Pediatric nursing ch 7 Flashcards
Developmental milestones
Birth to 3 months
Weight: gains 5 to 7 oz weekly during the first month and then 1 to 2 lb per month
Feeding: Breastfed every 2 to 3 hours, formula-fed every 3 to 4 hours
Height: grows 1 inch per month for first 6 months of life
Head circumference: grows a half inch per month for first 6 months of life
Motor skills:
Wobbly at first, but soon can lift head when on abdomen
Grasps an object, kicks vigorously, and turns head from side to side
Needs to have the head and neck supported
Can get their hands and thumbs to their mouths
Musculoskeletal and orthopedic disorders occur during fetal development; the most common of these disorders are talipes equinovarus (club foot) and developmental hip dysplasia.
Reflexes: primitive reflexes remain
Hearing: should respond to parent’s voice and respond to loud noises by blinking, startling, frowning, or waking from light sleep
Vision: most newborns focus best on objects about 8 to 10 inches away, or the distance to your face during a feeding. Acuity is 20/100; they begin to recognize mother visually. Can track objects visually with more accuracy.
Communication: sensitive to the way they are held, rocked, and fed. By age 2 months, the infant should smile on purpose (social smile), blow bubbles, and coo when spoken to. At 3 months the infant may laugh out loud and express moods.
Three to six months
Birth weight doubles by 6 months of age
Height increases 1 inch per month for first 6 months
Can raise head (Figure 7–16) and support it by 4 months
Reaches and grasps objects, plays with hands, moves objects to mouth, plays with toes
Rolls from abdomen to back
More stabilized sleeping patterns at 3 months
Opens mouth for spoon
Binocular vision: ability to see with both eyes coordinated
Primitive reflexes begin to disappear
Begins to drool, chew on toys as teething begins (6 months)
Can sit when propped at 6 months
Can support some weight when held in a standing position
Recognizes familiar objects and people, expresses displeasure when those objects or people are removed, babbles to self
Six to nine months
All infants should be screened for developmental delays and disabilities at 9 months at the well-child visit
Rolls from back to stomach and stomach to back
Sits unsupported by 8 months
Transfers objects from hand to hand, points at objects, and picks them up at 9 months
Fine motor skills continue to develop
Puts feet in mouth, plays pat-a-cake, loves to see own image in a mirror
Develops and expresses taste preferences
Begins to understand differences between inanimate and animate objects
Displays stranger anxiety
Develops object permanence
Vocalizes with many-syllable vowel sounds and “m-m” with crying
Around 9 months, says “Dada” and “Mama” and understands bye-bye and no
Around 8 to 9 months begins to pull to stand, develops pincer grasp, crawls backward and then forward, and responds to own name (Figure 7–18)
Understands where to look for an object that has been dropped; practices grasp-release movements
Begins to test parent’s responses, such as watching the parent while dropping food on the floor
Distinguishes colors
Distance vision
Expresses emotions, including frustration and anger
Nine to twelve months
Birth weight triples
Birth length increases by 50%
Head and chest circumference are equal
Total of six to eight teeth
Knows name
Creeps along furniture
Drinks from a cup; should be weaned from a bottle
Stands alone for brief periods of time; raises arms when wants to be picked up
May take first steps or walk alone
Eats with spoon and cup but prefers fingers
Enjoys familiar surroundings and people, expresses dissatisfaction with strangers or strange surroundings (stranger anxiety)
May develop security objects such as favorite toys or blankets
Enjoys books, especially board books
Can understand simple communication or direction; says two or three words beyond Dada and Mama
One or both feet may slightly turn in; the infant’s lower legs are normally bowed
At around 12 months of age can transition to whole cow’s milk; do not use 1% or 2% because the infant needs the fat content for continuing brain development
Cognitive development
Cognitive development involves the infant’s processing of information, conceptual processes, intelligence, language development, memory, and perceptual skills.
Intellectual growth-begins at birth-memory-problem solving, exploring, concepts.
Primitive reflexes-disappear within months after birth(controlled by lower brain fuinctions)
Cognitive development affected by
occurs quickly and may substantially vary from month to month. Infants develop on all levels and are influenced by cultural context, neurological development, and experience with others.
Assessment models for infant cognitive development:
Brazelton Neonatal Behavioral Assessment Scale:
Tests an infant’s neurological development, behavior, and responsiveness. It is used only in the neonatal period.
Gesell Developmental Schedules:
Test for fine and gross motor skills, language, eye-hand coordination, imitation, object recovery, personal-social behavior, and play response.
Denver Developmental Screening Test
Used to identify problems or delays. It measures personal/social, fine and gross motor, language, and social skills.
Bayley Scales of Infant Development
Test the cognitive, behavioral, and motor domains of the infant. The assessment is used to identify infants with developmental disabilities. It is a highly reliable tool that uses mental, motor, and behavioral scales to rate an infant’s functioning. The mental test screens for such items as whether the infant turns to a sound or looks for a fallen object. The motor test screens for gross and fine motor skill development.
Developmental theorists:
Piaget(theory of cognitive development)
In sensorimotor stage, infants use five senses to explore their world; the theory includes six substages that describe the infant’s mental representation (see Chapter 6). Infants learn about their environments through their senses and begin to engage in goal-directed behaviors
Vygotsky (social context of cognitive development)
Describes how complex mental functioning originates in infants through social interactions. Cultural factors influence attainment. There is a close correlation between language acquisition and the development of thinking
Erikson (psychosocial development)
Highlights trust versus mistrust as the first psychosocial stage during the first year of life. This theory explains how the infant’s personality develops.
Trust requires a feeling of physical comfort and a minimal amount of fear and apprehension about the future. It is a time where the infant has certain expectations about the predictability of the environment. If this stage is not attained, the infant feels insecure and learns mistrust (see Chapter 6).
Trust in infancy provides lifelong expectation that the world will be a good and pleasant place to live.
Mahler (social development):
Describes how an infant develops a sense of self through symbiosis and separation, or individualism
Kohlberg (moral development):
Describes how moral reasoning aids in the development of ethical behavior and proceeds through six stages
Sensory development: Vision smell taste Touch
Vision: least-developed sense; infants are attracted to bright colors and black and white because of limited vision; objects appear two-dimensional with poor peripheral vision until 2 to 3 months of age
Smell: well-developed sense; especially recognizes smell of own mother
Taste: well-developed sense; sweet tastes are preferred
Examination of the ears of an infant: Pull the pinnae straight back and down.
Communications with infants are similar in different cultures, with a higher-pitched voice used when attempting to get the infant’s attention; deaf mothers use a slower pattern and sign more often.
Touch: Touch is extremely important for the newborn; gentle touch or massage is calming and pleasurable. Pain is a protective device; the infant responds by extending and retracting the extremities and crying.
Hearing
Hearing: can hear beginning in the womb and can identify mother’s voice; differentiates between male and female voices; hearing is critical for language development
Hearing test is administered before discharge, either through otoacoustic emissions or auditory brainstem response.
All 50 states, as well as Puerto Rico, Guam, and the District of Columbia, require hearing screening for newborns.
Tests are noninvasive, conducted before discharge by a trained professional, and performed in a quiet environment. Vernix, other fluids, and a withdrawing infant may affect the test.
Hearing tests:
Auditory brainstem response
Auditory brainstem response is a physiological measurement of the brainstem’s response to sound. A clicking sound is produced, and the electrical activity response from the nerve is recorded as waveforms on a computer. This noninvasive test requires electrodes to be placed on the infant’s scalp with adhesive and is conducted while the infant is sleeping
Otoacoustic emissions method
The otoacoustic emissions method uses an earplug that measures the responses of the cochlea to clicking sounds produced by a microphone. The infant is sleeping during the test. It is a noninvasive procedure
Soothing odors
Research has indicated that mothers pass on to their newborns chemosensory information that reveals her identity, the location of her breasts, and the composition of her milk. These pheromones help guide the newborn to finding the source of milk necessary for nutrition, fluids, and energy, and identify her to her newborn. Studies have shown that biologically meaningful odors such as amniotic fluid, colostrum, and breast milk are soothing to infants, particularly when obtained from the infant’s own mother. These odors support successful mother–infant bonding and increase breastfeeding success.
Hearing screening at birth
Some degree of hearing loss occurs in 3 out of 1,000 infants (AAP, 2017c). Any infant who does not pass the newborn hearing screening has the potential for a developmental emergency (AAP, 2016c). Initial newborn hearing screening occurs in the hospital setting by specially trained nursing staff with any necessary follow-up testing recommended in the pediatric medical home (AAP, 2017c). The State Early Hearing Detection and Intervention (EHDI) Laws and Regulations list the screening mandated by all 50 states and the District of Columbia
Language acuisition
is a partly innate and partly learned process.
Linguist Noam Chomsky (nativist theory) describes the infant’s acquisition of language as complex and not well understood; he coined the term language acquisition device.
Vygotsky proposed the interactionist theory of language acquisition, which states that language is learned through socialization within the family context.
Early speech is evidenced by crying, babbling, and mimicking of repetitive vowel sounds such as ma-ma-ma and da-da-da. Single words are then used and accumulate into the infant’s vocabulary. Children interact with other people and the environment, so favorable responses to speech encourage the infant to communicate.
Discipline
Although it is impossible to spoil an infant, discipline at this age should focus on setting limits for the child’s safety and well-being.
At 6 months of age, when the child is more mobile, use distraction to keep the child away from dangerous areas.
Temper tantrums are the infant’s way of expressing frustration, hunger, anger, illness, or fatigue.
Reward good behavior.
Remain calm, firm, and consistent.
Maintain a set routine.
SAFE AND EFFECTIVE NURSING CARE: Promoting Safety
Corporal Punishment
Corporal punishment of children, such as spanking or hitting, has been found to have negative consequences and is less effective than other forms of discipline, such as the withdrawal of positive reinforcement (loss of privileges, time-outs). Spanking has been associated with a higher incidence of aggressive behavior in children, increased substance abuse, and higher rates of crime and violence in older children (
Colic
Some infants experience a great deal of intestinal gas, resulting in frequent crying known as colic. Colic usually happens at the end of the day. Usually no medical problem is present, but the infant should be assessed by a pediatrician if it continues.
Parents of an infant with colic should be educated about the following:
Make sure the infant is burped frequently.
Parents should not change formula, unless directed by the pediatrician.
If the infant is breastfed, the mother should decrease the intake of spicy or gaseous food; dairy and corn can also cause gastrointestinal disturbances.
Infants tend to be sensitive to stimulation.
Try a car ride, movement, infant massage, carrying the infant in a carrier, or creating a white noise environment.
If a pacifier is used, it can help calm the infant; pacifiers have also been shown to decrease the incidence of sudden infant death syndrome (SIDS).
Colic usually disappears by about 12 to 16 weeks of age.
CRITICAL COMPONENT
Diagnostic Criteria for Infant Colic
Paroxysms of irritability, fussing, or crying that start or stop without obvious cause
Crying is turbulent and dysphonic, with a higher pitch
Episodes last 3 hours or longer and occur 3 days a week for at least 2 weeks, peaking at 6 weeks of age
Infant thriving
Diagnosis of exclusion
Care of the Infant With Colic
Swaddle infant.
Place in a safe area.
Remove yourself from the infant for a 10-minute break once the child is secured in a safe place.
Educate caregivers that colic is not a reflection of their caregiving skills.
Realize that it is a heightened time of stress for caregivers.
Simethicone drops have been prescribed to ease intestinal gas, but never give an infant an over-the-counter medication without consulting the child’s pediatrician.
Play
Play is how infants learn about the world and themselves. Infants are primarily sensorimotor focused, so play should involve sensory stimulation.
Explore with their mouths and imitate others.
toys- safety is the number one consideration; avoid detachable or removable pieces or parts. Simple toys should be used because attention span is short. Opt for unbreakable mirrors, rattles, soft (nonremovable pieces) stuffed animals, large snap toys, and musical pull toys.
Place infants on their stomachs for supervised tummy time.
Engage the infant with soothing tones and use of facial expressions.
Use soothing music.
If other siblings’ toys are lying around, safety for the infant requires the caregiver to be aware of small pieces.
Toys should help the infant in physical and fine motor development.
Infants enjoy looking at themselves in mirrors.
Play is essential in a hospitalized environment. The theorist Watson described the importance of positive play in fostering attachment between the infant and the caregiver.
Nutrition
The WHO recommends exclusive breastfeeding until the age of 6 months and to continue until the age of 2 years, with no supplementation of water, formula, or solids prior to this point . The decision to breastfeed versus bottle-feed is dependent on maternal knowledge, past exposure to breastfeeding, education level, perceptions of the benefits of breastfeeding, cultural factors, family and friend support, career barriers, husband or partner support, and support from health-care providers.
nutrition 6months -1 year
For infants between 6 months and 1 year of age:
Sufficient protein is needed to support growth and development.
Fats are needed to provide calories and support brain development.
Carbohydrates are needed to provide energy.
Infants need 100 to 116 kcal/kg/day for basic growth and development.
Adequate fluid and electrolyte intake is necessary.
Fluids, mainly water, should total 120 to 150 mL/kg/day for infants.
Supplemental iron is not necessary for breastfed infants before 6 months of age.
All infants 6 months or older require iron supplementation. Iron can be supplied through lean red meats, fortified infant cereals, spinach, broccoli, green peas, or beans.
Do not feed cow’s milk until after 1 year of age.
Soy formula is used for galactosemia, lactose intolerance, and allergies to cow’s milk.
Soy formulas not used for preterm infants.
Non nutritive sucking
Nonnutritive sucking is a self-soothing or comforting measure used by infants.
The infant’s sucking ability is necessary for neurological development and survival.
Pacifiers, fingers, or fists are used in self-sucking.
Suckling, which the infant does at the breast, requires a different set of mouth movements than does bottle feeding or the use of fingers, fists, or a pacifier.
Avoid using pacifiers in the early days of breastfeeding.
Educate caregivers on the use of a pacifier, such as not using it as a substitute for feeding or holding.
Never tie or clip the pacifier to the child’s clothing because this can be a source of strangulation, even in older infants.
Limit the use of the pacifier as the infant gets older to prevent creating a habit that will be difficult to break; distract the infant with an alternative.
Breastfeeding
Breastfeeding is the optimal method of feeding because it provides all necessary nutrients, minerals, and vitamins (Table 7–9).
Should begin within the first hour after birth during the initial period of reactivity
Infant should be fed on demand throughout the day and night
Reduces costs and preparation time
Promotes positive bonding between infant and mother
Decreases risk for obesity
Composition of breastmilk
Breast milk development begins early in pregnancy through the hormones of estrogen, progesterone, and prolactin. It is high in IgA and IgG, and contains higher levels of a protein with a laxative effect that aids in the passage of meconium. No immunoglobulins are found in formulas. Concentration of nutrients differs among women. Infant allergic responses to breast milk are rare. Components of breast milk include:
Large water content; fat content accounts for 52% (Durham & Chapman, 2014)
Carbohydrates (lactose, 42% of calories in breast milk)
Protein, specifically whey (60% to 80%) and casein (20% to 40%), makes up approximately 6% of calories in breast milk (Durham & Chapman, 2014)
Antibodies, bifidus factor (which stimulates the growth of lactobacillus)
Lipase, amylase, and other enzymes
Epidermal growth factor, nerve growth factor, other growth factors, and interleukins
Benefits of breastfeeding for mothers
- Decreased risk for breast cancer
- Lactational amenorrhea (although breastfeeding is not considered an effective form of contraception)
- Enhanced involution (due to uterine contractions triggered by the release of oxytocin) and decreased risk for postpartum hemorrhage
- Enhanced postpartum weight loss
- Increased bone density
- Enhanced bonding with infant
Benefits of breastfeeding for infants.
- Enhanced immunity through the transfer of maternal antibodies; decreased incidence of infections, including otitis media, pneumonia, urinary tract infections, bacteremia, and bacterial meningitis
- Enhanced maturation of the gastrointestinal tract
- Decreased likelihood of development of insulin-dependent (type 1) diabetes
- Decreased risk for childhood obesity
- Enhanced jaw development
- Protective effects against certain childhood cancers such as lymphoblastic leukemia, Hodgkin’s disease
Stages of Breast Milk
Stage 1
Stage one: Colostrum, a yellowish fluid, is present in the first 2 to 3 days after birth and can also be secreted in the last trimester of pregnancy. Colostrum has higher concentrations of protein and lower levels of fat, carbohydrates, and calories than mature milk. It contains large amounts of IgA and IgG, and assists in the passage of the infant’s first stool, known as meconium
Stage 2
Stage two: The milk transitions from colostrum to more mature milk at about 3 to 10 days after birth. It consists of increasing fat, carbohydrates, and calories
Stage 3
Stage three: Mature milk begins 10 days after birth. This mature milk has approximately 23 calories per ounce and is composed of foremilk and hind milk.
Foremilk is produced and released at the beginning of the feeding; it has a higher water and lactose content and a lower fat content.
The hind milk is released at the end of the feeding and has a higher fat content.
Production of Breast Milk
Lactation is the process of milk production (Figure 7–20). Once the baby is born, the levels of estrogen and progesterone are eliminated and prolactin becomes the predominant hormone. Infant stimulation influences supply and demand—as the infant demands, the woman’s body supplies. Oxytocin is released from the posterior pituitary, which affects the breasts and the uterus. Oxytocin produces the letdown reflex, which forces milk into the lactiferous ducts of the breast. The letdown reflex is responsible for milk ejection. This reflex can occur during sexual stimulation, when hearing a baby cry, or when thinking of the infant. It can be inhibited by anxiety, stress, fatigue, and pain (Durham & Chapman, 2014). Infant cues and readiness to breastfeed are important adaptations that mother and infant need to make to facilitate the supply and demand.
Early infant cues -
Rooting
Head bobbing up and down
Stirring and increased arm and leg movement
Burying head in mattress or mother’s chest
Late infant cues
Crying—extended crying can inhibit latching on to the breast
Agitation
Latching on
Hold the breast like a sandwich with the thumb on the top and the other fingers underneath. The baby should be held close; as the baby’s mouth is opened wide, place the breast fully (including the nipple and areola) into the baby’s mouth (Figure 7–22).
Encourage the infant’s mouth to open by stimulating the rooting reflex.
A successful latch is when the infant’s mouth is around the areola with the nipple at the back of the mouth.
The infant draws the milk forward in the breast.
The tip of the nose, cheeks, and chin should be touching the breast. Align the breast with the infant’s nose.
Suck and swallow should follow.
Often infants will feed from only one breast at a time for each feeding.
Latch Scoring System can help determine a successful latch
Common positions for breastfeeding
Cradle hold, football hold, side lying position.