Unique Considerations in Children

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

2. 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

3. 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

4. Loss of Control: Infants’ Needs • Trust • Consistent, loving caregivers • Daily routines

5. Loss of Control: Toddlers’ Needs • Autonomy • Daily routines and rituals • Loss of control may contribute to: • Regression of behavior • Negativity • Temper tantrums

6. Loss of Control: Preschoolers • Egocentric and magical thinking typical of age • May view illness or hospitalization as punishment for misdeeds • Preoperational thought

7. Loss of Control: School Age • Striving for independence and productivity • Fears of death, abandonment, permanent injury • Boredom

8. Loss of Control: Adolescents • Struggle for independence and liberation • Separation from peer group • May respond with anger, frustration • Need for information about their condition

9. Fears of Bodily Injury and Pain • Common fears among children • May persist into adulthood and result in avoidance of needed care

10. 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

11. Facial expression of physical distress and pain in the infant

12. Older Infant’s Response to Pain • Withdrawal from painful stimuli • Loud crying • Facial grimace • Physical resistance

13. 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.

14. Young Child’s Response to Pain • Loud crying, screaming • Verbalizations: “Ow”, “Ouch”, “It hurts” • Thrashing of limbs • Attempts to push away stimulus

15. School-Age Child’s Response to Pain • Stalling behavior (“wait a minute”) • Muscle rigidity • May use all behaviors of young child

16. Adolescent • Less vocal protest, less motor activity • Increased muscle tension and body control • More verbalizations (“it hurts”, “you’re hurting me”)

17. Effects of Hospitalization on 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

18. 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)

19. Changes in the Pediatric Population • 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

20. Beneficial Effects of Hospitalization • Recovery from illness • Increase coping skills • Master stress and feel competent in coping • New socialization experiences

21. Parental Responses to Stressors 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

22. Sibling Reactions • Loneliness, fear, worry • Anger, resentment, jealousy • Guilt

23. Altered Family Roles • Anger and jealousy between siblings and ill child • Ill child obligated to play sick role • Parents continue pattern of overprotection and indulgent attention

24. Preparation for Hospitalization • Assessment • Nursing diagnosis • Planning • Implementation • Evaluation

25. Preventing or Minimizing Separation • Primary nursing goal • Especially for children <5 yrs • Family-centered care • Parents are not “visitors” • Familiar items from home

26. “Normalizing” the Hospital Environment • Maintain child’s routine, if possible • Time structuring • Self-care (age appropriate) • School work • Friends and visitors

27. Pain • “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

28. Pain Facts and Fallacies • 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

30. Principles of Pain Assessment in Children: QUESTT • 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

31. Pain Rating Scales • 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

32. Pain Scales • 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)

35. Nonpharmacologic Interventions • Based on age • Swaddling, pacifier, holding, rocking • Distraction • Relaxation, guided imagery • Cutaneous stimulation

36. Anesthetics: Topical and Local • Major advancement for atraumatic care • EMLA • NUMBY stuff • Intradermal local anesthetics • Importance of timing

37. Numby Stuff System • 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.

38. Analgesics • Opioids • NSAIDs • “Potentiators” • Lytic cocktail (DPT)—Demerol, Phenergan, and Thorazine • Co-analgesics, amnesics, sedatives, etc. • Role of placebos

39. Dosage of Analgesia • Based on body weight up to 50 kg • Concept of “titration” • Ceiling effect of non-opioids • First pass effect • PCA

40. Nursing Care of the Family • Family assessment • Discharge assessment and planning • Encourage parent participation in planning and care • Information • Preparing for discharge and home care

41. Care of the Child and Family in Special Hospital Situations

42. Ambulatory/Outpatient • Benefits • Preparation of child can be challenging • The stress of waiting • Explicit discharge and follow-up instructions

43. Isolation • Added stressor of hospitalization • Child may have limited understanding • Dealing with child’s fears • Potential for sensory deprivation

44. Emergency Admission • Essentials of admission counseling • “Postvention”—counseling subsequent to the event • Participation of child and family as appropriate to situation

45. Intensive Care Unit • Increased stress for child and parents • Emotional needs of the family • Parents’ need for information • Perception of security from constant monitoring and individualized care

46. Q & A ?