Basics of pediatric care
chapter 55
Presentation by: Leslie Lehmkuhl, RN
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
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
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
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
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.
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
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
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
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
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
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
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
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
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)
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%
Physical Assessment
Length Infant to <2 years
measure from top of head to heel
> 2 years standing height
Physical Assessment
Weight < 2 years cover
on scale with no clothing on child
Toddler in underpants or light weight gown
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
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
Physical assessment
Carotenemia=orange to yellow color of skin Pallor Erythema=diffusely red Dark skinned infants may be dusky red to
violet
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
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
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
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
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”
Sites for Measuring Blood Pressure.
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
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
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
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
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.)
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
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
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
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.
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
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
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
Jugular Venipuncture
Mummy Restraint
Femoral Puncture
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
A, Modified side-lying position for lumbar puncture.B, Older child in side-lying position
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
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
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
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
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
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
OralMedsAdmin
Position the child in a semi-reclining position
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
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
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
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.
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
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
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
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
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..
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
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
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