Unique Considerations in Children

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Unique Considerations in Children

• Chapter 13-14, 16-20
• By Nataliya Haliyash, MD, BSN

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Lecture Objectives

• Upon completing the lecture the student will be
  able to
• Explain what communication is and its importance
  in developing positive relationships with
  children and their families.
• Describe verbal and nonverbal communication.
• Discuss the elements of communication, including
  rapport and trust, respect, empathy, listening,
  providing feedback, and conflict management.
• Describe the impact and challenges that a child's
  developmental level has on communication.
• Elicit a complete health history from a child and
  caregiver using standard components of a
  pediatric health history.
• Identify various techniques of approaching
  children at different developmental levels before
  initiating the physical assessment.
• Care of children who are hospitalized
• Provide pain management

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Stressors of Hospitalization

• Separation anxiety
• Protest phase
• Cry and scream, cling to parent
• Despair phase
• Crying stops evidence of depression
• Detachment phase
• Denial resignation and not contentment
• May seriously affect attachment to parent after
  separation

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Loss of Control Infants Needs

• Trust
• Consistent, loving caregivers
• Daily routines

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Loss of Control Toddlers Needs

• Autonomy
• Daily routines and rituals
• Loss of control may contribute to
• Regression of behavior
• Negativity
• Temper tantrums

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Loss of Control Preschoolers

• Egocentric and magical thinking typical of age
• May view illness or hospitalization as punishment
  for misdeeds
• Preoperational thought

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Loss of Control School Age

• Striving for independence and productivity
• Fears of death, abandonment, permanent injury
• Boredom

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Loss of Control Adolescents

• Struggle for independence and liberation
• Separation from peer group
• May respond with anger, frustration
• Need for information about their condition

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Fears of Bodily Injury and Pain

• Common fears among children
• May persist into adulthood and result in
  avoidance of needed care

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Young Infants Response to Pain

• Generalized response of rigidity, thrashing
• Loud crying
• Facial expressions of pain (grimace)
• No understanding of relationship between stimuli
  and subsequent pain

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Facial expression of physical distress and pain
in the infant
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Older Infants Response to Pain

• Withdrawal from painful stimuli
• Loud crying
• Facial grimace
• Physical resistance

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How to calm your infant and stop their crying by
just doing a few simple things

• Step 1 Swaddle your baby (this means wrapping
  your baby tightly in a blanket- similiar to how
  they do in the hospital)
• Step 2 Place pacifier in baby's mouth. If you
  baby cannnot hold their pacifier by themselves,
  you may choose to do this step after step 3.
• Step 3 Hold baby sideways against your stomach
  craddling their head and feet on your arms.
• Step 4 Sway from side to side slowly. You may
  even choose to bounce up and down slowly, which
  ever works for your baby.
• Step 5 Make a "shhh" noise or you may even turn
  on some music (classical would work best) and you
  can do these things pretty loud since the womb is
  as loud as a vaccum cleaner.
• Step 6 It may take a little time, but this will
  comfort baby and make them stop crying- and
  possibly make them fall asleep.

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Young Childs Response to Pain

• Loud crying, screaming
• Verbalizations Ow, Ouch, It hurts
• Thrashing of limbs
• Attempts to push away stimulus

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School-Age Childs Response to Pain

• Stalling behavior (wait a minute)
• Muscle rigidity
• May use all behaviors of young child

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Adolescent

• Less vocal protest, less motor activity
• Increased muscle tension and body control
• More verbalizations (it hurts, youre hurting
  me)

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Effects of Hospitalization on the Child

• Effects may be seen before admission, during
  hospitalization or after discharge
• Childs concept of illness is more important than
  intellectual maturity in predicting anxiety

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Individual Risk Factors That Increase
Vulnerability to Stresses of Hospitalization

• Difficult temperament
• Lack of fit between child and parent
• Age (especially between 6 mos and 5 yrs)
• Male gender
• Below-average intelligence
• Multiple and continuing stresses (e.g., frequent
  hospitalizations)

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Changes in the Pediatric Population

• More serious and complex problems
• Fragile newborns
• Children with severe injuries
• Children with disabilities who have survived
  because of increased technologic advances
• More frequent and lengthy stays in hospital

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Beneficial Effects of Hospitalization

• Recovery from illness
• Increase coping skills
• Master stress and feel competent in coping
• New socialization experiences

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Parental Responses to Stressors of Hospitalization

• Disbelief, anger, guilt
• Especially if sudden illness
• Fear, anxiety
• R/T childs pain, seriousness of illness
• Frustration
• Especially r/t need for information
• Depression

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Sibling Reactions

• Loneliness, fear, worry
• Anger, resentment, jealousy
• Guilt

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Altered Family Roles

• Anger and jealousy between siblings and ill child
• Ill child obligated to play sick role
• Parents continue pattern of overprotection and
  indulgent attention

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Preparation for Hospitalization

• Assessment
• Nursing diagnosis
• Planning
• Implementation
• Evaluation

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Preventing or Minimizing Separation

• Primary nursing goal
• Especially for children lt5 yrs
• Family-centered care
• Parents are not visitors
• Familiar items from home

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Normalizing the Hospital Environment

• Maintain childs routine, if possible
• Time structuring
• Self-care (age appropriate)
• School work
• Friends and visitors

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Pain

• Pain is whatever the experiencing person says it
  is, existing whenever the person says it does.
• McCaffery and Pasero, 1999
• This includes VERBAL and NONVERBAL expressions of
  pain

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Pain Facts and Fallacies

• FACT Children are under treated for pain
• FACT Analgesia is withheld for fear of the child
  becoming addicted
• FALLACY Analgesia should be withheld because it
  may cause respiratory depression in children
• FALLACY Infants do not feel pain

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Principles of Pain Assessment in Children QUESTT

• Question the child
• Use a pain rating scale
• Evaluate behavioral and physiologic changes
• Secure parents involvement
• Take the cause of pain into account
• Take action and evaluate results

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Pain Rating Scales

• Not all pain rating scales are reliable or
  appropriate for children
• Should be age appropriate
• Consistent use of same scale by all staff
• Familiarize child with scale

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Pain Scales

• WONG-BAKER faces pain scale
• Numeric scale
• FLACC scale each of these categories is scored
  from 0-2 to provide a total pain score ranging
  from 0-10.
• Facial expression
• Legs (normal relaxed, tense, kicking, drawn up)
• Activity (quiet, squirming, arched, jerking,
  etc)
• Cry (none, moaning, whimpering, scream, sob)
• Consolability (content, easy or difficult to
  console)

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Nonpharmacologic Interventions

• Based on age
• Swaddling, pacifier, holding, rocking
• Distraction
• Relaxation, guided imagery
• Cutaneous stimulation

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Anesthetics Topical and Local

• Major advancement for atraumatic care
• EMLA
• NUMBY stuff
• Intradermal local anesthetics
• Importance of timing

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Numby Stuff System

• A needle-free method for delivering anesthesia
  can help alleviate pain associated with local
  dermal procedures.
• Numby Stuff is 2 lidocaine with 11000,000 epi
  that is given transdermally by a machine similar
  to the one used for sweat chloride testing. It
  uses a small electrical current (2 - 4 milliamps)
  to deliver the positively charged lidocaine into
  the dermal tissues. It works by ionopheresis and
  makes the positive charged meds more positive,
  thus driving them into the skin. You can give a
  dose up to about 1 inch deep (an 80 mamp dose).
  It is used for PICC lines, IV starts, and
  tunneled CVL removals.

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Analgesics

• Opioids
• NSAIDs
• Potentiators
• Lytic cocktail (DPT)Demerol, Phenergan, and
  Thorazine
• Co-analgesics, amnesics, sedatives, etc.
• Role of placebos

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Dosage of Analgesia

• Based on body weight up to 50 kg
• Concept of titration
• Ceiling effect of non-opioids
• First pass effect
• PCA

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Nursing Care of the Family

• Family assessment
• Discharge assessment and planning
• Encourage parent participation in planning and
  care
• Information
• Preparing for discharge and home care

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Care of the Child and Family in Special Hospital
Situations
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Ambulatory/Outpatient

• Benefits
• Preparation of child can be challenging
• The stress of waiting
• Explicit discharge and follow-up instructions

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Isolation

• Added stressor of hospitalization
• Child may have limited understanding
• Dealing with childs fears
• Potential for sensory deprivation

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Emergency Admission

• Essentials of admission counseling
• Postventioncounseling subsequent to the event
• Participation of child and family as appropriate
  to situation

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Intensive Care Unit

• Increased stress for child and parents
• Emotional needs of the family
• Parents need for information
• Perception of security from constant monitoring
  and individualized care

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Q A ?