Pediatric Nutrition and Care Essentials

Pediatric Nursing Interventions

• Objectives: Discuss standards of practice and ethical considerations in pediatric clients. Describe the eight rights of pediatric medication administration. Integrate concepts of atraumatic care in medication administration. Discuss important concepts related to health assessment in children. Distinguish normal variations in physical examination from differences indicating serious issues.

Role of Therapeutic Relationships

• Goal-directed
• Mutual respect and trust
• Empathy
• Advocacy
• Avoidance of extremes in relationship continuum

Developmentally Appropriate Care

• Children are not mini-adults; they are developing in many realms.
• Use appropriate assessment tools (FLACC, FACES, NIPS, etc.)

Safety

• Medication errors
• Hospital-acquired infections
• Wrong surgery/site incidents
• Falls
• Skin breakdown
• Abduction

General Care

• Safety: Two patient identifiers, nurse maintains hand contact, medication precautions.

Hygiene

• Maintain healthy skin (turn every 2 hours)
• Bathing
• Hair care (at least 1-2 times per week)
• Diaper changes (at least every 3 hours with feeds/temps)
• Oral hygiene

Feeding Issues

• Feeding is work for infants; refusal to eat is common due to control issues.
• Allow choices.
• Make eating interesting.

Feeding an Infant

• 1-3 months: 3-5 oz formula
• 3-6 months: 5-6 oz formula
• 6-12 months: 6-7 oz formula
• Normal feeding schedule: 3-4 hours
• Remember to burp
• Do not allow feeding to extend beyond 20-30 minutes.
• Do not prop bottle (prevents choking and aspiration).

Alternative Feeding Techniques - Enteral

• Gavage feedings
• NG
• OG
• Gastrostomy feedings
• Jejunostomy feedings
• Continuous drip or intermittent (bolus) feedings

Skin-Level Gastrostomy Device

• A device used for feeding.

Improving Absorption of Feeds

• Use pacifier during alternative feeds; non-nutritive sucking improves digestion.
• Quiet, calm environment.
• Consistent feeding techniques by caregivers/family members.

Alternative Feeding Techniques - Parenteral

• TPN (Total Parenteral Nutrition)
• Interventions: Administer through a central line, use an in-line filter, check blood glucose, use aseptic technique, monitor vital signs (VS), monitor for infection, monitor for electrolyte imbalances, keep system closed (avoid air embolism), avoid administering medications through TPN line.

Medication Administration

• Eight rights of medication administration:
  • Right medication
  • Right patient
  • Right time
  • Right route (most commonly reported error)
  • Right dose
  • Right documentation
  • Right education
  • Right to refuse

Differences in Pediatrics (esp. Infants)

• Medications affected by higher percentage of body water, decreased body fat, liver immaturity, decreased plasma proteins available for binding, limited renal excretion.
• Oral medications: Slower gastric emptying, increased intestinal motility, higher pH, decreased lipase/amylase.
• Intramuscular: Faster absorption in infants due to muscle mass and tone.
• Topical: Increased absorption due to greater body surface area.

Differences in Pediatrics

• Pediatric dosages based on weight, body surface area (BSA), and maturation of body organs.

Oral Medication

• Greater risk of aspiration in children <6 years.
• Use liquids/crush & mix with small amount of liquid.
• Use calibrated equipment (oral syringe).
• Direct liquid to posterior side of mouth, small amount at a time.

Oral Medications (cont.)

• Use syringe/nipple
• Do not mix with formula (can turn away).
• Do not refer to as candy.
• Mix with small amount of syrup, applesauce, ice cream.
• Use popsicles to numb tongue.
• Use a "chaser" if appropriate.

Devices for Delivering Medication to Children

• Shows various devices for delivering medicine to children.

Rectal & Otic Administration

• Rectal: <3 years use fifth finger (pinky); >3 years use index finger.
• Otic: <3 years pull pinna down and back; >3 years pull pinna up and back.

Intramuscular Medications

• Preferred site: vastus lateralis (upper thigh).
• Deltoid may be used in children >5 years.
• Dorsogluteal not recommended under age 5.
• Needle size: Approximate 22-25 gauge/5/8 - 1 inch in younger children.
• Volume: 0.5 ml- 1 ml...school age 1.5-2ml.
• EMLA (helps numb the skin).

Intravenous Medications

• Use atraumatic care when inserting/removing PIV.
• EMLA, parent participation, therapeutic hugging, adhesive remover.
• Care must be taken to prevent fluid overload (<10 kg = 100 ml/kg/day).
• Always use a pump (syringe pump, "Buretrol" volume control device).
• Maintenance fluids much less in pediatrics.
• Prevent complications: Inspect site every 1-2 hours; change dressing and tubing per institution protocol.

Types of Venous Access

• Heplock (1-3 cc saline), I-Port (5cc saline---5cc 10 unit heparin), Broviac (3cc saline---3cc 10 unit heparin), PICC. Use at least 5 cc syringe!!!! Read Kardex for protocol.

Pediatric Health Assessment

• General information and key points about pediatric health assessments.

Health Assessment (cont.)

• Expert nurses evaluate patients constantly to evaluate willingness to cooperate.
• Allow "warm-up" periods.
• Alter exams to accommodate children's developmental level.
• Least invasive first (observation, auscultation, etc.).
• Involve children and families in examinations.
• Praise child for cooperation

Health Assessment (cont.)

• Perform assessment in a warm, well-lit, non-threatening environment.
• Examine child in a secure comfortable position.
• Get child involved (e.g., "blow out candles" during lung examination).
• Use age-appropriate language.
• Encourage questions from child/family.

Vital Signs

• Temperature (Normal: <37.7°C (99.9°F); report immediately young infant with temp > 38.0°C; older infants/children a fever is > 38.5°C).
• Pulse (higher in infants, slows as you grow; normal: "100ish" children under 12 should always have pulse greater than 60/minute).
• Respirations (higher in infants, slows as you grow; normal: "20-30ish" in infants/toddlers; "20ish" preschool & school age).
• Blood pressure (BP: lower in infants, gets higher with age; normal: "60-80/40-50" in infants; "100ish/50-70" in children).

Health Assessment (cont.)

• Evaluate growth using standardized growth charts (height, weight, head circumference <3 years).
• Example: http://www.cdc.gov/growthcharts/data/set1clinical/cj411017.pdf.

Health Assessment (cont.)

• General: muscle tone, body odor, eye contact (can be a sign of abuse or autism), follows commands, speech/language, motor skills, interaction with family.

Health Assessment (cont.)

• Skin, hair, nails, lymph nodes, head shape, fontanels (indications of hydration: posterior closes 2-3 months; anterior closes 12-18 months).

Health Assessment (cont.)

• Face, neck (assess ROM), eyes (visual acuity after 3 years old, corneal light reflex symmetrical by 4-6 months, PERLA, red reflex permanent color manifests by 1 year old).
• Ears (hearing, alignment, non-tender external exam, internal, 3 years or younger- pinna down and back, older than 3- pinna up and back), Nose, Mouth and throat (visible tonsils, first 2 years: age child in months- 6= number of teeth).
• Thorax and lungs (infant chest shape almost circular, <7 years of age abdominal movement during respirations).
• Assess for retractions, increased respiratory rate, increase respirations if noted, act quickly

Health Assessment (cont.)

• Heart/pulses: sinus arrhythmia associated with respirations is common; innocent murmurs common in children listen upright and reclined, PMI (infant to 4 years of age, 4 ICS medial left clavicular line, 4-6 years- 4 ICS left midclavicular line, 7 years and older- 5 ICS left midclavicular line). Listen to all four valvular areas, Pulses (infant-brachial, femoral).
• Abdomen, infants and toddlers have rounded abdomen, genitals are assessed male-locate testes, examine scrotum, examine meatus, assess for adhesions female-assess for discharge, adhesions, anus
• Musculoskeletal examination of spine, muscle tone, joints (swelling, redness, pain). Note gait, toddler normally bowlegged. Preschooler may appear knock-knee. Note feet and shoes.

Health Assessment (cont.)

• Neurologic system (innate reflexes, DTR, language, cognition, fine and gross motor development.