1
Q
atraumatic pediatric care
A
interventions to minimize physical and psychological distress for children and families
2
Q
ACEs
A
- Findings showed the more negative events a child experienced that higher the likelihood of adult experiencing health and behaviour problems
- Reducing pathologizing of symptomatic behaviour by viewing symptoms as normal reactions to abnormal experiences
3
Q
resilience
A
- Resilience involves being able to recover from difficulties or change – to function as well as before and then move forward.
- Factors include the protective or risk factors involving the individual, family and environment
4
Q
communicating with parents
A
- Encouraging parents to talk
- Directing the focus (ask directing questions/stay relevant/redirection)
- Listening and cultural awareness
- Providing anticipatory guidance (preparing them for what may happen, explain procedures, etc.)
- Avoiding blocks to communication (ie, information overload)
- Communicating with families through an interpreter
5
Q
risk factors for infant death
A
low maternal education
inadequate housing
lack of access to health care
food insecurity
Poverty
Unemployment
6
Q
Childhood morbidity
A
Prevalence of specific illnesses in the population at a particular time
7
Q
Most common morbidity in children
A
respiratory: asthma, RSV, etc
8
Q
Children with increased morbidity
A
Homeless and immigrant children; children living in poverty; Indigenous peoples; children in care of child services; low-birth-weight (LBW) children; children with chronic illnesses; and immigrant adopted children, genetics, family
9
Q
General Approaches Toward Examining the Child
A
- Minimize stress and anxiety associated with assessment of various body parts
- Foster trusting nurse–child–parent relationships
- Allow for maximum preparation of child
- Preserve security of parent–child relationship
- Maximize accuracy and reliability of assessment findings
10
Q
head circumference
A
under 3 years old
11
Q
growth charts
A
5-95% is normal
12
Q
BMI
A
- Measurement of body fat using height and weight
- BMI = Weight(kg)/Height(m)2
- Recommended for screening children two years and older to identify potential wasting, overweight or obesity.
- On growth charts for ages 2 to 20 years
- BMI <3rd% = underweight
- BMI >85th% = overweight
- BMI >97th% = obese
13
Q
temperature routes for children
A
- Birth-2 years - rectum (armpit)
- 2-5 - rectum (ear/armpit)
- 5+ - mouth (ear/armpit)
14
Q
pulse for children
A
- 1 full minute under 10 years
- Apical under 2 years of age
- Radial greater than 2 years
- Take brachial and femoral pulse together to make sure they are the same
15
Q
respirations for children
A
Infants - diaphragmatic breathers (abdomen moves)
16
Q
blood pressure for children
A
- Pay attention to pulse pressure
- Wide - 50+
- Narrow - less than 10
- Left arm first (closer to heart)
- If you have to recheck bp, wait 5 minutes
17
Q
airway <6 months
A
- Obligate nasal breathers (mucus in nose makes it hard to breathe)
- Passages easily obstructed with mucus secretions
- Prone to upper airway respiratory infections (throat up → ear, nose, throat)
- At risk of airway compromised (tongues are large in comparison to mouth, heavy head, face and mandible small)
18
Q
airway 3-8 years
A
- Problems because of adenotonsillar hypertrophy
- Horseshoe shaped epiglottis (flexible & flat in adults)
- Trachea short and soft
19
Q
cardiovascular
A
- Heart is higher in chest
- Heart rate higher on inspiration
- Resting heart rate higher than adult
- Sinus arrhythmia normal
- Children’s circulating blood volume is higher than adults
- 70 - 80 ml/kg but actual volume is small
- Therefore small blood loss may be significant in children
20
Q
ABCDEF
A
Airway
Breathing
Circulation
Disability - LOC, pain response, pupil size, light reaction, glucose
Exposure - remove clothing to look
Family - family interactions
21
Q
GCS 8 or less
A
intubate
22
Q
when do fetuses start feeling pain
A
24 weeks gestation
23
Q
response to pain: young infant
A
- Generalized body response of rigidity or thrashing, possibly with local reflex withdrawal of stimulated area
- Crying
- Facial expression of pain (brows lowered and drawn together, eyes tightly closed, mouth stretched open and squarish)
- No association demonstrated between approaching stimulus and subsequent pain
- Preterm infants feel more pain than term infant
24
Q
response to pain: older infant
A
- Localized body response with deliberate withdrawal of stimulated area
- Loud crying
Facial expression of pain or anger - Physical resistance, especially pushing the stimulus away after it is applied
25
response to pain: young child
- Loud crying, screaming
- Verbal expressions such as -“Ow,” “Ouch,” “It hurts”
- Thrashing of arms and legs
- Attempts to push stimulus away before it is applied
- Requests for termination of procedure
- Clinging to parent, nurse, or other significant person
- Requests for emotional support, such as hugs or other forms of physical comfort
- Becoming restless and irritable with continuing pain
- Behaviours occurring in anticipation of actual painful procedure
26
response to pain: school age
- May see all behaviours of young child, especially during actual painful procedure, but less in anticipatory period
- Stalling behaviour, such as “Wait a minute” or “I’m not ready”
- Muscular rigidity, such as clenched fists, white knuckles, gritted teeth, contracted limbs, body stiffness, closed eyes, wrinkled forehead
27
response to pain: Adolescent
- Less vocal protest
- Less motor activity
- More verbal expressions, such as “It hurts” or “You’re hurting me”
- Increased muscle tension and body control
28
QUESTT
Q - question the child and parent
U - use pain rating scale
E - evaluate behaviour and physiologic changes
S - secure parental involvement
T - take cause of pain into account
T - take action and evaluate results
29
FLACC Pain Assessment
Face
Legs
Activity
Cry
Consoliability
*Used for kids less than 3 years, or kids that can't tell us about their pain
30
FACES Pain Scale
- The child chooses a face that describes his or her pain
- Ages 3-10
31
Numeric rating scale
Useful in children 8 years and older
32
adolescent pediatric assessment scale
- Assesses pain location, intensity, and quality
- shade in body parts that have pain
- circle words on side that relate to pain
- Facilitates assessments of pain quality + location
- Useful for 8 and up
33
gold standard opioids for kids
morphine
34
what does the nurse do during a procedure?
- Before the procedure: adequate preparation reduces anxiety and promotes coping
- During the procedure: use a firm, positive, confident approach that provides the child with a sense of security
- After the procedure: hold and comfort the child
35
transporting infants and children
- Determined by age, condition, destination, and hospital policy
- Infants and small children can be carried short distances.
- Critically ill patients should always be transported on a bed/stretcher
- Can’t walk around with kid in arms, need to be in bed, stretcher, chair, etc
36
therapeutic holding
the parent or caregiver holds the child in a secure, comfortable position that provides close physical contact for 30 minutes or less
37
bone marrow aspiration or biopsy
Infants - tibia
Children - posterior or anterior iliac crest
38
Emla patch
(numbs) - put on 60 minutes before taking blood
39
pharmacodynamics
what the drug does to the body. Drugs physiological effects on molecular level
40
Pharmacokinetics
what the body does to the drug. how the drugs moves through the body, (distribution, absorption, metabolism, excretion)
41
Medication Administration: Age Based Considerations
- Infants: Need TLC before and after (parents too), trust
- Toddlers: Need immediate preparation. Do not offer unreal choices. Allow caregivers to help with oral meds.
- Preschool children: Need to know what they are expected to do. Let them handle equipment. A bandage is very important for body integrity.
- School-aged children: Need explanation of their role and choices when possible. Longer preparation time needed for invasive procedures.
- Adolescents: Generally want more information. Privacy is important. Recognize need for independence. Allow client choices.
42
oral medication
Under age 6 risk for aspiration so needs to be crushed
43
otic administration
- can be upsetting to child
- Reinforce need for head to be still
- Room temperature med
- Keep them laying on side for 2 minutes after
44
nasal administration
Head hyperextended for 1 minute post instillment
45
Intramuscular Injection sites
Vastus lateralis: for most medications
Ventro gluteal: not until 3 years
Deltoid: not until 4 years
46
Max fluid per day given
2400 mL
47
output
0.5-1 ml/kg/day
48
fluid replacement per day
below 10 kg - 100 ml/kg
10-20 kg - 1000 + 50 ml/kg
greater than 20 - 1500 + 20 ml/kg
49
fluid requirements per hour
below 10kg - 4ml/kg
10-20 kg - 2ml/kg for each kg more than 10
greater than 20 - 1 ml per kg for each kg greater than 20
50
how to take temp for child under 3
pull pinna down and back
51
how to take temp for child over 3
pull pinna up and back
52
indications for O2 therapy
1) Documented hypoxemia
2) An acute care situation in which hypoxemia is suspected
3) Severe trauma
4) Acute myocardial infarction
5) Short-term therapy (e.g., post-anesthesia recovery)
6) Increased metabolic demands, i.e. burns, multiple injuries, and severe infections.
53
Variations in Pediatric Anatomy & Physiology: Nose
-Infants up to 4-6 weeks are obligate nose breathers
- Upper respiratory mucus serves as a cleansing agent, yet newborns produce very little mucus making them more susceptible to infection
- Young infants nasal passages are smaller so any excess mucus can cause airway obstruction
- The frontal sinuses and the sphenoid develop by age 6-8 years making younger children less likely to acquire sinus infections compared to adults
54
Variations in Pediatric Anatomy & Physiology: Throat
- Infants oropharynx is larger than in adults
- Children tend to have enlarged tonsillar and adenoidal tissues even in the absence of illness
- The epiglottis in infants is hard, narrow and folded horseshoe shaped (flexible & flat in adults)
55
Variations in Pediatric Anatomy & Physiology: Trachea
- Infants trachea is approximately 4 mm wide compared to the width of adults of 20 mm
- A small reduction in the airway diameter of the pediatric child can increase resistance to airflow, leading to increased work of breathing
- In infants and children under 10 years the cricoid cartilage is underdeveloped, resulting in laryngeal narrowing and a funnel shape
56
Variations in Pediatric Anatomy & Physiology: Lower Respiratory Structures
- Bifurcation of the trachea occurs at T3 in children, compared with the level of the sixth thoracic vertebra in adults
- Bronchi and bronchioles of infants and children are narrower in diameter placing them at increased risk for lower airway obstruction
- Alveoli reach adult number around 7 or 8 years of age, placing the younger child, infant or premature infant at higher risk for hypoxemia and carbon dioxide retention as there are fewer overall gas exchange units
57
Variations in Pediatric Anatomy & Physiology: metabolic rate and oxygen needs
- Children have a significantly higher metabolic rate than adults
- Infants consume 6-8 L02/ min compared to adults of 3-4 L02/ min
- In any sort of respiratory distress children will develop hypoxemia more rapidly than adults
58
general ethology of respiratory infections
Infectious agents
-Most are viral (RSV)
Age
-<3 months have maternal antibodies and are better protected
-Infection rate increases from 3-6 months
Size
-Airway is smaller, more susceptible to obstruction from swelling and mucous
-Shorter distance between structures → easy spread of bacteria
Resistance
-Children who are breastfed have better immunity
Seasonal variations
59
general clinical manifestations of respiratory infections
Fever (first sign of infection)
Poor feeding and anorexia
Vomiting
Diarrhea
Abdominal pain
Nasal blockage
Nasal discharge
Cough
Respiratory sounds (cough, hoarseness, grunting, stridor, wheezing, crackles)
Sore throat
Meningismus
60
non specific signs of infection
Diarrhea, poor feeding, abdominal pain
61
easing respiratory efforts
Sit them up
Chest physio
Suctioning
Cool mist humidifier
High flow O2
Nebulizers or puffers
No cold meds under 6 (only supportive care)
62
nursing care for respiratory infections
Easing respiratory effort
Promoting rest
Promoting comfort
Reducing the spread of infection
Reducing temperature
Promoting hydration
Providing nutrition
Encouraging family support and home care
63
respiratory failure
-Defined as inability of respiratory system to maintain adequate oxygenation, with or without carbon dioxide retention
-Most common cause of cardiopulmonary arrest in children
64
respiratory arrest
Cessation of respirations
65
apnea
-Cessation of breathing for more than 20 seconds
-Cessation of breathing for a shorter period when associated with cyanosis, pallor, hypoxemia or bradycardia
Types
-Central - respiratory efforts absent for 20 seconds or more
-Obstructive - have respiratory efforts
-Mixed
66
respiratory insufficiency
-when there is increased work of breathing but gas exchange function is near normal
-when normal blood gas tensions cannot be maintained and hypoxemia and acidosis develop secondary to carbon dioxide retention
Nurs 3032
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