Pediatrics Overview
Pediatric Nursing Overview:
Today pediatric nursing focuses on preventing acute and chronic illnesses while promoting normal growth and development…

Societal trends:
•Immigration
•Poverty
•Homelessness
•Migrant farm workers
•Violence

Resulting in:
•Lower IQ’s
•Lower income
•Malnourishment
•Growth and development can be delayed
•Emotional and behavioral problems

Current Initiatives:
•Infant mortality
•Child mortality
•Access to health care - PCMH

Pediatric care involves:
•Family-centered care
•Atraumatic care

Pediatric nurse is:
•Advocate (first and foremost)
•Caregiver
•Educator
•Researcher
•Manager
•Leader

Challenges:
•Children in in-patient facilities more acute illnesses
•Short length of stay in facility
•Increased incidence of chronic illness
•Constraints on delivery of care
•Advances in technology

Legal Considerations for Pediatric Care
Check individual state laws
Informed consent for minors, exceptions:
Emancipated minors
Pregnancy, STDs, substance abuse
State may take custody if guardian refuses care for child
Divorce
Organ donation
Genetic testing
Research

Consents:
Informed Consent:
Must be obtained from a parent or legal guardian
Must be over 18 or emancipated
Must receive information with which to make a informed consent
Must be voluntary, no coercion

Assent should be obtained
Not a legal requirement, an ethical one

Written consents you will see...
HIPAA
General hospital consents
Consent to treatment
Lewis Blackmon

Lewis Blackman consent:



Confidentiality
*When can a health care provider breach confidentiality?
1. Mandatory child abuse reporting
2. Mandatory injury from gun, knife, criminal act; public health concerns - STDs, TB, HIV, hepatitis, poisonings
3. Duty to warn 3rd parties (psychiatrist); failure to warn
4. Ability to detect risks through genetic testing

HIPAA
2003 - Health Insurance Portability and Accountability Act
Prevent unauthorized access or disclosure

Nursing Ethical and Legal Terms
Negligence – Owes duty to another, failure to fulfill duty causes harm
Malpractice – Professional negligence, must be damages and harm
Duty – Care for patient during required time
Breach of Duty – Nurse fails to meet the standard of care
Causation – Injury result of the breach in standard of care
Damages - Unless there is damage when the mistake is made, there is no malpractice
Nurse Practice Act – Scope of nursing practice, defines illegal and unprofessional conduct, state specific – state board of licensing
Autonomy - freedom to make own decisions based on informed consent
Beneficence - 'to do good'
Nonmaleficence - 'first, do no harm'
Justice - fair and equitable care
Veracity - clear open communication
Fidelity - keeping one's word

Ethical Decision Making Process
Obtain all information
Define ethical dilemma
Determine stakesholders and values
Generate alternatives, weight options
Make decision, carry it out
Assess the outcomes
Examples: newborns on edge of viability, DNR orders, withdrawing treatment, prenatal genetic testing, newborn screening, immunizations, palliative care, organ donations, research.
*Ethics Councils
*Parents may ask...What would you do if this were your child? Reassure parents it is their decision based on the knowledge of their child and what they believe to be in the best interest of their child and family.


Ethical Considerations for Pediatric Care
Ethics - guide conduct
Bioethics - ethics in healthcare providers
Morals - based on personal values, spiritual or religious beliefs
Professional Code of Ethics
Assent
Confidentiality
HIPAA
Withholding or terminating life support
Genetic testing
Organ donation/transplantation
NB screening
Religious preferences and immunizations
Children in research
Ethics Councils

Guidance for Ethics provided by the
American Nurses Association - Code of Ethics for Nurses:
http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsforNurses/Code-of-Ethics.pdf


Cultural Considerations for Pediatric Care:
Culture – “A pattern of assumptions, beliefs, and practices that unconsciously frames or guides the outlook and decisions of a group of people…”

Differs from race and ethnicity
Culturally prescribed patterns of behavior for persons in a variety of social positions

Social groups -
Primary – intimate
Secondary – limited

Sub cultures in America:
Bi-Cultural
Minority - more at risk

Culture shock –
Confusion, food, language
Customs -
Religious activities, folk medicine
Misunderstanding
Coining
Cupping
Green tomatoes
Placenta

Heredity/Genetic considerations –
Susceptibility
Excellent family medicine article on cultural medicine addresses coining, cupping, and other terms and treatments
http://www.aafp.org/afp/2005/1201/p2267.html

http://childabuse.stanford.edu/faq.html

How can you be culturally competent?
Observe and respect
Question and accommodate
Golden Rule
*Need to be aware of own cultural values and spiritual beliefs*
Watch personal judgements!!!

Pediatric Assessment

~ "When I think about all the patients and their loved ones that I have worked with over the years, I know most of them don't remember me nor I them. But I do know that I gave a little piece of myself to each of them and they to me and those threads make up the beautiful tapestry in my mind that is my career in nursing."

Donna Wilk Cardillo reflected in A Daybook for beginning Nurses

6255850749_d2322ceb63_z.jpg
Hands by Kerry Goodwin creative commons attribution license, flickr


clients will change,
locations will change
diagnoses will change
what will not change is the public's view of your responsibility and the trust you will incur simply by your profession.

The biggest difference between medical surgical nursing and peds is the age and developmental stage of the patient.
Also, you are not simply dealing with the patient but also with the family.
Dynamics which may affect the patient include the age, diagnosis, family situation, culture, gender, religion.

*Your assessment is the most important skill you have, use it! Think through the nursing process with the information that you have …it's like CSI…only better.*


A head to toe assessment is needed in the hospital. This usually will be performed on admission and once a shift, every 12 hours, every 8 hours or every four hours, depending on the patient and their stability.
If the patient is brittle or postsurgical assessments are being completed in recovery they are performed every 5-15 minutes.
Once on the floor, immediate assessments may be every every 30 then every hour and then progress to every 4 hours.

But first things first...is the patient stable?

Assessment Triangle:

This first video introduces the assessment triangle.
This type of assessment is usually performed quickly in an outpatient setting or ER.
In addition to these quick assessments a detailed history is obtained.
The assessment triangle is used to quickly assess the needs of the patient.
Do they need O2, should they be seen first? Are they critical or stable, sick or not sick.
The triangle assesses the child's appearance, work of breathing and circulation.
It is non-invasive, non-threatening, quick and easy.

Appearance
Acronym TICLS to assess tone, interactiveness, consolability, look/gaze and speech/cry.
Breathing is assessed. Note the rate, the work involved ... retractions, nasal flaring, the child's position...tripoding, and the child's anxiety.
Circulation** is assessed. What is the child's color? Are they pale, mottled, ashen. Is there any cyanosis? How about capillary refill?

*A more detailed assessment is performed after the initial assessment triangle is completed and the patient is stabilized.*







*Pain is also assessed with all patients per JACHO standards.*
Infants are assessed using FLACC, children are asessed using FACE and older children and adults are assessed using NUMBER.
All these are rated using 1-10 with zero being no pain and ten being excruciating. Remember pain is what the patient says it is.

FlaccPainScoreMedscape.com.gif



*This is an example of a Face pain rating scale. Be aware that it can be based 0-5 or 0-10. The principle is the same. Most are based on the 0-10 scale as are the others.

faces_1.gif


In hospital health assessment:
Begin with Health History Interview:

Introduction Introduce yourself, state your title, where you are from, the purpose of the interview and approximately how long it will take.

Discussion
Name/DOB/allergies/medications
What brings you here today? Chief complaint?
When did it begin?
Where the symptoms are?
How long do they last?
Note characteristics of the symptoms.
What makes the symptoms better? Worse?
Are there accompanying symptoms?
Has self-treatment been tried?
Pain? where, when, how long, constant, intermittent, relief? 5th vital sign
Sleep - Is the patient resting well? What are their current sleep patterns like? Do they nap? How about caffeine ingestion?
Nutrition – Ask the patient about their nutrition and diet. Are there any food allergies or intolerances? Appetite? Note BMI

Summary – recaps the patient’s history and clarifies data received. It briefly retells what the nurse understands.


*The introduction, discussion and summary gives the nurse much needed information; while performing this history you are assessing their overall appearance and noting the patient's level of consciousness. Are they oriented to person, place and time?

Physical assessment:
Overall Appearance
Vital signs
Clean, well-rested, and talkative? Or disheveled, inattentive, and lethargic?
Note body movements, emotions, temperament, speech patterns and behavior
Observe for muscle tension, perspiration, or tremors
Alterations in some vital signs can influence other vital signs.
For example, an increased temperature can cause an increase in respiratory rate and heart rate. Pain can increase blood pressure.

Next begin to review each system:
*While completing the physical assessment the nurse uses her skills of inspection, palpation, percussion and auscultation. If pain is a symptom, palpation of the involved area is last!


Skin, hair, nails –
Skin integrity, breakdown, rashes, tears, bruises, birth marks, scars, moles, acne, discolorations, tatoos, texture and turgor
Incision and dressing for drainage
IV site for swelling or redness.
Hair for cleanliness, parasites, dryness or brittleness
Nail beds for integrity, cleanliness, or habitual nail biting

Head and neck –
Symmetry
ROM, movement
Tenderness, redness, swelling?
Palpate thyroid and lymph nodes
Ask, any headaches or dizziness?

Nose, paranasal sinuses, sinuses, mouth –
Oral, nasal facial symmetry
Nares for patency and color. Discharge? Color and amount? Odor?
Color, symmetry, moisture and texture of the lips. Moist, cracked, dry?
Gums, tongue, and throat for color, bleeding, or exudate. Oral hygiene. Oral lesions? Sore throat?

Ears and auditory system –
Alignment, position, placement on head,
Ear size, shape, symmetry, intactness, tags
External meatus for discharge or lesions.
Pull down and back under 3, Up and back over 3, to visualize the tempanic membrane
Responses to questions, can they hear without difficulty?
Any difficulties with ears? Tinnitus? Any ear pain?

Eyes and visual system –
Eyebrows, symmetry and hair distribution.
Eyelids, eyelashes, and blinking;
Globe position in the socket.
Color of the eye, the color of the conjunctiva
Lacrimal puncta for color, moisture or discharge.
Redness or crustiness need to be noted as such.
PERRLA - Pupils should be equal, round, reactive to light and accommodation.
Difficulties with their vision? Do they see spots, wear glasses or contacts?

Lungs and respiratory system –
Posture, appearance, effort, and positioning. Even and unlabored? Tripoding?
Shape, muscle development and symmetry of the chest. Anterior to posterior diameter, transverse diameter
Respiratory rate and quality, retractions, nasal flaring, O2 SAT
Auscultate breath sounds, wheezing, stridor, rhonchi
SOB or coughing. Is there any history of reactive airway disease or asthma?

Heart and peripheral vascular system –
Appearance
Position
Skin color? pale, cyanotic...
Breathing effort.
Blood pressure
Jugular vein for pulsations, lifts, or heaves.
Auscultate S1 and S2 heart sounds for rate, rhythm, pitch, or splitting.
Pulses for rate, rhythm, amplitude and contour.
Chest pain or palpitations?

Abdomen -
Tone, soft, hard, guarding the abdomen or are the legs drawn up in pain?
Bowel sounds? X4?
Incisions or dressings? Edges approximated? With steri strips? staples? sutures?
Drainage? color? amount? Dressing? Outline the drainage with a pen - date, time, initial - to see if the area enlarges.

Musculoskeletal - Extremities -
What is the tone of the muscles?
Are the reflexes normal?
Are the extremities normal color?
Is the skin well hydrated?
What is the capillary refill of the toenail beds?
Are the pedal pulses palpable?

Neurological -
Cognizant of the day and time?
What is their level of consciousness?
Can they move and respond appropriately?
PERRLA, Headache, blurred vision, photophobia


Rectum/Genitalia -
Preserve modesty.
Assessed only if problem with parent, guardian or chaperone.
Remind the child that this area is private.
This area can be assessed for rashes, sores, or discharges.

A pediatric hospital assessment


For documentation purposes note:
Diet - type and amount consumed. Was it tolerated?
Safety measures - call light proximity, clutter free floor, adequate lighting, age appropriate toys
Pain level - Pain is often called the fifth vital sign. Noting the pain level with an appropriate tool is a JACHO standard.
Incision: Are the edges approximated? Were sutures, staples or steri strips used? Is there redness, drainage?
Dressing: Is the dressing dry and intact? If there is drainage present is it new? Grossly bloody or serous fluid?
Drains: Is there a drain in place? Is there drainage? Note the amount and color.
Intake: Intake can come from many sources. Be sure and note the source, amount and how it is tolerated.

Calculate the weight of a child in kilograms:
Weight of child in pounds = Weight in kilograms example: 24 lb child = 10.91 kg
Divided by 2.2 pounds/kg 2.2 lb/kg

Diet
Infants require 100 calories per kilogram of body weight (Adults 30-40)
Intake:
Oral
G Tube
IV fluids
TPN

Output: Output can also occur in various forms. Be careful to note all output.

Bladder capacity in ounces = child’s age +2, Example - 3 year old has the capacity of 5 ounces.

Calculating output for infants = 1 - 2 ml/kg/hour, ex. 5kg infant has 5 - 10 ml. urine per hour.

1 gram weight diaper weight = 1 ml of urine

Urine
Emesis
Stool
Blood

*Pediatric drop factor for IV is 60

Newborn Assessment:




Pediatric Data Base and Concept Map is available for download and copying under the heading Pediatric Clinical.

Family Teaching/Education
*Often in the outpatient and ambulatory care system and later before discharge in an acute care setting, children are sent home with illnesses to recuperate. Parental teaching is vital to guide these parents as they care for their child so teaching is crucial. Remember to provide clear, simple explanations, have the patients acknowledge their understanding and ask the patient or caregiver to repeat back the instructions. Then document, patient acknowledged understanding and returned demonstration. If this is not done you cannot be reimbursed for this effort!

Family teaching topics often discussed:
Daycare centers sick policies, where food is prepared, ratio of children to daycare workers.
Immunizations questions welcomed and answered.
Medications, comfort measures, therapies
Sick child care
Discharge instructions
How do I know if they are not getting better?
When can they return to school or daycare?

Educate: use of medications, comfort measures and when to call the doctor.
Illness information
How long illness may last
How long they will be contagious
Signs and symptoms of worsening illness – spell it out!
Who to call, what to do and where to go if the child gets worse

Common OTC Medications:
Tylenol - analgesic, antipyretic; may be in cold meds, helps with headaches, malaise, sore throat, muscular aches,pain
Ibuprophen (also known as Motrin, Advil) takes care of these symptoms and relieves inflammation as well.
Benadryl or Atarax for itching
Beware of aspirin products and derivatives
Do not assume that parents know the differences between medications or what is in a cold and flu OTC medication

Comfort Measures/Teaching tips:
Handwashing! Cover your cough! No kissing!
Popsicles, gatorade, pedialyte, ice chips, suckers for sore throats (Boo-Boo pops) and dehydration, cool or warm compresses
Integumentary:
Pruritic lesions (chicken pox) can be soothed with baking soda or oatmeal added to baths.
Calamine can be applied topically to dry the lesions
Scratching needs to be discouraged, pat.
Aquaphor for eczema
Fingernails should be kept short and clean.
Cool the burn, but no ice! Blisters are the body’s Band-Aid.
GI bugs:
ORT, clear liquids
Monitor for output, sunken eyes
GU:
Monitor symptoms, record occurrences, diary
Diet – increase fiber, fluid
Baths, barrier cremes
Respiratory illnesses:
Humidifiers
Place child in the bathroom with mist from the shower, cold night air.
Monitor how hard they are breathing, are they making sounds?
Monitor color
Neuro:
Headaches/ joint aches – Dim lights, decrease sound and visitors, warm baths, ice or warm compresses, monitor for fever, nuchal rigidity
Musculoskeletal:
Injuries – 5 P’s, monitor pain, swelling, color, RICE, Ibuprophen

When to call the doctor:
*Dehydration - dry mouth, low output (not going to the bathroom, decrease in wet diapers), sunken fontaneles or eyes.
*Worsening condition - spell it out
*Difficulty breathing, color off
*Change in LOC: unrousable, lethargic...

*Some diseases are reportable by law to local and state health departments, who then report them to the CDC. The CDC monitors disease trends and the effectiveness of intervention


References:
Hockenberry, M. J., & Wilson, D. (2009). Wong's essentials of pediatric nursing (8th ed.). St. Louis, MO: Mosby Elsevier.

Potts, N. L., & Mandleco, B. L. (2012). Pediatric nursing: Caring for children and their families (3rd ed.). New York, NY: Delmar Cengage Learning.

Videos located at:
Lewis Blackman
http://youtu.be/WElE_hRucpo

HIPAA
http://youtu.be/5UNnsLvZ_Hc

References:

Hockenberry, M. J., & Wilson, D. (2009). Wong's essentials of pediatric nursing (8th ed.). St. Louis, MO: Mosby Elsevier.

Potts, N. L., & Mandleco, B. L. (2012). Pediatric nursing: Caring for children and their families (3rd ed.). New York, NY: Delmar Cengage Learning.

Videos located at:
Pediatric assessment triangle located at
http://youtu.be/ssqwGjwSI_8

Pediatric Assessment -
http://youtu.be/iRpt7eUZM0Y

Newborn Assessment

https://youtu.be/4Lvv0YQ4CmI