Peds Test 1

- inadequate assessment of pain r/t pain - Concern about side effects and tolerance of analgesics - Reluctance to report pain - Reluctance to take pain medications - Lack of adherence to treatment plan

Cultural background will influence the validity and reliability of pain assessment tools. What are some barriers to that?

Child is awake and alert and experiencing mild to moderate dehydration: - Attempt oral rehydration with oral rehydration solution (ORS) giving them 1oz at a time to see if they can tolerate - ORS should consist of adequate amts of Na+ as week as K+, Cl-, and glucose - Mild dehydration: try to rehydrate orally (50mL/kg of ORS) over 4-6 hrs - Moderate dehydration: try to rehydrate orally (100 mL/kg of ORS) over 4-6 hrs - If fluid loss is from Diarrhea, replace volume 1:1 or 10 ml/kg/stool replacement if unknown - If vomiting can still try ORS - Small frequent feeds If unable to tolerate ORS or severly dehydrated, need initiate parenteral fluids - Goal is to expand ECF compartment as quickly as possible to prevent shock - Solution is chosen based on probable type and cause of dehydration before lab values known - Check POCT or glucose to determine need for dextrose to be administered After rehydration - Reevaluate the need for further rehydration if rehydrated can initiate regular maintence fluids depending on age group - Infants resume formula or breastfeeding, toddlers resume soft foods/purees, older children resume regular diet as tolerated

How does the Therapeutic management of dehydration work?

NCCPC scale

Scale used for non-communicating children's pain checklist

PIPP Scale

Scale used on premature infants depending on weeks of gestation

Adenoidectomy

Surgical removal of the pharyngeal tonsils

Basic Beliefs: - Some healthcare professionals may underestimate pain severity - A person's self-report is the most reliable measure of pain Pain is a multi-dimensional phenomenon including emotional behavioral, cultural, and sensory components

What are some basic beliefs about pain? and what influences someone's pain experience?

- Diameter of airways plays a significant role in respiratory illness - In infants, airway resistance is about 15X that of an adults - Any edema, swelling, or infectious process will further narrow the airway causing increased airway resistance 1. Increased RR (first sign of RD in an infant as a compensatory mechanism for gas exchange), 2. Retractions, 3. Nasal flaring

What are some things to note about airways resistance in pediatrics? What are 3 things that indicate increased airways resistance?

Goals: - Prevent or minimize separation from the family - Promote sense of control for the child - Prevent or minimize bodily injury and pain ex: Foster the parent-child relationship, prepare child before any treatment or procedure, control pain, provide play activities for expression of fear and aggression Avoid: - Psychological distress - Physical distress (ex: keeping lights down, give rest/downtime, etc.)

What are goals of atraumatic care and things to avoid?

Airway - Positioning sitting upright with open airway - Bedrest if possible b/c don't want to dislodge the scar from the surgical site or they may hemorrhage --> Dark brown blood can be normal, but frank red blood indicates a fresh bleed --> want to avoid frequent suctioning Bleeding - observation - is there frequent swallowing? could indicate a hemorrhage has occurred - Prevention of recurrent bleeding - Maintain quiet environment, minimize agitation/crying - Checking VSs for a bleed Diet - Avoid straws - Red food (unable to get a visual, cannot tell a red popsicle from a bleed) - Soft liquid diet Pain - May use an ice collar - Tylenol or hydrocodone for the first 24-48 hrs for comfort

What are nursing considerations of a post-op tonsillectomy and adenoidectomy?

Infant - Provides ideal nutrition and promotes the best possible growth and development - Significantly decreases the incidence of diarrhea, lower respiratory tract infection, otitis media, bacteremia, etc. - May be protective against inflammatory bowel disease, leukemias, and certain genotypes of type 1 DM - Lowers risk of obesity in some pops - Promotes healthy neurological dev - May reduce the incidence of atopic illness, such as asthma or eczema, in children at genetic risk - Promotes close infant-mother connection Mother - Breastfeeding increases levels of oxytocin, which results in less PP bleeding and more rapid uterine involution - Lactating women have an earlier return to prepregnancy weight, delayed resumption of ovulation with increased child spacing, improved PP bone remineralization, and reduced risk of ovarian cancer and postmenopausal breast cancer - Lactation amenorrhea promotes the recovery of maternal iron stores depleted during pregnancy - Breastfeeding lowers the risk for maternal chronic diseases such as hypertension, DM 2, CAD, and some cancers

What are some benefits to breastfeeding for the infant? mother?

Acute: - Higher morbidity - Prolonged response to pain - Lower pain threshold - Breakdown of fat and carbohydrates stores Potential Long-term Consequences: - Higher somatic complaints of unknown origin - Behavioral problems - Poor adaptive behavior - Leaning deficits - Psychosocial problems *premies are already behind to it's another set back if pain is unrelieved*

What are some consequences of unrelieved pain in neonates?

Fever: can get very high fevers that can be normal and not concering, unless they get too high --> body's natural defense Anorexia: Can occur for along time after infection has gone away, appetite will return but very important to continue hydration N/V/D Abdominal Pain Cough, sore throat, nasal blockage, or discharge Respiratory sounds

What are some generalized s/s + local manifestations in young children of a respiratory tract infection?

Assessment of vocalization, facial expression, and body movements with specific validated tools Most reliable for short, sharp pain Less reliable for recurrent/chronic pain Most reliable for pain in infants and young children vs older children/adolescents May not correlate with child's self report of pain *pt's will hide pain to avoid having painful procedures done and this may indicate the need to rely on observational signals of pain*

What are some observational measures that indicate pain in a child?

Associated Observations: Retractions - Chest wall is more flexible and ribs cartilaginous b/c of this they use negative pressure from their diaphragm (abdominal breathers) to breath making it very common even in periods of mild distress - By age 6 ICM are more developed - Important when documenting to note the location of the retractions Nasal Flaring - should look very closely at nasal passages - Can be described as minimal or marked Head Bobbing - Late sign of RD bc indicates that child is tired out and using accessory muscles in neck to create negative pressure for breathing rather than diaphragm Grunting - Usually in older children but can be in any age - Attempt for patient to compensate for airways resistance by holding airways open for longer to increase gas exchange Cough - Will help expel things from the respiration pathways - Can indicate an airway infection or obstruction - Can be productive or nonproductive Color Changes - Molding can be normal in infancy when under color or periods of distress - Sign of RD in older children because body is shunting blood away from the periphery to the core - Full body cyanosis Adventitious breath sounds: Stridor - High pitched narrowing or swelling in the upper airway - Can be croup, FOA, etc. Wheezing - Musical sound in lower respiratory tract - Can be indicative of asthma

What are some observations made on a pediatric patient when they're in RD? What are some adventitious breath sounds you may hear?

H: Hypoglycemia (low BS)--> jittery hands, lower body temp, inconsolable and high-pitched crying, turning blue and seizures U: Unsatisfied nursing, lasting longer than 30 min and occurring more frequently than every 2 hours, crying despite prolonged breastfeeding N: Not waking for feeding q3h, difficult to arouse and very sleepy, not maintaining latch, limpness, and lethargy G: Growth or wt loss exceeding 7% at any time, which increases risk of high sodium levels (hypernatremia) and excessive jaundice R: Reduced wet and dirty diaper count (no wet diapers in 6 hrs), red brick dust on diapers (high uric acid concentration), dry lips and mouth, crying w/o tears Y: Yellowing of the skin or eyes, especially below the face, known as hyperbillirubemia or excessive jaundice

What are some of the signs to look for that indicate your baby is HUNGRY (acronym)?

Infants: Breastfeeding, sucrose pacifier, skin to skin care Toddlers and Small Children: Comfort Holds Older Children: Deep breathing, distraction, hypnosis and virtual reality Pharmacologic intervention options: - Anesthetic Creams (EMLA, LMX): Topical analgesia for short term procedures, takes 1 hour to take affect - Needle free jet injection with buffered lidocaine (J-Tip): 10-30 seconds onset, can be scary for children

What are some pain prevention techniques?

Increase HR, Increased BP, flushed skin, increased RR (hyperventilation), increased body tension, facial grimace/frown

What are some physiologic indicators of pain in a child?

- Therapeutic relationship - Family advocacy and caring - Disease prevention and health promotion - Health teaching - Support and counseling - Coordination and collaboration - Ethical decision making

What are some roles of the pediatric nurse?

Degree of dehydration in peds is based on % of BW dehydrated - Wt loss in peds patients is the most important predictor of dehydration - Loss of 50 ml/kg of fluid is mild, 100 ml/kg of fluid is considered severe Other predictors include: change in LOC (irritability to lethargy), altered response to stimuli, decreased skin elasticity, prolonged cap refill, increased HR, sunken eyes and fontanelles Easrliest sign is usually tachycardia, then dry skin and mucous membranes, sunken fontanelles, signs of circulatory failure (coolness, mottling), decreased skin elasticity and prolonged cap refill - Lethargy is a first sign - tachy HR because decreased fluid means heart has to work harder to maintain same level of hydration - Assess Urine output Shock is preceded by tachy HR, signs of poor perfusion, and tissue oxygenation. Peripheral circulation becomes poor, decreased urine output Hypotension is a late stage of circulatory collapse - No longer compensating has lost so much fluid --> kidneys are no longer producing hormone to increase BP

What are some things that can indicate a child's degree of dehydration?

- Being preterm - Second-Hand smoke - Lack of breastfeeding - Allergies - Air Pollution - Unhealthy diet - Recurrent infections at a young age

What are some things that could predispose a child to a respiratory tract disorder?

What is the child's pain history? - What has the child's experience of pain been in the past What words does the child use? - "ouchy boo boo" How does the parent know the child is in pain? - Ask parents because the parents can sometimes see that their child is in pain (they are the expert on their child) - Some children don't voice pain for fear of things being done with them What is the dev age of the child? - According to a pt's age, it helps the nurse devise a plan of action when it comes to nursing care Usual methods of "comfort"

What are some things to note about pain history in pediatrics?

Mental Health Concerns/Violence arise in the 10-19 yr range - Suicide rate increase with the availability to firearms - Higher levels of firearms/homicide rates in certain races for a variety of reasons - 1/5 adolescents have a mental health issue --> general mental health concern; 1/10 have a serious mental health issue - Children with mental health concerns are more likely to participate in risk taking behaviors - More screening tools for mental health in healthcare Injuries are at the top for all age ranges --> problematic because injuries are preventable. Type of injury will vary based on age: - Infants are prone to choking, falls, aspirating, suffocating, etc. - Toddlers prone to burns, collision injuries, aspirating, etc (r/t mobility) - School aged children prone to bike accidents, drowning, street traffic injuries - Adolescents prone to injury because of risk taking behaviors: burns, drowning, motor vehicles accidents (increased likelihood in boys) Parents will need anticipatory guidance so they know what injuries children are prone to at certain ages so the parents can be prepared --> thinking ahead of what the next developmental milestones are Obesity in childhood - Labeling children as obese/overwt can lead to adverse outcomes like increased wt gain, EDs, mental health issues, etc. - No evidence-based way to lose wt, so want to focus on associated health outcome that can occur b/c of increased wt (ex: focus on hyperlipidemia, something that can be focused on and reduced with evidence-based practice) - Dieting in adolescence is a risk factor for developing an ED - Overwt children at an increased risk for metabolic health syndrome (increased risk for other disorders with this) - Obsesity is BMI of over 95% for the normal percentile (about 1/5 children fall into this)--> differences in BMI due to racial group/SES - Prevalence of obesity increases with age (younger children at less risk than older children) - Causes of obesity: Maternal obesity, maternal microbiome, sedentary activities, lack of physical movement because lack of resources/unsafe neighborhoods, etc. - If a child is obese they will likely continue to be obese throughout their lifespan (if you tell someone to lose wt they often gain wt)

What are some things to note when assessing childhood health problems?

8 yrs + - Children must understand numbers

What are the age ranges for the NRS scale?

3-7 years old

What are the age ranges for the Wong-Baker FACES scale?

BW - 1-10 kg: 100mL/kg - 11-20 kg: 1000mL + 50 (x kg -10 kg) - >20 kg: 1500 mL + 20 (x kg -20kg)

What are the calculations to calculate daily fluid requirements?

Lymphoid Tissues: - Tonsils that will attack any antigens that enter the mouth or airways immediately (located in upper airway) Mucous Blanket: - Can trap if these particles get through the cilia - Alveoli don't have this because it would prevent gas exchange but they have a layer of WBCs on the surface to prevent infection Epiglottis: - Can cover the windpipe when eating and ensure food doesn't enter where it isn't supposed to Cough - Can cough mucous out of body or swallow it Humoral Defenses: - B and T cells/body's natural immune defense Ciliary Action: - Tiny hair like projection that line the airway that propel particles away from getting into the respiratory tract (ex: pollen) *When giving O2, want to add moisture so the tract doesn't get dry*

What are the defenses of the respiratory tract?

Since 80-90% of pharyngitis is viral, a throat culture or rapid strep test will be done to confirm --> this will come back in about 5 minutes - These tests can be negative even in the presence of strep which is also why a throat culture + sensitivity test will be sent

What are the diagnostic criteria for acute streptococcal pharyngitis?

Small sac like structures where CO2/O2 exchange occurs. Increase in shape and number throughout the first years of life (fully mature by age 12) - This lack of alveoli puts them at risk for atelectasis, etc. (less SA for gas exchange)

What are the differences in the infant/pediatric alveoli compared to adults?

- Divided into progressively smaller passages called bronchioles, as child grows, increased branching of the bronchioles occurs increasing lung SA - Higher and steeper bifurcation of the bronchi which means they're more prone to inhalation of objects (ex: FOA)

What are the differences in the infant/pediatric bronchi compared to adults?

Contains epiglottis which is large and floppy in children, vulnerable to swelling

What are the differences in the infant/pediatric larynx' compared to adults?

Small oral cavity and large tongue leave children prone to blockages - Because of this increased risk when their tongues lose tone such as in sleep for complications

What are the differences in the infant/pediatric mouths/oropharynx compared to adults?

Infants and children have smaller nares and nasal passages, more prone to obstruction - Will have more difficulty in breathing if resistance/blockage/swelling - Obligate nose breathers until 6 mo, but around 4 weeks they will gradually start to develop mouth breathing abilities

What are the differences in the infant/pediatric nose/nasal passages compared to adults?

Tonsils and adenoids can leave children prone to occlusions if they become inflamed - Large and floppier so it can be difficult to intubate/control

What are the differences in the infant/pediatric pharynx' (throats) compared to adults?

- Cartilage that support the trachea is less developed, airway more prone to collapse - Trachea higher than in adults, right bronchus is shorter, wider, and more vertically than the left

What are the differences in the infant/pediatric tracheas compared to adults?

Stage: Identity vs confusion - "who am I" - What is my gender identity, what do I like, etc. Depends on past experiences in childhood and future goals Develops personal values, wants to be an adult but needs support of adult or caregiver Interested in sexuality and gender roles Self Image is dependent on what others think Tests limits and rules Believes he or she is special or unique - There is an egocentrism to this group; lack perspective Go to peers for advice typically no longer parents

What is apart of adolescent development concerning erikson's psychosocial theory of dev?

Stage: Trust vs mistrust Ages: Birth to 1 year Basic Needs: Nourishment, attachment, and attention - Fully dependent on caregiver to meet all their needs ex: feeds, diapering, soothing, etc. - Needs to trust their needs will be met from their parent --> if feeling is not met than they will develop an insecure attachment - Infants learn whether people are reliable - Cannot "spoil" a baby

What is apart of infant development concerning erikson's psychosocial theory of dev?

- Incorporating and practice the recognition that the family is the constant in the child's life, whereas the service systems and support personnel within those systems fluctuate - Facilitating family-professional collaboration all levels of hospital home, and community care - Exchanging complete and unbiased information between family members and professional in a supportive manner at all times - Incorporating into policy and practice the recognition and honoring of cultural diversity, strengths, and individuality w/in and across all families including ethnic, racial, spiritual, social, economic, educational, and geographic diversity - Recognizing and respecting different methods of coping and implementing comprehensive policies and programs that provide developmental, educational, emotional, environmental, and financial support meet the diverse needs of families - Encouraging and facilitating family-to-family support and networking - Ensuring that home, hospital, and community service and support systems for children needing specialized health and developmental care and their families are flexible, accessible, and comprehensive in responding to diverse family-identified needs - Appreciating families as families and children as children, recognizing that they possess a wide range of strengths, concerns, emotions, and aspirations beyond their need for specialized health and developmental services and support

What are the key elements to family centered care?

1. Respiratory Illnesses - ex: asthma, common cold, etc. 2. Injuries 3. Infections and parasitic disease - ex: gasteroenterities, etc. *barriers to healthcare increases risk of morbidity*

What are the most common cause of infant and childhood acute illness?

Neonate-Infant (6 mo): 30-60 RR Toddler: 24-40 RR Pre-School: 22-34 RR School-Age: 18-30 RR adolescents-adults: 12-16 RR

What are the normal RR for each age group?

- Throat pain - tonsils inflamed and covered with exudate (white marbled appearance in back of the throat) - if exudate not present than it's probably a viral infection and not strep - headache - fever - abdominal pain - anterior cervical lymphadenopathy

What are the s/s of acute streptococcal pharyngitis?

Acute rheumatic fever - will occur 2-4 wks after infection, body has autoimmune response preventable with penicillin - What happens is cells in the heart and other tissues will mimic antigens to strep bacteria and the immune system will end up attacking those cells Acute glomerulonephritis - Not preventable with treatment, these strep bacteria can go into the kidney and clog the glomerulus causing it to become inflamed and possibly infected (not autoimmune) Scarlet fever (Not as common in the United States because of ability to vaccinate) - Caused by strep toxin, treatment is penicillin and alternative regimens if an allergy

What are the serious sequelae if a child with acute streptococcal pharyngitis is untreated?

Infant: Birth to 1 year (most change) Toddler: 1-3 years Preschool: 3-5 years School-Age: 5-12 years Adolescence: 12-18 years

What are the stages of childhood?

Penicillin + other abx - Needs a 10-day treatment to decrease risk of rheumatic fever + scarlet fever - If there are issues with medication compliance an IM penicillin G can be given with 1 injection --> this injection can be painful so a local anesthetic will be used - Need to be on abx for 24 hours to be considered not contagious --> family members will want to avoid contact with this family member in the meantime --> discard tooth brush b/c it will still have strep on it --> after 24 hrs the child will be able to resume social settings such as school or daycare, etc.

What are the treatment regimens for acute streptococcal pharyngitis?

Isotonic Dehydraton: electrolyte and water deficits occur in approximately balanced proportions - Primary for of dehydration in children - Therapy: isotonic fluids - Na+ 130-150mEq/L Hypotonic Dehydration: Electrolyte deficit>H20 deficit - Na+ 130 mEq/L or lower - Water flows into ICF d/t more Na+ in cells causing the cells to swell - Therapy: Hypertonic fluids Hypertonic Dehydration: Water deficit > electrolyte deficit - Na+ greater than 150mEq/L - Water flows out of cells d/t greater Na+ in ECF - Neuro disturbances are of concern, seizure risk - Therapy: hypotonic fluids

What are the types of dehydration?

Difficult to measure pain High risk for inadequate treatment of pain NCCPC scale - Need to observe for 10 min for signs of vocalizing (moaning, crying), socializing (cooperation), facial expression, activity, body/limb movement, physiological response

What are things to note about pain in children with communication and cognitive impairment?

Physical growth spurt during puberty that lasts 2-3 yrs - Girls: Gain 15-55 lbs, 2-8" in ht (usually stop growing 2 years after menstruation) - Boys gain 15-65 lbs, 4.5-12" in ht Maturation of sexual function --> tanner stages 1-5 Puberty: The process of becoming reproductively mature. Individualized and many factors contribute to variations - During puberty, the secretion of sex hormones increases (estrogen, progesterone, and androgens) which prompt the dev of secondary sex characteristics - Male secondary sex characteristics: penis, scrotum - Female secondary sex characteristics: Breast tissue, body hair, etc. Girls: Puberty begins between ages 8-13 and is completed in about 4 years - First signs are thelarche, then pubic hair, and beginning of menarche Boys: Puberty begins between 9-14 and is completed in about 3.5 yrs - First signs testicular enlargement Adolescence and focus on bodies - Early adolescence: Focus on physical changes of puberty, biology - Middle: Focus on experimentation - Late: 17-19 is a transition to adult behaviors

What are things to note about physical adolescent development?

Purpose: major cause of mortality and morbidity in adolescents is MVA, unwanted pregnancy, STIs, ED, and mood disorder HEADSS is a way to assess and identify areas of risk for adolescents while performing an interview - H: Home - E: Education/Employment - A: Activites - D: Drugs - S: Sexuality, What does sex mean to you? - S: Suicide/Depression Will want to first ask parents about their concerns about their child and then get the patient alone (usually starts around the age of 12) --> ease into the conversation - Don't want to assume anything about the child, but normalization is important ex: "some kids are having sex, do you know anything about that" There are circumstances in which the patient's parents don't have to be involved for children over the age of 12 such as treatment for SA, pregnancy, admission to a psychiatric facility, STD treatment, etc. - Need to be careful in how you word things are not to give private, confidential information to patients

What is apart of adolescent social development?

Peritonsillar abscess as it can prevent breathing from enlargement - Need to cut and drain the abscess into the back of the throat

What is considered an emergency complication of tonsillitis? and why?

Development from head-to-toe, center to periphery (cephalocaudal, Proximodistal) sequence - This means that they gain gross motor dev from head to toe and center to outside Biological development - Weight changes -->Double by 6 mo, triple by 12 mo - Head circumference and fontanelles --> head circumference should continue to increase in first 2 years because the brain should be increasing (if not increasing could indicate microcephaly, etc.; skull should be increasing on the same percentage each time indicating ICP) - Fontanelles close over time --> posterior fontanelle closes by 6-8 wks (if it closes too soon there will be inadequate brain growth); anterior fontanelle closes at 12-14 mo and can indicate hydration status (sunken means dehydration; bulging could indicate ICP) - Length --> should gain an inch per month in first 6mo and then 0.5in after that Fine Motor Development - Grasp reflect (2-3 mo) -Around 4 mo start to dev a voluntary grasp: can pull things towards them; this will increase their risk of aspirating - Progresses to pincer grasp (8-9 mo): use of thumb and index finger to hold things, will be course at first and become more refined (neat pincer graps @ 11-12mo) - Transferring objects from hand to hand (6-8 mo) Gross Motor Development - 2 mo: start to gain head control, want to support baby's neck until then - 4 mo: turns from abdomen to back - 6 mo: turns from back to abdomen, sits unattended by 7 mo - 8 mo: Locomotion (moving around), crawling (only using arms), and creeping (moving on all 4s) - 10 mo: cruising (starts taking deliberate steps using objects to support them) - 12 mo: walking *there will be some variability in these milestones, but most importantly we don't want to see the loss of these milestones*

What are things to note about physical infant development?

Biological development - Become more graceful, no longer squatting and potbellied - Ht and wt growth slow a bit --> not as much as abdominal protrusion Gross Motor - Rides a tricycle around 3 yrs (3 wheels; 3yrs) - Hops on one foot around 4-5 yrs old Fine Motor - Can draw discernable pictures and use scissors at 4-5 yrs

What are things to note about physical preschool age development?

Biological - Slow and steady pace of ht and wt growth - Beginning of school age: boys wt/ht >girls - End of school age: girls wt/ht>boys Pre-adolescence (tween yrs - 8/9-12yr) - Most girls have a rapid growth period in pre-adolescence this then switches at the end of the dev timeline - Can be when body image issues can occur Puberty: Onset of secondary sex characteristics (first signs usually breast buds in females ) - Usually onset: age 9-10 in girls; age 9.5-14 in boys --> large differences in maturation - early or late onset maturation can be very embarrassing for children --> want to take this into account when doing a physical assessment

What are things to note about physical school age development?

Biological development - Height and weight trends--> will have periods of growth and latency, a kid will be half their adult ht at age 2, will gain circumference and later height - Head circumference Gross Motor development - Pulls self up to stand and takes 2-3 steps independently by 1 year - Jumps, kicks a ball and pedals a tricycle around 2-3 years Fine Motor Development - Can hold a crayon by 1 year - Can draw simple shapes

What are things to note about physical toddler development?

Acute - Sudden onset, felt immediately following injury - Arises as a result of tissue injury and generally disappears when injury heals - Ex: twisting an ankle Chronic - 3 mo or more is defined as chronic - ex: vulvodynia Recurrent: - Pain that is episodic but recurs - Ex: back pain that comes and goes

What are types of pain and examples?

Response to pain may be behaviorally "blunted" or absent but they are neurologically capable of feeling pain --> why infants with lower GA score higher on the PIPP scale - Sleep states in preterm infants- more robust response to pain when awake but feel pain when asleep as well - Paralytic agents: unable to exhibit behavioral or visible pain response (same with older children who are paralyzed) - Important to presume that pain exists in all situations that are usually considered painful for adults and children, even with no behavioral or physiologic signs

What does pain look for in preterm infants?

Uses crying Reveals facial appearance of pain (brows lowered and drawn together, eyes tightly closed, and mouth open and squarish) Exhibits generalized body response of rigidity or thrashing possibly with local reflex withdrawal from what is causing the pain --> will not hide in an infant Shows no relationship btw what is causing the pain and subsequent response

What is a Newborn and young infant's response to pain?

Less vocal with less physical resistance More verbal inexpression such as "it hurts" or "you're hurting me" Displays increased muscle tension and body control - This relationship will be built on power and control --> try and give them as much control about their day as possible

What is a adolescent's response to pain?

Demonstrates behaviors of the young child, especially during actual painful procedure, but less before the procedure Exhibits time-wasting behavior, such as "wait-a-minute" or "I'm not ready" Displays muscular rigidity such as clenched fists, white knuckles, gritted teeth, contracted limbs, body stiffness, closed eyes, wrinkled forehead

What is a school-age child's response to pain?

Uses crying and screaming Uses verbal expressions such as "ow" "ouch" "it hurts" Uses thrashing of arms and legs to combat pain Attempts to push what is causing the pain away before it's applied Displays lack of cooperation; need for physical restraint Begs for the procedure to end Clings to parent, nurse, or other significant person Requests physical comfort, such as hugs or other forms of emotional support Becomes restless and irritable with ongoing pain Worries about the anticipation of the actual painful procedure

What is a young child's response to pain?

Uses crying Shows a localized body response with deliberate withdrawal from what is causing the pain --> will want to get away from you Reveals expression of pain or anger Demonstrates a physical struggle, especially pushing away from what is causing the pain

What is an older infant's response to pain?

A process in which child health care professionals anticipate emerging issues that a child and family may face and provide guidance - Infancy because its the most dramatic period for development and allow parents to avoid preventable injuries --> teach what is normal/abnormal for their child

What is anticipatory guidance? When is this extremely important?

Follow protocols for dehydration with replacement of stool losses 1:1

What is the treatment for diarrhea?

- Avoid vigorous tooth brushing, gargling, and hard foods - Encourage fluids - Educate about s/s of a hemorrhage and when to seek medical attention - Low grade fever may be normal, but call if having persistent cough/high fevers

What is apart of parent education for a patient who had a tonsillectomy/adenoidectomy?

1. 2 step strategy (multimodal/biobehavioral) - 1. Non-opioid analgesic for patients >3mo + biobehavioral - Tylenol: safe dosing is 10-15 mg/kg/dose q4-6 hrs - Ibuprofen: 5-10 mg/kg/dose q8-10hrs, can be used with infants greater than 6 mo - 2. Opioids: Used as first step for pain that is severe or second step if unrelieved by non-opioids + biobehavioral - Will want to infuse over a period of time for an infant and monitor RR for adverse rxns/resp distress 2. provide dosing at regular intervals - If expected to have continuous or significant pain, pain management should be delivered around the clock 3. Use the appropriate route of administration

What is apart of pharmacological management of pain in pediatrics?

Stage: Initiative vs guilt - Want to start and do tasks on their own Ages: 3-5 yrs old - Child expresses desire to take initiative in activities - Child learns about environment through play - ex: allow them to clean up their toys, make their bed, sweep the floor Play: Associative - Can now loosely play with another child, may start to take turns and acknowledge that their is another child there - Will initiate a make-believe game like --> more imaginative than just reactive - During this time they may create an imaginary friend; may blame friend for issues - Come up with their own tasks and games to achieve

What is apart of preschool child development concerning erikson's psychosocial theory of dev?

Stage: Industry vs Inferiority - Want to master skills and accomplish meaningful work ex: be the quickest to complete homework or fastest runner - Seeking to gain competence in skills - Acquisition of new skills, assuming new responsibilities, developing a sense of confidence in new skills - Projects are enjoyable, child follows rules and order - More peer influence during this part ex: a child w/ a disability or underlying condition may feel they are unable to meet this stage, important to think about as a provider

What is apart of school age development concerning erikson's psychosocial theory of dev?

Play: strong identification with peers - Focused on same sex interaction, friends are typically the same gender Tend to associate with same sex for play Group activites, clubs, and peer groups: conformity and rules to be "in" or "out" Social relationships are very important Peer Pressure present Bullying: Any recurring activity that intends to cause harm, distress, or control toward another individual where there is a perceived imbalance of power between the aggressor and the victim - Children targeted for bullying typically have increased anxiety, decreased self-esteem, etc. - Long term effects of bullying: criminal behaviors associated with being bullies or other antisocial behaviors Cyberbullying: using electronic medium to harm to bother another individual

What is apart of school age social development?

- Ease respiratory efforts - Promote rest - Promote Comfort - Prevent spread of infection - Reduce body temp - Promote hydration - Provide nutrition - Provide family support and care

What is apart of the care plan for a child with a respiratory tract infection?

- Trachea - Bronchi - Alveoli

What is apart of the lower respiratory tract?

- Collect throat culture - Compliance with medication - Infection control/risk - Comfort measures/supportive care --> Tylenol --> drink fluids --> get rest --> warm salt water rinses

What is apart of the nursing care management for a patient with acute streptococcal pharyngitis?

- Nose and nasal passages - Mouth and oropharynx - Pharynx (throat) - Larynx

What is apart of the upper respiratory tract?

Medical/Nursing Considerations: - Soft or liquid diet to minimize pain - Cool mist to hydrate the back of the throat - Warm water + salt gargles to decrease inflammation - Analgesia for pain Surgical - Tonsillectomy and/or adenoidectomy - Can be controversial because of modest benefits to children with frequent infections/complications - May be indicated with frequent recurrent streptococcal tonsillitis or peritonsillar abscesses

What is apart of therapeutic management of a patient with tonsillitis?

Stage: Autonomy vs doubt and shame - Focusing on independence (but also want to know that the caregiver will be a safety net) Ages: 1-3 yrs old - Children learn to do things on their own w/o help of their parents ex: going to the bathroom on own, learn to dress themselves, feed themselves on their own, test defiance to see how parents will act - Parents shouldn't be too disapproving of this autonomy - Toddlers learn to control their environment by using their own words, start to become independent - Negativism and ritualism (like patterns and routines so they know what to expect and have opportunities to push themselves away) - If criticized for showing autonomy, may develop shame and doubt Play: Parallel - Have no awareness of other people/children, no interactive play yet - Anything that promotes locomotion and tactile play will be very good for this group

What is apart of toddler development concerning erikson's psychosocial theory of dev?

Infants have a greater need for water and are more vulnerable to fluid and electrolyte imbalances because of their expanded ECF compartment - ECF constitutes more than half of the TBW, larger percentage amount than adults until age 2-3 - In general, most fluid loss occurs from the ECF compartment making infants more vulnerable to dehydration and shock - ECF compartment has a greater concentration of Na+ and CL- than ICF --> resulting in greater disturbances in water and electrolyte balance Infant and young children prone to insensible lossess because of relatively greater body surface area and insensible losses such as those that occur due to high fevers and higher RR Metabolic Rate greater than adults Kidney function: kidneys are immature, less able to concentrate urine, conserve or excrete Na+ or to acidify urine Fluid requirements: infants ingest and excrete greater amt of fluid per kg of BW than do other children

What is apart of water balance in infants?

Provision of therapeutic care in settings by personnel and through the use of interventions that eliminate or minimize the psychological and physical distress experienced by children and their families in the healthcare system - Don't want to create lifelong harm (decreasing fear of a procedure, avoiding pain, etc.

What is atraumatic care?

Death in children greater than 1 year of age - 5-14 is the lowest rate of death - Highest rate of death in 15-19 year olds due to: 1. Accidental injury 2. Suicide 3. Homicide

What is childhood mortality? and some things to note about it?

Breastfeeding is recommended for at least the first year of life because of its benefits to nutrition, GI function, host defense, neurodev, and psychological well being (can be protective for other health issues in the future) For infants who are not breastfed IRON FORTIFIED INFANT FORMULA is the recommended nutrition substitute during the first year of life - B/c if not iron fortified, baby is at risk for an iron deficiency - Cow's milk, goat's milk, soy bevs, and low-iron infant formula shouldn't be used during first year of life - Vit D supplement should be included when infant is not being breastfed - During the 4-6 mo period, solids should be beginning to be introduced --> before that they should not be introduced because there's increased choking risks due to inability to extrude food out of the mouth, poor head control, and is also associated with some disorders like chron's disease, eczema, etc. Take into account culture, some cultures will breastfeed their children until the age of 5 which is perfectly normal

What is considered healthy nutrition for a 0-12 month old?

Changes in appetite, picky eating common, continue to plot growth and weight charts Able to drink cow's milk at 1 yr, couldn't before because: - Kidneys are not fully developed and cannot handle the am of proteins in cows milk - Increased risk of lactose allergy - GI tract not deved and increased risk of GI bleeds

What is considered healthy nutrition for a 1-4 yr old?

Increased period of growth similar to first year of life, increased need for iron (IDA), folate (neural tube defects --> if a woman were to become pregnant during this timeframe), and calcium (bone growth) - This is because of rapid growth puberty - Time where a child's management of disease may decrease because of peer acceptability/socialization... ex: a diabetic teen doesn't want to check BS and eat what others are eating

What is considered healthy nutrition for a 11-21 yr old?

Continued need for high quality snacks and meals, continue to plt growth on height and weight charts, body fat increases to prepare for growth spurt Can be a period of rejection of cultural food because of peer socialization --> discomfort of not blending in

What is considered healthy nutrition for a 5-10 yr old?

Family Centered Care: Philosophy that recognizes that the family is the constant in the child's life - An approach to the planning, delivery, and evaluation of healthcare that is grounded in mutually beneficial partnerships among healthcare providers patients, and families GOAL: To create partnerships btw healthcare practitioners, patients, and families that will lead to the best outcomes and enhance the quality and safety of healthcare

What is family centered care? What is the goal of it?

Provides opportunities to reduce differences in current health status among members of different groups and ensure equal opportunities and resources to enable all children to achieve their fullest health potential

What is health promotion?

Human development is complex and period from birth to adolescence includes physical, psychological and emotional changes Continuous screening and assessment of development is essential for early intervention --> Want to find any delays for growth and development as early as possible to prevent further delays and get them caught up Parent child interaction is key to promote development

What is important to note about growth and development in childhood?

- Smiling face = no pain - Tearful face = worst pain - Need to FULLY explain the kids because can otherwise be confusing for them --> your explanation is what makes this scale work

What is important to note about the Wong Baker FACES scale?

Want to reassess pain using scale after an intervention to see how pain is trending

What is important when using the FLACC scale as an assessment tool?

Death during in first year of life per 1,000 live births Top Cases: 1. Birth Defects 2. Preterm Birth 3. Maternal Pregnancy Complications 4. SIDS (sleeping on a hard, flat surface decreases this risk) 5. Injuries (suffocating) Birth Weight is the greatest risk of mortality (the greater the infant BW the lower the risk of mortality)

What is infant mortality? What are the top causes and what puts a baby at risk for mortality?

Dental caries (tooth decay): single most common chronic disease in childhood, they are visible dental cavities - Dental caries are preventable with early dental preventive care, important for parents to brush the tooth when these arise - Dental hygiene beginning with first tooth eruption @ 4-7 mo - Dental care disparities to differ with SES - Role of fluoridated water and fluoride varnish at PCP - Encouraged to have first dental appointment at age 1

What is involved in the health promotion of dental care for children?

Pain rating from 0-10 (will still want to explain the pain that will be experienced at each number)

What is the NRS scale?

Group A beta-hemolytic streptococci (GABHS) infects the upper airway --> overcomes the immune response and attacks epithelial cells of the tonsils/upper tract (more common in older children over the age of 5)

What is the cause of acute streptococcal pharyngitis?

(amt of urine/number of hours)/weight

What is the equation for urine output in pediatrics?

Rota virus (all children will get before age of 5) --> Will start out with green stool

What is the most common causes of diarrhea?

Review individual immunization at every clinical visit Avoid missing opportunities to keep immunizations current Keep up with charges in immunization schedule, recommendations, and research r/t childhood vaccines - Communicate with the doctor that the child is off the immunization schedule (very easy to fall off) If someone doesn't want to vaccinate their child, give them the information to make an informed decision, if they still do not want to vaccinate then that is their choice Pain and swelling at the injection site is the most common side effect of a vaccine - Sometimes but not as common will the patient get a fever - Known allergic response is a contraindication to certain vaccines

What is the nurse's role when it comes to the health promotion of children's vaccines?

Tonsils filter and protect the respiratory system from invasion by pathogenic organisms - Children have larger tonsils than adults so are more prone to infections - Often occurs with pharyngitis

What is the pathophysiology of tonsillitis?

Infants under the age of 3 mo have maternal immunity against viruses - 3-6 mo is when they start to lose this and will see possible increased infection at this time, especially in children who attend day care - Because of this, an illness in a 2 mo old will be much more severe than a 2 year old (first exposure vs a child who has a more developed immune system) - *Respiratory infections are the cause of a majority of acute illnesses in children*

When is there an increased time of infection for children and why?

Because the antibodies from the mother are still circulating and can be inactivate the vaccine

Why are live vaccines not give until 1 yr of age?

There is an extreme pressure on parents/moms to breastfeed and when this is not possible they can feel like a failure - There can be a variety of reasons why a parent cannot breastfeed, but if they continue to breastfeed when its inadequate serious medical implications can occur so supplementation with formula will be necessary So technically yes breast is best, but if unable to fully breastfeed fed is best

Why has there been a switch from "breast is best" to "fed is best" when it comes to feeding an infant?

thelarche

beginning of breast development

FLACC scale

face, legs, activity, cry, consolability - score 0-2 for each category Typically used for children ages 2 mo- 7 res

Tonsilectomy

surgical removal of the palatine tonsils

menarche

the first menstrual period

Prevent and treat pain by interrupting the pain, fear, anxiety, and stress cycle - Teaching kids methods to help with the fear/anxiety of pain - May help with the fear, anxiety, and stress associated with the experience and decrease the pain perception of the experience EX: - Distractions - Relaxation - Guided Imagery

what are biobehavioral interventions ? and what are some examples?