CARE OF THE TRAUMATICALLY INJURED CHILD IN THE INTENSIVE CARE UNITThe differences in caring for children are also evident in the Intensive Care Unit. The child and his/her parents are actually one unit and should be cared for as one unit. Parents should be allowed to be with the child as much as they indicate they want to be. They will need assistance with understanding what is happening to their child, the equipment in Intensive Care and the enormity of what has happened in their lives. They may need assistance in dealing with feelings of guilt and inadequacy, especially if they feel they had some responsibility for the traumatic injury or for the accident that occurred. The family is an important part of the support system for the child, so the nurse needs to be prepared to communicate and relate effectively with the family members. The child is immature both emotionally and cognitively and will not understand all that is happening to him/her. For this reason, parents will need to be present to assist with explanations. They will know the child’s reference points and background and may be more effective in explaining something to the child based upon his/her own frame of reference. Parents are also more aware of the child’s nonverbal clues as to pain, discomfort, etc. The nurse needs to quickly develop a sensitivity to these clues so that he/she can meet the child’s needs even if parents are not at the bedside. The nurse is often the bridge between the high technology of the modern day intensive care unit and the patient and family. Bridging this gap is one of the exciting challenges of pediatric intensive care nursing. The nurses’ role as a patient educator will also be a challenging one because he/she will have not only the child to teach, but will also have adults to relate to and to teach. It is imperative to meet patient teaching needs on both levels. Learning takes place more easily when it proceeds from the simple to the more complex. This is a good way to build rapport not only with the child, but also with parents. The nurse can start by explaining to them what he/she is doing as a care is being delivered. The information will need to be repeated more than once because the child as well as the parent may only hear a portion of the information, depending upon the individual’s level of stress. Continuity of care givers is ideal, but not always realistic. Consistency can be established by having some written materials for the parents and for having some standard approaches as to what information is given to parents. Written material cannot be used as a substitute for verbal contact because some parents (as well as children) may not read. Health care workers can unwittingly raise the level of parental anxiety just by using different terminology to explain the same procedure. Parents may quickly decide that one person is more competent than another, not by care given, but by information related to them as to the care being given by the health care worker. The nurse is most often the center of this potential controversy just because of the amount of time spent at the bedside with the parents. Part of the goal for intervention with the family is not just to assist them to cope with the situation of hospitalization, but to actually grow and develop from the hospitalization and the traumatic injury. Physiologically, the nurse needs to modify assessment skills and the usual intervention techniques so that they will be appropriate for children. The physiological discussion from earlier in this course will apply in the Intensive Care Unit as well as in the Emergency Department. In addition, there are some important aspects about caring for children beyond the resuscitative phase that need to be noted. The pediatric intensive care nurse needs to develop some parameters by he/she can quickly determine the severity of the condition of the patient for whom he/she is caring. These will include both some qualitative and some quantitative measures and will give the nurse the overall impression of the patient’s condition and may be more important than the latest set of vital signs. This assessment will include the following: COLOR: A child’s color is normally the same on both trunk and extremities. Nail beds, hands, feet and mucous membranes will all be pink. If a child is having cardiorespiratory distress, mottling of skin begins to appear and extremities and mucous membranes become pale. Cyanosis will not usually be in evidence until much further along in the cardiorespiratory decompensation. WARMTH: The normal child’s skin temperature is warm with almost instantaneous capillary refill. Poor perfusion and/or stress will result in cool extremities and sluggish capillary refill. The environmental temperature has to be considered because the child’s extremities will also cool as a result of being cold. ACTIVITY LEVEL AND RESPONSIVENESS: These will change and will change quickly if the neurological function and/or the systemic perfusion changes. The normal infant will seek to look as a person’s face, making eye contact easily and consistently. He/she will follow brightly colored objects readily. Extremities move readily and frequently. An infant in distress may not sustain eye contact; may look away or refuse to make eye contact. The mildly distressed infant will hold his/her extremities flexed and will express facial grimaces. The infant’s will be increasingly irritable and the cry will be high pitched and weaker than normal. As the infant deteriorates, the cry becomes non-extent and the infant’s extremities become limp or flaccid. The toddler does not like the strangeness of the hospital and does not want to be separated from his/her parents. The normal toddler will protest both a stranger caring for him/her and his/her parents leaving. Usually, the toddler is happy only when a parent is at the bedside and touching him/her, especially if another person is doing a procedure to him/her. If the toddler becomes lethargic or does not object to parents leaving, be concerned. The child’s physical condition may have changed somewhat and may change more and quickly. The older preschooler is usually able to verbalize pain and its location. The child’s description of the intensity of the pain may not be reliable because the child has little reference point to describe the severity and quality of the pain. He/she just knows that it hurts. They will become paler and lethargic when they are tired or uncomfortable. The normal preschooler is interested in what the nurse or other health care worker is doing and in the equipment being used. The child will ask many questions. As a child’s condition worsens, a whining tone of voice will be heard, the questions will change to demands and the eyes take on a strained look. As the condition further deteriorates, the child becomes quieter, more listless and lethargic. The questions cease, the talking ceases and the child may just look away so as to avoid using the energy to make eye contact. The school age child is able to cooperate and is less fearful of procedures if they are explained ahead of time. This age child can also answer more completely the questions about symptoms. The child of this age is very sensitive about examinations, protective of their privacy and do not want their body exposed. An explanation of what is going to occur and provision for privacy will enlist their cooperation to a greater extent. The school age child whose condition is deteriorating becomes irritable, lethargic and then progress to unresponsive. Adolescents vary in their emotional maturity to such a great extent that it is more difficult to make generalized statements about them as a group. The normal adolescent is interested in what is happening to his/her body and will ask questions. Often, they are fearful about the ultimate outcome of their injuries. They are cooperative, can give accurate information and will try to assist. As the condition of an adolescent deteriorates, he/she may regress in behavior, withdraw, become lethargic and not want to see anyone. The normal behavior for a child of any age is to react to pain and attempt to withdraw from the pain. Absence of this response indicates either cardiorespiratory or neurological deterioration and should be responded to by the nurse. Also, if the child lies in bed, instead of sitting up, there is either pain, fear or serious illness present (Hazinski, 1992). REACTIONS TO THE INTENSIVE CARE UNITChildren admitted to an Intensive Care Unit will be affected by the strange environment and by the routines and equipment that he/she will encounter. Usual sleep cycles are not often considered when health care workers have procedures to do, when alarms are going off or when other tasks are to do accomplished in the environment. The environment for a young child in Intensive Care is quite different from children outside the unit—it’s a world of ventilators swishing, cardiac and other monitors beeping (all with different beeps) instead of lullaby music and other children laughing and playing. Imagine listening to those sounds every waking moment (and in your sleep). Light is also stimulating to very sick children, especially reflected off light to while walls.Suggestions for providing a more positive growth encouraging environment for any child in Intensive Care, including Neonatal Intensive Care are:
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