PEDS Exam 2 Study Guide

Chapter 21

- Acute pain: sudden pain of short duration associated with injury,

exacerbation of a chronic condition; an inflammatory response is what
helps sustain the pain response, pain decreases as healing occurs
- Chronic pain: pain lasting more than 3 months
o Nociceptive pain: normal processing of pain caused by tissue
injury or death
o Neuropathic pain: abnormal processing of pain stimuli by the
peripheral or central nervous system due to lesion or dysfunction
of the nervous system
- Pathophysiology of pain
o Nociceptors: free nerve endings at the site of tissue damage
Activated by bradykin, prostaglandins, serotonin, histamine
and substance P that allows for the transmission of pain
signals to the spinal cord dorsal horn from the injury site
o Mylenated A delta fibers: sends sharp pain signals to the brain
and triggers the protective withdrawal response
o Unmylenated C fibers: slow transmission of pain with bruns and
aches
o A beta fibers: touch, movement and vibration impulses
o Pain signal reaches the thalamus (center of all sensory info)
which is transmitted to the cerebral cortex, reticular and limbic
systems for processing and interpretation which leads to our
conscious awareness of the pain
- Endorphins, serotonin, and norepinephrine help with modulating the
pain signals as well as non pain impulses being sent along the same
pathways used for pain transmission
- Cultural Influences on Pain
o Infants are dependent on parents and caregivers to recognize
their pain and response; they learn directly and indirectly from
observing family members in pain and try to imitate their
responses
o Children learn how much pain should be tolerated and how much
discomfort justifies a complaint
- Physiologic consequences of pain
o Children will avoid pain by taking shallow breaths and
suppressing coughs which can lead to respiratory issues
 o Gi bleeding and slowed Gi function may occur from unreleieved
pain
o Effects on newborns
Drains energy resources needed for gowth and healing
Vital signs and ICP increase
Repeatitive unrelieved pain can lead to hypersensitivity to
pain and greater behavioral response to painful events
such as immunization
Hyperalgesia (increased response to pain stimulus)
and allodynia (hypersensitivity to light touch) may
occyr

o
- Pain assessment
o The goal is to provide accurate info on location and intensity of
pain; vital signs not a reliable assessment of pain in children
o Pain assessment scales for Newborns
 Neonatal Infant Pain Scale

CRIES Scale: developed for evaluation of postop pain in

preterm and full term neonates.
Behavioral indicators of infant pain: used to evaluate acute
pain in preterm infants
Premature infant pain profile: developed to evaluate
procedural pain in preterm and full term neonates between
 28 and 40 weeks gestation

o Pain assessment scales for Infants and Young Children

Face, legs, activity, cry and consolability (FLACC): assesses
acute pain in infacts and young children following surgery
(2months 7 years) or if child can self report pain
Observe child for 1 to 5 minutes during routine care and score

Noncommunicating Childrens pain checklist: NCCPC

desnged for children with cognitive impairment to assess
postop pain and pain in the home setting
Observe child for 10 minutes
Revised FLACC: postop pain in children with cognitive
impairment.
o Self report Pain Rating Tools for Children
Determining childs ability to self report: assses language
skills (ability to use words in sequence, follow simple
directions, answer simple questions), basic none, some, or
a lot scale used for children 2 to 3 years old
Preschool and school age children
 Wong Baker: after explanation of each face, child
selects face that is closest match to the pain felt,
Older children will used the words describing each
face

Oucher Scale: 6 photographs of a child expressing a

level of pain combined with a scale 1-10; the younger
child usually selects from the faces while the older

child will use the numbers

Older school age children and adolescents
Numeric pain scale: aka Visual Analogue Scale (VAS)
is a 10 cm horizontal or vertical with mark sfrom 0
[no pain] to 10 [most pain]. Child must have good
cognitive ability

Word graphic rating scale: uses horizontal line and

has words describing pain and child should mark the
line closest to pain felt; meant to help child
understand pain severity using five word anchors

Adolescent pain tool: uses all above scales to

indicate the location of all pain sites, provides
 various ways to characterize the pain. Used for potop
pain and assessing acute and chronic pain related to
disease
- Treatment of acute pain is typically for a specified length of
time (e.g., following surgery), with a primary focus of around-
the-clock pain relief. Pharmacologic and nonpharmacologic
therapies may be used in combination.
- Treatment of chronic pain focuses on improving function and
comfort with the understanding that complete pain relief may
not be possible.
- Acute Pain
o Physiologic indicators: stimulates the adrenergic nervous system
shown by tachycardia, tachypnea, hypertension, flushin or pallor,
pupil dilation, peripheral vasoconstriction, pallor, increased
perspiration, and decreased oxygen saturation
o Behavioral Indicators:
Newborns/Infants: knitted brows, squinted eyes, cheeks
raised, eyes closed, crying, jerky movement, stiff posture
Toddlers: crying, restlessness, agitation, sleep disturbance,
irritability
Older children/adolescents: short atten span, posturing,
lethargy, sleep disturbance, depression, aggressive
behavior
o Treatment
 Opioids: analgesics used for severe pain, such as after
surgery or significant injury
PO preferred for children because IM and SQ cause
pain and stress
Meperidine not used in children due to risk for
seizures
Morphine sulfate the GOLD STANDARD
SIDE EFFECTS: sedation, nausea and vomiting,
constipation, urinary retention, pruritis, respiratory
depression
Non-opioid Analgesic: Acetaminophen is an example as a
nonnarcotic analgesic that is used like an NSAID by raising
pain threshold and reducing fever however does not anti
inflammatory properties
No aspirin for children due to Reye;s syndrome
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
o Used for relief of mild to moderate pain
o As a general rule, aspirin is not given in
pediatrics (Reye syndrome)
o NSAIDs have analgesic, antipyretic and anti-
inflammatory actions
o Ibuprofen dose is usually 5-10 mg/Kg every 6
hours
o Do not give these agents to cancer patients or
those with bleeding disorders.
Continuous infusion analgesia: recommended to maintain
pain control for children with continuous or persisten pain
as it keep drug blood levels constant.
Patient controlled analgesia (PCA): a computerized pump
prorammed by healthcare professional and controlled by
the child through a button that provides a small dose of
analgesia
Useful for the first 48 hours postop for kids t years
and older but may be offered as young as 5 years
Safety: set max infusions per hour and max dosage
during a time period to prevent overdose
Educate children pain will be relieved after slight
delay and once they make the switch to PO, PCA is
discontinued
Regional Pain Management:
Epidural catheter placed in the lumbar or caudal
space and is admistered by intermittent bolus,
continuous infusion by small pump or by PCA 24 to
48 hours after surgery
 o Signs that the nerve block is receding are s/s of
tingling in the fingers or toes
Non pharm methods of pain management: Useful for
enhancing the effects of analgesics and maybe reduce
dosage
Cognitive or behavioral methodsL heat or cold apps,
touch, pacifier, therapeutic play, physical therapists
o Dolls, role-playing, role modeling, relaxation,
hypnosis,
o Distraction: engaging in pleasant activities to
focus attention away from pain and anxiety
o Guided imagery: using imagery as a distraction
from a painful procedure
o Cutaneous Simulation: gently rub painful area,
massage skin gently, and hold or rock the
child; competes with pain stimuli transmitting
to the brain
o Sucrose solution: proven effective in preterm
and newborns up to 2 during painful
procedures; thought to activatae endogenous
opioid system through taste
o Acupuncture: based on energy or chi flow in
the body connected by acupuncture points;
pain obstructs points and needles release them
o Electroanalgesia: aka transcutaneous electrical
nerve stimulation, delivers small amounts of
electrical stimulation to the skin by electrodes
which interferes with pain transmission
- Nursing Management
o The assessment and response to pain unique to each child.
Practice asking the right questions and using the best
assessment tools for pain in the child
Recognize factors that may alter child response to pain:
fear, anxiety, separation from parents, anger, culture, age,
etc
Use the same tool each time when assessing pain
Identify all sites of pain then assess intensity of each
o Potential nursing diagnosis
Pain, acute r/t injury
Anxiety r/t anaticipation of pain
Mobility impaired r/t pain
o Planning and Management
Pharm intervention: child usually has a specific pain rating
minimum for analgesia admin which will be given
according to physician prescription
 Monitor flow rate and infiltration site of IV, PCA and
PCA by proxy
Monitor vital signs, pulse oximeter, end tidal CO2
Keep analgesics antidote ON DECK, monitor for side
effects of analgesics and potential resp. depression
Regional Nerve Block
Assess for color, temp, and cap refill.
Assess motor function by asking child to move legs,
toes, and lift buttocks up; check Q2 for movement to
check if analgesia is receding
Protect extremities upon ambulation due to less
sensation to avoid injury
Nonpharm
Parents are one of the most powerful methos:
reduces child anxiety by making them feel more
secure
Educate parents on benefits
Increase comfort of child
Explain painful procedure (what to expect, what will
happen, etc)
Topical analgesics for immunzations, injections, Iv,
venipuncture, needlestick, etc
Newborn Pain management
Use assessment tools appropriate with age
NICU assessment important due to many painful
procedures that may happen on a daily basis, work to
minimize these procedures
Discharge teaching
Teach parents AND children about dosage, frequency
of admin and side effects as well as pain assessment
techniques
- Chronic Pain
o Patho: ongoing stimulation of nociceptors sensitize the peripheral
and CNS resulting in altered or enhanced transmission of pain
sensory info
Specific fibers become irritated leading to hyperalgesia and
allodynia
Headache, ab pain and skeletal pain account for majority of
pain
o S/S: inactivity, posturing, depression, difficulty concentrating and
sleeping
o Conditions
 Sickle Cell: Red blood cell change from round to sickle;
inherited blood disorder which causes small blood vessel
obstruction depriving oxygen to tissue
Treatment: IV opioids for acute crisis, PO NSAIDS and
opioids at home like codeine, hydromorphone, and
ocycodone
Cancer: children experience acute, chronic and intermittent
pain depending on procedure; they experience a wide
variety with possible multiple pain sites
Treatment: Acetaminophen, NSAIDS,
o Overall Treatment: Analgesic meds, transdermal fentanyl
patches, pain meds for acute flares, GABApentin for seizure,
exercise and physical therapy to improve functioning
- Sedation

o A medically controlled state f depressed consciousness used for

painful diagnostic and therapeutic procedures and analgesia
o Level of sedation on a continuum, monitor child to make sure he
doesnt progress to a sedation level too deep
o Analgeesia should be used in combo with sedation when
procedurs are painful
o Moderate sedation
Sedatives given in lower doses where child maintains
protective reflects and retains ability to maintain patent
airway and respond to tactile and verbal stimuli
o Deep sedation
Controlled state of depressed consciousness or
unconsciousness in which protective airway reflexes are
lost
o Nursing Management
Educate amount of time a child should fast before a
scheduled sedation, use complementary therapies as a
distraction for a child with anxiety towards sedation effect
Be aware of respiratory depression and airway obstruction
during sedation procedure: watch for respiratory effort,
color, vital signs, 02 stat,
 Discharge Criteria
Satisfactory and stable cardiovascular function
Patient and functional airway
Arouses easily and has intact protective reflexes
Hydrated
If infant able to hold head up and sit up unassisted if
they did that prior to procedure (return to baseline)
Discharge status the same as admission status

Chapter 26

- Pediatric Differences
o Fetal Circulation
Blood flows from the placenta to the fetus through the
umbilical vein. The blood then flows through thte ductus
venosus allowing the blood to enter the right atrium of the
heart. The foramen ovale allows the blood to flow to the
left atrium then left ventricle the to the aorta and into
systemic circulation.
Next blood returns to the right atrium through the superior
vena cava and flows to the right ventricle where its
pumped into the pulmonary artery. Majority of the blood
passes though to the ductus arteriosus, the fetal vascular
channel between the pulmonary artery and the descending
aorta, to enter systemic circulation. Eventually the blood
returns to the placenta through the umbilical arteries.
o Pulmonary Circulation
Once the umbilical cord is cut the baby must adapt quickly
to receciving oxygen in the lungs. Pressure in the left
atrium increases as blood flow is return from the lungs
through the pulmonary veins.
Systemic vascular resistance increases and pressure in the
left atrium stimulates closure of the foramen ovale, and
fibrin seals it.
Ductus arteriousus constricts na closes within 10 to 15
hours after birth, permanent closure 10-21 days after birth.
o Cardiovascular Changes
Right ventricle larger at birth due to high pulmonary
resistance during fetal life but it reverses over time as high
systemic vascular pressure forces left ventricle to develop
quickly
Neonates with conditions like alveolar hypoxia, acidosis,
and hypothermia may develop prolonged pulmonary
vasoconstriction
 o Oxygenation
Oxygen bound to hemoglobin is transported to the tissues
by the systemic circulation
Desaturated blood results when oxygenated and
unoxygenated blood mix due to a congenital heart defect
as well as a hematocrit of 50%+ because their bodies
attempt to increase available oxygen to the tissues by
increasing RBC production; increased risk of
thromboembolism
o Cardiac functioning
Cardiac output is the volume of blood ejected from the left
ventricle each minute controlled by
HR, Preload, contractility, afterload
Infant lack of compliance decreases the hearts ability to
increase stroke volume so they become tachycardic in
stressful situations to increase cardiac output
- Congenital Heart Disease
o Defect in the heart or great vessels, persistence of fetal structure
after birth
Most occur during during first 8 weeks of gestation where
they are most vulnerable to teratogens due to a combined
effect of environmental and genetic facors
Increased maternal age, prematurity, drugs, alcohol,
smoikking, viral infections, genetic factors (25%)

o S/S
Murmur usually first sign of congenital heart defect; blood
flowing with higher pressure than normal to get through a
narrow valve
Neworn may be initially asymptomatic but develop
symptoms in the first few days of life
 Other signs: chest pain, exercise intolerance, arrhythmias,
syncope, and sudden death.
o Treatment

-
- Nursing management of child undergoing cardiac catheterization
o NPO severeal hours before except for meds, arrive 1-2 hours
before procedure, void and take oral sedative
o Physio assessment: vital signs, H&H, cap refill, baseline skin
temp/color,
 o Psych assessment: focus on parents knowledge deficit, anxiety,
and child separation from parents
o Nurse planning
Educate and prepare parents and child on procedure,
maybe a tour of the cath lab with the child
Child stays on bedrest 4 to 6 hours to keep leg straight,
activity limited for 24 hours
Small amounts of clear liquid with steady increasing
amounts as the child can tolerate
- Congenital Heart Defects that INCREASE pulmonary blood flow
o A connection occurs between the left and right side of the heart,
increasing the blood that is pumped to the lungs
Increased pulmonary blood flow increases pulmonary
vascular resistance to reduce flow causing right ventricular
hypertrophy delivering more blood to the lungs
With the pulmonary system overloaded with blood, you may see dyspnea,
tachypnea, intercostal retractions, and periorbital edema
o Treatment
Surgery to correct defects should happen early to prevent
irreversible pulmonary artery hypertension which usually
leads to full recovery
 Conservative treatment includes waiting for symptoms to
appear before performing any procedure; sometimes a
defect may fix itself like a ventricular septal defect closing
on its own
o Nursing Management Prior to surgery
Physiologic assessment: assess growth (should be normal,
any lack of growth could an increased metabolic rate and
poor consumption of appropriate calories) and look for CHF
signs (increased resp. effort, poor feeding, diaphoresis,
fatigue, recurrent pulmonary infections).
Home care: Focus on growth by encouraging frequent
feeding for no longer than 30 minutes, especially
breastfeeding with all its benefits
o Nursing Management during Surgery
Assessment and Diagnosis
Take a careful history and physical exam to detect
presence or potential development of any acute
illness
Critical Care
Postop child ill be in ICU to be monitored with
invasive hemodynamic techniques, labs, and physical
examination (basically full head to toe)
Transfer to general nursing unit
Focus assessment on surgical complications like the
infection, rrhytmias, impaired tissue perfusion
Monitor all vital signs and inspect incision site, full
head to toe, I&O
ICU
Child is intubated and on a ventilator, suction is
performed, IVS placed, fever prevented, antibiotics
given prophylaxis
Pain: IV until able to take PO
Take deep breaths, cough, do incentive spirometry,
splint to promote respiratory function
Fluids/Nutrition
Encourage fluid intake while monitoring I&O
Have parents bring favorite foods to motivate eating
and promote bowel movement after surgery
Encourage gradual increase of activity every day,
provide diversional activities for pain and anxiety
Discharge
Info on diagnosis/surgery, meds, wound care,
nutrition
o Spread over a few days
 Reassure parents of the should have no
complications and promote return to normal living
- Defects causing DECREASED pulmonary blood flow and mixed defects
o Obstruction causing decreased blood flow to the lungs to be
oxygenated, a septal opening between atria and ventricles lead
to right to left shunting
o Kidneys produce erythropoietin to stimulate RBC production, too
much RBC (polycythemia) can lead to sluggish blood flow
increasing risk of thromboembolism in cerebral and pulmonary
vessels
o Infants may wake with cyanosis and experience a sudden
decrease in systemic vascular resistance and pulmonary blood
flow triggering a hypercyanotic episode
Combine this with increased cardiac output and venous
return from a stress reaction and the brain overreacts
causing increased resp. effort further increasing cardiac
output contributing to a life threatening decline unless
rapid intervention is successful
o MIXED DEFECTS
Mixing of oxygen saturated and desaturated blood results
in a general desaturated systemic blood flow and cyanosis.
Pulmonary congestion occurs because of increased
pulmonary blood flow and obstruction of systemic flow

o S/S
 Cyanosis shortly after birth that doesnt respond to 02,
dyspnea, and a loud murmur
Severe obstruction leads to hypercyanotic episodes
Treatment: squat to relieve dyspnea because it
reducse cardiac output by decreasing venous return
and increasing systemic vascular resistance
S/s: increased rate and depth of respirations,
increased cyanosis, pallor and poor tissue perfusion,
increased HR, diaphoresis, irritability and crying,
seizures and LOC
o Collaborative Care (Mixed Defects)
 Diagnostics: hypoxia test when <93%,
Treatment: corrective surgery in newborns, palliative
procedure (atrial balloon septostomy) to preserve life first
then corrective surgery,
Closure of the ductus arteriosus: PGE1 reopens it
providing time for newborn to be transferred for
diagnostic evaluation and surgical intervention
o Adverse effects of PGE1: respiratory depression
and apnea
 Hypercyanotic episodes: oral propranolol, knee-chest
position,
Long term therapy: children with complex congenital
heart defects require lifelong assessment and med
care
o Nursing Management
Focus on PGE1 therapy, treating hypercyanotic episodes,
and providing postsurgical care
Prior to surgery
At risk for CHF so monitor tachycardia, crackles,
tachypnea, secretions, low urine output and
pulmonary edema,
Monitor all vital signs and assess growth and cardiac
deterioration
Following surgery
Assess all vitals, I&O
Home care of the child before surgery
Referalls to community based early intervention
programs so that specialists can set goals for the
child
Treat child as normally as possible without adjusting
activity too much
Observe signs of worsening cyanosis, especially in
the morning
o Know baseline sp02 to know bad changes
o Call 911 and stay calm, place child in knee
chest position
Report signs of illness to the physician asap, fever
increases metabaolic rate and causes further stress
on the heart
Antipyretic meds and fluid volume replacement
necessary
- Defects OBSTRUCTING systemic blood flow
 o An anatomic stenosis causes obstruction of blood flow,
increasing pressure on the left ventricle with decreased cardiac
output and potential shock
o The blood cant move past the obstruction backing up into the
left atrium and the lungs leading to CHF and pulmonary edema
- Congestive Heart Failure
o Cardiac output inadequate to support the bodys circulatory and
metabolic needs
Causes: congenital heart defect that increases pulmonary
blood flow or obstruction of systemic outflow tract
S/s: early -infant tires easily especially in feeding, weight loss or lack of
normal weight gain, diaphoresis, irritability, and frequent respiratory
infections, later tachypnea, tachycardia, pallor, cyanosis, nasal flaring,
grunting, retractions, cough, or crackles, cardiomegaly enlargement of
 the heart with the heart compensating to maintain cardiac output

o Medications for the treatment of CHF