Chapter 3 communication w/ children/families

Strategies for managing conflict Understand the parents perspective (walk in their shoes) Determine a common goal and stay focused on it o (determine the agreed-on result and work toward it) Listen actively Openly express your feelings Summarize the decision

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Table 3-3 Developmental Milestones and their relationship to communication approaches continued Development Infants (0-12 months) experience through senses. Language Crying, babbling, cooing. Single word production. Name Simple Objects for cuddling/security. Responsive to environ. Distinguish b/w happy and angry voices/ familiar or strange. Separation anxiety. Emotional Dependent. Hi need Cognitive Interactions are reflexive. Begin to see repetition of activites. Short attention span 1-2 mins. Approach Calm. soft. Soothing voice. Responsive to cries. Turn taking vocalizations. Talk and read regularly. Slow approach and allow time to aquaint w/ child. Toddler (1-2 yrs) experience world thru senses Two word combinations. Turn taking in communication. No. able to use gestures and verbalize simple wants and needs. Need for security objects. anxiety. Parallel play. Thrive on routines. Independence starts. Dependent on adults. Experiment with objects. exploration. Experiment with variations of activities. Cause and effect relationships. Attention Learn toddlers words for common items. Descrive activities as theyre to be done. Picture books. Play for demonstrations. Responsive to childs receptivity

Separation/stranger Active

span 3-5 minutes. Preschool children (35) use words they dont fully understand. Nor know what others say Able to speak in full sentences. Growth in grammatical usage. Use pronouns. Articulation of sounds. Rapidly expanding vocab. Like to imitate activites and make choices. Strive for independence but need adult support and encouragement. Attention seeking behaviors. Cooperation and turn taking in game playing. Need clearly set boundaries and limits. Developing concept of time, space, quantity. Magical thinking is prominent. World only seen from childs perspective. Attention span 5-10 minutes.

toward you.

Try to offer choices. Use play. Use simple sentences. Picture and story books. Descrive activities and procedures. Limit explanations to <5 minutes. Engage in prep. Activities 1-3 hours before event.

School age children (611)

Expanding vocab. Child can describe concepts, thoughts, feelings. Conversational skills.

Interacts well with others. Rules to games. Interested in learning. Close freinships. Accept responsibilities. Competitiveness arises. Still dependent on adults.

Grasp concepts of classification, conversation. Concrete thinking emerges. Very oriented to rules. Attention span to 10-30 mins

Photos, books, diagrams, charts, videos to explain. Engage in convos that use critical thinking. Establish limits and set consequences. Prep materials 1-5 days in advance

Adolescents (12+) Able to create theories and generate many explanations for situations.

Verbalize and comprehend most adult topics.

Accept responsibility for own actions. Need independence. Competitive. Need for group identification. Small group of close friends. Question authority.

Think logically and abstractly. Attention span up to 60 mins.

Engage in conversations about adolescents intersts. Use photos books diagrams, charts, videos. Collaborative approach and support independence. Respect privacy. Introduce preparatory materials up to 1 week in advance.

Considerations in choosing language o o o o Use concrete terms, NOT ambiguous terms (get a CT VS take a picture of your insides, the machine works and sounds like) Take your temp. NOT take your vital signs Provide sensory info invite vhildren to see, hear, feel before experience. I.E show IV catheter and explain it before inserting Explain sequence of events, length of events.

CH 11
24 hours observation

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children can become ill and recover quickly. Sometimes acute care is only needed for short periods of time. Afte r24 hours child might be discharged.

Childrens response to illness Fear of unknown Separation anxiety Fear of pain or mutilation Loss of control Anger, guilt Regression Protest = child agitated, resists caregivers, cries, is inconsolable. Despair = child feels hopeless and becomes quiet, withdrawn, apathetic Detachment = child interested in new environment, plays, seems to form relationships with caregivers and other children. If parent reappears, child may ignore. Developmental approaches to Hospitaized child Neonate o o o o Infant o o o o o o o o o Expect regressive behaviors and inform parents to expect it and why Limit number of caregivers Encourage parents to be present during procedures Regression Follow home routines and rituals Use all possible methods of pain control Safe environment Encourage independence Approach with positive attitude Swaddle, oral stimulation Quiet environment Constant caregivers Collaborate with parents

Stages of separation

Toddler

Preschooler

o o o o o o o o o o o o o o o

Provide safe ways out of aggression Take time for communication, use concrete explanations Consistency Provide for play activities Inform of limits and enforce them Explain all procedures and allow time for questions and answers Privacy Assist in contacting friends Privacy Encourage street clothes Encourage questions about appearance and effects of illness Encourage peers to call Allow favorite foods Provide educational needs

School age child

Adolescent needs

KEY CONCEPTS

CH 13
Transportation Retraints

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Method depends on childs age, developmental level, physical condition, destination, safety factors, specialized equipment needed. Facilities require Docs orders stating why restraint is needed and how long it should be in plae. Hourly neurovascular checks Q 2 hours, record removal of restraints, range of motion, and position changes.

Standard precautions Used when dealing with blood, all body fluids, secretions, excretions except sweat, nonintact skin, mucous membrane Standard precautions considered first tier which means used with all patients in hospital. Second Tier precautions apply to specific clients and are known as Transmission based preautions Bathing Feeding Favorite and preffered foods and nutritious snacks can help to ensure appropriate caloric intake Newborns only submerged in water after umbilical stump and circ. Have healed Bath water should stay below 100 F, 37.7 C, warm-not-hot to touch. If no thermometer, use inside of wrist or elbow To prevent accidental drowning, fill tub with no more than 3 inches water When finished, wrap infant in dry towerl, cotton blanket in football hold. Avoid talcum powder or cornstarch. Allow for organism growth when moist After 1 year of age, child can be bathed safely in regular tub To remove excess food, bacteria. Wife gums after EACH feeding Children should brush twice a day using a PEA SIZED amount of toothpaste Discourage swallowing d/t excess of fluoride causing fluorosis (brown spots on the teeth) Soft brushes, spong covered toothettes, moistened gauze for kids at risk of gingival bleeding Oral Hygiene

Child with nausea should not be given favorite foods, meds should not be mixed with fave. Foods so there is no negative association with fave foods Hold infants during feedings. Never prop bottle Post feeding, place infant on RIGHT side to allow food to empty, do not let infants sleep on right side Colorful plates and cups to encourage eating, allow own cups or utensils from home Roaming while eating is discouraged. Restrict feeding time to 15 to 20 minutes. D/c if child plays with food

Vital Signs, Temperature Axillary and tympanic preferred. Least accurate. Some policies include 1 rectal temp/shift. Report any temp <36 or > 38 (especially in infants younger than 2 months) Axillary used in children under 4-6, immunocompromised, neurologically impaired, had oral surgery. Axillary temps are usually .6C lower than bodys actual core temp Pulse Apical pulse measurements recomnneded in children younger than 2 and in any kid with irregular rate or rhythm. Count for ONE full minute. Get pulse BEFORE administering medicine like digoxin Radial pulse appropriate if >2 years old Cheyne-Stokes respirations ok in babies up to 4 weeks old Ausculate for full minute Count respirations and apical HR first. These are best done on sleeping child Blood Pressure Appropriate cuff size is the width of the cuff is 40% the circumference of the arm. (10 cm arm = 4 cm width) BPs can be taken in upper arm, lower arm, thigh, calf, ankle If BP is elevated when taken electronically, take again by auscultation Diastolic reading is when sound becomes absent, not changes sounds. If systolic BP is heard all the way down to 0. Document as I.E (85/P) Respirations Avoid liquids 30 mins prior to oral temp. Temps might be inaccurate d/t oral intake, O2 admin, nebulized treatments, crying.

Medications and Environmental Management External cooling frequently used in hyperpyrexia, removing blankets, clothing also. Tepid sponge baths used. Antipyretics used are ibuprofen and acetaminophen (NOT ASPIRIN d/t association of Reye syndrome in children with flu, varicella). Specimen Collections (Urine) Parent collecting at home. Use glass container, boil for 20 minutes, remove and hold by not touching inside. Collect urine after cleaning perineal area. Catheter sizes o o o o Infants 1 year 15 Blood speciments Use of eutectic mixture of local anesthetics (EMLA) often to reduce childs discomfort. EMLA must be on site for a t least 45 minutes before needle inserted. Venipuncture uses butterfly catheter o Antecubital vein most common Finger puncture use ring finger, nondominant hand Heel used for infants, not used once walking Lavage = nasal washing used to obtain nose specimens. Used often for obtaining respiratory sunctial virus and pertussis Bone marrow aspirates Most common site is posterior iliac crest, other sites are anterior iliac and the tibia Gavage and Gastrostomy Children with head or nasal anomalies of imjuries / or children who are preferential nose breathers (<4 months) will need an orogastric tube Feeding tube of 5f-10f most common 8F 8F-12F 10F-14F school age asolescents 5f 8f

Sputum specimens

Tube placement verified @ time of insertion, before each bolus, any time feeding is interrupted, and Q 4-8 hours during continuous feeding. Auscultating of whoosing sound most commonmethod of checking placement Examination of aspirate and pH measurement of aspirate more accurate. o o o pH of stomach = <5 usually green, brown pH >5 means past pyloric valve, aspirate is yellow green Leaking Tube occlusion Malfunction of antireflux valve Abnormal tube position

Signs that G tube need replaced o o o o

Enemas Age Infant 2-4 year 4-10 11 + Ostomies

Provide pacifier so child can associate sucking with feeding To avoid overfeeding, use only amount of formula for 4 hours at a time Volume infused 120-240 ml 240-360 360-480 480-720 Depth of insertion 2.5 cm (1 inch) 5 cm 7.5 cm 10 cm

Anatomic location of stoma dicates stool consistency (higher the stoma, more liquid the stool) Management and care of stoma differs little from adults Nasal cannula o o Up to 6L/min Higher will irritate nasopharynx, cause GI distress O2 up to 40% Moderate amounts of 02 needed 35-60% O2 6-10 L

Oxygen therapy

Simple face mask, venturi mask o o o

o o o o

can do specific amounts of O2 50-60% o2 rate of 10-12 can deliver 100% o2 for 10-15 minutes

Partial and nonrebreathers

mist tent may be used humidified instances Relation between pulse ox and actual PaO2 are not exact. A small decrease decrease in pulse ox can represent a much larger decrease in paO2

Chest physiotherapy Percussion is rhythmic clapping with a cupped hand over the affected portion of the lung Percussion and postural drainage are usally done 3-4 times per day and more if indicated. Treatements are performed before meals or 1.5 hours after meals. Children receiving continuous feedings should have feed stopped 1 hour before treatment Length of Tx 20-30 mins Suctioning o o o o Catheter sizes 5f 14f Record and assess breath sounds, respiratory rate, characteristics of respirations q4 hours, suction 12-4 hours or as needed. When suctioning, insert suction an extra 0.5 inches with suction off before starting suction Limit insertion and suctioning time to less than 5 seconds to prevent hypoxia Stoma care o Surgery Children greater risk of dehydration than adults, so period of no fluids is shorter Guidelines for preop fasting o Fast from solid food and full liquids the night before. Light bfast might be allowed in morning Trach care/ cleaning should be done q 8 hours. Trach tube changed usually weekly Trach Care

o o o o

Stop breastfeeding 2 hours in advance of arrival at hospital Clear liquids can be taken up to 2 hours before Children recuperate more quickly in a familiar environment, so discharge is quick Children aged 7 years and older may need to give assent to some procedures

Postop care

ch 14
Pharmakokinetics Absorption ORAL ROUTE Most med absorption is in Small intestine Factors that influence process o o o o o

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Gastric acidity (childs is less acidic than adults, formula can increase alkalinity decreasing absorption of some meds) Gastric emptying time (usually intermittent and unpredictable in infants) GI motility, Function of pancreatic enzymes Childs periph. Circulation less reliable and more responsive to environmental changes than adult. Vasoconstriction/dilation can occur and alter absorption

OTHER ROUTES

o o

Infants body muscle = 25%, adult = 40%. Blood flow is erratic to kids and affects absorption Infants have larger BSA/weight (body surface area/weight ratio) Affects absorption of meds, causes 3x greater absorption than adult

Dsitribution Body fluid is 60-75% of body weight in children (60 = >2 years old) causing need of higher dose per kilogram of water soluble meds for desired distribution Kids have higher body fat, causes need for higher dosage for fat soluble meds Infants have lower levels of plasma proteins than older kids, causing more unbound drug circulating -> higher absopriton Blood brain barrier doesnt fully mature until 2 years old o Causes less selectiveness and high distribution of drug Metabolism Toddlers and preschoolers have greater metabolizing capacity than adults for some drugs, higher or more frequent doses of some drugs may be needed Serious side effect of meds in children is encephalophathy d/t this

Excretion Newborns GFR is 30-50% of adults. Adult rates reached at 1 year. Medications can circulate longer and reach toxic blood levels Loss of fluid may also decrease as child excretes medications, therefore dehydration has serious effect of drug serum levels Concentration Teaching Toddlers and preschoolers Benefit from therapeutic play and participation, nurse should allow control Offer lots of choice, these children cooperate more but may still need source of distraction Need praise, rewards Doses calculated as mg/kg/day (usually then divided into administrations) Can also be done by BSA (mg/m-squared) o Approximate = BSA of child / 1.7 x normal adult dose Calculations School age Doc may order peak and trough serum levels to monitor concentration. Peak may not be highest level but is level when med is distributed

Administration procedures Accurate d/c instructions important. Convert to lay terms (IE 1 teaspoon = 5 ml of something) ORAL MEDS One of lest reliable methods of administration d/t absorption differences in GI tract If tablet crushed, mix with nonessential food like applesauce/pudding Avoid syrup or high sugar substances NEVER give with honey (Honey can cause infantile botulism) Place syringe gently in mouth along side of cheek and squirt slowly as infant sucks on it Administering injections Most often used for one time doses of antibiotics Tell child that injection is not punishment but meant to make child healthier Apply ice to site for several minutes before injection (can interfere with absorption)

 Site

EMLA creams or topical lidocaine may be used in reducing pain Most needles and hubs have .2mL of dead space s oDO NOT flush needle and hub after injection Appropriate needle sizes = 21-25 gauge length = .5 1.5 inches Safe volumes = .5 to 2.5 mL depending on age and size of child Ages Usually used in kids < 3 years old. Amount .5 or less in < 3. 1.5 mL in kids 314. Up to 2 mL in older kids. Info To locate site, divide leg into thirds and give injection in middle to outer third Upper part of butt = location. Ask child to toe in to avoid flexion. Slowest and poorest absoption.

IM injections

Vastus Lateralis

Dorsogluteal

Should not be used until child has been walking for at least 1 year.

1 mL in 3-6 year olds. 1.5 to 2.5 in older.

Ventrogluteal

Children over 18 months.

Can hold up to 2.5 mL.

Free of major BV and nerves. Located center of side of hip.

Deltoid

Only in kids 6+

Holds up to 1 mL

Least painful site

Subcutaneous injections 25-27 gauge , .5 to 5/8 inch needle o insulin needle usually 30 gauge and shorter volumes < .5mL Massage insertion site after administration unless contraindicated (heparin) Intradermal Rectal 25-27 gauge, to 5/8 needle volume < .1mL if no wheal or if bleeding occurs, administration was probably too deep and should be repeated

 Vaginal Otic

Position child on left side with right leg flexed. Drape children in preschool and older Distance require for insertion = 1 to 2 cm Most often for candida infections or possibly birth control Clean procedure Allow to warm to room temp before administration Clean procedure Warm to room temp Child UNDER 3 = pinna down and back Effectiveness is increased with use of spacer. Allows for deep inhalation of meds

Opthalmic

Inhalation therapy

IV catheter insertion Hand, wrist, A/C sites most common Scalp veins = no valves, can be placed either direction 20-24 gauge most common Ice or EMLA may be used o EMLA 45-60 minutes prior to administration Providone-iodine may be used in immunosuppressed or children with alcohol sensitivity IV monitoring volumetric pumps used for very low volumes of fluids or meds Nurse should assess and document an IV site every hour for infiltration and phlebitis If signs of complications occur (boggy scalp site, infiltration, redness, etc) D/C IV then notify provider Childrens veind more fragile = IV site NOT changed q72 hours. IV fluids and containers changes QID DAILY MAINTENANCE FLUID RATES TABLE WEIGHT < 10 KG AMOUNT 100 mL/KG

10-20 > 20 IVPUSH IVPB Usually 5 mL or less Use port closest to child Use betadine if line is central

1000 mL + 50 mL/kG 1500 mL + 20 mL/kG

Flush tubing with 2-3 mL NS before and after administrations 16-20 mL usually needed to flush medications thru (make sure to account for it

IV retrograde Small volumes (1 ml) Clamp tubing below port nearest child, wipe port, inject med into port but away from child Some pumps do not allow retrograde o So connect empty syringe to port closest to IV pump, and as retrograde is administered, volume will displace into syringe Intermittent infusion ports (saline or hep locks) Routine flushing q6-12 hours Most often used for medications, blood, IV fluids, and parenteral nutrition Can be tunneled or nontunneled Aseptic technique Tunneled central lines are surgically placed by Dacron cuff, most commonly placed in jugular but can also be in cephalic, axillary subclavian, femoral, saphenous, internal jugular. Non-tunneled/ short term are frequently used in subclavian or femoral. Left for weeks to months. Major SE = phlebitis, infection, thrombosis, occlusion To prevent hypervolemia, packerd RBCs usually administered to infants and children Administer with Normal Saline Solution Rate of infusion = 2/3 mL/kG/hr. no more than 4 hours Central Lines

Blood products

ATI normal growth and function

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Babbling and cooing at 3 months, consonant sounds at 4-5 months, baby talk 6 months, 8-9 months = first words can understand commands, symbols; 1 year = 2+ word phrases, knows name Minimum urine output = 2-3 ml/kg infant and toddler, preschooler and schoolage = 1-2 , school age and adolescent = .5-1, or specific gravity <1.002 = dehydration Potassium only supplemented once urination is inititated, hypernatremic dehydration= lost fluids replaced slower to prevent sudden decrease in serum sodium Birth to 1 year Physical Development Poster fontanel closes at 3 months Anterior fontanel closes at 12-18 months DOUBLE birth weight by 6 months, TRIPLE by 1 year Height o o o o o o o Grow 1 inch per month 1st 6 months .5 inches per month 6-12 months 1.5 cm per month 1st 6 months .5 cm per month 6-12 months teething pain eased by cold teething rings, Tylenol, advil, motrin (motrin only after 6 months) clean with cool, wet washcloth Piaget (Sensorimotor Stage 0-24 months) o Separation infant learn to separate self from other objects in environment Object permanence infants know object still exist when not in view OCCURS AT 9 MONTHS Mental representation recognition of symbols Psychosocial development Erikson Trust V mistrust Cognitive development

Head growth

6-8 teeth should erupt by 1 year

 o o o o

Trust that feeding, comfort, stimulation, caring needs will all be met

Attachment infant begins to bond with parents Separation recognition infants learn physical boundaries from other people, positive interactions with people establish trust Separation anxiety (4-8 months) Stranger fear (6-8 months)less likely to accept strangers

By 1 year, infants will be able to distinguish themselves as being separate from their parents Mouths produce pleasure, hands and feet are objects of play, smiling causes reaction Age Appropiate activites o o o Rattles, teething toys, pat a cake, reading books, playing balls Breastfeeding is full diet for first 6 months Solids introduced between 4-6 months Indicators include interest in solid foods, voluntary control of head and trunk, hunger <4 hours after nursing Iron fortified rice cereal should be offered first New foods one at a time, over 5-7 day period (observe for allergy) Veggies and fruits started first (6-8 months), then meats may be introduced Table foods that are cooked, chopped, unseasoned at 9 months Finger foods = ripe bananas, toast strips, graham crackers, cheese cubes, noodles, peeled chunks of apples, pears, peaches Weaning after 6 months if infants able to drink from handled-cup Bedtime feedings last to be replaced Nutrition

Immunizations o o Birth HEP B 2 months

 o o o o

DTAP, rotavirus (RV), IPV poliovirus, HIB, (PCV) pneumococcal, Hep B

4 months DTAP, RV, IPV, HIB, PCV DTAP, IPV, PVC, Hep B, RV seasonal influenza Poliovirus (IPV), influenza b (HIB), pneumococcal (PCV), MMR, Varicella 6 moths 6-12 months 12 15 months

Safety o o o o Plants kept out of reach Infant seats kept on ground or floor if used outside of car and should not be left unattended on elevated surfaces Crib slats no more than 6 cm (2.4 inches) Crib mobiles removed by 4-5 months old

Toddler 1-3 years Anterior fontanels close at 18 months 30 months = 4x body weight toddlers grow at 7 cm (3 in) a year Cognitive o Piaget Preoperational stage (transition from sensorimotor) Object permanence fully developed Memories of events that relate to them Domestic mimicry )play house

Cant understand other viewpoints (EGOCENTRIC), but can symbolize obejcts and people to imitate previously sen activities

Language o o Vocab = 400 words, 2-3 word phrases Autonomy V shame/doubt Independence is paramount Separation anxiety continues Erikson

Develop gender identity by 3 years Solitary play evolves to parallel play, toddlers observe other children and may engage in activity nearby Toilet training o Begins when toddlers recognize sensation of needing to go, nighttime control develops latest

Immunizations o 12 15 months o o o Poliovirus (IPV), influenza b (HIB), pneumococcal (PCV), MMR, Varicella 12- 23 months Hep A (6months apart) DTAP yearly seasonal flu vaccine (TIV), attenuated influenza (LAIV) at 2 years old 15 -18 months 12 36 months

Nutrition o o o o o o 24-30 oz milk/day, whole milk-> low fat at 2 years old juice should be limited to 4-6 oz/day food serving size = 1 TBSP exposure to new food may need to occur 8 15 times before acceptance beware choking hazards (nuts, grapes, hot dogs, peanut butter, popcorn, tough meats, raw carrot) No drinking eating during play

Safety

o o o o

Car seat rear-facing until 20 lbs Forward facing car seat until 40 lbs or 4 years old No pillows in crib No drawstrings in jackets

Preschooler (3-6 years) Weight 2-3 kg/year Height 6-7 cm/year (2-3 inches) Body begins to have sturdy, normal physicality o Piaget Still in preoperational stage Preconceptual thought from 2 4 years old Make judgements based on visual appearances Artificialism everything created by humans Animism inanimate objects are alive Imminent justice universal code of law and order Intuitive thought 4 7 years old o o o Classify information, recognize cause/effect relationship TIME understand past, present, future. By end of preschool -> children know days of week LANGUAGE speak in sentences, identify colors, enjoy talking Initiative V Guilt Guilt occurs when not able to accomplish task or when misbehaving Erikson

Preschoolers continue good-bad orientation of toddler years, begin to understand behaviors as whats socially acceptable Preschoolers feel good about themselves as they accomplish tasks that assert independence (clothing self). During stress, insecurity -> revert to previous immature behaviors (nosepicking, thumbsucking)

Greatest fear is of bodily harm, afraid of dark/animals Pretend play is healthy Sleep disturbances are common (NEED ABOUT 12 HRS SLEEP/DAY), avoid allowing to sleep with parents Parallel play shifts to associative play o o Play ball, puzzles together, play pretend, role playing 4-6 DTAP, MMR, varicella, IPV Yearly influenza vaccine Immunizations

Health o o Visual screenings should occur as prekindergarten exam, Myopia (nearsighted) and amblyopia (lazy eye) can be detected

Nutrition o o o o Should eat half of what an adult would eat (1800 cals) By 5, should be willing to try different foods Need 13-19 g/protein/day Need Iron, folate, vitamins A and C Need car seat til 4 years old 40 lbs, booster seat in backseat until 80 lbs, 4 9

Safety o

School age child (6-12) weight gain usually 2-4 kg/year (9-12 years old for girls, 10+ for boys) Grow about 2 inches / year o Change in heaight usually occurs after 10 12 years for girls, 12 14 years for boys->after weight gain Puberty o Girls 1. Appearance of breast buds 2. Growth of pubic hair 3. Menarche o Boys 1. Increase in size of testes 2. Pubic hair 3. Increase in genitalia 4. Axillary hair 5. Downy hair on lip 6. Change in voice o o Piaget o Concrete operations Weight and volume as unchanging Simple analogies, can solve problems Understands time Understands emotions Permanent teeth erupt Vision to 20/20, sense of touch developed

Knows rules of grammar, words have multiple meanings Erikson o Industry V Inferiority Industry attained through advancements in learning, motivated by tasks of self-worth, fears ridicule

ill help you if you help me, children want to make best deal, do not consider elements of loyalty, gratitude, justice curiosity about sexuality should be addressed kids place more emphasis on privacy issues time period where best friends and clubs are popular children may rival same gender parent conformity becomes evident Age appropriate activites o 6-9 o 9-12 crafts/models collect things board/card games organized competitive sports simple board, number games hopscotch, jump rope collect things organized sports

Immunizations o o By 6 should have DTAP, MMR, IPV, varicella At 11-12 ->Tdap, HPV2 = girls, HPV4 males Screening for scoliosis should occur By end of school year age, kids eating adult proportions Avoid food as reward Stranger safety should be taught Teach fire safety and burn hazards Supervised when swimming, need to be taught to swim car seat rules, in back seat until 13

Health o o o Nutrition

Safety o o o o

o Adolescent 12 20 final 20-25% ht achieved during puberty girls cease to grow about 2 years after menarche o o will grow 5 20 cm, will gain 15 55 lbs will grow 10-30 cm, gain 15 60 lbs boys stop growing by around 18-20 PUBERTY OCCURS KNOW THE STEPS Sleep habits = staying up later, sleeping in. o Piaget o Formal operations Erikson o Identity role V role confusion Sense of identity influenced by expectations of families Group identity teen becomes part of peer group, greatly influences behavior Know conventional law and order rules are not seen as absolutes each situation is different Age appropriate activities o o o o Social events Caring for pet TDAP, MCV, HPV if not given by 11-12 Iron, calcium, vitamins a and C Think at adult level, abstractly Able to evaluate own thinking Able to maintain attention for longer Imaginiative, idealistic Logical operations Future oriented d/t increased metabolism/rapid growth

Able to communicate with peers one way and adults another

Immunizations Nutrients needed Be aware for changes in mood

18 Fluid and Electrolyte Alteration

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Maturity in body space distribution reached around 3 years of age Infants less able to concentrate urine d/t immature renal function Infants have harder time compensating for acidosis Acid Base balance Initially altered by bicarbonate (within minutes) When pH too much for buffer system respiratory and renal systems activated. o o o Lungs remove CO2 (raising pH) by increased respirations and depth During alkalosis, respirations will decrease to retain co2 and lower pH Kidneys will conserve bicarbonate to raise pH or exrete hydrogen ions/bicarbonate to lower pH Sodium Balance Normal = 135 150 Hyponatremia o o o o Caused by burns, wounds, fever, renal disease Increased HR, Low BP, cold, clammy skin, muscle cramps Caused by Hyperglycemia, water loss, Olguira, thirst, flushed skin,edema, seizures, irritability

Hypernatremia

Potassium balance 3.5-5.0 = Normal Hypokalemia o o o o Caused by stress, starvation, diuretics, vomiting, diarrhea, steroids Muscle weakness, leg cramps, ileus, arrhythmias Caused by Kidney failure, hyperglycemia, dehydration, burns Weakness, flaccid paralysis, cardiac arrest, respiratory arrest

Hyperkalemia

Calcium balance normal = 8.5 11.00 Hypocalcemia o o o o Tests Specific gravity NORMAL = 1.002 1.03 o Indications = altered fluid status Caused by VIT d deficient, alkalosis Tetany, trousseau and chovstek signs, hypotension Caused by Acidosis, renal disease, hyperthyroidism Lethargy, itching, NV, bradycardia

Hypercalcemia

Dehydration Classified as isonatremic, hyponatremic, hypernatremic o o o Isonatremic most common, water and electrolytes lost at same proportion Hyponatremic = electrolyte loss greater than water loss Na <135 Hypernatremic = water loss greater than electrolyte loss, resulting in Na >150 Series of Events o 1 -> precipitating event (vomiting, diabetes, hemorrhage, etc.) 2 > sudden ECF loss 3 -> imbalance in electrolytes 4->loss of ICF 5> cellular dysfunction 6 -> hypovolemic shock -> death Nursing care o Assessment Early signs = no wet diapers for 6-8 hours, diarrhea, vomiting, burns, diabetes, trauma, fever; diarrhea caused by infection is usually d/t gastroenteritis Output of 2-3 ml/kg/hr in infants, 1-2 in preschoolers, .5-1 in school age children or low specific gravity indicate dehydration o Diarrhea o Manifestations dry, hot skin, changes in skin texture, dry membranes, NV, large volume stools, urge to defacate, dark stool, increased heart and respiratory rate o Causes = infection, fungal overgrowth, food intolerance, malabsorption, colon disease, IBS, stress, infectious disease otitis media, upper respiratory infection, UTI o Foods to be given during diarrhea = rice, wheat, potatoes, cereals, yogurt, cooked vegetables, lean meats Dry or sticky membranes, absence of tears in infant over 4 months old Vital Signs pulse is rapid, weak, increase in respiratory rate High pitched cry Additional fluids Oral rehydration fluids (rehydralyte, infalyte, pedialyte) Regular water in large amounts can be dangerous

Interventions

o o o

Teas, juices, soft drinks and fatty foods should be avoided Eat frequently q3-4 hours, for severe dehrydation ORT is not recommended Nursing care Interventions Child should be weighed, unclothed on admission Each gram of diaper weight = 1mL fluid when weighing diapers Wash bum with warm water and mild soap after each loose stool and pat dry

Vomiting Complex reflex of sweating, salivation, tachycardia Regurgitation = GER, or overfeeding Projectile vomiting = pyloric stenosis, obstruction, tumor, increased intracranial pressure Green emesis = bile If accompanied by diarrhea = gastroenteritis Fecal odor = lower intestinal obstruction, peritonitis emesis might be blood tinged bright red, or like coffee grounds Bright red indicates the blood hasnt been in contact with gastric juices

ATI NOTES
Respiratory Hypercarbia o o o Restlessness, HTN, headache Hood Tents o NC Suction o o o o o o o o o 1-6 L/min 24%-40% o2 humidifcation if >4% Children >2-3 months Top is open Minimum flow rate of 4-5 L Oxygen hood, tent, NC

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No greater than 95 mmHg for infants, 110 for children Allow 30-60 seconds between sessions Oral care q2 hours Clean site with hydrogen peroxide full or strength Change nondisposable trachs q6-8 weeks Reposition q2 hours Decannulation after first 72 hours is medical emergency Caused by GABHS (obtain throat culture), preoperative CBC for anemia Postop Keep throat moist Avoid milk based foods May be blood stained mucus in vomitus Limit physical play for 2 weeks Full recovery in 10 days 2 weeks

Artifical airways

Tonsillitis / tonsillectomy

Epiglottitis o o o Caused by haemophilus infuenzae Dysphonia (difficulty speaking) Dysphagia

Limit use of nose drops or sprays to 3 days to prevent rebound congestion

Asthma o Meds Ipratropium (Atrovent) and other anticholinergic block the parasympathetic nervous systmen providing relief of acute symptoms o Dry mouth common Monitor for hyperglycemia Report black tarry stools Weight gain common Prednisone, fluticasone

Status asthmaticus Prepare to administer 3 nebulizer treatments of a beta agonist 20-30 minutes apart, ipratropium may be added Magnesium sulfate by IV, inhal results in smooth muscle relaxation Ketamine ketalar via IV

Cystic Fibrosis o o o o o o o Dysfunction of endocrine glands Autosomal recessive Meconium ileus at birth, absence of pancreatic enzyemes Thick, yellow gray mucous, cyanosis, difficulty exhaling, clubbing Excess salt in sweat, tears, Swear chloride test done (normal = <40) Chest CPT done 1 hr before and 2 hrs after all meals

Musculoskeletal DDH Barlow and ortalani tests (done thru 3 months of age) loud click sounds Trendelenburg sign o Abnormal downward titlting of pelvis on unaffected side when bearing weight on affected side Ultrasound should be done at 2 weeks of age X ray done at older than 4 months Pavlik harness used from birth to 5/6 months Hip spica cast used on older than 6 months

Clubfoot Scoliosis Brace must be worn 23 hrs a day Surgery needed if curve greater than 40 Surgical intervention should occur if casting corre tion not achieved by 3 months of age

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