Written Assessment Guidelines: Pediatrics
You must individualize this for each patient and rotation. Assess all these areas and record on your
NPW. It helps to be systematic. Be specific with descriptions.
Report: From nurse, notes – previous day/night. Problems, plans
Subjective: From patient – attitude, personality, fears
Vital Signs: BP, AP, P, R. Pulse Ox. Quality of pulses, respirations
Pain: PQRST for pain. Level on scale – name scale – 1-10, FACES, CRIES. Interventions for pain, result.
Watch for non-verbals–tears, guarding, whimpering, rubbing
Neuro assessment: Mental status – LOC (go beyond A&O X 3) – alert, groggy, lethargic, stuporous,
sleeping, arousable, unarousable. Oriented to time, place, person – themselves, you, others in room.
Appropriate to age/developmental level.
Pupils –size, equal, accommodate, change with light, extra-ocular movements (EOM)
Appropriateness of affect – behavior, speech – clarity, content. Age appropriate?
Cardiovascular assessment: HR, rhythm, strength of HR, meds affecting cardiac status. Cap refill –
upper and lower extremities. Homan’s sign, peripheral pulses (compare L/R), edema –anywhere? History
r/t cardiac problems. Tolerance of activities
Pulse Ox – on O2 or Room Air?
Chest/Respiratory Assessment: IPPA, quality of respiratory effort, work of breathing, color – describe.
Pallor. Dyspnea? Sputum, drainage. Tolerance of activities
Abdominal Assessment: IAPP, scars, incisions, tubes.
Neurovascular: Mobility of extremities – R/L & compare. Circulation, Sensation, Movement (CSM)
Motor Assessment: Strength, gait, balance, ROM, alignment, weight bearing, need for assistance,
appropriate to age?
Integument: Skin condition, incisions, IV’s, buttocks, areas at high risk.
Nutrition: Fluid requirements – ml/kg/day, Diet type. % eaten. Total intake – Oral + IV. IV type and rate.
Amount INFUSED into patient. Nausea/vomiting. ADL ability. Age appropriate diet. Weight. Height.
Elimination: OUTPUT – Urine – quantity, color, consistency, odor, devices
- Bowel – BM, color, consistency, last BM. Meds for.
Safety and Security: Incisions, IV’s, dressings, drains, siderails, restraints, changes in condition, LABS,
procedures.
Meds: In each section or by self.
Psychosocial/Communication: Family unit – who do they live with; home situation, grade in school,
likes/dislikes, social service needs, discharge planning.
PLAY NEEDS: Usual activities for age. Activities to provide in hospital, what is child playing with. Toy
choices.
Health teaching/ Discharge Planning needs: Level for child / parents. Referrals needed.
Misc: History, anything that doesn’t fit a category above.
Equipment and new orders:
Unit IV-7
Unit IV-7
NIAGARA COUNTY COMMUNITY COLLEGE
NURSING EDUCATION
NUR 211
Unique Needs of Children
Guidelines to Complete Developmental Worksheets
3 required- Toddler, Preschool, School-Age
PURPOSE: To help students gain an understanding of normal growth and development of individuals. The levels described by
Erikson are utilized with a focus on the individuals’ basic needs.
SOURCES: Site sources used. Suggestions: NUR 211 Unit IV packet notes, Textbooks: Pediatric Nursing Care, Fundamentals of
Nursing, Medical-Surgical, Anatomy and Physiology, Developmental Psychology, Handbook of Lab Values.
GENERAL DIRECTIONS: Describe in succinct form the normals and deviations seen in each level of development as pertinent to
the physiologic system you are considering. Changes in values or ability should be noted as a person ages from the beginning of
the stage to the end, when appropriate.
INCLUDE RELATED TO EACH NEED:
Oxygen: Normal vital signs – BP, HR, RR, Temp. Vital lung capacity. Normal values for common lab tests which signal adequate
oxygenation: RBC, HCT, HGB, O2 sat, CO2. Physiology related to age and common alterations noted due to age progression.
Children: Difference in cardiac and respiratory systems for age and average physical height and weight.
Sleep, Rest and Activity: Normal hours of sleep needed and usual patterns of sleep and rest. Delineate the ability of
individuals to be active according to the level. What physiologic changes occur to change the levels of activity? Be specific
when the activity changes from beginning of level to end, as in infants 0-1 year.
Activities/Diversional Suggestions for Age.
Children: Play needs at various ages, selection of play material, motor control at various ages.
Nutrition: Normal caloric needs of male and female according to age. Fluid needs for normal hydration – ml/kg. Food
preferences: types and textures. Specific nutrients that need increasing or decreasing due to physiology at this age.
Children: Appropriate servings of nutrients and diet for age and patterns of eating.
Elimination: Expectations of normal patterns. Lab values for routine lab tests done. Alterations r/t physiology as age change.
Children: Common elimination problems at various ages.
Safety and Security: Immunizations pertinent to age level. Infections commonly seen and preventive measures. Safety issues
related to activity, choices, physiology within developmental level.
Children: Age related common accidents and safety measures.
Health Maintenance Recommendations: Health Care Provider visit recommendations, immunizations at the stage, screenings
for age group and timing of visits.
Love and Belonging/Sexuality: Physiologic changes to sex organs. Common problems associated with sexuality. Psychologic
needs related to feeling loved and having a sense of belonging. Problems seen when need for love is interrupted.
Children: Effects of hospitalization and separation, usual fears.
Self-Esteem: Areas of personal accomplishment needed to develop adequate self-esteem as related to age. Developmental
tasks to be completed successfully prior to movement to the next developmental level.
Children: Vocalization and socialization, mental abilities, play needs.
Unit IV-8
NIAGARA COUNTY COMMUNITY COLLEGE
NURSING EDUCATION
NAME _____________________________
DATE ________________________
AGE-RELATED CHANGES AND DEVELOPMENTAL WORKSHEET
AGE GROUP ________
ERIKSON’S DEVELOPMENTAL LEVEL ______________________________
OXYGEN
SLEEP, REST AND ACTIVITY
Activity/Diversion Suggestions for age
NUTRITION
ELIMINATION
Unit IV-9
SAFETY AND SECURITY
HEALTH MAINTENANCE RECOMMENDATIONS (Physician visits, immunizations, screenings)
SELF-ESTEEM
DEVELOPMENTAL TASKS TO ACCOMPLISH
LOVE AND BELONGING
Unit IV-10
NIAGARA COUNTY COMMUNITY COLLEGE
NURSING EDUCATION
NAME _____________________________
DATE ________________________
AGE-RELATED CHANGES AND DEVELOPMENTAL WORKSHEET
AGE GROUP ________
ERIKSON’S DEVELOPMENTAL LEVEL ______________________________
OXYGEN
SLEEP, REST AND ACTIVITY
Activity/Diversion Suggestions for age
NUTRITION
ELIMINATION
Unit IV-11
SAFETY AND SECURITY
HEALTH MAINTENANCE RECOMMENDATIONS (Physician visits, immunizations, screenings)
SELF-ESTEEM
DEVELOPMENTAL TASKS TO ACCOMPLISH
LOVE AND BELONGING
Unit IV-12
NIAGARA COUNTY COMMUNITY COLLEGE
NURSING EDUCATION
NAME _____________________________
DATE ________________________
AGE-RELATED CHANGES AND DEVELOPMENTAL WORKSHEET
AGE GROUP ________
ERIKSON’S DEVELOPMENTAL LEVEL ______________________________
OXYGEN
SLEEP, REST AND ACTIVITY
Activity/Diversion Suggestions for age
NUTRITION
ELIMINATION
Unit IV-13
SAFETY AND SECURITY
HEALTH MAINTENANCE RECOMMENDATIONS (Physician visits, immunizations, screenings)
SELF-ESTEEM
DEVELOPMENTAL TASKS TO ACCOMPLISH
LOVE AND BELONGING
Unit IV-14
NIAGARA COUNTY COMMUNITY COLLEGE
NURSING EDUCATION
NUR 211
Unique Needs of Children
Developmental Stages and Nursing Implications
Erikson's Stages
I.
Trust vs. Mistrust
Birth to 1 year
II.
Autonomy vs.
Shame & Doubt
1 to 3 years
III.
Initiative vs. Guilt
3 to 6 years
IV.
Industry vs. Inferiority
6 to 12 years
V.
Identity vs.
Role Confusion
12 to 19 years
Developmental Need
Facilitating Environment
Needs to establish a basic trust
relationship
Constant, ongoing, loving,
significant, caretaker to meet
needs promptly
Nursing Approach
TLC and "binkie"
Limit caregivers
Sensory stimulation
Include mother
Nor prolonged crying
Needs to develop independence Safe environment
Climber crib
and self-control
Stimulating and open adults secure Transitional objects
in own autonomy, loving and
Push and pull toys, build and
supportive and patient
take apart toys
Needs to explore and make simple Give simple choices
choices
Allow to feed self and wash
Needs safe limits
own hands and face
Guided exploration
Needs to develop self-esteem and Guided independence
Provide materials for creativity
self-worth
Initiate own activities
Allow and encourage choice of
Creative media
activities, food
Peer socialization
Answer questions simply and
Questions answered
truthfully
Toleration of fantasy play
Self care - stay with
Limits
Join fantasy play
State rules or limits
Needs to develop proficiency and Needs honest praise and rewards Medals, ribbons, token as
accuracy in skills and abilities
Needs approval and
rewards for difficult Tx or
Needs to succeed! To experience encouragement to finish projects meds
failure destroys a sense of industry started
Monitor projects and games
Needs to compete
Encourage completion - help
Needs limits - will challenge until prn
they are stated
Contests for self care or
eating, competitive board
games. Place in room with
same age and sex. State limits
clearly and conditions
Needs to find oneself and develop Needs peer group
Allow to make decision
self-concept and self-confidence Needs privacy
relevant to his care
Needs to integrate his values with Needs mobility
Allow privacy
society's values
Needs freedom to choose
Be supportive
Needs to accomplish
regarding education and career, Listen - No "when I was your
emancipation
marriage or vocation, life style
age"
Honest explanations
Provide for peer contact
History from adolescent not
parent
Don't give unasked for advice
Unit IV-15
NUR 211NIAGARA COUNTY COMMUNITY COLLEGE
NURSING EDUCATION
NUR 211
UNIT IV Unique Needs of Children
INTRODUCTION TO NURSING CARE OF CHILDREN AND FAMILIES
Concepts of Pediatric Nursing:
Wellness focus
Health teaching
Healthy growth & nutrition
Safety
Psychological growth
Learning and growing in intellect
Unit IV - 16
Focus of care:
Family Centered Care
Support systems
Appropriate care for age, developmental level, physiology
Infant
Toddler
Pre-school
School-Age
Adolescent
Intellectual /maturational delays
Atraumatic Care- use the least disruptive, invasive possible
Coping mechanisms – wellness, stress and illness
Consequences of inappropriate interventions, caring, support
Unit IV - 17
NIAGARA COUNTY COMMUNITY COLLEGE
NURSING EDUCATION
NUR 211
Unit IV
Unique Needs of Children
REACTION TO ILLNESS AT DEVELOPMENTAL LEVELS
Illness and Hospitalization
Infant - 0-6
months
Global reactions
7 mos. - 1 year
Separation anxiety
Toddler - 2-3
years
"Peak of separation anxiety." Fear of
separation; "may lose mother"; may lose
self-intrusive procedures (temps, "shots").
Loss of autonomy and ritual
Punishment, guilt, hurt, pain (phallic stage).
Bodily mutilation
Bodily mutilation; punishment, guilt (oedipal
stage)
Pre-schooler 3-5 years
School age 5-9 years
9-11 years
Adolescence 12-19 years
Restriction of activities (feels anger); cause
of problems between parents (feels guilty)
Loss of control over life and decreased
mobility; decreased socialization. Feels angry
and/or depressed
II. REACTIONS TO MAJOR CHANGES IN FAMILY STRUCTURE
Infant and
None
Toddler
Pre-school
Feels guilty, frightened and bewildered
School age 6-8 years
Disorganized, retreats
9-12 years
Angry, sad, caught between
Adolescence
12-19 years
Resents being used for emotional support at
time when they need it. Hard to cope with
parents' dating and weekend Santa. May
become manipulative or absorbed in dream
wish to get parents back together
Unit IV - 18
Manifestations
Cries, raised temperature, vomits, weight
loss. May become rigid or flaccid, no affect.
May progress to marasmus
Depression, crying, sad, forlorn, may
progress to anaclitic depression and
marasmus
Protest - screams, hits, cries unending!
Despair - said, withdrawn, regression; Denial
- detachment
Protest - more verbal; Despair - guilt, shame,
regression
Lonely, bored, angry, hostile, frustrated.
May be brave, passively accept or whine and
cry
The age of hero worship; acts brave, tries to
resist help for pain. Watch non-verbals!
Anger - acting our behaviors or Depressed withdraws; Intellectualizes - denies
III. CHILD'S PERCEPTION OF DEATH
None
Equates with "sleep" or "going away." Can't
comprehend finality of death
Personifies death; "boogie man," "eagle;"
skeleton and ghost. More aware of finality of
death (loss of pet)
Realizes it is an "end point" of life and that
everything must die. Interested in cause of
death and what happens after death
(physical and spiritual)
Very concerned, often preoccupied with
death. Views in terms of past experiences,
religious beliefs and family culture. Fears
death yet is fascinated with the phenomena.
Does not want to die without fulfilling
dreams and ambitions.
NIAGARA COUNTY COMMUNITY COLLEGE
NURSING EDUCATION
Pediatric Medication Administration
Calculation of Safe Dosage
 Immaturity of body systems
 Based on body weight or surface area
 Analysis of safe dose vs. ordered dose
Developmental Issues:
INFANT– Trust vs. Mistrust - Provide for comfort and love after giving medication.
Liquids used most often. If necessary – crush meds and add to small amount of semi-solid or liquid
Use common sense in giving – into side of cheek with oral syringe.
Nipple can be used for infant - but NEVER into a bottle of milk, formula, juice, etc
No threatening – use firm request. Don’t give a choice when there isn’t one.
Helpers – Mom and Dad can assist if better for cooperation. But DO NOT leave med without seeing it taken.
Be honest about taste or prick if needle.
Use extra hands when needed.
TODDLERS- Autonomy vs. Shame - Wants to do for self.
Capable of picking up cup by self but may drop pills.
Allow choices when there is one - choosing order of taking, which color first, what liquid to take with.
Utilize chewables as much as possible.
Mix crushed medications and liquids with a small amount of non-essential food (not in milk, vegetables, meat, etc.).
Don't threaten/punish child. Elicit cooperation. Let them help as they are able.
Reward/praise for good behavior.
Be Truthful!!
Never say medication is candy or looks or tastes like candy.
Take/use extra hands! Elicit parents as needed.
PRE-SCHOOL -- Initiative vs. Guilt & SCHOOL AGE--Industry vs. Inferiority
Strive for independence is strong.
They are strong as well.
Be honest. Elicit cooperation.
Reward with praise and small rewards or opportunities. DO NOT scold or punish or threaten.
Allow self-administration as appropriate.
Adolescent-- Identity vs. Role Confusion
Invincible feeling
Tries to get out of taking meds
Knows better than you do
Doesn’t want to be “different” from peers
Not as easily bribed with treats or rewards.
May need to use Behavior Modification techniques esp. with long-term meds
Unit IV - 19
Calculating Pediatric Medication Doses
Medications given to children must be calculated with more caution than adults due to the immature
functioning of organs and the risk for altered reactions to increased dosages. In order to accurately administer
medications to children, drugs are most often ordered as: mg/kg/day or mg/kg/dose. Most drug guides list a
safe dose range for medications for children. To ensure safe administration, the nurse must evaluate that the
dose ordered is within the safe range. The nurses’ responsibility includes recording the accurate weight of the
child as well as comparing the dose ordered to the safe dose recommended by the manufacturer of the drug or
by current pediatric practice.
To calculate pediatric doses The process involves several steps (NOTE: kg weights may be rounded to the nearest tenth of a kg)
 Calculate the amount of drug that the child receives in a day/24 hour time period or per dose (depends
on the drug that is ordered).
 Check resources to see what the recommended amount of drug per kg and amount per 24 hrs or dose.
 Compare the amounts- Is what is ordered within the safe range for the child?
EXAMPLE 1
A 10 year old weighing 70 lbs is receiving 300mg of Ampicillin q6hr.
The safe dose is 25-50mg/kg/24hours.
A. Determine how much Ampicillin the patient is receiving in 24 hours. (q6hr=4x/day)
300mg x 4 times per day = 1200mg/day
B. Calculate safe dose range for patient. (weight based problem using safe dose guidelines)
Lowest safe dose: 25mg x 70lbs x 1kg =
1kg/day
1
2.2lbs
795 mg/day
Highest safe dose: 50mg x 70lbs x 1kg =
1kg/day
1
2.2lbs
1590 mg/day
C. Is the ordered dose safe? Compare 24 hour amount (step A) to safe dose range (step B) to determine if dose
ordered is safe. (Yes dose is safe because 1200 mg/day from step A falls within the safe dose range of 7951590 mg/day calculated in step B)
D. How much Ampicillin will you administer for one dose if supplied as 250 mg/ 5 ml?
EXAMPLE 2
Another situation would be calculating safe dose recommendation for per dose orders:
A 7 year old patient weighing 24 kg has an order for Morphine 2 mg q2hr for sickle cell crisis.
The safe dose recommendation for pediatrics is 0.05 – 0.1 mg/kg/dose. Determine if this dose is safe. Calculate
safe dose range for patient. (weight based problem using safe dose guidelines)
Lowest effective dose recommendation: 0.05mg x 24kg
1kg/dose
1
=
1.2 mg/dose
Highest effective dose recommendation: 0.1mg x 24kg
1kg/dose
1
Is the ordered dose safe?
=
2.4 mg/dose
Unit IV - 20
NIAGARA COUNTY COMMUNITY COLLEGE
NURSING EDUCATION
Pediatric Medication Administration
With the following dosage problems for oral, IM administration, determine if the ordered dose is sage and how
much of the drug should be given.
Kg should be rounded to the nearest tenth.
1. Treatment for a child with a seizure disorder:
Order:
Weight:
Ped dose:
Available:
Dilantin 40mg po bid
15 lbs
5-7 mg/kg/day
Dilantin 30mg/5ml suspension
2. Treatment for a child with a UTI
Order:
Weight:
Ped dose:
Available:
Gantrisin 1.5GM po quid
66 lbs
150-200 mg/kg/day
Gantrisin 500mg tabs
3. Child with cystic fibrosis – exposed to influenza A
Order:
Weight:
Ped dose:
Available:
Symmetrel 25mg po tid
25 lbs
4-8 mg/kg/day
Symmetrel 50mg/5ml suspension
4. Child has nausea post-surgery
Order:
Weight:
Ped dose:
Available:
Phenergan 20mg IM q6h
82 lbs
0.25-0.5 mg/kg/dose – repeat 4-6 hours
Phenergan 25 mg/ml
5. Child has 25 percent second degree burns
Order:
Weight:
Ped dose:
Available:
Morphine 2-3 mg IM q4hr prn
15 kg
0.1-0.2 mg/kg/dose
Morphine 10mg/ml
6. Child with cellulitis of right eye
Order:
Penicillin G 150,000u IM q 12hrs
Weight:
19lb 12 oz
Ped dose: 25,000030,000 u/day in divided doses q 4-12hr
Available: Penicillin G 500,000u/1ml
Unit IV - 21
FLUIDS
•Children do not have reserves of fluids to draw from during illness. They must have replacement throughout the
day.
Daily Maintenance Fluid Requirements for Children:
Body Weight in Kg
Amount of Fluid/Day
1-10
100 ml/kg
11-20
1000 ml plus 50 ml/kg for each kg > 10 kg
>20
1500 ml plus 20 ml/kg for each kg> 20kg
Divide total by 24 for ml/hour fluid needs.
•For children over 50 Kg—use adult amounts.
•IV + PO is often calculated so child does not always have to be hooked up to IV solution during the day.
•DO NOT let several hours pass without fluid management. YOU are accountable!!!
Example: Calculate fluid needs for an 8 week old weighing 5 Kg.
IMPORTANT NOTES IN SKILL ADAPTATIONS
•Cribs and siderails
•Restraints – to save IV sites; dressings
•Urine samples – U-bag or straight cath
•Output amounts from diaper – weigh dry diaper and wet and subtract dry weight.
Urine calculation: 1 gm = 1 ml
•IM – never dorsogluteal before walking well. Ventrogluteal also discouraged until walking. Deltoid only for small
amounts. Best place vastus lateralis or rectus femoris.
•GT /MIC-KEY BUTTON. Same check as with NG or GT as adults but only 5 – 10 ml water for flush.
•GT feeds need extra water for metabolism and peristalsis.
•Oxygen – oxyhood for infants. Nasal cannula can be used- taped to face. Pulse oximetry done routinely; sometimes
continuously d/t poor O2 reserves. Do not let go < 90 %
•Suctioning - only go as far as ¼ inch below trach tube. Need to have measurement of tube.
•IV locks are kept patent with 1 ml Heparin 10 units/ml. Use SASH technique
Unit IV - 22
VITAL SIGNS
•Variations according to age. Look them up and know them for clinical. You must know when a child’s VS are
abnormal.
•Temperature – use axillary and adjust for it or oral (rectal rarely used—risk of trauma)
•Apical pulse must be done for most children – wrists are not easy to assess
•Respiration rates are extremely important to children – less oxygen supplies and small resp structures.
•The BP cuff must be the appropriate size – 2/3 of the axilla to the antecubital space. Legs can also be used.
OCH Pediatric Vital Signs Protocol:
 Any vital sign which deviates from the established norms for that patient will be brought to the attention of
the RN who will notify the appropriate physician.
 The physician is to be notified for all vital signs falling outside the physician’s written parameters or
Temperatures ≤ 36°C or ≥ 38° C
HR, RR, or BP < or > 20% difference than expected normal
PEDIATRIC ADVANCED WARNING SCORE (PAWS)
Evidence-based practice has been introduced to alert nursing and medical staff to the declining
status of a pediatric client. The physiology-based scoring system can help identify children
requiring urgent assessment. Introduced in Europe, the system is in use at John R. Oishei
Children’s Hospital in Buffalo. A total score of 3 or higher is a trigger to intervene.
PAWS
0
Playing/
appropriate
1
Sleeping
3
Behavior
Lethargic
Confused or
reduced response
to pain
Cardiovascular Pink or capillary
Pale or
Grey or capillary
Grey or mottled
refill 1-2 seconds capillary refill 3
refill 4 seconds
OR
seconds
OR
Capillary refill 5
Tachycardia of 20 seconds or above
above normal
OR
rate
Tachycardia or 30
above normal rate
or bradycardia
Respiratory
Within normal
>10 above
>20 above normal
5 below normal
parameters, no
normal
parameters,
parameters with
retractions
parameters
retractions
retractions
using accessory
OR
AND/OR
muscles
40+% FiO2 or 6+
50% FiO2 or 8+
OR
liters/min O2
liters/min O2
30+% FiO2 or
3+liters/min 02
Score 2 extra for ¼ hourly nebulizers or persistent vomiting following surgery
Unit IV - 23
2
Irritable
Total
Blood Pressure Monitoring in Children
a. Width of the cuff should cover 2/3 of the distance from the patient’s antecubital space to the axilla,
allowing one inch space in the antecubital area to place the stethoscope if necessary. The cuff must
also cover the circumference of the arm.
b. Either arm may be used unless contraindicated. Position the arm at the level of the heart.
c. Alternate sites include the calf, thigh, and forearm. When alternate sites are used, document the
site. The same principle of 2/3 – 3/4 of the surface must be covered by the cuff.
Age
Heart
Rate
Respiratory
Rate
Systolic
Blood
Pressure
Diastolic
Blood
Pressure
Temperature
Neonate(<28Days)
120-160
30-53
60-96
20-62
36.6-38.0
Infant(1mo-1yr)
120-160
30-53
72-104
37-56
36.6-38.0
Toddler(1-2yr)
98-140
22-37
86-106
42-63
36.6-38.0
Preschool(3-5yr)
90-140
20-28
89-112
46-72
36.6-38.0
School-age(6-11yr)
80-120
18-25
97-120
57-80
36.6-38.0
Adolescent(1215yr)
60-100
12-20
90-120
60-85
36.6-38.0
Unit IV - 24
(blank)
Unit IV - 25
Unit IV - 26