care of hospitalized child

• Care of child at risk or with problems (acute and chronic)


  • Focus in caring for a hospitalized child:
  • Alleviating the anxieties of children
  • Major factors in support of coping during illness and hospitalization
  • Preparation of children and families for hospitalization
• Alleviating the anxieties of children

  1. Apprehensive and frightened when they anticipate or experience pain

  2. Use pain-free or topical anesthetics

  3. Use sedatives to prevent and moderate pain environment

  4. For neonates - use oral glucose pacifiers

  5. Use procedural information and sensory information
• Major factors to support coping during illness and hospitalization

  • Inner strengths, talents, and attributes of the child
  • Expertise of the nurse: understanding verbal and non-verbal behavior of the ill child, discerning the meaning intended, responding skillfully and accurately
  • Support of families: relationship between nurses and families, climate of pediatric unit as supportive environment, play as therapeutic in facilitating coping
• Preparation of children and families for hospitalization

  1. Provide information

  2. Encourage emotional expression

  3. Establish trusting relationships

  4. Teach coping strategies (thorough tour, use of puppets, medical play, children's literature, audiovisual media)
• Pain


  In children, it is not only a hurting sensation, but also a confusing one because a child does not anticipate the pain, does not have words to explain how it feels, and cannot always understand its cause
• Pain physiology


  • Nociceptors: free nerve endings with specific receptors found in tissue throughout the body
  • Four reasons for pain:
  • Reduced oxygen in tissues from impaired circulation,
  • Pressure on tissue
  • External injury
  • Overstretching of body cavities with fluid or air
• Pain receptor


  A sensory neuron that responds to damaging or potentially damaging stimuli by sending "possible threat" signals to the spinal cord and the brain
• Pain impulses

  1. Stimulated by neurotransmitters conducted by:

  A-alpha and A-beta fibers

  (large, myelinated, rapid conduction, sharp, well localized pain)

  
  

  A-delta nerve fibers

  (smaller, slower conduction, light pressure and vibration)

  
  

  C-nerve fibers

  (slowly conducting un-myelinated axons, diffuse, dull, burning and chronic pain)

  
  

  2. Join central nervous system (CNS) fibers in the dorsal horn of the spinal cord

  -Projected upward to the brain, where they will be perceived as pain
• Acute pain


  Sharp pain
• Chronic pain


  Pain that lasts for a prolonged period (often defined as 6 months)
• Classification of pain


  • Cutaneous pain (arises from superficial structures such as the skin and mucous membrane)
  • Somatic pain (originates from deep body structures such as muscles or blood vessels)
  • Visceral pain (involves sensations that arise from internal organs)
  • Referred pain (pain that is perceived at a site distant from its point of origin)
• Mechanism/flow of pain


  • Pain impulse stimulated by noxious stimuli (mechanical, chemical, thermal) -> electrical activity, transduction, transmission moves along peripheral - sensory nerves, spinal column and brain
  • Gate Control Theory: pain impulses travel and interpreted in the body
• Pain assessment

  1. Pain interview and history (PQRST: Presence, Quality, Radiation/location, Severity, Timing)

  P-Presence of pain

  Q-Quality ie. sharp, burning, tinggling)

  R-Radiation or location of the pain, does it shoot ot radiate anywhere else?

  S-Severity (pain scale 1-10)

  T-Timing (how long is the pain already eg. weeks)

  
  

  2. Objective measures (used by observer to score client behavior or physiologic parameters associated with painful response, HR, BP, and self reporting instruments)

  
  

  3. Subjective (self-rating) measures (when children measure the pain themselves)
• Pain management


  • Nonpharmacologic: distraction, preparation, relaxation, cutaneous stimulation, self-exercises, hypnosis
  • Pharmacologic: Analgesics-NSAIDS, Local or regional anesthesia
• LBW Infants: Less than 2,500 grams or less at birth regardless of gestational age

  SGA (small for gestational age)

  -Have intrauterine growth retardation (IUGR)
• SFD (small for date)


  Birth weight falls below 10% percentile on intrauterine growth charts
• LBW (low birth weight) infants


  Less than 2,500 grams or less at birth regardless of gestational age
• LGA (large for gestational age)


  Weight above 90% on intrauterine growth chart
• Gestational age

  • Premature (preterm) infants (delivered before 37 weeks from 1st day of LMP)
  • Full term infants (born between 37- and 42-weeks gestation)
  • Postmature infants (born after a prolonged gestation, after 42nd weeks)
• Prematurity


  • A preterm infant is traditionally defined as a live-born infant born before week 37 of gestation
  • Preterm neonate is at risk for complications because the organ systems are immature
  • The degree of complications depends on gestational age
• Causes of prematurity


  • Multiple pregnancy
  • Adolescent pregnancy
  • Lack of prenatal care
  • Substance abuse
  • Smoking
  • Previous preterm delivery
  • High, unexplained alpha fetoprotein level in 2nd trimester
  • Abnormalities of the uterus
  • Cervical incompetence
  • Premature rupture of membranes
  • Placenta previa
  • Pregnancy Induced Hypertension (PIH)
• Clinical manifestations of prematurity


  • Respiratory: Tachypnea, grunting, nasal flaring, retractions, cyanosis, decreased oxygen saturation, decreased oxygen levels, abnormal arterial blood gas (ABG) values
  • Cardiovascular: poor tissue perfusion, hypotension, patent ductus arteriosus
  • Gastrointestinal: Feeding intolerance, gastric reflux, vomiting, gastric residuals
  • Altered fluid status: Fluid excess (edema, congestive heart failure), fluid deficit (tachycardia, poor skin turgor, decreased urine output, abnormal electrolyte levels, decreased blood pressure)
  • Iatrogenic anemia (lowered hematocrit and hemoglobin count, tachycardia, pallor, decreased blood pressure, increasing oxygen requirements, apnea)
  • Infection, hypoglycemia, hyperglycemia, ineffective temperature control, neuromuscular system issues (decreased suck and swallow reflex, hypotonia, altered state transition), hyperbilirubinemia
• Diagnostic tests for prematurity


  • Chest X-ray
  • ABG Analysis
  • Head ultrasound
  • Echocardiography
  • Eye examination- retinal specialist
  • Serum glucose
  • Serum calcium
  • Serum bilirubin
  • Euglobulin lysis time
  • CBC
• Medical management of premature neonates


  • Cared for by a specially trained staff in the neonatal intensive care unit (NICU)
  • Supporting the cardiac and respiratory systems
  • Providing thermoregulation
  • Starting IV
  • Gavage nutrition
• Nursing management of premature neonates


  1. Assess heart sounds, apical pulse, perfusion, monitor vital signs

  2. Maintain an environment like the intrauterine environment

  3. Provide adequate fluids, electrolytes and nutrition

  4. Maintain a neutral thermal environment

  5. Prevent infection

  6. Assess for readiness for selected interventions, provide stimulation when appropriate

  7. Encourage flexion in the supine position, provide body boundaries

  8. Promote parent-newborn attachment

  9. Initiate phototherapy as required
• Complications of prematurity


  • Respiratory Distress Syndrome (RDS)
  • Retinopathy of Prematurity (ROP)
  • Patent Ductus Arteriosus
  • Necrotizing Enterocolitis (NEC)
• Respiratory distress syndrome (RDS)


  Condition in premature neonates where lungs lack surfactant, which prevents alveolar collapse at the end of respiration

  Leading cause of morbidity and mortality among prem neonates
• Treatment of RDS


  1. Administration of surfactant

  2. Oxygen administration

  3. Mechanical ventilation
• Retinopathy of prematurity (ROP)


  Disease caused by abnormal growth of retinal blood vessels, which can be exacerbated by supplemental oxygen

  ROP can cause mild to severe eye problems

  Treatment: laser surgery or cryotherapy
• Patent ductus arteriosus (PDA)


  The ductus arteriosus reopens after birth due to lowered oxygen tension associated with respiratory impairment
• Treatment of PDA


  1. Fluid regulation

  2. Respiratory support

  3. Administration of indomethacin

  4. Surgical ligation (if neonate doesn't respond to other therapies)
• Necrotizing enterocolitis (NEC)


  Inflammatory disease of the GI mucosa that occurs in neonates whose GI tract has suffered vascular compromise

  Bowel wall swells and breaks down
• Treatment of NEC


  1. Discontinuation of enteral feedings

  2. Nasogastric suction

  3. Administration of IV antibiotics

  4. Parenteral fluid administration

  5. Surgery
• Bronchopulmonary dysplasia (BPD)


  Chronic lung disease where lungs may be less compliant due to damage from prematurity, infection, or mechanical ventilation
• Treatment of BPD


  1. Supplying oxygen

  2. Maintaining good nutrition

  3. Preventing respiratory illness
• Apnea of prematurity


  Common phenomenon in premature neonates due to immature neurologic and chemical respiratory control mechanisms
• Treatment of apnea of prematurity


  1. Theophylline

  2. Caffeine

  3. Providing gentle sensory stimulation

  4. Blood transfusion (if due to anemia)
• Postmature infant


  Infant born after 42nd week of pregnancy, at risk due to placental insufficiency
• Postmature infant


  • If placenta continues to function well, fetus will continue to grow resulting in large for gestational age infant with problems like birth trauma and hypoglycemia
  • If placental function decreases, fetus may not receive adequate nutrition and utilize subcutaneous fat stores, resulting in fetal dysmaturity syndrome
• 3 stages of fetal dysmaturity syndrome


  • Stage 1 - Chronic placental insufficiency (dry, cracked, peeling skin, malnourished appearance)
  • Stage 2 - Acute placental insufficiency (all stage 1 features plus meconium staining and perinatal depression)
  • Stage 3 - Subacute placental insufficiency (findings of stages 1 and 2 plus green staining, higher risk of fetal/neonatal death)