Pediatric Nursing Care Ch 30 C

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Anticipatory Guidance

psychological preparation of a patient for an event expected to be stressful, as you do when preparing a child for surgery by explaining what will happen and what it will feel like; also used to prepare parents for normal growth and development of their children) means to teach parents (and children when they are old enough to understand) what is likely to occur in the coming weeks and months so that it is possible to lay the groundwork now to protect and promote the child's well-being at that time.

Guidelines for Performing Pediatric Physical Assessment

Look for behaviors that signal child's readiness to cooperate:
—Talking to nurse
—Making eye contact
—Accepting offered equipment
—Allowing physical touching
—Choosing to sit on examining table rather than parent's lap
• If you observe no signs of readiness, use the following techniques:
Talk to patient; gradually focus on a favorite object, such as doll
— Make complimentary remarks about child, such as appearance, dress, or a favorite object
— Tell a funny story or play a simple magic trick
— Have a nonthreatening "friend" available, such as a hand puppet, to "talk" to child for the nurse

Height and Length

Length refers to measurements taken when children are supine. Until children are 2 years old, you will measure recumbent length. Have someone assist by holding the child's head in midline while you extend the child's legs to take a measurement.
Height refers to a measurement when a child stands upright.

Vital Signs

For best results in taking vital signs of an infant, count respirations first, before the infant is disturbed; take pulse second, and temperature last.)

The oral, rectal, and axillary sites are all common ones in clinical practice. Other sites that are now used for temperature measurement are the tympanic membrane and temporal artery (temporal artery thermometry).

Blood Pressure

best to explain each step. For preschool and early school-age children, explain how the cuff will feel, such as "tight feeling," "arm hug," or "I want to feel your muscle." Use an explanation such as, "I want to see how strong your muscle is."

Nutrition

most important influence on growth,
human milk most desirable 1st 6 months, only breast milk or formula til 12 mos, cows milk can cause gi bleeding, 4 to 6 months cereal, introduce new foods at weekly intervals to recognize allergies, no honey or syrup, table food 12 to 15,
weaning. Cholesterol screening for adolescent with parents with high cholesterol or at age 19
focus on adequacy of iron, calcium, multivitamins with folic acid for pregnant teens

preadmission programs

iming of the orientation is important. There has to be enough advance time for the child to be able to assimilate the information after the program, but not so much time that the child will forget the information. Generally, the younger the child, the shorter the period between when the child is told about pending hospitalization and the actual admission date. Usually, a toddler is told only days before. However, school-age children have a better understanding of time and the future; it is therefore possible to tell them that they are going to the hospital "in 2 weeks." Tell adolescents as far in advance as possible to allow them time to inform peers and solicit their support.

It is necessary to allow children to prepare for this new experience in their own way. This preparation involves telling friends and selecting pictures of family members, toys, or clothes they wish to take, if they are permitted. Packing a bag with these items reinforces the event's reality.

Parents also benefit from such orientation programs. They receive information that is helpful in answering a child's questions at home. Printed materials provide parents a reference guide for reviewing what the child has been told.

Hospital policies

family centered care, fear of parental isoloation separation anxiety 15 to 30 mos.

Developmental support

not unusual for children to regress when hospitalized. vulnerable to the emotional and developmental consequences of hospitalization.

Infancy

Parents close, separation anxiety,handling fear and pain room-in, cuddle rock sing talk

toddler

separation anxiety major issue, restrictions change in routine, fear of injury and pain, regression lack of consideration, praise good behavior, try to keep close to home routine

Preschool

fear of mutilation, perceived as punishment, anger toward primary caregivers, protest, accept and provide outlets, acceptance of anger, communicate love , restate, reassurance.

SCHOOL AGE

lack of body control and mastery. Feelings of inadequacy are possible. The child may become demanding and rebellious to maintain semblance of control. Regression: consistent visiting pattern; implement plan for continued education and teacher visit; set limits for self-care tasks that are attainable; praise for appropriate behavior (e.g.,

Adolescence

threat to independence. feelings of abandonment that substantiate a sense of worthlessness. There is concern about status. Rejection; uncooperativeness; withdrawal; Support the adolescent's need for independence, confidentiality, and decision making.

Fear under 5

what , where, who, show recovery, have parents on hand

fear younger school age

waking up during surgery, show mask, explain how gas or medicine works

fear older school age

does doctor know how and when to awaken me,
stress special sleep, special person job to control sleep, mutilation, death

fear adolescents

same as older school age, peer reaction, effect on sexuality, intro to peer with similiar surgery

Gavage

used in tachycardic or infants with lack of sucking reflex
To measure the tube before placing it, a qualified staff member will use one of the following procedures: (1) measure from the nose to the distal area of the earlobe and then to the end of the xiphoid process or (2) measure from the nose to the earlobe and then to a point midway between the xiphoid process and the umbilicus.

Some restraint of infant activity is likely to be necessary when passing the tube. Pulling up the bottom of the shirt over both arms is often all that is needed to restrain the newborn.

To prevent nausea and regurgitation, use rates of no more than 5 mL every 5 to 10 minutes in premature and very small infants and 10 mL per minute in older infants and children. At the completion of the feeding, flush the tube with sterile water (using from 1 or 2 mL for small tubes to 5 mL or more for large

Safety reminder devices

Maintaining oxygen therapy without interruption
•Protection from harm if child has an indwelling catheter, IV tubes, pacemaker wire, or sutures
•Patients who are confused, agitated, or unable to comprehend instructions
Remove the SRD every 2 hours to permit exercise of the body area. If you need to restrain the extremities, release them one at a time so that the child cannot pull out an IV or NG tube. Attach the ties of all SRDs to bed frames only, not to side rails.

Elbow Safety Reminder Devices

Elbow SRDs prevent flexion or bending of elbows. They allow an infant or toddler to move the upper extremities but prevent them from touching the head

Mummy Safety Reminder Device

A mummy SRD is used when it is necessary to immobilize head, neck, trunk, and upper and lower extremities. A jugular venipuncture or the insertion of an NG tube will sometimes call for this type of SRD.

Clove-Hitch Safety Reminder Device

A clove hitch is not a square knot. Make a figure-8 with the material, slip it over the padded wrist or ankle, and tighten it gently (see Chapter 14). Check each SRD frequently to be sure that circulation is not affected and pressure is not excessive. Use a slip knot to tie the ends of this SRD to the bed frame.

Jacket Safety Reminder Device

You will sometimes use a jacket SRD to keep an extremely active older infant or toddler safely in bed or in a high chair. It resembles a vest and has ties in the back.

mist tents

improve a child's respiratory status by liquefying pulmonary secretions. You will easily be able to observe the child through the plastic canopy. All of the device's working parts are outside of the tent, which is a distinct advantage when a toddler needs this form of therapy. Compressed air or oxygen runs through sterile water to form the therapeutic mist.
limit the number of times the tent is opened, to make it possible to maintain desired concentrations and give the child longer rest periods. Tuck the tent under the mattress of a crib to maintain humidity levels. If the tent is functioning efficiently, dampness within it is significant, and frequent (every 3 to 4 hours) linen and clothing changes will often be necessary.

suctioning

Recommended pressures for airway suctioning using wall suction range from 50 to 95 mm Hg for infants to 95 to 110 mm Hg for children.
child possibly needs suctioning include pallor; restlessness or anxiety; increased pulse, respiration, and temperature; dyspnea; bubbling (copious amounts of thin secretions); rattling (thick, tenacious secretions); drooling; mouth breathing; nasal flaring; grunting; gasping; retractions; cyanosis; and erythema (flushed face). Infants often have an anxious look in their eyes or fidget constantly. An older child will perhaps constantly seek attention with no explanation, toss and turn in bed, or finger the edge of a blanket.
Depth: Approximately ¼ to ½ inch beyond the tip of the artificial airway; determine placement by placing an appropriately sized suction catheter into an artificial airway of the same size, insert the catheter to the appropriate depth, mark with tape, and keep at the bedside as a reference.
• Timing: Limit suctioning to not more than 5 seconds.
• Frequency: Allow 30 seconds between suctioning attempts (two or three attempts at most).

Oral Medications

To encourage the child's acceptance of oral medications:

•Give the child an ice pop or small ice cube to suck to numb the tongue before giving the drug.
•Mix the drug with a small amount (about 1 tsp) of a sweet-tasting substance such as honey (except in infants because of the risk of botulism), flavored syrups, jam, fruit purées, or ice cream; avoid using essential food items, because the child may later refuse to eat them.
•Give a "chaser" of water, juice, a soft drink, or an ice pop or frozen juice bar after the drug.
If nausea is a problem, give a carbonated beverage poured over finely crushed ice before or immediately after the medication.
• When medication has an unpleasant taste, have the child pinch the nose and drink the medicine through a straw. Much of what we taste is associated with smell.

Intramuscular Medications Administration

max 1ml, The primary site for IM injections are the vastus lateralis muscle and the ventrogluteal muscle, smallest diam, lying or sitting, no standing, med at room temp, distraction, point of concentration, cold compress, Say to child, "If you feel this, tell me to take it out, please."
• Have child hold a small bandage and place it on puncture site after intramuscular (IM) injection is given.

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