Pediatrics Physical Assessment/Pain/Interventions/FCC fsu nursing – Flashcards
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Goals of Pediatric Assessment
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• Minimize stress and anxiety associated with assessment -trusting nurse-child-parent relationships • Preserve security of parent-child relationship (not making parents the bad guy) -knowing differences in normals/abnormal acting fast upon it
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Preparation of the Child
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• Child's perception of painful procedures- perception is reality • Cooperation enhanced with parent's presence • Age-appropriate techniques
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Pediatric facts
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Body surface area-large for weight - hypothermia Anterior fontanel and open sutures palpable up to 18-24 months. Posterior fontanel closes 2-3 months Up to 6 to 7 years old, diaphragm is primary breathing muscle=respiratory acidosis Children will compensate for a long time and then deteriorate quickly unlike adults
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Physical Exam: Physical Apearance
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color of skin/nailbeds, facial expressions and appearance (scared, happy, unhappy, distress, etc), LOC (awake, alert, oriented), hygiene (unkempt or clean, odor, condition of teeth, hair, nails), symmetry of extremities or body parts, any swelling or abnormal coloring
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Physical exam: s/s of distress
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-respiratory rate (nasal Flaring, Retractions), effort of breathing, use of accessory muscles, LOC (Glasgow coma) -color around mouth/central body(mottled,pink, blue), diaphoresis, nasal flaring, head bobbing,
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Physical exam: Nutrition
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• State of nutrition- malnourished, over/underweight, what are they eating (look around the room at the trays, cups, snacks, etc)
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Physical exam: Behavior/Personality
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Interactions with parents/siblings, nurses; personality (easy going, difficult, slow to warm up), activity level (children's job is to play, if they are not playing or are very active this is a good indicator of feeling very bad), reaction to stress, frustrations, requests
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Physical Exam: • Posture and movement
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- able to sit, crawl, stand, walk and if so how well or with any issues, types of body movements, favoring a body part (pain, injury, IV), body language
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Physical Exam: • Development
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gross/fine motor movements and also include info under behavior, speech, personality.
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Physical Exam: Speech
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based on age/development can they or should they be speaking? If so is it clear, understandable, appropriate (Glasgow coma scale), do they speak without you in the room
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Physical Exam: Head and neck
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Bulging- increased intracranial pressure (fluid overload, infection, mass). Sunken- dehydration or loss of CSF. Normal finding is flat, soft and non-tense. *can also feel if have a temperature**can feel startle or if alert X3*
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Physical Exam: Eyes
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symmetry, drainage, redness, swelling, abnormal eye movements or position, tears with crying (dehydration if not present), PERRLA
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Physical exam: Ears and nose
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• For Infants to 3 years of age- the canal curves upward so you need to pull the pinna down and back towards 6 to 9 o'clock. • For children older than 3 years of age- the canal curves downward and forward so you need to pull the pinna up and back towards 10 o'clock.
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Physical exam: Chest
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-Inspection- size, skin (color, rashes, markings), shape, symmetry, movement, breast development, and bony landmarks -Palpation- movement, temperature, moisture, texture. Palpation can be very helpful with counting respiration's as well
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Physical Exam: Chest Movement
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-In children less than 6-7 breathing is primarily abdominal -children (>7yo) breathing becomes more thoracic **intercostal retractions and if left untreated will lead to sternal and suprasternal retractions* (NEED TO ACT QUICKLY)
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Physical Exam: Lungs
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-Inspection (this goes along with chest movement)-rate, rhythm (regular, irregular, periodic), depth (deep or shallow), quality (effortless, difficult, or labored). Note characteristics of lung sounds
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Physical Exam: Lungs Auscultation
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-. Compare anterior and posterior, left to right and upper and lower. Ideally needs to be done when child is calm, not crying -Blow pinwheels, bubbles, blow out birthday candles to get kids to take deep breaths (encourage deep breaths) -Also need to listen to neck for stridor or constriction of trachea
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Physical exam: Heart--Inspection-
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-Inspection- may see pulsation in very thin children on the chest. Also need to evaluate skin color, neck veins (distended), clubbing of fingers, peripheral/central cyanosis, edema, blood pressure and respiratory status to fully evaluate cardiac functions/status.
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Physical exam: Heart--Palpate/Auscultate
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-point of maximum impulse (PMI)****, radial and pedal pulses (compare right to left, upper to lower) and move inward towards more central pulses if you need to. Cap refill. -listening- same as adults
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Physical Exam: Neurological
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• Glasgow coma scale (LOC) 15 norm/8definite coma/3 deep coma and Orientation pg 1419 • Vital signs • Neuromuscular assessment and posturing • PERRLA • Protective reflexes (pupillary, cough, gag)
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Assessment of Acute Pain and common causes
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• Medical procedures (IV, Immunizations, blood draws, LP, wound care/dressing changes) • Surgical and orthopedic procedures • Medical treatments • Injury (fractures, burns, falls, MVAs) • Infection • Exacerbation of disease-related pain (arthritis, cancers, sickle-cell crisis
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Pain Intensity/Rating Scales
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FLACC (pg 830)- 2 mos to 7 yrs. Range 0 (no pain) to 10 (worst pain). Face (0-2) Legs (0-2) Activity (0-2) Cry (0-2) Consolability (0-2) Wong-Baker FACES (pg 830) Numeric Pain Scale (pg 832) *know categories of this (what age would you use for?)
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Pain Management
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- Nonpharmacologic management (1st option) • Distraction • Relaxation • Guided imagery • Cutaneous stimulation • Containment and swaddling • Nonnutritive sucking • Kangaroo care
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Pharmacologic management
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-•Pre-treat for pain whenever possible -• Doses are calculated according to body weight except in children with a weight greater than 50kg (110lbs), in whom the adult dose would be used -medications are based on mg/kg/dose
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Pharm treatment: Ranges
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-(NSAIDs) are good choices for mild pain (<3 on 0-10 scale) -• Opioids are needed for moderate (3-6) to severe pain (7-10). -• Transmucosal and transdermal analgesia=be EMLA (60 minutes) or LMX (15 minutes)-
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pharm lookup: pain
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Monitoring side effects- review side effect management table 30-5
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How often do we check for pain?
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15-30min after each dose
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Transporting Patients
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-Always transport in a bed or secured in a chair. Parents can hold on lap in a wheelchair if bed is not needed for testing/procedure -Need to make sure you/family is using safe holds (cradle, football etc) -extended trips: Bassinettes or cribs Strollers or wagons Wheelchair or stretcher
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Npo peds for surgeries
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-Children may be permitted clears up till 2 hours before procedure or breastmilk until 4 hours
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Controlling elevated temperatures or hyperthermia
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-Acetaminophen and Ibuprofen are the most common. Ibuprofen can only be used in children older than 6 months (PARENT EDUCATION).
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Tylenol dosages
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10-15mg/kg/dose every 4-6 hours Maximum total daily dose: 75 mg/kg/day
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Ibuprofen Dosages
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• Ibuprofen dosage: 10mg/kg/dose. Maximum dose is 40mg/kg/day
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Intravenous Devices
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Assure that it will be removed as soon as the child is better Children may believe that the fluid will poison them A child may not understand the need for an IV especially if they are not "feeling sick" Be sure to acquaint the child with the equipment - use a doll to demonstrate Explain how the IV will effect mobility - explain how to roll IV poles and manipulate movement with active children Be sure to explain to the child and parents about playing or pulling on IV tubing Teach older children and adolescents about the signs and symptoms of infiltration and phlebitis
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• IV Site Selection
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- Infants and small children - scalp vein and superficial hand or arm veins are the sites most commonly used. - Foot or leg veins - these accesses the chance of thrombophlebitis & embolism so are used cautiously. - Use small gauge catheters (24 and 22)
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Iv assessment
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IV site without fluids- assess every 4 hours/flush once a shift IV site with fluids running need to assess every hour and set volume on pump for no more than 2 hours
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• Site protection- page 1175 Evidence based practice
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-hidden" from view (dont keep hidden) Med-cup cut in half lengthwise & tape over site (dont use) Arm boards and stockenette (not wrapped in gauze) -Do not use scissors and if you do make sure all fingers/toes are accounted for **use a commercial iv house protectant)
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• Peripherally inserted central catheters (PICCs)-
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-used for short-term or moderate-length therapy -Need two people to make sure arm stays still and PICC is stable.
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• Long-term tunneled catheter
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-Hickman, Broviac (most common), Groshong -Can be pulled out or dislodged easily -Reduces a childs ability to take baths or swim (risk infection/daily heparin flushes/pt must learn cath care)**risk infection**
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• Short term/nontunneled catheter
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Used in emergency situations when other access can't be obtained. Ex- femoral, jugular, subclavian (temporary)
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NG tube (5fr,8fr,10fr)
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pros:• Ability to administer medications/feedings around the clock without disturbing the child Cons:• Occlusion, clogging -Usually 3-10ml after meds or feeds
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• Gastrostomy feedings
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-used for children who require tube feedings for an extended period -May need to secure/hide the tubing from child so it is not pulled out. -in place for usually 3 months and then switched to a skin-level device (MIC-KEY button)
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Maintaining Fluid/ Diaper weight
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-weigh dry diaper and subtract that weight from wet diaper weight.
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Parenteral Fluid Therapy1: Infusion pumps
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-Calculate the amount to be infused -Set the infusion rate -•Monitor the device frequently (every 1-2 hours) *
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Iv Fluid therapy: Buretrols
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used to prevent more than 1 to 2 hours' worth of volume/medication to be given to a patient accidentally.
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Calculation of IV fluids Rate
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1-2ml/kg/hr
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Maintenance fluids are calculated based on body weight:
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0-10kg- 100ml/kg/day, 11-20kg- 1000ml + 50ml/kg/day for each kg >10 kg >20kg- 1500ml + 20ml/kg/day for each kg > 20 kg - Maximum total fluids are normally 2400ml/day
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Bolus
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- 10-20ml/kg per bolus -In severe dehydration you will give 20ml/kg bolus and push it • Can only bolus with NS (most common) or LR
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Iv electrolytes/Nutrition
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D5 ½ NS with 20 mEq/KCL D5 ¼ NS with 20 mEq/KCL (mild dehydration) Potassium (KCL) is only added after patient has urine output or serum potassium is determined. Dehydration can be associated with hyperkalemia. "No pee, no K"
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Aerosol Therapy
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•Deposits medication directly into the airway (nebulized medications, breathing treatments, inhalers/MDI) -Challenging in children who are too young to cooperate with controlling rate and depth of breathing
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Peds Inhalation therapy
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-Nasal cannula- 1/32 L to 2 L is most common -Will need to tape to cheeks and loop around the back of the head (key to keeping it on them)
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Regulating/monitoring 02
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-Weaning oxygen is a slower process -Monitoring O2 therapy- least invasive way is through the use of pulse ox. ***
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Bronchial (postural) drainage
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-done 3-4 times a day for about 20-30 minutes at a time -before meals or 1 ½ to 2 hours after meals (so dont vomit) -Most effective after bronchodialators/nebulizers are given
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Chest PT
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-helps to enhance clearance of mucus from airways -performed over the rib cage (anterior, posterior and axillary areas) -should hear a "popping" sound
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Chest PT- contraindications
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pulmonary hemorrhage, pulmonary embolism, end-stage renal disease
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Tracheostomy: intervention
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-Need to maintain patient airway, facilitate the removal of secretions, provide humidified air or oxygen, clean the stoma, assess child's ability to swallow.
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Tracheostomy: Required at the bedside
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trach tube of the same size (ties attached) and trach tube one size smaller, obturator.
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Tracheostomy: routine care
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-ties are changed daily -trach changed daily (dr does first, then 2 RN JOB) *steps*
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Major stressors of hospitalization include
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separation, loss of control, bodily injury, and pain.
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2. Separation Anxiety
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can be seen in children (protest, despair, detachment)
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Early childhood-toddlers
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toddlers(temper-tantrums, bedwetting, refusal to listen or comply with parent or regression of behavior) can also be a sign of anger
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Preschoolers
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-more secure and can handle brief periods of separation. -May see refusal to eat, decrease sleeping, crying for parents, withdrawl, breaking toys, hitting or refusal to cooperate.
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Late childhood and adolescence
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-Family does not play as important a role as peers -still tho Do not like to be alone in an unfamiliar environment. -• Maybe be seen as feelings of boredom, lonliness, isolation, and depression -Can be irritable, aggressive behavior, withdraw
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Changes in pediatric populations: Rn changes
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is really important to address and meet the developmental and psychosocial needs of the child in the hospital to avoid detrimental consequences of prolonged hospitalization.
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Beneficial Effects of Hospitalization
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• Recovery from illness • Competence in abilities to cope • Mastery of stress • New socialization experiences
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Parental reactions
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- we need to remain calm and non-judgemental -address their concerns and issues
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Sibling reactions
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----Experiencing many changes and being too young to understand them (loneliness, fear, worry, anger, resentment, jealously and guilt) ---- Being cared for by nonrelatives or outside of the home --Receiving little information about the ill brother or sister ----Perceiving that parents will treat the sick child differently
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Nursing care for the child and family who is hospitalized
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-we at least orient them to hospital routines, establish expectations/rules, and allow for questions
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preparing child for admission 2. Box 38.7
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Need to establish a relationship before we walk in and start asking question (creating trust)Pre admission:assign room base on dev stage/prepare roommates/admission forms for parents(eliminate need 4 leaving child) Admission:intro rn to them/explain room-call light bed/tvs)unit/ intro roommate/apply band/hosp rules/then vitals..
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Preventing or minimizing separation
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Parents are welcome anytime (no visitation hours anymore), chairs/beds for families, unit kitchen priveleges, Ronald McDonald housing, hotel vouchers, gas/phone cards.
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RN Care to help with seperation from parents
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1. Make sure we have contact info for parent/caregiver 2. Memorabilia from home (pictures, cards, books, clothing, etc) 3. Security objects if needed 4. Technology (facetime, skype, etc) 5. Decorate the walls with pictures, cards, rearrange furniture (make it their room)
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Minimizing loss of control
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-Promoting freedom of movement -keep parents involved -Appropiate cribs/beds -if isolation: (bring toys to child in room, move bed towards window, provide distraction activities)
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Maintaining child's routine
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-This info (naptime, feedings, bedtimes, routines are all part of the admission assessment) -You can work with the child, family, child-life specialist and establish a daily routine
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Encouraging independence and industry
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-requires us a nurses to be flexible and tolerant -helps to maintain the childs independence but also promotes their own involvement in their healthcare -Allow them to help in anyway possible (bathing, dressing changes, fingersticks, med administration, flushing IVs
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Providing developmentally appropriate activities
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-Remember these activities need to based on normal/child growth and development -Play is a child's job and integral part in development and an effective way to manage stress in a child -Use playrooms/activity centers (older school age/adolescent terminology) Box 38.9
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Examples of Activities/playrooms etc -1. Diversional activities
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-. Ex: crayons, coloring books, arts/crafts, model kits, playhouses, sandboxes, blocks, instruments, games (alone or with person), reading material, puzzles and puzzle books, movies, music, xbox/playstation, computers
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Expressive Activities
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-help to encourage emotional expression. May be used as a psychologic technique by trained therapists
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Toys
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-Physically active toys bikes, wagons, balls, swinging, beanbags, pounding boards,etc help with extra energy and aggression/aggravation (rewarding for possibly behaving well etc)
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Creative Expression-
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-drawing, painting, dancing/music
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Dramatic Play-
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acting/dress up, puppets, dolls, demonstration of procedures on doll/stuffed animal.
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Supporting family members
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-willingness to stay and listen to parents verbal/nonverbal messages.
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Family: Providing information
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-Education and Information are number 1 priority. -When they know what to expect it decreases fear and anxiety.
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Family: Encouraging parent participation
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-You are team with parents/caregivers and need to work together for the best outcomes for the patient. -need to take care of the parents. They become tired, stressed, scared and exhausted too
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Special Hospital Situations:A. Ambulatory or outpatient setting
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1. Helps minimize stress of hospitalization 2. Reduces chance of infection 3. Increases cost savings 4. Is most frequently used for surgical or diagnostic procedures 5. Education is huge because you have limited time
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Special Hospital situations: Isolation
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-Added stressor of hospitalization- can be viewed as punishment -Potential for sensory deprivation and restriction of movement/independence; need to provide appropriate diversional activities/toys. (remember for proper clening of toys brought into isolation)
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Emergency admission
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-focusing assessment on ABC's -use of childs name- info childs chief complaint etc.
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Intensive Care unit
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-prepare parents for childs appearance -providing info to parents ex where to stay, visiting hr etc
