Nursing III Prof. Fernandez 8.16.21 Exam 1 PEDIATRIC ASSESSMENT VARIABLES 1. Developmental ⬝ Average children don’t have medical history ⬝ Lots of accidents ⬝ The smaller the child, the larger the body area → changes dosing! ↳ Toxins can be more easily absorbed through skin ↳ High metabolic rate ↳ Immature immune systems ↳ High cell turnover rate → heal quicker 2. Dependency ⬝ Non-verbal + ↑ Level Needs = Higher Risk of Abuse 3. Different ⬝ Focus on pediatric & adult differences (rather than similarities!) ⬝ Epidemiology ⬝ Presentation of clinical manifestations APPROACH 1. Take Time with children & family before giving meds or doing any procedures ⬝ Children WILL be scared of you ⬝ Need to build rapport & trust ↳ Even taking vitals can induce fear 2. See & Talk so child & family can acclimate ⬝ Never “hit & run” ⬝ Talk to chile AND parents ⬝ Don’t knock on door & speak loudly ⬝ Morel Reflex → you will startle babies! 3. Assess & Respect cultural differences ⬝ Example → Moving arabic pt’s bed toward Mecca 4. Always Give TLC after interventions ⬝ Avoid saying “I’m sorry” - instead, explain WHY they needed that tx ↳ Simply Sayin’ App 5. Use Child Life Therapists ⬝ Can be there for pt when parents can’t ⬝ Decreases anxiety & make hospital experience less stressful PHYSICAL EXAM 1. Always go prepared ⬝ Have all supplies on hand so you don’t have to come & go 2. Focused Assessment 3. Move Quickly ⬝ Borrowed Time ⬝ Children can’t sit still for long time ⬝ Do focused assessment ↳ Example → child w/ RSV do respiratory & cardiac assessment. Check radial & pedal pulses only 4. Least → Most Invasive ⬝ Not necessarily Head-to-Toe ↳ Example → Development, Mobility ↳ Example → Sleeping infant - auscultate. Easier to get vitals & blood pressure gently. Opportunistic vitals! 5. Always clean equipment before going into room & b/t pts 6. Louisiana doesn’t require patients to stay at child’s bedside in Hospital ⬝ Don’t be biased! 7. Equipment & Safety ⬝ Don’t leave old IV poles, Oxygen tanks, etc. in the room ⬝ Don’t assume the worst → Check your equipment first ↳ Example → if pulsox starts alarming, child may have just pulled it off 8. Don’t always assume adults are mom & dad ⬝ Need to know if that adult can legally sign for that pt Stages Newborn 1. Exam Table Location for Exam 1. Caregiver’s Lap OR OR 2, Caregiver’s Lap 1. Keep Running dialogue w/ caregiver Exam Direction Infant 2. Explain each step as you do it Toddler Preschool 1. Allow some freedom of movement (when possible) 1. May be willing to sit on exam table w/ caregiver standing close by (w/ hand on leg) 1. Sitting on exam table w/ eye contact w/ caregiver 1. May be willing to have caregiver wait outside exam room 1. Explain to caregiver that they need privacy & that they should wait outside exam room - Include child in all parts of exam → Explain what you’re doing 1. Speak to child using mature language 1. Explain confidentiality to caregiver & teen - Use head-to-toe approach w/ genital exam last 2. Appeal to their desire for self-care 2. Exam Table (w/ Caregiver beside Infant) 2. Can stand between (sitting) caregiver’s legs OR sit in their lap 1. Continue to explain steps to caregiver 1. Introduce yourself to caregiver & child 1. Allow child to decide order of exam 2. Address child by name 2. Explain most steps to child & all steps to caregiver 2. Explain what the instruments do & Let child try them 3. Perform most invasive parts last 3. Allow child to handle instruments 4. Perform most invasive parts 3. Speak to caregiver before & after exam School Age - Speak to caregiver before & after exam Early Teen 3. Use head-to-Toe approach w/ genital exam Late Teen 2. Allow time talking w/ them together & separate 3. Use head-to-toe approach (w/ genital exam last) last DEVELOPMENT ⬝ ⬝ ⬝ Infants → Hold & Comfort Toddlers & Preschoolers → Like to Imitate/Help ↳ Use dolls to let pts imitate what you’re going to be doing School Age Kids → Explain what you’re doing ↳ Don’t explain before school age VITALS ⬝ ⬝ Oxygen Saturation ↳ Respiratory will usually get pulsox unless patient is on continuous Blood Pressure ↳ Usually taken via posterior tibial artery ⬞ Because less anxiety-inducing ⬞ Don’t take it here if they’ve been running around ↳ Hypotension in children is determined by age & systolic BP ⬞ This gives you the MINIMUM the systolic can be before requiring intervention! ⬞ Hypertension is easier to tx than hypotension in children ↳ Ages ⬞ Term Neonates (0 - 28 Days) → Systolic BP < 60 ⬞ Infants (1 - 12 months) → Systolic BP < 70 ⬞ Children (1 - 10 years - 5th BP Percentile) → Systolic BP = < 70 + (Age in years x 2) ⬝ Example → Determine Hypotension of Systolic Blood Pressure for a 7 Year Old 70 mmHg + (7 years x 2) = 70 mmHg + (14) = 84 mmHg → Therefore, a 7 year old child is hypotensive when systolic BP is < 84 mmHg Heart Rate & Respirations ↳ Apical Pulse & respirations for one full minute each ↳ Increased HR & RR can effect absorption & exposure ⬞ Example → get more medication through breathing tx ⬝ Age Awake HR Sleeping HR RR Neonate (0 - 1 m) 100 - 205 90 - 160 30 - 60 Infant (> 1 - 12 m) 120 - 180 80 - 160 30 - 60 Toddler (> 1 - 3 y) 90 - 40 70 - 120 24 - 40 Preschool (> 3 - 6 y) 80 - 110 60 - 90 22 - 34 School Age (> 6 - 12 y) 75 - 100 75 - 100 18 - 30 Adolescent (> 6 - 12 y) 60 - 90 50 - 90 12 - 16 PEWS: Pediatric Early Warning System ⬝ (Don’t need to memorize for test) ⬝ Early warning system to prevent codes ⬝ The lower the number, the lower the concern level ↳ If they get a “2” → May want to call for someone to look at pt 0 - Playing appropriately at baseline 1 - Fussy, but consolable 2 - Any neuro concern different from baseline 3 - Lethargic - Confused Behavior - Irritable & NOT consolable - Difficult to arouse - Decreased pain response - Pink - Tachycardia > 20 above normal rate - Tachycardia > 30 above normal rate - Tachycardia > 40 above normal rate - Cap Refill 1 - 2 Sec - Pale - Bradycardia of > 5 below normal rate Cardiovascular - Cap Refill > 3 Sec - Grey/Mottled - Cap Refill > 5 Sec - Within normal parameters - > 10 above normal parameters - > 20 above normal parameters - > 30 above OR below normal parameters - Retractions - 40% FiO2 via mask - Grunting - 30% FiO2 via mask - O2 via HFNC - > 40% FiO2 via mask - No retractions Respiratory - O2 via NC - Trach w/ or without vent FACES PAIN SCALE ⬝ ⬝ Wong-Baker FACES Pain Rating Scale Instructions ↳ Explain to pt that each face is a person who feels happy because they have no pain or hurt, or sad because they have some or a lot of pain ⬞ Face 0 is very happy because he doesn’t hurt at all ⬞ Face 1 hurts just a little bit ⬞ Face 2 hurts a little more ⬞ Face 3 hurts even more ⬞ Face 4 hurts a whole lot ⬞ Face 5 hurts as much as you can imagine, although you don’t have to be crying to feel this bad ↳ Ask pt to choose face that best describes how they’re feeling FLACC SCALE ⬝ ⬝ ⬝ ⬝ Behavior Observation Pain Rating Scale For non-verbal children por children who are too young (don’t need to memorize) Can also be used on non-verbal adults HEAD-TO-TOE 1. Length & Weight ↳ For < 2 year old on admit ↳ Length measured while pt is laying down ⬞ NEVER take your hand off an infant/toddler (they can fall) ↳ Weight done nude → must be very accurate 2. Height ↳ Older children stand for height ↳ To catch hydrocephalus ↳ School age children → make sure they aren’t on tippy toes 3. Head Circumference ↳ until 36 months 4. Weight ↳ Growth Chart ⬞ Weight & Height are plotted ⬞ P. 942 - 951 ⬞ Values compare child’s growth relative to others of the same age range → 5th to 95th percentile ⬞ If < 5% → at risk for failure to thrive ⬞ Trend is what is important - NOT just number! ⬝ Look at parents as well ⬝ Consider what the child was on their last visit ↳ Can call HCP office to get the last one to see trend ⬞ Know how to plot for test! 5. Neuro Exam ⬝ Awake, Alert & Oriented appropriate to developmental age 6. Anterior Fontanel (18 months) ⬝ Posterior closes first between 2 - 3 months ⬝ Anterior closes between 12 - 18 months ⬝ They should be flat & even w/ boney edges ⬝ Sunken fontanel → indicates dehydration ⬝ Constant swollen fontanel → worry about ↑ ICP ⬝ When baby cries the fontanel will fluctuate 7. Ear Differences ↳ Anatomy ⬞ Normal Ear Anatomy (1st picture) → Top of ear level with outer canthus of eye ⬞ Abnormal → child w/ low set ears ⬝ Common w/ many genetic disabilities ↳ Ear Exam ⬞ < 3 years → Pinna DOWN & back ⬞ > 3 years → Pinna UP & back 8. Mouth ↳ Dental Issues ⬞ During school-age years, children begin to lose “baby” teeth ⬝ Remember this when assassin 5 - 12 year olds ⬞ Check for loose teeth → Especially if patient is about to be intubated or pre-op! ↳ Tell pt to open wide & say “ahhh” ⬞ “Open wide like an alligator” ⬞ “Blow out candle when you’re done” ⬞ Bubbles good for respiratory expansion ⬞ Make everything a game & it will be more fun for both of you 9. Chest ↳ Physical chest deformities ⬞ Include: ⬝ Pectus Excavatum = Funnel Chest ⬝ Pectus Carinatum = Pigeon Chest ⬞ Common Sites of Retractions ⬝ If child has respiratory distress → Below are common sites of retractions ⬝ Retractions are very concerning & should be monitored closely ⬞ If < 6 year old → you may see more movement in abdomen than chest rise 10. Heart ↳ ↳ Location of Heart in child PMI can be b/t 3rd & 5th ICP at MCL (infant - school age) ↳ Use smaller sized-stethoscope to hear heart tones 11. Abdomen ↳ Umbilical Hernia ⬞ Common ⬞ Doesn’t always require surgery → especially if < 4 years old ↳ Percussion & palpation of abdomen will scare them ⬞ Let them help you or make it a game 12. Genitals ↳ Male Newborns → Observe if testes are distended or not ↳ If uncircumcised → Teach parent how to pull back & clean ↳ Female & Male Tanner Staging Puberty ⬞ Don’t need to memorize ⬞ Used to ID puberty stages BEGINNING OF EXAM ⬝ ⬝ ⬝ ⬝ ⬝ General Appearance Skin Hair & Nails Equipment Caregiver’s Present? QUICK EXAM ⬝ ⬝ ⬝ ⬝ ⬝ ⬝ General Appearance HEENT Breath Sounds/Heart Tones Bowel Sounds/Abdominal Exam Peripheral Pulses Anything Attached? 9 RIGHTS OF MED ADMINISTRATION 1. 2. 3. 4. 5. 6. 7. 8. 9. Right Child Right Med Right Dose Right Time Right Route Right Documentation Right Approach (G&D) Right to be Educated Right to Refuse a. Children CAN refuse, but they must be cognitively aware enough to make decision b. If parent wants you to come back w/ meds b/c child is sleeping → give them an hour UNLESS it’s an antibiotic MEDICATION ADMINISTRATION TIPS ⬝ ⬝ Educate patient & parents of their 9 rights Checking ID of pt ↳ ALWAYS Ask “What is your name?” AND check wristband ↳ NEVER say “Are you Susie Jones?” ⬞ Child may say “yes” to authority figure or be confused, drowsy or wanting to avoid their own therapy - Example → They may even switch beds ⬝ Problems with Dosing ↳ Lack of approved drugs for children ↳ Unique responses, side effects & long-term effects vary, lack of research ⬞ Experimentation in children is difficult ↳ Difficulty in establishing dosages for children → very individualized ↳ DOUBLE CHECK (w/ another nurse) ⬞ Insulin ⬞ Lanoxin ⬞ Heparin ⬞ Potassium ⬞ Narcotics ⬞ Blood Products ↳ Must assess child before & after giving meds ⬞ 10 - 15 minutes after ⬞ Document changes or findings ⬞ Reassess prn often CHILDREN ARE UNIQUE ⬝ ⬝ ⬝ ⬝ Communicate honestly with child ↳ About what to expect before you do anything to them ↳ NEVER LIE ↳ Example → Don’t tell children that a shot won’t hurt Developmental Appropriateness ↳ Example → stories, puppets & interactions ↳ Example → Give praise Provide Distractions ↳ Example → Toy box of med-related objects (syringes, med cups, droppers) for therapeutic play & familiarization Offer Choices → Not yes or no ↳ Example → Do you want to take this med with apple juice or orange juice? INJECTIONS ⬝ Positioning ⬝ ⬝ ⬝ ⬝ Sites ↳ ↳ < 2 years → Vastus Lateralis > 2 years AND has been walking for at LEAST 1 year: ⬞ Vastus Lateralis - good site w/ few nerves ⬞ Ventrogluteal ⬞ Deltoid ⬞ Dorsal Gluteal ↳ Infants use TB Syringe w/ ½ - ⅝ inch to max 1 inch needle ⬞ Smallest lumen is best Volumes ↳ Deltoid ⬞ Infants→ NOT recommended ⬞ Toddlers → 0.5 mL ⬞ Preschool & Older Child → 0.5 - 1 mL ⬞ Adolescents → 1 - 1.5 mL ↳ Ventrogluteal ⬞ Toddler → 2 mL max ⬞ Preschool & Older Children → 2 - 3 mL ⬞ Adolescent → 2 - 5 mL ↳ Vastus Lateralis ⬞ Infant → 1 mL max ⬞ Toddler → 2 mL max IM Injections ↳ Use Distractions ⬞ Examples → Sing, Talk, Count, Stroke Head/Body, Animal/Name Games, etc. ↳ Use Gate-Control Method (rubbing) ⬞ Stimulates nerve endings to decrease sharp or painful sensations ↳ Cuddle & praise child for whatever cooperation you get → ok to cry ↳ EMLA or lidocaine cream in advance ↳ Z Track method ⬞ NOT deltoid SubQ Injections ↳ 1 mL is max for all Sub Q ↳ Avoid abdomen for Sub Q until > 2 years old (if not older) ⬞ Large room for error ↳ Preferred site in children: ⬞ < 12 months → Anterolateral Thigh ⬞ > 12 months → SubQ over Triceps CALCULATING PEDIATRIC FLUID REQUIREMENTS ⬝ ⬝ Normal urinary output = > 2 mL/kg/hr for all ages < 18 years ↳ Pts < 1 mL/kg/hr will need intervention → can just be oral intake increase (least invasive first) ⬞ If this doesn’t work, may need to increase oral intake or may require fluids Formula for 24 hour fluid maintenance requirements: ↳ 100 mL/kg for 1st 10 kg of body weight ↳ 50 mL/kg for 11 - 20 kg of body weight ↳ 20 mL/kg for each additional kg of body weight over 20 kg ↳ Example → Child weighs 22.2 kg (100 mL x 10 kg) + (50 mL x 10 kg) + (20 mL x 2.2 kg) = 1544 mL/day, or 64.33 mL/hr
