Mod 5 learning outcomes Flashcards
- Explain techniques for performing a head-to-toe pediatric physical assessment (toddlers and preschoolers) based on developmental stages and physiologic characteristics.
Allow the child to select which digit to put the pulse oximeter on.
· May demonstrate use on the caregiver’s finger to show that it is a painless procedure.
· Allow child to select which arm to use for BP check when appropriate.
· Talk to the child and tell of the tight “hug” feeling to expect on the arm with BP check.
· Allow child to stay with caregiver so that respiratory rate and BP will not be falsely increased because of anxiety.
· Assess toddlers in their comfort zone, usually in a parent’s lap.
· Remember to protect a preschooler’s modesty.
· Approach children and get down to their eye level.
· Give praise whenever it is appropriate.
Slides-Start your assessment as soon as the family enters – use your observation skills to look at how the child presents; does it seem clean and well cared for; how does the family interact; is there a need for an interpreter; who is with the child (siblings, other family); look and listen
First, introduce yourself and clarify the identity of the person who has brought the child in for care.
It is important to build a relationship with the child’s parents and listen to their concerns.
Allow child to sit on parent’s lap
Give the child choices
Allow to inspect equipment
Praise
Systematic approach:
Health history-childhood illnesses, hospitalizations, surgeries, immunizations, and results of vision/hearing/developmental screens
chief complaint-current signs/symptoms or events leading to visit.
Review of systems
General survey
Vital signs and anthropometric measurements
Medications-daily prescription, over the counter, and natural therapies
Allergies: medications, foods, and environmental
Review of systems: Are they eating, sleeping, and eliminating well?
· Social history: living arrangements, day care/preschool, and behaviorExplain adaptations that may be required when you examine toddlers and preschoolers.
Physical exam
Ask the family about the past medical history; the family health history-genetic disorders, chronic diseases, childhood cancers; immunizations; patterns of daily activities (sleep, nutrition, play)
Least to most invasive/intrusive-leave painful areas for last
Screening tools at appointments-its recommended developmental screening done at 9, 18, and 30 months-Ages and Stages Questionnaire (ASQ), 4 to 60 months
Denver Developmental Screening Test II (DDST-II), 1 month to 6 years
Early Screening Inventory-Revised (ESI-R), 3 to 6 years
Survey of Well-Being of Young Children (SWYC), 2 to 60 months
Anthropometric
Anthropometric -of or relating to the scientific study of the measurements and proportions of the human body
Review of systems : full vs. focused
Measure head circumference till age 3(book says2)
Length/height
Weight
Body mass index after age 2
Use correct chart for age and gender
Plot intersection of horizonal axis and vertical access
Point will be near a percentage line
Height: standing when able to stand. Recumbent for young toddler, because lordosis is common in this age group.
· Weight: minimal clothing, diaper, or underwear only preferred for accuracy. Include body mass index for children older than 2 years.
· Head circumference: measured for all children younger than 2 years. May be assessed after 2 years of age if difficulty with bone growth or issues identified that impact the growth of the head.
What ages should you measure head circumference?
Up to 36 months (age 3)
Physical exam
Start with measurements
Toddler: heart, lungs while quiet; then head to toe; HEENT last
Preschool: head to toe if cooperative; same as toddler if uncooperative
Stay eye level with child
Gather information first by observation
Examine least invasive areas first
Use distraction techniques
Parents can be best allies when examining infants and young children
Vital signs: heart rate, respiratory rate, temperature, pulse oximetry, and blood pressure (BP) within normal range (Table 8–1). Use an appropriate-size cuff to measure the BP
Appearance: appropriate cleanliness, dress, and behavior
Check skin for abnormal bruising, rash, or lesions.
· General: hearing, vision, and speech for difficulty or delay; appropriate interaction with caregiver
Appearance: appropriate cleanliness, dress, and behavior
· General: hearing, vision, and speech for difficulty or delay; appropriate interaction with caregiver
· Nutrition status: hair is evenly dispersed, child is visually not overweight or underweight, and skin is not overly dry
· Head: ears, eyes, nose, mouth, teeth, throat, and neck for symmetry, drainage, enlarged lymph nodes, and pain and/or abnormalities
· Torso: chest, back, and abdomen for variations of the skin, enlarged lymph nodes, masses, nodules, rashes, and pain and/or abnormalities
· Extremities: range of motion, strength, symmetry of length, variations of the skin, pain, and/or abnormalities of the hands, feet, or joints
Auscultate lungs for clarity, abnormal lung sounds, neck for stridor or snoring , Heart for regularity murmur apically fullminute.
Bowel sounds for abnormalities.
Palpation- Abdomen for masses, organomegaly, and tenderness
Pulses for quality; should be equal bilaterally and equal in upper and lower extremities
Scalp for fontanels, which typically close by age 2 years
Heart rate:
Evaluate when child is at rest
Children under 2: apical pulse is most accurate
(children over 2: brachial or radial pulse)
Children have a more noticeable respiratory sinus arrhythmia; count heart rate for a full minute-Then gather vital signs
Where do you take a pulse in a young child?
Apical under age 2
Brachial or radial over age 2
Respiratory rate
Evaluate when child is at rest
Children under age 6: observe abdominal movements
Children over 6: observe rise and fall of chest
Look at the chest for labored respirations, accessory muscle use, and irregularity of breathing.
Note the position of comfort the child places themselves when having difficulty breathing.
Blood pressure
Routine screening begins at age 3, but may still need to assess
Be sure of correct cuff size: bladder width 40% of upper arm
Measure with child sitting/lying still for 3 minutes
Blood pressure formula–2x kids age + 90(systolic); diastolic about 2/3 of systolic BP
Example- 2x4=8+90=98 (systolic), 2/3 of 98 is 65 so 4 year olds BP 98/65
In book formula gives upper and lower end of normal systolic–Formula for calculating a child’s BP: 70 + 2 × age in years = lower end of systolic BP; 90 + 2 × age in years = upper end of systolic BP
Norms-from slides
1-3yrs HR 70-110
BP90-105/55-70
Resp-20-30
3-6yrs HR65-110
BP95-110/60-75
Resp-20-25
6-12yrs HR 60-95
BP100-120/60/75
Resp-14-22
Assessing temperature
Always chart route used
May use axillary, tympanic, temporal artery, forehead based on setting, equipment available, severity of illness
Oral temperatures can be used over age 5
Rectal temperatures are also used; caution with bleeding disorders or immunosuppressed
- Explain body mass index, when it is a good indicator of obesity, and when and how to use the BMI chart.
BMI should be used after 2 years old.
Relationship between height and weight; screening tool to assess total body fat and nutritional status
Metric: BMI = (weight in kg) / (height in meters)2
English: BMI = (weight in lbs x 703) / (height in inches)2
Adults: Normal BMI is 18.5-24.9
>25=overweight
>30=obese
Children: Normal BMI is 5th – 85th percentile for age
>85=overweight
>95=obese
Useful in identifying underweight and overweight/obese patients
Not useful under age 2, athletes, pregnant women, and postpartum women
BMI is a screening tool; additional testing is needed especially in special populations such as children, athletes due to percentage of body fat vs. muscle mass. Would do skinfold testing or other method to actually measure percent of body fat.
- Discuss the principles of growth and development concentrating on toddlers and preschoolers.
toddlers:
Generally fearful of strangers –first establish rapport
Average weight gain of 5lbs. per year-by 2 typically 27lbs, 34 in tall,
Head circumference is equal to chest circumference-12-18 months anterior fontanel closes
Ability to control anal and urethral sphincters between 18-24 months
by 10-15 months-Walk with a wide stance
by 2 can many can walk up and down stairs one step at a time, by 30 months can jump with both feet, before 3 can stand on one foot and climb steps alternating feet
Visual acuity improves to 20/40
May have transient periods of strabismus (crossed eyes)
Hearing- full developed by toddlerhood
Some toddlers are in diapers until age 3
Fine motor-by 15 months can not only grab small objects but also release them by 18 months can throw ball overhand
Resp and HR slow compared to infants-
BP increases
stomach increases in size
Preschool:
By 4 average weight 36lbs 40 in tall
by 5 gains additionmal 5 lbs grown 3 more inches in height
head and trunk proportions somewhat closer pot belly and exaggerated lumbar curve gradually disappear
HR 90-100, resp-22-25,
Vision- mature depth and color, 20/20 vision
Hearing mature
can hop jump and skip on one leg, artwork improved fine motor skills, dresses self
potty self
- Identify common health problems seen in developmental stages concentrating on toddlers and preschoolers.
Drowning is the leading cause of accidental death in this age group-unsupervised access to swimming pools or other water sources (bathtubs)
Also- falls, accidents, burns, choking
Increased mobility = increased access: poisonous chemicals; guns; knives
Regarding infection: Antibiotics not required for all illnesses –creating resistant strains; parent education (MRSA, VRE)
Unintentional injury
Infection: No longer have passive immunity acquired in utero
Exposed to more germs / out in public
Common infections toddlers: colds, ear infections, tonsillitis
Immunizations to be covered in health promotion
Preschoolers: similar to those of toddler,
Communicable diseases become an issue as preschoolers come into contact with other children. Some - i.e. respiratory infections; GI viruses; parasites (like lice)
Poisoning is a significant risk for preschooler-through imitation –ingesting substances like they see adults doing –prescription meds, alcohol
Enuresis-most cases resolve spontaneously with only occasional episode passed age 6-daytime wetting or soiling (encopresis) requires evaluation
.Child abuse –increased occurrence as children come in contact with others outside the home
What is the leading cause of accidental death in toddlers?
What are two important assessments to make when caring for preschoolers?
- Describe any special assessments unique to toddlers and preschoolers.
preschoolers
Nutrition –types/amounts Sleep habits Vision screening(between 3 and 5 years) Teach – Frequent/proper hand washing Dental hygiene-first visit by age 3 Balanced diet Adequate rest safety risks-Assess for parent and child knowledge of hazards and precautions. Because the preschool child is mobile and involved in active play (e.g., riding a tricycle, crossing streets) accidents increase.
School readiness-physical exam required before child enters school-includes an assessment for readiness-whether the child has acquired skills, such as an ability to converse with adults; follow instructions; hold a pencil; and perform a variety of motor skills, such as jump, hop, and walk a straight line
Immunization record
always assess for risk factors for abuse and for subtle signs of actual abuse
Assessment toddlers:
establish rapport-may include play -play catch or introduce you to their toy they brought-this is a non threatening way to assess language skills and motor development-parents hold child to reduce stress-Beginning at age 3, blood pressure should be checked at least once yearly and results recorded with age/gender/height percentile and reviewed with parents
- Describe the expected differences in assessment findings for toddlers and preschoolers compared to the older child or adult assessment.
· Proportionately larger heads as compared with bodies
· Greater ratio of body surface area to total weight
· Larger tongues and greater proportion of soft tissue in and around the airway
· Shorter, more narrow airway that is more elastic and collapsible
· More pliable chest
· Weaker abdominal muscles, creating the look of distention
· Belly breathers
· Higher metabolic rates
· Higher fluid requirements
· Higher total blood volumes
- Explain the steps to a comprehensive pain assessment for toddlers and preschoolers.
· should ask for caregiver opinion without them influencing the child’s response
· ask preschool-age children questions about the quality of their pain, and avoid making assumptions on the level of pain the child “should” be experiencing
· Assess for causes of pain such as infection, injury, surgical/procedural, or disease, as well as for elevated heart rate, BP, and respiratory rate.
· Choose the appropriate pain scale. There are 16 published postoperative pain scales for use with infants, toddlers, and preschool-age children
· When in doubt, assume pain is present and treat accordingly. Evaluate and document for efficacy of all pain-control interventions, including medication, repositioning, and/or consolation measures.
Origins of pain
Cutaneous or Superficial-In the skin or subcutaneous tissue
Visceral-Stimulation of deep internal pain receptors in abdomen, cranium or thorax
Deep Somatic-Ligaments, nerves, blood vessels and bones
Radiating-Begins in origin but extends to other locations
Referred-occurs in area that is distant from the original site
Phantom-Perceived to originate from an area that has been surgically removed
Psychogenic-Pain arising from the mind
Causes of pain
Nocioceptive-Most common type. Nocioreceptors or pain receptors respond to stimuli(noxious, thermal, chemical or mechanical stimuli) that can be damaging
Neuropathic-Complex and often chronic pain. Injury to one or more nerves results in repeated transmission of pain signals even in absence of painful stimuli.
Gate Control Theory of Pain Modulation
Meditation
Relaxation
Laughter
Music
Depression, Mood and Emotions
Fear, previous experience
p. 1152 Treas/Wilkinson
Gate control theory suggests that the perception of pain does not occur only by direct stimulation of nocioceptors (pain-producing fibers); instead pain is perceived by the interplay between two different kinds of fibers –those that produce pain and those that inhibit pain
Gates either allow or block transmission of pain to the brain as the impulses travel along C (small, slow fibers) fibers
A delta fiber stimulation results in a quick response to block sudden pain at the “gate” (hitting arm and rubbing it example)
Thoughts/mood/emotion can open/close gates
Non-pharmacological –compete with C fibers and block the gate
Assessing pain
Pain assessment is ALWAYS performed no matter the age of the patient
Pain is considered the 5th vital sign but is subjective
Pain assessment tools are an objective way to measure a subjective experience
Many different pain assessment tools are available
Assessment findings are used to direct pain management options and choices
History from parent, older child Onset: When did the pain start? Location: Where is the pain? Duration: How long does the pain last? Character: Can you rate your pain 1-10? Aggravating/Alleviating: What makes the pain better or worse? Timing: When does the pain start/stop?
Characteristics/quality: sharp, dull, aching, throbbing, stabbing, burning, tingling, etc.
Acute vs. chronic
Factors influencing pain
Developmental stage Previous pain experience Fear Confusion Helplessness Anger and depression
Signs of pain
Behavioral Signs Crying Tense Grimacing Agitation Guarding Physiologic Signs Increased respiratory rate Increased heart rate Pallor Sweating Nausea Vomiting
- Describe pain assessment tools and their appropriate use for toddlers and preschoolers considering developmental level.
Pain toddlers:
Response to pain is influenced by repeated exposure to painful events and by parental anxiety
Can’t describe pain
May use words like “boo-boo” or “owie”
Use FLACC pain scale; older may be able to use Wong Baker scale
Wong Baker scale –FACES pain rating scale
Flacc scale
Wong-baker faces rating scale
Face Legs Activity Crying Consolability
0, 1, 2,
higher number more pain
faces-0-10
6 faces
Other scales:
CHEOPS-childrens hospital of eastern ontario pain scale-intended age 1-5yrs, can be used 0-4, up to 7
behavioral scale, gives number for cry intensity, facial expression, child verbalization of pain, torso position, touch leg movement.
CHIPPS-children and infants postoperative pain scale-3-7 yrs
behavioral scale-number for cry intensity, facial expression, trunk position, leg movement, restlessness,
Wong baker FACES -3-7 yrs
FLACC-ages 2months to 7 yrsrecommended for 1-5 yrs or any preverbal child.
DEGR Douleur Enfant Gustave Roussy- children with cancer 2-6 yrs
Behavioral scale number 0for none 4 for extreme on 16 scale items
TPPPS- Toddler-preschooler postoperative pain scale- 1-5 yrs,
behavioral scale, number value for verbal response, facial expression, body language.
Pain Scales Are Not Reliable for All Cultures
Some pain scales may not be reliable for children of different cultures because of cultural influence on pain response. Nash (2012) discusses the Oucher scale, which provides seven versions for five different ethnicities and both sexes.
The nurse must choose a pain scale that is most appropriate for each individual child.
Pain: Preschoolers
View pain as a form of punishment
Can point to their area of pain but not describe it
Often don’t report their pain; they think the adults around them already know about it
Use Wong Baker pain scale
Pain management
Use multi-modal approach for all ages
Parent/family/friend involvement, distraction, environment, local/topical treatments, medications
Pain management strategies vary for each developmental level
Mild moderate severe
Pain management strategies for infant/toddler: controlled lighting and noise; pacifier; swaddling; rocking; eye contact; music
Pain management strategies vary for each level of pain
Reassess frequently
- Explain how toddlers and preschoolers experience pain based on their age and developmental level.
Young toddlers do not have the cognitive ability to convey the pain they are feeling, but this capability begins at about age 2 years.
Observe specific behaviors children display in reaction to pain, such as facial expression, movement, and vocalization (Fig. 8–3), including:
Furrowed brow and open-mouth-type grimace, or lack of expression
Restlessness or sleeping and withdrawal (ways to cope with pain)
Wariness/fear of movement
Irritability/agitation
No vocalization to harsh/high-pitched cry
The nurse should ask for caregiver opinion without them influencing the child’s response, ask preschool-age children questions about the quality of their pain, and avoid making assumptions on the level of pain the child “should” be experiencing
toddlers:
Response to pain is influenced by repeated exposure to painful events and by parental anxiety
Can’t describe pain
May use words like “boo-boo” or “owie”.
preschoolers:
View pain as a form of punishment
Can point to their area of pain but not describe it
Often don’t report their pain; they think the adults around them already know about it
Assess for causes of pain such as infection, injury, surgical/procedural, or disease, as well as for elevated heart rate, BP, and respiratory rate. (Reminder: These alone are considered poor indicators of pain.)
- Identify and explain various theories of growth and development concentrating on toddlers and preschoolers.
Growth and development can be discussed in terms of theoretical approaches or developmental domains.
Theoretical approach explains, describes, and predicts the various aspects of growth and development.
Developmental domain refers to a way of understanding the total child in relation to the mind, body, and spirit.
Refers to the psychological and emotional progression of the child and the relationships with others who are involved in the child’s life-examples freud and erikson-
individual theories on the following cards-
Erikson
Erikson—autonomy versus shame and doubt. In Erikson’s theory of psychosocial development, toddlers in this stage seek to attain autonomy by gaining more self-control in areas such as toileting and food and toy preferences. Success leads to self-confidence, and self-control, whereas feelings of shame and doubt in these areas may lead to a sense of inadequacy.
Slides-Erikson focused on the influence of social interaction.
Erikson identified seven stages of development.
Mastery of each stage requires that the individual achieve a balance between two tasks (conflicting variables).
Each stage represents a crisis that must be resolved to move on to the next stage in a healthy manner.
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: 12-21 years Intimacy vs. Isolation: 21-40 years Generativity vs. Stagnation: 40-65 years Ego Integrity vs. Despair: over 65 years
Toddlerhood also corresponds with Erikson’s stage of autonomy versus shame and doubt(1-3yrs).
Task is to balance independence against the risks of uncertainty
Child determines willpower and determination
Rules can result in internal conflict
). It is a time when the child makes every effort to “do it myself.” Mastery is an extremely important task of this stage of development. Because the toddler’s abilities begin to surpass cognitive judgment, it is also a time of potential hazard for the developing child. Care- givers must walk the fine line between allowing exploratory independence and “mastery” on one hand and vigilance on the other. It is often a time of bumps and “booboos.” It is frustrating to the toddler when confronted with blocks to budding mastery. The word “no” begins to signify the toddler’s simple response to frustrated emotions encountered.
This stage left unmet can lead to self-doubt later in life
preschool-
INITIATIVE VERSUS GUILT: 3-6 years
Child learns to be confident in trying new things
Parents should encourage this for the child to gain a sense of purpose
If unmet, may result in guilt and lack of resourcefulness During this stage, children will assert themselves more often; resistance met with control or criticism may result in guilt. Feelings of guilt will cause the child to become fearful, stay on the outside of groups, and become restricted by remaining dependent on adults and in developing play and imagination.
Freud
Freud—anal stage (age 1 to 3 years). In Freud’s psychosexual theory, toddlers are in the anal stage, which focuses on pleasure derived from the toddler’s enjoyment of holding and releasing bowel movements.
Toddlers typically exemplify characteristics of Freud’s anal stage
The child begins to develop a sense of self as separate from her mother. The toddler’s task is to move away from the primary caregiver while in some way maintaining enough connection to feel secure. This process, called rapprochement, is healthy and expected.
Preschoolers are described by Freud as being in the phallic, or oedipal period; whereby the child is becoming more aware of differences in genders; they may want to “marry” mom or dad.
Slides-Development was influenced by biological instincts.
Development of three essential aspects of the human personality:
the id, the ego, and the superego
initial aspect, the id, is the emotional part of the personality. The id is present at birth
Observed that these instincts were psychosexual in nature
progression through developmental stages based on resolution of conflicts surrounding urges and rules
ORAL STAGE (BIRTH-1 YEAR): infant is fixated on oral curiosity; infant derives pleasure from, and relieves anxiety through, oral sensations
ANAL STAGE (1-3 years): with control of elimination comes a desire to control other aspects in life and test boundaries
PHALLIC STAGE (3-6 years): discovery of sexual difference and notices differences in genders
LATENCY STAGE (6-12 years): child takes a “psychosexual break”, as Freud puts it, and spends time with friends of the same gender
GENITAL STAGE (12-18 years): puberty; exploring sexuality and relationships
Kohlberg
Kohlberg—preconventional. In Kohlberg’s theory of moral development, 2- to 7-year-olds are in the stage of preconventional moral reasoning, and tend to follow set rules for fear of punishment.
Level I. Preconventional
Stage 1—punishment–obedience orientation (right action is that which avoids punishment)
Stage 2—personal interest orientation (right action is that which satisfies personal needs)
Level II. Conventional
Stage 3—“good boy–nice girl” orientation (right actions are those that please others)
Stage 4—law-and-order orientation (right action is following the rules)
Level III. Postconventional, Autonomous, or Principled
Stage 5—legalistic, social contract orientation (right action is decided in terms of individual rights and standards agreed upon by the whole society)
Stage 6—universal ethical principles orientation (right action is determined by conscience and abstract principles such as the Golden Rule)
Slides-
Thinking processes involved when making moral decisions.
Identified three levels of moral development: pre- conventional, conventional, and postconventional.
Within Level I, the Preconventional Level
Stage 1: Obedience and Punishment
Stage 2: Individualism and Exchange
See Table 20-3 on p. 765
At this stage, the toddler identifies good and bad and right and wrong by virtue of whether or not it is rewarded or punished. This corresponds to Kohlberg’s preconventional level of moral development.
Early childhood typically corresponds with Kohlberg’s preconventional morality stage when the major impetus for moral judgment is to avoid punishment. It is common for the child in this age group to tell lies to avoid consequences. A child at this age may judge an action to be wrong only if caught. The young child is only guilty if the parent has seen the actions.
Piaget
Piaget—preoperational. In Piaget’s cognitive developmental theory, 2- to 7-year-olds are in the preoperational stage, which is characterized by magical thinking, the belief that their personal thoughts have a direct impact on the real world, and egocentrism, the inability to see things from another’s perspective.
slides-Thinking and learning for children take place through four distinct stages.
The initial period, the sensorimotor stage, takes place from birth to age 2.
During this time, the primary means of cognition is through the senses.
The infant must achieve three major tasks during this phase:
Separation
Object Permanence
Mental Representation
Cognitive:Thinking and learning for children take place through four distinct stages.
Preoperational (ages 2-7)
Development of motor skills
Toddler experiments and learns new behaviors; imitation; repetition
Likes order, not a disruption in routine
Early toddlerhood corresponds with Piaget’s fifth substage of cognitive development, tertiary circular reactions, during which time the toddler experiments and learns new behaviors. The toddler then transitions into Piaget’s sixth substage, mental combinations, when she begins to understand cause and effect and is able to imitate others and problem solve. The toddler loves to imitate the people around her. Much of the toddler’s behavior is replication of what she sees and hears. The toddler also learns through repetition. This is why a toddler may want the same book to be read over and over, staying engrossed in the story every time. A toddler also likes order and often responds with difficulty to any disruption in routine. The level of response is related to the temperament of the child. Some toddlers may revolt with temper tantrums, and others will calmly transition into an experience. Regardless of temperament, most children at this stage respond favorably to predictable routines.
With preschoolers: This period of development corresponds with Piaget’s preoperational stage (2–7years); and pre-conceptual (2-4 years). During this time, the preschooler increases the ability to verbalize. The preschooler can symbolically use language to represent concepts that need to be conveyed. The young child is still egocentric (focused only on her own sense of things) and therefore is limited socially. This is in large part because of concrete thinking processes and the inability to abstractly shift focus from self to others.
