• Normal reaction
• Encourage to bring items from home.
• Most difficult between 9 months-4yrs

• cry, scream for parents.
• Unconsolable.
• Toddlers will atack & be mean
• Biting, hitting, pulling hair

• Crying stops, Inactive phase.
• Become apathetic & withdrawn.
• Want to be left alone.
• Regress to bottling, sucking thumb, using diapers.
• Seen with prolonged separation

• Adjusted to loss.
• Become interested in other people.
• Resigned to fact that parents are gone.
• Sill want parents, but know they can't have them.

• Autonomy, daily routines. 
• Like to be in control. loss of control->regression
• Temper tantrums

• Magical thinking
• May view hospitalization as punishment for something they've done wrong.
• Let them handle equipment & explain procedures

• Scared of death & injury
• Fear of abandonment.
• Boredom common.
• Subborn or crabby b/c of loss of control.
• Explain schedules.
• Encourage to verbalize feelings.

• Most concerned w/ losing control, painful experience.
• Negotiate schedules- struggling for independence, but still scared.
• Struggle with separation from peers.
• May be angry or frustrated. 
• Need for info-explain things

• Disbelief, anger, guilt
• Fear, anxiety
• Frustration: can take out on nurse
• Depression

• Loneliness, fear, worry
• Anger, Resentment, Jealousy
• Guilt

• Use special treatment room
• Distraction
• Allow expression of feelings
• Praise the child

Airborne Precautions

(> 3 ft)

Droplet Precautions 

(< 3 ft)

• GI: C.diff, MRSA
• RSV, etc.

• Therapeutic hugging
• Jacket restraints
• Mummy or swaddle restraint
• Limb/Elbow restraints (take limb out often and move around to prevent freezing)

• Infant & Toddler- pinna pulled down & back
• > 3 yrs- pinna pulled up & back
• Remain on side for few minutes

• Crying
• Requiring increased O₂
• Increased vital signs
• Expression
• Sleeplessness

• Question the child
• Use a pain scale rating
• Evaluate behavioral & physiologic changes
• Secure parent's involvement
• Take the cause of pain into account
• Take action & evaluate results

• 3+years
• 6 faces from happy to sad
• choose face that best depicts how they feel

• concerns about addictions
• lack of knowledge
• inappropriate use of pain meds
• family issues & relationships

• Swaddling, positioning, nesting
• Nonnutritive sucking- oral sucrose
• Kangaroo holding

• Distraction
• Relaxation 
• Guided Imagery
• Cutaneous stimulation

• Moderate to Severe Pain
• Respiratory depression
• Oxycodone, Morphine (widely used), dilaudid, fentanyl (OR)

• Mild to Moderate Pain
• Tylenol, NSAIDs

• Combo acts on two levels to manage pain
• Acetaminphen w/ codeine
• Valium & Versed- enhance analgesics (relieve anxiety, sedation, amnesia)
• Tricyclic antidepressants

• Ok for kids 5+yrs
• Morphine drug of choice

• Topical analgesic used before IV insertion or blood draw.
• NUMBY stuff- transports lidocaine & epinephrine into skin

• S/E: stinging & burning on injection
• Buffered lidocaine/Warming lidocaine: reduces stinging

• Muscle rigidity, crying, grimace, withdrawal, sleeplessness
• Increased ICP, HR, RR, BP
• Decreased SaO₂

• Palliative Care- focuses on symptom control and support.

• person or nurse trained especially to work with the dying and their families

• gentle physical care and comfort measures for child
• Emotional support for child & family
• Understand own feelings about death/dying
• Know grieving process
• Be honest with child about illness, treatments, & prognosis

• little understanding of death
• fear separation from parents
• no recognition of impending death
• Nursing: answer questions honestly & simply, encourage family to stay with child, maintain routines as much as possible

• May believe they caused a death by thinking angry thoughts 
• Magical thoughts-beliefs about death
• View death as a kind of sleep
• May view illness as punishment for thoughts/actions

• see death as universal & irreversible
• Death personified: devil, God, monster, etc.
• View death as another new experience

• understands death, but feels immortal
• May express helplessness, anger, fear of pain, hopelessness, & depression
• Concerned about treatments that cause weakness & altered appearances
• Have the most difficulty coping with death

• Death not always painful.
• If death inevitable, interventions aimed at maintaining comfort.
• No maximum dosage limit to control pain.

• Afraid of abandonment
• Want someone they know and trust to stay with them to provide support & comfort
• May experience visions of angels, etc.

• Reassurance of not being alone, hearing last to go, gentle touch, pain meds, keep mucous membranes clean
• Petroleum jelly to lips for dryness & cracking
• Moisten conjunctiva w/ normal saline drops
• Keep skin clean & dry
• Turn & position regularly to prevent skin breakdown
• Talk to child & explain procedures

• Dysphagia
• Cheyne-Stokes breathing
• Blue/Cold Extremities
• Decreased GI/Urine output

• Positioning
• Pillows as needed
• Changing linens
• Skin & Mouth care
• Protection from friction
• Massage
• antiemetic, analgesics & stool softeners

• Grief before actual death
• Ensure privacy for family & child
• Attention to religious & cultural rituals

• Faces decisions about physical care
• Learning to live with dying child
• Encourage to talk to child about dying

• No opportunity to go through anticipatory grief
• Excessive guilt or remorse for things left unsaid or undone.

• Normal, natural response to a loss
• individual experience
• most profound when loss is a death

• individualized response to the loss of a significant person
• Attending funeral useful in resolvinng grief for family & nurse

• Tightness in chest, SOB, suffocation, generalized weakness, intense tightening in abdomen, emptiness or churning in stomach

• Intentional physical abuse
• Intentional neglect (60%)
• Emotional neglect
• Emotional abuse
• Sexual abuse

• deprivation of food, clothing, shelter, supervision, medical care, or education

• Lack of affection, attention & emotional nurturance

• Destroy or impair child's sef-esteem

• deliberate infliction of physical injury on a child

• Caregiver fabricates s/s of illness in child (proxy) to gain attention.
• Child may undergo unneeded & painful procedures
• 10% of cases fatal to child

• Use, persuasion or coercion of child to engage in sexual conduct or simulation of conduct for producing visual depiction of such conduct.
• Rape, molestation, prostitution, or incest w/children

• Identify abusive situations ASAP
• History of incident vs Evidence of maltreatment
• Pattern/Combo of indicators that arouse suspicion
• Protect Child from further abuse- Mandated Reporter