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
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. Toddler
• **Separation anxiety
• Nurses experience
protest and despair in
this group
• Fear of injury and pain
• Regressive behavior
7
9. 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quiet, withdrawn,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
compliant 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.
9
10. 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 – may see
illness as a form of punishment
10
See Video “Beginning Pediatric Nursing – Preschoolers”
11. 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
11
See Video “Beginning Pediatric Nursing – School-Age Children”
12. Review Question
• Which of the following nursing interventions is the
most appropriate when working with a school age
child who has a terminal illness?
A. Give factual explanations of the disease,
medications, and procedures.
B. Perform all care for the child.
C. Tell the child that everything will be okay.
D. Assure the child that being in the hospital is not a
punishment for any thoughts or actions.
12
13. Adolescent Child
• 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
13
See Video “Beginning Pediatric Nursing – Adolescents”
15. 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
15
16. 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
16
17. Nursing Care to Assist the
Child with Hospitalization
Related to Age
17
18. 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
18
19. 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.
19
20. 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 diversional
activities
• Avoid intrusive procedures
as much as possible
• Assess child’s perception by
asking to draw a picture and
tell about it
20
21. Preschooler
• This preschooler’s 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?
21
22. 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 feelings of inferiority)
• Use audiovisuals, pictures,
anatomical models, body outlines
• Suggest ways of maintaining
control (such as deep breathing
or 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
22
23. School-Age Child
• 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
23
24. School-Age Child
• 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
24
25. Adolescent – Identity vs. Role Confusion
• 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
25
26. Adolescents and Hospitalization
• Procedures
– Give full explanations
– More concerned with the present than the future
• Respect and Confidentiality
– Resent authority figure or nurses trying to be their
peers
– Like nurses to be friendly
• Restrictions
– Impose few restrictions, but do set limits
– May “sleep” or get on the phone to avoid discussions
26
28. 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.
28
29. 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 – band-aids, stethoscopes,
syringes without needles. – remove when finished playing
29
30. Therapeutic Play Techniques
• Preschooler
– 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
30
31. Pet Therapy
Hospitals may have pet therapy from specially
trained animals to provide comfort and
distraction during healthcare
31
32. 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
32
34. 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
34
35. 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
35
36. Preparation Strategies
• Allowing the child to
dress up as a doctor
or a nurse helps
prepare the child for
hospitalization
• Helps the child adjust
to treatment care and
recovery process
36
37. 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.
37
38. 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 and discuss family support, make referrals
38
39. • 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
39
Nursing Care to Assist Families to Cope
It is important to reunite the family
as soon as possible after surgery
40. 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
40
41. 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
41
43. 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
43
45. 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
45
See Video “Pain Management in Children”
46. 46
Neonatal Infant Pain Scale (NIPS)
•For newborns up to 6 weeks after birth
•Total pain scores range from 0-7
•Newborn facial expression, cry quality, breathing patterns,
arm and leg position, and state of arousal are observed
47. Pain Assessment
Neonatal characteristic facial responses to pain
include: bulged brow, eyes squeezed shut, furrowed
naso-labial creases, open lips, pursed lips, stretched
mouth, taut tongue, and a quivering chin
47
Physiological
Response =
increased B/P and
decreased arterial
saturation
49. FLACC Scale - Pain Assessment Tool
49
•For children ages 2-7 yrs, or children with intellectual disability
•Total pain scores range from 0 to 10
50. 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
50
52. 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
52
55. Consequences of Pain
• Cardiovascular and respiratory changes
– Tachypnea, increased BP/ heart rate
– Inadequate lung expansion, decreased arterial saturation
– Inadequate cough
• Neurologic changes
– Fight /flight response- Tachycardia, insomnia, increased 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
55
56. 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
56
59. 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
59
60. 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 minutes
60
63. Definition
• Signs and 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)
63
65. Contributing Factors
• Poly-drug use
• Smoking
• Alcohol use
• Length of drug use
• Time of last drug
use
• Amount of drug use
65
66. 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
66
67. 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)
67
68. 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)
68
72. 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
72
73. 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
73
74. 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
74
77. Disadvantages of Morphine
• Have to give q 3-4 hours due to short
half-life
• Respiratory depressant
• Hypotension
• Urinary retention
• Delay gastric emptying
77
79. Disadvantages of Methadone
• May take longer to wean (longer half-life)
• Does not prevent loose stools
• May mask the severity of NAS
79
80. 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
80
81. 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
81
82. 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
82
84. 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
84
87. 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
87
88. 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
88
89. 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
89
90. 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
90
91. Retraction Severity
• Mild retractions
– Subcostal or
Substernal
• Moderate retractions
– Intercostal or
Supraclavicular
• Severe retractions
– Suprasternal or
Sternal
http://intranet.tdmu.edu.ua
91
93. 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
93
96. 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
96
97. 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
97
101. 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
101
104. 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
104
107. 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
107
109. 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
109
