THEME 13 CARE OF THE HOSPITALIZED CHILD

YEAR 2- SEMESTER 1 FACILITATOR MRS PENE

INTRODUCTION
Hospitalization is an interruption of the childs active cycle of growth and development and his or her family's life cycle also. The child is removed from the daily routines of home life and contact with siblings, relatives and peers are limited. He or she may be required to experience strange and painful events and to communicate with strangers.

YOUR WORK IS VERY HARD BECAUSE YOU WANT ME TO GET WELL SOON. YOU CARE FOR ME AND MY FAMILY. I CAN BE VERY DIFFICULT AT TIMES IAM AFRAID

Nursing care needs to be based on the most common psychosocial and physiologic alterations that applies the principles of growth and development, and respect and appreciation of the parents and family as partners in the care of their children.

OBJECTIVES
At the end of this session, the student will be able to: 1. Define key terms relating to caring for children. 2. Administer medication to a hospitalized child. 3. Assess and manage pain 4. Transport the sick child. 5. Position and restrain a child.

1. Define key terms relating to caring for children.

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!

1. 2 3 4 5 6 7 8 9 10 11

KEY TERMS Pediatric Separation Protest Despair Detachment Inconsolable Agitated Resists Restraints development milestones distress

KEY TERMS 12 13 14 15 16 17 diversional Fallacies Opioids non-opioids Cutaneous Stimulation Desensitization

2. Administer medication to a hospitalized child.

 Medication management is clearly a complex role including: administering medication safely and efficiently assessing and monitoring the effects of medication interdisciplinary collaboration evaluating desired and undesired effects of medication (Watt, 2003; Galbraith et al, 2001)

Medication administration routes ?

Important Concepts

Practitioner Responsibilities Double Checking Family-centred care

a) Oral Medication
Procedure for the administration of medication. a)drug chart , medication and equipment 2. Performing the procedure

ORAL/ENTERAL MEDICATIONS
INFANTS A syringe or dropper provides the best control for administering medications Place small amounts of liquid along the side of the infant s mouth. Have the infant suck the liquid through a nipple. For unpleasant tasting medicine, other methods should be used so that the infant will not associate the unpleasant taste with the nipple. Disguise disagreeable tasting medications with sweettasting substances. However, present any altered medication to the child honestly and not as a food or a treat.

CHILDREN
Whenever possible, give children a choice between the use of a spoon, dropper, or syringe. Oral medications are usually prepared in sweetened liquid form to make them more palatable, Crush medications that are not supplied in liquid form and mix them with substances available on most pediatric units, such as honey, flavored syrup, jam, or a fruit puree Necessary food such as milk or orange juice should not be used to mask the taste of medications. Disguise disagreeable tasting medications with sweettasting substances. However, present any altered medication to the child honestly and not as a food or a treat.

Administer the medication slowly with a measuring spoon, plastic syringe, or medication cup.  If giving several medications by an enteral tube, administer medications separately and flush with 5-10 ml of warm water between each medication.

2. Performing the procedure

Systematic check of chart Allergies Weight/Age/Surface Area Right patient Right medicine Right Time Right Route Right Dose Signed by a prescriber Drug Commence date completed Expiry Double Checking this must occur from start to finish

Administering Medication
1. 2. 3. 4. Do not give while child is crying or sleeping. Reposition child if necessary. Allow time for the child to take the medicine Do not force the vessel/medicine into the child s mouth 5. Insert syringe /spoon into the side of the mouth between the cheek and the gum or can be placed on the tip of the tongue. Encourage older children to use a medicine pot or spoon to take medication

5. Ensure the medication is given slowly and use a medicine spoon to retrieve any medicine that has been spilt or spat out. Stroke a baby s cheek or under the chin 6. Encourage older children to use a spoon or medicine pot rather than a syringe 7. Unless contraindicated, offer the child a flavored drink/ice cube between and after medicines 8. Provide positive reinforcement as appropriate during and after the procedure

Post Administration of Medication

A. If the child refuses or is unable to take the prescribed medicine, inform the responsible doctor B. Document the incident C. Discard any unused medicine D. Ensure tray is clean. Wash hands E. Sign drug chart.

f. If the process required double-checking, ensure both signatures are on the prescription chart g. Monitor the effects of the medicine administered and document in the nursing records h. Observe and report immediately to the nurse in charge and responsible prescriber any adverse effects of the medication

Considerations when administrating oral medication

I. II. III. IV. V. Consider other routes if preparation of medication cannot be given. Inform doctor. Ensure the child s gag reflex is present. Post-operatively, ensure the child is sufficiently awake to take the medicine safely. If the volume of the suspension is large, consider using an alternative preparation (e.g. soluble tablets Crushing tablets or opening capsules generally makes the medication unlicensed for use .Any harm caused by this practice is a shared responsibility between the nurse administering the drug and the prescriber who has a legal requirement to authorise this practice ( It is understood that this is common in paediatric practice.

 Some tablets are not suitable for crushing. For example, slow release capsules SHOULD NOT be crushed as the coating prevents the release and absorption of the drug until it has reached the small intestine Soluble tablets/capsules should not be crushed but dissolved in water. Some capsules should not be broken or opened as the preparation inside the shell is coated in a matrix (e.g. Vancomycin tablets Tablets should not be broken in half unless they are scored and an appropriate tablet cutter should be used.

CONTRAINDICATIONS Unconscious child Absent gag reflex Inability to swallow Vomiting CAUTIONS Digestive tract trauma/illness Post gastro-intestinal surgery Nil-by-mouth Nausea Diarrhoea

2.Intramuscular injection

Intramuscular injection sites for infants and small children

Rectus femoris site for intramuscular injection

 Giving intramuscular injection to child. Vastus lateralis site for intramuscular injection

Intravenous route
Preparation Administration restrain, Diversional. Subcutaneous stimulation

Any questions ?

Lets take a break

3. Assessment and management of pain in infants and children

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: 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 Assessment I. General Principles A. Pain assessment - QUESTT model. components into their pain assessments: 1. Question the child 2. Use pain-rating scales 3. Evaluate behavior and physiological change 4. Secure parental involvement 5. Take cause of pain into account 6. Take action and evaluate results

B. Select a pain assessment tool based on the developmental age of child, and in collaboration with the child and family.
1) Use self-report scales whenever possible: (FACES & VAS).

2) Use behavioral scales with preverbal and nonverbal children: (PIPS, NIPS, Comfort).

PAIN ASSESSMENT SCALES

1.Premature Infant Pain Scale (PIPS) Use for premature infants (<36 weeks gestation) 2.Neonatal Infant Pain Scale (NIPS) Use for infants, toddlers, or any child who is nonverbal For children with severe developmental delay or severe cognitive delay,

3.Wong-Baker Faces Rating Scale (FACES) Use for children > 3 years old Self reports are valid and preferred for most children > 3 years old 4. Verbal Analogue Scale (VAS) Use for children > 8 who understand the concept of order and number

Pain Assessment: Subjective 3.Wong-Baker Faces Rating Scale (FACES)

 B. Regardless of the setting, if pain is present, an initial pain assessment will be completed as appropriate. The assessment may include the following components based on setting, developmental age of the child, diagnosis, and severity of the condition: Pain intensity Location Quality, patterns of radiation, character Onset, duration, variations and patterns Alleviating and aggravating factors

 Present pain management regimen and effectiveness Pain management history Medication history Presence of common barriers to reporting pain and using analgesics Past interventions and response Manner of expressing pain Effects of pain Impact on daily life, function, sleep, appetite, relationships with others, emotions, concentration, etc Patient s pain goal and goals related to function, activities, quality of life Physical exam/observation of the site of pain

 C. Child and family teaching, upon the initial assessment, will include the following: 1) Effective pain relief is an important part of their treatment 2) Health professionals will respond quickly to their reports of pain 3) A total absence of pain is often not realistic or even a desirable goal 4) Pain will be assessed at regular intervals through the use of self-report and/or behavioral observation tools. 5) Pain management plan 6) Possible side effects of any medications 7) Families can help their child by: Informing the nurse when the pain first begins Informing the nurse if the pain is not relieved Informing the nurse about any suspected side effects of pain interventions Asking any questions they may have regarding their child s pain management.

Pain Management
Non-pharmacological nonpharmacological technique based on developmental age of child; effectiveness of prior use; pain and anxiety level of patient and family; and ability andwillingness of patient and family to follow instructions. Involve Parents

Prepare the child without planting the idea of pain Distraction Cutaneous Stimulation Rewards

Sensory Physical

Cognitive

Cognitive/Behavioral

Cold/Heat Deep breathing Distraction Environmental modification Exercise Relaxation Massage

Guided imagery Information giving Choices control Positioning

Art and Play Modeling, role playing, behavioral rehearsal Desensitization* Mindful meditation Breathing/Relaxation

Pain Management
Pharmacological
Right Drug
opioids vs non-opioids?

Right Dose
body weight Parenteral vs Oral doses

4. TRANSPORTING A SICK CHILD

BASIC GUIDELINES Stabilize the neonate /child. Refer to the nearest /base hospital Inform the parents/family Prepare transport equipment (incubator),oxygen/ emergency kit. Continuing assessment of vitals

5. Position and Restraint of a child

Are we violating the childs rights by restraints? When is restraint and immobilisation necessary?

 One child named Sara, for instance, had attended nursery school and was becoming quite independent for her age before having a difficult hospital experience that included receiving 22 injections in just 2 days. After she returned home, she was highly anxious. Her mother reported: She follows me everywhere! I can t even go to the bathroom alone. She wakes up screaming five or six times at night, shaking and crying, The nurses are giving me shots! I can t run away! They re tying me down . . . and when I approach her, she backs away and shakes like a hurt puppy! (Ramsey, 1982, p. 332)

Defining Restraint
Restraint is involuntary restriction of movement of the whole or a portion of a patient s body as a means of controlling their physical activities in order to protect themselves or others from injury. Restraint may incorporate the use of a physical device (physical restraint) or the administration of medication (chemical restraint).

RESTRAINT EXCLUSIONS:
Medical Immobilization/Protection: Usual, customary devices that are considered normal standard care for hospitalized children and infants that are integral to medical, dental, and surgical procedures IV devices (arm boards, IV covers, arm cuffs, swaddling devices) Positioning (positioning during surgery, orthopaedic devices, swaddling devices) Protective devices (helmets, bedrails, bubble tops)

Restraint Applied Under Clinical Care Protocol (cont.)

The least restrictive device must be selected. Family notification required by health care team. Written Modification to the Care Plan Utilize On-Line Orders Alternatives tried, behavior indicating the need for restraint, type of restraint, body area and explanation to family Every 2 hours: Assessment of the patients behavior indicating the need to continue restraint

Alternatives to restraint tried Neurocirculatory, resporatory status, skin integrity, restraint effectiveness, patient needs addressed, release of restraint At the conclusion: patient behavior indicating why restraint was discontinued.

 A diagnostic procedure where a sterile needle is introduced into the lower spine (L2) to collect cerebrospinal fluid for diagnostic purposes. Chemical analysis, cellular analysis and CSF pressure can all be measured with this procedure. This test can aid in the diagnosis of meningitis, subarachnoid haemorrhage and multiple sclerosis.

a.Positioning a child for lumbar puncture

2.BED RAILS

Arm Restraints for Immobilisation

Conclusion
So do children, but their level of psychosocial development may make some aspects of the hospital experience particularly difficult for them. For one thing, children are less able than adults to influence and understand what is happening to them. The experience of being hospitalized is distressing for children of all ages, but the reasons for their distress tend to change as they get older . Nursing sick children is quite challenging.

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