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Hospitalized child nurs 3340 fall 2014

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  • 1. 1 Joyce Buck, MSN, RN-C, CNE Joy A. Shepard, PhD(c), RN-C, CNE
  • 2. Objectives • Contrast child’s understanding of health and illness according to child’s development • Explain effects and responses to illness and hospitalization • Describe child and family adaptation to hospitalization • Identify nursing strategies to minimize stressors of hospitalization experience • Integrate concept of family presence during procedures and nursing strategies to prepare family • Summarize strategies for discharge preparation • Evaluate effectiveness of teaching strategies • Analyze the behaviors of an infant or child to assess for pain • Assess a child’s readiness to use a self-report pain scale • Describe Neonatal Abstinence Syndrome • Describe the Pediatric Early Warning Syndrome • Discuss the safe administration of medications in the pediatric population 2
  • 3. 3
  • 4. Settings for Care • Hospital – 24-hour observation – Emergency hospitalization – Outpatient and day facilities – Rehabilitative care – Medical-surgical unit – Intensive care unit • School-based clinics • Community clinics • Home 4
  • 5. Common Stressors and Children’s Response to Hospitalization/Illness • Fear of the unknown • Separation anxiety • Fear of pain or mutilation • Loss of control • Anger • Guilt • Regression 5
  • 6. Infant • At about 6 months of age are acutely aware of the absence of parent and become fearful of unfamiliar persons. • They can sense the anxiety their parents are experiencing • Accustomed to having basic needs of food and sleep met by parent and constraints of hospitalization results in loss of needs being met. 6
  • 7. Toddlers • **Separation anxiety • Nurses experience protest and despair in this group • Fear of injury and pain • Regressive behavior 7
  • 8. Stages of Separation Protest Despair Detachment Screaming, crying, inconsolable Clinging to parents, pleading for parents to stay Agitated, temper tantrums, refuse to comply with care Resists caregivers Child becomes hopeless and becomes quiet, withdrawn, apathetic Sadness, depression Withdrawal or complaint behavior Crying when parents appear Lack of protest when parents leave Appearance of being happy and content with caregivers and other children. Close relationships not established If parents reappear, child may ignore. 8
  • 9. Preschooler • Separation anxiety generally less than the toddler • Less direct with protests; cries quietly • May be uncooperative • Fear of injury • Loss of control • Guilt and shame 9
  • 10. School Age Child • Separation: may have already experienced when starting to school • Fear of injury and pain • Want to know reason for procedures and  Like being involved and wants to make choices 10
  • 11. Adolescence • Separation from friends rather than family more important • Fear of altered appearance • Will act as though not afraid when they really are. • Give them some control to avoid a power struggle 11
  • 12. 12
  • 13. Children’s Understanding of Hospitalization • A child or adolescent bases their understanding of hospitalization on: – Cognitive ability at various developmental stages – Previous experiences with health care professionals 13
  • 14. Families Response to Hospitalization • Hospitalization is disruptive to the family’s usual routines – May lead to change in roles • Family members are anxious and fearful 14
  • 15. Nursing Care to Assist the Child with Hospitalization Related to Age 15
  • 16. Infant – Trust vs. Mistrust • Encourage parent to visit / rooming in • Encourage parents to participate in care, Teach parents procedures they are capable of doing • Discuss arrangements for care of other family at home • Try to simulate home routine • Try to assign same nurse • Allow parents to be present during procedures and comfort afterwards • Keep frightening objects from view • Provide swaddling, soft talking to soothe • Play close attention to light and sound stimulation • Allow non-nutritive sucking for comfort 16
  • 17. Older Infant / Toddler Autonomy vs. Shame and Doubt • Encourage parent to room in and if have to leave, leave when awake and leave something of meaning with child for support. • Provide warmth and support • Explain to parent stage child is in • Bring infants security object -- favorite toy, blanket • Set limits, give choices on simple decisions • Teach parents child may regress, may promote potty chair if child is trained. Offer frequently (4x per shift) • Promote ritualistic behavior for bedtime • Teach parents about hazards (crib, chair, toys, equipment) be sure to supervise when out of crib. 17
  • 18. Preschooler – Initiative vs. Guilt • Acknowledge child’s fears regarding hospitalization • Orient to the hospital, spend time with child to build trust • Encourage presence of parent if possible and encourage to participate in care. Provide comfort and support . • Nutrition – assess food likes (hamburger, PBJ sandwich, etc) Give small portions. Make environment comfortable and accept messes. Encourage intake of fluids with games. • Provide consistent environment ; Reinforce coping behavior • Provide with as much mobility as possible • Provide play and divisional activities • Avoid intrusive procedures as much as possible • Assess child’s perception by asking to draw a picture and tell about it 18
  • 19. This pre-schoolers parents are taking the time to prepare her for hospitalization by reading a book recommended by the nurse. Such material should be appropriate to the child’s age and culture. Why do you think that having the parents read this material is valuable? Preschooler 19
  • 20. School Age – Industry vs. Inferiority • Ascertain what child knows. Clarify using scientific terminology and how body functions • Direct questions more to the child when teaching them (help master over feelings of inferiority) • Use audiovisuals, pictures, body outlines. • Suggest ways of maintaining control (i.e.: deep breathing relaxation). • Gain cooperation. Give positive feedback • Include in decision-making (time to do it, preferred site). • Encourage active participation (removing dressings, doing PIN care). Plan child’s day if possible with child’s input • Maintain clear and consistent limits • Allow for privacy 20
  • 21. School Age Child Allowing the child to dress up as a doctor or a nurse helps prepare the child for the hospitalization experience. This helps the child adjust to treatment, care, and the recovery process. 21
  • 22. The child’s anxiety and fear often will be reduced if the nurse explains what is going to happen and demonstrates how the procedure will be done by using a doll. Based on your experience, can you list five actions you can take to prepare a school-age child for hospitalization? School Age Child 22
  • 23. Some hospitals offer a special classroom and teacher for children undergoing a lengthy hospital stay, enabling them to remain current with their school work. The child who falls behind other students might not fit in when he or she returns to school or might be required to repeat a grade. School Age Child 23
  • 24. Adolescent – Identity vs Identity Diffusion • Assess knowledge. • Encourage questioning regarding fears, or risks. • Involve in decision-making. • Ask if patient wants parent there. • Make as few of restrictions as possible. • Suggest ways of maintaining control. • Accept regression to more childish ways of coping. • Give positive reinforcement. • Provide privacy for care • Encourage to wear street clothes and perform normal grooming • Allow favorite food to be brought in if not on a special diet 24
  • 25. 25
  • 26. Advantages of play to the hospitalized child • Therapeutic – activities are guided • Emotional outlet – acts out real stressors • Used to teach child prior to situation • Enhances cooperation – used during an unpleasant procedure. 26
  • 27. Therapeutic Play Techniques • Infant – Crib Mobiles – Soft toys – Music • Toddler – Play peek-a-boo or Hide-and-Seek – Read familiar stories – Play with dolls that have similar “illness” as them – Puzzles, building blocks, push-and-pull toys – Play with safe hospital equipment – bandaids, stethoscopes, syringes without needles. – remove when finished playing 27
  • 28. Therapeutic Play Techniques • Pre-schooler – Play with safe hospital equipment – Crayons and coloring books, – Puppets, Felt and magnetic boards – Books and recorded stories – Videos • School-age – Dolls – Hospital equipment – Board games, crafts – Books, computers 28
  • 29. Pet Therapy Hospitals may have pet therapy from specially trained animals to provide comfort and distraction during healthcare. 29
  • 30. Children with Special Needs • For those with visual or hearing impairment – provide material in auditory, tactile, or visual means to assist child • Provide special equipment for those with psychomotor difficulties • During patient teaching - provide more reinforcement and shorter teaching sessions 30
  • 31. 31
  • 32. Nursing Measures to Tailoring Care • Encourage positive communication with health care team • View care as a partnership • Be aware that the parents are the ones who knows the child best • Provide support to the parents, allow them to assist with the care • Recognize influences of cultural background 32
  • 33. Preparation • Tour of the Hospital or surgical area • Photographs or a videotape of medical setting and procedures • Health Fairs • Contact with peers who had similar experience 33
  • 34. Preparation Strategies • Allowing the child to dress up as a doctor or a nurse helps prepare the child for hospitalization. • This helps the child adjust to treatment care and the recovery process. 34
  • 35. Things Parents can do to Prepare Child • Read stories • Talk about hospital and coming home • Encourage child to ask questions • Visit a hospital or surgical area and allow to touch equipment • Encourage child to draw pictures of what they think it will be like • Be honest and tell about pain, etc. 35
  • 36. Nursing Care to Assist Families to Cope • Orient to hospital • Assess what parent/child know of illness and treatment • Assess teaching needs - keep updated on condition of child • Reinforce and encourage questions • Discuss ways the parents can participate in the care • Assess & discuss family support, make referrals 36
  • 37. It is important to allow the parents to be a part of the child’s care. Reunite the family as soon as possible after surgery. This child has just undergone surgery and is in the post anesthesia care unit (PACU). Although the child’s physical care is immediate and important, remember that both the child and the family have strong psychosocial needs that must be addressed concurrently. It is important to reunite the family as soon as possible after surgery. Nursing Care to Assist Families to Cope 37
  • 38. Preparation for Procedures • Take the child to a treatment room • Encourage a parent or loved one to provide comfort and support • Use developmentally appropriate terminology • Offer the child choices • Tell the child and family how they can help with the procedure • Do not threaten punishment for lack of cooperation • Do not force an unwilling parent to stay; encourage participation 38
  • 39. Using Restraints • Use the least restrictive restraint • Choose proper device for condition • Ensure proper fit • Tie knots that can be untied easily for quick access • Secure ties to bed frames or another stable device • Frequently check the extremity distal to the restraint for circulation, sensation, and motion • Remove restraints every 2 hours for range-of-motion movement, repositioning and to offer child food or opportunity to use the bathroom • Document findings from neurovascular checks 39
  • 40. Child Life Specialist • A person who plans activities to provide age-appropriate playtime for children either in the child’s room or in a playroom. • Goal: Assist children to work through feelings about their illness 40
  • 41. 41
  • 42. Myths About Pain • Neonates do not experience pain • Children have no memory of pain • There is a correct amount of pain for a given injury • Children can easily become addicted to narcotics • Narcotics can easily cause respiratory depression 42
  • 43. Pain Assessment Neonatal characteristic facial responses to pain include: bulged brow, eyes squeezed shut, furrowed nasolabial creases, open lips, pursed lips, stretched mouth, taut tongue, and a quivering chin. Physiological Response = increased B/P and decreased arterial saturation 43
  • 44. FLACC Scale -- Pain Assessment Tool 44
  • 45. Oucher Scale • After determining that the child has an understanding of number concepts, teach the child to use the scale. Pre-schooler age is first to do this. • Point to each photo, explain that the bottom picture is a “no hurt,” the second picture is a “little hurt,” the third picture is “a little more hurt,” the fourth picture is “even more hurt” the fifth picture is “a lot of hurt” and the sixth picture is the “biggest or most hurt you could ever have.” • The numbers beside the photos can be used to score the amount of pain the child reports. 45
  • 46. Wong-Baker FACES Pain Rating Scale • Make sure the child has an understanding of number concepts and then teach the child to use the scale. • Point to each face and use the words under the picture to describe the amount of pain the child feels. • Then ask the child to select the face that comes closest to the amount of pain felt. 46
  • 47. Numerical Rating Pain Scale 47
  • 48. COMFORT Scale for Pain Assessment 48
  • 49. Consequences of Pain • Cardiovascular and respiratory changes – Tachypnea, increased BP and heart rate – Inadequate lung expansion, decreased arterial saturation – Inadequate cough • Neurologic changes – Fight /flight response- Tachycardia, insomnia, glucose • Metabolic changes – Increased fluid and electrolyte losses • Immune system changes – Depression of immune system with increase in risk for infection • Gastrointestinal changes – Increased intestinal secretions, prone to ileus 49
  • 50. Pain Management • The presence of the parent is an important part of pain management. Children often feel more secure telling their parents about their pain and anxiety 50
  • 51. Non-pharmacological Pain Management • Behavioral distraction • Assorted visuals • Breathing techniques • Comfort measure – Repositioning, holding – Touching, massaging – Warm or cold compresses • Diversional talk • Guided imagery • Biofeedback • Progressive muscle relaxation 51
  • 52. Pharmacologic Interventions for Pain • Analgesics – Patient-controlled analgesia – Topical anesthetic cream • Nonsteroidal antiinflammatory drugs • Opioids • Conscious sedation • Epidural analgesia 52
  • 53. Administering Analgesics to Children • The preferred routes are intravenous or oral. • Infants and children receiving IV and epidural opioids should be monitored by pulse oximetry. • If respiratory depression occurs with opioid use, naloxone hydrochloride should be used for reversal when oxygen and stimulation of the child are ineffective. 53
  • 54. Nursing Interventions • When painful procedures are planned, use EMLA cream to anesthetize the skin where the painful stick will be made. • Procedure : – Apply a thick layer of cream over intact skin. – Cover the cream with a transparent adhesive dressing, sealing all the sides. • The cream anesthetizes the dermal surface in 45 to 60 min. 54
  • 55. 55
  • 56. DEFINITION • Signs & symptoms infant may exhibit following delivery to a drug-dependent mother • Postnatal exposure to opioids (more common) • S/S of withdrawal @ birth • Peak @ 3-4 days of age (usually)
  • 57. OPIATE WITHDRAWAL • Peak @ 6 weeks of age • Sub-acute phase up to 4-6 months
  • 58. CONTRIBUTING FACTORS • Poly-drug use • Smoking • Alcohol use • Length of drug use • Time of last drug use • Amount of drug use
  • 59. ABSTINENCE SCORING • Initiated by MD, NNP, RN, LPN • Finnegan scoring system • Initiated when Hx maternal drug use, “suspected” exposure, or S/S withdrawal noted • Monitor sleep habits, temperature weight gain/loss • R/O other medical conditions
  • 60. FINNEGAN SCORING SYSTEM • Meant for term infants on q 4 hr feeding schedule • High-pitched cry • Sleep disturbances • Moro reflex (only if pronounced jitteriness) • Tremors (4 levels)
  • 61. FINNEGAN SCORING SYSTEM CONT’D • Increased muscle tone • Excoriation of chin, knees, elbows, toes, and nose (score given only when first appear, increase, or appear in new area) • Myoclonic jerks • Generalized seizures (includes staring, rapid eye movements, chewing, back arching, and fist clenching) • Sweating • Hyperthermia (axillary)
  • 62. FINNEGAN SCORING SYSTEM CONT’D • Yawning (> 3) • Mottling • Nasal stuffiness • Sneezing • Nasal flaring • RR (> 60) /retractions • Excessive sucking • Poor feeding • Regurgitation • Loose/watery stools
  • 63. SCORING • First one done 2 hours after birth • Score every 4 hours • If score remains </= 7,continue q 4 hours for 1st 96 hours • If score is >/= 8,score q 2 hours for next 24 hours • Continue q 2 hour scoring until scores remain </= 7 for 24 hours
  • 64. NON PHARMACOLOGICAL TX • Implement ASAP after birth • Quiet environment w/ dim lighting • Heartbeat audiotapes/soothing music is acceptable • Swaddle infant • Gentle handling of infant • Kangaroo care/infant sling promote bonding
  • 65. NON PHARMACOLOGICAL TX CONT’D • Massage/ baths may relax infant • Rocking gently, talking, & singing may help • Pacifier w/ mother’s permission • Hand mittens to reduce face/ hand trauma • High-calorie formulas • Educate parents
  • 66. PHARMCOLOGICAL TREATMENT • Initiated w/ NPT when score >/=8 of 3 consecutive scores • Oral morphine (preferred) or methadone
  • 67. ADVANTAGES OF MORPHINE • Faster weaning • Reduces bowel motility/ loose stools • Facilitates feedings & interaction
  • 68. DISADVANTAGES OF MORPHINE • Have to give q 3-4 hours due to short half-life • Respiratory depressant • Hypotension • Urinary retention • Delay gastric emptying
  • 69. ADVANTAGES OF METHADONE • Given only twice a day • Controls irritability & insomnia
  • 70. DISADVANTAGES OF METHADONE • May take longer to wean (longer half-life) • Does not prevent loose stools • May mask the severity of NAS
  • 71. OPIATE REPLACEMENT THERAPY • Initial dose of 0.04 mg/kg/dose q 3 hours (scores 8-10) • Dose of 0.06 mg/kg/dose q3 hours (scores 11- 13) • Dose of 0.08 mg/kg/dose q3 hours (scores 14- 16) • Dose of 0.1 mg/kg/dose q3 hours (scores > 17) • Same guide used to determine if dose increase needed
  • 72. OPIATE REPLACEMENT THERAPY CONT’D • Dose may need to be increased if score >/= 8 times 3 consecutive times, • Or if the average of 3 consecutive scores >/= 8, • Or if score is >/= 12 for 2 consecutive times, • Or if average of 2 consecutive scores >/= 12, • Or if infant has a seizure
  • 73. OPIATE REPLACEMENT THERAPY CONT’D • When scores stabilize and remain < 8, wean dose by 10% maximal total daily dose q 2 days • When dose decreases to < 0.02 mg/kg/dose, morphine may be DC’d • Continue to observe for another 2 days to monitor for any rebound S/S • Since October 2010, ECU pediatrics has been using clonidine PO along w/ morphine therapy
  • 74. QUESTIONS?
  • 75. 75
  • 76. Goals of PEWS • Start a simple scoring system that identifies patients at risk for clinical deterioration and provides needed interventions. • Reduce code events on pediatric floors • Improve communication between RN, RT, Resident, and Attending. • Establish baseline PEWS score in PICU and children’s ED • Use PEWS score in Children’s ED for guidance on admitting patient’s to PICU
  • 77. 77
  • 78. Behavior • Score of 0- – Patient is playing normal with appropriate interaction – Patient is sleeping normally and easily awakens • Score of 1- – Patient is irritable but consolable – The patient is fussy/annoyed but can be calmed down and manageable • Score of 2- – Patient is irritable and inconsolable – The patient can not be calmed down and is unmanageable • Score of 3- – Reduced response to pain or voice – Patient not responding to pain (sternal rub) or loud voice
  • 79. Cardiovascular • Score of 0 – Patient’s nail beds and lips are pink with capillary refill between 1-2 seconds • Score of 1 – Patient’s general skin color looks pale or pasty with capillary refill of 3 seconds • Score of 2 – Patient’s skin color is grey with capillary refill of 4 seconds – Tachycardia >20 above normal rate for age or established baseline for that patient • Score of 3 – Patient’s skin color is grey/mottled with capillary refill >/= 5 seconds – Tachycardia >30 above normal rate for age or established baseline for patient – Bradycardia
  • 80. Capillary Refill • Assessed by pressing firmly for a brief period of time on the patient’s fingernail and identifying the speed at which the blood flow returns • Capillary refill is important because it assesses cardiac output. – Low Cardiac output can lead to poor digital/peripheral perfusion which leads to slow blood flow to digits – Compensatory vasoconstriction occurs shunting blood toward vital organs
  • 81. Respiratory • Score of 0 – Patient’s respiratory rate is normal or within patient’s established baseline – Patient has no retractions or increased work of breathing and on room air. • Score of 1 – Patient’s respiratory rate is >10 above normal or patient’s established baseline with mild retractions – Patient’s oxygen flow up to 2 lpm or >30% FiO2 • Score of 2 – Patient’s respiratory rate is >20 above normal or patient’s established baseline with moderate retractions – Patient’s oxygen flow up to 4 lpm or >40% FiO2 • Score of 3 – Patient’s respiratory rate is >30 above normal or patient’s established baseline with severe retractions or grunting – Patient’s oxygen flow >/=5 lpm or >50% FiO2
  • 82. Retraction Severity • Mild retractions – Subcostal or Substernal • Moderate retractions – Intercostal or Supraclavicular • Severe retractions – Suprasternal or Sternal http://intranet.tdmu.edu.ua
  • 83. 84
  • 84. Dosage Calculation • Dosage is individualized for each child • Dosage is commonly determined by an assessment of body surface area (BSA) or kilograms of body weight – The BSA method is used to calculate safe pediatric doses for a limited number of drugs, such as chemotherapeutic agents • BSA is measured in meters squared (m2 ) • This method, although not the most common, may provide the most accurate calculation because the child’s BSA probably parallels his metabolic rate and organ growth and maturation – Pediatric dosages based on body weight are usually expressed as milligrams per kilogram per day (mg/kg/day) or per dose (mg/kg/dose) • For home medication administration: 1 teaspoon = 5 mL; 1 tablespoon = 15 mL; 1 oz = 30 mL 85
  • 85. 86 (Page 273)
  • 86. Table 11-4 (Cont’d, p. 273) Variations in Medication Administration to Children 87
  • 87. Oral Medications • Allow the child as much choice as possible (for instance, which pill to take first or which beverage to drink) • Hold the infant with his head elevated to prevent aspiration • For the infant, slowly instill liquid medication by dropper along the side of his tongue and the young child, crush pills and mix them with ½ teaspoon of baby food or any sweet-tasting substance; never crush time-release capsules or tablets or enteric-coated drugs (crushing destroys the coating that prevents stomach irritation and causes drugs to release at the right time) • For medications delivered through a gastrostomy or nasogastric tube, flush after administration 88
  • 88. Intramuscular (IM) or Subcutaneous (SubQ) Injections • Select the needle length according to the pt’s muscle size • Don’t inject into dorsogluteal muscle until age 3 – The child must be walking for at least 1 year and has well-developed muscle mass – Because the muscle isn’t well-developed until the child walks, the sciatic nerve occupies a larger portion of the area than it will later on and could become permanently damaged by gluteal injections – The vastus lateralis site (anterior thigh) is preferred for young children; it is the largest muscle mass in children less than 3 years of age – The deltoid site can be used after toddlerhood • The deltoid muscle is rarely used in young children except for the small vaccine doses • Don’t give an infant more than 0.5 mL in any site or a child more than 1 mL in any site 89
  • 89. IM Injection Sites in Children 90
  • 90. IM Injection Sites in Children 91
  • 91. IM Injection Sites in Children 92
  • 92. Intravenous Medications • IV site placement may be in a peripheral or central vein • Because pediatric patients can tolerate only a limited amount of fluid, dilute IV drugs and administer IV fluids cautiously • Always use an infusion pump- with infants and small children • Inspect IV sites frequently for signs of infiltration (cool, blanched, and puffy skin) or inflammation (warm and reddened skin) • Do this before, during, and after the infusion because children’s vessels are immature and easily damaged by drugs 93
  • 93. Peripherally Inserted Central Catheter (PICC) 94
  • 94. Intraosseous Administration • Emergency route used to administer fluids, blood, and medication when IV access is unavailable • Allows drug infusion through a needle in the medullary cavity of a long bone; from there, the medication drains through narrow sinusoids into large medullary venous channels and into the systemic circulation 95
  • 95. 96
  • 96. Nose, Ear, Rectal • Nose drops: – Instill in one naris at a time in infants because they are obligate nose breathers • Ear medications: – Pull the ear down and back to instill eardrops in infants; pull the ear up and out to instill eardrops in older children – Have medication at room temperature • Rectal medication: – Lubricate tip of suppository – Insert the suppository past the anal sphincter – Hold buttocks together for a few seconds after insertion to prevent expulsion of the medication 97
  • 97. 98
  • 98. Inhalers • Shake the inhaler for 2 to 5 seconds • Position the inhaler with the canister above the mouthpiece • After a normal exhale, have the child inhale slowly as the canister is pressed down • Have the child hold his breath for a few seconds after the medication is released • Inhalers without spacers aren’t placed in the mouth; inhalers with spacers require the child to make a seal around the mouthpiece before inhaling; masks with spacers can be used for infants 99

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