Pediatric Assessment (Health Supervision only) Flashcards
Exam 2
Principles of Health Supervision- What are the three components?
- Developmental surveillance and screening
- Injury and disease prevention
- Health promotion
Principles of Health Supervision involves what?
Involved providing service proactively with the goal of optimizing the child’s level of functioning
Principles of Health Supervision ensures what?
Ensures the child is growing and promotes health through education- anticipatory guidance
When does health supervision begin and continue through?
Health supervision begins at birth and continue through adolescence.
What is the focus of pediatric health supervision?
The focus of pediatric health supervision is wellness.
Settings for health supervision- What kind of place?
Any place that can be publicly accessed by children and their families
Settings for health supervision- Examples?
Private physician offices
Freestanding clinics in retail stores
Community health department clinics
Nonprofit community-based clinics with sliding scale payments
Homeless shelters
Daycare centers
Schools
Medical home is what kind of approach to care?
A medical home is an approach to care that builds a long-term and comprehensive relationship with the family.
Medical home: The continuing relationship between family and care team leads to what?
This continuing relationship promotes trust between the care team and the family leading to comprehensive, continuous, coordinated, and cost-effective care.
Medical home: Provider has what kind of relationship with the patient?
Provider has a long-term, trusting and comprehensive relationship with patient and family from infancy through adolescence
Medical home: What kind of care is provided?
Family-centered care; providers are respectful of family’s customs and beliefs
Medical home: How accessible is care in a medical home?
Care is accessible, affordable, and comprehensive
Medical home: How is specialty care received?
Delivery of specialty care is coordinated in the medical home
Provider is accessible for and responsive to questions
Medical home: Partnerships
The child is the focus.
Child’s health is linked to needs and resources of the family and community.
Partnerships between community agencies, schools, churches, other health facilities, programs can enhance the health of the child.
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Components of health supervision include:
History and physical assessment, including head circumference until 2 years old, height, and weight.
Developmental/behavioral assessment.
Sensory screening (vision and hearing).
Appropriate at-risk screening (lead, anemia, tuberculin, hypertension, cholesterol)
Immunizations
Health promotion/anticipatory guidance (injury prevention, violence prevention, nutrition counseling)
History and physical assessment, including head circumference until 2 years old, height, and weight.
When should this info be collected?
Recommendations are: within first week of life, 1 month, 2 months, 4, 6, 9, 12, 15, 18, 24, 30 months, and then yearly until age 21.
Developmental surveillance
Developmental surveillance: ongoing collection of skilled observations made over time during health care visits. These include:
Developmental surveillance includes:
Noting and addressing the parental concerns
Obtaining a developmental history
Making accurate observations
Consulting with relevant professionals
Developmental screenings:
brief assessment procedures that identify children who warrant more intensive assessment and testing. May be observational or by caregiver report.
APA recommends screening for autism when?
Risk of Drug Abuse when?
Risk of Depression when?
*AAP also recommends screening for autism 18-24 months and risk assessment for drug and alcohol abuse, as well as depression screening 11 -21 years of age.
What kind of child would need an immediate evaluation?
Any child that “loses” a developmental milestone needs an immediate evaluation
Risk factors for developmental problems
List first 6:
- Birthweight <1.5kg
- Gestational age <33 weeks
- Central nervous system abnormality
- Hypoxic ischemic encephalopathy
- Maternal prenatal alcohol or drug abuse
- Hypertonia
Risk factors for developmental problems
Next 6:
Hypotonia
Hyperbilirubinemia requiring exchange transfusion
Kernicterus
Congenital malformations
Symmetric intrauterine growth deficiency
Perinatal or congenital infection
Risk factors for developmental problems
Next 7:
Suspected sensory impairment
Chronic (>3mos) otitis media with effusion
Inborn error of metabolism
HIV
Lead level >5 mg/dL
Inappropriate parental concern about developmental issues (not allowing 3 year old to feed themselves)
Risk factors for developmental problems
Last 4
Parent with less than high school education
Single parent
Sibling with developmental problems
Parents with developmental disability or mental illness
Injury prevention: How is it accomplished?
accomplished through education, anticipatory guidance, and physical changes in the environment. (unintentional vs. intentional)
Disease prevention- why are interventions preformed?
Disease prevention –> interventions performed to protect children from a disease or to identify at an early stage and lessen its consequences. (ex: Screening tests, immunizations)
Screening Tests are what
Screening tests are procedures or lab analyses used to identify children with a certain condition.
These tests are done to ensure that no child is missed.
Screening tests have a high what and a low what?
They have a high sensitivity (high false-positive) and low specificity (low false negative rate).
What are the screening types:
- Risk assessments
- Universal screening
- Selective screening
Risk assessments- includes what and what does it determine
Includes objective and subjective data to determine the likelihood that the child will develop a condition
Universal screening
Screening of an entire population regardless of the child’s individual risk
Selective screening
Done when a risk assessment indicates the child has one or more risk factors for a disorder
Metabolic screening- who is it determined by?
Metabolic determined by state law.
All states screen for how many health conditions? How many more do others screen?
All states screen for 26 health conditions, some screen for over 50.
March of Dimes recommends screening for how many health conditions?
March of Dimes currently recommends 30 for which there are effective treatment options.
Hearing- Who does the AAP recommend this screening for?
Hearing –> AAP recommends screening for all infants.
What is a common condition in newborns?
Hearing loss is a common condition in newborns, and even if mild can cause serious developmental delays.
Mild hearing loss can lead to what in newborns?
mild can cause serious developmental delays.
Universal hearing screening with objective testing is recommended at ages:
Universal hearing screening with objective testing is recommended at ages 4, 5, 6, 8, and 10.
At ages 7, 9, and 11 through 21, appropriate risk assessment should be performed
For preverbal children (newborns and older) how are screening tests conducted?
Auditory skill monitoring by assessing reaction to sounds–does the child react to parent voice or loud noise appropriately?
Developmental surveillance–does the child try to vocalize?
Parental concerns–do the parents have concerns about the child hearing? Any changes in hearing?
For later hearing (older than 4 years) why are screening tests conducted?
Assessment of parental concerns
Difficulty hearing on the telephone
Difficulty hearing people in a noisy background
Frequent asking of others to repeat themselves
Turning the television up too loudly
Vision screening: When is this test done?
Vision –> performed at every visit.
Vision skills less than 3 years old
<3 years old –> ability to fixate and follow objects (neonate 10-12inches; by 2 months, follow 180 degrees)
Vision skills greater than 3 years old
> 3 years old –> screening vision charts: ex: tumbling E, Allen
Vision skills 5-6 years old
5-6 years old –> know alphabet, use Snellen chart
Steps of using snellen chart with a child
- Place chart at eye level
- Sufficient lighting
- Must be 10-20 feet from the chart (depends on which tool using)
- Align heel on the mark
- Have child read each line with one eye covered and then other eye covered.
- Explain to keep the eye covered but open.
- Have the child read each line with both eyes.
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What is the leading cause of nutritional deficiency in the US?
IDA
Iron deficiency anemia can cause what?
Can cause cognitive and motor deficits resulting in developmental delays and behavioral disturbances.
The AAP recommends assessing risk factors of IDA when?
AAP recommends assessing risk factors at 4, 15, 18, and 30 months, then annually.
Checking Hgb/Hct at 12 months.
What kind of kids are more at risk for iron deficiency anemia?
Kids who go through rapid growth
Lead screening: what levels are considered dangerous?
Elevated blood levels >5 microgram/dL is a preventable environmental health threat.
Lead poisoning can lead to a variety of symptoms including:
Headaches
Stomach pain
Inattentiveness
Irritability
Hyperactivity
Decreased bone and muscle growth
Poor muscle coordination
Problems with language and speech
Cognitive impairments
Hearing problems
Seizures
Lead can be where?
Homes or buildings built before 1978
Contaminated soil and dust
Water that flows through old lead pipes or faucets
Food stored in containers painted with lead paint (pottery)
Canned food (international)
Folk remedies
Old toys painted in lead paint
Hypertension screening: When does universal blood pressure screening start?
Universal blood pressure screening starts at 3 years old as recommended by AAP and Bright Futures.
Why would Hypertension screening be done on kids?
Obesity and resulting hypertension is on the rise and can lead to cardiovascular disease.
Risk Factors for hypertension:
Prematurity
Very low birthweight
Renal disease
Organ transplant
Congenital heart disease
Other illnesses associated with HTN
Hyperlipidemia screening- Why is it done?
Atherosclerosis has been identified in children.
Hyperlipidemia screening- When is it done?
Guidelines recommend screening once between 9 and 11 years and again between 18 and 21 years old.
Hyperlipidemia screening- When does screening start?
Risk assessment screening is appropriate starting at 24 months.
Immunity
Ability to destroy and remove a specific antigen from the body
Passive immunity
Produced when the immunoglobulins of one person are transferred to another
Active immunity
Acquired when a person’s own immune system generates the immune response
Types of vaccines (5 types)
Live attenuated vaccines
Killed vaccines
Toxoid vaccines
Conjugate vaccines
Recombinant vaccines
Vaccine Routes:
IM and SubQ
Types of vaccines
Diphtheria, tetanus, and pertussis (DTaP, TdaP)
Haemophilus influenzae type B (Hib)
Polio, measles, mumps, and rubella (IPV, MMR)
Hepatitis A and B (HepA, HepB)
Varicella (Var)
Pneumococcal (PCV, PPSV) and influenza (IIV, LAIV)
Rotavirus
Human papillomavirus (HPV2, HPV4)
Meningococcal
If you are allergic to egg, you should not get what vaccine?
Flu
What is the only permanent contraindication to a vaccine?
The only permanent contraindication to a vaccine is an anaphylactic or systemic allergic reaction to a vaccine component.
Who specifically should not receive vaccines?
Children who are severely immunocompromised or women who are pregnant should not receive live vaccines.
When would postponing vaccines be recommended?
Temporarily postponing vaccinations is recommended due for moderate to severe illness, immunosuppression, pregnancy, or recently received blood products or other antibody-containing products.
When should vaccines NOT be postponed?
Vaccination should not be postponed due to minor respiratory illness or low-grade fever.
Rights of Pediatric Medication Administration:
Right medication
Right patient
Right time
Right route of administration
Right dose
Right Approach
Right documentation, Right to be educated, Right to refuse, Right form
Factors Affecting Absorption of Medications in Children versus Adults
Oral Meds?
Gastric emptying, intestinal motility, size of small intestine, pH, secretions?
Oral medications: slower gastric emptying, increased intestinal motility, a proportionately larger small intestine surface area, higher gastric pH, and decreased lipase and amylase secretion compared with adults
Factors Affecting Absorption of Medications in Children versus Adults
IM absorption
Intramuscular absorption: decreased due to smaller muscle mass, muscle tone; other individual factors are perfusion and vasomotor instability
Factors Affecting Absorption of Medications in Children versus Adults
Subcutaneous absorption:
Subcutaneous absorption: any decreased perfusion = decreased absorption
Factors Affecting Absorption of Medications in Children versus Adults
Topical absorption of medications:
Topical absorption of medications: increased due to greater body surface area and greater permeability of infant’s skin
Factors Affecting Distribution of Medication in Children versus Adults
How is water is children v adults?
Higher percentage of body water than adults (amount of water relative to the amount of body fat)
Factors Affecting Distribution of Medication in Children versus Adults
Extracellular fluid exchange?
More rapid extracellular fluid exchange
Factors Affecting Distribution of Medication in Children versus Adults
Body fat?
Decreased body fat
Factors Affecting Distribution of Medication in Children versus Adults
Liver
Liver immaturity, altering first-pass elimination
Factors Affecting Distribution of Medication in Children versus Adults
Plasma proteins?
Decreased amounts of plasma proteins available for drug binding
Factors Affecting Distribution of Medication in Children versus Adults
BBB
Immature blood–brain barrier, especially neonates, allowing movement of certain medications into the CSF
Determining Pediatric Doses by Body Weight. Steps
Weigh the child
If the child’s weight is in pounds, convert it to kilograms (divide the child’s weight in pounds by 2.2)
Check a drug reference for the safe dose range (e.g., 10 to 20 mg/kg of body weight)
Calculate the low safe dose
Calculate the high safe dose
Determine if the dose ordered is within this range
Different IV accesses:
- Peripheral lock/heparin lock/saline lock
- Central venous access devices
- Peripherally Inserted central catheters (PICCs)
Central venous access devices include:
Short-term/nontunneled catheter
Long-term tunneled catheter
Implanted infusion ports
Providing Atraumatic Care When Administering Medications
What must be done?
Using comforting positions
Encourage child to participate in care
Give child developmentally appropriate options
Using topical anesthetic prior to injections
Guidelines for Administering Medications via Gastrostomy or Jejunostomy Tubes
What are the first 3 rules?
- Verify placement of tube
- Give liquid medications directly via syringe along with small amount of air
- Mix powdered medication with warm water; crush pills as finely as possible and mix with water prior to adding to tube
Guidelines for Administering Medications via Gastrostomy or Jejunostomy Tubes
What are the last 2 rules:
- Open up capsules and mix with water to dissolve contents
- Flush tube with water after administering medications
Nursing Care of the Child With an Enteral Tube:
First two rules:
Placement must be confirmed prior to adding anything
Nonradiologic methods to check include (if not high for aspirations)
Nursing Care of the Child With an Enteral Tube
Last two
Always assessing for signs indicative of feeding tube misplacement
Be aware of developmental needs that may be inhibited by tube feedings
Nursing Care of the Child With an Enteral Tube:
Nonradiologic methods to check include (if not high for aspirations):
Checking color and pH of aspirate
Checking external markings on the tbue and verifying external tube length
Nursing Care of the Child With an Enteral Tube
Always assessing for signs indicative of feeding tube misplacement
means looking out for:
Unexplained gagging, vomiting, or coughing
Signs and symptoms of respiratory distress
How can safety be achieved in a hospital setting:
can be achieved through environmental measures, limit setting, infection control, and safe transportation
Name bands/ Patient identity
Fall precautions –>place call light and desired items within reach and have child wear appropriate size gown and nonskid footwear
Activity supervision
How does the Joint Commission define retraint?
The Joint Commission defines restraint as “any method, physical or mechanical, which restricts a persons movement, physical activity, or normal access to his or her body.”
Two broad groups of restraints:
- Behavioral restraints
- Physical restraints
Type of Behavioral Restraint
Therapeutic hugging can avoid the use of restraints
Physical restraints include:
Jacket restraints
Mummy or swaddle restraint
Limb restraints
COLLECTION OF SPECIMENS:
How to obtain small amounts of urine from a diaper?
To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper.
COLLECTION OF SPECIMENS:
How to obtain small amounts of urine from a diaper with superabsorbent gel?
Diapers with superabsorbent gels absorb the urine;
if these are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine, and aspirate the urine with a syringe.
COLLECTION OF SPECIMENS
What else other than diaper/syringe can be used to collect urine?
Urine bag
COLLECTION OF SPECIMENS
How to stop bleeding?
Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation.
Pressure should be applied before a bandage or gauze pad is applied.
Oxygen Administration: How can oxygen be administered?
Oxygen can be administered by hood, mask, nasal cannula, incubator, or oxygen tent
Oxygen Administration: How should oxygen be administered to infants?
Oxygen delivered to infants is well tolerated by using a plastic hood
Oxygen Administration: how should humidified oxygen NOT be used?
The humidified oxygen should not be blown directly into the infants face
Oxygen Administration: Older infants and children should use what form of oxygen?
Older, cooperative infants and children can use a nasal cannula or prongs, which can supply a concentration of oxygen of about 40%
Oxygen administration: What to use if a mask is not tolerated well?
A mask is not well tolerated by children. For children beyond early infancy, the oxygen tent is a satisfactory means for administration of oxygen.
What kind of experience is pain?
Pain is individualized, subjective experience, affects person of any age.
Unpleasant sensory and emotional experience that is associated with actual or potential tissue damage or described in terms of such damage.
Pain is whatever the person says it is, existing whenever the person says it does.
Who is the only one who can identify pain?
Person experiencing pain is the only one who can identify pain and know what the pain is like.
Physiology of painSequence of events in the nervous system:
transduction –> transmission –> perception –> modulation
Transduction
Process of nociceptor activation
Transduction –> Process of nociceptor activation
How does it occur?
Spinal cord –> Peripheral nerve fibers (skin, joints, bones, organs) –> Nociceptors
Where are nociceptors located?
Nociceptors are at the end of the nerve fibers
When do nociceptors become activated?
Nociceptors are at the end of the nerve fibers and become activated when exposed to noxious stimuli.
What kind of stimuli activate nociceptors?
Mechanical:
Chemical:
Thermal:
Mechanical stimuli
Mechanical: intense pressure to an area, strong muscular contraction, pressure muscular overstretching
Chemical stimuli:
involve release of mediators, histamine, prostaglandins, leukotrienes, bradykinin as response to tissue trauma, ischemia, inflammation
Thermal stimuli:
extremes of hot and cold
Physiology of pain: How does transmission occur?
Nociceptors –> activated –> stimuli converted to electrical impulses –> peripheral nerves –> spinal cord and brain
What kind of nerves move impulses alone in transmission:
Specialized afferent nerves move impulses along:
What specifically are the afferent nerves that move impulses along in transmission:
Myelinated A-delta fibers
Unmyelinated C fibers
What kind of nerves are myelinated A-delta fibers?
What kind of stimuli do they handle??
LARGE AND RAPID
Fast pain
mechanical or thermal stimuli
What kind of nerves are Unmyelinated C fibers ?
What kind of stimuli do they handle??
small and slow
Slow pain
chemical or continued mechanical/thermal
Physiology of pain:
How does Perception occur?
Nerve fibers –> Dorsal horn of the spinal cord –> divide –> cross to opposite side and rise –> thalamus
Physiology of pain: What is the role of the Thalamus in perception?
- Messages somatosensory cortex of brain
- Messages Limbic system
- Messages brain stem centers
Physiology of pain:
Perception: When the thalamus messages somatosensory cortex of brain what then happens?
Impulse interpreted as physical pain
Physiology of pain:
Perception: When the thalamus messages the limbic system what then happens?
Interpreted emotionally
Physiology of pain:
Perception: When the thalamus messages the the brain stem what then happens?
Autonomic nervous system responses
Pain threshold
Pain Threshold: the point where the person feels the LOWEST intensity of the stimulus
Myelinated A delta fibers: What does the pain feel like?
sharp, stabbing local pain
Unmyelinated C delta fibers: What does the pain feel like?
diffuse, dull, burning, aching pain
Physiology of pain: Modulation
Neuromodulators modulate the pain sensation.
What are naturally occurring examples of neuromodulators that modulate the pain sensation in modulation?
Naturally occurring examples include serotonin, endorphins, enkephalins, and dynorphins.
What can interrupt for modulate the perception of pain?
Pharmacologic treatments can interrupt or modulate the perception of pain.
Where can pain sensation be modified?
Pain sensation can be modified peripherally (at the site) or centrally (in the brain).
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How is pain classified?
- Duration
- Etiology
- Location
What are 2 categories for duration of pain?
- Acute
- Chronic
What does acute pain usually indicate?
What does it stimulate?
Usually indicates tissue damage and resolves with healing of the injury
Stimulates nociceptors and is protective
How long does chronic pain occur?
What is the purpose of chronic pain?
Continues past the expected point of healing
Provides no protective function.
How does chronic pain occur?
What does it impair?
Continuous or intermittent, with and without periods of exacerbation or remission.
Impairs a person’s ability to function
What are the two etiologies of pain?
- Nociceptive
- Neuropathic
What occurs in nociceptive pain?
Noxious stimuli damages normal tissues (or can do so) if pain is prolonged.
How is the nervous system in nociceptive pain?
Nervous system functioning is intact
What are examples of nociceptive pain?
Examples: chemical burns, sunburn, cuts, appendicitis, and bladder distention
What is neuropathic pain due to?
Due to malfunctioning of the peripheral or central nervous system
What are examples of neuropathic pain?
Examples: posttraumatic and postsurgical peripheral nerve injuries, pain after spinal cord injury, metabolic neuropathies, phantom limb pain after amputation, and post-stroke pain.
What are the locations of pain?
- Somatic
- Visceral
What is somatic pain?
Develops in the tissues
What are the types of somatic pain?
- Superficial
- Deep
What is superficial pain?
Cutaneous, stimulation of nociceptors in skin, subcutaneous tissue, or mucous membranes.
Well localized
What is deep pain?
Involves the muscles, tendons, joints, fasciae, and bones
What is visceral pain?
Develops in organs: heart, lungs, GI tract, pancreas, liver, gallbladder, kidneys, or bladder.
Often fromdisease
Factors Influencing Pain
Age
Gender
Cognitive level
Temperament
Previous pain experiences
Family and cultural background
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SOOOO many words!!!
Myths and Misconceptions About Children and Pain:
Newborns don’t feel pain
Exposure to pain at an early age has little or no effect later
Infants and small children have little memory of pain
Intensity of the child’s reaction to pain indicates intensity of pain
A child who is sleeping or playing is not in pain
Children are truthful when asked if they are in pain
Children learn to adapt to pain and painful procedures
Children are more prone to addiction to narcotic analgesics
HEALTH HISTORY AND PAIN ASSESSMENT
Location, quality, severity, and onset of the pain, as well as the circumstances in which the child experiences the pain.
Conditions, if any, that preceded the onset of pain and conditions that followed the onset of pain.
Any measures that increase or decrease the pain.
Any associated symptoms, such as weight loss, fever, vomiting, or diarrhea, that may indicate a current illness.
Any recent trauma, including any interventions that were used in an attempt to relieve the pain.
Key Principles of Pain Assessment What does (QUESTT) stand for?
Question
Use
Evaluate
Secure
Take
Take
Q in (QUESTT)
Question the child.
U in (QUESTT)
Use a reliable and valid pain scale.
E in (QUESTT)
Evaluate the child’s behavior and physiologic changes to establish a baseline and determine the effectiveness of the intervention
S in (QUESTT)
Secure
Secure the parent’s involvement
T in (QUESTT)
Take
Take the cause of pain into account when intervening.
Pediatric Pain Assessment Tools
What tools are used for ages 3+?
FACES pain rating scale (ages 3+, emoticon-like faces)
Oucher pain rating scale (ages 3+, actual photos of children, must know number values)
Visual analog and numeric scales (ages 3+, scales of 0–10)
second T in (QUESTT)
Take
Take action.
Pediatric Pain Assessment Tools: For ages 4-7
Poker chip tool (ages 4-7, uses 1 to 4 poker chips to describe pain)
Pediatric Pain Assessment Tools: For ages 8-15
Word-graphic rating scale (ages 8 to 15, child selects pain rating)
Adolescent pediatric pain tool (ages 8 to 15, measures pain location, intensity and quality)
Physiologic and behavioral manifestations of pain:
What should be looking at in child?
Observe the child, keeping in mind the developmental level.
Watch movements and monitor vital signs.
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