Yikes Flashcards
Nursing process to implementing care
Assess
Plan
Implement
Evaluate
Assess
Structure and function Family as Context Family as Client Family as a System Family As component of society
Assess - AFSNAG (8)
Australian family strengths nursing assessment guide
- Communication
- Togetherness
- Sharing activities
- Affection
- Support
- Acceptance
- Commitment
- Resilience
Plan
Short and long term goals
Open discussions
SMART goals
Who will be responsible
Implement
Delivering care directly to patient (in hospital)
Who is responsible for implementing goals
Need to have knowledge, skill and ability
Evaluate
Recognise changes in family Identify need for any modifications Have goals been achieved Were they effective Goals need revision and updates
Airway anatomy in children
Large occiput Neck flexion caused airway to be cut off Head bobbing in respiratory distress Teeth can be loose Infant (less than 12 months) Less than 6 months means they breathe through nose only Large tongue and large amount of soft tissue - cause oedema Larynx is soft Cricoid ring is narrowest part of airway Trachea is shorter. Less bronchioles Prone to ear infections etc
Airway Assessment
Stridor- upper airway obstructing due to group or foreign object
Look, listen, feel
How hard are they working to get air in
Intensity of stridor does NOT indicate severity of obstruction
Airway positioning
Infants - put in neutral position
Children from ages 1-9 - sniffing position
Breathing physiological and anatomy
Air tissue SA is less in infants
Diaphragm principal respiratory muscle in infants - children are abdominal breathers
Thin chest wall so hard to hear lung sounds
Ribs positioned more horizontal (decreased tidal volume)
Can’t lift ribs up and out
Increased effort for breathing
When assessing child breathing
Check for
Effort of breathing - LOOK nasal flaring, head bobbing, respiratory rate and depth, accessory muscle use, tracheal tug and chest recession
Effectiveness of breathing - LOOK chest expansion, symmetry, trachea midline, abdominal excursion. LISTEN breath sounds, air movement, grunting, wheezing stridor
Effects of respiratory inadequacy - mental status (drowsiness or adjetated) heart rate (increased), skin colour (pale), oxygen saturation
Effects of respiratory inadequacy (pre terminal)
Exhaustion Bradycardia Cyanosis (central) Silent chest Hypotension
Fixed SV in children
1.5mL/kg infants
75mL/kg adults
SV increases as heart size increases therefore HR decreases with age
Hypotension in children is pre terminal
Circulation
Children exchange more than half of their extra cellular fluids daily - increased potential for dehydration
Must measure intake and output
BP and SVR increase with age
Higher metabolic rate
Renal tubule immaturity - can’t concentrate urine
Poo is more runny
Norms for HR and BP
Infant - 110-160, 70-90
2-5 - 95-140, 80-100
5-12 - 80-120, 90-110
>12 - 60-100, 100-120
Primary assessment process
Airway
Breathing
Circulation
Disability
AVPU
Alert Responds to voice GCS is less than 8 when in the pu (worry about respiratory rate) Responds to pain Unresponsive
QUESTT pain assessment
Question the child Use a pain rating scale Evaluate the behaviour and physiological changes Secure parents involvement Take cause of pain into account Take action and evaluate results
3 stages of separation anxiety
Protest - reluctance to leave area
Despair - withdrawn “settled in”
Detachment- stop attaching to others
Phase of protest
Cry Scream Search for parent with eyes Cling to parent Rejects contact with strangers Verbal/physical attack strangers Force parent to stay - “I’m gonna hate you if you go” Protests may only stop when the child is exhausted
Phase of despair
Be inactive Withdrawn from others Depressed Uninterested in environment Uncommunicative Regress to earlier behaviour May start sucking thumb or wetting bed Refuse to eat and drink
Nurse care for separation anxiety
Set expectations Development of trust Familiar objects Build anticipation Parents can always say goodbye
Phase of detachment
Appear happy
Form new but superficial relationships
Show an increase interest in their surroundings
Interacts with strangers or familiar care giver
Paediatric mortality highest in children under 1 year
Stats:
Neonates: congenital, prematurity
Infants: SIDS, sepsis
Toddlers: trauma
Adolescents: risk taking behaviours
4 main reasons why kids get seriously unwell and die
- Fluid maldistribution - sepsis, anaphylaxis and spinal shock
- Fluid loss - gastroenteritis, burns and blood loss
- Respiratory distress - croup, asthma and foreign body
- Respiratory desperation - seizure, poisoning and CNS depression
Erickson’s
Infant - trust vs mistrust Toddler - autonomy vs doubt Pre schooler - initiative vs guilt School kid - industry vs inferiority Adolescent - identify vs role confusion
Piaget’s stages
Semimotor stage
Preoperational stage
Concrete operations stage
Formal operations stage - abstract, idealist and logic
Gillick competence
Child achieves sufficient understanding and intelligence to understand the proposed treatment and consequences of the treatment their parents right to consent of their behalf ceases
Doctor decides competence
Treatment and consequences are understood and in best interest for patient
HEADSSS Assessment
Home or housing Education or employment Activities Drugs/ dieting Sex and sexuality Suicide and depression Safety
Family Systems Theory
Change in one individual will impact all persons within a family.
Family as a social and emotional unit
Helps with genograms
Family can create balance between change and stability
Contains boundaries (values, beliefs etc)
Doesn’t prove explicit guidance for nurses and doesn’t provide a view of the family over time
1. All parts are interconnected; 2. Whole is more than sum of its parts; 3. There are boarders and family controls who goes in and out; 4. Systems sorted into subsystems
Family development theory
Family move through expected stages
Face predictable developmental tasks
Nurses can assess the extent to which developmental milestone has been achieved by the family
Doesn’t consider the experience of non-nuclear families or families facing impacts of non-normal events
Structural/ Functional Family Theory
The structure facilitates the function
Understanding family dynamics and how these influence the families purpose
Doesn’t explain how families develop and manage over time
Doesn’t have a cross cultural component nor reflects diverse family types
Manifest Functions: placed intentionally to keep society moving forward
Latent functions: unintended consequences
Health priorities and social policies in Australia
National evidence-based antenatal care guidelines (care for healthy preg women)
Australian National breastfeeding strategy (improve health of infants)
National framework for universal child and family health services (0-8 year children and fam access to healthcare)
National framework for protecting Australia’s children (reduce levels of child abuse and neglect)
Family and domestic violence strategy (government response to violence)
Tools used in child and family nursing (6)
- Genograms
- Ecograms (circle with multiple lines one)
- Calgary Family Assessment Model (structural, developmental and functional)
- Friedman Family Assessment Model (fam is subsystem and assesses values and stress)
- Family Systems Stressor-Strength Inventory (big table showing from not applicable to high stress)
- Australian Family Strengths Nursing Assessment guide (8 activities eg sharing activities)
Natal definitions
Preconception: prior to pregnancy Prenatal: pregnancy to labour Gestation: number of weeks pregnant Perinatal: 20 weeks pregnant to 28 days after birth Postnatal: first 6 weeks after birth Neonate: first 4 weeks of life
Pregnancy phases
Trimester 1 (0-12 weeks): hormones released Trimester 2 (13-27 weeks): begin to show Trimester 3 (28-40 weeks): random tightening of uterus (braxton hicks) increased movement of baby
Stages of vagina birth
1st stage: 12-19 hours of labour. Regular contractions every 5-20 mins. Water breaks and mucus plug is discharged
2nd stage: labour lasts 20min-2hours. Cervix dilates 10cm. Baby delivered and umbilical cord cut
3rd stage: 5-30min mild contractions assist placenta to be delivered. During this stage baby can begin bonding through skin to skin touch and breast feeding. Uterus shrinks to control bleeding.
Principles of growth and development
It is a continuous process from conception to death
It proceeds in an orderly sequence but happens at different rates
It is cephalocaudal (head to feet)
It proceeds in a proximodistal manner (center outwards)
Development of gross motor skills develops before fine motor skills
Child abuse
4 types: emotional, neglect, physical and sexual
Child protection act 1999 says nurses are mandatory reporters required to report a suspicion on whether a child has suffered, is suffering or risk of suffering significant harm caused by abuse and do not have a parent or guardian willing to protect child
8 stages Erickson’s
Trust vs mistrust Autonomy vs shame Initiative vs guilt Industry vs inferiority Identity vs role confusion Intimacy vs isolation Generativity vs stagnation Integrity vs despair
Piaget’s 4 stages
Sensory motor stage
Preoperational stage
Concrete operational stage
Formal operational stage
6 stages of play
Unoccupied Onlooker Solitary Parallel Associative Cooperative
APGAR Assessment
0-3 is severe distress, 4-7 moderate distress, 7-10 all good
Appearance (skin colour)
Pulse (heart rate)
Grimace (reflex response)
Activity (spontaneous movement/ muscle tone)
Respiration (breathing)
