Infant (birth to 1 year)

Freud : Oral Stage

The baby obtains pleasure and comfort through the mouth

When a baby is not able to take foods or fluids, offer a pacifier if not contraindicated . After painful procedures, offer a baby bottle or pacifier or have the mother breastfeed

6 moths

No understanding of pain; responsive to parental anxiety

Generalized body movements, chin quivering. Facial grimacing, poor feeding

Cries

3-4 months Babbles speech like sounds, including p,b,m Erikson: Trust vs mistrust stage

Baby establishes a sense of trust when basic needs are met.

Hold hospitalized baby often. Offer comfort after painful procedures. Meet the babys needs for food and hygiene. Encourage parents to move in. Manage pain effectively with use of pain meds & other measures

6-12 months

Has pain memory; is responsive to parental anxiety

Reflex withdrawal to stimulus, facial grimacing, disturbed sleep, irritability, restlessness

Cries

12months 1-2 words mama dada byebye

The baby learns from movement and sensory input

Use crib mobiles, manipulative toys, wall murals, and bright colors to provide interesting stimuli and comfort. Use toys to distract baby during procedure and assessment

Transfer objects between hands Thumb finger grasp

12 months

5-6 months

Piaget:Sensorim otor stage 8 months

Stand without support briefly

Toddler (1-3 years)

Freud: Anal Stage

The child derives gratification from control over body secretions

Ask about toilet training and the childs rituals and words for elimination during admission history. Continue childs normal patterns of elimination in the hospital Do not begin toilet training during illness and hospitalization. Accept regression in toilet during illness and hospitalization. Have potty chairs available in hospital and childcare centers

1-3 years

Does not understand what causes pain and why they might be experiencing it

1-2 years increase words each month, 2 word combination s where baby want cookie The child is increasingly independent in many spheres of life

Localized withdrawal, resistance of entire body, aggressive behavior, disturbed sleep

Cries and scream, cannot describe intensity or type of pain. Use common words such as owie and boo-boo

Walks alone well 15 months Builds 2 block towers 15 months Walks backwards 2 years Thumb finger grasp, feeds self, scribbles w/ Balances 1 foot

Allow self-feeding opportunities Encourage child to remove and put own clothes, brush teeth or assist with hygiene.

2-3 years

Erikson: Autonomy vs

2-3 word sentences, to ask for things or talk about things, large vocabulary, speech understood by family members

shame and doubt stage

If immobilization is necessary, proceed quickly, providing explanations and comfort

18 months

crayon or pencil, builds 4 block tower

3 years

momentarily

Piaget: Sensorimotor stage (end) Preoperational (beginning)

The child shows increasing curiosity and explorative behavior. Language Skills improve

Ensure safe surroundings to allow opportunities to manipulate objects. Name objects and give simple explanations

Preschooler (3-6 years ) 3-4 years sentences may have 4 or more words, speech understood by most people

Freud: Phallic stage

The child initially identifies with the parent of the opposite sex but by the end of this stage identifies with the same-sex parent

Be alert for children who appear more comfortable with male or female nurses, and attempt to accommodate them

3-6 years (preoperatio nal)

Pain is hurt Does not relate pain to illness; may relate to pain to an injury. Often believes pain is punishment. Unable to understand why a painful procedure will help them to feel better or why an injection takes the pain away

Active physical resistance, directed aggressive behavior, strikes out physically and verbally when hurt, low frustration level

Has the language skills to express pain on a sensory level Can identify location and intensity of pain, denies pain, may believe his or her pain is obvious to others

The child likes to initiate play activities Encourage parental involvement care. Erikson: Initiative vs guilt Plan for playtime and offer a variety of materials from which to choose . Offer medical equipment for play to lessen anxiety about strange objects. The child is increasingly verbal but has some limitations in thought processes. Causality is often confused, so the child may feel responsible for causing illness. Decisions are based on desire to please others and to avoid punishment Assess childrens concerns as expressed through their drawings. Accept the childs choices and expression of feelings.

4-5 years says most sounds correctly except few like, l,s,r,v,z,ch,sh ,th tells stories and grammar same as rest of the family 4-7 years old

Offer explanations about all procedures and treatments. Clearly explain that the child is not responsible for causing an illness in self or family members.

Piaget: Preoperational stage

Kohlberg: Preconventional

School age (6-12 years)

Freud: Latency Stage

The child places importance on privacy and understanding the body

Provide gowns, cover and underwear

7-9 years (concrete operation)

Does not understand the cause of pain, but understand simple relationships about pain and disease. Understands the need for painful procedures to monitor or treat disease. May associate pain with feeling bad or angry . May recognize psychologic pain related to grief and hurt feelings

Knock on door before opening The child gains sense of self-worth from involvement in activities Explain treatments and procedure Encourage the child to continue school work while hospitalized Encourage child to bring favorite past times to hospital. Help child adjust to limitations on favorite activities. Give clear instructions about details of treatment Show the child equipment that will be used in treatment

Passive resistance. Clenches fists, holds body rigidly still, suffers emotional withdrawal, engages in plea bargaining

Can specify location and intensity of pain and describes pain physical characteristics in relation to body parts.

Erikson: industry vs inferiority stage.

Piaget: Concrete operational stage

The child is capable of mature thought when allowed to manipulate and see objects

10-12 years (transitional)

Better understanding of the relationship between an event and pain Has more complex awareness of physical and psychologic pain, such as moral dilemmas and mental pain

May pretend comfort to project bravery, may regress with stress and anxiety

7-12 years old

Kohlberg: Conventional

Conscience or an internal set of standards becomes important. Rules are important and must be followed to please other people and be good

Able to describe intensity and location with more characteristics, able to describe psychologic pain

Adolescent (12-18 years)

Freud: Genital Stage

The adolescents focus is on genital function and relationships.

Ensure access to gynecologic care for adolescent females and testicular examination for adolescent males. Provide information on sexuality Ensure privacy during healthcare Have brochures and videos available for teaching about sexuality.

13-18 years (formal operations)

Has a capacity for sophisticated and complex understanding of the causes of physical and mental pain Recognizes that pain has both qualitative and quantitative characteristics Can relate to the pain experienced by others

Want to behave in a socially acceptable manner (like adults), show a controlled behavioral response May not complain about pain if given cues that nurses and other healthcare providers believe it should be tolerated

More sophisticated descriptions as experience is gained; may think nurses are in tune with their thoughts, so they dont need to tell the nurse about their pain.

Provide separate recreation rooms for teens who are hospitalized The adolescents search for self identity leads to independence from parents and reliance on peers

Erikson: Identity vs role confusion stage

Take health history and perform examinations without parents present. Introduce adolescent to other teens with same health problem. Give clear and complete information about healthcare and treatments Offer both written and verbal instructions Continue to provide education about the disease to the adolescent with chronic illness, as mature thought now leads to greater understanding

The adolescent is capable of mature, abstract thought Piaget: Formal operational stage.