Lecture 2: Assessment of the Pediatric Pt Flashcards
how much % of brain growth is achieved in
1) 1st yr of life
2) by age 3
3) by age 6
1) 50%
2) 75%
3) 90%
how much does ur brain weigh at…
1) birth
2) by 1st bday
3) by 5-6 yrs of age
1) 12%
2) doubles
3) triples
how does the pediatric CNS and nerve fibres look
- discuss reflexes, the BBB, and myelination
- CNS immature
- nerve fibres poorly developed
- numerous reflexes present initially
- BBB not mature until 2 yrs, so increased risk for meningitis
- myelination over 1st yr of life
what are fontanelles and sutures
- sutures are separations between bones of skull that have not yet joined
- fontanelles are formed at the intersection of these sutures
allow pass thru birth canal, which cause the brain to grow and expand
what are fontanelles covered by
tough membranous tissue that protects the brain
when does the posterior fontanelle close by
2-3 months
when are the anterior fontanelle and sutures palpable up till
18 months of age
what is included in a complete neuro assessment
- PEERLA
○ Pupils equal and reactive to light- Newborn Reflexes (When they are present, when they should disappear, etc.)
- Coordination
- Can they follow commands
- Can they move all their limbs
- Hypertonicity - what diagnosis can cause this: NAS (neonatal abstinence syndrome)
- Hypotonicity - what diagnosis can cause this: Ehlers Danlos syndrome, down syndrome
- Ask about seizures
- Palpate the Fontenelle
- Bulging Fontenelle: increased intracranial pressure or fluid overload
- Sunken Fontenelle: dehydration
- Ask pt how old they are, pets, grade are you, who’s here with you?
- Is the behaviour or development appropriate for their age?
- Having no interest in anything -> NOT GOOD
- Correcting their age -> for preemies they should meet their milestones normally at 2 yrs otherwise a bad sign
- Intercranial pressure signs: swelling of their fontanelle, crying
- Cardiac babies don’t have a strong cry
- High pitched cry: sign of increased intracranial pressure or NAS
- Pain: good strong cry
- Neuro Vitals: PERLA, Glasgow coma scale, pupils, and motor strength
Strength of suck
what is the #1 code in peds
respiratory arrest
when does a pediatric resp tract constantly grow/change until
12 yrs
what are 5 upper airway differences in peds
- neck is shorter, resulting in airway structures closer together
- trachea is shorter and narrower, creating risk for obstruction
- newborns are obligatory nose breathers - will not automatically open mouth if nose is obstructed therefore nasal patency is critical
- larynx and glottis high in neck therefore increases risk of aspiration
- tongue is large relative to small nasal and oral airway passages
*nose breathers so keep nasal patency open
what are 6 lower airway differences in pediatrics
- at birth the lung tissue contains only 25 million alveoli, which are not fully developed
- # of alveoli increases to 300 mil by age 8
- smaller alveoli predispose infants to alveolar collapse
- less lung volume
- children up to age 6 are primarily dependent on their diaphragm to breathe
- CO2 is not effectively expired when child is distressed, making child susceptible to metabolic acidosis
why is airway resistance greater in children
- greater in children than in adults - children airway is narrower than adults
- in infants, airway resistance is about 15x that of an adult
- w edema and swelling the airway is further narrowed
- airway resistance = harder to breathe = increased WOB
September spike in asthma exacerbation
what is included in a complete respiratory assessment
- Work of breath
- If u see ribs they have intercostal indrawing or retraction
- Auscultating the lungs: crackles, wheezes, stridor (tracheal swell in croup)
- Oxygen Delivery
- Airway obstruction
- Newborns are periodic breathers
- Air passing through nasal congestion
- Decreased air entry - what intervention: reposition
- Mucus
- Notice any cough
Apnea classification: 20 seconds
describe wheezing
- musical high pitched squeaking sounds often heard mid to late expiration
- air is squeezed or compress through passageways narrowed almost to closure through collapsing airways, swelling, secretions
- may be high or low pitched
describe crackles
fine - high pitched crackling or popping sound heard on inspiration not cleared by coughing
- inhaled air collides w previously deflated airways which will pop open
course - low pitched bubbling and gurgling sounds that start in early inspiration and may be present in expiration
- inhaled air collides with secretions in trachea or large bronchi
- sounds like velcro
pneumonia, broncholotis, mucous
stridor
- high pitched crowing sound
- originated in larynx or trachea
- obstruction from swollen inflamed tissues or lodged foreign body
obstruction, pertussis
transmitted sounds heard on auscultation
- may seem to originate in the lungs but is referred from the upper airway i.e. mucous in the throat or nose
common in newborns
what to look for when doing an assessment for work of breathing
- retractions/in drawing
- accessory muscle use
- grunting
- head bobbing
- nasal flaring
- tracheal tug
what do kids usually have tachypnea more than adults
Kids hearts beat fast, because they cannot beat harder so tachycardia is very common
what are CVS pediatric differences
- cardiac output is rate dependent not stroke volume dependent
- HR is labile
- during stress, exercise, fever, or respiratory distress, infants and children become tachycardic, which increases their cardiac output
- lower BP: thought to be related to underdeveloped left ventricle
- lower absolute blood volume: vulnerable to fluid and electrolyte imbalances
what are potential causes of tachycardia
Infection, stress, trouble breathing/respiratory distress, dehydration
what is low bp a late sign in children for…
dehydration, otherwise their bp doesn’t change much
Children - dehydration is a priority they cannot handle it like adults can
what is included in a complete CVS assessment
- Murmur - abnormal blood flow
- Capillary refill, less than 3 secs
- Colour of skin: not cyanotic, not pale, not jaundice
- Heart rate for a whole minute
- Cant feel radial until about 4-6 years of age, so feel apically
- Best time to do infant bp is when they r sleeping
- Where are you going to see edema in children: their face and their eyes (periorbital edema), genitals
- Hydration status via skin turgor, weight, mucus membranes
- When dehydrated they won’t have tears or sweat when they are dehydrated
Temperature
normal peds vital sign ranges for infants
systolic: 74-100
diastolic: 50-70
HR/min: 120-160
Resp/min: 30-60
normal peds vital sign ranges for toddlers
systolic: 80-112
diastolic: 50-80
HR/min: 90-140
Resp/min: 24-40
normal peds vital sign ranges for preschoolers
systolic: 82-110
diastolic: 50-78
HR/min: 80-110
Resp/min: 22-34
normal peds vital sign ranges for school aged children
systolic: 84-120
diastolic: 54-80
HR/min: 75-100
Resp/min: 18-30
normal peds vital sign ranges for adolescents
systolic: 94-140
diastolic: 62-88
HR/min: 60-90
Resp/min: 12-16
why might an infant be cyanotic
- an infant may be cyanotic bc of cardiac or pulmonary disorder
cyanosis that worsens with crying is likely due to…
a CVS issue
what does crying due to the CVS
increases the pulmonary resistance to blood flow, resulting in increased right to left shunt
cyanosis that improves w crying is most likely due too…
pulmonary - deep breathing improves tidal volume
acrocyanosis
cyanosis of extremities - normal in newborn
peripheral cyanosis
extremities, perioral - may represent hypothermia or decreased flow
central cyanosis
- inside mucous membranes, reduced hemoglobin sat
central cyanosis
- in their mouth
what is most often hear in resp system in peds
transmitted noises
why are peds at more risk for getting things stuck in their throat
trachea shorter and more narrow
when does saliva production begin
4 months
when is the sucking and extrusion reflex present until
3-4 months
how much does stomach capacity increase in the 1st yr of life
30-300 mls
what happens to the intestinal flora in the 1-3 yrs of life
becomes more adult like - stomach acid increases
what happens around 2 yrs with the myelination of nerves
w the myelination of nerves to the anal sphincter it allows physiologic control of bowel function around 2 yrs
what causes babies regurg
lower esophageal sphincter muscle tone not fully developed until 1 month
does not hurt them bc their stomach acid isn’t like adults yet it doesn’t burn
what is extrusion reflex
tongue pushes stuff out until 3-4 months
size of small intestine in infants vs adults
infants: 250 cm
adults: 600 cm
in kids how much does the liver weigh in comparison to adults
liver is 5% of body wt compared to 2% as adult
is the liver mature/immature at birth
liver is immature at birth inefficient detoxifying of substances and medications
why are infants more prone to hypoglycemia
slow development of glycogen storage capacity
what are infants more prone to *constant theme
infants more prone to dehydration and fluid and electrolyte imbalances - more body water than adults - higher for fluid deficit w illness
why are liver and spleens more susceptible to trauma
abdomen offers poor protection
is gastric digestion less or more functional in kids
less duh
what is included in a complete GI assessment
Auscultate bowel sounds and palpate all 4 quadrants
Observe: is it distending, etc.
Post op abdominal sounds will be extremely decreased
Stool charting - what it looks like, undigested material
Seeing if abdomen is soft, and palpable
Any vomiting, bile, etc?
Passing gas, have they had a BM.
how much kidney wt change in 1st month of life
doubles in wt
why are infants more vulnerable to dehydration and fluid overload
bc they can’t concentrate or excrete urine in response to changes in fluid status
what is the bladder capacity of infants/adults
infants: 15-20mls
adults: 600-800mls
why is the kidney susceptible to trauma
relatively large for body size and age
describe urethra in females, and in infants
shorter in females, closer to rectum in infants
describe bladder control in children less than 2
maintain bladder control due to insufficient nerve development
for the 1st yr the child has: KNOW THIS
- poor fluid volume control
- less ability to conserve water
- prone to over and dehydration
- unable to excrete excessive sodium, nitrogenous wastes and drug metabolites
- can’t conserve alkaline buffers or actively secrete hydrogen ions
- risk for acidosis
- infants lungs provide little opportunity for fast removal of CO2
term neonate
% water by wt:
ECF:
ICF:
% water by wt: 75%
ECF: 45%
ICF: 30%
6 months
% water by wt:
ECF:
ICF:
% water by wt: 65%
ECF: 25%
ICF: 40%
2 yrs
% water by wt:
ECF:
ICF:
% water by wt: 60%
ECF: 20%
ICF: 40%
adult
% water by wt:
ECF:
ICF:
% water by wt: ~60%
ECF: 20%
ICF: 40%
whats included in a complete GU assessment
Toilet training at 2 is earliest
Urethra is closer to rectum - UTI
1st yr of life is an ability to conserve water
Urine outs and ins (1-2mL per hour)
Children’s intestine is greater than an adult
Infants are prone to hypoglycemia
*remember the 421 rule
Ex: calculate the TFI for a pt weighing 17Lg using the 421 rule” answerb 54
daily fluid calculation for peds
100 mL/kg for first 10kg
+50mL/Kg for 2nd 10kg
+20mL/kg for each kg >20kg
= mL/day
hourly fluid calculation for peds
4mL/kg x first 10 kg
+2mL/kg x second 10 kg
+1mL/kg x for each kg >20kg
= mL/hr
S/S of increased fluid
fever, vomiting, diarrhea, diabetes insipidus, burns, tachypnea, chemo
S/S of decreased fluid
meningitis
congestive heart failure
renal failure
SIADH
until puberty, the percent of ________ if higher and why
percent of cartilage in ribs is higher, making them more flexible and compliant
what are pediatric bones like
bones are soft and more easily bent and fractured
bones tend to heal faster - more osteogenic potential, younger you are faster you heal
during infancy how are the muscles doin
muscles lack tone, power, and coordination
muscle mass in % in infant and adult
infant: 25%
adult: 40%
pediatric differences in endocrine system in relation to thermoregulation and temp
thermoreg is immature in infants therefore hypothermia is a risk
temperature lability present - temp can increase to very high levels even in minor infections
what is the ratio to temp elevation in peds
elevation is 4:1 (4 extra breaths for every 1 degree F above N)
children have ________ metabolic rate, ___________ oxygen needs, ______ caloric needs
higher!
skin surface area in kids is approximately what in comparison to adults
skin surface area is approx 2.5 x that of an adult
describe pediatric immune system
- immune system immature, slow response to infection
- immunization schedule
- GI infections common
how many infections per yr for infants
6-9 resp infections/yr
how many infections by age 6
4-5 resp infections/yr
describe peds allergies
- allergies common (may manifest in skin, resp, GI) important to ask about family history of allergies
- allergies/sensitivities to meds should be carefully monitored and recorded
how to assess pain sympt in peds
behaviour, linguistic, physiological
how do you do pain assessments in peds
validated pain scales
- numeric, faces, FLACC, NIPS
what are 4 pieces to the puzzle to determine pediatric risk
appearance, behaviour, cognition, thoughts = risk
mental status exam - ASEPTIC
Appearance
Speech
Emotions
Perception
Thoughts
Insights
Cognition
for an aseptic exam describe A
- grooming, facial expression, tremors, dress, skin condition, identifying characteristics (ex: tattoos, piercings), scars, age, body build, position, alertness, affect
- psychomotor: gait, pacing, crying, threatening, withdrawn, angry, suspicious, attention to events, eye contact, agitation, tremor, grimace
describe the S in ASEPTIC
- rate, amount, style, tone of speech
- loud, quiet, slow, rapid, over-talkative, pressured, mute, slurred, incoherent, stuttering, long pauses, mute
describe the E in ASEPTIC
emotional state (mood) and visible expression (affect: description and variability; congruence of mood, range
describe the P in ASEPTIC
hallucinations, illusions, depersonalizations, derealizations
describe the T in ASEPTIC
- content: suicidal, homicidal, guilt, worthlessness, hopelessness, obsessions, ruminations, phobias, paranoia, hallucinations, delusions
- process: coherence, logical, perseveration, flight of ideas, blocking, tangential, attention (distractible, concentration)
describe the I in ASEPTIC
insight into illness and treatment
judgement
describe the C in ASEPTIC
LOC, orientation, attention, memory, intelligence
mental health
a persons ability to process information
emotional health
a persons ability to express feelings
behavioural health
what a person does
alexithymia
problem with feeling emotion
describe anxiety
- anxiety that interferes with enjoyment of life and ability to perform tasks
(separation anxiety, generalized anxiety, obsessive-compulsive, panic, phobia, and PTSD)
symptoms of anxiety
expressing symptoms of anxiety most days, trouble concentrating, being unusually irritable or easily upset, difficulty sleeping at night or being unusually tired and sleepy in the daytime
anxiety nursing care
- assess of mental, emotional, behaviour symptoms
- Box 55.1
- primary goal: to resume typical activities appropriate to development
- learning to cope
- learning about biological connection to emotions
- cognitive behavioural therapy
- medication
temporary depression
acute depression precipitated by a traumatic event
chronic depression
- may accompany chronic illness or disability
- familial circumstances
- history of frequent disruptions in important relationship
sympt of depression
Box 55.3
nursing care of depression
- careful assessment of child: assess for suicide risk, Box 55.4
- treatment: CBT, meds, environmental supports, appropriate referrals
suicide
deliberate act of self-injury with the intent of death
2nd leading cause of death in adolescents
common warning signs of suicide
- box 55.5
- most children have psychiatric disorder before the suicide
- individual factors
- family factors
- social and environmental factors
high risk for suicide
indigenous and LBGTQ2S+
suicidal ideation
a preoccupation with suicidal thoughts
suicide attempt
intended to cause death or serious injury
parasuicide
behaviours ranging from gestures to serious attempts to kill oneself
suicide nursing considerations
recognizing warning signs
crisis management
prevention
nursing alert for suicide in adolescents
youth expressing suicidal feelings and have a specific plan should be monitored at all times. have no access to anything that can harm them, and possibly restrained until a psychiatrist or psychologist can assess them.
substance abuse + greatest concern
use of substances for peer approval or for intoxication
Box 55.7
greatest concern:
- high doses or mixed drugs w the danger of overdose
- individuals vulnerable to dependence, withdrawal syndromes, an altered lifestyle
- tabacco
- electronic cigarettes
- smokeless tobacco
- cannabis
2 CNS stimulants
cocaine
methamphetamine
disturbances in eating related behaviour nursing care
- complete history + physical
- Box 55.8
- focus on complications of altered nutritional status and purging
- assess for physical side effects of eating disturbances: electrolyte imbalance, UTI
what are the 3 goals for disturbances in eating related behaviour
- reinstitution of normal nutrition or reversal of severe malnutrition
- resolution of disturbed pattern of family interactions
- individual psychotherapy to correct deficits and distortions in psychological functions
