Health Promotion
Through Childhood:
Infant – Adolescent
Joy A. Shepard, PhD(c), RN-C, CNE
Joyce Buck, MSN, RN-C, CNE
1
Objectives
• Recognize major developmental milestones
• Describe the role of play
• Describe and plan nursing intervention...
Nursing Diagnoses
• Readiness for Enhanced Knowledge
• Readiness for Enhanced Parenting
• Readiness for Enhanced Immunizat...
Developmental Age Groups
• Neonate: First 28 days of life
• Infancy: Birth to 1 year
• Toddler: 1 to 3 years
• Preschooler...
Infant
5
Infancy
• Infancy: Age birth to 1 year. Includes neonatal period
(birth to 28 days)
• Dramatic growth and change
• Body sy...
Infancy
• Vital Signs:
• HR & respirations ↓; BP ↑(as infant gets older)
• Growth and Development:
• Best indication good ...
Infancy
• Weight:
• 1st 6 months—5 – 7 oz
(140-200 g)/ week
• 6-12 monthsslows
• 6 months—doubles
birth weight
• 12 month...
Infancy
• Height:
• 1st 6 months1.5
cm per month
• 6-12 months1 cm
per month
• At 12
monthslength
increased by 50%
9
Infancy
• Head Growth:
• When the baby is born, head slightly larger than
chest
• 1st 6 months1.5 cm per month
• 6-12 mon...
Measurement of Head
Circumference
• Measuring tape that
cannot be stretched
• Securely wrap tape
around widest possible
ci...
Infancy: Body Systems
• Neurologic System:
• Brain growth very rapid during 1st yr of life: brain
doubles in weight
• Brai...
Infancy: Body Systems
• Immune System:
• Immature immune systems: Risk for Infection
• Newborn with very little own immuni...
Infancy: Motor
Development
• Weight gain and muscle growth: increased
control of reflexes, increasingly coordinated
moveme...
Infancy: Cognitive
Development
• Piaget—Sensorimotor stage: birth to 2 years
• From reflexive activity to purposeful acts
...
Infancy: Language
• Cries—first attempt at communication
• Distinguish normal from abnormal
• High-pitched—usually neurolo...
Infancy: Vision
• Acuity: 20/100 to 20/400 at birth. Focus on
objects 8”-12" from face at birth (en face
position)
• Color...
Nystagmus & Strabismus
(pp. 512; 519)
• Young infants lack eye
coordination
• Transient nystagmus or
strabismus normal var...
Infancy: Hearing
• Acute at birth;
Mandatory
newborn hearing
screening
• Hearing
milestones: refer
to chart
19
Ear Exam
Pinna is pulled down and back to straighten ear canal in children under 3
years.
Infancy: Psychosocial
• Erikson—Trust vs Mistrust
• Foundation of personality; establish sense of trust
• Related to feedi...
Review Question
• The pediatric RN would expect a 10-
month-old infant to respond to the staff
upon admission to the hospi...
Infancy: Sleep (p. 193)
• Newborn to 3 mos: 10 – 16 hours/ day
• Most infants begin to sleep for longer periods
during the...
Steps to Ensure a Safe Sleep Environment
& Reduce Risk of SIDS (p. 561-562)
• Place infant on back to
sleep, for naps and ...
Apparent Life-Threatening Event
(ALTE) (p. 559)
• Episode that frightens a child’s caretaker
• Can involve any of the foll...
Nutrition
• Utmost importance for
growth and development
• Breast milk or
commercially prepared
formulas: foundation of
nu...
Breastfeeding
• Breastfeeding
• Very important for infant health
• Recommended over formula
• Easier to digest, natural an...
28
Bottlefeeding
• Bottle feeding
• Formula meets energy and basic nutritional requirements
• Does not have disease-fighting ...
Weaning and Solid Food
Introduction (Table 14-3, p. 339)
• Weaning (6 to 12 months):
• NOT during stress; gradual: replaci...
31
Keep your sense of humor and
enjoy watching him make some
tasty discoveries!
Caution
• Cow’s milk—not recommended until 12 months of age
• Inadequate iron & linoleic acid; excessive sodium, phosphoru...
Review Question
• During a 4-month-old’s well child checkup, the nurse
discusses introduction of solid foods into the infa...
Immunizations
• Check CDC National Immunization Program site for up-to-date
information:
• http://www.cdc.gov/vaccines/par...
35
36
Review Question
• Which of the following sets of injections is
typically given at the 4-month checkup?
• A. DTaP, Hib, RV,...
Dental Care (p. 191)
• Deciduous teeth:
• Age 6-10 months: Eruption of first teeth
• 12 months: 6-8 teeth
• No teeth erupt...
Safety (REVIEW pp. 195-199)
• Accidental injury: LEADING cause of death during
infancy
• Common causes: Suffocation and as...
Safety Cont’d….
• Crib safety: distances between slats must be no more than 2-3/8 inches wide to
prevent entrapment of the...
Infant in Rear-Facing Only Car Seat
41
Infant seats can ONLY be used rear-facing; for babies who weigh 5-22 lbs
Toddler
42
Toddler: 12-36 mos (1-3 yrs)
• Struggle for autonomy: develops sense of self separate from parent
• Growth slacks off: gro...
Toddler: Vital Signs &
Physical Characteristics
• HR: 80-120
• Respirations: 20-30
• BP: 88/45 (BP estimate: systolic 80 +...
Review Question
• A mother of a 15-month-old brings her son to
the clinic. While doing a nursing assessment,
the mother ma...
Toddler: Play & Language
• Parallel Play:
• Gross Motor:
• Ride-on toys; push and pull toys
• Fine Motor:
• Crayons--with ...
• Vision:
• Toddler period—20/40-20/50
acuity level
• Screen for poor vision:
clumsy, running into things,
won't follow ob...
Toddler: Toilet Training
• One of biggest tasks during this period
• Refer to "Toddler Characteristics"
• Signs of Toilet ...
Signs of Toilet Training
Readiness
49
Toddler: Psychosocial
Development
• Erickson: Autonomy vs shame and doubt
• Autonomy--wanting to be in control. Conflict. ...
Toddler
• Separation anxiety (15-18 mos):
• Peaks in the toddler period
• Stressful: Inform child honestly and clearly
abo...
Separation Anxiety within the
Hospital Setting (p. 264)
52
Review Question
• The nurse is planning care for a 2
year-old hospitalized child. Which
of the following will produce the
...
Toddler
• Discipline:
• Role modeling (guiding behavior), ignoring, and/ or time
out (placing the child in a nonstimulatin...
Toddler Sensorimotor Phase,
1-2 yrs (pp. 79-80)
• Learning by physical trial and error; imitate older
children and adults
...
Toddler Preoperational Phase,
2-4 yrs (pp. 79-80)
• ↑Understanding time and space
• ↑Use of language
• Mental trial and er...
Toddler: Nutrition
• Rate of growth/ appetite slows: "Physiologic Anorexia"
• Calorie requirements: 1300 calories/day (~ 1...
Toddler: Nutrition
• 2-3 servings milk group
daily
• After 2 yrs, low-fat (2%)
milk
• Milk intake: limit to 2 - 3
cups/day...
Toddler: Dental Care
• 33 months old: complete set of 20 baby teeth (deciduous teeth)
• Healthy teeth:
• Diet: low in swee...
Toddler: Car Safety
• Car: Door locks
• Safety seats:
http://www.buckleupnc.org/occupant-
restraint-laws/child-passenger-s...
Toddler Safety (pp. 212-214)
• Fire and burns:
• No dangling cords from
irons or other small
appliances
• Keep away from o...
Toddler Safety (pp. 212-214)
• Water safety:
• NEVER leave a child alone in water (can drown
in 1” of water)
• Preventing ...
Toddler: Poisons (pp. 464-465)
• Poisoning – Ingestion of or exposure to toxic substances
• Children < 6 yrs more at risk ...
Toddler: Poisons (pp. 464-465)
• Primary prevention is key. See “Avoiding Childhood
Poisoning,” p. 466
• Keep medicines, v...
Lead Poisoning (pp. 463-464)
• Ingestion, inhalation, or absorption through skin
• Primary source: deteriorating lead-base...
66
Potential Sources of Lead
• Because the harm from
lead is irreversible,
primary prevention
efforts that identify and
reduc...
Lead Poisoning (pp. 463-464)
• Screening: 12 & 24 mos, or between 3-6 yrs
• Chelation therapy:
• Binds with lead, removes ...
69
Preschooler
70
Preschool Child (3-6 yrs):
Psychosocial Development
• Erikson Initiative vs Guilt Stage
• Initiative: sense of confidence ...
Preschooler: Gender Role Identity
• Becomes aware of their similarity to parent
of the same sex
• Usually like to be like ...
Preschooler Cognitive
Development (p. 80)
• Pre-operational or Intuitive ( 4-7 yr)
• Transition to increased symbolic func...
Preschooler Play
• Associative play
• Similar activity but
no rigid organization
• Motor activity!
• Love to be on the go
...
Preschoolers: Pain Perception
• Assessment tools
• Can use multiple tools
• Ask parents
• Verbal ability and Fears
• Bette...
Therapeutic strategies with young children
involve various methods of communication,
such as dramatic play and art
Review Question
• Before cleaning an abrasion on a 3 year old,
what could the nurse use to help decrease
the child’s anxie...
School-Age Child
78
School Age Development: 6-12 yrs
• Erikson—Industry vs. Inferiority
• Piaget—Concrete operational
• Conservation
• Develop...
School Age and Play
• Cooperative Play
• Teams, organized clubs
• Rules
• Likes competition
• Construction
• Enjoys buildi...
School Age Social Development
• Concrete Thinking
• Conservation of matter
• Able to have mental representations
• Concept...
Cooperative Play
82
Anticipatory Guidance: Promote
Use of Protective Gear
83
School Age and Hospitalization
• Fears
• Concern for physical harm
• Separation from friends and school
• Loss of control
...
Review Question
• Which of the following nursing interventions is
the most appropriate when working with a
school age chil...
Adolescent
86
Adolescent Development:
12-18 years old
• Erikson—Identity vs. Role Confusion
• Piaget– Formal operations
• Developmental ...
Adolescents and Social Activity
• FRIENDS
• Sports
• School Activities
• Dances, Movies, Dating
• Music
• Computer, Textin...
Adolescents and Peers
89
Adolescents and Hospitalization
• Procedures
• Give full explanations
• More concerned with the present than the future
• ...
School Age and Teen Diet
• Decreased parental control
• High fat, sugar and salt diets
• Vending machines
• Decreased acti...
Review Question
• A 13-year-old boy is hospitalized for a femur
fracture because he was hit by a car while
racing bikes wi...
Confidentiality Issues
• Minors in all 50 states have the right to consent to
STI treatment and testing
• Most states allo...
Adolescents and Pain
• Verbal skills
• Excellent ability to verbalize
• Can use adult pain assessment tools
• Adult level ...
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Health Promotion through Childhood

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  • Infancy: Age birth to 1 year. Includes neonatal period (birth to 28 days).
    During no time after birth does a human being grow and change as dramatically as during infancy.
    During the first year of life, the infant’s organs grow and mature at a rapid rate, yet organ systems of infants remain very different than those of older children and adults because they are immature.
    Risks caused by immature body systems:
    More at risk for respiratory infection or aspiration (immature respiratory system tiny, collapsible airways).
    More at risk for infection (immature immune system).
    More at risk for fluid and electrolyte imbalances (immature renal system cannot concentrate urine efficiently).
  • Breastfeeding is one of the most important contributors to infant health and is recommended over formula. Breast milk is easier to digest than formula, provides natural antibodies that help protect infants from common childhood diseases, and it is less expensive than formula.
    Breastfed infants tend to gain less weight than bottle-fed infants. Adults who were breastfed as infants have lower incidence of obesity and hypertension, and have higher IQ’s.
    Breastfeeding mothers may need referral to a lactation specialist or to a support group such as La Leche League.
     
    Breastfeeding should not be used if the mother uses illegal drugs, is taking certain prescribed drugs, has untreated active tuberculosis, or is infected with the human immunodeficiency virus (HIV).
    Breast milk is a body fluid that can carry the HIV infection.
  • The DTaP, Hib, RV, IPV, and PCV immunizations should be given at 4 months of age.

    At 6 months of age, the infant should receive the DTaP, RV, IPV, PCV, and Hep B immunizations.
    In addition to these immunizations, infants 6 to 12 months of age should receive yearly
    seasonal influenza vaccinations. DTaP, MMR, PVC, varicella, and Hep A immunizations
    should be given to toddlers 12 months to 3 years of age. In addition, toddlers should receive
    the Hep A vaccine in two doses, at least 6 months apart, and a yearly seasonal influenza
    vaccine.
  • Three phases of separation anxiety exhibited in young children who are separated from their mothers for long periods of time.
    If possible, the family is encouraged to remain with, and actively participate in care of the hospitalized child.
  • A. Give factual explanations of the disease, medications, and procedures.
  • Health promotion through childhood nurs 3340 fall 2014 slideshare

    1. 1. Health Promotion Through Childhood: Infant – Adolescent Joy A. Shepard, PhD(c), RN-C, CNE Joyce Buck, MSN, RN-C, CNE 1
    2. 2. Objectives • Recognize major developmental milestones • Describe the role of play • Describe and plan nursing interventions to meet nutritional needs • Identify major health concerns • Apply communication skills according to the child’s developmental level • Use anticipatory guidance to promote positive parenting, child safety, and prevent injury 2
    3. 3. Nursing Diagnoses • Readiness for Enhanced Knowledge • Readiness for Enhanced Parenting • Readiness for Enhanced Immunization Status • Readiness for Enhanced Family Coping • Deficient Knowledge • Ineffective Family Therapeutic Regimen Management • Ineffective Infant Feeding Pattern • Risk for Aspiration • Risk for Electrolyte Imbalance • Risk for Infection • Risk for Injury • Risk for Falls • Risk for Delayed Development • Risk for Sudden Infant Death Syndrome • Risk for Poisoning 3
    4. 4. Developmental Age Groups • 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 12 years • Adolescent: 12 to 18 years
    5. 5. Infant 5
    6. 6. Infancy • Infancy: Age birth to 1 year. Includes neonatal period (birth to 28 days) • Dramatic growth and change • Body systems immature • Risks r/t immature body systems: • More at risk for respiratory infection or aspiration (immature respiratory system tiny, collapsible airways) • More at risk for infection (immature immune system) • More at risk for fluid and electrolyte imbalances (immature renal system cannot concentrate urine efficiently) 6
    7. 7. Infancy • Vital Signs: • HR & respirations ↓; BP ↑(as infant gets older) • Growth and Development: • Best indication good health: steadily increasing growth • Measured by: height, weight, head circumference, and weight-for-length (BMI) • Plot anthropometric data on growth chart to see if growth pattern conforms to normal growth curves • ~As the child grows, the growth rate slows~ 7
    8. 8. Infancy • Weight: • 1st 6 months—5 – 7 oz (140-200 g)/ week • 6-12 monthsslows • 6 months—doubles birth weight • 12 months—triples birth weight 8
    9. 9. Infancy • Height: • 1st 6 months1.5 cm per month • 6-12 months1 cm per month • At 12 monthslength increased by 50% 9
    10. 10. Infancy • Head Growth: • When the baby is born, head slightly larger than chest • 1st 6 months1.5 cm per month • 6-12 months1 cm per month • 12 months—head circumference = chest circumference • Fontanels accommodate rapidly growing brain: • 2-3 months: posterior fontanel closes • 12-18 months: anterior fontanel closes 10
    11. 11. Measurement of Head Circumference • Measuring tape that cannot be stretched • Securely wrap tape around widest possible circumference of head • Take measurement 3 Xs • Select largest measurement to nearest 0.1cm 11
    12. 12. Infancy: Body Systems • Neurologic System: • Brain growth very rapid during 1st yr of life: brain doubles in weight • Brain growth depends on nutrition • Without proper nutrition: developmental problems • Rapid growth: increased number of synapses, myelination • Cephalocaudal pattern • Primitive reflexes replaced by purposeful movement 12
    13. 13. Infancy: Body Systems • Immune System: • Immature immune systems: Risk for Infection • Newborn with very little own immunity; passive immunity if breastfed • Breastfeeding decreases: ear, respiratory tract, GI, and urinary tract infections; diarrhea; sepsis • First year of life: infant develops own immunity • Immunizations: health promotion & disease prevention 13
    14. 14. Infancy: Motor Development • Weight gain and muscle growth: increased control of reflexes, increasingly coordinated movement • Risk for Injury • Anticipatory guidance: prevent accidents • Milestones: screen for motor development problems • Expected MilestonesFine (purposeful use of hands and fingers) and Gross Motor: refer to chart 14
    15. 15. Infancy: Cognitive Development • Piaget—Sensorimotor stage: birth to 2 years • From reflexive activity to purposeful acts • Egocentrism—Child at center of own little universe; views nothing but himself • Object Permanence: 9 months—Infant can locate object hidden from view • Play: • Enhances growth & development • Solitary play, but human interaction & stimulation very important • Make sure toys are age-appropriate 15
    16. 16. Infancy: Language • Cries—first attempt at communication • Distinguish normal from abnormal • High-pitched—usually neurological problem • Hearing and understanding (receptive speech) come before expressive speech • Language Developmental Milestones: refer to chart 16
    17. 17. Infancy: Vision • Acuity: 20/100 to 20/400 at birth. Focus on objects 8”-12" from face at birth (en face position) • Colors: High-contrast, primary colors • 6 months of age—able to distinguish pastel colors • Vision milestones: refer to chart • Can assess “PERRL” but NOT “PERRLA” – Accommodation (except with accommodative toys) 17
    18. 18. Nystagmus & Strabismus (pp. 512; 519) • Young infants lack eye coordination • Transient nystagmus or strabismus normal variant until 4 months • Alignment of eye important due to correlation with brain development • Nystagmus: involuntary rapid eye movements • Treatment: eyeglasses, surgery of eye muscles • Strabismus: misaligned eyes • Treatment: Surgical correction, optometric vision training • Untreated: can lead to amblyopia (lazy eye) (p. 519) 18 Normal: Reflections of light are symmetrical
    19. 19. Infancy: Hearing • Acute at birth; Mandatory newborn hearing screening • Hearing milestones: refer to chart 19
    20. 20. Ear Exam Pinna is pulled down and back to straighten ear canal in children under 3 years.
    21. 21. Infancy: Psychosocial • Erikson—Trust vs Mistrust • Foundation of personality; establish sense of trust • Related to feeding cycle • Freud—Oral stage: • Oral stimulation: source of pleasure and satisfaction • Parent-Infant Attachment: • One of most important features of psychosocial development • Critical for normal development and survival; infant is active participant • Stranger Anxiety: 6-7 mos; Infant cries, clings to parents, turns away from strangers • Separation Anxiety: 9 mos; 15-18 mos; inconsolable crying, distress, when parents are not present • Anticipatory guidance: health promotion, injury prevention 21
    22. 22. Review Question • The pediatric RN would expect a 10- month-old infant to respond to the staff upon admission to the hospital in which manner? A. Outward hostility B. Frequent negativism C. Occasional jealousy D. Fear of strangers 22
    23. 23. Infancy: Sleep (p. 193) • Newborn to 3 mos: 10 – 16 hours/ day • Most infants begin to sleep for longer periods during the nights as they get older • Sleep patterns will be alternating the first year of life—sleep a lot at first, then not sleeping as much • Sudden Infant Death Syndrome (SIDS) – Sudden, unexplained death of an infant younger than 1 yr old • Third leading cause of death in infants < 12 mos 23 See Risk Factors for SIDS (Box 20-1), p.
    24. 24. Steps to Ensure a Safe Sleep Environment & Reduce Risk of SIDS (p. 561-562) • Place infant on back to sleep, for naps and at night • Place infant on firm sleep surface (e.g., safety approved crib mattress with fitted sheet) • NO soft surfaces (e.g., pillow, quilt, or sheepskin) • Keep soft objects out of infant’s sleep area 24
    25. 25. Apparent Life-Threatening Event (ALTE) (p. 559) • Episode that frightens a child’s caretaker • Can involve any of the following: • Apnea • Color change (cyanosis, pallor, erythema, plethora) • Marked change in muscle tone (limpness) • Choking or gagging • Most common causes: prematurity, GERD, sepsis, lower respiratory tract infections, seizures, child abuse • Treatment: hospitalization (to determine underlying cause), home apnea monitor 25
    26. 26. Nutrition • Utmost importance for growth and development • Breast milk or commercially prepared formulas: foundation of nutrition throughout infancy • Calorie needs: 95-110 kcal/kg/day • Fluid needs: 100 ml/kg/day • Output: At least 6 wet diapers/day 26
    27. 27. Breastfeeding • Breastfeeding • Very important for infant health • Recommended over formula • Easier to digest, natural antibodies, less expensive • Breastfed infants • Gain less weight than bottle-fed infants • Less chance: otitis media, obesity, NEC, type II DM, & cardiovascular disease • Contraindicated: Galactosemia; mother substance abuser, taking certain prescribed drugs, has untreated active TB, or is infected with human immunodeficiency virus (HIV) 27
    28. 28. 28
    29. 29. Bottlefeeding • Bottle feeding • Formula meets energy and basic nutritional requirements • Does not have disease-fighting antibodies • Not as easily digested as breast milk (5-fold ↑risk NEC) • Mothers who choose not to breast-feed should not be made to feel guilty because of their choice • Support should be given for selected feeding choice • Proper preparation and storage of formula: • Improper use: infection, hyponatremia, or malnutrition • Ready-to-use preparations: never diluted; opened containers refrigerated and used within 24 hours • Do not microwave! 29
    30. 30. Weaning and Solid Food Introduction (Table 14-3, p. 339) • Weaning (6 to 12 months): • NOT during stress; gradual: replacing one feeding at a time • Solid Foods (4 to 6 months): • Ready: can sit, extrusion reflex gone, can reach for objects and bring to mouth, can indicate desire or refusal for food, and is able to safely move food to back of mouth and swallow • Solids should be introduced one at a time in small amounts; wait at least 3 to 5 days before introducing a new food; feed only from a spoon • 4-6 months: rice cereal with iron • 6-8 months: pureed vegetables first, then pureed fruits • 8-10 months: pureed meats • 8-12 months: table foods (soft bland foods) • Salt, sugar, and spices should not be added • Food Allergies • Abdominal pain, diarrhea, nasal congestion, wheezing, cough, vomiting, and rashes 30
    31. 31. 31 Keep your sense of humor and enjoy watching him make some tasty discoveries!
    32. 32. Caution • Cow’s milk—not recommended until 12 months of age • Inadequate iron & linoleic acid; excessive sodium, phosphorus, & protein • May cause kidney problems, digestive problems (GI bleeds), dehydration, iron-deficiency, and allergies • Avoid honey until at least 1 yr of age • Infants cannot detoxify clostridium botulinum spores sometimes present in honey – can lead to infant botulism • Delay strawberries, wheat, corn, fish, and nut products until 2 yrs of age – highly allergenic • AVOID hard & small food items: hot dogs, chunks of meat or cheese, hard candy, raw vegetables or fruit chunks, whole grapes, raisins, seeds, nuts, popcorn, peanut butter, chewing gum, lollipops, and marshmallows - choking hazard 32 Risk for Aspiration
    33. 33. Review Question • During a 4-month-old’s well child checkup, the nurse discusses introduction of solid foods into the infant’s diet and concerns for foods commonly associated with food allergies. Therefore, the parents are instructed to delay until after 1 year of age introduction of? A. Strawberries, corn, and wheat. B. Honey, tomatoes, and spinach. C. Carrots, beets, and spinach. D. Squash, pork, and tomatoes. 33
    34. 34. Immunizations • Check CDC National Immunization Program site for up-to-date information: • http://www.cdc.gov/vaccines/parents/index.html • Substantially reduced child mortality • Informed consent • Nurse: document manufacturer & lot number, expiration date, administration site • Contraindications: severe febrile illness, immunodeficiency, known allergy to the vaccine or to egg whites • Common side effects: redness or soreness at the site and a mild, low- grade fever • Give liquid acetaminophen (Tylenol) or ibuprofen—do not give aspirin to a pediatric patient under age 19 during episodes of fever-causing or viral illnesses (risk of Reye’s Syndrome) 34
    35. 35. 35
    36. 36. 36
    37. 37. Review Question • Which of the following sets of injections is typically given at the 4-month checkup? • A. DTaP, Hib, RV, IPV, PCV, and Hep B • B. DTaP, RV, IPV, PCV, and Hep B • C. DTaP, Hib, RV, IPV, and PCV • D. DTaP, MMR, PVC, varicella, and Hep A 37
    38. 38. Dental Care (p. 191) • Deciduous teeth: • Age 6-10 months: Eruption of first teeth • 12 months: 6-8 teeth • No teeth eruption by 12 months think endocrine disorder • Teething: cool liquids, cold teething rings, teething gel • Dental hygiene—use a soft washcloth • NO toothpaste for children under age 2 (toxic levels of fluoride) • After age 2: pea-sized amount of toothpaste per day, don’t allow to swallow • Fluoride drops (0.25 mg) recommended > 6 mos (with unfluoridated water) • Dental fluorosis white spotted, yellow or brown stained and sometimes crumbly teeth • Bottle of juice or formula should never go to bed with the infant— bottle mouth caries, middle ear infections (otitis media) 38
    39. 39. Safety (REVIEW pp. 195-199) • Accidental injury: LEADING cause of death during infancy • Common causes: Suffocation and aspiration of small objects, motor vehicle crashes, drowning, fire/ burns, poisoning, and falls (p. 7) • Safe to Sleep—Helps prevent sudden infant death syndrome (SIDS) • Prevent asphyxiation—asphyxiation (suffocation) occurs when air cannot get into or out of the lungs and oxygen supplies are depleted • Choking: major concern in infancy and toddlerhood • Substances or objects aspirated into airway • Partial or complete obstruction of the lungs • Strangulation: constriction of the neck; also blockage of nose & mouth by airtight material • All plastic bags or covers kept out of the infant’s reach • NO latex balloons 39
    40. 40. Safety Cont’d…. • Crib safety: distances between slats must be no more than 2-3/8 inches wide to prevent entrapment of the infant’s head or body. No drop side rails. Minimal gap (less than 2 fingerbreadths) between crib mattress and interior of the crib. Lead- free paint, no decorative enhancements on the crib, no elevated cornerposts, child- proof latches. No pillows or “fluffy” items in the crib (“Bare is Best”). DON'T place a baby on sheepskin or on a waterbed. Position crib at least 3 inches away from drapes, ribbons, blind cords, and decorative wall hangings. • http://www.thebabydepartment.com/nursery/crib-safety-standards.aspx • In a vehicle, children <5 yrs of age, < 40 lbs should be placed in the back seat in a rear-facing approved car seat; NEVER in the front seat • NC Child Passenger Safety Law: http://www.buckleupnc.org/occupant-restraint-laws/child- passenger-safety-law-summary/ • Burn safety—Temperature settings on hot water heaters < 120 F. Test bath water with back of wrist. Turn cooking handles toward the back of the stove. Cover outlets • Prevent falls by restraining straps in high chairs. Never leave baby unattended on a changing table or other high surface, not even for a second. Infants begin to roll over by themselves as early as 2 months of age. Fence all stairways 40
    41. 41. Infant in Rear-Facing Only Car Seat 41 Infant seats can ONLY be used rear-facing; for babies who weigh 5-22 lbs
    42. 42. Toddler 42
    43. 43. Toddler: 12-36 mos (1-3 yrs) • Struggle for autonomy: develops sense of self separate from parent • Growth slacks off: growth spurts and lags (step-like growth curve) • Anthropometric Measurements: • Toddler's height: increased 50% since birth • ~3 inches per year • Toddler's weight: • Triples birth weight by age 1 • ~5 pounds per year • Quadruples birth weight by age 2 • Head circumference: at 12 mos, head = chest • 24 months: chest greater than the head • American Academy of Pediatrics: plot ≤ 2 yrs (anterior fontanel closed) • Microcephaly, macrocephaly • CDC Birth to 36 mos growth chart: Head circumference-for-age 43
    44. 44. Toddler: Vital Signs & Physical Characteristics • HR: 80-120 • Respirations: 20-30 • BP: 88/45 (BP estimate: systolic 80 + [ 2x age]; diastolic 2/3s systolic) • Affected by fever, dehydration, respiratory illnesses and drugs • Measure BP at every provider’s office visit • Physical Characteristics: • Brain growing rapidly (good nutrition essential): 80% adult size by 2 yrs • Whole milk until age 2, then 2% milk (need fat for brain development) • Nervous system: continues to myelinate; fine motor control is refining • Muscle tissue replacing adipose tissue (baby fat) present during infancy • Gaining physical strength and ability • Motor Development • Gross Motor: refer to chart • Fine Motor: refer to chart 44
    45. 45. Review Question • A mother of a 15-month-old brings her son to the clinic. While doing a nursing assessment, the mother makes the following comments. Which comment merits further investigation by the nurse? A. “My son cries sometimes when I leave him at his grandparent’s house.” B. “My son always takes his blanket with him.” C. “My son is not crawling yet.” D. “My son likes to eat mashed potatoes.” 45
    46. 46. Toddler: Play & Language • Parallel Play: • Gross Motor: • Ride-on toys; push and pull toys • Fine Motor: • Crayons--with supervision • Tasks: fine & gross motor development • Language (refer to chart): ability developing rapidly • RECEPTIVE SPEECH before EXPRESSIVE SPEECH • Tantrums (p. 210) 46
    47. 47. • Vision: • Toddler period—20/40-20/50 acuity level • Screen for poor vision: clumsy, running into things, won't follow objects • By age 3 – optometric eye examination • Depth perception continuing to develop: inquisitiveness, poor judgment, and occasional lack of coordination Toddler: Sensory 47 •Hearing: Should be able to hear well; Whisper test •Taste and Smell: well- developed; less likely to taste something new •Rest and Sleep: 10-12 hrs at night, one or two daytime naps (very individualistic)Risk for Falls
    48. 48. Toddler: Toilet Training • One of biggest tasks during this period • Refer to "Toddler Characteristics" • Signs of Toilet Training Readiness • Myelinization of spinal cord before child can voluntarily control bowel and bladder sphincters. At least age 18 to 24 months • Must be able to stand and walk well, to pull pants up and down, to recognize the need to eliminate and then be able to wait to go in the bathroom • 24 to 30 months: • Less negativity, usually more willing to please their parents • Control of the anal and urethral sphincters--can voluntarily open and close them • Bowel control: usually achieved before bladder control • Daytime bladder control: before nighttime bladder control • Parent: relaxed approach. Give guidance to sit on the toilet about 10 minutes Praise efforts; never punish them. 48
    49. 49. Signs of Toilet Training Readiness 49
    50. 50. Toddler: Psychosocial Development • Erickson: Autonomy vs shame and doubt • Autonomy--wanting to be in control. Conflict. Give them choices that are appropriate • Freud: Anal stage. Best example is toilet training; as their sphincters become mature, they can assert control, autonomy over the bowel • Moral development: Don’t know “right from wrong” • No formed conscience: avoids punishment by controlling his or her behavior • Right and wrong are determined by the consequences of actions • Negativism: refer to "Toddler Characteristics” • Temper tantrums--refer to "Toddler Characteristics;” also, p. 210 • Ritualism: refer to "Toddler Characteristics" 50
    51. 51. Toddler • Separation anxiety (15-18 mos): • Peaks in the toddler period • Stressful: Inform child honestly and clearly about a separation shortly before it occurs • Parallel Play: • Plays alongside, but not with, other children • Egocentric, shamelessly aggressive • Lacks cognitive/ social skills for interacting or playing well with others 51
    52. 52. Separation Anxiety within the Hospital Setting (p. 264) 52
    53. 53. Review Question • The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produce the most stress at this age? • A. Separation anxiety B. Fear of pain C. Loss of control D. Bodily injury 53
    54. 54. Toddler • Discipline: • Role modeling (guiding behavior), ignoring, and/ or time out (placing the child in a nonstimulating environment) • Key ingredients: consistency, loving, immediate, realistic and age-appropriate • See “Families Want to Know: Positive Discipline,” p. 208 • Sibling rivalry: • Make older child feel important, involved in care of younger sibling • Safety is concern • Needs constant supervision: Child < 3-1/2 yrs should never be left alone with an infant 54
    55. 55. Toddler Sensorimotor Phase, 1-2 yrs (pp. 79-80) • Learning by physical trial and error; imitate older children and adults • Using all senses to explore environment; starting to think before acting • Rudimentary awareness of cause/ effect • Rudimentary awareness of spatial relationships • Object permanence--well established by toddler age • Domestic mimicry--a toddler at this stage is often seen imitating the parent of the same sex, performing household tasks 55
    56. 56. Toddler Preoperational Phase, 2-4 yrs (pp. 79-80) • ↑Understanding time and space • ↑Use of language • Mental trial and error rather than physical • Problem solving based on what they see or hear • Egocentrism: views everything in relation to self; unable to consider another's point of view • Transductive reasoning: reasoning from one particular fact or case to another similar fact or case; unrealistic understanding cause-and-effect • Magical thinking: feels extremely powerful; believes thoughts or wishes cause events to happen • Animism: believes that inert objects such as stuffed animals are alive and have wills of their own • Centration: ability to consider only one aspect of a situation at a time • Irreversibility: cannot see a process in reverse order 56
    57. 57. Toddler: Nutrition • Rate of growth/ appetite slows: "Physiologic Anorexia" • Calorie requirements: 1300 calories/day (~ 100 kcal/ kg/ day) • Prone to anemia • Well-balanced meals. Small/ more frequent feedings. Allow healthy, nutritious choices • Avoid junk foods, non-nutrient foods, concentrated sweets, fats, fast foods • Food jags: fixate on one food and want that food for an extended period of time; usually passes with time • Environment: sitting at table with family, minimal distractions (NO TV) • Rest period before meal time to help increase appetite 57
    58. 58. Toddler: Nutrition • 2-3 servings milk group daily • After 2 yrs, low-fat (2%) milk • Milk intake: limit to 2 - 3 cups/day; can lead to deficiencies (especially iron-deficiency anemia) • Limit juice: 6 ounces/ day • If the toddler is overweight (85%-95% BMI) or obese (>95% BMI), don't restrict calories. Instead, promote a healthy diet and encourage regular physical activity. Cut down on portion sizes, and don't offer too much milk, juice, 58
    59. 59. Toddler: Dental Care • 33 months old: complete set of 20 baby teeth (deciduous teeth) • Healthy teeth: • Diet: low in sweets (especially sticky sweets), high in nutritious foods • Enough dietary calcium • Taking care of teeth by brushing: • By parent or parent-supervised, after each meal and at bedtime • Soft bristle nylon brush or washcloth • Under age 2: NO toothpaste (sodium fluoride is potent poison) • After age 2: only a pea-size amount of toothpaste per day, don’t let child swallow (must be CAREFULLY supervised) • Flossing • Prevent bottle caries (Early childhood caries): • Wean from the bottle at one year • Don’t allow the bottle (or tippy cup!) in bed • First dental visit 6 months after first primary tooth erupts, or no later than 1 yr of age; once or twice yearly afterwards 59
    60. 60. Toddler: Car Safety • Car: Door locks • Safety seats: http://www.buckleupnc.org/occupant- restraint-laws/child-passenger-safety-law- summary/ • Children < 5 yrs, < 40 lbs restrained in back seat (preferably center) • Rear-facing child restraints for children until at least age 2 yrs • When children outgrow rear-facing seats: forward-facing car seats with harnesses until they reach the upper weight or height limit of the seat 60 Forward-facing (FF) “toddler” / “combination” seats are used only in the forward-facing direction and never for a child who weighs less than 20 lbs or is less than 2 yrs of age. FF car seats generally fit a child who weighs 20-40 lbs or more and up to 40” tall.
    61. 61. Toddler Safety (pp. 212-214) • Fire and burns: • No dangling cords from irons or other small appliances • Keep away from open fires and heaters • Electrical outlet covers • Turn handles in on top of stove • Water heaters 120 or less • Preventing falls: • Stairway gate • Locks on doors and windows; guards over screened windows 61
    62. 62. Toddler Safety (pp. 212-214) • Water safety: • NEVER leave a child alone in water (can drown in 1” of water) • Preventing poisoning: • Locks on cabinets; child-resistant containers; “Mr. Yuk” stickers, Poison Control Center number by every telephone (800-222-1222) • Firearm safety: • Keeping guns locked up and unloaded 62
    63. 63. Toddler: Poisons (pp. 464-465) • Poisoning – Ingestion of or exposure to toxic substances • Children < 6 yrs more at risk due to developmental level • Toddlers lack cognitive ability to know what is dangerous; caretakers need to be on guard • Most poisonings occur in the child’s home or homes of relatives or friends • Most is oral ingestion: medications, household chemicals, cosmetics, plants, and heavy metals • Common toxic substances ingested by children include acetaminophen, ibuprofen, aspirin, iron, hydrocarbons, corrosives, and/or lead • Grandma’s purse: One pill can kill 63
    64. 64. Toddler: Poisons (pp. 464-465) • Primary prevention is key. See “Avoiding Childhood Poisoning,” p. 466 • Keep medicines, vitamins and household products out of sight and reach—locked is better than high • NO syrup of Ipecac; call Poison Control Center (800-222- 1222) or 911 • Decontamination strategies (Emergency Department): reverse toxicity by giving an antidote (e.g., N- acetylcysteine, glucagon, naloxone); gastric lavage (with life-threatening ingestions and within 60 minutes of ingestion; must protect patient’s airway); gastric decontamination with activated charcoal (1 g/ kg; often requires placement of NG tube); whole bowel irrigation (prevents further absorption of sustained-release medications) 64 See “Clinical Manifestations: Commonly Ingested Toxic Agents,”
    65. 65. Lead Poisoning (pp. 463-464) • Ingestion, inhalation, or absorption through skin • Primary source: deteriorating lead-based paint (structures built before 1978; old toys/ from China, jewelry, and furniture coated with lead paint) • Most harmful to children under the age of 6 • Lead affects every system of the body, ESPECIALLY the rapidly developing brain and nervous system (causes irreversible CNS damage) • Lead stored in the bones/ teeth; very difficult to remove from body (lead lines on bones; blue-black gum lines) • S/S: learning disabilities, developmental delays, decreased IQ scores, behavioral problems (e.g., attention deficit hyperactivity disorder [ADHD], oppositional/conduct disorders, & delinquency), seizures, hearing loss, malformed bones, slowed body growth, loss of appetite, digestive issues, and kidney damage • Anemia: lead interferes with the production of hemoglobin (↓ H & H) 65
    66. 66. 66
    67. 67. Potential Sources of Lead • Because the harm from lead is irreversible, primary prevention efforts that identify and reduce or eliminate lead hazards in children’s environments before they are exposed are critical • Name sources of lead and how these can be avoided 67
    68. 68. Lead Poisoning (pp. 463-464) • Screening: 12 & 24 mos, or between 3-6 yrs • Chelation therapy: • Binds with lead, removes it from the blood (through urine and stool) • Oral/ IV; dose/type depends on blood lead level (BLL) • Edetate Calcium Disodium (CaNa2EDTA), dimercaprol (BAL), 2,3 Dimercaptosuccinic Acid (DMSA), penicillamine • Many repeated doses required • Long-term follow-up essential • Remove lead hazards in child’s environment 68
    69. 69. 69
    70. 70. Preschooler 70
    71. 71. Preschool Child (3-6 yrs): Psychosocial Development • Erikson Initiative vs Guilt Stage • Initiative: sense of confidence that allows child to plan, take action & test what kind of person he/she can be Reinforced by freedom, opportunity, encouragement • Outcome: purpose & direction • Guilt: occurs when made to feel bad about initiatives made • Outcomes: guilt, anxiety, fear, dependence • Freud Phallic Stage • Recognizes differences between sexes • Identification with parent of same sex 71
    72. 72. Preschooler: Gender Role Identity • Becomes aware of their similarity to parent of the same sex • Usually like to be like the same sex parent • Reinforced by the parent • Girls—cooking with mom; Boys—working with dad in the shop • Not absolute—many identify with both parents 72
    73. 73. Preschooler Cognitive Development (p. 80) • Pre-operational or Intuitive ( 4-7 yr) • Transition to increased symbolic functioning • Ability to think in terms of classes, see relationships, deal with number concepts • Defines objects in terms of their use • Still egocentric; can't see beyond how circumstances and events relate to him • Moral Development: Preconventional (4-7 yr) • Decisions based on desire to please others & avoid punishment • Learning to distinguish right & wrong; developing a conscience 73
    74. 74. Preschooler Play • Associative play • Similar activity but no rigid organization • Motor activity! • Love to be on the go and moving • Dramatic play • Dress up, imitation • Games • Rules are absolute and rigid in games 74
    75. 75. Preschoolers: Pain Perception • Assessment tools • Can use multiple tools • Ask parents • Verbal ability and Fears • Better verbal ability, but fear the consequences. The pain reliever may be worse than the pain • Fear healthcare workers • May cry and cling • May become passive 75
    76. 76. Therapeutic strategies with young children involve various methods of communication, such as dramatic play and art
    77. 77. Review Question • Before cleaning an abrasion on a 3 year old, what could the nurse use to help decrease the child’s anxiety? Choose all that apply: A. Give the child pain medication as prescribed. B. Tell the child what to expect 2 hours before the intervention C. Allow the child to pick out a sticker. D. Have the child “clean the owie” on her doll. 77
    78. 78. School-Age Child 78
    79. 79. School Age Development: 6-12 yrs • Erikson—Industry vs. Inferiority • Piaget—Concrete operational • Conservation • Developmental Approach • Better understanding of cause and effect • Likes to be with same gender • Likes competition • Likes to learn • Appreciates tangible rewards • Limit “screen time” • Video, TV, cell phone, computer. • Direct link to obesity 79
    80. 80. School Age and Play • Cooperative Play • Teams, organized clubs • Rules • Likes competition • Construction • Enjoys building and constructing things • Computer games • Watch amount of TV or “screen” time • It is recommend not to have computer in the bedrooms until college 80
    81. 81. School Age Social Development • Concrete Thinking • Conservation of matter • Able to have mental representations • Concept of time and body parts • Likes to learn • Interested in learning new skills and information • Interested in friends and school • Clubs and sports 81
    82. 82. Cooperative Play 82
    83. 83. Anticipatory Guidance: Promote Use of Protective Gear 83
    84. 84. School Age and Hospitalization • Fears • Concern for physical harm • Separation from friends and school • Loss of control • Procedures • Explain more fully. Use diagrams and books • Coping • Reports pain • Will be open to learning distraction techniques 84
    85. 85. Review Question • Which of the following nursing interventions is the most appropriate when working with a school age child who has a terminal illness? A. Give factual explanations of the disease, medications, and procedures. B. Perform all care for the child. C. Tell the child that everything will be okay. D. Assure the child that being in the hospital is not a punishment for any thoughts or actions. 85
    86. 86. Adolescent 86
    87. 87. Adolescent Development: 12-18 years old • Erikson—Identity vs. Role Confusion • Piaget– Formal operations • Developmental approach • Likes independence and autonomy • Capable of abstract thinking • Peer relationships are VERY important • Keen awareness of body image (often comparing themselves with peers) • Idealistic: ripe for health teaching 87
    88. 88. Adolescents and Social Activity • FRIENDS • Sports • School Activities • Dances, Movies, Dating • Music • Computer, Texting – Their way to communicate • Development of “Views” • What are the safety concerns of adolescents? • Target teaching and education toward sex, drugs and alcohol, gun safety, suicide, risky behaviors, driving, Internet safety, etc. 88
    89. 89. Adolescents and Peers 89
    90. 90. Adolescents and Hospitalization • Procedures • Give full explanations • More concerned with the present than the future • Respect and Confidentiality • Resent authority figure or nurses trying to be their peers • Like nurses to be friendly • Restrictions • Impose few restrictions, but do set limits • May “sleep” or get on the phone to avoid discussions 90
    91. 91. School Age and Teen Diet • Decreased parental control • High fat, sugar and salt diets • Vending machines • Decreased activity • Obesity epidemic • Eating Disorders • Anorexia, Bulimia 91
    92. 92. Review Question • A 13-year-old boy is hospitalized for a femur fracture because he was hit by a car while racing bikes with his friends. The parents are concerned about his judgment. What should the nurse understand? A. This behavior is typical of young teens. B. The behavior is related to hormonal surges. C. This was an isolated incident and likely to not happen again. D. This behavior is related to teen rebellion. 92
    93. 93. Confidentiality Issues • Minors in all 50 states have the right to consent to STI treatment and testing • Most states allow HIV testing of minors and a few states require parental consent for HIV treatment • Adolescents who want 100% assurance of confidential testing should be referred to health departments or federally funded family planning centers • At private clinics, bill statements from the insurance company may go directly to the parents • When is it NOT Confidential? • Youth in danger of harming themselves or others • Certain types of addiction treatments may not be considered confidential 93
    94. 94. Adolescents and Pain • Verbal skills • Excellent ability to verbalize • Can use adult pain assessment tools • Adult level response to pain • Fears • Fears loss of control. • Give information and provide privacy • Coping • Will appreciate and participate in coping methods 94

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