Pediatric+Hospitalization


 * 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)

 <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Just learning to make sense of the world; child can become very unsettled when cared for by multiple or different providers. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Cannot understand how various procedures and treatments that he or she perceives to “hurt” can actually produce recovery or make them well <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* From about age 6 months and older, child can become very afraid if parents leave him or her.
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Infant Considerations: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Issues of separation, rather than being ill, can be the major stress for child if required to stay in hospital. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Has no concept or understanding of what is happening when they are ill <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Does not understand time and space so all this can be very frightening for them
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Toddler considerations: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Fear of the unknown and being left alone are major concerns. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Have limited ability to distinguish fantasy from reality <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Tend to misunderstand words they hear, leading to misconceptions <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* May view hospitalization as a punishment—fearing needles, body mutilation, or loss of function
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Preschool Considerations: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Almost all school-age children will have seen and heard about illness and hospitals on TV. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* May have seen people “die” in hospital and know about cancer and other illnesses that can cause children to die <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* 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 <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Often misunderstand what they overhear; require opportunities to ask questions
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">School age Considerations: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Understands what causes illness and how it affects the body <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Fears separation from peers and group activities <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* 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. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* May express anger or indifference to mask feelings of fear <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* May feel bothered by frequent examinations by different professionals <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">* Hospitalization represents a challenge to all teens, especially teens from ethnic, religious, or cultural minority groups.
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Adolescent Considerations: **

<span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Fears: <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">May be illogical <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">What is the last thing you feared...Why? <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Due to limited understanding and limited life experiences <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Separation <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Mutilation <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Pain <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Loss of control <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Equipment <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Strangers <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Strange sights, sounds and smells <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Getting lost

<span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Bright colors, playful clothes <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Parental rooming in <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Explanations, demonstrations, handling of equipment <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Therapeutic play releases or expresses anger, fear, sorrow <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Safe rooms <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Favorite, personal possessions <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">See shoes <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Drawing, music, writing, games <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Offer choices when appropriate <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Be honest <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Set limits
 * <span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Coping: **

<span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 220%;">Pediatric Pain: <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Assess by verbal, nonverbal, physiological <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">FLACC, Face, number (see pediatric assessment page) <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">May deny if afraid will get a injection <span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 220%;">Nonpharmacological Comfort Measures: <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Infants - pacifiers, holding, rocking, swaddling, sweetease <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Toddlers/preschoolers - books, music, television, bubbles <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">School age/ adolescents -guided imagery, deep breathing, hot or cold, massage <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Nonpharmacologic methods first

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<span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Informed Consent: <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Must be obtained from a parent or legal guardian <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Must be over 18 or emancipated <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Must receive information with which to make a informed consent <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Must be voluntary, no coercion

<span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;"><span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Assent should be obtained <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Not a legal requirement, an ethical one

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<span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 240%;">Communication

<span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Communicate: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">verbally, non verbally or through writing, drawing, play, story telling, music

<span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Barriers/Influences: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">body language, facial expressions, language, medical terminology, personal judgements, environmental factors, pain, temperature, age, culture, religion, developmental level

<span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Effective Communication: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Positive, honest, unhurried, developmentally appropriate, private <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Allow freedom of expression, <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Offer limited choices and rewards prizes <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Parental involvement

<span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 240%;">~ What did you say? Talking to Children ~

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">It's just a little 'stick' in your arm... <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">We just put 'dye' in your veins... <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">You will need a 'shot'... like people on TV? <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">We're going to 'put you to sleep'... like my dog? <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">CAT scan ... Are there cats there? <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Stool collection ... a collection of little chairs? <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Stretcher ... stretch who? <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Flush your IV... down the toilet? <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Change your dress..ing?

<span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Versus <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">A 'poke' <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Open your mouth wide like a lion and roar... <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Help you take a nap... <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">BP cuff is going to 'give you a hug'... <span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Words can be hard or soft... <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Hurt ... sore, achy, scratchy, tight, snug, full, sting, pinch <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Burn ... warm feeling <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Taste or smell bad ... taste or smell different than anything you have

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Child Life Therapist: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">A pediatric nurses best friend! <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">They are the experts at age appropriate explanations and distraction <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">media type="youtube" key="IghVvQ1wgoM" width="560" height="315"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Comfort Positioning is an important aspect of Atraumatic Care

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<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Therapeutic Communication?

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<span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Nursing Interventions:

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<span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Injection Methods - Intramuscular, subcutaneous, intradermal, or intravenous

<span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Clean the site of an injection with an alcohol swab prior to the procedure. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">IV insertion, placement of central VADs or before blood cultures, <span style="color: #ca2121; font-family: 'Times New Roman',Times,serif;">chlorhexidine is superior to povidone-iodine.

<span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Intramuscular injections <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Vastus lateralis is the most likely site until the child is over 3 <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">After 3 the deltoid in the arms or the ventrogluteal in the hip can be used. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Given at a 90 degree angle to the skin. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Aspiration employed when no blood is seen... <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Medication is injected quickly, the needle withdrawn quickly and the needle safety mechanism latched. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Do not recap needles ever. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Not only is this a safety violation but hospitals are charged penalties when recapped needles are found in sharps containers.

<span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Subcutaneous injections <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Administered in the fatty portion of the legs, arms, hips or stomach. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">A TB syringe is used or a syringe with a smaller needle (5/8 inch) <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Medication is injected into the child at a 45 degree angle. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">You do **not** need to aspirate with subcutaneous injections! <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Just inject, withdraw quickly and pop the safety latch.

<span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Intradermal injections <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Used for tuberculin skin tests or allergy testing. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">The injections are administered at a 15 degree angle into the skin. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">If performed correctly a wheel will form. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">TB syringes are generally used.

<span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Intravenous administration <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Involves starting an IV and leaving a catheter in the vein after the needle is withdrawn. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">This allows for continued medication or fluid administration over several hours or days. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">These can be continuous or intermittent. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Intermittent infusions may be called heparin locks or saline wells. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">These are maintained as any IV site and flushed after the administration of any medication. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Studies have indicated that pushing saline while closing the clamp helps keep the IV patent.

<span style="color: #ca2121; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Central Venous Access Devices (VADs) <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">In emergencies or if IV medications are to be used for longer periods of time a VAD may be utilized. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Generally placed in the subclavian, femoral, or jugular veins. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">X-ray confirms placement. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">A PICC (Peripherally inserted central catheter) line is another such device. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">It is inserted into the cephalic or basilic veins and threaded into the superior vena cava. <span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Long term central VAD devices include implanted infusion ports.

<span style="color: #404040; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Other medication administration methods include: aerosols, oral, optic, otic, nasal, nasogastric, gastrostomic, or rectal methods.

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<span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Right patient <span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Right medication <span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Right dose <span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Right route <span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Right time <span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 180%;">Plus a few new rights... <span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 180%;">(Right documentation) <span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 180%;">(Right to refuse)
 * <span style="color: #19d727; font-family: 'Times New Roman',Times,serif; font-size: 180%;">5 Rights of medication Administration **

<span style="color: #df3a3a; font-family: 'Times New Roman',Times,serif; font-size: 14pt;">References:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">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

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">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

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">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

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 17px;">Videos located at: <span style="color: #000000; font-family: 'Times New Roman',Times,serif; font-size: 17px;">Communication []

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/AX_RHZ7c0Qs

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">http://youtu.be/VG7gW-HwyG0 Child life videos

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