NSB103 Paediatric Assessment PDF

NSB103 Paediatric Assessment Ibi Patane, Clinical Lecturer, Credited Paediatric Nurse, QUT SON ACKNOWLEDGEMENT OF TRADITIONAL OWNERS QUT acknowledges the Turrbal and Yugara, as the First Nations owners of the lands where QUT now stands. We pay respect to their Elders, lores, customs and creation s...

NSB103 Paediatric Assessment Ibi Patane, Clinical Lecturer, Credited Paediatric Nurse, QUT SON ACKNOWLEDGEMENT OF TRADITIONAL OWNERS QUT acknowledges the Turrbal and Yugara, as the First Nations owners of the lands where QUT now stands. We pay respect to their Elders, lores, customs and creation spirits. We recognise that these lands have always been places of teaching, research and learning. QUT acknowledges the important role Aboriginal and Torres Strait Islander people play within the QUT community. Learning outcomes Review physical assessment practices in paediatric patients Paediatric Triangle & A, B, C, D Taking vital signs Respiratory Neurological Pain Taking a health history Family assessment Skin assessment Musculoskeletal assessment Pressure injury Risk assessment Nutrition risk assessment Falls risk assessment Why are children different? Response to illness differs from adults Absolute size and relative body proportions change with age Observation & assessment of children must be linked to their age and understanding Therapy and evaluation must be related to age and weight Psychological and social needs of the individual and family must also be considered Assessment of children Sound knowledge of range of normal Engage parents in the process - rapport Relax the child - make it fun – prepare LOOK BEFORE TOUCHING Appropriate concepts & language for age Baseline status Opportunistic, continuous process Least invasive first then progress to invasive or painful Paediatric Triangle Rapid assessment of children Determines need for further immediate assessment & emergency action From: Horeczko, T., Enriquez, B., McGrath, N., Gausche-Hill, M. & Lewis, R. (2013) The Paediatric assessment triangle: Accuracy of its application by nurses in the triage of children. Journal of Emergency Nursing, 39(2), 182-189. Using the Paediatric Triangle: Which child would you assess first and consider your priority? Airway Large tongue Obligate nose breather Cricoid cartilage narrow Short neck, short trachea Smaller tubes Breathing Compensatory method less effective Higher metabolic rate Respiratory rate varies with age Thin chest wall Cartilaginous sternum, poorly developed intercostals, flat diaphragm Fewer alveoli = lower surface area (Smith & Radford, 2022) Respiration Rate varies with age Rate / minute- >40 is always cause for immediate assessment by skilled practitioner effort of breathing - look for presence of sub- sternal recession, intercostal retractions or tracheal tug You can see an example of extreme recession in this YouTube clip: https://www.youtube.com/watch?v=uA02h6FYSYQ Recession in infant Recession https://www.youtube.com/watch?v=uA02h6FYSYQ Circulation Decreased circulating blood volume Infants 90 ml/kg Child 80ml/kg Adult 70 ml/kg Rapid heart rate, Higher cardiac output = higher O2 demand, less reserve Strong compensatory mechanism Higher % of body water for weight Capillary refill in an infant  Compensatory mechanisms will shunt blood from peripheries to vital organs Cardiac output is maintained by increasing HR Compensation Children will remain normotensive until 25% of blood volume lost Children with respiratory distress will compensate by working harder but tire easily = rapid decompensation Disability Need to consider neurological assessment and modifications to assess young/distressed/non-verbal children & infants (Neurological evaluation): use AVPU initially ALERT Response to VOICE Responses to PAIN UNRESPONSIVE And then proceed to further neurological assessment as indicated by clinical condition - which may or may not include: Pupillary size and reaction Presence of abnormal movements Glasgow Coma Scale / Grimace score Blood Sugar Level (Collins, 2022) Neurological Assessment Child’s response to environment and people Nurse needs to be creative with < 5yrs to get best motor response and visual / auditory response to stimuli Not useful as single assessment item - should be included as part of complete clinical picture Document observed data -note any change and nurse actions in chart Alert or lethargic; grumpy or irritable; asleep or comatose Adapted tools should be used for non-verbal children Vital signs Pulse – apex beat, use stethoscope Palpation difficult, age dependent (brachial or femoral young child , similar to an adult for older child) Range varies with age & activity Infant (0-12 months) 100-160b/m Toddler (13-36 months) 70-150b/min Blood Pressure – age dependent, late sign NB: measurement variable with cuff size: correct sizing important Capillary refill – reflects cardiac perfusion  delivery of oxygen and nutrients like glucose. Technique: apply pressure for 5 sec then release, distal to central Child refill less than 2 seconds, Adults 1-2 or 3 seconds  Temperature Normal range: 36.6-37.5 0C Fever is immune response to illness and should in most cases be observed not managed Infants have poor temperature regulation- prone to hypothermia Use of axillary site – digital or glass if directly supervised Not oral / rectal Tympanic thermometers if available, can be user error with infants (source: Middleton, 2022) Blood Pressure Hypotension is a late finding in children with cardiopulmonary compromise, and is an indicator of decompensated shock and possible imminent cardiopulmonary arrest. The blood pressure of the child with compensated shock may be normal; signs of inadequate perfusion such as decreased level of consciousness, prolonged capillary refill, and tachycardia are usually observed before hypotension is seen. The most important consideration to ensure BP measurement is correct is the cuff size. 3 A cuff that is too small will over estimate the BP, whereas a cuff that is too large will result in an under estimate the BP. The correct cuff size is determined by the size of the child, not their age (Middleton, 2022) Blood Pressure Middleton, 2022 Taking the Blood pressure A quiet environment is desirable as anxiety or distress may increase the BP reading 3, therefore some age appropriate strategies should be employed to gain cooperation – some suggestions include – Infants- toys, distraction, when calm, asleep Toddlers- simple explanation, games, demonstrate on parent/toy Older children- rewards, stickers, explanation, allow child to press tart button Adolescent- choice of limb Child should be seated or supine with limb at heart level Pain myths in children Pain control is a medical role As the nervous system is incompletely myelinated pain is poorly perceived Opiate addiction is likely and may occur Respiratory depression will cause hypoxia Children who can play or be involved in another activity are not in significant pain Less analgesics administered is better (PRN) Nurses should wait for pain to get ‘bad’ before giving analgesia Children who are quiet and ‘good’ need less analgesia NB: Research demonstrates children are consistently under medicated for pain (sub optimal dose of analgesic agent /kg/ frequency) yet health professionals perceive they do “a good job” of pain control Pain responses Physiological stress responses - inaccurate and limited value as body adapts rapidly Parent / care giver impression Non-verbal responses & body language Facial expression, palm sweatiness Individual ++ FLACC pain scale Head to Toe Assessment A focused head-to-toe assessment may be used as a simple check of the patient to ensure all aspects have been considered or it may be used for a complete assessment of body systems as part of patient admission / care. The head to toe assessment should take into consideration the presenting complaint, general and clinical appearance and child’s developmental level History An essential component of a comprehensive assessment is obtaining information regarding: Any previous and/or relevant health history History of current health problem History of treatments (orthodox and complimentary) and their response and Immunisation status Usually the parent/carer will provide the majority of the information. Family Identify who the family is Any custody/visitation issues Any disability or social/psychosocial/financial factors that impact ability to care Desired level of involvement in child’s care Cultural or religious beliefs that impact acre Parent/carer needs (eg food, sleep, stress) (Patane & Forster, 2019) Skin assessment Skin assessment often reveals sign and symptoms of other health conditions Inspection of the skin may reveal Allergies Signs of infectious diseases (measles, chicken pox) Lesions that may be malignant/non-malignant Conditions such as hyperbilirubinemia (jaundice in infants or liver disease in older child) Systemic disease (Lyme disease, systemic lupus erythematosus) Infestations- scabies, ring worm Wounds (Patane, 2022) Pressure injury risk assessment Children are subject to pressure injuries given the same set of circumstances as adults Pressure Moisture Shearing Friction Most pressure injuries in children are related to devices so nursing care essential to identify risk and take action to prevent (Patane 2022) Neurovascular assessment Principles the same as adults but additional challenges due to age, developmental level, cognitive level and cooperation. Fear and pain/distress compound the difficulties Permanent damage can occur to muscles after 4 hours; nerves after 12hours Visually assess the limb and check capillary refill Check sensation as able due to limiting factors related to age Check active and passive movement Check pulses (Moyo, 2022)  Compartment syndrome  Paraesthesia: Change/decrease in sensation including tingling, burning, and numbness.  Pain: Increase in pain not relieved by analgesia, positioning or support, and occurs on passive movement.  Pressure: tense, swollen, warm limb or muscle compartment; the skin takes on a shiny and stretched appearance.  Pallor: alteration in skin colour may progress from reddened to cyanosed to pale. Assessment of capillary refill is essential in skin with a reddened hue. (late sign)  Paralysis: reduction in active movement of involved limb or distally. (late sign)  Pulselessness: Weak or absent pulse (late sign). (Hopper, 2015; Drummond & Curry, 2015)  Musculoskeletal assessment Consider Mobility Gait Symmetry of limbs, joints & muscles pain Common musculoskeletal issues in young patents are Scoliosis Fractures Developmental dysplasia of the hip Soft tissue injuries  Nutrition screening All inpatients to have a height and weight recorded* Has child unintentionally lost weight lately? No Yes Has child had poor weight gain over the last few months? No Yes Has child been eating less in the last few weeks? No Yes Many tools Is child obviously underweight/significantly overweight? No Yes If yes to any above – implement actions as listed Keep it simple for screening and - Strict food intake record - Weigh twice weekly refer to dietitian where indicated - Refer to Dietitian All patients screened on *Please note it is highly recommended to plot height and weight on CDC percentile charts to assist in the identification of children who are malnourished. admission Illness further impacts or causes malnutrition Malnourished children can be overweight White & Bell, 2015) Children at risk of nutritional deficit (White & Bell, 2016) About 40% of children in hospital are at risk NGT feeding NBM Vomiting Diarrhoea Pain Fever Viral illness (White & Bell, 2015) Hydration Skin turgor - elasticity indicates hydration look distal - central Mucous membranes - mouth wet & shiny ++ or dull - lips dry. Tears? Activity – drowsy, limp or irritable Sunken eyes and fontanelle Cool and pale Decreased urine output Changes to vital signs – initial tachycardia, then bradycardia, BP may be low Fluids: Infants formula 100-150ml/kg/day up to 1000ml Older children as desired – more self regulation/frequently offered is key Falls Risk Assessment On admission and when condition changes Children fall frequently as they develop ambulatory skill Assess the following: Functional assessment Safety management Falls education (most falls in hospital occur under the supervision of the parent/carer) Risk assessment and management plan-eg sedated child  REFERENCES ENA (Emergency Nurses Association). Emergency Nursing Pediatric Course (2014). USA:ENA Collins, W. (2022) The child with cerebral dysfunction. In Wong’s nursing care of infants and children (ANZ edition 1). pp 819-864 Hockenberry, M. & Wilson, D. (eds) (2019). Wong’s Essentials of pediatric nursing. (8th ed) Canada: Mosby Elsevier Horeczko, T., Enriquez, B., McGrath, N., Gausche-Hill, M. & Lewis, R. (2013) The Paediatric assessment triangle: Accuracy of its application by nurses in the triage of children. Journal of Emergency Nursing, 39(2), 182-189 Middleton, A. (2022) Communication, physical and developmental assessment. In Wong’s nursing care of infants and children (ANZ edition 1). pp.50-96 Patane, I (2022). The child with integumentary dysfunction. In Wong’s nursing care of infants and children (ANZ edition 1). pp 891-910 Patane, I. (2019) Family & Community. In Paediatric nursing in Australia, Forster et al (eds). pp38-51 Smith, K. & Radford, F. (2022) The child with respiratory dysfunction. In Wong’s nursing care of infants and children (ANZ edition 1). pp 637-700 White, M. & Bell, K. (2016) Nutrition Screening Tools & their implementation in practice https://dietitianconnection.com/app/uploads/2016/11/Kristie%20and%20Melinda%20webinar.pdf