Pediatric Assessment & Care Management

1. Pediatric Assessment&Care Management RN Residency Core Curriculum

2. Class Objectives Cont. • Understand charting by exception and documentation at CCHMC. • Understand the daily RN responsibilities. • Identify safety standards here at CCHMC. • Review case studies pertinent to pediatric nursing care.

3. Class Objectives • Understand policies and procedures related to assessment and how to locate them. • Describe the components of the pediatric health and physical assessment. • Identify age appropriate exam techniques.

5. Components of the Pediatric Health Assessment • Past Medical History • History of Present Illness • Family History • Social and Environmental History • Review of systems (Physical Assessment)

6. ICIS Admission Info

7. Admission History Categories Select 2-3 categories at a time and click on “Document” to complete the screens. An * means that the category is not complete. “P’ means partially complete, and “C” means the entire category is finished.

8. These are sample screens of the patient’s health history and development.

10. Perinatal history Birth History Hospitalizations Previous Illnesses Allergies Current Medications Immunizations Nutrition Growth and Development Past Medical History

11. History of Present Illness • Signs • Symptoms • Onset • What makes it better/worse?

12. Components of Pediatric Physical Assessment • General Appearance • Laboratory Values • Vital Signs • Physical Assessment

13. History... Social and Environmental Family

15. Neurological Respiratory Cardiac GI GU HEENT Skin Also include: PAIN ACCESS Chart body assessment findings in ICIS according to policy VI-101 Review of Systems (Physical Assessment)

16. ICIS Body System Assessment Charting by exception guidelines are displayed. Select the body system you want to chart by clicking on it and click “Document.”

17. Charting Click on the descriptions that apply to your patient. Click “Next” or “Previous” to move through the screens. Click “Complete” when finished.

18. General Appearance • Physical Appearance • Facial expression • Posture, position and types of movement • Activity • Pain

19. Normal Vital Signs by Age

20. In ICIS, you can access policies, forms and in this case, a chart of the normal ranges for vital signs in children. Just click on the “i link” and a new window will open with information.

21. Normal Temperature by Age

22. Physical Assessment Where to start.

24. Before Starting your Assessment • Receive report from off-going RN • Organize yourself. • Ensure you have your equipment. • Tell the parent what you are going to do. • Enlist the parent(s) help. • Wash your hands. • Physical Exam should be flexible • Allow for play and exploration • Least invasive to the most intrusive • Inspect, “look” • Auscultate, “listen” • Palpate/percussion, “feel”.

25. Head to Toe • Neurological • Respiratory • Cardiac • GI • GU • HEENT • Skin/Musculoskeletal

26. HEENT • Fontanels, suture lines • Look for asymmetry • Distended neck veins • Swollen glands • Eyes (PEARL, Tracking, Size) • Ears • Nose (Nasal Flaring = respiratory difficulty) • Nasal membranes • Mouth (Mucus membranes)

27. Neurological Assessment • Level of Consciousness (LOC) • Fontanels • Head Circumference • Pupillary Response • MAE • Pain

28. Pain Assessment in ICIS Select a pain scale and fill out the information about the patient’s pain. If the patient is not having pain, click on the “No Pain” button. If this is a re-assessment of a previous intervention, you must complete the entire assessment and may not click on “No Pain.”

29. Charting the Pain Assessment Select the pain level the child reported, or follow the prompts to determine a pain level. Note if the present pain control is satisfactory and what interventions you performed.

30. Respiratory Assessment • Respiratory Rate • Work of Breathing • Color • Air Movement • O2 Saturations • O2 Requirements • What do they sound like?

31. Pediatric Respiratory Differences • Airway Differences • Smaller upper and lower airways • Infants obligate nose breathers • Tongue is larger in proportion to mouth • Less compensatory reserve than adults • Infants rely primarily on diaphragm for breathing

32. Cardiac Assessment • Heart rate/rhythm: WNL for age (use apical) • Murmur: Present or not. • Palpable pulses: Radial, brachial, femoral, pedal. • Capillary refill: < 3 seconds • Skin color: noncyanotic, warm & dry • Urine output: WNL • Blood pressure: WNL for age • Edema • Access (PIV, PICC, CVC)

33. CVC Assessments Charting for a Central Venous Catheter (CVC), Port, PICC, EVD or New IV can be done on the “Invasive Lines” tab. Select the type of line to chart on and click on “Chart on CVC #.”

34. Chart dressing changes, flushes and cap changes on these screens. When you are finished, click “Complete.”

35. GI/GU Assessment • Feeding and Swallowing • Abdomen • Intestinal Motility • Stool • Diet • Tubes • Urine output

36. Musculoskeletal • Motor Movement/gait • Muscle strength • Devices/casts • Temperature • Color • Moisture • Turgor • Lesions, Rashes, scars Skin

37. Tx/Interventions Each shift you will chart on the treatments and interventions performed on your patient. Click the boxes that apply to him or her.

38. Q Shift Care Click on the boxes that describe the patient’s care and activity during your shift.

39. Age Appropriate Exam Techniques

40. Preparation Completely undress Leave diaper on male infant Pacify with bottle Avoid abrupt movements Enlist parent’s help Positioning Before sits alone: supine or prone After sits alone: sit in parents lap Infants

41. Preparation/Sequence Have parent remove clothing Allow underpants to be worn Use restraint when appropriate Praise cooperation Inspect body through play (count fingers) Use minimal physical contact initially Introduce equipment slowly Positioning Sitting or standing; on or by parent Toddlers

42. Preschool Child Preparation/Sequence • Request self undressing • Allow underpants to be worn • Offer equipment for inspection • Make-up story about procedure Position Prefer standing or sitting Prefers parent close by

43. School-age Child Positioning • Prefers sitting • Younger child prefers parent’s presence Preparation/Sequence • Request self undress • Allow underpants to be worn • Head to toe assessment • Respect need for privacy

44. Charting by Exception and Documentation

45. Getting Report • Basics – Name, age, weight, allergies • Hx – Previous medical (surgeries, significant hospitalizations) • Dx – Why are they here? • Head to Toe > Neurological > HEENT > Respiratory > Access > Cardiac > Pain > GI/GU > Skin

46. Receive report. Check orders – Shift check. Review chart and update report notes as needed. Initial brief check of patients. Check all IV rates and fluids. Complete assessment of patients within first 2 hours of your shift. Verify your patient medications are available for shift. RN Shift Responsibilities

47. RN Shift Responsibilities • Update the family/caregiver as needed. • Provide Discharge teaching and document any teaching or education performed. • Coordinate ancillary services as needed • Social Work • Case Management • Child Life • Chaplain • Coordinate any off unit tests and arrange for transport.

48. RN Shift Responsibilities • Provide Team Leader/Charge Nurse with updates on your patients as needed. • Chart I & O’s at 0559, 1359 & 2159 and clear/zero pumps. • Restock bedside supplies for on-coming nurse. • Order medications/fluids for on-coming nurse.

49. Patient Safety • Armbands • Infection control • Medication 5 rights • Call light access • Side rails • Needle safety

50. More Safety • Emergency code blue • Monitors on with alarms set • Fire alarm and extinguishers • Abduction prevention plan