Developmental Assessment Of Hospitalized Child

Developmental Assessment of Hospitalized Child Mike Cowell NSG 315 National University

Introduction Developmental assessment of a pediatric patient is essential in providing quality patient care. Providing developmentally appropriate care is the framework of pediatric nursing. Psychosocial, cognitive, and gross/fine motor development all grow and change simultaneously throughout life. Stimulation and interaction with the environment allows a child’s developmental process to take place (Ball & Binder, 2008). “They learn skills at different ages, but the order in which they learn them is universal” (Ball & Binder,2008, p. 59). Pediatric nurses must be knowledgeable in all psychosocial, cognitive, and fine/gross motor developmental stages. Nurses use these developmental stages as a reference point when implementing the plan of care for particular age groups. This reference allows nurses to assess and monitor whether a particular patient is making the developmental progress appropriate for their age group. Not only can nurses use the developmental stages as a reference point, but they can also use them as a guideline in the planning of care. Before meeting patients, nurses can already have a guideline, or concept, of where a patient is in their developmental growth. This allows nurses to plan and implement care that is appropriate for a particular patients developmental level. “During each of the stages, certain issues are dominant and consume more of the individual’s attention and energy. The stages are not precisely distinct; transitions occur and overlap exists between stages” (Jarvis, 2008). It is important for nurses to connect with each patient, but keep in mind that each patient connects in their own way. It is up to the nursing staff to plan and implement care accordingly to each patients unique developmental level and individual personality.

Identifying Data:

E.K. is a 5 year 9 month old female. Upon entering her room for the first time, E.K. appeared calm and cooperative. Patient was resting in bed, with her mother present bedside. E.K. was diagnosed with ulcerative colitis in 2004, and has had 5 previous admissions. She did well after the first treatment in 2005 with prolonged remission. Mother brought E.K. to the ED because she has had severe diarrhea and mother noticed blood present with bowel movements. BP 90/60, Pulse 80, Resp. 24, Temp. 36.8 C, O2 Sat. 98 (RA), Pain is 6/10 before and after bowel movements, resting pain is 0/10. A&O x 3. PERRLA. Skin is pink, dry and intact. Mucous membranes pink and moist. Extremities are warm to touch, with no edema present. Cap refill brisk. Peripheral pulses palpable and equal bilaterally.S1 and S2 present, no gallops, rubs , or murmurs. Breath sounds clear and equal bilaterally, no adventitious sounds. Full ROM in all extremities, and active in play. Reported slight pain upon urination. Bowel sounds hypoactive in all four quadrants. Abdomen soft/non-distended. Pain upon palpation below umbilicus. Diarrhea reported and observed with blood present. E.K. is having 5-7 bowel movements per day. Character of bowel movements is consistent with diarrhea, and no abnormal odor noted . Patients weight is 19.7 kg. Diet is clear liquids with a maximum of 2oz/2hr. TPN and lipids at 1500 ml Q 20hr. PICC line inserted , site free from edema and redness. I.D. band checked. Call light within reach, and bed rails up. Mother present at bedside. Psychosocial Development: Erikson’s expected stage of development for E.K. is the initiative vs guilt stage. During this stage children use initiative in developing their ego. “ With increasing locomotor and mental power, the child now has an energy surplus, resulting in determination and enterprise” (Jarvis, 2008). Children typically explore their environment and experiment with new tasks. When parents support this new found initiative, children can learn to be self sufficient, assertive, and it can

give them direction and purpose (Jarvis, 2008). However, when the parent(s) prohibit the child from using their initiative to accomplish new task, the child can feel guilty. This feeling of guilt can linger and have a negative impact on a child’s self esteem. “ By nurturing success and promoting a healthy self-image, the parents help the preschooler develop self-esteem” (Jarvis,2008). E.K. was observed performing task that fit the initiative vs guilt stage. She would take initiative in measuring out her ml’s of Ensure and ice chips. She wanted to always do the measuring herself, and her mother encouraged her to do it every time. It was easy to see that she had fun doing it and it gave her a sense of accomplishment. E.K. liked to take initiative when it came to her own care, she would always warm her hot-pack after a bowel movement to help alleviate some of the pain. Although at first shy, E.K. was quickly converted into a question machine. She would want to know what the nurses were doing, if there was anything she could do to help, and was always ready to go to the activities room right when it opened. There was no major impact of illness and/or hospitalization, or maladaptive behaviors, E.K. had a good attitude and appeared happy. Encouraging developmental progression after discharge can be obtained by educating patients mother. First it is important to teach that rules should only be used to enforce undesirable behavior. Parents must allow E.K. to explore environment, and encourage/praise her when she is attempting new task. Mother should spend time interacting with daughter, and allow E.K. to interact positively with others her age. E.K.’s parents should also encourage and reward any positive behavior that shows initiative, such as picking up her bedroom or clearing the table after dinner(Ball & Binder, 2008). In the hospital it will be important for staff to have a positive attitude towards E.K. and encourage her curiosity. Cognitive Development:

Piaget’s preoperational stage is the expected developmental stage during the ages of 2 to 7 years old. Children in this stage are egocentric, meaning they do not see other peoples points of view, and they believe that everyone else has the same views as they do. This stage is “characterized by symbolic function, because the child uses symbols and words to represent people, objects, and events” (Jarvis,2008). During this stage, language develops and children express themselves more vocally. “Children’s symbolic play behavior corresponds to their cognitive abilities and usually centers on imagined patterns and relationships and serves many functions in child development” (Dougherty & Ray, 2007). E.K. displayed the use of delayed imitation. Delayed imitation occurs when a child observes something and then later reenacts the event. E.K. had a teddy bear that she would “give” medications to. She taped a port to the teddy bears arm, and would pretend she was giving the bear medicine through an IV push. She knew how to connect and disconnect the NS flush from the port, and would tell the bear that it wouldn’t hurt. She was pretending to be a veterinarian, and told me this was her office. Together, we pretended that the teddy bear was sick, and once it had medicine it would be happy.We used different scenarios with the bear, and E.K. seemed to enjoy role playing. It was difficult to identify the impact of illness and/or hospitalization and maladaptive behaviors in E.K. The only observation made was that E.K. would get anxiety when mother was out of sight. Her mother stated she had not left the hospital since her admission because E.K. would get upset. New interventions to promote cognitive tasks would include giving her toys that promote cognitive development, both while she is hospitalized and also educating her mother on age appropriate toys. Other interventions include frequently talking with E.K., allowing her to express her feelings/point of view, and truthfully answering any

questions she may have. Encourage her to draw pictures and enjoy arts and crafts, these activities encourage development. Promote activities that involve exploring, investigating, and stretching her imagination. Gross and Fine Motor Development: E.K. appeared to have age appropriate skills. Using the Denver assessment tool, and observation, E.K. proved her fine motor skills by using spoon and fork, drawing person with 6 parts, wiggling her thumb, copying square, letters, numbers. She also demonstrated the ability to make paper flowers with paper, scissors, and glue. Other fine motor achievements includes the ability to put on her clothes, and brush her teeth. E.K. is unable to tie her shoes. Gross motor skills tested with Denver and observed while hospitalized include ability to balance on each foot for six seconds, heel-to-toe walk, hop, throw ball overhand, kick ball forward. Mother reports E.K. rides bicycle with training wheels at home. Gross motor skills appear appropriate for the age of 5, and there is no need for concern. Play or other age appropriate interventions to promote gross and fine motor skills include encouragement for E.K. to write, drawing, play musical instruments, play board games, arts and crafts, biking on two wheeler, swimming, running, jump rope. Obviously, play activities during hospitalization are important for the nurse to encourage gross and fine motor development. This activities could include making sure E.K. gets adequate exercise, playing board game, craft projects, drawing, writing, puzzles, and helping her practice tying her shoes. Safety issues for this age group include car accidents, car/pedestrian accidents, improper use of safety gear, and drowning. By now E.K. is not using a booster seat in the car. Mother needs to make sure E.K. understands the importance of safety belts and mom

must also teach E.K. about correct use of belt. Parents need to teach E.K. that she should not be playing anywhere near a road, and when she does go near a road she needs to be taught proper way of looking out for traffic. E.K. needs to be taught importance of correctly using bicycle helmet and how to correctly put on helmet. If E.K. enjoys swimming she might think it is alright to go into a lake or pool when no one is around, this is not acceptable. Parents need to be insistent to their children that these actions are never permitted. Social Development: E.K.’s temperament appears easy, her attitude is positive, and doesn’t get upset easily. Her social and interpersonal skills seem adequate for her age.. She acknowledges staff and family that enter her room, she likes to interact and talk about herself with other people, and she enjoys asking questions. She does play well with other children in the activities room, and never plays games by herself. She enjoys playing games and drawing with others around her. She does seem to focus on herself most of the time, but at her age children are egocentric. Interventions for social and interpersonal skills include play time with E.K., and making sure there is plenty of interaction with nursing staff and possibly other children in the play room. Giving E.K. time to ask questions, and allowing her to fully explain any thoughts she has. Also, encourage the friends and family to visit to promote interaction. Conclusion: It is obvious to see the importance of assessing the developmental milestones E.K. has reached. Understanding psychosocial, cognitive, and gross/fine motor development allows nurses to understand the whole patient. Understanding milestones and achievements that should have taken place allow the nursing staff to incorporate a plan of care that caters to a particular child. Pediatric nurse must be able to assess and recognize if a patient is progressing.

If children are not reaching age appropriate developmental levels, then nurses must use interventions to help progression. The developmental assessment of a hospitalized child was very interesting. The larger picture of nursing tells pediatric nurses to treat the whole child, not just the illness they are hospitalized for.

References Ball, J. & Binder, R. (2008). Pediatric Nursing Care for Children (4th ed.). New Jersey: Pearson Prentice Hall. Dougherty, J. & Ray, D. (2007). Differential Impact of Play Therapy on Developmental Levels of Children. International Journal of Play Therapy, 16(1), 2-19. Retrieved August 22, 2008 from Proquest database. Ignatavicius, D. & Workman, M. (2006). Medical-Surgical Nursing (5th ed.). St. Louis, MO: Saunders Elsevier. Jarvis, C. (2008). Physical Examination & Health Assessment (5th ed.). St. Louis, MO: Saunders Elsevier.