Lecture#1 01-14-14 Why is Nursing of children Different? Because children are not just little adults.

. Personal skills that are paramount Listening, Talking WITH patients and families, and focus more on caring aspects It is import to stress the caring and compassion that includes the family Health Promotion Leading causes of death and disability can reduced by addressing 6 categories of behavior Tobacco use Behaviors resulting in injury and violence Alcohol/substance abuse Dietary and hygiene behaviors o Diabetes is an example, Asthma is closest related to diabetes Sedentary lifestyle o Addicted to screens increase risk Risky sexual behavior Childhood Health Problems Obesity and Type 2 Diabetes Obesity is the most common nutritional problem in American children. Television/screen time has contributed to inactivity Childhood Injuries Most common cause of death and disability in children in the US. Type of injury and circumstances are closely related to normal growth and development Violence Permeates households through TV, video games, movies Higher homicide rates in minority populations Substance Abuse Mental Health Problems Affects 1 of every 5 school age child in the US. Role of the Pediatric Nurse Responsible for promoting the health and well-being of the child and family. Establish MEANINGFUL/Professional Relationships o Meaningful is not equal to becoming with patients and family, RN needs to set clear boundaries that the patient is not their children o Support and counseling Helping patients get what they need through collaborative care Health Teaching Ethical decision-making o Helping them make decision not making decision for them Research and Evidence based practice (EBP) Advocacy of the family and child o Coordination and collaboration Disease prevention and health promotion o Assess growth and development

Anticipatory guidance o Need to know where the childs developmental is in order to properly treat that child

Infant Mortality-Not on the test Defined as the number of deaths in the first year of life. In 2012 US ranks 174/222, with 5.98 births/1000 live births Birth weight is a major determinant of infant mortality**. Race, prenatal care, education also affect it Top 5 causes of death in infants** Congenital anomalies, short gestation/birth weight, SIDS, maternal complications, unintentional injury Mortality decreases after age 1 Ages 5-14 has the lowest mortality Sharply increases age 15-19 After age 15, causes are homicide, injuries, and suicide Leading causes of mortality in those less than 15 Unintentional injury Violence Accidents Childhood Morbidity Morbidity is difficult to define and can be acute illness, chronic disease or disability Respiratory illness accounts for 50% of acute conditions Injury and disabilities New concerns: barriers to health Homelessness, poverty, chronic health problems, foreign born/adopted, childcare situations The New Morbidity Problems caused by behavioral, social and educational issues Poverty Aggression/Violence Adjustment to death/divorce School Failure Obesity Injuries Healthy People 2020 10-year agenda for improving the nations health. Overarching Goals: High-quality, longer lives free of preventable disease, disability, injury and premature death Health equity, eliminate disparities, improve the health of all groups. Create social and physical environment that promote good health for all Promote quality of life, healthy development and health behaviors across all life stages

Global Health Concerns Why is this important to address? Increased travel increased incidence of bringing illness to US The effects of war on children Increases in foreign adoptions new diseases and concerns we are not used to Supporting child and maternal health is an investment for all Malnutrition contributes to approximately 50% of deaths globally. This means that malnutrition is implicated in causing and adding to the development of mortality even though it may not specifically be the single cause of death. Malnourishment in pregnancy Malnourishment leading to weakened immune systems Also non-nourishing foods are less expensive possibly adding to prevalence of Obesity and Type II DM Its not just disease affecting children War Death and psychological implications of armed conflicts. Terror, disability Poverty Abuse What can we do? Teach about, understand the consequences of global inequities Increase awareness Can we change something at the local level?

Important Pediatric concepts Family- Centered Care Recognizes that the family is integral to a childs life. o Family is essential part of health care team Family is the expert in the care of their child Enable and empower the family Meeting the families needs helps meet the childs needs The family IS the patient o Ordinary day of a nurse equal horrific day of a family Atraumatic care Use procedures and approaches to minimize trauma o Physical and psychological trauma o Treatment should not be done in a safe places, (bed/ play room) but should be in a treatment room Three principles o Prevent/minimize separation from the family o Promote a sense of control o Prevent/minimize bodily injury and pain Can we eliminate all pain and trauma? o No but can try to minimize it.

Goals of Pediatric Hospital Care Use developmentally appropriate approach and care (not always same as chronologic) Use important assessment and observation skills. Minimize distress o Is very important and it is okay to say you do not know it and tell that you will seek out help/information for patient Honest, truthful approach Use of play to interact, teach, assess and to help with coping. Hospitalization interrupts their development! Respect of family as experts of their child Safety!!!! Developmental Milestones Understand the progression Know the important milestones***Know a childs base line

Helps in your developmental approach to caring for the child and family Helps the nurse assess the childs neurological level, developmental level.

Regression Return to an earlier developmental level or ability A coping mechanism Occurs when there is a threat to autonomy Common to occur in times of stress Hospitalization, family stresses, etc Temporary Best approach: Ignore and praise appropriate behavior Children and Pain Pain tends to be underestimated in children. There are physiological and psychological effects when pain is not treated adequately Myths: Infants do not experience pain Children are more prone to complications of pain management Children are always honest about pain If a child is sleeping or playing, they must not be in pain. Multiple ways of treating pain Pharmacologic Non opioids and opioids o Can use opioids on children but need to have Narcan on hand and need to watch them carefully o IM injection is not routinely give for children PCA (must be physically able to push button and understand it) o Break through pain is very difficult to control once it happens Epidural Topical Nonpharmacologic Sucking, kangaroo care, distraction such as blowing bubbles Complementary and Alternative Medicine Pain Assessment in Children Pain is whatever the experiencing person says it is, existing whenever the person says it does o Need to assess pain scale before and after procedures o Behaviors such as vocalization, facial expression and body movement help measure pain. Assessment tools used based on development and age FLACC, CHEOPS o Modified CHEOPS used for non -verbal childrenused over at SLCH. FACES, poker chips Numbers and Visual analogue (plain line) o Visual analogvertical or horizontal line with one end being no pain and the other worst pain. Ask parents o Parents often have good insight in their childrens pain. o Ask the child if possiblethey know how they feel. Self report is the GOLD standard

FLACC Tool*** Need to memorize for the test!!!! o Face, leg, activities, Cry & consolable o Know what acronym stand for, Do not need to know the number
FLACC Pain Assessment Tool
Categories Face Score 0
No particular expression or smile

Score 1
Occasional grimace or frown, withdrawn, disinterested

Score 2
Frequent to constant frown, clenched jaw, quivering chin

Legs

Normal position or relaxed

Uneasy, restless, tense

Kicking, or legs drawn up

Activity

Lying quietly, normal position, moves easily

Squirming, shifting back and forth, tense

Arched, rigid, or jerking

Cry

No cry (awake or asleep)

Moans or whimpers, occasional complaint Reassured by occasional touching, hugging, or being talked to, distractable

Crying steadily, screams or sobs, frequent complaints

Consolability

Content, relaxed

Difficult to console or comfort

Merk el, S., Voepel-Lewis, T., Shayevitz, J., & Malviya, S. (1997). The FLACC: A behavioral scale for scoring postoperative pain in young children. Pediatric Nursing 23(3),293-297.

How to use it? o Patients who are awake Observe for 1-5 min Observe legs and body, uncovered Reposition patient/observe activity Assess body for tenseness/tone Initiate consoling if needed o Patients who are asleep Observe for 5 min Observe body uncovered If possible reposition patient Touch body/assess for tenseness Face o 0 - relaxed, interested in surroundings o 1 - worried, lowered eye brows, eyes partially closed o 2 - furrow in forehead, deep lines around nose Legs o 0 - usual tone and motion o 1 - increased tone, rigidity, tense o 2 - hypertonicity, exaggerated flexion/extension of limbs Activity o 0 - moves easily o 1 - hesitant to move, tense torso o 2 - fixed position, side to side head movement Cry o 0 - no cry o 1 - occasion moan, whimpers, sighs o 2 - frequent cries ,grunts Consolability o 0 - calm

o 1 - responds to touch or talk 1/2-1 min. o 2 constant comfort, unable to console. Interpreting the score o 0 relaxed and comfortable o 1-3 mild discomfort o 4-6 moderate pain o 7-10 severe discomfort or pain or both. FACES o Brief word instructions: Point to each face using the words to describe the pain intensity. Ask the child to choose face that best describes own pain and record the appropriate number. o Rating scale is recommended for persons age 3 years and older.

NUMBERS/NRS/Visual analogue 0-10, 0 being no pain, 10 is worst pain. Developmentally appropriate tool, meaning must understand numbers and their relationship to one another. Probably most used tool in the world. Does the child understand the concepts of simple math? Needs to understand that 5 is more than 3, etc. Question. A 10-year-old child has just had an appendectomy following a ruptured appendix. Which of the following tools is most appropriate for assessing the childs pain? A. FLACC B. FACES C. CHEOPS D. Numbers Scale Childrens understanding and reactions to death-Not need to memorize for the test Infants and Toddlers No concept, but reacts to changes in routine Reacts to parents anxiety and sadness Preschool Children Death is temporary, reversible May feel guilty, responsible, or punished May engage in strange activities, as they dont understand how to deal with it. School Age Children Death is final and irreversible. Understand death in a concrete sense. Very interested in the funeral and rituals. May still associate misdeeds with causing death

Adolescent Adult understanding Death is final, irreversible and universal May intellectualize death Understands the spiritual implications of death May engage in high risk activities o Understand they can die, but do not think it will happen to them. May reject the adult rituals.

Newborns Neonatal period: First 28 days Refer back to OB class for some specifics Umbilical care, feeding, Breast milk preparation, stools, swaddling Important Temperature regulation, hypoglycemia Poor ability to fight infectionimmature immune system Other Milia, Cradle Cap Jaundice and phototherapy Common Infant Concerns Vision Yeast Thrush Diaper Dermatitis Dental Care Teething Sleep recommendations SIDS AAP Recommendations Car Seat Safety Feeding Infant Vision Eye fully formed, but vision and eye muscles are immature o Put patches on good eyes to make the bad eyes muscle strengthening Bright or moving object 8 inches from the face is easiest for them to focus on Strabismus Common until 4 months of age Binocular vision by 4 months Patching or surgery to treat if continues Thrush (Oral Candidiasis) White adherent patches on tongue, palate, and inner aspects of cheek. o Can wipe away with wash cloth vs. cancer cannot Painful, infant may refuse to suck Use oral nystatin over the patches 4x a day and continue beyond symptoms for at least 2 days. Gentian violet may be used in chronic cases

Diaper Dermatitis (Rash) Caused by prolonged exposure to irritants Management is aimed at altering the pH, wetness, and irritants Change diaper as soon as wet Expose to air, but no heat Use barrier ointments o OTC with zinc oxide and petroleum based preparations Super absorbent diapers are helpful No talcum powder o Risk of respiratory distress o Friedlander, S. F., et al. (2009). Diaper dermatitis: Appropriate evaluation & optimal management strategies. Contemporary Pediatrics, April, 2009, pp. 115 supplement. Note: o Caused by prolonged and repetitive contact with irritants such as urine, feces, soaps, detergents, ointments and friction. o Treatment is aimed at prevention. Topical steriods are used cautiously and for short periods of time d.t thinning of skin and possible systemic steriod effects. o Treatment: need to alter wetness, pH and fecal irritants. o Avoid over irritating the skin by scrubbing off barrier creams. Wipes may be irritating as well. Candidiasis - Diaper Area Common with prolonged diaper dermatitis, use of antibiotics or immunocompromised state. Lasts longer than 72 hours, then usually Candidiasis Yeast-like fungus with diarrhea, antibiotic use, and thrush as predisposing factors. Very confluent, red rash with satellite lesions Treated with antifungal creams (such as nystatin)

Dental Care of the Infant Start when the teeth erupt Clean, soft, damp cloth (no toothbrush or toothpaste initially) Fluoridestart after 6 months if non fluoridated water and maintain until 3 years. Dental visits Start no later than age 3. ADA recommends a dental home by age 1 year. Teething Cold is soothing Discourage oragel, numbing agents o Numbing agents why?? Low sugar diet Baby bottle caries Discourage baby bottles in bed. o Can cause ear infection because of straight eustation tube, milk can sit there can cause infection Discourage use of baby bottle as a pacifier

Sleep Recommendations Newborn 16-20 hours in 1-4 hour intervals Infant 0-3 months, sleeps in 3-4 hour intervals Day night differentiation by 3 months Infants 4 months14-15 hours in 6-8 hour intervals Infants 6 months13-14 hours (includes 2 naps) Toddlers12 hours (includes 1 nap) Preschoolers11-12 hours (nap over by age 5) School age10-11 hours Adolescence9 hours Can be irregular After puberty, later bedtimes and later rise times due to circadian phases Sudden Infant Death Syndrome (SIDS) Unexplained, sudden death of an infant under age 1 year. Etiologycause is unknown Risk factors include: Maternal smoking during pregnancy and tobacco exposure during infancy Co-sleeping or soft bed surfaces Prone sleeping Pre term infants (LBW and low APGAR), siblings of 2 or more with SIDS, male babies, recent viral illness Nursing Care of SIDS o Education!!!! AAP recommendations of back to sleep Firm sleep surface with no loose bedding Do not co-sleep with infant (keep infant in same room, not same bed) In the last year SLCH has had 7 babies arrive DOA in the ED because of infants being suffocated while co-sleeping with the parents !!! Avoid overheating/overbundling child Sleep with pacifier and breast feeding may be protective Provide supervised tummy time to avoid flat occiput Car Seat Safety Most significant risk factor for death and serious injury in a car crash is the failure to use a size-appropriate restraint system. Use approved car seat for age AND weight. Infants rear facing until at least 2 years and 30-40 pounds. When child reaches maximum height and weight recommendations of car seat manufacturer o Height and weight is more important than age A convertible car seat with a weight limit of 35 lbs. can be used rear-facing until 2-4 years. Back seat is always the safest for all children until 13 years of age. o The belt should on the pubic symphasis area not the stomach! Toddler seatingappropriate harness placement and height of car seat. Proper lap belt placement for older children and those in boosters. Review your book for specifics.

Infant Nutrition Breast milk or formula Prefer breast milk as complete diet for first 6 months o Decreased respiratory infections, asthma, OM, obesity, diabetes, SIDS, leukemia Prefer iron fortified formulas No additional water needed How do you prepare and store BM? Introduction of foods!!! Test Decreased tongue thrust, can hold head up when sitting, interested, can signal refusal. Now suggested about 6 months of age o Give rice cereal first b/c low risk food allergiesveggies/fruits meat Introduce food one at a time. Book says wait 5-7days Limit juice intake to < 4 oz/day Begin with rice cereal Use single item foods only for 4-7 days No Honey until after 1 year Why? o Can cause Botulism

Juice Recommendations Juice should be 100% Pasteurized Fruit Juice and not Fruit Drinks Amounts recommended: NO need to memorize! < 6 months none 6-12 months - 4-6 oz in a sippy cup not in a bottle 1 yr-6yrs-4-6 oz > 6 yrs-8-12 oz Older children should be encouraged to eat whole fruits as opposed to drinking juice Infant Feeding Concerns Spit up VS. Vomiting Normal occurrence Reduce by frequent burping, minimum handling during and after feeding Vomiting can cause increasing of intracranial pressure or pyloric stenosis Colic (Paroxysmal Abdominal Pain) Loud crying and drawing up of knees more than 3 hours a day more than 3X a week. Usually gains weight and thrives Weaning from Bottle Goal: to be off by 12 months Offer juice in cup Switch to cows milk at 12 months Whole milk or 2 % o B/c they need fat for the neuron development No skim milk until 2 years of age Physiologic Anorexia Prefer no more than 20-24 oz of cows milk per day Risk of iron deficiency anemia 32 oz of milk is high risk for iron deficiency anemia

Questions When does dental care begin? o First teeth What are the SIDS recommendations? o Back to sleep o No comforter o No-co sleeping o No soft matter o Elevate the bed What is the safest spot for all children in the car? o Back seat When/how do you introduce solid foods? o At 6 months, know signs o Rice cerealveggies & fruitsmeat eggs When do you introduce cows milk? o At 12 months Know FLACC