Test 1 Objectives - Lecture notes 1-4 PDF

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Pediatric Nursing course with Dr. Brasher and Dr. Moreland...

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Week 1 Objectives Chapter 4- Communication, Physical, and Developmental Assessment 1. Identify strategies to effectively communicate with pediatric patients and their family a. establish setting (introduction/ privacy/ confidentiality); play provision to keep child distracted during parent-nurse interview b. encourage parents to talk during interview c. direct the focus: guiding statements, listening/ using silence, empathy d. anticipatory guidance: provide families with info on normal growth/ nutrition, safety, etc. e. avoid information overload 2. Identify methods to effectively complete an interview with the family of a pediatric patient a. I messages: instead of saying you start with “I sometimes…” b. Third person: “some parents find this helpful…” 3. Perform a complete age-specific head-to-toe assessment a. infants i. sequence: examine heart, lungs, abdomen, hips→ spine, back, sacrum (traumatic procedures last) ii. prep: undress to diaper, distraction techniques b. toddler i. sequence: minimal physical contact initially, play, auscultate, percuss, palpate while quiet ii. prep: parent removes clothing, allow them to inspect equipment, praise the child c. preschool i. sequence: perform head to toe if cooperative ii. prep: children undress, brief demonstration of equipment, describe the process 4. Understand the importance of a thorough history a. Chief Complaint (CC): establish reason for seeking health care b. History of Present Illness (HPI): obtain all details related to CC c. Medical History: birth history, dietary history, illness/ injuries, allergies, vaccines, medications, growth/ development, sexual history (adolescents) 5. Identify how to obtain physiologic measures in the pediatric patient a. count respirations first (before disturbing the child) b. count apical heart rate second c. measure BP third d. measure temp. last 6. Understand the importance of atraumatic care a. avoid invasive procedures when possible, choose words carefully 7. Understand the key components of the individual systems during a physiologic assessment (i.e., what are we looking for?) ati ch. 2 a. growth measurements, growth charts b. temp: method based on facility, age, development, illness severity i. axillary for infants, tympanic/ axillary/ oral for toddlers and older

c. pulse: 92% (ideally near 100%) g. skin: birthmarks, palms, abuse, lesions/ rashes, color, texture, temp. HSN i. cafe au lait (not size and #; implicated neurofibromatosis) ii. mongolian spot: present at birth and fades iii. palm creases: Simian crease (transverse palmar crease)--> Down Syndrome iv. palpable lymph nodes; are they painful, red, moveable h. head and neck: shape, symmetry, head control/ range of motion, facial symmetry/ movement/ appearance, fontanels (anterior→ 12-18 months; posterior→ 2-3 months) i. ears: i. external structures alignment, pits/ tags/ sinuses/ discharge ii. internal: assess canal/ tympanic membrane→ pull pinna down and back j. nose: internal turbinates, septum, smell k. mouth/ throat: lip color/ moisture, tongue movement/ appearance, buccal mucosa, thrush, dentition, tonsils/ uvula/ oropharynx l. chest: size, shape, symmetry, movement, breast development m. lungs: breathing effort, rate/ rhythm, depth, quality, retractions, sounds n. heart: apical pulse, rate, rhythm, sound (murmur 1-5), heaves, thrills, lifts o. abdomen: 4 quadrants, inspection (umbilicus stump falls at 2 weeks), hernias), auscultation (sounds), palpation p. genitalia: tanner staging, signs of abuse (tears, bruising, discharge) q. spine and extremities: curvature, tuft of hair/ dimples (spina bifida), ROM, joints, muscles (strength, ROM, gait, posture), deformities r. neuro: physical, behavioral, emotional, cerebellar function, reflexes (primitive reflexes, DTRs), cranial nerves i. babinski reflex gone by 1 year (fanning of toes) s. developmental: denver ii, ages/stages, autism Chapter 5- Pain Assessment and Management in Children 1. Identify influencing factors on pain assessment a. age, developmental level, cause/ nature of pain, ability to express pain, cultural consideration 2. Understand the differences in the types of pain (e.g., chronic, recurrent) a. acute: less than 3 months b. chronic: longer than 3 months or after illness has been resolved (headaches) c. recurrent: pain that is episodic/ recurs (migraines, sickle cell pain, etc.) 3. Understand how to appropriately assess pain in children a. behavioral (infants to age 4 years)

i. observational→ vocalization, facial expression, body movements, crying, rigidity/ sudden movements ii. FLACC scale (2m-7y): facial expression, leg movement, activity, cry, consolability iii. CRIES (neonates)- observational; crying, requires O2, increased BP/HR, expression, sleepless b. self report (> 4 years) i. faces scale, numeric rating scale (8y and older) c. children with communication/ cognitive impairment i. high risk for inadequate treatment of pain ii. Non-Communicating Children’s Pain Checklist (NCCPC): vocal, social, facial activity, body and limbs iii. Pain Indicator for Communicatively Impaired Children d. Children with chronic and complex pain i. difficult to isolate pain symptom from other symptom (children with cancer) ii. rating pain does not always accurately convey how they really feel e. Assessment components: OLDCARTS (onset, location, duration, characteristics, aggravating factors, relieving, severity), is current treatment effective 4. Identify how and when to evaluate pain relief a. dangers of unrelieved pain: longterm consequences, physiologic stress: increased ICP, HR, RR, BP, decreased SaO2, behavioral changes (muscle rigidity, facial expression, crying, withdrawal, sleeplessness, chronic pain syndromes b. nonpharmacologic interventions i. distraction, relaxation, guided imagery, cutaneous stimulation ii. decrease perceived threat of pain, provide sense of control, enhance comfort, promote rest/ sleep iii. infants 1. non-nutritive sucking (pacifier), sucrose, swaddling/ containment 2. kangaroo holding (skin to skin contact) c. medications i. nonopiods→ mild to moderate pain (acetaminophen, ibuprofen) 1. antipyretic, antiinflammatory, analgesic 2. good for nociceptive pain (tissue injury) ii. opiods→ moderate to severe pain (morphine, codeine, hydromorphone, fentanyl, oxycodone) 1. potential side effects: constipation, respiratory depression, sedation, N/V, agitation, mental clouding, tolerance, withdrawal 2. physical dependence: stopping the opioid results in withdrawal symptoms iii. timing is important 1. continuous pain→ around the clock (ATC); helps to avoid pain breakthrough 2. clock-watching: can occur with prn orders; meds administered only when pain has broken through→ can result in higher

dosages leading to a cycle of undermedication and overmedication and drug toxicity→ erratic pain control 3. Patient controlled analgesia (PCA) 4. basal rate: amount given every hour 5. bolus doses iv. transdermal analgesia 1. fentanyl transdermal patch (Duragesic), anesthetic creams (EMLA, LMX), refrigerant sprays (ethyl chloride, floromethane→ work quickly) v. evaluating effectiveness 1. when?--> 15-30 minutes after intervention 2. document finding and complete ongoing assessments d. cultural barriers to pain treatment i. inadequate assessment, concern about side effects, fear that pain equals worse disease, reluctance to report pain/ take pain meds Chapter 22- Family Centered Care of the Child During Illness and Hospitalization 1. Understand the effects of hospitalization on the child and the family a. alters the parental role: helpless, questioning staff skills, need info to be explained in simple language, fear, uncertainty b. siblings: loneliness, fear, jealousy, guilt c. infants and preschool: separation anxiety, stage of protest (inconsolable, refusing attention), stage of despair (depression, withdrawn, distraction, inactive), denial/ detachment (resigned from the fact that the mother is gone) d. early childhood: separation anxiety is greatest e. late childhood to adolescence: loneliness/ isolation, fear of treatment, anger, sadness, stress, regression 2. Identify ways to minimize loss of control in the pediatric client during hospitalization a. consulting child life b. promote freedom of movement, minimize/ preventing fear of bodily injury, maintain routine and independence (provide info/ resources) 3. Understand the importance of play during hospitalization a. provide diversions, creative expression Chapter 10- Health Promotion of the Infant and Family 4. Describe the major physical and developmental milestones expected in the first year as discussed in class a. rapid growth during 1st year (2x birth weight by 6 months, 3x birth weight by 1 year) i. will lose up to 10% of birth weight by 3-4 days and regained after 10th14th day ii. gain about 1.5 lbs per month during first 5 months b. avg. height is 74 cm by 1 year, birth length has increased by almost 50% i. grown about 2.5 cm per month in first 6 months c. head growth is rapid (46 cm by 12 months)--> avg. head circumferance btw 33-35

cm i. posterior fontanel fuses by 6-8 weeks ii. anterior fontanel fuses by 12-18 months d. teeth: 6-8 teeth by 1 year e. parachute reflex appears by 7 months f. moro reflex disappears by 3 months 5. Identify the effects of maturation on systems a. respiratory: RR slows down, tract elongates/ enlarges as they grow b. cardiovascular: HR slows, BP increases [sinus arrhythmia] c. immunologic: immunity develops over time w/ exposure i. IgG levels decrease: d. fetal HgB drops (after first 5 months) and adult HgB develops i. physiologic anemia (3-6 months)--> HgBf results in shorter survival of RBCs e. renal: immature renal structure→ dehydration i. weight loss of up to 10% newborn birth weight is normal f. fine motor development i. grasps objects→ 2-3 months ii. transfers objects between hands→ age 7 months iii. crude pincer grasp (3 hours/ day occuring >3 days/ week and lasting >3 weeks) i. infants...