Pediatric Exam Two

•Immunity

-Ability to destroy and remove a specific antigen from the body

•Active immunity

-Acquired when a person's own immune system generates the immune response; person own immune system generates response; ex. vaccinations and illnesses; lasts many years

Palpation

-Assessing warmth, texture, and unusual findings through touch.

•Selective screening

-Done when a risk assessment indicates the child has one or more risk factors for a disorder; ex. cystic fibrosis

•Minimize physical distress during procedures

-Engage the child in identifying what would make him or her comfortable -Use positions that are comfortable to the child -Therapeutic hugging (have sit on parents lap -Use distraction methods (music, conversation)(ipad use); ask child what would make them comfortable

•Parental education

-Engages parents as active participants in health care team

•Provide effective communication and teaching

-Find a balance between neutral and effective communication (be aware of body language) -Use verbal communication and nonverbal communication -Use developmental techniques for communicating with children -Assess parental and child learning needs and create educational plan based upon individual needs and learning styles; if knowledge deficit how correct it

Percussion

-Focused tapping to determine the location, size, and density of organs or masses.

Components of a Complete Physical Examination •Assessment

-General appearance, vital signs, body measurements (height, weight, head circumference, BMI), activity level, orientation, mood, and pain assessment.

•Therapeutic communication

-Goal directed -Focused and purposeful; give info they need but don't overload

Components of a Complete Physical Examination •Examination (develop a consistent head-to toe pattern)

-Head, neck, eyes, ears, nose, mouth and throat, skin, thorax and lungs, breasts, heart and peripheral perfusion, abdomen, musculoskeletal system, and neurologic system, genitalia and rectum.; know their trends incorporate play in exam for toddlers

•Child education

-Helps child understand the reason for the hospitalization/procedures in developmentally appropriate ways

•Risk assessment

-Includes objective and subjective data to determine the likelihood that the child will develop a condition; ex. asthma

Auscultaton

-Listening to heart, lungs, and abdomen with stethoscope.

•Passive immunity

-Produced when the immunoglobulins of one person are transferred to another; antiote to snake venom, breast milk to baby; lasts weeks to months

•Therapeutic play

-Provides emotional outlet or coping devices

•Universal screening

-Screening of an entire population regardless of the child's individual risk; ex. blood dot test after birth and hearing screenings

Observation

-Visual observations such as skin color, any asymmetry, gait and any unusual movements; smelling for any odor.

Developmental Considerations for Examination •Plan the exam format and environment based on the developmental stage of the child.

-infants and toddlers may prefer to be examined on caretaker's lap. -preschool or school age may want to inspect stethoscope; need sense of control. -teens prefer privacy.

Developmental Considerations for Examination •Direct the conversation related to the exam process:

-to the caregiver for young children. -engage older child/teen in conversation as appropriate.

respiratory rate adolescent

12-18

respiratory rate school-age

14-22

respiratory rate preschooler

20-25

respiratory rate toddler

20-30

respiratory rate infant

25-55

heart rate adolescent

55-95

heart rate school-age

60-100

heart rate preschooler

65-110

heart rate toddler

70-120

Heart rate infant

80-150

Vaccine Administration Routes Box 9.8 Intramuscular

DTaP, DT, Tdap Hepatitis A, hepatitis B Hib Influenza (trivalent) Pneumococal HPV MCV4

Is the following statement true or false? The nurse is eliciting a health history from an adolescent. It is recommended that the nurse acts like the teenager's peer in order to gain respect and acceptance.

False. It is not recommended that the nurse acts like the teenager's peer in order to gain respect and acceptance. Rationale: The nurse should remain in the role of the health care provider while demonstrating respect and acceptance toward the teen. The nurse should also clarify the meaning of jargon or slang that the teen uses, but not use these words in the interview; the teen will simply not accept the nurse as a peer.

Is the following statement true or false? The nurse is providing atraumatic care to a child who is undergoing surgery and the child's family. The focus of this type of care is solely on meeting the physical needs of the child.

False. The focus of atraumatic care is minimizing or eliminating the psychological and physical distress experienced by children and their families in the health care system (Hockenberry & Wilson, 2009; Wong, n.d.). Rationale: Atraumatic care involves guiding children and their families through the health care experience using a family-centered approach by promoting family roles, fostering family support of the child, and providing appropriate information.; techniques- use lay terms that patient and parents understand. Explain what gonna do before doing

Is the following statement true or false? The nurse preparing discharge teaching for the parents of a hospitalized child should base this teaching on the fact that adults are present focused and do not value past experiences.

False. The nurse preparing discharge teaching for the parents of a hospitalized child should base this teaching on the fact that adults are problem focused and value past experiences and beliefs. Rationale: Adults value independence and want to learn on their own. Adults learn best when they perceive there is a gap in their knowledge base and want information and skills to fill the gap. Adults bring an accumulated wealth of experiences to each health care encounter; this provides a rich base for new learning.

Is the following statement true or false? The nurse providing pediatric health supervision should focus on the illness of children.

False. The nurse providing pediatric health supervision should focus on the wellness of children. Rationale: The health supervision visit provides an opportunity to maximize health promotion for the child, family, and community and nurses have the ability to promote optimal health during these encounters. Health supervision visits should be viewed as part of a continuum of care, not as the accomplishment of isolated tasks.

Vaccine Administration Routes Box 9.8 Subcutaneous

IPV MMR Varicella MPSV4

Early Hearing Risk Assessment

In the preverbal child (newborns and older): •Auditory skill monitoring by assessing reaction to sounds-does the child react to parent voice or loud noise appropriately? •Developmental surveillance-does the child try to vocalize? •Parental concerns-do the parents have concerns about the child hearing? Any changes in hearing?

Chapter 9: Health Supervision

PP

Chapter 8: Atraumatic Care of Children and Families

PP; minimize as much trauma as possible for child and family

Chapter 10: Health Assessment of Children

PP; not focused, squirmy, talkative

Cuff Placement Positions

Size of cuff must be proportionate to size of child's extremity; pp image; size can cause inaccurate readings

Documentation of Child and Family Teaching

The learning needs assessment Information on the child's medical condition and plan of care Goals of child education; date goal is met Teaching method used and how received by child and family Medications, including drug-drug and drug-food interactions Modified diets and nutritional needs Safe use of medical equipment Follow-up care and community resources discussed

Is the following statement true or false? The community can be a contributor to a child's health or it can be the cause of his or her illnesses.

True. The community can be a contributor to a child's health or it can be the cause of his or her illnesses. Rationale: The child is a member of a community as well as a family and a culture. The child's health cannot be totally separated from the health of the surrounding community. Each community has unique strengths, weaknesses, and values that can affect a child's health.; know unique strengths and weaknesses of community

The nurse is performing a physical assessment of a child. Which of the following reflects the order in which the assessment techniques are normally performed? a. Inspection, palpation, percussion, auscultation b. Palpation, percussion, auscultation, inspection c. Percussion, palpation, inspection, auscultation d. Inspection, auscultation, palpation, percussion

a. Inspection, palpation, percussion, auscultation. This describes the order in which the physical assessment is performed. Rationale: The physical examination of children begins with a systematic inspection, checking color, warmth, characteristics, and texture visually and smelling for any odor. Palpation follows inspection to validate observations. Percussion determines the location, size, and density of organs or masses. The stethoscope is used to auscultate the heart, lungs, and abdomen.

The nurse is conducting a health assessment of a teenager and asks about his daily routine. What aspect of the health history is the nurse assessing? a. Developmental history b. Functional history c. Family health history d. Demographics

b. Functional history. The functional history involves asking about the child's daily routine. Rationale: The developmental history determines the age when landmarks in gross motor control were achieved. The family health history obtains information about the family's health, and demographics refers to data such as the child's name, birth date, gender, race, ethnicity, and language spoken.

The nurse is conducting developmental surveillance on a child and his family. Which of the following is a component of this process? a. measuring the child's head circumference b. administering vaccinations c. addressing parental concerns d. performing a physical assessment

c. addressing parental concerns is a component of developmental surveillance. Rationale: Developmental surveillance is an ongoing collection of skilled observations made over time during health care visits and includes noting and addressing parental concerns. Measuring the head circumference, administering vaccinations, and performing a physical assessment are components of the screenings conducted at the health supervision visit.

The nurse is preparing a child for a vision screening. How far would the nurse place the child from the chart? a. 5 feet b. 10 feet c. 15 feet d. 20 feet

d. 20 feet. The nurse would place the child 20 feet from the vision screening chart. Rationale: When screening for vision, the nurse would place the chart at the child's eye level, place a mark on the floor 20 feet from the chart, and align the child's heels on the mark.

The nurse is performing a physical assessment of a 16-year-old girl. Which of the following is a recommended guideline for interviewing a child at this developmental stage? a. During the interview ask the caregiver to answer any questions the teen is too embarrassed to answer b. Keep up a running dialogue with the caregiver, explaining each step as it is performed c. Perform the genital exam first, and then use a head-to-toe approach to examine other systems d. Explain to the caregiver that the teen needs privacy and ask him or her to wait outside the room

d. Explain to the caregiver that the teen needs privacy and ask the caregiver to wait outside the room during the physical examination. Rationale: The nurse should explain confidentiality to the teen and caregiver, and interview each together and separately. The nurse performing a physical examination of the older teenager should ask the caregiver to wait outside to provide privacy for the teen. The nurse should also use a head-to-toe approach with the genital exam performed last.; some things can't be confidential like abuse

The nurse is providing atraumatic care to a child hospitalized for cardiac surgery. Which of the following is a recommended guideline when communicating with the child's parents? a. do not cause undue stress by providing details of the surgery b. direct the focus of the parent from providing routine care of the child to preparing for the surgery c. direct the parents to the physician if they have questions about the surgery d. treat the parents as equal partners in the care of their child by allowing them to perform as much care as possible

d. treat the parents as equal partners in the care of their child by allowing them to perform as much care as possible. Rationale: The nurse should allow the parent to express concerns and ask questions, as well as explain equipment and procedures thoroughly. The nurse should also teach and encourage the parent to perform as much of the child's care as is reasonable and permitted. This helps to give the parents a sense of value and control.

Cone of Learning

look at PP.; after two weeks we tend to remember 10% of what we read, 20% of what we hear, 30% of what we see, 50% of what we hear and see, 70% of wat we say, 90% of what we say and do

Family-Centered Approach to Health Care

rooming in

Genogram

used with specific genetic conditions

Therapeutic Communication Techniques

•Active listening. •Using open-ended questions. •Identifying and eliminating barriers to communication. •Establishing rapport.

Specific Learning Principles Related to Parents

•Adults are self-directed •Adults are problem focused and task oriented •Adults want an immediate need satisfied •Adults value past experiences and beliefs -Knowles (1990)

Positive Outcomes of Family-Centered Care for Children

•Anxiety is decreased •Children are calmer and pain management is enhanced •Recovery times are shortened •Families' confidence and problem-solving skills are improved •Communication between the health care team and the family is also improved •A decrease in health care costs is seen •Health care resources are used more effectively

Components of Learning Needs Assessment

•Assessment must include child and family •Follows nursing process: assess, plan implementation, evaluate, and document teaching • •Identify learning styles and preferences, and potential barriers to learning • •Consider cultural factors that may impact learning • •Assess health literacy (being able to understand material related to health; first do this to know what to assess and address; pamphlets should max be written at middle school level

Health Supervision in Chronic Illness

•Children with chronic illnesses may need specialized health supervision needs and more frequent visits •Critical need for coordination of services from multiple specialties through medical home •Families with a member with a chronic illness may need additional supports •Coordination of community resources to support family's needs •Ongoing assessments of family needs

Collecting A Complete History

•Collecting a thorough history and review of systems can often identify risk factors. • •Events in the perinatal and newborn period can influence growth and development later in childhood. • •Include family history as part of interview to identify risks with genetic component.

Special Issues in Health Supervision

•Cultural influences •Community influences •Health supervision and the chronically ill child •Health supervision and the internationally adopted child

Components of the Health History

•Demographics •Chief complaint and history of present illness •Past health history •Review of systems •Family health history •Developmental history •Functional history •Family composition, resources, and home environment

Three Components of Health Supervision

•Developmental surveillance and screening •Injury and disease prevention •Health promotion; usually newborns seem within 48 hours after birth then 2 weeks then 1 month-12 months then yearly; lot of time on parent

Red Flags Indicating Poor Literacy Skills

•Difficulty filling out forms •Frequently missed appointments •Noncompliance and lack of follow-up with treatment regimens •History of medication errors •Responses such as "I forgot my glasses" or "I'll read this when I get home" •Inability to answer questions about treatment or medicines (if grandma takes child instead of primary caregiver) •Avoiding asking questions for fear of looking stupid (any qustion is appropriate)

Other Types of Vaccines

•Diphtheria, tetanus, and pertussis (DTaP, TdaP); dtap original given to infants and childrens and tdap given to 11-12 year old booster •Haemophilus influenzae type B (Hib) •Polio, measles, mumps, and rubella (IPV, MMR) •Hepatitis A and B (HepA, HepB) •Varicella (Var) •Pneumococcal (PCV, PPSV) and influenza (IIV, LAIV) •Rotavirus •Human papillomavirus (HPV2, HPV4); not available anymore now Gardasil-9 •Meningococcal; document vaccination name, lot # and expieration date, manufacturer, where vac given, how given, who admin., facility admin, VISC, legally required to give to parents vaccine info sheet. CDC vaccinations, vaccine hesitancy

Exploring Family Dynamics During the Health History

•Does the parent make eye contact with the infant and anticipate and respond to the infant's needs? •Are the parents calm and effective when dealing with a toddler's temper tantrum? •Do the parents' comments increase the school-age child's sense of self-worth? •Are the parents comfortable having a teen respond to questions? •Behavioral observations are crucial to proper assessment of the family's needs.

Role of the Nurse When Performing a Physical Assessment of a Child

•Establish rapport and trust. •Demonstrate respect for the child and parent/caregiver. •Approach child in a developmentally appropriate manner. •Communicate effectively by listening actively, demonstrating empathy, and providing feedback. •Observe systematically (head to toe). •Obtain accurate data. •Validate and interpret data accurately.; do abdominal assessment last if painful; do ears last usually

Role of the Nurse When Performing a Physical Assessment of a Child

•Establish rapport and trust. •Demonstrate respect for the child and parent/caregiver. •Communicate effectively by listening actively, demonstrating empathy, and providing feedback. •Observe systematically. •Obtain accurate data. •Validate and interpret data accurately.; no pt. situation if vitals out of whack (due to shots)

Specific Learning Principles Related to Children

•Establishing rapport with the child is the first step •The age and developmental level of the child will determine the amount, format, and timing of the information given •Create a teaching plan that addresses the developmental stage of the child •Adolescents are particularly sensitive about maintaining body image and feelings of control and autonomy

Review of Systems

•Growth and development •Skin •Head and neck •Eyes and vision •Ears and hearing •Mouth, teeth, and throat •Respiratory system and breasts •Cardiovascular system •Gastrointestinal system •Genitourinary system •Musculoskeletal system •Neurologic system •Endocrine system •Hematologic system

Distraction Methods

•Have the child point toes inward and wiggle them •Ask the child to squeeze your hand •Encourage the child to count aloud •Sing a song and have the child sing along •Point out the pictures on the ceiling •Have the child blow bubbles •Play music appealing to the child; hospitalized children their room should be safe place. avoid doing procedures in room

Issues Covered in Psychosocial Assessments

•Health insurance coverage- may not be able to afford antibiotic, etc. •Transportation to health care facilities •Financial stressors •Family coping (parents, siblings, extended family) •School's response to the child with a chronic illness- miss more days of school

Components of the Health Assessment

•Health interview and history.- can't help very much with that •Observation of the parent-child interaction. •Assessment of the child's emotional, physiologic, cognitive, and social development. •Physical assessment.

Assessing Growth and Development

•Height and weight plotted on appropriate growth chart. •Growth charts for special populations (Downs, preemie, breast-fed infants). •Age-for-weight (on growth chart). •Head circumference. •Body mass index (calculated from weight and height by age)(actually months; infants have instead of BMI- weight for length and growth chart)

Working with an Interpreter

•Help the interpreter prepare and understand what needs to be done ahead of time -The interpreter is the communication bridge, not the content expert; the interpreter's timing may not match that of others involved •Speak slowly and clearly; avoid jargon •Pause every few sentences so the interpreter can translate your information •Talk directly to the family, not the interpreter •Give the family and the interpreter time to respond •Ask family to repeat back their understanding of the topic •Express the information in two or three different ways if needed. Use metaphors to illustrate points •Use an interpreter to help ensure the family can read and understand translated written materials •Avoid side conversations during sessions •Remember that just because someone speaks another language, it doesn't mean he or she will be a good interpreter •Do not use children as interpreters; speak in sentence or two then have answer, avoid medical jargon when using interpreter services; patients can be fearful, appointments take longer, hard to build trust

Screenings Conducted at the Health Supervision Visit

•History and physical assessment •Developmental/behavioral assessment •Sensory screening (vision and hearing) •Appropriate at-risk screening •Immunizations •Health promotion

Risk Factors for Cardiac Problems in Children

•History of prematurity, very low birthweight, or other issues requiring neonatal intensive care stay. •Congenital heart disease. •Malignancy, bone marrow transplant, or solid organ transplant. •Treatment with medications that raise BP. •Systemic illnesses associated with hypertension such as neurofibromatosis and tuberous sclerosis. •Genetic disorders. •Family history of early or sudden death.

Using a Vision Screening Chart

•Identify the most appropriate chart for the child •Place the chart at the child's eye level •Place a mark on the floor 20 feet from the chart •Align the child's heels on the mark •Have the child read each line with one eye covered and then with the other eye covered •Have the child read each line with both eyes; visual acuity

Goals of Child and Family Education

•Improve the child and family's health literacy •Encourage communication with physicians or nurse practitioners •Improve health outcomes and promote healthy lifestyles •Encourage involvement of child and family in care and decision making about care •Improve compliance with care and treatment plan •Promote a sense of autonomy and control; teaching should begin at earliest opportunity

Types of Vaccines

•Live attenuated vaccines- weakned viruses/bacteria •Killed vaccines •Toxoid vaccines- proteins produced by bacteria and weakned •Conjugate vaccines- take part of bacterial cell wall and link it •Recombinant vaccines- genetically engineered orgnaisms; don't have differentiate

Specific Types of Screenings Performed

•Metabolic •Hearing •Vision •Iron-deficiency anemia •Lead- 6 mon- 6 years of age. if poison questionairre then follow up with blood test •Hypertension •Hyperlipidemia

Grading Heart Murmurs in Children

•Murmurs are common finding in children. •Grading is based upon how loud the murmur is: Grade I (soft and intermittent) to Grade IV (loud, can be heard without the stethoscope touching chest). •Note the anatomic location where the murmur is best heard. •Note where and if murmur radiates to other parts of the chest.

Benefits of Health Partnerships With Child, Parents, and Community

•Mutual goal setting/benefits •Marshalling of resources •Development of optimal health practices

Components of Developmental Surveillance

•Noting and addressing parental concerns •Obtaining a developmental history •Using the appropriate screening assessment •Making accurate observations •Consulting with relevant professionals (speech, OT, PT, Dietitian, audiologist; absence or loss of skill can inicate neurological prob.

Steps of the Physical Examination

•Observation •Palpation •Percussion •Auscultation

Evaluating Respirations in Children

•Observe rate and respiratory effort—easy, labored? •Note retractions or use of accessory muscles to breathe. •Listen for unusual sounds—wheezing, stridor, crackles. •Describe cough if present—dry, hacking, wet, productive.

Later Hearing Risk Assessment

•Older than 4 years old •Assessment of parental concerns •Difficulty hearing on the telephone •Difficulty hearing people in a noisy background •Frequent asking of others to repeat themselves •Turning the television up too loudly

Determining Characteristics of Chief Complaints

•Onset, duration, characteristics, and course (location, signs, symptoms, exposures, etc.). •Previous episodes in the child or family members. •Any changes in environment/daily routine. •Previous testing or therapies; what makes it better or worse. •What the concern means to the child and family. •Inquiry about any exposure to infectious/toxic agents.

Aspects of the Past Health History

•Prenatal or perinatal history, past illnesses, other developmental concerns. •Prior history of illnesses, accidents, or injuries. •Any operations or hospitalizations. •Diet (specifics) and allergies (type and reactions). •Immunization status. •Any OTC or prescription medications child is taking. •Menstrual history in adolescent females.

Principles of Atraumatic Care

•Prevent or minimize physical stressors, including pain, discomfort, immobility, sleep deprivation, inability to eat or drink, and changes in elimination •Prevent or minimize parent-child separation •Promote family-centered care, treating the family as the patient Promote a sense of control; allow parents to be present for CPR if wish

Settings for Health Supervision

•Private physician offices •Freestanding clinics in retail stores •Community health department clinics •Nonprofit community-based clinics with sliding scale payments ex. cross trails; pt what income, determines on what pay;can't deny care •Daycare centers •Schools

Topics for Anticipatory Guidance

•Promoting oral health care •Promoting healthy weight •Promoting healthy activity •Promoting personal hygiene •Promoting safe sun exposure

Providing a Sense of Control for the Hospitalized Child

•Provide effective communication and teaching •Assist family to obtain necessary information and resources

Role of Child Life Specialists in Atraumatic Care

•Provide programs to prepare children for hospitalization and painful procedures •Provide support during medical procedures •Therapeutic play and activities to support normal growth and development (help stay dev. on track while in hospital) •Sibling support; advocacy for the child and family •Grief and bereavement support- ex. pet therapy

Characteristics of a Medical Home

•Provider has a long-term, trusting and comprehensive relationship with patient and family from infancy through adolescence •Family-centered care; providers are respectful of family's customs and beliefs •Care is accessible, affordable, and comprehensive •Delivery of specialty care is coordinated in the medical home •Provider is accessible for and responsive to questions; prolems with just going to random clinics- random doc., polypharmacy, random clinics don't know full story of conditions, stable relationships with primary provider

Principles of Health Supervision

•Providing services proactively •Optimizing child's level of functioning •Ensuring child is growing and developing appropriately •Promoting best possible health of child •Preventing injury and illness through child teaching;

Focus of Family-Centered Care

•Respect for the child and family; family may extend beyond parents and siblings •Recognition of the effects of cultural, racial, ethnic, and socioeconomic diversity on the family's health care experience (look for strengths of patient and family) •Identification of and expansion of the family's strengths •Support of the family's choices related to the child's health care •Maintenance of flexibility •Provision of honest, unbiased information in an affirming and useful approach; convey information in formats consistent with successful learning •Assistance with the emotional and other support the child and family require •Collaboration with families; encourage parents to report their observations related to changes in the child (especially in outpatient setting) •Empowerment of families (better treatment for child, parents more trusting of health care provider); look at AAP def.; figure out learning styles

Techniques to Improve Learning

•Slow down and repeat information often •Speak in conversational style using plain language; consider using metaphors to illustrate complex points •"Chunk" information and teach in small bites •Prioritize information and teach "survival skills" first •Use visuals •Teach using an interactive, "hands on" approach; know why med is given, dosage, how give

Evaluating Learning

•The child or family demonstrates a skill •The child or family repeats back or teaches back the information in own words •The child or family answers open-ended questions •The child or family responds to a pretend scenario in their home

Techniques for Providing Atraumatic Care

•Therapeutic communication •Therapeutic play •Child education •Parental education; remember to review developmental levels

Calculation of Body Mass Index

•Used to calculate a single metric that accounts for height and weight. •Tracked over time on growth charts as part of growth and development assessment. •BMI metrics used to define under/overweight •Multiple online calculators for both English and metric.; know if under or overweight and how to address

Questions Appropriate to Ask When Performing a Cultural Assessment

•Who is the person caring for the child at home?- info can be lost in translation •Who is the authority figure in the family?- ex. middle eastern families •What is the social support structure? •Are there any special dietary needs and concerns? •Are any traditional health practices used? •Are any special clothes or other items used to help maintain health? •What religious beliefs, ceremonies, and spiritual practices are important on a daily basis or as they relate to health?; some people hesitant to share info; don't assume their practices based on race/ethnicities