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Chapter 2 Care of the Child with Medical/Surgical Needs Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. Key Terms • • • • • • • Adventitious Case manager Contaminated Critical pathways Disinfected Dramatic play Hospice • Hypnosis • Pediatric nurse practitioner (PNP) • Reconciled • Standard precautions • Therapeutic holding • Triage Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-2 Health Care Delivery Settings Clinics and Offices • Outpatient facilities and/or community clinics – Run by a larger hospital – A collaborating group of physicians, or a private physician’s office • Both general and specialty clinics exist – Cardiac, orthopedic, respiratory, etc • Elective surgery for uncomplicated conditions is routinely done in outpatient clinics – Parents/caretakers must be taught to meet all of a child’s recovery needs at home for a same-day discharge procedure Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-3 Health Care Delivery Settings Clinics and Offices • Triage – In most offices/clinics, nurses triage (prioritize) and respond to telephone inquiries • Pediatric Nurse Practitioner (PNP) – Provide in-clinic patient care, including routine physical exams in collaboration with the physician – Often they are the primary contact person for children in the health care system Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-4 Health Care Delivery Settings Home Care • Increasingly popular due to technical improvements – – – – Ongoing IV therapy home care Phototherapy home care for jaundice Lower cost Increased patient satisfaction • Case Manager – Plays a vital role in home care arrangements by managing complete medical care for the patient – Facilitates linking home care families into a wide variety of network services • Hospice – A team of hospice nurses and caregivers assist the families in providing home care for terminally ill children Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-5 Health Care Delivery Settings Other Settings • Support groups – Geared toward family support and learning – Group therapy aids in the prevention of mental health problems for children who have undergone stressful situations • Camps – Many exist in the U.S. for children with chronic illnesses – Camp nurses ensure children receive proper care • Parish nurses – Promote health within the context of a faith community • Long-term care facilities – May be necessary for children with severe mental retardation, multiple disabilities or medical fragility Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-6 The Hospital Setting • Pediatric units differ from adult units – A more cheerful, casual atmosphere in keeping with the child’s emotional and physical needs • Most pediatric departments include a playroom with toys for various age groups run by a child life specialist – Nurses provide age-appropriate toys to children who can’t leave their rooms • A flexible routine is typically maintained in regards to eating, play, and rest • Most hospitals provide beds and encourage parents to stay with their children Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-7 The Child’s Reaction to Hospitalization • Factors – – – – Age Previous illness-related experiences Support of family and health professionals Emotional status • Stressors – – – – Separation anxiety Loss of control Bodily injury Pain Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-8 Question 2.1 Which of the following is true pertaining to a child in isolation? A. The child may visit play areas with other children, as long as careful sanitation procedures are followed B. The child shouldn’t be allowed any toys because his/her disease is very contagious and could spread easily through toys C. The nurse may provide age-appropriate toys to the child in his/her room D. Both A & C Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-9 The Child’s Reaction to Hospitalization Infants and Toddlers • Separation anxiety – The major stressor of hospitalization for toddlers – Occurs in the following stages • Grief – Protesting loudly and crying for their mothers until falling asleep from exhaustion • Despair – Depression, lethargy, refusal to eat • Denial – Deny the need for mother by appearing detached and uninterested in her visits – A disguise to prevent further emotional pain Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-10 The Child’s Reaction to Hospitalization Infants and Toddlers • Loss of control • Regression – Toddlers will abandon recently acquired skills and demand assistance with tasks previously mastered – Nurses should remind parents that this is normal behavior when toddlers are hospitalized • Fear of injury – Minimizing fear of injury stressors Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-11 The Child’s Reaction to Hospitalization Infants and Toddlers • Dealing with the stressors of hospitalization – Toddlers achieve control through choices – Forewarn children about any unpleasant or new experience immediately beforehand – Be honest about procedures, etc., that may hurt – Explain procedures step-by-step as they occur Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-12 The Child’s Reaction to Hospitalization Infants and Toddlers • Dealing with the stressors of hospitalization – Encourage play with safe equipment; i.e., stethoscopes under supervision – Administer treatments in a room other than the child’s room – Allow toddlers out of the crib whenever possible Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-13 The Child’s Reaction to Hospitalization Preschoolers • Separation anxiety • Uncooperative; frequently ask for parent • Loss of control – Many preschoolers perceive hospitalization as punishment • Regression – E.g.: bedwetting • Fantasy • – – – Pre-logical thinking; fantasy Fear of hospital machinery Nightmares Fear of bodily harm during procedures Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-14 The Child’s Reaction to Hospitalization Preschoolers • Communication between nurse and patient – Use understandable language when describing procedures – Communicate time as a series of events, not hours and minutes – Be aware of verbal and nonverbal cues – Participate in fantasies in a positive way, giving the child control over imagined situations Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-15 The Child’s Reaction to Hospitalization Preschoolers • Dealing with the stressors of hospitalization – Dramatic play • Children act out situations that are a part of their hospital experience • Allows children to “work through” emotions • Make a doll with a dressing or an IV so the child can act out the care they receive in order to displace their fears. Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-16 The Child’s Reaction to Hospitalization School-Age Children • Separation anxiety • Miss parents but miss friends more • Loss of control – Children in this age group are learning to control their feelings and actions – Independence is limited – They may have changes in vital signs due to stress when hospitalized, even if making efforts to seem calm • Fear of pain, bodily harm, permanent disability, body disfigurement or death Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-17 The Child’s Reaction to Hospitalization School-Age Children • Dealing with the stressors of hospitalization – Bring items from home for familiarity and control – Drawing – Board games with involved adults – Maintain the child’s privacy – Continue education; connect to the outside world – Encourage classmate correspondence; Oh, the cell phones!!! Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-18 The Child’s Reaction to Hospitalization Adolescents • May be hesitant to have visitors – May be embarrassed by appearance – Fear that illness or procedures will change them • Compliance may be a problem with a chronic disease – Probably afraid and stressed, even if they seem calm • Dealing with the stressors of hospitalization – Fear of the unknown; explain everything in an age-appropriate manner – Offer choices to maintain control and independence – Clear limits and expectations so adolescents feel less confused Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-19 Question 2.2 A mother is distraught to find her toddler uninterested in her presence as she visits him in the hospital. She begins reprimanding him. What action should the nurse take? A. None; a nurse shouldn’t come between a mother and her child. B. Explain that the child must be in a bad mood today, and the mother should visit tomorrow. C. Explain that his behavior is normal and encourage continued frequent parental visits. D. Discourage subsequent visits until the child is discharged for his own mental health. Assure her that he is in good hands. Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-20 The Hospitalized Child The Family’s Reaction to Hospitalization • Parents may initially feel guilty, helpless, and anxious • Developing a trusting relationship with parents is often the key to helping the child • Hospitalization may cause financial problems for the family • The nurse assesses the family’s needs and develops interventions to meet these needs Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-21 The Hospitalized Child The Family’s Reaction to Hospitalization • Nursing Interventions – Assist parents in obtaining written and verbal information concerning the condition of the child and the treatment plan – Orient the family to the hospital – Explain all procedures – Refer the parents as needed to social services – Listen to parents’ concerns and clarify information – Involve parents in the care of the child – Provide for rooming-in – Reinforce positive parenting – Provide educational resources as necessary Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-22 The Nurse’s Role Admission Process • Provide a tour for the parents and child before admission, if possible to decrease fear of the unknown • Focus on pleasant and positive aspects—but not to the point where hospitalization seems to involve no discomforts • Security objects from home reduce anxiety in an unfamiliar setting • In addition to explaining certain procedures, listen to patients and encourage questions • After essential admission information is documented, the nurse performs a systems review and physical examination of the child • All medications are reconciled upon admission, transfer, and discharge Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-23 The Nurse’s Role Health History • Statistical information (name, address, phone number) • Patient profile (eating and sleeping habits, educational level, developmental level, etc.) • Health history (birth history, illnesses, immunizations, previous hospitalizations, allergies, etc.) • Family history (information concerning the health status of the immediate family) • Lifestyle and life patterns (social, psychological, physical, and cultural environment) • Review of systems Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-24 The Nurse’s Role Systems Review • When examining the child, generally proceed in a head-to-toe manner while collecting vital signs • Note the facial expression and the general appearance of the child • Always talk to the parents about how they think their child is doing, because they know their child best • Be sure to document and report any unusual or abnormal findings Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-25 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-26 The Nurse’s Role Systems Review • Pulse – The pulse rate varies considerably in different children of the same age and size – An apical pulse is recommended for infants and small children – The normal pulse and respiratory rates of the newborn infant are high – Both pulse and respiratory rates gradually decrease with age until adult values are reached Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-27 The Nurse’s Role Systems Review • Respirations – Counted by observing the movement of the abdominal wall because respirations are primarily abdominal at this time – After about age 7 years, the child’s respirations are measured in the same way as the adult’s – Lungs should be clear to auscultation with no adventitious or abnormal breath sounds Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-28 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-29 The Nurse’s Role Cultural and Religious Preferences • Cultural beliefs affect how a family perceives health and illness • Some practices raise concerns of abuse – E.g.: Coining; cupping • Inform families that strict disciplinary practices may place them in jeopardy with child protective services • Respect any rites, dietary restrictions, etc., associated with a family’s religion, as long as it does not interfere with the child’s well-being Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-30 The Nurse’s Role Care Plans and Critical Pathways • Most hospitals use nursing care plans – Written expression of the nursing process • Critical pathways – Convert expected medical, nursing, social, and emotional outcomes for a particular problem into actions necessary to achieve the outcomes within a specified time frame Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-31 The Nurse’s Role Discharge Planning • Preparation for discharge begins on admission • Directions for home treatment should be given to parents gradually throughout their child’s hospitalization • Charting includes time of departure, person with whom the child departs, patient’s behavior, instructions/medications given to the patient or parents, and weight/vital signs upon discharge Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-32 The Nurse’s Role Discharge Planning • Prepare parents for potential post-hospitalization behavior problems – Clinging, regression in bowel and bladder control, aggression, fears, nightmares, negativism – Return former family responsibilities within the limits of the child’s present abilities as soon as possible – Avoid making the child a center of attention because of illness. Praise accomplishments unrelated to illness – Be kind, firm, and consistent if the child misbehaves – Be truthful to maintain trust – Provide suitable play materials: Clay, paints, doctor/nurse kits. Allow free play – Listen to the child, clear up misconceptions about the illness – Don’t leave child alone for a long period or overnight until a sense of security is regained Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-33 Safety Transporting, Positioning, and Restraining the Child • Means of transportation varies with a child’s age • Ensure that a patient’s identification band is secure before leaving the unit • Holding a baby – Head and back support is necessary for young infants – Random movements of small children necessitate secure holding • Restraints should rarely be used – Detailed documentation is required – Restraints must be removed at least every 2 hours to avoid impairing circulation • Therapeutic holding – Holding a child in a secure, comfortable manner Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-34 Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-35 Safety Transporting, Positioning, and Restraining the Child Do • Check wheelchairs and stretchers before placing patients in them • Use safety straps with children when they are in a highchair, swing, infant seat, stroller, and so on • Apply restraints correctly to prevent constriction of a part. Check institutional policy on frequency of releasing restraints and providing range of motion • Handle infants and small children carefully. Use elevators rather than stairs. Walk at the child’s pace • Place a hand on the infant or child’s back or abdomen when you turn your back to the child • Always look for small objects which can become choking hazards Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-36 Safety Transporting, Positioning, and Restraining the Child Do • Protect children from entering the treatment room, elevator, utility rooms, and stairwells • Keep crib sides up at all times when the patient is unattended in bed. Use enclosed (bubble top) cribs for older infants and toddlers to keep them from falling or climbing out of the crib • Turn an infant perpendicular to the side of the bed when rails are down. This helps ensure that the infant will not roll off when side rails are down • Place cribs so that children cannot reach electrical outlets and appliances • Check hospital policy for children who are alone (for instance, policy may recommend that the door be kept open) Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-37 ADAPTED CRIB FOR SAFETY Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-38 Safety Transporting, Positioning, and Restraining the Child Don’t • Don’t force-feed small children. There is a danger of choking, which may cause lung disease or sudden death • Don’t allow ambulatory patients to use wheelchairs or stretchers as toys • Don’t leave a child unattended in a highchair, infant seat, swing or stroller • Don’t leave a child unattended on an examination table – Always keep your hand on the child • Don’t leave a child unattended in an infant seat if it is placed on any area above the floor • Don’t leave small children unattended out of their cribs in their rooms • Don’t leave a child unattended in the bathtub • Do not tie balloons to the crib rails Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-39 Safety Medical Asepsis • Contaminated – A person/object that has come into contact with an infected patient • Disinfected – Killing microorganisms physically or chemically Do • Wash your hands before and after caring for each patient • Properly disinfect any item brought out of an isolation room Don’t – Don’t cause cross-infection • Diapers, toys, and materials that belong in one patient’s storage unit should not be borrowed for another patient’s use Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-40 Safety Preventing the Transmission of Infection • Standard precautions—Followed because a history and physical exam cannot identify all patients infected with HIV or other blood-borne pathogens – – – – – Handwashing Gloves Masks Gowns Protective eyewear Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-41 Safety General Safety Guidelines Do • • • • • • • • • • Inspect toys for sharp edges and removable parts Identify the patient properly before giving medications Keep medications and solutions out of reach of the child Keep the medication room locked when not in use Keep lotions, tissues, disposable pads and diapers, and safety pins out of infant’s reach Locate fire exits and extinguishers on the unit and learn how to use them properly. Become familiar with the facility's fire manual Supervise playroom activity Take proper precautions when oxygen is in use Use electrical outlet safety plugs on the unit Continually assess the patient setting for safety issues Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-42 Safety General Safety Guidelines Don’t • Don’t leave medications at the bedside • Don’t leave any medication administration materials in the child’s bed or infant’s crib • Be aware of wear you place the caps from the pediatric oral syringes. Do not leave in the bed! Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-43 Safety Education of the Family • • • • Importance of immunizing children Proper food handling Handwashing Primary modes of infectious disease spread and how to avoid them Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-44 Implications of Pediatric Surgery Patient Preparation • The nurse should give simple information about the system that will be affected – Stress that this is the only area of the body that will be involved • Children need to know what to expect on the day of surgery • Children are particularly fearful of surgery and need both physical and psychological preparation • The child should be able to easily understand explanations and information given in simple terms • It is important to always be truthful; this establishes trust Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-45 The Child in Pain Definition and Challenges • Children of all ages experience pain and are entitled to appropriate pain management • Pain is an individual, subjective experience, and health care providers need to identify and treat pain adequately Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-46 The Child in Pain Evaluation • Always ask the child and/or the parents about past pain experiences and known coping mechanisms • When evaluating the child, include precipitating factors, location, onset, duration, quality, intensity, and characteristics of the pain • Pain scales – 1 to 10 – FLACC • Infants and young children – Oucher Scale • 2- to 7-year-olds – Wong-Baker FACES Pain Rating Scale • Preschool and young school-age Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-47 Wong and Baker Faces scale Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-48 FLACC pain scale Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-49 The Child in Pain Intervention • Oral administration is generally used for mild to moderate pain • When the child needs immediate pain relief for more intense pain, intravenous administration is indicated • For moderate to severe pain that is expected to persist, continuous dosing or around-the-clock dosing at fixed intervals is recommended • Pain medication may also be administered rectally, by intramuscular (IM) injection, transdermally, or topically (EMLA, LMX) • Nonopioid analgesics are most effective for mild to moderate pain and have antipyretic effects as well • Opioids are used to manage most forms of moderate to severe acute and chronic pain Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-50 The Child in Pain Intervention • Nonpharmacologic interventions – Used in conjunction with pharmacologic interventions or by themselves – Complementary or alternative medicine (CAM) • Hypnosis • • • • – Altered state of consciousness. Suggestions can lead to changes in behavior or physical sensations TENS unit Acupuncture Chiropractors Massage therapy Copyright © 2012 by Saunders, an imprint of Elsevier, Inc. 2-51