What is

1. What is Paediatric Nursing?

2. On children • It takes special understanding to know children • They are complex, they are hard to understand • They are different • They are valuable • They are vulnerable • They have a need to be loved and to be valued

3. Paed-iatric, (Pais Iatros) • Pais = Latin = child • Iatros = Greek = physician, to treat or ‘hospital’ (‘iatrogenic’) The Americans don’t know much Latin and consequently they have confused ‘Pais’ with the Latin ‘Ped’. Probably, after the French variant of ‘pais’ (‘ped’). Hence the US ‘pediatric’ (foot physician).

4. Just words Children’s Nurse • Is modern usage • Grammatically incorrect (where do you put the apostrophe ?) • What is a nurse – therapist – physician’s attendant or carer? The term ‘pediatric’ was first used in the USA, from about the middle of the nineteenth century. The first time it was used in the UK was in 1928 when Sir Frederick Still gave birth to the British Paediatric Association. He put an ‘a’ in the word to be true to correct Latin usage. Forfar, J. O., A. D. M. Jackson, et al. (1989). The British Paediatric Association 1928-1988. London, The Royal College of Child Health and Paediatrics.

5. What IS a child? Children: • Are louder than adults • Get into trouble faster • Fall off a theatre trolley faster than an adult • Will never take their medicine but … • Eat bleach • Swallow 50 Ferrous Sulphate tablets in one go

6. What IS a child? The child: • Is more intelligent than an adult (you try learning a new language in three years) • Is physically optimal • Loves, unconditionally • Forgives, unconditionally • Is more beautiful • Has a future, not a past And he said: "I tell you the truth, unless you change and become like little children, you will never enter the kingdom of heaven. Matthew 18:3

7. On children And a women who held a babe against her bosom said, Speak to us of children. And he said: Your children are not your children. They are the sons and daughters of life's longing for itself. They come through you but not from you, And though they are with you yet they belong not to you. You may give them your love but not your thoughts. For they have their own thoughts. You may house their bodies but not their souls, For their souls dwell in the house of tomorrow, which you cannot visit, not even in your dreams. You may strive to be like them, but seek not to make them like you. For life goes not backward nor tarries with yesterday. You are the bows from which your children as living arrows are sent forth. The Archer sees the mark upon the path of the infinite, and He bends you with His might that His arrows may go swift and far. Let your bending in the Archer's hand be for gladness; For even as He loves the arrow that flies, so He loves also the bow that is stable. Kahlil Gibran The Prophet 1926

8. Physiological differences Children are faster • Respiratory rate adult 18 child 20-40 • Oxygen consumption child ↑ • Fluid intake adult 1500ml, Child ↑ adult 70ml / kg / day newborn baby 150ml / kg / day • Fluid output adult 1500ml child 1ml/kg/hr↑ than adult • Cardiac rate Child ↑, adult 70, baby 120 The younger the child, the bigger the difference Physiological differences not commensurate with size Children are not small adults THEY ARE DIFFERENT

9. Healing Time taken for a femoral fracture to heal: Newborn One week 5-yr old Four weeks 10-yr old Eight weeks Adolescent Three months Adult Four months or longer

10. Drugs • Higher doses given to children (higher metabolic rate, larger extracellular space) • Smaller physical doses given • Some drugs not given • The younger the child (foetus) the more different re drugs (Thalidomide) • Need for greater accuracy • Different routes

11. Body proportion • Relatively large head and brain • Head receives greater proportion of cardiac output • Head surface area greater • Greater heat loss from head

12. Small adults? • Surface area: body weight ratio is double (infants / adults) = greater heat loss • Oxygen consumption relative to body weight is double that of adults (6-7 ml/kg/min) • Higher metabolic rate

13. Vital signs Not determinable from the adult value

14. Cardiac output • Babies have limited ability to increase stroke volume hence higher heart rate • Cardiac output is higher per unit of body weight • Lower vascular resistance hence lower BP • Tachycardia most effective means of increasing cardiac output and the first sign of shock • Cardiac output decreases with HR less than 180bpm

15. Fixed stroke volume (infant) • Bradycardia = decreased cardiac output • Bradycardia caused by: • Hypoxia • Vagal stimulation (laryngoscopy) • Halothane • Etc.

16. Heart • Changes from foetal circulation may be incomplete (heart sounds) • The need to watch for signs of congenital HD, especially when the ductus arteriosus closes • Poor feeding (exhaustion) • Palour, • Cyanosis (right to left shunt)

17. Ventilation Ribs in neonates are more horizontal (limits anterio-posterior chest expansion, limited ‘bucket handle’ effect)  Infant much more dependent on diaphragm and susceptible splinting with • gas in the stomach (ventilation with bag and mask) • Position (lithotomy)

18. Respiratory rate Estes, M.E. (2002). Health assessment and physical examination. Albany. Delmar.

19. Airway • Airways have smaller diameter • Cartilage of trachea is softer • Airway more easily obstructed (can be obstructed by mucus) • Airway can be compressed if the neck is flexed or hyperextended • Sternum, ribs (chest wall) is cartilaginous and soft • Intercostal muscles much less effective • Infants may be obligatory nose breathers for first 4 weeks • Recession, grunting, wheeze

20. Intubation -1 • Shorter time before hypoxia develops because of higher oxygen consumption (6-7ml/kg/min compared to 3ml/kg/min in an adult) • Larynx is higher (infant C3, adult C6) • Larger tongue • Epiglottis is U shaped and longer • Angle of the mandible is greater (120 degrees) • Trachea has anterior inclination • Large head

21. Intubation before puberty • Cricoid cartilage narrowest point of the larynx before puberty and is circular •  an uncuffed tube can be used until 10-12 years • Nose accommodates the same size of tube as does the larynx before puberty • Length of trachea varies  need to check that both lungs are being ventilated

22. Dental development

23. Dental development

24. Injection sites and need for greater accuracy

25. Small limbs and safety

26. Blood • Blood volume greater (80-85ml/kg) at term but absolute volume is small • Haemoglobin greater 180-200gm/l at term • Premature babies: Hb low because iron stores are laid down late in pregnancy • Hb predominantly foetal (takes up oxygen at low tension but releases it less well to tissues)

27. Fluid • At birth, about 80% water (60-65% in adults) • Premature babies have more water  fluid loss more critical • Neonates and infants initially lose extracellular water • Extracellular space is larger at this age (50%) body weight •  fluid losses are greater • Smaller intracellular space has less fluid to shift when losses occur (babies become sicker quicker) • Minor blood loss may be important in a small child

28. Extracellular Space • Bigger extracellular space = higher dose of drugs which are distributed there • Extracellular electrolytes (chloride) lost in larger amounts in dehydration

29. Circulating blood volume

30. Dehydration • Higher proportion of water • Children exchange 50% water daily (adults 17%) • Child metabolic rate higher (more water produced and excreted, greater risk of acidosis) • Immature renal apparatus (neonates) • Large surface area (skin) • Large surface area (gut)

31. Maintenance requirements

32. Small vessel large spout Adult Child

33. Kidneys • Differences only an issue in the first few weeks • Glomerular filtration less • Reabsorption of water reduced (cortical tubules and  sodium excretion not fully developed •  Dehydration occurs faster

34. Liver • Lack of some liver enzymes in neonates and premature babies • Poor metabolism of some drugs (chloramphenicol) • Idiosyncratic metabolism of some drugs (morphine) • High levels of bilirubin in the neonate

35. Brain and NS • Brain is immature (different) in ways that are not understood (febrile convulsion) • Centrally acting drugs (morphine, barbiturates) have a greater depressant effect • Not all myelinated fibres are myelinated

36. Temperature regulation • Temperature regulation less efficient • High surface area • Premature babes have thin skin and less subcutaneous fat (body stores less heat) • Neonates do not shiver • Brown fat • Seriously prone to hypothermia

37. Assessment of shock • depression of the nail bed / forehead should result in return to normal in 0.5 secs • tachycardia is a sign of shock • bradycardia is a very late sign and may indicate imminent death • Hypotension late sign

38. Skin • More liable to thermal injury • Saturation monitoring not reliable in the first 24h after birth and in premature babies (transcutaneous monitoring may be used instead) • Skin is thinner and can leak fluid in the very premature baby

39. Immune system • babies more vulnerable to gram –ve bacteria • University students more vulnerable to bacterial meningitis

40. Safety

41. What is paediatric nursing? Paediatric nursing is an ancient craft, the exercise of which has sought to ameliorate suffering throughout the ages; Paediatric nursing exists as a therapeutic intervention and is not merely ‘supportive’; Medicine’s primary goal is to cure the patient of disease and to remedy the effects of trauma. In contrast, paediatric nursing’s primary goal is to reduce discomfort and ameliorate the effects of disease, trauma and of treatment itself; Paediatric nursing uses science, including social, psychological and medical science to achieve its goal; however, paediatric nursing is not driven by science. Rather, paediatric nursing is driven by the therapeutic influence which one caring person can have on a suffering human being. It follows that, it is the relationship between the nurse and the child patient and family that is at the heart of the therapeutic activity called nursing. Paediatric nurses achieve much by simply being there with the suffering person, by demonstrating empathy and an unconditional regard for the child patient and his or her family and in relation to which, the words ‘affection’ and ‘love’ are fully appropriate.

42. NAWCH Charter • Children shall be admitted to hospital only if the care they require cannot be equally well provided at home or on a day basis. • Children in hospital shall have the right to have their parents with them at all times provided this is in the best interest of the child. Accommodation shall therefore be offered to all parents, and they should be helped and encouraged to stay. In order to share in the care of their child, parents should be fully informed about ward routine and their active participation encouraged. • Children and/or their parents shall have the right to information appropriate to age and understanding. • Children and / or their parents shall have the right to informed participation in all decisions involving their health care. Every child shall be protected from unnecessary medical treatment and steps taken to mitigate physical and emotional distress. • Children shall be treated with tact and understanding and at all times their privacy shall be respected. • Children shall enjoy the care of appropriately trained staff, fully aware of the physical and emotional needs of each age group. • Children shall be able to wear their own clothes and have their own personal possessions. • Children shall be cared for with other children of the same age group. • Children shall be in an environment furnished and equipped to meet their requirements, and which conforms to recognised standards of safety and supervision. • Children shall have full opportunity for play, recreation and education suited to their age and condition. NAWCH is now called Action for Sick Children Look it up!

43. Professional organisations • ABPN Association of British Paediatric Nurses • NMC Nursing and Midwifery Council • Is not a professional body (often thought to be) • Is a government agency associated with the Department of Health • Is largely inactive in relation to paediatric nursing ABPN – check it out!

44. Anne Casey’s model of paediatric nursing Date published 1988 Senior Nurse. 8(4): 8-9 Based on Roper / Clarke Type - Concept isolating • Key concepts: • child • family • nurse • partnership • ability of child / family to participate in care • health • environment • conception - maturity continuum • dependent - independent continuum • functioning, growing and developing • physically • emotionally • intellectually • socially • spiritually

45. The perfect model • We don’t have the perfect model • Can you invent the perfect model • You could be famous • You could make some money • Try it now, invent your own model

46. Family Centred Care ‘a way of caring for children and their families within health services which ensures that care is planned around the whole family, not just the individual child/person and in which all the family members are recognised as care recipients'. Shields, L. (2010). "Questioning family-centred care." Journal of Clinical Nursing 19(17/18): 2629-2638.

47. What is Paediatric Nursing?