Read through the Kami
and answer the questions
Online Video: Pediatric IM Injections
below
CHAPTER 8
UNIT
FOUNDATIONS OF NURSING CARE OF CHILDREN
1
SECTION:
CONSIDERATIONS OF
KURS NG CARE OF CHILDREN
Oral
This route of medication administration
is
preferred
for children.
afe Administration
of Medication
•
Growth and organ system maturity
affect the
•
metabolism and excretion of medications
in
infants
and
Determine the child's ability to swallow pills.
Use the smallest measuring device for doses of liquid
medication. Use an oral medication syringe for smaller
amounts, and a medication cup for larger amounts.
Avoid measuring liquid medication in a teaspoon or
tablespoon.
Avoid mixing medication with formula or putting
bottle of formula because the infant
entire feeding,
children. Administration of
in a
it
might not take the
and the medication can
alter the taste of
the formula.
medications to the pediatric population can
be challenging and requires
critical
thinking,
•
•
nursing patience, and creativity. Pediatric
aspiration.
•
dosages are based on age, body weight, and
body surface
area.
DATA COLLECTION
•
Medication and food allergies
Appropriateness of medication dose for age and weight
•
•
Child's developmental age
Child's physiological
•
Tissue and skin integrity
when administering
•
intramuscular (IM), subcutaneous, and topical
medications
Intravenous (IV) patency
IV medications
Administer the medication in the side of the mouth
in small amounts. This allows the infant or child to
swallow.
Only use the droppers that come with the medication for
measurement.
Stroke infants under the chin to promote swallowing
while holding cheeks together.
Reinforce teaching with the child to swallow tablets
that aren't available in liquid form and can't be crushed.
Instruct in short sessions using verbal instruction,
and psychological condition
•
Hold infants in a semireclining position similar to a
feeding position.
Hold small children in an upright position to prevent
demonstration, and positive reinforcement.
Provide atraumatic care.
Mix
the medication in a small
when administering
Add
dosage
•
for medication.
Notify the charge nurse and provider
if medication
determined to be outside the safe dosage
range, and for any questions about medication
dosage
•
•
•
•
to
allow the infant to suck the
Administer medications via a feeding tube.
Confirm placement.
Use liquid formulation.
Do not add medication to the formula bag.
Flush with water to clear tubing of residual
medication.
is
preparation or route.
•
not
medication.
MEDICATION ADMINISTRATION
•
if
flavoring to medications as available.
Use a nipple
• Calculate the safe
of nonessential
contraindicated.
Compatibility with other prescribed medications
NURSING INTERVENTIONS
amount
food (applesauce, sherbet).
Offer juice or a snack after administration
Double-check high-risk and facility-regulated
medications with another nurse.
Use two client identifiers prior to administration (client
name, date of birth). Use parent(s) for verification of
infants or nonverbal children. Two identifiers from the
ID band must be confirmed (client name, date of birth,
hospital identification number).
Determine parental involvement with administration.
Allow the child to make appropriate choices regarding
administration (choosing the left or right leg, whether
the parent or nurse will administer the medication).
Prepare the child according to age and
Optic
•
Place the child in a supine or sitting position.
•
Pull the lower eyelid
•
Administer ointments before nap or bedtime.
Provide atraumatic care.
Extend the child's head and ask the child to look up.
downward and apply medication in
the pocket.
•
If
an infant clenches his eyes closed, place the drops
When the infant opens his eyes,
in the nasal corner.
the medication will enter the eye.
Apply light pressure to the lacrimal punctum for
1
min
to prevent unpleasant taste.
Play
games with younger children.
developmental stage.
SERIES
PN NURSING
CARE OF CHILDREN
CHAPTER
a SAFE
ADMIN:STRATON OF MEDICATION
41
Intradermal
Otic
•
Place the child in a prone or supine position with the
•
affected ear upward.
•
•
Children younger than 3 years: Pull the pinna
•
and straight back.
Children older than
and back.
•
Provide atraumatic care.
3 years: Pull the
downward
pinna upward
Insert needle at 150 angle.
•
Do not
aspirate.
Give in areas of adequate subcutaneous tissue.
sites are the lateral aspect of the
Common
upper arm, abdomen, and
anterior thigh.
administration.
games with younger children.
Nasal
•
than 0.5 mL.
a 26- to 30-gauge needle.
Insert at a 900 angle. Use a 450 angle for children who
•
Check policy
•
Inject
volumes of
•
Use a
1
less
mL syringe with
are thin.
•
Position the child with the head extended.
•
Use a football hold for infants.
Provide atraumatic care.
•
•
Subcutaneous
Allow refrigerated medications to warm to room
temperature prior to administration.
Massage the outer area for a few minutes following
Play
Administer on the inside surface of the forearm.
Use a TB syringe with 26- to 30-gauge needle with an
intradermal bevel.
o Insert the tip into the naris vertically,
for aspiration practices.
Intramuscular
then angle
it
Use a 22-
to
25-gauge,
1/2- to
I-inch needle.
prior to administration.
Play
games with younger children.
Vastus lateralis
•
Aerosol
•
•
Use a mask for younger children.
Provide atraumatic care.
Allow parents to hold the child during treatment.
Use distraction.
•
Insert beyond both rectal sphincters.
•
Hold the buttocks gently together for 5 to 10 min.
Halve the medication lengthwise, if necessary.
Provide atraumatic care.
•
is
the
recommended
site in infants
and small
children.
Rectal
•
This
Perform the procedure quickly.
Use distraction.
Injection
•
Change needle
•
Secure the infant or child prior to injections.
•
Determine the need for assistance.
•
Avoid tracking (leaking) of medication.
•
When
if it
pierced a rubber stopper on a vial.
selecting sites, consider the following.
Medication amount, viscosity, and type
Muscle mass, condition, access of site, and potential
for contamination
Treatment course and number of injections
Age and size of child
•
Position the child supine, side-lying, or sitting.
•
Inject
•
Inject
up
up
mL for infants.
mL for children.
to 0.5
to 2
Ventrogluteal
• Position the child supine, side-lying, or prone.
•
Inject 0.5 to 1
•
Inject
up
to 2
mL, depending on muscle
size of infant.
mL in children.
Deltoid
•
Position the child sitting or standing.
•
Inject
•
Provide atraumatic care
up
to
1
mL.
Apply eutectic mixture of lidocaine and prilocaine
(EMLA) to the site for 60 min prior to injection.
Change needle after puncturing a rubber
stopper.
Use the smallest gauge of needle possible.
Use therapeutic hugging.
Secure the child firmly to decrease movement of the
needle while injecting.
Use distraction.
Encourage parents to hold the child
after.
Offer praise.
Use play therapy.
Offer sucrose pacifiers to infants.
CONTENT MASTERY S
Peripheral venous access devices
Intravenous
•
Use
Use
•
administration.
Short-term IV therapy can be completed at
•
•
Inspect venipuncture site per facility protocol and prior
to administration of medications.
•
Provide atraumatic care.
Discuss with the charge nurse the possible need for a
a
24- to 20-gauge catheter.
for continuous
the assistance of a
and intermittent IV medication
home health
home with
nurse.
peripherally inserted central catheter (PICC) before
•
Short term: nontunneled catheter or PICC
Avoid terminology such as a ('bee sting" or "stick."
•
Long term: tunneled catheter or implanted
Attach an extension tubing to decrease movement of
on
#11,
Central venous access devices
multiple peripheral attempts.
Use a transilluminator to assist in vein location.
and
infusion ports
the catheter.
o Use play therapy.
O Apply EMLA to the site for 60
min
prior to attempt.
Keep equipment out of site until procedure begins.
o Perform procedure in a treatment room.
who
o
PRACTICE Active Learning Scenario
Use nonpharmacologic therapies.
o Allow parents to stay
if
they prefer.
A nurse
is caring for a toddler who requires
insertion of an IV access. What actions should the
nurse plan to take? Use the ATI Active Learning
Template: Basic Concept to complete this item.
O Use therapeutic holding.
o Avoid using the dominant or sucking hand.
O Cover site with a colorful wrap.
o
Swaddle infants.
o Offer nonnutritive
and
NURSING INTERVENTIONS:
Describe
10 atraumatic care jnterventions.
sucking to infants before, during,
after the procedure.
Application Exercises
A nurse
planning to administer
the influenza vaccine 0.5 mL IM to
1.
is
a toddler.
Which of the following
actions should the nurse take?
3.
A nurse is reinforcing teaching
in
B.
the abdomen.
use a 20-gauge needle.
administration of oral medications.
the following actions should the
Which
nurse take? (Select
of the following information
teaching? (Select
two
B.
injections.
C.
supine position.
*fre
A nurse is preparing to administer
an intramuscular (IM) injection to
a child. Which of the following
muscle groups
is
contraindicated?
A. Deltoid
B. Ventrogluteai
C. Vastus lateralis
the
that apply,)
Tell
C. Calcu;ate the safe dosage.
D.
the medication to a
Hold the
Ask the toddler what
toy he wants to hold
during administration.
Use the nipple of a bottle to
E.
administer the medication.
E.
the parent to administer
the medication.
formula bottle before feeding.
D.
that apply.)
asking the parent.
B.
Ask the pharmacy to add
Add
all
A. Identify the toddler by
flavoring to the medication.
D. Place the child in the
2.
alE
in
A. use a universal dropper for
medication administration.
C. Divide the medication
into
A nurse is preparing to administer
medication to a toddler. Which of
should the nurse include
A. Administer the medication
4.
with the parent of an infant about
Offer juice after the
medication.
infant in a
semireclining position.
5.
A nurse
is
caring for an infant
who needs otic medication.
Which
of the following actions
should the nurse take?
A. Hold the infant
D. Dorsogluteal
in
an
upright position.
B. Pull the pinna
and
downward
straight back,
C. Hyperextend the infant's neck.
Answer the questions above
SERIES
NURSING CARE OF CHILDREN
D. Ensure that the
medication is cool.
CHAPTER
8 SAFE
ADWNSTRATION OF MEDICATION
43
CHAPTER 9
UNIT
1
Online Video: Pain Evaluation
FOUNDATIONS OF NURSING CARE OF CHILDREN
in
Children
School-age child
Stalling behavior
• Muscular rigidity
SECTION: SPECIFIC CONSIDERATIONS OF
NURSING CARE OF CHtLDREN
•
ain Management
•
Any behaviors
of the toddler, but less intense in
the anticipatory phase and
more intense with
painful stimulus
fhoWd
Adolescent
Determination of pain depends on the
child's cognitive, emotional,
development. Pain
is
and physical
managed by
•
More
•
Muscle tension with body control
verbal expressions of pain with less protest
atraumatic,
Pain intensity
(9.1)
nonpharmacologicatj and pharmacological
Data collection
interventions. Atraumatic care
is
the use of
Self-report
interventions that minimize or eliminate physical
and psychological
*Ill
is
multidimensional and includes
behavioral measures and self-report.
is
distress.
verbally report their pain.
Multiple tools are reliable are available for the nurse to
•
4.
INFLUENTIAL FACTORS
method used for children 4 years or
younger than 4 cannot accurately or
the
older. Children
use
when evaluating
a child's pain.
A nurse should choose a
Factors that can have a positive or negative effect on
pain perception
•
pain tool that will adequately
determine the severity of the infant or child's pain.
Include the parent or caregiver in rating the child's pain.
Age
Development stage
Determine the location,
quality,
and severity of pain.
Chronic or acute disease
•
•
PATIENT-CENTERED CARE
Prior experiences with pain
Personality
Family dynamics
NURSING CARE
Culture
•
Socioeconomic status
Recheck the child's pain
Use nonpharmacological and/or pharmacological
approaches to manage pain.
Ask a parent or caregiver to monitor the child's
•
Ask the parent or caregiver
management.
•
Monitor the child
DATA COLLECTION
pain
EXPECTED FINDINGS
Developmental characteristics
level frequently.
•
level.
their satisfaction of the pain
for adverse reactions to
pain
medications.
Young infant
•
(birth to 5
months)
Review laboratory reports.
Loud cry
Monitor the child's physical functioning following pain
•
•
•
body or thrashing
Local reflex withdrawal from pain stimulus
Rigid
management
mouth open in
eyebrows lowered and drawn together)
Lack of association between stimulus and pain
Expressions of pain (eyes tightly closed,
a squarish shape,
•
Older infant (6
• Loud cry
months
to 12
months)
intervention.
Monitor for negative effects or distress the child
might experience related to pain (anxiety, withdrawal,
sleep disruption, fear, depression, unhappiness).
ATRAUMATIC MEASURES
•
Deliberate withdrawal from pain
Use a private treatment room
•
Facial expression of pain
Avoid procedures in "safe places" (play room, the
for painful procedures.
child's bed).
Toddler
Loud cry or screaming
•
Verbal expressions of pain
Thrashing of extremities
Attempt to push away or avoid stimulus
Noncooperation
•
•
•
•
Clinging to a significant person
•
Behaviors occur in anticipation of painful stimulus
Requests physical comfort
•
SERIES
Use developmentally suitable terminology when
•
PN NURSING CARE
OF CHILDREN
•
explaining procedures.
Offer choices to the child.
•
Allow parents to stay with the child during painful
procedures.
•
Use play therapy to explain procedures, allowing the
child to perform the procedure on a doll or toy.
CHAPTER 9 PAIN MANAGEMENT
45
PHARMACOLOGICAL MEASURES
•
•
A two-step approach
for
of pain in children
recommended.
months of age who have
is
Use nonopioid and opioid medications.
Acetaminophen and NSAIDs are indicated for mild
moderate pain.
Opioids are indicated for moderate to severe
pain. Medications used include morphine sulfate,
oxycodone, and fentanyl.
Combining a nonopioid and an opioid medication
treats pain peripherally and centrally. This offers
pharmacological management
For children older than 3
mild pain, the
first
step
is
to administer a nonopioid.
Nonsteroidal anti-inflammatory drugs (NSAlDs) are
frequently used for mild pain.
The second step
for children
who have moderate or
greater analgesia with fewer adverse effects
severe pain is to administer a strong opioid. Morphine
is the medication of choice.
(respiratory depression, constipation, nausea).
•
•
Administer an optimal dosage of medication to control
pain without causing severe adverse effects.
Select the least traumatic route for medication
IM injections
are not
recommended
for pain control
in children.
recommended
Intranasal medications are not
for
children younger than 18 years.
administration.
•
Rectal medications have variable absorption rates,
Give medications routinely (vs. PRN) to manage pain
that is expected to last for an extended period of time,
Combine adjuvant medications
to
and
children dislike them.
Intradermal medications are used for skin anesthesia
(steroids,
prior to procedures.
antidepressants, sedatives, antianxiety medications,
muscle relaxants, anticonvulsants) with analgesics.
9.1
Pain assessment tool for evaluation by
age
Numeric scale: 5 years and older
FLACC: 2 months to 7 years
on
on
to 10.
Pain rated
Observe behaviors of the
child.
Explain to the child that
O
O
Pain rated
a scale of
a scale of
and 10 means "worst
FACE
(F)
Smile or no expression
1:
Occasional frown or grimace, withdrawn
2:
Frequent or constant frown, clenched jaw, quivering chin
FACES: 3 years and older
Pain rated
on
a scale of
O
to 5 using a
diagram of
six faces.
(L)
O:
Relaxed or expected position
1:
Uneasy, restless, tense
2:
Kicking or legs
ACTIVITY
Explain each face to the child; ask the child to choose
a face that best describes how they are feeling.
drawn up
(A)
moves easily, expected
O:
Lying quietly,
1:
Squirming. shifting, tense
2:
Arched, ridged, or jerking
O:
No hurt
3:
1:
Hurts a bit
4;
Hurts a whole
2:
Hurts a
5:
Hurts the worst
little
more
Hurts even more
lot
position
Noncommunicating children's
checklist: 3 to 18 years
pain
Intended for use with children who are unable to communicate
due to postoperative status, cognitive impairment, or disabilities.
Behaviors are observed for 10 min.
CRY (C)
O; No cry
I:
Moans or whimpers,
2:
Crying, screaming. sobbing, frequent complaints
CONSOLABILITY
O:
pain."
child verbally report a number or point
to their level of pain on a visual scale.
Have the
O:
LEGS
to 10.
O means "no pain"
occasional complaints
Six subcategories are
(C)
Content or relaxed
1:
Reassured by occasional touching or hugging. Able to distract
2'.
Difficult to
O:
Not at
1:
Just a
ali
little
each scored on a 0 to 3
2: Fairly
3:
scale.
NA: Not
often
applicable
Very often
SUBCATEGORIES
Vocal
Facial
Body and limbs
Social
Ac tivity
Physiological
console or comfort
CUTOFF SCORES
11
or higher indicates moderate to severe pain.
6 to 10 indicates mild pain.
AGE: O
3
5
7
10
13
15
18
FLACC
FACES
NUMERIC SCALE
NONCOMMUNICATING CHILDREN'S PAIN CHECKLIST
O PAIN
MANAGEMENT
CONTENT MASTERY Si
ROUTES OF ADMINISTRATION
Positive self-talk:
Have the
child say positive things
during a procedure or painful episode.
Oral
•
•
Route is preferred due to convenience, cost, and ability
to maintain steady blood levels.
Takes 1 to 2 hr to reach peak analgesic effects. Oral
medications are not suited for children experiencing
pain that requires rapid
relief or
pain that
is
fluctuating
Topical/transdermal
NURSING ACTIONS
Lidocaine is available in a cream or gel.
• Used for any procedure in which the skin will be
punctured (IV insertion, biopsy) 60 min prior to a
superficial puncture and 2.5 hr prior to a deep puncture.
Place an occlusive dressing over the cream after
•
•
Give time limits for the child to cooperate.
•
Reinforce cooperation with a reward.
Containment
Swaddle the
•
in nature.
•
Behavioral contracting
Use stickers or tokens as rewards.
•
application.
Prior to procedure,
remove the dressing and
Place rolled blankets around the child.
•
Maintain proper positioning.
Nonnutritive sucking
Offer pacifier with sucrose before, during, and after
•
painful procedures.
•
Kangaroo care: skin-to-skin contact between infants
and parents
Complementary and alternative medicine
•
Offer foods, vitamins, or supplements.
Demonstrate to the child that the skin
•
Offer massage or chiropractic options.
•
Review energy-based treatments such as magnets.
Discuss mind-body techniques (hypnosis, homeopathy,
is
not sensitive
lightly.
•
Transdermal fentanyl
•
•
•
Offer nonnutritive sucking during episodes of pain.
clean the skin.
by tapping or scratching
•
infant.
•
Use
Use
naturopathy).
than 12 years of age.
to provide continuous pain control. Onset of
12 to 24 hr and a duration of 72 hr.
for children older
Use an immediate-release opioid for breakthrough pain.
Monitor for respiratory depression and assist with the
administration of naloxone if this adverse
effect occurs.
QE
COMPLICATIONS
Chronic pain syndromes: Poorly controlled pain
predisposes children to chronic pain conditions.
NURSING ACTIONS
Monitor pain thoroughly and adequately.
Administer medications in a timely manner.
Evaluate and monitor the child's response to treatments.
NONPHARMACOLOGICAL MEASURES
Distraction
•
computer game, or
•
Use
•
Tell jokes or a story to the child.
play, music, a
a movie.
Titrate analgesic medications to achieve optimal dosing.
Recommend alternate medications if needed.
Relaxation
•
Hold or rock the infant or young child.
•
Assist older children into a comfortable position.
•
Assist with breathing techniques.
Guided imagery
•
•
an imaginary experience.
Have the child describe the details.
Assist the child in
PN NURSING CARE
OF CHILDREN
CHAPTER 9 PAIN MANAGEMENT
47
Application Exercises
1.
A nurse is caring for a preschooler
who is experiencing mild
pain.
3•
A nurse is collecting data from
an
Which of the following
infant.
identify that
types of medication should
following findings indicates
that the infant
first?
pain? (Select
B. Antianxiety
C. Nonsteroidal anti-
inflammatory drug
D. Sedative
A nurse
Lowered eyebrows
take? (Select
B.
body
is
contributing to the
plan of care for an infant
procedure with the
child in his bed.
NSAlDs
for
pain greater than 7
on
(Select
a scale of O to 10.
make
one choice regarding
the procedure.
E.
Apply lidocaine cream to
three potential insertion
sites.
that apply.)
A. Offer a pacifier.
Administer intranasal
B.
analgesics PRN.
C. Administer
all
D. Allow the child to
who
is experiencing pain. Which
of the following interventions
should the nurse recommend?
A. Administer
Ask the parents to leave
during the procedure.
Pushes away stimulus
4. A nurse
that apply.)
C. Plan to assist with the
contributing to the
plan of care for a child following
all
A. Explain the procedure using
the child's favorite toy.
lips
Loud cry
D. Rigid
a surgical procedure. Which
of the following interventions
should the nurse recommend?
B.
that apply.)
B.
A nurse is preparing a toddler for
following actions should the nurse
experiencing
C
E.
is
ali
A. Pursed
medication
is
5.
insertion of an IV catheter. Using
atraumatic care, which of the
which of the
the nurse administer
A. Opioid analgesic
2.
The nurse should
Use guided imagery.
C, Use "addling.
IM
analgesics for pain.
D. Administer analgesics
on a schedule.
D
Initiate
E.
Encourage kangaroo
a behavioral contract.
care.
PRACTICE Active Learning Scenario
A nurse is reviewing pain evaluation tools with a group
of newly licensed nurses. What should the nurse
include in the discussion? Use the ATI Active Learning
complete
Template: Nursing
Skill
DESCRIPTION OF
SKILL: Describe four pain
tools
to
used with pediatric
this item.
clients.
Answer the questions above
CONTENT MASTERY
Application Exercises Key
I.
r
for
A. The nurse should administer an opioid analgesic if the
preschooler's pain becomes moderate to severe. However,
evidence-based practice ind•cates that the nurse should take a
different action first.
ourse
Using the ATI Active Learning Template: Nursing Skill
DESCRIPTION OF SKILL
•
The nurse should administer an adjuvant medication, such as an
B.
antianxiety medication, aFong with an analgesic if an analgesic alone
ineffective. However, the nurse should take a different action first.
FLACC (2 months to
Observe behaviors of the
• 2:
Frequent or constant frown, clenched jaw, quivering chin
D. The nurse should administer an adjuvant medication, such as a
sedative, along with an analgesic if an analgesic alone is ineffective.
However, the nurse should take a d.fferent action first.
Legs (L)
• O: Relaxed or expected position
• 1: Uneasy, restless, tense
U NCLEP
• 2: Kicking
Connection, Pharmacological Therapies,
Pharmacological Pain Management
A. NSAlDs are used for mild to moderate pain.
B. Intranasal analgesics are
C. IM analgesics are not
used
for clients
recommended
Oder than
for pain
18 years.
CORRECT: The nurse should
management
on a schedule to
administer
2:
•
O:
No cry
•
1:
Moans or whimpers,
Reassured by occasional touching
or hugging. Able to distract
2: Difficult to console or comfort
•
in a
•
who are experiencing pain
Infants who are experiencing pain
Infants
exhibit a loud cry.
FACES (3 years and older)
Pain rated on a scale of O
lower and draw
CORRECT: Infants who are experiencing pain exhibit a rigid body.
Infants who are experiencing pain exh;bit a local reflex to withdraw
from the stimulus.
U NCLEX* Connection: Health Promotion and Maintenance,
• O:
No hurt
•
I:
Hurts a
bit
• 2:
Hurts a
little
• 3:
Hurts even
Hurts a whole
• 5:
Hurts the worst
child to
A. CORRECT: The nurse should provide nonnutritive sucking as a
nonpharmacological strategy for infants who are experiencing pain.
Guided imagery is a nonpharmacological strategy used
with children.
C.
CORRECT; The nurse should use swaddling as a nonpharmacological
management strategy for infants who ate experiencing pain.
pain
D. Behavioral contracts are a nonpharmacological strategy
with children.
E.
used
CORRECT: The nurse should encourage skin-to-skin touch
who are experiencing pain.
as a
relaxation technique for infants
•
choose a face that best
feeling
and older)
Pain rated on a scale of O to 10.
Explain to the child that O means "no pain"
and 10 means "worst pain."
Have the child verbally report a number or
point on a visual scale their pain level.
Noncommunicating children's pain checklist (3 to 18
Numeric
scale (5 years
years)
Intended for us with chifdren who are unable
to communicate due to postoperative status,
cognitive impairment, or disabilities.
Behaviors are observed for 10 min.
Six subcategories are
NCLEX' Connection: Basic Care and Comfort,
scored on a scale O to
3.
Subcategories ate vocal, social, facial, activity, body and limbs.
and physiological each with observable behaviors to be scored.
Nonpharmacologicol Comfort Interventions
5.
six faces.
lot
how they are
describes
B.
diagram of
more
more
• 4:
Ask the
Data Collection Techniques
4.
to 5 using a
Explain each face to the child.
together their eyebrows.
E-
occasional complaints
screaming, sobbing, frequent complaints
• 1:
squarish shape.
D.
Arched, ridged, or jerking
(C)
Consolability (C)
Content or relaxed
A. Infants who are experiencing pain have their mouth open
CORRECT:
C. CORRECT:
•
Lying quietly, moves easily, expected position
Squirming, shifting, tense
• O:
Therapies,
Expected Actions/Outcomes
B.
1:
• 2: Crying.
achieve optimal pain management.
U NCLEP Connection: Pharmacological
•
cry
in children,
D.
or tegs drawn up
Activity (A)
• O:
3.
child.
Face (F)
• 0: Smite or no expression
• I: Occasional frown or grimace, withdrawn
to evidence •based practice, the nurse
should first administer a nonopioid such as a nonsteroidal anti•
'nftammatory drug or acetaminophen for children older than 3 months
of age who have mild pain.
2.
7 years)
Pain rated on a scale of O to 10.
is
CORRECT: According
C.
using
Answer
PRACTICE
A. CORRECT: The nurse should explain the procedure using the
toddler's favorite toy to manage fears and provide atraumatic care.
The nurse should allow the toddler's parents to remain for
procedures to offer comfort to the toddler.
•
O:
Not
1:
Just a
at
•
2: Fairly
•
3:
B.
all
little
Often
Very often
NA: Not applicable
Cutoff scores:
•
C. The nurse shoutd avoid the use of safe places, such as the toddler's
bed, for procedures.
CORRECT; The nurse should allow the toddler to make choices
when possible to offer a sense of control over the situation and to
D.
provide atraumatic care.
E.
CORRECT: The nurse should apply a
topical analgesic, such as
lidocaine cream, prior to IV insertion to decrease pain
and
more indicates moderate to severe
•
11 or
•
6 to 10 indicates mild pain.
U NCLEP Connection: Pharmacological and
Therapies, Pharmacological Pain
pain.
Parenteral
Management
to provide
atraumatic care.
U NCLEX' Connection: Health Promotion and Maintenance,
Developmental Stages and Transitions
NURSING CARE OF CHILDREN
CHAPTER 9 PAIN MANAGEMENT
49
CHAPTER 10
UNIT
FOUNDATIONS OF NURSING CARE OF CHILDREN
1
SECTION: SPECIFIC CONSIDERATIONS OF
NURSING CARE OF CHILDREN
LEVEL OF UNDERSTANDING
ospitalization,
Illness,
Toddler
and Play
•
Limited ability to describe illness
•
Poorly developed sense of body image and boundaries
•
Limited understanding of the need for therapeutic
•
procedures
Limited ability to follow directions
EFFECT OF HOSPITALIZATION
Nurses encounter children
hospitalized.
it
is
When
who
are
ill
or
•
caring for these children,
important to know what play
activities are
considered appropriate.
Experiences separation anxiety
exhibit an intense reaction to any type of procedure
due to the intrusion of boundaries
•
Can
•
Behavior can regress
Preschooler
LEVEL OF UNDERSTANDING
Hospitalization
•
and illness
for evidence of stress
child's
The nurse should monitor
and intervene as needed
age and developmental
for the
children are
•
•
Fears related to magical thinking
•
Ability to understand cause and effect inhibited
level as well as the
Families should be considered clients
illness feels like
Limited ability to describe manifestations
by
concrete thinking
EFFECT OF HOSPITALIZATION
Can experience separation anxiety
• Can harbor fears of bodily harm
Might believe illness and hospitalization
family's individual needs.
•
Limited understanding of the cause of illness but knows
what
•
Families and children can experience major stress
related to hospitalization,
•
when
•
ill.
Separation anxiety manifests in three behavioral
a
responses.
Protest: screaming, clinging to parents, verbal and
physical aggression toward strangers (this stage
is
expected during hospitalization)
Despair: withdrawal from others, depression,
are
punishment
School-aqe child
LEVEL OF UNDERSTANDING
Beginning awareness of body functioning
•
decreased communication, developmental regression
(this stage is expected during hospitalization)
•
Detachment: interacting with strangers, forming new
relationships, happy appearance (this stage is rarely
observed during hospitalization)
Each child's understanding of illnesses and
hospitalization is dependent on the child's stage of
development and cognitive ability.
•
Ability to describe pain
•
Increasing ability to understand cause and effect
EFFECT OF HOSPITALIZATION
•
Fears loss of control
•
Seeks information as a way to maintain a sense
of control
•
•
EFFECT BASED
ON DEVELOPMENT
Can sense when not being told the truth
Can experience stress related to separation from peers
and regular routine
Adolescent
Infant
LEVEL
LEVEL OF UNDERSTANDING
•
and follow directions
•
Inability to describe illness
•
Lack of understanding of the need of therapeutic
procedures
•
•
•
•
Experiences stranger anxiety between 6 and
18 months of age
Displays physical behaviors as expressions of discomfort
due
to inability to verbalize
Can experience sleep deprivation due to strange
monitoring devices, and procedures
Can experience anxiety due to the unfamiliar
environment and fear of the unknown
NURSING CARE OF CHILDREN
Perceptions of illness severity are based on the degree of
body image changes
EFFECT OF HOSPITALIZATION
EFFECT OF HOSPITALIZATION
•
•
OF UNDERSTANDING
Increasing ability to understand cause and effect
noises,
Develops body image disturbance
Attempts to maintain composure but is embarrassed
about losing control
Experiences feelings of isolation from peers
Worries about outcome and impact on school/activities
Might not adhere to treatments/medication regimen due
to peer influence
CHAPTER
10 HOSPITALIZATION, ILLNESS,
AND
PLAY
51
Online Video: Interventions for Hospitalizati
Family responses
Preschoolers
•
Fear and guilt regarding not bringing the child in for
care earlier
•
•
Frustration due to the perceived inability to care
for the child
•
•
Encourage independence by letting the child provide
self-care.
Altered family roles
Encourage the child to express feelings.
Worry regarding finances if work is missed
Worry regarding care of other children within
i
Explain procedures using simple, clear language. Avoid
medical jargon and terms that can be misinterpreted.
•
Validate the child's fears
•
Provide toys that allow for emotional expression, such
and concerns.
the household
as a pounding board to release feelings of protest.
Fear related to lack of knowledge regarding illness
or treatments
Provide consistency in assigning caregivers.
Give choices when possible, such as, "Do you want your
medicine in a cup or a spoon?"
Siblings can experience loneliness, jealousy, guilt,
Allow younger children
fear, or anger
Caregiver role strain, related to the effect of
•
hospitalization on family processes
School-aqe children
DATA COLLECTION
Provide factual information.
Encourage the child to express feelings.
Try to maintain a normal routine for long
hospitalizations, including time for school work.
Encourage contact with peer group.
illness or the
Childis
•
•
reason for hospitalization
Stressors unique to the child and family (needs of other
children in the family, socioeconomic situation, health
Adolescents
members)
Past experiences with hospitalization and illness
Developmental level and needs of child/family
if it is safe.
•
•
of extended family
handle equipment
•
•
and family's understanding of the
to
•
Provide factual information.
•
Allow the adolescent to contribute to the plan of care
relieve feelings of powerlessness and lack of control.
Parenting role and the family's perception of
to
Encourage contact with peer group.
changes
Support available to the child/family
Coping strategies for periods of crisis
role
Play
hospitalization.
•
•
Encourage family members to stay with the child during
•
•
•
the hospital experience to reduce the stress.
Maintain routine as much as possible.
Encourage independence and choices.
Allows children to express feelings and fears.
Facilitates mastery of developmental stages and assists
in the development of problem solving abilities.
Allows children to learn socially acceptable behaviors.
A means of protection from everyday stressors.
The nurse should select play activities that are specific
•
The nurse can use play
NURSING INTERVENTIONS
•
•
Discuss with the child and family what to expect during
to
Explain treatments, procedures, and cares to the child.
each child's stage of development.
to reinforce teaching
with children.
Provide developmentally appropriate activities.
CONTENT OF PLAY
Infants
•
Place infants
whose parents
are not in attendance
Social affective: taking pleasure in relationships
close to nurses' stations so that their needs can be
Sense-pleasure: objects in the environment catching the
quickly met,
•
child's attention
Provide consistency in assigning caregivers.
Skill:
demonstrating new
abilities
Toddlers
Unoccupied behavior: focusing attention on something
•
•
Encourage parents to provide routine care for the
such as changing diapers and feeding.
Encourage the child's autonomy by offering
52
of interest
Dramatic: pretending and fantasizing
Games:
appropriate choices.
•
child,
imitative, formal, or competitive
Provide consistency in assigning caregivers.
CHAPTER 10 HOSPITALIZATION,
ILLNESS,
AND
PLAY
CONTENT MASTERY SERI
Hospitalization
SOCIAL CHARACTER OF PLAY
Onlooker:
Avoid
reted.
A child
A child
Solitary:
Adolescents
observes others,
•
plays alone.
•
Parallel: Children play independently but
which
is
sports
School activities
ide
children,
Team
among
other
characteristic of toddlers.
Reading, listening to music
Technology-based games and
and
social
visits,
phone
calls,
media
Associative: Children play together without organization,
which is characteristic of preschoolers.
m such
t.
ant
activities
Peer interactions through in-person
Cooperative play: Organized playing in groups, which
characteristic of school-age children.
your
THERAPEUTIC PLAY
is
Encourages the acting out of feelings of fear, anger,
and sadness
Enables the child to learn coping strategies in a
safe environment
hostility,
jit is
safe.
FUNCTIONS OF PLAY
Play helps in the development of various types of skills.
•
Assists in gaining cooperation for medical treatment
Intellectual
Sensorimotor
DATA COLLECTION
Social
Self-awareness
Developmental level of the child
Creativity
•
Therapeutic and moral values
•
Motor
•
Level of activity tolerance
skills
Chi Id's preferences
PLAY ACTIVITIES RELATED TO AGE
d care to
nol.
NURSING INTERVENTIONS
Infants
Birth to 3 months: colorful
moving mobiles,
Select toys that are safe for the child.
•
music/sound boxes
Consider isolation precautions and the child's illness in
relation to toy selection.
3 to
6 months: noise-making objects, soft toys
6 to 9 months: teething toys, social interaction
enhance development.
Observe the child's play for clues to the child's fears or
Select activities that
•
anxieties.
assists
9 to 12 months: large blocks, toys that pop apart,
Encourage parents to bring one favorite toy from home.
Use dolls or stuffed animals to demonstrate a procedure
before it is performed.
push-and-pull toys
Lwicrs.
Toddlers
•
*cific
•
Cloth books, puzzles with large pieces
•
Large crayons and paper
•
•
Push-and-pull toys, balls
•
Tricycles
Educational media programs
Provide play opportunities that meet the child's level of
activity tolerance.
Allow the child to go to the play room if able.
Encourage the adolescent's peers to visit.
Consult with a child life specialist about
recommendations for activities. QJC
Preschoolers
Imitative
.ngthe
and imaginative play
•
Drawing, painting, riding a tricycle, swimming,
•
jumping, running
Educational media programs
School-aqe children
Games that can be played alone
Team sports
or with another person
Musical instruments
Arts
and crafts
Collections
SERIES
NURSING
CARE OF CHILDREN
CHAPTER 10 HOSPITALIZATION.
'LLNESS,
AND
PLAY
53
Application Exercises
1.
A nurse is caring for a preschooler.
Which
3.
A nurse is reinforcing teaching with a
parent about parallel play in children.
Which of the following statements
should the nurse include?
of the following should
the nurse identify as an expected
behavior for preschoolers?
A, "The child
A. Describing manifestations
of illness
B.
B.
"The
play
magical thinking
should the nurse include?
A. Separation anxiety
when
in
the school-age
a group."
B.
D, "The child plays independently
when
in a
is
commonly observed
in
child.
The detachment stage of
separation anxiety
Awareness of body
is
expected
during hospitalization.
group."
C. Separation anxiety
begins with the child
A nurse on a pediatric unit is
caring for a toddler.
of the following information
child exhibits organized
C. "The child plays atone."
functioning
2.
and observes
others playing."
Relating fears to
C. Understanding cause of illness
D.
sits
4. A nurse is reinforcing teaching
with a group of parents about
separation anxiety. Which
withdrawing from others.
The nurse
should identify which of the
D.
The
child might kick health
following behaviors as expected
care staff during the protest
effects of hospitalization for a
stage of separation anxiety.
toddler? (Select
all
that apply.)
A. Believes the experience
is
B.
a punishment
Experiences
separation anxiety
C. Displays intense emotions
D. Exhibits regressive behaviors
E.
Manifests disturbance
in
body image
PRACTICE Active Learning Scenario
A nurse working in a pediatric unit is assisting with
the planning
of play activities for a group of children of different ages. What
activities should the nurse recommend? Use the ATI Active
Learning Template: Basic Concept to complete this item.
RELATED CONTENT:
Identify appropriate toys
activities for children in three
age groups.
Answer the questions above
and
Application Exercises Key
A. Preschoolers have limited ability to describe manifestations
of ;Lness.
1.
3.
A. On'ooker play
B.
B.
CORRECT: The nurse should expect preschoolers to be
and
egocentric
C. Solitary play
relate fears to magical thinking.
D.
Awareness of body functioning
is
when
and observes others
playing.
a child exhibits organized play
in
a group.
a child plays alone.
play
when
is
a child plays
independently but
is
a group,
in
Aging Process
Developmental Stages and Transitions
4.
is
child sits
when
U NCLEP Connection: Health Promotion and Maintenance,
a behavior of an adolescent.
A. Belief that hospitalization is a punishment
hospitalization in a preschoolers.
is
is
like.
U NCLEX' Connection: Health Promotion and Maintenance,
2.
when a
D. CORRECT: Parallel
among other children
C. Preschoolers have limited understanding of cause-and-effect
relatonships but understand what illness feels
is
Cooperative play
B.
CORRECT: The
C.
CORRECT: The nurse shoud expect intense emotions
A. Separation anxiety
B.
an expected effect of
is
commonly observed
The detachment stage
is
C. Withdrawing from others
rarely
is
observed
in
in
toddlers.
the hospital setting.
expected as the child moves from the
protest stage to the despair stage of separation anxiety.
nurse shoutd expect separation anxiety as a
potential effect of hospitalization in a toddler.
D. CORRECT: Children can demonstrate aggression toward health
care staff during as an expected behavior during the protest stage of
as a potential
separation anxiety.
effect of hospitalization in a toddler.
U NCLEP Connection: Health Promotion and Maintenance,
D. CORRECT: The nurse should expect regressive behaviors as a
potential effect of hospitalization in a toddler.
E.
Body image disturbances are an expected effect of hospitalization
in
adolescents,
Developmental Stages and Transitions
U NCLEPConnection: Health Promotion and Maintenance,
Developmental Stages and Transitions
PRACTICE
Answer
Using the ATI Active Learning Template: Basic Concept
RELATED CONTENT
Infants
• Birth
to 3 months:
colorful
•
moving mobiles,
music/sound boxes
3 to 6 months:
noise.making
Toddlers
• Cloth books
•
•
Large crayons and paper
Push-and-pult toys
•
. Balls
6 to 9 months: teething
•
Puzzles with large pieces
Educational television
•
Videos
•
and
imaginative play
Tricycles
objects, soft toys
•
Preschoolers
• Imitative
•
Drawing, painting, riding
a tricycle, swimming,
jumping, running
Educational television
and videos
School-age children
Games that can be
played atone or with
another person
•
•
•
•
•
9 to 12 months: large
blocks, toys that
•
sports
Musical instruments
Arts and crafts
Collections
fot children
Team
sports
School activities
Reading,
hstening to music
Team
toys, social interaction
•
Adolescents
•
Techno•ogy based
games and
activities
Peer interactions
through
cabls,
visits,
and
phone
social
media
pop
apart, push-and-pull toys
U NCLEP Connection: Health Promotion and Maintenance, Developmental Stages and Transitions
NURSING CARE OF CHILDREN
CHAPTER 10 HOSPITALIZATION, 'UNESS. AND PLAY
55