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Pediatric Assessment Elisa A. Mancuso RNC, MS, FNS Professor of Nursing Course Requirements Course Objectives Schedule-Lecture & Clinical Assignments- (Page 7 & 8) Lecture- 3 exams = 95% + 1 ATI Exam (5%) = 100% Clinical- (Packet page 2.) 1 Pediatric NCP 2 Journals Daily Nursing Process Plan (1 per patient) 1 Clinical Case Study Presentation Leadership Assignment Assignments not submitted on time will result in a failed clinical day. Maximum 2 failed clinical days for NUR 246. Course Requirements Academic Integrity = Professionalism! BLS CPR certification must be current until 12/22/11 Dosage Calculation Assessment 90% or higher to pass IV rates (gtts/min) Conversions: mg ↔ grains , grams ↔ micrograms Pediatric Calculations: mg per kg = dose 2.2 pounds = 1 kg Two opportunities within one week. Texts Required (page 10) ATI: Nursing care of children: RN edition - 8.0 Elllis and Hartley (2009) Managing and coordinating nursing care (5th ed.) ISBN-13: 9780781774109 London, M. et al (2011) Maternal & child nursing care. (3rd ed) ISBN- 13: 978-0-135-07846-4. London, M., et al (2011) MyNursingLab with Pearson eText Student Access Code Card for Maternal and Child Nursing Care (3rd ed.) ISBN-13: 978-0-132-11511-7). URL: http://www.mynursinglab.com Suffolk County Community College NUR 246/248 Case Studies Maternal & Child Health Nursing (2010) ISBN-13: 978-0-558-72350-7 Pediatric Assessment Children are not small adults! Family Involvement Identify their developmental level and needs: Infants - Trust vs. Mistrust Toddlers - Autonomy vs. Shame & Doubt Preschool – Initiative vs. Guilt School-Age – Industry vs. Inferiority Adolescent – Identity vs. Role Confusion Establish Trust Approach adult first, then acknowledge child. Get down to child’s eye level. Identify self and nature of visit. Reinforce what will be done and how it will feel. Maintain a sense of humor and have fun! Communication is Key Recognize developmental needs. Use age appropriate language. Assess child’s prior health care experiences. Encourage child to answer questions independently. Encourage child to ask questions. Provide privacy from family/parents if desired. Listen Physical Exam Let child handle equipment. “Examine” toys or doll first. Allow patient to examine doll or RN. Provide information during exam. Encourage child to participate. Be honest and prepare for all sensations child may experience. Select a coping technique; hold bear, wiggle toes. Illness and Hospitalization Major life crisis. Change from usual state of health and routine. Loss of control. Unfamiliar environment and people. Parental response Anger At child for becoming ill & causing stress Revise routine to accommodate work and child Anxiety Regarding potential diagnosis & painful procedures Financial and family obligations. Guilt Did they cause their child’s illness? Parental response Loss of Objectivity Apply different rules to ill child Allow manipulation by ill child. Healthy children are “forgotten” Feelings of Inadequacy Feel helpless in parenting role Allow staff to assume decision making and caretaking responsibilities. Children’s Response Infants 0 to 1 year Trust vs. Mistrust Separation Anxiety @ 6 months Behavior Body Rigidity Irritability Altered Feeding, Sleeping and Stool patterns Infants Nursing Interventions Primary RN for consistency Encourage parents to participate in care Simulate Bath home routine time, Meal time & Nap time Bring familiar objects from home Allow self-comforting Pacifier, Blanky or lovey Toddlers 1 to 3 years Autonomy vs. Shame and Doubt Behavior Seeks independence “Me Do” Mobility = Control Temper Tantrums Separation anxiety @ 18 – 24 mos. Toddlers 3 Distinct Stages of Separation Anxiety Protest Despair Denial/Detachment Toddlers Protest Cry constantly = terrified Clings to Parent Searches Avoids for parent and Rejects stranger contact Toddlers Despair Hopelessness Sadness Less Activity & Crying Regression Withdrawal Disinterested in play Anorexia Toddlers Denial/Detachment Superficial Adjustment Appears happy Eats & plays Accepts other adults Self-centered behaviors Resignation Nursing Interventions Accept child’s hostility Acknowledge feelings to gain trust Simulate home environment/schedule Allow maximum mobility Provide comfort measures Allow child to make choices Encourage parents to stay with child Pre-School 3 to 5 years Initiative vs. Guilt Behavior Fear of : Mutilation, Intrusion, Abandonment and Punishment Fantasy and unrealistic reasoning Hostility & Aggression Physical & Verbal Pre-School Protest, Despair & Detachment Nursing Interventions Allow child to verbalize Accept regressive behavior Provide play activities Provide honest and simple preparation Immediately before procedure School-Age 6 to 12 years Industry vs. Inferiority Behavior Loneliness & Boredom Isolated from Peers Displaced anger Postpone procedures Passively accept pain School-Age Nursing Interventions Explore feelings RT Illness Encourage child’s participation in care I&O Dressing Changes Provide projects & activities Encourage peer visits, phone calls, email Arrange tutors for school work Adolescents 13 to 18 years Identity vs. Role Diffusion Behavior Rejection, Withdrawal Non compliant Anxious Fear of change in body image Loss of identity Adolescents Nursing Interventions Encourage verbalization of feelings Help develop + coping skills Explain information honestly Maintain privacy Provide demonstrations & encourage accountability Allow peer visitations PRN Support pt’s identity Decorate room, wear own clothes, Children’s Adjustment Impacting Factors: Age of child and development Previous health care experiences Coping skills/preparation Nature of health needs Severity of illness and symptoms Acute vs. chronic Degree of discomfort Required procedures Perception of illness Children’s Stress Responses Loss of appetite Disinterest in environment Loss of previously acquired tasks Regressive behavior Thumb sucking, bed wetting Temper tantrums Clinging & Irritability Demanding & Possessive Pre-Op Care Assess psychological preparation Orient to room, staff and unit. Review process and procedures. What, where, when, & how Use dolls, toys and videos. Preparation ID Band and alarm tag Review orders and procedure consent Parents role √ completion of Pre-Op Check list Encourage questions Comfort and support Pre-op Meds Valium Robinol “Special Sleep” = Anesthesia Antibiotics Physical Prep Vital Signs: √ for loose teeth & document! NPO status – Varies according to age Age, Ht, Wt (kg), HR, RR, T & BP Infants 2-4 h, Toddlers 4-6 h, School-Age 6-8 h Review all ordered tests; CBC, UA, X-Rays, Type & X, etc are completed Results attached & MD notified PRN Dress in gown & ID any toy/blanket child takes. Remove any prosthetic devices; Retainers or Body piercing Encourage use of bathroom prior to transport Administer pre-op meds & review SEs Keep side rails up! Update all documentation & verbally review with transport personnel. Review with parents how and where information will be communicated. Post-Op First 24 hours are most crucial. Assessments must be frequent and complete to identify any changes in status. Ventilation & Perfusion Fluid & Electrolyte Balance Temperature Regulation Energy Needs Pain Management Reinforce necessity of assessment to parents. Respiratory Maintain Airway Patency Rate & Rhythm Pulse Oximeter Breath sounds Anterior & Posterior Depth & Symmetry Color lips & mucous membranes Secretions Amount, type, color Cardiovascular Apical Rate & Rhythm Listen for a full minute! (Compare with baseline data.) Blood Pressure Extremities - Compare bilaterally Peripheral Pulses Color & Temp Capillary Refill Neurological Status LOC PERLA Behavior/Activity PAIN S = subjective L = location I = intensity D = duration A = associated factors Skin Integrity Check all dressings, wounds, drains/tubes. Note patency & drainage. Color & amount Document q h or PRN Check dependent areas for breakdown. Elevate any edematous areas. Fluid Balance Check IV Solution and rate. (Confirm MD orders) All Pediatric patients must be on IV Pumps. Hydration therapy = ml/kg/day (Ex. 25 kg child) 100 ml (for 1st 10 kg) x 10 kg = 1000 ml/d 50 ml (for 2nd 10 kg) x 10 kg = 500 ml/d 20 ml (Per add’l kg) x 5 kg = 100 ml/d 25 kg = 1600 ml/d or 65 ml/h Fluid Deficit (FD) FD = Pre-illness weight (kg) – Current weight (kg) Pre-illness weight (kg) Strict I & O. All fluids: PO, IV, urine, feces, emesis, diaphoresis & wound drainage. Gastrointestinal NPO until Positive Gag reflex & Bowel sounds x 4 Nausea & Vomiting (N & V) Amount & type of emesis Medicate as ordered: Tigan 100-200mg PR Zofran 0.1 mg/kg/dose x 1 IV √ Abdominal Distention; & measure Abd. Girth (cm) NG tube Patency Drainage Color, viscosity and amount Thermoregulation Temperature Shivering Rectal most accurate Oral when compliant Tympanic unreliable Increases BMR & Temp Extremities Color & Temp Pain Management Assess pain accurately with appropriate scale; Review prior effective RX Faces, numbers and/or colors or FLACC Tylenol vs. Motrin vs. Opiods Interventions, least to most invasive: Positioning Distraction/Guided Imagery Massage Medications IV or PO never IM! No Demerol! (Metabolite = ↑ seizures) MSO4 0.1 – 0.2 mg/kg/dose q 2-4h PRN (Max dose = 15mg) Parents’ Needs Review child’s status Procedures, explain equipment used, etc. Anticipated LOS and treatments ordered. Review family role: Comforting not monitoring Collaborative partners in care Encourage verbalization of concerns Reinforce need for frequent assessment Based on child’s condition Patient Advocacy You have more than one patient! Optimal outcome for all: Child Physical and Emotional Parents Emotional + Healthcare experience Rev 1/11