Peds slide shows for exam 1

10-12 months

Gains 85-140 g (3-5 oz)/week Grows 1 cm (3/8 in.)/month Head circumference equals chest circumference Triples birth weight by 1 year May hold crayon or pencil and make mark on paper Places objects into containers through holes (O) Stands alone (P) Walks holding onto furniture Sits down from standing (Q) Plays peek-a-boo and patty cake

Family Assessment Tools

Genogram: Inheritance patterns, Family illness, Family members, Family relationship, Significant dates ECOMAP: Illustration of family's relationships and social networks Calgary family assessment: Offers a framework to help organize large amounts of data about a family; Structure, Development, Function of a family HOME: • Home • Observation • Measurement • Environment Cultural assessment: 4 types of cultural assessment models

Pain Assessment

Pain history How does the child typically express pain What are the child's previous experience with pain Memories of past pain can trigger anxiety that elevates the pain response. What works to reduce the child's pain Parent and child's preference for analgesic use and other pain interventions

Moro reflex.

until about 6 months of age. Elicited when the newborn is startled by a loud noise or lifted slightly above the crib and then suddenly lowered. In response, the newborn straightens arms and hands outward while the knees flex. Slowly the arms return to the chest, as in an embrace. The fingers spread, forming a C, and the newborn may cry. When surprised of starrled Moro reflex The Moro reflex is often called a startle reflex. That's because it usually occurs when a baby is startled by a loud sound or movement. In response to the sound, the baby throws back his or her head, extends out his or her arms and legs, cries, then pulls the arms and legs back in. A baby's own cry can startle him or her and trigger this reflex. This reflex lasts until the baby is about 2 months old.

CAM

(Complimentary and Alternative Medicine) TherapiesDistractionGuided imageryRelaxation techniquesBreathing techniquesHypnosisAcupunctureCutaneous Stimulation Distraction: Help your child learn to focus his attention on something other than pain. Distraction includes activities such as painting, playing board or video games, or watching TV. Visiting with friends or playing with animals may also be a form of distraction. Guided imagery: This teaches your child to put pictures in his mind that will make pain less intense. It may help him learn how to change the way his body senses and responds to pain. Relaxation exercises: Teach your child to breathe in deeply until his stomach rises a bit and then breathe out slowly. To relax his muscles, teach your child to tense up his muscles and then relax them. Guide him through this exercise starting from his foot muscles, slowly going up to his leg, body, arms, and head. Breathing Techniques: Hypnosis: hypno-analgesia is associated with significant reductions in: ratings of pain, need for analgesics or sedation, nausea and vomiting, and length of stay in hospitals. Hypnosis has also been associated with better overall outcome after medical treatment and greater physiological stability. Acupunture: Cutaneous stimulation: stimulate nerve in one way so the signal gets mixed up

Oucher Scale

- 3-13 yrsSix pictures - Available in gender and ethnic versions

Tonic neck reflex

0-3months (fencer position) Elicited when the newborn is supine and the head is turned to one side. In response, the extremities on the same side straighten, whereas on the opposite side they flex. This reflex may not be seen during the early newborn period, but once it appears it persists until about the third month. One arm out with head and one arm up

Circulatory System

1) infant: heart is more horizontally in chest so apex at 4th intercostal just lateral to LML, apical pulse will be light tap 2) toddler/preschooler/school-age: heart horizontally placed so apex at 4th, by 7yrs heart is at 5th intercostal at midclavicular line 3) adolescent: apex at 5th intercostal midclavicular

Children and Pain

Children may not complain of pain Due to limited vocabulary and experience In an effort to be brave Because they assume nurse knows they have pain Afraid treatment will be worse than pain itself

Palmar grasp reflex.

5 to 6 months toes lasts 9 to 12 months. Elicited by stimulating the newborn's palm with a finger or an object. The newborn grasps and holds the object or finger firmly enough to be lifted momentarily from the crib. Grasp reflex Stroking the palm of a baby's hand causes the baby to close his or her fingers in a grasp.

Emancipation

A minor may consent to all types of treatment if he/she meets 1 or more of the following: 1. Independent. Minor has been living separately from parents or guardians for at least 60 days & is independent of parental support. 2. Married. Minor is or was legally married. 3. Military. Minor is or was a member of the Armed Forces of the U.S. 4. Emancipated. Minor has been emancipated by the court pursuant to 15 M.R.S.A. sec. 3506-A (age 16 or older). Am I automatically emancipated if I get married? Yes. In Maine, if you are 16 or 17 years old and want to be married, you must have your parent's or legal guardian's written permission. Once you are married, you are automatically emancipated. This is the only situation where you are emancipated without going to Court. In Maine, am I automatically emancipated if I have a baby? No. Although some girls believe that having a baby make them legally emancipated, it does not.

Nine Parameters of Personality

Activity level - The degree of motion during eating, playing, sleeping, bathing Scored as high, medium, or low Rhythmicity - The regularity of schedule maintained for sleep, hunger, elimination. Scored as regular, variable, or irregular Approach or withdrawal - The response to a new stimulus such as a food, activity, or person Scored as approachable, variable, or withdrawn Adaptability - The degree of adaptation to new situations Scored as adaptive, variable, or nonadaptive Threshold of responsiveness - The intensity of stimulation needed to elicit a response to sensory input, objects in the environment, or people Scored as high, medium, or low Intensity of reaction - The degree of response to situations Scored as positive, variable, or negative Quality of mood - The predominant mood during daily activity and in response to stimuli Scored as positive, variable, or negative Distractibility - The ability of environmental stimuli to interfere with the child's activity Scored as distractible, variable, or nondistractible Attention span and persistence - The amount of time devoted to activities (compared with other children of the same age) and the degree of ability to stick with an activity in spite of obstacles Scored as persistent, variable, or nonpersistent

Advocacy

Advocacy Enable child and family to adjust to changes in child's health. In their own way and time Needs of both children and adults Awareness of resources Psychosocial needs

Pain Scale -Wong Baker Faces Scale-Children 3 and up

Ages 3 and older We use this scale by telling children "These faces show how much something can hurt. This face [point to left-most face] shows no pain. The faces show more and more pain [point to each from left to right] up to this one [point to right-most face] - it shows very much pain. Point to the face that shows how much you hurt [right now]."

Hearing Assessment

American Academy of Pediatrics recommend universal screening for all newborns before discharge -auditory brainstem response-evoked otoacoustical emissions-Evoked otoacoustical emissions Auditory diagnostics -tympanometry (objective test of middle-ear function) - for doc-otoscope (visual examination of eardrum/outer ear)-audiometry American academy of pediatrics joint committee of infant hearing (universal screening all newborns before discharge) Auditory Brainstem Response (ABR) is an objective test that can be used to estimate hearing sensitivity and to identify neurological abnormalities of the auditory nerve and the auditory pathway up through the brainstem. Otoacoustic emissions (OAEs) are sounds given off by the inner ear when the cochlea is stimulated by a sound. When sound stimulates the cochlea, the outer hair cells vibrate. The vibration produces a nearly inaudible sound that echoes back into the middle ear. -if infant fails: needs retesting and intervention before 1 month of age Tympanometry is an examination used to test the condition of the middle ear and mobility of the eardrum (tympanic membrane) and the conduction bones by creating variations of air pressure in the ear canal. Hearing impairment signs and symptoms -lack of startle reflex-failure to localize source of sound by 6 months-lack of response to spoken word-preference for playing alone

Using Evidence-Based Practice

Ask and clearly describe specific clinical question. Collect most relevant and best evidence from well-designed studies. Review, synthesize, analyze evidence using critical thinking. Integrate evidence with clinical experience. Develop practice guideline. Evaluate change in practice for effect on quality care. EBP is important because it aims to provide the most effective care that is available, with the aim of improving patient outcomes. Patients expect to receive the most effective care based on the best available evidence.

Culturally Sensitive Care

Ask questions and learn preferences. Incorporate cultural preferences into all care. Determine how condition influences family functioning. Identify family member responses. Show respect and nonjudgmental attitude.

Resiliency Model

Assessment Application to nursing care

Chest Movement and Auscultation

Diaphragm is primary muscle used by infants and young children As thoracic muscles develops, they become the primary ventilation muscles Respiratory movement should be symmetric bilaterally Auscultation of breath sounds When infant is crying, listen to breath sounds on inspiration Encourage toddlers and pre-schoolers to take deep breaths by blowing a pinwheel, or a piece of tissue in your hand. This may increase opportunity to hear subtle wheezes that occur at the end of expiration Encourage child to breath normally while auscultating the chest. Use suggestive language to increase cooperation. Breath sounds-inspiration louder and longer than expiration, soft vesicular sounds over all

Nursing Care Plan of Children Experiencing Acute Pain

Assessment Cognitive and developmental status Emotional status Previous pain experience Parental input Nonverbal children Diagnoses (examples) Acute pain Anxiety Impaired Physical Mobility Nausea Planning/implementation Pharmacologic Non-steroidal anti-inflammatory drugs (NSAIDs) Administration Purpose Effectiveness Planning/implementation Opioids Route of administration Purpose Side effects Effectiveness Planning/implementation Regional anesthesia Assessment Catheter function Catheter patency Neurologic functioning Planning/implementation Complementary therapies Purpose Effectiveness Reassessment of therapies Discharge planning Planning with families Pain management at home Evaluation Effectiveness of medication Guidelines for medication selection Dose Route of administration

Nursing Management for Chronic Pain

Assessment Obtain history, intensity, duration, and so on. Learn impact on child's daily life. Identify methods for coping. Ask about current treatments/complementary and alternative medicine (CAM). Observe appearance, posture, gait, emotional and cognitive state. Neurologic exam Pain journal Pain assessment scale Care plan for painful episodes Develop complimentary therapies. Encourage daily exercise.

Nursing Management

Assessment and diagnosis Ask about home management - culture Identify family's expectations of healthcare team. Prepare ecomap and genogram. Planning and implementation Provide support to manage multiple stressors and plan ongoing care. Establish therapeutic relationship and identify decision maker(s). Identify goals, strengths, cultural considerations. Use respectful, nonjudgmental approach. Offer choices whenever possible. Provide information on resources. Ensure family has a care coordinator. Provide referrals as needed. Evaluation Collaboration Case manager Teaching successful, as evidenced by appropriate care provided by family.

Nursing Management For Family Assessment

Assessment and diagnosis Physical assessment Psychosocial assessment, culture New medical issue can add developmental risk. Choose appropriate tool. Identify stressors that must be considered. Information gathered helps the nurse work more effectively with the family to meet the child's needs

Assessment and Intervention

Assessment of infant/child and parent Are temperaments a good fit b/w child and parent "Goodness of fit" Parent education Strategies to improve fit

Assimilation vs. Acculturation

Assimilation a process by which members of an ethnic minority group lose cultural characteristics that distinguish them from the dominant cultural group or take on the cultural characteristics of another group. add or combind new knowledge - indainas become americans Acculturation occurs when the minority culture changes but is still able to retain unique cultural markers of language, food and customs Acculturation is the transfer of values and customs from one group to another. Japanese people dressing in Western clothing is an example of acculturation. cahnge own belifes - indains come over and get some traditions but not all

3-6 years

Associative play is facilitated by simple games, puzzles, nursery rhymes, songs Dramatic play is fostered by dolls and doll clothes, play houses and hospitals, dressup clothes, puppets Stress is relieved by pens, paper, glue, scissors Cognitive growth is fostered by educational television shows, music, stories, and books All parts of speech are developed and used, occasionally incorrectly Communicates with a widening array of people Play with other children is a favorite activity Health professionals can: Verbalize and explain procedures to children Use drawings and stories to explain care Use accurate names for body functions Allow the child to talk, ask questions, and make choices

Heart

Auscultation Heart sounds - S1 is the first sound heard, followed by S2 Listen for quality - (distinct vs. muffled) and intensity (loud vs. soft) Rate and rhythm - Count apical pulse by auscultation, rarely use wrist Palpation Apical impulse - Changes as the child's rib cage grows (under 7 yrs.: 4th intercostal space) Thrills - Vibration that may feel like a cat's purr Auscultation - Listen with the child first while sitting, and then reclining. S1 is sound of tricuspid and mitral valves close. S2 is second sound produced by closure of aortic and pulmonary valve Rate and rhythm - Palpation Apical impulse Thrills

Parenting Styles

Authoritarian High control, low warmth Child may become fearful, withdrawn, unassertive. Girls often passive and dependent. Boys often rebellious and aggressive. Permissive Low control, high warmth Child may become rebellious, aggressive, socially inept, self-indulgent, or impulsive, or; Child may be creative, active, and outgoing. Authoritative Moderately high control, high warmth Child tends to be well adjusted, self-reliant, self-controlled, and socially competent. Child's self-esteem and school performance generally good. Indifferent Low control, low warmth Child may show high degree of self-destructive impulses and delinquent behavior.

Children Are Not Just Small Adults!

Because their bodies are still growing and developing, children have different needs and even different anatomies, and their bodies and health issues are often much different than those of adults. By monitoring growth and development, and taking care of illnesses and health issues early, pediatric nurses can help children grow up strong and healthy. Children are not just small adults, especially when it comes to their growing bodies and health. Because their bodies are still growing and developing, they have different needs and even different anatomies, and their bodies and health issues are often much different than those of adults. Healthy bodies and minds, as well as proper healthcare, is extremely important during childhood. Pediatric nurses spend a great deal of time providing education to young patients and their families, helping parents learn how to keep their children safe and healthy and properly manage ongoing conditions. Parents with sick children often seek out the care of a pediatric nurse, as their job requires them to be sensitive to the needs of young patients and have a special way of understanding and relating to them.

Cultural Practices Influencing Healthcare

Family roles and organization Communication (verbal and nonverbal) Time orientation

Nervous System

Behavior - alertness indicated by behavior Communication skills - listen to speech articulation and compare with standards of social development Memory - children can remember 3 words or numbers at age 4 yr, 4 words by 5 yr Level of consciousness - observe consciousness including facial expression, gestures and interaction. A sleeping child should be easily awakened. Assess by watching them play Cognitive functioning Behavior Communication skills Memory Level of consciousness Cerebellar function Balance Coordination Locomotion, gait Balance - observe during play for walking, standing on one foot (see developmental milestones) Coordination - fine motor skills can be used to assess coordination in young children. After 6 yrs, finger to finger, finger to nose, etc. Gait - Inspect the walking from front and rear views. Toddlers beginning to walk have a wide-based gait and limited balance and eventually gain more balance and a more narrow-based gait. Sensory functioning - can they see, hear, touch, Primitive reflexes

Physiologic and Behavioral Consequences of Pain

Behavioral effects School age 7 to 9 years - rigid, still, emotional withdrawal Don't have control over their muscles 10 to 12 years - may project bravery, may regress Brave then last minute be sad Adolescents Controlled behavioral response May find distraction or deny pain

Physiologic and Behavioral Consequences of Pain

Behavioral effects Infant Less than 6 months - grimacing, poor feeding 6 to 12 months - crying, irritability, restlessness Toddlers Aggressive behavior Physical resistance - no I don't want to

SCHOOL-AGE CHILD 10-12 years (transitional) The Child's Understanding of Pain, Behavioral Responses, and Verbal Descriptions by Developmental Stage

Better understanding of the relationship between an event and pain Has a more complex awareness of physical and psychologic pain, such as moral dilemmas and mental pain May pretend comfort to project bravery, may regress with stress and anxiety Able to describe intensity and location with more characteristics, able to describe psychologic pain

Growth Charts

Birthweight - 6 months has doubled 12 month old should have tripled Head circumference Centimeters and inches Paper tape Measure twice Up to age 2 years Around supraorbital and occipital prominences Hydrocephalous and encephalopathy

Family Composition

Blended/reconstituted nuclear family Binuclear family Heterosexual cohabiting family Gay or lesbian family Blended family (reconstituted) at least 1 step-parent, stepsibling, or 1/2 sibling Binuclear - separated parents, each with their own household co-parent their children Heterosexual cohabiting Gay or lesbian Nuclear family - married and biological babies Child-free family Extended family/ extended kin network family Single-parent family Single-mother-by-choice family Blended family Traditional nuclear family Married couple & their biological children (only full brothers & sisters) Nuclear family Two parents and their children (biologic, adopted, step) Extended family at least 1 parent, at least 1 child, & other individuals (related or not)

Children Are Not Just Small Adults

Body surface area is large for weight Large tongue large R/T nasal and oral passages Short, narrow trachea Until school-age, cardiac output is rate dependent - bad for incr activity all they can do is beat more times = tachycardia abdomin offers poor protection to liver and spleen Until 12-18 months, kidneys do not concentrate urine effectively and do not exert optimal control over electrolytes and absorbtion Until puberty, bones are soft and more easily bent of fractured

Thorax

Chest shape Ribs and sternum Movement Thyroid gland should rise as a mass as the child swallows Have infant drink from a bottle and observe swallowing The thyroid gland MAY NOT be felt in infants and young children Infants = round chest, newborns = incr breast size

Chronosystems

Child's and parents' ages Period in historic time

Contemporary Pediatric Nursing Care

Children < 18 are more than 23% of population. Cultural group sizes are changing. Diversity is increasing. Family-centered care Families are partners in care. Family is at the center

IM Injections

Choose the right site Under 1 Anterior or lateral thigh Over 1 deltoid and thighs can be used Choose the right syringe and needle Amount of medication - give 2 shots at the same time, no more than 3mls usually, no muscle in butt, no shots in butt IM vs SQ Appropriate site and needle length depends on age and body mass. neonates (first 28 days of life)/preterm infants = anterolateral thigh ⅝-inch needle 90-degree angle to the skin.• younger than age 12 months anterolateral thigh 1-inch, 22- to 25-gauge needle is sufficient. For toddlers 12 months through 2 years anterolateral thigh muscle is preferred at least 1 inch long deltoid muscle can be used if the muscle mass is adequate age 3 through 19 years deltoid muscle is preferred anterolateral thigh can be used deltoid muscle= 22 to 25 gauge ⅝ to 1 inch depending on the technique used.

Data to Be Collected on the Child

Client information - (name, age, gender, DOB, address should be on admission forms) emergency contact number, name of person giving the info Physiological data - information about the child's health problem, including: Chief complaint - why are they in the hospital today? Present illness or injury - description of what happened, what symptoms they have, onset, location, duration Past medical history - Description of other health problems from the past and/or concurrent Current health status -health maintenance, dentist, current meds prescribed and OTC, allergies, immunizations, nutrition, exercise, sleep Familial and hereditary diseases - three generations of familial or hereditary disease Review of Systems - physical assessment Psychosocial data - family composition, finances, home environment, family stressors Developmental status - age at which the child achieved key developmental milestones Client information Chief complaint Physiological data: Present illness or injury Past medical history Current health status Familial and hereditary diseases Review of Systems Psychosocial data Developmental status

School-Age Child

Cognitive development Concrete operations Conservation Psychosocial development Cooperative play Psychosocial development Peers and friends Psychosocial development Industry and achievement Psychosocial development Mature understanding of language Sexuality Application to nursing care

Toddler

Cognitive development Sensorimotor and preoperational thought Object permanence well developed Psychosocial development Independence, negativism, tantrums Parallel play Language milestones The terrible 2s Pot bellied Application to nursing care - don't give choices if none exist, talk to parent first so toddler can evaluate you

Kohlberg Stages of Moral Development

Cognitive development related to moral reasoning Not used a lot Preconventional stage - do what they do, behave to avoid punishment 4 to 7 years Conventional stage - do not hit, do not bite 7 to 11 years Postconventional stage - ethics are set, justice, ethics of justice is not ethics of care, cant compare to other kids lost hair, did lose hair needs to be explained to them 12 years and older Application to nursing care

Skin, hair and Nails

Color Temperature Moisture Texture Skin lesions Symmetrical skin folds Note variations of color or presence of Mongolian spots Note ecchymosis or bruising (note if in differing stages of healing) Feels warm to slightly cool to touch Moisture - normally feels dry to touch Resilience - Briskly elastic, well hydrated Texture - evidence of roughness or thickening Skin lesions - macules, papules, vesicles

Family Strengths in Coping with Stressors

Communication skills Shared values and beliefs Intra-family support - have more family that can help out Self-care abilities Problem-solving skills Community linkages

Exosystems

Community centers Local political influences Parents' work Parents' friends and activities Social services Health care Libraries

Oral Administration

Correct dosing Dosing syringe Teaspoons are inaccurate Droppers are good if they come with the medication Dissolved in solution Usually sweetened Avoid adding it to large amount of liquid or formula

Macrosystems

Cultural group membership Beliefs and values of group Political structure

Infant in pain

Figure 15-4Characteristic neonatal pain facial expressions include bulged brow, eyes squeezed shut, furrowed nasolabial creases, open lips, pursed lips, stretched mouth, taut tongue, and a quivering chin.Source: Adapted from Carlson, K. L., Clement, B. A., & Nash, P. (1996). Neonatal pain: From concept to research questions and the role of the advanced practice nurse. Journal of Perinatal Neonatal Nursing, 10(1), 64-71.

Sucking reflex.

Disappears by 12 months Elicited when object is placed in newborn's mouth/ touches the lips. Newborns suck even while sleeping. This is called nonnutritive sucking. Can have a quieting effect on the baby. Will do it in their slee Will loose this if not being fed - aka if intibated Rooting helps the baby become ready to suck. When the roof of the baby's mouth is touched, the baby will begin to suck. This reflex does not begin until about the 32nd week of pregnancy and is not fully developed until about 36 weeks. Premature babies may have a weak or immature sucking ability because of this. Because babies also have a hand-to-mouth reflex that goes with rooting and sucking, they may suck on their fingers or hands.

Other Major Family Events

Divorce Step-parenting Foster care Adoption Divorce - About 50% of children experience divorce, Involves a lot of conflict and hostility, disruption in child's life Step-parenting - child may respond with ambivalence, blending the family requires negotiation of new roles, customs, traditions, Foster care - demanding job, usually subsidize the child's care from their own funds Adoption - Most children in the US today are usually older children, often with special healthcare needs

Hinduism Considerations

Dont prolong life Personal hygiene is valued. Some are vegetarian or vegan May lie on floor while dying Thread placed around neck/wrist Family pours water into mouth Family bathes the body May want to be cremated.

Pharmacological Therapies

Dosages by weight ALWAYS, ALWAYS, ALWAYS CALCULATE ORDERED DOSE BEFORE ADMINISTERING MEDICATION. QUESTION ANY DOSE THAT IS MORE THAN OR LESS THAN THE EXPECTED DOSE.

Education

Education May be challenging because of range of understanding Goals in helping child and parents/guardians. Make informed choices. Adapt to healthcare settings. Prepare for procedures.

Erikson Theoretical Framework

Eight psychosocial stages Focus on lifespan development Developmental crises Healthy vs. unhealthy outcomes Trust vs. mistrust Autonomy vs. shame and doubt - toilet training Initiative vs. guilt - preschool Industry vs. inferiority - school, working hard Identity vs. role confusion Application to nursing care Different tasks for different age groups

Planning Nursing Interventions

Encourage appropriate growth and development while hospitalized Infants Toddlers Preschool children School-age children Adolescents Encourage play while hospitalized Play is important to encourage development. Include social interaction when hospitalized Roommates Play room/recreation room activities Ensure that schoolwork continues while hospitalized Include anticipatory guidance during and after hospitalization Age appropriate Developmentally appropriate Safe

Assessment Findings That Are Normal in Children

Epicanthal eye folds - slanting Sucking pads in infant's mouth - callus in mouth Rounded chest in infants Breath sounds heard over entire chest Splitting of S2 with breathing Abdominal movement with breathing Bowlegs and knock knees Pubertal development

Nursing Considerations

Exam room should be warm and well-lit Keep medical equipment out of sight until needed Provide privacy. *Older school agers and adolescents may or may not prefer caregiver to stay in room Explain each step of the examination Examine the child in a secure, comfortable position* Proceed in organized sequence if possible Encourage questions during the exam *Explain exam by using age-appropriate language Demonstrate on dolls of puppets, use drawings Allow child to handle the equipment Encourage child to use equipment on others *on parent's lap

Musculoskeletal System

Extremities Joints Spine Gait Extremities - Length, position and size - symmetrical Joints- Stable, symmetric with full ROM, no crepitus or swelling Spine-Infants: midline with no dimples or tufts of hair, Spine- Toddlers: squat with short legs and protuberant ABD, Pre-schoolers more erect, older children and adolescents with adult-like shape, midline with no abnormal curvature Gait-Toddlers and young children: bowlegged or knock-knee appearance is common, feet face forward when walking

Healthcare Issues

Financing Healthcare technology Legal issues Medicaid provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults and people with disabilities. Medicaid is administered by states, according to federal requirements. The program is funded jointly by states and the federal government. The Children's Health Insurance Program (CHIP) is a partnership between the federal and state governments that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid. ... Each state offers CHIP coverage, and works closely with its state Medicaid program. ACA bridges the gap for children whose family earns too much for Medicaid but still cant afford private insurance Technology has allowed many children with congenital anomalies or premature birth to survive Legal - Nurse practice acts in each state are laws that define responsibilities of the nurseand "scope of practice" - the range of activities and services as well as the qualifications for practice. The acts are intended to protect patients from harm as a result of unsafe or incompetent practice, or unqualified nurses

Family Assessment Tools

Focus on family strengths, strategies, stresses Tools help nurse learn more about family. Comprehensive family assessment examines the strengths, needs, and capacities of parents and caregivers, including relative caregivers. Assessment strategies and tools for parents and caregivers gather information to determine the need for interventions to prevent maltreatment, strengthen family functioning, and increase family stability. The family systems theory is a theory introduced by Dr. Murray Bowen that suggests that individuals cannot be understood in isolation from one another, but rather as a part of their family, as the family is an emotional unit. Family stress theory. ... Major stressful life events, particularly those that have chronic hardships, create a crisis for families that often leads to reorganization in the family's style of functioning. A major factor in this reorganization is the meaning the family gives to the stressful event Family Development Theory -The emotional and intellectual stages you pass through from childhood to your retirement years as a member of a family are called the family life cycle. In each stage, you face challenges in your family life that allow you to build or gain new skills.

Neonatal Infant Pain Scale (NIPS)

For infants up to 2 months Pain Level Intervention 0-2 = mild to no pain None 3-4 = mild to moderate pain Non-pharmacological intervention with a reassessment in 30 minutes >4 = severe pain Non-pharmacological intervention and possibly a pharmacological intervention with reassessment in 30 minutes

Co-analgesics

For symptoms and side effects Diazepam and midazolam (anti-anxiety) Anti-seizure meds for nerve pain. Co-analgesics for symptoms and side effects Diazepam and midazolam (anti-anxiety) Anti-seizure meds for nerve pain.

Major Developmental Theories

Freud Psychosexual focus of personality development Erikson Developmental challenges throughout life Piaja How the brain thinks

2-3 years

Gains 1.4-2.3 kg (3-5 lb)/year Grows 5-6.5 cm (2-2.5 in.)/year Draws a circle and other rudimentary forms Learns to pour Learning to dress self (D) Jumps Kicks ball Throws ball overhand

4-6 months

Gains 140-200 g (5-7 oz)/week Doubles birth weight at 5-6 months Grows 1.5 cm (1/2 in.)/month Head circumference increases 1.5 cm (1/2 in.)/month Teeth may begin erupting by 6 months Ingests 100 mL/kg/24 hr (1-1/2 oz/lb/24 hr) Grasps rattles and other objects at will; drops them to pick up another offered object (H) Mouths objects Holds feet and pulls to mouth Holds bottle Grasps with whole hand (palmar grasp) Manipulates objects (I) Head held steady when sitting No head lag when pulled to sitting Turns from abdomen to back by 4 months and then back to abdomen by 6 months When held standing supports much of own weight (J) Examines complex visual images Watches the course of a falling object

Birth to 1 month

Gains 140-200 g (5-7 oz)/week Grows 1.5 cm (1/2 in.) in first month Head circumference increases 1.5 cm (1/2 in.)/month Holds hand in fist (A) Draws arms and legs to body when crying Inborn reflexes such as startle and rooting are predominant activity May lift head briefly if prone (B) Alerts to high-pitched voices Comforts with touch (C) Prefers to look at faces and black-and-white geometric designs Follows objects in line of vision (D)

2-4 months

Gains 140-200 g (5-7 oz)/week Grows 1.5 cm (1/2 in.)/month Head circumference increases 1.5 cm (1/2 in.)/month Posterior fontanelle closes Ingests 120 mL/kg/24 hr (2 oz/lb/24 hr) Holds rattle and other objects when placed in hand (E) Looks at and plays with own fingers Brings hands to midline Moro reflex fading in strength Can turn from side to back and then return (F) Decrease in head lag when pulled to sitting position; sits with head held in midline with some bobbing When prone, holds head and supports weight on forearms (G) Follows objects 180 degrees Turns head to look for voices and sounds

1-2 years

Gains 227 g (8 oz) or more per month Grows 9-12 cm (3.5-5 in.) during this year Anterior fontanelle closes By end of second year, builds a tower of four blocks (A) Scribbles on paper (B) Can undress self (C) Throws a ball Runs Shows growing ability to walk and finally walks with ease Walks up and down stairs a few months after learning to walk with ease (E) Likes push-and-pull toys (F) Visual acuity 20/50

8-10 months

Gains 85-140 g (3-5 oz)/week Grows 1 cm (3/8 in.)/month Picks up small objects (L) Uses pincer grasp well (M) Crawls or pulls whole body along floor by arms (N) Creeps by using hands and knees to keep trunk off floor Pulls self to standing and sitting by 10 months Recovers balance when sitting Understands words such as "no" and "cracker" May say one word in addition to "mama" and "dada"

6-8 months

Gains 85-140 g (3-5 oz)/week Grows 1 cm (3/8 in.)/month Growth rate slower than first 6 months Bangs objects held in hands Transfers objects from one hand to the other Beginning pincer grasp at times Most inborn reflexes extinguished Sits alone steadily without support by 8 months (K) Likes to bounce on legs when held in standing position Responds readily to sounds Recognizes own name and responds by looking and smiling Enjoys small and complex objects at play

6-12 years

Gross motor development is fostered by ball sports, skating, dance lessons, water and snow skiing/boarding, biking A sense of industry is fostered by playing a musical instrument, gathering collections, starting hobbies, playing board and video games Cognitive growth is facilitated by reading, crafts, word puzzles, schoolwork Mature use of language Ability to converse and discuss topics for increasing lengths of time Spends many hours at school and with friends in sports or other activities Health professionals can: Assess child's knowledge before teaching Allow the child to select rewards following procedures Teach techniques such as counting or visualization to manage difficult situations Include both parent and child in healthcare decisions Variation in age of growth spurt During growth spurt, girls gain 7-25 kg (15-55 lb) and grow 2.5-20 cm (2-8 in.); boys gain approximately 7-29.5 kg (15-65 lb) and grow 11-30 cm (4 1/2-12 in.) Skills are well developed (A) New sports activities attempted and muscle development continues (B) Some lack of coordination common during growth spurt full sensory

Analyzing the Data

Group abnormal findings for each system Compare to other system abnormalities Use clinical judgement to identify patterns of abnormalities

Growth and Development Principles

Growth = Physical size and quantitative changes Development = Capabilities or functions Cephalocaudal = Head to tail Proximodistal = Center to distant parts Maturation = Final stage of differentiation, brain is size it needs to be but not fully developed

ADOLESCENT 13-18 years (formal operations) The Child's Understanding of Pain, Behavioral Responses, and Verbal Descriptions by Developmental Stage

Has a capacity for sophisticated and complex understanding of the causes of physical and mental pain Recognizes that pain has both qualitative and quantitative characteristics Can relate to the pain experienced by others Wants to behave in a socially acceptable manner, shows a controlled behavioral response May immerse self in an activity as a pain distraction May not complain about pain if given cues that nurses and other healthcare providers believe it should be tolerated More sophisticated descriptions as experience is gained; may think nurses are in tune with their thoughts, so they do not need to tell the nurse about their pain

The Child's Understanding of Pain, Behavioral Responses, and Verbal Descriptions by Developmental Stage INFANT 0-6 months 6-12 months

Has no understanding of pain; is responsive to parental anxiety Has a pain memory; responsive to parental anxiety Generalized body movements, chin quivering, facial grimacing, poor feeding Reflex withdrawal to stimulus, facial grimacing, disturbed sleep, irritability, restlessness cries

Current Health Status

Health Maintenance Medications Allergies Immunizations Safety Measures Activities and Exercise Nutrition Sleep Health Maintenance - Primary care provider and timing of last visit Medications - Prescribed or over-the-counter, regular or PRN Allergies - to food, medications, animals insects, etc and the type of reaction Immunizations - Review of dates immunizations were received, Inquire about reason if not up-to-date Safety Measures - Car restraint system, window guards, protective gear Activities and Exercise - usual play and/or sports activities, physical mobility Nutrition - formula-fed or breastfed, when solid foods were introduced, examples of usual foods Sleep - infant sleep position, night terrors or nightmares, where the child sleeps, snoring

Pediatric Healthcare

Healthcare occurs on continuum of: Settings Community, schools, camps, childcare centers Hospitals, rehab centers, residential treatment centers Child's home Complexity of care

Hair and Scalp

Inspect for color, distribution and cleanliness Observe for presence of infestation Note hair in unexpected places Palpate hair for texture Note any unusually low hair lines on neck or forehead (hypothyroidism?) Hair tuft at base of spine - occult spinal defect Texture should be soft or silky

Abdomen

Inspection Shape Umbilicus Rectus muscle Abdominal movements Inguinal area Normally symmetric and rounded or flat. A scaphoid or sunken ABD is abnormal Umbilical stump drainage, presence of umbilical hernia ABD movement - peristaltic waves are abnormal Inguinal area - presence of inguinal hernias

Musculoskeletal System

Inspection of alignment of arms, minimal flexion at elbows Count fingers, Check for transverse line in palm Transverse crease - goes straight across hands = down syndrom Upper extremities Shoulders Arms and elbows Hands and wrist

Risks to Consider

Illness and hospitalization can interfere with the normal developmental processes. Hospitalization keeps child from moving. Causes fear and anxiety in many children Defense mechanisms may be used = influences development Illness adds challenges for the nurse to promote normal growth and development. Energy of the child - shy kid = hard to tell Child's ability to concentrate - ADHD may effect mile stones Anxiety of child and parent Prematurity of an infant greatly interferes with normal development. Inadequate respiratory function Inability to suck Inadequate kidney function Lowered immune protection Neurologic immaturity Internationally adopted children may have profound alterations in developmental progression. Amount of adult interaction Impact of poverty in country of origin Culture Language Use theorist frameworks to recognize lack of development. Kohlberg theory of moral development Social learning theory Piaget theory of cognitive development Use theorist frameworks to recognize lack of development. Freud theory of psychosocial development Erikson theory of psychosocial development Assess the communication abilities of an infant, child, and adolescent. Ability to see Ability to hear Response to adult communication Watch a child play to assess development - helps to see each stage Impact of resiliency (how quick can bounce back from trauma) when developmental risks are present. Protective factors - family, religion Risk factors - ADHA

Case Management

Importance of coordinated interprofessional team Nurse is often aware of family's desires. Continuity of care Interprofessional Practice (IPP) is a collaborative practice which occurs whenhealthcare providers work with people from within their own profession, with people outside their profession and with patients and their families.

Ecologic Theory

Importance of nature and nurture Mutual interaction of child and environment Both act on eachother Assessment of environmental systems Microsystem Mesosystem Exosystem Macrosystem Chronosystem Application to nursing care

The Role of Play

Infant Engages primarily in solitary play, although social interaction enhances play Learns and matures through feel and sound of activities and objects As the infant begins to crawl and walk, the sphere of play enlarges and the effect of play on growth and development increases. Toddler Increased motor skills enable the toddler to engage in new ways of playing. Play becomes more social, and often includes parallel play with other toddlers. Engages in imitative behavior, which teaches new actions and skills Increased cognitive abilities enable toddler to manipulate objects and learn about their qualities. Preschooler Interacts with others in associative play Enjoys large motor activities - ride bikes Demonstrates increased manual dexterity in greater complexity of play activities Enhances growth and development through fantasy play School-Age Increased physical abilities allow greater range and complexity of activities Engages in cooperative play, which increases social and cognitive skills Adolescent Increased maturity leads to new activities and ways to play driving Peer group (as the focus of activities) plays an important role in establishing the adolescent's identity. Participate in and learn from social interactions fundamental to adult relationships

Indicators of Hearing loss

Infant No startle to loud noises Does not turn toward sounds by 4 months of age Babbles as young infant but does not keep babbling or develop speech sounds after 6 months Young Child No speech by 2 years of age Inability to follow age-appropriate directions Speech sounds not distinct at appropriate age

Pediatric Mortality

Infant mortality was 5.96 deaths/1000 live births in 2013. Disparities Mortality more than twice as high in non-Hispanic Black infants as in non-Hispanic White infants Most common cause of death for children 1 to 19 years of age is unintentional injury.

Circulatory System

Infants - Brachial, temporal and femoral pluses should be palpable, full and localized Children and adolescents - Pulse locations and expected findings are the same as with adults

Legal Issues

Informed consent Child's versus parent's rights - needs to be thought about Confidentiality Patient Self-Determination Act - if very sick can be mature minor with long disease so they can make their choice

Neck

Inspect Size Symmetry swelling or other abnormalities Palpate Lymph nodes Trachea ROM Thyroid gland should rise as a mass as the child swallows Have infant drink from a bottle and observe swallowing The thyroid gland MAY NOT be felt in infants and young children

Musculoskeletal System

Inspect alignment of legs as child stands, skin folds should be symmetrical, iliac crests should be level Infants are often born with tibial torsion due to inter-uterus positioning. Toddler go through a skeletal alignment sequence of bowlegs and knock knees before the legs assume straight alignment Lower extremities Hips Legs Feet Inspect alignment of legs as child stands, skin folds should be symmetrical, iliac crests should be level Infants are often born with tibial torsion due to inter-uterus positioning. Toddler go through a skeletal alignment sequence of bowlegs and knock knees before the legs assume straight alignment Should have no more than 2 inches b/w ankles

Non-Opioid Pain Medication

Intravenous acetaminophen has a faster onset and results in more predictable pharmacokinetics than oral or rectal acetaminophen What Acetaminophen will not do is reduce inflammation. So, if you have a muscle sprain, or you're suffering from arthritis or any other condition that has inflammation, Acetaminophen may help with the pain, but it will not reduce the inflammation. Non-opioid analgesics - Acetaminophen (Tylenol) given oral, rectal, IV Use for mild to moderate pain Ensure that families avoid liver toxicity by using appropriate dosing Such as cold meds Give with food to decrease gastric upset Give no more than 5 doses in 24 hours

General Appearance and Behavior of Child

Is the child encouraged to speak? Is the parent supportive? Is the child comfortable and calm? Can the child follow simple commands? Is the growth appropriate to age? You can tell a lot from the doorway Irritable? Sleepy? Inquisitive? Shy? Excitable? Appears comfortable and calm Appears clean and well-kept Good muscle tone Makes eye contact when addressed (except infants) Follows simple commands Uses speech, language and motor skills spontaneously Growth appropriate to age

Female Genitalia

Labia-symmetric, without lesions, moist on inner aspects Clitoris - small without bruising or edema Urethral meatus - slit-like in appearance with no discharge Vaginal orifice - No lesions or signs of inflammation Is there hair on the mons pubis? Hair distribution over mons pubis should appear as inverted triangle Labia-symmetric, without lesions, moist on inner aspects Clitoris - small without bruising or edema Urethral meatus - slit-like in appearance with no discharge Vaginal orifice - No lesions or signs of inflammation are expected

TODDLER 1-3 years The Child's Understanding of Pain, Behavioral Responses, and Verbal Descriptions by Developmental Stage

Lacks understanding of what causes pain and why it might be experienced Demonstrates fear of painful situations; may resist with entire body or localized withdrawal; aggressive behavior, disturbed sleep Cries or wails, cannot describe intensity or type of pain Uses common words for pain such as owie and boo-boo

Anthropometric Measurements

Length Birth to 24 months Measuring board Height After age 2 years Stadiometer (standing) Weight Infant scale Kilograms, grams, and pounds and ounces Standing scale Diapers and clothing

How is Children's Pain Different

Like adults, it is what the person tells you it is... Unlike adults children may rate pain differently because of: -Age -Developmental stage -Chronic or acute disease -Prior bad/good experiences with pain -Personality -Family dynamics -Culture

Ethical Issues

Limiting or withdrawing life-sustaining treatment Ability to maintain life Quality of life Family's wishes Form therapeutic alliance Help resolve conflicts Choosing among treatment options Religious and cultural differences Examples: Withdrawal of life support Withholding treatment Genetic testing Organ transplantation Genetic testing - Duchenne muscular dystrophy, CF, Sickle cell Organ transplant issues - limited supply of organs

Mouth

Lips Gums mucous membranes Tongue Hard and soft palates Uvula Tonsils Speech Lips - darker pigmentation than facial skin, Shape, smooth, soft, moist, symmetric Gums - coral pink, tight against teeth mucous membranes - without lesions, moist, pink, smooth, glistening Tongue - color, moistness, size, tremors, lesions. Infants may have white coating from milk, if so, it is easy to wipe away. If not, oral candidiasis? Older -pink symmetric tongues that they can stick out Hard and soft palates - firm, intact, concave Uvula - intact, moves with vocalization Tonsils -infants, may not be able to visualize, older-barely visible to prominent, same color as surrounding mucosa Speech - infants, strong cry, older - clear and articulate

Abdomen

Listen in all 4 quadrants Bowel sounds every 10-30 seconds Light palpation to assess tenderness or masses of ABD infant: rounded/ protruded b/c immature muscle, visible veins ok, umbilical hernia 2-3wk and more prominent when crying but disappears by 1yr toddler/preschooler/school-age: abdomen protrudes until 4yrs, lumbar lordosis protrudes abdomen when standing and >4yrs but flat on lying, abdominal breathers until 6yrs adolescent: scaphoid/sunken in is sign of dehydration/ malnutrition

Buddhist Considerations

May refuse care on holy days. May refuse analgesics or strong sedatives. Some are veg. May avoid tobacco and alcohol May fast on holy days May request monk or nun for last rites. Chanting is common. Brain death is not a req. for death.

Nonsteroidal Anti-inflammatory Drugs (NSAIDS)

Medication Acetylsalicylic Acid (Aspirin) given orally Ibuprofen ( Motrin) Naproxen (Aleve) Ketorolac (Toradol) given IV (kidney failure) NSG Management Use for short-term management of mild to moderate pain Do not use Aspirin in children under 18years Give with food to decrease GI up-set Monitor for prolonged bleeding time Liver function tests should be followed if in long-term use

Opioid Administration

Methods of administration Oral (preferred) Subcutaneous Intramuscular Intravenous (preferred) Topical

Nose

Midline position, septum intact, proportional to face Nasal membranes Presence of drainage Pain in sinuses? Membranes - Deep pink and moist Discharge descriptions - Watery clear, bilateral - allergy (Allergy Salute) Serous unilateral - Spinal fluid from basilar skull fracture Mucoid or purulent Bilateral - URI Unilateral - foreign body Bloody Nosebleed, trauma

Opioids

Morphine - IV, IM, SQ, oral Hydromorphone (Dilaudid) oral, IM, IV, rectal Levorphanol (Levo-Dromoran) IM, IV, oral Methadone (Dolophine) Oral, IV Fentanyl IV (don't give too fast - chest reguity - chest doesn't expand), Intranasal, Transmucosal, transdermal Use for moderate to severe pain Careful calculation of dose and double-check Obtain baseline VS before administering Monitor vital signs and for respiratory depression May be used Q4 hours or continuous infusion Observe for thoracic rigidity (fentanyl)

Birth History for Young Infants

Mother's pre-natal condition Intrapartum - description of birth Condition of infant at birth Post-natal condition A birth history should be collected for young infants

Pediatric Pain Meds

NSAIDS and non opioids for mild to moderate pain Aspirin - don't really give bc Reye Syndrome ibuprofen (Advil) naproxen sodium (Aleve) Acetaminophen (Tylenol) Can use Advil and Tylenol together bc on different nerve tract OPIOIDS for moderate to severe pain Morphine Hydromorphone Fentanyl Co-analgesics for symptoms and side effects Diazepam and midazolam (anti-anxiety) Anti-seizure meds for nerve pain - bc calms down the nerves and they don't fire as much Help primary pain med do a better job

Developmental Periods

Newborn (0 to 1 month old) Prenatal influences on growth and development Infant (1 to 12 months of age) Toddler (1 to 3 years of age) Preschooler (3 to 6 years of age) School-age child (6 to 12 years of age) Adolescence (12 to 18 years of age) Influences on growth and development

Misconceptions About Pain in Children

Newborns and infants do not feel pain, children feel a decreased level of pain as compared to adults Parents exaggerate or aggravate the child's pain Children are not in pain if they can be distracted or are sleeping Children will tell you if they are in pain. They do not need medication unless they ask for it Children are at greater risk of becoming addicted to pain medications

Temperament Theory

Nine parameters of response to daily events Identified characteristics of personality Infant characteristics are not predictive of future behavior. Adult characteristics can be seen in review of childhood behaviors.

Cultural Practices Influencing Healthcare

Nutrition and food choices Hot and cold - certain diseases are hot and cold so food has to corrolate Health beliefs, approaches, practices Complementary therapies

Careful Listening

Observe behavior during the interview Does the parent hesitate or avoid answering certain questions? Pay attention to parents attitude or tone of voice when the child' problems are discussed Be alert to underlying themes. Observe parent's non-verbal behavior Underlying themes - parent talks about child's diagnosis, but repeatedly refers to the financial impact, asking that these issues be discussed non-verbal behavior - posture, gesture, eye contact, facial expressions

Routes of Administration

Oral- may require higher dosing than parenteral. Sublingual-faster acting than oral IV bolus and continuous dosing (most effective) IM Topical - tansdermal Rectal Oral: preferred due to convenience, cost and maintenance of blood levels - (may take up to 1-2 hours to peak) -not appropriate for children that require rapid pain relief or fluctuating pain Sublingual administration involves placing a drug under your tongue to dissolve and absorb into your blood through the tissue there. IV-can be periodic or PCA pump - rapid control in approx. 5 minutes morphine, hydromorphone continuous: provides steady bloody level IM - IM injection is usually more rapid and predictable than after oral administration. A disadvantage of this route is that the dose maybe too large (side effects) or too small (no pain relief). In addition, the injections are painful and the onset of pain relief is delayed while the drug is absorbed Transdermal: 60 min prior for superficial, 2.5hr prior deep puncture place dressing over cream reddened or balanced skin equals adequate response effective for long term relief, may take some time to begin. Fentanyl patch. Rectal - many meds are available in suppository form

Pain Scales - FLACC

Originally developed for post-op pain assessment Interpreting the Behavioral Score Each category is scored on the 0-2 scale, which results in a total score of 0-10. 0-Relaxed and comfortable 4-6-Moderate pain 1-3-Mild discomfort 7-10-Severe discomfort

Patient Controlled Anesthesia

PCA are frequently used for postoperative or children in severe pain Pain level should be assessed before pushing the button PCA's in children may be used by Children over 6 yrs old Parent or primary caregiver who has been instructed to use it Nurse caring for child

PRESCHOOLER 3-6 years (preoperational) The Child's Understanding of Pain, Behavioral Responses, and Verbal Descriptions by Developmental Stage

Pain is a hurt Does not relate pain to illness; may relate pain to an injury Often believes pain is punishment or someone else is responsible for the pain Unable to understand why a painful procedure will help them feel better Active physical resistance, directed aggressive behavior, strikes out physically and verbally when hurt, easily frustrated Has the language skills to express pain on a sensory level Can identify location and intensity of pain, may deny pain, may believe their pain is obvious to others

Types of Pain

Pain is often considered a fifth vital sign, assessed along with temperature, pulse, respiration, and blood pressure. Because pain can affect patients' physical, emotional, and mental well-being, it must be managed immediately and effectively so that they can perform daily activities. Acute - associated with a single event such as surgery, injury or exacerbation of a condition such as Sickle Cell An immediate pain response that occurs at the time of tissue damage and the inflammatory response that follows Pain decreases as healing occurs Chronis - usually associated with a prolonged disease process. affects entire nervous system and child has increased neuron responsiveness to painful and non-painful stimuli Recurrent Pain - Pain alternating with non painful episodes. If pain is untreated or poorly treated, neurons over-react to pain stimulus and initiate a pain memory and potentially permanent alterations in pain pathways of young infants Acute - sudden and of short duration Chronic - persistent, lasting longer than 3 months Recurrent Pain - Pain alternating with non painful episodes.

Head

Palpate/observe skull for patent sutures, fontanels, fractures and swellings Observe for symmetry of appearance and movement infants: ok if asymmetric head due to childbirth, prominent occipital area, flattening and loss of hair in one area due to lying toddler/preschooler/school age: round with prominent occipital, head circumference until 3yrs3) adolescent: normal shape Plagathepath - misshapen skull form laying on one side/back Buldging = pressure, sunken in = dehydrated Flat head = from laying down or from birthing cancal Symmetric, size grossly appropriate for age and size of child. Plagiocephaly =positional; the weight of the head causes it to become misshapen Fontanels: Should be flat Posterior- Closes 2nd month Anterior- Closes12-18 months (soft spot)

Microsystems

Parents Significant others in close contact Childcare arrangements School Neighborhood contacts Clubs Friends, peers Religious community (e.g., churches, synagogues, mosques)

Informed Consent in Pediatric Care

Parents are usually asked to give consent for the child. Must be clear that child or parents can refuse consent at any time Divorced and joint custody Divorced and one parent has custody Proxy custody - foster care Emancipated minors Mature minors Assent - agree to care by child Parents who are married share the right to make decisions on behalf of their minor children. Each parent, acting alone, can consent to the health treatment of his or her minor child(ren). While it is generally advisable to seek the consent of both parents, therapists are not legally required to do so in cases where the parents' marriage is intact. Divorced- When a parent has sole legal custody, that parent has the sole right to make decisions for his or her child. When parents have joint legal custody, they share the right to make decisions for their child. Thus, here too, either parent, acting alone can consent to the treatment of his or her minor child(ren), unless the court included language to the contrary in the custody order. Consent by Proxy The process by which people delegate to another person the legal right to consent to medical treatment for themselves, for a minor, or for a ward is called consent by proxy. There are 3 fundamental con-straints on this right to delegate for children: 1) the guardian of a minor must have the right to consent to medical treatment for that minor; 2) the guardian must be legally and medically competent to delegate the right to consent to medical treatment for that child; 3) the right to consent to medical treatment for the child must be delegated to a legally and medically competent adult. The mature minor doctrine is an American term for the statutory, regulatory, or common law policy accepting that an unemancipated minor patient may possess the maturity to choose or reject a particular health care treatment, sometimes without the knowledge or agreement of parents, and should be permitted to do so. In all other situations, parents or other surrogates provide informed permission for diagnosis and treatment of children with the assent of the child whenever appropriate.

Mesosystems

Parents' involvement in child care or school Parents' involvement in community Parents' relationships with significant others (e.g., grandparents, care providers) Influences of religious community (e.g., church, synagogue, mosque) or parents and school

Nose

Patent nostrils To test for nasal patency, occlude one nostril and observe child's effort to breathe. Newborns and infants under 6 months will not automatically open their mouth to breathe when their nose is occluded, such as by mucus. This is called "obligate nose breathing." - brain does not realize if nose is closed they can open their mouth Assess sense of smell by choosing scents children will usually recognize, such as peanut butter, orange or mint. With child's eyes closed, occlude one nostril and hold scent under nose. Ask the child to take a sniff and identify the scent.

Temperament

Patterns of response to stimuli Easy temperament Difficult temperament Slow-to-warm-up temperament Dimensions of response

Male Genitalia

Penis Should appear straight Meatus should be at tip Foreskin may not be retractable in infants and young children Scrotum Separate from penis Skin on scrotum has a rugose appearance Inguinal canal should be absent of swelling Testicles should be palpabable

Chronic Pain

Persistent Lasting longer than 3 months Generally associated with a prolonged disease process Such as juvenile idiopathic arthritis or cancer Affects the entire central nervous system Child has increased neuron responsiveness to painful and non-painful stimuli. Chronic pain may be nociceptive or neuropathic. Nerve pain or overall since of discomfort Behavioral indicators Fatigue Inactivity Posturing Difficulty concentrating and sleeping Withdrawal Mood disturbances Physiologic adaptation Focus on improving function and comfort Cognitive behavioral therapy Physical and occupational therapy Individualized pain management regimen Complementary therapies Relaxation Ice/Heat - need doc note, can put washcloth on head tho Analgesics Complete pain relief may not be possible Antidepressants

Family-Centered Care

Philosophy of care with mutually beneficial partnership between family and healthcare team - everyone should know what everyone knows Each party respect what other brings to interactions. Versus family-focused care, in which health professional is the expert Collaboration brings optimal outcome. Parent' perspective can be critical to quality care. Core Concepts of Patient- and Family-Centered Care. Dignity and Respect. Health care practitioners listen to and honor patient and family perspectives and choices. Patient and family knowledge, values, beliefs and cultural backgrounds are incorporated into the planning and delivery of care.

Quick Tips For Physical Assessment

Physical Exam should be flexible Least invasive to the most intrusive Use developmentally appropriate approach Allow for play and exploration Inspect, "look" Auscultate, "listen" Palpate/percussion, "feel"

Toddler

Physical growth and development Growth pattern Milestones

Preschooler

Physical growth and development Growth pattern Milestones Cognitive development Preoperational thought characteristics Use of symbols Psychosocial development Associative, dramatic, fine motor, and active play Peers Language skills Gains 1.5-2.5 kg (3-5 lb)/year Grows 4-6 cm (1 1/2-2 1/2 in.)/year Uses scissors (A) Draws circle, square, cross (B) Draws at least a six-part person Enjoys art projects such as pasting, stringing beads, using clay Learns to tie shoes at end of preschool years (C) Buttons clothes (D) Brushes teeth (E) Uses spoon, fork, knife Eats three meals with snacks Throws a ball overhand Climbs well (F) Rides bicycle (G) Visual acuity continues to improve Can focus on and learn letters and numbers (H)

School-Age Child

Physical growth and development Growth pattern: boys and girls Milestones Last time boys and girls are the same size and shapes Gains 1.4-2.2 kg (3-5 lb)/year Grows 4-6 cm (1 1/2-2 1/2 in.)/year Enjoys craft projects Plays card and board games Rides two-wheeler (A) Jumps rope (B) Roller skates or ice skates Can read Able to concentrate for longer periods on activities by filtering out surrounding sounds (C)

Infant (1 Month to 1 Year)

Physical growth and development Weight and height increases. Teeth begin to erupt. Closely associated with type and quality of feeding Cognitive development Brain growth accompanied by development of functions. Sound, language, grasping and holding Psychosocial development Play Personality and temperament Communication Application to nursing care

Adolescence

Physical growth and development - are divergent Growth pattern: boys 13 and girls 10 Milestones Application to nursing care - will test the rules = noncompliant , need independence Cognitive development Formal operations Abstract thinking Psychosocial development Independence Identity Peers Language use Exploration and rebellion Need for privacy Sexuality - #1 thing in life rn Sports—ball games, gymnastics, water and snow skiing/boarding, swimming, school sports School activities—drama, yearbook, class office, club participation Quiet activities—reading, schoolwork, television, computer, video games, music Increasing communication and time with peer group—movies, dances, driving, eating out, attending sports events Applying abstract thought and analysis in conversations at home and school

Consequences of Pain

Physiologic effect Stress response Respiratory - rapid, shallow breathing, inadequate lung expansion and cough -can lead to low O2 sats, atelectasis or pneumonia Neurologic Increase in heart rate, blood sugar, cortisol levels Altered sleep patterns Metabolic Increase in fluid and electrolyte losses Immune system Suppressed immune and inflammatory process causing increased risk of infection, delayed wound healing Gastrointestinal decreased gastric acid secretion and intestinal motility Respiratory changes Neurological changes Metabolic changes Immune system changes Gastrointestinal changes

Nails

Pink, white at tips Smooth, firm and flexible (except infants) No clubbing

Genitalia and Perineal Areas

Positioning - Examination of the genitalia and perineal area is stressful for children. Position on parent's lap with legs spread apart, or positioned on the exam table in frog position Timing in examination - In younger child, the genitalia are examined immediately after the ABD Anus and rectum - exterior sphincter usually closed, inspect for inflammation, fissures or lesions, a slight touch of the anal opening should produce a "wink"

Newborn to 1-Month-Old Infant

Prenatal, maternal, and paternal influences If mom does drugs or didn't take meds Physical growth and development Reflexes help infant receive input, nourishment, comfort Cognitive development Learns through reflexes; e.g., grasping, eating Psychosocial Attachment Nurturing through physical and sensory stimulation Application to nursing care Promote attachment Support parents Provide education

Components of Intervention in the Resiliency Wheel

Provide caring and support. - Listen to concerns. Provide information based on developmental level. Set and communicate high expectations. - Express confidence in child's ability to succeed. Provide youth and families with resources. Provide opportunities for meaningful participation. - Express confidence in child's ability to succeed. Provide youth and families with resources. Increase prosocial bonding. - Assist youth to work with others on positive, purposeful activities. Facilitate community participation. Set and communicate high expectations. - Communicate rules and establish routines. Assist families in setting clear expectations for behaviors and consequences. Teach life skills. - Encourage communication of thoughts and feelings. Facilitate critical thinking and problem solving skills

Freud Theoretical Framework

Psychosexual energy Three components of personality Id Ego Superego Defense mechanisms of children Regression Return to earlier behavior Toilet training but in hospital stress = wetting the bed Repression Involuntary forgetting Abused child Rationalization Unacceptable becomes acceptable "He hit me first!" Fantasy Mind creation to protect self Special powers, superman Oral Infancy - sucking is pleasurable Anal Toddler - worried about potty training Phallic Preschooler - difference in boys and girls Latency School age - places and importance of privacy, understand body works Genital Adolescence - genital functions nad relationships Application to nursing care

Circulatory System Assessment

Pulses Capillary refill Neck veins Clubbing Peripheral cyanosis Edema Blood pressure Respiratory status All included in circulatory system assessment S1 and S2 should be clear and crisp Physiological splitting in normal in some children Sinus arrhythmias that are associated with respirations are common Pulse can go down during expiration = normal

Piaget Theory of Cognitive Development

Qualitative changes in thought processes Assimilation - 1st time have ice cream understand cold, sweet, will dri Accommodation - adapts to new experences Developmental stages Cognitive thinking how your brain has what it has Sensorimotor Period: Birth to 2 Years Reflexive Birth to 1 month Primary circular reactions - know sucking brings pleasure 1 to 4 months Secondary circular reactions - cause and effect hear sounds of bottle = eat 4 to 8 months Coordination of secondary schemes - will reach for rattle cause like it 8 to 12 months Object permanence - peak a boo Tertiary circular reactions - explore, dump legos like sound 12 to 18 months Mental combinations - hear bottle, can think about events before they happen "mommy is coming home" 18 to 24 months Application to nursing care Preoperational Period: 2 to 7 Years Preconceptual substage - think in symbols and words, no logic 2 to 4 years Egocentrism - only see from their point of view Intuitive substage 4 to 7 years Transductive reasoning - one thing causes the other even if they dont Magical thinking - one thing causes the other even if they dont Centration (only see from their point of view) and animism (life to inanimate objects) Application to nursing care - be honest, specific, fell surgery right before it happens ex - "im gonna take a picture of your lungs" don't give them a choice if there isn't a choice Concrete Operational Period: 7 to 11 Years Cause-and-effect thinking Reasoning tied to concrete experiences Conservation - tall thin glass vs short fat glass = same they get this Application to nursing care - loyalty and conformity, want to fit in, value for fam and culture Formal Operational Period: 11 Years and Older Mature thought Abstract thinking Alternative outcomes to problems Idealism Application to nursing care - need to show correct behavior they want to do this, begin to question rules or laws and how they exist and apply to their life, use items or food from culture, talk to them logically

Nursing Care for Child With Acute Pain

Reassess frequently Use non-pharmacological and pharmacological or both to manage pain Ask the caregiver to help reassess the pain level Observe for adverse reactions to pain medicines Resp, rash, hives Assess the child's physical functioning following pain management interventions

1-3 years

Refines fine motor skills by use of cloth books, large pencil and paper, wooden puzzles Facilitates imitative behavior by playing kitchen, grocery shopping, toy telephone Learns gross motor activities by riding Big Wheel tricycle, playing with soft ball and bat, molding water and sand, tossing ball or bean bag Cognitive skills develop with exposure to educational television shows, music, stories, and books Increasingly enjoys talking Exponential growth of vocabulary, especially when spoken and read to Needs to release stress by pounding board, frequent gross motor activities, and occasional temper tantrums Likes contact with other children and learns interpersonal skills

Resiliency Theory

Resilience Ability to function with healthy responses, even in adverse situation Developmental and situational stresses Protective factors Risk factors Stress crisis Adjustment phase Adaptation phase

Opioid Issues and Treatment

Respiratory Depression Naloxone (Narcan) Constipation Diet modification, fiber and fluids Nausea and vomiting Other meds to help decrease, usually declines after 1-2 days Pruritis (itching) Anti-itch meds Nalbuphine and diphenhydramine Nubain and benderyl

Cephalocaudal and proximodistal

development. In normal cephalocaudal growth, the child gains control of the head and neck before the trunk and limbs. In normal proximodistal growth, the child controls arm movements before hand movements. For example, the child reaches for objects before being able to grasp them. Children gain control of their hands before their fingers; that is, they can hold things with the entire hand before they can pick something up with just their fingers.

Role of nurse

Role of nurse Interact effectively with children and family. Modify physical assessment techniques to age. Identify strategies to reduce pain and stress. Calculate accurate medication dosages. Provide safety for child's developmental status. Anyone under 2 is a fall risk, if you put down a side rail you cant step away Adapt procedures to child's age and development.

Neck

Short in infants No palpable masses or nodes Mid-line trachea Full range-of-motion (active or passive)

Eyes

Size and spacing of eyes Eyebrows symmetrical and evenly distributed Inspect eye lid for color, size, position, motility Condition of the eye lashes Condition of conjunctiva Size and spacing - Same size, symmetrical, iris round Pupils - round, equal in size, reactive to light, accommodating (When you focus on an object that is far away, your pupils will slightly dilate. If you focus on something like a finger or a pen, and bring it closer to your eye, your eyes will converge and the pupils will constrict. Eyebrows symmetrical and evenly distributed between inner to outer canthus Inspect eye lid for color, size, position, motility Condition of the eye lashes - should curve outward and have even distribution Condition of conjunctiva - Palpebral- pink, (back of eye lid) bulbar - transparent Bulbar conjunctiva - That part of the conjunctiva, a clear membrane of the eye, which covers the outer surface of the eye. Palpebral conjunctiva- which lines the inside of the eyelids. The bulbar conjunctiva is also called the ocular conjunctiva. Extraocular Movement: Six cardinal field of gaze Conjugate gaze - both eyes to focus on the same thing at the same time Extraocular movement - cover/uncover test show equal movement of eyes (The single cover test is a test is used to determine if there is evidence of strabismus or misalignment that is always present. The first eye is covered for approximately 1-2 seconds. As this eye is covered, the uncovered eye is observed for any shift in fixation Corneal reflex should be symmetrical Six cardinal field of gaze with no nystagmus Conjugate gaze: the ability to move both eyes in the same direction

Skin and Hair

Skin Color, temperature, moisture Rashes, lesions Skin turgor Hair Texture, amount, fullness Breaking off? Head lice

Social Learning Theory

Social exchange with parents, other adults, other children Modeling or imitation of behaviors Self-efficacy - child doesn't take responsibility of test BS, they need to have power???? Influence of modeling and behavioral reinforcement Focus on their beliefs on who controls their health Application to nursing care

Behaviorism

Stimulus for behaviors Positive reinforcement - cause behavior to happen again Negative reinforcement - to get ride of behavior

ears

Symmetry and alignment External Internal Hearing Symmetry and alignment- top of ears should be on the imaginary line from outer canthus of eye External- Free of tenderness, lesions, foreign bodies or discharge, cerumen is normal finding Internal- pink ear canal, TM pearly pink or grey Below 3yrs of age, pull pina down and back, over 3 years, up and back to examine HEARING -trained personnel or audiogram -rubbing fingers together inches from each ear or whispered word -infant: stand 2feet and do bell/rattle for turning in that direction= intact cranial nerve VIII

Face

Symmetry when cry/smile Draw an imaginary line down middle of face Presence of rashes/birthmarks infant: symmetry when cry/smile, rashes/birthmarks 2) toddler/preschooler/ schoolage: symmetry at rest/smiling, CHECK parotid swelling by looking at ceiling and seeing it below jaw 3) adolescent: test cranial nerve V by biting down and feeling contraction of temporal muscle at temple and masseter muscle in front ear

Mouth

Teeth should have 6-8 by 12 months should have 20 deciduous teeth should have 32 permanent teeth Teeth- should be smooth and white First teeth begin to come in at about 6 months of age. Usually, the first two teeth to erupt are the two bottom central incisors (the two bottom front teeth). Next, the top four front teeth emerge. After that, other teeth slowly begin to fill in, usually in pairs -- one each side of the upper or lower jaw -- until all 20 teeth (10 in the upper jaw and 10 in the lower jaw) have come in by the time the child is 2 ½ to 3 years old. The complete set of primary teeth is in the mouth from the age of 2 ½ to 3 years of age to 6 to 7 years of age. 8-12m = 2 and 2 9-13 = next 2 16-22 = 1 13-19 = 1 25-33 = 1

Interaction Theories Influencing Development

Temperament Ecologic - nature vs nurture Resiliency - coping

Patterns of Temperament

The "easy" child Generally moderate in activity Shows regularity in patterns of eating, sleeping, and elimination Usually positive in mood Adapts to new situations when subjected to new stimuli Able to accept rules Works well with others Approximately 40% The "difficult" child Displays irregular schedules for eating, sleeping, and elimination Adapts slowly to new situations and persons Displays a predominantly negative mood Intense reactions to the environment common Approximately 10% The "slow-to-warm-up" child Initial withdrawal, followed by gradual, quiet, slow interaction with the environment Adapts slowly to new situations Mild reactions to environment Approximately 15% Mixed Some of each personality type's characteristics apparent Approximately 35%

Planning Assessments

The nurse must assess a child according to developmental age. Make comparisons between actual and expected age based on physical, cognitive, and psychosocial changes at each stage. Make referrals for disparity between actual and expected age. Newborn Plan assessments based on: Presence or absence of reflexes. Attachment behaviors. States of alertness. High-risk status. Infant Plan assessments based on: Appropriate serial weight and height measurements. Presence of tooth eruptions. Ability to walk and talk. Toddler Plan assessments based on: Increasing verbal ability and skill at walking. Ability to control elimination. Tooth eruption. Sense of cause and effect with understanding of object permanence. Increasing independence. Preschooler Plan assessments based on: Presence of preoperational thought. Use of dramatic play. Increasing command of language and a corresponding increase in curiosity about the environment. School-age Plan assessments based on: Growing interest in peer group and extracurricular activities. Growth spurt occurring earlier in girls than boys. Ability to think about solutions and determine the best among several alternatives. Understanding of the concept of conservation. Adolescence Plan assessments based on: Child undergoing identity formation. Sexual maturity nearing completion. Formal operational thought processes becoming possible. Importance of peer relationships and seriousness of romantic or emotional relationships. Knowledge that privacy, confidentiality, and honesty are means to gain trust in adolescent patients.

Planning Interventions

The nurse must plan interventions for a child according to developmental age and corresponding abilities. Comparisons between actual and expected age are based on physical, cognitive, and psychosocial changes at each stage. Further assessments and/or referrals are made for disparity between actual and expected age. Newborn ( 4 week premature = 4 weeks off age) Plan interventions based on: Presence or absence of reflexes - stroke face = should try to suck Attachment behaviors present - stare eye to eye States of alertness - if not do they not see, hear? High-risk status Infant Plan interventions based on: Appropriate serial weight and height measurements - follow closely Presence of tooth eruptions. Ability to walk and talk. Evident temperament and personality. Toddler Plan interventions based on: Incr verbal ability and skill at walking. Ability to control elimination. Tooth eruption. Sense of cause and effect with understanding of object permanence Straw into vein Incr independence NO! Preschooler Plan interventions based on: Presence of preoperational thought. Use of dramatic play. Increasing command of language, and corresponding increase in curiosity about their environment and body functions. School-age Plan interventions based on: Growing interest in peer group and extracurricular activities. Growth spurt occurring earlier in girls than boys. Care what friends are doing and not family = do conference call with friends or have class send cards Ability to think about solutions and determine the best among several alternatives. More than one way to do something = reasonable choices Understanding of the concept of conservation. Incr interest in sexuality and the opposite gender. Adolescence Plan interventions based on: Change in identity formation. Sexual maturity nearing completion. Formal operational thought processes possible. Plan interventions based on: Peer relationships important. Different-gender relationships become serious Worry about missing out on things with friends Knowledge that privacy, confidentiality, and honesty are means to gain trust in adolescent clients. Don't want parent present

Assessment Questions to Determine Resilience Capability

To determine risk factors, ask: Describe the event that occurred and what it has been like for your family. What other stressors do you have in your family right now? Are there financial worries? Are there things you think and worry about late at night? Describe your job, your friends. What is a typical day like? Describe your neighborhood. Do you have friends, people to call in emergencies? To determine protective factors, ask: What gives you strength? How do you deal with this stress? What do you think you do well in your family? Who do you call when you need help? Do you have a computer? Internet access? Are you religious? Spiritual? Do you exercise regularly? How do you spend free time?

Family Functioning

Transition to parenthood Parental influences Family size Siblings Becoming a parent is a major life change Quality of family relationships effects the ability of the family to function In larger families, individual children have less personal attention Siblings are the child's first peers, sibling rivalry, differing personalities

Obtaining the Child's History

Try to ensure the parent, care giver and patient correctly interpret communication Build rapport by introducing yourself, explaining the purpose of the interview Provide privacy Ask one question at a time Involve the child Use language style that best understood by parent and child Listen Carefully! Ask open ended questions Rapport - A close and harmonious relationship in which the people or groups concerned understand each other's feelings or ideas and communicate well. Listen carefully A health history is a very personal interview

SCHOOL-AGE CHILD 7-9 years (concrete operations) The Child's Understanding of Pain, Behavioral Responses, and Verbal Descriptions by Developmental Stage

Understands simple relationships between pain and disease Understands the need for painful procedures to monitor or treat disease May associate pain with feeling bad or angry May recognize psychologic pain related to grief and hurt feelings Passive resistance, clenches fists, holds body rigidly still, suffers emotional withdrawal, engages in plea bargaining They stall - any reason to postpone Can specify location and intensity of pain; can describe physical characteristics of pain in relation to body parts

Document Effect of Meds

Use consistent scale to document relief or change in pain Pain should be assessed before and after med is given

Pain Assessment Tools

Various scales and tools have been used to assess pain in children. In order to be accepted as tools, they must have: Validity Reliability The following tools have validity and reliability established Validity - accurately measures the concept it was designed to measure Reliability - consistent results are obtained when measured by the same or different raters The first 2 pain scales can also be used for non-verbal patients who are older

Evaluate Growth Pattern

Weigh the child, taking two measurements and averaging them. Measure the infant's length or child's height. Measure the infant's head circumference (up to age 2 years). Plot the child's current measurement on a growth curve appropriate for age and gender that has prior measurements plotted. Identify the percentile in which weight, length, or height and head circumference fall. If below 10th percentile = say below 10th If above 95th = say above 95th Determine if plotted prior measurements indicate steady expected growth or a change in percentile that reflects poor growth or faster growth than expected for age. Plot the infant's weight for length or calculate and plot the child's body mass index to determine if the child's weight is appropriate for height.

Stepping reflex.

When held upright with one foot touching a flat surface, the newborn puts one foot in front of the other and "walks" (stepping reflex). Aka - dancing reflex This reflex is more pronounced at birth and is lost in 4-8 weeks. This reflex is also called the walking or dance reflex because a baby appears to take steps or dance when held upright with his or her feet touching a solid surface

What are some social and community factors that influence health?

Work stress Unemployment Crowded living conditions Feelings of powerlessness Social isolation Lack of community resources (playgrounds, parks, theaters) Socioeconomic status (SES) underlies three major determinants of health: health care, environmental exposure, and health behavior. In addition, chronic stress associated with lower SES may also increase morbidity and mortality. Poverty Homelessness Migrant families Transient or unstable living situations Access to health care issues Utilization of health care issues Health risks associated with high and low socioeconomic status

Visual Assessment

infants Blink reflex - move your hand rapidly toward the infant's eyes - they should blink Track object allen picture eye chart - pics snellen - E HOTV - letters

Rooting reflex.

lasts about 4 months. Elicited when the side of the newborn's mouth or cheek is touched. In response, the newborn turns toward that side and opens the lips to suck (if not fed recently). This reflex begins when the corner of the baby's mouth is stroked or touched. The baby will turn his or her head and open his or her mouth to follow and root in the direction of the stroking. This helps the baby find the breast or bottle to begin feeding. Turn toward food source

Palpebral Slant

normal corner of eyes are striaght asain - inside eye is lower syndrom - inside of eye is higher

Numeric Pain Scale

over 5 yrs Explain that 0 is no pain and 10 is the worst pain. Have them verbally report or point to a number that is their level of pain

Exceptions to the General Rule

• Emergency care. AMA Ethics Opinion 8.08, Informed consent; 24 M.R.S.A. sec. 2905, Informed consent to health care treatment. • Minor's status. Some minors may consent to all health care treatment. • Sensitive types of treatment. All minors may consent to some health care treatment. All minors may give consent to certain sensitive types of treatment where an obligation of parental consent may be an obstacle to treatment and, therefore, may not be in the best interest of the minor.