Pediatric Care Best Practices: Chapter 21 & 22 Highlights

1. Highlights of Chapter 21 and 22 The Child’s Experience and Adapting to Pediatric Care

2. Preparing a Child for a Procedure • Box 21.1 Page 464 • Infants • Toddlers • School Age • Teen • Remember the principle of regression in ALL!

3. Fear Questions • What are toddlers most afraid of in a hospitalization? 474 • What are pre schoolers most afraid of in a hospitalization? 476 • How would one help a pre schooler work through their fear? • What is a school age child’s primary concern? • What is a teenager’s primary concern? 476

4. Separation Anxiety • 6 months up • Most pronounced in toddler • Protest • Despair • Denial or Detachment • Prolonged detachment=disruption of bonding • Principle of reverting back to previous stage

6. Separation Anxiety Questions • At what age is separation anxiety at its peak? 465 • When a nurse or parent leaves a toddler or preschooler how would they explain when they will return?

7. Pain in Children • Under treated due to: • Misconceptions about pain • Misconceptions about opioid use • Lack of awareness of detrimental affects of pain • Verbal ability of children

8. Developmental Expectations of Children in communicating pain • All infants and children experience pain • Newborn and early childhood pain communicated through physical and behavioral response • Pain words emerge at 18-24 months • Description and gross indication of intensity by 3-5 • Able to give better description of intensity by age 7 due to ability to rank, serialize

9. QUEST • Question the child. • Use pain rating scales. • Evaluate behavior and physiologic changes. • Secure parents' involvement. • Take cause of pain into account. • Take action and evaluate results.

10. Physiological Responses to Pain • Increased BP, respirations, pulse • Flushing of the skin • Sweating • Restlessness • Decreased O2 sats • Dilation of pupils

11. WEBSURFING ON PAIN • http://www.childcancerpain.org/frameset.cfm?content=assess01 • Let’s take a couple of minutes and look at this site.

12. A preschool pain rating scale

13. Category Scoring 1 2 3 Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant quivering chin, clenched jaw Legs Normal position or relaxed Uneasy, restless, tense Kicking, or legs drawn up Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid or jerking Cry No cry (awake or asleep) Moans or whimpers; occasional complaint Crying steadily, screams or sobs, frequent complaints Consolability Content, relaxed Reassured by occasional touching, hugging or being talked to, distractible Difficult to console or comfort FLACC Scale

14. References • The FLACC pain scale and Riley pain scale can be found at this website: • http://www.childcancerpain.org/frameset.cfm?content=assess01

15. Pediatric Pain Medications • Non Opioid: • Tylenol, Ibuprofen • Opioid: • Codeine, hydrocodone, meperidine, morphine oxycodone, fentanyl • Adjunctive: • Tricyclic antidepressents in chronic pain • Benzodiazepines to reduce anxiety and produce amnesia

16. Children’s TylenolKnow the difference

17. Infant Drops • Tylenol infant drops come in a concentration of 160 mg/1.6 ml • The dropper is a .8 ml dropper for 80 mgs • Dose 15 mg/kg/dose

18. Tylenol suspension 160mg/5 mls Dose is 15 mg/kg q4h for a maximum of 5 doses a day Children’s Tylenol Suspension

19. Children’s IbuprofenKnow the difference

20. Children’s Ibuprofen Syrup • Advil (Ibuprofen) suspension or syrup 100 mg/5 ml • 8-10 mg/kg/6hrs • Do not exceed 40 mg/kg/day (4 doses)

21. Ibuprofen Pediatric or Infant Drops • 50 mg/1.25 ml • Dose 8-10 mg/kg/6h • Do not exceed 40 mg/kg/day

22. Four math problems • 12 kg infant receiving Tylenol Suspension at dose in previous slide; how much? • 6 kg infant receiving Tylenol Infant Drops at dose in previous slide; how much • 15 kg infant receiving Ibuprofen Suspension at dose in previous slide; how much • 5 kg infant receiving Ibupofen Pediatric Drops at dose in previous slide; how much

23. Cultural Sensitivity • Page 470 • Be yourself • Be aware that people express themselves differently • Always go on the principle of good will and intent

24. The Hospitalized Infant • Frustration in their needs not being met. • Do not expect them to develop new habits • Emphasis in assisting with the: • Parent/infant attachment • Sensorimotor opportunities • Gentle • Cuddle and comfort • Liberal visiting policies • Consistency

25. The Hospitalized Toddler • Separation anxiety at it’s peak 474 • Box 21-2 Nursing Goals • Transitional objects • Restraints and “autonomy vs. shame and doubt” • Distractions • Choice when able

26. The Hospitalized Preschooler • Feelings of guilt • Very afraid of bodily harm, mutilation and invasive procedures • Praise is important • Role playing through experiences • See box 21.3 page 476

27. The Hospitalized School Ager • More able to endure the separation • Force dependency is the big issue • Loss of control and security • Need to feel grown up and have independence • Education must continue • Scheduling around important routine in child’s life • See nursing tip page 477

28. The Hospitalized Adolescent • Loss of control • Dependence/independence issues • Threat to identity • Response • Withdrawal • Non compliance • Anger

29. Early, Middle, Late Adolescence • Early • Threat to body image more than forced dependence • Middle • Sex appeal and sex role expectations • Relinquish of control is also a issue • Late • More concerned with the interference in life

30. Chapter 22; Admission • Identification • Safety Do’s and Don’ts page 482 • Holding an infant; watch the head • Mummy restraint when necessary

31. Pediatric Adaptationstympanic temperature • Down and back under three • Slightly up and back over three. • Aim it at the opposite eye brow • Use only in infants over three months

32. Head circumference measurement • Tape measure around the head, slightly above the eyebrows and ears and around the occipital prominence of the skull

33. Body influences on medication in infants and children • Gastrointestinal: • infants have a lower level of acid content in the stomach up to age two • Children under five may have a more rapid intestinal transit time • Lower pancreatic enzymes • New book 495 old book 508

34. Body influences on medication in infants and children • Integumentary • Thin stratum corneum allows topicals to be absorbed at a greater amount • Larger skin surface area also increases absorption • Diapers are an occlusive dressing and may increase absorption of medications

35. Body influences on medication in infants and children • Parenteral Medications • Slower absorption of IM in young infant • In neonates medication may pass the blood brain barrier more easily than in older children, therefore be more guarded with regards to respiratory depression.

36. Body influences on medication in infants and children • Liver immaturity until ages 2-4 therefore drugs metabolized by liver metabolize more slowly • Medications given at frequent intervals may result in toxic levels and responses

37. Body influences on medication in infants and children • Immature kidney function prevents effective excretion of drugs from infants under a year of age

38. Fever and hyperthermia • Page 488 new book • Fever: hypothalamus has raised the body temperature set point as a respond to bacteria or toxins in conjunction with body’s prostaglandins • Hyperthermia increase in core body temperature ocurring with CNS impairment or overheating.

41. Body Surface Area • A method to accurately dose a drug for a pediatric patient • Usually used in highly toxic drugs • Used in converting adult doses to pediatric doses • You will probably not see this method in your career unless you go into oncology • BSA/1.7 X adult dose= child dose

44. Pediatric dosing; Mg/kg • Pablo Martinez, a 5-year-old boy, is diagnosed with bacterial meningitis. He weighs 19 kgs. • The MD orders cefuroxime IM 950mg q8h • Dosage is 200-240 mg/kg/day divided q 6 or 8 • Is the above dose appropriate?

45. Fun drug test to take • http://classes.kumc.edu/son/nurs420/clinical/basic_review.htm#Pediatric%20calculations • http://classes.kumc.edu/son/nurs420/clinical/basic_practice_.htm

46. Oral Medication Points • Cherry syrup or jelly to mix not other nutritious food • Syringe down the side of the mouth • Position on page 500/513 good way to hold • Bib yourself! • Do not place in bottle with juice or water

47. IM injections • Page 515 old book 502 new book • Discuss sites, size of needle and amounts

48. Nursing Assessment for IV • Monitor IV site hourly • Flow rate • Swelling at needle site • Low volume in IV bag/burette • Pain or redness at insertion site • Moisture at or around site • Accurate I & O