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. 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.

3. 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.

4. 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

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. 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.

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

10. 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?

11. 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.

12. Children’s ResponseInfants 0 to 1 year Trust vs. Mistrust Separation Anxiety @ 6 months Behavior Body Rigidity Irritability Altered Feeding, Sleeping and Stool patterns

13. 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

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

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

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

17. Toddlers Despair - Hopelessness Sadness Less Activity & Crying Regression Withdrawal Disinterested in play Anorexia

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

19. 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

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

21. 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

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

23. 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

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

25. 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

26. 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

27. 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

28. 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.

29. 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

30. 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

31. 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.

32. 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.

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

34. 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

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

36. 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.

37. 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.

38. 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 Color, viscosity and amount

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

40. 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: 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 2-4h PRN Max MSO4 = 15mg/dose

41. 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!

42. Patient Advocacy You have more than one patient! Optimal outcome for all: Child Physical and emotional Parents Emotional + Healthcare experience Rev 6/09