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• Health Promotion, Restoration and Maintenance of the Family: The Hospitalized Child

Health Assessment of Children

• Child health assessment requires a professional approach
• Address children and parents by their preferred names
• Adjust approach based on the child's developmental stage
• Using play can help gain the child's trust
• Infants and toddlers may feel more comfortable being examined in a parent's lap
• Make eye contact and be at the child's eye level
• Appropriately allow children to handle equipment, such as a BP cuff
• Observe family interactions during the assessment

Physiologic Measurements

• Vital signs include temperature, pulse, respiration, blood pressure, and oxygen saturation
• Pain is considered the 5th vital sign
• When taking an apical pulse in children younger than 7, place stethoscope lateral to the left midclavicular line and fourth intercostal space
• When taking apical pulse in children older than 7, be lateral to the left MCL and fifth ICS

BP Cuff Selection

• The cuff bladder should be at least 40% of the upper arm circumference at its midpoint in width
• Cuff bladder length should cover 80-100% of the upper arm circumference
• Blood pressure sites can be the upper arm, lower arm or forearm, thigh, and calf or ankle

The Ins and Outs of Pulse Oximetry

• Pulse oximetry sensor placement can be on the foot, hand, finger, toe, or earlobe
• Pulsatile blood flow is the primary factor affecting the accuracy of the pulse oximetry reading

The Hospitalized Child

• Children may respond to hospitalization with separation anxiety, regression, anxiety and fear, and loss of control
• Their response is impacted by developmental level and previous experiences

The Family Unit: Negative Feelings/Stressors

• Parents may experience guilt, denial, anger, depression, and strained marriage
• Siblings may experience jealousy, insecurity, resentment, confusion, or anxiety

Nursing Strategies to Reduce Fears

• Introduce yourself to the child
• Establish rapport by talking about favorite toys or TV shows
• Create a trusting relationship
• Prepare the child for all procedures, using appropriate language, games, play, and Child Life Therapy Specialists
• Offer choices and follow through
• Provide comfort and reassurance
• Praise the child, and offer toys from home for comfort

Preparing Children for Procedures

• Infants need to develop a sense of trust
• Toddlers need to develop a sense of autonomy
• Preschoolers need to develop a sense of initiative
• School-age children need to develop a sense of industry
• Adolescents need to develop a sense of indentity

The Importance of Play Activities

• Utilize the Child Life Department, playroom, and procedure room
• Be creative and knowledgable about child development when using play
• Deep breathing exercises, ROM, injections, and ambulation are good activities

General Hygiene & Care

• Provide healthy skin care, bathing, oral hygiene, hair care, feeding and nutritional care, and monitor intake and output

The Care of Children With Special Needs

• Decline in mortality rate increases with health care needs for children with special needs
• Focus on developmental, not chronological, age
• Maximize independence and minimize the effects of chronic conditions
• Provide family-centered care by assessing the family's response to illness, involving the family in care, and assisting the family to promote maximum growth and development
• Common chronic childhood conditions include respiratory issues such as asthma, speech and sensory impairments, as well as mental and nervous system disorders
• While hospitalized make sure to determine how a child is taken care of at home, maintain routines, respect the family's expertise in care, be attentive to parents/caregiver, hold care conferences for sharing mutual concerns and encourage independence/self-care
• Parents face the daily challenge of accepting and managing the child's condition
• Parents must meet the child's and other family members' needs
• It's important for parents cope with ongoing stress and periodic crisis, help family members manage their feelings, educate others, and establish a support system

Impact on the Infant (Trust)

• The impact of a child's condition depends on developmental level and onset of illness
• The earlier the onset of a limiting condition, the better the child is able to adapt
• Such conditions may delay bonding with parent and motor abilities due to crib confinement
• Infants may associate touch with pain affecting their ability to give and receive affection

Impact on the Toddler (Autonomy)

• Potentially delays mastery of locomotor and language skill
• Overprotective parents may hinder advancement
• Separation can cause anxiety from infancy through preschool

Impact on the Preschooler (Initiative)

• Social development may be delayed
• May feel embarrassed to lose milestones
• Guilt can be felt if they think the disability caused
• May believe believe they are being punished

Impact on the School-Age Child (Industry)

• Any Physical impairment may affect the ability to achieve and compete
• May need to repeat a grade, and feel shame, inadequacy & inferiority
• Self-esteem can be damaged if viewed as “different” by peers
• Can strive for independence & control; may refuse care plan (POC) compliance

Impact on the Adolescent (Identity)

• This stage of life is considered vulnerable to emotional stress
• May grieve a lost "perfection"
• Rejection may be felt for personal appearance or inability to engage in activities
• Is considered an identity stage
• Strive for independence/control; may refuse care plan (POC) compliance
• Can have a strained parent-child relationship
• Can have fear of altered body image

Medication and Children: Key Points

• Pediatric medication considerations include response to drugs, differences in child versus adult responses, routes, medication administration, pain management, and assessment

Response to Drugs: Child versus Adult

• Pharmacodynamics refers to how the body responds to a drug
• Physiologic immaturity in body systems affects pharmacodynamics in children
• Drug effects may be enhanced or diminished, meaning that the dosage may have to be adjusted

Response to Drugs: Child versus Adult: Pharmacokinetics

• Absorption can be altered based on age, weight, and body surface area (BSA)
• PO route: Can have slower gastric emptying, increased GI motility, larger small intestine, higher gastric pH, decreased lipase and amylase secretion
• IM/SC route: Is affected by muscle masss, muscle tone, and perfusion
• Topical route: Greater BSA and greater permeability of skin leads to increase absorption rate

Response to Drugs: Child versus Adult: Distribution

• Distribution of drugs into cells differs in children
• Children have a greater percentage of water, more rapid extracellular fluid change, decreased body fat, and liver immaturity
• There is a decreased ability to bind drugs for transport and immature blood-brain barrier

Response to Drugs: Child versus Adult

• Metabolism is altered due to increased metabolism, difference in hepatic enzyme production, and immature kidneys until 1-2 years of age
• May have a longer half-life; potential for toxicity primarily with kidney-excreted drugs

Rights of Pediatric Medication Administration

• The standard "rights" of medication administration include the right medication, patient, time, route, and dose
• You must also ensure documentation, education, honoring the right to refuse, form (PO vs IV), and right approach

Pain Management: Right Dosage

• The goal is optimal dosage for pain control without side effects
• Treatment is commonly started at the lower end of the does range
• 6+ month old children metabolize drugs more rapidly. May need larger doses to achieve analgesia
• Doses should be weight based, but >50 kg patients should use adult guidelines

Routes of Med Administration

Oral

• Infants: Use a dropper or oral syringe (calibrated) or nipple from a bottle; give in 45-degree upright position, aiming toward the posterior side of the mouth in small amounts
• Toddlers: Use an oral syringe or medication cup
• Older children: Utilise medication cup

Rectal

• This route is not preferred because of unpredictable absorption and is invasive, but useful if a child is vomiting or NPO

Ophthalmic

• Administer drops or ointment while maintaining sterile technique
• Instill drops into the lower conjunctival sac and instill ointment from the inner canthus outward

Optic

• For children younger than 3 years, pull the pinna (auricle) down and back
• For older children and adults, pull the pinna (auricle) up and back

Intramuscular

• Should be performed only if neccessary for IM vaccines
• Infants (birth-12 month) = vastus lateralis
• Toddlers (1-3 yr) = vastus lateralis or deltoid
• Preschooler (3-6 yr) = vastus lateralis, deltoid or ventrogluteal
• School age (6-12 yr) = vastus lateralis, deltoid, ventrogluteal or dorsogluteal
• Needle length and gauge is important

Subcutaneous

• This is commonly used primarily with certain meds and vaccines
• Insert in anterior thigh, lateral upper arms & abdomen

Intravenous infusion

• Common for sick children
• Important to knowmed, amount, solution, compatibility, time, rate, patancy, use medinfusion pump/syringe

Direct IV push

• Dilute solution when indicated, know the rate
• Administration over 1-2 minutes or mg/minute

Pediatric Pain Assessment

• Pain assessment is a major component of nursing care for children
• Assessment and reassessment includes pain assessment, description of the pain's history, and previous painful experiences
• Must use pain rating scales and re-evalaute pharmacologic and nonpharmacologic interventions

Comprehensive Pain Assessment Questions

• When did it begin? Is it ongoing or intermittent?
• What does it feel like, can you describe it?
• Where and does it spread? What makes it better or worse?
• What is your pain level on a scale of 0-10?
• Reassessment of pain after an intervention

Pain Assessment Acronyms

• QUESTT: Question the child, Use a valid pain scale, Evaluate behavior and physiologic changes, Secure parental involvement, Take the cause of pain into account, and Take action
• OLD CARTS: Onset, Location, Duration, Characteristics, Aggravates, Relieves, Timing, and Severity

Indications of Pain

• Behavioral indicators include Limb withdrawal, swiping, thrashing, rigidity, flaccidity, eye clinch, brow furrow, pulling ears, and refusing body parts from use
• Physiological indications include dilated pupils, diaphoresis, heart rate change, respirations change, increased blood pressure and basal metabolic rate, pallor or flushing, and nausea/vomiting

Pain Scales

• Choose appropriate pain scale appropriate for the child's development
• Faces
• Oucher
• Poker Chip
• Visual Analong
• Numeric pain scale
• Verbal Rating
• FLACC

Nonpharmacological Pain Interventions

• Behavioral-Cognitive Strategies: Distraction, guided imagery & positive self-talk
• Biophysical interventions: Sucking and sucrose, heat and cold packs, massage
• Specialized interventions: Therapeutic touch, acupressure, reiki

Age-Appropriate Distraction Methods

• 0-2 years: Touching, stroking, patting, rocking, melodies, mobiles
• 2-4 years: Puppet play, storytelling, books, breathing, bubbles
• 4-6 years: Breathing, storytelling, favorite things
• 6-11: Music, breathing, eye fixation, squeezing, humor

Pharmacological Pain Management

• Mild to moderate pain: Use Tylenol, Motrin, Ketorolac, Aleve, Indocin, and Voltaren
• Moderate to severe pain: Use morphine, codeine, fentalyl, demerol, dilaudid, oxycontin, hydrocodone, and methadone
• Nonopiods: Attacks pain primarily at the peripheral nervous system (PNS)
• Opiods: Attack pain primarily at the central nervous system (CNS).
• Combination drugs: Tylenol with Codeine or Percocet (Oxycodone & Tylenol) and Vicodin (Hydrocodone & Tylenol)
• Benzodiazepines can be used as adjuvants to relieve anxiety and cause amnesia
• Nononpioids have have a ceiling effect but opiiods do not

Opioid Side Effects

• Respiratory depression
• Sedation
• Confusion/hallucinations
• Constipation
• Nausea/vomiting
• Pruritus
• Urinary retention

Patient-Controlled Analgesia (PCA)

• A PCA gives the patient control over the amount & frequency of the analgesic with a patient administered bolus
• Pumps can be preset with parameters to prevent an overdose
• Is for 5-6 year old with with inteligent enough to use a video game or computer
• PCA needs enough intelligence, manual dexterity & strength to push pump button
• RN or parents can also control analgesia

Common Prescribed Opioids in PCA

• Morphine
• Hydromorphone
• Fentanyl
• Continued pain assessment is necessary while using the medication and PCA
• Use for postoperative pain, sickle cell crisis, trauma, and cancer pain
• Narcan (narcotic antagonist) can be used if the patient cannot be aroused or has a slow respiratory rate or is apneic

Epidural Analgesia

• Commonly used for post-op patients and patients in select cases of terminal caner
• Placed in the epidural space of the spinal column
• Short term approach
• Combination of opioids and long-acting local anesthetics (bupivacaine) used
• Can be given as a bolus, continuous infusion, or PCA

Topical Anesthetics

• Lidocaine & prilocaine (EMLA) and lidocaine & tetracaine (Synera) penetrate intact skin to provide local anesthesia & decrease pain
• Apply 30 to 60 minutes prior to procedures & cover with an occlusive dressing
• Do not apply to abraded skin or mucous membranes
• Injected for IV inserton, lumbar puncture, PICC line insertion, injections and suturing

Child Abuse

• Report any recent act or failure to act by a parent or caretaker, resulting in death or abuse

Types of Neglect

• Physical: Deprivation of food, clothing, shelter, supervision, medical care, and education
• Emotional: Lack of affection, attention, and emotional nurturance

Emotional Abuse

• It destroys impairs a child's self-esteem by rejecting, isolating, terrorizing, ignoring, , verbally assaulting, or over-pressuring

Physical Abuse

• Nonaccidental Trauma results from the deliberate infliction of physical injury on children

Shaken Baby Syndrome (SBS)

• Results from the violent shaking of infants & young children
• It can lead to injuries and permanent damage
• Long-term effects are developmental delays, hearing loss, blindness, and cerebral palsy

Sexual Abuse

• According to The Child Abuse and Prevention Act (Public Law 93-247), the use, persuasion, or coercion of any child to engage in sexually explicit conduct (or any simulation of such conduct) for producing any visual depiction of conduct, or rape, molestation, prostitution, or incest with children

Types of Sexual Maltreatment

• Incest
• Molestation
• Exhibitionism
• Child Pornography
• Child Prostitution
• Pedophilia

Mandated Reporters

• Nurses, physicians, and other health professionals are mandated reporters
• Head-to-toe skeletal survey, CT, bone scan, and specimens for sexually transmitted diseases can be used as diagnostic tests
• Pattern of indicators for maltreatment of a child warrant further investigation
• Report child to protective services