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Introduction to Maternal And child health nursing

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Introduction to Child Health Nursing

Jan 20, 2013

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Introduction to Child Health Nursing. Who is your patient?. 6 year old female admitted to the hospital with a medical diagnosis of pneumonia Currently in 1 st grade Lives at home with Mother, Father, and 2 year old sibling Both parents work full time outside the home

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• physical exam guidelines
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Who is your patient? • 6 year old female admitted to the hospital with a medical diagnosis of pneumonia • Currently in 1st grade • Lives at home with Mother, Father, and 2 year old sibling • Both parents work full time outside the home • Grandparents live in near by town and assist with child care

Pediatric Nursing • A parent-nurse partnership • Nurse’s goals are to promote • therapeutic relationship between parent and child • continued growth and development

Growth and Development

Definitions of Growth and Development • Growth • Increase in physical size of a whole or any of its parts • Increase in number and size of cells • Growth can be measured • Development • A continuous, orderly series of conditions • leads to activities and patterns of behavior

Pace of Growth • A rapid pace from birth to 1 ½-2 years • A slower pace from 2 years to puberty • Expected 4-6 lb/year • A rapid pace from puberty to approximately 15 years • A sharp decline from 16 years to approximately 24 years when full adult size is reached

Stages of Growth and Development • Neonate first 28 days of life • Infancy birth to 12 months • Toddler 1 to 3 years • Preschooler 4 to 5 years • School-ager 6 to 10 years • Prepubertal 11 to 12 years • Adolescent 13 to 18 + years

Development Psychosocial & Intellectual

Theorists Associated with Development • Piaget Stages of cognitive development • Erikson Stages of psychosocial development • Kohlberg Stages of moral development • Freud Stages of psychosexual development

Psychosocial Development Trust vs. Mistrust (birth to 1 year) • Establishes a sense of trust when basic needs are • Nurses should provide consistent, loving care Autonomy vs. Shame & Doubt: (1-3 yrs) • Increasingly independent in many spheres of life • Nurses should allow for choices and self care

Psychosocial Development Initiative vs. Guilt (3-6 yrs) • Learns to initiate play activities, imitate adult behavior • Nurses should encourage to explore environment with senses, promote imagination • Industry vs. Inferiority (6-12 yrs) • Learns self worth as workers & producers • Nurses should promote children to compete and cooperate

Psychosocial Development Identity vs. Role Confusion (12-18 yrs) • Forms identity and establishment of autonomy from parents • Peers and society big influence • Nurses should encourage peer visitation, texting, phone calls

Intellectual Development Sensorimotor (birth to 2) • Learns from movement and sensory input • Learns cause & effect Preoperational (2 to 7 years) • Increasing curiosity and explorative behavior • Thinking is concrete • Egocentrism is dominant

Intellectual Development Concrete Operational (7 to 11 years) • Logical & coherent thought • Can now distinguish fact from fantasy Formal Operations (11 to adulthood) • Acquisition of abstract reasoning leading to • Analytical thinking • Problem solving • Planning for the future

Factors Influencing Growth and Development • Genetics • Environment • Culture • Nutrition • Health status • Family • Parental attitudes • Child-rearing philosophies

Purpose of Play • Sensorimotor development • Intellectual development • Socialization • Creativity • Self-awareness • Moral value • Therapeutic value

Types of Play • Solitary • Parallel • Associative • Cooperative • Onlooker • Dramatic • Familiarization

Communicating with Children

Infancy • Responds to physical contact • Use a gentle voice • Sing-song quality • High pitched • Need to be held, cuddled

Early Childhood < 7 yrs • Remember they are egocentric and interpret words literally • Tell them what “children” can do • Let them touch equipment • Nonverbal messages should be clear • Maintain eye level • Use quiet, calm voice • Be specific, use simple words, short sentences, be honest

School Age • Wants to know why an object exists • How it works • Why it is being done to them • Concerned about body integrity

Adolescents • Needs undivided attention • Listen, be open-minded • Avoid criticizing • Make expectations clear

Physical & Developmental Assessment

Physical Exam Guidelines • Non-threatening environment • Place frightening equipment out of sight • Provide privacy • Provide time for play (stuffed animals, dolls) • Observe for behaviors re: child’s readiness to cooperate • Begin with the least intrusive examination (observation)

Age-specific approaches to exam • 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 and Adolescents: head to toe, genitalia last, respect privacy

Pediatric Physical Exam • Growth measurements • Height, weight, head circumference (<3 yrs) • Physiologic measurements (VS) • General appearance (hygiene, posture, behavior) • Body Systems (heart, lungs, abdomen are key areas)

Denver Developmental Screening Test (DDST-II) • Evaluates development for children 0-6 in four areas • Personal-social • Fine-motor • Language • Gross motor • Child’s mood must be typical for results to be valid • Results may be altered if child is not feeling well, sedated

Denver Developmental Screening Test (DDST-II) • Provides a clinical impression on child’s overall development • Not a predictor of future development, not an IQ test • Used for noting problems, monitoring, and to base a referral for additional developmental testing

Nursing Interventions based on Developmental Age (not Chronological Age) • Infants (0-12m) • Use soft voice, sing-song, • Talk to and describe procedures as they are done • Toddlers (1-3 yr) • Separation anxiety peaks (nurse is a stranger) • Preparation for a procedure should begin immediately before the event

Nursing Interventions based on Developmental Age (not Chronological Age) • Preschool (4-5 yr) • Explain procedures according to senses (what child will feel, see, hear) • Imagination is active...may see procedures as a consequence for misbehavior • School-age (6-10 yr) • Use books, pictures to explain procedures • Developmentally ready for detailed explanations • Organizing and collecting is an enjoyed activity • Peers become more important, parents still main influence

Nursing Interventions based on Developmental Age (not Chronological Age) • Pre-Adolescents/Adolescents (11 & up) • Value privacy, group identification is important • May have an need for independence • Older adolescent can understand adult concepts • Can be prepared for a procedure up to a week in advance

Discipline (Limit Setting) • Reinforcement of desired behaviors is most effective • Consequences for negative behaviors • Teaching parents how to discipline avoids problems related to incorrect use • Appropriate limit setting • Consistency • Consequences should be told in advance • Include truthful explanation of why behavior is unacceptable • Physical punishment is the least effective

Limit Setting and the Toddler • Discipline must be consistent, immediate, realistic, age-appropriate, and related to the incident • Clearly explain limits and give time for toddlers to respond • Avoid arguments and extensive explanations • Avoid withdrawing love as punishment • Separate toddler from behavior • Praise toddler for good behavior

Infancy 0-6 months • Breastmilk most desirable • Fe fortified formula alternative • No whole milk until 1 year old • Altered ability to be digested • Increased risk of contamination • Lack of components needed for appropriate growth

Infancy 6-12 months • Breast milk or formula remains the primary source of nutrition • May begin addition of solids b/c: • GI tract is mature to handle complex nutrients • GI tract is less sensitive to allergenic foods • Extrusion reflex has disappeared • Swallowing is more coordinated • Head control is well developed, voluntary grasping begins

Infancy 6-12 months • 4- 6 months infant cereal mixed with formula or Breast milk (Rice, then oatmeal, barley) • 6 months can introduce crackers as a teething food. • 6 months fruit juice to substitute for one milk feeding • Baby food (pureed fruits and vegetables) • Introduce one food at a time at 4-7 day intervals • No strawberries, eggs, peanuts until after 12 months of age

Infancy 0-6 months No solids before 4-6 months of age b/c: • Solids are not compatible with GI tract • Exposure to food antigens that may produce a food-protein allergy • Extrusion reflex still present (pushes food out of mouth)

Infancy 6-12 months • By 8-9 months junior foods & finger foods • By 1-year well-cooked table foods

Toddlerhood • From 12-18 months rate of growth slows • At 18 months decreased nutritional need, appetite declines, picky eaters • At 18 months may be able to adeptly use spoon, prefer fingers • Do not force food

Toddlerhood • Mealtime should be pleasant • What is eaten is more important than how much is eaten • General serving size is ¼ to 1/3 of the adult portion • May have a hard time sitting through an entire meal

Preschool • Needs are similar to toddler • Average daily intake: 1800 calories • More agreeable to try new foods • Ready to socialize during meals • General serving size is ½ of an adult’s portion

School Age Years • Food likes and dislikes are established • Important for parents to choose foods that promotes growth • Children eat away from home • Important to teach Food Pyramid Guide for nutrition instruction • Encourage the child to make good choices

Adolescence • Caloric and protein requirements are higher than almost any time in life • Eating habits easily influenced by peers • Fad diets, high caloric foods low in nutritional value popular

Care of the Hospitalized Child

“Atraumatic Care” Interventions that eliminate or minimize psychological and physical distress experienced by children and their families in the health care system

Stressors of Hospitalization • Separation Anxiety • Loss of Control • Bodily Injury & Pain

Stages of Separation Anxiety (Universal fear of toddler) • Protest • loud, demanding cries, rejects comfort measures • Despair • lies on abdomen, flat facial expression, weight loss, insomnia, loss of developmental skills • Denial or Detachment • silent expressionless child, deterioration of developmental milestones, may have trouble forming close relationships

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• About Adverse Childhood Experiences
• Risk and Protective Factors
• Program: Essentials for Childhood: Preventing Adverse Childhood Experiences through Data to Action
• Adverse childhood experiences can have long-term impacts on health, opportunity and well-being.
• Adverse childhood experiences are common and some groups experience them more than others.

What are adverse childhood experiences?

Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). Examples include: 1

• Experiencing violence, abuse, or neglect.
• Witnessing violence in the home or community.
• Having a family member attempt or die by suicide.

Also included are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding. Examples can include growing up in a household with: 1

• Substance use problems.
• Mental health problems.
• Instability due to parental separation.
• Instability due to household members being in jail or prison.

The examples above are not a complete list of adverse experiences. Many other traumatic experiences could impact health and well-being. This can include not having enough food to eat, experiencing homelessness or unstable housing, or experiencing discrimination. 2 3 4 5 6

Quick facts and stats

ACEs are common. About 64% of adults in the United States reported they had experienced at least one type of ACE before age 18. Nearly one in six (17.3%) adults reported they had experienced four or more types of ACEs. 7

Preventing ACEs could potentially reduce many health conditions. Estimates show up to 1.9 million heart disease cases and 21 million depression cases potentially could have been avoided by preventing ACEs. 1

Some people are at greater risk of experiencing one or more ACEs than others. While all children are at risk of ACEs, numerous studies show inequities in such experiences. These inequalities are linked to the historical, social, and economic environments in which some families live. 5 6 ACEs were highest among females, non-Hispanic American Indian or Alaska Native adults, and adults who are unemployed or unable to work. 7

ACEs are costly. ACEs-related health consequences cost an estimated economic burden of $748 billion annually in Bermuda, Canada, and the United States. 8

ACEs can have lasting effects on health and well-being in childhood and life opportunities well into adulthood. 9 Life opportunities include things like education and job potential. These experiences can increase the risks of injury, sexually transmitted infections, and involvement in sex trafficking. They can also increase risks for maternal and child health problems including teen pregnancy, pregnancy complications, and fetal death. Also included are a range of chronic diseases and leading causes of death, such as cancer, diabetes, heart disease, and suicide. 1 10 11 12 13 14 15 16 17

ACEs and associated social determinants of health, such as living in under-resourced or racially segregated neighborhoods, can cause toxic stress. Toxic stress, or extended or prolonged stress, from ACEs can negatively affect children’s brain development, immune systems, and stress-response systems. These changes can affect children’s attention, decision-making, and learning. 18

Children growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. 18 These effects can also be passed on to their own children. 19 20 21 Some children may face further exposure to toxic stress from historical and ongoing traumas. These historical and ongoing traumas refer to experiences of racial discrimination or the impacts of poverty resulting from limited educational and economic opportunities. 1 6

Adverse childhood experiences can be prevented. Certain factors may increase or decrease the risk of experiencing adverse childhood experiences.

Preventing adverse childhood experiences requires understanding and addressing the factors that put people at risk for or protect them from violence.

Creating safe, stable, nurturing relationships and environments for all children can prevent ACEs and help all children reach their full potential. We all have a role to play.

• Merrick MT, Ford DC, Ports KA, et al. Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017. MMWR Morb Mortal Wkly Rep 2019;68:999-1005. DOI: http://dx.doi.org/10.15585/mmwr.mm6844e1 .
• Cain KS, Meyer SC, Cummer E, Patel KK, Casacchia NJ, Montez K, Palakshappa D, Brown CL. Association of Food Insecurity with Mental Health Outcomes in Parents and Children. Science Direct. 2022; 22:7; 1105-1114. DOI: https://doi.org/10.1016/j.acap.2022.04.010 .
• Smith-Grant J, Kilmer G, Brener N, Robin L, Underwood M. Risk Behaviors and Experiences Among Youth Experiencing Homelessness—Youth Risk Behavior Survey, 23 U.S. States and 11 Local School Districts. Journal of Community Health. 2022; 47: 324-333.
• Experiencing discrimination: Early Childhood Adversity, Toxic Stress, and the Impacts of Racism on the Foundations of Health | Annual Review of Public Health https://doi.org/10.1146/annurev-publhealth-090419-101940 .
• Sedlak A, Mettenburg J, Basena M, et al. Fourth national incidence study of child abuse and neglect (NIS-4): Report to Congress. Executive Summary. Washington, DC: U.S. Department of Health an Human Services, Administration for Children and Families.; 2010.
• Font S, Maguire-Jack K. Pathways from childhood abuse and other adversities to adult health risks: The role of adult socioeconomic conditions. Child Abuse Negl. 2016;51:390-399.
• Swedo EA, Aslam MV, Dahlberg LL, et al. Prevalence of Adverse Childhood Experiences Among U.S. Adults — Behavioral Risk Factor Surveillance System, 2011–2020. MMWR Morb Mortal Wkly Rep 2023;72:707–715. DOI: http://dx.doi.org/10.15585/mmwr.mm7226a2 .
• Bellis, MA, et al. Life Course Health Consequences and Associated Annual Costs of Adverse Childhood Experiences Across Europe and North America: A Systematic Review and Meta-Analysis. Lancet Public Health 2019.
• Adverse Childhood Experiences During the COVID-19 Pandemic and Associations with Poor Mental Health and Suicidal Behaviors Among High School Students — Adolescent Behaviors and Experiences Survey, United States, January–June 2021 | MMWR
• Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics. 2004 Feb;113(2):320-7.
• Miller ES, Fleming O, Ekpe EE, Grobman WA, Heard-Garris N. Association Between Adverse Childhood Experiences and Adverse Pregnancy Outcomes. Obstetrics & Gynecology . 2021;138(5):770-776. https://doi.org/10.1097/AOG.0000000000004570 .
• Sulaiman S, Premji SS, Tavangar F, et al. Total Adverse Childhood Experiences and Preterm Birth: A Systematic Review. Matern Child Health J . 2021;25(10):1581-1594. https://doi.org/10.1007/s10995-021-03176-6 .
• Ciciolla L, Shreffler KM, Tiemeyer S. Maternal Childhood Adversity as a Risk for Perinatal Complications and NICU Hospitalization. Journal of Pediatric Psychology . 2021;46(7):801-813. https://doi.org/10.1093/jpepsy/jsab027 .
• Mersky JP, Lee CP. Adverse childhood experiences and poor birth outcomes in a diverse, low-income sample. BMC pregnancy and childbirth. 2019;19(1). https://doi.org/10.1186/s12884-019-2560-8 .
• Reid JA, Baglivio MT, Piquero AR, Greenwald MA, Epps N. No youth left behind to human trafficking: Exploring profiles of risk. American journal of orthopsychiatry. 2019;89(6):704.
• Diamond-Welch B, Kosloski AE. Adverse childhood experiences and propensity to participate in the commercialized sex market. Child Abuse & Neglect. 2020 Jun 1;104:104468.
• Shonkoff, J. P., Garner, A. S., Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–e246. https://doi.org/10.1542/peds.2011-2663
• Narayan AJ, Kalstabakken AW, Labella MH, Nerenberg LS, Monn AR, Masten AS. Intergenerational continuity of adverse childhood experiences in homeless families: unpacking exposure to maltreatment versus family dysfunction. Am J Orthopsych. 2017;87(1):3. https://doi.org/10.1037/ort0000133 .
• Schofield TJ, Donnellan MB, Merrick MT, Ports KA, Klevens J, Leeb R. Intergenerational continuity in adverse childhood experiences and rural community environments. Am J Public Health. 2018;108(9):1148-1152. https://doi.org/10.2105/AJPH.2018.304598 .
• Schofield TJ, Lee RD, Merrick MT. Safe, stable, nurturing relationships as a moderator of intergenerational continuity of child maltreatment: a meta-analysis. J Adolesc Health. 2013;53(4 Suppl):S32-38. https://doi.org/10.1016/j.jadohealth.2013.05.004 .

Adverse Childhood Experiences (ACEs)

ACEs can have a tremendous impact on lifelong health and opportunity. CDC works to understand ACEs and prevent them.

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