Cabinet Stopper

An Outlet Cover

Anticipatory Guidance Care of Family Teach parent to understand the infants

needs (food, comfort, stimulation). Provide information on how to understand the infants temperament. Help parent understand that infants express their wants through crying. Plan anticipatory guidance for safety.

Stress need for immunization.

 Prepare for weaning/introduction of solid food. Prepare parents for childs stranger anxiety/separation anxiety. Encourage use of negative voice & eye contact rather than physical punishment as a means for discipline. Encourage showing most attention when infant is behaving well, rather than when infant is crying. Encourage parents to leave child with suitable caregiver to allow for some free time.

DEVELOPMENTAL TASKS
Psychosocial Tasks
Cries to express needs or displeasure Smiles indiscriminately Comforted through sucking Vocalization at 1-4 months (squeals, coos, laughs) Imitates sounds at 5-6 months Social smile at 2 months

Cognitive Tasks Reflexive behavior only Repetitive actions Begins to understanding object permanence

Fears
Separation anxiety Pain (can be distracted with talking, sucking, toys, opportunities) Play Solitary play

TOYS to GIVE
Brightly colored objects , different sizes & textures to hold on & squeeze Hang mobiles within 8-10 inches of infants face Rattles, musical toys

Thank You For Listening.