Class three Flashcards
What should be assessed first? Why?
Heart first
As the exam goes, they fuss which leads to an increase in the HR
Where do you listen for heart rate on a child? How long do you listen to each site for?
Apical pulse for 1 minute
Upper left sternal border
Right sternal border (listen long enough to hear any irregular sounds)
Why are murmurs common in children?
Children have a really high HR so they have turbulent blood flow –> benign murmur
What should be assessed second? How long should you listen and why?
Respirations
Listen for one minute because their respirations are fast and irregular so you need to listen for a full minute to get an accurate count
What are two skin colors that are not concerning
Mottling: bad at auto regulation especially temperature
Acrocyansosis: warm and cyanotic/purple feet and hands d/t poor regulation of vascular stability
What skin coloring is concerning?
Cicroralcyanosis
Around the mouth
What else can you look for while just looking at the patient?
Assess for color
Neuro: sleeping, awake, arousable, reflexes
S/S of distress: pain?
General growth: malnourished, dehydrated, proportionate
What should you check third? Where and why?
Pulses
Femoral (diaper line) or brachial (inside of inner arm)
Cant use radial/pedal because vasculature is not well developed so weak
What are fontanelles and suture lines? What is the purpose for them?
Spot spots and openings in the cranium
Squish for delivery and allow for brain growth
When do fontanelles and sutures close? What do you measure to check these and for how long do you measure them?
Anterior: closes at 9-18 months
Posterior: 2 month
Sutures: 18-24 months
Measure head circumference until 2 years
How do you do an assessment on a pediatric patient?
Quiet/least invasive parts of the exam first
What will be examined last in a pediatric assessment and why?
Head
Most invasive so should be last
What is the doorway assessment?
Things that you can look at by just looking at the patient
What are some general appearance things to look at?
Overall health and age
Activity/behavior
Development
Nourishment
Statue
Head to toe
Growth charts
What can you learn form just a cry?
Respiratory status
Cardiac
Neuro/development
Emotional status
Communication
What does a cry tell you about respiratory status?
Patent airway
Stridor, wheezing, absent could mean obstruction
What does crying tell you about cardiac?
Cyanotic with crying
What does crying tell you about neuro/development?
High pitched: underlying neuro symptoms
What does crying tell you about communication?
Pain
Afraid
Stranger anxiety
How does a cry tell you how sick the patient is?
How they are reacting to painful things - should cry with pain
What are some differences in pediatric assessment data?
Higher baseline metabolic needs
Poor auto regulation
Primitive reflexes
Soft spots
Disproportionate head: body
Disproportionate facial features
What is poorly regulated in pediatrics?
RR and HR
Higher water content
Increased insensible water losses
What is the concern about having a higher water content?
Increase risk of fluid and electrolyte shifts –> electrolyte imbalances
What is the concern about poor auto regulation r/t HR?
children decompensated quickly so when HR is not longer sustained –> cardiopulmonary arrest
What is the difference between sensible and insensible water loss?
Sensible: can be seen like sweating, urine, vomit, bleeding, diarrhea
Insensible: can’t be seen like normal respirations, evaporation from skin, fever (infants have increase RR and skin doesn’t have a lot of fat to hold water)
What is PEWS and what is the purpose of it?
Tool created by clinical staff to support clinical judgment and give nurses power and objective data to decrease pediatric codes
Help to detect early decompensation, improves response time/early intervention, improves team communication, and improves outcomes
How early does PEWS detect prior to cardiac arrest?
12-24 hours before
What 3 domains are assess in the PEWS score?
Behavior
Respiratory
Cardiovascular
A PEWS score above what requires action?
score above 2
What is a a good PEWS score?
0-2
What should occur with a PEWS score of 0-1?
Continue monitoring and document as usual
What should occur with a PEWS score of 2?
Continue monitoring and document as usual
Review patient with more experience healthcare provider
Escalate if deemed further consolation required OR resources do not allow to meet care needs
What should occur for a PEWS score of 3?
Moved to yellow
Review patient with more experience healthcare provider
Escalate if deemed further consolation required OR resources do not allow to meet care needs
Increase frequency of assessments and document per plan form consult with more experienced care provider
What should occur for a PEWS score of 4?
Review patient with more experience healthcare provider
Escalate if deemed further consolation required OR resources do not allow to meet care needs
Notify most responsible physician (MRP) or delegate
MRP or delegate communicate plan of care to mitigate contributing factors of deterioration
Increase assessment frequency and document
Reassess adequacy of resources available and escalate to meet deficits
Consider internal or external transfer to higher level of care
What should occur for a PEWS score of 5?
Review patient with more experience healthcare provider
Escalate if deemed further consolation required OR resources do not allow to meet care needs
Notify most responsible physician (MRP) or delegate
MRP or delegate
MRP assess patient immediately and if can’t attend call STAT for physician review per MRP’s direction
Appropriate “sensor” review
MRP or delegate communicate plan of care to mitigate contributing factors of deterioration
Increase assessment frequency and document
Increase nursing to 1:1
Reassess care location to higher level of care
What is a change in neuro status consistent with?
End organ damage
Neuro decompensation can tell us the effects off loss of circulation to other parts of the body like kidneys
How do you assess orientation in children? Infants?
Responsive?
Ask who mom and dad is if they are in the room
Ask parents if child has had an changes in their baseline behavior like losing milestones
Infant: sternal rub/foot flick
What are the interaction that are included in behavior parameters?
Restless
Irritable
What is the activity included in the behavior parameters?
Sleeping
Playing
What are behaviors parameters that are assessed in PEWS?
Orientation
Interactions/behavior
Activity
What are the cardiac perfusion parameters for PEWS?
Pulse
Cap refill
Color and temp (central and peripheral)
Where should you check cap refill on an infant?
Circulatory system is immature so fingers and toes might not be reliable so assess for cap refill somewhere central like ears and belly
Why are BP and UOP not used for PEWS?
Both are not immediate/late assessment findings so may not change for hours or days
BP can compensate for changes in BP especially by increase HR
What are the respiratory distress parameters for PEWS?
Resp rate
Work of breathing
Oxygen requirement
Continuous nebs
Why isn’t SpO2 a parameter for Respiratory distress?
Because circulation system is immature so fingers and toes might not be reliable
How do you determine if if a benign murmur?
Murmur decreases in intensity with standing
Due to instability b/t skin and internal, where should you get the temperature of a child?
Rectal temps are more accurate
What are signs of difficulty warming yourself up in infants?
Acrocyanosis and mottling
What occurs because of poor auto regulation?
Temp instability between skin and internal
Overheat easily because can’t sweat
Skin turgor/fat helps w. temp stability
High water content b/c fat holds onto water
Difficulty warming self up
What overstimulates infants?What does this lead to?
Infants are easily overstimulated by changes in environment
Leads to an increase in metabolic demand
What are cues of distress in an infant?
Subtle (increase in HR)
Hiccup (could mean over fed or over stimulated)
Looking away
Mottling
Changes in resp. effort
What age are abdominal breathers?
under 7 years old
What are some common chest wall variations?
Chest wall has same diameter as head
Barrel shape b/c alveoli are immature so they stay inflated
Infant ribcage is flexible so retractions are common
What is in a general pediatric nervous system assessment?
Developmental milestones appropriate for age
Reflexes and tone (strength assessment for neuro issues)
Measurement of head circumference for fontanels, sutures and ICP
What is the muscle and tone for a patient with muscular dystrophy?
Flaccid and weak
What is the muscle and tone for a patient with cerebral palsy?
Spasticity
What are infant reflexes?
- Sucking
- Rooting
- Moro
- Parachute
- Fencing
- Babinski
- Stair stepping
When should primitive reflexes disappear?
6 - 9 months
What is the rooting reflex?
Stroke cheek and infant suckles
What is the moro reflex?
Hands open, arms go out and head throws back
Usually because startled
What it the parachute reflex?
Lift feet
What is the point of infant reflexes?
Helps to keep baby alive and helps neuro system develop
When does sucking and rooting generally go away?
Gone by 4 months
Where do you measure head circumference?
Right above eyebrows and ears around the broadest part of head
How do you determine if an infants large head is benign or worrisome?
By looking at developmentally normal or delay/losing milestones
What is hydrocephaly?
Big head
Worrisome if prominent veins or eye gaze like crosseyed
What is microcephaly?
Small head
Cognition various but generally delays
What is plagiocephaly? How do you fix it? What can it cause?
Flat head usually from sleeping on back
Fixed with a helmet
Can cause facial asymmetry if not corrected
When should the eyes be lined up by?
6 months
Aka: intermitente eso/exotropia normal until 6 months
When is 20/20 vision obtained?
early childhood
What is suborbital shiners? What is this common in?
Dark circles under the eyes
Common in allergies
What could low set ears indicate?
Development/neuro delay
What could an ear tag/disformed ears indicate?
Renal abnormality
What should you assess for the nose, mouth and throat?
Tongue protruding and size?
Palate high and intact?
Tonsils - hypertrophy to adolescence
Sinuses are not fully developed until school age
Shoddy lymph nodes
When do you lose baby teeth? When do adult teeth come in?
Baby teeth lost at 6-12 years
Adult teeth come in at 6-18 years
When should the belly begin to thin out?
By school age
What occurs in an infant’s skin?
More water
More fat
Lanugo
Downy hair
Rashes
What kind of rashes do infants get? Is this worrisome?
Sensitive skin
Milia and infant acne
Cradle cap
Diaper dermatitis
Most go away on own
Why is there a caution of IVs with infants? What should you look for?
There is more fat so it can be hard to determine if the IV has infiltrated
To determine this, look at temp, compare with other side, redness/pale, irritability, assess IV every hour
What is the general rule for bruises?
If a baby isn’t causing, there should be no bruising
Where are bruises usually found?
On bony prominences like
Forehead, elbows, knees, ankles, heels
Where are is bruising rare/abnormal?
Soft tissue injuries like the face, trunk, abdomen, buttocks, armpits, genitals, neck, inner legs, upper and lower back
Why is it important to be aware of patterns regarding burns?
To know accidental vs. intentional
HISTORY HISTORY HISTORY
What is the degree of a burn a factor of?
Skin thickness (full thickness is intentional)
Temp of the solid/liquid or gas
Length of contact with solid/liquid or gas
Where are the most common areas of trauma regarding burns?
Perineum and extremities
What are some suspicious burn patterns?
“dip” burns
Back/buttock in infant/toddler
Burn on dorsum of hand (kids will touch with their palms so back of hands/feet is not normal)
Deep contact burn with pattern of contact surface
What are some misconceptions reading pain in children?
Infants don’t feel pain
Children and adolescents will become addicted if treated with opioids
Children who are playing, sleeping or can be distracted are not in pain
Children can tolerate pain better than adults
Children cannot tell you where it hurts
Children always tell the truth about pain
Children become accustomed to painful procedures
What are some signs of pain in young infant?
Generalized response of body trashing
Loud crying
Facial expressions of pain like brows lowered and drawn, eyes closed tightly, mouth open
What are some signs of pain in an older infant?
Localized body response with deliberate withdrawal of stimulated area
Loud crying
Facial expressions of pain or anger
Pushing the stimulus away after it is applied
What are some signs of pain in a young child like toddler and school age?
Loud screaming and crying
“ow”, “ouch” “that hurts”
Thrashing of arms and legs
Pushes away before stimulus applied
Clings to parents
May become restless and irritable
Stalling behavior like “wait”
Muscle rigidity, clenched fists, white knuckles, contracted limbs, stiffness, closed eyes, wrinkles forehead
What are some signs of pain in an adolescent?
Less vocal protest
More motor activity
More verbal expression like it hurt or you’re hurting me
Increased muscle tension/boy control
When is it appropriate to use the FLACC scale?
Newborns to 7 years old
What does FLACC stand for? What type of scale is this?
Face, Legs, Activity, Cry, Consolability
Oberserver-rating scale
What does the CRIES pain scale stand for?
Crying
Requires O2 for 95% sat
Increase VS
Expression
Sleepless
What does a cries score less than 4 mean? More than 4?
Less than 4: non-charm measures
More than 4: pharm and non pharm measures
When is it appropriate to use the Wong-baker faces
3 years and older
When is it okay to use the numeric pain scale?
Over the age of 9
What is the individualized numeric rating scale?
Parents come up with a scale that is specific to their child’s behavior and how their child usually acts/behaves based on no pain to severe pain
What are non-pharmacologic methods for pain control?
Distraction
Relaxation
Guided imagery
Positive self-talk
Containment
Nonnutritive sucking
Sucrose
Kangaroo care
Complementary and alternative medicine
Heat and cold
Music therapy
Play therapy
Pet therapy
Consult child life specialist
What is the 2 step approach to pharm methods of pain relief in children?
Older than 3 months in mild pain first consider nonopioid like Tylenol and NSAIDS
Second step for child with moderate-severe pain is administer opioid like morphine
What is the goals for pain relief win children?
Optimal dosing of meds to control pain w/o severe side effects
Select least traumatic route
Combine non pharm and pharm
Evaluate effectiveness on intervention
What are a couple pharm options for pain control in children
- Eutectic mixture of local anesthetics (EMLA)
- Lipsomal lidocaine 4-5% (LMX4 or LMX5)
- PCA
How long at administration of an IV pain med should you recheck pain? PO pain med?
IV: 15 minutes
PO: 60 minutes
