EXAM 1 STUDY GUIDE

Types of communication include

• verbal

• nonverbal

• play

• silence

Types of communication: verbal includes

• waiting for them to give an answer

• spoken words

Types of communication: nonverbal includes

• writing

• drawing

• magic

Types of communication: comm through play includes

• Games

• SET CLEAR BOUNDARIES

• Mimicking

• Do AFTER nursing tasks for pt are completed

Types of communication: silence includes

• can be helpful

• gives the patient time to gather thoughts and emotions

Assessment considerations for age and development

• open ended questions

• non judgemental comments

• adolescents may need parents to leave to communicate honestly and openly

Assessment considerations for age and development: Newborns and Infants

• Count RR and HR prior to touching

  • RR FIRST ALWAYS THEN FOLLOWED BY HR

• Auscultate while infant is asleep or calm

• Head to toe manner for infants

  • Leaving invasive items for last

    • Ears

    • Nose

    • Mouth

    • Throat

• Parents should be support/nurturer

  • NOT assisting during procedures

Assessment considerations for age and development: Toddlers

• incorporate play

• introduce equipment slowly

• allow child to handle equipment

• ALWAYS praise the child

  • they did a good job

• perform the most invasive items last

Assessment considerations for age and development: Preschooler

• Allow the child to help

• Offer the child choices

• allow the child to decide the order of the exam

• explain instruments and let the child try

Assessment considerations for age and development: School Aged children

• avoid using medical jargon or words that have double meaning

• describe everything in words and phrases that the child can understanding

• head to toe approach

  • genitalia last

• describe the comment on the finding of the exam outloud

Assessment considerations for age and development: Adolescent

• Provide privacy

• Head to toe

  • expose only areas that are needed

• explain what we’re doing, why, and findings

• Allow time for them to talk confidentially

Assessment considerations for age and development: Steps of the exam

• Note differences related to

  • age

  • developmental level

• review all items of the physical exam

Assessment considerations for age and development: Appropriate vital signs

• RR FIRST

• HR after RR

• then temperature last

• include

  • temp

  • pulse

  • respirations

  • BP

Types of pain scales

• Wong Bakers Faces pain rating scale

• FLACCs

• Numerical

What is Wong Bakers faces pain rating scale

• consists of six cartoon faces ranging from smiling face for “no pain” to tearful face for “worst pain”

• child is asked to select the picture of a face that best represents their pain intensity

• for children 3-4

What is FLACCs pain rating scale

• OBSERVATIONAL TOOL

• Includes 5 categories

  • facial

  • leg movement

  • activity

  • cry

  • consolability

• rate each category on a scale of 0-2, total scores 0-10

• sum them up in the end to get your pain level

What is Numerical pain rating scale

• points to each section of scale to explain variations in pain intensity

• children as young as 8 years

• verbal scale or line scale that 0 is no pain and 10 is worst pain

What pain scale do infants and neonates use

• FLACCs scale

What other peds patients use the FLACCs sclae

• pts that are developmentally delayed

• coming out of surgery

• irritable children who will not coooperate

Which pain scale do toddlers use

FLACC scale

Which pain scale do preschoolers use

Wong Bakers Face pain scale

Which pain scale do school aged children use

• depends on age

• wong baker

Which pain scale do adolescents use

Numerical rating scale

Side effects of narcotics include two types:

• short term

• long term

Side effects of narcotics: short term

• Respiratory depression

• N/V

• Miosis

• Constipation

• Sedation

• Euphoria

• Agitation

• Mental clouding

• Hallucinations

• Pruritus

• Ortho hypo

• Anaphylaxis

Side effects of narcotics: long term

• Increased seizures

• Tolerance

• Withdrawal

Pharmacological interventions

• Determine best medication

• Questions

• Nonopioid analgesics

• acetaminophen

• Ibuprofen

• Other NSAIDs

• opioid analgesics

Pharmacological interventions: determine best medication

• based on status, type, intensity, location of pain, pain influences

Pharmacological interventions: questions

• what do i need to monitor

• how often

• are they developmentally able to do or understand

Pharmacological interventions: acetaminophen

can be admin IV

Pharmacological interventions: other NSAIDs

• ketorolac

  • IV FORM of ibuprofen

• indomethacin

• naproxen

• ibuprofen

Pharmacological interventions: opioid analgesics

• morphine

  • pain 6 and up

• can produce respiratory depression

• Gold standard

• 0.1 mg/kg per dose Q2

• have naloxone available

• meperidine (demerol)

  • not recommended as a first choice again in children due to toxicity on the CNS

• Codeine and tramadol

  • contraindicated in children <12 years

• PCA

  • hospital policy

  • reduces risk of overdose and medication errors

• Consideration of age and ability

What pain medications are contraindicated in children <12 years?

• tramadol

• codeine

What medications are NOT used for PAIN or FEVER management in a pediatric patient?

• ASPIRIN

  • used to thin blood

  • used to prevent clotting

  • DOES NOT TREAT FEVERS

  • can give appropriately

What else can be done to help with pain other than providing medications?

• biobehavioral techniques

  • distractions

  • relaxation and breathing

  • guided imagery anf hypnosis

  • cognitive behavioral therapy

• implementation

  • considerer developmental factors

  • allow the child to choose for themselves

  • always show my tech BEFORE pain occurs

  • involve parents

    • they know the childs usual coping mechanism, help identify strategies, and learn skills with child and coach

What is considered a fever?

• Infant >100.4

• Child >101

Antipyretics - lower fever and increase comfort: Tylenol dose recommendation

10-15 mg/kg/dose q 4-6

Major benefits for decreasing fever

• increase comfort

• decreasing fluid requirements

Pediatric nursing intervention: Consent/Informed consent

• Only 1 parent is reuqired to give informed consent for non urgent care

• No parent is required if it is life threatening

  • but obtain if parent is available

• generally whoever is the LEGAL guardian

• First ask

  • did the provider come and talk to you?

• Physician/surgeon responsibility to explain

• Nurses witness and reinforce physician

• adolescents

• if they deny to sign or change mind

  • use communication and over explanations

• person must be capable of giving consent

• must receive information needed to make an intelligent decision

• must act voluntarily when exercising freedom of choice without force, fraud, deceit, duress, or other forms of constraint or coercion

Pediatric nursing intervention: Consideration for adolescents

• All 50 states adolescents can consent without parents to:

  • STD treatment

  • mental health services

  • alcohol and drug dependency

  • pregnancy

  • contraceptive advice

  • IF TREATED, PARENTS DO NOT HAVE THE RIGHT TO THIS INFORMATION

Medication administration: eye drops

1. keep eye closed until ready to admin

2. have child look up

3. pull lower lid down

4. rest hand holding the dropper on the child’s head

   1. prevents trauma to the eye

5. do not let dropper touch eyes

6. place medication in the pocket that is formed

Medication administration: IV

• insertion may be traumatic for some kids

  • less traumatic compared to multiple injections

• Check site for patency minimum Q2

• Syringe pumps

  • smaller volumes of medication is administered

• Medications are calculated based on weight

• Volume of fluid must be considered

IV pain medications

opioid analgesics

IV types include

• Peripheral IV

• Central lines

Types of central lines include

• PICC line

• CVC

• Broviac (tunneled)

• Port-a-Cath

IV types: Peripheral IV

• locations

  • hand

  • feet

  • Antecubital

  • scalp veins

  • ankles

• NOT SUTURED IN

  • CAN EASILY PULL AND RIP OUT

• Can take it out but only if given an order

How to puff up a scalp vein

• DO NOT PUT TOURNIQUETTE AROUND NECK

  • put around head like a headband

• scalp veins do not have valves

IV types: PICC LINE

• Short term

• used for

  • neonates

    • in the legs and ankles going up

• can take out but only if given the order

IV types: CVC

• short term

• locations include large vessels

  • neck

  • groin

  • subclav

  • femoral

  • jugular

• sutured in

• high risk of infection

• multiple lumens —> variety of different things

• cant leave hospital with them

• can take it out but ONLY if given the order

IV types: Broviac (tunneled)

• come out of the center of the chest

• Long term use

  • TPN

• surgically placed meaning it has to be surgically removed with an order

• CAN leave with them

• Live with these for life

• accessed frequently

IV types: port a cath

• upper chest or abdomen under the skin

• give long term meds

• not accessed frequently or on a continuous basis

• great risk for infection

• can do anything unless it needs to be accessed by a needle

• surgically placed meaning it has to be surgically removed with an order

Taking off/out an IV

• note if catheter if fully intact when taken out

• if it is NOT in tact, take out a tourniquet so it doesn’t move → lay them flat —> call physician

IV care for neonates and infants

• secure with a pillow to help secure the site and keep it flat/straight but only as needed

• arm board ot secure IV

IV care: Broviac

• Daily hep flushes

• Semipermeable dressing over exit site at all times

  • Changed when loose or soiled

• Must be clamped at nearly all times

• Must keep exit site dry

• Restrict heavy activity

• Water sport restriction

• Risk of infection

• Susceptible to damage from sharp instruments and may be pulled out

IV care: Port a cath

• Pain with needle insertion

• Special needle used for port

• Skin prep needed prior to injection

• Difficult to manipulate for self admin infusions

• Catheter tip may migrate

• Vigorous contact sports are not allowed

• Removal is surgical

IV assessment

• Check site of insertion for patency

  • such as brisk blood return and flushing easily without resistance resistance

IV management

• never flush against resistance, if resistance is encountered, access integrity should be further evaluated

• only one antibiotic should be administered at a time

• never administer medications into the same IV tubing with blood products

Feeding the sick child

• Refusing to eat could be the child’s way to control a situation

• Do not wake the child to take fluids

• Make mealtimes pleasant

  • Adult should supervise mealtimes

• Do not give all the food at one time

  • Offer small amounts

  • Start with nutrition foods first

• Monitor amount consumed

  • Descriptions need to be accurate

    • Ex. 4 oz of juice, ½ pancake

• Appetite will improve as the child feels better

• Encourage family to bring in food from home

• Praise child for amount consumed

• Do not punish

• Do not use food as a reward

Appropriate foods

• Nutritious foods

Collection of specimens include

• Urine

• Stool

• Blood

• Respiratory

Collection of specimens include: Urine steps/consideration

• urinal or bedpan

• urine collection bags used on younger children

• clean catch

• cotton balls in diapers can be used for urine dips

• catheterization

Collection of specimens include: Stool steps/consideration

• separate hat in toiler

• use a tongue depressor to collect stool from diaper

Collection of specimens include: Blood steps/consideration

• Smaller bore catheters

• Smaller amount of blood withdrawn

  • usually 0.5-1 mL

  • when drawing form CVL - less waste drawn back (smaller lumen)

Collection of specimens include: Respiratory steps/consideration

• sputum culture

• nasal swab or washings

• specimens may be difficult to obtain for infants and small children

  • unable to follow directions

  • unable to perform action

• suck out boogers and send down to labs

Types of IVs include

• PICC

• CVC

• Brovaic (tunnled)

• Port-a-cath

Types of IVs recommendations for use: PICC

• short term use

• not sutured so be careful

Types of IVs recommendations for use: CVC

• short term but sutured in with multiple lumens for access

Types of IVs recommendations for use: Broviac

• Long term and is accessed frequently

  • TPN

Types of IVs recommendations for use: Port-a-cath

• Long term but not accessed AS frequently

  • chemo

  • for long term medications

Maintaining safety

• Identification band must be in place on child at all times

• Keep bed in the lowest position

• The environment

• Toys

• Preventing falls

Maintaining safety: The environment

• practice proper care and disposal of small object

  • cap, needle covers, temperature probes, etc.

• Crib sides up when caregiver not at beside

• Back to sleep if <1 yr

• No pillow

Maintaining safety: Toys

• Age appropriate

• Washable

• No small, removeable parts

Maintaining safety: Preventing falls

• Floor clear and debris

• Bed in lowest position

• Crib side rails up

• Slide resistant socks

• Hands on the infant at all times

• Medication side effects

  • Sedation

• Altered mental status

• Altered or limited mobility

• Postoperative children

• Call for assistance

Enteral Feedings

• NG tube

• G-tube

Enteral Feedings: G tube

• NG

  • decompresses the stomach and promotes blood flow through fluid maintenance

• Silastic

• Mickey button

• Flush with 1-2 mL

  • do NOT flush between medications

• Dissolve all medications

  • crush and dissolve throughly

• Always check placement prior to feeding or q4 for continous feeding

• Xray is required prior to initiating feeding and if concerned

• after initial xray use multiple alternate methods

Parenteral nutrition

• central IV access required

• Not the most preferred route because it may cause many complications

immunization contraindications

• Severe febrile illness

• misconceptions

  • combination vacs may overload immune system

  • not part of natural immunity and may decrease it

• Live viruses

  • MMR

  • Varicella

• Allergic response to previous admin vaccine or substance in vaccine

Immunization contraindications: Live viruses

• Contraindicated for those with altered immune systems as they may induce vaccine illness

• Live viruses to those immunocompromised

• Live viruses in presence of blood transfusions, immunoglobulin, or maternal antibodies

• MMR and varicella should be postponed fro a minimum of 3 months after passive immunizations with immunoglobulins and blood transfusion

Isolation disease include

• Chicken pox

• Rubeola (measles)

• Pertussis

• Scarlet fever

• Conjunctivitis

Isolation disease include: Chicken pox

• Airborne

Isolation disease include: Rubeola (measels)

• Airborne

Isolation disease include: Pertussis

• droplet

Isolation disease include: Scarlet fever

• Droplet

Isolation disease include: Conjunctivitis

• Contact

Chicken pox causative agent

• varicella sozter virus

Chicken pox infectious period

• 1-2 days BEFORE onset of rash and until all lesions are crusted over

When is chicken pox contagious until

• CONTAGIOUS UNTIL ALL LESIONS BURST AND CRUST OVER

Chicken pox isolation is

• airborne

Chicken pox (varicella) is

• usually self limiting

• has supportive measures for treatment

Varicella vaccines

• LIVE VIRUS vaccines

  • MMR

  • varicella

• 2 doses

  • 1st at 1 year of age & 2nd between 4-6 years of age

Varicella supportive measures

• important to stop scratching and picking to prevent scarring

Varicella nursing care

• Airborne precautions

• Away from susceptible individuals

• Skin care

  • Baths and change clothes

  • Change linens daily

• Admin topical calamine lotion

• Keep fingernails short and clean

• Apply mittens for scratching prn

• Keep cool

• Avoid aspirin

• Apply pressure rather than scratching

Rubeola (measles) is

• RNA virus

• Has symptomatic treatment

Measles precaution

• airborne isolation

Measles manifestations

• respiratory symptoms

• Koplik spots on mucosa

• Rash

Measles complications

• Secondary infections

  • bronchopneumonia

  • Croup

• CNS

  • encephalitis

• Premature birth or miscarriage

MMR vaccine is available for

• Measles, mumps, rubeola

  • live virus vaccine

  • 1st at 1 year of age and 2nd between 4 and 6

Pertussis is

• Acute respiratory disorder characterized by paroxysmal cough (whooping cough) and copious secretions

Pertussis causitive agent

• bordetella pertussis

Pertussis management

• DTaP vaccine

• hospitalization

  • eradicating the bacterial infection using antibiotics

• Respiratory support

• oxygen

• dehydration

Pertussis precautions

droplet