Pediatric Nursing Care of Children and their Families

Pediatric Care Challenges

-Homelessness

-Violence

-Poverty and uninsured

-Less outdoor play

-Latch key kids

-Increased injury rates

What is the nurses role when the patient is experiencing pediatric care challenges?

Empowerment and Enabling

Homelessness:

when a person doesn't have a place to stay that is a steady home (ex: hotels, shelters, living with other families, couch hopping)

Latch key kids:

term used to describe kids who go home after school with no adult supervision until their parents get home from work

If a child comes in with an injury make sure that their injury matches their ________

story on how it happened

How are children different than adults?

-Lungs are smaller as a child causing RR to be faster

-Have less blood than an adult so they will bleed out faster

-Metabolic rate is faster

-Lose heat very quickly and get cold faster

-Have no immune system

-Vitals are higher in kids to compensate for blood and air exchange in the body

Hospitalization

-Orientation to Pediatric Unit

-Play is important

-Respect a child's fears

-Learn child's coping style and personality

-Dealing with intrusive procedures

-Minimizing child and parent stress

Ouch-free rooms/zones

small play area that no needles or medications are brought into, all procedures are done in a special exam room

How can you help to minimize child and parent stress?

by always telling the parent what you know because it will help them trust you reduce anxiety

Hospitalization safety measures

-National safety goals

-Prevent medication errors

-Safe environment

-Sleeping/ Beds

-Confidentiality

-Culture/ Therapeutic Communication

-Positive outcomes of play

-Child life specialists

Family advocate:

empowers family to speak out themselves or the nurse advocates and speaks for them

Child life specialist:

Trained professional who plans therapeutic activities for hospitalized children

-helps reduce stress in children, help the kids understand medical procedures by using dolls, toys, etc. & encourage normal child development & education

#1 National safety goal when caring for children is ____________

preventing medication errors because they can be deadly

Children's Fears

-Separation Anxiety

-Pain

-Fear

-Regression

-Positive sleeping habits

Separation anxiety is normal and has 3 stages:

-Protest

-Despair

-Detachment

Protest stage of separation anxiety:

when the child is yelling and screaming for their parent

-the loudest phase

Despair stage of separation anxiety:

when the crying stops and the child looks sad, depressed and withdrawn & does not play with their toys

Detachment stage of separation anxiety:

when the child appears to deny the need for their parent and they become more interested in their surroundings as they are starting to adjust to separation

-start to play and socialize with other kids

-they child is not actually adjusting but is doing this to help cope

__________ scale uses body language to help us to figure out if a infant is in pain

NIPS

Not uncommon for ____________ to increase when children are in severe pain

temperature

Regression:

loss of an achieved function

(ex: start going back to needing a diaper, having accidents at night, or going back to sippy cups)

Pain control methods:

-Narcotics

-Creams (Emla cream)

-Distractions

EMLA cream

lidocaine based cream that will help numb an area to lessen the pain before injections or IVs for children

EMLA cream takes ______ minutes to kick in

30 minutes

Pain assessment tools:

-Wong-Baker (ages 2 and up)

-NIPS scale (infants)

-FLACC scale (non-verbal children)

-Number scale

Wong-Baker Pain Scale

most common faces scale for assessing pain

-ages 2 and up

NIPS Scale (Neonatal-infant pain scale)

Rates facial expression, arm movement, cry, leg movement, respirations, and arousal

-Scored 0-2

FLACC scale for pain

Used for those who cant/wont communicate, this scale is a behavioral scale

-Face

-Legs

-Activity

-Cry

-Consolability

Infants

Up to one year old

-No behavioral problems

-Physical Development

-Promote parent-infant bonding

-Liberal visiting hours

-Immediate gratification

-NIPS scale to determine pain level

-Used to getting what they want when they want it and have very few behavioral problems

NAS (Neonatal Abstinence Syndrome)

a condition that starts at birth after a baby was exposed to drugs during pregnancy

__________ are typically constantly crying, very jittery and shaky & only stop when they are held or swaddled, pacifiers can help

NAS babies

Parent-infant bonding:

infant is rarely away from the parent

-if the infant needs a procedure the parent will stay with the child as long as possible to help decrease anxiety

Liberal visiting hours

a time-sharing arrangement in which the specifics of child visitation are essentially left up to the parents to agree upon

-Parents encouraged to stay to promote bonding

Toddlers

1-3 years old

-Behavioral problems (temper tantrums when separated from parents)

-Physical development

-Transitional objects

-Separation Anxiety remedies

-Restraining, swaddling (mummy)

-Try to take home habits and put them into everyday routines to make them more comfortable

Ex of a transitional object for toddlers

Favorite blanket or stuffed animal from home

Toddlers can not understand time so use situations they can understand such as:

-mom will be back after lunch

-mom will be back after your nap

Monitor parents of toddlers for signs of ________ because having a sick toddler can be very stressful

fatigue

mummy restraint

only restraining method we use is in children, it is a swaddling technique to keep the baby still and immobilize their arms when we don't want them to grab anything

Ex of when this might be used: putting IV in head, stitches on face

Preschooler

3-5 years old

-Normal G&D

-Hospital is seen as punishment

-Let them decorate their personal space to feel more safe

-Understands concept of time but still used references to make it easier

-Choose descriptive language carefully

-Fears bodily harm

-Games

-Easier for them to be separated from their parents because they are used to being separated for school

Magical thinking

Ideas that one's thoughts or behaviors have control over specific situations

Ex: knocking on wood to prevent misfortune, avoiding sidewalk cracks and believing you've saved a loved one from a terrible fate

School Aged

5- 10 years old

-Stage of Industry & Independence

-Allow them to participate in their care, feel “grown up”

-Methods to help cope: Tries to “be brave”

-Keeping up on schoolwork is very important

-Observe for nonverbal signs of pain and stress

Encourage school aged children to draw their feelings so they can express their __________ and __________

fears and anxiety

Adolescence

10-19 years old

-Admitted due to injury and/or death

-Narcissist concerns (about ht, wt, and sexual development)

-Fear loss of control and independence

-Roommates in hospital, select carefully (same sex)

-Confidentiality

____________ adolescents should always have their own room to respect their feelings without jeopardizing the feelings of another pt

Transgender

A minor can be treated without consent if _______________

it is life threatening

Medication Administration: Absorption issues

-Newborns no HCL (hydrochloric acid)

-Formula interferes with absorption

-Less than 5 yrs old increased GI motility

-Topical ointments absorbed quickly

-Plastic diapers increase absorption!!!!

-Metabolic issues: Liver enzymes not fx properly until 2-4 yrs old. Children metabolize slowly.

-Monitor for toxicity!

___________ diapers can increase the absorption of medications because the diaper is keeping the skin moist and warm allowing the skin to dilate and absorb the medication quicker

Plastic

Liver enzymes do not function properly until _____ years old

2-4

Hydrochloric acid is not made in the _________ therefore there is no acid-medium to help digest the medicine that is why it is not always absorbed correctly

neonate

______________ makes it harder for children to excrete medications which increases the risk of toxicity

Immature kidney function

1 kg = ______ lbs

2.2 lbs

Safe dose range (SDR) is based on ________, there is no such thing as average dose.

weight

Clark’s rule:

Used in absence of SDR when only an adult dose range is noted in drug book

-Child’s weight/150 x dose

Oral Medications

-Review rights of drug administration

-Make sure you have the right route and form for age

-Medication is not candy!!! (do not flavor it)

-Devices to administer

Nose drops Positioning and technique

-Immobilize infant using mummy restraint

-Wipe excess mucus from nose

-Place infant on back with head over the side of the mattress or the neck extended over a pillow

-Encircle the infants cheeks and chin with the non-dominant arm and hand to steady

-Instill drops with dominant hand

-Keep infant in this position for 30sec-1min to allow drops to reach the proper area

Ear drops

-Place in supine position with unaffected ear down

-Instill the ordered number of drops

-Gently massage the area in front of the ear to facilitate entry of drops

-Keep in supine position for a few minute to permit the fluid to be absorbed

Children under the age ____ can not safely swallow pills because the mobility does not break down the pill

5

Do not lie to your child about the medication tasting good, inform them it might not taste good but they can have ________ after to wash it down

juice

Do not mix medication with _________ to dilute it

anything

Give liquid medication on the side of the mouth ensuring to never push it down the throat so the fluid does not ______________

end up in their lungs

Intramuscular Injections volume maximum dose for infants

0.5ml

Infant: vastus lateralis only, up to 1ml

Intramuscular Injections volume maximum dose for toddlers

1ml

Intramuscular Injections volume maximum dose for toddlers school age or adolescent

1-2ml

Infants can receive 1ml injections in ____________ only

vastus lateralis

Children older than ____ can get injections in the deltoid

2

Ways to help reduce discomfort when giving injections

-Position

-Technique comfort

-EMLA cream

-Hug position

-Distraction

For school age adolescent patients injections in the deltoid should never be more than 1ml but in the vastus lateralis can give ____ml

2ml

Intravenous

-Sites checked hourly

-Prevent dislodgement (use armboard)

-Long term VAD use

-Know nursing guidelines and care for your facility

Intravenous sites used in children

-Scalp veins

-Subclavian veins

-Dorsal hand veins

-External jugular veins

-Forearm veins

-Dorsal foot veins

Check ___________ hourly and look for inflammation and infiltration (in active kids infiltration may happen because they move around a lot)

IV sites

VAD =

vascular access devices

Never remove an IV until _______________

the child is ready to go home to prevent having to re-stick them

Children won't be discharged until ________________

labs come back and are normal

Postoperative Care Considerations

-Addressing fear issues

-Tattoo and piercings

-Summary of care

-Parent involvement and education

Piercings can be left in as long as they do not ________________

interfere with the procedure

_________ areas are more at risk for edema so monitor the site and document where they are

Tattoo

Enteral Feedings

-Position child flat or with head slightly elevated, can give pacifier to relax the infant

-Place absorbent pad under tube extender to protect linens

-Check residual stomach contents by attaching syringe to gastrostomy tube and aspirating

-Attach syringe barrel to the tube

-Fill with formula

-Remove clamp

-Elevate the receptacle and allow formula to flow slowly with gravity

-Continue to add formulate

-Clamp the tube as the final formula or water is passing through the lower part of the syringe

-Reposition in fowlers position or R side to promote gastric emptying

Enemas

-Isotonic only

-Retention

Tracheostomy Care

-Cleaning and suctioning

-Complications

-Airway

-Oxygen therapy

GT/JT enteral feeding nursing responsibilities:

-Make sure tube isn't clogged

-Crushed or liquid meds only

In children with a GT or JT medications are typically mixed in with ____________ to prevent them from getting full too fast

their feedings

Isotonic enema solution:

normal saline

When giving an enema in children monitor for any S/S of ________________

bowel perforation

Enemas no more than _____ml for infants and tube is inserted 3-5 inches

50ml

Enemas up to ________ml for adolescents and tube is inserted 3-5 inches

500-750ml

With Tracheostomy care oxygenate the pt and then suction for _____ seconds

15 seconds

Stool specimens can be collected with a bedpan or a hat in adolescents, however stool collection can be ____________

embarrassing

How do you collect an infants stool?

can be scrapped from the diaper

Diaper weighs 50gm = ___ml of urine

50ml

Most common location to check heart rate in infants

Apical

Heart rate in Neonate <28 days

Awake: 100-200

Asleep: 90-160

Heart rate in Infant 1-12 months:

Awake: 100-190

Asleep: 90-160

Heart rate in Toddlers 1-3 yrs:

Awake: 98-140

Asleep: 80-120

Heart rate in Preschool 3-5:

Awake: 80-120

Asleep: 65-100

Heart rate in School aged 6-11:

Awake: 75-118

Asleep: 58-90

Heart rate in Adolescent 12-15:

Awake: 60-100

Asleep: 50-90

Check __________ pulse for CPR, but when doing an assessment check Apical pulse

Brachial

Respiratory rates:

Newborn: 30-60

Preschool: 20-28

Infant: 30-53

School aged: 18-25

Toddler: 22-37

Adolescent: 12-20

Check BP in children older than ___ years old

3 years old

-Under 3yrs if cardiac history

Blood pressure ranges

Infant: 72-104/ 37-56

Toddler: 86-106/ 42-63

Pre-school: 89-112/ 46-72

School aged: 97-115/ 57-76

Pre-Adolescents 10-11: 102-120/61-80

Adolescent: 110-131/ 64-83