CHAPTER 21: CARING FOR THE CHILD IN THE HOSPITAL, COMMUNITY, AND ACROSS CARE SETTINGS

How to calculate BMI:

Kg/Cm^2 x 10,000 Ex: P/t= 26 kg Height= 135 cm (26/135^2) x 10,000= 14.26 Then you would plot and see where it falls in the graph to determine if the BMI for age is appropriate for child

Nutrition: Average Daily Normal Requirements For Children

0-1 MONTH: >100-110 KCAL/KG/DAY 2-4 MONTHS: >90-100 KCAL/KG/DAY 5-60 MONTHS: >70-90 KCAL/KG/DAY GREATER THAN 5 YEARS: >1,500 KCAL FOR FIRST 20 KG + 25 KCAL FOR EACH ADDITIONAL KG

Identify Assessment and Management Issues Related To the Child in Pain: Assessment

"PAIN IS WHATEVER THE CHILD SAYS IT IS" >Assessment -What kinds of pain has your child has in the past? -How does child respond to pain? -What do you know when he is hurting? -What does he do when he is hurting? -What works best to relieve child's pain? -Is there anything special you would like me to know about your child's pain?

Holistic Nursing Care for the Child: Average daily caloric requirements for children

0-1 month: >100-110 kcal/kg/day 2-4 months: >90-100 kcal/kg/day 5-60 months: >70-90 kcal/kg/day Greater than 5 years: >1,500 kcal for first 20 kg + 25 kcal for each additional kg/day

Discuss a Developmental Approach to gathering the history and physical assessment of the child: Comprehensive Health History: Family Medical and Social History

> Ages and cause of death of any deceased parents, grandparents, siblings? >Chronic illness experienced by family members >Inherited diseases >Parents professions, religious affiliations or spiritual beliefs, and family activities >For the older child, interviewed without the presence of the parent, the social history must include information regarding grade level, friendships, drug/alcohol abuse, smoking, sexual activity, and safe sex practices

Discuss a Developmental Approach to gathering the history and physical assessment of the child: Comprehensive Health History: Immunizations

> Any immunizations received are documented, and the chart is reviewed before the interview to determine if immunizations are current >Important for the nurse to be aware of and follow the most current guidelines

Physical Assessment of The Child: Taking Vital Signs: Respiration

> Counted for 1 full minute and can be assessed accurately when not crying > Good time to count them is when child is sleeping/resting quietly in parent's arms > If possible, it is wise to start assessment with respiration count >Inspection -Respirations are regular and effortless -No nasal flaring, grunting, or retractions -A presence of the above symptoms are signs of respiratory distress in children >Auscultation -Adventitious breath sounds are absent -Absent or diminished breath sounds are ALWAYS abnormal and require further evaluation >WHERE TO LOOK FOR RETRACTION: -Clavicular -Suprasternal -Intercostal -Substernal -Subcostal

Dosing of Acetaminophen from Temperatures:

> Fever less than 102.6F -5 mg/kg of body weight >Fever greater than 102.6 - 10 mg/kg of body weight Efficacy of acetaminophen is assessed by re-taking temperature 1 hour after administration

Discuss a Developmental Approach to gathering the history and physical assessment of the child: Comprehensive Health History: Past Medical Hx

> History of the pregnancy, labor, delivery, and the health of baby are documented including the birth weight, APGAR scores, >Any difficulties with feeding, breathing, jaundice, or other medical problems in early neonatal period >Documentation of acute illnesses >Chronic illnesses and medications that been prescribed >Documentation of herbal products and remedies >Resultant medical diagnoses/and outcomes of previous treatments

Prioritize Developmentally appropriate and holistic nursing care for the child and family across health care settings: Areas for Care in the Hospital

>24 Hour observation Unit -Child becomes suddenly ill and will recover quickly -Rehydration -Aerosol tx for asthma -Medication for allergic rxn. -Nurse explains medical orders >Ambulatory Surgery Center -Children receive minimal surgical treatment, recover from the procedure, discharged soon after surgery **Children more vulnerable to stress of hospitalization because they do not have full coping mechanisms** >Fast Track Care -Minor illness such as ear infection -"Urgent Care" >Emergency Dept. -Child become suddenly ill/severe injury -Rapid screening to establish nature and severity >Critical Care Unit -Child becomes very ill on med surg floor -Baby who requires intensive care -Cardiac, surgical, or psychiatric critical care units -Receives specialized care, meds, IV fluid, Repiratory/ventilator support

Acute Pain vs. Chronic Pain

>Acute pain -Identifiable cause -Short duration -Sudden onset -Well defined -Limited -Decreases with healing -Reversible -Signs and symptoms present -Anxiety >Chronic Pain -Cause hard to find -Lasts > 3 months -Begins gradually and persists -May/may not be well defined -Unlimited -Persists beyond healing time -Exhausting and useless -Signs and symptoms absent -Depression & Fatigue

Age specific interview and assessment tips: Preschool Child

>Ask simple questions >Allow child to ask questions >Enlist the child's help during examination (ex: allowing them to place the stethoscope in place) >Explain what the child will feel (ex: stethoscope is going to be cold) >Utilize the child's imagination through puppets and play >Give child choices when possible

FOCUS ON SAFETY: ASPIRIN

>Aspirin is not given because of the correlation between the use of aspirin and the development of Reye Syndrome (swelling in the liver & brain) in children with viral infections commonly with flu/chickenpox

Holistic Nursing Care for the Child: Rest

>Assess normal sleep patterns >Allow family and child to "sleep in" >Provide uninterrupted nap time

Physical Assessment: Skin Assessment

>Assessed for color, turgor, lesions >Carotenemia -benign yellowing of the skin caused by excessive carotene in the blood may be present in the child with a diet high in yellow and orange vegetables >Yellowing of the skin and sclerae -may indicate dysfunction of the liver >Pallor -Indicative of anemia >Cyanosis -compromised cardiorespiratory rate >Petechial lesions -infectious process -blood disorder >Ecchymosis lesions -blood disorder -tell tale sign of past accidental/non-accidental injury >Assess skin turgor -grasping small area of skin and lifting up -should return back quickly -"Tented skin" = dehydration >Rash present/Jaundice suspected -Nurse determines if skin blanches or turns pale -Nurse applies pressure to the skin with thumbs 1-2 in. apart -Jaundice= yellowish underlying color -Petechial lesions DO NOT blanch >Cradle Cap skin -thick crusty scales over scalp -THIS IS NORMAL >Nails -Pink and convex -White edges extending over fingers -Clubbed nails= cardiac disease >Palms -Normally has 3 creases -One crease may indicate genetic disorder (Down's Syndrome)

Physical Assessment of The Child: Taking Vital Signs: Blood pressure

>BP done when child reaches 3 y.o > Reading important for dizziness, dehydration, kidney disease, cardiac issues, pulmonary issues regardless of age >Appropriate cuff size -Width of bladder is 40% -Length is approx 80% circumference of the arm

Explore Health-Care Needs of the family and child living with a disability: Developmental Concerns

>Because of constant medical and surgical interventions, child may experience: 1) Regression 2)Maturity beyond their years

FOCUS ON SAFETY: HAND-OFF COMMUNICATION

>Interactive process for relaying important patient information from one team member to the next >This is used to improve patient safety >Utilize SBAR >Hand-offs can be tape recordings, face-to-face, or at the bedside of the patient

Critical Nursing Action: Before during and After procedure

>Before -think through the procedure to anticipate problems -Gather equipment and check the functioning -Establish trust with child first -Use of play on doll -Offer coping strategy -Give child realistic choices -Informed consent signed -Wash hands -OK to cry >During -Schedule treatments away from bed or safe area -Expect child to do well -Talk to child and ask how they are doing -Keep child informed on the progress -Use distraction techniques -Allow decisions when appropriate -Involve parent to add comfort >After -Praise child -Allow them to verbalize feelings -If parents were not involved, comment a positive aspect (they did a good job) -Give reward (stickers, small toy agreed upon with parents) -Document child response to outcome of procedure

Age specific interview and assessment tips: Infants

>Before procedure, talk and touch the infant >Use a gentle touch/speak softly >Let infant hold favorite toy >Perform traumatic procedures last >Use distractions (bright objects, rattles) >When child is quiet, auscultate heart, lungs, and abdomen sounds

Physical Assessment: Lungs

>Best heard while child is sitting >Take slow deep breaths through an open mouth >Auscultation -Hear all 5 lobes -MUST DO POSTERIORLY/ANTERIORLY -Begin with apices and move side-to-side to compare lung sounds -Best to do it early in the exam while the child is quiet >Hyperpnea -Too deep breathing -Associated with fever >Hypopnea -Too shallow breathing -Associated with CNS depression >Posture of respiratory distress -Tripod position sitting upright -leaning forward on outstretched arms with jaw thrust forward -Allow them to assume position of comfort -

Physical Assessment: Musculoskeletal

>Can be observed as child is moving in the exam room -Observed for: 1)Range of motion 2)Symmetry of movement 3)General Alignment 4)Deformities >Upper extremity strength -Child holds both arms out to the sides/front -Nurse applies downward pressure on both arms -Symmetry of strength is done by having the child squeeze the nurse's index finger -Strength of legs is done by having child lay in supine position and raising child's legs and downward pressure is exerted -Screen for scoliosis at age 9-15 y.o -Scoliometer= used to assess the condition of the back >Abnormal: -Lateral curvature of spine indicates scoliosis

Explore Health-Care Needs of the family and child living with a disability: Physical Concerns

>Child with disability undergoing surgery, especially at a younger age may experience: 1) Rapid fluid and electrolyte changes >Severe congenital heart problems -Lifetime corrective procedures to augment initial surgies or pharmacological therapies -Takes time, energy, and finances -Need to learn physical self care-techniques (diabetes, and anticoagulation monitoring)

PAIN MANAGEMENT STRATEGIES FOR AGE GROUPS: School (6-11 years)

>Concerns/Reactions -Has questions regarding body and illness -Concerns of helplessness, passivity, & dependency -Tend to be phobic and develop fears -Anger >Distractions -Deep breathing -Hand squeezing -Riddles/Trivia -Pretend games -Talking -Distraction kit >Environment -Use treatment room -Music -Controlled lighting and noise >Parent Involvement -Encourage presence of parents -Provide guidance -Encourage parents to be part of team >Preparation -Simple terms to describe what will happen -Allow appropriate play with medical equipment -Allow participation by patient >Positions -Lap -Present patient with choices -Parent may support patient >Post procedure -Praise patient with stickers -Play, Medical play -Stories -Evaluate procedures and discuss suggestions for next time

PAIN MANAGEMENT STRATEGIES FOR AGE GROUPS: Teens (12+)

>Concerns/Reactions -Illness interferes with struggle for independence -Illness is a major threat to developing self image -Very threatened by helplessness and loss of privacy -Denial, withdrawal, anger, hostility, disappointment >Distractions -Imagery -Tablet -Deep breathing -Hand squeezing -Talking -Jokes -Distraction kit >Environment -Use treatment room -Music -Controlled lighting and noise >Parent Involvement -Ask permission of patient for parents -Encourage parents to be part of team >Preparation -Clarify misconceptions and initiate discussions about past experiences with procedures -Allow appropriate participation -Pre procedural teaching utilizing medical play >Positions -Present patient with choices -Plan positioning with teen >Post Procedure -Praise /Reward with stickers -Play,Medical play -Stories -Evaluate procedures and suggestions for next visit

PAIN MANAGEMENT STRATEGIES FOR AGE GROUPS: Pre-School (3-6 year)

>Concerns/Reactions -Separation anxiety -Concerns with body image -Develops fantasies with illness -Battle for control >Distractions -Distraction kit -Deep breathing -Bubble blowing -Counting -Singing >Environment -Use treatment room -Music -Controlled lightning and noise >Parent Involvement -Encourage presence of parent -Provide guidance >Preparation -Medical play with relevant medical equipment and participation -Pre-procedure teaching -Reassurance of what child is to expect---focus on senses >Positions -Lap -Parent/Staff may support -Present patient with choices >Post Procedure -Praise and reward with stickers -Medical play -Stories

PAIN MANAGEMENT STRATEGIES FOR AGE GROUPS: Infant/Toddler (0-3 years old)

>Concerns/Reactions -Separation anxiety -Protest -Despair -Denial >Distraction -Pacifier -Swaddling -Rocking -Eye contact -Music -Picture books >Environment -Controlled lighting and noise -Use treatment room >Parental Involvement -Encourage presence of parents -Provide guidance -Cuddle/comfort baby during procedure >Preparation -Prepare parent -Offer explanations on what they will see and hear -Develop a plan/Who will do what? >Positions -Swaddle -Cuddle >Post-procedure -Soothe -Swaddle -Hold & rock -Soft music -Soothing voice

Discuss a Developmental Approach to gathering the history and physical assessment of the child: Asking Questions

>Conducted in a comfortable room with eye level to the parent and child >An unhurried life encourages the parent to ask questions appropriate to the health of the child >Nurse projects a genuine interest in and a desire to help the child and family, this lays a foundation for therapeutic communication >Begin with open-ended questions (allows for concerns to be explored), "How can I help you today?"/"What made you come in today?" >When clarifying the child's history use mnemonic "OLD CAT" O: Onset--> When did the pain start? L: Location--> Where is the pain? D: Duration--> How long does the pain last? C: Character -Can you tell me on scale 1-10 how bad it is? -For a younger child, ask the parent, "How much pain do you think the child is experiencing?" or use pain scale appropriate for child's level of development A: Aggravating/Alleviating--> What has made the pain better or worse? T: Timing---> When does the pain start/stop? **After chief complaint is determined, the child's past medical history is reviewed. This includes past acute illnesses, history of chronic illnesses, immunizations, hospitalizations, emergency room visits, and current medication use**

Holistic Nursing Care for the Child: Medication Administration

>Consider developmental level of child >Administering meds to infant may require additional help >Aspirin NOT recommended or given to children >Infant needs immediate cuddling and comfort after med administration >Toddler may consider medication to be punishment >To increase compliance of toddler, it may be needed to have parent administer the oral medications >Oral medication in cup or ORAL syringe can be self-administered by the pre-schooler under direct and close supervision >School aged child is far more cooperative >Nurse must be patient and allow time for more complex questions from adolescent >Education to parent/child about med is important >Always use 6 rights (route, med, patient, dosage, time, documentation) **Many facilities require a 2nd RN to check all medications being given**

Physical Assessment of The Child: Taking Vital Signs: Pulse

>Counted for 1 full minute while child/infant is quiet >Uncooperative infant -Femoral arteries are used -Brachial arteries are used

ABNORMAL BREATH SOUNDS

>Crackles -Sounds like light rice crispies -Heard on inspiration/expiration >Pleural Friction Rub -Low pitched -Sounds like sandpaper -Inspiration/Expiration >Rhonci -Low pitched snoring sounds -Heard primarily on expiration but also throughout respiratory cycle >Stridor -High pitched crowing sound -Heard on inspiration -Louder in neck rather than chest wall >Wheezes -High pitched "whistling" sounds -Heard on expiration and sometimes inspiration

Physical Assessment: Head Assessment

>Craniosynostosis -premature fusing of one or more of the cranial sutures or from gravitational influences by infant's head being kept in same position >Plagiocephaly -Origin is from recommended supine position -Flattening of the occiput >Posterior Fontanelle -closes 1-3 months after birth >Anterior Fontanelle -Diamond shaped -Remains open until 12-18 months of age -Most significant for evaluation -Delayed closure may = hypothyroidism, Down Syndrome, Achonroplasia(congenital dwarfism), or increased intracranial pressure >Face -Micrognathia (shortened chin) -low set ears -flattened nasal bridge -enlarged/protruding tongue -Allergic shiners (dark under eye rings) -Wide flattened philtrum (vertical groove from bottom of nose to the upper lip)

Critical Nursing Action: PREPARING A TODDLER FOR PROCEDURE

>DESCRIBE PROCEDURE >USE PLAY TO DEMONSTRATE PROCEDURE; ENCOURAGE HIM TO PRACTICE/DEMONSTRATE WITH A DOLL OR TEDDY BEAR >USE SIMPLE CONCRETE LANGUAGE. LIMIT PREP. FOR 5-10 MINS BECAUSE OF SHORT ATTENTION SPAN >IDENTIFY RESTRAINTS AND WHY NECESSARY >ALLOW PARENTS TO DECIDE IF THEY WANT TO BE PRESENT. ALLOW PARENTS TO STROKE THEIR CHILD SPEAKING SOOTHINGLY IF THEY REMAIN IN ROOM

Fever Reducing Measures: Environmental

>Decreasing room temp >Cool Compresses >Lighter layer of clothing >If using a cooling blanket -Placed on the bed with sheet covering -Set to a temp of 98.6F -Temperature decreased in response to cooling -RECTAL TEMP MUST BE USED Q15 MINS while child is on blanket and assessed for shivering -Only used in circumstances warranting an immediate drop of a very high fever

Critical Nursing Action: PREPARING AN INFANT FOR PROCEDURE

>Describe procedure to parents, explaining what will happen, how long, and encourage patient to stop you at any point if there is a question >Remind parents that infants often cry for reasons other than discomfort but be honest about any discomfort the infant may endure >Identify what restraints will be used and why it is necessary >Allow parents to decide if they would like to be present

Discuss a Developmental Approach to gathering the history and physical assessment of the child: Comprehensive Health History: Developmental Milestones

>Developmental assessment is important to determine if child's development is within normal range, delayed, or child is at risk >Denver II Screening--> developmental milestones can be assessed from birth - 6 years of age a) Assesses personal-social b) Assesses fine motor-adaptive c) Assesses gross motor d) Assesses language skills >Nurse documents child's behavior during administration of the test, including compliance, interest in surroundings, fearfulness, and a subject measure of the child's attention span. >After test is administered, the parents way be asked if the child's performance was a characteristic of his normal behavior >Referral is needed when the child has "failed" the test with 2 or more (2+) delays, if there is no improvement in areas of concern 3 months after initial screen, or if the child is determined to be "un-testable" at two consecutive screenings

Critical Nursing Action: PREPARING A PRESCHOOLER FOR PROCEDURE

>EXPLAIN IN A WAY THEY WILL UNDERSTAND > BEGIN PREP IMMEDIATELY PRIOR TO PROCEDURE SO THEY WILL NOT WORRY FOR HOURS OR DAYS >USE PLAY WITH DOLL/TEDDY BEAR >ALLOW CHILD TO YELL AS LOUD AS SHE WANTS BUT MUST REMAIN STILL >GIVE LEGITIMATE CHOICE TO CHILD WHENEVER POSSIBLE >ALLOW PARENTS TO BE PRESENT/LEAVE ROOM IF NECESSARY >USE DISTRACTION TECHNIQUES SUCH AS DEEP BREATHING, SINGING, SQUEEZING PARENT OR NURSES HANDS

Age specific interview and assessment tips: Toddler

>Encourage parents to be there during interview >Allow toddler to be close to parents >Provide simple explanations with simple language >Watch for separation anxiety >Use toddler's favorite toy for communication purposes >Use play (count fingers, tickle toes) to assess body parts >Use parents assistance during examination

Physical Assessment: Throat/Mouth

>Examination saved for last in younger, less cooperative children >Eliciting sound "eehhh" -flattens tongue better than "ahhh" >Lips -Observed for shape, symmetry, color, dryness, fissures at the corners of the mouth indicative of Vitamin B2 (riboflavin) deficiency and clefts >Teeth -Inspected for number present, condition, color, and caries -Nurse can expect 1 tooth per month after 6 months of age -Gingival tissue should be same color as the surrounding tissue and should not be hypertrophied or show evidence of bleeding

Physical Assessment: Ear Assessment

>Examined for: -Size, shape, placement, pain, and drainage of ear canal >Low set ears -May be indicative of Down Syndrome >Assess for pain -Nurse moves pinna up and down >Purulent Drainage -indicative of foreign body -indicative of ruptured tympanic membrane >Clear drainage after head trauma/cranial infections -should be reported to HCP STAT -indicative of being CSF >Usage of otoscope -Pinna pulled down and back (3 years and younger) -Pinna pulled up and back (Older than 3 years) -Have child lay supine or sit in parents lap

Dosage Recommendations for Acetaminophen:

>Neonates (0-4 weeks) -10 to 15 mg/kg/dose Q6-8H >Infants (1-12 months) - 10 to 15 mg/kg/dose Q4-6H PRN MDD= 5 in 24 hours >Children (1-12 years) - 10 to 15 mg/kg/dose Q4-6H PRN MDD= 5 in 24 hours >Children (>12 yrs) -325 to 650 mg Q4-6H prn MDD= 4 GRAMS/24 Hours

Pain Assessment Scales: FLACC SCALE

>FLACC -Face -Legs -Activity -Cry -Consolability >Face 0= No particular expression or smile; disinterested 1=Occasional grimace frown/withdrawn 2= Frequent to constant frown; clenched jaw, quivering chin >Legs 0=Normal position or relaxed 1=Uneasy, restless, tense 2= Kicking or legs drawn up >Activity 0=Lying quietly, normal position, moves easily 1=Squirming, shifting back n forth, tense 2=Arched, rigid, or jerking >Cry 0=No cry (awake or sleep) 1=Moans/whimpers; occasional complaint 2=Crying steadily, screams/sobs, frequent complaints >Consolability 0=Content/Relaxed 1=Reassured by occasional touching, hugging or talking to, distractible 2=Difficult to console or comfort **Total Score is between 0-10** **This is a behavioral assessment tool for use in nonverbal patients unable to provide reports of pain**

Physical Assessment: Genitourinary

>Females -Enlarged nodes may indicate STI -Enlarged nodes may indicate inflamed hair follicle after shaving >Labia minora/major, clitoris, vaginal opening, urinary meatus -Examined for the presence of lesions, discharge and irritation -Occasionally the labia minora is fused together because of adhesions--->> MUST BE REPORTED TO HCP >Malodorous discharge- -Indicative of a foreign body -Indicative of infection -First GYN visit between 13-15 y.o -Pelvic Exams at 21 or sooner if child is sexually active >Males -Penis should be straight -Glans clean and smooth -Slit shaped urinary meatus near end of glans >Enlarged scrotum -Should be transilluminated to assess for hydrocele (accumulation of serous fluid in the scrotum) versus a possible hernia -Penlight on scrotum will illicit a "red glow" with hydrocele >Hard Testicle -Must be reported to rule out tumor -Must report if one or both testicles have not descended -Testicular self exam @ 14 yrs of age -Cancer common in males 15-34 y.o >Anal Examination -Something must be abnormal to examine anus -Side lying position with knees flexed -Inspected for lesions, trauma, irritations, fissures, bleeding, leakage of stool, hemorrhoids, and general cleanliness -Tone can be assessed by lightly touching anus and observing anal reflex -If digital exam is necessary 1)explain procedure in appropriate manner for age 2)provide distraction during procedure 3)ask child to push down to relax anal sphincter ABNORMAL: -Tenderness/pain over kidneys -Bruits over renal arteries

Discuss a Developmental Approach to gathering the history and physical assessment of the child: Establishing a relationship with the patient and the family

>For the infant of nonverbal child, nurse begins the health history with an interview of the parents, grandparents, foster parents, stepparents, nannies, etc.... >Nurse must establish a rapport with parents first to make children feel secure before engaging in conversation >Older school age child may elect to be interviewed without parent in the room >Nurse should speak with parents separately to determine if the parent has specific concerns or issues that may need to be addressed during the visit >With adolescent, nurse may ask parent to leave the room during the discussion of issues related to social and sexual content >Adolescent must known conversation can take place without the parents knowledge >Exceptions to maintaining confidentiality involve instances concerning abuse or life-threatening situation

Holistic Nursing Care for the Child: Feeding

>Formula fed infants require no more than 24-32 ounces of iron fortified formula a day >Assess food preferences for the older child >Children are prescribed a diet as tolerated >Foods also important for their fluid content >Encourage parents to bring food from home

Explore Health-Care Needs of the family and child living with a disability: Resiliency

>Four common attributes of resilient children -Social competence -Problem solving skills -Autonomy -Sense of purpose and future >Ways to promote resiliency -Express love and gratitude -Foster competency and positive attitudes -Nurture positive emotions -Encourage helping others -Teach peace building skills -Reinforce positive behaviors -Reduce stress

Age specific interview and assessment tips: School Age Child

>Help child vocalize needs >Allow child to engage in conversation >Allow child to undress himself >Respect child's need for privacy

Prioritize Developmentally appropriate and holistic nursing care for the child and family across health care settings: Hospital/Children's Hospital/Day Hospital

>Hospital -May be a new experience for child and family -Exposed to unfamiliar medical environment -Offer many health care services >Children's Hospital -Provide many health care services -Employees specially trained to work with children >Day Hospital -These types of hospital serve children who require: 1)blood transfusions 2)chemotherapy 3)steroid pulse therapy 4)IV hydration 5)IV antibiotic therapy 6)Immunoglobulin therapy 7)infliximab transfusions

Physical Assessment: General Impression

>How does child react to questions? >What is the child's speech like? >Is child quiet, pleasant, talkative, uninterested, angry? > Does child listen to parents? >Is the child clean and appropriately dressed for the season? >Body, size, skin color, eyes, and the condition of the hair are observed for evidence of a good overall nutritional state

dentify Assessment and Management Issues Related To the Child in Pain: Developmental Perspective

>Infants- Age 2 -Piaget's sensorimotor stage of development -Experience pain, but do not understand it -Will use words such a boo-boo or owie to express pain but do not understand it >Age 2-7: -(2-4) Substage of preconceptual development -(4-7) Progress through substage of intuitive development -Believe they are experiencing pain through form of punishment -Recognize presence of pain but do not report it because they believe adults know that it already exists -Can point to area, but cannot describe it >Ages 7-11 -Concrete operational stage of Piaget's -Begin to understand that injury and illness may be accompanied by pain, but do not understand the cause -More descriptive of pain such as it "comes and goes", cramping, burning, dull, or sharp -Begin to differentiate between physical and psychological or emotional pain >Ages 11-18 -Formal operational thought final stage of Piaget's -Develop an advanced understanding of pain and its causes to describe it in more detail -Need for control and independence is significantly impacted by presence of pain -Think they should "grin and bear" like they perceive an adult might or if they believe the nurse thinks the pain should be tolerated.

Reasons for Accessing Medical Care:

>Injuries -Falls -Being striked by another person -Head/neck injuries from bike accidents and motor vehicle accidents -Concussions from sports -Strains/sprains/fractures >Illnesses -Fever(leading cause) -Cough(leading cause) -Diarrhea(leading cause) -Upper respiratory infections -Abdominal pain -Asthma

Discuss a Developmental Approach to gathering the history and physical assessment of the child: Comprehensive Health History: Patterns of Daily Activity (Nutrition)

>Is the infant breast-fed? If so, how often and how long is the child fed @ each feeding? >How many wet diapers are changed in the course of the day? (With sufficient breast milk intake, infant will have 6 or more wet diapers/day and gain weight >For the infant getting formula -Type of formula? -Amount taken @ each feeding? -Number of feedings/day? -Also important to note if and when juices or solid foods have been started and whether supplements/vitamins have been prescribed? >When assessing children and adolescents, a 24 hr Recall is elicited to the food eaten in a typical day and reflects sociocultural trends. **> NURSE MUST DOCUMENT FOOD ALLERGIES FOR ALL CHILDREN**

Physical Assessment: Neck Assessment

>It is common for young children to have palpable, painless, movable nodes up to 1 cm in diameter >Pain upon palpation may be indicative of upper airway infection >Lateral deviation of trachea may be caused by a mass or collapsed lung

CRITICAL NURSING ACTION: CHILD CONFINED TO BED

>Keep skin clean and dry >Assess nutritional status for adequate protein >Use draw sheet for position changes >Assess skin for irritated areas >Assess for pressure ulcers by looking for "red flush" (first sign for tissue compromise and ischemia)

Holistic Nursing Care for the Child: Safety measures

>Keep toxic materials out of reach >Know who are the "official parents" >Verify child by checking the bands >Know whereabouts of child on unit >Provide safe environment >Transport child safely >Restraint devices on high chairs, strollers, and beds are kept in locked and lowest position >Crib and bed-side rails are elevated >Bubble tops may be needed

Management of Pain: Chronic Pain

>Lasting more than 3 months >Results in: -Fear of reinjury -Anorexia -Weight loss -Changes in sleep patterns -Guarded movements -Rigid facial expression -Dimishment of child's joy of living >Management -Careful observation of which pain relief measures work best -Decreasing pain to ACL's that allow child to carry on with as many age appropriate activities as possible

Discuss a Developmental Approach to gathering the history and physical assessment of the child: Comprehensive Health History: Patterns of Daily Activity (Nutrition) / Macronutrients (pg 792)

>Macronutrients -Daily caloric intake must have a balance of protein, carbs, and fat to maintain and provide a healthy diet >Protein -**10-35% of daily caloric intake mus come from protein** sources such as dairy products, eggs, lean meat, seafood, poultry, beans, peas, nuts, and seeds -After age of 2, should be switched to low-fat/skim milk >Carbohydrates -**Account for 45-65%** -Include grains, fruits, and veggies -Half of all grain servings should be whole grain (oatmeal, brown rice, pasta) >Fats -20-35 % of caloric intake should be from fat -Animal fat (meat/milk products) main source of saturated fats -Important to recommend skinless poultry, lean meat, and fat free milk for children

Restraining The Child:

>May be necessary to provide further injury to operative site >Inform parents why it is necessary >Extremity checked every 15 mins for the first hour after initial application >Child must be checked and skin condition documented every 1-2 hours >Physical restraint 1) Elbow restraint>>prevents flexing of elbow from removing IV line. Remove one at a time every hour to allow exercise of the arm 2) Papoose restraint>> More like swaddling an infant. Total body restraint. Allows still motion when assessing head, neck, or throat >Pharmacologic restraint -Chloral hydrate (Aquachloral) -25mg/kg/day PO Q6-8 HRS up to 500mg/dose -Peak time is 1 hour -Assess LOC at time of peak. Notify HCP if sedative is not reached -Duration of action Q4-8H -Monitor for dizziness, confusion, excessive sedation, and paradoxical excitation.

Physical Assessment: Neurological

>Mental Status Assessed by: -Observing child interact with parent -By asking older child questions and listening to speech >Cerebellar function -Observing child's gait and posture -Use finger to nose test -Romberg test >Assessed for persistence of primitive reflexes: -Abnormal if they appear -Babinski, Moro, Palmar, Plantar, Tonic neck

Management of Pain: Mild Pain

>Mild Pain -Minor analgesics -Comfort measures -Distraction (coping mechanism, does not mean NO pain) >Pharmacologic Intervention -Children's acetaminophen (Tylenol) -Children's ibuprofen (Advil/Motrin)

Common Pediatric Pain Medications & Considerations

>Morphine -Give single IV doses slowly over at least 5 mins -Use only preservative free preparations in neonates -Monitor the patient for respiratory depression after administration >Acetaminophen -Watch for signs and symptoms of hepatoxicity after administration, even with moderate doses -DO NOT ADMINISTER MORE THAN 5 DOSES IN 24 HOURS >Ibuprofen -Instruct patient/parents that drug should be taken with meals or milk to avoid GI upset -Tablets may be crushed if child cannot swallow them -Alternatives come in suspension or drops

Reasons for Accessing Medical Care: Poisoning

>Most common is ingestion of medicine -Iron -Acetaminophen (1st common) >Treatment for acetaminophen overdose -NAC solution (n-acetyl-cysteine) -NAC has foul smelling odor (mix with fruit juice orally) -If oral is not tolerated, NG tube is inserted -NAC given Q4H for 20-72 hours depending on level of toxicity >Heavy metal ingestion -Most common is lead -Found in contaminated soil -Water that flows through old pipes -Food stored in bowls glazed/painted with lead -Toys, Jewelry, Folk Remedies >What lead interferes with: -Normal body function -Toxic to kidneys, heart, bones, intestines, &reproductive system -Nervous system development which causes behavior/learning disorders >Symptoms of lead poisoning -Abdominal pain -Confusion -Headache -Anemia -Irritability -Coma -Death >CDC standard for elevated lead in children -5 mcg/dL -Routine screening for lead is done during latter part of infancy -Tx: lead is removed and chelation therapy in hospital

Pain Assessment Scales:

>Most commonly Used -FLACC -Numerical -Wong Faces Scale -CHEOPS (Recommended 1-7 Y.0, Score >4 indicates pain) **Nurse asks about intensity, duration, and location of pain**

Physical Assessment: Nose/Sinus Assessment

>Nasal mucosa inspected for color and inflammation >Allergic rhinitis -Pale, boggy mucosa >Upper respiratory infection -nasal mucosa appears erythematous >Note any bleeding of the mucosal lining -Indicates injury >Purulent Discharge from nose -Viral/Bacterial condition >Purulent discharge from one nostril -Foreign body in opposite nostril

Common Toxic Ingestions: Lead>>>Led paint used before 1978/ May be inhaled or ingested

>Neuro -learning disability/motor deficit >GI -abdominal pain -N/V -Constipation -Anorexia >Heme -Hemolysis -Iron deficiency >MS -Muscle/joint pain >Soft tissue -blue/black lines in gum margin >Endocrine -Short stature

Physical Assessment of The Child: Taking Vital Signs: Temperature

>Newborns -Axillary Temp >Rectal -Not routinely used -Do not exceed more than 1/2 inch in anus >Older children -Tympanic membrane or temporal temps are obtained because they register in seconds -This route is convenient one in pediatrics

Discuss a Developmental Approach to gathering the history and physical assessment of the child: Comprehensive Health History: Patterns of Daily Activity (Sleep)

>Newborns sleep about 16-17 hrs/day, typically in stretches of 2-3 hours at a time > Babies typically able to sleep through the night by age 6 months >Night terrors occur during the 1st few hours of sleep (child has no recollection)

Physical Assessment: Abdominal Assessment

>Normal Inspection -Child in supine position -Abdomen symmetry -No umbilical herniation -Visible peristaltic waves may be a normal finding in infants and thin children; however, they also may indicate obstructive disorders such as pyloric stenosis >Normal Auscultation -Normal Bowel sounds -Possible borborygmi (rumbling from fluid & gas) -Bowel sounds occur Q5-10 seconds >Abnormal Auscultation -Absent bowel sounds -Hyperactive bowel sounds -High pitched tinkles in the presence of abdominal distention and or peritoneal signs suggests acute abdominal condition -Nurse must listen for 1 minute to determine absence of bowel sounds in any one quadrant

Physical Assessment: Cardiac

>Normal Inspection -Skin is pink, warm, dry -Chest is symmetrical -Pulsations may be visible in children with thin chest walls -Point of maximum impulse is commonly visible -Capillary refill is no longer than 2 seconds >Abnormal Inspection -Cyanosis may be an early sign of cardiac condition in an infant or a child -Dependent edema is a late sign of heart failure in children >Normal Auscultation -Heart sounds regular in rhythym, clear, and distinct (not weak, muffled, pounding, or distant) -Best heard over mitral and tricupsid areas -Second heart sounds best heard over aortic and pulmonary area -Third heart sound best heard over mitral area (normal in children/abnormal in older adults) Abnormal Heart Sounds -4th heart sound requires further evaluation (referred to as "Tennessee") -Murmurs in children may be innocent, functional, or organic. If a murmur is heard, note its location, timing within the cardiac cycle, intensity in relation to the child's position and loudness.

Reasons for Accessing Medical Care: Epistaxis

>Nosebleeds r/t increased vascularity of nasal mucosa >CRITICAL NURSING ACTION -Don gloves -Place child in sitting position -Have them lean forward -Apply direct pressure to anterior nasal septum for 10-15 mins -Remind child to breathe through mouth -Apply ice to nose is beneficial -Large blood loss=monitor vital signs -If bleeding is beyond 10-15 mins may require nasal packing along with topical epinephrine -Infection= antibiotics -Nurse keeps the child and family and quiet while providing support -Important that family is able to demonstrate first aid measures

Physical Assessment: Chest

>Nurse inspects chest for size, shape, symmetry, respiratory effort, and breast development >Equal anteroposterior and lateral diameter after age 2 -indicative of chronic lung disease >Chest larger on left compared to right -Indicative of enlarged heart -Indicative of collapsed lung >Pectus Carinatum -Protrusion of the chest -Abnormal chest shape >Pectus Excavatum -Abnormal depression of the lower portion of the sternum -Abnormal chest shape

CRITICAL NURSING ACTION-NURSE ROLE MODELS FOR THE CHILD

>Nurse says "I am going to give you medicine to help you feel better" >Nurse pretends to drink the medicine >Nurse offers praise and gives stickers

Physical Assessment: Eye Assessment

>Observation includes: -symmetry -shape -placement in relation to the nose -size of pupils in response to light -Chalazions (small discrete swellings of upper lid when oil gland becomes blocked) -Sclerae inspected for color -Nurse notes erythema, swelling, discharge from eye

5 P's of Musculoskeletal Injury

>Pain -Ask the child whether he feels pain. If he does, assess its location, severity, and quality >Paresthesia -Assess the child for loss of sensation by touching the injured site with a tip of an open safety pin. Abnormal sensation or loss of sensation indicates neurovascular involement >Paralysis -Assess whether patient can move affected area. If he cant might be nerve tendon damage >Pallor -Paleness,discoloration,and coolness on the injured side may indicate neurovascular compromise >Pulse -Check all pulses distal to the injury site. If pulse is decreased or absent, blood supply to the area is reduced.

Management of Pain: Acute Pain

>Pain occurs 24-48 hours after trauma after surgery >Initially experienced as severe pain and subsides over time >With orthopedic trauma, a short period of auto-anesthesia can occur that belies the extent of the injury. >Because narcotics do not relieve all of the pain following surgery, they can be accompanied with some success by comfort measures,

Common Toxic Ingestions: Acetaminophen

>Phase 1 -Often Asymptomatic -Nausea and vomiting >Phase 2 -18 to 72 hours -RUQ abdominal pain -Poor appetite -Tachycardia -Hypotension >Phase 3 -72 to 96 hours -Above symptoms -Liver dysfunction -Jaundice -Encephalopathy -Acute Renal failure -Death from multisystem organ failure >Phase 4 -4 days to 3 weeks -Those who survive have complete recovery and resolution of organ failure

Physical Assessment of The Child: Measuring Length

>Place infant's head in midline position at top of measurement board >Hold one knee down with your hand and gently press it down toward the table while its fully extended >Take length from tip of infant's head to the heel >Stadiometer= device used to measure length

ABDOMINAL QUADRANT ORGANS

>RUQ -Transverse colon -Ascending colon -Gallbladder -Pancreas -Right Kidney >LUQ -Transverse colon -Descending colon -Pancreas -Spleen -Left kidney >RLQ -Colon -Appendix -Rectum -Right ovary and fallopian tube >LLQ -Descending colon -Sigmoid colon -Left ovary and fallopian tube

Transmission of Infection

>Requirements of transmission -microorganism -a susceptible host -method of transmission >Transmission -Droplet -Contact -Airborne -Common Vehicle -Vector borne >Standard precautions -universal precaution designed to reduce the risk of transmission of blood borne pathogens >Transmission precautions -Implement what needs to be done **Use diversional activities for child in isolation**

Explore Health-Care Needs of the family and child living with a disability: Caregiver fatigue

>Respite care agencies -Developed in response to the needs of parents of extremely disabled to give short-term relief from 24 HR surveillance >Most disabilities result from: -multiple visits to clinics, hospitals, rehab centers, thus disrupting normal activity and sleep patterns >Requires much more energy in disabled child to perform simple tasks >Disabled children extra requirements for: -Stamina -Calories -Vitamins -Minerals -Protein -These are needed to carry out normal activities let alone learning developmentally appropriate skills >Disable children need additional sleep

Management of Pain: Severe Pain

>Signs -pallor -sweating -piloerection (elevation of hair above the skin) -dilated pupils -increased respiration -increased blood pressure -muscle tension -Low BP and Pulse when intense pain subsides >Management -Surgical interventions -Morphine Sulfate (maximum allowable dosage according to the child's weight in kg may be started in the recovery room and followed by regular dosing, within the allowable limit for the specific child.

Explore Health-Care Needs of the family and child living with a disability: Emotional Concerns

>Stressing because of the disruption of "normal routine" >Financial complications >Often, parent is required to stop working to become a full-time caregiver

Fever Reducing Measures

>Temp greater than 100.4F or 38C >Natural beneficial response to invasion of microorganism to help "kill" virus/bacteria >Antipyretics given -Acetaminophen -NSAIDs -Work to lower set point at thermoregulatory centerin hypothalamus >Acetaminophen -Little risk for hepatoxicity >Ibuprofen (Children's Advil) -Advantageous when rest is crucial or when med administration is a challenging task -Comes in chewable tablet, caplet, or liquid -Dyspepsia (indigestion)/Nausea common SE -Can be given with food/after meals if GI upset occurs -Child monitored for GI bleeding -Dosing is dependent on the temperature of child

Ways To Decrease Stress of Hospitalization

>Therapeutic play -Decrease fears and anxiety -Child life therapist can assist -Provides non-threatening approach that lets child express fears and frustration >Guided imagery -Encompasses the power of the mind to help the body heal >Role modeling -Child learns certain behavior by watching others

Pain Assessment Scales: WONG BAKER FACES

>This is for children who are old enough to speak and understand sufficiently, three useful tools can help them communicate information for measuring their pain. >Child age 3 and older can use these faces scale to rate his pain. When using this tool, make sure he can see and point to each face and then describe the amount of pain each face is experiencing. >If the child can read, have them read it. If not, parents can read it to them. **This scale is used for preschool through school-age**

QUALITIES OF NORMAL BREATH SOUNDS:

>Tracheal -Harsh, high-pitched sound -Heard over trachea >Bronchial -Loud, high pitched -Heard next to trachea >Bronchovesicular -Medium loudness and pitch -Heard next to sternum >Vesicular -Soft, low pitched - Heard throughout remainder of lungs

Infection Control Measures:

>Use of waterless, alcohol-based hand rubs is the preferred method for hand hygiene. Must use for 15 seconds >Hand washing with soap and water to cover all surfaces of the hands and fingers with 15 seconds of rubbing causes friction is to be done when the hands are visibly soiled, after restroom, before eating, and after caring for patients with diarrhea >Gloves to be used in direct-care situations in which there is a high risk for exposure to bodily fluids. Gloves must be changed when moving from a contaminated area to a clean area on the same patient. After care, hand hygiene STAT. >Isolation precautions include standard/transmission based precautions >Place isolation guidelines on door with step-by-step instructions

Physical Assessment of The Child: Measuring Head Circumference

>Use paper measuring tape to avoid stretching (avoid cloth tape) >Use landmarks -place tape above the infant's eye brows -then around the occpital prominence around the back of head to get the largest diameter

Physical Assessment of The Child: Measuring BMI

>Used to assess total body fat and nutritional status >BMI represented as a percentile >BMI for age under 5th percentile indicates underweight >BMI for age between 5th and less than 85th percentile is considered a healthy weight >BMI for age between the 85th percentile and less than 95th percentile is considered overweight >BMI for age greater than 95% is considered obese

Management of Pain: Moderate pain

>Using a child's vivid imagination is effective in pain management in conjunction with timed analgesic administration including minor opioids >Pharmacologic -Acetaminophen with codeine[combination drug]

Physical Assessment of The Child: Measuring Weight

>Using an infant scale lined with a thin paper cover >Set the scale to 0 and remove clothing on baby >Baby weighed in supine or sitting position >Nurse protects the baby from accidental fall by placing a hand over infant WITHOUT ACTUALLY touching them

Common Toxic Ingestions: Iron

>Vomiting >Hematemesis >Diarrhea (+/-) bloody stools >Abdominal pain >Metabolic Acidosis >Coagulopathy >Shock >Coma

FOCUS ON SAFETY: Naloxone (Narcan)

>When giving morphine sulfate, be sure to have narcan on hand if respiratory depression occurs >Dose for children is 5-10 mcg/kg

Physical Assessment of The Child: Taking Vital Signs

Average Range for Pediatric Vital Signs >Infant -HR: 80-150 -RR: 25-55 -BP systolic: 65-100 -BP diastolic: 45-65 >Toddler -HR: 70-110 -RR: 20-30 -BP systolic: 90-105 -BP Diastolic: 55-70 > Preschooler -HR: 65-110 -RR: 20-25 -BP systolic: 95-110 -BP Diastolic: 60-75 >School age -HR: 60-95 -RR: 14-22 -BP systolic: 100-120 -BP diastolic: 60-75 >Adolescent -HR: 55-85 -RR: 12-18 -BP systolic: 110-125 -BP diastolic: 65-85

Nutrition: Recommended Food Group Servings by Age:

CHILDREN 2-3 Y.O: >Protein= 2oz >Veggies= 1 cup >Fruit= 1 cup >Grain (at least 1/2 has to be whole grain)= 1.5oz whole/other grains >Dairy= 2 cups >Fats= 3tsp CHILDREN 4-8 Y.O: >Protein= 4oz >Veggies= 1.5 cups > Fruit = 1-1.5 cups >Grains (1/2 has to be whole grain) = 2.5 oz whole/other grains >Dairy=2.5 cups >Fats= 4tsp GIRLS 9-13 Y.O: >Protein= 5oz >Veggies= 2 cups >Fruit= 1.5 cups >Grain= 3oz whole/other grains >Dairy= 3 cups >Fats= 5tsp GIRLS 14-18 Y.O: >Protein= 5oz >Veggies= 2.5 cups >Fruit= 1.5 cups >Grain= 3oz whole/other grains >Dairy= 3 cups >Fats = 5tsp BOYS 9-13 Y.O: >Protein= 5oz >Veggies= 2.5 cups >Fruit= 1.5 cups >Grain= 3oz whole/other grains >Dairy= 3 cups >Fats = 5tsp BOYS 14-18 Y.O: >Protein= 6.5 cups >Veggies = 3 cups >Fruit= 2 cups >Grain= 4oz whole/other gains >Dairy= 3 cups > Fats= 6tsp **NOTE: THE GRAINS ARE COMBINED FOR EXAMPLE, 3OZ WHOLE/OTHER GRAINS IS A TOTAL OF 6 GRAINS**

Critical Nursing Action: ADOLESCENT FOR PROCEDURE

EXPLAIN BENEFITS AND RISKS OF PROCEDURE DESCRIBE POTENTIAL PAIN RISKS ALLOW THEM TO TAKE ACTIVE ROLE AS POSSIBLE PRACTICE POSITIONING OR DEMONSTRATING EQUIPMENT GIVES THEM A SENSE OF CONTROL PROVIDE A VIDEO IF POSSIBLE ALLOW THEM TO MAKE DECISION SUCH WHEN THE PROCEDURE SHOULD TAKE PLACE IF POSSIBLE ALLOW OPTION OF HAVING PARENT IN THE ROOM

Informed Consent

Provides patient and family with knowledge to make decisions regarding health care Implies they know benefits and risks or refusal of treatment Legal age is required Required before diagnostic, medical/surgical procedures, immunizations Written consent needed before procedure performed

Discuss a Developmental Approach to gathering the history and physical assessment of the child: Asking Questions (SODA MNEMONIC)

S: Sleep--> How has your child been sleeping? O: Output--> How many times per day do you urinate/defecate? (Or for younger child, ask how many wet diapers has he had today?) D: Diet--> How much fluid has your child taken in today?/Has the illness affected the child's appetite or diet? A: Activity--> Has the child's activity level changed since hes been ill?

Critical Nursing Action: SCHOOL AGED CHILD

SAME AS CARD ABOVE BUT ALLOW PATIENT TO TOUCH AND EXPLORE THE EQUIPMENT