Nursing Care of the Pediatric Patient

Mary E. Amrine, BSEd, BSN, RN

Children are more than just

“little adults”

Lake Health Pediatric Policies

Lake Health defines a pediatric patient as someone greater than 28 days of age through 17 years of age.

Pediatric patients greater than 28 days of age will be admitted to the

Medical-Surgical divisions.

4th floor @ West&

Surgical Telemetry @ TriPoint

Pediatric patients who require telemetry or hardware monitoring will not be admitted to Lake Health’s

Critical Care Units.

These patients are defined as: a. 15 years or youngerb. Less than 60 inches in heightc. Less than 34 kilograms in weight

All pediatric patients are weighed and measured to determine if they meet the criteria for the

Broselow-Hinkle Emergency System

• Less than 36 kilograms in weight are identified with the appropriate Broselow-Hinkle color coding which alerts team members how to respond appropriately

in an emergency.

Broselow-Hinkle Equipment• Responsibility of the Central Supply Processing

department.• Must be signed out• Kept on the Nursing division with the adult crash cart

until discharge of the patient.• The Measuring tape is located in the side pocket on

the outside of the bag. • If equipment is opened or lock broken, it is to be sent

to Central Processing for exchange.• If the equipment is not used, it is returned

immediately to central Processing upon discharge of the patient.

Locations of Broselow-Hinkle Equipment:

• Same Day Surgery (SDS)- TriPoint and West

• Emergency Department - Tripoint and West

• Operating Room/Post Anesthesia Care Unit PACU – TriPoint and West

• Central Processing – TriPoint and West

Note:

No Medications are kept in the Broselow-Hinkle Pediatric Emergency

System ( Bag).

Appropriate Medications are found in the adult emergency crash cart.

Room Preparation

Safety is imperative!

• Safety caps on outlets• All sharp objects are removed from room• Oxygen and suctioning equipment is to be set up and

“ready to go”• Toys /personal items brought with child inspected for

safety• Crib if applicable

Admission Procedure:

• Obtain a weight measurement

• If needed, obtain height by using the Broselow – Hinkle measuring tape if not done in emergency department.

• Inpatient’s Broselow color will be identified on the door, chart, and arm band.

• Parent or Guardian given name bands with patient’s height, weight and B.H. color code on it.

• Broselow color card placed on door

• Parent or guardian encouraged to stay

• Incorporate “family - centered care”

What does family-centered care mean??

The philosophy of “family - centered care”

recognizes the familyas the one constant

in a child’s life.

Three key components include:

Respect

Collaboration

Support

(Galvin and others 2000)

• The philosophy of family-centered care facilitates family and professional collaboration at all levels of hospital, home and community care.

• Parents serve as respected equals with professionals and have the right to decide what is important for themselves and their family.

• Strives to exchange complete and unbiased information between family members and professionals in a supportive manner at all times.

• Incorporating into policy and practice the recognition and honoring of cultural diversity, strengths, and individuality within and across all families, including ethnic, racial, spiritual, social, economic, educational, and geographical diversity.

Communication Tips

• Incorporate family - centered care• Allow time for child and family to settle in• Knock to announce your presence and introduce

yourself• Remember what you may think is welcoming, to

a frightened child may indeed be threatening. Slow down! • Explain what and why you are interviewing them

• Begin your interview in an unhurried manner

• Assume a position that is eye level with the child

• Address both the child and the parents

• Speak in a soft voice

• Use open-ended questions

• Communication with children must reflect their developmental stage.

• For the younger child – communicate through the use of transition objects such as, stuffed animals or dolls.

• For the school aged child- use concrete examples and utilize pictures and materials when possible.

• Provide both written and verbal instructions for the teenager.

• Assess what the child already knows before providing explanations and instructions.

• Use simple words and be careful with medical terminology as this is often very foreign to families!

• Allow and encourage child of any age to express their concerns and fears.

• Be a good listener – don’t interrupt.• Give parents an opportunity to express their concerns.• Be aware of non verbal communication cues as well as verbal cues.• State directions and suggestions positively.• Never assume!

• Explain the hospital routine!

• Let child and parents know what to anticipate.

• Be looking for signs of information overload!

• Remain open, accepting and non-judgmental throughout the interview and assessment.

Review of Growth and Development Principles

Three basic principles:

• It is predictable

• It is complex, continuous, Irreversible and lifelong

• It is directional and follows a prescribed sequence

Growth is an increase in physical size

Development is an increase in capacity or function.

Infants & Children

• During this stage of development, physical growth and development are rapid, especially in infancy.

• It is important for the child to build muscle skills which include from rolling, crawling, and standing as to running and drinking from a cup.

• In infancy, the child needs to develop a sense of trust and sense of being loved.

• This in turn will help the toddler attempt to become more independent.

• Play is the “work” of children!

• Play allows the child to learn, express their anxiety, and achieve a sense of control.

• Infants can only communicate by crying and making simple sounds.

• The typical toddler is able to say simple words and by age three is able to talk in simple sentences.

When caring for this age group, the nurse wants to remember…..

• Educate the parents about the importance of check-ups, screenings, and immunizations.• Pay attention to safety and providing for the child’s

comfort. • Talk in soothing tones• Explain procedures to parents and child in simple terms.• Keep the parent with the child and involve the parents

with the care of their child.• Encourage questions and concerns• Reinforce teaching on basic care, including feeding

hygiene, and safety.

Points to remember…

• A recent Pennsylvania poll found that just over half ( 50%) of the adults surveyed knew that babies should always be put to sleep on their backs!• When asked…… “ In what position is it best for a baby to sleep?” • 54.5% knew the correct answer• 26.1 % answered on the baby’s side• 19.5% answered on the baby’s stomach.

• Babies that sleep on their sides or stomachs are at a higher risk for sudden infant death syndrome (SIDS).

• Every parent and child caretaker needs to know this!

Preschoolers

• Growth is slower during these years. • Children are active and continue to develop coordination

and strength.

• Can feed and are able to toilet themselves as well as dress themselves.

• By nature, children tend to be curious and imaginative. They like make-believe play.

• Fear of separation, mutilations and death is real.

When caring for this age group the nurse wants to remember……..

• Continue to stress to parents the importance of check-ups, screenings, and immunizations.• Procedures and objects should be explained in a way that

the child can understand.• Avoid words that can be scary and easily misunderstood.• Explain the procedure first and reinforce that his is not a

punishment.• Allow the child to express feelings and asks questions.• Encourage parents to bring s security object to the

hospital for the child.• Include parents and asks if they have any questions or

concerns.

Points to remember……….Furniture Tip-Over Injuries

• Nearly 15,000 children are treated in emergency departments every year for injuries caused by furniture that has tipped over on them.• 75% are 6 years old and younger• The most common scenario is a child climbing on or pulls

over a piece of tall furniture.• A falling television was involved in half of the incidents• 40% sustained injuries to their heads or necks.• Over the last 17years, the number of injuries are increasing!

School Age Children

• Growth continues at a slower rate until puberty.

• Muscle skills and coordination continue to develop.

• Children can now accept rules and responsibilities.

• In order to develop self esteem, children need to be able to complete tasks, master new skills, and have their achievements recognized.

• As children get older, their friends become more important and they begin to want privacy.

When caring for this age group the nurse wants to remember……..

• Continue to remind parents about the need for immunizations, check-ups, and screenings.• Show a genuine interest in child and their activities.• Explain equipment and procedures in advance.• Use correct terms.• Respect privacy• Praise cooperative behavior• Teach child about healthy and safe behaviors • Encourage parents to talk with their children especially

about issues such as drugs and sexuality.

Points to Remember……..

Obesity & Children

• As children become more obese, they are showing signs of the same chronic diseases that we see in adults!

• Overweight is defined as a BMI at or above the 85th percentile and lower than the 95th percentile

• Obesity is defined as a BMI at or above the 95th percentile for children for the same age and sex.

• We are seeing signs of Metabolic Syndrome in children. These children have increases in blood pressure, and declines in insulin sensitivity.

• As our children get more obese, they are beginning to develop adult disease at younger ages.

• It is important to stress prevention…preventing the situation from getting worse.

• Simply changing daily energy balance by 100 calories a day will stop weight gain in adults.

• Advocates treating children strongly recommend small changes over large changes.

Studies have showed consistently that when people make small changes, they tend to make more and more small changes.

Changes to incorporate would be:

• Reduce intake - stress smaller portions• Reduce fat• Use of non-caloric sweeteners• Increase physical activity

Recommendations for physical activity in children are:

• 60 minutes a day moderate to vigorous physical activity and 3 of those days should be vigorous activity.

• The two goals of physical activity in children need to be to:a. Strengthen musclesb. Strengthen bones!

Adolescent-Young Adult• Puberty usually begins in girls about 2-3 years earlier than in

boys.• A growth spurt may affect height, weight, and coordination.• Secondary sex characteristics develop.• Children are forming and developing their identity.• Often self conscious about their body image.• Experience increased peer pressure.• Eating disorders can occur.• Mood swings are common.• Still tend to live in the present and not think about long term

consequences of their actions.

When caring for this age group the nurse wants to remember……..

• Reinforce continual need for checkups, screenings, and immunizations.• Provide privacy for procedures and teaching• Encourage involvement in care and decisions.• Reassure about pain medications• Help set limits while in hospital.• Continue to encourage parents involvement • Reinforce that you, the nurse, are available for questions

or concerns.

Points to remember………

• Cigarette smoking is the leading cause of preventable death in this country!• In the US, 20% of high school students are

smoking.• It is estimated that approximately 3600 youths

(ages 12-17) take up cigarette smoking every day.• Adolescents may become addicted the very first

time that they smoke!

Recently a study on was completed by researchers in Department of Family Medicine and Community Health, at the University of Massachusetts Medical School, and listed are the conclusions of that research:

• First, the ease of accessibility to cigarettes did increase the risk of smoking among adolescents• Having friends that smoke• Being exposed to cigarettes in the home (parents are the role

models for their children)• Parental permission to watch R-rated movies ( may be due to

lax parental supervision) All of these risks increased the likelihood of youths smoking!

Parents can reduce the risk of their child initiating smoking by:

• Having a smoke free home• Setting age appropriate limits• Helping their child develop the tools to resist peer

pressure and in turn build self confidence.• Having honest and open dialogue about smoking.

Underage Drinking

Sobering StatisticsA survey completed by the national Monitoring the Future from 2008 reported:• 16% of 8th graders have had a drink in the past 30 days• Over 33% of 10th graders and 44% of high school seniors

reported similar use.• The 2009 survey showed that 33% of seniors report

having been drunk and 25% admit to binge drinking (defined as having 5 or more drinks on one occasion)• 3% describe daily drinking!

• Studies are showing that individuals ho have had their first drink at age 12 ( 8th grade) or younger, the prevalence of lifetime alcohol dependence was just over 40% compared with those over 10% for those who started after age 21.

• Brain development is not complete until a person is in his mid 20s. In particular, the frontal lobe which is responsible for inhibition, emotional regulation, planning and organization continues to develop into young adulthood.

• Thus the brain’s immaturity makes adolescents more vulnerable to both the toxic and addictive effects of alcohol.

• Brain scans show abnormalities in structure and volume in patients who began drinking at an early age.

• Teens with alcohol problems often have difficulty learning new information as well as trouble with memory.

• According to the National Institute on Alcohol Abuse and Alcoholism high school students who frequently binge drink are more likely to:

• Drive drunk• Not wear seat belts• Carry weapons• Get into fights• Attempt suicide

• 5000 people under the age of 21 die every year from alcohol related injuries!

Admission Documentation

• Lake Hospital System Inpatient Pediatric Hospital Admission Information

( to be filled out by family)• Pediatric Admission Data Record General Information can be obtained by RN, LPN, or PCA. • Because the Ohio Board of Nursing prohibits IV insertion and

administration of IV medication by anyone other than a RN; the RN is strongly encouraged to assume the care of the pediatric patient. • Therefore, the rest of the 4 page admission data record is

completed by the RN.

Pediatric Assessment

• As you assess the pediatric patient, be alert for any signs of child abuse.

• Ohio Law mandates if a healthcare or child care provider suspects child abuse – it must be reported.

Age requirements include: Infant to 18 years of age

21 years of age if person is mentally or physically handicapped.

Child Abuse

• Is any mistreatment or neglect of a child resulting non-accidental harm or injury which cannot be reasonably explained.• Abuse usually involves an act of commission or actively doing

something to a child• Neglect is an act of omission such as not providing for basic

needs.• Circumstances that place families under severe duress such as

poverty, divorce, sickness, disability , lack of parental skills will often be the underlying cause of child abuse.• In addition, children who were abused often abuse their

children later on.

• Despite the efforts of the child protection system, child maltreatment fatalities remain a serious problem. Although the untimely deaths of children due to illness and accidents have been closely monitored, deaths that result from physical assault or severe neglect can be more difficult to track because the perpetrators, usually parents, are less likely to be forthcoming about the circumstances.

- US Dept of Health & Human Services

How Many Children Die Each Year From Child Abuse or Neglect?

• The national Child Abuse and Neglect data System ( NCANDS) reported an estimated 1,740 child fatalities in 2008.

• This translates to a rate of 2.33 children per 100,000 children in the general population.

• NCANDS defines “ child fatality” as the death of a child caused by an injury resulting from abuse or neglect or where abuse or neglect was a contributing factor.

• The number and rate of fatalities have been increasing during the past few years.

• Most date on child fatalities comes from State child welfare agencies.

• States may also draw on other sources of data including health departments, vital statistics departments, medical examiners offices, and fatality review teams.

• This coordination of information contributes to

better estimates.

• However many researchers and practioners believe child fatalities due to abuse and neglect are still underreported!

• Studies in Colorado and Nevada have estimated that as many as 50-60% of child deaths resulting from abuse or neglect are not recorded !

Issues affecting the accuracy and consistency of child fatality date include:

• Variations in reporting requirements• Variation in investigative systems and lack of

training for these types of investigations• Variation in state child fatality review and reporting

processes.• The amount of time (as long as a year in some

cases) it may take to establish abuse or neglect as the cause of death

• Inaccurate determination of the manner and cause of death resulting in the miscoding of death certificates.

• The ease with which the circumstances surrounding many child maltreatment deaths can be concealed.

• Lack of coordination or cooperation among different agencies and jurisdictions.

What Groups of Children Are Most Vulnerable?

• Very young children ages 4 and younger are most frequent victims of child fatalities.

• NCANDS data for 2008 demonstrated that children younger than 1 year accounted for45.3% of fatalities while children under 4 years of age accounted for nearly 80% of fatalities.

Why this Age Group?

• Because of their dependency• Small size• Inability to defend themselves

How do these deaths occur?

• Fatal child abuse may involve repeated abuse over a period of time i.e. battered child syndrome or it may involve a single impulsive incident, i.e. drowning, suffocating, or shaking a baby.

• In cases, of fatal neglect, the child’s death results nor from anything the caregiver does, but from a caregiver's failure to act.

• The neglect may be chronic i.e. extended malnourishment or acute i.e. an infant who drowns after being left unsupervised in the bathtub.

• In 2008, nearly 40% of fatalities ( 39.7%) were caused by multiple forms of maltreatment.

• Neglect accounted for 31.9% • Physical Abuse accounted for 22.9%• Medical neglect accounted for 1.5%

Who Are the Perpetrators?

• Foremost, they are the individual responsible for the care and supervision of their victims.

• In 2008 , parents, acting alone or with another person were responsible for 71.0 % of child abuse or neglect fatalities.

• More 25% of these fatalities were perpetrated by the mother acting alone.

Although there are no single profiles of a perpetrator of child abuse, there are certain characteristics that reappear in studies. These include:

• A young adult in his or her mid twenties • No high school diploma• Living at or below the poverty line• Depressed• Have difficulty coping with stressful situations.

• In many circumstances, the perpetrator has experienced violence first hand.

(Cavanaugh, Dobash, R. E. Dobash, R. P. 2007)

• Fathers and boyfriends are most often the perpetrators in abuse deaths

• Mothers are more often at fault in neglect fatalities.

Types of Abuse

Physical: most obvious

• Deliberate application of force to any part of a child’s body causing physical damage.

• Injuries associated with physical abuse include hitting, punching, shaking, kicking, and beating, biting or burning or otherwise damaging tissue.

• Patterns or shapes suggesting instrument use i.e.: belts

• Injuries do not match explanation or match child’s developmental level of functioning

• Old or healed injuries in areas where new injuries of the same type are reported.

• Burns or bruises in area normally covered by clothing

Emotional Abuse

• Defined as the systematic tearing down of another human being or acts that are psychologically damaging.• Acts of omission would include absence of positive parenting.• Acts of commission would include verbal assaults and

aggressiveness and acts of hostility toward the child.• Emotional abuse can include destroying a child’s personal

property, such as a photograph, books, toys, killing or giving away a pet.• This type of abuse results in fear which in turn allows the

perpetrator to control the child.

Sexual Abuse

• Defined as the exploitation of a child for the sexual gratification of another person.

• Child will most likely experience severe emotional disturbances related to feelings of shame and guilt.

• Includes non-touching offenses

• Vaginal or rectal penetration by an unrelated person is rape; if the adult is related it is considered incest.

Neglect

• Failure to meet a child’s basic physical and medical needs.

• Emotional deprivation, or desertion is often an overlooked form of neglect.

• Includes failure to provide educational opportunity, protection and supervision.

Shaken Baby Syndrome

• Is a type of inflicted traumatic brain injury that occurs when a baby is violently shaken.

• A baby has weak neck muscles and a large heavy head.

• Shaking makes the fragile brain bounce back and forth in side the skull.• Studies have shown that this type of damage is not

inflicted (opposite of popular thought) from rough-housing and tossing children into the air.

• The degree of brain damage depends on the amount and duration of the shaking and the forces involved in impact of the head.

Signs and symptoms range on a spectrum of neurological alterations from:

Minor: irritability, lethargy, tremors, vomiting

Major:seizures, coma, stupor death

Triad of Symptoms:

Subdural hematomaBrain swelling

Retinal hemorrhage

• May also be accompanied by bruising of the part of the body used as a “handle” for shaking. Fractures of the long bones and or of the ribs may also be seen.• Shaking probably lasts a maximum of 20 seconds or less

In most cases the shaking lasted between 5-10 seconds• Evidence supports that in order to lift an infant and shake that

violently requires an adult or adult sized person.• 2003: 1300 children in the US, experienced severe head

trauma from child abuse.

• Shaken baby injuries usually occur in children younger than 2 years gf age but may be seen in children up to the age of 5.• Poor prognosis• 20% of cases are fatal in the first few days after the injury• Survivors will have some form of neurological or mental

disability such as learning disabilities, cerebral palsy( of undefined origin), mental retardation which may be fully apparent until 6 years of age, to blindness, paralysis, inability to eat or exist in a permanent vegetative state.• Children with shaken baby syndrome (SBS) will require

lifelong medical care.