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Unique Considerations in Children. Chapter 13-14, 16-20 By Nataliya Haliyash, MD, BSN. 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.

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Unique considerations in children

Unique Considerations in Children

Chapter 13-14, 16-20

By Nataliya Haliyash, MD, BSN

Lecture objectives
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

Stressors of hospitalization
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

Loss of control infants needs
Loss of Control: Infants’ Needs

  • Trust

  • Consistent, loving caregivers

  • Daily routines

Loss of control toddlers needs
Loss of Control: Toddlers’ Needs

  • Autonomy

  • Daily routines and rituals

  • Loss of control may contribute to:

    • Regression of behavior

    • Negativity

    • Temper tantrums

Loss of control preschoolers
Loss of Control: Preschoolers

  • Egocentric and magical thinking typical of age

  • May view illness or hospitalization as punishment for misdeeds

  • Preoperational thought

Loss of control school age
Loss of Control: School Age

  • Striving for independence and productivity

  • Fears of death, abandonment, permanent injury

  • Boredom

Loss of control adolescents
Loss of Control: Adolescents

  • Struggle for independence and liberation

  • Separation from peer group

  • May respond with anger, frustration

  • Need for information about their condition

Fears of bodily injury and pain
Fears of Bodily Injury and Pain

  • Common fears among children

  • May persist into adulthood and result in avoidance of needed care

Young infant s response to pain
Young Infant’s Response to Pain

  • Generalized response of rigidity, thrashing

  • Loud crying

  • Facial expressions of pain (grimace)

  • No understanding of relationship between stimuli and subsequent pain

Older infant s response to pain
Older Infant’s Response to Pain infant

  • Withdrawal from painful stimuli

  • Loud crying

  • Facial grimace

  • Physical resistance

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

Young child s response to pain
Young Child’s Response to Pain a few simple things

  • Loud crying, screaming

  • Verbalizations: “Ow”, “Ouch”, “It hurts”

  • Thrashing of limbs

  • Attempts to push away stimulus

School age child s response to pain
School-Age Child’s Response a few simple thingsto Pain

  • Stalling behavior (“wait a minute”)

  • Muscle rigidity

  • May use all behaviors of young child

Adolescent a few simple things

  • Less vocal protest, less motor activity

  • Increased muscle tension and body control

  • More verbalizations (“it hurts”, “you’re hurting me”)

Effects of hospitalization on the child
Effects of Hospitalization a few simple thingson the Child

  • Effects may be seen before admission, during hospitalization or after discharge

  • Child’s concept of illness is more important than intellectual maturity in predicting anxiety

Individual risk factors that increase vulnerability to stresses of hospitalization
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)

Changes in the pediatric population
Changes in the Pediatric Population Stresses of Hospitalization

  • 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

Beneficial effects of hospitalization
Beneficial Effects of Hospitalization Stresses of Hospitalization

  • Recovery from illness

  • Increase coping skills

  • Master stress and feel competent in coping

  • New socialization experiences

Parental responses to stressors of hospitalization
Parental Responses to Stressors of Hospitalization Stresses of Hospitalization

  • Disbelief, anger, guilt

    • Especially if sudden illness

  • Fear, anxiety

    • R/T child’s pain, seriousness of illness

  • Frustration

    • Especially r/t need for information

  • Depression

Sibling reactions
Sibling Reactions Stresses of Hospitalization

  • Loneliness, fear, worry

  • Anger, resentment, jealousy

  • Guilt

Altered family roles
Altered Family Roles Stresses of Hospitalization

  • Anger and jealousy between siblings and ill child

  • Ill child obligated to play sick role

  • Parents continue pattern of overprotection and indulgent attention

Preparation for hospitalization
Preparation for Hospitalization Stresses of Hospitalization

  • Assessment

  • Nursing diagnosis

  • Planning

  • Implementation

  • Evaluation

Preventing or minimizing separation
Preventing or Minimizing Separation Stresses of Hospitalization

  • Primary nursing goal

  • Especially for children <5 yrs

  • Family-centered care

  • Parents are not “visitors”

  • Familiar items from home

Normalizing the hospital environment
“Normalizing” the Hospital Environment Stresses of Hospitalization

  • Maintain child’s routine, if possible

  • Time structuring

  • Self-care (age appropriate)

  • School work

  • Friends and visitors

Pain Stresses of Hospitalization

  • “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

Pain facts and fallacies
Pain Facts and Fallacies Stresses of Hospitalization

  • 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

Principles of pain assessment in children questt
Principles of Pain Assessment in Children: QUESTT Stresses of Hospitalization

  • Question the child

  • Use a pain rating scale

  • Evaluate behavioral and physiologic changes

  • Secure parent’s involvement

  • Take the cause of pain into account

  • Take action and evaluate results

Pain rating scales
Pain Rating Scales Stresses of Hospitalization

  • 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

Pain scales
Pain Scales Stresses of Hospitalization

  • 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)

Nonpharmacologic interventions
Nonpharmacologic Interventions Stresses of Hospitalization

  • Based on age

  • Swaddling, pacifier, holding, rocking

  • Distraction

  • Relaxation, guided imagery

  • Cutaneous stimulation

Anesthetics topical and local
Anesthetics: Topical and Local Stresses of Hospitalization

  • Major advancement for atraumatic care

  • EMLA

  • NUMBY stuff

  • Intradermal local anesthetics

  • Importance of timing

Numby stuff system
Numby Stuff System Stresses of Hospitalization

  • A needle-free method for delivering anesthesia can help alleviate pain associated with local dermal procedures.

  • Numby Stuff is 2% lidocaine with 1:1000,000 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.

Analgesics Stresses of Hospitalization

  • Opioids

  • NSAIDs

  • “Potentiators”

  • Lytic cocktail (DPT)—Demerol, Phenergan, and Thorazine

  • Co-analgesics, amnesics, sedatives, etc.

  • Role of placebos

Dosage of analgesia
Dosage of Analgesia Stresses of Hospitalization

  • Based on body weight up to 50 kg

  • Concept of “titration”

  • Ceiling effect of non-opioids

  • First pass effect

  • PCA

Nursing care of the family
Nursing Care of the Family Stresses of Hospitalization

  • Family assessment

  • Discharge assessment and planning

  • Encourage parent participation in planning and care

  • Information

  • Preparing for discharge and home care

Care of the child and family in special hospital situations
Care of the Child and Stresses of HospitalizationFamily in Special Hospital Situations

Ambulatory outpatient
Ambulatory/Outpatient Stresses of Hospitalization

  • Benefits

  • Preparation of child can be challenging

  • The stress of waiting

  • Explicit discharge and follow-up instructions

Isolation Stresses of Hospitalization

  • Added stressor of hospitalization

  • Child may have limited understanding

  • Dealing with child’s fears

  • Potential for sensory deprivation

Emergency admission
Emergency Admission Stresses of Hospitalization

  • Essentials of admission counseling

  • “Postvention”—counseling subsequent to the event

  • Participation of child and family as appropriate to situation

Intensive care unit
Intensive Care Unit Stresses of Hospitalization

  • Increased stress for child and parents

  • Emotional needs of the family

  • Parents’ need for information

  • Perception of security from constant monitoring and individualized care

Q & A ? Stresses of Hospitalization