Assessment and Intervention Flashcards
what things should you consider when obtaining a consent for someone younger than 21 (2)
parent or legal guardian will sign consent
any one who takes the child to the hospital can give consent
what can help the child develop coping skills
imagery
distraction
relaxation
when allowing the child handle objects that will be used in their care, what does this help do
helps to develop familiarity with the objects and helps reduce the threat often associated with their use
what can “play” be used to do
express feelings, teach, reach a therapeutic goal (child give shot to doll), have fun
when should you tell the child their are getting a procedure
the younger the child the closer to the procedure
what should we do for the parents who DO want to stay with the child
give them a job to do
what should we do for the parents who DONT want to be present with child
tell them how long it will take, and where they need to wait
also we need to respect their choice
where can the procedure take place and how should it go
treatment room
playroom
should be organization and confident
after the procedure what should be done
praise the child
reward the child
allow child to talk about what happened
return to see the child shortly after procedure
what should be done to measure recumbent length for birth-2 years
hold head in midline
push knees flat and fully extended
mark paper and measure between marks
when measuring height or stature in children older than 2 years of age what should be done
standing up they should be touching in 3 points against wall or measuring device
who are platform scales used for
infants and very young children (weigh infants nude)
in failure to thrive babies what may ftt be a result of
physical problems psychosocial issues poverty health beliefs family stress feeding issues
what percentile do the ftt babies fall on
weight less than 5th percentile
what should you ask the parent of an ftt baby
diet history
parent height
physical
assessment of meal time rituals, behaviors
take a look at parent child interaction
(R?O lead toxicity, anemia, ova and parasites
what is the nursing care management with an ftt baby
provide positive feedings
doc childs behavior and parent child interaction during feeding
provide primary core of nurses
introduce new foods slowly
when assessing the pt what should you do first (atraumatic care)
1st= respirations 2nd= heart rate last= blood pressure and temp
what is best practice when obtaining a pulse
apical pulse for 1 full minute
if a child is in-between blood pressure cuff sizes what should the nurse do
choose the bigger one
what blood pressure location is least invasive
dorsalis pedis artery because its farther from the core
what factors affect body temp
active exercise
stress
crying
environment
what is the first thing that should be given to a child with fever
antipyretics
when can you start interventions related to fever
an hour after antipyretics are given
what things can be done after antipyretics have not sufficiently lowered the temp of child
minimal clothing
increasing air circulation
applying cool, moist compresses (do not use if causes shivering)
caused by prolonged and repetitive contact with an irritant or combination or irritants
diaper dermatitis “diaper rash”
white patches on the tongue, palate, and inner aspects of the cheeks that do not scrape off
oral candidiasis (thrush)
when will thrush start going away
may take 2 months to resolve but in the meantime it may spread
if a child has thrush what should be given 4 times a day
nystatin
what is important to know about administering nystatin
give after feeding so it doesn’t get washed down
swab over surface of oral mucosa and tongue
swallow remainder
if the child with thrush is breastfed who should be treated
both mother and baby
how should bottles, nipples and pacifiers be cleaned if the child has thrush
boil for 20 minutes (spores are resistant to heat)
when should the posterior fontanel be closed
by 2 months of age
when should the anterior fontanel be closed
by 12-18 months of age
what is know as the red reflex
fundus
when should the child have binocular vision
4 months
one eye does not fixate correspondingly
strabismus
lazy eye, brain started turning off and eventually that eye will become blind
amblyopia
when looking at the ear what is important
the top of ear is aligned with outer corner of eye
low set ears usually indicate
autism
why are children more prone to ear infections
because they have wide open flat lying eustachian tubes and that is great for bacteria to get into
for access to canal of a child less than 3 years what should you do
pull pinna down and back
for access to canal of child older than 3 years what should you do
pull pinna up and back
what is it called when the chest bones are sunken in
excavatum
what is it called when the chest bones are sticking out
carinatum
where can you check the pulse rate on a child
less than 7= fourth intercostal
greater than 7= fifth intercostal
what is a normal finding when listening to a childs heart
sinus arrhythmia
what are 6 signs of respiratory failure
nasal flaring retractions cyanosis asthma (wheezing) grunting crackles
if pt is nearing respiratory failure what mask will be most beneficial
non rebreather
what 5 things should be done when suctioning a trach
- suction should be 1/2 diameter of tube
- humidify before and after procedure with 100% O2
- < 5 seconds down and for infants and <10 for children
- rest 30-60 sec between
- always monitor pulse ox during procedure
what fluid is preferred for an enema
isotonic fluid (DO NOT GIVE tap water)
1Gm of wet diaper weight=
1mL of urine
what is the minimum acceptable urine output formula for an infant (birth-2)
1mL/kg/hr
what is the minimum acceptable urine output for a child (2 and greater)
0.5mL/kg/hr
how often should you assess IV site
every 1-2 hrs
for implanted ports how often are they heparinized
once a month or after an infusion
for broviac (tunneled catheter) how often are they heparinized
daily
what should pediatric “rate to be infused” be set
for 2 hours of fluid and attend to IV alarms promptly because their iv sites can clot and or infiltrate really fast
what are the 8 s/s of a hemolytic reaction (after administration of blood products)
sudden severe HA chills fever shaking N/V chest tightness flank pain if there is a reaction turn off blood, maintain IV of NS
when using an oral syringe for oral medications where should it be placed
to side of tongue so it goes back of mouth and give slowly (NEVER mix medication in milk bottle or formula because they may not finish it)
for a baby, what amount can you inject into one muscle
no more than 0.5- may need to split into two injects if volume is too much
for a small child, what amount can you inject into one muscle
1 mL is appropriate
for children, what amount can you inject into one muscle
never inject more than 2mL into their muscle
can painful injections be mixed with lidocaine
yes but there has to be an order
what is the preferred method of IM administration for infants and children
vastus lateralus (90 degree angle)
for a deltoid what volume should you never exceed
1 mL of fluid
what are the scared points of children before surgery
taking off their gown, taking off underwear, giving up their transitional item
