Applying General Nursing Techniques Flashcards
General Principles
- Hands approach to assessment
- Establish rapport with child and family
- Process observations with information to draw conclusions
- Communication is important
- Listening to parent’s/carer’s concerns helps them to trust
- Always address the child and family
Stages of development
Prenatal Neonatal Infancy Early Childhood Middle Childhood Adolescence
Separation anxiety stages
Phase 1 – Protest
Phase 2 – Despair
Phase 3 – Detachment
hospitalised child effects on family
Disruption for all members of the family Effects on development – regression Separation anxiety Loss of control – child’s life Finance – who is going to pay to bills? Parental relationships Siblings – show a range of reactions Grieving – all families grieve for loss of normality
Respiratory Assessment
Hands off Observe first - Activity level/interaction - Position - Colour - Use of accessory muscles - Respiratory Rate Touch second - Auscultation - Percussion - SaO2 – fingers, toes, ears
Cardiovascular Assessment
Colour – if dark skin then assess mucous membranes
Pallor
Level of activity eg Sleeping more than developmentally appropriate
Pulses – not just radial
Capillary refill - instantaneous
Blood pressure
Heart Rate
Children under 5yr are rate dependant
Apical location changes as child grows
7yrs –5th intercostal space, midclavicular line
Pulses
Brachial, radial and femoral pulses should be assessed for;
- Frequency
- Rhythm
- Intensity/amplitude
0 - absent pulse 1 - weak and easily obliterated 2 - normal easily palpable 3 - full pulse 4 - bounding and easily visible
Blood Pressure
Upper arm or lower leg
Little difference for young children
BP cuff should cover 2/3 of the limb
Upper arm 2/3 distance from elbow to shoulder – arrow over cubital fossa
Lower leg 2/3 of distance from knee to ankle, with the arrow over outer ankle
Pain Assessment
FLACC pain assessment tool
Nutrition
Toddlers are grazers
Healthy foods promotes lifelong habits
Can have cow’s milk after 12 months
Administration of medication
Oral also PEG and NG Rectal as for adult Subcutaneous as for adult Intramuscular most common site – vastus lateralis Intravenous most reliable Inhaled a wide variety
Newborn Screening Test
48-72hrs regardless of gestational age or feeding status
Tests for: Phenylketonuria (PKU), Cystic Fibrosis (CF), Congenital Hypothyroidism (CH), Other detectable genetic conditions
The Average Newborn measurements
Weight – 2500 to 4000 grams
Length – 45 to 52.5cm
Chest Circumference – 30.5 to 33 cm
Head Circumference – 33 to 35.5 cm
Reflexes – grasp, rooting, sucking, step, moro, tonic neck
Infants identify with the primary care giver – so include them in nursing care and interaction
Pregnancy terms
Pre-term – before 37 weeks gestation
Term – 37 to 42 weeks gestation
Post term – after 42 weeks gestation
