Introduction to pediatric nursing nurs 3341 slideshare


Published on


Published in: Education
No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Introduction to pediatric nursing nurs 3341 slideshare

  1. 1. Introduction to Pediatric Nursing Joy A. Shepard, PhD(c), RN-C, CNE Joyce Buck, MSN, RN-C, CNE 1
  2. 2. Objectives 1. Discuss key differences in children versus adults 2. Discuss the roles of nurses in caring for children 3. Demonstrate differences in physical assessment techniques according to age and development 4. Describe key concepts of family-centered care and atraumatic care 5. Define health promotion and health maintenance 6. Explore the leading causes of morbidity and mortality in children 7. Utilize effective communication to interact with patients and families 8. Identify patterns of transmission in genetic disorders
  3. 3. Introduction • Children are members of families, communities and society • The wellbeing of children is associated with wellbeing of their families, communities and the society in which they live 3
  4. 4. Health During Childhood (p. 164) • “Health is a state of complete physical, mental, and social well-being and not merely the ABSENCE of DISEASE” (World Health Organization) – Mere absence of disease is NOT health – Three dimensions of health – Complete wellbeing on three dimensions – Fourth dimension ‘spiritual’ now added 4
  5. 5. Why is Nursing of Children Different? (p. 111, 474-476) • Because children are NOT just “little adults” • Differences relate to both growth and development patterns • Differences exist in motor skills and coordination; and in anatomical, metabolic, psychosocial, behavioral, language, and cognition areas Pediatric vital signs vary with age Children eat more food, drink more fluids, and breathe more air in proportion to their body weight than adults Children’s neurological, immunological, digestive, and other bodily systems are still developing Child’s metabolism may be less capable than an adult’s of breaking down, inactivating, or activating medications or other substances 5
  6. 6. Children are not just “little adults” (p. 111) 6 66
  7. 7. Pediatric Vital Signs Normal Ranges by Age (pp. 137; 140) Age Respiratory Rate (breaths/min) Heart Rate (beats/min) Newborn 30-55 100-170 1 year 25-40 90-140 3 years 20-30 80-120 6 years 16-22 70-120 10 years 16-20 60-110 17 12-20 60-100 BP (estimate, <10yrs): systolic 80 + ( 2x age); diastolic 2/3s systolic Age 10-17 – VS very close to that of the adult 7
  8. 8. Pediatric Vital Signs (pp. 137-143) • Least invasive to most invasive: – 1) Respiratory Rate; 2) Heart Rate; 3) BP; 4) Temperature  Best to measure vital signs while the child is quiet  Respiratory Rate & Heart Rate: count for a full 60 seconds  Auscultate the apical pulse (Heart Rate) with a stethoscope  Heart Rate, BP, & Respiratory Rate ↑ during fever/ stress  In a clinically decompensating child, BP is the last to change  Bradycardia in children is ominous, usually a result of hypoxia 8
  9. 9. Differences in Performing a Pediatric Physical Examination Compared to Adult (pp. 111-113) • General Approach: • Gather as much data as possible by observation first • Position of child: parent’s lap vs. exam table • Stay at the child’s eye level as much as possible. Do not tower!! • Order of exam: least distressing to most distressing – Rapport with child – Include child - explain to the child’s level 9
  10. 10. Differences in Performing a Pediatric Physical Examination Compared to Adult (pp. 111-113) • Distraction is a valuable tool • Examine painful area last-get general impression of overall attitude • Be honest. If something is going to hurt, tell them that in a calm fashion. • Don’t lie or you lose credibility! • Understand developmental stages’ impact on child’s response. For example, stranger anxiety is a normal stage of development, which tends to make examining a previously cooperative child more difficult. 10
  11. 11. Age-Specific Approaches to Exam (pp. 116-117) • Infant: auscultate heart, lungs first (head-to-toe NOT always appropriate) • Toddler: inspect body area through play, introduce equipment slowly • Preschool: if cooperative: proceed head-to-toe; if not, same as toddler • School-age: head-to-toe, genitalia last, respect privacy • Adolescent: same as school-age
  12. 12. Impact on Medications (pp. 111, 272, 474-476) • Pediatric dosages differ from adult medication dosages as a result of differences in physiology A. Immature liver function B. Immature kidney function C. Decreased gastric function D. Decreased plasma protein concentration • Altered body composition – (1) Decreased fat – (2) Increased water 12
  13. 13. Impact on Medications (pp. 10-12) • Infants and young children require very small doses of medication, thus making accurate calculation/ measurement very important • Calculate dosage based on Body Weight (kg) or Body Surface Area (m2) to ensure the child receives the correct drug dosage within a safe therapeutic range – Body weight = mg/kg/day or mg/kg/dose (commonly) – BSA (m2) = • Compare ordered dosage to recommended dosage • If dosage seems unsafe, consult with ordering practitioner before administering • Use special measuring devices to accurately provide the prescribed dosage – Measuring out a dose with common household utensils is unacceptable • Monitor child closely for signs/ symptoms of toxicity 13 See Box 1-4 “System Strategies to Reduce Pediatric Medication Errors” p. 12 ht (cm)  wt (kg) 3,600
  14. 14. Review Question • In order to administer a medication safely to a pediatric client, what drug information must the nurse be aware of that is not always essential when administering a medication to an adult client? A. Indicators of drug toxicity. B. Recommended dose per kg of body weight. C. Incompatibilities with other medications. D. Commonly expected side effects. 14
  15. 15. Box 1-4 System Strategies to Reduce Pediatric Medication Errors 15 (Page 12)
  16. 16. 16 (Page 273)
  17. 17. Table 11-4 (Cont’d, p. 273) Variations in Medication Administration to Children 17
  18. 18. Total Daily IV Fluid for Children (p. 484) • Use this formula to calculate the daily rate of pediatric maintenance IV fluids: – 100 mL per kg per day for the first 10 kg of body weight – 50 mL per kg per day for the next 10 kg of body weight – 20 mL per kg per day for each kg above 20 kg of body weight 18 See Box 18-1 “Calculation of Intravenous Fluid Needs” p. 484 See Video: Pediatric Lab Fluid Requirements
  19. 19. Total Daily IV Fluid for Children • Child who weighs 24 kg – 100 mL per kg per day × 10 kg = 1000 mL per day (for first 10 kg) – 50 mL per kg per day × 10 kg = 500 mL per day (for next 10 kg) – 20 mL per kg per day × 4 kg = 80 mL per day (for remaining 4 kg) – TOTAL 1580mL per day 19
  20. 20. Total Daily IV Fluid for Children Calculating Hourly IV Flow Rate 20 1000 mL per day + 500 mL per day + 80 mL per day = 1580 mL per day 1,580 mL 24 h  65.8 mL per hour  66 mL per hour
  21. 21. Definition of Terms (p. 3) • Pediatrics: Branch of medicine that deals specifically with children, their development, childhood diseases, and their treatment • Pediatric Nursing: The art and science of giving nursing care to children from birth through adolescence with a holistic family-centered approach, including emphasis on their physical growth, mental, emotional, psychosocial, and spiritual development 21
  22. 22. Review Question • Nursing care of children focuses on improving a child’s quality of care by: A. Providing an environment for optimal growth and development B. Focusing on curing childhood illnesses C. Addressing problems caused by communicable disease D. Treating medical problems of infants, children, and adolescents 22
  23. 23. The Pediatric Nurse (p. 3) • Important member of healthcare team • Provides care to infants, children and adolescents in a wide variety of settings spanning the entire healthcare continuum from well-child care to illness and death – Hospitals (pediatric wards, intensive care units, newborn nurseries, emergency departments); the child’s home; rehabilitation centers; skilled nursing facilities; schools; daycare centers; camps 23
  24. 24. Competencies of the Pediatric Nurse (p. 3)  Thorough understanding of the unique anatomical, physiological, and developmental differences of children  Knowledge of growth and development  Communication skills with children and their families  Understanding of family dynamics and parent-child relationships  Sensitivity to cultural issues  Knowledge of common childhood illnesses and injuries  Knowledge of health promotion and anticipatory guidance See Box 1-1 “Expected Competencies of the Pediatric Nurse,” p. 3 24
  25. 25. Roles of the Pediatric Nurse (pp. 3-4) • Direct nursing caregiver – Healthcare planning & delivery – Ethical decision making • Patient education – Health teaching – Anticipatory guidance • Patient advocacy – Support/ counseling – Health services • Case management – Coordination/ collaboration • Research – Evidence-based practice 25 Two primary goals of pediatric care in all roles/ settings: 1) Health Promotion, and 2) Health Maintenance (pp. 164-165)
  26. 26. Review Question • Which role would the nurse be serving when helping parents understand and respond to the needs of an ill child’s siblings? A. Case manager. B. Educator. C. Researcher. D. Advocate. 26
  27. 27. Settings of the Pediatric Nurse (pp. 2; 5-6) • Hospital Nurse • School nurse • Primary health centers • Community health nurse 27
  28. 28. Advance Practice Roles for Nurses in Child Health Nursing • Family nurse practitioner • Neonatal nurse practitioner • Pediatric nurse practitioner • Nurse midwife 28
  29. 29. Continuum of Pediatric Health Care for Children and Their Families (p. 2) 29
  30. 30. Important Pediatric Concepts • Family-Centered Care • Atraumatic Care • Child-Oriented Environment • Play During Hospitalization • Health Promotion & Disease Prevention 30
  31. 31. Family-Centered Care Approach (pp. 6; 20-23; 267) • Recognizes the family as the constant in the child’s life • Family is the expert in the care of their child • Family is vital in helping the child recover from an illness or injury • Family is an essential part of the healthcare team • Family IS the patient • Enable and empower the family: – Child AND family primary focus of the nursing process – Needs of child AND family taken into account – Child AND family treated as a unit – Meeting family’s needs helps meet the child’s needs – Aim: Strengthen family’s ability to provide care for their child 31
  32. 32. Review Question • Which of the following outcomes of family-centered care is most illustrative of the concept? A. The nurse and parents mutually develop strategies of care. B. The child is viewed as the most important family member. C. All family members enjoy unlimited visiting hours. D. Health professionals implement a sensitive plan of care for the child and family. 32
  33. 33. Atraumatic Care (pp. 262-269) • Use of interventions that eliminate or minimize psychological and physical distress or trauma that is experienced by children and their families in the healthcare system – Treatments not done in safe places (bed/ play room) but in a treatment room • Three principles: 1. Prevent/minimize separation from the family 2. Promote a sense of control 3. Prevent/minimize bodily injury and pain • Can we eliminate all pain and trauma? – No, but can try to minimize it 33 See Box 11-5, “Treatment Room,” p. 275
  34. 34. Child-Oriented Environment (pp. 269-272) • A child-friendly environment should be provided to a child who is admitted to the hospital 34
  35. 35. Play is the Work of Children • Enhances motor skills • Enhances social skills • Enhances verbal skills • Expresses creativity • Decreases stress • Helps solve problems 35
  36. 36. Functions of Play in the Hospital (pp. 279-283) • Facilitates mastery over an unfamiliar situation • Provides opportunity for decision making and control • Helps to lessen stress of separation • Provides opportunity to learn about parts of body, their functions, and own disease/disability 36 See Table 11-7 “Therapeutic Play Techniques,” p. 281
  37. 37. Functions of Play in the Hospital Cont’d…. • Corrects misconceptions about the use and purpose of medical equipment and procedures • Provides diversion and brings about relaxation • Helps the child feel more secure in a strange environment • Provides a means to release tension and express feelings • Encourages interaction and development of positive attitudes toward others 37
  38. 38. Review Question • What is the best nursing approach to decrease a preschooler’s anxiety about having his blood pressure measured? A. Take the blood pressure while the child is sleeping B. Ask the child’s mother to take the blood pressure C. Demonstrate the procedure on a doll prior to performing it on the child D. Tell the child that big boys and girls do not cry when they have their blood pressure taken. 38
  39. 39. Health Promotion & Disease Prevention (pp. 164-165) • Health promotion: activities that increase well-being and enhance wellness or health – Strengths and goals; seeks to attain greater wellness – Anticipatory guidance • Health maintenance: activities that preserve an individual’s state of present health; prevent disease or injury – Known potential health risks; seeks to prevent them – Three levels of prevention 39
  40. 40. Health Maintenance: Prevention (p. 165) • Prevention is any activity that reduces the burden of mortality or morbidity from disease • Services performed in a clinical setting that are designed to prevent disease, injury, or disability, prolong life, and promote health are known as preventive health services 40
  41. 41. Three Levels of Prevention (p. 165) 41
  42. 42. Primary Prevention • In primary prevention, a disorder is actually prevented from developing… 42
  43. 43. Primary Prevention (pp. 173-174; 175-176) • Education: Patient, family, caregiver – Injury prevention (e.g., car safety, poison prevention) – Child abuse prevention (e.g., Stewards of Children training program) – Reduce disease transmission (e.g., hand hygiene, sanitize toys/ surfaces) – Anticipatory guidance • Immunizations • Exercise programs • Comprehensive tobacco prevention programs • Nutritional assessment & guidance – Well-balanced diet 43
  44. 44. Secondary Prevention • In secondary prevention, disease that has not yet become symptomatic is detected and treated early, thereby minimizing serious consequences… 44
  45. 45. Secondary Prevention – Early Intervention (p. 173) • Screenings throughout childhood: • Newborn screening • Vision & hearing screenings • Iron-deficiency anemia screening • Developmental screening (e.g., Denver II Assessment) • Autism screening • Lead screening • Hypertension school screenings 45
  46. 46. Review Question • A 4-year-old scores two failures on the Denver II. Which of the following statements is most accurate? A. The child is not as intelligent as expected for age and should be referred to a learning specialist. B. The child has a speech problem and should be referred to a speech therapist. C. The child is at risk for school problems and should be retested. D. The failures are to be expected in preschoolers who may not be cooperative with testing. 46
  47. 47. Tertiary Prevention • In tertiary prevention, an existing, usually chronic disease is managed to prevent complications or further damage. For example, tertiary prevention for children with diabetes focuses on tight control of blood sugar, eye examinations, excellent skin care, frequent examination of the feet, and exercise to prevent heart and blood vessel disease… 47
  48. 48. Tertiary Prevention – Restoration, Rehabilitation • Manage clinical diseases (esp chronic diseases) to prevent them from progressing (pp. 291-293) – Aim: optimal functioning; avoid disability & complications • Diabetes management • Childhood asthma management • Pediatric Rehabilitation Unit: physical, occupational, speech (p. 271) – Catastrophic injury (e.g., after a motor vehicle crash) • Disaster preparedness (pp. 255-259) – Safe housing, counseling, physical care 48
  49. 49. Review Question • While interviewing the parents of a 2-year-old female, the nurse notes the mother is pregnant. At the end of the visit, the nurse decides to give a new pamphlet to the parents about car seat usage for newborns. This action is an example of: A. Developmental screening. B. Primary preventative health maintenance. C. Secondary preventative health maintenance. D. Tertiary preventative health maintenance. 49
  50. 50. Sociocultural Influences on Pediatric Health (pp. 6; 38-44) • Children comprise greater than 27% of U.S. population • Growing diversity • Multicultural sensitivity • Family’s health-related beliefs and practices 50
  51. 51. Childhood Mortality (pp. 6-7) • Mortality: Number of deaths from a specific cause in a given year • Nutrition, antibiotics, preventive measures (immunizations), & sanitation have decreased child mortality • Injuries: the leading killer in childhood • Unintentional injury – Leading cause of death in all age-groups of children (older than age 1) in the U.S. • For children older than one year, death rates have always been less than those for infants • In later adolescence, there is a sharp rise in deaths 51 See Figure 1-6 “Age-Specific Death Rates per 100,000 Children in the U.S.,” p. 7
  52. 52. Childhood Mortality Cont’d… • Ages 5-14 has the lowest mortality • Sharply increases age 15-19 – After age 15, causes are injuries, homicide, and suicide • Leading causes of mortality in those less than 15 – Unintentional injury – Congenital malformations – Cancer – Violence 52 See Figure 1-6 “Age-Specific Death Rates per 100,000 Children in the U.S.,” p. 7
  53. 53. Table 1-1 Five Leading Causes of Injury Death by Age Group, 2006 53 (Page 7)
  54. 54. Review Question • The nurse is planning educational interventions to reduce the incidence of the number one cause of mortality in children ages 1-4. Recognizing the developmental needs of this age group, the nurse would focus the session on which topic? A. Seizure disorder management. B. Sudden infant death syndrome (SIDS) recognition. C. Child abuse prevention. D. Unintentional injury awareness. 54
  55. 55. Infant Mortality (pp. 6-7) • Number of deaths per 1000 live births during 1st year of life • Indicator of how healthy the nation is • This rate is used to compare national health care to previous years and to other countries • In 2014, U.S. ranks 169/224, with 6.17 deaths/1000 live births • Birth weight is a major determinant of infant mortality • Race, prenatal care, education also affect infant mortality – Mortality rate for black infants ≥ twice that of white infants 55
  56. 56. Infant Mortality Cont’d… • Top 5 causes of death in infants – Congenital malformations – Short gestation/ low birth weight – SIDS – Maternal complications – Unintentional injury • Mortality decreases after age 1 56 See Figure 1-5 “Comparison of the Five Leading Causes of Infant Mortality,” p. 7
  57. 57. Figure 1-5 Comparison of the five leading causes of infant mortality by rate in 2006 and 1996. 57
  58. 58. Childhood Morbidity (pp. 8-9) • An illness or injury that limits activity, requires medical attention or hospitalization, or results in a chronic condition • Prevalence of chronic health conditions in children increasing as a result of advanced health care and treatment • Factors that contribute to childhood morbidity: general health, socioeconomic status, access to health care, & psychosocial factors 58
  59. 59. Childhood Morbidity Cont’d…. (pp. 8-9) • Leading causes of hospitalization: – 1-9 yrs: Respiratory diseases – 15-21 yrs: Mental disorders; injuries; digestive diseases; complications pregnancy/ childbirth • Respiratory illness accounts for 50% of acute conditions • Injury and disabilities – significant effect 59
  60. 60. Review Question • The nurse recognizes the need to update knowledge related to the most common cause of hospitalization in children. On which body system should continuing education focus? A. Gastrointestinal. B. Respiratory. C. Cardiac. D. Musculoskeletal. 60
  61. 61. Healthy People 2020 (p. 9) • 10-year agenda for improving the nation’s health • Overarching Goals: – High-quality, longer lives free of preventable disease, disability, injury and premature death – Health equity, eliminate disparities, improve the health of all groups – Create social and physical environment that promote good health for all – Promote quality of life, healthy development and health behaviors across all life stages 61 Maternal, Infant, and Child Health Data Details Early and Middle Childhood Adolescent Health
  62. 62. Injury Prevention & Safety Issues (pp. 173-176) • Most childhood mortality & hospitalization is related to injury • Accidents account for 1/3 of all fatalities – Mechanical suffocation causes most accidental deaths in children < 1 yr – Accidents are the leading cause of death in infants and toddlers (motor vehicle, drowning, falls, burns) – School-age and adolescents – motor vehicle accidents • Safety must be part of nursing care • Safety teaching must be part of family-centered care: an essential aspect of primary prevention • 90% of all accidents are preventable! 63
  63. 63. Informed Consent in Pediatrics (pp. 13-14) • Formal authorization by child’s parent or guardian allowing an invasive procedure to be performed • Expected care or treatment, potential risks/ benefits, and alternatives, and what might happen if the parent chooses not to consent • Parents have full legal control and responsibility of minors. Informed consent must be given by parents before any medical treatment or procedure • Physician’s responsibility: explain procedure, risks, benefits and alternatives • Nurse witnesses parent’s signature; reinforces information • If parent/guardian is not present in an emergency, consent of two licensed professionals can be used • Verbal consent by phone may be obtained with two witnesses 64
  64. 64. Informed Consent in Pediatrics Cont’d…. • Married Parents – permission of one parent is required • Divorced Parents – permission must be obtained from custodial parent • Emancipated (married, pregnant, high school graduate, or military) may sign own consent • In North Carolina, teenagers can consent to the following: contraceptive services, prenatal care, STI/ HIV care, treatment for alcohol/ drug abuse, and outpatient mental health services. They need parental consent for abortion services • Confidential treatment can be obtained for STIs, alcohol and drug treatment, and contraceptive advice in all states, without parental consent • State can override parental rights in cases of life and death or risk to health 65
  65. 65. Law & Ethics: Informed Consent 66
  66. 66. Pediatric Ethical Issues (pp. 15-16) • Withholding/ withdrawing treatment • Genetic testing • Organ transplantation • Research assent 67
  67. 67. Communication – Essential Skill (pp. 111-113)  Communication is crucial to the establishment of a trusting relationship with children and their families; helps promote a therapeutic environment  Be aware of both verbal and non-verbal communication  Pediatric patients prefer types of communication that are easily understood and processed  Use normal language instead of medical terminology  Children communicate at different levels according to age and cognitive development – Young children can’t always clearly communicate – Use concrete terms instead of abstract terms with young children – Young children interpret words according to their primary meaning (literal thinking) 68
  68. 68. Genetics – Patterns of Transmission (pp. 51-61) • Virtually all diseases (except trauma) have a genetic component • Patterns of transmission in genetic disorders: – Autosomal dominant – Autosomal recessive – X-linked conditions – Multifactorial 69
  69. 69. Autosomal Dominant (pp. 57-58) • Both males and females are affected in equal numbers • 50% chance offspring affected • A single abnormal gene on one of the autosomal chromosomes (one of the first 22 "non-sex" chromosomes) from either parent can cause the disease • One of the parents will have the disease (since it is dominant) in this mode of inheritance and that person is called the CARRIER • Only one parent must be a carrier in order for the child to inherit the disease • Adult onset 70
  70. 70. Autosomal Dominant 71
  71. 71. Autosomal Recessive (p. 58) • Both males and females are affected in equal numbers • Unaffected carrier father and unaffected carrier mother: 25% chance offspring affected • Genes come in pairs; recessive inheritance means BOTH genes in a pair (on one of the autosomal chromosomes) must be defective to cause the disease • People with only one defective gene in the pair are considered carriers; however, they can pass the abnormal gene to their children • Childhood onset 72
  72. 72. Autosomal Recessive 73
  73. 73. X-Linked Recessive Conditions (pp. 58-59) • Almost always occur in males, since males have only one X chromosome • A single defective recessive gene on that X chromosome will cause the disease • Pattern of maternal transmission (to sons) – Transmitted by female carriers & expressed in males • No male-to-male inheritance – Lack of male-to-male transmission = hallmark • An affected male will have all carrier daughters • If the mother is a carrier (one abnormal X chromosome), there is a 50% chance of a boy with disease, with every pregnancy with a male fetus 74
  74. 74. X-Linked Recessive Conditions 75
  75. 75. Multifactorial Inheritance (pp. 60-61) • “Many factors" (multifactorial) are involved in causing a condition • Genetic + environmental factors • Factors are both genetic and environmental, where a combination of genes from both parents, in addition to unknown environmental factors, produce the trait or condition • Often one gender (either males or females) is affected more frequently than the other in multifactorial traits • Tends to recur in families, but do not follow characteristic Mendelian patterns of inheritance seen with single-gene conditions • First degree relatives mainly affected 76
  76. 76. Review Question • What types of disorders are abnormalities that result from inherited abnormal genes and environmental factors? • A. Autosomal dominant • B. Autosomal recessive • C. Multifactorial • D. X-linked 77
  77. 77. Examples of Genetic Conditions (pp. 57-61) • Autosomal dominant: neuofibromatosis; achondroplasia (dwarfism); Marfan syndrome; Huntington disease; familial hypercholesterolemia; osteogenesis imperfecta • Autosomal recessive: cystic fibrosis; sickle cell anemia; Tay-Sachs disease; phenylketonuria • X-linked: Duchenne muscular dystrophy; hemophilia • Multifactorial: neural tube defects; congenital heart defects; cleft lip and palate; autism spectrum disorder; diabetes mellitus 78
  78. 78. Review Question • Which of the following hereditary disorders is transmitted by autosomal dominance? • A. Cystic fibrosis • B. Duchenne muscular dystrophy • C. Huntington disease • D. Neural tube defects 79
  79. 79. 80 We hold the future in our hands and it is our children…..