DEBORAH K. MARTIN, RN, BSN

• artn

When you're used to caring for adults only, the admission of a child to your unit may be challenging. But there's much you can do, right now, to be better prepared.

A 3-year-old boy dies of pul­monary edema after he is given several liters of IV fluid; his daily fluid requirement was closer to 450 ml.

The child, who had a car­diac condition, had been ad­mitted to a community hos­pital in Tennessee for an upper respiratory infection and as­signed a room on the adult med /surg unit. It turns out that his nurses incorrectly cal­culated the amount of fluid he needed, providing continuous infusion from 1,000 ml bags.

Unfortunately, tragedies like this one happen because children are often trea ted in fac ilities that are designated for adults. In this casc, an experienced pediatric nurse would have instituted safe­gua rd s aga inst fluid ove r­load or performed morc fre­quent assessments because of the child's medical history. Of the more than 6 million chil­dren who are hospitalized in the Uni ted States each year, nearly half receive ca re in community hospitals-many

of which lack the equ ipment, staffing, diagnostic resources, and treatment appropriate for pediatriC patients.l And when a crisis arises, few of these hospitals have protocols fo r obtaining a pediatric consul ­tation.

According to a recent study, access to pedia tric care ap­pears to be a "hit or miss" proposition fo r many ch il­d ren and their famil ies. Even though pediatric patients have special needs, they often end up on adult units, with doc­tors and nurses who have had li ttle or no pediatric training. ~ On these units, they tend to be treated as miniature adults, despite the fact that children suffer from a different spec­trum of d iseases and injuries than adults do and have physiological and emotional responses that are unique to their young age.

lf you care primarily for adu lts, there are a variety of ways to enhance your skills and make you better able to ra pidly assess and care for a

DEBORAH MARTlN is a clinicaJ education speciaJist at Connecticut Children's Medical Center in Hartford, The author has no financial relatiooships to disclose. STAFF EDITOR: Linda M. Roman

• t

34 RN SEPTEMBER 2005 Vol. 68, No.9 www.rnweb.com

-• --

www.rnweb.com

• --• • .. '. '." '.:* '.:. • • • -- '. • • · - ---

Vol. 68, NO.9

,

pediatric patient. The practical tips you'll find here should help you toward that end .

Tailor your assessment to fit the child

To be beller prepared for a pediatric emergency on your nursing un it, it's essential thai you have the proper equip­ment and supplies on hand. (For a list of these necessities, see the box on page 37.) H's also importanl lo have cu rrent pediatric references, such as the American Hea rl Associa­tion's Pediatric Advllllced Life Supporf guidelines, which may be ordered for $30 fro m www . a merien n hea rt .org I p resen ler .jhtml?identifier=30117S4.

A 1001 you'll find hel pfu l when ca ring for children is the Pediatric Assessment Triangle (PAT), accessible at www . hea I th .sln te. ny .us/ n ysdo h / ems/ pdf / pediatricreference card-04.pdf. The PAT offers advice on how to assess a child in distress simply by looking at him. If the child isn' t crying or speaking, is unresponsive to his parents, or has floppy or rigid muscle tone, there's a problem. Other red flags in­clude nasa l flaring, noisy breathing, a lack of respiratory effort, cyanosis, mottling, pa l­lor, and, of COUTSe, significant bleeding. Any of these signs may ind icate a life-threatening condition requiring immedi­ate resuscitation measures.3

If your observa tions deter-

SEPTEMBER 2005 AN 35

mine that the child is not in an emergent or life· threatening situ­ation, you can continue with your assessmen t, keeping in mind the potential for rapid deterioration in a child .

Control of the airway is of paramount importance. The in· ability to establish or maintain a patent airway can lead to inade­quate ventilat ion and hypoxia and is the most common cause of cardiorespiratory arrest in a child.4 Make sure the airway isn' t blocked-by objects, vomit, or blood, fo r example. If you need to open the airway, perform a basic maneuver, such as the head· tilt / chin·lift or the jaw·thrust; if you suspect trauma, don ' t use the head-tilt / chin-lift maneuver .~

Once airway patency is estab· lished, continue to carefully as­sess the child's breathing. Clinical signs of respiratory distress or failure include tachypnea, abnor­mal breath sounds, and changes in mental s tatus. Initially, a child in respiratory distress or failure may be tachycardic, but brady­cardia often ensues. An infant or young child experiencing diffi­culty breathing may exhibit one of the following types of retrac-

tions: intercostal, s terna l, sub­costal, or supraclavicular. Retrac­tions are not as prominent in older children because the inter­costal muscles are s tronger, the chest waU is more rigid , and the soft tissues overlying the rib cage are thicker.)

If you detect signs of respira­tory distress, provide supplemen­tal oxygen immediately.6 If the child won't wear an oxygen mask, hold the mask or tubing near his mouth and nose so that he can inha le the "blow-by" oxygen.'

If the child's respiratory sta tus continues to deteriorate, provide additional support through arti­ficial ventilation with a properly s ized bag-valve-mask device­particularly if the child is tiring from the increased work of breath­ing- and prepare fo r poss ible endotrachea l intubation.

Children are more than just little adults

A child 's airway is anatomically different from an adult 's, and these differences can make intuba­tion more challenging. A child's tongue is disproportionately large and his epiglottis is floppy, which

~ Nearly hall of the 6 million children hospitalized each year go to community hospitals that often lack pediatric resources and equipment.

~ A child's shorter neck and smaller anterior larynx make accidental intubation of the esophagus more likely.

~ It's important to consider reasons other than pain, such as wetness or hunger, for a child's discomfort.

36 RN SEPTEMBER 2005 Vol. 68, No.9 www.rnweb.com

makes visualization of the larynx and vocal cords more difficult. In add ition, a child has a shorter neck and smaller anterior larynx, making accidental intubation of the esophagus more likely.',s To facilitate intubation, use the jaw­thrus t maneU\'er as detailed in the Pediatric Advanced Life Sup­port guidelines.

It's important to use the appro­priate-sized equipment. The s ize of the endotrachea l tube (ET) may be estimated by holding it next to the child's pinky. Or you can use the fo llowing formula:'

(child 's age + 16) '"" 4 = size (in millimeters). The Broselow Pediatric Emer­

gency Tape is also useful in iden­tifying the proper tube size for a child of any age. The tape esti­mates weight, medication dosage, and appropriate equipment size based on the child 's length, which must be carefully measured.

A circulatory assessment should include skin temperature and color, quality of peripheral pulses as compared to central pulses, level of consciousness, and blood pressu re. Capillary refill a t the palms, soles, fo rehead, and central body should be less than two sec­onds. See the table on page 38 for a list of norma l vital sign ranges according to age.

Be su re to remember that a child initially compensates for lost blood volume with an increased heart rate and peripheral vaso­constriction.9 In addition to tachy­cardia, early signs of shock may include menta l status changes, respiratory compromise, absence of peripheral pulses, delayed cap­illary refill, pallor, and h ypo­thermia.

Also bear in mind that norma l vital signs are no guarantee that the child's ci rcu lation is uncom­promised . Obvious signs of shock,

What to keep on hand for kids

Even if your community hospital doesn't have a pediatric unit, it should be prepared to handle a pediatric emergency. It's a good idea to keep the following items al the ready:

Resuscitation cart Bag-valve-mask device (450 ml) with

oxygen reservoir and without pop-off valve

Clear oxygen masks for neonate, infant, and child

Nasal cannulas for infant and child Suction devices; catheters 6 - 14 F;

Yankauer-tip Oral airways, sizes 0 - 5 Nasal airways for infant and child Nasogastric tubes, sizes 6 - 16 F Laryngoscope handle and blades:

curved 2, 3; straight or Miller, 0, 1, 2, 3 EKG monitor/defibrillator with pediatric

paddles Endotracheal tubes: uncuffed, 2.5 - 5.5;

cuffed, 6.0 - 9.0 Pediatric endoscopes and bronchoscopes Pediatric ventilators

Equipment Scales that weigh children in kilograms only,

to avoid medication errors. Pulse oximeter with pediatriC probes Blood pressure cuffs to fit infants and children Cardiopulmonary monitor with pediatric capability Doppler and noninvasive BP monitoring equipment

with infant and child cuffs

IV solutions and pediatric trays Normal saline, lactated Ringer's solution, dextrose

with X normal saline (05 X NS), 250 ml and 500 ml bags IV catheters-la-gauge to 24-gauge Lumbar puncture with needles appropriate for infants

and children Urinary catheterization tray with Foley a - 14 F Venous cutdown tray

~

l ~ •

Source: Sigrest, T. D., & American Academy of Pediatrics Committee on Hospital care. 'Facilities and equipment for the care 01 ~ pediatric patients in the community: 2003. 'N'NW.pediatrics.orgIcgilcontenVIu1V111 /S/1120 (13 June 2005). II! L-______________________________________________________ ~ !

such as hypotension and reduced urinary output, may not occur until more than 30% of blood vol­ume has been lost; in a child, the circulating blood volume is about 80 ml/ kg.s

There are many ways to identify pain

Children may not always be wilJ­ing or able to adequately com­munica te or describe their pain. Therefore, routine assessment of pain---especially pa in that's not responding to treatment- is cru­cia l. Try to determine the words or sounds the child uses to con­vey pain, such as "boo-boo" or "owie." If the ch ild can't effec­ti vely communicate what he's experiencing, use an assessment tool such as The Faces Scale, The scale, which can be used fo r most age groups, consis ts of six cartoon faces ranging from a very happy,

smiling face depicting "no pain," to a tearful, sad face depicting "worst pain." The child simply points to the face that portrays how he fcc ls. (The scale can be accessed online at www3.us,else vierhea lth.com / WOW I graphics I FACES.pd f. ) In the absence of a child's accurate self-report or ob­vious signs of pain, parents often can tell you whether their child is in dis tress.

The fo llowing tips may also be useful when assessing and man­aging pain in chiidrenYI .. Don' t assume that because a child is lying still that he's not in

• pam. .. When there is pain, there may be nausea. Treat both. .. Medication for children- in­duding pain med ication-should be dosed in milligrams per kilo­gram. Children should always be weighed in kilograms, and not pounds, fo r this reason. Weigh ing

in pounds can increase the risk of error. .. Do not under-medicate. To achieve pa in control, child ren often requ ire more pain medica­tion per kilogram than adults do; children's tolerance for pain in­creases with age. .. Titrate pain medication in in­crements when possible, .. Assess for side effects of pain medication, such as respiratory depression, and be ready to inter­vene. Have airway equipment a t the bedside. ... Always consider other reasons, besides pain, fo r the patient's dis­comfort. Is the child wet or hun­gry? Does she want her parents?

Training can help enhance pediatrics skills

Nurses caring for sick children must have a strong knowledge base and confidence in their abiH-

www.rnweb.comVoI.68.No. 9 SEPTEMBER 2005 RN 37

Pediatric assessment: What 's normal

Respiratory rate Pulse rate Age (breaths per minute) (beats per minute) Systolic BP {mm H9J

Infant « 1 year) 30-60 100 - 160 >60 (or strong pulses)

Toddler (1 - 3 years) 24 - 40 90 - 150 >70 (or Slrong pulses)

Pre-schooler (4 - 5 years) 22 -34 80 - 140 >75

School-age Child (6 - 12 years) 18-30 70 - 120 >80

Adolescent (13 - 18 years) 12 - 20 60 - 100 >90

Source: NeN York State Emergency Medica! Services. "Pediatric assessment." 2004. www.hea/th.state.rrt.USInySdOhIemslpdf Ipedialricl'efSl'eOCecard.()4.pdI (16.M1e 2(l()5).

tics, even if they don't see seri­ously ill or injured children on a regula r basis. Th ree nationall y recognized courses offer instruc­tion in caring for pediatric pa­tients and managing pedia tric emergencies:

Pediatric Advallced Life SIIP­port (PALS), by the American Academy of Ped iatrics (AAP) and the American Hearl Association, is a course that focuses primarily on prevention and management of cardiopulmonary arrest. It also covers postresuscitation care and stabilization and transport to a tertiary care center.

atric tertiary care center, which will ex pose you to assessment skills. s tandards o f ca re, pain management strategies, and age­appropriate appro.'lches to ca ring for children who require emer­gency care or hospi talization. That's the type of program I coor­dinate with community hospitals through the "Circle of Caring" at Connecticut Child ren's Med ical Center (CCMC) in Hartford . To increase the level of ca re for chil­d ren throughout the state, CCMC has become partners in children's health with many com munity hospitals.

Similarly, the MCKay- Dee Hos­pital in Ogden, Utah, shares its

pediatrics experti se with rural hospitals nea rby. McKay-Dee has a pediatrics unit, and the pedi­atric nurse manager offers skills labs, educational materials, and chart audits to outlying hospitals that don' t have ped iatric units. In addition, the pediatric nurse manager is available to the out­lying hosp itals for telephone con­sultations.

Providing high-quality care to child ren in an adult-oriented com­munity hospital is a challenge. But as this rev iew demonstrates, there are things you can do and re­sources you can tum to to step up your care fo r that younger-than­usual patient. RN

TI,e Emergency Nurse Pedi· a t ric Course (EN PC), by the Emergency Nurses Association, add resses the care of children in the ED. A special aspect of this course is its guidance on how nurses can teach families to re­duce the risks of injury and ill· ness. ENPC also includes a sys­tematic method to assess and triage the ped iatric patient .

--+1 REFERENCES " --

TIle Pediatric Education for Prellospital Professionals (PEPP) is sponsored primarily by the AA P. Although it's designed fo r emergency responders, much of the information also applies to hospital care.

There are other ways to bui ld your know ledge base, as well . Consider cross-training in a pedi-

1. Sigroot. T. D., & American Academy 01 Pediatrics Ccmnillee on Hospital Care. -FacMies and eQUipment for the care 01 pediatric patients in the communily." 2000. WWW.pediatrics.Ofg/o;jItX:A'ItentIhA 1111/5111 20 (13 June 2(05). 2. Athey. J .. Dean. M., et aI. (200 1). Ability 01 hospitals to care lor pediatric emer· gency pat ients. Pediatr Emerg care. 17(3). 170. 3. Emergency Medical Services for ChH· dren. 'Pediatric emergency care course'-2000. www.ems,c.orgtsearclVframesea rch.htm (23 June 2005). 4. StaffOfd. P. W .• BIinman. T. A.. & Nance. M. L. (2002). Plactical points in evaliation and resllsc::itatlOO 01 the .-.xed child. Surg an North Am. 82(2). 273. 5. American Heart ASSOCiatlOO. "IlCQR /vJviso(y Statements: Pediatnc resuscita· tion-F'9lKes." 2005. www.arnericanheart

38 RN SEPTEMBER 2005 Vot. 68, NO.9 www.rnweb .com

.org/present(lf.jhtml?ldentilier= 1792 (IS JIXIe 20(5). 6. American Ilea<1 Association. 'Pediatric Actvanced Life Support: 2000. http://c::¥c .aha;oumals.org/cgVcontenVfulll02/sup pt1l1·291 'SECI3 (28 Jtly 20(5). 7. RzucidIo. S. E.. & Shirk. B. J. (2004). Trauma nursing: Pediatric: patients. RN. 67(6). 36. 8. Nguyen. T. D., Raju. R .. & Lee. S. -eon· slderations in pediatric trauma'- 2000. www.emeclicine.comImedfl0pic3223.htm (14 June 2005). 9. Hazinski. M. F., Ct\ameIdes. L.. et aI. (Eds.) (2002). Pediatric arJvancecJ life sup. port provider manual. Da1as: American Heart AssociatlOO. 10. Univefsity of MJCtjgan I tealth System. 'Pediatnc pain management -Staff edu· cation'- 2005. www.med.l.II.Tich.ed.llpain l pedatric:.htm (8 July 2(05).