Basics of Pediatric Care Chapter 55: Family-Centered Approach

1. Basics of pediatric care chapter 55 Presentation by: Leslie Lehmkuhl, RN

2. 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 Family-centered care

3. 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 Pediatric assessment

4. 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 Terms

5. 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 Admission

6. 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. Preoperative

7. 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 Surgery

8. 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 Explanations

9. Child encouraged to bring in blanket, toy Child may have less anxiety with familiar object With reduced anxiety: may need less premedication for surgery Familiar toys

10. 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 Fears/Anxiety

11. 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 Separation anxiety

12. 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/Shame

13. 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 Fears

14. 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 Post operative assessment

15. 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) Pain/ Discharge

16. 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

17. Length Infant to <2 years measure from top of head to heel > 2 years standing height Physical Assessment

18. Weight < 2 years cover on scale with no clothing on child Toddler in underpants or light weight gown Physical Assessment

19. 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

20. 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

21. Physical assessment • Carotenemia=orange to yellow color of skin • Pallor • Erythema=diffusely red • Dark skinned infants may be dusky red to violet

22. 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

23. 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

24. 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

25. 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

26. 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”

27. Sites for Measuring Blood Pressure.

28. 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

29. 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

30. 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

31. 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

32. Figure 30-10 (From Lowdermilk, D.L., Perry, S., Bobak, I.M. [1997]. Maternity & women’s health care. [6th ed.]. St. Louis: Mosby.) Mummy restraint.

33. 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

34. 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

35. Figure 30-12 Alcohol pad 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.)

36. 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.

37. 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

38. 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

39. 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

40. Jugular Venipuncture

41. Mummy Restraint

42. Femoral Puncture

43. 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

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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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