NURS 207: Promoting Pediatric Wellness in the Family

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NURS 207 Promoting Pediatric Wellness in the
Family Community

• Allan J. V. Cresencia, MSN, CPN, RN
• Samson Yigezu, PhD, RN
• Christine Limann, BS, CPN, RN
• West Coast University - Los Angeles

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Theories of Development

• Personality Development
• Freud - Psychosexual
• Erickson - Psychosocial
• Mental Development
• Piaget - Cognitive
• Kohlberg - Moral

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Erikson Stages of Psychosocial Development

• 1. Infancy Birth to 18 Months
• Ego Development Outcome Trust vs. Mistrust
• Basic strength Drive and Hope

2. Toddler 18 Months to 3 Years Ego Development
Outcome Autonomy vs. Shame Basic Strengths
Self-control, Courage, and Will
3. Preschooler 3 to 5 Years Ego Development
Outcome Initiative vs. Guilt Basic Strength
Purpose
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Erikson Stages of Psychosocial Development
4. School Age 6 to 12 Years Ego
Development Outcome Industry vs.
Inferiority Basic Strengths Method and Competence
5. Adolescence 12 to 18
Years Ego Development Outcome Identity vs. Role
Confusion Basic Strengths Devotion and Fidelity
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Theories of Development

• Piaget Mental
• Sensorimotor birth to 2 years
• Preoperational 2 to 7 years
• Concrete operations 7 to 11 years
• Formal operations 11 to 15 years

• Kohlberg Moral
• Preconventional level good/bad or right/wrong
• Conventional level approval by being nice
• Postconventional, autonomous, or principled level
  formal operations

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Piaget Stages of Cognitive Development

• Sensorimotor period Years 0-2
• In this stage, infants construct an understanding
  of the world by coordinating sensory experiences
  (such as seeing and hearing) with physical,
  motoric actions.
• Infants gain knowledge of the world from the
  physical actions they perform on it.
• An infant progresses from reflexive, instinctual
  action at birth to the beginning of symbolic
  thought toward the end of the stage.
• Object permanence is key word.

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Infant Stimulation

• Newborn prefers human face for stimulation
• Visual benefit of black-and-white objects for
  stimulation
• Stimulation of human voice
• Importance of tactile stimulation

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Focus on Visual Objects
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Fine Motor Development

• Grasps object, age 2 to 3 months
• Transfers object between hands, age
• 7 months
• Pincer grasp, age 10 months
• Removes objects from container, age
• 11 months
• Builds tower of two blocks, age 12 months

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Crude Pincer Grasp
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Neat Pincer Grasp
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Gross Motor Development

• Head control
• Rolls over, age 5 to 6 months
• Sits alone, age 7 months
• Moves from prone to sitting position, age
• 10 months

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Head Control
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Locomotion

• Cephalocaudal direction of development
• Crawling, age 6 to 7 months
• Creeping, age 9 months
• Walk with assist, age 11 months
• Walk alone, age 12 months

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Psychosocial Development

• Eriksons phase I developing a sense of trust
• Trust vs. mistrust
• Importance of caregiver-child relationship
• Delayed gratification
• Importance of consistency of care

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Finding Hidden Object
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Development of Body Image

• Concept of object permanence
• By end of first year, recognize that they are
  distinct from parents

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Viewing Own Image
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Development of Sexual Identity

• Hormonal influences
• Infant
• Parental influences on development of sexuality

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Social Development

• Attachment
• Reactive attachment disorder (RAD)
• Separation anxiety
• Stranger anxiety
• Play as major socializing agent

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Stranger Fear
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Language Development

• Crying is first verbal communication
• Vocalizations
• Three to five words with meaning by age
• 1 year

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Infants Health Promotion

• Promoting Infant Safety
• Aspirations
• Falls
• Car (MVA)
• Siblings
• Bathing and Swimming
• Childproofing

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Infants Health Promotion

• Nutritional Health
• Recommended dietary reference intakes
• Introduction of solid foods
• Loss of extrusion reflex
• Techniques for feeding solid foods

• Nutritional Health
• Quantities and types of food
• Cereal
• Vegetables and fruit
• Meat and eggs
• Table food
• Chart on next slide.

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Infants Health Promotion

• Development in Daily Activities
• Bathing
• Diaper-area care
• Use of pacifiers
• Care of teeth
• Dressing
• Sleep patterns
• Exercises

• Nutritional Health
• Establishment of healthy eating patterns
• Weaning
• Self-feeding
• Adequate intake with a vegetarian diet

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Infants Health Promotion

• Parental Concerns and Problems
• Diaper dermatitis skin condition
• Miliaria sebaceous glands
• Baby-bottle syndrome dental carries
• Obesity no comment!

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Baby-bottle syndrome dental carries
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Health Problems During Infancy

• Chapter 13

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Protein and Energy Malnutrition

• Kwashiorkor
• Severe protein malnutrition, especially in
  children after weaning, marked by lethargy,
  growth retardation, anemia, edema, potbelly,
• Marasmus
• A progressive wasting of the body, occurring
  chiefly in young children and associated with
  insufficient intake or malabsorption of food

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Food Sensitivity

• Cows milk allergy
• Lactose intolerance

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Feeding Difficulties

• Regurgitation and spitting up
• Reflux/GERD
• Colic (paroxysmal abdominal pain)
• Failure to thrive
• Organic FTT
• Nonorganic FTT

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The Colic Carry
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A Consistent Nurse in Nonorganic FTT
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SKIN DISORDERS
Diaper Dermatitis

• Principal factors in development
• Therapeutic management
• Nursing considerations

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Seborrheic Dermatitis

• Chronic, recurrent, inflammatory reaction
• of the skin
• Scalp cradle cap
• Eyelids blepharitis
• External ear otitis externa
• Cause unknown
• Nursing considerations
• Head Shoulders to wash hair 1-2 times

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Atopic Dermatitis

• Also called eczema
• Is a category of dermatologic diseases and not a
  specific etiology
• Pruritic
• Usually associated with allergy
• Hereditary tendency

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Therapeutic Management
Atopic Dermatitis-

• Hydrate the skin
• Relieve pruritus
• Reduce inflammation
• Prevent and control secondary infection
• Nursing considerations

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Disorders of Unknown Etiology

• Sudden infant death syndrome (SIDS)
• Apparent life-threatening events (ALTEs)
• Back to Sleep campaign
• Increased incidence of positional plagiocephaly

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Infants at Risk for SIDS

• Unknown Etiology
• Infants with one or more severe Apparent
  life-threatening events (ALTEs) requiring CPR or
  vigorous stimulation
• Preterm infants experiencing apnea at time of
  discharge from hospital
• Sibling of two or more SIDS victims
• History of central hypoventilation

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Health Promotion of the Toddler and Family

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Biologic Development

• Weight gain slows to 4 to 6 pounds per year
• Birth weight should be quadrupled by
• 2½ years of age
• Height increases about 3 inches per year
• Growth is steplike rather than linear

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Maturation of Systems

• Most physiologic systems relatively mature by the
  end of toddlerhood
• Upper respiratory infections, otitis media, and
  tonsillitis are common among toddlers
• Voluntary control of elimination
• Sphincter control age 18 to 24 months

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Gross and Fine Motor Development

• Locomotion
• Improved coordination between ages 2 and 3
• Fine motor development
• Improved manual dexterity ages 12 to 15 months
• Throw ball by age 18 months

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Typical Toddling Gait
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Psychosocial Development

• Erikson developing autonomy
• Autonomy vs. shame and doubt
• Negativism
• Ritualization provides sense of comfort
• Id, ego, superego/conscience

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Promoting Optimum Growth and Development

• The terrible 2s
• Ages 12 to 36 months
• Intense period of exploration
• Temper tantrums, obstinacy occur frequently
• Developing independence vs. parental control

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Piaget Stages of Cognitive Development

• Preoperational period (years 2 to 6)

• Learn spatial relationships
• Awareness of causal relationships between two
  events
• the child learns to use and to represent objects
  by images, words, and drawings
• The child is able to form stable concepts as well
  as mental reasoning and magical beliefs
• Thinking is still egocentric The child has
  difficulty taking the viewpoint of other

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Moral Development

• Kohlberg preconventional or premoral level
• Punishment and obedience orientation
• Time out is useful at this age
• -1 minutes per year of age

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Development of Body Image

• Refer to body parts by name
• Avoid negative labels about physical appearance
• Recognize sexual differences by age 2

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Development of Sexuality

• Exploration of genitalia is common
• Gender roles understood by toddler
• Playing house or pirates

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Social Development

• Differentiation of self from mother and from
  significant others
• Separation
• Individualization

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Language

• Increasing level of complexity
• Increasing ability to understand

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Personal Social Behavior

• Toddlers develop skills of independence
• Skills for independence may result in tyrannical,
  strong-willed, volatile behaviors
• Skills include feeding, playing, and dressing and
  undressing self

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Playing Dress-Up
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Transitional Objects Provide Security
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Play

• Magnifies physical and psychosocial development
• Parallel play
• Imitation
• Locomotive skills
• Tactile play

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Coping with Concerns Related to Normal Growth and
Development

• Toilet training
• Sibling rivalry
• Temper tantrums
• Negativism
• Regressive behavior

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Toilet Training
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Assessing Readiness for Toilet Training

• Voluntary sphincter control
• Able to stay dry for 2 hours
• Fine motor skills to remove clothing
• Willingness to please parents
• Curiosity about adults or siblings toilet
  habits
• Impatient with wet or soiled diapers

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Promoting Optimum Health During Toddlerhood

• Nutrition
• Phenomenon of physiologic anorexia
• Sleep and activity
• Dental health
• Regular dental exams
• Removal of plaque
• Fluoride
• Low-cariogenic diet

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Toothbrushing
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Injury Prevention

• Motor vehicle injuries car seat safety
• Drowning
• Burns
• Poisoning
• Falls
• Aspiration and suffocation
• Bodily damage

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Forward-Facing Convertible Seat
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Matches Are a Potentially Deadly Hazard
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Plastic Caps for Electrical Sockets
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Storage of Cleaning Agents
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Health Promotion of the Preschooler and Family

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PROMOTING OPTIMUM GROWTH AND DEVELOPMENT

• Preschool period
• 3 to 5 years of age
• Refining tasks mastered in toddlerhood

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Biologic Development

• Physical growth rate slows and stabilizes during
  preschool years
• Physical proportions change
• Slender but sturdy
• Graceful, agile
• Posture erect
• Males and females similar in size and proportion

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Gross Motor Behavior

• By 36 months
• Walking, running, climbing, jumping
• By age 4 years
• Skips and hops on one foot
• Catches ball
• By age 5 years
• Skips on alternate feet, jumps rope, learns to
  skate and swim

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4-Year-Old Hops on One Foot
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Psychosocial Development Erikson

• Developing a sense of initiative
• Initiative vs. guilt
• Development of superego (conscience)
• (Freud)

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Cognitive Development Piaget

• Preoperational phaseages 2 to 7
• Preconceptual phase ages 2 to 4
• Intuitive thought ages 4 to 7
• Causality
• Time
• Magical thinking
• Logical thinking

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Moral Development Kohlberg

• Preconventional (premoral)
• Punishment and obedience orientation ages
• 2 to 4
• Naïve instrumental orientation ages 4 to 7

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Preschoolers Enjoy Friends
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Spiritual Development

• Parental influences
• Concrete representation of spiritual beings
• Development of conscience related to
• spiritual development

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Development of Body Image

• Increasing awareness of self and others
• Poorly defined body boundaries
• Poor understanding of internal anatomy

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Development of Sexuality

• Sexual identity
• Sexual beliefs
• Sex typing
• Gender behaviors
• Sexual exploration of children is main health
  concern

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Social Development

• Individuation-separation process
• Effects of prolonged separation (such as
  hospitalization)

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Language

• Ages 4 to 5 four- and five-word sentences
• Age 6 understand all parts of speech identify
  opposites

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Preschooler Dressing Himself
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Personal-Social Behavior

• Self-assertion is a major theme
• Independent in dressing, eating, toileting by
  ages 4 to 5
• Desire to please
• Internalized values--conscience morals
• More secure with new sibling arrival at this age

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Play

• Associative play
• Make up rules as they go along
• Imitation
• Imaginary playmates
• Mutual play with parents

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Preschoolers Enjoy a Sense of Accomplishment
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Preschoolers Enjoy Imaginative and Imitative Play
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Coping with Concerns Related to Normal Growth
andDevelopment
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Preschool and Kindergarten Experience

• Learning group cooperation
• Peer group experiences
• Readiness for academics
• Preparing the child

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Sex Education

• Find out what the child knows and thinks
• Be honest with responses
• Understanding the broader concept of sexuality
• Resources
• Sexuality Information and Education Council of
  the United States (SIECUS)
• American Academy of Pediatrics (AAP)

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Aggression

• Definition behavior to hurt person or destroy
  property
• Frustration
• Modeling
• Reinforcement
• Professional help for parenting

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Fears

• Night terrors
• Animism ascribing lifelike characteristics to
  inanimate objects
• Techniques to overcome fears

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PROMOTING OPTIMUM HEALTH DURING THE PRESCHOOL
YEARS
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Nutrition

• Nutritional requirement approximately
• 90 kcal/kg
• Fluid requirement approximately 100 ml/kg daily
• MyPyramid application to preschoolers
• Concerns about childhood obesity

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Choosing Healthy Foods
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Assist in Food Preparation
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Sleep and Activity

• Sleep average is 12 hours per night for preschool
• Sleep problems
• Sleep rituals help establish routine
  consistency

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Dental Health

• Eruption of primary teeth is complete in
  preschoolers
• Need assistance with toothbrushing
• Routine prophylaxis including fluoride
  supplements

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Injury Prevention

• Poisoning
• Drowning
• Pedestrian motor vehicle injuries
• Seat belts
• Bicycle helmets
• Emphasis on protection and education for safety

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Health Problems of Early Childhood
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Infectious Disorders

• Communicable diseases
• Incidence has declined with increase of
  immunizations
• Further decreased with use of antibiotics and
  antitoxins

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Nursing Assessment in Identification of Infection

• Recent exposure to infectious agents
• Prodromal symptoms
• Immunization history
• History of having the disease

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Prevent Spread of Disease

• Primary prevention of the disease
• Immunization
• Control spread of disease to others
• Reduce risk of cross-transmission of organisms
• Infection control policies
• Hand washing

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Caution for Compromised Children

• Children with immunodeficiency
• ? Receiving steroid therapy
• Other immunosuppressive therapies
• Generalized malignancies
• Immunologic disorder
• Risk for complications from communicable
  diseases, especially varicella (chickenpox) and
  erythema infectiosum (EI)
• Risk for viremia from varicella zoster virus

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Chickenpox

• Agent varicella zoster virus
• VZG also causes herpes zoster (shingles)
• VZIG treatment for children at risk
• Transmission direct contact, droplet, and
  contaminated objects
• Incubation 2 to 3 weeks
• Communicability 1 day before eruption until all
  lesions crusted

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Erythema Infectiosum (Fifth Disease)

• Agent human parvovirus
• Rash in three stages
• Slapped face appearance disappears in
• 1 to 4 days
• Maculopapular rash on extremities lasts 7 days
  or more
• Rash subsides but reappears if skin irritated or
  traumatized by heat, cold, friction, etc.

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Roseola

• Agent human herpesvirus type 6
• Incubation 5 to 15 days
• Persistent high fever for 3 to 4 days otherwise
  appears well
• After fever subsides, rash appears
• Rash first on trunk, then face and extremities

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Rubeola (Measles)

• Agent virus
• Transmission secretions, droplets
• Incubation 10 to 20 days communicability from 4
  days before to 5 days after appearance of rash
• Koplik spots appear 2 days before rash

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Mumps

• Agent paramyxovirus
• Transmission via droplet or direct contact
• Incubation 14 to 21 days
• Fever, headache, malaise, followed by parotitis
• May cause orchitis and meningoencephalitis

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Pertussis (Whooping Cough)

• Agent Bordetella pertussis
• Transmission droplet or direct contact
• Incubation 6 to 20 days
• Cough short rapid coughs followed by crowing or
  whoop sound
• Complications pneumonia (usual cause of death)

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Rubella (German Measles)

• Agent rubella virus
• Transmission direct contact or indirect contact
  with article freshly contaminated with
  nasopharyngeal secretions, blood, stool, or urine
• Incubation 14 to 21 days
• Complications rare greatest danger is
  teratogenic effect on fetus

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Scarlet Fever

• Agent group A hemolytic streptococci
• Transmission droplet or direct contact
• Incubation 1 to 7 days
• Complications carditis, peritonsillar abscess,
  glomerulonephritis

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Scarlet Fever (Cont.)
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Conjunctivitis

• Newborns chlamydia, gonorrhea or herpes simplex
  virus
• Infants may be sign of tear duct obstruction
• Children causes are bacterial (most common),
  viral, allergic, or foreign body

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Intestinal Parasitic Diseases

• Ascariasis (common roundworm)
• Hookworm
• Strongyloidiasis (threadworm)
• Giardiasiscaused by a protozoon

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Ingestion of Injurious Agents

• Cosmetics and personal care products
• Cleaning products
• Plants
• Foreign bodies, toys, and miscellaneous
  substances
• Hydrocarbons (gasoline)

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Principles of Emergency Treatment

• Poison control center
• Call first, before initiating any interventions
• Assessment
• Gastric decontamination
• Induce vomiting, absorb toxin, or perform gastric
  lavage depending upon agent ingested
• Prevent recurrence

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Heavy Metal Poisoning

• Mercury toxicity (less frequently)
• Air water pollutant from coal plants,
  etc
• Most common is lead ingestion
• Most common by peeling lead-based paint
• Micro particles of lead contaminate bare
  soil
• Can be inhaled or ingested
• Affects renal, hematologic, and
  neurologic
• systems developing brain and nervous
  
• are especially vulnerable

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Effects of Lead on Body Systems
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Lead Poison Diagnosis

• Rarely symptomatic
• Venous blood sample of 10 mcg/dl
• Screening for lead poisoning at ages
• 1 and 2 years
• Chelation therapy with calcium disodium edetate
  (EDTA) and succimer (DMSA)
• Prognosis

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Child Maltreatment

• Intentional physical abuse (22) or neglect (54)
• Emotional abuse (4) or neglect
• Sexual abuse of children (8)

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Types of Neglect

• Physical neglect
• Deprivation of food, clothing, shelter,
  supervision, medical care, and education
• Emotional neglect
• Lack of affection, attention, and emotional
  nurturance
• Emotional abusedestroy or impair childs
  self-esteem

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Munchausens Syndrome by Proxy

• Caregiver fabricates signs and symptoms of
  illness in child (the proxy) to gain attention
  from medical staff
• Child may undergo needless and painful procedures
  and treatments10 of cases may be fatal to the
  child

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Factors Predisposing to Physical Abuse

• Parental characteristics
• Social isolation, poor support systems
• Parental low self-esteem and less adequate
  maternal functioning

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Child Characteristics Predisposing to Physical
Abuse

• Compatibility between childs and parents
  temperament and parents ability to deal with
  behavioral style
• Removing the child victim from the home may place
  other siblings at risk for abuse

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Environmental Characteristics

• Chronic stress
• Divorce, poverty, unemployment, poor housing,
  substance abuse, frequent relocation, crowded
  living conditions
• Child abuse can occur in any socioeconomic
  population

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Sexual Abuse

• Defined as the use, persuasion, or coercion of
  any child to engage in sexually explicit conduct
  or simulation of such conduct for producing
  visual depiction of such conduct, or rape,
  molestation, prostitution, or incest with
  children

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Characteristics of Abusers and Victims

• Typical abuser is a male the victim knows but may
  be ANYONE
• All socioeconomic backgrounds

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Nursing Care of theMaltreated Child

• Identify abusive situations as early as possible
• History pertaining to the incident
• Evidence of maltreatment
• Pattern or combination of indicators that arouse
  suspicion and further investigation
• Protect child from further abuse

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References

• Hockenberry, M. J. (2005). Wongs Essentials of
  Pediatric Nursing 8th ed. St. Louis, Missouri
  Elsevier Mosby.
• Jordan, D. N.(2005). Nursing 202 Lecture 1 Power
  Points. Los Angeles, CA.
• Pillitteri, A. (2007). Maternal Child Health
  Nursing Care of the Childbearing Childrearing
  Family 5th ed. Philadelphia, PA Lippincott
  Williams Wilkins.