peds caring for hospitalized children

developmental impact of illness

hospitalizations often first major stressor.
Infant: no concept, anxiety comes from separation/strangers, sleep deprivation, NPO. limited understanding, short attention span, poor body boundaries
Preschoolers: magical thinking, separation anxiety, fear bodily harm, regression, limited ability to describe what illness feels like
School aged: sense when lied to and may act out, fear loss of control, stress with separation, peers and routine
Adolescent: body image is important (judge degree of illness off of changing body image), loss of control (dont like increased reliance on parents), isolation from peers (worry how illness will impact social/school life), encourage peer visitation and contact, compliance issues (don’t like side effects)

developmental impact of death

Infant: no concept of death
Preschoolers: magical thinking, think death is temporary, view illness/death as punishment
School aged: understand death is permanent at 6yo
Adolescent: adult concept of death

developmental impact of stressors on child

Stages of separation anxiety: protest (scream, aggressive, hours to days), despair (no crying, no eating, depressed, may initially reject parent), detatchment/denial (prolonged, appear adjusted superficially but internally depressed
Loss of control, bodily injury (fear mutation, intrusion, disability, death), pain (shots and IV most feared)

What factors affect reaction to illness/hospitalizations

previous experience (if poor handling likely negative past experiences), recent stresses, parents response (weakened trust if not truthful, kids cling to parents, help maintain parent as safe/trustworthy, routine, discipline), sibling response (rivalry is normal response to increased attention on kid, worrried about sibling, worried they will get same disease, encourage visits!)

Nursing interventions for children

Atraumatic care, prevent or minimize separation, minimize loss of control, fear of bodily injury, choices when possible, therapeutic and atypical play, encourage school work, allow to touch medical equipment, painful procedures in tx room (playroom is safe space), peer-interaction for school aged children and adolescents (teen room)

Types of restraints in children

Mummy restraint/swaddle, arm and leg restraints, elbow restraints
Use as little as possible

What are not considered restraints?

mechanical support, developmentally appropriate safety interventions (ex. arm boards and IV house), comfort positioning (parent hold and comfort)

NG/NO placement

measurement tip of nose → earlobe → midpoint between xiphoid process and umbilicus
lubricate tube and insert to marked area (choking, coughing, change in voice, cyanosis → remove)
Have child test swallow, secure tube to cheek
Enteral feeds: hold infant, mimic hoe they would be fed at home, risk oral aversion, make it enjoyable, sucking = good

How to keep kids safe

ID bands, document location, hospital childproof, supervison/restriction/containment, cribs (if can stand, crib top)

Fall Prevention

fall risk/bracelets (med effects, altered mental status, altered mobility, post-op), side rails/crib top, call bells and items wihtin reach, offer toileting, wheelchairs locked, gown, nonskid footwear
Sit = side rails, Climbing = crib top

Med Pharmacokinetics

Absorption: gastric pH higher in infant lowers med absorption, like adult by 2. Prolonged gastric emptying, increased skin permeability
Distribution: higher proportion in water (higher distribrtion so need higher dose), lower body fat (tox risk of lipid soluble meds), immature BBB
Metabolism: Higher metabolic rate, hepatic clearance
Excretion: low GFR, low renal tubular absorbtion and secretion

Nursing Assessment

med and food allergies, appropriate med dose by weight, childs developmental age, child phys/psych, tissue and skin integrity, IV patency

What weight do you start using adult doses/ dose safety

65kg, notify provider if outside of safe dose
independant double check for high risk meds, 2pt identifiers

Dev considerations for med administration

ability to swallow pills, hx injection sites, never give option to not take
Infant: involve parents
Toddler: routine, simple choices, touch equipment, allow to take themselves
Preschoolers: allow play with equipment, simple choices, suppositories upsetting, bandaid fix all, take by themself
School age: purpose in simple terms, have child help, reward
Adolescent: same as adults, maintain privacy

Oral Administration

No peds pills, adult but crush/cut
smallest measuring device possible
if crush pill: mix smallest about liquid/apple sauce, dont use formula
side of tongue/mouth or buccal pocket (small amts, watch for swallowing)
Dont refer to meds as candy, never hold nose for child, atraumatic care

Feeding tube administration

assess proper placement, small tubes, flush start/between meds/after
If resistance: stop giving med and flush

IV administration

Push vs infusion (nurse choose, kids tolerate pump better), min/max infusion times, IV assessment (infiltration vs fear), Sites (scalp, feet. central lines: groin), Syringe pump/always piggyback (so no med get stuck), flush tubing at the same rate!

4-2-1 Rule

Hourly maintenance IV Fluids
4ml/kg 1st 10
2ml/kg next 10
1ml/kg for each kg over 20

Optic administation

supine/sitting, back of head against bed to lower movement. heel of hand on forehead, look up
Drops: pull lower eyelid down, apply in conjunctival pocket
Ointments: inner to outer canthus
Atraumatic: apply pressure to inner eyelid, administer before nap or sleep

otic administration

Affected ear upwards
Under 3: pinna down and back
Over 3: up and back
Atraumatic care: warm meds to prevent nausea and vertigo, push on tragus to be on side for less time

Injections

Site: determined by age, amount, frequently
plan on needing to restrain child
Atraumatic care: topical lidocaine 1 hr before, freeze spray, buzzy (between brain and injection site, distraction, infant use sucrose on paci, have kid sit, PRAISE!

SQ sites

Under 1yr: anteriolateral thigh
over 1yr: upper arm
adolescent: 90 degrees unless little fat

IM sites

Under 3yrs: anterior vastus lateralis
Over 3: deltoid

Max injection volume by age

Infant: 0.5mL
Toddler: 0.5-1mL
Preschooler: 1mL
School age (6-10): 1.5-2mL
Late school aged/adolescent: up to 3mL

IF NEED TO SPLIT DOSE: 2 nurses do it at same time

Principles of pain management

pharm and nonpharm, use oral when possible! anticipate and treat side effects, pain service when inpatient

Non pharm pain management

Phys: heat, cold, massage, containment, kangaroo, non nutritive sucking
Behavioral: relaxation, behavioral contracts
Cog: distraction, guided imagery, positive self talk
Comp: acupuncture

Pharm pain managment

Two step approach
Mild: NSAIDs over 6mo, combo and alternate with acetaminophen
Mod/severe: add opiod (morphine, hydromorphone, fent, oxy)
Dose at regular intervals, appropriate route, adapt to pt, narcan on hand

Contraindications for codeine

If post tonsillectomy or adenoidecomy: all ages under 18
Anybody under 12
12-18: obese, OSA, compromised respiratory function, known ultrarapid CYPSD6 metabolizer

Strategies for painful procedures

Explanation: under 6 right before, over 6 give time to process. ALL: be honest
Contact w/ parents for toddlers and preschoolers
perform as quickly as possible, comfort items from home, distraction, do not cluster painful procedures