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Page 1: Basics of pediatric care       chapter  55

Basics of pediatric care

chapter 55

Presentation by: Leslie Lehmkuhl, RN

Page 2: Basics of pediatric care       chapter  55

Family-centered care

Pediatric nursing involves working with the child and the family

Family-centered care is a philosophy that includes family contribution and involvement

Nurses recognize the importance of family centered care

Because children are different than adults POC is always guided by the developmental level of the child

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Pediatric assessment

Nurse assesses the following areas: physical, emotional, cognitive, developmental level,

Educational needs, developmental needs, socialization, dynamics of the family

Neonate: birth to 28 days Infant: 1 month to 1 year Toddler: 12 mo’s to 3 yrs Preschool: 3-6 years School age: 6-10 years Preadolescent: 10-12 yrs Adolescent: 13-20 years

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Terms

Assent Child life specialist Emancipated minor Family centered care Infant mortality rate Standard of care

WIC: supplemental food program for women, infants, children

Denver developmental and growth screening test ii

Developmental milestones

Egocentrism Object permanence

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Admission

Preparation for planned admission is important for a child/caretakers

Visit playroom, play with toys, read books, see videos, talk to staff, ask questions, see environment

Information regarding child: nutrition, allergies, routines, fears, eating habits, sleep habits (data is used to identify Nx Dx & est. POC)

Reaction to pain, prior medication, play, ID band

Rooming in available Lab tests Greet by name Treatments Side rails/crib Diet and/or NPO

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Preoperative

Play therapy: arts, crafts, toys, socialization

Parent present- reduces fear and anxiety

Use drawings, puppets, models, dolls, handle stethoscope, dressings, surgical mask

Bring to hospital: favorite toy or article.

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Surgery

Parent may accompany child to operating room

Child may take favorite toy to operating room

<18 years parents/legal guardians must give informed consent.

Child selects favorite gas (anesthesia). Chocolate, watermelon..

Parents called when child brought to recovery room. may be with child

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Explanations

Infant- explanations given to caregiver

Toddler- use dolls, puppets, explain 3 days prior to surgery

Preschool- books, art, video explain 1 week in advance

School age- brief explanation, tour, video, method for comfort

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Familiar toys

Child encouraged to bring in blanket, toy

Child may have less anxiety with familiar object

With reduced anxiety: may need less premedication for surgery

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Fears/Anxiety

Unknown- fear of environment, routine change, different people in room

Separation anxiety (6-30 months)

When child is hospitalized and parents are not able to visit, the child may experience anxiety

Stages: protest, despair, detachment

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Separation anxiety

Protest: child cries, rejects others

Despair: child feels hopeless, becomes quiet and withdrawn

Provide the child with favorite toy or blanket.

Detachment: child becomes interested in environment, plays ignores parents…..Coping mechanism of child to prevent emotional pain of separation

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Fears/Shame

Pain and mutilation: infants and toddlers view intrusion of body as painful

Loss of control: toddlers need rituals, routines at this time.

May have temper tantrums due to frustration

Toddlers need rituals for feeding, bedtime, toileting

Preschool and school age may have loss of independence and loss of self care

The child needs to have some control

Shame/guilt: preschool may believe he/she did something to cause the illness or believe thatIllness is a punishment

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Fears

Anger: related to loss of control, loss of friends, pain

Methods used for release : punching bag, clay, painting

Regression: common during and after hospitalization

This is normal at this time

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Post operative assessment

ABC Head to toe LOC, speech, VS, IV

fluids, dressing, drains, voiding, pain, breath sounds, nausea, vomiting,

Bowel function/bowel sounds, extremity movement

Assess for dehydration, shock, infection

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Pain/ Discharge

IV medication may be given then oral medication

Discharge planning begins at admission

Discharge planner may be needed

Social service may be used for referrals

Teach that child may develop behavior changes or regression (e.g. withdrawal, aggression, demanding bx)

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Physical assessment

Prepare parents and child for the exam

Assess each system related to age of the child

Know the normally for age groups to detect the abnormally

Sequence: head to toe

Growth charts are used to compare child to national average

Normal ranges-5-95%

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Physical Assessment

Length Infant to <2 years

measure from top of head to heel

> 2 years standing height

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Physical Assessment

Weight < 2 years cover

on scale with no clothing on child

Toddler in underpants or light weight gown

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Physical assessment

For older children weight done in street clothes..shoes off, heavy clothing off usually ht and wt are the only measurements taken

Children under 2 years: Measure height, weight, head circumference, chest circumference, abdominal circumference

For the first year, head circumference is larger than chest circumference

Head- measure above brow, above pinna, around occipital prominence

Chest- measure at nipple line

Abdominal- measure at umbilicus

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Physical assessment

Color variations: Melanin reflects the

skin color Vitiligo=patches of

depigmentation

Jaundice=dark skinned infants, jaundice may appear darker

Cyanosis=dark skinned infants, cyanosis may appear black

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Physical assessment

Carotenemia=orange to yellow color of skin Pallor Erythema=diffusely red Dark skinned infants may be dusky red to

violet

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Vital signs

Infants- count resp, pulse, (both for 1 min) Thermometers used in peds: Electronic, digital, tympanic Axiliary temp used for newborn, premature,

children under 3 years Oral temp for children over 6 years old

<3

>6

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Vital signs

Rectal temp used when no other route available

Rectal temp not used for: Preterm, immunosuppressed, rectal surgery,

GI disorders as bleeding, diarrhea Lubricated, rectal thermometer not inserted

more than 2.5 cm

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Heart rate

Apical pulse done on children under 3 years, children with heart

Disease, or irregular heart rhythm Stethoscope placed on left midclavicular line-

5th intercostal space Over 3 years may use radial pulse

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Respirations

Infant- abdominal respirations Newborns are nose breathers for 3-4 weeks

and then can breathe through the mouth Newborn 30-50/min 6-12 months 20-40/min 3yr 20-30/min 6yr 16-22/min

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Blood Pressure

Bladder of the cuff is 2/3 the width of the limb (if cuff is too large BP reading will be low, if

too small the BP reading will be high) Sites: upper arm, wrist, leg or foot Arteries used: radial, brachial, popliteal,

posterior tibial Preschool/school age: explain steps “may

feel like a hug on the arm”

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Sites for Measuring Blood Pressure.

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Denver Developmental Screening Test II

Developmental assessment of children from birth to 6 years

125 items Areas: personal: social Fine motor skills: eye hand coordination Language: understanding Large motor skills: jumping

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Denver Developmental

Evaluation: Observation of child Asking parents questions Child performing tasks This is not an IQ test Detects developmental delays and allows for

intervention

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Safety restraints

Types: mittens, ankle, wrist, vest, elbow, mummy

Applied for child safety Mittens-to prevent pulling at iv tubes, gt,

dressings Elbow- prevents flexion of elbow Use: after surgery for cleft palate, cleft lip,

head or neck surgery, iv infusion

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Restraints

Ankle: prevents falls/climbing out of crib Vest: prevents falls/getting out of bed, crib,

high chair Mummy: used for short time for procedures to

reduce movement May be used when IV needs to be started

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Figure 30-10

Mummy restraint.

(From Lowdermilk, D.L., Perry, S., Bobak, I.M. [1997]. Maternity & women’s health care. [6th ed.]. St. Louis: Mosby.)

Page 33: Basics of pediatric care       chapter  55

Restraints

Nursing: remove restraint q2h and exercise limbs, check sites for irritation

Document color, warmth, capillary refill of extremities

Check restraints in 15 min after application and then q1h

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Urine specimen

Tests: blood, protein, glucose, bilirubin, drugs, metals, electrolytes, infection, ph, specific gravity, hormones

Infant: plastic collection bag Female- apply skin prep and apply bag

around labia Male- apply skin prep and apply bag around

scrotum

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Figure 30-12

Application of a urine collection bag.

(From Wong D.L., Perry, S.E., Hockenberry-Eaton, M.J. [2002]. Maternal-child nursing care. [2nd ed.]. St. Louis: Mosby.)

Alcohol pad

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Urine Collection

Cut a slit in the diaper and pull the bag through…. Will see when child voids

Older child- clean catch Male - have child clean head of penis x3,

urinate a small amount, stop voiding, void in container, empty bladder in toilet, send specimen to lab

Stroke the child's abd w/alcohol prep and fanning dry often stimulates urination.

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Urine specimen

Female - have child clean sides of labia, clean meatus,(front to back) urinate a small amount, stop voiding, void in container, empty bladder in toilet, send specimen to lab

Document in nursing notes/flow sheet

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Stool specimen

Test for: fat, blood, bacteria, parasites Infant: obtain from diaper and place in

container Older child: use bedpan, or bedside

commode place specimen in container and send to lab

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Blood specimen

Jugular- head and shoulders extended at edge of table

Mummy child Physician draws the sample Femoral - child in froglike position On back may mummy child Physician draws the sample

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Jugular Venipuncture

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Mummy Restraint

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Femoral Puncture

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Lumbar puncture

Child in sitting or side lying position Consent needed Side lying- nurse has one hand on back of

neck and one hand behind the knees of the child

Write down the pressure, color and number of samples obtained

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A, Modified side-lying position for lumbar puncture.B, Older child in side-lying position

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Intake and output

Infant- weigh a dry diaper Weigh the damp diaper and subtract the weight of

the dry diaper 1mg=1ml of urine Pediatric fluids include: jello, gatorade, pedialyte,

flavored ice, sweetened tea, ice cream,… all children are on i&o in the hospitals unless stated

otherwise

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Medication

Physiological differences of the pediatric client:

Absorption: child has reduced gastric acidity Gastric acidity reaches adult level at 3 years Topical: medication is absorbed faster due to

thinner skin and large surface area

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Medication

Intramuscular absorption varies due to peripheral circulation

Decreased gastric motility reduces medication absorption

Distribution- total body water content is higher in infants and children

Protein binding is less due to immature liver

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Medication

Blood brain barrier is immature and more drugs enter the brain

Metabolism- metabolic rate is higher in children 2-6 years

Microsomial enzymes are less to an immature liver

Elimination- glomerular filtration is less due to an immature kidney

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Medication

Pediatric doses calculated by

Mg/kg/day may give divided doses

Wt is the most common and reliable method to calculate drug administration.

Body surface area Oral meds: preferred

route Age birth to 3 months:

give med before meals when child is hungry

semi-reclining position

Page 50: Basics of pediatric care       chapter  55

Medication

Methods: nipple, dropper that is calibrated, syringe without a needle, spoon, plastic cup

Angle syringe toward the cheek and give slowly

Allow child to sit on parents lap Do not: force child to take med, put

medication in formula or milk

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OralMedsAdmin

Position the child in a semi-reclining position

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Medication

Bitter medication: may use ice in mouth for a few minutes before taking med

Some medications may be crushed and mixed with a sweet syrup

Suppository: use little finger to insert med for children under 3 years

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Medication

Intramuscular- vastus lateralis site for children under 3 years

If the child is over 3 years and was walking for over a year, the gluteal sites may be used

Dorsal gluteal- child on abdomen with toes pointed inward

Use distraction- blowing bubbles, stroke skin before, during injection

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IV Medication

IV has the least variation in absorption Methods: IV bolus, soluset, syringe pump,

central venous access site, saline lock, percutaneous implanted catheter, implanted venous device

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Medication

All IV fluids administered by a pump Tubing: 60-100/gtt/ml IV site selected to not limit activity, not on

dominant side, smallest gauge needed The IV site should be checked every hour.

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Medication

Deltoid site not used for children under 18 months as the site is not developed until adolesence

Subcutaneous needle length ranges from 3/8 to 5/8 inch

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Medication

Otic: Child is on the side with the affected ear up Clean ear as needed Under 8 years- pull pinna back and down Over 8 years- pull pinna back and up

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Safety

Primary focus of Nursing care is child safety and protection..

Hospitals are concerned with choking and falls

Adult must be present when child is eating Key locks on doors for security Code purple is child abduction

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Medication safety

Do not: disguise medication in food, formula Talk about medicine as candy Children will know medicine from candy be

honest Do: keep medicines in a locked cabinet Teach that herbal medication may not be

safe for children

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Dying child

Gentle emotional and physical care to child and family

Anticipate grieving know stages of grieving Infants and toddlers- have no clear

understanding of death 3-5 years- death may be a sleeplike state

interchangable with life..

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Dying child

School age- understand that death is final Adolescent- have an understanding of death Parents may fear what death may be like Children may fear dying alone and fear pain

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Dying child

Child- encourage the child to talk about their feelings

Encourage drawing, painting, writing to express feelings

Siblings- may have anticipatory grief may resent the attention given to the dying child

Need to included in care of dying child and to express feelings

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Support

Nurse needs support from peers Needs empathy, confidence, manage own

stress Sources of support for the family: support

groups, hospice service, American Cancer Society,

Home health, relatives, friends, Religion


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