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Basics of pediatric care chapter 55

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Basics of pediatric care chapter 55 Presentation by: Leslie Lehmkuhl, RN Family-centered care Pediatric nursing involves working with the child and the family ... – PowerPoint PPT presentation

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Title: Basics of pediatric care chapter 55


1
Basics of pediatric care chapter 55

Presentation by Leslie Lehmkuhl, RN
2
Family-centered care
  • Pediatric nursing involves working with the child
    and the family
  • Family-centered care is a philosophy that
    includes family contribution and involvement
  • Nurses recognize the importance of family
    centered care
  • Because children are different than adults POC is
    always guided by the developmental level of the
    child

3
Pediatric assessment
  • Nurse assesses the following areas physical,
    emotional, cognitive, developmental level,
  • Educational needs, developmental needs,
    socialization, dynamics of the family
  • Neonate birth to 28 days
  • Infant 1 month to 1 year
  • Toddler 12 mos to 3 yrs
  • Preschool 3-6 years
  • School age 6-10 years
  • Preadolescent 10-12 yrs
  • Adolescent 13-20 years

4
Terms
  • Assent
  • Child life specialist
  • Emancipated minor
  • Family centered care
  • Infant mortality rate
  • Standard of care
  • WIC supplemental food program for women,
    infants, children
  • Denver developmental and growth screening test ii
  • Developmental milestones
  • Egocentrism
  • Object permanence

5
Admission
  • Preparation for planned admission is important
    for a child/caretakers
  • Visit playroom, play with toys, read books, see
    videos, talk to staff, ask questions, see
    environment
  • Information regarding child nutrition,
    allergies, routines, fears, eating habits, sleep
    habits (data is used to identify Nx Dx est.
    POC)
  • Reaction to pain, prior medication, play, ID band
  • Rooming in available
  • Lab tests
  • Greet by name
  • Treatments
  • Side rails/crib
  • Diet and/or NPO

6
Preoperative
  • Play therapy arts, crafts, toys, socialization
  • Parent present- reduces fear and anxiety
  • Use drawings, puppets, models, dolls, handle
    stethoscope, dressings, surgical mask
  • Bring to hospital favorite toy or article.

7
Surgery
  • Parent may accompany child to operating room
  • Child may take favorite toy to operating room
  • lt18 years parents/legal guardians must give
    informed consent.
  • Child selects favorite gas (anesthesia).
    Chocolate, watermelon..
  • Parents called when child brought to recovery
    room. may be with child

8
Explanations
  • Infant- explanations given to caregiver
  • Toddler- use dolls, puppets, explain 3 days prior
    to surgery
  • Preschool- books, art, video explain 1 week in
    advance
  • School age- brief explanation, tour, video,
    method for comfort

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

10
Fears/Anxiety
  • Unknown- fear of environment, routine change,
    different people in room
  • Separation anxiety (6-30 months)
  • When child is hospitalized and parents are not
    able to visit, the child may experience anxiety
  • Stages protest, despair, detachment

11
Separation anxiety
  • Protest child cries, rejects others
  • Despair child feels hopeless, becomes quiet and
    withdrawn
  • Provide the child with favorite toy or blanket.
  • Detachment child becomes interested in
    environment, plays ignores parents..Coping
    mechanism of child to prevent emotional pain of
    separation

12
Fears/Shame
  • Preschool and school age may have loss of
    independence and loss of self care
  • The child needs to have some control
  • Shame/guilt preschool may believe he/she did
    something to cause the illness or believe
    thatIllness is a punishment
  • Pain and mutilation infants and toddlers view
    intrusion of body as painful
  • Loss of control toddlers need rituals, routines
    at this time.
  • May have temper tantrums due to frustration
  • Toddlers need rituals for feeding, bedtime,
    toileting

13
Fears
  • Anger related to loss of control, loss of
    friends, pain
  • Methods used for release punching bag, clay,
    painting
  • Regression common during and after
    hospitalization
  • This is normal at this time

14
Post operative assessment
  • ABC
  • Head to toe
  • LOC, speech, VS, IV fluids, dressing, drains,
    voiding, pain, breath sounds, nausea, vomiting,
  • Bowel function/bowel sounds, extremity movement
  • Assess for dehydration, shock, infection

15
Pain/ Discharge
  • IV medication may be given then oral medication
  • Discharge planning begins at admission
  • Discharge planner may be needed
  • Social service may be used for referrals
  • Teach that child may develop behavior changes or
    regression (e.g. withdrawal, aggression,
    demanding bx)

16
Physical assessment
  • Prepare parents and child for the exam
  • Assess each system related to age of the child
  • Know the normally for age groups to detect the
    abnormally
  • Sequence head to toe
  • Growth charts are used to compare child to
    national average
  • Normal ranges-5-95

17
Physical Assessment
  • Length
  • Infant to lt2 years measure from top of head to
    heel
  • gt 2 years standing height

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

19
Physical assessment
  • For older children weight done in street
    clothes..shoes off, heavy clothing off usually ht
    and wt are the only measurements taken
  • Children under 2 years Measure height, weight,
    head circumference, chest circumference,
    abdominal circumference
  • For the first year, head circumference is larger
    than chest circumference
  • Head- measure above brow, above pinna, around
    occipital prominence
  • Chest- measure at nipple line
  • Abdominal- measure at umbilicus

20
Physical assessment
  • Color variations
  • Melanin reflects the skin color
  • Vitiligopatches of depigmentation
  • Jaundicedark skinned infants, jaundice may
    appear darker
  • Cyanosisdark skinned infants, cyanosis may
    appear black

21
Physical assessment
  • Carotenemiaorange to yellow color of skin
  • Pallor
  • Erythemadiffusely red
  • Dark skinned infants may be dusky red to violet

22
Vital signs
  • Infants- count resp, pulse, (both for 1 min)
  • Thermometers used in peds
  • Electronic, digital, tympanic
  • Axiliary temp used for newborn, premature,
    children under 3 years
  • Oral temp for children over 6 years old

lt3
gt6
23
Vital signs
  • Rectal temp used when no other route available
  • Rectal temp not used for
  • Preterm, immunosuppressed, rectal surgery, GI
    disorders as bleeding, diarrhea
  • Lubricated, rectal thermometer not inserted more
    than 2.5 cm

24
Heart rate
  • Apical pulse done on children under 3 years,
    children with heart
  • Disease, or irregular heart rhythm
  • Stethoscope placed on left midclavicular line-5th
    intercostal space
  • Over 3 years may use radial pulse

25
Respirations
  • Infant- abdominal respirations
  • Newborns are nose breathers for 3-4 weeks and
    then can breathe through the mouth
  • Newborn 30-50/min
  • 6-12 months 20-40/min
  • 3yr 20-30/min
  • 6yr 16-22/min

26
Blood Pressure
  • Bladder of the cuff is 2/3 the width of the limb
  • (if cuff is too large BP reading will be low,
    if too small the BP reading will be high)
  • Sites upper arm, wrist, leg or foot
  • Arteries used radial, brachial, popliteal,
    posterior tibial
  • Preschool/school age explain steps may feel
    like a hug on the arm

27
Sites for Measuring Blood Pressure.
28
Denver Developmental Screening Test II
  • Developmental assessment of children from birth
    to 6 years
  • 125 items
  • Areas personal social
  • Fine motor skills eye hand coordination
  • Language understanding
  • Large motor skills jumping

29
Denver Developmental
  • Evaluation
  • Observation of child
  • Asking parents questions
  • Child performing tasks
  • This is not an IQ test
  • Detects developmental delays and allows for
    intervention

30
Safety restraints
  • Types mittens, ankle, wrist, vest, elbow, mummy
  • Applied for child safety
  • Mittens-to prevent pulling at iv tubes, gt,
    dressings
  • Elbow- prevents flexion of elbow
  • Use after surgery for cleft palate, cleft lip,
    head or neck surgery, iv infusion

31
Restraints
  • Ankle prevents falls/climbing out of crib
  • Vest prevents falls/getting out of bed, crib,
    high chair
  • Mummy used for short time for procedures to
    reduce movement
  • May be used when IV needs to be started

32
Figure 30-10
(From Lowdermilk, D.L., Perry, S., Bobak, I.M.
1997. Maternity womens health care. 6th
ed.. St. Louis Mosby.)
Mummy restraint.
33
Restraints
  • Nursing remove restraint q2h and exercise limbs,
    check sites for irritation
  • Document color, warmth, capillary refill of
    extremities
  • Check restraints in 15 min after application and
    then q1h

34
Urine specimen
  • Tests blood, protein, glucose, bilirubin, drugs,
    metals, electrolytes, infection, ph, specific
    gravity, hormones
  • Infant plastic collection bag
  • Female- apply skin prep and apply bag around
    labia
  • Male- apply skin prep and apply bag around
    scrotum

35
Figure 30-12
Alcohol pad
Application of a urine collection bag.
(From Wong D.L., Perry, S.E., Hockenberry-Eaton,
M.J. 2002. Maternal-child nursing care. 2nd
ed.. St. Louis Mosby.)
36
Urine Collection
  • Cut a slit in the diaper and pull the bag
    through. Will see when child voids
  • Older child- clean catch
  • Male - have child clean head of penis x3,
    urinate a small amount, stop voiding, void in
    container, empty bladder in toilet, send specimen
    to lab
  • Stroke the child's abd w/alcohol prep and fanning
    dry often stimulates urination.

37
Urine specimen
  • Female - have child clean sides of labia, clean
    meatus,(front to back) urinate a small amount,
    stop voiding, void in container, empty bladder in
    toilet, send specimen to lab
  • Document in nursing notes/flow sheet

38
Stool specimen
  • Test for fat, blood, bacteria, parasites
  • Infant obtain from diaper and place in container
  • Older child use bedpan, or bedside commode
    place specimen in container and send to lab

39
Blood specimen
  • Jugular- head and shoulders extended at edge of
    table
  • Mummy child
  • Physician draws the sample
  • Femoral - child in froglike position
  • On back may mummy child
  • Physician draws the sample

40
Jugular Venipuncture
41
Mummy Restraint
42
Femoral Puncture
43
Lumbar puncture
  • Child in sitting or side lying position
  • Consent needed
  • Side lying- nurse has one hand on back of neck
    and one hand behind the knees of the child
  • Write down the pressure, color and number of
    samples obtained

44
A, Modified side-lying position for lumbar
puncture. B, Older child in side-lying position
45
Intake and output
  • Infant- weigh a dry diaper
  • Weigh the damp diaper and subtract the weight of
    the dry diaper
  • 1mg1ml of urine
  • Pediatric fluids include jello, gatorade,
    pedialyte, flavored ice, sweetened tea, ice
    cream,
  • all children are on io in the hospitals unless
    stated otherwise

46
Medication
  • Physiological differences of the pediatric
    client
  • Absorption child has reduced gastric acidity
  • Gastric acidity reaches adult level at 3 years
  • Topical medication is absorbed faster due to
    thinner skin and large surface area

47
Medication
  • Intramuscular absorption varies due to peripheral
    circulation
  • Decreased gastric motility reduces medication
    absorption
  • Distribution- total body water content is higher
    in infants and children
  • Protein binding is less due to immature liver

48
Medication
  • Blood brain barrier is immature and more drugs
    enter the brain
  • Metabolism- metabolic rate is higher in children
    2-6 years
  • Microsomial enzymes are less to an immature liver
  • Elimination- glomerular filtration is less due
    to an immature kidney

49
Medication
  • Pediatric doses calculated by
  • Mg/kg/day may give divided doses
  • Wt is the most common and reliable method to
    calculate drug administration.
  • Body surface area
  • Oral meds preferred route
  • Age birth to 3 months give med before meals when
    child is hungry
  • semi-reclining position

50
Medication
  • Methods nipple, dropper that is calibrated,
    syringe without a needle, spoon, plastic cup
  • Angle syringe toward the cheek and give slowly
  • Allow child to sit on parents lap
  • Do not force child to take med, put medication
    in formula or milk

51
OralMedsAdmin
Position the child in a semi-reclining position
52
Medication
  • Bitter medication may use ice in mouth for a few
    minutes before taking med
  • Some medications may be crushed and mixed with a
    sweet syrup
  • Suppository use little finger to insert med for
    children under 3 years

53
Medication
  • Intramuscular- vastus lateralis site for
    children under 3 years
  • If the child is over 3 years and was walking for
    over a year, the gluteal sites may be used
  • Dorsal gluteal- child on abdomen with toes
    pointed inward
  • Use distraction- blowing bubbles, stroke skin
    before, during injection

54
IV Medication
  • IV has the least variation in absorption
  • Methods IV bolus, soluset, syringe pump, central
    venous access site, saline lock, percutaneous
    implanted catheter, implanted venous device

55
Medication
  • All IV fluids administered by a pump
  • Tubing 60-100/gtt/ml
  • IV site selected to not limit activity, not on
    dominant side, smallest gauge needed
  • The IV site should be checked every hour.

56
Medication
  • Deltoid site not used for children under 18
    months as the site is not developed until
    adolesence
  • Subcutaneous needle length ranges from 3/8 to 5/8
    inch

57
Medication
  • Otic
  • Child is on the side with the affected ear up
  • Clean ear as needed
  • Under 8 years- pull pinna back and down
  • Over 8 years- pull pinna back and up

58
Safety
  • Primary focus of Nursing care is child safety and
    protection..
  • Hospitals are concerned with choking and falls
  • Adult must be present when child is eating
  • Key locks on doors for security
  • Code purple is child abduction

59
Medication safety
  • Do not disguise medication in food, formula
  • Talk about medicine as candy
  • Children will know medicine from candy be
    honest
  • Do keep medicines in a locked cabinet
  • Teach that herbal medication may not be safe for
    children

60
Dying child
  • Gentle emotional and physical care to child and
    family
  • Anticipate grieving know stages of grieving
  • Infants and toddlers- have no clear
    understanding of death
  • 3-5 years- death may be a sleeplike state
    interchangable with life..

61
Dying child
  • School age- understand that death is final
  • Adolescent- have an understanding of death
  • Parents may fear what death may be like
  • Children may fear dying alone and fear pain

62
Dying child
  • Child- encourage the child to talk about their
    feelings
  • Encourage drawing, painting, writing to express
    feelings
  • Siblings- may have anticipatory grief may
    resent the attention given to the dying child
  • Need to included in care of dying child and to
    express feelings

63
Support
  • Nurse needs support from peers
  • Needs empathy, confidence, manage own stress
  • Sources of support for the family support
    groups, hospice service, American Cancer Society,
  • Home health, relatives, friends,
  • Religion
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