PEDS Hospitalized Child

Disadvantages of Morphine

•Have to give q 3-4 hours due to short half-life •Respiratory depressant •Hypotension •Urinary retention •Delays gastric emptying

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

12 month old should be able to

build a two block tower

Children's Understanding of Hospitalization is determined by

cognitive ability at various developmental stages (what they can understand) and previous experiences with HCP's

When the NAS scores are stabilized and opioids are weaned

continue to observe for two days to monitor for rebound s/s

Intravenous Medications

•Inspect IV sites frequently for signs of infiltration (cool, blanched, and puffy skin) or inflammation (warm and reddened skin) -Always use an infusion pump -monitor hourly

Disadvantages of Methadone

•May take longer to wean (longer half-life) •Does not prevent loose stools -May mask the severity of NAS

Nursing care of preschooler

-Acknowledge child's fears, -orient to hospital, -encourage presence of parent, -nutrition: allow favorite foods unless contraindicated, -encourage intake of fluids with games, -reinforce coping behavior, -provide mobility, -provide play, -avoid intrusive procedures, -allow child to draw pictures to express feelings, -allow child to handle equipment, -use dolls

Preschooler common stressors

-Being alone -Being in the dark -Fear of abandonment -Fear of loss of control related to body and emotions -Fear of bodily injury or mutilation -Guilt and shame - may see illness as a form of punishment

Withdrawal Assessment Tool (WAT)

Used with critically ill children who are exposed to opioids and benzodiazepines for prolonged periods; results in tolerance, withdrawal, & physical dependency after long-term sedation & analgesia in PICU

Finnegan NAS scoring tool

21 items -CNS disturbances -Metabolic/ Vasomotor/ Respiratory Disturbances -GI disturbances

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.

A.Give factual explanations of the disease, medications, and procedures.

Eye Medications

Pull lower lid down Apply drops or thin string of ointment as ordered Release lower lid -apply lacrimal pressure @ least 60 seconds

Despair

Sad, depressed, withdrawn and quiet or compliant & may cry when parents return

Protest

Screaming, crying, temper tantrums, clinging to parents and pleading them to stay, resistant to care or attempts to comfort them

Detachment

Appear to be happy & content; do not protest when parents leave and may actually ignore parents when they return

FACES Pain Rating Scale

Ask the child to select the appropriate face It can be used in children over the age of 3, and in adults.

Neurologic changes to pain

insomnia -fight or flight response

Contributing Factors to NAS

•Poly-drug use •Smoking •Alcohol use •Length of drug use •Time of last drug use •Amount of drug use (•S/S of withdrawal may be present @ birth •Peak @ 3-4 days of age (usually))

Infant common stressors

•Separation from parents (most common) (6-8 months) •Stranger anxiety (6-18 months) •Painful procedures •Immobilization of extremities •Sleep deprivation -They can sense the anxiety their parents are experiencing

Adolescent Stressors

•Separation from peers, home, & school •Preoccupation with appearance & body image •Loss of independence, control & privacy •Fear of injury or altered appearance •Fear of disability, pain, & death -may hide fear •Give them some control to avoid a power struggle

How to reduce anxiety and fear in a school aged child

•nurse explains what is going to happen and demonstrates how the procedure will be done by using a doll

Infant Therapeutic Play Techniques

-Crib Mobiles -Soft toys -Music

Immune system changes to pain

-Depression of immune system with increase risk for infection

Numerical Rating Pain Scale

Over age nine

Stages of separation

protest, despair, detachment

Nursing care of older infant/toddler

-Encourage parent to room in & if have to leave, leave when awake, -explain developmental stage to parent, -bring security object(s), -set limits, -give choices on simple decisions, - -Teach parents child may regress, -promote ritualistic behavior before bedtime, -teach parents about environmental hazards (ie. crib)

Nursing care of School-age

-Encourage them to continue with schoolwork as well as to participate in creative activities -assess knowledge and use scientific terminology, -direct questions more to child, -use audiovisuals to teach, -teach coping (ie. deep breathing), -provide positive feedback, -include in decision-making when possible, -encourage active participation (ie. pin care), -maintain clear consistent limits, -allow for privacy, -use dolls for teaching

Neonatal Infant Pain Scale (NIPS)

Used for newborns up to 6 weeks Facial expression: relaxed vs. grimace Cry:no cry, whimper, or vigorous cry Breathing patterns: relaxed vs. irregular or fast Arm & leg movements: relaxed vs. flexed or extended State of arousal: sleeping vs. awake or fussy

Advantages of Methadone

•Given only twice a day -Controls irritability & insomnia

A 4-year-old is hospitalized for severe gastroenteritis. The child is crying and clinging to the mother. The mother becomes very upset and is afraid to leave the child. Which of the following nursing interventions would be appropriate to alleviate the child's fears and the mother's anxiety? A.Reassure the mother that the child will be fine after she leaves B.Give the mother the telephone number of the pediatric unit and tell the mother to call any time C.Ask the mother if she would like to stay overnight with the child D.Tell the mother to bring the child's favorite toys the next time she comes to the hospital to visit.

C.Ask the mother if she would like to stay overnight with the child -child is in the protest stage of separation

The nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and appropriately includes which of the following: A.Keep the infant as quiet as possible B.Place small toys in the crib to provide stimulation for the infant C.Restrain the infant to prevent tubes from being dislodged D.Provide a consistent routine such as touching, rocking, and cuddling throughout the hospitalization

D. Provide a consistent routine such as touching, rocking, and cuddling throughout the hospitalization

Administering Medications to Children

Dosage calculation: weight in kg (most common) or BSA (chemotherapy or burn injuries)

Intraosseous Administration

Emergency route used to administer fluids, blood, and medication when IV access is unavailable

FLACC Scale

Face Legs Activity Cry Consolability ages 2-7, or children with intellectual disability

PAT: Pain Assessment Tool

Infants up to 10 months Looks at VS and body language, as well as the nurse's perception (no pain observed vs. infant appears to be in pain) -Try to do pain assessment before touching infant

Peripherally Inserted Central Catheter (PICC)

Measure arm circumference & length of catheter @ site q shift (from skin to hub)

Finnegan Scoring System (abstinence scoring) is initiated when:

-History of maternal drug use -Suspected exposure -S/S withdrawal

Pediatric Early Warning Score (PEWS)

-Identifies patients at risk for clinical deterioration; reduces code events on peds floor, improves communication between RN, RT, resident & attending -establish baseline score in PICU & ED -The lower the score the better the outcome -Score based on: HR, RR, BP, O2 sat, O2 therapy, cap refill

Gastrointestinal changes to pain

-Increased intestinal secretions, prone to ileus

Toddler Therapeutic Play Techniques

-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

Preschooler Therapeutic Play Techniques

-Play with safe hospital equipment -Crayons and coloring books, -Puppets, Felt and magnetic boards -Books and recorded stories -Dolls

School-age Therapeutic Play Techniques

-Videos -Hospital equipment -Board games, crafts -Books, computers (to promote sense of industry)

Nursing Care of the Adolescent

-assess knowledge, -involve in decision-making, -ask if wants parent present, -limit restrictions, -accept regression, -give positive reinforcement, -provide privacy, -allow favorite food unless restrictions, -give full explanations, -more concerned with present than future

Adolescent Therapeutic Play Techniques

-books -computers -encourage interaction with peers

Neonatal Pain Assessment

-bulged brow, -eyes squeezed shut, -furrowed naso-labial creases, -open lips, -pursed lips, -stretched mouth, -taut tongue, -a quivering chin -Increased BP and HR

Metabolic changes to pain

-Increased fluid and electrolyte losses -increased glucose

A 7-year-old is hospitalized with a fracture of the femur and is placed in traction. In meeting the psychosocial needs of the child, the nurse appropriately selects which of the following play activities for the child? A.A coloring book with crayons B.A finger-painting set C.A large puzzle D.A board game

D.A board game (because they are in cooperative play stage)

Intramuscular (IM) medications

do not use dorsogluteal (use of controversial in children) til walking at least 1 year; preferred site is vastus lateralis or could use rectus femoris; deltoid for toddlers; do not administer more than 0.5 ml in infant or greater than 1 ml in child in any site

NAS s/s:

high-pitched cry, sleep disturbances, moro reflex, tremors, ámuscle tone, excoriation (chin, knees, elbows, toes, nose), myoclonic jerks, generalized seizures (staring, rapid eye movements, chewing, back arching, fist clenching), sweating, hyperthermia (axillary), yawning, mottling, nasal stuffiness, sneezing, nasal flaring, RR greater than 60 with retractions, excessive sucking, poor feeding, regurgitation, loose/watery stools

Neonatal Abstinence Syndrome

is the occurrence of signs and symptoms in an infant born to a substance-dependent mother or postnatal exposure to opioids

Pharmacological Treatment for NAS

oral Morphine is usually used (preferred), or methadone

Administering Analgesics to Children

preferred routes (oral or IV), if receiving IV or epidural opioids apply pulse oximetry, naloxone hydrochloride for respiratory depression if stimulation or oxygen ineffective

Oucher Scale

preschool and up Explain each picture to the child and ask the child to choose the picture that best describes their pain and choose the number that correlates

What age group is most Impacted by Separation Anxiety?

toddlers

COMFORT Scale for Pain Assessment

used when a person cannot describe or rate their pain ex. children cognitively impaired adults the intellectually-disabled sedated patients

toddler common stressors

•*Separation anxiety (more pronounced than in infancy) •Fear of injury and pain •Disruption of routine -regression -•Nurses experience protest and despair in this group

Pharmacologic Interventions for Pain

•Analgesics -Patient-controlled analgesia -Topical anesthetic cream (EMLA) •Non-steroidal anti-inflammatory drugs •Opioids •Conscious sedation •Epidural analgesia

Nursing Care to Assist Families to Cope

•Assess what parent/child already knows of illness and treatment -It is important to reunite the family as soon as possible after surgery -orient to hospital, -assess knowledge, -encourage questions, -assess family support and make referrals, -allow parents to participate

Advantages of Morphine

•Faster weaning •Reduces bowel motility/ loose stools •Facilitates feedings & interaction

Nursing care of infants

-encourage parent to room-in & participate in care; -simulate home routine, -assign same nurse, -allow parents to be present for procedures & comfort afterward, -keep frightening objects from view, -provide swaddling & soft talk, -minimize light & sound stimulation, -allow non-nutritive sucking for comfort

Oral Medications

allow as much choice as possible (which pill to take 1st), hold infant upright, instill med. along side of tongue into cheek, crush pills and give with pudding, ice cream, etc., flush meds given via GT or NG/OG

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

Common Stressors

•Fear of the unknown •Separation anxiety (toddlers) •Fear of pain or mutilation (preschoolers) •Loss of control •Anger •Guilt •Regression - especially bed wetting

NAS Scoring

•First one done 2 hours after birth •Score every 4 hours (if score is high, obtain more frequently)

Using Restraints

•Frequently check the extremity distal to the restraint for circulation, sensation, and motion (neuromuscular checks) -Use least restrictive, ensure proper fit, do not secure to bedrail, remove and assess every 2 hours and document

School-Age: Sources of Stress

•Separation: may have already experienced when starting to school •Fear of injury and pain •Want to know reason for procedures -Like being involved and wants to make choices -privacy issues

Advantages of Play

•Therapeutic - activities are guided (relieves stress and anxiety) •Emotional outlet - acts out real stressors (allows child to be in control) •Used to teach child prior to situation •Enhances cooperation - used during an unpleasant procedure. (distraction)

Non Pharmacological Tx for NAS

-implement ASAP after birth, -quiet environment with dim lighting, -soothing music/ heartbeat tapes, -swaddle infant, -gentle handling of infant, -kangaroo care/infant sling, -massage/ baths, -gentle rocking, talking, singing, -pacifier with mother's permission, -hand mittens to reduce face trauma, -high-calorie formulas

Cardiovascular and respiratory changes to pain

-increased BP/ heart rate -Inadequate lung expansion -Inadequate cough -decreased O2 sats

Preparation for admission to the hospital

-prepare by giving tour of hospital, -photographs or video of medical setting and procedures, -health fairs, -contact with peers who had similar experience, -allow child to dress up as doctor or nurse

Things Parents can do to Prepare Child for admission to a hospital

-read stories, -talk about hospital, -encourage questions, -tour of hospital, -encourage child to draw pictures, -be honest about pain

Preparation for Procedures

-take child to treatment room, -encourage parent to comfort child, -use developmentally-appropriate terminology, -offer child choices where possible, -do not threaten punishment for lack of cooperation, -do not force unwilling parent to stay