NU 435 Week 2 Week 2 Agenda Item / Activity Allotted Time Announcements & check-in 2 – 2:10pm (1) Patient & family assessment 2:10 – 2:35pm Break #1 2:35 – 2:45pm (2) Pediatric physical assessment 2:45 – 3:10pm (3) Communication with patient & families 3:10 – 3:30pm Break #2 3:30 – 3:40pm (4) Genetic conditions & considerations 3:40 – 4:10pm (5) Peds math intro 4:10 – 4:25pm Closing announcements & wrap-up 4:25 – 4:30pm Childhood Ages & Stages Growth & Development Stages Across Childhood… + https://www.healthychildren.org/english/ages-stage s/pages/default.aspx AAP Healthy Children website (excellent resource for parents) + Continued discussion throughout course Resources on Bb (Course Materials – Growth & Development folder) Ages & Stages + Prenatal (335) – pregnancy up to birth + Infancy – birth up to 12 months old + Toddler – 1 year up to 3 years old Ages & Stages + Preschooler – 3 years up to 5 years old + School-Age children – 5 years up to approx. 12 years old + Adolescents – Approx. 12 years up to 18 years old + Young adults – 18 years up to 21+ years old Tips for Developmentally Appropriate Communication Newborn and infant + Approach and attentiveness Quiet voices and then gentle touch + Communication Infants may fix and follow or cry, trash, grimace + Facilitate parent involvement Kangaroo care, for example Toddler & Preschooler • Begin to verbalize their thoughts and feelings • Concrete, literal, & egocentric • Magical thinkers • Short attention spans & limited memory • Don’t give choices that they don’t really have School – Aged Child • Now uses logic & prior knowledge to understand current problems • Start assessing knowledge and levels of understanding • Allow to participate in decision-making • Be direct, honest, and socially contextualizing (“some kids feel…”) Adolescents • Assess cognitive ability, emotional intelligence, insightfulness • Build rapport and a trusting relationship • Assist in transition to adult self-care and management • Maintain confidentiality, as appropriate Social, Cultural, Religious, and Family Influences on Child Health Promotion Family Is whatever a person considers it to be May be consanguineous (blood relationship) May be affinal (marital relationship) The family of origin is the family unit into which one is born The term household is used increasingly to accommodate a variety of family styles Family Systems Theory The family is a system that continually interacts with its members and the environment Emphasis is on interaction between members Problems do not lie in any one member but in the type of interactions used by the family Makes the family the “patient” and the focus of care Family Stress Theory Families encounter stressors, both predictable and unpredictable Multiple stressors in a short period of time can be overwhelm ability to cope, which may lead to crisis Adaptation requires a change in the family structure and/or interaction Developmental Theory Addresses family change over time Family is a semi-closed system that interacts with the larger social system Predictable changes in structure, function, and roles The age of the oldest child marks stage transitions What is Family-Centered Care? Family/Nurse Communicatio n Respect and Incorporate Diversity and Cultural Difference Holistic Philosophy Specialized service and support systems The Famil y Facilitation of Peer Support Family/Nurse Collaboration Coping – Recognition and support Many ways to define a family + Self-Identified + US Census Bureau: “Two or more individuals who are joined together by marriage, birth, or adoption and live together.” + Dynamic + Safe + Defined by roles + Common goals, values, beliefs + Joined by/dependent upon each other for shared resources, emotional closeness, physical support Every family is different… https://youtu.be/YsfMWr3nyE Family Function Based on interactions of family members Quality of family relationships Informs the nursing process Predicts how a family may cope Predicts the family’s response to a stressful event Guides individualized support Identifies appropriate resources Family Roles and Relationships Each family will define its traditions, values, and standards for interaction inside and outside of the family structure. Each individual has a position in structure and plays culturally and socially defined roles Roles are learned through socialization Conflicts arise when people do not fulfill roles that meet other members’ expectations Sociocultural Influences on Children and Families Multifactorial layers of influence on children and families, which may include social, cultural, and religious influences. Prominent influences include: Parents Extended family Community School Communities Learning and development are cumulative and synergistic Important sites for health promotion Cultural diffusion is prominent Peer cultures impact child socialization Broader Influences on Child Health Social media and mass media Race and ethnicity Poverty and economy Parental education Land of origin and immigration status Religion and spiritual identity Importance of Cultural Humility Recognize that “culture” is not only race and ethnicity, but also social class, age, sexual orientation, sexuality, gender, ability, and professional discipline, among other things. Cultural humility: openness, self-awareness, egolessness, supportive interactions, self-reflection and critique Physical Assessment Growth Assessment + Infants through 36 months Recumbent length, weight and head circumference + After 36 months Standing height, weight, body mass index (BMI) after + Plot measurements on proper growth chart + Important to note the TREND of growth, not the individual measurements Ethnic and gender differences Expected growth rate varies by age Growth Assessment Cont. + Growth is different than development. Growth is somatic growth Development is maturation, milestone achievement, etc + Following a child’s own growth curve is important. + Variation from the growth curve should be assessed. Assessing growth, skin, muscle mass + https://www.cdc.gov/growthcharts/ Physiologic Measurements + Physiologic measurements are indicators of overall physical status + Comparison with normal-range values for each age group + Often assessed from least to most invasive + Vital sign assessment (often in this order): Respiratory rate (RR) Heart rate (HR): apical Blood pressure (BP) Temperature (T) Pain Vital Sign in Childhood Blood Pressure Measurement Assessment 1-<13 years old ≥ 13 years old Normal BP < 90th percentile <120/<80 mmHg Elevated BO ≥ 90th - < 95th percentile or 120/80 mmHg whichever is lower 120/<80 to 129/<80 mmHg Stage 1 HTN ≥ 95th to < 95th +12 mmHg or 130/80 to 139/89 whichever is lower ≥ 95th percentile =12 mmHg or ≥ 140/90 mmHg whichever is lower 130/80 to 139/89 mmHg Stage 2 HTN ≥ 140/90 mmHg AAP, 2017 Physical difference s of Infants Neurological Difference + Maturation is child dependent + Infant reflexes: previously covered in Maternity/Mother-Baby Care Khan Academy video: https://youtu.be/ARZD9Qid9lU Physical Assessment Overview + General appearance + Skin + Hair, nails, hygiene + Lymph nodes + Head and neck + Eyes, ears, nose, and throat (EENT) Physical Assessment Overview + Chest + Lungs + Heart + Abdomen + Genitalia + Back and extremities + Neurologic assessment Pediatric Assessment – ROS 40 Physical Assessment of Children ⦁ Adults, identify subjective and objective findings via oral communication & head-to-toe assessments ⦁ Children, some unwilling/unable to communicate with nurse (stranger) ⦁ More successful exam with less structured, hands-on approach 41 Examination ⦁ Inspection, palpation, percussion, and auscultation ⦁ Abdominal exam inspection, auscultation, percussion, palpation (as with adults) ⦁ Speak slowly and clearly with plain language ⦁ Use warm hands ⦁ Assume same height as child ⦁ Be honest with child, esp. if procedure will hurt ⦁ Use play 42 Obtaining info from a child ⦁ Be age-appropriate ⦁ Establish rapport ⦁ Listen ⦁ Important to include child when appropriate ⦁ Child should feel a part of the HPI ⦁ Interview adolescents in private 43 Physical exam ⦁ Observation ⦁ Measure height, weight, head circumference ⦁ Obtain VS ⦁ Head & Neck ⦁ Fontanels ⦁ Neck ROM ⦁ EENT ⦁ Dentition 44 Physical Exam continued ⦁ Pulmonary & chest exam ⦁ Adolescents: note breast development ⦁ Observe, palpate, percuss, auscultate ⦁ Cardiovascular exam ⦁ Heart rate (count for 1min), rhythm, presence of murmurs ⦁ Peripheral pulses & perfusion 45 Physical Exam continued ⦁ Abdominal exam ⦁ Use your four quadrants ⦁ Auscultate first (warm stethoscope) ⦁ Slight protrusion of abdomen WNL for infants and small children ⦁ Genitalia and rectum ⦁ Respect child's privacy and consider age/developmental stage ⦁ Males: assess for cryptorchidism 46 Physical Exam continued ⦁ Neuro checks ⦁ Developmental considerations ⦁ Mental status ⦁ Cranial nerves ⦁ Muscle tone/strength, gait ⦁ Reflexes 47 Acute / emergent: Think ABCDEs ⦁ Airway ⦁ Breathing ⦁ Circulation ⦁ Disability ⦁ Alert ⦁ Vocal response vs. Pain response ⦁ Nonresponsive ⦁ Exposure 48 Pediatric Assessment Triangle (PAT) ⦁ Dieckmann et al (2010) describe assessment tool for prioritizing assessment during acute or emergent pediatric cases 49 PAT continued Characteristics of Appearance: The ‘‘Tickles’’ (TICLS) Mnemonic* Characteristic Normal Findings Tone Moves spontaneously Resists examination Sits or stands (age appropriate) Interactiveness Appears alert and engaged with clinician or caregiver Interacts with people, environment Reaches for toys, objects (eg, penlight) Consolability Stops crying with holding and comforting by caregiver Has differential response to caregiver versus examiner Look/gaze Makes eye contact with clinician Tracks visually Speech/cry Has strong cry Uses age-appropriate speech * Dieckmann et al (2010) adapted from AAP 50 Practice case A parent brings her 18-month-old girl to your clinic for a well-child visit. She's a new patient without available past medical records, but her parent declares no know health issues. Her diet is varied, but she is a picky eater with frequent tantrums when given anything beyond fried foods and juices. 51 Primary Assessment ⦁ Afebrile, VSS & WNL ⦁ Alert, interactive, gross neuro intact ⦁ Weight = <5th percentile on growth chart ⦁ Height/length = 25th percentile ⦁ HC = 50th percentile ⦁ Exam is WNL 52 What are the next steps? ⦁ What additional assessment data would you like to collect? ⦁ What strategies would you use to assess this 18mo old girl? ⦁ What do you think about the growth curve data? ⦁ What is the most likely diagnosis? ⦁ What guidance would you give to her parent about eating? 53 Practice Questions The nurse is developing a plan of care to prevent separation behaviors in children who are hospitalized for long periods of time. Which of the following statements should the nurse include in the plan? Select all that apply. 1. Provide the child with the child's favorite transitional object 2. When possible, assign the same nurse to care for the child each day. 3. Admit the child to the patient room closest to the nurse's station. 4. Tape pictures of the child's friends and family to the walls of the child's hospital room. 5. Inform the parents that a least one person must stay with the child at all times during the hospitalization. 54 Practice Questions The nurse is developing a plan of care to prevent separation behaviors in children who are hospitalized for long periods of time. Which of the following statements should the nurse include in the plan? Select all that apply. 1. Provide the child with the child's favorite transitional object. 2. When possible, assign the same nurse to care for the child each day. 3. Admit the child to the patient room closest to the nurse's station. 4. Tape pictures of the child's friends and family to the walls of the child's hospital room. 5. Inform the parents that a least one person must stay with the child at all times during the hospitalization. 55 Mini-break! + Stand up, stretch + Deep breathe + We’ve GOT this!! Communicatio n with the Child and Family Guidelines for Communication + Interviewing is goal-directed communication + Introduction Introduce self Ask names of family members and how to address Include children in interaction + Privacy and confidentiality Minimize distractions Confidentiality Communicating with Parents + Encourage talking; use open-ended questions + Direct the focus + Listening and cultural awareness + Use silence and empathy + Provide anticipatory guidance + Use professional interpreters if the family speaks another langue Do not use children as interpreters Communicating with Children + Be developmentally appropriate + Use simple terms, questions and instructions + Get on the child’s eye level + Approach the child gently and quietly while involving the parent or caregiver + Always be truthful + Give the child choices as appropriate + Include play, including role-play when possible Developmentally Appropriate Communication + Infants: primarily nonverbal Crying, smiling and vocalizing + Early childhood: focus on the child Allow children to touch medical equipment Repeat information in simple, consistent terms + School-age: focus on concrete explanations Encourage child to touch and practice with equipment + Adolescents: be honest, and explain thoroughly Be aware of privacy, potential for regression Play + Play is a child’s “work”; the universal language + Play is a child’s “developmental workshop” + Play can serve as a Therapeutic intervention Stress reliever for the child and family Pain reliever and distracter Barometer of illness History Taking + Chief complaint (CC) + History of present illness (HPI) + Family history (FH) and structure + Psychosocial history + Review of Systems + Nutritional assessment Approaches to Examining a Child + Pediatric assessment sequencing is altered from the typical headto-toe sequence used in adults Alter sequence to accommodate developmental needs Often from least invasive/distressing to most Use communication techniques, play, and parental assistance to complete the examination + Minimize the stress and anxiety associated with the assessment of various body parts + Maximize the accuracy of assessment findings Preparation of the Child Preparation of the Child Genetics and Genomics Spring 2021 Genetic Testing ⦁ Genetic testing is voluntary ⦁ Testing can be conducted in many settings/situations ⦁ Predictive testing ⦁ Carrier Testing, pre-implantation testing, prenatal testing ⦁ Newborn Screening ⦁ Diagnostic testing ⦁ Many kinds of tests ⦁ Molecular genetic tests or single gene studies ⦁ FMR1 DNA test ⦁ Chromosomal tests analyze whole chromosomes of lengths of DNA ⦁ Karyotyping, such as for sex chromosomes or testing for Trisomy 21 ⦁ Biochemical genetic tests evaluate the amount or the activity of specific proteins to examine changes in DNA due to a genetic d/o ⦁ Used with concerns for inborn errors of metabolism, for example U.S. National Library of Medicine, 2019 Nursing Assessment + Obtain a family health history + Construct a pedigree + Conduct health and physical assessments + Analyze the findings + Evaluate patient’s (and family’s) knowledge + Develop a plan of care that involved genetic and genomic information National Human Genome Research Institute, n.d. Inform diagnosis Promote risk assessment and stratification Family Histor y Build a rapport with patients and families Change managemen t Pedigree + 3 generation pedigree + Proband: affected family member (usually first brings attention to the concern) + Consultand: first contact with healthcare professional Identification of Risk factors ⦁ Screen patients that may benefit from genetic and genomic services ⦁ Provide the patient and/or family with up-todate and accurate resources ⦁ Address the legal, ethical, and societal issues that arise ⦁ Have special considerations that may or do undermine the patient’s (and/or family’s) rights “ Referral Activities ⦁ Facilitate referrals for comprehensive genetic and genomic services Provision of education, care, and support ⦁ Provide patients (and/or families) with appropriate, current, and accurate genetic information, resources, services, and health care ⦁ Incorporate the genetic and genomic risk factors into health promotion and prevention ⦁ Add genetic and genomic interventions targeted to improve patient outcomes ⦁ Collaborate with other healthcare providers and insurance companies ⦁ Evaluate the effectiveness of genetic and genomic interventions Professional responsibilities Competencies ⦁ Recognize your own values around genetics and genomics ⦁ Reexamine your own competency in genetics and genomics ⦁ Incorporate genetic technology and information into your practice ⦁ Advocate for your patient’s access to and their rights regarding genetic and genomic care Specific Genetic/Genomic applications Turner Syndrome + Monosomy – XO + Due to nondisjunction during cell division + Features: Short stature Early loss of ovarian function Infertility + Can receive hormonal therapy Webbed neck Low hairline at the neck Lymphedema Coarctation of the aorta U.S. National Library of Medicine, 2019 Klinefelter Syndrome ⦁ XXY ⦁ Random nondisjunction ⦁ Physical effects ⦁ Small testes, reduced testosterone ⦁ Gynecomastia ⦁ Decreased muscle mass and bone density ⦁ Cryptorchidism, hypospadias, micropenis ⦁ 5th finger clinodactyly ⦁ Cognitive delay ⦁ Anxiety, depression, impaired social skills, ADHD, limited executive functioning ⦁ Higher risk of autism spectrum disorder ⦁ Risk for autoimmune d/o Down Syndrome (Trisomy 21) ⦁ Mental ⦁ Mild to moderately lower than average IQ ⦁ Physical ⦁ Congenital heart defects ⦁ Flattened midface ⦁ Upslanting palpebral fissures ⦁ Short neck ⦁ Small, posteriorly rotated ears ⦁ Protruding tongue ⦁ Palmar crease ⦁ 5thfinger clinodactyly ⦁ Hypotonia ⦁ Short stature Mendelian Inheritance + Autosomal Dominant 50% chance of passing condition to offspring + Examples Huntington Disease Marfan syndrome Autosomal Dominant https://www.researchgate.net/figure/Pedigree-of-the-family-indicated-autosomal-dominant-inheritance-Open-symbols-indicate_fig2_6288035 Mendelian Inheritance +Autosomal recessive +25% chance for condition with each offspring +Examples: +Cystic fibrosis and sickle cell disease Autosomal Recessive Disorder X-Linked Dominant + Mutations on X chromosome + Only need one copy to produce symptoms + Fathers cannot pass to their male offspring + Examples: Fragile X X linked Recessive + Change in gene on X chromosome + One altered copy can cause condition for males + Females would need 2 copies of the altered gene + Males > Females + Fathers cannot pass to their sons Mitochondrial Disorders + Mitochondria are the structures in every cell that produce energy + Mutations in mitochondrial DNA: maternal inheritance + Mutations in nuclear DNA can be autosomal dominant, autosomal recessive, or X-linked Intro to Pediatric Math Overview • Fluid bolus and maintenance rates • Safe range and dosage for children • TBSA% estimate • Parkland Fluid Resuscitation Formula for Burns Calculating safe doses + In peds, we calculate safe doses by: + Body surface area (BSA), e.g. 20mg/m 2 + Kilograms, e.g. 20mg/kg BSA calculation + Use nomogram + 16lbs & 35in + BSA = 0.42m2 BSA Calculation formula + = √( height (cm) x weight (kg) ÷ 3600) + "square root of..." + Example: Weight 16lbs and Height 35in + Convert to kg and cm • 16lbs ÷ 2.2kg/lb = 7.3kg • 35in x 2.54cm/in = 88.9cm BSA Calculation formula + = √ (height (cm) x weight (kg) ÷ 3600) + = (88.9cm x 7.3kg) ÷ 3600 + = 0.18 ---> take the square root + = 0.42m2 + Note: BSA always calculate to the nearest hundredth (2 decimal places to the right of decimal point) In general, safe practice is to round to nearest tenth (1 decimal place to right) for integers >1.0 and to the nearest hundredth for integers <0.0 Calculation of Medication Dosage Calculating Maintenance Fluids: 2 Methods + 100 / 50 / 20 rule (24-hour fluid requirements) Safe Medicate uses Use for all fluid calculations in 435 + 4 / 2 / 1 rule (hourly fluid requirements) Use in clinicals per faculty guidance Quick estimate of hourly fluid needs What are the basic daily fluid requirements for hydration of a 4-year-old weighing 42 pounds? (19.1kg) 100/50/20 Rule For this child: 100 mL/kg 1 – 10 kg 1 – 10 kg of weight 100mL x 10kg= 1000mL (1 10 kgs) * But this child is > 10kg so… 50 mL/kg 11 – 20 kg 9.1 kg remaining 50mL x 9.1kg= 455 (2nd 10 kgs) 20 mL/kg >20 kg 0 kg remaining 20mL x 0kg= 0 (Remaining kgs) TOTAL VOLUME: 1455mL/day st Calculate hourly rate: 1455 mL ÷ 24hrs = 60.6 mL/hr 100/50/20 Rule For this child: 100 mL/kg 1 – 10 kg 1 – 10 kg of weight 100mL x 10kg= 1000mL (1 10 kgs) * But this child is > 10kg so… 50 mL/kg 11 – 20 kg 9.1 kg remaining 50mL x 9.1kg= 455 (2nd 10 kgs) 20 mL/kg >20 kg 0 kg remaining 20mL x 0kg= 0 (Remaining kgs) TOTAL VOLUME: 1455mL/ day st Calculating Maintenance Fluids: 4/2/1 Child (19.1 kgs) Body Weight (kg) Maintenance 4 x first 10kg = 2 x next 10kg = 18.2 (9.1kg x 2) Total = 58.2ml/hr 40 Example is 25 kg patient Needs (Fluid/hour) 4 x first 10 Kg 40 2 x next 10 kg 20 1 x remaining kg 5 Closing Announcement s + Module #1 Assignments posted Calc Quiz #1 by Wed. Feb. 2 @ noon + Revised syllabus & sched-at-a-glance to be posted Closing Announcements + Safe Medicate Exam Feb. 3rd – Feb. 5th Complete practice modules !! Complete practice test Password: Test + Med math review session (@ 6pm tonight on Zoom) + https://umassboston.zoom.us/j/96381421649 Thank you! -Dr. Miano
