Health Promotion, Restoration, Family, Hospitalized Child - PDF

Health Promotion, Restoration and Maintenance of the Family: The Hospitalized Child Professor Meghan McCrillis DNP PHNL CNE Quinsigamond Community College NUR201 Sharing and Copyright Infringement Any handout...

Health Promotion, Restoration and Maintenance of the Family: The Hospitalized Child Professor Meghan McCrillis DNP PHNL CNE Quinsigamond Community College NUR201 Sharing and Copyright Infringement Any handouts or postings related to course content is the intellectual property of QCC faculty and cannot be shared by any means to other students or outside entities. Health Assessment of Children  It’s all in the approach…..  Be professional  Ask what children and parents prefer to be called  Approach slowly according to developmental stage  Use play to gain trust  Infant or toddler may feel less stressed when examined in parents lap  Make eye contact  Be at the eye level of the child  Allow children to handle equipment when appropriate  BP cuff etc.  Observe family interaction Physiologic Measurements  Vital Signs  Temperature  Pulse  Respiration  Blood pressure  Oxygen saturation  **5th VS = Pain 3 BP Cuff Selection  Cuff bladder width should be at least 40% of the circumference of the upper arm at its midpoint.  Cuff bladder length should cover 80-100% of the circumference of the upper arm. 4 5 The Ins and Outs of Pulse Oximetry Sensor Placement  Foot  Hand  Finger  Toe  Earlobe  Pulsatile blood flow is the primary physiological factor that influences the accuracy of your reading 6 The Hospitalized Child  How children may respond to the stress of hospitalization  Separation anxiety  Regression  Anxiety & fear  Loss of control  Developmental level  Previous experience The Family Unit- Negative Feelings/Stressors  Parents  Siblings   Jealousy Guilt   Insecurity Denial  Anger  Resentment  Depression  Confusion  Strained marriage  Anxiety Nursing Strategies to Reduce Fears  Introduction  Initial contact with child  Establish report by conversing about a favorite toy or TV show  Trusting relationship  Prepare child for all procedures  Use appropriate language, games, play and Child Life Therapy Specialist  Decision-making  Give appropriate choices and follow through  Provide comfort & reassurance  Praise the child, offer toys from home for comfort  Preparing Children for Procedures Developing a sense of…..  Infant: trust  Toddler: autonomy  Preschooler: initiative  School-age Child: industry  Adolescent: identity 10 The Importance of PlaY ActIviTieS  Child Life Department  Playroom  Procedure room  Be creative  Be knowledgeable about child development  Deep breathing exercises….  ROM….  Injections….  Ambulation…. 11 Promoting Safety 12 General Hygiene & Care  Healthy Skin  Bathing  Oral Hygiene  Hair Care  Feeding and Nutritional Care  Intake and Output 13 The Care of Children With Special Needs What parents face on a daily basis…  Accept the child’s condition  Manage the child’s condition on a day-to-day basis  Meet the child’s normal developmental needs  Meet the needs of others family members  Cope with ongoing stress and periodic crisis  Help family members manage their feelings  Educate others about the child’s condition  Establish a support system Impact on the Infant  Infant (Trust)  Impact depends greatly on developmental level and onset of illness  The earlier the onset of a limiting condition, the better the child is able to adapt  Delay in bonding with parent  Motor abilities may be delayed due to confinement to a crib  May associate touch with pain compromising ability to give & receive affection Impact on the Toddler  Toddler (autonomy)  Mastery of locomotor & language skills can be delayed  Overprotective parents may hinder the child from advancing  Separation is the most anxiety producing event (infancy through preschool) Impact on the Preschooler  Preschooler (initiative)  Social development may be delayed  May feel embarrassed if loses an achieved milestone like potty training  May feel guilty if they think they caused the disability  May believe they are being punished Impact on the School-Age Child  School-age (industry)  Physical impairment can affect the ability to achieve & compete  May need to repeat a grade  Feelings of shame, inadequacy & inferiority  Self-esteem can be damaged if viewed as “different” by peers  Strive for independence & control and may refuse to comply with plan of care (POC). Impact on the Adolescent  Adolescent (identity)  At no other time in life is an individual so vulnerable to emotional stress  May grieve for a lost “perfection”  May feel rejected because of personal appearance or inability to engage in activities  May rebel, take risks, noncompliance with POC, & a strained parent-child relationship  May have fear of altered body image Medication and Children: Key Points Kn  Response to Drugs th ow  Child versus Adult pe os di e  Medication Administration c a t  Various Routes p sc ai ri  Pain Management and al n Assessment es  Tools to use ! Response to Drugs: Child versus Adult  Pharmacodynamics  Physiologic immaturity in some body systems can affect how the body responds to the drug  The effect of the drug may be enhanced or diminished  Assess effect as the dosage may need to be adjusted Response to Drugs: Child versus Adult  Pharmacokinetics  Absorption can be altered based on the child's age, weight, and body surface area (BSA).  PO route: Slower gastric emptying, increased GI motility, larger small intestine, higher gastric PH, decreased lipase and amylase secretion.  IM/SC route: affected by muscle mass, muscle tone and perfusion.  Topical route: greater BSA and greater permeability of skin may increase absorption rate Response to Drugs: Child versus Adult  Distribution into the cells  Greater percentage of water than adults  More rapid extracellular fluid change  Decreased body fat  Liver immaturity  Decreased ability to bind drugs for transport  Immature blood-brain barrier allowing permeation of certain drugs Response to Drugs: Child versus Adult  Metabolism is altered due to:  Increased metabolism  Difference in hepatic enzyme production  Immature kidneys until 1-2 years of age  Longer half life, potential for toxicity primarily for drugs excreted by the kidneys.  Rights of Pediatric Medication  Administration… Right  Medication  Patient  Time  Route  DOSE  Documentation  To be educated  To refuse  Form (PO vs IV)  Right approach Pain Management: Right Dosage  The optimal dosage is one that controls pain without causing side effects.  Start with the lower end of the safe dose range and then titrate for effect  Children > 6 months of age metabolize drugs more rapidly than adults & may require higher doses to achieve analgesia.  Doses are calculated based on weight  > 50 kg use adult guidelines because the weight formula may exceed the adult dose. Medicating Children: Various Routes 30  Routes of Med Administration Oral  Infant  Dropper & oral syringe (calibrated), nipple from a baby bottle  45-degree upright position, aim med toward the posterior side of mouth in small amounts allowing infant to swallow.  Toddler  Oral syringe or med cup  Older children  Med cup  Rectal Routes of Med Administration  Not preferred route due to unpredictable absorption and is invasive  Use when child is vomiting or NPO  Ophthalmic  Drops or ointment  Maintain sterile technique  Instill drops into the lower conjunctival sac  Instill ointment from inner canthus outward  Optic  Younger than 3 years: pull pinna (auricle) down and back  Older child and adult: pull pinna (auricle) up and back  Routes of Med Administration  Intramuscular  Use this route only if necessary as in IM vaccines  Needle length and gauge is important (table 13.2)  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  Subcutaneous  Used primarily for certain meds as with insulin and MMR vaccine  Anterior thigh, lateral upper arms & abdomen  Routes of Med Administration  Intravenous infusion  Common route for med delivery for sick children  What to know: knowledge of med, amount to be administered, type of solution used for dilution, compatibility with solution and/or other meds, time to infuse, rate of administration, check for IV site patency, use med infusion pump/syringe  Direct IV push  Dilute when indicated, know the rate of administration i.e. over1-2 minutes or mg/minute. Pain Assessment and Pain Management Operational Definition for Pain Pain is whatever the experiencing person says it is, existing whenever the person says it does.  Accurate Assessment Comfort Appropriate Non-Pharm drug doses Best outcome for child Involve family Establish Pt’s support Trust Education Pediatric Pain Assessment Pain assessment is a major component of nursing care for the child.  Careful assessment and reassessment includes:  Pain assessment as the 5th vital sign  A detailed description of the pain  A detailed history of previous painful experiences.  The use of pain rating scales is essential for the nurse to determine the perception of the child's pain as well as to obtain parent feedback. Continuity is a key element.  Continued assessment/reassessment at regular intervals during pharmacologic and nonpharmacologic interventions for pain. The nurse's failure to assess pain is a critical factor leading to under treatment of pain in children. A comprehensive pain assessment includes… ….not just utilizing a pain scoring tool but also asking the right questions like:  When did it begin?  Is it ongoing or intermittent?  What does it feel like, can you describe it?  Where is it, does it spread anywhere?  What makes it better or worse?  What is your pain level on a scale of 0-10  Not all patients will score a 0/10 even after an intervention, especially a fresh post-op.  Reassessment of pain after an intervention is essential to providing optimal pain management. Pain Assessment Acronym: QUESTT Q: question the child U: use a valid pain scale. Use the same one for continuity E: evaluate behavior and physiologic changes S: secure the parents involvement T: take the cause of pain into account when intervening T: take action Pain Assessment Acronym: Old Carts O – Onset L – Location D – Duration C – Characteristics A – Aggravates R – Relieves T – Timing S – Severity  Behavioral Indications Limb withdrawal, swiping, or Indications of Pain thrashing  Rigidity Physiological Indications  Flaccidity  Dilated pupils  Clenching of fists  Increased perspiration/ diaphoresis  Eyes tightly closed or opened  Increased rate/ force of heart  Furrowing or bulging of brow rate  Quivering of chin  Increased rate/depth of  Pulling ears respirations  Increased blood pressure  Rolling head from side to side  Increased basal metabolic rate  Lying on side with legs flexed on abdomen  Pallor or flushing  Limping  Nausea/vomiting  Refusing to move a body part  Choose Developmentally Appropriate Pain Scale  FLACC Pain Scale: 2 months – 7 years Criteria Score 0 Score 1 Score 2 Face No particular Occasional grimace or frown, Frequent to constant expression or smile withdrawn, uninterested quivering chin, clenched jaw Legs Normal position or Uneasy, restless, tense Kicking, or legs drawn relaxed up Activity Lying quietly, normal Squirming, shifting back and Arched, rigid or position, moves forth, tense jerking easily Cry No cry (awake or Moans or whimpers; Crying steadily, asleep) occasional complaint screams or sobs, frequent complaints Consolability Content, relaxed Reassured by occasional Difficult to console or touching, hugging or being comfort talked to, distractible Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0-2, From The FLACC: A behavioral scale for scoring postoperative pain in young children, by which results in a total score between zero and ten. S Merkel and others, 1997, Pediatr Nurse 23(3), p. 293-297. FACES Pain Scale: 3 years and older Brief word instructions: Point to each face using the words to describe the pain intensity. Ask the child to choose face that best describes own pain and record the appropriate number. Original instructions: Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn't hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you don't have to be crying to feel this bad. Ask the person to choose the face that best describes how he is feeling. Rating scale is recommended for persons age 3 years and older. http://www1.us.elsevierhealth.com/FACES/ Numeric Pain Recommended age:Scale children as young as 8 years  Nonpharmacological Pain Interventions  Behavioral-Cognitive Strategies  Distraction, guided imagery & positive self-talk are easy techniques to learn and can be used with young children.  Biophysical Interventions  Sucking and sucrose, heat & cold packs, and massage & pressure.  Additional interventions requiring specialized training include therapeutic touch, accupressure and reiki.  However, nonpharmacologic interventions are an adjunct to, not a substitute, for pharmacological interventions.  These interventions can also be used to decrease anxiety  Age Appropriate Distraction Techniques AGE METHODS 0 - 2 years Touching, stroking, patting, rocking, playing music, using mobiles over the crib 2 - 4 years Puppet play, storytelling, reading books, breathing, blowing bubbles 4 - 6 years Breathing, storytelling, puppet play, talking about favorite places, TV shows, activities 6 - 11 years Music, breathing, counting, eye fixation, thumb squeezing, talking about favorite places, activities on TV shows, humor Pharmacological Pain Management NSAID’s: Opiods: Mild to moderate pain Moderate to severe pain Acetaminophen (Tylenol) (for Morphine analgesic use only; not an NSAID) Codeine Ibuprofen (Motrin) Fentanyl Ketorolac (Toradol) Meperidine (Demerol) Naproxen (Aleve) Hydromorphone (Dilaudid) Indomethacic (Indocin) Oxycodone (OxyContin) Diclofenac (Voltaren) Hydrocodone Methadone Pharmacological Pain Management  Nonopioids  Attacks pain primarily at the peripheral nervous system (PNS)  Opiods  Attacks pain primarily at the central nervous system (CNS).  Combination drugs  Tylenol with Codeine  Percocet (Oxycodone & Tylenol)  Vicodin (Hydrocodone & Tylenol)  Pharmacological Pain Management  Benzodiazepines as an adjuvant  These drugs are anxiolytics and they relieve anxiety, cause sedation & provide amnesia.  ***They are not analgesics***  Diazepam (Valium)  Midazolam (Versed)  Ceiling Effect  Nonopiods have a ceiling effect which means that doses higher than recommended will not produce greater pain relief unlike Opioids. Opioid Side Effects  Respiratory depression  Sedation  Confusion/hallucinations  Constipation  Nausea/vomiting  Pruritus  Urinary retention  Patient Controlled Analgesia (PCA)  The patient controls the amount & frequency of the analgesic.  Patient-administered bolus  Continuous basal rate  The pump is preset with parameters that will prevent an overdose.  Children who are able to play a video game or computer (5-6 yrs of age) often can successfully use a PCA  Must have enough intelligence, manual dexterity & strength to push the button that operates the pump.  PCA cont’  Nurse or parent controlled analgesia is an option  Continued pain assessment is necessary  Typical uses  Controlling postoperative pain, sickle cell crisis, trauma & cancer  Commonly prescribed opioids  Morphine, Hydromorphone & Fentanyl  Narcan (narcotic antagonist)  Use when patients cannot be aroused, have a slow respiratory rate or are apneic  Ambu bag with mask, O 2  Usually used for post-op Epidural Analgesia patient or in selected cases of terminal cancer Administration  Placed in the epidural space Bolus, continuous of the spinal column infusion or patient-  This method is usually used controlled (PCA). for a short term basis  Drugs  Combination of opioids (Fentanyl, Hydromorphone & Morphine) and long- acting local anesthetic (Bupivacaine)  lidocaine & prilocaine (EMLA) lidocaine & tetracine (Synera)  Penetratesintact skin to provide local anesthesia & decrease pain.  Apply 30 to 60 minutes prior to procedures & cover with an occlusive dressing.  Never apply to abraded skin or mucous membranes.  Useful for:  IV insertion  Lumbar puncture  PICC line insertion  Injections  Suturing Child Maltreatment 57 Definitions of Child Abuse and Neglect Federal Law  Federal legislation provides guidance to States by identifying a minimum set of acts or behaviors that define child abuse and neglect. The Federal Child Abuse Prevention and Treatment Act (CAPTA) (42 U.S.C.A. § 5106g), as amended by the CAPTA Reauthorization Act of 2010, defines child abuse and neglect as, at minimum:  "Any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation"; or "An act or failure to act which presents an imminent risk of serious harm." https://www.childwelfare.gov/can/defining/federal.cfm 58 Neglect & Abuse  Types of neglect  Physical neglect  Deprivation of food, clothing, shelter, supervision, medical care, and education  Emotional neglect  Lack of affection, attention, and emotional nurturance  Emotional abuse  Destroys or impairs child’s self-esteem  Rejecting, isolating, terrorizing, ignoring, corrupting, verbally assaulting, or over-pressuring the child. 59 Physical Abuse  Nonaccidental Trauma (NAT)  Deliberate infliction of physical injury on a child 60 Shaken Baby Syndrome (SBS)  Violent shaking of infants & young children  It is estimated that every year in the United States,1000-3000 children are victims of SBS  25% die as a result of injuries & 80% of survivors suffer from permanent damage  Vomiting, irritability, poor feeding, listlessness, seizures, intracranial bleeding, retinal hemorrhages, ribs & long bone fractures.  Long term effects can be developmental delays at varying levels, hearing loss, blindness, cerebral palsy etc. https://www.health.ny.gov/prevention/injury_prevention/shaken_baby_syndrome/sbs_fact_sheet.htm 61  SBS con’t  In the U.S., the costs of hospitalization and continuing care for SBS victims can total 1.2 to 16 billion dollars each year  Usually results from the caregivers frustration with inconsolable crying  Legislation mandated Shaking Baby Syndrome (SBS) education passed in 2006, and the Massachusetts became the first state in the nation to appropriate funds for this program.  To date, $1,961,778 has been appropriated for this cause.  Education is mandatory as part of discharge teaching in the state of Massachusetts in all birthing hospitals. http://www.hfcm.org/default.asp?id=GrantsByInit&init=41 62  Munchausen Syndrome by Proxy  Also known as medical child abuse  Child may undergo needless and painful procedures and treatments.  Caregiver fabricates signs and symptoms of illness in child to gain attention from medical staff.  The caregiver meets their own psychological needs by having an ill child.  Psychiatric treatment needed. 63 Sexual Abuse  Defined as: “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 such conduct, or rape, molestation, prostitution, or incest with children” The Child Abuse and Prevention Act (Public Law 93-247) 64 Types of Sexual Maltreatment  Incest  Molestation  Exhibitionism  Child Pornography  Child Prostitution  Pedophilia 65 Nursing Care of the Maltreated Child  Identify abusive situations as early as possible  Know the warning signs  History pertaining to the incident  Diagnostic tests  Head to toe skeletal survey, CT, bone scan, specimens for sexually transmitted disease.  Support child  Ask the right questions  Maintain a therapeutic relationship with the family  Evidence of maltreatment  Pattern or combination of indicators that arouse suspicion and further investigation  Protect child from further abuse  Referral to Child Protective Services 66 Mandatory Reporters of Child Abuse and Neglect Professionals Required to Report (Citation: Gen. Laws ch. 119, § 51A) Mandatory reporters include:  Physicians, hospital personnel, medical examiners, emergency medical technicians, dentists, nurses, chiropractors, optometrists, or psychiatrists  Teachers, educational administrators, daycare workers or persons paid to care for or work with children in facilities that provide daycare or residential services, family daycare systems and child care food programs, or school attendance officers  Psychologists, social workers, licensed allied mental health and human services professionals, drug and alcoholism counselors, clinical social workers, or guidance or family counselors 67 Mandatory Reporters of Child Abuse and Neglect cont’  Probation officers, clerk or magistrates of district courts, parole officers, foster parents, firefighters, or police officers  Priests, rabbis, clergy members, ministers, leaders of any church or religious body, accredited Christian Science practitioners, persons performing official duties on behalf of a church or religious body, leader of any church or religious body, or persons employed by a church or religious body to supervise, educate, coach, train, or counsel a child on a regular basis childwelfare.gov 68 Dr. Seuss Inspiration of the Day D R. M E G H A N M C C R I L L I S N U R 2 0 1 P E D I AT R I C S 69