NCLEX-RN: Pediatric Nursing

Pediatric Nursing:GROWTH AND DEVELOPMENT

Focus topic: Pediatric Nursing

Pediatric Nursing: GENERAL PRINCIPLES

Focus topic: Pediatric Nursing

A. Growth: increasing number and/or size of cells as they divide and synthesize new proteins resulting in increased size and weight of the whole and/or any part.

B. Development: gradual change and advancement from less to more complex; emerging and expanding capacities, new activities, and patterns of behavior.

C. Maturation: increasing competence and adaptability with physical change in the complexity of body structures, allowing functioning at a higher level.

D. Differentiation: process of developing from simple to more complex activities and functions. Often used in reference to early structures and cells as they are modified from mass to specific to achieve specific characteristics.

E. Growth proceeds in cephalocaudal (head-to-tail) and proximodistal (mid line to peripheral) direction.

F. Sensitive periods exist during all phases of prenatal and postnatal growth and development, when the individual interacts with positive or negative environmental influences and is more susceptible to these influences.

G. All individuals develop in a fixed, predictable sequence, but great variation exists in rate of development and age at which milestones are reached.

Pediatric Nursing

Pediatric Nursing: PHYSICAL GROWTH

Focus topic: Pediatric Nursing

Infants

A. Adjustments are made for premature infants, in corrected gestational age. Guidelines below are for term infants.

B. Birth–6 months.

  •  Birth weight generally should double by 6 months.
  •  Length increases by about 2.5 cm (0.98 inch) per month (measured supine, head to heel) for the first 6 months, then 1.2 cm (0.47 inch) per month for the remainder of the first year.
  •  Head (orbit of rontal cortex; OFC) circumference: average newborn head is 33–35.5 cm (12.99 to 13.97 inches) (range from 32–38 cm or 12.6 to 14.9 inches), increases about 1.5 cm (0.6 inch) per month for the first 6 months.
  •  Anterior fontanelle: should be flat and soft (usually closes by 12–14 months). It may close as late as 18 months.
  •  Posterior fontanelle usually closes by 6–8 weeks.

C. 6–12 months.

  • Birth weight approximately triples at end of 12 months.
  •  Birth length increases approximately 50% by 12 months.
  •  OFC approximately equal to chest circumference at 12 months; grows approximately 0.5 cm per month from 6–12 months.

Pediatric Nursing: Children (1–6 Years)

Focus topic: Pediatric Nursing

A. Toddlers (1–3 years).

  •  Birth weight quadruples by 2½ years; yearly gain 2–3 kg, roughly 2.25 kg (or 5 lbs.).
  •  Height increases about 12 cm by 24 months, about 6–8 cm from 24–36 months, roughly 7.5 cm (or 3 inches).
  •  Measure height standing at 24 months old; continue measuring OFC until 36 months.

B. Preschoolers (3–6 years).

  •  Weight gain 2–3 kg per year, roughly 2.25 kg (or 5 lbs.).
  •  Measure height standing; should grow 5.5 cm (2 inches) per year.

Pediatric Nursing: Middle Childhood to Adolescence

Focus topic: Pediatric Nursing

A. School age (6–12 years).

  •  Weight continues to increase 2–3 kg per year.
  •  Height slows to about 5 cm per year.

B. Adolescents (prepubertal 10–13 years; 12–18 years).

  • Characterized by pubertal growth spurt: 10–14 years in females and 11–16 years in males.
  •  Females gain 7–25 kg (mean 17.5 kg) and 5–25 cm (mean 20.5 cm) during this time. Onset of menses most commonly at 10–13 years.
  • Males gain 7–30 kg (mean 23.7 kg) and 10–30 cm (mean 27.5 cm) between 11 and 16 years .

Pediatric Nursing: Developmental Milestones

Focus topic: Pediatric Nursing

Neonates

A. Physiologic development transition to extrauterine life.

  •  Onset of breathing is the most important task to successfully transition to extra uterine life. Careful monitoring is required. Neonates normally may cough and sneeze to clear fluid present from intrauterine development.
  •  Major changes occur in the cardiovascular system with the closure of fetal shunts and increase in pulmonary blood flow.
  •  Neurologic function characterized by generalized, reflexive responses to stimuli. Primitive reflexes present include sucking, rooting, gagging, grasping, Babinski, Moro, startle, asymmetric tonic neck reflex, and stepping.
    a. Adequate functioning of autonomic nervous system important in regulating respiratory and cardiovascular status, maintaining acid– base balance and thermoregulation.
    b. Should be able to focus and follow object, turn toward noises, console to parental comfort. Should have flexed posture.
  •  Must be able to ingest, digest, absorb, and metabolize food in order to survive.
    a. Liver must be able to handle by-products and toxins (and conjugate bilirubin). Any jaundice (yellow hue to the skin) before 24 hours of age has a pathological cause.
    b. Meconium should pass in first 24–48 hours after birth, followed by transitional stools. Stools will vary depending on milk ingested (breast milk or formula).
    c. Normal blood glucose at birth should be 40–60 mg/dL on Day 1, then 50–90 mg/ dL thereafter.
  •  Renal functioning—kidneys must be able to cope with changing fluid and electrolyte status and concentrate urine. Structures must be patent to allow adequate urine output. The expected urinary output for newborns is one to two wet diapers per 24 hours initially and six wet diapers per 24 hours by Day 4. The normal specific gravity of the newborn’s urine ranges from 1.002–1.010. Normal output values can range from 2–5 mL/kg/hour.
  •  Thermoregulation newborns subject to heat loss and stress from cold, due to large body surface area and thin subcutaneous fat. Neonates are incapable of shivering. Brown fat stores may help in heat regulation.
  •  Newborns should demonstrate normal hearing as measured by noninvasive hearing screening tests (evoked otoacoustic emissions or auditory brain stem responses prior to discharge from the hospital).

B. Behavioral development.

  •  Major developmental task is bonding to parents.
  •  Sleep patterns: average neonate sleeps 16–22 hours per day. Varying “states” evident from birth: sleep, quiet alert, active alert, crying, drowsy, etc.
  •  Developmental theorists.
    a. Erikson: trust versus mistrust.
    b. Piaget: sensorimotor.
    c. Freud: oral.

C. Anticipatory guidance.

  •  Car seats (rear-facing in the back seat of the car).
  •  Place the infant supine on a firm surface with loose bedding or toys. Use a crib next to the mother’s bed. Discourage co-sleeping. Place infant on abdomen for “tummy time play” when awake and being observed.
  •  Feeding issues and position upright to feed.
  •  Care of umbilicus and circumcision. Clean umbilical cord with water only when necessary; keep it clean and dry. After circumcision, change the bandage with each diaper change, and apply a dab of petroleum jelly to the tip of the penis to keep it from sticking to the diaper.
  •  Regular well-child exam and immunization schedule.
  •  Thermoregulation.
  •  Prevention of diaper rash.
  •  Bathing (water temperature).
  •  Stress management/prevention of child abuse/ shaken baby syndrome.

 Infants

A. General concepts.

  • Rapid period of physical and cognitive development.
  •  Role transition in family structure, important to successfully incorporate infant into family unit.
  •  Interest in auditory stimuli begins by 2 months, turns to sounds by 4–6 months.
  •  “Stranger danger” (anxiety) begins by 6 months.
  • Responds to own name and begins to play interactive games (peek-a-boo, pat-a-cake) by 9 months.

B. Behavioral development.

  •  Erikson: trust versus mistrust.
  • Piaget: sensorimotor (primary to secondary circular reactions).
  •  Freud: oral.

C. Moral development: Kohlberg “amoral” stage.

D. Language development.

  • Cooing stage usually beginning by 2 months.
  •  Reciprocal babbling by 2–6 months. Attentive to voices, smiles, laughs, and squeals at 4 months.
  •  Understands simple commands and may imitate sounds by about 9 months.
  • By 12 months, usually can say a few words, imitates variety of vocalizations, waves “bye-bye.”

E. Motor development.

  •  2 months: some head control in upright position; when prone can lift head, neck, and upper chest with support on forearms.
  •  4 months: able to roll from prone to supine; when prone holds head erect and raises body on hands.
    a. Reaches for and bats at objects.
    b. Grasps rattle, opens hands and holds own hands.
  •  6 months: rolls over; no head lag when pulled to sitting; sits with support; able to stand and bear weight when placed.
    a. Grasps objects and brings to mouth.
    b. Begins to self-feed.
    c. Interested in toys, transfers objects from one hand to another, rakes for small objects.
  •  9 months: sits independently; crawls, creeps, or scoots to move forward.
    a. May pull to stand; shakes, bangs, or throws objects.
    b. Feeds self with fingers, starts to use cup, uses inferior pincer grasp.
  •  12 months: pulls to stand, cruises, may take a few steps alone.
    a. Feeds self.
    b. Has precise pincer grasp, bangs two blocks together.

F. Anticipatory guidance.

Birth to 2 months.
a. General safety issues: use of car seats at all times. Continue to put baby to sleep in supine position (on back), turn hot water heater temperature down to 120°F, (48.8°C) and continue to test water before bathing. Keep home a nonsmoking environment; caution when out in sun, fall prevention (never leave baby alone or with young sibling or pet) and smoke detectors in home. Recognition of early signs of illness, immunizations, and emergency procedures.

b. Nutrition: Ensure adequate nutrition and hydration, do not put infant to bed with a bottle. See Appendix 13-1.
c. Breast milk or formula only until 6 months is recommended. Needs 100–108 Kcal/kg/day.
d. Supplemental vitamin D 400 IU daily is recommended for breastfed infants and infants who consume less than 1 liter (or 33 oz) of vitamin D–fortified formula per day.
e. Stress management: Never shake baby  may result in shaken baby syndrome.
f. Immunizations (see schedules, Appendix 13-2): First dose of hepatitis B vaccineis given at birth and the second dose of
hepatitis B is given 1–2 months later. The regular immunization schedule begins at approximately 8 weeks of age.
g. Car seat recommendations: Infants should be in a rear-facing car seat, properly installed in the rear seat of the vehicle and properly buckled, according to manufacturer’s recommendations. Use of rear-facing car seats advised to at least 24 months of age.

  •  4 months.
    a. General safety issues: aforementioned items plus keep sharp objects out of reach. Do not allow infant to play with plastic bags, balloons, or small objects. Keep poisonous objects in a safe place, out of baby’s reach and sight.
    b. Nutrition: Continue to ensure adequate nutrition. Exclusively breastfed infants need iron supplements. See previous vitamin D supplementation recommendations.
    c. Play: Encourage play with appropriate toys. Establish a bedtime routine. Do not use walkers or rolling wheels.
  •  6 months.
    a. General safety issues: Continue car seat use, teach fall prevention, and keep hazardous items up and out of baby’s reach. Put plastic plugs in electrical sockets, check floor from baby’s eye level for hazards. Keep baby away from tubs and swimming pools, lower crib mattress, avoid dangling cords, and install safety locks on cabinets and drawers. Begin dental health (see Appendix 13-1); establish consistent sleep habits.
    b. Nutrition: Introduce solids at 6 months starting with single-grain iron-fortified cereals, adding one new food only every 4–7 days in 1 teaspoon to 1–2 tablespoon amounts, then pureed fruits and vegetables; add pureed meats last. Begin offering cup; avoid objects that can be aspirated hot dogs, peanuts, raw vegetables, whole grapes. Always supervise eating, no bottles in bed, limit juice to 4–6 oz per day. No honey until after 1 year old.
    c. Begin cleaning teeth with eruption using soft gauze or toothbrush without toothpaste.
    d. Play: Provide opportunities for exploration, read to baby, play music. Play interactive games (peek-a-boo and pat-a-cake). Introduce transitional object, play with age-appropriate toys.
  • 4. 9 months.
    a. General safety issues: car safety and injury prevention as in previous months. Fall prevention—install gates at top and bottom of stairs, safety devices on windows. Learn child cardiopulmonary resuscitation (CPR). Continue to keep hazardous substances and items out of sight and reach. Vigilance around swimming pools, lakes, ponds, or ocean. Careful selection of caregivers.
    b. Nutrition: Continue to supervise meals. Introduce small bite-sized table foods; baby has increased interest in self-feeding. Cup feeding continues. Avoid foods that can be aspirated.
    c. Play: Encourage vocalizations, play imitative games, continue talking and reading to baby. Provide age-appropriate toys, avoiding small objects that can be aspirated.
  • 12 months.
    a. General safety issues: Continue car safety, fall prevention, poisons out of reach, water safety, hot water precautions. Keep smokers out of baby’s environment. Test smoke detectors yearly. Keep away from cars, lawn mowers, and driveways—keep stairs gated. Begin brushing teeth with tiny amount of toothpaste.
    b. Nutrition: Begin to feed at family mealtimes with two to three nutritious snacks per day. Allow child to self-feed; amounts eaten will vary. Continue cup training and wean from bottle. Avoid high-sugar drinks; change from formula to whole milk. Avoid foods that may be aspirated (peanuts, popcorn, hard candy, whole grapes).
    c. Play: Encourage exploration and initiative. Provide push and pull toys that encourage large motor skills, teddy bears or transitional objects, musical toys, picture books; read to child daily.
    d. Discipline: Praise good behavior. Set limits and use distraction, “time out,” removal from conflict situation. Discipline geared toward teaching and protection, not punishment.

Pediatric Nursing: Toddlers (12–36 Months)

Focus topic: Pediatric Nursing

A. General concepts.

  •  Time of intense curiosity and exploration of the environment.
  •  Often characterized as the “terrible twos”; obstinacy, temper tantrums, and negativism prevail.3. Physical growth slows after infancy. Senses of vision, hearing, taste, and smell develop well and become coordinated.
  •  Respiratory tract continues to mature, increase in size and number of functioning units, and lessen some factors predisposing to frequent illness.
  •  Gastric and bladder capacities increase; sphincter control occurs around 24 months (physiological readiness for toilet training).
  •  Most children walk well. Stoop and climb stairs by 15 months, throw ball by 18 months.
    a. Refine gross motor skills between 2 and 3 years.
    b. Fine motor control continues to improve; able to stack two blocks and can drop a pellet into narrow bottle at 15 months. Uses a spoon by about 24 months.
  • Separation from mother and differentiation from others begins. Toilet training, sibling rivalry, tantrums, and regression during illness are all common in toddlerhood.

B. Behavioral development.

  • Erikson: autonomy versus shame and doubt.
  • Piaget: sensory motor (tertiary circular reactions) to preconceptual phase (preoperational).
  •  Freud: anal.
  • Development of spirituality, sexuality, and body image begin.

C. Moral development.

  •  Kohlberg: preconventional (good/bad, right/ wrong).
  •  Magical thinking begins (“bad” thoughts make “bad” things happen).
  •  D. Language development.

D. Language development.

  •  Ability to understand far outweighs words spoken.
  • By age 2, has vocabulary of around 300 words, uses short sentences, speaks intelligibly to family, and understands simple instructions.
  •  By age 3, has vocabulary of over 900 words and can follow two-step instructions and speaks intelligibly to strangers.

E. Anticipatory guidance.

  • Injury prevention: car seats, in rear seats only in car with air bags. Car seats must also have upper anchorage devices and locking clips, or Universal Child Safety Seat System (UCSSS). Child should remain in an approved rear-facing car seat until age 2 or have reached height and weight requirements required by car seat manufacturer. After age 2, the child should be placed in an upright forward-facing safety seat with a three- to five-point harness (American Academy of Pediatrics [AAP], 2011). Water safety, prevention of burns, poisoning prevention, preventing falls, aspiration and choking precautions.
  • Monitor for obesity. Obtain body mass index (BMI) for age beginning at age 2. At risk if BMI for age > 85th percentile.Considered obesity if BMI > 95th percentile.
    a. If present, monitor blood pressure (BP) for hypertension, blood glucose (for type 2 diabetes), and lipid profile.
    b. Risk factors are genetics, psychosocial issues, inactivity, and minority and low income family.
    c. Dietary counseling aimed at the family and increasing exercise and can prevent obesity in even preschool children.
  • General issues.
    a. Toilet training.
    b. Dental health first visit to dentist should occur at 12–24 months.
    c. Sleep and activity total hours of sleep decrease; encourage routines.

F. Nutrition.

  • Toddlerhood is the phase of “physiological anorexia.”
  •  Intake varies daily, may eat large amounts one day and almost nothing the next.
  •  Eating habits established in first 3 years may last whole life avoid using food as punishment or reward; mealtimes should be enjoyable, give appropriate-size portions, make snacks nutritious.

G. Play.

  •  Increased locomotion skills; beginning tricycles, wagons, balls, low slides—safety should be foremost in toy selection.
  •  Interest in artwork begins crayons, finger paints, chalk.
  • Puzzles, blocks toys that stimulate creativity, freedom of expression.
  •  Limit use of television and other electronic devices.

H. Discipline.

  • Provide limits. Allow choices when possible.
  •  Tell child specifically and briefly why discipline is necessary and be consistent.
  •  Avoid power struggles with toddlers.
  • Use “time out” when needed, teach toddler about disciplinary measures when child is fed, rested, and not angry. “Catch” the child being good and offer praise.

Pediatric Nursing: Preschoolers (3–6 Years)

Focus topic: Pediatric Nursing

A. General concepts.

  • Physical growth slows, potbelly of toddlerhood disappears, child becomes taller, more slender, sturdy, and agile.
  • Gross motor skills continue to improve and become more coordinated. Child is able to run well, climb, ride tricycle, balance on one foot, skip; can roller skate by 5 years.
  •  Fine motor skills improve with improved hand–eye coordination. Child can draw recognizable person with three parts by age 4; can dress self without help by age 5, print letters, and copy shapes.
  •  Preschoolers are energetic learners and most eagerly anticipate social and educational opportunities at preschool. Enjoy magical thinking and “make believe.”
  •  Beginning to test limits with adults, but respond well to clearly stated rules and praise.
  •  Becoming curious about own bodies, sexual identity, and exploration begins to emerge.
  • Sleep problems common difficulty falling asleep, nightmares, sleep terrors. Routine bedtime rituals helpful in helping child settle down for sleep. Average preschooler sleeps 12 hours at night with infrequent daytime nap.

B. Behavioral development.

  •  Erikson: stage of initiative versus guilt.
  •  Piaget: preoperational stage age 2–7.
    a. Age 2–4 is preconceptual phase.
    b. Age 4–7 is intuitive thought phase.
  •  Freud: Oedipal phase.

C. Moral development.

  • Kohlberg: preconventional stage from 2 to 4 years, child’s moral thinking and behavior is guided by punishment and obedience orientation.
  •  From 4 to 7 years, thinking is more self centered and concrete sense of justice, characterized as “naive instrumental orientation”; is sensitive to feelings of others.

D. Language development.

  •  Speech and language become more complex. Child speaks intelligibly to strangers. At age 5, able to use the past tense and sentences of four or five words, up to short paragraphs.
  •  From age 3–4, speech is telegraphic only most essential words used.
  •  At age 4, can remember nursery rhymes, may have some stuttering.
  •  At age 5, able to recite address and phone number, may have vocabulary of > 2100 words, understands opposites.

E. Anticipatory guidance.

  •  Injury prevention.
    a. Child is ready for a properly installed and fitted booster seat when child reaches the top weight or height allowed for infant/ toddler car seats, shoulders are above harness slots and ears have reached top of the seat. A high seat back is preferred.
    b. Bicycle safety, water safety swimming lessons feasible, use of sunscreen, smoke detectors and fire drills in home, poisons/ toxins out of reach and locked.
  •  Parents should be conscious of role-modeling healthy behavior, encouraging regular exercise, limiting television use.
  •  Child should be taught about personal hygiene, sexuality, and keeping their own bodies safe.
  •  Establish dental hygiene habits.

F. Nutrition.

  •  Preschoolers should have three meals and two snacks at regular times during the day. Encourage healthy breakfast at home or at school.
  •  Calorie requirements approximately 90 cal/kg and 1.2 g/kg protein per day. Energy needs vary from 1400–1800 kcal/day according to size, gender, and activity level see U.S. Department of Agriculture Web site Choose My Plate.gov for guidelines and daily menus. Many are “picky” eaters and refuse to try new foods.
  •  By age 5, child may be able to sit through adult meal; important for parents to role model good eating habits.

G. Play/social development.

  •  Most preschool play is associative; groups involved in similar activities. Play centers on motor skills—running, jumping, riding tricycles and bicycles. Becomes attached to a “favorite” toy, may engage in elaborate fantasy play (“house”), plays interactive games with peers. Can sit still to listen to a story; improving manual dexterity allows interest in drawing, painting, simple carpentry, and sewing. May have imaginary playmate.
  •  Preschoolers more eager to please, can verbalize desires and usually heed warnings of danger.
  •  By 4–5 years, begin to test boundaries.

H. Discipline.

  •  Promote physical activity without aggressiveness. Set developmentally appropriate limits. Use time out, removal of source of conflict for unacceptable behavior, establish consequences for unacceptable behavior.
  •  Help child learn how to get along with peers, teach to respect authority, how to manage anger and resolve conflicts without violence. Parents should be aware of importance of role modeling.

Pediatric Nursing: School-Age Children (6–12 Years)

Focus topic: Pediatric Nursing

A. General concepts.

  •  Height and weight continue to increase at slower pace. Boys and girls are similar size until pubescent growth spurt. Bodies become slimmer, fat distribution changes and diminishes, legs lengthen, and muscle groups become stronger.
  •  Deciduous teeth are lost and replaced by permanent teeth during middle childhood; “the ugly duckling years”; dental hygiene more important.
  •  Physiologic maturity continues in gastrointestinal (GI) system; fewer GI upsets occur and stomach capacity increases. Immune system continues to become more competent; child has fewer illnesses normally than during preschool years.
  •  Increase in stress-related complaints in older school-age children.
    a. Somaticized as stomach pain, headache, sleep disturbances, changes in eating.
    b. Generally are less fearful than preschoolers, but worry about bodily harm, occasionally about frightening events heard on news kidnapping, violence.
  •  Curiosity increases about bodily functions and sex.
    a. Ideal time for matter-of-fact sex education and information about sexual maturation and reproduction.
    b. Girls need concrete information about menstruation, as age of men arche continues to decline in United States.
  • Neighborhood and friends take on a more important role. Children begin to look outside parents/family for approval.

B. Behavioral development.

  •  Erikson: industry versus inferiority.
  •  Piaget: concrete operations; characterized by conservation age 5–7 and classification skills in later school-age years.
  •  Freud: latency period.

C. Moral development.

  •  Kohlberg: Children interpret accidents or mishaps as punishment for bad behavior.
  •  Called “conventional morality” phase; child views rules for the good of all, and by following the rules, he or she is viewed as a “good” child.

D. Language.

  • Speech becomes progressively more complex, begins to use proper nouns, pronouns, and prepositions. By end of school-age period, has basic mastery of grammar.
  •  Able to write letters by age 6–7.
  • Reading proficiently by 8–9 years.

E. Anticipatory guidance.

  •  Promote healthy habits, encourage regular exercise/physical activity, limit television to 1 hour/day, personal care, and hygiene.
  •  Car seat recommendations.
    a. Children should ride in back seat only until age 13.
    b. Children should stay in a booster seat in rear seat until child reaches about 4 feet 9 inches (114 cm) in height and is 8–12 years of age.
    c. Child is ready to use a lap and shoulder seat belt when belt fits properly.
  •  Bike/skateboard helmets, water safety swimming lessons, sunscreen, protection from assault.
  • Safety rules in home, ensure guns are locked and unloaded, ensure child has supervision before and after school, teach a family “password” to protect from strangers.
  •  Begin smoking, drug, and alcohol education/ avoidance.
  •  Help child learn to get along with peers and conflict resolution promote positive interactions between the child, teachers, peers, and adults.
  • Begin sexuality education; prepare girls for menstruation, boys for development and nocturnal emissions.

F. Nutrition.

  •  Encourage three regular meals and healthy snacks. Avoid fad diets, sugary drinks, and consumption of “junk food.”
  •  Parents should model healthy eating and encourage meals together with family.
  •  Calorie needs decrease relative to body size, need approximately 2000 cal/day and 28 g protein, depending on gender, size, and activity levels (See Choose My Plate.gov).
  •  Monitor for obesity. At risk if BMI for age > 85th percentile.
    a. If present, monitor BP for hypertension, blood glucose (for type 2 diabetes), and lipid profile.
    b. Risk factors are genetics, psychosocial issues, inactivity, and minority and low income family.

c. Dietary counseling, weight loss, and exercise programs aimed at children as young as age 6 have been proven to be effective.

  •  Encourage regular activity/exercise.

G. Play/social development.

  •  Trend toward earlier participation in organized competitive sports. Friends become bigger part of life; focus on group activities. Commonly enjoy model or construction kits, swimming, bicycling, skateboarding, video games, swimming, painting, pottery, card and board games.
  •  Children usually can be responsible for designated household chores with financial compensation allowances.

H. Discipline.

  •  Parents should be encouraged to set limits and establish consequences for bad behavior. Children should be expected to follow family rules for bedtime, TV, and chores.
  • Reasoning works well with school-age children; allow some choices. Children can help problem solve.
  •  Withholding privileges is generally effective disciplinary consequence also contracting and imposing penalties.

Pediatric Nursing: Adolescents (12–18 Years)

Focus topic: Pediatric Nursing

A. General concepts.

  •  Major development is onset of puberty and development of primary and secondary sex characteristics; secretion of estrogen and androgens.
  •  Physical growth marked by the adolescent growth spurt—begins between 9 and 14 years in girls, and 10 and 16 years in boys.
    a. The final 20–25% of height occurs over a 24–36-month period. Amount of growth varies; boys may gain 10–30 cm (3.9-11.8 inches) and 7–30 kg (15.4- 66 lbs); girls gain 5–20 cm (1.96-7.8 inches) and 7–25 kg. (15.4 to 55 lbs).
    b. Growth ceases about 2 years after men arche for girls; at 18–20 years in boys.
  • Physiologic growth in size and strength of muscles, particularly heart, respiratory volume and vital capacity dramatically increase; exercise performance increases dramatically.
  • Parents become less important and influential; peer relationships play major role as adolescents struggle for autonomy and separation from parents.
  •  Experimentation in risky behavior is common sexual activity; alcohol, drug, and cigarette use; other risk taking with automobiles and sporting activities.
  •  Attitudes and values formulated by late adolescence, which will affect future behavior and quality of life.
  •  Stress, depression, and social withdrawal common parents should be aware of alarming symptoms.
  • Adolescents seek some financial independence household chores and allowance often obtain part-time employment.
  •  Physical exam should include screening for human immunodeficiency virus/sexually transmitted diseases (HIV/STDs), scoliosis, blood pressure, weight, hemoglobin (Hbg) and hematocrit (Hct) in girls with heavy menses, weight loss, athletic development; screening for diabetes mellitus and hyperlipidemia if positive family history or BMI for age > 85–95th percentile.

B. Behavioral development.

  •  Erikson: identity versus role diffusion.
  •  Piaget: formal operations, characterized by formal operations.
  •  Freud: genital stage.

C. Moral development.

  • Kohlberg: Adolescents begin to substitute their own set of values and beliefs for parents’; phase of “principled morality based on what is “universally ethical” on basis of own conscience.
  •  Moral conduct is based largely on the desire to avoid the loss of respect of the peer group and a sense of obligation to democratic law.

D. Social development.

  •  Primary task is to separate from parents, reestablish relationship with family based on “mutual affection and equality” rather than parental dominance. Separation often difficult for adolescent and parents; conflict is common.
  • Peer group more important, school important as academic and social focus. Groups important, as are best friends and emergence of heterosexual friendships of varying “seriousness.”
  •  Some adolescents identify as homosexual by late teens; sexual activity encountered by the majority by age 18.

E. Anticipatory guidance.

  •  Immunizations at age 11–12 for both girls and boys: tetanus, diphtheria, pertussis (Tdap), human papillomavirus vaccine (HPV), and the meningococcal vaccine: MCV4 (Menactra or Menveo). A second meningococcal vaccine should be given at age 16 (most current recommendations found at Centers for Disease Control and Prevention (CDC Web site: www.cdc.gov).
  • Becoming responsible for own body and health, establishing healthy activities, avoiding risky behavior.
  • Injury prevention: focusing on automobile safety, water safety, respect for firearms, prevention of substance use/abuse. Use of sunscreen, protective sports gear, and helmet use for bicycles and motorcycles.
  •  If sexually active, protection from HIV, birth control; self-defense and avoidance of potentially abusive relationships/situations.
  •  Mental health issues: stress management, conflict resolution, seeking help if depressed, hopeless, or angry; setting realistic goals; increasing self-confidence; time management for school, friends, family, and employment.
  •  Mental health: Monitor for depression, suicidal thoughts, aggressive behavior, antisocial activity.

F. Nutrition.

  •  High caloric and protein requirements during periods of rapid growth. Protein requirements in males 45–60 g/day (age 11–18), females 44–46 g/day (age 11–18); caloric needs: approximately 2500–3000/day in males (age 11–18) and approximately 2200/day in females (see Choose My Plate.gov).
  •  Menstruating girls need extra iron, especially if physically active. Frequent time for girls to diet observe for continued weight loss.
  •  Adolescents (especially girls) need 1000–
    1300 mg of calcium per day and sufficient
    vitamin D to prevent osteoporosis while bone is being formed during period of rapid growth.

G. Sleep and activity.

  • Sleep needs are variable many teens have propensity for staying up late at night, sleeping late in morning whenever possible.
  •  Regular patterns of exercise should become established during adolescence and maintained into adulthood.

FURTHER READING/STUDY:

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