Pediatric Nursing Process Flashcards
You are informed a patient is arriving. How do you prepare/
- Activate the team and assign roles
- Prepare the room with pedi equipment
- Don PPE
The patient arrives. Assess your general impression? How would you do this?
PAT- Pediatric assessemnt triangle
Appearance - TICLS (tone, interacion, consolability,look/gaze,sounds{crying vocalization})
Work of Breathing - Tachy/brady, tripod, stridor, head bob, gasping
Circulation to the Skin - Color, visible rashes
Catergorize based on across the room assessment
Sick - No alterations
Sicker - One alteration
Sickest - Two or more alterations
After the PAT and catergorizing the patient, what is assessed next?
** Assess for “OBVIOUS” uncontrolled bleedding**
C-A-B
or
A-B-C
“assess for pulse”, “control external hemmorhage”, “initiate chest compresion”
p. 289
If there is no need to reorder for C-A-B , how do you proceed?
Assess “A” Airway/Alertness WITH C-spine
- AVPU
- Open airway
- Assess patency using (at least FOUR)
tongue, teeth, trash, blood, emesis, edema, bony deformity,
Sounds- snoring, gurgling, stridor
LOOK, LISTEN, FEEL
INTERVENTIONS: if deficts found, intervene
Anticipate need for intubation
insert OPA/NPA
place padding under shoulders
position patient to optimize airway
remove FBO
Suction the airway
Ater assessing and intervening on Airway/Alertness, what next?
BREATHING and VENTILATION
Assess breathing for effectiness using at least FOUR
Are they breathing?
Rate, depth, pattern, syymetrical chest rise
Breath sounds
Increasd WOB - posturing, grunting, head bobbing, nasal flaring
Retractions/accesory muscle use
tachynpea
open wounds or deformities
skin color
SC emphysema
Interventions:
Apply 02
PPV
needle decompression
medications (nebs)
intubation
chest tube
If intubation is a intervention what must the nurse assess and do?
Identify all THREE
Co2 detector
look for chest rise and fall
auscultate over epigastrum 1st then lung feilds
(may use capnography at this point credit given under step 23)
If intubated
1. note position at teeth
2. secure ETT with commercial device
3. continue PPV or start ventilator
After Breathing and Ventilation are addressed, what happens next?
Circulation and control of bleeding
Assess circulation using ALL THREE:
1. Assess capillary refill
2. Inpect and Palpate skin for color/temprature/moisture
3. Palpate a pulse
Interventions:
Apply cardiac monitor (credit given for step 21)
Apply pelvic binder
Assess IV line patentcy if pre-hospital
Compare central and peripheral pulses
Consider source of internal bleeding
Control bleeding
Draw labs (credit for step 20)
FAST sonogram
Initiate CPR if no pulse
FLUID BOLUS 20ml/kg
Consider blood 10ml/kg
After Circulation and bleeding are controlled, what next?
Disability (Neuro Status)
Assess GCS Assess PERRLA
eye opening
verbal response
motor
Interventions:
Assess BGL
intubation for GCS less than 8
Anticipate CT
After Disability, what is assessed?
Exposure/Environmental controls
Assess:
remove all clothes AND inspect for obvious injuries and abnormalities
LACE (laceration, abrasion, contusion, ecchymosis, defomity,bleeding)
Remove transport device (backboard) if appropriate
** evaluate of the patient can be turned/rolled at this time** p.293
Interventions:
Blankets
increased room temprature
warming fluids
warming lights
After Exposre/Environment, what is next?
Full set of Vital signs/Familry prescence
Also obtain KG wieght if possible
HR/RR/BP/T/POX
What comes next after Full set of vital signs and family prescence?
Get adjuncts/Give Comfort (LMNOP)
L - Labs
M - Monitors - tele, need for ekg
N - NGT/OGT
O-Oxygen assesment and capnogrpahy if not already initiated
P- Pain
Interventions for Pian
distractions
family prescence
padding over bony prominences
respositioning
splinting
verbal reassurance
Possibel ice but be awawre of hypothermia on small patients
IS THERE A NEED TO TRANSFER
After the primary survey, what assessment begins the Secondary Survey?
History and head to toe
Obtain history from ONE of the following
Medical records
prehospital report
SAMPLE
Head - to -Toe Assessment
Look, listen and Feel all body components
Head
Neck - remove and reapply C-collar
face
Chest - AUSCULTATE LUNG SOUNDS AND HEART SOUNDS
Abdomen - BOWEL SOUNDS
Flanks
Pelvis - Downward/inward pressure to iliav crest, (if stable) then downward pressure over pubis symphysis
Perineium - bleeding at meatus/urethra? Consider foley
All four limbs - neurvascular status and abnormalities (LACE)
After Head to Toe, what comes next?
Inspect posterior surfaces
Can we safely turn the patient? due to injury or imaging clearance?
Inspect and palpate posterior surfaces
Bleeding
LACE, deformity
What interventions and disgnositcs can you anticipate for this patient?
Identify at least THREE
Abx
consults
CTs
imaging
mandatory report
social services
splinting
tetanus
wound care
