Transcript Pediatric Assessment - Suffolk County Community College

Pediatric
Assessment
Elisa A. Mancuso RNC, MS, FNS
Professor of Nursing
Course Requirements
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Course Objectives
Schedule-Lecture & Clinical
Assignments- (Page 7 & 8)
 Lecture- 3 exams = 95% + 1 ATI Exam (5%) = 100%
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Clinical- (Packet page 2.)
 1 Pediatric NCP
 2 Journals
 Daily Nursing Process Plan (1 per patient)
 1 Clinical Case Study Presentation
 Leadership Assignment
Assignments not submitted on time will result in a failed clinical day.
Maximum 2 failed clinical days for NUR 246.
Course Requirements
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Academic Integrity = Professionalism!
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BLS CPR certification must be current until 12/22/11
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Dosage Calculation Assessment
90% or higher to pass
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IV rates (gtts/min)
Conversions: mg ↔ grains , grams ↔ micrograms
Pediatric Calculations: mg per kg = dose
2.2 pounds = 1 kg
Two opportunities within one week.
Texts
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Required (page 10)
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ATI: Nursing care of children: RN edition - 8.0
Elllis and Hartley (2009) Managing and coordinating nursing care
(5th ed.) ISBN-13: 9780781774109
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London, M. et al (2011) Maternal & child nursing care. (3rd ed) ISBN-
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13: 978-0-135-07846-4.
 London, M., et al (2011) MyNursingLab with Pearson eText Student
Access Code Card for Maternal and Child Nursing Care (3rd ed.) ISBN-13:
978-0-132-11511-7). URL: http://www.mynursinglab.com
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Suffolk County Community College NUR 246/248 Case Studies Maternal
& Child Health Nursing (2010) ISBN-13: 978-0-558-72350-7
Pediatric Assessment
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Children are not small adults!
Family Involvement
Identify their developmental level and needs:
Infants - Trust vs. Mistrust
 Toddlers - Autonomy vs. Shame & Doubt
 Preschool – Initiative vs. Guilt
 School-Age – Industry vs. Inferiority
 Adolescent – Identity vs. Role Confusion
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Establish Trust
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Approach adult first, then
acknowledge child.
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Get down to child’s eye level.
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Identify self and nature of
visit.
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Reinforce what will be done
and how it will feel.
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Maintain a sense of humor
and have fun!
Communication is Key
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Recognize developmental needs.
Use age appropriate language.
Assess child’s prior health care experiences.
Encourage child to answer questions
independently.
Encourage child to ask questions.
Provide privacy from family/parents if desired.
Listen
Physical Exam
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Let child handle equipment.
“Examine” toys or doll first.
Allow patient to examine doll or RN.
Provide information during exam.
Encourage child to participate.
Be honest and prepare for all sensations child
may experience.
Select a coping technique; hold bear, wiggle toes.
Illness and Hospitalization
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Major life crisis.
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Change from usual state
of health and routine.
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Loss of control.
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Unfamiliar environment
and people.
Parental response
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Anger
At child for becoming ill & causing stress
 Revise routine to accommodate work and child
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Anxiety
Regarding potential diagnosis & painful procedures
 Financial and family obligations.
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Guilt
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Did they cause their child’s illness?
Parental response
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Loss of Objectivity
Apply different rules to ill child
 Allow manipulation by ill child.
 Healthy children are “forgotten”
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Feelings of Inadequacy
Feel helpless in parenting role
 Allow staff to assume decision making and
caretaking responsibilities.
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Children’s Response
Infants
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0 to 1 year
Trust vs. Mistrust
Separation Anxiety
@ 6 months
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Behavior
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Body Rigidity
Irritability
Altered Feeding, Sleeping
and Stool patterns
Infants
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Nursing Interventions
 Primary RN for consistency
 Encourage parents to
participate in care
 Simulate
 Bath
home routine
time, Meal time & Nap time
 Bring
familiar objects from home
 Allow self-comforting
 Pacifier,
Blanky or lovey
Toddlers
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1 to 3 years
Autonomy vs. Shame and
Doubt
Behavior
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Seeks independence
“Me Do”
Mobility = Control
Temper Tantrums
Separation anxiety @ 18 – 24
mos.
Toddlers
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3 Distinct Stages of
Separation Anxiety
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Protest
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Despair
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Denial/Detachment
Toddlers
 Protest
 Cry
constantly = terrified
 Clings
to Parent
 Searches
 Avoids
for parent
and Rejects
stranger contact
Toddlers
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Despair
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Hopelessness
Sadness
Less Activity & Crying
Regression
Withdrawal
Disinterested in play
Anorexia
Toddlers
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Denial/Detachment
Superficial Adjustment
Appears happy
Eats & plays
Accepts other adults
Self-centered behaviors
Resignation
Nursing Interventions
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Accept child’s hostility
Acknowledge feelings to gain trust
Simulate home environment/schedule
Allow maximum mobility
Provide comfort measures
Allow child to make choices
Encourage parents to stay with child
Pre-School
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3 to 5 years
Initiative vs. Guilt
Behavior
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Fear of :
Mutilation, Intrusion,
Abandonment and
Punishment
Fantasy and unrealistic
reasoning
Hostility & Aggression
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Physical & Verbal
Pre-School
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Protest, Despair &
Detachment
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Nursing Interventions
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Allow child to verbalize
Accept regressive behavior
Provide play activities
Provide honest and simple
preparation
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Immediately before procedure
School-Age
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6 to 12 years
Industry vs. Inferiority
Behavior
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Loneliness & Boredom
Isolated from Peers
Displaced anger
Postpone procedures
Passively accept pain
School-Age
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Nursing Interventions
 Explore feelings RT Illness
 Encourage child’s participation
in care
I&O
 Dressing Changes
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Provide projects & activities
Encourage peer visits, phone
calls, email
Arrange tutors for school work
Adolescents
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13 to 18 years
Identity vs. Role
Diffusion
Behavior
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Rejection, Withdrawal
Non compliant
Anxious
Fear of change in body
image
Loss of identity
Adolescents
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Nursing Interventions
Encourage verbalization of feelings
 Help develop + coping skills
 Explain information honestly
 Maintain privacy
 Provide demonstrations & encourage accountability
 Allow peer visitations PRN
 Support pt’s identity
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Decorate room, wear own clothes,
Children’s Adjustment
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Impacting Factors:
Age of child and development
 Previous health care experiences
 Coping skills/preparation
 Nature of health needs
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Severity of illness and symptoms
 Acute vs. chronic
 Degree of discomfort
 Required procedures
 Perception of illness
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Children’s Stress Responses
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Loss of appetite
Disinterest in environment
Loss of previously acquired tasks
Regressive behavior
Thumb sucking, bed wetting
 Temper tantrums
 Clinging & Irritability
 Demanding & Possessive
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Pre-Op Care
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Assess psychological
preparation
Orient to room, staff and
unit.
Review process and
procedures.
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What, where, when, &
how
Use dolls, toys and
videos.
Preparation
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ID Band and alarm tag
Review orders and procedure consent
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Parents role
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√ completion of Pre-Op Check list
Encourage questions
Comfort and support
Pre-op Meds
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Valium
Robinol
“Special Sleep” = Anesthesia
Antibiotics
Physical Prep
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Vital Signs:
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√ for loose teeth & document!
NPO status – Varies according to age
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Age, Ht, Wt (kg), HR, RR, T & BP
Infants 2-4 h, Toddlers 4-6 h, School-Age 6-8 h
Review all ordered tests;
CBC, UA, X-Rays, Type & X, etc are completed
 Results attached & MD notified PRN
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Dress in gown & ID any toy/blanket child takes.
Remove any prosthetic devices;
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Retainers or Body piercing
Encourage use of bathroom prior to transport
Administer pre-op meds & review SEs
Keep side rails up!
Update all documentation & verbally review with
transport personnel.
Review with parents how and where information
will be communicated.
Post-Op
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First 24 hours are most crucial.
Assessments must be frequent and complete to
identify any changes in status.
Ventilation & Perfusion
 Fluid & Electrolyte Balance
 Temperature Regulation
 Energy Needs
 Pain Management
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Reinforce necessity of assessment to parents.
Respiratory
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Maintain Airway Patency
Rate & Rhythm
Pulse Oximeter
Breath sounds
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Anterior & Posterior
Depth & Symmetry
Color lips & mucous
membranes
Secretions
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Amount, type, color
Cardiovascular
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Apical Rate & Rhythm
Listen for a full minute!
(Compare with baseline data.)
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Blood Pressure
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Extremities - Compare
bilaterally
Peripheral Pulses
Color & Temp
Capillary Refill
Neurological Status
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LOC
PERLA
Behavior/Activity
PAIN
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S = subjective
L = location
I = intensity
D = duration
A = associated factors
Skin Integrity
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Check all dressings, wounds, drains/tubes.
Note patency & drainage.
 Color & amount
 Document q h or PRN
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Check dependent areas for breakdown.
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Elevate any edematous areas.
Fluid Balance
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Check IV Solution and rate. (Confirm MD orders)
 All Pediatric patients must be on IV Pumps.
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Hydration therapy = ml/kg/day (Ex. 25 kg child)
100 ml (for 1st 10 kg) x 10 kg = 1000 ml/d
50 ml (for 2nd 10 kg) x 10 kg = 500 ml/d
20 ml (Per add’l kg) x 5 kg = 100 ml/d
25 kg = 1600 ml/d or 65 ml/h
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Fluid Deficit (FD)
FD = Pre-illness weight (kg) – Current weight (kg)
Pre-illness weight (kg)
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Strict I & O.
 All fluids: PO, IV, urine, feces, emesis, diaphoresis & wound drainage.
Gastrointestinal
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NPO until
 Positive Gag reflex & Bowel sounds x 4
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Nausea & Vomiting (N & V)
 Amount & type of emesis
 Medicate as ordered:
 Tigan 100-200mg PR
Zofran 0.1 mg/kg/dose x 1 IV
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√ Abdominal Distention; & measure Abd. Girth (cm)
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NG tube
 Patency
 Drainage
 Color, viscosity and amount
Thermoregulation
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Temperature
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Shivering
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Rectal most accurate
Oral when compliant
Tympanic unreliable
Increases BMR & Temp
Extremities
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Color & Temp
Pain Management
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Assess pain accurately with appropriate scale;
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Review prior effective RX
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Faces, numbers and/or colors or FLACC
Tylenol vs. Motrin vs. Opiods
Interventions, least to most invasive:
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Positioning
Distraction/Guided Imagery
Massage
Medications IV or PO never IM!
 No Demerol! (Metabolite = ↑ seizures)
 MSO4 0.1 – 0.2 mg/kg/dose q 2-4h PRN
(Max dose = 15mg)
Parents’ Needs
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Review child’s status
Procedures, explain equipment used, etc.
 Anticipated LOS and treatments ordered.
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Review family role:
Comforting not monitoring
 Collaborative partners in care
 Encourage verbalization of concerns
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Reinforce need for frequent assessment
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Based on child’s condition
Patient Advocacy
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You have more than one
patient!
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Optimal outcome for all:
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Child
 Physical and Emotional
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Parents
 Emotional
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+ Healthcare experience
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Rev 1/11