Transcript Pediatric Assessment

Pediatric
Assessment
Elisa A. Mancuso RNC, MS, FNS
Professor of Nursing
Course Requirements
• Course Objectives
• Schedule-Lecture & Clinical
• Assignments-Page 7.
– Lecture- 2 exams = 95% + 1 ATI Exam (5%) = 100%
– Clinical Assignments
» 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
• Academic Integrity = Professionalism
• BLS CPR certification must be current to
12/22/09
• Dosage Calculation Assessment
90% or higher to pass
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
• Required
– ATI: Nursing care of children: RN edition - 7.0
– Elllis and Hartley (2005) Managing and coordinating
nursing care (4th ed.)
– London, M. et al (2007) Maternal & child nursing care.
(2nd ed) Vol 2
• Strongly Recommended
– Laboratory Diagnostic text.
– Binder, R.C. et al (2007) Clinical skills manual for
maternal & child nursing care.
– NCLEX Review text: Silvestri, L.A. (2009) Saunders
comprehensive review for NCLEX-RN
Pediatric Assessment
• Children are not small adults!
• Family Involvement
• Identify their developmental level
and needs:
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Infants - Trust vs. Mistrust
Toddlers - Autonomy vs. Shame & Doubt
Preschool – Initiative vs. Guilt
School-Age – Industry vs. Inferiority
Adolescent – Identity vs. Role Confusion
Establish Trust
• Approach adult first, then acknowledge child.
• Get down to child’s eye level.
• Identify self and nature of visit.
• Reinforce what will be done and how it will feel.
• Maintain a sense of humor and have fun!
Communication is Key
• 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.
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
• Major life crisis.
• Change from usual state of health
and routine.
• Loss of control.
• Unfamiliar environment and people.
Parental response
• Anger
– At child for becoming ill & causing
stress
– Revise routine to accommodate work and
child
• Anxiety
– Regarding potential diagnosis & painful
procedures
– Financial and family obligations.
• Guilt
Parental response
• Loss of Objectivity
– Apply different rules to ill child
– Allow manipulation by ill child.
– Healthy children are “forgotten”
• Feelings of Inadequacy
– Feel helpless in parenting role
– Allow staff to assume decision making
and caretaking responsibilities.
Children’s Response
Infants
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0 to 1 year
Trust vs. Mistrust
Separation Anxiety @ 6 months
Behavior
– Body Rigidity
– Irritability
– Altered Feeding, Sleeping and Stool patterns
Infants
• Nursing Interventions
– Primary RN for consistency
– Encourage parents to participate in
care
– Simulate home routine
• Bath time, Meal time & Nap time
– Bring familiar objects from home
• Allow self-comforting
• Pacifier, Blanky or lovey
Toddlers
• 1 to 3 years
• Autonomy vs. Shame and Doubt
• Behavior
– Seeks independence
“Me Do”
– Mobility = Control
– Temper Tantrums
• Separation anxiety @ 18 – 24 mos.
Toddlers
• 3 Distinct Stages of Separation Anxiety
– Protest
– Despair
– Denial/Detachment
Toddlers
– Protest
• Cry constantly = terrified
• Clings to Parent
• Searches for parent
• Avoids and Rejects stranger contact
Toddlers
• Despair
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Hopelessness
Sadness
Less Activity & Crying
Regression
Withdrawal
Disinterested in play
Anorexia
Toddlers
• 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
• 3 to 5 years
• Initiative vs. Guilt
• Behavior
– Fear of :
Mutilation
Abandonment
Punishment
– Fantasy and unrealistic reasoning
– Hostility & Aggression
• Physical & Verbal
Pre-School
• Protest, Despair & Detachment
• Nursing Interventions
– Allow child to verbalize
– Accept regressive behavior
– Provide play activities
– Provide honest and simple preparation
• Immediately before procedure
School-Age
• 6 to 12 years
• Industry vs. Inferiority
• Behavior
– Loneliness & Boredom
– Isolated from Peers
– Displaced anger
– Postpone procedures
– Passively accept pain
School-Age
• Nursing Interventions
– Explore feelings RT Illness
– Encourage child’s participation in care
•I&O
• Dressing Changes
– Provide projects & activities
– Encourage peer visits, phone calls, email
- Arrange tutors for school work
Adolescents
• 13 to 18 years
• Identity vs. Role Diffusion
• Behavior
– Rejection, Withdrawal
– Non compliant
– Anxious
– Fear of change in body image
– Loss of identity
Adolescents
• Nursing Interventions
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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
• Decorate room, wear own clothes
Children’s Adjustment
• Impacting Factors:
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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
Children’s Stress
Responses
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Loss of appetite
Disinterest in environment
Loss of previously acquired tasks
Regressive behavior
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Thumb sucking, bed wetting
Temper tantrums
Clinging & Irritability
Demanding & Possessive
Pre-Op Care
• Assess psychological preparation
– Ask, “What are you in the hospital for?”
• Orient to room, staff and unit.
• Review process and procedures.
– What, where, when, & how
– Use dolls, toys and videos.
Preparation
• ID Band and alarm tag
• Review orders and procedure consent
– √ completion of Pre-Op Check list
– Encourage questions
• Parents role
– Comfort and support
• Pre-op Meds
– Valium
Robinol
– “Special Sleep” = Anesthesia
– Antibiotics
Physical Prep
• Vital Signs:
– Age, Ht, Wt (kg), HR, RR, T & BP
• √ for loose teeth & document!
• NPO status – Varies according to age
– Infants: 2-4 h, Toddlers: 4-6 h,
School-Age: 6-8 h
• Review all ordered tests;
CBC, UA, X-Rays, Type & X, completed
Results attached & MD notified PRN
• Dress in gown & ID any toy/blanket
• Remove any prosthetic devices;
– 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
• First 24 hours are most crucial.
• Assessments must be frequent and
complete to identify any changes in
status.
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Ventilation & Perfusion
Fluid & Electrolyte Balance
Temperature Regulation
Energy Needs
Pain Management
Reinforce necessity of assessment to
parents.
Respiratory
Maintain Airway Patency
• Rate & Rhythm
• Pulse Oximeter
• Breath sounds
– Anterior & Posterior
– Depth & Symmetry
• Color lips & mucous membranes
• Secretions
– Amount, type, color
Cardiovascular
• Apical Rate & Rhythm
Listen for a full minute!
(Compare with baseline data.)
• Blood Pressure
– Check cuff size!
• Extremities - Compare bilaterally
Peripheral Pulses
Color & Temp
Capillary Refill
Neurological Status
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LOC
PERLA
Behavior/Activity
PAIN
– S = subjective
– L = location
– I = intensity
– D = duration
– A = associated factors
Skin Integrity
• Check all dressings, wounds,
drains/tubes.
– Note patency & drainage.
– Color & amount
– Document q h or PRN
• Check dependent areas for
breakdown.
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Elevate any edematous areas.
Fluid Balance
• Check IV Solution and rate. (Confirm MD orders)
– All Pediatric patients must be on IV Pumps.
• 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
• Fluid Deficit (FD)
FD = Pre-illness weight (kg) – Current weight (kg)
Pre-illness weight (kg)
Strict I & O.
• All fluids: PO, IV, urine, feces, emesis, diaphoresis &
Gastrointestinal
• NPO until
– Positive Gag reflex & Bowel sounds x 4
• Nausea & Vomiting (N & V)
– Amount & type of emesis
– Medicate as ordered:
– Tigan 100-200mg PR
– Zofran 0.1 mg/kg/dose x 1 IV
• Abdominal Distention; + measure Abd. Girth
• NG tube
– Patency
– Drainage
Thermoregulation
• Temperature
– Rectal most accurate
– Oral when compliant
– Tympanic unreliable
• Shivering
– Increases BMR & Temp
• Extremities
– Color & Temp
Pain Management
• Assess pain accurately with appropriate
scale;
– Faces, numbers, colors or FLACC
• Review prior effective RX
– 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)
– Morphine (MSO4) 0.1 – 0.2 mg/kg/dose q 2-
Parents’ Needs
• Review child’s status
– Procedures, explain equipment used, etc.
– Anticipated LOS and treatments
ordered.
• Review family role:
– Comforting not monitoring
– Collaborative partners in care
– Encourage verbalization of concerns
• Reinforce need for frequent
assessment
Patient Advocacy
• You have more than one patient!
• Optimal outcome for all:
– Child
• Physical and emotional
– Parents
• Emotional
+ Healthcare experience
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Rev 6/09