Assessment

Measuring pulse

-For infants and children younger than two and in any child who has a irregular heart rate or known congenital heart disease -Apical heart rate determined before giving digoxin

Evaluating respirations

-Have a regular respiratory rates that change with simulation crying and feeding -First observed the pattern of inspiration and expiration to determine any irregular rhythm -Next with an infant or young child who is quiet and arrest measure the respiratory rate By auscultatimg for one full minute -Next with an infant or young child who is quiet and at rest measure the respiratory rate but I was waiting for one full minute -For the children either observe chest movement or ascultate respirations

Lymph nodes

-Assess for enlarged lymph nodes in the head and neck this supraclavicular area the auxiliary region the arms and the inguinal area -Use the distal portion of the fingers in and gently but firmly move the fingers in a circular motion to determine the note characteristics and mobility -Lymph nodes that are enlarged warm firm and fluctuant indicate infection -Notes that are small firm are healthy -No it's greater than 1 to 1.5 cm should not be concerning -Enlarged supraclavicular lymph node on the left is called sentinel node because it may suggest a Wilms tumor or neoplastic disease

Peripheral vascular system

-Comparison of opposite pulses is necessary in children -Compare one femoral pulse was the opposite radio pulse for equality a diminish femoral pulse compared to the radial pulse can indicate coarctation Of the aorta in infants and children

Measuring blood pressure

-If abnormalities detector or child's condition is unstable BP checks are done more frequently -Consider child's age gender in height when interpreting the bp results -You can measure BP when infants and young children lying down -Find the midpoint of the right upper arm between the Shoulder and Elbow -Holding the ladder in the Cath Lab ways to bother with should cover approximately 40% of the upper arm circumference -When you wrap the curb around the arm to take the blood pressure the bladder shouldn't circle 80 to 100% arm without overlap -Palpate the brachial artery please please that is the bell Below the cuff -Measure the blood pressure with the arm at heart level after the child has been at rest for 3 to 5 minutes -For children blood pressure can be measured in the upper arm lower arm thigh calf or ankle -To ensure consistency take measurements in the same limb in the same place and with the child in the same position -The systolic BP is determined by the onset of the Korotoff tapping sound -Diastolic reading is the number at which the korotoff Sound disappears -Mercury sphygmomanometer Have been replaced by aneroid sphygmomanometer -Children with high blood pressure and adolescents have a higher incidence of cardiovascular risk factors putting them at risk for future cardiovascular disease

General approaches to physical assessment

-Nurse supplies knowledge of growth and development when preparing the child and parents for performance of the physical exam -Establishing trust between the child and examiner is important -Providing a quiet environment is important - The classic systematic approach to the physical exam is to begin at the hair and proceed to the entire body to the toes -The examiner Taylor is the assessment to the child's age and developmental level

Measuring temperature

-Oral and rectal auxiliary temporal artery and tympanic membrane -Thermometers should not contain mercury because of toxicity risk -The temperature should be measured at the same site in with the same device to maintain consistency in the long reliable comparison and tracking of temperatures over time - Digital thermometers measure temp quickly usually less than 30 seconds -To prevent cross-contamination a child may have a single thermometer kept in the hospital room -If an electronica thermometer is used for multiple patients and you disposable probe cover is used for each new patient -For infants and children who are unable to properly hold an oral thermometer in her mouth exhilarate and temporal artery or to panic thermometers are used -Rectal temperatures are more accurate in measuring core body temperature particularly in advance and are the preferred site of measuring core body temperature's -Inserting a thermometer into a child rectum is invasive it may be contraindicated for children at risk working or back to injury infection or bleeding -Temporal artery into panic membrane causes minimal discomfort to the child -There are inconsistencies with tympanic membrane measurement -Temporal artery measurement can be used for infants older than three months who show no signs of fever -Auxiliary temperatures are appropriate for infants and children younger than 4-6 years for the child who cannot safely hold and oral thermometer in the mouth -Auxiliary temperatures are approximately 1°F lower than the body core temperature -Accurate reading the thermometer is held in the child eggs off for up to five minutes, Help the child remains still or consider holding him or her on your lap -Temperature is measured orally and children's six years and up -Keeping a thermometer in the correct location in the mouth can be a Challenge for any child -The child is instructed to keep the mouth closed with lips and a kiss position and not too bite at the thermometer. s-Intake of food and liquids should be avoided for 30 minutes before the oral temperature measurement -Oral intake oxygen and nebulizer treatments or crying can alter the oral temperature -Oral temperature measurement should not be used in any child who is her oral or tonsil surgery on him epiglottis is suspected *If an elevated or low oral auxiliary temporal Tim panic temperature reading is obtain consider measuring the temperature via another route -Report a temp measurement of less than 96.8 or more than 100.4 search reporting is critical for an infant younger than three months of age

Parent Teaching

-Parents need to learn how to take the child'sTemperature at home -You're seven threes how to take it and observes a parent performing -It's important to ensure that the parent is comfortable with the procedure and is able to read the thermometer accurately -Some parents need to be taught how to correctly determine their child's heart rate and respiratory rate as well as the acceptable range for their child -Special instructions given to parents for children on certain medications such as digoxin -If the child requires home blood pressure monitoring the nurse provides information about the size of the curve and ensure that the parents can perform the procedure

Musculoskeletal system

-The examination focuses on upper and lower extremities and the spinal column -The child can be dressed in shorts or underwear during the examination examiner compares the two sides of the body for cemetery contour size and involuntary movement -Then observes for swelling Adema or discoloration - Common deformities of the extremities are Varus and valgus deformities - varus Is a medical adduction or turning inward (bow-legged example) -valgus Meteor abduction or turning out the word (knock knee example) - Injuries to the extremities caused by overexertion and stress movements are common in children -Sprains are the most common injury followed by fractures dislocations lacerations overuse injuries common in school-age children and adolescents are caused by repetitive microtrauma that exceeds the bodies rate of repair -Overuse injuries commonly occur in sports emphasizing repetitive motion such as swimming running gymnastics skating Infants> -Symmetrical flexion of the arms and legs is noted limbs should be freely movable with symmetry of the auxiliary femoral and Popliteal creases - Yep but age 2 months the infant can lift the head while prone -The infant normally wedges securely between the examiners hands when lifted under the axilla -Check the hips for congenital dislocation by comparing leg length -The babies feet our place flat on the table in the knees flexed up -Posterior gluteal fold should be equal on both sides Toddlers and preschoolers and school-age children> -Start with the child's hands and arms by checking for range of motion in the presence of pain while the child is sitting -Lordosis is common in young children -The examiner begins with the feet in observance for adduction and pronation of the foot - Pronation is common between ages 12 and 30 months -And action or towing is demonstrated when the child walks on the lateral side of the foot -Adduction tends to correct itself by age 3 years as long as the food is flexible - Bowleg is present when I space of more than 2.5 cm measured between the knees it is normal after the child has begun to walk and may persist until the child is three years old -genu Vagum Is present between ages two and 3.5 years Adolescents> -Have kyphosis caused by poor posture -Racing in exercises can be successful -Screening recommended for girls age 10 to 12 and once for boys age 13 and 14 -While standing the child is told to bend forward wow in the shoulders to droop with the arms hanging freely the nurse looks for unilateral elevation of the Lowerr thoracic ribs Range of motion> -There should be no pain limitation of movement spastic movement joint instability deformity or crepitation during movement Muscle strength and mass> -The examiner assesses the strength of each muscle group -The child is asked to flex the muscle and then resist as opposing force is applied against flexion -Muscle tone should be firm on palpation -When appropriate the evaluation of muscle strength is integrated with examination of the associated joint for range of motion -Cranial nerve five evaluated by the application of opposing force to the temporalis muscle while the child clenches the teeth -Cranial nerve XI Is tested by assessing the strength of these sternocleidomastoid and trapezius muscles during the rotation of the head from side to side and from chin to shoulder -When atrophy or hypertrophy I suspected the examiner measures muscle mass -Muscles are best measured at their greatest circumference -With the joint used as a landmark the distance from the joint to a point on the extremity is measured and compared with the opposite muscle -One measurement is not as significant as a series of measurements to determine changes in size of muscles Joints> -Palpates for temperature tenderness swelling crepitation and masses -In children fatigue stiffness or weakness along with he and redness or frequently associated with disorders of the joints -Children will not move a joint if it is painful Gait> -Assessed in two phases stance and swing -The stance phase begins when the heel strike the floor and the wait is transferred to the ball of the foot in the toes push off the floor -The swing phase occurs when the foot is off the floor and consisting of a celebration swing through and deceleration

Nose mouth and throat

-Wear gloves when doing the nasal examination noting any drainage coming from the nose -Patency can be determined by including one nostril and having the child Smith and then repeating on the other side -The external nose is observed for symmetry deformity information or skin lesions -Allergies salute frequent wiping of the nose because of drainage produces a transverse crease on the child's news it is suggested that the child has allergies -Your nose entire external nose palpated for septal deviation -Sense of smell met mediated by cranial nerve one -Function can be evaluated by having the child close the eyes include one nostril and identify a familiar odors suggest cinnamon and peppermint and orange and cherry -Nasal cavity can be examined by inserting the short white tips speculum on the out of scope into the nasal vestibule With precautions taken to not put pressure on the nasal septum -Nasal mucosa is inspected for color in moisture -Should be smooth and moist with bright pink color -And children with allergies to because his pale and appears boggy -With infectious diseases, because it is everyday matters and swollen and the nasal drainage may be yellow or green -Nasal septum is examined for intactness in for any deviation -Rental and maxillary sinuses are inspected in palpated -Areas over the sinuses are examined for color and swelling -Puffiness and redness over the sinuses and dark circles under the eyes may indicate an inflammatory process in children -Frontal sinuses are palpated by pressing over the sinuses below the eyebrow -Exhilarate sinuses are palpated by pressing a board with the thumbs under maxillary bones Mouth and throat> -Assessment of mouth and young child should be performed at the end of exam because it can cause anxiety -The philtrum which is a little notch between the nose and upper lip should be in tact -Wear gloves when doing the oral examination -It's unladen penlight assist with visitation -The alveolar frenulum Which attaches to the lips to the gums And should be in tact -For the child cooperation when examining the mouth the examiner may want to demonstrate on a dog or on the parent or allow the child to place a tongue blade in the parents mouth -Buccal mucosa should be paying smooth and moist -Dark skin children may have patchy areas of hyperpigmentation - irruption of deciduous teeth begins around the six months of extrauterine life - -Dark skin children have a dark pigmented line along the gingival margin -Dorsum of the tongue should appear door red moist listening with the white coat -Interior portion of the tongue should have a slightly rough and appearance with papillae Small fishers -To prevent being bitten by a child for the child's cheeks -Cranial nerve X11 examined by asking a child to stick up the tongue -Examine strength of tongue by placing a finger to the side of the child's cheek and asking the child to press the tongue against the finger -Do you valuate hard palate soft palate uvula examiner asked the child to tilt the head back - Hard palate is Whitish and convex with transverse Ruege -Soft palate is continuous with the hard palate and his concane and pinker -Examiner palpates the hard palate for the height of the arch in for intactness -Cranial nerves 1X and X -Tonsils should be pin -Large tonsils are common in young children -With inflammation the Crypts can contain exudate -Child whose parents comment on the child snoring or being awakened by snoring may have grossly in large tonsils -Posterior wall the pharynx should be smooth and shiny, Pink in color and a regular spots of lymphatic tissue may be observed

Abdomen

Abdomen -Abdominal relaxation is enhanced if the child bladder is empty - The child is placed supine with a pillow under her head and the knees flexed -For an infant or young child it can be done while the child is laying in the parents lap -The child and parent should be asked about urinary and bowel patterns -Inspection auscultation percussion palpation -Inspection - Contor is described as flat scaphoid rounded or protuberant -A protuberant abdomen is typical for the toddler -The umbilicus is normally inverted -There should be no signs of discoloration Information or hernia -A fine Venous network may be seen in infants and small children -The abdomen is inspected for pulsation and movement -And then children all stations from the aorta beneath the skin in the epigastric area -Whose children have abdominal movement with respirations and peristalsis of the abdomen should not be visible auscultation > -Bal sounds are high pitch irregular and occur from 5 to 34 times per minute -The bell of the stethoscope is used to listen for Bruits Over the aortic renal iliac and fee moral artery's Palpation -OK can be done with the child in the lap of the parent as a child lies with the head and thorax across the parents legs the child's knees are flexed to prepare the child for palpation of the abdomen -Distracting a young child is helpful to reduce fear and anxiety begin with my palpation to show the child at palpation will not hurt - Examine older child who is anxious or ticklish to assist with the part of the examination -The child places a hand on the abdomen in the examiner place is a hand with fingers touching the abdomen on top of the child's hand and asked the child to push the examiner pushes -This helps reduce the sensation of tickling -To assist with relaxation of the abdominal muscles the examiner can ask a child to take deep breath's -Light palpation with the Palmer Surface of the fingers no more than 1 cm into the abdomen -Guarding resistance and tenderness should alert the examiner to move cautiously with deeper palpation -Tenseness And rigidity can be caused by fear and anxiety distracting the child are waiting for the child to breathe helps determine whether the tenseness is voluntary or involuntary -Examine her gently and dance the fingers into the abdominal wall during inspiration -With even pressure of the abdomen should feel soft -Rigidity a constant born like hardness of the abdomen is usually associated with the acute inflammation of the peritoneum -Examiner performs deep palpation by pushing down 5 to 8 cm beginning in the right lower quadrant and is searching for palpable organs and masses -To palpate the liver begin at the umbilicus using the side of the hand to indent the abdomen approximately 5 to 8 cm with deep penetration of the abdominal wall the hand is greatly inverted toward the cost of margin -The edge of the liver should feel soft and smooth the firm border moves down word when a child takes a deep breath -In infants and young children the examiner begins at the cost of margin and using the Palmer aspects of the fingers and then it's 5 to 8 cm move down the cost of margin until they hand falls off the edge of the liver border in infants and toddlers the liver edge is probable 1 to 3 cm below the costal margin -Low power pain in the abdomen the examiner checks skin Sugar in palpates me for moral pulses and inguinal lymph nodes -To observe for rebound tenderness please see hand perpendicularly to the abdomen push down slowly and deeply into the Hampton and then lift a hand quickly with peritoneal inflammation the sudden release of the pressure will cause severe pain and muscle rigidity

Acute and chronic pain

Acute and chronic pain -Acute pain is a result of invasive procedures such as injections or complications such as tissue injury from IV infiltration -Pain from such procedures affect children with cancer or other chronic illnesses that require frequent medical care - Acute pain is also experienced with acute disease is after surgery and after trauma such as falls or non-accidental injury from child abuse -Events that caused acute pain may persist leading to the development of chronic pain -Chronic pain continues for an unpredictable. Beyond the expected recovery period is unlikely to resolve quickly and can adversely affect the child's daily activities of living -Causes and types of chronic pain very widely -Conditions such as juvenile arthritis sickle cell disease cancer have chronic repeated acute pain -Neuropathic pain is one of the most complex types of chronic pain to treat -Chronic pain in childhood as more prevalent in previously realized - Show me the chronic pain is very difficult it leads to concerns regarding the long term functional consequences of chronic childhood pain -It advocates for increased education of all health professionals and more research on pediatric pain management -Children with chronic pain or increased risk for anxiety disorders that could affect her every day lives contributors to school avoidance in often cause poor family functioning -Improvement in pain management have been able children with pain related to chronic conditions to achieve a higher quality of life -They were able to enjoy a greater degree of normalcy by spending less time in the hospital and actively participating in school play and other activities of childhood -

Adolescence

Adolescence -More comfortable with a straightforward non-condescending approach -Decisions about who should be present during the exam should be openly discussed with the adolescents - Examined without a parent present -Parents should be given the opportunity to talk to the nurse about any concerns - Order of examination is the same as for the school-age child -Incorporate genital exam in the middle of the exam -Proceed from the abdominal exam to the genital exam to allow ample time for questions and discussions about this part of the exam -It allows the opportunity to assure the child about normal development stages and to answer your concerns children this age have about what is happening to their bodies -Expected to undress and wear a gown

Adopting the physical exam to the child

Adopting the physical exam to the child -Begin at ahead and proceed to the toes -For children painful are frightening procedures should be left until last -Involving parents by asking them to hold or stand by the child can decrease child's anxiety and assist them in and relaxing

Anthropometric measurements

Anthropometric measurements -Measuring human body and assessing nutritional status as well as growth and development -Weight height head circumference measures and children and their compared with averages for age group and gender -Body fat should be measured on the basis of PMI -These growth measures went for it on a growth curve and evaluated seriously so that trends can be monitored -Measuring high BMI a routine procedures that provide valuable information about a child health -Children grow and develop properly this growth and development must be constantly evaluated -A child's physical measurements reflect the rate of growth -A failure and growth or an acceleration and growth can be the first clue to a serious health problem - Growth charts> -Assess body size and monitor her growth and adolscents -Use the world health organization growth standards to monitor growth for infants and children ages 0 to 2 years in the CDC growth charts for children two years and older -Data collected for who growth charts represent infants and children who are breast-fed during their first year of life and this is considered to be the optimal standard of measurement for comparison -WHO growth charts ages birth to age years two years, plot length, weight head -circumference -On the way to length relationship which can be used as an indicator of overweight or obesity in children -Siri see charts ages two through 20 years plus measurements of stature weight and BMI for age -BMI used primarily to screen for children who are overweight although we can also be used to describe children who are underweight -Special growth charts for premature are available

Assessment of pain and children

Assessment of pain and children -Effected by developmental level, emotional status, previous paint experiences, culture in his nursery, personality type, gender, genetic variations, parental response to the child's pain -Assessing pain in infants and children are more challenging than adults -The nurses role is to assess for pain provide nonpharmacologic in pharmacological interventions along with the healthcare team and evaluate effectiveness of those interventions -Infants and young children may not have a language or cognitive abilities to communicate their pain -There crying and verbal responses occur for many other reasons including hunger sleepiness and anxiety -The nurse miss use a combination of behavioral and physiologic signs together with an appropriate pain assessment tool to determine the pain level and infants and some children -Vitals are good indicators for pain however these signs are also affected by illness fever medications -Assessment of pain and children who are giving a verbal report of pain that -differs from their nonverbal behaviors -And example as a child who gives a verbal report of little or no pain or concern that someone will become angry where that pain medication might involve an injection -Visually the nurse might see the child grimacing perhaps with tears lying rigidly in bed and not moving -Search nonverbal behaviors will leave the nurse to speak and interact gently with the child about the actual level of pain to ensure appropriate pain management -Children who suffer from chronic pain but not demonstrate behavioral changes that are not spoke to the nurse and they be unable to accurately describe their plan Level -It's important to assess the impact of pain on a child social life including sleeping eating attending school and social physical activities and interactions with family and peers - Impairs school functioning may be subtle signs that a child is experiencing pain -For older children they may be able to verbalize her discomfort but are often afraid of treatment that includes a people procedures such as an injection they have also been told to be brave and not verbalize or demonstrate the pain they are experiencing -Children as young as five or six years maybe fearful of taking pain medication because of the emphasis on saying no to drugs -Some children translate this message to me and they should not use any drugs even appropriate and necessary pain medications -nurses provide education of children and their parents to overcome barriers to paint assessment and management -Paid assessment and treatment are influenced by culture believes and the nurse should work to understand the impact of cultural differences on pain management - Some cultures have nonverbal expressions of pain words used for pain descriptions of pain

Assessment tools for pain

Assessment tools for pain -Children benefit when pain assessment tools are used because they were given in a simple and effective way to communicate the pain they are experiencing -The tools provide more objective data reducing the chance that discrete signs of pain will be overlooked -—Assessment tool corresponds to the child's developmental abilities -Selecting an assessment tool let's be appropriate for the child's developmental level and can facilitate the development of an effective pain management plan based on the information gathered from the assessment -Play verbal or nonverbal assessment tools for neurologically on responsive or developmentally delayed children can benefit from this -Cognitively impaired children are at increased risk for untreated pain the nurses should use an inappropriate tool such as the revised FLACC which includes parents input of indications of pain in addition to the parents and behaviors of a child -Children verbalize words for pain by approximately 18 months of age and cognitive Development is sufficient for reporting the extent of pain by 3 to 4 years of age -We can match a tool to the child ethnicity and language to provide better for Maisch and about pain -The same tool should be used each time a child is this Thursday to obtain consistent data into avoid confusing the child -Whenever possible the child should be taught how to use the rating tool before Pain is experienced -In assessing pain in obtaining pain history the nurse should first ask the child and family which words the child uses to indicate pain -A child they use words such as owie or Ouchi -Information to be gathered includes the child about experiences with paying for the child reacts to pain the person the child tells about the pain of the parents know when their child is in pain what works best to take the child pain away -Documentation includes the tool used to assess pain -Patient should be reassessed in a timely manner and children since undetected pain is often untreated -Computerized documentation that alerts the nurse went to reassess pain is helpful and increase in compliance

Breast

Breast -In both genders of the breast may be engorged because of maternal estrogen crossing the placenta -Thelarche Or breast development marks the beginning of puberty and pre-adolescent girls -Nipples can appear to be inverted or everted -Skins should be free of any dumpling -All girls should be taught to do a breast self exam once they reach menarche -The adolescent girl is talk to do breast self exam 3 to 4 days after menses -In the male the examiner expects to feel it in there a fatty tissue overlying the muscle in during puberty some boys experience enlargement of breast tissue in it is temporary

Cardio respiratory monitors

Cardio respiratory monitors -So that heart rate respiratory rate blood pressure and temperature can be continuously measured -For children who are ill or who are undergoing procedures might be placed on one of these -They sound an alarm to Warren changes in the tiles cardio respiratory status -Nursing sure set the monitors are functioning correctly because false alarms can of her whenever a monitor alarm sounds the nurses first look at the child and perform an assessment and then intervene if indicated -If that line on the ECG does not always signal a cardiac arrest as it can be caused by a loose monitor lead

Common alterations in chest configuration

Common alterations in chest configuration

Fever reducing measures

Description of fever> -Body temperature greater than 100.4 or 99.5 Rectally -Illness or disease makes the bodies setpoint temperature rise to a higher than normal level after the cause of the fever is removed the body resets at setpoint at the normal level -The bodies attempt to defend itself against us is manifested by fever -Endogenous pyrogens trigger fever produced during the inflammatory response -Male degrees a fever may or may not require intervention depending on the underlying calls in the child's response -Most are brief And resolve on the underlying infection resolves -Children with chronic cardiac respiratory disease neurological disease in prone to febrile seizures should be treated for fever -Children with fevers greater than 104 or higher should be treated -Fevers make children uncomfortable and can make them irritable -As the temperature elevates the metabolic rate increases and increases insensible fluid loss increasing oxygen consumption and increased stress on the cardiovascular system -Medications and management> -Antipyretics -Dressing the child appropriately neither overdressed nor underdressed, adequate fluids, monitoring signs of dehydration, administering an appropriate antipyretic -tepid sponging To reduce a fever can actually cause shivering and increase temperature as well as increased discomfort for the child -Antipyretics such as acetaminophen or ibuprofen given to children with fevers -Aspirin is not used to treat fever because it's associated with Reye syndrome and viral illnesses like influenza and varicella -Provide parents with written instructions regarding the correct closing in dosing interval antipyretics to avoid inaccurate -Loss of appetite is common -Dehydration can occur from decreased oral intake and increase insensible water loss through the lungs in skin - Over the child or a flu is frequently especially during times when the temperature drops -Child who cannot ingest oral fluids may need IV fluids -Do you maintain body temperature and reduce heat loss infants are placed in radiant warmers or incubators -Children in these radiant warmers need to be monitored carefully because they can cause excessive heating and insensible water loss is greatly at risk so it's important to calculate fluid replacement

Disadvantages of intramuscular analgesics

Disadvantages of intramuscular analgesics

Documenting a vital measurement

Documenting a viral measurement - Nurse documents are vital signs, measures the result, the method used to measure each vital signs, the site were each measurement was obtained, any action taken included -It's essential that the nurse report any abnormal findings or findings that are significant different from the individual child's baseline

Eyes

External Eye> -Evaluated for a position and placement -Epicanthal folds Seeing an Asian children in some non-Asian children this land of the eyes is determined by drawing in imaginary line across the inner canthi -Lacrimal apparatus assessed by asking the child to look down -Outer part of the upper lid is palpated along the building orbit for any discomfort swelling or redness -Punctum or tear duct on the inner canthus is palpated for obstruction in the infant -Probation of the eye can cause anxiety and small children and should not be done unless there is a serious concern about the size of the eye -With the eyelids open the upper lid normally falls below the superior limbus but does not cover any of the pupil -The lower lids normally fine just as inferior limbus -The limbers is a point where the sclera of the eye meets the color portion of the iris -When closed the eyelids approximate each other completely without tremor or tics -The conjunctiva are examined by pulling down as a child looks up it should be clear pink with several small blood vessels -The upper lid is not done because I am manipulation because apprehension and a child -Sclera should be white and Lara of dark skin children can have gray blue or multi color variations -Some dark skin children have small brown macule around the limbus - The corneas are clear transparent and very sensitive -Shining a light obliquely across the cornea highlights any abnormal irregularly's on the cornea surface -The iris rounds in contains muscle fibers that contract or expand in response to light -The pupillary light reflex is tested by darkening the room and asking the child to gaze into the distance - Eli is brought from the side and examiner notes to change the size of the people the procedures repeated by the opposite eyes observed -The opposite I should constrict in response to light and they both should constrict at equal speeds and into the same degree -People should be the same in both eyes - unequal pupils indicates a central nervous system injury -When asking the child to locate an object and look at it the pupils should dilate Ophthalmoscopic examination> Requires cooperative child -Requires lights in the room to be dim -The scope is placed in front of the people in the light hits the lens a red color is reflected from the retina to the examiner -The retina choroid optic disc macula fovea centralis Reno vessels are also visible with the ophthalmoscope Binocular vision and strabismus> -Does binocular vision in the presence of strabismus -Strabismus or crossed eyes is the abnormal Or incomplete development of binocular visual alignment -Corneal light reflex test> Assessed by shining a light directly onto the irises from a distance of approximately 40.5 cm - Reflection of light should Appear in exactly the same spot on both eyes if the light falls off center then the eyes are maligned -Children with epicanthal folds Vertical fold the partially or completely cover the inner can't I can give a false impression of malalignment (pseudostrabismus) Field of vision test> Holding a child chin so that the head does not move and asking a child to follow a puppet worry familiar objects how old approximately 12 inches away from the fees as the object is moved to each of the six Cardinal positions -As the object is moved to the margins the beach, no position the examiner holds it momentarily in that position before proceeding back to the center - The eyes will track in a parallel fashion to each position -As the eyes are in the margins of each position the examiner can note end stage nystagmus (gentle oscillation of the Eye) -Children younger than 2 to 3 years being not be able to cooperate with this test Test for eye muscle function> -Testing for extraocular muscles function in children younger than five years is critical to identify any muscle in balance so that it can be corrected at any early age to preserve vision Peripheral vision> -The examiner covers one eye and has a child mimic by covering the opposite Eye -A puppet or some other test object is Lily brought from the periphery into the child's field of vision -The object should come from my position slightly behind the childhood and the child is asked to say now with the object in its view -Testing for visual acuity and visual fields evaluates cranial nerve to the optic nerve which mediate vision Visual acuity> Acuity develops over time in the valuation requires a child cooperation -Infant from birth to age one or two months this is a black and white contrasting figures and faces -Age 4 weeks or older an infant fixates on a brightly colored objects And follows it -Visual acuity testing for children begins at age 3 -Items needed for visual acuity are and Ieye cover and vision charts -The Leah chart in the HO TV matching test is used for visual acuity test -Visual acuity test recommended at least once between ages three and five to detect amblyopia -Preschool children can be tested using the HO TV chart at 10 feet -A card printed with HOTNV is given to the child to hold when I was covered and the child is instructed to match the letters on the health card with the chart at 10 feet using the uncovered I screening is begun at the 20 /50 line For children younger than four and the 20/40 for children 45 and 20/30 for children that are older -The child passes the test they can identify four of the five symbols Snellen chart is done by placing it on the wall 20 feet away from the child the chart should have no glare and should be well illuminated no other materials should be around or near the chart -Both eyes are tested together first and then each eyes tested separately -If the child has correct of lenses the procedure should be repeated with the correct of lenses on -Unless the child is known to have very poor vision testing is began at the line on the chart for 40 feet - To determine at what level the child cannot see the examiner find the distance at which the child misses half plus one of the symbols on a line on the chart -The visual acuity is in designated as the smallest line at which the child is able to identify more than half the symbols on the line -For correct of lenses and the examiner notes the last date the child was examined for a prescription -This annotation means that the child has correctly interpreted the letters on the chart for 20 feet at a distance of 20 feet which matches with the average child can see that distance -If the child correctly identifies letters on the line labeled 45 the child can see it 20 feet with the average child can see it 40 feet. Birth Fixates on objects 8 to 12 inches 20/100 to 20/150 -Four months 20/50 to 20/70 One year 20/4220/70 Four years 20/42 so 20/50m Five years 20/2220/30. Color vision> Color blindness is a inherited recessive X linked trait can affect a child's ability to discern traffic lights brake lights and color coordinated clothing -Color discrimination occurs through integration of information from the con pigments in the retinal layers of the eye -The jeans for some colors are located on X chromosome and because boys have only one X chromosome they are more likely to have color vision deficit -Color vision deficit can affect a learning if the learning is color related related

Ears

External ear> Soft yellow brown cerumen is normally seen The bony prominence of the mastoid process behind that year is palpated for tenderness -The oracles or Julie pooled to determine whether this action causes discomfort Otoscopic examination> Is my child is positioned on the parents live in the parent secures the child's arm-—The examiner uses the largest speculum that will fit complete into the ear canal -Younger than three years the ear canal is trained by pulling the ear down in back -The child is three years or older the The ears pulled up and back -A puff of air is injected into the canal and the Tim panic membrane is observed for movement Hearing acuity> And the older infant hearing is it sized by asking the parents to speak to the infant from behind and observing the infants response to the parents voice -The examiner can stand behind the infant and ring the bell or make a sound the infant is familiar with and observe the infant turning to locate the sound -A very young infant younger than four months wmay demonstrate is there a reflex to loud sounds Preschool and school-age assessment> Child is placed in a soundproof room and has asked for identify tones of different frequencies played at a specific decibel level -With the audio meter to test are used to evaluate hearing - the sweep Test is used to screen for hearing loss is -The pier tone test used to determine the exact extent of the hearing loss -If a child misses a tone the test should be repeated but no more than four times - The whisper> Examiner stands behind the child and exhales and whispers a series of three numbers and letters and if the child correctly repeats the letter or number Siri's hearing is considered normal -For preschoolers, the examiner whispers a command such as please put the toy in the floor and observes to see if the child follow the command indicating normal hearing Conduction test tuning fork hearing test> Tuning fork test or qualitative test to determine the ability to hear by air conduction and by bone conduction -Rinne Hearing test is used to determine whether air conduction is greater than bone conduction -Weber hearing test determines the child's ability to hear by bone conduction

Head neck and face

Head> -Head examined for symmetry paralysis weakness and movement -Examine her notes lumps bumps that are seen or felt -Suture lines in infants should be palpated -Suture I felt as prominent ridges in the neonate but usually flatten by six months of age -Paralysis and weakness of the head are directly related to the condition of the neck muscles -Paralysis of the head and weakness of the head of her with paralysis or weakness of the neck muscles -Head movement is evaluated by observing the child's spontaneous head movement her control is observed with the infant in a supine position in while the examiner graphs in bins hands in pools in fit into a sitting position -Infant younger than four months Mitchelson her leg and fit in upright position should be able to maintain to head up right now several seconds - Her leg after six months suggest poor muscle development - Increase next extensor and exhale tone in the young infant make head control of your better than it actually is and is suggestive of neuromuscular problems such as cerebral palsy -It should be put through a full range of motion -After four months inability to move the head or to hold her head in the upright position indicates paralysis or weakness of the neck muscles -The posterior fontanelle is closed by age 2 to 3 months -The anterior fontanelle should we stopped in fact when the child is sitting and should be less than 5 cm in length after age 12 months and should be closed at 12 to 24 months -Thanking about an hour associated with dehydration and bulging want to now associate with intracranial pressure -Bulging fontanelle is normally seeing when an infant cries coughs or vomits -Inability to palpate the anterior fontanelle may be an indicator of premature closer known as craniosynostosis Neck> - In Vinson Nick is short in length and width as the child grows -Webbing of the neck in the presence of extra fold of skin posteriorly is associated with chromosomal abnormality's suggest trisomy 21 or Down syndrome -Nick is mobile and supple -Palpate the thyroid gland by identifying the isthmus the thyroid across the trachea -To identify in large thyroid in a child the examiner gently displaces the thyroid gland that early in poppies thyroid tissue with the opposite thumb and fingers -The lobe may be more palpable when the child swallows Face> - Adema such as cellulitis is noted -Hypertelorism a condition in which the eyes are unusually widely spaced -hypotelorism Eyes are unusually close together - The nose should not have hypoplastic philtrum ( shallow crease or absence of a crease below the nose ) -Lips should be equal on either side of the midline -Low set ears identified when the oracle of the year does not cross or touched the occiput line -Position of the Oracle should be almost vertical with no more than a 10° lateral posterior angle -Turning on or five evaluated by observing chewing or sucking in by touching the child forehead and cheeks with a piece of cotton the child should move the head or bat the object away -Cranial nerve seven evaluated by asking a child to frown smile or make a face while examiner observes symmetry & Having the child perfect the cheeks or whistle also allows the examiner to evaluate cranial nerve seven

Heart

Heart -Where the infants or young child examiner might want to listen to the child's heart while the parent is holding the child before doing other parts of the examination Inspection> -Anterior chest because he's on second right intercostal a.k.a. aortic area, second left intercostal space a.k.a. Homonick area, left sternal border a.k.a. right ventricular area, fifth left intercostal space in the mid clavicular line a.k.a. in just below the xiphoid process a.k.a. Epi gastric. -For infants the heart is more horizontal in the Borax in the apex is one or two intercostal space is above the thing cost in space and lateral to the midclavicular line -The examiner locate intercostal space by identifying the sternal angle -The second room is attached to the sternum just below or at the sternal angle Palpation> -Located apical pulse sometimes called the point of maximum impulse -It is hers younger than seven the PMI is located in the fourth intercostal -Child older than seven is located in the fifth intercostal -You Spohn to fill for thrills which are palpable vibrations of the heart auscultation > -While the child is lying supine, left lateral recumbent position, sitting up -Heart sounds are the closing in the heart valves - To listen for heart sounds you listen to the aortic valve area, Pulmonic, tricuspid, mitral -It is best to listen to heart sounds by inching The stethoscope across from the base of the heart across and down and from the apex upward -All areas are auscultated of the bell and the diaphragm -S1 and S2 heard using a diagram - S1 heard best at aortic or pulmonic area -S1 described as s1 -second heart sound =dub -S2 splittingIs audible between the closing of the aortic and Paul Monic Valves and this is normal in children, Heard best at the Paul Monic area and is greatest at the peak of inspiration and decreases their goes away during expiration -Children's heart rates often increase with inspiration and slow down during expiration -Do you decrease irregular rhythm associated with respirations examiner has the child hold the breath of the examiner continues to listen to the heart -Extra heart sounds including murmurs -Described as opening snaps or injection clicks or mid systolic too late systolic clicks and murmurs -Snaps in clicks are short high-pitched sounds that do not vary with respirations -Memories are blowing swishing sound that occur because of turbulence of blood flow into and out of the heart and Are heard best with the bell -Innocent or functional heart murmurs are frequently heard in children -Innocent murmur is occur during systole I heard best along the left sternal border

Physical examination continued

Height> Infant and toddler length measured with the child laying down on a flat measuring board -Mark the point where the heel touches the surface they mark the point where the top of the head is lying on the surface - then measure the distance between the two points with a measuring tape measuring the length of the child in this manner is not as accurate as using a measuring board -A standing measurement may be done measuring from the toes to the top of the head if this is the first standing measurement there may be a slight discrepancy from the lying measurement -When a child is able to cooperate and stand without support around age 2 years this measurement can be done Weight> -Infants Place Position on a regular baby scale with other clothing removed -Older children who are able to stand or walk without support maybe wait on the adult standing scale -For older children remove all clothing except underwear like height weight is spotted on a standardized growth -Height and we light are related to Hereditary factors and will vary from child to child Head circumference> -Measured and our children from birth to age 36 months and plotted on the standard growth chart -If older than three with Concerning head size Such as macrocephaly the head circumference to be measured at every visit -Non-stretching measuring tape wrapped above the supra orbital ridges in over the most prominent part of the occipital -During the first your life that circumference increases by 1.2 cm each month -Head circumference can reflect in a normal rate of development give medication and Richard general status and possibly indicate tumor growth or an abnormal cumulation of CSF - Any increase and head circumference measurements during infancy requires a referral for evaluation Chest circumference > -Routinely measured only in the newborn infant -newborn head circumference is larger than the chest circumference -chest circumference is almost equal to head circumference after age one -To measure chest circumference the measuring tape is wrapped around the chest at the nipple line -Measurement taken between inspiration and expiration Mid arm circumference> - Reflects muscle mass in fat -The midpoint on the arm between the acromion process and olcranon process is determined -With the arm hanging loosely at the side it is measured at the midpoint using a tape measure -Measurement recorded in centimeters -With a decrease in fat or maybe muscle is your fee the mid arm circumference decreases it will increase with weight gain Triceps skinfold> -Indicates a total body fat because at least half of body fat is directly below the skin -Metal calipers are used to obtain this measurement -On the non-dominant arm the midpoint the arm is determined with the same method that is used for Measuring mid arm circumference -With arm hanging loosely at the side a fold of skin is a grasp -To avoid error the child is asked to flex the arm muscle after the examiner grasp the skin - Of contraction is felt muscles as well as fat Has been grasped -Examine her reply is the caliber and take the reading after waiting three seconds -That stores degrees with long-term under nutrition and malnutrition

Measuring with vital signs

Measuring with vital signs

Infants from 6 to 12 months

Infants from 6 to 12 months -For another infant follow the same procedures used for the infant from birth six months -Infants in this age group feel stranger anxiety and are more difficult to examine -Distracting a child of this age with a toy or object maybe useful -It's easier to do as much of the examination as possible with the child held on the parents lap -Leave ear oral and other procedures until last

Infants from birth to six months

Infants from birth to six months -Responsive to human faces, increasingly interested in the environment, don't mind being undressed -The examination should be easy -If infant is nursing or asleep listen to the heart lungs and abdomen without waking the baby -Effective examination can be accomplished with them lying or sitting in the parents arms or on the lap -As body parts are examined evaluate the reflexes such as Palmer grasp plantar grass placing stepping in tonic neck reflexes -Leave uncomfortable procedures such as the abduction of the hips in speculum examination of the Tim panic membrane and more reflex until last - Before the examination undress, the infant leaving the diaper on a male child and refocus eight and happy Advent by calmly talking in a soft voice distracting with a Rattle or offering a pacifier

Learn pharmacologic and pharmacologic pain interventions

Learn pharmacologic and pharmacologic pain interventions -Multi modal using an effective combination of a quiet calm environment in both nonpharmacologic and pharmacologic approaches -The nurses assessment helps determine the suitable intervention

Assessment according to developmental level

Neonates and infants> -They do feel pain in that event his pain is not addressed can experience long-term negative consequences -Rapid changes in infants behavioral state and sleep activity patterns signal pain -Behaviors are often service indicators of them fit pain include crying Fist clenching grimacing wrinkling on the forehead fussiness and restlessness -Facial expression is considered the most consistent you available one judging pain -Facial expression in combination with short latency to onset of cry and a long duration of the first cry cycle typifies infants reactions to painful procedures -Cries associated with pain or higher pitch tents harsh differing from those associated with hunger discomfort stress -Parents are nurses may be able to differentiate between usual cries or infants and the cries of pain -Motor movements associated with pain progress from generalized body responds to more purposeful movements -Infants age 9 to 12 months can use their hands to push the nurse away if they perceive a paid for action is about to begin -The response of mayonnaise to painful stimuli or sometimes described as total body responses -The infants extremities be thrashed about and some infants exhibit tremors -Older infants me rub the painful area pull away or regard the involves body part -Do you need to experience prolonged persistent pain may not exhibit the usual behaviors signs of pain seeing units for experiencing acute pain instead of signs and symptoms of energy conservation -Physiologic changes may be more difficult to assess in serve that's just one part of a complete pain assessment -A nurse should I suspect that and then fill experiences pain before physiologic changes or observed -Increased blood pressure heart rate respirations and decreased oxygen saturation has been associated with pain and neonates Toddlers> -Preverbal toddlers are often unable to describe the pain which puts them at risk for untreated pain -The toddler in pain tends to cry longer than the infant -As verbal abilities become more advanced the toddler can vocalize displeasure when a painful experience occurs -The toddler may ask for parents whose words indicate discomfort and verbalize negative emotions about the nurse -May try to delay the nurses implementation of a procedure judged as painful -The older toddler can often over by the pain and point to the body part that hurts -Generalized restlessness guarding the site and touching the pain for area or signs of pain in the toddler -I told her my associate discomfort with a particular procedure such as dressing change and my run from the nurse when approached -Facial expressions can indicate anger and fear might avoid eye contact or look sad we demonstrate regression to earlier more comfortable behaviors such as lying on parents live in a fetal position Pre Schoolers> -Egocentric -Difficulty associating discomfort with any positive outcome and this can intensify there. Experience for example they will not understand that debriefing a painful burn will ultimately have a positive effect -Children of this age Group are able to describe the location and intensify of pain -Intensive think Pena will magically go away now experiencing pain as punishment for some previous thought or deed -They also fear body mutilation particularly of the genitals -Preschoolers made an opening for me surgical incision for example in order to avoid an invasive procedure such as a pain medication injection the mail so cry and struggle in an attempt to escape from the procedure -Preschoolers can request to earlier more comfortable behaviors such as thumbsucking in response to pain or they can withdraw and not participate in play activities School age children> -Describe in accurately and related to a specific body part as well as quantify pain intensity -Beginning to understand the need for painful procedures in the fear body harm and have awareness of death -May appear to overreact illness or injury -Remember his previous paint experiences which will affect the current response the child's culture gender in cognitive abilities were affect the pain experience -The child may exhibit a stiff body posture , withdraw, or be found quietly sobbing -Resist the treatment cries loudly or otherwise ask in a aggressive manner by later deny the behavior -Attempt to procrastinate or bargain to delay a painful procedure -Demonstrate regressive behavior is when experiencing pain -Difficulty functioning in school -Adolescence> -Think abstractly and understand cause-and-effect -Describe and quantify pain intensified And their feelings about pain -They are able to perceive and understand pain at a physical emotional and cognitive level -Having the abilities does not mean that adolescents will use them -Confused by control issues in our uncertain of the rules as a move from childhood to adult hood -Regression may occur in relation to pain -Conflicted between striving for autonomy and having their parents involved in their care -Egocentric intend to think that others focus on their behaviors therefore they suppress the manifestations of pain -My not report pain because they believe that the nurse knows when they hurt they expect to receive pain medication when they need it and not just when they ask for it -Tend to exhibit few were our signs of pain as compared to younger children -Possible science include increased muscle tension with drawl decreased motor activity -Hospitalized adolescence use words such as sore pounding miserable to describe pain

Non-pharmacological interventions

Non-pharmacological interventions -Can be provided in addition to pharmacological interventions -Can help Minimize or Aleve pain by reducing anxiety and fear of the unknown -Non-pharmacological interventions must be suitable for the child stage of development -Parents play a very important role in assessing and providing pain management for the children -They are a resource for determining what methods of pain relief were effective in the past -They can help the nurse assess their child's current pain status the need for intervention -Re-positioning holding touching massage warm or cold compress breathing techniques distraction guided imagery muscle relaxation -This practice gives parents hands-on involvement in a sense of control when their child is hospitalized -Swaddling breastfeeding and infant kangaroo care or effective pain reduction interventions -Distraction can be one of the more effective adjuvants for pain management -Distraction works by refocusing the child's attention from the pain to something else -A child brought to the emergency department after an accident is invariably frightened -Even if the injury is mine or the fear and pain are real to the child -But he's in distraction the nurse can decrease the child anxiety and the pains decreases -Engage in activities on their own in an effort to ignore or forget the pain -The form of distraction used should be appropriate for the child's developmental level -Techniques include blowing bubbles listening to music or stories reading playing video board games watching a video multiplication tables for spelling words - Allow the child to help by handing opening or holding objects -If your child has a favorite doll or stuffed animal it can be used to create a story or a game -Children love to talk about their pets and the nurse can ask the child to tell her favorite story about the pet xEngaging in child in conversation that is meaningful to the child Natalie is in pain control but facilitates development of therapeutic nurse patient relationship -Although each child is different kills her verbal instruction from the child and the parent can indicate whether the nurse should hold a child hand touch the child's head or provide some other inventions that are appropriate and comforting to the child -A child life specialist is a great resource in providing effective coping techniques Taylor to the child such as the use of play and self-expression activities -Oral sucrose with or without non-nutritive sucking on pacifiers as a non-for neonatal and infant pain management -Giving oral sucrose alone and with NNS before and during a procedure or safe and effective interventions that reduce procedural pain in infants

Obstacles to pain management in children

Obstacles to pain management in children -Include belief in myths, knowledge deficits, especially with regards to pharmacologic properties of pain management medications often used in children, inaccuracy of pain assessment in pain assessment measures, insufficient awareness of pain management interventions, lack of confidence regarding the efficacy of pain management, lack of communication with children and their parents and personal attitudes and believes about pain -The two believes of parents and nurses that are most likely to interfere with the provision of adequate pain relief in infants and children are fear of respiratory depression in fear of addiction -In addition many nurses believe that children over reports her pain -One strategy used to a pediatric institutions to provide a comprehensive pain management program is a pain management team and it's composed of nurses certified in pain management -Parents often feel that communication with the nurses about pain management plan for the child is liking or a consistent the team may offer pain management recommendations based on the most current knowledge -Availability in personalization of judge Acacian can provide motivation for changes in believes in attitudes am on healthcare providers as well as patients and families -Pain management team members can also train resource nurses from each hospital unit to provide advice and support to their colleagues on best practices in pain management for children -Nurses who recognize the importance of implementing appropriate pain management strategies need ongoing access to the most current information -The Internet can be a powerful tool for accessing instant up-to-date information -Nurses and families or caution to ensure that they obtain information from trustworthy websites

Pharmacologic interventions

Pharmacologic interventions -Reluctance to administer an RG 62 infants and children stems from the fears of many nurses and physicians that the pain medication will cause respiratory depression or lead to addiction -If a procedure surgery or trauma causes pain in adult it will cause pain in a child and pain medication is necessary -It's important to ensure that the correct medication in those ordered and administered xIn some cases the pain meds is underdosed and the child still experiences been treated unwarranted pain -Increased pain management experience and research I've taught that a combination of medications are often far more effective than a single analgesic -No one analgesic or Combination of analgesics will provide optional pain management for all patients or in all circumstances -The chosen analgesic therapy must have a prompt Onset of action Administering analgesics> -The least invasive brow that provides optimum energy easier should always be chosen -As soon as the child can tolerate oral nutrition pain medication should be given for the oral route whenever possible -Let the medication should be avoided because this route can be very disturbing your children and is generally disliked -The IM route Is used infrequently because many children are very afraid of injections PCA> -Administer his IV bolus of pain medication with or without a continuous infusion of the same medication -I sedated or sleeping patient will not be able to activate a bolus dose thereby decreasing the risk of overdose -With the child needs pain medication is models of the opiate medication is received after a button connect to the pump is pushed -After checking to ensure that all doses or with an appropriate range for the child to register nurse is supposed check the bag or syringe of medication before hanging it -After a PCA pump is programmed it must then be double checked by a second register nurse -The opioid bag or syringe is locked into the PC pump and the pump itself is locked to the IV pole -The specialized PCA tubing does not have IV access ports - Child is monitored frequently to ensure that pain control is effective in that the equipment is functioning correctly -The nurse should carefully assess the child for signs of over medication such as respiratory depression - Many institutional policies require that children receiving PCA therapy be placed on continuous pulse ox symmetry cardiac and respiratory monitoring for both -Oxygen a bag valve mask and I having a lock sound should be readily available -No Lochstone only repeated administration every 30 to 60 minutes some hospitals require a physician to be present as rapid infusion can result in cardiac arrest -Frequent pain assessment is essential usually everyone for hours with anybody the stows to assess the effectiveness of PC therapy in general and of the bolus -31 include hourly documentation as to the number of boneless doses received and the number of bolus attempts made by the child -Children 5 to 7 years and older can use PCA children younger than that can I have a parent family member or healthcare provider administer PCA by proxy -Unauthorized staff and families not to administer bolus doses for the patient Topical anesthetic agent's> -Useful for injections venipunctures lumbar punctures bone marrow aspiration's -Mini pediatric institutions Mandy that numbing agents be used for our IV catheter insertion's unless it is on an emergency basis -Lidocaine prilocaine Was the first agent that demonstrated efficacy for numbing the skin for invasive procedures -amethocaine gel, Liposomal lidocaine, Synera patch, terracaine -A creamer patch is applied to intact skin with no open wounds burns abrasions cuts or inflammation -And aesthetic cream is applied on the skin but the procedure site for 60 minutes to 1 20 minutes and provide the numbing effect for one or two hours after removal -Parents can I buy an agent at home before I schedule procedures such as a immunization injection to prevent pain -Parents are instructed to wear gloves when applying and anesthetic creams -Young children must be supervised so they do not remove the dressing rub the cream in their eyes or ears read the cream which we look like a cake frosting -Main side effects of any topical anesthetic cream for skin redness or blanching with normal skin color returning in a few hours -The child should be monitored for burning swelling and itching rash in this occurs in mediately remove the cream from the skin -The vapor coolant sprain is used to provide immediate numbing of the skin for urgent procedures -Call spray sprayed either directly on the skin at the site around us through condo which is an applied to the site for 15 seconds -onset of action is immediate and the numbing effect last approximately 15 seconds - Lidocaine hydrochloride epinephrine topical solution comes as a patch and uses inotophpresis A mild electric current to push lidocaine and epinephrine into the skin to a depth of 10 MM -j tip device Some studies have shown use of the G-tube to reduce pain for children during IV catheter insertion's although it's efficacy over other topical anesthetics is still being investigated -Topical agents along with a distraction or other nonpharmacologic methods and parental presents were together to leave a pain and stress for the child and family

Preparing to Child and family

Preparing to Child and family -Child and family are informed about the purpose of obtaining vitals -Children should be allowed to examine or handle equipment while the nurse explains how it's used -Many children have toy medical instruments at home it may be familiar with the concept of taking vital signs - Tell children that blood pressure cuff feels like a hug or squeeze on their arm or leg

Preschoolers

Preschoolers - More cooperative than toddlers but still like to have their parents nearby -Happy to show nurses that they can in unaddress them selves -Expected to cooperate -Nurse should still have the same more invasive procedures such as a speculum exam and oral examination until last -Examine reinforces the trams interest by allowing the child to participate in the exam in by praising a child for cooperating

Potential indicators of child abuse

Problem oriented historyPotential indicators of child abuse

Research on pain and childre

Research on pain and children -WHO three-step analgesic letter was developed in 1986 to improve treatment for cancer pain it suggests non-opioid analgesics for mild pain, Week opioids for mild to moderate pain and Opioid analgesics for severe pain -The guidelines are the basis for pain management of children and adults particularly related to multidrug therapy -The APS develop clinical guidelines related to care of pediatric and adult patients with acute and chronic pain associated with sickle cell disease cancer chronic arthritis and fibromyalgia -The joint commission accreditation standards how continue to address both pain assessment and management by requiring health care agencies to provide pain management education and guarantee or hospitalized patients the right to develop the appropriate comprehensive pain assessment and management from admission until discharge -Did you find the under treatment of pain Wilson and Pendleton coined the term oligoanalgesia, Children who experience pain or a risk for increased pain sensitivity later in life -Improvements are still needed in the following areas including research on nurse position collaboration for pediatric pain management, education of healthcare providers about appropriate effective pain management, increase information about pain management in units in infants, testing for the safety and efficacy specially. Pacifically and children of new analgesics as they are introduced

School age children

School age children -To establish trust with this child the examiner asked the child questions the child can answer -Children in elementary school will talk about school friends and activities -Examiner encourages a parent support and reinforce the child's participation in the exam -Exam proceeds from head to toe -Children of this age prefer a simple drape over there under pants or a colorful exam down in the examiner should be sensitive to the child's modesty -Exam is a wonderful opportunity to teach the child about the volume personal care

Sequence of physical exakination

Sequence of -General appearance -Determines child's age sex and race and identifies clues concerning the child's behavior and health status -Child has their own unique differences in behavior and health status related to growth and development -Examiner continually notes the child-parent interaction and the way the parent response to the child's needs and behavior -Physical and emotional neglect as well as inadequate parental Supervision for the child's age History taking -The complete or initial history is gathered about the child from the time of conception to the child's current status -The well interim history includes data gathered about the child from the last well visit to the current visit -When doing well in tear in history the examiner seems that a database is In place -In problem oriented or episode of history information is gathered about a current problem and information about a specific problem is then added to the existing database

Sequence of physical examination

Sequence of physical examination -Recording data -Information gathered concisely to provide all necessary information from pregnancy to the child's current status - Milestones and growth and development immunizations and family status are always included in the child's history Vital signs -Taking up a revisit in our monitor throughout the day -Parents are encouraged to take auxiliary rather than rectal temperatures -Reasons to avoid rectal temperatures are questionable accuracy with febrile children because feces retain body heat for hours after a fever and has diminished —temporal artery Measurement accurately measure his body temperature in infants and children older than three months and are less invasive in more time efficient than rectal or axillary temperatures -When taking Tim panic temperature the side is noted as variations can occur from one ear to another in the same child -Oral temperature starts at five or six years of age Pulse> Apical pulse measured in children younger than two and a child who has irregular heart rate or known congenital heart disease -Radio pulses taken and children older than two -Arterial pulse is palpated to determine pulse rate and rhythm in to evaluate blood flow and artery wall elasticity and vessel patency -To determine the position of the heart in the anterior precordium the nurse palpates the apical impulse and infants and children younger than six -Epochal impulse is always palpated and every child in the location of the aprical impulse is noted - Examiner and how Peyton compares fee moral radio and carotid pulses and children of any age -Nurse can compare a carotid pulse with a from Morrow or radio pulse for equality of pulses -The nurse notes the pulsating anterior fontanelle -The pulse can increase in anxiety fever exercise inflammatory illness shock or heart disease -The rhythm of the heartbeat is assessed for equal spacing between consecutive beats -Irregular cardiac rhythms are not uncommon in children and are often related to changes in rhythm that occurs in response to respiratory inspiration and expiration Respirations> -In infants the rate of respirations can be observed by abdominal excursion -Because the movements are regular the rate should be assessed for one minute and infants and young children -Respirations best counted when the child is not paying attention to the examiner -Respirations counted while the examiner continues to keep fingers on the pulse is this one sure that the child is unaware that the examiner is counting respirations -Respirations should be quiet and appear effortless - Strider a crowning noise heard on inspiration and her daughter over the net is worrisome and a child and may be a sign of croup or a late sign in epiglottis -Inspiratory strider indicates a partial obstruction of airway -Continuous inspiratory and expiratory strainer can be related to delayed development of the Cartlidge in the trach your rings or to a relatively small larynx Blood pressure:> -Routine blood pressure measurement beginning at three years - An average of at least three abnormal blood pressure measurements taken on separate occasions require further evaluation -If an adolescent blood pressure is greater than 120/80 the adolescent is considered to be prehypertensive even if there's value is below the 90th percentile -Small curves will cause falsely elevated values and large cups will cause an accurate low values -Use distractions such as allowing the child to take blood pressure and the doll or stuffed animal to alleviate anxiety that can result in inaccurate measurements Pain> Pain is a 5th vital sign

Skin hair nails

Skin hair nails Skin> -inSpection> -In dark skinned infants and children erythema appears dusky red or violet and cyanosis appears black And jaundice appears Diffusely darker -It's important to monitor skin color and skin color change in dark skinned children as increased pigmentation and thickening of the skin on the posterior neck armpits and behind the knees and elbows can be an indication of type two diabetes in children Palpation> - Moisture assessed by lightly stroking the skin surface in body creases and the external skin on exposed areas is normally drier than unexposed areas of the skin -Temperature is assessed by using the back of the hand because it is more sensitive to skin changes The two sides of the child's body are compared -Normal texture of the skin is described as being smooth and soft and scars should be noted -Tugor by Grasping the skin between the thumb and index finger in quickly releasing it -The skin normally returns to place without excessive skin markings —Skin that tense, when released, indicates dehydration the abdomen and upper arm are the best places to test for tissue turgor on a child -Adema possessed by pressing the thumb and noting Indentation as the classic areas to palpate for our the extremities and butt ox and Perry orbital Adema is observed on the eyelids -Lesions are identified noting configuration distribution color and size - Primary lesions are freckles secondary lesions are scabs Hair> Find Downey hair is normal for a newborn infant where as the older child it would leave the examiner to consider nutritional and endocrine abnormalities -In most children Hair begins in a whorl It is then distributed over the head - Some children have more than one whorl -Scalp hair does not grow beyond the nape of the neck or down to the eyebrows -The Scalp should be clean and free from any infestations -Expect head lice if children are scratching their head > Nails> -Should be flat or slightly convex the edge of the nails should be smooth rounded and clean -Clubbing of the finger nails can be identified by looking at the Annex finger to see if the nail bulges upward -If the angle between the nail base in the fingertip is greater than 160° clubbing is present -A diamond of light below the knuckle and above where the finger nails touch will be present in early clubbing the diamond shape is decreased or not a parent -Capillary refill should return within 1 to 2 seconds a capillary refill more than two seconds may be caused by circulatory compromise fluid and balances and an impediment to peripheral circulation

Smell

Smell -To detect general body odors common in children who are neglected or dirty -Order may indicate infection -Odors from the mouth urine or feces can be important

Techniques for a physical exam

Techniques for a physical exam -The exam includes inspection palpation percussion auscultation in that order -During the abdominal exam, inspection is performed first and then auscultation percussion palpation -Percussion determines the size of abdominal organs before palpation Inspection> -Direct inspection looks at sight and hearing -Color shape size movement -Indirect inspection uses otoscope to examine specific body areas Palpation > -Feels for positions vibrations to locate structures in masses - Determine characters of size texture warms mobility tenderness of various areas of the body -The finger pads used to palpate the breast my fingertips are used to palpate the lymph nodes and pulses -Back of the hand is used to assess temperature, palm of hand is used to detect vibrations -The light population is gently applying for your tip pressure to the press the skin surface and then moving the fingertips in a circular motion -The patient identifies a domino structures such as a liver spleen kidneys and detects abdominal masses - Deep palpation follows light palpation -My manual palpation is performed with both hands examiner superimposes one hand over the other hand to increase pressure or places one hand near the other to capture in trap in mass or structure between them such as a kidney or the spleen Percussion -Quick sharp tapping of the fingers or hands to produce sounds -Perform to locate the position size and density of the underlying structure's auscultation -Most sounds result from air-fluid movement within the body -Diagram of the stethoscope is most effective in assessing high pitch sounds such as heart and breath sounds -Sounds are described as pitch intensity duration and quality

Thorax and lungs

Thorax and lungs -In a sleeping infant, The nurse is wise to seize the opportunity to inspect and auscultation breath sounds -In an infant lung tissue on the anterior chest can be located from the Apex above the clavicle to the level of the fifth rib in the midclavicular line -By age 61 tissue is accessed from the Apex to the level of the sixth rib in the middle clavicular in line - Lung tissue is this Thursday from the axilla to the level of the eighth rib -Posteriorly lungs are assessed from the level of the first thoracic vertebra 10th thoracic vertebra Inspection> -Inspect for cough strider grunting hoarseness snoring wheezing type and amount of any sputum -Respiratory rate and pattern or observed -In young children and infants breathing is more diaphragmatic or abdominal -The chest wall should expand symmetrically during respiration -Rapid respirations retractions nasal flaring head-bobbing may indicate respiratory difficulty -In infants and young children the thorax is more rounded -Some children have Harrison groove which is a horizontal line in the rib cage extending from the sternum to the mid axillary line |Scoliosis can cause the impaired pulmonary function Palpation> -Begins with the posterior chest -To alleviate fear in a young child the examiners just stand in a position that allows the child to see the examiner at all times -The posterior chest is palpated for areas of tenderness tactile fremitus and chest excursion -The examiner touches the entire thorax with Palmer aspects of the fingers to palpate for tenderness -The presence or absence of tactile fremitus vibration fell on the chest wall when the child is crying or speaking indicate airway alterations -Hyperresonance Is normal in the infant in the young child because of the thin chest wall Auscultation> -It is best to listen to breath sounds with the child sitting upright -Infants and toddlers can be held in the parent's lap -The examiner positions on one side of the child allowing the child to observe the examiners movements -Before touching the chest the examiner allows a young child to hold her play with the stethoscope -For the inconsolable child examiner license for breath sounds between cries if the young child is sleeping or comfortable in the parent's arms the examiner listens to the chest first before proceeding to the rest of the examination -Name to the posterior thorax the child is positioned with the headband Foward in hands folded in front -Having the child raising arms overhead while sitting erect a lousy examiner to listen laterally -To listen in the posterior thorax the child open the mouth and breathe in and out and having a young child blow bubbles pertaining to blow out birthday candles or blow it issue increase his breath sounds -Have a child inhale deeply and then blow the breath out of forcibly assist with identification of adventitious breath sounds -Dang auscultation follows is zigzag pattern comparing sounds from right to left Adventitious breath sounds> -Additional sounds heard any abnormal clinical state in the examiner notes if they are continuous or discontinuous

Toddler's

Toddler's -Most challenging to examine because least likely to cooperate -Examiner begins by sitting or standing next to the parent - To facilitate relaxation examiner can provide a few toys and books and encourage the child to explore -Allowing the child to handle objects During an exam Can reduce fear's -Communicating with the child using age-appropriate words to describe what is about to be done can also help Decrease fear -Portions of exam can be done before the child is totally undressed -Order of examination is flexible receiving from least to most invasive procedure -Resistance in crying are common -Nurse for sure his appearance at the child's response to the exam is normal -Parents is the best resource for getting the child cooperation during the exam -Parents he's familiar purchase to soothing and comforting the child