What is

What isPaediatric Nursing?

On children

• It takes special understanding to know children

• They are complex, they are hard to understand

• They are different• They are valuable• They are vulnerable• They have a need to be loved and to

be valued

Paed-iatric, (Pais Iatros)• Pais = Latin = child• Iatros = Greek = physician, to

treat or ‘hospital’ (‘iatrogenic’)

The Americans don’t know much Latin and consequently they have confused ‘Pais’ with the Latin ‘Ped’. Probably, after the French variant of ‘pais’ (‘ped’). Hence the US ‘pediatric’ (foot physician).

Just words

The term ‘pediatric’ was first used in the USA, from

about the middle of the nineteenth century.

The first time it was used

in the UK was in 1928 when Sir Frederick Still gave birth to the British

Paediatric Association. He put an ‘a’ in the word to be true to correct Latin usage.

Forfar, J. O., A. D. M. Jackson, et al. (1989). The British Paediatric Association 1928-1988. London, The Royal College of Child Health and Paediatrics.

Children’s Nurse• Is modern usage• Grammatically incorrect

(where do you put the apostrophe ?)

• What is a nurse – therapist – physician’s attendant or carer?

What IS a child?

Children:• Are louder than adults• Get into trouble faster• Fall off a theatre trolley

faster than an adult• Will never take their

medicine but …– Eat bleach– Swallow 50 Ferrous

Sulphate tablets in one go

What IS a child?The child:• Is more intelligent than an

adult (you try learning a new language in three years)

• Is physically optimal• Loves, unconditionally• Forgives, unconditionally• Is more beautiful• Has a future, not a past

And he said: "I tell you the truth, unless you change and become like little children, you will never enter the kingdom of heaven. Matthew 18:3

On childrenAnd a women who held a babe against her bosom said, Speak to us of children. And he said:Your children are not your children.They are the sons and daughters of life's longing for itself.They come through you but not from you,And though they are with you yet they belong not to you. You may give them your love but not your thoughts.For they have their own thoughts.You may house their bodies but not their souls,For their souls dwell in the house of tomorrow, which you cannot visit, not even in your dreams.You may strive to be like them, but seek not to make them like you.For life goes not backward nor tarries with yesterday. You are the bows from which your children as living arrows are sent forth.The Archer sees the mark upon the path of the infinite, and He bends you with His might that His arrows may go swift and far.Let your bending in the Archer's hand be for gladness;For even as He loves the arrow that flies, so He loves also the bow that is stable.

Kahlil GibranThe Prophet 1926

Physiological differencesChildren are faster

– Respiratory rate adult 18 child 20-40– Oxygen consumption child ↑– Fluid intake adult 1500ml, Child ↑

adult 70ml / kg / daynewborn baby 150ml / kg / day

– Fluid output adult 1500ml child 1ml/kg/hr ↑ than adult

– Cardiac rate Child ↑, adult 70, baby 120

The younger the child, the bigger the differencePhysiological differences not commensurate with size

Children are not small adults THEY ARE DIFFERENT

Healing

Time taken for a femoral fracture to heal:Newborn One week5-yr old Four weeks10-yr old Eight weeksAdolescent Three monthsAdult Four months or longer

Drugs• Higher doses given to

children (higher metabolic rate, larger extracellular space)

• Smaller physical doses given

• Some drugs not given• The younger the child

(foetus) the more different re drugs (Thalidomide)

• Need for greater accuracy• Different routes

Body proportion

• Relatively large head and brain

• Head receives greater proportion of cardiac output

• Head surface area greater

• Greater heat loss from head

Small adults?• Surface area: body

weight ratio is double (infants / adults) = greater heat loss

• Oxygen consumption relative to body weight is double that of adults (6-7 ml/kg/min)

• Higher metabolic rate

Vital signs

Age Pulse Respiration Weight B.P.

Birth 120-140 30-50 3.4 Kg 80 / 45

6/12 120 25-35 7.5 Kg 90 / 60

1y 110 20-30 10 Kg 95 / 65

3-6y 90-100 20-30 14.5 Kg (3 yrs) 100-110 / 60-70

7-10y 80-100 20-24 23Kg (7 yrs) 100-120 / 60-80

11-14y 70-90 20 34Kg (11 yrs) 110-120 / 70-80

Not determinable from the adult value

Cardiac output

• Babies have limited ability to increase stroke volume hence higher heart rate

• Cardiac output is higher per unit of body weight• Lower vascular resistance hence lower BP• Tachycardia most effective means of increasing

cardiac output and the first sign of shock• Cardiac output decreases with HR less than 180bpm

Fixed stroke volume (infant)

• Bradycardia = decreased cardiac output

• Bradycardia caused by:– Hypoxia– Vagal stimulation (laryngoscopy)– Halothane– Etc.

Heart

• Changes from foetal circulation may be incomplete (heart sounds)

• The need to watch for signs of congenital HD, especially when the ductus arteriosus closes– Poor feeding (exhaustion)– Palour, – Cyanosis (right to left shunt)

Ventilation

Ribs in neonates are more horizontal (limits anterio-posterior chest expansion, limited ‘bucket handle’ effect)

Infant much more dependent on diaphragm and susceptible splinting with – gas in the stomach (ventilation with

bag and mask)– Position (lithotomy)

Respiratory rate

Age RRTerm 30-501 year 20-403 years 20-306 years 16-2210 years 16-2014 years 14-2018 years 16-20

Estes, M.E. (2002). Health assessment and physical examination. Albany. Delmar.

Airway• Airways have smaller diameter• Cartilage of trachea is softer• Airway more easily obstructed (can be obstructed by

mucus)• Airway can be compressed if the neck is flexed or

hyperextended• Sternum, ribs (chest wall) is cartilaginous and soft• Intercostal muscles much less effective• Infants may be obligatory nose breathers for first 4 weeks• Recession, grunting, wheeze

Intubation -1• Shorter time before hypoxia develops because of

higher oxygen consumption (6-7ml/kg/min compared to 3ml/kg/min in an adult)

• Larynx is higher (infant C3, adult C6)• Larger tongue• Epiglottis is U shaped and longer• Angle of the mandible is greater (120 degrees)• Trachea has anterior inclination• Large head

Intubation before puberty

• Cricoid cartilage narrowest point of the larynx before puberty and is circular

• an uncuffed tube can be used until 10-12 years

• Nose accommodates the same size of tube as does the larynx before puberty

• Length of trachea varies need to check that both lungs are being ventilated

Dental development

Dental development

Injection sites and need for greater accuracy

Small limbs and safety

Blood

• Blood volume greater (80-85ml/kg) at term but absolute volume is small

• Haemoglobin greater 180-200gm/l at term• Premature babies: Hb low because iron stores are

laid down late in pregnancy• Hb predominantly foetal (takes up oxygen at low

tension but releases it less well to tissues)

Fluid

• At birth, about 80% water (60-65% in adults)• Premature babies have more water fluid loss more critical• Neonates and infants initially lose extracellular water • Extracellular space is larger at this age (50%) body weight• fluid losses are greater• Smaller intracellular space has less fluid to shift when losses

occur (babies become sicker quicker)• Minor blood loss may be important in a small child

Extracellular Space

• Bigger extracellular space = higher dose of drugs which are distributed there

• Extracellular electrolytes (chloride) lost in larger amounts in dehydration

Circulating blood volume

Neonates 90ml/kg

Infant 80ml/kg

Child 70ml/kg

Adult 65-70ml/kg

Dehydration

• Higher proportion of water• Children exchange 50% water daily (adults 17%)• Child metabolic rate higher (more water produced

and excreted, greater risk of acidosis)• Immature renal apparatus (neonates)• Large surface area (skin)• Large surface area (gut)

Maintenance requirements

Body weight Age IV maintenance

< 10 kg 1-12 months

100-120ml/kg/day

10-30kg 1-10 years 60-90ml/kg/day

>30kg 10 years + 40-90ml/kg/day

Small vessel large spout

Adult

Child

Kidneys

• Differences only an issue in the first few weeks• Glomerular filtration less• Reabsorption of water reduced (cortical

tubules and sodium excretion not fully developed

• Dehydration occurs faster

Liver

• Lack of some liver enzymes in neonates and premature babies

• Poor metabolism of some drugs (chloramphenicol)

• Idiosyncratic metabolism of some drugs (morphine)

• High levels of bilirubin in the neonate

Brain and NS

• Brain is immature (different) in ways that are not understood (febrile convulsion)

• Centrally acting drugs (morphine, barbiturates) have a greater depressant effect

• Not all myelinated fibres are myelinated

Temperature regulation• Temperature regulation less efficient• High surface area• Premature babes have thin skin and less

subcutaneous fat (body stores less heat)• Neonates do not shiver• Brown fat• Seriously prone to hypothermia

Assessment of shock

• depression of the nail bed / forehead should result in return to normal in 0.5 secs

• tachycardia is a sign of shock

• bradycardia is a very late sign and may indicate imminent death

• Hypotension late sign

Skin

• More liable to thermal injury• Saturation monitoring not reliable in the first

24h after birth and in premature babies (transcutaneous monitoring may be used instead)

• Skin is thinner and can leak fluid in the very premature baby

Immune system

• babies more vulnerable to gram –ve bacteria

• University students more vulnerable to bacterial meningitis

Safety

What is paediatric nursing?Paediatric nursing is an ancient craft, the exercise of which has sought to ameliorate suffering throughout the ages;Paediatric nursing exists as a therapeutic intervention and is not merely ‘supportive’;Medicine’s primary goal is to cure the patient of disease and to remedy the effects of trauma. In contrast, paediatric nursing’s primary goal is to reduce discomfort and ameliorate the effects of disease, trauma and of treatment itself;Paediatric nursing uses science, including social, psychological and medical science to achieve its goal; however, paediatric nursing is not driven by science. Rather, paediatric nursing is driven by the therapeutic influence which one caring person can have on a suffering human being. It follows that, it is the relationship between the nurse and the child patient and family that is at the heart of the therapeutic activity called nursing. Paediatric nurses achieve much by simply being there with the suffering person, by demonstrating empathy and an unconditional regard for the child patient and his or her family and in relation to which, the words ‘affection’ and ‘love’ are fully appropriate.

NAWCH Charter• Children shall be admitted to hospital only if the care they require cannot be equally well provided at

home or on a day basis.• Children in hospital shall have the right to have their parents with them at all times provided this is in the

best interest of the child. Accommodation shall therefore be offered to all parents, and they should be helped and encouraged to stay. In order to share in the care of their child, parents should be fully informed about ward routine and their active participation encouraged.

• Children and/or their parents shall have the right to information appropriate to age and understanding.• Children and / or their parents shall have the right to informed participation in all decisions involving their

health care. Every child shall be protected from unnecessary medical treatment and steps taken to mitigate physical and emotional distress.

• Children shall be treated with tact and understanding and at all times their privacy shall be respected.• Children shall enjoy the care of appropriately trained staff, fully aware of the physical and emotional needs

of each age group.• Children shall be able to wear their own clothes and have their own personal possessions.• Children shall be cared for with other children of the same age group.• Children shall be in an environment furnished and equipped to meet their requirements, and which

conforms to recognised standards of safety and supervision.• Children shall have full opportunity for play, recreation and education suited to their age and condition.

NAWCH is now called Action for Sick ChildrenLook it up!

Professional organisations• ABPN Association of British

Paediatric Nurses

• NMC Nursing and Midwifery Council– Is not a professional body (often

thought to be)– Is a government agency associated

with the Department of Health– Is largely inactive in relation to

paediatric nursing

ABPN – check it out!

Anne Casey’s model of paediatric nursing

Date published 1988Senior Nurse. 8(4): 8-9Based on Roper / ClarkeType - Concept isolating

Key concepts:childfamilynursepartnershipability of child / family to participate in carehealthenvironmentconception - maturity continuumdependent - independent continuumfunctioning, growing and developingphysicallyemotionallyintellectuallysociallyspiritually

The perfect model

• We don’t have the perfect model

• Can you invent the perfect model

• You could be famous• You could make

some money• Try it now, invent

your own model

Family Centred Care‘a way of caring for children and their families within health services which ensures that care is planned around the whole family, not just the individual child/person and in which all the family members are recognised as care recipients'.

Shields, L. (2010). "Questioning family-centred care." Journal of Clinical Nursing 19(17/18): 2629-2638.

What is

Paediatric Nursing?