Module 6 Exam NP3

Acetaminophen/anti-inflammatory drugs & Opiates for for Children

Acetaminophen & anti-inflammatory drugs: o Aspirin (acetylsalicylic acid) is not used in children bc of Reyes syndrome--causes confusion, brain swelling, & liver damage. o Acetaminophen (Tylenol) is most common analgesic for mild-moderate pain, also Tx for fevers in children. Minimal anti-inflammatory effects; ST use is safe, even w/ neonates; does NOT have gastric irritation & GI bleeding effects associated w/ other analgesics. Hepatic damage can occur, usually w/ overdosage. RN must monitor the amount given bc often combined w/ other prescription & OTC meds to Tx pain, fever, & s/s URT infection & flu. o NSAIDs: Ibuprofen(Advil, Motrin, Nurofen), naproxen [sodium] (Aleve, Naprosyn, Anaprox), ketorolac (Toradol) Tx mild-moderate pain in children. Reduce pain, fever, & inflammation by inhibiting prostaglandin production. Do NOT give to infants <6mo old. • Opioids: Fentanyl, hydrocodone, hydromorphone, methadone, morphine, & oxycodone; Oral route best when child can take & tolerate PO opiates. o Opioids bind to the CNS opioid receptors & control pain by depressing pain impulse transmission. Used to control moderate-severe acute & chronic pain—post-Op, post-traumatic, SCD vaso-occlusive crisis, & cancer pain. o Effects: analgesia, sedation, respiratory depression, constipation, pruritus, n/v, cough suppression, & urinary retention. Pruritus, nausea, sedation, & urinary retention usually resolve in 1-3 days; Tx w/ antipruritic & antiemetic meds. Constipation does not resolve, RN advocate for laxatives & stool softeners. § Codeine is a weak opioid; it is NOT recommended because of potential overdose that can occur in patients who have the ultrarapid-metabolizer phenotype; allergic rx. § Morphine is the preferred drug for kids; IV peaks at 10-20 min, PO peaks at 1hr. If sedation occurs, max respiratory depression will occur 7min after IV admin. Nausea is common, report if vomiting occurs. Dizziness & lightheadedness can occur, so supervise ambulation & initiate safety precautions. Assess respiratory status frequently & carefully; assess CNS changes & implement safety measures. Monitor I&O rt urinary retention & constipation. Begin w/ lowest dose, titrate up or down to max pain relief & minimize adverse effects. § Demerol(Meperidine) for ST pain only, ex. post-op; infrequently prescribed for kids bc can cause convulsions w/ as low as 2 doses, also causes hallucinations & agitation. Admin when child has allergy or intolerance to other opiates. Duration is shorter than morphine.

Approaches to the Physical Assessment: Infant, older infant, toddler, preschooler, school-age, adolescent.

Approaches to the Physical Assessment: • Knowledge of physical G&D: Assessment of children requires creativity & flexibility, allow the child to hold medical equipment (if safe/clean) to reduce anxiety & increase cooperation. Allow the child to remain on mother's lap, enlisting the child's trust and increasing the likelihood of a successful physical exam. Involve parents in the exam as much as possible. • Provide a quiet, private environment for the H&P (not always possible in an ER situation). • Be sensitive to cultural needs of the family. • Systematic approach: from head to toe, same process as adults, but tailor it to the age & developmental level of the child. -Infant: birth to 6mo; if asleep or nursing in mom's arms auscultate heart, lungs, ABD w/o waking; if awake allow them to stay held by mom. Undress, leave diaper on male, assess body systems while checking reflexes. Leave all uncomfortable assessments last (Moro, hip abduction, tympanic membrane). If unhappy, speak softly, distract w/ rattle or pacifier. -Older Infant: 6-12mo; same as w/ infant, but have more stranger anxiety, increasing difficulty. Do as much of exam as possible w/ them on moms lap. Leave ear, oral, & uncomfortable exams for last; distract w/ toy or object. -Toddlers: most challenging to exam; uncooperative. Form supportive relationship by sitting next to the parent; help toddler relax w/ toys & books to encourage exploration; let them handle exam tools. Communicate w/ age-appropriate words about what will be done. Parts of exam can be done before they are totally undressed; order is flexible (least to most invasive). Reassure mom that resistance & crying is common & normal. Parent is best resource for cooperation; sooth & comfort child in familiar way. -Preschooler: more cooperative than toddler; still want mom near. Happy to show RN they can undress themselves; cooperation can be expected. Proceed head to toe, most invasive last--speculum exam of ear & exam of mouth. Reinforce interest by letting them participate in exam & praise their cooperation. -School-Age: establish trust by asking questions they can answer; elementary age will talk about school, friends, activities; older need encouragement to talk about school performance & activities. Encourage parent to support & reinforce child's participation in exam. Proceed head to toe. Simple drape over underwear or colorful gown; be sensitive to their modesty. Teach them about the body & care; answer questions openly & in simple terms. -Adolescent: comfortable w/ straightforward, non-condescending approach; openly discuss w/ teen who should be present during the exam--usually exam w/o parent present. Give parent time to talk about concerns to the RN. They will undress & wear gown, & be draped appropriately during exam. Proceed from head to toe. Genital exam should be in the middle, after ABD, to allow more time for questions & discussion. Assure the pubertal child about normal stages & answer concerns about their body.

Assessing Pain According to Developmental Age: Neonates/Infants & Toddlers

Assessment of Pain in Children: assessment is more challenging—may not have language or cognitive abilities to communicate pain. Crying & other nonverbal responses occur bc of hunger, sleepiness, & anxiety. RN interviews the parent & child, & uses a combination of behavioral & physiologic indicators, plus the appropriate pain-assessment tool to ID the pain level in infants & some kids. Changes in VS may be an indicator but due to their condition—illness, fever, or disease—they may already be altered from that. • Neonates & infants: assessment based on behavior & physiological indicators. Can't verbalize pain but show rapid changes in behavioral state—sleep/activity patterns. Generalized, whole body response, becomes more localized w/ maturity—older infant will rub the area & guard it. Distinctive motor movements (behavior) associated with pain; high-pitched tense/harsh crying, grimacing, wrinkled brow, surprised look, fist clenching, fussiness, restlessness, pull legs up to ABD; face expressions are most consistent cue. May show increase in HR/BP & decrease in O2sat. May thrash extremities & have tremors. Physiologic indicators are a source of info for assessing pain, but other states like fear/anxiety can cause physiologic changes; may not be valid as an assessment if pain is chronic or sustained bc they may return to normal; if chronic, exhibit s/s of energy conservation. Use parents as one of 1st resources when child is unable to verbalize. • Toddlers: Generalized restlessness, guarding of the painful site, touch the site, excessive/loud crying (more than w/ infants); perceive discomfort with a procedure & attempt to delay it by running from the RN —face expressions show anger/fear. Verbalize pain w/ words like "ouch", "boo-hoo", "hurt"; or verbalize dislike of the RN; older toddler is better able to localize pain & point to body part. Avoid eye contact or look sad; may regress to comfort behaviors like laying on parent's lap in fetal position.

Dying Process & RN Care

Dying Process & RN Care: • Principles of palliative care: Pain and s/s management is priority in a terminal illness; RN educates family on pain control methods (Morphine) & reassures them the child isn't likely to become addicted; pain is assessed frequently to ID need for increased pain med dosages (increased VS=pain). Keep the child clean & presentable. • Communication: Reassure the child their illness is not their fault. They need complete love & acceptance; reassure them that their feelings & thoughts are not wrong. Parents, siblings, & family may need assistance to understand these intense emotions; give them time away from the dying child to express their feelings & prevent the child from feeling responsible for their emotions, esp. the parents. Keep their environment soothing, comfortable, & as stress-free as possible. Open communication with trusted individuals—inform parents that if the child asks you about death, you will respond openly and honestly (even if parents ask you not to). The patient is your #1 priority; don't bring it up w/ the child but be truthful if they ask you—they need to be able to talk & completely trust someone, the RN may be that person. • Provide privacy for the child and family. • Changes in family routines: Allow maximum time with family & siblings; siblings may not understand why the attention is on the sick child. RN should speak to them [if possible], the explanation will be based on their developmental age, tell them this is a 'special time' & their parents' attention will be back on them in a little bit. • Concerns about oral intake: Normal to have decrease in intake, "not starving"; explain to the parents that the cessation of eating/drinking is part of the dying process. • Fluids and oral intake: Ice chips, small amounts - avoid choking; if they have dry lips & say they're thirsty & you know they aren't going to choke, you can give them small amounts of ice chips or put some in a cup—don't overdo it. If at risk for aspiration, don't provide ice chips. • Responsiveness: Variations depending on the stage of death, may have alert time just before death leading to false hope for the family; explain this to the family, this is the "last goodbye". Hearing is the last sense to stop functioning—encourage family members to talk to the child and maintain physical contact. • Imminent death: o HR increases but decrease in peripheral pulses, BP decreases. o Increased work of breathing with apnea - Cheyne-Stokes respirations (aka agonal, don't use this term w/ family bc implies pain) which are a cyclic period of slowing RR w/ apnea, then increased RR to a peak, then slowing & apnea again—lead to respiratory arrest. o As death nears, respiratory sounds are more audible followed by expiratory sigh—moaning doesn't indicate pain, reassure the family. o All these respiratory variations will result in hypoxia or hypercapnia. Hypoxia Tx- oxygen and morphine IV or sublingual—to physically comfort the child & emotionally comfort the family. As CO2 increases, it acts like a sedative & analgesic—increasing the child's comfort. o Noisy breathing (death rattle) is from upper airway secretions, occurs when the child has lost energy to clear/swallow the secretions. Educate the family that this is normal; the child is rarely aware of the changes. RN can suction secretions frequently, position side-lying, & put a cloth under the mouth; diphenhydramine & atropine can decrease the amount of secretions. o When RR stops it may take seconds-minutes for the heart to stop; final gasp may occur when cardiac & respiratory function have ceased, may be preceded by a pause that seemed like death had already occurred. Reassure family this is normal & not painful.

G&D Issues in ER Care: Physiologic & psychological differences in terms of G&D

G&D Issues in ER Care: - The infant- use pacifiers, use quiet/soothing voice; you or the parent should hold or rock the baby, can hold securely or swaddle. Keep warm, if they must be undressed, use a radiant warmer. Allay the parents' fears, so it will not be communicated to the baby. Infants feel pain, must manage this. - The toddler- perform most intrusive procedure last. Procedures done while they sit up on the stretcher, exam table, or parents lap. Tell parents the child will benefit from their confidence. Let the child have familiar (transitional) objects like a blanket, doll, or toy to help them feel safe. Keep frightening objects away from their line of vision, take loud machines away. Praise & distraction can decrease anxiety & increase cooperation. - The preschooler- explain procedure seconds before doing it, not minutes—keeps them from imagining scary fantasies. Talk throughout the procedure, explain what sensations they will/are feeling, tell them how they can help. Distract w/ noises or bright objects, some may like it if you count or sing ABCs w/ them to help keep them calm. Avoid criticizing them for crying, struggling, or fighting during Tx. Tell them they "did try their best to cooperate" can help build a positive self-image. Encourage them to talk about how the illness or injury occurred, if they are inappropriately taking responsibility for it, reassure them it is not their fault. They appear to understand more than they do, don't overestimate their comprehension, explain things w/ words they understand. Avoid scary words like "shot" & "cut"; use positive words like "make better" & "help". Use adhesive bandages over small wounds & injection sites bc they may think their blood will leak out. - The school-aged child- offer simple choices to help them feel more in control. Ex. what arm to get a shot in, what hand to hold nebulizer in—don't ask questions that allow for yes/no response. Talk directly to the child & explain Tx in simple terms; when explaining care/Tx to parents, include the child. Ask the child about their level of understanding & allow time for questions. Address their fears/concerns directly, don't treat their fears as foolish or inconsequential. Give physical rewards after a procedure, regardless of good/bad behavior—it's a reward for undergoing the Tx. - The adolescent- preserve modesty, offer choices about parents being present for the H&P, allow opportunity for questions, explain procedures thoroughly & allow choices—teens are capable of complex abstract thinking, can make intelligent & reasoned decisions about their own care. Consider legal issues regarding right to privacy in teen pregnancy & STIs. Listen to their concerns w/o judging or belittling. Don't tease them, potential for harm & embarrassment.

Assessing the Ears

• External ear: inspect & palpate; ear placement & position was checked during facial assessment. Exam the external ear for malformations or markings, note any discharge from the meatus & its color & character. Cerumen (soft, yellow-brown) is normal in meatus. Palpate bony prominence of mastoid process behind the ear to check for tenderness, & pull auricles to ID discomfort. • Otoscopic examination: assesses inner ear; have parent hold child & secure their arms. Child <3yrs, pull pina down/back; child >3yrs pull pina up/back. Inspect for lesions & cerumen; tympanic membrane for landmarks, color, mobility (puff of air injected). • Children do not like having ears examined; may be crying, causing the tympanic membrane to be red. Younger children have shortened eustachian tubes, increasing frequency of ear infections. Assess external ear & canal, as much as possible of the canal should be visible before inserting speculum into auditory meatus to assess the tympanic membrane. • Hearing acuity: - Infant assessment: after birth [before D/C] test for response of acoustic nerve; infant <4mo may exhibit startle reflex to loud noise; older infant should turn around & try to locate noise/voice coming from behind. - Audiometry: preschool & school-aged, precise (quantitative) assessment of hearing ability; placed in soundproof room & asked to ID tones at different frequencies & specific decibels (20 db). 1.) Sweep test: screen for hearing losses. 2.) Pure tone test: ID exact extent of hearing loss. Child misses tone, repeat test, no more than 4x. - Whisper test: preschool, school-aged, adolescents; stand approx. 0.6m (2ft) behind child, exhale & whisper 3 letters/numbers—child repeats correctly = normal hearing. Adapt for preschoolers by whispering a command & seeing if they do it. - Conduction tests: tuning fork tests are qualitative; ID ability to hear by air & bone conduction. Normal = air > bone; Rinne tests air vs bone conduction; Webber ID ability to hear by bone conduction.

Administration of Blood Products to Children

Administration of Blood Products: ex. chemo Tx, leukemia, SCD. • Confirm ABO blood types and Rh factor. • Comprehensive baseline assessment, including VS. • Know rate of infusion, & amount to be admin—may not be getting the entire unit (ex. NICU admin 10-15cc). Blood must be admin w/in 4hrs of pulling from blood bank. • Monitor closely for signs of an adverse reaction. o VS (including BP) every 15 min for first 1-2hrs and then hourly. o Fever, chills, headache, nausea, pain, difficulty in breathing • If reaction is suspected, stop the transfusion immediately and notify the HCP. Don't do anything until HCP determines what is needed. If rx is present, send all blood & tubing back to the blood bank.

Cultural Differences: Asians & Pacific Islanders, Hispanics, African Americans, Native Americans, Middle Easterners.

-Asians & Pacific Islanders: family is highly valued, many generations may remain close, self-sufficiency & self-control are highly valued. High value on honor, may be unwilling to do anything that could cause them to "loose face". W/ meds or Tx, seldom say "no", but may not adhere to med or appts. Herbal meds, music Tx, acupressure may be important part of healing. Southeast asians speak softly & avoid prolonged eye contact--considered rude. May need an interpreter, avoid yes/no questions, instead have them demonstrate the teaching. -Hispanics: men are HOH & considered strong/macho. Women are homemakers. Close extended family w/ high value on kids; family is more important than anything else. Polite & gracious, preliminary small talk is important to as not offend them. Religion & health are tied, curandero is a folk healer & may be consulted before a HCP. -African Americans: part of a close extended family, but many HOH are single women. Loyal to their people & community; may distrust the majority group. Minister is highly influential; rituals (prayer) are often used; illness may be seen as the will of God. -Native Americans: a willful child is strong; a docile child is weak. Close family ties & respect for elders. Each tribe has its own beliefs, but overall view that health reflects harmony w/ nature; disease is associated w/ society, supernatural powers cause/cure disease. May use medicine man, granted supernatural powers to heal; may use herbs & rituals to cure. -Middle Eastern: man is HOH; religion Islam--pray 5x/day, no pork, no meat unless prepared correctly, no alcohol. Many are vegetarians; dietary laws vary according to branch. Women prefer female HCP bc laws of modesty; may cover head, arms, legs; may need ritual cleansing before putting clothing back on & leaving hospital room. Communication is elaborate, family affairs are kept in the family; may have to do assessment gradually. Interpreters should preferable be from same country & religion bc of regional differences & hostilities. Paternalistic; ask husband's permission or opinion when family needs HC.

Denver Screening Test II

Assessment of Development: combination of developmental surveillance and screening. Observation is often the most valuable method. • Assessment includes: Interview of parents; Assess child's ability to think through situations; Assess child's verbal ability; Carefully observe the child. • Denver Developmental Screening Test II: • Personal-social: Getting along with others/personal needs • Fine motor: Eye-hand coordination/problem solving • Language: Hearing, using and understanding language • Gross motor: Sitting, jumping

Assessment of the Eyes: Visual Acuity & the Snellen Chart

Assessment of the Eyes: inspect/palpate shape, distance apart, inner/outer canthus; evaluate of function- visual acuity & extra-ocular muscles, color, peripheral vision, strabismus. Assessment guides what further tests are performed beyond the routine tests. Get family Hx of eye ds at every well visit, starting w/ 1st checkup. • Visual acuity: screen for impairment at least once between 3-5yrs. Test w/ Snellen (>6yrs), Rosenbaum charts, Lea/HOTV for preschoolers (3-6yrs). -Snellen: std. chart w/ graduated letters for testing far vision of kids at 20ft, used w/ kids >6yrs old. Test eyes together, then each eye separately. Repeat w/ corrective lenses on, if child wears them & note the day of the last exam. Begin at the line for 40ft, unless you know the kids has poor vision. Find the line where the kid misses ½ + 1 symbol, to ID what level they can't see. Visual Acuity = smallest line where kid can see >½ the symbols. Record findings by noting the distance of the line correctly read for both eyes. - Ex. right 20/20, left 20/20= correctly ID letters for 20ft, at a distance of 20ft (average finding). - Ex. Correctly ID line labeled 40ft = child can see at 20ft, what the average child can see at 40ft (20/40) - Acuity changes w/ age & testing method used. -Normal Visual Acuity Ranges Based on Age: • Birth: fixate on objects (8-12in), 20/100 to 20/150. • 4mo: 20/50 to 20/80. • 1yr: 20/40 to 20/70. • 4yrs: 20/40 to 20/50. • 5yrs: 20/20 to 20/30.

Cardiorespiratory Resuscitation (CPR) of the Child

CPR of the Child: Factors leading to shock & respiratory failure are the most common causes of cardiopulmonary arrest in kids. Early ID & Tx of respiratory distress & compensated shock can be life-saving—assist w/ ventilation & admin fluids to prevent deterioration of condition. • Larger size head & weaker supporting muscles—reposition head & put rolled towel under shoulders to facilitate improved air exchange. • Airway and breathing: - Limited assessment and intervention: when child is not breathing & unconscious, initiate CPR (BLS). Child w/ spontaneous respiratory effort or pulse will need evaluation to ID if CPR is indicated. - Cardiopulmonary resuscitation: Progress to respiratory failure & shock = initiate CPR. Chest compression only CPR not recommended in kids bc cardiac arrest is usually caused by respiratory arrest (asphyxiation). -Obstructed airway management: s/s inability to inflate the lungs (ventilate). Tongue often the cause in young children bc it is larger rt the oropharynx; foreign body aspiration—common among kids bc put small objects in mouth can be Tx w/ Heimlich maneuver, if child is conscious & >1yr old. Unresponsive infant/child w/ foreign body aspiration initiate CPR. Try to visualize the object for removal before each ventilation sequence. • Infant: place in downward slant; give 5 back blows alternating w/ 5 chest compressions—don't use ABD thrust bc risk of liver injury. Don't do blind finger sweep, can push the object farther down or injuring supraglottic area. If you see the object, remove it. • If obstruction continues after maneuvers: direct laparoscopy & Magill forceps to remove object; tracheostomy is a last resort. Lower airway obstruction from dz (asthma), give meds to open the airway. • Safety Alert: child is in significant respiratory distress, but it coughing or able to breathe adequately despite partial obstruction—let them sit however is comfortable to them until specialized care is available. Ex. small child in caregiver's arms—RN remains w/ child & encourages them to remain calm by reassuring in a soothing tone. • Circulation: - CAB (circulation, airway, breathing): new common CPR thoughts for Peds; child >1yr palpate carotid or femoral artery & look for s/s of circulation like movement. Child <1yr palpate the brachial artery bc short, thick neck makes palpation of carotid difficult. Begin compressions if no pulse felt for 10s, or if HR <60BPM & perfusion is poor. CPR: 100+ compressions/min, depress at least 1/3 of chest w/ complete recoil. - Automatic external defibrillation (AED): <8yrs best if you use a AED that can ID Peds shockable rhythms & can attenuate the energy of the shock, if not available use adult AED. Witnessed arrest: use AED ASAP; Arrest not witnessed: do CPR for 5 cycles (2min) w/ minimal interruptions in compression BEFORE using AED.

Assisting the child w/ chronic illness & family members in Managing Feelings

Assisting Family Members in Managing Feelings: Stages of Grief—denial, anger, bargaining, sadness, or depression, & acceptance. • Shock and denial: 1st denial, "no, not me"; disbelief & shock; when they first hear the Dx or find out on their own. 2nd anger, range & resentment at themselves or others; "why me?"; can recur at any point during illness. 3rd bargaining, try to postpone the inevitable; usually directed towards God, but can also be with self or others. 4th depression, sadness for past loses or impending loss; physical or appearance loss, lifestyle changes, or changes in physical ability; imminent loss of loved one or preparing loved ones for the absence created by death. 5th (last) acceptance, no longer depressed or angry; not necessarily happy, but a time of comfort & peace. • Adjustment Phase: reintegration and acknowledgment that the illness is real & ongoing; as adjustment to the condition progresses, some parents may have "Chronic Sorrow" rt the unending nature of the illness & ongoing feelings of loss—deep sadness is common in bereavement, turns into solace. Chronic sorrow is normal; may never resolve, but adaptation to illness occurs & family forms a "new normal" & family life continues. "Chronic Grief" is an excessive duration of mourning, it interferes w/ the ability to return to normal life after the death. Poor grief outcomes ID by stress s/s like poor sleeping, anxiety, insecurity, fatigue, & depression. • Establishing a support system: RN must help the family establish a support system or refer to support groups to help them manage their feelings in this illness. • Dx of the child can create a situational crisis - an unexpected crisis for which the family's usual problem-solving abilities are not adequate. Some families become stronger; these families are considered resilient. Even when the child doesn't realize their illness has an effect on the family, RNs must assist family in managing feelings. The Child with Special Needs: RN must care for the concerns/needs rt their condition & successfully navigate their stages of G&D. Their response to the illness is affected by their age at the onset of the illness, & G&D concerns throughout the course of the illness—plan RN care accordingly. • Developmental aspects: needs will vary w/ each age group; RN must understand developmental aspects to successfully navigate these stages of G&D. Sometimes it's the emotional developmental aspect, & not the chronological age—ex. autistic child is 14yrs old but has the understanding of a 4yr old; don't speak to the child on the developmental level of a 14yr old. RN should understand issues w/ autonomy & self-esteem rt to each stage of G&D. • Coping mechanisms: are present, but they are more likely to experience behavioral and psychological issues w/ any of these special needs. • Hopefulness is present. • Health education and self-care: RN must assist w/ these • Goal is to maintain highest level of health & function possible—cognitively, emotionally, physically & psychosocially; achieve & maintain normalization. • Goal for the whole family is to remain intact; achieve & maintain normalization; maximize function throughout the course of the illness. • Not every child is in a hospital setting & not every RN is working in a hospital setting, so the RN process is on-going for the duration of the illness; achievement of these goals necessitates a family-centered approach to RN care.

Ingestion and Poisoning & Tx

Ingestion and Poisoning: • Poisoning: a substance that can cause toxic effects; usually occurs in children 1-5yrs old—curious & innocently ingest toxic substance in a matter of seconds. In adolescents, the risk is higher for deliberate ingestion and have higher mortality rate. Most parents take patients to ED immediately except with lead poisoning which they are not aware of. • Assessment of poison ingestion - Substance ingested, if known - Amount ingested (how many pills are missing?) - Approximate time of ingestion - Change in the child's condition - Treatment administered at home • Other exposures: ocular, dermal inhalation parenteral & envenomation (insect or animal bites). Treatment for poisons: • Removal of Dermal and Ocular Toxins: for dermal exposure remove anything that is causing the irritation on the skin or eye; remove clothing, brush powder from skin & liberally wash—mandatory w/ skin exposure. W/ ocular exposure need copious irrigation w/ NS or H20; if alkaline substance, irrigate till eyes reach normal pH. • Diluting the Ingested Toxin: these are caustic substances, so you do not want to induce vomiting; no longer recommend syrup of ipecac. Call poison control right away, get to the ER. Substance is caustic until neutralized. • Activated charcoal: not used as much today; binds to the toxin and passes it through the GI system. Best used if its w/in 60min of poison ingestion (PO or NGT); admin w/ sorbitol facilitates elimination & prevents constipation. Tastes & looks gross, so mix w/ other liquids & put in a cup that hides the color. Admin can be repeated for delayed release suspensions, to prevent reabsorption of the toxin. • Specific antidotes: they inhibit absorption of the toxin at receptor sites or lowers its concentration. Mucomyst (N-acetylcysteine) for acetaminophen; Naloxone (Narcan) for narcotics.

RN interventions that prevent or minimize fear & the stress of separation & loss of control during hospitalization.

Play for the Ill Child: provide diversion & allow interaction with other children. Children learn through play; important to allow them to continue to play, but also allow them to learn through play. Play can allow you to assess how the child is coping w/ the stress of hospitalization. Ex. the play therapist wheels the child, while still in bed with traction in place, to the playroom. • Playrooms: children can play w/ toys, participate in age-appropriate arts & crafts, & socialize w/ other kids. This is a safe place, where medical Tx do not take place. When stable, kids can be taken to playroom in wheelchairs & beds. If possible, provide a separate area for teens to listen to music, play video games, use computer, & visit w/ peers. If playroom isn't available, provide age-appropriate toys, games, & books. • Therapeutic play: component of the plan of care; HC team guided activities that are planned to meet the physiological & psychological needs. Used to assess what a child is thinking or to help them through a dz process. Interpretation of play behavior & some types of therapeutic play require guidance w/ play therapist. Provides an emotional outlet, instruct, & improve physical abilities. Can do supervised play w/ medical equipment to reduce anxiety & separate fear from fantasy. If RN is using this method, you must put an evaluation of the play in the RN care plan. Goals: maintain normal living patterns, minimize psychological trauma, & promote optimal development. • Emotional play: AKA dramatic play; children act out real life stressors; can use dolls. Can tell you fears, experience w/ sexual abuse, emotional or physical stressors; can help w/ the healing process. Injection play (must be done safely) for the child who has undergone frequent Tx w/ needles; allows them to inject doll & release stress or anger. Assess cognitive level 1st. • Teaching through play: educate on pre-OP; before a new, painful, or extensive procedure. Assess cognitive level, teach per their level. Demonstrate things like taking a BP or doing a breathing Tx on the child's doll, before doing it on them. Drawings & diagrams may help; pre-OP visits where children can meet the staff, see the environment, ask questions, & meet other kids who underwent the OP can help the child cope. • Enhancing cooperation: stimulate & engage the child to participate in care; use age-appropriate developmental activities. School-age kids love competition & games—will increase ROM if points are made each time a foam ball is thrown through a hoop. Have the child blow bubbles, whistle, blow a pinwheel, or simulate blowing out the penlight can increase DB exercises. ROM can be done w/ throwing foam balls, beanbags, & paper balls. To increase intake, make a graph that shows the amount taken in & give them a reward for a selected goal. Include the child in the plan of care & ID rewards & goals to enhance motivation; use stickers, pencils, baseball cards, & small toys as rewards. • Unstructured play: allowing them an outlet to behave in whatever manner they need, helps them get sense of control back; control events, ideas, & relationships. Ex. music Tx w/ choices of instruments &/or singing, animal Tx to interact w/ animals & their trainers. • Evaluation of play: therapeutic play should be reflected in the care plan; when evaluating look at outcome criteria to ID if play has facilitated the achievement of the goals. Is the child coughing & DB every 2hrs? Are they expressing feelings about separation? Are they eating & sleeping? Have their goals been achieved?

Sequence of Physical Examination & VS by Age

Sequence of Physical Examination: • General appearance: Forming an initial impression; indicators of child abuse. • History taking: Accurate history is the most important component. Take your time & get all the info, children don't have a lengthy Hx, so what you do note must be accurate. • Recording of data: Completely and concisely • VS: These should be recorded at every visit. Their condition determines how often to get VS. - Normal Vital signs by Age: • Newborn: 97.7-99.1F axillary (36.5-37.3C), HR 100-150, RR 35-55, BP 65-95/30-60 • 2yrs: 97.5-98.6F axillary (36.4-37C), HR 70-110, RR 20-30, Girls BP 85-91/43-47; Boys BP 84-92/39-44 • 4yrs: 97.5-98.6F axillary (36.4-37C), HR 65-110, RR 20-25, Girls BP 88-94/50-54; Boys BP 88-97/47-52 • 10yrs: 97.5-98.6F oral (36.4-37C), HR 60-95, RR 14-22, Girls BP 98-105/59-62; Boys 97-106/58-63 • 16yrs: 97.5-98.6F oral (36.4-37C), HR 55-85, RR 12-18, Girls BP 108-114/64-68; Boys BP 111-120/63-67

Secondary Assessment

Secondary Assessment (FGHI): done after the completion of the primary & when interventions (if necessary) have stabilized the child; VS, pain assessment, Hx & H/T, & inspection. -Full Set of VS: bc age variations make their significance more difficult to interpret, they are not as important compared to an adult ER assessment. Sequence: 1st RR then HR (full 1min), last get temp. & BP bc they may be more upsetting to the child & alter the other VS. Remember to use the right sized BP cuff, RR & HR counted for 1min; kids RR & HR are higher & BP is lower than adults. Continuously monitor the VS, evaluate need for monitoring & additional Tx based on their condition. - Infant: may not have a fever or be hypothermia in presence of infection. Be alert to supporting s/s. - Relationship of VS: alteration in 1 causes alterations in the others; ex. abnormally high HR & RR can be from hyperthermia, crying, pain, hypoxemia, or hypovolemia. - Get their weight in Kg; keep the family present, communicate w/ them, assess their needs; apply continuous monitoring when indicated (cardiac or pulse Ox). -Give Comfort Measures: discomfort rt to underlying problem; use pain assessment scales for kids. Frequently monitor pain level & response to relief-measures; include non-pharm techniques. -Head-to-Toe & Hx: • Hx: use "SAMPLE"- S/S, Allergies, Medications taken and immunizations, Prior illness or injury, Last meal & eating habits, Events surrounding this injury or illness (length of illness or mechanism of injury). Determine if their medical Hx will play an important role in assessing & Tx their current illness/injury. • Head-to-toe assessment: done after the brief Hx; document findings that may reflect their condition. During triage assessment, a focuses assessment rt the chief complaint can be used. Compare assessment findings w/ Hx to aid Dx & look for inconsistencies. Continuously monitor for changes in condition, assess for unusual odors. - Pain: assess presence & pattern, described by child or caregiver. - Pneumothorax or hemothorax: decreased breath sounds on affected side, s/s hypoxemia & shock. - ABD: palpate & auscultate for BS. - GU: hematuria suggests GU injury or infection. Blood in urinary meatus suggests disruptive injury of the lower UT—do NOT insert a cath. -Inspect Posterior Surfaces: reinspect all body surfaces for fractures, lacerations, contusions, & penetrating injuries. Observe for petechia, purpura, or rashes. Inspect posterior for obvious & hidden injuries; assess for communicable illnesses & susceptibility to illnesses. • Dx tests: after the initial assessment & interventions; assist in evaluation process. Standard tests: CBC w/ differential, serum electrolytes, glucose (bedside), & urinalysis. Additional for multiple trauma: coagulation, BUN, creatine, glucose, amylase, lipase, AST, ALT, blood type & cross match. Also radiologic films; placement of GT or urinary cath. Orogastric tube for suspected head trauma bc risk of misplacement & injury w/ NGT, if basilar skull & facial fracture present. GT reduces gastric inflation that places pressure on diaphragm & decreases ventilation (children are diaphragmatic breathers). • Weight: essential in ER for med & fluid amounts/doses, measured in Kg; obtain w/ scale if possible per policy (w/ or w/o clothing or diaper), or use a measuring tape (Broselow: length based resuscitation tape). Broselow includes dose calculations, fluid vL, defibrillator energy levels, etc printed on the tape—use cautiously in overweight children. • Parent-child relationship: if it does not appear to be close, comfortable, trusting—RN may want to explore later after child is stable & things have settled down.

Admitting the Child to a Hospital Setting: Priorities & Safety Concerns

Admitting the Child to a Hospital Setting: Priorities • Physical examination: • Initial inspection; Baseline data (PulseOx & VS on admit to ER); Always involve the parents & consider their other needs—children at home, what are their biggest anxieties now. • Taking a history: begins in the ED; continues while admitting the child into the hospital—can be delayed depending on condition, ex. if you need to start an IV or give a med, or any immediate care. Safety Issues in the Hospital: • Safety is of paramount importance for children of all ages. • Infants & toddlers are at the greatest risk for injury. Always place a hand on their ABD or back when rails are down, or if they are on an elevated surface (scale, Tx table). • Techniques such as distraction are utilized whenever possible when you are trying to provide Tx or care. • Restraints should be implemented only as a last resort—requires a HCP order. • Crib and bed rails should be always up (ensure they are ALL the way up).

Components of Effective Communication

Components of Effective Communication: establish rapport w/ family to ID goals & facilitate outcomes for the child. · Touch: how, where, & who you touch; RN must consider cultural differences before using, also if patient is autistic; infants' sense emotional support w/ touch, toddlers & preschools are comforted being held or rocked, school age children & adolescents appreciate hugs or a pat on the back. RN: must get permission from parents for any contact beyond causal touch w/ school age & adolescent children. · Physical proximity: consider cultural differences, generally we stay a comfortable distance away; comfort w/ proximity is based on an individual's preferences. RN: move cautiously when meeting new kids & family, sit or stoop down to eye level. · Environment: put yourself in their shoes; use kid sized furniture, hang art at their eye level, use colorful banners & signs, & appropriately aged toys. Make sure the environment promotes communication & listening, maintain privacy (esp. w/ adolescents), no hallway talk outside pt rooms. · Listening: message must be received for communication to be complete. RN use active listening to be effective in role. · Visual communication: eye contact enhances communication by confirming attention & interest; consider cultural background & monitor their response. Clothing, appearance, & held objects are also visual communicators—RN must anticipate what stimuli will be startling & pleasing to a child. · Tone of voice: can communicate more than the words themselves; communication = what is said + how it's said. People respond better to a relaxed, calm, sweet voice (higher voices are better). RN can assess infant's awareness & sensitivity to messages by observing their body language. Infants express verbal communication through crying (cue to assess their needs) & cooing/babbling (communication in 1styr of life, contentment). RN should ensure that the words & tone of a message are congruent, incongruent tones & words confuse them. Don't talk down to children & don't expect them to understand adult vocab., technical HC terms are used selectively & jargon is avoided. · Body language: ex. Good: can be holding an infant or listening attentively to a teens story, show a genuine smile; Bad: crossing arms, walking in aggressively, being assertive, towering over the child. Use an open stance to invite communication & interaction. Avoid a closed stance, it impedes communication & interaction. Open postures improve the understanding of all parties involved in communication; RN must learn to read body language & become more aware of personal body language. · Timing: recognizing the appropriate time to communicate information is a developed skill; right timing enhances productiveness of the conversation & the child's understanding, the "right" time is after the child has had a chance to make a transition—calm them down & comfort them first. Convenience of meeting the RNs schedule is secondary to meeting the child's needs. Scheduling of teaching sessions in the OP or wellness visit should be done at the parents' convenience, this ensures attention bc they are not worrying about needing to be at work or elsewhere.

Child with special needs & how it affects the family, RN role

Child with special needs: child may require special care, causing increased stress, financial burden, & strain on relationships. -Initially shock & disbelief, then eventual acceptance of the child's limitations—but the grief may be long term when they see other kids doing things their child can't [or will never] do, & they realize their child will never be "normal". -Financial hardships when insurance runs out, or if 1 parent has to quit working to provide care. -Strains the marriage & relationships w/ other children; little time or energy to nurture other relationships, & divorce brings added stressors. Siblings may resent special needs child, & feel guilty for their thoughts or comments. -RN: support the family & teach coping skills; if the family learns to cope w/ added stressors, potential to grow in their maturity, compassion, & strength of character.

IM Injections

IM Injections: Safe volume, site, size needle; depending on the size of the child; 22-25 gauge, ½ to 1 ½ inch, greater size for viscous medication (ex. Bicillin). 2 injections may be needed for larger doses. · Premature: Vastus lateralis; 0.5mL · Neonate: Vastus lateralis; 0.5-1mL · Infant (1-12mo): Vastus lateralis; 1mL (Babies <1yr, use vastus lateralis to avoid damaging the sciatic nerve w/ gluteal injection) · Toddler (13-36mo): Deltoid 0.5mL; Ventrogluteal 1mL; Vastus lateralis 1-1.5mL · Young Child (3-6yrs): Deltoid 0.5-1mL; Ventrogluteal 1.5mL; Vastus lateralis 1.5-2mL · Older Child (6-14yrs): Deltoid 0.5-1mL; Ventrogluteal 1.5-2mL; Vastus lateralis 1.5-2mL · Adolescent (15yrs-adult): Deltoid 1mL; Ventrogluteal 2-3mL; Vastus lateralis 2-3mL

Potential Indicators of Child Abuse

Potential Indicators of Child Abuse: • Dress - inappropriate for weather, ragged, no shoes, excessively dirty. • Grooming and personal hygiene: unclean, body odor. Dirty teeth, broken & dirty nails, matted & dirty hair. • Posture and movements: startle excessively when you get close, shrink away. Its normal for kids to be a bit frightened of medical staff & strangers. Crouching in a corner, slow, concentrated movements. • Body image distortion - thin but think they are fat • Speech and Communication - one-word answers (syllables), may not answer at all & put head down, refuse to interact. Look to others to respond first, seek approval for answer. ID if they are nervous to be at hospital or if there is something going on at home. • Facial characteristics and expression - fearful, anxious, tearful, sad, or angry expressions. • Psychological state - labile, demanding, bizarre, overly dramatic, or condescending. • Additional thoughts - parents answering for a child (that can speak for themselves) and not allowing them to speak. History of injury does not match the actual injury.

Primary Assessment: part of initial triage (ABCDEs)

Primary Assessment: part of initial triage (ABCDEs) • Airway assessment: assess patency, positioning for air entry, audible sounds, airway obstruction (blood, mucus, edema); bc of alterations in A&P, children are at greater risk of airway problems than adults. 2 common causes of death are respiratory failure & shock—Tx includes respiratory & circulatory support. Recognizing s/s of respiratory distress is more important than ID cause of distress/failure—Tx is the same regardless of cause. Distress may be from rib fracture or metabolic acidosis. Listen to breath sounds (audible or stethoscope); snoring (upper airway obstruction, child w/ decreased MS), stridor (high pitch: on inspiration is laryngeal obstruction; on inspiration & expiration midtracheal obstruction), wheezing (high-pitched, musical on expiration; lower airway obstruction), grunting. Crackles or rales (fine popping noises on inspiration; fluid) indicate pneumonia. -RN: allow them to maintain position of comfort or manually position the airway (jaw-thrust, head-tilt, chin-lift); encourage them to avoid hyperextending or flexing the neck; use spinal immobilization & airway adjuncts as required. • Breathing assessment: LOC, RR & depth, sounds, & effort indicate oxygenation; assess decreased LOC, increased or decreased work of breathing, nasal flaring, retractions, RR, pattern, quality, O2sat. - Hypoxia: anxiety or decreased responsiveness; Peds have increased BMR & O2 demand--hypoxia can be rapid. - Respiratory Distress: rapid RR w/ shallow breathing; prefer to sit up to breath, lean forward w/ jaw thrust forward ("tripod")—done to get in as much air as possible. - Respiratory failure: very slow breathing in an ill child is an ominous s/s; indicates they don't have the energy for ventilation bc they used it up compensating. RN must check respiratory status often if indicated by condition, a child w/ rapid RR that turns into slow RR is NOT evidence of them getting better. - Absence of air in lung fields: increased work of breathing w/ quiet sounds. - ABD breathing: normal for infants & young children; RN will observe rise/fall of ABD instead of chest, to count the RR. -RN: give O2, initiate ventilation w/ bag-valve-mask; prep for intubation if indicated; provide gastric decompression w/ OG or NGT; provide comfort measures, encourage family to stay to decrease anxiety. • Cardiovascular assessment: assess skin color & temperature, cap refill, central & peripheral PR & quality. - Child can compensate more effectively for fluid loss than an adult, bc increased HR & peripheral vasoconstriction. Higher fluid% in the ECF, leading to rapid fluid shifts; higher BMR & O2 demand require increased HR; Tachycardia = 1st compensatory mech for low O2 (NOT hypotension!) - Early s/s of CV compromise: tachycardia & decreased peripheral perfusion; requires immediate intervention to prevent decompensation. - Late s/s of CV compromise: hypotension indicates shock; manifests after significant fluid loss bc of the child's compensatory mechanisms that cause vasoconstriction—indicates the mechanisms are no longer adequate to maintain CO. -RN: control bleeding by applying direct pressure; obtain IV access, initiate vL replacement; perform chest compressions, defib or cardioversion; initiate drug Tx. • Disability: assess LOC or activity level (Neuro); response to environment (esp. parents); pupil response. - Altered LOC: irritability or agitation, lethargy, unable to recognize caregivers—can be 1st s/s of respiratory compromise or a worsening condition. - Rapid Neuro-Assessment: 1.) Pupils reactivity & size; 2.) brief MS exam: AVPU (alert, responds to voice, responds to pain, unresponsive). - Serial assessments needed; progressive loss of LOC can be from hypoxemia, hypercapnia, hypoglycemia, increased ICP, or other life-threatening conditions. Open fontanel can delay s/s of brain trauma (increased ICP). -RN: Tx the cause--increased ICP, fluid/blood deficit, hypoglycemia, hypothermia, hypoxia; compare assessment w/ parents perceptions ("norms"). • Exposure: remove their clothing to ID additional injuries or indicators of illness. - Child Abuse: Bruising, burns, vaginal tearing, rectal bleed, discharge; preserve clothing appropriately if it is to be used as evidence. -Swelling/Deformities: underlying trauma to vital organs. -Infections dz: bulging fontanel, periorbital edema, rashes, edema/exudate in pharynx. - Hypothermia: infants & children have larger BSA to weight increasing risk of hypothermia; maintaining heat w/ shivering increases metabolic needs (O2 & glucose) when the child has little reserves. - Neonates: higher risk of hypoglycemia & hypoxia bc use brown fat to increase heat (non-shivering thermogenesis) & increase in metabolic demand secondary to an infectious or physiologic process. - Keep warm: overhead warmers & heat lamps, warmed IV fluids, humidified O2, remove wet clothes, provide warmed blankets. -RN: remove all clothing & diapers; save if needed for evidence, maintain a warm environment.

Principles of Growth and Development

Principles of Growth and Development: · Growth: an increase in the physical size of a whole or any of its parts or an increase in number and size of cells; can be measured easily and accurately (measure height, head circumference, BMI, etc.). · Development: a continuous, orderly series of conditions that leads to activities, new motives for activities, and patterns of behavior. Also an increase in function & complexity that occurs through growth, maturation, & learning (an increase in capabilities). Ex. Normal activities or behaviors can be observed depending on their age. · Learning and maturation: development of the brain results in ability to read, write, etc. Ex. 10-12mo old will use single words to communicate simple desires or needs; 4-5yr old will use complete & complex sentences to relate tales. Language can be measured w/ vocabulary, articulation, & word use. o Maturation: physical change in the complexity of body structures that enable a child to function at increasingly higher levels. It is genetically programmed & occurs as result of changes to the body. o Learning: changes in behavior that occur as result of both maturation & experience w/ the environment. Occurs in a predictable pattern, that is orderly, sequential, & progressive. · RN: there are wide variations that can occur in G&D, each child is unique, reassure parents when variations are still w/in norm; parameters are used to ID abnormalities—detect delays early & start interventions ASAP to minimize the effect of the delay.

Active Listening

RN use active listening to be effective in role, active listening includes: o Attentiveness: RN intentionally gives speaker undivided attention—maintain eye contact, close the door, & eliminate potential distractions. o Clarification through reflection: using similar words, RN expresses to speaker what was heard & understood about the message. o Empathy: RN ID & acknowledges the feelings expressed in the message. o Impartiality: RN listens w/ an open mind, to understand & avoid prejudicing what was heard w/ personal bias. Don't put your own values or thoughts into the message, let them be the communicator.

Sequence for Listening to Breath Sounds, Adventitious Breath Sounds, & Chest Configurations

Sequence for Listening to Breath Sounds: If child is crying, you would have to listen between breaths. Best if child is asleep or quiet, to reduce anxiety let them play w/ stethoscope, distract w/ a toy, involve parents, always warm hands & stethoscope bell. If infant is sleeping/quiet, listen before you proceed to other assessments. Points 1-14 on posterior side, zigzag pattern. Points 15-22 on anterior side, same zigzag pattern. • Adventitious breath sounds: additional sounds heard in abnormal clinical state; have the child inhale deeply & forcefully blow out. Describe quality, continuous or discontinuous, where they occur in resp. phase, & presence of cough; also location, timing, & intensity. • Discontinuous: crackles (rales, crepitations) = fluid in airways; pleural friction rub = pleurae lost lubrication from inflammation. • Continuous: High-pitched wheeze = narrowing of air passageway from fluid, swelling, spasm, or tumor. Low-pithed wheeze (sonorous rhonchi) = more prominent on expiration & may clear w/ coughing, airflow obstruction (bronchitis). • Common Alterations in Chest Configuration: determine shape & symmetry of chest from front, sides, & back; infant & child <6yrs should have rounded (barrel) thorax, barrel thorax in child >6yrs indicate chronic pulmonary dz (asthma or cystic fibrosis).

Discuss the nurse's role in various settings where care is given to ill children.

Settings of Care for the Ill Child: • The hospital: hospitalized child is more likely to have chronic or terminal dz or have special needs w/ specialized care. RN needs to care for their illness, stressors, & developmental needs to resolve the immediate crisis & deal w/ future illnesses. RN is the 1st person they see in HC setting, spends the most time with them—RN can influence their physical & emotional health. o Pediatric observation units or 24-h observation: kids get sick & well quickly; ex. may just need rehydration after diarrhea, after Tx observe/reevaluate to determine if they will be an inpatient or get D/C. o Emergency hospitalization; Outpatient and day facilities; Rehabilitative care. o Medical-surgical unit: depending on age of child; acutely ill or have a chronic dz or disability that requires frequent LT hospitalization. o Intensive care unit or Peds ICU. • School-based clinics: may have a NP or an RN, or a HC worker. • Community clinics: RNs today help take HC on the road to provide services to those who otherwise might not obtain them (ex. rural areas). Van could be stationed at a public school, where it offers health screenings and prevention services to children. • Home care: for kids receiving RT, dressing changes, TPN, or need skilled care for a chronic illness or injury.

Snake and spider bites

Snake and spider bites: also jellyfish & stingrays; antivenin Tx for snakes, supportive care for spider, jellyfish, & stingray bites. Teach kids to avoid snakes, HCP should be familiar w/ native snakes. Antivenin for severe black widow bite; brown recluse bite Tx w/ daily cleansing & ice for 3 days, antibiotics to prevent secondary bacterial infection, & meds & IV fluids to manage systemic dz. - S/S of envenomation: fang mark bite, burning at site, ecchymosis & erythema, pain or numbness, progressing edema. Severe envenomation: n/v, sweating/chills, numbness- paresthesia of the tongue & perioral region, hypotension, & coagulopathies. Substantial amount of venom w/ delayed Tx can result in coagulopathies, respiratory failure, seizures, shock, & death (rare). - Early ID & Tx w/ antivenin can prevent injury, even after admin of antivenin child must stay at hospital for close monitoring for at least 24hrs.

Stages of Separation Anxiety

Stages of Separation Anxiety: greatest in kids 6mo-30mo old (infants & toddlers); stress increases anxiety rt separation. Separation is a major stressor, traumatic to the child & parent. • Protest: child is agitated, angry, & upset; resists caregivers & only want parents; cries, and is inconsolable. • Despair: child feels hopeless and becomes quiet, withdrawn; crying decreases & they become apathetic. • Detachment: when separation from the parent continues; child becomes interested in environment, plays, & seems to form relationships w/ caregivers & other children; if parents reappear, the child may ignore their return. RN may misinterpret this phase as positive adjustment to the hospital, in reality they have "given up". Parents may think the child doesn't want to see them, but this is the child's coping mechanism to protect themself from further emotional pain rt separation.

Techniques for Physical Examination: 5

Techniques for Physical Examination: 1.) Inspection: visual observation- survey an area, then focus on size, color, shape, movement. Direct = w/ eyes, Indirect= w/ equipment 2.) Palpation: use touch to ID pulsations & vibrations, locate structures & masses 3.) Percussion: tapping of the fingers to produce sounds, ID position, size & density of structures 4.) Auscultation: listening to body sounds of the heart, lungs, BVs, ABD; usually w/ stethoscope. Diaphragm= high pitched sound; heart & lungs. Bell= low pitched sounds; BVs & BP. Assess pitch, intensity, duration, quality. 5.) Smell: general body orders are common in kids who are neglected or dirty. Odor can be infection—check mouth, urine, feces. Mouth odor can be from particular dz. • ABD exam: not normal order bc you don't want to change bowel sounds; first inspect, then auscultate, percuss, & palpate last. Percussion ID size of ABD organs before you palpate.

Therapeutic Relationship: Over & Under-Involvement

Therapeutic relationship & RNs Involvement: • Appropriate involvement by the nurse: over-involvement vs under-involvement; sense of partnership w/ the family, but being overly involved can inhibit a healthy relationship. Balance appropriate involvement w/ professional separation. • Professional separation: RN must constantly be aware of fine line between empathy & over-involvement. · Maintaining professional boundaries - drawing a fine line between empathy and over involvement. o Over-involvement: It's easy to get over-involved w/ children bc they are somewhat helpless & RNs want to help to the fullest extent. Child may be receiving inadequate care from family & you feel you can do better, or you may really like the family—either way you can become over-involved. o Under-Involvement: When the family upsets you & you avoid the child, or when you don't want to provide care & ask for a different assignment; s/s of under-involvement. End up spending less time w/ the child—ask yourself why/what is making me avoid this child. Every patient deserves your best RN care.

Temperament: 9 characteristics [attributes]

· Characteristics of Temperament: 3 categories of temperament (easy, difficult, slow to warm up) are based on these 9 characteristics. 1.) Level of Activity: intensity & frequency of motion during playing, eating, bathing, dressing, or sleeping. 2.) Rhythmicity: regularity of biologic functions; patterns of sleep, eat, & elimination. 3.) Approach/Withdrawal: initial response of a child to a new stimulus--ex. new people, food, toys. 4.) Adaptability: ease or difficulty in adjustment to a new stimulus. 5.) Intensity of Response: the amount of energy w/ which a child responds to a new stimulus. 6.) Threshold of Responsiveness: the amount or intensity of stimulation necessary to evoke a response. 7.) Mood: frequency of cheerfulness, pleasantness, & friendly behavior vs unhappiness, unpleasantness, & unfriendly behavior. 8.) Distractibility: how easily the child's attention can be diverted from an activity by external stimuli. 9.) Attention Span/Persistence: how long the child pursues an activity & continues, despite frustration & obstacles.

Assessing Pain According to Developmental Age: Preschoolers, School-Age, & Adolescents

• Preschoolers: egocentric; only understand the present; difficult to associate pain of Tx w/ positive outcomes. Cry & struggle to escape Tx; withdrawal; fear body mutilation, esp. genital. May deny pain to avoid Tx, thinks it will magically go away; deny bc parent said to "be brave". Can describe w/ "a little" or "a lot"—point to location & verbalize intensity, "ear hurts bad"; Sees pain as a punishment for some thought or action; Regressive behaviors (thumb sucking, loss of bladder or bowel control). • School-age: Assess nonverbal & behavioral cues. Can describe accurately, ID intensity & location. Fears bodily injury, has awareness of death—may overreact to illness or injury; begin to understand need for painful Tx. Stiff body posture, withdrawn, quietly sob; Regressive behaviors; possible difficulty functioning in school. May procrastinate or bargain to delay Tx; if aggressive or resistant to Tx, may later deny the behavior. May become very quiet & withdrawn when ill or in pain. Can remember previous painful experiences, affects present response, along w/ culture, gender, & cognitive abilities. • Adolescents: Can describe pain & ID quantity, location, & their feelings about pain—use words like "sore", "ache", "miserable", or "pounding". Perceive pain on physical, emotional, & cognitive level; understands cause/effect; ability to describe & understand doesn't mean they will use it. Exhibit fewer outward s/s vs younger kids; muscle tension, withdrawal, or decreased motor activity. Often confused about control issues & are uncertain of their roles as they move from childhood to adulthood; conflicted between autonomy (being adult-like) & having parents involved in their care (regress to childhood). Egocentric thinking makes them think people are observing their behaviors, may suppress pain behaviors. May not report pain bc they think the RN "knows" when they hurt; expect to receive meds when they need it, not just when they ask.

Med Admin: Psychological and Developmental Factors, Strategies for Med Admin w/ Children

Psychological and Developmental Factors: • G&D principles: Always approach a child according to their developmental level—get down to their eye level, provide explanations about meds; Give as many choices as possible—decreases powerlessness—ex. ask the preschooler, "Would you like to hold the cup or have X hold it while you take the med?". • Differences among age groups: Toddler may see as punishment (esp. needles), so allow them to examine/play w/ equipment (empty orange syringe). School age may feel loss of control, so offer choices. • Eliciting support from parents will alleviate a child's fears; ensure they are not threatening punishments—tell them "It's okay for the child to be upset or cry". Restraints are seldom necessary for med admin; an RN can assist child hold still for injection, parents can distract & comfort. Honesty, praise, & reward are important in all ages—name 1+ positive thing they did, tell them if something tastes bad or if it will hurt, & how long it will hurt. Strategies for Medicating Children: • Infants: cuddle & comfort before/after the admin; RN or caregiver. • Toddlers: use play, minimize restraint, & give praise and stickers as rewards. • Preschoolers: offer choices, give praise. Adhesive bandages are important because they feel it will make it better bc they believe it 'plugs up the hole', & it offers them a choice. • School-aged children: provide choices, explanations, distraction, and support; Still like praise & rewards. • Adolescents: explain, allow participation in decisions, & provide outlet for frustrations—ex. drawing & writing.

Epinephrine, Atropine, Sodium Bicarbonate, Dextrose, Inotropic meds, & Naloxone

-Epinephrine: potent vasopressor & inotropic properties; drug of choice for cardiac arrest, admin IV/IO 1:10,000; arrhythmias, & hemodynamic instability; can be given to an ET tube if needed (1:1000). Vasoconstrictor & BP support; can Tx asthma attacks; allergic rx to stings/bites, drugs & allergens in an emergency. Tx bradycardia or pulseless arrest, hypotensive shock, anaphylaxis, toxins/OD (Beta-Blockers, Ca-Channel Blockers). Vasoconstrictors increase vascular tone & counteract effects of toxins. -Atropine: diminishes vagally mediated bradycardia (Tx symptomatic bradycardia); reduce salivation & bronchial secretions before OP; antidote for OD of cholinergic meds or mushroom poisoning; toxins/OD. organophosphates. -Sodium Bicarbonate: given on basis of ABG results; Tx severe metabolic acidosis, hyperkalemia, & Sodium-Channel Blocker OD. -Dextrose (25%, 50%): can be given on basis of blood results for kids unresponsive to other resuscitative efforts. Tx hypoglycemia, a common complication of dehydration, sepsis, & resuscitation. -Inotropic Meds: Tx hypotension & hypoperfusion, severe CHF, or CV shock. Ex. + inotropes--Dobutamine, Dopamine, & Milrinone initial meds for Tc of cardiogenic shock. Increase the strength of the hearts contractions. -Naloxone Hydrochloride: reverse effects of opiate narcotics. Admin slowly.

Medication Administration Procedures w/ Children

Medication Administration Procedures: • Adhere to the "six rights": Child, Drug, Dose, Time, Route, & Documentation. • Check the orders for transcription errors. Confirm allergies. Always double check med calculation—most Peds unit require a 2nd nurse, NICU does as well. Double check unit dosages. Ask another RN for a 2nd check on high-alert meds. o High-alert meds: Insulin, oral hypoglycemic agents, Dextrose 20% or greater, narcotics (transdermal, IV and oral), epidural, chemotherapy, digoxin, anticoagulants, aesthetic and moderate sedation (inhaled or IV), KCL, hypertonic NaCL, magnesium sulfate for injection. • When you can't confirm the child, confirm w/ the parent who is present. Less transcription errors when HCP puts the order into the EMAR directly, check it if handwritten & check against pharmacy. Calculating Dosages: • Always verify the accuracy of the ordered dose of medication—esp. w/ children bc missed dose or OD can be damaging. • Recommend medication dose of mg/kg/day is calculated. • If it gives indication of divided doses, then the number of divided doses is confirmed. • Some dosages can be calculated based on body surface area (BSA). Formula in textbook: BSA of child (m^2) / 1.7 x adult dose

Heat-related illnesses & Tx

• Heat-related illnesses: sunburn, heat cramps, heat rash, heat exhaustion, stroke. Heat exhaustion & heat stoke are the most serious, could result in death. In evaluation of a heat related illness, consider the environmental temperature & humidity—high humidity & exertion cause the body to be unable to maintain temperature though evaporation of sweat, system gets overwhelmed, creating a cascade of life threatening events. - Tx: child safety considerations in heat related illness; may also need to Tx skin for burns. - Overexertion: muscles generate head during exertion; fluids lost through sweat; rapid RR, & increased metabolic demands. S/S dizziness, flushed, diffuse muscle cramps. Tx: move to cool environment, offer PO fluids, loosen clothing. - Exhaustion: increased loss of fluids, increased BF to skin causes decreased O2 & BF to vital organs. S/S heavy sweating, n/v, dizziness or fainting, exhaustion, headache, cramps; skin is cool, moist, or flushed, core temp may be slightly elevated. Tx: move to cool environment, apply cool/moist clothes to skin, remove clothing or change to dry clothing, elevate legs, offer PO rehydration fluids if no altered MS or vomiting. - Stroke: thermoregulation ineffective; sweating has stopped; vascular collapse & severe CNS abnormalities noted bc hyperthermia & insufficient circulating vL. S/S hot, dry, red skin; change in LOC or coma; rapid, weak pulse; rapid, shallow breathing; elevated core temperature 40.6C (>105F). Tx: emergency transport to the ER; rapid cooling w/ moist/cool cloths & fans; admin O2 via a non-rebreather mask or intubate for respiratory insufficiency; aggressive IV rehydration; intervene PRN to maintain vital functions.

Suture lines & Fontanels

• Suture lines: prominent ridges in infant, flatten out by 6mo old. May be approximated, separated, or overriding depending on age. • Fontanels: assess size, tenseness, pulsation. -Posterior closed by 2-3mo old. -Anterior should be soft/flat when sitting, measure W&L of open anterior fontanel; >12mo old anterior <5cm L&W, completely closed at 12-24mo old (average of 18mo old). Sunken = dehydration; bulging = increased ICP (seen when infant cries, coughs, vomits). --Craniosynostosis- inability to palpate anterior fontanel bc of premature closure. - The anterior fontanel normally closes by 18-24 months of age (and often sooner). The posterior fontanel normally closes by 2-3 months of age. Mrs. Deakin says she has noticed that the "front space" on Jason's head bulges when he cries. You explain to Mrs. Deakin that this bulging of the anterior fontanel with crying is normal. - A consistently bulging (tense) anterior fontanel may be abnormal, and a result of: • Increased intracranial pressure—a bulging anterior fontanel is associated with increased ICP. A variety of conditions may result in increased ICP that is reflected as a bulging anterior fontanel. These include space-occupying lesions such as tumors, infections (encephalitis, meningitis), disorders of cerebrospinal fluid production/absorption (hydrocephalus), metabolic disorders, and intracranial injury. - A consistently depressed (sunken) anterior fontanel is also cause for concern. A sunken anterior fontanel is usually a sign of: • Dehydration—w/ dehydration, a depressed (sunken) anterior fontanel is usually observed. With dehydration, body fluids are more concentrated than normal and the amount of fluid in interstitial spaces is decreased. A depressed (sunken) anterior fontanel reflects a decrease in CSF & ICP.

Patterns of growth and development

Patterns of growth and development: o 1st direction of growth: cephalocaudal, from head to lower extremities (toe). Structures & functions in the head develop before the lower parts. Occurs in part bc of the myelinization of nerves in the brain, that later spreads downward. Ex. Baby raises its head before it can sit, & sits before it can walk. o 2nd aspect of directional growth: proximodistal, prom proximal to distal. Or from the center outward, midline to periphery. Ex. Trachea is center of respiratory tree, formed by 24 days gestation—bronchi, bronchioles, & alveoli G&D by branching out in fetal/infant life; alveoli are the most distal, continue to G&D till middle childhood. o General to specific: maturity causes the activities to be less general & more focused. Ex. Baby's pain response is general crying & flailing (whole body response), as child matures pain response is more specific to the local area that hurts (ABD pain = guarding ABD). o From simple to complex: easily observed in language development. Toddler uses simple sentences, noun + verb. By age 5yrs, construct detailed stories using complex modifiers. o Rate of G&D is not constant: spurts occur often before a developmental task needs to be mastered. o Wide variations w/in normal limits: mastery of a task is not static or permanent, developmental stages don't always correlate w/ chronological age. Child may master a task, then regress when ill or stressed. Struggle w/ the task can occur throughout life, even when more advanced levels are achieved. o Critical/Sensitive Periods: blocks of time when the child is ready to master a task; these periods exist after birth, for optimal G&D. Mastery can occur outside of the period, but some tasks may be learned easier during the period. Ex. Critical period for walking is the late 1st-early 2nd yr, driven by an urge to walk & are prideful w/ success. Kids who are immobilized at 10-18mo can learn to walk but may have more difficulty. Injury, illness, & malnutrition can also affect these periods. · Heredity determines each growth rate; normal pace for all children falls into these 4 patterns: 1. A rapid pace from birth to 2 years 2. A slower pace from 2 years to puberty 3. A rapid pace from puberty to approximately 15 years 4. A sharp decline from 16 years to approximately 24 years, when full adult size is reached. · Directional Patterns of Growth and Development: o Growth spurts alternate with periods of slow or stagnant growth. Cephalocaudal (head to toe), head grows fastest in the fetus, then the trunk in the infant, then the legs in the child. Resulting in the baby being able to raise head, then sit, & finally walk. Proximodistal (center outward), 1st trachea develops in the embryo, then the tree branches outward in the fetus & infant. Motor control of the arms, then control of the hands, then control of the fingers. o G&D effected by: genetics, environment, culture, nutrition, health, family structure, parental attitudes, & child-rearing philosophies.

The Family of a Child with Chronic Illness: Effects of the child's chronic illness or disability

The Family of a Child with Chronic Illness: • Parents: o Parental roles: may be changed bc of the illness; "vulnerable child syndrome" can make them doubt their ability to care for their child. o Mother-father differences: in how the illness should be handled; focusing too much on the child can make their relationship suffer. o Single-parent families: have additional difficulties that affect resilience and impede normalization. May not have adequate social support in family structure, so at an increased risk of social isolation. • Siblings: may have issues w/ the chronic illness of their brother/sister; ill child gets more attention, may feel left out or jealous—may act out w/ negative behavior. • Chronic illness or condition: is LT, persisting > 3mo. So, children with special HC needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional conditions. Need resources beyond those required for children generally.

Oral medications

o Oral medications - liquid is best for young kids; tablet, capsule, powder. o Per os = by mouth; used by older HCPs, means PO. o G-tube administration - 1st check placement; HCP order will specifically say GT route. o Most widely used but least reliable methods—bc gastric emptying time, GI motility, & stomach acidity. Before admin assess gag reflex & swallow. o Less predictable due to loss to spillage, leaking or spitting out—can't determine how much of the med the kid took. Do not crush time released capsule or enteric coated tablets. o Watch your dose - doctors order in mg but we give in mL—do med math; Only use mL with oral (orange) dosing syringe (babies dose <5mL)—to ensure an oral med isn't given as an IV; dose >5 mL should be put in a medicine cup, holds up to 30mL (1oz). o Avoid putting medicine in necessary food, like formula bc if it changes the taste, they won't drink it anymore; can mix in a small amount of applesauce or pudding in a med cup—if portion is too big & they don't eat it all, then they don't get the full dose. o Infant - put inside of cheek slowly as the baby sucks; can do while sucking on pacifier. o Toddlers & Preschoolers can use oral syringe • Injections: o Intramuscular - rapidly absorbed; use of EMLA- eutectic mixture of local anesthetic, put on 1hr before so it's not used in the ED. 2 methods of holding a child are supine (x2 assist) or sitting on parents lap; at the vastus lateralis is preferred. Insert - bevel up with dart like motion; After removing needle, do not massage. Use dry gauze, not alcohol. o Subcutaneous: Given in the connective tissue below the dermal layer. For meds that provide sustained effect—ex. Heparin, insulin. Give only in healthy tissue—avoid bruises, burns, scapes; Admin in outer aspects of upper arms, anterior aspect of thighs, abdomen (>2in around umbilicus). o Intradermal: Enters the dermis layer of the skin which is just below the epidermis. Admin in inner aspect of the forearm or on the upper back. Used for allergy testing or TB screening, PPD. Inject slowly and form a bleb or wheal.

Culture, Ethnocentrism, RNs Role

· Culture: The sum of the beliefs and values transmitted from generation to generation by a particular group. · Ethnocentrism: Belief that one's cultural values are superior to those of other groups; basis for many conflicts that occur when people from different cultural groups have frequent contact. · Iceberg: the tip is the visible behaviors we see; foundation (under the water) is the Hx, traditions, beliefs, values, & religion that we do not see—it forms the basis on which behavior is based. · RN: seek knowledge & understanding of behaviors displayed by different groups, w/in context of mutual respect & sincere desire to understand the patients "lived experience". But 1st you must know your own culture & recognize biases. After you gain the knowledge of yourself & patients culture, you can apply the knowledge to complete the process. o Spiritual & religious beliefs have a strong influence during a crisis, beliefs may be about the cause, Tx, & cure of the illness—know the beliefs to empower the family as they cope w/ the crisis.

Apply the concepts of death and dying as they relate to the pediatric patient.

Coping & the Child's Concept of Death: • Infants/Toddlers (0-2yrs): sensorimotor; React to the anxiety of their parents (verbal & nonverbal); mirror their parents' stress; affected by loss of comfort measures. Rx to parents' emotions w/ crying, attachment to the primary caregiver, & separation anxiety increases more than normal. • Preschooler (Early Childhood: 2-7yrs): pre-operational; Views as a temporary separation or departure; reversible ("they'll come back"); magical thinking & egocentricity lead to guilt/shame bc they think they caused the death; 1st exposure to loss is usually a dead animal. When they are dying, they think it's a punishment for their thoughts or deeds & respond w/ anger, sadness, fear—think others see them as "bad", may be withdrawn from loved ones or show intense anger. Emotions may be labile; RNs & family must be patient; child feels more secure when discipline & limits are enforced. • School Age (Middle Childhood: 7-12yrs): concrete operations; Understands death as a sad & irreversible event, but not necessarily inevitable. Age 10, realize they can die; may have feelings of guilt bc believe they caused the death, or it is a punishment for wrongdoings. Have increased cognition & resources for coping w/ death but it may lead to more questions & fears ("Why am I ill? Why do I have to die so young?"). Fear about process of dying & what follows arise, even w/ spiritual beliefs fear persists bc don't have concrete knowledge of what it's like after a person dies. May fear being w/o love/support of parents & family; feel vulnerable & doubt ability to cope w/ knowing their death is impending & the death experience. • Adolescents (12yrs+): formal operations; Understand death as a permanent & irreversible event; See death as distant & view themselves as invulnerable to death rt their increasing independence. Don't always have an emotional acceptance of impending death. Guilt results when they try to separate from parents & test/break rules; guilt in the dying child when contemplating spirituality. Ill teens become isolated from peers; healthy peers avoid their friend bc it makes them question they own mortality. Dying teens may isolate themselves from family & HCP bc feel that no one understands them—leads to them feeling lonely & fear they will die w/o love & support. Anger & sadness result when they realize they will die when life is just beginning & they will never reach adulthood; contributes to onset of depression.

Cultural Assessment

Cultural Assessment: of a child/family, done to provide adequate care to the whole family. Understand meanings of health & illness to the cultural group. · Ethnic affiliation · Values, practices, customs, and beliefs related to pregnancy & birth, parenting, & aging. · Language barriers & communication styles. · Family, newborn, & child-rearing practices · Religious and spiritual beliefs; changes or exemptions during illness, pregnancy, or after birth. · Nutrition and food patterns · Ethnic health care practices: how time is marked, rituals to restore health or ease passage to afterlife, & other views of life & death. · Health promotion practices · How HC professionals can be the most helpful · After the assessment, plan should show respect for their differences & traditional healing practices. RN should accept the practice as long as it is not harmful, if it is harmful the seek advice from staff who is familiar w/ the culture, to provide care & info to the family.

Developmental milestones & their relationship to communication approaches: Infants & Toddlers

Developmental milestones & their relationship to communication approaches: o Infants (0-12mo): experience world through senses; language- babbling, crying, cooing, single-words, name simple objects. Emotional- dependent on others, high need for cuddling & security, responsive to environmental stimuli, can distinguish between happy/angry voices & familiar/strange voices, begin to experience separation anxiety. Cognitive- interactions are reflexive, begin to see repetitions of activities & movements, begin to initiate interactions intentionally, short attention span 1-2min. RN Communication: calm, soft, soothing voice; respond to cries; engage in turn-taking vocalizations (imitate their noises); talk & read to regularly; talk to them about what you are going to do to prep them for care; use slow approach & allow time to get to know you. o Toddlers (1-2yrs): experience world through senses; language- 2-word combinations, turn taking communication, "No" is favorite word, use gestures & verbalize simple wants/needs. Emotional- strong need for security objects, heightened separation [stranger] anxiety, parallel play, thrive on routines, beginning of independence ("Want to do by self"), very depended on significant adults. Cognitive- experiment w/ objects, active exploration, variations on activities, begin to ID cause/effect, short attention span 3-5min. RN Communication: learn & use their words for common items, describe Tx/activities as they are about to be done, use picture books, use play to demonstrate, respond to their receptivity of you & approach cautiously, prep occurs immediately before an event.

Developmental milestones & their relationship to communication approaches: Preschoolers, School-Age, Adolescents

Developmental milestones & their relationship to communication approaches: o Preschool (3-5yrs): use words they don't fully understand, don't fully understand words used by others. Language- further developed word combination (full sentences), growth in grammar usage, use pronouns, clearer articulation, vocab. expansion is rapid but may not understand words they use. Emotional- like to imitate activities & make choices, strive for independence but need adult support & encouragement, purposeful attention-seeking behaviors, learn cooperation & taking-turns in games, need clear limits & boundaries. Cognitive- begin to develop concepts of time, space, quantity; prominent magical thinking, only see from their perspective, short attention span 5-10min. RN Communication: offer choices, explain activities/Tx w/ play, use simple sentences & relative concepts, use pictures/storybooks & puppets, describe activities/Tx as they are about to be done, be concise & limit explanation to 5min, prep activities occur 1-3hrs before event. o School-Age (6-11yrs): can communicate thoughts & appreciate other viewpoints, words w/ multiple meanings & those describing things not yet experienced are not fully understood. Language- expanding vocab. allows to describe concepts, thoughts, feelings; conversational skills develop. Emotional- interact well w/ others, understands game rules, very interested in learning, build close friendships, begin to accept responsibility for actions, competition emerges, still depended on adults to meet needs. Cognitive- understand concepts of classification & conversation, emergence of concrete thinking, very "rule" oriented, process info in serial format, lengthened attention span 10-30min. RN Communication: to explain use photos, books, charts, diagrams, videos—make explanation sequential, engage in conversation that encourages critical thinking, set limits & consequences, used medical play techniques, prep materials used 1-5 days before the event. o Adolescents (12yrs+): can create theories & generate many explanations for situations, begin to communicate like an adult. Language- can verbalize & understand most adult concepts. Emotional- begin to accept responsibility for actions, perception of "imaginary audience", need independence, competitive drive, strong need for group ID, usually have small group of very close friends, question authority, strong need for privacy. Cognitive- think logically & abstractly, attention span up to 60min. RN Communication: engage in conversation about their interests; to explain use photos, books, charts, diagrams, videos; collaborate w/ them & foster/support independence, prep materials given 1wk before event, respect needs for privacy.

The Ill Child's & their family

Effect of the Ill child on the Parents: o Situational crisis for the family—not sure what to do or how to care for child (hold, bathe), not in control, confused. o Guilt—for not bringing child to doctor earlier or missing s/s in child. o Denial—that the child was ill (esp. if serious like cancer, celiac dz). o Anger—result of denial; anger against RNs, family, God; may seem like it's aimed at you, but it's not. o Depression—result of anger; exhausted physically & psychologically from spending a long time in the hospital & concerns outside of hospital w/ work or other kids. • Siblings: Jealousy & resentment towards ill sibling, confusion as to whats going on, anxiety; may act out at home or in the hospital to get parents to pay attention to them (ex. pressing alaris buttons, or other actions that could cause problems w/ patients care). Could feel guilt; think something they said/did to their sibling made them ill. Children's Response to Illness: each child is unique, so its difficult to predict response; hospitalization results 1+ of in these threats or fears in children: Fear of the unknown; Separation anxiety; Fear of pain or mutilation; Loss of control; Anger; Guilt; Regression (ex. previously potty trained, now child doesn't use toilet; reassure parents this is a normal response). • RN: educate parents about what to expect; if child's behavior is different than normal, explain it may be a result of the illness (normal response); support their participation in the child's care to decrease parental stress & enable them to facilitate their child's adjustment. • Parents are encouraged to stay with their child whenever possible, if it is in the best interest of the child. If the child wants a family member w/ them, we allow & encourage it—promotes calming & feelings of security, helps w/ Tx when parent holds them. -Availability of Interpreters: the family of a hospitalized child may not speak the prevailing language. Interpreters are available (on-site or on-call) at many hospitals to help parents and children communicate with HC team members. This arrangement provides a familiar link to the parents' and child's culture and language. Having the child interpret is usually not appropriate; ensure there is a medical interpreter available to provide appropriate info when w/ Hx, teaching, consents, & D/C teaching.

Erikson's psychosocial theory

Erikson's psychosocial theory: based on Freud; development is a lifelong series of conflicts affected by social & cultural factors; each conflict must be resolved for the person to progress emotionally, otherwise they will be emotionally disabled. • Trust vs. Mistrust: Infancy • Develop the sense that the self is good & world is good, when consistent, predictable, reliable care is received (needs are met). Characterized by hope. • Autonomy vs. Shame and Doubt: Toddlerhood • Sense of control over self and bodily functions; Exerts self; Characterized by will. • Temper tantrums are common & normal in toddlers; striving for autonomy & confronted with many challenges. Any rules or demands that interfere with a desired activity, lead to frustration, and perhaps explosive activity (tantrum) that helps release pent-up tensions. • Initiate vs. Guilt: Preschool Age • Can-do attitude about self, want to do things independently; Behavior is goal directed, competitive, imaginative. Understands gender role, Characterized by purpose. • Industry vs. Inferiority: School Age • Develop/mastery of useful skills & tools of the culture; Learning how to play and work with peers, Characterized by competence. • Identity vs. Role Confusion: Adolescence • Develop a sense of "I", lifelong process; Peers are of paramount importance, independence from parents, Characterized by faith in self. • Intimacy vs. Isolation: Adulthood • Ability to lose the self in genuine mutuality with another, characterized by falling in love. • Generativity vs. Stagnation: Adults • Production of ideas & materials through work; Creation of children, characterized by care. • Ego Integrity vs Despair: Older Adults • Realization that there is order and purpose to life; realization of mortality. Characterized by wisdom.

Describe the factors that affect children's responses to hospitalization and treatment.

Factors Affecting the Child's Response to Hospitalization: • Perception of events: "perception is everything"; effects how the child responds before, during, after the illness or hospitalization. • Cognitive development [age]: developmental differences are considered in planning RN care; how to prepare the child for hospitalization differs w/ each developmental level/age. The content, time frame, setting, & methods of prep are all based on the child's G&D. Speak to them in the language that they most understand. • Parental response: parental anxiety/fear will transfer to the child. If they talk outside the child's room or w/in hearing range but in a whisper, the child (esp. preschooler) may invent elaborate stories to explain what is happening. Parents who don't answer the child's questions or who aren't truthful bc they don't want to scare the child, end up confusing them & weakening their trust. Kids want to believe someone is in control & they can trust their parents. Some parents can't be honest bc they are afraid & insecure—RN must assess for all these issues. • Preparation: stress is a nonspecific response of the body to any demand made on it. Adaptation to stress is affected by the perceived stressors, conditioning factors brought to the situation, & coping mechanisms. Prep helps decrease stress by exploring the child's & parents' perception of the event, explore previous experiences w/ HC or illness that may affect impending hospitalization, & ID previous use of coping strategies. Prep as much as possible about what will happen; plan teaching sessions; teaching is more effective when RN & family develop trust & there is honesty. • Previous illness or hospitalization: Hx of illness or hospitalization & their experience/response to the event will greatly affect their future perceptions [vs a child w/ no experience]. • Coping skills of the child and family: coping is the process of contending w/ difficulties in an effort to overcome or work through them. How the child copes is rt their age, perception of event, Hx of hospitalization or encounters w/ HC staff, support from significant others, & the child's/parents' coping skills. • Psychological benefits: stress of illness & hospitalization can enhance G&D by promoting child's use of coping skills & bolster self-esteem. Kids can increase confidence as they overcome anxiety rt hospitalization & may master self-care skills.

Family-Centered Communication

Family-Centered Communication: you are caring for the WHOLE family, support parents in their roles, let them choose the level of care they provide--this is a partnership, respect their diversity, child's recovery is enhanced when they participate so ask for their input. · Establishing rapport: RN convey genuine respect & concern during 1st encounter. Be nonjudgmental & willing to assist family w/ caring for their child—demonstrates interest in their wellbeing. · Availability and openness to questions: families need & want unrushed time w/ the RN, if this is difficult, then purposely schedule it into your day. When pressed for time, empathize w/ their feelings, explain that you need to tend to another patient, tell them when you're coming back to talk, provide info on printouts, encourage them to write down questions. · Family education and empowerment: empowerment occurs when you educate family about child's condition & the skills they need to participate—ensuring their continued involvement in planning & evaluating the plan of care. Support them as they gain confidence in their skills, guide them as they navigate the HC experience. Communication enhances when they feel competent & confident in their abilities. Assess who needs to be educated & ask if theres anyone else who needs the info, so all parties are involved. · Effective management of conflict: parents may be divorced or just have differing opinions on care; RN must manage conflict quickly & consider the child, ask them "what is the best thing for the child?"—allowing the conflict to progress may lead to further breakdown in communication. · Feedback from children and families: assess verbal & nonverbal cues; frequently check in w/ them to receive feedback & ID their experience, satisfaction w/ communication, education sessions, & HC goals. Explain how their feedback will be used, & observe closely to see if they are telling you the truth. ID if there is a secondary person who should be involved in the education & planning. · Spirituality: what are their spiritual needs; spiritual care is a vital coping mechanism for kids. Assess their beliefs & rituals, assist them w/ maintaining these (prayers, songs, blessing at meals)—offers hope, encouragement, comfort, & respect. Pastoral care or the chaplains department can be a good resource.

Fever-Reducing Measures in Children; Throat & nasopharyngeal Swabs

Fever-Reducing Measures: • Fever: Body temperature > 38°C rectally or 37.5°C orally. Triggered by endogenous pyrogens during the inflammatory process. • Medications & environmental management: o Antipyretics: ex. acetaminophen & ibuprofen; Do not use Aspirin because of association of Rye's Syndrome & viral illnesses (flu, varicella). Provide parents written instructions on correct dosing & dosing intervals to avoid inaccuracies in med admin. o Providing adequate fluids; monitoring for signs of dehydration. Dehydration is due to loss of appetite & insensible water loss; may need IV fluids if severe. • Throat and nasopharyngeal Swabs: Be sure the child does not have signs of epiglottitis (sudden onset of high fever, drooling, muffled voice, erythema or exudate) before you put anything down their throat (swab, blade, q-tip)—can cause them to have a complete closure of their throat (sudden airway obstruction), this is a medical emergency requiring a tracheostomy. Swab beyond the back of the nares for flu/strep, swab back of the throat/pharyngeal area for strep.

Freud's theory of psychosexual development

Freud's theory of psychosexual development: early childhood experiences provide unconscious motivation for actions later in life. • Oral Stage: Infancy • Oral Passive Substage (first ½ infancy): Focus on the mouth, get pleasure from taking in & exploring by putting objects in oral cavity. • Oral Aggressive Substage (latter ½ infancy): Strikes out with teeth (biting phase). • Anal Stage: Toddlerhood • Early childhood, when toilet training is a major task, the focus shifts to the anus. • Time of holding on & letting go. Sense of control or autonomy develops as they master (control) their bodily functions. May joke about bodily functions, "potty mouth". • Phallic (or Oedipal/Electra) Stage: Preschool • Genitals become the focus of sexual curiosity, curious about anatomical differences, birth, & sexuality. Children ask questions, expose genitalia, want to "peek" at other genitalia, may masturbate. Oedipus or Elektra complex—child becomes possessive of opposite-sex parent, aggressive toward same-sex parent—shows a heightened interest in sex. To resolve these disturbing feelings, the child ID w/ or becomes more like the same-sex parent. • Superego develops (similar to the conscience: inner voice that reprimands us & evokes guilt); feeling of guilt may emerge. • Latency Stage: School age • Sexual feelings firmly repressed by the superego, period of relative calm. Best-friends & same-sex peer groups are influential. Younger often refuse to play w/ opposite sex, prepubertal begin to desire companionship in opposite sex. • Genital Stage: Adolescence • Interest in sex flourishes again as they search for their identity. Increase in hormones, physical changes, & shifting relationships cause them to develop a more adult view of sexuality. • Sexual energy wells up, resulting in personal and family turmoil. Cognitive skills not fully developed (esp. young adolescents), decisions are based on emotional state & not critical reasoning—leads to questionable judgments about sexual matters, or confusion about sexual feelings & behaviors.

Heart Assessment

Heart: inspect, palpate, auscultate; percussion not normally done, but ID heart size/shape. Infant: listen to heart w/ parent holding them before you proceed. Assess w/ child supine, left lateral recumbent, & sitting while leaning forward slightly. • Inspection: 2nd right intercostal space (aortic), 2nd left intercostal space (pulmonic), left sternal boarder (RV area), 5th left intercostal space at midclavicular line (apex), just below the xiphoid (epigastric area). Inspect precordium (anterior chest over the heart & great BVs) for bulges, lifts, heaves, & apical impulse. Apical impulse is a visible pulsation on anterior wall w/ every heartbeat. By age 7yrs, the apical is at the 5th intercostal space midclavicular line. • Palpation: each area of the precordium, assess for thrills (vibrations); PMI (apical) for child <7yrs at 4th intercostal, lateral to the midclavicular line. PMI for child >7yrs 5th intercostal, midclavicular line. • Auscultation: Both the bell and the diaphragm of the stethoscope should be used. Not uncommon for baby to have a murmur, usually benign; splitting of S2 is also normal (heard at pulmonic at peak of inspiration). If the murmur continues after neonatal period, investigate further. Listen to 4 traditional areas in a "Z" pattern; asses for S1 (lub- closing of mitral & tricuspid) at the apex, assess for S2 (dub- closing of the aortic & pulmonic) at the base. - 1.) ID rate & rhythm by listening for 1full min; 2.) ID S1 & S2; 3.) Assess S1 & S2 separately to ID where they are heard best; 4.) Listen for extra heart sounds; 5.) ID murmurs - Murmurs: an extra heart sound; innocent or functional murmurs are common in children. Blowing or whooshing sound heard bc of turbulence of BF into, through, or out of the heart; best heard w/ bell. Innocent murmurs occur during systole, best heard along left sternal boarder, do not radiate, & change w/ position changes.

Hib (haemophilus influenzae type B) Vaccine

Hib (haemophilus influenzae type B): -Hib is the haemophilus influenzae type b conjugate vaccine, which is designed to prevent invasive bacterial infections from haemophilus influenzae type b, which can cause meningitis, epiglottis, and pneumonia; meningitis in infants & young kids. Hib infections have dramatically decreased since the vaccine was introduced. In developing countries it's the leading cause of respiratory deaths. -Admin: Vaccine is generally started at 2mo of age w/ 2-3 primary doses (depending on the manufacturer), followed by a booster at 12-15mo old. -All vaccines can potentially cause anaphylaxis, RN must ask about allergies & Hx of rx before admin. -When giving DTaP, Hib, & HepB vaccines simultaneously, admin the most reactive vaccine (DTaP) in 1 leg, & inject the others into the other leg.

Implications of Cultural Diversity for Nurses

Implications of Cultural Diversity for Nurses: · Providing effective care: it's impossible to know everything, so ask questions. o How does their culture influence beliefs about health, illness, and aging? Ex. Not going to the HCP for an illness may be bc of cultural influence. o Dissonance in beliefs among generations when assimilation into the host environment occurs; Dissonance - a tension or clash. Ex. Teen may want to go off & be independent bc of influence of Western culture, but older generations think they are misbehaving. o RN: Each family is unique and should be assessed and evaluated as such. Research cultural norms before trying to help or educate these families but realize the research does NOT indicate factual info about the family, so don't assume anything. o Many health care workers have limited knowledge about other cultures. Culture is a very significant factor that influences parenthood, health & illness, & aging.

Initial Observation for Triage

Initial Observation for Triage: combines 3 essential factors; RN must know how to do a full physical assessment, to know how to do a focused assessment in an emergency situation. • RR & effort: Is the child's breathing rapid or shallow, or is the child using accessory muscles? What is the child's position of comfort (sitting up or laying down)? - Dyspnea in a child: use of accessory muscles to help breathe; substernal, intercostal, or subclavicular retractions are s/s of serious breathing difficulties. Nasal flaring, head bobbing, grunting, stridor, upright position, & prolonged expiration sign of increased work of breathing. Slow RR in a child, seems like a normal rate for an adult—hypoventilation is of great concern, can signal imminent respiratory arrest. Observe for abnormal breath sounds & assess O2sat. • Skin color: Is the child's skin pale, mottled, or cyanotic? Get pulseOx reading. - Abnormal color in child: can indicate 2 great threats to life—respiratory distress/failure & inadequate tissue perfusion (shock). • Response to the environment: Is the child alert (oriented), interactive, crying, sleeping, or limp? Is the child smiling & able to play? Does the child make eye contact & interact appropriately? - Response to environment is more difficult to assess in preverbal child, responsiveness is an important part of the assessment. Well child should look around, fixate on objects, & appear to recognize caregivers. Orientation: may not know where they are, but know they aren't home; do they recognize their caregivers. Anxious appearing child may indicate respiratory distress; flaccid, disinterested child may be in respiratory failure or frank shock. • Compare abnormalities found to the caregiver's perception ("Is this his normal color?"), if results of this assessment appear normal, the RN can complete a more thorough & in-depth evaluation. If the impression is that the child is seriously ill, RN intervenes immediately & combines additional evaluation w/ interventions.

Ibuprofen & Ketorolac

NSAIDS: Tx mild-moderate pain in children. Reduce pain, fever, & inflammation by inhibiting prostaglandin production. Do NOT give to infants <6mo old. o Ibuprofen(Advil, Motrin, Nurofen): NSAID; blocks prostaglandin synthesis. Relieves mild-moderate pain in kids >6mo old; also chronic symptomatic arthritis. o PO dose 5-10mg/kg every 6-8hrs; Max dose 40mg/kg/24hrs. Peds arthritis 30-50mg/kg/24hrs. Liquid available for young kids. o Absorbed in GI (80%); peaks in 1-2hrs. o Excreted primarily in urine; some biliary. o Contraindications: <6mo old, previous rx to NSAIDs (urticaria, severe rhinitis, bronchospasm, angioedema, nasal polyps); active peptic ulcer, bleeding problems. o Precautions: HTN, Hx GI ulcer, impaired hepatic or renal function, chronic renal failure. o Adverse Rx: heartburn, N/V, epigastric or ABD discomfort or pain, GI ulcer. o RN: give w/ meals or milk to decrease GI intolerance; if unable to swallow tablet, admin liquid form; if not enteric coated, can be crushed & mixed w/ small amount of food or liquid. o Ketorolac (Toradol): NSAID; blocks prostaglandin synthesis. ST management of moderate acute pain. o Dose in kids >6mo old, IV 0.5-1mg/kg one time, up to 30mg followed by 0.5mg/kg/dose every 6hrs; Max of 60mg/24hrs. o Absorption: peak in 15min. o Excreted in urine; effect lasts 4-6hrs o Contraindications: previous rx to NSAIDs (urticaria, severe rhinitis, bronchospasm, angioedema, nasal polyps); active peptic ulcer, bleeding problems, severe renal impairment. o Precautions: w/ Hx of ulcers, impaired hepatic or renal function. o Adverse Rx: drowsiness, dizziness, nausea, GI pain, hemorrhage. o RN: do not admin >5 day; monitor liver & renal function studies, s/s of GI upset or bleeding.

Obstructed airway management

Obstructed airway management: s/s inability to inflate the lungs (ventilate). Tongue often the cause in young children bc it is larger rt the oropharynx; foreign body aspiration—common among kids bc put small objects in mouth can be Tx w/ Heimlich maneuver, if child is conscious & >1yr old. Unresponsive infant/child w/ foreign body aspiration initiate CPR. Try to visualize the object for removal before each ventilation sequence. • Infant: place in downward slant; give 5 back blows alternating w/ 5 chest compressions—don't use ABD thrust bc risk of liver injury. Don't do blind finger sweep, can push the object farther down or injuring supraglottic area. Only if you see the object, remove it. • If obstruction continues after maneuvers: direct laparoscopy & Magill forceps to remove object; tracheostomy(intubation) is a last resort. Lower airway obstruction from dz (asthma), give meds to open the airway. • Safety Alert: child is in significant respiratory distress, but it coughing or able to breathe adequately despite partial obstruction—let them sit however is comfortable to them until specialized care is available. Ex. small child in caregiver's arms—RN remains w/ child & encourages them to remain calm by reassuring in a soothing tone.

Identify nurse's role in providing family center support to child w/ chronic or terminal illness, siblings & parents

On-going care in chronic/terminal illness: continuous care involving the child & family; address physical & psychosocial needs. • Education: involvement of child life specialist; uses methods that are educational, supportive, & therapeutic—ex. play therapy or art. • Communication: involves honesty and compassion; based on child's age and development. • Care for Parents: grief education and support; cultural and religious beliefs; referrals (specialists, HCPs, etc.); schooling—child should receive appropriate education services and attend public school (laws protecting rights of special needs kids, allowing them to be in public school; school RN provides care). Promoting Normal Development: • Early childhood: basic trust, problems w/ separation from parents, beginning of independence. o Infant Task: achieve awareness that they are a separate being from their significant other; illness may distort this differentiation. o Toddler Task: initiation of autonomy; illness can interfere w/ or make them lose their sense of control & independence. o Preschooler Task: creation of their sense of initiative; illness can cause an interference w/ or loss of accomplishments like walking, talking, & control of basic bodily functions. • School age Task: sense of industry/activity; illness can cause feelings of inadequacy or inferiority if autonomy & independence are compromised. • Adolescence Task: achieving a sense of identity, developing independence/autonomy; peers are very important. Illness can cause an alteration in or relinquishment of newly acquired roles & responsibilities.

Pediatric Trauma: Waddell's Triad, Assessment-Primary & Secondary

Pediatric Trauma: Mechanisms of injury • Blunt trauma: Motor vehicle trauma, Pedestrian injury, Falls (from any height). • Penetrating trauma: Stabbing, Firearms, Impaling injuries. • Multiple trauma: Injury to more than one body system. • Trauma is still the leading cause of morbidity and mortality among children in the US. MVA for all children under 19 yo especially unrestrained. • Waddell's Triad of Injuries: - 1. Struck by car: ABD or thoracic injuries - 2. Propelled into the air & lands on the ground: femur or leg injury, & surface trauma. - 3. Child is propelled to the ground: large size/weight of the head causes skull fracture or closed head injury to the contralateral side of the head. -Primary survey - Airway assessment and management: always remember ABCs; first assess & ensure they have a patent airway. - Cervical spine injury: the child with multiple trauma injuries must remain on an immobilization board (long backboard) with a cervical immobilization device in place until the child has been evaluated for spinal injuries. May need padding under the shoulders for neutral alignment of the cervical spine—opens airway up to allow for max ventilation. If child is in the car seat, do not remove—tape head to prevent moving; assessment & x-rays can be done w/ them in the car seat. - Breathing assessment and management - Circulation assessment and management: think hypovolemia w/ multiple injury or trauma; is there any internal or external bleeding. Hypotension is a LATE s/s of shock. - Disability: brief neuro-exam is done at this time; establish LOC, pupil size & reactivity, & muscle movement. AVPU can assess MS; sudden changes (agitation or somnolence) indicate hypoxia or decreased cerebral perfusion. Trauma Assessment: after assessed that patient is stable w/ ABCs; airway patient, breathing, stable, & immobilized—then get Hx. • Secondary survey: - Obtaining a Hx of the injury: asking specific questions of the MV collision, fall or penetrating injury - Trauma scoring - Assessing for child abuse: Hx inconsistent with findings. Ex. baby comes in as a full code, parents say baby was "sleeping" or "we found them like that"; x-rays show shaken baby syndrome. RN must look at the full clinical picture--duty to report, go up chain of command. • The child during recovery: recover better than adults, even w/ multiple trauma; after child is stabilized, assist w/ recovery phase.

Pharmacokinetics in Children

Pharmacokinetics in Children: the study of the action of drugs within the body, including the mechanisms of drug absorption, distribution, metabolism, and excretion; onset of action; duration of effect; biotransformation; and effects and routes of excretion of the metabolites of the drug. • Absorption: Oral route: Absorbed in the GI tract; Influenced by—Acidity, Emptying time, Motility, Function of the pancreatic enzymes (variable in <3mo old). Other routes: IV - immediate absorption in the bloodstream; Peripheral circulation is less reliable in kids. Topical - children have thinner skin & larger BSA; Absorption is greater than adults. • Distribution: refers to the general & specific concentration of the med in body fluids and tissues. Differences in body fluids - distribution of fluids & fluid intake needs vary based on age & size. Infant/young child have increased fluid, stored in the ECF; higher doses of H20 soluble meds needed; illnesses that cause fluid loss require dose to be adjusted to avoid OD or under-dose. Differences in fat percentages - 1st increased then decreased; infant fat = 16% of weight, increases in 1yr old, decreases in preschooler. Body fat must be saturated w/ fat-soluble meds before med is detectable in blood, so doses are often varied to achieve the desired effects. Differences in proteins - preterm/newborns have lower levels (more free med circulating); meds bind to plasma protein (albumin), only free/unbound med can be absorbed by the body. Blood-brain barrier - is not mature until 2yrs old; immaturity results in the barrier being less selective, allowing the distribution of meds into the CNS. • Metabolism: occurs mostly in liver; Preterm/newborn less mature; Older infants, toddlers, & preschoolers more rapidly than adults. • Excretion: through renal system; Adult levels not reached until between 1-2yrs old. Infants & young children have reduced ability to concentrate urine, compared to older children & adults. • Concentration: maintain safe therapeutic levels; measure w/ peaks & troughs—gentamicin, caffeine, digoxin—monitor carefully in a child.

Pharmacologic Interventions: Admin of analgesics & pain management for children

Pharmacologic Interventions: Admin of analgesics • Ensure the correct med & dose are ordered & admin; combination of meds are more effective that single med; no 1 med or combination of meds will work for all patients & in all circumstances. Chosen Tx must have prompt onset of action, predictable duration of action, manageable SE, & a reversal agent. • Routes: PO, rectal, intranasal, topical, transdermal, IV, IM, SQ, & epidural—avoid rectal & IM w/ kids; choose least invasive route that provides optimal analgesia; once child tolerates PO nutrition, switch med to PO. Give meds by PO whenever possible. Pain Management for Children: • Preferred routes are IV or PO. • As soon as the child can tolerate oral intake, the route should be changed from IV to PO. • After starting w/ recommended initial dose for opioids, the dose is titrated to achieve best pain management w/ fewest SE. • Opiates do not have a dose limit, the max dose is the one that causes unacceptable SE. • Infants & children receiving epidural opioids should be monitored by cardiac & apnea monitor, & pulse oximetry. • Cardiac & apnea monitor, & pulse oximetry may be required for certain infants & children receiving IV opiates—neonates, opioid-naïve kids, Hx of apnea or respiratory difficulties; risk of respiratory depression is greatest in first 24hrs of admin. • Infants & children receiving IV & epidural opioids should be monitored by pulse oximetry. • If respiratory depression occurs with opioid use, naloxone hydrochloride should be used for reversal when oxygen & stimulation of the child are ineffective.

Nurse's Role in Promoting Optimal G&D: Play

Play: in childhood is similar to adult work, it is undertaken by the child to accomplish developmental tasks & master the environment. Learn about shape, color, cause/effect, & themselves; promotes cognitive thinking, learn social interaction, & psychomotor skills. Can communicate joy, sorrow, grief, & anxiety. Classifications of play: -Sensorimotor or functional (infants)- activate or manipulate an object & derives enjoyment from the result, repeat action for fun. -Symbolic or pretend (young child)- plays with an object/toy that represents something else; imaginative, no rules, can assist them adjust to a new or painful experience. -Games (young children to adults)- include rules & are usually played by 2+ people; child <4yrs usually wont play games w/ rules, or they may change the rules each time; older children will have set rules in place—boardgames help kids learn to play by the rules & take turns. • Social aspects of play: -Solitary (infant to toddler); parallel- play side by side w/o interacting (toddler or older); associative- group play w/o goals or rules (toddler to preschool); cooperative- group play w/ goals, 1+ leader, in-or-out of group (late preschool or older); onlooker- child watches or asks questions about a group but doesn't attempt to play (toddler or older). • Types of play: -Dramatic- kids act out roles & experiences of what has happened, what they fear, or what they have observed in others; can be spontaneous or guided, often uses medical or RN equipment bc helpful for kids who have or will have OP. -Familiarization- allow child to handle & explore medical materials in a fun & nonthreatening way; can help prep a child for an OP & hospital experience. • Functions of play: physical- fine/gross motor, language, writing; emotional- reduce anxiety w/ role play, escapism, reality/fantasy, self-awareness, feel important & cared for when adult participates; social- infants learn concept of self vs others, imitation [language], role play to learn rules of settings, learn sharing/taking-turns, win/lose, boundaries, competition, negotiation, teamwork; moral- learn acceptable behavior, taking turns is rewarded & cheating is not, group play teaches teamwork, sharing, & feelings of others. -Important to give them time to play, let them play w/ hands—not video games or watching TV excessively. Must learn to build & create through trial & error.

Preparing Children for Procedures

Preparing Children for Procedures: • A treatment room is the preferred location for painful procedures. • Ensure that a person the child trusts is there for support—ex. mom, dad, or RN if parents are unable or uncomfortable. • Use developmentally appropriate terminology. • Offer the child choices if appropriate—ex. "Do you want a red or green band aid?"—only offer choices that you can accept any answer to; if you offer then renege, you lose the child's trust. • Tell the child & parents how they can help with the procedure—ex. "You can help me by staying very still, or do you need someone to hold your arms to help you remember not to move?". • Do not threaten punishment for lack of cooperation—parents often do this; RN must encourage parents not to do this. Instead of "I'm going to take away X, if you don't to X", they should say "You can do X, when we are done doing X". RNs should have realistic expectations based on developmental level & capacity to cooperate. • Encourage parental participation, but do not force an unwilling parent to stay. -Consent for Procedures: • Informed consent: Procedures that involve risk to the child, such as surgery or Dx & invasive procedures—Ex. Surgeries, Lumbar puncture, chest tube, bone marrow. Signed by the parent, even if child is 17yrs old, give explanation of the procedure to the parent & child. • General consent: done when child is admitted to the hospital; routine procedures such as medication administration, IV insertion, specimen collection. • Assent: It is customary to obtain agreement with the child if he or she is 7 years or older; indicates they agree w/ what Tx the HC team is going to provide. Don't ask "Is it okay if we put in an IV?", bc the answer will be "no". Phase in a way that their answer will be acceptable & in line w/ plan of care. -Documentation: Preparation process is done before the child enters the Tx room; Document the key elements of the procedure—who performed the procedure, child's tolerance of the procedure, & the outcome.

Reaction to Illness and Hospitalization: Adolescent

Reaction to Illness and Hospitalization: Adolescent § Separation: unsure of whether they want parents there; some enjoy freedom & independence, others become dependent on parents, & some cant decide (frustrates parents). Reassure parents this is normal teen behavior. Separation from peers is the major source of anxiety; some teens are uncomfortable visiting them in the hospital—causes the patient to be upset that their friends are "moving on" or "excluding" them. RN must provide activity areas & opportunities for them to socialize w/ other teens. § Fear of Injury & Pain: their appearance is crucial, an illness changes their self-perception can have a major impact; a once well-adjusted kid w/ chronic illness, can have difficulty in the teen yrs bc don't want to be different. Can be non-adherent to Tx plans, meds, diets to appear normal & not stand out. Think being "cool" means being in control; may be terrified even when they don't show it; may question everything or appear overly confident. Concern w/ their bodies; guarded during exams connected to sexual development. RN needs to be sensitive to their concerns, reassure them they are normal (if its true). Some believe they are invincible; nothing can hurt or kill them; may take risks or be non-adherent to plan bc they don't understand consequences of behavior. § Loss of control: RN must understand many of issues involved in teen care stem from control; give them some control to avoid power struggles. Loss of control can cause anger, withdrawal, & uncooperativeness. They desire autonomy, social acceptance, & increased self-esteem. Include them in the plan of care to increase control; ask about their perspective to increase feelings of involvement & responsibility. Give all explanations about care & condition; answer all their questions; must include them & realize that illnesses that change self-perception can have a major impact on their life. § Fear of the unknown: present for all children; sights & sounds of hospital can be confusing & cause anxiety. May have many questions about what they see & what we are doing to them; disruptions in their routine make them wonder what will happen next. RN must understand these fears to structure care & teaching in a way that avoids unnecessary anxiety. -Reduce Stress: Activities for the hospitalized child are important for G&D, stress relief, socialization, & a sense of control. Provide them w/ distractions that make them feel like a normal kid, even w/ their present illness/condition.

Reaction to Illness and Hospitalization: School-aged

Reaction to Illness and Hospitalization: School-aged § Separation: already accustomed to separation from parents, but it's more difficult w/ added stressors. Younger child may already have separation anxiety bc starting school; older may be worried about missing school & fear their friends will forget them. Unfamiliar environment w/ regression seen in ill kids, increase likelihood of separation anxiety occurring—become distressed over separation from family/peers. § Fear of body disability and death: more relaxed w/ physical exam & eye/ear exam; uncomfortable w/ genital exam. Understand cause-effect relationship & can relate actions to illness; they ask relevant questions about illness & want reasons for Tx & tests. Parents tell them that if they don't eat/sleep well, they will get a cold—so they associate their actions w/ the dz. RN should talk to them & not just the parents. § Loss of Control: "movers & shakers"; control their self-care & highly social. Like being involved & doing activities; illness changes these patterns. Physical limitations can cause helplessness & dependence; anxiety results from loss of control, hospitalization, & environmental changes—this changes the way they view the experience & resulting stress, may see hospital as a threat. Coping activities include sleeping, socializing, play, & distraction activities. Deal w/ stress of hospital better bc able to reason & communicate needs/thoughts; better understanding of HCP explanations; unsatisfied when lacking info about their care. Friends are important, may think their friends will forget about them. Normally make choices about meals & activities; RN should encourage them to be involved in care—select their menu, assist w/ some Tx, keep room neat, visit other kids when appropriate. Opportunities for independence help them retain sense of control, enhance self-esteem, & allow them to continue to achieve sense of industry.

Stressors Associated with Hospitalization: Infants and toddlers

Stressors Associated w/ Hospitalization: Infants & toddlers ◦ Separation anxiety: RNs in acute care will see stage 1 & 2, stage 3 is usually in LT care settings. Parents may view it as behavioral issues; RN must reassure them this is normal & is usually not permanent. For this age group, the older child will have more elaborate protests & create a scene; tell parents this rx is a sign of a healthy parent-child relationship. Toddler may resist bedtime & eating, have temper tantrums more frequently, regression may occur in toileting & eating—explain this is normal, tell parents to reinforce appropriate behavior & allow regressive to occur. Avoiding separation can increase the child's resilience during hospitalization. ◦ Fear of injury and pain: past experience, separation from parents, & preparation affect their rx to pain & bodily injury; view pain/injury as concrete; most will rx to any intrusive procedure whether its painful or not. ◦ Loss of control: Erikson- task is autonomy, need to have control; experience environment through senses & love exploring; need same-ness, rituals, & routines to provide stability & security. Routines of the hospital may disrupt their lives bc everything is unfamiliar. Ask the parents about their routines around bedtime, feeding, & playing; offer simple choices to increase their autonomy. Weakened autonomy/control can result in regressive behaviors & temper tantrums. o Reduce Stressors: try not to separate the child from the parents; allow parents to be always there, as much as possible; encourage parents to stay or "room-in", most Peds units have a bed available for parents & bring parents meals, to help them through this time.

Stressors Associated with Hospitalization: Preschooler

Stressors Associated with Hospitalization: Preschooler • Separation anxiety: is less obvious and less serious than in the toddler. May already be spending time away from home at daycare or preschool, but illness adds stress that makes separation more difficult. Have good recall of medical experiences, so make it positive for them by allowing them to express feelings & stress. Express similarly to toddler, but less direct—may quietly cry in a corner; may refuse to eat, take meds, & cooperate. May repeatedly ask when parents will visit & try to constantly call them on the phone—all these behaviors are s/s of difficulty coping w/ situation. • Fear of injury and pain: specifically, the fear of mutilation; OP on a limb or body part increases this fear bc don't understand body integrity. Fear of pain & procedures that may cause pain (shots, blood draws); perform potentially painful procedures in Tx room, their room & the playroom is a safe space. Literal interpretation of words, imagine things to be worse than in reality. Imagination is more active during illness; may believe they caused their illness w/ their behaviors/actions. • Loss of control: they have attained independence in self-care & been given independence in the home & school. May expect to keep this independence & become upset when told to stay in their room or bed. They like routines & rituals; may regress if not allowed to maintain some control. Give them a simple choice & some control, while maintaining boundaries. • Guilt and shame: thinking is egocentric & magical; may believe they caused their illness w/ a thought or deed, leading to guilt, shame, & increased stress when they are already trying to cope w/ other stressors. RN must be aware of these feelings of guilt bc they usually don't tell adults about it. RN must assess for this type of thinking, assist them ID unfounded fears & beliefs. Dolls or drawings can help them deal w/ feelings. Helping them ID perceived punishments & reassuring them their illness is not their fault, can greatly decrease anxiety. o Reduce Stress:Safe-Space; designated safe area can enhance a child's sense of security. Ex. their room. Intrusive procedures should take place in a treatment room, not the child's room. The playroom should not be used for treatments and/or administering medications.

Surgical Procedures for Children & Preparation

Surgical Procedures: appendectomy or fixation of a broken leg are common in kids. • Prep: Usually NPO the night before, depending on OP they may allow a light, early breakfast. Peds patients are often put 1st on the schedule, so they don't have to wait to eat. Breastfed child should stop eating >2hrs before arrival time. Formula feeding should stop the night before the OP. Clear liquids allowed up to 2hrs before arrival time—always clarify w/ HCP or their orders bc you don't want to have to postpone their OP bc they ate/drank something. • Preparation for OP: Educate & prepare child and family—Increases knowledge and decreases anxiety, builds trust with the nurse. • Preoperative meds: Pre-OP sedative meds - will need constant observation, so HCP may not admin till child gets down to OR unit; common is midazolam/versed. • Anesthesia induction: Sometimes parents are allowed to stay until child is under, then they leave & wait for OP to finish & the child to wake up. • Post anesthesia care: Usually goes to PACU until "awake" & then the parents allowed to see the child; usually when they wake up, they are tired, upset, & want to see a familiar person right away. Once out of PACU & met all requirements, send child back up to their floor. • Postoperative care: frequent VS checks; check surgical site; Pain control.

Temperament Categories, Misbehavior & Role of RN

Temperament: the way children behave or their behavioral style. Children start to view themselves the way their parents view them--"self fulfilling prophecy". RN may view a child in a certain way based on what the parent tells you. o Temperament Categories: · Easy: even tempered, predictable, & regular in habits. React positively to new stimuli. · Difficult: Highly active, irritable, moody and irregular in habits. Adapt slowly to new stimuli & often express intense negative emotions. · Slow to warm up: Inactive, moody, and moderately irregular in habits. Adapt slowly to new stimuli & express mildly intense negative emotions. o RN: teach parents that a "difficult" child is normal. Know that the parent-child relationships will have less conflict if the child's temperament meets parents expectations. o Misbehavior: behavior outside norms of acceptance w/in the family. RN should aid in the child's socialization & increase self-esteem, teach parents how to discipline, through formal instruction & informal role modeling. Maintain a positive & loving relationship between parents & child; use positive reinforcement & encouragement to promote cooperation & desired behaviors; remove reinforcement or apply punishment to reduce or eliminate undesired behavior. Discourage corporal punishment.

The Child in Shock- Septic Shock

The Child in Shock: an acute, complex physiologic state of inadequate oxygen delivery to the tissues and organs. Prolonged can cause irreversible tissue & organ damage. 3 causes of shock, w/ some overlaps; regardless of the cause body's compensation is similar, in response to alteration in perfusion, transport of O2 & metabolic substances. • Distributive (septic) shock: result of abnormality in distribution of BF or inability of the body to maintain vascular tone through vasoconstriction. Septic Shock: most common cause of distributive shock; response to toxins (bacteria, fungi, virus, rickettsiae) or organisms in the blood; including endocrine, metabolic and immunologic reactions w/ clinical changes, result in impaired organ perfusion & hypotension. Hypotension in Children with Shock: • Hypotension is a late sign of shock; children can compensate for a 25% blood loss. In early stages kids compensate w/ tachycardia, tachypnea, & vasoconstriction to maintain CO. If the condition can't be reversed, a decompensated state occurs w/ altered perfusion (delayed cap refill, weak pulses, cool extremities, & hypotension) & profoundly altered MS. Progression results in CV collapse & death. • Lower limits for systolic BP: Infants younger than 1 month: >60 mm Hg; Infants 1-12 months: >70 mm Hg; Children older than 1 year: 70 + 2x the child's age in years mm Hg; Children older than 10 years: > 90mmHG. Manifestations of Septic Shock in Children: • Compensate w/ Tachycardia, tachypnea, and vasoconstriction to maintain CO—failure to reverse the condition results in: • Septic shock: early; Vasodilation; Extremities that are warm to the touch; Tachypnea; Tachycardia. • Septic shock: late; Rapid, thready pulse; Cyanosis; Cold, clammy skin; Purpuric skin lesions; Narrow pulse pressure; Oliguria or anuria • Tx of Septic Shock: restore hemodynamic status w/ fluid resuscitation & promptly Tx cause. Septic: admin IV antibiotics. Inotropic meds & vasodilators manage CV instability; vasoconstrictors (epi) increase venous tone & counteract effects of toxins & prevent cardiac arrest; steroids, meds to Tx hypoglycemia & electrolyte imbalances, & admin blood products may be needed. If significant respiratory distress occurs, may need to maintain a patent & secure airway. OP may be needed to eliminate the source of infection or stabilize CNS &/or a spinal injury.

Thorax and Lungs

Thorax and Lungs: Have parents help w/ cooperation of the child, don't wake a baby up—listen 1st before proceeding w/ assessment. Stand where the child can see you, let them play w/ stethoscope first. • Inspection: RR & pattern listen for 1 full min- easy, regular, & w/o distress; normal for young children & infants have diaphragmatic or ABD breathing. Resp. Difficulty: rapid RR, retractions nasal flaring, & head bobbing. Observe for cough, stridor, grunting, hoarseness, snoring, wheezing, & sputum (type/amount). Retractions: subcostal, intercostal, substernal, suprasternal. • Palpation: w/ any palpation, use warm hands and warm the stethoscope bell. A&P: tenderness, tactile fremitus, symmetry, depth/quality of expansion, & chest excursion. Tactile Fremitus is vibration on chest wall when child speaks/cries, indicates airway alteration. Note masses or edema. • Percussion: done by Adv. Practitioners; ID changes in sound produced by density of underlying tissues. Hyper-resonance is normal in infants & young children bc of thin chest wall. Auscultation: w/ stethoscope, tell child to open mouth & breathe in/out; assess intensity, pitch, quality, duration. Follow zig-zag pattern to compare R&L; normal sequence: posterior, R&L lateral, & anterior (can make adjustments). If child is inconsolable, listen between the cries. For posterior, have child sit w/ head bent forward & hands in lap; for lateral, sit erect w/ hands above head; for anterior, sit erect w/ shoulders back.

Use of Restraints in Children

Using Restraints: doesn't require a HCP order, if being used for a procedure (ex. Papoose device). • Use the least restrictive restraint. • Choose the proper device & size for the child's condition. • Ensure proper fit of the device. • When tying down the hands or feet, tie knots that can be untied easily for quick access—same as w/ adults. • Secure ties to bed frames or to the frames of wheelchairs. • Follow facility protocol for documentation. • Check the extremity distal to the restraint for circulation, sensation, and motion—every 15 min for the first hour, subsequently as agency policy dictates. • Remove restraints every 1-2 h for ROM, repositioning, and to offer child food or opportunity to use the bathroom. • Document findings from neuro-vascular checks—documentation occurs hourly. • Usually, you need a doctor's order for a restraint other than used for a procedure. Most policies are very strict & guided by TJC & Medicare.

How to Assess VS in Children

Vital Signs: know normal ranges based on age • RR: done 1st bc they are calmest at beginning of assessment. For infants, RR changes w/ stimulation, crying, feeding; 1st observe pattern to ID irregular rhythm, then w/ infant or young child at rest & quiet, auscultate for 1min. Older child, observe chest movement or auscultate to get the RR. • Temperature: Oral- younger kids may not hold it in their mouth, Axillary- upsets babies, Rectal- true core temp., Temporal- most frequently used right now. Whatever method is chosen, always measure at the same site w/ the same method. If elevated/low temp. reading is obtained, consider measuring via a different route. Report if <98.6F (36C) or >100.4F (38C)--reporting is critical for an infant <3mo old. • Pulse: Apical pulse is preferred (esp. <2yrs old, irregular HR, or congenital Heart dz); Count for a full minute, when the child is quiet. Radial is appropriate for kids >2yrs. • BP: Choose a cuff of the appropriate size—BP is off, may indicate incorrect size so recheck it before you tell the HCP the BP is abnormal; make sure you document the site—upper arm, lower arm, thigh, calf, or ankle (esp. w/ younger child). Take BP in same site consistently when possible; changing the site can result in inaccurate & inconsistent readings. Know what is normal for the age of the child!

COMFORT Behavioral Scale & FACES Pain Rating Scale

• COMFORT Behavior Scale: Infants/Children in critical HC setting; 6 categories; Alertness; Calmness/Agitation; Respiratory Response (if on ventilator) or Crying (if spontaneously breathing); Physical Movement; Muscle Tone; Facial Tension. 1-5 points for each category, total of 6-30; Higher score = greater pain/distress. • FACES Pain Rating Scale: children 3yrs+; 6 cartoon faces w/ neutral to gradually increasing painful expressions, corresponding to an analog scale w/ words ranging from: -Happy face (0; No hurt) -Less happy face (1/5 or 2/10; Hurts little bit) -Neutral face (2/5 or 4/10; Hurts little more) -Slight frowny face (3/5 or 6/10; Hurts even more) -Very sad face (4/5 or 8/10; Hurts whole lot) -Crying face (5/5 or 10/10; Hurts worst) -Accommodates a 0-5 or 0-10 system. Explain what each face means, so they pick the correct one. o Explain to the child that each face is for a person who feels happy because he or she has no pain ("hurt") or sad because he or she has some or a lot of pain. Ask the child to choose the face that best describes his or her own pain. (Wong-Baker FACES Pain Rating Scale)

PCA & Topical Anesthetics for Children

• PCA: Patient-controlled analgesia; one of the most effective ways to admin opiates; depending on policy, may need continuous monitoring w/ Pulse oximeter, Cardio-Respiratory monitoring, O2 must be available at bedside & Narcan (naloxone- admin slowly to prevent cardiac arrest) available for reversal. Children 5-7yrs if developmentally appropriate for them to be taught & use the PCA. Safety Benefit: a sedated or sleeping patient will not be able to activate a bolus dose. Children <5 or unable to operate a PCA: HCPs or family can admin "PCA by proxy"; AACA (authorized agent-controlled analgesia)—carefully select & educate RNs or caregivers, provide oral & written instructions on when the child should/not receive the bolus, select a single RN or caregiver who will be there consistently to assess for med effects & consequences, document teaching & supervision of the person giving the AACA. • Topical anesthetic agents: Lidocaine 5% EMLA cream, or patches; numbs the skin before invasive procedures or Tx pain on skin (ex. bee sting). Site must be intact & healthy, clean the site & dry, perform hand hygiene & wear gloves. Place a mound of EMLA cream (2.5g; ½ a 5g tube) on the site & cover w/ occlusive, transparent dressing—do not rub into skin. Leave for >1hr, max of 4hrs. Hand hygiene & gloves, remove dressing & all the cream. Begin the procedure, numbing will last 1-2hrs. Caution w/ infants <12mo old; do not apply to mucus membranes; prevent accidental ingestion in infants & young children; do NOT admin to child w/ methemoglobinemia.

Procedural Sedation & Epidural Analgesia w/ Children

• Procedural sedation: Depressed consciousness, conscious sedation—allows the patient to respond to tactile & verbal stimulation, maintain O2, & airway control independently (cough/gag reflex); ex. IV sedative-hypnotic (Midazolam/versed, propofol), analgesic/opioid, dissociative/ketamine, or a combination of these meds—multiple routes can be used. Levels: minimum, moderate-"conscious sedation", & deep. Need to monitor, airway management (HCP standing by, RN monitoring, & RT maintaining the airway). RN participates in frequent assessment & documentation of VS, O2sat, capnography, LOC during & after the procedure. o Midazolam/versed: used for sedation, induction of general anesthesia; short acting sedative-hypnotic, can be given via multiple routes. Often used for procedural sedation bc it has minimal SE, its short-acting, & can be used w/o IV access. It has no analgesic properties, so must be combined w/ opiate for painful Tx. • Epidural analgesia: often used w/ ABD, anal & GI OP & procedures; open-heart & thoracic OP; orthopedic OP of LE. Pain meds—like an opiate, local aesthetic, or both—admin into the epidural space of the spinal canal, catheter is secured to their back w/ occlusive dressing. o Admin directly to nerves that transmit pain, so smaller dose is needed, also has fewer SE compared to systemic opiate admin. o RN care similar to PCA—continuous cardiac monitor & pulseOx; assess for pain relief, adverse effects (decreased RR), complications rt cath placement (slippage). SE same w/ opiates + sensory & motor block. o Assess dermatome/sensory-blockade level & motor responses Q4; avoid actions that could displace or put tension on the cath. o Report immediately to HCP [anesthesiologist]: displacement, bleeding, leakage of CSF, & hematoma.