The Hospitalized Child

1
The Hospitalized Child

• Four primary problems of the Pediatric Nurse when
  dealing with the hospitalized child
• Separation Anxiety
• Loss of Control
• Pain management
• Diversional Activities reflective of
  developmental stage of client

2
The Hospitalized Child

• Separation Anxiety!
• Early Childhood
• Protest
• Despair
• Detachment
• Later Childhood
• Loneliness
• Boredom
• Isolation
• Attitude is everything!

3
The Hospitalized Child

• Loss of Control!
• Early Childhood
• Trust
• Limitation of movement
• Regression
• Fantasy (can not synthesize beyond senses)
• Later Childhood
• Loss of independent activities
• Depersonalization
• Attitude is everything!

4
The Hospitalized Child

• Pain!
• Fallacies
• Infants do not feel pain
• Children tolerate pain better than adults
• Children can not tell you where they hurt
• Children always tell you the truth about pain
• Children become used to pain and painful
  procedures
• Pain intensity is reflected by a childs behavior
• Opioids are too dangerous for children

5
Pain AssessmentSubjective
6
Pain AssessmentObjective

• Body rigidity, thrashing about, loud crying,
  restlessness
• Flushing of skin
• Blood Pressure, pulse, resp increase
• Pupils Dilate
• O2 Sat decreases
• These are less reliable than subjective- better
  to believe what the child tells you than to rely
  on objective signs

7
Pain Management

• Non-pharmacological
• Involve Parents
• Prepare the child without planting the idea of
  pain
• Distraction
• Cutaneous Stimulation
• Rewards

8
Pain Management

• Pharmacological
• Right Drug
• opioids vs non-opioids?
• Right Dose
• body weight
• Parenteral vs Oral doses

9
Pain Management

• Pharmacological
• Right Route
• Oral
• IM
• EMLA
• buffered lidocaine
• IV
• Side effects
• Attitude is everything!

10
Diversional Activities

• Play is the work of children and is critical in
  their development
• JCAHO requirements
• puts children in charge- all children even the
  sick ones!
• Play Room
• should be a sanctuary

11
The Hospitalized Child

• Care Plan
• Fear related to separation anxiety
• withdrawal
• regression

12
The Hospitalized Child

• Care Plan
• Alteration in comfort related to pain
• Non-pharmacological
• Pharmacological
• Side Effects

13
The Hospitalized Child

• Care Plan
• Powerlessness related to hospitalization

14
The Hospitalized Child

• Care Plan
• Diversional Activity Deficit related to
  immobility and hospitalization
• Activity Levels
• Adequate rest

15
Pediatric Variations from AdultsAssessment and
Techniques

• Safety!
• Language!
• Medication Administration!
• PO
• IM
• IV
• PR

16
Positioning

• Lumbar Puncture
• lie on side with knees flexed to the abdomen and
  chin flexed to chest
• infant- two hands
• child- lean over body using forearms against the
  thighs
• Papoose Board/ Mummy Restraint
• IVs, phlebotomy, suturing,

17
Normal Pediatric Heart Rates- Always Apical!!

• Newborn- 120-170
• 1 year- 100-130
• 3 years 80-120
• 5 years- 70-110
• 10 years 60-100
• affected by fever, dehydration, respiratory
  illnesses and drugs

18
Respiratory Rates- Abdominal rather than chest
movements!!

• Newborn 30-60
• 1 year 24-40
• 3 years 24-30
• 6 years 18-22
• 10 years 12-20
• Affected by anxiety, fever, drugs, illness

19
Blood Pressures- neonatal, infant, child, small
adult cuffs

• Newborn 70/50
• 1 year 90/50
• 3 years 90/60
• 6 years 100/60
• 12 years 110/60
• 18 years 120/70
• affected by pain, dehydration, anxiety

20
Temperature an elevated temperature is called a
fever!!

• Any temp. gt100.5 in a childlt3 mos- is serious-
  seek medical attention!!
• Mercury Glass Thermometer
• oral- no seizure, 4 or older, 3 minutes, under
  tongue
• rectal- lubrication, 2 minutes, usually younger
  than 2, insert 1/2 inch (no immunosuppressed!!!)
• both require protective sheath!

21
Temperature- continued

• Axillary- last resort- usually in public places,
  seizure prone and immunosuppressed!
• Press arm close to side- hold in place 6 minutes!
  
• Rectaloral plus 1 degree or axillary plus 2
  degrees
• Oral axillary plus one degree

22
Temperature- continued

• Tympanic- not recommended for children less than
  2 years- but is done all the time!
• Use probe cover
• pull pinna back and down, insert probe covering
  entire canal, parallel to face, then rotate
  towards mouth- like speaking into telephone-
  press scan button. Discard probe.

23
Oxygen saturation- normal- 95 or greater!

• Indicated in any patient with abnormal vital
  signs, cough, excessive secretions, sedation, or
  whenever the nurse feels it is necessary.
• Spot check vs continuous
• Usually children require taping probe over
  thumbnail nail or large toenail, can also use
  pinna of ear
• Measurement of oxygenation as well as perfusion!

24
Intake and Output

• Measured in ccs or mLs- useless without daily
  weights!
• 1 gram 1cc (1,000 grams 1Kg1liter!)
• Used on the following- renal disease, IV fluids,
  surgery, DM, hypovolemic, dehydrated (vomiting),
  CHI, burns, CHF, certain medications, meningitis
  (ICP)
• Weigh all diapers!

25
Specimen Collection (less than 5 years old)

• Venipuncture- usually do not use a vacutainer on
  children- a 20-25 gauge needle with a syringe-
  usually 3 ccs enough. Do not put in regular
  blood tubes, but rather pedi bullets. Can do a
  heel stick if unable to get blood on kids less
  than 1- need lancet and micro-sized collection
  tubes. Must wipe away the first drop of blood.

26
Specimen Collection- Urine

• Cath
• Clean Catch
• Pedibag- clean meatus before applying the bag
  with a soap solution, sterile water, and sterile
  gauze - wipe from the tip of the penis towards
  the scrotum or from the clitoris towards the anus
  on three separate wipes.
• Attach the bag with adhesive tabs around the
  labia or around the scrotum
• Should be done before any other specimen
  collection!

27
Specimen Collection- Throat Culture

• Open the culturette- do not let it come into
  contact with anything- hold in dominant hand.
  (contains two swabs in one) Have patient open
  mouth and say AHHH. (May need tongue depressor
  to get tongue out of way) Do not let swab come
  into contact with the tongue- swab each tonsil
  with a different swab. Expect patient to gag!
  Place swab back into culturette tube- Label!!