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 childs 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 childs 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 childs 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
Childrens ResponseInfants

• 0 to 1 year
• Trust vs. Mistrust
• Separation Anxiety _at_ 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 _at_ 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 childs 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 childs 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 pts identity
• Decorate room, wear own clothes

26
Childrens 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
Childrens 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
• v 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
• v 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 addl 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 childs 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 childs 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