Erikson: Trust vs Mistrust

Piaget: Sensorimotor (substage 1-5)

Infant 0-12 mo

(in hospitalized infant)

• Physical needs: hunger, comfort, warmth
• Safety: sensorimotor, activity level, mobility, hand-mouth activity, food selections, curious
• Communication: voice tone, play, parent present (do not want overstimulation)
• Fears: stranger anxiety
• Coping: parent, familiar adult, rocking, stroking, distraction
• Cognitive status: shows joy, anger, frustration

• examine in parents arms/lap
• VS, ab while quiet/sleeping
• delay examine head & mouth
• quiet voice, dont elicit startle reflex, unhurried motions
• distraction if crying
• not subtle s/s of distress, discomfort
• eye contact
• decrease painful procedures, comfort after
• support caregivers, and respect in presence

Erikson: Autonomy vs. Shame and Doubt

Piaget: Sensorimotor - Preoperational Stage

TODDLER 18mo-3yr (hospitalized)

• Safety: toy, play, equipment, water
• Communication: literal interpretation of words(less expressive language)
• Fears: separation anxiety peaks 18mo, active imagination
• Coping: protest, temper tantrum, regression, transitional object (teddy)

• introduce self, explain what will do
• allow movement
• parent available for support
• VS, ab while quiet
• Head, mouth last
• Incorporate play
• allow to hold equip
• praise cooperative behavior
• observe nonverbal s/s of distress
• provide home routin, independence
• how toddler is comforted
• provide choices

Erikson: Initiative vs. Guilt

Piaget: Preoperational Stage (preconceptual - intuitive stage)

EARLY CHILDHOOD 3-5yr (hospitalized)(preschool)

• safety: self care, play
• Communication: preop thinking, magical thinking, sense of imminent justick, asks questions to learn
• Fears: bodily harm (put bandaid on), separation
• Coping: activity, rituals, regression, attack, ask questions, dramatic play

egocentric, no good concept of time

• may willing to sit on exam/bed while parent holding/nearby
• may unwilling to completely undress
• Vs, ab first, may tolerate head next, genitals last
• Use simple explanations
• allow to "help" by holding steth, encourage involvemnt (initiative)
• inform who is caring,who to call for help
• make convo ab current tv, etc
• emphasive treatments are NOT punishment, explain reason
• explore preconception/understandings of illness/treatment

Erikson: Initiative vs. Guilt (industry vs inferiority)

Piaget: Preop stage (intuitive stage)

MIDDLE CHILDHOOD 5-8 yr

• Safety: bike, pedestrian, sports
• Comm: logical thinkers and use verbal exchange to understand events, hesitant to share feelings
• Fears: multiple, loss of control, unjury/pain
• Coping: aggression, withdrawal, projection, ritual, humor

Erikson: Industry vs Inferiority

Piaget: Concrete Operations

LATE CHILDHOOD 8-12yr

• Safety: activities/equipment, sports
• comm: more advanced cognitvely
• Fears: loosing status, not having friends, not doing well in school, disappointing parents
• Coping: control, bossy, practice, self-critical

• simple explanations of how equip works, why things
• colorful equip help coop
• respect desire to avoid pain, insult
• teach, visual aids, stories (reduce fear)
• humor, jokes to enhance coping
• drawing, journaling (creative expression)
• encourage contact w/ friends, introduce to peers on unit
• encourage schoolwork asap

Erikson: Identity vs Role Confusion

Piaget: Formal operation

ADOLESCENCE (EARLY, MIDDLE, LATE)

• Safety: personal safety, risky behaviors
• comm: adult vocab, cognitive conceit, abstract thinking, solves verbal and mental problems
• Fears: body image, being different, separation from peers
• Coping: imaginary audience, intellectualization, rationalization, denial

• PRIVACY
• approach w/ respect
• use/explain proper terminology
• avoid cutesy childlike equip when possible
• uninterrupted teaching/responses
• involvement in decisions
• creative means of expression
• encourage discussion, not lecture
• place topics in perspective (other teens said they are worried about X)

~do not promise confidentiality if you cant deep

~do not give number/email/fb

Preop: psychosocial and physical prep

Postop: Psychological care

Physcial care = VITAL SIGNS 1st, loc, monitor resp distress, fluid loss/balance, pain

• tightly shut eyes
• furrowed brow
• "squarish" mouth
• cupped tongue
• pitch is diff cry

• relate to pain as physical experience
• hold somone/thing accountable for pain (don't understand the physiology)
• fear loss of/change to body integrity (insides will be sucked out if hole)
• magical disappearance of pain (don't understand that tylenol helps)
• more likely to strike out physically/verbally when hurt
• "boo-boo" "owie" (include in NA)
• cry/scream is combo of fear/pain
• bandaids for scrapes (afraid body is coming apart)
• can tell generally where pain is but not point
• can start to describe level of pain

• able to specify location of pain
• fear of bodily harm is strong
• injury-related guilt high
• respond well to activities that aid in controlling pain
• has understanding of cause and effect (take this and will make feel better)
• Pain = punishment

• able to grasph IF..THEN
• response r/t level of anxiety
• responses may not always honest - project "brave" selfimage (charlie brown)
• can describe precise description of pain amd compare
• describes intensity and location
• requests pain relief, good concept of time and use of coping strategies
• communicates effectiveness of relief measures

• can problem solve at advanced level but lacks experience
• fears "loosing face"
• hesistant to express feelings of pain
• privacy is key to coping
• seeks info
• wants to be in control, may resist relax strategies (you can be in control of your pain by...)
• Queit & sullen, moody, irritable and uncooperative
• demanding
• asks multiple questions ab detail - to keep nurse by w/o admitting

~used in infants

~highest = 10

F-face

L-legs

A-activity

C-cry

C-consolability

• modify environmental stimuli
• positioning (comfort)
• touch (soothing)
• heat
• pacifier/sucrose (painful procedures)
• distraction (singing, mobile, rocking)

• monitor carefulling for resp depression
• VS q 15 min till fully conscious
• resus equip ready
• can be aroused still, should respond to physical stimuli
• uses: cardiac caths, burn dressings, MRI/CAT scans
• morphine

• newborn has more ECF (easier to lose fluid b/c not in cell)
• child & adult has more ICF
• do not produce tears under 6 wks
• lose fluids thru GI tract more easily - prone to diarrhea
• less prone for absorption in GI - wet stools
• dont concentrate urine as well
• normal urine output = 1-2ml/kg/hr

• gen app: initial impression level of distress, listless eyes dull, face expressionless
• skin: dry, pale, ft/hands cool, quality of skin turgor, absence of tears, sunken eyeballs, cap refill > 3sec, look sick, fontanel sunken, groin and lower ab good to assess skin & turgor, also check tinting
• neuromuscular: LOC, quality of cry(not as high), seizures, lethargy, change in muscle tone
• Cardiovascular: pulse rate, quality, rhythm, change in BP (is a late sign)
  
• Resp: rate, quality: deep or shallow
• Gastro: ab distension, peristaltic waves
• Renal: change in output, freq, amt, sp gravity
• Weight change: very sensitive indicator
• Lab values: hydration status effect on normal values, renal function

• Na and water loss or gain proportional
• ICF & ECF losses are equal - hypovolemic shock
• Causes: vomiting/diarrhea
• Treatment: give 1/2 of daily require w/in 8 hrs, second half over next 16 hrs
• Ensure urine output adequate prior to adding K - want to know kidneys are working, dont want cardiac irregularities

• Loss of Na is greater than loss of water (water retention)
• serum NA < 130
• fluid loss from ECF so will alter systemic perfusion quicker - risk for hypovolemic shock and cerebral edema
• Causes: inappropriate IVF or oral (diluted formula), gastroenteritis, unreplaced gastric suction, diuretics, SIADH

• excess salt na > 150
• risk for seizures, cerebral hemorrhage
• Causes: vomiting, watery diarrhea, insensible fluid loss (heat stroke, prolonged fever), DI, major burns
• S/S: extreme thirst, low grade fever, very dry, sticky tongue/oral mucosa, lethargy progressing to coma, hyperactive deep tendon reflexes, doughy skin turgor
• Treatment: Give NS til norm VS, then D5/0.45NS and monitor elect closely
• na down slowly - or cerebral edema or hemorrhage

~Imbalance: H2CO3 carbonic acid excess, CO2 is retained and pH decreases

~Causes:diarrhea stool (contain a lot of bicarbonate), hypovolemia, diabetic ketoacidosis, inborn errors of metabolism

~Worsened by: 1) increased acid production from protein and fat during starvation (ketosis), 2) decreased renal acid excretion caused by reduction in renal perfusion, 3) shock induced lactic acidosis

~Causes: Loss of HCl acid (vomit, NG, excessive antacids w/ calcium carbonate diuretics

~S/S of dehydration, muscular changes

~Rentention of CO2 & a decrease in pH CO2 causes vasodilation

~Causes: 

• alveolar hypoventilation
• depression of resp drive or ventilation
• asthma
• pneumonia
• bronciolitis
• tumors
• muscular dystrophy
• opiates/barbiturates, alcohol

Alveolar hyperventilation

anxiety

ingestions

loss of CO2

tachypnea and hyperventilation are NOT the same...refer to depth and empty alveoli levels