Families Exam 3

Family Unit Assessment:

performed to identify strengths & weaknesses

Family Unit Assessment: History

medical hx for grandparents, parents, & siblings

Family Unit Assessment: Structure

family members (mom, dad, siblings)

Family Unit Assessment: Developmental tasks

tasks a family works on as the child grows (parents with a school-age child helping them develop peer relations)

Family Unit Assessment: Family Characteristics

cultural, religious, economic influences on behavior, attitudes, & actions

Family Unit Assessment: Family stressors

expected (birth of child) & unexpected (illness, divorce, or death of family member) events that cause stress

Family Unit Assessment: Environment

availability of and family interactions with community resources

Family Unit Assessment: Family Support System

availability of extended family, work & peer relationships, social systems, & community resources (to assist the fam in meeting needs or adapting to stressors)

Single Parents

Increased stress --> affects how they retain information we give
1. Finances
2. Frustration
3. Role changes
4. Abandonment issues

Toddlers' psychosocial/developmental changes (1-3yrs)

Erikson: autonomy vs shame & doubt – potty training!

- Independence is paramount: attempting to do everything themselves

- Use negativism, or negative responses, as they begin to express their independence

- Routines = provide a sense of comfort

Toddlers’ Moral and Physical Development

Moral

- Egocentric: can't see from other’s POV

- Punishment & disobedience orientation: sense that good behavior is rewarded & bad is punished

Physical:

- Anterior Fontanelle: closed by 18 mo

- Posterior Fontanelle: closed by 8 weeks

Toddlers’ Language Development

- 1 year: one-word sentences (holophrases) ("mine", "go"), 2-3 words, understand no

- 2 years: multi-word sentences (2-3 word phrases)(vocabulary 50-300 words)

- 3 years: several words for simple sentences with grammar rules

Develop gender identity by 3 years of age

Toddlers' immunizations (ages 1-3)

12-15 months

- Inactivated poliovirus (3rd dose between 6-18 months)

- Haemophilus influenza type B

- Pneumococcal conjugate vaccine

- MMR: measles, mumps, & rubella

- Varicella

12-23 months: Hep. A: given in 2 doses at least 6 months apart

15-18 months: DTaP (diphtheria, tetanus, acellular pertussis)

12-36 months

- Yearly flu vaccine

- Live attenuated flu by nasal spray (2 years or older), inactivated if < 2 years

Toddlers' nutrition (ages 1-3)

· Physiological anorexia occurs -> fussy eaters because of decreased appetite -> not growing as fast

· May need to expose food 15-20x before child accepts it (picky eater) --> FINGER foods

· Should consume 16-24 oz of milk/day: may switch from whole milk to drinking LOW-FAT skim after age 2.. NOT 2% milk

· Juice should be limited to 4-6 oz/day

· Avoid trans & fatty acids, high sugar, high fat, & sodium

Choking hazards (until 4yrs old) – foods to avoid

- Nuts

- Grapes

- Hot dogs

- PB

- Raw carrots

- Dried beans

- Tough meats

- Popcorn

· Should not be allowed to engage in drinking/eating during playtime or while laying down and must have adult supervision

· Food serving size: 1 tbsp for each year of age

· Consume iron (best with vitamin C) and Vitamin D (milk, cow, soy + fatty fish, sunlight)

Toddlers' safety (ages 1-3)

· Aspiration
· Bodily harm
· Burns: thermostats or water heater should be set at less 120
· Drowning
· Falls: normal bumps & bruises on knees/elbows
· MVI
- Remain in rear-facing car seat until 2 years
- Backseat is safest
· Poisoning
· Suffocation

Toddlers' (ages 1-3) - gross motor skills

Large Muscles

15 months

- Walk without help

- Creep up stairs

18 months

- Runs clumsily; falls often

- Throws ball overhand

- Jumps in place with BOTH feet

- Pulls & pushes toys

2 years

- Walk up/down stairs by placing both feet on each step

2.5 years

- Jumps across floor & off a chair or step using both feet

- Stands on one foot momentarily

- Takes a few steps on tiptoe

Toddlers' (ages 1-3) - fine motor skills

Small Muscles

15 months

- Uses cup well

- Build tower of TWO blocks

18 months

- Manages a spoon without rotation

- Turns pages in book (2-3 at a time)

- Builds tower of 3 or 4 blocks

2 years

- Build tower of 6-7 blocks

- Turns pages 1 at a time

2.5 years

- Draws circles

- Good hand-finger coordination

Toddlers' (ages 1-3) sleep disturbances

· Resistance to bedtimes & nightmares
· Maintain regular bedtime & bedtime routines
· 11-12 hours of sleep/day, including naps (until older toddlerhood)

Preschool psychosocial/developmental changes

(3-6 yrs old)

Erikson: initative vs guilt – exploration!

- Begin to assert control/power over environment = initiative

- Misbehavior or unable to accomplish task = guilt

Social Development:

- no stranger anxiety + less separation anxiety (prolonged separation = anxiety -> decrease w toys/play)

- pretend play = healthy

- parallel play shifts to associative play

Preschool immunizations

· 3-6 years: seasonal flu, trivalent inactivated flu, or live attenuated flu by nasal spray
· 4-6 years: Dtap, MMR, varicella, IPV (inactivated polio vaccine)

Preschool nutrition (3-6 yrs old)

· Mildly active: need 1,200-1,400 kcal/day
· Finicky(picky) eating until year 5
· 13-19 g/day of protein, adequate calcium, iron, folate, vitamin A & C
· 5 servings of fruits & veggies per day
Concerns:
- Overeating
- High fat & sugar foods
- Lead poisoning (putting stuff in mouth)
- Iron deficiency anemia

Preschool reportable findings

Regression: regress to play like a toddler, rather than a preschooler
- Nose picking, bed wetting, thumb sucking

Preschool safety

· Bodily harm
· Burns
· Drowning
· MVIs: once forward-facing car seat is outgrown, use booster until 8-12 years or 4'9

Preschool - gross motor skills

· 3 years: ride tricycles, jump off the bottom step, and stand on one foot for a few sec.
· 4 years: skips & hops on one foot, throws ball overhead, catches ball reliability
· 5 years: jumps rope, walks backward heel to toe, throws & catches ball with ease

Preschool - fine motor skills

· Dresses independently
· Holds a pencil, draws self & others
· Plays simple board games

Preschool sleep disturbances

· Need 12 hours of sleep

· Problem range from difficulty going to bed (night terrors)

Interventions

- Bedtime routine

- Night light in room

- Give their favorite toy

- Leave water by bed

- Reassure preschoolers who are frightened but AVOID allowing preschoolers to sleep with parents(Ex: DO NOT stay with child and watch movie with them till they fall asleep)

Adolescents' psychosocial/developmental changes

(13-20)

Erikson: identity vs role confusion – social relationships!

- Need to develop a sense of self & personal identity

- Success=sense of competence

- Failure = feelings of inferiority

- Group identity: become part of peer group that influences behavior

Psychological health

- Mood swings

- Introspection(examining owns feelings) is increased in mild adolescence

- Behavioral autonomy: ability to make decisions

- Body image established during adolescence is retained throughout life

Adolescents' immunizations

- Yearly flu
- Meningococcal (MCV4): booster if first shot was taken before 13-15 years

Adolescents' nutrition

High metabolism = increased quality of nutrients

- Additional calcium, iron, protein, zinc

Overeating & undereating

- Avoid using food as a reward

- Encourage physical activity

- Healthy food choices is the key

Eating disorders

- Yearly assessment of height, weight, & BMI to identify nutritional issues & early identification

Adolescents' reportable findings

· Be aware of mood changes: monitor for self-harm
· Poor school performance
· Lack of interest in things that were interesting before
· Social isolation
· Sleep/appetite disturbance

Adolescents' safety

· Bodily harm
· MVI
· Substance use disorder
· Burns
· Drowning

Adolescents' informed consent

Can make decisions at age 18!!
- if emancipated and have documents they can give consent < 18

VS ranges: from birth - 4 weeks

HR: 110-160

RR: 30-60

BP: 64/41

VS ranges: infant (1-12 months)

HR: 90-160

RR: 25-30

BP: 85/50

Temperature

3 - 6 months: 99.5F

1 year: 99.9F

VS ranges: toddler (1-2 years)

HR: 80-140

RR: 25-30

BP: Sys/Dia

- Male: 85-91 / 37-46

- Female: 86-89 / 40-49

Temperature (1 year): 99.9

VS ranges: preschooler (3-5 years)

HR: 70-120

RR: 20-25

BP: Sys/Dia

- Male: 91-98 / 46-53

- Female: 89-93 / 49-52

Temperature:

- 3 years: 99

- 5 years: 98.6

VS ranges: school age (6-12 years)

HR: 60-110

RR: 20-25

BP: Sys/Dia

- Male: 96-106 / 55-62

- Female: 94-105 / 56-62

Temperature:

- 7 years: 98.2

- 9 years: 98.1

- 11 years: 98.1

VS ranges: adolescent (13-18 years)

HR: 50-100
RR: 16-20
BP: 120/80
Temperature: 97.9 (13 years)

Infant assessment: Circulatory system

· Neck veins

· Clubbing of fingers, peripheral cyanosis

· Edema

· BP, pulses, cap refill

· Respiratory status

· Heart sounds

- S1 louder over apex & S2 louder over base

- Sinus arrythmia associated with respirations are common

- Splitting of S2 & S3 are expected in some children

· Pulses

- Infants = brachial, temporal, femoral

- Children & adolescents = same as adults

Infant assessment: Abdomen

· Infants & toddlers = round abdomen

Infant Assessment: Spine

· Without dimples or tufts of hair

· Overall C-shaped lateral curve

Infant Assessment: Neuro

· Infant reflexes

· Cranial reflexes

· DTRs

Infant reflexes

Birth – 1 month: stepping

Birth – 4 months

- Sucking & rooting (stroking the cheek/edge of mouth: newborn turns head toward side and starts to suck)

- Palmar grasp: baby curls fingers around examiners hand

- Tonic neck reflex/fencer (turns newborn's head quickly to one side· Newborn's arm & leg on that side extend & opposing arm & leg flex)

- Moro reflex: let them fall & they form c shape

Birth – 8 months

- Plantar grasp

Birth – 1 year

- Babinski (stroke outer edge of foot and toes fan out)

Pediatric & infant dosage calculations & admin: Oral Method

preferred: available in liquids, chewable, & meltaway

- Use smallest measuring device for doses of liquid med

- Use an oral med syringe for smaller amounts & plastic med cup for larger amounts; NEVER SPOON NOR PAPER CUP

- Avoid measuring in tbsp or tsp

- Avoid mixing meds or using in formula

- Admin in side of mouth in small amounts and stroke under chin to promote swallowing

Pediatric & infant dosage calculations & admin: Optic

place supine or sitting -> look up and extend head -> pull lower eyelid down inward -> admin ointment from inner-outer canthus before nap/bedtime

Pediatric & infant dosage calculations & admin: Otic

- Younger than 3 yrs: pull pinna downward & straight back

- Older than 3 yrs: pull upward & back

Pediatric & infant dosage calculations & admin: Aerosol

use mask for younger children

Pediatric & infant dosage calculations & admin: Injections

SQ: inject volumes < than 0.5mL with a 26-30G needle (90 degree - normal, 45 degree for thin children)

IM: use 22–25- 1/2-1 in. gauge needle, vastus lateralis is recommended for infants & small children (up to 0.5 ml in INFANTS and 2mL in CHILDREN)

IV: use 24-22 gauge catheter

Infant & pediatric-specific methods of med admin

Provide atraumatic care when administering meds to children
- Use approaches appropriate to their developmental level
- Give choices to decrease powerlessness
- DO NOT use restraints unless necessary for safety
- Give honest explanations
- Use familiar & understandable terms such as "pinching" "stinging"
- Give age-appropriate rewards AFTER admin to encourage the child & reinforce appropriate behavior
- Encourage parents to help distract & hold the child

Pain assessment: Infants

Young infant

· Loud cry

· Rigid body or thrashing

· Local reflex withdrawal from pain stimulus

· Eyes tightly closed, mouth open, eyebrows drawn together

Older infant

· Loud cry

· Deliberate withdrawal from pain

· Facial expressions

Pain Assessment: Toddler

· Loud cry or screaming

· Verbal expressions of pain

· Thrashing of extremities and attempt to push away or avoid stimulus

· Clinging to significant person/noncooperation

Pain Assessment: School-age & Adolescent

School-age

· Stalling

· Muscular rigidity

Adolescent

· More verbal expressions with less protest

· Muscle tension with body control

Pain scales: FLACC

2 months-7 years

· Face

· Legs

· Activity

· Cry

· Consolability

Pain scales: Numeric scale

5 years & older

· Pain rated 0-10

Pain scales: FACES (Oucher)

3-13 years

· Pain rated 0-5 using 6 photos

· Ask child to choose pic that best describes how they are feeling

Pain scales: Non-communicating children's pain checklist

3 years & older

· Behaviors are observed for 10 min

· 6 subcategories are each scored on a scale 0-3

· 6-10 = mild pain

· 11+ = moderate to severe pain

Opioid admin

· Used for moderate to severe pain

· Morphine sulfate is the drug of choice

· Fentanyl for ages older than 12

· Rapid relief = IV bolus

Oral meds

- 1-2 hours for peak effects

- Not suited for kids in pain requiring rapid relief/fluctuating pain

· IM injections: not recommended

NSAIDs

· Used for mild pain in ages greater than 3 months
· Acetaminophen & NSAIDs are acceptable for moderate pain
· NO Ibuprofen until greater than 6 months
· NO ASPIRIN = Reye's Syndrome!

Tracheostomy care

- No inner cannula

- Provide humidification: adequate hydration

- Oral care Q2

- Trach care Q8

- Clean with soap & water, dry area, assess for infection, skin breakdown

- Change non-disposable tube Q6-8 weeks

For emergencies

- Keep same trach size & one size smaller at bedside

- Obturator at beside

- Scissors to cut old strings

Croup syndromes: acute laryngotracheobronchitis Priority findings

· Low-grade fever (less than 101.4)

· Restlessness/Hoarseness

· Barky cough

· Inspiratory stridor

· Retractions

· Infants/toddlers may have nasal flaring

Croup syndromes: acute spasmodic laryngitis (non-bacterial) priority findings

· Paroxysmal (sudden) attacks of laryngeal obstruction that usually occur at night

· Croupy barky cough

· Restlessness/Hoarseness

· Difficulty breathing

Croup syndromes: acute laryngotracheobronchitis & acute spasmodic laryngitis (non-bacterial) nursing interventions

· Provide humidity with cool mist, admin O2 PRN

· Continuous pulse ox

· Admin nebulized racemic epinephrine

· Admin oral/IM corticoidsteroids: dexamethasone or nebulized budesonide

· Encourage oral intake

· Admin IVF

Croup syndromes: bacterial epiglottis (acute supraglottis) priority findings

MED EMERGENCY!

- Hoarseness (dysphonia) - Absence of cough, high fever

- Restlessness/Tripod position

- Drooling = airway obstruction

- Agitation

- Inspiratory stridor (upper airway narrowing) * steeple sign on x-ray (dx) or thumb sign (x-ray shows inflammation)

- Dysphagia

- Sore throat

Croup syndromes: bacterial epiglottis (acute supraglottis) nursing interventions

· DO NOT ASSESS AIRWAY or THROAT CULTURE UNTIL STABLE

· Prepare for intubation

· Provide blow by humidified O2 (dinosaur mask)

· Droplet isolation precautions for first 24 hr after IV ABX started (usually ceftriaxone)

· Cortocoidsteroids & IVF

diagnostic = lateral neck radiograph = thumb print

Bronchiolitis causative agent

Mostly caused by respiratory syncytial virus (RSV)

Bronchiolitis/RSV priority findings

initially: rhinorrhea, intermittent fever, cough and wheezing etc

Severe:

- Apnea - no respirations for more than 20 seconds + hypoxia and bradycardia

- Poor breath sounds/air exchange, cyanosis, listlessness, apneic spells

- RR greater than 70/min

Bronchiolitis plan of care

· Suction first!!!!!
· Change to IVF or tube feeding, no oral feeding for RR >60
· Corticosteroids & bronchodilators NOT recommended
· Encourage fluid intake if able to tolerate
· ABX if coexisting infection is present
· Maintain O2 > 90%
· Encourage breastfeeding if baby's RR less than 60, if above 70 = NPO

Bacterial pneumonia lab findings

· X-ray infiltrates
· Gram stain/culture
· Blood cultures
· Elevated ASO titer: blood test to measure antibodies against streptolysin O (produced by group A strep)

Bacterial pneumonia nursing care/interventions

· Chest physiotherapy (CPT) and postural drainage can be helpful: pounding on chest/back to beat things up
· Culture first then abx
· O2 & pulse ox
· Increase fluid intake
· Antipyretics for fever
· REST

Tonsillitis priority to report

· Trismus (inability to open mouth) = lockjaw = immediately report
· Sore throat, difficult swallowing
· Ear infection/hearing loss
· Mouth odor
· Fever, tonsillar exudate

Tonsilitis pre- op/post op care

Pre-op: NPO

Post-op:

Positioning: side lying to facilitate draining, elevate HOB when fully awake

Assessment: assess for evidence of bleeding:

- frequent swallowing, restlessness, bright red emesis, tachycardia, pallor, persistent cough, increased BP – drop in BP

Comfort measures

- Admin acetaminophen, hydrocodone(for children having difficulty drinking fluids), or tetracaine lollipops

- Ice collar

- Ice chips & water

Diet

- Clear liquid after return of gag reflex – NO RED liquids/citrus juice/milk foods initially

- Advanced diet with SOFT bland foods for 2 weeks

Tonsillitis parent education

· Contact provider if child has difficulty breathing, lack or oral intake, increased pain
· Soft foods for 2 weeks even if feeling better
· No nose blowing/strenuous activity
· Increase fluids
· Watch for S/Sx of infection &/or hemorrhage (frequent swallowing and clearing of throat, tachycardia, hemoptysis)

Tonsillitis complications

· Hemorrhage -> greatest risk = first 72 hrs then 7-10 days (hypotension is a late sign)
· Dehydration
· Chronic infection -> rheumatic fever (fever, painful tender joints)
· Kidney infection

Cystic fibrosis nutrition

- 3 meals & snacks: HIGH calorie and HIGH protein

- Pancreatic enzymes

· Give with food within 30 min (ALL meals & snacks)

· Swallow or sprinkle on food (NOT protein)

· Monitor stools (1-2/day)

- Daily multivitamin & fat-soluble vitamins: ADEK

- Laxatives/stool softeners for constipation

Cystic fibrosis priority findings

Meconium ileus at birth - EARLIEST sign

(distention of abd, vomiting, inability to pass meconium)

Early Manifestations: wheezing, rhonchi, dry cough

Respiratory:

- cyanosis

- barrel-shaped chest

- clubbing of fingers & toes

·- frequent respiratory infections: multiple episodes of bronchitis

- mucus plug

Steatorrhea

- large bulky foul smelling stools

- voracious appetite - EARLY

- loss of appetite - LATE

- failure to gain weight or weight loss

Skin: SALTY TASTE TO SKIN

- sweat, tears, & saliva are excessively high (chronic metabolic alkalosis)

Cystic fibrosis Dx

· Sweat chloride test (pilocarpine iontophoresis)

- confirmation: Chloride > than 40 for infants less than 3 months and > 60 for everyone else

· DNA testing

· PFT (Pulmonary function tests)

· Chest x-ray

· Stool analysis

Cystic fibrosis self-management

For cystic fibrosis-related diabetes (CFRD)
- Quarterly A1C levels
- Insulin
ACT: airway clearance therapy (avoid immediately before and after meals)
· CPT & breathing exercises
· Immunizations: flu & pneumococcal
· Physical activity

Cystic fibrosis: what is Dornase Alfa (aerosol)

· Decreases the viscosity of mucus & improves lung function

· Given with Albuterol by nebulizer in combo with CPT

· Refrigerate and protect from light, store in foil and AVOID before/after meals

Cystic fibrosis administration of aminoglycosides

· Tobramycin, ticarcillin, gentamicin
· Monitor therapeutic levels before and after (peaks & troughs)

Asthma priority findings

· Absence of wheeze after audible wheeze -> severely constricted alveoli
· Silent chest -> severe obstruction
· Decreased peak flow
· Coarse lung sounds, crackles, CHEST TIGHTNESS
· Use of accessory muscles
· Inspiratory AND expiratory strider

Asthma triggers

· Indoor: mold, cockroach antigen, dust, animal hair, dander
· Outdoor: grass/trees/weeds, pollen, shrub, molds, spores, air pollution
· Irritants: tobacco smoke, wood smoke, odors, sprays
· Exercise
· Weather/environment changes
· Aspirin, NSAID, ABX, BBs
· Strong emotions: fear, anger, laughing, crying
· Foods

Asthma peak flow meter

· Use same time daily
· Ensure marker is zeroed
· Stand up straight
· Close lips tightly around mouthpiece, blow OUT as hard & quickly as possible
· Write down #, wait 30 sec., then do again (3x total) & record highest #
· Green zone: 80-100%
· Yellow zone: 50-79%, changes to meds needed
· Red zone: < 50% use SABA call/see provider
<50% despite Tx? Go to ER

Asthma: complications of inhaled corticosteroids

Candidiasis/thrush: use a spacer, rinse mouth & spit after each use, clean MDI after each use

Asthma education

Albuterol = used for ACUTE exacerbations - tx can take 10-15 min (prevention of exercise induced asthma so give before)
· Identify and avoid triggers (get rid of carpet)
· Learn how to recognize an exacerbation: decreased PEFR, increased use of SABA, difficulty eating/speaking
· Exercise regularly

Drowning risk factors

· Ages 0-4
· Swimming
· Inadequate supervision, not wearing life jackets
· Child abuse

Drowning expected findings

· Hx of event: lake, pool, beach
· Temperature of water
· Respiratory assessment
· Body temperature (hypothermia)
· Bruising, spinal cord injury

Drowning nursing care

- depends on degree of cerebral insult

- Admin meds, IVF, O2 - may need mechanical ventilation
- Chest physiotherapy
- Monitor for cerebral edema, respiratory distress than can occur 24 hr after

Drowning education

· Lock toilet seat when child is home
· Do not leave child unattended in bathtub
· Life jackets when boating
· Even a small amount of water can lead to drowning (1 inch of water)

SIDS risk factors

· Maternal smoking/second hand smoke
· Sleeping with parents
· Prone or side-lying sleeping
· Nonstandard bed (sofa, water beds, pillows/toys in crib)
· Prematurity/low Apgar score/multiple birth

SIDS education: How to reduce SIDS

· Place on back for sleep and give pacifier
· Prevent overheating and no smoking
· Use a firm tight fitting mattress in the infants crib
· Nothing in crib during sleep
· Breastfeeding

SIDS: expected findings

- sudden unpredictable death of an infant w/o any identified cause

- Hx of illness

- pregnancy and birth hx

- presence of risk factors

SIDS: nursing care

- provide support

- allow the infant’s family an opportunity to express feelings

- plan a home health visit to follow a death

- refer to support groups, counseling

Poisoning: risk factors

· Children < 6
· Improperly stored meds, chemicals, substances
· Lead ingestion from paints/soil
· Exposure to plants, cosmetics, heavy metals

Poisoning: expected findings- Hydrocarbons

(gasoline, kerosene, lighter fluid, paint thinner, turpentine)

• Gagging, choking, coughing, n/v

• Lethargy, weakness, tachypnea, cyanosis, grunting, & retractions

Lead poisoning expected findings

· Distractibility

· Impulsive

· Hyperactive

· Cognitive delays

· Hearing impaired

· Blindness

· Paralysis

· Tx = chelation therapy

Poisoning: expected findings- Corrosives

(household cleaners, batteries, denture cleaners, bleach):

• Pain and burning in mouth, throat, and stomach

• Edematous lips, tongue, and pharynx with white mucous membranes

• Violent vomiting with hemoptysis

• Drooling, anxiety, shock

Poisoning: education

• Keep toxic agents out of reach of children

• Lock cabinets containing potentially harmful substances

• Do not take meds in front of children

• Discard unused meds

• Routine screening for lead level at 1, 2, 3

Poisoning: Nursing care: General

• Admin IV fluids

• Provide cardiac monitoring

• Admin antidote

• Assist with gastric decontamination •

• Activated charcoal

• Gastric lavage

• • Increasing bowel motility

• • Syrup of ipecac is CONTRAINDICATED for routine poison control treatment

Posioning Nursing Care: Hydrocarbons

• DO NOT induces vomiting

• Intubation with cuffed endotracheal tube prior to any gastric decontamination

• Treatment of chemical pneumonia

Posioning Nursing Care: Corrosives

• Airway maintenance

• Intubation with cuffed endotracheal tube

• NPO

• No attempt to neutralize acid

• DO NOT induce vomiting

• Analgesics for pain