Pediatric Assessment Elisa A. Mancuso RNC, MS, FNS Professor of Nursing

1. Pediatric AssessmentElisa A. Mancuso RNC, MS, FNS Professor of Nursing

2. Course Requirements • Course Objectives • Schedule-Lecture & Clinical • Assignments- (Page 7 & 8) • Lecture- 3 exams = 95% + 1 ATI Exam (5%) = 100% • 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.

3. Course Requirements • Academic Integrity = Professionalism! • BLS CPR certification must be current until 12/22/11 • 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.

4. Texts • Required (page 10) • ATI: Nursing care of children: RN edition - 8.0 • Elllis and Hartley (2009) Managing and coordinating nursing care (5th ed.) ISBN-13: 9780781774109 • London, M. et al (2011) Maternal & child nursing care. (3rd ed) ISBN-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 • Suffolk County Community College NUR 246/248 Case Studies Maternal & Child Health Nursing (2010) ISBN-13: 978-0-558-72350-7

5. Pediatric Assessment • 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

6. 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!

7. 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.

8. Listen

9. Physical Exam • 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.

10. Illness and Hospitalization • Major life crisis. • Change from usual state of health and routine. • Loss of control. • Unfamiliar environment and people.

11. 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 • Did they cause their child’s illness?

12. 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.

13. Children’s Response

14. Infants • 0 to 1 year • Trust vs. Mistrust • Separation Anxiety @ 6 months • Behavior • Body Rigidity • Irritability • Altered Feeding, Sleeping and Stool patterns

15. 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

16. Toddlers • 1 to 3 years • Autonomy vs. Shame and Doubt • Behavior • Seeks independence “Me Do” • Mobility = Control • Temper Tantrums • Separation anxiety @ 18 – 24 mos.

17. Toddlers • 3 Distinct Stages of Separation Anxiety • Protest • Despair • Denial/Detachment

18. Toddlers • Protest • Cry constantly = terrified • Clings to Parent • Searches for parent • Avoids and Rejects stranger contact

19. Toddlers • Despair • Hopelessness • Sadness • Less Activity & Crying • Regression • Withdrawal • Disinterested in play • Anorexia

20. Toddlers • Denial/Detachment Superficial Adjustment Appears happy Eats & plays Accepts other adults Self-centered behaviors Resignation

21. Nursing Interventions • 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

22. Pre-School • 3 to 5 years • Initiative vs. Guilt • Behavior • Fear of : Mutilation, Intrusion, Abandonment and Punishment • Fantasy and unrealistic reasoning • Hostility & Aggression • Physical & Verbal

23. 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

24. School-Age • 6 to 12 years • Industry vs. Inferiority • Behavior • Loneliness & Boredom • Isolated from Peers • Displaced anger • Postpone procedures • Passively accept pain

25. 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

26. Adolescents • 13 to 18 years • Identity vs. Role Diffusion • Behavior • Rejection, Withdrawal • Non compliant • Anxious • Fear of change in body image • Loss of identity

27. Adolescents • 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 • Decorate room, wear own clothes,

28. Children’s Adjustment • Impacting Factors: • Age of child and development • Previous health care experiences • Coping skills/preparation • Nature of health needs • Severity of illness and symptoms • Acute vs. chronic • Degree of discomfort • Required procedures • Perception of illness

29. Children’s Stress Responses • Loss of appetite • Disinterest in environment • Loss of previously acquired tasks • Regressive behavior • Thumb sucking, bed wetting • Temper tantrums • Clinging & Irritability • Demanding & Possessive

30. Pre-Op Care • Assess psychological preparation • Orient to room, staff and unit. • Review process and procedures. • What, where, when, & how • Use dolls, toys and videos.

31. 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

32. 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, etc are completed • Results attached & MD notified PRN

33. Dress in gown & ID any toy/blanket child takes. 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.

34. Post-Op • 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 • Reinforce necessity of assessment to parents.

35. Respiratory • Maintain Airway Patency • Rate & Rhythm • Pulse Oximeter • Breath sounds • Anterior & Posterior • Depth & Symmetry • Color lips & mucous membranes • Secretions • Amount, type, color

36. Cardiovascular • Apical Rate & Rhythm Listen for a full minute! (Compare with baseline data.) • Blood Pressure • Extremities - Compare bilaterally Peripheral Pulses Color & Temp Capillary Refill

37. Neurological Status • LOC • PERLA • Behavior/Activity • PAIN • S = subjective • L = location • I = intensity • D = duration • A = associated factors

38. Skin Integrity • Check all dressings, wounds, drains/tubes. • Note patency & drainage. • Color & amount • Document q h or PRN • Check dependent areas for breakdown. • Elevate any edematous areas.

39. 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 & wound drainage.

40. 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 (cm) • NG tube • Patency • Drainage • Color, viscosity and amount

41. Thermoregulation • Temperature • Rectal most accurate • Oral when compliant • Tympanic unreliable • Shivering • Increases BMR & Temp • Extremities • Color & Temp

42. Pain Management • Assess pain accurately with appropriate scale; • Faces, numbers and/or colors or FLACC • Review prior effective RX • Tylenol vs. Motrin vs. Opiods • Interventions, least to most invasive: • 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)

43. 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 • Based on child’s condition

44. Patient Advocacy • You have more than one patient! • Optimal outcome for all: • Child • Physical and Emotional • Parents • Emotional • + Healthcare experience • Rev 1/11