Pediatric Pediatric AssessmentAssessment

Elisa A. Mancuso RNC, MS, Elisa A. Mancuso RNC, MS, FNSFNS

Professor of Nursing Professor of Nursing

Course RequirementsCourse Requirements• Course Objectives Course Objectives • Schedule-Lecture & Clinical Schedule-Lecture & Clinical • Assignments-Page 7.Assignments-Page 7.

– LectureLecture- - 2 exams = 95% + 1 ATI Exam (5%) = 2 exams = 95% + 1 ATI Exam (5%) = 100%100%

– Clinical AssignmentsClinical Assignments

» 1 Pediatric NCP1 Pediatric NCP» 2 Journals2 Journals» Daily Nursing Process Plan (1 per patient) Daily Nursing Process Plan (1 per patient) » 1 Clinical Case Study Presentation1 Clinical Case Study Presentation» Leadership AssignmentLeadership Assignment

Assignments not submitted on time will result in a Assignments not submitted on time will result in a failed clinical day.failed clinical day.

Maximum 2 failed clinical days for NUR 246.Maximum 2 failed clinical days for NUR 246.

Course Requirements Course Requirements

• Academic Integrity = ProfessionalismAcademic Integrity = Professionalism

• BLS CPR certification must be current to 12/22/09BLS CPR certification must be current to 12/22/09

• Dosage Calculation AssessmentDosage Calculation Assessment90% or higher to pass90% or higher to passIV rates (gtts/min) IV rates (gtts/min) Conversions: mg ↔ grains , grams ↔ microgramsConversions: mg ↔ grains , grams ↔ microgramsPediatric Calculations: mg per kg = dosePediatric Calculations: mg per kg = dose

2.2 pounds = 1 kg2.2 pounds = 1 kg Two opportunities within one week.Two opportunities within one week.

Texts Texts

• RequiredRequired– ATIATI: : Nursing care of children: RN edition - 7.0Nursing care of children: RN edition - 7.0– Elllis and HartleyElllis and Hartley (2005) (2005) Managing and coordinating Managing and coordinating

nursing carenursing care (4 (4thth ed.) ed.)– LondonLondon, M. et al (2007) , M. et al (2007) Maternal & child nursing care.Maternal & child nursing care.

(2(2ndnd ed) Vol 2 ed) Vol 2

• Strongly RecommendedStrongly Recommended– Laboratory Diagnostic text.Laboratory Diagnostic text.– Binder, R.C. et al (2007) Binder, R.C. et al (2007) Clinical skills manual for Clinical skills manual for

maternal & child nursing care.maternal & child nursing care.– NCLEX ReviewNCLEX Review text: Silvestri, L.A. (2009) text: Silvestri, L.A. (2009) Saunders Saunders

comprehensive review for NCLEX-RN comprehensive review for NCLEX-RN

Pediatric AssessmentPediatric Assessment

• Children are not small adults!Children are not small adults!• Family InvolvementFamily Involvement• Identify their developmental level and Identify their developmental level and

needs:needs:– Infants - Trust vs. MistrustInfants - Trust vs. Mistrust– Toddlers - Autonomy vs. Shame & DoubtToddlers - Autonomy vs. Shame & Doubt– Preschool – Initiative vs. GuiltPreschool – Initiative vs. Guilt– School-Age – Industry vs. InferioritySchool-Age – Industry vs. Inferiority– Adolescent – Identity vs. Role ConfusionAdolescent – Identity vs. Role Confusion

Establish TrustEstablish Trust

• Approach adult first, then acknowledge child.Approach adult first, then acknowledge child.

• Get down to child’s eye level.Get down to child’s eye level.

• Identify self and nature of visit.Identify self and nature of visit.

• Reinforce what will be done and how it will Reinforce what will be done and how it will feel.feel.

• Maintain a sense of humor and have fun!Maintain a sense of humor and have fun!

Communication is KeyCommunication is Key• Recognize developmental needs.Recognize developmental needs.• Use age appropriate language.Use age appropriate language.• Assess child’s prior health care Assess child’s prior health care

experiences.experiences.• Encourage child to answer questions Encourage child to answer questions

independently.independently.• Encourage child to ask questions.Encourage child to ask questions.• Provide privacy from family/parents if Provide privacy from family/parents if

desired.desired.

Physical ExamPhysical Exam• Let child handle equipment.Let child handle equipment.• ““Examine” toys or doll first.Examine” toys or doll first.• Allow patient to examine doll or RN.Allow patient to examine doll or RN.• Provide information during exam.Provide information during exam.• Encourage child to participate.Encourage child to participate.• Be honest and prepare for all Be honest and prepare for all

sensations child may experience.sensations child may experience.• Select a coping technique; hold Select a coping technique; hold

bear, wiggle toes.bear, wiggle toes.

Illness and Illness and HospitalizationHospitalization

• Major life crisis.Major life crisis.

• Change from usual state of health and Change from usual state of health and routine.routine.

• Loss of control.Loss of control.

• Unfamiliar environment and people.Unfamiliar environment and people.

Parental responseParental response

• AngerAnger– At child for becoming ill & causing stressAt child for becoming ill & causing stress– Revise routine to accommodate work and childRevise routine to accommodate work and child

• AnxietyAnxiety– Regarding potential diagnosis & painful Regarding potential diagnosis & painful

proceduresprocedures– Financial and family obligations.Financial and family obligations.

• GuiltGuilt– Did they cause their child’s illness?Did they cause their child’s illness?

Parental responseParental response

• Loss of ObjectivityLoss of Objectivity– Apply different rules to ill childApply different rules to ill child– Allow manipulation by ill child.Allow manipulation by ill child.– Healthy children are “forgotten”Healthy children are “forgotten”

• Feelings of InadequacyFeelings of Inadequacy– Feel helpless in parenting roleFeel helpless in parenting role– Allow staff to assume decision making and Allow staff to assume decision making and

caretaking responsibilities.caretaking responsibilities.

Children’s ResponseChildren’s ResponseInfantsInfants

• 0 to 1 year0 to 1 year• Trust vs. MistrustTrust vs. Mistrust• Separation Anxiety @ 6 monthsSeparation Anxiety @ 6 months• BehaviorBehavior

– Body RigidityBody Rigidity– IrritabilityIrritability– Altered Feeding, Sleeping and Stool Altered Feeding, Sleeping and Stool

patternspatterns

InfantsInfants• Nursing InterventionsNursing Interventions

– Primary RN for consistencyPrimary RN for consistency– Encourage parents to participate in careEncourage parents to participate in care– Simulate home routineSimulate home routine

•Bath time, Meal time & Nap timeBath time, Meal time & Nap time

– Bring familiar objects from homeBring familiar objects from home•Allow self-comfortingAllow self-comforting•Pacifier, Blanky or loveyPacifier, Blanky or lovey

ToddlersToddlers

• 1 to 3 years1 to 3 years• Autonomy vs. Shame and DoubtAutonomy vs. Shame and Doubt• BehaviorBehavior

– Seeks independence Seeks independence

““Me Do”Me Do”– Mobility = ControlMobility = Control– Temper TantrumsTemper Tantrums

• Separation anxiety @ 18 – 24 mos.Separation anxiety @ 18 – 24 mos.

ToddlersToddlers

• 3 Distinct Stages of Separation 3 Distinct Stages of Separation AnxietyAnxiety

– ProtestProtest

– Despair Despair

– Denial/DetachmentDenial/Detachment

ToddlersToddlers

– ProtestProtest

• Cry constantly = terrifiedCry constantly = terrified

• Clings to ParentClings to Parent

• Searches for parentSearches for parent

• Avoids and Rejects stranger contactAvoids and Rejects stranger contact

ToddlersToddlers

• DespairDespair-- HopelessnessHopelessness– SadnessSadness– Less Activity & CryingLess Activity & Crying– Regression Regression – WithdrawalWithdrawal– Disinterested in playDisinterested in play– AnorexiaAnorexia

ToddlersToddlers

• Denial/DetachmentDenial/Detachment

Superficial AdjustmentSuperficial Adjustment

- Appears happy- Appears happy

- Eats & plays- Eats & plays

- Accepts other adults- Accepts other adults

- Self-centered behaviors- Self-centered behaviors

- Resignation- Resignation

Nursing InterventionsNursing Interventions

• Accept child’s hostilityAccept child’s hostility• Acknowledge feelings to gain trustAcknowledge feelings to gain trust• Simulate home environment/scheduleSimulate home environment/schedule• Allow maximum mobilityAllow maximum mobility• Provide comfort measuresProvide comfort measures• Allow child to make choicesAllow child to make choices• Encourage parents to stay with childEncourage parents to stay with child

Pre-SchoolPre-School• 3 to 5 years3 to 5 years• Initiative vs. GuiltInitiative vs. Guilt• BehaviorBehavior

– FearFear of : of : MutilationMutilation AbandonmentAbandonment PunishmentPunishment

– Fantasy and unrealistic reasoningFantasy and unrealistic reasoning– Hostility & AggressionHostility & Aggression

•Physical & VerbalPhysical & Verbal

Pre-SchoolPre-School

• Protest, Despair & DetachmentProtest, Despair & Detachment• Nursing InterventionsNursing Interventions

– Allow child to verbalizeAllow child to verbalize– Accept regressive behaviorAccept regressive behavior– Provide play activitiesProvide play activities– Provide honest and simple Provide honest and simple

preparationpreparation•Immediately before procedureImmediately before procedure

School-AgeSchool-Age

• 6 to 12 years6 to 12 years• Industry vs. InferiorityIndustry vs. Inferiority• BehaviorBehavior

– Loneliness & BoredomLoneliness & Boredom– Isolated from PeersIsolated from Peers– Displaced angerDisplaced anger– Postpone proceduresPostpone procedures– Passively accept painPassively accept pain

School-AgeSchool-Age

• Nursing InterventionsNursing Interventions– Explore feelings RT IllnessExplore feelings RT Illness– Encourage child’s participation in careEncourage child’s participation in care

• I & O I & O • Dressing ChangesDressing Changes

– Provide projects & activitiesProvide projects & activities– Encourage peer visits, phone calls, emailEncourage peer visits, phone calls, email

- Arrange tutors for school work- Arrange tutors for school work

AdolescentsAdolescents

• 13 to 18 years13 to 18 years• Identity vs. Role DiffusionIdentity vs. Role Diffusion• BehaviorBehavior

– Rejection, WithdrawalRejection, Withdrawal– Non compliantNon compliant– AnxiousAnxious– Fear of change in body imageFear of change in body image– Loss of identityLoss of identity

AdolescentsAdolescents

• Nursing InterventionsNursing Interventions– Encourage verbalization of feelingsEncourage verbalization of feelings– Help develop + coping skillsHelp develop + coping skills– Explain information honestlyExplain information honestly– Maintain privacyMaintain privacy– Provide demonstrations & encourage Provide demonstrations & encourage

accountabilityaccountability– Allow peer visitations PRNAllow peer visitations PRN– Support pt’s identitySupport pt’s identity

•Decorate room, wear own clothesDecorate room, wear own clothes

Children’s AdjustmentChildren’s Adjustment

• Impacting Factors:Impacting Factors:– Age of child and developmentAge of child and development– Previous health care experiencesPrevious health care experiences– Coping skills/preparationCoping skills/preparation– Nature of health needs Nature of health needs

• Severity of illness and symptomsSeverity of illness and symptoms• Acute vs. chronicAcute vs. chronic• Degree of discomfortDegree of discomfort• Required proceduresRequired procedures• Perception of illnessPerception of illness

Children’s Stress Children’s Stress ResponsesResponses

• Loss of appetiteLoss of appetite• Disinterest in environmentDisinterest in environment• Loss of previously acquired tasksLoss of previously acquired tasks• Regressive behaviorRegressive behavior

– Thumb sucking, bed wettingThumb sucking, bed wetting– Temper tantrumsTemper tantrums– Clinging & IrritabilityClinging & Irritability– Demanding & PossessiveDemanding & Possessive

Pre-Op CarePre-Op Care

• Assess psychological preparationAssess psychological preparation– Ask, “What are you in the hospital for?”Ask, “What are you in the hospital for?”

• Orient to room, staff and unit.Orient to room, staff and unit.• Review process and procedures.Review process and procedures.

– What, where, when, & howWhat, where, when, & how– Use dolls, toys and videos.Use dolls, toys and videos.

PreparationPreparation

• ID Band and alarm tagID Band and alarm tag• Review orders and procedure consentReview orders and procedure consent

– √ √ completion of Pre-Op Check listcompletion of Pre-Op Check list– Encourage questionsEncourage questions

• Parents roleParents role– Comfort and supportComfort and support

• Pre-op MedsPre-op Meds– ValiumValium RobinolRobinol– ““Special Sleep” = AnesthesiaSpecial Sleep” = Anesthesia– AntibioticsAntibiotics

Physical PrepPhysical Prep• Vital Signs:Vital Signs:

– Age, Ht, Wt (kg), HR, RR, T & BPAge, Ht, Wt (kg), HR, RR, T & BP

• √ √ for loose teeth & document!for loose teeth & document!• NPO status – Varies according to ageNPO status – Varies according to age

– Infants: 2-4 h,Infants: 2-4 h, Toddlers: 4-6 hToddlers: 4-6 h, , School-School-Age: 6-8 hAge: 6-8 h

• Review all ordered tests;Review all ordered tests; CBC, UA, X-Rays, Type & X, CBC, UA, X-Rays, Type & X,

completed completed

Results attached & MD notified PRN Results attached & MD notified PRN

• Dress in gown & ID any toy/blanket Dress in gown & ID any toy/blanket • Remove any prosthetic devices; Remove any prosthetic devices;

– Retainers or Body piercingRetainers or Body piercing

• Encourage use of bathroom prior to Encourage use of bathroom prior to transporttransport

• Administer pre-op meds & review SEsAdminister pre-op meds & review SEs• Keep side rails up!Keep side rails up!• Update all documentation & verbally Update all documentation & verbally

review with transport personnel. review with transport personnel. • Review with parents how and where Review with parents how and where

information will be communicated.information will be communicated.

Post-Op Post-Op • First 24 hours are most crucial.First 24 hours are most crucial.• Assessments must be Assessments must be frequent frequent

and completeand complete to identify any to identify any changes in status. changes in status. – Ventilation & PerfusionVentilation & Perfusion– Fluid & Electrolyte BalanceFluid & Electrolyte Balance– Temperature RegulationTemperature Regulation– Energy NeedsEnergy Needs– Pain ManagementPain Management– Reinforce Reinforce necessitynecessity of assessment to of assessment to

parents.parents.

RespiratoryRespiratory

Maintain Airway PatencyMaintain Airway Patency• Rate & RhythmRate & Rhythm• Pulse OximeterPulse Oximeter• Breath soundsBreath sounds

– Anterior & PosteriorAnterior & Posterior– Depth & SymmetryDepth & Symmetry

• Color lips & mucous membranesColor lips & mucous membranes• SecretionsSecretions

– Amount, type, colorAmount, type, color

CardiovascularCardiovascular• Apical Rate & Rhythm Apical Rate & Rhythm

Listen for a Listen for a full minutefull minute!!(Compare with baseline data.)(Compare with baseline data.)

• Blood Pressure Blood Pressure – Check cuff size!Check cuff size!

• Extremities - Compare bilaterallyExtremities - Compare bilaterallyPeripheral PulsesPeripheral PulsesColor & TempColor & TempCapillary RefillCapillary Refill

Neurological StatusNeurological Status• LOCLOC• PERLAPERLA• Behavior/ActivityBehavior/Activity• PAINPAIN

– SS = subjective = subjective– LL = location = location– II = intensity = intensity– DD = duration = duration– AA = associated factors = associated factors

Skin IntegritySkin Integrity

• Check all dressings, wounds, Check all dressings, wounds, drains/tubes.drains/tubes.– Note patency & drainage.Note patency & drainage.– Color & amountColor & amount– Document q h or PRNDocument q h or PRN

• Check dependent areas for breakdown.Check dependent areas for breakdown.• Elevate any edematous areas.Elevate any edematous areas.

Fluid BalanceFluid Balance• Check IV Solution and rate. (Confirm MD orders)Check IV Solution and rate. (Confirm MD orders)

– All Pediatric patients All Pediatric patients must be on IV Pumps.must be on IV Pumps.

• Hydration therapy = ml/kg/dayHydration therapy = ml/kg/day (Ex. 25 kg child) (Ex. 25 kg child)

100 ml (for 1100 ml (for 1stst 10 kg) x 10 kg = 1000 ml/d 10 kg) x 10 kg = 1000 ml/d 50 ml (for 250 ml (for 2ndnd 10 kg) x 10 kg = 500 ml/d 10 kg) x 10 kg = 500 ml/d 20 ml (Per add’l kg) x 20 ml (Per add’l kg) x 5 kg = 100 ml/d5 kg = 100 ml/d

25 kg25 kg = = 1600 ml/d or 65 ml/h1600 ml/d or 65 ml/h• Fluid Deficit (FD)Fluid Deficit (FD)

FD = FD = Pre-illness weight (kg) – Current weight (kg)Pre-illness weight (kg) – Current weight (kg)Pre-illness weight (kg)Pre-illness weight (kg)

Strict I & O.Strict I & O.• All fluids: PO, IV, urine, feces, emesis, diaphoresis & All fluids: PO, IV, urine, feces, emesis, diaphoresis &

wound drainage.wound drainage.

GastrointestinalGastrointestinal• NPO untilNPO until

– Positive Gag reflex & Bowel sounds x 4Positive Gag reflex & Bowel sounds x 4• Nausea & Vomiting (N & V)Nausea & Vomiting (N & V)

– Amount & type of emesisAmount & type of emesis– Medicate as ordered: Medicate as ordered: – Tigan 100-200mg PR Tigan 100-200mg PR – Zofran 0.1 mg/kg/dose x 1 IVZofran 0.1 mg/kg/dose x 1 IV

• Abdominal Distention; Abdominal Distention; ++ measure Abd. Girth measure Abd. Girth• NG tubeNG tube

– PatencyPatency– Drainage Drainage

» Color, viscosity and amountColor, viscosity and amount

ThermoregulationThermoregulation• TemperatureTemperature

– Rectal most accurateRectal most accurate– Oral when compliantOral when compliant– Tympanic unreliableTympanic unreliable

• ShiveringShivering– Increases BMR & TempIncreases BMR & Temp

• ExtremitiesExtremities– Color & TempColor & Temp

Pain ManagementPain Management

• Assess pain accurately with appropriate scale;Assess pain accurately with appropriate scale;– Faces, numbers, colors or FLACCFaces, numbers, colors or FLACC

• Review prior effective RXReview prior effective RX– Tylenol vs. Motrin vs. OpiodsTylenol vs. Motrin vs. Opiods

• Interventions, least to most invasive:Interventions, least to most invasive:– PositioningPositioning– Distraction/Guided ImageryDistraction/Guided Imagery– MassageMassage– Medications IV or PO never IM!Medications IV or PO never IM!

– No Demerol!No Demerol! (Metabolite = ↑ seizures) (Metabolite = ↑ seizures)– Morphine (MSO4) 0.1 – 0.2 mg/kg/dose q 2-4h PRN Morphine (MSO4) 0.1 – 0.2 mg/kg/dose q 2-4h PRN – Max MSO4 = 15mg/doseMax MSO4 = 15mg/dose

Parents’ NeedsParents’ Needs

• Review child’s statusReview child’s status– Procedures, explain equipment used, etc.Procedures, explain equipment used, etc.– Anticipated LOS and treatments ordered.Anticipated LOS and treatments ordered.

• Review family role: Review family role: – ComfortingComforting not monitoring not monitoring– Collaborative partners in careCollaborative partners in care– Encourage verbalization of concernsEncourage verbalization of concerns

• Reinforce need for frequent Reinforce need for frequent assessmentassessment

– Based on child’s condition!Based on child’s condition!

Patient AdvocacyPatient Advocacy

• You have more than one patient!You have more than one patient!

• Optimal outcome for all:Optimal outcome for all:– ChildChild

•Physical and emotionalPhysical and emotional– ParentsParents

•EmotionalEmotional

+ Healthcare experience+ Healthcare experience

• Rev 6/09Rev 6/09