Highlights of Chapter 21 and 22

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Highlights of Chapter 21 and 22

• The Childs Experience and
• Adapting to Pediatric Care

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Preparing a Child for a Procedure

• Box 21.1 Page 464
• Infants
• Toddlers
• School Age
• Teen
• Remember the principle of regression in ALL!

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Fear Questions

• What are toddlers most afraid of in a
  hospitalization? 474
• What are pre schoolers most afraid of in a
  hospitalization? 476
• How would one help a pre schooler work through
  their fear?
• What is a school age childs primary concern?
• What is a teenagers primary concern? 476

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Separation Anxiety

• 6 months up
• Most pronounced in toddler
• Protest
• Despair
• Denial or Detachment
• Prolonged detachmentdisruption of bonding
• Principle of reverting back to previous stage

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Separation Anxiety Questions

• At what age is separation anxiety at its peak?
  465
• When a nurse or parent leaves a toddler or
  preschooler how would they explain when they will
  return?

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Pain in Children

• Under treated due to
• Misconceptions about pain
• Misconceptions about opioid use
• Lack of awareness of detrimental affects of pain
• Verbal ability of children

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Developmental Expectations of Children in
communicating pain

• All infants and children experience pain
• Newborn and early childhood pain communicated
  through physical and behavioral response
• Pain words emerge at 18-24 months
• Description and gross indication of intensity by
  3-5
• Able to give better description of intensity by
  age 7 due to ability to rank, serialize

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QUEST

• Question the child.
• Use pain rating scales.
• Evaluate behavior and physiologic changes.
• Secure parents' involvement.
• Take cause of pain into account.
• Take action and evaluate results.

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Physiological Responses to Pain

• Increased BP, respirations, pulse
• Flushing of the skin
• Sweating
• Restlessness
• Decreased O2 sats
• Dilation of pupils

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WEBSURFING ON PAIN

• http//www.childcancerpain.org/frameset.cfm?conten
  tassess01
• Lets take a couple of minutes and look at this
  site.

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A preschool pain rating scale
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FLACC Scale
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References

• The FLACC pain scale and Riley pain scale can be
  found at this website
• http//www.childcancerpain.org/frameset.cfm?conten
  tassess01

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Pediatric Pain Medications

• Non Opioid
• Tylenol, Ibuprofen
• Opioid
• Codeine, hydrocodone, meperidine, morphine
  oxycodone, fentanyl
• Adjunctive
• Tricyclic antidepressents in chronic pain
• Benzodiazepines to reduce anxiety and produce
  amnesia

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Childrens TylenolKnow the difference
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Infant Drops

• Tylenol infant drops come in a concentration of
  160 mg/1.6 ml
• The dropper is a .8 ml dropper for 80 mgs
• Dose 15 mg/kg/dose

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Childrens Tylenol Suspension

• Tylenol suspension 160mg/5 mls
• Dose is 15 mg/kg q4h for a maximum of 5 doses a
  day

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Childrens IbuprofenKnow the difference
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Childrens Ibuprofen Syrup

• Advil (Ibuprofen) suspension or syrup 100 mg/5
  ml
• 8-10 mg/kg/6hrs
• Do not exceed 40 mg/kg/day (4 doses)

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Ibuprofen Pediatric or Infant Drops

• 50 mg/1.25 ml
• Dose 8-10 mg/kg/6h
• Do not exceed 40 mg/kg/day

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Four math problems

• 12 kg infant receiving Tylenol Suspension at dose
  in previous slide how much?
• 6 kg infant receiving Tylenol Infant Drops at
  dose in previous slide how much
• 15 kg infant receiving Ibuprofen Suspension at
  dose in previous slide how much
• 5 kg infant receiving Ibupofen Pediatric Drops at
  dose in previous slide how much

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Cultural Sensitivity

• Page 470
• Be yourself
• Be aware that people express themselves
  differently
• Always go on the principle of good will and intent

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The Hospitalized Infant

• Frustration in their needs not being met.
• Do not expect them to develop new habits
• Emphasis in assisting with the
• Parent/infant attachment
• Sensorimotor opportunities
• Gentle
• Cuddle and comfort
• Liberal visiting policies
• Consistency

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The Hospitalized Toddler

• Separation anxiety at its peak 474
• Box 21-2 Nursing Goals
• Transitional objects
• Restraints and autonomy vs. shame and doubt
• Distractions
• Choice when able

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The Hospitalized Preschooler

• Feelings of guilt
• Very afraid of bodily harm, mutilation and
  invasive procedures
• Praise is important
• Role playing through experiences
• See box 21.3 page 476

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The Hospitalized School Ager

• More able to endure the separation
• Force dependency is the big issue
• Loss of control and security
• Need to feel grown up and have independence
• Education must continue
• Scheduling around important routine in childs
  life
• See nursing tip page 477

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The Hospitalized Adolescent

• Loss of control
• Dependence/independence issues
• Threat to identity
• Response
• Withdrawal
• Non compliance
• Anger

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Early, Middle, Late Adolescence

• Early
• Threat to body image more than forced dependence
• Middle
• Sex appeal and sex role expectations
• Relinquish of control is also a issue
• Late
• More concerned with the interference in life

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Chapter 22 Admission

• Identification
• Safety Dos and Donts page 482
• Holding an infant watch the head
• Mummy restraint when necessary

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Pediatric Adaptationstympanic temperature

• Down and back under three
• Slightly up and back over three.
• Aim it at the opposite eye brow
• Use only in infants over three months

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Head circumference measurement

• Tape measure around the head, slightly above the
  eyebrows and ears and around the occipital
  prominence of the skull

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Body influences on medication in infants and
children

• Gastrointestinal
• infants have a lower level of acid content in the
  stomach up to age two
• Children under five may have a more rapid
  intestinal transit time
• Lower pancreatic enzymes
• New book 495 old book 508

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Body influences on medication in infants and
children

• Integumentary
• Thin stratum corneum allows topicals to be
  absorbed at a greater amount
• Larger skin surface area also increases
  absorption
• Diapers are an occlusive dressing and may
  increase absorption of medications

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Body influences on medication in infants and
children

• Parenteral Medications
• Slower absorption of IM in young infant
• In neonates medication may pass the blood brain
  barrier more easily than in older children,
  therefore be more guarded with regards to
  respiratory depression.

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Body influences on medication in infants and
children

• Liver immaturity until ages 2-4 therefore drugs
  metabolized by liver metabolize more slowly
• Medications given at frequent intervals may
  result in toxic levels and responses

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Body influences on medication in infants and
children

• Immature kidney function prevents effective
  excretion of drugs from infants under a year of
  age

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Fever and hyperthermia

• Page 488 new book
• Fever hypothalamus has raised the body
  temperature set point as a respond to bacteria or
  toxins in conjunction with bodys prostaglandins
• Hyperthermia increase in core body temperature
  ocurring with CNS impairment or overheating.

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Body Surface Area

• A method to accurately dose a drug for a
  pediatric patient
• Usually used in highly toxic drugs
• Used in converting adult doses to pediatric doses
• You will probably not see this method in your
  career unless you go into oncology
• BSA/1.7 X adult dose child dose

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Pediatric dosing Mg/kg

• Pablo Martinez, a 5-year-old boy, is diagnosed
  with bacterial meningitis. He weighs 19 kgs.
• The MD orders cefuroxime IM 950mg q8h
• Dosage is 200-240 mg/kg/day divided q 6 or 8
• Is the above dose appropriate?

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Fun drug test to take

• http//classes.kumc.edu/son/nurs420/clinical/basic
  _review.htmPediatric20calculations
• http//classes.kumc.edu/son/nurs420/clinical/basic
  _practice_.htm

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Oral Medication Points

• Cherry syrup or jelly to mix not other nutritious
  food
• Syringe down the side of the mouth
• Position on page 500/513 good way to hold
• Bib yourself!
• Do not place in bottle with juice or water

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IM injections

• Page 515 old book 502 new book
• Discuss sites, size of needle and amounts

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Nursing Assessment for IV

• Monitor IV site hourly
• Flow rate
• Swelling at needle site
• Low volume in IV bag/burette
• Pain or redness at insertion site
• Moisture at or around site
• Accurate I O

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Tracheostomy Suctioning Points

• Suction catheter ½ size of tube
• Sterile procedure
• Suction applied only when withdrawn
• Tube rotated while withdrawing
• Saline may be added before suctioning
• Do not suction more than 10 seconds
• Reoxygenation is important
• Limit suctioning to the length of the tracheotomy
  tube
• Clear catheter with sterile water in between
  insertions
• Discard catheter when done

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Tracheostomy sizing charts
Bivona Bivona Bivona Bivona Bivona Shiley Shiley Shiley Shiley Shiley
Size I.D. O.D. Length mm Suction Catheter Size I.D. O.D. Length mm Suction Catheter
2.5 NEO 2.5 4.0 30 6          
3.0 NEO  3.0 4.7 32 6 or 8 3.0 NEO 3.0 4.5 30 6
3.5 NEO 3.5 5.3 34 6 or 8 3.5 NEO 3.5 5.2 32 6 or 8
4.0 NEO 4.0 6.0 36 6 or 8 4.0 NEO 4.0 5.9 34 6 or 8
          4.5 NEO 4.5 6.5 36 6 or 8
2.5 PED 2.5 4.0 38 6          
3.0 PED 3.0 4.7 39 6 or 8 3.0 PED 3.0 4.5 39 6
3.5 PED 3.5 5.3 40 6 or 8 3.5 PED 3.5 5.2 40 6 or 8
4.0 PED 4.0 6.0 41 6 or 8 4.0 PED 4.0 5.9 41 6 or 8
4.5 PED 4.5 6.7 42 6 or 8 4.5 PED 4.5 6.5 42 6 or 8
5.0 PED 5.0 7.3 44 8 or 10 5.0 PED 5.0 7.1 44 8 or 10
5.5 PED 5.5 8.0 46 10 or 12 5.5 PED 5.5 7.7 46 10 or 12
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Great websites

• http//www.tracheostomy.com/care/suction.htm
• For sizing of Trachs
• http//www.tracheostomy.com/resources/more/table.h
  tm

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Gastrostomy Tube Issues

• Securing
• Cleaning
• Bathing
• Venting/Burping
• Tube displacement
• Leakage
• Skin Breakdown
• Box 22-5 (old) 22-9 new 511

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