Day 14 (until NCLEX-RN): Nursing Care of Children

14 days till I sit for my exam, 6 months since I was supposed to take my NCLEX at the "optimal" time, 7 months since I was diagnosed with cancer, 2 months since I finished chemo.  Still fighting some chemo brain, definitely forgot a lot of material.  Not enough time.  So, come with me while I cram through a review book, section by section, starting with the parts I am the least confident about--KIDS!  Those little buggers who keep changing the game on you as they grow and develop.  I'm going to try to show you all of the ways I help myself remember things.  Let me apologize beforehand, Blogger doesn't do the whole outline thing, so this is going to look whacky.

Remember, the nursing care of children is family focused, and (as with all nursing) safety focused.

1. Identify the legal guardian.  Parent, grandparent (remember, diversity!), guardian, state, the child him/herself (emancipated, pregnant, or married). 
2. Assess for abnormal guardian-child interaction (neglect, physical, sexual, emotional abuse, Munchausen syndrome by proxy esp <6y-o).  Usually the parent has poor self-esteem/shitty coping skills, hx abuse, lacks knowledge, lacks a support system, or the pregnancy was unwanted (rape, or accidental pregnancy).  

• Look for children who are difficult to manage (autistic, tempermental, etc.), and families that have a history of chronic stress (eg. socioeconomically insecure).
• Look for failure to thrive/poor hygiene, poor bonding/developmental delay/extreme reactions/poor self-esteem, weight <5th percentile/poor health/lack of immunizations, indifference from parent.
• Look for unconscious child with retinal hemorrhage and no external signs of trauma=shaken baby syndrome, spiral fx, burns (immersion lines, perfect circles), and bruises on soft tissue with varying degrees of healing.  Bruising on bony prominences are most often normal falls and bumps.  
• Look for delays in seeking medical attention
• STI, genital bruising, sudden changes in behavior

Teach (growth and development, safety), teach (adaptations for special needs), teach (participation in care), teach (community resources).

INFANTS: (<12 months)

VS: see newborn

CRIES Neonatal Postoperative scale (crying, vs changes, expression changes, altered sleeping patterns)  

Think: MILESTONES ARE (generally) MULTIPLES OF 2

I. Growth Milestones (Head to toe)

1. Fontanelles: posterior 2-3 months (think: you lay the baby back to sleep, so the back of the head needs to harden first), anterior 12-18.  
2. Teeth: First tooth at 6 months, 1 tooth per month afterwards.  Use frozen cloths/pacifiers, and tylenol for pain.  Wash with a wet cloth (have you tried brushing a 6 month old's single tooth with a toothbrush--yeah, that's why we use a wet cloth).  Extrusion (pushing of food out of mouth due to sucking motion) begins to fade around 4-6 months, so soft foods can be introduced then.*  NO JUICE in bottles--causes cavities.
3. Eyes: Strabismus is normal in the beginning, the ocular muscles are still developing.
4. Height and Weight: Anything between 5th percentile to 95th percentile is considered "average."  Yep.   Birth: 5%-10% weight loss immediately after birth.  Next, remember: 2x6=12, which stands for 2 weeks to regain birth weight, 6 months to double birth weight, 12 months to triple birth weight.    

II. Motor Skill Milestones.  The important thing to remember is that these are the late end for milestones, so if the baby isn't displaying these skills by the months stated, they needed to be assessed for delayed development.

1. 1 month: head lag, and strong palmar reflex (they make little fists for everything)
2. 2 months: head lift and hands are open when relaxed.  Think: Tummy time frustration
3. 3 months: head and shoulders lift, loss of palmar reflex--Note: in Newborn Assessments, this is when the tonic neck reflex (fencing pose) begins to go away, and it is hypothesized this is why babies who are left on their stomachs have a higher incidence of SIDS.  They essentially smother themselves with their arms.  
4. 4 months: rolls from back to side (think: not quite enough juice to get to the front)
5. 5 months: front to back roll (we have liftoff!) and intentional palmar *grasp* (not reflex, remember, we lose the reflex at 3 months)
6. 6 months: back to front and holds bottle with two hands.
7. 7 months: BEAR WEIGHT while being held (test question), transfers object from hand to hand
8. 8 months: SITTING UP INDEPENDENTLY (test question) begins with pincer grasp
9. 9 months: Pulls self to feet.
10. 10 months: Sit upright from laying prone.  One hand grasp (rattle, bottle, etc.), and fine motor pincer (can feed self with finger foods).
11. 11 months: Walks with aid.  (I always hear "Walk This Way" in my head.  I don't know.  It helps.)  Can put toys in a bucket.  
12. 12 months: Sits down without help.  STACKS TWO BLOCKS (test question).

Reflexes lost in order of months

3 months: palmar, tonic neck 

4 months: sucking/rooting; moro

8 months: plantar

1 year: babinski

III.  Cognitive/Psychosocial development

1. Piaget (sensorimotor):  Ok, this always confuses me, but the thing to remember is that Piaget is about how the baby figures out how the world relates to his body.  Just remember: Object permanence at 9 months, recognizes symbols (like a fork, plate, and spoon shape).
2. Erikson (psychosocial): Trust v. Mistrust.  Just remember: separation anxiety occurs at 4-8 months, which is about when baby also realized there is a difference between self and not-self. 
3. Language: According to the Denver Developmental Screening Examination, @8 months the baby says babbles ("dada, mama") non-specifically. Specificity and use of 2-3 word phrases occurs @ 12 months.  A child responds to specific commands or identify objects upon command @ 17 months.  (Lippincott was nuts about this.)
4. Appropriate toys require short attention spans, and are designed for solitary play (rattles, mobiles, teething toys, pat-a-cake, peek-a-boo, reading).

IV. Immunizations: 

1. birth with 5/8" needle: hep B
2. 1 month 1" needle : hep B
3. 2-4-6 month: RV, DTaP, Hib, PCV, IPV, @6mos: HepB, starting annual flu
4. 12 months: motherload: Hib, PCV, IPV, MMR, varicella, HepA + annual flu

V. Nutrition: remember babies lose extrusion ~4-6 months, and start teething at ~6 months, which might coincide with weaning, cause no one wants their nipples to be chomped on.  

1. Breastfeeding or iron-fortified formula for ~6 months (when weaning can begin) + soft foods with the disappearance of extrusion (~4-6 months).
2. Start with iron fortified cereal, then move onto one food per week to evaluate allergies--avoid eggs, wheat, peanuts, honey, citrus, or milk (yup, no milk until 12 months, then whole milk)--and chop foods into fine pieces
3. pincer grasp at 9 months helps with finger foods

VI. Safety: There are too many things to mention, so I'll just pick the ones that regularly pop up as test questions.

1. Aspiration: chop foods finely, crib slats are no more than 6 cm apart, remove mobiles before 8 months (sitting).  CPR: if the child is turning blue, don't sweep or check in the mouth--move straight to back blows and chest thrusts (reference Lippincott), 2 person CPR is 15:2, no AED for <12mos (reference: ATI).
2. Burns: Thermostats at 49C or 120F, sunscreen ALWAYS, don't microwave bottles.
3. Drowning and Falls, basically, keep an eye on your kids always, put in safety gates, and cover pools/toilets.
4. Poisonings: Never refer to medicine as candy.  Seriously.  That's just dumb.
5. MVI: Rear-facing, middle seating till 2 with a 5 point harness.
6. SIDS: risks: male, 2-4 mos (tonic neck reflex), preterm, smoking, multiples.  Use breastfeeding, place on back with a pacifier.

VII. Nursing Interventions for Hospitalization: keep infants close to nursing station to quickly meet their needs.

TODDLERS: (1-3 y-o)

VS: 95/65; 80-100bpm; 30rpm

CRIES Neonatal Postoperative scale (crying, vs changes, expression changes, altered sleeping patterns)

I. Growth Milestones (Head to Toe):

1. Fontanelles (more specifically, the anterior) have closed by 18 mos.  
2. Weight quadruples by month 30 (2.5 years).  So, remember, the rule was multiples of 2: 2 weeks to regain birthweight, 6 months to double, 12 months to triple, 30 months to quadruple.

II. Motor Skills Milestones: (Remember we left off with sitting down without help at 12 months.)

1. 15 mos: Walking/standing independently, creeps up stairs, independent sippy cup, builds a 2 block tower (don't ask me why, it's always a test question).
2. 18 mos: Prefers to stand (rather than crawl); uses a spoon properly and turns pages 2-3 at a time.
3. 24 mos: walks up and down stairs independently, kick a ball (Lippincott); builds 6-7 block towers.
4. 30 mos: jumps with both feet, can stand momentarily on 1 foot; can draw a closed circle.
5. 3 years old: Tricycle

III. Cognitive/Psychosocial Development:

1. Piaget: sensorimotor-->preoperational.  Preoperational means the child Language has developed to ~400 words in 2-3 word phrases.  
2. Erikson: Autonomy vs. Shame and Doubt--as long as safety is assured, allow the child to make choices, help with tasks, throw temper tantrums--and children know that good behavior is rewarded and bad behavior results in punishment.  Rituals help children gain autonomy (eg, sleeping alone at night), and become adjusted to separation (recall: separation anxiety starts at ~4-8 months and peaks with toddlers).  Gender identity forms at 3 years of age.  
3. Solitary play will evolve into parallel play: containers, blocks, picture books, push-pull toys, ball toss.
4. Toilet training is based upon neurological, psychological, and physical development.  Are the nerves for the bladder and sphincter sensation developed?  Is the child able to dress and undress himself?  Can he balance on a toilet bowl?  

IV. Immunizations: Annual Influenza and any catch up vaccines.
V. Nutrition:

1. Whole milk till 24 mos, then skim milk
2. No bottles after 12 months + Teeth brushing
3. 1 TBSP=serving size.  Finger foods to encourage autonomy.

VI. Safety:

1. Choking hazards: hot dogs, nuts, grapes, peanut butter, raw veggies or fruits, tough meat, popcorn.
2. Firearms need to be locked up (but duh), and teach stranger danger.
3. Again with the water at 120F or 49C, and the crib slats <6cm (2.4in).
4. Again, don't let your kids drown.  Teach them to swim.
5. Lock your doors and windows, use safety gates, and lower the bed of the crib as low as possible.
6. So, about this carseat thing..."New guidelines from the American Academy of Pediatrics and Canadian Pediatric Society recommend that parents keep their toddlers in a rear-facing car seat until 2 years of age.  ...  Boosters are recommended for children until they are 4 feet 9 inches" (~8-12 y-o) "and they should ride in the back seat until 13 years of age to minimize injury should airbags be deployed." (Lippincott page 194)  But, like I said, I don't know that the NCLEX will go that far into detail.  Just remember: back-facing, back seat middle.
7. Again with the poisoning.  Lock everything up.

VII. Nursing Interventions for Hospitalization: Consistently assign the same caregivers, encourage autonomy, encourage parents to provide routine care.

PRESCHOOL (3-6 y-o)

VS: 105/65; 70-100bpm; 21rpm

FACES Pain Rating Scale

Non-communicating children's pain checklist (VAS/FACES + vocalization, socialization, facial expression, activity level, extremities, physiologic changes)

I. Growth Milestones:

1. 3 years: rides a (3)tricycle, jumps off a step, stands on one foot briefly
2. 4 years: skips and hops on one foot, throws a ball overhead
3. 5 years: jumps rope, walks backwards heel-toe, stairs are a breeze

II.  Cognitive/Psychosocial Milestones

1. Piaget: Preoperational: animation (2-4 yo)--may cause the child to be afraid of the dark or monsters, and intuitive thought=cause and effect eg., reward vs punishment (4-7).  Time becomes salient.  Speaks with sentences.
2. Erikson: Initiative v Guilt (for failing)--Set the kid up to succeed.  The child becomes attuned to "socially acceptable" standards.
3. Children develop "imaginary friends," and may be scared of the dark, but their separation anxiety decreases. Give them play that doesn't have the threat of failure: dress up, puzzles, tricycles, painting, reading books, playing ball non-competitively, etc.

III. Immunizations/health screens

1. Immunizations @ 4: DTaP, IPV, MMR, Varicella.  Annual flu.
2. Begin annual/biannual dental and vision screenings.

IV. Nutrition--duh
V. Safety:

1. Tricycle: wear helmet
2. Sunscreen, sunscreen, sunscreen.

VI. Nursing Interventions for Hospitalization: Use non-ambigious, colloquial language.  Encourage self care, and give choices.  Encourage and validate the expression of feelings, allow for play with instruments and mock procedures.  STRESS THAT ILLNESS AND HOSPITALIZATION ARE NOT PUNISHMENT.

SCHOOL AGE (6-12 y-o)  

VS: 105/65; 70-110bpm; 21rpm

FACES and VISUAL ANALOG SCALE (purely numbers 0-10)

I. Growth Milestones

1. Puberty (F: 10; M 12).
2. Permanent teeth.  

II.  Cognitive/Psychosocial Milestones

1. Piaget Concrete Operational: Logic, reversible, understands analogies, empathetic/non-egocentric.
2. Erikson: Industry v inferiority: FEARS RIDICULE-->drives them to find niches and cliques were they excel.  In need of encouragement.
3. Moral: Will find the loopholes initially, then graduate to --> Law and Order.
4. Body image and sexuality develops-->same gendered friends common, and rivalry with same gendered parent is common.  Conformity occurs.  And it's healthy to have a best friend (Lippincott).

III. Immunizations/health screens:

1. @12 years DTaP and HPV, Hib-MenCy (meningitis)
2. Screen for obesity, scoliosis esp. with females, and regular dental/floss/flouride tx.

IV. Nutrition: Prevent fast food, parents model behavior.  BMI: (kg)/(m^2)   OR  703x [(lbs)/(in^2)]

V. Safety

1. No trampolines.  Helmets and safety pads.  
2. MVI: Booster until 4'9", backseat until 13, DEactivated air bags (yes, seriously).  Seat belt should be across the upper thighs NOT THE ABDOMEN, and across the shoulder and chest NOT THE NECK.
3. Substance abuse

VI. Nursing Interventions for Hospitalization: Provide facts to help cope with loss of control.  Encourage feelings.  Maintain time for school work and contact with peers.

ADOLESCENT (12-20)

VS@13: 110/65; 55-90bpm; 18rpm

VS@17--like adult's

FACES, VAS

I. Physical Development: Puberty, acne, and sleep needs increase with increased growth metabolism (how can it increase more than 12 hours?  Ironic, that we sleep the least when we need it the most.)
II. Cog/Psychosocial development:

1. Piaget: Formal operational (abstract, self-aware, multi-stepped/deductive problem solving).  Idealistic.   Uses generational slang with peers and formal speech with superiors.
2. Erikson: Identity v Role Confusion--family, friends, career, sexual orientation, invincibility. 
3. Kohlberg Post-Conventional law (shades of grey, and each situation needs to be analyzed).
4. Try to keep their activity content non-violent (music, sports, video games, books), and teaching them empathy by giving them a pet.
5. Body Image-->can lead to eating disorders

III. Immunizations/Screening

1. HPV!!!  STI screenings, birth control
2. Scoliosis, breast and testicular self-checks.
3. TESTICULAR CANCER is the most common cancer for males 15-34 years old.

IV. Nutrition: Body image-->eating disorders.   The most deficient nutrients are iron (menstruation), calcium, and vit A and C.

V. Safety:

1. The three leading causes of death are homicide, suicide, MVI
2. Invincibility may cause injury from burns, drowning, and substance abuse.

VI. Nursing Interventions for Hospitalization: Provide facts, include the adolescent in planning of care.  Encourage contact with peers, but guard against body image disturbances and non-compliances due to peer influence.

Pain Management

CRIES for infants
FLACC (facial, legs, activity, crying, consolability) for infants-7 y-o
FACES, Noncommunicating Children's Pain Checklist for 3+ y-o
VAS and Noncommunicating Children's pain checklist 7+

Be wary of pain for 2-3 mos old because of immature liver.
Fentanyl can only be used for children 12+ y-o.
Know that topical/transdermal EMLA (eutectic mixture of local anesthetics=lidocaine + prilocaine) takes 60 minutes to prepare for superficial, and 2hr for deep puncture).

Medicine Administration

Don't mix medicine with milk or food.
Administer with a needleless syringe to the side of the tongue.
Auricle down (always down, regardless of age), and BACK in children <3 y-o.
IM 5/8" (newborn) -2"

Surgery

Teach with dolls, books, or tours depending on age, and document behavior.

Terminal Illness, Death &Dying

It is important to encourage parents to stay connected and involved with their child, and for the child to continue connecting with peers if at all possible and constructive.  It is also important to maintain an environment of open communication and expression of feelings, and to promote independence and autonomy for as long as possible.  Even when the child is unconscious, continue to discuss special memories, people, reading books, provide favorite toys, and allow sibling contact.

0-3 years (infant/toddler): Mirrors parents' emotions, anxiety, regression.  No concept of death.
3-6 (preschool): Magical thinking, belief that they caused the illness=shame.  Doesn't understand the permanence of death.
6-12 (school): Fear is often displayed as uncooperative behavior.  May be curious about the funeral and what happens to the body after death--allow them to participate in plans for the funeral service.
12-20 (adolescent): Isolation from peers, difficulty accepting death/stressed about appearance.  Guilt/shame of being a burden.