Basics of pediatric care chapter 55

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Basics of pediatric care chapter 55

Presentation by Leslie Lehmkuhl, RN
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Family-centered care

• Pediatric nursing involves working with the child
  and the family
• Family-centered care is a philosophy that
  includes family contribution and involvement

• Nurses recognize the importance of family
  centered care
• Because children are different than adults POC is
  always guided by the developmental level of the
  child

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Pediatric assessment

• Nurse assesses the following areas physical,
  emotional, cognitive, developmental level,
• Educational needs, developmental needs,
  socialization, dynamics of the family

• Neonate birth to 28 days
• Infant 1 month to 1 year
• Toddler 12 mos to 3 yrs
• Preschool 3-6 years
• School age 6-10 years
• Preadolescent 10-12 yrs
• Adolescent 13-20 years

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Terms

• Assent
• Child life specialist
• Emancipated minor
• Family centered care
• Infant mortality rate
• Standard of care

• WIC supplemental food program for women,
  infants, children
• Denver developmental and growth screening test ii
• Developmental milestones
• Egocentrism
• Object permanence

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Admission

• Preparation for planned admission is important
  for a child/caretakers
• Visit playroom, play with toys, read books, see
  videos, talk to staff, ask questions, see
  environment
• Information regarding child nutrition,
  allergies, routines, fears, eating habits, sleep
  habits (data is used to identify Nx Dx est.
  POC)

• Reaction to pain, prior medication, play, ID band
• Rooming in available
• Lab tests
• Greet by name
• Treatments
• Side rails/crib
• Diet and/or NPO

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Preoperative

• Play therapy arts, crafts, toys, socialization
• Parent present- reduces fear and anxiety

• Use drawings, puppets, models, dolls, handle
  stethoscope, dressings, surgical mask
• Bring to hospital favorite toy or article.

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Surgery

• Parent may accompany child to operating room
• Child may take favorite toy to operating room
• lt18 years parents/legal guardians must give
  informed consent.

• Child selects favorite gas (anesthesia).
  Chocolate, watermelon..
• Parents called when child brought to recovery
  room. may be with child

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Explanations

• Infant- explanations given to caregiver
• Toddler- use dolls, puppets, explain 3 days prior
  to surgery

• Preschool- books, art, video explain 1 week in
  advance
• School age- brief explanation, tour, video,
  method for comfort

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Familiar toys

• Child encouraged to bring in blanket, toy
• Child may have less anxiety with familiar object

• With reduced anxiety may need less
  premedication for surgery

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Fears/Anxiety

• Unknown- fear of environment, routine change,
  different people in room
• Separation anxiety (6-30 months)

• When child is hospitalized and parents are not
  able to visit, the child may experience anxiety
• Stages protest, despair, detachment

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Separation anxiety

• Protest child cries, rejects others
• Despair child feels hopeless, becomes quiet and
  withdrawn
• Provide the child with favorite toy or blanket.

• Detachment child becomes interested in
  environment, plays ignores parents..Coping
  mechanism of child to prevent emotional pain of
  separation

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Fears/Shame

• Preschool and school age may have loss of
  independence and loss of self care
• The child needs to have some control
• Shame/guilt preschool may believe he/she did
  something to cause the illness or believe
  thatIllness is a punishment

• Pain and mutilation infants and toddlers view
  intrusion of body as painful
• Loss of control toddlers need rituals, routines
  at this time.
• May have temper tantrums due to frustration
• Toddlers need rituals for feeding, bedtime,
  toileting

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Fears

• Anger related to loss of control, loss of
  friends, pain
• Methods used for release punching bag, clay,
  painting
• Regression common during and after
  hospitalization
• This is normal at this time

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Post operative assessment

• ABC
• Head to toe
• LOC, speech, VS, IV fluids, dressing, drains,
  voiding, pain, breath sounds, nausea, vomiting,

• Bowel function/bowel sounds, extremity movement
• Assess for dehydration, shock, infection

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Pain/ Discharge

• IV medication may be given then oral medication
• Discharge planning begins at admission

• Discharge planner may be needed
• Social service may be used for referrals
• Teach that child may develop behavior changes or
  regression (e.g. withdrawal, aggression,
  demanding bx)

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Physical assessment

• Prepare parents and child for the exam
• Assess each system related to age of the child
• Know the normally for age groups to detect the
  abnormally

• Sequence head to toe
• Growth charts are used to compare child to
  national average
• Normal ranges-5-95

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Physical Assessment

• Length
• Infant to lt2 years measure from top of head to
  heel

• gt 2 years standing height

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Physical Assessment

• Weight
• lt 2 years cover on scale with no clothing on
  child
• Toddler in underpants or light weight gown

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Physical assessment

• For older children weight done in street
  clothes..shoes off, heavy clothing off usually ht
  and wt are the only measurements taken
• Children under 2 years Measure height, weight,
  head circumference, chest circumference,
  abdominal circumference

• For the first year, head circumference is larger
  than chest circumference
• Head- measure above brow, above pinna, around
  occipital prominence
• Chest- measure at nipple line
• Abdominal- measure at umbilicus

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Physical assessment

• Color variations
• Melanin reflects the skin color
• Vitiligopatches of depigmentation

• Jaundicedark skinned infants, jaundice may
  appear darker
• Cyanosisdark skinned infants, cyanosis may
  appear black

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Physical assessment

• Carotenemiaorange to yellow color of skin
• Pallor
• Erythemadiffusely red
• Dark skinned infants may be dusky red to violet

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Vital signs

• Infants- count resp, pulse, (both for 1 min)
• Thermometers used in peds
• Electronic, digital, tympanic
• Axiliary temp used for newborn, premature,
  children under 3 years
• Oral temp for children over 6 years old

lt3
gt6
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Vital signs

• Rectal temp used when no other route available
• Rectal temp not used for
• Preterm, immunosuppressed, rectal surgery, GI
  disorders as bleeding, diarrhea
• Lubricated, rectal thermometer not inserted more
  than 2.5 cm

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Heart rate

• Apical pulse done on children under 3 years,
  children with heart
• Disease, or irregular heart rhythm
• Stethoscope placed on left midclavicular line-5th
  intercostal space
• Over 3 years may use radial pulse

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Respirations

• Infant- abdominal respirations
• Newborns are nose breathers for 3-4 weeks and
  then can breathe through the mouth
• Newborn 30-50/min
• 6-12 months 20-40/min
• 3yr 20-30/min
• 6yr 16-22/min

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Blood Pressure

• Bladder of the cuff is 2/3 the width of the limb
• (if cuff is too large BP reading will be low,
  if too small the BP reading will be high)
• Sites upper arm, wrist, leg or foot
• Arteries used radial, brachial, popliteal,
  posterior tibial
• Preschool/school age explain steps may feel
  like a hug on the arm

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Sites for Measuring Blood Pressure.
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Denver Developmental Screening Test II

• Developmental assessment of children from birth
  to 6 years
• 125 items
• Areas personal social
• Fine motor skills eye hand coordination
• Language understanding
• Large motor skills jumping

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Denver Developmental

• Evaluation
• Observation of child
• Asking parents questions
• Child performing tasks
• This is not an IQ test
• Detects developmental delays and allows for
  intervention

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Safety restraints

• Types mittens, ankle, wrist, vest, elbow, mummy
• Applied for child safety
• Mittens-to prevent pulling at iv tubes, gt,
  dressings
• Elbow- prevents flexion of elbow
• Use after surgery for cleft palate, cleft lip,
  head or neck surgery, iv infusion

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Restraints

• Ankle prevents falls/climbing out of crib
• Vest prevents falls/getting out of bed, crib,
  high chair
• Mummy used for short time for procedures to
  reduce movement
• May be used when IV needs to be started

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Figure 30-10
(From Lowdermilk, D.L., Perry, S., Bobak, I.M.
1997. Maternity womens health care. 6th
ed.. St. Louis Mosby.)
Mummy restraint.
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Restraints

• Nursing remove restraint q2h and exercise limbs,
  check sites for irritation
• Document color, warmth, capillary refill of
  extremities
• Check restraints in 15 min after application and
  then q1h

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Urine specimen

• Tests blood, protein, glucose, bilirubin, drugs,
  metals, electrolytes, infection, ph, specific
  gravity, hormones
• Infant plastic collection bag
• Female- apply skin prep and apply bag around
  labia
• Male- apply skin prep and apply bag around
  scrotum

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Figure 30-12
Alcohol pad
Application of a urine collection bag.
(From Wong D.L., Perry, S.E., Hockenberry-Eaton,
M.J. 2002. Maternal-child nursing care. 2nd
ed.. St. Louis Mosby.)
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Urine Collection

• Cut a slit in the diaper and pull the bag
  through. Will see when child voids
• Older child- clean catch
• Male - have child clean head of penis x3,
  urinate a small amount, stop voiding, void in
  container, empty bladder in toilet, send specimen
  to lab
• Stroke the child's abd w/alcohol prep and fanning
  dry often stimulates urination.

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Urine specimen

• Female - have child clean sides of labia, clean
  meatus,(front to back) urinate a small amount,
  stop voiding, void in container, empty bladder in
  toilet, send specimen to lab
• Document in nursing notes/flow sheet

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Stool specimen

• Test for fat, blood, bacteria, parasites
• Infant obtain from diaper and place in container
• Older child use bedpan, or bedside commode
  place specimen in container and send to lab

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Blood specimen

• Jugular- head and shoulders extended at edge of
  table
• Mummy child
• Physician draws the sample
• Femoral - child in froglike position
• On back may mummy child
• Physician draws the sample

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Jugular Venipuncture
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Mummy Restraint
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Femoral Puncture
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Lumbar puncture

• Child in sitting or side lying position
• Consent needed
• Side lying- nurse has one hand on back of neck
  and one hand behind the knees of the child
• Write down the pressure, color and number of
  samples obtained

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A, Modified side-lying position for lumbar
puncture. B, Older child in side-lying position
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Intake and output

• Infant- weigh a dry diaper
• Weigh the damp diaper and subtract the weight of
  the dry diaper
• 1mg1ml of urine
• Pediatric fluids include jello, gatorade,
  pedialyte, flavored ice, sweetened tea, ice
  cream,
• all children are on io in the hospitals unless
  stated otherwise

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Medication

• Physiological differences of the pediatric
  client
• Absorption child has reduced gastric acidity
• Gastric acidity reaches adult level at 3 years
• Topical medication is absorbed faster due to
  thinner skin and large surface area

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Medication

• Intramuscular absorption varies due to peripheral
  circulation
• Decreased gastric motility reduces medication
  absorption
• Distribution- total body water content is higher
  in infants and children
• Protein binding is less due to immature liver

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Medication

• Blood brain barrier is immature and more drugs
  enter the brain
• Metabolism- metabolic rate is higher in children
  2-6 years
• Microsomial enzymes are less to an immature liver
• Elimination- glomerular filtration is less due
  to an immature kidney

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Medication

• Pediatric doses calculated by
• Mg/kg/day may give divided doses
• Wt is the most common and reliable method to
  calculate drug administration.

• Body surface area
• Oral meds preferred route
• Age birth to 3 months give med before meals when
  child is hungry
• semi-reclining position

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Medication

• Methods nipple, dropper that is calibrated,
  syringe without a needle, spoon, plastic cup
• Angle syringe toward the cheek and give slowly
• Allow child to sit on parents lap
• Do not force child to take med, put medication
  in formula or milk

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OralMedsAdmin
Position the child in a semi-reclining position
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Medication

• Bitter medication may use ice in mouth for a few
  minutes before taking med
• Some medications may be crushed and mixed with a
  sweet syrup
• Suppository use little finger to insert med for
  children under 3 years

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Medication

• Intramuscular- vastus lateralis site for
  children under 3 years
• If the child is over 3 years and was walking for
  over a year, the gluteal sites may be used
• Dorsal gluteal- child on abdomen with toes
  pointed inward
• Use distraction- blowing bubbles, stroke skin
  before, during injection

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IV Medication

• IV has the least variation in absorption
• Methods IV bolus, soluset, syringe pump, central
  venous access site, saline lock, percutaneous
  implanted catheter, implanted venous device

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Medication

• All IV fluids administered by a pump
• Tubing 60-100/gtt/ml
• IV site selected to not limit activity, not on
  dominant side, smallest gauge needed
• The IV site should be checked every hour.

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Medication

• Deltoid site not used for children under 18
  months as the site is not developed until
  adolesence
• Subcutaneous needle length ranges from 3/8 to 5/8
  inch

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Medication

• Otic
• Child is on the side with the affected ear up
• Clean ear as needed
• Under 8 years- pull pinna back and down
• Over 8 years- pull pinna back and up

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Safety

• Primary focus of Nursing care is child safety and
  protection..
• Hospitals are concerned with choking and falls
• Adult must be present when child is eating
• Key locks on doors for security
• Code purple is child abduction

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Medication safety

• Do not disguise medication in food, formula
• Talk about medicine as candy
• Children will know medicine from candy be
  honest
• Do keep medicines in a locked cabinet
• Teach that herbal medication may not be safe for
  children

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Dying child

• Gentle emotional and physical care to child and
  family
• Anticipate grieving know stages of grieving
• Infants and toddlers- have no clear
  understanding of death
• 3-5 years- death may be a sleeplike state
  interchangable with life..

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Dying child

• School age- understand that death is final
• Adolescent- have an understanding of death
• Parents may fear what death may be like
• Children may fear dying alone and fear pain

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Dying child

• Child- encourage the child to talk about their
  feelings
• Encourage drawing, painting, writing to express
  feelings
• Siblings- may have anticipatory grief may
  resent the attention given to the dying child
• Need to included in care of dying child and to
  express feelings

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Support

• Nurse needs support from peers
• Needs empathy, confidence, manage own stress
• Sources of support for the family support
  groups, hospice service, American Cancer Society,
• Home health, relatives, friends,
• Religion