U2L1: Caring for Hospitalized Children

concept of death & illness in infant

no concept

hospital affects on infants (3)

- separation & stranger anxiety

- sleep deprivation -> change in routine

- NPO

concept of death & illness in toddlers

no concept

hospital affects on toddlers (5)

- separation anxiety

- intense rxns to procedures -> poor body boundaries

- behavior regression

- can follow directions but short attention span

- remembers ppl who have caused them pain

concept of death & illness in preschoolers

magical thinking -> believes death is temporary or views it as a punishment

- doesn't know what causes illness but knows what it feels like

hospital affects on preschoolers (3)

- separation anxiety

- fears bodily harm

- regression -> usually only if hospitalized

concept of death & illness in school age

6 y/o -> understands death is permanent

- can sense when lied do & may act out when processing illness

hospital affects on school age (2)

- fears loss of control -> acts out

- stress w separation from peers & routine

concept of death & illness in adolescence

adult concept of death

hospital affects on adolescence (5)

- worried how illness affects body image

- impact of illness on activities

- isolation from peers -> encourage visitation

- loss of control

- compliance issues -> not taking meds

hospital stressors (4)

- separation anxiety

- loss of control

- bodily injury

- pain

stages of separation anxiety

1. protest

2. despair

3. detachment/denial

protest phase of separation anxiety

screaming & aggressive when separated -> can last hours to days

despair phase of separation anxiety

crying stops & appears depressed -> stops eating & playing

- if parent returns, may reject initially

detachment phase of separation anxiety

appears adjusted superficially but is not content -> adjusted to the fact that parents are not there anymore

what pain is most feared in the hospital setting?

shots & IVs

factors affecting rxn to illness/hospitalization (4)

- previous experiences

- recent stressors

- parents response

- sibling response

how can parents improve their childs rxn to illness? (3)

- be truthful

- remain calm -> children can take on parents anxiety

- appear as if parent is in control -< same routine & keep discipline

how can you minimize loss of control for children in the hospital? (3)

- promote hall time

- daily routine

- bring belongings from home

developmentally appropriate language/activities to decrease hospital stress (3)

- give choices when possible

- therapeutic play w child life specialist, typical play, schoolwork

- allow to touch medical equipment

nursing interventions to decrease hospital stress (2)

- painful procedures in treatment room instead of bedroom

- peer interaction for school age & adolescence

what things are not considered restrains but can be mistaken as one? (3)

- mechanical supports -> IV house or arm board

- anything used outside hospital for child safety -> side rails, seatbelt

- comfort positioning -> holding child

types of pediatric restraints (3)

- mummy restraint/swaddle

- arm & leg restraints

- elbow restraints -> prevents bending

proper measurement for NG palcement

tip of nose -> earlobe -> midpoint between xiphoid process & umbilicous (goes deeper than adult)

what should you do if feeling resistance while inserting NG tube?

reposition head chin to chest -> shouldn't feel resistance

what are signs you should remove the NG tube while trying to insert? (3)

- choking

- change in voice

- cyanosis

what can enteral feeds in infants cause?

oral aversion due to associating everything put into mouth as bad

how can you prevent oral aversion in enteral fed infants?

hold infant and have them such on paci while being fed so they associate sucking w feeling full

ways to keep children safe in the hospital (4)

- id bands

- child proofed room

- if env can't be made safe -> supervision or containment

- side rails up on cribs

posy bed

used for >3 but still need to be confined -> sides are zippered up

peds consideration for pharm absorption (4)

- increased pH -> decreased absorption

- shorter gut -> decreased absorption

- prolonged gastric emptying -> delayed affect

- increased skin permeability -> increased absorption

when do children reach adult pH?

2 y/o

peds consideration for pharm distribution (3)

- high water proportion -> increase dose for water soluble drugs

- lower body fat -> decrease dose for lipid solid meds (not fully distributed into fat)

- immature BBB -> more meds can permeate BBB

peds consideration for pharm metabolism (2)

- varied hepatic clearance

- increased BMR

peds consideration for pharm excretion (2)

- decreased GFR

- decreased renal tubular absorption & secretion

nursing assessment regarding med adm (4)

- appropriateness of dose age & weight -> if obese can exceed max adult dose

- childs developmental age

- tissue & skin integrity

- IV patency

nursing interventions regarding med adm (5)

- notify provider if dosage outside of safe range or inappropriate route

- independent double checks for high risk meds

- 2 pt identifiers

- give choices

- prepare child

infant considerations for med adm

involve parents -> usually prefer them to give meds

toddler considerations for med adm (4)

- follow routine

- simple choices

- allow to touch equipment

- allow to take themselves if able

preschooler considerations for med adm (5)

- allow playtime w equipment

- simple choices

- suppositories can be upsetting

- band aid after inj

- allow to take themselves

school age considerations for med adm (3)

- simple terms

- have child help prepare meds if able

- rewards

adolescent considerations for med adm (2)

- same as adults

- maintain privacy

dosing consideration for oral adm

no peds dose usually so have to take adult pill & crush or open capsule & pour out dose

oral adm considerations (4)

- use smallest measuring device

- mix crushed pill into smallest amt liquid & adm in syringe

- don't refer to meds as candy

- don't hold childs nose -> they can do it themselves

how should you adm oral liquid meds? (4)

- to side of tongue or cheek pocket

- position infant like you are giving them bottle

- give small amts then let child suck

- watch for swallowing

proper considerations for adm via feeding tubes (3)

- assess proper placement

- flush before, in between, & after meds

- small tubes -> can get clogged easily

what do you do if you feel resistance?

stop giving meds & flush

- if clogged warm water or creon can help

types of feeding tubes

NG, ND, GT, GJ

IV med adm considerations (5)

- rate of adm

- IV assessment

- IV location

- syringe pump or piggyback

- flush tubing

rate of IV med adm

should calculate safe rate for both push & infusion -> max & min

IV assessment

hard to differentiate if pt is crying bc in pain or fear -> can always just infuse instead of push

common IV sites for peds

scalp, feet, & groin for central line

when do we typically use syringe pumps

what does 4-2-1 rule calculate?

hourly maintenance IV fluids in children -> not set in stone, can adjust based on child

how do you calculate 4-2-1 rule?

1. 4 mL/kg/hr for 1st 10 kg of body weight

2. plus 2 mL/kg/hr for next 10 kg

3. plus 1 mL/kg/hr for each kg over 20

what position should child be in for optic adm?

supine or sitting w back & head up against bed

proper head & hand placement when adm optic meds

- their head should be extended & looking up

- pull lower eye lid down & heel of hand should be on their forehead

where should you adm ointments for optic meds?

adm from inner to outer canthus

where should you adm drops for optic meds?

inner corner of the eye

atraumatic care for optic adm (2)

- apply pressure on inner eyelid -> retains meds in eye & prevent systemic abs

- adm ointment before nap or sleep -> can make vision blurry

positioning for otic adm

position prone or supine w affected ear upwards

otic adm for

pull pinna/auricle downward & straight back

otic adm for >=3 y/o

pull pinna/auricle upward & back

atraumatic care for otic adm

warm refrigerated meds to room temp

what is the purpose of a scape for metered dose inhalers?

allows to children properly breath in med bc isn't able to coordinate breathing w pushing device

considerations for spacer use (3)

- make sure face mask is sealed tightly

- take 5-6 breaths

- yellow flap moving indicated breathing

MDI use steps (5)

1. take cap off & shake

2. stand up & breath out

3. as you breathe in push down on inhaler & keep breathing in slowly

4. hold breath for 10 secs then breathe out

5. wait 1 min in between puffs if multiple are ordered

considerations for nasal adm (4)

- clear nasal passages first

- instruct not to blow nose after

- inform child they may taste med

- don't let dropper touch nose

positioning for nasal adm

head hyperextended -> use pillows under shoulders & football hold for infants

atraumatic care for nasal adm

insert vertically then aim out & back

- aiming inward can cause interceptum bleeding

contraindications for rectal adm (3)

- neutropenia

- thrombocytopenia

- rectal surgery

how can you prepare child for rectal adm?

explain procedure -> may be difficult so utilize child life specialist esp if preschooler

considerations when adm rectal meds (5)

- avoid handling -> makes it soft

- lubricate suppository

- insert past rectal & anal sphincter pointy end 1st

- if need half dose cut lengthwise

- if pushed out can insert same suppository

how far should you insert suppository for a small child?

1/2 in

how far should you insert suppository for a older child?

1 in

what should you do after adm rectal meds? (2)

- can hold buttocks tgt so they don't push it out

- check diaper within 15 mins

how does age affect injections?

site, needle length, & gauge

what is site determined by?

age, amt, & frequency

atraumatic care for inj (6)

- topical lidocaine

- freeze spray -> blocks pain signals

- buzzy -> ice pack & vibrates

- distractions

- non nutritive sucking

- positioning

non nutritive sucking

sucrose paci for infants -> only decreases pain for abt 5 mins

subQ site for

anterolateral thigh

subQ site for >12 months

upper arm

subQ site for adolescent

abdomen but make sure there is sufficient fat

insertion angles

usually 90 or 45 if little fat

IM site for

anterior vastus lateralis -> inserted horizontally in the middle space between greater trochanter & knee

IM site for >3 y/o

deltoid

how do you adm inj if dose is double the max volume?

have 2 nurses give 2 shots at the same time in different sites

intraosseous inj

used in emergent situations if they can't get access in 90 secs & child is arresting -> IV into bone

what site is most common for intraosseous inj

anterior tibia most common -> then can be used as a central line

med safety considerations (3)

- don't adm outside safe doses -> call MD

- don't leave meds at bedside

- caps are choking hazards -> never leave near bed

med pt & family education (4)

- use, side effects, interactions, etc

- return demonstration

- provide written instructions

- assist w scheduling

general principles of pain management (4)

- should include non pharm & pharm

- use oral route when possible to avoid pain

- anticipate & treat side effects

- referrals to pain service

physical non pharm measures for pain (4)

- heat/cold compress

- massages

- skin to skin/kangaroo care

- non nutritive sucking

behavioral non pharm measures for pain (2)

- relaxation -> holding/rocking

- behavioral contracting -> time limits & rewards

cognitive non pharm measures for pain (3)

- distraction

- guided imagery

- positive self talk

WHO recommendation for mild pain (3)

- non-opioid, non steroidal anti inflammatory (NSAIDs) if >6 months old

- can combine w acetaminophen

- should be given at reg intervals -> 1 med q 3 hrs

WHO recommendation for moderate to severe pain

in addition to mild pain medications ass an opioid -> treats pain peripherally & centrally

WHO recommendations for pharm measures (3)

- dose at reg intervals

- always have narcan

- adapt to individual

codeine contraindications (3)

- post tonsillectomy/adenoidectomy

oral med adm considerations

peak effect at 1-2 hrs