CHILD HEALTH NURSING

UNIT I
INTRODUCTION TO CHILD HEALTH

Introduction
Pediatrics isa derived nfrom the greek words ‘pedia’ means child , ‘iatrike’ means treatment and
‘ics’ means branch of science.

Abraham Jacob(1830-1919) is known as father of pediatrics

PEDIATRICS:

Pediatric is the branch of medical science that deals with the care of childhood from conception to
adolescent in health and illness. It concern with prevention, promotion, curative and rehabilitative care
of children.

PEDIATRICS NURSING
It is defined as the diagnosis and treatment of human responses treatment of human responses to
actual or potential health to actual or potential health problems”.
----(Wong)
GOALS OF PAEDIATRIC NURSING:
 To provide skilful intelligent need based comprehensive care to the children health and illness
 To interpret the basic needs of children to their parents and family members and to guide them
in child care
 To promote Growth and Development of children
 To prevent disease and alleviate suffering in children.
QUALITIES
 Love for children
 Patience and pleasant
 Good IPR and safety and security to the children
 Friendly, honest and diligent
 Good observation, judgment and communication ability-based on scientific knowledge and
experience.
 Skillful, responsible, well informed and truthful.
CONCEPT OF PAEDIATRIC NURSING
 Well-being of the children towards optimal functioning.
 Integration of developmental needs of children into nursing care with holistic approach
 Integration of scientific principles and theory related to child health into nursing practice.
 Delivering care to the family-child unit.
 Interdisciplinary team approach to plan and provide child care in comprehensive manner.
 Focusing on the ethical, moral and legal problems regarding child care.
ROLE OF THE PEDIATRIC NURSE
 Primary caregiver :
 Pediatric nurse should provide preventive, promotive, curative and rehabilitative
care of children.
 Care in all levels of health services, as therapeutic agent.
  Primary care includes providing comfort, feeding, bathing, safety etc.
 Health assessment and immunization is primary care in the community level.
 Health educator
 To deliver planned and incidental health Care teaching and information to the patient
 To create awareness about healthy life style and maintenance of health
 Nurse- counselor
 Problem solving approach and necessary guidelines in health hazards of children to
minimize or to solve the problem
 To help the parents and family member for independent decision making in different
situation
 Social worker
 Try to alleviate social problems related to child health.
 She can participate in available social services
 Can refer child and family for necessary social support from the child welfare agency.
 Team coordinator and collaborator
 Cooperation and good communication among team members should be promoted by
nurse.
 Manager
 The pediatric nurse is the manager of pediatric Care in hospital, Clinics, and
community .
 Child care advocate
 As an advocate the pediatric nurse can assist the child to obtain the best care possible
from the particular units
 Recreationist
 The supportive role of pediatric nurse is important for the child to adjust to the crisis
imposed by illness or hospitalization
 She can organize play activities for recreation and diversion for child’s emotional outlet
Nurse consultant
 Nurse consultant
 Paediatric nurse act as a consultant to guide the parents and family members for
maintained and promote of health and prevention of childhood illness
 Nurse researcher
 Nursing research is the integral part of professional nursing
 Perform research projects related to child health.
 The basis for changes in nursing practice and improvement, in the health care of
children
TRENDS IN PEDIATRIC NURSING
 Expanded role of Paediatric Nurse
 Family centred care
 Child initiated care
 Nursing Process Approach
  Inter disciplinary approach
 Rooming in approach
 Minimal hospital stay policy
 Intensive care Unit
ISSUES IN CHILD HEALTH NURSING
 Social issues
 Ethical issues cultural issues
 Legal issues
 Conceptual issues
 Cultural issues
 Genetic issues
 Research issues
RIGHTS OF THE CHILD:
1. Right to develop in an atmosphere of affection and security and protection against all forms of
neglect, cruelty, exploitation and traffic.
2. Right to enjoy the benefits of social security, including nutrition, housing and medical care.
3. Right to a name and nationality.
4. Right to free education.
5. Right to full opportunity for play and recreation.
6. Right to special treatment, education and appropriate care, if handicapped.
7. Right to be among the first to receive protection and relief in times of disaster.
8. Right to learn to be useful member of society and to develop in a healthy and normal manner and in
conditions of freedom and dignity.
9. Right to be brought up in spirit of understanding, tolerance, friendship among people, peace and
universal brotherhood.
10.Right to enjoy these rights, regardless of race, color, sex, religion, national or social origin
HOSPITALIZATION OF SICK CHILD:
 Family integrity and child's relationship should be maintained.
 The sick child should be supported and guided to learn to handle new experiences
 Needs of each child are different , assessment of these needs as well as those of family
members forms the basis of nursing interventions.
 The paediatric nurse seeks to promote , maintain and restore health in both children and their
parents by health counselling and teaching about the needs.
 Nurses follow the scientific principles of disease process and nursing
 Family participation for planning , implementation and evaluating process.
 The sick child needs expert physical care , emotional support, expression of feelings and
continuation of school education , to promote continued growth , both in acute and chronic
illness.
 Parents should have trusting relationship with nurses and health team members
 Family members and their child , who are under great stress , when a child is terminally ill or
dying must be supported emotionally .
 Hospitalisation is the break in the unity of the family .
EFFECTS OF HOSPITALISATION ON THE FAMILY
 Break in the unity of family.
  Separation from the children.
 Feeling of inadequacy as others care for their children .
 They feel anxiety, anger, fear, disappointment , self blame, and possible guilt feeling due to
lack of confidence and competence for caring the child in illness and wellness.
 Parental anxiety related to
 Strange environment in the hospital.
 Unknown events and outcome
 Spread of infections of other members from the family
 Society will look upon the illness as a reflection of something wrong with the parents.

DIFFERENCE BETWEEN AN ADULT AND CHILD.

SYSTEM CHILD ADULT
Indegumentary Skin Conditions are These problems are not occur in
common in Infants and Adults.
children like Liner’s disease,
Scleremaneonatorum,
Tineacapitis and Tineapedis
Respiratory Alveolar Sacs are shallow Produce sufficient mucous.
in neonates and dead air
spaces is large, So more air
must be move in and out for
that reason respiration is
rapid in babies.
Circulatory Oxygenated blood is After birth placenta is separated.
delivered to fetus from
placenta to deoxygenated
blood is returned to
placenta.
Hematology RBC life span 60-80 days RBC life span 110-120 days
Fluid & Electrolytes Total body water in infants Total body water in adult 550
750 ml/kg (75-80%) of body ml/kg (60%) of body weight.
weight.
Infant cannot maintain
normal fluid balance
because of immature
homeostatic mechanism like
dehydration .
Gastrointestinal system The cardiac sphincter of The cardiac sphincter of stomach
stomach is quite relaxed is fairly tight.
resulting in vomiting and
regurgitation.
Urinary Infants kidneys are The young kidneys are grow and
immature with reduced increase the number of
ability of concentrate urine. functioning nephrons.
Endocrine Secrete hormones are least Its is properly developed and
developed homeostatic mature.
control is lacking till the age
of 12-18 months.
 Reproductive Female: Ovaries -10mm in
length and 2-4 mm in width
Male: Testis-1.5-2 cm
long and 0.7-1 cm wide
Ovaries – ovulation begin at 12-
13 years of age
Testis – increases gradually and
reach maturity between 13-17
years.

Musculoskeletal Infant bones are neither  Height doesn’t increase after

farm and nor as brittle.
Fractures rarely occur in
infants & if it all they occur,
healing is very quick.
Children height increase
as bones grow.
Neurologic Weight of brain is about
300-500 grams, brain
doubles in size by 1 year of
age.
Reflex activities that are
present during infancy.
Lymphoid and Immune The lymphoid tissue is small
but well developed at birth.
certain age
Weight of brain is about 1,300 -
1,400 grams.
Disappear in adult as voluntary
control is developed.
Lymphoid tissue is increase
rapidly in size up to the age of
10-11 years.
Immune system in young
children is depressed and
immature.

VITAL STATISTICS

Vital Statistics are statistics relating to vital events of life name births, death, marriage and sickness
that occurring in community.

DEFINITION

vital statistics is the numerical description birth, death, abortion, marriage, divorce, adoption,
and judicial separation

IMPORTANT VITAL STATISTICAL RATES

 Birth rate
 Specific death rate
 Perinatal mortality rate
 Neonatal mortality rate
 Postnatal mortality rate
 Infant mortality rate
 Under five mortality rate
PERINATAL MORTALITY RATE

Perinatal mortality rate = Late fetal and early neonatal deaths weighing over 10009 at birth
---------------------------------------------------------------------------- X 1000
Total number of live births weighing over 1000g at birth

NEONATAL MORTALITY RATE

Neonatal mortality rate is the number of neonates dying before reaching 28 days of age, per
1,000 live births in a given year.

Neonatal mortality rate =

Number of neonatal deaths in a year
------------------------------------------ X 1000
Total number of live births in the same year
POSTNEONATAL MORTALITY RATE

Postneonatal mortality rate = Number of death of children between 28 days and

one year of age in a year
---------------------------------------------------------------- X 1000
Total number of live births in the same year

INFANT MORTALITY RATE

Infant mortality rate = Number of death of children less than

one year of age in a year
---------------------------------------------------------------- X 1000
Number of live births in the same year

UNDER-FIVE MORTALITY RATE

Under- five mortality rate = Number of death of children less than

5 year of age in a given year
---------------------------------------------------------------- X 1000
Number of live births in the same year

CHILDS REACTION TO HOSPITALISATION AND ILLNESS

1) REACTIONS OF NEONATES :
 Interrupts in the early stages of development of a healthy mother-child relationship and
family integration.
 Impairment of bonding and trusting relationship
 Inability of the parents to love and care for the baby and
 Inability of the baby to respond to parents and family members.
2) REACTION OF INFANTS
 Infants separation anxiety and disturbance of development.
  Emotional withdrawal and delayed developments also found.
 Older infants 8 to 12 months fear of strangers , excessive crying , clinging and
overdependence on mother .
3) REACTIONS OF TODDLERS
 The toddlers PROTESTS by frequent crying , shaking crib, rejecting nurses attention ,
urgent desire .
 In DESPAIR , the toddler becomes hopeless , apathetic , anorectic , listless ,looks sad ,
cry continuously or intermittently .
 In DENIAL ,the child reacts by accepting care without protest and represses all
feelings.
 The toddler may react by REGRESSION in an attempt to regain control of a stressful
situation.
4) REACTIONS OF PRESCHOOL CHILD
 The preschool children adopt various mental mechanisms (defence mechanisms) to
adjust with the stressful experiences of hospitalization and prolonged illness.
 They react by exhibiting regression , repression , projection , replacement ,
identification , aggression , denial , withdrawal and fantasy .
 The stage of PROTEST in preschool children is usually less aggressive and direct .
5) REACTIONS OF SCHOOL AGED CHILDREN’S
 They react with defense mechanisms like regression , separation anxiety , negativism ,
depression , phobia , unrealistic fear , suppression or denial of symptoms .
6) REACTIONS OF ADOLESCENTS
 Adolescents are concerned with lack of privacy , separation from peers or family and
school.
 They may adopt mental mechanism like intellectualization about disease , rejection of
treatment , depression ,denial or withdrawal.

ROLE OF NURSE TO HELP TO COPE WITH HOSPITALISATION OF CHILDREN .

The nurse should earn sufficient confidence to develop positive relationship with the children
and their parents . Nurse should have patience, tenderness and emotional strength in times of stress.

Provide family centred care with different approach to specific age group.

1) IN NEONATE: Rooming in and sensory motor stimulation.

2) IN INFANTS : Encourage mother to balance her responsibilities and minimize separation ,
mother can be allowed during procedure , providing toys to relieve tension.
3) IN TODDLERS : Rooming in , unlimited visiting hours to express child's feelings, no
punishment to the child, home routines can be continued , allow play , encourage independence
, encourage family interaction.
4) IN PRESCHOOLER: Provide parental participation in care , plan to shorten the hospital stay,
careful reparation for all procedures by privacy and explanation, encourage the child to
participate in the selfcare and hygiene, remove fear , reassure the child.
5) IN SCHOOL CHILDREN :Help the parent to prepare child for elective hospitalisation ,
provide privacy , thorough nursing history should be obtained for plan of care , explain the
procedures and its purpose , encourage play , self care and continue schoolwork, ensure parents
 to cope with their own anxieties, introduce to other parents in the same unit and consistent
visiting pattern.
6) IN ADOLESCENTS: Prepare the parents for planned hospital admission , available hospital
facilities should be explained soon after admission, respect the personal preference on selfcare
and food habit , explain all procedure, provide opportunities for recreation , peer relationships,
interaction with other adolescent patients and expression of feelings.

NURSING INTERVENTIONS AND ADAPTATION IN NURSING CARE OF SICK CHILD

 Psychological stress
 Physiological stress
 Environmental stress
 Biological stress
 Chemical stress

GRIEF & BEREAVEMENT

GRIEF

Grief is powerful emotional reaction to a separation or loss like declining health, impeding health, death of
loved ones or loss of valuable object.

Healthy grieving is time limited, becoming less intense as time passed but takes 1 year or more to resolve
fully.

BEREAVEMENT

Bereavement is a state of being deprived of someone by death & refers to being in the state of mourning.

MOURNING:-

Mourning is the normal psychological processes that follows the loss of loved one.

MOURNING INCLUDES 4 PHASES:-

1. A short phase of numbness & denial

2. Protest marked by intense pining for the death
3. Disorganization marked by pain & despair
4. Detachment & disorganization of love relationship.

CAUSES:

Grief may be caused by -

- Relationship break up

- Loss of health

- Loss of friendship

- Illness of loved one

 - Death of pet

STAGES OF GRIEF

D-DENIAL

A- ANGER

B-BARGAINING

D-DEPREESION

A-ACCEPTANCE

STAGES OF CHILDREN’S GRIEF

1. DISORGANIZATION: -

The initial expressions of grief in children range from regression, temper tantrum, lack of
concentration, and mood swings in older children.

2. TRANSITION:-
Feeling of hopelessness, helplessness, & despair follow stress & chaotic behavior. Many
children will exhibit true depression. More common are symptoms of withdrawal, aggression & giving
up in school.
3. RECORGANIZATION:-
when painful feeling are expressed their emotional energy fades & children fell better. During
this stage children have more energy & motivation for moving forward to resolve grief.

SYMPTOMS OF GRIEF
TYPES OF GRIEF

1. ANTICIPATORY GRIEF
2. ACUTE GRIEF
3. DYSFUNCTIONAL GRIEF
4. CHRONIC SORROW

FACTORS INFLUENCING GRIEF RESPONSE

A number of factors influencing grief response.

 The bereaved person was strongly depend on deceased.

 A love-hate relationship existed between the bereaved and lost.
 The bereaved has experienced a number of recent losses.
 The loss is that of a child of young person.
 The bereaved person holds himself responsible for loss.

GRIEF MANAGEMENT IN CHILDREN

FOR PRESCHOOLER :

- Answer the child’s question honestly and simply

- Allow them to talk about loss, help them share their fears & worries.
- Provide simple routine
- Give the child affection & nurturing, attend to connect with them.
- Provide more opportunity for play and recreation

FOR SCHOOL AGE CHILD:

- Keep the child busy task & provide them simple tasks.
- Help them to express out their feelings
- Encourage them to let you know when they are worried or having a difficult time.

PRE TEENS AND ADOLESCENTS:

- Accepts their mood swings and physical symptoms.

- Encourage them to express their emotions & feelings.
- Be truthful & factual in explaining the loss.

HELPING TEENAGERS DURING GRIEVING

- Although late teens grieve more like adults but they may not want to participate in activities associated
with a major loss. So respect your teen's position.
- Do not force the teens to participate in activities that he or she feels uncomfortable while doing.
- Help them to find activities to express their grief.
PRINCIPLES OF PRE AND POSTOPERATIVE CARE

INTRODUCTION:

The patient who consents to have surgery, renders himself dependent on knowledge, skills and integrity
of health care team. The period extending from the time of hospitalization for surgery to the time of discharge is
the perioperative period. It is essential to provide perioperative care to the patients during this phase. It includes
care of patients prior to surgery, i.e. in preoperative phase, during surgery and then in postoperative phase.

PREOPERATIVE CARE

Preoperative phase is the period in which patient is to be prepared both emotionally and physically for
surgery. There are specific principals which must be followed during this phase.

PRINCIPLES OF EMOTIONAL PREPARATION IN PREOPERATIVE PHASE

• Assess and correct psychological problems of the patient, that may increase the surgical risk.

• Patient and significant others should be explained in detail about every aspect of surgery.

• Management of fears related to surgery is essential. Nurses must recognize these fears in children as
well as parents and deal with them properly.

• Parents and child (patient) should be given opportunity to describe their reactions and feelings.

• Nurses should be honest and truthful while answering questions of parents and children.

• The questions that should not be answered or the nurse is unable to answer should be referred to
physician.

• The parents and child should be oriented to the recovery room, postoperative ward and the equipment
there, as the child will be kept there, after surgery.

• The parents and child should be prepared for discharge in preoperative period.

• Good communication between all the members of health care team and will ensure that patient is well
prepared and ready to undergo surgery.

PRINCIPLES OF PHYSICAL PREPARATION IN PREOPERATIVE PHASE

Doctor's orders for preoperative care are to be implemented.

- Enema is to be administered the night before surgery, if ordered. Cleansing the colon of fecal matter
helps in reducing chances of wound infection during surgery involving bowel.
- Follow the physician's orders for diet. Usually patients are to be kept NPO from midnight onwards
before surgery.
- Bath should be given to the child in the morning to make the skin free of microorganisms. This helps in
reducing the possibility of postoperative infection.
- Make the child wear clean hospital gown after bath.
 - Legal consent must be signed by the guardians of the child.
- All the laboratory reports should be attached to the patient's file and sent with patient to the OT.
- Vital signs should be checked and recorded in patient's file.
- Administer preoperative medication as prescribed by the doctor.
- Send the child to the OT with identification band tied on wrist to prevent any fault in identification of
the patient.

POSTOPERATIVE CARE

Surgery causes physiological stress on the body. The principles of safe and effective postoperative care
include recognizing hypovolemia, maintaining fluid and electrolyte balance, maintaining oxygen saturation in
body, managing pain and preventing postoperative complications. All these measures are essential elements of
postoperative nursing care.

IMMEDIATE POSTOPERATIVE CARE

- An operation bed should be kept ready to receive the patient after surgery.
- As soon as the patient is shifted in recovery room, monitor the indicators of hemodynamic stability
including Blood Pressure, Peripheral oxygen saturation, Heart rate, Respiration and temperature.
- Maintain patent airway by keeping the child in side lying position.
- If required suction airway to remove the secretions.
- Administer oxygen if peripheral oxygen saturation is below 90%.
- Replacement of fluids in postoperative period is essential to ensure adequate hydration of thebody.
- Maintain intake and output chart.
- Restrain the child to prevent any injury and dislodging of IV tubes, drainage tubes, dressings, etc.
- Pain following surgery is inevitable for children. Good pain management can help reduce postoperative
complication. Administer the prescribed analgesic.
- Check the drainage tubes, if any.
- Ensure that guardians are with the child in recovery room.
- Keep patient nil per orally till he regains consciousness.

CARE AFTER 24 HOURS OF SURGERY

- Keep monitoring the vital signs.

- Observe the patient for hydration status, intake and output, any drainage from surgical site,dressing
on surgical site, return of bowel sounds and level of consciousness.
- Administer the medications like antibiotics and analgesics as prescribed by the physician.
- Dressing of operative site should be done using strict aseptic techniques.
- Provide IV fluids till paralytic ileus disappears and bowel sounds return. Start with sips of water
after peristalsis begins.
- Maintain the personal hygiene of the child.
- Ensure adequate rest, sleep and comfort.
- Simple nursing interventions like early ambulation and active or passive exercises help in reducing
the risk of postoperative complications.
- Provide diversion therapy to the child.
- Plan for discharge from hospital and teach parents regarding home based care, diet, medications
and follow-up.
- Provide complete details of all the investigations, treatment, surgical procedure done and follow-up
care to the parents.