Module 1: Caring Interventions Flashcards
What to consider for the child ?
-Age, past experiences, perceptions and cognitive development.Is illness their fault? A punishment?
Parental consideration:
-Presence, preparation, fear, anxiety about condition, illness
-Parent presence- altered family roles
Preparation of the child:
-Explanation of procedure, visited hospital, development level
-Coping skills of child and family separation, despair, detachment, loss of control, regression
Psychological benefits:
-Pain management, distraction
Nurse Role in Communicating to Children and Adolscents
-Appropriate communication, developmental, eye level, vocabulary
-Allow children time to feel comfortable, use play
-Avoid sudden rapid movements and advances especially for younger children
-Talk to parents first with younger child to encourage trust
-Communicate with dolls, puppets, and stuffed animals before questioning the child directly
-Offer choices only when a choice exists
-Use simple words and a quiet voice
-Be honest
-Consider the timing of education
-Expect success and cooperation
-Consider talking to older children and adolescents alone (READ NOTES)
What should the nurse do when communicating with adolescents?
-establish relationships,
-give undivided attention
-encourage them to share their feelings
-show respect
-promote privacy
-avoid being judgmental
- set a good role model.
What are words the nurse should not say to the child?
-shot or bee sting
-Deaden ( make noise less intense)
-Take your blood pressure
-Stool
- Test
553-557 - for more information
Types of play techniques for procedures
-Role play before
-Magic wand
What is the Play technique for Fluid intake?
crazy straws, decorating cups
What is Play techniques for deep breathing?
-bubbles
-Three little pigs
What is Play techniques for Range of Motions?
-Wii ( game)
-Bean bags
-basketball
-velcro darts
What is play techniques for Medication?
Collection of syringes
What is play techniques for ambulation?
-push toys for toddlers
-parades
What is play techniques for hospital Play?
Anything
-crafts
-cars
-art
-video
-dolls
Who should the nurse measure input and output on ?
-Infants less than a year should be on strict intake and output
-Any child losing fluid through NG, stomas, sweat, drainage tubes
-Children on IV therapy
-Children who just had a recent surgery.
Children with medical diagnoses such as that are affected by fluid fluctuations-
Examples- Respiratory, Cardiac, Endocrine-Others??
Measuring output:
How do you check the output on infants?
Zero the scale with a dry diaper and weigh the diaper
Mildly dehydrated child requires ______ Therapy using small amounts of fluid that contains electrolytes
oral rehydration
Severe dehydration cases of a sick child will need_____ Rehydration.
IV
How to notice a sick child?
Feeding- Look at feedings
Fluids- Look at fluids
Fever- Hyperpyrexia-38 or 38.5 ( 100.4-101.3)
Acetaminophen- 10-15 mg/kg q 4
Ibuprofen- 5-10 mg/kg q 6
Hydration
Call for temp for continued elevated fever-40-40.6,
What is the temp for a sick child who has a fever?
38.0 -38.5 C ( Hyperpyrexia)
How to treat a sick child with a fever?
-Acetaminophen: 10-15 mg/kg q 4
Ibuprofen-:5-10 mg/kg q 6
Hydration
Call for temp for continued elevated fever-40-40.6,
What are considered restraints for a child?
-Mummy
-Swaddle
-Distraction
-Arm boards – IV House
-Elbow restraints
-Mittens
-Stockinettes
-Crib tops
-Side Rails
Specimen collection for specific procedures
- Mom’s lap
-Therapeutic Holding
-Lumbar puncture: Flexed sitting, side lying, headaches less common in children
-Bone Marrow- posterior iliac crest, give analgesia
Heel stick - stick the side of the heel
Types of Oxygen Therapy in Peds used
-Nose breathers-BNC, high flow ( peds breathe through their nose)
-Masks
-Humidity ( Oxygen almost always requires humidity)
-Cool air
-Ventilators
-Tracheostomies
Type of suctions used for children
-bulb ( nose pump)
-Little suckers
-Nasal Oral
How should the nurse care for skin/wound prevention?
-Do not make assumptions that parents are bathing the child
-Keep perineal area dry and protected
-Use caution with tape
-Change electrode and pulse oximeter sites frequently( every 4 hours)
Pressure ulcers are usually from medical devices-
Nursing action would be to: _________
-turn the pt every 2 hours or as needed based on order.
- make sure all tubes and chords are removed away from the pt body.
- Change pulse Ox probes and Assess skin sites
Surgical Consideration of the Child
-NPO- can have clear liquids after >2 hours,
-hours for breast milk >4 hours
- infant formula >6 hours before procedure (Look at the hospital’s policy. It may depend on age.)
- kids body can not go to long w/o fluids
-Parent’s presence in holding areas: sedation induction and recovery
-Pain management- the nurse needs to stay ahead, watch dosage
-Slow increase in diet- the nurse assesses bowel sounds
-Assess for urinary retention
-Remember changes occur quickly with children- greater percentage of body is water.
What are reasons that require a child to have alternative feedings?
-Structural, functional or malabsorption
-Gastrochesis ( birth defect, where there is a hole in the abdominal wall beside the belly button, gut is outside the body
-Short gut
FTT-Failure to Thrive ( a child weight is significantly below that of other children)
-GERD-Gastroesophageal Reflux Disease
-TEF- (malformations of trachea and esophagus)
-Nutritional supplements- CF, Anorexia
what are some tubes that is used for nutrition?
-Oral or nasogastric lavage
-Gastrostomy- MicKey Tube
-Jejunostomy
Steps for Gavage Feeding
-insert 5 or 8 French
-Always check residual as directed.
-Check placement by pH, X-ray, Measure for placement
-Feed over prescribed time while maintaining position.
-X-ray is the gold star- but not appropriate for repeated checks.
How to improve Absoprtion of feeds for a child
-Use a pacifier during alternative feeds
-Nonnutritive sucking improves digestion
-Quiet, calm environment
-Consistent feeding techniques by caregivers/family members
What are nine rules for giving medication to pediatrics?
-Do not give a child a choice of the medication.
-Allow choices the child can have some control over
-Do not lie, saying it won’t hurt or taste bad
-Give brief explanations about the meds
-Tell the child is ok to be scared.
- Always include the child when talking to the parents during med administration.
-Be confident and positive when approaching the child.
-The younger the child the shorter time between explanations and administration.
-Involve the parent when giving meds
How is renal function different in children ?
-Renal function in infants:
-Newborn function is very immature
-Medicines can remain in the system longer.
Differences in children’s (Liver Size)
Liver size in toddler, preschool are proportionally large, using up the medications rapidly
Differences in chidren ( GI)
GI-Children’s GI system have differences in motility, acidity and enzymes.
Differences in Children ( Water)
The amount of water in the body
Differences in Children ( Calculation)
Calculations: per weight in kg and meter squared
-mg/kg: (1 mg/1 kg)X \_\_\_ kg=dose mg -mg X kg= dose mg
Medication Measurements
1kg=
2.2 pounds
1 inch =
2.54cm
BSA=
BSA = ht (cm) x wt (kg) - square root
BSA = ht (in) x wt (lbs) /3131
BSA is documented in hundreaths;
What to consider when giving oral medication administration?
6 rights for giving meds ( Right dose, right pt, right time , right medication, right route, right documentation)
Oral Medication Administration
- Calculate proper dosage (mg/kg, mg/m2, safe dose ranges)
-Use oral syringes for LIQUID medications.
-For infants place syringe on the side of the mouth.
-May use a nipple for infant to suck.
-NEVER mix meds with bottle of formula.
When may you need to mix small amount of liquid with medication?
-Giving Capsules- opened and given with food
- Giving Chewables are good for preschoolers.
- Crushing pills and mixing with liquid is acceptable for many medications.
Needle size, gauge and amount volume ( IM Administration,Vastus Lateralis) Thigh
5/8 -1 inch
22-25 gauge
0.5 ml infant,
2 ml small child
Needle size, gauge and amount volume ( IM Administration, Ventrogluteal ( Buttock/ Hip)
5/8 -1 inch
22-25 gauge
0.5 ml infant,
2 ml small child
Needle size and guage and amount volume ( IM Administartion, Deltoid) Arm
½-1 inch
22-25 gauge
0.5- 1 ml volume
IV Therapy - Basics
-select appropriate site
-Remember pain management
- Central Access- PICC, Hickman, Broviac, Portacath
-Assess IV sites q 1-2 hours
- Calculate Fluid needs for 24 hours
0-10 kg 100 ml kg/day
11-20 kg 1000 + 50ml/kg /day for every kg >10
20kg 1500 + 20 ml/kg/day for >20
Observe for s/s of fluid overload
STRICT Intake and Output
IV Pumps
-Remember to include IV fluid amounts in I and O.
-Observe the site every hour
-Pressures may be monitored.
- Syringe pumps are used for IV medications- Needed information for use includes-
Respiration Vitals / Peds
How long does the nurse observe respiratory pattern?
60 seconds
True or False? Normal RR decreases as age increases
true
Is irregular respiratory pattern seen in infants?
Yes
What can the nurse assess when checking a child’s respiratory pattern
nurse can assess abdominal movements
The nurses use which pulse in the hospital to check a child’s heart rate?
The nurse uses Apical Heart rate almost always
When do you start to check the apical heart rate in infants?
infant - 2 years old
True or False?
The nurse can check the radial pulse if over 2 years old?
true
True or False?
Heart rate decreases as age increases.
True
Axillary is preferred in
infants to 2 years
When is a rectal temperature is needed?
Rectal temps are used if accuracy is needed ( age over 1 month)
Axillary or Tympanic Membrane Temperature is taken between which ages?
Ages 2-5 years
Can the nurse take a child’s temperature orally when a child can hold the probe under the tongue?
yes
________ RR is the most reliable.
Sleeping
Any RR of over _____ is abnormal always.
60
As the child gets older the BP is _____
higher
Normal BP in infants is around______?
90/50
Normal BP for a child is around___?
100/60
Normal BP for an Adolescent / Adult?
110/70
Age: 1 week to 3 months HR Awake / Sleep
Awake - 100 to 220/min
Sleep- 80 to 200/min
Age: 3 months to 2 years HR Awake/ Sleep
Awake-80 -150/min
Sleep- 70-120/min
True or false?
All toddlers fall
true
True or false ?
All 4 side rails go up with kids
True, this is not considered a restraint
Age 2 years -10 years Awake HR/ Sleep HR
Awake: 70 to 110 min
Sleep: 60 to 90 min
Nwbrn to 1 yr - RR
30 to 60/miin
Age:1 to 2 Years RR
25 to 30 /min
Age: 2 to 6 RR
21 -25 / min
Age:6-12 years RR
19- 21/ min
Age:12 years and older
16 to 19 / min
What are myths about Pain assessment and management in Pediatrics?
-Myth-Newborns cannot feel pain – no medication for circumcision
-Immature CNS
What does untreated pain leads to in Peds?
**Untreated pain leads to complications
-Delayed recovery
-Stress and anxiety (fear)
-Alterations in sleep and nutrition
Nursing Assessment for Pain in Children
**Verbal reports by the nurse:
Children as young as 3 can report pain, location and degree
EX: May be reported as really bad pain in arm for a fractured elbow
**Non-verbal
Irritability, restlessness, difficulty sleeping or feeding, inconsolable crying, grimacing
Physiologic response
How does pain assessment relate to the developmental level of Infants?
Infants uses:
Pre-verbal, behavioral, & physiologic cues remember infants communicate all needs frequently through crying
- Facial expression is most reliable
-Older infant may push or pull away
How does pain assessment relate to the developmental level of a toodler?
Toddler :
Loud crying, say’s word that indicate pain “ouchie” or stay very still
- Guards painful site, touches the painful area, runs away in anticipation of painful
How does pain assessment relate to the developmental level of a preschooler ?
Preschoolers :
Views pain as a punishment for thoughts/behavior
Crying and kicking
Regression to earlier behaviors (bed wetting, thumb sucking)
Describes location and intensity of pain “arm hurts bad”
Denies pain – fear of pain-relieving measures “shots”
Avoid telling child to be “brave” or good boy or girl after procedure
Fears body mutilation
Need all their parts; Band-Aids are important, magical thinking
How does pain assessment relate to the developmental level of a School-age child?
School-age children :
Describes pain and can quantify intensity (if scale is explained in simple terms)
Fears body harm
Awareness of death
Bargains or tries to “make a deal”
I’ll let you change my dressing after this tv show
How does pain assessment relate to the developmental level of a Adolescent?
Adolescent:
Understands cause and effect
Quantifies pain
Describes pain as “ache”, “sore” “pounding”
What are types of Pain Assessment used in peds ?
-Nips
-FLACC Pain Scale
-Oucher Scale
-Faces Pain Scale
-Numeric Pain Scale
Age range for pain scale
-NIPS- Neonatal Infant Pain Scale-birth -1 month
-FLACC Pain Scale- Face Legs Arms Crying Consolability
(2 month -7 years)
For non-verbal child use:
Evaluation through facial expression, leg movement, activity, cry and consolability
-Oucher Scale 0-5 scale
-Faces Pain Scale: Use with children as young as 3 years and older
- Numeric Pain Scale: Children 5 -7 years and older
Nursing Intervention for Pediatrics Pain
The nurse should :
-Watch communication
-General principles
-Presence, education, trust, family approach
-Distraction
-Relaxation
-Positive self talk
-Behavioral Contracts
-Child Life
Interventions that can be used before poking a patient
Nonnutritive sucking-Sweet ease
Ice
Sprays
Tens units
EMLA cream- (eutectic mixture of lidocaine-apply 60 minutes before poke)
EMLA cream is great for spinal taps and IV starts.
Shot Blocker
Buzzy
Lidocaine
Nursing Interventions to help with pain
Non-pharmacological
-Assess child’s age and developmental level
-Infants respond to touch, holding, rocking, pacifiers, Sweet Ease
-Toddlers and preschoolers may respond to distraction – books, videos, music, bubbles
-School-age and adolescents can be taught guided imagery
-Deep breathing, massage, heat /cold applications all apply
-Be creative with each child
-Have the child blow out imaginary birthday candles
What are some pharmacologic Pain Management?
-Calculate the safe dose based on child’s weight
-Give smallest dose 1st
-Monitor child’s response
- Take Vital signs before & after narcotics
-Children as young as 5 years can be taught to use the PCA pump
- Remember to calculate BMI and M2
What are the routes for pain meds in pediatrics?
-PO, sublingual, buccal, patch
-IV
-Continuous- PCA- Morphine or Dilaudid
-Family controlled or Nurse controlled PCA
-IM
-Intranasal
-Topical- EMLA, patch, vapo-coolant (Pain Ease), Lidocaine
-Epidural-long acting lidocaine, and/or opioid watch for side effects
What are Pain Medications given in Pediatrics?
Tylenol (Acetaminophen) 10-15 mg / kg q 4 hours
Ibuprofen – 5-10 mg/kg q 8 hours
Morphine- IM, IV, PCA
Dilaudid
Fentanyl-patch
Codeine 1 mg/kg q 3-4 hours
Titration is the key ( Medication is started at a low dose )
Interview communication with parents and patients
-Whatever the parents sees as a problems should be a concern for the nurse
-Confidentiality concerns: abuse, suicide, sexuality
-Ask preferred names.
-Don’t call parents “mom” and “dad”
By what age does most children describe their symptoms
age 7
Warning signs of stress and anxiety in younger children
Sleep problems
Headaches
Stomach aches
Increased crying
Clingy
Bed wetting
Baby talk
Developing new fears
Warning signs of stress and anxiety for school age and teens
Poor coping skills
Behavior and learning difficulties
Mood swings
Sleep issues
Overeating
Compulsive behaviors
General Appearance
General Survey
Distress
Eye Contact
Cleanliness
Muscle tone
Odor
Follows simple, age-appropriate commands
Appropriate speech, language, and motor skills
Growth of the infant
Length (not height) measured with measuring board or tray until 24-36 months ; Stretch legs
Weight: Zero scale prior to weight; Use Dry diaper and subtract weight of diaper
Growth of an Infant ( Head Circumference)
Reflects brain growth
Measure above eyes
Measure until 36 months
Growth of an Infant ( Weight)
Weight:
Infants-Regain birthweight by 2 weeks
Double birth weight by 6 months
Triple birth weight by 1 year
BMI for Age
-Underweight < 5th percentile
-At risk of overweight ≥ 85th percentile
-Overweight ≥ 95th percentile
What does pediatric growth chart contain?
Contain height, weight, and head circumference for age
- Growth is faster in infancy than any other age.
Vital Signs ( Blood Pressure)
Blood pressure (cover upper 80-100% of extremity or 40% of diameter of arm)
Measure annually in children age 2 years and older
Line up arrow with brachial artery.
BP increases as age increases
Discrepancy of upper extremity and lower extremity BP could indicate COA (Coarctation of the Aorta- Heart Defect)
Fontanels in infants
Palpate while quiet and sitting upright
Normal soft/flat
Anterior fontanel closes by 12-18 months
Posterior fontanel closes by 6-8 weeks
Bulging occurs with crying, vomiting, or can indicate pathology of increased ICP
Sunken fontanels can indicate dehydration
A bulging or sunken fontanelle is abnormal
Eyes and Vision
Visual screening should be done at 3 years of age
Strabismus (cross-eyed)
TWO Tests for Strabismus: Esotropia & Exotropia
-Corneal light reflex test
-Cover/Uncover test
-Opthalmoscopic exam
Red reflex
Examining the mouth/neck
Examine in front of a mirror Turn it into a game
For infant, examine when crying
Avoid tongue blades unless necessary
Demonstrate on parent or older sibling
Tonsils may be enlarged at baseline. Report any exudate.
Examine teeth (loose, missing, hygiene, caries, alignment)
Infants should have 6-8 teeth by one year of age
20 primary (deciduous) teeth, 32 permanent teeth
Examination of the neck
-Small, non-tender, mobile nodes are normal in children
-Tender, enlarged, warm nodes indicate infection
Cardiac assessment finding in children
-Sinus arrhythmia is common in children
-S2 (physiologic) split common;splits during inspiration
-Innocent murmur: no abnormality
-Functional murmur: no anatomic abnormality, but physiologic abnormality like anemia is present
-Organic murmur: cardiac defect +/- physiologic condition
Weaker lower extremity pulses can be a sign of cardiac issues
An accepted core temp for children ( rectal)
37- 37.5 C ( 98.6-99.5 F)
An accepted core temp for neonates
36.5- 37.6 ( 97.7- 99 F)
Types of Themometers used to measure Temp in infants and children
infared Themometer
Thermal radiation is measured from the axilla, ear canal, or tympanic membrane.
Temperature measurement appears on the digital display in approximately 1
second.
Three types are available for ear-based use: tympanic, ear canal, and arterial
heat balance via the ear canal (AHBE).
Often these devices are all inappropriately referred to as tympanic thermometers.
Temperatures measured in this way reflect arterial (bloodstream) temperature.
Ear Sensor ( Light Touch LTX)
Ear Sensor (LighTouch LTX)
This measures the infrared heat energy radiating from ear canal opening, scans
ear canal for highest temperature reading, and then calculates arterial temperature (correlates highly with core or internal body temperature).
- Available in 2 sizes
Axillary Sensor ( LightTouch LTN)
Axillary Sensor (LighTouch LTN)
This measures the infrared heat energy radiating from the axilla.
It can be used on wet skin; in incubators; or under radiant heaters, warming
pads, or other heat sources
Digital Thermometer
Digital Thermometer
A probe is connected to a microprocessor chip, which translates signals into
degrees and sends temperature measurement to digital display.
It is used like an oral electronic thermometer and can be used for measuring oral,
rectal, and axillary temperature.
It is more accurate and easier to read but somewhat more expensive than a
plastic strip thermometer.
Liquid Crystal Skin Contact
Liquid Crystal Skin Contact Thermometer (Chemical Dot
Thermometer)
This single-use, disposable, flexible thermometer has a specific chemical mixture
in each circle that changes color to measure temperature increments of 2
⁄10
degree.
There are two types:
1. Kept in mouth (1 minute), axilla (3 minutes), or rectum (3 minutes); color
change is read 10 to 15 seconds after removing the thermometer
2. Wearable, continuous-use thermometer, which is placed under axilla; may
be read within 2 to 3 minutes after placement and continuously thereafter;
discard and replace every 48 hours
Grading of Pulses in Infants and children
0 -Not palpable
+1 -Difficult to palpate, thready, weak, easily obliterated with pressure
+2- Difficult to palpate, may be obliterated with pressure
+3 - Easy to palpate, not easily obliterated with pressure (normal)
+4 -Strong, bounding, not obliterated with pressure
Respiration
- Count RR the same as adults
infants, observe abdominal movements, because respirations are primarily diaphragmatic. Because the movements are irregular, count them for 1 full minute for accuracy .
When is BP measured in children?
BP should be measured annually in children 3 years old through adolescence
Gold Standard method of BP Measurement
Auscultation
Most important factor in accurately measuring BP
is the use of selecting the correct cuff size
What is OH?
Orthostatic hypotension (OH), also called postural hypotension or orthostatic intolerance, often manifests as syncope (fainting), vertigo (dizziness), or lightheadedness and is caused by decreased blood flow to the brain (cerebral hypoperfusion).
Most effective preparation for children procedures includes…
providing sensory- procedural information and help the child develope coping skills such as imagery or relaxation
Selecting Nonthreatening
Words or Phrases
Shot, bee sting, -stick Medicine under the skin, poke that
will feel like a pinch
Organ Place in body: Test To see how (specify body part) is
working
Incision, cut : Make an opening
Edema : Puffiness
Stretcher, gurney : Rolling bed, bed on wheels
Stool, urine : Child’s usual term
Dye: Medicine to help place in your body show up on a picture
Pain : Hurt, discomfort, “owie,” “boo-boo,” sore, achy, scratchy, pinch
Deaden, numb : Not feel body part as much
Fix Make better
Take (as in “take your temperature”) : See how warm you are
Take (as in “take your blood pressure”): Check your pressure, hug your arm
Put to sleep, anesthesia : Different kind of sleep so you won’t
feel anything
Catheter: Soft tube, small straw
Nips pain scale is used for
Neonatal infants - 1month
Flacc pain is used for
Age : 2months to 7 years or for non-verbal child
Evaluation of face, leg movements, activity,cry, consolability
Faces pain scale is used …
With children as young as 3 and older
Pictures of faces
Numeric pain scale
Children 5-7 years of age
Routes for pain meds in peds
PO, sublingual,buccal,patch
IV
Continuous PCA - Morphine or Dilaudid
FAmily PCA
IM
Intranasal
Topical
Epidural
Pain medication
Tylenol {Acetaminophen} 10-15mg/kg q4hours
Ibuprofen-5-10mg/kg q 8hrs
Dilaudid
Fentanyl patch
Codeine - 1mg/kg q 3-4 hours
Side effects of narcotics
Respiratory depression
Slow HR
Constipation
Low BP
Urinary retention
Who gives consent when preparing for procedures?
Parents
Adolescents: for pregnancy, STD, mental, drug and alcohol use
Emancipated minors: teens who are pregnant, legalized as adults
Potential causes for increase in RR
Respiratory distress
Fluid volume excess
Hypothermia
Elevated temp
Pain
Potential cause for a decrease in RR
Anesthetic opioids and pain
