The Hospitalized Child

Four primary problems of the Pediatric Nurse when dealing with the hospitalized child:– Separation Anxiety– Loss of Control– Pain management– Diversional Activities reflective of

developmental stage of client

The Hospitalized Child Separation Anxiety!

– Early Childhood• Protest• Despair• Detachment

– Later Childhood• Loneliness• Boredom• Isolation

– Attitude is everything!

The Hospitalized Child Loss of Control!

– Early Childhood• Trust• Limitation of movement• Regression• Fantasy (can not synthesize beyond senses)

– Later Childhood• Loss of independent activities• Depersonalization

– Attitude is everything!

The Hospitalized Child

Pain!– Fallacies

• Infants do not feel pain• Children tolerate pain better than adults• Children can not tell you where they hurt• Children always tell you the truth about pain• Children become used to pain and painful

procedures• Pain intensity is reflected by a child’s behavior• Opioids are too dangerous for children

Pain Assessment:Subjective

Pain Assessment:Objective

Body rigidity, thrashing about, loud crying, restlessness

Flushing of skin Blood Pressure, pulse, resp increase Pupils Dilate O2 Sat decreases

• These are less reliable than subjective- better to believe what the child tells you than to rely on objective signs

Pain Management

Non-pharmacological– Involve Parents– Prepare the child without planting the idea

of pain– Distraction– Cutaneous Stimulation– Rewards

Pain Management

Pharmacological– Right Drug

• opioids vs non-opioids?

– Right Dose• body weight• Parenteral vs Oral doses

Pain Management

Pharmacological– Right Route

• Oral• IM

– EMLA– buffered lidocaine

• IV

– Side effects– Attitude is everything!

Diversional Activities

Play is the work of children and is critical in their development– JCAHO requirements– puts children in charge- all children even

the sick ones! Play Room

– should be a sanctuary

The Hospitalized Child

Care Plan:– Fear related to separation anxiety

• withdrawal

• regression

The Hospitalized Child

Care Plan– Alteration in comfort related to pain

• Non-pharmacological

• Pharmacological

• Side Effects

The Hospitalized Child

Care Plan– Powerlessness related to hospitalization

The Hospitalized Child

Care Plan:– Diversional Activity Deficit related to

immobility and hospitalization

• Activity Levels

• Adequate rest

Pediatric Variations from Adults:Assessment and Techniques

Safety! Language! Medication Administration!

– PO– IM– IV– PR

Positioning

Lumbar Puncture– lie on side with knees flexed to the

abdomen and chin flexed to chest• infant- two hands• child- lean over body using forearms against

the thighs

Papoose Board/ Mummy Restraint– IV’s, phlebotomy, suturing,

Normal Pediatric Heart Rates- Always Apical!!

Newborn- 120-170 1 year- 100-130 3 years 80-120 5 years- 70-110 10 years 60-100 affected by fever, dehydration,

respiratory illnesses and drugs

Respiratory Rates- Abdominal rather than chest movements!!

Newborn: 30-60 1 year: 24-40 3 years: 24-30 6 years: 18-22 10 years: 12-20 Affected by anxiety, fever, drugs, illness

Blood Pressures- neonatal, infant, child, small adult cuffs Newborn: 70/50 1 year: 90/50 3 years: 90/60 6 years: 100/60 12 years: 110/60 18 years: 120/70 affected by pain, dehydration, anxiety

Temperature: an elevated temperature is called a fever!!

Any temp. >100.5 in a child<3 mos- is serious- seek medical attention!!

Mercury Glass Thermometer– oral- no seizure, 4 or older, 3 minutes, under

tongue– rectal- lubrication, 2 minutes, usually younger

than 2, insert 1/2 inch (no immunosuppressed!!!)

– both require protective sheath!

Temperature- continued

Axillary- last resort- usually in public places, seizure prone and immunosuppressed!

Press arm close to side- hold in place 6 minutes!

Rectal=oral plus 1 degree or axillary plus 2 degrees

Oral = axillary plus one degree

Temperature- continued

Tympanic- not recommended for children less than 2 years- but is done all the time!

Use probe cover pull pinna back and down, insert probe

covering entire canal, parallel to face, then rotate towards mouth- like speaking into telephone- press scan button. Discard probe.

Oxygen saturation- normal- 95% or greater!

Indicated in any patient with abnormal vital signs, cough, excessive secretions, sedation, or whenever the nurse feels it is necessary.

Spot check vs continuous Usually children require taping probe over

thumbnail nail or large toenail, can also use pinna of ear

Measurement of oxygenation as well as perfusion!

Intake and Output

Measured in cc’s or mL’s- useless without daily weights!– 1 gram = 1cc (1,000 grams = 1Kg=1liter!)– Used on the following- renal disease, IV

fluids, surgery, DM, hypovolemic, dehydrated (vomiting), CHI, burns, CHF, certain medications, meningitis (ICP)

– Weigh all diapers!

Specimen Collection (less than 5 years old)

Venipuncture- usually do not use a vacutainer on children- a 20-25 gauge needle with a syringe- usually 3 cc’s enough. Do not put in regular blood tubes, but rather pedi bullets. Can do a heel stick if unable to get blood on kids less than 1- need lancet and micro-sized collection tubes. Must wipe away the first drop of blood.

Specimen Collection- Urine

Cath Clean Catch Pedibag- clean meatus before applying the bag with a

soap solution, sterile water, and sterile gauze - wipe from the tip of the penis towards the scrotum or from the clitoris towards the anus on three separate wipes.

Attach the bag with adhesive tabs around the labia or around the scrotum

Should be done before any other specimen collection!

Specimen Collection- Throat Culture

Open the culturette- do not let it come into contact with anything- hold in dominant hand. (contains two swabs in one) Have patient open mouth and say AHHH. (May need tongue depressor to get tongue out of way) Do not let swab come into contact with the tongue- swab each tonsil with a different swab. Expect patient to gag! Place swab back into culturette tube- Label!!