Family Health and Infants (week 8)

defining family

• primary unit of socialization

  • influenced by ppl/institutions

• no universal definition

  • nuclear

  • multigenerational/extended

  • blended

  • lone-parent

  • same-sex parent

impact of change on family system

• one-parent family

• divorce

• ill family member

• complex med conditions

family’s role in growth/develpment

• proved safe, caring, supportive environment

• help children learn, grow, build confidence

• teach values, culture, traditions passed via generations

• sense of identity/belonging 

Calgary Family Assessment Model 

• CFAM

• guide to understand family structure, development, functioning

structural assessment (CFAM)

• identify family members, relationships, contet

• genograms (family trees) + ecomaps (outside connections (social relationships/supports))

• sample questions

  • Who are the members of your family?

  • Has anyone moved in or out lately?

  • Are there family members who don’t live with you?

developmental assessment (CFAM)

• describe development life cycle/stages 

• sample questions 

  • What do you most enjoy about your life?

  • What do you regret?

  • Have you planned for care as health declines?

functional assessment (CFAM)

• how family members interact

  • instrumental aspects = daily activities (meals, meds)

  • expressive aspect = communication, problem solving, roles 

• sample questions

  • Who ensures Grandma takes her medicine?

  • Whose turn is it to make dinner?

  • How can we get Martin to help with care?

cultural safety

• ensure care is free of discrimination/racism

• focuses on power balance in nurse-pt relationship

• pt decides if care feels safe

cultural humility

• approach as learner, reflecting on own biases

• build respect, trust-based relationships

• recognized that your cultural norms are NOT the standard 

family decision making + nurses support

• families create own way to solve problems/make decisions

• choices based on values, beliefs, social influences

• decision-making stems from tradition or discussion 

• all families = strength/potential for growth

• nurses recognize/support strengths to promote well-being 

Family Nursing

• families central to perinatal/paediatric nursing

• nurses treat families with respect/dignity

• listen to family POV/honor choices

• share info clear, accurate, helpful

• Support families to take part in care/decisions at their comfort level

Family Nursing - Family-Centred Care

• nurse = unique communication style/beliefs

• nurses must respect culture differences

• focus on whole family, not just indivisuals

• consider home, community, social factors that affect health

• build meaningful relationships to support wellness/equity 

Summary of Family Nursing

• collaborative - family needs/goals

• strength-based - family + communication resources

• respectful - value family knowledge/expertise

• family-centered - multidisciplinary/family-focused care principles

Paediatric nursing

• improve quality of healthcare for children/families

• health promotion/surveillance - well-child/baby visits 

  • developmental

  • nutrition

  • oral health (start solids)

• children health problems

• trusting/collaborative relationship with child/family 

philosophy of care - paediatric nursing

• Canadian Paediatric Nursing Standards (5 standards)

  • I = supporting/partnering with child + family (engagement/empowerment)

  • II = advocating for equitable access + rights of children + their family (SDOH + systematic influences)

  • III = delivering developmentally appropriate pediatric care (validated tools, knowledge of growth, developmental parameters)

  • IV = creating child-and-family-friendly environment (family assessment, inclusive/safe)

  • V = enabling successful transitions  

family-centered care + SickKids Model of Child/family-centered care - paediatric nursing

• enable and empower

• SickKids

  • respect

  • communication

  • partnership 

• pt experience

• pt safety

• health equity

• optimal health 

atraumatic care - paediatric nursing

• WHO, WHAT, WHERE, WHEN, WHY, HOW of any procedure

• minimize physical/psychological distress 

• do no harm 

Adverse Childhood Experience (ACE)

• negative impacts on children’s experience

• impacts mental and physical health

• from childhood carried through to adulthood 

• we want to minimize the risk of retraumatization the patient 

therapeutic relationships

• boundaries established

• communication with families + children

  • appropriate introduction

  • assurance of privacy/confidentiality 

parents - communicating with families

• encourage parent to talk

• directing focus

• listening/cultural awareness

• providing anticipatory guidance

• avoiding communication blocks

  • communication barriers

  • info overload

• communicating with families via interpreter

children - communicating with families

• infancy

  • non-verbal communication

  • rely on cues

  • infants respond to adults non-verbal behaviours

• early childhood

  • <5 yrs

  • egocentric = communication focussed on them

  • touch/examine articles 

  • “stick in the arm” is literal to them = avoid (unfamiliar equipment kept out of view)

• school-aged

  • rely on what they know 

  • want to know function of objects 

  • concern with body integrity = provide reassurance  

• adolescence

  • more willing to interact with someone outside the family 

  • reject those who try to impose their own values on them 

  • if parent present, talk with adolescent first 

  • confidentiality important 

identifying info - PED health hx

• name, DOB, gender, religion, place of birth

• adress, phone #, email

• date of interview, name of informant, relationship to pt

presenting health concern - PED health hx

• RSC

• avoid leading/labelling-type questions 

hx of present illness (HPI) - PED health hx

• onset/duration of symptoms

• description/progression of illness

• current status of condition

• RSC now

past health hx - PED health hx

• gives us pt risk factors

• previous illness

• hospitalizations

• surgeries 

general - PED health hx

• allergies (food, med, environment, associated reactions)

• current meds

• immunizations 

• growth/development

  • growth patterns (weight/length), teeth, milestones (head control, sit, walk, first word), school, family incomes, MH, substance use, food security 

• habits

  • concerns of habits, activities, development

    • walking on ties, picky eater 

family med hx - PED health hx

• identify genetic/hereditary conditions and family disease patterns

• assess potential exposure to communicable disease/environmental risks

  • smoking/chemical use 

family and social background - PED health hx

• family composition/home environment

• occupation/education of family members

• cultural, religious, community influences 

• family functioning/relationships

review of systems (ROS)/Head-to-toe - PED health hx

• general

• skin

• HEENT

• chest

• respiratory

• CV

• GI

• GU/GYN

• MSK

• Neuro

• Endocrine

general ROS - PED health hx

• overall health

• fatigue

• recent weight changes

• fever

skin ROS - PED health hx

• rashes (location)

• pruritus (itching)

• bruises

HEENT ROS - PED health hx

• headaches

• visual changes

• eye/ear discharge

• limited ROM

chest ROS - PED health hx

• breast enlargement

• masses

• enlarged axillary nodes

respiratory ROS - PED health hx

• cough

• SOB

• wheezing 

CV ROS - PED health hx

• tachycardia

• pale

• cyanosis

• fatigue on exertion

GI ROS - PED health hx

• loss of appetite

• vomiting

• diarrhea

GU/GYN ROS - PED health hx

• dysuria

• polyuria

• discharge

MSK ROS - PED health hx

• weakness

• fractures

• abnormal gait

neuro ROS - PED health hx

• seizures

• tremors

• speech impairment

endocrine ROS - PED health hx

• excessive sweating

• early/late puberty 

general approach to examining children

• least → most invasive (BP, rectal temp, ears, eyes, throat)

• use developmental/chronical age 

  • minimize stress/anxiety associated with assessment

  • foster trusting nurse-child-parent relationship

  • all max prep of the child

  • preserve security of parent-child relationship (young children)

  • max accuracy/reliability of findings 

assessment approach - infants

• before able sit alone = examine on parent lap when possible

• after able to sit alone

  • examine on parent lap or exam table

  • always keep parent in full view

  • prep tips

    • undress infant, but keep warm

    • use distraction aid cooperation (toys/talking)

    • speak soft, gentle touch

    • pacifiers as permitted = sooth

    • involve parent for comfort/safe restraint

assessment sequence - infants

• auscultation (HR, RR) - if quiet

• front - back (anterior-posterior) 

• palpate/percuss after inspection

• head-toe sequence

• eyes, ears, mouth = INVASIVE (assess near end)

• reflexes last (avoid distress) 

PED Assessment Triangle

• initial across-the-room assessment

  • rapid evaluation tool

  • establishes clinical status 

    • identify critically ill/sudden deterioration

  • 60 sec - no equipment 

• Guides clinical decision-making

  • How severe is the injury/illness?

  • What is the potential physiologic abnormality?

  • How urgent is treatment needed?

• consider child’s normal baselines

Components of PED Assessment Triangle

• Appearance (TICLS)

  • tone

  • interactiveness

  • consolability

  • look/gaze

  • speech 

• Work of Breathing

  • breath sounds

  • positioning

  • retractions

  • flaring

  • apnea/gasping 

• Circulation

  • pallor

  • mottling

  • cyanosis 

respiratory differences 

• narrow airway = risk of obstruction

• high metabolic rate = faster RR for O2 consumption

• ventilation relies on diaphragm = tire quicker

• less alveoli = impaired O2 = faster RR

cardiovascular differences

• low circulating blood volume = faster HR, sensitive to fluid loss

• large body surface area = greater fluid loss via evaporation 

neuro differences

• thermoregulation no well developed (infants) = hypothermia

• immature motor development = risk for falls 

GI differences

• high metabolic rate = high food/fluid requirements

• poor glycogen storage = rapid hypoglycemia 

renal differences

• inability to concentrate urine = water loss

  • expected urine OP = 1-2mL/kg/day 

• slower excretion of some drugs 

airway

• patent

• smaller airway - obstruction risk

• supporting cartilage

  • not developed until school aged

• larynx = anterior-superior

  • narrowest portion at cricoid cartilage

• large tongue/head + weak neck muscles = obstruction risk

• neonates = nose breathers 

breathing

• small thorax + closely positioned organs

• cartilaginous ribs (twice as flexible as adults)

  • chest retractions = distress

• horizontal ribs = limited chest expansion

• underdeveloped intercostal muscles 

  • relies on diaphragm/abdo muscles 

• lower lung volume/compliance = less compensatory reserve 

  • tires easily

• immature immune system (lower IgA (secretions, first line of defense), IgG (long-term immunity, secondary immune response)

  • higher risk of infections

breathing - normal findings

• regular breath pattern

  • no extra effort/audible sounds

• thin, flexible chest wall

  • movements/sounds easily seen/heard

beginning - respiratory distress to failure continuum

• tachypnea

• nasal flaring

• stridor

• expiratory wheeze

• pale

• compensate for long time but crash quickly 

middle - respiratory distress to failure continuum

• tachypnea, RR >60

• grunting

• mottled

• head bobbing

• inspiration/expiration wheeze

• diminished air entry

• compensate for long time but crash quickly 

end - respiratory distress to failure continuum

• dyspnea

• seesaw respirations

• grey/cyanotic

• silent chest

• changes in LOC/activity

• stop breathing → cardiac arrest next 

• compensate for long time but crash quickly 

circulation

• growth = HR decrease, BP increase (normal trend)

• cardiac output depends on HR

  • decrease HR = decrease CO

• hypotension late sign of cardiac compromise (opposite of adults)

  • infants SBP <79 mmHG = hypotension 

  • infant is compensating, will crash quickly

circulation - normal findings

• skin = warm, normal colour, well-perfused (cap refill)

• pulse = central/peripheral strong/equal 

• assess quality, intensity, rate, rhythm, presence of murmurs, apical impulse location 

neuro

• cerebral cortex function

  • AVPU response scale

  • glasgow coma scale 

• LOC

• mental status, interaction

• activity, movement, muscle tone

• age-appropriate responses

neuro - glasgow coma scale PED

• eye - 4

  • 1 = no eye open

  • 2 = to pain

  • 3 = to speech

  • 4 = spontaneous

• verbal - 5

  • 1 = none

  • 2 = moan to pain

  • 3 = inappropriate words

  • 4 = cries but consolable 

  • 5 = coos/babbles (normal for age)

• motor - 6

  • 1 = no movement

  • 2 = abnormal extension

  • 3 = abnormal flexion

  • 4 = withdraws from pain

  • 5 = localizes pain (move to pain)

  • 6 = obeys commands/moves appropriately  

• score

  • <8 = severe injury/coma

  • 9-12 = moderate injury/decreased LOC

  • 13 - 15 = midl injury/ fully alert 

neuro - AVPU PED

• Alert

  • awake, interacts appropriately for age 

  • eye contact, track movements, smiles, cries appropriately, responds to caregivers/toys 

• responds to verbal stimuli

  • responds when spoken to/caregiver voice heard

  • turns head to voice

  • opens eyes/noise when called

• responds to pain

  • not to voice but painful stimulus

  • cries, withdraws, grimace

• unresponsive 

  • no response to voice/pain

    • no movement, cry, eye open

    • flaccid tone

head and neck

• shape and symmetry

  • even moulding

  • occipital prominence

• fontanelles + suture lines (smooth, flat, not bulging (intracranial pressure) or sunken (dehydration))

  • anterior closes @ 12-18 months 

  • posterior closes @ 2 months 

• large head + shorter neck

• thyroid NOT visible 

eyes

• light perception, fix + follow

• fixate on one visual field, binocularity (use both eyes together) 3-4 months

• depth perception 7-9 months 

mouth + throat

• pink, moist, smooth lip + mucous membrane

• large tongue = obstruction risk

• primary teeth (5-6 months)

  • lower central incisors = drooling 

abdomen

• round, cylindrical/prominent (especially after feeds)

• active BS, peristaltic waves 

immunologic system maturation

• maternal IgG = passive immunity for 1st few months of life

• IgG = systemic, long-term defense, crosses placenta, secondary (memory) 

hematologic system maturation

• transition from fetal Hg (HgbF) → hemoglobin (HgbA) 

• may cause physiological anemia 2-3 months 

digestive system maturation

• enzyme activity (amylase (carbs), lipase (fats)) immature

• limiting fat/starch digestion 

thermoregulation maturation

• more efficient as infant matures

renal function maturation

• immature kidneys = limited ability to concentrate urine

• high risk of dehydration

sensory development maturation

• hearing well developed

• vision improves gradually

• binocularity + depth overtime

  • bino = 3-4 months

  • depth = 7-9 months

infant vital signs

• Temp ALWAYS 36.5°C – 37.5°C

• HR decrease with age

• RR decrease with age

• BP increase with age 

• always consider child’s normal range, clinical condition, VS trend 

0-3 months - infant vital signs

• HR = 100 - 160

• BP = 65-85/45-55

• RR = 30-60

• Temp =  36.5°C – 37.5°C

3-6 months - infant vital signs

• HR = 90-120

• BP = 70-90/50-65

• RR = 30-45

• Temp =  36.5°C – 37.5°C

6-12 months - infant vital signs

• HR = 80-120

• BP = 80-100/55-65

• RR = 25-40

• Temp =  36.5°C – 37.5°C

assessing vital signs

• temp = axillary/rectal

• pulse

  • apical 1 min

  • rate, rhythm, quality

  • location = 4th intercostal, left midclavicular line

• resp

  • 1 min count

  • crying? - wait to do RR

• BP

  • not in healthy newborns

  • cuff size (40% arm circumference = width, 80-100% = length) 

  • method

• O2 sat

  • adhesive sensor or clip on 

  • location

• pain

  • FLACC (face, legs, activity, cry, consolability)

  • NIPS (face, cry, breathing, arms, legs, arousal)

doppler BP

• ONLY SYSTOLIC measurement

• doppler detects arterial BF = sounds each heart beat

• inflate cuff to stop BF

• deflate slowly until sounds returns = SBP

4 screening tools + growth charts

• Rourke baby record

• nipissing district developmental screen (NDSS)

• greig health record

• WHO growth charts 

Rourke baby record

• newborn - age 5

• documentes

  • well-baby

  • child visits

  • immunizations

  • resources

• Growth monitoring, assessing nutrition, physical examination, education, and health care advice

• chart development, child behaviour, parenting resources, immunization, and infectious diseases

• Visits at 1 and 2 weeks; 1, 2, 4, 6, 9,12, 15, 18, 24,

  36, 48, and 60 month

nipissing district developmental screen (NDSS)

• parent-completed tool screen

• for developmental delays

  • 1 month - age 6

• age-specific checklist

• promotes early detection + intervention

• fine/gross motor skills, speech/language, cognitive, social/emotion, self-help/adaptive skills

WHO growth standard - WHO growth charts for canada

• assess ideal growth

• monitor growth (weight, length, height, head circumference, BMI)

  • birth - 59 months (age 5)

• ID growth patterns/nutritional/health concerns 

WHO growth references - WHO growth charts for canada

• observe growth

• track school-aged and adolescent trends

• 5 to 19 yrs 

parameters plotted - WHO growth charts for canada

• weight for age

• length/height for age

• weight for length

• BMI for age

• head circumference for age 

• data plotted as percentiles 

  • ex. 10th percentile weight =

    • 10 children weigh less

    • 90 children weigh more

  • can be normal if child is still on growth curve

    • skipping curves = concern

weight - normal growth/development

• gains 150-200g/week until age 5-6 months

  • 30grams/day 1 month

  • 20grams/day 4 months 

• double birth weight by 4-6 months

• triple birth weight by 1 yr

height - normal growth/development

• increased by 2.5 cm per month for 6 months

• then in “spurts” 

Biologic growth is influenced by…

• Genetic

• Metabolic

• Environment

• Nutrition

• Health status

fine motor development

• birth = hands closed, grasp, clench

• 5 months = grasp voluntarily

• 6 months = grasp/manipulate small objects 

• 8-10 months = crude pincer = whole hand + thumb

• 11 months = neat pincer = tip of hand + thumb

• 12 months = turns pages of book 

gross motor development

• head 1st, then trunk

• birth = marked head lag

• 2 months = less head lag

• 4-6 months = good head control

• 5 months = sit with support, turn abdo to back

• 6 months = back to abdo, sit with support

• 8 months = sit WITHOUT support

• 11 months = cruises + furniture hold

• 12 months = walk with 1 hand held 

Erikson - psych development

• trust vs mistrust

• birth 1 yr

• importance of caregiver/infant relationship

  • caregiver ID cries

Piaget - cognitive development

• sensorimotor stage

  • senses + ability to move = understand the world

  • colour, images, sounds, etc

• birth - 24 months

• object permanence

  • visualize object that is outside field of view 

• reflective → simple repetitive acts 

language + personal-social behaviour

• cry = 1st communication

• vocalization week 5-6

• cries → coos → babbles

• “dada” + “mama” with meaning + ‘bye'-bye” @ 10 months

• 12months - 3-5 words 

concerns related to normal growth/development

• attachment

  • separation anxiety = 6-8 months

  • stranger danger/fear

• limited setting/discipline

  • time-out (playpen, baby gate)

  • no cost-effect

  • put way dangerous household items

• thumb sucking/pacifier

• teething 

Health Promotion and Anticipatory Guidance for Familie

• nutrition

• sleep

• immunizations

• dental health

• injury prevention/safety

  • falls, MVA, choking, burn, abusive head trauma (shaken baby syndrome)

• ingestion 

infant nutrition

• 6 months = BF/formula

• solids at 6 months

  • iron fortified cereal

  • rice, barley, oatmeal, multigrain 

• veggies, fruits, strained meats

  • introduce 1 at a time

• eggs/nuts

  • NO LONGER delayed to 1 yr

    • introduce allergens one at a time when introducing solids

• whole cows milk/honey

  • DELAYED until 1 yr

  • milk = affects Fe absorption = anemia

  • honey = botulism (blood poisoning) = paralysis

• vitamin D (400 IU daily)

2-4 months immunizations

• DTap-IPV-Hib

• Pneu-C-13

• Rota

6 months immunizations

• DTap-IPV-Hib

• Rota

12 months immunizations 

• Men-C-C

• MMR

• Pneu-C-13

additional immunizations

• influenza - during flu season

• RSV - for high risk pt

• Hep B - if warranted

bronchiolitis

• LOWER resp tract infection

• caused by RSV (incubation period 2-8 days)

• epithelial cells of resp tract swell, fuse, obstruct 

• highly contagious

• common <2yrs (day care)

• droplet + contact (NOv-Apr)

risk factors for severe bronchiolitis

• chronic lung disease

• congenital heart defects (ex. PDA)

• neuromuscular/immunodeficiency comorbidities