Pediatric Hospitalization

Hospitalization General Considerations:


*More than 3 million children in the United States are hospitalized annually (Schmidt et al, 2007).

Developmental ages and stages must be considered.
Vital signs vary depending on the age and condition of the child
Assessment techniques may need to be modified
Introduce yourself at eye level
Play is a child's work and the international language of children!
Remember to involve and partner with the care givers
Utilize child life
Employ comfort measures and comfort holds when possible.
Their room and the playroom is their safe haven, use the procedure room for painful interventions!
Plan ahead!

Care Planning Considerations
(Doenges, Moorhouse, & Murr, 2010)


Infant Considerations:
* Just learning to make sense of the world; child can become very unsettled when cared for by multiple or different providers.
* Cannot understand how various procedures and treatments that he or she perceives to “hurt” can actually produce recovery or make them well
* From about age 6 months and older, child can become very afraid if parents leave him or her.


Toddler considerations:
* Issues of separation, rather than being ill, can be the major stress for child if required to stay in hospital.
* Has no concept or understanding of what is happening when they are ill
* Does not understand time and space so all this can be very frightening for them

Preschool Considerations:
* Fear of the unknown and being left alone are major concerns.
* Have limited ability to distinguish fantasy from reality
* Tend to misunderstand words they hear, leading to misconceptions
* May view hospitalization as a punishment—fearing needles, body mutilation, or loss of function

School age Considerations:
* Almost all school-age children will have seen and heard about illness and hospitals on TV.
* May have seen people “die” in hospital and know about cancer and other illnesses that can cause children to die
* Need to know what will happen to them, and that they will not die from this illness—may be too frightened to ask about this themselves
* Often misunderstand what they overhear; require opportunities to ask questions

Adolescent Considerations:
* Understands what causes illness and how it affects the body
* Fears separation from peers and group activities
* Hospitalization represents a loss of control over almost all areas of life, even the most basic aspects—when the teen eats, sleeps, or uses the bathroom, coupled with a loss of privacy at a time when self-consciousness is peaking.
* May express anger or indifference to mask feelings of fear
* May feel bothered by frequent examinations by different professionals
* Hospitalization represents a challenge to all teens, especially teens from ethnic, religious, or cultural minority groups.


Fears:
May be illogical
What is the last thing you feared...Why?
Due to limited understanding and limited life experiences
Separation
Mutilation
Pain
Loss of control
Equipment
Strangers
Strange sights, sounds and smells
Getting lost

Coping:
Bright colors, playful clothes
Parental rooming in
Explanations, demonstrations, handling of equipment
Therapeutic play releases or expresses anger, fear, sorrow
Safe rooms
Favorite, personal possessions
See shoes
Drawing, music, writing, games
Offer choices when appropriate
Be honest
Set limits

Pediatric Pain:
Assess by verbal, nonverbal, physiological
FLACC, Face, number (see pediatric assessment page)
May deny if afraid will get a injection
Nonpharmacological Comfort Measures:
Infants - pacifiers, holding, rocking, swaddling, sweetease
Toddlers/preschoolers - books, music, television, bubbles
School age/ adolescents -guided imagery, deep breathing, hot or cold, massage
Nonpharmacologic methods first




Informed Consent:
Must be obtained from a parent or legal guardian
Must be over 18 or emancipated
Must receive information with which to make a informed consent
Must be voluntary, no coercion

Assent should be obtained
Not a legal requirement, an ethical one




Communication

Communicate:
verbally, non verbally or through writing, drawing, play, story telling, music

Barriers/Influences:
body language, facial expressions, language, medical terminology, personal judgements, environmental factors, pain, temperature, age, culture, religion, developmental level

Effective Communication:
Positive, honest, unhurried, developmentally appropriate, private
Allow freedom of expression,
Offer limited choices and rewards prizes
Parental involvement

~ What did you say? Talking to Children ~

It's just a little 'stick' in your arm...
We just put 'dye' in your veins...
You will need a 'shot'... like people on TV?
We're going to 'put you to sleep'... like my dog?
CAT scan ... Are there cats there?
Stool collection ... a collection of little chairs?
Stretcher ... stretch who?
Flush your IV... down the toilet?
Change your dress..ing?

Versus
A 'poke'
Open your mouth wide like a lion and roar...
Help you take a nap...
BP cuff is going to 'give you a hug'...
Words can be hard or soft...
Hurt ... sore, achy, scratchy, tight, snug, full, sting, pinch
Burn ... warm feeling
Taste or smell bad ... taste or smell different than anything you have

Child Life Therapist:
A pediatric nurses best friend!
They are the experts at age appropriate explanations and distraction


Comfort Positioning is an important aspect of Atraumatic Care





Therapeutic Communication?




Nursing Interventions:



Injection Methods - Intramuscular, subcutaneous, intradermal, or intravenous

Clean the site of an injection with an alcohol swab prior to the procedure.
IV insertion, placement of central VADs or before blood cultures, chlorhexidine is superior to povidone-iodine.

Intramuscular injections
Vastus lateralis is the most likely site until the child is over 3
After 3 the deltoid in the arms or the ventrogluteal in the hip can be used.
Given at a 90 degree angle to the skin.
Aspiration employed when no blood is seen...
Medication is injected quickly, the needle withdrawn quickly and the needle safety mechanism latched.
Do not recap needles ever.
Not only is this a safety violation but hospitals are charged penalties when recapped needles are found in sharps containers.

Subcutaneous injections
Administered in the fatty portion of the legs, arms, hips or stomach.
A TB syringe is used or a syringe with a smaller needle (5/8 inch)
Medication is injected into the child at a 45 degree angle.
You do not need to aspirate with subcutaneous injections!
Just inject, withdraw quickly and pop the safety latch.

Intradermal injections
Used for tuberculin skin tests or allergy testing.
The injections are administered at a 15 degree angle into the skin.
If performed correctly a wheel will form.
TB syringes are generally used.

Intravenous administration
Involves starting an IV and leaving a catheter in the vein after the needle is withdrawn.
This allows for continued medication or fluid administration over several hours or days.
These can be continuous or intermittent.
Intermittent infusions may be called heparin locks or saline wells.
These are maintained as any IV site and flushed after the administration of any medication.
Studies have indicated that pushing saline while closing the clamp helps keep the IV patent.

Central Venous Access Devices (VADs)
In emergencies or if IV medications are to be used for longer periods of time a VAD may be utilized.
Generally placed in the subclavian, femoral, or jugular veins.
X-ray confirms placement.
A PICC (Peripherally inserted central catheter) line is another such device.
It is inserted into the cephalic or basilic veins and threaded into the superior vena cava.
Long term central VAD devices include implanted infusion ports.

Other medication administration methods include: aerosols, oral, optic, otic, nasal, nasogastric, gastrostomic, or rectal methods.




5 Rights of medication Administration
Right patient
Right medication
Right dose
Right route
Right time
Plus a few new rights...
(Right documentation)
(Right to refuse)

References:


Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span (8th ed.). Philadelphia, PA: F. A. Davis Company.

Diggle, L. (2007). Injection technique for immunization. Practice Nurse, 33(1), 34-37. Retrieved from http://mendel.csuniv.edu/login?url=http:search.ebscohost.com/login.aspx?direct=true&db=hch&AN=23790461&site=ehost-live

Hunter, J. (2007). Intramuscular injection techniques. Nursing Standards, 22(24), 35-40. Retrieved n.d. from Retrieved from EBSCOhost. Retrieved from http://mendel.csuniv.edu/login?url=http:search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2009815670&site=ehost-live

Hockenberry, M. J., & Wilson, D. (2009). Wong's essentials of pediatric nursing (8th ed.). St. Louis, MO: Mosby Elsevier.

Ipp, M., Taddio, A., Sam, J., Gladbach, M., & Parkin, P. (2007). Vaccine-related pain: Randomised controlled trial of two injection techniques. Archives of Disease in Childhood, 92, 1105-1108. doi:10.1136/adc.2007.118695

Potts, N. L., & Mandleco, B. L. (2012). Pediatric nursing: Caring for children and their families (3rd ed.). New York, NY: Delmar Cengage Learning.

STTI International Nursing Research Congress (2009). To apirate or not to aspirate that is the question: An integrative review of the evidence [PowerPoint slides]. Retrieved April 3, 2011, from http://www.stti.iupui.edu/pp07/vancouver09/41810.Crawford,%20Cecelia%20L.-F%2010.pdf

Videos located at:
Communication
http://youtu.be/W1RY_72O_LQ

http://youtu.be/AX_RHZ7c0Qs

http://youtu.be/VG7gW-HwyG0
Child life videos

https://youtu.be/VOqIVIFN5Bo

https://youtu.be/IghVvQ1wgoM