The hospitalized child Pediatrics II Pediatrics 2 The hospitalized child Darlene Curran, RN Prince William County School of Practical Nursing

In Pediatric Health Care Settings… Pediatrics II In Pediatric Health Care Settings… Goal is promoting a positive experience for the child Cheerful, casual, safe atmosphere is important Positive attitude of staff is of the utmost importance The parents should be involved in the preparation and initiation of a treatment or procedure when possible Child should be prepared according to developmental level

Preparing the Child… Infant Toddler and Preschooler Involve parents Pediatrics II Preparing the Child… Infant Involve parents Include familiar objects (blanket, toy, pacifier) Restrain as needed Soothe and hug afterward Toddler and Preschooler Model desired behavior (open your mouth) Tell child it is ok to yell Use distractions Explain treatment in simple terms and give one direction at a time Allow children to handle some equipment while keeping other equipment out of sight

Preparing the Child… School-age Adolescents Pediatrics II Preparing the Child… School-age Explain in advance what the treatment is and why it is needed Allow child to assist with simple tasks (applying tape) Adolescents Explain in more detail Involve in decision-making Encourage questions

Pediatric units are not designed for adults Pediatrics II Pediatric units are not designed for adults Cheerful casual atmosphere Staff wears colorful uniforms Rooms are cheerful and colorful and are considered safe zones No lab sticks or procedures in rooms Child taken to treatment room Special considerations for pediatric patients: Wagons for transport Playroom (another safe zone) Furniture is child-sized

The Child’s Reaction to Hospitalization Pediatrics II The Child’s Reaction to Hospitalization Depends on: Age Amount of preparation given Security of home life Previous hospitalizations Support of family and medical personnel Child’s emotional health Major causes of stress for children of all ages: Separation Pain Fear of body intrusion

Separation Anxiety Occurs in infants age 6 months and older Pediatrics II Separation Anxiety Occurs in infants age 6 months and older More pronounced in toddlers Three stages of coping mechanisms: Protest Despair Denial or detachment

Pediatrics II Regression Reverting back to a lower level of achievement or behavior during stressful situations Examples: Child drinks from a cup at home, but demands a bottle while in the hospital Potty trained child who wets in underwear Walking child who wants to be carried Regression should not be punished When the child is free of the stress that causes the regression, praise will motivate the achievement of appropriate behavior

Cultural Sensitivity Showing cultural sensitivity decreases anxiety Pediatrics II Cultural Sensitivity Showing cultural sensitivity decreases anxiety One cultural group may prize autonomy and initiative, whereas others may tolerate only complete obedience Respecting cultural and religious beliefs will enhance compliance Interpreters should be used if needed in the case of language barriers Approaches to various cultures involve knowing what is and is not acceptable as it relates to: Respecting personal space Smiling Eye contact Touch

The Nurse’s Role Admit new patients to the unit Develop a plan of care Pediatrics II The Nurse’s Role Admit new patients to the unit Develop a plan of care Must be prepared to meet the emotional needs of those involved Encourage parents to be matter-of-fact about the hospital experience Don’t go into great detail about what is going to happen because it may increase the child’s anxiety Focus on the positive aspects Allow patient to bring favorite toy or blanket

Pediatric Action Plans Pediatrics II Pediatric Action Plans Assessment: Describe the condition/illness/disease and the student’s signs and symptoms, along with your actual assessment (5 pts) Diagnosis: P (5 pts) E   S Short Term Goal: (5 pts.) Nursing Interventions (5 pts) Rationale (5 pts) Evaluation: (5 pts) Goal met / Partially met / Not met Explain all: Full head to toe assessment goes here along with a description of the illness ordisease s/sx Only need a short term goal…not a long term goal All pediatric action plans need ONE intervention for therapeutic play and ONE intervention for patient/family teaching.

Hospitalized Infant Used to getting what they want when they want it Pediatrics II Hospitalized Infant Used to getting what they want when they want it Miss continuous affection of their parents Daily schedules are disrupted Major goal: assist with the parent-infant attachment process and promote sensorimotor activities Liberal visiting hours Siblings can visit if not contagious Consistency in caregivers is important at this stage of development

Pediatrics II Hospitalized Toddler World revolves around parents, especially their primary caregiver Parents should return as promised Maintain sense of trust Incorporate habits from home Transitional Object: blanket or toy from home Use terms child understands Preparation & explanation are done immediately before the procedure Distraction is effective to reduce anxiety & pain

Hospitalized Preschooler Pediatrics II Hospitalized Preschooler Operate with concrete thinking, may be better able to understand what is happening Children are afraid of bodily harm Explanations must be made in realistic terms Need to be clear, understandable, and truthful Use non-threatening words Children who ask questions should be complimented and listened to; any misinterpretations should be corrected Teach parents that upon discharge, the child may be demanding and irritable

Hospitalized School-Age Child Pediatrics II Hospitalized School-Age Child In a stage of industry and independence Forced dependency in the hospital can result in a feeling of loss of control and loss of security Can participate in own care and be offered simple choices to foster feelings of independence Choosing own food “Helping” the nurse Common for this age to be “brave” and to show little, if any, fear in situations that are actually quite upsetting Observe body language Nurse’s presence during unfamiliar procedures is comforting

The Hospitalized Adolescent Pediatrics II The Hospitalized Adolescent Experiences feelings of loss of control during hospitalization Is capable of participating in decisions related to treatment and care & can understand the implications of the illness If no pediatrics unit Usually do better with a roommate Avoid placing in a room with a senile patient or an infant 10-13 years Worried about body image and how illness will affect physical appearance, functioning and mobility 14-16 years Anxious about ability to appeal to opposite sex Allow choices, privacy Allow friends to visit 17 and older Primary person of importance is the dating partner Is more concerned with school/work and activities and if they will have to postpone plans

Emancipated Minors Under the age of 18 Pediatrics II Emancipated Minors Under the age of 18 No longer under the parent’s authority Married or in military Laws vary from state to state Be familiar with state law as it applies to adolescent patients

Admission to the Pediatric Unit Pediatrics II Admission to the Pediatric Unit What are the Nursing Responsibilities?

What is Informed Consent? Pediatrics II What is Informed Consent? The parent or guardian must understand: Information given Purpose and risks of any procedures Voluntarily agrees with the procedure Nurse acts as a patient advocate by ensuring the consent has been signed before the procedure Parent or guardian sign consent for treatment, invasive procedures, and surgeries

Pediatrics II Identification ID bracelet must be applied upon admission to the nursing unit Should be snug enough that it can’t be removed by the child Parent/guardian is also given one to wear, and the identification numbers must match what is on the child’s bracelet ID bracelet must be verified before any medication, treatment, or procedure is provided

Taking A Medical History Pediatrics II Taking A Medical History Affords the nurse the opportunity to teach parents about child’s needs as well as injury and illness prevention Immunization history Should also include: Child’s health and eating habits Sleeping Toileting Activity patterns Use of special words or gestures in order to communicate with others

Important Infant/Child Vital Signs Pediatrics II Important Infant/Child Vital Signs BP Pulse Respirations Temp Weight Pain Head Circumference Height/Length

Hospital Safety Measures The Do’s Pediatrics II Keep crib sides up at all times when the child is unattended in bed Identify a child by ID bracelet and NOT by room or bed number Use a bubble-top or plastic-top crib for infants and children capable of climbing over the crib rails Place cribs so that children cannot reach sockets and appliances Inspect toys for sharp edges and removable parts Keep medications and solutions out of reach of the child Prevent cross-infection Take proper precautions whenever oxygen is being administered

Hospital Safety Measures The Do Not’s Pediatrics II Hospital Safety Measures The Do Not’s Do not allow ambulatory patients to use wheelchairs or stretchers as toys Do not leave an active child in a baby swing, feeding table, or high chair unattended Do not leave a small child unattended when out of the crib Do not leave medications at the bedside Do not prop nursing bottles or force-feed small children Do not borrow items such as toys from one child and give to another without cleaning the toy per hospital policy first

Discharge from the Pediatric Unit Pediatrics II Discharge from the Pediatric Unit If possible give parents 24 hours notice of patient discharge to allow arrangements to take off work to pick up patient Approximate hour of discharge should also be given Nurse usually accompanies child and parents to exit Child should be placed in appropriate car seat by parents under supervision of nurse Discharge documentation should include: Final VS Instructions and prescriptions given to the parent or guardian Behavior and condition of the child Time of discharge Method of transportation to the lobby Name of person the child was released to

Restraints, Positioning, and Collecting Specimens Pediatrics II Restraints, Positioning, and Collecting Specimens

Pediatric Restraints Papoose Board Mummy Restraint Pigg-o-stat Pediatrics II Papoose Board Mummy Restraint Pigg-o-stat

Pediatrics II Positioning C

Pediatrics II Lumbar Puncture

Specimen Collection 1 gram of weight = 1 ml of output Pediatrics II Specimen Collection To determine urinary output in infants Weigh the dry diaper in grams & mark the weight on the outside of the diaper Subtract the weight of the dry diaper from the weight of the wet diaper 1 gram of weight = 1 ml of output Urine should not be collected from a disposable diaper because chemicals in the diaper will alter the results Stool sample can be scraped from diaper with a tongue depressor All procedures require cleansing of the perineum with an antiseptic. Always rinse and dry

Applying a Pediatric Urine Collection Bag Pediatrics II Applying a Pediatric Urine Collection Bag

Medicating Children Pediatrics II Harriet Lane Handbook is the #1 choice for dependable dosing of pediatric patients.

Pain Assessment Tools for Children Pediatrics II Pain Assessment Tools for Children

Pediatrics II

Excretion of Medications in Infants and Children Pediatrics II Excretion of Medications in Infants and Children Several differences in infants and children alter the way medications are metabolized Stomach: absence of free hydrochloric acid Intestines: rapid intestinal transmit time Thin stratum corneum (outermost layer of the epidermis) Poor peripheral perfusion Liver: immature function Kidneys: immature function Combination of all of these can result in toxic drug levels and altered responses to medications

Common Drugs Used For Pain Relief In Infants & Children Pediatrics II Common Drugs Used For Pain Relief In Infants & Children Sweet-Ease EMLA cream Acetaminophen (15mg/kg/dose q 4 hr) Motrin (10mg/kg/dose q 6 hr) Opioids Patient-controlled analgesia (PCA)

Pediatrics II Conscious Sedation IV drugs given to impair consciousness but retain the ability to maintain a patent airway and respond to physical and verbal stimuli Used for diagnostic procedures outside the OR A 1:1 nurse-patient ratio till: VS are stable Age-appropriate motor and verbal abilities Adequate hydration Pre-sedation level of responsiveness & orientation

Nursing Responsibilities Pediatrics II Nursing Responsibilities Observe for toxic symptoms whenever medications are administered Document positive and negative responses Every medication administered should have the safety of the dose prescribed calculated before administration

Giving medications with a Syringe Pediatrics II Giving medications with a Syringe The syringe is placed midway back in the cheek Water, fruit juice or frozen ice-pops can be given after medications to help with the taste

IM Injections 1 mL is max volume given in one site Pediatrics II IM Injections 1 mL is max volume given in one site When possible, a second person should assist by distracting and restraining the child

is the preferred site for IM injections in Pediatrics II Vastus Lateralis is the preferred site for IM injections in children under the age of 3

Calculating Drug Doses Pediatrics II Calculating Drug Doses Most drugs in children are dosed according to body weight (mg/kg) or body surface area (BSA) (mg/m2) Must be careful to properly convert body weight from pounds to kilograms before calculating doses based on body weight. Doses are often written as mg/kg/day or mg/kg/dose BSA Calculations will not be on test

Dimensional Analysis Uses basic math and algebra unit x dosage wanted Pediatrics II Dimensional Analysis Uses basic math and algebra unit x dosage wanted Dosage on hand unit to give Problem: 0.025g ordered, you have 12.5mg tabs You know that 1000mg = 1g 1000mg x 0.025mg = 1000 x 0.025 = 25mg 1g ?mg You have: 1 tab x 25mg = 2 tab 12.5mg ? Tabs Each tab is 12.5 mg so you would give 2 tabs

Pediatrics II Let's Do Some Drug Calcs

Pediatrics II Timmy is having surgery. He is supposed to get 2mg of a medication per kg of body wt. The label on the bottle reads 0.5g/5mL. Timmy weighs 50 lbs. How many mL will you give?

Pediatrics II The doctor orders 10 mg of Demerol for an infant after surgery. The label reads 50 mg/1mL. You would give how much?

Your medication comes in 200mg/5ml. How much will you give? Pediatrics II Your patient weighs 45lbs. The order reads to give 7.5mg/kg. How much will you give? Your medication comes in 200mg/5ml. How much will you give?

A child with pneumonia has Keflex ordered at 0.5 g po q 8 hrs. Pediatrics II A child with pneumonia has Keflex ordered at 0.5 g po q 8 hrs. You have bottle with 500mg per teaspoon. How much will you give?

Pediatrics II The doctor orders Pediazole 6ml po q 8 hrs for a child with an ear infection. The child weighs 38 lb. Pediazole contains erythromycin ethylsuccinate 200 mg and sulfisoxazole acetyl 600 mg in a 5 ml suspension. How many mg of erythromycin will the child receive in a 24 hr period? How many mg of sulfisoxazole acetyl will the child receive in a 24 hr period?

Pediatrics II Medication Dose Ordered: 9 mg po tid. Child weighs 13 lbs. The safe dosage is 3 –6 mg/kg/24 hrs. Supplied as 20mg/5ml a. What is the safe 24-hr range? b. Is the ordered dose safe for a 24-hr period? c. How much would you give?

Pediatrics II Medication Dose Ordered: 120 mg po tid. Child weighs 13 lbs. The safe dosage is 30 –60 mg/kg/24 hrs. Supplied as 120mg/5ml a. What is the safe 24-hr range? b. Is the ordered dose safe for a 24-hr period? c. How much would you give?

Pediatrics II Parent Teaching Is essential to ensure compliance when the child is sent home with medications Teaching should include: The importance of administering and completing the medications as prescribed Techniques of measuring and administering each dose Techniques for encouraging child compliance Importance of writing and following a schedule for medication administration

Pediatrics II IV sites for children

Child Receiving IV Fluids Pediatrics II Child Receiving IV Fluids All IVF should be placed on a pump with buretrol Observe the child hourly for Low volume in the bag or the need to refill the burette (buretrol) The rate of flow of the solution Pain, redness, or swelling at the needle insertion site Moisture at or around the needle insertion site An accurate I&O is kept for all children receiving IV fluids Protection of the IV site means you may have to restrain the extremity with a pediatric arm board

Pediatrics II Buretrol IV Tubing Buretrol or Burette tubing should be used on all pediatric patients The chamber contains the amount of solution to be administered in 1 hour This reduces the risk of the child receiving too large of a fluid bolus and cause fluid overload

Pediatrics II Syringe Pumps Control small volumes of fluids

Pediatrics II IV Fluid Calculations Formula to calculate the daily rate of pediatric maintenance IV fluids is: 100ml/kg/day for the first 10 kg of body weight 50ml/kg/day for the next 10 kg of body weight 20ml/kg/day for each kg above 20 kg of body weight

Formula for IV fluids: 100ml/kg/day for the first 10 kg Pediatrics II A child weighing 18 lb is receiving maintenance IV fluids. What would the daily IV fluid volume be for this child? What would the hourly rate be? Let’s Break It Down: Change pounds to Kg 18/ 2.2 = 8.18 or 8.2 kg Formula for IV fluids: 100ml/kg/day for the first 10 kg 100ml x 8.2 = 820ml/day 820 ml / 24 hrs = 34.1 or 34 ml/hr

Nutrition, Digestion, and Elimination Pediatrics II Nutrition, Digestion, and Elimination Gavage feeding (NG tube) Gastrostomy (PEG Tube) Review 520, skill 22-10 for feeding Brown or green drainage may indicate that the tube has slipped from the stomach into the duodenum. This can cause an obstruction and is reported immediately

Pediatrics II Enemas Administration is essentially the same as with adults with these modifications: Type of solution: Saline only, no tap water Amount: exact amount should be prescribed Distance of insertion: 1 to 4 inches according to size of child Infants & small children may not be able to retain the solution May need to hold buttocks together for a short time

Pediatrics II Tracheostomies Child is unable to talk or cry so needs to be in highly visible area Trache can quickly become plugged by mucus or other secretions and cause the child to suffocate Plastic or silastic tubes are used because they are more flexible and reduce crust formation Suction as necessary when you hear: Noisy breathing, bubbling of mucus, moist cough or respirations

If you must suction... Suction only as you withdraw the catheter Pediatrics II If you must suction... Suction only as you withdraw the catheter Limit suctioning to no more than 10 seconds Patient can become hypoxic and you cause the lung to collapse St. Jude recommends suctioning no longer than 5-10 seconds. Limit depth of suctioning to the length of the trache tube or till you stimulate coughing Bag to give 2-3 breaths between suctioning Clear the catheter with sterile water between insertions Discard after use unless in-line catheter is used on a vented patient

Oxygen Therapy Can be given via several adjuncts: Pediatrics II Oxygen Therapy Can be given via several adjuncts: Mist tent: keeps cool, humidified oxygen environment Blow-by: blows oxygen by the nose/mouth Child should not be given stuffed toys, mechanical, battery operated or electronic toys When weaning off O2 need to watch sats Increased restlessness, pulse, resp. rate or dropping sats mean that the child is not tolerating the weaning process

Pediatrics II Review how to clear airway obstructions in Infants & Children There may be test questions ;-)