Pediatric Nursing

Growth and Development

1. Developmental Milestones (Infant, Toddler, Preschool, School-Age, Adolescent)

Children develop through a predictable sequence of physical, cognitive, language, and psychosocial milestones. While each child’s timeline may vary, recognizing approximate ages for these milestones can help detect delays and customize care.

A. Infancy (Birth to 12 Months)

  1. Physical Growth
    • Weight: Typically doubles by 5–6 months and triples by the end of the first year.
    • Height: Grows by about 50% during the first year.
    • Head Circumference: Rapid brain development; the posterior fontanel closes around 2 months, and the anterior fontanel closes between 12–18 months.
  2. Motor Milestones
    • Gross Motor
      • 1 month: Lifts head briefly when lying on stomach.
      • 4 months: Rolls from stomach to back.
      • 6 months: Sits with support, rolls in both directions.
      • 8–9 months: Sits steadily without support, may begin crawling or creeping.
      • 9–10 months: Pulls to stand, cruises while holding onto furniture.
      • 12 months: May walk independently, stands briefly without support.
    • Fine Motor
      • 1 month: Hands mostly clenched.
      • 3–4 months: Reaches for objects, bats at hanging items.
      • 6 months: Passes objects from one hand to another.
      • 9–10 months: Develops a pincer grasp (using thumb and forefinger).
      • 12 months: May attempt to stack small objects, can drop items into a container.
  3. Language/Cognitive
    • Begins cooing around 2 months, babbling by 6 months, and may say first words (like “mama” or “dada”) around 9–12 months.
    • Object Permanence: Emerging around 8–9 months (enjoys peek-a-boo games).
  4. Psychosocial (Erikson Stage: Trust vs. Mistrust)
    • Consistent caregiving helps build trust.
    • Stranger anxiety starts around 6–7 months, with separation anxiety peaking around 9 months.

B. Toddler (1–3 Years)

  1. Physical Growth
    • Slower growth compared to infancy: Gains about 4–6 lbs per year and grows 3 inches per year.
    • By age 2–3, head circumference becomes more proportional to the body.
  2. Motor Milestones
    • Gross Motor
      • 15 months: Walks independently, climbs stairs with assistance.
      • 18 months: Climbs, throws a ball without losing balance.
      • 2 years: Runs well, kicks a ball, can climb stairs with one foot on each step.
      • 3 years: Can ride a tricycle, stands on one foot briefly.
    • Fine Motor
      • Scribbles spontaneously, stacks 2–4 blocks by 18 months, 6–7 blocks by 2 years.
      • Can turn book pages, uses a spoon/fork (although messily), unzips or unbuttons large buttons.
  3. Language/Cognitive
    • Vocabulary grows from around 10–20 words at 18 months to approximately 300 words by age 2–3.
    • By age 2, can use 2-word phrases (“want milk,” “mommy go”).
    • Understands and points to familiar objects/pictures, follows simple commands.
  4. Psychosocial (Erikson Stage: Autonomy vs. Shame and Doubt)
    • Toddlers seek independence and may frequently assert “Me do it!” and show negative responses like “No!”
    • Parallel play: Play alongside others but not interactively.

C. Preschool (3–5 Years)

  1. Physical Growth
    • Gains about 4–5 lbs per year, and grows around 2–3 inches annually.
    • Body becomes leaner and more coordinated.
  2. Motor Milestones
    • Gross Motor
      • Hops on one foot, climbs well, skips, catches a ball reliably around 4–5 years.
    • Fine Motor
      • Copies shapes (circle by 3 years, square/triangle by 5 years), dresses with minimal help, uses scissors around 4 years.
      • Draws a person with 2–4 body parts by age 4, and more detailed figures by age 5.
  3. Language/Cognitive
    • Vocabulary exceeds 2,000 words by age 5, and sentences grow to 5+ words.
    • Can tell stories, identify some colors, and count objects.
    • Magical Thinking: Preschoolers often believe that their thoughts can influence events, and they may struggle to distinguish fantasy from reality.
  4. Psychosocial (Erikson Stage: Initiative vs. Guilt)
    • Preschoolers love exploring, asking “why,” and engaging in imaginative and role-playing activities.
    • Associative play: Playing in groups with some shared goals but no strict organization.

D. School-Age (6–12 Years)

  1. Physical Growth
    • Gains about 4–7 lbs per year and grows approximately 2–2.5 inches per year.
    • Permanent teeth erupt, and body proportions approach those of an adult.
  2. Motor Development
    • Improved coordination, skill development (bike riding, sports).
    • Enhanced fine motor abilities, such as printing and cursive writing, detailed drawing, and crafts.
  3. Cognitive/Language
    • Begins concrete operational thinking (Piaget), understanding logical relationships, conservation, and categorization.
    • Vocabulary continues to expand, and reading and writing skills improve.
  4. Psychosocial (Erikson Stage: Industry vs. Inferiority)
    • Focus shifts to achievement, and self-esteem grows from accomplishments in school, hobbies, and sports.
    • Cooperative play: Engages in organized games, sports, and team activities, following rules and playing fairly.

E. Adolescent (12–18 Years)

  1. Physical Growth
    • Puberty occurs, marked by a growth spurt and sexual maturation.
    • Girls typically begin puberty between ages 8–13, and boys around 9–14.
    • Final 20–25% of height is achieved, with significant weight and muscle changes.
  2. Motor/Cognitive
    • Gross and fine motor skills are fully developed, though some adolescents continue to refine specialized skills in sports or the arts.
    • Formal operational thinking (Piaget) emerges: ability to think abstractly, reason hypothetically, and consider future possibilities.
  3. Psychosocial (Erikson Stage: Identity vs. Role Confusion)
    • Adolescents are focused on defining their personal identity, influenced heavily by peers, and may experience heightened self-consciousness regarding body image.
    • Risk-taking behaviors may increase during this stage.
  4. Communication
    • Independence and autonomy are essential, and open, respectful communication fosters trust.
    • Privacy and confidentiality are critical, especially during healthcare visits.

2. Nutritional Needs at Different Developmental Stages

Children’s nutritional requirements evolve with their growth rate and developmental needs. A well-rounded intake of macronutrients (carbohydrates, proteins, fats) and micronutrients (vitamins, minerals) is essential for proper development.

A. Infants

  1. Breastfeeding or Formula
    • Exclusive breastfeeding or iron-fortified formula is recommended for the first 6 months.
    • If exclusively breastfed, consider iron supplements starting at 4–6 months, as recommended by pediatric guidelines.
  2. Introducing Solids
    • Begin introducing solid foods around 4–6 months, starting with iron-fortified single-grain cereals, followed by pureed fruits, vegetables, and meats.
    • Introduce new foods one at a time and observe for potential allergic reactions.
  3. Foods to Avoid
    • Avoid cow’s milk before 12 months due to risks like gastrointestinal bleeding and insufficient iron intake.
    • Honey should not be given before 1 year due to the risk of botulism.

B. Toddlers

  1. Transition to Cow’s Milk
    • Offer whole milk from ages 1 to 2 years to support brain development, then switch to 2% or lower-fat milk after age 2 if the child is growing well.
  2. Serving Sizes
    • A general guideline is to serve 1 tablespoon of food per year of age (for example, a 2-year-old would have around 2 tablespoons of vegetables).
  3. Picky Eaters
    • It’s common for toddlers to be selective eaters. Provide a variety of healthy foods and limit sugary snacks and fruit juices.
    • Encourage the use of utensils to promote independence.

C. Preschoolers

  1. Balanced Diet
    • Offer a similar diet to toddlers, with slightly larger portions.
    • Encourage meals with a variety of colorful foods, including fruits, vegetables, and whole grains.
    • Limit fruit juice to 4–6 oz per day.
  2. Healthy Habits
    • Establish family mealtime routines and avoid using food as a form of reward or punishment.
    • Allow preschoolers to participate in simple meal preparation to spark interest in food.

D. School-Age Children

  1. Steady Appetite
    • Maintain balanced meals with approximately 3 meals a day and 1–2 snacks.
    • Include protein-rich foods, fruits, vegetables, whole grains, and calcium-rich foods for proper bone development.
  2. Common Concerns
    • Obesity Risk: Monitor portion sizes, avoid excessive high-calorie snacks and fast foods, and encourage physical activity.
    • Peer Influence: Children may be influenced by school lunches or snacks from vending machines, impacting their eating habits.

E. Adolescents

  1. Increased Caloric Needs
    • Due to rapid growth during puberty (earlier in girls, more intense in boys), adolescents have higher calorie requirements.
    • Protein, iron, and calcium needs peak during this time. For example, adolescents require about 1300 mg of calcium per day.
  2. Dietary Habits
    • Adolescents may skip meals, particularly breakfast, and often consume fast food.
    • Emphasize the importance of healthy snacks, balanced macronutrient intake, and sufficient micronutrients (such as folic acid and vitamins).
    • Body Image Concerns: Adolescents may develop disordered eating patterns, such as anorexia or bulimia, due to concerns about their body image.
  3. Counseling
    • Support adolescents in making independent food choices while guiding them toward nutritious options.
    • Stress the importance of staying hydrated, especially during physical activities, and limit consumption of energy drinks.

Common Pediatric Disorders

3-5. Immunization Schedules

Birth to 6 Years

  • Hepatitis B: Administer 3 doses (at birth, 1–2 months, and 6–18 months).
  • DTaP (Diphtheria, Tetanus, acellular Pertussis): Administer 5 doses (at 2, 4, 6, 15–18 months, and 4–6 years).
  • Polio (IPV): Administer 4 doses (at 2, 4, 6–18 months, and 4–6 years).
  • Hib (Haemophilus influenzae type b) and PCV (Pneumococcal): Administer series during infancy (at 2, 4, 6, and 12–15 months).
  • MMR (Measles, Mumps, Rubella) and Varicella: Administer 2 doses (at 12–15 months and 4–6 years).
  • Rotavirus: Administer 2 or 3 doses, depending on the brand (at 2, 4, ±6 months).

7–18 Years

  • Tdap: Administer a booster at 11–12 years.
  • HPV: Administer the series at 11–12 years (2 or 3 doses, depending on age at the first dose).
  • Meningococcal: Administer at 11–12 years and a booster at 16 years.
  • Annual Influenza vaccine: Recommended yearly.
  • Catch-up vaccines: As needed for missed vaccinations (e.g., MMR, Varicella, HepA/HepB).

Nursing Considerations for Immunizations

  • Screen for allergies (e.g., egg or latex) and any previous severe reactions.
  • Educate parents on common side effects (e.g., low-grade fever, soreness at the injection site).
  • Keep thorough and accurate records of immunization schedules and any contraindications (e.g., moderate or severe illness).

Communicable Diseases

  • Many communicable diseases can be prevented by adhering to the CDC immunization schedule.
  • Isolation precautions may vary based on the disease, such as droplet, contact, or airborne precautions.
  • Watch for potential complications, including encephalitis, pneumonia, or secondary infections.

Respiratory Issues (RSV, Asthma)

  • RSV: A leading cause of infant hospitalizations during winter and spring. Focus on airway clearance and hydration.
  • Asthma: Ensure the use of an action plan, including peak flow monitoring, proper inhaler use, and avoiding triggers.

GI Concerns (Gastroenteritis, Pyloric Stenosis)

  • Hydration: Essential in managing gastrointestinal illnesses—watch for signs of dehydration, such as reduced output or sunken fontanels.
  • Pyloric Stenosis: This condition presents with projectile vomiting in infants around 2–8 weeks old; surgical intervention is typically required and is curative.

Cardiac Conditions (VSD, TOF)

  • VSD (Ventricular Septal Defect): Pay attention to feeding difficulties and failure to thrive due to the increased effort in breathing or heart failure.
  • TOF (Tetralogy of Fallot): In cases of “Tet spells,” position the infant in a knee-chest position to improve systemic vascular resistance and reduce the right-to-left shunt.

Neurological Conditions (Seizures, Cerebral Palsy)

  • Seizure Management: Ensure safety by clearing the area, positioning the child on their side, timing the seizure, and never restraining or placing objects in the mouth during the event.
  • Cerebral Palsy: Customize interventions to enhance mobility and independence, and involve a multidisciplinary team (including physical therapy, occupational therapy, and speech therapy).

Pediatric Medication Administration and Safety

6. Weight-Based Dosage Calculations

Administering medication to children requires precise attention to dosage based on factors like weight, body surface area (BSA), and developmental stage. Incorrect dosing can lead to severe complications due to a child’s smaller size and immature organ systems.

A. Importance of Weight-Based Dosing

  1. Variability in Pediatric Patients
    • Children vary greatly in terms of age, weight, body composition (fat vs. muscle mass, total body water), and metabolism.
    • Standard adult doses are often inappropriate for children, making it necessary to base doses on the child’s weight (kg) or body surface area (BSA).
  2. Drug Metabolism and Immaturity
    • Infants, especially neonates, have underdeveloped liver and kidney function, which can affect the metabolism and excretion of drugs.
    • Without proper adjustments, some medications may accumulate more rapidly or have extended effects, which could be harmful.
  3. Use of BSA (Body Surface Area)
    • Some medications (e.g., chemotherapy drugs) require dosing based on BSA rather than weight alone.
    • The BSA formula, such as the Mosteller formula, combines both height and weight to calculate the appropriate dosage.

B. Calculation Principles

  1. Converting Weight
    • Always measure weight in kilograms (kg), where 1 kg equals 2.2 lbs.
    • Verify the accuracy of the child’s weight using infant scales and minimal clothing.
  2. Safe Dose Ranges
    • Ensure the calculated dose falls within the safe dose range (mg/kg/dose or mg/kg/day) as specified by a pediatric drug reference.
    • If the calculated dose exceeds the maximum recommended dose, consult a physician or pharmacist.
  3. Example of Weight-Based Calculation
    • Ordered: Amoxicillin 50 mg/kg/day in divided doses every 12 hours.
    • Child’s Weight: 10 kg.
    • Total Daily Dose: 50 mg/kg/day × 10 kg = 500 mg per day.
    • Per Dose (every 12 hours): 500 mg ÷ 2 = 250 mg per dose.
  4. Rounding and Documentation
    • Follow facility policies for rounding, such as to the nearest tenth or hundredth.
    • Record calculations clearly and use electronic systems to minimize errors.

C. Safety Strategies

  1. Double-Check
    • Always double-check calculations for high-alert medications (e.g., insulin, heparin, chemotherapy).
    • In some healthcare settings, two licensed professionals may be required to verify pediatric drug calculations.
  2. Consider Medication Formulation and Route
    • For liquid medications, use a syringe or calibrated dropper to ensure precise dosing.
    • Avoid using teaspoons or tablespoons at home, as these can lead to dosing inaccuracies.
  3. Monitor for Adverse Effects
    • Regularly monitor vital signs, sedation levels, infusion rates for IV medications, and potential allergic reactions.
    • Infants and young children may not be able to communicate side effects, so observe for changes in behavior, feeding habits, and sleep patterns.
  4. Parental Involvement
    • If medications are to be administered at home, educate parents on proper measurement techniques, such as using syringes instead of household spoons.
    • Ensure parents understand the correct dosing schedule (e.g., every 6 hours versus 4 times daily), proper storage, and possible side effects.

7. Family-Centered Care and Education

Pediatric nursing involves a holistic approach that extends care beyond just the child to include the entire family. By fostering collaboration, empathy, and education, this approach aims to ensure safe medication practices and promote positive health outcomes.

A. Core Principles of Family-Centered Care

  1. Respect and Collaboration
    • Acknowledge the parent or caregiver as the primary, constant figure in the child’s life.
    • Foster open and honest communication regarding goals, concerns, and any cultural or personal preferences.
  2. Shared Decision-Making
    • Provide families with clear, evidence-based information to help them make informed decisions regarding treatments, including medication plans.
    • Actively listen to their input, gently clarify misunderstandings, and respect family values when making decisions.
  3. Supportive Environment
    • Encourage family bonding, allow for regular visits, and involve siblings when appropriate.
    • Recognize that illness and hospital stays can disrupt family routines and offer resources such as social workers or support groups to help navigate these challenges.

B. Medication Teaching for Families

  1. Using Simple, Understandable Language
    • Avoid using medical jargon; explain concepts in layman’s terms (e.g., “This medicine helps treat the infection in your child’s ear.”).
    • Use visual aids or demonstrate complex instructions (e.g., how to use an inhaler or nebulizer).
  2. Demonstration and Return Demonstration
    • Demonstrate how to measure liquid doses or operate devices like an inhaler, nebulizer, or EpiPen.
    • Ask parents to repeat the procedure to ensure they understand and can accurately perform the task.
  3. Written Instructions
    • Provide clear, written instructions or medication calendars that match the family’s reading level.
    • Include detailed information on dosing times, possibly using color-coded schedules for easier reference.
  4. Answering the “Why”
    • Parents and children often ask why the medicine is necessary.
    • Provide clear, age-appropriate explanations—older children might appreciate more detailed scientific reasoning, while younger ones simply need reassurance.

C. Home Safety Measures

  1. Medication Storage
    • Stress the importance of storing medications in locked cabinets with childproof caps and avoiding referring to medicine as “candy.”
    • Teach parents how to contact poison control (1-800-222-1222 in the US) in case of an emergency.
  2. Monitoring
    • Encourage parents to keep track of their child’s symptoms, side effects, and any signs of improvement.
    • Advise parents on when to reach out to the pediatrician, such as if they notice unusual rashes, persistent vomiting, or breathing difficulties.
  3. Consistency and Routine
    • Advise maintaining a consistent medication schedule to help children adapt to the routine and reduce missed doses.
    • For older children, use positive reinforcement techniques, like reward charts, to encourage adherence to their medication regimen.

Posted

in

by

angelicasale08

Tags: