1. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Unique Considerations in Children Chapter 13-14, 16-20 By Nataliya Haliyash, MD, BSN

2. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Loss of Control: Infants’ Needs Trust Consistent, loving caregivers Daily routines

5. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Loss of Control: Toddlers’ Needs Autonomy Daily routines and rituals Loss of control may contribute to: –Regression of behavior –Negativity –Temper tantrums

6. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Loss of Control: Preschoolers Egocentric and magical thinking typical of age May view illness or hospitalization as punishment for misdeeds Preoperational thought

7. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Loss of Control: School Age Striving for independence and productivity Fears of death, abandonment, permanent injury Boredom

8. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Fears of Bodily Injury and Pain Common fears among children May persist into adulthood and result in avoidance of needed care

10. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Facial expression of physical distress and pain in the infant

12. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Older Infant’s Response to Pain Withdrawal from painful stimuli Loud crying Facial grimace Physical resistance

13. Mosby items and derived items © 2005, 2001 by Mosby, Inc. How to calm your infant and stop their crying by just doing a few simple things Step 1:Step 1: Swaddle your baby (this means wrapping your baby tightly in a blanket- similiar to how they do in the hospital) Step 2: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:Step 3: Hold baby sideways against your stomach craddling their head and feet on your arms. Step 4: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: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: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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Young Child’s Response to Pain Loud crying, screaming Verbalizations: “Ow”, “Ouch”, “It hurts” Thrashing of limbs Attempts to push away stimulus

15. Mosby items and derived items © 2005, 2001 by Mosby, Inc. School-Age Child’s Response to Pain Stalling behavior (“wait a minute”) Muscle rigidity May use all behaviors of young child

16. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Adolescent Less vocal protest, less motor activity Increased muscle tension and body control More verbalizations (“it hurts”, “you’re hurting me”)

17. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Beneficial Effects of Hospitalization Recovery from illness Increase coping skills Master stress and feel competent in coping New socialization experiences

21. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Sibling Reactions Loneliness, fear, worry Anger, resentment, jealousy Guilt

23. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Preparation for Hospitalization Assessment Nursing diagnosis Planning Implementation Evaluation

25. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Preventing or Minimizing Separation Primary nursing goal Especially for children <5 yrs Family-centered care Parents are not “visitors” Familiar items from home

26. Mosby items and derived items © 2005, 2001 by Mosby, Inc. “Normalizing” the Hospital Environment Maintain child’s routine, if possible Time structuring Self-care (age appropriate) School work Friends and visitors

27. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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

29. Mosby items and derived items © 2005, 2001 by Mosby, Inc.

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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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)

33. Mosby items and derived items © 2005, 2001 by Mosby, Inc.

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

36. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Anesthetics: Topical and Local Major advancement for atraumatic care EMLA NUMBY stuff Intradermal local anesthetics Importance of timing

37. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Analgesics Opioids NSAIDs “Potentiators” Lytic cocktail (DPT)—Demerol, Phenergan, and Thorazine Co-analgesics, amnesics, sedatives, etc. Role of placebos

39. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Dosage of Analgesia Based on body weight up to 50 kg Concept of “titration” Ceiling effect of non-opioids First pass effect PCA

40. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Care of the Child and Family in Special Hospital Situations

42. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Ambulatory/Outpatient Benefits Preparation of child can be challenging The stress of waiting Explicit discharge and follow-up instructions

43. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Isolation Added stressor of hospitalization Child may have limited understanding Dealing with child’s fears Potential for sensory deprivation

44. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Emergency Admission Essentials of admission counseling “Postvention”—counseling subsequent to the event Participation of child and family as appropriate to situation

45. Mosby items and derived items © 2005, 2001 by Mosby, Inc. 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. Mosby items and derived items © 2005, 2001 by Mosby, Inc. Q & A ?