NUR 416 Exam 2 Blueprint: Essentials of Pediatric Nursing Chapters 12-20

NUR 416 Exam 2 Blueprint: Essentials of Pediatric Nursing Chapters 12-20 Chapter 12: Nursing Care of the Special needs Child - Additional stress can be felt by the child with a chronic illness and their family during times of transition. What is an example of a transition? o Initial diagnosis or change in prognosis o Increased symptoms o When the child moves to a new setting (hospital, school) o During a parent’s absence o During periods of developmental change o Arrival of new family members. - What is vulnerable child syndrome? o Vulnerable child syndrome is a clinical state in which the parents’ reactions to a serious illness or event in the child’s past continue to have long term psychologically harmful effects on the child and parents for many years. o Parents can exhibit excessive unwarranted concerns and seek health care for their child frequently. o Risk factors of vulnerable child syndrome ▪ Preterm birth ▪ A congenital anomaly ▪ Newborn jaundice ▪ A handicapping condition ▪ An accident or illness that the child is not expected to recover from ▪ Crying/feeding problems within the first 5 years of life. o The parent has difficulty separating from the child, and the child senses that anxiety nd then develops symptoms that reinforce the parents’ fears. o The parents’ may try to retain control, especially at times of increasing independence, and fear disciplining their child as they do not want to “upset” the child. Chapter 13: Medication Administration - Calculate the low and high safe dose range for a 44 lb child obtaining a drug with a range of 10- 20mg/kg/day o 44/2.2 = 20 kg o Low  20 x 10 mg/kg/day = 200 mg/day o High  20 x 20 mg/kg/day = 400 mg/day - What is the proper way to administer ear drops in a different ages? o When administering pediatric ear drops, pull the pinna down and back is correct if the child is younger than 3 years of age. o To administer ear drops to a child who is 4 years old and older, the nurse should pull the pinna up and back. o Have the patient in a side lying position with the affected ear exposed. Have them maintain this position for a few minutes to ensure that the medication stays in the ear canal. Massage the area anterior to the affected ear to promote passage of the medication into the ear canal. o If necessary, place a piece of cotton or a cotton ball loosely in the ear canal to prevent the medication from leaking. - What are nursing instructions you may give a parent on giving medications at home? o Ensure thorough instruction, including frequency of administration, when the next dose is due, and the length of time the medication is to be given. Emphasize the importance of completing the prescribed dose. o Demonstrate use with an actual syringe if possible, encourage return demonstration of medication administration, advise against the use of home-measuring devices, and emphasize the importance of always using the calibrated dispensing device that was given with the medication. o If the medication is given via injection, parents and caregivers need to learn how to administer the injection properly. Encourage questions or concerns from parents or caregivers. o Provide with tips for administration, such as mixing unpleasant tasting medicines with apple sauce or yogurt or offering a favorite as a chaser. o Also teach the parents how to properly measure the amount of drug to be given. - Should you aspirate prior to giving an IM injection? o Traditional technique  insert the needle into the skin at a 90 degree angle. Aspirating and, if no blood was present, injecting the medication was the traditional procedure. o However, recent research has shown decreased discomfort and no associated complications with rapid injection of IM immunizations without aspiration. SO NOW YOU DO NOT NEED TO ASPIRATE WITH IM INJECTIONSSSSSS. - Calculate IV fluid maintenance for an 8kg child. o 100 ml per kg of weight = # mL for 24 hours o example  8kg x 100 ml/kg = 800 ml per day. 800ml / 24 hr = 33.33333 ml/hr - **** there are other equations for weight that’s over 10kg. this equation is only for those who weigh less than 10 kg. Chapter 14: Pain management - How is pain classified? o Pain is classified based on its duration, etiology, or source or location. o Classification by Duration ▪ Acute pain  pain that is associated with a rapid onset of varying intensity. It usually indicates tissue damage and resolves with healing of the injury. Acute pain reflects stimulation of nociceptors and serves a protective function (i.e. alerting the patient to a problem). ▪ Chronic pain  is defined as pain that continues past the expected point of healing for injured tissue. It provides no protective function. May be continuous or intermittent,, with and without periods of exacerbation or remission. It often interferes with sleep and performance of ADLs. It can result in loss of appetite and depression. • Impairs a person’s ability to function. • In children, chronic pain is most commonly associated with abdominal pain, nonspecific headache, limb pain, or chest pain. • Some conditions such as sickle cell disease and migraines, have characteristics of both acute and chronic pain. ▪ Children often experience pain associated with various procedures done in healthcare settings. This type of pain is usually short in duration. Preparation of the child and family will help to decrease fears or anxiety. Depending on the type of procedure and the child’s age, cognitive level, and temperament, various techniques and methods can be used. Advocating for atraumatic care and adhering to its guidelines will help to minimize procedure related pain. o Classification by Etiology ▪ Nociceptive pain  reflects pain due to noxious stimuli that damages normal tissues or has the potential to do so if the pain is prolonged. The pain perceived often correlates closely with the degree or intensity of stimulus and the extent of real or possible tissue damage. Nervous system functioning is still intact. • Sharp, dull, burning, aching, stabbing • Ex of conditions  chemical burns, sunburn, cuts, appendicitis, and bladder distention. ▪ Neuropathic pain  due to the malfunctioning of the peripheral or central nervous system. It may be continuous or intermittent and is commonly described as burning, tingling, shooting, squeezing, or spasm like pain. • Ex of conditions  posttraumatic and postsurgical peripheral nerve injuries, pain after spinal cord injury, metabolic neuropathies, phantom limb pain after amputation, and poststroke pain. o Classification by Source of location ▪ Somatic pain  refers to pain that develops in the tissues. It can be further divided into superficial and deep • Superficial cutaneous pain involves stimulation of nociceptors in the skin, subq tissue, or mucous membranes. Typically the pain is well localized and described as sharp, pricking, or burning sensation. Superficial somatic pain may be due to external mechanical, chemical, or thermal injury or skin disorders. Tenderness is commonly present. • Deep somatic pain  involves the muscles, tendons, joints, fascae, and bones. It can be localized or diffuse and is usually described as dull, aching, or cramping. Deep somatic pain may be due to strain from overuse or direct injury, ischemia, and inflammation o Tenderness and reflex spams may be present. The patient may exhibit sympathetic nervous system activation such as tachycardia, hypertension, tachypnea, diaphoresis, pallor, and pupillary dilation. ▪ Visceral pain  develops within organs such as the heart, lungs, GI tract, pancreas, liver, gallbladder, kidneys or bladder. It is often produced by disease. It is usually diffuse or poorly localized and is described as a deep ache or sharp stabbing sensation that may be referred to other areas. Visceral pain may be due to distension of the organ, organ muscular spasm, contraction, pulling, ischemia, or inflammation. • Tenderness, nausea, vomiting, and diaphoresis may be present. - A child coming in for routine infusion for management of their Crohn’s disease no longer feels pain related to IV insertion. True or False. o False - How do we observe for pain based on development? o Infants  believed that neonates experience pain at greater intensity than older age children and adults. ▪ Facial expression  brow contracting and chin quivering, and high pitched shrill crying, eyes tightly closed, ▪ Physiologic  increased heart rate, decreased oxygen saturation, decreased vagal tone, palmar or plantar sweating (as measured by skin conductivity testing) not reliable in infants before 37 weeks gestation, increase in plasma cortisol or catecholamine levels. ▪ Although infants usually exhibits typical behaviors indicating pain, absence of these manifestations does not indicate lack of pain; response to pain is highly variable o Toddlers  intense emotional upset and physical resistance or aggression. They may bite, hit, scream, or kick. ▪ Other behaviors include: being very queit, pointing to where it hurts, or saying such words as “owwww.” ▪ Facial grimacing and teeth clenching may be noted. They may also react with fear and try to hide or leave the room. They often have limited vocabularies, so it may be difficult for them to express pain. ▪ Toddlers may demonstrate regressive behavior, such as clinging to the parent or crying loudly. o Preschoolers ▪ Become quiet or try to withdraw and hide in response to actual or perceived pain. For example, the child may say he or she needs to go to the bathroom or needs to get something from another room. ▪ Because of their magical thinking, preschoolers may believe pain is a punishment for misbehaving or having bad thoughts. ▪ They may not verbally report their pain, thinking that pain is something to be expected or that the adults are aware of their pain. ▪ They can tell someone where it hurts and can use various tools to describe the severity of pain. ▪ They may have difficult from distinguishing between types of pain (sharp or dull), describing the intensity of the pain, and determining whether the pain is worse or better. o School Age Children ▪ Can usually communicate the type, location, and severity of pain. Children older than 8 years can use specific words, such as “sharp as a knife,” “burning,” or “pulling” to describe their pain. ▪ However, they may deny pain in an attempt to appear brave or to avoid further pain related to a procedure or intervention. ▪ They may be more concerned with their fear about the illness and its effects rather than the pain. ▪ They may also fear being embarrassed by acting out behaviors in response to pain, such as screaming or thrashing. ▪ Typical response might be to withdraw by staring at the television. ▪ Other indicators of pain are clenching of the fists, muscular rigidity, stiffening of the body, closing the eyes, wrinkling the forehead, or gritting the teeth. o Adolescents ▪ Primarily be concerned about body image and fear losing control over their behavior. This may result in denial or refusal of medications. Their mood and what they think is expected of them will also affect their response to pain. ▪ They ask a lot of questions and pay close attention to how others respond to them. ▪ They may attempt to be stoic and not exhibit emotion so that they are not viewed as juvenile. ▪ Subtle changes such as increased muscle tension with clenched fists and teeth, rapid breathing, and guarding the affected body part may occur. ▪ May show a lack of interest in everyday activities or a decreased ability to concentrate. - List 2 non-pharmacologic pain management strategies. o Relaxation, distraction, imagery, biofeedback, thought stopping, positive self-talk, sucking and sucrose, heat and cold applications, massage and pressure - List a nursing implication for a child receiving morphine. o Morphine is an opioid agonist that is used to treat moderate to severe acute and chronic pain. Morphine specifically is used for intractable pain, preoperative sedation. o Assess respiratory status frequently, noting any decrease in ventilator rate or changes in breathing patterns; have naloxone readily available in case of respiratory depression (particulary morphine, fentanyl, hydromorphone) o Monitor for sedation, dizziness, lethargy, confusion o Educate parents and child that the drug may make the child sleepy, drowsy, or lightheaded. o Institute safety measures to prevent injury to the child o Assess bowel sounds for decreased peristalsis; observe for abdominal distention o Ensure adequate fiber intake and administer stool softeners as prescribed to minimize risk for constipation o Monitor urine output for changes and report o Morphine may cause itching, particularly facial itching. - Pain scales for different ages o FACES pain rating scale (ages 3+, emoticon-like faces) o Oucher pain rating scale (ages 3+, actual photos of children, must know number values) o Visual analog and numeric scales (ages 3+, scales of 0–10) o Poker chip tool (ages 4-7, uses 1 to 4 poker chips to describe pain) o Word-graphic rating scale (ages 8 to 15, child selects pain rating) o Adolescent pediatric pain tool (ages 8 to 15, measures pain location, intensity and quality) o TABLE 14.2 THE NEONATAL INFANT PAIN SCALE (NIPS) Parameter Finding Score Facial expression 0 - Relaxed (restful face; neutral expression) 1 - Grimace (tight facial muscles; furrowed brow, chin, or jaw; negative facial expression) Cry 0 - No cry (quiet; not crying) 1 - Whimper (mild intermittent moaning) 2 - Vigorous crying (loud screaming, shrill, continuous) Breathing patterns 0 - Relaxed 1 - Change in breathing (irregular; faster than usual; gagging; breath holding) Arms 0 - Relaxed (no muscular rigidity; occasional random movements of arm) 1 - Flexed/extended (tense, straight, rigid, or rapid fl exion or extension) Legs 0 - Relaxed (no muscular rigidity; occasional random movements of leg) 1 - Flexed/extended (tense, straight, rigid, or rapid fl exion or extension) State of arousal