Pediatrics Bailey Burge RN, BSN Burn Intensive Care Unit

PediatricsBailey Burge, BSN, RNBurn Intensive Care UnitSeptember 26, 2012

Can be scary. And nurse should be scared. Can rapidly deteriorate1ObjectivesList anatomical and physiological differences in pediatric patientsDiscuss why it may be necessary to vary your approach based on ageIdentify normal ranges for pediatric vital signsIdentify differences in medication administration

Anatomical Differences

NOT LITTLE ADULTSBody ProportionsHead largerGreater body surface area to total body weightThinner skin

Unique anatomical and physiological attributes. They are like charlie brown, different body proportions than the adults. Big head, little bodies. Cant use the standard rules of nines.

Thinner skin: takes less time and less heat to produce deep partial thickness compared to adult. Hot water heater temperature should be set at 120, good educational tip for caregivers. Maybe difficult to estimate depth.

Able to lose more body heat and water through skin. Prone to hypothermia and dehydration.3Rule of Nines

Anatomical DifferencesAirway:Large TongueTrachea shorter & narrowerCartilage is more elasticLarger portion of soft tissue in airwayAirways smaller & narrowerMusculoskeletal:FontanelsChest wall softer & more compliantWeaker abdominal musclesAbdominal breathers till around 8 yr old

Large tongue: increased chance of obstructionCartliage: can collapse easier, keep head in neutral positionSoft tissue: Susceptible to swelling from edema and inflammation from foreign objects, allergic reactions, bacterial or viral infectionsAirway smaller: narrowest part of airway is at the cricoid cartilage, unlike the adult which is at the level of the vocal cords. Why dont need cuffed ett.

Fontanels: newborns have 2. anterior and posterior. Posterior closes 1-3months anterior closes 10-16 months. Can assess anterior for dehydration and increased intracranial pressure.

Chest wall: doesnt protect internal organs very well. Rib fractures very unlikely.

Abdominal muscles: abdomen appears to be distended. Avoid pressure on abdomen so can breath. 5Physiological DifferencesHigher metabolic rateHigher fluid requirementsLimited glycogen storesTotal circulating blood volume per kg greater than adultThey require more energy and consume more oxygen (illness and stress accelerates metabolic rate further)Prone to hypoxia; provide high oxygen environment for critically ill or injured children Higher fluid requirements due to higher metabolic rates; newborn's total body weight is 70-80% water (adult only 50-60%) Prone to dehydration when there is increased fluid loss due to diarrhea, vomiting, or conditions that increase metabolic rateGlycogen: Do not give children 50% dextrose. Can destroy veins. Too hyper. Dilute 50% with equal parts of sterile water

Total circulating blood volume per unit of body weight greater than an adult by 25%; can be estimated to be 80-90 ml per kg6AssessmentApproach to physical exam:Consider age and developmental levelInfants: Calm, soothing voices, warm handsToddlers: Incorporate play, give limited choices, positive reinforcementPreschoolers: Use concrete words, let them help & play with equipmentSchool-Age: Explain, allow questions, participate in care, ask if want caregiver presentAdolescents: Treat as adult, be honest, give concrete info

Always consider the developmental stage of the child before entering a room. If the child is in the parent lap and happy, leave them there, will make assessment much easier.

Infants: 1-12 months of age. noone is stranger, just want basic needs met. Do not like loud and rapid movements. Toddlers: 1-3 years. They like quiet, soothing voices as well. Incorporate play, let them play with stethescope, blood pressure cuff, etc. use a doll to show what you are going to do or use caregiver. dont give them the choice of taking medicine, give choice of momma giving or nurse giving. This gives them some sense of control. Always give positive reinforcement no matter what their reaction is. Preschoolers: 3-5 years. Magical illogical thinkers. School age: 5-11 years. Participate: open bandages, remove bp cuff. Adolescents: 11-18 years. They want to be treated as an adult. Age where they know everything, parent knows nothing. Give concrete information about their injury, poc, treatments and tests. Crying is more than likely going to happen so listen before this happens.

Chest wall is thin and what can be thought of as bilateral breath sounds could just be breath sounds being transmitted from one side to the other. 7AssessmentApproach to physical exam:Always observe firstEye levelVary the sequence with activity levelAuscultate if calm and quietBegin with least invasive, end with most invasiveAcross the room assessment. Observing can tell you a lot about the children. Can get a lot of assessment done by watching, respiratory rate, work of breathing, pain, once you touch, going to upset the child and hard to determine if its you or something else bothering them.

Children are afraid of people in blue, going to make them cry 95% of time so start with what you need them queit for first. 8AssessmentSpecial PointsHeadAnterior Fontanel:Remains open for 12-18 monthsSinks in dehydrationBulges with increased intracranial pressure9AssessmentSpecial PointsChestTransmitted breath soundsListen mid-axillaryRed flags:GruntingNasal flaringStridor NeurologicalSilence is not goldenRecognizes parentsAVPUModified Glasgow Coma ScaleWhen start tracking

Can go into respiratory distress fast

Fentanyl can cause chest wall rigidity if given too rapidly.

GCS is what is appropriate for their age group. May not be able to verbalize, but is normal for age group. 10AssessmentPainDifficult & Challenging Control Constant background pain + exacerbationAssessBehavioral, physiologic and self-reportScales: FACES, Numeric, FLACCHarmful effects with unrelieved painMeds for pain, meds for burn careDifficult and challenging to control and assess in pediatric population

Faces and Numeric are self-report examples.

FLACC= Face, Legs, Activity, Cry, ConsolabilityIs an example of behavioral

Physiologic vital signs.

Admission orders for medications for pain that include tylenol, po morphine, iv morphine and methadone. Schedule for a reason, so administer. PI team also has been recommending lortab.

Pain meds for tank room include: po morphine, iv morphine, versed and fentanly lollipops that can be given more frequently.

Harmful Effects: breakdown of fat and carb stores, prolonged hyperglycemia, hypersensitity to pain, lower pain threshold, memory of painful procedures. 11Vascular AccessPeripheralSupplies:EMLA cream, heat packsIV: 22-24 GExplainDont use parent to restrainPapoose Look distally if non-emergentSPECIAL POINTS

EMLA: dermal anesthetic. Use if you have time. Rub on, place tegaderm over, wait 20-30 mins. Dorsum on hand good for chubby infants. With hands, make fist and flex wrist to visualize better.Dark skin, can use PILight on small, thin children. PI has machine, vein finder in med room. Ambulatory children will pull out IV lines by stepping on them

Scalp veins do not have valves, can start in any direction.

IO: must be underpressure, clots easily, mark after pulling out so another one does not get put in same place12Vascular AccessVisualize veinLightVein finderProvodine for darker skinChange when Insert with bevel down for flashback

Location:HandsGood site for chubby kidsMake fist, flex wristFeetAntecubital fossaSecureVisualize insertion siteTapeArm board

Avoid dominant hand and feet in ambulatory children

With arm board: make sure fingers are extended over board so have movement and tape when pulses can still be checked. 13Vascular AccessIntraosseousEmergencyTibia preferred siteDistal femur, medial malleolus, iliac crestAvoid growth plateAdvance till no resistanceAspirate bone marrowFlushObserve for swellingOur kit is in the top drawer of Pedi Cart. In black box.

May not aspirate any bone marrow.No swelling after flushing, use it. 14Vascular AccessIntraosseousStabilize Flush with 5ml after med administrationOnly good for 24 hoursDiscontinue:Twist and pullPressure for several minsApply dressing with date and time

Only good: if putting in, hopefully physician will get a central line, but after fluid bolus, veins may be easier to detect. Date and time so no one else tries to use location again. 15Vascular AccessCentral Venous LineMore complications than adultsFemoral, internal jugular, subclavianAdvocate Large burnFrequent laboratory dataProlonged venous accessHeparinHeparin: Pediatric IV flush order set.3ml of heparin based on weight:10units/ml for patients less than 18kg100units/ml for patients great than 18kg 16Medication Administration CautionFlushesMixing meds with juices/milkToo much diluentOral MedicationsSyringe for accurate dosageGive when head raisedPlace syringe between gum & cheekGastric tubesPulsate piston syringe

Be sure not to give too much fluid based on childs weightMay not want to drink that anymore so stay away from formula and medsDont dilute too much or child might not finish it all.

Oral:Head raised: to prevent aspirationGive in small increments

Gastric Tubes: pulsate because of small lumen size17Medication Administration IntramuscularInfants0.5 ml 1 ml per siteOlder childrenMax 2ml per siteSites:Vastus lateralis: 3 years oldDeltoid

Medication AdministrationDextrose: >8 yo (D50) 1-2ml/kg/IV1-8 yo (D25) 2-4ml/kg/IV0-1 yo (D10) 5-10ml/kg/IVNewborn (D10) 2ml/kg/IV

50% dextrose can destroy veins because hypertonic. If only have 50%, dilute with equal parts of sterile water. 19NutritionEnteral FeedingsWeight Initial volume (ml/hr)Advancement