Nursing Care for Pediatric Patients

Introduction to Pediatric Nursing

• Presenter: Charity Vinyl, Registered Nurse.
• Objective: Care for pediatric patients, apply nursing principles, and perform health assessments.

Introduction to the Patient

• Greeting: Nurse introduces herself and engages with the child (Johnny Lewis, 10 years old) at their eye level to establish rapport.
• Mother: Miss Johnson, expressing concern and emotional state, which requires empathetic acknowledgement from the nurse.
• Importance of appropriate introductions and maintaining a professional, calm demeanor around patients and families to build trust and reduce anxiety.

Patient Admission Process

• Admission to the pediatric unit involves a series of initial questions and assessments to establish a baseline, identify immediate concerns, and plan initial care.
• Scenarios: Different approaches to engage with the patient and the family, adapting to their comfort levels and readiness to communicate.
• Recognition of busy environments in healthcare settings, necessitating clear, concise communication and efficient information gathering even under pressure.

Communication Techniques

• Importance of clear introductions by nurses to build trust, stating name and role.
• Maintaining privacy and confidentiality by ensuring conversations are held in appropriate settings, encouraging open conversation from parents by active listening.
• Use of empathy: Acknowledging family stresses (e.g., housing instability, financial strain, fear of the unknown) through validating statements.
• Example: Nursing response to a parent in distress: "I’m sorry you’re going through that. We are here to help, and I'll do my best to ensure Johnny receives the best care."
• Recognition of nonverbal cues from families (e.g., crossed arms, fidgeting, averted gaze, tense posture) and how to respond therapeutically to de-escalate frustration or encourage sharing.
• Example: A parent expressing frustration or anger due to waiting times; respond with calm reassurance and update on expected wait.

Developmentally Appropriate Communication

• Strategies for effective communication with children based on age and cognitive ability.
• Younger children (toddlers, preschoolers) may need visual aids (dolls, stuffed animals, coloring books) to explain procedures or express feelings; use simple, concrete language. Speak softly and gently.
• School-aged children can understand more complex explanations; involve them in their care by offering choices. Be honest and straightforward.
• Adolescents often appreciate being addressed directly and involved in decision-making, respecting their need for privacy and autonomy.
• Speak to children at eye level, gently, to alleviate fears and create a sense of safety.
• Importance of honesty about procedures and giving choices to children when possible (e.g., "Do you want your medicine in juice or water?" "Which arm do you prefer for the blood pressure cuff?") to grant them a sense of control.

Health History and Assessment Techniques

• Steps in performing a thorough health history involve a systematic approach to gather comprehensive data:
  • Engagement with families through open-ended questions and active listening, allowing them to fully describe their concerns.
  • Asking pertinent questions about illness history, focusing on the onset, duration, characteristics, and previous episodes.
  • Example Chief Complaint: "Fever for 3 days, accompanied by vomiting and decreased appetite." Further inquire about associated symptoms (e.g., rash, cough, diarrhea), hydration status (urine output, tears), and child's typical behavior.
  • Accessing accurate historical data from caregivers, including pertinent negatives (e.g., "No known sick contacts at home"), sibling illnesses, and duration of symptoms to help narrow down potential diagnoses.

Medication and Reconciliation

• Inquire about all current medications, including over-the-counter drugs, herbal supplements, vitamins, and prescribed medications, to avoid drug interactions and ensure continuity of care.
• If a child takes folic acid, consider underlying conditions such as sickle cell anemia, thalassemia, or other anemias. Always verify dosages and frequency.
• Importance of medication reconciliation includes comparing home medications with hospital orders and maintaining a patient’s home regimen as appropriate, ensuring accuracy and patient safety.

Immunizations and Health History

• Assess vaccination status thoroughly. This includes routine childhood immunizations, plus specific emphasis on flu and COVID vaccines due to current health climate and potential for severe illness in children.
• Importance of pain history: Utilize a systematic approach to asking about pain, including its location, intensity, quality, duration, and what makes it better or worse.
• Scale and measurement techniques for children of various ages; selecting the appropriate tool is crucial for accurate assessment and effective pain management.

Psychosocial and Family Assessment

• Questions regarding family structure (single parent, two-parent, blended), dynamics (communication patterns, support available), and any reliance on social networks (extended family, community resources).
• Consideration for children living in shelters or unstable housing situations, as this significantly impacts access to care and health outcomes. Inquire about parents' occupations and potential environmental exposures.
• Importance of asking appropriate questions about siblings' health as it reflects potential exposures to infectious illnesses or genetic predispositions within the household.

Topics of Discussion

• Overview of vital sign assessment, including appropriate techniques and identifying normal ranges for children, which vary significantly by age.
  • Normal heart rate ranges (approximate for well-rested children):
  • Infants $(0-3$ months): $100-150$ bpm
  • Infants $(3-6$ months): $90-120$ bpm
  • Babies $(6-12$ months): $80-120$ bpm
  • Children $(1-10$ years): $70-110$ bpm
  • Children (>10 years) and adolescents: $55-90$ bpm
  • Normal respiratory rates (approximate):
  • Infants: $30-60$ breaths/min
  • Toddlers: $24-40$ breaths/min
  • Preschoolers: $22-34$ breaths/min
  • School-aged: $18-30$ breaths/min
  • Adolescents: $12-16$ breaths/min
• Considerations for temperature regulation based on ambient conditions, clothing, and metabolic state.
• Identifying specific psychosocial histories: Living situations (e.g., rural vs. urban, apartment vs. house), parental situations (single, divorced, remarried, incarcerated), health habits (nutrition, exercise, screen time), and school performance, as these all impact a child's overall well-being.

Health Assessment Techniques

• Sequence for assessment in pediatrics often proceeds from least invasive to most invasive, especially with younger children:
  • General physical appearance: Observe skin color (pallor, cyanosis, jaundice), observable distress signs (e.work of breathing, grimacing), symmetry, and overall hygiene. Note level of activity and alertness.
  • Neurological assessments: Assess pupils for PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation), and responsiveness using the AVPU scale (Alert, Verbal, Pain, Unresponsive).
  • Heart rate obtainment methods: Apical pulse for infants and young children (auscultate for a full minute); radial pulse for older children. Note rate, rhythm, and strength.
  • Importance of thorough, objective documentation after assessments to prevent future liability, provide legal record, and ensure continuity of care across shifts and providers.

Pain Assessment

• Definitions and considerations of pain: Subjective nature increases complexity in assessment for children who may not be able to verbalize their pain or may deny it due to fear.
• Importance of using appropriate, age-specific scales for pain assessment:
  • CRIES scale: For neonates ($0-6$ months), assesses Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness.
  • FLACC scale: For infants, toddlers, and nonverbal children, assesses Face, Legs, Activity, Cry, Consolability.
  • Wong-Baker Faces Pain Rating Scale: For children aged $3$ and older, uses cartoon faces depicting increasing levels of pain.
  • Numeric Pain Scale ($0-10$): For children generally aged $8$ and older who can quantify their pain.
• Understanding nonverbal cues and behavioral signs in children who cannot articulate pain levels: Examples include grimacing, guarding a body part, withdrawal from touch, moaning, irritability, or decreased activity.

Cultural Considerations in Nursing

• Importance of cultural competence: Respecting self-identification, including gender, ethnicity, and spiritual beliefs, and understanding how these relate to providing culturally sensitive care.
• Understanding family dynamics, including roles of various family members, decision-making hierarchies, and preferences for how family members are identified or involved in care (e.g., involving grandparents or tribal elders).
• Be aware of specific cultural practices that may impact care (e.g., dietary restrictions, modesty requirements, use of traditional healers, views on pain expression or end-of-life care).

Documentation and Reporting

• Role of nurses in reporting required information in suspected cases of abuse or neglect adheres to mandatory reporting laws. This means reporting observations and concerns to the appropriate authorities (e.g., Child Protective Services) and the nursing supervisor.
• Emphasis on privacy laws (HIPAA) and understanding when confidentiality can be legally breached due to safety concerns (e.g., child abuse, suicidal ideation, immediate danger to self or others).

Conclusion

• Importance of familiarity with hospital protocols and policies to ensure consistent, safe, and effective care delivery.
• Need for nurses to adapt their approach to the individual needs of patients and their families, recognizing that each child is unique.
• Acknowledgment of the emotional and social factors influencing a child’s health, reinforcing the holistic nature of pediatric nursing care.