Pediatrics Flashcards
Selection of ambulatory care for pediatrics is dependent on?
- complexity of procedure
- Anesthesia consideration for safety
- Pain management
- Known incidence of complication associated with procedure
- postoperative monitoring
Non candidates for pediatric ambulatory surgery?
- premature infants with respiratory difficulties
- apneic episodes
- feeding difficulties
- poorly controlled seizures
- uncontrolled diabetes
Candidates for pedi ambulatory surgery must meet what ASA classification
ASA classification scale of Class 1 and II older than six months
Eriksons developmental stage: Neonates
First 28 days extrauterine life
premature remains in this category until three months
Eriksons developmental stage: Infant
- 28 to 18 months
- trust vs mistrust
Eriksons developmental stage: Toddler
18 to 30 months
autonomy vs shame doubt
Eriksons developmental stage: preschool
2.5 to 5 years
imitative vs guilt
Eriksons developmental stage: school age
6 to 12
industry vs inferiority
Eriksons developmental stage: Adolescents
12 to 16
Identity vs Role confusion
What are the fears and stressors of Infants?
- Self separate from environment
- Attached to caregivers
- Make sounds, short words
- comfort from oral sources ( pacifiers)
- Comfort being rock and held
- hospital seen as abandonment
What are the fears and stressors of Toddlers?
- Separation anxiety
- Being left alone
- Strange bed or room
- Loss of comfort of home family and possessions
- in contact with unfamiliar people
- painful procedure
- medical equipment that looks and sound scary
- feeling helpless
- communicate in sentences
- needs familiar objects
What are the fears and stressors of Preschool?
fears
- being away from family and home being left alone
- having part of body damage
- needles and shot
- waking up during surgery
- pain
- the dark
- real and imagined situation
- thinks their in the hospital because they are in trouble
- Uses compound sentences
- provides opportunity for independence
What are the fears and stressors of School Age?
- Being away from school and friends
- identifying with social group
- likes to imitate heroes
- Thinks being in hospital is because they were bad or being punished
- Having part of body destroyed or injured
- loss of control
- pain
- needles and shots
- wants honest explanation
- understand death is permanent
- after of dying during surgery
- communicate well verbally and basic writing skill
- give positive reinforcement for cooperation
What are the fears and stressors of Adolescents?
- Fear loss of privacy
- Body image important
- Understand rules, values, ideas
- Aware of opposite sex
- Globally communicates verbally in writing
What are the respiratory differences in pediatric pt anatomically?
- Smaller than adults
- Tongue of infant relative to oropharynx is larger
- epiglottis is narrower
- In children less than 10 the narrowest portion of the airway is below the vocal cords at the level of the cricoid cartilage
The larynx of a child is what shape?
Funnel shape
What are the consequences of respiratory difference?
- Small amounts of edema or obstruction can significantly reduce pediatric airway diameter and INCREASE resistance to flow
- Posterior displacement of the tongue may cause severe airway obstruction
*What is the difference between and adult ET tube versus a Pediatric?
- ET in children are UNCUFFED unlike adults and can easily be dislodged resulting in accidental extubation
How is a pediatric pt respiratory rate different?
- Respiratory rate is directly correlated with cardiac rhythm in the child
- The faster a child breathe the faster the heart rate
- The slower they breathe the slower the heart rate
What is bradycardia related to in pedi pts?
hypoxia
What is the difference between cardiac arrest in children versus adults?
- Cardiac in children is rare and is linked to AIRWAY OBSTRUCTION
- In adults it is due to ELECTRICAL CONDUCTION
What is the cardiovascular difference ?
- Peds do not have physiologic reservoirs ( blood volume) to rely upon in situations in which shock can occur
- If shock or airway problems are not rectified rapidly the pediatric pt status will deteriorate two to three times faster
The the normal blood volume in children is?
85ml/kg
How are the levels of hemoglobin in children?
- hemoglobin and hematocrit are high in infants up to three months of age after that they approximate adult normal range
Why do infants need glucose?
- Because their glucose stores are rapidly depleted
Why are body temperature regulations different in pedi pt?
- Peds are very sensitive to heat loss due to large surface areas small amounts of subcutaneous fat and poor vasomotor control
How can RNs help maintain normal body temps?
- Increase room temperature
- Use warming lights
- Warming device placed on pt
Follow manufacture’s instruction for use of any and all equipment
Pain assessment for peds
- Behavioral observation scale
- FLACC (face, legs, activity, cry and consolability)
- To assess a preverbal or non communicative child
What pain assessment scale should be used for pt age 3 and up?
Wong- Baker Face Scale
What pain assessment scale should be used for pt age 7 and up?
- Use 0 to 10 rating scale
Ways to help a child in pain?
- Hold or rock pt if appropriate because it will help relax the child
- Provide glucose in a baby’b bottle reduces pain and relieves anxiety
Pediatric medication safety
- weight should be in kg and pounds to decrease medication errors from (estimating)
Why are infants more prone to dehydration?
- Infants are prone to dehydration due to immature renal function at birth and limited ability of the kidneys to concentrate urine
- Do not overload pediatric with fluids*
Preoperative Fasting Guidelines for Clear liquids
2 hours
Preoperative Fasting Guidelines for Breast milk
4 hours
Preoperative Fasting Guidelines for Infant Formula?
6 Hours
Preoperative Fasting Guidelines for Non human milk?
6 hours
Preoperative Fasting Guidelines for light meal?
6 hours
Informed consent for peds?
- Parents or legal guardian sign for children unless child is emancipated minor as described by law
*What are 3 elements of the universal protocol?
- preoperative verification
- site marking
- time out
Who are an exception to site marking element because skin marks may permanently stain the skin?
Neonates
Preoperative education for infants include?
- Focusing on parent and caregiver
- keep babies on their routine
- Make plans for at least one parent to be with baby
Preoperative education for toddler include?
- preparation should take place a day or two
- interactive play with doll and stuffed animals can help toddler be more secure in hospital environment
- Keep explanations simple and be careful with your words
- its not unusual for toddlers to regress
Preoperative education for Preschool include?
- Major fear of unknown
- Children should be told of surgery days prior
- provide a tour
- dramatic play is a big part of preschoolers
- use pictures , stuffed animals or toys to help children understand
- Tell the truth in simple term and answer all their questions
Preoperative education for School Age include?
- Should take place a week or two before surgery preparation too far in advance can produce anxiety
- Emphasize surgery is not a punishment
- Have child explain back what is going to happen
- Give child choices to increase sense of control
- Allow visits from friends
- Treat as big kid but may have baby insecurities
- May feel pain intensely
- Use common interest to build trust
- Question child directly and simply
- Offer limited choices
- Don’t tell them not to cry
Preoperative education for Adolescent include?
- Privacy is much a need for teenager
- Allow teens to be part of decision making
- Encourage them to make a list of questions to ask physicians
- Be truthful may become angry if think you’re keeping secrets from them
- Identity and peer relationships are key issues
- Concerned with body image
- Reaction can be over and under exaggerated
- Regression behavior is common
- Concerned with modesty and privacy
Important pediatric reminders
- Use simple words
- use open body language
- don’t ever intentionally lie to a child
- if they ask always tell a child if something is going to hurt
- Explain procedure in simple easily understood terms but not until it is time for the procedure to begin
Communication with parents and caregivers
- Treat children as people
- Learn and use their preferred names
- Treat every child as if they are the most beautiful child
- Listen to what the child says
- Keep children physically and emotionally comfortable as possible
- Basic and advance pain management is important
- Try to relieve fear and anxiety as early as possible
What are preoperative concerns for pediatrics?
- Non verbal communication
- A smile is calming
- get to child’s eye level
- try not to make the child look at you in an awkward angle
- for preverbal children use a happy voice and bring the tone up at the end of the sentences
- Use a soft voice with moderate pace and interrupt only when necessary
- Use noise like uh hum and I see to encourage children to talk
What are intra-operative safety concerns with fluid management?
- For healthy elective patients anesthesia providers start the peripheral IV access line after induction of inhaled anesthetic
- Central venous access devices, central line, intravenous lines can be inserted for emergency access for fluid resuscitation
- An intraosseous needle or bon marrow aspiration needle is placed in the anterior aspect of the tibia place a pillow under the knee and secure and stabalize the line for rapid infusion of fluids
What are intra-operative safety concerns with airway safety?
- Because of use of uncuffed ET tubes it is imperative to secure and maintain the airway for patient safety, ET tubes can easily dislodge
- Pediatric code sheet of emergency medication based on pt weight in kilograms and pound have this immediately available for all perioperative team members
- Never leave child alone safety straps when applicable need to be applieds
- Make sure child is focus on attention
- Attention to blood loss is extremely important
Keeping pediatric patients normothermic?
- Hypothermia increase oxygen consumption leads to hypoxia respiratory depression , acidosis, hypoglycemic and alters medication metabolism
- Hypothermia prolongs neuromuscular blocking agents and delays the emergence from anesthetic agents
Equipment safety
- Use age and size appropriate for all equipment
- Use appropriate energy settings per manufacture instruction
- Defibrillator settings
- ESU settings
Intraoperative concerns: Pediatric foley catheter placement?
-Order from physician’s required before placement
What are common indications for bladder catheterization?
- To obtain a urine specimen
- To monitor urine output
- To relieve urinary retention
- For genitourinary testing procedure such as cystogram
- Lengthy surgical procedures
Intraoperative pt assessment
- Check for allergies
- Avoid latex catheters
- Use silicon catheter if possible
How to select appropriate catheter?
- Select appropriate size
- perform the procedure using sterile technique
- Position patient for the procedure
- Provide adequate lighting
- Sizes go up by weight
Straight and indwelling catheter sizes
Neonate- 5-6 F infant to 3 5-8 F 4-8 yrs 8 F 8 yrs- 10-12 F puberty 12-14 F
Hyperactivity
- Pediatric pt recovering from anesthesia routinely exhibit hyperactive behavior ( excitement phase)
- It is important to assess the cause
- Drug response
- Hypoxemia
- Pain
- Awakening in strange surrounding
Postoperative concerns
- Check teeth of school age children before and after the procedure especially if loose tooth are present
- If teeth are removed to prevent accidental dislodgement and possible aspiration be sure the patient is given the tooth before leaving
- Note the documentation of the tooth removed in anesthesia record
Recovery position
- The best position for postop is LATERAL
- For children who have had intraoral procedures the best position is SEMIPRONE to facilitate drainage of secretion or blood
- Side rails should be up and padded where necessary
- An infant may need to be cocooned in a blanket to prevent injury
- Safety retraints may need to be applied per facility policy to prevent accidental dislodging of tubes and drains
Peds with Cancer
- It is common for health care organizations to have policy for “consent on file” consistency of RN assignment can help decrease anxiety
Life specialist
- Experts in child development and help pediatric patients cope with hospitalization through play, education, and activities
Child abuse and neglect
- RNs considered mandated reporters
S/s of child abuse
- Shaken baby syndrome
- Unexplained fracture and falls
- Signs of lack of physical and medical care
- Unexplained or deliberate burns, hairloss, multiple skin injuries
Post mortem care
- Trauma is the leading cause of death in pediatric pts
- It is the responsibilty of the physician caring for the pt to communicate to the parents the death of the child
