Transcript Pain in Children

Highlights of Chapter 21 and 22
The Child’s Experience and
Adapting to Pediatric Care
Preparing a Child for a Procedure
Box 21.1 Page 464
Infants
Toddlers
School Age
Teen
Remember the principle of regression in
ALL!
Fear Questions
What are toddlers most afraid of in a
hospitalization? 474
What are pre schoolers most afraid of in a
hospitalization? 476
How would one help a pre schooler work through
their fear?
What is a school age child’s primary concern?
What is a teenager’s primary concern? 476
Separation Anxiety
6 months up
Most pronounced in toddler
Protest
Despair
Denial or Detachment
Prolonged detachment=disruption of
bonding
Principle of reverting back to previous stage
Separation Anxiety Questions
At what age is separation anxiety at its
peak? 465
When a nurse or parent leaves a toddler or
preschooler how would they explain when
they will return?
Pain in Children
Under treated due to:
Misconceptions about pain
 Misconceptions about opioid use
 Lack of awareness of detrimental affects of
pain
 Verbal ability of children

Developmental Expectations of
Children in communicating pain
All infants and children experience pain
Newborn and early childhood pain communicated
through physical and behavioral response
Pain words emerge at 18-24 months
Description and gross indication of intensity by 35
Able to give better description of intensity by age
7 due to ability to rank, serialize
QUEST
Question the child.
Use pain rating scales.
Evaluate behavior and physiologic changes.
Secure parents' involvement.
Take cause of pain into account.
Take action and evaluate results.
Physiological Responses to Pain
Increased BP, respirations, pulse
Flushing of the skin
Sweating
Restlessness
Decreased O2 sats
Dilation of pupils
WEBSURFING ON PAIN
http://www.childcancerpain.org/frameset.cf
m?content=assess01
Let’s take a couple of minutes and look at
this site.
A preschool pain rating scale
FLACC Scale
Categor
y
Scoring
1
2
3
Face
No particular expression or smile
Occasional grimace or frown, withdrawn, disinterested
Frequent to constant quivering chin,
clenched jaw
Legs
Normal position or relaxed
Uneasy, restless, tense
Kicking, or legs drawn up
Activity
Lying quietly, normal position,
moves easily
Squirming, shifting back and forth, tense
Arched, rigid or jerking
Cry
No cry (awake or asleep)
Moans or whimpers; occasional complaint
Crying steadily, screams or sobs, frequent
complaints
Consolab
ility
Content, relaxed
Reassured by occasional touching, hugging or being
talked to, distractible
Difficult to console or comfort
References
The FLACC pain scale and Riley pain scale
can be found at this website:

http://www.childcancerpain.org/frameset.cfm?c
ontent=assess01
Pediatric Pain Medications
Non Opioid:

Tylenol, Ibuprofen
Opioid:

Codeine, hydrocodone, meperidine, morphine
oxycodone, fentanyl
Adjunctive:


Tricyclic antidepressents in chronic pain
Benzodiazepines to reduce anxiety and produce
amnesia
Children’s Tylenol
Know the difference
Infant Drops
Tylenol infant drops
come in a
concentration of 160
mg/1.6 ml
The dropper is a .8 ml
dropper for 80 mgs
Dose 15 mg/kg/dose
Children’s Tylenol
Suspension
Tylenol suspension
160mg/5 mls
Dose is 15 mg/kg q4h
for a maximum of 5
doses a day
Children’s Ibuprofen
Know the difference
Children’s Ibuprofen Syrup
Advil (Ibuprofen)
suspension or syrup
100 mg/5 ml
8-10 mg/kg/6hrs
Do not exceed 40
mg/kg/day (4 doses)
Ibuprofen Pediatric or Infant
Drops
50 mg/1.25 ml
Dose 8-10 mg/kg/6h
Do not exceed 40
mg/kg/day
Four math problems
12 kg infant receiving Tylenol Suspension
at dose in previous slide; how much?
6 kg infant receiving Tylenol Infant Drops
at dose in previous slide; how much
15 kg infant receiving Ibuprofen Suspension
at dose in previous slide; how much
5 kg infant receiving Ibupofen Pediatric
Drops at dose in previous slide; how much
Cultural Sensitivity
Page 470
Be yourself
Be aware that people express themselves
differently
Always go on the principle of good will and
intent
The Hospitalized Infant
Frustration in their needs not being met.
Do not expect them to develop new habits
Emphasis in assisting with the:


Parent/infant attachment
Sensorimotor opportunities
Gentle
Cuddle and comfort
Liberal visiting policies
Consistency
The Hospitalized Toddler
Separation anxiety at it’s peak 474
Box 21-2 Nursing Goals
Transitional objects
Restraints and “autonomy vs. shame and
doubt”
Distractions
Choice when able
The Hospitalized Preschooler
Feelings of guilt
Very afraid of bodily harm, mutilation and
invasive procedures
Praise is important
Role playing through experiences
See box 21.3 page 476
The Hospitalized School Ager
More able to endure the separation
Force dependency is the big issue
Loss of control and security
 Need to feel grown up and have independence

Education must continue
Scheduling around important routine in
child’s life
See nursing tip page 477
The Hospitalized Adolescent
Loss of control
Dependence/independence issues
Threat to identity
Response
Withdrawal
 Non compliance
 Anger

Early, Middle, Late Adolescence
Early

Threat to body image more than forced
dependence
Middle
Sex appeal and sex role expectations
 Relinquish of control is also a issue

Late

More concerned with the interference in life
Chapter 22; Admission
Identification
Safety Do’s and Don’ts page 482
Holding an infant; watch the head
Mummy restraint when necessary
Pediatric Adaptations
tympanic temperature
Down and back under three
Slightly up and back over three.
Aim it at the opposite eye brow
Use only in infants over three months
Head circumference
measurement
Tape measure around
the head, slightly
above the eyebrows
and ears and around
the occipital
prominence of the
skull
Body influences on medication in
infants and children
Gastrointestinal:
infants have a lower level of acid content in the
stomach up to age two
 Children under five may have a more rapid
intestinal transit time
 Lower pancreatic enzymes
 New book 495 old book 508

Body influences on medication in
infants and children
Integumentary
Thin stratum corneum allows topicals to be
absorbed at a greater amount
 Larger skin surface area also increases
absorption
 Diapers are an occlusive dressing and may
increase absorption of medications

Body influences on medication in
infants and children
Parenteral Medications
Slower absorption of IM in young infant
 In neonates medication may pass the blood
brain barrier more easily than in older children,
therefore be more guarded with regards to
respiratory depression.

Body influences on medication in
infants and children
Liver immaturity until ages 2-4 therefore
drugs metabolized by liver metabolize more
slowly
Medications given at frequent intervals may
result in toxic levels and responses
Body influences on medication in
infants and children
Immature kidney function prevents
effective excretion of drugs from infants
under a year of age
Fever and hyperthermia
Page 488 new book
Fever: hypothalamus has raised the body
temperature set point as a respond to
bacteria or toxins in conjunction with
body’s prostaglandins
Hyperthermia increase in core body
temperature ocurring with CNS impairment
or overheating.
Pathogenesis of Fever and the
Use of Antipyretics

Infection from bacteria and other toxins stimulates immune
substances to work along with prostaglandins, to stimulate the
hypothalamus to raise the body temperature




Triggers vasoconstriction, shivering, and decreased peripheral
perfusion
Decreases body heat loss while maintaining homeostasis
Antipyretic medications inhibit prostaglandin production
Fever increases metabolic demand on the heart and lungs
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier Inc.
Slide 13
Hyperthermia


An increase in core body temperature
occurs with central nervous system
impairment
Prostaglandins are not involved


Homeostasis mechanism is bypassed
Treatment involves vigorous cooling
measures
Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier Inc.
Slide 14
Body Surface Area
A method to accurately dose a drug for a
pediatric patient
Usually used in highly toxic drugs
Used in converting adult doses to pediatric
doses
You will probably not see this method in
your career unless you go into oncology
BSA/1.7 X adult dose= child dose
Pediatric dosing; Mg/kg
Pablo Martinez, a 5-year-old boy, is
diagnosed with bacterial meningitis. He
weighs 19 kgs.
The MD orders cefuroxime IM 950mg q8h
Dosage is 200-240 mg/kg/day divided q 6
or 8
Is the above dose appropriate?
Fun drug test to take
http://classes.kumc.edu/son/nurs420/clinical
/basic_review.htm#Pediatric%20calculation
s
http://classes.kumc.edu/son/nurs420/clinical
/basic_practice_.htm
Oral Medication Points
Cherry syrup or jelly to mix not other
nutritious food
Syringe down the side of the mouth
Position on page 500/513 good way to hold
Bib yourself!
Do not place in bottle with juice or water
IM injections
Page 515 old book 502 new book
Discuss sites, size of needle and amounts
Nursing Assessment for IV
Monitor IV site hourly
 Flow rate
 Swelling at needle site
 Low volume in IV bag/burette
 Pain or redness at insertion site
 Moisture at or around site
Accurate I & O
Tracheostomy Suctioning Points
Suction catheter ½ size of tube
Sterile procedure
Suction applied only when withdrawn
Tube rotated while withdrawing
Saline may be added before suctioning
Do not suction more than 10 seconds
Reoxygenation is important
Limit suctioning to the length of the tracheotomy tube
Clear catheter with sterile water in between insertions
Discard catheter when done
Tracheostomy sizing charts
Bivona
Shiley
Size
I.D.
O.D.
Length
mm
Suction
Catheter
Size
I.D.
O.D.
Length
mm
Suction
Catheter
2.5 NEO
2.5
4.0
30
6
3.0 NEO
3.0
4.7
32
6 or 8
3.0 NEO
3.0
4.5
30
6
3.5 NEO
3.5
5.3
4.0 NEO
4.0
6.0
34
6 or 8
3.5 NEO
3.5
5.2
32
6 or 8
36
6 or 8
4.0 NEO
4.0
5.9
34
6 or 8
2.5 PED
2.5
4.5 NEO
4.5
6.5
36
6 or 8
4.0
38
6
3.0 PED
3.5 PED
3.0
4.7
39
6 or 8
3.0 PED
3.0
4.5
39
6
3.5
5.3
40
6 or 8
3.5 PED
3.5
5.2
40
6 or 8
4.0 PED
4.0
6.0
41
6 or 8
4.0 PED
4.0
5.9
41
6 or 8
4.5 PED
4.5
6.7
42
6 or 8
4.5 PED
4.5
6.5
42
6 or 8
5.0 PED
5.0
7.3
44
8 or 10
5.0 PED
5.0
7.1
44
8 or 10
5.5 PED
5.5
8.0
46
10 or 12
5.5 PED
5.5
7.7
46
10 or 12
Great websites
http://www.tracheostomy.com/care/suction.
htm
For sizing of Trachs:

http://www.tracheostomy.com/resources/more/t
able.htm
Gastrostomy Tube Issues
Securing
Cleaning
Bathing
Venting/Burping
Tube displacement
Leakage
Skin Breakdown
Box 22-5 (old) 22-9
new 511