UNIT 1: HISTORICAL & SOCIETAL TRENDS
Health=state complete physical, mental, & social well-being & not just absence of disease-WHO
INTRODUCTION TO PEDIATRIC NURSING--APPROACHES TO HEALTH CARE
 Curative vs. preventable approach to child health (curative= fix when ill, now focus on illness & prevention.
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Health maintenance vs. health promo
FACTORS IMPACTING CHILD HEALTH
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Medical personnel - Training
 Epidemics – caused by lack of immunizations
 Asepsis = Infection ctl. Sanitation (milk not pasteurized) / 2 types (medical, surgical)
 Isolation – used curtain to separate pt, now use contact, universal, drop, isolation precaution, no aseptic tech
 Child dvlpmt –seen as small adult. lack knowledge (Erikson, Piaget, Freud) Came from dvlpmt theories
Assets had to work, long hours, & ↑ income, No ped nurse, considered young adult NOW: pediatricians, peds nurses, ICU
STATE/FEDERAL/LOCAL AGENCIES INFLUENCES ON PEDIATRIC HEALTH
US children’s Bureau: addresses issues r/t maternal/child health- regulate child labor: # of hrs
Medicaid:↑access to health care
Title V, SS Act: Grants for maternal/child health svcs/special svcs=hematological, respir, orthopedic services
WIC:women infant children=↓ income < age 5 – supplement food, MD & nurse make refer, mostly social svs case mgrs
Head Start: Low income ages 3-6 >>meds, health, nutrition, daycare
Department of Children & Families (DCF): Addres issues r/t children=adoption, abuse, neglect, health, ed
Family & Medical Leave Act (FMLA):’93=12 wks off w/o pay care ill family mbr
Diagnostic Related Grp (DRG’S): Dis grpd together for cost contain. Complication = DRG #=home health Medicaid
OTHER INFLUENCES ON CHILD HEALTH
Bright Futures: Maternal/child health services=insurance, scholarships
Lillian Wald: Founder of community health nursing=NY=1st community health nurse
Lina Rogers: 1st school nurse
Abraham Jacobi: Father of peds=1st studied peds as a specialty – saw children as children, not just sm adults
CURRENT TRENDS
 ↑ home health care, – do hyperalimentation, antibiotic therapy,< expensive
 ↑ technology in health care
1 Meditech = computerized charting
2 E-Mar = electronic mar >> reduces med errors (broward calls it bar-coding)
 Changes: labs on computer vs. calling lab directly
 Palm Pilots for nutrition fulfillment
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FUTURE TRENDS: HEALTHY PEOPLE 2010
 Goals initiated by US Dept. of Health & Human Services towards improvement in child health & entire
nation. Goals are to increase quality & length of healthy life. Eliminate health disparities.
 Leading health indictors: physical activity, overwt & obesity, tobacco use, substance abuse, responsible
sexual behavior, mental health, injury & violence, environ quality, immunization & access to health care.
(dental care, nutrition, immunization, type 2 diabetes, childhood injuries,
 Target=mortality, safety, hlth disparity, immunization, nutrition access to care, ↑ health promo
 Carried out to 2010, working on 2020
 Mortality rate: 7/100,000 (reached)
 Immunization rate : school =catch-up
 Safety –amber alert, car seats, helmets, wash toys, identikit, DNA ID, cord blood bank, baby lojac
 Nutrition – fast food=salad, school=better vending machine choices, better cafeteria food, try prevent obesity
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MORBIDITY RATE (ILLNESS)
 Specific illness rate per 1000 individuals (which illness is more prevalent than others)
MAJOR CAUSES OF MORBIDITY
 Based on age grp=younger more susceptible to certain conditions
 1 to14
1 Respiratory (seasonal-↑during fall, winter, spring) –germ contact w/ other kids
2 GI disorders, diarrhea, parasites
3 Injuries-seen in summer months
 15 to 18 - pregnancy/childbirth (#1 reason), mental (many on antidepressants) & chronic conditions
GRPS W/ INCREASED MORBIDITY
 Homeless
 Underprivileged
 Low birth weight
 chronically ill
 foreign-born adopted children
 children in daycare
NEW MORBIDITY
 Behavioral/social/educational problems
 High risk grps: underprivileged, single parent families, chronic illnesses,
Absenteeism from school, < age 14
MORTALITY RATE (DEATH)
 # of deaths per 100,000 live births
 Infant mortality infancy (birth to 1)
 Neonatal mortality birth to 28 days (sometimes 1 month)
 Postnatal mortality 1 month (29 days) to 12 months
 Childhood mortality 1 yr to 18 yrs
 Ages 5 – 14 → lowest mortality rate highest = under age 5
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MAJOR CAUSES OF AGE-RELATED DEATHS
 INFANTS (sensorimotor—explores environ thru taste & touch)
o Congenital disorders (#1 = 20%)
o SIDS (#3=8.1%)
o Low birth weight
o Injuries (#7=3.5%)
 INFANT MORTALITY RISK FACTORS
o African American race
o males
o short or long gestation
o maternal age (younger or older)
o Maternal education (nutrition, prenatal care)
 CHILDHOOD MORTALITY
o Object permanence (search for attractive object), cause & effect (unaware consequential dangers),
may fail to learn from experiences, magical & egocentric thinking (can’t comprehend danger)
o Lowest mortality rate= ages 5-14
o Infants=highest
 LEADING CAUSES CHILDHOOD MORTALITY
o Major Cause: unintentional injuries Transit cognit process can’t understand causal relationships
o Adolescent – form operation, preoccupied w/abstract think, lose sight reality.
o Motor vehicles – leading cause in > 1 yoa due to unrestrained
o Unattended drowning
o Injuries/burns (1 – 14 yoa)
o Firearms (5-14 yoa)
AGES 1 – 9
o Unintentional injuries (accidents) (#1)
o Congenital disorders #2 (1-4) #3 (5-9)
o Cancers #3 (1-4) #2 (5-14)
o Not usually suicide – they aren’t smart enough to develop a plan
 AGES 10 – 14
o Unintentional injuries (#1)
o Cancer
o Suicide
o Homicide
o Congenital anomalies
 AGES 15 – 18
o Unintentional Injuries (#1=32.8%)
o Homicides (#2=9.4%)
o Suicide (#3=7.9%) have to have a plan. Ask what plan is? If plan present, Baker act pt
o Cancer
o Heart disease
o Motor vehicle, firearms
BENEFITS (OF KNOWN FACTORS) OF TRACKING MORTALITY/MORBIDITY
 Increased Awareness of high risk grps
 Assist in directing focus on prevention & txt measures
 Provides a guide for health care planning.
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INTERVENTIONS FOR ↓ MORTALITY/MORBIDITY
 PRIMARY INTERVENTION – Screening ex. immunization, nutrition, well child clinics, safety programs
(bike helmets, seat belts, car seats, child proof containers) sanitation measures (chlorine in water, garbage
removal), parenting classes.--Early recognition, health promo & prevention
 SECONDARY INTERVENTION – condition present; just tx. TB & lead screening, mental health
counseling for divorce, community natural disasters.--early dx. Early txt.
 TERTIARY INTERVENTION – defects w/o repair; wheelchair, walker. Crutches, optimizing fxn for
children w/chronic disease.--Rehab & dis maintenance (asthma, sickle cell, cancer, anorexia)
ROLES OF THE NURSE IN PEDIATRICS
 Advocacy/Caring – empathetic relation, aware of family need/resource, Ex Tell parent how child’s nite went.
Encouraging informed choices. Therapeutic relationship=well defined boundries
 Dis Prevent/Health Promo- health ed, preventive care based on Growth & Devlpmnt
 Health Teach, Support/Counsel-restorative care (ADL’s) (“Can I bring supplies so you can bathe child?”),
assist to adapt (explain why they are there), prep proced. (ANTICIPATORY GUIDANCE - orient info on
procedure, cartoon on TV, age approp toys), ex. Watch what they are eating & that they are indeed eating.
NURSING: DO FOR PT WHAT CAN’T DO FOR SELVES – encourage them to do what they can for selves
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PEDIATRIC NURSING SPECIALTIES
 Pediatric Nurse take care kid/flr, home, spe, clinic, hospital/LPN, RN, Charge. in hospital, Dr office, clinic
 Ped Nurse Specialist employed by teach facilities, – orient new nurse; resource for flr nurse; does in-svcs;
change agent (ex. paper to electronic charting), educator, resource person for flr nurses. Masters degree
 Advanced Registered Nurse Practitioner primary care; physical assess; Rx med, referral, Dx (Master’s)
 Public Health Nurse health promo; well baby ck; immunization – clinic setting, prime focus well-child care
 Home Health Nurse works in home
 Case Manager coord care; LPN’s=insur comp (review cht); RN in hospital; Quality care=most cost effect;
implmnt critical path (path to follow from admin to dscg), dscg plan, make sure pt received charted services
FAMILY-CENTERED CARE – All Ages
 Emotional, social, dvlpmtal needs of child & family
 Family as constant in a child’s life
 Family as active participants in child’s care
 System must support, respect, encourage, & enhance the family’s strength & competence.
 Empower family members, give them appropriate info to help them w/ decision making
 Discipline=consistent, timing, commitment, unity, flexible, planned, behav orient, private, terminate (clean
slate after punish)—behav mod. Time out vs. corp punish.
TYPES FAMILY STRUCTURES--FAMILY=biology, psychology, economics
 Nuclear – 2 parents & kids
Communal – diverse belief, comun, cult, grp
 Extended – gr&parents, aunt, uncle
Binuclear – joint custody
 Reconstituted – step parent
Polygamous – multi spouse, africa & utah
 Single Parent - dad or mom
Homosexual – surrogate or adoption
 Family System Theory – Family is whole or system; 1 pt fail whole system affected=characterized by pds
rapid growth & change & pds stability. Too little/too much change=dysfxn. Can initiate change or rxt to it.
 Dvlpmntl theory=fam dvlp & change over time. Perform time specific task, disequilibrium= enter new life
cycle=dynamic not static vue of fam, anticipate poten stress. Use w/ anticipatory guidance to strengthen fam
 Marriage & joining of family, infant, preschool, schoolchildren, teens, launching ctr, middle aged, age
 Family stress theory=how family rxts to stress & how resilient they are
DIVORCE:
 Infancy-↓ or lack of mothering, increased irritability, disturbed sleep, eating, elimination
 Early preschool (2-3 yoa): scared/confuse, blame self for divorce, fear ab&on, irritable, tantrum, regres behav
 Later preschool (3-5); fear ab&on, blame self for divorce, confused, aggressive
 Early school age (5-6): depres, loss appetite, sleep, increased anxiety, feel ab&on
 Middle school 6-8: panic, profound sad, depress, fear future, anger @ parent, decline in school, bossy, irritable,
manipulative, cry, loss appetite, sleep
 Later school 9-12: understanding divorce, intense anger, divide loyal, ashame parents, desire for revenge, altered
peer relationship, decline in school, lying, temper tantrum
 Adolescents 12-18: Disengage profound sense loss, worry about selves/siblings, angers ad, w/drawn, & act out.
UNITED NATIONS DECLARATION OF THE RIGHTS OF THE CHILD
 To be free from discrimination
 To develop physically & mentally in freedom & dignity
 To have a name & nationality
 To have adequate nutrition, housing, recreation, & medical services
 To receive special txt if handicapped
 To have love, understanding, & material security
 To receive an education & develop his/her abilities
 To be the 1st to receive protection in disaster
 To be protected from neglect, cruelty, & exploitation
 To be brought up in a spirit of friendship among people
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CULTURE=Lifestyle acquired as a result of physical/social environ=pattern learn belief, value & practice that are share
w/in Grp including practices, customs, views on roles & relationships including parenting & communications & language.
 Symbols, Heroes, Rituals, Values, Practices.
 Race=division of humans possessing traits that are sufficient to characterize it as distinct human type
 Ethnicity=share unique cultural social & linguistic, food pref, moral code & express emotion or heritage
 Socialization=process by which society impart values & expectations to children.
 Primary grp=intimate, continued face to face contact w/mutual support of members. Ex. Family & peer grp.
 Secondary grp=off litter in ways of support ex. Prof assoc, church grp.
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IMPACT OF CULTURE
o Custom & Folkways=sim food, eye contact, not shaking hand
o Health Belief – no blood for some, health-seeking behaviors, when do they go to MD, cu&ero, etc?
o Heredity–culture rel sickle-cell=blck & Hispanic; HTN=blck; Diabete=nat Am, Tay-Sachs= Ash Jew
o Socioeconomics – Know funds available for meds, etc.
o Religion – rosary @ bedside for catholic; prayer grp @ bed, illness related to wrongdoing, God’s will
o Ex. Hands on head makes child stupid
CULTURALLY SENSITIVE CARE - aware & respect for cultural divers, incorp into plan of care. Know
they don’t eat pork, don’t put in diet. Make sure MD aware of diet pref. Same-gender care. Time for prayer.
(Awareness, Skill, Knowledge, Encounters, Desire)
CULTURAL SHOCK - expose to diverse culture, affluent→poor, feeling or state of discomfort or
disorientation by outsider attempting to comprehend or effectively adapt to a different cultural grp.
CULTURAL RELATIVITY - specific to cultures, Jehovah’s Witnesses don’t take blood or blood products.
OR- understanding of behaviors in someone else’s cultural context & that person eventually sees other ways
of doing things as different but valid. OR concept any behavior judge 1st in context of culture in which occur
ETHNOCENTRISM - belief ones’ ethnic grp superior
INFLUENCES ON GROWTH & DVLPMT
 Genetics=Chromosomal disorder=down syndrome, retardation growth/fxng
 Prenatal health status mom –drug, alcohol (Fet alc synd), affect attention span, dvlpmntly challenge
o Health status - diet, exposure
 Cultural influence - food, practice, could be thin/fat base on diet – may not reach ht/wt norm –
 Sex of child – girls mature faster than boys
 School/community – helps kids to learn & to grow
 Kids need to be nurtured physically & emotionally; no nurture = fail to thrive
COMPONENTS OF THE NURSING PROCESS=(Health promo, nutrition, elimin, activity/rest, perception/cognition,
self perception, role relationships, sexuality, coping/stress toler, life principles, safety/protection, comfort, growth/dvlpmt)
 Assessment – gather info, assess for S&S, observe for subjective & objective data
 Diagnosis – statements – Problem identification
 Planning – goals/interventions
 Implementation - action
 Evaluation – check is goal is met--Documentation
 Critical Thinking=Nursing process =GOAL DIRECTED THINKING
1 Be aware, appearance vs reality, disinfo. what you should think about next time you encounter info
2 Truth, lies agenda, bias?
3 Use past hx on particular incidence looking for the best outcome
EVIDENCE-BASED NURSING PRACTICE
 Ask the question
 Search for evidence
 Critically analyze the evidence
 Apply the evidence to practice: nursing implications
 Incorp knowl, clinic experience & intuition to influence decision making & support best practice (eval effective)
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HEALTH PROMO IN THE COMMUNITY
 COMMUNITY - residents of specific geographical location
 EPIDEMIOLOGY- study of causes of morbidity & mortality
 EPIDEMIOLOGICAL PROCESS–ID distribut & determinants of dis/injuries & prevent meas = Infect Ctl
o Exam of causes of illness & injuries (agent, environ, host)
o Prevent of morbidity & mortality
 COMMUNITY NURSING PROCESS , like the nursing process in general
Assessment (analytic) & Diagnosis – resource of community, environ, park (kids MUST play),
street light, how kids get to school, church in area – what they have & what they need. Collect subjec
& object info bout target pop. Dx=after info collect, problem can be dx base on community need
o Planning (policy dvlpmnt/program planning) dvlpmnt of community centered goals. – how to take
care of deficits, working w/ city offices
o Implementation-nurse implement program to allow community to reach goals.
o Evaluation-goal met?–Reassess–how many kids using new park? Too danger
ROLE OF NURSE COMMUNITY SETTING
o Knowledge of family/community resources
o Collaborates w/ community services – how being used
o Health supervision – smoke? Bad habit? Eat well/24-hr recall – Open-ended questions...
1 History of conditions
2 Assist w/clean home – make surrounding acceptable ex. Work w/school & city officials.
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LEGAL ISSUES IN PEDIATRIC NURSING
 Autonomy=pt rt self govern, nonmaleficience=prevent harm, beneficence= promo well being. Justice= fair
 CHILDREN’S BILL OF RIGHTS-copy to parent on every admin=right to care that is individualized, etc
o Rights of child & family identified -Hospital makes pt aware of rights-Ex. Txt pt w/respect
o Book bill of rights: respect & personal dignity, care that supports you & your family, info you can
understand, quality health care, emotional support, care that respects your need to grow play & learn,
make choices & decisions.
 INFORMED CONSENT
 Legal & ethical requirement
 Age of majority (18) & competent
 Procedure, risks, alternate txt, benefits, & risks must be identified
 adequate inform –sign & witnes (RN); school-age & adolescents informed as well as parent
 Make sure pt understand what MD said, get form from chart, ID pt & have them sign when
you are sure they understand what they are consenting to
o SITUATIONS REQUIRING INFORMED CONSENT
 Invasive procedures
 Taking photos (photo on admission for ID)
 Post mortem exam (silence doesn’t equal consent)
 Examination of medical records
 Participation in research
 Removal of child against medical advice
o ELIGIBILITY
 Parents/guardian may give consent. If married, only 1, if divorced both.
 Telephone consents=2 licensed persons–listen concurrently (on phone @ same time), not
consecutively (handing phone over for repeat of info)
o MATURE MINOR DOCTRINE
 Minors consent for STDs, drug, ETOH txt
o JOINT CUSTODY – parent who is the primary residence for child gives consent
o EMANCIPATED MINOR
 < age 18 & self-supporting: high school graduate, pregnant, married, residing in military
o ASSENT
 Child or adolescent has been informed about what will happen during the txt or procedure &
is willing to permit a health care provider to perform it. Need to allow pt to achieve a
dvlpmtaly approp awareness of nature of his or her condition. Tell pt what he/she can expect,
make clinical assessment of pt understanding solicit an expression of pt willingness to accept
proposed procedure of care.
 Not a legal requirement but an ethical one to protect the rights of children.
 Verbal agreement, ethical, but not legal–often held up in court
CHILD’S CONCEPT OF DEATH
 Infants & Toddlers< age 2 – no knowledge of death.
 Loss can be profound if attachment occurs w/ infant. Prolonged separation during 1st several yrs can
disrupt future physical, social & emotional growth.
 Toddlers are egocentric & can only think about here & now.
 May continue to act as though person is still alive.
 Ritualism is important w/ a change, can cause anxiety
 React more to pain of illness than death
 Preschool 3 to 5–death as temp, reversible, believe thought cause death ex. Pet die think sleep & will wake
 Believe thoughts are sufficient to cause death consequence=burden of guild, shame & punishment
 Egocentricity implies sense of self power & omnipotence
 Usually has some understanding of meaning of death.
 Think o illness as punishment for their thought or actions
 May feel guilty & responsible for death of sibling
 Engage in activities that seem strange or abnormal to adults
 May regress to earlier dvlpmntl skills
 School Age 6 to 9 – personifies death w/ devil/ghost
 Still assoc misdeeds or bad thought w/cause death & feel intense guilt & responsible for event
 Respond well to logical explanations
 Deeper understanding of death in a concrete sense
 Fear mutilation & punishment associate w/death
 By 9/10 hae adult concept of death that it is inevitable, universal & irreversible
 May fear process of dying & death
 Fear of unknown is > fear of known.
 Exhibit fear thru verbal uncooperativeness rather than actual physical aggression
 Adolescents 10 to 12 – views death as inevitable, irreversible, universal
 Mature understanding of death, still influenced by guilt or shame.
 Most difficulty in coping w/death
 Least likely to accept cessation of life
 Concern is for the present more than past or future
 May criticize funeral rites as barbaric
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UNIT 2: GROWTH & DVLPMT
GROWTH → ↑ size (increase in cells as well as physical attributes)
 Continuous process
 Sequence predictable - growth of head before torso
 Rate unpredictable-based on heredity (some kids bigger, some smlr) & environ factor (nutrition/chemicals)
DVLPMT→ ↑ capability/fxn skill dvlpmt
 Rate variable - based on growth, maturity(how fast), & learning (ability to learn)
DIRECTIONAL TRENDS OF GROWTH
 CEPHALOCAUDAL
o Head to toe: dev. of head before body
 PROXIMODISTAL
o Ctr to periphery: acquires palmar grasp-whole hand (growth motor skill) before pincer (fine motor).
o Whole hand before fingers
 DIRECTIONAL/DIFFERENTIATION
o Simple to Complex
o Gross motor skills accomplished before fine motor (ex. HAND)
DVLPMTAL THEORIES
 ERIKSON Psychosocial dvlpmnt. Emphasizes a healthy personality as opposed to a pathologic approach.
Each stage has 2 components, favorable & unfavorable.
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FREUD Psychosexual dvlpmnt. Psychic energy divided into id (unconscious), ego (conscious-reality),
superego (the conscience-moral arbitrator)
PIAGET cognitive dvlpmnt=age related changes. Intelligence enables individuals to make adaptations to
environ that increase probability of survival & thru their behavior individuals establish & maintain
equilibrium w/environ.
KHOLBERG Moral dvlpmnt based on cognitive dvlpmnt.
TYPES OF PLAY – Children have the need to play THIS IS THE BUSINESS OF CHILDHOOD
 ONLOOKER PLAY-unoccupied behavior, play is absent, daydreaming
o Observes others playing – Far off
o No interaction
 SOLITARY PLAY-grp of kids in circle all playing w/diff types of toys
o Plays alone in same location as others
o Activities differ, no interest in others
o Typical of toddlers.
o Ex. playing w/ different toys
o Key Word: Activities Differ
 PARALLEL PLAY-activities similar in same location but not playing together
o Plays alone in same location as others
o Activities similar, typical of toddlers
o Ex. riding a big wheel
o Characteristic of Toddlers = everything is mine
o Key Word: Activities Similar
 ASSOCIATIVE PLAY-socializing, ok to touch other’s toys, but no grp goal
o Social interaction occurs, no mutual goal, sharing
o Typical of preschoolers
o Ex. playing together w/ a doll; 1 put on shoes, 1 put on dress
 COOPERATIVE PLAY-able to follow rules, working together
o Organized, leaders & followers
o Can follow rules
o Goal oriented, typical of school age
o Ex. Little league, or football
 BENEFITS OF PLAY
o Promotes Growth & dvlpmt
o Enhances Emotional & social dvlpmt
o Releases tension & anxiety may see child hitting toy on table to relieve stress
o Teaches culture & adult occupation (mom, dad, teacher, may carry a handbag etc)
TOY SELECTION
 Based on safety, child dvlpmt, interest, personality, & ability--No sharp/pointed/small objects-goes in mouth
 The smaller the child the larger the toy=rule of thumb
 Directions for operation; give instruction to the child
 AGE APPROPRIATE TOYS THINK: is this dvlpmtally appropriate for a child.
 Infant – rattle, mirror, black & white, colorful
 Toddlers – blocks, phones, push/pull toys,
 Preschool – phones, manipulateable toys
 School – books, assembly toys, games, things that can be done w/others
 Adolescents – games: computer, board & video
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INFANCY - BIRTH - 1 YEAR – BASIC NEEDS: COMFORT, FOOD, LOVE
 Primary caretaker: whoever takes care of primary needs.
 DEVEOPMENTAL THEORIES
o Erikson - Trust (met) vs. mistrust (not met)
Trust in self & environ. Consistent caring by nurturing person. Tasks need to be met (comfort,
food, love) by primary care taker. Needs met consistently=trust, not=mistrust. Result is faith
& optimism
o Freud - Oral stage
 Sucking, biting, chewing, vocalizing--Mouth is seen as sense of pleasure
o Piaget: Sensorimotor phase
 Reflex, repetitive acts
 2 main concerns: separation & object permanence (objects exist even though it is no longer
visible), begin to use language & representational thought) (OCCURS @ 9-10 MOS)
 Separation anxiety – parent leaves = anxious; after 6 months, avg. 6-18mos.
 Object permanence – knowing something exists out of sight
WEIGHT @ BIRTH – KNOW HEIGHT & WEIGHT FOR AGE GRPS
o 6 – 9 ½ lbs.
o Average male – 7 ½ lbs.
o Average female – 7 lbs.
o Loses 5–10% weight during 1st week (cause is ↓ intake & loss of meconium); regains by 1 oz/day or
1 ½ lbs/month.
o ****Birth weight doubles by 5-6 months. & triples by 1 year****by 2 ½ it’s 4 x’s
o Avg wt 6 mo child is 16 lbs.
LENGTH @ BIRTH
o 19 – 21 inches
o Average male – 20 inches
o Average female - 19 inches
o ↑by ½ -1 inch/month 1st 6 months; 3/8 - ½ inch/month following 6 months.
o ↑by approx. 1 ft. 1st. year
o Growth mainly in trunk
VITAL SIGNS
o Temperature: Ax.: 97.9 – 99.7
 1st temperature is taken rectally (core)
 Checks if rectum perf, patent Thermometer won’t go in=Imperforated rectum = no hole
 Rest of temps taken in axillary until age 3 Axillary + 1 = oral; Oral + 1 = core
 Rectal=core=higher temp 99.9-101.7
 Oral= 1 degree ↓than rectal 96.8-98.6
 Axillary=2 degree ↓than rectal 97.9 – 99.7
 If fluctuates check every hour, High temperature = seizures
 Birth-2 yoa axillary & rectal
 2-5 yoa axillary, tympanic, oral, rectal---->5 yoa oral, axillary, tympanic.
 Temperature depends on day, age & physical activity. Hi temp is as follows
 Infants ≤3 mos:≥100.4
 Infants 3-36 mos ≥102
 Children of an age >104
o Pulse: Apical: x 1 min.: 120 – 160 (140 in book), ↑ 180 w/ activity (under 1)
 Pulse taken radially in children > 2 yoa, infants & young child listen thru stethoscope apical.
 Calm + 80 = report
 >160 = no feeding (indicates respiratory distress)
 Taken for 1 minute b/c rate is usually irregular
 Left side of 4th intercostal space @ midclavicular line up to age 7 (usually just below nipple)
o Respirations: x 1 min. : 30 – 40
 May increase w/ activity
 Resp > 60 = no feeding (indicates respiratory distress) raise head of bed, check pulse ox 1st.
 Don’t record the values of a crying infant
 Observe abdominal movements in infants since they are primarily diaphragmatic breathers.
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Note: respirations. & pulse rates may ↑ w/ activity or crying also respirations in older
infants ↓
NOTE: BP there are variations between girls & boys: means:
 Newborn 65/41-------1mo-2yrs 95/58-------2-5 yrs 101/57
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HEAD CIRCUMFERENCE (FOC) – Frontal Occipital Circumference
o 33 – 35.5 cm
o ↑ 1.5 cm 1st 6 mos., then slowly ↑, then ↓ @ 1-2 years
o Use most prominent area head. Pt lying down (use paper tape but watch out for giving paper cuts.
o Rapid 1st 6 mos increases ½ inch per month.
o Average size @ 6 mos is43 cm or 17 inches & 46 cm (18 inches) @ 1 year
 FONTANELS – an area of unoccifed membrane “soft spots”
o Posterior: closes 6 – 8 wks. (triangle shape)-----Anterior: closes 12 – 18 mos. (diamond shape)
o Flat except when crying, coughing, or supine (slight bulging)
 Flat & pulsating normally May bulge when crying or coughing, may be sunken when supine.
 Hydrocephalis is indicated by bulging fontanel
 Suture line may be open slightly
 NUTRITION
o Breast Feeding
 Encourage 15 - 20 min./each breast per feeding
o Bottle Feeding
 Nipple filled w/ formula, causes less air to be taken in
o Choice of formula depends on physician & mother
 Winter = soy b/c of respiratory conditions & formula = ↓ secretions (prevent spit-up)
 Summer = regular formula
o Burp after each oz.
 Preemies: burp after each ½ ounce
o Upright position on right side & leave undisturbed x 20 min. after feeding
 Don’t change them right away unless BM – then raise head
 Prevents spit-up
Weaning – Introduction of solid foods
o Begins @ 5-6 months (average 5 months)
o Sequence: cereal (rice <least allergies>, oatmeal)→fruits→vegetables→meat→ fish/poultry
o Format recommended but doctor may change
 Ex. Veges then fruit otherwise child may not want veggies b/c of sweetness of fruits
 Age 1 eggs/cheese are added
 4 mos to add diluted fruit juices, apple juice
General Principles of Weaning
o Give new foods @ beginning of meal
o Give one food @ a time one week apart (why: for allergies)
o Mix foods w/ formula or juice & feed from spoon (not in bottle)
 SAFETY
o Crib rails up (1 rail up for care; 2 rails up when leaving bedside) & canopy down when unattended
o Support back & head when holding 4-6 mos
o No pillows in cribs < age 1 (if parents bring, we have to remove it)
o Use mummy wrap to maintain warmth < 3 months
o Newborn precautions < 3 months = wear a gown
o Discard nipples & bottles after each use – Disposable-If bottle beyond 2 hours, get new bottle
o Appropriate use of car seats – rear facing in back seat in the middle (for side impact crash)
1 20-40lbs = front facing convertible
2 40-60lbs = booster
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11
THE TODDLER - AGES 1 TO 3
 DVLPMTAL
o Age of discovery: language, locomotion (skills dvlpd), move poisons out of reach
o Limit setting & guidance important, need to tell them no
o Toddlers are talking, walking, moving around the house
 DVLPMTAL THEORIES
o Erikson: Autonomy vs. shame & doubt ,
 Able to ctl body, acquire motor skills of walking, climbing & manipulating.
 Favorable outcome=self ctl & willpower
 Gaining independence from parents; shame/doubt if failed
 Let them do these things - safely
o Freud: Anal stage: potty-training - major task,
 Sphincter ctl, able to w/hold or expel fecal material @ will.
o Piaget: Sensorimotor/preconceptual phase – cognition
 Behavior is repetitive & imitative
 Differentiate selves from environ, objects have object permanence.
o Kohlberg: Preconventional stage – right vs wrong
 Physical pleasurable consequences of their actions
 Children 1st determine goodness or badness of action in terms of consequences. Avoid
punishment & obey w/o question those who have power to determine & enforce rules. Later
determine right behavior =which satisfies own needs & sometimes needs of others.
 WEIGHT – 3-5lb/yr; approx. 10 lbs total @ 2 ½
o Gains 4 to 6 lbs. between 1 to 2
o Gains 3 to 5 lbs. between 2 to 3
o @ age 2 ½ weighs approx. 34 lbs. = 4 x birth weight.
o Growth more in trunk vs legs, squat, pot bellied
 HEIGHT – 2-5”/yr, total = 7”
o Gains 3 ½ to 5 inches between 1 – 2
o Gains 2 to 2 ½ inches between 2 to 3
 HEAD CIRCUMFERENCE
o Equals chest circumference between ages 1 to 2
o ↑ By 1 inch 2nd year.
 HEAD CTL
o Usually accomplished between 5-6 months; able to hold head erect
o Some head ctl @ 3 months
o Always support back & head
o Head Ctl while pulled into sitting position
 Complete head lag @ 1 month
 Partial head lag @ 2 months
 Almost no head lag @ 4 months
o Head Ctl while prone
 Infant momentarily lifts head @ 1 month
 Infant lifts head & chest 90 degrees & bears weight on forearms @ 4 months
 Infant lifts head, chest & upper abdomen & can bear weight on hands @ 6 months
o Parachute Reflex – feels like falling > puts out hands to protect head
 SITTING UP
o 1 month: back completely round & infant has no ability to sit upright
o 2 months: exhibits more ctl; back is still rounded, but infant can try to pull up w/ some head ctl
o 4 months: back is rounded only in the lumbar area, & infant is able to sit erect w/ good head ctl
o 7 months: Infant can sit alone, leaning on hands for support
o 8 months: Infant sits w/out support
o **Note: transferring objects occurs @ 7 months
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o 6 months = high chair or older
o 6-7 months = sit w/assistance
o 8 months = no support
MISC
o Crude pincer grasp (fine motor) = 8-10 months (thumb & index finger used on larger objects)
o Object permanence = 9 months will start searching for something lost behind something else
o Neat pincer grasp (thumb & index finger) = 10-11 months , for small objects
o Parachute reflex=hold prone & downward, hands will go down 1st to protect head, birth reflex
DENTITION
o Deciduous set by age 2 ½ = 20 teeth
o Care starts from eruption, erupts 6 mos, use soft cloth to clean teeth. As a toddler then start brushing.
o Dental hygiene w/ supervision (brushing = kids do front only)
o Dental visits = as soon as teeth start
o Fluoridation if H2O supply doesn’t contain fluoride/parents don’t use bottled H2O w/fluoride ->
supplement may be needed
o 1st tooth 6 mos=lower. 1 ea month after that, @ 1 yr should have teeth. Some will start to teeth later.
TOILET TRAINING – Major Task of Toddler
o Accomplished after walking (18 –24 mos.)
o Good sphincter ctl, need to recognize urge to hold on or let go.
o Bowel training accomplished before bladder training
 Easier = stronger urge, easier to regulate, every morning, after breakfast, put on potty.
o Nighttime ctl @ age 6 (not until 5, some have good ctl @ 3), can continue to wet bed until age 15
o Need appropriate equipment
 Free standing potty chair = feels safe, feet on flr
 Rear facing on big toilet = feeling safe
o Should not sit longer than 10-15min – will forget & start playing
o Provide positive reinforcement
TEMPER TANTRUMS – How they cope w/ an obstacle
o Starts @ 18 mos. They say “no” for everything
o May respond by screaming, kicking, crying, holding breath, falling backwards
o Allow to have tantrum (recommended)
o Attention seeking behavior – no spanking, no eye contact but stay close, don’t pay attention
o Decrease stimulation – take to another area
NEGATIVISM caregiver must respond back w/ “no” for everything
o Evident @ 18 months
o No response to every request
o Developing autonomy
o Offer choices & challenges
o Ex. I can stick my tongue out faster than you.
o Ex. Do you want to go outside now or in 5 minutes?
NUTRITION
o Period of physiologic anorexia - good appetite (period of growth) alternating w/ poor appetite (no
growth) dr says this is ok b/c it’s related to the amt of food actually need
o Finicky eaters: finger foods, plain foods, ex. mash potatoes w/out gravy
o Ritualistic: same seating for meals
o Imitative: Imitate likes/dislikes of family members
DVLPMT
o Gross/fine/personal/social Dvlpmt (see handout)
PLAY
o Parallel play predominates
DISCIPLINE
o Encourage family members to set realistic & concrete goals
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o Limits should be consistent, clear, positive, give a reason, “don’t climb or you will fall & hurt self”
o Punishment should be timeout
o Provide positive reinforcement, emphasize consequences
o Don’t offer food as reinforcement – can become overweight
SAFETY
o Protective gates,
o Child-proof medicine caps (not all drug companies use them)
o Car seats, forward facing up to 40 lbs, booster up to 60 lbs
 Convertible restraint=infant in rearward-facing position & for toddlers in forward facing
position. Must be @ least 20 lbs & 1 yr age to reverse position. must use five point harness,
 Booster seat not restraint system; depend on vehicle belt to hold child & booster seat in place.
 Shoulder lap safety belt
o Stove top covers – will turn stove on & check to see if hot.
o
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THE PRE-SCHOOLER –AGES 3 TO 5
o Influence – caretaker & extended family
 DVLPMT
o Age of CREATIVITY & CURIOSITY
o Speak >2100 words by age 5
 Understand the literal meaning of the word
 Understands time in relation to events (dinner vs. tomorrow)
 Thoughts are magical & powerful, if you think of something it can happen.
 DVLPMT THEORIES
o Freud: Phalic stage identification sexes; main focus elimin; sit vs stand; use simple explanations
 Oedipus & Electra complexes, penis envy & castration anxiety center
o Erikson: Initiative vs. guilt – energetic learners; sense of satisfaction; allow to utilize initiative
 Strong imagination. Explore physical world develop a conscience. Has an inner voice.
 If bad produce sense of guilt. Outcome is direction & purpose
o Piaget: Preoperational stage – preconceptional, intuitive thought, egocentric outlook, imaginative,
 everything is magic here
 Can’t reason beyond the observable. Lack ability to make deductions or generalizations.
o Kohlberg: Preconventional stage – actions good or bad; based on reward or punishment system
 Best form of punishment = time-out
 WEIGHT
o Annual gain 3 – 5 lbs.(4 ½ to 6 lbs)
o Avg wt is 32 lbs
 HEIGHT
o Annual gain 1.5 – 2.5 inches (2 ½ to 3 ½ inches)
o Growth occurs in legs vs. trunk (can balance on one leg) slender & graceful
 NUTRITION
o Similar to toddlers, physiological anorexia
o Imitative
o Age 5 more receptive new foods, size & portions served on sm plate & give choice like & dislike
 SLEEPING PROBLEMS
o Relates to daytime level of activity. Norm sleep 12 hr nite w/ daytime naps. have night terrors
1 More active = more problems sleeping
o Consistent bedtime rituals
o Transitional objects, night light
 PRESCHOOL/DAY CARE
o Most significant change for preschooler, more active can cause problems settling down @ nite.
Foundation for language & personality dvlpmt
Initially w/draws from environment
1st day parent should accompany child entire day
Preparation necessary
 Give history to school: food likes/dislikes, health history, sleep habits
 Tour school = school should reflect type of child (ex. Quiet/active)
 Tell child what will happen @ school
o Security objects encouraged (recommended), blankets, fav toy or stuffed animal
SIBLING RIVALRY = things in nose, pull hair, pinch
o New sibling regarded as replacement, separate rooms, become hostile to new baby
o Provide guidance
o Help prepare child for baby (involve in care = fold clothes, get diapers)
OEDIPAL COMPLEX
o Rivalry w/ same sex parent for attention of opposite sex parent
o Wish parent will die - if happens child feels guilt
IMAGINARY PLAYMATE
o Evident @ ages 2 ½ to 3
o Becomes friends in times of loneliness
o Carries blame for wrong-doing
o Helps differentiates between pretend & reality
o Can’t allow child to escape from punishment
SEX EDUCATION
o Questions everything – “why”
o Explore child’s thoughts
o Give simple answers, clear up misconceptions
HOSPITALIZATION
o Traumatic - regresses (wears diapers & uses bottles; after dscg will potty train again) & w/draws
(doesn’t want to talk), may not want to eat or drink.
SAFETY
o Provide guidance
o Ex. Assist w/ crossing streets, talk about strangers, touching of body areas
o Safety measures, protective gates or clamps on doors
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SCHOOL AGE – AGES 6 TO 12
 WEIGHT
o Gains 3 to 5 lbs per year 4 ½-6 lbs--------33 lbs
 HEIGHT
o Gains – 1 ½ to 2 ½ inches per year--------18 inches
 DVLPMTAL THEORIES
o Freud: Latency period (Long) – sexual latency;
 May have boyfriend/girlfriend
 More likely to have boys w/boys & girls w/girls
 Vigorous play
o Erikson: Industry vs. inferiority – skill dvlpmt; pursues tasks to completion\
 W/ others vs alone
 Likes to build things w/hands, want achievement
 Likes to be commended for finishing task & likes to be rewarded
 Outcome is competence
o Piaget: Concrete operations – respects views of other; understand relationships (teach tables, 1+1=2,
good w/numbers); make judgments; concept of conservation (water amount same despite change in
shape of container)
 Thoughts become increasingly logical & coherent.
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 Dvlp concept of permance=conservation. They realize that physicl factors vol, wt, # remain
same even tho outward looks change. (water in 2 diff size cups)
 Thinking has become socialized, consider points of view other than own
o Kohlberg: Conventional stage – Thoughts more logical, acceptable standards of behavior
 Obey the rules, doing one’s duty, showing respect for authority & maintain social order.
NUTRITION
o Diet influenced by mass media
o 5 major food grps--Provide health promo: healthy snacks, balanced diet.
o May start losing teeth
SOCIALIZATION
o School & family are socializing agents
o Child learns acceptable values, grp participation, respect for authority
 Principal, teacher, head of class, captain of team
PEER RELATIONSHIP
o Learns to respect opinions of others learn to respect authority (ex. Principle or peer of class)
o Danger = Gang
o Learns to deal w/ hostility
o May become sensitive to peer pressure-----Dress certain way, walk certain way
SAFETY
o Safety measures: protective helmet
o Parents need to Emphasize dangers of experimentation
o Children start as early as 1st grade
PLAY
o Typical play – team games, football COOPERATIVE PLAY--Games w/ rules & rituals
SEX EDUCATION
o Ideal age to begin teaching --Be honest, Ask what they already know--Clear up misconception
o 1st approach – ID what they know
DISCIPLINE
o Encourage family members to set consistent limits
o W/draw privileges
o Follow thru on threats = make threats real--ex. doesn’t say, “I will kill you.” Not real.
o Emphasize consequences, if you tell school age child they can’t go out to play, go to room, they may
be happy, can occupy time in room & have fun.
o Antisocial behavior may include lying, cheating, stealing
LATCHKEY CHILDREN
o Children @ home w/out supervision (part of day)
o Recommended: key pinned to pocket; if around neck, friends can take off & child loses key
o More common in single parenting
o Telephone check-in – ask child to call you--, have call from house phone to confirm location
o Contact person in neighborhood (watch grps)
o Advise child to not answer door @ all
o After school programs have been set up to prevent children home alone
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ADOLESCENCE – AGES 12 TO 18 BIGGEST INFLUENCE: TEACHERS & FAMILY
 WEIGHT
o Boys gain approximately up to 65 lbs. --------Girls gain approximately up to 55 lbs.
 HEIGHT 2nd period of accelerated growth
o Boys gain approximately 12 inches
 4.5 to 12 inches
o Girls gain approximately 8 inches (age 9 ½-14 1/2)
 2 to 8 inches
 GROWTH SPURT/Physiological Changes
Period of accelerated growth – 2nd major period
Peak ages – girls, age 10; boys, age 13
↑ body mass, ↑ activity of sebaceous gl&s
↑ muscle mass & adipose tissue
↑ metabolism/appetite, HR & respirations (reach adult levels), need for sleep (14 hours per day)
Physiologic growth (ht, wt inc, adipose tissue, perspire more= more acne, heart size & strength
changes, blood vol increases
o BP, HR & resp rate same as adult starting age 12)
o Primary sex characteristics=ext & int organs that carry out reproduction (ovary, uterus, breast, penis)
o 2ndary sex characters=change thru body result of hormones (voice , facial hair, pubic hair, fat deposit
PUBERTY – if later, considered delayed
o Dvlpmt of secondary sexual characteristics
o Sexual dvlpmt, voice change, menarche, ↑ hair
o Need to explain to a child this is going to happen as ANTICIPATORY GUIDANCE
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16
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TANNERS STAGES
 GIRLS
 Breast changes
 Rapid increase in height & weight
 Growth of pubic hair
 Appearance of axillary hair
 Menstruation (usually begins 2 years after 1st signs)
 Abrupt deceleration of linear growth
 BOYS
 Enlargement of testicles
 Growth of pubic hair, axillary hair, hair on upper lip, hair on face, & elsewhere on body (facial
hair usually appears about 2 years after appearance of pubic hair)
 Rapid increase in height
 Changes in the larynx & consequently the voice (usually take place along w/ growth of penis)
 Nocturnal emissions
 Abrupt deceleration of linear growth
DVLPMTAL THEORIES
o Freud: Genital stage – Sexual maturation
o Erikson: Identity vs. role confusion - independence from parents
 Rapid & marked physical changes.
 Overly preoccupied w/way appear in eyes of others as compared to own self concept
 Success =devotion/fidelity
o Piaget: Formal operations – thoughts logical, respects opinion of others
 Thought is adaptable & flexible.
 Think in abstract terms & abstract symbols.
o Kohlberg: Post-conventional/autonomous=reach cognitive stage form ops. Correct behav tend to be
defined in terms of gen individual rts & standards that have been examine & agree by entire society
NUTRITION
o ↑need for calories: up 2400/day – they eat more
o Influences - peers, culture, self-concept
o influenced by: time (work part time), convenience (where they hang out: McDonald’s, Burger King)
RELATIONSHIP W/ PARENTS
o Mutual affection & equality--Child doesn’t always agree that there is equality
o Struggling for independence
o Conflict in value system = parent vs child, child thinks parent is old fashioned
o Parent should promote independence & privacy--Ex. Don’t search room
PARENTAL GUIDANCE
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o Promote independence
o Provide privacy
o Clarify rules
o Emphasize consequences adolescents don’t think of consequences
o Expect turbulent
o Unpredictable behavior ex. Child cursed parent on plane
PEER RELATIONSHIP
o Peers provide support, sense of belonging, always on phone w/ peers,
o More heterosexual relationships
o ↑ego dvlpmt
IMPACT STRESS OF ILLNESS
 Interferes w/ struggle for independence
 Concerns w/ body image & sexuality, esp w/ loss of limb
 Anxiety: absence of peers & family
 Capitalize on gains from illness—2ndary gain--ex. normally bath self but asks someone else to do it
↓ STRESS OF ILLNESS
 Assess impact, choices – when they want self-care
 Promote Identity: decorate room, personal clothing
 Allow access to phone, peer visits--Ex. Sign – don’t enter before 11am sign – check pt once
 Teen room is always open
HEALTH PROMO
o Health teaching
o Encourage annual Physical exam--Ask 1st if this has been done
o Teach BSE (for both) & Testicular Self Exam (usually lumps malig in teens) tell them to “show me”
o Safety education - drivers’ education, injuries from accidents #1 cause of death in adolescents.
AGE GRP
INFANTS
Birth-6 mos
6-12 mos
TODDLERS
WEIGHT
Weekly gain (5-7 oz)
Birth wt doubles by end of 1st 4-7 mos
Wt gain 3-5 oz
Birth wt quadruples by age 2 ½
PRESCHOOLERS Yrly gain 4.5-6.5 lbs
SCHOOL AGE
Yearly gain 4.5-6.5 lbs
PUBERTAL
GROWTH SPURT Wt gain 15.5-55 lbs
Females 10-14
Mean 38.5 lbs
yr
Monthly gain ½”
Ht age 2 approx 50% adult by end 1st
yr
Gain in 2nd yr 4.7”
Gain 3rd yr 2.4-3.1”
Birth length doubles by age 4
Yearly gain 2-3”
Yearly gain after 7 is 2”
Birth length triples by age 13
Ht gain 2-10”, approx 95% mature ht
achieved by onset of menarche or
skeletal age of 13
Mean=8”
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Wt gain 15.5-66 lbs
Mean 52.2 lbs
Males 11-16 yrs
HEIGHT
Monthly gain 1”
Ht gain 4-12”, approx 95% of mature
ht achieved by skeletal age of 15
Mean=11”
PSYCHOSEXUA
L (FREUD)
PSYCHOSOCIAL
(ERIKSON)
Infancy
Birth to 1
yr
Oral
Derives pleasure
from mouth
Sucking/chewing/v
ocalizing
Trust vs mistrust
Establishes trust in
caregivers. Mistrust
dvlps if needs are
unmet
Toddlerhoo
d
1-3 years
Anal
Pleasure centers
in anal area
Ctls
urination/deficatio
n
Autonomy v shame
& doubt
Independence & ctl
over environ
Early
childhood
3-6 yrs
Phallic
Learns sexual ID
thru awareness of
area
Initiative vs. guilt
Initiates new
activities. Expjlores
the world. Repeated
criticisms result in
feelings of guild
Middle
childhood
6-12 years
Latency
Sexual dries
submerged, adopts
gender roles
Adolescenc
e
12-18 years
Genital
Develops sexual
maturity,
establishes
relationships
w/opposite sex
Industry vs
inferiority
Learns self worth,
masters psychosocial /
cognitive /
physiological skills.
Society/peer focus
Identity vs role
confusion seeks ID,
gains independence
from parents, mature
abstract thought
COGNITIVE
(PIAGET)
Abstract reasoning
Sensorimotor (b-2yrs)
Birth-1 mmo uses reflex
behaviors
1-4 mos=repetitive actions
due to pleasure of reflex
acts
4-8 mos=understands
cause/effect relationships
9-10 mos= object
permenance
Preoperational,
preconceptual phase
(transductive reasoning
(eg. Specific to specific 24yr)
↑language/comprehension,
egocentric thought
Preoperational thought,
intuitive phase 4-7 yr
Transductive reasoning,
magical thinking
MORAL
JUDGMENT
(KOHLBERG)
Concrete operations
(inductive reasoning &
beginning logic ) 7-11 yr
Aware of relationships,
classification,
conservation, reversibility,
less egocentric
Formal operations
(deductive & abstract
reasoning) 11-15 years)
Capable of systematic
abstract thought
Conventional, goodboy, nice-girl
orientation. Law &
order orientation
Respects & obeys
authority.
Preconventional,
punishment &
obedience orientation
Preconventional
(premoral) level.
Naïve instrumental
orientation (age 4-7)
Behavior based on fear
of punishment/rewards
Postconventional or
principled level, socialcontract orientation
Decisions based on
ethical standards.
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UNIT 3: PHYSICAL ASSESSMENT
 Process of Data Collection
 Includes Date = history & physical examination-analyze & utilize info to care for pt on individual basis
GENERAL APPROACHES
 Environment - private & quiet (TV off), close curtain-Why: No distraction, pt provides open info
 Systematic approach: head to toe
 Sequence alter base on age (ex. On mom’s lap = tk HR & Resp 1 st), dvlpmtal level, chief complaint (in
emergency = do focus assess)
 Cultural considerations (oriental person > need to ask permission to touch head)
 Painful/frightening procedures done last
 If in distress, need to do a quick assessment, must address/stabilize focus problem
COMMUNICATION STRATEGIES
 Introduce self – give name & student status
 Explain purpose of interview/exam, say you will “examining” head to toe, don’t say do “physical assessment”
 Provide privacy
 Ask one question @ a time
 Involve child when questioning--School-age/Preschool = where does it hurt?
 Use age-appropriate language--Don’t use abdomen; use belly or tummy
 Use of interpreters –number can call in hospital--Don’t use family members
1 Some culture don’t want you touch child head, says it disrupt intelligence, ask “is it ok to examine head”
 Use open ended questions, avoid questions that begin w/ Does, did or Is. Use instead What, How, Tell me.
Open ended =non-threatening.
 Redirect focus when parent gets off topic.
 Listen= most import component effective communication. Consciously ctl rxns, responses & techniques used.
 Silence permits interviewee to sort thru thoughts & feelings & search for responses to questions. Silence can
be a cue for interviewer to go more slowly, reexamine the approach & not push too hard.
 Be empathetic=capacity to understand what another person is experiencing from w/in that person’s frame of
reference, it is ability to put oneself in another’s shoes. It is an accurate understanding of another’s feelings.
 differs from sympathy=having feeling or emotions in common w/another person rather than understanding
those feelings. Sympathy= not therapeutic in helping relationship cause it lead to over involvement
emotionally & potentially to professional burnout.
CHARACTERISTICS OF COMMUNICATIVE DVLPMT IN YOUNG CHILDREN
 Perlocutionary Stage (0-9 mos)-child is reflexive to stimuli, child shows ↑ purpose in action
 Emerging Illocutionary Stage (8-9 to 12-15 mos) child communicates intentionally w/signals & gestures
 Conventional Illocutionary-Emerging Locutrionary Stage (12-15 to 18 -24 mos) child communicates
intentionally w/gestures, vocalizations & verbalizations.
 Infancy=nonverbal communication. A stranger is potential threat til proven otherwise. In gen, infant at ease
upright rather than horizontal. Hold infant so see parents. Smile & coo when content & cry when distress. Quiet
when cuddled. Cry is provoked by unpleasant stimuli from in or outside (hunger, pain, body restraint or loneli
 Early Childhood= < 5 egocentric. see only in r/t selves & from POV. Push unwanted object away, pull another
person to show them something, point & cover mouth that is say something don’t wish to hear. Focus about them,
let them touch equip & see how works. Interpret words literal. Keep unfamiliar equip out view until necessary.
 School Age= rely< on what see & >on what know when face w/new prob. Want explanation & reason. Want
know why object exists, works, & intent of user. Concern w/body integrity. R simple explanations.
 Adolescence= flux tween child & adult think & behavior. Quick to reject person who impose value on them, have
little respect or who they are & what they think or say. Accept of anyone who display genuine interest in them.
Interview w/parent present & again alone to get both sides of story. due to confidentiality, disclosures will not be
shared unless they indicate need for intervention=suicidal behavior. Build foundation & communicate effective.
AGE-RELATED APPROACHES
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COMMUNICATION TECHNIQUES
 Play- 1 of most import form of commun & can be effect tech in r/t children. Ex. Peek-a-boo= non-threatening &
safe for infant. Sessions are not assessment tools for determining children’s awareness & perception of their
illness but also as methods of intervention & evaluation.
CONSIDERATIONS
 Observe child’s reaction to questioning (frightened/nervous), hesitant
 Observe child’s interaction w/ parents (seeking attn or far away), seeking comfort?
 Be attentive to parents concerns (financial, siblings, seriousness of condition)
 Observe non-verbal’s (concealing info, no concern, overly concerned by parent)
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INFANT – Head to toe may NOT be possible
o Parental assistance; ask to hold child, don’t take child away from parent
o Don’t wake child to do stuff, do what you can & come back later, also do traumatic things later
1 ex. Eyes, ears, mouth (while crying)
o Calm approach - soft voice
o Provide distraction - rattle, pacifier, mirror (dvlpmtally appropriate)
TODDLER - Head to toe may NOT be possible
o Provide distraction - toys, books, cell phone
o Allow to manipulation equipment (pen light), stethoscope
o They may be afraid you will hurt them--They run away or hit you
o Parental assistance, standing or sitting on or by parent
o Age-appropriate communication, belly, tummy
o Use play to inspect (tickle toes, count fingers)
PRESCHOOLER
o Head to toe approach possible, sitting if possible
o Give explanation
o Solicit participation ex. Remove clothes
o Uniform = hurting them (shot)
o Positive reinforcement: praise, favorite TV show, bring a toy, offer juice/sticker
SCHOOLAGE – Definitely a head to toe can be done
o Question both child & parent
o Provide privacy, very modest, needs to be covered
o reinforcement, tell them they are doing well
ADOLESCENT
o Offer choice if wants parent present
o May need to ask parent to leave
 Teen may not tell truth in front of parent
 Reassure them that info is confidential except involving health, harm to self, harm to others Ex.
Suicide, pregnancy
o Drape appropriately during PE, privacy for undressing
o Health promo: annual PE, monthly BSE, TSE. = “Show me”
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TECHNIQUES OF PHYSICAL EXAM
 INSPECTION= senses (look, listen, touch) collect info – direct (eyes) vs. indirect (instrument – ophtscope).
 PALPATION: feel underlying organs, use of touch – light(pads ½ -3/4”)/deep(1 ½-3”)/bimanual(both hands,
1 over the other – result: ↑ pressure & ↑ depth OR child’s hand followed by your hand – result: avoids
tickling)
 PERCUSSION: tapping on body to evaluate underlying structures
1 Tympany = stomach
2 Dull = organs; liver
3 Resonance = lungs
4 Flat = bone
 AUSCULTATION: elicit sounds using stethoscope; bell (low – bruits low)to listen to “normal” or vescicular
breath sounds vs. diaphragm (high)- (bell, diaphragm, bladder, ear pieces)
 Abdominal Assessment = Inspection, Auscultation, palpation
DATA COLLECTION/COMPONENTS OF PHYSICAL ASSESSMENT
 HEALTH HISTORY
o Chief complaint (reason for admin, must have time frame connected ex abdom pain for 3 days)
1 chief complaint w/ no time = sign or symptom
o History (chronological) of present illness – how long it existed, have you had it before, what tx used,
aggravating (↑ severity)/relieving factors, meds taken, what happens after meds, particular position helps.
Hx includes details of onset, complete interval hx, present status & reason for seeking help now.
Past medical history & hospitalization, birth hx, mom’s health status while pregnant, was child
resuscitated @ birth, Apgar scores @ birth immunizations, menarche, dvlpmntl milestones, habits (thumb
sucking, sleep, bed wetting, anxieties, chemical exposure, smoking or drinking (adolescents)
o Current health status – allergies (food/drugs), nutrition (24 hr recall), meds, immunizations, other health
probs, sleep, wt., ht., ,
o Psychosocial data – temperament, tantrums, school, sleep, bedwetting, over 5
REVIEW OF SYSTEMS
o Review of each body system-ex. headaches for neuro assessment-ex. Ask cough for respir assessment
o
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GENERAL APPEARANCE (Overall Pix)-age, race, sex, nutrition, hygiene, phys dvlpmt (thin/obese), pain, activity,
restless, behav (interaction w/parents) (descript: 4 yr old white female, happy, calm, neat appear, no distress), overall
state health, fatigue, recent or unexplain wt loss/gain, exercise, fever, chill, freq infection, ability carry out ADL’s
BASICS - height/weight (≤ 3 = use balance scale, child is naked (Make sure to zero out scale, weigh arm-boards to
estimate extra wt on child); ≥ 3 use upright (standing) scale, head/heels @ edge, no shoes – clothes on)/FOC/chest
circum.(measure when relaxed @ nipple line ≤ 3 yoa)/ Abdominal Circum. (measure @ umbilicus)/VS. Head
circumference ≤ 3 yoa. Generally head & chest circumferences are equal at about 1-2 yoa. During childhood chest
circumference exceeds head size by about 2-2.75 inches. Count respiration 1st, take pulse then measure temp last.
BP: Can be taken on ↑ or ↓ extremities
Cuff size – make sure cuff is 80% of arm; 2/3 of arm
Too small cuff = false high BP
Too big cuff = false low BP
Sites
Upper arm = brachial artery
Forearm = radial artery
Upper leg = Popliteal artery
Lower led = dorsalis pedis & posterior tibial artery
**Lower BP is always higher b/c more force to get blood to legs (10-20mmHg higher)
Young children will mostly use leg for BP, hard to get reading on moving arm
GROWTH CHARTS
 CDC & American Academy of Pediatrics Statistics: birth – 36 mos., 2 – 20 (boys/girls)
 % physical growth plotted on chart--3rd – 97 percentile
 Measurements compared w/ general population, same age
 Term height (or stature) refers to the measurements taken when children are standing upright.
 Length= measurements taken when children are supine (also called recumbent length). Until children are
24 mos old (or 36 mos if using the chart for birth to 36 mos), measure recumbent length.
 Weight to the nearest 10 g for infants & 100 g for children. Must zero the scale before weighing.
 Chart to use depends on scale used to measure statistics--Take heredity into account when looking @ results
PHYSICAL EXAM (NORMAL/ABNORMAL FINDINGS)
Orient to time, place & person (Awake, Alert, & orient. Infant & toddler, can’t assess orientation will be AA only.
HEAD:suture, fontanel—use index & middle finger-palpate suture line & fontanel, FOC (1x/per shift up to 2)
hair texture (fontanels=soft, flat, pulsating)
1 Microcephaly = small head
2 hydrocephaly = big head
3 Both means continue to measure head over age 2
 EYES: color of sclera, conjunctiva, PERRLA vs PERRL (not under 3)
1 Icteric – jaundice
2 EOM = not always possible under the age of 3
3 Accommodation test is to have child look at bright shiny object at a distance & quickly move object
toward face. Pupils should constrict as object brought near eye.
 EARS: place (same plane of pinnas w/(outer canthus) corners eye-have up to 10% differenation), drainage
(pull down & back < 3) (up & back > 3yoa), discomfort, position child in side lying or have mom hug hold.
 MOUTH: tongue (coated?), mucous membranes, teeth, gag reflex (cough or ahhh), check strength of muscles
 NECK: extra fold, place trachea (should be straight, midline—determine by hold up index finger); deviation
= collapsed lung), thyroid = non-palpable, gag reflex—have cough, if can’t cough doesn’t have a gag reflex.
 SKIN: color/perfusion (warm, pink)/turgor/texture/presence of lesions.
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LUNGS: AP/lateral diameter (< 2 yoa = same; >2 yr= AP < diameter 1:2) (chest= circular in infancy w/AP =
transverse diameter. child grows, chest ↑ in transverse direction causing AP diameter to be < lateral diameter),
chest expansion, breath sounds (normal[vesicular]/abnormal[adventitious])
Vescicular breath sounds=heard over entire surface lungs w/exception of up intrascapular area & area beneath
manubrium. Inspiration louder, longer & higher pitched than expiration, sound is soft swishing noise
Bronchovesicular breath sounds=heard over manubrium & in upper intrascapular regions where trachea &
bronchi bifurcate. Inspiration is louder & higher pitched than in vesicular breathing
Bronchial breath sound=heard over trachea near suprasternal notch. Inspirtory =short & expir phase long
Examine:
1 2
4
3
5
6
8
7
9
10
 Adventitious Sounds
1. Crackles – air thru fluid (=sound of hair rub thru fingers)
1. Rales – fines
2. Rhonchi – coarse
3. Ask them to cough; If sound ↓ or disappears w/cough = rhonchi
2. Stridor = high pitch; Indicates obstruction
1. No throat exam
2. No tongue blade
3. Exam only if intubation tray @ bedside, i.e. no internal exam (mouth, nose)
3. Friction Rub – grating sound; low pitch
4. Wheezes – musical sounding; on inspiration & expiration; caused by air thru narrow passage
5. When bronchiole constricted, easy to get air in, hard to get out
HEART:PMI (< 7 @ 4th intercostal space, left Midclavicular line: LMCL; >7 @ 5 th intercostal space LMCL)
 Note: below clavicle is intercostals space 1, followed by 2, etc
 Aortic (right of the sternal border at the 2nd intercostal space)
 Pulmonic (left of the sternal border at the 2nd intercostal space)
 Erbs point (left of the sternal border at the 3rd intercostal space)
 Tricuspid (left of the sternal border at the 5th intercostal space)
 Mitral (left of the midclavicular line at the 5th intercostal space—third to fourth intercostal space
& lateral to left of the midclavicular line in infants)
 Lub (S1) closure of tricuspid & mitral valves. Louder at the apex of the heart
 Dub (S2) closure of the pulmonic & aortic valves. Louder near the base of the heart
 S3 heard in children
 S4 rarely heard as a normal heart sound
 Evaluate for quality (clear), intensity, rate, rhythm (regular & even)
 Heart murmurs=vibrations (innocent=no anatomic/physiologic abnormalities), fxnal=no
automatic cardiac defect by physiologic abnormality such as anemia is present, organic=cardiac
defect w/wo physiologic abnormality. (describe as location, time, intensity, loudness
ABDOMEN: size, contour, herniation, BS w/ herniation, protrusion will get bigger when crying
 Umbilical hernias=common in infants (african am esp). (at the umbilicus)
 Inguinal hernia=pertrusion of peritoneum thru abd wall in the inguinal canal. Common in males.
 Femoral hernia=more often in girls, occurs on anterior surface of the thigh just below the
inguinal ligament in femoral canal.
Look, auscultate, palp, chk femoral pulse along inguinal liga mid tween iliac crest & symphysis pubis
REPRODUCTIVE: decent of testes, hair growth, over 3 = no assessment
MUSCULOSKELTAL: hands abnormal palmar creases = simian lines (3 creases is normal, 2 crease=
transpalmar & can indicate down syndrome), extra digits (polydactly), webbing (syndactyl), contractures,
abnormal curvatures. Check ROM at all joints, view legs for knock knee or bowlegs.
NEUROLOGICAL: cranial nerves fxns; most we have already done by this point in the assess
 Gait & balance cerebellum ctls balance & coordination.
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Romberg’s sign: stand w/eyes closed & heels together, fall or lean to one side=abn &= + sign
Heel-to-shin test-stand-run heel 1foot down shin or ant aspect of tibia of other leg, w/eyes open & close
Finger-to-nose test w/arm extend, ask to touch nose w/index finger w/eyes open & then closed.
Can also test balance by balancing on one foot & do a heel-to toe walk. To test coordination, ask child to
reach for a toy, button closes, tie shoes or draw a straight line on a piece of paper.
CN I
Olfactory
Smell
CNII
Optic Nerve
sight
CN III
Oculomotor nerve
PERRLA
CN IV
Trochlear nerve
6 cardinal positions of gaze
CN V
Trigeminal Nerve
bite down, blink
CN VI
Abducens
look toward temporal side
CN VII
Facial
raise eyebrow, smile
CN VIII
Auditory, Acoustic or vestibulocochlear
whisper
CN IX
Glossopharyngeal Nerve
gag, swallow
CN X
Vagus
uvula rises-swallow, midline
CN XI
Accessory
shrug shoulder while hold down
CN XII
Hypoglossal
stick tongue out side to side
(On, Old Olympus, Towering Tops A Fin & German Viewed A Hop)
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DVLPMTAL MILESTONES: Age-appropriate gross/fine motor, language dev.
AGE
1 MONTH
GROSS MOTOR
Head lag when pull to sit
position
Turns head from side to
side when prone
FINE MOTOR
Grasp reflex strong
2-4 MONTHS
Hold rattle-doesn’t reach
for it @ 4 mos
Lifts head prone @ 4 mos
Some head lag
Palmer grasp @ 4 mos
No head lag @ 5 mos’
roll from abd to back by 5
mos & back to abd by 6
mos
Sit in high chair @ 6 mos
Part wt bear on ft @ 6
mos
Sits leaning forward on
both hands @ 7 mos
Bounce when stand 7 mos
Sits unsupported @ 8
mos
Crawl to creep @ 9 mos
Pulls self to standing
position @ 9 mos
Stands while holding on
to furniture @ 10 mos
Walks holding on to
furniture @ 11 mos
Gets to sitting from
Holds rattle
Grasps objects w/both
hands @ 4 mos
Brings objects to mouth
9-10 MONTHS
11-12 MONTHS
Squeals @ 5 mos
Discriminate stranger
from family @ 5 mos
Turns head to seek
dropped objects @ 6 mos
Transfer object tween
hands
Beginning crude pincer
grasp @ 8 mos
Says dada (no meaning)
Plays peek-a-boo
Crude pincer grasp
Hand dominance @ 9
mos
Understands “no” @ 9
mos
Says dada & mama
w/meaning @ 10 mos
23
7-8 MONTHS
Palmar grasp @ 5 mos
Holds bottle @ 6 mos
Neat pincer grasp @ 11
mos
Places objects into
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5-6 MONTHS
LANGUAGE/SOCIAL
Make throaty sound
Follow bright object to
midline
Prefers black/white
designs
Vocalizes @ 5-6 wks
Social smile @ 2
mos’coos & babbles @ 34 mos
Seeks hidden object
Says 3-5 words
Recognizes objects by
1-2 YEARS
3-4 YEARS
5-6 YEARS
name
Build tower 2 blocks 15
mos 3-4 @ 18 mos, 6-7
@ 2 yrs
Undresses self
Turns doorknob
Says ≥ 10 words @ 18
mso
Vocab, ≤300 words by 2
Temper tantrums @ 18
mos
Builds tower of 9-10
blocks by age 3
Draws circle @ age 3
Draws 3-part figure @
age 4
Ties shoelaces @ age 5
Does buttons uses
scissors
Draws 7-9 pt figure @
age 5
Names one color @ age 3
Vocab of 900 words by
age 3, 1500 by age 4
Dresses self
Vocab 2100 words
Uses ≥ 6 word sentences
DVLPMTAL ASSESSMENT TESTS
o Denver Dvlpmtal Test II=not intelligence test=method showing what child can do at particular age
 Ages birth - 6 years
 Needs to get 255th to 75th to pass
 Don’t have child fatigued when tested
 Requires chart – exp person needs to administer test
 Tasks grouped into 4 categories (social contact, fine motor skill, language, & gross motor)
Interpretation of scores:
 Advanced=passed an item completely to the right of he age line (passed by <25% of children)
 OK=passed, failed, or refused an item intersected b th age line tween 25-75 th percentile
 Caution=failed or refused items intersected by age line on or tween 75-90 th percentile
 Delay=failed an item completely to left of age line. Refusals to left of age line may also be
considered delays, since reason for refusal may be inability to perform task.
Interpretation of test
 Normal=no delays & a max of 1 caution
 Suspect=one orem ore delays or two or more cautions
 Untestable=refusal 1 or more items to left of age line or on more than 1 item intersected by age line in
75-95th percentile
Recommendations for referral for suspect & untestable results
 Rescreen in 1-2 wks to rule out temp factors
 Rescreen=suspect or untestable, use clinical judgment based on: # of caution & delay, which item are
caution & delay, rate past dvlpmnt, clinical exam & hx & availability of referral resources.
o
Draw a Person Test
 Assesses dvlpmt & intelligence--Ages 3-10--Done in schools--Ex. Age 2 = 3 part figure
McCarthy’s Scales Children’s Abilities: assess motor, verbal, cognition, memory, perception &
performance (2 ½ to 8 ½)
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containers @ 11 mos
PREPARATION FOR HOSPITALIZATION ANTICIPATORY PREPARATION=Rationale for prep
children for hospital experience & related procedures is based on principle that fear of unknown (fantasy)
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standing w/o assistance
@ 12 mos
Walk w/1 hand held 12
mos
Walks alone @ 13 mos
Throw ball ovrhand 18
mos
Walk up & down stair
(don’t alt footing) @ 2
years
Balances on one foot
Walk on tiptoes
Climbs stair alternate
footin
Rides tricycle
Skips/hops on alternate
feet
Uses jump rope
Rides bike
exceeds fear of the known. When children don’t have paralyzing fear to cope w/they are able to direct their
energies to dealing w/other unavoidable stresses of hospitalization.
o Dvlpmtal influence: timing
 Over 7 = 2 weeks ahead of time
 Under 2 = very short time 1 to 2 days before
 3-7 = some time in between, about 1 week in advance
o Preparation measures: preadmission visits (tour: OR, unit), booklets, videos/photos, health fairs, parties
STRESSORS OF HOSPITALIZATION 3 major (separation anxiety, loss ctl, injury/pain)
o Other--Sights & sounds, changes in routine, procedures, different cultures
SEPARATION ANXIETY(anaclitic depression)= away from home--Major; esp. 6-30 months
 Major stressor of hospitalization—especially in infant, toddler, pre-schooler
 3-Phases of Separation Anxiety – protest despair denial/detachment (look at pg 691-692 at chart)
 PROTEST:
o Behaviors observed during later infancy=cries, screams, searches for parent w/eyes, clings to parent,
avoids & rejects contact w/strangers
o Addt’l behavior observe in toddler= verbally attacks strangers (go away), physically attacks (kicks,
bites, hits, pinches), attempts to escape to find parent, attempts to physically force parent to stay.
o Behaviors last from hours to days, protests such as crying may be continuous, ceasing only
w/physical exhaustion, approach of stranger may precipitate increased protest
 DESPAIR:
o Observed behavior= inactive, w/draw from others, depressed, sad, lack interest in environ,
uncommunicative, regresses to earlier behav, physical condition deteriorate (refuse eat/drink/move)
 DETACHMENT
o Observ behav=show ↑ interest in surrounding, interact w/stranger, superficial relation, appear happy
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LOSS OF CTL
o Infants: hospitalization interferes w/ need to develop trust → inconsistency of caregivers
Infants=(Trust/mistrust) & deviations from infant daily routine lead to mistrust & ↓sense of ctl
o Toddlers & Preschoolers: may be related illness-associated dependency, physical restrictions, altered
routines & rituals, can’t walk free around hospital like @ home, prevents “autonomy” & dvlpmt @
this stage. egocentric pleasure meet w/obstacle, toddlers rxt w/negativism esp temper tantrum. Rely
on consistency & familiarity to provide stability & ctl life. Main areas for rituals=eating, sleeping,
bathing, toileting & play.
o Preschooler-ctl loss=physical restriction, altered routines & enforced dependency. Preoperational
think means they understand explanations only in terms of real events. When combined w/egocentric
&magical think, lead to interpret message according to past experience. concept of nurses is they
inflict pain, preschoolers think every nurse or everyone wearing sim uniform also inflict pain
o School age: r/t altered family roles, lack productivity, & boredom, schooling continued in hospital =,
parent may be @ home w/ other siblings (striving for independence & productivity)=particularly
vulnerable to events that may lessen feeling of ctl & power, esp in altered family role.
o Adolescence: may be r/t lack of privacy & separation from peers, threat to loss of identity-esp if loss
of body part & lack of privacy when everyone is examining (dr, students, specialists) struggle for
independence, self assertion, liberation
PAIN ASSESSMENT
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PAIN-important components of assessment=onset, duration or pattern effectiveness of current txt,
factors that aggravate or relieve the pain, interference w/child’s mood, fxn & interaction w/family.
 Infants - react by crying or grimacing, controversy—does infant feel pain or are they just crying. If they do
experience pain, do they just not understand the location or where it comes from?
 Toddlers - react by clenching teeth , may become violent (hit or bite) or runaway to avoid painful experience
 Older Children – rxt by verbal presence pain, scream, or exerting self-ctl – may grimace which shows pain
Behavioral-cry, grimace, guard, restless, irritable. More time consuming than self report. reliable when
measur short, sharp procedural pain such as during injection. Less reliable when measur longer lasting pain.
 Physiologic=↑ HR, ↑resp, ↑ BP, dilated pupil, pallor, diaphoresis, hyperglycemia, ↓pH, indirect estimate pain
 Self Report=tell you it hurts,
PAIN SCALES (many exist)
 Faces-point to the face (0 not hurt → 5 worst hurt)
 FLACC= face, leg, activity, cry, consobility (0-2)
0
1
2
o Face= no expression/smile
grimace/frown
freq to constant frown, clenched jaw, quiver chin
o Legs=normal position/relax
uneasy/restless
kicking/legs drawn up
o Activity=lying quiet
squirm/shifting
arched/rigid, jerking
o Cry=no cry
moans/whimper
crying steady/screams/sobs
o Consolability=content
reassure by touch/hug difficult to console/comfort
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Numerical scale (0-10 no hurt to worst) 0-3=mild pain=reposition pt, 4-6= moderate=medicate pt, if pain
becomes too severe then it will be impossible to stop pain)
 Oucher (0-100) 0=none/100=worst pain possible)=pictures of baby crying-can see facial expression & help
determine what kind a pain an infant or toddler may be experiencing. Can also use ocher for school age (612), they may say they don’t feel pain when they do b/c they don’t want a shot, IV or medication)
NURSING MANAGEMENT FOR DECREASING STRESSORS (ANTICIPATORY GUIDANCE)
o Encourage rooming in (in semi-private = only 1 parent can stay)--↓ anxiety
o Security objects (transitional objects) – from infant to adolescent
o Involve child in decision making ex. Bath, bedtime, cookies, drink (allow to play w/equipment)
 NOT MEDS – tk when prescribed
o Avoid painful experience, pain assessment------Pain scale based on age
 EMLA protocol (local)----½ to 1 hour before----cover w/occlusive dressing
 Avoid IM or PR – use IV or PO
NUSING DIAGNOSES FOR HOSP. CHILD
o Parental role conflict r/t lack of knowledge
o Anxiety r/t illness & hospitalization
o Self-care deficit r/t physical disability
o Altered nutrition r/t unfamiliar foods
o Sleep pattern disturbance r/t pain or noise
o Altered parenting = vacation, other siblings @ home
o Altered growth & dvlpmt
PREPARATION FOR DIAGNOSTIC/SURGICAL PROCEDURES
Atraumatic care in hospital, the goal is to inflict the least amt of pain. Prepping child decreases anxiety, promos
cooperation, supports coping skills & teaches them new ones. Prevent info overload. Procedure—we must know all preprocedure procedures including any type of preps, NPO, laxative, post procedure care etc. Must know when the pt returns
to the flr what position they should be in, VS/how often.
 Consent for procedure,--1st & foremost, chk chart- make sure sign, not sign, anesthesia not come to visit yet.
 Teaching aids, site tours-brochures, videos, models, (ICU) = ↓ anxiety
 NPO after midnight – water pitcher turned over, save the tray if pt will be back soon, sign on door
 Void before pre-op meds, consent & toilet before meds (meds usually given in holding area)
 Baseline VS.(usually taken w/in 1 hr of leaving flr)
 Check ID/labs (charted on pre-op check list),
 EKG, K+, H/H, PT, PTT, INR—labs essential esp K+ & H/H = indicator of heart beat regulation.
 No jewelry (swelling can happen, ring may be cut off), secure personal belongings. description of ring may be
yellow ring w/clear stone (don’t’ say gold w/diamonds), send home w/family, be very specific on counting
money (2 x $10, 1 x $5 etc)
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MEASURES TO PROMOTE COPING DURING HOSPITALIZATION
 Child life programs
 Child life coordinator = role is to reduce stress in hospital - peer modeling video or show --ex. MRI pix
 Therapeutic play--Playing out feelings w/ doll, pictures, painting
 Schooling during hospitalization
 Dscg planning occurs upon admission
COMPARE FAMILY RESPONSE TO HOSPITALIZATION OF CHILD Situational crisis for family
 Parents’ response – blame themselves, --change in routines & roles, ↑stress & concerns
 Siblings’ response – blame themselves, responsible, jealous, -- jealousy in the sense of insecurity, anxiety or
resentment that an ill child is getting more attention., may fear death for sibling
IDENTIFY DSCG PLANNING MEASURES
 Equip ordered & delivered to hospital for demonstration
 Equip ordered & delivered to home = nurse trains in home
 Famiy have transition or trial period to assume cre w/minimal health care supervision. Can be done at home,
a motel close to hospital. This allows safe practice pd for family w/ assistance readily available when needed.
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AFTER IM & SQ, APPLY B&-AID = LEAKAGE OF INSIDES