NCLEX-RN: Pediatric Nursing

Pediatric Nursing: GENERAL ASSESSMENT OF THE CHILD

Focus topic: Pediatric Nursing

Pediatric Nursing: General Principles for Assessing Children

Focus topic: Pediatric Nursing

A. Maturational ability of the child to cooperate with the examiner is of major importance to adequate physical assessment.

B. When planning physical assessment of the child, the following points should be considered:

  •  Establish a relationship with the child prior to the examination.
    a. Determine child’s developmental level.
    b. Allow the child an opportunity to become accustomed to the examiner, preferably an opportunity to observe the examiner from a distance.
  •  Explain in terms appropriate to the child’s level of understanding the extent and purpose of the examination.
  •  Realize that the physical examination may be a stressful experience for the child, who depends on others for protection.
  •  Limit the physical examination to what is essential in determining an adequate nursing diagnosis when a focused assessment is desired.
  •  Proceed from the least to the most intrusive procedures.
  •  Allow active participation of the child whenever possible.
  •  Allow parents to participate in assessment of younger children. Allow adolescents the option of having parent stay during the exam.
  •  Consider cultural influences and practices incorporate appropriately into exam.

 

Pediatric Nursing: Pediatric Physical Assessment

Focus topic: Pediatric Nursing

Pediatric Nursing
Pediatric Nursing
Pediatric Nursing
Pediatric nursing
Pediatric Nursing

Pediatric Nursing: Assessment of the Infant

Focus topic: Pediatric Nursing

A. Accomplish as much of the examination as possible while the infant is sleeping or resting undisturbed.

B. History: gestational age/birth weight, discharge from hospital, weight gain, and sleep patterns.

C. Assess general condition.

  •  Symmetry and location of body parts.
  •  Color and condition of the skin.
  •  State of restlessness and sleeplessness.
  • Adjustment to feeding regimen.
  •  Quality of cry.
  • Interactions with parents/caregivers present.

D. Utilize screening procedures for assessment.

  •  Developmental screening: Current recommendations include the use of evidence-based quality developmental–behavioral screening tools such as “Parents Evaluation of Developmental Status” (PEDS), the “Ages and Stages Questionnaire” (ASQ), or other products listed in Performing Preventive Services, A Bright Futures Handbook (American Academy of Pediatrics, 2010).
    a. Properly administering the Denver II can take up to 2 hours by a skilled examiner and the DDST II does not have the same specificity and sensitivity as evidence-based tools listed above.
    b. If indicated, the nurse may refer the child for further screening.
  •  Vision.
  •  Hearing.
  •  Growth charts: head circumference, weight, length available on CDC Web site (www.cdc.gov).
  •  Hemoglobin to screen for anemia at age 9–12 months.
  •  Lead screening (serum lead level if indicated at 12 months).
  • Tuberculosis screening questionnaire (tuberculin skin test [TST] if indicated).

E. Provide teaching in the following areas:

  •  Growth and development changes.
  •  Language development.
  •  Anxiety toward strangers.
  •  Separation anxiety.
  •  Transitional objects.

F. Anticipatory guidance.

  •  Accident prevention: use of car seats, fall prevention, poisoning, water heater temperature, prevention of foreign body aspiration.
  •  Immunizations, influenza vaccine beginning at age 6 months.
  •  Feeding—introduction of solids, weaning from breast or bottle.
  •  Eruption of deciduous teeth and dental hygiene.

G. Assess for nonaccidental trauma.

 Assess for Congenital Anomalies

A. Neurological system.

  •  Reflexes: absent or asymmetrical see Neurological section, see pages 652–662.
  •  Head circumference: microcephaly, hydrocephaly from growth chart.
  •  Fontanelles: closed or bulging.
  •  Eyes: cataracts, lid folds, spots on iris, pupillary responses, abnormal eye movements, and absence of red reflex if in scope of practice.

B. Respiratory system.

  •  History: prematurity, apnea, siblings, previous children with sudden infant death syndrome (SIDS).
  •  Signs of respiratory distress: tachypnea, retractions, nasal flaring, head bobbing, grunting, stridor, cough, asymmetry of chest, crackles, wheezes.

C. Cardiovascular system.

  •  Perfusion: Assess pulses in all four extremities; temperature of extremities, quality of peripheral pulses (for age), oxygen saturation, capillary refill time, skin color, color of mucous membranes and nail beds (pale, mottled or cyanotic).
  •  Auscultation: regularity, tachycardia, bradycardia, relationship to respiratory cycle.
  •  Activity: Infant tires and may become cyanotic.
    a. Does infant tire with feeding?
    b. Does skin color change with cry?
  •  Umbilical vessels: normally two arteries and one vein.

D. Gastrointestinal tract.

  • History of polyhydramnios.
  •  Patency: coughing, choking, mucus, spitting, cyanosis, ability to pass nasogastric (NG) tube to stomach, pass meconium stool?
  •  Mouth: palate and lips intact?
  •  Anus: patent? Stool present? Passage of meconium?
  •  Olive-shaped mass in region of pyloric valve with history of forceful projectile vomiting and immediate hunger may indicate hypertrophic pyloric stenosis.

E. Genitourinary system.

  •  Urine: stream and position of meat us.
  •  Masses: abdominal possible Wilms’ tumor. DO NOT PALPATE.
  •  Boys: undescended testicles, hernia, urethra position of testicles, position of urethral meat us on penis, presence of hernia.
  •  Girls: labia mobile, structures identifiable, presence of discharge.
  • Genitalia: clearly male or female or ambiguous?

F. Skeletal system.

  •  Clavicles: intact or fractured?
  •  Hips: check for dislocation asymmetric major gluteal or thigh folds, hip clunk on adduction.
  • Legs and feet: clubbing, without straight tibial line.
  •  Spine: curved, flexibility, open, presence of masses or dimples.

Common Problems

A. Respiratory infections.

  •  Assess duration and severity of symptoms, medications given.
  •  Look for signs of respiratory distress: wheezing, barking cough, anxiety, restlessness, use of accessory muscles.
  •  Check for white patches on tonsils, unless toxic appearing and drooling.
  •  Feeding difficulties crying with swallowing, hydration status.
  •  Chronic lung disease in infants with history of prematurity.

B. Ear infections.

  • Assess for fever, irritability, pulling or rubbing ear(s).
  • Determine if change in eating habits has occurred recently. (Does infant go to bed with a bottle?)
  • Previous or recent upper respiratory infections (URI).
  • Previous ear infections.

C. Rashes.

  •  Assess onset, duration, and location; association with new foods/medications, aggravating or alleviating factors.
  •  Elicit accurate description of rash.

D. Contact dermatitis.

  •  Assess if history of allergies, and family history.
  •  Evaluate diaper area rash: use of lotions, powders, frequency of diaper changes, type of diaper used (cloth vs. paper).
  •  Determine method of cleaning cloth diapers.
  •  Atopic dermatitis: rashes in skin creases and scalp, oozing blisters, or dry scales.

E. Hernias.

  •  For inguinal, assess for lump in groin, reducible with or without pain.
  •  For umbilical, determine if lump can be pushed back without difficulty or pain.

F. Scalp: “cradle cap” (seborrheic dermatitis).

  • Assess for scaling or crusted areas.
  • Determine method of washing hair.
  • Evaluate lotions or balms applied to hair.

G. Birthmarks.

  •  Assess for change in size, color, or shape.
  •  Look for any bleeding or irritation.

H. Eye symmetry.

  •  Assess position of eyes, presence of doll’s eye reflex, ability to focus and follow 180 degrees.
  •  Determine presence of conjunctivitis redness, discharge.
  • Evaluate for strabismus/amblyopia; determine if light reflex is symmetrical in both eyes, assess extra ocular movements, perform cover/ uncover test.

Pediatric Nursing: Assessment of the Toddler and the Preschool Child

Focus topic: Pediatric Nursing

A. General considerations.

  •  Remember that separation anxiety is most acute at toddler age and body integrity fears are most acute at preschool age.
  •  Involve the parent in examination as much as possible.
  •  Give simple explanation of each portion of the exam. Proceed in calm and matter of fact fashion. Start with least invasive moving to more invasive.
  •  Allow the child to handle the equipment and try out on teaching doll; use play and distraction as needed.
  •  Take into account child’s need for autonomy.
  •  Do not disparage imaginary friends.
  •  Allow for rituals and routines, security objects.

B. Utilize screening procedures for assessment.

  •  Developmental landmarks: Denver II data or results using evidence-based screening tools such as PEDS or ASQ
  •  Vision.
  •  Hearing.
  •  Language: At age 18 months, autism specific screening is indicated, using a product such as the Modified Checklist for Autism in Toddlers (M-CHAT).
  •  Growth charts: head circumference, weight, length, and BMI for age.
  •  Hemoglobin and lead screening serum lead level, if indicated.
  •  Tuberculosis screening questionnaire TST if indicated.
  •  Skin and teeth.

C. Immunization history, annual influenza vaccine.

D. Blood pressure measurement, preferably with appropriate size manual cuff by age 3, or sooner if cardiac or renal disease is suspected.

E. Anticipatory guidance: car seats/seat belts, avoidance of accidental ingestions, hot water heater temp, traffic safety, bicycle helmets, dental hygiene, water safety.

 Common Problems

A. Feeding and eating.

  • Review food intake for last 72 hours, commonly “picky” eaters.
  •  Assess types of food ingested amount of fat and sweets.
  • Ensure adequate source of vitamins and minerals,use of supplements.

B. Temper tantrums.

  • Assess frequency and duration.
  •  Determine precipitating event.
  •  Evaluate response of caretaker.

C. Toilet training.

  • Ability to ambulate fine and gross motor capability neuromuscular maturity.
  •  Determine if child is bothered by wet diapers.
  •  Evaluate child’s and parent’s interest in toilet training.

D. Respiratory infections.

  • Assess duration and severity of symptoms.
  •  Look for wheezing, barking cough, anxiety, restlessness, use of accessory muscles.
  •  If throat is sore, check for white patches on tonsils, unless toxic appearing and drooling.

E. Communicable diseases.

  •  Assess exposures and onset of symptoms.
  •  Evaluate progression of disease.
  •  Determine treatment of symptoms.

F. Gastrointestinal infections.

  •  Assess onset and duration.
  • Evaluate intake and output (I&O).
  • Check for signs of dehydration dry mucous membranes, tachycardia, tachypnea, decreased urine output.

G. Dental caries.

  •  Examine teeth for obvious caries.
  •  Dental care and use of fluoride if indicated.

Pediatric Nursing: Assessment of the School-Age Child

Focus topic: Pediatric Nursing

A. General considerations.

  •  Modesty important, heightened concern for privacy.
  •  Explain all procedures clearly.
  •  Direct questions to child, not to parent.

B. Utilize screening procedures for assessment.

  •  Snellen vision testing.
  •  Sweep check audiometry.
  •  Height, weight, and BMI for age measurements.
  • Hemoglobin.
  •  Skin and teeth.
  •  Assess for scoliosis. Routine screening no longer indicated assess if concerned.
  • Tuberculosis screening questionnaire TST if indicated.
  •  Baseline lipid screening at age 10.

C. Blood pressure measurement, preferably with appropriate size manual cuff.

D. Immunization history catch-up if needed; annual influenza vaccine.

Common Problems

A. School.

  • Determine child’s attitude toward school, ability and participation.
  •  Assess for signs of school-related problems: procrastination, GI symptoms, depression, anger.

B. Nervous habits.

  •  Assess onset and duration of such habits as stuttering, twitching.
  •  Determine precipitating event.
  •  Evaluate anxiety of child and parent over problem.

C. Anticipatory guidance: seat belts, bicycle helmets, skateboarding gear helmets and pads, water safety, sports participation protective gear; diet, nutrition; dental hygiene need for orthodontics, cavity prevention.

D. Accidental trauma.

  • Provide anticipatory guidance.
  •  Assess if physical limitations may have caused accident.

E. Respiratory infections.

  •  Assess duration and severity of symptoms.
  •  Look for wheezing, barking cough, anxiety, restlessness, use of accessory muscles.
  •  If throat is sore, check for white patches on tonsils.

F. Gastrointestinal infections.

  •  Assess onset and duration.
  •  Evaluate intake and output.
  •  Check for signs of dehydration.

G. Dental caries

  •  Examine teeth for obvious caries.
  • Dental care and use of fluoride (if indicated).

Pediatric Nursing: Assessment of the Adolescent

Focus topic: Pediatric Nursing

A. General considerations.

  •  Privacy is important. Give the adolescent the choice of having the parent present.
  •  Note signs of puberty (Tanner stages).
  •  Ascertain feelings about body image.

B. Utilize screening procedures for assessment.

  •  Snellen vision testing.
  •  Sweep check audiometry.
  •  Height, weight, and BMI for age measurements.
  •  Hemoglobin.
  •  Tuberculosis screening questionnaire (TST if indicated).
  •  Scoliosis screening, if a concern.
  •  Skin and teeth.

C. Blood pressure measurement.

D. Provide anticipatory guidance in the following areas.

  •  Hazards of cigarette smoking, alcohol, drugs, and firearms.
  •  Transmission, symptoms, and prevention of STDs, HIV.
  • Sex education and need for contraception.
  •  Accident prevention, particularly automobile; seat belts and traffic safety.
  •  Principles of nutrition, assess for obesity or excessive dieting, eating disorders (e.g., anorexia nervosa, bulimia).
  •  Breast and testicular self-exam.
  •  Sports participation and proper protective equipment.
  •  Dental problems.
  •  Mental health assessment: signs of depression or suicidal thoughts, eating disorders, bipolar disease, schizophrenia, antisocial or sociopathic behavior, substance abuse, sexual or physical abuse.

Common Problems

A. Obesity, eating disorders, nutritional habits.

  •  Determine eating patterns; investigate intake of calcium and iron.
  •  Evaluate family concern and handling of problem.
  •  Assess amount of exercise.

B. Dysmenorrhea.

  •  Evaluate degree of pain (i.e., absences from school).
  •  Determine use of analgesics.
  •  Assess amount of exercise.

C. Mood changes.

  •  Be alert to signs of depression.
  •  Inquire about outlook for future, attentive to any indication of suicidal thoughts.
  •  Assess anger management strategies.

D. Acne.

  •  Evaluate existing skin care program.
  •  Assess child’s personal hygiene.

IMPACT OF HOSPITALIZATION

Focus topic:  Pediatric Nursing

Pediatric Nursing: INFANT

Focus topic: Pediatric Nursing

Assessment

A. Obtain history and usual behavior/developmental milestones achieved.

B. Assess psychosocial implications of hospitalization on child.

  •  Separation from the parent.
  • Decrease in sensory stimuli.
  •  Breakdown in parent–infant relationship due to:
    a. Parental guilt.
    b. Unfamiliar hospital environment.
    c. Feelings of inadequacy in the parenting role.
    d. Subordination of the parents by the staff.

C. Assess behavior of infant in response to illness.

  •  Indication of discomfort or pain.
    a. Cries frequently.
    b. Displays excessive irritability.
    c. Appears lethargic or prostrate.
    d. Low-grade fever.
    e. Poor feeding.
    f. Grimaces or cries to touch.
    g. Use of NIPS (Neonatal Infant Pain Scale).
    h. Use of FLACC scale (Face, Limbs, Activity, Cry, Consolability).
  • Positive reaction behaviors.
    a. Cries loudly.
    b. Appears fussy and irritable.
    c. Rejects everyone except parent.
  •  Negative reaction behaviors.
    a. Withdraws from everyone.
    b. Cries monotonously.
    c. Appears completely passive.

 Implementation

A. Nursing actions help lessen the detrimental effects of hospitalization.

B. Hold a prehospitalization nursing interview with the parents and give a tour of the pediatric unit when possible.

  •  Parents should meet the staff, have procedures and regulations explained to them, and be told the rationale behind the rules.
  •  They should be encouraged to visit frequently and/or to room in if possible.

C. Counsel the parents regarding the infant’s illness, and elicit their understanding of the disease and its course of action. Correct any misconceptions, and if appropriate, reassure them that they are not the cause of the illness.

D. Encourage the parents to participate in the infant’s care.

  •  Teach the parents procedures they can perform at appropriate times for learning.
  •  Show respect for their superior knowledge of infant’s likes, dislikes, and habits.
  •  Most institutions now allow/encourage 24-hour visitation. Encourage rooming-in and allow parent to be primary caregiver whenever possible.

Pediatric Nursing: Toddler and Preschooler

Focus topic: Pediatric Nursing

Assessment

A. Assess psychosocial implications of hospitalization.

  •  Hospitalization is a very threatening experience to the child because of the total number of new experiences involved.
  •  Because of the threat involved, hospitalization has the potential for disrupting the toddler’s new sense of identity and independence.
  •  Separation anxiety the child mourns the absence of parent through protest, despair, and denial.
    a. Cries loudly, throws tantrums.
    b. Child withdraws and shows no interest in eating, playing, etc.
    c. Behavior often mistaken for happy adjustment; ignores parent and may regress.
    d. Nursing behaviors: Reassure the parent, build a relationship with the child, and provide warmth and support to the child during long hospitalization.
  •  The child fears the loss of “body integrity” (prevalence of magical thought). The child also has no realistic perception of how the body functions and may overreact to a simple procedure. Some toddlers believe that drawing blood will leave a hole and that the rest of their blood will leak out.
  •  The child resents the disruption of normal rituals and routines. Toddlers are often very rigid about certain procedures, which allows them a sense of security and control over otherwise frightening circumstances.
  •  Loss of mobility is frustrating to the child.
  • Regression the toddler frequently abandons the most recently acquired behaviors and reverts to safer, less mature patterns.

B. Assess behavior of toddlers and preschoolers in response to illness.

  • Indications of discomfort or pain.
    a. Cries frequently.

b. Displays excessive irritability.
c. Appears lethargic, withdrawn.
d. Changes eating pattern.
e. Verbalizes discomfort or becomes stoic.
f. Use pain assessment tool Wong-Baker Faces or Oucher.

  •  Positive reaction behaviors.
    a. Shows aggressive behavior.
    b. Appears occasionally withdrawn.
    c. Fantasizes about illness and procedures.
    d. Shows regressive behavior.
  •  Negative reaction behaviors.
    a. Appears completely passive or excessively aggressive.
    b. Displays excessive regressive behavior.
    c. Withdraws from everyone.

Implementation

A. Suggest that the parent leave a favorite object of his or hers that the child would recognize for the child to “care for” until he or she can return. This procedure assures the child that the parent will return.

B. Encourage the parents to be honest about when they are going and coming  i.e., do not tell the child they will stay all night and then leave when the child is asleep.

C. Use puppet or doll play to explain procedures and to gain an understanding of the child’s perception of hospitalization. Use puppets or dolls to work out child’s anxiety, anger, and frustration.

D. During developmental history, elicit exact routines and rituals that the child uses; attempt to modify hospital routine to continue these rituals.

E. Keep consistency among nursing staff in guidelines for behavior that is acceptable; set firm limits.

F. Maintain a schedule that is consistent and as closely resembling the usual routine as possible.

Problem Behaviors

A. Depressed behavior.

  •  Encourage child to express himself or herself through play. (See Table 13-2.)
  •  Talk through a doll or stuffed animal for younger children.
  •  Don’t avoid child; continue to interact and support.
  •  Consult with other professionals.

B. Aggressive behavior.

  •  Channel energy positively: Older children may enjoy competitive activities; younger children can release tension through pounding boards, large motor activity, or clay projects.
  • Set limits and praise for jobs well done.
  •  Help child gain a sense of mastery.

C. Passive behavior.

  •  Structure the child’s day, provide consistency.
  •  Spend more time with the child and attempt to stimulate interest.
  •  Provide “win–win” choices.

D. Regressed behavior.

  •  Regression is acceptable to a point because it allows child a brief return to a less mature and demanding time.
  •  Support independence, mastery of tasks, and self-care.

Pediatric Nursing: School-Age Child

Focus topic: Pediatric Nursing

 Assessment

A. Assess psychological implications of hospitalization.

  •  The school-age child wants to understand why things are happening.
  • There is a heightened concern for privacy.
  •  The child is modest and fears disgrace.
  •  Hospitalization means an interruption in the child’s busy school life, and the child fears that he or she will be replaced or forgotten by peer group.
  • Absence from peer group means a disruption of close friendships.

B. Assess behavior of school-age children in response to illness.

  •  Indications of discomfort or pain.
    a. Expresses that something is wrong. “I feel sick.”
    b. Cries easily.
    c. Tells adult he or she is ill so adult can do something about it.
  •  Use pain assessment tool (e.g., Eland Color Tool, Visual Analog Scale, or Wong-Baker Faces).
  •  Positive reaction behaviors.
    a. Shows anger.
    b. Feels guilty.
    c. Fantasizes and is fearful.
    d. Displays increased activity in response to anxiety.
    e. Reacts to immobility by becoming depressed or angry or by crying.
    f. Cries or aggressively resists treatment.
    g. Needs parents and authority.
  •  Negative reaction behaviors.
    a. Is excessively guilty and angry and is unable to express feelings.
    b. Experiences night terrors.
    c. Displays excessive hyperactivity.
    d. Will not talk about experience.

Pediatric Nursing: Managing Behavior Through Play

Focus topic: Pediatric Nursing

Pediatric Nursing

e. Is regressive and completely withdrawn.
f. Shows excessive dependency.
g. Has insomnia.

Implementation

A. Teach the child about his or her illness; take the opportunity to explain the functioning of the body.

B. Explain all procedures completely; allow the child to see special rooms (e.g., intensive care, cardiac catheter lab) prior to being sent there for treatments. Whenever possible, provide honest and direct explanations in age-appropriate language.

C. Provide opportunities for the child to socialize with peer group.

  •  Allow telephone privileges for calls to home and friends.
  •  Provide outlets for anger and frustration (perhaps Velcro or suction dartboard).

D. Give the child the opportunity to make choices and be independent, whenever possible.

E. Protect child’s privacy.

F. Continue child’s schooling by providing tutors, time for schoolwork, quiet, needed supplies, turning off television and/or video games.

G. Provide child with the opportunity to master developmental tasks of age group.

Pediatric Nursing: Adolescent

Focus topic: Pediatric Nursing

 Assessment

A. Assess psychological implications of illness.

  • Disruption of social system and peer group.
  •  Alteration of body image.
  •  Fear of loss of independence or actual loss.
  •  Alteration in plans for future.
  •  Interruption in development of relationships.
  •  Loss of privacy.
  •  The degree to which the young adult is affected is dependent on:
    a. Whether the illness is chronic or acute.
    b. Whether the prognosis necessitates a change in the client’s future aspirations.
    c. How many changes must be accepted.

B. Assess behavior of adolescents in response to illness.

  •  Indications of discomfort or pain.
    a. Realizes something is wrong and seeks help.
    b. Shows high anxiety level.
    c. Verbalizes discomfort.
    d. Use pain assessment tool (e.g., Eland Color Tool or 1–10 Visual Analog Scale).
  •  Positive reaction behaviors.
    a. Shows resistance to accepting illness.
    b. Rebels against authority.
    c. Demands control and independence.
    d. Is fearful.
    e. Temporarily withdraws from social scene.
    f. Verbalizes how illness has affected him or her.
  •  Negative reaction behaviors.
    a. Holds in feelings about illness.
    b. Tries to manipulate staff.
    c. Becomes completely dependent.
    d. Denies illness.
    e. Becomes stoic and doesn’t acknowledge pain.

Implementation

A. Adolescents should be in rooms with other adolescents, away from young children.

B. Allow telephone and visitation privileges, with some limit setting.

C. Encourage the feeling of self-worth by allowing as much independence as possible.

D. Allow relationships to develop within reason.

E. Provide for privacy.

F. Assist client in identifying role models.

G. Realistically discuss problems of illness.

  •  Always provide information honestly.
  • Encourage the adolescent, if possible, to accept some responsibility on the hospital unit.

 

FURTHER READING/STUDY:

Resources:

 

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