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C H A P T E R 1 8 Growth, Development, and Stages of Life: From Saunders Comprehensive Review for the NCLEX-RN Examination 8th Edition. (Available: https://bit.ly/2HeJuMt ). Contains Practice questions and Answers with the Rationale, Test-Taking Strategy, Level of Cognitive Ability, Client Needs, Integrated Process, Content Area, Health Problem, Priority Concepts and References

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Priority Concepts Development, Family Dynamics I. The Hospitalized Infant and Toddler A. Separation anxiety 1. Protest a. Crying, screaming, searching for a parent; avoidance and rejection of c... ontact with strangers b. Verbal attacks on others c. Physical fighting: Kicking, biting, hitting, pinching 2. Despair a. Withdrawn, depressed, uninterested in the environment b. Loss of newly learned skills 3. Detachment a. Detachment is uncommon and occurs only after lengthy separations from the parent. b. Superficially, the toddler appears to have adjusted to the loss. c. During the detachment phase, the toddler again becomes more interested in the environment, plays with others, and seems to form new relationships; this behavior is a form of resignation and is not a sign of contentment. d. The toddler detaches from the parent in an effort to escape the emotional pain of desiring the parent’s presence. e. During the detachment phase, the toddler copes by forming shallow relationships with others, becoming 546increasingly self-centered, and attaching primary importance to material objects. f. Detachment is the most serious phase because reversal of the potential adverse effects is less likely to occur once detachment is established. g. In most situations, the temporary separation imposed by hospitalization does not cause such prolonged parental absence that the toddler enters into detachment. B. Fear of injury and pain: Affected by previous experiences, separation from parents, and preparation for the experience C. Loss of control 1. Hospitalization, with its own set of rituals and routines, can severely disrupt the life of a toddler. 2. The lack of control often is exhibited in behaviors related to feeding, toileting, playing, and bedtime. 3. The toddler may demonstrate regression. D. Interventions 1. Provide cuddling and touch and talk softly to the infant. 2. Provide opportunities for sucking and oral stimulation for the infant, using a pacifier if the infant is NPO (nothing by mouth). 3. Provide stimulation, if appropriate, for the infant, using objects of contrasting colors and textures. 4. Provide choices as much as possible to the toddler to enable him or her to have some control. 5. Approach the toddler with a positive attitude. 6. Allow the toddler to express feelings of protest. 7. Encourage the toddler to talk about parents or others in their lives. 8. Accept regressive behavior without ridiculing the toddler. 9. Provide the toddler with favorite and comforting objects. 10. Utilize play therapy for the toddler. 11. Allow the toddler as much mobility as possible. 12. Anticipate temper tantrums from the toddler and maintain a safe environment for physical acting out. 13. Employ pain reduction techniques, as appropriate. For the hospitalized toddler, provide routines and rituals as 547close as possible to what he or she is used to at home. II. The Hospitalized Preschooler A. Separation anxiety 1. Separation anxiety is generally less obvious and less serious than in the toddler. 2. As stress increases, the preschooler’s ability to separate from the parents decreases. 3. Protest a. Protest is less direct and aggressive than in the toddler. b. The preschooler may displace feelings onto others. 4. Despair a. The preschooler reacts in a manner similar to that of the toddler. b. The preschooler is quietly withdrawn, depressed, and uninterested in the environment. c. The child exhibits loss of newly learned skills. d. The preschooler becomes generally uncooperative, refusing to eat or take medication. e. The preschooler repeatedly asks when the parents will be visiting. 5. Detachment: Similar to the toddler B. Fear of injury and pain 1. The preschooler has a general lack of understanding of body integrity. 2. The child fears invasive procedures and mutilation. 3. The child imagines things to be much worse than they are. 4. Preschoolers believe that they are ill because of something they did or thought. C. Loss of control 1. The preschooler likes familiar routines and rituals and may show regression if not allowed to maintain some control. 2. Preschoolers’ egocentric and magical thinking limits their ability to understand events, because they view all experiences from their own self-referenced (egocentric) perspective. 3. The child has attained a good deal of independence and self-care at home and may expect that to continue in the hospital. D. Interventions 5481. Provide a safe and secure environment. 2. Take time for communication. 3. Allow the preschooler to express anger. 4. Acknowledge fears and anxieties. 5. Accept regressive behavior; assist the preschooler in moving from regressive to appropriate behaviors according to age. 6. Encourage rooming-in or leaving a favorite toy. 7. Allow mobility and provide play and diversional activities. 8. Place the preschooler with other children of the same age if possible. 9. Encourage the preschooler to be independent. 10. Explain procedures simply, on the preschooler’s level. 11. Avoid intrusive procedures when possible. 12. Allow the wearing of underpants. III. The Hospitalized School-Age Child A. Separation anxiety 1. The school-age child is accustomed to periods of separation from the parents, but as stressors are added, the separation becomes more difficult. 2. The child is more concerned with missing school and the fear that friends will forget her or him. 3. Usually, the stages of behavior of protest, despair, and detachment do not occur with school-age children. B. Fear of injury and pain 1. The school-age child fears bodily injury and pain. 2. The child fears illness itself, disability, death, and intrusive procedures in genital areas. 3. The child is uncomfortable with any type of sexual examination. 4. The child groans or whines, holds rigidly still, and communicates about pain. C. Loss of control 1. The child is usually highly social, independent, and involved with activities. 2. The child seeks information and asks relevant questions about tests and procedures and the illness. 3. The child associates his or her actions with the cause of the illness. 4. The child may feel helpless and dependent if physical limitations occur. D. Interventions 1. Encourage rooming-in. 2. Focus on the school-age child’s abilities and needs. 5493. Encourage the school-age child to become involved with his or her own care. 4. Accept regression but encourage independence. 5. Provide choices to the school-age child. 6. Allow expression of feelings verbally and nonverbally. 7. Acknowledge fears and concerns and allow for discussion. 8. Explain all procedures, using body diagrams or outlines. 9. Provide privacy. 10. Avoid intrusive procedures if possible. 11. Allow the school-age child to wear underpants. 12. Involve the school-age child in activities appropriate to the developmental level and illness. 13. Encourage the school-age child to contact friends. 14. Provide for educational needs. 15. Use appropriate interventions to relieve pain. IV. The Hospitalized Adolescent A. Separation anxiety 1. Adolescents are not sure whether they want their parents with them when they are hospitalized. 2. Adolescents become upset if friends go on with their lives, excluding them. For the hospitalized adolescent, separation from friends is a source of anxiety. B. Fear of injury and pain 1. Adolescents fear being different from others and their peers. 2. Adolescents may give the impression that they are not afraid, even though they are terrified. 3. Adolescents become guarded when any areas related to sexual development are examined. C. Loss of control 1. Behaviors exhibited include anger, withdrawal, and uncooperativeness. 2. Adolescents seek help and then reject it. D. Interventions 1. Encourage questions about appearance and effects of the illness on the future. 2. Explore feelings about the hospital and the significance that the illness might have for relationships. 3. Encourage adolescents to wear their own clothes and 550carry out normal grooming activities. 4. Allow favorite foods to be brought into the hospital if possible. 5. Provide privacy. 6. Use body diagrams to prepare for procedures. 7. Introduce them to other adolescents in the nursing unit if appropriate and possible. 8. Encourage maintaining contact with peer groups. 9. Provide for educational needs. 10. Identify formation of future plans. 11. Help develop positive coping mechanisms. V. Communication Approaches A. General guidelines (Box 18-1) B. Infant 1. Infants respond to nonverbal communication behaviors of adults, such as holding, rocking, patting, cuddling, and touching. 2. Use a slow approach and allow the infant to get to know the nurse. 3. Use a calm, soft, soothing voice. 4. Be responsive to cries. 5. Talk and read to infants. 6. Allow security objects such as blankets and pacifiers if the infant has them. C. Toddler 1. Approach the toddler cautiously. 2. Remember that toddlers accept the verbal communications of others literally. 3. Learn the toddler’s words for common items and use them in conversations. 4. Use short, concrete terms. 5. Prepare the toddler for procedures immediately before the event. 6. Repeat explanations and descriptions. 7. Use play for demonstrations. 8. Use visual aids such as picture books, puppets, and dolls. 9. Allow the toddler to handle the equipment or instruments; explain what the equipment or instrument does and how it feels. 10. Encourage the use of comfort objects. D. Preschooler 1. Seek opportunities to offer choices. 2. Speak in simple sentences. 3. Be concise and limit the length of explanations. 5514. Allow asking questions. 5. Describe procedures as they are about to be performed. 6. Use play to explain procedures and activities. 7. Allow handling of equipment or instruments, which will ease fear and help to answer questions. E. School-age child 1. Establish limits. 2. Provide reassurance to help in alleviating fears and anxieties. 3. Engage in conversations that encourage thinking. 4. Use medical play techniques. 5. Use photographs, books, dolls, and videos to explain procedures. 6. Explain in clear terms. 7. Allow time for composure and privacy. F. Adolescent 1. Remember that the adolescent may be preoccupied with body image. 2. Encourage and support independence. 3. Provide privacy. 4. Use photographs, books, and videos to explain procedures. 5. Engage in conversations about the adolescent’s interests. 6. Avoid becoming too abstract, too detailed, and too technical. 7. Avoid responding by prying, confronting, condescending, or expressing judgmental attitudes. VI. Car Safety Seats and Guidelines A. The safest place for all children to ride, regardless of age, is in the back seat of the car. B. Lock the car doors; 4-door cars should be equipped with child safety locks on the back doors. C. There are different types of car safety seats, and the manufacturer’s guidelines need to be followed. D. For specific information regarding car safety, refer to Car seats: information for families (copyright © 2018 American Academy of Pediatrics), found at https://www.healthychildren.org/English/safety-prevention/onthe-go/Pages/Car-Safety-Seats-Information-for-Families.aspx VII. Preventive Pediatric Health Care A. The American Academy of Pediatrics (AAP) and Bright Futures have developed guidelines regarding the recommended ages children should receive certain assessments and screenings. See Box 18-2 for more information regarding the recommended types of assessments and screenings and see Box 18-3 for the suggested 552timeline for preventive services, also known as well-child checks. For detailed information on these screenings and the timeline, access the following links: B. Well-checks are important in promoting health early in childhood and preventing diseases later in life. Childhood obesity, type 2 diabetes mellitus, and hyperlipidemia are noted to have an increased incidence in recent years. See Chapters 32 and 36 for more information on these problems. https://brightfutures.aap.org/Pages/default.aspxhttps://www.aap.org/enus/Documents/periodicity_schedule.pdf VIII. Immunizations A. Guidelines (see Priority Nursing Actions) Priority Nursing Actions Administering a Parenteral Vaccine 1. Verify the prescription for the vaccine. 2. Obtain an immunization history from the parents and assess for allergies. 3. Provide information to the parents about the vaccine. 4. Obtain parental consent. 5. Check the lot number and expiration date and prepare the injection. 6. Select the appropriate site for administration. 7. Administer the vaccine. 8. Document the administration and site of administration and lot number and expiration date of the vaccine. 9. Provide a vaccination record to the parents. Reference Hockenberry. Wilson, Rodgers. 2017;151–169. 1. Immunizations are an important aspect of health promotion during childhood. 2. In the United States, the recommended age for beginning primary immunizations of infants is at birth. 3. Children who began primary immunizations at the recommended age but failed to receive all required doses do not need to begin the series again; they need to receive only the missed doses. 4. If there is suspicion that the parent will not bring the child to the pediatrician or health care clinic for follow-up immunizations according to the optimal immunization schedule, any of the recommended vaccines can be administered simultaneously. B. General contraindications and precautions 1. A vaccine is contraindicated if the child experienced 553an anaphylactic reaction to a previously administered vaccine or a component in the vaccine. 2. Live virus vaccines generally are not administered to individuals with severely deficient immune systems, individuals with a severe sensitivity to gelatin, or pregnant women. 3. A vaccine is administered with caution to an individual with a moderate or severe acute illness, with or without fever. 4. See Section IX, Recommended Childhood and Adolescent Immunizations, for specific information for each type of vaccine. C. Guidelines for administration (Box 18-4) Children born preterm should receive the full dose of each vaccine at the appropriate chronological age. IX. Recommended Childhood and Adolescent Immunizations (Box 18-5) A. For the most up-to-date information, refer to Centers for Disease Control and Prevention (CDC) Web site: http://www.cdc.gov/vaccines/schedules/index.html. B. Hepatitis B vaccine (HepB) 1. Administered by the intramuscular route 2. Contraindications: Severe allergic reaction to previous dose or vaccine component (components include aluminum hydroxide, yeast protein) 3. Precautions: An infant weighing less than 2000 g or an infant with moderate or severe acute illness with or without fever 4. HBsAg (hepatitis B surface antigen)-positive mothers a. Infant should receive HepB vaccine and hepatitis B immunoglobulin (HBIG) within 12 hours of birth. b. Infant should be tested for HBsAg and antibody to HBsAg after completion of HepB series (9 to 18 months of age). 5. Mother whose HBsAg status is unknown a. Infant should receive the first dose of hepatitis vaccine series within 12 hours of birth. b. Maternal blood should be drawn as soon as possible to determine the mother’s HBsAg status. c. If the mother’s HBsAg test result is positive, the infant should receive HBIG as soon as possible (no later than 1 week of age). 554C. Rotavirus vaccine (RV) 1. Rotavirus is a cause of serious gastroenteritis and is a nosocomial (hospital-acquired) pathogen that is most severe in children 3 to 24 months of age; children younger than 3 months have some protection because of maternally acquired antibodies. 2. Vaccines are available and are administered by the oral route because the vaccine must replicate in the infant’s gut. 3. Vaccine may be withheld if an infant is experiencing severe vomiting and diarrhea; it is administered as soon as the infant recovers. D. Diphtheria, tetanus, acellular pertussis (DTaP); tetanus toxoid; reduced diphtheria toxoid and acellular pertussis vaccine (Tdap adolescent preparation) 1. Administered by intramuscular route 2. The Tdap (adolescent preparation) is recommended at 11 to 12 years of age for children who have completed the recommended childhood DTaP series but have not received a tetanus and diphtheria toxoid (Td) booster dose; children 13 to 18 years old who have not received Tdap should receive a dose. 3. Td does not provide protection against pertussis; Td is used as a booster every 10 years after Tdap is administered at 11 to 18 years of age. 4. Encephalopathy is a complication. 5. Contraindications: Encephalopathy within 7 days of a previous dose or a severe allergic reaction to a previous dose or to a vaccine component E. Haemophilus influenzae type b (Hib) conjugate vaccine (Hib) 1. Protects against numerous serious infections caused by H. influenzae type b, such as bacterial meningitis, epiglottitis, bacterial pneumonia, septic arthritis, and sepsis 2. Administered by the intramuscular route 3. Contraindications: Severe allergic reaction to a previous dose or vaccine component F. Influenza vaccine: Vaccine is recommended annually for children beginning at age 6 months. G. Inactivated poliovirus vaccine (IPV) 1. IPV is administered by the subcutaneous route (it may also be given by the intramuscular route). 2. Contraindications: Severe allergic reaction to a previous dose or vaccine component; components may include formalin, neomycin, streptomycin, or polymyxin B H. Measles, mumps, rubella (MMR) vaccine 1. Vaccine is administered by the subcutaneous route. [Show More]

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