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Pediatrics > Care of the Hospitalized Child and Pain > Flashcards

Care of the Hospitalized Child and Pain Flashcards

1
Q

Pain Assessment: Influencing Factors

A

age
developmental level
cause and nature of the pain
ability to express the pain

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2
Q

Types of Pain

A

acute
chronic
recurrent

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3
Q

Chronic Pain

A
  • pain that persists for 3 months or more

- pain that persist beyond expected period of healing

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4
Q

Recurrent Pain

A

episodic
recurs
ex) migraines, sickle cell pain, recurrent abdominal pain, limb pain

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5
Q

Pain Assessment: Components

A
  • onset of pain
  • pain duration/pattern
  • is current tx effective?
  • factors that aggravate or relieve the pain
  • other symptoms and complications concurrently felt
  • interference w/ the child’s mood, function, and interactions with family
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6
Q

Pain Assessment Tools

A

behavioral:
- infants to age 4

physiologic

self report:
-not valid for children younger than 4

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7
Q

Behavioral Pain Assessments

A
  • assessment of vocalization, facial expression, and body movements w/ specific tool
  • most reliable for short, sharp pain and in infants
  • less reliable for recurrent or chronic pain and in older children (may not correlate w/ child’s self-report of pain)
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8
Q

Behavioral Pain Assessment Tools

A
  • FLACC
  • FACES Pain Scales
  • Numeric Pain Ratings
  • Premature Infant Pain Profile (PIPP)
  • Neonatal Pain, Agitation, and Sedation Scale (NPASS)
  • Oucher Pain Scale
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9
Q

FLACC

A 
Face
Legs
Activity
Cry
Consolability

0-2 score for each

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10
Q

FACES Pain Scales

A

Wong-Baker FACES Pain Scale
-six cartoon faces

  • smiling face = no pain
  • tearful face = worst pain

child chooses a face that describes his/her pain

widely used in US

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11
Q

Numeric Pain Ratings

A

0-10 scale widely used

easy to use

for 8 years and older

little research for reliability and validity

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12
Q

Premature Infant Pain Profile (PIPP)

A
  • specifically developed for premature infants
  • gives higher pain score to infants w/ lower gestation age
  • gives higher pain score to blunted behavior response
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13
Q

Neonatal Pain, Agitation, and Sedation Scale (NPASS)

A

used in neonates from 23 weeks of gestation up to 100 days of age

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14
Q

Measuring Pain in Children w/ Communication and Cognitive Impairment

A

difficult to measure pain

high risk for inadequate tx of pain

NCCPC: non-communicating children’s pain checklist

PICIC: pain indicator for communicatively impaired children

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15
Q

Oucher Pain Scale

A
  • for 3-12 year olds
  • validated w/ african-american and caucasian children
  • hispanic version of APTT scale available for children/adolescents w/ cancer

uses body outline diagram of the APPT for non-english speaking children and adolescents

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16
Q

Cultural Barriers to Pain Tx

A
  • inadequate assessment of pain
  • concern about side effects and tolerance of analgesics
  • fear that pain means worse disease
  • reluctance to report pain
  • reluctance to take pain meds
  • lack of adherence to tx plan
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17
Q

Children w/ Chronic Illness and Complex Pain

A
  • difficult to isolate pain symptom from other symptoms

- rating pain does not always accurately convey to others how they really feel

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18
Q

Barriers to Pain Management

A
  • family issues and relationships
  • fears and concerns about addictions
  • lack of knowledge about pain
  • inappropriate use of pain meds
  • ineffective management of adverse effects from meds
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19
Q

Nonpharmacologic Pain Interventions

A
  • distraction
  • relaxation
  • guided imagery
  • cutaneous stimulation
  • heat or ice pack for older children
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20
Q

Nonpharmacologic Pain Interventions for Infants

A
  • containment
  • positioning
  • “non nutritive” sucking
  • kangaroo holding
  • sucrose
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21
Q

ComplementaryAnd Alternative Medicine (CAM)

A

diverse practice which is grouped into 5 classes:

  • biologically based: foods, special diets, herbal, vitamins
  • manipulative treatments: chiropractic, osteopathy, massage
  • energy based: reiki, magnetic treatment, pulsed fields
  • alternative medical systems: homeopathy, traditional Chinese medicine
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22
Q

Pharmacologic Management

A
  • non-opioids for mild to moderate pain (acetaminophen, NSAIDs)
  • opioids for moderate to severe pain (morphine, codeine, hydromorphone, fentanyl)
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23
Q

SE of Opiods

A
  • respiratory depression
  • constipation
  • pruritus
  • n/v
  • sedation
  • tolerance
  • physical dependence
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24
Q

Tolerance

A
  • dose must be increased to achieve the same effect
  • may develop after 10-21 days
  • Tx: increase dose, decrease duration between doses
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25
Q

Evaluation of Effectiveness of Pharmacologic and Nonpharmacologic Interventions

A
  • evaluate q15-30min after intervention
  • document findings
  • ongoing assessment
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26
Q

Consequences of Unrelieved Pain in Neonates

A

physiologic changes:

  • increased ICP, HR, RR, BP
  • decreased SaO2

behavioral changes:

  • muscle rigidity
  • facial expression
  • crying
  • withdrawal
  • sleeplessness
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27
Q

Normal Stressors for Children

A
  • potty training
  • puberty
  • starting school
  • birth of sibling
  • loss of a loved object
  • loss of a loved one
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28
Q

Patient and Family Centered Care (PFCC)

A
  • family is the child’s primary source of strength and support
  • hospitalization alters the parental role
  • nurses are role models and mentors for engaging parents in hospital in hospital routines and daily care that benefits the child
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29
Q

Why are children particularly vulnerable to illness and hospitalization?

A
  • illness and hospitalization constitute a major life crisis
  • stress represents change from the usual routine
  • usual coping mechanisms are inadequate to solve the problem
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30
Q

How children respond to illness and hospitalization depends on:

A
  • child’s coping abilities
  • temperament
  • past experiences
  • family support
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31
Q

Major stressors for infants/children/adolescents when hospitalized:

A
  1. Separation
  2. Loss of Control
  3. Bodily injury
32
Q

Infancy: Stage and Age

A

Trust vs Mistrust (0-1YO)

Separation

33
Q

Separation in Infants

A
  • pre-attachment: major reaction to illness and hospitalization are pain, immobilization, and change in normal routine
  • young infants react w/ crying, fussiness, decreased sleep, and loss of appetite

-attachment: by end of 4-6 months, major reaction occurs as a result of separation, should be avoided

34
Q

Toddler: Stage and Age

A

Time of Autonomy

12 months - 2 years

35
Q

Toddler: Causes of Main Reaction to Stress

A
  1. Separation
  2. Loss of Control
  3. Bodily Injury
36
Q

Separation in Toddlers

A

separation anxiety

  1. Protest: cries loudly, screams for mom/dad/caretaker, refuses attention from anyone else, inconsolable grief, acutely distressed
  2. Despair: crying stops, increasing hopelessness, less active, disinterested in toys or play or food, withdraws. Child looks lonely, isolated, depressed, child may regress.
  3. Detachment: superficially the child has adjusted to loss, becomes more interested in surroundings, plays w/ others, seems to form attachments, but when parent coms in - ignores parent, does not acknowledge, will not greet, keeps on playing
37
Q

Nursing Care During Separation Stages in Toddlers

A

protest: don’t leave alone, reassure
despair: spend time with, talk about family, don’t leave alone, TLC
detachment: help parents understand this stage, they need to give lots of TLC
* toddlers after separation may regress when parent returns

38
Q

Loss of Control in Toddlers

A
  • any restriction on newly acquired skills is a threat to sense or security
  • any alteration in routines and rituals
  • unfamiliar environment (new sounds, smells)
  • end result = regression, increased fear, fussiness, restlessness, change in sleep patterns, refusing to eat
39
Q

Bodily Injury and Pain in Toddlers

A
  • intrusive procedures are very anxiety producing
  • toddlers react to painless procedures just as intensely as painful procedures
  • toddlers remember painful procedures (Elamax Cream)
  • if toddlers c/o pain, take it seriously
40
Q

Preschool: Stage and Age

A

initiative stage
pre-operational
magical thinking

3-5 YO

41
Q

Separation in Preschool Age

A

can tolerate brief periods of separation from parents

  • are able to develop substitute trust in other significant adults
  • protest behaviors are often more subtle and passive (may withdraw, refuse to eat, cry silently, express anger through throwing toys and refusing to do self care activities)
42
Q

Loss of Control in Preschool Age

A

caused by:

  • physical restriction
  • altered routines
  • enforced dependency

cognitive level and magical thinking makes them feel out of control

  • fantasize that hospitalization may be a punishment
  • need reassurance that it is not their fault
43
Q

Bodily Injury and Pain in Preschool Age

A
  • body integrity poorly defined so intrusive procedures (whether painful or painless) are threatening
  • reacts to painful procedures much like toddlers
  • painless procedures are more tolerated
  • preschoolers may benefit from preparation before painful procedures
44
Q

Reaction to Pain in Preschool Age

A
  • aggression: push person away or lock themselves in a safe place
  • verbal response: “go away” or “I hate you”
  • dependency: clinging to parent

they need support, so let them act out

45
Q

Mutilation in Preschool Age

A

this is a huge fear at this age

loss of body part is very threatening

limited comprehension of body functioning and increases difficulty understanding how or why body parts are fixed

46
Q

School Age: Stage and Age

A

Industry
Concrete Operational
Past/Present/Future Time Oriented

6-13 YO

47
Q

Separation in School Age

A
  • better able to cope w/ separation, but need parental presence
  • middle and late school age children may react more to separation from their usual activities and friends than absence of parent
  • loneliness and boredom, depression
48
Q

Loss of Control in School Age

A
  • striving for independence and productivity
  • lessens their feeling of control and power
  • lack of privacy

give them back control:
-helping to choose schedule, assist w/ procedures, choose what to wear, choose their menu

49
Q

Bodily Injury and Pain in School Age

A
  • less concern w/ pain than w/ disability, uncertain recovery and death
  • know death is final
  • major fear is being told something is wrong with them
  • they take active interest in their health or illness
  • education works well w/ this age group
  • They want answers, so deal w/ injury and pain w/ factual information
  • Intrusive procedures are well tolerated, concerns for privacy
  • may deal w/ painful procedure by participating in the procedure
  • give some control “which arm would you like your shot in”
50
Q

Indirect Request for Support or Help in School Age

A

nonverbal cues:

  • half hearted “I’m fine”
  • lack of activity
  • social isolation
51
Q

Adolescence: Stage and Age

A

identity
formal operation

over 13 YO

52
Q

Main threats in Adolescence

A
  1. Loss of control - especially in terms of identity
  2. Fear of altered body image
  3. Separation - primarily from members of their support group
53
Q

Separation in Adolescence

A
  • loss of peer group contact may be great emotional threat
  • teens greatly benefit from other teens while in the hospital
  • may welcome separation from parents
54
Q

Loss of Control in Adolescence

A
  • illness and hospitalization separates them from peers
  • lack of physical activity
  • pt role fosters dependence and depersonalization
  • due to these items, teens may reject care, be uncooperative, withdraw, show anger/frustration, be aggressive
55
Q

Bodily Injury and Pain in Adolescence

A
  • biggest stressor for teens = fear of being different from one’s peers
  • reaction to pain is generally much more controlled and physical resistance and aggression are unusual at this time
56
Q

Nursing Interventions to Minimize the Stressors of Illness and Hospitalization

A
  • realize the stressors of each age period
  • accept the behavioral reactions
  • provide support and assistance needed for successful coping
  • teach parents about developmental needs, reactions to illness and hospitalizations
57
Q

How to Prevent or Minimize Separation

A
  • primary nursing
  • encourage parents to participate in the planning and carrying out of the child’s care
  • provide options about participation, may need a rest or break
  • assess the situation and provide support
  • help families determine how to best meet the needs of the whole family
  • picture of family
  • recording of family voices reading or telling stories
  • help parents separate (no sneaking out)
  • help parents explain separation and when they will be back
  • encourage frequent parental visits
  • explain to parents how the child acted after separation
  • create familiar surroundings
  • help children maintain usual contacts and routines
  • talk to children about their feelings
  • encourage playroom
58
Q

How to Minimize Loss of Control

A
  • increase mobilization by carriage, stroller, wagon, wheelchair
  • maintain consistent and normalized daily schedule/routine
  • encourage choice in schedule
  • keep busy
  • encourage independence and self care (wear street clothes)
  • provide developmentally appropriate activities
59
Q

How to Decrease Bodily Injury and Pain

A
  • prepare children for procedures (simple honest explanations)
  • 3YO+ use dolls, pictures, verbal and demonstrate
  • very young children: perform procedures as quick as possible, maintaining parent/child contact, distraction does very little, anticipatory teaching only often increases fears
  • give permission to express pain
  • use band-aid
  • assess pain and take measures to relieve pain
  • play to decrease anxiety and increase coping
  • use tx room for painful or invasive procedures
  • divisional activities
60
Q

Following Hospitalization

A

under 4YO, will demonstration effects of hospitalization including:

  • aloofness
  • increased fears
  • oppose any separation
  • new fears
  • nightmares
  • regression
  • enuresis
  • withdrawal and shyness
  • temper tantrums
  • anger at parents

may last days to 1 month

61
Q

Parent Reaction when a child is hospitalized

A
  • guilt
  • ashamed
  • left out
  • self pity
  • grief
  • anxiety
  • resentment
  • fear of replacement
  • helplessness
62
Q

Sibling Response to Hospitalized Child

A
  • behavior changes: loneliness, fears, anger, resentment, jealousy, guilt
  • parents need to know that siblings are affected
  • siblings need to know that their feelings are common
  • siblings need to be incorporated in the plan of care, teaching plan
63
Q

Care of Infants, Children, and Adolescents during Pre-Op Period

A

children need to be prepared psychologically

help deal w/ common fears:

  • under 4: separation
  • 4-7: punishment and mutilation
  • 8-13: reality and death
  • teens: being different
64
Q

What to Teach Pre-Op and Post-Op

A

pre-op: NPO, procedures, meds

post-op: NG, catheter, IV, PCA, ambulation, IS, C&DB

65
Q

Timeframe for teaching about surgery

A
  • older child and teen: 1 week before
  • 4-7: 1-2 days before
  • 3-4: 1 day before
  • 2 and under: morning of or just before

always include parents in teaching

66
Q

NPO in Peds

A
  • after midnight: no food, milk, milk products or non-clear juice
  • breastfed: up to 4 hours before
  • clear fluids: until 2 hours before
  • push fluids the night before
67
Q

During Surgery

A
  • anesthesia: rapid RR maintained
  • blood loss of 10% can lead to shock
  • fluid balance: infants dehydrate quickly, strict I&O’s
68
Q

Causes of Temp Increase

A
  • infection
  • excess blankets/coverings
  • warm room
  • malignant hyperthermia
69
Q

Causes of Increased HR

A
  • increased temp
  • pain
  • shock
  • meds
70
Q

Causes of Decreased BP

A
  • shock
  • opioids
  • vasodilating meds
71
Q

Causes of Increased RR

A
  • increased temp
  • pain
  • increased fluid volume
  • respiratory distress
72
Q

Causes of Temp Decrease

A
  • cool room
  • muscle relaxants
  • infusion of cool fluids
  • sepsis (infants)
  • shock
73
Q

Causes of Decreased HR

A
  • hypoxia
  • increased ICP
  • meds
74
Q

Causes of Increased BP

A
  • increased ICP
  • pain
  • meds
  • increased fluid volume
75
Q

Causes of Decreased RR

A
  • opioids

- anesthetics

76
Q

Post-op Care to Reduce the Risk of Infection

A
  • diaper below incision line (if abdominal)
  • reinforce dressing until changed by surgery for the first time
  • frequent VS
  • assess for unusual drainage, discharge
77
Q

Post-Op

A

IV hydration and feeding:

  • NPO until awake and alert
  • start w/ sips and chips
  • strick I&Os
  • weight is best judge of I&O
  • prevent complications
  • ambulate early
  • discharge instructions

Pediatrics (14 decks)

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