Mod 6 learning outcomes Flashcards
- Explain techniques for performing a head-to-toe pediatric physical assessment for the school-age child based on developmental stages and physiologic characteristics.
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.
Anthropometric measurements Height Weight Body mass index (BMI) Start with measurements
The school-age child should have a routine health maintenance visit every 1 or 2 years. Annual physical exams are scheduled for those who participate in sports. Allow time to meet with the child alone as well as time with the caregiver present. School-age children often have questions about puberty and the changes their bodies are undergoing. Private time with the child will allow you to explore these concerns in a private manner.
Vital signs should not be hard to get- let them pick which side
O2- 93-100%
Gain 3 kg/year in weight
Gain 5 cm/year in height
Experience a growth spurt at age 10 to 12 years for girls and around age 12 years for boys
FACES scale younger, visual analog scale or numeric of 1 to 10 for older
Annual assessments check height, weight, body mass index (BMI), blood pressure, hearing, vision, and anemia.
Ask the child whether he or she would like the parent or primary caregiver present during the assessment.
Use inspection of the genital area during the physical assessment as a springboard for discussing good/bad touches.
Younger school age children are closer to preschoolers and older school age children are closer to adolescents.
School-age children should be cooperative with the physical assessment.
Ask the child whether he or she would like the parent or primary caregiver present during the assessment.
Typically, younger school-age children will like to have the primary caregiver present and older school-age children may or may not want the primary caregiver present during the entire assessment.
Speak and ask questions directly to the child. Give the child rationales for all actions you perform
At this age, it is important to guard the child’s privacy. As a nurse, be aware of self-conscious behavior related to physical changes occurring in the body. Along with privacy, the nurse must be aware of other issues affecting the child and family related to menstruation, secondary sexual characteristics, hormone imbalances, mood swings, and social needs, as well as other specific areas identified by the child and family.
Privacy important
Systemic approach- Health history and chief complaint, Review of systems, General survey, Vital signs and anthropometric measurements, Physical exam
Head to toe, observation first, examine least to most invasive, talk through what you are doing
Nutrition, sleep, vision, dental, BMI, scoliosis screen, immunizations
Nursing Interview The nursing interview should cover the following topics: on next slides
nutrition
slides-Nutrition. Assess the child’s eating patterns and the intake of key nutrients such as calcium, vitamin D, and iron.
Allergies
Allergies. Ask the child whether he ever experiences difficulty breathing or feels too tired to play. Ask about symptoms such clear nasal discharge, frequent sneezing, or watery eyes. Listen to breath sounds and observe for allergy symptoms.
Visual Acuity
Visual Acuity. Ask about any eye screening. Because children do not complain about visual difficulties, the AAP recommends that children aged older than 5 years should be screened every 1 to 2 years (2012). Many school systems have regular vision screening programs that are carried out by professionals and properly trained volunteers. Screening can be done there quickly, accurately, and with minimal expense.
Dental hygiene
Dental Hygiene. Interview the child to determine his knowledge of dental hygiene. Inspect the mouth for secondary teeth eruption according to expected patterns ands for tooth decay and gum disease.
visit every 6 mon
Sleep
Sleep Pattern. Assess the child’s sleep pattern. To remain healthy and function well at school, the school-age child needs 9 to 10 hours of sleep each night.
BMI
BMI At each visit, asses the child’s vital signs, height, weight, and developmental skills. After weighing the child, correlate your measurements with growth charts. The American Heart Association (2013) BMI classifications are as follows: OverweightAt 85th percentile
ObeseAt the 95th percentile or above
Scoliosis
Scoliosis Screening Scoliosis is an abnormal spinal curvature that affects primarily females. Screening is done in the preadolescent period, usually in the sixth grade. Refer to an orthopedic surgeon for evaluation and follow-up if an abnormal curvature is discovered.
Immunizations
Immunizations Review the immunization record. Although immunization against hepatitis B is recommended in infancy, many parents skip these immunizations. Several states require students to complete the hepatitis B series prior to entry into seventh grade. The child must begin the series at or before 12 years of age to complete it in time for seventh grade. The CDC (2015a) recommends the following vaccines for school-age children: human papillomavirus; meningococcal; pneumococcal; influenza; hepatitis A; hepatitis B; inactivated poliovirus; measles, mumps, and rubella; varicella; and tetanus, diphtheria, and pertussis booster.
School readiness
Physical examination is required before the child enters school
Assess skills
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
Also, review the immunization record
This exam should include 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. Also review the immunization record. Several boosters and immunizations are due at this time, and any that have been missed must be administered before the child enters school. To see the CDC Catch-up Immunization Schedule,
- Explain adaptations that may be required when you examine the school-age child.
Ask the child whether he or she would like the parent or primary caregiver present during the assessment. Typically, younger school-age children will like to have the primary caregiver present and older school-age children may or may not want the primary caregiver present during the entire assessment. Speak and ask questions directly to the child.
Give the child rationales for all actions you perform (
Use inspection of the genital area during the physical assessment as a springboard for discussing good/bad touches. Indicate which areas the child should report to a trusted adult if anyone touches them, including the breasts, buttocks, and genitals.
School-age children should be able to assist in the medication administration process.
When caring for this age group, it is important to gain the trust of the child before beginning assessment or procedures. Explain procedures in an age-appropriate way. Do not lie if a procedure will be uncomfortable or painful; this will cause you to lose the child’s trust.
Tell the child and the parents/caregivers what you will be doing before doing it. Try the following approach:
Look: Assess the child’s appearance, muscle tone, and skin.
Talk: Discuss with the child and the parents/caregivers any recent history or problems. Listen to what the child tells you.
Touch: Be nonthreatening by avoiding sudden movements and staying at the level of the child whenever possible.
Allow for privacy.
Appropriate rewards such as stickers or small toys may be given after the examination.
If a procedure must be performed, have the instruments ready and inform the child immediately before the procedure. The longer a child is aware that a painful or uncomfortable procedure is coming, the greater the stress that can occur.
Do the least invasive parts of an examination first. If part of the examination is invasive or painful, this will make the child fearful of further, even noninvasive, painless parts of the examination.
You will use a growth chart
Gain 3 kg/year in weight
Gain 5 cm/year in height
Experience a growth spurt at age 10 to 12 years for girls and around age 12 years for boys
- Describe the expected differences in assessment findings for the school-age child compared to the adolescent or adult assessment.
High fevers greater than 104°F or 40°C in children do not indicate that the infection is more serious, as they may in adults, because less-refined pediatric immune systems may produce higher fevers than needed
Loss of primary (baby) teeth and eruption of new adult teeth starting with 6-year molars
children are growing at a slower rate than before but still accomplishing important developmental milestones.
- Explain the steps to a comprehensive pain assessment for the school-age child.
slides-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
Some understanding of pain Able to describe pain in more detail Pain scales: based on age developmental level language literacy anxiety state, etc.
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 Agitation Tense Grimacing Guarding
Physiologic Signs Increased respiratory rate Increased heart rate Pallor Sweating Nausea Vomiting
- Describe pain assessment tools and their appropriate use for the school-age child considering developmental level.
Pain scales
Wong-baker FACES rating scale 0, 2, 4, 6, 8, 10 faces representing that level of pain
Simple descriptor
Line one end says No pain-mild pain-moderate pain-severe pain-very severe pain-worst pain possible
Book:
Pain assessment: The nurse can choose between a few different pain scales depending on age and developmental level. Each pain assessment begins by explaining how the pain scales work and assessing the child’s ability to properly use the scale. Make sure to specifically ask the child about pain level, not how he or she feels; being sick and in the hospital may cause the child to give a higher rating than is accurate.
The FACES scale may be used for younger school-age children. (See Chapter 8 for information on the FACES scale.)
This age group can also point to where it hurts and describe the pain with words like stabbing or burning.
The FACES scale has been proved over time to correlate highly with the visual analog scale (Thrane, Wanless, Cohen, & Danford, 2016).
One downside noted with the FACES scale is that some children will choose the smile face because that is the most desirable. In addition, if a child is feeling pain, he or she may automatically be drawn to the crying face, number 10. Educate the child to point to the face that reflects the level of pain he or she is experiencing.
Older school-age children may be able to use a visual analog scale or numeric of 1 to 10. As children grow older, increased vocabulary increases their ability to describe pain.
Parents or the child’s primary caregiver will be able to assist in the assessment of pain. They will notice minute differences in their children that the nurse may not immediately notice.
Facial expression as a sole means of determining pain is not recommended.
- Explain how the school-age child experiences pain based on their age and developmental level.
The older they get, the more they understand their pain and are able to describe their pain in more detail. As children grow older, increased vocabulary increases their ability to describe pain. People of all ages experience pain the same, younger kids may just not be able to explain it.
Behavioral Signs: Crying, Agitation Tense Grimacing Guarding
Physiologic Signs:Increased respiratory rate Increased heart rate Pallor, Sweating, Nausea Vomiting
Influences on pain: Developmental stage, Previous pain experience, Fear, Confusion, Helplessness, Anger and depression.
Pain management
Use multi-modal approach for all ages
Pain management strategies vary for each developmental level
Pain management strategies vary for each level of pain
Mild
Moderate
Severe
Remember to re-assess frequently
Use multi-modal approach for all ages
Parent/family/friend involvement, distraction, environment, local/topical treatments, medications
Concerns/reactions: Has questions regarding body and illness Concerns of helplessness, passivity, and dependency Tend to be phobic and develop fears Anger
Distraction: Deep breathing Hand squeezing Riddles/trivia Pretend games Talking Distraction kit
Use treatment room Music Controlled lighting and noise
Pain management strategies for infant/toddler: controlled lighting and noise; pacifier; swaddling; rocking; eye contact; music
- Describe the best procedure for measuring temperature, pulse, respiration, and blood pressure including site and equipment for the school-age child.
book- Vital signs (Table 9–1): Attainment of vital signs should not be difficult with this population. Explain the procedures to the child and allow him or her to choose, as appropriate, which side blood pressure will be taken, oral versus axillary temperature, and which finger to use for pulse oximetry. Pulse oximetry values should be the same as adult values (93% to 100%). Pulse oximetry values may be different if there is an underlying cardiac or pulmonary diagnosis. A fever is generally considered to be a temperature greater than 101.4°F or 38.5°C. Fevers do not cause seizures, although a sudden increase in body temperature may result in a febrile seizure. High fevers greater than 104°F or 40°C in children do not indicate that the infection is more serious, as they may in adults, because less-refined pediatric immune systems may produce higher fevers than needed
Any temp minus rectal unless you have to (be careful with bleeding disorders or immunosuppressed. Oral temp after 5y. Blood pressure (begins at 3y) cuff must be an appropriate size. Child must sit or lie down for 3 minutes before hand. Pulse moves from apical to radial or brachial.
Cultural considerations
The tooth fairy is a modern U.S. construct with origins in Norse mythology and Northern European traditions (Saunders, 2016). Do not assume that the “tooth fairy” visits every home because this is influenced by culture.
- Explain the normal ranges of vital signs for the school-age child.
6-12 years
HR-60-95, BP 100-120/60/75 Resp 14-22
6-t98.6, HR 95, resp 20-25, systolic BP 95, diastolic bp 55-70
9-98.1, HR 95, resp 17-22, sys BP 105-110, dia BP 60-75
12- 97.8, HR 85, resp 17-22, sys BP 118-120, dia BP 62-76
- Describe how to use height and weight percentiles to evaluate physical growth in the school-age child.
Anthropometric measurements- Height Weight BMI body mass index Start physical assessment with measurements
Use correct chart for age and gender
Plot intersection of horizontal axis and vertical access
Point will be near a percentage line
Can determine what percentile child is at- can sometimes determine failure to thrive.
Chart will be maintained in patient record to keep track of growth and weight -assess BMI
- Explain the normal ranges of vital signs for the school-age child.
6-12 years
HR-60-95, BP 100-120/60/75 Resp 14-22
6-t98.6, HR 95, resp 20-25, systolic BP 95, diastolic bp 55-70
9-98.1, HR 95, resp 17-22, sys BP 105-110, dia BP 60-75
12- 97.8, HR 85, resp 17-22, sys BP 118-120, dia BP 62-76
fluid req. by weight 11-20kg 1000ml +50 mL for each kg above 10 kg
lgreater than 20 kg 1500 ml +20 ml for each kg above 20 kg
expected urine output
6-7yrs 1-2ml/kg/hr
8-12yrs0.5-1ml/kg/hr
- Discuss the principles of growth and development concentrating on the school-age child.
By age 6: has a vocabulary of 3,000 words and usually can read
By age 7: tie their own shoelaces; print their names; and perform self-care, such as bathing and feeding themselves. Many can even prepare simple meals.
By age 8: improved fine motor skills allow the child to begin to write, learn to knit or crochet, and/or take up a musical instrument.
By age 9: motor development approaches that of an adult. Fears of ghosts and monsters may continue through age 7 but give way to more realistic fears, such as of school failure or divorce of parents, by age 8 or 9.
By the end of the school-age period, the child can write complex compositions with appropriate grammar, spelling, and accurate description.
School-age children understand the concept of payment for work and the value of money.
By age 7, most children can tie their own shoelaces; print their names; and perform self-care, such as bathing and feeding themselves. Many can even prepare simple meals. By age 8, improved fine motor skills allow the child to begin to write, learn to knit or crochet, and/or take up a musical instrument. By age 9, motor development approaches that of an adult. School-age children understand the concept of payment for work and the value of money. Fears of ghosts and monsters may continue through age 7 but give way to more realistic fears, such as of school failure or divorce of parents, by age 8 or 9. By age 6, the child has a vocabulary of 3,000 words and usually can read. By the end of the school-age period, the child can write complex compositions with appropriate grammar, spelling, and accurate description. Psychosocial development includes team play, peer friendships, and ability to look beyond family members for social support.
Cognitive development
Use their thought processes to experience actions and events
Concrete and systematic thinking
Want to understand how things really are
Can see another person’s point of view and develops an understanding of relationships
Learns to classify objects according to similarities
Enjoys learning by handling and manipulating objects
Learns to tell time
Reads independently; does numerical calculations without representative objects, such as fingers or beads
School-age children use their thought processes to experience actions and events. Piaget describes this as concrete operations.
Concrete and systematic thinking
Magical beliefs gradually replaced with a passion to understand how things really are
Can see another person’s point of view and develops an understanding of relationships
Learns to classify objects according to similarities
Enjoys learning by handling and manipulating objects
Learns to tell time; gains an experiential understanding of the length of days, months, and years
Reads independently; does numerical calculations without representative objects, such as fingers or beads
By the end of this stage, is able to think through a task and understand it without actually performing the task
- Discuss the principles of growth and development concentrating on the school-age child.
By age 6: has a vocabulary of 3,000 words and usually can read
By age 7: tie their own shoelaces; print their names; and perform self-care, such as bathing and feeding themselves. Many can even prepare simple meals.
By age 8: improved fine motor skills allow the child to begin to write, learn to knit or crochet, and/or take up a musical instrument.
By age 9: motor development approaches that of an adult. Fears of ghosts and monsters may continue through age 7 but give way to more realistic fears, such as of school failure or divorce of parents, by age 8 or 9.
By the end of the school-age period, the child can write complex compositions with appropriate grammar, spelling, and accurate description.
School-age children understand the concept of payment for work and the value of money.
By age 7, most children can tie their own shoelaces; print their names; and perform self-care, such as bathing and feeding themselves. Many can even prepare simple meals. By age 8, improved fine motor skills allow the child to begin to write, learn to knit or crochet, and/or take up a musical instrument. By age 9, motor development approaches that of an adult. School-age children understand the concept of payment for work and the value of money. Fears of ghosts and monsters may continue through age 7 but give way to more realistic fears, such as of school failure or divorce of parents, by age 8 or 9. By age 6, the child has a vocabulary of 3,000 words and usually can read. By the end of the school-age period, the child can write complex compositions with appropriate grammar, spelling, and accurate description. Psychosocial development includes team play, peer friendships, and ability to look beyond family members for social support.
Increase 4-6 pounds each year; and 2 inches each year
Posture straightens
Facial features become more refined
Begin development of secondary sex characteristics
Gross motor skills
Increased dexterity
Improved coordination, strength, and balance
Climbs, bikes
Learns to swim, to do somersaults, to skate
Fine motor skills
Good hand-eye coordination
Arts and crafts
Builds models
Video games
Plays musical instruments
Language
Language improves considerably
Can use metaphors and similes
Can effectively use language to express themselves
May experiment with profanity
Psychosocial and play
Increases peer group; builds self-esteem
Cooperative play teaches reasoning, cooperation, and increases social skills
General survey
determine developmental history, family composition, and school performance. Somatic complaints without verified diagnostic clinical data—such as chronic pain, dizziness, sweating, headaches, chest pain, shortness of breath, gastrointestinal issues, nausea, vomiting, diarrhea, or back or joint pain—may be an indication of school or home avoidance/problems, anxiety and stress, or depression (Kaneshiro, Zeive, & Ogilvie, 2014) (see Chapter 14). Yearly health maintenance visits with a primary care provider are recommended for school-age children
Annual assessments check height, weight, body mass index (BMI), blood pressure, hearing, vision, and anemia. Immunizations should also be given as recommended by the schedule updated each year in January at the CDC Web site (see Chapter 22). The nurse should also assess the following areas:
SKin
Assess for signs of child abuse, such as bruises in various stages of healing, bruises on unusual parts of the body, and cigarette burns.
Assess for dryness, rashes, eczema, abrasions, and contusions or scratches.
Abused children in this age group may fear that they have done something wrong or that they somehow deserve what is happening to them. Primary caregivers should make sure that children understand good touch/bad touch and the danger of engaging with strangers. Caregivers should listen to children’s concerns, ask questions about the adults/peers at school/activities, and monitor for changes in mood or behavior, which may indicate that abuse has taken place. After-school time should be supervised and structured.
Head
Assess for lice (Fig. 9–2).
Assess hair for dryness and brittleness that can indicate nutrition status.
Assess for open lesions/signs of trauma.
Assess for symptoms or recent history of head trauma, including headaches, difficulty concentrating, or loss of consciousness.
Eyes/ears
Assess for use of glasses/contacts.
Assess visual acuity.
Assess for broken blood vessels, jaundice, and dryness.
Assess for hearing aid use and hearing acuity.
Assess for buildup of earwax, which can impair hearing.
Assess for an excess buildup of fluid in the canal.
