PEDS Ch 37 exam1 - Lecture notes ch 37 PDF

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Chapter 37- Nursing Care of a Family When a Child Needs Diagnostic or Therapeutic Modalities...

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Chapter 37- Nursing Care of a Family When a Child Needs Diagnostic or Therapeutic Modalities Diagnostic and Therapeutic Modalities in Children #1 Illness can be particularly stressful if many diagnostic and therapeutic procedures are necessary for diagnosis or care.  With less time for teaching and preparation than was once available, good planning and follow-through are essential. Diagnostic and Therapeutic Modalities in Children #2  Supporting a child and family during a diagnostic procedure can not only aid in an efficient diagnosis but also may help establish a trusting relationship between the family and healthcare providers that will make all future interactions more successful. 2020 National Health Goals Related to Keeping Children Well  Reduce hospitalizations for asthma among children under age 5 years from a baseline of 41.4% to a target level of 18.1%.  Increase age-appropriate vehicle restraint systems in children aged 4 to 7 years from a baseline of 43% to a target level of 47%.  Increase the number of adolescents who have had a wellness checkup in the past 12 months from 68.7% to 75.6%.  NOT GOING TO BE TESTED OVER 2020 NHG’S Modifying Procedures According to a Child’s Age and Developmental Stage #1  Consider a child’s age and potential understanding of procedures when planning the number and order of tests and the way they will be performed. o Infant- we want to keep painful or uncomfortable procedures to an absolute minimum, to avoid Messing with Developmental stages such as trust versus mistrust. – too many painful procedures can interfere, so we want to make sure they get to this stage successfully o Toddler and preschooler- tent to resist any kid of diagnostic testing because they don’t want to deal with any uncomfortable, painful procedures, scary or anything that’s unfamiliar to them, for this age group you want to give a short explanation of what to expect and want to wait until it’s close to the time of the procedure that way the child is not just sit there and worry about what’s going to happen. You want to familiarize the child with things that they are familiar with for an example: If the child is going for X Ray You can tell that child is like a big camera that’s going to take pictures of your bones. You will want to introduce new equipment Such as an NG tube, allow the child to play with it look at it touch it, you can show the procedure on a doll That way the child knows what to expect, (therapeutic play)- let them see that doll is not injured o School-age children School age children are concrete thinkers, they are interested in theory and the reason why procedure Is being performed. They need good explanations. o For adolescents They will act mature And Act like this doesn’t bother them, - but they still get scared sometimes depending to procedure so make sure that you provide Comfort, support and good explanations.

Modifying Procedures According to a Child’s Age and Developmental Stage #2

This is just dealing with cultural diversity and Keeping things in mind such as different languages and family dynamics and such when we're doing planning procedures

Nursing Process: The Child Who Needs Diagnostic or Therapeutic Procedures (should be familiar with it)  Assessment  Nursing diagnosis- biggest part need to be familiar with  Outcome identification and planning  Implementation  Outcome evaluation Nursing Diagnoses #1  Fear related to new and strange surroundings of the procedure room Fear related to -anticipatory pain  Pain related to a lumbar puncture procedure  Deficient knowledge related to the technique for 24-hour urine collection  Deficient diversionary activity related to hospitalization and lengthy procedures Nursing Diagnoses #2  Imbalanced nutrition, less than body requirements, related to need for food restriction pre-procedure and post procedure: BIG MAKE SURE WE PAY attention to the nutrition!  Risk of injury related to need for intrusive procedures

Quality & Safety Education for Nurses (QSEN)  Patient-Centered Care - making sure you are specifying type of edu, interventions, prep, diversionary technique.  Teamwork & Collaboration  Evidence-Based Practice  Quality Improvement  Safety  Informatics This is just making sure that your specifying the type of education preparation intervention diversionary techniques play those kinds of things These are tailored to each individual child and their developmental stage to provide the best quality care

Nursing Responsibilities #1  Obtaining informed consent (KNOW)  It is a physician’s job to explain the suggested treatment, alternatives to that treatment, risks and benefits and potential for injury related to suggested treatment – Physician explain procedure and answer family questions  Nurse is responsible for getting the sign consent, chart been filled out and patient and family is ready for procedure NOTE: Emancipated minors- legally they have the same rights as adults they can consent or refuse their medical care. Same with adolescents that live on their own or that or married OR serving with the armed forces  Verifying procedure  Explaining procedures Make sure you explain procedures clearly an answer any questions appropriately as a general guide A child needs a detailed description of what to expect, EXAMPLE: finger stick with the glucose test: you would say “I’m going to clean your finger and you’ll feel a small pin prick. “you would also explain why the procedure is being performed You would explain that the doctor needs to look at their blood to see why your so sick.  Where is procedure will be done: You want to prepare the child for anything specific o example 1: If they need to go for X Ray explain the room to them.  Any unusual sensation example 2: the alcohol that I’m going to use to clean your finger will be cold.  Any pain involved you need to make sure they know beforehand. example 3: I am starting an IV you will state the needle will sting, but I will put some cream on 1st to dull the feeling, (EMLA cream).  You will want to explain the equipment, the room, and length of time the procedure will take. Any special care after the procedure  You will want to use the appropriate language for example: don’t say “TEST” with school age children because they might associate that with a pass/ fail situation. The word TEST could make the child wonder if they passed a procedure, causing them anxiety. If unfamiliar with procedure never guess about a procedure or answer that to child because it can confuse them even more and causes trust issue, if you don’t know the answer tell them you will find out and come back to them.  Scheduling  If the child is not NPO you want to make sure that you schedule meals and play time to decompressed In between Scheduled procedures. On the flip side if they are on fluid restriction/

NPO, for multiple procedures we want to get them done as quickly as possible and together, so that we can get that child eating and drinking ASAP.  Preparing child and family  Physically and psychologically for procedure we want to reduce the anxiety as much as we can, our job is to let them know what to expect. EXAMPLE: a painful procedure when a child has to be very cooperative Such as a bronchoscopy this might require some moderate sedation such as versed during IV medication, these reduce pain and allows the child to breath on their own, and follow command, please can be used in ambulatory or inpatient settings. With moderate sedation you want to still have emergency equipment ready just in case. You want to watch respiratory depression with these drugs have your emergency equipment ready pharm logical medications available. (Narcan). = have Respiratory and pharmacological measure ready for medication rehearsal- those MUST be on hand  Monitor vital signs Blood pressure, heart rate, oxygen saturation ect…  Accompanying child  We want parents to accompany the child as much as possible, because it lowers the child stress level. The parent cannot Accompany the child to the OR but can wait in the waiting room you want to make sure that you provide good directions, comfort and support to the parents. EXAMPLE: you can wait here will be right down the Hall and will come and inform you when the procedure is over, also let the parents know there will be updates throughout the procedure- we routine care of parent as well as child  Providing support  Provide support verbally, presence Build trust with the parents, family, and child. Provide a comforting touch to the child hand on the arm, rub their back.

Nursing Responsibilities #2  Procuring necessary equipment  Ensuring safety  Safety #1 especially with infants and very Young children, identification is huge always make sure that they have their arm bands on. EXAMPLE: if you need to move their current armband, to put in a new IV you will want to cut off the arm band and immediately put on another extremity. For infant they have one on the ankle and arm, older children it’s usually only in one place. You will Immediately tape it to the opposite extremity and request a new band. the child will always need a form of identification on them.  Big thing with safety is the used with restraints- the use of a restraint is always to protect the child from injury, always use alternative methods first such as family present, use of sitters, distraction, RETRAINTS should only be used as a last resort! They need to be removed as soon as possible. Page 1026 TABLE 37.1 pic on 1027 figure 37.1 TABLE 37.1 SAFETY WITH RESTRAINTS Type of Restraint Wheelchairs and carts

Purpose

Method

Promote safety while transporting For a wheelchair, use a vest restraint. Attach straps to the frame of the children to and from a healthcare wheelchair with enough slack so the child has some mobility. For a facility procedure department. cart, fasten a restraining belt and raise the side rails. Even with restraints in place, never leave a child unattended in hallways outside departments in a wheelchair or on a cart. Not only is this unsafe because the child may attempt to get down from the cart or wheelchair but also the anxiety of waiting in a strange department for a procedure without a support person with them may be too acute for

young children to handle. Clove-hitch restraints

Secure one arm or leg for a Use disposable restraints, gauze, or soft muslin tape. Soft muslin tape procedure, such as an intravenous “gives” a little if the child exerts pressure against it so it will not pull infusion. too tight and reduce circulation or cause pain. Tie the restraint as shown in Figure 37.1A. If a child struggles against restraints, fold several layers of soft gauze around the wrist or ankle under the restraint. Secure the restraint to the underpart of the bed. Never tie restraints to side rails; when a side rail is lowered, it will jerk the child’s arm or leg and possibly cause an injury. Release arm and leg restraints whenever someone can be with the child to keep the limb in the desired position.

Jacket restraints

Restrain children younger than 6 months in a supine position.

Elbow restraints

Prevent children from touching the Dress the baby in a long-sleeved shirt to prevent irritation from the head or face (e.g., following facial restraint. Slip a commercial restraint such a NoNoSleeve up over the surgery). infant’s arm and secure it by the Velcro strips (see Fig. 37.1C). Assess the infant’s fingers to ensure the sleeve is not too tight that it interferes with circulation.

Mummy or blanket restraints

Temporarily immobilize young Use this only for the duration of the procedure because it is a total body children for a procedure involving restraint. Follow the steps shown in Figure 37.1D. If the child is exceptionally strong, a few safety pins can be used to hold the head, neck, or throat (e.g., the restraint even more firmly in place. during insertion of a nasogastric For the infant who needs continuous observation for respiratory tube or blood drawing). function, fold the mummy restraint so the chest is exposed. For newborns or infants, use a Papoose Board, a commercial restraint used in the same way as a full or mummy restraint (see Fig. 37.1E).

Fasten the ties at the back of the jacket. Tie strips attached to the sides of the jacket under the mattress to keep the child in one position (see Fig. 37.1B). Assess that the restraint is not pressing against the neck or could be causing interference with a child’s airway.

 Providing care after procedures  You want to see how well they reacted by observation in history, allow the child to explain what happened to them It helps them retrace the procedure in their mind. This allows them to talk about it and overcome any fear, providing therapeutic play After the procedure helps reduce anxiety  Following infection precautions if there’s a dressing we want to make sure that we’re keeping it clean and dry also during the procedure we need to make sure we keep a sterile field.  Assessing response to procedure  Collecting specimens  Tissue samples obtain during the procedure you want to make sure that they are properly labeled and sent to the lab right away.  Documenting Always document what you have done,

Nursing Responsibilities: Restraints

A is a clove hitch restraint B jacket restraint C NONO sleeve or commercial elbow restraint D Mummy restraint – for newborn/ infant’s weekend swaddled in and leave one foot out to get our heel stick E Papoose boards restraint

Nursing Responsibilities: Recovery: PASSING SCORE IS AT LEAST 10 WITH LEVEL OF

CONSCIOUSNESS SCORE NO LOWER THAN 4.

This is on page 1028 figure 37.2 this is a test

question remember this for the test!

 After procedure - recovery: we want to make sure that we're meeting our criteria for discharge either from PACU or inpatient unit or even home  Some children can be discharged in a little 30 minutes o As long as they are: Blood pressure, heart rate and respiratory weight should be age appropriate and they should be reasonably free from pain  Awake, oriented, patent air way  Respiratory status is without retraction, strider or wheezing and is on 95% or greater on room air  PACU assessments and scored the criteria will varies from facility to facility but remember the bolded passing score for EXAM

Measurement of Vital Signs  Temperature: Has a range It goes from 97 to 100.4 specific values children same as adults  Temporal artery thermometer- put the thermometer flush on the forehead midway between the hair Line in brow, press down on the button keeping the device flush to the skin Until you reach the hairline. IDEAL for children assessment - Quick 2 sec. - they are non- invasive, cause less fear and anxiety. They have been proven correlated to rectal temperatures, newborns use temporal artery thermometer, getting away from using rectal temperatures in newborns because it’s at risk for damaging the rectal

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mucosal, children receiving chemotherapy have a fragile rectal mucosal these children should not have a rectal temperature taken Tympanic- the nurse will need to straighten the ear canal. In children younger than 2 years old to straighten the ear canal you would pulled down and children older than 2 years old You would pull up (KNOW) the pinna of the ear, then the nurse would gently insert the tip of the tympanic thermometer in the ear where the sensor will pick up the tympanic membrane temperature even with children with excessive earwax, you will still be able to get an accurate reading. Axillary thermometers- you must make sure that the temperature monitor is in the axilla and the center and hold the child’s arm down to the side to keep it sealed, this allows the thermometer Stay firmly in place. These work better for infants, bigger kids not so much because they can move more. Oral thermometers- the nurse must assess beforehand, if the child had something cold or hot to eat or drink this will affect the temperature of the oral thermometer.

 Pulse rate Best children grow older the heart rate will slow o Young children: the radial pulse is hard to palpate, we will want to do in an apical pulse, you will listen through the stethoscope and listen for a full minute. o Infant: the point of maximum intensity for the Apical pulse (where heartbeat can be heard most distinctly)- can be heard just above and outside the left nipple, at third or fourth intercostal space, it will be more lateral to the midclavicular line. As the child grows by age 7 the pulse Will be located more at the midclavicular line, at the fourth or fifth intercostal space.  Respiratory rate  Respiratory rate should be measured, this should happen before the young child or infant Becomes upset for instance crying.  Count respirations o Infant: while they’re being held by the parent or family member or laying in a crib. Infants tend to breath with their abdominal muscle muscles, you may count respirations by watching the movements of the abdominal muscles as well as counting chest movements. Count for a full minute.  For an older child count respiration while they are seated on the lap of a parent or seated in a chair.  Blood pressure  Blood pressure should start being measured around 3 years of age, usually after well child checkup, unless it’s specifically indicated for another reason. The nurse will want to offer an age appropriate explanation, 1st let the child play with the cuff and squeeze the ball at the end for a minute, then explain that it’s going to hug their arm, this explanation is good because a hug is generally a good thing and it’s not scary.  Biggest thing with blood pressure in children You must have the right size cuff, pick up that is 2 wide or 2 big will give a lower read out and because that is too narrow or too tight Will give a high reading.  In infants the cuff must be no more than 2/3 of the upper arm and not less than ½ in Length of the upper arm. If a child’s arm is not free for BP due do IV lines, cast, or a wound, nurse May take a blood pressure on the upper thigh or on the lower leg specially in an infant making sure that you get the popliteal artery on the infant.  When assessing the BP you want to pay attention to the pulse pressure, which is the difference between the diastolic and systolic readings, because an unusually wide pulse pressure which is more than 50 millimeters of Mercury, or a pulse pressure that is narrow which less than 10 millimeters of Mercury. These can suggest congenital heart disease.  Narrow pulse pressure (less than 10) Can indicate Aortic stenosis. Taking Tympanic Membrane and Axillary Temperature

Taking Blood Pressure Measurement

Common Diagnostic Procedures #1  Electrical impulse studies o ECG or EEG  ECG- (Electrocardiography)  EEG (Electroencephalography) o Both are painless procedures and can be scary for the child Because they see the wires being connected to them, because young children have been told not to touch wires, so this becomes scary for them. o You want to explain that these procedures are safe and were going to apply stickers to you, biggest thing is to make sure that the child understands that the electrodes are just like sticky tape and will be removed easily.  X-ray studies: are used to inspect internal aspects of the body, mostly bony structures. o Flat-plate  X-rays are for the bony structures. They can be used to diagnose and evaluate the progress of certain illnesses, as well to assess the placement of devices such as a NG tube. Usually children are OK with X Rays because you can compare it with a camera, and it decreases their anxiety about the procedure.  A child will receive a lead apron and thyroid shield to protect certain body parts for exposure is not needed. Anyone remaining in the X Ray room will need to have a lead apron as well. You’ll want to remove any objects that contain metal, because they mess with the image. o Dye contrast  Dye contrast is used to visualize a body cavity, radio opaque died may be sw...