Lecture 01 Family Centered Nursing Care of Child/Adole 1&2 Flashcards
What would Family Centered Care involve?
- Supports cultural, ethnic & social diversity
- Empowers families in all aspects of health care system
- Facilitates involvement in decision-making process
- Examines barriers to active involvement
- Improves quality/safety/cost effectiveness of health care
•Recognizes family as constant in the child’s life
•Acknowledges parents as experts in care of child
•Supports Family Centered Rounding (in-patient)
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What are some culturally sensitive strategies? (6)
- Identify key family members
- Invite family members to chose position of comfort & distance to care provider
- Observe family to determine acceptable body gestures.
- Use interpreter & community resources
- Avoid stereotyping
- Ask family members to share important aspects of their culture, ethnic, social and community needs
KNOW: When does the anterior fontanel close?
12 to 18 months
KNOW: When does the posterior fontanel close?
By 6 to 8 weeks.
When does dentition typically occur in infants?
First tooth between 6 and 10 months with 6 to 8 teeth in the first year
When does infant’s weight double? Triple?
Weight double at 5~6 months and triple at 1 year.
Read Head Control Sequence
Head Control
- Two to three weeks: turns head side to side when prone
- Two to three months: holds head erect for short time while prone; three months can raise chest while supported by forearms
- Four months: holds head erect without head lag; when pulled to sitting
Sequence of baby rolling over
Rolls
- 3-4 months back to side
- 5-6 months front to back
- 6 months back to front
Sequence of Grasp/Hand Control
Grasp/Hand Control
- Four to six months: palmar grasp (voluntary; can hold objects)
- Eight to ten months: pincer grasp
- Seven months: transfer object hand to hand
- Nine months: drinks from a cup
When does a child start sitting?
Sitting
- Six months: sit with support of both hands Seven to eight months: sits steadily without support
- Six months: lack of visual coordination resolves
When does infants start crawling?
Crawling and Walking
–Seven months: begins to crawl
–Nine months: pulling to standing and cruising
–Twelve months: walking alone or holding 1 hand
4 Characteristics of Erikson Infant: Trust vs Mistrust
- Developmental Task of Infancy (Birth to 1 year)
- Infant needs for comfort, feeding stimulation & caring met; sense of trust develops
- Infant needs are not met; sense of mistrust develops
- Task based on achieving quality caregiver-infant relationship
Social Psychosocial Development in infants (6)
- Attachment
- Discriminate mother
- Object Permanence: know whether the object is there or not
- Separation Anxiety
- Stranger Fear
- Temperament
Psychosocial development of Body image
- Infant discovers mouth can produce pleasure
- Hands/feet play objects
- Smiling causes others to react
Piaget Cognitive Development? (3)
Piaget:
•Neonate-18/24 months
Sensory-motor/Imitative
- Progression from reflex activity to imitative or repetitive behavior
- Separation
–Separate self from objects
–Object Permanence
–Symbols/Mental Representation
Language Development info, read
Language:
- Crying as form of communication
- Vocalizes with cooing
- Responds to noises (turns head)
- Laughs
- Single-syllable words
- Two word phrases by 1 year
- Three to five words by 1 year
- Comprehends word ‘no’ by 1 year
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Nutrition: What recommended exclusively for the first 6 months?
Breat milk/iron fortified formula.
Breast fed babies do not need extra water
When may babies start having solids?
5~6 months.
Introduce 1 food at a time.
Rice cereal, vegetables, fruits, meat, egg yolk.
Avoid nuts, foods with seeds, raisins, popcorn, grapes
Limit milk intake to 1 quart/day once solids are established.
What are leading causes in neonatal/infant mortality?
- Congenital anomalies leading cause death under 1 year (neonates & infants)
- Congenital Cardiac Defects # 1
- Accidents leading cause death infants
Aspiration of Foreign Objects
- Leading cause fatal injury children under 1 year
- Small pliable objects < 3.2 cm can cause complete obstruction
- Baby powder
- Propping bottles
What are parts of unsafe pacifier construction?
•Unsafe Pacifier Construction Perry p 626
–Detachable parts can be aspirated
–Ribbons or strings can be dangerous
–Soft, Pliable materials may be easily aspirated
–Attached to soft toys poses risk of asphyxia
One piece pacifier construction with easily grasped handle and flange large enough to prevent mouth entry recommended. But know they are unsafe ones with detachable parts or strings attached to it.
Young infants are very aware of surroundings in the hospital and simtulated by taactile, auditory and visual senses. What should you do?
Establish a calm, comforting environment with visual, auditory and tactile stimulation.
What are infant interventions in the hospital?
- Meet physical needs
- Parents as partners/participants in care
- Address stranger anxiety
- Calm, comforting environment
- Consistency in care (staff & routine)
- Comfort and pain reducing measures
- Safety measures
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What occurs to a Toddler’s physical body? (4)
Physical
- Weight gain slows from infancy
- Age 2, height doubled = adult height
- Trunk/head slower growth arms/legs
–Bowlegged with wide base stance; toddles
–Falls easily; pot belly
•Dentition:
–All primary teeth by 2 ½ to 3 years
–Recommend first visit to Dentist at age 2
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What happens to a todder’s motor skills? (4)
Motor
•Walks by 12 to 13 months
–Runs by age 2
–Up and down steps age 2
–Unsteady on feet
•Begins to master fine motor skills
–Feeds self with spoon by 12-18 months
–Scribbles 15 months
–Removes socks and shoes 16 to 18 months
–Dress self in simple cloths 2 years
- Tries to be independent
- High energy with no impulse control
What’s the psychosocial development of a toddler? (3)
- Self-Concept Development
- Body Image Changes
–Body Parts
–Gender Identity
- Erikson: Autonomy vs Shame and Doubt
What occurs in Erikson: Autonomy vs Shame and Doubt?
What occurs during the Toddler’s Piaget development? (7)
Piaget: Sensory-motor continues to 18/24 months
- Object Permanence Fully Developed
- Egocentric
- Learn to separate from mother
- Memories of events r/t self
- Begin to control socially unacceptable behavior
- Learning sex role distinctions based on culture
•Lacks concept of conservation (example ?)
What occurs ina Toddler’s Language development?
Language 2-3 word phrases (use of short sentences)
- Family understands speech (2 years)
- Strangers understand speech (3 years)
- Understanding of language exceeds ability to verbalize
- Inability to transfer knowledge to new situations:
Toddler Nutrition info (8)
- Appetite decreases
- Picky eater
- Needs high protein diet for brain development
- Needs snacks
- Table food by 12 to 15 months (majority food)
- Whole milk with vitamin D (limit 1 quart/day)
- Limit juice (4 to 6 oz/day)
- ‘Dental (brushing, fluorination, bottles, sweets)
Dental visit recommended at 2-years
5 characteristics about Toy & Play for toddlers
Parallel and Solitary Play
- Minimal sharing/cooperation
- Special toy/blanket
- Learning what is his/hers
- Parallel play; side by side with little cooperation
- Toys, manipulative, blocks, shapes, crayons, books, telephones, kitchen sets
What are some issues related to normal G&D (2)
Toilet Training
- Freud’s Psychosexual Anal Stage
- Major task of toddlers with readiness between 18 months and 2 years after child is walking (voluntary control of anal & urethral sphincters achieved)
- Refer to Perry (2014) p. 931, Assessing Toilet Training Readiness
4 characteristics with Sibling Rivalry
–This is a natural response of jealousy and resentment
–Response to changes in toddlers life
–Anticipatory guidance with parents indicated
–May see regression
What exactly are tantrums?
–Expression of independence may be exhibited through violent objection to discipline (kicking, screaming & breath holding)
–Anticipatory guidance with parents
Negativism
– “NO” is an expression of self-control and independence.
– Provide choices that do not provide for a “no” answer
What is Regression? (3)
–Reverting to previous patterns of functioning usually related to
stress or discomfort (thumb sucking, bed wetting, ‘baby talk’)
–Common with toddlers especially in illness, hospitalization, separation, birth of sibling
–Illness & hospitalization may cause regression
What’s the highest incidence of death in toddler’s age 1~4 ?
Kids falling
- Highest incidence death occurs ages 1 to 4 (outside of adolescent age group).
- Freedom achieved through locomotion and lack of awareness of unsafe behaviors results in very high injury risk
- Refer to Perry (2014) Table 32-4, Injury Prevention During Early Childhood
- Injuries include: Motor Vehicle Related, Drowning, Burns, Poisoning, Falls, Choking & Bodily Damage
What are norms in hospitalized toddler? (5)
Norms
- Separation anxiety peaks
- Vocabulary increases however understanding language exceeds ability to verbalize
- Toddlers becoming independent from parent/caretaker
- Daily routines of waking, sleeping, eating and play are established
- Development focused on mobility and learning to communicate
10 toddler interventions
- Parents as partners/participants in care
- Address stranger anxiety (ex: exam on parent lap)
- Exam/assessment start with least intrusive
- Encourage use of comfort/transitional objects (blanket, stuffed animal, family pictures)
- Incorporate home routines into care
- Maximize mobility, play and control opportunities
- Prepare toddler for “routine” care and procedures
- Maximize comfort and pain reduction measures
- Maximize consistency (staff & hospital routine/procedures)
- Maintain safety measures
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Preschool age is 3~6.
What are some motor skills that are developed?
Motor
Increased strength and agility
3-year-old 3 wheels (tricycle), copies a circle
4-year-old skips/hops one foot, throw ball overhand, copies a square
5-year-old can recite phone number, jumps rope, balance on 1 foot, walks backwards
What would pre school age appetite be like?
- Appetite gradually decreases
- Food preferences
- Appetite sporadic & inconsistent
Preschool Psychosocial Development
Describe Erikson: Initiative vs Guilt
•Explore physical world taking on new activities
–Imagination
–Enterprise
–Guilt with perceived misbehavior or failure
to accomplish a task
Psychosocial Develpment: Moral
- Develop a conscience
- Social Acceptability
Psychosocial development: Body Image Changes
- Misconceptions: fantasies & fears
- Begin to recognize differences
- Poorly defined body boundaries (example ?)
Psychosocial Development: Social
- Less separation and stranger anxiety
- Pretend play helps differentiate reality from fantasy
What does the Piaget: Preoperational Thought (2~7) involve? (4)
Piaget: Pre-operational Thought (2 to 7)
- Intuitive Thought (unaware how gained information)
- Predominate egocentricity to beginning social awareness
- Thinking based on visual appearances
–Magical thinking (thoughts are all-powerful)
–Animism (equipment is alive)
–Centration (focus on one aspect of object without considering whole)
•Concept of time related to routine events (ex: meals, bedtime)
What is language development like in Pre School age? (2~7)
Language 3 years
- Understood by non-family members
- Stuttering common especially when stressed
What are normal personal-social deveopments of Pre-School aged children? (4)
Personal-Social
- Imaginary friends
- Imitates caregivers
- Domestic role playing
- Sexuality
–Knows own sex and that of others
–Masturbation normal
Issues related to normal G&D of pre school kids (4)
What are health promotions for pre schoolers?
Injury Prevention/Safety
- Accidents remain leading cause of death
- MVA & Burns
- Improved gross & fine motor skills, listening to parental instructions and awareness of dangers
Read, what are some pre school norms? (10)
Norms
- Gross motor skills VIP running, jumping climbing
- Difficulty distinguishing reality from fantasy (magical thinking)
- Poorly defined body boundaries
- Egocentric (experiences from own perspective) (events are their fault)
- No understanding of cause & effect
- Illness seen as punishment
- Family important. Separation anxiety remains strong
- Continued independence
- Communication skills increasing, asks questions
- Likes consistency in daily routines
What can hospitalization/illness hinder in developing pre schoolers? (5)
Hospitalization/Illness
- Mobility
- Fears
- Body Image/Esteem
- Independence
- Routine
What are preschooler interventions? (5)
- Parents as partners/participants in care
- Maintain link with home
- Decrease immobility as much as possible & maximize control of situation
- Prepare for “routine” care & procedures in simple concise manner & use of hands on play with medical equipment
- Provide concrete explanations/hands on for unfamiliar equipment, environment, procedures (fantasy thinking may make hospital environment/routine bizarre/frightening)
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What are some ways to act towards a hospitalized preschooler?
•Address fears of bodily injury/mutilation and pain
–Major fear in preschooler
–Avoid intrusive procedures
- Allow choices and participation in care
- Bandages/Band-Aids
- Allow child to express feelings of anger, fear, and frustration in an acceptable manner
- Provide praise and rewards
- Continue home routines (bedtime rituals, schedule)
- Music and Pet therapy
Let them know what behavior is acceptable (can’t bite but can squeeze hand)
What are Physical chagnes in school aged children? (6~12)
•Pre-adolescent years (10-13) rapid growth boys & girls
–Growth spurt age 9-10 girls & 12 for boys (girls surpass boys in weight & height)
–Rapid growth in height and weight
•Dentition
–Permanent teeth erupt
what is the Psychosocial Development of school aged children? 6~23.
For Erison: industry vs. Inferiority
What is the moral development of school aged children?
Moral Development
- Internal set of standards
- Obeying rules of correct behavior is important
- Behavior that pleases others is considered good
Define Piaget: Concrete Operations (7~11)
(2)
•Develop logical & coherent thought
–Take incident and generalize from it
–Systematic way of solving problems
•Able to sort, classify, order & organize facts
What are common safety issues for school aged children? (3)
- Motor Vehicle Accidents Pedestrian or passenger most common cause of serious injury or death
- Bikes, skate boards, in line skates, ATV’s (not recommended for children less than 16 years per AAP) (Perry pp.1001)
- Firearms
What are some Health Promotions for school aged kids? (3)
- Increased use of drug, alcohol, and tobacco in this age group.
- Obesity
- Anorexia
What are school aged interventions? (6)
- Give child as much control as possible
- Parents as partners/participants in care
- Involvement in unit activities with other children & provide “free time”
- Encourage expression of feelings related to illness/hospitalization (play, journal, art/drawing, verbalizing)
- Validate fears & anxieties; Mutilation fears remain
- Encourage participation in daily activities
What are norms of school aged children
Norms
- Performs many physical activities
- Beginning to understand cause & effect
- Social dependence on peers strong
- Continues to learn ways to express feelings verbally and with play
- Dependent on home/school routines
- Developing self-esteem; likes praise & rewards
- Striving for independence
Adolescent years are
11 to 21 years
What happens to an adolescent physically?
Physical
Progressive Tanner stages (male & female)
- Puberty onset; age 10 (girls), 12 (boys)
- Major growth spurt (height & weight) (Most rapid after 1st year)
- Develops secondary sex characteristics
What are motor skills like in adolescents?
Motor
- Gross motor reaches adult levels
- Fine motor continues development
- Strong, but awkward
- May be unsure how to handle wt./ht increases
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Adolescent: What’s Erikson’s Identity vs Role Confusion?
Erikson: Identity vs. Role Confusion
- Developing a sense of self
- Exploring alternatives while attempting to understand ‘self’ as related to peers, family & society
What’s Moral development like in adolescents?
- Decisions based on standards; social responsibility recognized
- Able to consider 2 different moral approaches to problems and decisions
What are some personal social issues with adolescents?
Personal-Social
- Identity issues
- Status
- Relationships
What are some body image issues with adolescents?
Body Image
- Major concern
- Impact Media
- Depression and Eating Disorders
Adolescents: Define Piaget Formal Operations
Piaget: Formal Operations
- Thinking at adult level
- Consider alternative outcomes in abstract way
- Ability to think in abstract terms & use abstract symbols
- Future Oriented
What are leading cuases of death in adolescents?
Injury Prevention/Safety:
- Accidents leading cause death in adolescents (MVA)
- Homicide & Suicide 2nd & 3rd leading cause death
- Risk Factors?
- Drivers Education
- Drug & Alcohol abuse education
What are some concerns related to normal G&D of adolescents?
Concerns Related to Normal Growth & Development
- Relationships with Family & Peers
- Body Image & Self Concept
- Sexuality, STD’s & Pregnancy
What are some nutrition needs of adolescents?
•Nutrition
–Needs up to 3,500 cal/day
–Hugh appetite (rapid growth & high energy levels)
–Junk food may be major source calories
Anorexia nervosa & bulimia (more common girls)
What are some norms in early adolescents 11~13
Norms
- Less interest in parental activities
- Mood swings
- Preoccupation with self
- Intense same sex relationships
- Increased cognition, fantasy world, vocational goals, privacy need, lack impulse control
What are some normal development of middle adolescents 14~17?
What are normal development in late adolescents 18~21?
Norms
- Reacceptance of parental values/advice
- Acceptance of pubertal changes and feelings
- Peer group less important & more time with intimate relationships
- Practical, realistic vocational goals
- Ability to compromise and set limits
What are adolescent health care interventions?
- Encourage expression of feelings
- Family participation and peer visitation
- Continue schooling as appropriate
- Offer choices and involve as much as possible in decision making & daily routine
- Encourage self care
- Be sensitive to the importance of personal appearance
- Provide clear, honest information & explanations
- Provide privacy (physical and personal information)
–Health assessment must include private time with adolescent
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What is separation anxiety?
•Major stress for infants and toddlers between 6 months to 30 months is separation from parent or familiar caretaker
What are some ways to communicate with a child? (5)
- Allow the child to express fears and ask questions
- Give choices when they exist
- Do NOT lie to a child
- Be honest
- Use creative communication techniques. Perry (2014) Box 29-4 and Guidelines p. 775
What are some concern’s of pt’s siblings?
- May experience jealousy, insecurity, resentment, confusion & anxiety
- May not understand why ill sibling getting attention
- May feel abandoned or ignored by parent
- May feel they caused illness
•May have same level of stress as ill child
What are some considerations with pediatric pain?
- Unrelieved pain has negative physical & psychological consequences
- Prevention is better than treatment
- Assessment and treatment of pain is a collaborative process between nurse and child/family
- Pain reduction is a realistic goal
What are some pain MYTHs
- Infants don’t feel pain
- Young children will “forget” pain
- Children tolerate pain better than adults
- Narcotics should be avoided in infants/children because of respiratory depression & are more addicting than in adults
- Children will tell you when they are in pain
- Pain is “obvious”
- Children become accustomed to pain or painful procedures
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Toddler’s response to pain?
Toddler
- Reacts to any intrusive procedure as if painful (BP, Temp, exam)
- Intense emotional/physical resistance
- Can talk about pain; take complaints seriously
- Can’t describe pain, but can localize
- Does NOT know how to fake or imagine pain
Preschool aged children’s response to pain?
Preschool Aged
- Age 4, degree self-control
- Can localize and describe
- Begin to realize pain may be temporary and will feel better later
- May use illness to avoid unpleasant activities
- Recurrent abdominal pain frequently seen as response to anxiety (beginning school)
What’s a school aged response to pain?
School Aged
- Verbalizes pain, location, description, intensity
- Response is more ‘adult like’
- Tolerance levels very individualized
- May still feel guilt about being ill
- May be more cooperative
Adolescent Response to pain?
Adolescent
- May see much self control
- Can verbalize pain
- May be reluctant to verbalize pain
- Pain tolerance very individualized
- Aware of effects & uses pain meds
- Able and willing to request pain meds
What are 3 keys questions on asking the history of pain?
- What type of pain has the child experienced in the past?
- How do you know when the child is in pain?
- What has worked in the past to manage the child’s pain?
In what ages do you use the FLACC scale?
Infant to age 6
In what children do you use the Face Scale?
Age 6 and older
When do you use the numeric scale for pain?
Older school age/ adolescent
What are some non pharmacologic interventions for pain?
- Parental Support
- Holding/Rocking
- Comforting Environment
- Therapeutic Communication
- Positioning
- Age Appropriate Distraction & Play (comfort boxes)
- Relaxation techniques
- Guided Imagery
What are some psychological effects in an immobilized child?
•Psychological Effects (Perry pp. 1534-1536)
–Outlet for emotions, anxiety and impulse control
–Physical growth and development
–Sensory depravation
–Language and speech development
–Depression, alterations in self-esteem and regression can occur
–Outlets for fears, anxiety, monotony and boredom need to be identified
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What are some techniques to prep toddlers for procedures?
- Continue infant techniques
- Expect resistance & negativism
- Give simple & easy to follow instructions
- Allow child to handle equipment, practice on doll/parent/nurse
- Explanations are sensory based (see, hear, feel..)
- Use distraction (bubbles, music, books, videos)
- Keep frightening objects out of view; be prepared
- Allow choices whenever possible
- Provide comfort objects (doll, blanket)
- Limited time concept; prep just before procedure and keep it short & simple
How to prep preschoolers for procedures?
- Continue to stress sensory aspects of experience
- Positioning for comfort
•Focus on playing with equipment, how it works, what it feels like (alcohol prep is wet & cool)
•Be very careful with the language you use
•Major fear is bodily harm, mutilation & castration
- May think equipment is alive
- Child may see procedure as punishment
•Bandages very important for body integrity
- Find ways for the child to “help with procedure” & praise for efforts
- Preparation occurs shortly before procedure
- Post procedure with dolls /equipment
- Child Life Prepping for IV Insertion 2:23
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How to prep school aged children for procedures?
- Increased language skills allow for explanations with correct terminology, use of diagrams, pictures
- Explain use of equipment in terms of function
- May fear ‘loss of blood’ with phlebotomy
- Help child maintain self-control (deep breathing, counting) & sense of “industry” (help with procedure, decision making)
- Preparation can occur in advance of procedure & with longer teaching sessions
•Allow time for questions & concerns; but without undo “delay tactics”
- Provide privacy, offer praise & accept regressive behavior
- May need and want support; often do not request
What are some techniques to prep infants for procedurs?
- Parental involvement
- Stranger Anxiety
- Comfort measures (pharmacological & non pharmacological)
- Positioning for Comfort
- Use of treatment room
- Older infants do remember unpleasant people, places & equipment
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How would you prep an adolescent for procedures?
- May include discussion of benefits & long term consequences
- Encourage expression of fears, and alternatives
•Involve in decision making as much as possible (parents present, timing)
- Provide suggestions to maintain control (imagery, relaxation, music)
- Accept regression; remember adolescent may look like an adult but they do not have adult coping mechanisms
- Privacy
- Preparation can occur ahead of time
What are some post hospital behaviors in young children?
Young Children
- Aloofness toward primary caretaker
- Dependency behaviors
–Clinging to caretaker
–Demanding attention
–Opposing any separation
•Other Behavioral Changes
–New fears
–Bed time fears, night waking
–Increased activity
–Tantrums
–Food pickiness
–Blanket/toy attachment
–Regression in newly acquired skills
What are some post hospital behaviors of older children? (3)
Older Children
- Emotional coldness versus intense demanding dependence
- Anger toward caretaker
- Jealousy especially towards siblings
