Nursing Care of Child(ren)

growth in the first year

very rapid

birth weight by 6 months

doubles

birth weight by 12 months

triples

typical growth on a growth chart

growth should follow an arc on the growth chart

measurement of growth

central to evaluating health status → all plotted on growth charts

height/length and weight

measured on all visits

using centimeters/kilograms

head circumference

measured every visit up until 36 months

BMI

measured starting after 2 years of age

age appropriate techniques for pediatric physical assessment

let the child guide you & participate in their care

ask family for assistance to make VS less traumatic

follow their lead with assessment → they are the expert

a good nurse hones their assessment skills

look at the room for clues regarding coping, family dynamics

VS during pediatric assessment

progress from least invasive to most invasive

RR → HR → temp → BP → height and weight

respiratory rate during a pediatric physical assessment

count for 1 minute → auscultation

heart rate during a pediatric physical assessment

apical pulse → count for 1 minute

radial pulse in children

not accurate measure until after age 2

temperature during a pediatric physical assessment

rectal, oral, axillary, temporal

BP during a pediatric physical assessment

may use upper arm, lower leg, upper leg

rights to med administration

right patient

right medication

right dose

right time

right route

right documentation

oral medication for children

liquid or suspension in syringe, cup, or spoon

pill swallowing → starts between ages 6-11

oral med administration

slide syringe into cheek pocket → administer medication

if administered in food → use smallest amount possible

positioning for optic med administration

supine or sitting

may need to papoose

head up → look down

optic med administration

pull lower eyelid down → apply medication in lacrimal pocket

best time for optic med administration

before nap or bedtime

positioning for otic med administration

prone position with affected ear towards you

otic med administration in younger than 3 years

pull ear back and down

otic med administration in older than 3 years

pull ear back and up

otic medications

usually in the form of drops

why should you let refrigerated otic meds come to room temperature?

can cause pain and vertigo

positioning for nasal med administration

head extended or hyperextended

can use a pillow or rolled towel to extend neck

football hold for infants

nasal med administration

insert tip just inside nares or at the tip of the inside of the nose

positioning for aerosolized med administration

sitting upright

positioning for rectal med administration

side lying with one leg positioned forward to allow visual inspection of the rectum

rectal med administration

halve the medications lengthwise if possible

hold buttocks cheeks closed as long as baby will allow → 10-15 mins

rectal med administration in immunocompromised children

contraindicated

vaccine refusal

tackle it with evidence → dramatic decline in infectious diseases due to widespread use of immunizations

required vaccines

determined by the state for school attendance

recommended vaccines

the AAP recommends the entire schedule

hepatitis A vaccine

fecal - oral (food handlers)

hepatitis B vaccine

starts at birth

polio

give IPV → no longer use OPV

HIB vaccine

huge reduction in HIB meningitis

PCV/pneumococcal vaccine

PCV for under 2 years old

pneumococcal for over 2 years old

influenza

during flu season, give if > 6 months of age

flu season

october - march

MMR

live virus → only given in combo now

DTaP

given for pertussis → resurgence in school age & adolescents has caused a revised schedule to include a booster

why is pertussis a problem for infants?

causes apnea

acellular form of DTaP vaccine

has less of a reaction

adult version of DTaP

Tdap

meningococcal vaccine

MCV4

varicella vaccine

given as a live virus

rotavirus vaccine

oral → defined time period for administration

HPV vaccine

boys and girls should both receive

controversy regarding the HPV vaccine

whether or not to receive → it’s more than just cervical cancer

when is it OK to give a vaccine?

mild to moderate local reaction to a past vaccine

mild, acute illness with OR without low grade fever

current antibiotic therapy

prematurity

family history of seizure, SIDS, or adverse reaction to a vaccine

breastfeeding or household contact with a pregnant woman

contraindications for vaccine admin

severe febrile illness

past serious adverse reaction to the vaccine or the vaccine component

long term (> 2 weeks) use of systemic steroids

pregnancy → no live vaccines

recent blood, plasma, or IgG for live virus vaccines → wait a min of 3 months

seizure within days of receiving a prior dose of vaccine

immunosuppression

why are vaccines contraindicated in transplant patients?

no live vaccines if undergoing immunosuppression therapy

why are vaccines contraindicated in patients with HIV?

can receive live virus if asymptomatic

why are vaccines contraindicated in patients undergoing chemotherapy?

wait at least 6 months usually to restart vaccination schedule

safety in injection administration

a good restraint

Ok to give multiple injections → use different sites

correct storage & reconstitution

do not combine vaccines

developmental approach to injection administration

give injection quickly with help and warning, but not extended periods of time for child to get upset → children younger than school age have a hard time with time measurement

documentation of vaccine administration

in patient permanent record, MAR, & paperwork with caregiver

VIS, site, lot number, consent

location for intramuscular injections

vastus lateralis until age 1

deltoid after 12 months

ventrogluteral only in children who are walking

needle size for intramuscular injections

½ - 1 inch

what are intramuscular injections used for?

immunizations and medications → usually antibiotics

location for subcutaneous injections

fatty tissue over thigh muscle until 12 months of age

arm for immunizations → after 12 months

what are subcutaneous injections used for?

injected live virus vaccines → MMR & varicella

used for insulin, hormone replacement, allergy shots, some vaccines

intradermal injection administration

place the needle almost flat against the patient’s skin with the bevel side up → insert the needle into the skin ¼ in. with entire bevel under the skin

needle size for intradermal injections

½ and 5/8 inch

implications for intradermal injections

do not massage area after injection

withdrawing at the same angle as insertion minimizes discomfort to the patient and damage to the tissue

proper needle disposal prevents needle-stick injuries

what are intradermal injections used for?

PPD or allergy testing are most common

intramuscular injection angle

90 degrees

subcutaneous injection angle

45 degrees

intradermal injection angle

15 degrees

immediate evaluation of a fever

any infant < 3 months old

any child with a fever > 105

a child that “looks” or “acts” very sick

fever evaluated within 24 hours

fever 104-105

younger than 2 years

fever > 3 days → or > 24 hours without reason

fever gone for 24 hours, then returns

parental concerns

fever in a newborn less than 28 days

receives a complete septic workup

fever

temperature > 38C or 100.4F

helpful in increasing WBC and interferon effectiveness

most are brief with limited consequences and are viral in origin

treatment for fever

aimed at relieving discomfort

medications → used to lower the set point

acetaminophen to treat fever

10-15 mg/kg per dose

no > 5 doses in 24 hours

ibuprofen to treat fever

5-10 mg/kg per dose

after 6 months of age

aspirin to treat fever

never → reye’s syndrome

infants & pain

infants do experience pain

children are not more prone to complications of pain management

children can be good reporters of their pain when development is taken into consideration → use appropriate pain scale

if a child is sleeping or playing they can still be in pain

influential factors on pain

age

developmental level

chronic or acute disease

prior experience with pain

personality

dynamins (stressors)

culture

socioeconomic status

assessment tools for pain

use based on development and age

CRIES or NIPS

neonatal postoperative pain management scale

FLACC scale

nonverbal children ages 2 months - 7 years

1-3: mild

4-6: moderate

7-10: severe

FACES scale

3 years old and older

point to each face using the words to describe the pain intensity → ask the child to choose face that best describe their own pain

record the appropriate number

NUMBERS/NRS/Visual analogue

0-10 scale → 0 being no pain, 10 being worst pain

must understand numbers and their relationship to one another

does the child understand concepts of simple math?

appropriate for ages 8 and above

non-pharmacological treatment of pain in children

distraction such as blowing bubbles

relaxation

guided imagery

containment

sucking

kangaroo care

complementary alternative medicine

developmental considerations for med administration in infants & babies

perform procedure quickly

ask parents for support & information on best way to approach infant

support parents

allow infant to swallow → pacifier, bottle, or breast

provide comfort measures → holding, cuddling, rocking

developmental considerations for med administration in toddlers & preschools

BRIEF, concrete explanation immediately before performing

expect aggressive behavior, within limits → plan accordingly, provide outlet for response

provide comfort measures such as touch → holding, cuddling, favorite stuffed animal or blanket

provide a toy reward, sticker, and a bandaid

developmental considerations for med administration in school age

explain procedure

it’s all about control

set appropriate behavior limits

resist using phrases such as “be a big girl/boy”

developmental considerations for med administration in adolescents

explain procedure, allowing for control over body and situation → mom or dad in or out of the room

explore concepts of illness, hospitalization, correct misconceptions

encourage self expression, individuality, and self care needs

encourage participation in the procedure