Exam 1 Flashcards
Focuses of pediatric nursing
Treating disease, health promotion, and disease prevention
Anticipatory guidance definition
The process of understanding upcoming developmental needs and then teaching caretakers to meet those needs
Essential roles of pediatric nurse
- Understand physiological changes to child vs adult
- Recognize these differences quickly
- Apply developmental age to care
- Understand common conditions and anticipatory guidance/health promotion (maximize health outcomes)
Six standards of practice in nursing
- Assess patient
- Nursing diagnosis (NANDA)
- Identify outcomes
- Create a plan/interventions
- Implement interventions
- Evaluate
Family-centered care
Child and family are intertwined; child outcomes tie closely with family dynamics. Nurse supports this, often through therapeutic relationship.
Anterior fontanel closes:
At 12-18 months of age
Posterior fontanel closes:
At 2-3 months of age
Chief complaint:
Why they came in
History of present illness (HPI):
When did it start, how much does it bother you, what have you tried for relief, etc.
Past history (PMH):
Other conditions (associated or not), birth history for kids
Current health status:
Current other conditions
Familial/hereditary disease:
Predispositions
Review of systems:
Ask about a focused system and what’s going on
Psychosocial data:
Family assessment, home life, etc.
Developmental data:
Developmental age of patient
Considerations for newborn/infants (<6 months)
- Keep parent present
- Use distraction (i.e. noise)
- Look at activity level, mood, and responsiveness to handling (leave in parents’ arms if already there and you’re able to)
- Be flexible
Considerations for infants >6 months
- Increased separation/stranger anxiety
- Observe general activity, mood, and responsiveness
- Smile
- Use pacifier as needed
- Be flexible
Considerations for toddlers (1-3 years)
- Stranger anxiety (use caregiver)
- Explain each step of assessment
- Let patient have some control - may prevent child from acting out
Considerations for preschool (3-5 years)
- Involve play
- Give simple explanations
- Allow control
Considerations for school-age (6-12 years)
- Anticipate increased desire for modesty
- Privacy vs. parent/sibling present
- Head to toe assessment can begin here
- Explanations should be more logical and detailed
- Give empowerment/involvement
Considerations for adolescent (13-18 years)
- Modesty and privacy are important
- May have fear of something being permanent
- Continue with head to toe assessments
- Give reassurance
BMI can be measured after age:
2
BP can be measured after age:
3 for outpatient; may be used at any age for inpatient
Concerns of growth
Head circumference, height (should follow curve; concern if they go way high or way low off of the curve)
Skin assessment
- Inspection (even color distribution, bruising, abnormalities (flushing, cyanosis, pallor)), lesions
- Palpation (temp, texture, moistness, resilience, turgor, edema)
- Capillary refill (<2 seconds)
Hair assessment
- Inspection (color, distribution, abnormalities (lice), hair loss)
- Palpation (texture)
Head and face assessment
- Palpate skull sutures in <2 years old
- Palpate fontanels in 18 months or less (both closed by 18 months)
- Head circumference in <3 years
- Assess facial symmetry (droopy, even, etc.)
Eye assessment
- Inspect external structures (eye size/spacing, eyelids, eyelashes, eye color, pupils and pupillary response); variations in color of iris may indicate conditions
- Inspect eye muscles (extra ocular movements, corneal light reflex, cover uncover test)
- Check blink reflex and tracking in infants/toddlers
- Use standard visualization charts >3-4 years of age
- Inspect internal structures, red reflex, branching of blood vessels, optic disc margin, macula
Ear assessment
- Inspect external structures (position and characteristics)
- Inspect tympanic membrane (using otoscope)
- Perform age-appropriate hearing assessment: infant and toddler you make noise and check reaction; preschool and older children you whisper words and may use bone and air conduction of sound (Weber/Rinne)
Nose assessment
- in kids, nostrils are smaller and more easily obstructed - inspect and palpate patency
- inspect external nose - shape, size, symmetry, midline placement
- inspect internal nose - mucus membranes, nasal septum, discharge
- inspect sinuses/palpate
- assess smell with easily recognized smells (i.e. peppermint, orange, etc.)
Mouth/throat assessment
Mouth: inspect lips, teeth, gums, buccal mucosa, tongue, hard and soft palate, and tonsils; inspect for odors; inspect suck reflex in infants for strength
Throat: inspect color, swelling, lesions, tonsils
Neck assessment
- make sure trachea is midline and symmetrical
- check range of motion
- palpate cervical lymph nodes and thyroid
Chest/lung assessment
- inspect size, shape, movement, respiratory effort (use of accessory muscles - the higher up it is, the more concerning), respiratory rate (remember this is age-dependent)
- palpate chest wall and for tactile remits/hyperresonance
- auscultate (intensity, pitch, rhythm of breath sounds - absent breath sounds = TROUBLE)
- Percuss
Heart assessment
- Inspect apical pulse (much more reliable in kids than in adults); inspect capillary refill, skin color, respiratory distress
- Palpate apical pulse and extremity pulses
- auscultate rhythm and rate, heart sounds, splitting of heart sounds (splitting in s2 is ok at young age), murmurs
- BP if >3 years old outpatient and in all inpatient
Abdominal assessment
- Inspect shape, contour, abdominal movement, inguinal area
- Auscultate bowel sounds
- percuss dullness vs. tympani (more tympani over stomach, more dullness over liver when felt)
- Palpate lightly first, then deep
Musculoskeletal assessment
- Inspect bones, muscle joints for alignment, contour, skin folds (important for infants for hip dysplasia - asymmetric skin folds is considered an early clinical sign for diagnosing hip dysplasia), length, deformities, size, discoloration, ease of movement
- Inspect lower extremities (hips, skin folds, legs, feet). in legs, look for genu varum vs. genu valgum
- inspect upper extremities (alignment, nails, count fingers and creases)
- palpate muscle tone (hypertonic/spastic or low tone/unable to hold something), masses, tenderness
- posture/alignment of spinal cord
Nervous system assessment
- cognitive function (behavior, expressions, communication, memory, level of consciousness
- cerebellar function (balance, coordination, gait)
- cranial nerve function (olfactory, optic, etc.)
- sensory function (superficial tactile sensation, superficial pain sensation)
- infant primitive reflexes
- superficial/deep tendon reflexes
infant age
birth-1 year
toddler age
1-2 years
preschooler age
3-5 years
school-age age
6-12 years
adolescent age
13-18 years
infant stressors
separation anxiety (especially 6-9 months), stranger anxiety, sleep deprivation, and sensory overload
infant care recommendations
encourage parent presence, eliminate excess noise, do the least unpleasant thing first, and bring security item from home
toddler stressors
separation anxiety, loss of self-control, and fears (of dark, injury, etc.)
toddler care recommendations
encourage parent presence in care, allow choices when possible (i.e. when doing vitals), and explain things in simple terms (only explain just before the event, not in advance)
preschool stressors
fear (huge in this age group), guilt (as they do not understand cause and effect), and may see hospitalization as a punishment
preschool care recommendations
create a routine with the family, encourage with play, encourage choices/independence, encourage parent involvement (as they know the child best)
school-age stressors
privacy/modesty, fear of injury/pain/death, and separation anxiety
school-age care recommendations
honesty about procedures (they are rational and do understand cause and effect), promote child participation in care, encourage creative activities (i.e. music, art, etc. that are in line with child’s hobbies), and use child life specialist
adolescent stressors
loss of independence/privacy/control (at this age they know what they want), fear of injury (associated with body image), and separation from peers, school, and home
adolescent care recommendations
encourage social/coping skills, and allow visiting hours/internet/phone access/etc.
family stressors
parental role change (now they are not the ones that are caring for the child), stress of missing work/expenses/other siblings/guilt (especially if hospitalization is result of injury/accident)
family care recommendations
give regular updates on the child’s condition, encourage/support/resources, build trusting relationship, assess resources (including finances and family dynamics)
explanation of procedure for infant
none, explain to parents
explanation of procedure for toddler
give explanation just before procedure
explanation of procedure for school-age
simple/short explanations, drawings; explain right before procedure and change words as needed to meet their understanding
explanation of procedure for adolescent
oral and written clear/complete explanation; may give explanation in advance
pediatric early warning systems (PEWS) scale
evaluates for decompensation ahead of vital signs (behavioral, CV, respiratory); higher scale is more concerning
discharge begins:
at admission
response to pain <6 months
jerky movements, chin quiver, crying
response to pain 6-12 months
facial grimace, disturbed sleep, irritable, crying, arching back
response to pain 1-3 years
aggressive behavior (as they cannot verbally explain yet), disturbed sleep, crying/screaming, “booboo”
response to pain 3-6 years
more localized description of pain, aggressive behavior, etc.
response to pain 7-9 years
clench fist, withdrawn, specifies location/type/intensity/characteristics
response to pain 10-12 years
stress/anxiety, try to be brave/appear brave, describes pain accurately and reliably
response to pain 13-18 years
controlled behavioral response, sophisticated descriptions
rapid/shallow breathing in response to pain may lead to
alkalosis/hypoxia
increased metabolic rate/perspiration in response to pain may lead to
fluid/electrolyte loss
depressed immune system in response to pain may lead to
increased risk of infection
nausea/anorexia in response to pain may lead to
poor/inadequate nutrition
increased pain sensitivity in response to pain may lead to
memory of painful experiences
fentanyl patch
use in >12 year olds, used for continuous pain control. onset = 12-24 hours, duration = 72 hours
IV therapy
fastest route, continuous meds provide stable live. reassess in 15-30 mins
oral therapy
convenient and cost effective but takes 1-2 hours to reach peak effect. reassess between 30-60 minutes (pain should at least be minimized by this point)
topical/transdermal therapy
anesthetics should be applied one hour before procedure and will numb in 15 mins
PCA therapy
often used after injury or for chronic conditions and is computerized/controlled by patient. use in older school age and adolescents at appropriate developmental age. parents should not control these.
opioid therapy
given for severe pain (may be oral, subQ, IM, IV). side effects = sedation, N/V, constipation, urinary retention, respiratory depression (this is urgent). examples = morphine, codeine, hydromorphone, methadone, oxycodone, fentanyl
NSAID therapy
used for mild to moderate and chronic pain. used especially for bone/inflammatory disease. not given in <6 months unless indicated and should not be given with kidney disease. primarily oral (but may also be IV or IM). examples = aspirin (never give <19 years), Motrin, naproxen, ketorolac.
acetaminophen/tylenol therapy
used for mild/moderate and chronic pain (but is not anti-inflammatory). give every 4-6 hours (and may alternate with NSAIDs). do not use in patients with liver disease. watch for double dosing as many meds also contain acetaminophen.
Nonpharm therapy
relaxation, distraction, breathing, sucrose solution (infants), application of heat/cold, etc.
Anxiolysis definition
minimal sedation (awake but relaxed) and not fully aware
moderate sedation
low dose so child can self-maintain airway and has appropriate response to stimuli
deep sedation
controlled state of unconsciousness, intubated; sedation drugs include benzodiazepines, barbiturates, analgesics. Monitor respiration, color/appearance, and vitals with sedation.
pain med reassessment times
IV: 15 mins
IM: 30 mins
oral/nonpharm: 30-60 mins
cephalocaudal development
head to foot development (i.e. kids gain head control before they begin walking; meet one milestone before they can move on)
proximodistal development
muscle control goes from the trunk out (i.e. kids learn to sit up before they start standing)
Freud theory focus
unconscious thought
freud stages of development
oral (birth-1 year) anal (1-3 years) phallic (3-6 years) latency (6-12 years) genital (12-adulthood) *think that freud basically follows normal age groups we study*
freud’s oral stage
(birth-1 year): infant derives pleasure from the mouth (i.e. sucking and eating). disruption at this stage causes emotional issues or impaired bonding with the parent/caregiver. for example, offer pacifier.
freud’s anal stage
(1-3 years): potty training, the child derives pleasure from control over body secretions; kids may be constipated often at this age.
freud’s phallic stage
(3-6 years): genitalia focus for kids, working out relationship with parents (child identifies here with parent of the opposite sex but by the end of this stage identifies with the same sex parent). accommodate for children who want to be with male or female nurses.
freud’s latency stage
(6-12 years): sexual energy is at rest and is channeled into productive activities, learning skills, etc. Support modesty in this stage. the chid places emphasis on privacy and understanding the body.
freud’s genital stage
(12-adulthood): the adolescent’s focus is on genital function and relationships. ensure privacy and education. testicular exams for boys.
Erikson theory focus
psychosocial
Erikson stages of development
trust vs. mistrust (birth-1 year)
autonomy vs. shame and doubt (1-3 years)
initiative vs. guilt (3-6 years)
industry vs. inferiority (6-12 years)
identity vs. role confusion (12-18 years)
think that Erickson basically follows normal age groups we study
erikson’s trust vs. mistrust
(birth-1 year): ability of infant to trust others (parents are providing food, comfort, shelter, etc.)
erikson’s autonomy vs. shame and doubt
(1-3 years): toddlers start to develop self control and start wanting independence (includes potty training). may have doubt/shame if no independence
erikson’s initiative vs. guilt
(3-6 years): child is learning limits, exploring, trying to develop new things. may have guilt/lack of purpose if they do not gain independence. the child likes to initiate play activities
erikson’s industry vs. inferiority
(6-12 years): industry is a sense of confidence and purpose. kids here develop hobbies, interests, and creativity. the child gains a sense of self-worth from involvement in activities.
erikson’s identity vs. role confusion
the adolescent’s search for self-identity leads to independence from parents and reliance on peers.
Piaget theory focus
cognitive
Piaget’s stages of development
sensorimotor (birth-2 years)
preoperational (2-7 years)
concrete operational (7-11 years)
formal operational (11 years-adulthood)
Piaget’s sensorimotor stage
(birth-2 years): children learn through senses and motor activities. learning how things work. use manipulative toys.
Piaget’s preoperational stage
(2-7 years): children start to think by using symbols such as words and letters. they are not totally logical, still magical. they can only really think of one thing at a time.
Piaget’s concrete operational stage
(7-11 years): kids develop mental processes. kids begin to understand basic reasoning and how things relate to one another. more logic and less magical thinking.
Piaget’s formal operational stage
(11-adulthood): kids can think abstractly/theoretically and can take multiple perspectives to a situation.
Kohlberg’s theory focus
moral development
kohlberg’s theory stages
preconventional (4-7 years)
conventional (7-12 years)
post conventional (12 years +)
kohlberg’s preconventional stage
(4-7 years): avoiding punishment, wanting to please others. rule following.
kohlber’s conventional stage
(7-12 years): sense of conscience develops. begin to understand right and wrong - not just doing what parents say.
kohlberg’s post conventional stage
(12+ years): set internal/ethical standards and gain sense of social responsibility.
birth weight changes
at 5-6 months, birthweight doubles; by one year, birthweight triples
tooth eruption
6-10 months: central lower
8-10 months: central upper
9-13 months: lateral upper
10-16 months: lateral lower
why give vaccines early in life
immune system mainly from mother first 6 months of life, longer if breastfeeding (antibodies are passed on)
infant gross motor skills developed:
posture, head control, sitting, standing, walking
infant fine motor skills:
starts with palm grasp and raking motion, moves to pincer grasp (two fingers)
newborn reflex (trunk incurvature)
until 2 months: finger run down spine trunk flexes and pelvis swings toward stimulated side
newborn reflex (tonic neck)
until 2-3 months: when head is turned, extremities on same side extend outward, opposite side flexes
newborn reflex (grasping)
until 3-4 months: grasp fingers placed in hand
newborn reflex (rooting)
until 3-4 months: cheek is stroked, turns head in direction of stroke
newborn reflex (moro/startle)
until 4-6 months: lifted high and suddenly lowered; arms and legs extend and abduct while fingers spread to form a “c”
newborn reflex (sucking)
until 6 months: occurs when nipple placed in mouth
newborn reflex (babinski sign)
until 2 years: sole on side of small toe is stroked, toes fan upward (negative may indicate nerve problems)
newborn reflex (stepping)
until variable times: hold upright with feet touching flat surface, dancing or stepping occurs
